APOL1-Mediated Kidney Disease.

This JAMA Insights reviews the origin of APOL1 high-risk genetic variants, defines APOL1-mediated kidney disease, and discusses recommendations for screening and management.

Hepatocellular carcinoma risk in sub-Saharan African and Afro-Surinamese individuals with chronic hepatitis B living in Europe.

BACKGROUND & AIMS: Sub-Saharan African (SSA) ethnicity has been associated with a higher risk of hepatocellular carcinoma (HCC) among individuals with chronic hepatitis B in cross-sectional studies. However, the incidence of HCC and performance of HCC risk scores in this population are unknown. METHODS: We conducted an international multicenter retrospective cohort study of all consecutive HBV-monoinfected individuals of SSA or Afro-Surinamese (AS) ethnicity managed at sites in the Netherlands, the United Kingdom and Spain. We assessed the 5- and 10-year cumulative incidences of HCC in the overall study population, among different clinically relevant subgroups and across (m)PAGE-B subgroups. Next, we explored the different risk factors for HCC. RESULTS: During a median follow-up of 8 years, we analyzed 1,473 individuals of whom 34 developed HCC. The 5- and 10-year cumulative incidences of HCC were 1% and 2.4%. The 10-year cumulative incidence of HCC was 0.7% among individuals without advanced fibrosis at baseline, compared to 12.1% among individuals with advanced fibrosis (p <0.001). Higher age (adjusted hazard ratio [aHR] 1.05), lower platelet count (aHR 0.98), lower albumin level (aHR 0.90) and higher HBV DNA log10 (aHR 1.21) were significantly associated with HCC development. The 10-year cumulative incidence of HCC was 0.5% among individuals with a low PAGE-B score, compared to 2.9% in the intermediate- and 15.9% in the high-risk groups (p <0.001). CONCLUSIONS: In this unique international multicenter cohort of SSA and AS individuals with chronic hepatitis B, we observed 5- and 10-year cumulative HCC risks of 1% and 2.4%, respectively. The risk of HCC was negligible for individuals without advanced fibrosis at baseline, and among individuals with low baseline (m)PAGE-B scores. These findings can be used to guide HCC surveillance strategies. IMPACT AND IMPLICATIONS: Sub-Saharan African ethnicity has been associated with a higher risk of hepatocellular carcinoma among individuals with chronic hepatitis B. In this international multicenter cohort study of sub-Saharan African and Afro-Surinamese individuals living with chronic hepatitis B in Europe, we observed 5- and 10-year cumulative incidences of hepatocellular carcinoma of 1% and 2.4%, respectively. The risk was negligible among individuals without advanced fibrosis and a low baseline (m)PAGE-B score. These findings can be used to guide HCC surveillance strategies in this population.

Intimate partner violence and child loss: an evaluation of 7 sub-Saharan African countries.

Purpose: Intimate partner violence (IPV) and child loss disproportionately affect women in sub-Saharan Africa (SSA). Little research has examined the relationship between IPV and child loss in SSA. Methods: We used data from Demographic Health Surveys in 7 countries in SSA (Côte d'Ivoire, Democratic Republic of the Congo, Namibia, Sierra Leone, Togo, Zambia, and Rwanda). Women's Health Module questions assessed lifetime physical, sexual, and emotional IPV. Child loss was calculated as the difference between the number of child births and the number of living children. Logistic regression was conducted adjusting for age, marital status, educational attainment, location of residence, wealth, sexually transmitted infections, and country of origin. Data were weighted and analysed using STATA Software (14.0). Results: Among women who gave birth, approximately one third (31.7%) reported that they lost 1 or more children. Nearly half (44.3%) reported that they experienced physical IPV during their lifetime. Women who had experienced physical, emotional, or sexual IPV were significantly more likely to report a loss of 1 or more children (OR=1.20, 95% confidence interval (CI)= [1.08, 1.33]; OR=1.30, 95% CI= [1.16, 1.45]; OR=1.42, 95% CI= [1.23, 1.65], respectively) in comparison with women who had not experienced IPV controlling for potentially influential covariates. Women who were older, married, had lower educational attainment, and had lower income were more likely to have lost 1 or more children. Conclusion: These results suggest that women who experienced all types of and cumulative exposure to IPV may be more likely to lose a child in SSA.

Changes in rates of psychiatric beds and prison populations in sub-Saharan Africa from 1990 to 2020.

Background: Psychiatric bed numbers (general, forensic, and residential) and prison populations have been considered indicators of institutionalization. The present study aimed to assess changes of those indicators across sub-Saharan Africa (SSA) from 1990 to 2020. Methods: We retrospectively obtained data on psychiatric bed numbers and prison populations from 46 countries in SSA between 1990 and 2020. Mean and median rates, as well as percentage changes between first and last data points were calculated for all of SSA and for groups of countries based on income levels. Results: Primary data were retrieved from 17 out of 48 countries. Data from secondary sources were used for 29 countries. From two countries, data were unavailable. The median rate of psychiatric beds decreased from 3.0 to 2.2 per 100 000 population (median percentage change = -16.1%) between 1990 and 2020. Beds in forensic and residential facilities were nonexistent in most countries of SSA in 2020, and no trend for building those capacities was detected. The median prison population rate also decreased from 77.8 to 71.0 per 100 000 population (-7.8%). There were lower rates of psychiatric beds and prison populations in low-income and lower-middle income countries compared with upper-middle income countries. Conclusions: SSA countries showed, on average, a reduction of psychiatric bed rates from already very low levels, which may correspond to a crisis in acute psychiatric care. Psychiatric bed rates were, on average, about one twenty-fifth of countries in the Organization for Economic Co-operation and Development (OECD), while prison population rates were similar. The heterogeneity of trends among SSA countries over the last three decades indicates that developments in the region may not have been based on coordinated policies and reflects unique circumstances faced by the individual countries.

Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers.

BACKGROUND: Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development. OBJECTIVES: We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024). RESULTS: In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11). CONCLUSIONS: Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials.

BACKGROUND: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design. OBJECTIVES: We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS: SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation. CONCLUSIONS: The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Small-quantity lipid-based nutrient supplements for the prevention of child malnutrition and promotion of healthy development: overview of individual participant data meta-analysis and programmatic implications.

Small-quantity lipid-based nutrient supplements (SQ-LNSs) were designed to provide multiple micronutrients within a food base that also provides energy, protein, and essential fatty acids, targeted towards preventing malnutrition in vulnerable populations. Previous meta-analyses demonstrated beneficial effects of SQ-LNSs on child growth, anemia, and mortality. To further examine the efficacy and effectiveness of SQ-LNSs, and explore study-level and individual-level effect modifiers, we conducted an individual participant data meta-analysis of 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n > 37,000). We examined growth, development, anemia, and micronutrient status outcomes. Children who received SQ-LNSs had a 12-14% lower prevalence of stunting, wasting, and underweight; were 16-19% less likely to score in the lowest decile for language, social-emotional, and motor development; had a 16% lower prevalence of anemia; and had a 64% lower prevalence of iron-deficiency anemia compared with control group children. For most outcomes, beneficial effects of SQ-LNSs were evident regardless of study-level characteristics, including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average reported compliance with SQ-LNSs. For development, the benefits of SQ-LNSs were greater in populations with higher stunting burden, in households with lower socioeconomic status, and among acutely malnourished children. For hemoglobin and iron status, benefits were greater in populations with higher anemia prevalence and among acutely malnourished children, respectively. Thus, targeting based on potential to benefit may be worthwhile for those outcomes. Overall, co-packaging SQ-LNSs with interventions that reduce constraints on response, such as the prevention and control of prenatal and child infections, improving health care access, and promotion of early child development, may lead to greater impact. Policymakers and program planners should consider including SQ-LNSs in strategies to reduce child mortality, stunting, wasting, anemia, iron deficiency, and delayed development. This study was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592, CRD42020159971, and CRD42020156663.

Mapping socioeconomic inequalities in malaria in Sub-Sahara African countries.

Despite reductions in malaria incidence and mortality across Sub-Saharan (SSA) countries, malaria control and elimination efforts are currently facing multiple global challenges such as climate and land use change, invasive vectors, and disruptions in healthcare delivery. Although relationships between malaria risks and socioeconomic factors have been widely demonstrated, the strengths and variability of these associations have not been quantified across SSA. In this study, we used data from population-based malaria indicator surveys in SSA countries to assess spatial trends in relative and absolute socioeconomic inequalities, analyzed as social (mothers' highest educational level-MHEL) and economic (wealth index-WI) inequalities in malaria prevalence. To capture spatial variations in socioeconomic (represented by both WI and MHEL) inequalities in malaria, we calculated both the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) in each administrative region. We also conducted cluster analyses based on Local Indicator of Spatial Association (LISA) to consider the spatial auto-correlation in SII and RII across regions and countries. A total of 47,404 participants in 1874 Primary Sampling Units (PSU) were analyzed across the 13 SSA countries. Our multi-country assessment provides estimations of strong socioeconomic inequalities between and within SSA countries. Such within- and between- countries inequalities varied greatly according to the socioeconomic metric and the scale used. Countries located in Eastern Africa showed a higher median Slope Index of Inequality (SII) and Relative Index of Inequality (RII) in malaria prevalence relative to WI in comparison to countries in other locations across SSA. Pockets of high SII in malaria prevalence in relation to WI and MHEL were observed in the East part of Africa. This study was able to map this wide range of malaria inequality metrics at a very local scale and highlighted the spatial clustering patterns of pockets of high and low malaria inequality values.

Technical viability of the YF MAC-HD ELISA kit for use in yellow fever-endemic regions.

Yellow fever (YF), an arboviral disease, affects an estimated 200,000 people and causes 30,000 deaths per year and recently has caused major epidemics in Africa and South America. Timely and accurate diagnosis of YF is critical for managing outbreaks and implementing vaccination campaigns. A YF immunoglobulin M (IgM) antibody-capture (MAC) enzyme-linked immunosorbent assay (ELISA) kit, the YF MAC-HD, was successfully introduced starting in 2018 to laboratories in Africa and South America. The YF MAC-HD kit can be performed in 3.5 hours, test up to 24 samples, and includes all reagents necessary to perform the test, except for water used to dilute wash buffer. In 2018 and 2019, a total of 56 laboratory personnel from 39 countries in Africa and South America were trained to use the kit during workshops, followed by take-home YF IgM proficiency testing (PT) exercises. Participants received either a 10- or 20-sample YF PT panel and performed testing using the YF MAC-HD kit. All countries obtained 90% or higher correct results. These results verified the technical viability and transferability of YF MAC-HD kit use for laboratories in YF-endemic countries.

With Bare Feet in the Soil: Podoconiosis, a Neglected Cause of Tropical Lymphoedema.

Podoconiosis is a form of lymphoedema that occurs in tropical highland areas in genetically susceptible individuals who are exposed to irritant volcanic soils. The disease is preventable through consistent use of footwear and attention to foot hygiene; however, in endemic areas there is a strong barefoot tradition, and many cannot afford shoes. Patients with podoconiosis face significant physical disability, psychological comorbidity, reduced quality of life and experience frequent episodes of systemic illness due to acute dermatolymphangioadenitis. This review provides an overview of this important and neglected tropical skin disease and summarizes the latest research findings.

One size does not fit all. How universal standards for normal height can hide deprivation and create false paradoxes.

Public health practitioners and social scientists frequently compare height against one-size-fits-all standards of human growth to assess well-being, deprivation, and disease risk. However, underlying differences in height can make some naturally tall populations appear well-off by universal standards, even though they live in severe states of deprivation. In this article, I describe the worldwide extent of these population differences in height and illustrate how using a universal yardstick to compare population height can create puzzling disparities (eg, between South Asia and sub-Saharan Africa) while also underestimating childhood stunting in specific world regions (eg, West Africa and Haiti). I conclude by discussing potential challenges of developing and implementing population-sensitive standards for assessing healthy development.

Correlates of diabetic polyneuropathy of the elderly in Sub-Saharan Africa.

BACKGROUND: Diabetic polyneuropathy is associated with significant physical disability among older adults. However, their frequency and correlates are not well known in the older adults in Sub-Saharan-Africa. The objectives were to evaluate the hospital-based prevalence of diabetic polyneuropathy and identify its correlates in older adults. METHODS: Over a period of 5 months, a cross-sectional survey was carried out at Douala Laquintinie Hospital (DLH), a main reference hospital in Douala, the economic capital of Cameroon. Participants in our study group comprised all patients with type 2 diabetes, whatever the reason for their reporting to the hospital. Diabetic Polyneuropathy was defined according to a Diabetic Neuropathy Examination score > 3/16. RESULTS: A total of 159 older adults with diabetes were examined during this recruitment period, among whom 106 (66.7%) were women. The mean age was 68.3 ± 6.5 years. Diabetes median duration was 108 months. For all patients assessed using the Diabetic Neuropathy Examination score, polyneuropathy was reported in 31.4%; among them, polyneuropathy proved symptomatic in 78% of them. Correlates of polyneuropathy were glycated hemoglobin (p = 0.049), HIV infection (p = 0.031) and albuminuria (p< 0.001), even after adjustment for age, gender and duration of diabetes. CONCLUSION: A third of older adults with diabetes who visited our hospital were diagnosed with prevalent diabetes-related polyneuropathy. It shows that early detection is required through routine screening and regular follow-up examinations in order to reduce the risk of disability and improve the quality of life in elderly diabetics.

Incidence and characteristics of pregnancy-related death across ten low- and middle-income geographical regions: secondary analysis of a cluster randomised controlled trial.

OBJECTIVE: The aim of this article is to describe the incidence and characteristics of pregnancy-related death in low- and middle-resource settings, in relation to the availability of key obstetric resources. DESIGN: This is a secondary analysis of a stepped-wedge cluster randomised controlled trial. SETTING: This trial was undertaken at ten sites across eight low- and middle-income countries in sub-Saharan Africa, India and Haiti. POPULATION: Institutional-level consent was obtained and all women presenting for maternity care were eligible for inclusion. METHODS: Pregnancy-related deaths were collected prospectively from routine data sources and active case searching. MAIN OUTCOME MEASURES: Pregnancy-related death, place, timing and age of maternal death, and neonatal outcomes in women with this outcome. RESULTS: Over 20 months, in 536 233 deliveries there were 998 maternal deaths (18.6/10 000, range 28/10 000-630/10 000). The leading causes of death were obstetric haemorrhage (36.0%, n = 359), hypertensive disorders of pregnancy (20.6%, n = 206), sepsis (14.1%, n = 141) and other (26.5%, n = 264). Approximately a quarter of deaths occurred prior to delivery (28.4%, n = 283), 35.7% (n = 356) occurred on the day of delivery and 35.9% (n = 359) occurred after delivery. Half of maternal deaths (50.6%; n = 505) occurred in women aged 20-29 years, 10.3% (n = 103) occurred in women aged under 20 years, 34.5% (n = 344) occurred in women aged 30-39 years and 4.6% (n = 46) occurred in women aged ≥40 years. There was no measured association between the availability of key obstetric resources and the rate of pregnancy-related death. CONCLUSIONS: The large variation in the rate of pregnancy-related death, irrespective of resource availability, emphasises that inequality and inequity in health care persists. TWEETABLE ABSTRACT: Inequality and inequity in pregnancy-related death persists globally, irrespective of resource availability.

The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries.

INTRODUCTION: Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission-the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. METHODS: We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. RESULTS: Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. CONCLUSIONS: No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.

Treatment Options for Hypopharyngeal Cancer in Developing Countries in Africa/South America/Asia.

Most cancers occur in developing countries, and therefore, a discussion about cancer care would be incomplete without providing a developing world perspective. This chapter focuses on challenges and practices relating to hypopharyngeal cancer in limited-resource public healthcare systems in developing countries and specifically in Sub-Saharan Africa, India and South America and by extension, most patients in the developing world. Management of hypopharyngeal cancer must be adapted to the availability of specialised diagnostic and therapeutic services, radiotherapy and surgical expertise, and tailored to patient factors such as reliability of follow-up and social support. A particular challenge for physicians is to decide who can be denied the opportunity to be cured when the burden of cancer cases exceeds available resources. Public education campaigns about reducing risk factors for hypopharyngeal cancer are an important aspect of reducing the burden of cancer.