Incidence of Coronavirus Disease 2019 (COVID-19) among healthcare workers during the first and second wave in the Democratic Republic of the Congo: a descriptive study.

BACKGROUND: Healthcare workers (HCWs) are at the frontline of response to the COVID-19 pandemic. Protecting HCWs is of paramount importance to the World Health Organization (WHO). Outbreak investigation which is based on a critical assessment of core components of infection prevention and control (IPC) programs allows for the identification of different sources of exposure to the COVID-19 virus and for informing additional IPC recommendations. To date, the Democratic Republic of the Congo (DRC) is categorized as a high-risk country due to weaknesses in the health system, low capacity for diagnosis, socioeconomic characteristics of the population, and insufficient vaccination coverage. AIM: To investigate the burden of COVID-19 among HCWs and identification of IPC gaps to reduce HCWs-associated infection at different levels (facilities, communities, and points of entry) following the WHO strategy for IPC program implementation during the first to the third wave of the pandemic. METHODS: A retrospective cohort study was conducted using the DRC National Department of Health (NDOH) database and WHO questionnaire suspected and confirmed COVID-19 cases among HCWs from 10/03/2020 to 22/06/2021. The investigation was conducted by a trained IPC response team to identify the sources of the exposures. The questionnaire included demographics, profession, types of interaction between HCWs and patients, and community-based questions regarding family members and other behaviors. These variables were assessed using a multimodal strategy framework. Knowledge and adherence to IPC gaps using WHO guidelines were performed for each COVID-19-positive or suspected HCW. WHO rapid Scorecard dashboard was conducted for evaluating healthcare facilities (HCFs) performance during the COVID-19 pandemic. RESULTS: Cumulative incidence of positive HCWs was 809 /35,898(2.2%) from the first to the third wave of COVID-19 among 6 provinces of DRC. The distribution of the HCWs infected by COVID-19 was predominated by nurses (42%), doctors (27%), biologists (8%), environmental health practitioners (5%), interns (3%), and other categories (15%). Other categories included nutritionists, physiotherapists, midwives, pharmacists, and paramedics. The investigation revealed that about 32% of HCWs were infected from household contacts, 11% were infected by HCFs, 35% were infected in the community and 22% were infected from unknown exposures. The mean score of IPC performance for all evaluated HCFs was 27/42(64%). This shows that IPC performance was moderate. Lower or minimal performance was noted in the implementation of the IPC program at the national and facility level, triage and screening, isolation handwashing and multimodal strategies of hand hygiene, PPE availability, and rationale, waste segregation, waste disposal, sterilization, and training of HCWs. CONCLUSION: This study revealed that the prevalence of HCWs who tested positive for the COVID-19 virus was high among frontline healthcare workers from 6 provinces of DRC. A high prevalence of nosocomial infection was correlated with insufficient IPC adherence in the context of COVID-19. Strategies to strengthen IPC capacity building and provide HCWs with sufficient PPE stocks and budgets may improve IPC performance in the Democratic Republic of the Congo. This will further allow for adherence to WHO recommendations for successful program implementation to minimize COVID-19 transmission in HCFs, communities, and public gatherings. And this may be transferable to other infectious diseases.

COVID-19 impact on gender-based violence among women in South Africa during lockdown: a narrative review.

COVID-19, first detected in Wuhan, China, in December 2019, was declared a global pandemic by the WHO following the rapid spread of cases worldwide. The pandemic resulted in governments enforcing nationwide lockdowns, halting economic activities except for essential services. This review aims to explore the impact of the COVID-19 pandemic on gender-based violence (GBV) among women in South Africa. The literature search for this review was limited to African peer-reviewed articles and studies published in English between March 2020 and July 2021. EBSCOhost (PubMed, EBSCOhost, APA PsycArticles, APA PsychINFO, Academic Search Ultimate, Africa-Wide Information, Sociology Source Ultimate, CAB Abstracts, CINAHL with full text, and MEDLINE) electronic database platforms and the Google Scholar search engine and bibliographies of identified sources were used to identify studies that are included in the review. 82 studies were identified for this review and 18 were included in the synthesis. Multiple factors contributed to the surge in GBV cases in South Africa, including alcohol availability and consumption, job losses, financial dependence, psychological distress, and emotional imbalances. Effective intervention strategies are proposed, calling for more research to better understand women's experiences of GBV during the COVID-19 pandemic.

Mortality in patients with HIV-1 infection starting antiretroviral therapy in South Africa, Europe, or North America: a collaborative analysis of prospective studies.

BACKGROUND: High early mortality in patients with HIV-1 starting antiretroviral therapy (ART) in sub-Saharan Africa, compared to Europe and North America, is well documented. Longer-term comparisons between settings have been limited by poor ascertainment of mortality in high burden African settings. This study aimed to compare mortality up to four years on ART between South Africa, Europe, and North America. METHODS AND FINDINGS: Data from four South African cohorts in which patients lost to follow-up (LTF) could be linked to the national population register to determine vital status were combined with data from Europe and North America. Cumulative mortality, crude and adjusted (for characteristics at ART initiation) mortality rate ratios (relative to South Africa), and predicted mortality rates were described by region at 0-3, 3-6, 6-12, 12-24, and 24-48 months on ART for the period 2001-2010. Of the adults included (30,467 [South Africa], 29,727 [Europe], and 7,160 [North America]), 20,306 (67%), 9,961 (34%), and 824 (12%) were women. Patients began treatment with markedly more advanced disease in South Africa (median CD4 count 102, 213, and 172 cells/µl in South Africa, Europe, and North America, respectively). High early mortality after starting ART in South Africa occurred mainly in patients starting ART with CD4 count <50 cells/µl. Cumulative mortality at 4 years was 16.6%, 4.7%, and 15.3% in South Africa, Europe, and North America, respectively. Mortality was initially much lower in Europe and North America than South Africa, but the differences were reduced or reversed (North America) at longer durations on ART (adjusted rate ratios 0.46, 95% CI 0.37-0.58, and 1.62, 95% CI 1.27-2.05 between 24 and 48 months on ART comparing Europe and North America to South Africa). While bias due to under-ascertainment of mortality was minimised through death registry linkage, residual bias could still be present due to differing approaches to and frequency of linkage. CONCLUSIONS: After accounting for under-ascertainment of mortality, with increasing duration on ART, the mortality rate on HIV treatment in South Africa declines to levels comparable to or below those described in participating North American cohorts, while substantially narrowing the differential with the European cohorts. Please see later in the article for the Editors' Summary.

Mental health impact of COVID-19 on healthcare workers versus adults in Africa.

BACKGROUND: This review mapped the impact of the coronavirus disease 2019 (COVID-19) pandemic on the mental health of healthcare workers (HCWs) and the adult general population in Africa. AIM: The study focussed on anxiety, depression, post-traumatic stress disorder and suicide cases to determine the impact of COVID-19 on the mental health of the selected population. METHOD: A scoping review was conducted on relevant database and search engines. The search resulted in 143 studies. Five studies met the inclusion criteria for synthesis. RESULTS: Results indicated anxiety was more prevalent among HCWs as opposed to the adult general population, which was in the rise of suicide cases. Among HCWs, mental health was negatively impacted by the loss of their infected patients and concerns over infecting family members. The adult general population was impacted because of isolation and their fear of contracting the virus. CONCLUSION: The COVID-19 pandemic led to the increase of mental health issues among HCWs as evidenced by a high prevalence of anxiety compared to that of the adult general population. There was, however, a rise in depression and suicide cases among the adult general population.Contribution: This study will assist in adding more knowledge to build a robust and responsive strategy to mental health problems during and post-pandemics like COVID-19. Strategies that have appeared effective in combatting the impact of COVID-19 on mental health include support packages established for frontline HCWs such as social media online chat groups.

When to start antiretroviral therapy in children aged 2-5 years: a collaborative causal modelling analysis of cohort studies from southern Africa.

BACKGROUND: There is limited evidence on the optimal timing of antiretroviral therapy (ART) initiation in children 2-5 y of age. We conducted a causal modelling analysis using the International Epidemiologic Databases to Evaluate AIDS-Southern Africa (IeDEA-SA) collaborative dataset to determine the difference in mortality when starting ART in children aged 2-5 y immediately (irrespective of CD4 criteria), as recommended in the World Health Organization (WHO) 2013 guidelines, compared to deferring to lower CD4 thresholds, for example, the WHO 2010 recommended threshold of CD4 count <750 cells/mm(3) or CD4 percentage (CD4%) <25%. METHODS AND FINDINGS: ART-naïve children enrolling in HIV care at IeDEA-SA sites who were between 24 and 59 mo of age at first visit and with ≥1 visit prior to ART initiation and ≥1 follow-up visit were included. We estimated mortality for ART initiation at different CD4 thresholds for up to 3 y using g-computation, adjusting for measured time-dependent confounding of CD4 percent, CD4 count, and weight-for-age z-score. Confidence intervals were constructed using bootstrapping. The median (first; third quartile) age at first visit of 2,934 children (51% male) included in the analysis was 3.3 y (2.6; 4.1), with a median (first; third quartile) CD4 count of 592 cells/mm(3) (356; 895) and median (first; third quartile) CD4% of 16% (10%; 23%). The estimated cumulative mortality after 3 y for ART initiation at different CD4 thresholds ranged from 3.4% (95% CI: 2.1-6.5) (no ART) to 2.1% (95% CI: 1.3%-3.5%) (ART irrespective of CD4 value). Estimated mortality was overall higher when initiating ART at lower CD4 values or not at all. There was no mortality difference between starting ART immediately, irrespective of CD4 value, and ART initiation at the WHO 2010 recommended threshold of CD4 count <750 cells/mm(3) or CD4% <25%, with mortality estimates of 2.1% (95% CI: 1.3%-3.5%) and 2.2% (95% CI: 1.4%-3.5%) after 3 y, respectively. The analysis was limited by loss to follow-up and the unavailability of WHO staging data. CONCLUSIONS: The results indicate no mortality difference for up to 3 y between ART initiation irrespective of CD4 value and ART initiation at a threshold of CD4 count <750 cells/mm(3) or CD4% <25%, but there are overall higher point estimates for mortality when ART is initiated at lower CD4 values. Please see later in the article for the Editors' Summary.

Effects of COVID-19 on malaria elimination initiatives in sub-Saharan Africa: a scoping review protocol.

INTRODUCTION: The occurrence of the COVID-19 pandemic significantly impacted health systems, resulting in varied outcomes of different variables in terms of health. Due to the nature of the causative organism that is spread mainly in the air, the disease rapidly spread to numerous countries, leading to a series of mitigation measures being proposed and implemented, including but not limited to travel restrictions, decongesting and in some instances closure of workplaces and schools and banning of social gatherings. This could have negatively impacted implementing strategies meant to ensure the effective management of malaria, hoping to eliminate it in different countries in sub-Saharan Africa (SSA). This review seeks to explore the effect of the COVID-19 pandemic on malaria elimination initiatives in SSA. METHODS AND ANALYSIS: An exploratory scoping review will be conducted on literature (searched using keywords and a search strategy) sources published in English on Web of Science, Cochrane Library, PUBMED, Dimensions, ProQuest, Scopus and African Journals Online. These would then be imported to Rayyan Software for screening for possible inclusion. The JBI Guidelines on Reviews, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist would guide the data collection, extraction and analysis from the accessed literature. Furthermore, charting, trends and developing themes would ensure the findings are presented comprehensively and yet understandable. The data collection and analysis process leading to the final submission of a review paper to a journal will be conducted from September 2023 to February 2024. ETHICS AND DISSEMINATION: An application for ethical approval was lodged with the Health Sciences Research Ethics Committee at the University of the Free State in Bloemfontein, South Africa. This ethics committee granted ethics clearance (ethics number: UFS-HSD2022/1754). Results will be communicated through peer-reviewed publications, presentations, conferences, workshops and other means and forums to reach the critical stakeholders.

Knowledge of HIV and/or AIDS and HIV testing services among young men in South Africa.

BACKGROUND: The youth is at a heightened risk of immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV and/or AIDS) infection because of risk-taking behaviour. There remains a gap in understanding young men's knowledge of HIV and/or AIDS and HIV testing services (HTS) in hard-to-reach communities in South Africa. AIM: This article aimed to explore young men's knowledge of HIV and/or AIDS, including HTS in Ladysmith, KwaZulu-Natal (KZN). SETTING: Rural and peri-urban areas around the town of Ladysmith. METHODS: Employing a qualitative descriptive research design, 17 young men aged between 18 and 30 years were purposively and conveniently sampled and interviewed using WhatsApp and landline audio calls to collect their data, which was thematically analysed. RESULTS: Young men had good knowledge of HIV and/or AIDS but lacked knowledge about HTS and HIV self-testing (HIVST). They obtained their information about HIV and/or AIDS and HTS from various sources and were aware of where to access HTS. They were generally unaware and supportive of HIVST. CONCLUSION: Male-targeted HIV and/or AIDS knowledge and testing interventions are needed to encourage and support young men to test for HIV. Human immunodeficiency virus self-testing should be explored as an alternative to clinic-based service to encourage young men to know their status, specifically those with limited access to or are reluctant to attend clinics. Strengthening HIV and/or AIDS education could facilitate better decision-making towards HIV testing among young men.Contribution: This study contributes to an understanding of young adult men's knowledge of HIV and/or AIDS and HTS in underserved settings in South Africa.

Long-term effects of aromatase inhibitors on body mass index among postmenopausal breast cancer survivors in Africa: observational cohort study.

PURPOSE: this study was conducted to assess the impact of AIs on body mass index and high sensitivity as prognostic predictors to be incorporated into point of care technology (POCT) testing in postmenopausal breast cancer women after a 24 month follow up in Africa. An observational cohort study was conducted; including 126 female BC patients with stages ranging from 0-III initially subjected to AIs and subsequently followed up for 24 months. Multiple imputation model was conducted to predict missing data. RESULTS: Random effects model was used to monitor the changes over the time. The study revealed stronger statistically association between BMI and homocysteine (p = 0.021, 95%CI: 0.0083 to 0.1029). Weight and total body fat were strongly associated after 24 months follow up. Hs-CRP was associated with BMI (p = 0.0001), and hs-CRP was associated with other biomedical markers such as calcium (p = 0.021, 95% CI: 0.01 to 0.10), phosphate (p = 0.039, 95%CI: 0.01 to 0.10), and ferritin (p = 0.002, 95%CI: 0.02 to 0.08) and calcium. The patients subjected to AIs are likely to develop cardiovascular adverse events. POCT of care strategy which include clinical, biomedical and genetic predictor's measurement is required to improve BC survivorship.

Maternal HIV infection associated with small-for-gestational age infants but not preterm births: evidence from rural South Africa.

BACKGROUND: Human immunodeficiency virus (HIV) is prevalent in many countries where small-for-gestational age (SGA) and premature delivery are also common. However, the associations between maternal HIV, preterm delivery and SGA infants remain unclear. We estimate the prevalence of SGA and preterm (<37 weeks) births, their associations with antenatal maternal HIV infection and their contribution to infant mortality, in a high HIV prevalent, rural area in South Africa. METHODS: Data were collected, in a non-randomized intervention cohort study, on all women attending antenatal clinics (2001-2004), before the availability of antiretroviral treatment. Newborns were weighed and gestational age was determined (based on last menstrual period plus midwife assessment antenatally). Poisson regression with robust variance assessed risk factors for preterm and SGA birth, while Cox regression assessed infant mortality and associated factors. RESULTS: Of 2368 live born singletons, 16.6% were SGA and 21.4% were preterm. HIV-infected women (n= 1189) more commonly had SGA infants than uninfected women (18.1 versus 15.1%; P = 0.051), but percentages preterm were similar (21.8 versus 20.9%; P = 0.621). After adjustment for water source, delivery place, parity and maternal height, the SGA risk in HIV-infected women was higher [adjusted relative risk (aRR) 1.28, 95% confidence interval (CI): 1.06-1.53], but the association between maternal HIV infection and preterm delivery remained weak and not significant (aRR: 1.07, 95% CI: 0.91-1.26). In multivariable analyses, mortality under 1 year of age was significantly higher in SGA and severely SGA than in appropriate-for-gestational-age infants [adjusted hazard ratio (aHR): 2.12, 95% CI: 1.18-3.81 and 2.77, 95% CI: 1.56-4.91], but no difference in infant mortality was observed between the preterm and term infants (aHR: 1.18 95% CI: 0.79-1.79 for 34-36 weeks and 1.31, 95% CI: 0.58-2.94 for <34 weeks). CONCLUSIONS: Maternal HIV infection increases the risk of SGA, but not preterm births, in this cohort.

Feasibility of point of care testing for prevention and management of breast cancer therapy associated comorbidities in 6 African countries: short communication.

OBJECTIVE: Obesity and mediators of inflammation have been identified as the most important risk and predictive factors in postmenopausal breast cancer (BC) survivors using aromatase inhibitors (AIs). This study was conducted to assess the impact of point of care technology (PCOT) as part of pathology supported genetic testing (PSGT) to prevent BC therapy-associated comorbidities in African settings. RESULTS: The study revealed that high sensitivity C-reactive protein (hs-CRP) and body mass index (BMI) are predictors of cardiovascular (CVD) related adverse events in obese postmenopausal patients subjected to AIs. There were statistically significant variations in total body fat (TBF), weight, hs-CRP, body mass index (BMI), homocysteine, ferritin, and calcium between baseline and after 24 months of follow-up. The above inflammatory markers can be incorporated in pathology supported genetic testing (PSGT) using HyBeacon® probe technology at POC for prediction and management of AI-associated adverse events among postmenopausal breast cancer survivors and associated comorbidities. The barriers for implementation of POCT application among six African countries for diagnosis of breast cancer were documented as insufficient of BC diagnosis and management capacity at different levels of health system.

Validating child vaccination status in a demographic surveillance system using data from a clinical cohort study: evidence from rural South Africa.

BACKGROUND: Childhood vaccination coverage can be estimated from a range of sources. This study aims to validate vaccination data from a longitudinal population-based demographic surveillance system (DSS) against data from a clinical cohort study. METHODS: The sample includes 821 children in the Vertical Transmission cohort Study (VTS), who were born between December 2001 and April 2005, and were matched to the Africa Centre DSS, in northern KwaZulu-Natal. Vaccination information in the surveillance was collected retrospectively, using standardized questionnaires during bi-annual household visits, when the child was 12 to 23 months of age. DSS vaccination information was based on extraction from a vaccination card or, if the card was not available, on maternal recall. In the VTS, vaccination data was collected at scheduled maternal and child clinic visits when a study nurse administered child vaccinations. We estimated the sensitivity of the surveillance in detecting vaccinations conducted as part of the VTS during these clinic visits. RESULTS: Vaccination data in matched children in the DSS was based on the vaccination card in about two-thirds of the cases and on maternal recall in about one-third. The sensitivity of the vaccination variables in the surveillance was high for all vaccines based on either information from a South African Road-to-Health (RTH) card (0.94-0.97) or maternal recall (0.94-0.98). Addition of maternal recall to the RTH card information had little effect on the sensitivity of the surveillance variable (0.95-0.97). The estimates of sensitivity did not vary significantly, when we stratified the analyses by maternal antenatal HIV status. Addition of maternal recall of vaccination status of the child to the RTH card information significantly increased the proportion of children known to be vaccinated across all vaccines in the DSS. CONCLUSION: Maternal recall performs well in identifying vaccinated children aged 12-23 months (both in HIV-infected and HIV-uninfected mothers), with sensitivity similar to information extracted from vaccination cards. Information based on both maternal recall and vaccination cards should be used if the aim is to use surveillance data to identify children who received a vaccination.

Levels of childhood vaccination coverage and the impact of maternal HIV status on child vaccination status in rural KwaZulu-Natal, South Africa*.

OBJECTIVES: To analyse coverage of childhood vaccinations in a rural South African population and investigate whether maternal HIV status is associated with children's vaccination status. METHODS: 2 431 children with complete information, 12-23 months of age at some point during the period January 2005 through December 2006 and resident in the Africa Centre Demographic Surveillance Area at the time of their birth were investigated. We examined the relationship between maternal HIV status and child vaccination status for five vaccinations [Bacillus Calmette-Guérin (BCG), diphtheria-tetanus-pertussis (DTP3), poliomyelitis (polio3), hepatitis B (HepB3), and measles] in multiple logistic regressions, controlling for household wealth, maternal age, maternal education and distances to roads, fixed and mobile clinics. RESULTS: Coverage of the five vaccinations ranged from 89.3% (95% CI 81.7-93.9) for BCG to 77.3% (67.1-83.6) for measles. Multivariably, maternal HIV-positive status was significantly associated with lower adjusted odds ratios (AOR) of child vaccination for all vaccines [(AOR) 0.60-0.74, all P < or = 0.036] except measles (0.75, P = 0.073), distance to mobile clinic was negatively associated with vaccination status (all P < or = 0.029), household wealth was positively (all P < or = 0.013) and distance to nearest road negatively (all P < or = 0.004) associated with vaccination status. CONCLUSION: Positive maternal HIV status independently reduces children's probability to receive child vaccinations, which likely contributes to the morbidity and mortality differential between children of HIV-positive and HIV-negative mothers. As a means of increasing vaccination coverage, policy makers should consider increasing the number of mobile clinics in this and similar communities in rural Africa.

Growth in Virologically Suppressed HIV-Positive Children on Antiretroviral Therapy: Individual and Population-level References.

BACKGROUND: Combination antiretroviral therapy (ART) suppresses viral replication in HIV-infected children. The growth of virologically suppressed children on ART has not been well documented. We aimed to develop dynamic reference curves for weight-for-age Z scores (WAZ) and height-for-age Z scores (HAZ). METHODS: Children aged <11 years at ART initiation with continuously undetectable viral loads (<400 copies/mL) treated at 7 South African ART programs with routine viral load monitoring were included. We used multilevel models to define trajectories of WAZ and HAZ up to 3 years and developed a web application to monitor trajectories in individual children. RESULTS: A total of 4876 children were followed for 7407 person-years. Analyses were stratified by baseline Z scores and age, which were the most important predictors of growth response. The youngest children showed the most pronounced increase in weight and height initially but catch-up growth stagnated after 1-2 years. Three years after starting ART, WAZ ranged from -2.2 [95% prediction interval (PrI), -5.6 to 0.8] in children with baseline age >5 years and Z score less than -3 to 0.0 (95% PrI, -2.7 to 2.4) in children with baseline age <2 years and WAZ greater than -1. For HAZ, the corresponding range was -2.3 (95% PrI, -4.9 to 0.3) in children with baseline age >5 years and Z score less than -3 to 0.3 (95% PrI, -3.1 to 3.4) in children with baseline age 2-5 years and HAZ greater than -1. CONCLUSIONS: We have developed an online tool to calculate reference trajectories in fully suppressed children. The web application could help to define "optimal" growth response and identify children with treatment failure.

Prognosis of children with HIV-1 infection starting antiretroviral therapy in Southern Africa: a collaborative analysis of treatment programs.

BACKGROUND: Prognostic models for children starting antiretroviral therapy (ART) in Africa are lacking. We developed models to estimate the probability of death during the first year receiving ART in Southern Africa. METHODS: We analyzed data from children ≤10 years of age who started ART in Malawi, South Africa, Zambia or Zimbabwe from 2004 to 2010. Children lost to follow up or transferred were excluded. The primary outcome was all-cause mortality in the first year of ART. We used Weibull survival models to construct 2 prognostic models: 1 with CD4%, age, World Health Organization clinical stage, weight-for-age z-score (WAZ) and anemia and the other without CD4%, because it is not routinely measured in many programs. We used multiple imputation to account for missing data. RESULTS: Among 12,655 children, 877 (6.9%) died in the first year of ART. We excluded 1780 children who were lost to follow up/transferred from main analyses; 10,875 children were therefore included. With the CD4% model probability of death at 1 year ranged from 1.8% [95% confidence interval (CI): 1.5-2.3] in children 5-10 years with CD4% ≥10%, World Health Organization stage I/II, WAZ ≥ -2 and without severe anemia to 46.3% (95% CI: 38.2-55.2) in children <1 year with CD4% < 5%, stage III/IV, WAZ< -3 and severe anemia. The corresponding range for the model without CD4% was 2.2% (95% CI: 1.8-2.7) to 33.4% (95% CI: 28.2-39.3). Agreement between predicted and observed mortality was good (C-statistics = 0.753 and 0.745 for models with and without CD4%, respectively). CONCLUSIONS: These models may be useful to counsel children/caregivers, for program planning and to assess program outcomes after allowing for differences in patient disease severity characteristics.

Exclusive breastfeeding, diarrhoeal morbidity and all-cause mortality in infants of HIV-infected and HIV uninfected mothers: an intervention cohort study in KwaZulu Natal, South Africa.

INTRODUCTION: Antiretroviral drug interventions significantly reduce the risk of HIV transmission to infants through breastfeeding. We report diarrhoea prevalence and all-cause mortality at 12 months of age according to infant feeding practices, among infants born to HIV-infected and uninfected mothers in South Africa. METHODS: A non-randomised intervention cohort study that followed both HIV-infected and HIV-uninfected mothers and their infants until 18 months of age. Mothers were supported in their infant feeding choice. Detailed morbidity and vital status data were collected over the first year. At the time, only single dose nevirapine was available to prevent mother-to-child transmission of HIV. RESULTS: Among 2,589 infants, detailed feeding data and vital status were available for 1,082 HIV-exposed infants and 1,155 HIV non-exposed infants. Among exclusively breastfed (EBF) infants there were 9.4 diarrhoeal days per 1,000 child days (95%CI. 9.12-9.82) while among infants who were never breastfed there were 15.6 diarrhoeal days per 1,000 child days (95%CI. 14.62-16.59). Exclusive breastfeeding was associated with fewer acute, persistent and total diarrhoeal events than mixed or no breastfeeding in both HIV-exposed infants and also infants of HIV uninfected mothers. In an adjusted cox regression analysis, the risk of death among all infants by 12 months of age was significantly greater in those who were never breastfed (aHR 3.5, p<0.001) or mixed fed (aHR 2.65, p<0.001) compared with those who were EBF. In separate multivariable analyses, infants who were EBF for shorter durations had an increased risk of death compared to those EBF for 5-6 months [aHR 2.18 (95% CI, 1.56-3.01); p<0.001]. DISCUSSION: In the context of antiretroviral drugs being scaled-up to eliminate new HIV infections among children, there is strong justification for financial and human resource investment to promote and support exclusive breastfeeding to improve HIV-free survival of HIV-exposed and non-exposed infants.

Temporal trends in the characteristics of children at antiretroviral therapy initiation in southern Africa: the IeDEA-SA Collaboration.

BACKGROUND: Since 2005, increasing numbers of children have started antiretroviral therapy (ART) in sub-Saharan Africa and, in recent years, WHO and country treatment guidelines have recommended ART initiation for all infants and very young children, and at higher CD4 thresholds for older children. We examined temporal changes in patient and regimen characteristics at ART start using data from 12 cohorts in 4 countries participating in the IeDEA-SA collaboration. METHODOLOGY/PRINCIPAL FINDINGS: Data from 30,300 ART-naïve children aged <16 years at ART initiation who started therapy between 2005 and 2010 were analysed. We examined changes in median values for continuous variables using the Cuzick's test for trend over time. We also examined changes in the proportions of patients with particular disease severity characteristics (expressed as a binary variable e.g. WHO Stage III/IV vs I/II) using logistic regression. Between 2005 and 2010 the number of children starting ART each year increased and median age declined from 63 months (2006) to 56 months (2010). Both the proportion of children <1 year and ≥10 years of age increased from 12 to 19% and 18 to 22% respectively. Children had less severe disease at ART initiation in later years with significant declines in the percentage with severe immunosuppression (81 to 63%), WHO Stage III/IV disease (75 to 62%), severe anemia (12 to 7%) and weight-for-age z-score<-3 (31 to 28%). Similar results were seen when restricting to infants with significant declines in the proportion with severe immunodeficiency (98 to 82%) and Stage III/IV disease (81 to 63%). First-line regimen use followed country guidelines. CONCLUSIONS/SIGNIFICANCE: Between 2005 and 2010 increasing numbers of children have initiated ART with a decline in disease severity at start of therapy. However, even in 2010, a substantial number of infants and children started ART with advanced disease. These results highlight the importance of efforts to improve access to HIV diagnostic testing and ART in children.

National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010.

BACKGROUND: National estimates for the numbers of babies born small for gestational age and the comorbidity with preterm birth are unavailable. We aimed to estimate the prevalence of term and preterm babies born small for gestational age (term-SGA and preterm-SGA), and the relation to low birthweight (<2500 g), in 138 countries of low and middle income in 2010. METHODS: Small for gestational age was defined as lower than the 10th centile for fetal growth from the 1991 US national reference population. Data from 22 birth cohort studies (14 low-income and middle-income countries) and from the WHO Global Survey on Maternal and Perinatal Health (23 countries) were used to model the prevalence of term-SGA births. Prevalence of preterm-SGA infants was calculated from meta-analyses. FINDINGS: In 2010, an estimated 32·4 million infants were born small for gestational age in low-income and middle-income countries (27% of livebirths), of whom 10·6 million infants were born at term and low birthweight. The prevalence of term-SGA babies ranged from 5·3% of livebirths in east Asia to 41·5% in south Asia, and the prevalence of preterm-SGA infants ranged from 1·2% in north Africa to 3·0% in southeast Asia. Of 18 million low-birthweight babies, 59% were term-SGA and 41% were preterm-SGA. Two-thirds of small-for-gestational-age infants were born in Asia (17·4 million in south Asia). Preterm-SGA babies totalled 2·8 million births in low-income and middle-income countries. Most small-for-gestational-age infants were born in India, Pakistan, Nigeria, and Bangladesh. INTERPRETATION: The burden of small-for-gestational-age births is very high in countries of low and middle income and is concentrated in south Asia. Implementation of effective interventions for babies born too small or too soon is an urgent priority to increase survival and reduce disability, stunting, and non-communicable diseases. FUNDING: Bill & Melinda Gates Foundation by a grant to the US Fund for UNICEF to support the activities of the Child Health Epidemiology Reference Group (CHERG).

Treating HIV-infected mothers reduces under 5 years of age mortality rates to levels seen in children of HIV-uninfected mothers in rural South Africa.

BACKGROUND: Maternal and child survival are highly correlated, but the contribution of HIV infection on this relationship, and in particular the effect of HIV treatment, has not been quantified. We estimate the association between maternal HIV and treatment, and under 5 years of age (under-5) child mortality in a rural population in South Africa. METHODS: All children born between January 2000 and January 2007 in the Africa Centre Demographic Surveillance Area were included. Maternal HIV status information was available from HIV surveillance; maternal antiretroviral treatment (ART) information from the HIV Treatment Programme database was linked to surveillance data. Mortality rates were computed as deaths per 1,000 person-years observed. Time-varying maternal HIV effect (positive, negative, ART) on under-5 mortality was assessed in Cox regression, adjusting for other factors associated with under-5 mortality. RESULTS: In total, 9,068 mothers delivered 12,052 children, of whom 947 (7.9%) died before age 5. Infant mortality rate declined by 49% from 69.0 in 2000 to 35.5 in 2006 deaths per 1,000 person-years observed; a significant decline was observed post-ART (2004-2006). The estimated proportion of deaths across all age groups were higher among the children born to the HIV-positive and HIV-not-reported status women than among children of HIV-negative women. Multivariably, mortality in children of mothers on ART was not significantly different from children of HIV-negative mothers (adjusted hazard ratio 1.29, 0.53-3.17; P=0.572). CONCLUSIONS: These findings highlight the importance of maternal HIV treatment with direct benefits of improved survival among all children under-5. Timely HIV treatment for eligible women is required to benefit both mothers and children.

Cell-free (RNA) and cell-associated (DNA) HIV-1 and postnatal transmission through breastfeeding.

INTRODUCTION: Transmission through breastfeeding remains important for mother-to-child transmission (MTCT) in resource-limited settings. We quantify the relationship between cell-free (RNA) and cell-associated (DNA) shedding of HIV-1 virus in breastmilk and the risk of postnatal HIV-1 transmission in the first 6 months postpartum. MATERIALS AND METHODS: Thirty-six HIV-positive mothers who transmitted HIV-1 by breastfeeding were matched to 36 non-transmitting HIV-1 infected mothers in a case-control study nested in a cohort of HIV-infected women. RNA and DNA were quantified in the same breastmilk sample taken at 6 weeks and 6 months. Cox regression analysis assessed the association between cell-free and cell-associated virus levels and risk of postnatal HIV-1 transmission. RESULTS: There were higher median levels of cell-free than cell-associated HIV-1 virus (per ml) in breastmilk at 6 weeks and 6 months. Multivariably, adjusting for antenatal CD4 count and maternal plasma viral load, at 6 weeks, each 10-fold increase in cell-free or cell-associated levels (per ml) was significantly associated with HIV-1 transmission but stronger for cell-associated than cell-free levels [2.47 (95% CI 1.33-4.59) vs. aHR 1.52 (95% CI, 1.17-1.96), respectively]. At 6 months, cell-free and cell-associated levels (per ml) in breastmilk remained significantly associated with HIV-1 transmission but was stronger for cell-free than cell-associated levels [aHR 2.53 (95% CI 1.64-3.92) vs. 1.73 (95% CI 0.94-3.19), respectively]. CONCLUSIONS: The findings suggest that cell-associated virus level (per ml) is more important for early postpartum HIV-1 transmission (at 6 weeks) than cell-free virus. As cell-associated virus levels have been consistently detected in breastmilk despite antiretroviral therapy, this highlights a potential challenge for resource-limited settings to achieve the UNAIDS goal for 2015 of eliminating vertical transmission. More studies would further knowledge on mechanisms of HIV-1 transmission and help develop more effective drugs during lactation.

Epidemic cholera in Kakuma Refugee Camp, Kenya, 2009: the importance of sanitation and soap.

INTRODUCTION: Cholera remains a major public health problem that causes substantial morbidity and mortality in displaced populations due to inadequate or unprotected water supplies, poor sanitation and hygiene, overcrowding, and limited resources. A cholera outbreak with 224 cases and four deaths occurred in Kakuma Refugee Camp in Kenya from September to December 2009. METHODOLOGY: We conducted a case-control study to characterize the epidemiology of the outbreak. Cases were identified by reviewing the hospital registry for patients meeting the World Health Organization (WHO) case definition for cholera. For each case a matched control was selected. A questionnaire focusing on potential risk factors was administered to cases and controls. RESULTS: From 18 September to 15 December 2009, a total of 224 cases were identified and were hospitalised at Kakuma IRC hospital.  Three refugees and one Kenyan national died of cholera. V. cholerae O1, serotype Inaba was isolated in 44 (42%) out of 104 stool specimens collected. A total of 93 cases and 93 matched controls were enrolled in the study. In a multivariate model, washing hands with soap was protective against cholera (adjusted odds ratio [AOR] =0.25[0.09-0.71]; p < 0.01), while presence of dirty water storage containers was a risk factor (AOR=4.39[1.12-17.14]; p=0.03). CONCLUSION: Provision of soap, along with education on hand hygiene and cleaning water storage containers, may be an affordable intervention to prevent cholera.