PHOTOTHERAPY DEVICE EFFECTIVENESS IN NIGERIA: CURRENT IRRADIANCE LEVELS AND SIMPLE STRATEGIES FOR IMPROVEMENT

B. K. CLINE1, 2, H. J. VREMAN3, K. L. FABER4, H. H. LOU1, K. M. DONALDSON1, 2, E. AMUABUNOSI5, G. OFOVWE5, V. K. BHUTANI3, T. M. SLUSHER6

1D-REV: DESIGN FOR THE OTHER 90%, PALO ALTO, CA; 2HASSO PLATTNER INSTITUTE OF DESIGN, STANFORD UNIVERSITY, STANFORD, CA3DIVISION OF NEONATOLOGY AND DEVELOPMENTAL MEDICINE, DEPARTMENT OF PEDIATRICS, STANFORD UNIVERSITY, STANFORD, CA; 4PEDIATRICS, UNIVERSITY OF LOUISVILLE, LOUISVILLE, KY

5PEDIATRICS, UNIVERSITY OF BENIN, BENIN CITY, EDO, NIGERIA; 6PEDIATRICS, UNIVERSITY OF MINNESOTA, MINNEAPOLIS, MN

CONCLUSIONSPoor irradiance levels are frequently delivered by PT devices at the 16 hospitals surveyed in Nigeria. With simple, low cost adjustments, the e�cacy of PT devices can often be improved substantially. More e�cacious PT should decrease both the incidence of kernicterus and the need for exchange blood transfusions. There is a need for educational outreach to ensure that e�ective treatment is provided from existing PT devices.

ACKNOWLEDGEMENTSThe authors gratefully acknowledge the doctors and nurses in Nigeria who spoke with us and provided access to their facilities. Supported in part by NCIIA Grant 6885-09.

RESULTS SUMMARY OF RESULTS

• Mean irradiance of all PT devices (n=76) was 7.6 ± 5.9 μW/cm2/nm. Only one device (1%) had an irradiance exceeding the American Academy of Pediatrics intensive phototherapy standard of 30 μW/cm2/nm (Pediatrics 2004). 29 devices (38%) had irradiances below 5 μW/cm2/nm. • Devices were found to be at an excessive distance from the patient. The mean distance was 39.6 cm ± 12.6 cm SD (range 20 to 79 cm), compared to the minimum recommended distance of 10 to 15 cm (Pediatrics 2004).• Spectral irradiance of n=25 devices was significantly improved (p<0.001) from 9 ± 6.6 SD before adjustments to 27.3 ± 15.2 SD after adjustments. • Commercially manufactured devices (n=68) had statistically significantly higher (p<0.01) spectral irradiance (8.1 ± 5.9 SD) than homemade devices (2.3 ± 2.8 SD).• Suboptimal illumination spectrua were qualitatively observed. Several devices contained white or green lamps.

Fig. 1. n = 76 phototherapy devices were evaluated in six southern and central Nigerian (indicated by red dots).1 Map of Nigeria. www.un.org/Depts/Cartographic/map/profile/nigeria.pdf

Table 1. Adjustments found to improve irradiance levels.

Fig. 2. Distribution of irradiance of all measured devices (n=76) ranged from 0.3 to 30 μW/cm2/nm.

Fig. 3. Distribution of distance to patient of all overhead devices (n=73) ranged from 20 to 79 cm.

Fig. 4. Observed barriers to device e�cacy included excessive distance between patient and device (left) and use of suboptimal spectral emissions (right).

METHODS

INTRODUCTION

OBJECTIVETo survey the e�cacy of PT devices in resource-diverse Nigerian hospitals and identify strategies to improve performance.

Neonatal hyperbilirubinemia is a major cause of neonatal morbidity and mortality in resource limited settings. Recent surveys, including a 2011 survey of phototherapy devices in Nigerian hospitals (Owa et al., Indian Journal of Pediatrics 2011), have shown that phototherapy (PT) devices for neonatal hyperbilirubinemia in these settings frequently deliver suboptimal treatment. There is a need for identification of means for improving e�ectiveness of treatment delivered by existing devices, in order to reduce the incidence of kernicterus and the need for blood exchange transfusions.

• PT devices were evaluated in hospitals selected by convenience sampling across 4 Nigerian states and the Federal Capital Territory. The sampled 16 urban and semi-urban hospitals included both public and private facilities. • Spectral irradiance was measured for each device as found, using a GE Healthcare BiliBlanket Light Meter I or II, or Minolta Fluoro-Lite 451 meter. • For a subset of devices where consent was obtained, adjustments were made and the optimized irradiance levels were subsequently recorded. Irradiance data are reported as mean level ± SD μW/cm2/nm. • Statistical comparisons were made using Student’s t-test.

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Adjustments found to improve irradiance levels: • Decreasing distance between device and

patient • Turning all switches on for devices with

multiple switches • Replacing broken, missing, and non-blue lamps

with new blue lamps • Improving alignment of device relative to the

patient, ensuring that illumination footprint is centered about the patient

• Removing dust from the plastic screen between the lamps and patient (for devices with such a screen)

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Fig. 5. Distribution of irradiance of devices that were adjusted (n=25).

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Map No. 4228 UNITED NATIONSOctober 2004

Department of Peacekeeping OperationsCartographic Section

0 50 100 150 200 km

0 50 100 mi

National capitalState capitalTown, villageMajor airportInternational boundaryState boundaryHighwayMain roadSecondary roadRailroad

NIGERIA

The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations.

NIGERIA