Outbreak of beriberi among African union troops in Mogadishu, Somalia

Context and Objectives: In July 2009, WHO and partners were notified of a large outbreak of unknown illness, including deaths, among African Union (AU) soldiers in Mogadishu. Illnesses were characterized by peripheral edema, dyspnea, palpitations, and fever. Our objectives were to determine the cause of the outbreak, and to design and recommend control strategies. Design, Setting, and Participants: The illness was defined as acute onset of lower limb edema, with dyspnea, chest pain, palpitations, nausea, vomiting, abdominal pain, or headache. Investigations in Nairobi and Mogadishu included clinical, epidemiologic, environmental, and laboratory studies. A case-control study was performed to identify risk factors for illness. Results: From April 26, 2009 to May 1, 2010, 241 AU soldiers had lower limb edema and at least one additional symptom; four patients died. At least 52 soldiers were airlifted to hospitals in Kenya and Uganda. Four of 31 hospitalized patients in Kenya had right-sided heart failure with pulmonary hypertension. Initial laboratory investigations did not reveal hematologic, metabolic, infectious or toxicological abnormalities. Illness was associated with exclusive consumption of food provided to troops (not eating locally acquired foods) and a high level of insecurity (e.g., being exposed to enemy fire on a daily basis). Because the syndrome was clinically compatible with wet beriberi, thiamine was administered to ill soldiers, resulting in rapid and dramatic resolution. Blood samples taken from 16 cases prior to treatment showed increased levels of erythrocyte transketolase activation coefficient, consistent with thiamine deficiency. With mass thiamine supplementation for healthy troops, the number of subsequent beriberi cases decreased with no further deaths reported. Conclusions: An outbreak of wet beriberi caused by thiamine deficiency due to restricted diet occurred among soldiers in a modern, well-equipped army. Vigilance to ensure adequate micronutrient intake must be a priority in populations completely dependent upon nutritional support from external sources

Longitudinal Patterns of Antimicrobial Resistance in Escherichia coli Isolated from Children <5 Years of Age Following Hospital Discharge in Kenya and the Impact of a 5-Day Course of Azithromycin

Thesis (Master's)--University of Washington, 2023Introduction: Antimicrobial resistance (AMR) is a growing concern worldwide, especially among gram-negative bacteria. One gram-negative species, E. coli, is responsible for most deaths attributed to AMR, especially in sub-Saharan Africa. Hospitalization is a time of increased exposure to pathogens and antibiotics. However, there is limited data on the burden of AMR post-hospital discharge and factors associated with the occurrence of extended-spectrum β-lactamase (ESBL) - producing E. coli within communities.Methods: A sequential cross-sectional data analysis from E. coli isolated from fecal samples collected from children <60 months old in Homabay and Kisii counties of Western Kenya. Fecal samples were collected at hospital discharge, and at three-month and six-month follow-ups. Fecal samples from each unique child were cultured in triplicate for E. coli. If E. coli was isolated from at least one of the samples tested in triplicate, the child was considered to have a positive E. coli culture. Any unique child with E. coli isolated at enrollment with antimicrobial susceptibility testing (AST) results was included in our analysis. We evaluated changes in the proportion of AMR to twelve selected antibiotics over six months following hospital discharge and determined AMR decline by comparing the proportion of AMR between discharge and three months and between three- and six-months post-discharge. We also determined the occurrence of ESBL-producing E. coli at six months post-hospital discharge. We conducted a univariate analysis to determine the burden of AMR post-hospital discharge and a Multivariate Poisson regression to evaluate the association between the occurrence of ESBL-producing E. coli at six months post-hospital discharge and selected risk factors. We then conducted a sensitivity analysis to examine differences in phenotypic AMR among isolates detected at discharge, three months, and six months post-hospital discharge. Results: 406 unique children were enrolled in the study, and all had E. coli isolated at the discharge time point. Most of the children (323, or 80%) had E. coli isolated at each time point (discharge, month three, and month six). E. coli isolates were predominantly from males (59.5%) and the median age of the included children was 19 months (IQR 23 months) at enrollment. Most children were hospitalized for at least three days, were of low socio-economic status (65.2%), and were HIV unexposed (84%).   There was a statistically significant decline in the proportional non-susceptibility to all antibiotics from hospital discharge to three months. The proportion of non-susceptibility isolates between three months and six months was not statistically significant for most antibiotics, except for ceftazidime 0.58 (0.36 - 0.95, p0.031), gentamicin 0.44 (0.30 - 0.63, p<0.001), and ESBL-producing E. coli 0.55 (0.32 - 0.94, p0.029). Non-susceptibility to ampicillin (AMP) and trimethoprim-sulfamethoxazole (TMP/SMX) remained highest at the end of follow-up at month six (72% and 84%, respectively). Carriage of ESBL-producing E. coli dropped from 44% at hospital discharge to 11% at six months post-hospital discharge. There were no statistically significant risk factors associated with the occurrence of ESBL-producing E. coli at six months post-hospital discharge. Conclusions: At hospital discharge, non-susceptibility to E. coli remained high, suggesting that exposure to antibiotics in the hospital is a driver of AMR in these children. Non-susceptibility to all antibiotics significantly declined up to three months post-discharge suggesting that when antibiotic pressure associated with illness and hospitalization is removed, AMR emergence also stabilizes. ESBL-producing E. coli remained stable up to six months post-hospital discharge. There were no significant correlates of ESBL-producing E. coli at six months post-hospital discharge among the risk factors examined. Overall, these findings highlight the urgent need for facility-based interventions, including increased surveillance, antibiotic stewardship, and other control measures, to reduce the spread of antimicrobial-resistant bacteria in sub-Saharan Africa

Prevalence and risk factors associated with asymptomatic Plasmodium falciparum infection and anemia among pregnant women at the first antenatal care visit: A hospital based cross-sectional study in Kwale County, Kenya.

BackgroundPrevalence of Prevalence of malaria in pregnancy (MiP) in Kenya ranges from 9% to 18%. We estimated the prevalence and factors associated with MiP and anemia in pregnancy (AiP) among asymptomatic women attending antenatal care (ANC) visits.MethodsWe performed a cross-sectional study among pregnant women attending ANC at Msambweni Hospital, between September 2018 and February 2019. Data was collected and analyzed in Epi Info 7. Descriptive statistics were calculated and we compared MiP and AiP in asymptomatic cases to those without either condition. Adjusted prevalence Odds odds ratios (aPOR) and 95% confidence intervals (CI) were calculated to identify factors associated with asymptomatic MiP and AiP.ResultsWe interviewed 308 study participants; their mean age was 26.6 years (± 5.8 years), mean gestational age was 21.8 weeks (± 6.0 weeks), 173 (56.2%) were in the second trimester of pregnancy, 12.9% (40/308) had MiP and 62.7% had AiP. Women who were aged ≤ 20 years had three times likelihood of developing MiP (aPOR = 3.1 Cl: 1.3-7.35) compared to those aged >20 years old. The likelihood of AiP was higher among women with gestational age ≥ 16 weeks (aPOR = 3.9, CI: 1.96-7.75), those with parasitemia (aPOR = 3.3, 95% CI: 1.31-8.18), those in third trimester of pregnancy (aPOR = 2.6, 95% CI:1.40-4.96) and those who reported eating soil as a craving during pregnancy (aPOR = 1.9, 95%CI:1.15-3.29).ConclusionsMajority of the women had asymptomatic MiP and AiP. MiP was observed in one tenth of all study participants. Asymptomatic MiP was associated with younger age while AiP was associated with gestational age parasitemia, and soil consumption as a craving during pregnancy

Additional file 1: Figure S1. of The contribution of respiratory pathogens to fatal and non-fatal respiratory hospitalizations: a pilot study of Taqman Array Cards (TAC) in Kenya

Schematic diagram of the two versions of Taqman array cards (TAC) used in the study. Table S1. Viral and bacterial pathogens detected using Taqman array cards (TAC) among non-fatal and fatal cases and asymptomatic controls, by age group, western Kenya, 2009-11. Table S2. Distribution of respiratory pathogens among cases (non-fatal and fatal) and corresponding asymptomatic controls in rural western Kenya, 2009-11. (DOCX 614 kb

Available laboratory results for cases referred for admission to AKUH-N (n = 33).

1<p>Aga Khan Laboratories- Nairobi, Kenya.</p>2<p>Center for Disease Control and Prevention Laboratories-Nairobi, Kenya.</p>3<p>Kenya Medical Research Institute-Kisumu, Kenya.</p>4<p>Walter Reed Army Medical Laboratories-Nairobi, Kenya.</p>5<p>National Influenza Center, Nairobi, Kenya.</p

Results of case control study conducted August 19–21, 2009 in Mogadishu, Somalia.

<p>*Statistically significant (p<0.05).</p

A diagnostic and epidemiologic investigation of acute febrile illness (AFI) in Kilombero, Tanzania

<div><p>Introduction</p><p>In low-resource settings, empiric case management of febrile illness is routine as a result of limited access to laboratory diagnostics. The use of comprehensive fever syndromic surveillance, with enhanced clinical microbiology, advanced diagnostics and more robust epidemiologic investigation, could enable healthcare providers to offer a differential diagnosis of fever syndrome and more appropriate care and treatment.</p><p>Methods</p><p>We conducted a year-long exploratory study of fever syndrome among patients ≥ 1 year if age, presenting to clinical settings with an axillary temperature of ≥37.5°C and symptomatic onset of ≤5 days. Blood and naso-pharyngeal/oral-pharyngeal (NP/OP) specimens were collected and analyzed, respectively, using AFI and respiratory TaqMan Array Cards (TAC) for multi-pathogen detection of 57 potential causative agents. Furthermore, we examined numerous epidemiologic correlates of febrile illness, and conducted demographic, clinical, and behavioral domain-specific multivariate regression to statistically establish associations with agent detection.</p><p>Results</p><p>From 15 September 2014–13 September 2015, 1007 febrile patients were enrolled, and 997 contributed an epidemiologic survey, including: 14% (n = 139) 1<5yrs, 19% (n = 186) 5-14yrs, and 67% (n = 672) ≥15yrs. AFI TAC and respiratory TAC were performed on 842 whole blood specimens and 385 NP/OP specimens, respectively. Of the 57 agents surveyed, <i>Plasmodium</i> was the most common agent detected. AFI TAC detected nucleic acid for one or more of seven microbial agents in 49% of AFI blood samples, including: <i>Plasmodium</i> (47%), <i>Leptospira</i> (3%), <i>Bartonella</i> (1%), <i>Salmonella enterica</i> (1%), <i>Coxiella burnetii</i> (1%), <i>Rickettsia</i> (1%), and West Nile virus (1%). Respiratory TAC detected nucleic acid for 24 different microbial agents, including 12 viruses and 12 bacteria. The most common agents detected among our surveyed population were: <i>Haemophilus influenzae</i> (67%), <i>Streptococcus pneumoniae</i> (55%), <i>Moraxella catarrhalis</i> (39%), <i>Staphylococcus aureus</i> (37%), <i>Pseudomonas aeruginosa</i> (36%), Human Rhinovirus (25%), influenza A (24%), <i>Klebsiella pneumoniae</i> (14%), Enterovirus (15%) and group A <i>Streptococcus</i> (12%). Our epidemiologic investigation demonstrated both age and symptomatic presentation to be associated with a number of detected agents, including, but not limited to, influenza A and <i>Plasmodium</i>. Linear regression of fully-adjusted mean cycle threshold (C_t) values for <i>Plasmodium</i> also identified statistically significant lower mean C_t values for older children (20.8), patients presenting with severe fever (21.1) and headache (21.5), as well as patients admitted for in-patient care and treatment (22.4).</p><p>Conclusions</p><p>This study is the first to employ two syndromic TaqMan Array Cards for the simultaneous survey of 57 different organisms to better characterize the type and prevalence of detected agents among febrile patients. Additionally, we provide an analysis of the association between adjusted mean C_t values for <i>Plasmodium</i> and key clinical and demographic variables, which may further inform clinical decision-making based upon intensity of infection, as observed across endemic settings of sub-Saharan Africa.</p></div

Characteristics of beriberi cases admitted to the Aga Khan Hospital, Nairobi, Kenya (N = 33).

<p>Characteristics of beriberi cases admitted to the Aga Khan Hospital, Nairobi, Kenya (N = 33).</p

Box plots of parasite load (C_t) by level of parasite intensity.

<p>Box plots of parasite load (C_t) by level of parasite intensity.</p