BACKGROUND:Benzathine penicillin G (BPG) is a proven preventive agent for preventing the progression of rheumatic heart disease (RHD) and is recognized as a standard of care. However, ensuring adherence to BPG remains a global challenge. The objective of this review was to synthesize the available evidence on the barriers to and facilitators of BPG adherence among RHD patients. METHODS:This systematic review included both qualitative and quantitative studies on RHD patients published in the English language. This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search strategy involved PubMed, Embase, CINAHL, Global Health, Scopus, and Web of Sciences databases to identify keywords and terms contained in the title and abstract and the index terms used to describe articles. The review included papers published from January 1, 2000, to March 30, 2024. Two independent reviewers screened, appraised, and extracted the data. The data analysis was carried out deductively to fit onto the components of the COM-B (Capability, Opportunity, Motivation-Behaviour) model. RESULTS:In this review, 1067 records were screened, and 22 studies with 7338 participants were included. Thirty-five barriers and twenty facilitators were identified and mapped onto COM-B components. Physical capability (e.g., felt healthy), psychological capability (e.g., lack of knowledge), reflective motivation (e.g., poor patient handling), automatic motivation (e.g., BPG injection pain), physical opportunity (e.g., BPG unavailability) and social opportunity (e.g., inadequate counseling) were identified as barriers. The most discussed barrier was automatic motivation, followed by psychological capability and physical opportunity. CONCLUSIONS:Our review revealed variable levels of BPG adherence across studies and identified significant barriers and facilitators. Further research is recommended to identify contextual interventions to address barriers and capitalize on facilitators. SYSTEMATIC REVIEW REGISTRATION:PROSPERO CRD42024535398.

BackgroundDilated cardiomyopathy (DCM) is a myocardial disease characterized by a dilated left ventricle (LV) and reduced LV systolic function. The clinical profile of DCM is not well studied in Africa with no reports from Ethiopia. This study aimed to describe the clinical profile of DCM and the factors associated with its clinical outcome in a tertiary center.ResultsThis study included 75 DCM patients, males 52%. The median age at DCM diagnosis was 18 months (Interquartile range/IQR: 7-46). The major DCM clinical presentations were cough, 84%, fast breathing, 64% and shortness of breath, 56%. The median left ventricular systolic ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) at diagnosis were 30% (IQR: 24-36) and 14% (IQR: 11-18), respectively. The majority don't have a cause labeled or documented, 81.3% while HIV and anthracycline-related DCM accounted for 6.7% each. Concerning outcomes, the majority didn't show any clinical status change or were static, 62.7% while one-third, 32%, showed improvement. The case fatality rate in this series was 5.3% [4] (95% CI: 1.47-13.1). The presence of severe acute malnutrition (wasting) at presentation, p 0.017; the latest LV systolic function (LVEF, p 0.000 and LVFS, p 0.000) and the use of enalapril, p 0.017, were associated with DCM clinical outcome.ConclusionBoys in their second birth year were most affected by DCM. The major DCM presentations were a mix of respiratory and cardiac symptoms with severely depressed LV systolic function. Nutritional status at presentation, recent LV systolic function and enalapril use were associated with DCM clinical outcome. Timely nutritional assessment, treatment and support, and enhanced HF medical treatment are recommended to improve DCM clinical outcomes.

Background Pericardial effusion (PE) is a rare yet an important cause of child mortality due to collection of excess fluid in pericardial space. The study aimed to describe the PE profile in the national cardiac referral hospital, Addis Ababa, Ethiopia. Methods The study employed cross-sectional study design for a 7-year review of childhood PE in Tikur Anbessa Specialized Hospital. Descriptive and analytic statistics were applied. Results There were 17,386 pediatric emergency/ER admissions during the study period, and PE contributed to 0.47% of ER admissions. From 71 included subjects, 59% (42) were males with mean age of 7.8 ± 3.3 years. Cough or shortness of breath,73.2% (52) and fever or fast breathing, 26.7% (19), were the common presenting symptoms. The median duration of an illness before presentation was 14days (IQR: 8–20). The etiologies for pericardial effusion were infective (culture positive–23.9%, culture negative–43.6%, tuberculous-4.2%), hypothyroidism (4.2%), inflammatory (12.7%), malignancy (7%) or secondary to chronic kidney disease (1. 4%). Staphylococcus aureus was the most common isolated bacteria on blood culture, 12.7% (9) while the rest were pseudomonas, 7% (5) and klebsiella, 4.2% (3). Mild, moderate and severe pericardial effusion was documented in 22.5% (16), 46.5% (33), and 31% (22) of study subjects, respectively. Pericardial tamponade was reported in 50.7% (36) of subjects. Pericardial drainage procedure (pericardiocentesis, window or pericardiotomy) was performed for 52.1% (37) PE cases. The case fatality of PE was 12.7% (9). Pericardial drainage procedure was inversely related to mortality, adjusted odds ratio 0.11(0.01–0.99), p 0.049). Conclusion PE contributed to 0.47% of ER admissions. The commonest PE presentation was respiratory symptoms of around two weeks duration. Purulent pericarditis of staphylococcal etiology was the commonest cause of PE and the case fatality rate was 12.7%. Pericardial drainage procedures contributed to reduction in mortality. All PE cases should be assessed for pericardial drainage procedure to avoid mortality.

Electrocardiography (ECG) interpretation competency is vital to ensure the timely initiation of life-saving treatment for emergent ECG conditions. This competency has not been well-studied among pediatric and child health residents. Hence, the study aimed to determine the competency in ECG interpretation and its predictors among residents at the National University of Ethiopia. This cross-sectional study employed standard ECG Wave-Maven strips, a web-based ECG self-assessment tool. The association between dependent and independent variables was tested using a chi-square test and Fisher’s exact test. The study included 95 residents with male dominance, 61.1

The behavioral disorder is characterized by a profound abnormality in an individual’s cognition, emotion or behavior that reflects in psychological, biological or developmental dysfunction. Rheumatic heart disease (RHD) is a long-term sequel of single or recurrent acute rheumatic fever. Children with RHD are thought to be at increased risk for behavioral problems due to autoimmunity seen in pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Behavior disorder is not well studied among children with RHD. Hence, this study aimed to assess the pattern and predictors of behavioral problems among children with RHD enrolled in chronic care at a national cardiac referral Hospital. This cross-sectional study used a validated parental-reported Amharic Strengths and Difficulties Questionnaire (SDQ) to assess behavior problems. Children with RHD aged 6–17 years on chronic outpatient cardiac care at Tikur Anbessa Specialized Hospital, Ethiopia between February and May 2023 were included. Factors associated with behavior problems were assessed using logistic regression models. The study included 166 children with a median age of 15 years [Interquartile range (IQR):13–17 years]. One-fourth of children, 24.7

To develop a model for increasing the coverage of kangaroo mother care (KMC), which involved ≥8 h of skin‐to‐skin contact per day and exclusive breastfeeding, for small babies with birth weight < 2000 g in South Ethiopia.

Aim To estimate incremental costs of an implementation model for scaling up Kangaroo Mother Care (KMC) for neonates with birthweight <2000 g. Methods Seven sites across Ethiopia and India collected data for 2018-19 to calculate incremental recurrent costs (of health worker time, supplies, and operations) and start-up costs for KMC scale up. The costs were estimated per live newborn Scaling up KMC in study districts required average incremental costs of US$59 (95% CI US$ 52-67) in Ethiopia and US$72 (95% CI US$ 41-103) in India per eligible newborn in the population. Most of these costs were recurrent; the annualised start-up costs per eligible newborn ranged from 12%-25% of total costs in Ethiopia and 9%-16% in India. The major cost driver was human resources, followed by initial and recurrent training, supplies, and communications costs. Incremental infrastructure costs were only 2%-6% of total costs in both countries. Most of the costs were for activities at the KMC implementing facility, accounting for 79%-88% of the total costs in Ethiopia and 89%-93% of those in India. Conclusion The costs for successful scale up of KMC seem affordable but must be included in programme budgets.

BACKGROUND: Bacterial Sepsis is a serious medical problem affecting children with Congenital Heart Disease (CHD). The pattern and factors predicting outcome of bacterial sepsis have not been studied in Africa. The study aimed to describe the pattern and outcome of bacterial sepsis among children with CHD in Tikur Anbessa Specialized Hospital (TASH).METHODS: A cross-sectional study was carried out among children with CHD and sepsis at TASH between May 2017 and July 2020. Structured questionnaires were used for data collection. Statistical significance was set at P value < 0.05, and multivariable logistic regression was used to determine predictors.RESULTS: This study included 384 CHD children with sepsis. Proportion of culture proven bacterial sepsis was 17.1 % (66) (95% CI: 13.6- 21.3). Coagulase negative staphylococcus aureus 7% (27), Staphylococcus aureus 4.4% (17) and Actinobacteria 1.8% (7) were the common isolated bacteriological agents. Death was documented in 25% (96) of study subjects. Down syndrome subjects were 2.4 times [aOR=2.416 (95%CI: 1.367-4.264)] more likely to die from sepsis. Those with associated comorbidities (Apert syndrome, Cerebral palsy, Chiari 2 malformation, Patau syndrome, Noonan syndrome, Congenital Rubella, Portal vein thrombosis, HIV, Scoliosis and VACTERL association) were 4.4 times more likely to die from sepsis [aOR=4.418 (95%CI: 1.617-12.072)].CONCLUSION: Bacterial sepsis is a common problem among children with CHD. Gram positive bacteria were common causes. Down syndrome and other co morbidities predicted bacterial sepsis mortality. Blood culture and sensitivity tests are recommended to halt the high mortality seen in Down syndrome or those with co morbidities.

Background Subjective wellbeing (SWB) is a self-reported positive life judgment and good feeling. RHD, rheumatic heart disease, is a long-term sequel of single or recurrent acute rheumatic fever. There are no studies that assessed SWB in RHD patients. We aimed to assess SWB among RHD subjects enrolled in chronic care at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. Methods This observational cross-sectional study employed a validated Amharic WHO-5 wellbeing index to assess SWB. Sociodemographic and clinical data were collected using structured questionnaire. RHD subjects aged 9 years and above were included. Factors associated with SWB were assessed using logistic regression models. Results The study included 384 subjects, females 68.2% (262). Children, < 18 years, constituted one third of study subjects, 32.8% (126). Moderate and severe echocardiographic RHD dominated, 85.9% (330) with no associated comorbidity, 84.4% (324). Only 17.2% (66) had surgical or device intervention. Poor SWB was documented in 9.6% of study subjects (95% CI: 6.88–13.04). On multivariable regression, those with younger age RHD diagnosis, < 20 years, had almost three times higher odds of poor SWB, adjusted odds ratio (aOR) 2.69(95% CI: 1.30–5.58, P 0.008). Those with monthly family income of < 1000 Ethiopian Birr had three times higher odds of poor SWB, aOR 2.97(95% CI: 1.24–7.1, P 0.014). Study subjects who had good medication adherence had reduced odds of poor SWB, aOR 0.37(95% CI: 0.18–0.77, P 0.028). Those who received psychologic support from their families also had reduced odds of poor SWB, aOR 0.26(95% CI: 0.11–0.64, P 0.003). Conclusion Poor SWB was documented in one-tenth of RHD patients. Family income, younger age at RHD diagnosis, medication adherence and psychological support predicted poor SWB. Poor SWB has to be considered and assessed among RHD patients particularly among those with younger age at RHD diagnosis and poor family income. Further mixed studies are recommended to assess how medication adherence and psychological supports associate with positive SWB among RHD patients.

Context and objective Ethiopia’s primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0–59 months of age and evaluate the healthcare providers’ adherence to referral guidelines.Design A cross-sectional facility-based survey.Setting This study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child’s characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions.Outcome measure Referral to the nearest health centre of sick young infants aged 0–59 days and sick children 2–59 months.Results The health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2–59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group.Conclusion Few children with severe illness were referred from health posts to health centres. Improving the health posts’ medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.

Introduction The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers’ experiences and proposed mitigation strategies. Methods Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions. Results We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother–baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families’ fear of visiting hospitals (~73%). Conclusion Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Background Institutional delivery is one of the key interventions to reduce maternal death. It ensures safe birth, reduces both actual and potential complications, and decreases maternal and newborn death. However, a significant proportion of deliveries in developing countries like Ethiopia are home deliveries and are not attended by skilled birth attendants. We investigated the prevalence and determinants of home delivery in three districts in Sidama administration, Southern Ethiopia. Methods Between 15–29 October 2018, a cross sectional survey of 507 women who gave birth within the past 12 months was conducted using multi-stage sampling. Sociodemographic and childbirth related data were collected using structured, interviewer administered tools. Univariate and backward stepwise multivariate logistic regression models were run to assess independent predictors of home delivery. Results The response rate was 97.6% (495). In the past year, 22.8% (113), 95% confidence interval (CI) (19%, 27%) gave birth at home. Rural residence, adjusted odds ratio (aOR) = 13.68 (95%CI:4.29–43.68); no maternal education, aOR = 20.73(95%CI:6.56–65.54) or completed only elementary school, aOR = 7.62(95% CI: 2.58–22.51); unknown expected date of delivery, aOR = 1.81(95% CI: 1.03–3.18); being employed women (those working for wage and self-employed), aOR = 2.79 (95%CI:1.41–5.52) and not planning place of delivery, aOR = 26.27, (95%CI: 2.59–266.89) were independently associated with place of delivery. Conclusion The prevalence of institutional delivery in the study area has improved from the 2016 Ethiopian Demography Health Survey report of 26%. Uneducated, rural and employed women were more likely to deliver at home. Strategies should be designed to expand access to and utilization of institutional delivery services among the risky groups.

Background We have shown that Ethiopian primary healthcare providers refer only half of the severely sick children who, according to guidelines, should get an urgent referral. Frequently parents of referred ill children don't bring their children to the next level. We aimed to describe the referral of severely ill Ethiopian children based on primary healthcare register reviews and explore health care providers' and parents' perceptions regarding factors that hinder or enhance referral. Methods A mixed-methods study was conducted in 11 districts and a town administration of the Hadiya zone in Ethiopia's Southern region from May to June 2019. Data collection included interviews and focus group discussions with healthcare providers, key informant interviews with parents of sick children who had been referred, and reviewing registers of sick children treated during the last 12 months at health posts and health centres. We analysed the association between healthcare providers' and sick children's characteristics and providers' compliance with referral guidelines for sick children 0-59 months old. Content analysis was undertaken to explore the perceived factors that influenced referral and adherence to referral from providers' and parents' perspectives. Results Healthcare providers did not refer nearly half of the severely ill children that should have been referred, according to guidelines. Providers who had received in-service training on child healthcare were more likely to adhere to referral guidelines. The severity of the child's illness and mobile phone communication and transport availability were perceived to be positively associated with adherence to referral guidelines. Lack of knowledge of treatment guidelines and skills, and high health worker workload, were among the factors perceived to be linked to lower adherence to guidelines. The healthcare providers considered parents of referred sick children as having low compliance with the referral advice. In contrast, parents had the opinion that compliance with a referral for sick children was high. Perceived awareness of severity of the child's illness, ability to afford referral costs, and availability of transport or ambulance services were perceived to motivate parents to take their children to the referral facility. Traditional illness perceptions, lack of confidence in the referral site's medical care, and a long distance were perceived to hurdle caregivers' referral compliance. Conclusions We found that the healthcare providers' adherence to referral guidelines was not optimal. Care providers and parents had divergent opinions on parents' compliance with referral advice. Factors related to the health system, family economy, and available ambulance services influence whether care providers and parents pursued severely ill children's referral. Adequate referral of sick children is an aspect of primary healthcare quality that is essential to avoid unnecessary under-five deaths.

Background: COVID-19 is disrupting health services for mothers and newborns, particularly in low- and middle-income countries (LMIC). Preterm newborns are particularly vulnerable. We undertook analyses of the benefits of kangaroo mother care (KMC) on survival among neonates weighing <= 2000 g compared with the risk of SARS-CoV-2 acquired from infected mothers/caregivers. Methods: We modelled two scenarios over 12 months. Scenario 1 compared the survival benefits of KMC with universal coverage (99%) and mortality risk due to COVID-19. Scenario 2 estimated incremental deaths from reduced coverage and complete disruption of KMC. Projections were based on the most recent data for 127 LMICs (similar to 90% of global births), with results aggregated into five regions. Findings: Our worst-case scenario (100% transmission) could result in 1,950 neonatal deaths from COVID-19. Conversely, 125,680 neonatal lives could be saved with universal KMC coverage. Hence, the benefit of KMC is 65-fold higher than the mortality risk of COVID-19. If recent evidence of 10% transmission was applied, the ratio would be 630-fold. We estimated a 50% reduction in KMC coverage could result in 12,570 incremental deaths and full disruption could result in 25,140 incremental deaths, representing a 2.3 similar to 4.6% increase in neonatal mortality across the 127 countries. Interpretation: The survival benefit of KMC far outweighs the small risk of death due to COVID-19. Preterm newborns are at risk, especially in LMICs where the consequences of disruptions are substantial. Policymakers and healthcare professionals need to protect services and ensure clearer messaging to keep mothers and newborns together, even if the mother is SARS-CoV-2-positive. (C) 2021 The Authors. Published by Elsevier Ltd.

Abstract Background: COVID-19, the disease caused by the new coronavirus SARS-CoV-2 is among the most obscure global pandemics resulting in diverse health and economic disruptions. It adversely affects the routine health care delivery and health service uptake by patients. However, its impact on care-seeking behavior is largely unknown in Ethiopia. Objective: This study was to determine the impact of the pandemic on the care-seeking behavior of patients with chronic health conditions at Tikur Anbessa Specialized Hospital in Addis Ababa. Methods: A cross-sectional hospital-based survey conducted between May and July 2020 on patients whose appointment was between March to June 2020. A sample of 750 patients was approached using phone calls and data collection was done using a pretested questionnaire. After cleaning, the data entered into the IBM SPSS software package for analysis. Results: A total of 644 patients with a median age of 25 years, and an M: F ratio of 1:1.01 was described with a response rate of 86%. A loss to follow-up missed medication and death occurred in 70%, 12%, and 1.3% of the patients respectively. In the multivariable logistic regression analysis, patients above 60 years old were more likely to miss follow-up (OR-23.28 (9.32-58.15), P<001). Patients who reported fear of COVID-19 at the hospital were 19 times more likely to miss follow-up (adjusted OR=19.32, 95% CI:10.73-34.79, P<0.001), while patients who reported transportation problems were 6.5 times more likely to miss follow-up (adjusted OR=6.11, 95% CI:3.06-12.17, P<0.001). Conclusions: COVID-19 pandemic affected the care-seeking behavior of patients with chronic medical conditions adversely and the impact was more pronounced among patients with severe disease, fear of COVID19, and transportation problems. Education on preventive measures of COVID-19, use of phone clinics, and improving chronic illness services at the local health institutions may reduce loss to follow-up among these patients.

ObjectivesKangaroo Mother Care (KMC), prolonged skin-to-skin care of the low birth weight baby with the mother plus exclusive breastfeeding reduces neonatal mortality. Global KMC coverage is low. This study was conducted to develop and evaluate context-adapted implementation models to achieve improved coverage.DesignThis study used mixed-methods applying implementation science to develop an adaptable strategy to improve implementation. Formative research informed the initial model which was refined in three iterative cycles. The models included three components: (1) maximising access to KMC-implementing facilities, (2) ensuring KMC initiation and maintenance in facilities and (3) supporting continuation at home postdischarge.Participants3804 infants of birth weight under 2000g who survived the first 3days, were available in the study area and whose mother resided in the study area.Main outcome measuresThe primary outcomes were coverage of KMC during the 24 hours prior to discharge and at 7days postdischarge.ResultsKey barriers and solutions were identified for scaling up KMC. The resulting implementation model achieved high population-based coverage. KMC initiation reached 68%-86% of infants in Ethiopian sites and 87% in Indian sites. At discharge, KMC was provided to 68% of infants in Ethiopia and 55% in India. At 7days postdischarge, KMC was provided to 53%-65% of infants in all sites, except Oromia (38%) and Karnataka (36%).ConclusionsThis study shows how high coverage of KMC can be achieved using context-adapted models based on implementation science. They were supported by government leadership, health workers' conviction that KMC is the standard of care, women's and families' acceptance of KMC, and changes in infrastructure, policy, skills and practice.Trial registration numbersISRCTN12286667; CTRI/2017/07/008988; NCT03098069; NCT03419416; NCT03506698.

Background Children with Congenital Heart Disease (CHD) are at increased risk for severe acute malnutrition (SAM). We aimed to determine the magnitude and determinants of SAM among children with CHD in a tertiary hospital. Methods Retrospective cross-sectional study was conducted among children with CHD between 2016 and 2019. Clinical and anthropometric data were retrieved from medical records. Anthropometric assessment was done by using WHO standard growth curves. Data analysis was done using Statistical Package for Social Sciences V22. Statistical significance was set at p-value <0.05, and multivariable logistic regression was used to determine predictors. Results There were 2400 pediatric admissions during the study period, CHD accounted for 6.5%(156) of admissions. For review, 141 records were eligible. The gender distribution was comparable, males 51.1% (72). Infants (<12 months) and older children (≥12 months) accounted for 57.4% (81) and 42.6% (60) of study subjects, respectively. SAM was documented in 51.8% (73) of the study subjects, [95% CI: 44.7–60.2]. Infants had higher odds of SAM compared to children aged ≥12 months[adjusted odds ratio (AOR)= 4.48, 95%CI:2.07–9.70]. Anemic children had higher odds for SAM[AOR =3.76, 95% CI:1.54–9.18]. Children without acyanotic CHD with heart failure(HF) were 58% less likely to develop SAM[AOR= 0.42, 95% CI:0.19–0.96]. Conclusion The burden of SAM among children with CHD is high. Younger age, anemia and acyanotic CHD with HF predicted SAM. Screening for anemia and targeted anthropometric assessment are recommended for early SAM detection.

An amendment to this paper has been published and can be accessed via the original article.

AIM:This study aimed at assessing the referral of sick young infants and children from the community, health posts and health centres to higher levels. METHODS:A cross-sectional survey was conducted in four of the largest Ethiopian regions from December 2016 to February 2017. Referral practices were assessed at each level in 46 districts of these regions. Interviews were supplemented by reviews of registers at health posts and health centres. RESULTS:The women's development group leaders, who do not provide health services, referred half of the sick children they visited in the community to the health posts. The health extension workers referred 16% of the sick young infants and 6% of older infants and children to higher levels. From health centres, the health workers referred 6% of sick young infants and 1% of older infants and children to hospital. Many cases of possible severe bacterial infection were not referred to higher levels. A functional ambulance was available for a bit more than a third of the health centres. CONCLUSION:Referral practices of sick young infants and children at all levels were weak that may threaten the continued reduction of child mortality in Ethiopia. Referral logistics were insufficient, which partly could explain the missing referrals of severely ill infants and children.

Background Unilateral pulmonary artery absence or discontinuity is a rare congenital abnormality. Its reported prevalence is 1 in 150,000 adults. Case Presentation A 22-month-toddler girl was referred from a general hospital for cardiac follow-up to our hospital after diagnosis of severe pulmonary hypertension was made. She presented with generalized body swelling, cough, fast breathing and high-grade fever of four days duration. She had repeated severe chest infections. Echocardiography and chest computed tomography revealed right pulmonary artery discontinuity. Acute care was given and chronic care was established. Conclusion Pulmonary artery discontinuity is a rare anomaly. It should be considered in any child presenting with recurrent chest infections/pulmonary hypertension. Appropriate and timely diagnostic work up will avoid misdiagnosis.