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Lorenz von Seidlein and colleagues discuss improving house designs in rural Africa to benefit health. [ABSTRACT FROM AUTHOR]

Objective: To obtain the perspectives of health professionals and community health workers on factors that determine health service coverage and maternal health outcomes so as to understand variations between districts. Methods: 16 Focus group discussions involving four different groups of participants were conducted in May 2015 in four purposively selected districts, complemented by three key informant interviews in one of the districts. Results: The solidarity support for poor people and the interconnectedness between local leaders and heads of health facilities were identified as enablers of health service utilization. Geographical factors, in particular location close to borders with mobile populations and migrants, and large populations with sparsely distributed health infrastructure, exacerbated by hilly topography and muddy roads were identified as barriers. Shortages of skilled health providers at the level of district hospitals were cited as contributing to poor maternal health outcomes. Conclusion: There is a need to take into account disparities between districts when allocating staff and financial resources in order to achieve universal coverage for high-quality maternal health services and better outcomes. Local innovations such as the use of SMS and WhatsApp text messages by health workers and financial protection schemes for poor patients improve solidarity and are worth to be scaled up. [ABSTRACT FROM AUTHOR]

Scapsipedus icipe Hugel and Tanga (Orthoptera: Gryllidae) is a newly described edible cricket species. Although, there is substantial interest in mass production of S. icipe for human food and animal feed, no information exists on the impact of temperature on their bionomics. Temperature-dependent development, survival, reproductive and life table parameters of S. icipe was generated and integrated into advanced Insect Life Cycle Modeling software to describe relative S. icipe population increase and spatial spread based on nine constant temperature conditions. We examined model predictions and implications for S. icipe potential distribution in Africa under current and future climate. These regions where entomophagy is widely practiced have distinctly different climates. Our results showed that S. icipe eggs were unable to hatch at 10 and 40°C, while emerged nymphs failed to complete development at 15°C. The developmental time of S. icipe was observed to decrease with increased in temperature. The lowest developmental threshold temperatures estimated using linear regressions was 14.3, 12.67 and 19.12°C and the thermal constants for development were 185.2, 1111.1- and 40.7-degree days (DD) for egg, nymph and pre-adult stages, respectively. The highest total fecundity (3416 individuals/female/generation), intrinsic rate of natural increase (0.075 days), net reproductive rate (1330.8 female/female/generation) and shortest doubling time (9.2 days) was recorded at 30°C. The regions predicted to be suitable by the model suggest that S. icipe is tolerant to a wider range of climatic conditions. Our findings provide for the first-time important information on the impact of temperature on the biology, establishment and spread of S. icipe across the Africa continent. The prospect of edible S. icipe production to become a new sector in food and feed industry is discussed. [ABSTRACT FROM AUTHOR]

Background: The underutilization of formal, evidence-based maternal health services continues to contribute to poor maternal outcomes among women living in rural Africa. Women’s choice of the type of maternal care they receive strongly influences their utilization of maternal health services. There is therefore a need to understand rural women’s preferred choices to help set priorities for initiatives attempting to make formal maternal care more responsive to women’s needs. The aim of this review was to explore and identify women’s preferences for different sources of childbirth and postnatal care and the factors that contribute to these preferences. Methods: A systematic literature search was conducted using the Ovid Medline, Embase, CINAHL, and Global Health databases. Thirty-seven studies that elicited women’s preferences for childbirth and postnatal care using qualitative methods were included in the review. A narrative synthesis was conducted to collate study findings and to report on patterns identified across findings. Results: During the intrapartum period, preferences varied across communities, with some studies reporting preferences for traditional childbirth with traditional care-takers, and others reporting preferences for a formal facility-based childbirth with health professionals. During the postpartum period, the majority of relevant studies reported a preference for traditional postnatal services involving traditional rituals and customs. The factors that influenced the reported preferences were related to the perceived need for formal or traditional care providers, accessibility to maternal care, and cultural and religious norms. Conclusion: Review findings identified a variety of preferences for sources of maternal care from intrapartum to postpartum. Future interventions aiming to improve access and utilization of evidence-based maternal healthcare services across rural Africa should first identify major challenges and priority needs of target populations and communities through formative research. Evidence-based services that meet rural women’s specific needs and expectations will increase the utilization of formal care and ultimately improve maternal outcomes across rural Africa. [ABSTRACT FROM AUTHOR]

Introduction: There are few studies describing Escherichia coli (E. coli) bloodstream infection (BSI) among children in Africa, yet E.coli is increasing in importance as a cause of antibiotic resistant infection in paediatric settings. Methods: In this retrospective, descriptive study aspects of E. coli BSI epidemiology are described over a 10-year period including incidence risk, risk factors for extended-spectrum β-lactamase (ESBL)-producing E. coli BSI, antibiotic susceptibility of the bacterial isolates and outcome including risk factors for severe disease. Results: There were 583 new E. coli BSI episodes among 217,483 admissions, an overall incidence risk of 2.7 events/1,000 hospital admissions. Of 455 of these E. coli BSI episodes that were analysed, 136 (29.9%) were caused by ESBL-producing isolates. Risk factors for ESBL-producing E. coli BSI included hospitalization in the 28-day period preceding E. coli BSI episodes, having an underlying chronic illness other than HIV infection at the time of the E. coli BSI and having a temperature of 38° Celsius or higher at the time of the E. coli BSI. None of the E. coli isolates were resistant to carbapenems or colistin. The mortality rate was 5.9% and admission to the intensive care unit was required in 12.3% of BSI episodes. Predictors of severe disease included age less than 1 month, hospitalization in the 28-day period preceding E. coli BSI and BSI without a definable focus. Conclusions: These findings extend our understanding of E. coli BSI in a sub-Saharan African setting, provide useful information that can guide empiric treatment choices for community- and hospital-acquired BSI and help inform prevention strategies. [ABSTRACT FROM AUTHOR]

Yellow fever is a vector-borne disease endemic in tropical regions of Africa, where 90% of the global burden occurs, and Latin America. It is notoriously under-reported with uncertainty arising from a complex transmission cycle including a sylvatic reservoir and non-specific symptom set. Resulting estimates of burden, particularly in Africa, are highly uncertain. We examine two established models of yellow fever transmission within a Bayesian model averaging framework in order to assess the relative evidence for each model’s assumptions and to highlight possible data gaps. Our models assume contrasting scenarios of the yellow fever transmission cycle in Africa. The first takes the force of infection in each province to be static across the observation period; this is synonymous with a constant infection pressure from the sylvatic reservoir. The second model assumes the majority of transmission results from the urban cycle; in this case, the force of infection is dynamic and defined through a fixed value of R0 in each province. Both models are coupled to a generalised linear model of yellow fever occurrence which uses environmental covariates to allow us to estimate transmission intensity in areas where data is sparse. We compare these contrasting descriptions of transmission through a Bayesian framework and trans-dimensional Markov chain Monte Carlo sampling in order to assess each model’s evidence given the range of uncertainty in parameter values. The resulting estimates allow us to produce Bayesian model averaged predictions of yellow fever burden across the African endemic region. We find strong support for the static force of infection model which suggests a higher proportion of yellow fever transmission occurs as a result of infection from an external source such as the sylvatic reservoir. However, the model comparison highlights key data gaps in serological surveys across the African endemic region. As such, conclusions concerning the most prevalent transmission routes for yellow fever will be limited by the sparsity of data which is particularly evident in the areas with highest predicted transmission intensity. Our model and estimation approach provides a robust framework for model comparison and predicting yellow fever burden in Africa. However, key data gaps increase uncertainty surrounding estimates of model parameters and evidence. As more mathematical models are developed to address new research questions, it is increasingly important to compare them with established modelling approaches to highlight uncertainty in structures and data. [ABSTRACT FROM AUTHOR]

Land use influences the prevalence and distribution of ticks due to the intimate relationship of ticks with their environment. This relationship occurs because land use alters two essential tick requirements: vertebrate hosts for blood meals and a suitable microclimate when off-host. Given the risks to human and animal health associated with pathogens transmitted by ticks, there is an ongoing need to understand the impact of environmental drivers on tick distributions. Here, we assessed how landscape features, neighborhood effects, and edges influenced tick occupancy and abundance across an agricultural landscape in southern Africa. We found that Rhipicephalus appendiculatus and Rhipicephalus simus increased in abundance closer to protected savanna, while Haemaphysalis elliptica increased in abundance closer to human habitation. The composition of the landscape surrounding savanna patches also differentially influenced the occupancy of each tick species; H. elliptica was more likely to be found in savanna patches surrounded by subsistence agriculture while R. appendiculatus and R. simus were more likely to be found in savanna surrounded by sugarcane monocultures. At the local scale we found that R. appendiculatus and R. simus avoided savanna edges. The availability of hosts and variation in vegetation structure between commercial agriculture, subsistence agriculture, and savanna likely drove the distribution of ticks at the landscape scale. Understanding how anthropogenic land use influences where ticks occur is useful for land use planning and for assessing public and animal health risks associated with ticks and tick-borne diseases. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the distribution of corneal spherical aberration (SA) in Tanzanian people of African descent, and to examine the correlation between corneal SA and ocular parameters. Design: Cross-sectional population-based study. Methods: Residents aged 40 years and older in three villages in the Mkuranga district in Tanzania were enlisted as study participants. Corneal higher-order aberrations (HOAs) for the right eye were measured with a wavefront analyzer (KR-1W, Topcon) and calculated for the central 6.0-mm zone. Corneal curvature radius (CR), corneal astigmatism, and axial length (AL) were also measured and their correlation with corneal SA was assessed. Results: The right eyes of 657 participants (336 male, 321 female) were analyzed. The mean age of the subjects was 57.2 ± 10.3 years (mean ± SD). The mean corneal SA (Zernike spherical aberration coefficient C40) was 0.188 ± 0.095 μm (-0.242 to 0.613). The SAs in about three-quarters of all subjects were between 0.10 and 0.30 μm. The root mean squares of total corneal HOAs and the third- and fourth-order aberrations were 0.629 ± 0.250 μm, 0.539 ± 0.236 μm, and 0.269 ± 0.110 μm, respectively. Corneal SA showed weak significant correlations with CR (Spearman’s rank correlation coefficient, r = -0.177, p < 0.001), corneal astigmatism (r = -0.142, p < 0.001), AL (r = -0.168, p < 0.001), and age (r = -0.085, p < 0.05). Conclusions: This finding may be beneficial for selecting aspheric intraocular lens in this population. [ABSTRACT FROM AUTHOR]

Background: Malnutrition in pregnancy remains unacceptably high across all regions of Africa though promising progresses have been made globally. Primary studies might not be sufficient to portrait a comprehensive picture of malnutrition during pregnancy and its main risk factors. Therefore, we intended to review the burden of malnutrition, for this specific review implies to protein energy malnutrition, during pregnancy in Africa to present its magnitude and determinant factors. Methods: We did a systematic review of observational studies published from January 1/2008 to January 31/2018. The (EBSCO), , Emcare, databases and Google scholar were searched. Articles quality was assessed using the Newcastle-Ottawa Scale and studies with fair to good quality were included. We pooled malnutrition prevalence and an odds ratio estimates for risk factors after checking for heterogeneity and publication bias. This review has been registered in Prospero with a protocol number CRD42018114949. Result: 23 studies involving 20,672 pregnant women were included. Using a random effect model, the overall pooled prevalence of malnutrition among pregnant women in Africa was 23.5% (95%CI: 17.72–29.32; I2 = 98.5%). Based on the current review pooled odds ratio finding; rural residency (POR = 2.6%; 95%CI: 1.48–4.65; I2 = 0%), low educational status of partners (POR = 1.7%; 95%CI: 1.19–2.53; I2 = 54.8%), multiple pregnancy (POR = 2.15%; 95%CI: 1.27–3.64; I2 = 0%) and poor nutritional indicators (POR = 2.03%; 95%CI: 1.72–2.4, I2 = 0%) were positively determine maternal malnutrition. On contrary, better household economic status (POR = 0.47%; 95%CI: 0.36–0.62; I2 = 24.2%) negatively determine maternal malnutrition. Conclusion: A significant number of the pregnant population in Africa are suffering of malnutrition, above 10% of the standard acceptable malnutrition rate. Thus, efforts should be renewed to ensure a proper and widespread implementation of programs that would address issues identified in the current review to reduce the burden of malnutrition. [ABSTRACT FROM AUTHOR]

Chikungunya virus (CHIKV) is a re-emerging arbovirus known to cause chronic myalgia and arthralgia with high morbidity. CHIKV is now considered endemic in many countries across Asia and Africa. In this study, the susceptibility of various human, mammalian and mosquito cell lines to CHIKV infection was evaluated. CHIKV infection was found to be cell-type dependent and virus strain-specific. Furthermore, SJCRH30 (human rhabdomyosarcoma cell line) was showed to be highly permissive to CHIKV infection, with maximum production of infectious virions observed at 12 h.p.i. Pre-infection treatment of SJCRH30 with various inhibitors of endocytosis, including monodansylcadaverine (receptor-mediated endocytic inhibitor), dynasore (clathrin-mediated endocytic inhibitor), as well as filipin (caveolin-mediated endocytosis inhibitor), resulted in minimal inhibition of CHIKV infection. In contrast, dose-dependent inhibition of CHIKV infection was observed with the treatment of macropinocytosis inhibitor, 5-(N-ethyl-N-isopropyl)amiloride (EIPA). Furthermore, siRNA-mediated knockdown of sortin nexin 9 (SNX9) a protein involved in macropinosome formation, also resulted in a significant dose-dependent reduction in viral titre. By performing a virus entry assay, CHIKV particles were also observed to colocalize with FITC-dextran, a macropinosome marker. This study shows for the first time, that the infectious entry of CHIKV into human muscle cells is mediated by macropinocytosis. Together, the data from this study may pave the way for the development of specific inhibitors that target the entry process of CHIKV into cells. [ABSTRACT FROM AUTHOR]

Background: Severe falciparum malaria is a medical emergency characterised by potentially lethal vital organ dysfunction. Patient fatality rates even with parenteral artesunate treatment remain high. Despite considerable research into adjuvant therapies targeting organ and tissue dysfunction, none have shown efficacy apart from renal replacement therapy. Understanding the causal contributions of clinical and laboratory abnormalities to mortality is essential for the design and evaluation of novel therapeutic interventions.Methods and Findings: We used a structural model causal inference approach to investigate causal relationships between epidemiological, laboratory, and clinical variables in patients with severe falciparum malaria enrolled in clinical trials and their in-hospital mortality. Under this causal model, we analysed records from 9,040 hospitalised children (0-12 years, n = 5,635) and adults (n = 3,405, 12-87 years) with severe falciparum malaria from 15 countries in Africa and Asia who were studied prospectively over the past 35 years. On admission, patient covariates associated with increased in-hospital mortality were severity of acidosis (odds ratio [OR] 2.10 for a 7-mEq/L increase in base deficit [95% CI 1.93-2.28]), renal impairment (OR 1.71 for a 2-fold increase in blood urea nitrogen [95% CI 1.58, 1.86]), coma (OR 3.59 [95% CI 3.07-4.21]), seizures (OR 1.40 [95% CI 1.16-1.68]), shock (OR 1.51 [95% CI 1.14-1.99]), and presumed pulmonary oedema (OR 1.58 [95% CI 1.04-2.39]). Lower in-hospital mortality was associated with moderate anaemia (OR 0.87 for a decrease of 10 percentage points in haematocrit [95% CI 0.80-0.95]). Circulating parasite density was not associated with mortality (OR 1.02 for a 6-fold increase [95% CI 0.94-1.11]), so the pathological effects of parasitaemia appear to be mediated entirely by the downstream effects of sequestration. Treatment with an artemisinin derivative decreased mortality compared with quinine (OR 0.64 [95% CI 0.56-0.74]). These estimates were consistent across children and adults (mainly representing African and Asian patients, respectively). Using inverse probability weighting, transfusion was not estimated to be beneficial in children with admission haematocrit values between 15% and 25% (OR 0.99 [95% CI 0.97-1.02]). Except for the effects of artemisinin treatment and transfusion, causal interpretations of these estimates could be biased by unmeasured confounding from severe bacterial sepsis, immunity, and duration of illness.Conclusion: These data suggest that moderate anaemia is associated with a reduced risk of death in severe falciparum malaria. This is possibly a direct causal association. The severe anaemia threshold criteria for a definition of severe falciparum malaria should be reconsidered. [ABSTRACT FROM AUTHOR]

Background: Achieving Universal Health Coverage (UHC) by improving financial protection and effective service coverage is target 3.8 of the Sustainable Development Goals. Little is known, however, about the extent to which paying bribes within healthcare acts as a financial barrier to access and, thus, UHC. Methods: Using survey data in adults from 32 sub-Saharan African countries in 2014–2015, we constructed a multilevel model to evaluate the relationship between paying bribes and reported difficulties of obtaining medical care. We controlled for individual-, region-, and country-level variables. Results: Having paid bribes for medical care significantly increased the odds of reporting difficulties in obtaining care by 4.11 (CI: 3.70–4.57) compared to those who never paid bribes, and more than doubled for those who paid bribes often (OR = 9.52; 95% CI: 7.77–11.67). Respondents with higher levels of education and more lived poverty also had increased odds. Those who lived in rural areas or within walking distance to a health clinic had reduced odds of reporting difficulties. Sex, age, living in a capital region, healthcare expenditures per capita, and country Corruption Perception Index were not significant predictors. Conclusions: We found that bribery in healthcare is a significant barrier to healthcare access, negatively affecting the potential of African countries to make progress toward UHC. Future increases in health expenditures—which are needed in many countries to achieve UHC—should be accompanied by greater efforts to fight corruption in order to avoid wasting money. Measuring and tracking health sector-specific corruption is critical for progress toward UHC. [ABSTRACT FROM AUTHOR]

Background: Endemic areas for soil-transmitted helminthiases often lack the tools and trained personnel necessary for point-of-care diagnosis. This study pilots the use of smartphone microscopy and an artificial neural network-based object detection application named Kankanet to address those two needs. Methodology/Principal findings: A smartphone was equipped with a USB Video Class (UVC) microscope attachment and Kankanet, which was trained to recognize eggs of Ascaris lumbricoides, Trichuris trichiura, and hookworm using a dataset of 2,078 images. It was evaluated for interpretive accuracy based on 185 new images. Fecal samples were processed using Kato-Katz (KK), spontaneous sedimentation technique in tube (SSTT), and Merthiolate-Iodine-Formaldehyde (MIF) techniques. UVC imaging and ANN interpretation of these slides was compared to parasitologist interpretation of standard microscopy.Relative to a gold standard defined as any positive result from parasitologist reading of KK, SSTT, and MIF preparations through standard microscopy, parasitologists reading UVC imaging of SSTT achieved a comparable sensitivity (82.9%) and specificity (97.1%) in A. lumbricoides to standard KK interpretation (97.0% sensitivity, 96.0% specificity). The UVC could not accurately image T. trichiura or hookworm. Though Kankanet interpretation was not quite as sensitive as parasitologist interpretation, it still achieved high sensitivity for A. lumbricoides and hookworm (69.6% and 71.4%, respectively). Kankanet showed high sensitivity for T. trichiura in microscope images (100.0%), but low in UVC images (50.0%). Conclusions/Significance: The UVC achieved comparable sensitivity to standard microscopy with only A. lumbricoides. With further improvement of image resolution and magnification, UVC shows promise as a point-of-care imaging tool. In addition to smartphone microscopy, ANN-based object detection can be developed as a diagnostic aid. Though trained with a limited dataset, Kankanet accurately interprets both standard microscope and low-quality UVC images. Kankanet may achieve sensitivity comparable to parasitologists with continued expansion of the image database and improvement of machine learning technology. [ABSTRACT FROM AUTHOR]

We aimed to describe incidence, trends of tuberculosis (TB) over 18 years and to evaluate the impact of the BCG vaccine after four decades of immunization program according to three protocols. We performed a cohort study including declared cases in Monastir from January 1, 2000 to December 31, 2017. We reported 997 cases of TB. The predominant site was pulmonarylocalization (n = 486). The age standardized incidence of pulmonary and lymph node TB per 100,000 inh were 5.71 and 2.57 respectively. Trends were negative for pulmonary TB (PTB) (b = - 0.82; r = -0.67; p<10−3) and positive for lymph node localization (b = 1.31; r = 0.63; p<10−3). We had not notified cases of HIV associated with TB. Crude incidence rate (CIR) of PTB per 100,000 inh was 8.17 in Non-Vaccinated Cohort (NVC) and 2.85 in Vaccinated Cohort (VC) (p < 0.0001). Relative risk reduction (RRR) of BCG vaccination was 65.1% (95%CI:57.5;71.4) for pulmonary localization and 65% (95%CI:55; 73) for other localizations. We have not established a significant RRR of BCG vaccination on lymph node TB. Protocol 3 (at birth) had the highest effectiveness with a RRR of 96.7% (95%CI: 86.6%; 99.2%) and 86% (95%CI:71%;91%) in patients with PTB and other localizations TB respectively. In Cox regression model the HR was 0.061 (95% CI 0.015–0.247) for PTB and 0.395 (95% CI 0.185–0.844) for other localizations TB in patients receiving protocol 3 compared to NVC. For lymph-node TB, HR was 1.390 (95% CI 1.043–1.851) for protocol 1 and 1.849 (95% CI 1.232–2.774) for protocol 2 compared to NVC. Depending on the three protocols, the BCG vaccine had a positive impact on PTB and other TB localizations that must be kept and improved. However, protocols 1 and 2 had a reverse effect on lymph node TB. [ABSTRACT FROM AUTHOR]

Background: Despite significant improvement in prevention and control over the past decades malaria remains a significant public health concern in Tanzania with 93% of the population being at risk. To prevent malaria infection and promote malaria free zones, understanding the community’s knowledge, attitudes, and practices toward malaria control are essential. This study therefore aimed at determining the levels of understanding, and attitudes, as well as socio-cultural aspects of malaria prevention and treatment-seeking behaviours among suspected malaria patients. Methods: This study was a hospital based cross-sectional study, in which patients attending Tumbi Referral Hospital with symptoms and signs that warrant inclusion of suspicion of malaria, were recruited. We used a pre-tested semi-structured questionnaire to collect participants’ demographic characteristics, as well as information on their knowledge, attitudes, and practices towards malaria infection. Data were analysed using Stata Version 12.1. Results: We enrolled a total of 295 respondents of which 179 (60.68%) were females. Participants’ ages ranged from 1–91 years, with a mean of 31.4 years. Seventy-nine (26.8%) patients reported having malaria in the previous 28 days, with 57 (72.2%) being laboratory confirmed. Only 52 (65.8%) individuals reported taking prescribed medications for malaria. A total of 277 (93.90%) were aware of malaria, and 264 (95.31%) knew that it is transmitted by mosquito. Nearly all participants (263, 94.95%), identified sleeping under bed nets to be protective against malaria. About half of the respondents either agreed 63 (22.74%) or strongly agreed 62 (22.38%) that malaria can be transmitted like the common cold. Self-reported mosquito net use was 88.09% (244). Conclusion: Despite the endemicity of malaria in our study site, patients had adequate knowledge, encouraging attitudes, and good practices related to malaria prevention and control. [ABSTRACT FROM AUTHOR]

Excessive use of antibiotics, especially watch group antibiotics such as ceftriaxone leads to emergence and spread of antimicrobial resistance (AMR). In low and middle-income countries (LMICs), antibiotics are overused but data on consumption is scarcely available. We aimed at determining the extent and predictors of ceftriaxone use in a tertiary care university teaching hospital in Kilimanjaro, Tanzania. A hospital-based cross-sectional study was conducted from August 2013 through August 2015. Patients admitted in the medical, surgical wards and their respective intensive care units, receiving antimicrobials and other medications for various ailments were enrolled. Socio-demographic and clinical data were recorded in a structured questionnaire from patients’ files and logistic regression was performed to determine the predictors for ceftriaxone use. Out of the 630 patients included in this study, 322 (51.1%) patients were on ceftriaxone during their time of hospitalization. Twenty-two patients out of 320 (6.9%) had been on ceftriaxone treatment without evidence of infection. Ceftriaxone use for surgical prophylaxis was 44 (40.7%), of which 32 (72.7%) and 9 (20.5%) received ceftriaxone prophylaxis before and after surgery, respectively. Three (6.8%) received ceftriaxone prophylaxis during surgery. Predicting factors for that the health facility administered ceftriaxone were identified as history of any medication use before referral to hospital [OR = 3.4, 95% CI (1.0–11.4), p = 0.047], bacterial infection [OR = 18.0, 95% CI (1.4–225.7, p = 0.025)], surgical ward [OR = 2.9, 95% CI (0.9–9.4), p = 0.078] and medical wards [OR = 5.0, 95% CI (0.9–28.3), p = 0.070]. Overall, a high ceftriaxone use at KCMC hospital was observed. Antimicrobial stewardship programs are highly needed to monitor and regulate hospital antimicrobial consumption, which in turn could help in halting the rising crisis of antimicrobial resistance. [ABSTRACT FROM AUTHOR]

Background: Worldwide, snakebite envenomations total ~2.7 million reported cases annually with ~100,000 fatalities. Since 2009, snakebite envenomation has intermittently been classified as a very important ‘neglected tropical disease’ by the World Health Organisation. Despite this emerging awareness, limited efforts have been geared towards addressing the serious public health implications of snakebites, particularly in sub-Saharan Africa, where baseline epidemiological and ecological data remain incomplete. Due to poverty as well as limited infrastructure and public health facilities, people in rural Africa, including Ghana, often have no other choice than to seek treatment from traditional medical practitioners (TMPs). The African ‘snakebite crisis’ is highlighted here using regionally representative complementary data from a community-based epidemiological and ecological study in the savanna zone of northern Ghana. Methodology and findings: Our baseline study involved two data collection methods in the Savelugu-Nanton District (in 2019 the district was separated into Savelugu and Nanton districts) in northern Ghana, comprising a cross-sectional study of 1,000 residents and 24 TMPs between December 2008 and May 2009. Semi-structured interviews, as well as collection of retrospective snakebite and concurrent rainfall records from the Savelugu-Nanton District Hospital and Ghana Meteorological Authority respectively over 10-years (1999–2008) were used in the study. Variables tested included demography, human activity patterns, seasonality, snake ecology and clinical reports. Complementary data showed higher snakebite prevalence during the rainy season, and a hump-shaped correlation between rainfall intensity and snakebite incidences. Almost 6% of respondents had experienced a personal snakebite, whereas ~60% of respondents had witnessed a total of 799 snakebite cases. Out of a total of 857 reported snakebite cases, 24 (~2.8%) died. The highest snakebite prevalence was recorded for males in the age group 15–44 years during farming activities, with most bites occurring in the leg/foot region. The highest snakebite rate was within farmlands, most severe bites frequently caused by the Carpet viper (Echis ocellatus). Conclusion: The relatively high community-based prevalence of ~6%, and case fatality ratio of ~3%, indicate that snakebites represent an important public health risk in northern Ghana. Based on the high number of respondents and long recording period, we believe these data truly reflect the general situation in the rural northern savanna zone of Ghana and West Africa at large. We recommend increased efforts from both local and international health authorities to address the current snakebite health crisis generally compromising livelihoods and productivity of rural farming communities in West Africa. [ABSTRACT FROM AUTHOR]

Background: Preventive chemotherapy (PC) with benzimidazole drugs is the backbone of soil-transmitted helminth (STH) control programs. Over the past decade, drug coverage has increased and with it, the possibility of developing anthelmintic resistance. It is therefore of utmost importance to monitor drug efficacy. Currently, a variety of novel diagnostic methods are available, but it remains unclear whether they can be used to monitor drug efficacy. In this study, we compared the efficacy of albendazole (ALB) measured by different diagnostic methods in a head-to-head comparison to the recommended single Kato-Katz. Methods: An ALB efficacy trial was performed in 3 different STH-endemic countries (Ethiopia, Lao PDR and Tanzania), each with a different PC-history. During these trials, stool samples were evaluated with Kato-Katz (single and duplicate), Mini-FLOTAC, FECPAKG2, and qPCR. The reduction rate in mean eggs per gram of stool (ERR) and mean genome equivalents / ml of DNA extract (GERR) were calculated to estimate drug efficacy. Principal findings and conclusions: The results of the efficacy trials showed that none of the evaluated diagnostic methods could provide reduction rates that were equivalent to a single Kato-Katz for all STH. However, despite differences in clinical sensitivity and egg counts, they agreed in classifying efficacy according to World Health Organization (WHO) guidelines. This demonstrates that diagnostic methods for assessing drug efficacy should be validated with their intended-use in mind and that other factors like user-friendliness and costs will likely be important factors in driving the choice of diagnostics. In addition, ALB efficacy against STH infections was lower in sites with a longer history of PC. Yet, further research is needed to identify factors that contribute to this finding and to verify whether reduced efficacy can be associated with mutations in the β-tubulin gene that have previously been linked to anthelmintic resistance. Trial registration: ClinicalTrials.gov . [ABSTRACT FROM AUTHOR]

Background: Serious childhood illnesses (SCI), defined as severe pneumonia, severe dehydration, sepsis, and severe malaria, remain major contributors to amenable child mortality worldwide. Inadequate recognition and treatment of SCI are factors that impact child mortality in Botswana. Skills assessments of providers caring for SCI have not been validated in low and middle-income countries. Objective: To establish preliminary inter-rater reliability, validity evidence, and feasibility for an assessment of providers who care for SCI using simulated patients and remote video capture in community clinic settings in Botswana. Methods: This was a pilot study. Four scenarios were developed via a modified Delphi technique and implemented at primary care clinics in Kweneng, Botswana. Sessions were video captured and independently reviewed. Response process and internal structure analysis utilized intra-class correlation (ICC) and Fleiss’ Kappa. A structured log was utilized for feasibility of remote video capture. Results: Eleven subjects participated. Scenarios of Lower Airway Obstruction (ICC = 0.925, 95%CI 0.695–0.998) and Hypovolemic Shock from Severe Dehydration (ICC = 0.892, 95%CI 0.596–0.997) produced excellent ICC among raters while Lower Respiratory Tract Infection (LRTI, ICC = 0, 95%CI -0.034–0.97) and LRTI + Distributive Shock from Sepsis (0.365, 95%CI -0.025–0.967) were poor. Oxygen therapy (0.707), arranging transport (0.706), and fluid administration (0.701) demonstrated substantial task reliability. Conclusions: Initial development of an assessment tool demonstrates many, but not all, criteria for validity evidence. Some scenarios and tasks demonstrate excellent reliability among raters, but others may be limited by manikin design and study implementation. Remote simulation assessment of some skills by clinic-based providers in global health settings is reliable and feasible. [ABSTRACT FROM AUTHOR]

Background: Many low and middle-income countries are increasingly cognisant of the need to offer financial protection to its citizens through pre-payment schemes in order to curb high out of pocket expenditure and catastrophic spending on healthcare. However, there is limited rigorous contextual evidence to make decisions regarding optimal design of such schemes. This study assesses the willingness-to-pay (WTP) for the recently introduced state contributory health insurance scheme (SHIS) in Nigeria. Methods: The study took place in 6 local government areas in Kaduna state, North-west Nigeria. Data were collected from a household survey using a three-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 4000 individuals in 1020 households. Contingent valuation was used to elicit the willing to pay (WTP) for the household using the bidding game technique. The relationship between socioeconomic status and WTP was also examined using logistic regression models. Findings: About 82% of the household heads were willing to pay insurance premiums for their households, which came to an average of 513 Naira (1.68 USD) per month per person. The average amount individuals were willing to pay was lower in rural areas (611 Naira) compared to urban areas (463 Naira). These results were influenced by household size, level of education, occupation and household income. In addition, only 65% of the households had the ability to pay the average premium. Conclusion: Socioeconomic factors influence individuals’ WTP for contributory health insurance schemes. It is important to create awareness about the benefits of the insurance scheme, especially in rural areas, and in both the formal and informal sectors in Nigeria. WTP information can inform the amount of insurance premiums. However, it is important to consider differences between the WTP and the cost of benefits package to be offered, as the premium amount may need to be subsidized with public financing. [ABSTRACT FROM AUTHOR]

Background: In Equatorial Guinea, malaria continues to be one of the main causes of morbidity and mortality among children. The National Therapeutic Guide established artesunate-amodiaquine (ASAQ) as first-line treatment for uncomplicated malaria, but compliance with this treatment is low. The aim of this study was to assess, for the first time, the performance of public healthcare workers in the diagnosis and treatment of uncomplicated malaria, their compliance with first-line Malaria National Therapeutic Guide and the associated factors. Methods: A cross-sectional survey was conducted at the nine public health facilities in the Bata District of Equatorial Guinea to assess the management of uncomplicated malaria in children < 15 years of age. Bivariate and multivariate statistical analyses were used to determine the recommended treatment compliance and related factors. Results: A total of 227 children with uncomplicated malaria were recorded from 9 public health facilities. Most of the treatments prescribed (83.3%) did not follow the first-line treatment recommended for uncomplicated malaria. The diagnosis was established with parasite confirmation in 182 cases (80.2%). After adjustment for other variables, children under 2 months of age, the use of parasite confirmation to the diagnosis of malaria and being familiar with the national therapeutic guide were significantly associated with the prescription of the first-line recommended treatment. Cases attended at the hospital or in a health facility with ASAQ in the pharmacy at the time of the study were also more likely to be prescribed with the recommended treatment, but with non-significant association after adjustment for other variables. Conclusions: This study identified the factors associated with the low compliance with the first-line treatment by the public healthcare facilities of Bata District of Equatorial Guinea. It seems necessary to improve case management of children with uncomplicated malaria; to reinforce the use of Malaria National Therapeutic Guide and to inform about the danger of using artemisinin monotherapy. Furthermore, it is crucial to provide recommended first-line treatment to the pharmacies of all public health facilities to ensure access to this treatment. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) and HIV co-infection challenges treatment and worsens the outcome of TB treatment. This study aimed to assess the outcome of TB treatment and factors facilitating treatment success among people living with HIV/AIDS in Fako Division of the South West Region of Cameroon. Methods: A hospital-based retrospective cohort study was conducted by manually reviewing medical records of HIV/TB co-infected patients from January 2010 to September 2017. A structured data collection form was used to review the medical records of HIV patients co-infected with TB aged 10 years and older. Patients with incomplete files were dropped from the study. Treatment success was defined as the sum of patients who were declared cured and those who had completed treatment, as per the World Health Organization’s recommendations. Data were analyzed using Statistical Package for Social Sciences version 21. Bivariate and multivariate logistic regression model was carried out to identify factors facilitating successful TB treatment outcome. Significance was obtained through adjusted odds ratio with its 95% confidence interval and a p<0.05. Results: A total of 2,986 files were reviewed but 2,928 (98.1%) were retained. Out of the 2,928 medical files of adult TB patients reviewed, 1,041 (35.6%, [95% CI 33.8%-37.3%]) were HIV/TB co-infected. The 1,041 co-infected patients had a mean age of 37.07 (SD of10.02) years and 56.3% were females. The treatment outcome of TB patients were 795(76.4%) cured, 23(2.2%) treatment completed, 99(9.5%) were lost to follow-up, 16 (1.5%) failed, 72(6.9%) died and 36(3.5%) transferred out. A successful treatment outcome was achieved in 818(78.6%,[95% CI: 76.0%–81.0%]) patients. Being a female [COR 1.61, 95% CI: 1.19–2.17, p = 0.002], receiving TB treatment in 2014 [COR 2.00, 95% CI: 1.11–3.60, p = 0.021] and 2015 [COR 2.50, 95% CI: 1.39–4.50, p = 0.002], having relapsed TB infection [COR 0.46, 95% CI: 0.23–0.93, p = 0.031], receiving ART [COR 1.95, 95% CI: 1.28–2.97, p = 0.002] and Cotrimoxazole [COR 2.03, 95% CI: 1.12–3.66, p = 0.019] were factors significantly associated with successful treatment. After adjusting for confounders, successful treatment outcome were associated with being a female [AOR 1.6; 95% CI: 1.21–2.22, p = 0.001], diagnosis of TB in 2014 [AOR 1.90; 95% CI: 1.04–3.45, p = 0.036] and 2015 [AOR 2.43; 95% CI: 1.33–4.43, p = 0.004]. Conclusion: There is a high TB treatment success rate among HIV/TB co-infected patients in our setting, although below the target set by the WHO. Specific interventions aimed at enhancing patient outcomes are recommended. [ABSTRACT FROM AUTHOR]

Objective: Voluntary Counseling and Testing for HIV (VCT) and increasing access to male condoms are common strategies to respond to the HIV/AIDS pandemic. Using biological and behavioral outcomes, we compared programs to increase access to VCT, male condoms or both among youth in Western Kenya with the standard available HIV prevention services within this setting. Design: A four arm, unblinded randomized controlled trial. Methods: The sample includes 10,245 youth aged 17 to 24 randomly assigned to receive community-based VCT, 150 male condoms, both VCT and condoms, or neither program. All had access to standard HIV services available within their communities. Surveys and blood samples for HSV-2 testing were collected at baseline (2009–2010) and at follow up (2011–2013). VCT was offered to all participants at follow up. HSV-2 prevalence, the primary outcome, was assessed using weighted logistic regressions in an intention-to-treat analysis. Results: For the 7,565 respondents surveyed at follow up, (effective tracking rate = 91%), the weighted HSV-2 prevalence was similar across groups (control group = 10.8%, condoms only group = 9.1%, VCT only group = 10.2%, VCT and condoms group = 11.5%). None of the interventions significantly reduced HSV-2 prevalence; the adjusted odds ratios were 0.87 (95% CI: 0.61–1.25) for condoms only, 0.94 (95% CI: 0.64–1.38) for VCT only, and 1.12 (95% CI: 0.79–1.58) for both interventions. The VCT intervention significantly increased HIV testing (adj OR: 3.54, 95% CI: 2.32–5.41 for VCT only, and adj OR: 5.52, 95% CI: 3.90–7.81 for condoms and VCT group). There were no statistically significant effects on risk of HIV, or on other behavioral or knowledge outcomes including self-reported pregnancy rates. Conclusion: This study suggests that systematic community-based VCT campaigns (in addition to VCT availability at local health clinics) and condom distribution are unlikely on their own to significantly reduce the prevalence of HSV-2 among youth. [ABSTRACT FROM AUTHOR]

Ebolaviruses cause an often rapidly fatal syndrome known as Ebola virus disease (EVD), with average case fatality rates of ~50%. There is no licensed vaccine or treatment for EVD, underscoring the urgent need to develop new anti-ebolavirus agents, especially in the face of an ongoing outbreak in the Democratic Republic of the Congo and the largest ever outbreak in Western Africa in 2013–2016. Lectins have been investigated as potential antiviral agents as they bind glycans present on viral surface glycoproteins, but clinical use of them has been slowed by concerns regarding their mitogenicity, i.e. ability to cause immune cell proliferation. We previously engineered a banana lectin (BanLec), a carbohydrate-binding protein, such that it retained antiviral activity but lost mitogenicity by mutating a single amino acid, yielding H84T BanLec (H84T). H84T shows activity against viruses containing high-mannose N-glycans, including influenza A and B, HIV-1 and -2, and hepatitis C virus. Since ebolavirus surface glycoproteins also contain many high-mannose N-glycans, we assessed whether H84T could inhibit ebolavirus replication. H84T inhibited Ebola virus (EBOV) replication in cell cultures. In cells, H84T inhibited both virus-like particle (VLP) entry and transcription/replication of the EBOV mini-genome at high micromolar concentrations, while inhibiting infection by transcription- and replication-competent VLPs, which measures the full viral life cycle, in the low micromolar range. H84T did not inhibit assembly, budding, or release of VLPs. These findings suggest that H84T may exert its anti-ebolavirus effect(s) by blocking both entry and transcription/replication. In a mouse model, H84T partially (maximally, ~50–80%) protected mice from an otherwise lethal mouse-adapted EBOV infection. Interestingly, a single dose of H84T pre-exposure to EBOV protected ~80% of mice. Thus, H84T shows promise as a new anti-ebolavirus agent with potential to be used in combination with vaccination or other agents in a prophylactic or therapeutic regimen. [ABSTRACT FROM AUTHOR]

Background: Increased second-line antiretroviral therapy (ART) failure rate narrows future options for HIV/AIDS treatment. It has critical implications in resource-limited settings; including sub-Saharan Africa (SSA) where the burden of HIV-infection is immense. Hence, pooled estimate for second-line HIV treatment failure is relevant to suggest valid recommendations that optimize ART outcomes in SSA. Methods: We retrieved literature systematically from PUBMED/MEDLINE, EMBASE, CINAHL, Google Scholar, and AJOL. The retrieved studies were screened and assessed for eligibility. We also assessed the eligible studies for their methodological quality using the Joanna Briggs Institute’s appraisal checklist. The pooled estimates for second-line HIV treatment failure and its associated factors were determined using STATA, version 15.0 and MEDCALC, version 18.11.3, respectively. We assessed publication bias using Comprehensive Meta-analysis software, version 3. Detailed study protocol for this review/meta-analysis is registered and found on PROSPERO (ID: CRD42018118959). Results: A total of 33 studies with the overall 18,550 participants and 19,988.45 person-years (PYs) of follow-up were included in the review. The pooled second-line HIV treatment failure rate was 15.0 per 100 PYs (95% CI: 13.0–18.0). It was slightly higher at 12–18 months of follow-up (19.0/100 PYs; 95% CI: 15.0–22.0), in children (19.0/100 PYs; 95% CI: 14.0–23.0) and in southern SSA (18.0/100 PYs; 95% CI: 14.0–23.0). Baseline values (high viral load (OR: 5.67; 95% CI: 13.40–9.45); advanced clinical stage (OR: 3.27; 95% CI: 2.07–5.19); and low CD4 counts (OR: 2.80; 95% CI: 1.83–4.29)) and suboptimal adherence to therapy (OR: 1.92; 95% CI: 1.28–2.86) were the factors associated with increased failure rates. Conclusion: Second-line HIV treatment failure has become highly prevalent in SSA with alarming rates during the 12–18 month period of treatment start; in children; and southern SSA. Therefore, the second-line HIV treatment approach in SSA should critically consider excellent adherence to therapy, aggressive viral load suppression, and rapid immune recovery. [ABSTRACT FROM AUTHOR]

Over recent decades, Salmonella infection research has predominantly relied on murine infection models. However, in many cases the infection phenotypes of Salmonella pathovars in mice do not recapitulate human disease. For example, Salmonella Typhimurium ST313 is associated with enhanced invasive infection of immunocompromised people in Africa, but infection of mice and other animal models with ST313 have not consistently reproduced this invasive phenotype. The introduction of alternative infection models could help to improve the quality and reproducibility of pathogenesis research by facilitating larger-scale experiments. To investigate the virulence of S. Typhimurium ST313 in comparison with ST19, a combination of avian and insect disease models were used. We performed experimental infections in five lines of inbred and one line of outbred chickens, as well as in the alternative chick embryo and Galleria mellonella wax moth larvae models. This extensive set of experiments identified broadly similar patterns of disease caused by the African and global pathovariants of Salmonella Typhimurium in the chicken, the chicken embryo and insect models. A comprehensive analysis of all the chicken infection experiments revealed that the African ST313 isolate D23580 had a subtle phenotype of reduced levels of organ colonisation in inbred chickens, relative to ST19 strain 4/74. ST313 isolate D23580 also caused reduced mortality in chicken embryos and insect larvae, when compared with ST19 4/74. We conclude that these three infection models do not reproduce the characteristics of the systemic disease caused by S. Typhimurium ST313 in humans. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that disclosure of HIV status between partners may influence prevention of maternal-to-child transmission of HIV (PMTCT) outcomes. We report partner disclosure in relation to maternal antiretroviral therapy (ART) uptake and adherence, and MTCT among postpartum HIV-infected Malawian women. Methods: A cross-sectional mixed-method study was conducted as part of a nationally representative longitudinal cohort study. Between 2014–2016, all (34,637) mothers attending 54 under-5 clinics with their 4–26 week-old infants were approached, of which 98% (33,980) were screened for HIV; infants received HIV-1 DNA testing. HIV-exposure was confirmed in 3,566/33,980 (10.5%). Baseline data from mothers who were known to be HIV-infected at time of screening were included in the current analysis. Guardians (n = 17), newly diagnosed HIV-infected mothers (n = 256) and mothers or infants with undetermined HIV status (n = 30) were excluded. Data collected included socio-demographics, partner disclosure, maternal ART uptake, and adherence. Between 2016–2017, in-depth interviews and focus group discussions were conducted with adult mothers (n = 53) and their spouse/cohabiting partners (n = 19), adolescent mothers (n = 13), lost-to-follow up (LTFU) mothers (n = 22), community leaders (n = 23) and healthcare workers (n = 154). Results: Of 3153 known HIV-infected mothers, 2882 (91.4%) reported having a spouse/cohabiting partner. Among 2882 couples, both partners, one partner, and neither partner disclosed to each other in 2090 (72.5%), 622 (21.6%), and 169 (5.9%), respectively. In multivariable models, neither partner disclosing was associated with no maternal ART (aOR 4.7; 95%CI 2.5–8.8), suboptimal treatment adherence (aOR 1.8; 95%CI 1.1–2.8) and MTCT (aOR 2.1; 95%CI 1.1–4.1). Women’s fear of blame by partners was central to decisions not to disclose within couples and when starting new relationships. LTFU mothers struggled to accept and disclose their status, hindering treatment initiation; some were unable to hide ART and feared involuntary disclosure. Conclusion: Partner disclosure seems to play an important role in women’s decisions regarding ART initiation and adherence. Inter-partner non-disclosure was associated with no ART uptake, suboptimal treatment adherence and MTCT. [ABSTRACT FROM AUTHOR]

Background: A knowledge brokering (KB) intervention was implemented in Burkina Faso. By creating partnerships with health system actors in one district, the broker was expected to assess their knowledge needs, survey the literature to provide the most recent research evidence, produce various knowledge translation tools, and support them in using research to improve their actions. The purpose of this study was to analyze the key factors that influenced the KB project and to make recommendations for future initiatives. Methods: The qualitative design involved a single case study in which the KB intervention implementation was evaluated retrospectively. Data came from interviews with the intervention team (n = 4) and with various actors involved in the intervention (n = 16). Data from formative evaluations conducted during the KB implementation and observation data from a two-month field mission were also used. Two conceptual frameworks were combined to guide the analysis: the Consolidated Framework for Implementation Research (Damschroder et al., 2009) and the Ecological Framework (Durlak & DuPre, 2008). Results: Various KB activities were conducted during the first two years of implementation at the local level. The project came to an early end following vain efforts to relocate the intervention at the central level in order to further influence the policy process. Certain shortcomings in the implementation team negatively influenced the implementation: inadequate leadership, no shared vision regarding the reorientation of the intervention, challenges related to the KB role, and lack of frank communications internally. Other impediments to the intervention’s deployment included local actors' lack of decision-making authority, the unavailability of resources and of organizational incentives for involvement in the KB intervention, and contextual challenges in accessing the central level. However, the KB strategy presented several strengths: collaborative development, support provided to local partners by the broker, and training opportunities and support provided to the broker. Conclusions: More attention must be paid to intervention planning, partners’ engagement, human, financial and technical resources availability, continuous development of skills and of communications within the KB team, and periodic assessment of potential obstacles related to the complexity of the system within which the intervention has been implemented. Using implementation science frameworks when developing KB strategies in the West African context should be promoted. [ABSTRACT FROM AUTHOR]

The tsetse fly, Glossina morsitans morsitans, is a significant problem in Zambia and Malawi. It is the vector for the human infective parasite Trypanosoma brucei rhodesiense, which causes human African trypanosomiasis, and various Trypanosoma species, which cause African animal trypanosomiasis. Understanding the genetic diversity and population structure of G. m. morsitans is the basis of elucidating the connectivity of the tsetse fly populations, information that is essential in implementing successful tsetse fly control activities. This study conducted a population genetic study using partial mitochondrial cytochrome oxidase gene 1 (CO1) and 10 microsatellite loci to investigate the genetic diversity and population structure of G. m. morsitans captured in the major HAT foci in Zambia and Malawi. We have included 108 and 99 G. m. morsitans samples for CO1 and microsatellite analyses respectively. Our results suggest the presence of two different genetic clusters of G. m. morsitans, existing East and West of the escarpment of the Great Rift Valley. We have also revealed genetic similarity between the G. m. morsitans in Kasungu National Park and those in the Luangwa river basin in Zambia, indicating that this population should also be included in this historical tsetse belt. Although further investigation is necessary to illustrate the whole picture in East and Southern Africa, this study has extended our knowledge of the population structure of G. m. morsitans in Southern Africa. [ABSTRACT FROM AUTHOR]

Background: Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues.Methods and Findings: We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis.Conclusions: In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated.Clinical Trial Registration: NCT02536768. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB) is a public health problem worldwide. Characterizing its trends over time is a useful tool for decision-makers to assess the efficiency of TB control programs. We aimed to give an update on the current chronological trends of TB in Southern Tunisia from 1995 to 2016 and to estimate future trajectories of TB epidemic by 2030. Methods: We retrospectively collected data of all notified TB new cases by the Center of Tuberculosis Control between 1995 and 2016 in South of Tunisia. Joinpoint Regression Analysis was performed to analyze chronological trends and annual percentage changes (APC) were estimated. Results: In the past 22 years, a total of 2771 cases of TB were notified in Southern Tunisia. The annual incidence rate of TB was 13.91/100,000 population/year. There was a rise in all forms of TB incidence (APC = 1.63) and in extrapulmonary tuberculosis (EPTB) (APC = 2.04). The incidence of TB increased in children and adult females between 1995 and 2016 (APC = 4.48 and 2.37, respectively). The annual number of TB declined in urban districts between 2004 and 2016 (APC = -2.85). Lymph node TB cases increased (APC = 4.58), while annual number of urogenital TB decreased between 1995 and 2016 (APC = -3.38). Projected incidence rates would increase to 18.13 and 11.8/100,000 population in 2030 for global TB and EPTB, respectively. Conclusions: Our study highlighted a rise in all forms of TB and among high-risk groups, notably children, females and lymph node TB patients in the last two decades and up to the next one. [ABSTRACT FROM AUTHOR]

Introduction: Significant gap exists in knowledge about employee-centred human resources practices that address motivation and retention of local government tuberculosis control programme supervisors (LGTBS) in Nigeria. The study examined the role of quality of worklife (QWL) in motivating and retaining LGTBS. Materials and methods: The study was conducted in south-eastern region of Nigeria comprising five states and 95 local government areas. The design was mixed-methods. We used cross-sectional survey to collect quantitative data on socio-demographic factors, QWL, motivation and retention from a total sample of LGTBS. The qualitative component involved focus group discussions (n = 3) with 26 LGTBS. Quantitative data were analysed using exploratory factor analysis, descriptive statistics, Spearman correlation, Mann-Whitney test, Kruskal-Wallis test and multiple linear regression. Qualitative data were analysed using a thematic framework approach. Results: The final 40-item QWL scale was found to be valid and reliable. The LGTBS had high QWL (M = 5.15, SD = 0.88) and motivation (M = 5.92, SD = 1.08), but low intention to leave their jobs (M = 2.68, SD = 1.59). Education significantly predicted satisfaction with overall QWL, work-family balance and work design; but tenure predicted satisfaction with work context. Work design and work-family balance significantly predicted motivation of LGTBS. Motivation mediated the relationship between QWL and intention to leave and accounted for 29% variance in intention to leave. Whereas LGTBS were motivated by responsibility, learning opportunities, achievement and recognition; they were dissatisfied with lack of flexible work schedules, involvement in non-TB tasks, long hours at work, limited opportunities for vacation, resource inadequacy, work-related stigma, lack of promotional opportunities, and pay disparity and delay. Conclusion: Addressing work design, work-family balance and working conditions may increase the motivation and retention of LGTBS and improve human resources for TB at the district level and performance of the TB control programme. [ABSTRACT FROM AUTHOR]

Background: Despite considerable efforts to prevent HIV and other sexually transmitted infections (STI) among female sex workers (FSW), other sexual and reproductive health (SRH) needs, such preventing unintended pregnancies, among FSW have received far less attention. Programs targeting FSW with comprehensive, accessible services are needed to address their broader SRH needs. This study tested the effectiveness of an intervention to increase dual contraceptive method use to prevent STIs, HIV and unintended pregnancy among FSW attending services in drop-in centers (DIC) in two cities in Kenya. The intervention included enhanced peer education, and routine screening for family planning (FP) needs plus expanded non-condom FP method availability in the DIC. Methods: We conducted a two-group, pre-/posttest, quasi-experimental study with 719 FSW (360 intervention group, 359 comparison group). Participants were interviewed at baseline and 6 months later to examine changes in condom and non-condom FP method use. Results: The intervention had a significant positive effect on non-condom, FP method use (OR = 1.38, 95%CI (1.04, 1.83)), but no effect on dual method use. Consistent condom use was reported to be high; however, many women also reported negotiating condom use with both paying and non-paying partners as difficult or very difficult. The strongest predictor of consistent condom use was partner type (paying versus non-paying/emotional); FSW reported both paying and non-paying partners also influence non-condom contraceptive use. Substantial numbers of FSW also reported experiencing sexual violence by both paying and non-paying partners. Conclusions: Self-reported difficulties with consistent condom use and the sometimes dangerous conditions under which they work leave FSW vulnerable to unintended pregnancy STIs/HIV. Adding non-barrier FP methods to condoms is crucial to curb unintended pregnancies and their potential adverse health, social and economic consequences. Findings also highlight the need for additional strategies beyond condoms to reduce HIV and STI risk among FSW. Trial registration: Clinicaltrials.gov [ABSTRACT FROM AUTHOR]

Introduction: Immunization is a cost-effective intervention that prevented more than 5 million deaths worldwide from 2010 to 2015. Despite increased vaccination coverage over the past four decades in many African countries, including Ethiopia, universal coverage has not yet been reached. Only 39% of children aged 12–23 months received full vaccinations in Ethiopia, according to the 2016 Ethiopian Demographic Health Survey. This study aimed to evaluate immunization coverage and identify individual and community factors that explain incomplete vaccination coverage among children aged 6–36 months in the Wonago district of southern Ethiopia. Methods: We conducted a community-based, cross-sectional study in three randomly selected kebeles in the Wonago district from June to July 2017. Our nested sample of 1,116 children aged 6–36 months included 923 child-mother pairs (level 1) within kebeles (level 2). We conducted multilevel regression analysis using STATA software. Results: Among participants, 85.0% of children aged 12–36 months received at least one vaccine, and 52.4% had complete immunization coverage. After controlling for several individual and community variables, we identified six significant predictor variables for complete immunization: Older mothers’ age (AOR = 1.05, 95% CI: 1.00–1.09), higher utilization of antenatal care (AOR = 1.36, 95% CI: 1.14–1.62), one or more tetanus-toxoid vaccination during pregnancy (AOR = 2.64, 95% CI: 1.43–4.86), mothers knowing the age at which to complete child’s vaccinations (AOR = 2.00, 95% CI: 1.25–3.20), being a female (AOR = 0.64, 95% CI: 0.43–0.95), and child receiving vitamin A supplementation within the last 6 months (AOR = 2.79, 95% CI: 1.59–4.90). We observed a clustering effect at the individual and community levels with an intra-cluster correlation coefficient of 48.1%. Conclusions: We found low immunization coverage among children in the Wonago district of southern Ethiopia, with significant differences across communities. Promoting maternal health care and community service could enhance immunization coverage. [ABSTRACT FROM AUTHOR]

Background: In 2016 the first African emergency care clinical practice guideline (CPG) was developed for national uptake in the prehospital sector in South Africa, with implementation starting in 2018. Comprehensive uptake of CPGs post development is not a given, as this requires effective and efficient dissemination and implementation strategies that take into account the perceptions, barriers and facilitators of the local end-users. This study aimed to identify prehospital end-users’ perceptions of the emergency care guidelines, including barriers and facilitators for national decision makers, to strengthen CPG uptake in South Africa. Methods: Our study employed a descriptive qualitative research design, including nine focus groups with 56 operational emergency care providers across four major provinces in South Africa. Data was analysed using thematic analysis in ATLAS.ti. Ethics approval was provided by Stellenbosch University. Results: Themes related to provider perceptions, expectations and guideline uptake emerging from the data was unofficial and unclear communication, broadening versus limiting guideline expectations, conflicted personal reactions and spreading the word. Challenges to dissemination and implementation included poor communication, changes to scope of practice, and limited capacity to upskill existing providers. Facilitators included using technology for end-user documents, local champions to support change, establishing online and modular training, and implementation by independent decision makers. Conclusion: This study provides an overview of the perceptions of operational emergency care providers and how their experiences of hearing about and engaging with the guidelines, in their industry, can contribute to the dissemination, implementation and uptake of emergency care guidelines. In order to disseminate and implement an emergency care CPG, decision makers must take into account the perceptions, barriers, and facilitators of local end-users. [ABSTRACT FROM AUTHOR]

Background: Research on contraceptive behaviour changes over time in Uganda is scarce, yet it has among the highest fertility and maternal mortality rates of any country in the East African region. Understanding temporal patterns of contraceptive use for both women and men is vital in evaluating the effectiveness of family planning interventions and strategies, and identifying those with the most unmet need. Using repeated nationally representative cross-sectional samples, this study charts the changes in Uganda’s population-based contraceptive use over recent years. Methods: Five Demographic and Health Survey datasets for Uganda over 21 years, from 1995 to 2016, were sourced and interrogated. Eligible participants included all women aged 15–49 years and men aged 15–54 years. Responses to questions on modern and any (modern or traditional) contraceptive use were analysed. Stratified by gender, weighted regression analyses were employed to detect change over time. The patterns associated with key demographic variables were also investigated. Results: Overall, 50,027 women and 14,092 men were included within the study. In 2016, 30.3% of women and 39.9% of men were using any contraceptive method, a significant non-linear increase from 13.4% of women and 20.3% of men in 1995. Furthermore, 27.3% of women and 35.9% of men were using modern contraceptive methods in 2016, an increase from 7.4% of women and 10.4% of men in 1995. All considered demographic variables were significantly associated with contraceptive use for both women and men (all P<0.001); and for women, all variables differentially changed over time (all P<0.001). Conclusion: This study showed a significant increase and dynamism across key demographic variables in contraceptive uptake by both women and men. Sustained family planning programs and interventions have successfully resulted in behaviour change across the Ugandan population. However, continued efforts are needed to further reduce Uganda’s relatively high fertility and associated maternal mortality rates. [ABSTRACT FROM AUTHOR]

Lead and malaria both present significant health risks to children in Sub-Saharan Africa. Previous studies have shown that high blood lead levels in children act as a protective factor against subsequent malaria incidence. The main objective of this study was to investigate associations between blood lead level and malaria outcomes prospectively in Beninese children from 12 to 24 months of age. Two-hundred and four children were assessed for lead at 12 months and closely followed until 24 months for malaria; when symptoms and parasite density were also recorded. Univariate and multivariate negative binomial and linear regression models tested associations between blood lead level quartile and total episodes of malaria (total symptomatic and asymptomatic episodes) and parasite density, respectively. Median blood lead level among children measured at 12 months was 56.50 (4.81–578) μg/L. During the 12-month follow-up, 172 (84.31%) children had at least one malaria episode. Univariate and multivariate negative binomial and linear regressions did not reveal significant associations between blood lead level quartile and malaria outcomes. Iron deficiency was not found to be an effect modifier. Results from this prospective child-cohort study investigating associations between blood lead level and malaria did not confirm results from previous cross-sectional studies. Further research is needed to further explore this relationship and other co-morbidities due to malaria and lead. [ABSTRACT FROM AUTHOR]

Background: Geospatial data are important in monitoring many aspects of healthcare development. Geographically linking health facility data with population data is an important area of public health research. Examining healthcare problems spatially and hierarchically assists with efficient resource allocation and the monitoring and evaluation of service efficacy at different levels. This paper explored methodological issues associated with geographic data linkage, and the spatial and multilevel analyses that could be considered in analysing maternal health service data. Methods: The 2016 Ethiopia Demographic and Health Survey and the 2014 Ethiopia Service Provision Assessment data were used. Two geographic data linking methods were used to link these two datasets. Administrative boundary link was used to link a sample of health facilities data with population survey data for analysing three areas of maternal health service use. Euclidean buffer link was used for a census of hospitals to analyse caesarean delivery use in Ethiopia. The Global Moran’s I and the Getis-Ord Gi* statistics need to be carried out for identifying hot spots of maternal health service use in ArcGIS software. In addition to this, since the two datasets contain hierarchical data, a multilevel analysis was carried out to identify key determinants of maternal health service use in Ethiopia. Results: Administrative boundary link gave more types of health facilities and more maternal health services as compared to the Euclidean buffer link. Administrative boundary link is the method of choice in case of sampled health facilities. However, for a census of health facilities, the Euclidean buffer link is the appropriate choice as this provides cluster level service environment estimates, which the administrative boundary link does not. Applying a False Discovery Rate correction enables the identification of true spatial clusters of maternal health service use. Conclusions: A service environment link minimizes the methodological issues associated with geographic data linkage. A False Discovery Rate correction needs to be used to account for multiple and dependent testing while carrying out local spatial statistics. Examining maternal health service use both spatially and hierarchically has tremendous importance for identifying geographic areas that need special emphasis and for intervention purposes. [ABSTRACT FROM AUTHOR]

Background: The gap between fertility outcomes and fertility ideals is notably higher in sub-Saharan Africa (SSA) than elsewhere, relating to both under- and overachievement of fertility ideals. We consider the extent to which the relationship between fertility ideals and fertility outcomes is related to educational achievement. Further, we consider if these educational differentials are the same or different in SSA, and thereby consider the extent to which increasing levels of education in SSA may decrease fertility. Data and methods: We use 227 Demographic and Health Surveys (DHSs) from 58 countries worldwide to look at population- level measures of the mismatch between fertility ideals and fertility outcomes. Population level measures are used to assess whether the correspondence between fertility intentions and achievements differ by level of education. We then look at the individual-level determinants of both under- and overachieving fertility intentions. Data from the most recent DHS in 54 of the original countries is used for the individual level analysis, with five countries excluded due to the most recent available survey being out of date. Results: An average of 40% of women in SSA underachieve their stated fertility intentions compared to 26% in non-SSA countries. Furthermore, compared to other LMICs, higher levels of education are not related to better correspondence between fertility intentions and outcomes in SSA. In Middle/Western Africa countries, on average, 48% of women with secondary or higher education have fewer children than their ideal, compared to just 24% who have more children than their ideal. Conclusion: We argue that the phenomenon of underachieving fertility ideals (or unrealized fertility) may be of particular importance for the ongoing fertility transition throughout SSA, especially as more highly educated groups do not appear to be following the patterns observed elsewhere. [ABSTRACT FROM AUTHOR]

Typhoid fever is endemic across sub-Saharan Africa. However, estimates of the burden of typhoid are undermined by insufficient blood volumes and lack of sensitivity of blood culture. Here, we aimed to address this limitation by exploiting pre-enrichment culture followed by PCR, alongside routine blood culture to improve typhoid case detection. We carried out a prospective diagnostic cohort study and enrolled children (aged 0–4 years) with non-specific febrile disease admitted to a tertiary hospital in Blantyre, Malawi from August 2014 to July 2016. Blood was collected for culture (BC) and real-time PCR after a pre-enrichment culture in tryptone soy broth and ox-bile. DNA was subjected to PCR for invA (Pan-Salmonella), staG (S. Typhi), and fliC (S. Typhimurium) genes. A positive PCR was defined as invA plus either staG or fliC (CT<29). IgM and IgG ELISA against four S. Typhi antigens was also performed. In total, 643 children (median age 1.3 years) with nonspecific febrile disease were enrolled; 31 (4.8%) were BC positive for Salmonella (n = 13 S. Typhi, n = 16 S. Typhimurium, and n = 2 S. Enteritidis). Pre-enrichment culture of blood followed by PCR identified a further 8 S. Typhi and 15 S. Typhimurium positive children. IgM and IgG titres to the S. Typhi antigen STY1498 (haemolysin) were significantly higher in children that were PCR positive but blood culture negative compared to febrile children with all other non-typhoid illnesses. The addition of pre-enrichment culture and PCR increased the case ascertainment of invasive Salmonella disease in children by 62–94%. These data support recent burden estimates that highlight the insensitivity of blood cultures and support the targeting of pre-school children for typhoid vaccine prevention in Africa. Blood culture with real-time PCR following pre-enrichment should be used to further refine estimates of vaccine effectiveness in typhoid vaccine trials. [ABSTRACT FROM AUTHOR]

Contact patterns strongly influence the dynamics of disease transmission in both human and non-human animal populations. Domestic dogs Canis familiaris are a social species and are a reservoir for several zoonotic infections, yet few studies have empirically determined contact patterns within dog populations. Using high-resolution proximity logging technology, we characterised the contact networks of free-ranging domestic dogs from two settlements (n = 108 dogs, covering >80% of the population in each settlement) in rural Chad. We used these data to simulate the transmission of an infection comparable to rabies and investigated the effects of including observed contact heterogeneities on epidemic outcomes. We found that dog contact networks displayed considerable heterogeneity, particularly in the duration of contacts and that the network had communities that were highly correlated with household membership. Simulations using observed contact networks had smaller epidemic sizes than those that assumed random mixing, demonstrating the unsuitability of homogenous mixing models in predicting epidemic outcomes. When contact heterogeneities were included in simulations, the network position of the individual initially infected had an important effect on epidemic outcomes. The risk of an epidemic occurring was best predicted by the initially infected individual’s ranked degree, while epidemic size was best predicted by the individual’s ranked eigenvector centrality. For dogs in one settlement, we found that ranked eigenvector centrality was correlated with range size. Our results demonstrate that observed heterogeneities in contacts are important for the prediction of epidemiological outcomes in free-ranging domestic dogs. We show that individuals presenting a higher risk for disease transmission can be identified by their network position and provide evidence that observable traits hold potential for informing targeted disease management strategies. [ABSTRACT FROM AUTHOR]

Evidence suggests that people with disabilities are the most marginalised and vulnerable group within any population. However, little is known about the extent of inequality between people with and without disabilities in contexts where the majority of persons experience extreme poverty and hardship. This includes in Liberia, where very little is understood about the lives of disabled people in general. This study uses a multidimensional wellbeing framework to understand perceived relative inequality associated with disability by assessing several facets of wellbeing across and within households containing disabled members (N = 485) or households with no disabled members (N = 538) in Liberian communities (Total individuals surveyed, N = 2020). Statistical comparisons (adjusted for age, sex, education and wealth differences and clustered at the household, village and county level) reveal that disabled Liberians are managing similarly to non-disabled Liberians in terms of income and education, but experience many perceived relative inequalities including in life satisfaction, transport access, political participation and social inclusion. Our results further suggest that disability may lead to perceived relative inequality at the household level in terms of trust held in neighbours. However, they also show that being the head of a household may protect against perceived relative inequality in certain dimensions (e.g. healthcare and transport access, political participation) irrespective of disability status. Results are discussed in terms of practical implications for development efforts in Liberia and for disabled people in other low- and middle-income settings. [ABSTRACT FROM AUTHOR]

The East African Indian (EAI) and Central Asian (CAS) lineages of Mycobacterium tuberculosis complex (MTBC) mainly infect tuberculosis (TB) patients in the eastern hemisphere which contains many of the 22 high TB burden countries including China and India. We investigated if phylogeographical, epidemiological and demographical characteristics for these 2 lineages differed in SITVIT2 database. Genotyping results and associated data (age, sex, HIV serology, drug resistance) on EAI and CAS lineages (n = 10,974 strains) were extracted. Phylogenetic and Bayesian, and other statistical analyses were used to compare isolates. The male/female sex ratio was 907/433 (2.09) for the EAI group vs. 881/544 (1.62) for CAS (p-value<0.002). The proportion of younger patients aged 0–20 yrs. with CAS lineage was significantly higher than for EAI lineage (18.07% vs. 10.85%, p-value<0.0001). The proportion of multidrug resistant and extensively drug resistant TB among CAS group (30.63% and 1.03%, respectively) was significantly higher than in the EAI group (12.14% and 0.29%, respectively; p-value<0.0001). Lastly, the proportion of HIV+ patients was 20.34% among the EAI group vs. 3.46% in the CAS group (p-value<0.0001). This remarkable split observed between various parameters for these 2 lineages was further corroborated by their geographic distribution profile (EAI being predominantly found in Eastern-Coast of Africa, South-India and Southeast Asia, while CAS was predominantly found in Afghanistan, Pakistan, North India, Nepal, Middle-east, Libya, Sudan, Ethiopia, Kenya and Tanzania). Some geo-specificities were highlighted. This study demonstrated a remarkable cleavage for aforementioned characteristics of EAI and CAS lineages, showing a North-South divide along the tropic of cancer in Eastern hemisphere–mainly in Asia, and partly prolonged along the horn of Africa. Such studies would be helpful to better comprehend prevailing TB epidemic in context of its historical spread and evolutionary features, and provide clues to better treatment and patient-care in countries and regions concerned by these lineages. [ABSTRACT FROM AUTHOR]

Background: Undifferentiated febrile illness (UFI) is one of the most common reasons for people seeking healthcare in low-income countries. While illness and death due to specific infections such as malaria are often well-quantified, others are frequently uncounted and their impact underappreciated. A number of high consequence infectious diseases, including Ebola virus, are endemic or epidemic in the Federal Republic of Sudan which has experienced at least 12 UFI outbreaks, frequently associated with haemorrhage and high case fatality rates (CFR), since 2012. One of these occurred in Darfur in 2015/2016 with 594 cases and 108 deaths (CFR 18.2%). The aetiology of these outbreaks remains unknown. Methodology/Principal findings: We report a retrospective cohort study of the 2015/2016 Darfur outbreak, using a subset of 65 of 263 outbreak samples received by the National Public Health Laboratory which met selection criteria of sufficient sample volume and epidemiological data. Clinical features included fever (95.8%), bleeding (95.7%), headache (51.6%) and arthralgia (42.2%). No epidemiological patterns indicative of person-to-person transmission or health-worker cases were reported. Samples were tested at the Public Health England Rare and Imported Pathogens Laboratory using a bespoke panel of likely pathogens including haemorrhagic fever viruses, arboviruses and Rickettsia, Leptospira and Borrelia spp. Seven (11%) were positive for Crimean-Congo haemorrhagic fever virus (CCHFV) by real-time reverse transcription PCR. The remaining samples tested negative on all assays. Conclusions/Significance: CCHFV is an important cause of fever and haemorrhage in Darfur, but not the sole major source of UFI outbreaks in Sudan. Prospective studies are needed to explore other aetiologies, including novel pathogens. The presence of CCHFV has critical infection, prevention and control as well as clinical implications for future response. Our study reinforces the need to boost surveillance, lab and investigative capacity to underpin effective response, and for local and international health security. [ABSTRACT FROM AUTHOR]

Background: Breast cancer is the most common cancer in women worldwide. Considerable funding and efforts are invested in breast cancer research and healthcare, but only a fraction of this reaches women and healthcare systems in low income countries. Surgical treatment is an essential part of breast cancer care, but access to surgery is in general very limited in low income countries such as Uganda. In this study, the previously unknown nationwide rate of breast cancer surgery was investigated. Methods and findings: This was a multicenter, retrospective study, investigating breast cancer surgery in the public healthcare system in Uganda. Data were collected from operating theater registries at primary, secondary and tertiary level healthcare centres throught the country, including 14 general hospitals, the 14 regional referral hospitals and the national referral hospital. Patients who underwent major surgery for breast cancer at these hospitals during 2013 and 2014 were included. The number of breast cancer procedures performed, geographical variation, level of healthcare staff performing surgery and patient characteristics were investigated. After correction for missing data, a total of 137 breast cancer procedures were performed each year within the public healthcare system, corresponding to 5.7% of the breast cancer incidence in the country at that time. Most procedures (n = 161, 59.0%) were performed at the national referral hospital by qualified surgeons. Many of the patients were young; 30.1% being less than 40 years old. The proportion of male breast cancers in the study was large (6.2%). Conclusions: The rate of breast cancer surgery in Uganda is minimal and in several parts of the country breast cancer surgery is not performed at all. More resources must be directed towards breast cancer in low income countries such as Uganda. The fact that the patients were young calls for further research, prevention and treatment specifically targeting young women in the study setting. [ABSTRACT FROM AUTHOR]

Introduction: Over the past few decades, the prevalence of hypertension has dramatically increased in Sub-Saharan Africa. Poor adherence has been identified as a major cause of failure to control hypertension. Scarce data are available in Africa. Aims: We assessed adherence to medication and identified socioeconomics, clinical and treatment factors associated with low adherence among hypertensive patients in 12 sub-Saharan African countries. Method: We conducted a cross-sectional survey in urban clinics of both low and middle income countries. Data were collected by physicians on demographics, treatment and clinical data among hypertensive patients attending the clinics. Adherence was assessed by questionnaires completed by the patients. Factors associated with low adherence were investigated using logistic regression with a random effect on countries. Results: There were 2198 individuals from 12 countries enrolled in the study. Overall, 678 (30.8%), 738 (33.6%), 782 (35.6%) participants had respectively low, medium and high adherence to antihypertensive medication. Multivariate analysis showed that the use of traditional medicine (OR: 2.28, 95%CI [1.79–2.90]) and individual wealth index (low vs. high wealth: OR: 1.86, 95%CI [1.35–2.56] and middle vs. high wealth: OR: 1.42, 95%CI [1.11–1.81]) were significantly and independently associated with poor adherence to medication. In stratified analysis, these differences in adherence to medication according to individual wealth index were observed in low-income countries (p<0.001) but not in middle-income countries (p = 0.17). In addition, 26.5% of the patients admitted having stopped their treatment due to financial reasons and this proportion was 4 fold higher in the lowest than highest wealth group (47.8% vs 11.4%) (p<0.001). Conclusion: This study revealed the high frequency of poor adherence in African patients and the associated factors. These findings should be useful for tailoring future programs to tackle hypertension in low income countries that are better adapted to patients, with a potential associated enhancement of their effectiveness. [ABSTRACT FROM AUTHOR]

In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm3 (interquartile range, 161–518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of primary data to understand the overall pattern of disease and injuries as well as related health-service utilization in resource-poor countries in Africa. Objective: To generate reliable and robust data describing the pattern of emergency presentations attributable to communicable disease (CD), non-communicable disease (NCD) and injuries in three different regions of Mozambique. Methods: We undertook a pragmatic, prospective, multicentre surveillance study of individuals (all ages) presenting to the emergency departments of three hospitals in Southern (Maputo), Central (Beira) and Northern (Nampula) Mozambique. During 24-hour surveillance in the seasonally distinct months of April and October 2016/2017, we recorded data on 7,809 participants randomly selected from 39,124 emergency presentations to the three participating hospitals. Applying a pragmatic surveillance protocol, data were prospectively collected on the demography, clinical history, medical profile and treatment of study participants. Findings: A total of 4,021 males and 3,788 (48.5%) females comprising 630 infants (8.1%), 2,070 children (26.5%), 1,009 adolescents (12.9%) and, 4,100 adults (52.5%) were studied. CD was the most common presentation (3,914 cases/50.1%) followed by NCD (1,963/25.1%) and injuries (1,932/24.7%). On an adjusted basis, CD was more prevalent in younger individuals (17.9±17.7 versus 26.6±19.2 years;p<0.001), females (51.7% versus 48.7%—OR 1.137, 95%CI 1.036–1.247;p = 0.007), the capital city of Maputo (59.6%) versus the more remote cities of Beira (42.8%—OR 0.532, 95%CI 0.476–0.594) and Nampula (45.8%—OR 0.538, 95%CI 0.480–0.603) and, during April (51.1% versus 49.3% for October—OR 1.142, 95%CI 1.041–1.253;p = 0.005). Conversely, NCD was progressively more prevalent in older individuals, females and in the regional city of Beira, whilst injuries were more prevalent in males (particularly adolescent/young men) and the northern city of Nampula. On a 24-hour basis, presentation patterns were unique to each hospital. Interpretation: Applying highly pragmatic surveillance methods suited to the low-resource setting of Mozambique, these unique data provide critical insights into the differential pattern of CD, NCD and injury. Consequently, they highlight specific health priorities across different regions and seasons in Southern Africa. [ABSTRACT FROM AUTHOR]

Background: Podoconiosis, also known as mossy foot or endemic non-filarial elephantiasis, is a preventable form of lower-leg lymphoedema caused by prolonged (typically barefoot) exposure to soil derived from volcanic rocks. Acute adenolymphangitis (also called ‘acute attack’) is a serious complication of podoconiosis resulting in significant symptoms and worsening disability. Despite the well-known morbidity associated with podoconiosis, to date there have been no studies looking at the impact, or burden, of podoconiosis on caregivers. This study explored the experiences and impact of acute attacks on the caregivers of those with podoconiosis in one endemic district of Ethiopia. Methods/Principal findings: This qualitative study was based in Wayu Tuka woreda (district), Oromia, Western Ethiopia. 27 semi-structured interviews of those with podoconiosis and their caregivers were conducted in June 2018. Here we report the findings from the caregiver’s interviews. Data were analysed using NVivo 12. Directed content analysis, a qualitative approach related to thematic analysis, was used to analyse the results. This study highlights a previously unreported impact of acute attacks on the caregivers of those affected by podoconiosis. The findings demonstrate the significant social and financial pressures placed on podoconiosis-affected families which are exacerbated during acute attacks. This study also highlighted the emotional burden experienced by caregivers, the range of care activities placed on them and the limited support available. Conclusions: This study found a significant impact on the caregivers of those with podoconiosis, especially during acute attacks, in in Wayu Tuka woreda. It also highlighted the limited support available to caregivers. Further research is needed to understand whether this impact applies to podoconiosis caregivers across Ethiopia, and beyond, and to establish if there are wider implications of this important consequence of podoconiosis, for example on the economy and caregivers’ mental and physical health. [ABSTRACT FROM AUTHOR]

This study assessed households’ resilience to climate change-induced shocks in Dinki watershed, northcentral highlands of Ethiopia. The data were collected through a cross-sectional survey conducted on 288 households, three focus group discussions, and 15 key informant interviews. The Climate Resilience Index (CRI) based on the three resilience capacities (absorptive, adaptive and transformative) frame was used to measure households’ resilience to climate change-induced shocks on an agro-ecological unit of analysis. A principal component analysis (PCA) and multiple regression analysis were used to identify determinant factors and indicators to households’ resilience, respectively. Findings indicate that the indexed scores of major components clearly differentiated the study communities in terms of their agro-ecological zones. Specifically, the absorptive capacity (0.495) was the leading contributing factor to resilience followed by adaptive (0.449) and transformative (0.387) capacities. Likewise, the Midland was relatively more resilient with a mean index value of 0.461. Both the PCA and multiple regression analysis indicated that access to and use of livelihood resources, such as farmlands and livestock holdings, diversity of income sources, infrastructure and social capital were determinants of households’ resilience. In general, it might be due to their exposure to recurrent shocks coupled with limited adaptive capacities including underdeveloped public services, poor livelihood diversification practices, among others, the study communities showed minimal resilience capacity with a mean score of 0.44. Thus, in addition to short-term buffering strategies, intervention priority focusing on both adaptive and transformative capacities, particularly focusing on most vulnerable localities and constrained livelihood strategies, would contribute to ensuring long-term resilience in the study communities. [ABSTRACT FROM AUTHOR]