Ovarian cancer survival in sub-Saharan Africa by human development index and histological subtypes: A population-based registry study

Ovarian cancer (OC) is the fourth most common cancer of women in sub-Saharan Africa (SSA), although few data have been published on population-level survival. We estimate ovarian cancer survival in SSA by human development index and histological subtype, using data from seven population-based cancer registries in six countries: Kenya (Nairobi and Eldoret), Mauritius, Uganda (Kampala), Cote d'Ivoire (Abidjan), Ethiopia (Addis Ababa) and South Africa (Eastern Cape). A total of 644 cases diagnosed during 2008-2014 were included, with 77% being of epithelial subtypes (range 47% [Abidjan]-80% [Mauritius]). The overall observed survival in the study cohort was 73.4% (95% CI: 69.8, 77.0) at 1 year, 54.4% (95% CI: 50.4, 58.7) at 3 years and 45.0% (95% CI: 41.0, 49.4) at 5 years. Relative survival at Year 1 ranged from 44.4% in Kampala to 86.3% in Mauritius, with a mean for the seven series of 67.4%. Relative survival was highest in Mauritius at 72.2% and lowest in Kampala, Uganda at 19.5%, with a mean of 47.8%. There was no difference in survival by age at diagnosis. Patients from high and medium HDI countries had significantly better survival than those from low HDI countries. Women with cancers of epithelial cell origin had much lower survival compared to women with other histological subtypes (p = .02). Adjusted for the young age of the African patients with ovarian cancer (44% aged <50) survival is much lower than in USA or Europe, and underlines the need for improvements in the access to diagnosis and treatment of OC in SSA.

Prevalence and risk factors of metabolic dysfunction-associated steatotic liver disease in south Central Uganda: A cross-sectional survey

BACKGROUND

Despite numerous risk factors and serious consequences, little is known about metabolic dysfunction-associated steatotic liver disease (MASLD) at population level in Africa.

AIM

The aim of the study was to estimate the prevalence and risk factors of MASLD in people living with and without HIV in Uganda.

METHODS

We collected data from 37 communities in South Central Uganda between May 2016 and May 2018. We estimated MASLD prevalence using the fatty liver index and advanced liver fibrosis using the dynamic aspartate-to-alanine aminotransferase ratio. We collected additional data on sociodemographics, HIV and cardiovascular disease (CVD) risk factors. We used multivariable logistic regression to determine the association between HIV, CVD risk factors and MASLD.

RESULTS

We included 759 people with HIV and 704 HIV-negative participants aged 35-49. MASLD prevalence was 14% in women and 8% in men; advanced liver fibrosis prevalence was estimated to be <1%. MASLD prevalence was more common in women (15% vs. 13%) and men (9% vs. 6%) with HIV. Being female (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.4-3.3) was associated with a higher odds of MASLD after adjustment for confounders; HIV infection was borderline associated with MASLD (OR = 1.4; 95% CI: 1.0-2.0).

CONCLUSIONS

In a relatively young cohort in Uganda, 14% of women and 8% of men had MASLD. There was an indication of an association between HIV and MASLD in multivariable analysis. These data are the first to describe the population-level burden of MASLD in sub-Saharan Africa using data from a population-based cohort.

Prevalence and Predictors of Gestational Diabetes Mellitus in Sub-Saharan Africa: A 10-Year Systematic Review

BACKGROUND

Gestational diabetes mellitus (GDM) remains a global public health problem, which affects the well-being of mothers and their children in sub-Saharan Africa (SSA). Studies conducted in different geographical areas provide varied results on its prevalence and predictors. Understanding the extent and predictors of GDM in SSA is important for developing effective interventions and policies. Thus, this review aimed to investigate the prevalence of GDM and its predictive factors in sub-Saharan Africa.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards in this review. An extensive search of the PubMed, Web of Sciences and EMBASE databases was carried out covering papers from 2012 to 2022 to assess the prevalence and predictors of GDM. Microsoft Excel 2019 was utilised for study management. GraphPad Prism Version 8.0 and the MedCalc statistical software were employed for data analysis. The findings were analysed using textual descriptions, tables, forest plots and heat maps.

RESULTS

Using 30 studies with 23,760 participants that satisfied the inclusion criteria, the review found the overall prevalence of GDM in SSA to be 3.05% (1.85%-4.54%). History of preterm delivery, alcohol consumption, family history of diabetes, history of stillbirths, history of macrosomia, overweight or obesity and advanced mother age were all significant predictors of gestational diabetes. Additionally, various biomarkers such as haemoglobin, adiponectin, leptin, resistin, visfatin, vitamin D, triglycerides and dietary intake type were identified as significant predictors of GDM.

CONCLUSION

In sub-Saharan Africa, there is a high pooled prevalence of gestational diabetes mellitus. In the light of the predictors of GDM identified in this review, it is strongly recommended to implement early screening for women at risk of developing gestational diabetes during their pregnancy. This proactive approach is essential for enhancing the overall well-being of both mothers and children.

Advances in pediatric anesthesia services over the past 10 years in French-speaking sub-Saharan Africa

INTRODUCTION

To improve and maintain quality and safety in anesthesia, standards have been proposed regarding human resources, facilities and equipment, medications and intravenous fluids, monitoring, and the conduct of anesthesia. Compliance with these standards remains a challenge in French-speaking sub-Saharan Africa (SSA) and results in high morbidity and mortality particularly in children. This aim of this study was to assess the progress made in improving the pediatric anesthesia infrastructures, human resources, education, medications, and equipment in French-speaking SSA over the past 10 years (2013-2022).

METHODS

This is a descriptive, multicenter, cross-sectional study with retrospective data collection, conducted from September 1 to November 5, 2023. Comparative data from 2012 to 2022 were collected through an online survey. Descriptive statistics were used to summarize data.

RESULTS

Data were obtained from 12 countries out of 14. The number of hospitals providing pediatric surgery and anesthesia rose from 94 in 2012 to 142 in 2022 (+51%). The total number of physician anesthesiologists rose from 293 (0.1 physician anesthesiologists/100 000 inhabitants) in 2012 to 597 (0.2 physician anesthesiologists/100 000 inhabitants) in 2022 (+103.7%). Five (0.006 physician anesthesiologists/100 000 children) had completed a fellowship in pediatric anesthesia and intensive care in 2012, and 15 (0.01 physician anesthesiologists/100 000 children) in 2022 (+200%). Five physician anesthesiologists had an exclusive pediatric anesthesia practice in 2012, whereas they were 32 in 2022 (+540%). There is no specialized training in pediatric anesthesia and intensive care in any of these countries. Halothane was always available in 81.5% of the hospitals in 2012, and in 50.4% of the hospitals in 2022. Sevoflurane was always available in 5% of the hospitals in 2012, and in 36.2% in 2022. Morphine was always available in 32.2% in 2012, whereas it was available in 52.9% of them in 2022. Pediatric pulse oximeter sensors were available in 36% of the hospitals in 2012, and in 63.4% in 2022. Capnography was available in 5.3% of the hospitals in 2012, and in 48% in 2022.

CONCLUSION

Progress have been made over the last 10 years in French-speaking SSA to improve infrastructures, human resources, education, medications, and equipment for pediatric anesthesia in French-speaking SSA. However, major efforts must be continued. Standards adapted to the local context should be formulated.

Blood pressure and the hypertension care cascade in The Gambia: Findings from a nationwide survey

Community treatment of hypertension in sub-Saharan Africa is hampered by gaps at several stages of the care cascade. We compared blood pressure (BP) levels (systolic, diastolic and pulse pressures) in four groups of participants by hypertension and treatment status. We conducted a nationally representative survey of adults 35 years and older using a multistage sampling strategy based on the 2013 Gambia Population and Housing Census. The BP measurements were taken in triplicate 5 min apart, and the average of the last two measurements was used for analysis. Systolic and diastolic BP levels and pulse pressure were compared by hypertension status using mean and 95% confidence intervals (CI). 53.1% of the sample were normotensive with mean systolic BP (SBP) of 119.2 mmHg (95% CI, 118.7-119.6) and diastolic BP (DBP) of 78.1 mmHg (77.8-78.3). Among individuals with hypertension, mean SBP was 148.7 mmHg (147.7-149.7) among those unaware of their hypertension, 152.2 mmHg (151.0-153.5) among treated individuals and was highest in untreated individuals at 159.3 mmHg (157.3-161.2). The findings were similar for DBP levels, being 93.9 mmHg (93.4-94.4) among the unaware, 95.1 mmHg (94.4-95.8) among the treated and highest at 99.1 mmHg (98.1-100.2) in untreated participants. SBP and DBP were higher in men, and SBP was as expected higher in those aged ≥55 years. BP level was similar in urban and rural areas. Our data shows high BP levels among participants with hypertension including those receiving treatment. Efforts to reduce the health burden of hypertension will require inputs at all levels of the care cascade.

Review of epilepsy care in the Democratic Republic of the Congo

Epilepsy imposes a substantial burden on the Democratic Republic of Congo (DRC). These challenges encompass the lack of comprehensive disease surveillance, an unresolved understanding of its pathophysiology, economic barriers limiting access to essential care, the absence of epilepsy surgical capabilities, and deeply ingrained societal stigmas. Notably, the national prevalence of epilepsy remains undetermined, with research primarily concentrating on infectious factors like Onchocerca volvulus, leaving other potential causes underexplored. Most patients lack insurance, incurring out-of-pocket expenses that often lead them to opt for traditional medicine rather than clinical care. Social stigma, perpetuated by common misconceptions, intensifies the social isolation experienced by individuals living with epilepsy. Additionally, surgical interventions are unavailable, and the accessibility of anti-seizure medications and healthcare infrastructure remains inadequate. Effectively tackling these interrelated challenges requires a multifaceted approach, including conducting research into region-specific factors contributing to epilepsy, increasing healthcare funding, subsidizing the costs of treatment, deploying mobile tools for extensive screening, launching awareness campaigns to dispel myths and reduce stigma, and promoting collaborations between traditional healers and medical practitioners to enhance local understanding and epilepsy management. Despite the difficulties, significant progress can be achieved through sustained and compassionate efforts to understand and eliminate the barriers faced by epilepsy patients in the region. This review outlines essential steps for alleviating the epilepsy burden in the DRC. PLAIN LANGUAGE SUMMARY: There are not enough resources to treat epilepsy in the DRC. PWEs struggle with stigma and the lack of money. Many of them still use traditional medicine for treatment and hold wrong beliefs about epilepsy. That is why there is a need for more resources to make the lives of PWEs better in the DRC.

High pre-Delta and early-Omicron SARS-CoV-2 seroprevalence detected in dried blood samples from Kinshasa (D.R. Congo)

Studies on the impact of the COVID-19 pandemic in sub-Saharan Africa have yielded varying results, although authors universally agree the real burden surpasses reported cases. The primary objective of this study was to determine SARS-CoV-2 seroprevalence among patients attending Monkole Hospital in Kinshasa (D.R. Congo). The secondary objective was to evaluate the analytic performance of two chemiluminescence platforms: Elecsys® (Roche) and VirClia® (Vircell) on dried blood spot samples (DBS). The study population (N = 373) was recruited in two stages: a mid-2021 blood donor cohort (15.5% women) and a mid-2022 women cohort. Crude global seroprevalence was 61% (53.9%-67.8%) pre-Delta in 2021 and 90.2% (84.7%-94.2%) post-Omicron in 2022. Anti-spike (S) antibody levels significantly increased from 53.1 (31.8-131.3) U/mL in 2021 to 436.5 (219.3-950.5) U/mL in 2022 and were significantly higher above 45 years old in the 2022 population. Both platforms showed good analytic performance on DBS samples: sensitivity was 96.8% for IgG (antiN/S) (93.9%-98.5%) and 96.0% (93.0%-98.0%) for anti-S quantification. These results provide additional support for the notion that exposure to SARS-CoV-2 is more widespread than indicated by case-based surveillance and will be able to guide the pandemic response and strategy moving forward. Likewise, this study contributes evidence to the reliability of DBS as a tool for serological testing and diagnosis in resource-limited settings.

Identifying Profiles of Support for Legal Abortion Services in Zambia: A Latent Class Analysis

Relative to neighboring countries, Zambia has among the most progressive abortion policies, but numerous sociopolitical constraints inhibit knowledge of pregnancy termination rights and access to safe abortion services. Multistage cluster sampling was used to randomly select 1,486 women aged 15-44 years from households in three provinces. We used latent class analysis (LCA) to partition women into discrete groups based on patterns of endorsed support for legalized abortion on six socioeconomic and health conditions. Predictors of probabilistic membership in latent profiles of support for legal abortion services were identified through mixture modeling. A three-class solution of support patterns for legal abortion services emerged from LCA: (1) legal abortion opponents (∼58 percent) opposed legal abortion across scenarios; (2) legal abortion advocates (∼23 percent) universally endorsed legal protections for abortion care; and (3) conditional supporters of legal abortion (∼19 percent) only supported legal abortion in circumstances where the pregnancy threatened the fetus or mother. Advocates and Conditional supporters reported higher exposure to family planning messages compared to opponents. Relative to opponents, advocates were more educated, and Conditional supporters were wealthier. Findings reveal that attitudes towards abortion in Zambia are not monolithic, but women with access to financial/social assets exhibited more receptive attitudes towards legal abortion.

No Evidence for an Association of HIV and Antiviral Treatment With Changes in Framingham Cardiovascular Risk Score in the Ndlovu Cohort Study

BACKGROUND

HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease (CVD) risk in high-income countries. The authors studied the longitudinal association between HIV and ART and nonlaboratory Framingham Risk Score (FRS) in a middle-income country.

METHODS AND RESULTS

This longitudinal analysis of the NCS (Ndlovu Cohort Study), South Africa used baseline to 36-month follow-up data. Demographics, HIV, ART status, and cardiometabolic measures were obtained. FRS was used as a CVD risk measure. Through linear mixed models, FRS trends over time and the association with HIV were studied. Analysis included 1136 participants, with 609 (54%) having HIV, and 495 (81%) taking ART. At baseline, 9.8% of participants had a high FRS. People living with HIV (PLHIV) had a 3.2% lower FRS than HIV-negative participants (P<0.001). FRS increased similarly for both groups over time. Other factors associated with FRS were secondary and higher education (ß value: -0.075, P<0.001; ß value: -0.084, P<0.001) and alcohol consumption (ß value: 0.011, P<0.001).

CONCLUSIONS

CVD risk increased for all participants over 36 months, suggesting classic risk factors rather than HIV status or ART to be drivers of CVD risk. People living with HIV had a significantly lower FRS than their HIV-negative counterparts, possibly related to HIV itself or a more frequent interaction with healthcare services. No association of HIV and ART with changes in FRS over 36 months was observed, suggesting the need for research using clinical endpoints to elucidate the effects of HIV and ART on CVD risk. Population-based prevention of CVD risk factors in sub-Saharan Africa is warranted, regardless of HIV status.

Functional foods of sub-Saharan Africa and their implications in the management of type 2 diabetes: A review

Throughout the world, the prevalence of metabolic diseases in general and type 2 diabetes (T2DM) in particular is constantly growing, and sub-Saharan Africa (SSA) is not spared. The use of functional foods is a more practical option among the different approaches used in the management of T2DM owing to the fact that they are relatively less costly, safer, and more accessible. In addition to their low glycemic index just like foods currently used to manage diabetes, functional foods contain bioactive compounds such as polyphenols, dietary fibers, saponins, and peptides. They are so named because they have additional health advantages beyond their basic nutritional worth. Bioactive compounds can be found in a variety of SSA plant-based foods, such as spices, fruits, vegetables, legumes, starchy foods, prepared foods, mixed foods, and prepared dishes. The goal of this review is to highlight some of the investigations into the effectiveness of local food and their antidiabetic mechanisms that have been studied in various SSA regions. Using the literature review as a basis, the authors state that SSA foods are rich in various bioactive compounds capable of regulating blood sugar through enhanced glucose tolerance, antioxidant effects, insulin sensitivity, and inhibition or activation of some key enzymes of the glucose metabolism that are linked to the prevention and management of T2DM. Many of the cited findings are preliminary, obtained from cell and preclinical studies, and therefore other studies need to be done to demonstrate the full potential of these foods to serve as bases for dietary guidelines.

Spatial Optimization Methods for Malaria Risk Mapping in Sub-Saharan African Cities Using Demographic and Health Surveys

Vector-borne diseases, such as malaria, are affected by the rapid urban growth and climate change in sub-Saharan Africa (SSA). In this context, intra-urban malaria risk maps act as a key decision-making tool for targeting malaria control interventions, especially in resource-limited settings. The Demographic and Health Surveys (DHS) provide a consistent malaria data source for mapping malaria risk at the national scale, but their use is limited at the intra-urban scale because survey cluster coordinates are randomly displaced for ethical reasons. In this research, we focus on predicting intra-urban malaria risk in SSA cities-Dakar, Dar es Salaam, Kampala and Ouagadougou-and investigate the use of spatial optimization methods to overcome the effect of DHS spatial displacement. We modeled malaria risk using a random forest regressor and remotely sensed covariates depicting the urban climate, the land cover and the land use, and we tested several spatial optimization approaches. The use of spatial optimization mitigated the effects of DHS spatial displacement on predictive performance. However, this comes at a higher computational cost, and the percentage of variance explained in our models remained low (around 30%-40%), which suggests that these methods cannot entirely overcome the limited quality of epidemiological data. Building on our results, we highlight potential adaptations to the DHS sampling strategy that would make them more reliable for predicting malaria risk at the intra-urban scale.

Hypertension treatment in sub-Saharan Africa: a systematic review

Sub-Saharan Africa (SSA) faces the highest rate of hypertension worldwide. Blood pressure (BP) control rests on the association of lifestyle modification and antihypertensive medicines. We aimed to systematically review antihypertensive strategies implemented in SSA to achieve BP control. A systematic search beginning in 2003 was performed in MEDLINE, COCHRANE and EMBASE. We included only original and observational studies in SSA countries. Thirty studies were included from 11 countries. No study was multinational. The number of patients varied from 111 to 897 (median: 294; IQR: 192-478). Overall, 21% of patients received monotherapy, 42.6% two-drug and 26.6% three-drug combinations. Out of all the strategies, renin-angiotensin system (RAS) blockers were mostly prescribed, followed by diuretics and calcium channel blockers. In monotherapy, RAS blockers were the first to be prescribed. Only 10 articles described antihypertensive strategies beyond triple combinations. BP control was highly variable (range: 16.4 to 61.2%). Multicentre studies performed in several SSA countries are needed to ensure international guidelines actually do improve outcomes in SSA.

Multiple indicators of violence against female sex workers and its associated factors in Ghana: Evidence from the 2015 integrated bio-behavioral surveillance survey cross-sectional study

Background and Aims

Violence against female sex workers (FSWs) is a widespread phenomenon, especially in African nations like Ghana where sex work is outlawed primarily because of the pervasive worldview that sex work is a contravention of morality. Violence against FSWs deters them from accessing critical health services and heightens their risk of STIs including HIV infection. The study examined the prevalence and the associated factors of multiple indicators of violence against FSWs.

Methods

The study utilized a cross-sectional secondary data from the 2015 Integrated Bio-Behavioral Surveillance Survey conducted among FSWs and their nonpaying partners by Ghana AIDS Commission. We analysed data on a total of 4279 participants. Bivariate, and multivariable logistic regression analyses were utilized to identify factors associated with physical and sexual violence against FSWs. Data were analysed using Stata version 15.

Results

Of the 4279 FSWs, 433 (10%) and 1059 (25%) suffered physical and sexual violence, respectively. The predictors of physical violence are being a seater (adjusted odds ratio [aOR] = 0.53, 95% confidence interval [CI]: 0.36-0.74), aged ≥40 (aOR = 0.23, 95% CI: 0.08-0.64), nonuse of drugs (aOR = 0.56, 95% CI: 0.44-0.70), not using alcohol before sex (aOR = 0.69, 95% CI: 0.56-0.86) and petty business (aOR = 1.39, 95% CI: 1.05-1.82). Sexual violence was predicted by those aged 31-40 (aOR = 0.68, 95% CI: 0.49-0.94) and age ≥40 (aOR = 0.38, 95% CI: 0.22-0.66), currently married (aOR = 0.42, 95% CI: 0.27-0.67), having no living children (aOR = 0.69, 95% CI: 0.51-0.94), nonuse of drugs (aOR = 0.80, 95% CI: 0.68-0.94), and not using alcohol before sex (aOR = 0.74, 95% CI: 0.63-0.86). Region was associated with both physical and sexual violence. Both physical and sexual violence had negative consequences on consistency of condom use and condom failure among FSWs.

Conclusion

Physical and sexual violence against FSWs is pervasive, and a critical public health issue in Ghana. The identified associated factors could be considered as part of an overall strategy aimed at addressing the menace.

Health facility delivery and early initiation of breastfeeding: Cross-sectional survey of 11 sub-Saharan African countries

Background and Aims

Early initiation of breastfeeding (EIB) remains one of the promising interventions for preventing neonatal and child deaths. EIB is positively associated with healthcare delivery or childbirth. Meanwhile, no study in sub-Saharan Africa (SSA) appears to have investigated the relationship between health facility delivery and EIB; thus, we assessed the correlation between health facility delivery and EIB.

Methods

We used data from the Demographic and Health Survey (DHS) of 64,506 women from 11 SSA countries. The outcome variable was whether the respondent had early breastfeeding or not. Two logistic regression models were used in the inferential analysis. With a 95% confidence interval (CI), the adjusted odds ratios (aORs) for each variable were calculated. The data set was stored, managed, and analyzed using Stata version 13.

Results

The overall percentage of women who initiated early breastfeeding was 59.22%. Rwanda recorded the highest percentage of early initiation of breastfeeding (86.34%), while Gambia recorded the lowest (39.44%). The adjusted model revealed a significant association between health facility delivery and EIB (aOR = 1.80, CI = 1.73-1.87). Compared with urban women, rural women had higher likelihood of initiating early breastfeeding (aOR = 1.22, CI = 1.16-1.27). Women with a primary education (aOR = 1.26, CI = 1.20-1.32), secondary education (aOR = 1.12, CI = 1.06-1.17), and higher (aOR = 1.13, CI = 1.02-1.25), all had higher odds of initiating early breastfeeding. Women with the richest wealth status had the highest odds of initiating early breastfeeding as compared to the poorest women (aOR = 1.33, CI = 1.23-1.43).

Conclusion

Based on our findings, we strongly advocate for the integration of EIB policies and initiatives with healthcare delivery advocacy. Integration of these efforts can result in drastic reduction in infant and child mortality. Essentially, Gambia and other countries with a lower proclivity for EIB must reconsider their current breastfeeding interventions and conduct the necessary reviews and modifications that can lead to an increase in EIB.

Improving cardiovascular outcomes for patients with heart failure in sub-Saharan Africa: conference proceedings of the 2022 Nigerian Cardiovascular Symposium

The Nigerian Cardiovascular Symposium is an annual conference held in partnership with cardiologists in Nigeria and the diaspora to provide updates in cardiovascular medicine and cardiothoracic surgery with the aim of optimising cardiovascular care for the Nigerian population. This virtual conference (due to the COVID-19 pandemic) has created an opportunity for effective capacity building of the Nigerian cardiology workforce. The objective of the conference was for experts to provide updates on current trends, clinical trials and innovations in heart failure, selected cardiomyopathies such as hypertrophic cardiomyopathy and cardiac amyloidosis, pulmonary hypertension, cardiogenic shock, left ventricular assist devices and heart transplantation. Furthermore, the conference aimed to equip the Nigerian cardiovascular workforce with skills and knowledge to optimise the delivery of effective cardiovascular care, with the hope of curbing 'medical tourism' and the current 'brain drain' in Nigeria. Challenges to optimal cardiovascular care in Nigeria include workforce shortage, limited capacity of intensive care units, and availability of medications. This partnership represents a key first step in addressing these challenges. Future action items include enhanced collaboration between cardiologists in Nigeria and the diaspora, advancing participation and enrollment of African patients in global heart failure clinical trials, and the urgent need to develop heart failure clinical practice guidelines for Nigerian patients.

Exploring the cognitive development of children born to adolescent mothers in South Africa

This study explores the cognitive development of children born to adolescent mothers within South Africa compared to existing reference data, and explores development by child age bands to examine relative levels of development. Cross-sectional analyses present data from 954 adolescents (10-19 years) and their first-born children (0-68 months). All adolescents completed questionnaires relating to themselves and their children, and standardized child cognitive assessments (Mullen Scales of Early Learning) were undertaken. Cognitive development scores of the sample were lower than USA reference population scores and relative performance compared to the reference population was found to decline with increasing child age. When compared to children born to adult mothers in the sub-Saharan African region, children born to adolescent mothers (human immunodeficiency virus [HIV] unexposed; n = 724) were found to have lower cognitive development scores. Findings identify critical periods of development where intervention may be required to bolster outcomes for children born to adolescent mothers.

Highlights

An exploration of the cognitive development of children born to adolescent mothers within South Africa utilizing the Mullen Scales of Early Learning.Cognitive development scores of children born to adolescent mothers within South Africa were lower compared to USA norm reference data and declined with child age.Previous studies utilizing the Mullen Scales of Early Learning within sub-Saharan Africa were summarized, and comparisons were made with the current sample.Findings highlight a potential risk of developmental delay among children born to adolescent mothers compared to children of adult mothers in the sub-Saharan African region.

Molecular detection and quantification of the Striga seedbank in agricultural soils

Striga hermonthica (Del.) Benth is a devastating parasitic weed in Sub-Saharan Africa (SSA) and its soil seedbank is the major factor contributing to its prevalence and persistence. To date, there is a little information on the Striga seedbank density in agricultural fields in SSA due to the lack of reliable detection and quantification methods. We developed a high-throughput method that combines density- and size-based separation techniques with quantitative polymerase chain reaction (qPCR)-based detection of Striga seeds in soil. The method was optimised and validated by introducing increasing numbers of Striga seeds in two physicochemically different Striga-free agricultural soils. The results showed that as little as one seed of S. hermonthica per 150 g of soil could be detected. This technique was subsequently tested on soil samples of 48 sorghum fields from different agro-ecological zones in Ethiopia to map the geospatial distribution of the Striga seedbank along a trajectory of more than 1500 km. Considerable variation in Striga seed densities was observed. Striga seeds were detectable in 75% of the field soils with densities up to 86 seeds per 150 g of soil. The Striga seed density in soil and the number of emerged Striga plants in the field showed a non-linear relationship. In conclusion, the method developed allows for accurate mapping of the Striga seedbank in physicochemically diverse SSA field soils and can be used to assess the impact of management strategies on Striga seedbank dynamics.

Acute Coronary Syndromes in Sub-Saharan Africa: A 10-Year Systematic Review

Background Data in the literature on acute coronary syndrome in sub-Saharan Africa are scarce. Methods and Results We conducted a systematic review of the MEDLINE (PubMed) database of observational studies of acute coronary syndrome in sub-Saharan Africa from January 1, 2010 to June 30, 2020. Acute coronary syndrome was defined according to current definitions. Abstracts and then the full texts of the selected articles were independently screened by 2 blinded investigators. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. We identified 784 articles with our research strategy, and 27 were taken into account for the final analysis. Ten studies report a prevalence of acute coronary syndrome among patients admitted for cardiovascular disease ranging from 0.21% to 22.3%. Patients were younger, with a minimum age of 52 years in South Africa and Djibouti. There was a significant male predominance. Hypertension was the main risk factor (50%-55% of cases). Time to admission tended to be long, with the longest times in Tanzania (6.6 days) and Burkina Faso (4.3 days). Very few patients were admitted by medicalized transport, particularly in Côte d'Ivoire (only 34% including 8% by emergency medical service). The clinical presentation is dominated by ST-elevation sudden cardiac arrest. Percutaneous coronary intervention is not widely available but was performed in South Africa, Kenya, Côte d'Ivoire, Sudan, and Mauritania. Fibrinolysis was the most accessible means of revascularization, with streptokinase as the molecule of choice. Hospital mortality was highly variable between 1.2% and 24.5% depending on the study populations and the revascularization procedures performed. Mortality at follow-up varied from 7.8% to 43.3%. Some studies identified factors predictive of mortality. Conclusions The significant disparities in our results underscore the need for a multicenter registry for acute coronary syndrome in sub-Saharan Africa in order to develop consensus-based strategies, propose and evaluate tailored interventions, and identify prognostic factors.

Multilevel modeling, prevalence, and predictors of hypertension in Ghana: Evidence from Wave 2 of the World Health Organization's Study on global AGEing and adult health

BACKGROUND AND AIMS

Hypertension is a major public health issue, an important risk factor for cardiovascular diseases and stroke, especially in developing countries where the rates remain unacceptably high. In Africa, hypertension is the leading driver of cardiovascular disease and stroke deaths. Identification of critical risk factors of hypertension can help formulate targeted public health programs and policies aimed at reducing the prevalence and its associated morbidity, disability, and mortality. This study attempts to develop multilevel regression, an in-depth statistical model to identify critical risk factors of hypertension.

METHODS

This study used data on 4667 individuals aged ≥18 years from the nationally representative World Health Organization Study on global AGEing and adult health (SAGE) Ghana Wave 2 conducted in 2014/2015. Multilevel regression modeling was employed to identify critical risk factors for hypertension based on systolic blood pressure (SBP) (ie, SBP > 140 mmHg). Of the 4667, 27.3% were hypertensive. Final data on 4381 individuals residing in 3790 households were analyzed using multilevel models, and results were presented as adjusted odds ratios (aOR) and their associated 95% confidence intervals (CI).

RESULTS

Risk factors for hypertension identified were age (aOR) = 5.4, 95% CI: 4.11-7.09), obesity (aOR = 1.51, 95% CI: 1.19-1.91), marital status (aOR = 0.75, 95% CI: 0.64-0.89), perceived health state (moderate; aOR = 1.38, 95% CI: 1.15-1.65 and bad/very bad; aOR = 1.35, 95% CI: 1.0-1.83), and difficulty with self-care (aOR = 1.64, 95% CI: 1.1-2.44). We found unobserved significant differences in the likelihood of hypertension prevalence between different households.

CONCLUSION

Addressing the problem of obesity, targeting specific interventions to those aged over 50 years, and improvement in the general health of Ghanaians are paramount to reducing the prevalence and its associated morbidity, disability, and mortality. Lifestyle modification in the form of dietary intake, knowledge provision supported with strong public health message, and political will could be beneficial to the management and prevention of hypertension.

Individual-, household-, and community-level factors associated with pregnant married women's discriminatory attitude towards people living with HIV in sub-Saharan Africa: A multicountry cross-sectional study

BACKGROUND AND AIMS

Discriminatory attitude towards people living with human immunodeficiency virus (HIV) remains a major problem in the prevention and treatment of HIV in sub-Sahara Africa (SSA). Understanding the multiple factors linked to discriminatory attitude towards people living with HIV/AIDS (PLWHA) in SSA is necessary for developing appropriate interventions. This study aimed at investigating the individual, household, and community-level factors associated with pregnant married women's discriminatory attitude towards people living with HIV/AIDS.

METHODS

We used data from the Demographic and Health Surveys of 12 sub-Saharan African countries conducted between 2015 and 2019. Data on 17 065 pregnant married women were analyzed. Bivariate (chi-squared test) and multivariable multilevel logistic regression analyses were applied to investigate the factors associated with discriminatory attitude towards PLWHA. The results were reported as adjusted odds ratio (aOR) at 95% confidence interval (CI).

RESULTS

The mean age of participants was 31.2 ± 8.5. The prevalence of discriminatory attitude towards PLWHA was 36.2% (95% CI: 33.4%-39.1%). Individual/household-level factors associated with discriminatory attitude towards PLWHA were women's educational level (secondary school-aOR = 0.49, 95% CI: 0.26-0.93), husband's educational level (higher education-aOR = 0.35, 95% CI: 0.16-0.76), decision-making power (yes-aOR = 0.51, 95% CI: 0.38-0.69), wife-beating attitude (disagreement with wife beating-aOR = 0.58, 95% CI: 0.43-0.79), and religion (Muslim-aOR = 1.92, 95% CI: 1.22-3.04). Community socioeconomic status (medium-aOR = 0.61, 95% CI: 0.41-0.93) was the only community-level factor associated with discriminatory attitude towards PLWHA.

CONCLUSION

More than one-third of pregnant married women in SSA had discriminatory attitude towards PLWHA. Women's educational level, husband's educational level, decision-making power, wife-beating attitude, religion, and community socio-economic status were associated with discriminatory attitude towards PLWHA. To lessen the prevalence of discriminatory attitude towards PLWHA, considering these significant factors is needed. Therefore, governments and other stakeholders in the respective countries need to increase education coverage. Moreover, empowering women through education and economy is crucial. Finally, working with religious leaders to increase awareness about HIV and discriminatory attitude towards PLWHA should also be a priority in SSA.

Prevalence, patterns and predictors of dyslipidaemia in Nigeria: a report from the REMAH study

AIM

The aim of this study was to determine the prevalence and predictors of dyslipidaemia in adults in Nigeria.

METHODS

Using the WHO criteria, we determined dyslipidaemia using serum lipid levels of 3 211 adult Nigerians, aged at least 18 years, obtained between March 2017 and February 2018 from two communities (rural and urban) in a state from each of the six geopolitical zones of Nigeria.

RESULTS

The overall prevalence of low high-density lipoprotein cholesterol (l-HDL), elevated low-density lipoprotein cholesterol (e-LDL), hypertriglyceridaemia (h-TG) and hypercholesterolaemia (h-CHL) were 72.5,13.6, 21.4 and 7.5%, respectively. The adjusted odds of h-CHL [odds ratio (95% confidence interval) 1.47 (1.10-1.95)], h-TG [1.89 (1.48-2.41)] and e-LDL [1.51 (1.03-2.15)] increased with obesity. Being a rural dweller increased the odds of h-TG [1.55 (1.29-1.85)], e-LDL [1.38 (1.10-1.73)] and l-HDL [1.34 (1.14-1.58)]. The odds of h-CHL [2.16 (1.59-2.95)], h-TG [1.21 (1.01-1.47)], e-LDL [1.42 (1.13-1.80)] and l-HDL [0.78 (0.65-0.93)] increased with hypertension. Diabetes mellitus doubled only the odds of h-TG [2.04(1.36-3.03)].

CONCLUSION

The prevalence of dyslipidaemia, particularly low HDL-C, is high among adult Nigerians.

Incidence of Acute Myocardial Infarction in Northern Tanzania: A Modeling Approach Within a Prospective Observational Study

Background

Rigorous incidence data for acute myocardial infarction (AMI) in sub‐Saharan Africa are lacking. Consequently, modeling studies based on limited data have suggested that the burden of AMI and AMI‐associated mortality in sub‐Saharan Africa is lower than in other world regions.

Methods and Results

We estimated the incidence of AMI in northern Tanzania in 2019 by integrating data from a prospective surveillance study (681 participants) and a community survey of healthcare‐seeking behavior (718 participants). In the surveillance study, adults presenting to an emergency department with chest pain or shortness of breath were screened for AMI with ECG and troponin testing. AMI was defined by the Fourth Universal Definition of AMI criteria. Mortality was assessed 30 days following enrollment via in‐person or telephone interviews. In the cluster‐based community survey, adults in northern Tanzania were asked where they would present for chest pain or shortness of breath. Multipliers were applied to account for AMI cases that would have been missed by our surveillance methods. The estimated annual incidence of AMI was 172 (207 among men and 139 among women) cases per 100 000 people. The age‐standardized annual incidence was 211 (263 among men and 170 among women) per 100 000 people. The estimated annual incidence of AMI‐associated mortality was 87 deaths per 100 000 people, and the age‐standardized annual incidence was 102 deaths per 100 000 people.

Conclusions

The incidence of AMI and AMI‐associated mortality in northern Tanzania is much higher than previously estimated and similar to that observed in high‐income countries.

Fatal cerebral venous sinus thrombosis as a manifestation of uncontrolled systemic lupus erythematosus in a young African female

In a young patient with systemic lupus erythematosus presenting with status epilepticus and neurological deficits, early brain imaging, risk factor identification and prompt treatment of underlying lupus flare-up and cerebral venous sinus thrombosis could significantly improve the management and prognosis.

Dysbiotic Fecal Microbiome in HIV-1 Infected Individuals in Ghana

HIV-1 infected individuals under antiretroviral therapy can control viremia but often develop non-AIDS diseases such as cardiovascular and metabolic disorders. Gut microbiome dysbiosis has been indicated to be associated with progression of these diseases. Analyses of gut/fecal microbiome in individual regions are important for our understanding of pathogenesis in HIV-1 infections. However, data on gut/fecal microbiome has not yet been accumulated in West Africa. In the present study, we examined fecal microbiome compositions in HIV-1 infected adults in Ghana, where approximately two-thirds of infected adults are females. In a cross-sectional case-control study, age- and gender-matched HIV-1 infected adults (HIV+; n = 55) and seronegative controls (HIV-; n = 55) were enrolled. Alpha diversity of fecal microbiome in HIV+ was significantly reduced compared to HIV- and associated with CD4 counts. HIV+ showed reduction in varieties of bacteria including Faecalibacterium, the most abundant in seronegative controls, but enrichment of Proteobacteria. Ghanaian HIV+ exhibited enrichment of Dorea and Blautia; bacteria groups whose depletion has been reported in HIV-1 infected individuals in several other cohorts. Furthermore, HIV+ in our cohort exhibited a depletion of Prevotella, a genus whose enrichment has recently been shown in men having sex with men (MSM) regardless of HIV-1 status. The present study revealed the characteristics of dysbiotic fecal microbiome in HIV-1 infected adults in Ghana, a representative of West African populations.

The potential of utilizing Provitamin A-biofortified maize in producing mutwiwa, a Zimbabwean traditional fermented food

Biofortification interventions have the potential to combat micronutrient deficiencies, such as vitamin A deficiency (VAD), which is prevalent in Zimbabwe. The poor acceptability of provitamin A (PVA)-biofortified maize is still a challenge that exists in Zimbabwe. This study investigated the effect of replacing white maize (WM) with PVA-biofortified maize on the nutritional composition of mutwiwa, a Zimbabwean traditional food, and its microbiological safety. Chemical and microbiological tests were conducted using AOAC standard methods. Total carotene content was 12.78 µg/g dry weight (DW) in PVA-biofortified maize and 1.52 µg/g DW in WM. The proximate composition of PVA-biofortified mutwiwa (PVABM) was 5.2, 28.6, 2.1, 62.2, and 2.0 g/100 g wet basis (w.b) for protein, carbohydrates fiber, moisture, and ash, respectively. Total soluble solids, β-carotene, vitamin C, and vitamin A contents were 3.6 oBrix, 110 µg/100 g, 0.54 mg/100 g, and 9 µg REA/100 g, respectively. Lysine, phenylalanine, and histidine contents were 0.71, 1.15, and 0.56 g/100 g w.b, respectively. Iron, calcium, phosphorus, and zinc content were 7.8, 60.5, 410.8, and 60 mg/100 g w.b, respectively. Mesophilic bacteria, lactic acid bacteria, coliforms, yeast, and molds were all <1 Log CFU/ml. The nutritional, amino acid and mineral contents were significantly different (p < .05). In conclusion, the results of this study were satisfying and recommend the processing of PVA-biofortified maize as a potential strategy to combat VAD and mineral malnutrition in Zimbabwe and other regions in Sub-Saharan Africa.

Effectiveness of interventions based on patient empowerment in the control of type 2 diabetes in sub-Saharan Africa: A review of randomized controlled trials

Background

It is estimated that 1.6 million deaths worldwide were directly caused by diabetes in 2016, and the burden of diabetes has been increasing rapidly in low- and middle-income countries. This study reviews existing interventions based on patient empowerment and their effectiveness in controlling diabetes in sub-Saharan Africa.

Method

PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO and Global Health were searched through August 2018, for randomized controlled trials of educational interventions on adherence to the medication plan and lifestyle changes among adults aged 18 years and over with type 2 diabetes. Random-effects meta-analysis was used.

Results

Eleven publications from nine studies involving 2743 participants met the inclusion criteria. The duration of interventions with group education and individual education ranged from 3 to 12 months. For six studies comprising 1549 participants with meta-analysable data on glycaemic control (HbA1c), there were statistically significant differences between intervention and control groups: mean difference was -0.57 [95% confidence interval (CI) -0.75, -0.40] (P < .00001, I2 = 27%). Seven studies with meta-analysable data on blood pressure showed statistically significant differences between groups in favour of interventions. Subgroup analyses on glycaemic control showed that long-term interventions were more effective than short-term interventions and lifestyle interventions were more effective than diabetes self-management education.

Conclusion

This review supports the findings that interventions based on patient empowerment may improve glycaemia (HbA1c) and blood pressure in patients with diabetes. The long-term and lifestyle interventions appear to be the most effective interventions for glycaemic control.

Effect of a Triage-Based Screening Protocol on Diagnosis and Treatment of Acute Coronary Syndrome in a Tanzanian Emergency Department: A Prospective Pre-Post Study

Background Evidence suggests that acute coronary syndrome (ACS) is underdiagnosed in sub-Saharan Africa. Triage-based interventions have improved ACS diagnosis and management in high-income settings but have not been evaluated in sub-Saharan African emergency departments (EDs). Our objective was to estimate the effect of a triage-based screening protocol on ACS diagnosis and care in a Tanzanian ED. Methods and Results All adults presenting to a Tanzanian ED with chest pain or shortness of breath were prospectively enrolled. Treatments and clinician-documented diagnoses were observed and recorded. In the preintervention phase (August 2018 through January 2019), ACS testing and treatment were dictated by physician discretion, as per usual care. A triage-based protocol was then introduced, and in the postintervention phase (January 2019 through October 2019), research assistants performed ECG and point-of-care troponin I testing on all patients with chest pain or shortness of breath upon ED arrival. Pre-post analyses compared ACS care between phases. Of 1020 total participants (339 preintervention phase, 681 postintervention phase), mean (SD) age was 58.9 (19.4) years. Six (1.8%) preintervention participants were diagnosed with ACS, versus 83 (12.2%) postintervention participants (odds ratio [OR], 7.51; 95% CI, 3.52-19.7; P<0.001). Among all participants, 3 (0.9%) preintervention participants received aspirin, compared with 50 (7.3%) postintervention participants (OR, 8.45; 95% CI, 3.07-36.13; P<0.001). Conclusions Introduction of a triage-based ACS screening protocol in a Tanzanian ED was associated with significant increases in ACS diagnoses and aspirin administration. Additional research is needed to determine the effect of ED-based interventions on ACS care and clinical end points in sub-Saharan Africa.

Primary PCI in the management of STEMI in sub-Saharan Africa: insights from Abidjan Heart Institute catheterisation laboratory

BACKGROUND

Implementation of primary percutaneous coronary intervention (PCI) in sub-Saharan Africa remains a challenging issue. The aim of this study was to report the results of primary PCI and outcomes in the catheterisation laboratory of the Abidjan Heart Institute.

METHODS

Between April 2010 and March 2019, all patients aged 18 years presenting to the Abidjan Heart Institute for ST-segment elevation myocardial infarction (STEMI) over the study period and who underwent primary PCI were included. We considered primary PCI when it was performed within 48 hours of the onset of symptoms. Baseline data, PCI characteristics and outcomes were analysed.

RESULTS

Among a total of 780 patients hospitalised for STEMI, 471 were admitted within 48 hours of the onset of symptoms. One-hundred and sixty six patients underwent primary PCI, with a ratio of primary PCI/STEMI of up to 21.3%. One hundred and six patients (63.9%) were admitted within 12 hours of the onset of symptoms. The femoral approach was the most commonly used (78.3%). Primary PCI was performed with stent implantation in 84.3% of patients. Drug-eluting stents (DES) were used in 42.1% of patients. In most cases, angiographic success was observed (157/166, 94.6%). Non-fatal complications were mainly haematomas (3.6%). Peri-procedural mortality rate was 1.2%.

CONCLUSIONS

Primary PCI can be performed safely in some small-volume centres in sub-Saharan Africa. Healthcare policies and regional networks must be encouraged in order to improve management of STEMI patients.

Cardiovascular Disease Burden in Rural Africa: Does HIV and Antiretroviral Treatment Play a Role?: Baseline Analysis of the Ndlovu Cohort Study

Background

HIV is associated with an increased risk of cardiovascular disease (CVD) in high‐income countries. Little is known about the CVD burden in sub‐Saharan Africa, where 70% of the world's HIV‐positive population lives. This study aims to provide insight into the burden of CVD risk in a rural setting in sub‐Saharan Africa considering HIV infection and antiretroviral therapy (ART).

Methods and Results

A cross‐sectional analysis was conducted of the baseline of the Ndlovu Cohort study including HIV‐negative and HIV‐positive participants in rural South Africa between 2014 and 2017. Information was collected on demographics, socioeconomic status, and CVD risk factors. Carotid intima‐media thickness measurement was performed. The influence of HIV and ART on the burden of CVD was determined by comparing HIV‐positive participants who were ART naive on first‐line or second‐line ART with HIV‐negative participants. In total, 1927 participants were included, of whom 887 (46%) were HIV positive and 54% women. The median age was 38 years. Overall, 690 participants (79%) were on ART, with 613 (89%) on first‐line and 77 (11%) on second‐line therapy. Participants with HIV had lower values for most of the CVD risk factors but higher C‐reactive protein levels than HIV‐negative participants. ART‐naive, HIV‐positive participants had similar carotid intima‐media thickness compared with HIV‐negative participants but carotid intima‐media thickness was increased for participants on ART aged 30 years and older compared with HIV‐negative participants.

Conclusions

HIV‐positive participants presented with a favorable CVD risk profile compared with HIV‐negative participants. However, carotid intima‐media thickness was increased in HIV‐positive participants on ART, indicating a higher burden of subclinical CVD for the HIV‐positive population.

Maternal death and postpartum hemorrhage in sub-Saharan Africa - A pilot study in metropolitan Mozambique

BACKGROUND

Maternal mortality in sub-Saharan Africa is approximately 500 to 1000 per 100 000 births (vs. approximately 5-20 in developed countries). Postpartum hemorrhage (PPH) is deemed responsible for 30% to 50% of the deaths.

OBJECTIVE

To study PPH, risk factors, and mortality in metropolitan Mozambique to inform future studies and intervention strategies.

MATERIALS/METHODS

Retrospective cross-sectional data extraction from all charts available to us (n = 495) recording deliveries between January and June 2018 at Maputo Central Hospital. Data included age, maternal survival, HIV status, parity, delivery mode, complications, vital signs, laboratory values, and maternal/fetal data. PPH was determined by charted diagnosis, interventions for hemorrhaging, placental abruption, transfusion, or blood loss. Autopsy reports from all deceased patients (n = 35) were examined.

RESULTS

Median age was 29 years with 17% HIV prevalence. Risk factors for PPH (frequency, 12%) included parity (adjusted odds ratios (AORs) for 3+ versus nulliparity, 7.20 (95% confidence interval [CI], 2.46-21.10), gestation length (AOR, 0.86; CI, 0.81-0.92 per week), and body temperature (AOR, 1.10; CI, 1.04-1.16 per 0.1°C). Maternal mortality was strongly associated with PPH (AOR, 5.22; 95% CI, 2.26-12.08) and HIV (AOR, 11.66; 95% CI, 4.72-28.78). Laboratory values (n = 241) were available from mothers experiencing complications (approximately 50%). Anemia (prevalence 54%) was a strong predictor of PPH with an inverse relationship between hemoglobin levels on admission (AOR, 0.62; 95% CI, 0.50-0.77 per g/dL higher hemoglobin) and the probability of later suffering from PPH. Mothers who died following PPH had lower median hemoglobin (6.2 g/dL) than mothers who survived (9.2 g/dL). Protocols to estimate peripartum blood loss were not used; antifibrinolytics and/or cryoprecipitate were unavailable.

CONCLUSION

Postpartum hemorrhage is a serious problem even in metropolitan areas of sub-Saharan Africa, and anemia influenced bleeding and death substantially. To address this problem, it is critical to raise awareness and region-specific prevention and intervention protocols.

Ex-ante evaluation of promising soybean innovations for sub-Saharan Africa

This study undertakes an ex-ante evaluation of the effects of alternative technology and policy options on soybean supply and demand in sub-Saharan Africa (SSA) to 2050. Current soybean consumption in SSA is dominated by cooking oil followed by soybean cake used as animal feed. Due to weak processing sectors and low soybean yields, the region is currently importing about 70% of its consumption requirements. Based on the results from a geospatial bio-economic modeling framework, soybean consumption in SSA is projected to more than double by 2050 compared to 2010 due in part to a rising population and rising incomes. On the other hand, supply from domestic production is projected to increase by 80% over the same period. Hence, by 2050, net imports into SSA would be nearly 4 times higher than supply from domestic production. Under a future drier climate, some of the production gains achieved through soybean research and extension would be lost and this would further worsen the soybean demand gap in SSA relative to the baseline. This study shows that relying on conventional breeding alone to increase soybean yields in SSA would not be enough to substantially reduce the future demand gap. A combination of promising innovations affecting the soybean value chain across SSA would be needed to close the soybean demand gap in SSA by 2050 under a drier future climate.

Classical Cardiovascular Risk Factors and HIV are Associated With Carotid Intima-Media Thickness in Adults From Sub-Saharan Africa: Findings From H3Africa AWI-Gen Study

Background Studies on the determinants of carotid intima-media thickness ( CIMT ), a marker of sub-clinical atherosclerosis, mostly come from white, Asian, and diasporan black populations. We present CIMT data from sub-Saharan Africa, which is experiencing a rising burden of cardiovascular diseases and infectious diseases. Methods and Results The H3 (Human Hereditary and Health) in Africa's AWI-Gen (African-Wits-INDEPTH partnership for Genomic) study is a cross-sectional study conducted in adults aged 40 to 60 years from Burkina Faso, Kenya, Ghana, and South Africa. Cardiovascular disease risk and ultrasonography of the CIMT of right and left common carotids were measured. Multivariable linear and mixed-effect multilevel regression modeling was applied to determine factors related to CIMT. Data included 8872 adults (50.8% men), mean age of 50±6 years with age- and sex-adjusted mean (±SE) CIMT of 640±123μm. Participants from Ghana and Burkina Faso had higher CIMT compared with other sites. Age (β = 6.77, 95%CI [6.34-7.19]), body mass index (17.6[12.5-22.8]), systolic blood pressure (7.52[6.21-8.83]), low-density lipoprotein cholesterol (5.08[2.10-8.06]) and men (10.3[4.75- 15.9]) were associated with higher CIMT. Smoking was associated with higher CIMT in men. High-density lipoprotein cholesterol (-12.2 [-17.9- -6.41]), alcohol consumption (-13.5 [-19.1--7.91]) and HIV (-8.86 [-15.7--2.03]) were inversely associated with CIMT. Conclusions Given the rising prevalence of cardiovascular diseases risk factors in sub-Saharan Africa, atherosclerotic diseases may become a major pan-African epidemic unless preventive measures are taken particularly for prevention of hypertension, obesity, and smoking. HIV -specific studies are needed to fully understand the association between HIV and CIMT in sub-Saharan Africa.

Clinical and etiological characteristics of epilepsy in people from Niger: a hospital-based study from a tertiary care referral center of Niamey, Niger

OBJECTIVES

Epilepsy constitutes a major public health concern in the world particularly in developing countries, especially in sub-Saharan African countries. We designed this study to evaluate epilepsy management at a tertiary referral center in Niger to obtain a comprehensive understanding to determine the intrahospital deficiencies to improve and to make recommendations in terms to improve epilepsy management in Niger.

METHODS

We conducted a retrospective study at the Neurology Outpatient Clinic of the National Hospital of Niamey (Niger) between May 2013 and May 2018 (5 years), collecting all cases of patients diagnosed with epilepsy by the neurologists. From the registers of consultation, we collected for each patient the demographic, clinical, etiological, and therapeutic data, as well as the outcomes during follow-up visits.

RESULTS

Of the 4576 patients seen during the period of the study, 1350 patients consulted for epilepsy with a hospital frequency of 29.5%. The mean age of the patients was 18.55 ± 17.15 years (range: 3 months to 83 years) with a predominance of the male sex (sex ratio at 1.5). Patients younger than 20 years were the most represented (61.6%). All patients underwent EEG. Only 463 patients (35.2%) underwent brain imaging. Generalized tonic-clonic seizures were the most frequent (50%) followed by typical absences seizures (11.8%). Cerebrovascular disease, central nervous system infections, and head injuries were the main etiologies. First-generation AEDs were the most prescribed (99%). The proportion of patients with drug-resistance was 9.6%.

SIGNIFICANCE

Our study shows limited access to newer generation AEDs and diagnostic tests of epilepsy in Niger. Considerable efforts should be made to facilitate for people living with epilepsy the accessibility to diagnostic tests and newer generation AEDs in order to improve the quality of epilepsy management in Niger.

Factors associated with sub-optimal control of anticoagulation in patients with prosthetic heart valves taking oral anticoagulants in a sub-Saharan African setting

BACKGROUND

Replacement of diseased valves reduces the morbidity and mortality rate associated with native valvular disease but comes at the expense of risking complications related to the implanted prosthetic device. Establishing the desired anticoagulation level in a sub-Saharan African setting may be a challenge.

OBJECTIVES

This study was conducted to determine the challenges of maintaining a desired level of anticoagulation and factors associated with sub-optimal anticoagulation in patients with prosthetic heart valves on chronic anticoagulation.

METHODS

We reviewed 73 patients who had undergone prosthetic valve replacement for chronic rheumatic valvular heart disease and were taking warfarin. The follow up ranged from one to 13 years. We studied international normalised ratio (INR) profiles of the patients for the six months preceding the study and defined optimal control as an INR of 2.5-3.5. We aimed to determine if there were factors associated with sub-optimal control of INR.

RESULTS

Forty-two patients (57.5%) were female. Mean age of the participants was 21.5 ± 3.1 years (range 14-25 years). Warfarin was the anticoagulant in 55 (75.3%) of the patients and 18 (24.7%) were on combined warfarin and aspirin anticoagulation. Thirty-five (47.9%) patients had optimal control of their INR. Educational level of primary school or less, distance from follow-up medical facility of more than 300 km, quarterly or less-frequent check-up visit, and public health institution as a source of free warfarin supply were found to be significantly associated with sub-optimal control of INR.

CONCLUSIONS

Educational level, distance from follow-up facility, number of follow-up visits and source of warfarin supply were found to be significantly associated with sub-optimal control of INR.

Cardiovascular risk factors among people living with HIV in rural Kenya: a clinic-based study

OBJECTIVE

To determine the prevalence of cardiovascular risk factors and their association with antiretroviral therapy (ART) among HIV-infected adults in a rural sub-county hospital in Kenya.

METHODS

This was a descriptive survey of patient charts characterising cardiovascular risk among adult patients (> 18 years) at Ukwala sub-county hospital between June 2013 and January 2015. Post-stratification survey weights were applied to obtain prevalence levels. Adjusted odds ratios (AOR) for each variable related to cardiovascular risk factors were calculated using logistic regression models.

RESULTS

Overall, the prevalence of diabetes mellitus was 0.4%, 0.3% of patients had had a previous cardiovascular event (heart attack or stroke), 40.4% had pre-hypertension, while 10.4% had stage 1 and 2.9% stage 2 hypertension. Up to 14% of patients had elevated non-fasting total cholesterol levels. Factors associated with hypertension were male gender (AOR 1.59, p = 0.0001), being over 40 years of age (AOR 1.78, p = 0.0001) and having an increased waist circumference (OR 2.56, p = 0.0014). Raised total cholesterol was more likely in those on tenofovir disoproxil fumarate (TDF) (AOR 2.2, p = 0.0042), azidothymidine (AZT) (AOR 2.5, p = 0.0004) and stavudine (D4T) -containing regimens (AOR 3.13, p = 0.0002).

CONCLUSIONS

An elevated prevalence of undiagnosed cardiovascular risk factors such as hypertension and raised total cholesterol levels was found among people living with HIV. There was an association between raised total cholesterol and nucleoside reverse-transcriptase inhibitor (NRTI) -based ART regimens. Our findings provide further rationale for integrating routine cardiovascular risk-factor screening into HIV-care services.

Impact of human disturbance on bee pollinator communities in savanna and agricultural sites in Burkina Faso, West Africa

All over the world, pollinators are threatened by land-use change involving degradation of seminatural habitats or conversion into agricultural land. Such disturbance often leads to lowered pollinator abundance and/or diversity, which might reduce crop yield in adjacent agricultural areas. For West Africa, changes in bee communities across disturbance gradients from savanna to agricultural land are mainly unknown. In this study, we monitored for the impact of human disturbance on bee communities in savanna and crop fields. We chose three savanna areas of varying disturbance intensity (low, medium, and high) in the South Sudanian zone of Burkina Faso, based on land-use/land cover data via Landsat images, and selected nearby cotton and sesame fields. During 21 months covering two rainy and two dry seasons in 2014 and 2015, we captured bees using pan traps. Spatial and temporal patterns of bee species abundance, richness, evenness and community structure were assessed. In total, 35,469 bee specimens were caught on 12 savanna sites and 22 fields, comprising 97 species of 32 genera. Bee abundance was highest at intermediate disturbance in the rainy season. Species richness and evenness did not differ significantly. Bee communities at medium and highly disturbed savanna sites comprised only subsets of those at low disturbed sites. An across-habitat spillover of bees (mostly abundant social bee species) from savanna into crop fields was observed during the rainy season when crops are mass-flowering, whereas most savanna plants are not in bloom. Despite disturbance intensification, our findings suggest that wild bee communities can persist in anthropogenic landscapes and that some species even benefitted disproportionally. West African areas of crop production such as for cotton and sesame may serve as important food resources for bee species in times when resources in the savanna are scarce and receive at the same time considerable pollination service.

Toward improving photosynthesis in cassava: Characterizing photosynthetic limitations in four current African cultivars

Despite the vast importance of cassava (Manihot esculenta Crantz) for smallholder farmers in Africa, yields per unit land area have not increased over the past 55 years. Genetic engineering or breeding for increased photosynthetic efficiency may represent a new approach. This requires the understanding of limitations to photosynthesis within existing germplasm. Here, leaf photosynthetic gas exchange, leaf carbon and nitrogen content, and nonstructural carbohydrates content and growth were analyzed in four high-yielding and farm-preferred African cultivars: two landraces (TME 7, TME 419) and two improved lines (TMS 98/0581 and TMS 30572). Surprisingly, the two landraces had, on average, 18% higher light-saturating leaf CO 2 uptake (Asat) than the improved lines due to higher maximum apparent carboxylation rates of Rubisco carboxylation (Vcmax) and regeneration of ribulose-1,5-biphosphate expressed as electron transport rate (Jmax). TME 419 also showed a greater intrinsic water use efficiency. Except for the cultivar TMS 30572, photosynthesis in cassava showed a triose phosphate utilization (TPU) limitation at high intercellular [CO 2]. The capacity for TPU in the leaf would not limit photosynthesis rates under current conditions, but without modification would be a barrier to increasing photosynthetic efficiency to levels predicted possible in this crop. The lower capacity of the lines improved through breeding, may perhaps reflect the predominant need, until now, in cassava breeding for improved disease and pest resistance. However, the availability today of equipment for high-throughput screening of photosynthetic capacity provides a means to select for maintenance or improvement of photosynthetic capacity while also selecting for pest and disease resistance.

Ancient oncogenesis, infection and human evolution

The recent discovery that malignant neoplastic lesions date back nearly 2 million years ago not only highlights the antiquity of cancer in the human lineage, but also provides remarkable insight into ancestral hominin disease pathology. Using these Early Pleistocene examples as a point of departure, we emphasize the prominent role of viral and bacterial pathogens in oncogenesis and evaluate the impact of pathogens on human evolutionary processes in Africa. In the Shakespearean vernacular "what's past is prologue," we highlight the significance of novel information derived from ancient pathogenic DNA. In particular, and given the temporal depth of human occupation in sub-Saharan Africa, it is emphasized that the region is ideally positioned to play a strategic role in the discovery of ancient pathogenic drivers of not only human mortality, but also human evolution. Ancient African pathogen genome data can provide novel revelations concerning human-pathogen coevolutionary processes, and such knowledge is essential for forecasting the ways in which emerging zoonotic and increasingly transmissible diseases might influence human demography and longevity in the future.

Agriculture, Food Systems, and Nutrition: Meeting the Challenge

Malnutrition is a global challenge with huge social and economic costs; nearly every country faces a public health challenge, whether from undernutrition, overweight/obesity, and/or micronutrient deficiencies. Malnutrition is a multisectoral, multi-level problem that results from the complex interplay between household and individual decision-making, agri-food, health, and environmental systems that determine access to services and resources, and related policy processes. This paper reviews the theory and recent qualitative evidence (particularly from 2010 to 2016) in the public health and nutrition literature, on the role that agriculture plays in improving nutrition, how food systems are changing rapidly due to globalization, trade liberalization, and urbanization, and the implications this has for nutrition globally. The paper ends by summarizing recommendations that emerge from this research related to (i) knowledge, evidence, and communications, (ii) politics, governance, and policy, and (iii) capacity, leadership, and financing.

Magnitude and factors associated with nonadherence to antiepileptic drug treatment in Africa: A cross-sectional multisite study

Objectives

The epilepsy treatment gap is large in low‐ and middle‐income countries, but the reasons behind nonadherence to treatment with antiepileptic drugs (AEDs) across African countries remain unclear. We investigated the extent to which AEDs are not taken and associated factors in people with active convulsive epilepsy (ACE) identified in cross‐sectional studies conducted in five African countries.

Methods

We approached 2,192 people with a confirmed diagnosis of ACE for consent to give blood voluntarily. Participants were asked if they were taking AEDs, and plasma drug concentrations were measured using a fluorescence polarization immunoassay analyzer. Information about possible risk factors was collected using questionnaire‐based clinical interviews. We determined factors associated with nonadherence to AED treatment in children and adults, as measured by detectable and optimal levels, using multilevel logistic regression.

Results

In 1,303 samples assayed (43.7% were children), AEDs were detected in 482, but only 287 had optimal levels. Of the 1,303 samples, 532 (40.8%) were from people who had reported they were on AEDs. The overall prevalence of nonadherence to treatment was 63.1% (95% confidence interval [CI] 60.5–65.6%) as measured by detectable AED levels and 79.1% (95% CI 73.3–84.3%) as measured by optimal AED levels; self‐reported nonadherence was 65.1% (95% CI 45.0–79.5%). Nonadherence was significantly (p < 0.001) more common among the children than among adults for optimal and detectable levels of AEDs, as was the self‐reported nonadherence. In children, lack of previous hospitalization and learning difficulties were independently associated with nonadherence to treatment. In adults, history of delivery at home, absence of burn marks, and not seeking traditional medicine were independently associated with the nonadherence to AED treatment.

Significance

Only about 20% of people with epilepsy benefit fully from antiepileptic drugs in sub‐Saharan Africa, according to optimum AEDs levels. Children taking AEDs should be supervised to promote compliance.

Estimating the Enduring Effects of Fertiliser Subsidies on Commercial Fertiliser Demand and Maize Production: Panel Data Evidence from Malawi

Most studies of input subsidy programmes confine their analyses to measuring programme effects over a one-year period. This article estimates the potential longer-run or enduring effects of fertiliser subsidy programmes on smallholder farm households' demand for commercial fertiliser and maize production over time. We use four waves of panel data on 462 farm households in Malawi for whom fertiliser use can be tracked for eight consecutive seasons between 2003/2004 and 2010/2011. Panel estimation methods are used to control for potential endogeneity of subsidised fertiliser acquisition. Results indicate that farmers acquiring subsidised fertiliser in three consecutive prior years are found to purchase slightly more commercial fertiliser in the next year. This suggests a small amount of crowding in of commercial fertiliser from the receipt of subsidised fertiliser in prior years. In addition, acquiring subsidised fertiliser in a given year has a modest positive impact on increasing maize output in that same year. However, acquiring subsidised fertiliser in multiple prior years generates no statistically significant effect on maize output in the current year. These findings indicate that potential enduring effects of the Malawi fertiliser subsidy programme on maize production are limited. Additional interventions that increase soil fertility can make using inorganic fertiliser more profitable and sustainable for smallholders in sub-Saharan Africa and thereby increase the cost-effectiveness of input subsidy programmes.

Clinical and Epidemiological Implications of 24-Hour Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Kenyan Adults: A Population-Based Study

BACKGROUND

The clinical and epidemiological implications of using ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension have not been studied at a population level in sub-Saharan Africa. We examined the impact of ABPM use among Kenyan adults.

METHODS AND RESULTS

We performed a nested case-control study of diagnostic accuracy. We selected an age-stratified random sample of 1248 adults from the list of residents of the Kilifi Health and Demographic Surveillance System in Kenya. All participants underwent a screening blood pressure (BP) measurement. All those with screening BP ≥140/90 mm Hg and a random subset of those with screening BP <140/90 mm Hg were invited to undergo ABPM. Based on the 2 tests, participants were categorized as sustained hypertensive, masked hypertensive, "white coat" hypertensive, or normotensive. Analyses were weighted by the probability of undergoing ABPM. Screening BP ≥140/90 mm Hg was present in 359 of 986 participants, translating to a crude population prevalence of 23.1% (95% CI 16.5-31.5%). Age standardized prevalence of screening BP ≥140/90 mm Hg was 26.5% (95% CI 19.3-35.6%). On ABPM, 186 of 415 participants were confirmed to be hypertensive, with crude prevalence of 15.6% (95% CI 9.4-23.1%) and age-standardized prevalence of 17.1% (95% CI 11.0-24.4%). Age-standardized prevalence of masked and white coat hypertension were 7.6% (95% CI 2.8-13.7%) and 3.8% (95% CI 1.7-6.1%), respectively. The sensitivity and specificity of screening BP measurements were 80% (95% CI 73-86%) and 84% (95% CI 79-88%), respectively. BP indices and validity measures showed strong age-related trends.

CONCLUSIONS

Screening BP measurement significantly overestimated hypertension prevalence while failing to identify ≈50% of true hypertension diagnosed by ABPM. Our findings suggest significant clinical and epidemiological benefits of ABPM use for diagnosing hypertension in Kenyan adults.

The Accessibility of Parkinson's Disease Medication in Kenya: Results of a National Survey

Background

There is a dearth of knowledge about the availability and affordability of the different drug treatments for Parkinson's disease (PD) across sub-Saharan Africa (SSA). We aimed to determine the availability and affordability of drugs for treating PD in Kenya.

Methods

A facility-based survey was conducted in selected medicine outlets (pharmacies) in what were formerly the headquarter towns of the eight provinces of Kenya. We used the World Health Organization/Health Action International methodology to obtain data for drugs used to treat PD. Unit price for each drug was obtained.

Results

Forty-eight outlets were visited in total, six in each of Kenya's eight provinces. Levodopa (L-dopa) was available in only 24 (50.0%) outlets. Only one public pharmacy sold l-dopa (14 were private and nine were other types of outlet). Ergot-derived dopamine agonists (DAs) and anticholinergics were available in 37 and 35 outlets, respectively. Monoamine-oxidase inhibitors, non-ergot-derived DAs, and catechol-O-methyl transferase inhibitors were available in four, two and zero outlets, respectively. Mean cost of 100 l-dopa tablets was $48.2, though costs varied widely (range, $28.2-$82.4). Only five outlets considered l-dopa affordable, all of which sold 100 tablets for less than $31.

Conclusion

There is a lack of availability of PD drugs in Kenya, particularly in public pharmacies, where costs are generally lower. Few pharmacists consider the drugs available to be affordable. If PD is to be effectively managed in Kenya, then strategies are needed to increase the availability and affordability of medication.

'Behold, a virgin is with HIV!' misreporting sexual behavior among infected adolescents

In four Southern African countries where the HIV prevalence rate is among the highest in the world, 46.4% of a sample of female adolescents infected with HIV report having never engaged in sex. This would indicate either the dominance of non-sexual modes of HIV transmission or rampant misreporting of sexual behavior in the sample. We propose a method to estimate the extent of misreporting and calculate that the true percentages of virgins among the sample of HIV-infected adolescent women is 32.1%. After accounting for misreporting, the contribution of sexual modes of HIV transmission is projected as 50.4%, compared with an estimate of 35.5% if we assume no misreporting.

Human papillomavirus distribution in invasive cervical carcinoma in sub-Saharan Africa: could HIV explain the differences?

OBJECTIVES

To describe human papillomavirus (HPV) distribution in invasive cervical carcinoma (ICC) from Mali and Senegal and to compare type-specific relative contribution among sub-Saharan African (SSA) countries.

METHODS

A multicentric study was conducted to collect paraffin-embedded blocks of ICC. Polymerase chain reaction, DNA enzyme immunoassay and line probe assay were performed for HPV detection and genotyping. Data from SSA (Mozambique, Nigeria and Uganda) and 35 other countries were compared.

RESULTS

One hundred and sixty-four ICC cases from Mali and Senegal were tested from which 138 were positive (adjusted prevalence = 86.8%; 95% CI = 79.7-91.7%). HPV16 and HPV18 accounted for 57.2% of infections and HPV45 for 16.7%. In SSA countries, HPV16 was less frequent than in the rest of the world (49.4%vs. 62.6%; P < 0.0001) but HPV18 and HPV45 were two times more frequent (19.3%vs. 9.4%; P < 0.0001 and 10.3%vs. 5.6%; P < 0.0001, respectively). There was an ecological correlation between HIV prevalence and the increase of HPV18 and the decrease of HPV45 in ICC in SSA (P = 0.037 for both).

CONCLUSION

HPV16/18/45 accounted for two-thirds of the HPV types found in invasive cervical cancer in Mali and Senegal. Our results suggest that HIV may play a role in the underlying HPV18 and HPV45 contribution to cervical cancer, but further studies are needed to confirm this correlation.

Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis

OBJECTIVES

To assess the proportion of patients lost to programme (died, lost to follow-up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub-Saharan Africa, and determine factors associated with loss to programme.

METHODS

Systematic review and meta-analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow-up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random-effects meta-analysis.

RESULTS

Twenty-nine studies from sub-Saharan Africa including 148,912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta-analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60-84) had a CD4 cell count measured, 40 (95% CI 26-55) were eligible for ART and 25 (95% CI 13-37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio-economic status and in recent time periods.

CONCLUSIONS

Monitoring and care in the pre-ART time period need improvement, with greater emphasis on patients not yet eligible for ART.

Adult deaths and the future: a cause-specific analysis of adult deaths from a longitudinal study in rural Tanzania 2003-2007

OBJECTIVES

To determine patterns and risk factors for cause-specific adult mortality in rural southern Tanzania.

METHODS

The study was a longitudinal open cohort and focused on adults aged 15-59 years between 2003 and 2007. Causes of deaths were ascertained by verbal autopsy (VA). Cox proportion hazards regression model was used to determine factors associated with cause-specific mortality over the 5-year period.

RESULTS

  Thousand three hundred and fifty-two of 65 548 adults died, representing a crude adult mortality rate (AMR) of 7.3 per 1000 person years of observation (PYO). VA was performed for 1132 (84%) deaths. HIV/AIDS [231 (20.4%)] was the leading cause of death followed by malaria [150 (13.2%)]. AMR for communicable disease (CD) causes was 2.49 per 1000 PYO, 1.21 per 1000 PYO for non-communicable diseases (NCD) and 0.53 per 1000 PYO for accidents/injury causes. NCD deaths increased from 16% in 2003 to 24% in 2007. High level of education was associated with a reduction in the risk of dying from NCDs. Those with primary education (HR = 0.67, 95% CI: 0.49, 0.92) and with education beyond primary school (HR = 0.11, 95% CI: 0.02, 0.40) had lower mortality than those who had no formal education. Compared with local residents, in-migrants were 1.7 (95% CI: 1.37, 2.11) times more likely to die from communicable disease causes.

CONCLUSION

NCDs are increasing as a result of demographic and epidemiological transitions taking place in most African countries including Tanzania and require attention to prevent increased triple disease burden of CD, NCD and accident/injuries.