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Frallonardo L, Segala FV, Chhaganlal KD, Yelshazly M, Novara R, Cotugno S, Guido G, Papagni R, Colpani A, De Vito A, Barbagallo M, Madeddu G, Babudieri S, Lochoro P, Ictho J, Putoto G, Veronese N, Saracino A, Di Gennaro F. Incidence and burden of long COVID in Africa: a systematic review and meta-analysis. Sci Rep 2023; 13:21482. [PMID: 38057338 PMCID: PMC10700349 DOI: 10.1038/s41598-023-48258-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023] Open
Abstract
Long COVID, also known as "post-acute sequelae of COVID-19," affects at least 65 million individuals worldwide with a wide spectrum of symptoms that may last weeks, months, or permanently. Its epidemiology and burden in Africa are unclear. This meta-analysis examines long-term COVID-19 effects in the WHO African Region. A systematic search in several databases was carried out up to 12 February 2023 including observational studies from African countries reporting the cumulative incidence of long COVID signs and symptoms. Only studies conducted in African countries were included. Several sensitivity and meta-regression analyses were performed. Among 1547 papers initially screened, 25 were included, consisting of 29,213 participants. The incidence of any long COVID symptomatology was 48.6% (95% CI 37.4-59.8) as psychiatric conditions were the most frequent, particularly post-traumatic stress disorder reaching a cumulative incidence of 25% (95% CI 21.1-30.4). Higher age (p = 0.027) and hospitalization (p = 0.05) were associated with a higher frequency of long COVID. Long COVID poses a significant burden in Africa, particularly concerning psychiatric conditions. The study recommends identifying at-risk people and defining treatment strategies and recommendations for African long-COVID patients. High-quality studies addressing this condition in African setting are urgently needed.
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Affiliation(s)
- Luisa Frallonardo
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Francesco Vladimiro Segala
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Kajal D Chhaganlal
- Department of Research, Faculty of Health Sciences, Universidade Catolica de Mocambique, Beira, Mozambique
| | - Mohmaoud Yelshazly
- Department of Research, Faculty of Health Sciences, Universidade Catolica de Mocambique, Beira, Mozambique
| | - Roberta Novara
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Sergio Cotugno
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Giacomo Guido
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy.
| | - Roberta Papagni
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Agnese Colpani
- Unit of Infectious and Tropical Diseases, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Andrea De Vito
- Unit of Infectious and Tropical Diseases, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Mario Barbagallo
- Geriatrics Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Giordano Madeddu
- Unit of Infectious and Tropical Diseases, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Sergio Babudieri
- Unit of Infectious and Tropical Diseases, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | | | | | - Giovanni Putoto
- Operational Research Unit, Doctors with Africa CUAMM, Padua, Italy
| | - Nicola Veronese
- Geriatrics Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - Annalisa Saracino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Francesco Di Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari "Aldo Moro", 70124, Bari, Italy
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Marotta C, Giaquinto C, Di Gennaro F, Chhaganlal KD, Saracino A, Moiane J, Maringhini G, Pizzol D, Putoto G, Monno L, Casuccio A, Vitale F, Mazzucco W. Pathways of care for HIV infected children in Beira, Mozambique: pre-post intervention study to assess impact of task shifting. BMC Public Health 2018; 18:703. [PMID: 29879951 PMCID: PMC5992883 DOI: 10.1186/s12889-018-5646-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/31/2018] [Indexed: 11/25/2022] Open
Abstract
Background In 2013, Mozambique implemented task-shifting (TS) from clinical officers to maternal and child nurses to improve care for HIV positive children < 5 years old. A retrospective, pre-post intervention study was designed to evaluate effectiveness of a new pathway of care in a sample of Beira District Local Health Facilities (LHFs), the primary, local, community healthcare services. Methods The study was conducted by accessing registries of At Risk Children Clinics (ARCCs) and HIV Health Services. Two time periods, pre- and post-intervention, were compared using a set of endpoints. Variables distribution was explored using descriptive statistics. T-student, Mann Whitney and Chi-square tests were used for comparisons. Results Overall, 588 HIV infected children (F = 51.4%) were recruited, 330 belonging to the post intervention period. The mean time from referral to ARCC until initiation of ART decreased from 2.3 (± 4.4) to 1.1 (± 5.0) months after the intervention implementation (p-value: 0.000). A significant increase of Isoniazid prophylaxis (O.R.: 2.69; 95%CI: 1.7–4.15) and a decrease of both regular nutritional assessment (O.R. = 0.45; 95%CI: 0.31–0.64) and CD4 count at the beginning of ART (O.R. = 0.46; 95%CI: 0.32–0.65) were documented after the intervention. Conclusions Despite several limitations and controversial results on nutrition assessment and CD4 count at the initiation of ART reported after the intervention, it could be assumed that TS alone may play a role in the improvement of the global effectiveness of care for HIV infected children only if integrated into a wider range of public health measures.
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Affiliation(s)
- Claudia Marotta
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy.
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | | | - Kajal D Chhaganlal
- Center for Research in Infectious Diseases, Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | | | - Jorge Moiane
- Center for Research in Infectious Diseases, Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | | | - Damiano Pizzol
- Operational Research Unit, Doctors with Africa, Beira, Mozambique
| | - Giovanni Putoto
- Operational Research Unit, Doctors with Africa, Padova, Italy
| | - Laura Monno
- Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Alessandra Casuccio
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
| | - Francesco Vitale
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
| | - Walter Mazzucco
- Department of Science for Health Promotion and Mother to Child Care "G. D'Alessandro", University of Palermo, via del vespro, 133, 90127, Palermo, Italy
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Pizzol D, Di Gennaro F, Chhaganlal KD, Fabrizio C, Monno L, Putoto G, Saracino A. Prevalence of diabetes mellitus in newly diagnosed pulmonary tuberculosis in Beira, Mozambique. Afr Health Sci 2017; 17:773-779. [PMID: 29085405 PMCID: PMC5656213 DOI: 10.4314/ahs.v17i3.20] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction Data regarding the association between diabetes mellitus (DM) and tuberculosis (TB) in Africa are scarce. DM screening among TB patients in Mozambique was carried out. Methods The study was implemented from January to August 2016 in three Urban Health Centers in Beira, Mozambique and recruited adult (>18 years) patients newly diagnosed with pulmonary TB. Results Three hundred and one patients were enrolled (67.4%, males mean age 31.7(SD 11 years). Diabetes was diagnosed in only 3 patients (1%) and impaired glucose tolerance (IGT) in an additional 6 subjects (2%). Conclusion A lower than expected prevalence of DM was observed, which could be explained by the lack of traditional risk factors for DM (overweight, age over 45 years, hypertension and smoking) in Mozambique.
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Pizzol D, Di Gennaro F, Chhaganlal KD, Fabrizio C, Monno L, Putoto G, Saracino A. Tuberculosis and diabetes: current state and future perspectives. Trop Med Int Health 2016; 21:694-702. [PMID: 27102229 DOI: 10.1111/tmi.12704] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This review outlines the association between tuberculosis and diabetes, focusing on epidemiology, physiopathology, clinical aspects, diagnosis and treatment, and evaluates future perspectives, with particular attention to developing countries.
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Affiliation(s)
- Damiano Pizzol
- Research Section, Doctors with Africa CUAMM, Beira, Mozambique
| | | | - Kajal D Chhaganlal
- Center for Research in Infectious Diseases, Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | | | - Laura Monno
- Clinic of Infectious Diseases, University of Bari, Bari, Italy
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Imwong M, Woodrow CJ, Hendriksen ICE, Veenemans J, Verhoef H, Faiz MA, Mohanty S, Mishra S, Mtove G, Gesase S, Seni A, Chhaganlal KD, Day NPJ, Dondorp AM, White NJ. Plasma concentration of parasite DNA as a measure of disease severity in falciparum malaria. J Infect Dis 2014; 211:1128-33. [PMID: 25344520 PMCID: PMC4354984 DOI: 10.1093/infdis/jiu590] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In malaria-endemic areas, Plasmodium falciparum parasitemia is common in apparently healthy children and severe malaria is commonly misdiagnosed in patients with incidental parasitemia. We assessed whether the plasma Plasmodium falciparum DNA concentration is a useful datum for distinguishing uncomplicated from severe malaria in African children and Asian adults. P. falciparum DNA concentrations were measured by real-time polymerase chain reaction (PCR) in 224 African children (111 with uncomplicated malaria and 113 with severe malaria) and 211 Asian adults (100 with uncomplicated malaria and 111 with severe malaria) presenting with acute falciparum malaria. The diagnostic accuracy of plasma P. falciparum DNA concentrations in identifying severe malaria was 0.834 for children and 0.788 for adults, similar to that of plasma P. falciparum HRP2 levels and substantially superior to that of parasite densities (P < .0001). The diagnostic accuracy of plasma P. falciparum DNA concentrations plus plasma P. falciparum HRP2 concentrations was significantly greater than that of plasma P. falciparum HRP2 concentrations alone (0.904 for children [P = .004] and 0.847 for adults [P = .003]). Quantitative real-time PCR measurement of parasite DNA in plasma is a useful method for diagnosing severe falciparum malaria on fresh or archived plasma samples.
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Affiliation(s)
| | - Charles J Woodrow
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine, Churchill Hospital, University of Oxford
| | - Ilse C E Hendriksen
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine, Churchill Hospital, University of Oxford
| | - Jacobien Veenemans
- Cell Biology and Immunology Group, Wageningen University Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, the Netherlands
| | - Hans Verhoef
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, United Kingdom Cell Biology and Immunology Group, Wageningen University MRC Keneba, the Gambia
| | | | | | - Saroj Mishra
- Department of Medicine, Ispat Hospital, Rourkela, India
| | - George Mtove
- Amani Centre, National Institute for Medical Research, Muheza
| | - Samwel Gesase
- Korogwe Research Laboratory, National Institute for Medical Research, Tanga, Tanzania
| | | | - Kajal D Chhaganlal
- Hospital Central da Beira Faculty of Health Sciences, Catholic University of Mozambique, Beira, Mozambique
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine, Churchill Hospital, University of Oxford
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine, Churchill Hospital, University of Oxford
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine, Churchill Hospital, University of Oxford
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Hendriksen ICE, Ferro J, Montoya P, Chhaganlal KD, Seni A, Gomes E, Silamut K, Lee SJ, Lucas M, Chotivanich K, Fanello CI, Day NPJ, White NJ, von Seidlein L, Dondorp AM. Diagnosis, clinical presentation, and in-hospital mortality of severe malaria in HIV-coinfected children and adults in Mozambique. Clin Infect Dis 2012; 55:1144-53. [PMID: 22752514 PMCID: PMC3447636 DOI: 10.1093/cid/cis590] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background. Severe falciparum malaria with human immunodeficiency virus (HIV) coinfection is common in settings with a high prevalence of both diseases, but there is little information on whether HIV affects the clinical presentation and outcome of severe malaria. Methods. HIV status was assessed prospectively in hospitalized parasitemic adults and children with severe malaria in Beira, Mozambique, as part of a clinical trial comparing parenteral artesunate versus quinine (ISRCTN50258054). Clinical signs, comorbidity, complications, and disease outcome were compared according to HIV status. Results. HIV-1 seroprevalence was 11% (74/655) in children under 15 years and 72% (49/68) in adults with severe malaria. Children with HIV coinfection presented with more severe acidosis, anemia, and respiratory distress, and higher peripheral blood parasitemia and plasma Plasmodium falciparum histidine-rich protein-2 (PfHRP2). During hospitalization, deterioration in coma score, convulsions, respiratory distress, and pneumonia were more common in HIV-coinfected children, and mortality was 26% (19/74) versus 9% (53/581) in uninfected children (P < .001). In an age- and antimalarial treatment–adjusted logistic regression model, significant, independent predictors for death were renal impairment, acidosis, parasitemia, and plasma PfHRP2 concentration. Conclusions. Severe malaria in HIV-coinfected patients presents with higher parasite burden, more complications, and comorbidity, and carries a higher case fatality rate. Early identification of HIV coinfection is important for the clinical management of severe malaria.
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Affiliation(s)
- Ilse C E Hendriksen
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Dondorp AM, Fanello CI, Hendriksen ICE, Gomes E, Seni A, Chhaganlal KD, Bojang K, Olaosebikan R, Anunobi N, Maitland K, Kivaya E, Agbenyega T, Nguah SB, Evans J, Gesase S, Kahabuka C, Mtove G, Nadjm B, Deen J, Mwanga-Amumpaire J, Nansumba M, Karema C, Umulisa N, Uwimana A, Mokuolu OA, Adedoyin OT, Johnson WBR, Tshefu AK, Onyamboko MA, Sakulthaew T, Ngum WP, Silamut K, Stepniewska K, Woodrow CJ, Bethell D, Wills B, Oneko M, Peto TE, von Seidlein L, Day NPJ, White NJ. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet 2010; 376:1647-57. [PMID: 21062666 PMCID: PMC3033534 DOI: 10.1016/s0140-6736(10)61924-1] [Citation(s) in RCA: 637] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Severe malaria is a major cause of childhood death and often the main reason for paediatric hospital admission in sub-Saharan Africa. Quinine is still the established treatment of choice, although evidence from Asia suggests that artesunate is associated with a lower mortality. We compared parenteral treatment with either artesunate or quinine in African children with severe malaria. METHODS This open-label, randomised trial was undertaken in 11 centres in nine African countries. Children (<15 years) with severe falciparum malaria were randomly assigned to parenteral artesunate or parenteral quinine. Randomisation was in blocks of 20, with study numbers corresponding to treatment allocations kept inside opaque sealed paper envelopes. The trial was open label at each site, and none of the investigators or trialists, apart from for the trial statistician, had access to the summaries of treatment allocations. The primary outcome measure was in-hospital mortality, analysed by intention to treat. This trial is registered, number ISRCTN50258054. FINDINGS 5425 children were enrolled; 2712 were assigned to artesunate and 2713 to quinine. All patients were analysed for the primary outcome. 230 (8·5%) patients assigned to artesunate treatment died compared with 297 (10·9%) assigned to quinine treatment (odds ratio [OR] stratified for study site 0·75, 95% CI 0·63-0·90; relative reduction 22·5%, 95% CI 8·1-36·9; p=0·0022). Incidence of neurological sequelae did not differ significantly between groups, but the development of coma (65/1832 [3·5%] with artesunate vs 91/1768 [5·1%] with quinine; OR 0·69 95% CI 0·49-0·95; p=0·0231), convulsions (224/2712 [8·3%] vs 273/2713 [10·1%]; OR 0·80, 0·66-0·97; p=0·0199), and deterioration of the coma score (166/2712 [6·1%] vs 208/2713 [7·7%]; OR 0·78, 0·64-0·97; p=0·0245) were all significantly less frequent in artesunate recipients than in quinine recipients. Post-treatment hypoglycaemia was also less frequent in patients assigned to artesunate than in those assigned to quinine (48/2712 [1·8%] vs 75/2713 [2·8%]; OR 0·63, 0·43-0·91; p=0·0134). Artesunate was well tolerated, with no serious drug-related adverse effects. INTERPRETATION Artesunate substantially reduces mortality in African children with severe malaria. These data, together with a meta-analysis of all trials comparing artesunate and quinine, strongly suggest that parenteral artesunate should replace quinine as the treatment of choice for severe falciparum malaria worldwide. FUNDING The Wellcome Trust.
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Affiliation(s)
- Arjen M Dondorp
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Caterina I Fanello
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ilse CE Hendriksen
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Amir Seni
- Hospital Central da Beira, Beira, Mozambique
| | | | | | | | | | | | | | | | | | | | - Samwel Gesase
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | - Catherine Kahabuka
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | | | - Behzad Nadjm
- Teule Designated District Hospital, Muheza, Tanzania
| | | | | | - Margaret Nansumba
- Mbarara University of Science and Technology and Epicentre Research Base, Mbarara, Uganda
| | - Corine Karema
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Noella Umulisa
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Aline Uwimana
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | | | | | | | - Antoinette K Tshefu
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Marie A Onyamboko
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Tharisara Sakulthaew
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirichada Pan Ngum
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kamolrat Silamut
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kasia Stepniewska
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Delia Bethell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Bridget Wills
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Tim E Peto
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Nicholas PJ Day
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Correspondence to: Prof N J White, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand
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