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We assessed paediatric care in the 13 public hospitals in the north-east of the United Republic of Tanzania to determine if diagnoses and treatments were consistent with current guidelines for care. Data were collected over a five-day period in each site where paediatric outpatient consultations were observed, and a record of care was extracted from the case notes of children on the paediatric ward. Additional data were collected from inspection of ward supplies and hospital reports. Of 1181 outpatient consultations, basic clinical signs were often not checked; e.g. of 895 children with a history of fever, temperature was measured in 57%, and of 657 of children with cough or dyspnoea only 57 (9%) were examined for respiratory rate. Among 509 inpatients weight was recorded in the case notes in 250 (49%), respiratory rate in 54 (11%) and mental state in 47 (9%). Of 206 malaria diagnoses, 123 (60%) were with a negative or absent slide result, and of these 44 (36%) were treated with quinine only. Malnutrition was diagnosed in 1% of children admitted while recalculation of nutritional Z-scores suggested that between 5% and 10% had severe acute malnutrition; appropriate feeds were not present in any of the hospitals. A diagnosis of HIV-AIDS was made in only two cases while approximately 5% children admitted were expected to be infected with HIV in this area. Clinical assessment of children admitted to paediatric wards is disturbingly poor and associated with missed diagnoses and inappropriate treatments. Improved assessment and records are essential to initiate change, but achieving this will be a challenging task.

Objective Rapid diagnostic tests for malaria seem cost effective in standard analyses, but these do not take account of clinicians’ response to test results. This study tested the impact of clinicians’ response to rapid diagnostic test or microscopy results on the costs and benefits of testing at different levels of malaria transmission and in different age groups.Design Cost-benefit analysis using a decision tree model and clinical data on the effectiveness of diagnostic tests for malaria, their costs, and clinicians’ response to test results.Setting Tanzania.Methods Data were obtained from a clinical trial of 2425 patients carried out in three settings of varying transmission.Results At moderate and low levels of malaria transmission, rapid diagnostic tests were more cost beneficial than microscopy, and both more so than presumptive treatment, but only where response was consistent with test results. At the levels of prescription of antimalarial drugs to patients with negative tests that have been found in observational studies and trials, neither test methodis likely to be cost beneficial, incurring costs 10-250% higher, depending on transmission rate, than would have been the case with fully consistent responses to all test results. Microscopy becomes more cost beneficial than rapid diagnostic tests when its sensitivity under operational conditions approaches that of rapid diagnostic tests.Conclusions Improving diagnostic methods, including rapid diagnostic tests, can reduce costs and enhance the benefits of effective antimalarial drugs, but only if the consistency of response to test results is also improved. Investing in methods to improve rational response to tests is essential. Economic evaluations of diagnostic tests should take into account whether clinicians’ response is consistent with test results.

Objectives To assess the performance of WHO’s “Guidelines for care at the first-referral level in developing countries” in an area of intense malaria transmission and identify bacterial infections in children with and without malaria.Design Prospective study.Setting District hospital in Muheza, northeast Tanzania. Participants Children aged 2 months to 13 years admitted to hospital for febrile illness.Main outcome measures Sensitivity and specificity of WHO guidelines in diagnosing invasive bacterial disease; susceptibility of isolated organisms to recommended antimicrobials.Results Over one year, 3639 children were enrolled and 184 (5.1%) died; 2195 (60.3%) were blood slide positive for Plasmodium falciparum, 341 (9.4%) had invasive bacterial disease, and 142 (3.9%) were seropositive for HIV. The prevalence of invasive bacterial disease was lower in slide positive children (100/2195, 4.6%) than in slide negative children (241/1444, 16.7%). Non-typhi Salmonella was the most frequently isolated organism (52/100 (52%) of organisms in slide positive children and 108/241 (45%) in slide negative children). Mortality among children with invasive bacterial disease was significantly higher (58/341, 17%) than in children without invasive bacterial disease (126/3298, 3.8%) (P<0.001), and this was true regardless of the presence of P falciparum parasitaemia. The sensitivity and specificity of WHO criteria in identifying invasive bacterial disease in slide positive children were 60.0% (95% confidence interval 58.0% to 62.1%) and 53.5% (51.4% to 55.6%), compared with 70.5% (68.2% to 72.9%) and 48.1% (45.6% to 50.7%) in slide negative children. In children with WHO criteria for invasive bacterial disease, only 99/211(47%) of isolated organisms were susceptible to the first recommended antimicrobial agent.Conclusions In an area exposed to high transmission of malaria, current WHO guidelines failed to identify almost a third of children with invasive bacterial disease, and more than half of the organisms isolated were not susceptible to currently recommended antimicrobials. Improved diagnosis and treatment of invasive bacterial disease are needed to reduce childhood mortality.

Objective Tanzania has a policy of free provision of inpatient care for young children in order to promote timely access and thus reduce the current levels of mortality. However, little is known about out-of-pocket costs that may be incurred by families in seeking care for sick children. We conducted this study to identify the magnitude of these costs in relation to family income. Methods Five hundred and ten caretakers were interviewed on the day of discharge of their child from 11 hospitals in north-east Tanzania. Caretakers were asked to report expenditure related to hospitalization in various categories and family wealth was assessed through reported expenditure in the previous month. Results Food (mean US$2.2, median US$1.6), transport (mean US$1.7, median US$0) and medicines (mean US$1.0, median US$0.4) were the leading categories of expenditure, and overall the mean out-of-pocket expenditure was US$5.5 (median US$3.7) per admission. Mean out-of-pocket expenditure was more than 1.5 times higher for households in the highest monthly expenditure quintile compared with those in the lowest. However, this differential was reversed when expenditure was considered as a proportion of family expenditure in the previous month; for the lowest quintile, families spent more than three-quarters of their total monthly expenditure on a single paediatric admission. Conclusion Out-of-pocket expenditure on child hospitalization places a considerable burden on poor families. Our findings justify a closer scrutiny of how this expenditure could be reduced, particularly through the provision of adequate food for both children and caretakers and through reducing stock-outs of essential medicines.

Among 509 inpatients weight was recorded in the case notes in 250 (49%), respiratory rate in 54 (11%) and mental state in 47 (9%). Of 206 malaria diagnoses, 123 (60%) were with a negative or absent slide result, and of these 44 (36%) were treated with quinine only. Malnutrition was diagnosed in 1% of children admitted while recalculation of nutritional Z-scores suggested that between 5% and 10% had severe acute malnutrition; appropriate feeds were not present in any of the hospitals. A diagnosis of HIV-AIDS was made in only two cases while approximately 5% children admitted were expected to be infected with HIV in this area. Sur 509 patients hospitalises, le poids a ete enregistre dans le dossier dans 250 cas (49 %), la frequence respiratoire dans 54 cas (11%) et l'etat mental dans 47 cas (9 %). Sur 206 diagnostics de paludisme, 123 (60 %) avaient ete etablis en presence d'un resultat negatif de l'examen sur lame ou en l'absence d'un tel resultat et 44 (36 %) des cas etaient traites par la quinine uniquement. Une malnutrition a ete diagnostiquee chez 1% des enfants hospitalises, alors qu'un nouveau calcul des z-scores evaluant I'etat nutritionnel laissait prevoir une malnutrition aigue severe chez 5 a 10 % de ces enfants. Aucun des hopitaux ne disposait d'aliments appropries pour de tels cas. Un depistage du VIH/sida n'avait ete pratique que chez 2 patients, alors qu'on peut s'attendre & ce qu'environ 5 % des enfants hospitalises soient infectes par le VIH dans cette zone. Metodos Durante un periodo de cinco dias se reunieron datos en cada uno de los sitios donde se observaron las consultas de pediatria ambulatoria, y se elaboro un registro de la atencion dispensada a partir de las notas de seguimiento de los ninos atendidos en la sala de pediatria. Se obtuvieron tambien otros datos mediante la inspeccion de los suministros de sala y los informes hospitalarios. De 509 ninos hospitalizados, se registro el peso en las notas de seguimiento de 250 (49%), la frecuencia respiratoria en 54 (11%), y el estado mental en 47 (9%). De 206 diagnosticos de malaria, 123 (60%) se hicieron con frotis negativo o sin frotis, y 44 (36%) de esos casos fueron tratados solo con quinina. Se diagnostico malnutricion en un 1% de los ninos ingresados, mientras que recalculando los valores zeta nutricionales se pudo deducir que un 5%-10% de ellos habian sufrido malnutricion aguda grave; ninguno de los hospitales disponia de los alimentos apropiados. Solo se diagnostico VIH/SIDA en dos ninos, cuando lo previsible en la zona era que hubiese aproximadamente un 5% de casos entre los ninos ingresados. [TEXT NOT REPRODUCIBLE IN ASCII]

OBJECTIVE: We assessed paediatric care in the 13 public hospitals in the north-east of the United Republic of Tanzania to determine if diagnoses and treatments were consistent with current guidelines for care. METHODS: Data were collected over a five-day period in each site where paediatric outpatient consultations were observed, and a record of care was extracted from the case notes of children on the paediatric ward. Additional data were collected from inspection of ward supplies and hospital reports. FINDINGS: Of 1181 outpatient consultations, basic clinical signs were often not checked; e.g. of 895 children with a history of fever, temperature was measured in 57%, and of 657 of children with cough or dyspnoea only 57 (9%) were examined for respiratory rate. Among 509 inpatients weight was recorded in the case notes in 250 (49%), respiratory rate in 54 (11%) and mental state in 47 (9%). Of 206 malaria diagnoses, 123 (60%) were with a negative or absent slide result, and of these 44 (36%) were treated with quinine only. Malnutrition was diagnosed in 1% of children admitted while recalculation of nutritional Z-scores suggested that between 5% and 10% had severe acute malnutrition; appropriate feeds were not present in any of the hospitals. A diagnosis of HIV-AIDS was made in only two cases while approximately 5% children admitted were expected to be infected with HIV in this area. CONCLUSION: Clinical assessment of children admitted to paediatric wards is disturbingly poor and associated with missed diagnoses and inappropriate treatments. Improved assessment and records are essential to initiate change, but achieving this will be a challenging task.