Virus kinetics and biochemical derangements among children with Ebolavirus disease.

Background: A paucity of data is available on virologic and biochemical characteristics of paediatric Ebolavirus disease (EVD), compared to adults. Methods: We conducted a retrospective chart review of children (<16 years old) and a comparator group of young adults (16-44 years) from two treatment centres during the 2018-2020 EVD epidemic in Eastern Democratic Republic of the Congo. Statistical methods included chi-squared and Fisher's exact tests (dichotomous and categorical variables), Mann-Whitney U-test (continuous variables), multivariable linear regression (for determinants of admission viral load), linear mixed-effects models (for analysis of longitudinal viral load), and Cox proportional hazard models (to examine risk factors for mortality). Findings: We included 73 children and 234 adults admitted from April to October 2019. Paediatric patients commonly had electrolytes imbalances: hypokalaemia in 26/73 (36%), hyperkalaemia in 38/73 (52%), and hyponatraemia in 54/73 (74%). Hypoglycaemia occurred in 20/73 (27%), acute kidney injury in 43/73 (59%), and rhabdomyolysis in 35/73 (48%). Biochemical abnormalities were detected in a similar proportion of children and adults. The viral load (VL, log10 copies/mL) at admission (7.2 versus 6.5, p=0.0001), the peak viral load (7.5 versus 6.7, p=<0.0001), and the time for viraemia clearance (16 days versus 12 days, p=<0.0001) were significantly different in children. The duration of hospital stay was prolonged in children (20 versus 16 days, p=<0.0001). Risk factors for mortality in children were: VL >7.6 log10copies/mL, alanine transaminase >525 U/L, C-reactive protein >100 mg/L, blood urea nitrogen >7.5 mmol/L, rhabdomyolysis, and.acute kidney injury. Interpretation: Paediatric EVD patients, like adults, experience multiorgan dysfunction with life-threatening electrolyte imbalances, hypoglycaemia, kidney injury, liver injury, and rhabdomyolysis. Paediatric patients have significantly higher VLs throughout the course of EVD than adults. Funding: This study was not funded.

Use and disuse of malaria bed nets in an internally displaced persons camp in the Democratic Republic of the Congo: A mixed-methods study.

INTRODUCTION: Malaria is a major cause of morbidity and mortality among displaced populations in tropical zones. Bed nets are widely used to prevent malaria; however, few data are available on bed net distribution within displaced populations. METHODS: Mixed methods study in a single internally displaced persons (IDP) camp and neighboring community in Eastern Democratic Republic of the Congo (DRC). Qualitative data (focus group discussions, FGDs) and quantitative data (door-to-door survey and individual testing using malaria rapid diagnostic test, RDT) were collected. RESULTS: Ten FGDs were conducted with 55 individuals. Although malaria was widely recognized as a significant threat and bed nets were freely distributed in the camp, many households did not own or use them. IDPs converged on the following reasons for low bed net ownership and use: inconvenience of net installation and sale of nets to meet immediate needs such as food. One hundred households, comprised of 411 individuals, were surveyed in Birambizo. The burden of malaria was high (45/78 (58%) of children <5 were positive for malaria by RDT) and bed net utilization was low (29/100 (29%) households owned a bed net, and 85/411 (20%) individuals slept under a bed net the previous night). Children <5 were more likely to use a bed net than older children or adults (OR 3.4 (95%CI 2.0-5.8), p<0.0001). Compared to 29 bed nets currently in use by study participants, 146 bed nets had been sold (82%) or exchanged (18%) either in the camp (27%) or in the neighbouring village market (73%). CONCLUSIONS: Qualitative descriptions and quantitative analysis revealed pragmatic barriers to bed net usage and widespread sale of freely distributed bed nets within IDP camps, despite a high burden of malaria. Additional strategies, beyond bed net distribution, are warranted to combat malaria in vulnerable and hard-to-reach population.

Is maternal education a social vaccine for childhood malaria infection? A cross-sectional study from war-torn Democratic Republic of Congo.

In zones of violent conflict in the tropics, social disruption leads to elevated child mortality, of which malaria is the leading cause. Understanding the social determinants of malaria transmission may be helpful to optimize malaria control efforts. We conducted a cross-sectional study of healthy children aged 2 months to 5 years attending well-child and/or immunization visits in the Democratic Republic of Congo (DRC). Six hundred and forty-seven children were tested for malaria antigenemia by rapid diagnostic test and the accompanying parent or legal guardian simultaneously completed a survey questionnaire related to demographics, socioeconomic status, maternal education, as well as bednet use and recent febrile illness. We examined the associations between variables using multivariable logistic regression analysis, chi-squared statistic, Fisher's exact test, and Spearman's rank correlation, as appropriate. One hundred and twenty-three out of the 647 (19%) children in the study tested positive for malaria. Higher levels of maternal education were associated with a lower risk of malaria in their children. The prevalence of malaria in children of mothers with no education, primary school, and beyond primary was 41/138 (30%), 41/241 (17%), and 39/262 (15%), respectively (p = 0.001). In a multivariable logistic regression model adjusting for the effect of a child's age and study site, the following remained significant predictors of malaria antigenemia: maternal education, number of children under five per household, and HIV serostatus. Higher maternal education, through several putative causal pathways, was associated with lower malaria prevalence among children in the DRC. Our findings suggest that maternal education might be an effective 'social vaccine' against malaria in the DRC and globally.

Burden of malaria is higher among children in an internal displacement camp compared to a neighbouring village in the Democratic Republic of the Congo.

BACKGROUND: In the Democratic Republic of the Congo (DRC), violent conflict has caused the displacement of millions of people into camps where they are exposed to poor living conditions and high rates of infectious diseases. Malaria, in particular, is a major cause of mortality in children under five; however, the burden of disease in displacement camps has not previously been described. METHODS: Two cross-sectional surveys were performed. First, prevalence of Plasmodium falciparum antigenemia was measured in a random sample of 200 children living in a displacement camp and 200 children from a nearby village (control group). Second, the proportion of febrile illness attributable to malaria was measured in a study of 100 children from the displacement camp and 100 children from the control village presenting to the same health clinic with fever. All participants were tested for P. falciparum with a rapid diagnostic test and additional demographic data, clinical characteristics, and malaria risk factors were determined using a parental questionnaire. RESULTS: In the community survey, children living in the displacement camp had a higher prevalence of P. falciparum infection (17 %) than controls (7.5 %) (OR 2.6; 95 % CI 1.3-4.1; P = 0.0095). In the clinic-based survey, the proportion of febrile illness attributable to malaria was higher among children from the displacement camp (78 %) than controls (39 %) (OR 5.5; 95 % CI 3.0-10.3; P < 0.001). Household bed net ownership and use was significantly lower in the displacement camp than control village in both surveys. Statistically significant differences in household wealth, maternal education, and exposure to community violence were also found. CONCLUSIONS: Population displacement due to violent conflict appears to be a risk factor for malaria, a major cause of child mortality. Children living in displacement camps are a relatively understudied population, but have a high burden of malaria, despite control programmes focused on bed net distribution.

Lack of household clustering of malaria in a complex humanitarian emergency: implications for active case detection.

BACKGROUND: Malaria contributes to elevated morbidity and mortality in populations displaced by conflict in tropical zones. In an attempt to reduce malaria transmission in an internally displaced persons (IDP) camp in eastern Democratic Republic of Congo (DRC), we tested a strategy of active case detection of household contacts of malaria cases. METHODS: Prospective community-based survey. RESULTS: From a convenience sample of 100 febrile patients under 5 years of age from the IDP camp presenting to a nearby clinic for management of a fever episode, 19 cases of uncomplicated malaria and 81 controls with non-malarial febrile illness (NFMI) were diagnosed. We engaged community health workers in the IDP camp to screen their household contacts for malaria using rapid diagnostic tests. We detected 29 cases of malaria through this active case-finding procedure. Household contacts of children with uncomplicated malaria were no more likely to have positive Plasmodium falciparum antigenemia than controls with NFMI (OR 0.89, 95% CI 0.33 to 2.4, p = 1.0), suggesting that malaria cases did not cluster at the household level. However, household contacts reporting mild symptoms at the time of community survey (headache, myalgia) had a higher odds of malaria than asymptomatic individuals (OR 14 (95% CI 4.2-48), p ≤ 0.001 and 18 (95% CI 5.9-54), p ≤ 0.001, respectively). CONCLUSION: Screening household contacts of malaria cases was not an efficient case-finding strategy in a Congolese IDP camp. Symptom-based screening may be a simpler and cost-effective method to identify individuals at increased risk of malaria for targeted screening and treatment in an IDP camp.

Sexual violence toward children and youth in war-torn eastern Democratic Republic of Congo.

BACKGROUND: The epidemic of gender-based violence in the Democratic Republic of the Congo (DRC) has garnered popular media attention, but is incompletely described in the medical literature to date. In particular, the relative importance of militarized compared to civilian rape and the impact on vulnerable populations merits further study. We describe a retrospective case series of sexual abuse among children and youth in eastern DRC. METHODS: Medical records of patients treated for sexual assault at HEAL Africa Hospital, Goma, DRC between 2006 and 2008 were reviewed. Information extracted from the chart record was summarized using descriptive statistics, with comparative statistics to examine differences between pediatric (≤ 18 yrs) and adult patients. FINDINGS: 440 pediatric and 54 adult sexual abuse cases were identified. Children and youth were more often assaulted by someone known to the family (74% vs 30%, OR 6.7 [95%CI 3.6-12], p<0.001), and less frequently by military personnel (13% vs 48%, OR 0.14 [95%CI 0.075-0.26], p<0.001). Delayed presentation for medical care (>72 hours after the assault) was more common in pediatric patients (53% vs 33%, OR 2.2 [95%CI 1.2-4.0], p = 0.007). Physical signs of sexual abuse, including lesions of the posterior fourchette, hymeneal tears, and anal lesions, were more commonly observed in children and youth (84% vs 69%, OR 2.3 [95%CI 1.3-4.4], p = 0.006). Nine (2.9%) pediatrics patients were HIV-positive at presentation, compared to 5.3% of adults (p = 0.34). INTERPRETATION: World media attention has focused on violent rape as a weapon of war in the DRC. Our data highlight some neglected but important and distinct aspects of the ongoing epidemic of sexual violence: sexual abuse of children and youth.

Fistula and traumatic genital injury from sexual violence in a conflict setting in Eastern Congo: case studies.

The Eastern region of the Democratic Republic of Congo (DRC) is currently undergoing a brutal war. Armed groups from the DRC and neighbouring countries are committing atrocities and systematically using sexual violence as a weapon of war to humiliate, intimidate and dominate women, girls, their men and communities. Armed combatants take advantage with impunity, knowing they will not be held to account or pursued by police or judicial authorities. A particularly inhumane public health problem has emerged: traumatic gynaecological fistula and genital injury from brutal sexual violence and gang-rape, along with enormous psychosocial and emotional burdens. Many of the women who survive find themselves pregnant or infected with STIs/HIV with no access to treatment. This report was compiled at the Doctors on Call for Service/Heal Africa Hospital in Goma, Eastern Congo, from the cases of 4,715 women and girls who suffered sexual violence between April 2003 and June 2006, of whom 702 had genital fistula. It presents the personal experiences of seven survivors whose injuries were severe and long-term, with life-changing effects. The paper recommends a coordinated effort amongst key stakeholders to secure peace and stability, an increase in humanitarian assistance and the rebuilding of the infrastructure, human and physical resources, and medical, educational and judicial systems.