Improving Clinician Awareness of and Screening for Chagas Disease with an Educational Intervention.

Chagas disease is an underrecognized, chronic, and potentially life-threatening disease caused by the parasite Trypanosoma cruzi. We aimed to improve awareness and screening for Chagas disease among patients from endemic areas using a large safety-net academic hospital system in the United States. We developed an educational intervention consisting of a case-based didactic session presented to physicians, trainees, and other healthcare providers at conferences across different departments. Performance on a knowledge assessment administered before and after the presentation was analyzed with paired Student's t-test for within-subject difference testing. Institutional testing rates for T. cruzi were evaluated for an equal time period (29 months) before and after the start of the intervention. Testing rates were compared by a Welch's unequal variances t-test and by interrupted time series based on multivariate linear regression. Eleven educational sessions were held over the intervention period, and 103 participants completed the pre- and post-presentation surveys. The mean survey scores were 59.2% before the presentation and 96.6% after presentation (P <0.001). Trypanosoma cruzi testing during the postintervention period was significantly higher than testing during the pre-intervention period (171 patients pre-intervention versus 378 patients postintervention [P = 0.015]). Notable increases in testing from the pre-intervention to postintervention periods occurred among midwives (1-68 patients tested) and trainees (57-133 patients tested). Overall, 56/537 (10.4%) nonduplicate T. cruzi commercial screening tests were positive. Testing increased over time, both at an institutional level and within targeted departments. In addition to the educational program, other factors likely influenced expanded testing.

Self-Rated Competence of Ugandan Healthcare Workers to Obtain Informed Consent for Autopsy.

We examined the self-rated competence of Ugandan healthcare workers (HCWs) in obtaining informed consent for autopsies, considering the challenges of low autopsy acceptance rates globally. In September and October 2023, we conducted a nationwide cross-sectional study of HCWs, who provided informed consent to participate and completed an online, self-administered questionnaire. Participants' self-rated competence in obtaining informed consent for autopsy was assessed through Likert scale questions. Knowledge and practices were also assessed. All scores were converted to percentages, with scores ≥80% indicating higher competence. We enrolled 216 HCWs (including 145 [67.1%] doctors), with a mean age of 31.6 ± 7.2 years. Overall, 55.6% (n = 120) had ever assisted in obtaining consent for autopsy, 43.6% (n = 100) had ever obtained consent for autopsy themselves, and 13.4% (n = 29) had ever attended training on obtaining consent for autopsy. The mean competency score was 59.8 ± 17.0% (perfect score, 100%), with 29 (13.4%) participants demonstrating high competence. Healthcare workers with adequate knowledge had higher competence scores (odds ratio [OR]: 15.0, 95% CI: 6.17-36.58, P <0.001). Compared with nurses/midwives, doctors had 73% lower odds of having a high competence score (adjusted OR: 0.27, 95% CI: 0.08-0.94, P = 0.040). Fewer than one in five Ugandan HCWs demonstrated high self-rated competence or possessed adequate knowledge regarding informed consent for autopsies, and only a few had received specialized training on how to obtain consent for an autopsy. Therefore, there is a pressing need for enhanced training and increased awareness among Ugandan HCWs in obtaining informed consent for autopsies.

Neonatal Physical Growth Predicts Electroencephalography Power in Rural South African Children.

Anthropometric measures at birth, indexing prenatal growth, are associated with later cognitive development. Children in low- and middle-income countries (LMIC) are at elevated risk for impaired prenatal and early postnatal growth and enduring cognitive deficits. However, the associations of neonatal physical growth with neural activity are not well-characterized in LMIC contexts, given the dearth of early childhood neuroimaging research in these settings. The current study examined birth length, weight, and head circumference as predictors of EEG relative power over the first three years of life in rural Limpopo Province, South Africa, controlling for postnatal growth and socioeconomic status (SES). A larger head circumference at birth predicted lower relative gamma power, lower right hemisphere relative beta power, and higher relative alpha and theta power. A greater birth length also predicted lower relative gamma power. There were interactions with timepoints such that the associations of birth head circumference and length with EEG power were most pronounced at the 7-month assessment and were attenuated at the 17- and 36-month assessments. The results identify birth head circumference and length as specific predictors of infant neural activity within an under-resourced context.

Organ donation and HIV: Awareness and willingness to be a living donor among people with HIV in Uganda.

BACKGROUND: HIV+-to-HIV+ organ transplantation has demonstrated promise and is now authorized for research purposes in certain countries. However, organ transplantation is dependent on the availability of organ donors. We assessed the awareness and willingness to donate organs among people with HIV (PWH) in Uganda. METHODS: We conducted a multicenter cross-sectional study between October 2023 and January 2024 in four large HIV clinics in Northern Uganda. The study population consisted of PWH. A structured questionnaire was used to collect data regarding awareness, willingness, and beliefs regarding organ donation. Organ donation was defined as the willingness to be a living donor of a solid organ. We conducted multivariable logistic regression to assess for an association between willingness to donate organs and selected exposures. Data were analyzed in Stata version 15.0. Results are expressed as adjusted odds ratio (AOR) with 95% confidence intervals (CI). RESULTS: A total of 232 participants were recruited. The mean age ± standard deviation of the participants was 42.2±11.8 years. All participants were on antiretroviral therapy. Sixty-two (26.7%) had a CD4 count less than or equal to 200 cells/mm3. The majority (80.6%, n = 187) had ever heard of organ donation. Slightly more than a third (34.9%, n = 81) were willing to donate organs. Factors associated with willingness to be a living organ donor included being female (AOR: 1.56; 95% CI: 1.15-2.11), having a tertiary education level (AOR: 1.79; 95% CI: 1.03-3.11), average monthly income >500 000 UGX (135.1USD) (AOR: 5.5; 95% CI: 1.97-15.40), ever heard about organ donation (AOR: 5.4; 95% CI: 1.67-17.8), and attending an organ donation campaign (AOR: 2.0; 95% CI: 1.07-3.74). CONCLUSIONS: Awareness about organ donation was high but the willingness to be a living organ donor was low among PWH in Uganda. There is a need to sensitize the community about the need and benefits of organ donation with the involvement of media and the healthcare workers.

Travel surveillance uncovers dengue virus dynamics and introductions in the Caribbean.

Dengue is the most prevalent mosquito-borne viral disease in humans, and cases are continuing to rise globally. In particular, islands in the Caribbean have experienced more frequent outbreaks, and all four dengue virus (DENV) serotypes have been reported in the region, leading to hyperendemicity and increased rates of severe disease. However, there is significant variability regarding virus surveillance and reporting between islands, making it difficult to obtain an accurate understanding of the epidemiological patterns in the Caribbean. To investigate this, we used travel surveillance and genomic epidemiology to reconstruct outbreak dynamics, DENV serotype turnover, and patterns of spread within the region from 2009-2022. We uncovered two recent DENV-3 introductions from Asia, one of which resulted in a large outbreak in Cuba, which was previously under-reported. We also show that while outbreaks can be synchronized between islands, they are often caused by different serotypes. Our study highlights the importance of surveillance of infected travelers to provide a snapshot of local introductions and transmission in areas with limited local surveillance and suggests that the recent DENV-3 introductions may pose a major public health threat in the region.

Current Status of La Crosse Virus in North America and Potential for Future Spread.

La Crosse virus (LACV) is an arthropod-borne RNA virus with substantial potential for future spread in North America. La Crosse virus is responsible for La Crosse encephalitis, a leading cause of arboviral encephalitis in children in the United States. Primarily transmitted by Aedes triseriatus (Eastern treehole) mosquitos and amplified by small mammal hosts, LACV has caused infections throughout the upper Midwest and, more recently, the mid-Atlantic and southeastern United States. Notably, in recent years, infections have also been identified increasingly in the Appalachian region. Anthropogenic and environmental factors have likely contributed to recent LACV spread, including the introduction of invasive vector species (especially Ae. albopictus), biotic interactions between and among vector and host species, land-use change, habitat disturbance, increased human travel and transport, and rising global temperatures. Prevention and control strategies, such as increased surveillance of vector and host populations, increased awareness among populations at risk for infection, and increased awareness among physicians are needed to limit future spread. Continued climate change with increases in global temperatures and erratic weather patterns may result in the expansion of competent mosquito vector species and thus could facilitate the geographic spread of LACV.

Impact of COVID-19 on food security and diet quality in Chilanga District, Zambia.

INTRODUCTION: Food security and nutrition have been severely impacted during the COVID-19 pandemic, particularly in low- and middle-income countries (LMICs). We aimed to quantify the impacts of the pandemic on food security and diet diversity within Chilanga District in Zambia and identify target areas for high-impact social protection and safety net programs. METHODS: We conducted a cross-sectional study in Chilanga district immediately after the Omicron variant surge in February 2022. Diet quality and food security were assessed based on a household diet questionnaire and a Minimum Dietary Diversity-Women (MDD-W) score was calculated. A paired t-test was used to determine whether there was a statistically significant change in the MDD-W score and McNemar test was used to investigate the change in food security between the pre- and peri-COVID-19 period. RESULTS: Compared to the pre-COVID-19 period, there were increases in food prices across the board in the peri-COVID-19 period and decreased consumption of key food categories including legumes, dairy and vitamin A rich foods. Despite high rates of food insecurity, only 6.6% of surveyed households received any cash or in-kind assistance from a government agency, non-profit, or other organization in the post-COVID-19 period. CONCLUSION: The COVID-19 pandemic had significant impacts on food security and dietary diversity in Chilanga district. This is particularly relevant in the low-income communities that we surveyed, which had pre-existing challenges with food security. Additional resources must be invested in Chilanga District and similarly affected areas to address this gap in access to food and promote national equity. Trial Registration N/A.

Chikungunya infection in returned travellers: results from the geosentinel network, 2005-2020.

BACKGROUND: Chikungunya is an important travel-related disease because of its rapid geographical expansion and potential for prolonged morbidity. Improved understanding of the epidemiology of travel-related chikungunya infections may influence prevention strategies including education and vaccination. METHODS: We analysed data from travellers with confirmed or probable chikungunya reported to GeoSentinel sites from 2005 to 2020. Confirmed chikungunya was defined as a compatible clinical history plus either virus isolation, positive nucleic acid test or seroconversion/rising titre in paired sera. Probable chikungunya was defined as a compatible clinical history with a single positive serology result. RESULTS: 1202 travellers (896 confirmed and 306 probable) with chikungunya were included. The median age was 43 years (range 0-91; interquartile range [IQR]: 31-55); 707 (58.8%) travellers were female. Most infections were acquired in the Caribbean (28.8%), Southeast Asia (22.8%), South Central Asia (14.2%) and South America (14.2%). The highest numbers of chikungunya cases reported to GeoSentinel were in 2014 (28.3%), 2015 (14.3%) and 2019 (11.9%). The most frequent reasons for travel were tourism (n = 592; 49.3%) and visiting friends or relatives (n = 334; 27.7%). The median time to presentation to a GeoSentinel site was 23 days (IQR: 7-52) after symptom onset. In travellers with confirmed chikungunya and no other reported illnesses, the most frequently reported symptoms included musculoskeletal symptoms (98.8%), fever/chills/sweats (68.7%) and dermatologic symptoms (35.5%). Among 917 travellers with information available, 296 (32.3%) had a pretravel consultation. CONCLUSIONS: Chikungunya was acquired by international travellers in almost 100 destinations globally. Vector precautions and vaccination where recommended should be integrated into pretravel visits for travellers going to areas with chikungunya or areas with the potential for transmission. Continued surveillance of travel-related chikungunya may help public health officials and clinicians limit the transmission of this potentially debilitating disease by defining regions where protective measures (e.g. pretravel vaccination) should be strongly considered.

Chagas cardiomyopathy in Boston, Massachusetts: Identifying disease and improving management after community and hospital-based screening.

BACKGROUND: Limited data exist regarding cardiac manifestations of Chagas disease in migrants living in non-endemic regions. METHODS: A retrospective cohort analysis of 109 patients with Chagas disease seen at Boston Medical Center (BMC) between January 2016 and January 2023 was performed. Patients were identified by screening and testing migrants from endemic regions at a community health center and BMC. Demographic, laboratory, and cardiac evaluation data were collected. RESULTS: Mean age of the 109 patients was 43 years (range 19-76); 61% were female. 79% (86/109) were diagnosed with Chagas disease via screening and 21% (23/109) were tested given symptoms or electrocardiogram abnormalities. Common symptoms included palpitations (25%, 27/109) and chest pain (17%, 18/109); 52% (57/109) were asymptomatic. Right bundle branch block (19%, 19/102), T-wave changes (18%, 18/102), and left anterior fascicular block (11%, 11/102) were the most common electrocardiogram abnormalities; 51% (52/102) had normal electrocardiograms. Cardiomyopathy stage was ascertained in 94 of 109 patients: 51% (48/94) were indeterminate stage A and 49% (46/94) had cardiac structural disease (stages B1-D). Clinical findings that required clinical intervention or change in management were found in 23% (25/109), and included cardiomyopathy, apical hypokinesis/aneurysm, stroke, atrial or ventricular arrhythmias, and apical thrombus. CONCLUSIONS: These data show high rates of cardiac complications in a cohort of migrants living with Chagas disease in a non-endemic setting. We demonstrate that Chagas disease diagnosis prompts cardiac evaluation which often identifies actionable cardiac disease and provides opportunities for prevention and treatment.

Institutionalizing Innovation: From Pilot to Scale for Co-Packaged Oral Rehydration Salts and Zinc-A Case Study in Zambia.

We document the development and institutionalization in Zambia of a health innovation for diarrhea treatment aimed at children aged younger than 5 years: a unique oral rehydration salts and zinc (ORSZ) co-pack. Seven recommendations from the World Health Organization/ExpandNet are used retrospectively to analyze and describe the successful scale-up of this innovation from its concept stage, including in-country expansion and policy, institutional, and regulatory changes. The 7 recommendations comprise using a participatory process, tailoring to the country context, designing research to test the innovation, testing the innovation, identifying success factors, and scaling up. The scale-up of co-packaged ORSZ in Zambia is shown to be sustainable. Five years after donor funding ended in 2018, an independent, local manufacturer continues to supply the private and public sectors on a commercially viable basis. Furthermore, national coverage of ORSZ increased from less than 1% in 2012 to 34% in 2018. A key success factor was the continuous facilitation over 8 years (spanning planning, trial, evaluation, and scale-up) by a learning and steering group chaired by the Ministry of Health, open to all and focused on learning transfer and ongoing alignment with other initiatives. Other success factors included a long lead-in of inclusive initial consultation, ideation, and planning with all key stakeholders to build on and mobilize existing resources, knowledge, structures, and systems; alignment with government policy; thorough testing and radical review of the product and its value chain before scale-up, including manufacture, distribution, policy, and regulatory matters; and adoption by the government of a co-packaging strategy to ensure cases of childhood diarrhea are treated with ORSZ. With appropriate local adaptations, this approach to scale-up could be replicated in other low- and middle-income countries as a strategy to increase coverage of ORSZ and potentially other health products.

Transmission Dynamics and Rare Clustered Transmission Within an Urban University Population Before Widespread Vaccination.

BACKGROUND: Universities returned to in-person learning in 2021 while SARS-CoV-2 spread remained high. At the time, it was not clear whether in-person learning would be a source of disease spread. METHODS: We combined surveillance testing, universal contact tracing, and viral genome sequencing to quantify introductions and identify likely on-campus spread. RESULTS: Ninety-one percent of viral genotypes occurred once, indicating no follow-on transmission. Less than 5% of introductions resulted in >3 cases, with 2 notable exceptions of 40 and 47 cases. Both partially overlapped with outbreaks defined by contact tracing. In both cases, viral genomics eliminated over half the epidemiologically linked cases but added an equivalent or greater number of individuals to the transmission cluster. CONCLUSIONS: Public health interventions prevented within-university transmission for most SARS-CoV-2 introductions, with only 2 major outbreaks being identified January to May 2021. The genetically linked cases overlap with outbreaks identified by contact tracing; however, they persisted in the university population for fewer days and rounds of transmission than estimated via contact tracing. This underscores the effectiveness of test-trace-isolate strategies in controlling undetected spread of emerging respiratory infectious diseases. These approaches limit follow-on transmission in both outside-in and internal transmission conditions.

Frequency of fungal pathogens in autopsy studies of people who died with HIV in Africa: a scoping review.

BACKGROUND: Fungal infections are common in HIV-infected individuals and significantly contribute to mortality. However, a substantial number of cases are undiagnosed before death. OBJECTIVE: To determine the frequency of fungal pathogens in autopsy studies of people who died with HIV in Africa. METHODS: We conducted a scoping review of autopsy studies conducted in Africa. DATA SOURCES: PubMed, Scopus, Web of Science, Embase, Google Scholar, and African Journal Online. STUDY ELIGIBILITY CRITERIA: The review encompasses studies published from inception to September 2023, and no language restrictions were imposed during the search process. We included studies that reported histopathological or microbiological evidence for the diagnosis of fungal infections and other pathogens. DATA SYNTHESIS: Data were summarized using descriptive statistics and no meta-analysis was performed. RESULTS: We examined 30 articles reporting studies conducted between 1991 and 2019, encompassing a total of 13 066 HIV-infected decedents across ten African countries. In five studies, the autopsy type was not specified. Among those studies with specified autopsy types, 20 involved complete diagnostic autopsies, whereas 5 were categorized as partial or minimally invasive autopsies. There were 2333 pathogens identified, with 946 (40.5%) being mycobacteria, 856 (36.7%) fungal, 231 (3.8%) viral, 208 (8.9%) parasitic, and 92 (3.9%) bacterial. Of the 856 fungal pathogens identified, 654 (28.0%) were Cryptococcus species, 167 (7.2%) Pneumocystis jirovecii, 16 (0.69%) Histoplasma species, 15 (0.64%) Aspergillus species, and 4 (0.17%) Candida species. Other major non-fungal pathogens identified were cytomegalovirus 172 (7.37%) and Toxoplasma gondii 173 (7.42%). CONCLUSIONS: Invasive fungal infections occur in over one-third of people who succumb to HIV in Africa. In addition to cryptococcosis and Pneumocystis jirovecii pneumonia, integrating other priority fungal pathogen detection and management strategies into the broader framework of HIV care in Africa is recommended. This involves increasing awareness regarding the impact of fungal infections in advanced HIV disease and strengthening diagnostic and treatment capacity.

Isolated renal and urinary tract aspergillosis: a systematic review.

Background: Aspergillosis localized to the kidneys and the urinary tract is uncommon. We conducted a comprehensive systematic review to evaluate risk factors and clinical outcomes of patients with isolated renal and genito-urinary tract aspergillosis. Methods: We systematically searched Medline, CINAHL, Embase, African Journal Online, Google Scholar, and the Cochrane Library, covering the period from inception to August 2023 using the key terms 'renal' OR 'kidney*' OR 'prostate' OR 'urinary bladder' OR 'urinary tract*AND 'aspergillosis' OR 'aspergillus' OR 'aspergilloma' OR 'mycetoma'. We included single case reports or case series. Review articles, guidelines, meta-analyses, animal studies, protocols, and cases of genitourinary and /or renal aspergillosis occurring as a part of disseminated disease were excluded. Results: We identified 91 renal and urinary aspergillosis cases extracted from 76 publications spanning 1925-2023. Among the participants, 79 (86.8%) were male, with a median age of 46 years. Predominantly, presentations consisted of isolated renal infections (74 instances, 81.3%), followed by prostate (5 cases, 5.5%), and bladder (7 cases, 7.7%) involvement. Aspergillus fumigatus (42.9%), Aspergillus flavus (9.9%), and Aspergillus niger/glaucus (1.1% each) were isolated. Underlying risk factors included diabetes mellitus (29.7%), HIV (12.1%), haematological malignancies (11%), and liver cirrhosis (8.8%), while common symptoms encompassed flank pain (36.3%), fever (33%), and lower urinary tract symptoms (20.9%). An autopsy was conducted in 8.8% of cases. Diagnostic work-up involved histopathology (70.5%), renal CT scans and urine microscopy and culture (52.6% each), and abdominal ultrasound (17.9%). Treatments included amphotericin B (34 cases, 37.4%) and azole-based regimens (29 cases, 31.9%). Nephrectomy was performed in 16 of 78 renal cases (20.5%). All-cause mortality was 24.4% (19 cases). No significant mortality rate difference was observed among antifungal regimens (p = 0.739) or nephrectomy status (p = 0.8). Conclusion: Renal and urinary aspergillosis is an important cause of morbidity and mortality, particularly in immunocompromised and people with diabetes mellitus. While varied treatment strategies were observed, mortality rates showed no significant differences based on treatments or nephrectomy status. Further research is needed to refine diagnostics, optimize treatments, and enhance awareness among clinicians for early detection and management. PROSPERO registration number: CRD42023430959.

What you need to know now about kidney and urinary tract infections caused by the fungus aspergillus In this study, we investigated the rare occurrence of aspergillosis, a fungal infection caused by the mold Aspergillus, specifically affecting the kidneys and urinary tract (ureters, urinary bladder, prostate and urethra). This disease was first described in 1891 in Germany. To update our current understanding of this rare disease, we conducted a thorough review, examining risk factors and outcomes for individuals with Aspergillus infection of the kidney and/or urinary tract. We found 91 cases from 76 published articles spanning nearly a century, identifying common features such as predominantly male patients (almost every 9 in 10 cases) and isolated infection of one or both kidneys being the most common (8 in 10 cases). Diabetes mellitus, HIV infection, and certain cancers were noted as underlying risk factors, with symptoms ranging from flank pain, passing of blood in urine, passing of fungal particles (bezoars) in urine, pain while passing urine to fever. Diagnostic methods included histopathology and imaging techniques, while treatments varied, involving antifungal medications such as voriconazole and amphotericin B, drainage of abscesses, and, in some cases, surgical removal of the affected kidney (nephrectomy). Overall, about 1 in every 4 of the affected people died. Despite diverse treatment approaches, the study found no significant difference in mortality rates, emphasizing the need for further research to improve diagnostics, refine treatments, and raise awareness for early detection and management, especially among immunocompromised individuals such as those with diabetes mellitus and HIV infection.

Travel surveillance uncovers dengue virus dynamics and introductions in the Caribbean.

Dengue is the most prevalent mosquito-borne viral disease in humans, and cases are continuing to rise globally. In particular, islands in the Caribbean have experienced more frequent outbreaks, and all four dengue virus (DENV) serotypes have been reported in the region, leading to hyperendemicity and increased rates of severe disease. However, there is significant variability regarding virus surveillance and reporting between islands, making it difficult to obtain an accurate understanding of the epidemiological patterns in the Caribbean. To investigate this, we used travel surveillance and genomic epidemiology to reconstruct outbreak dynamics, DENV serotype turnover, and patterns of spread within the region from 2009-2022. We uncovered two recent DENV-3 introductions from Asia, one of which resulted in a large outbreak in Cuba, which was previously under-reported. We also show that while outbreaks can be synchronized between islands, they are often caused by different serotypes. Our study highlights the importance of surveillance of infected travelers to provide a snapshot of local introductions and transmission in areas with limited local surveillance and suggests that the recent DENV-3 introductions may pose a major public health threat in the region.

Undernutrition in older children and adolescents in peri-urban Zambia.

Background: Adolescents make up roughly a quarter of the population in Zambia; however, most nutrition-related programming is targeted at the under-five population. Understanding the scale of undernutrition in older children and adolescents is fundamental to alleviating food insecurity and addressing undernutrition across all age groups. Methods: A cross-sectional survey was performed in four low-income, peri-urban compounds in Chilanga District which included anthropometric measurements of children between ages 6 months-19 years and a household-level diet diversity and food security questionnaire. Wasting was used for children under 5 and thinness for children 5-19 years. Descriptive analysis and multivariate logistic regression were conducted to quantify the prevalence and distribution of malnutrition and understand the impact of food security. Results: We surveyed 393 households and 1,004 children between the ages of 6 months and 19 years. Children aged 6-9 years had the highest prevalence of severe thinness (5.2%) and adolescents (10-19 years) had the highest rates of moderate thinness (6.5%). Across all age groups, more than 75% of children were in households that worried about running out of food in the previous month. 24.9% of adolescents and 28.4% of older children were in households were more likely to go a whole day without eating compared to 16.9% of children under 5. Conclusion: Our survey indicated that malnutrition in adolescents and older children living in Chilanga district was comparable to those under 5. Interventions to address undernutrition must be targeted at older children and adolescents in order to ameliorate this burden.