Pulmonary hemorrhage and associated risk factors among newborns admitted to a tertiary level neonatal unit in Botswana.

Introduction: Pulmonary hemorrhage (PH) is a life-threatening complication seen in very sick newborns with high morbidity and mortality. There is little data on the incidence, risk factors, and ultimate survival of newborns with pulmonary hemorrhage in sub-Saharan countries, where the healthcare provision and facility differ in many ways compared to high-income countries. Hence, this study aimed to determine the incidence, identify the risk factors, and describe the outcome of pulmonary hemorrhage in newborns in a low middle income country setting. Methods and materials: A cohort study with prospective data collection was conducted in a public, tertiary-level hospital in Botswana, the Princess Marina Hospital (PMH). All newborns admitted to the neonatal unit from 1 January 2020 to 31 December 2021 were included in the study. Data were collected using a checklist developed on the RedCap database (https//:ehealth.ub.ac.bw/redcap). The incidence rate of pulmonary hemorrhage was calculated as the number of newborns who had pulmonary hemorrhage per 1,000 newborns in the 2-year period. Group comparisons were made using X2 and Student's t-tests. Multivariate logistic regression was used to identify risk factors independently associated with pulmonary hemorrhage. Result: There were 1,350 newborns enrolled during the study period, of which 729 were male newborns (54%). The mean (SD) birth weight was 2,154(±997.5) g, and the gestational age was 34.3 (±4.7) weeks. In addition, 80% of the newborns were delivered in the same facility. The incidence of pulmonary hemorrhage was 54/1,350 {4% [95% CI (3%-5.2%)]} among the newborns admitted to the unit. The mortality rate in those diagnosed with pulmonary hemorrhage was 29/54 (53.7%). Multivariate logistic regression identified birth weight, anemia, sepsis, shock, disseminated intravascular coagulopathy (DIC), apnea of prematurity, neonatal encephalopathy, intraventricular hemorrhage, mechanical ventilation, and blood transfusion as risk factors independently associated with pulmonary hemorrhage. Conclusion: This cohort study identified a high incidence and mortality rate of pulmonary hemorrhage in newborns in PMH. Multiple risk factors, such as low birth weight, anemia, blood transfusion, apnea of prematurity, neonatal encephalopathy, intraventricular hemorrhage, sepsis, shock, DIC, and mechanical ventilation, were identified as independently associated risk factors for PH.

Symptoms of depression, anxiety, and thoughts of suicide/self-injury in adolescents and young adults living with HIV in Botswana.

Globally, mental health problems have been reported to be more common in youth living with HIV (YLWH) than in the general population, but routine mental health screening is rarely done in high-volume HIV clinics. In 2019, YLWH in a large HIV clinic in Botswana were screened using the Generalized Anxiety Scale-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) in a pilot standard-of-care screening programme. Two-way ANOVA was used to describe the effects of age group (12-<16, 16-<20 and 20-25 years old) and sex on GAD-7 and PHQ-9 scores. Chi-square statistics were used to compare characteristics of YLWH with and without potential suicidality/self-harm symptoms based on question 9 in the PHQ-9. Among 1 469 YLWH, 33.1%, 44.3% and 15.0% had anxiety, depression and potential suicidality/self-harm symptoms respectively. YLWH of 20-25 years old and 16-<20 years old had higher GAD-7 scores compared to 12-<16-year-olds (p = 0.014 and p = <0.001 respectively). Female YLWH of 20-25 years old had higher PHQ-9 scores compared to 12-<16-year-olds (p = 0.002). There were no other sex-age dynamics that were statistically significant. Female YLWH endorsed more thoughts of suicidality/self-harm than males (17% versus 13%, p = 0.03 respectively). Given the proportion of YLWH with mental health symptoms, Botswana should enhance investments in mental health services for YLWH, especially for young female adults who bear a disproportionate burden.

Ophthalmomyiasis in a preterm neonate resulting in blindness: A case report from Botswana.

Myiasis is an infestation of human tissue by insect larvae. While rare, healthcare-associated myiasis has been reported from immobilized patients in resource-limited healthcare facilities in warm climates without adequate vector control measures. We describe a case of Ophthalmomyiasis in a hospitalized neonate in Botswana that resulted in vision loss. The neonate, who was initially hospitalized due to the complications of prematurity, received phototherapy for jaundice, and to avoid phototherapy-related retinopathy, the neonate's eyes were covered using cotton gauze and adhesive tapes that potentially damaged the skin as commercially available eye covering was not in stock. Therefore, eye covering was not changed and when the eye covering was removed almost 3 days after placement, insect larvae were noted in the patient's eyes and nose. Ophthalmologic evaluation revealed perforated corneal ulcer and uveal prolapse in the right eye resulting in complete blindness and corneal scarring of the left eye. The patient's clinical course was further complicated by an Enterobacter species bloodstream infection. This case highlights the importance of vector control as a major patient safety measure for neonatal units in warm climates. Flies had been observed in the room and mitigation measures included reducing fly populations through traps, screens, and removal of standing water and leftover food. Every mother and staff were sanitizing hands when entering the room and gowns were used. This case also reinforces the importance to conduct vigilant monitoring of patients, especially neonates with eyes covered during phototherapy.

Nosocomial SARS-CoV-2 transmission in a neonatal unit in Botswana: chronic overcrowding meets a novel pathogen.

We describe a cluster of six SARS-CoV-2 infections occurring in a crowded neonatal unit in Botswana, including presumed transmission among mothers, postnatal mother-to-neonate transmission and three neonate-to-healthcare worker transmissions. The affected neonate, born at 25 weeks' gestation weighing 785 g, had a positive SARS-CoV-2 test at 3 weeks of age which coincided with new onset of hypoxaemia and worsening respiratory distress. Because no isolation facility could accommodate both patient and mother, they were separated for 10 days, during which time the patient was switched from breastmilk to formula. Her subsequent clinical course was marked by several weeks of supplemental oxygen, sepsis-like presentations requiring additional antibiotics and bronchopulmonary dysplasia. Despite these complications, adequate growth was achieved likely due to early initiation of nutrition. This nosocomial cluster highlights the vulnerabilities of neonates, caregivers and healthcare workers in an overcrowded environment, and underscores the importance of uninterrupted bonding and breast feeding, even during a pandemic.

Laboratory-confirmed bloodstream infections in two large neonatal units in sub-Saharan Africa.

BACKGROUND: Epidemiological data on neonatal bloodstream infections (BSI) in sub-Saharan Africa are extremely limited. METHODS: A comparative analysis of laboratory-confirmed neonatal BSI episodes was conducted retrospectively in two large neonatal units in Botswana and South Africa (January 1 to December 31, 2017). Routine laboratory and ward register data were used to determine BSI rates, the pathogen spectrum, and BSI outcomes. RESULTS: In 2017, the Princess Marina Hospital (PMH) and Tygerberg Hospital (TBH) neonatal units admitted 1187 and 2826 neonates, respectively. The BSI incidence rate was 12.1/1000 patient-days (95% confidence interval (CI) 10.2-14.3) at PMH and 3.5/1000 patient-days (95% CI 2.9-4.1) at TBH (p < 0.0001). Most BSI episodes were hospital-acquired (260/284; 91.6%). The blood culture contamination rate was substantially higher at PMH than TBH (152/1116 (13.6%) vs 122/2559 (4.8%); p < 0.001). The crude mortality rate in neonates with BSI was 21.2% (53/250) and significantly higher at TBH than PMH (38/128 (29.7%) vs 15/122 (12.3%), p = 0.001). Factors independently associated with death were birth weight <1500 g (adjusted odds ratio (aOR) 2.8, 95% CI 1.3-6.4; p = 0.02) and male sex (aOR 2.1, 95% CI 1.1-3.7; p = 0.01). Klebsiella pneumoniae was the dominant BSI pathogen in both units, accounting for two-thirds of BSI, and was associated with a large infection outbreak at PMH. Antibiotic resistance rates were substantial in both neonatal units, particularly for K. pneumoniae (98/122 (80.3%), extended-spectrum beta-lactamase (ESBL)-producers) and Staphylococcus aureus (22/33 (66.7%), methicillin-resistant). CONCLUSIONS: BSI rates and associated mortality were substantial in these two neonatal units in sub-Saharan Africa. ESBL-producing K. pneumoniae remains a leading BSI and outbreak pathogen.

Incidence of Retinopathy of Prematurity in Botswana: A Prospective Observational Study.

BACKGROUND: Retinopathy of prematurity (ROP) is a widely recognized cause of blindness after preterm birth. The incidence of ROP is rising especially in low- and middle-income countries (LMIC) because of improved neonatal care and increased survival of very premature neonates. To date, there is no data on incidence of ROP in Botswana. OBJECTIVE: The purpose of this study was to provide initial data and determine ROP-associated risk factors from a single neonatal care center on the incidence of ROP in Gaborone, Botswana. METHODS: A prospective observational study was conducted at Princess Marina Hospital (PMH) in Gaborone, Botswana. Premature neonates with birth weights (BW) of <1,801 g or gestational age (GA) of <34 weeks were enrolled in this study. Diagnostic examinations were conducted using an indirect ophthalmoscope with 28D lens. ROP findings were classified according to the most advanced stage of ROP reached using the International Classification of ROP (2005). Data were entered into STATA version 15 statistical software for analysis. RESULTS: There were 264 premature infants enrolled in the study. ROP screening was performed on 200 (75.8%). Of all 264 enrolled patients 133 (50.4%) were female. The mean GA was 30.3±2.6 (range 24-37) weeks and the mean BW was 1302.2±285.9 g (range 725-2035). Out of 200 who were screened, we identified 22 with ROP with a ROP incidence of 11%. The incidence of type 1 ROP (sight-threatening) was found to be 3.5%. This study identified a significant difference in possible ROP risk factors between those infants who develop ROP and those who do not, eg, BW (p<0.001), GA (p=0.024) and blood transfusion (p=0.001). CONCLUSION: This study demonstrates that ROP is a treatable cause of blindness in Botswana. Lack of a proper screening protocol, delay in diagnosis and management are plausible reasons for poor outcome in those who were diagnosed with type 1 ROP.

Pediatric Spectrum of Allergic Diseases and Asthma in a Tertiary Level Hospital in Botswana: an Exploratory Retrospective Cross-Sectional Study.

PURPOSE: This study aims to describe the spectrum of allergic diseases of children and adolescents in a single allergy treatment centre in Botswana, over a period of 8 years. PATIENTS AND METHODS: A retrospective cross-sectional study was conducted using medical records of all patients aged 18 years or younger, seen at an allergy treatment centre in Botswana. Data were presented descriptively. Association between variables was explored by χ 2-test. RESULTS: Four hundred and seven patients with a mean age of 5.8 years (SD 4.4) at the time of presentation included 239 (58.7%) females and 365 (87.5%) black Africans. The most common diseases were asthma (n=249, 61.2%) followed by allergic rhinitis (AR) (n=232, 57.0%) and atopic dermatitis (AD) (n=165, 40.5%). One hundred and fifteen cases (46.2%) of asthmatic patients were skin prick test positive; sensitized to grass, moulds, dust mites and animal dander, in decreasing frequency, whereas those with allergic rhinitis (AR) and allergic conjunctivitis (AC) were sensitized to trees and all allergens identified in asthmatics. Concomitant asthma was diagnosed in 171 (73.7%) with AR, 71 (68.3%) with AC, 75 (45.5%) with AD and 42 (47.7%) with food allergy. The most common triggers for asthma exacerbations include upper respiratory tract infections, weather changes, and exposure to passive cigarette smoke. Paternal allergy and allergic disease in grandparents are predisposing factors for asthma (p=0.016 and p=0.001, respectively). Paternal allergy is also predisposed to AR (p=0.007), while maternal history of allergic disease was associated with AD (p=0.019). CONCLUSION: The most common chronic pediatric conditions seen in our allergic disease study were asthma, allergic rhinitis and atopic dermatitis with the most common triggers being viral upper respiratory tract infections, weather changes and exposure to cigarette smoke, all of which are modifiable risk factors. This exploratory study lays the foundation for future interventional studies that may be directed towards the spectrum of allergic diseases.

Sight threatening vitreous haemorrhage and retinal detachment in a patient with sickle cell disease.

We report a case of sight threatening vitreous haemorrhage and retinal detachment as complication of sickle cell disease (SCD). A 35 years old female Nigerian patient had presented to ophthalmology clinic of Princess Marina Hospital, Botswana, with two weeks history of poor vision in the left eye. The loss of vision was due to vitreous haemorrhage and retinal detachment which was confirmed by direct and indirect ophthalmoscopy and B-Scan ultrasound. Prior to presentation, patient didn't have any follow up by an ophthalmologist as part of regular medical care for patients with SCD. We emphasize the importance of regular follow up for early detection, treatment and prevention of complication associated with sickle cell disease.

Presenting signs of retinoblastoma at a tertiary level teaching hospital in Ethiopia.

INTRODUCTION: Retinoblastoma is a primary malignant intraocular neoplasm that arise from immature retinoblasts with in developing retina. The commonest presenting sign in developing country is proptosis which is the late presenting sign. We report presenting signs of retinoblastoma in Ethiopian children seen at a tertiary level teaching hospitals in Ethiopia. METHODS: Prospective case series study was done on children who presented with retinoblastoma between May 1, 2005 and September 1, 2006. This study was done as part of requirement for partial fulfilment of certificate of specialty study in ophthalmology during the year 2005 to 2006. SPSS 11 statistical package was used to analyse the data. RESULTS: Among 41 patients seen during the study period, 24 (58.5%) were males and 17(41%) were females. Unilateral retinoblastoma was found in 32 (78%) patients and bilateral cases were found in 9(22%). Mean age of onset for right eye was 27.5 months and left eye 33.7 months. The mean ages of presentation at time of diagnosis for right and left eye were 34.4 and 40.2 months, respectively .In bilateral retinoblastoma mean age of presentation was 33.3 months. The commonest presenting sign was proptosis 22(53.7%) followed by leucocorea nine (22%),ocular inflammation four (9.0 %), strabismus three (7.3%), glaucoma one (2.4%), loss of vision one (2.4%)and hyphemaone (2.4%). CONCLUSION: The commonest presenting signs of retinoblastoma in our set up were Proptosis followed by leucocorea. This is due to late presentation of patient and late referral by medical professionals. Health education to the public and health professionals will help early detection of retinoblastoma.