Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Retrospective Analysis of Three Years of a Programme in Lusaka

Background

While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka.

Programme Activities and Analysis

Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression.

Findings

1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM (RR of SAM 10.9; 95%CI 3.4,34.8; P<0.0001), and higher in children with HIV infection (RR 5.2, 95%CI 2.9, 9.0; P<0.0001). In multivariate analysis, HIV (OR 5.2; 95%CI 2.6, 10.1; P<0.0001), MUAC <11.5cm (OR 4.1; 95%CI 2.2, 7.4; P<0.0001) and the first year of the programme (OR 1.9; 95%CI 1.0, 3.4; P = 0.04) all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality (RR 0.23; 95%CI 0.10, 0.57; P = 0.0008).

Interpretation

Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.     

Yields and accumulations of N and P in farmer-managed intercrops of maize–pigeonpea in semi-arid Africa

Maize (Zea mays L.) is a major staple food in Sub-Saharan Africa but low soil fertility, limited resources and droughts keep yields low. Cultivation of maize intercropped with pigeonpea (Cajanus cajan L. Millsp.) is common in some areas of eastern and southern Africa. The objectives of this study were (1) to investigate dry matter, nitrogen (N) and phosphorus (P) accumulation in different plant components of maize–pigeonpea intercropping systems and (2) to report the effects of the intercrops on soil fertility. Maize–pigeonpea intercrops were compared to sole maize grown using farmersȁ9 practices. Intercropping maize and pigeonpea increased (P < 0.05) total system yield compared to sole maize in terms of biomass, N and P accumulation. Pigeonpea planted in maize did not reduce (P < 0.05) the accumulation of dry matter, N nor P in the maize grain. The harvest indices of maize, calculated on basis dry matter, N or P did not differ either (P < 0.05). Total soil C and N contents and inorganic N content, nitrate and ammonium, were not affected by two seasons of maize–pigeonpea intercropping compared to sole maize (P > 0.11). Nitrate and ammonium levels in soil were still not affected by the treatments after the soils were incubated in anaerobic conditions for 8 days at 37°C (P > 0.11). However, pigeonpea added up to 60 kg of N ha⁻¹ to the system and accumulated up to 6 kg of P ha⁻¹ and only 25% of this N and P were exported in the grain. In conclusion, beside the added grain yield of pigeonpea in the intercropped systems, pigeonpea increased the recirculation of dry matter, N and P, which may have a long-term effect on soil fertility. Furthermore, the stems from pigeonpea contributed to household fuel wood consumption. The intercropped system thus had multiple benefits that gave significant increase in combined yield per unit area without additional labour requirements. The main requirement in order to up-scale the maize–pigeonpea intercropping approach is sufficient supply of high-quality pigeonpea seeds.     

Phase II Evaluation of Sensitivity and Specificity of PCR and NASBA Followed by Oligochromatography for Diagnosis of Human African Trypanosomiasis in Clinical Samples from D.R. Congo and Uganda

Background

The polymerase chain reaction (PCR) and nucleic acid sequence-based amplification (NASBA) have been recently modified by coupling to oligochromatography (OC) for easy and fast visualisation of products. In this study we evaluate the sensitivity and specificity of the PCR-OC and NASBA-OC for diagnosis of Trypanosoma brucei gambiense and Trypanosoma brucei rhodesiense human African trypanosomiasis (HAT).

Methodology and Results

Both tests were evaluated in a case-control design on 143 HAT patients and 187 endemic controls from the Democratic Republic of Congo (DRC) and Uganda. The overall sensitivity of PCR-OC was 81.8% and the specificity was 96.8%. The PCR-OC showed a sensitivity and specificity of 82.4% and 99.2% on the specimens from DRC and 81.3% and 92.3% on those from Uganda. NASBA-OC yielded an overall sensitivity of 90.2%, and a specificity of 98.9%. The sensitivity and specificity of NASBA-OC on the specimens from DRC was 97.1% and 99.2%, respectively. On the specimens from Uganda we observed a sensitivity of 84.0% and a specificity of 98.5%.

Conclusions/Significance

The tests showed good sensitivity and specificity for the T. b. gambiense HAT in DRC but rather a low sensitivity for T. b. rhodesiense HAT in Uganda.     

Mechanisms of arsenical and diamidine uptake and resistance in Trypanosoma brucei

Sleeping sickness, caused by Trypanosoma brucei spp., has become resurgent in sub-Saharan Africa. Moreover, there is an alarming increase in treatment failures with melarsoprol, the principal agent used against late-stage sleeping sickness. In T. brucei, the uptake of melarsoprol as well as diamidines is thought to be mediated by the P2 aminopurine transporter, and loss of P2 function has been implicated in resistance to these agents. The trypanosomal gene TbAT1 has been found to encode a P2-type transporter when expressed in yeast. Here we investigate the role of TbAT1 in drug uptake and drug resistance in T. brucei by genetic knockout of TbAT1. Tbat1-null trypanosomes were deficient in P2-type adenosine transport and lacked adenosine-sensitive transport of pentamidine and melaminophenyl arsenicals. However, the null mutants were only slightly resistant to melaminophenyl arsenicals and pentamidine, while resistance to other diamidines such as diminazene was more pronounced. Nevertheless, the reduction in drug sensitivity might be of clinical significance, since mice infected with tbat1-null trypanosomes could not be cured with 2 mg of melarsoprol/kg of body weight for four consecutive days, whereas mice infected with the parental line were all cured by using this protocol. Two additional pentamidine transporters, HAPT1 and LAPT1, were still present in the null mutant, and evidence is presented that HAPT1 may be responsible for the residual uptake of melaminophenyl arsenicals. High-level arsenical resistance therefore appears to involve the loss of more than one transporter.     

Cerebrospinal fluid neopterin as marker of the meningo-encephalitic stage of Trypanosoma brucei gambiense sleeping sickness

Background

Sleeping sickness, or human African trypanosomiasis (HAT), is a protozoan disease that affects rural communities in sub-Saharan Africa. Determination of the disease stage, essential for correct treatment, represents a key issue in the management of patients. In the present study we evaluated the potential of CXCL10, CXCL13, ICAM-1, VCAM-1, MMP-9, B2MG, neopterin and IgM to complement current methods for staging Trypanosoma brucei gambiense patients.

Methods and Findings

Five hundred and twelve T. b. gambiense HAT patients originated from Angola, Chad and the Democratic Republic of the Congo (D.R.C.). Their classification as stage 2 (S2) was based on the number of white blood cells (WBC) (>5/µL) or presence of parasites in the cerebrospinal fluid (CSF). The CSF concentration of the eight markers was first measured on a training cohort encompassing 100 patients (44 S1 and 56 S2). IgM and neopterin were the best in discriminating between the two stages of disease with 86.4% and 84.1% specificity respectively, at 100% sensitivity. When a validation cohort (412 patients) was tested, neopterin (14.3 nmol/L) correctly classified 88% of S1 and S2 patients, confirming its high staging power. On this second cohort, neopterin also predicted both the presence of parasites, and of neurological signs, with the same ability as IgM and WBC, the current reference for staging.

Conclusions

This study has demonstrated that neopterin is an excellent biomarker for staging T. b. gambiense HAT patients. A rapid diagnostic test for detecting this metabolite in CSF could help in more accurate stage determination.     

Density‐dependent reproduction and pollen limitation in an invasive milkweed,Calotropis procera (Ait.) R. Br. (Apocynaceae)

Calotropis procera (Ait.) R.Br. (Apocynaceae), an invasive woody milkweed, has expanded its range in northern Australia affecting rangeland and pastoral productivity. While self‐compatibility should enhance the species range expansion, spread of C. procera is limited by the availability of larger wasp and bee species that are able to vector its solid pollinia. Pollination efficiency is thus likely dependent on both pollinator abundance and plant density. Calotropis procera flowers year round in Australia but fruiting is limited to the warm months of the year when pollinators are most abundant, indicating that seasonal regulation of reproduction may be due to pollinator limitation. We examine the propositions that C. procera reproduction is regulated by the interaction between plant population density and pollinator pressure and that low pollinator pressure causes low per capita plant fecundity. All pollinators belonged to Order Hymenoptera and pollinator composition was similar at six of the seven sites. Fruit production per plant (fecundity) was lower above and below intermediate densities (350–550 plants ha^?1) of flowering plants with evidence of a weak Allee effect at lower plant density. Pollinator visitation rates per plant were low at high and low plant densities, and greatest at intermediate densities, while pollen supplementation experiments showed that C. procera is pollen limited (Pollen Limitation Index_fruit = 0.9) even at intermediate densities. Pollen limitation caused by low pollinator pressure at low plant densities and pollinator satiation at high plant densities may account for these fruit production trends. Management should be conducted in the colder months when pollinator pressure is low and plants are not reproducing. In addition, where stand eradication cannot be achieved in one attempt, management should reduce flowering plants to below intermediate densities where the fecundity per plant is low.     

Cellular phone‐based photoplethysmographic imaging

We present study results on visible light reflection photoplethysmographic (PPG) imaging with a mobile cellular phone operated in video imaging mode. PPG signal components around 0.1 Hz attributed to the sympathetic component of the heart rate, 1 Hz as the heart rate and 2 Hz as heart rate high order harmonic were quantified on the index finger of a healthy volunteer. The green channel reported PPG signals throughout the sampled area. The blue and red channel returned plethysmographic information, but the signal strength was highly position specific. Our results obtained with a cellular phone as the data acquisition device are encouraging, especially in the broad context of personal or home‐based care and the role of cellular phone technology in medical imaging. (© 2011 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

Plant genomics in Africa: present and prospects

Plants are the world’s most consumed goods. They are of high economic value and bring many health benefits. In most countries in Africa, the supply and quality of food will rise to meet the growing population’s increasing demand. Genomics and other biotechnology tools offer the opportunity to improve subsistence crops and medicinal herbs in the continent. Significant advances have been made in plant genomics, which have enhanced our knowledge of the molecular processes underlying both plant quality and yield. The sequencing of complex genomes of African plant species, facilitated by the continuously evolving next-generation sequencing technologies and advanced bioinformatics approaches, has provided new opportunities for crop improvement. This review summarizes the achievements of genome sequencing projects of endemic African plants in the last two decades. We also present perspectives and challenges for future plant genomic studies that will accelerate important plant breeding programs for African communities. These challenges include a lack of basic facilities, a lack of sequencing and bioinformatics facilities, and a lack of skills to design genomics studies. However, it is imperative to state that African countries have become key players in the plant genome revolution and genome derived-biotechnology. Therefore, African governments should invest in public plant genomics research and applications, establish bioinformatics platforms and training programs, and stimulate university and industry partnerships to fully deploy plant genomics, particularly in the fields of agriculture and medicine.     

Optimizing vaccine development

Optimizing the development of modern molecular vaccines requires a complex series of interdisciplinary efforts involving basic scientists, immunologists, molecular biologists, clinical vaccinologists, bioinformaticians and epidemiologists. This review summarizes some of the major issues that must be carefully considered. The intent of the authors is to briefly describe key components of the development process to give the reader an overview of the challenges faced from vaccine concept to vaccine delivery. Every vaccine requires unique features based on the biology of the pathogen, the nature of the disease and the target population for vaccination. This review presents general concepts relevant for the design and development of ideal vaccines protective against diverse pathogens.