Schistosomiasis control in adults: a call for action towards the goal of universal health coverage

Background

Schistosomiasis is a high-burden parasitic disease and endemic in tropical climates, such as Madagascar. Recently it is emerging in Europe. Chronic infections lead to disabilities including loss in work productivity. Current control strategies focus on school-aged children, thereby systematically excluding adults. The goal to eliminate the disease as a public health problem is aligned with the Sustainable Development Goals agenda, including Universal Health Coverage (UHC). We aim at assessing the distribution of schistosomiasis among adults in Madagascar, in order to promote more targeted public health initiatives against the disease.

Methods

In a cross-sectional study, 1477 blood samples were collected at three primary health-care centers in Madagascar from 03.21 to 01.22. A semi quantitative PCR assay was used to assess the presence of Schistosoma. Positivity rates with 95% Confidence Intervals (CI) were reported by gender and age groups.

Results

Our study population had a balanced gender distribution with 54.2% [CI: 51.7;56.8] of females and a median age of 37 years (IQR: 24-48). Preliminary results show an overall Schistosome positivity rate of 59.5% [CI: 57.0;62.0]. Positivity was higher in males 62.4% [CI: 58.7;66.1], than in females 57.1% [CI: 53.5;60.5]. Highest positivity was seen in the 18-34 year age group with 66.2% [CI: 62.7;69.6]. Lowest positivity of 46.2% [CI: 39.2;53.2] was observed in adults aged over 55 years.

Conclusions

Our preliminary results provide evidence of high positivity rates of schistosomiasis among adults in a highly endemic country. Differently from many studies, males seem more affected than females. The youngest age group, representing the more active workforce of a population, shows a higher positivity rate. Our data suggests that, in the logic of UHC and health as a human right, public health strategies for schistosomiasis need to be re-addressed towards a universal coverage of affected individuals.

Key messages

Study of enteric pathogens among children in the tropics and effects of prolonged storage of stool samples

The study was performed to compare real-time PCR after nucleic acid extraction directly from stool samples as well as from samples stored and transported on Whatman papers or flocked swabs at ambient temperature in the tropics. In addition, the possible suitability for a clear determination of likely aetiological relevance of PCR-based pathogen detections based on cycle threshold (Ct) values was assessed. From 632 Tanzanian children <5 years of age with and without gastrointestinal symptoms, 466 samples were subjected to nucleic acid extraction and real-time PCR for gastrointestinal viral, bacterial and protozoan pathogens. Equal or even higher frequencies of pathogen detections from Whatman papers or flocked swabs were achieved compared with nucleic acid extraction directly from stool samples. Comparison of the Ct values showed no significant difference according to the nucleic acid extraction strategy. Also, the Ct values did not allow a decision whether a detected pathogen was associated with gastrointestinal symptoms.

Fast and reliable easy-to-use diagnostics for eliminating bilharzia in young children and mothers: An introduction to the freeBILy project

Schistosoma antigen detection tests have a large potential for schistosomiasis control programs due to their ability to detect active and ongoing Schistosoma infections, their much higher sensitivity compared to microscopical methods, and the possibility to use non-invasive urine samples. Pregnant women and young children could especially benefit from affordable and easy-to-use antigen tests as inclusion of these vulnerable groups in mass drug administration campaigns will always require higher justification hurdles, especially in low to middle endemic regions with a higher proportion of individuals who are not infected and thus unnecessarily exposed to praziquantel. The overall objective of the 'fast and reliable easy-to-use diagnostics for eliminating bilharzia in young children and mothers' (freeBILy, www.freeBILy.eu) project is to thoroughly evaluate the point-of-care circulating cathodic antigen (POC-CCA) and the up-converting phosphor reporter particle, lateral flow circulating anodic antigen (UCP-LF CAA) urine strip tests to diagnose Schistosoma infections in pregnant women and young children and to assess their potential as a schistosomiasis control tool in test-and-treat strategies. The freeBILy project will generate valuable, evidence-based findings on improved tools and test-and-treat strategies to reduce the burden of schistosomiasis in pregnant women and young children.

Prospective, observational study to assess the performance of CAA measurement as a diagnostic tool for the detection of Schistosoma haematobium infections in pregnant women and their child in Lambaréné, Gabon: study protocol of the freeBILy clinical trial in Gabon

BACKGROUND

Schistosoma antigen detection in urine is a valuable diagnostic approach for schistosomiasis control programmes because of the higher sensitivity compared to parasitological methods and preferred sampling of urine over stool. Highly accurate diagnostics are important in low Schistosoma transmission areas. Pregnant women and young children could particularly benefit from antigen testing as praziquantel (PZQ) can be given to only confirmed Schistosoma cases. This prevents the unborn baby from unnecessary exposure to PZQ. We present here the protocol of a diagnostic study that forms part of the freeBILy project. The aim is to evaluate the accuracy of circulating anodic antigen (CAA) detection for diagnosis of Schistosoma haematobium infections in pregnant women and to validate CAA as an endpoint measure for anti-Schistosoma drug efficacy. The study will also investigate Schistosoma infections in infants.

METHODS

A set of three interlinked prospective, observational studies is conducted in Gabon. The upconverting phosphor lateral flow (UCP-LF) CAA test is the index diagnostic test that will be evaluated. The core trial, sub-study A, comprehensively evaluates the accuracy of the UCP-LF CAA urine test against a set of other Schistosoma diagnostics in a cross-sectional trial design. Women positive for S. haematobium will proceed with sub-study B and will be randomised to receive PZQ treatment immediately or after delivery followed by weekly sample collection. This approach includes comparative monitoring of CAA levels following PZQ intake and will also contribute further data for safety of PZQ administration during pregnancy. Sub-study C is a longitudinal study to determine the incidence of S. haematobium infection as well as the age for first infection in life-time.

DISCUSSION

The freeBILy trial in Gabon will generate a comprehensive set of data on the accuracy of the UCP-LF CAA test for the detection of S. haematobium infection in pregnant women and newborn babies and for the use of CAA as a marker to determine PZQ efficacy. Furthermore, incidence of Schistosoma infection in infants will be reported. Using the ultrasensitive diagnostics, this information will be highly relevant for Schistosoma prevalence monitoring by national control programs as well as for the development of medicaments and vaccines.

TRIAL REGISTRATION

The registration number of this study is NCT03779347 ( clinicaltrials.gov , date of registration: 19 December 2018).

Sparing the control arm using well-characterized diagnostic approaches – the Gart and Buck prevalence estimator for efficacy estimation in single-arm trials

Efficacy estimation of medical interventions in clinical trials requires diagnostics to assess the study endpoint. The imperfect nature of diagnostics often leads to biased efficacy estimations, usually underestimation, that could result in failure of clinical trials. Adjustment methods can be used if sensitivity and specificity are known, but they are not regularly applied. Double-arm clinical trials are the standard for demonstrating the superiority of a medical intervention. However, sometimes single-arm trials are the only option: for example, if a parallel group trial design with a control group is regarded as unethical. Based on the Gart and Buck prevalence estimator (aka the Rogan-Gladen estimator), we demonstrate how the concept of diagnostic accuracy-adjusted effect estimation can be used for estimating the efficacy in single-arm trials. The accuracy of the diagnostic measure (sensitivity and specificity) used for endpoint assessment as well as the predictive accuracy of a predictor and its allocation among the study population have to be known to obtain consistent efficacy estimation of a medical intervention. If double-arm trials are not feasible, an approach such as that described here can provide evidence regarding the efficacy of a medical intervention based on a single-arm trial.

Evaluation of the multiplex real-time PCR assays RealStar malaria S&T PCR kit 1.0 and FTD malaria differentiation for the differentiation of Plasmodium species in clinical samples

BACKGROUND

Two commercial PCR assays were assessed in a retrospective study to determine their reliability as tools for the differentiation of Plasmodium species in human blood.

METHODS

A total of 1022 blood samples from 817 patients with suspected or confirmed malaria submitted to the German National Reference Centre for Tropical Pathogens were subjected to malaria microscopy using thick and thin blood films as well as to a genus-specific malaria real-time PCR. Parasite-positive samples were analysed by RealStar Malaria S&T PCR Kit 1.0 (altona Diagnostics) and FTD Malaria Differentiation (Fast Track Diagnostics) multiplex real-time PCR assays targeting species-specific Plasmodium DNA.

RESULTS

Out of the 1022 blood samples, 247 (24.2%) tested positive for Plasmodium spp. The two multiplex assays showed rather similar performance characteristics and provided concordant species information in 98.9% of samples positive by malaria microscopy and in 95.1% (RealStar) and 96.8% (FTD) of samples positive by genus-specific PCR. Compared to FTD, RealStar revealed slightly reduced sensitivity for submicroscopic, low-level P. falciparum infections, while FTD was unable to detect P. knowlesi.

CONCLUSIONS

The two commercial malaria PCR assays assessed are suitable for discriminating Plasmodium species in clinical samples, and can provide additional information in cases of microscopically uncertain findings.

Detection of Tropheryma whipplei in stool samples by one commercial and two in-house real-time PCR assays

OBJECTIVE

Tropheryma whipplei, the causative agent of Whipple's disease, can also be identified in stool samples of humans without systemic disease. It is much more frequently detected in human stool samples in tropical environments than in industrialized countries. PCR-screening has been applied for point prevalence studies and environmental assessments in tropical settings, but results depend on the applied assay. We compared one commercial qPCR kit with two well-described in-house assays for detection of T. whipplei from stool.

METHODS

Residual materials from nucleic acid extractions of stool samples from two groups with presumably different prevalences and increased likelihood of being colonized or infected by T. whipplei were tested. One group comprised 300 samples from study participants from western Africa (group 1); the second group was of 300 returnees from tropical deployments (group 2). Each sample was assessed with all three qPCR assays. Cycle threshold (C_t ) values were descriptively compared.

RESULTS

Based solely on mathematical modeling, the three PCR assays showed considerably different detection rates of T. whipplei DNA in stool samples (kappa 0.67 (95% confidence interval [0.60, 0.73])). Considering the calculated test characteristics, prevalence of 28.3% for group 1 and 5.0% for group 2 was estimated. Discordant test results were associated with later C_t values. The study did not validate the assays for the detection of T. whipplei in Whipple's disease and for diagnostic purposes since clinical specificity and sensitivity were not investigated.

CONCLUSIONS

In spite of the observed diagnostic uncertainty, PCR-based screening approaches can be used for epidemiological purposes and environmental samples to define the source and reservoir in resource-limited tropical settings if prevalence is calculated using diagnostic accuracy-adjusted methods.

PCR-based rapid diagnostic tests as a strategy for preventing infections with sexually transmitted diseases-a 'diagnostics-as-prevention' modelling approach

The potential was modelled of molecular rapid diagnostic tests (RDTs) that target agents of sexually transmitted diseases (STDs) to contribute to a reduction in the exposure risk for sexually active populations who prefer condom-free high-risk contacts. The biostatistical approach is exemplified by considering the use of a PCR-based RDT for Chlamydia trachomatis and Neisseria gonorrhoeae in a population of German men having sex with men. We modelled the exposure risk as risk of sexual contact with individuals infected by a STD in spite of multiple RDTs having been conducted to identify STDs that could lead to avoidance of an infectious sexual contact. The risk for a given specific disease is influenced by the diagnostic accuracy of all diagnostic tests conducted. The simulation showed a reduction in exposure risk through conducting the selected PCR-based RDT as a strategy to prevent infections with C. trachomatis and N. gonorrhoeae in comparison with unprotected sexual contact of >97% for C. trachomatis and ≥96% for N. gonorrhoeae. Reliable knowledge of the performance characteristics of the diagnostic tests applied is essential for a thorough risk assessment based on such diagnostic approaches.

SIGNIFICANCE AND IMPACT OF THE STUDY

A low-threshold use of molecular rapid diagnostic tests in settings where risky sexual activity is undertaken with deliberate non-use of condoms is modelled. Such an approach might contribute to a considerable reduction in the exposure risk if positively tested individuals are excluded from unprotected sexual intercourse. Protective effects are influenced by the prevalence of the disease and the performance characteristics of the applied tests. Precise knowledge of the performance characteristics of the test assays employed are prerequisites of a reliable risk assessment. The modelling approach is of particular use for preventive health experts.

Comparing a single-day swabbing regimen with an established 3-day protocol for MRSA decolonization control

OBJECTIVES

Success of methicillin-resistant Staphylococcus aureus (MRSA) decolonization procedures is usually verified by control swabs of the colonized body region. This prospective controlled study compared a single-day regimen with a well-established 3-day scheme for noninferiority and adherence to the testing scheme.

METHODS

Two sampling schemes for screening MRSA patients of a single study cohort at a German tertiary-care hospital 2 days after decolonization were compared regarding their ability to identify MRSA colonization in throat or nose. In each patient, three nose and three throat swabs were taken at 3- to 4-hour intervals during screening day 1, and in the same patients once daily on days 1, 2 and 3. Swabs were analysed using chromogenic agar and broth enrichment. The study aimed to investigate whether the single-day swabbing scheme is not inferior to the 3-day scheme with a 15% noninferiority margin.

RESULTS

One hundred sixty patients were included, comprising 105 and 101 patients with results on all three swabs for decolonization screening of the nose and throat, respectively. Noninferiority of the single-day swabbing scheme was confirmed for both pharyngeal and nasal swabs, with 91.8% and 89% agreement, respectively. The absolute difference of positivity rates between the swabbing regimens was 0.025 (-0.082, 0.131) for the nose and 0.006 (-0.102, 0.114) (95% confidence interval) for the pharynx as calculated with McNemar's test for matched or paired data. Compliance with the single-day scheme was better, with 12% lacking second-day swabs and 27% lacking third-day swabs from the nostrils.

CONCLUSIONS

The better adherence to the single-day screening scheme with noninferiority suggests its implementation as the new gold standard.

Serological approaches for the diagnosis of schistosomiasis - A review

Schistosomiasis is a common disease in endemic areas of Sub-Saharan Africa, South America and Asia. It is rare in Europe, mainly imported from endemic countries due to travelling or human migration. Available methods for the diagnosis of schistosomiasis comprise microscopic, molecular and serological approaches, with the latter detecting antigens or antibodies associated with Schistosoma spp. infection. The serological approach is a valuable screening tool in low-endemicity settings and for travel medicine, though the interpretation of any diagnostic results requires knowledge of test characteristics and a patient's history. Specific antibody detection by most currently used assays is only possible in a relatively late stage of infection and does not allow for the differentiation of acute from previous infections for therapeutic control or the discrimination between persisting infection and re-infection. Throughout the last decades, new target antigens have been identified, and assays with improved performance and suitability for use in the field have been developed. For numerous assays, large-scale studies are still required to reliably characterise assay characteristics alone and in association with other available methods for the diagnosis of schistosomiasis. Apart from S. mansoni, S. haematobium and S. japonicum, for which most available tests were developed, other species of Schistosoma that occur less frequently need to be taken into account. This narrative review describes and critically discusses the results of published studies on the evaluation of serological assays that detect antibodies against different Schistosoma species of humans. It provides insights into the diagnostic performance and an overview of available assays and their suitability for large-scale use or individual diagnosis, and thus sets the scene for serological diagnosis of schistosomiasis and the interpretation of results.

Antibiotic resistance and clonal diversity of invasive Staphylococcus aureus in the rural Ashanti Region, Ghana

Background

Staphylococcus aureus is among the most common pathogens isolated from blood cultures in Ghana; yet the epidemiology of blood infections in rural settings is poorly described. This study aims to investigate antimicrobial susceptibility and clonal diversity of S. aureus causing bloodstream infections in two hospitals in the Ashanti Region, Ghana.

Methods

Blood cultures were performed for all febrile patients (≥37.5 °C) on hospital admission. Antibiotic susceptibility testing for S. aureus isolates was carried out by the VITEK 2 system. Multiplex polymerase chain reaction (PCR) was used to detect S. aureus-specific nuc gene, Panton-Valentine leukocidin (PVL), and methicillin-resistant S. aureus (MRSA)-specific mecA and mecC genes. The population structure of S. aureus was assessed by spa typing.

Results

In total, 9,834 blood samples were cultured, out of which 0.6% (n = 56) were positive for S. aureus. Multidrug resistance (MDR) was detected in 35.7% (n = 20) of the S. aureus strains, of which one was a MRSA. The highest rate of antibiotic resistance was seen for commonly available antibiotics, including penicillin (n = 55; 98.2%), tetracycline (n = 32; 57.1%) and trimethoprim/sulfamethoxazole (n = 26; 46.4%). Of all S. aureus strains, 75.0% (n = 42) carried the PVL-encoding genes. We found 25 different spa types with t355 (n = 11; 19.6%), t314 (n = 8; 14.3%), t084 (n = 8; 14.3%) and t311 (n = 5; 8.9%) being predominant.

Conclusion

The study exhibited an alarmingly large level of antibiotic resistance to locally available antibiotics. The frequency of genetically diverse and PVL-positive methicillin-sensitive S. aureus (MSSA) was high and could represent a reservoir for the emergence of virulent PVL-positive MRSA clones.

[Epidemiology of Ebola virus disease and of other highly contagious, life-threatening diseases with low incidence in Germany]

Das Vorkommen von Ebolafieber, der Marburgvirus-Krankheit sowie von Lassa-Fieber ist – abgesehen von vereinzelten eingeschleppten Fällen – auf den afrikanischen Kontinent beschränkt. Hämorrhagisches Krim-Kongo-Fieber kommt in Südosteuropa, jedoch bisher nicht in Deutschland vor. Weitere hämorrhagische Fiebererkrankungen sind regional auf dem südamerikanischen Kontinent verbreitet. Die Lungenpest ist die bakterielle Infektionskrankheit mit der höchsten Kontagiösität und Letalität und ist vor allem in Madagaskar und Ostafrika, aber auch in vielen anderen Ländern beheimatet, wie z. B. in Indien und in den USA. Affenpocken haben in entlegenen Regionen des Kongobeckens zu Ausbrüchen geführt, die sich in Zukunft aufgrund der nicht mehr durchgeführten Pockenimpfung häufen könnten. Das 2002/2003 neu aufgetretene Severe Acute Respiratory Syndrome (SARS) ist eine weitere Erkrankung mit hohem epidemischen Potenzial. Typisch für diese hochkontagiösen Erreger ist, dass sie meist unerkannt zwischen Reservoirtieren abseits des Menschen zirkulieren. Durch sporadischen Kontakt zwischen infizierten Tieren und dem Menschen können diese übertragen werden. Die dann folgende Mensch-zu-Mensch-Übertragung kann zu ausgedehnten Epidemien, wie dem derzeitigen Ausbruch des Ebolafiebers in Westafrika, führen.

Influenza A and Parvovirus B19 Seropositivity Rates in Gabonese Infants

Clinical and epidemiological data from Central Africa on influenza A and parvovirus B19 infections are limited. We analyzed 162 blood samples of infants 3, 9, 15, and 30 months of age for IgG antibodies against both pathogens. Antibody responses were 0, 3.7%, 12.3%, and 20.4% against influenza A; and 1.2%, 2.5%, 3.1%, and 9.3% against parvovirus B19, respectively. Seropositivity rates were 89.5 (95% confidence interval [CI]: 59-120.1) and 38.2 (95% CI: 18.9-57.6)/1,000 person-years at risk for influenza A and parvovirus B19, respectively. Our data add to the understanding of the epidemiology of both conditions.

Molecular epidemiology and seroprevalence in asymptomatic Plasmodium falciparum infections of Malagasy pregnant women in the highlands

Background

Malaria epidemiology in Madagascar is classified into four different areas, ranging from unstable seasonal transmission in the highlands to hyperendemic perennial transmission areas in the costal level. Most malaria studies in Madagascar are focused on symptomatic children. However, because of the low transmission in some areas with correspondingly low level of semi-immunity, adults are also at risk, in particular pregnant women. The objective of this study was to gain information on the genetic epidemiology of malarial infections in pregnant women in order to provide information for malaria control and elimination programmes in Madagascar.

Methods

Between May and August 2010, we carried out cross-sectional surveys targeting healthy pregnant women in six locations, three in the coastal area and three in the highlands at 850–1300 m. 1244 blood samples were screened for anti-Plasmodium falciparum antibodies by immunofluorescence test and for malarial infection by realtime-PCR. The prevalence of chloroquine and sulphadoxine-pyrimethamine resistance markers was also determined in all Plasmodium falciparum samples by PCR-RFLP as well as the multiplicity of infection through genotyping six neutral microsatellites.

Results

In the highlands, 67.4% of the women presented antibodies against Plasmodium falciparum and 9.2% were carrying parasites, at the coast 95.6% and 14.8%, respectively. In the mean, 1.2 clones were detected in infected pregnant woman in the highlands and 1.5 at the coast. A higher level of monoclonal infections was found in the highlands (85.4%) compared to the coast (61.8%). Resistance markers for sulphadoxine-pyrimethamine were present only in two sites.

Conclusion

Immunity is triggered in Malagasy highland populations when they are infected with malaria parasites, but these populations could also serve as a reservoir for epidemics.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0704-5) contains supplementary material, which is available to authorized users.

PCR for enteric pathogens in high-prevalence settings. What does a positive signal tell us?

BACKGROUND

Molecular methods, in particular PCR, are increasingly used for the diagnosis of enteric pathogens in stool samples. In high-endemicity settings, however, asymptomatic carriage or residual DNA from previous infections will hamper the interpretation of positive test results. We assessed the quantitative dimension of this problem in schoolchildren in the rural highlands of Madagascar.

METHODS

Stool samples were collected from 410 apparently healthy Madagascan schoolchildren and analysed by multiplex real-time PCR for enteroinvasive bacteria (Salmonella spp., Shigella spp./enteroinvasive Escherichia coli (EIEC), Campylobacter jejuni, Yersinia spp.), enteric protozoa (Entamoebea histolytica, Giardia duodenalis, Cryptosporidium spp., Cyclospora spp.), and helminths (Ascaris lumbricoides, Ancylostoma spp., Necator americanus, Strongyloides stercoralis). Symptoms of gastrointestinal disease were assessed.

RESULTS

Among the 410 samples, we detected Giardia duodenalis in 195, Campylobacter jejuni in 91, Ascaris lumbricoides in 72, Cyclospora cayetanenesis in 68, Shigella spp./EIEC in 56, and Strongyloides stercoralis and Cryptosporum spp. in 1 case each. Salmonella spp., Yersinia spp. and hookworms were not observed. Relative risk assessment suggested few and incoherent associations with pathogen detections, indicating asymptomatic carriage or DNA residuals. Only 26.1% of the schoolchildren were tested negative for all analysed pathogens.

CONCLUSIONS

The very high risk of detecting traces of asymptomatic carriage or residual DNA from previous infections limits the value of highly sensitive PCR for the causal attribution of detected enteric pathogens from stool samples to an infectious gastrointestinal disease in the high-endemicity setting. Evaluated standards for the interpretation of such results are needed both for the diagnostic routine and for epidemiological assessments.

Schistosoma mansoni in schoolchildren in a Madagascan highland school assessed by PCR and sedimentation microscopy and Bayesian estimation of sensitivities and specificities

Madagascar is an endemic area for schistosomiasis, but recent prevalence data are scarce. We investigated stool samples of 410 children aged 4-18 years from a combined primary and secondary school in a Madagascan highland village near Ambositra in order to assess the prevalence of Schistosoma mansoni using microscopy and real-time polymerase chain reaction (PCR). A high prevalence of S. mansoni of 77.1% was detected by PCR, while only 15.2% of microscopic examinations of sedimentation-enriched stools were positive. We estimated the sensitivity and specificity of stool sedimentation microscopy (19.7% and 98.8%) and of PCR (98.9% and 89.3%) using a Bayesian approach for two dependant tests in one population without a reference standard. Our Bayesian posterior estimate of the prevalence is 80.2%. Simple sedimentation technique misses about 4/5 of all PCR-confirmed infections and is insufficient to determine the prevalence of S. mansoni. A survey comparing PCR with a classical standard technique (KatoKatz) is desirable.

Difficulties in species identification within the genus Haemophilus - A pilot study addressing a significant problem for routine diagnostics

Diagnostic misidentifications of commensalic Haemophilus haemolyticus as pathogenic Haemophilus influenzae are frequent. This pilot study evaluates whether isolations of H. haemolyticus are frequent enough in Germany to cause a relevant diagnostic problem, considering the fact that even H. influenzae is a mere colonizer in about 30% of isolations. In microbiological laboratories of two hospitals located in Northern and Southern Germany, the distribution of Haemophilus spp. was analyzed during a six-month-period. Site of infection, sex, and age of the patients was taken into consideration. A total of 77 Haemophilus spp. isolates was acquired and discriminated on species level, comprising: 48 H. influenzae, 25 Haemophilus parainfluenzae, 3 H. haemolyticus, and 1 Haemophilus parahaemolyticus. The proportion of H. haemolyticus was calculated to range between 1.2% and 16.2 % within the 95% confidence limits. Commensalic Haemophilus spp. were isolated from oropharynx-associated sites only. H. influenzae, in contrast, was detected in clinically relevant materials like lower respiratory materials and conjunctiva swabs. Altogether, there was a low proportion of clinical H. haemolyticus isolates. Accordingly, the problem of unnecessary antibiotic therapies due to misidentifications of H. haemolyticus as H. influenzae is quantitatively negligible compared with the risk of confusing H. influenzae colonizations with infections.

Is rapid hepatitis C virus testing from corpses a screening option for index persons who have died after mass-casualty incidents in high-prevalence settings in the field?

INTRODUCTION

We tested a commercially available rapid hepatitis C virus (HCV) test assay for its potential use for analyses of corpses as a screening option for index persons who have died after mass-casualty incidents in high-prevalence settings in the field.

MATERIALS AND METHODS

50 blood samples were drawn from 16 recently deceased confirmed HCV-positive patients whose corpses were stored at 4°C in the mortuary and were analysed at admission and up to 48 h post mortem by rapid serological testing using the ImmunoFlow HCV test (Core Diagnostics, Birmingham, UK) in comparison with automated serological assays and PCR. Samples from 50 HCV-negative corpses were also analysed.

RESULTS

The blood of only four of the 16 HCV-positive corpses reacted clearly with the ImmunoFlow HCV test, while in five cases the result was only weakly reactive and three cases showed very weak reactivity. Four of the infected corpses showed initially negative results, three of which became very weakly reactive 48 h post mortem. 49 out of 50 samples (98%) from HCV-negative corpses tested negative.

DISCUSSION

The rapid test system we investigated showed insufficient sensitivity regarding the identification of HCV positivity. Automated serological testing or PCR should be preferred if it is realistically available in the deployed military setting.

Fluorescence in situ hybridization (FISH) for rapid identification of Salmonella spp. from agar and blood culture broth--an option for the tropics?

BACKGROUND

Salmonella enterica is an important cause of diarrhea with the potential to cause systemic infection including sepsis, particularly in the tropics. Sepsis in particular requires quick and reliable identification to allow a rapid optimization of antibiotic therapy. We describe the establishment and evaluation of fluorescence in situ hybridization (FISH) as a rapid and easy-to-perform molecular identification procedure from agar and blood culture broths.

METHODS

Two newly developed FISH probes with specificity for Salmonella spp. were evaluated with 10 reference strains, 448 clinical isolates of Gram-negative bacteria from Germany and Ghana including 316 Salmonella spp. strains, and 39 environmental Salmonella spp. isolates from rivers and streams in Ghana. One FISH probe was further tested with 207 pre-incubated blood culture broths from Germany with Gram-negative rod-shaped bacteria in Gram stain.

RESULTS

Evaluation of the newly designed FISH probes demonstrated sensitivity of 99.2% and specificity of 98.4% for clinical isolates, sensitivity of 97.4% for environmental Salmonella spp. isolates, and sensitivity of 100% and specificity of 99.5% for blood culture materials.

CONCLUSIONS

FISH proved to be highly reliable for a rapid identification of Salmonella spp. directly from pre-incubated blood culture broths as well as after growth on agar. The inexpensive and easy-to-perform procedure is particularly suitable for resource-limited areas where more sophisticated procedures are not available.

Seroprevalence of antibodies against Chikungunya, Dengue, and Rift Valley fever viruses after febrile illness outbreak, Madagascar

In October 2009, two-3 months after an outbreak of a febrile disease with joint pain on the eastern coast of Madagascar, we assessed serologic markers for chikungunya virus (CHIKV), dengue virus (DENV), and Rift Valley fever virus (RVFV) in 1,244 pregnant women at 6 locations. In 2 eastern coast towns, IgG seroprevalence against CHIKV was 45% and 23%; IgM seroprevalence was 28% and 5%. IgG seroprevalence against DENV was 17% and 11%. No anti-DENV IgM was detected. At 4 locations, 450-1,300 m high, IgG seroprevalence against CHIKV was 0%-3%, suggesting CHIKV had not spread to higher inland-altitudes. Four women had IgG against RVFV, probably antibodies from a 2008 epidemic. Most (78%) women from coastal locations with CHIKV-specific IgG reported joint pain and stiffness; 21% reported no symptoms. CHIKV infection was significantly associated with high bodyweight. The outbreak was an isolated CHIKV epidemic without relevant DENV co-transmission.

Food and drinking water hygiene and intestinal protozoa in deployed German soldiers

This report analyzes the occurrence of Cryptosporidium spp., E. histolytica, and G. intestinalis in stool of returnees from military deployments and the impact of hygiene precautions. Between 2007 and 2010, stool samples of 830 returnees that were obtained 8-12 weeks after military deployments in Afghanistan, Uzbekistan, the Balkans, Democratic Republic of the Congo/Gabonese Republic, and Sudan and 292 control samples from non-deployed soldiers were analyzed by PCR for Cryptosporidium spp., E. histolytica, G. intestinalis, and the commensal indicator of fecal contamination E. dispar. Data on hygiene precautions were available. The soldiers were questioned regarding gastrointestinal and general symptoms. Among 1122 stool samples, 18 were positive for G. intestinalis, 10 for E. dispar, and no-one for Cryptosporidium spp. and E. histolytica. An increased risk of acquiring chronic parasitic infections in comparison with non-deployed controls was demonstrated only for G. intestinalis in Sudan, where standardized food and drinking water hygiene precautions could not be implemented. Standard food and drinking water hygiene precautions in the context of screened military field camps proved to be highly reliable in preventing food-borne and water-borne chronic infections and colonization by intestinal protozoa, leading to detection proportions similar to those in non-deployed controls.

Compliance with antimalarial chemoprophylaxis in German soldiers: a 6-year survey

PURPOSE

Since 1992, German soldiers have been deployed in areas where malaria is endemic. Antimalarial chemoprophylaxis (CP) is directed according to the assessed risk and is provided free of charge. Compliance is crucial if its effect is to be reliable. This study analysed compliance with directed CP in German soldiers as well as its determinants.

METHODS

Between 2003 and 2009, standardized questionnaire-based interviews were performed with 2,149 out of approximately 100,000 German soldiers who were deployed during this period in areas where malaria is endemic. The questionnaires dealt with information that the soldiers had received about malaria prior to their missions, with their adherence to mosquito-protective and antimalarial chemoprophylactic procedures, and their estimations of their individual level of exposure.

RESULTS

About 1,308 out of 2,149 interviewed soldiers had been ordered to take CP, allowing for an assessment of the outcome parameter "CP-compliance". About 76.9 % out of 1,308 soldiers to whom regular CP was directed took it regularly. The exposure variables "age", "satisfaction with malaria counselling", "perceived threat due to insects or mosquitoes" and "use of insect repellents" were positively associated with compliance with directed antimalarial CP.

CONCLUSIONS

The study confirms the findings of the French and US armies that even free-of-charge access to antimalarial medication will not lead to 100 % acceptance. The compliance problem is aggravated by the generally low age of deployed soldiers. Adequate counselling is crucial to increase adherence to antimalarial CP.

Extrapolating respiratory tract infection incidences to a rural area of Ghana using a probability model for hospital attendance

OBJECTIVE

The aim of the current study was to extrapolate incidences for respiratory tract infections (RTI) using referral data from a local hospital in Ghana weighted by the individual likelihood of a hospital visit.

METHODS

Diagnoses from children visiting a rural hospital in Ghana during August 2007 to September 2008 were recorded. A logistic regression model, based on a population study conducted within the hospital catchment area, was used to calculate the individual probability of clinic attendance and to extrapolate the number of recorded cases. Cumulative incidences for children living in the hospital catchment area were estimated.

RESULTS

Upper RTI was the most common respiratory diagnosis, with an extrapolated incidence of 17481 cases per 100000 per year, followed by pneumonia with an incidence of 2496 per 100 000 per year. All diseases analyzed were most common in the first year of life.

CONCLUSIONS

In general the study results are in line with comparable studies. Several methodological issues biasing the results in different directions were identified. For example, opportunistic infections that are more often observed in hospital attendees are likely to be overestimated. However, the applied approach presents a tool for areas where disease monitoring systems are not established.

ABO blood group and the risk of placental malaria in sub-Saharan Africa

BACKGROUND

In malarious areas of the world, a higher proportion of the population has blood group O than in non-malarious areas. This is probably due to a survival advantage conferred either by an attenuating effect on the course of or reduction in the risk of infection by plasmodial parasites. Here, the association between ABO blood group and incidence of placental malaria was assessed in order to determine the possible influence of the former on the latter.

METHODS

Data from a study in Lambaréné, Gabon, and data from three previously published reports of studies in The Gambia, Malawi and Sudan, were compiled and compared. ABO blood groups were cross-tabulated with placental malaria stratified by parity. Odds ratios (OR), stratified by parity, were calculated for the outcome, placental parasitaemia, and compared between blood group O vs. non-O mothers in all four studies. Random effects meta-analysis of data from individual studies from areas with perennial hyper/holoendemic transmission was performed.

RESULTS

In Gabon, the odds ratio (OR) for active placental parasitaemia in mothers with group O was 0.3 (95% CI 0.05-1.8) for primiparae and 0.7 (95% CI 0.3-1.8) for multiparae. The OR for primiparae in the published study from The Gambia was 3.0 (95% CI 1.2-7.3) and, in Malawi, 2.2 (95% CI 1.1-4.3). In the Sudanese study, no OR for primiparae could be calculated. The OR for placental parasitaemia in group O multiparae was 0.8 (95% CI 0.3-1.7) in the Gambia, 0.6 (95% CI 0.4-1.0) in Malawi and 0.4 (95% CI 0.1-1.8) in Sudan. Combining data from the three studies conducted in hyper-/holo-endemic settings (Gambia, Malawi, Gabon) the OR for placental malaria in blood group O multiparae was 0.65 (95% CI 0.44-0.96) and for primiparae 1.70 (95% CI 0.67-4.33).

CONCLUSION

Studies conducted in The Gambia and Malawi suggest that blood group O confers a higher risk of active placental infection in primiparae, but a significantly lower risk in multiparae. These findings were not confirmed by the study from Gabon, in which statistically non-significant trends for reduced risk of placental parasitaemia in those with blood group O, regardless of parity, were observed.

Systemic bacteraemia in children presenting with clinical pneumonia and the impact of non-typhoid salmonella (NTS)

Background

The diagnosis and antimicrobial treatment of pneumonia in African children in the absence of diagnostic means such as x-ray facilities or microbiological laboratories relies primarily on clinical symptoms presented by the patients. In order to assess the spectrum of bacterial pathogens, blood cultures were performed in children fulfilling the clinical criteria of pneumonia.

Methods

In total, 1032 blood cultures were taken from children between 2 months and 5 years of age who were admitted to a rural hospital in Ghana between September 2007 and July 2009. Pneumonia was diagnosed clinically and according to WHO criteria classified as "non-severe pneumonia" and "severe pneumonia" ("severe pneumonia" includes the WHO categories "severe pneumonia" and "very severe pneumonia").

Results

The proportion of bacteriaemia with non-typhoid salmonella (NTS) was similar in children with pneumonia (16/173, 9.2%) compared to children hospitalized for other reasons (112/859, 13%). NTS were the predominant organisms isolated from children with clinical pneumonia and significantly more frequent than Streptococcus pneumoniae (8/173, 4.6%). Nine percent (9/101) of children presenting with severe pneumonia and 10% (7/72) of children with non-severe pneumonia were infected with NTS. Nineteen out of 123 NTS isolates (15%) were susceptible to aminopenicillins (amoxycillin/ampicillin), 23/127 (18%) to chlorampenicol, and 23/98 (23%) to co-trimoxazole. All NTS isolates were sensitive to ceftriaxone and ciprofloxacin.

Conclusion

In Sub-saharan Africa, sepsis with NTS should be considered in children with symptoms of pneumonia and aminopenicillins might often not be the adequate drugs for treatment.

No rebound of morbidity following intermittent preventive sulfadoxine-pyrimethamine treatment of malaria in infants in Gabon

In the context of a trial studying intermittent preventive sulfadoxine-pyrimethamine treatment of malaria in infants in Lambaréné, Gabon, children aged 18-30 months were followed up after having received their last dose at an age of 15 months. In the intention-to-treat population, the protective efficacy against all malaria episodes was -18.0 (95% confidence interval, -97.4 to 29.5; P = .529). The protective efficacy against first or only anemia episode was -45.3 (95% confidence interval, -234.5 to 36.3; P=.375). The protective efficacies were negative and were not statistically significant. These results do not appear to support the concept of a rebound effect after intermittent preventive sulfadoxine-pyrimethamine treatment of malaria in infants. Clinical trials registration. NCT00167843.

National health insurance coverage and socio-economic status in a rural district of Ghana

OBJECTIVE

To explore the association between socio-economic status (SES) and health insurance subscription to the Ghanaian National Health Insurance Scheme (NHIS) of residents of the Asante Akim North district of the Ashanti Region, Ghana.

METHODS

In the course of a community survey, data on asset variables (e.g. electricity, housing conditions and other variables) and on NHIS subscription were collected on the household level in 99 villages. Using principal components analysis, households were classified into three categories of SES (20% high, 40% middle and 40% low SES). Odds ratios of NHIS subscription were calculated for all SES categories, using the low category as the reference group and adjusting for travelling time to health facilities by public transport.

RESULTS

Of the 7223 households surveyed, 38% subscribed to the NHIS, of these 21% were low, 43% middle and 60% high SES households. SES was significantly associated with NHIS subscription (high SES: OR 4.9, 95% CI 4.3-5.7; middle SES: OR 2.5, 95% CI 2.2-2.9; low SES: OR 1, reference group).

CONCLUSION

Four years after its introduction, the NHIS has reached subscription rates of 38% in the district surveyed. However, to achieve the aim of assuring universal access to health care facilities for all residents of Ghana, in particular for individuals living under socio-economic constraints, increasing subscription rates are necessary.

Reasons for non-adherence to vaccination at mother and child care clinics (MCCs) in Lambaréné, Gabon

The aim of this paper is to explore attitudes of mothers towards childhood vaccinations and reasons for non-attendance and non-adherence to mother-child clinics (MCCs). Forty in-depth interviews with mothers of children under 5 years of age revealed positive attitudes towards vaccination that seem at odds with the region's observed low vaccination coverage. Important reasons for MCC non-attendance included distance to the MCC, transport costs, negative experiences at MCCs (such as interactions with unfriendly staff) and mothers' feeling of shame provoked by different, often poverty-associated reasons such as attending the clinic with a dirty or poorly clothed child.

Placental malaria increases malaria risk in the first 30 months of life

BACKGROUND

Plasmodium falciparum infection during pregnancy is associated with stillbirth, fetal growth restriction, and low birth weight. An additional consequence may be increased risk of malaria in early life, although the epidemiological evidence of this consequence is limited.

METHODS

A cohort of 527 children were observed actively every month for 30 months after delivery. Offspring of mothers with microscopically detectable placental P. falciparum infection at the time of delivery were defined as exposed. The outcome measure was malaria (parasitemia and fever). Analyses were performed using Cox proportional hazard models and were stratified by gravidity.

RESULTS

Overall, offspring of mothers with placental P. falciparum infection had a significantly higher risk of clinical malaria during the first 30 months of life (adjusted hazard ratio, 2.1; 95% confidence interval [CI], 1.2-3.7). The adjusted hazard ratio for offspring of multigravidae was 2.6 (95% CI, 1.3-5.3), and that for primigravidae was 1.5 (95% CI, 0.6-3.8). The offspring of placenta-infected primigravidae had no episodes of malaria during the first year of life.

CONCLUSIONS

Our findings show that active placental P. falciparum infection detected at delivery is associated with an approximately 2-fold greater risk of malaria during early life, compared with noninfection. The fact that persons born to infected multigravidae rather than primigravidae appear to be at greater risk emphasizes the importance of preventing malaria in mothers of all gravidities.

Therapeutic and prophylactic effect of intermittent preventive anti-malarial treatment in infants (IPTi) from Ghana and Gabon

Background

Intermittent preventive treatment in infants (IPTi) with sulphadoxine-pyrimethamine (SP) reduces the incidence of malaria episodes in young children. The exact mechanism by which the protective effect is mediated needs to be defined. This study aimed to investigate therapeutic, prophylactic, and possible exceeding effects of SP-based IPTi in two clinical trials.

Methods

Protective efficacies from two IPTi trials performed in Kumasi, Ghana, and Lambaréné, Gabon, were assessed for overlapping time series of 61 days. For six-months periods after each of three IPTi doses a multivariate Poisson regression model with the respective cohort as co-variate was generated and effect modification of protective efficacy with time strata was evaluated by log-likelihood tests.

Results

Protective efficacies were not significantly different between the two study cohorts. Study-cohort corrected protective efficacy was highest for the first 61 days after each IPTi application and decreased continuously. For the first 61 days after IPTi-1, IPTi-2, and IPTi-3 the protective efficacy was 71%, 44%, and 43%, respectively. A reduction of the malaria incidence rate was detectable for the first 60, 30 and 40 days after IPTi-1, IPTi-2 and IPTi-3 drug application, respectively. After IPTi-3 a higher risk for malaria could be seen after day 60. This effect was mainly based on the overwhelming influence of the Kumasi cohort.

Conclusion

The results suggest that SP-based IPTi mainly works through a therapeutic and prophylactic effect over 30 to 60 days after drug application and that a sustained effect beyond post-treatment prophylaxis might be very low.

Trial registration

Data analysis from clinical trials NCT ID # 00206739 (Kumasi Trial) and NCT ID # 00167843 (Lambaréné Trial), .

A food-borne outbreak of hepatitis A virus (HAV) infection in a secondary school in Upper Normandy, France, in November 2006

In November 2006, six symptomatic cases of hepatitis A in pupils of a secondary school in Upper Normandy, France, were reported to the district health service. This paper describes the outbreak investigation undertaken with the aim to identify the vehicle and source of infection, implement control measures and estimate the size of the outbreak. A primary case at the secondary school was defined as a pupil or a member of the staff with IgM anti-HAV detected in the serum and with onset of symptoms between 12 and 21 November 2006; a secondary case was defined as a contact to a primary case and who developed symptoms and had IgM anti-HAV two to seven weeks later. We performed a case control study of primary cases, controls being pupils visiting the same school (cases/controls 1:4) and inspected the canteen facilities. All 13 canteen employees were examined for anti-HAV IgM antibodies. A phylogenetic analysis of HAV of cases was performed. We identified 10 primary and 5 secondary cases. Among primary cases 90% reported eating liver pate at the canteen compared to 62% among controls (OR 5.5, 95% CI 0.62-256.9).One liver pate sample contained markers of faecal contamination. HAV genotypes were of one identical type. All 13 canteen employees were negative for IgM anti-HAV while four had anti-HAV total antibodies. We found deficiencies regarding food preparing procedures and insufficient hand washing facilities. The vehicle of the outbreak was believed to be the liver pate but the source of HAV could not be identified. Insufficient facilities in the canteen hindered staff from maintaining a high hygiene standard and were subsequently improved.

A food-borne outbreak of hepatitis A virus (HAV) infection in a secondary school in Upper Normandy, France, in November 2006

In November 2006, six symptomatic cases of hepatitis A in pupils of a secondary school in Upper Normandy, France, were reported to the district health service. This paper describes the outbreak investigation undertaken with the aim to identify the vehicle and source of infection, implement control measures and estimate the size of the outbreak. A primary case at the secondary school was defined as a pupil or a member of the staff with IgM anti-HAV detected in the serum and with onset of symptoms between 12 and 21 November 2006; a secondary case was defined as a contact to a primary case and who developed symptoms and had IgM anti-HAV two to seven weeks later. We performed a case control study of primary cases, controls being pupils visiting the same school (cases/controls 1:4) and inspected the canteen facilities. All 13 canteen employees were examined for anti-HAV IgM antibodies. A phylogenetic analysis of HAV of cases was performed. We identified 10 primary and 5 secondary cases. Among primary cases 90% reported eating liver pate at the canteen compared to 62% among controls (OR 5.5, 95% CI 0.62-256.9). One liver pate sample contained markers of faecal contamination. HAV genotypes were of one identical type. All 13 canteen employees were negative for IgM anti-HAV while four had anti-HAV total antibodies. We found deficiencies regarding food preparing procedures and insufficient hand washing facilities. The vehicle of the outbreak was believed to be the liver pate but the source of HAV could not be identified. Insufficient facilities in the canteen hindered staff from maintaining a high hygiene standard and were subsequently improved.

Socio-economic status is inversely related to bed net use in Gabon

BACKGROUND

Insecticide-treated bed nets (ITNs) range among the most effective measures of malaria prophylaxis, yet their implementation level in sub-Saharan Africa is still low. The goal of this study was to investigate the influence of socio-economic factors on the use of bed nets by mothers in Gabon.

METHODS

A cross-sectional study was conducted completing pre-tested, interviewer-administered questionnaires exploring socioeconomic proxy measures with 397 mothers or guardians of young children. Respondents were grouped according to their socio-economic situation, using scores. The condition of the bed nets was evaluated during a home visit.

RESULTS

Socio-economic factors of wellbeing were negatively associated with bed net use, such as living in a stone house (OR 0.26, 95% CI 0.14-0.48), running water in the house (OR 0.44, 95% CI 0.21-0.92), shower/flush toilet in the house (OR 0.39/0.34, 95% CI 0.21-0.75/0.16-0.73), ownership of a freezer (OR 0.50, 95% CI 0.26-0.96) and belonging to the highest group in the economic score (OR 0.32, 95% CI 0.15-0.67). In contrast, similar factors were positively associated with a good maintenance condition of the bed nets: higher monthly income (OR 5.64, 95% CI 2.41-13.19) and belonging to the highest group in the economic score (OR 2.55, 95% CI 1.19 - 5.45).

CONCLUSION

Among the poorest families in Lambaréné the coverage with untreated nets (UTNs) is the highest, but the condition of these UTNs is the worst. To achieve a broad implementation of ITNs in Lambaréné, there is an urgent need for educational programmes as well as need-tailored marketing strategies for ITNs.

Mumps outbreak ongoing since October 2007 in the Republic of Moldova

The Republic of Moldova is experiencing a nationwide mumps outbreak, with a total of 19,550 notified cases as of 23 March 2008. The outbreak started in October 2007, with 105 cases notified in that month compared to an average number of 24 cases per month notified between January and September 2007. Between 1 October and 31 December 2007, 1,524 cases were notified.

Intermittent preventive treatment against malaria in infants in Gabon--a randomized, double-blind, placebo-controlled trial

BACKGROUND

Intermittent preventive treatment aims to maximize the protective effects of malaria chemoprophylaxis while minimizing the deleterious effects.

METHODS

In Gabon, 1189 infants received either sulfadoxine-pyrimethamine (SP; 250 and 12.5 mg, respectively) or placebo at 3, 9, and 15 months of age. Children were actively followed-up until 18 months of age.

RESULTS

In the intention-to-treat population at 18 months of follow-up, 84 children (17%) in the SP group had > or =1 episode of anemia, versus 108 (21%) in the placebo group (protective efficacy, 22% [95% confidence interval {CI}, -1% to 40%]; P=.06). In the intervention group, there were 66 episodes during 485 person-years at risk, compared with 79 episodes during 497 years in the placebo group (protective efficacy, 17% [95% CI, -24% to 45%; P=.36). The effects were similar at 12 months of follow-up. The study drug was safe and well tolerated.

CONCLUSIONS

The intervention was efficacious, producing a reduction in risk for anemia but a smaller effect against malaria. It is a valuable additional tool to control malaria in a highly vulnerable age group. Remaining important questions are currently being addressed in further studies.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00167843.

5-day nonobserved artesunate monotherapy for treating uncomplicated Falciparum malaria in young Gabonese children

Despite different recommendations from WHO and national authorities, artesunate monotherapy is increasingly used for treating African children with malaria. A 5-day course of oral artesunate (first day: 4 mg/kg body weight, observed intake; and 2 mg/kg body weight on the following days with nonobserved drug intake) yielded a PCR-corrected Day 28 cure rate of 90% (45 of 50 patients; CI 78-97%) in Gabonese children aged between 2 and 18 months. Artesunate was well tolerated, and no severe adverse events were reported.

Effectiveness of quinine monotherapy for the treatment of Plasmodium falciparum infection in pregnant women in Lambaréné, Gabon

Pregnant women participating in a longitudinal immuno-epidemiologic survey in Lambaréné, Gabon, and presenting with Plasmodium falciparum parasitemia at monthly blood smear examinations were offered treatment with oral 7-day quinine monotherapy according to national health guidelines. A total of 50 pregnant women were offered 7-day oral quinine sulfate 10 mg/kg thrice daily. Clinical examinations and laboratory tests were performed on Days 28 and 56 to assess the effectiveness of this standard regimen. By Day 28, the effectiveness of the 7-day quinine regimen was 60% (95% confidence interval: 46-72%). We conclude that a 7-day course of quinine has a poor effectiveness and that alternative treatment regimens for malaria in pregnant women should be assessed.

Malaria and asymptomatic parasitaemia in Gabonese infants under the age of 3 months

We determined the incidence of both malaria and asymptomatic parasitaemia in infants under the age of 3 months within the framework of a longitudinal cohort study in Lambaréné, Gabon, between December 2002 and July 2004. Of 878 infants who were included at birth, we identified malaria in three infants and, additionally, asymptomatic parasitaemia in six infants. The malaria incidence density was 1.1/1000 person-months or 0.1% of observations. Our findings underpin the notion that the incidence of malaria and parasitaemia in infants below the age of 3 months is very low.

Shared breastfeeding in central Africa

In this study, shared breastfeeding is described asa novel risk factor for vertical HIV transmission. This cross-sectional survey conducted in the central African country Gabon found that 40% of lactating mothers also breastfed other children than their own, and as many children were additionally breastfed by other women. Shared breastfeeding is increasing the exposure to potentially infectious individuals and has therefore to be considered in breastfeeding recommendations.