Hindawi Publishing Corporation

Emergency Medicine International

Volume 2015, Article ID 108247, 5 pages
http://dx.doi.org/10.1155/2015/108247

Research Article
Morbidity and Mortality following Traditional Uvulectomy
among Children Presenting to the Muhimbili National Hospital
Emergency Department in Dar es Salaam, Tanzania

H. R. Sawe,1,2 J. A. Mfinanga,1,2 F. H. Ringo,2 V. Mwafongo,1,2

T. A. Reynolds,2,3 and M. S. Runyon1,4
1
Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
2
Muhimbili National Hospital, Dar es Salaam, Tanzania
3
University of California, San Francisco, CA, USA
4
Carolinas Medical Center, Charlotte, NC, USA

Correspondence should be addressed to M. S. Runyon; michael.runyon@carolinas.org

Received 3 April 2015; Revised 3 June 2015; Accepted 4 June 2015

Academic Editor: Wen-Jone Chen

Copyright © 2015 H. R. Sawe et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Traditional uvulectomy is performed as a cultural ritual or purported medical remedy. We describe the associated
emergency department (ED) presentations and outcomes. Methods. This was a subgroup analysis of a retrospective review of
all pediatric visits to our ED in 2012. Trained abstracters recorded demographics, clinical presentations, and outcomes. Results.
Complete data were available for 5540/5774 (96%) visits and 56 (1.0%, 95% CI: 0.7–1.3%) were related to recent uvulectomy, median
age 1.3 years (interquartile range: 7 months–2 years) and 30 (54%) were male. Presenting complaints included cough (82%), fever
(46%), and hematemesis (38%). Clinical findings included fever (54%), tachypnea (30%), and tachycardia (25%). 35 patients (63%,
95% CI: 49–75%) received intravenous antibiotics, 11 (20%, 95% CI: 10–32%) required blood transfusion, and 3 (5%, 95% CI: 1–15%)
had surgical intervention. All were admitted to the hospital and 12 (21%, 95% CI: 12–34%) died. By comparison, 498 (9.1%, 95% CI:
8–10%) of the 5484 children presenting for reasons unrelated to uvulectomy died (𝑝 = 0.003). Conclusion. In our cohort, traditional
uvulectomy was associated with significant morbidity and mortality. Emergency care providers should advocate for legal and public
health interventions to eliminate this dangerous practice.

1. Introduction In sub-Saharan Africa, traditional uvulectomy is largely

driven by indigenous beliefs and cultural practices [9, 10],
Traditional uvulectomy is an excision of the uvula, usually with many local nonphysician healers believing and preach-
performed by nonphysician healers. The procedure has been ing that the uvula is the main organ responsible for all
touted as a remedy for, or prevention of, infections associated throat and chest problems and should be removed as early as
with throat and chest and has also been completed as part possible in childhood [11]. Despite being a common cultural
of ritual practice [1–4]. Unlike the uvulopalatoplasty, which practice, traditional uvulectomy has been associated with
is typically performed by an otolaryngologist to treat snoring substantial number of harmful outcomes with significant
or obstructive sleep apnea [5–7], the traditional uvulectomy morbidity and mortality largely from haemorrhage and sepsis
is performed by local healers who inherit the skills from [9, 11, 12].
their predecessors with no formal medical training. It is In Tanzania, the practice of uvulectomy is a relatively
often completed without regard to recommended standards common phenomenon [10, 13] carried out by traditional heal-
of good surgical practices [8]. ers, most of who are not recognized by the ministry of health,
2 Emergency Medicine International

despite the government stance on discouraging dangerous Table 1: Baseline characteristics of the patients.
traditional practices. The prevalence of traditional uvulec-
tomy in Tanzania has been estimated at 3.6% [14]. There are Variable All (𝑁 = 56)∗
reports of traditional practitioners using the same instru- Age
ments to perform the procedure in multiple patients without Overall: median 1.3 years
cleaning, disinfecting, or sterilizing, thus potentially expos- (interquartile range) (7 months–2 years)
ing the children to life threatening communicable infections 1–6 months 7 (13)
[15]. 6 months–<1 year 18 (32)
In this retrospective chart review study, we reviewed 1 year–5 years 30 (54)
the records of all pediatric patients seen in the emergency
>5 years 1 (2)
department of a large national hospital during the year 2012 to
describe the clinical presentations and outcomes of children Gender
presenting with complications from traditional uvulectomy. Male 30 (54)
Female 26 (46)
∗
2. Methods Except as specified, values are counts (percentages).

2.1. Study Setting. The investigation was conducted at the

Muhimbili National Hospital (MNH) Emergency Depart- counts and percentages as appropriate for the data type and
ment (ED) in Dar es Salaam, Tanzania. Established in 2010, distribution. Confidence intervals were calculated by the
the MNH ED is the first full-capacity ED in Tanzania and Clopper-Pearson (exact) method. Categorical values were
is the clinical training site for the country’s first emergency compared between groups using the Chi Square test.
medicine residency program.
The department is staffed by interns (fresh graduates from 2.4. Ethics. The Senate research and publication committee
medical school), registrars (registered medical practitioners of the Muhimbili University of Health and Allied Sciences
each with 1–3 years of clinical experience following intern- reviewed the study protocol and granted ethical approval,
ship), and emergency medicine residents (all had already including waiver of informed consent.
worked as registrars before joining the 3-year residency pro-
gram). These doctors work under the clinical supervision of 3. Results
the locally trained emergency physician faculty with support
and consultation from board-certified emergency physicians According to the patient logs, a total of 5774 children pre-
from the USA, Canada, and South Africa. sented to the MNH ED from 1 January 2012 to 31 December
MNH is the largest tertiary care center in Tanzania and 2012. Of these, 5540 (96%) patient files were available for
the ED serves a high acuity patient population from within review and data abstraction. A total of 56 patients (1.0%, 95%
Dar es Salaam as well as referral patients from throughout the CI: 0.7–1.3%) met our inclusion criteria of presentation due
country. Of the 36000 adult and pediatric patients seen each to complaint associated with recent traditional uvulectomy.
year, only 20% are discharged home from the ED. The top five Of those included, 30 (53.6%) of the study populations were
categories of complaints seen in the department are trauma, male, with median age of 1.3 years (interquartile range: 7
infectious, mental health, neoplastic, and pregnancy-related months to 2 years), and 55 (98%) were below 5 years of age
issues [16]. (Table 1).
The main presenting symptoms were cough in 46 (82%),
2.2. Study Design. This was a prespecified subgroup analysis report of fever prior to presentation in 26 (46%), and
of a retrospective chart review of all children (less than 18 hematemesis in 21 (38%). The main physical examination
years old) seen in the MNH ED from 1 January 2012 to 31 findings documents in the ED charts were fever in 30 (54%),
December 2012. Trained physician abstractors reviewed the tachypnea in 17 (30%), tachycardia in 14 (25%), and hypoxia
ED and inpatient records for all children presenting to the in 6 (11%) (Table 2).
MNH ED during the study period. Data were recorded on a The most common final ED diagnoses were pneumonia
structured case report form, including basic demographics, in 23 (41%), severe anemia, classified according to the World
reported initial complaints, final EMD diagnoses, and final Health Organization definition as a hemoglobin measure-
hospital discharge diagnosis. ment of less than 7 g/dL [17], in 20 (36%), and upper GI
For this investigation, we examined all presentations bleeding in 20 (36%). Bronchitis was the least common final
associated with complications of traditional uvulectomy, ED Diagnosis (Table 3).
including the clinical findings, treatment rendered, and The most common final hospital discharge diagnoses
patient outcomes. were pneumonia in 23 patients (44%), upper GI bleeding
in 24 patients (46%), Malaria in 22 patients (42%), HIV in
2.3. Statistical Analysis. Data were imported into an Excel 11 patients (21%), and severe anemia and malnutrition in 10
spreadsheet (Microsoft Corporation, Redmond, WA, USA), patients (19%). As was seen with the ED diagnoses, bronchitis
cleaned, and analyzed with StatsDirect (v 3.0.133, Cheshire, was the least common hospital discharge diagnosis (Table 4).
UK). We report descriptive statistics, including mean and Treatment included intravenous antibiotics for 35
standard deviations, medians and interquartile ranges, and patients (63%, 95% CI: 49–75%), blood transfusions for 11
Emergency Medicine International 3

Table 2: Clinical findings during EMD presentation. Table 5: Disposition.

Presenting symptoms 𝑁 = 56∗ Disposition All (𝑁 = 56)∗

Cough 46 (82) General pediatric ward 42 (75)
Report of fever prior to presentation 26 (46) Intensive care unit 7 (13)
Vomiting blood 21 (38) Pediatric surgery 3 (5)
Difficulty in breathing 12 (21) Died at EMD 4 (7)
Abdominal distension 6 (11) Clinical outcome All (𝑁 = 56)∗∗
Chest pain 5 (9) Survived to discharge 44 (79; 66–88)
Others∗∗ 10 (18) Died (both in the ward and EMD) 12 (21; 12–34)
Physical findings and vital signs 𝑁 = 56∗ ∗
Values are counts (percentages).
∗∗
Temperature > 37.5∘ C 30 (54) Values are counts (percentages; 95% confidence intervals).
Tachypnea 17 (30)
Tachycardia 14 (25) the study cohort (Table 5). By comparison, 498 (9%, 95%
Oxygen saturation < 90% 6 (11) CI: 8–10%) of the 5484 children with complete data who
Bradycardia (<80 beats/min) 5 (9) presented to the ED for reasons not related to complications
∗
Values are counts (percentages). of uvulectomy died (𝑝 = 0.003).
∗∗
Others include black stool, bleeding, convulsions, and oral ulcers.
4. Discussion
Table 3: Final ED diagnoses.
Our investigation found that 1% of children presenting to
Diagnoses 𝑁 = 56∗ the MNH ED in the year 2012 had complaints related to
Pneumonia 23 (41) a recent traditional uvulectomy and nearly all were under
Upper GI bleeding 20 (36) the age of 5 years. These findings are similar to those seen
Severe anemia 20 (36) in other African countries [9, 12], where the procedure is
Malaria 10 (18) predominantly performed in the early years of life due to
HIV 8 (14) the belief that the elongated uvula is responsible for myriad
Tuberculosis 3 (5)
potential maladies, including sleep disturbances, respiratory
infections, and even suffocation of children in their sleep [18].
Bronchitis 1 (2)
∗
The predominant symptoms at ED presentation in
Values are counts (percentages). Some patients had more than one diagno-
our cohort were cough, difficulty in breathing, fever, and
sis listed.
hematemesis. All the children had at least one abnormal
physical finding or vital sign at the time of presentation to the
Table 4: Final hospital diagnoses.
emergency medicine department, with more than half of the
Diagnoses 𝑁 = 52∗ patients presenting with fever. Other observed abnormalities
Upper GI bleeding 24 (46%) included tachypnea, tachycardia, and hypoxia. We were not
Pneumonia 23 (44%)
able to establish with certainty that the presenting symptoms
of our cohort were due to complications of the procedure
Malaria 22 (42%)
or from preexisting medical conditions that prompted the
HIV 11 (21%)
procedure. Regardless, the observed mortality was more than
Severe anemia 10 (19%) twice that of all other children presenting to the ED during
Malnutrition 10 (19%) the study period. Previous studies from throughout Africa
Septicemia 3 (6%) have shown that cough, throat pain, dysphagia, and loss of
Tuberculosis 3 (6%) appetite are among the most common indications for tradi-
Bronchitis 1 (2%) tional uvulectomy as stated by the traditional healers [19].
∗
Values are counts (percentages). 4 patients who died in the ED were The top final ED diagnoses were pneumonia, upper
excluded. Some patients had more than one diagnosis listed. GI bleeding, and severe anemia. The most common hos-
pital discharge diagnoses were similar but also included
malaria. Prior work in similar settings has demonstrated
(20%, 95% CI: 10–32%), and surgical interventions for 3 (5%, that respiratory infections and malaria remain among the
95% CI: 1–15%); these surgical interventions included suture top causes of hospital admission [20–22]. Acknowledging
ligation for hemostasis, packing, and electrical cauterization the previously mentioned clinical uncertainty, it is likely that
to achieve hemostasis. Four patients (7%, 95% CI: 2–17%) these diagnoses were responsible for the initial presentation
died in the ED and the rest were admitted to the hospital: 42 to the traditional healers that resulted in the uvulectomy.
(75%) to the general pediatric ward, 7 (13%) to the pediatric Though respiratory infections and malaria remain among
intensive care unit, and 3 (5%) to the pediatric surgical the top causes of death [23] in children under the age of 5
service. Eight of the admitted patients died in the hospital years, these conditions are imminently treatable and curable
for a total mortality of 12 (21%, 95% CI: 12–34%) among with timely and appropriate clinical intervention. Not only
4 Emergency Medicine International

is uvulectomy ineffective but also it carries the threat of UK: United Kingdom
significant morbidity and mortality while delaying treatment USA: United States of America.
of any significant underlying medical condition.
None of the children in this group were discharged from Conflict of Interests
the emergency department, 63% received intravenous antibi-
otics, 20% received a blood transfusion, and 5% required The authors declare that there is no conflict of interests
immediate surgical intervention for hemorrhage control. regarding the publication of this paper.
Prior studies have reported infections and bleeding as the
major complications of uvulectomy, including one in which
hemorrhage was present in over 50% of the patients, with the
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