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The differential spread and impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing Coronavirus Disease 2019 (COVID-19), across regions is a major focus for researchers and policy makers. Africa has attracted tremendous attention, due to predictions of catastrophic impacts that have not yet materialized. Early in the pandemic, the seemingly low African case count was largely attributed to low testing and case reporting. However, there is reason to consider that many African countries attenuated the spread and impacts early on. Factors explaining low spread include early government community-wide actions, population distribution, social contacts, and ecology of human habitation. While recent data from seroprevalence studies posit more extensive circulation of the virus, continuing low COVID-19 burden may be explained by the demographic pyramid, prevalence of pre-existing conditions, trained immunity, genetics, and broader sociocultural dynamics. Though all these prongs contribute to the observed profile of COVID-19 in Africa, some provide stronger evidence than others. This review is important to expand what is known about the differential impacts of pandemics, enhancing scientific understanding and gearing appropriate public health responses. Furthermore, it highlights potential lessons to draw from Africa for global health on assumptions regarding deadly viral pandemics, given its long experience with infectious diseases.

Background International Sustainable Development Goals (SDGs) for elimination of hepatitis B virus (HBV) infection set ambitious targets for 2030. In African populations, infant immunisation has been fundamental to reducing incident infections in children, but overall population prevalence of chronic hepatitis B (CHB) infection remains high. In high-prevalence populations, adult catch-up vaccination has sometimes been deployed, but an alternative Test and Treat (T&T) approach could be used as an intervention to interrupt transmission. Universal T&T has not been previously evaluated as a population intervention for HBV infection, despite high-profile data supporting its success with human immunodeficiency virus (HIV). Methods and findings We set out to investigate the relationship between prevalence of HBV infection and exposure in Africa, undertaking a systematic literature review in November 2019. We identified published seroepidemiology data representing the period 1995–2019 from PubMed and Web of Science, including studies of adults that reported prevalence of both hepatitis B surface antigen (HBsAg; prevalence of HBV infection) and antibody to hepatitis B core antigen (anti-HBc; prevalence of HBV exposure). We identified 96 studies representing 39 African countries, with a median cohort size of 370 participants and a median participant age of 34 years. Using weighted linear regression analysis, we found a strong relationship between the prevalence of infection (HBsAg) and exposure (anti-HBc) (R2 = 0.45, p < 0.001). Region-specific differences were present, with estimated CHB prevalence in Northern Africa typically 30% to 40% lower (p = 0.007) than in Southern Africa for statistically similar exposure rates, demonstrating the need for intervention strategies to be tailored to individual settings. We applied a previously published mathematical model to investigate the effect of interventions in a high-prevalence setting. The most marked and sustained impact was projected with a T&T strategy, with a predicted reduction of 33% prevalence by 20 years (95% CI 30%–37%) and 62% at 50 years (95% CI 57%–68%), followed by routine neonatal vaccination and prevention of mother to child transmission (PMTCT; at 100% coverage). In contrast, the impact of catch-up vaccination in adults had a negligible and transient effect on population prevalence. The study is constrained by gaps in the published data, such that we could not model the impact of antiviral therapy based on stratification by specific clinical criteria and our model framework does not include explicit age-specific or risk-group assumptions regarding force of transmission. Conclusions The unique data set collected in this study highlights how regional epidemiology data for HBV can provide insights into patterns of transmission, and it provides an evidence base for future quantitative research into the most effective local interventions. In combination with robust neonatal immunisation programmes, ongoing PMTCT efforts, and the vaccination of high-risk groups, diagnosing and treating HBV infection is likely to be of most impact in driving advances towards elimination targets at a population level., Anna McNaughton and colleagues study the epidemiology of hepatitis B virus in African countries, and assess strategies to reduce disease burden., Author summary Why was this study done? Hepatitis B virus (HBV) infection is a major global health problem, with an estimated 290 million infections worldwide; international targets set the challenge for this public health threat to be eliminated by 2030. Administering HBV vaccine to babies is a very successful way to prevent new infections, but previous studies have shown that this strategy will take many decades to bring about elimination targets. We set out to investigate other approaches that can be used in combination with the infant vaccination schedule, using data from a meta-analysis and modelling the impact of vaccinating older children and adults, or enhancing testing and treatment (T&T) of existing HBV infections. What did the researchers do and find? We undertook a review and meta-analysis of all the published data describing the frequency of HBV infection, as well as the frequency of exposure to HBV infection in African populations, working with data from 96 studies published between 1995 and 2019. Using these data, we demonstrated a significant relationship between exposure and infection (overall p < 0.001) and identified differences between geographic regions. Using an existing mathematical model, our findings suggest that vaccinating older age groups has negligible sustained effect on HBV rates in a population, but universal T&T of HBV is predicted to have a substantial impact. What do these findings mean? Our results show different patterns of HBV infection and transmission in different regions of Africa, illustrating that interventions may need to be tailored according to the specific setting. We have demonstrated that vaccination campaigns targeting older children and adults are unlikely to be an effective use of resources in most African populations, and that resources are better diverted to improving diagnosis and treatment of existing infections. The study is limited by gaps in existing data, such that many populations in Africa are poorly represented. Our conclusions are drawn from the output of a model and will need to be validated in clinical practice.

Background: Under-five and maternal mortality were halved in the Millennium Development Goals (MDG) era, with slower reductions for 2.6 million neonatal deaths and 2.6 million stillbirths. The Every Newborn Action Plan aims to accelerate progress towards national targets, and includes an ambitious Measurement Improvement Roadmap. Population-based household surveys, notably Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys, are major sources of population-level data on child mortality in countries with weaker civil registration and vital statistics systems, where over two-thirds of global child deaths occur. To estimate neonatal/child mortality and pregnancy outcomes (stillbirths, miscarriages, birthweight, gestational age) the most common direct methods are: (1) the standard DHS-7 with Full Birth History with additional questions on pregnancy losses in the past 5 years (FBH+) or (2) a Full Pregnancy History (FPH). No direct comparison of these two methods has been undertaken, although descriptive analyses suggest that the FBH+ may underestimate mortality rates particularly for stillbirths.Methods: This is the protocol paper for the Every Newborn-INDEPTH study (INDEPTH Network, International Network for the Demographic Evaluation of Populations and their Health Every Newborn, Every Newborn Action Plan), aiming to undertake a randomised comparison of FBH+ and FPH to measure pregnancy outcomes in a household survey in five selected INDEPTH Network sites in Africa and South Asia (Bandim in urban and rural Guinea-Bissau; Dabat in Ethiopia; IgangaMayuge in Uganda; Kintampo in Ghana; Matlab in Bangladesh). The survey will reach >68 000 pregnancies to assess if there is ≥15% difference in stillbirth rates. Additional questions will capture birthweight, gestational age, birth/death certification, termination of pregnancy and fertility intentions. The World Bank's Survey Solutions platform will be tailored for data collection, including recording paradata to evaluate timing. A mixed methods assessment of barriers and enablers to reporting of pregnancy and adverse pregnancy outcomes will be undertaken.Conclusions: This large-scale study is the first randomised comparison of these two methods to capture pregnancy outcomes. Results are expected to inform the evidence base for survey methodology, especially in DHS, regarding capture of stillbirths and other outcomes, notably neonatal deaths, abortions (spontaneous and induced), birthweight and gestational age. In addition, this study will inform strategies to improve health and demographic surveillance capture of neonatal/child mortality and pregnancy outcomes.

BackgroundThis is the first cross-national study of intermittent explosive disorder (IED).MethodA total of 17 face-to-face cross-sectional household surveys of adults were conducted in 16 countries (n = 88 063) as part of the World Mental Health Surveys initiative. The World Health Organization Composite International Diagnostic Interview (CIDI 3.0) assessed DSM-IV IED, using a conservative definition.ResultsLifetime prevalence of IED ranged across countries from 0.1 to 2.7% with a weighted average of 0.8%; 0.4 and 0.3% met criteria for 12-month and 30-day prevalence, respectively. Sociodemographic correlates of lifetime risk of IED were being male, young, unemployed, divorced or separated, and having less education. The median age of onset of IED was 17 years with an interquartile range across countries of 13–23 years. The vast majority (81.7%) of those with lifetime IED met criteria for at least one other lifetime disorder; co-morbidity was highest with alcohol abuse and depression. Of those with 12-month IED, 39% reported severe impairment in at least one domain, most commonly social or relationship functioning. Prior traumatic experiences involving physical (non-combat) or sexual violence were associated with increased risk of IED onset.ConclusionsConservatively defined, IED is a low prevalence disorder but this belies the true societal costs of IED in terms of the effects of explosive anger attacks on families and relationships. IED is more common among males, the young, the socially disadvantaged and among those with prior exposure to violence, especially in childhood.

Background In sub-Saharan Africa, individuals infected with HIV who are severely immunocompromised have high mortality (about 10%) shortly after starting antiretroviral therapy (ART). This group also has the greatest risk of morbidity and mortality associated with immune reconstitution inflammatory syndrome (IRIS), a paradoxical response to successful ART. Integrase inhibitors lead to significantly more rapid declines in HIV viral load (VL) than all other ART classes. We hypothesised that intensifying standard triple-drug ART with the integrase inhibitor, raltegravir, would reduce HIV VL faster and hence reduce early mortality, although this strategy could also risk more IRIS events. Methods and findings In a 2×2×2 factorial open-label parallel-group trial, treatment-naive adults, adolescents, and children >5 years old infected with HIV, with cluster of differentiation 4 (CD4) 0.7) and despite significantly greater VL suppression with raltegravir-intensified ART at 4 weeks (343/836 [41.0%] versus 113/841 [13.4%] with standard ART, p < 0.001) and 12 weeks (567/789 [71.9%] versus 415/803 [51.7%] with standard ART, p < 0.001). Through 48 weeks, there was no evidence of differences in mortality (aHR = 0.98 [95% CI 0.76–1.28], p = 0.91); in serious (aHR = 0.99 [0.81–1.21], p = 0.88), grade-4 (aHR = 0.88 [0.71–1.09], p = 0.29), or ART-modifying (aHR = 0.90 [0.63–1.27], p = 0.54) adverse events (the latter occurring in 59 [6.5%] participants with raltegravir-intensified ART versus 66 [7.3%] with standard ART); in events judged compatible with IRIS (occurring in 89 [9.9%] participants with raltegravir-intensified ART versus 86 [9.5%] with standard ART, p = 0.79) or in hospitalisations (aHR = 0.94 [95% CI 0.76–1.17], p = 0.59). At 12 weeks, one and two raltegravir-intensified participants had predicted intermediate-level and high-level raltegravir resistance, respectively. At 48 weeks, the nucleoside reverse transcriptase inhibitor (NRTI) mutation K219E/Q (p = 0.004) and the non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations K101E/P (p = 0.03) and P225H (p = 0.007) were less common in virus from participants with raltegravir-intensified ART, with weak evidence of less intermediate- or high-level resistance to tenofovir (p = 0.06), abacavir (p = 0.08), and rilpivirine (p = 0.07). Limitations of the study include limited clinical, radiological, and/or microbiological information for some participants, reflecting available services at the centres, and lack of baseline genotypes. Conclusions Although 12 weeks of raltegravir intensification was well tolerated and reduced HIV viraemia significantly faster than standard triple-drug ART during the time of greatest risk for early death, this strategy did not reduce mortality or clinical events in this group and is not warranted. There was no excess of IRIS-compatible events, suggesting that integrase inhibitors can be used safely as part of standard triple-drug first-line therapy in severely immunocompromised individuals. Trial registration ClinicalTrials.gov NCT01825031. Trial registration International Standard Randomised Controlled Trials Number ISRCTN 43622374., In the factorial randomised REALITY trial, Sarah Walker and colleagues document outcomes of intensified initial antiretroviral treatment for people with advanced HIV disease., Author summary Why was this study done? Individuals in Africa who are HIV positive and initiating treatment with severe immunosuppression (CD4 < 100 cells/mm3) have high risks of dying shortly after starting treatment. It would be expected that adding an integrase inhibitor (raltegravir) to standard triple-drug antiretroviral therapy for 12 weeks would reduce HIV viral load faster: we wanted to find out whether this would reduce high early mortality. What did the researchers do and find? We randomly allocated 1,805 adults, adolescents, and older children to receive standard antiretroviral therapy with or without 12 weeks of adjunctive raltegravir. We found that the group receiving 12 weeks of adjunctive raltegravir had significantly faster declines in HIV viral load. However, we found no significant difference in deaths within 24 weeks of starting treatment between those receiving adjunctive raltegravir (97/902 [10.9%]) or not (91/903 [10.2%]); nor were there differences in clinical disease progression, immune reconstitution, inflammatory syndrome, or adverse events. What do these findings mean? In this study, we found that intensifying the potency of initial antiretroviral therapy did not reduce early mortality on treatment, providing no support for its widespread use in individuals initiating treatment with severe immunosuppression. However, it also did not increase the rates of clinically important immune reconstitution inflammatory syndrome, suggesting that integrase inhibitors could replace other components of standard first-line antiretroviral therapy safely.

Cryptococcal meningitis is a neglected disease and an AIDS-defining illness, responsible for 15% of all AIDS-related deaths globally. In 2014, the estimated number of incident cryptococcal meningitis cases was 223 100, with 73% of them occurring in Africa. Currently available data on the prevalence, incidence, aetiologies and mortality of cryptococcal meningitis across Africa are sparse and of limited quality. We propose to conduct the first systematic review to summarise the epidemiological data available on cryptococcal meningitis and its aetiological causes in Africa. We will search PubMed, MEDLINE, Excerpta Medica Database, ISI Web of Science, Africa Index Medicus, Cumulative Index to Nursing and Allied Health for studies on cryptococcal meningitis published between 1st January 1950 and 31st December 2017, involving adults and/or children residing in Africa. After study selection, full text paper acquisition and data extraction, we will use validated tools and checklists to assess the quality of reporting and risk of bias for each study. Heterogeneity across studies will be assessed using the χ 2 test on Cochrane's Q statistic and a random effect meta-analysis will be used to estimate the overall prevalence, incidence density and mortality of cryptococcal meningitis across studies with similar characteristics. This protocol is prepared and presented in accordance with the 2015 Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. Reporting of the results will be compliant with the Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. There is no requirement for ethical approval since we will be using data from published studies. The final report will be published in a peer-reviewed journal and further presented at conferences. This study is expected to provide useful contextual estimates needed to inform treatment policies on the African continent and assess the impact of diagnostic and prevention strategies on the burden of cryptococcal meningitis in the post antiretroviral therapy era. CRD42017081312.

Summary Background There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. Methods We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899). Findings We recruited 11 422 patients (median 29 [IQR 10–70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000–2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2–1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65–578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1–2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4–18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died. Interpretation Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective. Funding Medical Research Council of South Africa.

Surgical site infections (SSIs) are the most frequent health-care-associated infections in developing countries. Specific prevention measures are highly effective, but are often poorly implemented. We aimed to establish the effect of a multimodal intervention on SSIs in Africa.We did a before-after cohort study, between July 1, 2013, and Dec 31, 2015, at five African hospitals. The multimodal intervention consisted of the implementation or strengthening of multiple SSI prevention measures, combined with an adaptive approach aimed at the improvement of teamwork and the safety climate. The primary outcome was the first occurrence of SSI, and the secondary outcome was death within 30 days post surgery. Data on adherence to SSI prevention measures were prospectively collected. The intervention effect on SSI risk and death within 30 days post surgery was assessed in a mixed-effects logistic regression model, after adjustment for key confounders.Four hospitals completed the baseline and follow-up; three provided suitable (ie, sufficient number and quality) data for the sustainability period. 4322 operations were followed up (1604 at baseline, 1827 at follow-up, and 891 in the sustainability period). SSI cumulative incidence significantly decreased post intervention, from 8·0% (95% CI 6·8-9·5; n=129) to 3·8% (3·0-4·8; n=70; p0·0001), and this decrease persisted in the sustainability period (3·9%, 2·8-5·4; n=35). A substantial improvement in compliance with prevention measures was consistently observed in the follow-up and sustainability periods. The likelihood of SSI during follow-up was significantly lower than pre-intervention (odds ratio [OR] 0·40, 95% CI 0·29-0·54; p0·0001), but the likelihood of death was not significantly reduced (0·72, 0·42-1·24; p=0·2360).Implementation of our intervention is feasible in African hospitals. Improvement was observed across all perioperative prevention practices. A significant effect on the overall SSI risk was observed, but with some heterogeneity between sites. Further large-scale experimental studies are needed to confirm these results and to improve the sustainability and long-term effect of such complex programmes.US Agency for Healthcare Research and Quality, WHO.

Dengue; Vigilància; Importació Dengue; Vigilancia; Importación Dengue; Surveillance; Importation We describe the epidemiological pattern and genetic characteristics of 242 acute dengue infections imported to Europe by returning travellers from 2012 to 2014. The overall geographical pattern of imported dengue (South-east Asia > Americas > western Pacific region > Africa) remained stable compared with 1999 to 2010. We isolated the majority of dengue virus genotypes and epidemic lineages causing outbreaks and epidemics in Asia, America and Africa during the study period. Travellers acted as sentinels for four unusual dengue outbreaks (Madeira, 2012–13; Luanda, 2013; Dar es Salaam, 2014; Tokyo, 2014). We were able to characterise dengue viruses imported from regions where currently no virological surveillance data are available. Up to 36% of travellers infected with dengue while travelling returned during the acute phase of the infection (up to 7 days after symptom onset) or became symptomatic after returning to Europe, and 58% of the patients with acute dengue infection were viraemic when seeking medical care. Epidemiological and virological data from dengue-infected international travellers can add an important layer to global surveillance efforts. A considerable number of dengue-infected travellers are viraemic after arrival back home, which poses a risk for dengue introduction and autochthonous transmission in European regions where suitable mosquito vectors are prevalent.

OBJECTIVES: The occurrence of postoperative pancreatic fistula (POPF) is the main cause of severe complications, including death, after pancreatic surgery. This study was conduced to evaluate current practice in the management of POPF after Whipple surgery and distal pancreatectomy (DP). METHODS: An online survey endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) was conducted among surgical departments active in pancreatic surgery. A total of 108 centres were contacted by e-mail. The survey focused on the use and timing of drainage, nutrition strategies, provision of somatostatin and antibiotic therapies, imaging strategy and indications for reoperation when POPF is diagnosed after pancreatic surgery. RESULTS: A total of 55 centres (51%) completed the survey. Overall, responses showed poor agreement among centres (Fleiss' kappa

Background Currently available tools for assessing high cardiovascular risk (HCR) often require measurements not available in resource-limited settings in low- and middle-income countries (LMIC). There is a need to assess HCR using a pragmatic evidence-based approach. Objectives This study sought to report the prevalence of HCR in 10 LMIC areas in Africa, Asia, and South America and to investigate the profiles and correlates of HCR. Methods Cross-sectional analysis using data from the National Heart, Lung, and Blood Institute - UnitedHealth Group Centers of Excellence. HCR was defined as history of heart disease/heart attack, history of stroke, older age (≥50 years for men and ≥60 for women) with history of diabetes, or older age with systolic blood pressure ≥160 mm Hg. Prevalence estimates were standardized to the World Health Organization's World Standard Population. Results A total of 37,067 subjects ages ≥35 years were included; 53.7% were women and mean age was 53.5 ± 12.1 years. The overall age-standardized prevalence of HCR was 15.4% (95% confidence interval: 15.0% to 15.7%), ranging from 8.3% (India, Bangalore) to 23.4% (Bangladesh). Among men, the prevalence was 1.7% for the younger age group (35 to 49 years) and 29.1% for the older group (≥50); among women, 3.8% for the younger group (35 to 59 years) and 40.7% for the older group (≥60). Among the older group, measured systolic blood pressure ≥160 mm Hg (with or without other conditions) was the most common criterion for having HCR, followed by diabetes. The proportion of having met more than 1 criterion was nearly 20%. Age, education, and body mass index were significantly associated with HCR. Cross-site differences existed and were attenuated after adjusting for age, sex, education, smoking, and body mass index. Conclusions The prevalence of HCR in 10 LMIC areas was generally high. This study provides a starting point to define targeted populations that may benefit from interventions combining both primary and secondary prevention strategies. Fil: Carrillo Larco, Rodrigo M.. Cronicas Centro de Excelencia En Enfermedades Crónicas; Perú Fil: Miranda, J. Jaime. Cronicas Centro de Excelencia En Enfermedades Crónicas; Perú. Universidad Peruana Cayetano Heredia; Perú Fil: Li, Xian. Peking University; China Fil: Cui, Chendi. University of Pittsburgh; Estados Unidos Fil: Xu, Xiaolin. Duke Kunshan University; China Fil: Ali, Mohammed. Centre For Chronic Disease Control; India Fil: Alam, Dewan S.. International Centre For Diarrhoeal Disease Research Bangladesh; Bangladesh Fil: Gaziano, Thomas A.. Harvard University. Harvard School of Public Health; Estados Unidos Fil: Gupta, Rajeev. Fortis Healthcare Limited; India. Rajasthan University Of Health Sciences; India Fil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Levitt, Naomi S.. University of Cape Town; Sudáfrica Fil: Prabhakaran, Dorairaj. Public Health Foundation Of India; India. Centre For Chronic Disease Control; India Fil: Rubinstein, Adolfo Luis. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Steyn, Krisela. University of Cape Town; Sudáfrica Fil: Tandon, Nikhil. Centre For Chronic Disease Control; India Fil: Xavier, Denis. St. John's Medical College; India Fil: Wu, Yangfeng. Peking University; China Fil: Yan, Lijing L.. Duke Kunshan University; China. Peking University; China

OBJECTIVE: To assess the epidemiology of endemic health-care-associated infection (HAI) in Africa. METHODS: Three databases (PubMed, the Cochrane Library, and the WHO regional medical database for Africa) were searched to identify studies published from 1995 to 2009 on the epidemiology of HAI in African countries. No language restriction was applied. Available abstract books of leading international infection control conferences were also searched from 2004 to 2009. FINDINGS: The eligibility criteria for inclusion in the review were met by 19 articles, only 2 of which met the criterion of high quality. Four relevant abstracts were retrieved from the international conference literature.The hospital-wide prevalence of HAI varied between 2.5% and 14.8%; in surgical wards, the cumulative incidence ranged from 5.7% to 45.8%.The largest number of studies focused on surgical site infection, whose cumulative incidence ranged from 2.5% to 30.9%. Data on causative pathogens were available from a few studies only and highlighted the importance of Gram-negative rods, particularly in surgical site infection and ventilator-associated pneumonia. CONCLUSION: Limited information is available on the endemic burden of HAI in Africa, but our review reveals that its frequency is much higher than in developed countries.There is an urgent need to identify and implement feasible and sustainable approaches to strengthen HAI prevention, surveillance and control in Africa.

Background: The most common type of arrhythmia in the USA and in European countries is atrial fibrillation (AF). The prevalence of AF is increasing worldwide with advances in technology, better prediction methods and increased awareness among healthcare professionals and patients. Methods: This article summarises the literature on the epidemiology of AF worldwide according to continents, age and ethnicity/race, and also includes the prevalence of AF in stroke patients. Results: In Australia, Europe and the USA, the current estimated prevalence of AF is about between 1% and 4%, with lower prevalence evident in Asia (0.49%-1.9%). AF prevalence is highest among Whites. In Western Europe, Australia and North America 70% of people with AF are aged >65 years, whereas the average age of AF patients in other geographical regions is often lower. Conclusions: Although the prevalence of AF worldwide is increasing steadily, large variation can be seen between studies and countries. Further epidemiological studies should be undertaken globally, especially in Asian and African countries so that a better and more accurate picture of the incidence and prevalence of AF can be captured, to enable stroke prevention strategies to be appropriately implemented to prevent or reduce the risk of stroke, the most severe consequence of AF.

Plasmodium vivax is the geographically most widespread human malaria parasite. To analyze patterns of microsatellite diversity and population structure across countries of different transmission intensity, genotyping data from 11 microsatellite markers was either generated or compiled from 841 isolates from four continents collected in 1999–2008. Diversity was highest in South-East Asia (mean allelic richness 10.0–12.8), intermediate in the South Pacific (8.1–9.9) Madagascar and Sudan (7.9–8.4), and lowest in South America and Central Asia (5.5–7.2). A reduced panel of only 3 markers was sufficient to identify approx. 90% of all haplotypes in South Pacific, African and SE-Asian populations, but only 60–80% in Latin American populations, suggesting that typing of 2–6 markers, depending on the level of endemicity, is sufficient for epidemiological studies. Clustering analysis showed distinct clusters in Peru and Brazil, but little sub-structuring was observed within Africa, SE-Asia or the South Pacific. Isolates from Uzbekistan were exceptional, as a near-clonal parasite population was observed that was clearly separated from all other populations (F ST>0.2). Outside Central Asia F ST values were highest (0.11–0.16) between South American and all other populations, and lowest (0.04–0.07) between populations from South-East Asia and the South Pacific. These comparisons between P. vivax populations from four continents indicated that not only transmission intensity, but also geographical isolation affect diversity and population structure. However, the high effective population size results in slow changes of these parameters. This persistency must be taken into account when assessing the impact of control programs on the genetic structure of parasite populations., Author Summary Plasmodium vivax is the predominant malaria parasite in Latin America, Asia and the South Pacific. Different factors are expected to shape diversity and population structure across continents, e.g. transmission intensity which is much lower in South America as compared to Southeast-Asia and the South Pacific, or geographical isolation of P. vivax populations in the South Pacific. We have compiled data from 841 isolates from South and Central America, Africa, Central Asia, Southeast-Asia and the South Pacific typed with a panel of 11 microsatellite markers. Diversity was highest in Southeast-Asia, where transmission is intermediate-high and migration of infected hosts is high, and lowest in South America and Central Asia where malaria transmission is low and focal. Reducing the panel of microsatellites showed that 2–6 markers are sufficient for genotyping for most drug trials and epidemiological studies, as these markers can identify >90% of all haplotypes. Parasites clustered according to continental origin, with high population differentiation between South American and Central Asian populations and the other populations, and lowest differences between Southeast-Asia and the South Pacific. Current attempts to reduce malaria transmission might change this pattern, but only after transmission is reduced for an extended period of time.

The control of human onchocerciasis (river blindness) is one of the most successful global partnerships ever supported by the World Bank. Mectizan mass treatments have greatly contributed to this success and have shaped the strategies of the programmes in which the World Bank has been involved - the Onchocerciasis Control Programme (OCP), which covered onchocerciasis control in West Africa until 2002, and the African Programme for Onchocerciasis Control (APOC), which is currently working in 30 countries, to protect millions of people from onchocerciasis. Through the strategy of community-directed treatment with ivermectin (CDTI), onchocerciasis control in Africa was transformed from a technologically-driven and vertical health initiative to a community-directed process of treatment and empowerment. Together, CDTI and the donation of Mectizan also reduced costs, producing one of the most effective and affordable disease-control schemes ever seen, and the CDTI strategy is now being applied to other disease-control initiatives. The onchocerciasis programmes have also been exemplary in shaping partnerships with communities, countries, the World Health Organization, governments, non-governmental development organizations, and the private sector. The Bank's involvement in onchocerciasis control has helped mobilize funds, giving confidence to other donors. More than U. S.$800 million was raised for both the OCP and APOC (excluding the initial costs of Mectizan). With these funds and the commitment of the partners involved, high coverages have been achieved in the Mectizan distributions. The Bank is confident that, during the years to come, the partners will continue their success, and that the APOC will achieve its goals by the target date for its closure, in 2015.

CONTEXT: Long-term antiretroviral therapy (ART) use in resource-limited countries leads to increasing numbers of patients with HIV taking second-line therapy. Limited access to further therapeutic options makes essential the evaluation of second-line regimen efficacy in these settings. OBJECTIVES: To investigate failure rates in patients receiving second-line therapy and factors associated with failure and death. DESIGN, SETTING, AND PARTICIPANTS: Multicohort study of 632 patients > 14 years old receiving second-line therapy for more than 6 months in 27 ART programs in Africa and Asia between January 2001 and October 2008. MAIN OUTCOME MEASURES: Clinical, immunological, virological, and immunovirological failure (first diagnosed episode of immunological or virological failure) rates, and mortality after 6 months of second-line therapy use. Sensitivity analyses were performed using alternative CD4 cell count thresholds for immunological and immunovirological definitions of failure and for cohort attrition instead of death. RESULTS: The 632 patients provided 740.7 person-years of follow-up; 119 (18.8%) met World Health Organization failure criteria after a median 11.9 months following the start of second-line therapy (interquartile range [IQR], 8.7-17.0 months), and 34 (5.4%) died after a median 15.1 months (IQR, 11.9-25.7 months). Failure rates were lower in those who changed 2 nucleoside reverse transcriptase inhibitors (NRTIs) instead of 1 (179.2 vs 251.6 per 1000 person-years; incidence rate ratio [IRR], 0.64; 95% confidence interval [CI], 0.42-0.96), and higher in those with lowest adherence index (383.5 vs 176.0 per 1000 person-years; IRR, 3.14; 95% CI, 1.67-5.90 for < 80% vs ≥ 95% [percentage adherent, as represented by percentage of appointments attended with no delay]). Failure rates increased with lower CD4 cell counts when second-line therapy was started, from 156.3 vs 96.2 per 1000 person-years; IRR, 1.59 (95% CI, 0.78-3.25) for 100 to 199/microL to 336.8 per 1000 person-years; IRR, 3.32 (95% CI, 1.81-6.08) for less than 50/microL vs 200/microL or higher; and decreased with time using second-line therapy, from 250.0 vs 123.2 per 1000 person-years; IRR, 1.90 (95% CI, 1.19-3.02) for 6 to 11 months to 212.0 per 1000 person-years; 1.71 (95% CI, 1.01-2.88) for 12 to 17 months vs 18 or more months. Mortality for those taking second-line therapy was lower in women (32.4 vs 68.3 per 1000 person-years; hazard ratio [HR], 0.45; 95% CI, 0.23-0.91); and higher in patients with treatment failure of any type (91.9 vs 28.1 per 1000 person-years; HR, 2.83; 95% CI, 1.38-5.80). Sensitivity analyses showed similar results. CONCLUSIONS: Among patients in Africa and Asia receiving second-line therapy for HIV, treatment failure was associated with low CD4 cell counts at second-line therapy start, use of suboptimal second-line regimens, and poor adherence. Mortality was associated with diagnosed treatment failure.

Noma (cancrum oris) is a devastating gangrenous disease that leads to severe tissue destruction in the face and is associated with high morbidity and mortality. It is seen almost exclusively in young children living in remote areas of less developed countries, particularly in Africa. The exact prevalence of the disease is unknown, but a conservative estimate is that 770000 people are currently affected by noma sequelae. The cause remains unknown, but a combination of several elements of a plausible aetiology has been identified: malnutrition, a compromised immune system, poor oral hygiene and a lesion of the gingival mucosal barrier, and an unidentified bacterial factor acting as a trigger for the disease. This review discusses the epidemiology, clinical features, current understanding of the pathophysiology, and treatment of the acute phase and sequelae requiring reconstructive surgery. Noma may be preventable if recognised at an early stage. Further research is needed to identify more exactly the causative agents.

The energy cost of walking (Cw) and running (Cr), and the maximal O2 consumption (VO2max) were determined in a field study on 17 Pygmies (age 24 years, SD 6; height 160 cm, SD 5; body mass 57.2 kg, SD 4.8) living in the region of Bipindi, Cameroon. The Cw varied from 112 ml.kg-1.km-1, SD 25 [velocity (v), 4 km.h-1] to 143 ml.kg-1.km-1, SD 16 (v, 7 km.h-1). Optimal walking v was 5 km.h-1. The Cr was 156 ml.kg-1.km-1, SD 14 (v, 10 km.h-1) and was constant in the 8-11 km.h-1 speed range. The VO2max was 33.7 ml.kg-1.min-1, i.e. lower than in other African populations of the same age. The Cr and Cw were lower than in taller Caucasian endurance runners. These findings, which challenge the theory of physical similarity as applied to animal locomotion, may depend either on the mechanics of locomotion which in Pygmies may be different from that observed in Caucasians, or on a greater mechanical efficiency in Pygmies than in Caucasians. The low Cr values observed enable Pygmies to reach higher running speeds than would be expected on the basis of their VO2max.