Conference Material > Abstract
Fidelle L, Mahajan R, Gallo J, Biague E, Goncalves R, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/EGpRP15g
BACKGROUND AND OBJECTIVES
Over half of childhood tuberculosis (TB) remains undiagnosed yearly. TB culture is often unavailable. WHO recommends Xpert-Ultra as first test for diagnosis of paediatric TB, but microbiological confirmation remains low and often requires invasive procedures. We aimed to determine the utility of Xpert-Ultra in stools and urine samples to diagnose TB in children living with HIV (CLWH) in two high-TB burden settings.
METHODS
This cross-sectional multicentric study took place at Simão Mendes hospital, Guinea-Bissau, from July 2019 to April 2020, and in Malakal hospitals, South Sudan, from November 2019 to June 2023. Children 6 months to 15 years with suspected TB underwent clinical and laboratory assessment, with one respiratory or extrapulmonary sample (gold standard (GS)), one stool and one urine specimen per patient analysed with Xpert-Ultra.
RESULTS
A total of 93 HIV-positive children were enrolled from Bissau (n=57) and Malakal (n=36), with 49 (53%) females and median (IQR) age of 3.3 (1.5-10) years. Three-quarters of children had severe acute malnutrition (SAM). A total of 72 (77%) children were on ART at baseline and 26/77 (34%) had CD4 count <200cells/mm3. Confirmation of TB was achieved in 20 (22%); 51 (55%) had unconfirmed TB, and 22 (24%) had unlikely TB. Of 93 children with GS diagnosis, the overall yield of positive TB results was 22% (20/93): 10% (9/90) in pulmonary samples and 20% (1/5) in extrapulmonary samples. A total of 86 and 91 samples were used to evaluate Xpert-Ultra on stools and urine, respectively. Compared to GS, sensitivity and specificity on stools were 87.5% (95%CI:52.9-97.8) and 100% (95%CI: 95.3-100), whereas on urine were 30% (95%CI:10.8-60.3) and 100% (95%CI:95.5-100), respectively. No patients were positive in stools or urine and negative with GS.
CONCLUSIONS
Xpert-Ultra in stools showed high sensitivity and specificity in HIV-infected children when compared to gold standard. Sensitivity of urine was low, but more research is needed to determine its clinical indication.
Over half of childhood tuberculosis (TB) remains undiagnosed yearly. TB culture is often unavailable. WHO recommends Xpert-Ultra as first test for diagnosis of paediatric TB, but microbiological confirmation remains low and often requires invasive procedures. We aimed to determine the utility of Xpert-Ultra in stools and urine samples to diagnose TB in children living with HIV (CLWH) in two high-TB burden settings.
METHODS
This cross-sectional multicentric study took place at Simão Mendes hospital, Guinea-Bissau, from July 2019 to April 2020, and in Malakal hospitals, South Sudan, from November 2019 to June 2023. Children 6 months to 15 years with suspected TB underwent clinical and laboratory assessment, with one respiratory or extrapulmonary sample (gold standard (GS)), one stool and one urine specimen per patient analysed with Xpert-Ultra.
RESULTS
A total of 93 HIV-positive children were enrolled from Bissau (n=57) and Malakal (n=36), with 49 (53%) females and median (IQR) age of 3.3 (1.5-10) years. Three-quarters of children had severe acute malnutrition (SAM). A total of 72 (77%) children were on ART at baseline and 26/77 (34%) had CD4 count <200cells/mm3. Confirmation of TB was achieved in 20 (22%); 51 (55%) had unconfirmed TB, and 22 (24%) had unlikely TB. Of 93 children with GS diagnosis, the overall yield of positive TB results was 22% (20/93): 10% (9/90) in pulmonary samples and 20% (1/5) in extrapulmonary samples. A total of 86 and 91 samples were used to evaluate Xpert-Ultra on stools and urine, respectively. Compared to GS, sensitivity and specificity on stools were 87.5% (95%CI:52.9-97.8) and 100% (95%CI: 95.3-100), whereas on urine were 30% (95%CI:10.8-60.3) and 100% (95%CI:95.5-100), respectively. No patients were positive in stools or urine and negative with GS.
CONCLUSIONS
Xpert-Ultra in stools showed high sensitivity and specificity in HIV-infected children when compared to gold standard. Sensitivity of urine was low, but more research is needed to determine its clinical indication.
Conference Material > Slide Presentation
Fidelle L, Mahajan R, Gallo J, Biague E, Goncalves R, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/rZE9YDiu3
Journal Article > ResearchFull Text
Open Forum Infect Dis. 2 May 2024; Volume 11 (Issue 5); ofae221.; DOI:10.1093/ofid/ofae221
Moretó-Planas L, Mahajan R, Fidelle Nyikayo L, Ajack YBP, Tut Chol B, et al.
Open Forum Infect Dis. 2 May 2024; Volume 11 (Issue 5); ofae221.; DOI:10.1093/ofid/ofae221
BACKGROUND
Over half of childhood tuberculosis (TB) remains undiagnosed yearly. WHO recommends Xpert-Ultra as a first paediatric diagnosis test, but microbiological confirmation remains low. We aimed to determine the diagnostic performance of Xpert-Ultra on stool and urine in presumptive paediatric TB cases in two high-TB burden settings.
METHODS
This Médecins sans Frontières cross-sectional multicentric study took place at Simão Mendes hospital, Guinea-Bissau (July 2019 to April 2020) and in Malakal hospital, South Sudan (April 2021 to June 2023). Children 6 months to 15 years with presumptive TB underwent clinical and laboratory assessment, with one respiratory and/or extrapulmonary sample (gold standard (GS)), one stool and one urine specimen analysed with Xpert-Ultra.
RESULTS
A total of 563 children were enrolled in the study, 133 from Bissau, 400 from Malakal; 30 were excluded. Confirmation of TB was achieved in 75 (14.1%) while 248 (46.5%) had unconfirmed TB. Of 553 with GS specimen, the overall diagnostic yield was 12.4% (66/533). A total of 493 and 524 samples were used to evaluate Xpert-Ultra on stool and on urine, respectively. Compared to GS, sensitivity and specificity of Xpert-Ultra on stool were 62.5%(95%CI:49.4-74) and 98.3%(95%CI:96.7-99.2), whereas on urine were 13.9%(95%CI:7.5-24.3) and 99.4%(95%CI:98.1-99.8), respectively. Nine patients were positive on stool and/or urine but negative on GS.
CONCLUSIONS
Xpert-Ultra on stool showed moderate to high sensitivity and high specificity when compared to GS and an added diagnostic yield when GS was negative. Xpert-Ultra on stool was useful in extrapulmonary cases. Xpert-Ultra in urine showed low test performance.
Over half of childhood tuberculosis (TB) remains undiagnosed yearly. WHO recommends Xpert-Ultra as a first paediatric diagnosis test, but microbiological confirmation remains low. We aimed to determine the diagnostic performance of Xpert-Ultra on stool and urine in presumptive paediatric TB cases in two high-TB burden settings.
METHODS
This Médecins sans Frontières cross-sectional multicentric study took place at Simão Mendes hospital, Guinea-Bissau (July 2019 to April 2020) and in Malakal hospital, South Sudan (April 2021 to June 2023). Children 6 months to 15 years with presumptive TB underwent clinical and laboratory assessment, with one respiratory and/or extrapulmonary sample (gold standard (GS)), one stool and one urine specimen analysed with Xpert-Ultra.
RESULTS
A total of 563 children were enrolled in the study, 133 from Bissau, 400 from Malakal; 30 were excluded. Confirmation of TB was achieved in 75 (14.1%) while 248 (46.5%) had unconfirmed TB. Of 553 with GS specimen, the overall diagnostic yield was 12.4% (66/533). A total of 493 and 524 samples were used to evaluate Xpert-Ultra on stool and on urine, respectively. Compared to GS, sensitivity and specificity of Xpert-Ultra on stool were 62.5%(95%CI:49.4-74) and 98.3%(95%CI:96.7-99.2), whereas on urine were 13.9%(95%CI:7.5-24.3) and 99.4%(95%CI:98.1-99.8), respectively. Nine patients were positive on stool and/or urine but negative on GS.
CONCLUSIONS
Xpert-Ultra on stool showed moderate to high sensitivity and high specificity when compared to GS and an added diagnostic yield when GS was negative. Xpert-Ultra on stool was useful in extrapulmonary cases. Xpert-Ultra in urine showed low test performance.
Journal Article > ResearchFull Text
Front Epidemiol. 21 March 2024; Volume 4; 1309149.; DOI:10.3389/fepid.2024.1309149
Gutierrez R, Landa M, Sambou M, Bassane H, Dia N, et al.
Front Epidemiol. 21 March 2024; Volume 4; 1309149.; DOI:10.3389/fepid.2024.1309149
BACKGROUND
With growing use of parasitological tests to detect malaria and decreasing incidence of the disease in Africa; it becomes necessary to increase the understanding of causes of non-malaria acute febrile illness (NMAFI) towards providing appropriate case management. This research investigates causes of NMAFI in pediatric out-patients in rural Guinea-Bissau.
METHODS
Children 0–5 years presenting acute fever (≥38°) or history of fever, negative malaria rapid diagnostic test (mRDT) and no signs of specific disease were recruited at the out-patient clinic of 3 health facilities in Bafatá province during 54 consecutive weeks (dry and rainy season). Medical history was recorded and blood, nasopharyngeal, stool and urine samples were collected and tested for the presence of 38 different potential aetiological causes of fever.
RESULTS
Samples from 741 children were analysed, the protocol was successful in determining a probable aetiological cause of acute fever in 544 (73.61%) cases. Respiratory viruses were the most frequently identified pathogens, present in the nasopharynx samples of 435 (58.86%) cases, followed by bacteria detected in 167 (22.60%) samples. Despite presenting negative mRDTs, P. falciparum was identified in samples of 24 (3.25%) patients.
CONCLUSIONS
This research provides a description of the aetiological causes of NMAFI in West African context. Evidence of viral infections were more commonly found than bacteria or parasites.
With growing use of parasitological tests to detect malaria and decreasing incidence of the disease in Africa; it becomes necessary to increase the understanding of causes of non-malaria acute febrile illness (NMAFI) towards providing appropriate case management. This research investigates causes of NMAFI in pediatric out-patients in rural Guinea-Bissau.
METHODS
Children 0–5 years presenting acute fever (≥38°) or history of fever, negative malaria rapid diagnostic test (mRDT) and no signs of specific disease were recruited at the out-patient clinic of 3 health facilities in Bafatá province during 54 consecutive weeks (dry and rainy season). Medical history was recorded and blood, nasopharyngeal, stool and urine samples were collected and tested for the presence of 38 different potential aetiological causes of fever.
RESULTS
Samples from 741 children were analysed, the protocol was successful in determining a probable aetiological cause of acute fever in 544 (73.61%) cases. Respiratory viruses were the most frequently identified pathogens, present in the nasopharynx samples of 435 (58.86%) cases, followed by bacteria detected in 167 (22.60%) samples. Despite presenting negative mRDTs, P. falciparum was identified in samples of 24 (3.25%) patients.
CONCLUSIONS
This research provides a description of the aetiological causes of NMAFI in West African context. Evidence of viral infections were more commonly found than bacteria or parasites.
Journal Article > ReviewFull Text
E Clinical Medicine. 11 March 2024; Volume 70; 102508.; DOI:10.1016/j.eclinm.2024.102508
Ruef M, Emonet S, Merglen A, Dewez JE, Obama BM, et al.
E Clinical Medicine. 11 March 2024; Volume 70; 102508.; DOI:10.1016/j.eclinm.2024.102508
BACKGROUND
The increasing resistance of Enterobacterales to third-generation cephalosporins and carbapenems in sub-Saharan Africa (SSA) is a major public health concern. We did a systematic review and meta-analysis of studies to estimate the carriage prevalence of Enterobacterales not susceptible to third-generation cephalosporins or carbapenems among paediatric populations in SSA.
METHODS
We performed a systematic literature review and meta-analysis of cross-sectional and cohort studies to estimate the prevalence of childhood (0-18 years old) carriage of extended-spectrum cephalosporin-resistant Enterobacterales (ESCR-E) or carbapenem-resistant Enterobacterales (CRE) in SSA. Medline, EMBASE and the Cochrane Library were searched for studies published from 1 January 2005 to 1 June 2022. Studies with <10 occurrences per bacteria, case reports, and meta-analyses were excluded. Quality and risk of bias were assessed using the Newcastle-Ottawa scale. Meta-analyses of prevalences and odds ratios were calculated using generalised linear mixed-effects models. Heterogeneity was assessed using I2 statistics. The protocol is available on PROSPERO (CRD42021260157).
FINDINGS
Of 1111 studies examined, 40 met our inclusion criteria, reporting on the carriage prevalence of Enterobacterales in 9408 children. The pooled carriage prevalence of ESCR-E was 32.2% (95% CI: 25.2%-40.2%). Between-study heterogeneity was high (I2 = 96%). The main sources of bias pertained to participant selection and the heterogeneity of the microbiological specimens. Carriage proportions were higher among sick children than healthy ones (35.7% vs 16.9%). The pooled proportion of nosocomial acquisition was 53.8% (95% CI: 32.1%-74.1%) among the 922 children without ESCR-E carriage at hospital admission. The pooled odds ratio of ESCR-E carriage after antibiotic treatment within the previous 3 months was 3.20 (95% CI: 2.10-4.88). The proportion of pooled carbapenem-resistant for Enterobacterales was 3.6% (95% CI: 0.7%-16.4%).
INTERPRETATION
This study suggests that ESCR-E carriage among children in SSA is frequent. Microbiology capacity and infection control must be scaled-up to reduce the spread of those multidrug-resistant microorganisms.
The increasing resistance of Enterobacterales to third-generation cephalosporins and carbapenems in sub-Saharan Africa (SSA) is a major public health concern. We did a systematic review and meta-analysis of studies to estimate the carriage prevalence of Enterobacterales not susceptible to third-generation cephalosporins or carbapenems among paediatric populations in SSA.
METHODS
We performed a systematic literature review and meta-analysis of cross-sectional and cohort studies to estimate the prevalence of childhood (0-18 years old) carriage of extended-spectrum cephalosporin-resistant Enterobacterales (ESCR-E) or carbapenem-resistant Enterobacterales (CRE) in SSA. Medline, EMBASE and the Cochrane Library were searched for studies published from 1 January 2005 to 1 June 2022. Studies with <10 occurrences per bacteria, case reports, and meta-analyses were excluded. Quality and risk of bias were assessed using the Newcastle-Ottawa scale. Meta-analyses of prevalences and odds ratios were calculated using generalised linear mixed-effects models. Heterogeneity was assessed using I2 statistics. The protocol is available on PROSPERO (CRD42021260157).
FINDINGS
Of 1111 studies examined, 40 met our inclusion criteria, reporting on the carriage prevalence of Enterobacterales in 9408 children. The pooled carriage prevalence of ESCR-E was 32.2% (95% CI: 25.2%-40.2%). Between-study heterogeneity was high (I2 = 96%). The main sources of bias pertained to participant selection and the heterogeneity of the microbiological specimens. Carriage proportions were higher among sick children than healthy ones (35.7% vs 16.9%). The pooled proportion of nosocomial acquisition was 53.8% (95% CI: 32.1%-74.1%) among the 922 children without ESCR-E carriage at hospital admission. The pooled odds ratio of ESCR-E carriage after antibiotic treatment within the previous 3 months was 3.20 (95% CI: 2.10-4.88). The proportion of pooled carbapenem-resistant for Enterobacterales was 3.6% (95% CI: 0.7%-16.4%).
INTERPRETATION
This study suggests that ESCR-E carriage among children in SSA is frequent. Microbiology capacity and infection control must be scaled-up to reduce the spread of those multidrug-resistant microorganisms.
Conference Material > Poster
Moreto-Planas L, Mahajan R, Sagrado MJ, Flevaud L, Gallo J, et al.
MSF Scientific Day International 2023. 7 June 2023; DOI:10.57740/0xmg-7p42
Journal Article > ResearchFull Text
Public Health Nutr. 1 June 2023; Volume 26 (Issue 6); 1210-1221.; DOI:10.1017/S1368980023000149
Briend A, Myatt M, Berkley JA, Black RE, Boyd EM, et al.
Public Health Nutr. 1 June 2023; Volume 26 (Issue 6); 1210-1221.; DOI:10.1017/S1368980023000149
OBJECTIVE
To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children.
DESIGN
Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations.
SETTING
Community-based, prospective studies from twelve countries in Africa and Asia.
PARTICIPANTS
Children aged 6–59 months living in the study areas.
RESULTS
For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone.
CONCLUSIONS
Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.
To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children.
DESIGN
Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations.
SETTING
Community-based, prospective studies from twelve countries in Africa and Asia.
PARTICIPANTS
Children aged 6–59 months living in the study areas.
RESULTS
For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone.
CONCLUSIONS
Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.
Journal Article > ResearchFull Text
BMJ Open. 19 May 2023; Volume 13 (Issue 5); e066937.; DOI:10.1136/bmjopen-2022-066937
Moretó-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
BMJ Open. 19 May 2023; Volume 13 (Issue 5); e066937.; DOI:10.1136/bmjopen-2022-066937
OBJECTIVE
Description of tuberculosis (TB)-focused point-of-care ultrasound (POCUS) findings for children with presumptive TB.
DESIGN
Cross-sectional study (July 2019 to April 2020).
SETTING
Simão Mendes hospital in Bissau, a setting with high TB, HIV, and malnutrition burdens.
PARTICIPANTS
Patients aged between 6 months and 15 years with presumptive TB.
INTERVENTIONS
Participants underwent clinical, laboratory and unblinded clinician-performed POCUS assessments, to assess subpleural nodules (SUNs), lung consolidation, pleural and pericardial effusion, abdominal lymphadenopathy, focal splenic and hepatic lesions and ascites. Presence of any sign prompted a POCUS positive result. Ultrasound images and clips were evaluated by expert reviewers and, in case of discordance, by a second reviewer. Children were categorised as confirmed TB (microbiological diagnosis), unconfirmed TB (clinical diagnosis) or unlikely TB. Ultrasound findings were analysed per TB category and risk factor: HIV co-infection, malnutrition and age.
RESULTS
A total of 139 children were enrolled, with 62 (45%) women and 55 (40%) aged <5 years; 83 (60%) and 59 (42%) were severely malnourished (SAM) and HIV-infected, respectively. TB confirmation occurred in 27 (19%); 62 (45%) had unconfirmed TB and 50 (36%) had unlikely TB. Children with TB were more likely to have POCUS-positive results (93%) compared with children with unlikely TB (34%). Common POCUS signs in patients with TB were: lung consolidation (57%), SUNs (55%) and pleural effusion (30%), and focal splenic lesions (28%). In children with confirmed TB, POCUS sensitivity was 85% (95% CI) (67.5% to 94.1%). In those with unlikely TB, specificity was 66% (95% CI 52.2% to 77.6%). Unlike HIV infection and age, SAM was associated with a higher POCUS-positivity. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9.
CONCLUSIONS
We found a high prevalence of POCUS signs in children with TB compared with children with unlikely TB. POCUS-positivity was dependent on nutritional status but not on HIV status or age. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
Description of tuberculosis (TB)-focused point-of-care ultrasound (POCUS) findings for children with presumptive TB.
DESIGN
Cross-sectional study (July 2019 to April 2020).
SETTING
Simão Mendes hospital in Bissau, a setting with high TB, HIV, and malnutrition burdens.
PARTICIPANTS
Patients aged between 6 months and 15 years with presumptive TB.
INTERVENTIONS
Participants underwent clinical, laboratory and unblinded clinician-performed POCUS assessments, to assess subpleural nodules (SUNs), lung consolidation, pleural and pericardial effusion, abdominal lymphadenopathy, focal splenic and hepatic lesions and ascites. Presence of any sign prompted a POCUS positive result. Ultrasound images and clips were evaluated by expert reviewers and, in case of discordance, by a second reviewer. Children were categorised as confirmed TB (microbiological diagnosis), unconfirmed TB (clinical diagnosis) or unlikely TB. Ultrasound findings were analysed per TB category and risk factor: HIV co-infection, malnutrition and age.
RESULTS
A total of 139 children were enrolled, with 62 (45%) women and 55 (40%) aged <5 years; 83 (60%) and 59 (42%) were severely malnourished (SAM) and HIV-infected, respectively. TB confirmation occurred in 27 (19%); 62 (45%) had unconfirmed TB and 50 (36%) had unlikely TB. Children with TB were more likely to have POCUS-positive results (93%) compared with children with unlikely TB (34%). Common POCUS signs in patients with TB were: lung consolidation (57%), SUNs (55%) and pleural effusion (30%), and focal splenic lesions (28%). In children with confirmed TB, POCUS sensitivity was 85% (95% CI) (67.5% to 94.1%). In those with unlikely TB, specificity was 66% (95% CI 52.2% to 77.6%). Unlike HIV infection and age, SAM was associated with a higher POCUS-positivity. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9.
CONCLUSIONS
We found a high prevalence of POCUS signs in children with TB compared with children with unlikely TB. POCUS-positivity was dependent on nutritional status but not on HIV status or age. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
Journal Article > ResearchFull Text
AIDS Res Hum Retroviruses. 11 April 2023; Volume 10 (Issue 1); 1-6.; DOI:10.24966/CMPH-1978/1000125
Temessadouno FW, Hiffler L, Gallo J, Gignoux EM, Domenichini C, et al.
AIDS Res Hum Retroviruses. 11 April 2023; Volume 10 (Issue 1); 1-6.; DOI:10.24966/CMPH-1978/1000125
CONTEXT
The Paediatric Early Warning System (PEWS) is a clinical monitoring tool used routinely in emergency and observation rooms to detect rapid deterioration in paediatric patients, allowing timely action. MSF has been using an adapted version of PEWS in all paediatric projects since 2013 and started using it in the Simao Mendes National Hospital (HNSM) in 2017. The PEWS has not been previously considered as a predictive tool for mortality risk. In this study, we evaluate whether the PEWS could be validated as a paediatric mortality risk score in our Paediatric Intensive Care Unit (PICU) setting.
METHODS
This is an observational study with prospective data collection among children admitted to the HNSM PICU, assessing an adapted version of PEWS on admission, 24 hours after admission, and notification of the outcome of the hospitalization. Data analysis, using State 15.0, was conducted in three stages: description of participants, univariate analysis, and multivariate analysis.
RESULTS
The main analysis showed that the greater the PEWS score, the higher the risk of death. However, only a PEWS score >7 was significantly associated with an increased risk of death, OR =5.9; 95% CI: 2.3 - 12.9, p < 0.001. In addition, having an underlying pathology increased the risk of death, OR=4.2; 95% CI: 1.3 - 13.2, p=0.015. Age was not significantly associated with increased risk of death, which may be due to the small sample size of patients less than one year old. A PEWS score greater than five, 24 hours after admission, indicated a significantly higher risk of death, OR=6.2; 95% CI: 2.8 - 13.6, p < 0.001.
CONCLUSION
Our evaluation of PEWS among children on admission to the PICU found that it could be a simple and useful predictive tool of mortality risk in low resource settings. It may allow better organization of the human resources, and improve the analysis of the mortality ratio, in a PICU. However, adequate follow-up and management of those classified as orange, yellow, or even green by the PEWS should be maintained as the PEWS would fail to identify a significant proportion of patients at risk of death.
The Paediatric Early Warning System (PEWS) is a clinical monitoring tool used routinely in emergency and observation rooms to detect rapid deterioration in paediatric patients, allowing timely action. MSF has been using an adapted version of PEWS in all paediatric projects since 2013 and started using it in the Simao Mendes National Hospital (HNSM) in 2017. The PEWS has not been previously considered as a predictive tool for mortality risk. In this study, we evaluate whether the PEWS could be validated as a paediatric mortality risk score in our Paediatric Intensive Care Unit (PICU) setting.
METHODS
This is an observational study with prospective data collection among children admitted to the HNSM PICU, assessing an adapted version of PEWS on admission, 24 hours after admission, and notification of the outcome of the hospitalization. Data analysis, using State 15.0, was conducted in three stages: description of participants, univariate analysis, and multivariate analysis.
RESULTS
The main analysis showed that the greater the PEWS score, the higher the risk of death. However, only a PEWS score >7 was significantly associated with an increased risk of death, OR =5.9; 95% CI: 2.3 - 12.9, p < 0.001. In addition, having an underlying pathology increased the risk of death, OR=4.2; 95% CI: 1.3 - 13.2, p=0.015. Age was not significantly associated with increased risk of death, which may be due to the small sample size of patients less than one year old. A PEWS score greater than five, 24 hours after admission, indicated a significantly higher risk of death, OR=6.2; 95% CI: 2.8 - 13.6, p < 0.001.
CONCLUSION
Our evaluation of PEWS among children on admission to the PICU found that it could be a simple and useful predictive tool of mortality risk in low resource settings. It may allow better organization of the human resources, and improve the analysis of the mortality ratio, in a PICU. However, adequate follow-up and management of those classified as orange, yellow, or even green by the PEWS should be maintained as the PEWS would fail to identify a significant proportion of patients at risk of death.
Journal Article > ResearchFull Text
Public Health Nutr. 3 February 2023; Volume 26 (Issue 4); 803-819.; DOI:10.1017/S136898002300023X
Khara T, Myatt M, Sadler K, Bahwere P, Berkley JA, et al.
Public Health Nutr. 3 February 2023; Volume 26 (Issue 4); 803-819.; DOI:10.1017/S136898002300023X
OBJECTIVE
To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme implications.
DESIGN
A multiple cohort individual data meta-analysis of mortality risk (within 6 months of measurement) by anthropometric case definitions. Sensitivity, specificity, informedness and inclusivity in predicting mortality, face validity and compatibility with current standards and practice were assessed and operational consequences were modelled.
SETTING
Community-based cohort studies in twelve low-income countries between 1977 and 2013 in settings where treatment of wasting was not widespread.
PARTICIPANTS
Children aged 6 to 59 months.
RESULTS
Of the twelve anthropometric case definitions examined, four (weight-for-age Z-score (WAZ) <−2), (mid-upper arm circumference (MUAC) <125 mm), (MUAC < 115 mm or WAZ < −3) and (WAZ < −3) had the highest informedness in predicting mortality. A combined case definition (MUAC < 115 mm or WAZ < −3) was better at predicting deaths associated with weight-for-height Z-score <−3 and concurrent wasting and stunting (WaSt) than the single WAZ < −3 case definition. After the assessment of all criteria, the combined case definition performed best. The simulated workload for programmes admitting based on MUAC < 115 mm or WAZ < −3, when adjusted with a proxy for required intensity and/or duration of treatment, was 1·87 times larger than programmes admitting on MUAC < 115 mm alone.
CONCLUSIONS
A combined case definition detects nearly all deaths associated with severe anthropometric deficits suggesting that therapeutic feeding programmes may achieve higher impact (prevent mortality and improve coverage) by using it. There remain operational questions to examine further before wide-scale adoption can be recommended.
To understand which anthropometric diagnostic criteria best discriminate higher from lower risk of death in children and explore programme implications.
DESIGN
A multiple cohort individual data meta-analysis of mortality risk (within 6 months of measurement) by anthropometric case definitions. Sensitivity, specificity, informedness and inclusivity in predicting mortality, face validity and compatibility with current standards and practice were assessed and operational consequences were modelled.
SETTING
Community-based cohort studies in twelve low-income countries between 1977 and 2013 in settings where treatment of wasting was not widespread.
PARTICIPANTS
Children aged 6 to 59 months.
RESULTS
Of the twelve anthropometric case definitions examined, four (weight-for-age Z-score (WAZ) <−2), (mid-upper arm circumference (MUAC) <125 mm), (MUAC < 115 mm or WAZ < −3) and (WAZ < −3) had the highest informedness in predicting mortality. A combined case definition (MUAC < 115 mm or WAZ < −3) was better at predicting deaths associated with weight-for-height Z-score <−3 and concurrent wasting and stunting (WaSt) than the single WAZ < −3 case definition. After the assessment of all criteria, the combined case definition performed best. The simulated workload for programmes admitting based on MUAC < 115 mm or WAZ < −3, when adjusted with a proxy for required intensity and/or duration of treatment, was 1·87 times larger than programmes admitting on MUAC < 115 mm alone.
CONCLUSIONS
A combined case definition detects nearly all deaths associated with severe anthropometric deficits suggesting that therapeutic feeding programmes may achieve higher impact (prevent mortality and improve coverage) by using it. There remain operational questions to examine further before wide-scale adoption can be recommended.