Overuse of antibiotics for urinary tract infections in pregnant refugees, Lebanon.

Objective: To determine whether adding urine culture to urinary tract infection diagnosis in pregnant women from refugee camps in Lebanon reduced unnecessary antibiotic use. Methods: We conducted a prospective, cross-sectional study between April and June 2022 involving pregnant women attending a Médecins Sans Frontières sexual reproductive health clinic in south Beirut. Women with two positive urine dipstick tests (i.e. a suspected urinary tract infection) provided urine samples for culture. Bacterial identification and antimicrobial sensitivity testing were conducted following European Committee on Antimicrobial Susceptibility Testing guidelines. We compared the characteristics of women with positive and negative urine culture findings and we calculated the proportion of antibiotics overprescribed or inappropriately used. We also estimated the cost of adding urine culture to the diagnostic algorithm. Findings: The study included 449 pregnant women with suspected urinary tract infections: 18.0% (81/449) had positive urine culture findings. If antibiotics were administered following urine dipstick results alone, 368 women would have received antibiotics unnecessarily: an overprescription rate of 82% (368/449). If administration was based on urine culture findings plus urinary tract infection symptoms, 144 of 368 women with negative urine culture findings would have received antibiotics unnecessarily: an overprescription rate of 39.1% (144/368). The additional cost of urine culture was 0.48 euros per woman. Conclusion: A high proportion of pregnant women with suspected urinary tract infections from refugee camps unnecessarily received antibiotics. Including urine culture in diagnosis, which is affordable in Lebanon, would greatly reduce antibiotic overprescription. Similar approaches could be adopted in other regions where microbiology laboratories are accessible.

Model of care, Noma Children's Hospital, northwest Nigeria.

The Nigerian Ministry of Health has been offering care for noma patients for many years at the Noma Children's Hospital (NCH) in Sokoto, northwest Nigeria, and Médecins Sans Frontières has supported these initiatives since 2014. The comprehensive model of care consists of four main components: acute care, care for noma sequelae, integrated hospital-based services and community-based services. The model of care is based on the limited evidence available for prevention and treatment of noma and follows WHO's protocols for acute patients and best practice guidelines for the surgical treatment of noma survivors. The model is updated continually as new evidence becomes available, including evidence generated through the operational research studies performed at NCH. By describing the model of care, we wish to share the lessons learned with other actors working in the noma and neglected tropical disease sphere in the hope of guiding programme development.

Predictors of virological failure among people living with HIV receiving first line antiretroviral treatment in Myanmar: retrospective cohort analysis.

BACKGROUND: Progress toward the global target for 95% virological suppression among those on antiretroviral treatment (ART) is still suboptimal. We describe the viral load (VL) cascade, the incidence of virological failure and associated risk factors among people living with HIV receiving first-line ART in an HIV cohort in Myanmar treated by the Médecins Sans Frontières in collaboration with the Ministry of Health and Sports Myanmar. METHODS: We conducted a retrospective cohort study, including adult patients with at least one HIV viral load test result and having received of at least 6 months' standard first-line ART. The incidence rate of virological failure (HIV viral load ≥ 1000 copies/mL) was calculated. Multivariable Cox's regression was performed to identify risk factors for virological failure. RESULTS: We included 25,260 patients with a median age of 33.1 years (interquartile range, IQR 28.0-39.1) and a median observation time of 5.4 years (IQR 3.7-7.9). Virological failure was documented in 3,579 (14.2%) participants, resulting in an overall incidence rate for failure of 2.5 per 100 person-years of follow-up. Among those who had a follow-up viral load result, 1,258 (57.1%) had confirmed virological failure, of which 836 (66.5%) were switched to second-line treatment. An increased hazard for failure was associated with age ≤ 19 years (adjusted hazard ratio, aHR 1.51; 95% confidence intervals, CI 1.20-1.89; p < 0.001), baseline tuberculosis (aHR 1.39; 95% CI 1.14-1.49; p < 0.001), a history of low-level viremia (aHR 1.60; 95% CI 1.42-1.81; p < 0.001), or a history of loss-to-follow-up (aHR 1.24; 95% CI 1.41-1.52; p = 0.041) and being on the same regimen (aHR 1.37; 95% CI 1.07-1.76; p < 0.001). Cumulative appointment delay was not significantly associated with failure after controlling for covariates. CONCLUSIONS: VL monitoring is an important tool to improve programme outcomes, however limited coverage of VL testing and acting on test results hampers its full potential. In our cohort children and adolescents, PLHIV with history of loss-to-follow-up or those with low-viremia are at the highest risk of virological failure and might require more frequent virological monitoring than is currently recommended.

Growth and neurodevelopment in low birth weight versus normal birth weight infants from birth to 24 months, born in an obstetric emergency hospital in Haiti, a prospective cohort study.

BACKGROUND: Low birthweight (LBW) infants are at higher risk of mortality and morbidity (growth, chronic disease and neurological problems) during their life. Due to the high incidence of (pre-) eclampsia in Haiti, LBW infants are common. We assessed the anthropometric growth (weight and length) and neurodevelopmental delay in LBW and normal birthweight (NBW) infants born at an obstetric emergency hospital in Port au Prince, Haiti, between 2014 and 2017. METHODS: Infants were followed at discharge and 3, 6, 12, 15, 18, 21 and 24 months of corrected gestational age. At each visit they underwent a physical checkup (weight, length, physical abnormalities, identification of morbidities). At 6, 12, 18 and 24 months they underwent a neurodevelopmental assessment using the Bayley Scale III (motor, cognitive and communication skills). We modelled the trajectories between birth and 24 months of age of NBW compared to LBW infants for weight, length, and raw scores for Bayley III assessments using mixed linear models. RESULTS: In total 500 LBW and 210 NBW infants were recruited of which 333 (46.7%) were followed up for 24 months (127 NBW; 60.5% and 206 LBW; 41.2%) and 150 died (LBW = 137 and NBW = 13). LBW and NBW babies gained a mean 15.8 g and 11.4 g per kg of weight from discharge per day respectively. The speed of weight gain decreased rapidly after 3 months in both groups. Both groups grow rapidly up to 6 months of age. LBW grew more than the NBW group during this period (22.8 cm vs. 21.1 cm). Both groups had WHZ scores <- 2 up to 15 months. At 24 months NBW babies scored significantly higher on the Bayley scales for gross motor, cognitive and receptive and expressive communication skills. There was no difference between the groups for fine motor skills. CONCLUSION: LBW babies that survive neonatal care in urban Haiti and live up to 24 months of age, perform similar to their NBW for weight, length and fine motor skills. LBW babies are delayed in gross motor, cognitive and communication skills development. Further research on the clinical significance of these findings and long term implications of this neurodevelopmental delay is needed.

Risk factors for adverse outcomes in women with high-risk pregnancy and their neonates, Haiti.

OBJECTIVES: To determine the prevalence of maternal death, stillbirth and low birthweight in women with (pre-)eclampsia and complicated pregnancies or deliveries in Centre de Références des Urgences Obstétricales, an obstetric emergency hospital in Port-au-Prince, Haiti, and to identify the main risk factors for these adverse pregnancy outcomes. METHODS: We conducted a retrospective cohort study of pregnant women admitted to Centre de Référence des Urgences Obstétricales between 2013 and 2018 using hospital records. Risk factors investigated were age group, type of pregnancy (singleton, multiple), type of delivery and use of antenatal care services. RESULTS: A total of 31 509 women and 24 983 deliveries were included in the analysis. Among these, 204 (0.6%) maternal deaths (648 per 100 000 women giving birth), 1962 (7.9%) stillbirths and 11 008 (44.1%) low birthweight neonates were identified. Of all admissions, 10 991 (34.9%) were women with (pre-)eclampsia. Caesarean section significantly increased the risk of maternal death in the women with a complicated pregnancy and women with (pre-)eclampsia, but reduced the risk of stillbirth in such women. Not attending antenatal care was associated with a significantly higher risk of stillbirth (odds ratio (OR) 4.82; 95% confidence interval (CI) 3.55-6.55) and low birthweight (OR 1.40; 95% CI 1.05-1.86) for women with complicated pregnancies. CONCLUSION: To prevent and treat pregnancy complications as early as possible, antenatal care attendance is crucial. Improving the quality of and access to antenatal care services and providing it free to all pregnant women in Haiti is recommended.

Does community-wide water chlorination reduce hepatitis E virus infections during an outbreak? A geospatial analysis of data from an outbreak in Am Timan, Chad (2016-2017).

Hepatitis E Virus (HEV) genotype 1 and 2 infect an estimated 20 million people each year, via the faecal-oral transmission route. An urban outbreak of HEV occurred in Am Timan, Chad, between September 2016 and April 2017. As part of the outbreak response, Médecins Sans Frontières and the Ministry of Health implemented water and hygiene interventions, including the chlorination of town water sources. We aimed to understand whether these water treatment activities had any impact on the number of HEV infections, using geospatial analysis of epidemiological and water treatment monitoring data. By conducting cluster analysis we investigated whether there were areas of particularly high and low infection risk during the outbreak and explored the reasons for this. We observed two high-risk spatial clusters of suspected cases and one high-risk cluster of confirmed cases. Our main finding was that confirmed HEV cases had a higher median number of days of exposure to unsafe water compared to suspected and non-confirmed cases (Kruskal-Wallis Chi Square: 15.5; p < 0.001). Our study confirms the mixed, but shifting, transmission routes during this outbreak. It also highlights the spatial and temporal analytical methods, which can be employed in future outbreaks to improve understanding of HEV transmission.

Seroprevalence and risk factors of recent infection with hepatitis E virus during an acute outbreak in an urban setting in Chad, 2017.

BACKGROUND: From September 2016-April 2017, Am Timan, Chad, experienced a large HEV outbreak in an urban setting with a limited impact in terms of morbidity and mortality. To better understand HEV epidemiology in this context, we estimated the seroprevalence of anti-HEV antibodies (IgM and IgG) and assessed the risk factors for recent HEV infections (positive anti-HEV IgM) during this outbreak. METHODS: A serological survey using simple random sampling was implemented in Am Timan at the tail-end of the outbreak (sample size aim = 384 household). Household members provided us with blood samples and household heads answered questions around water, sanitation and hygiene practices and animal ownership. Blood samples were tested for HEV IgG and IgM antibodies using Enzyme-Immune-Assay (EIA). We calculated weighted prevalence estimates and prevalence ratios (PRs) for possible risk factors for recent infection using multivariate Cox regression. RESULTS: We included 241 households (1529 participants). IgM prevalence decreased with age: 12.6% (< 5 years) to 4.3% (> 15 years). IgG prevalence increased with age: 23.5% (< 5 years) to 75.9% (> 15 years). Risk factors for recent HEV infections included: sharing the sanitation facility with other HHs (PR 1.72; 95%CI: 1.08-2.73), not systematically using soap for HW (PR 1.85; 95%CI: 1.30-2.63) and having animals sleeping inside the compound (PR 1.69; 95%CI: 1.15-2.50). CONCLUSIONS: Evidence suggests that Am Timan was already highly endemic for HEV before the outbreak, potentially explaining the limited extent of the outbreak. Recent infection with HEV was linked to household level exposures. Future HEV outbreak response must include ensuring access to safe water, and reducing household level transmission through active hygiene and sanitation promotion activities.

Impact of war on child health in northern Syria: the experience of Médecins Sans Frontières.

Few data are available to evaluate the impact of Syrian war on civilian population; to describe this impact on child health, this article uses data from Médecins Sans Frontières-Operational Centre Amsterdam's activities in Tal-Abyad and Kobane cities, northern Syria (2013-2016). Data were obtained from routine medical datasets and narrative reports, for out-patient clinics, immunisation, nutritional monitoring and assessments, and in-patient care, and were analysed quantitatively and qualitatively. Infections were the largest contributor to morbidity. The proportion of < 5 year out-patient consultations of infectious diseases that are listed for outbreak monitoring in emergencies was 15% in 2013, 51% in 2014, 75% in 2015 and 70% in 2016. Thalassemia was recorded in 0.5% of 2014 < 5 year out-patient consultations and 3.4% of 2013-2014 < 18-year in-patient admissions. Measles immunisation activities and routine Extended Programme for Immunisation were re-activated across northern Syria; however, immunisation coverage could not be calculated. Results from our routine data must be compared cautiously, due to differences in settings and disease categories. CONCLUSION: With such scattered interventions, routine data are limited in providing a quantified evidence of emergency's health impact; however, they help in drawing a picture of children's health status and highlighting difficulties in providing curative and preventive services, in order to reflect part of population's plight. What is Known • Few data exist to evaluate the impact of the Syrian war on the health of children; • Médecins Sans Frontières (MSF-OCA) has worked in northern Syria during different times since 2013. What is New • Quantitative and qualitative analysis of MSF's routine medical data and situtation reports show that one fifth of all consultations in children < 5 years in MSF health facilities in northern Syria 2013-2016 were due to communicable diseases; • The analysis also highlights the burden of chronic conditions that were prevalent in Syria before the war, e.g. thalassemia.

Learning from water treatment and hygiene interventions in response to a hepatitis E outbreak in an open setting in Chad.

In September 2016, Médecins Sans Frontières responded to a hepatitis E (HEV) outbreak in Chad by implementing water treatment and hygiene interventions. To evaluate the coverage and use of these interventions, we conducted a cross-sectional study in the community. Our results showed that 99% of households interviewed had received a hygiene kit from us, aimed at improving water handling practice and personal hygiene and almost all respondents had heard messages about preventing jaundice and handwashing. Acceptance of chlorination of drinking water was also very high, although at the time of interview, we were only able to measure a safe free residual chlorine level (free chlorine residual (FRC) ≥0.2 mg/L) in 43% of households. Households which had refilled water containers within the last 18 hours, had sourced water from private wells or had poured water into a previously empty container, were all more likely to have a safe FRC level. In this open setting, we were able to achieve high coverage for chlorination, hygiene messaging and hygiene kit ownership; however, a review of our technical practice is needed in order to maintain safe FRC levels in drinking water in households, particularly when water is collected from multiple sources, stored and mixed with older water.

Using lot quality assurance sampling to assess access to water, sanitation and hygiene services in a refugee camp setting in South Sudan: a feasibility study.

BACKGROUND: Humanitarian agencies working in refugee camp settings require rapid assessment methods to measure the needs of the populations they serve. Due to the high level of dependency of refugees, agencies need to carry out these assessments. Lot Quality Assurance Sampling (LQAS) is a method commonly used in development settings to assess populations living in a project catchment area to identify their greatest needs. LQAS could be well suited to serve the needs of refugee populations, but it has rarely been used in humanitarian settings. We adapted and implemented an LQAS survey design in Batil refugee camp, South Sudan in May 2013 to measure the added value of using it for sub-camp level assessment. METHODS: Using pre-existing divisions within the camp, we divided the Batil catchment area into six contiguous segments, called 'supervision areas' (SA). Six teams of two data collectors randomly selected 19 respondents in each SA, who they interviewed to collect information on water, sanitation, hygiene, and diarrhoea prevalence. These findings were aggregated into a stratified random sample of 114 respondents, and the results were analysed to produce a coverage estimate with 95% confidence interval for the camp and to prioritize SAs within the camp. RESULTS: The survey provided coverage estimates on WASH indicators as well as evidence that areas of the camp closer to the main road, to clinics and to the market were better served than areas at the periphery of the camp. This assumption did not hold for all services, however, as sanitation services were uniformly high regardless of location. While it was necessary to adapt the standard LQAS protocol used in low-resource communities, the LQAS model proved to be feasible in a refugee camp setting, and program managers found the results useful at both the catchment area and SA level. CONCLUSIONS: This study, one of the few adaptations of LQAS for a camp setting, shows that it is a feasible method for regular monitoring, with the added value of enabling camp managers to identify and advocate for the least served areas within the camp. Feedback on the results from stakeholders was overwhelmingly positive.

Factors Related to Fetal Death in Pregnant Women with Cholera, Haiti, 2011-2014.

We assessed risk factors for fetal death during cholera infection and effect of treatment changes on these deaths. Third trimester gestation, younger maternal age, severe dehydration, and vomiting were risk factors. Changes in treatment had limited effects on fetal death, highlighting the need for prevention and evidence-based treatment.

Prospective Outcomes of Noma Facial Reconstructive Surgery in Sokoto, Nigeria.

Background: Noma is a gangrenous infection of the face that results in severe facial deformity, occurring primarily in malnourished and impoverished populations. Objective: To assess clinician- and patient-reported outcomes (PROs) before and after reconstructive surgery for patients with noma in northwest Nigeria. Methods: Objective outcomes were recorded using the noma-specific NOITULP (nose, outer cheek, inner cheek, trismus, upper/lower lip, particularities) classification system. PROs were recorded using a locally developed tool. Postsurgical changes were assessed by Wilcoxon signed-rank testing. Linear regression was used to look for associated risk factors. The inter-rater reliability (IRR) of the NOITULP score was assessed using the weighted kappa statistic. Results: Forty-nine patients (median age 25 years, 71% male) underwent local/regional flap reconstruction and/or trismus release. Twelve complications were reported. Univariate analysis showed a 3.20 change in PRO score (95% confidence interval 0.59 to 5.81, p = 0.018) per kilogram the patient underwent at time of surgery. The NOITULP score improved from a presurgery median of 3.5 to 2.3 (p < 0.0001), however, the IRR was poor (kappa = 0.0894, p < 0.0001). The PRO score also improved from a median of 7.0 to 12.0 (p < 0.0001). Conclusions: Facial reconstructive surgery improves the NOITULP score and PROs in patients with noma in northwest Nigeria. Clinical Trial Registration: OCA017-63.

Correction: Exploring factors influencing patient mortality and loss to follow-up in two paediatric hospital wards in Zamfara, North-West Nigeria, 2016-2018.

[This corrects the article DOI: 10.1371/journal.pone.0262073.].

Correction: Evaluation of community based surveillance in the Rohingya refugee camps in Cox's Bazar, Bangladesh, 2019.

[This corrects the article DOI: 10.1371/journal.pone.0244214.].

Correction: Translating drug resistant tuberculosis treatment guidelines to reality in war-torn Kandahar, Afghanistan: A retrospective cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0237787.].

Correction: Early warning for healthcare acquired infections in neonatal care units in a low-resource setting using routinely collected hospital data: The experience from Haiti, 2014-2018.

[This corrects the article DOI: 10.1371/journal.pone.0269385.].

Retrospective analysis of fungemia among children in Anka General Hospital, Nigeria, from October 2018 to November 2021: a case series.

Yeast-related bloodstream infections (BSIs) in pediatric patients are associated with severe acute malnutrition (SAM), hematological/oncological malignancies and admission to an intensive care unit. These infections are rarely described from low- and middle-income countries. We describe a case series of pediatric patients diagnosed with severe sepsis and yeast isolated from their blood culture in a conflict-affected area of Nigeria from October 2018 to November 2021. We identified 20 patients with yeast BSIs, among whom 17 were also diagnosed with SAM. We recommend the inclusion of antifungal treatment for empiric treatment guidelines for children with SAM and severe sepsis in similar settings.

Advanced HIV disease and associated attrition after re-engagement in HIV care in Myanmar from 2003 to 2019: a retrospective cohort study.

BACKGROUND: The burden of advanced HIV disease (AHD) and predictors of outcomes among people living with HIV (PLHIV) re-engaging in care are not well known. METHODS: We conducted a retrospective cohort study of PLHIV who re-engaged in care after being lost to follow-up (LFU), from 2003 to 2019, in Myanmar. We calculated the incidence rates of attrition after re-engagement and performed Cox regression to identify risk factors for attrition. RESULTS: Of 44 131 PLHIV who started antiretroviral treatment, 12 338 (28.0%) were LFU at least once: 7608 (61.6%) re-engaged in care, 4672 (61.4%) with AHD at re-engagement. The death and LFU rates were 2.21-fold (95% CI 1.82 to 2.67) and 1.46-fold (95% CI 1.33 to 1.61) higher among patients who re-engaged with AHD (p>0.001). Death in patients who re-engaged with AHD was associated with male sex (adjusted HR [aHR] 2.63; 95% CI 1.31 to 5.26; p=0.006), TB coinfection (aHR 2.26; 95% CI 1.23 to 4.14; p=0.008) and sex work (aHR 7.49, 95% CI 2.29 to 22.52; p<0.001). History of intravenous drug use was identified as a predictor of being LFU. CONCLUSIONS: Re-engagement in HIV care in Myanmar is frequent and those who re-engage carry a high burden of AHD. As AHD at re-engagement is associated with higher attrition rates, implementation of differentiated interventions that enable earlier linkage to care and prompt identification and management of AHD in this population is necessary.

Proportion of paediatric admissions with any stage of noma at the Anka General Hospital, northwest Nigeria.

INTRODUCTION: Noma is a rapidly spreading infection of the oral cavity which mainly affects young children. Without early treatment, it can have a high mortality rate. Simple gingivitis is a warning sign for noma, and acute necrotizing gingivitis is the first stage of noma. The epidemiology of noma is not well understood. We aimed to understand the prevalence of all stages of noma in hospitalised children. METHODS: We conducted a prospective observational study from 1st June to 24th October 2021, enrolling patients aged 0 to 12 years who were admitted to the Anka General Hospital, Zamfara, northwest Nigeria. Consenting parents/ guardians of participants were interviewed at admission. Participants had anthropometric and oral examinations at admission and discharge. FINDINGS: Of the 2346 patients, 58 (2.5%) were diagnosed with simple gingivitis and six (n = 0.3%) with acute necrotizing gingivitis upon admission. Of those admitted to the Inpatient Therapeutic Feeding Centre (ITFC), 3.4% (n = 37, CI 2.5-4.7%) were diagnosed with simple gingivitis upon admission compared to 1.7% of those not admitted to the ITFC (n = 21, CI 1.1-2.6%) (p = 0.008). Risk factors identified for having simple gingivitis included being aged over two years (2 to 6 yrs old, odds ratio (OR) 3.4, CI 1.77-6.5; 7 to 12 yrs OR 5.0, CI 1.7-14.6; p = <0.001), being admitted to the ITFC (OR 2.1; CI 1.22-3.62) and having oral health issues in the three months prior to the assessment (OR 18.75; CI 10.65, 33.01). All (n = 4/4) those aged six months to five years acute necrotizing gingivitis had chronic malnutrition. CONCLUSION: Our study showed a small proportion of children admitted to the Anka General Hospital had simple or acute necrotizing gingivitis. Hospital admission with malnutrition was a risk factor for both simple and acute necrotizing gingivitis. The lack of access to and uptake of oral health care indicates a strong need for oral examinations to be included in routine health services. This provision could improve the oral status of the population and decrease the chance of patients developing noma.

Early warning for healthcare acquired infections in neonatal care units in a low-resource setting using routinely collected hospital data: The experience from Haiti, 2014-2018.

In low-resource settings, detection of healthcare-acquired outbreaks in neonatal units relies on astute clinical staff to observe unusual morbidity or mortality from sepsis as microbiological diagnostics are often absent. We aimed to generate reliable (and automated) early warnings for potential clusters of neonatal late onset sepsis using retrospective data that could signal the start of an outbreak in an NCU in Port au Prince, Haiti, using routinely collected data on neonatal admissions. We constructed smoothed time series for late onset sepsis cases, late onset sepsis rates, neonatal care unit (NCU) mortality, maternal admissions, neonatal admissions and neonatal antibiotic consumption. An outbreak was defined as a statistical increase in any of these time series indicators. We created three outbreak alarm classes: 1) thresholds: weeks in which the late onset sepsis cases exceeded four, the late onset sepsis rates exceeded 10% of total NCU admissions and the NCU mortality exceeded 15%; 2) differential: late onset sepsis rates and NCU mortality were double the previous week; and 3) aberration: using the improved Farrington model for late onset sepsis rates and NCU mortality. We validated pairs of alarms by calculating the sensitivity and specificity of the weeks in which each alarm was launched and comparing each alarm to the weeks in which a single GNB positive blood culture was reported from a neonate. The threshold and aberration alarms were the strongest predictors for current and future NCU mortality and current LOS rates (p<0.0002). The aberration alarms were also those with the highest sensitivity, specificity, negative predictive value, and positive predictive value. Without microbiological diagnostics in NCUs in low-resource settings, applying these simple algorithms to routinely collected data show great potential to facilitate early warning for possible healthcare-acquired outbreaks of LOS in neonates. The methods used in this study require validation across other low-resource settings.