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Chabala C, Wobudeya E, van der Zalm MM, Kapasa M, Raichur P, Mboizi R, Palmer M, Kinikar A, Hissar S, Mulenga V, Mave V, Musoke P, Hesseling AC, McIlleron H, Gibb D, Crook A, Turkova A. Clinical outcomes in children living with HIV treated for non-severe tuberculosis in the SHINE Trial. Clin Infect Dis 2024:ciae193. [PMID: 38592950 DOI: 10.1093/cid/ciae193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/23/2024] [Accepted: 04/05/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Children living with HIV(CLWH) are at high risk of tuberculosis(TB) and face poor outcomes, despite antiretroviral treatment(ART). We evaluated outcomes in CLWH and HIV-uninfected children treated for non-severe TB in the SHINE trial. METHODS SHINE was a randomized trial that enrolled children aged <16 years with smear-negative, non-severe TB who were randomized to receive 4 vs 6 months of TB treatment and followed for 72 weeks. We assessed TB relapse/recurrence, mortality, hospitalizations, grade ≥3 adverse events by HIV status, and HIV virological suppression in CLWH. RESULTS Of 1204 enrolled, 127(11%) were CLWH, of similar age (median(IQR) 3.6(1.2, 10.3) vs. 3.5(1.5, 6.9)years, p= 0.07), but more underweight (WAZ; -2.3(-3.3, -0.8) vs -1.0(-1.8, -0.2), p<0.01) and anemic (hemoglobin 9.5(8.7, 10.9) vs 11.5(10.4, 12.3)g/dl, p<0.01) compared to HIV-uninfected children. 68(54%) CLWH were ART-naïve; baseline median CD4 count 719(241-1134) cells/mm3, CD4% 16(10-26)%). CLWH were more likely to be hospitalized (aOR=2.4(1.3-4.6)) and die (aHR(95%CI) 2.6(1.2,5.8)). HIV status, age <3 years (aHR 6.3(1.5,27.3)), malnutrition (aHR 6.2(2.4,15.9)) and hemoglobin <7g/dl(aHR 3.8(1.3,11.5) independently predicted mortality. Among children with available VL, 45% and 61% CLWH had VL<1000copies/ml at weeks 24 and 48, respectively. There was no difference in the effect of randomized treatment duration (4 vs 6 months) on TB treatment outcomes by HIV status (p for interaction=0.42). CONCLUSIONS We found no evidence of a difference in TB outcomes between 4 and 6 months of treatment for CLWH treated for non-severe TB. Irrespective of TB treatment duration, CLWH had higher rates of mortality and hospitalization than HIV-uninfected counterparts.
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Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospital-Children's Hospital, Lusaka, Zambia
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Eric Wobudeya
- Makerere University-John Hopkins Hospital Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Marieke M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospital-Children's Hospital, Lusaka, Zambia
| | - Priyanka Raichur
- Byramjee Jeejeebhoy Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Robert Mboizi
- Makerere University-John Hopkins Hospital Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Syed Hissar
- Indian Council of Medical Research - National Institute for Research in Tuberculosis, Chennai, India
| | - Veronica Mulenga
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospital-Children's Hospital, Lusaka, Zambia
| | - Vidya Mave
- Byramjee Jeejeebhoy Medical College- Johns Hopkins University Clinical Research Site, Pune, India
| | - Philippa Musoke
- Makerere University-John Hopkins Hospital Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen McIlleron
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Diana Gibb
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Angela Crook
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Anna Turkova
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
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Robinson ML, Johnson J, Naik S, Kinikar A, Dohe V, Kagal A, Randive B, Kadam A, Karyakarte R, Mave V, Gupta A, Milstone AM, Manabe YC. The source of Drug-Resistant Bloodstream Infection in the Neonatal Intensive Care Unit, an Ongoing Conversation. Clin Infect Dis 2024:ciae045. [PMID: 38301661 DOI: 10.1093/cid/ciae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/13/2023] [Accepted: 01/26/2024] [Indexed: 02/03/2024] Open
Affiliation(s)
- Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shilpa Naik
- Department of Obstetrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vaishali Dohe
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Anju Kagal
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Rajesh Karyakarte
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Sornillo JB, Ditangco R, Kinikar A, Wati DK, Du QT, Nguyen DQ, Khol V, Nguyen LV, Puthanakit T, Ounchanum P, Kurniati N, Chokephaibulkit K, Jamal Mohamed TA, Sudjaritruk T, Fong SM, Kumarasamy N, Kosalaraksa P, Nallusamy RA, Nik Yusoff NK, Sohn AH, Kariminia A. The changing characteristics of a cohort of children and adolescents living with HIV at antiretroviral therapy initiation in Asia. PLoS One 2023; 18:e0291523. [PMID: 37708128 PMCID: PMC10501581 DOI: 10.1371/journal.pone.0291523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
Despite improvements in HIV testing and earlier antiretroviral therapy (ART) initiation in children living with HIV through the years, a considerable proportion start treatment with advanced disease. We studied characteristics of children and adolescents living with HIV and their level of immunodeficiency at ART initiation using data from a multi-country Asian cohort. We included children and adolescents who were ART-naïve and <18 years of age at ART initiation from 2011 to 2020 at 17 HIV clinics in six countries. Incidence rates of opportunistic infections (OIs) in the first two years of triple-drug ART (≥3 antiretrovirals) was also reported. Competing risk regression analysis was performed to identify factors associated with first occurrence of OI. In 2,027 children and adolescents (54% males), median age at ART initiation increased from 4.5 years in 2011-2013 to 6.7 in 2017-2020, median CD4 count doubled from 237 cells/μl to 466 cells/μl, and proportion of children who initiated ART as severely immunodeficient decreased from 70% to 45%. During follow-up, 275 (14%) children who received triple-drug ART as first treatment and had at least one clinic visit, developed at least one OI in the first two years of treatment (9.40 per 100 person-years). The incidence rate of any first OI declined from 12.52 to 7.58 per 100 person-years during 2011-2013 and 2017-2020. Lower hazard of OIs were found in those with age at first ART 2-14 years, current CD4 ≥200 cells/μl, and receiving ART between 2017 and 2020. The analysis demonstrated increasing number of children and adolescents starting ART with high CD4 count at ART start. The rate of first OI markedly decreased in children who started ART in more recent years. There remains a clear need for improvement in HIV control strategies in children, by promoting earlier diagnosis and timely treatment.
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Affiliation(s)
- Johanna Beulah Sornillo
- Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Manila, Philippines
| | - Rossana Ditangco
- Medical Department, Research Institute for Tropical Medicine, Manila, Philippines
| | - Aarti Kinikar
- BJ Medical College and Sassoon General Hospital, Pune, India
| | - Dewi Kumara Wati
- Department of Pediatrics, Sanglah Hospital, Udayana University, Bali, Indonesia
| | - Quy Tuan Du
- Infectious Diseases Department, Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Dinh Qui Nguyen
- Infectious Diseases Department, Children’s Hospital 2, Ho Chi Minh City, Vietnam
| | - Vohith Khol
- National Center for HIV/AIDS, Dermatology and STD, Phnom Penh, Cambodia
| | - Lam Van Nguyen
- Infectious Diseases Department, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine and Research Unit in Pediatric and Infectious Diseases, Chulalongkorn University, Bangkok, Thailand
| | - Pradthana Ounchanum
- Department of Pediatrics, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
| | - Nia Kurniati
- Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo, Jakarta, Indonesia
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Tavitiya Sudjaritruk
- Department of Pediatrics, Faculty of Medicine, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Siew Moy Fong
- Department of Pediatrics, Hospital Likas, Kota Kinabalu, Malaysia
| | | | - Pope Kosalaraksa
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | | | - Annette H. Sohn
- TREAT Asia, amfAR—The Foundation for AIDS Research, Bangkok, Thailand
| | - Azar Kariminia
- The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
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Schiess N, Kulo V, Anand P, Bearden DR, Berkowitz AL, Birbeck GL, Cervantes-Arslanian A, Chan P, Chishimba LC, Chow FC, Elicer I, Fleury A, Kinikar A, Kvalsund M, Mateen FJ, Mbonde AA, Meyer ACL, O'Carroll CB, Ogunniyi A, Patel AA, Rubenstein M, Siddiqi OK, Spudich S, Tackett SA, Thakur KT, Vora N, Zunt J, Saylor DR. Consensus Competencies for Postgraduate Fellowship Training in Global Neurology. Neurology 2023; 101:357-368. [PMID: 36997322 PMCID: PMC10449442 DOI: 10.1212/wnl.0000000000207184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 01/27/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Use a modified Delphi approach to develop competencies for neurologists completing ≥1 year of advanced global neurology training. METHODS An expert panel of 19 United States-based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, United States-based neurologists participated in 3 rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of 7 neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies. RESULTS Three rounds of surveys, a conference call with United States-based experts, and a semistructured questionnaire and focus group discussion with LMIC experts were used to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across 8 domains: (1) cultural context, social determinants of health and access to care; (2) clinical and teaching skills and neurologic medical knowledge; (3) team-based practice; (4) developing global neurology partnerships; (5) ethics; (6) approach to clinical care; (7) community neurologic health; (8) health care systems and multinational health care organizations. DISCUSSION These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.
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Affiliation(s)
- Nicoline Schiess
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Violet Kulo
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Pria Anand
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - David R Bearden
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Aaron L Berkowitz
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Gretchen L Birbeck
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Anna Cervantes-Arslanian
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Phillip Chan
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Lorraine Chishimba Chishimba
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Felicia C Chow
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Isabel Elicer
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Agnes Fleury
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Aarti Kinikar
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Michelle Kvalsund
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Farrah J Mateen
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Amir A Mbonde
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Ana-Claire L Meyer
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Cumara B O'Carroll
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Adesola Ogunniyi
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Archana A Patel
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Michael Rubenstein
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Omar K Siddiqi
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Serena Spudich
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Sean A Tackett
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Kiran T Thakur
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Nirali Vora
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Joseph Zunt
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Deanna R Saylor
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle.
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Robinson ML, Johnson J, Naik S, Patil S, Kulkarni R, Kinikar A, Dohe V, Mudshingkar S, Kagal A, Smith RM, Westercamp M, Randive B, Kadam A, Babiker A, Kulkarni V, Karyakarte R, Mave V, Gupta A, Milstone AM, Manabe YC. Maternal Colonization Versus Nosocomial Transmission as the Source of Drug-Resistant Bloodstream Infection in an Indian Neonatal Intensive Care Unit: A Prospective Cohort Study. Clin Infect Dis 2023; 77:S38-S45. [PMID: 37406039 PMCID: PMC10321698 DOI: 10.1093/cid/ciad282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Drug-resistant gram-negative (GN) pathogens are a common cause of neonatal sepsis in low- and middle-income countries. Identifying GN transmission patterns is vital to inform preventive efforts. METHODS We conducted a prospective cohort study, 12 October 2018 to 31 October 2019 to describe the association of maternal and environmental GN colonization with bloodstream infection (BSI) among neonates admitted to a neonatal intensive care unit (NICU) in Western India. We assessed rectal and vaginal colonization in pregnant women presenting for delivery and colonization in neonates and the environment using culture-based methods. We also collected data on BSI for all NICU patients, including neonates born to unenrolled mothers. Organism identification, antibiotic susceptibility testing, and next-generation sequencing (NGS) were performed to compare BSI and related colonization isolates. RESULTS Among 952 enrolled women who delivered, 257 neonates required NICU admission, and 24 (9.3%) developed BSI. Among mothers of neonates with GN BSI (n = 21), 10 (47.7%) had rectal, 5 (23.8%) had vaginal, and 10 (47.7%) had no colonization with resistant GN organisms. No maternal isolates matched the species and resistance pattern of associated neonatal BSI isolates. Thirty GN BSI were observed among neonates born to unenrolled mothers. Among 37 of 51 BSI with available NGS data, 21 (57%) showed a single nucleotide polymorphism distance of ≤5 to another BSI isolate. CONCLUSIONS Prospective assessment of maternal GN colonization did not demonstrate linkage to neonatal BSI. Organism-relatedness among neonates with BSI suggests nosocomial spread, highlighting the importance of NICU infection prevention and control practices to reduce GN BSI.
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Affiliation(s)
- Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shilpa Naik
- Department of Obstetrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Sunil Patil
- Department of Obstetrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Rajesh Kulkarni
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vaishali Dohe
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Swati Mudshingkar
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Anju Kagal
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Rachel M Smith
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Ahmed Babiker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Rajesh Karyakarte
- Department of Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sinha P, Ponnuraja C, Gupte N, Prakash Babu S, Cox SR, Sarkar S, Mave V, Paradkar M, Cintron C, Govindarajan S, Kinikar A, Priya N, Gaikwad S, Thangakunam B, Devarajan A, Dhanasekaran M, Tornheim JA, Gupta A, Salgame P, Christopher DJ, Kornfeld H, Viswanathan V, Ellner JJ, Horsburgh CR, Gupte AN, Padmapriyadarsini C, Hochberg NS. Impact of Undernutrition on Tuberculosis Treatment Outcomes in India: A Multicenter, Prospective, Cohort Analysis. Clin Infect Dis 2023; 76:1483-1491. [PMID: 36424864 PMCID: PMC10319769 DOI: 10.1093/cid/ciac915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Undernutrition is the leading risk factor for tuberculosis (TB) globally. Its impact on treatment outcomes is poorly defined. METHODS We conducted a prospective cohort analysis of adults with drug-sensitive pulmonary TB at 5 sites from 2015-2019. Using multivariable Poisson regression, we assessed associations between unfavorable outcomes and nutritional status based on body mass index (BMI) nutritional status at treatment initiation, BMI prior to TB disease, stunting, and stagnant or declining BMI after 2 months of TB treatment. Unfavorable outcome was defined as a composite of treatment failure, death, or relapse within 6 months of treatment completion. RESULTS Severe undernutrition (BMI <16 kg/m2) at treatment initiation and severe undernutrition before the onset of TB disease were both associated with unfavorable outcomes (adjusted incidence rate ratio [aIRR], 2.05; 95% confidence interval [CI], 1.42-2.91 and aIRR, 2.20; 95% CI, 1.16-3.94, respectively). Additionally, lack of BMI increase after treatment initiation was associated with increased unfavorable outcomes (aIRR, 1.81; 95% CI, 1.27-2.61). Severe stunting (height-for-age z score <-3) was associated with unfavorable outcomes (aIRR, 1.52; 95% CI, 1.00-2.24). Severe undernutrition at treatment initiation and lack of BMI increase during treatment were associated with a 4- and 5-fold higher rate of death, respectively. CONCLUSIONS Premorbid undernutrition, undernutrition at treatment initiation, lack of BMI increase after intensive therapy, and severe stunting are associated with unfavorable TB treatment outcomes. These data highlight the need to address this widely prevalent TB comorbidity. Nutritional assessment should be integrated into standard TB care.
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Affiliation(s)
- Pranay Sinha
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Chinnaiyan Ponnuraja
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospitals–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Center for Infectious Diseases in India, Johns Hopkins India, Pune, Maharashtra, India
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | | | - Samyra R Cox
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Sonali Sarkar
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospitals–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Center for Infectious Diseases in India, Johns Hopkins India, Pune, Maharashtra, India
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospitals–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Center for Infectious Diseases in India, Johns Hopkins India, Pune, Maharashtra, India
| | - Chelsie Cintron
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - S Govindarajan
- Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
- National Tuberculosis Elimination Program, Puducherry, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | - Nadesan Priya
- Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjay Gaikwad
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune, Maharashtra, India
| | | | | | | | - Jeffrey A Tornheim
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Amita Gupta
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Padmini Salgame
- Center for Emerging Pathogens, Department of Medicine, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
| | | | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Vijay Viswanathan
- Prof. M. Viswanathan Diabetes Research Centre, Chennai, Tamil Nadu, India
| | - Jerrold J Ellner
- Center for Emerging Pathogens, Department of Medicine, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey, USA
| | - C Robert Horsburgh
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Akshay N Gupte
- Division of Infectious Diseases, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | | | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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7
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Humphrey J, Nagel E, Carlucci JG, Edmonds A, Kinikar A, Anderson K, Leroy V, Machado D, Yin DE, Tulio Luque M, Amorissani-Folquet M, Mbewe S, Suwanlerk T, Munyaneza A, Patel RC, Musick B, Abuogi L, Wools-Kaloustian K. Integration of HIV care into maternal and child health services in the global IeDEA consortium. Front Glob Womens Health 2023; 4:1066297. [PMID: 37139173 PMCID: PMC10150067 DOI: 10.3389/fgwh.2023.1066297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
The WHO recommends the integration of routine HIV services within maternal and child health (MCH) services to reduce the fragmentation of and to promote retention in care for pregnant and postpartum women living with HIV (WWH) and their infants and children exposed to HIV (ICEH). During 2020-2021, we surveyed 202 HIV treatment sites across 40 low- and middle-income countries within the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. We determined the proportion of sites providing HIV services integrated within MCH clinics, defined as full [HIV care and antiretroviral treatment (ART) initiation in MCH clinic], partial (HIV care or ART initiation in MCH clinic), or no integration. Among sites serving pregnant WWH, 54% were fully and 21% partially integrated, with the highest proportions of fully integrated sites in Southern Africa (80%) and East Africa (76%) compared to 14%-40% in other regions (i.e., Asia-Pacific; the Caribbean, Central and South America Network for HIV Epidemiology; Central Africa; West Africa). Among sites serving postpartum WWH, 51% were fully and 10% partially integrated, with a similar regional integration pattern to sites serving pregnant WWH. Among sites serving ICEH, 56% were fully and 9% were partially integrated, with the highest proportions of fully integrated sites in East Africa (76%), West Africa (58%) and Southern Africa (54%) compared to ≤33% in the other regions. Integration was heterogenous across IeDEA regions and most prevalent in East and Southern Africa. More research is needed to understand this heterogeneity and the impacts of integration on MCH outcomes globally.
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Affiliation(s)
- John Humphrey
- Department of Medicine, Indiana University, Indianapolis, Indiana, IN, United States
| | - Elizabeth Nagel
- Department of Medicine, Indiana University, Indianapolis, Indiana, IN, United States
| | - James G. Carlucci
- Department of Medicine, Indiana University, Indianapolis, Indiana, IN, United States
| | - Andrew Edmonds
- Department of Epidemiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Kim Anderson
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Valériane Leroy
- CERPOP- UMR 1295, Institut National de la Santé et de la Recherche Médicale, University Toulouse 3, France
| | - Daisy Machado
- Departamento de Pediatria, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Dwight E. Yin
- Maternal Adolescent and Pediatric Research Branch (MAPRB), Division of AIDS (DAIDS), Prevention Sciences Program (PSP), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, United States
| | - Marco Tulio Luque
- Departamento de Pediatría, Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | | | | | | | - Athanase Munyaneza
- Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | - Rena C. Patel
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Beverly Musick
- Department of Medicine, Indiana University, Indianapolis, Indiana, IN, United States
| | - Lisa Abuogi
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University, Indianapolis, Indiana, IN, United States
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8
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Suwanlerk T, Rupasinghe D, Jantarabenjakul W, An VT, Ross JL, Kariminia A, Van Lam N, Kinikar A, Ounchanum P, Puthanakit T, Nik Yusoff NK, Lumbiganon P, Chokephaibulkit K, Viet DC, Sudjaritruk T, Moy FS, Wati DK, Mohamed TJ, Nallusamy R, Kumarasamy N, Khol V, Khanh TH, Kurniati N. Lipid and glucose abnormalities and associated factors among children living with HIV in Asia. Antivir Ther 2023; 28:13596535231170751. [PMID: 37114944 PMCID: PMC10825667 DOI: 10.1177/13596535231170751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND Children living with HIV (CLHIV) on prolonged antiretroviral therapy (ART) are at risk for lipid and glucose abnormalities. Prevalence and associated factors were assessed in a multicentre, Asian longitudinal paediatric cohort. METHODS CLHIV were considered to have lipid or glucose abnormalities if they had total cholesterol ≥200 mg/dL, high-density lipoprotein (HDL) ≤35 mg/dL, low-density lipoprotein (LDL) ≥100 mg/dL, triglycerides (TG) ≥110 mg/dL, or fasting glucose >110 mg/dL. Factors associated with lipid and glucose abnormalities were assessed by logistic regression. RESULTS Of 951 CLHIV, 52% were male with a median age of 8.0 (interquartile range [IQR] 5.0-12.0) years at ART start and 15.0 (IQR 12.0-18.0) years at their last clinic visit. 89% acquired HIV perinatally, and 30% had ever used protease inhibitors (PIs). Overall, 225 (24%) had hypercholesterolemia, 105 (27%) low HDL, 213 (58%) high LDL, 369 (54%) hypertriglyceridemia, and 130 (17%) hyperglycemia. Hypercholesterolemia was more likely among females (versus males, aOR 1.93, 95% CI 1.40-2.67). Current PIs use was associated with hypercholesterolemia (current use: aOR 1.54, 95% CI 1.09-2.20); low HDL (current use: aOR 3.16, 95% CI 1.94-5.15; prior use: aOR 10.55, 95% CI 2.53-43.95); hypertriglyceridemia (current use: aOR 3.90, 95% CI 2.65-5.74; prior use: aOR 2.89, 95% CI 1.31-6.39); high LDL (current use: aOR 1.74, 95% CI 1.09-2.76); and hyperglycemia (prior use: aOR 2.43, 95% CI 1.42-4.18). CONCLUSION More than half and one-fifth of CLHIV have dyslipidemia and hyperglycemia, respectively. Routine paediatric HIV care should include metabolic monitoring. The association between PIs use and dyslipidemia emphasizes the importance of rapidly transitioning to integrase inhibitor-containing regimens.
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Affiliation(s)
| | | | - Watsamon Jantarabenjakul
- Department of Pediatrics, Faculty of Medicine and Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Vu T An
- Infectious Diseases Department, Children’s Hospital 2, Ho Chi Minh City, Vietnam
| | - Jeremy L Ross
- TREAT Asia, amfAR – The Foundation for AIDS Research, Bangkok, Thailand
| | | | - Nguyen Van Lam
- Infectious Diseases Department, National Hospital of Pediatrics, Hanoi, Vietnam
| | - Aarti Kinikar
- BJ Medical College and Sassoon General Hospitals, Maharashtra, India
| | - Pradthana Ounchanum
- Department of Pediatrics, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
| | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine and Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Nik K Nik Yusoff
- Department of Pediatrics, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia
| | - Pagakrong Lumbiganon
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Do C Viet
- Infectious Diseases Department, Children’s Hospital 2, Ho Chi Minh City, Vietnam
| | - Tavitiya Sudjaritruk
- Department of Pediatrics, Faculty of Medicine, and Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Fong S Moy
- Department of Pediatrics, Hospital Likas, Kota Kinabalu, Malaysia
| | - Dewi K Wati
- Department of Pediatrics, Prof. Dr. I.G.N.G Ngoerah Hospital, Udayana University, Bali, Indonesia
| | - Thahira J Mohamed
- Department of Pediatrics, Women and Children Hospital Kuala Lumpur (WCHKL), Kuala Lumpur, Malaysia
| | | | - Nagalingeswaran Kumarasamy
- VHS-Infectious Diseases Medical Centre, Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), Voluntary Health Services, Chennai, India
| | - Vohith Khol
- National Centre for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
| | - Truong H Khanh
- Infectious Diseases Department, Children’s Hospital 1, Ho Chi Minh City, Vietnam
| | - Nia Kurniati
- Department of Child Health, Universitas Indonesia – Cipto Mangunkusumo General Hospital, Indonesia
| | - on behalf of the TREAT Asia pediatric HIV Observational Database (TApHOD)
- TREAT Asia, amfAR – The Foundation for AIDS Research, Bangkok, Thailand
- The Kirby Institute, UNSW Sydney, Sydney, Australia
- Department of Pediatrics, Faculty of Medicine and Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
- Infectious Diseases Department, Children’s Hospital 2, Ho Chi Minh City, Vietnam
- Infectious Diseases Department, National Hospital of Pediatrics, Hanoi, Vietnam
- BJ Medical College and Sassoon General Hospitals, Maharashtra, India
- Department of Pediatrics, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
- Department of Pediatrics, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Pediatrics, Faculty of Medicine, and Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Pediatrics, Hospital Likas, Kota Kinabalu, Malaysia
- Department of Pediatrics, Prof. Dr. I.G.N.G Ngoerah Hospital, Udayana University, Bali, Indonesia
- Department of Pediatrics, Women and Children Hospital Kuala Lumpur (WCHKL), Kuala Lumpur, Malaysia
- Department of Pediatrics, Penang Hospital, Penang, Malaysia
- VHS-Infectious Diseases Medical Centre, Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), Voluntary Health Services, Chennai, India
- National Centre for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
- Infectious Diseases Department, Children’s Hospital 1, Ho Chi Minh City, Vietnam
- Department of Child Health, Universitas Indonesia – Cipto Mangunkusumo General Hospital, Indonesia
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9
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Sinha S, Bansal G, Samad SA, Ajayababu A, Lal BM, Kabra SK, Lodha R, Sangle SA, Guha SK, Rajput N, Pandey RM, Ranjan S, Salvi S, Mundhe S, More M, Modak D, Datta K, Das BK, Kinikar A. Survival of Children Living with HIV/AIDS: A Multicentric Study from India. Natl Acad Sci Lett 2023. [DOI: 10.1007/s40009-023-01242-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
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10
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Gafar F, Wasmann RE, McIlleron HM, Aarnoutse RE, Schaaf HS, Marais BJ, Agarwal D, Antwi S, Bang ND, Bekker A, Bell DJ, Chabala C, Choo L, Davies GR, Day JN, Dayal R, Denti P, Donald PR, Engidawork E, Garcia-Prats AJ, Gibb D, Graham SM, Hesseling AC, Heysell SK, Idris MI, Kabra SK, Kinikar A, Kumar AKH, Kwara A, Lodha R, Magis-Escurra C, Martinez N, Mathew BS, Mave V, Mduma E, Mlotha-Mitole R, Mpagama SG, Mukherjee A, Nataprawira HM, Peloquin CA, Pouplin T, Ramachandran G, Ranjalkar J, Roy V, Ruslami R, Shah I, Singh Y, Sturkenboom MGG, Svensson EM, Swaminathan S, Thatte U, Thee S, Thomas TA, Tikiso T, Touw DJ, Turkova A, Velpandian T, Verhagen LM, Winckler JL, Yang H, Yunivita V, Taxis K, Stevens J, Alffenaar JWC. Global estimates and determinants of antituberculosis drug pharmacokinetics in children and adolescents: a systematic review and individual patient data meta-analysis. Eur Respir J 2023; 61:2201596. [PMID: 36328357 PMCID: PMC9996834 DOI: 10.1183/13993003.01596-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Suboptimal exposure to antituberculosis (anti-TB) drugs has been associated with unfavourable treatment outcomes. We aimed to investigate estimates and determinants of first-line anti-TB drug pharmacokinetics in children and adolescents at a global level. METHODS We systematically searched MEDLINE, Embase and Web of Science (1990-2021) for pharmacokinetic studies of first-line anti-TB drugs in children and adolescents. Individual patient data were obtained from authors of eligible studies. Summary estimates of total/extrapolated area under the plasma concentration-time curve from 0 to 24 h post-dose (AUC0-24) and peak plasma concentration (C max) were assessed with random-effects models, normalised with current World Health Organization-recommended paediatric doses. Determinants of AUC0-24 and C max were assessed with linear mixed-effects models. RESULTS Of 55 eligible studies, individual patient data were available for 39 (71%), including 1628 participants from 12 countries. Geometric means of steady-state AUC0-24 were summarised for isoniazid (18.7 (95% CI 15.5-22.6) h·mg·L-1), rifampicin (34.4 (95% CI 29.4-40.3) h·mg·L-1), pyrazinamide (375.0 (95% CI 339.9-413.7) h·mg·L-1) and ethambutol (8.0 (95% CI 6.4-10.0) h·mg·L-1). Our multivariate models indicated that younger age (especially <2 years) and HIV-positive status were associated with lower AUC0-24 for all first-line anti-TB drugs, while severe malnutrition was associated with lower AUC0-24 for isoniazid and pyrazinamide. N-acetyltransferase 2 rapid acetylators had lower isoniazid AUC0-24 and slow acetylators had higher isoniazid AUC0-24 than intermediate acetylators. Determinants of C max were generally similar to those for AUC0-24. CONCLUSIONS This study provides the most comprehensive estimates of plasma exposures to first-line anti-TB drugs in children and adolescents. Key determinants of drug exposures were identified. These may be relevant for population-specific dose adjustment or individualised therapeutic drug monitoring.
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Affiliation(s)
- Fajri Gafar
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Roeland E Wasmann
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Helen M McIlleron
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Cape Town, Institute of Infectious Disease and Molecular Medicine, Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - H Simon Schaaf
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead, Sydney, Australia
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
| | - Dipti Agarwal
- Ram Manohar Lohia Institute of Medical Sciences, Department of Paediatrics, Lucknow, India
| | - Sampson Antwi
- Komfo Anokye Teaching Hospital, Department of Child Health, Kumasi, Ghana
- Kwame Nkrumah University of Science and Technology, School of Medical Sciences, Department of Child Health, Kumasi, Ghana
| | | | - Adrie Bekker
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - David J Bell
- NHS Greater Glasgow and Clyde, Infectious Diseases Unit, Glasgow, UK
| | - Chishala Chabala
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia
- University Teaching Hospitals - Children's Hospital, Lusaka, Zambia
| | - Louise Choo
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Geraint R Davies
- Malawi Liverpool Wellcome Clinical Research Programme, Clinical Department, Blantyre, Malawi
- University of Liverpool, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- University of Oxford, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Oxford, UK
| | - Rajeshwar Dayal
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Paolo Denti
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Peter R Donald
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Ephrem Engidawork
- Addis Ababa University, College of Health Sciences, School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Addis Ababa, Ethiopia
| | - Anthony J Garcia-Prats
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Pediatrics, Madison, WI, USA
| | - Diana Gibb
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Stephen M Graham
- University of Melbourne, Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Anneke C Hesseling
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Scott K Heysell
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Misgana I Idris
- University of Alabama at Birmingham, Department of Biology, Birmingham, AL, USA
| | - Sushil K Kabra
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
| | - Agibothu K Hemanth Kumar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Awewura Kwara
- University of Florida, Emerging Pathogens Institute, College of Medicine, Gainesville, FL, USA
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | | | - Nilza Martinez
- Instituto Nacional de Enfermedades Respiratorias y Del Ambiente, Asunción, Paraguay
| | - Binu S Mathew
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins University, Department of Medicine and Infectious Diseases, Baltimore, MD, USA
| | - Estomih Mduma
- Haydom Lutheran Hospital, Center for Global Health Research, Haydom, Tanzania
| | | | | | - Aparna Mukherjee
- All India Institute of Medical Sciences, Departments of Pediatrics, New Delhi, India
| | - Heda M Nataprawira
- Universitas Padjadjaran, Hasan Sadikin Hospital, Faculty of Medicine, Department of Child Health, Division of Paediatric Respirology, Bandung, Indonesia
| | | | - Thomas Pouplin
- Mahidol University, Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Geetha Ramachandran
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Jaya Ranjalkar
- Christian Medical College and Hospital, Department of Pharmacology and Clinical Pharmacology, Vellore, India
| | - Vandana Roy
- Maulana Azad Medical College, Department of Pharmacology, New Delhi, India
| | - Rovina Ruslami
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Ira Shah
- Bai Jerbai Wadia Hospital for Children, Department of Pediatric Infectious Diseases, Pediatric TB Clinic, Mumbai, India
| | - Yatish Singh
- Sarojini Naidu Medical College, Department of Pediatrics, Agra, India
| | - Marieke G G Sturkenboom
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute of Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Uppsala University, Department of Pharmacy, Uppsala, Sweden
| | - Soumya Swaminathan
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
- World Health Organization, Public Health Division, Geneva, Switzerland
| | - Urmila Thatte
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Department of Clinical Pharmacology, Mumbai, India
| | - Stephanie Thee
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Berlin, Germany
| | - Tania A Thomas
- University of Virginia, Division of Infectious Diseases and International Health, Charlottesville, VA, USA
| | - Tjokosela Tikiso
- University of Cape Town, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Anna Turkova
- University College London, Medical Research Council Clinical Trials Unit, London, UK
| | - Thirumurthy Velpandian
- All India Institute of Medical Sciences, Ocular Pharmacology and Pharmacy Division, Dr R.P. Centre, New Delhi, India
| | - Lilly M Verhagen
- Radboud University Medical Center, Radboud Center for Infectious Diseases, Laboratory of Medical Immunology, Section of Pediatric Infectious Diseases, Nijmegen, The Netherlands
- Radboud University Medical Center, Amalia Children's Hospital, Department of Paediatric Infectious Diseases and Immunology, Nijmegen, The Netherlands
- Stellenbosch University, Family Centre for Research with UBUNTU, Department of Paediatrics and Child Health, Cape Town, South Africa
| | - Jana L Winckler
- Stellenbosch University, Faculty of Medicine and Health Sciences, Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Tygerberg, South Africa
| | - Hongmei Yang
- University of Rochester, School of Medicine and Dentistry, Department of Biostatistics and Computational Biology, Rochester, NY, USA
| | - Vycke Yunivita
- Universitas Padjadjaran, Faculty of Medicine, Department of Biomedical Sciences, Division of Pharmacology and Therapy, Bandung, Indonesia
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Groningen, The Netherlands
| | - Jasper Stevens
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
- Both authors contributed equally and shared senior authorship
| | - Jan-Willem C Alffenaar
- The University of Sydney, Sydney Institute for Infectious Diseases, Sydney, Australia
- The University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia
- Westmead Hospital, Sydney, Australia
- Both authors contributed equally and shared senior authorship
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Hamada Y, Gupta RK, Quartagno M, Izzard A, Acuna-Villaorduna C, Altet N, Diel R, Dominguez J, Floyd S, Gupta A, Huerga H, Jones-López EC, Kinikar A, Lange C, van Leth F, Liu Q, Lu W, Lu P, Rueda IL, Martinez L, Mbandi SK, Muñoz L, Padilla ES, Paradkar M, Scriba T, Sester M, Shanaube K, Sharma SK, Sloot R, Sotgiu G, Thiruvengadam K, Vashishtha R, Abubakar I, Rangaka MX. Predictive performance of interferon-gamma release assays and the tuberculin skin test for incident tuberculosis: an individual participant data meta-analysis. EClinicalMedicine 2023; 56:101815. [PMID: 36636295 PMCID: PMC9829704 DOI: 10.1016/j.eclinm.2022.101815] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Evidence on the comparative performance of purified protein derivative tuberculin skin tests (TST) and interferon-gamma release assays (IGRA) for predicting incident active tuberculosis (TB) remains conflicting. We conducted an individual participant data meta-analysis to directly compare the predictive performance for incident TB disease between TST and IGRA to inform policy. METHODS We searched Medline and Embase from 1 January 2002 to 4 September 2020, and studies that were included in previous systematic reviews. We included prospective longitudinal studies in which participants received both TST and IGRA and estimated performance as hazard ratios (HR) for the development of all diagnoses of TB in participants with dichotomised positive test results compared to negative results, using different thresholds of positivity for TST. Secondary analyses included an evaluation of the impact of background TB incidence. We also estimated the sensitivity and specificity for predicting TB. We explored heterogeneity through pre-defined sub-group analyses (e.g. country-level TB incidence). Publication bias was assessed using funnel plots and Egger's test. This review is registered with PROSPERO, CRD42020205667. FINDINGS We obtained data from 13 studies out of 40 that were considered eligible (N = 32,034 participants: 36% from countries with TB incidence rate ≥100 per 100,000 population). All reported data on TST and QuantiFERON Gold in-Tube (QFT-GIT). The point estimate for the TST was highest with higher cut-offs for positivity and particularly when stratified by bacillus Calmette-Guérin vaccine (BCG) status (15 mm if BCG vaccinated and 5 mm if not [TST5/15 mm]) at 2.88 (95% CI 1.69-4.90). The pooled HR for QFT-GIT was higher than for TST at 4.15 (95% CI 1.97-8.75). The difference was large in countries with TB incidence rate <100 per 100,000 population (HR 10.38, 95% CI 4.17-25.87 for QFT-GIT VS. HR 5.36, 95% CI 3.82-7.51 for TST5/15 mm) but much of this difference was driven by a single study (HR 5.13, 95% CI 3.58-7.35 for TST5/15 mm VS. 7.18, 95% CI 4.48-11.51 for QFT-GIT, when excluding the study, in which all 19 TB cases had positive QFT-GIT results). The comparative performance was similar in the higher burden countries (HR 1.61, 95% CI 1.23-2.10 for QFT-GIT VS. HR 1.72, 95% CI 0.98-3.01 for TST5/15 mm). The predictive performance of both tests was higher in countries with TB incidence rate <100 per 100,000 population. In the lower TB incidence countries, the specificity of TST (76% for TST5/15 mm) and QFT-GIT (74%) for predicting active TB approached the minimum World Health Organization target (≥75%), but the sensitivity was below the target of ≥75% (63% for TST5/15 mm and 65% for QFT-GIT). The absolute differences in positive and negative predictive values between TST15 mm and QFT-GIT were small (positive predictive values 2.74% VS. 2.46%; negative predictive values 99.42% VS. 99.52% in low-incidence countries). Egger's test did not show evidence of publication bias (0.74 for TST15 mm and p = 0.68 for QFT-GIT). INTERPRETATION IGRA appears to have higher predictive performance than the TST in low TB incidence countries, but the difference was driven by a single study. Any advantage in clinical performance may be small, given the numerically similar positive and negative predictive values. Both IGRA and TST had lower performance in countries with high TB incidence. Test choice should be contextual and made considering operational and likely clinical impact of test results. FUNDING YH, IA, and MXR were supported by the National Institute for Health and Care Research (NIHR), United Kingdom (RP-PG-0217-20009). MQ was supported by the Medical Research Council [MC_UU_00004/07].
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Affiliation(s)
- Yohhei Hamada
- Institute for Global Health, University College London, London, United Kingdom
- Corresponding author.
| | - Rishi K. Gupta
- Institute for Global Health, University College London, London, United Kingdom
| | - Matteo Quartagno
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Abbie Izzard
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Neus Altet
- Unitat de Tuberculosis, Hospital Universitari Vall d’Hebron-Drassanes, Barcelona, Spain
- Unitat de TDO de la Tuberculosis ‘Servicios Clínicos’, Barcelona, Spain
| | - Roland Diel
- Institute for Epidemiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Jose Dominguez
- Institut d'Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Amita Gupta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Edward C. Jones-López
- Division of Infectious Diseases, Department of Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), Clinical Tuberculosis Unit, Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
- Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
| | - Frank van Leth
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Department of Health Sciences, VU University, Amsterdam, the Netherlands
- Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Qiao Liu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, PR China
| | - Wei Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, PR China
| | - Peng Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, Jiangsu Province, PR China
| | - Irene Latorre Rueda
- Institut d'Investigació Germans Trias i Pujol, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Leonardo Martinez
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, USA
| | - Stanley Kimbung Mbandi
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, and Division of Immunology, Department of Pathology, University of Cape Town, South Africa, Western Cape, South Africa
| | - Laura Muñoz
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | | | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins India, Pune, Maharashtra, India
| | - Thomas Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, and Division of Immunology, Department of Pathology, University of Cape Town, South Africa, Western Cape, South Africa
| | - Martina Sester
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | | | - Surendra K. Sharma
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
- Department of Molecular Medicine, Jamia Hamdard Institute of Molecular Medicine, Hamdard University, Delhi, India
- Departments of General Medicine & Pulmonary Medicine, JNMC, Datta Meghe Institute of Medical Sciences, Maharashtra, India
| | - Rosa Sloot
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Giovanni Sotgiu
- Tuberculosis Network European Trials Group (TBnet), Borstel, Germany
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Kannan Thiruvengadam
- National Institute for Research in Tuberculosis, Indian Council of Medical Research, Chennai, Tamil Nadu, India
| | - Richa Vashishtha
- Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, United Kingdom
| | - Molebogeng X. Rangaka
- Institute for Global Health, University College London, London, United Kingdom
- School of Public Health, and Clinical Infectious Disease Research Institute-Africa, University of Cape Town, Cape Town, South Africa
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12
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Kartikeswar G, Parikh T, Randive B, Kinikar A, Rajput U, Valvi C, Vaidya U, Malwade S, Agarkhedkar S, Kadam A, Smith R, Westercamp M, Schumacher C, Mave V, Robinson M, Gupta A, Milstone A, Manabe Y, Johnson J. Bloodstream infections in neonates with central venous catheters in three tertiary neonatal intensive care units in Pune, India. J Neonatal Perinatal Med 2023; 16:507-516. [PMID: 37718859 PMCID: PMC10875914 DOI: 10.3233/npm-221110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND Neonates admitted to the neonatal intensive care unit (NICU) are at risk for healthcare-associated infections, including central line-associated bloodstream infections. We aimed to characterize the epidemiology of bloodstream infections among neonates with central venous catheters admitted to three Indian NICUs. METHODS We conducted a prospective cohort study in three tertiary NICUs, from May 1, 2017 until July 31, 2019. All neonates admitted to the NICU were enrolled and followed until discharge, transfer, or death. Cases were defined as positive blood cultures in neonates with a central venous catheter in place for greater than 2 days or within 2 days of catheter removal. RESULTS During the study period, 140 bloodstream infections were identified in 131 neonates with a central venous catheter. The bloodstream infection rate was 11.9 per 1000 central line-days. Gram-negative organisms predominated, with 38.6% of cases caused by Klebsiella spp. and 14.9% by Acinetobacter spp. Antimicrobial resistance was prevalent among Gram-negative isolates, with 86.9% resistant to third- or fourth-generation cephalosporins, 63.1% to aminoglycosides, 61.9% to fluoroquinolones, and 42.0% to carbapenems. Mortality and length of stay were greater in neonates with bloodstream infection than in neonates without bloodstream infection (unadjusted analysis, p < 0.001). CONCLUSIONS We report a high bloodstream infection rate among neonates with central venous catheters admitted to three tertiary care NICUs in India. Action to improve infection prevention and control practices in the NICU is needed to reduce the morbidity and mortality associated with BSI in this high-risk population.
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Affiliation(s)
- G.A.P. Kartikeswar
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - T.B. Parikh
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - B. Randive
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - A. Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - U.C. Rajput
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - C. Valvi
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - U. Vaidya
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - S. Malwade
- Department of Pediatrics, Dr. D.Y. Patil Medical College, Pune, India
| | - S. Agarkhedkar
- Department of Pediatrics, Dr. D.Y. Patil Medical College, Pune, India
| | - A. Kadam
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - R.M. Smith
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - M. Westercamp
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - C. Schumacher
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - V. Mave
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - M.L. Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A. Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A.M. Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Y.C. Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J. Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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13
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Cox SR, Padmapriyadarsini C, Mave V, Seth B, Thiruvengadam K, Gaikwad S, Sahasrabudhe TR, Sane M, Tornheim JA, Shrinivasa BM, Lokhande R, Barthwal MS, Shivakumar SVBY, Krishnan S, Santhappan R, Kinikar A, Kakrani AL, Paradkar M, Bollinger RC, Sekar K, Gupte AN, Hanna LE, Gupta A, Golub JE. Characterising cause of death among people treated for drug-susceptible TB in India. Int J Tuberc Lung Dis 2023; 27:78-80. [PMID: 36853129 DOI: 10.5588/ijtld.22.0454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- S R Cox
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Padmapriyadarsini
- Indian Council of Medical Research-National Institute of Research in Tuberculosis, Chennai, India
| | - V Mave
- Johns Hopkins University School of Medicine, Baltimore, MD, USA, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University (BJGMC-JHU) Clinical Research Site, Pune, India, Johns Hopkins India, Pune, India
| | - B Seth
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Thiruvengadam
- Indian Council of Medical Research-National Institute of Research in Tuberculosis, Chennai, India
| | - S Gaikwad
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, India
| | - T R Sahasrabudhe
- Dr D. Y. Patil Medical College, Hospital and Research Centre, Dr D. Y. Patil Vidyapeeth, Pimpri-Chinchwad, India
| | - M Sane
- Johns Hopkins India, Pune, India
| | - J A Tornheim
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - B M Shrinivasa
- Indian Council of Medical Research-National Institute of Research in Tuberculosis, Chennai, India
| | - R Lokhande
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, India
| | - M S Barthwal
- Dr D. Y. Patil Medical College, Hospital and Research Centre, Dr D. Y. Patil Vidyapeeth, Pimpri-Chinchwad, India
| | | | - S Krishnan
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Santhappan
- Indian Council of Medical Research-National Institute of Research in Tuberculosis, Chennai, India
| | - A Kinikar
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, India
| | - A L Kakrani
- Dr D. Y. Patil Medical College, Hospital and Research Centre, Dr D. Y. Patil Vidyapeeth, Pimpri-Chinchwad, India
| | - M Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University (BJGMC-JHU) Clinical Research Site, Pune, India, Johns Hopkins India, Pune, India
| | - R C Bollinger
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K Sekar
- Indian Council of Medical Research-National Institute of Research in Tuberculosis, Chennai, India
| | - A N Gupte
- Boston University School of Public Health, Boston, MA, USA
| | - L E Hanna
- Indian Council of Medical Research-National Institute of Research in Tuberculosis, Chennai, India
| | - A Gupta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J E Golub
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Riche CT, Reif LK, Nguyen NT, Alakiu GR, Seo G, Mathad JS, McNairy ML, Cordeiro AA, Kinikar A, Walsh KF, Deschamps MM, Nerette S, Nimkar S, Kayange N, Jaka H, Mwaisungu HM, Morona D, Peter TY, Suryavanshi N, Fitzgerald DW, Downs JA, Hokororo A. "Mobilizing our leaders": A multi-country qualitative study to increase the representation of women in global health leadership. PLOS Glob Public Health 2023; 3:e0000646. [PMID: 36962949 PMCID: PMC10021821 DOI: 10.1371/journal.pgph.0000646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/21/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Women play an essential role in health care delivery, and it is vital that they have equal representation in health leadership for equity, innovation, and the strengthening of health systems globally. Yet women remain vastly underrepresented in global health leadership positions, providing a clear example of the deeply rooted power imbalances that are central to the calls to decolonize global health. We conducted a multi-country study in Haiti, Tanzania, India, and the USA to examine gender-based challenges to career advancement for women in the global health workforce. Quantitative data on the type and prevalence of gender-based challenges has been previously reported. In this study, we analyze qualitative data collected through focus group discussions and in-depth interviews to understand women's experiences of gender-based obstacles to career advancement, their perceptions of underlying drivers, and perspectives on effective solutions. Guided by an adaptation of the Social Action Theory, we conducted focus group discussions and in-depth interviews with women at 4 major academic centers for clinical care and research in Haiti, India, Tanzania, and the United States. In total, 85 women participated in focus groups and 15 also participated in in-depth interviews. Discussions and interviews were conducted in the local language, by an experienced local facilitator unaffiliated with the participating institution, between 2017 and 2018. Discussions were recorded, transcribed, and translated. Data were analyzed by interpretive phenomenological methods for emergent themes. Three transcendent themes on gender-based challenges were identified: 1) cultural power imbalance, referring to the prevailing norms and engrained assumptions that women are less capable than men and that women's primary responsibility should be to their families; 2) institutional power imbalance, referring to the systematic gender bias upheld by existing leadership and power structures, and ranging from exclusion from career development opportunities to sexual harassment and assault; and 3) restricted agency, referring to women's limited ability to change their circumstances because of unequal cultural and institutional structures. Participants also described local, actionable solutions to address these barriers. These included: 1) formal reporting systems for sexual harassment and assault; 2) peer support and mentorship; and 3) accessible leadership training and mandatory gender equity training. Participants proposed feasible strategies to address gender-based challenges that could improve women's retention in health careers and foster their rise to leadership. Increasing the representation of women in global health leadership positions responds directly to efforts to decolonize global health and is integral to strengthening health systems and improving health outcomes for women and children worldwide.
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Affiliation(s)
- Claudia T Riche
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Lindsey K Reif
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Natalie T Nguyen
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - G Rinu Alakiu
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Grace Seo
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Jyoti S Mathad
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Margaret L McNairy
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Alexandra A Cordeiro
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Aarti Kinikar
- BJ Government Medical College and Sassoon Hospital, Pune, India
| | - Kathleen F Walsh
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Marie Marcelle Deschamps
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Sandy Nerette
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Smita Nimkar
- BJ Government Medical College-Johns Hopkins University Clinical Trials Unit, Pune, India
| | - Neema Kayange
- Department of Pediatrics, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Hyasinta Jaka
- Department of Medicine, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- Department of Internal Medicine, Mwanza College of Health and Allied Sciences, Mwanza, Tanzania
| | - Halima M Mwaisungu
- Department of Medical Ethics, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Domenica Morona
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Thandiwe Yvonne Peter
- Department of Administration, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Nishi Suryavanshi
- BJ Government Medical College-Johns Hopkins University Clinical Trials Unit, Pune, India
| | - Daniel W Fitzgerald
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
| | - Jennifer A Downs
- Department of Medicine, Center for Global Health, Weill Cornell Medicine, New York, New York, United States of America
- Department of Medicine, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Adolfine Hokororo
- Department of Pediatrics, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
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15
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Bhardwaj S, Choudhary ML, Jadhav S, Vipat V, Ghuge R, Salvi S, Kulkarni R, Kinikar A, Padbidri V, Bafna S, Bavdekare A, D'costa P, Gujar N, Potdar V. A retrospective analysis of respiratory virus transmission before and during the COVID-19 pandemic in Pune the western region of India. Front Public Health 2022; 10:936634. [PMID: 36159243 PMCID: PMC9494283 DOI: 10.3389/fpubh.2022.936634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/18/2022] [Indexed: 01/25/2023] Open
Abstract
Background SARS-CoV-2 was first reported in China in December 2019 and quickly spread across the world. Non-pharmaceutical interventions (NPIs) are the key to control the transmission of respiratory viruses. To stop the spread, NPI is widely recommended and is still followed by most countries. Methods At the National Influenza Center of the Indian Council of Medical Research-National Institute of Virology (ICMR-NIV), the surveillance of severe acute respiratory illness and acute respiratory illness cases for influenza and other respiratory viruses is in place. In this study, we analyzed surveillance data on respiratory viruses and/or SARS-CoV-2 testing from January 2017 to December 2021. Multiplex real-time PCR was used to detect the respiratory viruses. Results Our findings indicate that during the pandemic, the positivity for influenza A and B, metapneumovirus, parainfluenza virus, respiratory syncytial virus, and human coronavirus declined significantly. Conclusion The annual distinct seasonal outbreaks of influenza, RSV, and other respiratory viruses as observed during the pre-COVID-19 period were not observed during the COVID-19 pandemic in years 2020 and 21. Social distancing, lock-downs, and non-pharmaceutical interventions may play an important role in the reduction of respiratory viruses. Understanding the seasonal respiratory virus decline could help public health experts prepare for future respiratory virus pandemics.
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Affiliation(s)
- Sumit Bhardwaj
- Influenza, National Institute of Virology (ICMR), Pune, India
| | | | - Sheetal Jadhav
- Influenza, National Institute of Virology (ICMR), Pune, India
| | - Veena Vipat
- Influenza, National Institute of Virology (ICMR), Pune, India
| | - Rohan Ghuge
- Influenza, National Institute of Virology (ICMR), Pune, India
| | - Sonali Salvi
- B. J. Medical College and Sassoon Hospital, Pune, India
| | | | - Aarti Kinikar
- B. J. Medical College and Sassoon Hospital, Pune, India
| | | | | | | | | | | | - Varsha Potdar
- Influenza, National Institute of Virology (ICMR), Pune, India,*Correspondence: Varsha Potdar
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16
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Marbaniang I, Borse R, Sangle S, Kinikar A, Chavan A, Nimkar S, Suryavanshi N, Mave V. Development of shortened HIV-related stigma scales for young people living with HIV and young people affected by HIV in India. Health Qual Life Outcomes 2022; 20:119. [PMID: 35909172 PMCID: PMC9340676 DOI: 10.1186/s12955-022-02030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/27/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND HIV-related stigma is associated with poor quality of life and poor healthcare-seeking behaviours in young people living with HIV (YPLHIV) and young people affected by HIV (YPAHIV). India has an estimated 120,000 YPLHIV and 4 million YPAHIV, but efforts to measure HIV-related stigma in them are sparse, impeded by the lack of measuring instruments. Here, we describe the development of the Pune HIV-Stigma Scale (PHSS) and modified-PHSS to measure HIV-related stigma among YPLHIV and YPAHIV, respectively, in India. METHODS We used data from a mental health study for YPLHIV and YPAHIV aged 15-25 years, conducted at Byramjee Jeejeebhoy Government Medical College & Sassoon General Hospitals, Pune, India, between August 2018 and June 2021. Findings from multiple confirmatory factor analyses and cognitive interviews guided the development of the 12-item PHSS. The modified-PHSS was developed by confirming the structure of the PHSS for YPAHIV. Convergent validity with Center for Epidemiological Studies Depression (CES-D) and UCLA Loneliness scales was assessed using Spearman's correlation coefficients. RESULTS Model fit indices were good for both the PHSS (χ2 = 65.0, df = 48, p value: 0.052; root mean square error of approximation (RMSEA): 0.054; comparative fit index (CLI): 0.980; Tucker-Lewis index (TLI): 0.972; and standardized root mean square residual (SRMR): 0.067), and the modified-PHSS (χ2 = 56.9, df = 48, p value: 0.176; RMSEA: 0.045; CLI: 0.983; TFI: 0.976, and SRMR: 0.078). Spearman's correlation coefficients indicated low to moderate convergent validity (ρ: 0.03-0.52) across different subscales of the PHSS and modified-PHSS. Cronbach's alpha for the PHSS was 0.82 and for the modified-PHSS 0.81. CONCLUSION We developed the first scales to measure HIV-related stigma among YPLHIV and YPAHIV in India. These concise scales can facilitate measurement of HIV-related stigma more frequently in research studies. We recommend that they be tested in different Indian languages.
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Affiliation(s)
- Ivan Marbaniang
- Byramjee-Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India ,grid.14709.3b0000 0004 1936 8649Department of Epidemiology, McGill University, 2001 McGill College, Suite 1200, Montreal, QC H3A 1G1 Canada
| | - Rohidas Borse
- Department of Medicine, Byramjee-Jeejeebhoy Government Medical College, Pune, India
| | - Shashikala Sangle
- Department of Medicine, Byramjee-Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Paediatrics, Byramjee-Jeejeebhoy Government Medical College, Pune, India
| | - Amol Chavan
- Byramjee-Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
| | - Smita Nimkar
- Byramjee-Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India
| | - Nishi Suryavanshi
- Byramjee-Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India ,grid.21107.350000 0001 2171 9311Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Vidya Mave
- Byramjee-Jeejeebhoy Government Medical College - Johns Hopkins University Clinical Research Site, Pune, India ,grid.21107.350000 0001 2171 9311Johns Hopkins University School of Medicine, Baltimore, MD USA
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17
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Boettiger DC, An VT, Lumbiganon P, Wittawatmongkol O, Truong KH, Do VC, Van Nguyen L, Ly PS, Kinikar A, Ounchanum P, Puthanakit T, Kurniati N, Kumarasamy N, Wati DK, Chokephaibulkit K, Jamal Mohamed TA, Sudjaritruk T, Yusoff NKN, Fong MS, Nallusamy RA, Kariminia A. Severe Recurrent Bacterial Pneumonia Among Children Living With HIV. Pediatr Infect Dis J 2022; 41:e208-e215. [PMID: 35185140 PMCID: PMC10140183 DOI: 10.1097/inf.0000000000003494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bacterial pneumonia imparts a major morbidity and mortality burden on children living with HIV, yet effective prevention and treatment options are underutilized. We explored clinical factors associated with severe recurrent bacterial pneumonia among children living with HIV. METHODS Children enrolled in the TREAT Asia Pediatric HIV Observational Database were included if they started antiretroviral therapy (ART) on or after January 1st, 2008. Factors associated with severe recurrent bacterial pneumonia were assessed using competing-risk regression. RESULTS A total of 3,944 children were included in the analysis; 136 cases of severe recurrent bacterial pneumonia were reported at a rate of 6.5 [95% confidence interval (CI): 5.5-7.7] events per 1,000 patient-years. Clinical factors associated with severe recurrent bacterial pneumonia were younger age [adjusted subdistribution hazard ratio (aHR): 4.4 for <5 years versus ≥10 years, 95% CI: 2.2-8.4, P < 0.001], lower weight-for-age z-score (aHR: 1.5 for <-3.0 versus >-2.0, 95% CI: 1.1-2.3, P = 0.024), pre-ART diagnosis of severe recurrent bacterial pneumonia (aHR: 4.0 versus no pre-ART diagnosis, 95% CI: 2.7-5.8, P < 0.001), past diagnosis of symptomatic lymphoid interstitial pneumonitis or chronic HIV-associated lung disease, including bronchiectasis (aHR: 4.8 versus no past diagnosis, 95% CI: 2.8-8.4, P < 0.001), low CD4% (aHR: 3.5 for <10% versus ≥25%, 95% CI: 1.9-6.4, P < 0.001) and detectable HIV viral load (aHR: 2.6 versus undetectable, 95% CI: 1.2-5.9, P = 0.018). CONCLUSIONS Children <10-years-old and those with low weight-for-age, a history of respiratory illness, low CD4% or poorly controlled HIV are likely to gain the greatest benefit from targeted prevention and treatment programs to reduce the burden of bacterial pneumonia in children living with HIV.
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Affiliation(s)
- David C. Boettiger
- The Kirby Institute, UNSW Sydney, Australia
- Institute for Health and Aging, University of California, San Francisco, USA
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Vu Thien An
- Children Hospital 2, Ho Chi Minh City, Vietnam
| | - Pagakrong Lumbiganon
- Division of Infectious Disease, Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Orasri Wittawatmongkol
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | | | - Penh Sun Ly
- National Centre for HIV/AIDS, Dermatology and STDs, Phnom Penh, Cambodia
| | - Aarti Kinikar
- BJ Medical College and Sassoon General Hospitals, Maharashtra, India
| | | | - Thanyawee Puthanakit
- Department of Pediatrics and Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nia Kurniati
- Cipto Mangunkusumo – Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site (CART CRS), VHS-Infectious Diseases Medical Centre, VHS, Chennai, India
| | | | - Kulkanya Chokephaibulkit
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thahira A. Jamal Mohamed
- Department of Pediatrics, Women and Children Hospital Kuala Lumpur (WCHKL), Kuala Lumpur, Malaysia
| | - Tavitiya Sudjaritruk
- Department of Pediatrics, Faculty of Medicine, and Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
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18
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Shivakumar SVBY, Padmapriyadarsini C, Chavan A, Paradkar M, Shrinivasa BM, Gupte A, Dhanasekaran K, Thomas B, Suryavanshi N, Dolla CK, Selvaraju S, Kinikar A, Gaikwad S, Kohli R, Sivaramakrishnan GN, Pradhan N, Hanna LE, Kulkarni V, DeLuca A, Cox SR, Murali L, Thiruvengadam K, Raskar S, Ramachandran G, Golub JE, Gupte N, Mave V, Swaminathan S, Gupta A, Bollinger RC. Concomitant pulmonary disease is common among patients with extrapulmonary TB. Int J Tuberc Lung Dis 2022; 26:341-347. [PMID: 35351239 PMCID: PMC8982647 DOI: 10.5588/ijtld.21.0501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND : Microbiologic screening of extrapulmonary TB (EPTB) patients could inform recommendations for aerosol precautions and close contact prophylaxis. However, this is currently not routinely recommended in India. Therefore, we estimated the proportion of Indian patients with EPTB with microbiologic evidence of pulmonary TB (PTB). METHODS : We characterized baseline clinical, radiological and sputum microbiologic data of 885 adult and pediatric TB patients in Chennai and Pune, India, between March 2014 and November 2018. RESULTS : Of 277 patients with EPTB, enhanced screening led to the identification of 124 (45%) with concomitant PTB, including 53 (19%) who reported a cough >2 weeks; 158 (63%) had an abnormal CXR and 51 (19%) had a positive sputum for TB. Of 70 participants with a normal CXR and without any cough, 14 (20%) had a positive sputum for TB. Overall, the incremental yield of enhanced screening of patients with EPTB to identify concomitant PTB disease was 14% (95% CI 12–16). CONCLUSIONS : A high proportion of patients classified as EPTB in India have concomitant PTB. Our results support the need for improved symptom and CXR screening, and recommends routine sputum TB microbiology screening of all Indian patients with EPTB.
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Affiliation(s)
| | - C Padmapriyadarsini
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - A Chavan
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - M Paradkar
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - B M Shrinivasa
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - A Gupte
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - K Dhanasekaran
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - B Thomas
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - N Suryavanshi
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - C K Dolla
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - S Selvaraju
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - A Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - S Gaikwad
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - R Kohli
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - G N Sivaramakrishnan
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - N Pradhan
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - L E Hanna
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - V Kulkarni
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - A DeLuca
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - S R Cox
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - L Murali
- District Tuberculosis Office, Thiruvallur, India
| | - K Thiruvengadam
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - S Raskar
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - G Ramachandran
- Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - J E Golub
- Johns Hopkins School of Medicine, Baltimore, MD, USA, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - N Gupte
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - V Mave
- Johns Hopkins India, Pune, India, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - A Gupta
- Johns Hopkins School of Medicine, Baltimore, MD, USA, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - R C Bollinger
- Johns Hopkins School of Medicine, Baltimore, MD, USA, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Pradhan NN, Paradkar MS, Kagal A, Valvi C, Kinikar A, Khwaja S, Dhage R, Chandane J, Ithape M, Bendre M, Madewar R, Nadgeri V, Nijampurkar A, Jain D, Gupte N, Gupta A, Mave V, Dooley KE, Thakur KT. Performance of Xpert ® MTB/RIF and Xpert ® Ultra for the diagnosis of tuberculous meningitis in children. Int J Tuberc Lung Dis 2022; 26:317-325. [PMID: 35351236 PMCID: PMC9592112 DOI: 10.5588/ijtld.21.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE: To assess Xpert® MTB/RIF (Xpert) and Xpert® MTB/RIF Ultra (Ultra) performance in diagnosing pediatric tuberculous meningitis (TBM).METHODS: We conducted a study among children with suspected meningoencephalitis in Pune, India. Clinical, radiological, laboratory, and treatment data were analyzed to classify disease as definite, probable, possible or no TBM, using microbiologic or composite reference standards. We tested cerebrospinal fluid (CSF) either using Xpert or Ultra and estimated test performance characteristics.RESULTS: Of 341 participants, 149 (43.7%) were tested using Ultra and 192 (56.3%) with Xpert. Ultra had higher sensitivity (50% vs. 18%), lower specificity (91% vs. 99%), poor positive predictive value (PPV) (13% vs. 75%), and higher negative predictive value (NPV) (99% vs. 93%) than Xpert using the composite reference standard, with similar results by the microbiologic reference standard. Of 10 participants with trace positivity on Ultra, none met clinical TBM definitions.CONCLUSION: This is the first study to report on diagnostic performance of Ultra in pediatric TBM, which showed higher sensitivity and NPV than Xpert. For children presenting with nonspecific clinical features, Ultra is a promising diagnostic test. Further studies are required to define its optimal clinical use, including interpretation of trace positive results.
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Affiliation(s)
- N. N. Pradhan
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins India, Pune, India
| | - M. S. Paradkar
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins India, Pune, India
| | - A. Kagal
- BJ Government Medical College and Sassoon General Hospitals, Pune, India
| | - C. Valvi
- BJ Government Medical College and Sassoon General Hospitals, Pune, India
| | - A. Kinikar
- BJ Government Medical College and Sassoon General Hospitals, Pune, India
| | - S. Khwaja
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - R. Dhage
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - J. Chandane
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - M. Ithape
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - M. Bendre
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - R. Madewar
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - V. Nadgeri
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - A. Nijampurkar
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins India, Pune, India
| | - D. Jain
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India
| | - N. Gupte
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A. Gupta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - V. Mave
- BJ Government Medical College-Johns Hopkins Clinical Research Site, Pune, India;,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K. E. Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K. T. Thakur
- Department of Neurology, Columbia University Irving Medical Center and the New York Presbyterian Hospital, New York, NY, USA
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20
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Paradkar MS, Devaleenal D B, Mvalo T, Arenivas A, Thakur KT, Wolf L, Nimkar S, Inamdar S, Giridharan P, Selladurai E, Kinikar A, Valvi C, Khwaja S, Gadama D, Balaji S, Yadav Kattagoni K, Venkatesan M, Savic R, Swaminathan S, Gupta A, Gupte N, Mave V, Dooley KE. Randomized Clinical Trial of High-Dose Rifampicin With or Without Levofloxacin Versus Standard of Care for Pediatric Tuberculous Meningitis: The TBM-KIDS Trial. Clin Infect Dis 2022; 75:1594-1601. [PMID: 35291004 PMCID: PMC9617573 DOI: 10.1093/cid/ciac208] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Pediatric tuberculous meningitis (TBM) commonly causes death or disability. In adults, high-dose rifampicin may reduce mortality. The role of fluoroquinolones remains unclear. There have been no antimicrobial treatment trials for pediatric TBM. METHODS TBM-KIDS was a phase 2 open-label randomized trial among children with TBM in India and Malawi. Participants received isoniazid and pyrazinamide plus: (i) high-dose rifampicin (30 mg/kg) and ethambutol (R30HZE, arm 1); (ii) high-dose rifampicin and levofloxacin (R30HZL, arm 2); or (iii) standard-dose rifampicin and ethambutol (R15HZE, arm 3) for 8 weeks, followed by 10 months of standard treatment. Functional and neurocognitive outcomes were measured longitudinally using Modified Rankin Scale (MRS) and Mullen Scales of Early Learning (MSEL). RESULTS Of 2487 children prescreened, 79 were screened and 37 enrolled. Median age was 72 months; 49%, 43%, and 8% had stage I, II, and III disease, respectively. Grade 3 or higher adverse events occurred in 58%, 55%, and 36% of children in arms 1, 2, and 3, with 1 death (arm 1) and 6 early treatment discontinuations (4 in arm 1, 1 each in arms 2 and 3). By week 8, all children recovered to MRS score of 0 or 1. Average MSEL scores were significantly better in arm 1 than arm 3 in fine motor, receptive language, and expressive language domains (P < .01). CONCLUSIONS In a pediatric TBM trial, functional outcomes were excellent overall. The trend toward higher frequency of adverse events but better neurocognitive outcomes in children receiving high-dose rifampicin requires confirmation in a larger trial. CLINICAL TRIALS REGISTRATION NCT02958709.
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Affiliation(s)
- Mandar S Paradkar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Bella Devaleenal D
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Tisungane Mvalo
- UNC Project Malawi, Lilongwe, Malawi,Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ana Arenivas
- Section of Neuropsychology, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York, USA
| | - Lisa Wolf
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Smita Nimkar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Sadaf Inamdar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | - Prathiksha Giridharan
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | | | - Aarti Kinikar
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Department of Pediatrics, BJ Government Medical College, Pune, India
| | - Chhaya Valvi
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Department of Pediatrics, BJ Government Medical College, Pune, India
| | - Saltanat Khwaja
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India
| | | | - Sarath Balaji
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Krishna Yadav Kattagoni
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Mythily Venkatesan
- Department of Clinical Research, Indian Council of Medical Research–National Institute for Research in Tuberculosis, Chennai, India
| | - Radojka Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
| | | | - Amita Gupta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nikhil Gupte
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vidya Mave
- BJ Government Medical College–Johns Hopkins Clinical Research Site, Pune, India,Johns Hopkins India, Pune, India,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly E Dooley
- Correspondence: K. Dooley, Johns Hopkins University School of Medicine, 600 N Wolfe St, Osler 527, Baltimore, MD 21287 ()
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21
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Turkova A, Wills GH, Wobudeya E, Chabala C, Palmer M, Kinikar A, Hissar S, Choo L, Musoke P, Mulenga V, Mave V, Joseph B, LeBeau K, Thomason MJ, Mboizi RB, Kapasa M, van der Zalm MM, Raichur P, Bhavani PK, McIlleron H, Demers AM, Aarnoutse R, Love-Koh J, Seddon JA, Welch SB, Graham SM, Hesseling AC, Gibb DM, Crook AM. Shorter Treatment for Nonsevere Tuberculosis in African and Indian Children. N Engl J Med 2022; 386:911-922. [PMID: 35263517 PMCID: PMC7612496 DOI: 10.1056/nejmoa2104535] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Two thirds of children with tuberculosis have nonsevere disease, which may be treatable with a shorter regimen than the current 6-month regimen. METHODS We conducted an open-label, treatment-shortening, noninferiority trial involving children with nonsevere, symptomatic, presumably drug-susceptible, smear-negative tuberculosis in Uganda, Zambia, South Africa, and India. Children younger than 16 years of age were randomly assigned to 4 months (16 weeks) or 6 months (24 weeks) of standard first-line antituberculosis treatment with pediatric fixed-dose combinations as recommended by the World Health Organization. The primary efficacy outcome was unfavorable status (composite of treatment failure [extension, change, or restart of treatment or tuberculosis recurrence], loss to follow-up during treatment, or death) by 72 weeks, with the exclusion of participants who did not complete 4 months of treatment (modified intention-to-treat population). A noninferiority margin of 6 percentage points was used. The primary safety outcome was an adverse event of grade 3 or higher during treatment and up to 30 days after treatment. RESULTS From July 2016 through July 2018, a total of 1204 children underwent randomization (602 in each group). The median age of the participants was 3.5 years (range, 2 months to 15 years), 52% were male, 11% had human immunodeficiency virus infection, and 14% had bacteriologically confirmed tuberculosis. Retention by 72 weeks was 95%, and adherence to the assigned treatment was 94%. A total of 16 participants (3%) in the 4-month group had a primary-outcome event, as compared with 18 (3%) in the 6-month group (adjusted difference, -0.4 percentage points; 95% confidence interval, -2.2 to 1.5). The noninferiority of 4 months of treatment was consistent across the intention-to-treat, per-protocol, and key secondary analyses, including when the analysis was restricted to the 958 participants (80%) independently adjudicated to have tuberculosis at baseline. A total of 95 participants (8%) had an adverse event of grade 3 or higher, including 15 adverse drug reactions (11 hepatic events, all but 2 of which occurred within the first 8 weeks, when the treatments were the same in the two groups). CONCLUSIONS Four months of antituberculosis treatment was noninferior to 6 months of treatment in children with drug-susceptible, nonsevere, smear-negative tuberculosis. (Funded by the U.K. Medical Research Council and others; SHINE ISRCTN number, ISRCTN63579542.).
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Affiliation(s)
- Anna Turkova
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Genevieve H Wills
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Eric Wobudeya
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Chishala Chabala
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Megan Palmer
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Aarti Kinikar
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Syed Hissar
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Louise Choo
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Philippa Musoke
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Veronica Mulenga
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Vidya Mave
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Bency Joseph
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Kristen LeBeau
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Margaret J Thomason
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Robert B Mboizi
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Monica Kapasa
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Marieke M van der Zalm
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Priyanka Raichur
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Perumal K Bhavani
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Helen McIlleron
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Anne-Marie Demers
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Rob Aarnoutse
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - James Love-Koh
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - James A Seddon
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Steven B Welch
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Stephen M Graham
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Anneke C Hesseling
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Diana M Gibb
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Angela M Crook
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
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22
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Tornheim JA, Paradkar M, Zhao H, Kulkarni V, Pradhan N, Kinikar A, Kagal A, Gupte N, Mave V, Gupta A, Karakousis PC. The Kynurenine/Tryptophan Ratio Is a Sensitive Biomarker for the Diagnosis of Pediatric Tuberculosis Among Indian Children. Front Immunol 2022; 12:774043. [PMID: 35095848 PMCID: PMC8790563 DOI: 10.3389/fimmu.2021.774043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives Pediatric tuberculosis (TB) remains difficult to diagnose. The plasma kynurenine to tryptophan ratio (K/T ratio) is a potential biomarker for TB diagnosis and treatment response but has not been assessed in children. Methods We performed a targeted diagnostic accuracy analysis of four biomarkers: kynurenine abundance, tryptophan abundance, the K/T ratio, and IDO-1 gene expression. Data were obtained from transcriptome and metabolome profiling of children with confirmed tuberculosis and age- and sex-matched uninfected household contacts of pulmonary tuberculosis patients. Each biomarker was assessed as a baseline diagnostic and in response to successful TB treatment. Results Despite non-significant between-group differences in unbiased analysis, the K/T ratio achieved an area under the receiver operator characteristic curve (AUC) of 0.667 and 81.5% sensitivity for TB diagnosis. Kynurenine, tryptophan, and IDO-1 demonstrated diagnostic AUCs of 0.667, 0.602, and 0.463, respectively. None of these biomarkers demonstrated high AUCs for treatment response. The AUC of the K/T ratio was lower than biomarkers identified in unbiased analysis, but improved sensitivity over existing commercial assays for pediatric TB diagnosis. Conclusions Plasma kynurenine and the K/T ratio may be useful biomarkers for pediatric TB. Ongoing studies in geographically diverse populations will determine optimal use of these biomarkers worldwide.
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Affiliation(s)
- Jeffrey A Tornheim
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Center for Clinical Global Health Education, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Henry Zhao
- Johns Hopkins University, Baltimore, MD, United States
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Anju Kagal
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Nikhil Gupte
- Center for Clinical Global Health Education, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Vidya Mave
- Center for Clinical Global Health Education, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Center for Clinical Global Health Education, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Petros C Karakousis
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Center for Clinical Global Health Education, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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23
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Shafiq M, Mathad JS, Naik S, Alexander M, Yadana S, Araújo-Pereira M, Kulkarni V, Deshpande P, Kumar NP, Babu S, Andrade BB, Leu CS, Khwaja S, Bhosale R, Kinikar A, Gupta A, Shivakoti R. Association of Maternal Inflammation During Pregnancy With Birth Outcomes and Infant Growth Among Women With or Without HIV in India. JAMA Netw Open 2021; 4:e2140584. [PMID: 34935918 PMCID: PMC8696571 DOI: 10.1001/jamanetworkopen.2021.40584] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE The association of elevated levels of specific inflammatory markers during pregnancy with adverse birth outcomes and infant growth could indicate pathways for potential interventions. OBJECTIVE To evaluate whether higher levels of certain inflammatory markers during pregnancy are associated with preterm birth (PTB), low birth weight (LBW), and infant growth deficits. DESIGN, SETTING, AND PARTICIPANTS In this cohort study of pregnant women with or without HIV, 218 mother-infant pairs were followed up from pregnancy through 12 months post partum from June 27, 2016, to December 9, 2019. Pregnant women aged 18 to 40 years and between 13 and 34 weeks of gestation who were receiving antenatal care were enrolled in a cohort stratified by HIV status; sampling was based on convenience sampling from women receiving antenatal care at Byramjee Jeejeebhoy Government Medical College. EXPOSURES Levels of multiple circulating inflammation markers during the third trimester of pregnancy. MAIN OUTCOMES AND MEASURES The primary study outcome was PTB (<37 weeks' gestation). Secondary outcomes were LBW (<2500 g) and repeated measures (delivery; 6 weeks post partum; and 3, 6, and 12 months post partum using multivariable generalized linear models) of infant growth outcomes (length-for-age, weight-for-age, and weight-for-length z scores). RESULTS The median age of the 218 women at enrollment was 23 years (IQR, 21-27 years). In multivariable models, higher pregnancy levels of interleukin 17A were associated with increased odds of both PTB (adjusted odds ratio [aOR], 2.62; 95% CI, 1.11-6.17) and LBW (aOR, 1.81; 95% CI, 1.04-3.15). Higher levels of interleukin 1β were associated with increased PTB (aOR, 1.47; 95% CI, 1.15-1.89) and infant growth deficits (lower length-for-age z score: adjusted β = -0.10; 95% CI, -0.18 to -0.01; lower weight-for-age z score: adjusted β = -0.07; 95% CI, -0.14 to 0.001). CONCLUSIONS AND RELEVANCE This study suggests that increased levels of certain systemic inflammatory markers, including interleukin 1β and interleukin 17A, during pregnancy were associated with adverse birth outcomes and infant growth deficits. Future studies should evaluate whether potential interventions to modulate specific inflammatory pathways during pregnancy could improve birth outcomes and infant growth.
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Affiliation(s)
- Mehr Shafiq
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Jyoti S. Mathad
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Shilpa Naik
- Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Mallika Alexander
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, India
| | - Su Yadana
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Mariana Araújo-Pereira
- Instituto Goncalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, India
| | - Prasad Deshpande
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, India
| | - Nathella Pavan Kumar
- National Institutes of Health, National Institute for Research in Tuberculosis, International Center for Excellence in Research, Chennai, India
| | - Subash Babu
- National Institutes of Health, National Institute for Research in Tuberculosis, International Center for Excellence in Research, Chennai, India
| | - Bruno B. Andrade
- Instituto Goncalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil
- Multinational Organization Network Sponsoring Translational and Epidemiological Research Initiative, Salvador, Brazil
- Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
- Curso de Medicina, Faculdade de Tecnologia e Ciências, Salvador, Brazil
- Universidade Salvador, Laureate Universities, Salvador, Brazil
- Curso de Medicina, Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil
| | - Cheng-Shiun Leu
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York
| | - Saltanat Khwaja
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, India
| | - Ramesh Bhosale
- Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Paediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Amita Gupta
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rupak Shivakoti
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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24
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Chabala C, Turkova A, Hesseling AC, Zimba KM, van der Zalm M, Kapasa M, Palmer M, Chirehwa M, Wiesner L, Wobudeya E, Kinikar A, Mave V, Hissar S, Choo L, LeBeau K, Mulenga V, Aarnoutse R, Gibb D, McIlleron H. Pharmacokinetics of first-line drugs in children with tuberculosis using WHO-recommended weight band doses and formulations. Clin Infect Dis 2021; 74:1767-1775. [PMID: 34420049 PMCID: PMC9155615 DOI: 10.1093/cid/ciab725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Dispersible pediatric fixed-dose combination (FDC) tablets delivering higher doses of first-line antituberculosis drugs in World Health Organization–recommended weight bands were introduced in 2015. We report the first pharmacokinetic data for these FDC tablets in Zambian and South African children in the treatment-shortening SHINE trial. Methods Children weighing 4.0–7.9, 8.0–11.9, 12.0–15.9, or 16.0–24.9 kg received 1, 2, 3, or 4 tablets daily, respectively (rifampicin/isoniazid/pyrazinamide [75/50/150 mg], with or without 100 mg ethambutol, or rifampicin/isoniazid [75/50 mg]). Children 25.0–36.9 kg received doses recommended for adults <37 kg (300, 150, 800, and 550 mg/d, respectively, for rifampicin, isoniazid, pyrazinamide, and ethambutol). Pharmacokinetics were evaluated after at least 2 weeks of treatment. Results In the 77 children evaluated, the median age (interquartile range) was 3.7 (1.4–6.6) years; 40 (52%) were male and 20 (26%) were human immunodeficiency virus positive. The median area under the concentration-time curve from 0 to 24 hours for rifampicin, isoniazid, pyrazinamide, and ethambutol was 32.5 (interquartile range, 20.1–45.1), 16.7 (9.2–25.9), 317 (263–399), and 9.5 (7.5–11.5) mg⋅h/L, respectively, and lower in children than in adults for rifampicin in the 4.0–7.9-, 8–11.9-, and ≥25-kg weight bands, isoniazid in the 4.0–7.9-kg and ≥25-kg weight bands, and ethambutol in all 5 weight bands. Pyrazinamide exposures were similar to those in adults. Conclusions Recommended weight band–based FDC doses result in lower drug exposures in children in lower weight bands and in those ≥25 kg (receiving adult doses). Further adjustments to current doses are needed to match current target exposures in adults. The use of ethambutol at the current World Health Organization–recommended doses requires further evaluation.
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Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia.,University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Anneke C Hesseling
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Kevin M Zimba
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Marieke van der Zalm
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Megan Palmer
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Maxwell Chirehwa
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Lubbe Wiesner
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Louise Choo
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Kristen LeBeau
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Veronica Mulenga
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Robb Aarnoutse
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Diana Gibb
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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25
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Johnson J, Robinson ML, Rajput UC, Valvi C, Kinikar A, Parikh TB, Vaidya U, Malwade S, Agarkhedkar S, Randive B, Kadam A, Smith RM, Westercamp M, Mave V, Gupta A, Milstone AM, Manabe YC. High Burden of Bloodstream Infections Associated With Antimicrobial Resistance and Mortality in the Neonatal Intensive Care Unit in Pune, India. Clin Infect Dis 2021; 73:271-280. [PMID: 32421763 PMCID: PMC8282256 DOI: 10.1093/cid/ciaa554] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 05/08/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a growing threat to newborns in low- and middle-income countries (LMIC). METHODS We performed a prospective cohort study in 3 tertiary neonatal intensive care units (NICUs) in Pune, India, to describe the epidemiology of neonatal bloodstream infections (BSIs). All neonates admitted to the NICU were enrolled. The primary outcome was BSI, defined as positive blood culture. Early-onset BSI was defined as BSI on day of life (DOL) 0-2 and late-onset BSI on DOL 3 or later. RESULTS From 1 May 2017 until 30 April 2018, 4073 neonates were enrolled. Among at-risk neonates, 55 (1.6%) developed early-onset BSI and 176 (5.5%) developed late-onset BSI. The majority of BSIs were caused by gram-negative bacteria (GNB; 58%); among GNB, 61 (45%) were resistant to carbapenems. Klebsiella spp. (n = 53, 23%) were the most common cause of BSI. Compared with neonates without BSI, all-cause mortality was higher among neonates with early-onset BSI (31% vs 10%, P < .001) and late-onset BSI (24% vs 7%, P < .001). Non-low-birth-weight neonates with late-onset BSI had the greatest excess in mortality (22% vs 3%, P < .001). CONCLUSIONS In our cohort, neonatal BSIs were most commonly caused by GNB, with a high prevalence of AMR, and were associated with high mortality, even in term neonates. Effective interventions are urgently needed to reduce the burden of BSI and death due to AMR GNB in hospitalized neonates in LMIC.
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Affiliation(s)
- Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Uday C Rajput
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Chhaya Valvi
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Tushar B Parikh
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Umesh Vaidya
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Sudhir Malwade
- Department of Pediatrics, Dr D. Y. Patil Medical College, Pune, India
| | | | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Rachel M Smith
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Vidya Mave
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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26
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Nimkar S, Joshi S, Kinikar A, Valvi C, Devaleenal DB, Thakur K, Bendre M, Khwaja S, Ithape M, Kattagoni K, Paradkar M, Gupte N, Gupta A, Suryavanshi N, Mave V, Dooley KE, Arenivas A. Mullen Scales of Early Learning Adaptation for Assessment of Indian Children and Application to Tuberculous Meningitis. J Trop Pediatr 2021; 67:fmaa034. [PMID: 32620972 PMCID: PMC8496186 DOI: 10.1093/tropej/fmaa034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Tuberculous meningitis (TBM) results in significant morbidity and mortality among children worldwide. Associated neurocognitive complications are common but not well characterized. The Mullen Scales of Early Learning (MSEL), a well-established measure for assessment of neurodevelopment, has not yet been adapted for use in India. This study's goal was to adapt the MSEL for local language and culture to assess neurocognition among children in India, and apply the adapted measure for assessment of children with TBM. METHODS Administration of MSEL domains was culturally adapted. Robust translation procedures for instructions took place for three local languages: Marathi, Hindi and Tamil. Multilingual staff compared instructions against the original version for accuracy. The MSEL stimuli and instructions were reviewed by psychologists and pediatricians in India to identify items concerning for cultural bias. RESULTS MSEL stimuli unfamiliar to children in this setting were identified and modified within Visual Reception, Fine-Motor, Receptive Language and Expressive Language Scales. Item category was maintained for adaptations of items visually or linguistically different from those observed in daily life. Adjusted items were administered to six typically developing children to determine modification utility. Two children diagnosed with confirmed TBM (ages 11 and 29 months) were evaluated with the adapted MSEL before receiving study medications. Skills were below age-expectation across visual reception, fine motor and expressive language domains. CONCLUSIONS This is the first study to assess children with TBM using the MSEL adapted for use in India. Future studies in larger groups of Indian children are warranted to validate the adapted measure.
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Affiliation(s)
- Smita Nimkar
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
- Department of Health and Biomedical Sciences, Symbiosis International (Deemed) University, Lavale, Pune, India
| | - Suvarna Joshi
- Department of Health and Biomedical Sciences, Symbiosis International (Deemed) University, Lavale, Pune, India
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Chhaya Valvi
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - D Bella Devaleenal
- Department of Clinical Research, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Kiran Thakur
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Manjushree Bendre
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Saltanat Khwaja
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Mahesh Ithape
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Krishna Kattagoni
- Department of Clinical Research, ICMR - National Institute for Research in Tuberculosis, Chennai, India
| | - Mandar Paradkar
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Nikhil Gupte
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amita Gupta
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nishi Suryavanshi
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Vidya Mave
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College, Johns Hopkins University Clinical Research Site, Pune, India
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ana Arenivas
- Department of Rehabilitation Psychology and Neuropsychology, The Institute for Rehabilitation and Research (TIRR) Memorial Hermann, Houston, TX, USA
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
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27
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Girish S, Kinikar A, Pardesh G, Shelke S, Basavaraj A, Chandanwale A, Kadam D, Josh S, Dhumal G, Lokhande N, Deluca A, Gupte N, Gupta A, Bollinger RC, Mave V. Utility of the Interferon-Gamma Release Assay for Latent Tuberculosis Infection Screening among Indian Health-Care Workers. Indian J Community Med 2021; 46:281-284. [PMID: 34321742 PMCID: PMC8281831 DOI: 10.4103/ijcm.ijcm_761_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/31/2021] [Indexed: 11/04/2022] Open
Abstract
Background The utility of interferon-gamma release assays (IGRAs) for latent tuberculosis infection (LTBI) screening among health-care workers (HCWs) in low- and middle-income countries (LMICs) remains unclear. Methods This was a prospective cohort study among HCW trainees undergoing annual LTBI screening via tuberculin skin test (TST) and QuantiFERON® TB Gold Test-in-tube (QFT-GIT) in Pune, India. TST induration ≥ 10 mm and QFT-GIT ≥ 0.35 IU/ml were considered positive. Test concordance was evaluated at entry among the entire cohort and at 1 year among baseline TST-negative participants with follow-up testing. Overall test agreement was evaluated at both timepoints using the kappa statistic: fair (k < 0.40), good (0.41 ≥ k ≤0.60), or strong (k > 0.60). Results Of 200 participants, prevalent LTBI was detected in 42 (21%) via TST and 45 (23%) via QFT-GIT; QFT-GIT was positive in 27/42 (64%) TST-positive and 18/158 (11%) TST-negative trainees. Annual TST conversion was 28% (40/142) and included 11 trainees with baseline TST-/IGRA+; QFT-GIT was positive in 17/40 (43%) TST-positive and 5/102 (5%) TST-negative trainees. Overall test concordance was 84% (k = 0.52; 95% confidence interval [CI]: 0.38-0.66) and 80% (k = 0.44; 95% CI: 0.29-0.59) at baseline and 12 months, respectively. Conclusions We observed good overall agreement between TST and QFT-GIT, and QFT-GIT detected additional LTBI cases among TST-negative trainees with possible early detection of LTBI conversion. Overall, our results support the use of IGRA for annual LTBI screening among HCWs in a high burden LMIC setting.
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Affiliation(s)
- Sunita Girish
- Department of Biochemistry, Byramjee Jeejeebhoy Government Medical College-Sassoon General Hospital, Pune, Maharashtra, India
| | - Aarti Kinikar
- Department of Paediatrics, Byramjee Jeejeebhoy Government Medical College-Sassoon General Hospital, Pune, Maharashtra, India
| | - Geeta Pardesh
- Department of Community Medicine, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sangita Shelke
- Department of Community Medicine, Byramjee Jeejeebhoy Government Medical College-Sassoon General Hospital, Pune, Maharashtra, India
| | - Anita Basavaraj
- Department of Medicine, Government Medical College, Miraj, Maharashtra, India
| | - Ajay Chandanwale
- Department of Orthopaedics, Byramjee Jeejeebhoy Government Medical College-Sassoon General Hospital, Pune, Maharashtra, India
| | - Dileep Kadam
- Department of Medicine, Smt.Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
| | - Samir Josh
- ENT, Byramjee Jeejeebhoy Government Medical College-Sassoon General Hospital, Pune, Maharashtra, India
| | - Gauri Dhumal
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, Maharashtra, India
| | - Nilima Lokhande
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, Maharashtra, India
| | - Andrea Deluca
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, Maharashtra, India
| | - Amita Gupta
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, Maharashtra, India.,Medicine and Public Health, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore
| | - Robert C Bollinger
- Medicine, Public Health, and Nursing, Division of Infectious Diseases, Johns Hopkins University School of Medicine, MD, USA
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, Maharashtra, India.,Medicine and Public Health, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore
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28
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Mave V, Kadam D, Gaikwad S, Kinikar A, Aguilar D, Chavan A, Paradkar M, Yogendra SVB, Bharadwaj R, Kagal A, Suryavanshi N, Golub J, Kulkarni V, Dooley KE, Gupta A, Bacchetti P, Gerona R, Gupte N, Gandhi M. Measuring TB drug levels in the hair in adults and children to monitor drug exposure and outcomes. Int J Tuberc Lung Dis 2021; 25:52-60. [PMID: 33384045 DOI: 10.5588/ijtld.20.0574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION: Testing for anti-TB drugs in small hair samples may serve as a non-invasive tool to measure cumulative drug exposure and/or adherence, as these determine treatment success. We aimed to assess how well hair assays of TB drugs predict TB treatment outcomes.METHODS: A small thatch of hair, ~30 strands, was cut from the occipital region in adults and children from a prospective TB cohort in India. Isoniazid (INH), acetyl-INH and pyrazinamide (PZA) were extracted from the hair samples and quantified using liquid-chromatography-tandem mass spectrometry. The relationship between drug concentrations in hair and time to unfavourable outcomes was assessed using Cox-proportional hazards regression models.RESULTS: A two-fold increase in hair acetyl-INH concentrations in the 264 participants in our cohort with hair assays for TB drugs indicated a lower hazard of unfavourable TB treatment outcomes (aHR 0.67, 95%CI 0.44-1.02) and TB treatment failure (aHR 0.65, 95%CI 0.42-1.01). Higher summed concentrations (a summed measure of INH and acetyl-INH) indicated a lower hazard of treatment failure (aHR 0.69, 95%CI 0.45-1.05)CONCLUSION: Hair levels of INH and its metabolite may predict TB treatment outcomes, indicating the potential utility of this measure to assess and optimise TB treatment outcomes.
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Affiliation(s)
- V Mave
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India, Johns Hopkins University School of Medicine, Baltimore, MD
| | - D Kadam
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - S Gaikwad
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - A Kinikar
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - D Aguilar
- University of California, San Francisco, CA, USA
| | - A Chavan
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - M Paradkar
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - S V B Yogendra
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - R Bharadwaj
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - A Kagal
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - N Suryavanshi
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - J Golub
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - V Kulkarni
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - K E Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Gupta
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India, Johns Hopkins University School of Medicine, Baltimore, MD
| | - P Bacchetti
- University of California, San Francisco, CA, USA
| | - R Gerona
- University of California, San Francisco, CA, USA
| | - N Gupte
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India, Johns Hopkins University School of Medicine, Baltimore, MD
| | - M Gandhi
- University of California, San Francisco, CA, USA
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29
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Tornheim JA, Madugundu AK, Paradkar M, Fukutani KF, Queiroz ATL, Gupte N, Gupte AN, Kinikar A, Kulkarni V, Balasubramanian U, Sreenivasamurthy S, Raja R, Pradhan N, Shivakumar SVBY, Valvi C, Hanna LE, Andrade BB, Mave V, Pandey A, Gupta A. Transcriptomic Profiles of Confirmed Pediatric Tuberculosis Patients and Household Contacts Identifies Active Tuberculosis, Infection, and Treatment Response Among Indian Children. J Infect Dis 2021; 221:1647-1658. [PMID: 31796955 DOI: 10.1093/infdis/jiz639] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/03/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Gene expression profiling is emerging as a tool for tuberculosis diagnosis and treatment response monitoring, but limited data specific to Indian children and incident tuberculosis infection (TBI) exist. METHODS Sixteen pediatric Indian tuberculosis cases were age- and sex-matched to 32 tuberculosis-exposed controls (13 developed incident TBI without subsequent active tuberculosis). Longitudinal samples were collected for ribonucleic acid sequencing. Differential expression analysis generated gene lists that identify tuberculosis diagnosis and tuberculosis treatment response. Data were compared with published gene lists. Population-specific risk score thresholds were calculated. RESULTS Seventy-one genes identified tuberculosis diagnosis and 25 treatment response. Within-group expression was partially explained by age, sex, and incident TBI. Transient changes in gene expression were identified after both infection and treatment. Application of 27 published gene lists to our data found variable performance for tuberculosis diagnosis (sensitivity 0.38-1.00, specificity 0.48-0.93) and treatment response (sensitivity 0.70-0.80, specificity 0.40-0.80). Our gene lists found similarly variable performance when applied to published datasets for diagnosis (sensitivity 0.56-0.85, specificity 0.50-0.85) and treatment response (sensitivity 0.49- 0.86, specificity 0.50-0.84). CONCLUSIONS Gene expression profiles among Indian children with confirmed tuberculosis were distinct from adult-derived gene lists, highlighting the importance of including distinct populations in differential gene expression models.
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Affiliation(s)
- Jeffrey A Tornheim
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anil K Madugundu
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India.,Department of Laboratory Medicine and Pathology and Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Kiyoshi F Fukutani
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil
| | - Artur T L Queiroz
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil
| | - Nikhil Gupte
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Akshay N Gupte
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Usha Balasubramanian
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Sreelakshmi Sreenivasamurthy
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Remya Raja
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | - Chhaya Valvi
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | | | - Bruno B Andrade
- Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.,Multinational Organization Network Sponsoring Translational and Epidemiological Research (MONSTER) Initiative, Salvador, Brazil.,Faculdade de Tecnologia e Ciências (FTC), Salvador, Brazil.,Universidade Salvador (UNIFACS), Laureate Universities, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, Brazil
| | - Vidya Mave
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Akhilesh Pandey
- Institute of Bioinformatics, Bangalore, Karnataka, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.,Department of Laboratory Medicine and Pathology and Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amita Gupta
- Center for Clinical Global Health Education, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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30
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Kulkarni R, Rajput U, Dawre R, Sonkawade N, Pawar S, Sonteke S, Varvatte B, Aathira KC, Gadekar K, Varma S, Nakate L, Kagal A, Kinikar A. Severe Malnutrition and Anemia Are Associated with Severe COVID in Infants. J Trop Pediatr 2021; 67:fmaa084. [PMID: 33313926 PMCID: PMC7798483 DOI: 10.1093/tropej/fmaa084] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND COVID-19 is uncommon and less severe in children than adults. It is thought that infants may be at higher risk for severe disease than older children. There is a paucity of literature on infants with COVID, particularly those with severe disease. OBJECTIVE We describe demographic, epidemiologic, clinical, radiological, laboratory features and outcomes of infants with confirmed SARS-CoV-2 infection admitted to a tertiary care teaching hospital in Pune, India. METHODOLOGY Infants who tested positive for SARS-CoV-2 and were admitted between 1 April 2020 and 7 August 2020 were included in the study. RESULTS A total of 13 infants were admitted during the study period. The median age was 8 months (IQR 6) and nine were male. Common presenting features were fever (n = 8, 62%), poor feeding, irritability, and runny nose (n = 3, 23%). Comorbidities noted were severe acute malnutrition (SAM) in three cases (23%) and nutritional megaloblastic anemia, iron deficiency anemia, sickle thalassemia and renal calculi in one case (8%) each. There was a history of low birth weight in two cases (15%). Pallor was noted in three cases (23%), SAM in three cases (23%) and tachypnea and respiratory distress in four cases (30%). Severe anemia, thrombocytopenia, elevated ferritin, abnormal procalcitonin, abnormal C Reactive Protein and deranged D-dimer was noted in three cases (23%) each. Neutrophil-lymphocyte ratio was normal in all cases. Three infants (43%) had evidence of pneumonia on the chest radiograph, of which one had adult respiratory distress syndrome (ARDS) like pattern, one infant had cardiomegaly and perihilar infiltrates. Hydroxychloroquine and azithromycin were given to five patients (38%), Intravenous Immunoglobulin and methylprednisolone were administered to one patient (8%). One infant died of ARDS with multi-organ dysfunction with refractory shock and hemophagocytic lymphohistiocytosis. CONCLUSION SAM and anemia may be associated with severe COVID in infants.
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Affiliation(s)
- Rajesh Kulkarni
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - Uday Rajput
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - Rahul Dawre
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - Naresh Sonkawade
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - Sameer Pawar
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - Somendra Sonteke
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - Balaji Varvatte
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - K C Aathira
- Department of Pediatrics, B.J. Government Medical College, Pune, India
| | - Kailas Gadekar
- Department of Biochemistry, B.J. Government Medical College, Pune, India
| | - Santosh Varma
- Department of Biochemistry, B.J. Government Medical College, Pune, India
| | - Leena Nakate
- Department of Pathology, B.J. Government Medical College, Pune, India
| | - Anju Kagal
- Department of Microbiology, B.J. Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, B.J. Government Medical College, Pune, India
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31
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Johnson J, Latif A, Randive B, Kadam A, Rajput U, Kinikar A, Malshe N, Lalwani S, Parikh TB, Vaidya U, Malwade S, Agarkhedkar S, Curless MS, Coffin SE, Smith RM, Westercamp M, Colantuoni E, Robinson ML, Mave V, Gupta A, Manabe YC, Milstone AM. Implementation of the Comprehensive Unit-Based Safety Program to Improve Infection Prevention and Control Practices in Four Neonatal Intensive Care Units in Pune, India. Front Pediatr 2021; 9:794637. [PMID: 35071137 PMCID: PMC8772032 DOI: 10.3389/fped.2021.794637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022] Open
Abstract
Objective: To implement the Comprehensive Unit-based Safety Program (CUSP) in four neonatal intensive care units (NICUs) in Pune, India, to improve infection prevention and control (IPC) practices. Design: In this quasi-experimental study, we implemented CUSP in four NICUs in Pune, India, to improve IPC practices in three focus areas: hand hygiene, aseptic technique for invasive procedures, and medication and intravenous fluid preparation and administration. Sites received training in CUSP methodology, formed multidisciplinary teams, and selected interventions for each focus area. Process measures included fidelity to CUSP, hand hygiene compliance, and central line insertion checklist completion. Outcome measures included the rate of healthcare-associated bloodstream infection (HA-BSI), all-cause mortality, patient safety culture, and workload. Results: A total of 144 healthcare workers and administrators completed CUSP training. All sites conducted at least 75% of monthly meetings. Hand hygiene compliance odds increased 6% per month [odds ratio (OR) 1.06 (95% CI 1.03-1.10)]. Providers completed insertion checklists for 68% of neonates with a central line; 83% of checklists were fully completed. All-cause mortality and HA-BSI rate did not change significantly after CUSP implementation. Patient safety culture domains with greatest improvement were management support for patient safety (+7.6%), teamwork within units (+5.3%), and organizational learning-continuous improvement (+4.7%). Overall workload increased from a mean score of 46.28 ± 16.97 at baseline to 65.07 ± 19.05 at follow-up (p < 0.0001). Conclusion: CUSP implementation increased hand hygiene compliance, successful implementation of a central line insertion checklist, and improvements in safety culture in four Indian NICUs. This multimodal strategy is a promising framework for low- and middle-income country healthcare facilities to reduce HAI risk in neonates.
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Affiliation(s)
- Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Asad Latif
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Bharat Randive
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Uday Rajput
- Department of Pediatrics, Byramjee-Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee-Jeejeebhoy Government Medical College, Pune, India
| | - Nandini Malshe
- Department of Neonatology, Bharati Vidyapeeth Deemed to Be University Medical College, Pune, India
| | - Sanjay Lalwani
- Department of Pediatrics, Bharati Vidyapeeth Deemed to Be University Medical College, Pune, India
| | - Tushar B Parikh
- Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Umesh Vaidya
- Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Sudhir Malwade
- Department of Pediatrics, Dr. D. Y. Patil Medical College, Pune, India
| | | | - Melanie S Curless
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Susan E Coffin
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, United States
| | - Rachel M Smith
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Vidya Mave
- Byramjee-Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India.,Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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32
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Johnson J, Johnson J, Robinson M, Naik SN, Patil S, Kulkarni R, Kinikar A, Dohe V, Mudshinkar S, Smith R, Westercamp M, Randive B, Kadam A, Kulkarni V, Mave V, Gupta A, Milstone A, Milstone A, Manabe YC. 1378. Reservoirs of Transmission of Resistant Gram-negative Pathogens Responsible for Neonatal Sepsis among Hospitalized Neonates in Pune, India. Open Forum Infect Dis 2020. [PMCID: PMC7776807 DOI: 10.1093/ofid/ofaa439.1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Neonatal infections with resistant Gram-negative (GN) organisms are associated with high rates of mortality, with limited antibiotic treatment options. The role of maternal colonization and environmental GN organisms as reservoirs for transmission to neonates has not been well described. Methods We performed a prospective cohort study from October 12, 2018, until October 31, 2019, to describe the role of maternal and environmental GN colonization in BSI among neonates admitted to the neonatal intensive care unit (NICU) at a tertiary care center in Pune, India. Women admitted to Labor & Delivery with risk factors for neonatal sepsis who provided consent were enrolled and their neonates were followed until hospital discharge. For neonates who developed bloodstream infection (BSI), colonization with resistant GN organisms was assessed in their mothers from frozen vaginal and rectal swabs collected at enrollment and at delivery and in the neonates from frozen skin swabs and peri-rectal swabs collected at day of life (DOL) 0, 3, 7, and weekly until discharge. Environmental colonization was assessed with weekly sampling of unit sinks and the immediate neonatal care environment. Colonization samples were processed to identify organisms that matched neonatal blood culture isolates. Results 953 women were enrolled, of whom 741 (78%) received antepartum antibiotics. Among 987 live born neonates, 12 (1%) died in the delivery room and 257 (26%) required NICU admission. Among neonates admitted to the NICU, 143 (56%) had at least one blood culture, of which 28 (20%) were positive; 21 (75%) had a GN BSI. The most common cause of neonatal BSI was Klebsiella pneumoniae, and 8 (38%) GN BSI were due to a carbapenem-resistant organism. No organism isolated from maternal samples matched organism and resistance pattern from neonatal blood culture. Matching strains were found in unit sinks and neonatal rectal and skin samples (Figure 1). Organism recovery from swabs and match to bloodstream isolate by sample source and time of collection from birth ![]()
Conclusion Among neonates born to mothers with risk factors for neonatal sepsis, GN organisms were the most common cause of neonatal BSI. Environmental and neonatal colonization may represent important reservoirs of transmission for these pathogens among neonates hospitalized in a tertiary care NICU in Pune, India. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | | | - Sunil Patil
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Rajesh Kulkarni
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Vaishali Dohe
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Swati Mudshinkar
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Rachel Smith
- Centers for Disease Control and Prevention, Decatur, GA
| | | | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
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33
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Nimkar S, Kinikar A, Chavan A, Sangle S, Rewari B, Gupta A, Mave V, Marbaniang I. High prevalence of late presentation of ART-naïve perinatally infected children for care in Pune, India. AIDS Care 2020; 32:1415-1420. [PMID: 32070118 PMCID: PMC7431379 DOI: 10.1080/09540121.2020.1727407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 02/03/2020] [Indexed: 10/25/2022]
Abstract
Delayed presentation to care of perinatally infected children in India continues to be a hindrance to achieving the "end pediatric HIV by 2020" goal. In this study, we characterize this issue by describing the prevalence, risk factors and temporal trends of delayed presentation to care of perinatally infected, antiretroviral therapy (ART) - naïve children using programmatic data from a tertiary care center in western India. Delayed presentation was defined as children presenting in moderate or severe WHO immunodeficiency categories. Of 269 children eligible for inclusion in the analysis, the median age at presentation was 4 years (IQR: 3-6 years) and prevalence of delayed presentation was 52%. Multivariable logistic regression identified domicile distance ≥20km from the ART center (OR: 2.2, 95% CI: 1.02-4.7) to be a risk factor for delayed presentation. An inverse association with increasing age (OR: 0.8, 95% CI: 0.7-0.9) was also seen. The proportion of children with delayed presentation between 2006 and 2016 remained unchanged (p = 0.36), although the median age at presentation over the same time period increased significantly (p < 0.001). Our results indicate the urgency of identifying strategies to improve linkage of perinatally infected ART-naïve children to care, earlier than what is currently observed.
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Affiliation(s)
- Smita Nimkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Amol Chavan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | | | - Bharatbhushan Rewari
- Former National Programme Officer, National AIDS Control Organization, New Delhi, India
| | - Amita Gupta
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ivan Marbaniang
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
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34
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Dolla CK, Padmapriyadarsini C, Thiruvengadam K, Lokhande R, Kinikar A, Paradkar M, Bm S, Murali L, Gupte A, Gaikwad S, Selvaraju S, Padmanaban Y, Pattabiraman S, Pradhan N, Kulkarni V, Shivakumar SVBY, Prithivi M, Kagal A, Karthavarayan BT, Suryavanshi N, Gupte N, Kumaran P, Mave V, Gupta A. Age-specific prevalence of TB infection among household contacts of pulmonary TB: Is it time for TB preventive therapy? Trans R Soc Trop Med Hyg 2020; 113:632-640. [PMID: 31225622 DOI: 10.1093/trstmh/trz049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/18/2019] [Accepted: 06/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Household contacts (HHCs) of TB patients are at high risk of developing evidence of latent TB infection (LTBI) and active disease from the index patient. We estimated the age-specific prevalence of LTBI and the force of infection (FI), as a measure of recent transmission, among HHCs of active TB patients. METHODS A cross-sectional analysis of HHCs of pulmonary TB patients enrolled in a prospective study, 'CTRIUMPh', was conducted at two sites in India. LTBI was defined as either a positive tuberculin skin test (induration ≥5 mm) or QuantiFERON-Gold in tube test (value ≥0.35 IU/ml) and was stratified by age. FI, which is a measure of recent transmission of infection and calculated using changes in age-specific prevalence rates at specific ages, was calculated. Factors associated with LTBI were determined by logistic regression models. RESULTS Of 1020 HHCs of 441 adult pulmonary TB cases, there were 566 (55%) females and 289 (28%) children aged ≤15 y. While screening for the study 3% of HHC were diagnosed with active TB. LTBI prevalence among HHCs of pulmonary TB was 47% at <6 y, 53% between 6-14 y and 78% between 15-45 y. FI increased significantly with age, from 0.4 to 1.15 in the HHCs cohort (p=0.05). CONCLUSION This study observed an increased prevalence of LTBI and FI among older children and young adults recently exposed to infectious TB in the household. In addition to awareness of coughing etiquette and general hygiene, expanding access to TB preventive therapy to all HHCs, including older children, may be beneficial to achieve TB elimination by 2035.
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Affiliation(s)
- Chandra Kumar Dolla
- Epidemiology, National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Chandrasekaran Padmapriyadarsini
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Kannan Thiruvengadam
- Epidemiology, National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Rahul Lokhande
- Pulmonary Medicine, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Aarti Kinikar
- Paediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Mandar Paradkar
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research site, Pune, Maharashtra, India
| | - Shrinivas Bm
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | | | - Akshay Gupte
- Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sanjay Gaikwad
- Pulmonary Medicine, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Sriram Selvaraju
- Epidemiology, National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Yashoda Padmanaban
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Sathyamurthy Pattabiraman
- Department of Clinical Research, ICMR-National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Neeta Pradhan
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research site, Pune, Maharashtra, India
| | - Vandana Kulkarni
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research site, Pune, Maharashtra, India
| | | | - Munivardhan Prithivi
- Epidemiology, National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Anju Kagal
- Microbiology, Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Barath Thopili Karthavarayan
- Epidemiology, National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Nishi Suryavanshi
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research site, Pune, Maharashtra, India.,Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nikhil Gupte
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research site, Pune, Maharashtra, India.,Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Paul Kumaran
- Epidemiology, National Institute for Research in Tuberculosis, 1, Mayor Sathyamoorthy Road, Chetpet, Chennai, Tamil Nadu, India
| | - Vidya Mave
- Clinical Trial Unit, Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research site, Pune, Maharashtra, India.,Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Amita Gupta
- Public Health, Johns Hopkins School of Medicine, Baltimore, MD, USA
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35
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Kulkarni R, Rajput U, Dawre R, Valvi C, Nagpal R, Magdum N, Vankar H, Sonkawade N, Das A, Vartak S, Joshi S, Varma S, Karyakarte R, Bhosale R, Kinikar A. Early-onset symptomatic neonatal COVID-19 infection with high probability of vertical transmission. Infection 2020; 49:339-343. [PMID: 32743723 PMCID: PMC7395939 DOI: 10.1007/s15010-020-01493-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 07/26/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are few reports of COVID-19 in neonates and most are suspected to be due to postnatal transmission. Vertical transmission has been proven in only a couple of cases so far. METHODS We describe early-onset, severe COVID-19 disease in a neonate with very strong evidence of vertical transmission of SARS-CoV-2. RESULTS A COVID-19 suspected mother, who tested negative by RT-PCR for COVID, but tested positive for SARS-CoV-2 by serology, delivered a term baby. The neonate was kept in strict isolation. Molecular tests for SARS-CoV-2 on umbilical stump, placenta, and nasopharyngeal aspirate of the neonate, collected at birth were positive. On day 2, the neonate developed clinical features of COVID in the form of fever, poor feeding, and hyperbilirubenemia along with elevated inflammatory markers. Antibiotics were started empirically pending cultures. Blood, CSF, and urine cultures were sterile. Baby tested RT-PCR positive for SARS-CoV-2 on two more occasions before testing positive for antibodies and was discharged on day 21 of life. CONCLUSION This report highlights a very strong possibility of vertical transmission of COVID-19 from a mildly symptomatic, RT-PCR negative but antibody-positive mother with significant symptomatic, early-onset neonatal infection.
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Affiliation(s)
- Rajesh Kulkarni
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Uday Rajput
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Rahul Dawre
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Chhaya Valvi
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Rema Nagpal
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Nikita Magdum
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Harshali Vankar
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Naresh Sonkawade
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Aiswarya Das
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Sagar Vartak
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Suvarna Joshi
- Department of Microbiology, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Santosh Varma
- Department of Biochemistry, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Rajesh Karyakarte
- Department of Microbiology, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Ramesh Bhosale
- Department of Obstetrics and Gynecology, B.J. Government Medical College, J. P. Narayan Road, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, B.J. Government Medical College, J. P. Narayan Road, Pune, India.
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36
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Paradkar M, Padmapriyadarsini C, Jain D, Shivakumar SVBY, Thiruvengadam K, Gupte AN, Thomas B, Kinikar A, Sekar K, Bharadwaj R, Dolla CK, Gaikwad S, Elilarasi S, Lokhande R, Reddy D, Murali L, Kulkarni V, Pradhan N, Hanna LE, Pattabiraman S, Kohli R, S. R, Suryavanshi N, B. M. S, Cox SR, Selvaraju S, Gupte N, Mave V, Gupta A, Bollinger RC. Tuberculosis preventive treatment should be considered for all household contacts of pulmonary tuberculosis patients in India. PLoS One 2020; 15:e0236743. [PMID: 32726367 PMCID: PMC7390377 DOI: 10.1371/journal.pone.0236743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/13/2020] [Indexed: 12/13/2022] Open
Abstract
The World Health Organization (WHO) recently changed its guidance for tuberculosis (TB) preventive treatment (TPT) recommending TPT for all pulmonary TB (PTB) exposed household contacts (HHC) to prevent incident TB disease (iTBD), regardless of TB infection (TBI) status. However, this recommendation was conditional as the strength of evidence was not strong. We assessed risk factors for iTBD in recently-exposed adult and pediatric Indian HHC, to determine which HHC subgroups might benefit most from TPT. We prospectively enrolled consenting HHC of adult PTB patients in Pune and Chennai, India. They underwent clinical, microbiologic and radiologic screening for TB disease (TBD) and TBI, at enrollment, 4–6, 12 and 24 months. TBI testing was performed by tuberculin skin test (TST) and Quantiferon®- Gold-in-Tube (QGIT) assay. HHC without baseline TBD were followed for development of iTBI and iTBD. Using mixed-effect Poisson regression, we assessed baseline characteristics including TBI status, and incident TBI (iTBI) using several TST and/or QGIT cut-offs, as potential risk factors for iTBD. Of 1051 HHC enrolled, 42 (4%) with baseline TBD and 12 (1%) with no baseline TBI test available, were excluded. Of the remaining 997 HHC, 707 (71%) had baseline TBI (TST ≥ 5 mm or QGIT ≥ 0.35 IU/ml). Overall, 20 HHC (2%) developed iTBD (12 cases/1000 person-years, 95%CI: 8–19). HIV infection (aIRR = 29.08, 95% CI: 2.38–355.77, p = 0.01) and undernutrition (aIRR = 6.16, 95% CI: 1.89–20.03, p = 0.003) were independently associated with iTBD. iTBD was not associated with age, diabetes mellitus, smoking, alcohol, and baseline TBI, or iTBI, regardless of TST (≥ 5 mm, ≥ 10 mm, ≥ 6 mm increase) or QGIT (≥ 0.35 IU/ml, ≥ 0.7 IU/ml) cut-offs. Given the high overall risk of iTBD among recently exposed HHCs, and the lack of association between TBI status and iTBD, our findings support the new WHO recommendation to offer TPT to all HHC of PTB patients residing in a high TB burden country such as India, and do not suggest any benefit of TBI testing at baseline or during follow-up to risk stratify recently-exposed HHC for TPT.
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Affiliation(s)
- Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins University Center for Clinical Global Health Education, Pune, Maharashtra, India
- * E-mail:
| | | | - Divyashri Jain
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | | | - Akshay N. Gupte
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Beena Thomas
- National Institute of Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Krithika Sekar
- National Institute of Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Renu Bharadwaj
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | | | - Sanjay Gaikwad
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - S. Elilarasi
- Institute of Child Health and Hospital for Children, Chennai, Tamil Nadu, India
| | - Rahul Lokhande
- Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospital, Pune, Maharashtra, India
| | - Devarajulu Reddy
- National Institute of Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Lakshmi Murali
- National Institute of Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins University Center for Clinical Global Health Education, Pune, Maharashtra, India
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins University Center for Clinical Global Health Education, Pune, Maharashtra, India
| | | | | | - Rewa Kohli
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins University Center for Clinical Global Health Education, Pune, Maharashtra, India
| | - Rani S.
- National Institute of Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins University Center for Clinical Global Health Education, Pune, Maharashtra, India
| | - Shrinivasa B. M.
- National Institute of Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Samyra R. Cox
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sriram Selvaraju
- National Institute of Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins University Center for Clinical Global Health Education, Pune, Maharashtra, India
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins University Center for Clinical Global Health Education, Pune, Maharashtra, India
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Amita Gupta
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Robert C. Bollinger
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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Valvi C, Chandanwale A, Khadse S, Kulkarni R, Kadam D, Kinikar A, Joshi S, Lokhande R, Pardeshi G, Garg P, Gupte N, Jain D, Suryavanshi N, Golub JE, Shankar A, Gupta A, Dhumal G, Deluca A, Bollinger RC. Delays and barriers to early treatment initiation for childhood tuberculosis in India. Int J Tuberc Lung Dis 2020; 23:1090-1099. [PMID: 31627774 DOI: 10.5588/ijtld.18.0439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: India accounts for 27% of global childhood tuberculosis (TB) burden. Understanding barriers to early diagnosis and treatment in children may improve care and outcomes.METHODS: A cross-sectional study was performed among 89 children initiated on anti-TB treatment from a public hospital in Pune during 2016, using a structured questionnaire and hospital records. Health care providers (HCPs) were defined as medical personnel consulted about the child's TB symptoms. Time-to-treatment initiation (TTI) was defined as the number of days between onset of TB symptoms and anti-TB treatment initiation. Based on Revised National TB Control Programme recommendations, delayed TTI was defined as >28 days.RESULTS: Sixty-seven (75%) of 89 enrolled children had significant TTI delays (median 51 days, interquartile range [IQR] 27-86). Sixty-six (74%) children visited 1-8 HCPs in the private sector before approaching the public sector. The median HCP delay was 28 days (IQR 10-75). Bacille Calmette-Guérin vaccination (aOR 10.96, P = 0.04) and loss of appetite (aOR 4.44, P = 0.04) were associated with delayed TTI.CONCLUSION: The majority of the children had TTI delays due to delays by HCPs in the private sector. Strengthening HCP competency in TB symptom screening and encouraging early referrals are crucial for rapid scaling up of early treatment initiation in childhood TB.
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Affiliation(s)
- C Valvi
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - A Chandanwale
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - S Khadse
- Rajiv Gandhi Medical College and Chatrapati Shivaji Maharaj Hospital, Kalwa, Thane
| | - R Kulkarni
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - D Kadam
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - A Kinikar
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - S Joshi
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - R Lokhande
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - G Pardeshi
- Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
| | - P Garg
- Byramjee Jeejeebhoy Government Medical College, Sassoon General Hospital, Pune
| | - N Gupte
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India
| | - D Jain
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India
| | - N Suryavanshi
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India
| | - J E Golub
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Shankar
- Department of Environmental Health and Engineering
| | - A Gupta
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India, Johns Hopkins University School of Medicine, Baltimore, MD
| | - G Dhumal
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India
| | - A Deluca
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - R C Bollinger
- Johns Hopkins University School of Medicine, Baltimore, MD
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Naik S, Robinson ML, Alexander M, Chandanwale A, Sambarey P, Kinikar A, Bharadwaj R, Sapkal GN, Chebrolu P, Deshpande P, Kulkarni V, Nimkar S, Mave V, Gupta A, Mathad J. Intensified Short Symptom Screening Program for Dengue Infection during Pregnancy, India. Emerg Infect Dis 2020; 26:738-743. [PMID: 32186485 PMCID: PMC7101120 DOI: 10.3201/eid2604.191476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Mosquitoborne diseases (e.g., malaria, dengue, and chikungunya) are endemic to India and pose diagnostic challenges during pregnancy. We evaluated an intensified short symptom screening program in India to diagnose dengue during pregnancy. During October 2017–January 2018, we screened pregnant women during antenatal surveillance for symptoms of mosquitoborne diseases (fever only, fever with conjunctivitis, fever with rash, or all 3 symptoms) within the previous 15 days. Of 5,843 pregnant women screened, 52 were enrolled and tested for dengue, chikungunya, and Zika viruses by using a Trioplex real-time reverse transcription PCR. Of 49 who had complete results, 7 (14%) were dengue positive. Of these ocular pain was seen in 4 (57%) and conjunctivitis in 7 (100%). Intensified symptom screening using conjunctivitis, in addition to rash, in pregnant women with fever might improve dengue case detection and can be included in routine symptom screening during pregnancy.
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Kulkarni R, Kinikar A. Protocol Driven Extubation in Neonates- A Quality Improvement Initiative. Indian Pediatr 2020; 57:183. [PMID: 32060252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Rajesh Kulkarni
- Department of Pediatrics, BJ Government Medical College, Pune, Maharashtra, India.
| | - Aarti Kinikar
- Department of Pediatrics, BJ Government Medical College, Pune, Maharashtra, India
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Hompe ED, Jacobson DL, Eudailey JA, Butler K, Edwards W, Pollara J, Brummel SS, Fouda GG, Chinula L, Kamanga M, Kinikar A, Moodley D, Owor M, Fowler MG, Permar SR. Maternal Humoral Immune Responses Do Not Predict Postnatal HIV-1 Transmission Risk in Antiretroviral-Treated Mothers from the IMPAACT PROMISE Study. mSphere 2019; 4:e00716-19. [PMID: 31645430 PMCID: PMC7407004 DOI: 10.1128/msphere.00716-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 11/20/2022] Open
Abstract
To design immune interventions that can synergize with antiretroviral therapy (ART) to reduce the rate of HIV mother-to-child transmission (MTCT), it is essential to characterize maternal immune responses in the setting of ART during pregnancy and breastfeeding and define their effect on MTCT. Prior studies reported an association between breast milk envelope (Env)-specific antibodies and antibody-dependent cell cytotoxicity (ADCC) activity with reduced postnatal transmission. In this study, we investigated whether these immune correlates were similarly associated with protection in a matched case-control study of mother-infant pairs receiving maternal ART or infant nevirapine prophylaxis during breastfeeding in the International Maternal-Pediatric-Adolescent AIDS Clinical Trials Network Promoting Maternal-Infant Survival Everywhere (PROMISE) trial, assessing postnatal transmission risk in 19 transmitting and 57 nontransmitting mothers using conditional logistic regression models adjusted for maternal plasma viral load. The odds ratios of postnatal MTCT for a 1-unit increase in an immune correlate were 3.61 (95% confidence interval [CI], 0.56, 23.14) for breast milk Env-specific secretory IgA (sIgA), 2.32 (95% CI, 0.43, 12.56) for breast milk and 2.16 (95% CI, 0.51, 9.14) for plasma Env-specific IgA, and 4.57 (95% CI, 0.68, 30.48) for breast milk and 0.96 (95% CI, 0.25, 3.67) for plasma ADCC activity, with all CIs spanning 1.0. Interestingly, although mucosal IgA responses are poor in untreated HIV-infected women, there was a strong correlation between the magnitudes of breast milk and plasma Env-specific IgA in this cohort. In this analysis of the small number of postnatal virus transmissions in the landmark PROMISE study, no single antibody response was associated with breast milk transmission risk.IMPORTANCE Each year, >150,000 infants become newly infected with HIV-1 through MTCT despite ART, with up to 42% of infections occurring during breastfeeding. Several factors contribute to continued pediatric infections, including ART nonadherence, the emergence of drug-resistant HIV strains, acute infection during breastfeeding, and poor access to ART in resource-limited areas. A better understanding of the maternal humoral immune responses that provide protection against postnatal transmission in the setting of ART is critical to guide the design of maternal vaccine strategies to further eliminate postnatal HIV transmission. In this study, we found that in women treated with antiretrovirals during pregnancy, there was a positive correlation between plasma viral load and breast milk and plasma IgA responses; however, conclusions regarding odds of MTCT risk were limited by the small sample size. These findings will inform future studies to investigate maternal immune interventions that can synergize with ART to eliminate MTCT during breastfeeding.
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Affiliation(s)
- Eliza D Hompe
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Denise L Jacobson
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Joshua A Eudailey
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin Butler
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Whitney Edwards
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Justin Pollara
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sean S Brummel
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Genevieve G Fouda
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lameck Chinula
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Melvin Kamanga
- Johns Hopkins University Research Project, Blantyre, Malawi
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Dhayendre Moodley
- Centre for the AIDS Programme of Research in South Africa and School of Clinical Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | - Maxensia Owor
- Johns Hopkins University Research Collaboration, Makerere University, Kampala, Uganda
| | - Mary Glenn Fowler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sallie R Permar
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
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Paradkar M, Devaleenal DB, Mvalo T, Arenivas A, Thakur KT, Afrin S, Giridharan P, Selladurai E, Kinikar A, Valvi C, Gupta A, Mave V, Dooley KE. Challenges in conducting trials for pediatric tuberculous meningitis: lessons from the field. Int J Tuberc Lung Dis 2019; 23:1082-1089. [DOI: 10.5588/ijtld.18.0786] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: TBM-KIDS is a phase I/II trial enrolling children with tuberculous meningitis (TBM) in three tertiary referral centers in India and Malawi.OBJECTIVE: To describe the challenges encountered in conducting the first randomized clinical trial of antimicrobial
agents in pediatric TBM.DESIGN: The sources of the data were primarily monthly trial reports, non-enrollment case report forms, study diaries and registers maintained for recruitment, experiences shared by key team members during regular study calls and comments from site review
visits. We reviewed, broadly categorized, and describe in detail the challenges encountered by study teams in trial implementation.RESULTS: Over 17 months, 3371 children with clinical presentations consistent with meningoencephalitis or undergoing lumbar puncture were assessed for
eligibility; 21 (<1%) met enrollment criteria. We encountered challenges related to diagnosis, management of sick children, large catchment areas, adverse event attribution, concomitant medications, infrastructure requirements, expensive pediatric formulations with short expiry, and detection
of treatment response in a highly variable disease across the age continuum. Training and adaptation of tools for neurocognitive and neurologic function assessment were necessary. Special care was undertaken to explain study participation to distraught caregivers and manage children longitudinally.CONCLUSION:
Interventional trials in pediatric TBM are challenging but are critically important for improving the treatment of a disease that disables children physically, cognitively and emotionally. Sharing these challenges may help to address them more effectively as a TB research community and to
advance treatments for this at-risk population.
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Affiliation(s)
- M. Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Research Site, Pune
| | - D. B. Devaleenal
- National Institute for Research in Tuberculosis, Indian Council for Medical Research, Chennai, India
| | - T. Mvalo
- University of North Carolina Project-Malawi, Lilongwe, Malawi, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, NC
| | - A. Arenivas
- The Institute for Rehabilitation and Research Memorial Hermann, Department of Rehabilitation Psychology and Neuropsychology, Houston, TX, Baylor College of Medicine, Department of Physical Medicine and Rehabilitation, Houston, TX
| | - K. T. Thakur
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - S. Afrin
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Research Site, Pune
| | - P. Giridharan
- National Institute for Research in Tuberculosis, Indian Council for Medical Research, Chennai, India
| | - E. Selladurai
- Institute of Child Health and Hospital for Children, Chennai
| | - A. Kinikar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Research Site, Pune, BJ Government Medical College, Pune, India
| | - C. Valvi
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Research Site, Pune, BJ Government Medical College, Pune, India
| | - A. Gupta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - V. Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Research Site, Pune, BJ Government Medical College, Pune, India
| | - K. E. Dooley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Belgaumkar V, Chandanwale A, Valvi C, Pardeshi G, Lokhande R, Kadam D, Joshi S, Gupte N, Jain D, Dhumal G, Deluca A, Golub J, Gupta A, Kinikar A, Bollinger RC. Barriers to screening and isoniazid preventive therapy for child contacts of tuberculosis patients. Int J Tuberc Lung Dis 2019; 22:1179-1187. [PMID: 30236186 DOI: 10.5588/ijtld.17.0848] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND India's guidelines recommend tuberculosis (TB) screening of household contacts aged <6 years and isoniazid preventive therapy (IPT) for children without active disease. We evaluated the current status and barriers to screening and IPT provision among the child contacts of TB patients. METHODS Questionnaire and health record data were collected from index cases and health care providers (HCPs) at Sassoon General Hospital, Pune, India. RESULTS Of 80 adult TB cases, 24 (30%) reported that an HCP recommended TB screening of their child contacts; 49/178 (28%) child contacts were screened. Sixteen (33%) children had active TB, and 28 (85%) of those who screened negative were prescribed IPT. Nineteen (76%) HCPs reported recommending child contact screening. Only 8 (32%) reported ever prescribing IPT. Lack of TB screening and IPT provision for child contacts was associated with inadequate HCP counseling (aOR 19.5, P < 0.001), a non-parent index case (aOR 3.72, P = 0.008) and lack of postgraduate HCP qualification (aOR 19.12, P = 0.04). CONCLUSIONS TB screening and IPT provision for child contacts of adults with TB were infrequent. Many screened children had active TB. Universal, timely TB screening and IPT for exposed children are urgently needed to reduce pediatric TB in India.
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Affiliation(s)
- V Belgaumkar
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune
| | - A Chandanwale
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune
| | - C Valvi
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune
| | - G Pardeshi
- Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
| | - R Lokhande
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune
| | - D Kadam
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune
| | - S Joshi
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune
| | - N Gupte
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India
| | - D Jain
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India
| | - G Dhumal
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India
| | - A Deluca
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J Golub
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Gupta
- Byramjee Jeejeebhoy Government Medical College/Johns Hopkins Clinical Trials Unit, Pune, India, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Kinikar
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune
| | - R C Bollinger
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Aibana O, Huang CC, Aboud S, Arnedo-Pena A, Becerra MC, Bellido-Blasco JB, Bhosale R, Calderon R, Chiang S, Contreras C, Davaasambuu G, Fawzi WW, Franke MF, Galea JT, Garcia-Ferrer D, Gil-Fortuño M, Gomila-Sard B, Gupta A, Gupte N, Hussain R, Iborra-Millet J, Iqbal NT, Juan-Cerdán JV, Kinikar A, Lecca L, Mave V, Meseguer-Ferrer N, Montepiedra G, Mugusi FM, Owolabi OA, Parsonnet J, Roach-Poblete F, Romeu-García MA, Spector SA, Sudfeld CR, Tenforde MW, Togun TO, Yataco R, Zhang Z, Murray MB. Vitamin D status and risk of incident tuberculosis disease: A nested case-control study, systematic review, and individual-participant data meta-analysis. PLoS Med 2019; 16:e1002907. [PMID: 31509529 PMCID: PMC6738590 DOI: 10.1371/journal.pmed.1002907] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 08/12/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Few studies have evaluated the association between preexisting vitamin D deficiency and incident tuberculosis (TB). We assessed the impact of baseline vitamins D levels on TB disease risk. METHODS AND FINDINGS We assessed the association between baseline vitamin D and incident TB in a prospective cohort of 6,751 HIV-negative household contacts of TB patients enrolled between September 1, 2009, and August 29, 2012, in Lima, Peru. We screened for TB disease at 2, 6, and 12 months after enrollment. We defined cases as household contacts who developed TB disease at least 15 days after enrollment of the index patient. For each case, we randomly selected four controls from among contacts who did not develop TB disease, matching on gender and year of age. We also conducted a one-stage individual-participant data (IPD) meta-analysis searching PubMed and Embase to identify prospective studies of vitamin D and TB disease until June 8, 2019. We included studies that assessed vitamin D before TB diagnosis. In the primary analysis, we defined vitamin D deficiency as 25-(OH)D < 50 nmol/L, insufficiency as 50-75 nmol/L, and sufficiency as >75nmol/L. We estimated the association between baseline vitamin D status and incident TB using conditional logistic regression in the Lima cohort and generalized linear mixed models in the meta-analysis. We further defined severe vitamin D deficiency as 25-(OH)D < 25 nmol/L and performed stratified analyses by HIV status in the IPD meta-analysis. In the Lima cohort, we analyzed 180 cases and 709 matched controls. The adjusted odds ratio (aOR) for TB risk among participants with baseline vitamin D deficiency compared to sufficient vitamin D was 1.63 (95% CI 0.75-3.52; p = 0.22). We included seven published studies in the meta-analysis and analyzed 3,544 participants. In the pooled analysis, the aOR was 1.48 (95% CI 1.04-2.10; p = 0.03). The aOR for severe vitamin D deficiency was 2.05 (95% CI 0.87-4.87; p trend for decreasing 25-(OH)D levels from sufficient vitamin D to severe deficiency = 0.02). Among 1,576 HIV-positive patients, vitamin D deficiency conferred a 2-fold (aOR 2.18, 95% CI 1.22-3.90; p = 0.01) increased risk of TB, and the aOR for severe vitamin D deficiency compared to sufficient vitamin D was 4.28 (95% CI 0.85-21.45; p = 0.08). Our Lima cohort study is limited by the short duration of follow-up, and the IPD meta-analysis is limited by the number of possible confounding covariates available across all studies. CONCLUSION Our findings suggest vitamin D predicts TB disease risk in a dose-dependent manner and that the risk of TB disease is highest among HIV-positive individuals with severe vitamin D deficiency. Randomized control trials are needed to evaluate the possible role of vitamin D supplementation on reducing TB disease risk.
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Affiliation(s)
- Omowunmi Aibana
- Department of Internal Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, United States of America
| | - Chuan-Chin Huang
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Upanga West, Dar es Salaam, Tanzania
| | | | - Mercedes C. Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Ramesh Bhosale
- Department of Obstetrics & Gynecology, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | | | - Silvia Chiang
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | | | - Ganmaa Davaasambuu
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jerome T. Galea
- School of Social Work, University of South Florida, Tampa, Florida, United States of America
| | | | | | | | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University CRS, Pune, India
| | - Rabia Hussain
- Department of Pathology and Microbiology, Aga Khan University, Karachi, Pakistan
| | | | - Najeeha T. Iqbal
- Department of Pediatrics and Child Health and Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
| | | | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Leonid Lecca
- Partners in Health—Socios En Salud Sucursal, Lima, Peru
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University CRS, Pune, India
| | | | - Grace Montepiedra
- Center for Biostatistics in AIDS Research and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ferdinand M. Mugusi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Upanga West, Dar es Salaam, Tanzania
| | - Olumuyiwa A. Owolabi
- Medical Research Council Gambia at London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Julie Parsonnet
- Departments of Medicine and of Health Research and Policy, Stanford University School of Medicine, Stanford, California, United States of America
| | | | | | - Stephen A. Spector
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, La Jolla, California, United States of America
| | - Christopher R. Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Mark W. Tenforde
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Toyin O. Togun
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - Rosa Yataco
- Partners in Health—Socios En Salud Sucursal, Lima, Peru
| | - Zibiao Zhang
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Megan B. Murray
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Mave V, Chandrasekaran P, Chavan A, Shivakumar SVBY, Danasekaran K, Paradkar M, Thiruvengadam K, Kinikar A, Murali L, Gaikwad S, Hanna LE, Kulkarni V, Pattabiraman S, Suryavanshi N, Thomas B, Kohli R, Sivaramakrishnan GN, Pradhan N, Bhanu B, Kagal A, Golub J, Gandhi N, Gupte A, Gupte N, Swaminathan S, Gupta A. Infection free "resisters" among household contacts of adult pulmonary tuberculosis. PLoS One 2019; 14:e0218034. [PMID: 31318864 PMCID: PMC6638997 DOI: 10.1371/journal.pone.0218034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 05/23/2019] [Indexed: 02/01/2023] Open
Abstract
Despite substantial exposure to infectious pulmonary tuberculosis (TB) cases, some household contacts (HHC) never acquire latent TB infection (LTBI). Characterizing these “resisters” can inform who to study immunologically for the development of TB vaccines. We enrolled HHCs of culture-confirmed adult pulmonary TB in India who underwent LTBI testing using tuberculin skin test (TST) and QuantiFERON TB Gold Test-in-tube (QFT-GIT) at baseline and, if negative by both (<5mm TST and <0.35IU/mL QFT-GIT), underwent follow-up testing at 4–6 and/or 12 months. We defined persons with persistently negative LTBI tests at both baseline and followup as pLTBI- and resisters as those who had a high exposure to TB using a published score and remained pLTBI-. We calculated the proportion of resisters overall and resisters with complete absence of response to LTBI tests (0mm TST and/or QFT-GIT <0.01 IU/ml). Using random effects Poisson regression, we assessed factors associated with pLTBI-. Of 799 HHCs in 355 households, 67 (8%) were pLTBI- at 12 months; 52 (6.5%) pLTBI- in 39 households were resisters. Complete absence of response to LTBI tests was found in 27 (53%) resisters. No epidemiological characteristics were associated with the pLTBI- phenotype. LTBI free resisters among HHC exist but are uncommon and are without distinguishing epidemiologic characteristics. Assessing the genetic and immunologic features of such resister individuals is likely to elucidate mechanisms of protective immunity to TB.
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Affiliation(s)
- Vidya Mave
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Amol Chavan
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | | | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Lakshmi Murali
- District Tuberculosis Officer, State Tuberculosis Office, Thiruvallur, Tamil Nadu, India
| | - Sanjay Gaikwad
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | | | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Beena Thomas
- National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Rewa Kohli
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Brindha Bhanu
- National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
| | - Anju Kagal
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Jonathan Golub
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Neel Gandhi
- Emory University, Atlanta, Georgia, United States of America
| | - Akshay Gupte
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | | | - Amita Gupta
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Kinikar A, Chandanwale A, Kadam D, Joshi S, Basavaraj A, Pardeshi G, Girish S, Shelke S, DeLuca A, Dhumal G, Golub J, Lokhande N, Gupte N, Gupta A, Bollinger R, Mave V. High risk for latent tuberculosis infection among medical residents and nursing students in India. PLoS One 2019; 14:e0219131. [PMID: 31283794 PMCID: PMC6613683 DOI: 10.1371/journal.pone.0219131] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/17/2019] [Indexed: 11/18/2022] Open
Abstract
Defining occupational latent tuberculosis infection (LTBI) risk among healthcare workers is needed to support implementation of prevention guidelines. Prospective cohort study of 200 medical residents and nursing students in India was conducted May 2016—December 2017. Tuberculin skin test (TST) and QuantiFERON TB Gold Test-in-tube (QFT-GIT) were performed at study entry and 12 months. Primary outcome was incident LTBI (≥10mm TST induration and/or ≥0.35IU/mL QFT-GIT) at 12 months; secondary outcomes included baseline LTBI prevalence and risk factors for incident and prevalent LTBI using Poisson regression. Among 200, [90 nursing students and 110 medical residents], LTBI prevalence was 30% (95% CI, 24–37); LTBI incidence was 26.8 (95% CI, 18.6–37.2) cases per 100 person-years and differed by testing method (28.7 [95% CI, 20.6–38.9] vs 17.4 [95% CI, 11.5–25.4] cases per 100 person-years using TST and QFT-GIT, respectively). Medical residents had two-fold greater risk of incident LTBI than nursing students (Relative Risk, 2.16; 95% CI, 1.05–4.42). During study period 6 (3%) HCWs were diagnosed with active TB disease. Overall, median number of self-reported TB exposures was 5 (Interquartile Range, 1–15). Of 60 participants with prevalent and incident LTBI who were offered free isoniazid preventive therapy (IPT), only 2 participants initiated and completed IPT. High risk for LTBI was noted among medical residents compared to nursing students. Self-reported TB exposure is underreported, and uptake of LTBI prevention therapy remains low. New approaches are needed to identify HCWs at highest risk for LTBI.
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Affiliation(s)
- Aarti Kinikar
- Department of Pediatrics, BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
- * E-mail:
| | - Ajay Chandanwale
- Department of Orthopedics, BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Dileep Kadam
- Department of Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
| | - Samir Joshi
- Department of ENT, BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Anita Basavaraj
- Department of Medicine, Government Medical College, Miraj, Maharashtra, India
| | - Geeta Pardeshi
- Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Sunita Girish
- Department of Biochemistry, BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Sangeeta Shelke
- Department of Community Medicine, BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Andrea DeLuca
- Department of Environmental Health and Engineering, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Gauri Dhumal
- BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Jonathan Golub
- Department of Medicine, Epidemiology and International Health, Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nilima Lokhande
- BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Nikhil Gupte
- BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Amita Gupta
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Robert Bollinger
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Vidya Mave
- BJGMC-JHU Clinical Trial Unit, Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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46
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Mathad JS, Reif LK, Seo G, Walsh KF, McNairy ML, Lee MH, Hokororo A, Kinikar A, Riche CT, Deschamps MM, Nerette S, Nimkar S, Kayange N, Jaka H, Joseph G, Morona D, Peter TY, Suryavanshi N, Fitzgerald DW, Downs JA. Female global health leadership: data-driven approaches to close the gender gap. Lancet 2019; 393:521-523. [PMID: 30739680 PMCID: PMC7391058 DOI: 10.1016/s0140-6736(19)30203-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 10/22/2018] [Accepted: 01/03/2019] [Indexed: 11/21/2022]
Affiliation(s)
- Jyoti S Mathad
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA; General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA.
| | - Lindsey K Reif
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Grace Seo
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Kathleen F Walsh
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA; General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Margaret L McNairy
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA; General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Myung Hee Lee
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Adolfine Hokororo
- Department of Pediatrics, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College and Sassoon Government Hospital, Pune, India
| | - Claudia T Riche
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Marie M Deschamps
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Sandy Nerette
- The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Smita Nimkar
- Johns Hopkins University Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune India
| | - Neema Kayange
- Department of Pediatrics, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Hyasinta Jaka
- Department of Medicine, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Glory Joseph
- Department of Pediatrics, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Domenica Morona
- Department of Parasitology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Thandiwe Yvonne Peter
- Department of Administration, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Nishi Suryavanshi
- Johns Hopkins University Byramjee Jeejeebhoy Government Medical College Clinical Trials Unit, Pune India
| | - Daniel W Fitzgerald
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Jennifer A Downs
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA; Department of Medicine, Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
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47
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Bharadwaj R, Robinson ML, Balasubramanian U, Kulkarni V, Kagal A, Raichur P, Khadse S, Kadam D, Valvi C, Kinikar A, Kanade S, Suryavanshi N, Marbaniang I, Nelson G, Johnson J, Zenilman J, Sachs J, Gupta A, Mave V. Drug-resistant Enterobacteriaceae colonization is associated with healthcare utilization and antimicrobial use among inpatients in Pune, India. BMC Infect Dis 2018; 18:504. [PMID: 30286741 PMCID: PMC6172743 DOI: 10.1186/s12879-018-3390-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 09/17/2018] [Indexed: 11/18/2022] Open
Abstract
Background Healthcare exposure may increase drug-resistant Enterobacteriaceae colonization risk. Nascent antimicrobial stewardship efforts in low- and middle-income countries require setting-specific data. We aimed to evaluate risk factors for inpatient drug resistant Enterobacteriaceae colonization in a resource-limited setting in India. Methods Patients age ≥ 6 months admitted with ≥24 h of fever to a tertiary hospital in Pune, India were enrolled in a prospective cohort. Perirectal swabs, collected on admission and hospitalization day 3 or 4, were cultured in vancomycin- and ceftriaxone-impregnated media to assess for ceftriaxone-resistant Enterobacteriaceae (CTRE) and carbapenem-resistant Enterobacteriaceae (CPRE). Multivariable analyses assessed risk factors for drug-resistant Enterobacteriaceae colonization among participants without admission colonization. Results Admission perirectal swabs were collected on 897 participants; 87 (10%) had CTRE and 14 (1.6%) had CPRE colonization. Admission CTRE colonization was associated with recent healthcare contact (p < 0.01). Follow-up samples were collected from 620 participants, 67 (11%) had CTRE and 21 (3.4%) had CPRE colonization. Among 561 participants without enrollment CTRE colonization, 49 (9%) participants were colonized with CTRE at follow-up. Detection of CTRE colonization among participants not colonized with CTRE at admission was independently associated with empiric third generation cephalosporin treatment (adjusted odds ratio [OR] 2.9, 95% CI 1.5–5.8). Follow-up transition to CPRE colonization detection was associated with ICU admission (OR 3.0, 95% CI 1.0–8.5). Conclusions Patients who receive empiric third generation cephalosporins and are admitted to the ICU rapidly develop detectable CTRE and CPRE colonization. Improved antimicrobial stewardship and infection control measures are urgently needed upon hospital admission. Electronic supplementary material The online version of this article (10.1186/s12879-018-3390-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Renu Bharadwaj
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India. .,Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India.
| | | | - Usha Balasubramanian
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Anju Kagal
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Priyanka Raichur
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Sandhya Khadse
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Dileep Kadam
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Chhaya Valvi
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Byramjee-Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Savita Kanade
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Ivan Marbaniang
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - George Nelson
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Julia Johnson
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jonathan Sachs
- Phoenix Children's Hospital / Maricopa Medical Center, Phoenix, AZ, USA
| | - Amita Gupta
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
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48
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Shivakoti R, Gupte N, Kumar NP, Kulkarni V, Balasubramanian U, Bhosale R, Sambrey P, Kinikar A, Bharadwaj R, Patil S, Inamdar S, Suryavanshi N, Babu S, Bollinger RC, Gupta A. Intestinal Barrier Dysfunction and Microbial Translocation in Human Immunodeficiency Virus-Infected Pregnant Women Are Associated With Preterm Birth. Clin Infect Dis 2018; 67:1103-1109. [PMID: 29590318 PMCID: PMC6137119 DOI: 10.1093/cid/ciy253] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/23/2018] [Indexed: 12/26/2022] Open
Abstract
Background Preterm birth (PTB) rates are high in human immunodeficiency virus (HIV)-infected populations, even when on treatment. Still, only a subset of all births in HIV-infected pregnant women result in PTB, suggesting that risk factors other than HIV infection itself are also important. Inflammation is a known risk factor in uninfected populations, but its role in HIV-infected population have not been studied; in addition, the immune pathways involved are not clear and noninvasive immune markers with predictive value are lacking. Our objective was to determine the association of select markers of inflammation with PTB in HIV-1-infected pregnant women. Methods Within a randomized trial of pregnant women receiving nevirapine (Six-Week Extended-Dose Nevirapine [SWEN] trial), we nested a case-control study (n = 107; 26 cases, 81 controls) to determine the association of maternal inflammation with PTB. Cases were defined as PTB (<37 weeks' gestational age). We assessed inflammation by measuring plasma levels of markers of general inflammation (C-reactive protein [CRP]), intestinal barrier dysfunction (intestinal fatty acid binding protein [I-FABP]), and microbial translocation/monocyte activation (soluble CD14 [sCD14] and CD163 [sCD163]). Multivariable logistic regression was used to determine the odds of PTB per log2 increase of each marker. Results In multivariable models, there was increased odds of PTB per unit increase of log2 sCD14 (adjusted odds ratio [aOR], 2.45; 95% confidence interval [CI], 1.24-4.86), log2 sCD163 (aOR, 3.87; 95% CI, 1.43-10.49), and log2 I-FABP (aOR, 2.28; 95% CI, 1.18-4.41) but not log2 CRP (aOR, 0.72; 95% CI, .48-1.09). Conclusions Our results show that select immune markers can identify women at higher risk for PTB in HIV-1-infected populations and suggest that modulating gut barrier integrity and microbial translocation may affect PTB. Clinical Trials Registration NCT00061321.
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Affiliation(s)
- Rupak Shivakoti
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
| | - Nikhil Gupte
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
| | - Nathella Pavan Kumar
- National Institutes of Health, National Institute for Research in Tuberculosis, International Center for Excellence in Research, Chennai
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
| | | | - Ramesh Bhosale
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Pradeep Sambrey
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Renu Bharadwaj
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Sandesh Patil
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
| | - Sadaf Inamdar
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
| | - Nishi Suryavanshi
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
| | - Subash Babu
- National Institutes of Health, National Institute for Research in Tuberculosis, International Center for Excellence in Research, Chennai
| | - Robert C Bollinger
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
| | - Amita Gupta
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Byramjee Jeejeebhoy Medical College, Johns Hopkins Clinical Research Site, Pune
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49
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Elf JL, Kinikar A, Khadse S, Mave V, Suryavanshi N, Gupte N, Kulkarni V, Patekar S, Raichur P, Paradkar M, Kulkarni V, Pradhan N, Breysse PN, Gupta A, Golub JE. The association of household fine particulate matter and kerosene with tuberculosis in women and children in Pune, India. Occup Environ Med 2018; 76:40-47. [PMID: 30194271 DOI: 10.1136/oemed-2018-105122] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 07/11/2018] [Accepted: 08/14/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Household air pollution (HAP) is a risk factor for respiratory disease, however has yet to be definitively associated with tuberculosis (TB). We aimed to assess the association between HAP and TB. METHODS A matched case-control study was conducted among adult women and children patients with TB and healthy controls matched on geography, age and sex. HAP was assessed using questionnaires for pollution sources and 24-hour household concentrations of particulate matter <2.5 μm in diameter (PM2.5). RESULTS In total, 192 individuals in 96 matched pairs were included. The median 24-hour time-weighted average PM2.5 was nearly seven times higher than the WHO's recommendation of 25 µg/m3, and did not vary between controls (179 µg/m3; IQR: 113-292) and cases (median 157 µg/m3; 95% CI 93 to 279; p=0.57). Reported use of wood fuel was not associated with TB (OR 2.32; 95% CI 0.65 to 24.20) and kerosene was significantly associated with TB (OR 5.49, 95% CI 1.24 to 24.20) in adjusted analysis. Household PM2.5 was not associated with TB in univariate or adjusted analysis. Controlling for PM2.5 concentration, kerosene was not significantly associated with TB, but effect sizes ranged from OR 4.30 (95% CI 0.78 to 30.86; p=0.09) to OR 5.49 (0.82 to 36.75; p=0.08). CONCLUSIONS Use of kerosene cooking fuel is positively associated with TB in analysis using reported sources of exposure. Ubiquitously high levels of particulates limited detection of a difference in household PM2.5 between cases and controls.
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Affiliation(s)
- Jessica L Elf
- Department of Medicine, Division of Infectious Diseases, Center for Clinical Global Health Education, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Department of Medicine, Division of Infectious Diseases, Center for TB Research, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.,Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Aarti Kinikar
- Pediatrics Department, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune, India
| | - Sandhya Khadse
- Pediatrics Department, Byramjee Jeejeebhoy Government Medical College and Sassoon General Hospitals, Pune, India
| | - Vidya Mave
- Department of Medicine, Division of Infectious Diseases, Center for Clinical Global Health Education, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Nikhil Gupte
- Department of Medicine, Division of Infectious Diseases, Center for Clinical Global Health Education, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Vaishali Kulkarni
- Byramjee Jeejeebhoy Government Medical College and Sassoon Government Hospitals, Pune, India
| | - Sunita Patekar
- Byramjee Jeejeebhoy Government Medical College and Sassoon Government Hospitals, Pune, India
| | - Priyanka Raichur
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins Clinical Trials Unit, Pune, India
| | - Patrick N Breysse
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Currently employed by the Centers for Disease Control and Prevention. Patrick Breysse is serving in his personal capacity
| | - Amita Gupta
- Department of Medicine, Division of Infectious Diseases, Center for Clinical Global Health Education, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.,Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jonathan E Golub
- Department of Medicine, Division of Infectious Diseases, Center for TB Research, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.,Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Elf JL, Kinikar A, Khadse S, Mave V, Suryavanshi N, Gupte N, Kulkarni V, Patekar S, Raichur P, Breysse PN, Gupta A, Golub JE. Sources of household air pollution and their association with fine particulate matter in low-income urban homes in India. J Expo Sci Environ Epidemiol 2018; 28:400-410. [PMID: 29789668 PMCID: PMC6013356 DOI: 10.1038/s41370-018-0024-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 11/16/2017] [Accepted: 12/17/2017] [Indexed: 05/19/2023]
Abstract
INTRODUCTION Household air pollution (HAP) is poorly characterized in low-income urban Indian communities. MATERIALS AND METHODS A questionnaire assessing sources of HAP and 24 h household concentrations of particulate matter less than 2.5 microns in diameter (PM2.5) were collected in a sample of low-income homes in Pune, India. RESULTS In 166 homes, the median 24 h average concentration of PM2.5 was 167 μg/m3 (IQR: 106-294). Although kerosene and wood use were highly prevalent (22% and 25% of homes, respectively), primarily as secondary fuel sources, high PM2.5 concentrations were also found in 95 (57%) homes reporting LPG use alone (mean 141 μg/m3; IQR: 92-209). In adjusted linear regression, log PM2.5 concentration was positively associated with wood cooking fuel (GMR 1.5, 95% CI: 1.1-2.0), mosquito coils (GMR 1.5, 95% CI: 1.1-2.1), and winter season (GMR 1.7, 95% CI: 1.4-2.2). Households in the highest quartile of exposure were positively associated with wood cooking fuel (OR 1.3, 95% CI: 1.1-1.5), incense (OR 1.1, 95% CI: 1.0-1.3), mosquito coils (OR 1.3, 95% CI: 1.1-1.6), and winter season (OR 1.2, 95% CI: 1.1-1.4). DISCUSSION We observed high concentrations of PM2.5 and identified associated determinants in urban Indian homes.
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Affiliation(s)
- Jessica L Elf
- Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Schroeder Institute for Tobacco Research and Policy Studies at Truth Initiative, Washington, DC, USA.
| | | | - Sandhya Khadse
- Byramjee Jeejeebhoy Government Medical College and Sassoon Government Hospitals, Pune, India
| | - Vidya Mave
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Nikhil Gupte
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Vaishali Kulkarni
- Byramjee Jeejeebhoy Government Medical College and Sassoon Government Hospitals, Pune, India
| | - Sunita Patekar
- Byramjee Jeejeebhoy Government Medical College and Sassoon Government Hospitals, Pune, India
| | - Priyanka Raichur
- Byramjee Jeejeebhoy Government Medical College and Sassoon Government Hospitals, Pune, India
| | | | - Amita Gupta
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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