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ObjectivesAccurate and timely diagnosis of common neonatal conditions is crucial for reducing neonatal deaths. In low/middle-income countries with limited resources, there is sparse information on how neonatal diagnoses are made. The aim of this study was to describe the diagnostic criteria used for common conditions in neonatal units (NNUs) in Nigeria and Kenya.DesignProspective observational study. Standard case report forms for suspected sepsis, respiratory disorders, birth asphyxia and abdominal conditions were co-developed by the Neonatal Nutrition Network (https://www.lstmed.ac.uk/nnu) collaborators. Clinicians completed forms for all admissions to their NNUs. Key data were displayed using heatmaps.SettingFive NNUs in Nigeria and two in Kenya comprising the Neonatal Nutrition Network.Participants2851 neonates, which included all neonates admitted to the seven NNUs over a 6-month period.Results1230 (43.1%) neonates had suspected sepsis, 874 (30.6%) respiratory conditions, 587 (20.6%) birth asphyxia and 71 (2.5%) abdominal conditions. For all conditions and across all NNUs, clinical criteria were used consistently with sparse use of laboratory and radiological criteria.ConclusionOur findings highlight the reliance on clinical criteria and extremely limited use of diagnostic technologies for common conditions in NNUs in sub-Saharan Africa. This has implications for the management of neonatal conditions which often have overlapping clinical features. Strategies for implementation of diagnostic pathways and investment in affordable and sustainable diagnostics are needed to improve care for these vulnerable infants.

BackgroundPreterm (born < 37 weeks’ gestation) and very low birthweight (VLBW; AimTo identify factors that influence the time to full enteral feeds, defined as tolerance of 120ml/kg/day, in hospitalised preterm and VLBW infants in neonatal units in two sub-Saharan African countries.MethodsDemographic and clinical variables were collected for newborns admitted to 7 neonatal units in Nigeria and Kenya over 6-months. Multiple linear regression analysis was conducted to identify factors independently associated with time to full enteral feeds.ResultsOf the 2280 newborn infants admitted, 484 were preterm and VLBW. Overall, 222/484 (45.8%) infants died with over half of the deaths (136/222; 61.7%) occurring before the first feed. The median (inter-quartile range) time to first feed was 46 (27, 72) hours of life and time to full enteral feeds (tFEF) was 8 (4.5,12) days with marked variation between neonatal units. Independent predictors of tFEF were time to first feed (unstandardised coefficient B 1.75; 95% CI 1.16 to 2.34; p value ConclusionThe use of standardised feeding guidelines may decrease variations in clinical practice, shorten tFEF and thereby improve newborn outcomes.

Background Carriers of persistent asymptomatic Plasmodium falciparum infections constitute an infectious reservoir that maintains malaria transmission. Understanding the extent of carriage and characteristics of carriers specific to endemic areas could guide use of interventions to reduce infectious reservoir. Methods In eastern Gambia, an all-age cohort from four villages was followed up from 2012 to 2016. Each year, cross-sectional surveys were conducted at the start and end of the malaria transmission season to determine asymptomatic P. falciparum carriage by microscopy while passive case detection was conducted during the transmission to determine incidence of clinical malaria. Association between carriage at the end of a season and at the start of the next and risk factors for this were assessed. Effect of carriage at the start of the season on risk of clinical malaria during the season was also examined. Results A total of 1403 individuals − 1154 from a semi-urban village and 249 from three rural villages were enrolled; median age was 12 years (IQR 6, 30) and 12 years (IQR 7, 27) respectively. In adjusted analysis, asymptomatic P. falciparum carriage at the end of a transmission season and at the start of the next were strongly associated (OR = 19.99; 95% CI 12.57–31.77, P P. falciparum carriage at the end of a transmission season strongly predicts carriage at the start the next season. Odds of carriage across seasons was higher in villages with relatively higher transmission and in older children. Interventions that reduce persistent asymptomatic infections can be applied in a targeted manner and may supress the initiation of yearly seasonal malaria transmission.

Objective To describe the patient population, priority diseases and outcomes in newborns admitted Study design In a network of seven secondary and tertiary level neonatal units in Nigeria and Kenya, we captured anonymised data on all admissions Results 2280 newborns were admitted. Mean birthweight was 2.3 kg (SD 0.9); 57.0% (1214/2128) infants were low birthweight (LBW; Conclusion Greater efforts are needed to address the very high burden of illnesses and mortality in hospitalized newborns in sub-Saharan Africa. Interventions need to address priority issues during pregnancy and delivery as well as in the newborn.

GMZ2 is a recombinant protein malaria vaccine, comprising two blood-stage antigens of Plasmodium falciparum, glutamate-rich protein and merozoite surface protein 3. We assessed efficacy of GMZ2 in children in Burkina Faso, Gabon, Ghana and Uganda. : Children 12-60months old were randomized to receive three injections of either 100μg GMZ2 adjuvanted with aluminum hydroxide or a control vaccine (rabies) four weeks apart and were followed up for six months to measure the incidence of malaria defined as fever or history of fever and a parasite density ⩾5000/μL. : A cohort of 1849 children were randomized, 1735 received three doses of vaccine (868 GMZ2, 867 control-vaccine). There were 641 malaria episodes in the GMZ2/Alum group and 720 in the control group. In the ATP analysis, vaccine efficacy (VE), adjusted for age and site was 14% (95% confidence interval [CI]: 3.6%, 23%, p-value=0.009). In the ITT analysis, age-adjusted VE was 11.3% (95% CI 2.5%, 19%, p-value=0.013). VE was higher in older children. In GMZ2-vaccinated children, the incidence of malaria decreased with increasing vaccine-induced anti-GMZ2 IgG concentration. There were 32 cases of severe malaria (18 in the rabies vaccine group and 14 in the GMZ2 group), VE 27% (95% CI -44%, 63%). : GMZ2 is the first blood-stage malaria vaccine to be evaluated in a large multicenter trial. GMZ2 was well tolerated and immunogenic, and reduced the incidence of malaria, but efficacy would need to be substantially improved, using a more immunogenic formulation, for the vaccine to have a public health role.

Multilingual abstract in the five official working languages of the United Nations. (PDF 446Â kb)

With the paradigm shift from the reduction of morbidity and mortality to the interruption of transmission, the focus of malaria control broadens from symptomatic infections in children ≤ 5 years of age to include asymptomatic infections in older children and adults. In addition, as control efforts intensify and the number of interventions increases, there will be decreases in prevalence, incidence and transmission with additional decreases in morbidity and mortality. Expected secondary consequences of these changes include upward shifts in the peak ages for infection (parasitemia) and disease, increases in the ages for acquisition of antiparasite humoral and cellular immune responses and increases in false-negative blood smears and rapid diagnostic tests. Strategies to monitor these changes must include: 1] studies of the entire population (that are not restricted to children ≤ 5 or ≤ 10 years of age), 2] study sites in both cities and rural areas (because of increasing urbanization across sub-Saharan Africa) and 3] innovative strategies for surveillance as the prevalence of infection decreases and the frequency of false-negative smears and rapid diagnostic tests increases.

Background Haematological and biochemistry reference values for children are important for interpreting clinical and research results however, differences in demography and environment poses a challenge when comparing results. The study defines reference intervals for haematological and biochemistry parameters and examines the effect of seasonality in malaria transmission. Methods Blood samples collected from clinically healthy children, aged 12–59 months, in two surveys during the dry and wet season in the Upper River region of The Gambia were processed and the data analysed to generate reference intervals based on the 2.5th and 97.5th percentiles of the data. Results Analysis was based on data from 1141 children with median age of 32 months. The mean values for the total white cell count and differentials; lymphocyte, monocyte and neutrophil decreased with increasing age, were lower in males and higher in the wet season survey. However, platelet values declined with age (p

Median and reference intervals (2.5th-97.5th) for all haematology and biochemistry parameters over age, by gender and/or season. (PDF 1045 kb)

Proportions of observations below predicted percentiles from models with and without outliers. (DOC 64 kb)

A study was conducted in 1997 to compare the accuracy of presumptive diagnosis of malaria in children aged 1–9 years performed by caretakers of the children to that of health centre staff in 2 ecological zones in southern Ghana. Similar symptoms were reported in the children at home and at the health centre. In the home setting, symptoms were reported the same day that they occurred, 77·6% of the children with a report of fever were febrile (axillary temperature ⩾37·5 °C) and 64·7% of the reports of malaria were parasitologically confirmed. In the health centre, the median duration of symptoms before a child was seen was 3 days (range 1–14 days), 58·5% of the children with a report of fever were febrile and 62·6% of the clinically diagnosed cases were parasitologically confirmed. In the 2 settings almost all the infections were due to Plasmodium falciparum . Parasite density was 3 times higher in the health centre cases compared to the home-diagnosed cases. Early and appropriate treatment of malaria detected in children by caretakers may prevent complications that arise as a result of persistence of symptoms and attainment of high parasitaemic levels.

Background Involvement in clinical research requires evidence of informed participant consent, and in many low-income countries with high illiteracy rates, this is done by a fingerprint impression on paper. Due to poor quality of the impression, the individual is often untraceable and this reduces the quality of the process. The study assesses the potential usefulness of fingerprints for consenting and automated participant identification. Methods As part of a survey in villages in the North Bank West region of The Gambia, individuals of all ages were invited to provide a fingerprint scan to update the pre-trial census records. Using commercial software, scanned impressions were stored on encrypted templates and linked to a unique identifier. A scan is successful if any of the five fingers on the left hand is captured but documented as a failure if none of the five fingers on the left hand records an impression on the scanner. We determined the proportion of successful attempts, and the effect of age and gender on the successful scan using a logistic regression model. Results A total of 5204 persons were scanned with 74.7% successes for any finger; 70.3% (1550/2206) in males and 78.0% (2339/2998) in females and gender was strongly associated with success rate (Chi2 0.001) and highest between ages 5–25 years (OR 8.32; 95% CI: 6.96–9.95; p Conclusions The use of fingerprint-based identification is promising. However, recognition rates are lowest in adult males, perhaps due to occupational practice. Potential for improving sensitivity and application in data retrieval and documenting consent is being explored.

The study sites for the West African ICEMR are in three countries (The Gambia, Senegal, Mali) and are located within 750 km of each other. In addition, the National Malaria Control Programmes of these countries have virtually identical policies: (1) Artemisinin Combination Therapies (ACTs) for the treatment of symptomatic Plasmodium falciparum infection, (2) Long-Lasting Insecticide-treated bed Nets (LLINs) to reduce the Entomololgic Inoculation Rate (EIR), and (3) sulfadoxine-pyrimethamine for the Intermittent Preventive Treatment of malaria during pregnancy (IPTp). However, the prevalence of P. falciparum malaria and the status of malaria control vary markedly across the four sites with differences in the duration of the transmission season (from 4-5 to 10-11 months), the intensity of transmission (with EIRs from unmeasurably low to 4-5 per person per month), multiplicity of infection (from a mean of 1.0 to means of 2-5) and the status of malaria control (from areas which have virtually no control to areas that are at the threshold of malaria elimination). The most important priority is the need to obtain comparable data on the population-based prevalence, incidence and transmission of malaria before new candidate interventions or combinations of interventions are introduced for malaria control.

Summary Background Malaria is a major cause of morbidity and mortality in Africa. International effort and funding for control has been stepped up, with substantial increases from 2003 in the delivery of malaria interventions to pregnant women and children younger than 5 years in The Gambia. We investigated the changes in malaria indices in this country, and the causes and public-health significance of these changes. Methods We undertook a retrospective analysis of original records to establish numbers and proportions of malaria inpatients, deaths, and blood-slide examinations at one hospital over 9 years (January, 1999–December, 2007), and at four health facilities in three different administrative regions over 7 years (January, 2001–December, 2007). We obtained additional data from single sites for haemoglobin concentrations in paediatric admissions and for age distribution of malaria admissions. Findings From 2003 to 2007, at four sites with complete slide examination records, the proportions of malaria-positive slides decreased by 82% (3397/10861 in 2003 to 337/6142 in 2007), 85% (137/1259 to 6/368), 73% (3664/16932 to 666/11333), and 50% (1206/3304 to 336/1853). At three sites with complete admission records, the proportions of malaria admissions fell by 74% (435/2530 to 69/1531), 69% (797/2824 to 89/1032), and 27% (2204/4056 to 496/1251). Proportions of deaths attributed to malaria in two hospitals decreased by 100% (seven of 115 in 2003 to none of 117 in 2007) and 90% (22/122 in 2003 to one of 58 in 2007). Since 2004, mean haemoglobin concentrations for all-cause admissions increased by 12 g/L (85 g/L in 2000–04 to 97 g/L in 2005–07), and mean age of paediatric malaria admissions increased from 3·9 years (95% CI 3·7–4·0) to 5·6 years (5·0–6·2). Interpretation A large proportion of the malaria burden has been alleviated in The Gambia. Our results encourage consideration of a policy to eliminate malaria as a public-health problem, while emphasising the importance of accurate and continuous surveillance. Funding UK Medical Research Council.

Background\ud Non-Plasmodium falciparum malaria infections are found in many parts of sub-Saharan Africa but little is known about their importance in pregnancy.\ud \ud \ud Methods\ud Blood samples were collected at first antenatal clinic attendance from 2526 women enrolled in a trial of intermittent screening and treatment of malaria in pregnancy (ISTp) versus intermittent preventive treatment (IPTp) conducted in Burkina Faso, The Gambia, Ghana and Mali. DNA was extracted from blood spots and tested for P. falciparum, Plasmodium vivax, Plasmodium malariae and Plasmodium ovale using a nested PCR test. Risk factors for a non-falciparum malaria infection were investigated and the influence of these infections on the outcome of pregnancy was determined.\ud \ud \ud Results\ud P. falciparum infection was detected frequently (overall prevalence by PCR: 38.8 %, [95 % CI 37.0, 40.8]), with a prevalence ranging from 10.8 % in The Gambia to 56.1 % in Ghana. Non-falciparum malaria infections were found only rarely (overall prevalence 1.39 % [95 % CI 1.00, 1.92]), ranging from 0.17 % in the Gambia to 3.81 % in Mali. Ten non-falciparum mono-infections and 25 mixed falciparum and non-falciparum infections were found. P. malariae was the most frequent non-falciparum infection identified; P. vivax was detected only in Mali. Only four of the non-falciparum mono-infections were detected by microscopy or rapid diagnostic test. Recruitment during the late rainy season and low socio-economic status were associated with an increased risk of non-falciparum malaria as well as falciparum malaria. The outcome of pregnancy did not differ between women with a non-falciparum malaria infection and those who were not infected with malaria at first ANC attendance.\ud \ud \ud Conclusions\ud Non-falciparum infections were infrequent in the populations studied, rarely detected when present as a mono-infection and unlikely to have had an important impact on the outcome of pregnancy in the communities studied due to the small number of women infected with non-falciparum parasites.

Additional file 1: Table S1. Random effects analyses assessing relationship between household characteristics and presence/absence of households inside a high space-time cluster.

Additional file 1: Table S1. Random effects analyses assessing relationship between household characteristics and presence/absence of households inside a high space-time cluster.