Trend of measles-rubella vaccination coverage and impact on measles epidemiology in the Savannah Region, Ghana; 2018-2022: A secondary data analysis

INTRODUCTION

Ghana witnessed an outbreak of measles in 2022 following the COVID-19 pandemic, and Savannah Region was among the regions severely impacted. The objective of this study was to conduct trend analysis of measles case incidence and measles-rubella (MR) vaccination coverage in the Savannah Region to identify gaps and propose remedial actions to mitigate future outbreaks of vaccine preventable diseases (VPDs).

METHODS

Analysis of measles surveillance and measles-rubella vaccination data for 2018-2022 was conducted to assess relationship between immunization coverage and measles case incidence. Data were extracted from the District Health Information Management System (DHIMS) platform and loaded into Microsoft Excel 16.0 spreadsheet for analysis. Coverages for first (MR1) and second (MR2) doses of measles-rubella vaccination, dropout rates, and measles incidence (per 100,000) were calculated.

RESULTS

The coverage trend for both vaccine doses followed similar trajectories, increasing from 2018 to a peak in 2019, and declining sequentially thereafter to the lowest (for the study period) in 2022. Generally, MR1/MR2 dropout rate was high across all districts during the entire study period. The regional incidence of confirmed measles rose sharply from less than 1/1,000,000 in 2018-2021 to 94 in 2022. Wide variations in vaccination coverage and dropout rates were observed among the districts. There was moderate to fairly strong negative correlation between MR vaccination coverage and measles case incidence.

CONCLUSIONS

The MR vaccination coverage in the Savannah Region declined probably due to pre-existing weaknesses in the immunization programme accentuated by impact of the COVID-19 pandemic. The lowered population immunity likely contributed to occurrence of the measles outbreak in 2022. Pragmatic actions are needed to catch-up on missed children, restore coverage to pre-pandemic levels, and strengthen the immunization programme as part of global efforts towards achieving the Immunization Agenda 2030 (IA2030) trajectory.

HHV-6 infections in hospitalized young children of Gabon

PURPOSE

Fever is a common cause for hospitalization among the pediatric population. The spectrum of causative agents is diverse. Human herpesvirus 6 (HHV-6) is a ubiquitous virus that often causes hospitalization of children in western countries. Previously, we investigated the cause of fever of 600 febrile hospitalized children in Gabon, and in 91 cases the causative pathogen was not determined. In this study, we assessed HHV-6 infection as potential cause of hospitalization in this group.

METHODS

Blood samples were assessed for HHV-6 using real-time quantitative PCR. Three groups were investigated: (1) group of interest: 91 hospitalized children with febrile illness without a diagnosed causing pathogen; (2) hospitalized control: 91 age-matched children hospitalized with febrile illness with a potentially disease-causing pathogen identified; both groups were recruited at the Albert Schweitzer Hospital in Lambaréné, Gabon and (3) healthy control: 91 healthy children from the same area.

RESULTS

Samples from 273 children were assessed. Age range was two months to 14 years, median (IQR) age was 36 (12-71) months; 52% were female. HHV-6 was detected in 64% (58/91), 41% (37/91), and 26% (24/91) of the samples from groups 1, 2, and 3, respectively; with statistically significant odds of being infected with HHV-6 in group 1 (OR = 4.62, 95% CI [2.46, 8.90]). Only HHV-6B was detected.

CONCLUSIONS

Although tropical diseases account for a large proportion of children's hospitalizations, considering common childhood diseases such as HHV-6 when diagnosing febrile illnesses in pediatric populations in tropical countries is of importance.

Species identification and drug susceptibility testing of non-tuberculous mycobacteria by Line Probe Assay in Lambaréné, Gabon-a cross-sectional study

BACKGROUND

Non-tuberculous mycobacteria (NTM) are a group of bacteria that cause rare lung infections and are increasingly recognized as causative agents of opportunistic and device-associated infections in humans. In Gabon, there is a lack of data on NTM species identification and drug susceptibility. The aim of this study was to identify the frequency of NTM species and their genotypic susceptibility pattern to commonly used antibiotics for NTM infections in Gabon.

METHODS

A cross-sectional study was conducted at the CERMEL TB laboratory from January 2020 to December 2022, NTM subspecies identification and drug susceptibility testing to macrolides and aminoglycosides were performed using the genotype NTM-DR kit.

RESULTS

The study found that out of 524 culture-positive specimens, 146 (28%) were NTM, with the predominant group being Mycobacterium avium complex (MAC) and Mycobacterium abscessus complex (MABC). All MAC isolates were fully susceptible to macrolides and aminoglycosides, while five MABC isolates carried mutations indicative of reduced susceptibility to macrolide and aminoglycoside drugs.

CONCLUSIONS

These findings suggest that clinicians may use macrolides and aminoglycosides to manage NTM infections caused by MAC, but further investigation is required to determine MABC drug susceptibility.

Screening of MMV pandemic response and pathogen box compounds against pan-drug-resistant Klebsiella pneumoniae to identify potent inhibitory compounds

Background

The recent emergence of pan-drug-resistant (PDR) K. pneumoniae strains hinders the success rate of treatment procedures for patients. High mortality, extended duration of hospitalization with high costs is associated with such infections. Discovery and identification of new drugs are inevitable to combat PDR clinical pathogens. We aim to identify and evaluate new compounds in vitro against a PDR clinical K. pneumoniae isolate using compounds of Pathogen Box and Pandemic Response Box from Medicines for Malaria Venture (MMV).

Methods

The PDR strain was initially screened with the 601 compounds from both Boxes at 10 ​μM concentration. Formation of dormant cells against the drug activity was assessed using persister assay. MIC was determined for the drugs inhibiting PDR K. pneumoniae during initial screening.

Results

Five compounds were identified to inhibit the test strain. MMV1580854 (94.60 ​%), MMV1579788 (94.65 ​%), MMV1578574 (eravacycline; 93.13 ​%), MMV1578566 (epetraborole; 95.29 ​%) and MMV1578564 (96.32 ​%) were able to exhibit a higher percentage of growth inhibition. Persisters were found to be growing in a range from 104 to 107 ​CFU/ml. Minimum inhibitory concentrations (MIC) of all compounds were ≥ 2 ​μM except for MMV1579788, which had a MIC of ≥ 5 ​μM.

Conclusion

Five novel compounds were identified against the highly evolved pan-drug-resistant K. pneumoniae. Among the five, epetraborole andMMV1578564 were identified as highly potent based on the persister frequency and MICs. The pan-drug resistant clinical isolate used in this study was found to be acting differently from the reference or wild type strains against the test compounds in a previous study.

Ganaplacide (KAF156) plus lumefantrine solid dispersion formulation combination for uncomplicated Plasmodium falciparum malaria: an open-label, multicentre, parallel-group, randomised, controlled, phase 2 trial

BACKGROUND

Emergence of drug resistance demands novel antimalarial drugs with new mechanisms of action. We aimed to identify effective and well tolerated doses of ganaplacide plus lumefantrine solid dispersion formulation (SDF) in patients with uncomplicated Plasmodium falciparum malaria.

METHODS

This open-label, multicentre, parallel-group, randomised, controlled, phase 2 trial was conducted at 13 research clinics and general hospitals in ten African and Asian countries. Patients had microscopically-confirmed uncomplicated P falciparum malaria (>1000 and <150 000 parasites per μL). Part A identified the optimal dose regimens in adults and adolescents (aged ≥12 years) and in part B, the selected doses were assessed in children (≥2 years and <12 years). In part A, patients were randomly assigned to one of seven groups (once a day ganaplacide 400 mg plus lumefantrine-SDF 960 mg for 1, 2, or 3 days; ganaplacide 800 mg plus lumefantrine-SDF 960 mg as a single dose; once a day ganaplacide 200 mg plus lumefantrine-SDF 480 mg for 3 days; once a day ganaplacide 400 mg plus lumefantrine-SDF 480 mg for 3 days; or twice a day artemether plus lumefantrine for 3 days [control]), with stratification by country (2:2:2:2:2:2:1) using randomisation blocks of 13. In part B, patients were randomly assigned to one of four groups (once a day ganaplacide 400 mg plus lumefantrine-SDF 960 mg for 1, 2, or 3 days, or twice a day artemether plus lumefantrine for 3 days) with stratification by country and age (2 to <6 years and 6 to <12 years; 2:2:2:1) using randomisation blocks of seven. The primary efficacy endpoint was PCR-corrected adequate clinical and parasitological response at day 29, analysed in the per protocol set. The null hypothesis was that the response was 80% or lower, rejected when the lower limit of two-sided 95% CI was higher than 80%. This study is registered with EudraCT (2020-003284-25) and ClinicalTrials.gov (NCT03167242).

FINDINGS

Between Aug 2, 2017, and May 17, 2021, 1220 patients were screened and of those, 12 were included in the run-in cohort, 337 in part A, and 175 in part B. In part A, 337 adult or adolescent patients were randomly assigned, 326 completed the study, and 305 were included in the per protocol set. The lower limit of the 95% CI for PCR-corrected adequate clinical and parasitological response on day 29 was more than 80% for all treatment regimens in part A (46 of 50 patients [92%, 95% CI 81-98] with 1 day, 47 of 48 [98%, 89-100] with 2 days, and 42 of 43 [98%, 88-100] with 3 days of ganaplacide 400 mg plus lumefantrine-SDF 960 mg; 45 of 48 [94%, 83-99] with ganaplacide 800 mg plus lumefantrine-SDF 960 mg for 1 day; 47 of 47 [100%, 93-100] with ganaplacide 200 mg plus lumefantrine-SDF 480 mg for 3 days; 44 of 44 [100%, 92-100] with ganaplacide 400 mg plus lumefantrine-SDF 480 mg for 3 days; and 25 of 25 [100%, 86-100] with artemether plus lumefantrine). In part B, 351 children were screened, 175 randomly assigned (ganaplacide 400 mg plus lumefantrine-SDF 960 mg once a day for 1, 2, or 3 days), and 171 completed the study. Only the 3-day regimen met the prespecified primary endpoint in paediatric patients (38 of 40 patients [95%, 95% CI 83-99] vs 21 of 22 [96%, 77-100] with artemether plus lumefantrine). The most common adverse events were headache (in seven [14%] of 51 to 15 [28%] of 54 in the ganaplacide plus lumefantrine-SDF groups and five [19%] of 27 in the artemether plus lumefantrine group) in part A, and malaria (in 12 [27%] of 45 to 23 [44%] of 52 in the ganaplacide plus lumefantrine-SDF groups and 12 [50%] of 24 in the artemether plus lumefantrine group) in part B. No patients died during the study.

INTERPRETATION

Ganaplacide plus lumefantrine-SDF was effective and well tolerated in patients, especially adults and adolescents, with uncomplicated P falciparum malaria. Ganaplacide 400 mg plus lumefantrine-SDF 960 mg once daily for 3 days was identified as the optimal treatment regimen for adults, adolescents, and children. This combination is being evaluated further in a phase 2 trial (NCT04546633).

FUNDING

Novartis and Medicines for Malaria Venture.

Schistosomiasis in Gabon from 2000 to 2021 - A review

INTRODUCTION

Schistosomiasis is a public health issue of concern in Gabon, with the disease being reported from all regions of the country. The topic has been of interest for the local researchers and physicians for over two decades. The objective of this narrative review was to provide an overview of the research activities in the area from 2000 to early 2021.

METHODS

We performed a narrative literature review. The search strategy was designed to get a broad overview of the different research topics on schistosomiasis and the national control programme, and included grey literature.

RESULTS

A total of 159 articles was screened, and 42 were included into the review in addition to the grey literature. During the past two decades, the work on schistosomiasis originated from five out of the nine provinces of the country, with diverse aspects of the disease investigated; including immunology, epidemiology, diagnosis and treatment. Several studies investigated various aspects of schistosomiasis-related morbidity in the respective study populations. The body of work demonstrates that much effort was made to understand the details of the host immune response to schistosomiasis, and the immune profile changes induced in patients treated with praziquantel. Although some MDA campaigns were conducted in the country; little, however, is known on the epidemiological situation of the disease, particularly of its distribution within the population, as well as co-infections with other parasitic diseases also endemic in the area.

CONCLUSION

Progress has been made over the past two decades in the understanding of schistosomiasis in the country, including disease-related morbidity and its interaction with other parasitic infections, and the immunology and epidemiology of the disease. However, for optimising control of the disease, there is a need to fine-tune these findings with detailed local epidemiological and malacological data. We call for such studies to accomplish the knowledge of schistosomiasis in the country, particularly in areas of moderate or high endemicity, and recommend this approach to comparable schistosomiasis-endemic areas elsewhere.

Transthoracic mediastinal ultrasound in childhood tuberculosis: A review

Diagnosing childhood tuberculosis (TB) is challenging, and novel diagnostic tools are urgently needed. Mediastinal lymphadenopathy is a hallmark of primary pulmonary TB (PTB) in children. We aimed to summarise available methodological and diagnostic data of transthoracic mediastinal ultrasound for childhood TB. Literature review identified two prospective and three retrospective studies, a case report, and a technical report including cases. All reported on suprasternal scanning of the mediastinum; additional parasternal scanning was reported by five studies. The proportion of children with lymphadenopathy detected by mediastinal ultrasound ranged between 15% and 85%, with studies including both supra- and parasternal scanning achieving higher detection ratios. Three retrospective studies reported mediastinal lymphadenopathy on ultrasound for most cases presenting with a normal or inconclusive CXR. Data on ultrasound for mediastinal lymphadenopathy in children are limited but indicate that mediastinal ultrasound can successfully detect mediastinal lymphadenopathy in children with TB.

Non-communicable disease co-morbidity and associated factors in tuberculosis patients: A cross-sectional study in Gabon

BACKGROUND

There are only limited data from resource-limited settings available on the prevalence of non-communicable diseases and associated risk factors of tuberculosis patients. This study investigated non-communicable disease co-morbidity in tuberculosis patients from Moyen Ogooué Province, Gabon.

METHODS

All patients aged 18 years or older consulting for tuberculosis (TB) symptoms in Gabon's Moyen Ogooué province and neighbouring provinces from November 2018 to November 2020 were screened for diabetes mellitus, hypertension, and risk factors thereof (obesity, dyslipidaemia, smoking and alcohol consumption). Logistic regression was performed to identify factors associated with TB-diabetes and TB-hypertension co-morbidities.

FINDINGS

Of 583 patients included, 227 (39%) were diagnosed with tuberculosis. In tuberculosis-confirmed patients, the prevalences of hypertension and diabetes were 16·3% and 12·8%, respectively. The prevalence of diabetes was twice as high in tuberculosis patients compared to non-tuberculosis patients. Factors independently associated with hypertension-tuberculosis co-morbidity were age >55 years (aOR=8·5, 95% CI 2·43, 32·6), age 45-54 years (aOR=4.9, 95%CI 1.3-19.8), and moderate alcohol consumption (aOR=2·4; 95% CI 1·02- 5·9), respectively. For diabetes-tuberculosis co-morbidity, age >55 years was positively (aOR=9·13; 95% CI 2·4-39·15), and moderate alcohol consumption inversely associated (aOR=0·26, 95% CI 0·08- 0·73). One-hundred-and-four (46%) of the tuberculosis patients had at least either dyslipidaemia, hypertension, diabetes, or obesity with a majority of newly-diagnosed hypertension and diabetes.

INTERPRETATION

Integration of screening of non-communicable diseases and their risk factors during TB assessment for early diagnosis, treatment initiation and chronic care management for better health outcomes should be implemented in all tuberculosis healthcare facilities.

FUNDING

This study was supported by WHO AFRO/TDR/EDCTP (2019/893,805) and Deutsches Zentrum für Infektiologie (DZIF/ TTU 02.812).

Non-tuberculous mycobacteria isolation from presumptive tuberculosis patients in Lambaréné, Gabon

OBJECTIVE

The prevalence of clinical cases of pulmonary non-tuberculous mycobacteria (NTM) is increasing worldwide. The aim of this study was to determine the proportion and the NTM species isolated from presumptive tuberculosis patients in Lambaréné, Gabon.

METHOD

From January 2018 to December 2020, sputum samples from presumptive TB patients were analysed at the tuberculosis reference laboratory of the Centre de Recherches Médicales de Lambaréné. Two sputum samples were collected per patient, and culture was performed using Bactec MGIT 960. The GenoType Mycobacterium CM/AS was used for NTM isolates confirmation and species differentiation.

RESULTS

Among 1363 sputum samples analysed, 285 (20.9%) were Auramin acid fast bacilli (AFB) smear-positive. NTM were isolated in 137/1363 (10%) of the samples. The most prevalent NTM species was Mycobacterium intracellulare (n=74; 54%).

CONCLUSION

These results show the presence of NTM among presumptive TB patients in Gabon, which could potentially complicate TB diagnosis. This presents a new public health challenge, and emphasises the need to consider NTM in planning the prevention and management of tuberculosis control.

Pilot Malacology Surveys for the Intermediate Hosts of Schistosomiasis in Rural and Semi-Urban Areas of the Moyen-Ogooué Province, Gabon

The objective of this pilot malacological survey was to identify the snail intermediate hosts for Schistosoma haematobium in endemic rural and semi-urban areas of Gabon. Snails were collected, morphologically identified, and tested for infection by cercarial shedding. Released cercariae were morphologically identified using low-power light microscopy. A total of six species of snails were collected throughout the study area, with Bulinus truncatus, B. forskalii, and Potadoma spp. being the most predominant species collected. Only the Bulinus species were tested for infection by cercarial shedding, of which only B. truncatus shed cercariae. Some B. truncatus shed mammalian schistosome cercariae, while others shed Gymnocephalus cercariae. Our results indicate that B. truncatus appears to be a potential intermediate host of schistosomiasis in Gabon, where cases of S. haematobium, S. guineensis, and S. intercalatum infection are reported. However, it will be important to further understand the species diversity and transmission dynamics of schistosomes.

A review of severe thrombocytopenia in Zika patients - Pathophysiology, treatment and outcome

BACKGROUND

During the 2015 Zika virus infection (ZVI) epidemic swiping through the Americas, few cases of ZVI with severe, potentially life-threatening thrombocytopenia were reported. Platelet transfusion, corticosteroids and intravenous immunoglobulins (IVIG) were in most cases applied as therapeutic options, predominantly with success. We present a comprehensive overview concerning the pathophysiology, treatment strategies and outcomes of patients with ZVI and severe thrombocytopenia (platelet count <50 × 10⁹/L).

METHOD

A literature search was performed.

RESULTS

Eleven case reports and case series with a total of 28 patients met the inclusion criteria; including five cases with lethal outcome. Therapeutic strategies, including platelet transfusion, administration of steroids and/or IVIG were described in 24 cases.

CONCLUSIONS

Severe thrombocytopenia is a rare, but potentially life-threatening complication of ZVI. The principal pathophysiological mechanism appears to immune-induced thrombocytopenia. Due to a paucity of cases, the optimal treatment strategy remains to be elucidated.

Knowledge, attitudes and practices pertaining to urogenital schistosomiasis in Lambaréné and surrounding areas, Gabon

Background

Control of schistosomiasis remains a priority in endemic areas. Local epidemiological data are necessary for a tailored control programme, including data on population behaviour in relation to the disease. The objective of this study was to assess schistosomiasis-related knowledge, attitudes and practices in the general population of Lambaréné, a small city in Gabon, in order to optimise the design and implementation of a local control programme that is tailored to need.

Methods

The study was cross-sectional in nature. Eligible adults and children living in the study area who volunteered (with informed consent) to participate in the study were interviewed using standardised questionnaires, one of which was a simplified version of the primary questionnaire for participants aged 6–13 years. Data on the participants’ knowledge, attitudes and practices that enhance the risk for contracting schistosomiasis were collected.

Results

A total of 602 participants were included. The mean (± standard deviation) age was 21.2 (± 15.0) years, the female:male gender ratio was 1.6 and 289 (48%) participants completed the simplified version the questionnaire. Of the 602 participants, 554 (92%) reported past or current contact with freshwater, 218 (36%) reported a history of a diagnosis of schistosomiasis and 193 (32%) reported past intake of praziquantel medication. The overall levels of knowledge and adequate attitudes toward schistosomiasis among young adults and adults were 68 and 73%, respectively. The proportion of participants pursuing risk-enhancing practices (REP) was 60% among the whole study population. Location was significantly associated with differences in knowledge and REP levels. A history of confirmed schistosomiasis and larger family size were significantly associated with an increase in good knowledge and REP levels. However, the indication of freshwater-associated activities was only associated with a significant increase in the REP level.

Conclusions

The results of this survey reveal a high level of population exposure to schistosomiasis, which is in line with known prevalence of schistosomiasis in Lambaréné and its surroundings. The local population has a reasonable level of knowledge of and adequate attitudes toward schistosomiasis but the level of REP is high, particularly in areas where piped water is absent. In terms of interventions, improving hygiene should have the highest priority, but in a context where provision of safe water is difficult to achieve, the effectiveness of praziquantel treatment and the education of at-risk populations on the need for protective behaviours should be a prominent feature of any local control programme.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-04905-0.

Percutaneous Versus Surgical Interventions for Hepatic Cystic Echinococcosis: A Systematic Review and Meta-Analysis

Purpose

This systematic review and meta-analysis summarises the current literature on invasive treatment options of cystic hepatic echinococcosis (CE), comparing percutaneous radiological interventions to surgery, still the cornerstone of treatment in many countries.

Methods

A literature search was conducted in Medline and EMBASE databases (PROSPERO registration number: CRD42019126150). The primary outcome was recurrence of cysts after treatment. Secondary outcomes were complications, duration of hospitalisation, mortality and treatment conversion.

Results

The number of eligible prospective studies, in particular RCTs, was limited. In the four included studies, only conventional surgery is compared directly to percutaneous techniques. From the available data, in terms of recurrence, percutaneous treatment of hydatid cysts is non-inferior to open surgery. With regard to complications and length of hospital stay, outcomes favour percutaneous therapy.

Conclusion

Although evidence from prospective research is small, percutaneous treatment in CE is an effective, safe and less invasive alternative to surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00270-021-02911-4.

Focused Assessment with Sonography for Urinary Schistosomiasis (FASUS)-pilot evaluation of a simple point-of-care ultrasound protocol and short training program for detecting urinary tract morbidity in highly endemic settings

BACKGROUND

Urogenital schistosomiasis (UGS) causes inflammation and fibrosis of the urinary tract. In resource-limited settings, affordable tools for morbidity assessment in clinical care are needed. Point-of-care ultrasound has not yet been validated for UGS-related pathology.

METHODS

We developed a protocol for Focused Assessment with Sonography for Urinary Schistosomiasis (FASUS), assessing pathology of the bladder wall, ureters and kidneys. Following standardized training, two clinicians performed FASUS on children and adults with hematuria in Lambaréné, Gabon. Recorded ultrasound clips were remotely reviewed by two ultrasound experts as a diagnostic reference.

RESULTS

In 2015 and 2016, scans were performed in 118 patients. The image quality was sufficient in 90% of bladder views and more than 97% of kidney views. UGS-compatible pathology was detected in 51/118 (43%) by the operator and in 46/107 (43%) by the experts among baseline scans of sufficient quality. Inter-rater agreement between operators and experts was very good (κ > 0.8) for hydronephrosis and good (κ > 0.6) for bladder wall thickening.

CONCLUSIONS

FASUS is a promising clinical, point-of-care tool for detecting UGS-related urinary tract morbidity in symptomatic patients. Based on larger validation studies, appropriate diagnostic and therapeutic algorithms for the use of FASUS should be established.

Perspectives of health workers on the referral of women with obstetric complications: a qualitative study in rural Sierra Leone

OBJECTIVES

Sierra Leone has one of the highest maternal mortality ratios in the world. Timely and well-coordinated referrals are necessary to reduce delays in providing adequate care for women with obstetric complications. This study describes factors affecting timely and adequate referral of women with obstetric complications in rural areas of Sierra Leone as viewed by health workers in rural health facilities.

DESIGN

Qualitative research with semi-structured interviews using open-ended questions. Data were analysed by systematic text condensation.

SETTING

Interviews were held in nine peripheral health units in rural Sierra Leone.

PARTICIPANTS

19 health workers including nurses, midwives and clinical health officers participated in nine interviews.

RESULTS

From the interviews, four major themes describing possible factors of delay in referral of women in need of emergency obstetric care emerged: (1) communication between healthcare workers; (2) underlying influences on decision-making; (3) women's compliance to referral and (4) logistic constraints.Several factors in rural Sierra Leone are perceived to complicate timely and adequate referral of women in need of emergency obstetric care. Notable among these factors are fear among women for being referred and fear among healthcare workers for having maternal deaths or severe obstetric complications occurring at their own facilities. Furthermore, decision-making of healthcare workers whether to refer a woman or not is negatively influenced by a hierarchical culture with high power distance between healthcare workers.

CONCLUSION

Factors identified that complicate timely and adequate referral of women in need of emergency obstetric care must be considered in efforts to reduce maternal mortality. Possible interventions that may reduce delay in referral include increased communication by mobile phones between health workers for advice and feedback regarding referrals, involvement of influential stakeholders to increase women's compliance to referral, and consistent use of standardised management protocols.

Epidemiological, Mycobacteriological, and Clinical Characteristics of Smoking Pulmonary Tuberculosis Patients, in Lambaréné, Gabon: A Cross-Sectional Study

Gabon carries a high burden of both tuberculosis (TB) and smoking. This study examines the disease characteristics of smoking pulmonary TB patients in Lambaréné. We interviewed adult pulmonary TB patients in Lambaréné, between March 2016 and April 2019. Clinical and biological patient characteristics were collected. Bivariate and logistic regression analyses were performed to assess factors associated with smoking. The mean age of patients included was 31 years (±13). The proportion of smokers in our study was 30% (89/295). Smoking was significantly associated with patient-related diagnostic delay (adjusted odds ratio [AOR] = 8.18; 95% CI = 3.67-19.56), a higher number of pulmonary TB signs and symptoms (AOR = 2.74; 95% CI = 1.18-6.73), and a higher sputum mycobacterial load (AOR = 3.18; 95% CI = 1.33-8.11). The prevalence of smoking among TB patients is high, and leading to aggravated disease as compared with controls. Our study findings suggest that smoking patients should be regularly screened for TB, to reduce diagnostic delay and TB transmission within community. Smoking cessation activities should be included in the national TB control program in Gabon.

Epidemiology of Schistosomiasis and Soil-Transmitted Helminth Coinfections among Schoolchildren Living in Lambaréné, Gabon

Schistosomiasis is a parasitic infection highly prevalent in Central Africa where it is co-endemic with many other parasitic infections, including soil-transmitted helminths (STHs). For its optimal control, there is a need of descriptive epidemiological data for each endemic region. The objective of the present study was to determine the epidemiological situation around schistosomiasis in Lambaréné, Gabon. A cross-sectional study was conducted among schoolchildren. One urine sample per day was collected on three consecutive days for the diagnosis of schistosomiasis using a urine filtration technique. One stool sample was collected for the detection of Schistosoma spp. and STH spp. eggs using the Kato-Katz technique, and for larvae, using the coproculture technique. A total of 614 schoolchildren were included in the analysis. The overall prevalence of schistosomiasis and STH infections was 26% (159/614) and 15% (70/473), respectively. Human-freshwater contact was the main risk factor for schistosomiasis in the area (relative risk (RR) = 2.96 [2.20-4.00], P < 0.001). Hematuria (RR = 5.53 [4.30-7.10], P < 0.001) and proteinuria (RR = 2.12 [1.63-2.75], P < 0.001) as well as infection with Trichuris trichiura (RR = 1.86 [1.33-2.61], P = 0.002) and Ascaris lumbricoides (RR = 1.96 [1.19-3.21], P = 0.039) were associated with an increased risk of schistosomiasis. Trichuris trichiura was the highest prevalent STH species in the area. Our study reports a moderate prevalence for schistosomiasis with human-water contact as the main risk factor, whereas the prevalence of STH infections appears to be low. Our results stress the need for the implementation of WHO recommendations for schistosomiasis control.

Seroprevalence of Toxocara spp. antibodies in humans in Africa: A review

BACKGROUND

Human toxocariasis occurs worldwide and is caused by nematodes of the species of the genus Toxocara. Infection occurs by the ingestion of eggs and is usually asymptomatic or oligosymptomatic. However, severe manifestations occur. The burden of disease and its public health impact remain ill-defined. The aim of this review was to summarize all available data on the seroprevalence of toxocariasis on the African continent and factors associated with seropositivity.

METHODS

Twenty-seven original papers published between 1991 and 2017 were identified that provided data suitable for this review. Case-control studies were included and the seroprevalence in the (healthy) control group was used as a surrogate parameter.

RESULTS

Antibodies against Toxocara spp. were found to be frequent in most populations and regions in Africa with the exception of two publications, one from the Democratic Republic of the Congo and one from Djibouti, where all participants were seronegative. The highest proportion of participants with antibodies was found on the island of La Réunion with 359 out 387 study participants being positive (92.8%). Factors associated with seropositivity were reported across studies, including-among others-older age, contact with soil via geophagia, agricultural activity or playing with soil, contact with animals, especially dogs, and low socio-economic status, defined as absence of water supply or poor housing. Three Egyptian studies found male gender to be associated with toxocariasis, whereas in La Réunion females were at increased risk.

CONCLUSIONS

Exposure to toxocariasis seems to be very frequent and common in large parts of the African continent. However, no data are available for most countries. The public health impact of human toxocariasis and the frequency of severe manifestations remain unclear.

Causes of fever in Gabonese children: a cross-sectional hospital-based study

The causes of infections in pediatric populations differ between age groups and settings, particularly in the tropics. Such differences in epidemiology may lead to misdiagnosis and ineffective empirical treatment. Here, we investigated the current spectrum of pathogens causing febrile diseases leading to pediatric hospitalization in Lambaréné, Gabon. From August 2015 to March 2016, we conducted a prospective, cross-sectional, hospital-based study in a provincial hospital. Patients were children ≤ 15 years with fever ≥ 38 °C and required hospitalization. A total of 600 febrile patients were enrolled. Malaria was the main diagnosis found in 52% (311/600) patients. Blood cultures revealed septicemia in 3% (17/593), among them four cases of typhoid fever. The other causes of fever were heterogeneously distributed between both bacteria and viruses. Severe infections identified by Lambaréné Organ Dysfunction Score (LODS) were also most often caused by malaria, but children with danger signs did not have more coinfections than others. In 6% (35/600) of patients, no pathogen was isolated. In Gabon, malaria is still the major cause of fever in children, followed by a bacterial and viral disease. Guidelines for both diagnosis and management should be tailored to the spectrum of pathogens and resources available locally.

Schistosoma haematobium infection morbidity, praziquantel effectiveness and reinfection rate among children and young adults in Gabon

Background

Sub-Saharan Africa carries most of the global burden of schistosomiasis. To optimize disease control and reduce morbidity, precise data are needed for control measures adapted to the local epidemiological situation. The objective of this study is to provide baseline information on schistosomiasis dynamics, including praziquantel (PZQ) treatment outcome in children and young adults living in the vicinity of Lambaréné, Gabon.

Methods

Eligible volunteers were included into a prospective longitudinal study. Urine filtration technique was used to detect eggs in urine for schistosomiasis diagnosis. Subjects were treated with 60 mg of PZQ once per month for three consecutive months, and the outcome was assessed by cure rate (CR) and egg reduction rate (ERR).

Results

A total of 328 volunteers were enrolled in the study with a mean (± SD) age of 12.2 ± 4.7 years-old. The female-to-male ratio was 0.99. Out of 258 participants in total, 45% had schistosomiasis during the survey and 43% presented with heavy infections. The incidences of haematuria and schistosomiasis were 0.11 and 0.17 person-years, respectively. After the first and third dose of PZQ, overall ERR of 93% and 95% were found, respectively; while the CR were 78% and 88%, respectively. Both ERR (100 vs 88%) and CR (90 vs 68%) were higher among females than males after the first dose. The CR increased for both groups after the third dose to 95% and 80%, respectively. After the first PZQ dose, ERR was higher for heavy compared to light infections (94 vs 89%), while the CR was higher for light than for heavy infections (87 vs 59%). After the third PZQ dose, ERR increased only for light infections to 99%, while CR increased to 98% and 75% for light and for heavy infections, respectively. The reinfection rate assessed at a mean of 44.6 weeks post-treatment was 25%.

Conclusions

The prevalence of schistosomiasis is moderate in communities living in the vicinity of Lambaréné, where a subpopulation with a high risk of reinfection bears most of the burden of the disease. To improve schistosomiasis control in this scenario, we suggest education of these high-risk groups to seek themselves a one-year PZQ treatment.

Trial registration clinicaltrials.gov Identifier NCT 02769103. Registered 11 May 2016, retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT02769013

Implementation of multidrug-resistant tuberculosis (MDR-TB) treatment in Gabon: lessons learnt from the field

PURPOSE

Since May 2016, WHO recommended a 9-12 month short-treatment regimen for multidrug-resistant tuberculosis (MDR-TB) treatment known as the 'Bangladesh Regimen'. However, limited data exist on the appropriateness thereof, and its implementation in low- and middle-income countries (LMIC). We report here on the pilot phase of the evaluation of the Bangladesh regimen in Gabon, prior to its endorsement by the WHO.

METHODS

This ongoing observational study started in September 2015. Intensive training of hospital health workers as well as community information and education were conducted. GeneXpert-confirmed MDR-TB patients received the second-line anti-tuberculosis drugs (4KmMfxPtoHCfzEZ/5MfxCfzEZ). Sputum smears and cultures were done monthly. Adverse events were monitored daily.

RESULTS

Eleven patients have been treated for MDR-TB piloting the short regimen. All were HIV-negative and presented in poor health with extensive pulmonary lesions. The overall sputum culture conversion rate was 64% after 4 months of treatment. Three patients developed marked hearing loss; one a transient cutaneous rash. Of 11 patients in our continuous care, 7 (63.6%) significantly improved clinically and bacteriologically. One (9.1%) patient experienced a treatment failure, two (18.2%) died, and one (9.1%) was lost to follow up.

CONCLUSIONS

Our pioneering data on systematic MDR-TB treatment in Gabon, with currently almost total absence of resistance against the second-line drugs, demonstrate that a 9-month regimen has the capacity to facilitate early culture negativity and sustained clinical improvement. Close adverse events monitoring and continuous care are vital to success.

Improving the diagnostics of tuberculosis and drug resistance with Xpert MTB/RIF in a district general hospital in Sierra Leone: a quality improvement project

Sierra Leone has a high tuberculosis (TB) burden with a prevalence of 441 cases per 100 000 population. As a result of the Global Fund, some facilities in the country have access to improved diagnostics, including Xpert MTB/RIF testing, of particular use in diagnosing those at risk of drug resistance, in the form of rifampicin-resistant (RR) TB. This quality improvement project describes how a small, rural district general hospital in Masanga village improved the diagnosis of TB and RR-TB by creating a formal link with the regional hospital in Makeni city. In an effort to improve diagnosis, all patients with a suspicion of TB and one of the following would have a sample sent for Xpert MTB/RIF testing: previous TB treatment (of any course length), HIV positive or known contact of a RR-TB case. The samples were transported by the logistics team, who already drove weekly from Masanga to Makeni for supplies, and the results were texted to the clinician in charge of the medical ward. Over the course of the first 4 months of this intervention, 34 samples had Xpert MTB/RIF testing performed compared with two samples in the previous 12 months since the machine had been installed. This yielded nine additional diagnoses of TB (in patients with negative or unavailable smear results) and five diagnoses of RR-TB with subsequent appropriate isolation and transfer to the central tertiary centre. This study shows that it is feasible to centralise Xpert MTB/RIF testing in low-resource settings using creative methods for sample transfer and results dissemination, leading to both improved diagnostics and infection control.

Import of community-associated, methicillin-resistant Staphylococcus aureus to Europe through skin and soft-tissue infection in intercontinental travellers, 2011-2016

OBJECTIVES

Recently, following import by travel and migration, epidemic community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has caused nosocomial outbreaks in Europe, sometimes with a fatal outcome. We describe clinico-epidemiological characteristics of CA-MRSA detected by the European Network for the Surveillance of imported S. aureus (www.staphtrav.eu) from May 2011 to November 2016.

METHODS

Sentinel surveillance at 13 travel clinics enrolling patients with travel-associated skin and soft-tissue infection (SSTI) and analysing lesion and nose swabs at one central laboratory.

RESULTS

A total of 564 independent case-patients with SSTI were enrolled and had 374 (67%) S. aureus-positive lesions, of which 14% (51/374) were MRSA. The majority of CA-MRSA isolates from SSTI were Panton-Valentine leucocidin (PVL) -positive (43/51, 84%). The risk of methicillin-resistance in imported S. aureus varied by travel region (p <0.001) and was highest in Latin America (16/57, 28%, 95% CI 17.0-41.5) and lowest in Sub-Saharan Africa (4/121, 3%, 95% CI 0.9-8.3). Major epidemic clones (USA300 / USA300 Latin-American Variant, Bengal Bay, South Pacific) accounted for more than one-third (19/51, 37%) of CA-MRSA imports. CA-MRSA SSTI in returnees was complicated (31/51 multiple lesions, 61%; 22/50 recurrences, 44%), led to health-care contact (22/51 surgical drainage, 43%; 7/50 hospitalization, 14%), was transmissible (13/47 reported similar SSTI in non-travelling contacts, 28%), and associated with S. aureus nasal colonization (28 of 51 CA-MRSA cases, 55%; 24 of 28 colonized with identical spa-type in nose and lesion, 85%).

CONCLUSIONS

Travel-associated CA-MRSA SSTI is a transmissible condition that leads to medical consultations and colonization of the infected host.

Effectiveness of service models and organisational structures supporting tuberculosis identification and management in hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review

OBJECTIVE

To determine which service models and organisational structures are effective and cost-effective for delivering tuberculosis (TB) services to hard-to-reach populations.

DESIGN

Embase and MEDLINE (1990-2017) were searched in order to update and extend the 2011 systematic review commissioned by National Institute for Health and Care Excellence (NICE), discussing interventions targeting service models and organisational structures for the identification and management of TB in hard-to-reach populations. The NICE and Cochrane Collaboration standards were followed.

SETTING

European Union, European Economic Area, European Union candidate countries and Organisation for Economic Co-operation and Development countries.

PARTICIPANTS

Hard-to-reach populations, including migrants, homeless people, drug users, prisoners, sex workers, people living with HIV and children within vulnerable and hard-to-reach populations.

PRIMARY AND SECONDARY OUTCOME MEASURES

Effectiveness and cost-effectiveness of the interventions.

RESULTS

From the 19 720 citations found, five new studies were identified, in addition to the six discussed in the NICE review. Community health workers from the same migrant community, street teams and peers improved TB screening uptake by providing health education, promoting TB screening and organising contact tracing. Mobile TB clinics, specialised TB clinics and improved cooperation between healthcare services can be effective at identifying and treating active TB cases and are likely to be cost-effective. No difference in treatment outcome was detected when directly observed therapy was delivered at a health clinic or at a convenient location in the community.

CONCLUSIONS

Although evidence is limited due to the lack of high-quality studies, interventions using peers and community health workers, mobile TB services, specialised TB clinics and improved cooperation between health services can be effective to control TB in hard-to-reach populations. Future studies should evaluate the (cost-)effectiveness of interventions on TB identification and management in hard-to-reach populations and countries should be urged to publish the outcomes of their TB control systems.

PROSPERO REGISTRATION NUMBER

CRD42015017865.

Schistosoma haematobium effects on Plasmodium falciparum infection modified by soil-transmitted helminths in school-age children living in rural areas of Gabon

BACKGROUND

Malaria burden remains high in the sub-Saharan region where helminths are prevalent and where children are often infected with both types of parasites. Although the effect of helminths on malaria infection is evident, the impact of these co-infections is not clearly elucidated yet and the scarce findings are conflicting. In this study, we investigated the effect of schistosomiasis, considering soil-transmitted helminths (STH), on prevalence and incidence of Plasmodium falciparum infection.

METHODOLOGY

This longitudinal survey was conducted in school-age children living in two rural communities in the vicinity of Lambaréné, Gabon. Thick blood smear light microscopy, urine filtration and the Kato-Katz technique were performed to detect malaria parasites, S. haematobium eggs and, STH eggs, respectively. P. falciparum carriage was assessed at inclusion, and incidence of malaria and time to the first malaria event were recorded in correlation with Schistosoma carriage status. Stratified multivariate analysis using generalized linear model was used to assess the risk of plasmodium infection considering interaction with STH, and survival analysis to assess time to malaria.

MAIN FINDINGS

The overall prevalence on subject enrolment was 30%, 23% and 9% for S. haematobium, P. falciparum infections and co-infection with both parasites, respectively. Our results showed that schistosomiasis in children tends to increase the risk of plasmodium infection but a combined effect with Trichuris trichiura or hookworm infection clearly increase the risk (aOR = 3.9 [95%CI: 1.7-9.2]). The incidence of malaria over time was 0.51[95%CI: 0.45-0.57] per person-year and was higher in the Schistosoma-infected group compared to the non-infected group (0.61 vs 0.43, p = 0.02), with a significant delay of time-to first-malaria event only in children aged from 6 to 10-years-old infected with Schistosoma haematobium.

CONCLUSIONS

Our results suggest that STH enhance the risk for P. falciparum infection in schistosomiasis-positive children, and when infected, that schistosomiasis enhances susceptibility to developing malaria in young children but not in older children.

Tuberculosis patients and resilience: A visual ethnographic health study in Khayelitsha, Cape Town

Khayelitsha, one of the biggest and poorest townships in South Africa, has a well-resourced tuberculosis (TB) programme with an interdisciplinary approach addressing the medical, social, and economic forces impacting TB care. Nevertheless, the area remains burdened with one of the highest TB rates in the world. Using a resilience-based approach, we conducted a critical ethnographic study to develop deeper insights into the complexities of patients' experiences with TB and care. Between October 2014 and March 2015, we approached 30 TB patients, 10 health-care workers, 10 pastors, and 10 traditional healers, using participant observation, in-depth interviews, and focus group discussions. In addition, seven key informants were filmed on a daily basis by the lead researcher. The work reported here (both text and short videos) illustrates the various manifestations of resilience that patients demonstrated and how these impacted on decisions involving treatment seeking and adherence. We have synthesized the data into the following inter-related themes: TB aetiologies and treatment; the embodied experience of TB treatment; alcohol consumption; financial constraints; and support and stigma. The findings from this research highlight patients' strategies for adapting to adversities, such as pausing TB treatment when lacking food to avoid becoming psychotic, consuming alcohol to better cope, obtaining social grants, and avoiding stigmatizing attitudes. Some manifestations of resilience may interact and, inadvertently, undermine TB patients' health. Other aspects of resilience, such as strong community ties, elicited long-term health benefits. TB programs would benefit from a resilience-building approach that builds on pre-existing strengths and vulnerabilities of TB patients and their communities. With the use of short videos, we provided patients with an alternative path for expressing their experiences, which we hope will support synergies between patients, researchers, and policy-makers for improved TB programmes.

Rabies antibody response after two intradermal pre-exposure prophylaxis immunizations: An observational cohort study

BACKGROUND

Rabies is a lethal, but vaccine preventable disease. Vaccination uptake is however hampered by the time-consuming three-dose, 21/28-day schedule. The aim of this study was to examine whether adequate rabies antibody titers are reached after two intradermal (ID) doses of rabies vaccine, with a seven-day window.

METHOD

We conducted an observational cohort study with military personnel. A titer was assessed by RFFIT, on the day of the third vaccination, to ensure an adequate rabies antibody response after ID immunization.

RESULTS

After this abbreviated two-dose, seven-day ID schedule, seroconversion was reached in 99.3% (427/430) with a geometric mean titer of 7.59 IU/mL (95% CI 7.04-8.17).

CONCLUSIONS

Implementation of this two-dose schedule will protect more people against Rabies. Travelers and military personnel under time constraints, who otherwise would remain unvaccinated, can be considered adequately protected after this two-dose schedule. For populations in endemic areas, local application of a two-dose schedule could provide an opportunity to vaccinate more people with less vaccine. Given the paucity of published data, this study adds relevant evidence in support of the new policy (2017) of WHO, concerning a two-dose, seven-day schedule is approved for all healthy individuals.

Fulminant presentation of oral mucosal leishmaniasis as severe stomatitis and periodontitis

This case report shows an atypical presentation of mucosal leishmaniasis infantum in the oral cavity resulting in severe stomatitis and periodontitis. The patient was immunocompromised because of rheumatoid arthritis for which he used prednisone and methotrexate. He was treated with intravenous liposomal amphotericin B and recovered within four weeks.

Abbreviated atovaquone-proguanil prophylaxis regimens in travellers after leaving malaria-endemic areas: A systematic review

BACKGROUND

We evaluated existing data on the prophylactic efficacy of atovaquone-proguanil (AP) in order to determine whether prophylaxis in travellers can be discontinued on the day of return from a malaria-endemic area instead of seven days after return as per currently recommended post-travel schedule.

METHODS

PubMed and Embase databases were searched to identify relevant studies. This PROSPERO-registered systematic review followed PRISMA guidelines. The search strategy included terms or synonyms relevant to AP combined with terms to identify articles relating to prophylactic use of AP and inhibitory and half-life properties of AP. Studies considered for inclusion were: randomized controlled trials, cohort studies, quasi-experimental studies, open-label trials, patient-control studies, cross-sectional studies; as well as case-series and non-clinical studies. Data on study design, characteristics of participants, interventions, and outcomes were extracted. Primary outcomes considered relevant were prophylactic efficacy and prolonged inhibitory activity and half-life properties of AP.

RESULTS

The initial search identified 1,482 publications, of which 40 were selected based on screening. Following full text review, 32 studies were included and categorized into two groups, namely studies in support of the current post-travel regimen (with a total of 2,866 subjects) and studies in support of an alternative regimen (with a total of 533 subjects).

CONCLUSION

There is limited direct and indirect evidence to suggest that an abbreviated post-travel regimen for AP may be effective. Proguanil, however, has a short half-life and is essential for the synergistic effect of the combination. Stopping AP early may result in mono-prophylaxis with atovaquone and possibly select for atovaquone-resistant parasites. Furthermore, the quality of the studies in support of the current post-travel regimen outweighs the quality of the studies in support of an alternative short, post-travel regimen, and the total sample size of the studies to support stopping AP early comprises a small percentage of the total sample size of the studies performed to establish the efficacy of the current AP regimen. Additional research is required - especially from studies evaluating impact on malaria parasitaemia and clinical illness and conducted among travellers in high malaria risk settings - before an abbreviated regimen can be recommended in current practice.

PROSPERO REGISTRATION NUMBER

CRD42017055244.

Low incidence of the immune reconstitution inflammatory syndrome among HIV-infected patients starting antiretroviral therapy in Gabon: a prospective cohort study

There is a paucity of data on the immune reconstitution inflammatory syndrome (IRIS) in the Central African region. We followed ART-naive HIV-infected patients initiating antiretroviral therapy in an HIV clinic in Gabon, for 6 months. Among 101 patients, IRIS was diagnosed in five. All IRIS cases were mucocutaneous manifestations. There were no cases of tuberculosis (TB) IRIS, but active TB (n = 20) was associated with developing other forms of IRIS (p = 0.02). Six patients died. The incidence of IRIS is low in Gabon, with mild, mucocutaneous manifestations.

Long-term sequelae of chikungunya virus disease: A systematic review

BACKGROUND

The acute phase of chikungunya is well documented; less so are its long-term effects. This systematic literature review provides an overview of the currently available data.

METHODS

We performed an electronic search in PubMed/Medline and checked reference lists. We included studies in English on long-term sequelae of chikungunya in adults and on long-term sequelae of congenital infection from 2000 to 2016. Case reports, reviews and studies with a follow-up shorter than 6 weeks were excluded.

RESULTS

In total, 37 studies were included; with follow-up periods ranging from 1.5 to 72 months. Most studies were questionnaire-based studies only, in which clinical diagnoses such as arthritis, alopecia and depression were mostly recorded without professional verification. Persisting arthralgia/arthritis (arthralgia/joint stiffness plus joint swelling) was the most frequent problem encountered. Further frequently mentioned sequelae were alopecia and depression. Quality of life was reduced in many for months to years after the acute phase of chikungunya. Female gender, older age, some co-morbidities and the severity of the acute phase were associated with persistent arthralgia. Congenital infection was associated with neurocognitive dysfunctioning in early childhood.

CONCLUSION

Chikungunya leads to (self-perceived) long-term sequelae in a considerable proportion of patients, impacting significantly on quality of life. Long-term chikungunya sequelae must be taken into account when dealing with this disease because of its important effect on public and individual health. Prospective large-scale, long-term studies with objective assessment of signs and symptoms attributed to the disease are needed to optimally quantify and qualify these problems.

Tackling TB in low-incidence countries: improving diagnosis and management in vulnerable populations

In low tuberculosis incidence regions, tuberculosis is mainly concentrated among hard-to-reach populations like migrants, homeless people, drug or alcohol abusers, prisoners and people living with HIV. To be able to eliminate tuberculosis from these low incidence regions tuberculosis screening and treatment programs should focus on these hard-to-reach populations. Here we discuss the barriers and facilitators of health care-seeking, interventions improving tuberculosis screening uptake and interventions improving treatment adherence in these hard-to-reach populations.

Drug-resistant tuberculosis clinical trials: proposed core research definitions in adults

Drug-resistant tuberculosis (DR-TB) is a growing public health problem, and for the first time in decades, new drugs for the treatment of this disease have been developed. These new drugs have prompted strengthened efforts in DR-TB clinical trials research, and there are now multiple ongoing and planned DR-TB clinical trials. To facilitate comparability and maximise policy impact, a common set of core research definitions is needed, and this paper presents a core set of efficacy and safety definitions as well as other important considerations in DR-TB clinical trials work. To elaborate these definitions, a search of clinical trials registries, published manuscripts and conference proceedings was undertaken to identify groups conducting trials of new regimens for the treatment of DR-TB. Individuals from these groups developed the core set of definitions presented here. Further work is needed to validate and assess the utility of these definitions but they represent an important first step to ensure there is comparability in clinical trials on multidrug-resistant TB.

Enhanced laboratory capacity development: a boost for effective tuberculosis control in resource-limited settings

Both routine and research tuberculosis (TB) laboratory capacity urgently need to be expanded in large parts of Sub-Saharan Africa. In 2009, the Centre de Recherches Médicales de Lambaréné (CERMEL) took a strategic decision to expand its activities by building TB laboratory capacity to address research questions and to improve routine diagnostic and treatment capacity. Over the past 7 years, a standard laboratory has been developed that is contributing significantly to TB diagnosis, treatment, and control in Gabon; training has also been provided for TB research staff in Central Africa. CERMEL has a cordial relationship with the Gabon National TB Control Programme (PNLT), which has culminated in a successful Global Fund joint application. This endeavour is considered a model for similar developments needed in areas of high TB prevalence and where TB control remains poor to date.

Monoclonal antibodies for the treatment of Ebola virus disease

INTRODUCTION

To date, the management of patients with suspected or confirmed Ebolavirus disease (EVD) depends on quarantine, symptomatic management and supportive care, as there are no approved vaccines or treatments available for human use. However, accelerated by the recent large outbreak in West Africa, significant progress has been made towards vaccine development but also towards specific treatment with convalescent plasma and monoclonal antibodies. Areas covered: We describe recent developments in monoclonal antibody treatment for EVD, encompassing mAb114 and the MB-003, ZMAb, ZMapp™ and MIL-77E cocktails. Expert opinion: Preventive measures, are, and will remain essential to curb EVD outbreaks; even more so with vaccine development progressing. However, research for treatment options must not be neglected. Small-scale animal and individual human case studies show that monoclonal antibodies (mAbs) can be effective for EVD treatment; thus justifying exploration in clinical trials. Potential limitations are that high doses may be needed to yield clinical efficacy; epitope mutations might reduce efficacy; and constant evolution of (outbreak-specific) mAb mixtures might be required. Interim advice based on the clinical experience to date is that treatment of patients with mAbs is sensible, provided those could be made available in the necessary amounts in time.