Last data update: May 06, 2024. (Total: 46732 publications since 2009)
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A model for accelerating access to care and treatment for children and adolescents living with HIV in Nigeria, Tanzania, Uganda, and Zambia: The Faith-Based Action for Scaling-Up Testing and Treatment for the Epidemic Response (FASTER) Initiative
Oliver D , Mabirizi D , Hast M , Alwano MG , Chungu C , Kelemani A , Mbanefo C , Gross J , Parris K , Dowling S , Clark A , Williams A , Simao L , Amole C , Suggu K , Kama J , Mpasela F , Mtui L , Nabitaka V , Saunders R , Williamson D , Rivadeneira ED , Hrapcak S , Nantume S , Nazziwa E , Itoh M , Machage E , Onyenuobi C , Munthali G , Rwebembera A , Mwiya M , Katureebe C , Ikpeazu A , Fenn T . J Int Assoc Provid AIDS Care 2023 22 23259582231186701 The number of children newly infected with HIV dropped by 50%, from 320 000 in 2010 to 160 000 in 2021. Despite progress, ongoing gaps persist in diagnosis, continuity of care, and treatment optimization. In response, the United States President's Emergency Plan for AIDS Relief created the Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response (FASTER). Faith-based Action for Scaling-Up Testing and Treatment for Epidemic Response addressed gaps in countries with the highest unmet need by working with government to operationalize innovative interventions and ensure alignment with national priorities and with communities living with HIV to ensure the change was community-led. Between 2019 and 2021, FASTER's interventions were incorporated into national policies, absorbed by Ministries of Health, and taken up in subsequent awards and country operating plans. Continued effort is needed to sustain gains made during the FASTER initiative and to continue scaling evidence-based interventions to ensure that children and adolescents are not left behind in the global HIV response. |
Hypertension among persons living with HIV - Zambia, 2021; A cross-sectional study of a national electronic health record system (preprint)
Hines JZ , Prieto JT , Itoh M , Fwoloshi S , Zyambo KD , Zachary D , Chitambala C , Minchella PA , Mulenga LB , Agolory S . medRxiv 2023 16 Background Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. Methods We did a cross-sectional study of hypertension prevalence among PLHIV aged >=18 years in Zambia during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with >=2 recorded blood pressure (BP) readings in 2021 were included. Hypertension was defined as >=2 elevated BP readings (i.e., systolic BP of >=140 mmHg or diastolic BP of >=90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR in the past five years. Multivariable logistic regression was used to assess associations between hypertension and independent variables. Results Among 750,098 PLHIV aged >=18 years with >=2 visits in SmartCare during 2021, 101,363 (13.5%) had >=2 blood pressure readings recorded in their EHR. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension during 2021. Only 8.9% of PLHIV with hypertension had an antihypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for >=60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and persons prescribed ART for >=6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Discussion Hypertension was common among a cohort of PLHIV in Zambia, with few having documentation of being on antihypertensive treatment. Most PLHIV were excluded from the analysis because of missing BP measurements in their EHR. Strengthening integrated management of non-communicable diseases in ART clinics might help to diagnose and treat hypertension in Zambia. Data completeness needs to be improved to routinely capture cardiovascular disease risk factors, including blood pressure readings consistently for PHLIV in their EHRs. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Hypertension among persons living with HIV-Zambia, 2021; A cross-sectional study of a national electronic health record system
Hines JZ , Prieto JT , Itoh M , Fwoloshi S , Zyambo KD , Sivile S , Mweemba A , Chisemba P , Kakoma E , Zachary D , Chitambala C , Minchella PA , Mulenga LB , Agolory S . PLOS Glob Public Health 2023 3 (7) e0001686 Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. We did a cross-sectional study of hypertension prevalence among PLHIV aged ≥18 years during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with ≥2 clinical visits in 2021 were included. Hypertension was defined as ≥2 elevated blood pressure readings (systolic ≥140 mmHg/diastolic ≥90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR ≤5 years. Logistic regression was used to assess for associations between hypertension and demographic characteristics. Among 750,098 PLHIV aged ≥18 years with ≥2 visits during 2021, 101,363 (13.5%) had ≥2 recorded blood pressure readings. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension. Only 8.9% of PLHIV with hypertension had an anti-hypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for ≥60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and on ART for ≥6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Hypertension was common among PLHIV in Zambia, with few having documentation of treatment. Most PLHIV were excluded from the analysis because of missing BP measurements. Strengthening integrated management of non-communicable diseases in HIV clinics might help to diagnose and treat hypertension in Zambia. Addressing missing data of routine clinical data (like blood pressure) could improve non-communicable diseases surveillance in Zambia. |
HIV viral load scale-up among children and adolescents: Trends in viral load suppression, sample type and processing in 7 PEPFAR countries, 2015-2018
Hrapcak S , Pals S , Itoh M , Peters N , Carpenter D , Hackett S , Prao AK , Adje-Toure C , Eboi E , Mutisya I , Nyabiage Omoto L , Ondondo RO , Bowen N , Nyanya W , Kayira D , Kaba MD , Mwenda R , Deus MI , Almeida J , Cuco RMM , Boylan A , Beard S , Ashikoto S , van Rooyen G , Kindra G , Diallo K , Carmona S , Nazziwa E , Mwangi C , Ntale J , Ssewanyana I , Nabadda SN , Nabukenya M , Ellenberger D , Rivadeneira E . Pediatr Infect Dis J 2023 42 (4) e102-e104 HIV-positive children and adolescents face gaps in viral load (VL) testing. To understand trends in pediatric/adolescent VL testing, 7 countries collected data from Laboratory Information Management Systems. Results showed increasing proportion of VL tests done through dried blood spot (DBS) and decreased sample rejection rates for DBS compared with plasma, supporting use of DBS VL when skilled phlebotomy is unavailable. |
Measuring oral pre-exposure prophylaxis (PrEP) continuation through electronic health records during program scale-up among the general population in Zambia
Heilmann E , Okuku J , Itoh M , Hines JZ , Prieto JT , Phiri M , Watala K , Nsofu C , Luhana-Phiri M , Vlahakis N , Kabongo M , Kaliki B , Minchella PA , Musonda B . AIDS Behav 2022 27 (7) 2390-2396 HIV pre-exposure prophylaxis (PrEP) is being scaled-up in Zambia, but PrEP continuation data are limited by paper-based registers and aggregate reports. Utilization of Zambia's electronic health record (EHR) system, SmartCare, may address this gap. We analyzed individuals aged ≥ 15 years who initiated PrEP between October 2020 and September 2021 in four provinces in Zambia in SmartCare versus aggregate reports. We measured PrEP continuation using Kaplan-Meier survival analysis and Cox proportional hazards models. SmartCare captured 29% (16,791/58,010) of new PrEP clients; 49% of clients continued at one month, and 89% discontinued PrEP by February 2022. Women were less likely than men to discontinue PrEP (adjusted hazard ratio [aHR]: 0.89, 95% CI 0.86-0.92, z = - 6.99, p < 0.001), and PrEP clients aged ≥ 50 years were less likely to discontinue PrEP compared to clients 15-19 years (aHR: 0.53, 95% CI 0.48-0.58, z = - 13.04, p < 0.001). Zambia's EHR is a valuable resource for measuring individual-level PrEP continuation over time and can be used to inform HIV prevention programs. |
Clinical Characteristics and Outcomes of Patients Hospitalized With COVID-19 During the First 4 Waves in Zambia.
Minchella PA , Chanda D , Hines JZ , Fwoloshi S , Itoh M , Kampamba D , Chirwa R , Sivile S , Zyambo KD , Agolory S , Mulenga LB . JAMA Netw Open 2022 5 (12) e2246152 IMPORTANCE: Few epidemiologic studies related to COVID-19 have emerged from countries in Africa, where demographic characteristics, epidemiology, and health system capacity differ from other parts of the world. OBJECTIVES: To describe the characteristics and outcomes of patients admitted to COVID-19 treatment centers, assess risk factors for in-hospital death, and explore how treatment center admissions were affected by COVID-19 waves in Zambia. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed patients admitted to COVID-19 treatment centers in 5 Zambian cities between March 1, 2020, and February 28, 2022. EXPOSURES: Risk factors for in-hospital mortality, including patient age and severity of COVID-19, at treatment center admission. MAIN OUTCOMES AND MEASURES: Patient information was collected, including inpatient disposition (discharged or died). Differences across and within COVID-19 waves were assessed. Mixed-effects logistic regression models were used to assess associations between risk factors and in-hospital mortality as well as between characteristics of admitted patients and timing of admission. RESULTS: A total of 3876 patients were admitted during 4 COVID-19 waves (mean [SD] age, 50.6 [19.5] years; 2103 male [54.3%]). Compared with the first 3 waves (pooled), the proportion of patients who were 60 years or older admitted during wave 4, when the Omicron variant was circulating, was significantly lower (250 of 1009 [24.8%] vs 1116 of 2837 [39.3%]; P<.001). Factors associated with in-hospital mortality included older age (60 vs <30 years; adjusted odds ratio [aOR], 3.55; 95% CI, 2.34-5.52) and HIV infection (aOR, 1.39; 95% CI, 1.07-1.79). Within waves, patients who were admitted during weeks 5 to 9 had significantly higher odds of being 60 years or older (aOR, 2.09; 95% CI, 1.79-2.45) or having severe COVID-19 at admission (aOR, 2.49; 95% CI, 2.14-2.90) than those admitted during the first 4 weeks. CONCLUSIONS AND RELEVANCE: The characteristics of admitted patients during the Omicron wave and risk factors for in-hospital mortality in Zambia reflect data reported elsewhere. Within-wave analyses revealed a pattern in which it appeared that admission of higher-risk patients was prioritized during periods when there were surges in demand for health services during COVID-19 waves. These findings support the need to expand health system capacity and improve health system resiliency in Zambia and other countries with resource-limited health systems. |
COVID-19 Vaccine Effectiveness Against Progression to In-Hospital Mortality in Zambia, 2021-2022.
Chanda D , Hines JZ , Itoh M , Fwoloshi S , Minchella PA , Zyambo KD , Sivile S , Kampamba D , Chirwa B , Chanda R , Mutengo K , Kayembe MF , Chewe W , Chipimo P , Mweemba A , Agolory S , Mulenga LB . Open Forum Infect Dis 2022 9 (9) ofac469 BACKGROUND: Coronavirus disease 2019 (COVID-19) vaccines are highly effective for reducing severe disease and mortality. However, vaccine effectiveness data are limited from Sub-Saharan Africa. We report COVID-19 vaccine effectiveness against progression to in-hospital mortality in Zambia. METHODS: We conducted a retrospective cohort study among admitted patients at 8 COVID-19 treatment centers across Zambia during April 2021 through March 2022, when the Delta and Omicron variants were circulating. Patient demographic and clinical information including vaccination status and hospitalization outcome (discharged or died) were collected. Multivariable logistic regression was used to assess the odds of in-hospital mortality by vaccination status, adjusted for age, sex, number of comorbid conditions, disease severity, hospitalization month, and COVID-19 treatment center. Vaccine effectiveness of 1 vaccine dose was calculated from the adjusted odds ratio. RESULTS: Among 1653 patients with data on their vaccination status and hospitalization outcome, 365 (22.1%) died. Overall, 236 (14.3%) patients had received 1 vaccine dose before hospital admission. Of the patients who had received 1 vaccine dose, 22 (9.3%) died compared with 343 (24.2%) among unvaccinated patients (P < .01). The median time since receipt of a first vaccine dose (interquartile range) was 52.5 (28-107) days. Vaccine effectiveness for progression to in-hospital mortality among hospitalized patients was 64.8% (95% CI, 42.3%-79.4%). CONCLUSIONS: Among patients admitted to COVID-19 treatment centers in Zambia, COVID-19 vaccination was associated with lower progression to in-hospital mortality. These data are consistent with evidence from other countries demonstrating the benefit of COVID-19 vaccination against severe complications. Vaccination is a critical tool for reducing the consequences of COVID-19 in Zambia. |
Testing Can Be Done Anywhere: A qualitative assessment of targeted community-based point-of-care early infant diagnosis of HIV in Lusaka, Zambia
Tembo T , Dale H , Muttau N , Itoh M , Williamson D , Mwamba C , Manasyan A , Beard RS , Cox MH , Herce ME . Glob Health Sci Pract 2022 10 (3) Introduction: Delayed HIV diagnosis in HIV-exposed infants (HEIs) results in missed opportunities for early antiretroviral therapy (ART), causing significant morbidity and mortality. Early infant diagnosis (EID) depends on the availability of accessible and reliable testing services. We explored the acceptability, appropriateness, and feasibility of deploying a targeted community-based point-of-care (POC) EID testing model (i.e., “community POC model”) to reach high-risk mother-infant pairs (MIPs) in Lusaka, Zambia. Methods: We conducted in-depth interviews with a purposive sample of health care workers, study staff, and caregivers in high-risk MIPs at 6 health facilities included in a larger implementation research study evaluating the community POC model. We defined “high-risk MIPs” as mothers who did not receive antenatal testing or an attended delivery or infants who missed EID testing milestones. Interviews were audio-recorded, translated, and transcribed verbatim in English. Content and thematic analysis were done using NVivo 10 software. Results: Health care workers (n=20) and study staff (n=12) who implemented the community POC model noted that the portability and on-screen prompts of the POC platform made it mobile and easy to use, but maintenance and supply chain management were key to field operations. Respondents also felt that the community POC model reached more infants who had never had EID testing, allowing them to find infants with HIV infection and immediately initiate them on ART. Caregivers (n=22) found the community POC model acceptable, provided that privacy could be ensured because the service was convenient and delivered close to home. Conclusion: We demonstrate the acceptability, appropriateness, and feasibility of implementing the community POC model in Zambia, while identifying potential challenges related to client privacy and platform field operations. The community POC model may represent a promising strategy to further facilitate active HIV case finding and linkage to ART for children with undiagnosed HIV infection in the community. © Tembo et al. |
The positive effect of malaria IPTp-SP on birthweight is mediated by gestational weight gain but modifiable by maternal carriage of enteric pathogens
Waltmann A , McQuade ETR , Chinkhumba J , Operario DJ , Mzembe E , Itoh M , Kayange M , Puerto-Meredith SM , Mathanga DP , Juliano JJ , Carroll I , Bartelt LA , Gutman JR , Meshnick SR . EBioMedicine 2022 77 103871 BACKGROUND: Poor pregnancy and birth outcomes are common in sub-Saharan Africa and have complex aetiologies. Sulfadoxine-pyrimethamine (SP), given for intermittent preventive therapy of malaria in pregnancy (IPTp), is one of few existing interventions that improves outcomes of both mother and baby despite widespread SP-resistant malaria. Compelling evidence exists that malaria-independent pathways contribute to this protective effect, but the exact sources of non anti-malarial protection remained unknown. We hypothesized that the beneficial effect of SP on birthweight is mediated by SP activity on maternal factors, including increased gestational weight gain and antibiotic activity on pathogens in the maternal gut. METHODS: Expectant mothers from a larger randomized control trial comparing the efficacy of IPTp-SP to IPTp with dihydroartemisinin-piperaquine (DP) were also enrolled in this sub-study study at their first antenatal care visit before commencement of IPTp (n = 105). Participants were followed monthly until delivery. Weights and mid-to-upper-arm circumferences (MUAC) were recorded. Monthly stool samples were collected and screened for five Escherichia coli pathotypes, Shigella spp., Vibrio cholerae, Salmonella, Campylobacter coli/jejuni, and three protozoa (Giardia spp., Entameba histolytica, and Cryptosporidium spp.) using previously validated molecular assays. FINDINGS: IPTp-SP vs. IPTP-DP was associated with higher maternal gestational weight gain (GWG) and nutritional indicators (MUAC and body-mass index, BMI). GWG was found to be a mediator of the birthweight and IPTp-SP relationship, as the birthweight of SP infants, but not DP infants, varied according to maternal GWG. The burden of maternal enteric infections was high. The three most commonly observed pathogens were enteroaggregative E. coli (EAEC), atypical enteropathogenic E.coli/enterohaemorrhagic E. coli (aEPEC/EHEC), and typical enteropathogenic E.coli (tEPEC). We found that SP reduced the prevalence of EAEC in a dose-dependent manner. After 3 or more doses, SP-recipients were 90% less likely to be infected with EAEC compared to DP-recipients (OR(adj) = 0.07, CI95 = 0.12, 0.39, p = 0.002). Compared to DP, this coincided with higher maternal gestational weight gain (GWG) and nutritional indicators (MUAC and body-mass index, BMI). The beneficial effect of SP on maternal GWG, MUAC and BMI, was lower if SP mothers had detectable EAEC, aEPEC/EHEC, tEPEC, and LT-ETEC at baseline. Maternal EAEC and tEPEC at baseline associated with lower birthweight for babies of both SP mothers and DP mothers. When comparing IPTp regimens, the positive effect of SP on birthweight compared to DP was only observed for infants of women who did not test positive for EAEC at baseline (adjusted mean birthweight difference SP vs. DP = 156.0 g, CI95 = -18.0 g, 336.9 g, p = 0.087), though confidence intervals crossed the null. INTERPRETATION: Our findings indicate that in pregnant Malawian women, IPTp-SP vs. IPTp-DP is consistently associated with higher MUAC, BMI, and GWG following the WHO-recommended regimen of at least 3 doses, but carriage of maternal gut pathogens before initiation of IPTp lessens this effect. Because GWG was a mediator of the association between birthweight and SP, we show that SP's previously proven positive effect on birthweight is by promoting maternal weight gain. Overall, our results present one plausible pathway SP exerts malaria-independent protection against poor birth outcomes in the context of its waning antimalarial activity and warrants further investigation. FUNDING: A full list of funding bodies that contributed to this study can be found in the Acknowledgements section. |
COVID-19 Severity and COVID-19-Associated Deaths Among Hospitalized Patients with HIV Infection - Zambia, March-December 2020.
Chanda D , Minchella PA , Kampamba D , Itoh M , Hines JZ , Fwoloshi S , Boyd MA , Hamusonde K , Chirwa L , Nikoi K , Chirwa R , Siwingwa M , Sivile S , Zyambo KD , Mweemba A , Mbewe N , Mutengo KH , Malama K , Agolory S , Mulenga LB . MMWR Morb Mortal Wkly Rep 2021 70 (22) 807-810 The effect of HIV infection on COVID-19 outcomes is unclear. Studies in South Africa (1) and the United Kingdom (2) found an independent association between HIV infection and COVID-19 mortality; however, other studies have not found an association between poor COVID-19 outcomes and either HIV status among hospitalized patients (3-5) or HIV-associated factors such as CD4 count, viral load, or type of antiretroviral therapy (ART) (6). The effect of HIV infection on COVID-19 outcomes remains an urgent question in sub-Saharan Africa, where many countries are experiencing dual HIV and COVID-19 epidemics, and capacity to treat severe COVID-19 is limited. Using data from patients with probable or confirmed COVID-19 admitted to specialized treatment centers during March-December 2020 in Zambia, the Zambian Ministry of Health and CDC assessed the relationship between HIV infection and severe COVID-19 and COVID-19-associated death. Among 443 patients included in the study, 122 (28%) were HIV-positive, and of these, 91 (89%) were receiving ART at the time of hospitalization. HIV status alone was not significantly associated with severe COVID-19 at admission or during hospitalization or with COVID-19-associated death. However, among HIV-positive persons, those with severe HIV disease were more likely to develop severe COVID-19 and were at increased risk for COVID-19-associated death. Ensuring that persons maintain HIV disease control, including maintaining ART continuity and adherence, achieving viral suppression, and addressing and managing underlying medical conditions, could help reduce COVID-19-associated morbidity and mortality in sub-Saharan Africa. |
Vital Signs: Clinical characteristics of patients with confirmed acute flaccid myelitis, United States, 2018
Kidd S , Lopez A , Nix WA , Anyalechi G , Itoh M , Yee E , Oberste MS , Routh J . MMWR Morb Mortal Wkly Rep 2020 69 (31) 1031-1038 BACKGROUND: Acute flaccid myelitis (AFM) is a serious neurologic syndrome that affects mostly children and is characterized by the acute onset of limb weakness or paralysis. Since U.S. surveillance for AFM began in 2014, reported cases have peaked biennially. This report describes the clinical characteristics of AFM patients during 2018, the most recent peak year. METHODS: Medical records from persons meeting AFM clinical criterion (acute onset of flaccid limb weakness) were submitted to CDC. Patients with confirmed AFM met the clinical criterion and had magnetic resonance imaging indicating spinal cord lesions largely restricted to gray matter and spanning one or more vertebral segments. Symptoms, physical findings, test and imaging results, and hospitalization data were abstracted and described. RESULTS: Among 238 patients with confirmed AFM during 2018, median age was 5.3 years. Among the 238 patients, 205 (86%) had onset during August-November. Most (92%) had prodromal fever, respiratory illness, or both beginning a median of 6 days before weakness onset. In addition to weakness, common symptoms at clinical evaluation were gait difficulty (52%), neck or back pain (47%), fever (35%), and limb pain (34%). Among 211 who were outpatients when weakness began, most (76%) sought medical care within 1 day, and 64% first sought treatment at an emergency department. Overall, 98% of patients were hospitalized, 54% were admitted to an intensive care unit, and 23% required endotracheal intubation and mechanical ventilation. CONCLUSION: Clinicians should suspect AFM in children with acute flaccid limb weakness, especially during August-November and when accompanied by neck or back pain and a recent history of febrile respiratory illness. Increasing awareness in frontline settings such as emergency departments should aid rapid recognition and hospitalization for AFM. |
Beyond early infant diagnosis: Changing the approach to HIV-exposed infants
Modi S , Broyles LN , Montandon M , Itoh M , Ochanda B , Langat A , Sullivan D , Dale H . J Acquir Immune Defic Syndr 2018 78 Suppl 2 S107-s114 Despite dramatic global progress with implementing prevention of mother-to-child HIV transmission (PMTCT) programs, there were 160,000 new pediatric HIV infections in 2016. More than 50% of infant HIV infections now occur in the postpartum period, reflecting the relatively high coverage of interventions in the antenatal period and the need for greater attention to the breastfeeding mother and her HIV-exposed infant (HEI). Early diagnosis and treatment are critical to prevent morbidity and mortality in HIV-infected children; however, early infant HIV testing rates remain low in most high HIV-burden countries. Furthermore, systematic retention and follow-up of HEI in the postpartum period and ascertainment of final HIV status remain major program gaps. Despite multiple calls to action to improve infant HIV testing rates, progress has been marginal due to a lack of focus on the critical health care needs of HEI coupled with health system barriers that result in fragmented services for HIV-infected mothers and their families. In this paper, we describe the available evidence on the health outcomes of HEI, define a comprehensive care package for HEI that extends beyond early HIV testing, and describe successful examples of integrated services for HEI. |
Association and birth prevalence of microcephaly attributable to Zika virus infection among infants in Paraiba, Brazil, in 2015-16: a case-control study
Krow-Lucal ER , de Andrade MR , Cananea JNA , Moore CA , Leite PL , Biggerstaff BJ , Cabral CM , Itoh M , Percio J , Wada MY , Powers AM , Barbosa A , Abath RB , Staples JE , Coelho GE . Lancet Child Adolesc Health 2018 2 (3) 205-213 Background: In 2015, the number of infants born with microcephaly increased in Paraiba, Brazil, after a suspected Zika virus outbreak. We did a retrospective case-control investigation to assess the association of microcephaly and Zika virus. Methods: We enrolled cases reported to the national database for microcephaly and born between Aug 1, 2015, and Feb 1, 2016, on the basis of their birth head circumference and total body length. We identified controls from the national birth registry and matched them to cases by location, aiming to enrol a minimum of two controls per case. Mothers of both cases and controls were asked about demographics, exposures, and illnesses and infants were measured at a follow-up visit 1-7 months after birth. We took blood samples from mothers and infants and classified those containing Zika virus IgM and neutralising antibodies as evidence of recent infection. We calculated prevalence of microcephaly and odds ratios (ORs) using a conditional logistic regression model with maximum penalised conditional likelihood, and combined these ORs with exposure probability estimates to determine the attributable risk. Findings: We enrolled 164 of 706 infants with complete information reported with microcephaly at birth, of whom we classified 91 (55%) as having microcephaly on the basis of their birth measurements, 36 (22%) as small, 21 (13%) as disproportionate, and 16 (10%) as not having microcephaly. 43 (26%) of the 164 infants had microcephaly at follow-up for an estimated prevalence of 5.9 per 1000 livebirths. We enrolled 114 control infants matched to the 43 infants classified as having microcephaly at follow-up. Infants with microcephaly at follow-up were more likely than control infants to be younger (OR 0.5, 95% CI 0.4-0.7), have recent Zika virus infection (21.9, 7.0-109.3), or a mother with Zika-like symptoms in the first trimester (6.2, 2.8-15.4). Once Zika virus infection and infant age were controlled for, we found no significant association between microcephaly and maternal demographics, medications, toxins, or other infections. Based on the presence of Zika virus antibodies in infants, we concluded that 35-87% of microcephaly occurring during the time of our investigation in northeast Brazil was attributable to Zika virus. We estimate 2-5 infants per 1000 livebirths in Paraiba had microcephaly attributable to Zika virus. Interpretation: Time of exposure to Zika virus and evidence of infection in the infants were the only risk factors associated with microcephaly. This investigation has improved understanding of the outbreak of microcephaly in northeast Brazil and highlights the need to obtain multiple measurements after birth to establish if an infant has microcephaly and the need for further research to optimise testing criteria for congenital Zika virus infection. Funding: Centers for Disease Control and Prevention. |
Efficacy of Artemether-Lumefantrine for Uncomplicated Plasmodium falciparum Malaria in Cruzeiro do Sul, Brazil, 2016.
Itoh M , Negreiros do Valle S , Farias S , Holanda de Souza TM , Rachid Viana GM , Lucchi N , Chenet S , Marchesini P , Povoa M , Faria ESilva Santelli AC , Macedo de Oliveira A . Am J Trop Med Hyg 2017 98 (1) 88-94 We evaluated the therapeutic efficacy of artemether-lumefantrine (AL) fixed-dose combination to treat uncomplicated Plasmodium falciparum malaria in Cruzeiro do Sul, Acre State, in the Amazon region of Brazil. Between December 2015 and May 2016, we enrolled 79 patients, 5-79 years old with fever or history of fever in the previous 48 hours and P. falciparum monoinfection confirmed by microscopy. Attempts were made to provide direct observation or phone reminders for all six doses of AL, and patients were followed-up for 28 days. AL was well tolerated, with no adverse events causing treatment interruption. All but one of the 74 patients who completed the 28-day follow-up had an adequate clinical and parasitologic response = 98.6% (95% CI: 93.2-100%). We could not amplify the one isolate of the case with recurrent infection to differentiate between recrudescence and reinfection. Five (6.3%) patients demonstrated persistent asexual parasitemia on Day 3, but none met definition for early treatment failure. We found no mutations in selected kelch13 gene domains, known to be associated with artemisinin resistance in P. falciparum isolates from Day 0. These results strongly support the continued use of AL as a first-line therapy for uncomplicated P. falciparum malaria in Acre. Routine monitoring of in vivo drug efficacy coupled with molecular surveillance of drug resistance markers remains critical. |
A conversation about chemoprophylaxis
Itoh M , Arguin PM . Travel Med Infect Dis 2016 14 (5) 434-435 Meg: I'm in Angola right now where the country is seeing the largest yellow fever outbreak since 1986 and the number of malaria cases appear to be higher than normal this time of the year. I was at dinner the other night among seasoned travelers and I was struck by how different our attitudes were about malaria prophylaxis. | Paul: I hope you're taking yours. | Meg: Of course! I'm religiously taking mine every morning. Some of us are meticulous about not missing a dose whereas others seem to have a more cavalier attitude about it. They don't seem to be aware of the potential serious consequences of a malaria infection. And I was surprised by the spectrum of side effects they say they've experienced in the past with the different prophylaxis options. A lot of GI upset, and of course, the most common – weird, vivid dreams with mefloquine. But I've also heard people tell me about neuropsychiatric side effects even on other antimalarials. |
A multicenter evaluation of diagnostic tools to define endpoints for programs to eliminate bancroftian filariasis
Gass K , Beau de Rochars MV , Boakye D , Bradley M , Fischer PU , Gyapong J , Itoh M , Ituaso-Conway N , Joseph H , Kyelem D , Laney SJ , Legrand AM , Liyanage TS , Melrose W , Mohammed K , Pilotte N , Ottesen EA , Plichart C , Ramaiah K , Rao RU , Talbot J , Weil GJ , Williams SA , Won KY , Lammie P . PLoS Negl Trop Dis 2012 6 (1) e1479 Successful mass drug administration (MDA) campaigns have brought several countries near the point of Lymphatic Filariasis (LF) elimination. A diagnostic tool is needed to determine when the prevalence levels have decreased to a point that MDA campaigns can be discontinued without the threat of recrudescence. A six-country study was conducted assessing the performance of seven diagnostic tests, including tests for microfilariae (blood smear, PCR), parasite antigen (ICT, Og4C3) and antifilarial antibody (Bm14, PanLF, Urine SXP). One community survey and one school survey were performed in each country. A total of 8,513 people from the six countries participated in the study, 6,443 through community surveys and 2,070 through school surveys. Specimens from these participants were used to conduct 49,585 diagnostic tests. Each test was seen to have both positive and negative attributes, but overall, the ICT test was found to be 76% sensitive at detecting microfilaremia and 93% specific at identifying individuals negative for both microfilariae and antifilarial antibody; the Og4C3 test was 87% sensitive and 95% specific. We conclude, however, that the ICT should be the primary tool recommended for decision-making about stopping MDAs. As a point-of-care diagnostic, the ICT is relatively inexpensive, requires no laboratory equipment, has satisfactory sensitivity and specificity and can be processed in 10 minutes-qualities consistent with programmatic use. Og4C3 provides a satisfactory laboratory-based diagnostic alternative. |
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