New enantioselective liquid chromatography method development and validation of dipeptidyl peptidase IV inhibitors using a macrocyclic glycopeptide (vancomycin) chiral stationary phase under polar ionic mode condition.

The direct separation of dipeptidyl peptidase IV (DPP-4) inhibitors such as Sitagliptin (STG), Linagliptin (LIG), and Saxagliptin (SAG) enantiomers in normal phase conditions have been achieved on immobilized polysaccharide-based chiral stationary phases (CSPs), as well as on the macrocyclic glycopeptide vancomycin chiral stationary phase (Chirobiotic V2) under polar ionic mode. The enantiomers of these targets could be separated completely (resolution factor Rs > 2) using the Chirobiotic V2 column in polar ionic mode with the mobile phase (MeOH/AcOH/TEA 100/0.3/0.1 v/v/v) in an isocratic elution at 1.0 ml min-1 . The effect of the mobile phase composition on separation, including buffer salts, acid-base modifiers, and analyte structures, was evaluated. The developed technique was validated in the polar ionic mode according to the International Conference on Harmonization (ICH) Q2R1 guidelines in terms of accuracy, precision, selectivity, linearity, limit of detection (LOD), and limit of quantification (LOQ). The calibration curve was linear in a concentration range from LOQ to 3.75 µg/ml. The LOD and LOQ of STG, LIG, and SAG were 0.15 and 0.45, 0.15 and 0.50, 0.16 and 0.50, respectively. The proposed method is said to be selective, accurate, and precise. Finally, the validated method was used successfully for the quantitative determination of DPP-4 enantiomers in pharmaceutical analytes.

Differentials in girl-child marriage and high fertility in Nigeria.

In a patriarchal and natural fertility society like Nigeria, girl-child marriage is synonymous with early sexual debut and a prolonged childbearing period, ultimately affecting fertility outcomes and behaviours. This study explored the differentials in child marriage in Nigeria across socio-economic and regional groups, and its association with fertility. The study analysed secondary data pertaining to women aged 15-49 who were currently or previously married from the 2018 Nigeria Demographic and Health Survey. About 54 percent of Nigerian women married before their eighteenth birthday. The prevalence of child marriage was high in the rural areas (61 percent), in the North West (78 percent) and the North East (70 percent) of Nigeria. Child-brides have higher fertility than women who entered marital life as adults (TFR 6.8 vs 5.9). The early entry into marriage by most women in Nigeria has a profound influence on overall fertility, given that an overwhelming majority of births in Nigeria take place within marriage. Through advocacy and social mobilization, families, communities, and religious leaders will understand the hazards of child marriage and their role and responsibility in eradicating it and empowering the girl-child through formal education.

Monitoring intrapartum fetal heart rates by mothers in labour in two public hospitals: an initiative to improve maternal and neonatal healthcare in Liberia.

BACKGROUND: In low-resource settings with few health workers, Fetal Heart Rate (FHR) monitoring in labour can be inconsistent and unreliable. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia; the country with the second lowest number of midwives and nurses in the world (1.007 per 10,000 of the population). The initiative assessed the feasibility of educating women in labour to monitor their own FHR and alert a midwife of changes detected. METHODS: Four hundred seventy-four women admitted in labour without obstetric complications were approached. Four hundred sixty-one consented to participate (97%) and 13 declined. Those consenting were trained to monitor their FHR using a sonicaid for approximately 1 minute immediately following the end of every uterine contraction and to inform a midwife of changes. If changes were confirmed, standard clinical interventions for fetal distress (lateral tilt, intravenous fluids and oxygen) were undertaken and, when appropriate, accelerated delivery by vacuum or Caesarean section. Participants provided views on their experiences; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded. RESULTS: Four hundred sixty-one out of 474 women gave consent, of whom 431 of 461 (93%) completed the monitoring themselves. Three hundred eighty-seven of 400 women who gave comments, reported positive and 13 negative experiences. FHR changes were reported in 28 participants and confirmed in 26. Twenty-four of these 26 FHR changes were first identified by mothers. Fetal death was identified on admission during training in one mother. Thirteen neonates required resuscitation, with 12 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl's ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes including one of birth weight 1.3 Kg who could not be resuscitated. There were no intrapartum stillbirths in participants. CONCLUSIONS: Women in labour were able to monitor and detect changes in their FHR. Most found the experience beneficial. The absence of intrapartum stillbirths after admission and the low rate of poor neonatal outcomes are promising and warrant further investigation.

Can married or cohabiting women negotiate protective sex? Findings from Demographic and Health Surveys of two West African countries.

Can married or cohabitating women in patriarchal societies, who are often disproportionately affected by STI/HIV infections, negotiate protective sex when perceived necessary by refusing sex or asking for condom use during sex? Protective sex negotiation was examined through measures of power relations related to whether or not a woman has a say in sexual activities within marriage. The study hypothesis was that women who are more able to refuse sex or ask for condom use before sexual intercourse will be more able to discuss and reach agreement with their spouses on protective sex practices when needed. The study used data from DHS surveys conducted in Cote d'Ivoire and Nigeria in 2012 and 2013 respectively. Multivariate logistic regression models were used to predict women's ability to negotiate protective sex in Cote d'Ivoire and Nigeria. The findings show that moderately high percentages of women in both countries reported the ability to negotiate protective sex, with a higher percentage reporting the ability to refuse sex compared with the ability to ask partners to use a condom. The logistic regression results showed that, in the two countries, women's ability to refuse sex or ask their partners to use a condom, varied by gender- and power-mediating factors, women's characteristics and behavioural factors. The study draws attention to the need to intensify efforts to promote more-egalitarian relationships between partners through culturally appropriate interventions.

In vitro susceptibility to 19 agents other than ß-lactams among third-generation cephalosporin-resistant Enterobacteriaceae recovered on hospital admission.

Objectives: As part of the multicentre Antibiotic Therapy Optimisation Study, MIC values of 19 non-ß-lactam agents were determined for third-generation cephalosporin-resistant Escherichia coli , Klebsiella species and Enterobacter species (3GCREB) isolates collected in German hospitals. Methods: A total of 328 E. coli , 35 Klebsiella spp. (1 Klebsiella oxytoca and 34 Klebsiella pneumoniae ) and 16 Enterobacter spp. (1 Enterobacter aerogenes and 15 Enterobacter cloacae ) isolates were submitted to broth microdilution antimicrobial susceptibility testing with the MICRONAUT system. MICs of fluoroquinolones (levofloxacin and moxifloxacin), aminoglycosides (gentamicin, tobramycin, amikacin, streptomycin, neomycin and paromomycin), tetracyclines (tetracycline, minocycline and tigecycline), macrolides (erythromycin, clarithromycin and azithromycin) and miscellaneous agents [trimethoprim/sulfamethoxazole, chloramphenicol, nitrofurantoin, colistin and fosfomycin intravenous (iv)] were determined and reviewed against 2016 EUCAST breakpoints. Results: The MIC of levofloxacin was >2 mg/L for 128 of 328 E. coli and 8 of 35 Klebsiella spp., but only 1 of 16 Enterobacter spp. Rates of resistance to trimethoprim/sulfamethoxazole were high (>70%), except for Enterobacter spp. Rates of resistance to colistin and fosfomycin iv were still low. About 20% of the tested isolates were resistant to chloramphenicol. Only 1 (of 328) E. coli isolate had an MIC of amikacin >16 mg/L and only 33 of 328 E. coli and 1 of 35 Klebsiella spp. had an MIC of tobramycin >4 mg/L, whereas average gentamicin MICs were in general more elevated. A tigecycline MIC >2 mg/L was only found for 1 of 16 Enterobacter spp., but in none of the E. coli or Klebsiella spp. isolates. Conclusions: Our study gives insight into previously unreported non-ß-lactam MIC distributions of 3GCREB isolates.

Secular trends in nosocomial bloodstream infections: antibiotic-resistant bacteria increase the total burden of infection.

BACKGROUND: It is unknown whether rising incidence rates of nosocomial bloodstream infections (BSIs) caused by antibiotic-resistant bacteria (ARB) replace antibiotic-susceptible bacteria (ASB), leaving the total BSI rate unaffected. METHODS: We investigated temporal trends in annual incidence densities (events per 100 000 patient-days) of nosocomial BSIs caused by methicillin-resistant Staphylococcus aureus (MRSA), ARB other than MRSA, and ASB in 7 ARB-endemic and 7 ARB-nonendemic hospitals between 1998 and 2007. RESULTS: 33 130 nosocomial BSIs (14% caused by ARB) yielded 36 679 microorganisms. From 1998 to 2007, the MRSA incidence density increased from 0.2 to 0.7 (annual increase, 22%) in ARB-nonendemic hospitals, and from 3.1 to 11.7 (annual increase, 10%) in ARB-endemic hospitals (P = .2), increasing the incidence density difference between ARB-endemic and ARB-nonendemic hospitals from 2.9 to 11.0. The non-MRSA ARB incidence density increased from 2.8 to 4.1 (annual increase, 5%) in ARB-nonendemic hospitals, and from 1.5 to 17.4 (annual increase, 22%) in ARB-endemic hospitals (P < .001), changing the incidence density difference from -1.3 to 13.3. Trends in ASB incidence densities were similar in both groups (P = .7). With annual increases of 3.8% and 5.4% of all nosocomial BSIs in ARB-nonendemic and ARB-endemic hospitals, respectively (P < .001), the overall incidence density difference of 3.8 increased to 24.4. CONCLUSIONS: Increased nosocomial BSI rates due to ARB occur in addition to infections caused by ASB, increasing the total burden of disease. Hospitals with high ARB infection rates in 2005 had an excess burden of BSI of 20.6 per 100 000 patient-days in a 10-year period, mainly caused by infections with ARB.

Analysis of transmission-related third-generation cephalosporin-resistant Enterobacterales by electronic data mining and core genome multi-locus sequence typing.

BACKGROUND: To contain intra-hospital transmission of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), contact isolation precautions are recommended. AIM: To quantify transmissions of 3GCR Escherichia coli and 3GCR Klebsiella pneumoniae within a hospital. METHODS: An automated outbreak detection system (AODS) was used to identify clusters (N≥2) of 3GCR Enterobacterales for the years 2016, 2018 and 2020. Clusters were defined by phenotypic agreement of microbiological results and spatial and temporal relationship. Core genome multi-locus sequence typing (cgMLST) was used to confirm whether the cluster isolates were transmitted between patients. FINDINGS: A total of 4343 3GCR E. coli and 1377 K. pneumoniae isolates were analysed. Among the 3GCR E. coli isolates, the AODS identified 304 isolates as cluster isolates, the median cluster size was two (range: 2-5). The cgMLST analysis revealed that a total of 23 (7.5%) 3GCR E. coli cluster isolates were transmission-associated, of which 20 isolates (87%) were detected in intensive care patients. Among the 3GCR K. pneumoniae isolates, the AODS identified 73 isolates as cluster isolates, the median cluster size was two (range: 2-4). CgMLST revealed that 35 (48%) 3GCR K. pneumoniae cluster isolates were transmission associated, of which 27 isolates (77%) were detected in intensive care patients. CONCLUSION: For 3GCR K. pneumoniae, cgMLST confirmed the AODS results more frequently than for 3GCR E. coli. Therefore, contact isolation precautions for 3GCR K. pneumoniae may be appropriate on intensive care units, but only in certain circumstances, such as outbreaks, for Enterobacterales with lower transmissibility, such as E. coli.

Parasitic Protozoans: Exploring the Potential of N,N'-Bis[2-(5-bromo-7-azabenzimidazol-1-yl)-2-oxoethyl]ethylene-1,3-Diamine and Its Cyclohexyl-1,2-diamine Analogue as TryR and Pf-DHODH Inhibitors.

PURPOSE: Major human parasitic protozoans, such as Plasmodium falciparum and Trypanosoma brucei, cause malaria and trypanosomiasis also known as sleeping sickness. In anti-parasitic drug discovery research, trypanothione reductase (TryR) and P. falciparum dihydroorotate dehydrogenase (Pf-DHODH) enzymes are key drug targets in T. brucei and P. falciparum, respectively. The possibility of co-infection of single host by T. brucei and P. falciparum is because both parasites exist in sub-Saharan Africa and the problem of parasite drug resistance necessitates the discovery of new scaffolds, which are strange to the organisms causing these infectious diseases-new scaffolds may help overcome established resistance mechanisms of the organisms. METHOD: In this study, N,N'-bis[2-(5-bromo-7-azabenzimidazol-1-yl)-2-oxoethyl]ethylene-1,3-diamine and its cyclohexyl-1,2-diamine analogue were explored for their inhibitory potential against TryR and Pf-DHODH by engaging density functional study, molecular dynamic simulations, drug-likeness, in silico and in vitro studies RESULTS/CONCLUSION: Results obtained indicated excellent binding potential of the ligands to the receptors and good ADMET (adsorption, desorption, metabolism, excretion, and toxicity) properties.

High prevalence of extended-spectrum-ß-lactamase-producing Enterobacteriaceae in organic and conventional retail chicken meat, Germany.

OBJECTIVES: To determine the prevalence of extended-spectrum ß-lactamase (ESBL) production in Enterobacteriaceae in retail chicken meat in Germany. METHODS: A total of 399 chicken meat samples from nine supermarket chains, four organic food stores and one butcher's shop in two geographically distinct regions (Berlin and Greifswald) were screened for ESBL production using selective agar. Phenotypic ESBL isolates were tested for bla(TEM), bla(CTX-M) and bla(SHV) genes using PCR and DNA sequencing. Antibiotic coresistances were determined and strain typing was performed using PCR-based phylogenetic grouping and XbaI-PFGE. RESULTS: A total of 185 confirmed ESBL isolates were obtained from 175 samples (43.9%) from all tested sources. The majority of isolates were Escherichia coli producing ESBL types SHV-12 (n = 82), CTX-M-1 (n = 77) and TEM-52 (n = 16). No differences could be observed in the prevalence of ESBL producers between organic and conventional samples. 73.0% of the ESBL producers showed coresistance to tetracycline, 35.7% to co-trimoxazole and 7.6% to ciprofloxacin. Strain typing of selected E. coli isolates from Berlin revealed identical macrorestriction patterns for several isolates from samples taken from the same stores. CONCLUSIONS: This is the first comprehensive study from Germany showing a high prevalence of TEM-, CTX-M- and SHV-type ESBLs in Enterobacteriaceae isolated from retail chicken meat. The high rate of coresistance to different classes of antibiotics in the ESBL producers might reflect the common veterinary usage of these and related substances. There is an urgent need to further evaluate the role of poultry in the transmission of highly resistant ESBL-producing bacteria in humans.

Pet animals and foreign travel are risk factors for colonisation with extended-spectrum ß-lactamase-producing Escherichia coli.

OBJECTIVE: The purpose of this study was to determine the prevalence of extended-spectrum ß-lactamase (ESBL) and vancomycin-resistant enterococci (VRE) colonisation among healthy infection control personnel and to determine risk factors for ESBL or VRE colonisation within this group. METHODS: Participants were recruited at an infection control symposium in 2011. Volunteers were asked to perform a rectal swab and to fill in questionnaires on risk factors of ESBL or VRE carriage (report on diet, contact with domestic or production animals, travel, hospital stay and antibiotic use all within the last 12 months). Rectal swabs were inoculated onto ESBL and VRE chromogenic agar; species identification and susceptibility testing was done by using a VITEK 2 system. In the multivariable analysis, a logistic regression with stepwise forward variable selection was performed. RESULTS: Two hundred and thirty people participated in the study, i.e. 36 % of the symposium attendees (231/639). No VRE faecium or faecalis were isolated, whereas ESBL were isolated from 8 out of 231 individuals, i.e. 3.5 % (95 % confidence interval 1.5-6.7). In the multivariable analysis, travel to Greece or Africa and contact with pets were independently associated with ESBL positivity. The odds ratios were as follows: travel to Greece 15.2, travel to Africa 14.8 and for having a pet animal 6.7. CONCLUSION: This is the first report showing that contact with pets increases by almost seven-fold the chance to be colonised with ESBL Escherichia coli. A colonisation rate of 3.5 % with ESBL-producing enterobacteriaceae among infection control personnel is of concern and reflects probably less an occupational health risk but the reservoir of and the expansion into the community, especially in persons with pet animals and travel history to high-endemicity countries.

Synthesis of 2-aryl-5-(arylsulfonyl)-1,3,4-oxadiazoles as potent antibacterial and antioxidant agents.

Ten novel 2-aryl-5-(arylsulfonyl)-1,3,4-oxadiazoles were produced and assessed for their in vitro antibacterial and antioxidant activities. Diverse spectroscopic methods like 1H NMR, 13C NMR, IR, and LCMS were used for the characterization of the prepared samples and all the data was in good agreement with the anticipated structures. The prepared compounds 6a-j were screened for their in vitro antibacterial activity against bacterial strains Pseudomonas aeruginosa, Enterobacter aerogenes, Escherichia coli (gram-positive), and Bacillus cerus, Staphylococcus aureus, Bacillus subtilis (gram-negative). The antimicrobial screening outcome revealed that the prepared 2-(3,4-dimethylphenyl)-5-tosyl-1,3,4-oxadiazole (6j), 2-(3-isopropylphenyl)-5-tosyl-1,3,4-oxadiazole (6c), and 2-(2-ethylphenyl)-5-tosyl-1,3,4-oxadiazole (6i) are most potent among all the examined compounds. Furthermore, the antioxidant activity of the prepared compounds was also investigated by DPPH radical scavenging method and the results showed that some of the compounds were moderately active.

[Clostridium difficile-associated infections. How dangerous are the new strains?]. / Clostridium-difficile-Infektionen. Wie gefährlich sind die neuen Stämme?

In recent years, a global increase of Clostridium difficile-associated infections (CDI) and the emergence of new hypervirulent strains causing numerous outbreaks was noticed. The appearance of these strains was accompanied by increased morbidity and mortality, affecting patients previously unknown to be at risk for CDI. Meanwhile, these hypervirulent strains occur in Germany as well. So far, the changing epidemiology of CDI did neither change diagnosis nor therapy of CDI but necessitates a series of preventive measures like the surveillance of CDI and contact precautions while caring for affected patients. If there are complicated or severe cases of CDI, the hypervirulent strains should be suspected and stool culture for isolation of C. difficile should be aimed.

Infections caused by extended-spectrum ß-lactamase-producing Enterobacterales after rectal colonization with ESBL-producing Escherichia coli or Klebsiella pneumoniae.

OBJECTIVES: Infections as a result of extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E) are considered infections with a high public health burden. In this study, we aimed to identify incidences of and risk factors for healthcare-associated infections (HAIs) after rectal colonization with ESBL-producing Escherichia coli (ESBL-EC) or Klebsiella pneumoniae (ESBL-KP). METHODS: This prospective cohort study was performed in 2014 and 2015. Patients colonized with ESBL-EC or ESBL-KP were monitored for subsequent HAI with ESBL-E and other pathogens. In the case of an ESBL-E infection, rectal and clinical isolates were compared using pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing (WGS) for ESBL-KP isolates. Proportional hazard models were applied to identify risk factors for HAIs, and to analyse competing risks. RESULTS: Among all patients admitted to the hospital during the study period, 13.6% were rectally screened for third-generation cephalosporin-resistant Enterobacterales (3GCREB). A total of 2386 rectal carriers of ESBL-EC and 585 of ESBL-KP were included in the study. Incidence density (ID) for HAI with ESBL-E was 2.74 per 1000 patient days at risk (95% confidence interval (CI) 2.16-3.43) among carriers of ESBL-EC, while it was 4.44 per 1000 patient days at risk (95% CI 3.17-6.04) among carriers of ESBL-KP. In contrast, ID for HAI with other pathogens was 4.36 per 1000 patient days at risk (95% CI 3.62-5.21) among carriers of ESBL-EC, and 5.00 per 1000 patient days at risk (95% CI 3.64-6.69) among carriers of ESBL-KP. Cox proportional hazard regression analyses identified colonization with ESBL-KP (HR = 1.58, 95% CI 1.068-2.325) compared with ESBL-EC as independent risk factor for HAI with ESBL-E. The results were consistent over all competing risk analyses. CONCLUSIONS: Clinicians should be aware of the increased risk of ESBL-E infections among patients colonized with ESBL-KP compared with ESBL-EC that might be caused by underlying diseases, higher pathogenicity of ESBL-KP and other factors.

Efficacy of oral chlorhexidine in preventing lower respiratory tract infections. Meta-analysis of randomized controlled trials.

Several randomized controlled trials (RCTs) have examined the influence of oral chlorhexidine (CHX) in preventing nosocomial lower respiratory tract infection (LRTI). Most have failed to demonstrate a reduction in the incidence of LRTI. The present meta-analysis summarizes the effect of oral CHX on the development of LRTI. RCTs were identified through searching PubMed, MEDLINE and the Cochrane Central Register of Controlled Trials databases. Those describing the use of chlorhexidine for oral decontamination and reporting the incidence of LRTI as a study outcome were included in the meta-analysis. Seven RCTs met the inclusion criteria; pooling the results from these reveals a reduction in the relative risk (RR) of LRTI in the CHX group [RR(random): 0.58, 95% confidence interval (CI): 0.45-0.74; and RR(fixed): 0.56, CI95: 0.44-0.72, respectively]. Further analyses showed that this result applied only to patients ventilated for up to 48h (RR(random): 0.58, CI95: 0.45-0.74; and RR(fixed): 0.56, 95% CI: 0.44-0.72). Oral CHX should be included among preventive measures performed to reduce nosocomial LRTI. Whether it has an impact on the development of LRTI in patients requiring mechanical ventilation for a longer period of time remains unresolved.

Surveillance of extended-spectrum beta-lactamase-producing bacteria and routine use of contact isolation: experience from a three-year period.

The usefulness and applicability of isolation precautions were questioned for extended-spectrum beta-lactamase (ESBL)-producing strains of Enterobacteriaceae in the endemic setting. We performed a surveillance programme for ESBL-positive organisms and the infection control management of patients colonized or infected with these organisms. Between 1 January 2002 and 31 December 2004, a total of 147 cases of ESBL-producing strains of Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis from 123 patients were noted. The overall incidence of ESBL-producing-strain-positive cases was 0.12/1000 patient-days. The proportion of referred cases was 35% (N=51); 65% of cases (N=96) were acquired in our institution. Infections developed in 57 cases (38.8%), of which 36 (63.3%) were nosocomial. Contact isolation precautions were carried out for 79.6% of the cases, with a median duration of contact isolation precautions for 14 days (range: 0-144). The contact isolation precautions resulted in 2985 isolation days in total, i.e. 995 isolation days per year. Typing by pulsed-field gel electrophoresis showed clonal diversity in 94.2% of the isolates from patients. Seven patient-to-patient transmissions were noted. Only in 10 cases (6.8%) was colonization with ESBL-producing strains cleared. Considering the large number of immunocompromised patients treated in our institution (>1500 bone marrow or solid organ transplantations performed during 2002-2004), we will continue to isolate patients who are colonized or infected with ESBL-producing organisms.

Dual indices for prioritizing investment in decentralized HIV services at Nigerian primary health care facilities.

Decentralizing health services, including those for HIV prevention and treatment, is one strategy for maximizing the use of limited resources and expanding treatment options; yet few methods exist for systematically identifying where investments for service expansion might be most effective, in terms of meeting needs and rapid availability of improved services. The Nigerian Government, the United States Government under the President's Emergency Plan for AIDS Relief (PEPFAR) program and other donors are expanding services for prevention of mother-to-child transmission (PMTCT) of HIV to primary health care facilities in Nigeria. Nigerian primary care facilities vary greatly in their readiness to deliver HIV/AIDS services. In 2012, MEASURE Evaluation assessed 268 PEPFAR-supported primary health care facilities in Nigeria and developed a systematic method for prioritizing these facilities for expansion of PMTCT services. Each assessed facility was scored based on two indices with multiple, weighted variables: one measured facility readiness to provide PMTCT services, the other measured local need for the services and feasibility of expansion. These two scores were compiled and the summary score used as the basis for prioritizing facilities for PMTCT service expansion. The rationale was that using need and readiness to identify where to expand PMTCT services would result in more efficient allocation of resources. A review of the results showed that the indices achieved the desired effect-that is prioritizing facilities with high need even when readiness was problematic and also prioritizing facilities where rapid scale-up was feasible. This article describes the development of the two-part index and discusses advantages of using this approach when planning service expansion. The authors' objective is to contribute to development of methodologies for prioritizing investments in HIV, as well as other public health arenas, that should improve cost-effectiveness and strengthen services and systems in resource-limited countries.

The use of vouchers in HIV prevention, referral treatment, and care for young MSM and young transgender people in Dhaka, Bangladesh: experience from 'HIM' initiative.

INTRODUCTION: The study described the effectiveness of a voucher scheme to access sexual and reproductive health and HIV services among young MSM and transgender people aged 15-24 years in Dhaka, Bangladesh, a country with HIV prevalence of less than 0.1%. METHODS: Descriptive and analytical methods were used to assess the net effects of biodemographic factors of the respondents on the voucher scheme. Effectiveness of the scheme was contextualized as target population coverage, and turnaround time of voucher redemption to access services. RESULTS AND DISCUSSION: A total of 210 (87.9%) out of the 239 vouchers distributed were redeemed. The mean age of the identified young people was 19.6 years (SD = +2.6 years). The coverage of the scheme against the target population of 200 young MSM and 936 young transgender people was 88% (n = 175) and 4% (n = 35) respectively, with P < 0.001. The median turnaround time for voucher redemption was 7 days. The predictors of voucher turnaround time were age, education, and population group (P < 0.001). HIV testing and counselling was accessed by 160 (76%) respondents, one was positive and linked to antiretroviral treatment and 110 (52%) were diagnosed and treated for sexually transmitted infections. CONCLUSION: The voucher scheme was effective in linking young MSM with sexual and reproductive health and HIV services in Dhaka, Bangladesh. The findings are consistent with the low HIV prevalence in the country. The scheme is, however, not optimal for linking young transgender people with services.

Analysis of the C5a anaphylatoxin core domain using a C5a phage library selected on differentiated U937 cells.

The human anaphylatoxin C5a is a 74-amino acid comprising polypeptide with a plethora of biological functions. Site directed mutagenesis studies suggest that several residues within the core and the C-terminus mediate the interaction with the C5a receptor. However, the contribution of particular core residues to receptor binding remained to be clarified. By means of the phage display technique, the loop between positions 35-40 was randomly mutated and the resulting C5a[35-40] fusion phage library affinity selected on C5a receptor expressing U937 cells. After five rounds of affinity enrichment, residues Arg37 and Arg40 were preferably selected. Enrichment was as high as 100% for Arg37 and 79% for Arg40. No significant enrichment of consensus residues could be obtained for positions 35, 36, 38 and 39. The core mutant C5a[A35E36R37A38S39R40], in which only Arg37/40 and Ala38 are of the native C5a sequence, was as potent as native C5a in both receptor binding and enzyme release examined on U937 cells. In contrast, replacement of Arg40 as in the mutant C5a[Q35E36R37I38L39N40] resulted in a 10-fold decrease in both binding and functional activities. Thus, selected out of a multiplicity of possibilities by the natural binding partner, Arg37 as well as Arg40 appear to be anchor residues in binding to the C5a receptor.

A selection system to study C5a-C5a-receptor interactions: phage display of a novel C5a anaphylatoxin, Fos-C5aAla27.

Binding and effector domains of the human anaphylatoxin C5a have been determined by either site directed mutagenesis or synthetic peptide studies. However, the lack of specific selection methods, which allow direct investigation of C5a-C5a-receptor interaction made these studies laborious. To overcome these limitations we have constructed a novel Fos-C5a expressed on the tip of a filamentous phage. To guarantee for a free C-terminus which is required for C5a activity C5a cDNA was cloned into the phagemid vector pJuFo. Helper phage infection of pJuFc-C5a transformed cells resulted in a mutant phage displaying Fos-C5a on its surface. However studies with Bt2cAMP differentiated U937 cells revealed that phage displayed Fos-C5a is functional inactive. Subsequently we replaced a nonconserved cysteine residue at position 27 by alanine and obtained Fos-C5aAla27. Both the purified and the phage displayed Fos-C5aAla27 proteins were functional active and induced enzyme release from differentiated U937 cells. In addition, purified Fos-C5aAla27 exhibited the same binding profile as compared to rhC5a. Fos-C5aAla27 displaying phages were mixed with phage harboring only the pJuFo plasmid at a ratio of 10(6). After four successive rounds of panning on differentiated U937 cells Fos-C5aAla27 phages were enriched to 100% as shown by C5a-specific ELISA. We expect this approach to prove helpful for studying C5a-C5a-receptor interactions. i.e. to screen C5a libraries for high affinity binders with agonistic or antagonistic properties directly on cells.