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OBJECTIVES: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub-Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. METHODS: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3-5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. FINDINGS: We studied 7195 children aged 2-59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. CONCLUSION: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children.

Although traditional uvulectomy, a procedure which consists of cutting away a part of the uvula, has been reported in several sub-Saharan African countries, in Maghreb and in Israel, epidemio-logical and anthropological data on this practice are rare. Severe complications may require hospitalization. The goal of this study was to assess the prevalence of this traditional procedure in Niamey, capital of Niger, the incidence of its severe complications and the beliefs and practices related to it. By the age of 5, 19.6% of the children in our survey had undergone uvulectomy. Severe complications of uvulectomy represented 7.8/1000 cases of hospitalization for children under 15 years of age. Complications were infections (including tetanus), hemorrhage and passage of the cut piece of uvula further down the respiratory tract. The children who had undergone uvulectomy belonged significantly more often to the Hausa ethnic group (66.2%) than to the majority Zarma ethnic group (18.3%) or to the other ethnic groups (15.5%). This can be explained by the fact that, in some Hausa subgroups, uvulectomy is systematically performed on the 7th day after birth, during the naming ceremony, to prevent death due to a 'swelling of the uvula'. In the other Hausa sub-groups and in the other ethnic groups, uvulectomy is solely a curative practice, both for children and adults, for vomiting, diarrhea, anorexia, the child's rejection of the breast, growth retardation and fever. Uvulectomy is performed in Niger by the barbers, whose functions are also to perform specialized surgery. These traditional surgeons claim there is no risk to this practice. However, this study showed that incidence of severe complications (for cases admitted in the hospital) was low but that the risk of death was high for complicated cases. A dialogue between medical institutions and the barbers associations should be initiated. Key words - uvulectomy, barbers, epidemiology, complications, Niger, traditional surgery