Paediatric in-patient care in a conflict-torn region of Somalia: are hospital outcomes of acceptable quality?

SETTING: A district hospital in conflict-torn Somalia. OBJECTIVE: To report on in-patient paediatric morbidity, case fatality and exit outcomes as indicators of quality of care. DESIGN: Cross-sectional study. RESULTS: Of 6211 children, lower respiratory tract infections (48%) and severe acute malnutrition (16%) were the leading reasons for admission. The highest case-fatality rate was for meningitis (20%). Adverse outcomes occurred in 378 (6%) children, including 205 (3.3%) deaths; 173 (2.8%) absconded. CONCLUSION: Hospital exit outcomes are good even in conflict-torn Somalia, and should boost efforts to ensure that such populations are not left out in the quest to achieve universal health coverage.

Practicing medicine without borders: tele-consultations and tele-mentoring for improving paediatric care in a conflict setting in Somalia?

OBJECTIVES: In a district hospital in conflict-torn Somalia, we assessed (i) the impact of introducing telemedicine on the quality of paediatric care, and (ii) the added value as perceived by local clinicians. METHODS: A 'real-time' audio-visual exchange of information on paediatric cases (Audiosoft Technologies, Quebec, Canada) took place between clinicians in Somalia and a paediatrician in Nairobi. The study involved a retrospective analysis of programme data, and a perception study among the local clinicians. RESULTS: Of 3920 paediatric admissions, 346 (9%) were referred for telemedicine. In 222 (64%) children, a significant change was made to initial case management, while in 88 (25%), a life-threatening condition was detected that had been initially missed. There was a progressive improvement in the capacity of clinicians to manage complicated cases as demonstrated by a significant linear decrease in changes to initial case management for meningitis and convulsions (92-29%, P = 0.001), lower respiratory tract infection (75-45%, P = 0.02) and complicated malnutrition (86-40%, P = 0.002). Adverse outcomes (deaths and lost to follow-up) fell from 7.6% in 2010 (without telemedicine) to 5.4% in 2011 with telemedicine (30% reduction, odds ratio 0.70, 95% CI: 0.57-0.88, P = -0.001). The number needed to be treated through telemedicine to prevent one adverse outcome was 45. All seven clinicians involved with telemedicine rated it to be of high added value. CONCLUSION: The introduction of telemedicine significantly improved quality of paediatric care in a remote conflict setting and was of high added value to distant clinicians.

Detection of malaria in relation to fever and grade of malnutrition among malnourished children in Ethiopia.

SETTING: Forty-eight nutritional rehabilitation centres in southern Ethiopia. OBJECTIVE: To determine 1) the frequency of temperature recording under programme conditions, 2) the proportion of malnourished children with and without fever who had falciparum malaria and 3) the association between malaria and grade of malnutrition. DESIGN: This was a retrospective analysis of routine programme data. RESULTS: Of 19 200 malnourished children, 16 716 (mean age 4.4 years, 7412 males) underwent a rapid malaria diagnostic test (Paracheck Pf (®)). Malnutrition was graded as severe (38%), moderate (35%) and mild (27%). Temperature was not recorded in 15 248 (91%) children. Malaria was diagnosed in 57 (28%) children with fever (n = 206) and 122 (10%) children with no fever (n = 1262). The prevalence of falciparum malaria was 9%. Malaria prevalence was significantly associated with grade of malnutrition: Paracheck Pf was positive in respectively 5%, 8% and 10% of children with mild, moderate and severe malnutrition (χ(2) for trend 78, P < 0.001). CONCLUSIONS: This study shows the value of routine malaria screening in malnourished children, especially those with more severe grades of malnutrition, irrespective of fever. Operational shortcomings are highlighted and ways forward to address these problems are discussed.

The experience of implementing a 'TB village' for a pastoralist population in Cherrati, Ethiopia.

SETTING: In Cherrati District, Somali Regional State (SRS), Ethiopia, despite a high burden of tuberculosis (TB), TB control activities are virtually absent. The majority of the population is pastoralist with a mobile lifestyle. TB care and treatment were offered using a 'TB village' approach that included traditional style residential care, community empowerment and awareness raising, provision of essential social amenities and essential food and non-food items. OBJECTIVE: To describe 1) key aspects of the implementation of the TB village approach, 2) TB treatment outcomes and 3) the lessons learnt during implementation. DESIGN: Descriptive study. RESULTS: A total of 297 patients entered the TB village between September 2006 and October 2008; 271 (91%) patients were treated successfully, nine (3%) defaulted and 13 (4%) died. CONCLUSIONS: For pastoralist populations, a TB village approach may be effective for improving access to TB care, ensuring proper adherence to treatment and achieving good overall TB outcomes. The successes and challenges of this approach are discussed.