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Individual and population-level risk factors for new HIV infections among adults in Eastern and Southern Africa.
No full textDespite substantial recent declines, general population HIV incidence in sub-Saharan Africa remains above international targets. Better description of risk factors for new infections would improve prioritisation of interventions. Using data from population-based cohorts in Kenya, Malawi, Tanzania, South Africa, Uganda, Zimbabwe we described the prevalence of risk factors for men and women aged 15-24 and 25-49 and estimated the association between individual and community-level risk factors and HIV acquisition between 2005 and 2016. Among 43,434 men and 55,919 women aged 15 to 49 there were 4,612 seroconversions. Education, marital status, male circumcision, new sexual partners, types of partner, prevalence of untreated HIV infection in the community and community partner acquisition rates were associated with HIV incidence. Only the prevalence of untreated HIV was a risk for both sexes and apparent at all ages. The prevalence of risk factors varied by age, sex and study. HIV incidence was higher in people aged 25-49 living in communities where men had high partner acquisition rates. Our results show potential for improved prevention through changed timing of prevention interventions relative to behaviour and the utility of using community characteristics to target prevention
Behavior change and infection induced immunity led to the decline of the 2022 Mpox outbreak in Berlin.
No full textBACKGROUND: Mpox denotes a viral zoonosis caused by the Orthopoxvirus monkeypox (MPXV), which is endemic in West and Central Africa. In spring 2022, notable outbreaks of MPXV clade IIb were recorded in several high-income countries, predominantly affecting men who have sex with men (MSM). At the peak of the outbreak, over 200 new mpox cases per week were reported in Berlin, which constitutes one of the largest MSM population in Europe. Within the same year, the outbreak significantly declined, and it is unclear which factors contributed to this rapid decrease.
METHODS: To investigate the concomitant effects of sexual contact networks, transient contact reductions and the effect of infection- vs. vaccine-derived immunity on the 2022 mpox outbreak, we calibrated an agent-based model with epidemic, vaccination, contact- and behavioral data.
RESULTS: Our results indicate that vaccination has a marginal effect on the epidemic decline. Rather, a combination of infection-induced immunity of high-contact individuals, as well as transient behavior changes reduce the number of susceptible individuals below the epidemic threshold. However, the 2022 mpox vaccination campaign, together with infection-derived immunity may contribute to herd-immunity in the Berlin MSM population against ongoing clade I mpox outbreaks. Demographic changes and immune waning may deteriorate this herd immunity over time.
CONCLUSIONS: These findings highlight that, in addition to vaccination, timely and clear communication of transmission routes may trigger spontaneous protective behavior within key populations; underscoring the importance of targeted sexual health education as a core component of outbreak response
Long-term socioeconomic outcomes in Danish children with moderate-to-severe atopic dermatitis.
Get PDFBACKGROUND: The long-term socioeconomic impact of atopic dermatitis (AD) is poorly understood.
OBJECTIVES: To examine if childhood AD is associated with labor market and relationship outcomes in adulthood.
METHODS: This nationwide registry-based Danish cohort study included children born between 1973 and 1991: 8409 with hospital-diagnosed AD before age 18 (baseline) and 853,228 without. A sibling cohort (5119 with AD; 6352 without) was used to control for family-related confounding. The main outcomes were earned income, long-term unemployment, single partnership status and childlessness by age 30. We used linear regression for income and Poisson regression for binary outcomes, adjusted for income, sex, calendar year, comorbidities and childhood socioeconomic status.
RESULTS: Children with AD had slightly lower income (adjusted mean percentile difference - 1.2) and higher risk of long-term unemployment (adjusted relative risk [aRR] 1.11; 95% CI: 1.05-1.17) by age 30, though the absolute difference was <1%. AD was not associated with secondary labor market outcomes (e.g. health-related work absenteeism), except for disability pension, but the RR decreased from 1.55 to 1.15 (95% CI: 1.02-1.30) when adjusting for comorbidities. By age 30, 22.1% with AD remained single versus 19.4% without (aRR 1.11; 95% CI: 1.06-1.15), with stronger associations among males, those with severe eczema, hand/contact dermatitis or low maternal education (aRRs up to 1.41). AD was not associated with childlessness at age 30 (57.7% vs. 56.7%; aRR 1.01; 95% CI: 1.00-1.03), but a 2.5% absolute difference appeared by age 40. In the sibling analysis, most associations diminished.
CONCLUSIONS: Moderate-to-severe childhood AD was not linked to labor market outcomes, apart from disability pensions, likely driven by comorbidities. The probability of partnership or parenthood was reduced in specific subgroups. Confounding from family-related factors cannot be excluded. Nevertheless, the results underscore the importance of considering patients' broader life situations to support them through adulthood
Trajectories of type 2 diabetes and cancer in 330 000 individuals with prediabetes: 20-year observational study in England.
Get PDFBACKGROUND: Higher than normal glucose concentrations have been linked to an increased risk of cancer. We aimed to describe the disease trajectories from prediabetes to cancer, accounting for the possible conversion to type 2 diabetes and risk of death.
METHODS: We used the Clinical Practice Research Datalink primary care records linked to hospital and mortality records to identify individuals aged 18-100 years with newly diagnosed prediabetes between Jan 1, 1998, and Nov 30, 2018, in England. Individuals were followed from the diagnosis of prediabetes until death or Nov 30, 2018, with two intermediate outcomes: type 2 diabetes and cancer. In a multistate model, we estimated state occupancy probabilities and lengths of stay (sojourn times) across eight states and seven transitions (eg, one transition from the prediabetes state to the cancer state; or three transitions from the prediabetes state to the type 2 diabetes, cancer, and death state).
FINDINGS: During a median follow-up of 7·7 years, 163 782 transitions occurred in 328 049 individuals. In both women and men, cancer incidence rates were greater in older individuals (aged ≥75 years at prediabetes diagnosis) and only marginally higher in those who developed type 2 diabetes versus those with prediabetes (over 10 years, the largest differences were 4·1 more cases per 1000 person-years in women and 4·8 more cases per 1000 person-years in men). 10 years after the diagnosis of prediabetes, the probability of remaining in the prediabetes state ranged from 23·2% (men aged ≥75 years at diagnosis) to 72·1% (men aged <55 years), the probability of death following prediabetes ranged from 1·2% (women aged <55 years) to 38·7% (women aged ≥75 years), the probability of developing type 2 diabetes and remaining in this state ranged from 7·9% (men aged ≥75 years) to 24·0% (women aged <55 years), and the probability of developing cancer and remaining in this state ranged from 1·9% (men aged <55 years) to 7·8% (men aged ≥65 to <75 years) in men and women. During the 10 years following the diagnosis of prediabetes, individuals spent between 5·34 years (men aged ≥75 years at diagnosis) to 8·34 years (men aged <55 years) in the prediabetes state. BMI, smoking, socioeconomic status, and ethnicity were associated with occupancy probabilities and sojourn times.
INTERPRETATION: The trajectories of type 2 diabetes and cancer following a diagnosis of prediabetes varied substantially by age at prediabetes diagnosis and, to a lesser extent, other sociodemographic and lifestyle factors, with most younger individuals (aged <55 years) remaining in the prediabetes state. Strategies to improve the prevention and early identification of type 2 diabetes and cancer in individuals with prediabetes should be tailored to the age at which prediabetes is diagnosed.
FUNDING: National Institute for Health and Care Research (NIHR) Applied Research Collaboration, East Midlands, NIHR Leicester British Retail Consortium, Hope Against Cancer
A Randomised Trial of Three Face-Washing Methods for the Removal of Chlamydia trachomatis From the Faces of Children With Severe Active Trachoma.
Get PDFOBJECTIVES: A three-arm, open, parallel-group randomised trial compared three face-washing methods for cleaning Chlamydia trachomatis from the faces of children with severe active trachoma. The impact of face-washing on Chlamydia trachomatis on the hands of children and their caregivers and Chlamydia trachomatis duration on faces and hands were investigated as secondary objectives. METHODS: Children aged 1-7 years in Oromia, Ethiopia, were screened for active trachoma. We aimed to recruit 470 children with severe conjunctival inflammation; 141 were expected to have concurrent conjunctival infection and facial Chlamydia trachomatis , detected by qPCR. Those with severe inflammation were randomly assigned to water alone, water with soap or damp, microfibre towel protocols. Swabs (children's faces/hands, caregivers' hands) were collected pre-wash, post-wash, and at 1, 2, 4, 6 and 8 h. Conjunctival swabs were tested for ocular Chlamydia trachomatis infection; only infected children with facial Chlamydia trachomatis were included in primary analysis, comparing the proportion of faces without Chlamydia trachomatis after each washing method. RESULTS: Of 470 children screened with severe inflammation, 25 (5%) had conjunctival infection and facial Chlamydia trachomatis . All three protocols (n = 12 water only, n = 8 water and soap, n = 5 damp towel) reduced discharge, but none removed Chlamydia trachomatis from faces immediately post-wash. No major facial Chlamydia trachomatis load reduction was observed. Face-washing removed Chlamydia trachomatis from some children's and caregivers' hands, but loads were not significantly reduced where Chlamydia trachomatis persisted. Though Chlamydia trachomatis was transiently absent from one face at 1 h and four at 2 h post-wash, all baseline Chlamydia trachomatis -positive children retained it at 8 h. CONCLUSIONS: No evidence of differential or overall effectiveness of the three washing methods at removing facial Chlamydia trachomatis from children with trachoma was found. This finding is limited by a smaller-than-anticipated sample size, potentially hindering detection of subtle differences or overall effects. TRIAL REGISTRATION: ISRCTN registry: ISRCTN12814010 (April 2023)
Effectiveness of domestic food hygiene interventions on the microbiological quality of child food and childhood diarrhoea: a systematic review and meta-analysis.
Get PDFBACKGROUND: Foodborne diseases are an important cause of global morbidity and mortality, particularly among children who often experience diarrhoeal illnesses linked to foodborne enteric infections. Evidence on the effectiveness of interventions to reduce diarrhoea remains limited. This review synthesised evidence on the effectiveness of domestic food hygiene interventions on microbiological quality of child food and diarrhoea in children under five. METHODS AND FINDINGS: Nine databases were searched, with screening and reviewing conducted independently by two reviewers. Eligible study designs included randomised and non-randomised controlled trials that clearly described a food hygiene intervention and included a concurrent control. Primary outcomes were the microbiological quality of child food and childhood diarrhoea. Risk of bias was assessed using an adapted Newcastle-Ottawa scale, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. Of the 15 586 records identified, 11 were included. Three of four studies that assessed food contamination outcomes reported evidence of reduction in Escherichia coli, faecal coliforms or other bacteria. Eight studies (10 comparisons) reported diarrhoea outcomes, with a pooled 24% reduction in diarrhoea prevalence or incidence (risk ratio, RR 0.76, 95% CI 0.57 to 1.01). Standalone food hygiene interventions (n=2) reduced childhood diarrhoea by 51% (RR 0.49, 95% CI 0.36 to 0.65), whereas combined food hygiene interventions with water, sanitation and hygiene (WASH), nutrition and childhood development (n=8) showed no evidence of an effect (RR 0.88, 95% CI 0.68 to 1.15). Three studies had high risk of bias. Certainty of evidence was moderate for food contamination outcomes and low for diarrhoea outcomes. CONCLUSIONS: Results suggest that standalone domestic food hygiene interventions can improve microbial food quality and reduce childhood diarrhoea. However, these interventions were not effective when integrated into broader packages with WASH, nutrition or childhood development. These findings underscore the importance of dedicated food hygiene interventions for improving child health outcomes. PROSPERO REGISTRATION NUMBER: CRD42022336954
Episiotomy and postpartum haemorrhage in women with moderate or severe anaemia: a cohort analysis of data from the WOMAN-2 trial
Get PDFBackground: Women with anaemia have a higher risk of postpartum haemorrhage than those without anaemia. We examined the association between episiotomy and postpartum haemorrhage in women with moderate or severe anaemia.
Methods: We conducted a cohort analysis using data from the World Maternal Antifibrinolytic-2 (WOMAN-2) trial. Women with moderate or severe anaemia who were giving birth vaginally were recruited from 34 hospitals in Nigeria, Pakistan, Tanzania, and Zambia. On arrival at hospital, the participants’ haemoglobin concentration was measured with a validated point-of-care haemoglobin test. Moderate anaemia was defined as a haemoglobin concentration of 70–99 g/L and severe anaemia as a haemoglobin concentration lower than 70 g/L. Episiotomy was defined as any perineal incision during delivery. Women were excluded from the WOMAN-2 trial if they were younger than 18 years and lacked consent from a guardian, had a known allergy to the trial intervention, had an indication or contraindication to the intervention, or were diagnosed with postpartum haemorrhage before the umbilical cord was clamped. The primary outcome was a clinical diagnosis of postpartum haemorrhage (estimated blood loss ≥500 mL or any blood loss causing haemodynamic instability), and the secondary outcome was calculated postpartum haemorrhage (estimated from peripartum change in haemoglobin concentration). We modelled the outcomes with multilevel logistic regression, adjusting for confounders with inverse probability of treatment weighting.
Findings: Between Aug 24, 2019, and Sept 19, 2023, 4355 (28·9%) of the 15 068 women recruited to the WOMAN-2 trial had an episiotomy. In primiparous women who had non-instrumental births, the incidence of episiotomy was 81·1% in Pakistan (2703 of 3335), 63·3% (307 of 485) in Nigeria, 28·5% (69 of 242) in Zambia, and 15·1% (111 of 735) in Tanzania. Clinically diagnosed postpartum haemorrhage occurred in 1034 (6·9%) of 15 066 participants, and calculated postpartum haemorrhage occurred in 1417 (9·5%) of 14 863. After adjustment for confounders, episiotomy was associated with clinically diagnosed postpartum haemorrhage (odds ratio 1·88, 95% CI 1·33–2·66) and calculated postpartum haemorrhage (1·63, 1·14–2·34).
Interpretation: Although WHO recommends against the routine use of episiotomy, many first-time mothers were given this procedure. Episiotomy might increase the risk of postpartum haemorrhage in women with moderate or severe anaemia. As anaemia is known to worsen the life-threatening complications of postpartum haemorrhage, the risks of routine episiotomy could be even greater in women with anaemia
Perspectives on play for young children with disabilities in South Africa: a qualitative study.
Get PDFPURPOSE: All children have the right to play. Children with disabilities are often excluded from play activities. We aimed to explore caregivers', older community members', and key stakeholders' perceptions and experiences of play as influenced by socio-cultural, institutional, and public policy factors. These insights informed the early stages of intervention development.
MATERIALS AND METHODS: In-depth semi-structured interviews (n = 23) were conducted with caregivers of children with disabilities aged 2-5 years, older community members, and key stakeholders who had experience working with children with disabilities. Data were thematically analysed, following a socio-ecological approach.
RESULTS: Four themes emerged: (i) making play doable and affordable, (ii) play away the challenges, (iii) playing together or not, and (iv) play opportunities. The results highlighted how intrapersonal and interpersonal factors and experiences shaped perspectives of play and play-based interventions for children with disabilities.
CONCLUSIONS: Our findings emphasise the importance of a community-informed approach in grounding the early stages of intervention development, which may help to ensure that a future play-based intervention is contextually appropriate
Long-acting HIV pre-exposure prophylaxis integrated with community-based sexual and reproductive health services in South Africa (LAPIS): study protocol for a hybrid (1a) cluster randomised controlled phase 3B trial of effectiveness and implementation.
No full textBACKGROUND: Barriers and challenges associated with daily oral HIV pre-exposure prophylaxis (PrEP) contribute to poor uptake, low retention, and adherence rates among youth. Offering a choice of PrEP modalities integrated with peer support and delivered through community-based sexual and reproductive health (SRH) services will overcome these challenges. We describe the design of a trial to evaluate this approach at a population level.
METHODS: We are conducting a type 1a hybrid effectiveness, phase 3B, cluster randomised controlled trial (LAPIS) to evaluate the effectiveness and implementation of offering PrEP modality choices through community-based SRH services amongst youth aged 15-30 years living in rural Kwa-Zulu Natal, South Africa. LAPIS is nested within Thetha nami ngithethe nawe (Let's Talk), an ongoing stepped-wedge trial with two periods investigating the effectiveness, implementation, and cost effectiveness of peer-led social mobilisation into decentralised integrated HIV and SRH services on the population prevalence of sexually transmissible HIV amongst youth. In the second period of Thetha nami, 40 trial clusters were randomised 1:1 to receive either a choice of PrEP modalities (oral PrEP, long-acting PrEP, i.e., two-monthly injectable cabotegravir (CAB LA) or dapivirine vaginal ring and HIV post-exposure prophylaxis [PEP] packs) or enhanced standard of care (ESoC) with oral PrEP only. All trial clusters are supported by peer navigators offering peer support and visited monthly by a mobile nurse-led clinic offering adolescent and youth-friendly HIV and SRH services. There are two primary outcomes: (1) effective uptake of PrEP or PEP, and (2) retention on PrEP, defined as attending at least one follow-up appointment after PrEP/PEP initiation, which are based on clinic data. Implementation outcomes are assessed using a mixed-methods and process evaluation following the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework.
DISCUSSION: LAPIS is a pragmatic trial to evaluate the addition of long-acting PrEP modalities to daily oral PrEP within community-based SRH services. By offering PrEP choices, LAPIS adopts a person-centred approach to improve adherence and retention among youth, including hidden key populations. Findings will provide insights into the real-world implementation of CAB-LA.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier-NCT06250504. Registered: 01 February 2024
Is breast cancer survival correlated with indicators of the right to health? An interdisciplinary study in 58 countries.
Get PDFBACKGROUND: Women with breast cancer have different chances of surviving their disease, depending on where they live. When breast cancer is diagnosed and treated early, the chances of longer-term survival improve. Inequalities in survival are deemed unfair, because high survival for breast cancer can be achieved. We enquired whether adoption of a human rights-based approach to breast cancer care and management is correlated with breast cancer survival. METHOD: We reviewed the law literature on key concepts of the human right to health and performed a scoping review of the public health literature. We then used a Delphi technique to identify indicators of the right to health, and collected information for 17 indicators for which consensus was achieved. We then examined correlations with five-year net survival for women diagnosed with breast cancer during 2010-14 in up to 58 OECD countries. We used survival estimates from the CONCORD programme for the global surveillance of cancer survival. RESULTS: Higher survival was correlated with the availability of radiotherapy equipment, financial availability of morphine, morphine consumption, the number of nurses and midwives, and the proportion of eligible women screened for breast cancer in the previous two years. Lower survival was correlated with the proportion of women diagnosed at an advanced stage, out-of-pocket expenditure, and legal recognition of the right to health. CONCLUSION: The findings show that some right-to-health components of health systems are correlated with higher survival for breast cancer, suggesting that adoption of a human rights-based approach to breast cancer care and management may help improve survival and reduce inequalities