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Background: The SpO2/FiO2 is a useful oxygenation parameter with prognostic capacity in patients with ARDS. We investigated the prognostic capacity of SpO2/FiO2 for mortality in patients with ARDS due to COVID–19. Methods: This was a post-hoc analysis of a national multicenter cohort study in invasively ventilated patients with ARDS due to COVID–19. The primary endpoint was 28–day mortality. Results: In 869 invasively ventilated patients, 28–day mortality was 30.1%. The SpO2/FiO2 on day 1 had no prognostic value. The SpO2/FiO2 on day 2 and day 3 had prognostic capacity for death, with the best cut-offs being 179 and 199, respectively. Both SpO2/FiO2 on day 2 (OR, 0.66 [95%–CI 0.46–0.96]) and on day 3 (OR, 0.70 [95%–CI 0.51–0.96]) were associated with 28–day mortality in a model corrected for age, pH, lactate levels and kidney dysfunction (AUROC 0.78 [0.76–0.79]). The measured PaO2/FiO2 and the PaO2/FiO2 calculated from SpO2/FiO2 were strongly correlated (Spearman's r = 0.79). Conclusions: In this cohort of patients with ARDS due to COVID–19, the SpO2/FiO2 on day 2 and day 3 are independently associated with and have prognostic capacity for 28–day mortality. The SpO2/FiO2 is a useful metric for risk stratification in invasively ventilated COVID–19 patients.

Advancements in medical diagnostics have allowed us to understand the underlying mechanism and treat the root cause for many diseases which had been causing morbidity and mortality up until this point in human history. Furthermore, many of the standard diagnostic procedures have now been transformed to provide answers at or near the point-of-care. However, the effects of these positive developments have not trickled down to the parts of our society which are considered underdeveloped and lack the necessary infrastructure and facilities. Diagnostics in such resource limited settings still lag behind and fail to provide the requisite healthcare. In order to translate the diagnostic solutions designed for central laboratories to resource limited settings, there are certain challenges that need to be addressed, such as portability, reduction in cost and ease-of-use, while keeping the sensitivity and specificity at the required level. The work presented in this thesis focuses on addressing some of these issues by using microfluidics to develop diagnostic platforms that are suitable to be used in resource limited settings. In paper I, a very low-cost and simple centrifugal microfluidic platform was developed to be used in settings which do not have a reliable supply of electricity. The platform uses a smartphone as a source of power and the sensors of the phone for speed control. In paper II, a portable and low-cost diagnostic platform was developed for multiplexed detection of biomarkers based on centrifugal microfluidics. The platform uses colorimetric detection and a simple readout method which does not require a spectrophotometer for quantification. In paper III, a platform was developed for COVID-19 diagnostics which combines centrifugal microfluidics with a novel bead-based strategy for signal enhancement. The platform uses fluorescent detection with a smartphone readout and has the capability to process up to 20 samples at the same time. In paper IV, as a follow up of paper III, a more advanced platform was developed for COVID-19 diagnostics which allows the operator to carry out nucleic acid amplification in a completely automated manner, from adding the sample to getting the final result. In paper V, an alternative method for detection of SARS-CoV-2 was developed using electrochemical biosensing. This work combines the electrochemical technique with a flexible printed circuit board for a rapid, amplification-free and label-free detection of target SARS-CoV-2 sequences. Framsteg inom medicinsk diagnostik har gjort det möjligt att förstå och behandla många sjukdomar som tidigare varit en betydande orsak till dödlighet. Trots framstegen har inte alla delar av samhället haft tillgång dessa diagnostiska verktyg på samma sätt, särskilt i resursbegränsade miljöer i låg- och medelinkomstländer. Detta har lett till en ojämlik tillgång till sjukvård. Den senaste utvecklingen inom mikrofluidik möjliggör utveckling av så kallade patientnära analysverktyg till en fraktion av kostnaderna i traditionella labb-baserade tester. För applikationer i resursbegränsade miljöer krävs diagnostiska lösningar som är portabla, kostnadseffektiva och användarvänliga samtidigt som de har hög känslighet och specificitet. I denna avhandling har vi jobbat med framtagande av mikrofluidik-baserade diagnostiska plattformar som är lämpliga för resursbegränsade miljöer. Syftet är att kunna göra avancerade tester på platser där sjukvårdstjänster tidigare varit otillgängliga eller kostsamma att etablera. För att lösa de tekniska utmaningarna har flera nya tekniker utvecklats, bland annat en centrifugalmikrofluidik-baserad plattform. Centrifugalmikrofluidik är en teknik för att hantera små mängder vätskor med hjälp av en roterande skiva, liknande CD/DVD skivor men i detta fall finns det mikrofluidiska kanaler mönstrade i skivan för att möjliggöra analys. När skivan roterar skapas centrifugalkraft som används för att flytta och manipulera vätskor i dessa kanaler för att utföra ett antal steg som är nödvändiga för att göra bioanalys av olika prover. Det finns olika applikationer för denna teknik inom biologi och vi har utvecklat olika typer av metoder i denna avhandling. I ett av projekten kombinerade vi centrifugalmikrofluidik med en mobiltelefon för att utveckla en diagnostisk plattform som använde mobiltelefonen som strömkälla, analysering av provresultat samt som sensor för att kontrollera rotationshastigheten av rotorn som driver disken med analysen. Dessutom använde vi oss av pappkartong för att montera rotorn och skivan där tanken är att slutanvändaren ska kunna montera ihop och använda en mobiltelefon för att utföra analysen i fältet. En annan plattform använde kolorimetrisk detektion av proteiner och en enkel avläsningsmetod integrerad på plattformen, som inte krävde en spektrofotometer för kvantifiering av proteinmängden på skivan. I ett tredje projekt utvecklades en plattform för COVID-19-diagnostik som kombinerade centrifugalmikrofluidik där skivan inkorporerar agaroskulor för signalförstärkning av nukleinsyror. Denna plattform använde fluorescensdetektion med avläsning av en smartphone. Skivan analyserar upp till 20 prover från COVID-19 patienter samtidigt och resultatet kan avläsas av en smartphone och hade förmågan att behandla upp till 20 prover samtidigt. Vi har vidareutvecklat metoden där vi inkorporerat en kamera istället för mobiltelefon för att automatisera bildanalysen och vi planerar att testa metoden på fält i olika länder i sub-Sahara Afrika inom en snar framtid. Slutligen utvecklades en alternativ metod för detektion av SARS-CoV-2 med hjälp av elektrokemisk biosensing. Denna metod använde ett flexibelt kretskort för en snabb detektion av SARS-CoV-2. Sammanfattningsvis har vi inom denna avhandling utvecklat ett antal patientnära analysmetoder som riktar in sig på utmaningarna i resursbegränsade miljöer. Det är viktigt att utvecklar tekniker som kan användas i dessa miljöer, där infrastruktur och faciliteter är begränsade eller saknas helt. Med hjälp av den senaste teknikutvecklingen inom mikrofluidik tror vi att det är fullt möjligt att utveckla diagnostiska plattformar som är kostnadseffektiva och användas där de behövs som bäst, på ett innovativt sätt. QC 2023-05-03

Background Ebola virus (EBOV); a public health emergency of international concern,is known to pose threat of global outbreaks. EBOV has spread in African continent and due to unchecked international travel, importation of cases has been reported in different countries. In this alarming scenario, developing countries need to evaluate and upgrade their preparedness plan to contain the spread of EBOV. The present review lays down the updated preparedness plan for developing countries to contain future EBOV outbreaks. Methods The literature on EBOV outbreaks and preparedness strategies reported were searched on Pubmed and Google Scholar using the MeSH terms such as "Ebola virus disease, Epidemic, Outbreak, Imported case, Preparedness, Public health interventions" combined with Boolean operator (OR) for the period of 2011–2020. Additionally, World Health organization (WHO) and Centers for Disease Control & Prevention (CDC) websites were searched for the guidelines, reports, containment strategies, containment plan of countries, actions taken by countries and international partners, etc. Results The present review analyzed the EBOV outbreaks between 2011–2020 and containment strategies used by the affected countries. Based on the lessons learned from EBOV outbreaks and personal experience in infectious disease management, we have recommended a preparedness and response plan for EBOV containment in developing countries. Conclusion Developing countries are particularly vulnerable to major outbreaks of EBOV due to increased international travel and unchecked transmission. The recommended preparedness plan will help developing counties to contain EBOV outbreaks in future.

Background Cryptococcosis is an opportunistic fungal infection that primarily affects people with advanced HIV/AIDS and is an important cause of morbidity and mortality around the globe. By far the most common presentation of the disease is cryptococcal meningitis (CM), which leads to an estimated 15–20% of all HIV related deaths worldwide, 75% of which are in sub-Saharan Africa. However, to the best of our knowledge there is quite limited reviewed data on the epidemiology of cryptococcal antigenemia in a large HIV-infected population in resource limited settings. Methods Articles published in English irrespective of the time of publication were systematically searched using comprehensive search strings from PubMed/Medline and SCOPUS. In addition, Google Scholar and Google databases were searched manually for grey literature. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. The pooled prevalence of cryptococcal antigenemia was determined with 95% confidence interval (CI). Results Among 2941 potential citations, we have included 22 studies with a total of 8338 HIV positive individuals. The studies were reported in ten different countries during the year (2007–2018). Most of the articles reported the mean CD4 count of the participants below 100 cells/μl. The pooled prevalence of cryptococcal antigenemia at different CD4 count and ART status was at 8% (95%CI: 6–10%) (ranged between 1.7 and 33%). Body mass index (BMI) 2, CD4 count Conclusions Implementing a targeted screening of HIV patients with low BMI, CD4 count

BackgroundThe use of mobile technology has been reported to help improve access to education for people in remote areas. However, there is limited evidence of its adoption in resource-limited settings. The aim of this study was to utilize stakeholder generated ideas to design and pilot a mobile learning curriculum, with the purpose of facilitating training to improve the quality of point-of-care diagnostics services in KwaZulu-Natal (KZN) rural clinics.MethodsNominal Group Technique was employed to enable collaboration with stakeholders in designing and piloting of a POC diagnostics curriculum. Stakeholders were selected from 11 KZN districts to participate in a clinic-based piloting of the curriculum using an online application. The application was designed in collaboration with a teacher training institute in Durban. Moodle was used as an established reliable online learning management system. During piloting, quantitative and qualitative data were generated and analyzed using descriptive statistics and content analysis.Findings and ConclusionGuided by the Nominal Group Technique results, five delivery modes for curriculum content through Mobile Learning were generated. An interactive course page was created on the Moodle site, titled: Quality HIV Point of Care Diagnostics Curriculum Delivery for Nurses in Rural Areas. The course content consisted of three teaching units, activities, an online quiz and an online survey. An analytic-algorithm built into the online course enabled monitoring of participation and assessment outcomes automatically. At piloting, 64% of the invited representative clinics were able to access the course, with 47% meeting the course completion requirements. All the participants achieved the set pass mark of 75% with an average of 87%. The activity completion report showed that topics presented through images, videos and simple text were accessed more than those presented as attachments of national documents. Despite poor network coverage and limited access to mobile technology, exacerbated by Covid-19 related restrictions, Point of care diagnostics Mobile Learning curriculum was well-received in participating rural clinics. Recommendations relating to course improvement and access, included extending collaboration with specialists in eHealth systems development and with South African cell phone network providers.

Abstract Background In many units around the world, microsurgical free-tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services. Methods A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to August 2021. All clinical studies presenting sufficient data on free-tissue transfer performed on short-term collaborative surgical trips (STCSTs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications, cost effectiveness, impact on training, burden of disease, legacy and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the ‘Revised Cochrane risk of bias tool for randomized trials’ (Rob2), the ‘Risk of bias in non-randomized studies of interventions’ (ROBINS-I) tool, or the National Institute for Health Quality Assessment tool for Case Series. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Discussion To-date the outcomes of microsurgical procedures performed on STCSTs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free-tissue transfer. STCSTs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes. Systematic review registration PROSPERO 225613

Background The SpO2/FiO2 is a useful oxygenation parameter with prognostic capacity in patients with ARDS. We investigated the prognostic capacity of SpO2/FiO2 for mortality in patients with ARDS due to COVID–19. Methods This was a post-hoc analysis of a national multicenter cohort study in invasively ventilated patients with ARDS due to COVID–19. The primary endpoint was 28–day mortality. Results In 869 invasively ventilated patients, 28–day mortality was 30.1%. The SpO2/FiO2 on day 1 had no prognostic value. The SpO2/FiO2 on day 2 and day 3 had prognostic capacity for death, with the best cut-offs being 179 and 199, respectively. Both SpO2/FiO2 on day 2 (OR, 0.66 [95%–CI 0.46–0.96]) and on day 3 (OR, 0.70 [95%–CI 0.51–0.96]) were associated with 28–day mortality in a model corrected for age, pH, lactate levels and kidney dysfunction (AUROC 0.78 [0.76–0.79]). The measured PaO2/FiO2 and the PaO2/FiO2 calculated from SpO2/FiO2 were strongly correlated (Spearman's r = 0.79). Conclusions In this cohort of patients with ARDS due to COVID–19, the SpO2/FiO2 on day 2 and day 3 are independently associated with and have prognostic capacity for 28–day mortality. The SpO2/FiO2 is a useful metric for risk stratification in invasively ventilated COVID–19 patients.

Introduction Liver abscesses are mainly caused by parasitic or bacterial infection and are an important cause of hospitalization in low-middle income countries (LMIC). The pathophysiology of abscesses is different depending on the etiology and requires different strategies for diagnosis and management. This paper discusses pathophysiology and epidemiology, the current diagnostic approach and its limitations and management of liver abscess in low resource settings. Sources of data We searched PubMed for relevant reviews by typing the following keywords: ‘amoebic liver abscess’ and ‘pyogenic liver abscess’. Areas of agreement Amoebic liver abscess can be treated medically while pyogenic liver abscess usually needs to be percutaneously drained and treated with effective antibiotics. Areas of controversy In an LMIC setting, where misuse of antibiotics is a recognized issue, liver abscesses are a therapeutic conundrum, leaving little choices for treatment for physicians in low capacity settings. Growing points As antimicrobial resistance awareness and antibiotic stewardship programs are put into place, liver abscess management will likely improve in LMICs provided that systematic adapted guidelines are established and practiced. Areas timely for developing research The lack of a quick and reliable diagnostic strategy in the majority of LMIC makes selection of appropriate treatment challenging.

Affordable, sensitive, and scalable technologies are needed for monitoring antiretroviral treatment (ART) success with the goal of eradicating HIV-1 infection. This review discusses use of Sanger sequencing and next generation sequencing (NGS) methods for HIV-1 drug resistance (HIVDR) genotyping, focusing on their use in resource limited settings (RLS). Sanger sequencing remains the gold-standard method for detecting HIVDR mutations of clinical relevance but is mainly limited by high sequencing costs and low-throughput. NGS is becoming a more common sequencing method, with the ability to detect low-abundance drug-resistant variants and reduce per sample costs through sample pooling and massive parallel sequencing. However, use of NGS in RLS is mainly limited by infrastructure costs. Given these shortcomings, our review discusses sequencing technologies for HIVDR genotyping, focusing on common in-house and commercial assays, challenges with Sanger sequencing in keeping up with changes in HIV-1 treatment programs, as well as challenges with NGS that limit its implementation in RLS and in clinical diagnostics. We further discuss knowledge gaps and offer recommendations on how to overcome existing barriers for implementing HIVDR genotyping in RLS, to make informed clinical decisions that improve quality of life for people living with HIV.

Introduction:pre-treatment drug resistance (PDR) can compromise the 3rd 95-95-95 global target for viral load suppression. The high complexity and cost of genotyping assays limits routine testing in many resource limited settings (RLS). We assessed the performance of a rapid HIV-1 drug resistance assay, the Pan Degenerate Amplification and Adaptation (PANDAA) assay when screening for significant HIV-1 drug resistance mutations (DRMs) such as K65R, K103NS, M184VI, Y181C and G190A. Methods:we used previously generated amplicons from a cross-sectional study conducted between October 2018 and February 2020 of HIV-1 infected antiretroviral therapy (ART)-naïve or those reinitiating 1stline ART (18 years or older). The performance of the PANDAA assay in screening K65R, K103NS, M184VI, Y181C, and G190A mutations compared to the reference assay, Sanger sequencing was evaluated by Cohen´s kappa coefficient on Stata version 14 (StataCorp LP, College Station, TX, USA). Results:one hundred and twenty samples previously characterized by Sanger sequencing were assessed using PANDAA. PDR was found in 14% (17/120). PDR to non-nucleoside reverse transcriptase inhibitors (NNRTIs) was higher at 13% (16/120) than PDR to nucleotide reverse transcriptase inhibitors (NRTIs), 3% (3/120). The PANDAA assay showed a strong agreement with the reference assay, i.e. Sanger sequencing for all five target DRMs (kappa (95%CI); 0.93(0.78-0.98)) and NNRTI DRMs (kappa (95%CI); 0.93(0.77-0.980), and a perfect agreement for NRTI DRMs (kappa (95%CI); 1.00(0.54-1.00)). Conclusion:the PANDAA assay is a simple and rapid method to identify significant HIV DRMs in plasma samples as an alternative to Sanger sequencing in many RLS.

Highlights • The management of idiopathic CNS inflammatory disorders (iCNSIDs) during the COVID-19 pandemic poses numerous challenges in resource limited settings such as Malaysia more so in the absence of guidelines within the south east asian region. • Patients with multiple sclerosis and related disorders have both pandemic associated disease related therapeutic issues and need surveillance to identify if they develop COVID-19 infection or its immune related complications. • Strategies such as virtual visits in the absence of conventional teleneurology and modifications to monitoring, treatments, drug delivery and COVID-19 infection prevention steps need to be in place both in the short term and long term to address these challenges., The Covid-19 pandemic poses a grave health management challenge globally of unprecedented nature. Management of idiopathic Central Nervous system inflammatory disorders (iCNSID) such as Multiple sclerosis, Neuromyelitis optica and its spectrum disorders and related conditions during this pandemic needs to be addressed with affirmative and sustainable strategies in order to prevent disease related risks, medication related complications and possible COVID-19 disease associated effects. Global international iCNSIDs agencies and recent publications are attempting to address this but such guidance is not available in South East Asia. Here we outline prospectively qualitatively and quantitatively novel strategies at a tertiary center in Malaysia catering for neuroimmunological disorders despite modest resources during this pandemic. In this retrospective study with longitudinal follow-up, we describe stratification of patients for face to face versus virtual visits in the absence of formal teleneurology, stratification of patients for treatment according to disease activity, rescheduling, deferring initiation or extending treatment intervals of certain disease modifying therapies(DMT's) or immunosuppressants(IS), especially those producing lymphocyte depletion in MS and the continuation of IS in patients with NMO/NMOSD. Furthermore, we highlight the use off-label treatments such as Intravenous immunoglobulins/rituximab,bridging interferons/Teriflunomide temporarily replacing more potent DMT choices,supply challenges of IS/DMT's and tailoring blood watches and neuroimaging surveillance based on the current health needs to stave off the pandemic and prevent at risk patients with iCNSID/health care workers from possibly being exposed to the COVID-19.

Background Sepsis is the leading cause of death and disability in children. Every hour of delay in treatment is associated with an escalating risk of morbidity and mortality. The burden of sepsis is greatest in low- and middle-income countries where timely treatment may not occur due to delays in diagnosis and prioritization of critically ill children. To circumvent these challenges, we propose the development and clinical evaluation of a digital triage tool that will identify high risk children and reduce time to treatment. We will also implement and clinically validate a Radio-Frequency Identification system to automate tracking of patients. The mobile platform (mobile device and dashboard) and automated patient tracking system will create a low cost, highly scalable solution for critically ill children, including those with sepsis. Methods This is pre-post intervention study consisting of three phases. Phase I will be a baseline period where data is collected on key predictors and outcomes before implementation of the digital triage tool. In Phase I, there will be no changes to healthcare delivery processes in place at the study hospitals. Phase II will involve model derivation, technology development, and usability testing. Phase III will be the intervention period where data is collected on key predictors and outcomes after implementation of the digital triage tool. The primary outcome, time to treatment initiation, will be compared to assess effectiveness of the digital health intervention. Discussion Smart technology has the potential to overcome the barrier of limited clinical expertise in the identification of the child at risk. This mobile health platform, with sensors and data-driven applications, will provide real-time individualized risk prediction to rapidly triage patients and facilitate timely access to life-saving treatments for children in low- and middle-income countries, where specialists are not regularly available and deaths from sepsis are common. Trial registration Clinical Trials.gov Identifier: NCT04304235, Registered 11 March 2020.

Lithography, the transfer of patterns to a film or substrate, is the basis by which many modern technological devices and components are produced. However, established lithographic approaches generally use complex techniques, expensive equipment, and advanced materials. Here, we introduce a water-based microcontact printing method using silk that is simple, inexpensive, ecofriendly, and recyclable. Whereas the traditional microcontact printing technique facilitates only negative lithography, the synergetic interaction of the silk, water, and common chemicals in our technique enables both positive and negative patterning using a single stamp. Among diverse application possibilities, we exemplify a proof of concept of the method through optimizing its metal lift-off process and demonstrate the fabrication of electromagnetic metamaterial elements on both solid and flexible substrates. The results indicate that the method demonstrated herein is universally applicable to device production and technology development., European Union (EU); H2020; European Research Council (ERC)

Objective Tobacco usage continues to be pronounced prominently as a public health concern distressing a broad-spectrum of health and well-being of populations around the world. Despite the harm caused by its consumption, the extent and its consequences to youths in resource limited settings is not known. To determine the enormity and consequences of tobacco usage among youths while specific objectives were to determine the level of usage, contributing factors and the consequences of its usage among youths in resource limited settings. Methods A cross-sectional study design with simple random sampling was used. An interviewer-administered questionnaire was used. Quantitative data was analyzed using SPSS. Chi- Square and Odds Ratio were used to test for significance of association. Results Tobacco usage and gender of the respondents was statistically significant at 95% confidence level with χ²=107.0; df =1; p=0.0001. Odds Ratio showed that males were 7.5 times more likely to use tobacco compared to female respondents. Main source of tobacco products was in markets (78%) and friends (22%). Peer pressure was reported by 48% as the main factor that drives youths to tobacco usage. A total of 56.6% of the respondents did not know any health consequences of tobacco usage. Conclusions The recommended intervention included awareness creation, reduction of accessibility to tobacco, health education and functional youth friendly centres.

The development of point of care diagnostics using recent advances in microfluidics have the potential to transform health care in several ways, especially in resource limited settings with limited access to advanced health care infrastructure. However, translating a point of care device to reality is often a challenging task because of the complexities involved in integrating a number of diverse engineering concepts into an easy to use, accurate and portable device. This thesis focuses on miniaturization of crucial diagnostic laboratory tools, that can be used in a portable point of care format without compromising on the accuracy or performance. The first part of the thesis (Paper I-III) focuses on understanding and applying elasto-inertial microfluidics, which is a label-free and passive bio-particle sorting and separation method. A basic understanding of particle trajectories in both inertial (Paper I) and visco-elastic flows (Paper II) is established, followed by an investigation on the combined effects of inertia and elasticity (Paper III). The second part of the thesis (Paper IV-VI) focuses on developing integrated microfluidic platforms, each of which addresses different aspects of point of care diagnostic applications. The applications include neonatal diagnostics using a hand-driven Slipdisc technique (Paper IV), rapid nucleic acid quantification using a novel precipitate-based detection on a centrifugal microfluidics platform (Paper V), and hematocrit level measurement in blood using a portable lab-on- Disc platform operated by a mobile phone (Paper VI). The proof of concept microfluidic tools presented in the scope of this thesis have the potential to replace a number of functions of standard laboratory equipment, at a fraction of the price and without compromising performance. Hence, the different methods developed should contribute towards decentralization of medical testing laboratories, making healthcare accessible to one and all. QC 20190228

Human immunodeficiency virus (HIV) is a global health problem. Early diagnosis, rapid antiretroviral therapy (ART) initiation and monitoring of viral load are the key strategies for effective HIV management. Many people in resource limited settings where timely access to medical care is a challenge and healthcare infrastructure is poor have no access to laboratory facilities and diagnosis is dependent on the presence of point of care (POC) devices. POC instruments have shown to be easy to operate, maintain and transport and can easily be operated by less skilled health workers. Additionally, POC tests do not require laboratory technicians to operate. POC devices have resulted in a growing number of people testing for HIV and thereby receiving treatment early. In recent years, there has been great improvement in the development of POC technologies for early HIV diagnosis, HIV viral load and cluster of differentiation 4 (CD4) measurement. This review discusses POC technologies that are currently available and in the pipeline for diagnosing and monitoring HIV. We also give an overview of the technical and commercialization challenges in POC diagnostics for HIV.

Virological monitoring is the best predictor for the management of chronic hepatitis B virus (HBV) infections. Consequently, it is important to use the most efficient, rapid and cost-effective testing systems for HBV DNA quantification. The present study compared the performance characteristics of a one-step HBV polymerase chain reaction (PCR) vs the two-step HBV PCR method for quantification of HBV DNA from clinical samples. A total of 100 samples consisting of 85 randomly selected samples from patients with chronic hepatitis B (CHB) and 15 samples from apparently healthy individuals were enrolled in this study. Of the 85 CHB clinical samples tested, HBV DNA was detected from 81% samples by one-step PCR method with median HBV DNA viral load (VL) of 7.50 × 103 lU/ml. In contrast, 72% samples were detected by the two-step PCR system with median HBV DNA of 3.71 × 103 lU/ml. The one-step method showed strong linear correlation with two-step PCR method (r = 0.89; p < 0.0001). Both methods showed good agreement at Bland-Altman plot, with a mean difference of 0.61 log10 IU/ml and limits of agreement of -1.82 to 3.03 log10 IU/ml. The intra-assay and interassay coefficients of variation (CV%) of plasma samples (4-7 log10 IU/ml) for the one-step PCR method ranged between 0.33 to 0.59 and 0.28 to 0.48 respectively, thus demonstrating a high level of concordance between the two methods. Moreover, elimination of the DNA extraction step in the one-step PCR kit allowed time-efficient and significant labor and cost savings for the quantification of HBV DNA in a resource limited setting. How to cite this article Rashed-Ul Islam SM, Jahan M, Tabassum S. Evaluation of a Rapid One-step Real-time PCR Method as a High-throughput Screening for Quantification of Hepatitis B Virus DNA in a Resource-limited Setting. Euroasian J Hepato-Gastroenterol 2015;5(1):11-15.

Background Current critical care prognostic models are predominantly developed in high-income countries (HICs) and may not be feasible in intensive care units (ICUs) in lower- and middle-income countries (LMICs). Existing prognostic models cannot be applied without validation in LMICs as the different disease profiles, resource availability, and heterogeneity of the population may limit the transferability of such scores. A major shortcoming in using such models in LMICs is the unavailability of required measurements. This study proposes a simplified critical care prognostic model for use at the time of ICU admission. Methods This was a prospective study of 3855 patients admitted to 21 ICUs from Bangladesh, India, Nepal, and Sri Lanka who were aged 16 years and over and followed to ICU discharge. Variables captured included patient age, admission characteristics, clinical assessments, laboratory investigations, and treatment measures. Multivariate logistic regression was used to develop three models for ICU mortality prediction: model 1 with clinical, laboratory, and treatment variables; model 2 with clinical and laboratory variables; and model 3, a purely clinical model. Internal validation based on bootstrapping (1000 samples) was used to calculate discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer-Lemeshow C-Statistic; higher values indicate poorer calibration). Comparison was made with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II models. Results Model 1 recorded the respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), blood urea, haemoglobin, mechanical ventilation, and vasopressor use on ICU admission. Model 2, named TropICS (Tropical Intensive Care Score), included emergency surgery, respiratory rate, systolic blood pressure, GCS, blood urea, and haemoglobin. Model 3 included respiratory rate, emergency surgery, and GCS. AUC was 0.818 (95% confidence interval (CI) 0.800–0.835) for model 1, 0.767 (0.741–0.792) for TropICS, and 0.725 (0.688–0.762) for model 3. The Hosmer-Lemeshow C-Statistic p values were less than 0.05 for models 1 and 3 and 0.18 for TropICS. In comparison, when APACHE II and SAPS II were applied to the same dataset, AUC was 0.707 (0.688–0.726) and 0.714 (0.695–0.732) and the C-Statistic was 124.84 (p < 0.001) and 1692.14 (p < 0.001), respectively. Conclusion This paper proposes TropICS as the first multinational critical care prognostic model developed in a non-HIC setting.

Background Current critical care prognostic models are predominantly developed in high-income countries (HICs) and may not be feasible in intensive care units (ICUs) in lower- and middle-income countries (LMICs). Existing prognostic models cannot be applied without validation in LMICs as the different disease profiles, resource availability, and heterogeneity of the population may limit the transferability of such scores. A major shortcoming in using such models in LMICs is the unavailability of required measurements. This study proposes a simplified critical care prognostic model for use at the time of ICU admission. Methods This was a prospective study of 3855 patients admitted to 21 ICUs from Bangladesh, India, Nepal, and Sri Lanka who were aged 16 years and over and followed to ICU discharge. Variables captured included patient age, admission characteristics, clinical assessments, laboratory investigations, and treatment measures. Multivariate logistic regression was used to develop three models for ICU mortality prediction: model 1 with clinical, laboratory, and treatment variables; model 2 with clinical and laboratory variables; and model 3, a purely clinical model. Internal validation based on bootstrapping (1000 samples) was used to calculate discrimination (area under the receiver operating characteristic curve (AUC)) and calibration (Hosmer-Lemeshow C-Statistic; higher values indicate poorer calibration). Comparison was made with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II models. Results Model 1 recorded the respiratory rate, systolic blood pressure, Glasgow Coma Scale (GCS), blood urea, haemoglobin, mechanical ventilation, and vasopressor use on ICU admission. Model 2, named TropICS (Tropical Intensive Care Score), included emergency surgery, respiratory rate, systolic blood pressure, GCS, blood urea, and haemoglobin. Model 3 included respiratory rate, emergency surgery, and GCS. AUC was 0.818 (95% confidence interval (CI) 0.800–0.835) for model 1, 0.767 (0.741–0.792) for TropICS, and 0.725 (0.688–0.762) for model 3. The Hosmer-Lemeshow C-Statistic p values were less than 0.05 for models 1 and 3 and 0.18 for TropICS. In comparison, when APACHE II and SAPS II were applied to the same dataset, AUC was 0.707 (0.688–0.726) and 0.714 (0.695–0.732) and the C-Statistic was 124.84 (p

Background Data on the cost effectiveness of hepatitis B virus (HBV) screening and vaccination strategies for prevention of vertical transmission of HBV in resource limited settings is sparse. Methods A decision tree model of HBV prevention strategies utilised data from a cohort of 7071 pregnant women on the Thailand-Myanmar border using a provider perspective. All options included universal HBV vaccination for newborns in three strategies: (1) universal vaccination alone; (2) universal vaccination with screening of women during antenatal visits with rapid diagnostic test (RDT) plus HBV immune globulin (HBIG) administration to newborns of HBV surface antigen positive women; and (3) universal vaccination with screening of women during antenatal visits plus HBIG administration to newborns of women testing HBV e antigen positive by confirmatory test. At the time of the study, the HBIG after confirmatory test strategy was used. The costs in United States Dollars (US$), infections averted and incremental cost effectiveness ratios (ICERs) were calculated and sensitivity analyses were conducted. A willingness to pay threshold of US$1200 was used. Results The universal HBV vaccination was the least costly option at US$4.33 per woman attending the clinic. The HBIG after (RDT) strategy had an ICER of US$716.78 per infection averted. The HBIG after confirmatory test strategy was not cost-effective due to extended dominance. The one-way sensitivity analysis showed that while the transmission parameters and cost of HBIG had the biggest impact on outcomes, the HBIG after confirmatory test only became a cost-effective option when a low test cost was used or a high HBIG cost was used. The probabilistic sensitivity analysis showed that HBIG after RDT had an 87% likelihood of being cost-effective as compared to vaccination only at a willingness to pay threshold of US$1200. Conclusions HBIG following confirmatory test is not a cost-effective strategy for preventing vertical transmission of HBV in the Thailand-Myanmar border population. By switching to HBIG following rapid diagnostic test, perinatal infections will be reduced by nearly one third. This strategy may be applicable to similar settings for marginalized populations where the confirmatory test is not logistically possible. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2660-x) contains supplementary material, which is available to authorized users.

Background : The 2016 World Health Organization (WHO) consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, recommended to start all HIV-infected children on antiretroviral therapy (ART). Here, we explore the possible benefits and risks of implementing universal ART for all HIV-infected children and adolescents and outline some of the key considerations that led to the 2016 revision of WHO guidelines. Methods : We conducted a review of the published data from 2000 to 2016, to ascertain the clinical and programmatic benefits, as well as the risks of implementing universal ART for all children. Results and discussion : Universal ART for all children has the potential to increase treatment coverage, which in 2015 was only 51% globally, as well as providing several biological benefits, by preventing: premature death/loss to follow-up, progressive destruction of the immune system, poor growth and pubertal delay, poor neuro-cognitive outcomes and future burden to the health care system with complications of untreated HIV-infection. However, the strategy could be associated with risks, notably development of HIV drug resistance, antiretroviral drug toxicities and increased costs to an already stretched health system. Conclusion : Overall, our findings suggest that the benefits could outweigh the risks and support universal ART for all HIV-infected children, but recognize that national programmes will need to put measures in place to minimize the risks if they choose to implement the strategy. Keywords Universal antiretroviral therapy; children; adolescents; resource limited settings; review; Sub Saharan Africa; WHO guidelines (Published: 27 June 2017) Barlow-Mosha L et al. Journal of the International AIDS Society 2017, 20 :21552 http://www.jiasociety.org/index.php/jias/article/view/21552 | http://dx.doi.org/10.7448/IAS.20.1.21552

Background Approximately 0.8% of adults aged 18–49 in Myanmar are seropositive for Human Immunodeficiency Virus (HIV). Identifying the demographic, epidemiological and clinical characteristics of people living with HIV (PLHIV) is essential to inform optimal management strategies in this resource-limited country. Methods To create a “snapshot” of the PLHIV seeking anti-retroviral therapy (ART) in Myanmar, data were collected from the registration cards of all patients who had been prescribed ART at two large referral hospitals in Yangon, prior to March 18, 2016. Results and discussion Anti-retroviral therapy had been prescribed to 2643 patients at the two hospitals. The patients’ median [interquartile range (IQR)] age was 37 (31–44) years; 1494 (57%) were male. At registration, injecting drug use was reported in 22 (0.8%), male-to-male sexual contact in eleven (0.4%) and female sex work in eleven (0.4%), suggesting that patients under-report these risk behaviours, that health care workers are uncomfortable enquiring about them or that the two hospitals are under-servicing these populations. All three explanations appear likely. Most patients were symptomatic at registration with 2027 (77%) presenting with WHO stage 3 or 4 disease. In the 2442 patients with a CD4+ T cell count recorded at registration, the median (IQR) count was 169 (59–328) cells/mm3. After a median (IQR) duration of 359 (185–540) days of ART, 151 (5.7%) patients had died, 111 (4.2%) patients had been lost to follow-up, while 2381 were alive on ART. Tuberculosis (TB) co-infection was common: 1083 (41%) were already on anti-TB treatment at registration, while a further 41 (1.7%) required anti-TB treatment during follow-up. Only 21 (0.8%) patients were prescribed isoniazid prophylaxis therapy (IPT); one of these was lost to follow-up, but none of the remaining 20 patients died or required anti-TB treatment during a median (IQR) follow-up of 275 (235–293) days. Conclusions People living with HIV in Yangon, Myanmar are generally presenting late in their disease course, increasing their risk of death, disease and transmitting the virus. A centralised model of ART prescription struggles to deliver care to the key affected populations. TB co-infection is very common in Myanmar, but despite the proven efficacy of IPT, it is frequently not prescribed.

Background Surgical site infection (SSI) is a common post-operative complication causing significant morbidity and mortality. Many SSI occur after discharge from hospital. Post-discharge SSI surveillance in low and middle income countries needs to be improved. Methodology We conducted an observational cohort study in Dodoma, Tanzania to examine the sensitivity and specificity of telephone calls to detect SSI after discharge from hospital in comparison to a gold standard of clinician review. Women undergoing caesarean section were enrolled and followed up for 30 days. Women providing a telephone number were interviewed using a structured questionnaire at approximately days 5, 12 and 28 post-surgery. Women were then invited for out-patient review by a clinician blinded to the findings of telephone interview. Results A total of 374 women were enrolled and an overall SSI rate of 12% (n = 45) was observed. Three hundred and sixteen (84%) women provided a telephone number, of which 202 had at least one telephone interview followed by a clinical review within 48 h, generating a total of 484 paired observations. From the clinical reviews, 25 SSI were diagnosed, of which telephone interview had correctly identified 18 infections; telephone calls did not incorrectly identify SSI in any patients. The overall sensitivity and specificity of telephone interviews as compared to clinician evaluation was 72 and 100%, respectively. Conclusion The use of telephone interview as a diagnostic tool for post-discharge surveillance of SSI had moderate sensitivity and high specificity in Tanzania. Telephone-based detection may be a useful method for SSI surveillance in low-income settings with high penetration of mobile telephones.

Introduction: Tuberculosis (TB) remains a global health problem with India having the highest burden. The commonest site of TB is the lungs (85%), the remaining 15% being clubbed as extra-pulmonary TB (EPTB). The diagnosis of TB poses a number of challenges which becomes more pronounced in resource limited settings. Aim: To ascertain the demographic characteristics, clinical spectrum and methods of diagnosis of TB in a tertiary care centre having limited culture based facilities. Materials and Methods: Hospital-based retrospective study in TB patients registered for treatment in a DOTS centre attached to a tertiary care teaching hospital in Northeast India, from January 2013 to December 2014. Data was collected from the TB registers and patient record sheets of the DOTS centre. All TB patients registered under DOTS centre were included in the study while patients found to have alternative diagnosis leading to discontinuation of anti-tubercular therapy were excluded. Results: There were 1344 participants with a male to female ratio of 1.15:1. Most of the patients (30.95%) were in the age group 21-30 years followed by 31-40 years (18.82%), with a mean and median age of 32.78±15.64 and 30 years respectively. Majority of patients had EPTB (57.22%). Majority of the patients with TB (83.22% of EPTB and 77.21% of PTB) were in the newly detected category. Among EPTB cases, pleural effusion was commonest (30.04%), followed by lymphadenitis (24.58%), abdominal TB (13.91%) and central nervous system TB (12.35%). Sputum for AFB was the commonest mode of diagnosis (29.91%) followed by body fluid analysis (25.30%), Fine Needle Aspiration (FNA) cytology (17.78%) radio-imaging techniques (15.57%) and DNA PCR (1.12%). Overall, acid fast bacilli could be demonstrated in 38.76% of the cases. Sputum was the commonest sample positive for AFB (77.16%), followed FNA specimens from lymph nodes (19.39%). Molecular methods (DNA PCR) were used for the diagnosis in only 1.12% of cases. Conclusion: Our study showed a high burden of TB with a very high proportion with EPTB. AFB demonstration, supplemented by ancillary investigations formed the cornerstone of TB diagnosis. Considering the very high EPTB prevalence, there is need for advanced diagnostic facilities for better diagnostic yield.

Background Antiretroviral therapy (ART) treatment interruptions lead to poor clinical outcomes with unplanned or unstructured TIs (uTIs) likely to be underreported. This study describes; uTIs, their risk factors and association with survival. Methods Analysis of ART programmatic data from 11 countries across Asia and Africa between 2003 and 2013 where an uTI was defined as a ≥90-day patient initiated break from ART calculated from the last day the previous ART prescription would have run out until the date of the next ART prescription. Factors predicting uTI were assessed with a conditional risk-set multiple failure time-to-event model to account for repeated events per subject. Association between uTI and mortality was assessed using Cox proportional hazards, with a competing risks extension to test for the influence of lost to follow-up (LTFU). Results 40,632 patients were included from 11 countries across 33 sites (17 Africa, 16 Asia). Median duration of follow-up was 1.61 years (IQR 0.54–3.31 years), 3386 (8.3 %) patients died, and 3453 (8.5 %) were LTFU. There were 14,817 uTIs, with 10,162 (25 %) patients having more than one uTI. In the adjusted model males were at lower risk of uTI (aHR 0.94, p < 0.01, and age 20–59 was protective compared to 350 cells/μL aHR 0.87, p < 0.01), whereas advanced clinical disease was associated with increased uTI rate (WHO stage 3 aHR 1.10, p < 0.01; WHO stage 4 aHR 1.21, p < 0.01). There was no relationship between uTI and mortality after adjusting for disease status and considering LTFU as a competing risk. Conclusions uTIs were frequent in people in ART programs in low-middle income countries and associated with younger age, female gender and advanced HIV. uTI did not predict survival when loss to follow-up was considered a competing risk. Further evaluation of uTI predictors and interventions to reduce their occurrence is warranted.

Background HIV voluntary counseling and testing (VCT) utilization remains low in many sub-Saharan African countries, particularly in remote rural settings. We sought to identify factors associated with service awareness and service uptake of VCT among female heads of household in rural Zambézia Province of north-central Mozambique which is characterized by high HIV prevalence (12.6%), poverty, and suboptimal health service access and utilization. Methods Our population-based survey of female heads of household was administered to a representative two-stage cluster sample using a sampling frame created for use on all national surveys and based on census results. The data served as a baseline measure for the Ogumaniha project initiated in 2009. Survey domains included poverty, health, education, income, HIV stigma, health service access, and empowerment. Descriptive statistics and logistic regression were used to describe service awareness and service uptake of VCT. Results Of 3708 women surveyed, 2546 (69%) were unaware of available VCT services. Among 1162 women who were aware of VCT, 673 (58%) reported no prior testing. In the VCT aware group, VCT awareness was associated with higher education (aOR = 2.88; 95% CI = 1.61, 5.16), higher income (aOR = 1.41, 95% CI = 1.06, 1.86), higher numeracy (aOR = 1.05, CI 1.03, 1.08), more children

Background Antiretroviral therapy markedly reduced mortality in HIV-infected individuals. However, in the previous studies, up to 50% of patients are compelled to modify their regimen in middle and low-income countries where salvage drug is still limited. This cohort study aimed to investigate the incidence and predictors of regimen modification from the first-line antiretroviral regimen in northern Thailand. Methods All HIV-infected patients starting antiretroviral therapy (ART) with generic drug (GPOvir®; stavudine, lamivudine and nevirapine) at a governmental hospital in northern Thailand from 2002 to 2007 were recruited. Baseline characteristics and detailed information of regimen modification until the end of 2010 were ascertained from cohort database and medical charts. As a potential genetic predictor of regimen modification, HLA B allele was determined by bead-based array hybridization (WAKFlow® HLA typing kit). We investigated predictors of the regimen modification using Cox’s proportional hazard models. Results Of 979 patients, 914 were eligible for the analysis. The observed events of regimen modification was 377, corresponding to an incidence 13.8/100 person-year-observation (95% CI:12.5-15.3) over 2,728 person years (PY) follow up. The main reasons for regimen modification were adverse effects (73.5%), especially lipodystrophy (63.2%) followed by rash (17.7%). Sixty three patients (17.1%) changed the regimen due to treatment failure. 2% and 19% of patients had HLA-B*35:05 and B*4001, respectively. HLA-B*35:05 was independently associated with rash-related regimen modification (aHR 7.73, 95% CI:3.16-18.9) while female gender was associated with lipodystrophy (aHR 2.11, 95% CI:1.51-2.95). Female gender (aHR 0.54, 95% CI: 0.30-0.96), elder age (aHR 0.56, 95% CI: 0.32-0.99) and having HLA-B*40:01 (aHR 0.29, 95% CI: 0.10-0.82) were protective for treatment failure related modification. Conclusion HLA-B*35:05 and female gender were strong predictors of regimen modification due to rash and lipodystrophy, respectively. Female gender, elder age, and having HLA-B*40:01 had protective effects on treatment failure-related regimen modification. This study provides further information of regimen modification for future tailored ART in Asia. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0565-5) contains supplementary material, which is available to authorized users.

Introduction: We evaluated the effects of highly-active-antiretroviral-therapy (HAART) in a resource-limited settings. Methods: A cross-sectional study was performed in patients who had initiated HAART at the HIV/AIDS-Center, Belgrade, Serbia. Treatment response was considered favorable in case of the achievement of undetectable HIVRNA plasma-viral-load (pVL lt 50 copies/mu L), and with the CD4+ T-cell counts increased above 350 cells/mu L. The treatment failure was defined as pVL over 1.7 log(10) copies/mL, regardless of immunological improvement. Results: Eight hundred and forty HIV infected patients were followed-up for 8.2 +/- 3.4 years. Out of 697 patients available for follow-up, 113 (16.2%) patients died, 44 (6.3%) experienced treatment failure, while 540 (77.5%) had sustained undetectable viremia. In 419 (60.1%) favorable treatment response was achieved, while the dissociation between immunological and virological responses to HAART occurred in 121 (14.4%). A baseline CD4+ T-cell counts above 200 cells/mL was the single independent predictor of a favorable treatment response (HR = 2, 95%CI = 1.69-2.61, P = 0.001), while pre-treatment with ART, HCV co-infection and AIDS at the time of treatment initiation, were all factors preventing a favorable response (HR = 0.27, 95% CI = 0.19-0.36, P = 0.001; HR = 0.75, 95% CI = 0.56-0.95, P = 0.02; HR = 0.73, 95% CI = 0.17-0.95, P = 0.018, respectively). A sustained viral suppression was an independent predictor of survival (HR = 0.2, 95% CI 0.07-0.61, P = 0.004). HAART treated HIV-infected patients who reach and maintain undetectable viremia, have an 80% probability of a 14-years survival (P = 0.08, log-rank). Conclusion: If patient with advanced HIV-related immunodeficiency reach and maintain optimal viral suppression during HAART, regardless of the level of immune recovery, and if they continue to maintain this, their prognosis may be fairly good even in the resource-limited settings.

Background Asthma is the most common chronic childhood illness, with rapidly increasing prevalence in low-income countries. Among young children, asthma is often under-diagnosed. We investigated the factors associated with asthma among under-fives presenting with acute respiratory symptoms at Mulago hospital, Uganda. Methods A hospital-based cross sectional study of 614 children with cough and/or difficult breathing, and fast breathing, was conducted between August 2011 and June 2012. A questionnaire focusing on clinical history of the child was administered to the caretakers. A physical examination and, laboratory and radiological investigations were done. Asthma was defined according to GINA (Global Initiative for Asthma) guidelines which were modified by excluding the symptom of “chest tightness”, spirometry/peak expiratory flow measurements and by adding chest x-ray findings to distinguish asthma from pneumonia. A panel of three paediatricians reviewed the participants’ case reports and, guided by the study definitions, made a diagnosis of asthma or other. Multivariable logistic regression analysis was done to determine factors independently associated with asthma. Results Of the 614 children, 128 (20.8%) had asthma, 125 (20.4%) bronchiolitis, 167 (27.2%) bacterial pneumonia only, 163 (26.5%) viral pneumonia while 31 (5.1%) had other diagnoses including pulmonary tuberculosis. The majority (71.1%) of children with asthma were aged ≥ 12 months. Factors associated with asthma included maternal asthma (AOR 2.4, 95% CI 1.2, 4.6), a history of allergy in the patient (AOR 2.6, 95% CI 1.2, 5.4,), use of gas for cooking (AOR 3.8, 95% CI 1.2, 13.3), prematurity (AOR 9.3, 95% CI 1.2, 83.3) and high level of education of caretaker (AOR 9.1, 95% CI 1.1, 72.8). Conclusion Maternal asthma, a history of allergy in the patient, use of gas for cooking, prematurity and high level of education of caretaker were significantly associated with asthma. There is need for studies to explore the role of the above factors in development and exacerbation of childhood asthma to provide information that can be used to design strategies for asthma prevention and control.

Background : Sub- Sahara Africa including Nigeria has the second largest global burden of chronic carriers of hepatitis B virus (HBV) infection after Asia. Mother-to-child transmission (MTCT) of HBV is the most commonroute of transmission in high endemic areas .MTCT of hepatitis B virus infection continues to occur despite the interventions of hepatitis B vaccinations and immunoglobulins in settings where it is practiced. Infants most at risk are those whose mothers have high HBV DNA viral loads and produce the protein HBeAg. Various Nigerian studies have reported high HBV infection rates as well as HBeAg positivity among pregnant women. These HBV infections usually occur intrapartum and rarely inutero. Mothers with HBeAg positivity known to be associated with higher HBV DNA viral loads have been linked with higher chances of MTCT as HBeAg is the only structural HBV protein that can cross into the placental circulation. In the absence of post exposure prophylaxis about 40 percent of infants delivered by HBV infected mothers could develop HBV infections, and about 25% of them may come down with chronic hepatitis and resulting possible complications including liver cirrhosis and hepatocellular cancer later in life. The prevention of transmission of retroviral infection from motherto- child has been a success story of the 21st century and such feat could be replicated for HBV infection. The standard PMTCT of HBV currently will comprise: timely prenatal screening, starting anti-viral therapy for pregnant women with HBeAg positivity and high viral load, infant postexposure prophylaxis and followup of infants of HBsAg positive mothers. There is no co-ordinated PMTCT of HBV programme in place in our setting despite the huge burden of the disease in Nigeria. Hence the need therefore to develop a home grown PMTCT programme of HBV to help tackle the burden of the disease in our country. An evidence based review of current best practice guidelines for the prevention of mother-to-child transmission of HBV for use in low and medium resource income settings with hepatitis B hyperendemicity will be quiet apt in this circumstance. This document therefore will be useful as a quick guide to Paediatricians, Obstetricians, Family Physicians, General Practice Doctors and other allied health workers charged with the care of pregnant mothers and their young children. Methods : Relevant literatures published in English language or translated into English were searched manually and electronically in PUBMED and SCOPUS for the period between 1990 and 2016 on the subject. Keywords searched included: epidemiology of HBV infection, MTCT of HBV, and its preventive strategies including prenatal screening, antiviral agents in pregnancy, infant post exposure prophylaxis and follow-up of infected children. Results : Over 35 scholarly articles on HBV epidemiology, MTCT, and preventive measures as well as follow –up models were retrieved and analyzed. Conclusion : Universal screening of all pregnant women for HBV infection is the most effective strategy for the prevention of MTCT of HBV, as effective preventive measures could be applied starting from pregnancy to delivery while infants of HBsAg positive mothers should receive timely post exposure prophylaxis and followed up for possible development of chronic hepatitis B infection. Key words : Prevention of mother to child transmission; Hepatitis B virus infection; Resource limited settings.

Background Nucleic acid amplification tests (NAATs) have offered hope for rapid diagnosis of tuberculosis (TB). However, their efficiency with smear-negative samples has not been widely studied in low income settings. Here, we evaluated in-house PCR assay for diagnosis of smear-negative TB using Lowenstein-Jensen (LJ) culture as the baseline test. Two hundred and five pulmonary TB (PTB) suspects with smear-negative sputum samples, admitted on a short stay emergency ward at Mulago Hospital in Kampala, Uganda, were enrolled. Two smear-negative sputum samples were obtained from each PTB suspect and processed simultaneously for identification of MTBC using in-house PCR and LJ culture. Results Seventy two PTB suspects (35%, 72/205) were LJ culture positive while 128 (62.4%, 128/205) were PCR-positive. The sensitivity and specificity of in-house PCR for diagnosis of smear-negative PTB were 75% (95% CI 62.6-85.0) and 35.9% (95% CI 27.2-45.3), respectively. The positive and negative predictive values were 39% (95% CI 30.4-48.2) and 72.4% (95% CI 59.1-83.3), respectively, while the positive and negative likelihood ratios were 1.17 (95% CI 0.96-1.42) and 0.70 (95% CI 0.43-1.14), respectively. One hundred and seventeen LJ culture-negative suspects (75 PCR-positive and 42 PCR-negative) were enrolled for follow-up at 2 months. Of the PCR-positive suspects, 45 (60%, 45/75) were still alive, of whom 29 (64.4%, 29/45) returned for the follow-up visit; 15 (20%, 15/75) suspects died while another 15 (20%, 15/75) were lost to follow-up. Of the 42 PCR-negative suspects, 22 (52.4%, 22/42) were still alive, of whom 16 (72.7%, 16/22) returned for follow-up; 11 (26.2%, 11/42) died while nine (21.4%, 9/42) were lost to follow-up. Overall, more PCR-positive suspects were diagnosed with PTB during follow-up visits but the difference was not statistically significant (27.6%, 8/29 vs. 25%, 4/16, p = 0.9239). Furthermore, mortality was higher for the PCR-negative suspects but the difference was also not statistically significant (26.2% vs. 20% p = 0.7094). Conclusion In-house PCR correlates poorly with LJ culture for diagnosis of smear-negative PTB. Therefore, in-house PCR may not be adopted as an alternative to LJ culture.

Background Changes in CD4 cell counts are poorly documented in individuals with low or moderate-level viremia while on antiretroviral treatment (ART) in resource-limited settings. We assessed the impact of on-going HIV-RNA replication on CD4 cell count slopes in patients treated with a first-line combination ART. Method Naïve patients on a first-line ART regimen with at least two measures of HIV-RNA available after ART initiation were included in the study. The relationships between mean CD4 cell count change and HIV-RNA at 6 and 12 months after ART initiation (M6 and M12) were assessed by linear mixed models adjusted for gender, age, clinical stage and year of starting ART. Results 3,338 patients were included (14 cohorts, 64% female) and the group had the following characteristics: a median follow-up time of 1.6 years, a median age of 34 years, and a median CD4 cell count at ART initiation of 107 cells/μL. All patients with suppressed HIV-RNA at M12 had a continuous increase in CD4 cell count up to 18 months after treatment initiation. By contrast, any degree of HIV-RNA replication both at M6 and M12 was associated with a flat or a decreasing CD4 cell count slope. Multivariable analysis using HIV-RNA thresholds of 10,000 and 5,000 copies confirmed the significant effect of HIV-RNA on CD4 cell counts both at M6 and M12. Conclusion In routinely monitored patients on an NNRTI-based first-line ART, on-going low-level HIV-RNA replication was associated with a poor immune outcome in patients who had detectable levels of the virus after one year of ART.

Background Limited data exist for the efficacy of second-line antiretroviral therapy among children in resource limited settings. We assessed the virologic response to protease inhibitor-based ART after failing first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. Methods A retrospective chart review was conducted at 8 Thai sites of children who switched to PI –based regimens due to failure of NNRTI –based regimens. Primary endpoints were HIV RNA Results Data from 241 children with median baseline values before starting PI-based regimens of 9.1 years for age, 10% for CD4%, and 4.8 log10 copies/ml for HIV RNA were included; 104 (41%) received a single ritonavir-boosted PI (sbPI) with 2 NRTIs and 137 (59%) received double-boosted PI (dbPI) with/without NRTIs based on physician discretion. SbPI children had higher baseline CD4 (17% vs. 6%, p 10 copies/ml, p Conclusion Second-line PI therapy was effective for children failing first line NNRTI in a resource-limited setting. DbPI were used in patients with extensive drug resistance due to limited treatment options. Better access to antiretroviral drugs is needed.

We evaluated 70 HIV-infected pregnant women with CD4⁺ cell count >350 cells per cubic millimeter who received zidovudine, lamivudine, and nevirapine from week 25 of gestation until 6 months after delivery and a 3-week tail of zidovudine and lamivudine at the moment of drug discontinuation. Forty days after the interruption of all drugs resistance mutations were present in 5 of 70 (7.1%) women. Two of them had the same mutation archived in baseline HIV DNA. The other 3 women had, at least once, detectable viral load and presence of mutations during treatment. Overall, the risk of developing resistance mutations in compliant women was low.

This editorial reviews objective is to support the development of strategies to maximize the effectiveness of first-line and second-line antiretroviral therapy (ART) regimens and optimize the training of regimen switching in lower-income and middle-income countries (LMICs). The support is required to fully utilize the survival benefit of available treatment options maintain program cost-effectiveness and enable achievement of universal access to HIV treatment and states that the comprehensive strategy must be evidence based and focused on the rational long-term use of ART at a population level.

Background A crucial goal of infectious disease surveillance is the early detection of epidemics, which is essential for disease control. In China, the current surveillance system is based on confirmed case reports. In rural China, it is not practical for health units to perform laboratory tests to confirm disease and people are more likely to get 'old' and emerging infectious diseases due to poor living conditions and closer contacts with wild animals and poultry. Syndromic surveillance, which collects non-specific syndromes before diagnosis, has great advantages in promoting the early detection of epidemics and reducing the necessities of disease confirmation. It will be especially effective for surveillance in resource poor settings. Methods/Design This is a field experimental study. The experimental tool is an innovative electronic surveillance system, combining syndromic surveillance with the existing case report surveillance in four selected counties in China. In the added syndromic surveillance, three types of data are collected including patients' major symptoms from health clinics, pharmaceutical sales from pharmacies and absenteeism information from primary school. In order to evaluate the early warning capability of the new added syndromic surveillance, the timelines and validity of the alert signals will be analyzed in comparison with the traditional case reporting system. The acceptability, feasibility and economic evaluation of the whole integrated surveillance system will be conducted in a before and after study design. Discussions Although syndromic surveillance system has mostly been established in developed areas, there are opportunities and advantages of developing it in rural China. The project will contribute to knowledge, experience and evidence on the establishment of an integrated surveillance system, which aims to provide early warning of disease epidemics in developing countries.

Background Linkage to HIV care is crucial to the success of antiretroviral therapy (ART) programs worldwide, loss to follow up at all stages of the care continuum is frequent, and long-term prospective studies of care linkage are currently lacking. Methods Consecutive clients who tested HIV-positive were enrolled from four HIV testing centers (1 health facility and 3 community-based centers) in the Kilimanjaro region of Tanzania as part of the larger Coping with HIV/AIDS in Tanzania (CHAT) prospective observational study. Biannual interviews were conducted over 3.5 years, assessing care linkage, retention, and mental health. Bivariable and multivariate logistic regression analyses were conducted to determine associations with early death (prior to the second follow up interview) and delayed (>6 months post-test) or failed care linkage. Results A total of 263 participants were enrolled between November, 2008 and August, 2009 and 240 participants not already linked to care were retained in the final dataset. By 6 months after enrollment, 169 (70.4 %) of 240 participants had presented to an HIV care and treatment facility; 41 (17.1 %) delayed more than 6 months, 15 (6.3 %) died, and 15 (6.3 %) were lost to follow up. Twenty-six patients died before their second follow up visit and were analyzed in the early death group (10.8 %). Just 15 (9.6 %) of those linked to care had started ART within 6 months, but 123 (89.1 %) of patients documented to be ART eligible by local guidelines had started ART by the end of 3.5 years. On multivariate analysis, male gender (OR 1.72; 95 % CI 1.08, 2.75), testing due to illness (OR 1.63; 95 % CI 1.01, 2.63), and higher mean depression scale scores (4 % increased risk per increase in depression score; 95 % CI 1 %, 8 %) were associated with early death. Testing at a community versus a hospital-based site (OR 2.89; 95 % CI 1.79, 4.66) was strongly associated with delaying or never entering care. Conclusions Nearly 30 % of the cohort did not have timely care linkage, ART initiation was frequently delayed, and testing at a hospital outpatient department versus community-based testing centers was strongly associated with successful care linkage.

Background Sexually transmitted diseases (STD) are frequently asymptomatic and increase the likelihood of transmitting and acquiring HIV. In Brazil, the guidelines for STDs diagnosis and treatment are based on the syndromic approach. Nucleic acid amplification tests (NAAT) has been recommended as routine STDs screening in some countries, especially for men who have sex with men (MSM). Limited data are available about how to best define target groups for routine screening by NAATs within this population. We aimed to assess the prevalence of rectal and urethral Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections and syphilis, and the factors associated with having at least one STD among HIV-infected and uninfected MSM in Rio de Janeiro, Brazil. Methods From August 2010 to June 2012, 391 MSM were enrolled into the Evandro Chagas National Institute of Infectious Diseases-INI-Fiocruz cohort, and 292 MSM (HIV-infected:211 and HIV-uninfected:81) were included in this study. NAATs were performed on the rectal swabs and urine for CT and NG. The rapid plasma reagin test and microhemagglutination assay for Treponema pallidum were performed for syphilis diagnosis. Results The overall prevalence of STD was 20.0 % (95%CI:15.7-25.1): 10 % anorectal chlamydia; syphilis 9.9 %; anorectal gonorrheae 2.5 %; and urethral chlamydia 2.2 %; no case of urethral gonorrheae was detected. The proportion of HIV-positive MSM who had at least one STD was nearly two times that of HIV-negative MSM (22.6 % vs 13.2 %; P = 0.09). The frequency of each STD, except for anorectal NG (1.5 % vs.5.2 %), was higher among HIV-positive than HIV-negative individuals. Among the 211 asymptomatic participants, 17.5 % (n = 37) were identified as having at least one STD; 10.4 % (n = 22/211) tested positive for anorectal chlamydia. Sixty five percent of HIV-positive MSM were asymptomatic at the time of the STD diagnosis, while 100.0 % of the HIV-negative MSM. Age (APR = 0.78; 95%CI:0.60-1.00 for each additional ten years) and a positive-HIV serostatus (APR = 2.05; 95%CI:1.03-4.08) were significantly associated with STD diagnosis. Conclusion An overall high STD-prevalence rate was observed, especially among HIV-infected and in younger individuals, and the majority of STDs were asymptomatic. STD screening using NAATs among asymptomatic MSM is a potentially cost-effective intervention for the prevention of HIV infection among MSM.

Background: Geographic Information Systems (GIS) have become an important tool in monitoring and improving health services, particularly at local levels. However, GIS data are often unavailable in rural settings and village-level mapping is resource-intensive. This study describes the use of community health workers’ (CHW) supervisors to map villages in a mountainous rural district of Northern Rwanda and subsequent use of these data to map village-level variability in safe water availability. Methods: We developed a low literacy and skills-focused training in the local language (Kinyarwanda) to train 86 CHW Supervisors and 25 nurses in charge of community health at the health center (HC) and health post (HP) levels to collect the geographic coordinates of the villages using Global Positioning Systems (GPS). Data were validated through meetings with key stakeholders at the sub-district and district levels and joined using ArcMap 10 Geo-processing tools. Costs were calculated using program budgets and activities’ records, and compared with the estimated costs of mapping using a separate, trained GIS team. To demonstrate the usefulness of this work, we mapped drinking water sources (DWS) from data collected by CHW supervisors from the chief of the village. DWSs were categorized as safe versus unsafe using World Health Organization definitions. Result: Following training, each CHW Supervisor spent five days collecting data on the villages in their coverage area. Over 12 months, the CHW supervisors mapped the district’s 573 villages using 12 shared GPS devices. Sector maps were produced and distributed to local officials. The cost of mapping using CHW supervisors was $29,692, about two times less than the estimated cost of mapping using a trained and dedicated GIS team ($60,112). The availability of local mapping was able to rapidly identify village-level disparities in DWS, with lower access in populations living near to lakes and wetlands (p < .001). Conclusion: Existing national CHW system can be leveraged to inexpensively and rapidly map villages even in mountainous rural areas. These data are important to provide managers and decision makers with local-level GIS data to rapidly identify variability in health and other related services to better target and evaluate interventions.