Infectious causes of fever of unknown origin in developing countries: An international ID-IRI study.

Background: Fever of unknown origin (FUO) in developing countries is an important dilemma and further research is needed to elucidate the infectious causes of FUO. Methods: A multi-center study for infectious causes of FUO in lower middle-income countries (LMIC) and low-income countries (LIC) was conducted between January 1, 2018 and January 1, 2023. In total, 15 participating centers from seven different countries provided the data, which were collected through the Infectious Diseases-International Research Initiative platform. Only adult patients with confirmed infection as the cause of FUO were included in the study. The severity parameters were quick Sequential Organ Failure Assessment (qSOFA) ≥2, intensive care unit (ICU) admission, vasopressor use, and invasive mechanical ventilation (IMV). Results: A total of 160 patients with infectious FUO were included in the study. Overall, 148 (92.5%) patients had community-acquired infections and 12 (7.5%) had hospital-acquired infections. The most common infectious syndromes were tuberculosis (TB) (n=27, 16.9%), infective endocarditis (n=25, 15.6%), malaria (n=21, 13.1%), brucellosis (n=15, 9.4%), and typhoid fever (n=9, 5.6%). Plasmodium falciparum, Mycobacterium tuberculosis, Brucellae, Staphylococcus aureus, Salmonella typhi, and Rickettsiae were the leading infectious agents in this study. A total of 56 (35.0%) cases had invasive procedures for diagnosis. The mean qSOFA score was 0.76±0.94 {median (interquartile range [IQR]): 0 (0-1)}. ICU admission (n=26, 16.2%), vasopressor use (n=14, 8.8%), and IMV (n=10, 6.3%) were not rare. Overall, 38 (23.8%) patients had at least one of the severity parameters. The mortality rate was 15 (9.4%), and the mortality was attributable to the infection causing FUO in 12 (7.5%) patients. Conclusions: In LMIC and LIC, tuberculosis and cardiac infections were the most severe and the leading infections causing FUO.

Understanding clinical outcomes and factors influencing mortality in intensive care unit patients with COVID-19-associated candidemia.

BACKGROUND: During the COVID pandemic, research has shown an increase in candidemia cases following severe COVID infection and the identification of risk factors associated with candidemia. However, there is a lack of studies that specifically explore clinical outcomes and mortality rates related to candidemia after COVID infection. OBJECTIVES: The aim of this international study was to evaluate the clinical outcomes and identify factors influencing mortality in patients who developed candidemia during their COVID infection. PATIENTS/METHODS: This study included adult patients (18 years of age or older) admitted to the intensive care unit (ICU) and diagnosed with COVID-associated candidemia (CAC). The research was conducted through ID-IRI network and in collaboration with 34 medical centres across 18 countries retrospectively, spanning from the beginning of the COVID pandemic until December 2021. RESULTS: A total of 293 patients diagnosed with CAC were included. The median age of the patients was 67, and 63% of them were male. The most common Candida species detected was C. albicans. The crude 30-day mortality rate was recorded at 62.4%. The logistic regression analysis identified several factors significantly impacting mortality, including age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07, p < .0005), SOFA score (OR 1.307, 95% CI 1.17-1.45, p < .0005), invasive mechanical ventilation (OR 7.95, 95% CI 1.44-43.83, p < .017) and duration of mechanical ventilation (OR 0.98, 95% CI 0.96-0.99, p < .020). CONCLUSIONS: By recognising these prognostic factors, medical professionals can customise their treatment approaches to offer more targeted care, leading to improved patient outcomes and higher survival rates for individuals with COVID-associated candidemia.

Predictors of non-adherence to antihypertensive medications: A cross-sectional study from a regional hospital in Afghanistan.

BACKGROUND: Non-adherence to antihypertensive medications (AHMs) is a widespread problem. Cardiovascular morbidity and mortality reduction is possible via better adherence rates among hypertensive patients. OBJECTIVES: This study aimed to assess the prevalence of non-adherence to AHMs and its predictors among hypertensive patients who attended Mirwais Regional Hospital in Kandahar, Afghanistan. METHODS: A cross-sectional study using random sampling method was conducted among hypertensive patients, aged ≥18 years in Mirwais Regional Hospital at a 6-month follow-up between October and December 2022. To assess non-adherence to AHMs, we employed the Hill-Bone Medication Adherence scale. A value below or equal to 80% of the total score was used to signify non-adherence. A multivariable binary logistic regression model was used to identify predictors of non-adherence to AHMs. RESULTS: We used data from 669 patients and found that 47.9% (95%CI: 44.1-51.8%) of them were non-adherent to AHMs. The majority (71.2%) of patients had poorly controlled blood pressure (BP). The likelihood of non-adherence to AHMs was significantly higher among patients from low monthly-income households [Adjusted odds ratio (AOR) 1.70 (95%CI: 1.13-2.55)], those with daily intake of multiple AHMs [AOR 2.02 (1.29-3.16)], presence of comorbid medical conditions [AOR 1.68 (1.05-2.67), lack of awareness of hypertension-related complications [AOR 2.40 (1.59-3.63)], and presence of depressive symptoms [AOR 1.65 (1.14-2.38)]. CONCLUSION: Non-adherence to AHMs was high. Non-adherence to AHMs is a potential risk factor for uncontrolled hypertension and subsequent cardiovascular complications. Policymakers and clinicians should implement evidence-based interventions to address factors undermining AHMs adherence in Afghanistan.

Conducting Health Research in the Current Afghan Society: Challenges, Opportunities, and Recommendations.

Research makes a significant contribution to academic excellence and holds the potential to facilitate societal development. Despite the increasing importance of health research in developing new therapies and galvanizing notable progress in public health, the landscape of health research in Afghanistan remains profoundly deficient. This article reveals that health research in Afghanistan requires significant growth to meet the standards set on regional and global grounds.

Prevalence of soil-transmitted helminths and associated risk factors among primary school children in Kandahar, Afghanistan: A cross-sectional analytical study.

BACKGROUND: Soil-transmitted helminth (STH) infections are global health problem, especially in low-income countries. Main objectives of this study were to estimate the prevalence and intensity of STH and its risk factors among school children in Kandahar city of Afghanistan. METHODOLOGY/PRINCIPAL FINDINGS: This was a school-based cross-sectional analytical study, with data collected during eight-month-period (May-December, 2022) from 6- and 12-years old school children in Kandahar city, Afghanistan. All the stool samples were examined by saline wet mount method and Kato-Katz technique. Data were analyzed by using descriptive statistics, Chi square test, and multivariate logistic regression. A total of 1275 children from eight schools of Kandahar city were included in this study. Mean age of these children was 8.3 years with 53.3% boys. The overall prevalence of any intestinal parasitic infection was 68.4%. The overall prevalence of STH infection was 39.1%, with Ascaris lumbricoides (29.4%) as the most prevalent STH species. Mean intensity of overall STH infection was 97.8. Multivariate logistic regression revealed playing barefoot (AOR 1.6, 95% CI 1.1-2.2), not washing hands after defecating and before eating (AOR 1.3, 95% CI 1.0-1.7), having untrimmed nails (AOR 1.4, 95% CI 1.1-1.8), and belonging to poor families (AOR 1.3, 95% CI 1.0-1.7) as the risk factors associated with the predisposition of school children for getting STH in Kandahar city of Afghanistan. CONCLUSIONS/SIGNIFICANCE: There is high prevalence of STH among school children of Kandahar city in Afghanistan. Most of the risk factors are related to poverty, decreased sanitation, and improper hygiene. Improvement of socioeconomic status, sanitation, and health education to promote public awareness about health and hygiene together with periodic mass deworming programs are better strategies for the control of STH infections in Afghanistan.

Knowledge, attitudes and practices of university students toward COVID-19 in Southern region, Afghanistan: a cross-sectional study.

BACKGROUND: Successful implementation of preventive measures and level of awareness in particular among university students in Afghanistan could play a crucial role in spreading the information for better control of the ongoing pandemic. Therefore, the aim of this study was to determine the level of knowledge, attitudes and practices (KAP) regarding COVID-19 among Kandahar university students. METHODS: A cross-sectional study conducted among undergraduate students to investigate their KAP regarding COVID-19 from January to March, 2021. The data were collected using a structured questionnaire (socio-demographic characteristics, KAP questionnaire) by phone call interviews. RESULTS: From 359 participants, 88.9% were males, 81.3% were single, 65.1% lived in urban areas, and more than 64% of the students were less than 23 years old. Overall, 86.6% of the study participants had adequate level of knowledge and 87.5% had positive attitudes toward COVID-19. Almost one-third of the participants had good practices regarding COVID-19. All KAP scores were higher in male students. Significant difference of good practice (p < 0.001) was observed among students who were in high socioeconomic status (SES) group. In univariate analysis, female sex (ß: -0.75, p = 0.007) was negatively and watching television (ß: 0.44; p = 0.014) was positively associated with knowledge score. However, in multivariate linear regression analysis, the knowledge score was significantly associated with age (ß: -0.115; p = 0.004); attitude score was significantly associated with female sex (ß: -2.776; p < 0.001) and radio use (ß: -0.974; p = 0.031); and practice score was significantly associated with female sex (ß: -3.704; p = 0.002) and urban area (ß: 1.702; p = 0.016). CONCLUSIONS: The overall knowledge and attitudes regarding COVID-19 among university students were desirable. Higher university year, young age, male sex and living in urban areas were significantly associated with good KAP regarding COVID-19. Good practices towards COVID-19 should be increased through awareness programs.

Post-traumatic stress disorder (PTSD) probability among parents who live in Kandahar, Afghanistan and lost at least a child to armed conflict.

The last 4 decades of conflict in Afghanistan resulted in incalculable deaths, injuries, and millions of displacements. Although there are routine reports on casualties of the warfare, the information on its long-term psycho-social sequelae is somehow discounted. This study aimed to assess post-traumatic stress disorder (PTSD) probability and its associated factors among parents who live in Kandahar, the southern province of Afghanistan, and lost at least one child to armed conflict. We conducted a health-facility-based cross-sectional study involving 474 bereaved parents in Kandahar province from November/2020 to January/2021. The questionnaire was composed of sections on socio-demographic characteristics and mental and medical histories of the parent, features of the traumatic event and the time elapsed since then, age and gender of the lost child, and PCL-5. We performed multivariable logistic analysis to determine factors associated with PTSD probability in such parents. A staggering number of the parents (430; 90.72%) scored > 33 on PCL-5 denoting presence of probable PTSD. We noticed that several attributes of the bereaved parents (rural residence [AOR = 3.71 (95% CI 1.37-9.97)], older age [AOR = 2.41 (95% CI 1.03-5.57)], experiencing more than one traumatic event [AOR = 2.91 (95% CI 1.05-7.94)], pre-existing medical condition [AOR = 3.5 (95% CI 1.55-8.05)], and losing a < 5-years-old child [AOR = 2.38 (95% CI 1.16-4.70)] were significantly associated with PTSD probability. We assert that a very high number of bereaved parents are susceptible to probable PTSD. This finding signifies the eminent necessity of mental health services in such settings and provides implicit insights to relevant humanitarian assistance providers.

Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.

BACKGROUND: Quality antenatal care (ANC) is one of the four pillars of safe motherhood initiatives and improves the survival and health of mother and neonate. The main objective of this study was to assess the barriers in the utilization of ANC services in Kandahar, Afghanistan. METHODS: This was a cross-sectional analytical study conducted over one year from December 2018-November 2019. Data were analyzed by descriptive statistics, Chi squared, and binary logistic regression. RESULTS: A total of 1524 women were recruited in this study with mean age of 30.3 years. Of these women, 848 (55.6%) were rural dwellers, 1450/1510 (96.0%) were illiterate, 438/608 (72.0%) belonged to low-income families, 1112/1508 (73.7%) lived in joint families, 1420/1484 (95.7%) lived in a house of >10 inhabitants, while 388/1494 (26.0%) had attended had at least one ANC visit during their last pregnancy. On univariate analysis, the main barriers in the utilization of ANC services were living in rural areas, being illiterate, having lower socio-economic status, remoteness of the health facility from home, bad behavior of clinic personnel, and unplanned pregnancy. Only lower socio-economic status and bad behavior of clinic personnel were independent explanatory variables in the regression model. CONCLUSIONS: Utilization of ANC services is inadequate in Kandahar province. Improving clinic staff professional behavior and status of women by expanding educational opportunities, and enhancing community awareness of the value of ANC are recommended.

Treatment outcomes and risk factors of death in childhood tuberculous meningitis in Kandahar, Afghanistan: a prospective observational cohort study.

BACKGROUND: Tuberculous meningitis (TBM) is the most severe form of TB. We prospectively documented the treatment outcomes and the risk factors for death in children with TBM from Kandahar, Afghanistan. METHODS: This prospective observational cohort study was conducted from February 2017 to January 2020 in hospitalised TBM children. All the patients were prospectively followed up for 12 mo. Data were analysed by using descriptive statistics, χ2 and multivariate logistic regression. RESULTS: A total of 818 TBM hospitalised patients with median age 4.8 (0.8-14.5) y were recruited. Females accounted for 60.9% (498/818). Upon admission 53.9% (n=441) and 15.2% (n=124) had TBM stages II and III, respectively, and 23.2% (n=190) had focal neurological signs. The case fatality rate was 20.2% (160/794) and 30.6% (243/794) survived with neurological sequelae. Independent risk factors for death were being unvaccinated for BCG (adjusted OR [AOR] 3.8, 95% CI 1.8 to 8.1), not receiving dexamethasone (AOR 2.5, 95% CI 1.5 to 4.2), being male (AOR 2.3, 95% CI 1.5 to 3.6), history of recent weight loss (AOR 2.2, 95% CI 1.3 to 3.9) and having stage III TBM (AOR 2.0, 95% CI 1.2 to 3.3). CONCLUSIONS: TBM continues to cause high morbidity and mortality in Afghan children. Strategies to reduce mortality should emphasise early diagnosis and treatment, routine use of dexamethasone and increased BCG vaccination.

Prevalence and associated risk factors of soil-transmitted helminth infections in Kandahar, Afghanistan.

BACKGROUND: Soil-transmitted helminth (STH) infections are still a major health problem, especially in resource-limited countries. The community-based prevalence of STH is unknown in Afghanistan. Main objectives of this study were to estimate the prevalence and associated factors of STH among children in Daman district of Kandahar province in Afghanistan. METHODS: This was a community-based cross-sectional study, with data collected during five months (June-October, 2020) from children living in five villages of Daman district in Kandahar, Afghanistan. All the stool samples were examined by saline wet mount method. Data were analyzed by using descriptive statistics, Chi square test, and multivariate logistic regression. RESULTS: A total of 1426 children were studied, with majority (61.8%) of males and the mean age of 6.3 years. The overall prevalence of any intestinal parasitic infection was 39.8%. The overall prevalence of STH infection was 22.7%, with Ascaris lumbricoides (18.7%) as the most prevalent STH species, followed by hookworm (7.5%) and Trichuris trichiura (1.4%). Single, double, and triple STH infections were present in 14.9%, 7.2%, and 0.6% of the children, respectively. Multivariate logistic regression revealed that not washing hands after defecating/before eating (AOR 7.0, 95% CI 3.4-14.0), living in mud house (AOR 3.5, 95% CI 1.6-7.4), walking barefoot (AOR 2.2, 95% CI 1.6-3.1), living in overcrowded house (AOR 1.6, 95% CI 1.1-2.3), and practicing open defecation (AOR 1.4, 95% CI 1.1-2.0) as the risk factors associated with the predisposition of rural children for getting STH in Daman district of Afghanistan. CONCLUSIONS: Prevalence of STH is high among children of Daman district in Afghanistan. Most of the risk factors are related to poverty, decreased sanitation, and improper hygiene. Improvement of socioeconomic status, sanitation, and health education to promote public awareness about health and hygiene together with periodic mass deworming programs are better strategies for the control of STH infections in Afghanistan. Also, government and international donor agencies in Afghanistan should help in improving socio-economic status of the rural areas through provision of basic facilities such as piped water, electricity, good housing, and proper toilets.

Outcome of acute bacterial meningitis among children in Kandahar, Afghanistan: A prospective observational cohort study.

BACKGROUND: Acute bacterial meningitis (ABM) is an important cause of morbidity and mortality in children but there are no published data on the treatment outcomes of ABM in Afghanistan. METHODS: We conducted a prospective observational cohort study over one year, February 2020 to January 2021 in a tertiary care hospital in Kandahar, Afghanistan. AMB was diagnosed clinically and on lumbar puncture findings. Binary logistic regression assessed factors for death. RESULTS: A total of 393 ABM children of mean age 4.8 years were recruited. Most were males [231 (58.8%)], living in rural areas [267 (67.9%)] and in households of >10 inhabitants [294 (74.8%)]. Only 96 (24.4%) had received against both Haemophilus influenzae type b (Hib) or pneumococcal (PCV) vaccines. Children were treated with combination of ceftriaxone and ampicillin and 169/321 (52.6%) received dexamethasone. Of the 321 children with a known outcome, 69 (21.5%) died. Death was significantly associated with: not receiving dexamethasone [adjusted odds ratio (AOR) 4.9 (95% CI 2.6-9.5, p <0.001)], coma on admission [AOR 4.6 (I 2.3-9.5, p <0.001)], no PCV [AOR 2.8 (1.2-6.6, p = 0.019)] or Hib vaccine [AOR 2.8 (1.2-6.6, p = 0.019)], and being male [AOR 2.7 (1.4-5.5, p = 0.005). CONCLUSIONS: ABM causes significant morbidity and mortality in Afghan children that may be improved by greater use of PCV and Hib vaccines. Adjunct dexamethasone should be evaluated formally in our setting.

Analyzing central-line associated bloodstream infection prevention bundles in 22 countries: The results of ID-IRI survey.

BACKGROUND: Because central line-associated bloodstream infections (CLABSIs) are a significant complication of central venous access, it is critical to prevent CLABSIs through the use of central line bundles. The purpose of this study was to take a snapshot of central venous access bundles in various countries. METHODS: The participants in intensive care units (ICUs) completed a questionnaire that included information about the health center, infection control procedures, and central line maintenance. The countries were divided into 2 groups: those with a low or low-middle income and those with an upper-middle or high income. RESULTS: Forty-three participants from 22 countries (46 hospitals, 85 ICUs) responded to the survey. Eight (17.4%) hospitals had no surveillance system for CLABSI. Approximately 7.1 % (n = 6) ICUs had no CLABSI bundle. Twenty ICUs (23.5%) had no dedicated checklist. The percentage of using ultrasonography during catheter insertion, transparent semi-permeable dressings, needleless connectors and single-use sterile pre-filled ready to use 0.9% NaCl were significantly higher in countries with higher and middle-higher income (P < .05). CONCLUSIONS: Our study demonstrated that there are significant differences in the central line bundles between low/low-middle income countries and upper-middle/high-income countries. Additional measures should be taken to address inequity in the management of vascular access in resource-limited countries.

Treatment outcome of tuberculosis treatment regimens in Kandahar, Afghanistan.

BACKGROUND: Tuberculosis (TB) is a chronic disease that mostly affects low-income countries. TB is transmitted through droplet aerosolization from a person with active pulmonary TB. Afghanistan is one of the 22 high TB burden countries where 39,445 people develop this disease and 7840 people die each year. Treatment outcome is one of the best measurements that explain how the current regimen works. MATERIAL AND METHODS: This was a retrospective cohort study, conducted in Kandahar Province, to find out the treatment outcome of anti-TB drugs regimens in TB patients. Data of pulmonary and extra-pulmonary TB patients, who fulfilled the eligible criteria of the study and were treated from 2005 to 2015, was retrieved from their medical record forms. RESULTS: Among 1000 TB patients, 599 (59.9%) were females and 401 (40.1%) males; most of the patients (678/1000 [67.8%]) were from Kandahar city while 322/1000 (32.2%) were from the other districts of Kandahar. Mean age of the patients were 36.1 years with SD of 19.3 years. Main signs and symptoms of fever, cough, and weight loss were present in 949/1000 (94.9%), 880/1000 (88%), and 544/1000 (54.4%) of the patients, respectively. On first visit 459/1000 (45.9%) patients were sputum AFB (acid fast bacilli) positive. Majority (247/459 [53.8%]) of these patients were AFB 2+. After 2 months of intensive anti-TB treatment, 9/459 (1.9%) patients were still AFB positive (1+). Treatment outcome of these 1000 patients showed that 479 (47.9%) completed the treatment, 298 (29.8%) were cured, 35 (3.5%) failed the anti-TB treatment, while 5 (0.5%) patients died. CONCLUSION: This clearly shows that TB is still one of the major threats to the people of Kandahar Province. There are cases of TB who do not respond to the first line regimens of anti-TB drugs advised by WHO and Afghan Ministry of Public Health (MoPH).

Determinants of treatment failure among tuberculosis patients in Kandahar City, Afghanistan: A 5-year retrospective cohort study.

Background: Tuberculosis (TB) is a preventable and treatable chronic disease. Afghanistan is among the high-TB-burden countries. The aim of this study is to find the determinants of treatment failure among TB patients in Kandahar City, Afghanistan. Methods: This was a retrospective cohort study conducted in Kandahar City during a period of 5 years (August 2014-July 2019). For data analysis; descriptive statistics, Chi-square test, and logistic regression were used. Results: Among 1416 TB patients, 894/1416 (63.1%) had pulmonary TB (PTB), whereas 522/1416 (36.9%) had extrapulmonary TB (EPTB). Mean age in these patients was 34.7 years while most of them were females in PTB (530/894 [59.3%]) and EPTB (340/522 [65.1%]) patients. Sputum smear was positive in 618/860 (71.9%) and 16/404 (4%) of PTB and EPTB patients, respectively. TB treatment failure was more in PTB (56/894 [6.3%]) than EPTB (4/522 [0.8%]). Chi-square test of TB cases showed that statistically significant determinants that may cause the treatment failure were re-treatment cases (crude odds ratio [COR] 7.7, P < 0.001), absence of fever (COR 5.2, P < 0.001), absence of cough (COR 1.7, P = 0.004), living in rural areas (COR 1.4, P = 0.035), and no weight loss (COR 1.3, P = 0.033). Binary logistic regression of the statistically significant variables revealed only absence of fever (adjusted odds ratio 6.0, P < 0.001) as the risk factor for treatment failure in TB patients. Conclusion: TB is still a major threat for Kandahar City. Low treatment success rate and increased number of defaulted cases are the major threats.

Severe vivax malaria: a systematic review and meta-analysis of clinical studies since 1900.

BACKGROUND: Malaria caused by Plasmodium vivax was long considered to have a low mortality, but recent reports from some geographical areas suggest that severe and complicated vivax malaria may be more common than previously thought. METHODS: The primary objective of this systematic review and meta-analysis was to describe the reported clinical characteristics and the geographical variation in prevalence of reported severe vivax malaria and its change over time derived from English-language articles published since 1900. Medline and Scopus databases were searched for original papers on severe vivax malaria, using as inclusion criteria modified 2010 WHO criteria for the diagnosis of severe falciparum malaria. Articles before 1949 were identified through reference lists in journals, textbooks, and personal collections of colleagues. RESULTS: A total of 77 studies with reported severe vivax malaria and 63 studies with no reported severe vivax malaria (totaling 46,411 and 6,753 vivax malaria patients, respectively) were included. The 77 studies with reported severe vivax malaria were mainly from India (n = 33), USA (n = 8), Indonesia (n = 6), and Pakistan (n = 6). Vivax endemic countries not reporting severe vivax malaria beyond individual case reports included: the Greater Mekong Sub-region, China, North Korea, Bangladesh, Afghanistan, Middle East (except Qatar), the horn of Africa, and Madagascar. Only 17/77 reports were from before 2000. Vivax mono-infection was confirmed by PCR in 14 studies and co-morbidities were ruled out in 23 studies. Among the 77 studies reporting severe vivax malaria, severe thrombocytopenia (<50,000/mm3) was the most common "severe" manifestation (888/45,775 with pooled prevalence of 8.6%). The case fatality was 0.3% (353/46,411). Severity syndromes varied widely between different geographical areas, with severe anaemia being most prominent in areas of high transmission and chloroquine resistance. CONCLUSION: Plasmodium vivax can cause severe and even fatal disease, but there is a recent increase in reports over the past 15 years with larger series restricted to a limited number of geographical areas. The biological basis of these variations is currently not known. More detailed epidemiological studies are needed which dissociate causation from association to refine the definition and estimate the prevalence of severe vivax malaria.