• 2017 Outbreak of Ebola Virus Disease in Northern Democratic Republic of Congo

      Nsio, J; Kapetshi, J; Makiala, S; Raymond, F; Tshapenda, G; Boucher, N; Corbeil, J; Okitandjate, A; Mbuyi, G; Kiyele, M; et al. (Oxford University Press, 2019-04-03)
      Background In 2017, the Democratic Republic of the Congo (DRC) recorded its eighth Ebola virus disease (EVD) outbreak, approximately 3 years after the previous outbreak. Methods Suspect cases of EVD were identified on the basis of clinical and epidemiological information. Reverse transcription–polymerase chain reaction (RT-PCR) analysis or serological testing was used to confirm Ebola virus infection in suspected cases. The causative virus was later sequenced from a RT-PCR–positive individual and assessed using phylogenetic analysis. Results Three probable and 5 laboratory-confirmed cases of EVD were recorded between 27 March and 1 July 2017 in the DRC. Fifty percent of cases died from the infection. EVD cases were detected in 4 separate areas, resulting in > 270 contacts monitored. The complete genome of the causative agent, a variant from the Zaireebolavirus species, denoted Ebola virus Muyembe, was obtained using next-generation sequencing. This variant is genetically closest, with 98.73% homology, to the Ebola virus Mayinga variant isolated from the first DRC outbreaks in 1976–1977. Conclusion A single spillover event into the human population is responsible for this DRC outbreak. Human-to-human transmission resulted in limited dissemination of the causative agent, a novel Ebola virus variant closely related to the initial Mayinga variant isolated in 1976–1977 in the DRC.
    • Acute respiratory failure in an infant and thiamine deficiency in West Africa: a case report

      Hiffler, L; Escajadillo, K; Rocaspana, M; Janet, S (Oxford University Press, 2020-06-25)
      In paediatrics, the overall clinical picture of thiamine deficiency (TD) is not easy to recognize, because it mimics or can be confused with other diseases even in cases of classic beriberi. Unsurprisingly, the likelihood of misdiagnosis of TD is even greater where beriberi has not been described. Critically ill patients have increased thiamine body consumption and dextrose-based IV fluid increases thiamine cellular demand even further. Consequently, severe acute conditions may result in TD, or trigger TD signs in patients with borderline thiamine status, with life-threatening consequences. Here, we describe the case of a young patient admitted to a West African hospital where TD is not well documented and diagnosed with severe pneumonia who responded dramatically to thiamine injection. The lack of rapid diagnostic capacity and the severe outcome of TD justify the use of a therapeutic thiamine challenge in cases with high clinical suspicion. Increased awareness about TD and low threshold for thiamine use should guide clinicians in their practice.
    • Adapting Reactive Case Detection Strategies for falciparum Malaria in a Low-Transmission Area in Cambodia.

      Rossi, G; Van den Bergh, R; Nguon, C; Debackere, M; Vernaeve, L; Khim, N; Kim, S; Menard, D; De Smet, M; Kindermans, JM (Oxford University Press, 2018-01-06)
      Reactive case detection around falciparum malaria cases in Cambodia presents a low output. We improved it by including individuals occupationally coexposed with index case patients and using polymerase chain reaction-based diagnosis. The positivity rate increased from 0.16% to 3.9%.
    • Addressing Diabetes Mellitus as Part of the Strategy for Ending TB

      Harries, A D; Kumar, A M; Satyanarayana, S; Lin, Y; Zachariah, R; Lönnroth, K; Kapur, A (Oxford University Press, 2016-03-01)
      As we enter the new era of Sustainable Development Goals, the international community has committed to ending the TB epidemic by 2030 through implementation of an ambitious strategy to reduce TB-incidence and TB-related mortality and avoiding catastrophic costs for TB-affected families. Diabetes mellitus (DM) triples the risk of TB and increases the probability of adverse TB treatment outcomes such as failure, death and recurrent TB. The rapidly escalating global epidemic of DM means that DM needs to be addressed if TB-related milestones and targets are to be achieved. WHO and the International Union Against Tuberculosis and Lung Disease's Collaborative Framework for Care and Control of Tuberculosis and Diabetes, launched in 2011, provides a template to guide policy makers and implementers to combat the epidemics of both diseases. However, more evidence is required to answer important questions about bi-directional screening, optimal ways of delivering treatment, integration of DM and TB services, and infection control. This should in turn contribute to better and earlier TB case detection, and improved TB treatment outcomes and prevention. DM and TB collaborative care can also help guide the development of a more effective and integrated public health approach for managing non-communicable diseases.
    • Analysis of Diagnostic Findings From the European Mobile Laboratory in Guéckédou, Guinea, March 2014 Through March 2015

      Kerber, R; Krumkamp, R; Diallo, B; Jaeger, A; Rudolf, M; Lanini, S; Bore, JA; Koundouno, FR; Becker-Ziaja, B; Fleischmann, E; et al. (Oxford University Press, 2016-09-16)
       A unit of the European Mobile Laboratory (EMLab) consortium was deployed to the Ebola virus disease (EVD) treatment unit in Guéckédou, Guinea, from March 2014 through March 2015.
    • Antibiotic resistance in conflict settings: lessons learned in the Middle East

      Kanapathipillai, R; Malou, N; Hopman, J; Bowman, C; Yousef, N; Michel, J; Hussein, N; Herard, P; Ousley, J; Mills, C; et al. (Oxford University Press, 2019-04-10)
      Me´decins Sans Frontie`res (MSF) has designed context-adapted antibiotic resistance (ABR) responses in countries across the Middle East. There, some health systems have been severely damaged by conflict resulting in delayed access to care, crowded facilities and supply shortages. Microbiological surveillance data are rarely available, but when MSF laboratories are installed we often find MDR bacteria at alarming levels.1 In MSF’s regional hospital in Jordan, where surgical patients have often had multiple surgeries in field hospitals before reaching definitive care (often four or more), MSF microbiological data analysis reveals that, among Enterobacteriaceae isolates, third-generation cephalosporin and carbapenem resistance is 86.2% and 4.3%, respectively; MRSA prevalence among Staphylococcus aureus is 60.5%; and resistance types and rates are similar in patients originating from Yemen, Syria and Iraq.1–3 These trends compel MSF to aggressively prevent and diagnose ABR in Jordan, providing ABR lessons that inform the antibiotic choices, microbiological diagnostics and anti-ABR strategies in other Middle Eastern MSF trauma projects (such as Yemen and Gaza). As a result, MSF has created a multifaceted, context-adapted, field experience-based, approach to ABR in hospitals in Middle Eastern conflict settings. We focus on three pillars: (1) infection prevention and control (IPC); (2) microbiology and surveillance; and (3) antibiotic stewardship.
    • Behind the Scenes of South Africa’s Asylum Procedure: A Qualitative Study on Long-term Asylum-Seekers from the Democratic Republic of Congo

      Schockaert, L; Venables, E; Gil-Bazo, MT; Barnwell, G; Gerstenhaber, R; Whitehouse, K (Oxford University Press, 2020-02-20)
      Despite the difficulties experienced by asylum-seekers in South Africa, little research has explored long-term asylum applicants. This exploratory qualitative study describes how protracted asylum procedures and associated conditions are experienced by Congolese asylum-seekers in Tshwane, South Africa. Eighteen asylum-seekers and eight key informants participated in the study. All asylum-seekers had arrived in South Africa between 2003 and 2013, applied for asylum within a year of arrival in Tshwane, and were still in the asylum procedure at the time of the interview, with an average of 9 years since their application. Thematic analysis was used to analyse the data. The findings presented focus on the process of leaving the Democratic Republic of Congo, applying for asylum and aspirations of positive outcomes for one’s life. Subsequently, it describes the reality of prolonged periods of unfulfilled expectations and how protracted asylum procedures contribute to poor mental health. Furthermore, coping mechanisms to mitigate these negative effects are described. The findings suggest that protracted asylum procedures in South Africa cause undue psychological distress. Thus, there is both a need for adapted provision of mental health services to support asylum-seekers on arrival and during the asylum process, and systemic remediation of the implementation of asylum procedures.
    • Burden of HIV-Related Cytomegalovirus Retinitis in Resource-Limited Settings: A Systematic Review

      Ford, Nathan; Shubber, Zara; Saranchuk, Peter; Pathai, Sophia; Durier, Nicolas; O'Brien, Daniel P; Mills, Edward J; Pascual, Fernando; Hoen, Ellen 't; Holland, Gary N; et al. (Oxford University Press, 2013-09-02)
      Background. Cytomegalovirus (CMV) is a late-stage opportunistic infection in people living with human immunodeficiency virus (HIV)/AIDS. Lack of ophthalmological diagnostic skills, lack of convenient CMV treatment, and increasing access to antiretroviral therapy have all contributed to an assumption that CMV retinitis is no longer a concern in low- and middle-income settings. Methods. We conducted a systematic review and meta-analysis of published and unpublished studies reporting prevalence of CMV retinitis in low- and middle-income countries. Eligible studies assessed the occurrence of CMV retinitis by funduscopic examination within a cohort of at least 10 HIV-positive adult patients. Results. We identified 65 studies from 24 countries, mainly in Asia (39 studies, 12 931 patients) and Africa (18 studies, 4325 patients). By region, the highest prevalence was observed in Asia with a pooled prevalence of 14.0% (11.8%-16.2%). Almost a third (31.6%, 95% confidence interval [CI], 27.6%-35.8%) had vision loss in 1 or both eyes. Few studies reported immune status, but where reported CD4 count at diagnosis of CMV retinitis was <50 cells/µL in 73.4% of cases. There was no clear pattern of prevalence over time, which was similar for the period 1993-2002 (11.8%; 95% CI, 8%-15.7%) and 2009-2013 (17.6%; 95% CI, 12.6%-22.7%). Conclusions. Prevalence of CMV retinitis in resource low- and middle-income countries, notably Asian countries, remains high, and routine retinal screening of late presenting HIV-positive patients should be considered. HIV programs must ensure capacity to manage the needs of patients who present late for care.
    • Causes and determinants of mortality in HIV-infected adults with tuberculosis: an analysis from the CAMELIA ANRS 1295-CIPRA KH001 randomized trial

      Marcy, Olivier; Laureillard, Didier; Madec, Yoann; Chan, Sarin; Mayaud, Charles; Borand, Laurence; Prak, Narom; Kim, Chindamony; Lak, Kim Khemarin; Hak, Chanroeurn; et al. (Oxford University Press, 2014-08)
      Shortening the interval between antituberculosis treatment onset and initiation of antiretroviral therapy (ART) reduces mortality in severely immunocompromised human immunodeficiency virus (HIV)-infected patients with tuberculosis. A better understanding of causes and determinants of death may lead to new strategies to further enhance survival.
    • Challenges in the management of disseminated progressive histoplasmosis in human immunodeficiency virus-infected patients in resource-limited settings

      Murphy, Richard A; Gounder, Lilishia; Manzini, Thandekile C; Ramdial, Pratistadevi K; Castilla, Carmen; Moosa, Mahomed-Yunus S (Oxford University Press, 2015-03-30)
      The diagnosis of histoplasmosis in patients with human immunodeficiency virus in southern Africa is complicated by the nonspecific presentation of the disease in this patient group and the unavailability of sensitive diagnostics including antigen assays. Treatment options are also limited due to the unavailability of liposomal amphotericin and itraconazole, and the inability to perform therapeutic drug monitoring further confounds management. We present 3 clinical cases to illustrate the limits of diagnosis and management in the southern African context, and we highlight the need for additional diagnostic tools and treatment options in resource-limited settings.
    • Clinical Chemistry of Patients With Ebola in Monrovia, Liberia

      de Wit, E; Kramer, S; Prescott, J; Rosenke, K; Falzarano, D; Marzi, A; Fischer, RJ; Safronetz, D; Hoenen, T; Groseth, A; et al. (Oxford University Press, 2016-07-28)
      The development of point-of-care clinical chemistry analyzers has enabled the implementation of these ancillary tests in field laboratories in resource-limited outbreak areas. The Eternal Love Winning Africa (ELWA) outbreak diagnostic laboratory, established in Monrovia, Liberia, to provide Ebola virus and Plasmodium spp. diagnostics during the Ebola epidemic, implemented clinical chemistry analyzers in December 2014. Clinical chemistry testing was performed for 68 patients in triage, including 12 patients infected with Ebola virus and 18 infected with Plasmodium spp. The main distinguishing feature in clinical chemistry of Ebola virus-infected patients was the elevation in alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and γ-glutamyltransferase levels and the decrease in calcium. The implementation of clinical chemistry is probably most helpful when the medical supportive care implemented at the Ebola treatment unit allows for correction of biochemistry derangements and on-site clinical chemistry analyzers can be used to monitor electrolyte balance.
    • Clinical predictor of mortality in patients with Ebola virus disease

      Barry, Moumié; Touré, Abdoulaye; Traoré, Fodé Amara; Sako, Fodé-Bangaly; Sylla, D; Kpamy, Dimai Ouo; Bah, Elhadj Ibrahima; Bangoura, M'Mah; Poncin, Marc; Keita, Sakoba; et al. (Oxford University Press, 2015-03-13)
      In an observational cohort study including 89 Ebola patients, predictor factors of death were analyzed. The crude mortality rate was 43.8%. Myalgia (OR; 4.04; P=0.02), hemorrhage (OR=3.52; P=0.02), and difficulty breathing (OR= 5.75; P=0.01) were independently associated with death.
    • Closing in on the Reservoir: Proactive Case Detection in High-Risk Groups as a Strategy to Detect Plasmodium falciparum Asymptomatic Carriers in Cambodia

      Rossi, Gabriele; Vernaeve, Lieven; Van den Bergh, Rafael; Nguon, Chea; Debackere, Mark; Abello Peiri, Carme; Van, Vuthea; Khim, Nimol; Kim, Saorin; Eam, Rotha; et al. (Oxford University Press, 2018-01-18)
      In the frame of elimination strategies of Plasmodium falciparum (Pf), active case detection has been recommended as complementary approach to the existing passive case detection programs. We trialed a polymerase chain reaction (PCR)-based active detection strategy targeting asymptomatic individuals, named proactive case detection (PACD), with the aim of assessing its feasibility, the extra yield of Pf infections, and the at-risk population for Pf carriage status.
    • Collaboration between Médecins Sans Frontières and Oxford Medical Case Reports

      Balinska, MA; Watts, RA (Oxford University Press, 2019-04-15)
    • Combination Treatment for Visceral Leishmaniasis Patients Co-infected with Human Immunodeficiency Virus in India

      Mahajan, Raman; Das, Pradeep; Isaakidis, Petros; Sunyoto, Temmy; Sagili, Karuna D; Lima, Marıa Angeles; Mitra, Gaurab; Kumar, Deepak; Pandey, Krishna; Van Geertruyden, Jean-Pierre; et al. (Oxford University Press, 2015-06-30)
      There are considerable numbers of patients co-infected with Human Immunodeficiency Virus (HIV) and Visceral Leishmaniasis (VL) in the VL-endemic areas of Bihar, India. These patients are at higher risk of relapse and death, but there are still no evidence-based guidelines on how to treat them. In this study, we report on treatment outcomes of co-infected patients up to 18 months following treatment with a combination regimen.
    • Community-based antiretroviral therapy programs can overcome barriers to retention of patients and decongest health services in sub-Saharan Africa: a systematic review

      Decroo, Tom; Rasschaert, Freya; Telfer, Barbara; Remartinez, Daniel; Laga, Marie; Ford, Nathan; Médecins Sans Frontières, Av. Eduardo Mondlane 38 - CP 262, Tete, Mozambique. (Oxford University Press, 2013-09-05)
      In sub-Saharan Africa models of care need to adapt to support continued scale up of antiretroviral therapy (ART) and retain millions in care. Task shifting, coupled with community participation has the potential to address the workforce gap, decongest health services, improve ART coverage, and to sustain retention of patients on ART over the long-term. The evidence supporting different models of community participation for ART care, or community-based ART, in sub-Saharan Africa, was reviewed. In Uganda and Kenya community health workers or volunteers delivered ART at home. In Mozambique people living with HIV/AIDS (PLWHA) self-formed community-based ART groups to deliver ART in the community. These examples of community ART programs made treatment more accessible and affordable. However, to achieve success some major challenges need to be overcome: first, community programs need to be driven, owned by and embedded in the communities. Second, an enabling and supportive environment is needed to ensure that task shifting to lay staff and PLWHA is effective and quality services are provided. Finally, a long term vision and commitment from national governments and international donors is required. Exploration of the cost, effectiveness, and sustainability of the different community-based ART models in different contexts will be needed.
    • Comparative Effectiveness of Interventions to Improve the HIV Continuum of Care and HIV Preexposure Prophylaxis in Kenya: A Model-Based Analysis

      Luong Nguyen, LB; Freedberg, KA; Wanjala, S; Maman, D; Szumilin, E; Mendiharat, P; Yazdanpanah, Y (Oxford University Press, 2020-10-27)
      Background In Western Kenya up to one-quarter of the adult population was human immunodeficiency virus (HIV)-infected in 2012. The Ministry of Health, Médecins Sans Frontières, and partners implemented an HIV program that surpassed the 90-90-90 UNAIDS targets. In this generalized epidemic, we compared the effectiveness of preexposure prophylaxis (PrEP) with improving continuum of care. Methods We developed a dynamic microsimulation model to project HIV incidence and infections averted to 2030. We modeled 3 strategies compared to a 90-90-90 continuum of care base case: (1) scaling up the continuum of care to 95-95-95, (2) PrEP targeting young adults with 10% coverage, and (3) scaling up to 95-95-95 and PrEP combined. Results In the base case, by 2030 HIV incidence was 0.37/100 person-years. Improving continuum levels to 95-95-95 averted 21.5% of infections, PrEP averted 8.0%, and combining 95-95-95 and PrEP averted 31.8%. Sensitivity analysis showed that PrEP coverage had to exceed 20% to avert as many infections as reaching 95-95-95. Conclusions In a generalized HIV epidemic with continuum of care levels at 90-90-90, improving the continuum to 95-95-95 is more effective than providing PrEP. Continued improvement in the continuum of care will have the greatest impact on decreasing new HIV infections.
    • Constraints in the diagnosis and treatment of Lassa Fever and the effect on mortality in hospitalized children and women with obstetric conditions in a rural district hospital in Sierra Leone

      Dahmane, A; van Griensven, J; Van Herp, M; Van den Bergh, R; Nzomukunda, Y; Prior, J; Alders, P; Jambai, A; Zachariah, R (Oxford University Press, 2014-03)
      Lassa fever (LF) is an acute viral haemorrhagic infection, endemic in West Africa. Confirmatory diagnosis and treatment (ribavirin) is difficult, expensive, and restricted to specialised hospitals. Among confirmed and suspected LF cases, we report on clinical and laboratory features, timing and administration of ribavirin and the relationship with case fatality.
    • The Continuing Burden of Advanced HIV Disease Over 10 Years of Increasing Antiretroviral Therapy Coverage in South Africa.

      Osler, M; Hilderbrand, K; Goemaere, E; Ford, N; Smith, M; Meintjes, G; Kruger, J; Govender, NP; Boulle, A (Oxford University Press, 2018-03-04)
      BACKGROUND: Antiretroviral treatment (ART) has been massively scaled up to decrease human immunodeficiency virus (HIV)-related morbidity, mortality, and HIV transmission. However, despite documented increases in ART coverage, morbidity and mortality have remained substantial. This study describes trends in the numbers and characteristics of patients with very advanced HIV disease in the Western Cape, South Africa. METHODS: Annual cross-sectional snapshots of CD4 distributions were described over 10 years, derived from a province-wide cohort of all HIV patients receiving CD4 cell count testing in the public sector. Patients with a first CD4 count <50 cells/µL in each year were characterized with respect to prior CD4 and viral load testing, ART access, and retention in ART care. RESULTS: Patients attending HIV care for the first time initially constituted the largest group of those with CD4 count <50 cells/µL, dropping proportionally over the decade from 60.9% to 26.7%. By contrast, the proportion who were ART experienced increased from 14.3% to 56.7%. In patients with CD4 counts <50 cells/µL in 2016, 51.8% were ART experienced, of whom 76% could be confirmed to be off ART or had recent viremia. More than half who were ART experienced with a CD4 count <50 cells/µL in 2016 were men, compared to approximately one-third of all patients on ART in the same year. CONCLUSIONS: Ongoing HIV-associated morbidity now results largely from treatment-experienced patients not being in continuous care or not being fully virologically suppressed. Innovative interventions to retain ART patients in effective care are an essential priority for the ongoing HIV response.