Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses.

BACKGROUND: The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics. METHODS: An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively. RESULTS: We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response. CONCLUSION: We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.

The Nairobi Declaration 2023: A commitment to address deadly yet neglected fungal diseases in Africa.

On May 30th and 31st, 2023, delegates representing various African subregions, together with global representatives from the International Society of Human and Animal Mycology (ISHAM), the European Confederation of Medical Mycology (ECMM), the United States Centre for Disease Control and Prevention (CDC), and Global Action for Fungal Infections (GAFFI), convened in Nairobi, Kenya under the aegis of the Pan African Mycology Working Group, a working group of ISHAM. The meeting objectives were, amongst others, to deliberate on a continental response to the World Health Organisation Fungal Priority Pathogen List and facilitate interaction between global and regional leaders. Country delegates and international speakers addressed Africa's fungal disease burden; capacity for diagnosis and management; ongoing surveillance; knowledge gaps and trends in invasive fungal diseases such as Candida auris, mucormycosis, aspergillosis, and Acquired Immune Deficiency Syndrome (AIDS)-related mycoses; and current laboratory practice. During the technical sessions, expert panels deliberated on establishing and financing of national/regional surveillance networks for mycoses; establishing and sustaining African-led collaborations; expanding on existing laboratory and point-of-care diagnostic capacity as well as planning a mycology reference laboratory service and network in Africa. The meeting also highlighted successful African-led collaborations, capacity building, and clinical trial initiatives. The meeting conclusions informed the resolutions of the Nairobi Declaration calling for improved awareness; strong collaborations between clinical and laboratory teams across Africa; improved fungal disease surveillance within the continent; access to antifungals and diagnostics; and leveraging qualified human resources for mycology present within and outside Africa to facilitate trainings, collaborations, and exchanges.

This review presents the current state of the art in medical mycology in Africa discussed at the first scientific meeting of the Pan African Mycology Working Group, an affiliate of the International Society for Human and Animal Mycology (ISHAM) held in Nairobi, Kenya on May 30th and 31st, 2023.

Eumycetoma causative agents: A systematic review to inform the World Health Organization priority list of fungal pathogens.

The World Health Organization, in response to the growing burden of fungal disease, established a process to develop a fungal priority pathogens list. This systematic review aimed to evaluate the epidemiology and impact of eumycetoma. PubMed and Web of Science were searched to identify studies published between 1 January 2011 and 19 February 2021. Studies reporting on mortality, inpatient care, complications and sequelae, antifungal susceptibility, risk factors, preventability, annual incidence, global distribution, and emergence during the study time frames were selected. Overall, 14 studies were eligible for inclusion. Morbidity was frequent with moderate to severe impairment of quality of life in 60.3%, amputation in up to 38.5%, and recurrent or long-term disease in 31.8%-73.5% of patients. Potential risk factors included male gender (56.6%-79.6%), younger age (11-30 years; 64%), and farming occupation (62.1%-69.7%). Mycetoma was predominantly reported in Sudan, particularly in central Sudan (37%-76.6% of cases). An annual incidence of 0.1/100 000 persons and 0.32/100 000 persons/decade was reported in the Philippines and Uganda, respectively. In Uganda, a decline in incidence from 3.37 to 0.32/100 000 persons between two consecutive 10-year periods (2000-2009 and 2010-2019) was detected. A community-based, multi-pronged prevention programme was associated with a reduction in amputation rates from 62.8% to 11.9%. With the pre-specified criteria, no studies of antifungal drug susceptibility, mortality, and hospital lengths of stay were identified. Future research should include larger cohort studies, greater drug susceptibility testing, and global surveillance to develop evidence-based treatment guidelines and to determine more accurately the incidence and trends over time.

Candida tropicalis-A systematic review to inform the World Health Organization of a fungal priority pathogens list.

In response to the growing global burden of fungal infections with uncertain impact, the World Health Organization (WHO) established an Expert Group to identify priority fungal pathogens and establish the WHO Fungal Priority Pathogens List for future research. This systematic review aimed to evaluate the features and global impact of invasive candidiasis caused by Candida tropicalis. PubMed and Web of Science were searched for studies reporting on criteria of mortality, morbidity (defined as hospitalization and disability), drug resistance, preventability, yearly incidence, diagnostics, treatability, and distribution/emergence from 2011 to 2021. Thirty studies, encompassing 436 patients from 25 countries were included in the analysis. All-cause mortality due to invasive C. tropicalis infections was 55%-60%. Resistance rates to fluconazole, itraconazole, voriconazole and posaconazole up to 40%-80% were observed but C. tropicalis isolates showed low resistance rates to the echinocandins (0%-1%), amphotericin B (0%), and flucytosine (0%-4%). Leukaemia (odds ratio (OR) = 4.77) and chronic lung disease (OR = 2.62) were identified as risk factors for invasive infections. Incidence rates highlight the geographic variability and provide valuable context for understanding the global burden of C. tropicalis infections. C. tropicalis candidiasis is associated with high mortality rates and high rates of resistance to triazoles. To address this emerging threat, concerted efforts are needed to develop novel antifungal agents and therapeutic approaches tailored to C. tropicalis infections. Global surveillance studies could better inform the annual incidence rates, distribution and trends and allow informed evaluation of the global impact of C. tropicalis infections.

Mucorales: A systematic review to inform the World Health Organization priority list of fungal pathogens.

The World Health Organization, in response to the growing burden of fungal disease, established a process to develop a fungal priority pathogens list (FPPL). This systematic review aimed to evaluate the epidemiology and impact of invasive fungal disease due to Mucorales. PubMed and Web of Science were searched to identify studies published between January 1, 2011 and February 23, 2021. Studies reporting on mortality, inpatient care, complications and sequelae, antifungal susceptibility, risk factors, preventability, annual incidence, global distribution, and emergence during the study time frames were selected. Overall, 24 studies were included. Mortality rates of up to 80% were reported. Antifungal susceptibility varied across agents and species, with the minimum inhibitory concentrations lowest for amphotericin B and posaconazole. Diabetes mellitus was a common risk factor, detected in 65%-85% of patients with mucormycosis, particularly in those with rhino-orbital disease (86.9%). Break-through infection was detected in 13.6%-100% on azole or echinocandin antifungal prophylaxis. The reported prevalence rates were variable, with some studies reporting stable rates in the USA of 0.094-0.117/10 000 discharges between 2011 and 2014, whereas others reported an increase in Iran from 16.8% to 24% between 2011 and 2015. Carefully designed global surveillance studies, linking laboratory and clinical data, are required to develop clinical breakpoints to guide antifungal therapy and determine accurate estimates of complications and sequelae, annual incidence, trends, and global distribution. These data will provide robust estimates of disease burden to refine interventions and better inform future FPPL.

Candida glabrata (Nakaseomyces glabrata): A systematic review of clinical and microbiological data from 2011 to 2021 to inform the World Health Organization Fungal Priority Pathogens List.

Recognising the growing global burden of fungal infections, the World Health Organization (WHO) established an advisory group consisting of experts in fungal diseases to develop a Fungal Priority Pathogen List. Pathogens were ranked based on their research and development needs and perceived public health importance using a series of global surveys and pathogen characteristics derived from systematic reviews. This systematic review evaluates the features and global impact of invasive disease caused by Candida glabrata (Nakaseomyces glabrata). PubMed and Web of Science were searched for studies reporting on mortality, morbidity (hospitalization and disability), drug resistance (including isolates from sterile and non-sterile sites, since these reflect the same organisms causing invasive infections), preventability, yearly incidence, diagnostics, treatability, and distribution/emergence in the last 10 years. Candida glabrata (N. glabrata) causes difficult-to-treat invasive infections, particularly in patients with underlying conditions such as immunodeficiency, diabetes, or those who have received broad-spectrum antibiotics or chemotherapy. Beyond standard infection prevention and control measures, no specific preventative measures have been described. We found that infection is associated with high mortality rates and that there is a lack of data on complications and sequelae. Resistance to azoles is common and well described in echinocandins-in both cases, the resistance rates are increasing. Candida glabrata remains mostly susceptible to amphotericin and flucytosine. However, the incidence of the disease is increasing, both at the population level and as a proportion of all invasive yeast infections, and the increases appear related to the use of antifungal agents.

Talaromyces marneffei, Coccidioides species, and Paracoccidioides species-a systematic review to inform the World Health Organization priority list of fungal pathogens.

The World Health Organization, in response to the growing burden of fungal disease, established a process to develop a fungal pathogen priority list. This systematic review aimed to evaluate the epidemiology and impact of infections caused by Talaromyces marneffei, Coccidioides species, and Paracoccidioides species. PubMed and Web of Sciences databases were searched to identify studies published between 1 January 2011 and 23 February 2021 reporting on mortality, complications and sequelae, antifungal susceptibility, preventability, annual incidence, and trends. Overall, 25, 17, and 6 articles were included for T. marneffei, Coccidioides spp. and Paracoccidioides spp., respectively. Mortality rates were high in those with invasive talaromycosis and paracoccidioidomycosis (up to 21% and 22.7%, respectively). Hospitalization was frequent in those with coccidioidomycosis (up to 84%), and while the duration was short (mean/median 3-7 days), readmission was common (38%). Reduced susceptibility to fluconazole and echinocandins was observed for T. marneffei and Coccidioides spp., whereas >88% of T. marneffei isolates had minimum inhibitory concentration values ≤0.015 µg/ml for itraconazole, posaconazole, and voriconazole. Risk factors for mortality in those with talaromycosis included low CD4 counts (odds ratio 2.90 when CD4 count <200 cells/µl compared with 24.26 when CD4 count <50 cells/µl). Outbreaks of coccidioidomycosis and paracoccidioidomycosis were associated with construction work (relative risk 4.4-210.6 and 5.7-times increase, respectively). In the United States of America, cases of coccidioidomycosis increased between 2014 and 2017 (from 8232 to 14 364/year). National and global surveillance as well as more detailed studies to better define sequelae, risk factors, outcomes, global distribution, and trends are required.

Organ donation and HIV: Awareness and willingness to be a living donor among people with HIV in Uganda.

BACKGROUND: HIV+-to-HIV+ organ transplantation has demonstrated promise and is now authorized for research purposes in certain countries. However, organ transplantation is dependent on the availability of organ donors. We assessed the awareness and willingness to donate organs among people with HIV (PWH) in Uganda. METHODS: We conducted a multicenter cross-sectional study between October 2023 and January 2024 in four large HIV clinics in Northern Uganda. The study population consisted of PWH. A structured questionnaire was used to collect data regarding awareness, willingness, and beliefs regarding organ donation. Organ donation was defined as the willingness to be a living donor of a solid organ. We conducted multivariable logistic regression to assess for an association between willingness to donate organs and selected exposures. Data were analyzed in Stata version 15.0. Results are expressed as adjusted odds ratio (AOR) with 95% confidence intervals (CI). RESULTS: A total of 232 participants were recruited. The mean age ± standard deviation of the participants was 42.2±11.8 years. All participants were on antiretroviral therapy. Sixty-two (26.7%) had a CD4 count less than or equal to 200 cells/mm3. The majority (80.6%, n = 187) had ever heard of organ donation. Slightly more than a third (34.9%, n = 81) were willing to donate organs. Factors associated with willingness to be a living organ donor included being female (AOR: 1.56; 95% CI: 1.15-2.11), having a tertiary education level (AOR: 1.79; 95% CI: 1.03-3.11), average monthly income >500 000 UGX (135.1USD) (AOR: 5.5; 95% CI: 1.97-15.40), ever heard about organ donation (AOR: 5.4; 95% CI: 1.67-17.8), and attending an organ donation campaign (AOR: 2.0; 95% CI: 1.07-3.74). CONCLUSIONS: Awareness about organ donation was high but the willingness to be a living organ donor was low among PWH in Uganda. There is a need to sensitize the community about the need and benefits of organ donation with the involvement of media and the healthcare workers.

Association between biomarkers of inflammation and dyslipidemia in drug resistant tuberculosis in Uganda.

BACKGROUND: Active tuberculosis (TB) significantly increases the risk of cardiovascular disease, but the underlying mechanisms remain unclear. This study aimed to investigate the association between inflammation biomarkers and dyslipidemia in patients with drug-resistant TB (DR-TB). METHODS: This was a secondary analysis of data from a cross-sectional multi-center study in Uganda conducted 2021. Participants underwent anthropometric measurements and laboratory tests included a lipid profile, full haemogram and serology for HIV infection. Dyslipidemia was defined as total cholesterol > 5.0 mmol/l and/or low-density lipoprotein cholesterol > 4.14 mmol/l, and/or triglycerides (TG) ≥ 1.7 mmol/l, and/or high density lipoprotein cholesterol (HDL-c) < 1.03 mmol/l for men and < 1.29 mmol/l for women. Biomarkers of inflammation were leukocyte, neutrophil, lymphocyte, monocyte, and platelet counts, as well as neutrophil/lymphocyte (NLR), platelet/lymphocyte, and lymphocyte/monocyte (LMR) ratios, mean corpuscular volume (MCV), and the systemic immune inflammation index (SII) (neutrophil × platelet/lymphocyte). Modified Poisson Regression analysis was used for determining the association of the biomarkers and dyslipidemia. RESULTS: Of 171 participants, 118 (69.0%) were co-infected with HIV. The prevalence of dyslipidemia was 70.2% (120/171) with low HDL-c (40.4%, 69/171) and hypertriglyceridemia (22.5%, 38/169) being the most common components. Patients with dyslipidemia had significantly higher lymphocyte (P = 0.008), monocyte (P < 0.001), and platelet counts (P = 0.014) in addition to a lower MCV (P < 0.001) than those without dyslipidemia. Further, patients with dyslipidemia had lower leucocyte (P < 0.001) and neutrophil (P = 0.001) counts, NLR (P = 0.008), LMR (P = 0.006), and SII (P = 0.049). The MCV was inversely associated with low HDL-C (adjusted prevalence ratio (aPR) = 0.97, 95% CI 0.94-0.99, P = 0.023) but was positively associated with hypertriglyceridemia (aPR = 1.04, 95% CI 1.00-1.08, P = 0.052). CONCLUSIONS: Individuals with dyslipidemia exhibited elevated lymphocyte, monocyte, and platelet counts compared to those without. However, only MCV demonstrated an independent association with specific components of dyslipidemia. There is need for further scientific inquiry into the potential impact of dyslipidemia on red cell morphology and a pro-thrombotic state among patients with TB.

One year overall survival of wilms tumor cases and its predictors, among children diagnosed at a teaching hospital in South Western Uganda: a retrospective cohort study.

BACKGROUND: Wilms tumor (WT) is the second most common solid tumor in Africa with both low overall survival (OS) and event-free survival (EFS) rates. However, no known factors are predicting this poor overall survival. OBJECTIVE: The study was to determine the one-year overall survival of WT cases and its predictors among children diagnosed in the pediatric oncology and surgical units of Mbarara regional referral hospital (MRRH), western Uganda. METHODOLOGY: Children's treatment charts and files diagnosed and managed for WT were retrospectively followed up for the period between January 2017 to January 2021. Charts of children with histologically confirmed diagnoses were reviewed for demographics, clinical and histological characteristics, as well as treatment modalities. RESULTS: One-year overall survival was found to be 59.3% (95% CI: 40.7-73.3), with tumor size greater than 15 cm (p 0.021) and unfavorable WT type (p 0.012) being the predominant predictors. CONCLUSION: Overall survival (OS) of WT at MRRH was found to be 59.3%, and predictive factors noted were unfavorable histology and tumor size greater than 115 cm.

Onychomycosis in Patients with Diabetes Mellitus in Africa: A Global Scoping Review, 2000-2021.

Onychomycosis is commonly studied in Africa but not in patients with diabetics despite having a significant number of her population living with diabetes mellitus (DM). Our review highlights a total of 15 studies with only two from Africa over the past two decades; 8 (53.3%) from Asia, 4 (26.7%) from Europe, 2 (13.3%) from Africa and 1 (6.7%) from North America. A total number of 4321 participants were involved with onychomycosis prevalence of 35.3% (1527/4321). Seven studies documented preponderance of onychomycosis in males, one showed preponderance in females, one showed no statistically significant difference in gender, while correlation with gender was unclear in the remainder. The risk factors identified were duration of diabetes, increasing age, occupation (agriculture), subclinical atherosclerosis, metabolic syndrome, obesity, triglyceride levels, and glycosylated haemoglobin. Three case control studies showed a statistically significant correlation between onychomycosis and individuals with DM. Diagnosis was mainly by microscopy and culture with Trichophyton (T) rubrum as the predominant isolate. Fungal nail infections are grossly underdiagnosed and/or underreported in Africa and hence the need for improved awareness and diagnosis especially in patients with DM. Although focused on Africa, this study also revealed paucity of data on onychomycosis in diabetic patients living in the Americas despite evidence from the literature showing a significant number of individuals from that region are living with diabetes. The need to evaluate this at-risk population for onychomycosis cannot be over emphasized.

The Impact of Chronic Pulmonary Aspergillosis Co-infection on the Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Uganda.

BACKGROUND: Both pulmonary tuberculosis (PTB) and chronic pulmonary aspergillosis (CPA) significantly affect health-related quality of life (HR-QoL). We aimed to determine the impact of CPA co-infection on the HR-QoL of Ugandans with PTB. METHODS: We conducted a prospective study as part of a larger study among participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020 and June 2021. HR-QoL was assessed using St. George Respiratory Questionnaire (SGRQ) at enrollment and at the end of PTB treatment (4 months apart). SGRQ scores range from 0 to 100, with higher score representing a poorer HR-QoL. RESULTS: Of the 162 participants enrolled in the larger study, 32 (19.8%) had PTB + CPA and 130 (80.2%) had PTB. The baseline characteristics of the two groups were comparable. Regarding overall health, a higher proportion of the PTB group rated their HR-QoL as "very good" compared to those who had PTB + CPA (68 [54.0%] versus 8 [25.8%]). At enrollment, both groups had comparable median SGRQ scores. However, at follow up, the PTB group had statistically significantly better SGRQ scores (interquartile range); symptoms (0 [0-12.4] versus 14.4 [0-42.9], p < 0.001), activity ((0 [0-17.1] versus 12.2 [0-35.5], p = .03), impact (0 [0-4.0] versus 3.1 [0-22.5], p = 0.004), and total scores ((0 [0-8.5] versus 7.6[(0-27.4], p = 0.005). CONCLUSION: CPA co-infection impairs HR-QoL of people with PTB. Active screening and management of CPA in patients with PTB is recommended to improve HR-QoL of these individuals.

Higher intensive care unit consultations for COVID-19 patients living with HIV compared to those without HIV coinfection in Uganda.

Coronavirus disease-2019 (COVID-19) is the leading cause of death worldwide from a single infectious agent. Whether or not HIV infection affects clinical outcomes in patients with COVID-19 remains inconclusive. This study aimed to compare the clinical outcomes of people living with HIV (PLWH) and non-HIV-infected patients hospitalized during the second wave of the COVID-19 pandemic in Uganda. We retrospectively retrieved data on patients with COVID-19 who were admitted to the Mulago National Referral Hospital in Uganda between April 2021 and mid-July 2021. We performed propensity-score-matching of 1:5 to compare outcomes in COVID-19 patients living with and those without HIV coinfection (controls). We included 31 PLWH and 155 non-HIV controls. The baseline characteristics were similar across groups (all p values > 0.05). PLWH had close to threefold higher odds of having ICU consultation compared to controls (odds ratio [OR]: 2.9, 95% CI: 1.2-6.9, p = 0.015). There was a trend toward having a severe or critical COVID-19 illness among PLWHIH compared to controls (OR: 1.9, 95% CI: 0.8-4.7, p = 0.164). Length of hospitalization was not significantly different between PLWH and non-HIV controls (6 days vs. 7 days, p = 0.184). Seven-day survival was 63% (95% CI: 42%-78%) among PLWH and 72% (95% CI: 61%-82%) among controls while 14-day survival was 50% (95% CI: 28%-69%) among PLWH and 65% (95% CI: 55%-73%) among controls (p = 0.280). There was another trend toward having 1.7-fold higher odds of mortality among PLWH compared to controls (OR: 1.7, 95% CI: 0.8-3.8, p = 0.181). Our data suggest that PLWH may be at an increased risk of severe or critical COVID-19 illness requiring ICU consultation. Further studies with larger sample sizes are recommended.

A 10-year retrospective study of lung cancer in Uganda.

BACKGROUND: Lung cancer is a leading cause of cancer-related deaths in Uganda. In this study, we aimed to describe the baseline characteristics and survival of patients with lung cancer at the Uganda Cancer Institute (UCI). METHODS: We retrospectively reviewed medical records of all patients with a histological diagnosis of lung cancer registered at UCI between January 2008 and August 2018. Data on demographic, clinical, and treatment characteristics, and vital status were abstracted and analyzed. Patients with undocumented vital status on the medical records were contacted through phone calls. We determined survival as time from histological diagnosis to death. The Kaplan-Meier survival analysis was performed to estimate the median survival time and the 5-year overall survival rate. RESULTS: Of the 207 patients enrolled, 56.5% (n = 117) were female, median age was 60 years (range: 20-94), 78.7% (n = 163) were never-smokers and 18 (8.7%) were living with HIV. Presumptive anti-tuberculosis treatment was given to 23.2% (n = 48). Majority had non-small cell lung cancer (96.6%, n = 200) with 74.5% (n = 149) adenocarcinoma and 19% (n = 38) squamous cell carcinoma. All had advanced (stage III or IV) disease with 96.1% (n = 199) in stage IV. Chemotherapy (44.9%, n = 93) and biological therapy (34.8%, n = 72) were the commonest treatments used. Overall survival at 6 months, 1-, 2- and 5-years was 41.7, 29.7, 11.8, and 1.7%, respectively. The median survival time of 4.4 months was not statistically significantly different between participants with NSCLC or SCLC (4.5 versus 3.9 months, p = .335). CONCLUSION: In Uganda, adenocarcinoma is the predominant histologic subtype of lung cancer and patients are predominantly females, and non-smokers. Patients present late with advanced disease and poor overall survival. Public awareness should be heightened to facilitate early detection and improve outcomes.

Availability and affordability of essential medicines and diagnostic tests for diabetes mellitus in Africa.

OBJECTIVE: To investigate the current status of the availability and affordability of specific essential medicines and diagnostics for diabetes in Africa. METHODS: Systematic review and meta-analysis. Studies conducted in Africa that reported any information on the availability and affordability of short-acting, intermediate-acting, and premixed insulin, glibenclamide, metformin, blood glucose, glycated haemoglobin or HbA1c, and lipid profile tests were included. Random-effect model meta-analysis and descriptive statistics were performed to determine the pooled availability and affordability, respectively. RESULTS: A total of 21 studies were included. The pooled availability of each drug was as follows: short-acting insulin 33.5% (95% CI: 17.8%-49.2%, I2  = 95.02%), intermediate-acting insulin 23.1% (95% CI: 6.3%-39.9%, I2  = 91.6%), premixed insulin 49.4% (95% CI: 24.9%-73.9%, I2  = 90.57%), glibenclamide 55.9% (95% CI: 43.8%-68.0%, I2  = 96.7%), and metformin 47.0% (95% CI: 34.6%-59.4%, I2  = 97.54%). Regarding diagnostic tests, for glucometers the pooled availability was 49.5% (95% CI: 37.9%-61.1%, I2  = 97.43%), for HbA1c 24.6% (95% CI: 3.1%-46.1%, I2  = 91.64), and for lipid profile tests 35.7% (95% CI: 19.4%-51.9%, I2  = 83.77%). The median (IQR) affordability in days' wages was 7 (4.7-7.5) for short-acting insulin, 4.4 (3.9-4.9) for intermediate-acting insulin, 7.1 (5.8-16.7) for premixed insulin, 0.7 (0.7-0.7) for glibenclamide, and 2.1 (1.8-2.8) for metformin. CONCLUSION: The availability of the five essential medicines and three diagnostic tests for diabetes in Africa is suboptimal. The relatively high cost of insulin, HbA1c, and lipid profile tests is a significant barrier to optimal diabetes care. Pragmatic country-specific strategies are urgently needed to address these inequities in access and cost.

Prevalence, antifungal susceptibility and etiology of vulvovaginal candidiasis in sub-Saharan Africa: a systematic review with meta-analysis and meta-regression.

Vulvovaginal candidiasis (VVC) is a commonly occurring form of mucocutaneous candidiasis in women. The aim of this study was to comprehensively investigate the prevalence, antifungal susceptibility, and etiology of VVC in sub-Saharan Africa (SSA). A search of studies was conducted in seven online databases and the reference lists of selected studies. Observational studies published between January 2000, to July 2021, that met the eligibility criteria were included. Meta-analyses with random and fixed-effects model, and subgroup analyses were performed using STATA 16.0. A total of 41 studies including 15 723 participants were included in the meta-analyses. The pooled prevalence of VVC was 33% (95% Confidence Interval (CI): 28-38%, I2 = 98%, P < 0.001). Pregnant women had 6% higher odds of having VVC compared to non-pregnant women Odds Ratio (OR): 1.06, 95% CI: 0.99-1.13, P = 0.107). The odds of diagnosing VVC were 40% higher in symptomatic patients than general study population (OR: 1.4, 95% CI: 1.3-1.5, P < 0.0001). In 17 studies, a total of 2112 isolates of Candida species were reported: 1514 (71.7%) Candida albicans, 510 (24.1%) non-albicans Candida (NAC) species and 88 (4.2%) unidentified Candida spp. Of the NAC species detected, Candida glabrata (40.9%, n = 209), Candida krusei (21.2%, n = 108), and Candida tropicalis (22.7%, n = 116) were the most common. Resistance to fluconazole in Candida albicans using disc diffusion methods ranged from 6.8% in Cameroon to 53.7% in Ethiopia. One-third of women in SSA have VVC, mainly caused by C. albicans. Data on the susceptibility of the Candida isolates to commonly used antifungal agents is limited and warrants further research. LAY SUMMARY: The overarching aim of this study was to comprehensively investigate the prevalence, antifungal susceptibility, and causative species of vulvovaginal candidiasis (VVC) in sub-Saharan Africa (SSA). A detailed search of studies was conducted to retrieve eligible observational studies published 'between' January 1, 2000, to July 31, 2021. From the 41 selected studies including 15 723 participants, VVC was found in 33% of the participants. The chances of diagnosing VVC was 40% higher in symptomatic patients compared to the general study population. In 71.7% of the cases, C. albicans was the causative species of VVC. We conclude that about one-third of women in SSA have VVC, mainly caused by C. albicans.

Prevalence of anaemia and associated factors among people with pulmonary tuberculosis in Uganda.

Anaemia predicts delayed sputum conversion and mortality in tuberculosis (TB). We determined the prevalence and factors associated with anaemia among people with TB at the National Tuberculosis Treatment Centre in Uganda. People with bacteriologically confirmed TB were consecutively enrolled in a cross-sectional study between August 2017 and March 2018. Blood samples were tested for a full blood hemogram, HIV infection, and CD4+ and CD8+ T-cell counts. Anaemia was defined as a haemoglobin level of <13.0 grams per decilitre (g/dl) for males and <12.0 g/dl for females. Of 358 participants, 210 (58.7%, 95% confidence interval (CI) 53.4-63.8) had anaemia. Anaemia was associated with night sweats, a longer duration of fever, low body mass index (BMI), hyperthermia, high sputum bacillary loads, HIV co-infection, and low CD4 and CD8 counts at bivariate analysis. Factors associated with anaemia at multivariable analysis were low BMI (odds ratio (OR) 2.93, 95% CI 1.70-5.05, P < 0.001), low CD4:CD8 ratio (OR 2.54, 95% CI 1.07-6.04, P = 0.035) and microcytosis (OR 4.23, 95% CI 2.17-8.25, P < 0.001). Anaemia may be associated with the features of severe TB disease and should be considered in TB severity scores.

Cardiovascular risk factors among people with drug-resistant tuberculosis in Uganda.

BACKGROUND: Tuberculosis (TB) and its risk factors are independently associated with cardiovascular disease (CVD). We determined the prevalence and associations of CVD risk factors among people with drug-resistant tuberculosis (DRTB) in Uganda. METHODS: In this cross-sectional study, we enrolled people with microbiologically confirmed DRTB at four treatment sites in Uganda between July to December 2021. The studied CVD risk factors were any history of cigarette smoking, diabetes mellitus (DM) hypertension, high body mass index (BMI), central obesity and dyslipidaemia. We used modified Poisson regression models with robust standard errors to determine factors independently associated with each of dyslipidaemia, hypertension, and central obesity. RESULTS: Among 212 participants, 118 (55.7%) had HIV. Overall, 196 (92.5%, 95% confidence interval (CI) 88.0-95.3) had ≥ 1 CVD risk factor. The prevalence; 95% CI of individual CVD risk factors was: dyslipidaemia (62.5%; 55.4-69.1), hypertension (40.6%; 33.8-47.9), central obesity (39.3%; 32.9-46.1), smoking (36.3%; 30.1-43.1), high BMI (8.0%; 5.0-12.8) and DM (6.5%; 3.7-11.1). Dyslipidaemia was associated with an increase in glycated haemoglobin (adjusted prevalence ratio (aPR) 1.14, 95%CI 1.06-1.22). Hypertension was associated with rural residence (aPR 1.89, 95% CI 1.14-3.14) and previous history of smoking (aPR 0.46, 95% CI 0.21-0.98). Central obesity was associated with increasing age (aPR 1.02, 95%CI 1.00-1.03), and elevated diastolic blood pressure (aPR 1.03 95%CI 1.00-1.06). CONCLUSION: There is a high prevalence of CVD risk factors among people with DRTB in Uganda, of which dyslipidaemia is the commonest. We recommend integrated services for identification and management of CVD risk factors in DRTB.

Chronic pulmonary aspergillosis in patients with active pulmonary tuberculosis with persisting symptoms in Uganda.

BACKGROUND: The occurrence of chronic pulmonary aspergillosis (CPA) among drug sensitive pulmonary tuberculosis (PTB) patients on optimal therapy with persistent symptoms was investigated. METHODS: We consecutively enrolled participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda, between July 2020 and June 2021. CPA was defined as a positive Aspergillus-specific IgG/IgM immunochromatographic test (ICT), a cavity with or without a fungal ball on chest X-ray (CXR), and compatible symptoms >3 months. RESULTS: We enrolled 162 participants (median age 30 years; IQR: 25-40), 97 (59.9%) were male, 48 (29.6%) were HIV-infected and 15 (9.3%) had prior PTB. Thirty-eight (23.4%) sputum samples grew A. niger and 13 (8.0%) A. fumigatus species complexes. Six (3.7%) participants had intracavitary fungal balls and 52 (32.1%) had cavities. Overall, 32 (19.8%) participants had CPA. CPA was associated with prior PTB (adjusted odds ratio [aOR]: 6.61, 95% CI: 1.85-23.9, p = .004), and far advanced CXR changes (aOR: 4.26, 95% CI: 1.72-10.52, p = .002). The Aspergillus IgG/IgM ICT was positive in 10 (31.3%) participants with CPA. CONCLUSIONS: Chronic pulmonary aspergillosis may cause persistent respiratory symptoms in up to one-fifth of patients after intensive treatment for PTB. The Aspergillus IgG/IgM ICT positivity rate was very low and may not be used alone for the diagnosis of CPA in Uganda.

Tuberculosis contact tracing yield and associated factors in Uganda.

BACKGROUND: The yield of tuberculosis (TB) contact tracing is historically low in Uganda. We determined factors associated with a positive contact tracing yield at an urban public TB clinic in Kampala, Uganda. METHODS: We reviewed contact tracing registers of index TB cases registered between 2015 and 2020 at Kitebi Health Center, a primary level facility. Contacts who had symptoms of TB were designated as having presumptive TB. A contact investigation that yielded a new TB case was designated as a positive yield. We used logistic regression to determine factors associated with a positive yield of contact tracing. RESULTS: Of 778 index TB cases, 455 (58.5%) had a contact investigation conducted. Index cases with a telephone contact in the unit TB register (adjusted odds ratio (aOR) 1.66, 95% CI 1.02-1.97, p = 0.036) were more likely to have a contact investigation conducted than those who did not. Of 1350 contacts, 105 (7.8%) had presumptive TB. Of these, 73 (69.5%) were further evaluated for active TB and 29 contacts had active TB. The contact tracing yield for active TB was therefore 2.1% (29/1,350). The odds of a positive yield increased tenfold with each additional presumptive contact evaluated for active TB (aOR 10.1, 95% CI 2.95-34.66, p < 0.001). Also, retreatment index TB cases were more likely to yield a positive contact (aOR 7.69 95% CI 2.08-25.00, p = 0.002) than to new cases. CONCLUSION: TB contact tracing should aim to evaluate all contacts with presumptive TB and contacts of retreatment cases to maximise the yield of contact tracing.