BACKGROUND
Hepatitis C virus (HCV) is a major cause of liver diseases globally. Transmission is primarily bloodborne through unsafe injections or healthcare practices. Effective treatment exists, yet access to diagnosis and treatment is limited. Few data indicated high HCV exposure among Rohingya refugees/FDMN residing in crowded camps in Cox’s Bazar District, Bangladesh, where Médecins Sans Frontières is pioneering HCV services. Representative information on the prevalence of active HCV infection and exposure risk factors was lacking.
METHODS
A cross-sectional survey was carried out in May-June 2023, including adults (≥18 years) by simple random geo-sampling (one participant per household, target sample 680), in seven camps (8W, 12, 13, 16, 17, 18, 19) in Cox’s Bazar District. Participants were screened with an HCV-antibody test (SD Bioline), and active infection assessed with Xpert® HCV Viral Load test (Cepheid) if seropositive. A structured questionnaire was administered to identify risk factors of exposure.
RESULTS
Of the 641 participants, median age was 34 years [IQR 28, 46], 66.3% were female. The estimated prevalence of HCV-seropositivity was 29.7% (95%CI: 26.0-22.8), and the prevalence of active infection was 19.6% (16.4-23.2). Multivariable regression revealed higher odds of HCV-seropositivity for female (adjusted odds ratio (aOR)=1.7 (1.0-2.6)), age groups ≥25 years old (aORs ranging from 2.3 to 2.9), reported medical injection(s) (aOR=1.7 (95% CI: 1.0-2.6)) or surgery (aOR=4.7 (95%CI: 1.3-16.7). Half of participants never heard about Hepatitis C, 4.0% of viremic participants reported previous HCV treatment.
CONCLUSION
The survey revealed a significant burden of active HCV infection among adult Rohingya camp residents, which, extrapolated may affect an estimated 86,000 individuals. Urgent action is required to expand diagnosis and treatment to prevent advanced liver disease and transmission. A collaborative task force with camp-based health stakeholders is now underway for a mass screening and treatment initiative, as well as a camp-wide HCV awareness campaign.
The 2014 West Africa Ebola outbreak underlined inadequacies of current personal protective equipment (PPE), such as being uncomfortable and hot, causing excessive sweating and rapid exhaustion, and limiting interactions between health workers and patients. The smartPPE development project responded to the urgent need for a more comfortable, simpler, and sustainable PPE solution for filovirus-outbreak front-line workers. A one- piece, reusable smartPPE with ventilation system was developed to address these challenges. We assessed ease-of-use, comfort, functionality, and perceived doffing-safety of the smartPPE prototype compared with currently used PPE (current-PPE) under simulated field conditions.
METHODS
In June 2023, we conducted a mixed-methods crossover usability study in a controlled high-heat/high-humidity indoor site in Brindisi, Italy. Ten test users (three female, seven with filovirus-front-line experience) assessed smartPPE and current- PPE in four guided sessions covering donning, (emergency) doffing, clinical tasks, and heavy physical WATSAN activities. User feedback was collected through structured questionnaires. Temperature, humidity, session duration, and vital signs were measured, and perceived exertion was assessed using Borg- scores (scale 6–20).
RESULTS
Median temperature and humidity were higher inside current- PPE than inside smartPPE (difference: 2.3°C [IQR 1.8–3.0] and 12.6 percentage points [8.8–19.6], respectively). Users endured heavy work sessions for significantly longer in smartPPE than in current-PPE (80.0 min [IQR 75–84] vs 49.5 min [45–56]). Median increases in body temperature (1.1°C [IQR 0.7–1.6] vs 0.7°C [0.3–0.9]; p<0.001) and respiratory rate (3.5 rpm [1–5] vs 1.5 rpm [0–3]; p=0.034), and reductions in O2 saturation (–2% [–5 to –1] vs –1.5% [–3 to 0]; p=0.027) were higher with current-PPE than with smartPPE. Peripheral vision was similarly rated, but hearing was compromised with smartPPE at ≥5 m. Median exertion- scores were lower for smartPPE (clinical tasks 8.5 [IQR 7–11] vs 15.5 [14–16] p<0.01; heavy physical activities 14 [13–17] vs 18 [17–20] p=0.035). All users preferred smartPPE for overall and thermal comfort, breathing, and doffing-safety; nine (90%) favoured it for non-verbal communication, eight (80%) for vision or longer-interval heavy WATSAN activities, six (60%) for longer- interval patient care, six (60%) for short-term clinical activities, and six (60%) for emergency doffing. Reported concerns were airflow obstruction while bending, hearing difficulties attributed to ventilation noise, and adjustments for headgear, ventilation, and suit fitting.
CONCLUSION
Test users confirmed the usability of smartPPE and favoured it, especially for doffing-safety, longer-interval clinical or physical work, and improved non-verbal interactions, whereas hearing was challenged by the ventilation. Adjustments are currently underway before design freeze. Stakeholder commitment will be crucial to ensure production at scale.
Many countries are now replacing non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line antiretroviral therapy (ART) with a regimen containing tenofovir disoproxil fumarate, lamivudine, and dolutegravir (TLD). Recognising laboratory limitations, Malawi opted to transition those on NNRTI-based first-line ART to TLD without viral load testing. We aimed to assess viral load and HIV drug resistance during 1 year following transition to TLD without previous viral load testing.
METHODS
In this prospective cohort study, we monitored 1892 adults transitioning from NNRTI-based first-line ART to the TLD regimen in the Médecins Sans Frontières-supported decentralised HIV programme in Chiradzulu District, Malawi. Eligible adults were enrolled between Jan 17 and May 11, 2019, at Ndunde and Milepa health centres, and between March 8 and May 11, 2019, at the Boma clinic. Viral load at the start of the TLD regimen was assessed retrospectively and measured at month 3, 6, and 12, and additionally at month 18 for those ever viraemic (viral load ≥50 copies per mL). Dolutegravir minimal plasma concentrations (Cmin) were determined for individuals with viraemia. Drug-resistance testing was done at the start of TLD regimen and at viral failure (viral load ≥50 copies per mL, followed by viral load ≥500 copies per mL; resistance defined as Stanford score ≥15).
FINDINGS
Of 1892 participants who transitioned to the TLD regimen, 101 (5·3%) were viraemic at TLD start. 89 of 101 had drug-resistance testing with 31 participants (34·8%) with Lys65Arg mutation, 48 (53·9%) with Met184Val/Ile, and 42 (40·4%) with lamivudine and tenofovir disoproxil fumerate dual resistance. At month 12 (in the per-protocol population), 1725 (97·9% [95% CI 97·1–98·5]) of 1762 had viral loads of less than 50 copies per mL, including 83 (88·3% [80·0–94·0]) of 94 of those who were viraemic at baseline. At month 18, 35 (97·2% [85·5–99·9]) of 36 who were viraemic at TLD start with lamivudine and tenofovir disoproxil fumarate resistance and 27 (81·8% [64·5–93·0]) of 33 of those viraemic at baseline without resistance had viral load suppression. 14 of 1838 with at least two viral load tests upon transitioning had viral failure (all with at least one dolutegravir Cmin value <640 ng/mL; active threshold), suggesting suboptimal adherence. High baseline viral load was associated with viral failure (adjusted odds ratio [aOR] 14·1 [2·3–87·4] for 1000 to <10 000 copies per mL; aOR 64·4 [19·3–215·4] for ≥10 000 copies per mL). Two people with viral failure had dolutegravir resistance at 6 months (Arg263Lys or Gly118Arg mutation), both were viraemic with lamivudine and tenofovir disoproxil fumarate resistance at baseline.
INTERPRETATION
High viral load suppression 1 year after introduction of the TLD regimen supports the unconditional transition strategy in Malawi. However, high pre-transition viral load, ongoing adherence challenges, and possibly existing nucleoside reverse transcriptase inhibitor resistance can lead to rapid development of dolutegravir resistance in a few individuals. This finding highlights the importance of viral load monitoring and dolutegravir-resistance surveillance after mass transitioning to the TLD regimen.