Tocilizumab in Patients Hospitalized with Covid-19 Pneumonia.

BACKGROUND: Coronavirus disease 2019 (Covid-19) pneumonia is often associated with hyperinflammation. Despite the disproportionate incidence of Covid-19 among underserved and racial and ethnic minority populations, the safety and efficacy of the anti-interleukin-6 receptor antibody tocilizumab in patients from these populations who are hospitalized with Covid-19 pneumonia are unclear. METHODS: We randomly assigned (in a 2:1 ratio) patients hospitalized with Covid-19 pneumonia who were not receiving mechanical ventilation to receive standard care plus one or two doses of either tocilizumab (8 mg per kilogram of body weight intravenously) or placebo. Site selection was focused on the inclusion of sites enrolling high-risk and minority populations. The primary outcome was mechanical ventilation or death by day 28. RESULTS: A total of 389 patients underwent randomization, and the modified intention-to-treat population included 249 patients in the tocilizumab group and 128 patients in the placebo group; 56.0% were Hispanic or Latino, 14.9% were Black, 12.7% were American Indian or Alaska Native, 12.7% were non-Hispanic White, and 3.7% were of other or unknown race or ethnic group. The cumulative percentage of patients who had received mechanical ventilation or who had died by day 28 was 12.0% (95% confidence interval [CI], 8.5 to 16.9) in the tocilizumab group and 19.3% (95% CI, 13.3 to 27.4) in the placebo group (hazard ratio for mechanical ventilation or death, 0.56; 95% CI, 0.33 to 0.97; P = 0.04 by the log-rank test). Clinical failure as assessed in a time-to-event analysis favored tocilizumab over placebo (hazard ratio, 0.55; 95% CI, 0.33 to 0.93). Death from any cause by day 28 occurred in 10.4% of the patients in the tocilizumab group and 8.6% of those in the placebo group (weighted difference, 2.0 percentage points; 95% CI, -5.2 to 7.8). In the safety population, serious adverse events occurred in 38 of 250 patients (15.2%) in the tocilizumab group and 25 of 127 patients (19.7%) in the placebo group. CONCLUSIONS: In hospitalized patients with Covid-19 pneumonia who were not receiving mechanical ventilation, tocilizumab reduced the likelihood of progression to the composite outcome of mechanical ventilation or death, but it did not improve survival. No new safety signals were identified. (Funded by Genentech; EMPACTA ClinicalTrials.gov number, NCT04372186.).

Clinical presentation and outcomes of care in adults with diabetic ketoacidosis pre-COVID-19 and during-COVID-19 at a tertiary, referral hospital in Nairobi, Kenya.

BACKGROUND: Prognosis of DKA has improved over time with the availability of evidence-based protocols and resources. However, in Kenya, there are limited resources for the appropriate diagnosis and management of DKA, mostly limited to tertiary-level referral facilities. This study aimed to review the clinical presentation, management, and outcomes of adult patients admitted with DKA and assess differences in these parameters before and during the COVID-19 pandemic. METHODS: This was a retrospective study of DKA admissions from January 2017 to December 2021. Patient data were retrieved from the medical records department using ICD-10 codes, and individual details were abstracted on clinical presentation, management, and outcomes of DKA. Comparisons were made between pre-COVID-19 and during COVID-19 durations. RESULTS: 150 patients admitted with DKA were included (n = 48 pre- COVID-19, n = 102 during COVID-19 (n = 23 COVID-19 positive, n = 79 COVID-19 negative)). Median age was 47 years (IQR 33.0, 59.0), median HbA1C was 12.4% [IQR 10.8, 14.6]), and most patients had severe DKA (46%). Most common DKA precipitants were infections (40.7%), newly diagnosed diabetes (33.3%) and missed medication (25.3%). There was a significant difference in pulmonary infections as a DKA precipitant, between the pre- COVID and during COVID-19 pandemic (21.6% during COVID-19 versus 6.3% pre- COVID-19; p = 0.012). Median total insulin dose used was 110.0 units [IQR 76.0, 173.0], and a 100% of patients received basal insulin. Median length of hospital stay was 4.0 days [IQR 3.0, 6.0] and time to DKA resolution was 30.0 h [IQR 24.0, 48.0]. There were 2 deaths (1.3%), none directly attributable to DKA. Severity of DKA significantly differed between pre- COVID-19, COVID-19 positive and COVID-19 negative DKA (52.2% of COVID-19 positive had moderate DKA compared to 26.6% of COVID-19 negative and 22.9% of Pre-COVID-19 (p = 0.006)). CONCLUSION: Even in developing regions, good outcomes can be achieved with the appropriate facilities for DKA management. Clinician and patient education is necessary to ensure early detection and prompt referral to avoid patients presenting with severe DKA. Exploratory studies are needed to assess reasons for prolonged time to DKA resolution found in this study.

British Association of Dermatologists guidelines for the management of adults with delusional infestation 2022.

The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for the management of delusional infestation (DI) in adults. Linked Comment: I. Coulson. Br J Dermatol 2022; 187:457.

Exploring the Psychological Profile of Patients with Delusional Infestation.

Delusional infestation (DI) is an uncommon psychiatric disorder in which patients present with the false and fixed belief (i.e. a delusion) that their skin and/or their environment is infested despite objective evidence to the contrary. Within psychodermatology specialist clinics there is a high rate of DI referrals. What is not known is the level of psychiatric and psychological co-morbidities associated with DI and whether psychiatric or psychological assessment would be warranted. One-hundred and thirty-eight adult patients with DI attending an outpatient psychodermatology clinic were given 3 standardised questionnaires. The results showed that 81% had a poor quality of life; 52% with anxiety, 41.6% with depression and 49% with appearance-related concerns. This study indicates high levels of psychiatric and psychological disorders in DI which require assessment and appropriate intervention.

Primum non nocere: how active management became modus operandi for intrahepatic cholestasis of pregnancy.

The Royal College of Obstetrics and Gynecology does not endorse routine active management of intrahepatic cholestasis of pregnancy (ICP)-affected pregnancies. In contrast, the American College of Obstetricians and Gynecologists supports active management protocols for ICP. To investigate this controversy, we evaluated the evidence supporting ICP as a medical indication for early term delivery and the evolution of active management protocols for ICP. Sixteen articles published between 1986 and 2011 were identified. We created 2 groups based on whether obstetric care included active management. Group 1 comprised 6 uncontrolled reports without active management that were published between 1967 and 1983 that described high perinatal mortality rates that primarily were related to prematurity sequel. This group became the fundamental 'core' evidence for ICP-associated stillbirths and by extrapolation justification for active management. Group 2 was comprised of 10 reports in which the authors credited empirically adopted active management with the observed low stillbirth rates in ICP-affected pregnancies. Although the group 1 articles routinely are cited as evidence of ICP-associated stillbirth risk, the 1.2% stillbirth rate (4/331) in this group is similar to the background stillbirth rates of 1.1% (11/1000) and 0.6% (6/1000) in 1967 and 2011, respectively (P = .062 and P = .0614, respectively). Likewise, the stillbirth rates for articles in group 2 were similar to their respective national stillbirth rate. Nevertheless, group 2 articles have become the evidence-based support for active management. We found no evidence to support the practice of active management for ICP.

HIV-1 progression links with viral genetic variability and subtype, and patient's HLA type: analysis of a Nairobi-Kenyan cohort.

In a Nairobi-Kenyan cohort of 50 HIV-1 positive patients, we analysed the prevalence of HIV-1 subtypes and human leucocyte antigen (HLA) alleles. From this cohort, 33 patients were selected for the analysis of HIV-1 infection progression markers (i.e. CD4 cell counts and viral loads) and their association with HIV-1 genetic variability and subtype, and patient's HLA type. HIV-1 gag genetic variability, analysed using bioinformatics tools, showed an inverse relationship with CD4 cell count whereas with viral load that relationship was direct. Certain HLA types and viral subtypes were also found to associate with patients' viral load. Associations between disease parameters and the genetic makeup of the host and virus may be crucial in determining the outcome of HIV-1 infection.

Surgical site infections post cesarean section and associated risk factors: a retrospective case-control study at a tertiary hospital in Kenya.

Background: Surgical site infection is a common healthcare-associated infection that affects maternal health, yet it can be prevented or controlled. Caesarian sections are most likely to develop surgical site infections. The rates of delivery by caesarian section in reported to be higher that the acceptable rates in some healthcare facilities. Risk factors for surgical site infections can be identified and modified to reduce the occurrence of surgical site infections. This study aims to determine the risk factors that contribute to surgical site infections post caesarian section in a tertiary teaching hospital in Kenya. Methods: This was a retrospective case-control (1:2 matched) study conducted between 1st November 2021 to 31st October 2022 at a tertiary hospital in Nairobi. Data was extracted on surgical site risk factors as per World Health Organization's recommended preoperative measures, for both cases and controls. Descriptive statistics was used to summarize the variables and the Chi-squared test and Fisher's Exact test were used for group comparisons. Results: A total of 1,262 caesarian deliveries were performed, 2.1% (27/1262) of which developed surgical site infections post caesarian section. The risk factors identified were not significantly associated with surgical site infection development (gestational age P=0.152, body mass index P=0.615, premature rupture of membranes P=0.253, and antibiotic prophylaxis P=0.108). Conclusions: There was no significant association of exposure to surgical site infection risk factors with surgical site infection despite a positive trend. Other prospective methods should also be used in addition to chart reviews to determine the level of effect each risk factor has on surgical site infection.

Switch to long-acting cabotegravir and rilpivirine in virologically suppressed adults with HIV in Africa (CARES): week 48 results from a randomised, multicentre, open-label, non-inferiority trial.

BACKGROUND: Long-acting injectable cabotegravir and rilpivirine is licensed for individualised treatment of HIV-1 infection in resource-rich settings. Additional evidence is required to support use in African treatment programmes where demographic factors, viral subtypes, previous treatment, and delivery and monitoring approaches differ. The aim of this study was to determine whether switching to long-acting therapy with injections every 8 weeks is non-inferior to daily oral therapy in Africa. METHODS: CARES is a randomised, open-label, non-inferiority trial being conducted at eight sites in Uganda, Kenya, and South Africa. Participants with HIV viral load below 50 copies per mL on oral antiretroviral therapy and no history of virological failure were randomly assigned (1:1; web-based, permuted blocks) to receive cabotegravir (600 mg) and rilpivirine (900 mg) by intramuscular injection every 8 weeks, or to continue oral therapy. Viral load was monitored every 24 weeks. The primary outcome was week 48 viral load below 50 copies per mL, assessed with the Food and Drug Administration snapshot algorithm (non-inferiority margin 10 percentage points) in the intention-to-treat exposed population. This trial is registered with the Pan African Clinical Trials Registry (202104874490818) and is ongoing up to 96 weeks. FINDINGS: Between Sept 1, 2021, and Aug 31, 2022, we enrolled 512 participants (295 [58%] female; 380 [74%] previous non-nucleoside reverse transcriptase inhibitor exposure). Week 48 viral load was below 50 copies per mL in 246 (96%) of 255 participants in the long-acting therapy group and 250 (97%) of 257 in the oral therapy group (difference -0·8 percentage points; 95% CI -3·7 to 2·3), demonstrating non-inferiority (confirmed in per-protocol analysis). Two participants had virological failure in the long-acting therapy group, both with drug resistance; none had virological failure in the oral therapy group. Adverse events of grade 3 or greater severity occurred in 24 (9%) participants on long-acting therapy and ten (4%) on oral therapy; one participant discontinued long-acting therapy (for injection-site reaction). INTERPRETATION: Long-acting therapy had non-inferior efficacy compared with oral therapy, with a good safety profile, and can be considered for African treatment programmes. FUNDING: Janssen.

HIV Prevalence and Characteristics Among Patients With AIDS-Defining and Non-AIDS-Defining Cancers in a Tertiary Hospital in Kenya.

PURPOSE: Antiretroviral therapy (ART) has resulted in a higher life expectancy of persons living with HIV. This has led to an aging population at risk for both non-AIDS-defining cancers (NADCs) and AIDS-defining cancers (ADCs). HIV testing among patients with cancer in Kenya is not routinely performed, making its prevalence undefined. The aim of our study was to determine the prevalence of HIV and the spectrum of malignancies among HIV-positive and HIV-negative patients with cancer attending a tertiary hospital in Nairobi, Kenya. MATERIALS AND METHODS: We conducted a cross-sectional study between February 2021 and September 2021. Patients with a histologic cancer diagnosis were enrolled. Demographic data and HIV- and cancer-related clinical variables were obtained. HIV pretest counseling and consent were done, and testing was performed using a fourth-generation assay. Positive results were confirmed using a third-generation assay. RESULTS: We enrolled 301 patients with cancer; 67.8% (204 of 301) were female; the mean age was 50.7 ± 12.5 years. From our cohort, 10.6% (95% CI, 7.4 to 14.7, n = 32 of 301) of patients were HIV-positive with the prevalence of a new HIV diagnosis of 0.7% (n = 2 of 301). Of the HIV-positive patients, 59.4% (19 of 32) had a NADC. The commonest NADC was breast cancer (18.8%; 6 of 32), whereas non-Hodgkin lymphoma (18.8%; 6 of 32) and cervical cancer (18.8%; 6 of 32) were the most prevalent ADCs among HIV-positive patients. CONCLUSION: The prevalence of HIV infection among patients with cancer was twice the Kenya national HIV prevalence. NADCs comprised a larger percentage of the cancer burden. Universal opt-out HIV testing of patients attending for cancer care regardless of cancer type may facilitate early recognition of HIV-infected patients and aid in appropriate selection of ART and cancer therapies and preventive strategies.

COVID-19 vaccination refusal trends in Kenya over 2021.

BACKGROUND: Vaccination refusal exacerbates global COVID-19 vaccination inequities. No studies in East Africa have examined temporal trends in vaccination refusal, precluding addressing refusal. We assessed vaccine refusal over time in Kenya, and characterized factors associated with changes in vaccination refusal. METHODS: We analyzed data from the Kenya Rapid Response Phone Survey (RRPS), a household cohort survey representative of the Kenyan population including refugees. Vaccination refusal (defined as the respondent stating they would not receive the vaccine if offered to them at no cost) was measured in February and October 2021. Proportions of vaccination refusal were plotted over time. We analyzed factors in vaccination refusal using a weighted multivariable logistic regression including interactions for time. FINDINGS: Among 11,569 households, vaccination refusal in Kenya decreased from 24 % in February 2021 to 9 % in October 2021. Vaccination refusal was associated with having education beyond the primary level (-4.1[-0.7,-8.9] percentage point difference (ppd)); living with somebody who had symptoms of COVID-19 in the past 14 days (-13.72[-8.9,-18.6]ppd); having symptoms of COVID-19 in the past 14 days (11.0[5.1,16.9]ppd); and distrusting the government in responding to COVID-19 (14.7[7.1,22.4]ppd). There were significant interactions with time and: refugee status and geography, living with somebody with symptoms of COVID-19, having symptoms of COVID-19, and believing in misinformation. INTERPRETATION: The temporal reduction in vaccination refusal in Kenya likely represents substantial strides by the Kenyan vaccination program and possible learnt lessons which require examination. Going forward, there are still several groups which need specific targeting to decrease vaccination refusal and improve vaccination equity, including those with lower levels of education, those with recent COVID-19 symptoms, those who do not practice personal COVID-19 mitigation measures, refugees in urban settings, and those who do not trust the government. Policy and program should focus on decreasing vaccination refusal in these populations, and research focus on understanding barriers and motivators for vaccination.

Unusual Presentation of Multisystemic Inflammatory Syndrome.

COVID-19 pneumonia in children presents with very mild symptoms through an entity of multisystem inflammatory syndrome and can result in a life-threatening hyperinflammatory condition, with involvement of at least four organ systems and a marked inflammatory state. We present an 18-year-old high school student who presented with a sore throat, macular rash, abdominal pain, diarrhea, fevers, and joint pains. He presented with acute kidney injury and confusion with multiple tests and was eventually diagnosed with multisystem inflammatory syndrome in children (MIS-C).

The burden and characteristics of HIV-infected COVID-19 patients at a tertiary care hospital in sub-Saharan Africa-A retrospective cohort study.

BACKGROUND: After the first case of COVID-19 caused by the novel SARS-CoV-2 virus was discovered in Wuhan, China, in December 2019, the disease spread viciously throughout the world. Little is known about the impact of HIV infection on the clinical outcomes of patients co-infected with SARS-CoV-2. Studying the characteristics and outcomes of COVID-19 among HIV-positive patients is key to characterising the risk of morbidity and mortality of HIV-positive patients from COVID-19. METHODS: In this retrospective cohort study, we included patients admitted to Aga Khan University Hospital, Nairobi, with laboratory-confirmed COVID-19 infection and who had consented to HIV screening. We compared the prevalence and characteristics of HIV patients with those of non-HIV patients and described the results for both groups. RESULTS: In our sample of 582 patients, the mean age was 49.2 years (SD = 15.2), with 68% of the sample being men. The cumulative HIV prevalence was 3.7%, and the most common symptoms were cough (58.1%), fever (45.2%), difficulty in breathing (36.8%) and general body malaise (23.9%). The most common comorbidities included hypertension (28.5%), diabetes mellitus (26.1%), and heart disease (4.1%). Most participants (228 or 49.5%) had mild COVID-19, and the mortality rate was 5%. Overall, there were no statistically significant differences in demographic characteristics, clinical characteristics, and outcomes between HIV-positive and HIV-negative patients. CONCLUSIONS: There was a 3.7% prevalence of HIV in COVID-19 positive patients. Demographic characteristics and clinical outcomes were similar between the two groups. Future studies should seek to achieve larger samples, include multiple study sites and conduct subgroup analyses based on the immunologic status of HIV-positive patients.

Preadmission testing for COVID-19 as a screening strategy: a retrospective chart review from a tertiary hospital in Kenya.

Background: Since COVID-19 was declared a pandemic in March 2020, hospitals and patient care facilities have faced challenges in protecting healthcare workers and patients from being exposed to the infection. The main challenge has been how exposure to COVID-19 can be controlled when asymptomatic patientscan transmit the infection. This study aims to evaluate pre-admission testing of COVID-19 in patients at the Aga Khan University Hospital, Nairobi as a screening strategy for understanding, preventing and controlling exposure to COVID-19. Methods: This was a descriptive retrospective chart review study that analysed the incidence of COVID-19, incidental detection of laboratory-confirmed COVID-19 and effects on plan of care in patients prior to admission at the Aga Khan University Hospital from April to December 31, 2020. Demographic data, clinical characteristics, COVID-19 test report and plan of care were retrieved from patients medical records review. Results: A total of 8837 pre-admission tests were done between April 2020 and December 2020, with a COVID-19 prevalence rate of 10.9% (961/8837). Among the positive pre-admission tests, 14.3% were incidental positive results (138/961). Among the 138 incidental positive tests 21% (30) had their plan of care affected, 14.5% [20] had their care interventions delayed, 4.3% [6] had their hospital stay shortened, 1.4% [2] their hospital stay prolonged and 0.7% [1] had their care diagnostics delayed. Conclusion: While community spread of COVID-19 fluctuated during this period; depending on the level of compliance to infection control measures, pre-admission prevalence rates were increasing as the year progressed. Mandatory testing of COVID-19 in hospital facilities remains an important admission requirement in controlling asymptomatic transmission of the virus. COVID-19 health burden justifies resource allocation for universal screening of all patients before hospital admission.

Secondary Infections in Patients with COVID-19 Pneumonia Treated with Tocilizumab Compared to Those Not Treated with Tocilizumab: A Retrospective Study at a Tertiary Hospital in Kenya.

Introduction: From the first case of SARS-Co-2 in Wuhan, China, to the virus being declared as a pandemic in March 2020, the world has witnessed morbidity and mortality on a global scale. Scientists have worked at a record pace to deliver a vaccine for the prevention of this deadly disease. Tocilizumab, an interleukin-6 (IL-6) blocker, received an emergency use authorization (EUA) by the Federal Drug Agency (FDA) in June 2021. Methods: This retrospective observational cohort study was conducted at the Aga Khan University Hospital, Nairobi, from March 8, 2020, to December 31, 2020. All patients with PCR confirmed COVID-19 pneumonia were included. Data were obtained from the medical records, and the admission registry was used to identify the patients, and both their electronic and paper-based files were retrieved from the medical records. Patient demographic data, medical history, baseline comorbidities, clinical characteristics, and outcome data were collected to study the infectious complications of Tocilizumab in patients affected by COVID-19 pneumonia. Results: A total of 913 patients who were diagnosed with COVID-19 were included. The overall superinfection infection rate among the COVID-19 patients was 6%. Superinfection in patients who received the Tocilizumab was 17.2% and in the non-Tocilizumab group was 4.8%. The superinfection rate among severe and critically ill patients was even higher at 41.8% and 69.9% (Tocilizumab group) and 2.1% and 11.8% (non-Tocilizumab group), respectively (p < 0.001). There was no difference in mortality observed between the groups (p = 0.846). Infection among HIV co-infection was very low at 2.3%. Conclusion: Contrary to some studies, a higher rate of infection was observed among the Tocilizumab group, and no difference in mortality was observed between Tocilizumab and the non-Tocilizumab group. Infection among patients with HIV remains low in this susceptible population.

Demographic, Clinical, and Co-Morbidity Characteristics of COVID-19 Patients: A Retrospective Cohort from a Tertiary Hospital in Kenya.

Introduction: The first documented case of COVID-19 in Kenya was recorded March of 2020. Co-morbidities including hypertension and diabetes have been associated with increased morbidity, hospitalization, and mortality among COVID-19 patients. This retrospective study describes the clinical characteristics, disease severity, and outcomes among the patient population at a tertiary hospital in Kenya. Methods: This was a retrospective descriptive study of COVID-19 patients who were admitted between March 2020 and December 2020 at the Aga Khan University Hospital in Nairobi, Kenya. Data collected include patient demographic and baseline characteristics. Differences between patients who were known to have diabetes and hypertension during admission were compared for statistical significance. Difference between those who survived and those who died were also compared for statistical significance. Results: A total of 913 records of patients were studied with a mean age of 51.2 years (SD = 16.7), 66.5% were male and 80.8% were of African origin. History of diabetes, hypertension, and HIV status were at 27.3%, 33.1%, and 2.3%, respectively. At presentation, 33.1% (302/913) of patients had known hypertension by history, and following admission, this proportion increased to 37.7% (344/913). At presentation, 27.3% (249/913) of patients had known diabetes. During hospital stay, 20.8% (190) more patients were found to have diabetes, raising the overall percent to 48.1% (439/913). When comparing diabetes and hypertension at baseline versus at the end of admission, diabetes increased by 20.8% (p < 0.001) and hypertension by 4.6% (p = 0.049). HIV co-infection was 2.3%, and no patient had tuberculosis. Conclusion: This study showed a high incidence of co-morbidities in patients infected with COVID-19. Diabetes was most common, followed by hypertension. All patients admitted with COVID-19 infection should routinely be tested for diabetes with HbA1c and have regular blood pressure monitoring in order to diagnose occult diabetes and hypertension. Adverse outcomes were found in patients with these co-morbidities and should be monitored and treated appropriately.

Clinical Characteristics of Peripheral Neuropathy in Kenyan Patients with HIV Infection Compared with Patients with Concurrent HIV Infection and Diabetes Mellitus.

INTRODUCTION: Persons living with human immunodeficiency virus (HIV) are living longer and at risk of non-communicable diseases, including diabetes mellitus (DM). Both HIV and DM place patients at risk of peripheral neuropathy (PN). Our aim was to demonstrate the prevalence and characteristics of PN in our population of patients with HIV infection compared with concomitant HIV and DM. METHODS: A prospective cross-sectional study was performed at the Aga Khan Hospital in Nairobi, Kenya. Data were collected on demographics and characteristics of DM and HIV. Symptoms and signs of PN were evaluated by Neuropathy Symptom Score, Neuropathy Disability Score, and 10 g monofilament testing. RESULTS: Two groups were recruited, each consisting of 68 patients: (1) HIV only, (2) HIV and DM. The median age of patients was 51 years (IQR 42.8-58.6) and 55% were male. Median duration for HIV was 10 years (IQR 5-12) with a median CD4 count of 524 cells/mm3 (IQR 369-731). Median duration for DM was 1 year with a median glycosylated hemoglobin of 6.7% (IQR 6.6-7.6). Sixty-nine percent of patients with HIV had suppressed viral loads, and 9 patients (6.6%) had a history neurotoxic antiretroviral therapy use. PN was detected in 11 (16%) HIV-only patients, and in 17 (25%) participants who had both HIV and DM (Fisher exact test chi-square = 0.4). Univariate analysis demonstrated older age, high body mass index, and long duration of HIV were associated with an OR of 1.07 (95% CI 1.02-1.11), 1.21 (95% CI 0.46-3.11), and 1.07 (95% CI 0.99-1.15) in the overall group, respectively. CONCLUSION: Our study demonstrates a higher but non-significant prevalence of PN in patients with both HIV and DM when compared to HIV alone. HIV disease control had no association with PN presence.

Seroprevalence, correlates and kinetics of SARS-CoV-2 nucleocapsid IgG antibody in healthcare workers and nonclinical staff at a tertiary hospital: A prevaccine census study.

BACKGROUND: Healthcare workers and nonclinical staff in medical facilities are perceived to be a high-risk group for acquiring SAR-CoV-2 infection, and more so in countries where COVID-19 vaccination uptake is low. Serosurveillance may best determine the true extent of SARS-CoV-2 infection since most infected HCWs and other staff may be asymptomatic or present with only mild symptoms. Over time, determining the true extent of SARS-CoV-2 infection could inform hospital management and staff whether the preventive measures instituted are effective and valuable in developing targeted solutions. METHODS: This was a census survey study conducted at the Aga Khan University Hospital, Nairobi, between November 2020 and February 2021 before the implementation of the COVID-19 vaccination. The SARS-CoV-2 nucleocapsid IgG test was performed using a chemiluminescent assay. RESULTS: One thousand six hundred thirty-one (1631) staff enrolled, totalling 60% of the workforce. The overall crude seroprevalence was 18.4% and the adjusted value (for assay sensitivity of 86%) was 21.4% (95% CI; 19.2-23.7). The staff categories with higher prevalence included pharmacy (25.6%), outreach (24%), hospital- based nursing (22.2%) and catering staff (22.6%). Independent predictors of a positive IgG result after adjusting for age, sex and comorbidities included prior COVID-19 like symptoms, odds ratio (OR) 2.0 [95% confidence interval (CI) 1.3-3.0, p = 0.001], a prior positive SARS-CoV-2 PCR result OR 12.0 (CI: 7.7-18.7, p<0.001) and working in a clinical COVID-19 designated area, OR 1.9 (CI 1.1-3.3, p = 0.021). The odds of testing positive for IgG after a positive PCR test were lowest if the antibody test was performed more than 2 months later; OR 0.7 (CI: 0.48-0.95, p = 0.025). CONCLUSIONS: The prevalence of anti- SARS-CoV-2 nucleocapsid IgG among HCWs and nonclinical staff was lower than in the general population. Staff working in clinical areas were not at increased risk when compared to staff working in non-clinical areas.

A case for implementation of adult pneumococcal vaccine program in Africa: review and expert opinion.

Vaccines are considered as a therapeutic area for children; the scientific community focuses mainly on managing chronic disease when it comes to adults. There currently is an increase in the burden of vaccine preventable illnesses in adults. Adult vaccination has been shown to dramatically increase the health and quality of life of older populations. Therefore, adult vaccinations need to be approached as a public health issue, similar to smoking cessation programs, for example. According to the Kenya Non-Communicable Diseases and injuries poverty commission report, 2018. Kenya has a high percentage of disability adjusted life years (DALYs) from communicable diseases at 63%, while non-communicable diseases (NCDs) contribute 30% of the DALYs. Specific to pneumococcal pneumonia (PP) in adults, the Global burden of disease (GBD) study in 2016 found that 2,377,697 people of all ages died from lower respiratory tract infections (LRTI) in 2016. Of these, more people died from Streptococcus pneumonia(SP) than from all other studied respiratory pathogens combined. While the incidence of LRTIs in children under five years old was reducing, partly as a result of well-established vaccination programs in children, the incidence, morbidity and mortality of PP was increasing in older populations. The expert recommendations included the following; i) all individuals 65 years of age and above, and individuals with a predisposing comorbidity regardless of age, should receive the pneumococcal vaccine; ii) several systemic modules can be emulated from the successful childhood vaccines programs onto an adult vaccine program; iii) formulation of an effective vaccine program will require collaboration from the public, the government, healthcare providers, and the media, to create awareness; iv) stakeholders who need to be involved in vaccine policy development and implementation include medical professional associations, nurses, pharmacists, clinical officers, payers (private and public insurances), government, medical learning institutions and faith-based medical organizations.

Intracardiac Thrombus in Coronavirus Disease-2019.

Intracardiac thrombus is often seen as a complication of ischemic heart disease (IHD) and non-ischemia cardiomyopathies (NICM). The advancements in imaging modalities and therapeutic options have helped reduce the complications arising from ventricular thrombi, such as systemic embolization. Here we present two cases of intracardiac thrombus associated with coronavirus disease (COVID) 19, one with an apical thrombus in the left ventricle and the other with a thrombus in the right ventricle adjacent to chordae tendinae. The effects of covid-19 on the cardiovascular system are yet to be thoroughly evaluated. Venous and arterial thrombosis is commonly associated with COVID-19 but in situ detection of intracardiac thrombus has not been very frequently reported. Intracardiac thrombus and embolization pose a very high risk of complications in COVID-19. The coronavirus pandemic caused by SARS-CoV-2 during 2019-2021 has caused several deaths and has resulted in many long-term consequences, many of which remain unclear. In-hospital complications from COVID-19 are better reported due to constant monitoring. The ongoing, late, and chronic complications arising from COVID-19 require more vigilant case-by-case screening and surveillance.

COVID-19 vaccine hesitancy among non-refugees and refugees in Kenya.

Factors associated with COVID-19 vaccine hesitancy (which we define as refusal to be vaccinated when asked, resulting in delayed or non- vaccination) are poorly studied in sub-Saharan Africa and among refugees, particularly in Kenya. Using survey data from wave five (March to June 2021) of the Kenya Rapid Response Phone Survey (RRPS), a household survey representative of the population of Kenya, we estimated the self-reported rates and factors associated with vaccine hesitancy among non-refugees and refugees in Kenya. Non-refugee households were recruited through sampling of the 2015/16 Kenya Household Budget Survey and random digit dialing. Refugee households were recruited through random sampling of registered refugees. Binary response questions on misinformation and information were transformed into a scale. We performed a weighted (to be representative of the overall population of Kenya) multivariable logistic regression including interactions for refugee status, with the main outcome being if the respondent self-reported that they would not take the COVID-19 vaccine if available at no cost. We calculated the marginal effects of the various factors in the model. The weighted univariate analysis estimated that 18.0% of non-refugees and 7.0% of refugees surveyed in Kenya would not take the COVID-19 vaccine if offered at no cost. Adjusted, refugee status was associated with a -13.1[95%CI:-17.5,-8.7] percentage point difference (ppd) in vaccine hesitancy. For the both refugees and non-refugees, having education beyond the primary level, having symptoms of COVID-19, avoiding handshakes, and washing hands more often were also associated with a reduction in vaccine hesitancy. Also for both, having used the internet in the past three months was associated with a 8.1[1.4,14.7] ppd increase in vaccine hesitancy; and disagreeing that the government could be trusted in responding to COVID-19 was associated with a 25.9[14.2,37.5]ppd increase in vaccine hesitancy. There were significant interactions between refugee status and some variables (geography, food security, trust in the Kenyan government's response to COVID-19, knowing somebody with COVID-19, internet use, and TV ownership). These relationships between refugee status and certain variables suggest that programming between refugees and non-refugees be differentiated and specific to the contextual needs of each group.