
For the hundreds of children who arrive every day at hospitals in parts of Africa unconscious and unresponsive, their survival chances have remained unchanged for nearly 50 years. But new research ihas suggested that a different – and simpler – approach could improve those chances.
Despite huge strides in healthcare and vaccination rates for children in sub Saharan Africa, the odds remain poor for those who become so ill they fall into a coma. Depending on the cause, between 17% and 45% are expected to die. Many more will be left with disabilities.
“It can become depressing,” says Dr Alice Muiruri-Liomba, who works in Blantyre, Malawi.
Now researchers have found that giving antibiotics immediately a child arrives at hospital could save tens of thousands of lives a year – and getting them to specialist care quickly could also reduce deaths and disability.
An analysis of multiple studies published in the Lancet Global Health shows that most of these children have a complication of malaria, called cerebral malaria. The second most common identified cause is bacterial meningitis.
A second study by the same team, focusing on Queen Elizabeth hospital in Blantyre, found that one in four children hospitalised in a coma with malaria also had bacterial infection.
“Too often, malaria parasites found in the blood of a sick African child stop medical staff looking for and treating additional bacterial infections,” says Dr Stephen Ray of the Oxford Vaccine Group, the study’s principal investigator.
“You treat the malarial parasites as the cause of the coma, and then actually that becomes a risk factor for dying from a bacterial underlying infection that has been untreated … we need to just make sure everyone that comes in with febrile coma gets antibiotics, as well as antimalarials.”
Making that standard practice could change how 2.3 million children a year in Africa are treated and save more than 20,000 lives, Ray says.
Data is patchy, but studies and doctors’ observations suggest non-traumatic coma is much more common among children in sub-Saharan Africa than it is in the global north.
“A child comes in, unfortunately, quite a lot later down the line than they would in a UK setting,” says Ray. That can mean “at up to a day, or over a day, of full, deep coma. Completely unconscious, unable to communicate, completely disoriented, with a very high fever.”
Those symptoms would prompt a UK ambulance “within minutes”. In Malawi, it can take days.
“That delay is catastrophic – we showed with brain scans, by the time they get to you, they’ve actually got quite a lot of neurological complications: brain swelling, brain injury,” says Ray.
Muiruri-Liomba says transport is an issue for families.
“We have cases where you have a mother carrying a convulsing child on her back the whole night, walking to a health facility. Then they get there, and in this health facility you don’t have ambulances … so these mothers are forced to go and source their own transport to a bigger hospital.”
Muiruri-Liomba works at Queen Elizabeth central hospital – which is relatively well resourced, boasting the country’s only portable MRI scanner. .
District hospitals can be poorly equipped with medicine shortages and basic facilities.
Children will usually have been treated at home, then at a clinic and a district hospital before reaching Queen Elizabeth, Muiruri-Liomba says. “We only take patients to the hospital once they complicate – and what that tells me is that they don’t understand the danger of what malaria is capable of doing, or what a febrile illness leading to seizures and coma is capable of doing.”
Muiruri-Liomba wants to raise awareness both in the community and among health professionals.
“Those children who present late are likely to have a bad outcome,” she stresses, which could be death or brain damage, probably caused by seizures that have not been managed at an earlier stage.
Dr Tarun Dua, who leads the Brain Health Unit at the World Health Organization (WHO), agrees that “systemic challenges or barriers that we see in access to care and delivery” is a key problem.
“In many of the countries in Africa, there is only one child neurologist per 4 million population,” she says. “If you think about where neuroimaging is available, it is in the capital or a couple of cities. There is a big rural/urban divide.”
WHO guidelines on meningitis care, updated in April, say children with suspected acute meningitis “need to start empiric antibiotics” before tests.
“Our task is, how do we get countries to implement those guidelines?” says Dua. She is hopeful of technological advances. Low-cost brain scans and better bedside tests are in development.
“Things are moving,” she says. “But I think accelerated action is important.”