• War, drought, malnutrition, measles--a report from Somalia.

      Cabrol, J-C; Doctors without Borders/Médecins sans Frontières, Geneva. (2011-11-17)
    • Wartime Colon Injuries: Primary Repair or Colostomy?

      Moreels, R; Pont, M; Ean, S; Vitharit, M; Vuthy, C; Roy, S; Boelaert, M; Médecins Sans Frontières, Brussels, Belgium. (Published by the Royal Society of Medicine, 1994-05)
      A retrospective non-randomized study, comparing primary repair with colostomy, was made on a series of 102 patients with penetrating intraperitoneal colon injuries, in a war surgery programme in Cambodia. The overall case fatality rate (CFR) was 25.5%, whereas in the primary repair group CFR was 20%, compared to 30.8% in the colostomy group. The difference was not statistically significant (P = 0.30). Adjustment for possible confounding factors in the two groups did not alter the results. Considering the numerous advantages to the patient of a primary closure in the precarious situations where war surgery is often performed, this technique merits consideration.
    • "We Are Part of a Family". Benefits and Limitations of Community ART Groups (CAGs) in Thyolo, Malawi: a Qualitative Study

      Pellecchia, U; Baert, S; Nundwe, S; Bwanali, A; Zamadenga, B; Metcalf, CA; Bygrave, H; Daho, S; Ohler, L; Chibwandira, B; et al. (International AIDS Society, 2017-03-28)
      In 2012 Community ART Groups (CAGs), a community-based model of antiretroviral therapy (ART) delivery were piloted in Thyolo District, Malawi as a way to overcome patient barriers to accessing treatment, and to decrease healthcare workers' workload. CAGs are self-formed groups of patients on ART taking turns to collect ART refills for all group members from the health facility. We conducted a qualitative study to assess the benefits and challenges of CAGs from patients' and healthcare workers' (HCWs) perspectives.
    • We Urge WHO to Act on Cytomegalovirus Retinitis

      Heiden, David; Saranchuk, Peter; Tun, NiNi; Audoin, Bertrand; Cohn, Jen; Durier, Nicolas; Holland, Gary; Drew, W Lawrence; Hoen, Ellen 't (2014-02)
    • Weight evolution in HIV-1 infected women in Rwanda after stavudine substitution due to lipoatrophy: comparison of zidovudine with tenofovir/abacavir.

      van Griensven, J; Zachariah, R; Rasschaert, F; Atté, E F; Reid, T; Médecins Sans Frontières, 7089 Kigali, Rwanda. (2009-02-01)
      This cohort study was conducted amongst female patients manifesting lipoatrophy while receiving stavudine-containing first-line antiretroviral treatment regimens at two urban health centres in Rwanda. The objectives were to assess weight evolution after stavudine substitution and to describe any significant difference in weight evolution when zidovudine or tenofovir/abacavir was used for substitution. All adult patients on stavudine-containing first-line regimens who developed lipoatrophy (diagnosed using a lipodystrophy case definition study-based questionnaire) and whose treatment regimen was changed were included (n=114). In the most severe cases stavudine was replaced with tenofovir or abacavir (n=39), and in the remainder with zidovudine (n=75). For patients changed to zidovudine a progressive weight loss was seen, while those on tenofovir/abacavir showed a progressive weight increase from six months. The between-group difference in weight evolution was significant from nine months (difference at 12 months: 2.3kg, P=0.02). These differences were confirmed by follow-up lipoatrophy scores. In multivariate analysis, substitution with tenofovir/abacavir remained significantly associated with weight gain. This is the first study in Africa assessing weight gain as a proxy for recovery after stavudine substitution due to lipoatrophy, providing supporting evidence that tenofovir/abacavir is superior to zidovudine. The weight loss with zidovudine might justify earlier substitution and access to better alternatives like tenofovir/abacavir.
    • Weight gain at 3 months of antiretroviral therapy is strongly associated with survival: evidence from two developing countries

      Madec, Yoann; Szumilin, Elisabeth; Genevier, Christine; Ferradini, Laurent; Balkan, Suna; Pujades, Mar; Fontanet, Arnaud; Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France; Medecins Sans Frontieres, Paris, France; Medecins Sans Frontieres, Nairobi, Kenya; Infectious Diseases Department, Khmero-Soviet Friendship Hospital, Phnom Penh, Cambodia; Epicentre, Paris, France (2009-04-27)
      BACKGROUND: In developing countries, access to laboratory tests remains limited, and the use of simple tools such as weight to monitor HIV-infected patients treated with antiretroviral therapy should be evaluated. METHODS: Cohort study of 2451 Cambodian and 2618 Kenyan adults who initiated antiretroviral therapy between 2001 and 2007. The prognostic value of weight gain at 3 months of antiretroviral therapy on 3-6 months mortality, and at 6 months on 6-12 months mortality, was investigated using Poisson regression. RESULTS: Mortality rates [95% confidence interval (CI)] between 3 and 6 months of antiretroviral therapy were 9.9 (7.6-12.7) and 13.5 (11.0-16.7) per 100 person-years in Cambodia and Kenya, respectively. At 3 months, among patients with initial body mass index less than or equal to 18.5 kg/m (43% of the study population), mortality rate ratios (95% CI) were 6.3 (3.0-13.1) and 3.4 (1.4-8.3) for those with weight gain less than or equal to 5 and 5-10%, respectively, compared with those with weight gain of more than 10%. At 6 months, weight gain was also predictive of subsequent mortality: mortality rate ratio (95% CI) was 7.3 (4.0-13.3) for those with weight gain less than or equal to 5% compared with those with weight gain of more than 10%. CONCLUSION: Weight gain at 3 months is strongly associated with survival. Poor compliance or undiagnosed opportunistic infections should be investigated in patients with initial body mass index less than or equal to 18.5 and achieving weight gain less than or equal to 10%.
    • Weight loss after the first year of stavudine-containing antiretroviral therapy and its association with lipoatrophy, virological failure, adherence and CD4 counts at primary health care level in Kigali, Rwanda.

      van Griensven, Johan; Zachariah, Rony; Mugabo, Jules; Reid, Tony; Médecins Sans Frontières, Operational Centre Brussels, Medical Department, Duprestraat 94, 1090 Brussels, Belgium. jvgrie@yahoo.com (2010-12)
      This study was conducted among 609 adults on stavudine-based antiretroviral treatment (ART) for at least one year at health center level in Kigali, Rwanda to (a) determine the proportion who manifest weight loss after one year of ART (b) examine the association between such weight loss and a number of variables, namely: lipoatrophy, virological failure, adherence and on-treatment CD4 count and (c) assess the validity and predictive values of weight loss to identify patients with lipoatrophy. Weight loss after the first year of ART was seen in 62% of all patients (median weight loss 3.1 kg/year). In multivariate analysis, weight loss was significantly associated with treatment-limiting lipoatrophy (adjusted effect/kg/year -2.0 kg, 95% confidence interval -0.6;-3.4 kg; P<0.01). No significant association was found with virological failure or adherence. Higher on-treatment CD4 cell counts were protective against weight loss. Weight loss that was persistent, progressive and/or chronic was predictive of lipoatrophy, with a sensitivity and specificity of 72% and 77%, and positive and negative predictive values of 30% and 95%. In low-income countries, measuring weight is a routine clinical procedure that could be used to filter out individuals with lipoatrophy on stavudine-based ART, after alternative causes of weight loss have been ruled out.
    • What can be learnt from Ebola about the dangers of the global health security approach?

      Roper, S (Transactions of the Royal Society, 2019-12-01)
      The current outbreak of Ebola that has been raging out of control for over 1 y in the Democratic Republic of Congo (DRC) has brought back painful memories from West Africa about the dangers of the global health security approach. Drawing on the author’s personal experience of working as a medic in both outbreaks, this article reflects on the challenges of responding to the disease inside a global health security framework. Insights and recommendations are made as to how the global health community can contribute towards gaining better control of Ebola both now and in the future.
    • What drives mortality among HIV patients in a conflict setting? A prospective cohort study in the Central African Republic

      Crellen, T; Ssonko, C; Piening, T; Simaleko, MM; Geiger, K; Siddiqui, MR (2019-11-14)
      BACKGROUND: Provision of antiretroviral therapy (ART) during conflict settings is rarely attempted and little is known about the expected patterns of mortality. The Central African Republic (CAR) continues to have a low coverage of ART despite an estimated 110,000 people living with HIV and 5000 AIDS-related deaths in 2018. We present results from a cohort in Zemio, Haut-Mboumou prefecture. This region had the highest prevalence of HIV nationally (14.8% in a 2010 survey), and was subject to repeated attacks by armed groups on civilians during the observed period. METHODS: Conflict from armed groups can impact cohort mortality rates i) directly if HIV patients are victims of armed conflict, or ii) indirectly if population displacement or fear of movement reduces access to ART. Using monthly counts of civilian deaths, injuries and abductions, we estimated the impact of the conflict on patient mortality. We also determined patient-level risk factors for mortality and how the risk of mortality varies with time spent in the cohort. Model-fitting was performed in a Bayesian framework, using logistic regression with terms accounting for temporal autocorrelation. RESULTS: Patients were recruited and observed in the HIV treatment program from October 2011 to May 2017. Overall 1631 patients were enrolled and 1628 were included in the analysis giving 48,430 person-months at risk and 145 deaths. The crude mortality rate after 12 months was 0.92 (95% CI 0.90, 0.93). Our model showed that patient mortality did not increase during periods of heightened conflict; the odds ratios (OR) 95% credible interval (CrI) for i) civilian fatalities and injuries, and ii) civilian abductions on patient mortality both spanned unity. The risk of mortality for individual patients was highest in the second month after entering the cohort, and declined seven-fold over the first 12 months. Male sex was associated with a higher mortality (odds ratio 1.70 [95% CrI 1.20, 2.33]) along with the severity of opportunistic infections (OIs) at baseline (OR 2.52; 95% CrI 2.01, 3.23 for stage 2 OIs compared with stage 1). CONCLUSIONS: Our results show that chronic conflict did not appear to adversely affect rates of mortality in this cohort, and that mortality was driven predominantly by patient-specific risk factors. The risk of mortality and recovery of CD4 T-cell counts observed in this conflict setting are comparable to those in stable resource poor settings, suggesting that conflict should not be a barrier in access to ART.
    • What happens after participants complete a Union-MSF structured operational research training course?

      Guillerm, N; Tayler-Smith, K; Berger, S D; Bissell, K; Kumar, A M V; Ramsay, A; Reid, A J; Zachariah, R; Harries, A D (International Union Against Tuberculosis and Lung Disease, 2014-06-12)
    • What happens after participants complete a Union-MSF structured operational research training course?

      Guillerm, N; Tayler-Smith, K; Berger, S D; Bissell, K; Kumar, A M V; Ramsay, A; Reid, A J; Zachariah, R; Harries, A D (The Union, 2014-06-21)
    • What happens to Palestine refugees with diabetes mellitus in a primary healthcare centre in Jordan who fail to attend a quarterly clinic appointment?

      Khader, A; Ballout, G; Shahin, Y; Hababeh, M; Farajallah, L; Zeidan, W; Abu-Zayed, I; Kochi, A; Harries, A D; Zachariah, R; et al. (Wiley-Blackwell, 2014-01-06)
      In a primary healthcare clinic in Jordan to determine: (i) treatment outcomes stratified by baseline characteristics of all patients with diabetes mellitus (DM) ever registered as of June 2012 and (ii) in those who failed to attend the clinic in the quarter (April-June 2012), the number who repeatedly did not attend in subsequent quarters up to 1 year later, again stratified by baseline characteristics.
    • What is a Hotspot Anyway?

      Lessler, J; Azman, A; McKay, H; Moore, S (American Society of Tropical Medicine and Hygiene, 2017-06)
      AbstractThe importance of spatial clusters, or "hotspots," in infectious disease epidemiology has been increasingly recognized, and targeting hotspots is often seen as an important component of disease-control strategies. However, the precise meaning of "hotspot" varies widely in current research and policy documents. Hotspots have been variously described as areas of elevated incidence or prevalence, higher transmission efficiency or risk, or higher probability of disease emergence. This ambiguity has led to confusion and may result in mistaken inferences regarding the best way to target interventions. We surveyed the literature on epidemiologic hotspots, examining the multitude of ways in which the term is used; and highlight the difference in the geographic scale of hotspots and the properties they are supposed to have. In response to the diversity in the term's usage, we advocate the use of more precise terms, such as "burden hotspot," "transmission hotspot," and "emergence hotspot," as well as explicit specification of the spatiotemporal scale of interest. Increased precision in terminology is needed to ensure clear and effective policies for disease control.
    • What is a traumatic experience if you live in Mogadishu?

      de Jong, K; Mental Health Specialist, Medecins Sans Frontieres, Amsterdam, Netherlands (BMJ Group Blog, 2012-03)
    • What is the best culture conversion prognostic marker for patients treated for multidrug-resistant tuberculosis?

      Bastard, M; Sanchez-Padilla, E; Hayrapetyan, A; Kimenye, K; Khurkhumal, S; Dlamini, T; Fadul Perez, S; Telnov, A; Hewison, C; Varaine, F; et al. (International Union Against Tuberculosis and Lung Disease, 2019-10-01)
      INTRODUCTION: Identification of good prognostic marker for tuberculosis (TB) treatment response is a necessary step on the path towards a surrogate marker to reduce TB trial duration. METHODS: We performed a retrospective analysis on routinely collected data in 6 drug-resistant TB (DRTB) programs. Culture conversion, defined as two consecutive negative cultures, was assessed, and performance of culture conversion at Month 2 and Month 6 to predict treatment success were explored. To explore factors associated with positive predicted value (PPV) and the specificity of culture conversion, a multinomial logistic regression was fitted. RESULTS: This study included 634 patients: 68.5% were males; the median age was 35 years, 75.2% were previously treated for TB, 59.4% were resistant only to isoniazid and rifampicin and 18.1% resistant to fluoroquinolones. Culture conversion at Month 2 and 6 showed similar PPV while specificity was much higher for culture conversion at Month 2: 91.3% (95%CI 86.1–95.1). PPV of culture conversion at Month 2 did not vary strongly according to patients' characteristics, while specificity was slightly higher among patients with fluoroquinolone-resistant strains. CONCLUSION: Culture conversion at Month 2 is an acceptable prognostic marker for MDR-TB treatment. Considering the advantage of using an earlier marker, further evaluation as a surrogate marker is warranted to shorten TB trials.
    • What is the relationship of medical humanitarian organisations with mining and other extractive industries?

      Calain, P; Unité de Recherche sur les Enjeux et Pratiques Humanitaires, Médecins Sans Frontières, Genève, Switzerland. philippe.calain@geneva.msf.org (Public Library of Science, 2012-08-28)
      Philippe Calain discusses the health and environmental hazards of extractive industries like mining and explores the tensions that arise when medical humanitarian organizations are called to intervene in emergencies involving the extractive sector.
    • What should be done in acute emergencies?

      Van Damme, W; Boelaert, M; Van Lerberghe, W; Harrell-Bond, B (Elsevier, 1996-12-14)
    • What was the Effect of the West African Ebola Outbreak on Health Programme Performance, and did Programmes Recover?

      Decroo, T; Fitzpatrick, G; Amone, J (International Union Against Tuberculosis and Lung Disease, 2017-06-21)
    • What's coming for health science and policy in 2018? Global experts look ahead in their field

      Swaminathan, S; Room, RS; Ivers, LC; Hillis, G; Grais, RF; Bhutta, ZA; Byass, P (Public Library of Science, 2018-01-30)
      In PLOS Medicine's first editorial of 2018, editorial board members and other leading researchers share their hopes, pleas, concerns, and expectations for this year in health research and policy.
    • When best practice is bad medicine: a new approach to rationing tertiary health services in South Africa.

      Kenyon, C; Ford, N; Boulle, A; Division of Infectious Diseases and HIV Medicine at Groote Schuur Hospital, Cape Town. chriskenyon1@absamail.co.za (South African Medical Society, 2008-05)