Journal of the Eritrean Medical Association

Lower extremity deep vein thrombosis among intensive care patients in Orotta national referral hospital, Asmara, Eritrea

G Hagos

Background: Deep Venous Thrombosis (DVT) with Venous Thromboembolism (VTE) is a major health problem with high mortality throughout the world. The patients at risk must be identified and given appropriate prophylaxis in order to decrease the mortality. Objective: To investigate and identify risk factors associated with DVT. Design: A retrospective medical chart review. Setting: Orotta National Referral Hospital, the largest teaching hospital in Eritrea. Methods: Review of medical records of all patients with final diagnosis of DVT between January 2005 and December 2008. Results: Of the 1,110 ICU admissions, 91 (8%) had lower extremity DVT. The mean age of these patients was 50 years and male to female ratio was 0.9 to 1. One or more risk factors for DVT from the following list; associated medical conditions contributed to 23 cases (25%), followed by post delivery(19%), major surgery (15%), malignancy (11%), pregnancy (6%), post trauma (6%), varicose vein (3%) and previous DVT (2%) were identified in 98% of the cases in the study population. Two or more risk factors were documented in 41% of the cases. The maximum number of DVT cases was recorded in the age-group of 30 to 39 years. In the absence of other known risk factors, age of 50 and above was observed as a risk factor in (11%) of the cases. No risk factor was identified in 2% of the cases. None of these patients had received any form of prophylaxis. Conclusion: Like elsewhere in the world, in Eritrea, DVT is a major health problem. Medical, surgical conditions and puerperium are among the most important risk factors identified. Prophylaxis against VTE was highly under utilised by the physicians and was not provided to any of the patients in the study. This study emphasizes the urgent need to implement DVT risk stratification strategy and to provide prophylaxis unless contraindicated.

The profile of CT scan findings in acute head trauma in Orotta Hospital, Asmara, Eritrea

M Mebrahtu-Ghebrehiwet, L Quan, T Andebirhan

Background: There are variations in outcomes of radiological investigations of head injuries in different studies from different countries. The use of investigation modalities are influenced by socioeconomic and cost effectiveness of the tests. Objective and methods: The purpose of the present five months observational study was to describe the profile of cranial computed tomography (CT) scan findings of 110 cases of acute head trauma in Orotta Hospital. Results: The mean age of the entire series was 32.5 years with SD of 20.9 years. The overall male to female ratio was 3:1. The commonest causes of head injury were falls (36.4%), car accident (29.0%), stone injuries (15%), and bicycle accident (9%). Abnormal CT findings were seen in 60 cases (54.5 %) and normal CT in 50 (45.5%). The most common CT findings were: intra cerebral hematoma 22 (20. %), cerebral contusion or laceration 18 (16.4%), skull fractures 16 (6%), and scalp swelling 3 (2.7%). Conclusion: The high prevalence of head trauma related CT findings justify the use of CT in acute head trauma in Eritrea. However; it should be done only when clinically indicated in order to reduce cost and avoid unnecessary irradiation.

Quality of Maternity Care at Health Facilities in Eritrea in 2008

Objective: To examine the quality of maternal health services at health facilities in Eritrea. Methods: The study was a cross-sectional survey of all hospitals and health centers and a random sample of a third of health stations. Extensive interviews with health providers and facility managers were undertaken using structured questionaires. Findings: The key findings of the study include: All hospitals and all health centers provided Basic Obstetric Emergency Care. However, only 11 of the 18 hospitals provided Comprehensive Obstetric Emergency Care including caesarian section. The national referral hospital treated 54 percent of obstetric complications, while health centers and health stations are not proportionally sharing the burden of work. Recommendations: Eritrean health system which was performing well with the current demand for services can improve its outputs. Upgrading of the function of existing facilities by strengthening the human resource capacity is needed to increase availability of emergency obstetric care by more than one third, using the existing physical structure of health facilities. Keywords: Maternity care, Quality, availability, accessibility, continuity, management, infrastrScope, Editorial

Caesarian section rates in private and public hospitals in Eritrea in 2007

B Sebhatu, A Zehaie

Background: Caesarian section is one of the skilled delivery attendance interventions that have proven to be a life saver. There are standard indications for its use in delivery. The practice of cesarean section in public and private hospitals has not been studied in Eritrea. Objective: The purpose of this retrospective descriptive study was to examine the practice of caesarian section in public and private hospital in Eritrea. Methods: The study used caesarian section data of 2007 from Orotta (public) and Sembel (private) maternity hospitals. The data was collected from the delivery records of both hospitals and was analyzed according to the time of the operation, indications, outcomes, and method of anesthesia used during the caesarian sections. Results: The rate of caesarian section delivery in this study was 10.4% [95% CI 9.3-11.5] in the public and 31.3% [95% CI of 26.2-36.4%] in the private hospital (p < 0.001). In the public hospital 75.3% of the operations were emergency caesarian sections as compared to 47.6% in the private hospital (p<0.001). Conclusion: The indications for the operations in public and private hospitals were compliant with international benchmarks. The different rates could be attributable to that private hospital was serving more of those who required elective operations.

Maternity waiting homes: A panacea for maternal/neonatal conundrums in Eritrea

G Andemichael, B Haile, A Kosia, J Mufunda

Background: Maternal mortality which is partly due to low skilled care delivery is still less than 30% in most developing countries including Eritrea. Maternity waiting homes were introduced in Eritrea in 2007 as a strategy to mitigate against the attendant high maternal mortality rates in hard to reach regions. Objective: To assess pregnancy outcomes verified through maternal mortality and perinatal mortality rates since the introduction of maternity waiting homes in some hard to reach sub-zobas of Eritrea. Methods: A rapid assessment of the maternity waiting homes was conducted in six sub-zobas of Northern and Southern Red Sea Zones during the period April 20-29, 2009 using questionnaires administered to health workers, community members, traditional birth attendants and the beneficiaries. Results: Heads of a total of 11 health facilities, community leaders, TBAs and mothers who stayed in the maternity waiting homes were interviewed. A total of 862 mothers had delivered in the 20 months since the introduction of the maternity homes from September 2007 till April 2009 averaging 425 annually compared to 266 deliveries in the same facilities prior to introduction of the waiting homes. No maternal death was recorded in the health facilities during that period. There were seven neonatal deaths and seven still births during the same period making the peri-natal death rate of 1.6%. Conclusion: Deliveries in the maternal waiting homes increased deliveries by 56% with no maternal deaths reported, making it a successful strategy targeted at reducing maternal and perinatal mortality rates. The study recommends the upscaling of the strategy because it is costeffective and acceptable to the community as evidenced by the support provided by the community.

Magnitude and Causes of Maternal Deaths at Health Facilities in Eritrea in 2007.

Objective: To measure the level of maternal mortality in health facilities as well as the magnitude and proportion of obstetric complications in health facilities in Eritrea. Methods: The study was a cross-sectional survey of all hospitals and health centers in Eritrea and a random sample of around a third of health stations. Medical records of all patients who encountered obstetric complications in 2007 were reviewed. Findings: The main causes of obstetric complications among hospital admissions in 2007 were abortion complications (45.6%), obstructed/prolonged labor (18.4%), abnormal fetal presentation (10.3%) and preeclampsia/ eclampsia (7.7%). The number of maternal deaths at facilities was relatively small. Out of the 6,315 patients who were admitted for obstetric complications in 2007, 41 were classified as maternal deaths. The leading causes of maternal deaths included pre-eclampsia/ eclampsia in 22.0 percent of the cases, abortion complications in 19.5 percent of the cases and postpartum sepsis in 17.1 percent of the cases and post-partum hemorrhage in 14.6 percent of cases. The case-fatality rate for obstetric complications was low at 0.75 percent. The majority of maternal deaths (65 percent) occurred in the post-partum period, while 32 percent occurred during the ante-partum period, and 3 percent during intra-partum or during labor or delivery Conclusion: Over all it can be concluded that the Eritrean health system is performing well with the current demand for services. The issue of abortion requires special attention because it is the leading obstetric complication, which accounts for 46 percent of maternal complications and is responsible for one fifth of maternal deaths. Although the case fatality rate of all obstetric complications combined is not high (0.75 percent), the cause specific case fatality rates for the leading causes of maternal mortality was high Keywords: Maternal mortality, obstetric complications, abortion, case fatality rate

Integration of pediatric mental health in general pediatrics in eritrea: improving access and collaboration

P Joshi, S Haile, F Gebremichael, A Aden, M Anderson

Background: Recognition of mental health problems among children continues to be a diagnostic challenge especially in resource poor countries where integration of such services within the primary health care framework has not been fully successfully. Objective: To document the prevailing mental services among children in Eritrea Methods: prospective descriptive study on policies, practices and interventions targeted at improvement of mental health services among children in Eritrea. Results: The Pediatric Residency Programme established at Orotta School Postgraduate School of Medicine developed a curriculum which was sensitive to recognition and management of mental disorders among children. Of a total of 42 children with mental health disorders, one third had anxiety disorders, 30% had pervasive developmental disorders one quarter psychosomatic disorders and 10% had behaviour disorders predominantly attention deficit disorder. Two illustrative cases have been presented to highlight the challenges and the requisite solutions. Conclusion: The establishment of the Pediatric residency with a dedicated curriculum to address mental health services has contributed to the awareness and integration of such services with primary health care in Eritrea.

Situation Analysis of Medico-Legal Issues in Asmara, Eritrea, in 2008

T Gebremariam, M Hagos

Background: The Transitional Civil Code of Eritrea (TCCE) enshrines general principles of professional ethics and responsibilities and general principles of ethics have been rendered by training institutions to medical personnel. However, there is serious gap of principles of ethical rules and legislations that serves as binding source governing medico-legal issues in the context of Eritrea. Objective: The general objective of the Study is to examine the situation of medico-legal issues in Eritrea and to have baseline data about the knowledge, attitude and awareness of the society, health professionals and legal practitioners on medico-legal issues. Methods: The Study adheres to a structured questionnaire and personal interview with semi-structured checklists developed and administered to respondents to address the socio-demographic data, awareness, attitude, knowledge and practices among randomly selected representatives of health workers, clients and legal practitioners. The Study was done in 3 National Referral Hospitals in Asmara namely, Orotta National Referral Medical Surgical Hospital, Orotta National Referral Maternity Hospital, Berhan Aini Referral Hospital and the High Court and Attorney General’s Office. Results: : A total of 144 respondents were interviewed; 75 clients, 54 health workers and 15 legal practitioners. The most common medico-legal issues identified in the Study are road traffic accidents, rape, homicidal injury and suicide, question of paternity, age determination, abortion, medical record asked by court, insurance, work accident and unknown cause of homicide. The identified medico-legal issues are consistent with the reports from the health personnel and legal practitioners. The health workers know well about their duties and the rights of their patients in rendering medical care. However, they lack the knowledge on the legal basis of their relationship with their clients. Nevertheless, the three hospitals use informed consent in the form of both written and oral forms; 94.1% in the form of written document and the remaining 5.9% orally. So far, there are no comprehensively legislated laws or approved detailed rules that govern the relationship of health personnel and the public. Consequently, there have been few medico-legal cases adjudicated before the courts. The few adjudicated cases were raised by the clients against certain members of health personnel. Conclusion and recommendations: The Study concludes that the knowledge and awareness of the health workers, the public and legal practitioners on medico-legal issues have been gradually increasing. The Study has identified inadequate medical expertise, such as pathologists (post-mortem expertise), psychiatrists and Geneticians (DNA analysis). Furthermore, the Study discovered lack of medical instruments and technical know how to address medicolegal issues, such as paternity and unknown cause of death of human being. The Study, therefore, recommends legislation of public health law that specifically deals with ethical principles, medical professional rights, duties and powers and training of medical expertise specifically on pathology, DNA analysis and psychiatry. Furthermore, the Study recommends inclusion of comprehensive medico-legal curricula in training medical personnel.

The quality of water served in the Orotta National Referral Hospital

Background: The principal risks to human health associated with the consumption of unsafe drinking water are microbiological. According to the WHO and UNICEF report 2.6 billion people do not have access to good quality of water. About 1.1 billion people globally do not have access. About 2 million people mostly of less than 5 years children also die as a result of diarrheal diseases related to consumption of water that is microbiologically contaminated. Objective: The objective of this study was to measure the quality of water served to the different sections of Orotta National Referral Hospital using WHO protocols. Methods: Water samples were collected from different sources in the National Referral Orotta Hospital compound according to the WHO guidelines and the multi-tube method or most probable number method was used for the microbiological count. Results: The findings from the study showed that some of the samples of water from National Referral Pediatric Hospital, and National Medical and Surgical Referral Hospital reservoirs did not meet some of the WHO guidelines for safe drinking water. Conclusion and recommendations: The water contamination emanated from the reservoirs of the Orotta Hospital, because the samples taken as a control from outside the Hospital compound were free of contamination. Water reservoirs should be washed on regular basis. Chlorination and other treatment modalities for the water in the reservoir should also be considered and applied. Water quality surveillance should be done several times in a year not only just once.

Knowledge, attitudes and practices (KAP) about malaria among people visiting referral hospitals of Eritrea in 2008

H Habtai, T Ghebremeskel, S Mihreteab, J Mufunda, A Ghebremichael

Background: Knowledge, attitudes, awareness, practices and beliefs of communities contribute immensely to sustainable control of endemic diseases such as malaria. Strategic malaria control involves primary prevention which focuses on vector elimination and personal behavior change specifically through the consistent use of insecticide-treated nets (ITNs) and prompt and effective case management. This health facility based study was conducted to investigate the knowledge, attitudes and practices toward malaria among people visiting referral Hospitals of Eritrea, so as to develop a cost effective behavioral change communication strategy for community based malaria control. Methods: The study was conducted in the Referral Hospitals of the four Zobas as well as Teseney Hospital where there was the highest malaria morbidity and mortality. A total of 250 people with 50 people from each hospital were randomly selected. A structured questionnaire covering information on respondent demographics, knowledge, attitudes and practices was administered upon receipt of an informed consent for participation. Results: All the study subjects knew at least one of the symptoms of malaria with nearly three quarters mentioning three or more of the classical symptoms including fever. More than 80% knew that mosquitoes were the vector for the disease with a similar proportion having participated in environmental preventive control measures. Nearly half (44.6%) of the respondents gave priority for usage of ITNs to children under 5 years, to both children and pregnant mother and 11.2% to pregnant mothers. Conclusion: The majority of the respondents in this study knew enough information about malaria, and had participated in environmental preventive measures. The primary prevention of malaria through uninterrupted use of ITNs and transformation of knowledge into practices requires emphasis on the development of a community based behavioral change communication strategy. Key words: KAP, malaria, Behavioral change communication strategy, Eritrea, ITNs

Effectiveness of the new water source intervention in reducing diarrheal diseases in Ghindae community, Eritrea

A Kebedom, T Teclebirhan, J Mufunda, A Gebremicheal

Background: Diarrheal diseases are an important cause of morbidity and mortality in developing countries particularly in children. In Ghindae, a town 45 km from Asmara the capital city of Eritrea, diarrheal diseases were the commonest disease among all age groups. Based on findings from operational research, the old water supply of the town was believed to be the main source of the disease. A new water supply system was built for the community. Objective: The objective of this study was to evaluate the effectiveness of the new water supply system intervention in reducing diarrheal diseases in Ghindae community. Methods: Retrospective study was done base on the records of the Hospital. Results: The incidence of diarrhea decreased by 15% after the introduction of a new water distribution system. The decrease was 44% for giardiasis and 25% for amoebiasis. There was no change in the bloody diarrhea disease burden. Conclusion: The incidence of diarrhea was still unacceptably high in spite of the revamping of the water system, an observation which calls upon other contributory factors such as point use contamination and socio-economic status.

Use integrated management of childhood illnesses guidelines: a need for adaptation for use in Ghindae hospital, Eritrea

A Kebedom, T Teclebirhan, W Beyene, J Mufunda, A Gebremicheal

Background: Diarrheal diseases are among the commonest causes of morbidity and mortality among infants and young children in the developing world and most commonly in the sub-Saharan including Eritrea. Integrated Management of Childhood Illnesses (IMCI) is a strategy developed by UNICEF and WHO for developing countries and other resource poor countries currently being practiced in Africa, Asia, and South America. IMCI guidelines are simplified system of diagnosis and treatment that is designed for use by health workers with limited training and little or no laboratory support. According to this guideline bloody diarrhea is treated with ORS, additional fluid support and cotrimoxazole empirically with the assumption that the etiologic agent is shigella. If the child does not improve on follow up then metronidazole is added with the assumption that the etiologic agent is parasitic mainly amoeba and giardia. Objective: The objective of this study was to assess the use of IMCI guidelines in children presenting with diarrhea at Ghindae Hospital. Methods: The study was a prospective in which all children below the age of 5 years, who presented primarily with all forms of diarrhea during the one month period from June 1st 2008 to June 30 2008, were included in the study. All stool samples were subjected to laboratory analysis. Results: Eighty seven children who presented with all forms of diarrhea to the IMCI OPD or as IPD were included in the study. More than 50% of the cases had parasitic infestation mainly Amoeba and Giardia. Less than 5% of the children presented with mild or severe dehydration. The majority (92%) of the cases had no dehydration had diarrhea with no dehydration. Conclusion: In Ghindae community there is a justification for use of metronidazole as a first line treatment of bloody diarrhea, because of the preponderance of parasitic infestation instead of bacterial causes for the majority of cases of children presenting with diarrhea, a clear need for adaptation of IMCI

Systemic lupus Erythematosus: 2 case reports from Eritrea

A Zerai

Systemic Lupus Erythematosus is an autoimmune disorder, occurring predominantly in women during reproductive age and characterized by the presence of antibodies in the serum against the nuclear components (ANA), leading to inflammation in kidney, brain, and skin manifestations. The diversity of the disease the clinical presentation with the accumulation of manifestations over time and the fluctuant disease course challenges many clinicians. Two cases of Systemic Lupus Erythematosus with different manifestations revealing, challenges in diagnostic, treatment, follow up and bleak prognosis are presented.

Tropical Splenomegaly Syndrome in a pregnant woman: A good response and prognosis to splenectomy

A Tesfamariam, Y Zekarias, A Tekle

The tropical splenomegaly syndrome (TSS) is characterized by massive splenomegaly with hypersplenism, moderate hepatomegaly, and lymphocytic infiltration of the hepatic sinusoids. TSS is restricted to native residents of and visitors to the “malaria belt,” which roughly encompasses equatorial regions of South America, Africa, the Middle East, South Asia, and Southeast Asia. A 24 years old female patient gravida II and para I with gestational age 24 weeks from south west of Eritrea (Shelallo) Gash Barka presented with dizziness, general body weakness, and abdominal discomfort for 3 weeks and left upper quadrant swelling of three years duration. Other associate symptoms were palpitation and dyspnea. She had history of repeated malaria attack. Physical examination revealed massive hepatosplenomegaly and pallor. Hematological studies revealed that severe anemia Hgb 3.8 g/dL, WBC 2.2× 103/mm3, MCV 97.6fl. Platelet 30×103/mm3, and reticulocyte count was 7%. Peripheral smear examination revealed normocytic normochromic red blood cells. Bone marrow examination revealed marked erythroid hyperplasia without sign of malignancy and left shift. The patient received 11 units of blood preoperative but, no improvement Hb remaining 3.7g/dl. Elective splenectomy was done. Intra-operatively and postoperatively she received an additional 5 units of blood. There was no postoperative complication. The patient was discharged with Hb of 6.0g/dl with slight improvement. The response to splenectomy was good. Four months postoperative and 40 days post delivery Hbg 16.3g/dl and platelet 254,000/mm and WBC 5000/ mm3. The outcome and prognosis of splenectomy in this patient was satisfactory.

Leech as a cause of abnormal vaginal bleeding: Presentation of three cases in adults

K Asrat

Vaginal bleeding in women during their reproductive years is a common presentation with diverse list of potential causes and hence differential diagnosis. The definitive diagnosis relies on meticulous history taking, past obstetric/gynecological and medical history as well as a judicious examination including speculum examination. Leech bites are a recognized cause of bleeding from any human orifice upon exposure to water which is infested with leeches. A high level of suspicion is necessary to make the diagnosis and institute cost-effective definitive treatment for leech bite induced bleeding including vaginal bleeding as has been revealed by the three cases presented in this report.

Vaginal bleeding in 6 years old young female: diagnostic challenge

H Habtai, T Teclebirhan, B Hebtezghi, J Mufunda

A 6 year old young girl was referred to Mendefera (Zoba Debub Referral) Hospital with vaginal bleeding of 4 days duration. She had a history of swimming in a river prior to the incident. An aquatic leech bloated with blood detached from the vagina after 100 milliliters of normal saline flushing into the vagina. The patient was discharged on the second day postremoval of the leech, on amoxicillin for 7 days and follow up. Health professionals must be aware of the possibility of leech bites in the vagina as the differential diagnosis for abnormal vaginal bleeding, especially in places where leech infestation is common, a high index of suspicion is of great help to make an early diagnosis and treatment. Key words: KAP, malaria, Behavioral change communication strategy, Eritrea, ITNs

Thoracopagus: a first case of incomplete conjoint twins in Eritrea

Z Ogbe

An eight hour old boy with incomplete duplication of the head was admitted in a tertiary paediatric referral hospital in Asmara, the capital city of Eritrea. The incompletely developed head with the neck of one twin was attached to the much larger and more fully developed one on the anterior aspect (ventral) of the chest. This abnormal union or fixation is termed thoracopagus which is the second most common distribution of ventral unions, parapagus (pelvis and variable trunk) being the most common. Although thoracopagus twins are more frequent, omphalopagus twins are more commonly encountered at birth, due to lower fetal mortality. The neonate also presented with multiple abnormalities, omphalocele, and congenital heart disease with VSD, deformed left external ear, high arched palate and supernumerary digit on the left 5th finger of the hand.

Timing, choice and duration of perioperative prophylactic antibiotic use in surgery: A teaching hospital based experience from Eritrea, in 2009

Y Yohannes, Y Mengesha, Y Tewelde

Background: The continuum from surgically clean, through antiseptic techniques to the use of perioperative antibiotic prophylaxis has revolutionized surgical practice and significantly reduced morbidity. Adherence to use of prophylactic antibiotic guidelines varies in different set ups and different diseases. Objective: To document the practice of perioperative prophylactic antibiotic use in a teaching hospital in Eritrea Methods: This is a prospective study conducted in 2009 in Halibet Hospital, Asmara, Eritrea Results: One hundred and one patients were enrolled in the study. Sixty nine percent received prophylactic antibiotics. Of these, 30% were preoperatively and 39% postoperatively. Twenty one percent the majority of whom were in the clean/contaminated group did not receive the required prophylaxis. The surgery site infection rate was 6% mostly from emergency operations recognized during the period of hospitalization. Discussion and conclusion: The use of prophylactic antibiotics in Halibet Hospital needs to be standardized and monitored based on evidence and international benchmarks.

Prevention of mother to child transmission of HIV/AIDS in Eritrea: the Eritrean experience

T Teclebirhan, A Berhane, J Mufunda, A Gebremichael

one third of live deliveries can be reduced to <2% through antiretroviral prophylaxis. The study was done to determine the effectiveness of prevention of mother to child transmission (PMTCT) of HIV/AIDS in Eritrea where skilled care delivery is less than 30%. Objective: The objective of this study was to assess the use of IMCI guidelines in children presenting with diarrhea at Ghindae Hospital. Methods: The retrospective study analyzed medical records of pregnant HIV positive women and their children before the introduction of PMTCT in 2002, while the prospective study followed up children born to pregnant HIV positive women who received PMTCT from 2006 to 2008. Findings: Twenty seven and 4.8% of the children born to HIV positive women prior to and after PMTCT were HIV positive when tested for HIV using ELISA at 18 months. Conclusion: Health promotion targeted at scaling up skilled care delivery attendance can further reduce childhood morbidity and mortality from HIV/AIDS. Keywords: PMTCT, Antiretroviral drugs, skilled care delivery, counseling.