Human meningitis due to Streptococcus suis in Lomé, Togo: a case report.

BACKGROUND: Streptococcus suis is a zoonotic pathogen which represents the leading cause of meningitis in Southeast Asia and an emerging pathogen in the Western world, the main risk factor for infection being contact with pigs. In Africa, the prevalence of S. suis infections in swine and humans is largely unrecognized, with only one recent report of a limited case series. CASE PRESENTATION: We describe a human case of meningitis due to S. suis in a 32-year-old man living in Togo. The patient had no particular medical history and no risk factors for immunodeficiency but reported regular contact with pork products. Using specific immunological and molecular methods, we characterized the isolate as S. suis serotype 2, ST1, one the most prevalent and virulent clone worldwide. The outcome was favorable after one week of adapted antibiotic therapy but the patient was left with severe hearing disorders. CONCLUSIONS: This work highlights the emergence of this pathogen in Africa and reinforces the need for accurate epidemiological and surveillance studies of S. suis infections and for educating clinicians and exposed groups in non-endemic countries.

Virological outcome among HIV-1 infected patients on first-line antiretroviral treatment in semi-rural HIV clinics in Togo.

BACKGROUND: Access to antiretroviral treatment (ART) in resource-limited countries has increased significantly but scaling-up ART into semi-rural and rural areas is more recent. Information on treatment outcome in such areas is still very limited notably due to additional difficulties to manage ART in these areas. RESULTS: 387 HIV-1 infected adults (≥18 years) were consecutively enrolled when attending healthcare services for their routine medical visit at 12 or 24 months on first-line ART in five HIV care centers (four semi-rural and one rural). Among them, 102 patients were on first-line ART for 12 ± 2 months (M12) and 285 for 24 ± 2 months (M24). Virological failure was observed in 70 (18.1 %) patients ranging from 13.9 to 31.6 % at M12 and from 8.1 to 22.4 % at M24 across the different sites. For 67/70 patients, sequencing was successful and drug resistance mutations were observed in 65 (97 %). The global prevalence of drug resistance in the study population was thus at least 16.8 % (65/387). Moreover, 32 (8.3 %) and 27 (6.9 %) patients were either on a completely ineffective ART regime or with only a single drug active. Several patients accumulated high numbers of mutations and developed also cross-resistance to abacavir, didanosine or the new NNRTI drugs like etravirine and rilpivirine. CONCLUSION: The observations on ART treatment outcome from ART clinics in semi-rural areas are close to previous observations in Lomé, the capital city suggesting that national ART-programme management plays a role in treatment outcome.

Prevalence and distribution of Human Papillomavirus (HPV) genotypes among HIV infected women in Lomé, Togo.

CONCLUSION: This study showed the diversity of circulating HPV genotypes in Togo. Programs of HPV vaccination and early detection of benign or precancerous lesions should be implemented to reduce cancer-related comorbidities.

High Prevalence of Hepatitis B Virus Infection in the Age Range of 20-39 Years Old Individuals in Lome.

BACKGROUND: Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). It affects all women and men irrespective of age. Although sub-Saharan Africa is an area of high prevalence of this disease, data on the prevalence of acute and chronic HBV infections in this region remain to be widely documented. OBJECTIVE: This study aimed to investigate the prevalence of HBV in relation to age in Centre Hospitalier Universitaire Campus (CHU-C), one of the two teaching hospitals of Lome, Togo. METHOD: The present study is a cross-sectional study about the prevalence of hepatitis B surface antigen (HBsAg) carriage from 2009 to 2011. All study participants were screened for HBsAg at the Immunology laboratory of CHU Campus of Lome. RESULTS: One thousand two hundred individuals were screened for HBsAg from 2009-2011. The overall prevalence of HBV infection was 19.08%. This prevalence was significantly higher in men (25.00%) than women (14.80%). The highest prevalence of HBV was observed in age range of 20-29 years and 30-39 years with respectively 26.33% and 21.67%. The lowest prevalence was 6.08%, found in people over 50 years. Concerning the clinical indication of the test, the prevalence during the clinical abnormalities related to liver (CARL) was the highest (26.21%), followed by the systematic screening (SS) with 20.25% while the pre-operative assessment (POA) showed the lowest prevalence with 5.56%. CONCLUSION: The study shows the high prevalence of HBsAg carriage in young people. This could be used to enhance prevention and treatment of HBV infection in Togo.

Genetic diversity and transmission networks of HIV-1 strains among men having sex with men (MSM) in Lomé, Togo.

Understanding the HIV epidemic in key populations is important. Today only scarce information is available on HIV-1 strains that circulate in men having sex with men (MSM) in sub-Saharan Africa. Here, we studied for the first time the genetic diversity of HIV-1 strains circulating in the MSM population in Lomé, the capital city from Togo. The overall subtype/CRF distribution in pol (protease and/or partial reverse transcriptase (RT)) among the 79 HIV-1 strains from MSM was as follows: CRF02_AG (72%, n=57), subtype G (2.5%, n=2), sub-subtype A3 (1.3%, n=1), and unique recombinant forms (URF) (24%, n=19). Among the 19 URFs four different mosaic structures were observed, annotated as URF1 to URF4. Fifteen sequences (URF1) had the same mosaic structure in pol (G/CRF02_AG) and could represent a new circulating recombinant form (CRF). Phylogenetic analysis of the RT sequences showed that there were several introductions of CRF02_AG strains in the MSM population, however half of the CRF02_AG and all URF1 strains formed a separate, well-supported cluster suggesting one major introduction of CRF02_AG in the MSM population followed by efficient transmission and emergence of a possible new CRF. At least 40% of the strains fell into recent transmission chains involving two to seven MSM. Comparison with >950 HIV-1 sequences from previous studies in Togo showed intermixing of the HIV-1 epidemics between MSM and the general population. Moreover, an HIV-1 strain from a recently HIV-1 infected male patient from Germany, fell within a cluster of HIV-1 strains from MSM from Togo, illustrating recent exchange between MSM from Africa and people from other geographic regions. With growing evidence of the importance of MSM in the dynamic of the HIV epidemic in Africa there is an urgent need for appropriate interventions to limit HIV transmission in this population group.

High rates of virological failure and drug resistance in perinatally HIV-1-infected children and adolescents receiving lifelong antiretroviral therapy in routine clinics in Togo.

INTRODUCTION: Antiretroviral treatment (ART) has been scaled up over the last decade but compared to adults, children living with HIV are less likely to receive ART. Moreover, children and adolescents are more vulnerable than adults to virological failure (VF) and emergence of drug resistance. In this study we determined virological outcome in perinatally HIV-1-infected children and adolescents receiving ART in Togo. METHODS: HIV viral load (VL) testing was consecutively proposed to all children and adolescents who were on ART for at least 12 months when attending HIV healthcare services for their routine follow-up visit (June to September 2014). Plasma HIV-1 VL was measured using the m2000 RealTime HIV-1 assay (Abbott Molecular, Des Plaines, IL, USA). Genotypic drug resistance was done for all samples with VL>1000 copies/ml. RESULTS AND DISCUSSION: Among 283 perinatally HIV-1-infected children and adolescents included, 167 (59%) were adolescents and 116 (41%) were children. The median duration on ART was 48 months (interquartile range: 28 to 68 months). For 228 (80.6%), the current ART combination consisted of two nucleoside reverse transcriptase inhibitors (NRTIs) (zidovudine and lamivudine) and one non-nucleoside reverse transcriptase inhibitor (NNRTI) (nevirapine or efavirenz). Only 28 (9.9%) were on a protease inhibitor (PI)-based regimen. VL was below the detection limit (i.e. 40 copies/ml) for 102 (36%), between 40 and 1000 copies/ml for 35 (12.4%) and above 1000 copies/ml for 146 (51.6%). Genotypic drug-resistance testing was successful for 125/146 (85.6%); 110/125 (88.0%) were resistant to both NRTIs and NNRTIs, 1/125 (0.8%) to NRTIs only, 4/125 (3.2%) to NNRTIs only and three harboured viruses resistant to reverse transcriptase and PIs. Overall, 86% (108/125) of children and adolescents experiencing VF and successfully genotyped, corresponding thus to at least 38% of the study population, had either no effective ART or had only a single effective drug in their current ART regimen. CONCLUSIONS: Our study provided important information on virological outcome on lifelong ART in perinatally HIV-1-infected children and adolescents who were still on ART and continued to attend antiretroviral (ARV) clinics for follow-up visits. Actual conditions for scaling up and monitoring lifelong ART in children in resource-limited countries can have dramatic long-term outcomes and illustrate that paediatric ART receives inadequate attention.

High Rates of Drug Resistance Among Newly Diagnosed HIV-infected Children in the National Prevention of Mother-to-child Transmission Program in Togo.

BACKGROUND: Prevention of mother-to-child transmission (PMTCT) programs have been largely scaled-up, but data on infant HIV drug resistance from PMTCT programs implemented in resource-limited countries are lacking. METHODS: Remnant dried blood spots from HIV-infected children (aged <18 months) tested through the Togo national early infant diagnosis program during 2012 and 2013 were collected and assessed for HIV drug resistance. Pol-RT (reverse transcriptase) region was amplified, sequenced and analyzed for the presence of drug resistance mutations (DRMs). RESULTS: Overall, 121 of 201 (60.2%) newly diagnosed children had detectable DRMs. Among the 131 of 201 (65.2%) children with reported exposure to maternal and/or infant antiretrovirals (ARVs), DRMs were detected in 99 children (75.6%). Importantly, in 41 of 201 children for whom no exposure to ARVs was reported, DRMs were detected in 11 children (26.8%). For 29 children, no data on ARV exposure were available. For the 121 of 201 children with DRMs, 99 of 121 (81.8%) had only nonnucleoside reverse transcriptase inhibitor DRMs detected but 21 of 121 (17.3%) had both nonnucleoside reverse transcriptase inhibitor and nucleoside reverse transcriptase inhibitor (NRTI) DRMs. Among breast-fed children, drug resistance was more frequent when mothers were on antiretroviral therapy (ART), 61 of 75 (81.3%) versus 14 of 39 (35.9%) when mothers were not on ART (P < 0.001). Nucleoside reverse transcriptase inhibitor resistance was more common when mothers were on ART. CONCLUSIONS: Scale-up and improvement of PMTCT strategies resulted in a global decrease of pediatric HIV infections, but our study shows high rates of drug resistance in infants for whom prevention failed.

Alarming rates of virological failure and drug resistance in patients on long-term antiretroviral treatment in routine HIV clinics in Togo.

Information on efficacy of long-term antiretroviral treatment (ART) exposure in resource-limited countries is still scarce. In 767 patients attending routine HIV centers in Togo and receiving first-line ART for more than four years, 42% had viral load greater than 1000 copies/ml and either were on a completely ineffective ART regime or were with only a single drug active. The actual conditions to ensure lifelong ART in resource-limited countries can have dramatic long-term outcomes.

[Blood transfusion safety in a limited resources setting: the elaboration of a rational National Blood Policy in Togo]. / Sécurité transfusionnelle dans un contexte de ressources limitées: processus de mise en place de la politique nationale transfusionnelle au Togo.

The demand for blood transfusion is high in subSaharan Africa because of the high prevalence of the anemia especially due to malaria and obstetrical damage. Providing a safe and confident system of transfusion requires more and more resources when, in developing countries, these are in fact limited. With a double view to improve the coverage in blood transfusion and ensure the security of blood products, the Ministry of Health of Togo launched in 1999 a series of operations for setting up a rational National Blood Transfusion Policy. The following steps were undertaken. A two-week situation analysis of the blood transfusion sector highlighted the lack of sector regulation, the multiplicity of blood unit production centres (n = 33 for a country of 56,000 km(2)) that could endanger the security of the products especially in limited resources conditions, the inadequacy in quality management in all areas of blood transfusion (insufficiency of human resources, equipment and supply, lack of procedures, etc.) and the lack of an information system on blood transfusion for retrospective survey and planning. The draft of the National Blood Transfusion Policy was then written in a week by two national consultants in accordance with the findings of the situation analysis. It was validated during a three-day multidisciplinary workshop and an ultimate validation was made by an international consultant in order to assess the adequacy of the options considered to the country's specific setting. The options retained for developing the Togolese blood transfusion sector development and which are consigned in the National Blood Transfusion Policy are as follows: development and implementation of blood transfusion regulations; reorganisation of the National Transfusion System by reducing it to 3 blood unit production centres: one in Lomé (the capital town), one in the centre of the country (Sokodé, 480 km from Lomé), and one in the Northern part (Dapaong, 870 km from Lomé); setting up of a system of blood collection, storage and distribution around these centres; promotion of voluntary and anonymous blood donation; promotion of quality assurance in the system and of good blood prescription practice; development and implementation of an appropriate and simple information system for better management; identification of a sustainable and equitable financing system in which the State must play a key role. The implementation of the National Blood Policy; and in particular the achievement of its goals requires: i) permanent State commitment; ii) the building of a rational action plan - with a financing framework for all blood transfusion partners; and iii) regular program evaluation.

Implementation of a national reference laboratory for Buruli ulcer disease in Togo.

BACKGROUND: In a previous study PCR analysis of clinical samples from suspected cases of Buruli ulcer disease (BUD) from Togo and external quality assurance (EQA) for local microscopy were conducted at an external reference laboratory in Germany. The relatively poor performance of local microscopy as well as effort and time associated with shipment of PCR samples necessitated the implementation of stringent EQA measures and availability of local laboratory capacity. This study describes the approach to implementation of a national BUD reference laboratory in Togo. METHODOLOGY: Large scale outreach activities accompanied by regular training programs for health care professionals were conducted in the regions "Maritime" and "Central," standard operating procedures defined all processes in participating laboratories (regional, national and external reference laboratories) as well as the interaction between laboratories and partners in the field. Microscopy was conducted at regional level and slides were subjected to EQA at national and external reference laboratories. For PCR analysis, sample pairs were collected and subjected to a dry-reagent-based IS2404-PCR (DRB-PCR) at national level and standard IS2404 PCR followed by IS2404 qPCR analysis of negative samples at the external reference laboratory. PRINCIPAL FINDINGS: The inter-laboratory concordance rates for microscopy ranged from 89% to 94%; overall, microscopy confirmed 50% of all suspected BUD cases. The inter-laboratory concordance rate for PCR was 96% with an overall PCR case confirmation rate of 78%. Compared to a previous study, the rate of BUD patients with non-ulcerative lesions increased from 37% to 50%, the mean duration of disease before clinical diagnosis decreased significantly from 182.6 to 82.1 days among patients with ulcerative lesions, and the percentage of category III lesions decreased from 30.3% to 19.2%. CONCLUSIONS: High inter-laboratory concordance rates as well as case confirmation rates of 50% (microscopy), 71% (PCR at national level), and 78% (including qPCR confirmation at external reference laboratory) suggest high standards of BUD diagnostics. The increase of non-ulcerative lesions, as well as the decrease in diagnostic delay and category III lesions, prove the effect of comprehensive EQA and training measures involving also procedures outside the laboratory.

High prevalence of HIV-1 drug resistance among patients on first-line antiretroviral treatment in Lomé, Togo.

BACKGROUND: With widespread use of antiretroviral (ARV) drugs in Africa, one of the major potential challenges is the risk of emergence of ARV drug-resistant HIV strains. Our objective is to evaluate the virological failure and genotypic drug-resistance mutations in patients receiving first-line highly active antiretroviral therapy (HAART) in routine clinics that use the World Health Organization public health approach to monitor antiretroviral treatment (ART) in Togo. METHODS: Patients on HAART for one year (10-14 months) were enrolled between April and October 2008 at three sites in Lomé, the capital city of Togo. Plasma viral load was measured with the NucliSENS EasyQ HIV-1 assay (Biomérieux, Lyon, France) and/or a Generic viral load assay (Biocentric, Bandol, France). Genotypic drug-resistance testing was performed with an inhouse assay on plasma samples from patients with viral loads of more than 1000 copies/ml. CD4 cell counts and demographic data were also obtained from medical records. RESULTS: A total of 188 patients receiving first-line antiretroviral treatment were enrolled, and 58 (30.8%) of them experienced virologic failure. Drug-resistance mutations were present in 46 patients, corresponding to 24.5% of all patients enrolled in the study. All 46 patients were resistant to non-nucleoside reverse-transcriptase inhibitors (NNRTIs): of these, 12 were resistant only to NNRTIs, 25 to NNRTIs and lamivudine/emtricitabine, and eight to all three drugs of their ARV regimes. Importantly, eight patients were already predicted to be resistant to etravirine, the new NNRTI, and three patients harboured the K65R mutation, inducing major resistance to tenofovir. CONCLUSIONS: In Togo, efforts to provide access to ARV therapy for infected persons have increased since 2003, and scaling up of ART started in 2007. The high number of resistant strains observed in Togo shows clearly that the emergence of HIV drug resistance is of increasing concern in countries where ART is now widely used, and can compromise the long-term success of first- and second-line ART.