A literature review and survey of childhood pneumonia etiology studies: 2000-2010.

The Pneumonia Etiology Research for Child Health (PERCH) project is the largest multicountry etiology study of childhood pneumonia since the Board on Science and Technology in International Development studies of the 1980s. However, it is not the only recent or ongoing pneumonia etiology study, and even with seven sites, it cannot capture all epidemiologic settings in the developing world. Funding providers, researchers and policymakers rely on the best available evidence to strategically plan programs, new research directions and interventions. We aimed to describe the current landscape of recent pneumonia etiology studies in children under 5 years of age in the developed and developing world, as ascertained by a literature review of relevant studies with data since the year 2000 and a survey of researchers in the field of childhood pneumonia. We collected information on the study population, study design, case definitions, laboratory samples and methods and identified pathogens. A literature review identified 88 studies with child pneumonia etiology results. As of June 2010, our survey of researchers identified an additional 65 ongoing and recently completed child pneumonia etiology studies. This demonstrates the broad existing context into which the PERCH study must be placed. However, the landscape analysis also reveals a multiplicity of case definitions, levels of clinician involvement, facility types, specimen collection, and laboratory techniques. It reinforces the need for the standardization of methods and analyses for present and future pneumonia etiology studies in order to optimize their cumulative potential to accurately describe the microbial causes of childhood pneumonia

Interpersonal violence against women and maternity care in Migori County, Kenya: evidence from a cross-sectional survey

BackgroundInterpersonal violence (IPV) is an issue of major public health concern, with 24% of Kenyan women reporting physical violence perpetrated by a current husband or partner. IPV has profound impacts on physical and mental health outcomes, particularly for pregnant women; it has been found to increase the risk of perinatal mortality, low birth weight, and preterm birth. This study aims to identify variables associated with IPV and assess the effects of IPV experience on prenatal and peripartum maternal healthcare in Migori County, Kenya. Findings build on a previous study that investigated a smaller region of Migori County.MethodsResponses to cross-sectional household surveys conducted in six wards of Migori County, Kenya in 2021 from female respondents aged 18 and older were analyzed. The survey contained validated screening tools for interpersonal violence. Group-wise comparisons, and bivariate and multivariate logistic regression analyses were performed to describe community prevalence, factors associated with IPV against women, and the effect of IPV exposure on prenatal and peripartum health care.ResultsThis study finds that 2,306 (36.7%) of the 6,290 respondents had experienced lifetime IPV. IPV experience was associated with the age group 25–49 (adjusted odds ratio (aOR) 1.208; 95%CI: [1.045–1.397]; p = 0.011), monogamous marriage [aOR 2.152; 95%CI: (1.426–3.248); p < 0.001], polygamous marriage [aOR 2.924; 95%CI: (1.826–4.683); p < 0.001], being widowed/divorced/separated [aOR 1.745; 95%CI: (1.094–2.786); p < 0.001], feeling an attitude of “sometimes okay” toward wife beating [aOR 2.002 95%CI: (1.651, 2.428); p < 0.001], having been exposed to IPV in girlhood [aOR 2.525; 95%CI: (2.202–2.896); p < 0.001] and feeling safe in the current relationship [aOR 0.722; 95%CI: (0.609, 0.855); p < 0.001]. A depression score of mild [aOR 1.482; 95%CI: (1.269, 1.73); p < 0.001] and severe [aOR 2.403; 95%CI: (1.429, 4.039); p = 0.001] was also associated with IPV experience, and women who experienced emotional abuse were much more likely to have experienced IPV [aOR 10.462; 95% CI: (9.037, 12.112); p < 0.001]. Adjusted analyses showed that having experienced IPV was negatively associated with attending at least four antenatal care visits during the most recent pregnancy (OR 0.849, p = 0.044) and with having a skilled birth attendant (OR 0.638, p = 0.007).ConclusionsIPV is prevalent in Migori County, Kenya, with increased prevalence among women aged 25–49, those residing in West Kanyamkago, those in a monogamous or polygamous marriage, those who have been widowed/divorced/separated, and those with severe depressive symptoms. Further, IPV exposure is associated with lower use of maternal care services and may lead to worse maternal health outcomes. There is need for enhanced effort in addressing social and gender norms that perpetuate IPV, and this study can contribute to guiding policy interventions and community responses towards IPV

Ten Years of Surveillance for Invasive Streptococcus pneumoniae during the Era of Antiretroviral Scale-Up and Cotrimoxazole Prophylaxis in Malawi

OBJECTIVE: To document trends in invasive pneumococcal disease (IPD) in a central hospital in Malawi during the period of national scale-up of antiretroviral therapy (ART) and cotrimoxazole prophylaxis. METHODS: Between 1 January 2000 and 31 December 2009 almost 100,000 blood cultures and 40,000 cerebrospinal fluid (CSF) cultures were obtained from adults and children admitted to the Queen Elizabeth Central Hospital, Blantyre, Malawi with suspected severe bacterial infection. RESULTS: 4,445 pneumococcal isolates were obtained over the 10 year period. 1,837 were from children: 885 (19.9%) from blood and 952 (21.4%) from CSF. 2,608 were from adults: 1,813 (40.8%) from blood and 795 (17.9%) from CSF. At the start of the surveillance period cotrimoxazole resistance was 73.8% and at the end was 92.6%. Multidrug resistance (MDR) was present in almost one third of isolates and was constant over time. Free ART was introduced in Malawi in 2004. From 2005 onwards there was a decline in invasive pneumococcal infections with a negative correlation between ART scale-up and the decline in IPD (Pearson's correlation r = -0.91; p<0.001). CONCLUSION: During 2004-2009, national ART scale-up in Malawi was associated with a downward trend in IPD at QECH. The introduction of cotrimoxazole prophylaxis in HIV-infected groups has not coincided with a further increase in pneumococcal cotrimoxazole or multidrug resistance. These data highlight the importance of surveillance for high disease burden infections such as IPD in the region, which will be vital for monitoring pneumococcal conjugate vaccine introduction into national immunisation programmes

Undisclosed Antiretroviral Drug Use in a Multinational Clinical Trial (HIV Prevention Trials Network 052)

The HIV Prevention Trials Network 052 study enrolled serodiscordant couples. Index participants infected with human immunodeficiency virus reported no prior antiretroviral (ARV) treatment at enrollment. ARV drug testing was performed retrospectively using enrollment samples from a subset of index participants. ARV drugs were detected in 45 of 96 participants (46.9%) with an undetectable viral load, 2 of 48 (4.2%) with a low viral load, and 1 of 65 (1.5%) with a high viral load (P < .0001); they were also detected in follow-up samples from participants who were not receiving study-administered treatment. ARV drug testing may be useful in addition to self-report of ARV drug use in some clinical trial settings

Randomized controlled phase IIa clinical trial of safety, pharmacokinetics and pharmacodynamics of tenofovir and tenofovir plus levonorgestrel releasing intravaginal rings used by women in Kenya

IntroductionGlobally, many young women face the overlapping burden of HIV infection and unintended pregnancy. Protection against both may benefit from safe and effective multipurpose prevention technologies.MethodsHealthy women ages 18–34 years, not pregnant, seronegative for HIV and hepatitis B surface antigen, not using hormonal contraception, and at low risk for HIV were randomized 2:2:1 to continuous use of a tenofovir/levonorgestrel (TFV/LNG), TFV, or placebo intravaginal ring (IVR). In addition to assessing genital and systemic safety, we determined TFV concentrations in plasma and cervicovaginal fluid (CVF) and LNG levels in serum using tandem liquid chromatography-mass spectrometry. We further evaluated TFV pharmacodynamics (PD) through ex vivo CVF activity against both human immunodeficiency virus (HIV)-1 and herpes simplex virus (HSV)-2, and LNG PD using cervical mucus quality markers and serum progesterone for ovulation inhibition.ResultsAmong 312 women screened, 27 were randomized to use one of the following IVRs: TFV/LNG (n = 11); TFV-only (n = 11); or placebo (n = 5). Most screening failures were due to vaginal infections. The median days of IVR use was 68 [interquartile range (IQR), 36–90]. Adverse events (AEs) were distributed similarly among the three arms. There were two non-product related AEs graded &gt;2. No visible genital lesions were observed. Steady state geometric mean amount (ssGMA) of vaginal TFV was comparable in the TFV/LNG and TFV IVR groups, 43,988 ng/swab (95% CI, 31,232, 61,954) and 30337 ng/swab (95% CI, 18,152, 50,702), respectively. Plasma TFV steady state geometric mean concentration (ssGMC) was &lt;10 ng/ml for both TFV IVRs. In vitro, CVF anti-HIV-1 activity showed increased HIV inhibition over baseline following TFV-eluting IVR use, from a median of 7.1% to 84.4% in TFV/LNG, 15.0% to 89.5% in TFV-only, and −27.1% to −20.1% in placebo participants. Similarly, anti-HSV-2 activity in CVF increased &gt;50 fold after use of TFV-containing IVRs. LNG serum ssGMC was 241 pg/ml (95% CI 185, 314) with rapid rise after TFV/LNG IVR insertion and decline 24-hours post-removal (586 pg/ml [95% CI 473, 726] and 87 pg/ml [95% CI 64, 119], respectively).ConclusionTFV/LNG and TFV-only IVRs were safe and well tolerated among Kenyan women. Pharmacokinetics and markers of protection against HIV-1, HSV-2, and unintended pregnancy suggest the potential for clinical efficacy of the multipurpose TFV/LNG IVR.Clinical Trial RegistrationNCT03762382 [https://clinicaltrials.gov/ct2/show/NCT03762382

Behind the data: establishing the Network for Surveillance of Pneumococcal Disease in the East African Region.

In a region with high rates of mortality among children aged <5 years, the underfunded health care systems of sub-Saharan Africa have few resources available to perform surveillance activities that can help determine the causes of morbidity and mortality in the region. At present, there are few examples of attempts to promote public health care surveillance that might inform current debates about how to expand and improve surveillance, particularly for bacterial diseases. Driven by this gap in knowledge, we attempted to explore the successes and failures of the Network for Surveillance of Pneumococcal Disease in the East African Region and to share the experiences of what are essentially nonresearch public-sector hospitals in East Africa, with the hopes that surveillance systems for other diseases, especially those that require complex diagnostic support, may be informed by these experiences. The state of services essential for surveillance and the measures taken to overcome any shortcomings are described, as is the progress made in improving clinical diagnosis, laboratory processing, and data management. For surveillance to play a role in public health care, ministries of health and associated institutions must own and push forward the surveillance agenda, with support from global partners, and take advantage of the developments that have been achieved within the institutions

Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment

OBJECTIVE: To evaluate the relative effectiveness of different policies in attracting nurses to rural areas in Kenya, South Africa and Thailand using data from a discrete choice experiment (DCE). METHODS: A labelled DCE was designed to model the relative effectiveness of both financial and non-financial strategies designed to attract nurses to rural areas. Data were collected from over 300 graduating nursing students in each country. Mixed logit models were used for analysis and to predict the uptake of rural posts under different incentive combinations. FINDINGS: Nurses' preferences for different human resource policy interventions varied significantly between the three countries. In Kenya and South Africa, better educational opportunities or rural allowances would be most effective in increasing the uptake of rural posts, while in Thailand better health insurance coverage would have the greatest impact. CONCLUSION: DCEs can be designed to help policy-makers choose more effective interventions to address staff shortages in rural areas. Intervention packages tailored to local conditions are more likely to be effective than standardized global approaches

Standardizing surveillance of pneumococcal disease

Background. Surveillance for invasive pneumococcal disease has been conducted using a variety of case ascertainment methods and diagnostic tools. Interstudy differences in observed rates of invasive pneumococcal disease could reflect variations in surveillance methods or true epidemiological differences in disease incidence. To facilitate comparisons of surveillance data among countries, investigators of Pneumococcal Vaccines Accelerated Development and Introduction Plan-sponsored projects have developed standard case definitions and data reporting methods. Methods. Investigators developed case definitions for meningitis, pneumonia, and very severe disease using existing World Health Organization guidelines and clinical definitions from Africa and Asia. Standardized case definitions were used to standardize reporting of aggregated results. Univariate analyses were conducted to compare results among countries and to identify factors contributing to detection of Streptococcus pneumoniae. Results. Surveillance sites varied with regard to the age groups targeted, disease syndromes monitored, specimens collected, and laboratory methods employed. The proportion of specimens positive for pneumococcus was greater for cerebrospinal fluid specimens (1.2%-19.4%) than for blood specimens (0.1%-1.4%) in all countries (range, 1.3-38-fold greater). The distribution of disease syndromes and pneumonia severity captured by surveillance differed among countries. The proportion of disease cases with pneumococcus detected varied by syndrome (meningitis, 1.4%-10.8%; pneumonia, 0.2%-1.3%; other, 0.2%-1.2%) and illness severity (nonsevere pneumonia, 0%-2.7%; severe pneumonia, 0.2%-1.2%), although these variations were not consistent for all sites. Antigen testing and polymerase chain reaction increased the proportion of cerebrospinal fluid specimens with pneumococcus identified by 1.3-5.5-fold, compared with culture alone. Conclusions. Standardized case definitions and data reporting enhanced our understanding of pneumococcal epidemiology and enabled us to assess the contributions of specimen type, disease syndrome, pneumonia severity, and diagnostic tools to rate of pneumococcal detection. Broader standardization and more-detailed data reporting would further improve interpretation of surveillance results. © 2009 by the Infectious Diseases Society of America. All rights reserved