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Improve the knowledge-base for interventions and their implementation
Identifying and supporting effective child health interventions
Improving hospital care for children
Rotavirus and global applications of its vaccine
PneumoCarr Microbiology project
Oxygen systems in Papua New Guinea
Identifying and supporting effective child health interventions
In its capacity as a member of the Knowledge Hub for Women's and Children's Health, CICH is participating in a project that aims to assist countries in the region to develop strategies for increasing equitable progress towards the Millennium Development Goals for maternal and child health (MDGs 4 and 5). The goal of this project is to build the national and sub-national evidence required to (a) identify the main health system constraints hampering the scaling-up of the "best-buy range of interventions" required to achieve equitable progress in maternal and child health, and (b) estimate the additional funding required to effectively address these constraints. The project design has been grounded on the view that it will support evidence-based policy and resource allocation in the selected countries to achieve equitable progress on MDGs 4 and 5. The Health Information Systems Knowledge Hub at the University of Queensland is leading the project, in close collaboration with UNICEF and national research counterparts. The project is funded by the Bill and Melinda Gates Foundation and AusAID.
Contact:
Sophie La Vincente - sophie.lavincente@rch.org.au
Improving hospital care for children
The WHO Pocketbook and ICHRC
Of the 10 million children that die every year before they reach the age of five, 99 per cent will be from low and middle-income countries. Most of these children die of causes that are routinely prevented or treated in the developed world: acute respiratory infection, diarrhoeal disease, meningitis, HIV, neonatal conditions such as low birth weight, birth asphyxia and infections. Most seriously-ill children have no access to paediatricians and are treated by nurses or paramedical workers who often have little training in the specific care of children. The small and rural hospitals in which they are treated often lack vital resources that sick children need. Therefore, improving the level of care in these hospitals would directly improve the health of millions of children and prevent many of their deaths.
CICH has been involved in developing a 3-part strategy for improving quality of care (elaborated on below):
1- Introducing standardized guidelines:
These take the form of the WHO Pocketbook of Hospital Care for Children. This book provides essential recommendations and guidelines for nurses and doctors who have basic or no specific training in the treatment of children. The book has been translated into many languages: French, Spanish, Portuguese, Turkish and Russian. Translations in other languages including Vietnamese, Indonesian, and languages of the Central Asian republics are currently underway.
2- Adapting these guidelines systematically:
CICH and WHO have produced a course to train health workers in how to use the Pocketbook in everyday clinical practice. This is in the form of an interactive CD, which contains case based teaching on each of the chapters in the WHO Pocketbook, videos and illustrations of clinical signs, procedures and common conditions. The course runs over about 4 days, or can be incorporated into pre-service or post-graduate curricula. During development, the CD was trialed in the Solomon Islands, Uzbekistan, Kazakhastan, Cambodia and China, where it is being used to introduce the WHO Pocketbook as national standard treatment guidelines for children in hospitals.
3- Collating an evidence-base which supports the standard recommendations:
To further support the implementation of the WHO Pocketbook, CICH is collaborating with paediatricians worldwide to critically appraise the medical evidence on which WHO bases its recommended treatments for children. This collation of evidence is essential in promoting the highest quality and most cost-effective care in developing countries, and is available at www.ichrc.org.
These initiatives put simple resources and essential information in the hands of child health workers world-wide, regardless of whether they work in poor, rural district hospitals and clinics, or in tertiary hospitals in developing countries.
For access to the pocketbook, the training materials and ICHRC, visit:
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WHO Pocketbook Training Materials [500MB] (Please note this is a very large file)
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WHO Pocketbook WHO Pocket Book of Hospital Care for Children
Contact:
Trevor Duke - trevor.duke@rch.org.au
Julian Kelly - julian.kelly@rch.org.au
Vaccine preventable diseases
Rotavirus and global applications of its vaccine
Diarrhoeal diseases account for 17% of all deaths in children under the age of 5 annually. Rotavirus infection is the leading cause of severe dehydrating gastroenteritis, which presents as diarrhoea. Recently two rotavirus vaccines have become commercially available world-wide. However, the burden of Rotavirus in the developing world has not been established, and it is not certain whether the vaccines will be effective in this setting.
CICH is currently engaged in 2 projects investigating the burden of Rotavirus, and aspects of the effectiveness of its vaccines:
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In Fiji and Papua New Guinea, CICH staff are investigating the burden of Rotavirus infection
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In Indonesia, CICH is involved in ongoing research aimed at describing the levels of rotavirus antibodies in the breast milk and blood of pregnant mothers which, when passed onto breast-fed infants, may interference with the live, oral rotavirus vaccines
For more information, see:
Glass R, Parashar U, Bresee J, Turcios R et.al., Rotavirus vaccines: current prospects and future challenges, Lancet. 2006; 368(9532):323-32.
Contacts:
Adam Jenney- jenneya@unimelb.edu.au
Jocylen Chan - y.chan7@ugrad.unimelb.edu.au
The Fiji Pneumococcal Project
The Fiji Pneumococcal Project is a collaborative project between the University of Melbourne, the Fiji Ministry of Health, and the Fiji School of Medicine. It commenced in 2003 and was originally funded to undertake a phase 2 pneumococcal vaccine trial to measure the immunogenicity and impact on nasopharyngeal carriage of reduced dosing schedules of the pneumococcal conjugate vaccine combined with a booster of the 23-valent polysaccharide vaccine. The aim was to expand the serotype coverage and improve affordability of the vaccine. Since then, the project has expanded its profile and now also gathers information countries need to make decisions regarding the impact of the new vaccines.
Based in Suva, Fiji, the project established and managed a research office of up to 18 staff with funding by the National Institutes of Health and NHMRC to undertake an international vaccine trial according to Good Clinical Practice. Subsequently further funding has been attracted from the World Health Organization, UNICEF, pneumoADIP, and the Grand Challenges in Global Health to undertake a number of studies including:
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Phase 2 pneumococcal randomised control trial
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Prospective meningitis aetiology & outcome study
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Nasopharyngeal pneumococcal carriage survey
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Cohort study on the quality of life of meningitis survivors
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Retrospective invasive pneumococcal disease study in under 5s
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Prospective IPD & serotyping study in all ages
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Cost effectiveness evaluation of pneumococcal vaccine
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Blood agar studies
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Multiserotype carriage studies
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Pneumococcal penicillin resistance surveillance
Other work in Fiji includes:
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Inpatient rotavirus diarrhoea surveillance in children under 5
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Cervical cancer burden of disease and HPV genotypes in Fiji
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Revision of the national Maternal and Child Health card
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Assessment of the impact of water and sanitation of health
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WHO consultancies to:
Contacts:
Kim Mullholand - kim.Mulholland@lshtm.ac.uk
Fiona Russel - fionarussell@connect.com.fj
The PneumoCarr Microbiology Project
Information about carriage of multiple serotypes of pneumococcus is particularly important when considering the link between immunisation and carriage. A major barrier to this study is that there is no standard method to directly detect nasopharyngeal carriage of pneumococcal strains of different serotypes. The PneumoCarr Microbiology Project aims to provide an avenue for global consensus on suitable methods by determining the sensitivity and specificity of available methods for the detection of carriage of multiple serotypes of pneumococci.
Methods
The project is being conducted in 3 stages:
Stage 1 - Produce a reference set on known sertotypes (including controls with no pneumococcus) on which to test the sensitivity and specficity of currently available detection methods.
Stage 2 - At least one hundred colonies from each clinical sample will be serotyped individually by PneumoCarr using established antibody-based methods including quellung and latex agglutination.
Stage 3 - Participants will be sent samples from the reference set to which they will apply their preferred method. The sensitivity and specificity of each method will then be determined and compared. Results will be shared amongst participating laboratories, although the identity of individual laboratories will be concealed.
Progress
Stage 1 & 2
Stage 3 - Preliminary discussions with some groups who are developing serotyping methods.
What next?
We are seeking expressions of interest from researchers with established or evolving methods that may be suitable to detect multiple pneumococcal serotypes in nasopharyngeal samples.
For more information, see:
Contacts:
Catherine Satzke - catherine.satzke@mcri.edu.au
Kim Mulholland - kim.Mulholland@lshtm.ac.uk
Acute respiratory infection
Oxygen systems in Papua New Guinea
The most common cause of death of children around the world is acute lower respiratory tract infection, usually presenting as pneumonia. Every year, around 11-20 million children are admitted to hospital with pneumonia. Out of the two million children who die from this condition each year, 98% live in developing countries. Severe cases of pneumonia need to be managed with antibiotics, and provided with supportive care. Recent studies have identified hypoxaemia (low oxygen saturation of arterial blood) as the most common fatal complication in pneumonia. Therefore, oxygen therapy is a vital component of in-hospital supportive care for pneumonia.
Oxygen is an expensive resource in developing countries. It is usually stored in cylinders, which are difficult to transport, expensive to rent and require regular replenishment. Given these barriers, the supply is often unreliable. Also, clinically diagnosing hypoxaemia is difficult, especially in heavily pigmented children.
Currently, the technology to overcome the above-mentioned barriers is available. Oxygen concentrators are machines that can generate concentrated oxygen from room air, and can therefore afford a continuous oxygen supply that entails no transportation or replenishment. Pulse oximeters are devises placed on the tip of the fingers or toes, and can estimated the oxygen concentration of arterial blood, providing an accurate means of diagnosing hypoxaemia.
Pulse oximeter: non-invasive measure of oxygen saturation
Some research have dealt with the application of either of these devices to developing country health facilities. However, none has tested the clinical impact, sustainability or cost-effectiveness of introducing an integrated system for oxygen therapy in developing countries for detecting and treating hypoxaemia.
In collaboration with the Papua New Guinea Ministry (PNG) of Health, CICH tested a system for diagnosing and treating hypoxaemia using oxygen concentrators and pulse oximeters in developing country hospitals. A multi-disciplinary ‘oxygen team' was formed to conduct staff training, equipment installation and servicing and to oversee the program. In 2004, pulse oximeters were introduced to 5 hospitals in PNG, and in mid 2005, oxygen concentrators were installed. Staff were given clinical and technical training. In October 2007, we conducted a systematic evaluation of this system which focused on clinical impact, sustainability and cost-effectiveness.
Oxygen concentrator: cost-effective source of oxygen in children's wards
The main findings of the evaluation were:
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A 35% reduction in child pneumonia mortality;
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A cost of $51 per DALY averted;
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An understanding of the importance of adapting a systematic and informed approach in introducing such technology to developing country health facilities.
For more information, see:
Duke T, Wandi F, Jonathan M, Matai S et al, Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea, Lancet 2008, 372; 9676, 1328-1333
Contacts:
Trevor Duke - trevor.duke@rch.org.au
Rami Subhi - rami.subhi@rch.org.au
