Imperial College London

ProfessorKathMaitland

Faculty of MedicineDepartment of Infectious Disease

Professor of Tropical Paediatric Infectious Diseases
 
 
 
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Contact

 

k.maitland CV

 
 
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Assistant

 

Ms Sian Haynes +44 (0)20 7594 3683

 
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Location

 

Based full-time at KEMRI/Wellcome Programme, KenyaNorfolk PlaceSt Mary's Campus

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Summary

 

Publications

Publication Type
Year
to

224 results found

Olupot-Olupot P, Engoru C, Nteziyaremye J, Chebet M, Ssenyondo T, Muhindo R, Nyutu G, Macharia A, Uyoga S, Ndila CM, Karamagi C, Maitland K, Williams Tet al., 2020, The clinical spectrum of severe childhood malaria in Eastern Uganda, Malaria Journal, Vol: 19, ISSN: 1475-2875

BackgroundFew recent descriptions of severe childhood malaria have been published from high-transmission regions. In the current study, the clinical epidemiology of severe malaria in Mbale, Eastern Uganda, is described, where the entomological inoculation rate exceeds 100 infective bites per year.MethodsA prospective descriptive study was conducted to determine the prevalence, clinical spectrum and outcome of severe Plasmodium falciparum malaria at Mbale Regional Referral Hospital in Eastern Uganda. All children aged 2 months–12 years who presented on Mondays to Fridays between 8.00 am and 5.00 pm from 5th May 2011 until 30th April 2012 were screened for parasitaemia. Clinical and laboratory data were then collected from all P. falciparum positive children with features of WHO-defined severe malaria by use of a standardized proforma.ResultsA total of 10 208 children were screened of which 6582 (64%) had a positive blood film. Of these children, 662 (10%) had clinical features of severe malaria and were consented for the current study. Respiratory distress was the most common severity feature (554; 83.7%), while 365/585 (62.4%) had hyperparasitaemia, 177/662 (26.7%) had clinical jaundice, 169 (25.5%) had severe anaemia, 134/660 (20.2%) had hyperlactataemia (lactate ≥ 5 mmol/L), 93 (14.0%) had passed dark red or black urine, 52 (7.9%) had impaired consciousness and 49/662 (7.4%) had hypoxaemia (oxygen saturations < 90%). In-hospital mortality was 63/662 (9.5%) overall but was higher in children with either cerebral malaria (33.3%) or severe anaemia (19.5%). Factors that were independently associated with mortality on multivariate analysis included severe anaemia [odds ratio (OR) 5.36; 2.16–1.32; P = 0.0002], hyperlactataemia (OR 3.66; 1.72–7.80; P = 0.001), hypoxaemia (OR) 3.64 (95% CI 1.39–9.52; P = 0.008), and hepatomegaly (OR 2.29; 1.29–4.06; P = 

Journal article

Uyoga S, Wanjiku P, Rop J, Makale J, Macharia A, Nyutu G, Shebbe M, Awuondo K, Mturi N, Woodrow C, Dondorp A, Maitland K, Williams T, Williams TNet al., 2020, Plasma Plasmodium falciparum Histidine-Rich Protein-2 concentrations in children with malaria infections of differing severity in Kilifi, Kenya, Clinical Infectious Diseases, ISSN: 1058-4838

BackgroundMost previous studies support a direct link between total parasite load and the clinical severity of Plasmodium falciparum malaria infections.MethodsWe estimated P. falciparum parasite loads in three groups of children with malaria infections of differing severity: (1) children with WHO-defined severe malaria (n=1,544); (2) children admitted with malaria but without features of severity (n=200) and; (3) children in the community with asymptomatic parasitemia (n=33).ResultsPeripheral parasitemias were highest in those with uncomplicated malaria (geometric mean 111,064; 95%CI 86,798-141,819 parasites/μl), being almost three times higher than those with severe malaria (39,588; 34,990-44,791 parasites/μl) and >100 times higher than in those with asymptomatic malaria (1,092; 523-2,280 parasites/μl). However, geometric mean PfHRP2 values (95% CI) increased with severity, being 7 (4-12) ng/ml in asymptomatic malaria, 843 (655-1,084) ng/ml in uncomplicated malaria and 1,369 (1,244-1,506) ng/ml in severe malaria. PfHRP2 concentrations were markedly lower in the sub-group of severe malaria patients with concomitant invasive bacterial infections (IBIs) of blood or CSF (GM 312 ng/ml; 95%CI 175-557; p<0.0001) than in those without IBIs (GM 1,439 ng/ml; 1,307-1,584; P<0.001).ConclusionsThe clinical severity of malaria infections related strongly to the total burden of P. falciparum parasites. A quantitative test for plasma concentrations of PfHRP2 could be useful in identifying children at the greatest clinical risk and to identify critically ill children in whom malaria is not the primary cause.

Journal article

Maitland K, Kiguli S, Olupot-Olupot P, Engoru C, Mellewa M, Goncalves PS, Opoka RO, Mpoya A, Alaroker F, Nteziyaremye J, Chagaluka G, Kennedy N, Nabawanuka E, Nakuya M, Namayanja C, Uyoga S, Byabazaire DK, Mbaya B, Wabwire B, Frost G, Bates I, Evans JA, Williams T, George EC, Gibb DM, Walker ASet al., 2020, Transfusion in African Children with Uncomplicated Severe Anemia, New England Journal of Medicine, ISSN: 0028-4793

Journal article

Olupot-Olupot P, Wabwire H, Ndila C, Adong R, Ochen L, Amorut D, Abongo G, Okalebo CB, Akello SR, Oketcho JB, Okiror W, Asio S, Odiit A, Alaroker F, Nyutu G, Maitland K, Williams TNet al., 2020, Characterising demographics, knowledge, practices and clinical care among patients attending sickle cell disease clinics in Eastern Uganda [version 2; peer review: 2 approved], Wellcome Open Research, Vol: 5, Pages: 87-87, ISSN: 2398-502X

Background: In Uganda to date, there are neither established registries nor descriptions of facility-based sickle cell disease (SCD) patient characteristics beyond the central region. Here, we summarize data on the baseline clinical characteristics and routine care available to patients at four clinics in Eastern Uganda as a prelude to a clinical trial.Methods: Between February and August 2018, we conducted a cross-sectional survey of patients attending four SCD clinics in Mbale, Soroti, Atutur and Ngora, all in Eastern Uganda, the planned sites for an upcoming clinical trial (H-PRIME: ISRCTN15724013). Data on socio-demographic characteristics, diagnostic methods, clinic schedules, the use of prophylactic and therapeutic drugs, clinical complications and patient understanding of SCD were collected using a structured questionnaire.Results: Data were collected on 1829 patients. Their ages ranged from 0 to 64 years with a median (IQR) of 6 (3-11) years. 49.1% of participants were male. The majority (1151; 62.9%) reported a positive family history for SCD. Approximately half knew that SCD is inherited from both parents but a substantial proportion did not know how SCD is transmitted and small numbers believed that it is acquired by either transfusion or from other people. Only 118/1819 (6.5%) participants had heard about or were using hydroxyurea while 356/1794 (19.8%) reported stigmatization. Participants reported a median of three (IQR 1-4) hospital admissions during the preceding 12 months; 80.8% had been admitted at least once, while 14.2% had been admitted more than five times. Pain was the most common symptom, while 83.9% of those admitted had received at least one blood transfusion.Conclusion: The majority of patients attending SCD clinics in Eastern Uganda are children and few are currently being treated with hydroxyurea. The data collected through this facility-based survey will provide background data that will be useful in planning for the H-PRIME trial.

Journal article

Uyoga S, Mpoya A, Olupot-Olupot P, Kiguli S, Opoka RO, Engoru C, Mallewa M, Kennedy N, M'baya B, Kyeyune D, Wabwire B, Bates I, Gibb DM, Walker AS, George EC, Williams TN, Maitland Ket al., 2020, Corrigendum: Haematological quality and age of donor blood issued for paediatric transfusion to four hospitals in sub-Saharan Africa, Vox Sanguinis: international journal of transfusion medicine, Vol: 115, Pages: 478-478, ISSN: 0042-9007

Journal article

Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes Aet al., 2020, Surviving sepsis campaign, Critical Care Medicine, Vol: 48, Pages: e440-e469, ISSN: 0090-3493

Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.Methods: We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.Results: The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which four are best practice statements, nine are strong recommendations, and 35 are weak recommendations. No recommendation was provided for six questions. The topics were: 1) infection control, 2) laboratory diagnosis and specimens, 3) hemodynamic support, 4) ventilatory support, and 5) COVID-19 therapy.Conclusion: The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new evidence in further releases of these guidelines.

Journal article

Olupot-Olupot P, Wabwire H, Ndila C, Adong R, Ochen L, Amorut D, Abongo G, Okalebo CB, Akello SR, Okecho JB, Okiror W, Asio S, Odiit A, Alaroker F, Nyutu G, Maitland K, Williams Tet al., 2020, Characterising demographics, knowledge, practices and clinical care among patients attending sickle cell disease clinics in Eastern Uganda [version 1; peer review: 1 approved, 1 approved with reservations], Wellcome Open Research, Vol: 5, Pages: 1-13, ISSN: 2398-502X

Background: In Uganda to date, there are neither established registries nor descriptions of facility-based sickle cell disease (SCD) patient characteristics beyond the central region. Here, we summarize data on the baseline clinical characteristics and routine care available to patients at four clinics in Eastern Uganda as a prelude to a clinical trial.Methods: Between February and August 2018, we conducted a cross-sectional survey of patients attending four SCD clinics in Mbale, Soroti, Atutur and Ngora, all in Eastern Uganda, the planned sites for an upcoming clinical trial (H-PRIME: ISRCTN15724013). Data on socio-demographic characteristics, diagnostic methods, clinic schedules, the use of prophylactic and therapeutic drugs, clinical complications and patient understanding of SCD were collected using a structured questionnaire.Results: Data were collected on 1829 patients. Their ages ranged from 0 to 64 years with a median (IQR) of 6 (3-11) years. 50.9% of participants were male. The majority (1151; 62.9%) reported a positive family history for SCD. Approximately half knew that SCD is inherited from both parents but a substantial proportion did not know how SCD is transmitted and small numbers believed that it is acquired by either transfusion or from other people. Only 118/1819 (6.5%) participants had heard about or were using hydroxyurea while 356/1794 (19.8%) reported stigmatization. Participants reported a median of three (IQR 1-4) hospital admissions during the preceding 12 months; 80.8% had been admitted at least once, while 14.2% had been admitted more than five times. Pain was the most common symptom, while 83.9% of those admitted had received at least one blood transfusion.Conclusion: The majority of patients attending SCD clinics in Eastern Uganda are children and few are currently being treated with hydroxyurea. The data collected through this facility-based survey will provide background data that will be useful in planning for the H-PRIME trial.

Journal article

Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, Oczkowski S, Levy MM, Derde L, Dzierba A, Du B, Aboodi M, Wunsch H, Cecconi M, Koh Y, Chertow DS, Maitland K, Alshamsi F, Belley-Cote E, Greco M, Laundy M, Morgan JS, Kesecioglu J, McGeer A, Mermel L, Mammen MJ, Alexander PE, Arrington A, Centofanti JE, Citerio G, Baw B, Memish ZA, Hammond N, Hayden FG, Evans L, Rhodes Aet al., 2020, Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19), Intensive Care Medicine, Vol: 46, Pages: 854-887, ISSN: 0342-4642

BackgroundThe novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.MethodsWe formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.ResultsThe Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy.ConclusionThe Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.

Journal article

Walker SM, Cox E, Revill P, Musiime V, BwakuraDangarembizi M, Mallewa J, Cheruiyot P, Maitland K, Ford N, Gibb DM, Walker AS, Soares M, Mugyenyi P, Kityo C, Musiime V, Wavamunno P, Nambi E, Ocitti P, Ndigendawani M, Kabahenda S, Kemigisa M, Acen J, Olebo D, Mpamize G, Amone A, Okweny D, Mbonye A, Nambaziira F, Rweyora A, Kangah M, Kabaswahili V, Abach J, Abongomera G, Omongin J, Aciro I, Philliam A, Arach B, Ocung E, Amone G, Miles P, Adong C, Tumsuiime C, Kidega P, Otto B, Apio F, Baleeta K, Mukuye A, Abwola M, Ssennono F, Baliruno D, Tuhirwe S, Namisi R, Kigongo F, Kikyonkyo D, Mushahara F, Okweny D, Tusiime J, Musiime A, Nankya A, Atwongyeire D, Sirikye S, Mula S, Noowe N, Lugemwa A, Kasozi M, Mwebe S, Atwine L, Senkindu T, Natuhurira T, Katemba C, Ninsiima E, Acaku M, Kyomuhangi J, Ankunda R, Tukwasibwe D, Ayesiga L, Hakim J, Nathoo K, BwakuraDangarembizi M, Reid A, Chidziva E, Mhute T, Tinago GC, Bhiri J, Mudzingwa S, Phiri M, Steamer J, Nhema R, Warambwa C, Musoro G, Mutsai S, Nemasango B, Moyo C, Chitongo S, Rashirai K, Vhembo S, Mlambo B, Nkomani S, Ndemera B, Willard M, Berejena C, Musodza Y, Matiza P, Mudenge B, Guti V, Etyang A, Agutu C, Berkley J, Maitland K, Njuguna P, Mwaringa S, Etyang T, Awuondo K, Wale S, Shangala J, Kithunga J, Mwarumba S, Said Maitha S, Mutai R, Lozi Lewa M, Mwambingu G, Mwanzu A, Kalama C, Latham H, Shikuku J, Fondo A, Njogu A, Khadenge C, Mwakisha B, Siika A, WoolsKaloustian K, Nyandiko W, Cheruiyot P, Sudoi A, Wachira S, Meli B, Karoney M, Nzioka A, Tanui M, Mokaya M, Ekiru W, Mboya C, Mwimali D, Mengich C, Choge J, Injera W, Njenga K, Cherutich S, Anyango Orido M, Omondi Lwande G, Rutto P, Mudogo A, Kutto I, Shali A, Jaika L, Jerotich H, Pierre M, Mallewa J, Kaunda S, Van Oosterhout J, O'Hare B, Heydermann R, Gonzalez C, Dzabala N, Kelly C, Denis B, Selemani G, Nyondo Mipando L, Chirwa E, Banda P, Mvula L, Msuku H, Ziwoya M, Manda Y, Nicholas S, Masesa C, Mwalukomo T, Makhaza L, Sheha I, Bwanali J, Limbuni M, Gibb D, Thomaset al., 2020, The cost‐effectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa, Journal of the International AIDS Society, Vol: 23, Pages: 1-11, ISSN: 1758-2652

IntroductionMany HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the cost‐effectiveness of this enhanced‐prophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count.MethodsThe REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause.ResultsEnhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 <200 cells/mm3 population providing enhanced‐prophylaxis components are sourced at lowest available prices. The ICER reduced in more severely immunosuppressed individuals (US$113 per QALY in the CD4 <100 cells/mm3 population) and increased

Journal article

Jobarteh ML, McCrory MA, Lo B, Sun M, Sazonov E, Anderson AK, Jia W, Maitland K, Qiu J, Steiner-Asiedu M, Higgins JA, Baranowski T, Olupot-Olupot P, Frost Get al., 2020, Development and validation of objective, passive dietary assessment Method for estimating food and nutrient intake in households in Low and Middle-Income Countries (LMICs): a study protocol, Current Developments in Nutrition, Vol: 4, Pages: 1-11, ISSN: 2475-2991

Malnutrition is a major concern in low- and middle-income countries (LMIC), but the full extent of nutritional deficiencies remains unknown largely due to lack of accurate assessment methods. This study seeks to develop and validate an objective, passive method of estimating food and nutrient intake in households in Ghana and Uganda. Household members (including under-5s and adolescents) are assigned a wearable camera device to capture images of their food intake during waking hours. Using custom software, images captured are then used to estimate an individual's food and nutrient (i.e., protein, fat, carbohydrate, energy, and micronutrients) intake. Passive food image capture and assessment provides an objective measure of food and nutrient intake in real time, minimizing some of the limitations associated with self-reported dietary intake methods. Its use in LMIC could potentially increase the understanding of a population's nutritional status, and the contribution of household food intake to the malnutrition burden. This project is registered at clinicaltrials.gov (NCT03723460).

Journal article

George EC, Kiguli S, Olupot PO, Opoka RO, Engoru C, Akech SO, Nyeko R, Mtove G, Mpoya A, Thomason MJ, Crawley J, Evans JA, Gibb DM, Babiker AG, Maitland K, Walker ASet al., 2019, Mortality risk over time after early fluid resuscitation in African children, Critical Care (UK), Vol: 23, Pages: 1-9, ISSN: 1364-8535

BackgroundAfrican children hospitalised with severe febrile illness have a high risk of mortality. The Fluid Expansion As Supportive Therapy (FEAST) trial (ISCRTN 69856593) demonstrated increased mortality risk associated with fluid boluses, but the temporal relationship to bolus therapy and underlying mechanism remains unclear.MethodsIn a post hoc retrospective analysis, flexible parametric models were used to compare change in mortality risk post-randomisation in children allocated to bolus therapy with 20–40 ml/kg 5% albumin or 0.9% saline over 1–2 h or no bolus (control, 4 ml/kg/hour maintenance), overall and for different terminal clinical events (cardiogenic, neurological, respiratory, or unknown/other).ResultsTwo thousand ninety-seven and 1041 children were randomised to bolus vs no bolus, of whom 254 (12%) and 91 (9%) respectively died within 28 days. Median (IQR) bolus fluid in the bolus groups received by 4 h was 20 (20, 40) ml/kg and was the same at 8 h; total fluids received in bolus groups at 4 h and 8 h were 38 (28, 43) ml/kg and 40 (30, 50) ml/kg, respectively. Total fluid volumes received in the control group by 4 h and 8 h were median (IQR) 10 (6, 15) ml/kg and 10 (10, 26) ml/kg, respectively. Mortality risk was greatest 30 min post-randomisation in both groups, declining sharply to 4 h and then more slowly to 28 days. Maximum mortality risk was similar in bolus and no bolus groups; however, the risk declined more slowly in the bolus group, with significantly higher mortality risk compared to the no bolus group from 1.6 to 101 h (4 days) post-randomisation. The delay in decline in mortality risk in the bolus groups was most pronounced for cardiogenic modes of death.ConclusionsThe increased risk from bolus therapy was not due to a mechanism occurring immediately after bolus administration. Excess mortality risk in the bolus group resul

Journal article

Maitland K, Gibb DM, Babiker A, 2019, Secondary re-analysis of the FEAST trial, The Lancet Respiratory Medicine, Vol: 7, Pages: E29-E29, ISSN: 2213-2600

Journal article

Levin M, Cunnington AJ, Hoggart CJ, 2019, Secondary re-analysis of the FEAST trial - Authors' reply, The Lancet Respiratory Medicine, Vol: 7, Pages: e31-e31, ISSN: 2213-2600

Journal article

Maitland K, Olupot-Olupot P, Kiguli S, Chagaluka G, Alaroker F, Opoka RO, Mpoya A, Walsh K, Engoru C, Nteziyaremye J, Mallewa M, Kennedy N, Nakuya M, Namayanja C, Kayaga J, Nabawanuka E, Sennyondo T, Aromut D, Kumwenda F, Musika CW, Thomason MJ, Bates I, von Hensbroek MB, Evans JA, Uyoga S, Williams TN, Frost G, George EC, Gibb DM, Walker ASet al., 2019, Co-trimoxazole or multivitamin multimineral supplement for post-discharge outcomes after severe anaemia in African children: a randomised controlled trial, The Lancet Global Health, Vol: 7, Pages: e1435-e1447, ISSN: 2214-109X

BackgroundSevere anaemia is a leading cause of paediatric admission to hospital in Africa; post-discharge outcomes remain poor, with high 6-month mortality (8%) and re-admission (17%). We aimed to investigate post-discharge interventions that might improve outcomes.MethodsWithin the two-stratum, open-label, multicentre, factorial randomised TRACT trial, children aged 2 months to 12 years with severe anaemia, defined as haemoglobin of less than 6 g/dL, at admission to hospital (three in Uganda, one in Malawi) were randomly assigned, using sequentially numbered envelopes linked to a second non-sequentially numbered set of allocations stratified by centre and severity, to enhanced nutritional supplementation with iron and folate-containing multivitamin multimineral supplements versus iron and folate alone at treatment doses (usual care), and to co-trimoxazole versus no co-trimoxazole. All interventions were administered orally and were given for 3 months after discharge from hospital. Separately reported randomisations investigated transfusion management. The primary outcome was 180-day mortality. All analyses were done in the intention-to-treat population; follow-up was 180 days. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN84086586, and follow-up is complete.FindingsFrom Sept 17, 2014, to May 15, 2017, 3983 eligible children were randomly assigned to treatment, and followed up for 180 days. 164 (4%) were lost to follow-up. 1901 (95%) of 1997 assigned multivitamin multimineral supplement, 1911 (96%) of 1986 assigned iron and folate, and 1922 (96%) of 1994 assigned co-trimoxazole started treatment. By day 180, 166 (8%) children in the multivitamin multimineral supplement group versus 169 (9%) children in the iron and folate group had died (hazard ratio [HR] 0·97, 95% CI 0·79–1·21; p=0·81) and 172 (9%) who received co-trimoxazole versus 163 (8%) who did not receive co-trimoxazole h

Journal article

Uyoga S, Macharia AW, Mochamah G, Ndila CM, Nyutu G, Makale J, Tendwa M, Nyatichi E, Ojal J, Otiende M, Shebe M, Awuondo KO, Mturi N, Peshu N, Tsofa B, Maitland K, Scott JAG, Williams TNet al., 2019, The epidemiology of sickle cell disease in children recruited in infancy in Kilifi, Kenya: a prospective cohort study., The Lancet Global Health, Vol: 7, Pages: e1458-e1466, ISSN: 2214-109X

BACKGROUND: Sickle cell disease is the most common severe monogenic disorder in humans. In Africa, 50-90% of children born with sickle cell disease die before they reach their fifth birthday. In this study, we aimed to describe the comparative incidence of specific clinical outcomes among children aged between birth and 5 years with and without sickle cell disease, who were resident within the Kilifi area of Kenya. METHODS: This prospective cohort study was done on members of the Kilifi Genetic Birth Cohort Study (KGBCS) on the Indian Ocean coast of Kenya. Recruitment to the study was facilitated through the Kilifi Health and Demographic Surveillance System (KHDSS), which covers a resident population of 260 000 people, and was undertaken between Jan 1, 2006, and April 30, 2011. All children who were born within the KHDSS area and who were aged 3-12 months during the recruitment period were eligible for inclusion. Participants were tested for sickle cell disease and followed up for survival status and disease-specific admission to Kilifi County Hospital by passive surveillance until their fifth birthday. Children with sickle cell disease were offered confirmatory testing and care at a dedicated outpatient clinic. FINDINGS: 15 737 infants were recruited successfully to the KGBCS, and 128 (0·8%) of these infants had sickle cell disease, of whom 70 (54·7%) enrolled at the outpatient clinic within 12 months of recruitment. Mortality was higher in children with sickle cell disease (58 per 1000 person-years of observation, 95% CI 40-86) than in those without sickle cell disease (2·4 per 1000 person-years of observation, 2·0-2·8; adjusted incidence rate ratio [IRR] 23·1, 95% CI 15·1-35·3). Among children with sickle cell disease, mortality was lower in those who enrolled at the clinic (adjusted IRR 0·26, 95% CI 0·11-0·62) and in those with higher levels of haemoglobin F (HbF; adjusted IRR 0·

Journal article

Maitland K, Olupot-Olupot P, Kiguli S, Chagaluka G, Alaroker F, Opoka RO, Mpoya A, Walsh K, Engoru C, Nteziyaremye J, Mallewa M, Kennedy N, Nakuya M, Namayanja C, Kayaga J, Nabawanuka E, Sennyondo T, Aromut D, Williams Musika C, Kumwenda F, Thomason M, Bates I, Boele von Hensbroek M, Evans JA, Uyoga S, Williams TN, Frost G, George EC, Gibb DM, Walker ASet al., 2019, Cotrimoxazole or multi-mineral multi-vitamins to improve post-discharge outcomes following severe anaemia in African children: a randomised controlled trial, The Lancet Global Health, ISSN: 2214-109X

Background: Severe anaemia (haemoglobin<6g/dl) is a leading cause of paediatric admission inAfrica; post-discharge outcomes remain poor with high 6-month mortality (8%) and re-admission(17%). This trial aimed to investigate pragmatic post-discharge interventions that might improveoutcomes.Methods: Within the factorial open-label TRACT trial, Ugandan and Malawian children aged 2months-12 years with severe anaemia (haemoglobin <6g/dl) at hospital admission wererandomised (using sequentially-numbered envelopes linked to a second set of non-sequentiallynumbered allocations, stratified by centre and severity) to enhanced nutritional supplementationwith iron and folate-containing multi-vitamin multi-mineral supplements (MVMM) or iron/folateat treatment doses (usual care), and to cotrimoxazole versus no cotrimoxazole, both given for 3months post-discharge. Separately-reported randomisations investigated transfusionmanagement. The primary outcome was 180-day mortality analysed by intention-to-treat; followup was to 180-days (completed).Findings: 3983 eligible children were randomised and followed for 180-days [164(4%) lost-tofollow-up]. Treatment was initiated in 1901(95%) MVMM, 1911(96%) iron/folate and 1922(96%)cotrimoxazole. By day-180, 166(8%) MVMM vs 169(9%) iron/folate had died (hazardratio(HR)=0.97 (95% CI 0.79-1.21); p=0.81) and 172(9%) cotrimoxazole vs 163(8%) nocotrimoxazole had died (HR=1.07 (95% CI 0.86-1.32); p=0.56). No evidence was seen ofinteractions between these randomisations or with transfusion randomisations (p>0.2). By day180, 489(24%) MVMM vs 509(26%) iron/folate had experienced one or more SAEs (HR=0.95 (0.84-1.07), p=0.40) and 500(25%) cotrimoxazole vs 498(25%) no cotrimoxazole (HR=1.01 (0.89,1.15)p=0.85). Most SAEs were readmissions, occurring in 692(17%) children (175(4%) with ≥2 readmissions).Interpretation: Neither enhanced supplementation with MVMM versus iron/folate treatment orcotrimoxazole prophylaxis improved 6-month survival. H

Journal article

Maitland K, Ohuma EO, Mpoya A, Uyoga S, Hassall O, Williams TNet al., 2019, Informing thresholds for paediatric transfusion in Africa: the need for a trial [version 2; peer review: 2 approved], Wellcome open research, Vol: 4, Pages: 1-25, ISSN: 2398-502X

Background: Owing to inadequate supplies of donor blood for transfusion in sub-Saharan Africa (sSA) World Health Organization paediatric guidelines recommend restrictive transfusion practices, based on expert opinion. We examined whether survival amongst hospitalised children by admission haemoglobin and whether this was influenced by malaria infection and/or transfusion. Methods: A retrospective analysis of standardised clinical digital records in an unselected population of children admitted to a rural hospital in Kenya over an 8-year period. We describe baseline parameters with respect to categories of anaemia and outcome (in-hospital death) by haemoglobin (Hb), malaria and transfusion status. Results: Among 29,226 children, 1,143 (3.9%) had profound anaemia (Hb <4g/dl) and 3,469 (11.9%) had severe anaemia (Hb 4-6g/d). In-hospital mortality rate was 97/1,143 (8.5%) if Hb<4g/dl or 164/2,326 (7.1%) in those with severe anaemia (Hb ≥4.0-<6g/dl). Admission Hb <3g/dl was associated with higher risk of death versus those with higher Hbs (OR=2.41 (95%CI: 1.8 - 3.24; P<0.001), increasing to OR=6.36, (95%CI: 4.21-9.62; P<0.001) in malaria positive children. Conversely, mortality in non-malaria admissions was unrelated to Hb level. Transfusion was associated with a non-significant improvement in outcome if Hb<3g/dl (malaria-only) OR 0.72 (95%CI 0.29 - 1.78), albeit the number of cases were too few to show a statistical difference. For those with Hb levels above 4g/dl, mortality was significantly higher in those receiving a transfusion compared to the non-transfused group. For non-malarial cases, transfusion did not affect survival-status, irrespective of baseline Hb level compared to children who were not transfused at higher Hb levels. Conclusion: Although severe anaemia is common among children admitted to hospital in sSA (~16%), our data do not indicate that outcome is improved by transfusion irrespective of malaria status. Given the limitations

Journal article

Maitland K, Ohuma E, Mpoya A, Uyoga S, Hassall O, Williams Tet al., 2019, Informing thresholds for paediatric transfusion in Africa: the need for a trial [version 2: peer review: 2 approved], Wellcome Open Research, Vol: 4, ISSN: 2398-502X

Background : Owing to inadequate supplies of donor blood for transfusion in sub-Saharan Africa (sSA) World Health Organization paediatric guidelines recommend restrictive transfusion practices, based on expert opinion. We examined whether survival amongst hospitalised children by admission haemoglobin and whether this was influenced by malaria infection and/or transfusion. Methods : A retrospective analysis of standardised clinical digital records in an unselected population of children admitted to a rural hospital in Kenya over an 8-year period. We describe baseline parameters with respect to categories of anaemia and outcome (in-hospital death) by haemoglobin (Hb), malaria and transfusion status. Results : Among 29,226 children, 1,143 (3.9%) had profound anaemia (Hb <4g/dl) and 3,469 (11.9%) had severe anaemia (Hb 4-6g/d). In-hospital mortality rate was 97/1,143 (8.5%) if Hb<4g/dl or 164/2,326 (7.1%) in those with severe anaemia (Hb ≥4.0-<6g/dl). Admission Hb <3g/dl was associated with higher risk of death versus those with higher Hbs (OR=2.41 (95%CI: 1.8 - 3.24; P<0.001), increasing to OR=6.36, (95%CI: 4.21–9.62; P<0.001) in malaria positive children. Conversely, mortality in non-malaria admissions was unrelated to Hb level. Transfusion was associated with a non-significant improvement in outcome if Hb<3g/dl (malaria-only) OR 0.72 (95%CI 0.29 - 1.78), albeit the number of cases were too few to show a statistical difference. For those with Hb levels above 4g/dl, mortality was significantly higher in those receiving a transfusion compared to the non-transfused group. For non-malarial cases, transfusion did not affect survival-status, irrespective of baseline Hb level compared to children who were not transfused at higher Hb levels. Conclusion : Although severe anaemia is common among children admitted to hospital in sSA (~16%), our data do not indicate that outcome is improved by transfusion irrespective of malaria status. Given the li

Journal article

Maitland K, Olupot-Olupot P, Kiguli S, Chagaluka G, Alaroker F, Opoka RO, Mpoya A, Engoru C, Nteziyaremye J, Mallewa M, Kennedy N, Nakuya M, Namayanja C, Kayaga J, Uyoga S, Byabazaire DK, M'baya B, Wabwire B, Frost G, Bates I, Evans JA, Williams TN, Goncalves PS, George EC, Gibb DM, Walker ASet al., 2019, Transfusion Volume for Children with Severe Anemia in Africa, New England Journal of Medicine, Vol: 381, Pages: 420-431, ISSN: 0028-4793

BackgroundSevere anemia (hemoglobin level, <6 g per deciliter) is a leading cause of hospital admission and death in children in sub-Saharan Africa. The World Health Organization recommends transfusion of 20 ml of whole-blood equivalent per kilogram of body weight for anemia, regardless of hemoglobin level.MethodsIn this factorial, open-label trial, we randomly assigned Ugandan and Malawian children 2 months to 12 years of age with a hemoglobin level of less than 6 g per deciliter and severity features (e.g., respiratory distress or reduced consciousness) to receive immediate blood transfusion with 20 ml per kilogram or 30 ml per kilogram. Three other randomized analyses investigated immediate as compared with no immediate transfusion, the administration of postdischarge micronutrients, and postdischarge prophylaxis with trimethoprim–sulfamethoxazole. The primary outcome was 28-day mortality.ResultsA total of 3196 eligible children (median age, 37 months; 2050 [64.1%] with malaria) were assigned to receive a transfusion of 30 ml per kilogram (1598 children) or 20 ml per kilogram (1598 children) and were followed for 180 days. A total of 1592 children (99.6%) in the higher-volume group and 1596 (99.9%) in the lower-volume group started transfusion (median, 1.2 hours after randomization). The mean (±SD) volume of total blood transfused per child was 475±385 ml and 353±348 ml, respectively; 197 children (12.3%) and 300 children (18.8%) in the respective groups received additional transfusions. Overall, 55 children (3.4%) in the higher-volume group and 72 (4.5%) in the lower-volume group died before 28 days (hazard ratio, 0.76; 95% confidence interval [CI], 0.54 to 1.08; P=0.12 by log-rank test). This finding masked significant heterogeneity in 28-day mortality according to the presence or absence of fever (>37.5°C) at screening (P=0.001 after Sidak correction). Among the 1943 children (60.8%) without fever, mortality was lower with

Journal article

Maitland K, Kiguli S, Olupot-Olupot P, Engoru C, Mallewa M, Saramago Goncalves P, Opoka RO, Mpoya A, Alaroker F, Nteziyaremye J, Chagaluka G, Kennedy N, Nabawanuka E, Nakuya M, Namayanja C, Uyoga S, Kyeyune Byabazaire D, M'baya B, Wabwire B, Frost G, Bates I, Evans JA, Williams TN, George EC, Gibb DM, Walker AS, TRACT Groupet al., 2019, Immediate Transfusion in African Children with Uncomplicated Severe Anemia., The New England journal of medicine, Vol: 381, Pages: 407-419, ISSN: 0028-4793

BACKGROUND:The World Health Organization recommends not performing transfusions in African children hospitalized for uncomplicated severe anemia (hemoglobin level of 4 to 6 g per deciliter and no signs of clinical severity). However, high mortality and readmission rates suggest that less restrictive transfusion strategies might improve outcomes. METHODS:In this factorial, open-label, randomized, controlled trial, we assigned Ugandan and Malawian children 2 months to 12 years of age with uncomplicated severe anemia to immediate transfusion with 20 ml or 30 ml of whole-blood equivalent per kilogram of body weight, as determined in a second simultaneous randomization, or no immediate transfusion (control group), in which transfusion with 20 ml of whole-blood equivalent per kilogram was triggered by new signs of clinical severity or a drop in hemoglobin to below 4 g per deciliter. The primary outcome was 28-day mortality. Three other randomizations investigated transfusion volume, postdischarge supplementation with micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. RESULTS:A total of 1565 children (median age, 26 months) underwent randomization, with 778 assigned to the immediate-transfusion group and 787 to the control group; 984 children (62.9%) had malaria. The children were followed for 180 days, and 71 (4.5%) were lost to follow-up. During the primary hospitalization, transfusion was performed in all the children in the immediate-transfusion group and in 386 (49.0%) in the control group (median time to transfusion, 1.3 hours vs. 24.9 hours after randomization). The mean (±SD) total blood volume transfused per child was 314±228 ml in the immediate-transfusion group and 142±224 ml in the control group. Death had occurred by 28 days in 7 children (0.9%) in the immediate-transfusion group and in 13 (1.7%) in the control group (hazard ratio, 0.54; 95% confidence interval [CI], 0.22 to 1.36; P = 0.19) and

Journal article

Uyoga S, Maitland K, 2019, Use of whole blood as the routine transfusion product in Africa, ISBT Science Series, Vol: 14, Pages: 300-307, ISSN: 1751-2816

In many countries in sub-Saharan Africa (sSA) whole blood is more commonly available from blood transfusion services than red cell concentrates. Although in recent years many countries have made significant progress in the implementing component preparation, this has largely been facilitated by external funding support. None of the sSA countries are leucocyte-reducing or irradiating blood for transfusion. Systems for the routine detection of adverse consequences of blood transfusions (hemovigilance) only exist where transfusion safety has been identified as a health priority by the government. As a resource the availability of blood transfusion in these countries is limited since less than 5 units of blood were donated per 1000 population far below the recommended requirement of 20 units/1000 per year. Young children are the main users of blood for transfusion in these sSA regions, largely due severe anaemia secondary to infection and sickle cell anaemia. Outcomes for children with severe anaemia are poor, even in those receiving a transfusion. Although it has been speculated that this may be due to transfusion-related cardiac or pulmonary events available data from observational studies and clinical trials indicates that these are rare complications of transfusion. Evidence from clinical physiology studies including those examining myocardial function before and after the receipt of whole blood provide reassuring evidence that volume overload is rare and clinical trials reporting outcomes in children receiving whole blood transfusion, including a Phase II trial examining higher volumes, indicate that there is no evidence of cardiac or pulmonary overload events.

Journal article

Njuguna P, Maitland K, Nyaguara A, Mwanga D, Mogeni P, Mturi N, Mohammed S, Mwambingu G, Ngetsa C, Awuondo K, Lowe B, Adetifa I, Scott JAG, Williams TN, Atkinson S, Osier F, Snow RW, Marsh K, Tsofa B, Peshu N, Hamaluba M, Berkley JA, Newton CRJ, Fondo J, Omar A, Bejon Pet al., 2019, Observational study: 27 years of severe malaria surveillance in Kilifi, Kenya, BMC Medicine, Vol: 17, ISSN: 1741-7015

BACKGROUND: Many parts of Africa have witnessed reductions in Plasmodium falciparum transmission over the last 15 years. Since immunity to malaria is acquired more rapidly at higher transmission, the slower acquisition of immunity at lower transmission may partially offset the benefits of reductions in transmission. We examined the clinical spectrum of disease and predictors of mortality after sustained changes in transmission intensity, using data collected from 1989 to 2016. METHODS: We conducted a temporal observational analysis of 18,000 children, aged 14 days to 14 years old, who were admitted to Kilifi County Hospital, Kenya, from 1989 to 2016 with malaria. We describe the trends over time of the clinical and laboratory criteria for severe malaria and associated risk of mortality. RESULTS: During the time periods 1989-2003, 2004-2008, and 2009-2016, Kilifi County Hospital admitted averages of 657, 310, and 174 cases of severe malaria per year including averages of 48, 14, and 12 malaria-associated deaths per year, respectively. The median ages in years of children admitted with cerebral malaria, severe anaemia, and malaria-associated mortality were 3.0 (95% confidence interval (CI) 2.2-3.9), 1.1 (95% CI 0.9-1.4), and 1.1 (95% CI 0.3-2.2) in the year 1989, rising to 4.9 (95% CI 3.9-5.9), 3.8 (95% CI 2.5-7.1), and 5 (95% CI 3.3-6.3) in the year 2016. The ratio of children with cerebral malaria to severe anaemia rose from 1:2 before 2004 to 3:2 after 2009. Hyperparasitaemia was a risk factor for death after 2009 but not in earlier time periods. CONCLUSION: Despite the evidence of slower acquisition of immunity, continued reductions in the numbers of cases of severe malaria resulted in lower overall mortality. Our temporal data are limited to a single site, albeit potentially applicable to a secular trend present in many parts of Africa.

Journal article

Houston KA, Gibb J, Olupot-Olupot P, Obonyo N, Mpoya A, Nakuya M, Muhindo R, Uyoga S, Evans JA, Connon R, Gibb DM, George EC, Maitland Ket al., 2019, Gastroenteritis aggressive versus slow treatment for rehydration (GASTRO): a phase II rehydration trial for severe dehydration: WHO plan C versus slow rehydration, BMC Medicine, Vol: 17, ISSN: 1741-7015

BackgroundWorld Health Organization rehydration management guidelines (plan C) for severe dehydration are widely practiced in resource-poor settings, but never formally evaluated in a trial. The Fluid Expansion as a Supportive Therapy trial raised concerns regarding the safety of bolus therapy for septic shock, warranting a formal evaluation of rehydration therapy for gastroenteritis.MethodsA multi-centre open-label phase II randomised controlled trial evaluated two rehydration strategies in 122 Ugandan/Kenyan children aged 60 days to 12 years with severe dehydration secondary to gastroenteritis. We compared the safety and efficacy of standard rapid rehydration using Ringer’s lactate (100 ml/kg over 3 h (6 h if < 1 year), incorporating 0.9% saline boluses for children with shock (plan C) versus slower rehydration: 100 ml/kg Ringer’s lactate over 8 h (all ages) without boluses (slow: experimental). The primary outcome was the frequency of serious adverse events (SAE) within 48 h including cardiovascular, respiratory and neurological complications. Secondary outcomes included clinical, biochemical and physiological measures of response to treatment by intravenous rehydration.ResultsOne hundred twenty-two eligible children (median (IQR) age 8 (6–12) months) were randomised to plan C (n = 61) or slow (n = 61), with two (2%) lost to follow-up at day 7). Following randomisation mean (SD) time to start intravenous rehydration started was 15 min (18) in both arms. Mean (SD) fluid received by 1 hour was greater in plan C (mean 20.2 ml/kg (12.2) and 33.1 ml/kg (17) for children < 1 year and >− 1 year respectively) versus 10.4 ml/kg (6.6) in slow arm. By 8 hours volume received were similar mean (SD) plan C: 96.3 ml/kg (15.6) and 97.8 ml/kg (10.0) for children < 1 and ≥ 1 year respectively vs 93.2 ml/kg (12.2) in slow arm. By 48-h, three (5%) plan C vs two (3%) slow had an SAE

Journal article

Uyoga S, Macharia AW, Mochamah G, Ndila CM, Nyutu G, Makale J, Tendwa M, Nyatichi E, Ojal J, Otiende M, Shebe M, Awuondo KO, Mturi N, Peshu N, Tsofa B, Maitland K, Scott JAG, Williams Tet al., The epidemiology of sickle cell disease in Kilifi, Kenya: A prospective cohort study of children recruited in infancy, The Lancet Global Health, ISSN: 2214-109X

BackgroundSickle cell disease (SCD) is the commonest severe monogenic disorder of humans. In Africa, 50-90% of children born with SCD die before they reach their fifth birthday. Through the current study, we aimed to describe the comparative incidence of a range of specific clinical outcomes among children aged 3 months-5 years with and without SCD who were resident within the Kilifi area of Kenya. Methods We conducted a prospective study among a cohort of children on the coast of Kenya. Members were typed for SCD and followed for survival status and disease-specific admission to Kilifi County Hospital by passive surveillance. Children with SCD were offered confirmatory testing and care at a dedicated outpatient clinic. FindingsOf 15,702 infants recruited to the study one-hundred-and-twenty-eight (0.8%) had SCD of whom 70 (54.7%) enrolled at the clinic. Mortality was higher in children with SCD than in those without [58 versus 2.4/1000PYO; adjusted Incidence Rate Ratio (aIRR) 23.1, 95% CI 15.1-35.3]. Among SCD children, mortality was lower in those who enrolled at the clinic (aIRR 0.26; 0.11-0.62) and in those with higher levels of Haemoglobin F (HbF) (aIRR 0.40; 0.17-0.94). The incidence of admission to hospital was also higher in children with than without SCD (210 versus 43/1000PYO; aIRR 4.80; 3.84-6.15). The most common reason for admission among those with SCD was severe anaemia (a haemoglobin concentration of <50g/L) [incidence 48 (32-71)/1000PYO]. Rates were lower in those with higher levels of HbF (aIRR 0.43; 0.2-0.7) or with co-existing homozygous -thalassaemia (aIRR 0.07; 0.01-0.83). InterpretationWhile both morbidity and mortality remain high in young children with SCD in this Kenyan cohort, both are reduced by early diagnosis and supportive care. The emphasis now must move towards early detection and on the prevention of long-term complications. FundingThe study was funded by Senior Research Fellowships awarded to TNW (091758 and 202800) and JAGS (09

Journal article

McCrory M, Sun M, Sazonov E, Frost G, Anderson A, Jia W, Jobarteh ML, Maitland K, Steiner-Asiedu M, Ghosh T, Higgins JA, Baranowski T, Lo Bet al., 2019, Methodology for objective, passive, image- and sensor-based assessment of dietary intake, meal-timing, and food-related activity in Ghana and Kenya (P13-028-19)., Current Developments in Nutrition, Vol: 3, Pages: 1247-1247, ISSN: 2475-2991

Objectives: Herein we describe a new system we have developed for assessment of dietary intake, meal timing, and food-related activities, adapted for use in low- and middle-income countries. Methods: System components include one or more wearable cameras (the Automatic Ingestion Monitor-2 (AIM), an eyeglasses-mounted wearable chewing sensor and micro-camera; ear-worn camera; the eButton, a camera attached to clothes; and eHat, a camera attached to a visor worn by the mother when feeding infants and toddlers), and custom software for evaluation of dietary intake from food-based images and sensor-detected food intake. General protocol: The primary caregiver of the family uses one or more wearable cameras during all waking hours. The cameras aim directly in front of the participant and capture images every few seconds, thereby providing multiple images of all food-related activities throughout the day. The camera may be temporarily removed for short periods to preserve privacy, such as during bathing and personal care. For analysis, images and sensor signals are processed by the study team in custom software. The images are time-stamped, arranged in chronological order, and linked with sensor-detected eating occasions. The software also incorporates food composition databases of choice such as the West African Foods Database, a Kenyan Foods Database, and the USDA Food Composition Database, allowing for image-based dietary assessment by trained nutritionists. Images can be linked with nutritional analysis and tagged with an activity label (e.g., food shopping, child feeding, cooking, eating). Assessment of food-related activities such as food-shopping, food gathering from gardens, cooking, and feeding of other family members by the primary caregiver can help provide context for dietary intake and additional information to increase accuracy of dietary assessment and analysis of eating behavior. Examples of the latter include assessment of specific ingredients in prepared

Journal article

Dauncey JW, Olupot-Olupot P, Maitland K, 2019, Healthcare-provider perceptions of barriers to oxygen therapy for paediatric patients in three government-funded eastern Ugandan hospitals; a qualitative study, BMC Health Services Research, Vol: 19, ISSN: 1472-6963

BackgroundThis study aimed to assess on-the-ground barriers to the provision of oxygen therapy for paediatric patients in three government-funded Eastern Ugandan district general hospitals (DGHs).MethodsSite visits to DGHs during March 2017 involved semi-structured interviews with medical officers, clinical officers, paediatric nurses and non-clinical staff (n = 29). MAXQDA qualitative data software was used to assist with response analysis.ResultsThe healthcare professionals reported that erratic electricity supplies, few and/or malfunctioning oxygen cylinders and concentrators, limited or no access to pulse oximetry, inadequate staffing and lack of continued professional training were key barriers to the delivery of oxygen therapy. Local populations were reportedly fearful of oxygen therapy and reluctant to consent for oxygen therapy to be administered to their children.ConclusionAccording to healthcare providers in three Eastern Ugandan DGHs, numerous barriers exist to oxygen therapy for paediatric patients. Healthcare professionals reported lack of facilities and training to effectively deliver oxygen therapy. Quality improvement work prioritising oxygen therapy in government-funded district general hospitals should focus on oxygen supply and delivery issues on a site-specific level and sensitizing communities to the potential benefits of oxygen.

Journal article

Obonyo NG, Byrne L, Tung J-P, Simonova G, Diab SD, Dunster KR, Passmore MR, Boon A-C, See Hoe L, Engkilde-Pedersen S, Esguerra-Lallen A, Fauzi MH, Pimenta LP, Millar JE, Fanning JP, Van Haren F, Anstey CM, Cullen L, Suen J, Shekar K, Maitland K, Fraser JFet al., 2019, Pre-clinical study protocol: Blood transfusion in endotoxaemic shock, MethodsX, Vol: 6, Pages: 1124-1132, ISSN: 2215-0161

The Surviving Sepsis Campaign (SCC) and the American College of Critical Care Medicine (ACCM) guidelines recommend blood transfusion in sepsis when the haemoglobin concentration drops below 7.0 g/dL and 10.0 g/dL respectively, while the World Health Organisation (WHO) guideline recommends transfusion in septic shock ‘if intravenous (IV) fluids do not maintain adequate circulation’, as a supportive measure of last resort. Volume expansion using crystalloid and colloid fluid boluses for haemodynamic resuscitation in severe illness/sepsis, has been associated with adverse outcomes in recent literature. However, the volume expansion effect(s) following blood transfusion for haemodynamic circulatory support, in severe illness remain unclear with most previous studies having focused on evaluating effects of either different RBC storage durations (short versus long duration) or haemoglobin thresholds (low versus high threshold) pre-transfusion.• We describe the protocol for a pre-clinical randomised controlled trial designed to examine haemodynamic effect(s) of early volume expansion using packed RBCs (PRBCs) transfusion (before any crystalloids or colloids) in a validated ovine-model of hyperdynamic endotoxaemic shock.• Additional exploration of mechanisms underlying any physiological, haemodynamic, haematological, immunologic and tissue specific-effects of blood transfusion will be undertaken including comparison of effects of short (≤5 days) versus long (≥30 days) storage duration of PRBCs prior to transfusion.

Journal article

Maitland K, 2019, Emergency fluid bolus therapy studies: first do no harm., Archives of Disease in Childhood, Vol: 104, Pages: 409-410, ISSN: 1468-2044

Journal article

Uyoga S, Mpoya A, Olupot-Olupot P, Kiguli S, Opoka RO, Engoru C, Mallewa M, Kennedy N, M'baya B, Kyeyune D, Wabwire B, Bates I, Gibb DM, Walker AS, George EC, Williams TN, Maitland Ket al., 2019, Haematological quality and age of donor blood issued for paediatric transfusion to four hospitals in sub-Saharan Africa, Vox Sanguinis, Vol: 114, Pages: 340-348, ISSN: 0042-9007

Background and ObjectivesPaediatric blood transfusion for severe anaemia in hospitals in sub-Saharan Africa remains common. Yet, reports describing the haematological quality of donor blood or storage duration in routine practice are very limited. Both factors are likely to affect transfusion outcomes. Materials and MethodsWe undertook 3 audits examiningthe distribution of pack types, haematological quality and storage duration of donor blood used in a paediatric clinical trial of blood at four hospitals in Africa (Uganda and Malawi). ResultsThe overall distribution of whole blood, packed cells(plasma-reduced by centrifugation) and red cell concentrates (RCC) (plasma-reduced by gravity-dependent sedimentation)used in a randomised trial was 40.7% (N=1215), 22.4% (N=669) and 36.8% (N=1099) respectively.The first audit found similar median haematocrits of 57.0% (50.0,74.0), 64.0% (52.0,72.5;p=0.238vs whole blood) and 56.0% (48.0,67.0;p=0.462) in whole blood, RCCand packed cells respectively, which resulted from unclear pack labelling by blood transfusion services (BTS). Retraining of the BTS, hospital blood banks and clinical teams led to, in subsequent audits, significant differences in medianhaematocrit and haemoglobins across the 3 pack types and values within expected ranges. Median storage duration time was 12 days (IQR 6,19) with 18.2% (537/2964) over 21 days in storage. Initially, 9 (2.8%)packswere issued past the recommended duration of storage, dropping to 0.3%(N=7) in the third audit post training. ConclusionThe study highlights the importance of close interactions and education between BTS and clinical services and the importance of haemovigilence to ensure safe transfusion practice.

Journal article

Passmore MR, Obonyo NG, Byrne L, Boon A-C, Diab SD, Dunster KR, Fung YL, Spanevello MM, Fauzi MH, Pedersen SE, Simonovah G, Anstey CM, Shekar K, Tung J-P, Maitland K, Fraser JFet al., 2019, Fluid resuscitation with 0.9% saline alters haemostasis in an ovine model of endotoxemic shock, Thrombosis Research: vascular obstruction, hemorrhage and hemostasis, Vol: 176, Pages: 39-45, ISSN: 0049-3848

IntroductionFluid resuscitation is a cornerstone of severe sepsis management, however there are many uncertainties surrounding the type and volume of fluid that is administered. The entire spectrum of coagulopathies can be seen in sepsis, from asymptomatic aberrations to fulminant disseminated intravascular coagulation (DIC). The aim of this study was to determine if fluid resuscitation with saline contributes to the haemostatic derangements in an ovine model of endotoxemic shock.Materials and methodsTwenty-one adult female sheep were randomly divided into no endotoxemia (n = 5) or endotoxemia groups (n = 16) with an escalating dose of lipopolysaccharide (LPS) up to 4 μg/kg/h administered to achieve a mean arterial pressure below 60 mmHg. Endotoxemia sheep received either no bolus fluid resuscitation (n = 8) or a 0.9% saline bolus (40 mL/kg over 60 min) (n = 8). No endotoxemia, saline only animals (n = 5) underwent fluid resuscitation with a 0.9% bolus of saline as detailed above. Hemodynamic support with vasopressors was initiated if needed, to maintain a mean arterial pressure (MAP) of 60-65 mm Hg in all the groups.ResultsRotational thromboelastometry (ROTEM®) and conventional coagulation biomarker tests demonstrated sepsis induced derangements to secondary haemostasis. This effect was exacerbated by saline fluid resuscitation, with low pH (p = 0.036), delayed clot initiation and formation together with deficiencies in naturally occurring anti-coagulants antithrombin (p = 0.027) and Protein C (p = 0.001).ConclusionsEndotoxemia impairs secondary haemostasis and induces changes in the intrinsic, extrinsic and anti-coagulant pathways. These changes to haemostasis are exacerbated following resuscitation with 0.9% saline, a commonly used crystalloid in clinical settings.

Journal article

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