What are we measuring? Comparison of household food security indicators in the Eastern Cape Province, South Africa

The development of national food security information systems is constrained by a lack of guidance on which indicators to use. This paper compares food security indicators across two seasons (summer and winter) in one of the most deprived areas of the Eastern Cape province of South Africa. The results show that only anthropometric indicators are sensitive enough to differentiate levels of food insecurity. The lack of consistent classification across indicators means that surveys must use a combination of food consumption and experience of hunger measures backed up by anthropometric measures. Targeting interventions is difficult if the measures cannot be relied on. Further investigation is needed to identify a suite of appropriate indicators for a national information and surveillance system.South African Water Research Commission (WRC Project No. Project K5/2172/4), the South African National Research Foundation (Grant numbers CPR20110706000020, 77053 and 80529), the University of Pretoria’s Institutional Research Theme on Food, Nutrition and Well-being, and the University of Pretoria’s Post-Doctoral Fellowship Programme.http://www.tandfonline.com/loi/gefn202017-09-30hb2016Agricultural Economics, Extension and Rural Developmen

Intracellular survival of Streptococcus pneumoniae in human alveolar macrophages is augmented with HIV infection

People Living with HIV (PLHIV) are at an increased risk of pneumococcal pneumonia than HIV-uninfected adults, but the reasons for this are still not well understood. We investigated whether alveolar macrophages (AM) mediated control of pneumococcal infection is impaired in PLHIV compared to HIV-uninfected adults. We assessed anti-bactericidal activity against Streptococcus pneumoniae of primary human AM obtained from PLHIV and HIV-uninfected adults. We found that pneumococcus survived intracellularly in AMs at least 24 hours post ex vivo infection, and this was more frequent in PLHIV than HIV-uninfected adults. Corroborating these findings, in vivo evidence showed that PLHIV had a higher propensity for harboring S. pneumoniae within their AMs than HIV-uninfected adults. Moreover, bacterial intracellular survival in AMs was associated with extracellular propagation of pneumococcal infection. Our data suggest that failure of AMs to eliminate S. pneumoniae intracellularly could contribute to the increased risk of pneumococcal pneumonia in PLHIV

Intracellular survival of Streptococcus pneumoniae in human alveolar macrophages is augmented with HIV infection

People Living with HIV (PLHIV) are at an increased risk of pneumococcal pneumonia than HIV-uninfected adults, but the reasons for this are still not well understood. We investigated whether alveolar macrophages (AM) mediated control of pneumococcal infection is impaired in PLHIV compared to HIV-uninfected adults. We assessed anti-bactericidal activity against Streptococcus pneumoniae of primary human AM obtained from PLHIV and HIV-uninfected adults. We found that pneumococcus survived intracellularly in AMs at least 24 hours post ex vivo infection, and this was more frequent in PLHIV than HIV-uninfected adults. Corroborating these findings, in vivo evidence showed that PLHIV had a higher propensity for harboring S. pneumoniae within their AMs than HIV-uninfected adults. Moreover, bacterial intracellular survival in AMs was associated with extracellular propagation of pneumococcal infection. Our data suggest that failure of AMs to eliminate S. pneumoniae intracellularly could contribute to the increased risk of pneumococcal pneumonia in PLHIV

TSCQ study: a randomized, controlled, open-label trial of daily trimethoprim-sulfamethoxazole or weekly chloroquine among adults on antiretroviral therapy in Malawi: study protocol for a randomized controlled trial.

BACKGROUND: Before antiretroviral therapy (ART) became widely available in sub-Saharan Africa, several studies demonstrated that daily trimethoprim-sulfamethoxazole (TS) prophylaxis reduced morbidity and mortality among HIV-infected adults. As a result, the World Health Organization (WHO) recommended administering TS prophylaxis to this group. However, the applicability of the results to individuals taking ART and living in sub-Saharan Africa has not been definitively evaluated. This study aims to determine if TS prophylaxis benefits HIV-infected Malawian adults after a good response to ART. If TS prophylaxis does indeed show benefit, it is important to determine if this is due to its antibacterial and/or antimalarial properties. METHODS/DESIGN: A randomized, controlled, open-label, phase III trial of continued standard of care prophylaxis with daily trimethoprim-sulfamethoxazole (TS) compared to discontinuation of standard of care TS prophylaxis and starting weekly chloroquine (CQ) prophylaxis or discontinuation of standard of care TS prophylaxis. The study will randomize 1400-1500 HIV-infected adults (equally divided over the three study arms) with a nondetectable viral load and a CD4 count of 250/mm(3) or more from antiretroviral therapy clinics in Blantyre and Zomba. The expected rate of primary endpoint events of death and WHO stage 3 and 4 events is 6.8 per 100 person-years of follow-up in all participants. Assuming the number of events follows a Poisson distribution and average participant follow-up after 10 % loss to follow-up is 41.6 months, the study will have approximately 85 % power to rule out a reduction of 35 % or more in primary endpoint events in the TS or CQ arms compared to discontinuation of TS prophylaxis-i.e., to show that discontinuation of TS prophylaxis is noninferior to either TS or CQ, with a noninferiority margin of 35 %. Ethical and regulatory approvals were obtained from the University of Malawi College of Medicine Research Ethics Committee; the Malawi Pharmacy, Medicines and Poisons Board; and the University of Maryland Baltimore Institutional Review Board. DISCUSSION: The study began recruitment activities at the Ndirande site in November 2012. The sponsor agreed to extend and expand the study in early 2015, and a second site, Zomba, was added for recruitment and follow-up in mid-2015. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01650558 (registered on 6 July 2012). PROTOCOL VERSION: Letter of amendment #1 to the DAIDS-ES 10822 TSCQ Malawi Protocol, Version 4.0, 16 December 2014

Effect of 13-valent pneumococcal conjugate vaccine on experimental carriage of Streptococcus pneumoniae serotype 6B in Blantyre, Malawi: a randomised controlled trial and controlled human infection study

Background The effect of childhood pneumococcal conjugate vaccine implementation in Malawi is threatened by absence of herd effect. There is persistent vaccine-type pneumococcal carriage in both vaccinated children and the wider community. We aimed to use a human infection study to measure 13-valent pneumococcal conjugate vaccine (PCV13) efficacy against pneumococcal carriage. Methods We did a double-blind, parallel-arm, randomised controlled trial investigating the efficacy of PCV13 or placebo against experimental pneumococcal carriage of Streptococcus pneumoniae serotype 6B (strain BHN418) among healthy adults (aged 18–40 years) from Blantyre, Malawi. We randomly assigned participants (1:1) to receive PCV13 or placebo. PCV13 and placebo doses were prepared by an unmasked pharmacist to maintain research team and participant masking with identification only by a randomisation identification number and barcode. 4 weeks after receiving either PCV13 or placebo, participants were challenged with 20 000 colony forming units (CFUs) per naris, 80 000 CFUs per naris, or 160 000 CFUs per naris by intranasal inoculation. The primary endpoint was experimental pneumococcal carriage, established by culture of nasal wash at 2, 7, and 14 days. Vaccine efficacy was estimated per protocol by means of a log-binomial model adjusting for inoculation dose. The trial is registered with the Pan African Clinical Trials Registry, PACTR202008503507113, and is now closed. Findings Recruitment commenced on April 27, 2021 and the final visit was completed on Sept 12, 2022. 204 participants completed the study protocol (98 PCV13, 106 placebo). There were lower carriage rates in the vaccine group at all three inoculation doses (0 of 21 vs two [11%] of 19 at 20 000 CFUs per naris; six [18%] of 33 vs 12 [29%] of 41 at 80 000 CFUs per naris, and four [9%] of 44 vs 16 [35%] of 46 at 160 000 CFUs per naris). The overall carriage rate was lower in the vaccine group compared with the placebo group (ten [10%] of 98 vs 30 [28%] of 106; Fisher's p value=0·0013) and the vaccine efficacy against carriage was estimated at 62·4% (95% CI 27·7–80·4). There were no severe adverse events related to vaccination or inoculation of pneumococci. Interpretation This is, to our knowledge, the first human challenge study to test the efficacy of a pneumococcal vaccine against pneumococcal carriage in Africa, which can now be used to establish vaccine-induced correlates of protection and compare alternative strategies to prevent pneumococcal carriage. This powerful tool could lead to new means to enhance reduction in pneumococcal carriage after vaccination

Orthopaedic Clinical Officer Program in Malawi: A Model for Providing Orthopaedic Care

Malawi has a population of about 13 million people, 85% of whom live in rural areas. The gross national income per capita is US$620, with 42$1 per day. The government per capita expenditure on health is US$5. Malawi has 266 doctors, of whom only nine are orthopaedic surgeons. To address the severe shortage of doctors, Malawi relies heavily on paramedical officers to provide the bulk of healthcare. Specialized orthopaedic clinical officers have been trained since 1985 and are deployed primarily in rural district hospitals to manage 80% to 90% of the orthopaedic workload in Malawi. They are trained in conservative management of most common traumatic and nontraumatic musculoskeletal conditions. Since the program began, 117 orthopaedic clinical officers have been trained, of whom 82 are in clinical practice. In 2002, Malawi began a local orthopaedic postgraduate program with an intake of one to two candidates per year. However, orthopaedic clinical officers will continue to be needed for the foreseeable future. Orthopaedic clinical officer training is a cost-effective way of providing trained healthcare workers to meet the orthopaedic needs of a country with very few doctors and even fewer orthopaedic surgeons

Combined DC resistivity and induced polarization (DC-IP) for mapping the internal composition of a mine waste rock pile in Nova Scotia, Canada

Mine waste rock piles (WRPs) can contain sulfidic minerals whose interaction with oxygen and water can generate acid mine drainage (AMD). Thus, WRPs can be a long-term source of environmental pollution. Since the generation of AMD and its release into the environment is dependent on the net volume and bulk composition of waste rock, effective characterization of WRPs is necessary for successful remedial design and monitoring. In this study, a combined DC resistivity and induced polarization (DC-IP) approach was employed to characterize an AMD-generating WRP in the Sydney Coalfield, Nova Scotia, Canada. Two-dimensional (2D) DC-IP imaging with 6 survey lines was performed to capture the full WRP landform. 2D DC results indicated a highly heterogeneous and moderately conductive waste rock underlain by a resistive bedrock containing numerous fractures. 2D IP (chargeability) results identified several highly-chargeable regions within the waste, with normalized chargeability delineating regions specific to waste mineralogy only. Three-dimensional (3D) DC-IP imaging, using 17 parallel lines on the plateau of the pile, was then used to focus on the composition of the waste rock. The full 3D inverted DC-IP distributions were used to identify coincident and continuous zones (isosurfaces) of low resistivity (0.4 mS/m) that were inferred as generated AMD (leachate) and stored AMD (sulfides), respectively. Integrated geological, hydrogeological and geochemical data increased confidence in the geoelectrical interpretations. Knowledge on the location of potentially more reactive waste material is extremely valuable for improved long-term AMD monitoring at the WRP

Application of Systems-Approach in Modelling Complex City-Scale Transdisciplinary Knowledge Co-Production Process and Learning Patterns for Climate Resilience

Literature shows that much research has been conducted on the co-production of climate knowledge, but it has neither established a standardized and replicable model for the co-production process nor the emergent learning patterns as collaborators transition from the disciplinary comfort-zone (disciplinary and practice biases) to the transdisciplinary third-space. This study combines algorithmic simulation modelling and case study lessons from Learning Labs under a 4-year (2016–2019) climate change management project called Future Resilience of African CiTies and Lands in the City of Blantyre in Malawi. The study fills the research gap outlined above by applying a systems-approach to replicate the research process, and a Markov process to simulate the learning patterns. Results of the study make a number of contributions to knowledge. First, there are four distinct evolutionally stages when transitioning from the disciplinary comfort-zone to the transdisciplinary third-space, namely: Shock and resistance to change; experimenting and exploring; acceptance; and integration into the third-space. These stages are marked by state probabilities of the subsequent stages relative to the initial (disciplinary comfort-zone) state. A complete transition to the third-space is marked by probabilities greater than one, which is a system amplification, and it signifies that there has been a significant increase in learning among collaborating partners during the learning process. Second, a four-step decision support tool has been developed to rank the plausibility of decisions, which is very hard to achieve in practice. The tool characterizes decision determinants (policy actors, evidence and knowledge, and context), expands the determinants, checks what supports the decision, and then rates decisions on an ordinal scale of ten in terms of how knowledge producers and users support them. Third, for a successful transdisciplinary knowledge co-production, researchers should elucidate three system-archetypes (leverage points), namely: Salient features for successful co-production, determinant of support from collaborators, and knowledge co-production challenges. It is envisioned that academics, researchers, and policy makers will find the results useful in modelling and replicating the co-production process in a methodical and systemic way while solving complex climate resilience development problems in dynamic, socio-technical systems, as well as in sustainably mainstreaming the knowledge co-produced in policies and plans

The cost-effectiveness of orthopaedic clinical officers in Malawi

Background In Malawi the orthopaedic clinical officer (OCO) training programme trains non-physician clinicians in musculoskeletal care. We studied the cost-effectiveness of this program. Methods Hospital logbooks were reviewed for data pertaining to activity in seven district hospitals over a 6-month period. The total costs were divided by the total effectiveness, calculated as disability adjusted life years (DALYs) averted. Results The total cost-effectiveness of providing orthopaedic care through the OCO training programme was US$92.06 per DALY averted. The mean per hospital was US$138.75 (95% CI: US$69.58–207.91) per DALY averted which is very cost-effective when compared with other health interventions. Of the 837 patients treated 63% were aged &lt;15 years and 36% were in the ‘economically active’ demographic of ages 15–74 years. Conclusion Training of clinical officers in orthopaedic surgery is very cost-effective and allows transfer of skills into rural areas. The demographics suggest that failure to provide such care would have a negative economic impact. </jats:sec

The demographics of patients affected by surgical disease in district hospitals in two sub-Saharan African countries:a retrospective descriptive analysis

BACKGROUND: There is a growing awareness of the importance of surgical disease within global health. We hypothesised that surgical disease in low income countries predominantly affects young adults and may therefore have a significant economic impact. METHODS: We retrospectively reviewed all surgical admission data from two rural government district hospitals in two different sub-Saharan African countries over a 6-month period. We analysed all surgical admissions with respect to patient demographics (age and gender), diagnosis, and procedure performed. RESULTS: Surgical admissions accounted for 12.9 and 19.8 % of all hospital admissions in Malawi and Sierra Leone respectively. 18.5 and 6.2 % of all hospital patients required a surgical procedure in Malawi and Sierra Leone respectively, with the low number in Sierra Leone accounted for in that many of the obstetric admissions were referred to a nearby Medicins Sans Frontiers (MSF) hospital for treatment. 17.9 and 10.5 % of surgical admissions were under the age of 16 in Malawi and Sierra Leone respectively, with 16–35 year olds accounting for 57.3 % of surgical admissions in Sierra Leone and 53.5 % in Malawi. Men accounted for 53.7 and 46.0 % of surgical admissions in Sierra Leone and Malawi respectively. An unexpected finding was the high level of patients who absconded from hospital in Sierra Leone after diagnosis but before treatment. This involved 11.8 % of all surgical patients, including 38 % with a bowel obstruction, 39 % with peritonitis and 20 % with ectopic pregnancy. CONCLUSIONS: Most people affected by disease requiring surgery are young adults and this may have significant economic implications