Practising obstetrics and gynaecology in areas with a high prevalence of HIV infection

Effect of Puerperal Infections on Early Neonatal Mortality: A Secondary Analysis of Six Demographic and Health Surveys

Background

Around 1.5 million annual neonatal deaths occur in the first week of life, and infections represent one of the major causes in developing countries. Neonatal sepsis is often strictly connected to infection of the maternal genital tract during labour.

Methods

The association between signs suggestive of puerperal infection and early neonatal mortality (<7 days of life) was performed using Demographic and Health Surveys (DHS) data of six countries, conducted between 2010 and 2013. The population attributable fraction (PAF) was generated using the estimates on early neonatal mortality of a 1990–2013 systematic analysis for the Global Burden of Disease Study.

Results

Signs of puerperal infection ranged from 0.7% in the Philippines to 16.4% in Honduras. Infection was associated with a 2.1 adjusted Risk Ratio (95% CI: 1.4–3.2) of early neonatal mortality. Around five percent of all deaths in the first week of life were attributable to signs suggestive of puerperal infections and varied from 13.9% (95% CI: 1.0–26.6) in Honduras to 3.6% (95% CI: 1.0–8.5) in Indonesia.

Conclusions

Targeted interventions should be addressed to contain the burden of puerperal infections on early neonatal mortality. Consideration of the PAF will help in the discussion of the benefits of antenatal and perinatal measures.

HIV and the risk of direct obstetric complications: a systematic review and meta-analysis

Background

Women of reproductive age in parts of sub-Saharan Africa are faced both with high levels of HIV and the threat of dying from the direct complications of pregnancy. Clinicians practicing in such settings have reported a high incidence of direct obstetric complications among HIV-infected women, but the evidence supporting this is unclear. The aim of this systematic review is to establish whether HIV-infected women are at increased risk of direct obstetric complications.

Methods and findings

Studies comparing the frequency of obstetric haemorrhage, hypertensive disorders of pregnancy, dystocia and intrauterine infections in HIV-infected and uninfected women were identified. Summary estimates of the odds ratio (OR) for the association between HIV and each obstetric complication were calculated through meta-analyses. In total, 44 studies were included providing 66 data sets; 17 on haemorrhage, 19 on hypertensive disorders, five on dystocia and 25 on intrauterine infections. Meta-analysis of the OR from studies including vaginal deliveries indicated that HIV-infected women had over three times the risk of a puerperal sepsis compared with HIV-uninfected women [pooled OR: 3.43, 95% confidence interval (CI): 2.00–5.85]; this figure increased to nearly six amongst studies only including women who delivered by caesarean (pooled OR: 5.81, 95% CI: 2.42–13.97). For other obstetric complications the evidence was weak and inconsistent.

Conclusions

The higher risk of intrauterine infections in HIV-infected pregnant and postpartum women may require targeted strategies involving the prophylactic use of antibiotics during labour. However, as the huge excess of pregnancy-related mortality in HIV-infected women is unlikely to be due to a higher risk of direct obstetric complications, reducing this mortality will require non obstetric interventions involving access to ART in both pregnant and non-pregnant women.

Fate of chemical warfare agents and toxic industrial chemicals in landfills

One component of preparedness for a chemical attack is planning for the disposal of contaminated debris. To assess the feasibility of contaminated debris disposal in municipal solid waste (MSW) landfills, the fate of selected chemical warfare agents (CWAs) and toxic industrial chemicals (TICs) in MSW landfills was predicted with a mathematical model. Five blister agents [sulfur mustard (HD), nitrogen mustard (HN-2), lewisite (L), ethyldichloroarsine (ED), and phosgene oxime (CX)], eight nerve agents [tabun (GA), sarin (GB), soman (GD), GE, GF, VX, VG, and VM], one riot-control agent [CS], and two TICs [furan and carbon disulfide] were studied. The effects of both infiltration (climate) and contaminant biodegradability on fate predictions were assessed. Model results showed that hydrolysis and gas-phase advection were the principal fate pathways for CWAs and TICs, respectively. Apart from CX and the TICs, none of the investigated compounds was predicted to persist in a landfill for more than 5 years. Climate had little impact on CWA/TIC fate, and biodegradability was only important for compounds with long hydrolysis half-lives. Monte Carlo simulations were performed to assess the influence of uncertainty in model input parameters on CWA/TIC fate predictions. Correlation analyses showed that uncertainty in hydrolysis rate constants was the primary contributor to variance of CWA fate predictions, while uncertainty in the Henry's Law constant and landfill gas-production rate accounted for most of the variance of TIC fate predictions. CWA hydrolysates were more persistent than the parent CWAs, but limited information is available on abiotic or biotic transformation rates for these chemicals.

Indoor sorption of surrogates for sarin and related nerve agents

Sorption rate parameters were determined for three organophosphorus (OP) compounds [dimethyl methylphosphonate (DMMP), diethyl ethylphosphonate (DEEP), and triethyl phosphate (TEP)] as surrogates for the G-type nerve agents sarin (GB), soman (GD), and tabun (GA). OP surrogates were injected and vaporized with additional volatile organic compounds into a 50 m3 chamber finished with painted wallboard. Experiments were conducted at two furnishing levels: (i) chamber containing only hard surfaces including a desk, a bookcase, tables, and chairs and (ii) with the addition of plush materials including carpet with cushion, draperies, and upholstered furniture. Each furnishing level was studied with aged and new painted wallboard. Gas-phase concentrations were measured during sealed chamber adsorb and desorb phases and then fit to three mathematical variations of a previously proposed sorption model having a surface sink and allowing for an embedded sink. A four-parameter model allowing unequal transport rates between surface and embedded sinks provided excellent fits for all conditions. To evaluate the potential effect of sorption, this model was incorporated into an indoor air quality simulation model to predict indoor concentrations of a G-type agent and a nonsorbing agent for hypothetical outdoor releases with shelter-in-place (SIP) response. Sorption was simulated using a range of parameters obtained experimentally. Simulations considered outdoor Gaussian plumes of 1- and 5-h duration and infiltration rates of 0.1, 0.3, and 0.9 h(-1). Indoor toxic loads (TL) for a 10-h SIP were calculated as integral C2 dt for a G-type agent. For the 5-h plume, sheltering reduced TLs for the nonsorbing agent to approximately 10-65% of outdoor levels. Analogous TLs for a G-type agent were 2-31% or 0.3-12% of outdoor levels assuming slow or moderate sorption. The relative effect of sorption was more pronounced for the longer plume and higher infiltration rates.

Postpartum maternal morbidity requiring hospital admission in Lusaka, Zambia - a descriptive study

Background

Information on the extent of postpartum maternal morbidity in developing countries is extremely limited. In many settings, data from hospital-based studies is hard to interpret because of the small proportion of women that have access to medical care. However, in those areas with good uptake of health care, the measurement of the type and incidence of complications severe enough to require hospitalisation may provide useful baseline information on the acute and severe morbidity that women experience in the early weeks following childbirth. An analysis of health services data from Lusaka, Zambia, is presented.

Methods

Six-month retrospective review of hospital registers and 4-week cross-sectional study with prospective identification of postpartum admissions.

Results

Both parts of the study identified puerperal sepsis and malaria as, respectively, the leading direct and indirect causes of postpartum morbidity requiring hospital admission. Puerperal sepsis accounted for 34.8% of 365 postpartum admissions in the 6-month period. Malaria and pneumonia together accounted for one-fifth of all postpartum admissions (14.5% & 6% respectively). At least 1.7% of the postpartum population in Lusaka will require hospital-level care for a maternal morbidity.

Conclusions

In developing country urban settings with high public health care usage, meticulous review of hospital registers can provide baseline information on the burden of moderate-to-severe postpartum morbidity.

Safer sex and reproductive choice: findings from "positive women: voices and choices" in Zimbabwe

Positive Women: Voices and Choices was an advocacy-research project developed by the International Community of Women Living with HIV/AIDS to explore the impact of HIV/AIDS on women's sexual and reproductive lives, challenge the violation of their rights and advocate improvements in policy and services. The project in Zimbabwe, the first one in three countries, was carried out from 1998 to 2001. This article presents selected findings from the Zimbabwe research report. It shows that HIV-positive women were unaware they were at risk before an HIV diagnosis, and that gender norms and economic dependence on husbands/partners restricted women's ability to control their sexual and reproductive lives. Prejudices that HIV-positive women should not be sexually active or have children meant women did not disclose their status to health workers, making it difficult for their needs to be acknowledged or addressed. Condom use was considered inappropriate in marriage. Younger childless women wanted to become pregnant, often in spite of previous miscarriage and stillbirths. Women with several children wanted to avoid further pregnancies, and contraceptive and condom use increased markedly after HIV diagnosis, especially among those attending support groups. Safe abortion was almost entirely inaccessible, though technically the law would have permitted it. Better economic opportunities for women, and integrated pregnancy and delivery care, family planning, STI and HIV-related services are needed which take account of HIV-positive women's needs.

Prevalence of HIV with conjunctival squamous cell neoplasia in an African provincial hospital

PURPOSE

To evaluate the prevalence of HIV seropositivity among patients with malignant conjunctival squamous cell carcinoma (SCC) and carcinoma in situ (CIS) and to reassess the potential linkage, albeit well documented, between ocular surface epithelial dysplasia (OSED) and HIV infection.

PATIENTS AND METHODS

A case-control design study was conducted in an African provincial hospital. Twenty-three African black patients underwent excisional biopsy of conjunctival malignant lesions. In 18 of these patients, ELISA for HIV antibodies was performed prior to the excisional biopsy.

RESULTS

Pathological evaluation revealed SCC in 12 (52%) patients, CIS in six (26%) patients, and Kaposi sarcoma (KS) in five (22%) patients. Eighteen patients (78.3%) agreed to take a serological HIV test, and among these, seropositivity for HIV was significantly (p < 0.01) higher (92.3%, 12 of 13) in the SCC/CIS subgroup than in a control group with benign conjunctival lesions (28.5%, two of seven). The most common (91.7%) clinical finding in the SCC/CIS/HIV group (12 patients) was corneal overriding. Conjunctival malignancy was the first presenting sign for AIDS in 50% of our patients.

CONCLUSIONS

A significantly high rate of HIV seropositivity was found in a group of African black patients with conjunctival SCC/CIS compared with a control group with benign conjunctival lesions. The direct correlation between HIV infection and SCC/CIS was reconfirmed in a case-control study. Therefore, an HIV test should probably be performed in cases of conjunctival SCC/CIS or dysplasia, especially among patients in high-risk populations.

The inter-relation of maternal immune competence, HIV-1 viral load, and nutritional status in preventing vertical transmission: an alternative to chemoprophylaxis?

As the human immunodeficiency virus (HIV) global pandemic moves towards the end of its second decade, women of reproductive age throughout the world have been shown to be increasingly at risk for acquiring HIV-1 infection. Recently, the focus for preventive measures has expanded to include preventing the perinatal transmission of HIV-1 to fetuses and newborns. This manuscript reviews the available literature that examines risk factors for perinatal transmission, immunopathogenesis of HIV-1 infection, and the role that antioxidant micronutrients play in modulating immune response to HIV-1 disease progression. The available information provides a compelling case for the design of studies that evaluate the extent to which maternal HIV-1 viremia and disease progression are modulated by her nutritional status. Should results from these studies confirm that antioxidant micronutrient status is inversely related to HIV-1 RNA load, particularly in economically vulnerable populations, carefully designed and executed supplementation trials would be warranted.

The placental barrier to maternal HIV infection

Infection with HIV destroys the immune system and causes acquired immunodeficiency syndrome (AIDS). Death results from common bacterial and opportunistic infections that are rare in persons with a healthy immune system. HIV infection frequently is a fatal sexually transmitted disease that can also be transmitted from an infected mother to her offspring.