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Paediatric Radiology Seen from Africa. Part I: Providing Diagnostic Imaging to a Young Population

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Paediatric Radiology Seen from Africa. Part I: Providing Diagnostic Imaging to a Young Population Pediatr Radiol DOI 10.1007/s00247-011-2081-8 REVIEW Paediatric radiology seen from Africa. Part I: providing diagnostic imaging to a young population Savvas Andronikou & Kieran McHugh & Nuraan Abdurahman & Bryan Khoury & Victor Mngomezulu & William E. Brant & Ian Cowan & Mignon McCulloch & Nathan Ford Received: 9 October 2010 /Revised: 30 December 2010 /Accepted: 14 March 2011 # Springer-Verlag 2011 Abstract Paediatric radiology requires dedicated equip- role in the treatment of these children, but is expensive and ment, specific precautions related to ionising radiation, and difficult to provide. The World Health Organisation specialist knowledge. Developing countries face difficulties initiatives, of which the World Health Imaging System for in providing adequate imaging services for children. In Radiography (WHIS-RAD) unit is one result, needs to many African countries, children represent an increasing expand into other areas such as the provision of maintenance proportion of the population, and additional challenges servicing. New initiatives by groups such as Rotary and the follow from extreme living conditions, poverty, lack of World Health Imaging Alliance to install WHIS-RAD units in parental care, and exposure to tuberculosis, HIV, pneumo- developing countries and provide digital solutions, need nia, diarrhoea and violent trauma. Imaging plays a critical support. Paediatric radiologists are needed to offer their services for reporting, consultation and quality assurance for free by way of teleradiology. Societies for paediatric radiology S. Andronikou (*) : V. Mngomezulu are needed to focus on providing a volunteer teleradiology Radiology Department, University of Witwatersrand, reporting group, informationonchildsafetyforbasic York Rd Parktown, Johannesburg Gauteng 2193, South Africa imaging, guidelines for investigations specific to the disease e-mail: [email protected] spectrum, and solutions for optimising imaging in children. K. McHugh Keywords Developing countries . Radiographic Radiology Department, . Great Ormond Street Hospital for Children, equipment Non-governmental organisation London, UK Role extension N. Abdurahman : B. Khoury Radiology Department, University of Cape Town, Cape Town, South Africa Introduction W. E. Brant Developing countries, and in particular those in sub- Radiology Department, University of Virginia, Saharan Africa, present radiologists and clinicians with Charlottesville, VA, USA substantial challenges when trying to offer paediatric I. Cowan imaging services. Difficulties include cost, patient difficulty Radiology Department, Christchurch Hospital, in accessing care, a massive disease burden, climate, Christchurch, New Zealand geographical extremes, poor infrastructure, human resource M. McCulloch shortages, and political factors such as instability and Evelyna Children’s Hospital, migration. Technical solutions have been developed to help London, UK overcome some of these challenges, often as a result of collaborative efforts by developing country clinicians, the N. Ford Public Health/Access, Médecins Sans Frontières, World Health Organisation (WHO) and non-governmental Cape Town, South Africa organisations (NGOs). New technology, often considered Pediatr Radiol too high-tech for resource-limited settings, may in fact difference is in paediatric healthcare and infant mortality. provide simplified solutions; an obvious example is digital In South Africa, the infant mortality rate is 44/1,000 imaging, which obviates film developing, and allows compared to 106/1,000 in Mozambique. Compounding a transfer of images over large distances so that remote higher overall burden of paediatric disease, the HIV experts may offer advice and diagnosis. Radiologists and epidemic has significantly changed the population pyramids radiographers can also help overcome the lack of of many African countries, with a dramatic loss of middle- specialised staff by “task shifting” certain skills to non- aged individuals who traditionally support both the younger radiologists/radiographers who may perform radiographs and older subpopulations. HIV has also caused a significant and interpret them where there is a need. Equipment increase in mother-and-child mortality [7]. vendors have a responsibility for making cheap and robust equipment available to those countries that cannot afford to pay Western prices and to offer technical assistance in Disease burden maintenance and repair to less skilled personnel. Govern- ments of developed nations and NGOs can assist, not only In 2000–2003, almost three-quarters of the 10.6 million financially, but also by investing in human resource annual deaths in children younger than 5 years were development. This paper highlights some of the most attributable to just six causes: pneumonia (19%), diarrhoea important challenges for offering a paediatric imaging (18%), malaria (8%), neonatal pneumonia or sepsis (10%), service in developing countries, and offers a roundup of preterm delivery (10%), and birth asphyxia (8%). Thus, new technology and ideas for training that may contribute four communicable diseases accounted for more than half to resolving some existing issues. of all child deaths. This pattern was comparable in all regions defined by the WHO, except for malaria, for which almost all childhood deaths occurred in Africa. Under- Poverty and access to health nutrition was an underlying cause in 53% of all deaths in children younger than of 5 years [8]. More than 80% of the world’s population live on less than In African children, respiratory illness is the most $10 (U.S.) per day [1]. As a result, almost one-third of important cause of mortality and morbidity. Pneumonia children in developing countries are malnourished or alone is responsible for approximately 21% of deaths in stunted, with the bulk of affected children living in sub- African children younger than 5 years of age each year. As Saharan Africa and South-East Asia. [2]. Of some 1.9 billion a result of the HIV epidemic in sub-Saharan Africa, HIV- children living in the developing world, more than one-third associated acute and chronic respiratory disease has have inadequate access to shelter, about one in five have no emerged as a major factor in the epidemiology of childhood access to safe water, and one in seven have no access to respiratory illness, and has increased the incidence, severity health services [3]. and mortality of pneumonia in African children [9]. Mortality in Africa HIV Worldwide, in 2004, 2.6 million deaths occurred in young According to the WHO AIDS Epidemic Update, in 2008, people between the ages of 10 and 24 years. Of these, 97% there were 2.1 million children younger than of 15 years were in the developing world [4]. The countries with the living with HIV worldwide, and 430,000 new infections. In top 30 infant mortality rates in the world are all in Africa. children younger than 15 years of age, 280,000 deaths were Nevertheless, there are stark disparities among countries. attributable to HIV or AIDS. Two-thirds of all HIV Nearly half (44%) of the population of Mozambique is infections occurred in sub-Saharan Africa, and 91% of younger than 14 years of age [5], and the mortality rate in newly infected children were born in Africa. Furthermore, children younger than 5 years old is 138/1,000 live births 14 million children in sub-Saharan Africa have lost at least [6]. This contrasts with neighbouring South Africa, a one parent to AIDS. While substantial progress has been relatively well developed sub-Saharan country, where the made in improving access to antiretroviral therapy, children corresponding rate is 69/1,000 [6], and only 29% of the remain under-served: 44% of the total HIV population has population is younger than 14 years of age. access to antiretroviral therapy, but only 15% of children do Despite the greater expenditure on healthcare in South [10]. Swaziland has the highest worldwide adult prevalence Africa compared to Mozambique, the gains in life expec- of HIV at 27%, while South Africa has the largest tancy and healthy life expectancy have been disappointing worldwide population living with HIV at 5.7 million. In [7]. However, the one area where there is a marked South Africa, 29% of females accessing antenatal care are Pediatr Radiol HIV-positive [11], which has an impact on child health by world [17]. For example, in Mozambique, only 57% of the means of vertical (mother-to-child) transmission, and as a population has access to water services, and in rural areas result of increased maternal mortality. only 25% of the population receives water at home [18]. Water is a basic requirement for hospitals, and it is important in film development and processing in radiology Tuberculosis services. Water is a key component in developer solutions (manual and automatic) as it acts as a solvent and forms More than 90% of children with tuberculosis (TB) live in an important component of processing tanks (Fig. 1). A the developing world. Where HIV is prevalent, a dangerous good water supply and drain is therefore essential for synergy ensues. HIV co-infection has been associated with any darkroom [19]. With many areas in developing less successful treatment of TB in children, partly due to countries having an inadequate water supply, a method social factors (parent illness or death), partly to immuno- of instantaneous drying processing seems a reasonable compromise [12]. The estimated incidence of TB in sub- alternative [19, 20], and computed (CR) or digital Saharan Africa is nearly
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