GEMLR Data Supplement

ECRLS

Ackaah W, Afukaar F, Agyemang W, et al. The use of non-standard motorcycle helmets in low- and middle-income countries: a multicentre study. Inj Prev 2013;19:158-63.

Non-standard motorcycle helmets are in widespread use in low- and middle-income countries, and their use is most significantly associated with their lower cost.

Summary: Reportedly the first multi-country analysis of non-standard helmet use in low- and middle-income countries, this study is a multi-country cross-sectional survey of helmet-wearing motorcyclists. Survey teams in nine countries approached motorists at fuel stations, and collected data on 5563 helmet-wearing motorcyclists. Although the demographics varied widely between countries, most subjects (81%) were male, and of the 5088 individuals who were interviewed, most were less than 50 years old (94%), owned their motorcycles (87%), were travelling from work (61%), and had at least secondary schooling (87%). Of the 5563 helmets observed, 54% had no certification markers or stickers, 19% of those with stickers were not authentic, and 49% overall were likely non-standard. There was wide inter-country variation; for example, 79% of helmets in China were deemed non-standard versus 13% in Thailand. Many helmets were considered non-standard due to their being designed for other purposes (26%) or because they were damaged (20%). In multivariate analyses, non-standard helmet use was associated with male subjects, riders with less than secondary education, riders engaged in commercial activities, pleasure riding, passengers, and those who did not own their motorcycles. Those who spent less than US$20 were found to be at risk of using non-standard helmets, with those spending less than US$5 having the highest risk by far (OR 24.89 vs. 1.28-1.66 for other factors). The authors also undertook a market survey of helmet cost and found that standard helmets were typically two to three times more expensive than non-standard helmets. Finally, the authors reviewed legislation governing helmet manufacturing, import, sale, and use of non-standard helmets in each country and found few comprehensive laws and almost no enforcement or reporting policies.

Comment: This is an ambitious multi-country survey that appears to be the first attempt to describe non-standard helmet use in nine low- and middle-income countries. The collaboration is impressive, with a single data gathering protocol implemented in nine very different countries, with a well-described methodology including discussion of inter-rater reliability through standardization of definitions and minimization of cross-country cultural biases. Despite a large sample size and high response rate (91%), the authors complicate their study by adding two separate, peripherally relevant surveys on local market helmet prices and individual country legislation. While these add some interesting data that inform the underlying study, each of these surveys may have been a separate study altogether and required more detailed methodology. Their inclusion diminishes the ability of the authors to devote more discussion of the variability in responses between countries – an interesting question that does not receive sufficient attention in the current paper. However, the overall conclusion that non-standard helmet use is widespread should call attention to the fact that while helmet use may be growing, the public health safety dividends may not pay off if motorcycle riders are likely to purchase cheaper, potentially hazardous non-standard safety equipment.

-Drs. Braden Hexom and Mark Foran

ECRLS

Breteler JK, Tam JS, Jit M, Ket JC, De Boer MR. Efficacy and effectiveness of seasonal and pandemic A (H1N1) 2009 influenza vaccines in low and middle income countries: A systematic review and meta-analysis. Vaccine 2013;31:5168-77

Influenza vaccination in middle-income countries is effective in reducing laboratory-confirmed influenza in children and the elderly, and comparable to published results in high-income countries

Summary: The aim of this study was to systematically review the published literature on the effectiveness and efficacy of seasonal and pandemic A (H1N1) 2009 influenza vaccines in various subpopulations in low-and middle-income countries (LMICs), and provide a meta-analysis of influenza vaccine effectiveness and efficacy in these countries. Forty one articles published in English, French, Spanish, or Portuguese between 1960 and 2011 were selected from three databases using specified search terms. The single study on pandemic A (H1N1) 2009 influenza vaccines found it effective in children against laboratory-confirmed influenza. Seasonal vaccines were efficacious in children against laboratory-confirmed influenza, any illness diagnosed as influenza-like illness or respiratory disease. Efficacy in adults was limited to efficacy against influenza-like illness, while in the elderly it was against laboratory-confirmed influenza and influenza-like illness. In patients with coronary syndromes, inactivated vaccine was effective against major cardiovascular events, cardiovascular deaths, and hospitalization.

Comments: The study provides insight into the effectiveness and efficacy of influenza vaccines in children in middle-income countries, though no strong evidence for the effectiveness or efficacy of influenza vaccination in other populations was found. The efficacy of influenza vaccines in young children in middle-income countries is important given the high burden of disease in particular in this age group. The incidence of influenza-associated acute lower respiratory infections and associated case–fatality ratios are substantially higher in young children in LMICs as compared with those measured in high-income countries. This study was limited by the lack of published data in low-income countries and few studies focusing on high-risk groups such as individuals infected with HIV.

-Drs. Benjamin Wachira and Herbert Duber

ECRLS

Cao AM, Choy JP, Mohanakrishnan LN, Bain RF, van Driel ML. Chest radiographs for acute lower respiratory tract infections. Cochrane Database Syst Rev 2013;12: doi: 10.1002/14651858.CD009119.pub2.

When compared to clinical judgment alone, a chest x-ray offers no benefit to patients with suspected lower respiratory tract infection.

Summary: This literature review published by the Cochrane group investigates the question of whether obtaining a chest radiograph (CXR) affects management or outcomes in suspected lower respiratory tract infections. Two randomized controlled trials were selected from a broad literature review and analyzed. The authors conclude that compared to clinical judgment alone, obtaining a CXR offers no benefit to patients with suspected lower respiratory tract infection.

Comment: This review concisely summarizes the best available data to date on the utility of chest radiographs for suspected pneumonia in adults and children. This subject is relevant to global emergency medicine because pneumonia is a common disease with a large global health burden, and because radiographs are a limited resource in the developing world. One of the article’s strengths is the carefully designed comprehensive search strategy that identified nearly 1200 potential publications and included only relevant randomized controlled trials. Although the design of the review is one of its strengths, the review is limited by the quality of data in the included studies, potentially biasing the results. For example, the two included studies were both from large urban centers (an Army hospital in Texas, USA, and a children’s teaching hospital in South Africa) where radiographs were available, potentially affecting the generalizability to less resourced settings. Additionally, both studies excluded the sickest patients, potentially biasing the study against more severe disease. Finally, one subgroup analysis indicated that the chest x-ray did affect outcomes (duration of illness) when it showed an infiltrate; this finding is in contrast to the paper’s assertion about the utility of chest x-rays and raises questions about the validity of the authors’ ultimate conclusions. In summary, while this literature review is comprehensive and thoughtful, the results are unlikely to change clinical management in the workup of suspected lower respiratory tract infections.

-Drs. Dan Millikan and Gabrielle Jacquet

ECRLS

Chisti MJ, Salam MA, Ashraf H, et al. Predictors and outcome of hypoxemia in severely malnourished children under five with pneumonia: a case control design. PLoS One 2013;8(1):e51376.

Mortality for hypoxemic pediatric patients in limited-resource settings remains high; tachypnea as well as accessory muscle use in this population may be early indicators of need for intervention with oxygen therapy.

Summary: This unmatched, case-control study was performed in Bangladesh to identify the prevalence, clinical predictors, and outcomes of hypoxemia in hospitalized, under five-year-old children with severe acute malnutrition (SAM) who present with pneumonia. The study authors note that both pulse oximetry and oxygen therapy are of limited availability in developing countries, but clinical signs of hypoxemia in children with pneumonia have low sensitivity. The study was conducted at Dhaka Hospital over one year and enrolled 37 SAM children with pneumonia and concurrent hypoxemia; 111 randomly selected SAM children with pneumonia but without hypoxemia served as the control group. Hypoxemia was defined as SpO2 on pulse oximetry of less than 90%. The case-fatality rate was significantly higher among the cases than the controls (30% vs. 4%; p<0.001). In logistic regression analysis, tachypnea (OR 95% CI = 1.09–13.55), lower chest wall in-drawing (95% CI = 2.48–43.41), and convulsion at admission (95% CI = 3.14–234.01) were identified as independent predictors of hypoxemia in this population. The sensitivities (with 95% CIs) of fast breathing, lower chest wall in-drawing, and convulsion at admission to predict hypoxemia were 84% (67–93%), 89% (74–96%), and 19% (9–36%), respectively, and their specificities were 53% (43–63%), 60% (51–69%), and 98% (93–100%), respectively. The authors concluded that tachypnea and lower chest wall in-drawing were the best predictors of hypoxemia in SAM children with pneumonia, and thus these clinical predictors of hypoxemia could be reliably used for early oxygen supplementation.

Comment: This study brings to light the high mortality and morbidity that still exists for pediatric patients with pneumonia worldwide, even in Dhaka, a large urban city of 14 million residents and the capital city of Bangladesh. Moreover, the study authors were able to identify several clinical signs that seem to be closely linked to hypoxemia, including tachypnea and “lower chest wall in-drawing”. The study’s case-control design, however, is somewhat troublesome. Of note, the subjects without hypoxemia were not matched to those in the hypoxemic cohort, and as a result significant bias could have been introduced. The mortality differences and clinical signs they identified as associated with hypoxemia in the study may simply be higher in the 37 patients they enrolled, rather than an objective finding for hypoxic pediatric patients with pneumonia. Nevertheless, this study is a robust contribution to the limited research that currently exists for this vulnerable population, and raises some interesting questions that will hopefully further generate interest and investigation in the future.

-Drs. Ambrose Wong and Erika Schroeder

ECRLS

Das D, Tripura R, Phyo AP, et al. Effect of high-dose or split-dose artesunate on parasite clearance in artemisinin-resistant Falciparum malaria. Clin Infect Dis 2013; 56(5):e48-58.

The emergence of artemisinin resistance necessitates the development of innovative therapies for malaria, but neither increasing nor splitting the treatment dose affects parasite clearance.

Summary: The rise of partial artemisinin resistance in Plasmodium falciparum on the Cambodia–Thailand and Myanmar–Thailand borders raises concern that malaria could become untreatable. This study investigated whether increasing or splitting the once daily dose of artesunate improves parasite clearance in patients with uncomplicated malaria in these two regions. Patients with acute malaria presenting in Pailin, western Cambodia, known for artemisinin resistance, and in Wang Pha, northwestern Thailand, where there is less resistance, were randomized to one of four treatments: 1) oral artesunate 6 mg/kg/d for 7 days; 2) 6 mg/kg/d split twice daily for 7 days; 3) 8 mg/kg/d for 3 days, followed by mefloquine; or 4) 8 mg/kg/d split twice daily for 3 days, followed by mefloquine. Parasite clearance and recrudescence for up to 63 days of follow-up were assessed. A total of 159 patients (79 patients in Pailin and 80 in Wang Pha) were enrolled. The median parasitemia half-life (interquartile range) was 6.03 (4.89 - 7.28) hours in Pailin versus 3.42 (2.20 - 4.85) hours in Wang Pha (P = 0.0001). Notably, splitting or increasing the dose of artesunate did not affect parasite clearance parameters in either site. Recrudescence rates of malaria also did not differ between treatment arms and sites.

Comment: Using a randomized design, this study investigated the effects of increased and more frequent artesunate dosing on malaria parasite clearance in two regions of varying resistance patterns. The study was well designed and, given the emergence of artemisinin resistance, is of important clinical significance to malaria treatment. Severe malaria cases, as well as all children under 6 years in Pailin and under 18 years in Wang Pha, were excluded, which limits generalizability. Also, the primary study endpoint was microscopic parasite clearance, which may not reflect effect on clinical outcomes. Despite these limitations, this study represents an important investigation into the treatment of malaria and draws attention to the urgent need for new drugs in the face of rising artesunate-resistant falciparum malaria.

-Drs. SamahChiry and Regan Marsh

EMD

Downie L, Armiento R, Subhi R, et al. Community-acquired neonatal and infant sepsis in developing countries: efficacy of WHO’s currently recommended antibiotics-systematic review and meta-analysis. Arch Dis Child 2013; 98(2):146-54.

Based on resistance patterns, the WHO current antibiotic guidelines for neonatal and infant sepsis in developing countries warrant revision.

Summary: Examining the etiology and antibiotic resistance patterns of community-acquired sepsis, this review article provides an evidence-based estimate of the likely efficacy of the World Health Organization’s recommended treatment for neonate and infant sepsis. Embase, Medline, and the Cochrane Library databases were searched for English-language studies meeting inclusion criteria. Studies at tertiary hospitals and those with clear sources of infection were excluded. Nineteen studies from 13 countries, with 11 from Africa and Asia, were included, yielding a total of 4,049 positive blood cultures. Fifteen of the studies reported antibiotic susceptibility data. The authors used random effects meta-regression to calculate the proportions of bacteremia due to different pathogens and reported the weighted prevalence of each, in addition to susceptibility to WHO-recommended antibiotic regimens. Among neonates with bacteremia, Staphylococcus aureus, Klebsiella species, and Escheria coli accounted for 55% (39-70%) of culture-positive sepsis. The prevalence of susceptible bacteria to the penicillin/gentamicin combination therapy and third-generation cephalosporins, as per WHO guidelines, was 57% and 56%, respectively. Among infants, Staphylococcus aureus, Escheria coli, Klebsiella species, Streptococcus pneumonia, and Salmonella species accounted for 59% (26-92%) of culture-positive sepsis. The prevalence of susceptible bacteria to penicillin/gentamicin combination therapy, chloramphenicol, and third-generation cephalosporins was 63%, 47%, and 64%, respectively. The authors conclude that there is a high rate of resistance to WHO first-line antibiotics within community-acquired sepsis and that revised recommendations for effective second-line treatment are urgently needed.

Comment:Because of the high risk of neonatal and infant death from sepsis in developing countries, this article is of clear importance to the field of global emergency medicine. Its strengths are its design as meta-analysis and generalizability with a focus on community-acquired sepsis without a source. It is limited by the heterogeneity of the quality of laboratory reporting and susceptibility testing methods among included studies. Most of the previous evidence supporting the current WHO antibiotic recommendations has largely been derived from tertiary hospital data. This study shows high rates of community-based resistance to first-line antibiotics. Therefore, this study demonstrates the importance of re-evaluating the current antibiotic recommendations to improve efficacy for this high-risk condition.

-Drs. Joshua Jauregui and Regan Marsh

EMD

Eze UO, Kipsaina CC, Ozanne-Smith J. Fatal road traffic injuries in Ibadan, using the mortuary as a data source. Inj Prev 2013;19:387-92.

This single-site study in Nigeria demonstrates that detailed fatality data on road traffic injuries can be collected via mortuary-based surveillance, although the resulting data are not comprehensive.

Summary: Collecting accurate data on road traffic injuries (RTI) in sub-Saharan Africa is a region-wide challenge. Most studies have used hospital records, police reports, or household surveys to determine local and regional incidence of RTI, yet leave significant data gaps that make epidemiological estimates unreliable. The authors describe a single-site survey of the major mortuary in Ibadan, Nigeria, a regional capital of approximately 2.9 million people. The mortuary admits about 75% of the coroner’s cases of reported deaths, mostly from local hospitals and direct admissions. Using a data collection form developed through a World Health Organization / university collaboration, researchers screened 304 total deaths over a five-month period and identified 80 RTI fatalities. Of these, 81.3% were male, the mean age was 38.8, and 51.3% were aged 15-44. Most fatalities were either riders or passengers on two-wheeled motor vehicles (35%) or pedestrians (35%). Males were most commonly killed as two-wheeler riders (38.5%), while females were more likely to have died as pedestrians (33.3%). The leading cause of death was head injury (70%). Additional data were collected on type of road user and the counterpart vehicle or object. The authors grant that as a pilot survey, the study was small in scope, thus making it inaccurate to extrapolate the data to estimate region-wide rates of RTI. However, they do conclude that the study shows that previous data collection instruments may be missing a significant number of RTIs, as the number of deaths from RTI identified in this study was higher than the previously published state-wide incidence rate.