Journal Article > ResearchFull Text
Trop Med Int Health. 2017 December 15; Volume 23 (Issue 3); DOI:10.1111/tmi.13025
Bedell RA, van Lettow M, Meaney C, Corbett EL, Chan AK, et al.
Trop Med Int Health. 2017 December 15; Volume 23 (Issue 3); DOI:10.1111/tmi.13025
BACKGROUND:
C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI).
METHODS:
In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment.
RESULTS:
Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models.
CONCLUSION:
High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB.
C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI).
METHODS:
In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment.
RESULTS:
Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models.
CONCLUSION:
High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB.
Journal Article > ResearchFull Text
Malawi Med J. 2012 June 1; Volume 24 (Issue 2); 29-33.
Khonje A, Metcalf CJ, Diggle E, Mlozowa D, Jere C, et al.
Malawi Med J. 2012 June 1; Volume 24 (Issue 2); 29-33.
BACKGROUND
Cholera is endemic in Malawi with seasonal outbreaks during the wet season. People living around Lake Chilwa rely on the lake for their water supply. From May 2009 to May 2010, a cholera outbreak occurred in fishing communities around Lake Chilwa. This paper describes the outbreak response and lessons learned for prevention and management of future outbreaks.
METHODS
Starting in January 2010, Médecins Sans Frontières (MSF) helped District Health Management Teams (DHMTs) to distribute educational materials, water disinfectant and hygiene supplies, and oral rehydration solution (ORS) in fishing communities. MSF also supported case management by mentoring health workers and providing equipment and supplies.
RESULTS
A total of 1,171 cholera cases and 21 deaths were reported in the districts around the lake, with cases also being reported on the Mozambican side of the lake. The attack rate was highest among people living on or around the lake, particularly among fishermen. Samples of lake water had high turbidity conducive to the propagation of Vibrio cholerae.
CONCLUSION
A number of practical measures could be taken to prevent future outbreaks and to manage outbreaks more effectively. These measures should address surveillance, environmental management, outbreak preparedness, and case management.
Cholera is endemic in Malawi with seasonal outbreaks during the wet season. People living around Lake Chilwa rely on the lake for their water supply. From May 2009 to May 2010, a cholera outbreak occurred in fishing communities around Lake Chilwa. This paper describes the outbreak response and lessons learned for prevention and management of future outbreaks.
METHODS
Starting in January 2010, Médecins Sans Frontières (MSF) helped District Health Management Teams (DHMTs) to distribute educational materials, water disinfectant and hygiene supplies, and oral rehydration solution (ORS) in fishing communities. MSF also supported case management by mentoring health workers and providing equipment and supplies.
RESULTS
A total of 1,171 cholera cases and 21 deaths were reported in the districts around the lake, with cases also being reported on the Mozambican side of the lake. The attack rate was highest among people living on or around the lake, particularly among fishermen. Samples of lake water had high turbidity conducive to the propagation of Vibrio cholerae.
CONCLUSION
A number of practical measures could be taken to prevent future outbreaks and to manage outbreaks more effectively. These measures should address surveillance, environmental management, outbreak preparedness, and case management.
Journal Article > ResearchFull Text
BJOG. 2012 January 18; Volume 204 (Issue 4); DOI:10.1093/infdis/jir093
van den Akker T, Bemelmans M, Ford NP, Jemu M, Diggle E, et al.
BJOG. 2012 January 18; Volume 204 (Issue 4); DOI:10.1093/infdis/jir093
Please cite this paper as: van den Akker T, Bemelmans M, Ford N, Jemu M, Diggle E, Scheffer S, Zulu I, Akesson A, Shea J. HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi. BJOG 2012;119:431-438. Objective To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-to-child transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services. Design Descriptive analysis. Setting Thyolo District, with a population of 600 000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004. Population Women attending reproductive health services care in 2005 and 2010. Methods Review of facility records and databases for routine monitoring. Main outcome measures Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care. Results There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40, 95% CI 4.25-4.55). Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52). Conclusions During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.
Journal Article > ResearchFull Text
Int J Tuberc Lung Dis. 2011 July 1; Volume 15 (Issue 7); 933-937.; DOI:10.5588/ijtld.10.0666
Zachariah R, Bemelmans M, Akesson A, Gomani P, Phiri K, et al.
Int J Tuberc Lung Dis. 2011 July 1; Volume 15 (Issue 7); 933-937.; DOI:10.5588/ijtld.10.0666
OBJECTIVE
To report on the trends in new and recurrent tuberculosis (TB) case notifications in a rural district of Malawi that has embarked on large-scale roll-out of antiretroviral treatment (ART).
METHODS
Descriptive study analysing TB case notification and ART enrolment data between 2002 and 2009.
RESULTS
There were a total of 10 070 new and 755 recurrent TB cases. ART scale-up started in 2003, and by 2007 an estimated 80% ART coverage had been achieved and was sustained thereafter. For new TB cases, an initial increase in case notifications in the first years after starting ART (2002–2005) was followed by a highly significant and sustained decline from 259 to 173 TB cases per 100 000 population (χ2 for trend 261, P < 0.001, cumulative reduction for 2005–2009 = 33%, 95%CI 27–39). For recurrent TB, the initial increase was followed by a significant drop, from 20 to 15 cases/100 000 (χ2 for linear trend = 8.3, P = 0.004, constituting a 25% (95%CI 9–49) cumulative reduction between 2006 and 2009. From 2005 to 2009, ART averted an estimated 1164 (95%CI 847–1480) new TB cases and 78 (95%CI 23–151) recurrent TB cases.
CONCLUSIONS
High ART implementation coverage is associated with a very significant declining trend in new and recurrent TB case notifications at population level.
To report on the trends in new and recurrent tuberculosis (TB) case notifications in a rural district of Malawi that has embarked on large-scale roll-out of antiretroviral treatment (ART).
METHODS
Descriptive study analysing TB case notification and ART enrolment data between 2002 and 2009.
RESULTS
There were a total of 10 070 new and 755 recurrent TB cases. ART scale-up started in 2003, and by 2007 an estimated 80% ART coverage had been achieved and was sustained thereafter. For new TB cases, an initial increase in case notifications in the first years after starting ART (2002–2005) was followed by a highly significant and sustained decline from 259 to 173 TB cases per 100 000 population (χ2 for trend 261, P < 0.001, cumulative reduction for 2005–2009 = 33%, 95%CI 27–39). For recurrent TB, the initial increase was followed by a significant drop, from 20 to 15 cases/100 000 (χ2 for linear trend = 8.3, P = 0.004, constituting a 25% (95%CI 9–49) cumulative reduction between 2006 and 2009. From 2005 to 2009, ART averted an estimated 1164 (95%CI 847–1480) new TB cases and 78 (95%CI 23–151) recurrent TB cases.
CONCLUSIONS
High ART implementation coverage is associated with a very significant declining trend in new and recurrent TB case notifications at population level.
Journal Article > ResearchFull Text
PLOS One. 2012 June 22; Volume 7 (Issue 6); DOI:10.1371/journal.pone.0039347
Bedell RA, Anderson ST, van Lettow M, Akesson A, Corbett EL, et al.
PLOS One. 2012 June 22; Volume 7 (Issue 6); DOI:10.1371/journal.pone.0039347
Background Tuberculosis (TB) and serious bloodstream infections (BSI) may contribute to the high early mortality observed among patients qualifying for antiretroviral therapy (ART) with unexplained weight loss, chronic fever or chronic diarrhea. Methods and Findings A prospective cohort study determined the prevalence of undiagnosed TB or BSI among ambulatory HIV-infected adults with unexplained weight loss and/or chronic fever, or diarrhea in two routine program settings in Malawi. Subjects with positive expectorated sputum smears for AFB were excluded. Investigations Bacterial and mycobacterial blood cultures, cryptococcal antigen test (CrAg), induced sputum (IS) for TB microscopy and solid culture, full blood count and CD4 lymphocyte count. Among 469 subjects, 52 (11%) had microbiological evidence of TB; 50 (11%) had a positive (non-TB) blood culture and/or positive CrAg. Sixty-five additional TB cases were diagnosed on clinical and radiological grounds. Nontyphoidal Salmonellae (NTS) were the most common blood culture pathogens (29 cases; 6% of participants and 52% of bloodstream isolates). Multivariate analysis of baseline clinical and hematological characteristics found significant independent associations between oral candidiasis or lymphadenopathy and TB, marked CD4 lymphopenia and NTS infection, and severe anemia and either infection, but low positive likelihood ratios (<2 for all combinations). Conclusions We observed a high prevalence of TB and serious BSI, particularly NTS, in a program cohort of chronically ill HIV-infected outpatients. Baseline clinical and hematological characteristics were inadequate predictors of infection. HIV clinics need better rapid screening tools for TB and BSI. Clinical trials to evaluate empiric TB or NTS treatment are required in similar populations.