This section contains articles written by MSF staff and MSF partners published in peer-reviewed journals. It contains research articles, reviews, editorials and letters. In all cases, the full text is available for free. Some articles are listed under more than one topic. The box on the right lists all the topics.

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  • Routine immediate eye examination at the point of care for diagnosis of AIDS-related Cytomegalovirus Retinitis among patients with a CD4-count < 100 in Myanmar

    Ei, WLSS; Soe, KP; Hilbig, A; Murray, J; Heiden, D (Oxford University Press, 2019-06-14)
    A retrospective review of diagnosis of cytomegalovirus retinitis (CMVR) before and after introduction of routine immediate eye examination among AIDS patient in Myanmar with an absolute CD4 T cell count <100 cells/microliter demonstrated an increased detection of CMVR from 1.1% (14/1233) to 10.7% (65/608), an improvement of approximately ten-fold. Diagnosis of CMVR was achieved a mean of 2 days after clinic enrollment.
  • Outcomes of patients enrolled in an antiretroviral adherence club with recent viral suppression after experiencing elevated viral loads

    Sharp, J; Wilkinson, L; Cox, V; Cragg, C; van Custem, G; Grimsrud, A (Health and Medical Publishing Group, 2019-06-11)
    Background: Eligibility for differentiated antiretroviral therapy (ART) delivery models has to date been limited to low-risk stable patients. Objectives: We examined the outcomes of patients who accessed their care and treatment through an ART adherence club (AC), a differentiated ART delivery model, immediately following receiving support to achieve viral suppression after experiencing elevated viral loads (VLs) at a high-burden ART clinic in Khayelitsha, South Africa. Methods: Beginning in February 2012, patients with VLs above 400 copies/mL either on firstor second-line regimens received a structured intervention developed for patients at risk of treatment failure. Patients who successfully suppressed either on the same regimen or after regimen switch were offered immediate enrolment in an AC facilitated by a lay community health worker. We conducted a retrospective cohort analysis of patients who enrolled in an AC directly after receiving suppression support. We analysed outcomes (retention in care, retention in AC care and viral rebound) using Kaplan–Meier methods with follow-up from October 2012 to June 2015. Results: A total of 165 patients were enrolled in an AC following suppression (81.8% female, median age 36.2 years). At the closure of the study, 119 patients (72.0%) were virally suppressed and 148 patients (89.0%) were retained in care. Six, 12 and 18 months after AC enrolment, retention in care was estimated at 98.0%, 95.0% and 89.0%, respectively. Viral suppression was estimated to be maintained by 90.0%, 84.0% and 75.0% of patients at 6, 12 and 18 months after AC enrolment, respectively. Conclusion: Our findings suggest that patients who struggled to achieve or maintain viral suppression in routine clinic care can have good retention and viral suppression outcomes in ACs, a differentiated ART delivery model, following suppression support.
  • Reproductive health in humanitarian settings in Lebanon and Iraq: results from four cross-sectional studies, 2014-2015.

    Balinska, MA; Nesbitt, R; Ghantous, Z; Ciglenecki, I; Staderini, N (BMC, 2019-06-10)
    BACKGROUND: Reproductive health is an important component of humanitarian response. Displaced women need access to family planning, antenatal care, and the presence of a skilled birth attendant at delivery. Since the beginning of the Syrian conflict in 2011, Lebanon and Iraq have been hosting large numbers of refugees, thereby straining local capacities to provide these services. In order to identify salient health needs, Médecins Sans Frontières conducted a survey in several sites hosting refugees and internally displaced persons across the region. Here we describe the reproductive health profile of Syrian refugees, Iraqi displaced persons, and vulnerable Lebanese and their use of services. METHODS: We conducted four cross-sectional surveys in 2014-2015 in two sites in Lebanon and two sites in Iraq. Depending on the site, two-stage cluster sampling or systematic sampling was intended, but non-probability methods were employed at the second stage due to implementation challenges. We collected information on overall health (including reproductive health) and demographic information from heads of households on the basis of a standardized questionnaire. Pearson chi-square tests were used to compare proportions, and generalized linear models were used to calculate odds ratios with regard to risk factors. All analyses were performed using the survey suite of commands in Stata version 14.1. RESULTS: A total of 23,604 individuals were surveyed, including 5925 women of childbearing age. Overall, it was reported that 7.5% of women were currently pregnant and 12.8% had given birth within the previous 12 months. It was reported that pregnancy was unplanned for 57% of currently pregnant women and 66.7% of women who had delivered in the previous year. A slight majority of women from both groups had accessed antenatal care at least once. Amongst women who had delivered in the previous year, 84.5% had done so with a skilled birth attendant and 22.1% had had a cesarean section. Location and head of household education were predictors of unplanned pregnancy in multivariable analysis. Head of household education was also significantly associated with higher uptake of antenatal care. CONCLUSIONS: Considering the large number of pregnant women and women having recently delivered in these settings, addressing their sexual and reproductive health needs emerges as a crucial aspect of humanitarian response. This study identified unmet needs for family planning and high cesarean section rates at all sites, suggesting both lack of access to certain services (contraception, antenatal care), but also over-recourse to cesarean section. These specific challenges can impact directly on maternal and child health and need today to be kept high on the humanitarian agenda.
  • Severe acute malnutrition results in lower lumefantrine exposure in children treated with artemether-lumefantrine for uncomplicated malaria

    Chotsiri, P; Denoeud-Ndam, L; Baudin, E; Guindo, O; Diawara, H; Attaher, O; Smit, M; Guerin, PJ; Duombo, OK; Weisner, L; Barnes, KI; Hoglund, RM; Dicko, A; Etard, JF; Tarning, J (American Society for Clinical Pharmacology and Therapeutics, 2019-06-01)
    Severe acute malnutrition (SAM) has been reported to be associated with increased malaria morbidity in Sub‐Saharan African children and may affect the pharmacology of antimalarial drugs. This population pharmacokinetic‐pharmacodynamic study included 131 SAM and 266 non‐SAM children administered artemether‐lumefantrine twice daily for 3 days. Lumefantrine capillary plasma concentrations were adequately described by two transit‐absorption compartments followed by two distribution compartments. Allometrically scaled body weight and an enzymatic maturation effect were included in the pharmacokinetic model. Mid‐upper arm circumference (MUAC) was associated with decreased absorption of lumefantrine (25.4% decrease per 1 cm reduction). Risk of recurrent malaria episodes (i.e. reinfection) were characterised by an interval‐censored time‐to‐event model with a sigmoid EMAX‐model describing the effect of lumefantrine. SAM children were at risk of under‐exposure to lumefantrine and an increased risk of malaria reinfection compared to well‐nourished children. Research on optimised regimens should be considered for malaria treatment in malnourished children.
  • Knowledge, attitudes, and practices related to antibiotic use in Paschim Bardhaman District: A survey of healthcare providers in West Bengal, India.

    Nair, M; Tripathi, S; Mazumdar, S; Mahajan, R; Harshana, A; Pereira, A; Jimenez, C; Halder, D; Burza, S (Public Library of Science, 2019-05-31)
    INTRODUCTION: Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature. OBJECTIVES: This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use. METHODS: We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender. RESULTS: Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics. CONCLUSIONS: Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention.
  • How patent law reform can improve affordability and accessibility of medicines in South Africa: Four medicine case studies

    Tomlinson, C; Waterhouse, C; Hu, YQ; Meyer, S; Moyo, H (Publisher Health & Medical Publishing Group, 2019-05-31)
    South Africa (SA) is in the process of amending its patent laws. Since its 2011 inception, Fix the Patent Laws, a coalition of 40 patient groups, has advocated for reform of SA’s patent laws to improve affordability of medicines in the country. Building on two draft policies (2013, 2017) and a consultative framework (2016) for reform of SA’s patent laws, Cabinet approved phase 1 of the Intellectual Property Policy of the Republic of South Africa on 23 May 2018. Fix the Patent Laws welcomed the policy, but highlighted concerns regarding the absence of important technical details, as well as the urgent need for government to develop bills, regulations and guidelines to provide technical detail and to codify and implement patent law reform in the country. In this article, we explore how reforms proposed in SA’s new intellectual property policy could improve access to medicine through four medicine case studies.
  • Exploring global and country-level barriers to an effective supply of leishmaniasis medicines and diagnostics in eastern Africa: a qualitative study.

    Sunyoto, T; Potet, J; den Boer, M; Ritmeijer, K; Postigo, JAR; Ravinetto, R; Alves, F; Picado, A; Boelaert, M (BMJ Publishing Group, 2019-05-30)
    OBJECTIVES: To understand stakeholders' perceptions of the access barriers to quality-assured diagnostics and medicines for leishmaniasis in the high-burden region of eastern Africa, and to identify key bottlenecks to improve the supply of commodities for neglected tropical diseases. DESIGN: Desk reviews and qualitative in-depth interview study with purposive sampling. METHODS: A landscape analysis through literature and desk review was performed. Next, 29 representatives from international organisations, non-governmental agencies, national control programmes from six countries (Ethiopia, Kenya, Somalia, South Sudan, Sudan and Uganda) and manufacturers were interviewed between May and July 2018. Participants were selected purposively and expanded through a snowballing technique.Data analysis was aided by NVivo, applying the framework method as a part of the thematic content analysis approach. RESULTS: The barriers along the visceral leishmaniasis (VL) supply chain were identified as emerging themes, grouped across supply chain activities and health systems component(s). Stakeholders expressed the perception of progress, but bottlenecks persist. VL medicines, in general, lack multisource production capacity and with small market volume, expansion of suppliers is difficult. Procurement is plagued by forecasting difficulties, complex regulatory policies and procedures, and distribution challenges. Weak communication and coordination across different levels resulted in shortages and loss of trust among different actors. Cross-cutting issues spanned from limited political and resource commitment due to low awareness and limited in-country capacity. However, study respondents were optimistic to pursue several remedies, most importantly to build bridges between supply and demand sides through continued dialogue and collaborations. Diagnostics supply has mostly been overlooked; thus, improved investment in this area is needed. CONCLUSIONS: Addressing supply barriers in eastern Africa requires consistent, specific efforts at the global and national levels, progressing from current partnerships and agreements. Priority actions include pooled procurement, improved forecast, and increased commitment and resources. Sustainability remains an elusive goal, yet to be integrated into discussions moving forward.
  • Congo’s Ebola epidemic—a failed response and the need for a reset

    Huster, K; Healy, J (BMJ Publishing Group, 2019-05-24)
  • Breast Tuberculosis in Women: A Systematic Review

    Quaglio, G; Pizzol, D; Isaakidis, P; Bortolani, A; Tognon, F; Marotta, C; Di Gennaro, F; Putoto, G; Olliaro, P (American Society of Tropical Medicine and Hygiene, 2019-05-20)
    Breast tuberculosis (TB) is rarely reported and poorly described. This review aims to update the existing literature on risk factors, clinical presentations, constitutional symptoms, diagnostic procedures, and medical and surgical treatments for breast TB. In all, 1,478 cases of breast TB were collected. Previous history of TB was reported in 19% of cases. The most common clinical appearance of the lesion was breast lump (75%). The most common associated finding was axillary lymphadenitis (33%) followed by sinus or fistula (24%). The most common symptoms were pain and fever, reported in 42% and 28% of cases, respectively. The most used diagnostic method was fine-needle aspiration cytology (32%), followed by biopsy (27%), acid-fast bacteria Ziehl–Neelsen stain (26%), culture (13%), and polymerase chain reaction (2%). These tested positive in 64%, 93%, 27%, 26%, and 58% of cases, respectively. The majority (69%) of patients received a 6-month anti-TB treatment (isoniazid, rifampicin, pyrazinamide, and ethambutol). Surgery consisted of excision in 39% of cases, drainage in 23%, and mastectomy in 5%. The great majority of patients had a positive outcome. It often mimics breast cancer, which makes it difficult to diagnose. Most patients, when diagnosed in time, respond to antitubercular therapy alone.
  • 'Working to stay healthy', health-seeking behaviour in Bangladesh's urban slums: a qualitative study.

    van der Heijden, J; Gray, N; Stringer, B; Rahman, A; Akhter, S; Kalon, S; Dada, M; Biswas, A (BioMed Central, 2019-05-17)
    BACKGROUND: Kamrangirchar and Hazaribagh are the largest slum areas in Dhaka, Bangladesh. In 2013, Médecins Sans Frontières initiated an urban healthcare programme in these areas providing services for factory workers and responding to the sexual and reproductive health needs of young women. Little in-depth information is available on perceptions of health and health seeking behaviour in this population. We aimed to provide a better understanding of community perceptions toward health and health care in order to inform programme strategies. METHODS: In-depth interviews were conducted with women (n = 13); factory workers (n = 14); and key informants (n = 13). Participants were selected using purposive maximum variation sampling and voluntarily consented to take part. Topic guides steered participant-led interviews, which were audio-recorded, translated and transcribed from Bangla into English. By comparing cases, we identified emerging themes, patterns and relationships in the data. NVivo11© was used to sort and code the data. RESULTS: Emerging themes indicated that in Kamrangirchar and Hazaribagh, health is seen as an asset necessary for work and, thus, for survival. Residents navigate a highly fragmented health system looking for 'quick fixes' to avoid time off work, with the local pharmacy deemed 'good enough' for 'common' health issues. Health care seeking for 'serious' conditions is characterised by uncertainty, confusion, and unsatisfactory results. Decisions are made communally and shaped by collective perceptions of quality care. People with limited socio-economic capital have few options for care. 'Quality care' is perceived as comprehensive care 'under one roof,' including predictive biomedical diagnostics and effective medication, delivered through a trusting relationship with the care provider. CONCLUSIONS: Health seeking behaviour of slum dwellers of Kamrangirchar and Hazaribagh is based on competing priorities, where quick and effective care is key, focussed on the ability to work and generate income. This takes place in a fragmented healthcare system characterised by mistrust of providers, and where navigation is informed by word-of-mouth experiences of peers. Improving health in this context demands a comprehensive and integrated approach to health care delivery, with an emphasis on rapid diagnosis, effective treatment and referral, and improved trust in care providers. Health education must be developed in collaboration with the community to identify knowledge gaps, support decision-making, and be channelled through existing networks. Further research should consider the effectiveness of interventions aiming to improve the practice of pharmacists.
  • Nagaland health assessment: High mortality rates and difficulty accessing essential health services in Lahe Township, Republic of the Union of Myanmar.

    Johnson, DC; Incerti, A; Thu Swe, K; Gignoux, E; Shwe Sin Ei, WL; Lwin Tun, T; Htun, C (Public Library of Science, 2019-05-14)
    INTRODUCTION: Lahe Township belongs to Myanmar`s Naga Self-administered Zone, which is one of the most remote and mountainous areas in Myanmar. However, the limited health data available for the region suggests that there could be neglected health needs that require attention. The purpose of this study was to assess the health status of the population of Lahe Township. METHODS: A cross-sectional study design incorporating a two-stage cluster sampling methodology recommended by the WHO was used to conduct a household level survey. In the first stage, 30 village clusters were selected from all villages situated in the Lahe Township through systematic sampling with probability of selection proportional to the population size of each village based on the 2014 Myanmar census. In the second stage, a GPS-based sampling method was used to select 30 households within a village cluster. The head of the household completed the survey for all members of the household. Questionnaires inquired about maternal health, mortality, morbidities, childhood nutritional status, access to health care, and water & sanitation. The resulting data was stratified by urban/rural status. RESULTS: Data was collected on 5,929 individuals living in 879 households, of which 993 individuals (16.7%) were children 5 years old or younger. The median age was 18.0 (IQR 8.0-35.0). Children 15 years old or younger represented 44.7% of the population. 19.8% of households reported at least 1 household member sick during the previous 30 days. The crude mortality rate per 10,000 people per day was 0.58 (95% CI: 0.48-0.69). The under 5 mortality per 10,000 people per day was 0.74 (95% CI: 0.50-1.06). Only 46.7% of households could access a hospital if there was a need. CONCLUSION: Our results demonstrate a high rate of mortality and the inability to access healthcare in Lahe Township, which should be addressed to prevent further deterioration of health.
  • Molecular epidemiology of hepatitis C virus in Cambodia during 2016-2017.

    Nouhin, J; Iwamoto, M; Prak, S; Dousset, JP; Phon, K; Heng, S; Kerleguer, A; Le Paih, M; Dussart, P; Maman, D; Rouet, F (Nature Publishing Group, 2019-05-13)
    In Cambodia, little epidemiological data of hepatitis C virus (HCV) is available. All previous studies were limited to only small or specific populations. In the present study, we performed a characterization of HCV genetic diversity based on demography, clinical data, and phylogenetic analysis of HCV non-structural 5B (NS5B) sequences belonging to a large cohort of patients (n = 3,133) coming from majority part of Cambodia between September 2016 and December 2017. The phylogenetic analysis revealed that HCV genotype 1 and 6 were the most predominant and sharing equal proportions (46%). The remaining genotypes were genotype 2 (4.3%) and unclassified variants (3.6%). Among genotype 1, subtype 1b was the most prevalent subtype accounting for 94%. Within genotype 6, we observed a high degree of diversity and the most common viral subtypes were 6e (44%) and 6r (23%). This characteristic points to the longstanding history of HCV in Cambodia. Geographic specificity of viral genotype was not observed. Risks of HCV infection were mainly associated with experience of an invasive medical procedure (64.7%), having partner with HCV (19.5%), and blood transfusion (9.9%). In addition, all of these factors were comparable among different HCV genotypes. All these features define the specificity of HCV epidemiology in Cambodia.
  • "If we miss this chance, it's futile later on" - late antenatal booking and its determinants in Bhutan: a mixed-methods study.

    Dorji, T; Das, M; Van den Bergh, R; Oo, MM; Gyamtsho, S; Tenzin, K; Tshomo, T; Ugen, S (BioMed Central, 2019-05-07)
    BACKGROUND: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. METHODS: This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May-August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. RESULTS: Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. CONCLUSION: Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.
  • Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan.

    Tounsi, LL; Daebes, HL; Warnberg, MG; Jaweed, M; Mamozai, BA; Nasim, M; Drevin, G; Trelles, M; von Schreeb, J (Springer, 2019-05-07)
    INTRODUCTION: There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. MATERIALS AND METHODS: This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression. RESULTS: Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453). CONCLUSION: Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.
  • Novel Approaches to Control Malaria in Forested Areas of Southeast Asia.

    von Seidlein, L; Peto, TJ; Tripura, R; Pell, C; Yeung, S; Kindermans, JM; Dondorp, A; Maude, R (Elsevier, 2019-05-07)
    The emergence and spread of drug resistance in the Greater Mekong Subregion (GMS) have added urgency to accelerate malaria elimination while reducing the treatment options. The remaining foci of malaria transmission are often in forests, where vectors tend to bite during daytime and outdoors, thus reducing the effectiveness of insecticide-treated bed nets. Limited periods of exposure suggest that chemoprophylaxis could be a promising strategy to protect forest workers against malaria. Here we discuss three major questions in optimizing malaria chemoprophylaxis for forest workers: which antimalarial drug regimens are most appropriate, how frequently the chemoprophylaxis should be delivered, and how to motivate forest workers to use, and adhere to, malaria prophylaxis.
  • Diagnostic Value of Histological Analysis of Punch Biopsies in Suspected Cutaneous Buruli Ulcer: A Study on 32 Cases of Confirmed Buruli Ulcer in Cameroon

    Ibrahim, YL; Masouye, I; Tschanz, E; Atangana, P; Etard, JF; Serafini, M; Mueller, YK; Trellu, LT (Karger, 2019-05-07)
    Background: Buruli ulcer (BU) is a cutaneous infectious disease caused by Mycobacterium ulcerans. In this prospective study, we aim to clarify the main histopathological features of cutaneous BU based on 4-mm skin punch biopsies and to evaluate the diagnostic value of this method. Methods: Between 2011 and 2013, a prospective study was conducted in Cameroon. Dry swabs from ulcerative lesions and fine-needle aspirates of nonulcerative lesions were examined for Ziehl-Neelsen (ZN) staining, followed by PCR targeting IS2404 and culture. Two 4-mm punch biopsies were performed in the center and in the periphery of each lesion. Results: The 364 patients included in the study had 422 lesions (381 were ulcerative and 357 lesions were biopsied). Among the 99 ulcerated lesions with a final diagnosis of BU, histological features for BU were fulfilled in 32 lesions. 32/32 showed subcutaneous necrosis with a neutrophilic inflammatory infiltrate. 26/32 presented alcohol-resistant bacilli confirmed by ZN stain on histology. Conclusion: Punch biopsies help in establishing the correct diagnosis of BU and also in the differential diagnosis of chronic ulcers. The main histological feature for BU is diffuse coagulative necrosis of subcutaneous tissue, with acid-fast bacilli detected by ZN stain.
  • Trends of and factors associated with cesarean section related surgical site infections in Guinea

    Delamou, A; Camara, BS; Sidibe, S; Camara, A; Dioubate, N; Ayadi, AME; Tayler-Smith, K; Beavogui, AH; Balde, MD; Zachariah, R (Page Press, 2019-05-03)
    Since the adoption of free obstetric care policy in Guinea in 2011, no study has examined the surgical site infections in maternity facilities. The objective of this study was to assess the trends of and factors associated with surgical site infection following cesarean section in Guinean maternity facilities from 2013 to 2015. This was a retrospective cohort study using routine medical data from ten facilities. Overall, the incidence of surgical site infections following cesarean section showed a declining trend across the three periods (10% in 2013, 7% in 2014 and 5% in 2015, P<0.001). Women who underwent cesarean section in 2014 (AOR: 0.70; 95%CI: 0.57-0.84) and 2015 (AOR: 0.43; 95%CI: 0.34-0.55) were less likely to develop surgical site infections during hospital stay than women operated in 2013. In the contrary, women with comorbidities were more likely to experience surgical site infection (AOR: 1.54; 95% CI: 1.25-1.90) than those who did not have comorbidities. The reductions achieved in 2014 and 2015 (during the Ebola outbreak) should be sustained in the post-Ebola context.
  • Investigating the addition of oral HIV self-tests among populations with high testing coverage - Do they add value? Lessons from a study in Khayelitsha, South Africa.

    Moore, HA; Metcalf, CA; Cassidy, T; Hacking, D; Shroufi, A; Steele, SJ; Duran, LT; Ellman, T (Public Library of Science, 2019-05-02)
    INTRODUCTION: HIV self-testing (HIVST) offers a useful addition to HIV testing services and enables individuals to test privately. Despite recommendations to the contrary, repeat HIV testing is frequent among people already on anti-retroviral treatment (ART) and there are concerns that oral self-testing might lead to false negative results. A study was conducted in Khayelitsha, South Africa, to assess feasibility and uptake of HIVST and linkage-to-care following HIVST. METHODS: Participants were recruited at two health facilities from 1 March 2016 to 31 March 2017. People under 18 years, or with self-reported previously-diagnosed HIV infection, were excluded. Participants received an OraQuick Rapid HIV-1/2 Antibody kit, and reported their HIVST results by pre-paid text message (SMS) or by returning to the facility. Those not reporting within 7 days were contacted by phone. Electronic and paper-based clinical and laboratory records were retrospectively examined for all participants to identify known HIV outcomes, after matching for name, date of birth, and sex. These findings were compared with self-reported HIVST results where available. RESULTS: Of 639 participants, 401 (62.8%) self-reported a negative HIVST result, 27 (4.2%) a positive result, and 211 (33.0%) did not report. The record search identified that of the 401 participants self-reporting a negative HIVST result, 19 (4.7%) were already known to be HIV positive; of the 27 self-reporting positive, 12 (44%) were known HIV positive. Overall, records showed 57/639 (8.9%) were HIV positive of whom 39/57 (68.4%) had previously-diagnosed infection and 18/57 (31.6%) newly-diagnosed infection. Of the 428 participants who self-reported a result, 366 (85.5%) reported by SMS. CONCLUSIONS: HIVST can improve HIV testing uptake and linkage to care. SMS is acceptable for reporting HIVST results but negative self-reports by participants may be unreliable. Use of HIVST by individuals on ART is frequent despite recommendations to the contrary and its implications need further consideration.
  • Bedaquiline and delamanid in combination for treatment of drug-resistant tuberculosis

    Mohr, E; Ferlazzo, G; Hewison, C; De Azevedo, V; Isaakidis, P (Elsevier, 2019-05-01)
    Here we report on the final outcomes for the cohort of 28 patients from Armenia, India, and South Africa who initiated regimens containing the combination of bedaquiline and delamanid from January to August, 2016, for the treatment of multidrug-resistant tuberculosis in our cohort study.1 The median duration on combination treatment was 12 months (interquartile range [IQR] 5·9–20·0); 17 (61%) of 28 patients received the combination for more than 6 months.
  • Outcomes of Bedaquiline Treatment in Patients with Multidrug-Resistant Tuberculosis

    Mbuagbaw, L; Guglielmetti, L; Hewison, C; Bakare, N; Bastard, M; Caumes, E; Frechet-Jachym, M; Robert, J; Veziris, N; Khachatryan, N; Kotrikadze, T; Hayrapetyan, A; Avaliani, Z; Schünemann, HJ; Lienhardt, C (Centers for Disease Control and Prevention, 2019-05-01)
    Bedaquiline is recommended by the World Health Organization for the treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB). We pooled data from 5 cohorts of patients treated with bedaquiline in France, Georgia, Armenia, and South Africa and in a multicountry study. The rate of culture conversion to negative at 6 months (by the end of 6 months of treatment) was 78% (95% CI 73.5%-81.9%), and the treatment success rate was 65.8% (95% CI 59.9%-71.3%). Death rate was 11.7% (95% CI 7.0%-19.1%). Up to 91.1% (95% CI 82.2%-95.8%) of the patients experienced >1 adverse event, and 11.2% (95% CI 5.0%-23.2%) experienced a serious adverse event. Lung cavitations were consistently associated with unfavorable outcomes. The use of bedaquiline in MDR and XDR TB treatment regimens appears to be effective and safe across different settings, although the certainty of evidence was assessed as very low.

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