Global Child Health and the Sustainable Development Goals – Tobias Alfvén's research group

EREMISS Project

Emergency case management, and subsequent referrals, have been highlighted as a key weakness of health systems in low-resource settings. The EREMISS project aims to explore the potential for implementing emergency triage and treatment within primary health centres in rural Malawi, and to describe both clinical progression across the referral pathway and care-seeking decisions.  We are collaborating with the Malawi College of Medicine and a local Malawian NGO, the Parent and Child Health Association.

The project is funded by the Swedish Research Council and the Einhorn Foundation (2018 – 2020).

Contact: Helena Hildenwall, Carina King

Technology and Innovation

Project: NeoTap

Heart rate assessment is crucial in neonatal resuscitation, but pulse oximetry and electrocardiography are rarely accessible in low- to middle-income settings. These studies evaluated a free-of-charge smartphone application, NeoTap Life Support (NeoTapLS), recording heart rate with a screen-tapping method bypassing mental arithmetic calculations. The two studies were conducted at Sachs´Children and Youth Hospital, Sweden and in Kampala, Uganda through collaboration with Kawempe National Referral Hospital, Uganda and the University of Bergen, Norway (2014-2019).

Article I was funded by the Laerdal Global Health Foundation and Sachs' Children and Youth Hospital. Article II was funded by the Research Council of Norway (RCN), Norway, through the FRIMEDBIO program.

Contact: Susanna Myrnerts Höök, Nicolas Pejovic, Thorkild Tylleskär, Tobias Alfvén, Josaphat Byamugisha, Jolly Nankunda

Publications

Accurate and fast neonatal heart rate assessment with a smartphone-based application - a manikin study.
Myrnerts Höök S, Pejovic NJ, Marrone G, Tylleskär T, Alfvén T
Acta Paediatr 2018 Mar;():

Smartphone app for neonatal heart rate assessment: an observational study.
Myrnerts Höök S, Pejovic NJ, Cavallin F, Lubulwa C, Byamugisha J, Nankunda J, Tylleskär T, Alfven T
BMJ Paediatr Open 2020 ;4(1):e000688

Project: The paediatric infection – point of care (PI-POC)

The paediatric infection – point of care project researches novel methods for improving and strengthening the differential diagnosis of suspected childhood CNS infections in low-income health systems.

Infectious diseases and outbreak control

Project: Cholera in Nigeria

The north-eastern region of Nigeria has several cholera hotspots, and ineffective implementation of multi-sectoral interventions in the region could make global cholera control out of reach. A major contributing factor to this challenge in this context is fragility. Given the complexity of disease control in such a fragile setting, this study aims to systematically examine the barriers and facilitators which influence the implementation of existing cholera interventions in Adamawa and Bauchi states, Nigeria. 

This study is conducted in collaboration with the Nigerian CDC, and is funded through a post-doctoral Forte fellowship (2020-2022).

Contact: Kelly Elimian

Publications

Understanding the factors enabling and blocking sustained implementation of cholera interventions in a fragile region of Nigeria: a multi-phase group model building study protocol [version 1; peer review: 1 approved with reservations]. Elimian K, King C, Diaconu K et al. F1000Research 2021, 10:85

Project: Measles in Vietnam

There have been some disturbing outbreaks of measles in Vietnam the last few years. Is everyone getting the vaccine and/or there people who choose not to vaccine their children? And since it’s a disease that easy transmits, it needs to be controlled, especially in the young infant to child population. In a controlled study we aim to evaluate and find risk factors for future outbreaks from the data sets that exist locally in Vietnam National Children’s Hospital and on a governmental level at MoH from outbreak 2014, 2019 and vaccination 2014, 2019 and 2020-date.

The project funded by in kind by KI researchers and locally by Vietnam National Children’s Hospital and MoH of Vietnam.

Contact: Linus Olson, Mattias Larsson, Nhung Hong, Dien Minh Tran

Project: Childhood infections in the DRC

Project summary: Despite gains in reducing deaths amongst children under-five, progress has been inequitable both between regions, and within countries. The DRC has one of the highest child mortality rates, but with large sub-national variation. Preventable infections and outbreaks still account for a large part of these deaths. This project aims to explore factors contributing to childhood infections and poor outcomes in the DRC.

This project involves a collaboration with UNICEF and the University of Kinshasa (2020 – 2026).

Contact: Mattias Schedwin, Carina King, Tobias Alfvén, Helena Hildenwall

Project: HIV-Chi

Children and adolescents with HIV on anti-retroviral treatment (ART) have about twice the rate of treatment failure compared to adults causing resistance that limits future therapeutic choices. This study aims to assess different support strategies, Enhanced Treatment Support (ETS) and Conventional Treatment Support (CTS), in relation to drug resistance and virological treatment failure. In a cross sectional pilot study the the rate and predictors of virological treatment failure will be assessed in relation to clinical and socioeconomic indicators among paediatric patients on treatment for more then 6 months.

The aim is to in a semi randomized controlled way assess effect of peer support to children and adolescents with HIV in relation to adherence, virological treatment failure, physical development and quality of life. This project will generate information of great value for evidence based pediatric ARV treatment strategies in low-income settings and may have an impact on treatment guidelines for HIV globally.

The partner hospitals in study are Vietnam National Childrens Hospital in Hanoi, Children hospital 1 and 2 from HCMC, Childrens hospitals in Quan Nhin and Hai Phong. The project is in collaboration with Hanoi Medical University,Vietnam, who is the implementing organization, with funding from an ERC Carrier Grant (2015 – 2021).

Contact: Linus Olson, Mattias Larsson, Chuc Kim Nguyen, Toan Khanh Tran

Newborn care

Project: NeoSpirit

Globally, birth asphyxia is responsible for close to 1 million deaths per year, of which almost all (98%) take place in low and middle-income countries. An even greater number suffer brain injury. The main objective of neonatal resuscitation is to maintain a patent airway and provide effective positive pressure ventilation (PPV). However, neonatal resuscitation with face mask ventilation requires adequate operator skills, and endotracheal intubations are performed in the neonate only by skilled anaesthesiologists or neonatologists. Previously conducted studies both from our group and others indicate that a laryngeal mask airway under some circumstances should replace intubation as the first choice when face-mask ventilation fails. This RCT aims to answer that question.

The project builds on ‘Neonatal care in Vietnam’ and is a collaboration with PhuSan Hanoi Hospital, University of Padova and the University of Bergen, funded by the Swedish Research Council (2019 – 2020).

Contact: Tobias Alfven, Tina Dempsey, Linus Olson, Nicolas Pejovic, Susanna Myrnerts-Höök

Project: NeoObs

Prospective, multinational, multicentre, observational cohort study of neonatal sepsis in partner institutions. The cohort study was designed to evaluate health care utilization and current clinical practice and to assess risk factors for and outcomes of babies with neonatal sepsis (culture-negative and culture-positive). The aim of this project is to study neonatal sepsis cases across hospitals globally.

We are involved in the component occurring in Vietnam, working in partnership with St Georges University and Vietnam National Children’s Hospital in a global multi central study.

Contact: Linus Olson, Mattias Larsson, NeoObs international team

Publications and other links

Article I: Towards understanding global patterns of antimicrobial use and resistance in neonatal sepsis: insights from the NeoAMR network.
Li G, Bielicki JA, Ahmed ASMNU, Islam MS, Berezin EN, Gallacci CB, Guinsburg R et al.
Arch Dis Child 2020 01;105(1):26-31

Trial registration

Project: NeoSupra Trial

Birth asphyxia is the third leading cause of under-five child mortality. Worldwide, the most common neonatal resuscitation method is face-mask ventilation. We aimed to investigate whether the use of a cuffless laryngeal mask airway rather than face-masks could reduce mortality and morbidity in asphyxiated neonates during neonatal resuscitation. We conducted a randomised controlled trial in Uganda to test this.

This was a collaborative project with Kawempe National Referral Hospital, University of Bergen and Padova University, funded by the Research Council of Norway through the FRIMEDBIO program and the Centre for Intervention Science in Maternal and Child Health (CISMAC).

Contact: Susanna Myrnerts Höök, Nicolas Pejovic, Tobias Alfvén

Publications and other links

A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation.
Pejovic NJ, Myrnerts Höök S, Byamugisha J, Alfvén T, Lubulwa C, Cavallin F, Nankunda J, Ersdal H, Blennow M, Trevisanuto D, Tylleskär T
N Engl J Med 2020 11;383(22):2138-2147

Trial registration

Project: Clinical and experimental implementation of standardized hypothermic treatment for neonatal asphyxia

Recent results from independent randomized clinical trials provide strong evidence that mild hypothermia treatment of newborn infants at risk for hypoxic-ischemic encephalopathy (HIE) started within 6 hours after birth reduces the risk for neurologic sequele. The present cooling equipments in clinical use are relatively complex, expensive and dependent on continuous electric power and water supply. A cheap and effective cooling method is needed for global implementation especially in remote settings and during transportation to neonatal intensive care units. We will assess and optimise a novel cooling method using a so-called Phase Changing Material (PCM). This material requires no external power or specific maintenance to be effective. 

Contact: Linus Olson, Tobias Alfven, Hang Tran

Publications

Hypothermic treatment for neonatal asphyxia in low-resource settings using phase-changing material-An easy to use and low-cost method.
Tran HTT, Le HTT, Tran HTP, Khu DTK, Lagercrantz H, Tran DM, Winbladh B, Hellström-Westas L, Alfvén T, Olson L
Acta Paediatr 2021 01;110(1):85-93

Project: Informing change – neonatal resuscitation in Uganda

Asphyxia is a main cause of neonatal mortality. Improved neonatal resuscitation guidelines implies changing behavior. Behavioral change models are useful to understand barriers and enablers. According to the COM-B model, three interacting core components generates behaviour (B): capability (C), opportunity (O) and motivation (M). Many global initiatives focus on improving capability (knowledge and skills) and opportunity (by provision of items) – potentially risking not focusing on the major underlying reasons for appropriate behavior. To inform future actions, we are exploring midwives' perception on neonatal resuscitation at Mulago Hospital, Uganda.

This project is being funded by the Research Council of Norway (2018 – 2020).

Contact: Susanna Myrnerts Höök, Tobias Alfven

Project: Neonatal care in Vietnam

The project is the first 2 parts that eventually will become the NeoSpirit or similar studies, it’s the baseline for new innovative studies together with partners in Vietnam in Neonatalcare.The aim is to record the incidence, detailed management and outcome of birth asphyxia to better understand where intervention is necessary in order to reduce neonatal morbidity and mortality related to neonatal resuscitation. The objective is to add valuable information to the planning of a RCT planned to follow on this study at Phu San Hanoi Hospital.

The project is funded by the Swedish Research Council (2020).

Contact: Tobias Alfvén, Tina Dempsey, Linus Olson, Nicolas Pejovic, Susanna Myrnerts-Höök, Anh Nguyen, Phuong Pham, Hien Vu, Lien Huong Nguyen, Thu Huong Nguyen, Xuan Anh Bui

Child development

CURIE-Cerebral palsy in Uganda: Epidemiology, risk factors and intervention project

Cerebral palsy (CP) is the most common childhood-onset motor disorder and most children with CP live in low- and middle-income countries with little access to services and support systems.

This project aims to understand the epidemiology and life situation for children with cerebral palsy in Uganda. We will explore prevalence, risk factors, premature mortality, functional impairments, participation in community and family life and access to therapies and specialized health services. We have also developed and will implement a multi-component community based intervention programme for children with cerebral palsy in Uganda, the Akwenda CP-programme.

This programme will contain 5 components: i) caregiver-led training workshops ii) therapist led practical group sessions iii) provision of technical assistive devices iv) goal-directed training v) community communication and advocacy. The CURIE project is a collaboration between Karolinska Institutet and Makerere University. The Akwenda-CP programme was developed by international experts, local therapists, caregivers of children with CP and the NGO Malamulele Onward in South Africa.

The research is funded by the Swedish Research Council, the Promobilia foundation, Frimurare Barnhuset, Sällskapet Barnavård, Folke Bernadotte Stiftelsen, and Sunnerdahl Handikappfond.

Contact: Carin Andrews

Publications

Prevalence of cerebral palsy in Uganda: a population-based study.
Kakooza-Mwesige A, Andrews C, Peterson S, Wabwire Mangen F, Eliasson AC, Forssberg H
Lancet Glob Health 2017 12;5(12):e1275-e1282

Excessive premature mortality among children with cerebral palsy in rural Uganda: A longitudinal, population-based study.
Namaganda LH, Almeida R, Kajungu D, Wabwire-Mangen F, Peterson S, Andrews C, Eliasson AC, Kakooza-Mwesige A, Forssberg H
PLoS One 2020 ;15(12):e0243948

Impairments, functional limitations, and access to services and education for children with cerebral palsy in Uganda: a population-based study.
Andrews C, Kakooza-Mwesige A, Almeida R, Swartling Peterson S, Wabwire-Mangen F, Eliasson AC, Forssberg H
Dev Med Child Neurol 2020 04;62(4):454-462

NHINZE child health project

Children with developmental delay and disability are often excluded from current development efforts, even though they have an increased need for health care, early childhood developmental services and educational services compared to their peers. The NHINZE Child Health Project utilizes a three-stage design to establish the prevalence of functional difficulties, developmental delay and neurodevelopmental disorder in the region of Iganga/Mayuge in Eastern Uganda.

The project further aims to validate the predictive value of the screening questions in the UNICEF/Washington Group on disability statistics’ module on child functioning to screen for neurodevelopmental disorders among children two to nine years of age in a rural Ugandan setting. In addition, Ugandan norms for some previously unused international assessments will be established, including setting thresholds for referral for further examinations and interventions.

The project is funded by the Swedish Research Council, Forskar-AT, Frimurare Barnhuset, and Sällskapet Barnavård.

Contact: Anna-Theresia Ekman, Tobias Alfven, Angelina Mwesige-Kakooza, Hans Forssberg

Project: Understanding childhood disability through large household survey data

Prevalence estimates of developmental delay and disabilities and neurodevelopmental disorders are important for local and national public health planning as well as for improved knowledge of underlying conditions. However, current global prevalence estimates are largely speculative and estimates from low-income countries are scarce.

Utilizing standardized household survey data can increase knowledge on children living with functional difficulties and symptoms reflecting neurodevelopmental disorders. For an individual child, better public health planning can translate into inclusion in early intervention programs and in established or emerging early childhood education programs. Both can lead to decreased suffering, better life-time prognosis and reduced stigma. Results can also feed into other ongoing early education and intervention initiatives.

The project is funded through RALF-funding and Forskar-AT.

Contact: Anna-Theresia Ekman, Helena Frielingsdorf, Tobias Alfvén.

Project: Neonatal complications and neurodevelopment

Project summary: This project aims to establish the prevalence of brain impairment and associated factors among young infants in Eastern Uganda. Further it will assess knowledge, perceptions and experiences of mothers of babies with infants with brain impairment and health facility readiness to care for high risk newborn babies. This project is being conducted at the Iganga Health and Demographic Surveillance site, Uganda and is funded SIDA.

Contact: Helena Hildenwall, Gertrude Namazzi

Publications

Neurodevelopmental outcomes of preterm babies during infancy in Eastern Uganda: a prospective cohort study.
Namazzi G, Tumwine JK, Hildenwall H, Ndeezi G, Mubiri P, Hanson C, Kakooza-Mwesige A, Waiswa P
Glob Health Action 2020 12;13(1):1820714

Caring for children with neurodevelopmental disability: Experiences from caretakers and health workers in rural eastern Uganda.
Namazzi G, Hanson C, Nalwadda C, Tetui M, Nampijja M, Waiswa P, Tumwine JK, Hildenwall H
PLoS One 2020 ;15(7):e0236488

Adolescent mental health and well-being

Project: Political Economy of Adolescent Mental Health and Wellbeing

Globally, adolescent mental health and wellbeing constitute an enormous, neglected problem. According to the World Health Organization, mental health conditions including depression and anxiety represent 16% of the global burden of disease among 10-19-year-olds. Despite the magnitude of problem, the issue has received limited attention and resources.

Karolinska Institutet, in collaboration with Johns Hopkins University, is undertaking a program of research and action that consists of global and national scientific studies, consultations and knowledge translation activities. The program aims at increasing knowledge of the political economy of adolescent mental health to reduce fragmentation, mobilize resources and facilitate multisectoral action for improved adolescent mental health and wellbeing. The studies will be based on data from document and literature reviews, key-informant interviews with experts and other key stakeholders, focus group discussions with adolescent advocates, and observations. A crucial component of the research is the involvement of adolescents and local investigators.

This project is funded through Carl Bennet AB (2021-2025).

Contact: Mariam Claeson, Stefan Peterson, Olivia Biermann