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Article ; Online: Diagnosing early-onset neonatal sepsis in low-resource settings: development of a multivariable prediction model.

Neal, Samuel R / Fitzgerald, Felicity / Chimhuya, Simba / Heys, Michelle / Cortina-Borja, Mario / Chimhini, Gwendoline

2023 Volume 108, Issue 8, Page(s) 608–615

Abstract: Objective: To develop a clinical prediction model to diagnose neonatal sepsis in low-resource settings.: Design: Secondary analysis of data collected by the Neotree digital health system from 1 February 2019 to 31 March 2020. We used multivariable ... ...

Abstract	Objective: To develop a clinical prediction model to diagnose neonatal sepsis in low-resource settings. Design: Secondary analysis of data collected by the Neotree digital health system from 1 February 2019 to 31 March 2020. We used multivariable logistic regression with candidate predictors identified from expert opinion and literature review. Missing data were imputed using multivariate imputation and model performance was evaluated in the derivation cohort. Setting: A tertiary neonatal unit at Sally Mugabe Central Hospital, Zimbabwe. Patients: We included 2628 neonates aged <72 hours, gestation ≥32 Interventions: Participants received standard care as no specific interventions were dictated by the study protocol. Main outcome measures: Clinical early-onset neonatal sepsis (within the first 72 hours of life), defined by the treating consultant neonatologist. Results: Clinical early-onset sepsis was diagnosed in 297 neonates (11%). The optimal model included eight predictors: maternal fever, offensive liquor, prolonged rupture of membranes, neonatal temperature, respiratory rate, activity, chest retractions and grunting. Receiver operating characteristic analysis gave an area under the curve of 0.74 (95% CI 0.70-0.77). For a sensitivity of 95% (92%-97%), corresponding specificity was 11% (10%-13%), positive predictive value 12% (11%-13%), negative predictive value 95% (92%-97%), positive likelihood ratio 1.1 (95% CI 1.0-1.1) and negative likelihood ratio 0.4 (95% CI 0.3-0.6). Conclusions: Our clinical prediction model achieved high sensitivity with low specificity, suggesting it may be suited to excluding early-onset sepsis. Future work will validate and update this model before considering implementation within the Neotree.
MeSH term(s)	Infant, Newborn ; Humans ; Neonatal Sepsis/diagnosis ; Models, Statistical ; Prognosis ; Sepsis/diagnosis ; ROC Curve
Language	English
Publishing date	2023-04-27
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	524-1
ISSN	1468-2044 ; 0003-9888 ; 1359-2998
ISSN (online)	1468-2044
ISSN	0003-9888 ; 1359-2998
DOI	10.1136/archdischild-2022-325158
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Article ; Online: "Getting pregnant during COVID-19 was a big risk because getting help from the clinic was not easy": COVID-19 experiences of women and healthcare providers in Harare, Zimbabwe.

Mupambireyi, Zivai / Cowan, Frances M / Chappell, Elizabeth / Chimwaza, Anesu / Manika, Ngoni / Wedderburn, Catherine J / Gannon, Hannah / Gibb, Tom / Heys, Michelle / Fitzgerald, Felicity / Chimhuya, Simbarashe / Gibb, Diana / Ford, Deborah / Mushavi, Angela / Bwakura-Dangarembizi, Mutsa

PLOS global public health

2024 Volume 4, Issue 1, Page(s) e0002317

Abstract: The COVID-19 pandemic and associated measures may have disrupted delivery of maternal and neonatal health services and reversed the progress made towards dual elimination of mother-to-child transmission of HIV and syphilis in Zimbabwe. This qualitative ... ...

Abstract	The COVID-19 pandemic and associated measures may have disrupted delivery of maternal and neonatal health services and reversed the progress made towards dual elimination of mother-to-child transmission of HIV and syphilis in Zimbabwe. This qualitative study explores the impact of the pandemic on the provision and uptake of prevention of mother-to-child transmission (PMTCT) services from the perspectives of women and maternal healthcare providers. Longitudinal in-depth interviews were conducted with 20 pregnant and breastfeeding women aged 20-39 years living with HIV and 20 healthcare workers in two maternity polyclinics in low-income suburbs of Harare, Zimbabwe. Semi-structured interviews were held after the second and third waves of COVID-19 in March and November 2021, respectively. Data were analysed using a modified grounded theory approach. While eight antenatal care contacts are recommended by Zimbabwe's Ministry of Health and Child Care, women reported only being able to access two contacts. Although HIV testing, antiretroviral therapy (ART) refills and syphilis screening services were accessible at first contact, other services such as HIV-viral load monitoring and enhanced adherence counselling were not available for those on ART. Closure of clinics and shortened operating hours during the second COVID-19 wave resulted in more antenatal bookings occurring later during pregnancy and more home deliveries. Six of the 20 (33%) interviewed women reported giving birth at home, assisted by untrained traditional midwives as clinics were closed. Babies delivered at home missed ART prophylaxis and HIV testing at birth despite being HIV-exposed. Although women faced multiple challenges, they continued to attempt to access services after delivery. These findings underline the importance of investing in robust health systems that can respond to emergency situations to ensure continuity of essential HIV prevention, treatment, and care services.
Language	English
Publishing date	2024-01-08
Publishing country	United States
Document type	Journal Article
ISSN	2767-3375
ISSN (online)	2767-3375
DOI	10.1371/journal.pgph.0002317
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Article ; Online: Refining clinical algorithms for a neonatal digital platform for low-income countries: a modified Delphi technique.

Evans, Mari / Corden, Mark H / Crehan, Caroline / Fitzgerald, Felicity / Heys, Michelle

BMJ open

2021 Volume 11, Issue 5, Page(s) e042124

Abstract: Objectives: To determine whether a panel of neonatal experts could address evidence gaps in local and international neonatal guidelines by reaching a consensus on four clinical decision algorithms for a neonatal digital platform (NeoTree).: Design: ... ...

Abstract	Objectives: To determine whether a panel of neonatal experts could address evidence gaps in local and international neonatal guidelines by reaching a consensus on four clinical decision algorithms for a neonatal digital platform (NeoTree). Design: Two-round, modified Delphi technique. Setting and participants: Participants were neonatal experts from high-income and low-income countries (LICs). Methods: This was a consensus-generating study. In round 1, experts rated items for four clinical algorithms (neonatal sepsis, hypoxic ischaemic encephalopathy, respiratory distress of the newborn, hypothermia) and justified their responses. Items meeting consensus for inclusion (≥80% agreement) were incorporated into the algorithms. Items not meeting consensus were either excluded, included following revisions or included if they contained core elements of evidence-based guidelines. In round 2, experts rated items from round 1 that did not reach consensus. Results: Fourteen experts participated in round 1, 10 in round 2. Nine were from high-income countries, five from LICs. Experts included physicians and nurse practitioners with an average neonatal experience of 20 years, 12 in LICs. After two rounds, a consensus was reached on 43 of 84 items (52%). Per experts' recommendations, items in line with local and WHO guidelines yet not meeting consensus were still included to encourage consistency for front-line healthcare workers. As a result, the final algorithms included 53 items (62%). Conclusion: Four algorithms in a neonatal digital platform were reviewed and refined by consensus expert opinion. Revisions to NeoTree will be made in response to these findings. Next steps include clinical validation of the algorithms.
MeSH term(s)	Algorithms ; Consensus ; Delphi Technique ; Humans ; Infant, Newborn ; Physicians ; Poverty
Language	English
Publishing date	2021-05-18
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2020-042124
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Article ; Online: Review of UK malaria treatment guidelines 2016 (Public Health England Advisory Committee on Malaria Prevention).

Evans, Ceri / Fitzgerald, Felicity / Cunnington, Aubrey

Archives of disease in childhood. Education and practice edition

2018 Volume 104, Issue 4, Page(s) 218–220

MeSH term(s)	Antimalarials/standards ; Antimalarials/therapeutic use ; England ; Humans ; Malaria/drug therapy ; Malaria/prevention & control ; Practice Guidelines as Topic ; Public Health/standards ; United Kingdom
Chemical Substances	Antimalarials
Language	English
Publishing date	2018-05-02
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2148818-6
ISSN	1743-0593 ; 1743-0585
ISSN (online)	1743-0593
ISSN	1743-0585
DOI	10.1136/archdischild-2017-314343
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Article ; Online: Risk factors of mortality in neonates with neonatal encephalopathy in a tertiary newborn care unit in Zimbabwe over a 12-month period.

Gannon, Hannah / Chimhini, Gwendoline / Cortina-Borja, Mario / Chiyaka, Tarisai / Mangiza, Marcia / Fitzgerald, Felicity / Heys, Michelle / Neal, Samuel R / Chimhuya, Simbarashe

PLOS global public health

2022 Volume 2, Issue 12, Page(s) e0000911

Abstract: Neonatal encephalopathy (NE) accounts for ~23% of the 2.4 million annual global neonatal deaths. Approximately 99% of global neonatal deaths occur in low-resource settings, however, accurate data from these low-resource settings are scarce. We reviewed ... ...

Abstract	Neonatal encephalopathy (NE) accounts for ~23% of the 2.4 million annual global neonatal deaths. Approximately 99% of global neonatal deaths occur in low-resource settings, however, accurate data from these low-resource settings are scarce. We reviewed risk factors of neonatal mortality in neonates admitted with neonatal encephalopathy from a tertiary neonatal unit in Zimbabwe. A retrospective review of risk factors of short-term neonatal encephalopathy mortality was conducted at Sally Mugabe Central Hospital (SMCH) (November 2018 -October 2019). Data were gathered using a tablet-based data capture and quality improvement newborn care application (Neotree). Analyses were performed on data from all admitted neonates with a diagnosis of neonatal encephalopathy, incorporating maternal, intrapartum, and neonatal risk predictors of the primary outcome: mortality. 494/2894 neonates had neonatal encephalopathy on admission and were included. Of these, 94 died giving a neonatal encephalopathy-case fatality rate (CFR) of 190 per 1000 admitted neonates. Caesarean section (odds ratio (OR) 2.95(95% confidence interval (CI) 1.39-6.25), convulsions (OR 7.13 (1.41-36.1)), lethargy (OR 3.13 (1.24-7.91)), Thompson score "11-14" (OR 2.98 (1.08-8.22)) or "15-22" (OR 17.61 (1.74-178.0)) were significantly associated with neonatal death. No maternal risk factors were associated with mortality. Nearly 1 in 5 neonates diagnosed with neonatal encephalopathy died before discharge, similar to other low-resource settings but more than in typical high-resource centres. The Thompson score, a validated, sensitive and specific tool for diagnosing neonates with neonatal encephalopathy was an appropriate predictive clinical scoring system to identify at risk neonates in this setting. On univariable analysis time-period, specifically a period of staff shortages due to industrial action, had a significant impact on neonatal encephalopathy mortality. Emergency caesarean section was associated with increased mortality, suggesting perinatal care is likely to be a key moment for future interventions.
Language	English
Publishing date	2022-12-20
Publishing country	United States
Document type	Journal Article
ISSN	2767-3375
ISSN (online)	2767-3375
DOI	10.1371/journal.pgph.0000911
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Article ; Online: Effects of the COVID-19 pandemic on the outcomes of HIV-exposed neonates: a Zimbabwean tertiary hospital experience.

Gannon, Hannah / Chappell, Elizabeth / Ford, Deborah / Gibb, Diana M / Chimwaza, Anesu / Manika, Ngoni / Wedderburn, Catherine J / Nenguke, Zivai Mupambireyi / Cowan, Frances M / Gibb, Tom / Phillips, Andrew / Mushavi, Angela / Fitzgerald, Felicity / Heys, Michelle / Chimhuya, Simbarashe / Bwakura-Dangarembizi, Mutsa

BMC pediatrics

2024 Volume 24, Issue 1, Page(s) 16

Abstract: Introduction: The COVID-19 pandemic has globally impacted health service access, delivery and resources. There are limited data regarding the impact on the prevention of mother to child transmission (PMTCT) service delivery in low-resource settings. ... ...

Abstract	Introduction: The COVID-19 pandemic has globally impacted health service access, delivery and resources. There are limited data regarding the impact on the prevention of mother to child transmission (PMTCT) service delivery in low-resource settings. Neotree ( www.neotree.org ) combines data collection, clinical decision support and education to improve care for neonates. Here we evaluate impacts of COVID-19 on care for HIV-exposed neonates. Methods: Data on HIV-exposed neonates admitted to the neonatal unit (NNU) at Sally Mugabe Central Hospital, Zimbabwe, between 01/06/2019 and 31/12/2021 were analysed, with pandemic start defined as 21/03/2020 and periods of industrial action (doctors (September 2019-January 2020) and nurses (June 2020-September 2020)) included, resulting in modelling during six time periods: pre-doctors' strike (baseline); doctors' strike; post-doctors' strike and pre-COVID; COVID and pre-nurses' strike; nurses' strike; post nurses' strike. Interrupted time series models were used to explore changes in indicators over time. Results: Of 8,333 neonates admitted to the NNU, 904 (11%) were HIV-exposed. Mothers of 706/765 (92%) HIV-exposed neonates reported receipt of antiretroviral therapy (ART) during pregnancy. Compared to the baseline period when average admissions were 78 per week (95% confidence interval (CI) 70-87), significantly fewer neonates were admitted during all subsequent periods until after the nurses' strike, with the lowest average number during the nurses' strike (28, 95% CI 23-34, p < 0.001). Across all time periods excluding the nurses strike, average mortality was 20% (95% CI 18-21), but rose to 34% (95% CI 25, 46) during the nurses' strike. There was no evidence for heterogeneity (p > 0.22) in numbers of admissions or mortality by HIV exposure status. Fewer HIV-exposed neonates received a PCR test during the pandemic (23%) compared to the pre-pandemic periods (40%) (RR 0.59, 95% CI 0.41-0.84, p < 0.001). The proportion of HIV-exposed neonates who received antiretroviral prophylaxis during admission was high throughout, averaging between 84% and 95% in each time-period. Conclusion: While antiretroviral prophylaxis for HIV-exposed neonates remained high throughout, concerning data on low admissions and increased mortality, similar in HIV-exposed and unexposed neonates, and reduced HIV testing, suggest some aspects of care may have been compromised due to indirect effects of the pandemic.
MeSH term(s)	Child ; Infant, Newborn ; Pregnancy ; Humans ; Female ; COVID-19/epidemiology ; Tertiary Care Centers ; Infectious Disease Transmission, Vertical/prevention & control ; Pandemics ; Zimbabwe/epidemiology ; HIV Infections/drug therapy ; HIV Infections/epidemiology
Language	English
Publishing date	2024-01-05
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2041342-7
ISSN	1471-2431 ; 1471-2431
ISSN (online)	1471-2431
ISSN	1471-2431
DOI	10.1186/s12887-023-04473-5
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Article ; Online: Development and Implementation of Digital Diagnostic Algorithms for Neonatal Units in Zimbabwe and Malawi: Development and Usability Study.

Gannon, Hannah / Larsson, Leyla / Chimhuya, Simbarashe / Mangiza, Marcia / Wilson, Emma / Kesler, Erin / Chimhini, Gwendoline / Fitzgerald, Felicity / Zailani, Gloria / Crehan, Caroline / Khan, Nushrat / Hull-Bailey, Tim / Sassoon, Yali / Baradza, Morris / Heys, Michelle / Chiume, Msandeni

JMIR formative research

2024 Volume 8, Page(s) e54274

Abstract: Background: Despite an increase in hospital-based deliveries, neonatal mortality remains high in low-resource settings. Due to limited laboratory diagnostics, there is significant reliance on clinical findings to inform diagnoses. Accurate, evidence- ... ...

Abstract	Background: Despite an increase in hospital-based deliveries, neonatal mortality remains high in low-resource settings. Due to limited laboratory diagnostics, there is significant reliance on clinical findings to inform diagnoses. Accurate, evidence-based identification and management of neonatal conditions could improve outcomes by standardizing care. This could be achieved through digital clinical decision support (CDS) tools. Neotree is a digital, quality improvement platform that incorporates CDS, aiming to improve neonatal care in low-resource health care facilities. Before this study, first-phase CDS development included developing and implementing neonatal resuscitation algorithms, creating initial versions of CDS to address a range of neonatal conditions, and a Delphi study to review key algorithms. Objective: This second-phase study aims to codevelop and implement neonatal digital CDS algorithms in Malawi and Zimbabwe. Methods: Overall, 11 diagnosis-specific web-based workshops with Zimbabwean, Malawian, and UK neonatal experts were conducted (August 2021 to April 2022) encompassing the following: (1) review of available evidence, (2) review of country-specific guidelines (Essential Medicines List and Standard Treatment Guidelinesfor Zimbabwe and Care of the Infant and Newborn, Malawi), and (3) identification of uncertainties within the literature for future studies. After agreement of clinical content, the algorithms were programmed into a test script, tested with the respective hospital's health care professionals (HCPs), and refined according to their feedback. Once finalized, the algorithms were programmed into the Neotree software and implemented at the tertiary-level implementation sites: Sally Mugabe Central Hospital in Zimbabwe and Kamuzu Central Hospital in Malawi, in December 2021 and May 2022, respectively. In Zimbabwe, usability was evaluated through 2 usability workshops and usability questionnaires: Post-Study System Usability Questionnaire (PSSUQ) and System Usability Scale (SUS). Results: Overall, 11 evidence-based diagnostic and management algorithms were tailored to local resource availability. These refined algorithms were then integrated into Neotree. Where national management guidelines differed, country-specific guidelines were created. In total, 9 HCPs attended the usability workshops and completed the SUS, among whom 8 (89%) completed the PSSUQ. Both usability scores (SUS mean score 75.8 out of 100 [higher score is better]; PSSUQ overall score 2.28 out of 7 [lower score is better]) demonstrated high usability of the CDS function but highlighted issues around technical complexity, which continue to be addressed iteratively. Conclusions: This study describes the successful development and implementation of the only known neonatal CDS system, incorporated within a bedside data capture system with the ability to deliver up-to-date management guidelines, tailored to local resource availability. This study highlighted the importance of collaborative participatory design. Further implementation evaluation is planned to guide and inform the development of health system and program strategies to support newborn HCPs, with the ultimate goal of reducing preventable neonatal morbidity and mortality in low-resource settings.
Language	English
Publishing date	2024-01-26
Publishing country	Canada
Document type	Journal Article
ISSN	2561-326X
ISSN (online)	2561-326X
DOI	10.2196/54274
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Article ; Online: Neonatal sepsis and antimicrobial resistance in Africa.

Iroh Tam, Pui-Ying / Bekker, Adrie / Bosede Bolaji, Olufunke / Chimhini, Gwendoline / Dramowski, Angela / Fitzgerald, Felicity / Gezmu, Alemayehu Mekonnen / Nkuranga, John Baptist / Okomo, Uduak / Stevenson, Alexander / Strysko, Jonathan P

The Lancet. Child & adolescent health

2023 Volume 7, Issue 10, Page(s) 677–679

MeSH term(s)	Infant, Newborn ; Humans ; Neonatal Sepsis/drug therapy ; Neonatal Sepsis/epidemiology ; Anti-Bacterial Agents/therapeutic use ; Drug Resistance, Bacterial ; Africa/epidemiology
Chemical Substances	Anti-Bacterial Agents
Language	English
Publishing date	2023-08-19
Publishing country	England
Document type	Editorial ; Research Support, Non-U.S. Gov't
ISSN	2352-4650
ISSN (online)	2352-4650
DOI	10.1016/S2352-4642(23)00167-0
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Article ; Online: What is broad-range 16S rDNA PCR?

Patel, Amani / Harris, Kathryn A / Fitzgerald, Felicity

Archives of disease in childhood. Education and practice edition

2017 Volume 102, Issue 5, Page(s) 261–264

MeSH term(s)	Bacteria/genetics ; Cell Culture Techniques ; Humans ; Polymerase Chain Reaction ; RNA, Bacterial/analysis ; RNA, Ribosomal, 16S/analysis
Chemical Substances	RNA, Bacterial ; RNA, Ribosomal, 16S
Language	English
Publishing date	2017-04-17
Publishing country	England
Document type	Journal Article
ZDB-ID	2148818-6
ISSN	1743-0593 ; 1743-0585
ISSN (online)	1743-0593
ISSN	1743-0585
DOI	10.1136/archdischild-2016-312049
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Article ; Online: Ebola response in Sierra Leone: The impact on children.

Fitzgerald, Felicity / Awonuga, Waheed / Shah, Tejshri / Youkee, Daniel

The Journal of infection

2016 Volume 72 Suppl, Page(s) S6–S12

Abstract: The West African Ebola virus disease (EVD) outbreak is the largest ever seen, with over 28,000 cases and 11,300 deaths since early 2014. The magnitude of the outbreak has tested fragile governmental health systems and non-governmental organizations (NGOs) ...

Abstract	The West African Ebola virus disease (EVD) outbreak is the largest ever seen, with over 28,000 cases and 11,300 deaths since early 2014. The magnitude of the outbreak has tested fragile governmental health systems and non-governmental organizations (NGOs) to their limit. Here we discuss the outbreak in the Western Area of Sierra Leone, the shape of the local response and the impact the response had on caring for children suspected of having contracted EVD. Challenges encountered in providing clinical care to children whilst working in the "Red Zone" where risk of EVD is considered to be highest, wearing full personal protective equipment are detailed. Suggestions and recommendations both for further research and for operational improvement in the future are made, with particular reference as to how a response could be more child-focused.
MeSH term(s)	Child ; Child Health ; Communicable Disease Control/methods ; Disease Outbreaks/prevention & control ; Epidemics ; Hemorrhagic Fever, Ebola/epidemiology ; Hemorrhagic Fever, Ebola/prevention & control ; Hemorrhagic Fever, Ebola/virology ; Humans ; Sierra Leone/epidemiology
Language	English
Publishing date	2016-05-11
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	424417-5
ISSN	1532-2742 ; 0163-4453
ISSN (online)	1532-2742
ISSN	0163-4453
DOI	10.1016/j.jinf.2016.04.016
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