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Background Timely and skilled care is key to reducing maternal and neonatal mortality. Birth preparedness involves preparation for safe childbirth during the antenatal period to reach the appropriate health facility for ensuring safe delivery. Hence, understanding the factors associated with birth preparedness and its significance for safe delivery is essential. This paper aims to assess the levels of birth preparedness, its determinants and association with institutional deliveries in High Priority Districts of Uttar Pradesh, India. Methods A community-based cross-sectional survey was conducted between June–October 2018 in the rural areas of 25 high priority districts of Uttar Pradesh, India. Simple random sampling was used to select 40 blocks among 294 blocks in 25 districts and 2646 primary sampling units within the selected blocks. The survey interviewed 9458 women who had a delivery 2 months prior to the survey. Descriptive statistics were included to characterize the study population. Multivariable logistic regression analyses were performed to identify the determinants of birth preparedness and to examine the association of birth preparedness with institutional delivery. Results Among the 9458 respondents, 61.8% had birth preparedness (both facility and transportation identified) and 79.1% delivered in a health facility. Women in other caste category (aOR = 1.24, CI 1.06–1.45) and those with 10 or more years of education (aOR = 1.68, CI 1.46–1.92) were more likely to have birth preparedness. Antenatal care (ANC) service uptake related factors like early registration for ANC (aOR = 1.14, CI 1.04–1.25) and three or more front line worker contacts (aOR = 1.61, CI 1.46–1.79) were also found to be significantly associated with birth preparedness. The adjusted multivariate model showed that those who identified both facility and transport were seven times more likely to undergo delivery in a health facility (aOR = 7.00, CI 6.07–8.08). Conclusion The results indicate the need for focussing on marginalized groups for improving birth preparedness. Increasing ANC registration in the first trimester of pregnancy, improving frontline worker contact, and optimum utilization of antenatal care check-ups for effective counselling on birth preparedness along with system level improvements could improve birth preparedness and consequently institutional delivery rates in Uttar Pradesh, India.

Background We assessed the effects of a nurse mentoring program on neonatal mortality in eight districts in India. Methods From 2012 to 2015, nurse mentors supported improvements in critical MNCH-related practices among health providers at primary health centres (PHCs) in northern Karnataka, South India. Baseline (n = 5240) and endline (n = 5154) surveys of randomly selected ever-married women were conducted. Neonatal mortality rates (NMR) among the last live-born children in the three years prior to each survey delivered in NM and non-NM-supported facilities were calculated and compared using survival analysis and cumulative hazard function. Mortality rates on days 1, 2–7 and 8–28 post-partum were compared. Cox survival regression analysis measured the adjusted effect on neonatal mortality of delivering in a nurse mentor supported facility. Results Overall, neonatal mortality rate in the three years preceding the baseline and endline surveys was 30.5 (95% CI 24.3–38.4) and 21.6 (95% CI 16.3–28.7) respectively. There was a substantial decline in neonatal mortality between the survey rounds among children delivered in PHCs supported by NM: 29.4 (95% CI 18.1–47.5) vs. 9.3 (95% CI 3.9–22.3) (p = 0.09). No significant declines in neonatal mortality rate were observed among children delivered in other facilities or at home. In regression analysis, among children born in nurse mentor supported facilities, the estimated hazard ratio at endline was significantly lower compared with baseline (HR: 0.23, 95% CI: 0.06–0.82, p = 0.02). Conclusion The nurse mentoring program was associated with a substantial reduction in neonatal mortality. Further research is warranted to delineate whether this may be an effective strategy for reducing NMR in resource-poor settings.

In India, frontline workers (FLWs) - public accredited social health activists (ASHAs) and private rural medical providers (RMPs) - are important for early detection and treatment of childhood diarrhoea and pneumonia. This cross-sectional study aims to measure knowledge and skills, and the gap between the two ('know-can' gap), regarding assessment of childhood diarrhoea with dehydration and pneumonia among FLWs, and to explore factors associated with them.We surveyed 473 ASHAs and 447 RMPs in six districts of Uttar Pradesh. We assessed knowledge and skills using face-to-face interviews and video vignettes, respectively, about key signs of both conditions. The 'know-can' gap corresponds to absent skills among FLWs with correct knowledge. We used logistic regression to identify the correlates of knowledge and skills.FLWs' correct knowledge ranged from 23% to 48% for dehydration signs and 27% to 37% for pneumonia signs. Their skills ranged from 3% to 42% for dehydration and 3% to 18% for pneumonia. There was a significant 'know-can' gap in all the signs, except 'sunken eyes'. Training and supervisory support was associated with better knowledge and skills for diarrhoea with dehydration, but only better knowledge for pneumonia.FLWs are crucial to the Indian health system, and high-quality FLW services are necessary for continued progress against under-five deaths. The gap between FLWs' knowledge and skills warrants immediate attention. In particular, our results suggest that knowledge-focused trainings are insufficient for FLWs to convert knowledge into appropriate assessment skills.En Inde, les travailleurs de première ligne (TPL) - activistes de la santé sociale accrédités par le public (ASSAP) et prestataires médicaux ruraux privés (PMRP) - sont importants pour la détection et le traitement précoces de la diarrhée et de la pneumonie infantiles. Cette étude transversale vise à mesurer les connaissances et les compétences, et l'écart entre les deux (écart ''savoir-pouvoir''), en ce qui concerne l'évaluation de la diarrhée infantile avec déshydratation et la pneumonie chez les TPL et à explorer les facteurs qui leur sont associés. MÉTHODES: Nous avons mené une enquête sur 473 ASSAP et 447 PMRP dans six districts de l'Uttar Pradesh. Nous avons évalué les connaissances et les compétences à l'aide d'entretiens de face à face et de vignettes vidéo, respectivement, sur les signes clés des deux conditions. L'écart «savoir-pouvoir» correspond à des compétences absentes parmi les TPL ayant des connaissances correctes. Nous avons utilisé la régression logistique pour identifier les corrélats des connaissances et des compétences. RÉSULTATS: Les connaissances correctes des TPL variaient de 23% à 48% pour les signes de déshydratation, 27% à 37% pour les signes de pneumonie. Leurs compétences variaient de 3% à 42% pour la déshydratation et de 3% à 18% pour la pneumonie. Il y avait un écart important dans le «savoir-pouvoir» pour tous les signes, à l'exception des «yeux enfoncés». La formation et le soutien à la supervision étaient associés à de meilleures connaissances et compétences pour la diarrhée avec déshydratation, mais seulement à de meilleures connaissances pour la pneumonie.Les TPL sont cruciaux pour le système de santé indien, et des services de TPL de haute qualité sont nécessaires pour continuer à lutter contre les décès d'enfants de moins de cinq ans. L'écart entre les connaissances et les compétences des TPL mérite une attention immédiate. En particulier, nos résultats suggèrent que les formations axées sur les connaissances sont insuffisantes pour que les TPL convertissent les connaissances en compétences d'évaluation appropriées.

Background Uttar Pradesh (UP), India continues to have a high burden of mortality among young children despite recent improvement. Therefore, it is vital to understand the risk factors associated with under-five (U5) deaths and episodes of severe illness in order to deliver programs targeted at decreasing mortality among U5 children in UP. However, in rural UP, almost every child has one or more commonly described risk factors, such as low socioeconomic status or undernutrition. Determining how risk factors for childhood illness and death are understood by community members, community health workers and facility staff in rural UP is important so that programs can identify the most vulnerable children. Methods This qualitative study was completed in three districts of UP that were part of a larger child health program. Twelve semi-structured interviews and 21 focus group discussions with 182 participants were conducted with community members (mothers and heads of households with U5 children), community health workers (CHWs; Accredited Social Health Activists and Auxiliary Nurse Midwives) and facility staff (medical officers and staff nurses). All interactions were recorded, transcribed and translated into English, coded and clustered by theme for analysis. The data presented are thematic areas that emerged around perceived risk factors for childhood illness and death. Results There were key differences among the three groups regarding the explanatory perspectives for identified risk factors. Some perspectives were completely divergent, such as why the location of the housing was a risk factor, whereas others were convergent, including the impact of seasonality and certain occupational factors. The classic explanatory risk factors for childhood illness and death identified in household surveys were often perceived as key risk factors by facility staff but not community members. However, overlapping views were frequently expressed by two of the groups with the CHWs bridging the perspectives of the community members and facility staff. Conclusion The bridging views of the CHWs can be leveraged to identify and focus their activities on the most vulnerable children in the communities they serve, link them to facilities when they become ill and drive innovations in program delivery throughout the community-facility continuum.

Background In 2018, 875 000 under-five children died in India with children from poor families and rural communities disproportionately affected. Community health centres are positioned to improve access to quality child health services but capacity is often low and the systems for improvements are weak. Methods Secondary analysis of child health program data from the Uttar Pradesh Technical Support Unit was used to delineate how program activities were temporally related to public facility readiness to provide child health services including inpatient admissions. Fifteen community health centres were mapped regarding capacity to provide child health services in July 2015. Mapped domains included human resources and training, infrastructure, equipment, drugs/supplies and child health services. Results were disseminated to district health managers. Six months following dissemination, Clinical Support Officers began regular supportive supervision and gaps were discussed monthly with health managers. Senior pediatric residents mentored medical officers over a three-month period. Improvements were assessed using a composite score of facility readiness for child health services in July 2016. Usage of outpatient and inpatient services by under-five children was also assessed. Results The median essential composition score increased from 0.59 to 0.78 between July 2015 and July 2016 (maximum score of 1) and the median desirable composite increased from 0.44 to 0.58. The components contributing most to the change were equipment, drugs and supplies and service provision. Scores for trained human resources and infrastructure did not change between assessments. The number of facilities providing some admission services for sick children increased from 1 in July 2015 to 9 in October 2016. Conclusions Facility readiness for the provision of child health services in Uttar Pradesh was improved with relatively low inputs and targeted assessment. However, these improvements were only translated into admissions for sick children when clinical mentoring was included in the support provided to facilities.

Background The primary aims of this study were to: 1) assess barriers and facilitators of completing scholarly projects from residents and faculty mentor perspectives, 2) determine the perceived value of new initiatives designed to support resident scholarly projects and 3) determine if these initiatives led to changes in resident publications. Design and methods Between June and September 2014, we surveyed 18 paediatric residents and 41 faculty mentors regarding barriers to resident scholarly project completion and the value of new initiatives to support scholarly activity. We also tracked scientific publications by residents before and after implementation of these initiatives. Results The primary perceived barriers to research for residents and faculty were lack of protected time (64.3% versus 68.6%, respectively), lack of resident interest in scholarly activity (50.0% versus 60.0%, respectively) and lack of mentor motivation. Mentors and residents did not agree that lack of proper training in research (29% versus 54%, respectively) and faculty motivation (29% versus 17%, respectively) were barriers to completing a project. A dedicated research coordinator (71.4% versus 70.6%, respectively), a revised research curriculum (71.4% versus 41.2%, respectively) and works in progress sessions (50.0% versus 61.8%, respectively) were perceived as valuable initiatives to the program. These initiatives were not associated with changes in annual resident publication rates. Conclusions Lack of time and competing clinical training are primary barriers to scholarly project completion for residents in addition to a lack of motivation on the part of faculty members. Improving program support was perceived as positive changes to address these barriers but did not increase resident publication rates. The information provided here could be used to tailor future resident research programs and highlight the value of gathering input from resident and faculty when designing initiatives to enhance resident research productivity.

Background On behalf of the Public Health Agency of Canada, the Committee to Advise on Tropical Medicine and Travel (CATMAT) developed the Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers for Canadian health care providers who are preparing patients for travel to malaria-endemic areas and treating travellers who have returned ill. These recommendations aim to achieve appropriate diagnosis and management of malaria, a disease that is still uncommon in Canada. Objective To provide recommendations on the appropriate diagnosis and treatment of malaria. Methods CATMAT reviewed all major sources of information on malaria diagnosis and treatment, as well as recent research and national and international epidemiological data, to tailor guidelines to the Canadian context. The evidence-based medicine recommendations were developed with associated rating scales for the strength and quality of the evidence. Recommendations Malarial management depends on rapid identification of the disease, as well as identification of the malaria species and level of parasitemia. Microscopic identification of blood samples is both rapid and accurate but can be done only by trained laboratory technicians. Rapid diagnostic tests are widely available, are simple to use and do not require specialized laboratory equipment or training; however, they do not provide the level of parasitemia and do require verification. Polymerase chain reaction (PCR), although still limited in availability, is emerging as the gold standard for high sensitivity and specificity in identifying the species.

Background: On behalf of the Public Health Agency of Canada, the Committee to Advise on Tropical Medicine and Travel (CATMAT) developed the Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers for Canadian health care providers who are preparing patients for travel to malaria-endemic areas and treating travellers who have returned ill. Objective: To provide guidelines on risk assessment and prevention of malaria Methods: CATMAT reviewed all major sources of information on malaria prevention, as well as recent research and national and international epidemiological data, to tailor guidelines to the Canadian context. The evidence- based medicine recommendations were developed with associated rating scales for the strength and quality of the evidence. Recommendations: Used together and correctly, personal protective measures (PPM) and chemoprophylaxis very effectively protect against malaria infection. PPM include protecting accommodation areas from mosquitoes, wearing appropriate clothing, using bed nets pre-treated with insecticide and applying topical insect repellant (containing 20%-30% DEET or 20% icaridin) to exposed skin. Selecting the most appropriate chemoprophylaxis involves assessment of the traveller's itinerary to establish his/her malaria risk profile as well as potential drug resistance issues. Antimalarials available on prescription in Canada include chloroquine (or hydroxychloroquine), atovaquone-proguanil, doxycycline, mefloquine and primaquine.

Background Birthing in health facilities in India has increased over the last few years, yet maternal and neonatal mortality rates remain high. Clinical mentoring with case sheets or checklists for nurses is viewed as essential for on-going knowledge transfer, particularly where basic training is inadequate. This paper summarizes a study of the effect of such a programme on staff knowledge and skills in a randomized trial of 295 nurses working in 108 Primary Health Centres (PHCs) in Karnataka, India. Methods Stratifying by district, half of the PHCs were randomly assigned to be intervention sites and provided with regular mentoring visits where case sheet/checklists were a central job and teaching aid, and half to be control sites, where no support was provided except provision of case sheets. Nurses’ knowledge and skills around normal labour, labour complications and neonate issues were tested before the intervention began and again one year later. Univariate and multivariate analyses were conducted to examine the effect of mentoring and case sheets. Results Overall, on none of the 3 measures, did case sheet use without mentoring add anything to the basic nursing training when controlling for other factors. Only individuals who used both case-sheets and received mentoring scored significantly higher on the normal labour and neonate indices, scoring almost twice as high as those who only used case-sheets. This group was also associated with significantly higher scores on the complications of labour index, with their scores 2.3 times higher on average than the case sheet only control group. Individuals from facilities with 21 or more deliveries in a month tended to fare worse on all 3 indices. There were no differences in outcomes according to district or years of experience. Conclusions This study demonstrates that provision of case sheets or checklists alone is insufficient to improve knowledge and practices. However, on-site mentoring in combination with case sheets can have a demonstrable effect on improving nurse knowledge and skills around essential obstetric and neonatal care in remote rural areas of India. We recommend scaling up of this mentoring model in order to improve staff knowledge and skills and reduce maternal and neonatal mortality in India. Trial registration This study is registered at clinicaltrials.gov, Identifier No. NCT02004912, November 27, 2013. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1933-1) contains supplementary material, which is available to authorized users.

Background Immigrant and refugee families form a growing proportion of the Canadian population and experience barriers in accessing primary health care services. The aim of this study was to examine the experiences of access to primary health care by African immigrant and refugee families. Methods Eighty-three families originating from 15 African countries took part in multiple open ended interviews in western Canada. Qualitative data was collected in six different languages between 2013 and 2015. Data analysis involved delineating units of meaning from the data, clustering units of meaning to form thematic statements, and extracting themes. Results African immigrant and refugee families experienced challenges in their quest to access primary health care that were represented by three themes: Expectations not quite met, facing a new life, and let’s buddy up to improve access. On the theme of expectations not quite met, families struggled to understand and become familiar with a new health system that presented with a number of barriers including lengthy wait times, a shortage of health care providers, high cost of medication and non-basic health care, and less than ideal care. On the theme of facing a new life, immigrant and refugee families talked of the difficulties of getting used to their new and unfamiliar environments and the barriers that impact their access to health care services. They talked of challenges related to transportation, weather, employment, language and cultural differences, and lack of social support in their quest to access health care services. Additionally, families expressed their lack of social support in accessing care. Privately sponsored families and families with children experienced even less social support. Importantly, in the theme of let’s buddy up to improve access, families recommended utilizing networking approaches to engage and improve their access to primary health care services. Conclusions African immigrant and refugee families experience barriers to accessing primary health care. To improve access, culturally relevant programs, collaborative networking approaches, and policies that focus on addressing social determinants of health are needed.

OBJECTIVE: To determine whether a simple monitoring and tracking tool, Mwanzo Mwema Monitoring and Tracking Tool (MMATT), would enable community health volunteers (CHVs) in Kenya to 1) plan their workloads and activities, 2) identify the women, newborns and children most in need of accessing critical maternal, newborn and child health (MNCH) interventions and 3) improve key MNCH indicators. METHODS: A mixed methods approach was used. Household surveys at baseline ( n = 912) and endline ( n = 1143) collected data on key MNCH indicators in the four subcounties of Taita Taveta County, Kenya. Eight focus group discussions were held with 40 CHVs to ascertain their perspectives on using the tool. RESULTS: Qualitative findings revealed that the CHVs found the MMATT to be useful in planning their activities and prioritizing beneficiaries requiring more support to access MNCH services. They also identified potential barriers to care at both the community and health system levels. At endline, previously pregnant women were more likely to have received four or more antenatal care visits, facility delivery, postnatal care within two weeks of delivery and a complete package of care than baseline respondents. Among women with children under 24 months, those at endline were more likely to report early breastfeeding and exclusive breastfeeding for the first six months. These results remained after adjustment for age, subcounty, gravida, mother’s education and asset index. CONCLUSION: Our results demonstrate that simple tools enable CHVs to identify disparities in service delivery and health outcomes, and to identify barriers to MNCH care. Tools that enhance CHVs’ ability to plan and prioritize the women and children most in need increase CHVs’ potential impact.

Travel vaccines comprise an essential component of pretravel health advice; however, many travelers do not take advantage of this preventive health strategy to decrease their risk of travel-related illness. Factors that impact on a traveler's decision on whether or not to be vaccinated are related to the knowledge, attitudes and beliefs of the traveler regarding travel vaccines, vaccine-preventable diseases, and other factors. Further research is required to increase travelers' awareness of the need for pretravel vaccination and then to translate that awareness into positive attitudes leading to increased travel vaccine uptake.

Malaria that is caused by Plasmodium falciparum is a significant global health problem. Genetic characteristics of the host influence the severity of disease and the ultimate outcome of infection, and there is evidence of coevolution of the plasmodium parasite with its host. In humans, pyruvate kinase deficiency is the second most common erythrocyte enzyme disorder. Here, we show that pyruvate kinase deficiency provides protection against infection and replication of P. falciparum in human erythrocytes, raising the possibility that mutant pyruvate kinase alleles may confer a protective advantage against malaria in human populations in areas where the disease is endemic.

Severe malaria causes an estimated 1.24 million deaths every year, mostly in children in sub-Saharan Africa (1). Canadian pediatric infectious diseases practitioners may encounter life-threatening malaria among children emigrating from or returning from travel to the tropics. There were 195 reported cases of severe malaria in Canada between 2001 and 2012 (2), and the recent death of a malaria-infected adult in Alberta provided a reminder of the potential severity of the disease. Two large, multicentre, randomized controlled trials conclusively demonstrated a mortality benefit for the use of artesunate over quinine, the centuries-old standard, for children and adults with severe malaria (3,4). As a result, intravenous artesunate is now the treatment of choice for severe malaria, as reflected in guidelines from the WHO and the Canadian Committee to Advise on Tropical Medicine and Travel (5,6). Severe malaria in children most often manifests as either a single, or a combination of three clinical syndromes: severe malarial anemia, cerebral malaria and/or respiratory distress. In addition, patients with a high parasite density are at elevated risk for progression to severe disease and death. In travellers from low-transmission settings, such as Canada, the parasitemia threshold suggested for close monitoring, hospitalization and parenteral therapy is >2% (6). It should be emphasized that circulating parasites represent only a fraction of the sequestered parasite biomass in severe malaria, such that this threshold is imprecise. Artesunate is a water-soluble, semi-synthetic derivative of artemisinin, the active antimalarial component of the herb Artemisia annua (qinghaosu). Its use in clinical practice is expanding in malariaendemic areas of Africa and Asia, replacing quinine as the mainstay of severe malaria treatment (7). It is available across Canada, 24 h per day, through the Canadian Malaria Network and Health Canada’s Special Access Program (8). If, despite national efforts to ensure its accessibility, artesunate cannot be obtained in a timely manner for a patient with severe malaria, alternative agents (eg, atovaquone-proguanil or quinine) should be initiated pending arrival of artesunate. Although the weight of evidence and international consensus favour artesunate treatment, some countries continue to list quinidine or quinine for severe malaria as they await regulatory approval of artesunate (9,10). Clinicians consulting widely available online (9,11) or print (10,12) treatment guidelines for severe malaria may be puzzled by the United States (US) Centers for Disease Control and Prevention’s listing of quinidine as first-line therapy in the US, or quinine in the United Kingdom (Table 1). WHO-prequalified artesunate (Guilin Pharmaceutical, China) was used in major clinical trials with excellent efficacy (3); however, it has not yet obtained Health Canada, US Food and Drug Administration or European Union regulatory approval, creating a gap between the preferred evidence-based regimen and the regimen approved by regulatory authorities. High-quality artesunate from the Walter Reed Army Institute of Research (Maryland, USA) is, nonetheless, widely used in Canada and the US, made available to Canadians through the Canadian Malaria Network (2) and to US hospitals through a Food and Drug Administration-approved investigational new drug protocol (9). In addition to reducing mortality in patients with severe malaria, artesunate treatment also results in remarkably rapid parasite clearance. The kinetics of parasite elimination from the peripheral circulation under artesunate treatment are summarized in Table 2. Parasite clearance kinetics link the three themes discussed in the present article: postartemisinin-delayed hemolysis (PADH), a newly recognized adverse event and consequence of rapid parasite clearance; pharmacokinetics and dosing in young children who exhibit slower parasite clearance; and artesunate resistance, heralded by slow parasite clearance.

Summary An increasing number of children travel internationally each year. Minimising the risk of acquiring infectious diseases during travel by appropriate anticipatory guidance is a key role of the travel physician. A child's routine, required and recommended travel vaccines must be brought up to date prior to travel. Malaria prevention depends on the use of personal protective measures and chemoprophylaxis as determined by the child's age and travel itinerary. The impact of travellers’ diarrhoea can be decreased by following food and water precautions, paying attention to hydration status, and antibiotic therapy if diarrhoea develops. Any child who develops symptoms after travel should seek prompt medical evaluation.

OBJECTIVES: To determine if a standardized global child health (GCH) modular course for pediatric residents leads to satisfaction, learning, and behavior change. METHODS: Four 1-hour interactive GCH modules were developed addressing priority GCH topics. “Site champions” from 4 Canadian institutions delivered modules to pediatric residents from their respective programs during academic half-days. A pre–post, mixed methods evaluation incorporated satisfaction surveys, multiple-choice knowledge tests, and focus group discussions involving residents and satisfaction surveys from program directors. RESULTS: A total of 125 trainees participated in ≥1 module. Satisfaction levels were high. Focus group participants reported high satisfaction with the concepts taught and the dynamic, participatory approach used, which incorporated multimedia resources. Mean scores on knowledge tests increased significantly postintervention for 3 of the 4 modules (P < .001), and residents cited increases in their practical knowledge, global health awareness, and motivation to learn about global health. Program directors unanimously agreed that the modules were relevant, interesting, and could be integrated within existing formal training time. CONCLUSIONS: A relatively short, participatory, foundational GCH modular curriculum facilitated knowledge acquisition and attitude change. It could be scaled up and serve as a model for other standardized North American curricula.

Background In India, although the proportion of institutional births is increasing, there are concerns regarding quality of care. We assessed the effectiveness of a nurse-led onsite mentoring program in improving quality of care of institutional births in 24/7 primary health centres (PHCs that are open 24 hours a day, 7 days a week) of two high priority districts in Karnataka state, South India. Primary outcomes were improved facility readiness and provider preparedness in managing institutional births and associated complications during child birth. Methods All functional 24/7 PHCs in the two districts were included in the study. We used a parallel, cluster randomized trial design in which 54 of 108 facilities received six onsite mentoring visits, along with an initial training update and specially designed case sheets for providers; the control arm received just the initial training update and the case sheets. Pre- and post-intervention surveys were administered in April-2012 and August-2013 using facility audits, provider interviews and case sheet audits. The provider interviews were administered to all staff nurses available at the PHCs and audits were done of all the filled case sheets during the month prior to data collection. In addition, a cost analysis of the intervention was undertaken. Results Between the surveys, we achieved coverage of 100% of facilities and 91.2% of staff nurse interviews. Since the case sheets were newly designed, case-sheet audit data were available only from the end line survey for about 80.2% of all women in the intervention facilities and 57.3% in the control facilities. A higher number of facilities in the intervention arm had all appropriate drugs, equipment and supplies to deal with gestational hypertension (19 vs.3, OR (odds ratio) 9.2, 95% C.I 2.5 to33.6), postpartum haemorrhage (29 vs. 12, OR 3.7, 95% C.I 1.6 to8.3); and obstructed labour (25 vs.9, OR 3.4, 95% CI 1.6 to8.3). The providers in the intervention arm had better knowledge of active management of the third stage of labour (82.4% vs.35.8%, AOR (adjusted odds ratio) 10, 95% C.I 5.5 to 18.2); management of maternal sepsis (73.5% vs. 10.9%, AOR 36.1, 95% C.I 13.6 to 95.9); neonatal resuscitation (48.5% vs.11.7%, AOR 10.7, 95% C.I 4.6 to 25.0) and low birth weight newborn care (58.1% vs. 40.9%, AOR 2.4, 95% C.I 1.2 to 4.7). The case sheet audits revealed that providers in the intervention arm showed greater compliance with the protocols during labour monitoring (77.3% vs. 32.1%, AOR 25.8, 95% C.I 9.6 to 69.4); delivery and immediate post-partum care for mothers (78.6% vs. 31.8%, AOR 22.1, 95% C.I 8.0 to 61.4) and for newborns (73.9% vs. 32.8%, AOR 24.1, 95% C.I 8.1 to 72.0). The cost analysis showed that the intervention cost an additional $5.60 overall per delivery. Conclusions The mentoring program successfully improved provider preparedness and facility readiness to deal with institutional births and associated complications. It is feasible to improve the quality of institutional births at a large operational scale, without substantial incremental costs. Trial registration ClinicalTrials.gov NCT02004912.

The aim of this study was to review the aspects of malaria at a Canadian pediatric hospital and to identify gaps in management. Thirty-eight cases were diagnosed in patients with an average age of 8.4 years, the majority of which were due to Plasmodium falciparum. Two required intensive care, but survived. The majority of patients were immigrants/refugees, and accounted for almost all cases over the last 8 years of review.

Caulobacterspecies have been rarely found to be a cause of human infection. A case of probableCaulobacterspecies meningitis occurring postneurosurgery in a pediatric patient is reported in the present article. Gram stain and colony morphology of the isolate were not consistent with the identification provided by commercial phenotypic identification systems. The present case illustrates the need to reconcile conflicting phenotypic test results using 16S ribosomal DNA sequencing.

Objective.To review the experiences at Winnipeg Children's Hospital (WCH) during the 2009 influenza season, with an emphasis on nosocomial transmission and infection prevention and control responses.Design.A case series of patients admitted to WCH who had laboratory-confirmed cases of influenza between January 1 and July 31, 2009, with a comparison of patients with seasonal influenza and those with pandemic (H1N1) 2009 influenza; a review of the impact of infection prevention and control modifications on nosocomial transmission.Patients and Setting.A total of 104 inpatients with influenza, 81 of whom had pandemic (H1N1) 2009 influenza, were reviewed at a large Canadian pediatric tertiary care center.Results.There were no differences in risk factors, presentation, or outcome between patients with seasonal influenza and those with pandemic (H1N1) 2009 influenza. There were 8 nosocomial cases of pandemic (H1N1) 2009 influenza. Excluding patients with nosocomial cases, mean length of hospital stay was significantly shortened to 3.7 days for individuals who had pandemic (H1N1) 2009 influenza and who received empiric oseltamivir on admission to the hospital, compared with 12.0 days for patients for whom treatment was delayed (P = .02). Treatment with oseltamivir of all patients with suspected cases of influenza and prompt modifications to infection control practices, including playroom closures and enhanced education of visitors and staff, terminated nosocomial transmission.Conclusions.Infection with pandemic (H1N1) 2009 influenza virus resulted in a substantial number of hospitalizations of pediatric patients in Manitoba, including those with nosocomial cases, thereby stressing the capacity of WCH. Immediate therapy with oseltamivir on admission to the hospital resulted in a significantly reduced length of hospitalization. This, coupled with intensified infection prevention and control practices, halted nosocomial transmission. These strategies should be considered in future pandemic influenza or other respiratory viral outbreaks.

A case of pulmonary blastomycosis in a pediatric patient diagnosed by gastric lavage is described. Use of gastric lavage averted the need for more invasive diagnostic techniques including bronchoscopy. Further study is required to define the sensitivity of gastric lavage for recovery of Blastomyces dermatitidis from pediatric patients with pulmonary blastomycosis.

Tuberculosis (Mtb) and malaria are among the most important infectious causes of morbidity and mortality worldwide, causing an estimated 1.5 million and 1 million deaths every year, respectively. Here we demonstrate a biological interaction between malaria and mycobacteria in vitro and in vivo. Murine macrophages co-incubated with Plasmodium falciparum parasitized erythrocytes demonstrated impaired control of intracellular Mtb replication, and reduced production of reactive nitrogen species in response to mycobacteria. Infection of C57BL/6 mice with Plasmodium species exacerbated the course of acute mycobacterial infection (57% increase in peak splenic CFU, p = 0.043 for difference over time course of infection), induced disruption of the structural integrity of established granulomas, and caused reactivation of latent mycobacterial infection (2.6-fold increase in peak splenic CFU, p = 0.016 for difference over time course of reactivation). Malaria pigment deposition within the granulomas of co-infected mice suggested that the influx of dysfunctional hemozoin-laden monocytes into the locus of mycobacterial control may contribute to impaired containment of mycobacteria. Collectively, these results point to malaria-induced dysregulation of innate and adaptive anti-mycobacterial defences, and suggest that the interaction of these globally important pathogens may potentiate Mtb infection and transmission.

Afive-year-old boy travelled with his family to Kenya to visit his grandparents. Two years before he was born, his parents had emigrated from Kenya. This was his first visit to the family’s home country where they spent time in Nairobi and also travelled ‘up-country’ to visit extended family. No pretravel advice was obtained; however, the boy’s routine immunizations were up to date. He was well during his trip, but one week after his return to Canada, he complained of headaches and abdominal pain that were associated with a body temperature of 39.5°C. Two days later, he presented to his paediatrician’s office with persistent fever. He had vomited once, but had no diarrhea. He had no upper respiratory symptoms and no evidence of rash. His mother said that he was not eating and was sleeping more than usual. On examination, he was noted to be sleepy but rousable; his examination was unremarkable, apart from a heart rate of 120 beats/min. His complete blood count revealed a white blood cell count of 7.8×10 9 /L, a hemoglobin level of 72 g/L and a platelet count of 82×10 9 /L. His liver enzymes were slightly elevated, but his renal function and glucose were normal. His malaria smear revealed 2% parasitemia with Plasmodium falciparum. He was admitted to hospital and initially treated with intravenous quinine and clindamycin, followed by oral atovaquone-proguanil, and he made a full recovery.

Malaria remains an important cause of global morbidity and mortality. As antimalarial drug resistance escalates, new safe and effective medications are necessary to prevent and treat malarial infection. Tafenoquine is an 8-aminoquinoline antimalarial that is presently under development. It has a long half-life of approximately 14 days and is generally safe and well tolerated, although it cannot be used in pregnant women and individuals who are deficient in the enzyme glucose-6-phosphate dehydrogenase. In well-designed studies, tafenoquine was highly effective in both the radical cure of relapsing malaria and causal prophylaxis of Plasmodium vivax and P. falciparum infections with protective efficacies of > or = 90%. Given its causal activity and safety profile, tafenoquine represents a potentially exciting alternative to standard agents for the prevention and radical cure of malaria.

For the past several years, more than 50,000 children have immigrated to Canada annually. These children are particularly vulnerable in terms of their health. Although the Immigration Medical Examination provides the required medical screening, a number of additional recommendations for the medical evaluation of immigrant children can optimize their health care as they transition to life in Canada. Furthermore, a number of other issues must be specifically addressed in the care of immigrant children, such as consideration of their culture, nutritional issues and growth, psychosocial issues and immunizations. Certain groups of immigrant children, such as internationally adopted children and refugees, may be even more vulnerable and have special needs. However, despite the numerous challenges in addressing the health issues of immigrant children, there are many resources available to help paediatricians provide these children with optimal care.

Congenital tuberculosis is uncommon, and nosocomial transmission from a congenitally infected infant to another infant has not been reported in the English literature. We report an investigation of 2 infants with tuberculosis who were cared for in the same neonatal intensive care unit. Isolates from both infants were genetically indistinguishable. Transmission between the 2 infants was likely due to contaminated respiratory equipment.

Background Members of the CD36 scavenger receptor family have been implicated as sensors of microbial products that mediate phagocytosis and inflammation in response to a broad range of pathogens. We investigated the role of CD36 in host response to mycobacterial infection. Methods Experimental Mycobacterium bovis Bacillus Calmette-Guérin (BCG) infection in Cd36 +/+ and Cd36 -/- mice, and in vitro co-cultivation of M. tuberculosis, BCG and M. marinum with Cd36 +/+ and Cd36 -/- murine macrophages. Results Using an in vivo model of BCG infection in Cd36 +/+ and Cd36 -/- mice, we found that mycobacterial burden in liver and spleen is reduced (83% lower peak splenic colony forming units, p < 0.001), as well as the density of granulomas, and circulating tumor necrosis factor (TNF) levels in Cd36 -/- animals. Intracellular growth of all three mycobacterial species was reduced in Cd36 -/- relative to wild type Cd36 +/+ macrophages in vitro. This difference was not attributable to alterations in mycobacterial uptake, macrophage viability, rate of macrophage apoptosis, production of reactive oxygen and/or nitrogen species, TNF or interleukin-10. Using an in vitro model designed to recapitulate cellular events implicated in mycobacterial infection and dissemination in vivo (i.e., phagocytosis of apoptotic macrophages containing mycobacteria), we demonstrated reduced recovery of viable mycobacteria within Cd36 -/- macrophages. Conclusions Together, these data indicate that CD36 deficiency confers resistance to mycobacterial infection. This observation is best explained by reduced intracellular survival of mycobacteria in the Cd36 -/- macrophage and a role for CD36 in the cellular events involved in granuloma formation that promote early bacterial expansion and dissemination.