Every breath counts: Lessons learned in developing a training NICU in Northern Tanzania.

Introduction: Neonatal mortality rates in resource-limited hospitals of Sub-Saharan Africa (SSA) remain disproportionately high and are likely underestimated due to misclassification of extremely preterm births as "stillbirths" or "abortions", incomplete death registries, fear of repercussions from hospital and governmental authorities, unrecorded village deaths, and cultural beliefs surrounding the viability of premature newborns. While neonatology partnerships exist between high income countries and hospitals in SSA, efforts have largely been directed toward improving newborn survival through neonatal resuscitation training and provision of equipment to nascent neonatal intensive care units (NICUs). These measures are incomplete and fail to address the challenges which NICUs routinely face in low-resource settings. We draw on lessons learned in the development of a low-technology referral NICU in Tanzania that achieved an overall 92% survival rate among infants. Lessons learned: Achieving high survival rates among critically ill and preterm neonates in SSA is possible without use of expensive, advanced-skill technologies like mechanical ventilators. Evidence-based protocols adapted to low-resource hospitals, mentorship of nurses and physicians, changes in hierarchal culture, improved nurse-infant staffing ratios, involvement of mothers, improved procurement of consumables and medications, and bedside diagnostics are necessary steps to achieving high survival rates. Our NICU experience indicates that low-technology solutions of thermoregulation, respiratory support via continuous positive airway pressure, feeding protocols and infection control measures can ensure that infants not only survive, but thrive. Conclusions: Neonatal mortality and survival of preterm newborns can be improved through a long-term commitment to training NICU staff, strengthening basic neonatal care practices, contextually appropriate protocols, and limited technology.

Albendazole therapy and enteric parasites in United States-bound refugees.

BACKGROUND: Beginning on May 1, 1999, the Centers for Disease Control and Prevention (CDC) recommended presumptive treatment of refugees for intestinal parasites with a single dose of albendazole (600 mg), administered overseas before departure for the United States. METHODS: We conducted a retrospective cohort study involving 26,956 African and Southeast Asian refugees who were screened by means of microscopical examination of stool specimens for intestinal parasites on resettlement in Minnesota between 1993 and 2007. Adjusted prevalence ratios for intestinal nematodes, schistosoma species, giardia, and entamoeba were calculated among refugees who migrated before versus those who migrated after the CDC recommendation of presumptive predeparture albendazole treatment. RESULTS: Among 4370 untreated refugees, 20.8% had at least one stool nematode, most commonly hookworm (in 9.2%). Among 22,586 albendazole-treated refugees, only 4.7% had one or more nematodes, most commonly trichuris (in 3.9%). After adjustment for sex, age, and region, albendazole-treated refugees were less likely than untreated refugees to have any nematodes (prevalence ratio, 0.19), ascaris (prevalence ratio, 0.06), hookworm (prevalence ratio, 0.07), or trichuris (prevalence ratio, 0.27) but were not less likely to have giardia or entamoeba. Schistosoma ova were identified exclusively among African refugees and were less prevalent among those treated with albendazole (prevalence ratio, 0.60). After implementation of the albendazole protocol, the most common pathogens among 17,011 African refugees were giardia (in 5.7%), trichuris (in 5.0%), and schistosoma (in 1.8%); among 5575 Southeast Asian refugees, only giardia remained highly prevalent (present in 17.2%). No serious adverse events associated with albendazole use were reported. CONCLUSIONS: Presumptive albendazole therapy administered overseas before departure for the United States was associated with a decrease in the prevalence of intestinal nematodes among newly arrived African and Southeast Asian refugees.

Pediatric travelers visiting friends and relatives (VFR) abroad: illnesses, barriers and pre-travel recommendations.

Global mobility has shown a steady rise in recent years, with increased immigration and international travel. The VFR traveler is a traveler whose primary purpose of travel is to visit friends and relatives (VFR), where there is a gradient of risk between home and destination. Children are more likely to be VFR travelers than adults. Pediatric VFR travelers have higher risks for certain infectious travel-related illnesses and face multiple barriers in receiving comprehensive pre-travel care. This review focuses on the current state of knowledge of the pediatric VFR traveler, including epidemiological risks, barriers to adequate pre-travel services, and specific recommendations for disease prevention.

Multidrug-resistant Salmonella enterica serotype Typhimurium associated with pet rodents.

BACKGROUND: An estimated 1.4 million salmonella infections occur annually in the United States. The majority of these infections are foodborne, but many are acquired by contact with animals. In August 2004, isolates of Salmonella enterica serotype Typhimurium, which were indistinguishable from one another by pulsed-field gel electrophoresis (PFGE), were obtained from eight hamsters from a Minnesota pet distributor. We conducted an investigation to determine whether human cases of salmonella could be linked to this rodent-borne strain. METHODS: To identify cases of human infection with S. enterica serotype Typhimurium potentially related to pet rodents, we reviewed salmonella PFGE patterns submitted to the National Molecular Subtyping Network for Foodborne Disease Surveillance. Patients with isolates matching the hamster strain were interviewed about exposure to pet rodents. Implicated rodents were traced to pet stores, distributors, and breeders. RESULTS: We identified matching S. enterica serotype Typhimurium isolates from 28 patients in whom the onset of illness occurred between December 2003 and September 2004. Of 22 patients (or in the case of children, their parents) interviewed, 13 patients (59%) in 10 states reported exposure to pet hamsters, mice, or rats, and 2 (9%) had secondary infections. The median age of the 15 patients with primary or secondary rodent exposure was 16 years, and 6 patients (40%) were hospitalized. Thirteen associated pet stores supplied by seven distributors were identified in 10 states. No single source of the rodents was identified. The outbreak strain of S. enterica serotype Typhimurium was cultured from a patient's pet mouse and from seven hamsters from pet stores. Closely related S. enterica serotype Typhimurium isolates were cultured from rodent cages and reusable transport containers at a pet distributor. Human, rodent, and environmental isolates were resistant to ampicillin, chloramphenicol, streptomycin, sulfisoxazole, and tetracycline. CONCLUSIONS: Pet rodents probably are an underrecognized source of human salmonella infection.

Coinfections acquired from ixodes ticks.

The pathogens that cause Lyme disease (LD), human anaplasmosis, and babesiosis can coexist in Ixodes ticks and cause human coinfections. Although the risk of human coinfection differs by geographic location, the true prevalence of coinfecting pathogens among Ixodes ticks remains largely unknown for the majority of geographic locations. The prevalence of dually infected Ixodes ticks appears highest among ticks from regions of North America and Europe where LD is endemic, with reported prevalences of < or =28%. In North America and Europe, the majority of tick-borne coinfections occur among humans with diagnosed LD. Humans coinfected with LD and babesiosis appear to have more intense, prolonged symptoms than those with LD alone. Coinfected persons can also manifest diverse, influenza-like symptoms, and abnormal laboratory test results are frequently observed. Coinfecting pathogens might alter the efficiency of transmission, cause cooperative or competitive pathogen interactions, and alter disease severity among hosts. No prospective studies to assess the immunologic effects of coinfection among humans have been conducted, but animal models demonstrate that certain coinfections can modulate the immune response. Clinicians should consider the likelihood of coinfection when pursuing laboratory testing or selecting therapy for patients with tick-borne illness.