Education and severe maternal outcomes in developing countries: a multicountry cross-sectional survey.

OBJECTIVE: To assess the relationship between education and severe maternal outcomes among women delivering in healthcare facilities. DESIGN: Cross-sectional study. SETTING: Twenty-nine countries in Africa, Asia, Latin America, and the Middle East. POPULATION: Pregnant women admitted to 359 facilities during a period of 2-4 months of data collection between 2010 and 2011. METHODS: Data were obtained from hospital records. Stratification was based on the Human Development Index (HDI) values of the participating countries. Multivariable logistic regression analyses were conducted to assess the association between maternal morbidity and education, categorised in quartiles based on the years of formal education by country. Coverage of key interventions was assessed. MAIN OUTCOME MEASURES: Severe maternal outcomes (near misses and death). RESULTS: A significant association between low education and severe maternal outcomes (adjusted odds ratio, aOR, 2.07; 95% confidence interval, 95% CI, 1.46-2.95), maternal near miss (aOR 1.80; 95% CI 1.25-2.57), and maternal death (aOR 5.62; 95% CI 3.45-9.16) was observed. This relationship persisted in countries with medium HDIs (aOR 2.36; 95% CI 1.33-4.17) and low HDIs (aOR 2.65; 95% CI 1.54-2.57). Less educated women also had increased odds of presenting to the hospital in a severe condition (i.e. with organ dysfunction on arrival or within 24 hours: aOR 2.06; 95% CI 1.36-3.10). The probability that a woman received magnesium sulphate for eclampsia or had a caesarean section significantly increased as education level increased (P < 0.05). CONCLUSIONS: Women with lower levels of education are at greater risk for severe maternal outcomes, even after adjustment for key confounding factors. This is particularly true for women in countries that have poorer markers of social and economic development.

Liver histopathology and biological correlates in five cases of fatal dengue fever in Vietnamese children.

We studied five fatal cases of dengue haemorrhagic fever (DHF), confirmed using the reverse transcriptase-polymerase chain reaction (RT-PCR) method, in Vietnamese children. The liver seems to be a target for dengue virus, so postmortem examinations were performed to investigate elementary lesions, local recruitment of inflammatory cells and whether the virus was present in target cells of the liver. We detected severe, diffuse hepatitis with midzonal necrosis and steatosis in two patients, focal areas of necrosis in two patients, and normal histology in one patient. Dengue virus antigen was detected using immunohistochemistry in hepatocytes from necrotic areas in four cases. There was no recruitment of polymorphonuclear cells, and no lymphocytes were detected in the liver lesions of patients who died from DHF. Lymphocytic infiltration occurred in only one hepatitis B virus-positive patient, with no signs of chronic hepatitis. Kupffer cells had mostly been destroyed in cases with focal or severe necrosis. TUNEL tests were positive in necrotic areas, with positive cells forming clusters, suggesting that an apoptotic mechanism was involved. Thus, we suggest that the hepatocyte and Kupffer cells may be target cells supporting virus replication and that the councilman body is an apoptotic cell, as in the pathogenesis of yellow fever.

Dengue epidemic in southern Vietnam, 1998.

A widespread epidemic of dengue hemorrhagic fever (DHF) occurred in southern Vietnam in 1998, with 438.98 cases/100,000 population and 342 deaths. The number of DHF cases and deaths per 100,000 population increased 152.4% and 151.8%, respectively, over a 1997 epidemic. Dengue viruses were isolated from 143 patient blood samples; DEN-3 virus was identified as the predominant serotype, although a resurgence of DEN-4 was noted.

Control of dengue fever with active surveillance and the use of insecticidal aerosol cans.

An interventional study was conducted in southern Vietnam to evaluate the feasibility and effectiveness of a new approach to control dengue fever. The approach consisted of active surveillance of dengue patients and the use of insecticidal aerosol cans. Febrile patients were tested serologically at local health centers and insecticidal aerosol cans were given to the family and employed in the neighborhood of dengue patients instead of ultra low volume (ULV) fogging with insecticide. The number of dengue IgM antibody positive cases among febrile patients, the number of reported dengue hemorrhagic fever patients and the total cost were compared in the 2 approaches (prompt focal ULV fogging and the use of insecticidal aerosol cans) in 1997. The aerosol cans were employed 5 times (in June, July, August, September and October) in the study area. ULV fogging in the control area was performed 5 times (in March, May, July, August and September). Twenty-two serologically positive cases were found in the study area which was about half that found in the control area (43 cases). A total of 16 dengue hemorrhagic fever patients was reported in the study area and 43 in the control area. Compared with the reported numbers of the previous year, the reduction rate in the number of dengue hemorrhagic fever cases was 71.4% in the study area and 51.7% in the control area. There were statistically significant differences in the morbidity of dengue fever and the reduction rate of dengue hemorrhagic fever. The cost of the insecticidal aerosol cans was US$393 which was lower than the cost of US$553 for ULV fogging. The findings suggest that insecticidal aerosol cans were effective and feasible for dengue fever control.

Poliomyelitis-like illness due to Japanese encephalitis virus.

BACKGROUND: Acute flaccid paralysis remains common among Vietnamese children despite a pronounced fall in the incidence of poliomyelitis. METHODS: During 1995, all 22 children presenting with acute flaccid paralysis to a referral centre in Ho Chi Minh City, Vietnam, had virological cultures and antibody measurements done on serum, cerebrospinal fluid, and faeces. A year later the children were reassessed and electrophysiological studies were done. FINDINGS: Wild poliovirus type 1 was isolated from the faeces of only one patient, and non-polio enteroviruses from three patients. 12 (55%) of the 22 children with acute flaccid paralysis had evidence of acute Japanese encephalitis virus (JEV) infection, compared with only one (1%) of 88 age-matched hospital controls (children with diphtheria; p<0.0001). Compared with JEV-negative patients, weakness in JEV-infected children was more rapid in onset, tended to be asymmetrical, but was less likely to involve the arms. All 12 children with JEV infection were febrile at the onset of weakness, seven had acute retention of urine, and ten had CSF pleiocytosis. Seven of eight JEV-negative patients met the case-definition of Guillain-Barré syndrome, compared with only one of 12 JEV-positive children. At follow-up, patients with JEV infection had greater disability and were more likely to have muscle wasting than were JEV-negative children. Nerve conduction and electromyographic studies indicated damage to the anterior horn cells. INTERPRETATION: JEV causes an acute flaccid paralysis in children that has similar clinical and pathological features to poliomyelitis. In endemic areas, children with acute flaccid paralysis should be investigated for evidence of JEV infection.

Tumor necrosis factor alpha levels in plasma and whole-blood culture in dengue-infected patients: relationship between virus detection and pre-existing specific antibodies.

The pathogenesis of dengue hemorrhagic fever (DHF) is not well known, but the role of host factors has been suggested. The level of immunoreactive circulating and cell-generated tumor necrosis factor alpha (TNF alpha) was studied in 35 patients with DHF; its relationship with virus isolation and/or genome detection by reverse transcription polymerase chain reaction (RT-PCR) and specific antibodies were detected by hemagglutination inhibition (HI). Large variation of TNF alpha plasma levels was obtained in dengue-infected patients at the same stage of the disease and at the same day after infection. Most of the patients (14 out of 17 patients) who displayed augmented spontaneous in vitro production of TNF alpha by heparinized whole-blood culture compared with controls also had elevated levels of TNF alpha in the plasma. The TNF alpha values in lipopolysaccharide and phytohemagglutinin heparinized whole-blood cultures were not higher in patients than in controls, but low TNF alpha levels were obtained in three out of 30 patients. An inverse correlation was observed between spontaneous in vitro TNF alpha production and viral replication, which raises the issue of the antiviral effect of TNF alpha in dengue infection. The results do not support the hypothesis of the role of antibody-dependent enhancement giving rise to increased viremic titers and production of TNF alpha in patients. The present study demonstrates the activation of the TNF alpha-producing cells in dengue-infected patients and suggests further investigation to define the mechanism and the role of TNF alpha in the pathogenesis of dengue virus infection.

Isolation of a newly recognized alphavirus from mosquitoes in Vietnam and evidence for human infection and disease.

During studies of arboviral epidemiology in Vietnam, five virus isolates were recovered from Culex tritaeniorhynchus mosquitoes. Three of the five isolates were identified as strains of Japanese encephalitis virus, but the others, collected at Me Tri village, Hanoi, were shown to represent an alphavirus, for which we propose the name Me Tri virus. This newly recognized virus is most closely related to Semliki Forest virus. The two isolates appear to be antigenic subtypes of a single virus, and each was associated with central nervous system illnesses in children. Serologic surveys indicate widespread distribution of these viruses in both humans and livestock in Vietnam. We suggest that Me Tri virus is an etiologic agent of human disease in southeast Asia.

Genetic study of Japanese encephalitis viruses from Vietnam.

Two hundred eighty-five nucleotides from the capsid/premembrane gene region of 16 isolates of Japanese encephalitis (JE) virus from the southern and northern regions of Vietnam obtained during the period 1964-1988 were sequenced and compared with each other and with wild JE virus strains from China and Japan. The 16 Vietnamese isolates showed low rates of genetic evolution (< or = 3.2%) and were classified into one genotype with an overall similarity of > or = 95.4%, including the Japanese JaArOS982 strain taken as reference, and earlier isolated strains from Japan (Nakayama 1935) and China (Beijing-1 1949 and SA14 1954), the wild-type strains used to derive JE vaccines. The implications of the close genetic relationship among Vietnamese strains of JE virus analyzed in our study in relation to their epidemiology and evolution are discussed.

Direct sequencing of genomic cDNA fragments amplified by the polymerase chain reaction for molecular epidemiology of dengue-2 viruses.

A nucleotide fragment encoding amino acids 29 to 94 in the E-protein of 28 dengue-2 isolates of diverse geographic and host origins was examined by direct sequencing of a polymerase chain reaction (PCR)-amplified product, and compared to six previously published sequences. Nucleotide divergence ranged from 0 to 19.8% corresponding to a maximum of 9% divergence in the amino acid sequence. Taking a divergence of 6% between the nucleotide sequence as a cut off for genotype classification, six groups have been established. Southeast Asian and the Jamaican 1983 genotypes show a high rate of similarity (> 95.2%). Our results suggest that virus of this group is now circulating as the dominant topotype in Brazil (1990) and in French Guyana (1986-1991). African strains fall into two groups, one endemic group (1970-1990) and one epidemic group (1986-1987). The three other groups correspond to viruses from Sri Lanka (1982) and the Seychelles (1977), from Puerto Rico (1973) and from Tahiti (1975). Our approach appears to be valuable characterizing dengue isolates, easily and rapidly.