Cost-effectiveness of remdesivir and dexamethasone for COVID-19 treatment in South Africa

Background South Africa recently experienced a first peak in COVID-19 cases and mortality. Dexamethasone and remdesivir both have the potential to reduce COVID-related mortality, but their cost-effectiveness in a resource-limited setting with scant intensive care resources is unknown. Methods We projected intensive care unit (ICU) needs and capacity from August 2020 to January 2021 using the South African National COVID-19 Epi Model. We assessed cost-effectiveness of 1) administration of dexamethasone to ventilated patients and remdesivir to non-ventilated patients, 2) dexamethasone alone to both non-ventilated and ventilated patients, 3) remdesivir to non-ventilated patients only, and 4) dexamethasone to ventilated patients only; all relative to a scenario of standard care. We estimated costs from the healthcare system perspective in 2020 USD, deaths averted, and the incremental cost effectiveness ratios of each scenario. Results Remdesivir for non-ventilated patients and dexamethasone for ventilated patients was estimated to result in 1,111 deaths averted (assuming a 0-30% efficacy of remdesivir) compared to standard care, and save $11.5 million. The result was driven by the efficacy of the drugs, and the reduction of ICU-time required for patients treated with remdesivir. The scenario of dexamethasone alone to ventilated and non-ventilated patients requires additional $159,000 and averts 1,146 deaths, resulting in $139 per death averted, relative to standard care. Conclusions The use of dexamethasone for ventilated and remdesivir for non-ventilated patients is likely to be cost-saving compared to standard care. Given the economic and health benefits of both drugs, efforts to ensure access to these medications is paramount.

Understanding the costs and the cost structure of a community-based HIV and gender-based violence (GBV) prevention program: the Woza Asibonisane Community Responses Program in South Africa

Background

The Woza Asibonisane Community Responses (CR) Programme was developed to prevent HIV infections and gender-based violence (GBV) within four provinces in South Africa. The Centre for Communication Impact (CCI) in collaboration with six partner non-governmental organizations (NGOs) implemented the programme, which was comprised of multiple types of group discussion and education activities organized and facilitated by each NGO. To date, little information exists on the cost of implementing such multi-objective, multi-activity, community-based programmes. To address this information gap, we estimated the annual cost of implementing the CR Programme for each NGO.

Methods

We used standard methods to estimate the costs for each NGO, which involved a package of multiple activities targeted to distinct subpopulations in specific locations. The primary sources of information came from the implementing organizations. Costs (US dollars, 2017) are reported for each partner for one implementation year (the U.S. Government fiscal year (10/2016–09/2017). In addition to total costs disaggregated by main input categories, a common metric--cost per participant intervention hour--is used to summarize costs across partners.

Results

Each activity included in the CR program involve organizing and bringing together a group of people from the target population to a location and then completing the curriculum for that activity. Activities were held in community settings (meeting hall, community center, sports grounds, schools, etc.). The annual cost per NGO varied substantially, from $260,302 to $740,413, as did scale based on estimated total participant hours, from 101,703 to 187,792 participant hours. The cost per participant hour varied from $2.8–$4.6, with NGO labor disaggregated into salaries for management and salaries for service delivery (providing the activity curriculum) contributing to the largest share of costs per participant hour.

Conclusions

The cost of implementing any community-based program depends on: (1) what the program implements; (2) the resources used; and (3) unit costs for such resources. Reporting on costs alone, however, does not provide enough information to evaluate if the costs are ‘too high’ or ‘too low’ without a clearer understanding of the benefits produced by the program, and if the benefits would change if resources (and therefore costs) were changed.

FRI0443 CLINICAL CHARACTERISTICS AND RELATED FACTORS OF COMMON RHEUMATIC DISEASES COMPLICATED WITH TUBERCULOSIS INFECTION

Background:

Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and syndrome(SS) are common rheumatic diseases with high incidence. Patients with those rheumatic diseases are at high risk of tuberculosis (TB) infection. However, manifestations can be atypical and easily confused with those of rheumatic disease itself. For those patients, diagnosis is usually much more difficult and further make treatment delayed. Sometimes it may lead to mistreatment. Therefore, it is important to recognize the clinical characteristics of those patients.

Objectives:

To explore the clinical characteristics and high risk factors of common systemic rheumatism complicated with tuberculosis infection.

Methods:

A total of 3,906 cases of RA, SLE, and SS common systemic rheumatism diagnosed in the People’s Hospital of Sichuan Province from January 2007 to January 2017 were collected with carefully exclusion with other infectious diseases and neoplastic disease. One hundred and five patients with TB were included as infection group, including 42 cases of RA, 41 cases of SLE, and 22 cases of SS. In the control group, 84 patients with RA, 82 patients with SLE, and 44 patients with SS were randomly selected from the corresponding rheumatoid non-infected patients hospitalized during the same period.

Results:

Fever was the most common symptom among 42 cases of RA, 41 cases of SLE, and 22 cases of SS with TB, accounting for 83.3%, 92.7%, and 68.2%, respectively. Cough, weight loss or fatigue was less common. For 41 cases of SLE and 22 cases of SS with TB, the proportion of pulmonary was 46.3%, 59.01%, respectively.In TB infection group, 27 cases of RA, 21 cases of SLE, and 13 cases of SS with TB had two or more chest CT findings, accounting for 59%, 57%, 62%, respectively. Lesions located in the posterior or posterior segment which TB usually affected were 9 cases(33.3%),9cases(42.9%),6cases(27.2%),respectively.The daily average dose of hormones within 1 year in TB infection group was higher than that in the control group (P<0.05). For SLE patients, lower counts of CD4+TL were found in TB infection group (P<0.05), while no such differences were found in RA and SS group.

Conclusion:

Patients with RA who have TB infection are mainly pulmonary TB. For SLE and SS patients, the chance of pulmonary tuberculosis and extra-pulmonary tuberculosis is similar.Symptoms of RA, SLE, SS with TB, such as fever, cough, weight loss, fatigue, are similar with the primary disease or other infection. Chest imaging is diversity. It is difficult to diagnose.Daily average dose of hormone within one year may be a common risk factor for RA, SLE and SS patients with TB. Decreased CD4+TL may also be a risk factor for SLE patients with TB.

References:

[1]Cantini F, Nannini C, Niccoli L, et al. Risk of Tuberculosis Reactivation in Patients with Rheumatoid Arthritis, Ankylosing Spondylitis, and Psoriatic Arthritis Receiving Non-Anti-TNF-Targeted Biologics[J]. Mediators of Inflammation, 2017, 2017(6):1-15.

[2]Ruangnapa K, Dissaneewate P, Vachvanichsanong P. Tuberculosis in SLE patients: rare diagnosis, risky treatment.[J]. Clinical & Experimental Medicine, 2015, 15(3):429-432.

[3]Manuela D F, Bruno L, Martina S, et al. Lung Infections in Systemic Rheumatic Disease: Focus on Opportunistic Infections[J]. International Journal of Molecular Sciences, 2017, 18(2):293-315.

[4]Disseminated tuberculosis masquerading as a presentation of systemic lupus erythematosus.Li JC, Fong W, Wijaya L, Leung YY.Int J Rheum Dis. 2017 Oct 2. doi: 10.1111/1756-185X.13195.

[5]Handa R, Upadhyaya S, Kapoor S, et al. Tuberculosis and biologics in rheumatology: India – A special situation[J]. International Journal of Rheumatic Diseases, 2017, 51(2):115.

Disclosure of Interests:

None declared

SAT0209 PREVALENCE AND RELATED FACTORS OF SLEEP DISTURBANCE IN PATIENTS WITH PRIMARY SJÖGREN’S SYNDROME

Background:

The incidence of primary Sjögren’s syndrome(pSS) is increasing gradually,and it was ranking second among connective tissue diseases(CTDs)in China.Studies recently have shown that many patients with various CTDs have sleep disturbances,which seriously degraded the patient’s quality of life.As well known, Sleep is an important physiological process to maintain human metabolism, tissue repair,and homeostasis. At present,there are relatively several studies on sleep quality in patients with Rheumatoid arthritis(RA)and Systemic lupus erythematosus(SLE),but less reports on pSS in China have been published.Therefore,it is important to explore the quality of sleep and its influencing factors in such patients.

Objectives:

The purpose of this study is to evaluate the quality of sleep and related factors in China Mainland patients with primary Sjögren’s syndrome(pSS),and to provide reference and theoretical basis for constructing targeted sleep interventions and improve their quality of life.

Methods:

A all of 103 pSS patients and 40 matched healthy controls were enrolled in a comparative study of sleep quality using the Pittsburgh Sleep Quality Index(PSQI),and demographic,clinical,and laboratory data were collected from them.The patients completed questionnaires on the European League Against Rheumatism (EULAR)SS Patient Reported Index(ESSPRI), EULAR SS Disease Activity Index (ESSDAI),Xerostomia inventory(XI)with the help of researchers,Pain and fatigue were evaluated with a 100-mm visual analogue scale(VAS).Generalized Anxiety Disorder(GAD-7) and Patient Health Questionnaire(PHQ-9) were used to assess anxiety and depression separately,and whether they have autonomic symptoms (such as sweating, palpitations.)will be asked.

Results:

The PSQI score and the frequency of poor sleep quality(PSQI>7) were higher in the pSS patients (11.60±5.03,71.8%)than the healthy controls(5.98±3.85,25%).Poor sleepers had a significantly higher GAD-7,PHQ-9,XI,ESSPRI,pain and fatigue VAS,and longer disease duration than good sleepers.Additionally, poor sleepers show more frequent autonomic symptoms.Sleep quality of patients with pSS was positive correlated with GAD-7,PHQ-9,XI,ESSPRI,pain and fatigueVAS scores,but no correlation with disease activity.Meanwhile,depression is a independent factor of sleep quality.

Conclusion:

Our study showed that the sleep disturbance seen in patients with pSS may contribute to the depression associated with this disease,Future research should investigate that whether antidepressant treatment improve sleep and directly improve quality of life.

References:

[1]AustadC, Kvien TK, Olsen I C.Sleep disturbance in patients with rheumatoid arthritis is related to fatigue, disease activity,and other patient-reported outcomes[J]. Scandinavian journal of rheumatology, 2017, 46(2): 95-103.

[2]Lewis I, Hackett K L,Ng W F,et al.A two-phase cohort study of the sleep phenotype within primary Sjögren’s syndrome and its clinical correlates[J].Clinical and experimental rheumatology,2019,37(3):78-82.

[3]Chung S W, Hur J, Ha Y J, et al. Impact of sleep quality on clinical features of primary Sjögren’s syndrome[J]. The Korean journal of internal medicine, 2019,34(5):1154.

[4]Liu X, Tang M, Hu L. Reliability and validity of the Pittsburgh sleep quality index[J].Chinese journal of psychiatry,1996,29:103-107.

[5]Grabovac I,Haider S, Berner C,et al.Sleep quality in patients with rheumatoid arthritis and associations with pain, disability, disease duration, and activity[J].Journal of clinical medicine,2018,7(10):336.

Disclosure of Interests:

None declared

The COVID-19 effect: number of patients presenting to The Mid Yorkshire Hospitals OMFS team with dental infections before and during The COVID-19 outbreak

This paper investigates the effect of the COVID-19 outbreak and closure of dental practices on the frequency and severity of dental infections presenting in our emergency department. We compared the mean number of daily emergency department referrals for dental abscesses in the two weeks prior to and following the Chief Dental Officer's statement advising general dental practitioners to cease routine appointments, the mean number decreased from 1 to 0.37. In contrast, the severity and requirement for admission of these infections rose from 35% to 80%. This highlights the importance of the provision of local urgent dental centres during the COVID-19 outbreak in order to reduce pressure on secondary and tertiary care centres.

Novel metric for evaluating pre-exposure prophylaxis programme effectiveness in real-world settings

Although large-scale provision of HIV pre-exposure prophylaxis (PrEP) is gaining momentum, no systematic method to evaluate or compare the effectiveness of different scale-up strategies in real-world settings exists. To date, estimating the effectiveness of PrEP has relied on clinical trials or mathematical models. We propose a novel and pragmatic metric to evaluate and compare programme effectiveness using routine implementation data. Using South African and Zambian PrEP guidelines, we provide two examples of how to consistently measure PrEP-programme effectiveness with routinely collected data. PrEP effectiveness should account for HIV seroconversion, the variable risk of HIV infection (seasons of risk) estimated with routine risk assessment at each clinic visit (when available), and the persistence of PrEP use. Three criteria should be met in order to be considered a successful outcome: first, a person who initiates PrEP must not seroconvert; second, there should be no more than one period at high risk of HIV infection during the follow-up period when not taking PrEP; and finally, an individual must continue to attend health-care visits or discontinue prophylaxis in consultation with a health-care provider within a specified follow-up period. The number of PrEP successes could then be compared with the total number of people initiating PrEP to establish a success ratio. This outcome is a useful and easily interpretable metric to monitor effectiveness of PrEP programmes with routinely collected clinical data and can be used in cost-effectiveness analyses. These measurements allow for comparisons of scale-up strategies for PrEP programmes and, if widely adopted, will allow comparative studies of different approaches for PrEP service delivery.

Differentiated models of service delivery for antiretroviral treatment of HIV in sub-Saharan Africa: a rapid review protocol

BACKGROUND

To meet global targets for the treatment of HIV, high-prevalence countries are launching or expanding differentiated models of service delivery (DSD) for antiretroviral therapy (ART). Ongoing studies report on metrics specific to individual models of care, but little is known about the overall scale, impact, costs, and benefits of widespread implementation of DSD. We will conduct a rapid review of recent literature on DSD currently in use in sub-Saharan Africa and identify gaps in the literature with respect to the description of delivery models, coverage, effectiveness, and cost.

METHODS

We will use an adapted version of the preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P) for reporting. To avoid repeating earlier reviews, only sources reporting data on interventions conducted and/or patients starting antiretroviral treatment since 1 January 2016 will be included. Other inclusion criteria: must report on HIV-positive patients receiving antiretroviral therapy (ART) for the treatment of HIV/AIDS in sub-Saharan Africa; must describe an antiretroviral care intervention and identify the location, visit frequency, provider, patient group, and intervention intensity; and must report at least one of the following outcomes: population coverage, intervention uptake, treatment outcomes, cost or resource allocation, acceptability, or feasibility.

EXCLUSION CRITERIA

receiving ART as part of prevention of mother-to-child transmission (PMTCT) program or receiving preventive ART (PEP or PrEP). This review will include peer-reviewed articles and conference abstracts. Publication databases to be searched include PubMed, EMBASE, and Web of Science. For analysis, where possible, we will group the DSD by key characteristics (e.g., population served, visit frequency, visit location) and then report means and/or medians of coverage and outcomes with confidence intervals or IQRs. We will also descriptively compare and contrast different models of care, implementation challenges, and other non-quantitative information.

DISCUSSION

This review will provide an initial picture of the status quo for the implementation of DSD in sub-Saharan Africa and identify directions for research and implementation support in the future. This big-picture analysis will be useful for ministries of health, implementers, and donor agencies to inform decision-making on DSD scale-up.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42019118230.

Data quality of drug-resistant tuberculosis and antiretroviral therapy electronic registers in South Africa

Background

To assess the quality and completeness of treatment and outcome data in the electronic tuberculosis (TB) and antiretroviral treatment (ART) registers in drug-resistant (DR-) TB patients at three treatment facilities in South Africa.

Methods

We did a retrospective cohort study using routinely-collected data from DR-TB registers of rifampicin resistant adults (≥18 years old), on ART, initiating DR-TB treatment between January 2012 and December 2013. We linked patient information from the DR-TB register to the ART register using patient identifiers and an algorithm based on string edit distance and date of birth. We describe data gaps and discrepancies found.

Results

Overall, 2852 DR-TB patients met our inclusion criteria based on the DR-TB register data, and of these, 1685 (59%) could be matched to the ART registers. An additional 253 patients from the DR-TB registers were found in the ART registers, having initiated ART, despite the DR-TB register indicating that they were not on ART (or this data was missing). 11% of matched patients did not have TB treatment status recorded in the ART register despite being recorded as being on TB treatment in the DR-TB register, and 78% did not have an ART start date recorded in DR-TB register despite being on ART treatment as per the ART register. 11% of matched patients had a death recorded in one register but not the other, and of those with death recorded in both, 15% of dates differed by > 1 month.

Conclusions

The underreporting of death and the lack of ART or TB status in the electronic DR-TB and ART registers could negatively impact monitoring efforts by downplaying the state of the TB/HIV epidemic. Improved recording of these data sources, and data integration across systems, could improve the accuracy of reporting for the national HIV/ART and TB programs.

[Expression of HLA-DP in patients with neuromyelitis optica spectrum disorders]

Objective: To investigate the effect of HLA-DP gene expression on the susceptibility and disease status of neuromyelitis optica spectrum disorders (NMOSD). Methods: A total of 86 NMOSD patients (52 in acute phase and 34 in remission phase), 52 multiple sclerosis (MS) patients (20 in acute phase and 32 in remission phase) diagnosed in Department of Neurology, the Third Affiliated Hospital of Sun Yat-sen University and 29 healthy controls were enrolled prospectively. Genotyping of HLA-DP was performed. The expression levels of HLA-DP molecules in peripheral blood B cells and monocytes were measured by flow cytometry. The transcription levels of HLA-DPB1 mRNA in peripheral blood mononuclear cells (PBMC) were measured by real time-PCR. The results were compared among different groups Results: There was no statistically significant difference of the distributions of HLA-DPB1*0501/HLA-DPB1*0501, HLA-DPB1*0501/X and X/X genotypes and the frequencies of allele of HLA-DPB1*0501 among NMOSD, MS patients and healthy controls (P=0.96 and 0.71, respectively). The expression levels of HLA-DP on the surface of B cells in NMOSD patients, especially in remission phase patients, were significantly higher than those in healthy controls(212±328 and 374±394 vs 55±57, P=0.049 and 0.002, respectively). The expression levels of HLA-DP on the surface of monocytes in NMOSD patients in acute phase were significantly higher than those in healthy controls(158±175 vs 65±90, P=0.025). The transcription levels of PMBC HLA-DPB1 mRNA in acute phase and remission phase of NMOSD patients were significantly higher than those in healthy controls (3.0±1.4 and 2.9±1.3 vs 1.5±1.4, P=0.000 and 0.003, respectively). The expression levels of HLA-DP molecules on the surface of peripheral blood B cells and monocytes and the transcription levels of PMBC HLA-DPB1 mRNA in MS patients at the acute and remission stages were not significantly different from those in healthy controls. The expression levels of HLA-DP molecules on the surface of B cells in patients with HLA-DPB1*0501/HLA-DPB1*0501, HLA-DPB1*0501/X and X/X genotypes were statistically different (P=0.017). Conclusion: HLA-DP gene transcription and molecular expression levels in antigen presenting cells may affect the susceptibility and disease status of NMOSD patients, while HLA-DPB1*0501 allele may affect the transcription and molecular expression levels of HLA-DP gene in antigen presenting cells.

Effective public-private partnerships for sustainable antiretroviral therapy: outcomes of the Right to Care health services GP down-referral program

Background

The recently increased access to antiretroviral therapy (ART) in South Africa has placed additional strain on human and infrastructure resources of the public health sector. Capacity from private-sector General Practitioners (GPs) could be leveraged to ease the current burden on the public health sector.

Methods

We conducted a retrospective record review of routine electronic medical record data on a systematic sample of HIV-infected adults (≥18 years old) initiated on ART at a tertiary hospital outpatient HIV clinic in Johannesburg, South Africa and down-referred to private-GPs for continued care after stabilization on ART. We compared these patients (“GP down-referred”) to a control-cohort who remained at the referring site (“Clinic A”) and patients from a regional hospital outpatient HIV clinic not offering down-referral to GPs (“Clinic B”). Study outcomes assessed are viral load suppression (VL < 50 copies/ml) and attrition from care (all-cause-mortality or > 90-days late for a last-scheduled visit) by 12 months of follow-up following down-referral or eligibility.

Results

A total of 3685 patients, comprising 373 (10.1%) GP down-referred, 2599 (70.5%) clinic A controls, and 713 (19.4%) clinic B controls were included in the analysis. Overall, 1535 patients (53.3%) had a suppressed viral load. A higher portion of GP down-referred patients had a suppressed viral load compared to clinic A and B patients (65.7% vs 49.1% vs 58.9%). After adjusting for demographic and baseline clinical covariates, we found no difference in viral load suppression between GP down-referred and control patients (adjusted relative risk [aRR] for clinic A vs GP down-referred 1.0; 95% CI: 0.9–1.1), (aRR for clinic B vs GP down-referred 1.0; 95% CI: 0.9–1.2).

Clinic B controls experienced the highest attrition compared to GP down-referred and clinic A controls (33.2% vs 11.3% vs 5.9%) and had a higher risk of attrition compared to GP down-referred patients (adjusted hazard ratio [aHR] 4.2; 95% CI: 2.8–6.5), whereas clinic B controls had a lower risk of attrition (aHR 0.5; 95% CI: 0.3–0.7).

Conclusions and recommendations

Our results show that private-GPs can contribute to caring for stabilized public sector HIV patients on life-long ART. However, they require special efforts to improve retention in care.

[The association between the whole blood riboflavin level and the occurrence, development and prognosis of esophageal squamous cell carcinoma]

Objective: To investigate the association between the whole blood riboflavin level and the occurrence, development and prognosis of esophageal squamous cell carcinoma (ESCC) in China. Methods: From March 2014 to September 2018, ESCC patients from three hospitals (the Affiliated Hospital of Medical College of Shantou University, Shantou Central Hospital in Southern Chaoshan area and First Affiliated Hospital of Zhengzhou University in Northern Taihang Mountain) were selected as a case group; non-esophageal patients who had a physical examination were selected as a control group. The case and control group were paired by age (±5 years) and a 1:1 ration. A total of 1 528 subjects were enrolled including 764 patients in the case group and 764 patients in the control group. About 3-5 ml venous blood samples were collected, and the erythrocyte glutathione reductase activity coefficient (GRAC) was measured to assess the whole blood riboflavin level. A multivariate conditional logistic regression model was used to analyze the association between the GRAC and the risk of ESCC. The association between the GRAC and the prognosis of ESCC was analyzed by using Cox proportional risk regression model based on 288 patients with complete survival data. They were divided into two groups, the high GRAC group (GRAC≥7.87) group and the low GRAC group (GRAC<7.87) according to the strongest correlation between the total survival time, survival outcome and GRAC (GRAC=7.87). Results: Among the 1 528 patients, 958 patients were from Southern Chaoshan area, including 479 patients in the case group with an average age about (59.90±9.34) years and 479 patients in the control group with an average age about (59.55±8.77) years. Other 570 patients were from Northern Taihang Mountain area, including 285 patients in the case group with an average age (58.39±5.19) years and 285 patients in the control group with an average age about (58.74±4.57) years. The multivariate conditional logistic regression showed that the OR (95%CI) of the GRAC and the risk of ESCC was 1.009 (0.998-1.019). The Cox proportional hazard regression model analysis showed that the HR (95%CI) of the high GRAC group was 1.712 (1.034-2.824) compared with the low GRAC group in the 50-70 years group. Conclusion: The whole blood riboflavin level might not be associated with the occurrence of ESCC. The high whole blood riboflavin level would be more beneficial to the prognosis of ESCC patients aged 50-70 years.

When donor funding leaves: an interrupted time-series analysis of the impact of integrating direct HIV care and treatment into public health services in a region of Johannesburg

Background

Early in South Africa’s HIV response, donor-funded organizations directly provided HIV treatment through Comprehensive HIV Care, Management and Treatment sites (CCMTs), using their own and government staff. From 2012 to 2014 the donor-funded CCMT model was phased out, leaving nurses in South Africa’s public clinics responsible for delivery of antiretroviral treatment (ART) services. We aimed to examine the impact on resources, staff workloads, and service delivery throughout this period of integration of HIV treatment into primary health clinics.

Methods

We conducted an Interrupted Time-Series Analysis (ITSA) using data from three public clinics, including one former CCMT site, in one administrative region of Johannesburg. The ITSA was complemented by visual inspection of the data in Excel. We compared trends in expenditure, clinical staffing levels, patient headcounts, and services rendered at the clinics during four periods: pre-CCMT (2004–2007), CCMT operational (2007–2012), CCMT closure (2012–2014), and post-CCMT (2014–2016). Data were drawn from the country’s District Health Information System, a national HIV treatment database, local budget and expenditure reports, National Health Laboratory Service charge records, and staff records.

Results

Closure of the CCMT differentially impacted the study clinics. As expected, ART services decreased at Clinic 1, where the CCMT was co-located, and increased at Clinics 2 and 3 possibly reflecting redistribution of patients. Despite a reduction in patient headcounts post-CCMT, Clinic 1 experienced a decrease in staff and a large increase in patients seen per clinical staff member per month. In contrast, Clinics 2 and 3 increased or maintained stable workforces, and staff workloads post closure were similar to pre-closure levels. Other primary care services—contraception and immunisations—seemed largely unaffected at Clinics 1 and 2. At Clinic 3, service delivery reduced, but this was accompanied by lowered patient headcounts generally, likely due to clinic renovations.

Conclusions

In this study, integration of HIV treatment into primary healthcare services did not result in large-scale reductions in overall service delivery. One facility did experience increased staff workloads, but we were unable to assess service quality. To mitigate potential problems, monitoring systems should be introduced in advance and acknowledge the disparate and decentralised management of various data sources.

A Meta-analysis Assessing Diarrhea and Pneumonia in HIV-Exposed Uninfected Compared With HIV-Unexposed Uninfected Infants and Children

OBJECTIVE

Previous studies have demonstrated that HIV-exposed uninfected (HEU) infants and children experience morbidity and mortality at rates exceeding those of their HIV-unexposed uninfected (HUU) counterparts. We sought to summarize the association between HEU vs. HUU infants and children for the outcomes of diarrhea and pneumonia.

DESIGN

Meta-analysis.

METHODS

We reviewed studies comparing infants and children in the 2 groups for these infectious disease outcomes, in any setting, from 1993 to 2018 from 6 databases.

RESULTS

We included 12 studies, and 17,955 subjects total [n = 5074 (28.3%) HEU and n = 12,881 (71.7%) HUU]. Random-effects models showed HEU infants and children had a 20% increase in the relative risk of acute diarrhea and a 30% increase in the relative risk of pneumonia when compared with their HUU counterparts. When stratifying by time since birth, we showed that HEU vs. HUU children had a 50% and 70% increased risk of diarrhea and pneumonia, respectively, in the first 6 months of life.

CONCLUSIONS

We show an increased risk of diarrhea and pneumonia for HEU vs. HUU infants and children. Although we acknowledge, and commend, the immense public health success of prevention of mother-to-child transmission, we now have an enlarging population of children that seem to be vulnerable to not only death, but increased morbidity. We need to turn our attention to understanding the underlying mechanism and designing effective public health solutions. Further longitudinal research is needed to elucidate possible underlying immunological and/or sociological mechanisms that explain these differences in morbidity.

[Clinical analysis of 555 outpatients with hand, foot and mouth diseases caused by different enteroviruses]

Objective: To study the clinical characteristics of outpatients with hand, foot and mouth disease (HFMD) caused by different serotypes of enteroviruses. Methods: This was a prospective study. From February 2017 to March 2018, 563 outpatients with HFMD were enrolled by systematic sampling in the Department of Infectious Diseases, Henan Children's Hospital. Throat swabs were collected to determine the serotypes via PCR. Demographic, clinical, and laboratory data were collected by standard questionnaire. All cases were followed up twice at 2 and 9 weeks after the initial outpatient visit through telephone interview. A total of 563 cases were enrolled and 555 (98.6%) cases were positive for human enteroviruses, including 338 (60.9%) males. Analyses were stratified by enterovirus serotypes, Chi square test or Fisher's exact test, Rank sum test was used for comparison among different groups. Results: The age of 555 cases was 24.2 (16.4, 41.3) months. Among them 44.0% (224 cases) were identified as coxsackievirus (CV)-A6, while 189 cases, 35 cases, 14 cases and 73 cases were identified as CV-A16, enterovirus (EV)-A71, CV-A10 and other serotypes, respectively. Fever (≥37.5 ℃) was present in 51.4% (285/555) of laboratory confirmed cases. The proportions of fever in cases of CV-A6 (68.9%(168/244)) and CV-A10 (12/14) were significantly higher than those in cases of CV-A16 (31.7%(60/189),χ(2)=57.344,14.313,both P=0.000), other serotypes (43.8%(32/73),χ(2)=15.101 and 8.242, P=0.000 and 0.004) and EV-A71 (37.1%(13/35), χ(2)=13.506 and 9.441, P=0.000 and 0.002) respectively. There was no significant difference between CV-A6 and CV-A10 in presentation of fever (χ(2)=1.785, P=0.182). There were 359 cases (64.7%) with eruptions in mouth, hands, feet and buttocks. Cases infected with EV-A71 had the highest proportions (74.3%(26/35)) of rash emerging simultaneously in mouth, hands, feet, and buttocks. The proportion in cases of CV-A16, CV-A6, CVA10 and other serotype were 73.5% (139/189), 61.9% (151/244), 7/14 and 49.3% (36/73), respectively. The proportion of rash on other parts of body, such as face, limbs or torso in cases infected with CV-A6 (16.8% (41/244)) was the higherest and the proportion in cases of CV-A16, EV-A71, CV-A10 or other serotypes were 8.5% (16/189) , 5.7% (2/35) , 1/14, 6.8% (5/73) , respectively. None of these cases developed serious complications. Desquamation occurred in 45.5% (179/393) cases 7.5 (5.0, 9.0) days after disease onset and 13.5% (53/393) cases showed onychomadesis 31.0 (18.0, 33.5) days after disease onset. The proportion of desquamation and onychomadesis associated with CV-A6 (64.2% (95/148) and 31.8% (47/148)) was significantly higher than CV-A16 (31.8% (49/154) and 1.3% (2/154), χ(2)=33.601 and 52.482, both P=0.000) and other serotypes (38.0%(19/50) and 6.0%(3/50),χ(2)=10.236 and 12.988, P=0.001 and 0.000). Desquamation appeared more in cases of CV-A6 than in cases of CV-A10 (2/11,χ(2)=9.386, P=0.002), with the proportion of onychomadesis higher in CV-A6 than in EV-A71 (3.3% (1/30),χ(2)=11.088, P=0.001). Conclusion: Clinical manifestation such as fever, rash emerging parts, desquamation and onychomadesis are different among outpatient HFMD cases infected with CV-A16, CV-A6, EV-A71, CV-A10 and other enteroviruses.

Treatment outcomes among children, adolescents, and adults on treatment for tuberculosis in two metropolitan municipalities in Gauteng Province, South Africa

Background

Gauteng Province has the second lowest tuberculosis (TB) incidence rate in South Africa but the greatest proportion of TB/HIV co-infection, with 68% of TB patients estimated to have HIV. TB treatment outcomes are well documented at the national and provincial level; however, knowledge gaps remain on how outcomes differ across detailed age groups.

Methods

Using data from South Africa’s National Electronic TB Register (ETR), we assessed all-cause mortality and loss to follow-up (LTFU) among patients initiating treatment for TB between 01/2010 and 12/2015 in the metropolitan municipalities of Ekurhuleni Metropolitan Municipality and the City of Johannesburg in Gauteng Province. We excluded patients who were missing age, had known drug-resistance, or transferred into TB care from sites outside the two metropolitan municipalities. Among patients assigned a treatment outcome, we investigated the association between age group at treatment initiation and mortality or LTFU (treatment interruption of ≥2 months) within 10 months after treatment initiation using Cox proportional hazard models and present hazard ratios and Kaplan-Meier survival curves.

Results

We identified 182,890 children (<10 years), young adolescent (10–14), older adolescent (15–19), young adult (20–24), adult (25–49), and older adult (≥50) TB cases without known drug-resistance. ART coverage among HIV co-infected patients was highest for young adolescents (64.3%) and lowest for young adults (54.0%) compared to other age groups (all over 60%). Treatment success exceeded 80% in all age groups (n = 170,017). All-cause mortality increased with age. Compared to adults, young adults had an increased hazard of LTFU (20–24 vs 25–49 years; aHR 1.43 95% CI: 1.33, 1.54) while children, young adolescents, and older adults had lower hazard of LTFU. Patients with HIV on ART had a lower risk of LTFU, but greater risk of death when compared to patients without HIV.

Conclusions

Young adults in urban areas of Gauteng Province experience a disproportionate burden of LTFU and low coverage of ART among co-infected patients. This group should be targeted for interventions aimed at improving clinical outcomes and retention in both TB and HIV care.

BMPRII deficiency impairs apoptosis via the BMPRII-ALK1-BclX-mediated pathway in pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a devastating cardiovascular disorder characterized by the remodelling of pre-capillary pulmonary arteries. The vascular remodelling observed in PAH patients results from excessive proliferation and apoptosis resistance of pulmonary arterial smooth muscle cells (PASMCs) and pulmonary arterial endothelial cells (PAECs). We have previously demonstrated that mutations in the type II receptor for bone morphogenetic protein (BMPRII) underlie the majority of the familial and inherited forms of the disease. We have further demonstrated that BMPRII deficiency promotes excessive proliferation and attenuates apoptosis in PASMCs, but the underlying mechanisms remain unclear. The major objective of this study is to investigate how BMPRII deficiency impairs apoptosis in PAH. Using multidisciplinary approaches, we demonstrate that deficiency in the expression of BMPRII impairs apoptosis by modulating the alternative splicing of the apoptotic regulator, B-cell lymphoma X (Bcl-x) transcripts: a finding observed in circulating leukocytes and lungs of PAH subjects, hypoxia-induced PAH rat lungs as well as in PASMCs and PAECs. BMPRII deficiency elicits cell specific effects: promoting the expression of Bcl-xL transcripts in PASMCs while inhibiting it in ECs, thus exerting differential apoptotic effects in these cells. The pro-survival effect of BMPRII receptor is mediated through the activin receptor-like kinase 1 (ALK1) but not the ALK3 receptor. Finally, we show that BMPRII interacts with the ALK1 receptor and pathogenic mutations in the BMPR2 gene abolish this interaction. Taken together, dysfunctional BMPRII responsiveness impairs apoptosis via the BMPRII-ALK1-Bcl-xL pathway in PAH. We suggest Bcl-xL as a potential biomarker and druggable target.

Exogenous Hydrogen Sulfide Protects SH-SY5Y Cells from OGD/RInduced Injury

BACKGROUND

Cerebral ischemia reperfusion (CIR) injury is the main pathological mechanism of ischemia stroke, and oxidative stress (OS) plays a vital role during the process of CIR. Recent studies have found that OS can activate MAPK pathway, which mainly functions as a mediator of cellular stresses. It revealed that H2S may exhibit multiple biological functions as a neuroprotector through protecting against OS-induced neuronal injury. But how H2S can attenuate ischemia/reoxygenation injury through MAPK signaling is not clear. The protective mechanism of exogenous hydrogen sulfide (H2S) on oxygen glucose deprivation/reoxygenation (OGD/R) at physiological doses in SH-SY5Y cells were investigated in this study.

METHODS

DCFH- DA probe is used to measure intracellular ROS, Real-time PCR and Western blot are used to detect the levels of p38 MAPK, ERK3 and Nrf2. CCK-8 is used to detect cell viability.

RESULTS

Comparing with the normal control group, the expressions of ERK3, p38MAPK and Nrf2 mRNA in other three groups were downregulated at the beginning of 24h. After 24h, the expressions of ERK3, p38MAPK and Nrf2 were upregulated significantly compared with the normal control group. When the cells were pretreated with 200μM NaHS at the beginning of 24h, the expressions of ERK3, p38MAPK and Nrf2 were decreased much more significantly than OGD/R and NaHS groups.

CONCLUSION

The present study demonstrated that exogenous H2S exerts a protective effect against OGD/R-induced injury by enhancing the activation of the ERK3, p38MAPK and Nrf2 mRNA.

Cost outcome analysis of decentralized care for drug-resistant tuberculosis in Johannesburg, South Africa

Background

Drug resistant-tuberculosis is a growing burden on the South African health care budget. In response the National Department of Health implemented two important strategies in 2011; universal access to drug-sensitivity testing for rifampicin with Xpert MTB/RIF as the first-line diagnostic test for TB; and decentralization of treatment for RR/MDR-TB to improve access and reduce costs of treatment.

Objective

Estimate the costs by treatment outcome of decentralized care for rifampicin and multi-drug resistant tuberculosis under routine conditions. The study was set at an outpatient drug resistant-tuberculosis treatment facility at a public academic hospital in Johannesburg, South Africa. During the study period 18–24 month long course treatment was offered for rifampicin-resistant and multi-drug-resistant tuberculosis.

Methods

Data are from a prospective observational cohort study. Costs of treatment were estimated from the provider perspective using bottom-up micro-costing. Costs were estimated as patient-level resource use multiplied by the unit cost of the resource. Clinic visits, drugs, laboratory tests, and total days hospitalized were collected from patients’ medical records. Staff time was estimated through a time and motion study. A successful treatment outcome was defined as cure or completion of the regimen.

Results

We enrolled 124 patients with 52% having a successful outcome. The average total cost/patient for all patients was $3,430 and $4,530 for successfully treated patients. The largest contributors to total cost across all outcomes were drugs (43%) and staff (28%). The average cost to achieve a successful outcome including all patients who started treatment (“production cost”) in the cohort is $6,684.

Conclusions

Decentralized, outpatient RR/MDR-TB care under South Africa’s 2011 strategy costs 74% less per patient than the previous strategy of inpatient care. The treatment cost of RR/MDR-TB is primarily driven by drug and staff costs, which are in turn dependant on treatment length.

"Even if you're HIV-positive there's life after if you take your medication": experiences of people on long-term ART in South Africa: a short report

South Africa's national antiretroviral treatment (ART) programme, initiated in 2004, is the largest HIV treatment programme in the world with an estimated 4.2 million people on ART. Today, an HIV diagnosis is no longer associated with certain death, but is rather a manageable chronic disease, with all HIV-positive patients now eligible to receive treatment. In this study, we explore patient experiences at the onset of the ART programme, including facilitators and barriers around decision-making along the HIV care cascade (HIV testing, ART initiation, retention, and adherence). We conducted twenty-four in-depth interviews among adults (≥18 years old) who initiated ART between April 2004 and March 2005 and were alive, on treatment at enrolment (October 2015-March 2016) at a large public-sector clinic in Johannesburg, South Africa. Data were analysed using a thematic analysis approach. Patients cited physical wellbeing, responsibility for raising children, supportive clinic staff and noticeable improvements in health on ART as key facilitators to continued care. In contrast, changing clinic conditions, fear of side-effects and stigma were mentioned as barriers. This study provides a unique lens through which to evaluate factors associated with long-term retention and adherence to ART at a crucial time in ART programming when more people will be initiating life-long treatment. We must continue to focus on supportive and empathetic clinic environments, more convenient ways to access medication for patients, and developing tools or interventions that continue to address the issues of stigma and discrimination and build the support networks for all those on treatment.

Impact of Xpert MTB/RIF and decentralized care on linkage to care and drug-resistant tuberculosis treatment outcomes in Johannesburg, South Africa

Background

In 2011, South Africa improved its ability to test for rifampicin-resistant TB (RR-TB) by introducing GeneXpert MTB/RIF. At the same time, the South African National TB program adopted a policy decentralized, outpatient treatment for drug resistant (DR-) TB. We aim to analyze the impact of these changes on linkage to care and DR-TB treatment outcomes.

Methods

We retrospectively matched adult patients diagnosed with laboratory-confirmed RR-TB in Johannesburg from 07/2011–06/2012 (early cohort) and 07/2013–06/2014 (late cohort) with records of patients initiating DR-TB treatment at one of the city’s four public sector treatment sites. We determine the proportion of persons diagnosed with RR-TB who initiated DR-TB treatment and report time to treatment initiation (TTI) before and after the implementation of Xpert MTB/RIF roll-out in Johannesburg, South Africa. We conducted a sub-analysis among those who initiated DR-TB treatment at the decentralized outpatient DR-TB centers to determine if delays in treatment initiation have a subsequent impact on treatment outcomes.

Results

Five hundred ninety four patients were enrolled in the early cohort versus 713 in the late cohort. 53.8 and 36.8% of patients were diagnosed with multi-drug resistant TB in the early and late cohorts, respectively. The proportion of RR-TB confirmed cases diagnosed by Xpert MTB/RIF increased from 43.4 to 60.5% between the early and late cohorts, respectively. The proportion who initiated treatment increased from 43.1% (n = 256) to 60.3% (n = 430) in the late cohort. Pre-treatment mortality during the early and the late cohort reduced significantly from 17.5 to 5.8% while lost to follow-up remained high.

Although TTI reduced by a median of 19 days, from 33 days (IQR 12–52) in the early cohort to 14 days (IQR 7–31) in the late cohort, this did not translate to improved treatment outcomes and we found no difference in terms of treatment success or on-treatment mortality for those that initiated without delay vs. those that deferred initiation.

Conclusion

Pre-treatment mortality reduced significantly during late Xpert MTB/RIF coverage but there was no significant difference after treatment was initiated. Despite improvements there is still a significant diagnosis and treatment gap for patients diagnosed with RR-TB and improving treatment outcomes remains critical.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3762-x) contains supplementary material, which is available to authorized users.

High rates of death and loss to follow-up by 12 months of rifampicin resistant TB treatment in South Africa

Introduction

Treatment success rates of rifampicin resistant (RR)/multi-drug resistant (MDR) tuberculosis (TB) in South Africa range from 43–48%, falling short of the World Health Organization’s target of ≥75%. We present rates and assess predictors of attrition by 12 months on treatment.

Methods

Prospective observational cohort analysis of adults (≥18 years) initiating RR/MDR-TB treatment from 01 March 2013 to 30 September 2016. Attrition was defined as a combination of death and loss to follow-up (LTFU; treatment interruption ≥2 months) by 12 months on treatment. Predictors of attrition were identified using Cox Proportional Hazards models to estimate crude (HR) and adjusted hazard ratios (aHR) with corresponding 95% confidence intervals.

Results

By 12 months on treatment, 75/240 (31.3%) patients had either died (37/240; 15.4%) or been LTFU (38/240; 15.8%). Patients with moderate/severe anaemia (aHR: 2.10; 95% CI 1.00–4.39), and those who were smear positive at baseline (aHR: 2.04; 95% CI 1.01–4.12) were significantly more likely to die or be lost from care.

Conclusion

At this outpatient DR-TB treatment site, there was a high rate of attrition halfway through the standard treatment course at 12 months of 31%. High rates of attrition by 12 months on treatment may continue during the second-half of therapy.