Context Improving the accuracy of malaria diagnosis using rapid diagnostic tests (RDT) has been proposed as an approach for reducing over-treatment of malaria in the current era of widespread implementation of artemisinin-based combination therapy in sub-Saharan Africa. Objective To assess the impact of microscopy and RDT use on prescription of antimalarials. Design, Setting, and Participants Cross-sectional, cluster sample survey of all sick outpatients seen at a health facility during one working day that included all public and mission health facilities in four sentinel districts in Zambia. Main Outcome Measures Proportions of patients undergoing malaria diagnostic procedures and receiving anti-malarial treatment. Results 17% of the 104 health facilities surveyed had functional microscopy, 63% had RDTs available, and 73% had at least one type of malaria diagnostics. 27.8% of subjects with fever (suspected malaria) seen in health facilities with malaria diagnostics were tested and 44.6% were positive. 58.4% of patients with negative blood smears were prescribed an antimalarial as were 35.5% of those with a negative RDT result. 65.9% of the subjects with fever who did not have diagnostic tests done were also prescribed antimalarials. In facilities with artemether-lumefantrine in stock, this antimalarial was prescribed to a larger proportion of febrile patients with a positive diagnostic test (blood smear 75.0%; RDT 70.4%) than those with a negative diagnostic test (blood smear 30.4%; RDT 26.7%). Conclusion Despite efforts to scale up the provision of malaria diagnostics in Zambia they continue to be under-utilized and patients with negative test results frequently receive antimalarials. The provision of new tools to reduce the inappropriate use of new expensive antimalarial treatments must be accompanied by a paradigm shift in clinical management of patients without evidence of malaria infection.

In a cluster randomized trial, Kojo Yeboah-Antwi and colleagues find that integrated management of malaria and pneumonia in children under five by community health workers is both feasible and effective.

SummaryBackgroundModelled mortality estimates have been useful for health programmes in low-income and middle-income countries. However, these estimates are often based on sparse and low-quality data. We aimed to generate high quality data about the burden, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa.MethodsIn this prospective cohort study done in 11 community-based research sites in south Asia and sub-Saharan Africa, between July, 2012, and February, 2016, we conducted population-based surveillance of women of reproductive age (15–49 years) to identify pregnancies, which were followed up to birth and 42 days post partum. We used standard operating procedures, data collection instruments, training, and standardisation to harmonise study implementation across sites. Verbal autopsies were done for deaths of all women of reproductive age, neonatal deaths, and stillbirths. Physicians used standardised methods for cause of death assignment. Site-specific rates and proportions were pooled at the regional level using a meta-analysis approach.FindingsWe identified 278 186 pregnancies and 263 563 births across the study sites, with outcomes ascertained for 269 630 (96·9%) pregnancies, including 8761 (3·2%) that ended in miscarriage or abortion. Maternal mortality ratios in sub-Saharan Africa (351 per 100 000 livebirths, 95% CI 168–732) were similar to those in south Asia (336 per 100 000 livebirths, 247–458), with far greater variability within sites in sub-Saharan Africa. Stillbirth and neonatal mortality rates were approximately two times higher in sites in south Asia than in sub-Saharan Africa (stillbirths: 35·1 per 1000 births, 95% CI 28·5–43·1 vs 17·1 per 1000 births, 12·5–25·8; neonatal mortality: 43·0 per 1000 livebirths, 39·0–47·3 vs 20·1 per 1000 livebirths, 14·6–27·6). 40–45% of pregnancy-related deaths, stillbirths, and neonatal deaths occurred during labour, delivery, and the 24 h postpartum period in both regions. Obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy, and pregnancy-related infections accounted for more than three-quarters of maternal deaths and stillbirths. The most common causes of neonatal deaths were perinatal asphyxia (40%, 95% CI 39–42, in south Asia; 34%, 32–36, in sub-Saharan Africa) and severe neonatal infections (35%, 34–36, in south Asia; 37%, 34–39 in sub-Saharan Africa), followed by complications of preterm birth (19%, 18–20, in south Asia; 24%, 22–26 in sub-Saharan Africa).InterpretationThese results will contribute to improved global estimates of rates, timing, and causes of maternal and newborn deaths and stillbirths. Our findings imply that programmes in sub-Saharan Africa and south Asia need to further intensify their efforts to reduce mortality rates, which continue to be high. The focus on improving the quality of maternal intrapartum care and immediate newborn care must be further enhanced. Efforts to address perinatal asphyxia and newborn infections, as well as preterm birth...

BackgroundSmoke from biomass burning has been linked to reduced birth weight; association with other birth outcomes is poorly understood. Our objective was to evaluate effects of exposure to biomass smoke on birth weight, preterm birth and stillbirth.MethodsInformation on household cooking fuel was available for secondary analysis from two cohorts of pregnant women enrolled at delivery in India (n = 1744). Birth weight was measured and the modified Ballard performed to assess gestational age. Linear and logistic regression models were used to explore associations between fuel and birth outcomes. Effect sizes were adjusted in multivariate models for socio-demographic characteristics using propensity score techniques and for medical/obstetric covariates.ResultsCompared to women who use gas (n = 265), women cooking with wood (n = 1306) delivered infants that were on average 112 grams lighter (95% CI -170.1, -54.6) and more likely to be preterm (OR 3.11, 95% CI 2.12, 4.59). Stillbirths were also more common in the wood group (4% versus 0%, p < 0.001). In adjusted models, the association between wood use and birth weight was no longer significant (14 g reduction; 95% CI -93, 66); however, the increased odds for preterm birth persisted (aOR 2.29; 95% CI 1.24, 4.21). Wood fuel use did not increase the risk of delivering either a low birth weight or small for gestational age infant.ConclusionsThe association between wood fuel use and reduced birth weight was insignificant in multivariate models using propensity score techniques to account for socio-demographic differences. In contrast, we demonstrated a persistent adverse impact of wood fuel use on preterm delivery. If prematurity is confirmed as a consequence of antenatal exposure to household air pollution, perinatal morbidity and mortality from household air pollution may be higher than previously appreciated.

Objectives:To assess the quality and safety of having community health workers (CHWs) in rural Zambia use rapid diagnostic tests (RDTs) and provide integrated management of malaria and pneumonia. Design/methods: In the context of a cluster-randomized controlled trial of two models for community-based management of malaria and/or non-severe pneumonia in children under 5 years old, CHWs in the intervention arm were trained to use RDTs, follow a simple algorithm for classification and treat malaria with artemether-lumefantrine (AL) and pneumonia with amoxicillin. CHW records were reviewed to assess the ability of the CHWs to appropriately classify and treat malaria and pneumonia, and account for supplies. Patients were also followed up to assess treatment safety. Results: During the 12-month study, the CHWs evaluated 1017 children with fever and/or fast/difficult breathing and performed 975 RDTs. Malaria and/or pneumonia were appropriately classified 94-100% of the time. Treatment based on disease classification was correct in 94-100% of episodes. Supply management was excellent with over 98% of RDTs, amoxicillin, and AL properly accounted for. The use of RDTs, amoxicillin, and AL was associated with few minor adverse events. Most febrile children (90%) with negative RDT results recovered after being treated with an antipyretic alone. Conclusions: Volunteer CHWs in rural Zambia are capable of providing integrated management of malaria and pneumonia to children safely and at high quality.

Background:Neonatal illness is a leading cause of death worldwide; sepsis is one of the main contributors. The etiologies of community-acquired neonatal bacteremia in developing countries have not been well characterized.Methods:Infants <2 months of age brought with illness to selected health facilities in Bangladesh, Bolivia, Ghana, India, Pakistan and South Africa were evaluated, and blood cultures taken if they were considered ill enough to be admitted to hospital. Organisms were isolated using standard culture techniques.Results:Eight thousand eight hundred and eighty-nine infants were recruited, including 3177 0–6 days of age and 5712 7–59 days of age; 10.7% (947/8889) had a blood culture performed. Of those requiring hospital management, 782 (54%) had blood cultures performed. Probable or definite pathogens were identified in 10.6% including 10.4% of newborns 0–6 days of age (44/424) and 10.9% of infants 7–59 days of age (39/358). Staphylococcus aureus was the most commonly isolated species (36/83, 43.4%) followed by various species of Gram-negative bacilli (39/83, 46.9%; Acinetobacter spp., Escherichia coli and Klebsiella spp. were the most common organisms). Resistance to second and third generation cephalosporins was present in more than half of isolates and 44% of the Gram-negative isolates were gentamicin-resistant. Mortality rates were similar in hospitalized infants with positive (5/71, 7.0%) and negative blood cultures (42/557, 7.5%).Conclusions:This large study of young infants aged 0–59 days demonstrated a broad array of Gram-positive and Gram-negative pathogens responsible for community-acquired bacteremia and substantial levels of antimicrobial resistance. The role of S. aureus as a pathogen is unclear and merits further investigation.

Background: Past studies in India included only symptomatic pregnant women and thus may have overestimated the proportion of women with malaria. Given the large population at risk, a cross sectional study was conducted in order to better define the burden of malaria in pregnancy in Jharkhand, a malaria-endemic state in central-east India.

BackgroundIn Ghana, between 1,400 and 3,900 women and girls die annually due to pregnancy related complications and an estimated two-thirds of these deaths occur in late pregnancy through to 48 hours after delivery. The Ghana Health Service piloted a strategy that involved training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). CHO-midwives collaborated with community members to provide skilled delivery services in rural areas. This paper presents findings from a study designed to assess the extent to which community residents and leaders participated in the skilled delivery program and the specific roles they played in its implementation and effectiveness.MethodsWe employed an intrinsic case study design with a qualitative methodology. We conducted 29 in-depth interviews with health professionals and community stakeholders. We used a random sampling technique to select the CHO-midwives in three Community-based Health Planning and Services (CHPS) zones for the interviews and a purposive sampling technique to identify and interview District Directors of Health Services from the three districts, the Regional Coordinator of the CHPS program and community stakeholders.ResultsCommunity members play a significant role in promoting skilled delivery care in CHPS zones in Ghana. We found that community health volunteers and traditional birth attendants (TBAs) helped to provide health education on skilled delivery care, and they also referred or accompanied their clients for skilled attendants at birth. The political authorities, traditional leaders, and community members provide resources to promote the skilled delivery program. Both volunteers and TBAs are given financial and non-financial incentives for referring their clients for skilled delivery. However, inadequate transportation, infrequent supply of drugs, attitude of nurses remains as challenges, hindering women accessing maternity services in rural areas.ConclusionsMutual collaboration and engagement is possible between health professionals and community members for the skilled delivery program. Community leaders, traditional and political leaders, volunteers, and TBAs have all been instrumental to the success of the CHPS program in the UER, each in their unique way. However, there are problems confronting the program and we have provided recommendations to address these challenges.