Successes and challenges of under-five child mortality reduction in West Africa

Background: Under-five mortality rate is an important index for assessing achievements by countries and thus its targeted reduction is adopted as benchmark towards realizing the Millennium Development Goal number4 by 2015. With less than 24 months to the deadline, West Africa still contributes significantly to the global burden of child mortality, with over half of the deaths caused by infections.Objective: To review the successes and challenges of reducingunder-five mortality in West Africa.Sources: A search was made in Pub Med and Google Scholar using the key words: Under-five, Children, Mortality, West Africa, Successes, Progress, Achievements and Challenges. Relevant publications and reports availableat WHO, UNICEF and UN websites were also consulted. Tables and charts were drawn from relevant data for West African Countries obtained from these sources using Microsoft® Excel® for Mac 2011 Version 14.1.0(110310).Results: Although significant under-five death reductions have been  recorded in countries of West Africa between 1990 and 2012, the reduction falls far short of the expected targets and infections still remain the leading causes of death. In spite of a fivefold rise of average annual rate of reduction of under-five deaths compared to a 3-fold rise of the global average and a 49.7% reduction in under-five mortality rate, the sub-region trails behind other parts of Africa. While only Liberia achieved the MDG 4 target, Niger, Cape Verde, Gambia, Guinea and Burkina Faso are on track. Nigeria’s huge child population, high under-five mortality burden and slow reduction, weighs down the sub-region’s averages. Neonatal death  proportions are rising, with four countries ranking amongst the world’s top ten. With less than 24 months left, the likelihood of achieving the reduction targets for under-five mortality in most of the countries in the sub-region by the end of 2015 remains a mirage.Conclusion: Numerous daunting challenges have contributed to slow the pace of under-five death reduction in West Africa. Countries in the sub-region need to address their challenges while scaling up proven interventions to accelerate progress towards further reductions of under-five deaths.Key words: Children, under-five, mortality, West Africa, progress, successes, achievements, challenge

Premature discharge of children from hospital admission at Ahmadu Bello University Teaching Hospital Zaria: A 3-year review

Introduction: Leaving hospital care prematurely could threaten the healthy survival of and expose children to a risk of harmful alternatives. It is also a concern and a challenge to healthcare providers and the health system. A better understanding of its characteristic could help mitigate the impact on children.Objective: To determine the prevalence, types of, and reasons for premature hospital discharge amongst children.Methods: We carried out a threeyear retrospective review of case notes of children who were taken away from hospital admission by their parents/caregivers before they were due for discharge.  Socio-demographic, clinical anddischarge information were collected and data was entered into Microsoft® Excel® for Mac 2011 (Version 14.1.0), cleaned and analysed. Results were presented as percentages, statistical means and standard deviations, tables and charts.Results: There were 56 cases of premature discharge out of 2858 admissions, giving a prevalence of 2.0%. Under-five children constituted 65.4%, with a male: female ratio of 2.3:1. Thirty-one (55.3%) children were absconded with while 25 (44.7%) were taken away by caregivers against medical advice. The commonest diagnoses were protein-energy malnutrition and pneumonia and majority were from poor socio-economic family background. The commonest reasons for discharge AMA were unaffordable costs and perception of improvement of child’s medical condition.Conclusion: Socio-economic factors were significant determinants of utilization of in-patient hospital services for the children studied. There is a need for provision of affordable health care as well as efficient discharge policy to protect children from potential risks associated with premature hospital discharge.Keywords: Children; admission; premature discharge; discharge against medical advice; absconding; elopemen

Typhoid fever in children presenting to paediatric medical wards of Ahmadu Bello University Teaching Hospital Zaria: A 13-month review

Typhoid fever is a systemic infection caused by the Gram-negative bacilli Salmonellae, transmitted via the feaco-oral route. It commonly affects children, leading to complications and death if untreated. This is a reportof typhoid fever admissions as seen at ABU Teaching Hospital Zaria over a 13-month period. Objectives: To describe the clinical presentation and management outcomes of children admitted with typhoid fever during a13-month period.Materials and methods: A retrospective review of demographic, clinical presentation and treatment response of children managed for typhoid fever was conducted. Results were presented as means with standard deviation, proportions, tables, figures and Chisquares with p values. The prevalence of typhoid fever admissions was obtained over the period from2008-2011.Results: A total of 779 children were admitted from 1st January 2011 to 31st January 2012, out of which 39 (4.9%) had a diagnosis of typhoid fever. There was a significant difference in prevalence of typhoid fever admissions from 2008-2010 compared to 2011 (X2 = 5.6651; p <0.019). The mean age was 7.2 (SD ± 4.3) years and 71.8% resided in the sameneighbourhood. All the children had pre-admission antibiotics, while 93.3% had abdominal pain, 64.1% had diarrhoea, 89.7% had fever and 69% had hepatomegaly. Widal test and blood cultures were positive in 46% and 10.3% respectively. Poor treatment response led to antibiotic switch for 61.1% started on chloramphenicol. Bowel perforation occurred in four(10.3%) who had laparotomy but there was no mortality, and all were discharged after recovery.Conclusion: A surge was observed in typhoid fever admissions associatedwith widespread use of preadmission antibiotics. Low rates of pathogen isolation and unaffordable costs precluded appropriate antibiotic choice for many at admission, and led to poor treatment response. Public health education should emphasize water hygiene and judicious use of antibiotics.Key words: Typhoid fever; Enteric fever; Children; Hospital admission

Purpura Fulminans with Disseminated Intravascular Coagulopathy and Symmetric Peripheral Gangrene Complicating Sepsis in an Infant: A Case Report

Purpura fulminans is a rare consequence of sepsis that could be complicated by DIC and gangrene. We report the case of a 2-months-old infant who developed gangrenous limbs. He presented with fever, diarrhoea, vomiting and irritability for 5 days and was dehydrated and unconscious with global hypertonia. With a clinical impression of sepsis antibiotics, IV fluids and supportive care were commenced. He developed purpuric rashes over the trunk and feet, the latter of which gradually ascended over the legs, with swellings and ischemic skin changes up to the knees. A diagnosis of purpura fulminans was made and further evaluation revealed deranged haematologic parameters, features of Disseminated Intravascular Coagulopathy (DIC), hypernatraemia, azotaemia and arterial occlusion. Despite blood transfusions and supportive care gangrene emerged and progressively ascended towards the knees. Parents however rejected offer for surgical amputation and left against medical advice. The coexistence of purpura fulminans with multiple triggers for DIC should alert clinicians of a potential risk of peripheral gangrene.Keywords: Infant, Sepsis, Purpura fulminans, DIC, Gangren

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries

Importance: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent. / Objective: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 countries in sub-Saharan Africa. / Design, Setting, and Participants: This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection. / Exposures: Age, sex, preexisting comorbidities, and region of residence. / Main Outcomes and Measures: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay. / Results: Among 469 hospitalized children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalized. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge. / Conclusions and Relevance: In this cohort study of children and adolescents hospitalized with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region

The Critical Need for Pooled Data on Coronavirus Disease 2019 in African Children: An AFREhealth Call for Action Through Multicountry Research Collaboration

Globally, there are prevailing knowledge gaps in the epidemiology, clinical manifestations, and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children and adolescents; and these gaps are especially wide in African countries. The availability of robust age-disaggregated data is a critical first step in improving knowledge on disease burden and manifestations of coronavirus disease 2019 (COVID-19) among children. Furthermore, it is essential to improve understanding of SARS-CoV-2 interactions with comorbidities and coinfections such as human immunodeficiency virus (HIV), tuberculosis, malaria, sickle cell disease, and malnutrition, which are highly prevalent among children in sub-Saharan Africa. The African Forum for Research and Education in Health (AFREhealth) COVID-19 Research Collaboration on Children and Adolescents is conducting studies across Western, Central, Eastern, and Southern Africa to address existing knowledge gaps. This consortium is expected to generate key evidence to inform clinical practice and public health policy-making for COVID-19 while concurrently addressing other major diseases affecting children in African countries

Effect of SARS-CoV-2 Infection in Pregnancy on Maternal and Neonatal Outcomes in Africa: An AFREhealth Call for Evidence through Multicountry Research Collaboration

In the African context, there is a paucity of data on SARS-CoV-2 infection and associated COVID-19 in pregnancy. Given the endemicity of infections such as malaria, HIV, and tuberculosis (TB) in sub-Saharan Africa (SSA), it is important to evaluate coinfections with SARS-CoV-2 and their impact on maternal/infant outcomes. Robust research is critically needed to evaluate the effects of the added burden of COVID-19 in pregnancy, to help develop evidence-based policies toward improving maternal and infant outcomes. In this perspective, we briefly review current knowledge on the clinical features of COVID-19 in pregnancy; the risks of preterm birth and cesarean delivery secondary to comorbid severity; the effects of maternal SARS-CoV-2 infection on the fetus/neonate; and in utero mother-to-child SARS-CoV-2 transmission. We further highlight the need to conduct multicountry surveillance as well as retrospective and prospective cohort studies across SSA. This will enable assessments of SARS-CoV-2 burden among pregnant African women and improve the understanding of the spectrum of COVID-19 manifestations in this population, which may be living with or without HIV, TB, and/or other coinfections/comorbidities. In addition, multicountry studies will allow a better understanding of risk factors and outcomes to be compared across countries and subregions. Such an approach will encourage and strengthen much-needed intra-African, south-to-south multidisciplinary and interprofessional research collaborations. The African Forum for Research and Education in Health's COVID-19 Research Working Group has embarked upon such a collaboration across Western, Central, Eastern and Southern Africa

Child Sexual Abuse in Minna, Niger State Nigeria

Background: Child sexual abuse is a widespread form of child abuse that has remained the most under-reported. In our communities, much remains unknown of this act which often leaves victims traumatised with unsavoury memory that tends to affect their psychosocial development. The study evaluted the socio-demographic features and the nature of sexual abuse as seen in the outpatient department of general hospital Minna, Niger state. Patients and Methods: The case notes of patients who presented to the General Out-patient Department (GOPD) of General Hospital Minna were analysed for cases, of sexual assault, sexual abuse or rape seen between January 2008 and December 2008. Results: A total of 32 cases were seen, 90.1% of whom were children less than 17 years old; 75% were aged 6 – 15 years. All the cases were of the penile penetrative type (vaginal in girls and anal in boys). All the perpetrators were adult males known to, and resident in, the neighbourhood of their victims. Conclusion: There is need to build the capacity of health care providers to enable them manage child sexual abuse and its long-term effects in Minna

A Novel Direct Factor Xa Inhibitory Peptide with Anti-Platelet Aggregation Activity from Agkistrodon acutus Venom Hydrolysates

Snake venom is a natural substance that contains numerous bioactive proteins and peptides, nearly all of which have been identified over the last several decades. In this study, we subjected snake venom to enzymatic hydrolysis to identify previously unreported bioactive peptides. The novel peptide ACH-11 with the sequence LTFPRIVFVLG was identified with both FXa inhibition and anti-platelet aggregation activities. ACH-11 inhibited the catalytic function of FXa towards its substrate S-2222 via a mixed model with a K(i) value of 9.02 μM and inhibited platelet aggregation induced by ADP and U46619 in a dose-dependent manner. Furthermore, ACH-11 exhibited potent antithrombotic activity in vivo. It reduced paralysis and death in an acute pulmonary thrombosis model by 90% and attenuated thrombosis weight in an arterio-venous shunt thrombosis model by 57.91%, both at a dose of 3 mg/kg. Additionally, a tail cutting bleeding time assay revealed that ACH-11 did not prolong bleeding time in mice at a dose of 3 mg/kg. Together, our results reveal that ACH-11 is a novel antithrombotic peptide exhibiting both FXa inhibition and anti-platelet aggregation activities, with a low bleeding risk. We believe that it could be a candidate or lead compound for new antithrombotic drug development