Vertical transmission of HIV-1 infection

Pregnant theatre staff in orthopaedic operating rooms: An observational study

PURPOSE

Trauma & Orthopaedic (T&O) surgery presents several occupational hazards to pregnant women and the unborn child. National bodies have produced guidelines to mitigate these risks as far as possible but individual trusts must be aware of them and implement them in their local policies. Our study aims to re-assess whether national guidelines for the protection of pregnant women are better adhered to nationally by providing a comparison to a previous study in 2018.

METHODS

A national observational study of 146 NHS trusts in the UK was conducted. Each trust was asked to complete a freedom of information request regarding all orthopaedic guidelines relating to pregnant theatre staff, which specifically related to the protection of the mother and foetus from exposure to harmful activity in theatre. Compliance was ascertained by cross-checking local policies with national guidelines.

RESULTS

82/146 (52.0%) of NHS trusts responded to the Freedom of Information  request. 31/75 (41.3%) respondents followed Health and Safety Executive (HSE) guidance for New and Expectant Mothers with 17/75 (22.7%) following multiple national guidelines. 16/75 (21.3%) NHS trusts do not follow any national guidelines in protecting new and expectant mothers from occupational hazards in the orthopaedic theatre setting.

CONCLUSIONS

Although an improvement has been made since 2018 in complying with national guidelines protecting new and expectant mothers from orthopaedic-related hazards, a sizeable proportion of NHS trusts do not comply with any national guidelines, putting employees at undue risk. There is a continued need for pregnant surgeons to be aware of and seek occupational health advice from dedicated professional bodies if the NHS trust does not provide specific guidance. Simultaneously, a sustained effort must be present to continue to inform NHS employers of their duty to protect new and expectant mothers and signpost them to relevant guidance.

Low transmission rates of Equine infectious anemia virus (EIAV) in foals born to seropositive feral mares inhabiting the Amazon delta region despite climatic conditions supporting high insect vector populations

Background

Marajó Island, within in the Amazon River Delta, supports numerous bands of feral equids including the genetically distinct Marajoara horses. Approximately 40% of the equids on the island are infected with Equine infectious anemia virus (EIAV). This high seropositivity rate coupled with the need to preserve rare breeds such as the Marajoara horse precludes euthanasia as the primary means for controlling EIAV in this region. In the absence of iatrogenic transmission, spread of this lentivirus is mediated primarily by hematophagous insects, whose year-round prevalence on the island is supported by favorable climatic conditions. In addition, cases of vertical EIAV transmission have been observed suggesting inclusion of seropositive mares in restorative breeding programs could result in their progeny becoming infected with this virus either pre-parturition or post-partum via hematophagous insects. Therefore, the aim of this study was to evaluate EIAV vertical and post-partum insect-mediated transmission rates among foals born to seropositive feral mares until natural weaning. Serum samples from foals born to seropositive feral mares within the Soure municipality, of Marajó Island, were collected to investigate their serological status, using an indirect ELISApgp45, with positive samples confirmed using the classical agar gel immunodiffusion (AGID) assay.

Results

The serological status of 28 foals were monitored over a 2-year period with some subjects, depending on their date of birth, being sampled up to six times. All foals remained with their respective mares until fully weaned at approximately 10 months of age. Only 2 foals (7.14%) in the study group became seropositive against EIAV.

Conclusion

The results demonstrate that in most cases it is possible to obtain seronegative foals born to and eventually weaned by EIA positive mares, even in equatorial regions where substantial rainfall and high temperatures favor the proliferation of insect vectors.

Field evaluation of the diagnostic performance of EasyScan GO: a digital malaria microscopy device based on machine-learning

BACKGROUND

Microscopic examination of Giemsa-stained blood films remains the reference standard for malaria parasite detection and quantification, but is undermined by difficulties in ensuring high-quality manual reading and inter-reader reliability. Automated parasite detection and quantification may address this issue.

METHODS

A multi-centre, observational study was conducted during 2018 and 2019 at 11 sites to assess the performance of the EasyScan Go, a microscopy device employing machine-learning-based image analysis. Sensitivity, specificity, accuracy of species detection and parasite density estimation were assessed with expert microscopy as the reference. Intra- and inter-device reliability of the device was also evaluated by comparing results from repeat reads on the same and two different devices. This study has been reported in accordance with the Standards for Reporting Diagnostic accuracy studies (STARD) checklist.

RESULTS

In total, 2250 Giemsa-stained blood films were prepared and read independently by expert microscopists and the EasyScan Go device. The diagnostic sensitivity of EasyScan Go was 91.1% (95% CI 88.9-92.7), and specificity 75.6% (95% CI 73.1-78.0). With good quality slides sensitivity was similar (89.1%, 95%CI 86.2-91.5), but specificity increased to 85.1% (95%CI 82.6-87.4). Sensitivity increased with parasitaemia rising from 57% at < 200 parasite/µL, to ≥ 90% at > 200-200,000 parasite/µL. Species were identified accurately in 93% of Plasmodium falciparum samples (kappa = 0.76, 95% CI 0.69-0.83), and in 92% of Plasmodium vivax samples (kappa = 0.73, 95% CI 0.66-0.80). Parasite density estimates by the EasyScan Go were within ± 25% of the microscopic reference counts in 23% of slides.

CONCLUSIONS

The performance of the EasyScan Go in parasite detection and species identification accuracy fulfil WHO-TDR Research Malaria Microscopy competence level 2 criteria. In terms of parasite quantification and false positive rate, it meets the level 4 WHO-TDR Research Malaria Microscopy criteria. All performance parameters were significantly affected by slide quality. Further software improvement is required to improve sensitivity at low parasitaemia and parasite density estimations. Trial registration ClinicalTrials.gov number NCT03512678.

SARS-CoV-2 in Pregnancy: Fitting Into the Existing Viral Repertoire

The risk of viral infection during pregnancy is well-documented; however, the intervention modalities that in practice enable maternal-fetal protection are restricted by limited understanding. This becomes all the more challenging during pandemics. During many different epidemic and pandemic viral outbreaks, worse outcomes (fetal abnormalities, mortality, preterm labor, etc.) seem to affect pregnant women than what has been evident when compared to non-pregnant women. The condition of pregnancy, which is widely understood as "immunosuppressed," needs to be re-understood in terms of the way the immune system works during such a state. The immune system gets transformed to accommodate and facilitate fetal growth. The interference of such supportive conversion by viral infection and the risk of co-infection lead to adverse fetal outcomes. Hence, it is crucial to understand the risk and impact of potent viral infections likely to be encountered during pregnancy. In the present article, we review the effects imposed by previously established and recently emerging/re-emerging viral infections on maternal and fetal health. Such understanding is important in devising strategies for better preparedness and knowing the treatment options available to mitigate the relevant adverse outcomes.

Prenatal Biochemical and Ultrasound Markers in COVID-19 Pregnant Patients: A Prospective Case-Control Study

This prospective observational study aimed to evaluate whether women with SARS-CoV-2 infection during the first trimester of pregnancy are at higher risk of noninvasive prenatal screening test alterations and/or of congenital fetal anomalies at the second-trimester fetal anatomy scan. Maternal symptoms were secondly investigated. The study was carried out on 12-week pregnant women admitted for noninvasive prenatal testing (16 April and 22 June 2020). The cohort had seromolecular tests for SARS-CoV-2, after which they were divided into a positive case group and a negative control group. Both groups had 20-week ultrasound screening. Seventeen out of the 164 women tested positive for SARS-CoV-2 (10.3%). There were no significant differences in mean nuchal translucency thickness or biochemical markers (pregnancy-associated plasma protein A, alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol) between cases and controls (p = 0.77, 0.63, 0.30, 0.40, 0.28) or in the fetal incidence of structural anomalies at the second-trimester fetal anatomy scan (p = 0.21). No pneumonia or hospital admission due to COVID-19-related symptoms were observed. Asymptomatic or mildly symptomatic SARS-CoV-2 infection during the first trimester of pregnancy did not predispose affected women to more fetal anomalies than unaffected women. COVID-19 had a favorable maternal course at the beginning of pregnancy in our healthy cohort.

INFECTIONS IN PREGNANCY WITH COVID-19 AND OTHER RESPIRATORY RNA VIRUS DISEASES ARE RARELY, IF EVER, TRANSMITTED TO THE FETUS: EXPERIENCES WITH CORONAVIRUSES, HPIV, hMPV RSV, AND INFLUENZA

SARS-CoV-2, the agent of COVID-19, is similar to two other coronaviruses, SARS-CoV and MERS-CoV, in causing life-threatening maternal respiratory infections and systemic complications. Because of global concern for potential intrauterine transmission of SARS-CoV-2 from pregnant women to their infants, this report analyzes the effects on pregnancy of infections caused by SARS-CoV-2 and other respiratory RNA viruses, and examines the frequency of maternal-fetal transmission with SARS-CoV-2, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza, respiratory syncytial virus (RSV), parainfluenza (HPIV) and metapneumovirus (hMPV). There have been no confirmed cases of intrauterine transmission reported with COVID-19 or any other coronavirus infections. Influenza virus, despite causing approximately one billion annual infections globally, has only a few cases of confirmed or suspected intrauterine fetal infections reported. RSV is in an unusual cause of illness among pregnant women, and with the exception of one premature infant with congenital pneumonia, no other cases of maternal-fetal infection are described. Parainfluenza virus and human metapneumovirus can produce symptomatic maternal infections but do not cause intrauterine fetal infection. In summary, it appears that the absence thus far of maternal-fetal transmission of the SARS-CoV-2 virus during the COVID-19 pandemic is similar to other coronaviruses, and is also consistent with the extreme rarity of suggested or confirmed cases of intrauterine transmission of other respiratory RNA viruses. This observation has important consequences for pregnant women as it appears that if intrauterine transmission of SARSCoV-2 does eventually occur, it will be a rare event. Potential mechanisms of fetal protection from maternal viral infections are also discussed.

Fertility Desire And Associated Factors Among HIV Positive Women Attending ART Clinics In Amhara Region Referral Hospitals In Northwest Ethiopia, 2017

Background

“Fertility desire” is the intention of people to have more children despite being diagnosed with HIV, whereas intentions denote a commitment to implement that desire. Despite the overwhelming effects of HIV on a fetus, there is a desire for fertility among people positive for the virus/disease worldwide.  Therefore, this study aimed to assess fertility desires and factors associated with sexually active HIV positive reproductive-age women attending ART clinics at Amhara region referral hospitals, Northwest Ethiopia.

Methods

An institution-based cross-sectional study was conducted on reproductive-age women attending the clinics at the hospitals. A total of 427 eligible women were systematically included in the study. A semi-structured questionnaire was used to collect data via interviewer-administered techniques. EpiInfo7 and STATA 14 software was used for data entry and analysis, respectively. The logistic regression analysis method was used to identify factors associated with fertility desire. Factors that had p-values of ≤0.05 were considered statistically significant.

Results

The findings indicated that 40.3% (95% CI; 35.7%, 45.0%) of the participants reported they had the desire to have children in the future. Variables such as women in the age group of 25–34 years (AOR= 2.80, 95% CI; 1.68, 4.68), participating with their sexual partner (AOR=3.52, 95% CI; 1.36, 9.13) and married women (AOR=2.32, 95% CI; 1.05, 5.10) had a positive association with the outcome variable, whereas having one or more live children (AOR=0.19, 95% CI; 0.09, 0.39) and having no formal education (AOR= 0.51, 95% CI; 0.29, 0.89) had a negative association with fertility desire.

Conclusion

The proportion of sexually active HIV-positive women with desire for children was high among women visiting referral hospitals. Therefore, programmers and policymakers need to expand new PMTCT services throughout the region and consider the effects of these factors on HIV-positive women, as they develop interventions.

Cross-sectional comparative study of risky sexual behaviours among HIV-infected persons initiated and waiting to start antiretroviral therapy in rural Rakai, Uganda

OBJECTIVES

To compare risky sexual behaviours between HIV-positive persons initiated on antiretroviral therapy (ART) (ART-experienced) and persons waiting to start on ART (ART-naive) and assess predictors of risky sexual behaviours among HIV-infected patients in rural Rakai district, Uganda.

STUDY DESIGN

This is a cross-sectional study that used data from the Rakai Community Cohort Study (RCCS) database between 2013 and 2014. A structured questionnaire was used for data collection. We used stepwise logistic regression as an index to estimate the adjusted ORs for the association between risky sexual behaviours and ART treatment status.

STUDY SETTING

This study was conducted in Rakai district, located in south-western Uganda. The data for this study were extracted from the RCCS. RCCS is an open prospective cohort of approximately 15 000 consenting participants aged 15-49 years.

PARTICIPANTS

HIV-positive participants aged 18-49 years who had sex at least once a month with any partner prior to the start of the study.

MAIN OUTCOME MEASURES

Inconsistent/no condom use in the last 12 months, alcohol use at last sexual encounter, and two or more sexual partners.

RESULTS

ART-naive participants were more likely to report inconsistent condom use (OR=1.74, 95% CI 1.11 to 2.73) and more likely to drink alcohol at last sexual encounter (OR=1.65, 95% CI 1.11 to 2.46), compared with ART-experienced patients. ART treatment status (p<0.001) was a significant predictor of risky sexual behaviours. Both marital status (p=0.016) and occupation level (p=0.009) were positively associated with inconsistent condom use, while sex (p<0.001) correlated with alcohol use at last sexual encounter.

CONCLUSION

ART-naive participants were more likely to exhibit risky sexual behaviours than the ART-experienced participants. The intensity of risk reduction counselling should be increased for HIV-positive persons waiting to start ART but already in HIV care.

Vitamin A supplements for reducing mother-to-child HIV transmission

BACKGROUND

Strategies to reduce the risk of mother-to-child transmission of the human immunodeficiency virus (HIV) include lifelong antiretroviral therapy (ART) for HIV-positive women, exclusive breastfeeding from birth for six weeks plus nevirapine or replacement feeding plus nevirapine from birth for four to six weeks, elective Caesarean section delivery, and avoiding giving children chewed food. In some settings, these interventions may not be practical, feasible, or affordable. Simple, inexpensive, and effective interventions (that could potentially be implemented even in the absence of prenatal HIV testing programmes) would be valuable. Vitamin A, which plays a role in immune function, is one low-cost intervention that has been suggested in such settings.

OBJECTIVES

To summarize the effects of giving vitamin A supplements to HIV-positive women during pregnancy and after delivery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to 25 August 2017, and checked the reference lists of relevant articles for eligible studies.

SELECTION CRITERIA

We included randomized controlled trials conducted in any setting that compared vitamin A supplements to placebo or no intervention among HIV-positive women during pregnancy or after delivery, or both.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed study eligibility and extracted data. We expressed study results as risk ratios (RR) or mean differences (MD) as appropriate, with their 95% confidence intervals (CI), and conducted random-effects meta-analyses. This is an update of a review last published in 2011.

MAIN RESULTS

Five trials met the inclusion criteria. These were conducted in Malawi, South Africa, Tanzania, and Zimbabwe between 1995 and 2005 and none of the participants received ART. Women allocated to intervention arms received vitamin A supplements at a variety of doses (daily during pregnancy; a single dose immediately after delivery, or daily doses during pregnancy plus a single dose after delivery). Women allocated to comparison arms received identical placebo (6601 women, 4 trials) or no intervention (697 women, 1 trial). Four trials (with 6995 women) had low risk of bias and one trial (with 303 women) had high risk of attrition bias.The trials show that giving vitamin A supplements to HIV-positive women during pregnancy, the immediate postpartum period, or both, probably has little or no effect on mother-to-child transmission of HIV (RR 1.07, 95% CI 0.91 to 1.26; 4428 women, 5 trials, moderate certainty evidence) and may have little or no effect on child death by two years of age (RR 1.06, 95% CI 0.92 to 1.22; 3883 women, 3 trials, low certainty evidence). However, giving vitamin A supplements during pregnancy may increase the mean birthweight (MD 34.12 g, 95% CI -12.79 to 81.02; 2181 women, 3 trials, low certainty evidence) and probably reduces the incidence of low birthweight (RR 0.78, 95% CI 0.63 to 0.97; 1819 women, 3 trials, moderate certainty evidence); but we do not know whether vitamin A supplements affect the risk of preterm delivery (1577 women, 2 trials), stillbirth (2335 women, 3 trials), or maternal death (1267 women, 2 trials).

AUTHORS' CONCLUSIONS

Antepartum or postpartum vitamin A supplementation, or both, probably has little or no effect on mother-to-child transmission of HIV in women living with HIV infection and not on antiretroviral drugs. The intervention has largely been superseded by ART which is widely available and effective in preventing vertical transmission.

Toll-like receptor (TLR4) Asp299Gly and Thr399Ile polymorphisms in relation to clinical falciparum malaria among Nigerian children: a multisite cross-sectional immunogenetic study in Lagos

INTRODUCTION

This study determined the association of TLR4 Asp299Gly and Thr399Ile with uncomplicated and severe malaria among Nigerian children of similar ethnic background in Lagos. The association of these SNPs with high parasite density, malnutrition, hyperpyrexia and anaemia was also investigated.

METHODS

Genomic DNA of the study participants was screened for the genotypes of TLR4 Asp299Gly and Thr399Ile by PCR-RFLP. Anthropometric measurement was performed on the Pf infected children stratified into asymptomatic malaria (control), uncomplicated and severe malaria (case). Parasites were detected by light microscopy and Hardy Weinberg Equilibrium (HWE) of SNP genotypes was also determined.

RESULTS

A total of 279 children comprising 182 children (62.1 % male; mean ± SEM age, 57.3 ± 1.7 months) with clinical falciparum malaria and 97 children (55.7 % male; mean ± SEM age, 55.6 ± 2.5 years) with asymptomatic falciparum malaria were enrolled. All the genotypes of both TLR4 SNPs were found in the study population with their minor alleles: 299Gly and 399Ile, found to be 17.6 % and 14.7 % in severe malaria children. Unlike in asymptomatic population, the genotype distribution of TLR4 Asp299Gly SNP was not in HWE in the clinical malaria group but did not condition susceptibility. However, Asp299Gly and Thr399Ile polymorphisms were found to increase the risk of severe malaria 3-fold and 8-fold respectively (P < 0.05). They also increased the risk of severe anaemia, high parasite density and severe malnutrition 3.8 -5.3-fold, 3.3 - 4.4-fold and 4-fold respectively.

CONCLUSIONS

Based on the above findings, we conclude that TLR4 Asp299Gly and Thr399Ile polymorphisms may modulate susceptibility to severe malaria among Nigerian children of Yoruba ethnic background.

[Comparison of the effectiveness of artemether and quinine for treatment of severe malaria in children, Bangui, Central African Republic]

The management of severe malaria is a major challenge in the health care services in sub-Saharan Africa. This study aimed to assess the efficacy and safety of artemether and quinine in severe malaria at Complexe pédiatrique of Bangui, Central African Republic. A total of 212 children among 1125 hospital admissions (18.8%), and aged 6 to 59 months were randomly treated with artemether and quinine. Anemia (58.5%) and seizures (33.5%) were the major syndromes observed. On the third day of follow up, a regression of clinical signs and parasite clearance were observed in 98.1% of children treated with artemether and 97.1% of children treated with quinine. The death rate was 2.3% due to anemic and neurological forms. These findings show that the artemether and quinine have similar efficacy. Hence, associated with adequate intensive health care, the use of these antimalarial drugs can significantly reduce mortality from severe malaria in the Central African Republic.

[IgG responses to candidate malaria vaccine antigens in the urban area of Dakar (Senegal): evolution according to age and parasitemia in patients with mild symptoms]

Malaria remains a major problem in African countries despite substantial decreases in morbidity and mortality due to sustained control programs. Studies for the evaluation of qualitative or quantitative Ab responses to key targets of anti-plasmodium immunity were mostly done in rural endemic setting compared to urban area. In a cohort of 200 patients with mild malaria and living in Dakar, we analyze total and subclasses IgG responses to a panel of P. falciparum blood stage antigens: MSP1p19, MSP3, EB200, GST-5 and R23. A mean age of 15 yrs (4 to 56 yrs) and parasitemia between 0.1 to 17% were found. Levels of IgG anti-MSP3 were higher in patients with low parasitemia (≤1%) and appear negatively correlated to parasite densities (Rho =. 0.54; p= 0.021). This correlation is more significant in children (≤ 15 yrs). In addition, an increase of IgG responses against MSP1p19 is highly observed in adults having a parasitemia less than 1%. In those patients, we find that IgG1 subclasses were predominant (p <0.01). Our study shows an association between Ab responses and parasitemia. This association is dependant to IgG anti-MSP3 in children and IgG anti-MSP1p19 in adults living in urban area.

Adverse drug reactions associated with antiretroviral therapy during pregnancy

INTRODUCTION

Antiretroviral (ARV) drug use during pregnancy significantly reduces mother-to-child HIV transmission, delays disease progression in the women and reduces the risk of HIV transmission to HIV-serodiscordant partners. Pregnant women are susceptible to the same adverse reactions to ARVs as nonpregnant adults as well as to specific pregnancy-related reactions. In addition, we should consider adverse pregnancy outcomes and adverse reactions in children exposed to ARVs during intrauterine life. However, studies designed to assess the safety of ARV in pregnant women are rare, usually with few participants and short follow-up periods.

AREAS COVERED

In this review, we discuss studies reporting adverse reactions to ARV drugs, including maternal toxicity, adverse pregnancy outcomes and the consequences of exposure to ARV in infants. We included results of observational studies, both prospective and retrospective, as well as randomized clinical trials, systematic reviews and meta-analyses.

EXPERT OPINION

The benefits of ARV use during pregnancy outweigh the risks of adverse reactions identified to date. More studies are needed to assess the adverse effects in the medium- and long term in children exposed to ARVs during pregnancy, as well as pregnant women using lifelong antiretroviral therapy and more recently available drugs.

Plasmodium falciparum clearance is rapid and pitting independent in immune Malian children treated with artesunate for malaria

BACKGROUND

In Plasmodium falciparum-infected patients treated with artemisinins, parasitemia declines through so-called pitting, an innate splenic process that transforms infected red blood cells (iRBCs) into once-infected RBCs (O-iRBCs).

METHODS

We measured pitting in 83 French travelers and 42 Malian children treated for malaria with artesunate.

RESULTS

In travelers, O-iRBCs peaked at 107.7% initial parasitemia. In Malian children aged 1.5-4 years, O-iRBCs peaked at higher concentrations than in children aged 9-13 years (91.60% vs 31.95%; P = .0097). The parasite clearance time in older children was shorter than in younger children (P = .0001), and the decline in parasitemia in children aged 1.5-4 years often started 6 hours after treatment initiation, a lag phase generally absent in infants and older children. A 6-hour lag phase in artificial pitting of artesunate-exposed iRBCs was also observed in vitro. The proportion of iRBCs recognized by autologous immunoglobulin G (IgG) correlated with the parasite clearance time (r = -0.501; P = .0006) and peak O-iRBC concentration (r = -0.420; P = .0033).

CONCLUSIONS

Antimalarial immunity correlates with fast artemisinin-induced parasite clearance and low pitting rates. In nonimmune populations, artemisinin-induced P. falciparum clearance is related to pitting and starts after a 6-hour lag phase. In immune populations, passively and naturally acquired immune mechanisms operating faster than pitting may exist. This mechanism may mitigate the emergence of artemisinin-resistant P. falciparum in Africa.

Association of candidate gene polymorphisms and TGF-beta/IL-10 levels with malaria in three regions of Cameroon: a case-control study

Background

Plasmodium falciparum malaria is one of the most widespread and deadliest infectious diseases in children under five years in endemic areas. The disease has been a strong force for evolutionary selection in the human genome, and uncovering the critical host genetic factors that confer resistance to the disease would provide clues to the molecular basis of protective immunity and improve vaccine development initiatives.

Methods

The effect of single nucleotide polymorphisms (SNPs) and plasma transforming growth factor beta (TGF-β) and interleukin 10 (IL-10) levels on malaria pathology was investigated in a case–control study of 1862 individuals from two major ethnic groups in three regions with intense perennial P. falciparum transmission in Cameroon. Thirty-four malaria candidate polymorphisms, including the sickle cell trait (HbS), were assayed on the Sequenom iPLEX platform while plasma TGF-β and IL-10 levels were measured by sandwich ELISA.

Results

The study confirms the known protective effect of HbS against severe malaria and also reveals a protective effect of SNPs in the nitrogen oxide synthase 2 (NOS2) gene against malaria infection, anaemia and uncomplicated malaria. Furthermore, ADCY9 rs10775349 (additive G) and ABO rs8176746 AC individuals were associated with protection from hyperpyrexia and hyperparasitaemia, respectively. Meanwhile, individuals with the EMR1 rs373533 GT, EMR1 rs461645 CT and RTN3 rs542998 (additive C) genotypes were more susceptible to hyperpyrexia while both females and males with the rs1050828 and rs1050829 SNPs of G6PD, respectively, were more vulnerable to anaemia. Plasma TGF-β levels were strongly correlated with heterozygosity for the ADCY9 rs2230739 and HBB rs334 SNPs while individuals with the ABO rs8176746 AC genotype had lower IL-10 levels.

Conclusion

Taken together, this study suggests that some rare polymorphisms in candidate genes may have important implications for the susceptibility of Cameroonians to severe malaria. Moreover using the uncomplicated malaria phenotype may permit the identification of novel pathways in the early development of the disease.

Imported malaria in Poland 2003 to 2011: implications of different travel patterns

BACKGROUND

The number of imported malaria cases in Poland compared with other European countries remains low. However, in view of the high mortality and the large proportion of severe clinical forms, a better understanding of the problem is required.

METHODS

Data reported to the surveillance system in Poland between 2003 and 2011 were reviewed retrospectively. All cases were laboratory confirmed as outlined by the EU case definition. Statistical analysis was performed using Epi Info 3.5.3 and STATA 10.

RESULTS

A total of 189 confirmed malaria cases, including 5 that were fatal, were reported in Poland during the study period. All cases were imported: 72% came from Africa. Among cases with a species-specific diagnosis, 118 (73%) were caused by Plasmodium falciparum. The median age of individuals afflicted was 36 years and 74% were males. Most cases occurred among work-related travelers (40%) or tourists (38%). Individuals born in malaria-endemic countries constituted 12% of all cases. The severe malaria form was identified in 23% of all cases and was more frequent among cases caused by P. falciparum (32%), in people older than 50 years (39%), and in cases when diagnosis was delayed (36%). The severe form occurred only in 9% of cases originating from malaria-endemic countries and there were no fatalities in this group. Fatal outcomes were associated with a delay in diagnosis (fatality = 10.5%) and falciparum malaria (fatality = 4%). Most of the delays resulted from a delay in seeking medical care, and less frequently due to misdiagnosis.

CONCLUSIONS

Tourists and work-related travelers make up most of the malaria patients in Poland and they are at a greater risk of the severe form of malaria and consequently death, possibly due to the lack of immunity. Delayed diagnosis is associated with mortality, implying low awareness of the threat that malaria poses, both among patients and doctors.

Plasmodium vivax associated severe malaria complications among children in some malaria endemic areas of Ethiopia

BACKGROUND

Although, Plasmodium vivax is a rare parasite in most parts of Africa, it has significant public health importance in Ethiopia. In some parts of the country, it is responsible for majority of malaria associated morbidity. Recently severe life threatening malaria syndromes, frequently associated to P. falciparum, has been reported from P. vivax mono-infections. This prompted designing of the current study to assess prevalence of severe malaria complications related to P. vivax malaria in Ethiopia.

METHODS

The study was conducted in two study sites, namely Kersa and Halaba Kulito districts, located in southwest and southern parts of Ethiopia, respectively. Children, aged ≤ 10 years, who visited the two health centers during the study period, were recruited to the study. Clinical and demographic characteristics such as age, sex, temperature, diarrhea, persistent vomiting, confusion, respiratory distress, hepatomegaly, splenomegaly, hemoglobinuria, and epitaxis were assessed for a total of 139 children diagnosed to have P. vivax mono-infection. Parasitological data were collected following standard procedures. Hemoglobin and glucose level were measured using portable hemocue instrument.

RESULTS

Median age of children was 4.25 ± 2.95 years. Geometric mean parasite count and mean hemoglobin level were 4254.89 parasite/μl and 11.55 g/dl, respectively. Higher prevalence rate of malaria and severe malaria complications were observed among children enrolled in Halaba district (P < 0.001). However, severe parasitemia was higher (72.4%) among children who visited Serbo health center (Kersa district). Male children had significantly higher risk of malaria infection (OR = 1.9, 95% CI, 1.08 to 3.34), while female had higher risk to anemia (OR = 1.91, 95% CI, 1.08 - 3.34). The observed number of anemic children was 43%, of which most of them were found in age range from 0-3 years. Furthermore, P. vivax malaria was a risk factor for incidence of anemia (P < 0.05) in the two sites.

CONCLUSION

P. vivax associated severe malaria complications observed in this study was lower than those reported from other countries. However, incidence of severe malaria complications in one of the sites, Halaba district, where there is highest treatment failure to first line drug, could have significant impact on national malaria prevention and control activities.

Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre

INTRODUCTION

Despite evidence from developing world trials that intravenous (IV) artesunate (AS) is superior to IV quinine (Q) in severe falciparum malaria (FM), IV AS remains unlicensed in the UK with national guidelines listing it as an acceptable alternative to IV Q as the drug of choice. We retrospectively evaluate the safety and effectiveness of IV AS in returning travellers with severe FM.

METHODS

We identified adults admitted to the Infectious Diseases unit with severe FM and treated with IV Q (1991-2009) or IV AS (2009-2011). Outcomes included adverse events, mortality, length of stay, admission to intensive care and, where data were available, parasite/fever clearance time and hypoglycaemic events.

RESULTS

Of 167 patients, 24 received IV AS and 143 IV Q. There was one potential AS-associated adverse event, a case of late onset haemolysis. Median length of stay (LOS) was significantly shorter for AS (3·5 versus 5 days, P = 0·017), even after adjusting for African ethnicity (for LOS ≥3 days, mhor = 0·33, P = 0·027; crude OR = 0·29, P = 0·013). In the AS group, there were no fatalities (versus five in Q group, NS) and fewer intensive care unit (ICU) admissions (NS). Median parasite clearance was significantly faster in AS (65 versus 85 hours in Q, P = 0·0045) with no hypoglycaemic episodes (versus five in Q).

DISCUSSION

We found IV AS to be safe and effective, with shorter LOS, faster parasite and fever clearance, no fatalities or hypoglycaemic events, and fewer ICU admissions versus IV Q. This corroborates both developing world trials and smaller European case series (although these lacked comparison groups). As well as obvious benefits for patients, there are potential resource savings. A case of late-onset haemolysis may represent an adverse event, particularly as it has been documented elsewhere, warranting further investigation. Nonetheless, our experience suggests IV AS should be first-line for treating severe FM in the UK.

Contraceptive practices amongst HIV-positive women on antiretroviral therapy attending an ART clinic in South Africa

Background

Effective contraceptive practices amongst HIV-positive women of reproductive age have been shown to reduce mother-to-child transmission of HIV by preventing unplanned pregnancies. However, most antiretroviral therapy (ART) programmes focus on treatment, neglecting comprehensive contraceptive services. This results in a high frequency of pregnancies amongst HIV-positive women attending the ART clinic of a regional hospital north of Durban.

Objectives

This research aimed to explore contraceptive use amongst HIV-positive women attending an ART clinic by determining, (1) prevalence of contraceptive use, (2) pregnancy rate, (3) contraceptive preferences and (4) factors associated with contraceptive use.

Methods

In this observational, analytical, cross-sectional study of 420 women, aged 15 to 49 years, participants were selected by systematic random sampling. They completed standardised questionnaires.

Results

Of all participants, 95% of the participants used contraception. Factors associated with contraceptive practice were knowledge of HIV status 292 (72.8%), health worker advice 84 (20.9%), and spousal insistence 33 (8.2%). Of the 130 women (31%) who had fallen pregnant whilst on ART, 73 (56.2%) said that the pregnancy had been unplanned, whilst 57 (43.8%) had wanted to fall pregnant because of: partner's insistence (45.6%), desire for a child (36.8%), desire to conceal HIV status (15.8%), not wanting to die childless (5.3%), and death of a previous child (1.8%).

Conclusion

Contraceptive use amongst these women was high but the number of pregnancies is a cause for concern. Information regarding contraceptive use should therefore be provided at all ART clinics.

Zinc, copper and C-reactive protein in children with severe Plasmodium falciparum malaria in an area of unstable malaria transmission in eastern Sudan

BACKGROUND

Few data exist on the role of trace element in the pathogenesis of severe malaria.

OBJECTIVES

The study was conducted at Kassala Hospital, eastern Sudan, to investigate the role of zinc, copper and C-reactive protein levels in children with severe Plasmodium falciparum malaria.

METHODS

Zinc, copper and C-reactive protein levels were measured in sera of three groups of children (35 in each arm): those with severe malaria, those with uncomplicated P. falciparum malaria and healthy controls.

RESULTS

Although the zinc levels were significantly lower, the levels of copper and C-reactive protein were significantly higher in patients with severe P. falciparum. There was a significant inverse correlation between zinc and C-reactive protein and significant positive correlation between copper and C-reactive protein.

CONCLUSION

The change in zinc and copper may play a role in pathogenesis of P. falciparum malaria.

Fasting predisposes to hypoglycemia in Surinamese children with severe pneumonia, and young children are more at risk

The objective of this study was to investigate glucose kinetics during controlled fasting in children with severe pneumonia. Plasma glucose concentration, endogenous glucose production and gluconeogenesis were measured in 12 Surinamese children (six young: 1-3 years, six older: 3-5 years) with severe pneumonia during a controlled 16 h fast using stable isotopes [6,6-(2)H2]glucose and (2)H2O at a hospital-based research facility. On admission, the glucose concentrations were comparable in both groups: young children: 5.1 ± 1.3 mmol/l, older children: 4.8 ± 0.6 mmol/l, p = 0.685, with a decrease during the first 8 h of fasting in the young children only to 3.6 ± 0.5, p = 0.04. Glucose production was comparable in both groups: young: 24.5 ± 8.3, older: 24.9 ± 5.9 µmol/kg(•)min, p = 0.926. Between 8 and 16 h of fasting, the glucose concentration decreased comparably in both groups (young: - 0.9 ± 0.7, p = 0.004; older: -1.0 ± 0.4 mmol/l, p = 0.001), as did glucose production (young: -6.8 ± 6.3, p = 0.003; older: -5.3 ± 3.4 µmol/kg(•)min, p = 0.001). Gluconeogenesis decreased in young children only: -5.0 ± 7.4, p = 0.029. We conclude that fasting predisposes to hypoglycemia in children with severe pneumonia. Young children are more at risk than older children. Glucose production is an important determinant of the plasma glucose concentration in young children with pneumonia, indicating an inability to reduce glucose usage. Our results are largely in agreement with the literature on the adaptation of glucose metabolism in children with malaria, although there seem to be disease-specific differences in the regulation of gluconeogenesis.

Anti-malarial IgG subclasses pattern and FcγRIIa (CD32) polymorphism among pregnancy-associated malaria in semi-immune Saudi women

Background

Pregnant women remain are at an increased risk of malaria with primigravidae being at the highest risk. Genetic polymorphism of the Fc receptor IIa for immunologlobulin (Ig) G (FcγRIIa) determines IgG subclass binding. Protection against pregnancy-associated malaria (PAM) is associated with the production of IgG specific for apical membrane antigen-1 (AMA-1). The present study was undertaken to examine the relationship between specific IgG/IgG subclasses and malaria infection. The second aim of the study is to examine the association between FcγRIIa R/H131 polymorphism in correlation with specific anti-malarial IgG antibodies of AMA-1 distribution and asymptomatic malaria infection among Saudi women living in the southern part of Saudi Arabia.

Methods

One hundred and twenty pregnant women living in an area of meso-endemic Plasmodium falciparum malaria infection were consecutively enrolled onto the study. These pregnant women were asymptomatic and attending routine antenatal clinics. The levels of plasma antibodies (IgG and subclasses AMA-1) were measured using indirect enzyme-linked immunosorbent assays (ELISA). Genotyping of FcγRIIa-R/H131 dimorphism was performed using gene-specific polymerase chain reaction (PCR) amplification with allele-specific restriction enzyme digestion (BstU1) of the PCR product.

Results

A total of sixty-two (52%) pregnant women was diagnosed with asymptomatic malarial infection (ASM) compared with 58 (48%) malaria free controls (MFC). In the ASM group, there were high levels of anti-malarial IgG1 and IgG3, when compared to MFC (P value <0.001, respectively). The FcγRIIa-R/R131 genotype and R131 were found to be statistically significantly more prevalent in the ASM group when compared to the MFC group [55% for ASM versus 12% for MFC, odds ratio (OR) 5.62, 95% confidence interval (CI)= (2.03- 15.58), P value= 0.001]. However, the H/H131 genotype showed statistically significant association with MFC [14% for ASM versus 50% for MFC, OR(0.36), 95% CI= (0.14- 0.95), P value= 0.03].

Conclusions

The study revealed that the ASM patients had higher anti-malarial IgG and IgG subclasses antibody levels when compared to the MFC. The FcγRIIa-R/R131 genotype and R131 allele were found to be statistically prevalent in the ASM when compared to the MFC group. The individuals carrying H/H131 were consistently associated with higher levels of anti-malarial IgG subclasses.

Ultrasonographic renal sizes, cortical thickness and volume in Nigerian children with acute falciparum malaria

BACKGROUND

Utility of sonographic assessments of renal changes during malaria illness are rarely reported in African children in spite of the high burden of malarial-related kidney damage.

METHODS

In this case-control study, renal sizes, cortical thickness and volume of the kidneys of 131 healthy children and 170 with acute falciparum malaria comprising 85 uncomplicated malaria (UM) and 85 complicated malaria (CM) cases, measured within 24 hours of presenting in the hospital were compared.

RESULTS

The mean age of children with UM, CM and control groups was 49.7 ± 26.2 months, 50.7 ± 29.3 months and 73.4 ± 25.5 months, respectively (p < 0.001). The mean right kidney length of CM group was higher than control by 0.41cm (95% CI = 0.16, 0.65; p < 0.001) and UM by 0.32 cm (95% CI = 0.02, 0.62; p = 0.030). Similarly, mean left kidney length of CM was higher than control and UM by 0.34 cm (95% CI = 0.09, 0.60; p = 0.005) and 0.41cm (95% CI = 0.09, 0.72; p = 0.006), respectively. Estimated mean renal volume of the CM group was significantly higher than control group by 7.82 cm(3) for right and by 5.79 cm(3) for left kidneys respectively; in the UM group by 9.31cm(3) for right and 8.87 cm(3) for left kidneys respectively.

CONCLUSION

There was a marginal increase in renal size of children with Plasmodium falciparum infection, which worsened with increasing severity of malaria morbidity. Ultrasonography provides important information for detecting renal changes in children with acute malaria.

Oral artesunate-amodiaquine and artemether-lumefantrine in the treatment of uncomplicated hyperparasitaemic Plasmodium falciparum malaria in children

The therapeutic efficacy, changes in haematocrit and declines in parasitaemias were evaluated in 56 children with uncomplicated falciparum hyperparasitaemia after oral artesunate-amodiaquine or artemether-lumefantrine. All children recovered clinically within 2 days and without progression to severe malaria. Falls in haematocrit in the first 3 days after treatment began were similar and <5%. Declines in parasitaemias were monoexponential with both treatments with an estimated half-life of 1 h.

Predicting the clinical outcome of severe falciparum malaria in african children: findings from a large randomized trial

Four predictors were independently associated with an increased risk of death: acidosis, cerebral manifestations of malaria, elevated blood urea nitrogen, or signs of chronic illness. The standard base deficit was found to be the single most relevant predictor of death.

Background. Data from the largest randomized, controlled trial for the treatment of children hospitalized with severe malaria were used to identify such predictors of a poor outcome from severe malaria.

Methods. African children (<15 years) with severe malaria participated in a randomized comparison of parenteral artesunate and parenteral quinine in 9 African countries. Detailed clinical assessment was performed on admission. Parasite densities were assessed in a reference laboratory. Predictors of death were examined using a multivariate logistic regression model.

Results. Twenty indicators of disease severity were assessed, out of which 5 (base deficit, impaired consciousness, convulsions, elevated blood urea, and underlying chronic illness) were associated independently with death. Tachypnea, respiratory distress, deep breathing, shock, prostration, low pH, hyperparasitemia, severe anemia, and jaundice were statistically significant indicators of death in the univariate analysis but not in the multivariate model. Age, glucose levels, axillary temperature, parasite density, heart rate, blood pressure, and blackwater fever were not related to death in univariate models.

Conclusions. Acidosis, cerebral involvement, renal impairment, and chronic illness are key independent predictors for a poor outcome in African children with severe malaria. Mortality is markedly increased in cerebral malaria combined with acidosis.

Clinical Trial Registration. ISRCTN50258054.

Thrombocytopenia in vivax and falciparum malaria: an observational study of 131 patients in Karnataka, India

BACKGROUND

Thrombocytopenia has been reported in the majority of malaria studies. Some but not all studies suggest the possible role of platelets in the pathology of severe malaria. We assess the association of admission platelet count with malaria complications and mortality in vivax and falciparum malaria.

METHODS

This is a prospective, observational study of patients aged 18 years and above admitted in a tertiary care teaching hospital from August 2004 to July 2006 in Manipal, India. Malaria was diagnosed based on clinical features along with positive Quantitative Buffy Coat method (QBC MP) or thin blood smear examination (Giemsa stain). Platelet counts were measured using Coulter LH 756 Analyser. Thrombocytopenia was defined as a platelet count <150×10(9)/l.

RESULTS

A total of 131 consecutive patients were included. Sixty patients (46%) were infected with Plasmodium vivax and the rest with Plasmodium falciparum. Forty-six (35%) patients had non-severe and 24 (18%) had severe falciparum infection. The prevalence of thrombocytopenia was similar in vivax and falciparum malaria. Patients with severe falciparum malaria had a statistically significant lower platelet count (P = 0·01) compared to non-severe falciparum malaria. Severe malaria patients with renal failure (P = 0·02) or hyperparasitaemia (P = 0·03) had a statistically significant lower mean platelet count compared to non-severe falciparum malaria. Patients with involvement of more than one organ system had a lower mean platelet count compared to those with single organ involvement.

CONCLUSIONS

The incidence of thrombocytopenia was similar in vivax and falciparum malaria. The admission platelet count is significantly lower in patients who have hyperparasitaemia and acute renal failure compared to patients without complications.

Cytokine profiles in children with severe Plasmodium falciparum malaria in an area of unstable malaria transmission in central Sudan

BACKGROUND

Few data exist concerning pathogenesis of severe malaria in areas of unstable malaria transmission.

OBJECTIVES

The study was conducted in Senga hospital, central Sudan, which is characterized by unstable malaria transmission to investigate the cytokine profiles in children with severe Plasmodium falciparum malaria.

METHODS

Enzyme-linked immunosorbent assay was used to measure the concentrations of three cytokines, interferon gamma (IFN-γ), interleukin-4 (IL-4) and IL-10, in sera of three groups of children (31 in each arm): those with one or more manifestations of severe malaria, those children with uncomplicated P. falciparum malaria and healthy controls.

RESULTS

The levels of both IFN-γ and IL-10 were significantly higher in patients with severe P. falciparum malaria. Medium positive correlations were observed between IFN-γ and IL-10.

CONCLUSION

Thus, the high levels of both IFN-γ and IL-10 indicated their role in the pathogenesis of severe P. falciparum malaria.

Changes in sexual desires and behaviours of people living with HIV after initiation of ART: implications for HIV prevention and health promotion

BACKGROUND

As immune compromised HIV sero-positive people regain health after initiating antiretroviral treatment (ART), they may seek a return to an active 'normal' life, including sexual activity. The aim of the paper is to explore the changing sexual desires and behaviour of people on ART in Uganda over a 30 month period.

METHODS

This study employed longitudinal qualitative interviews with forty people starting ART. The participants received their ART, adherence education and counselling support from The AIDS Support Organisation (TASO). The participants were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic or home-based) and HIV progression stage (early or advanced) and interviewed at enrolment, 3, 6, 18 and 30 months of their ART use.

RESULTS

Sexual desire changed over time with many reporting diminished desire at 3 and 6 months on ART compared to 18 and 30 months of use. The reasons for remaining abstinent included fear of superinfection or infecting others, fear that engaging in sex would awaken the virus and weaken them and a desire to adhere to the counsellors' health advice to remain abstinent. The motivations for resumption of sexual activity were: for companionship, to obtain material support, social norms around marriage, desire to bear children as well as to satisfy sexual desires. The challenges for most of the participants were using condoms consistently and finding a suitable sexual partner (preferably someone with a similar HIV serostatus) who could agree to have a sexual relationship with them and provide for their material needs.

CONCLUSIONS

These findings point to the importance of tailoring counselling messages to the changing realities of the ART users' cultural expectations around child bearing, marriage and sexual desire. People taking ART require support so they feel comfortable to disclose their HIV status to sexual partners.

Lack of evidence of myocardial damage in children with Plasmodium falciparum severe and complicated malaria from an endemic area for endomyocardial fibrosis

Malaria is among the factors thought to be involved in the pathogenesis of endomyocardial fibrosis (EMF), a restrictive cardiomyopathy of unclear etiology, with no specific therapy, which affects predominantly children and adolescents. In Africa, regions endemic with EMF are also areas with high prevalence of malaria. We studied 47 consecutive children aged 5- to 15-years old and concluded that myocardial damage and dysfunction are rare in severe and complicated Plasmodium falciparum malaria cases in children.

Efficacy and effectiveness of artemether-lumefantrine after initial and repeated treatment in children <5 years of age with acute uncomplicated Plasmodium falciparum malaria in rural Tanzania: a randomized trial

BACKGROUND

We assessed the efficacy, effectiveness and safety of artemether-lumefantrine, which is the most widely used artemisinin-based combination therapy in Africa, against Plasmodium falciparum malaria during an extended follow-up period after initial and repeated treatment.

METHODS

We performed an open-label randomized trial of artemether-lumefantrine with supervised (n=180) and unsupervised intake (n=179) in children <5 years of age with uncomplicated falciparum malaria in rural Tanzania. Recurrent infections between day 14 and day 56 were retreated within the same study arm. Main end points were polymerase chain reaction (PCR)-corrected cure rates by day 56 and day 42 after initial and repeated treatment, respectively, as estimated by survival analysis.

RESULTS

The PCR-corrected cure rate after initial treatment was 98.1% (95% confidence interval [CI], 94.2%-99.4%) after supervised and 95.1% (95% CI, 90.7%-98.1%) after unsupervised intake (P=.29). After retreatment of recurrent infections, the cure rates were 92.9% (95% CI, 81.8%-97.3%) and 97.6% (95% CI, 89.3%-98.8%), respectively (P=.58). Reinfections occurred in 46.9% (82 of 175) versus 50.9 % of the patients (relative risk [RR], 0.92 [95% CI, 0.74-1.14]; P=.46) after initial therapy and 32.4% (24 of 74) versus 39.0% (32 of 82) (RR, 0.83 [95% CI, 0.54-1.27]; P=.39) after retreatment. Median blood lumefantrine concentrations in supervised and unsupervised patients on day 7 were 304 versus 194 ng/mL (P<.001) after initial treatment and 253 versus 164 ng/mL (P=.001) after retreatment. Vomiting was the most commonly reported drug-related adverse event (in 1% of patients) after both initial and repeated treatment.

CONCLUSIONS

Artemether-lumefantrine was highly efficacious even after unsupervised administration, despite significantly lower lumefantrine concentrations, compared with concentration achieved with supervised intake, and was well-tolerated and safe after initial and repeated treatment.

CLINICAL TRIAL REGISTRATION

ISRCTN69189899.

Vitamin A supplementation for reducing the risk of mother-to-child transmission of HIV infection

BACKGROUND

Observational studies of pregnant women in sub-Saharan Africa have shown that low serum vitamin A levels are associated with an increased risk of mother-to-child transmission (MTCT) of HIV. Vitamin A is cheap and easily provided through existing health services in low-income settings. It is thus important to determine the effect of routine supplementation of HIV positive pregnant or breastfeeding women with this vitamin on the risk of MTCT of HIV, which currently results in more than 1000 new HIV infections each day world-wide.

OBJECTIVES

We aimed to assess the effect of antenatal and or postpartum vitamin A supplementation on the risk of MTCT of HIV as well as infant and maternal mortality and morbidity.

SEARCH STRATEGY

In June 2010 we searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, AIDS Education Global Information System, and WHO International Clinical Trials Registry Platform; and checked reference lists of identified articles for any studies published after the earlier version of this review was updated in 2008.

SELECTION CRITERIA

We selected randomised controlled trials conducted in any setting that compared vitamin A supplementation with placebo in known HIV-infected pregnant or breastfeeding women.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed trial eligibility and quality and extracted data. We calculated relative risks (RR) or mean differences (MD), with their 95% confidence intervals (CI) for each study. We conducted meta-analysis using a fixed-effects method (when there was no significant heterogeneity between study results, i.e. P>0.1) or the random-effects method (when there was significant heterogeneity), and report the Higgins' statistic for all pooled effect measures.

MAIN RESULTS

Five randomised controlled trials which enrolled 7,528 HIV-infected women (either during pregnancy or the immediate postpartum period) met our inclusion criteria. These trials were conducted in Malawi, South Africa, Tanzania, and Zimbabwe between 1995 and 2005. We combined the results of these trials and found no evidence that vitamin A supplementation has an effect on the risk of MTCT of HIV (4 trials, 6517 women: RR 1.04, 95% CI 0.87 to 1.24; I(2)=68%). However, antenatal vitamin A supplementation significantly improved birth weight (3 trials, 1809 women: MD 89.78, 95%CI 84.73 to 94.83; I(2)=33.0%), but there was no evidence of an effect on preterm births (3 trials, 2110 women: RR 0.88, 95%CI 0.65 to 1.19; I(2)=58.1%), stillbirths (4 trials, 2855 women: RR 0.99, 95%CI 0.68 to 1.43; I(2)=0%), deaths by 24 months (2 trials, 1635 women: RR 1.03, 95%CI 0.88 to 1.20; I(2)=0%), postpartum CD4 levels (1 trial, 727 women: MD -4.00, 95% CI -51.06 to 43.06), and maternal death ( 1 trial, 728 women: RR 0.49, 95%CI 0.04 to 5.37).

AUTHORS' CONCLUSIONS

Current best evidence shows that antenatal or postpartum vitamin A supplementation probably has little or no effect on mother-to-child transmission of HIV. According to the GRADE classification, the quality of this evidence is moderate; implying that the true effect of vitamin A supplementation on the risk of mother-to-child transmission of HIV is likely to be close to the findings of this review, but that there is also a possibility that it is substantially different.

The age patterns of severe malaria syndromes in sub-Saharan Africa across a range of transmission intensities and seasonality settings

Background

A greater understanding of the relationship between transmission intensity, seasonality and the age-pattern of malaria is needed to guide appropriate targeting of malaria interventions in different epidemiological settings.

Methods

A systematic literature review identified studies which reported the age of paediatric hospital admissions with cerebral malaria (CM), severe malarial anaemia (SMA), or respiratory distress (RD). Study sites were categorized into a 3 × 2 matrix of Plasmodium falciparum transmission intensity and seasonality. Probability distributions were fitted by maximum likelihood methods, and best fitting models were used to estimate median ages and to represent graphically the age-pattern of each outcome for each transmission category in the matrix.

Results

A shift in the burden of CM towards younger age groups was seen with increasing intensity of transmission, but this was not the case for SMA or RD. Sites with 'no marked seasonality' showed more evidence of skewed age-patterns compared to areas of 'marked seasonality' for all three severe malaria syndromes.

Conclusions

Although the peak age of CM will increase as transmission intensity decreases in Africa, more than 75% of all paediatric hospital admissions of severe malaria are likely to remain in under five year olds in most epidemiological settings.

Factors that predict fertility desires for people living with HIV infection at a support and treatment centre in Kabale, Uganda

Background

Studies from different contexts worldwide indicate that HIV positive patients manifest high-risk sexual behavior characterized by fertility intentions, multiple sexual partners, non-use of contraceptives and non-disclosure of HIV status to their sex partners. The objective was to analyze fertility desires among persons living with HIV at a treatment centre in Kabale Hospital, Southwestern Uganda.

Methods

From January to August 2009, we interviewed 400 HIV positive patients seeking care using an interviewer-administered questionnaire. We assessed socio-demographic variables, reproductive history, sexuality and fertility desires. At bivariate and multivariate analysis, characteristics of participants who reported or did not report desire to have a child in the near future were compared.

Results

Of the 400 respondents, (25.3%) were male, 47.3% were aged 25-34 years, over 85% were currently married or had ever been married, and the 62% had primary level of education or less. Over 17% had produced a child since the HIV diagnosis was made, and 28.6% reported that they would like to have a child in the near future. Age of the respondent, being single (versus being ever-married) and whether any of the respondents' children had died were inversely associated with fertility intentions.

Conclusion

Factors inversely associated with fertility intentions were age of the respondent, marital status and whether any of the respondents' children had died. Use of antiretroviral therapy was not associated with fertility intentions.

Malaria outbreak among French army troops returning from the Ivory Coast

In 2006, a French Army unit reported 39 malaria cases among service persons returning from Ivory Coast. Thirty, including three serious forms, occurred after the return to France. The risk of post-return malaria was higher than the risk in Ivory Coast. Half of the imported cases had stopped post-return chemoprophylaxis early.

Critical care aspects of malaria

Malaria remains a major health problem in much of Asia and Africa. A steady number of cases of imported malaria are also seen in many countries of the developed world. Plasmodium falciparum malaria and to some extent malaria caused by other species of Plasmodium can lead to many complications such as acute respiratory distress syndrome (ARDS), cerebral malaria, acute renal failure, severe anemia, thrombocytopenia, and bleeding complications. About 10% of patients with severe malaria die, usually as a result of multiorgan dysfunction. Critical care physicians should be aware of the complications and management of severe malaria. There has been significant progress in the understanding of pathogenesis of severe malaria over the last decade. Effective management of severe malaria includes early suspicion, prompt diagnosis, early institution of appropriate antimalarial chemotherapy, and supportive care, preferably in an intensive care unit. In this article, we review the different manifestations of severe malaria as relevant to critical care physicians and discuss the principles of laboratory diagnosis and management.

Plasmodium knowlesi malaria in humans is widely distributed and potentially life threatening

BACKGROUND

Until recently, Plasmodium knowlesi malaria in humans was misdiagnosed as Plasmodium malariae malaria. The objectives of the present study were to determine the geographic distribution of P. knowlesi malaria in the human population in Malaysia and to investigate 4 suspected fatal cases.

METHODS

Sensitive and specific nested polymerase chain reaction was used to identify all Plasmodium species present in (1) blood samples obtained from 960 patients with malaria who were hospitalized in Sarawak, Malaysian Borneo, during 2001-2006; (2) 54 P. malariae archival blood films from 15 districts in Sabah, Malaysian Borneo (during 2003-2005), and 4 districts in Pahang, Peninsular Malaysia (during 2004-2005); and (3) 4 patients whose suspected cause of death was P. knowlesi malaria. For the 4 latter cases, available clinical and laboratory data were reviewed.

RESULTS

P. knowlesi DNA was detected in 266 (27.7%) of 960 of the samples from Sarawak hospitals, 41 (83.7%) of 49 from Sabah, and all 5 from Pahang. Only P. knowlesi DNA was detected in archival blood films from the 4 patients who died. All were hyperparasitemic and developed marked hepatorenal dysfunction.

CONCLUSIONS

Human infection with P. knowlesi, commonly misidentified as the more benign P. malariae, are widely distributed across Malaysian Borneo and extend to Peninsular Malaysia. Because P. knowlesi replicates every 24 h, rapid diagnosis and prompt effective treatment are essential. In the absence of a specific routine diagnostic test for P. knowlesi malaria, we recommend that patients who reside in or have traveled to Southeast Asia and who have received a "P. malariae" hyperparasitemia diagnosis by microscopy receive intensive management as appropriate for severe falciparum malaria.

Allelic polymorphism of MSP2 gene in severe P. falciparum malaria in an area of low and seasonal transmission

The severe malaria (SM) and uncomplicated malaria (UM) infections are expected to have different genetic makeup. In this study, blood samples were obtained from 325 donors with SM and UM and malaria-free donors (including asymptomatic submicroscopic malaria--ASUM), from Eastern Sudan. The SM group included patients with cerebral malaria (CM), severe malarial anemia (SMA), and other complications. The MSP2 locus was exploited for parasite genotyping. We found that the genetic diversity of the parasite population was marked (51 genotypes). The overall multiplicity of infection (MOI) was 1.5, and it was comparable between SM and UM. However, the MOI in ASUM (1.0) and fatal CM (1.14) was comparable and significantly lower than in UM (1.53), SMA (1.52), and nonfatal CM (1.7). The ratio of the IC1 to FC27 allele families was comparable between SM and UM, and the distribution of the allele sizes was correlated (correlation coefficient = 0.59 and 0.718; P < 0.001). It is interesting to note that the FC27 genotype was overrepresented in ASUM (68.2%) and was not recognized in fatal CM, while in mixed-clone infections, the clearance of IC1 after quinine treatment was faster than FC27 clearance. Finally, the composition of the multiclone infections (IC1 and FC27) was suggesting a stronger cross-immunity within rather than between MSP2 gene families.

Dihydroartemisinin-piperaquine versus artesunate-amodiaquine: superior efficacy and posttreatment prophylaxis against multidrug-resistant Plasmodium falciparum and Plasmodium vivax malaria

BACKGROUND

Antimalarial drug resistance is now well established in both Plasmodium falciparum and Plasmodium vivax. In southern Papua, Indonesia, where both strains of plasmodia coexist, we have been conducting a series of studies to optimize treatment strategies.

METHODS

We conducted a randomized trial that compared the efficacy and safety of dihydroartemisinin-piperaquine (DHP) with artesunate-amodiaquine (AAQ). The primary end point was the overall cumulative parasitological failure rate at day 42.

RESULTS

Of the 334 patients in the evaluable patient population, 185 were infected with P. falciparum, 80 were infected with P. vivax, and 69 were infected with both species. The overall parasitological failure rate at day 42 was 45% (95% confidence interval [CI], 36%-53%) for AAQ and 13% (95% CI, 7.2%-19%) for DHP (hazard ratio [HR], 4.3; 95% CI, 2.5-7.2; P<.001). Rates of both recrudescence of P. falciparum infection and recurrence of P. vivax infection were significantly higher after receipt of AAQ than after receipt of DHP (HR, 3.4 [95% CI, 1.2-9.4] and 4.3 [95% CI, 2.2-8.2], respectively; P<.001). By the end of the study, AAQ recipients were 2.95-fold (95% CI, 1.2- to 4.9-fold) more likely to be anemic and 14.5-fold (95% CI, 3.4- to 61-fold) more likely to have carried P. vivax gametocytes.

CONCLUSIONS

DHP was more effective and better tolerated than AAQ against multidrug-resistant P. falciparum and P. vivax infections. The prolonged therapeutic effect of piperaquine delayed the time to P. falciparum reinfection, decreased the rate of recurrence of P. vivax infection, and reduced the risk of P. vivax gametocyte carriage and anemia.

von Willebrand factor propeptide in malaria: evidence of acute endothelial cell activation

The pathogenicity of Plasmodium falciparum is thought to relate to the unique ability of infected erythrocytes to adhere to and subsequently activate the vascular endothelium. To study the state of endothelial activation during falciparum malaria, we measured plasma levels of both von Willebrand factor (VWF) and its propeptide, indices of chronic and acute endothelial cell perturbation, respectively. Results were correlated with clinical and biochemical markers of disease severity, including plasma lactate. Our data show that acute endothelial cell activation is a hallmark of malaria in children, indicated by a significant rise in VWF and VWF propeptide. The highest VWF and propeptide levels were seen in cerebral and non-cerebral severe malaria, and associations found between VWF propeptide level and lactate (P < 0.001). Mean VWF propeptide levels (nmol/l) were in cerebral malaria 33.4, non-cerebral severe malaria 26.3, mild malaria 22.1, non-malaria febrile illness 10.2, and controls 10.1. Differences between patient and control groups were highly significant (P < 0.005). Follow-up of 26 cerebral malaria cases showed that levels of VWF propeptide, but not VWF fell by 24 h, following the clinical course of disease and recovery. These novel findings potentially implicate acute, regulated exocytosis of endothelial cell Weibel-Palade bodies in the pathogenesis of Plasmodium falciparum malaria.

Severe malaria in children in areas with low, moderate and high transmission intensity in Uganda

OBJECTIVES

Age and transmission intensity are known to influence the manifestations of severe falciparum malaria in African children. However, it is unclear how specific clinical features such as seizures, impairment of consciousness, or respiratory distress vary with the parasite load and transmission intensity. We examined how the peripheral parasite load varies with transmission intensity and how this influences the symptoms and manifestations of severe malaria in children under 5 years in three areas with different malaria transmission intensity across Uganda.

METHODS

We consecutively recruited 617 children with severe malaria presenting to three hospitals in areas with very low (51), moderate (367) and very high (199) transmission intensities and compared the age, admission parasite density and proportions of patients with different manifestations of severe disease.

RESULTS

The median age (months) was inversely proportional to transmission intensity and declined with rising transmission (26.4 in very low, 18.0 in moderate and 9.0 under very high transmission). The highest proportion of patients reporting previous malaria admissions came from the area with moderate transmission. The geometric mean parasite density (18,357, 32,508 and 95,433/microl) and the proportion of patients with seizures (13.7%, 36.8% and 45.7%, P < 0.001) from very low, moderate and very high transmission respectively, increased with rising transmission. A linear increase with transmission was also observed in the proportion of those with repeated seizures (9.8%, 13.4% and 30.2%, P < 0.001) or impaired consciousness (7.8%, 12.8% and 18.1%, P = 0.029) but not respiratory distress. The proportion of patients with severe anaemia (19.6%, 24.8% and 37.7%, P = 0.002) mirrored that of patients with seizures.

CONCLUSIONS

These findings suggest that heavy Plasmodium falciparum parasitaemia may be important in development of seizures, severe malarial anaemia and impaired consciousness in children under 5 years of age but may not be important in the development of respiratory distress.

Increased prevalence of severe malaria in HIV-infected adults in South Africa

BACKGROUND

Conflicting reports exist regarding the impact of human immunodeficiency virus (HIV) infection on the risk of severe malaria. We aimed to assess the effect of HIV infection status, advancing immunosuppression, and antimalarial immunity on the severity of malaria.

METHODS

A prospective cohort study was conducted. Consecutive hospitalized adult patients with falciparum malaria were tested for HIV antibodies and to determine CD4+ T cell count. Immunity to malaria was assessed by obtaining a history of childhood residence in an area where malaria is endemic. Patients were assessed for features of severe malaria.

RESULTS

Three hundred thirty-six patients were enrolled in the study, of whom 32 (10%) had severe malaria. The prevalence of HIV infection was 33%, and 111 patients (33%) were nonimmune to malaria. HIV-infected patients complained more frequently about respiratory and abdominal symptoms and less frequently about rigors and headache. Risk factors for severe malaria determined by multivariate analysis included being nonimmune to malaria, having a positive HIV serostatus, having an elevated parasite count, and having an increased white blood cell count. Risk of severe malaria was increased in HIV-infected patients with a CD4+ T cell count of < 200 x 10(6) cells/L (P < or = .001). Nonimmune HIV-infected patients were significantly more likely to have severe malaria (13 [36%] of 36 patients) than were nonimmune non-HIV-infected patients (9 [12%] of 75 patients; odds ratio, 4.15 [95% confidence interval, 1.57-10.97]; P = .003). HIV serostatus did not affect risk of severe malaria in the group from an area with endemicity (5 [7%] of 74 HIV-infected patients had severe malaria, and 5 [3%] of 151 non-HIV-infected patients had malaria; P = .248).

CONCLUSIONS

HIV-infected nonimmune adults are at increased risk of severe malaria. This risk is associated with a low CD4+ T cell count. This interaction is of great public health importance.

Vaginal disinfection for preventing mother-to-child transmission of HIV infection

BACKGROUND

Mother-to-child transmission (MTCT) of HIV infection is one of the most tragic consequences of the HIV epidemic, especially in resource-limited countries, resulting in about 650 000 new paediatric HIV infections each year worldwide. The paediatric HIV epidemic threatens to seriously undermine decade-old child survival programmes.

OBJECTIVES

To estimate the effect of vaginal disinfection on the risk of MTCT of HIV and infant and maternal mortality and morbidity, as well as tolerability of vaginal disinfection in HIV-infected women.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, Cochrane Pregnancy and Childbirth Register, PubMed, EMBASE, AIDSLINE, LILACS, AIDSTRIALS, and AIDSDRUGS, using standardised methodological filters for identifying trials. We also searched reference lists of identified articles, relevant editorials, expert opinions and letters to journal editors, and abstracts and proceedings of relevant conferences, and contacted subject experts and pharmaceutical companies. There were no language restrictions.

SELECTION CRITERIA

Randomised trials or clinical trials comparing vaginal disinfection during labour with placebo or no treatment, in known HIV-infected pregnant women. Trials had to include an estimate of the effect of vaginal disinfection on MTCT of HIV and or infant and maternal mortality and morbidity.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial eligibility and quality, and extracted data. Meta-analysis was performed using the Yusuf-Peto modification of Mantel-Haenszel's fixed effect method.

MAIN RESULTS

Only two trials that included 708 patients met the inclusion criteria. The effect of vaginal disinfection on the risk of MTCT of HIV (OR 0.93, 95% CI 0.65 to 1.33), neonatal death (OR 1.38, 95% CI 0.30 to 6.33), and death after the neonatal period (OR 1.45, 95% CI 0.47 to 4.45) is uncertain. There was no evidence that vaginal disinfection increased adverse effects in mothers (OR 1.15, 95% CI 0.41 to 3.22), and evidence from one trial showed that adverse effects decreased in neonates (OR 0.14, 95% CI 0.07 to 0.31).

AUTHORS' CONCLUSIONS

Currently, there is no evidence of an effect of vaginal disinfection on the risk of MTCT of HIV. Given its simplicity and low cost, there is need for a large well-designed and well-conducted randomised controlled trial to assess the additive effect of vaginal disinfection on the risk of MTCT of HIV in antiretroviral treated women.

Vitamin A supplementation for reducing the risk of mother-to-child transmission of HIV infection

BACKGROUND

Mother-to-child transmission (MTCT) of HIV is the dominant mode of acquisition of HIV infection for children, currently resulting in more than 2000 new paediatric HIV infections each day worldwide.

OBJECTIVES

To assess the effects of antenatal and intrapartum vitamin A supplementation on the risk of MTCT of HIV infection and infant and maternal mortality and morbidity, and the tolerability of vitamin A supplementation.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, AIDSLINE, LILACS, AIDSTRIALS, and AIDSDRUGS, using standardised methodological filters for identifying trials. We also searched reference lists of identified articles, relevant editorials, expert opinions and letters to journal editors, and abstracts or proceedings of relevant conferences; and contacted subject experts, agencies, organisations, academic centres, and pharmaceutical companies. There were no language restrictions.

SELECTION CRITERIA

Randomised trials comparing vitamin A supplementation with no vitamin A supplementation in known HIV infected pregnant women. Trials had to include an estimate of the effect of vitamin A supplementation on MTCT of HIV and or any other adverse pregnancy outcome to be included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and quality and extracted data. Effect measures (odds ratio [OR] for binary variables and weighted mean difference [WMD] for continuous variables) with their 95% confidence intervals (CI) were estimated for each study and combined using the fixed effect (Mantel-Haenszel) method, by intention to treat. Heterogeneity between studies was examined by graphical inspection of results followed by a chi-square test of homogeneity.

MAIN RESULTS

Four trials, which enrolled 3,033 HIV-infected pregnant women, are included in this review. There was no evidence of an effect of vitamin A supplementation on MTCT of HIV infection (OR 1.14, 95% CI 0.93 to 1.38). There was evidence of heterogeneity between the three trials with information on MTCT of HIV (I(2) =75.7%, P=0.02). While the trials conducted in South Africa (OR 0.98, 95% CI 0.67 to 1.42 at three months) and Malawi (OR 0.78, 95% CI 0.53 to 1.15 at 24 months) did not find evidence that the effect of Vitamin A supplementation was different from that of placebo, the trial in Tanzania did find evidence that vitamin A supplementation increased the risk of MTCT of HIV (OR 1.53, 95% CI 1.15 to 2.04 at 24 months). Vitamin A supplementation significantly improved birth weight (WMD 89.78, 95% CI 84.73 to 94.83), but there was no evidence of an effect of vitamin A supplementation on stillbirths (OR 0.99, 95% CI 0.67 to 1.46), preterm births (OR 0.89, 95% CI 0.71 to 1.11), death by 24 months among live births (OR 1.11, 95% CI 0.88 to 1.40), postpartum CD4 levels (WMD -4.00, 95% CI -51.06 to 43.06), and maternal death (OR 0.49, 95%CI 0.04 to 5.40).

IMPLICATIONS FOR PRACTICE

Currently available evidence do not support the use of vitamin A supplementation of HIV-infected pregnant women to reduce MTCT of HIV, though there is an indication that vitamin A supplementation improves birth weight.

IMPLICATIONS FOR RESEARCH

The awaited publication of data from a large trial involving 4,495 HIV infected pregnant women in Harare (Zimbabwe Vitamin A for Mothers and Babies Project), will further clarify the effect of vitamin A supplementation on MTCT of HIV. The current review will be updated as soon as the trial is published.

The prognostic value of measures of acid/base balance in pediatric falciparum malaria, compared with other clinical and laboratory parameters

BACKGROUND

Identifying severe, life-threatening falciparum malaria in African children allows for the prompt institution of appropriate management. In the past 2 decades, hyperlactatemia and acidosis have been identified as being associated with mortality in patients with severe malaria, but measurement of blood lactate concentration and base excess is expensive and technically demanding. In this large, prospective study, we examined the prognostic value of acidosis and hyperlactatemia and compared these markers to clinically assessed variables.

METHODS

We examined several clinical and laboratory measurements as prognostic markers of mortality in 14,605 parasitemic children admitted to 3 hospitals in Africa. Whole-blood lactate concentration and acid/base status were used to identify subjects who had hyperlactatemia and acidosis.

RESULTS

Using cut-points established by sensitivity and specificity curves, the sensitivities and positive predictive values for both lactate concentration and base excess were low, the specificities were moderate, and the negative predictive values were high (>97%). No reliable clinical surrogates for hyperlactatemia or acidosis were identified. Addition of lactate concentration and base excess to predictive models with previously identified clinical features (Blantyre Coma Score, deep breathing, prostration, and weight-for-age Z score) and 1 laboratory measure (blood glucose level) did not appreciably improve models to predict mortality.

CONCLUSIONS

Measurements of lactate concentration and acid/base balance are expensive to perform, and performance of the latter can be problematic. Severe falciparum malaria may be readily recognized in children at admission to hospitals in sub-Saharan Africa with use of simple, inexpensive means and does not require knowledge of lactate concentration and base excess.