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Xia FW, Guo BW, Zhao Y, Wang JL, Chen Y, Pan X, Li X, Song JX, Wan Y, Feng S, Wu MY. Type I Photosensitizer Targeting Glycans: Overcoming Biofilm Resistance by Inhibiting the Two-Component System, Quorum Sensing, and Multidrug Efflux. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2309797. [PMID: 37973189 DOI: 10.1002/adma.202309797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/03/2023] [Indexed: 11/19/2023]
Abstract
Stubborn biofilm infections pose serious threats to human health due to the persistence, recurrence, and dramatically magnified antibiotic resistance. Photodynamic therapy has emerged as a promising approach to combat biofilm. Nevertheless, how to inhibit the bacterial signal transduction system and the efflux pump to conquer biofilm recurrence and resistance remains a challenging and unaddressed issue. Herein, a boric acid-functionalized lipophilic cationic type I photosensitizer, ACR-DMP, is developed, which efficiently generates •OH to overcome the hypoxic microenvironment and photodynamically eradicates methicillin-resistant Staphylococcus aureus (MRSA) and biofilms. Furthermore, it not only alters membrane potential homeostasis and osmotic pressure balance due to its strong binding ability with plasma membrane but also inhibits quorum sensing and the two-component system, reduces virulence factors, and regulates the activity of the drug efflux pump attributed to the glycan-targeting ability, helping to prevent biofilm recurrence and conquer biofilm resistance. In vivo, ACR-DMP successfully obliterates MRSA biofilms attached to implanted medical catheters, alleviates inflammation, and promotes vascularization, thereby combating infections and accelerating wound healing. This work not only provides an efficient strategy to combat stubborn biofilm infections and bacterial multidrug resistance but also offers systematic guidance for the rational design of next-generation advanced antimicrobial materials.
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Affiliation(s)
- Feng-Wei Xia
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Bing-Wei Guo
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Yu Zhao
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Jia-Li Wang
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Yuan Chen
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Xiu Pan
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Xin Li
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Jia-Xing Song
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Yu Wan
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Shun Feng
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Ming-Yu Wu
- Sichuan Engineering Research Center for Biomimetic Synthesis of Natural Drugs, School of Life Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
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Arshad AR, Ijaz F, Siddiqui MS, Khalid S, Fatima A, Aftab RK. COVID-19 pandemic and antimicrobial resistance in developing countries. Discoveries (Craiova) 2021; 9:e127. [PMID: 34754900 PMCID: PMC8570918 DOI: 10.15190/d.2021.6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/23/2021] [Accepted: 05/08/2021] [Indexed: 12/23/2022] Open
Abstract
A wide range of antimicrobial agents were touted as potential remedies during the COVID-19 pandemic. While both developed and developing countries have recorded an increase in the use of antimicrobial drugs, use and misuse have occurred to a far greater degree in developing countries. This can have deleterious consequences on antimicrobial resistance, especially when various developing countries have already reported the emergence of various drug-resistant organisms even before the pandemic. Telemedicine services, societal and cultural pressures, and bacterial co-infections can predispose to overwhelming antimicrobial prescriptions. The emergence of new multidrug resistance species is a major concern for the developing world especially since health services are already overburdened and lack the diagnostic capabilities and basic amenities for infection prevention and control. This can lead to outbreaks and the rampant spread of such microorganisms. Improper waste management and disposal from hospitals and communities establish freshwater runoffs as hubs of various microorganisms that can predispose to the rise of multidrug-resistant species. Microplastics' ability to act as vectors for antibiotic-resistant organisms is also particularly concerning for lower-middle-income countries. In this review, we aim to study the impact of antimicrobial use during the COVID-19 pandemic and antimicrobial resistance in lower middle-income countries, by understanding various determinants of resistance unique to the developing world and exploring solutions to combat the problem.
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Affiliation(s)
- Abdul Rehman Arshad
- CMH Lahore Medical College and Institute of Dentistry, Abdur Rehman Road, Cantt, Lahore, Pakistan
| | - Farhat Ijaz
- CMH Lahore Medical College and Institute of Dentistry, Abdur Rehman Road, Cantt, Lahore, Pakistan
| | - Mishal Shan Siddiqui
- Dow Medical College, Dow University of Health Sciences, Mission Road, New Labour Colony Nankwara, Karachi, Pakistan
| | - Saad Khalid
- Dow Medical College, Dow University of Health Sciences, Mission Road, New Labour Colony Nankwara, Karachi, Pakistan
| | - Abeer Fatima
- Dow Medical College, Dow University of Health Sciences, Mission Road, New Labour Colony Nankwara, Karachi, Pakistan
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Buchek G, Mende K, Telu K, Kaiser S, Fraser J, Mitra I, Stam J, Lalani T, Tribble D, Yun HC. Travel-associated multidrug-resistant organism acquisition and risk factors among US military personnel. J Travel Med 2021; 28:6154715. [PMID: 33675647 PMCID: PMC8045176 DOI: 10.1093/jtm/taab028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND International travel is a risk factor for incident colonization with extended spectrum beta-lactamase (ESBL)-producing organisms. These and other multidrug-resistant (MDR) bacteria are major pathogens in combat casualties. We evaluated risk factors for colonization with MDR bacteria in US military personnel travelling internationally for official duty. METHODS TravMil is a prospective observational study enrolling subjects presenting to military travel clinics. We analysed surveys, antimicrobial use data, and pre- and post-travel perirectal swabs in military travellers to regions outside the continental USA, Canada, Western or Northern Europe, or New Zealand, presenting to one clinic from 12/2015 to 12/2017. Recovered Gram-negative isolates underwent identification and susceptibility testing (BD Phoenix). Characteristics of trip and traveller were analysed to determine risk factors for MDR organism colonization. RESULTS 110 trips were planned by 99 travellers (74% male, median age 38 years [IQR 31, 47.25]); 72 trips with returned pre- and post-travel swabs were completed by 64 travellers. Median duration was 21 days (IQR 12.75, 79.5). 17% travelled to Mexico/Caribbean/Central America, 15% to Asia, 57% to Africa and 10% to South America; 56% stayed in hotels and 50% in dormitories/barracks. Travellers used doxycycline (15%) for malaria prophylaxis, 11% took an antibiotic for travellers' diarrhoea (TD) treatment (fluoroquinolone 7%, azithromycin 4%). Incident MDR organism colonization occurred in 8 travellers (incidence density 3.5/1000 travel days; cumulative incidence 11% of trips [95% CI: 4-19%]), all ESBL-producing Escherichia coli. A higher incidence of ESBL-producing E. coli acquisition was associated with travel to Asia (36% vs 7%, P = 0.02) but not with travel to other regions, TD or use of antimicrobials. No relationship was seen between fluoroquinolone or doxycycline exposure and resistance to those antimicrobials. CONCLUSIONS Incident colonization with MDR organisms occurs at a lower rate in this military population compared with civilian travellers, with no identified modifiable risk factors, with highest incidence of ESBL acquisition observed after South Asia travel.
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Affiliation(s)
- Gregory Buchek
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Kalyani Telu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Susan Kaiser
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Indrani Mitra
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Jason Stam
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - David Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Heather C Yun
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Enteric Fever Diagnosis: Current Challenges and Future Directions. Pathogens 2021; 10:pathogens10040410. [PMID: 33915749 PMCID: PMC8065732 DOI: 10.3390/pathogens10040410] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/23/2021] [Accepted: 03/27/2021] [Indexed: 12/21/2022] Open
Abstract
Enteric fever is a life-threatening systemic febrile disease caused by Salmonella enterica serovars Typhi and Paratyphi (S. Typhi and S. Paratyphi). Unfortunately, the burden of the disease remains high primarily due to the global spread of various drug-resistant Salmonella strains despite continuous advancement in the field. An accurate diagnosis is critical for effective control of the disease. However, enteric fever diagnosis based on clinical presentations is challenging due to overlapping symptoms with other febrile illnesses that are also prevalent in endemic areas. Current laboratory tests display suboptimal sensitivity and specificity, and no diagnostic methods are available for identifying asymptomatic carriers. Several research programs have employed systemic approaches to identify more specific biomarkers for early detection and asymptomatic carrier detection. This review discusses the pros and cons of currently available diagnostic tests for enteric fever, the advancement of research toward improved diagnostic tests, and the challenges of discovering new ideal biomarkers and tests.
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5
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Fischer PR. Editorial. Paediatr Int Child Health 2021; 41:1-2. [PMID: 33843500 DOI: 10.1080/20469047.2021.1872262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Philip R Fischer
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA and Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, UAE., Minnesota
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Wilder-Smith A, Osman S. Public health emergencies of international concern: a historic overview. J Travel Med 2020; 27:6025447. [PMID: 33284964 PMCID: PMC7798963 DOI: 10.1093/jtm/taaa227] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 12/19/2022]
Abstract
RATIONALE The International Health Regulations (IHR) have been the governing framework for global health security since 2007. Declaring public health emergencies of international concern (PHEIC) is a cornerstone of the IHR. Here we review how PHEIC are formally declared, the diseases for which such declarations have been made from 2007 to 2020 and justifications for such declarations. KEY FINDINGS Six events were declared PHEIC between 2007 and 2020: the 2009 H1N1 influenza pandemic, Ebola (West African outbreak 2013-2015, outbreak in Democratic Republic of Congo 2018-2020), poliomyelitis (2014 to present), Zika (2016) and COVID-19 (2020 to present). Poliomyelitis is the longest PHEIC. Zika was the first PHEIC for an arboviral disease. For several other emerging diseases a PHEIC was not declared despite the fact that the public health impact of the event was considered serious and associated with potential for international spread. RECOMMENDATIONS The binary nature of a PHEIC declaration is often not helpful for events where a tiered or graded approach is needed. The strength of PHEIC declarations is the ability to rapidly mobilize international coordination, streamline funding and accelerate the advancement of the development of vaccines, therapeutics and diagnostics under emergency use authorization. The ultimate purpose of such declaration is to catalyse timely evidence-based action, to limit the public health and societal impacts of emerging and re-emerging disease risks while preventing unwarranted travel and trade restrictions.
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Affiliation(s)
- Annelies Wilder-Smith
- Global Health and Epidemiology, University of Umea, 901 87 Umea, Sweden.,Heidelberg Institute of Global Health, University of Heidelberg, Im Neuenheimer Feld 365, 6900 Heidelberg, Germany
| | - Sarah Osman
- Global Health and Epidemiology, University of Umea, 901 87 Umea, Sweden
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Qamar FN, Yousafzai MT, Dehraj IF, Shakoor S, Irfan S, Hotwani A, Hunzai MJ, Thobani RS, Rahman N, Mehmood J, Hemlock C, Memon AM, Andrews JR, Luby SP, Garrett DO, Longley AT, Date K, Saha SK. Antimicrobial Resistance in Typhoidal Salmonella: Surveillance for Enteric Fever in Asia Project, 2016-2019. Clin Infect Dis 2020; 71:S276-S284. [PMID: 33258934 PMCID: PMC7705872 DOI: 10.1093/cid/ciaa1323] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinicians have limited therapeutic options for enteric as a result of increasing antimicrobial resistance, and therefore typhoid vaccination is recommended as a preventive measure. As a part of the Surveillance for Enteric Fever in Asia Project (SEAP), we investigated the extent measured the burden of antimicrobial resistance (AMR) among confirmed enteric fever cases in Bangladesh, Nepal, and Pakistan. METHODS From September 2016-September 2019, SEAP recruited study participants of all age groups from its outpatient, inpatient, hospital laboratory, laboratory network, and surgical sites who had a diagnosis of febrile illness that was either suspected or blood culture confirmed for enteric fever. Antimicrobial resistance of isolates was determined by disc diffusion using Clinical and Laboratory Standard Institute cut-off points. We reported the frequency of multidrug resistance (MDR)(resistance to ampicillin, cotrimoxazole, and chloramphenicol), extensive drug resistance (XDR) (MDR plus non-susceptible to fluoroquinolone and any 3rd generation cephalosporins), and fluoroquinolone (FQ) and azithromycin non-susceptibility. RESULTS We enrolled 8,705 blood culture confirmed enteric fever cases: 4,873 (56%) from Bangladesh, 1,602 (18%) from Nepal and 2,230 (26%) from Pakistan. Of these, 7,591 (87%) were Salmonella Typhi and 1114 (13%) were S. Paratyphi. MDR S. Typhi was identified in 17% (701/4065) of isolates in Bangladesh, and 1% (19/1342) in Nepal. In Pakistan, 16 % (331/2084) of S. Typhi isolates were MDR, and 64% (1319/2074) were XDR. FQ nonsusceptibility among S. Typhi isolates was 98% in Bangladesh, 87% in Nepal, and 95% in Pakistan. Azithromycin non-susceptibility was detected in 77 (2%) in Bangladesh, 9 (.67%) in Nepal and 9 (.59%) isolates in Pakistan. In Pakistan, three (2%) S. Paratyphi isolates were MDR; no MDR S. Paratyphi was reported from Bangladesh or Nepal. CONCLUSIONS Although AMR against S. Paratyphi was low across the three countries, there was widespread drug resistance among S. Typhi, including FQ non-susceptibility and the emergence of XDR S. Typhi in Pakistan, limiting treatment options. As typhoid conjugate vaccine (TCV) is rolled out, surveillance should continue to monitor changes in AMR to inform policies and to monitor drug resistance in S. Paratyphi, for which there is no vaccine.
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Affiliation(s)
- Farah N Qamar
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Mohammad T Yousafzai
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Irum F Dehraj
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sadia Shakoor
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Seema Irfan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muhammad J Hunzai
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rozina S Thobani
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Najeeb Rahman
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Junaid Mehmood
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Caitlin Hemlock
- Applied Epidemiology, Sabin Vaccine Institute, Washington, DC, USA
| | | | - Jason R Andrews
- Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California, USA
| | - Stephen P Luby
- Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California, USA
| | - Denise O Garrett
- Applied Epidemiology, Sabin Vaccine Institute, Washington, DC, USA
| | - Ashley T Longley
- National Foundation for the Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kashmira Date
- National Foundation for the Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Samir K Saha
- Child Health Research Foundation, Department of Microbiology, Dhaka Shishu (Children) Hospital, Bangladesh
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Birabaharan M, Hagmann SHF. Typhoid in U.S. Children: A Need to Understand Prevention Attitudes in South Asian Immigrant Communities. Clin Infect Dis 2020; 73:e2846-e2848. [PMID: 33085748 DOI: 10.1093/cid/ciaa1609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Morgan Birabaharan
- Department of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, La Jolla
| | - Stefan H F Hagmann
- Steven and Alexandra Cohen Children's Medical Center, Northwell Health, Division of Pediatric Infectious Diseases, New Hyde Park, New York, United States.,Donald and Barbara Zucker School of Medicine/Hofstra Northwell, New Hempstead, New York, United States
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Iwu CJ, Jordan P, Jaja IF, Iwu CD, Wiysonge CS. Treatment of COVID-19: implications for antimicrobial resistance in Africa. Pan Afr Med J 2020; 35:119. [PMID: 33282074 PMCID: PMC7687464 DOI: 10.11604/pamj.supp.2020.35.23713] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/19/2020] [Indexed: 12/25/2022] Open
Abstract
There is currently no approved pharmaceutical product for the treatment of COVID-19. However, antibiotics are currently being used for the management of COVID-19 patients in many settings either treat to co-infections or for the treatment of COVID-19 itself. In this commentary, we highlight that the increased rates of antimicrobial prescribing for COVID-19 patients could further worsen the burden of antimicrobial resistance (AMR). We also highlight that though AMR is a global threat, Africa tends to suffer most from the consequences. We, therefore, call on African countries not to lose sight of the possible implications of the treatment of COVID-19 on AMR and a need to redouble efforts towards the fight against AMR while dealing with the pandemic.
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Affiliation(s)
- Chinwe Juliana Iwu
- Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Portia Jordan
- Department of Nursing and Midwifery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ishmael Festus Jaja
- Department of Livestock and Pasture Sciences, Faculty of Science and Agriculture, University of Fort Hare, Alice 5700, South Africa
| | - Chidozie Declan Iwu
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria 0001, South Africa
| | - Charles Shey Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Stellenbosch University, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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