Multisygdom: Pseudoepidemi og sølv-Tsunami

Multisygdom har altid eksisteret, men blev desmaskeret af hyperspecialiseringen i sundhedsvæsnet, der har gjort denne gruppe af patienter til et problem, de ikke var tidligere. Dét der opfattes som en epidemi af komplekse patienter, der skyl- ler ind over et forsvarsløst sundhedsvæsen, er i virkeligheden et problem, der primært blev skabt af en ukontrolleret hyperspecialisering, hvor præmissen er, at patienter har én sygdom. Patienter med enkeltstående sygdom fik en plads i hver deres speciale, mens multisyge blev marginaliserede uden en afdeling, uden spe- ciale. Samtidig har sundhedsvæsnet en forståelsesramme, hvor sygdomme opfat- tes og behandles løsrevet fra deres sociale kontekst. Multisyge starter en automa- tiseret patientkarriere, præget af øget sårbarhed for komplikationer og yderligere sygdomme. De psykosociale konsekvenser af sygdom er ofte en stor skjult byrde, der ender med at forstyrre selv ukomplicerede sygdomsforløb. Multisygdom præ- ges af syndemier, hvor sygdomme gensidigt gør hinanden værre, end de hver især ville være – der sker en forstærkning af sygelighed, som yderligere potenseres hvis patienten bor i udsatte nærmiljøer (udsatte boligområder, områder uden geografisk let adgang til sundhedsvæsnet). Multisygdom har en tung social slagside og er i udpræget grad et socialt fænomen, som i årsager og behandling, ligger langt udenfor sundhedsvæsnets indflydelse, rammer og kompetencer. I princip- pet burde multimorbiditet kun være et problem, hvis patienten taber modstands- kraft eller hvis sårbarheden øges, men desværre monitorerer sundhedsvæsnet ikke patienters resiliens, stress niveau eller sårbarhed og kan dermed skabe pro- blematisk multisygdom. Multisyge havner derfor ofte i en Bermuda trekant, fordi multimorbiditet skabes af en samtidig forstyrrelse i deres sociale netværk, deres biologiske netværk og derpå, gennem deres kompleksitet, ender med at skabe for- styrrelse i sundhedsvæsnet. Multisygdomsbegrebet er under forandring med input fra epigenetik, kaostænkning, miljøfaktorer, mikrobe-antropologi og analyser af informationsspredning i sociale netværk

Hvem vandt 1. Verdenskrig? - Krige, katastrofer og epidemier har altid hjulpet hinanden

Infektionssygdomme og krig har altid gået hånd i hånd. Tyfus og ”skyttegravsfeber” blev klassikere under første verdenskrig. I 1918 startede helt uventet en ny og meget alvorlig form for influenza (den spanske syge eller La Gripe). Den slog ca. 70 millioner mennesker ihjel, hvilket var flere end selve krigen gjorde, ligesom malaria gjorde under den amerikanske frihedskrig. Flere mener, den spanske syge var stærkt medvirkende til, at 1.verdenskrig stoppede. Marburgvirus epidemien i Den Demokratiske Republik Congo beskriver fint hvor mange faktorer, der spiller ind i sammenhængen mellem infektioner og krigslignende situationer, og hvordan politik og traditioner støder sammen med sikkerhedsspørgsmål og kan umuliggøre en målrettet indsats for at stoppe epidemien. En af de mest synlige konsekvenser af væbnede konflikter er de massive forflytninger af befolkninger, som bliver drevet på flugt af skyderier, vold og plyndringer samt svindende fødevareressourcer, og som ender i flygtningelejre. I disse lejre har mæslinger, diarré, lungebetændelse og i nogle tilfælde også kolera frit spil, hvilket forstærkes af den ofte meget lave vaccinationsdækning blandt børnene. Meget tyder på at dødelighedsniveauet under væbnede konflikter afspejler sundhedsvæsenets tilstand før konflikten startede. Konflikter afslører så at sige dybereliggende fejl og mangler i sundhedsvæsenet, der var tilstede før krigen, og som måske ligefrem har været et element i konflikten. De mest effektive redskaber til at sænke sygelighed og dødelighed i komplekse katastrofer inkluderer beskyttelse mod vold og overgreb, sikring af fødevarer, vaccinationskampagner, muligheder for håndvask, diarrékontrol, mor-barn sundhed og korrekt behandling af de hyppigste infektioner. Krige skaber flygtninge, og mobile befolkningsgrupper er sårbare uden socialt eller administrativt netværk. De er tvunget til at opholde sig i et nye miljøer med fremmede mikroorganismer og perfekte smittemuligheder. Her har epidemier frit spil, og det er oftest dem, der vinder krigene

The when and how of male circumcision and the risk of HIV: a retrospective crosssectional analysis of two HIV surveys from Guinea-Bissau

Introduction: Male circumcision (MC) reduces the risk of HIV, and this risk reduction may be modified by socio-cultural factors such as the timing and method (medical and traditional) of circumcision. Understanding regional variations in circumcision practices and their relationship to HIV is crucial and can increase insight into the HIV epidemic in Africa. Methods: We used data from two retrospective HIV surveys conducted in Guinea- Bissau from 1993 to 1996 (1996 cohort) and from 2004 to 2007 (2006 cohort). Multivariate logistical models were used to investigate the relationships between HIV risk and circumcision status, timing, method of circumcision, and socio-demographic factors. Results: MC was protective against HIV infection in both cohorts, with adjusted odds ratios (AORs) of 0.28 (95% CI 0.12-0.66) and 0.30 (95% CI 0.09-0.93), respectively. We observed that post-pubertal (≥13 years) circumcision provided the highest level of HIV risk reduction in both cohorts compared to non-circumcised. However, the difference between pre-pubertal (≤12 years) and post-pubertal (≥13 years) circumcision was not significant in the multivariate analysis. Seventy-six percent (678/888) of circumcised males in the 2006 cohort were circumcised traditionally, and 7.7% of those males were HIV-infected compared to 1.9% of males circumcised medically, with AOR of 2.7 (95% CI 0.91-8.12). Conclusion: MC is highly prevalent in Guinea-Bissau, but ethnic variations in method and timing may affect its protection against HIV. Our findings suggest that sexual risk behaviour and traditional circumcision may increases HIV risk. The relationship between circumcision age, sexual behaviour and HIV status remains unclear and warrants further research.Pan African Medical Journal 2016; 2

Awareness, attitudes and perceptions regarding HIV and PMTCT amongst pregnant women in Guinea-Bissau- a qualitative study.

BACKGROUND: The human immunodeficiency virus (HIV) continues to be a major cause of maternal and infant mortality and morbidity in sub-Saharan Africa. Prevention of mother-to-child transmission of HIV (PMTCT) strategies have proven effective in decreasing the number of children infected in utero, intrapartum and during the breastfeeding period. This qualitative study explores knowledge and perceptions of HIV amongst pregnant women, healthcare workers' experiences of the national PMTCT services, and barriers to PMTCT, during a period of programme scale-up in urban Guinea-Bissau (2010-11). METHODS: In-depth interviews were undertaken amongst 27 women and 19 key informants at local antenatal clinics and the national maternity ward in Bissau, Guinea-Bissau. RESULTS: Amongst women who had been tested for HIV, awareness and knowledge of HIV and PMTCT remained low. Testing without informed consent was reported in some cases, in particular when the test was performed around the time of delivery. Possible drivers of inadequate counselling included lack of confidentiality, suboptimal healthcare worker training, lack of time, and perceived occupational risk. Demand-side barriers to PMTCT included lack of HIV and PMTCT knowledge, customary and cultural beliefs associated with HIV and ill-health, HIV stigma and discrimination, and fear of partnership dissolution. CONCLUSIONS: Socio-cultural and operational challenges, including HIV testing without informed consent, present significant barriers to the scale-up of PMTCT services in Bissau. Strengthening local capacity for effective counselling and testing in the antenatal setting is paramount. Further research into local customary beliefs relating to HIV is warranted

HIV-1 and HIV-2 prevalence, risk factors and birth outcomes among pregnant women in Bissau, Guinea-Bissau: a retrospective cross-sectional hospital study

The human immunodeficiency virus (HIV) remains a leading cause of maternal morbidity and mortality in Sub-Saharan Africa. Prevention of mother-to-child transmission (PMTCT) has proven an effective strategy to end paediatric infections and ensure HIV-infected mothers access treatment. Based on cross-sectional data collected from June 2008 to May 2013, we assessed changes in HIV prevalence, risk factors for HIV, provision of PMTCT antiretroviral treatment (ART), and the association between HIV infection, birth outcomes and maternal characteristics at the Simão Mendes National Hospital, Guinea-Bissau’s largest maternity ward. Among 24,107 women, the HIV prevalence was 3.3% for HIV-1, 0.8% for HIV-2 and 0.9% for HIV-1/2. A significant decline in HIV-1, HIV-2, and HIV-1/2 prevalence was observed over time. HIV infection was associated with age and ethnicity. A total of 85% of HIV-infected women received ART as part of PMTCT, yet overall treatment coverage during labour and delivery declined significantly for both mothers and infants. Twenty-two percent of infants did not receive treatment, and 67% of HIV-2-infected mothers and 77% of their infants received ineffective non-nucleoside reverse transcriptase inhibitors for PMTCT. Maternal HIV was associated with low birth weight but not stillbirth. Inadequate continuity of care and ART coverage present challenges to optimal PMTCT in Guinea-Bissau

A prospective study of twinning and perinatal mortality in urban Guinea-Bissau

BACKGROUND: Despite twinning being common in Africa, few prospective twin studies have been conducted. We studied twinning rate, perinatal mortality and the clinical characteristics of newborn twins in urban Guinea-Bissau. METHODS: The study was conducted at the Bandim Health Project (BHP), a health and demographic surveillance site in Bissau, the capital of Guinea-Bissau. The cohort included all newborn twins delivered at the National Hospital Simão Mendes and in the BHP study area during the period September 2009 to August 2011 as well as singleton controls from the BHP study area. Data regarding obstetric history and pregnancy were collected at the hospital. Live children were examined clinically. For a subset of twin pairs zygosity was established by using genetic markers. RESULTS: Out of the 5262 births from mothers included in the BHP study area, 94 were twin births, i.e. a community twinning rate of 18/1000. The monozygotic rate was 3.4/1000. Perinatal mortality among twins vs. singletons was 218/1000 vs. 80/1000 (RR = 2.71, 95% CI: 1.93-3.80). Among the 13783 hospital births 388 were twin births (28/1000). The hospital perinatal twin mortality was 237/1000. Birth weight < 2000g (RR = 4.24, CI: 2.39-7.51) and caesarean section (RR = 1.78, CI: 1.06-2.99) were significant risk factors for perinatal twin mortality. Male sex (RR = 1.38, CI: 0.97-1.96), unawareness of twin pregnancy (RR = 1.64, CI: 0.97-2.78) and high blood pressure during pregnancy (RR = 1.77, CI: 0.88-3.57) were borderline non-significant. Sixty-five percent (245/375) of the mothers who delivered at the hospital were unaware of their twin pregnancy. CONCLUSIONS: Twins had a very high perinatal mortality, three-fold higher than singletons. A birth weight < 2000g was the strongest risk factor for perinatal death, and unrecognized twin pregnancy was common. Urgent interventions are needed to lower perinatal twin mortality in Guinea-Bissau