Morbidity and CD4+ Cell Counts at Initial Presentation of a Cohort of HAART-Naive, HIV Positive Kenyan Patients: Implications to Initiating HAART

Background: Sub-Saharan Africa with under 10% of the worldfs total population accounts for 60-70% of all HIV/AIDS cases. While these patients require HAART to manage the disease, HAART is not universally available. Majority of the patients are in resource-constrained settings, have multiple co- morbidities/infections, opportunistic infections, present late for treatment and are in the advanced stages of the HIV/A}IDSinfection.Objective: To describe the CD4+ cell counts, opportunistic infections and laboratory parameters of a cohort of HIV positive, HAART-naive patients at first presentation.Design: Cross sectional, prospective, descriptive, consecutive entry study.Setting: Kisumu District Hospital wards (medical, surgical) and medical outpatient clinic, Nairobi Rheumatology Clinic, Nairobi West Hospital and the Mater Hospital between January 2001 and December 2008.Main outcome measures: Socio-demographic parameters, opportunistic infections, CD4+ cell counts and complete blood count, biochemistry, HBsAg markers and anti- HCV serostatus.Results: Eight hundred and thirty four (350 males and 484 females) patients were screened. Three hundred and seventy (94 males and 276 females) patients were excluded. Four hundred and sixty four (256 males and 208 females) patients were finally included in the study. The mean age was 37.2 }10.6 years, range (12-78). The M: F ratio was 1.2:1. The mean CD4+ cell count was 106.5 } 125.2 cells/µl manifesting severe immnosuppression. Fifteen (3.2%), 19(4.1%), 43(9.3%) and 387(83.5%) had CD4+ cell counts of > 500, 350-499, 200-349 and < 200 cells/ƒÊl respectively. The mean white blood cell count was 8.63 } 8.8 ~ 103/ml (4.8-10.8 ~ 103/µl). Over half (51.3%) patients had leucopaenia, white cell count < 4.8 ~ 103/µl, 35 (7.5%) had leucocytosis and the rest 191 (41.2%) patients had normal white blood cell counts. The mean haemoglobin level was 7.16 } 5.01 g/dl (12-18 g/dl) and 154 (33.2%) had haemoglobin level < 5g/dl manifesting severe anaemia. The patients had multiple co-morbidities and 248 (53.4%) had . 2 co-morbidities.Conclusion: The patients presented with severe immunosuppression evidenced by low CD4+ cell counts, anaemia and multiple co-morbidities. Majority presented late at which point the cost of management is high and outcomes are likely to be poor. They required HAART and prompt  management of the co-morbidities to mitigate morbidity and reduce mortality. It would be prudent to study treatment outcomes and their determinants overtime in patients with severe HIV disease. Also, requiring study is how long such patients with severe HIV disease who commence HAART would last on first line treatment before requirement of alternative treatment

CD4 + Cell Response to Anti-Retroviral Therapy (ARTS) In Routine Clinical Care Over One Year Period in a Cohort of HAART Naive, HIV Positive Kenyan Patients

Background: Untreated HIV/AIDS leads to severe immune depletion with opportunistic                                                                    infections and other co-morbidities. Highly active anti-retroviral therapy (HAART) enhances immunity by sustained HIV- viral suppression, increase in CD4+ cell count and immune restoration. HAART reduces risk of neutropaenia, anaemia and accompanied decrease in incidence of opportunistic infections.Objectives: To study the CD4+ cell response in patients with severe HIV/AIDS disease over one year period while on HAART.Design: Observational, descriptive, longitudinal study.Setting: Kisumu District Hospital (Medical outpatient clinic, medical and surgical wards), Nairobi Rhematology clinic and The Mater Hospital between July 2001 and March 2007.Subjects: Four hundred and sixty three consenting patients were screened for the study.Intervention: The 103 patients included received HAART within one to four weeks and appropriate treatment for the opportunistic infections and other co-morbidities. Various HAART combinations including combivir/efavirenz, stavudine/lamivudine/nevirapine and triomune 30/40 (fixed dose combination of stavudine, nevirapine and lamivudine) were used. Some delayed HAART because of the co- morbidities which had to be managed first (severe anaemia, hepatitis and meningitis).Main outcome measures: CD4+ cell increase, new clinical events.Results: Four hundred and sixty three patients (256 males and 207 females) were screened. One hundred and three patients (55 males and 48 females) were included and 360 (201 males and 159 females) patients were excluded. Mean age was 37.9 ± 9.0 years range of (15-70). The mean CD4+ cell counts over the study period were 141.7 ± 176.5 (1-1022), 192.4 ± 198.5 (3-1275), 221.2 ± 178.0 (3-1300), 247.2 ± 197.7 (1-1401) and 268.6 ± 189.9 (1-1390) cells/µl at 0,3,6,9 and 12 months respectively. Nine patients had higher CD4+ cell counts > 350 cells/µl (433-1022) at baseline and higher HIV-viral RNA range between  51,830-1million copies/µl. The patients had multiple co-morbidities,namely, had tuberculosis, sepsis, cryptococcus meningitis, herpes zoster virus, four had non- Hodgkinfs lymphoma, oral candidiasis, hepatitis B virus, pneumocytis jiroveci pneumonia and HIV with renal dysfunction. Seventy (68%) patients had . 2 opportunistic infections. Mean AST, ALT and haemoglobin levels were 127.8 ± 79.8 IU/L, 157.2 ± 50.1 IU/L and 9.1 ± 4.3 g/dl respectively. No patient tested positive foranti-HCV antibodies.Conclusion: The majority of patients had advanced HIV infection at baseline. There was a slow but steady increase in CD4+ cell count over one year. However only 30(29.1%) of patients achieved immune restoration. Seventy three (70.9%) of patients still had immune depletion with low CD4+ cell counts at one year of receiving HAART. Patients with low CD4 + cell counts at baseline had a steady increase of CD4+ cells over the first six months and this emphasises the need to initiate HAART early in public health policy strategy. Expedited HAART initiation should be done in  patients with CD4+ cell counts < 350 cells/µl. Delayed HAART, at low CD4+ cell counts, is associated with poor immune recovery/restoration

Spatial distribution and habitat characterisation of mosquito species in the lake and land habitats of western Kenya

Background: Infections with mosquito-borne parasites are common in humanpopulations inhabiting tropical regions of the world. Malaria is endemic along Kenyan Lake Victoria basin and its vectors are fresh water breeders. However, much less is known about the current spatial distribution and habitat characterisation of mosquitoes including vectors of malaria in the lake waters and adjacent terrestrial aquatic habitats.Objectives: To characterise mosquito larval habitats and to determine the spatialdistribution of mosquito species in lake and land habitats, measure aquatic habitats’ (water) physic-chemical parameters, enumerate the number of phytoplankton, zooplankton and fish species and determine their effects on the abundance of mosquitoes. This could allow larval control to be more effectively targeted at specific sites which in its turn could reduce malaria transmission in the area.Design: Cross-sectional study.Setting: The Kenyan Lake Victoria Basin.Results: Anopheles and Culex species of mosquitoes were absent in different locations in the lake, but abundant in different aquatic habitats in different locations on land. There was heterogeneity in the relative abundance of Anopheles and Culex species in the aquatic habitats in different locations on land, p<0.001, Bartlett’s test. There were more Anopheles mosquito in quary and shoreline swamp puddles, flood plain, and stream edge puddles than natural swamps, rivers and permanent ponds habitats, P<0.001. There was no significant correlation of the abundance of Anopheles and physico-chemical parameters, P>0.05 (Pearsons correlation coefficiency). Also, there was no significant correlation between abundance of Anopheles mosquitoes and phytoplanktons, (P>0.05). Significant correlation was however, observed with Dinoflagellates on land, P=0.014. Clarias gariepinus were more insectivorous compared to Oreochromis niloticus, which mostly fed on zooplankton and food remains. The most abundant mosquitoes in the lake were Mansonia followed by Aedes species of mosquitoes.Conclusion: Anopheles species of mosquitoes do not breed in deep permanent lake waters even if it is heavily infested by water hyacinth and other aquatic weeds. However, they breed in temporary or seasonal aquatic land habitats such as pools and swamps, more so when infested by aquatic and other vegetations. We recommend that, focus of malaria vector control should concentrate on land sites. Health education and awareness programs should be scaled up to inform the local communities on mosquito species ecology in relation to transmission of malaria and other mosquito- borne diseases. There is need to introduce certain fish species (Clarias gariepinus) for biological control of mosquitoes breeding in the aquatic habitats near human habitats

Knowledge and Perceptions on Malaria and Its Association with Aquatic Habitats

Background: Malaria remains the major cause of morbidity and mortality among children in Kenya. About 70 percent of the population is at risk of infection, and roughly 34,000 young children die of malaria-related causes annually.Objective: To investigate the knowledge and perceptions of the local people for malaria in relation to aquatic habitats along the Kenyan Lake Victoria basin.Design: Community-based cross-sectional study.Setting: The Kenyan Lake Victoria basin Region.Subjects: Two hundred and fourty three individuals (both women and men residing in the beaches and surrounding areas) were interviewed about their knowledge and perceptions regarding malaria.Results: Mosquitoes were perceived to be the main cause of malaria. Most respondents were familiar with the main signs and symptoms of mild malaria. Majority of the respondents had poor knowledge of mosquito breeding habitats with 45% mentioning the lake and only 18.6 and 8.9% mentioning ponds and dams, respectively. Most female respondents did not know the difference between mosquitoes and lake flies, P=0.03, Fishers exact test. The majority (97.5%) of the respondents reported seeking conventional malaria treatment from health institutions.Conclusion: Mosquitoes are perceived to be the main cause of malaria by both males and females. A significant proportion of the respondents were familiar with the main signs and symptoms of malaria and sought conventional medicine for treatment of the disease. Most of the respondents, however, had poor knowledge on the breeding habitats of mosquitoes. Concerted effort is needed to scale-up health education and improve the knowledge of the community about mosquitoes and their breeding habitats, particularly malaria vectors which do not breed in deep lake waters. Effective anti-malarial drugs should also be available at the grassroots level where the problem of malaria is rampant

Cuidados paliativos

RESUMO Reconhecido como uma forma inovadora de assistência à saúde, o Cuidado Paliativo vem ganhando espaço no Brasil, especialmente na última década. Diferencia-se fundamentalmente da medicina curativa por focar no cuidado integral, através da prevenção e do controle de sintomas, para todos os pacientes que enfrentem doenças graves, ameaçadoras da vida - conceito que também se aplica a familiares, cuidadores e equipe de saúde e seu entorno, que adoece e sofre junto. Neste artigo, recuperamos o histórico do movimento dos Cuidados Paliativos no mundo, apresentamos seus conceitos e princípios e apontamos o estado da arte da prática no Brasil, especialmente da organização dos serviços e das recentes regulamentações a que estão submetidos profissionais, pacientes e instituições públicas e privadas que nela orbitam

Evaluation of a social marketing intervention promoting oral rehydration salts in Burundi

<p>Abstract</p> <p>Background</p> <p>Diarrhea is the second leading cause of death for children under five in Burundi; however, use of oral rehydration salts (ORS), the recommended first-line treatment, remains low. In 2004, PSI/Burundi launched a social marketing intervention to promote ORASEL among caregivers of children under five; the product was relaunched in 2006 with a new flavor. This study evaluates the intervention after the ORASEL relaunch, which included mass media and interpersonal communication activities. The study looks at trends in ORASEL use in Burundi and in behavioral determinants that may be related to its use.</p> <p>Methods</p> <p>In 2006 and 2007, PSI conducted household surveys among Burundian females of reproductive age (15-49). Both surveys used a two-stage sampling process to select 30 households in each of 115 rural and urban collines throughout the nation. Survey respondents were asked about diarrhea treatment-related behavior; key behavioral determinants; and exposure to the ORASEL intervention. Data were analyzed to identify trends over time, characteristics of ORASEL users, and associations between exposure to the intervention and changes in ORASEL use and related behavioral determinants.</p> <p>Results</p> <p>ORASEL use among caregivers at their children's last diarrheal episode increased significantly from 20% in 2006 to 30% in 2007, and there were also desirable changes in several behavioral determinants associated with ORASEL use. Evaluation analysis showed that a higher level of exposure to the social marketing campaign was associated with greater use of ORASEL and with significant improvements in perceived availability, knowledge of the signs of diarrhea and dehydration, social support, and self-efficacy.</p> <p>Conclusions</p> <p>ORS use can be improved through social marketing and educational campaigns that make the public aware of the availability of the product, encourage dialogue about its use, and increase skills and confidence relating to correct product preparation and administration. Further interventions in Burundi and elsewhere should promote ORS through a variety of mass media and interpersonal communication channels, and should be rigorously evaluated in the context of the total market for diarrhea treatment products.</p

The Recognition of and Care Seeking Behaviour for Childhood Illness in Developing Countries: A Systematic Review

Background: Pneumonia, diarrhoea, and malaria are among the leading causes of death in children. These deaths are largely preventable if appropriate care is sought early. This review aimed to determine the percentage of caregivers in low- and middle-income countries (LMICs) with a child less than 5 years who were able to recognise illness in their child and subsequently sought care from different types of healthcare providers. Methods and Findings: We conducted a systematic literature review of studies that reported recognition of, and/or care seeking for episodes of diarrhoea, pneumonia or malaria in LMICs. The review is registered with PROSPERO (registration number: CRD42011001654). Ninety-one studies met the inclusion criteria. Eighteen studies reported data on caregiver recognition of disease and seventy-seven studies on care seeking. The median sensitivity of recognition of diarrhoea, malaria and pneumonia was low (36.0%, 37.4%, and 45.8%, respectively). A median of 73.0% of caregivers sought care outside the home. Care seeking from community health workers (median: 5.4% for diarrhoea, 4.2% for pneumonia, and 1.3% for malaria) and the use of oral rehydration therapy (median: 34%) was low. Conclusions: Given the importance of this topic to child survival programmes there are few published studies. Recognition of diarrhoea, malaria and pneumonia by caregivers is generally poor and represents a key factor to address in attempts to improve health care utilisation. In addition, considering that oral rehydration therapy has been widely recommended for over forty years, its use remains disappointingly low. Similarly, the reported levels of care seeking from community health workers in the included studies are low even though global action plans to address these illnesses promote community case management. Giving greater priority to research on care seeking could provide crucial evidence to inform child mortality programmes