Incidence and predictors of immune reconstitution inflammatory syndrome in a rural area of Mozambique

Background

There is limited data on the epidemiology of Immune Reconstitution Inflammatory Syndrome (IRIS) in rural sub-Saharan Africa. A prospective observational cohort study was conducted to assess the incidence, clinical characteristics, outcome and predictors of IRIS in rural Mozambique.

Methods

One hundred and thirty-six consecutive antiretroviral treatment (ART)-naïve HIV-1-infected patients initiating ART at the Manhiça district hospital were prospectively followed for development of IRIS over 16 months. Survival analysis by Cox regression was performed to identify pre-ART predictors of IRIS development.

Results

Thirty-six patients developed IRIS [26.5%, incidence rate 3.1 cases/100 persons-month of ART (95% CI 2.2–4.3)]. Median time to IRIS onset was 62 days from ART initiation (IQR 35.5–93.5). Twenty-five cases (69.4%) were “unmasking”, 10 (27.8%) were “paradoxical”, and 1 (2.8%) developed a paradoxical worsening followed by the unmasking of another condition. Systemic OI (OI-IRIS) accounted for 47% (17/36) of IRIS cases, predominantly of KS (8 cases) and TB (6 cases) IRIS. Mucocutaneous IRIS manifestations (MC-IRIS) accounted for 53% (19/36) of IRIS events, mostly tinea (9 cases) and herpes simplex infection (3 cases). Multivariate analysis identified two independent predictors of IRIS development: pre-ART CD4 count <50 cells/µl (HR 2.3, 95% CI 1.19–4.44, p = 0.01) and body mass index (BMI) <18.5 (HR 2.15, 95% CI 1.07–4.3, p = 0.03). The pre-cART proportion of activated T-cells, as well as the immunologic and virologic response to ART were not associated with IRIS development. All patients continued on ART, 7 (19.4%) required hospitalization and there were 3 deaths (8.3%) attributable to IRIS.

Conclusions

IRIS is common in patients initiating ART in rural Mozambique. Pre-ART CD4 counts and BMI can easily be assessed at ART initiation in rural sub-Saharan Africa to identify patients at high risk of IRIS, for whom close supervision is warranted.     

Effect of birthplace on infants with low birth weight.

From December 1983 to June 1985, 162 infants of less than 32 weeks'' gestation or weighing less than 1,500 g, or both, were cared for at the regional neonatal intensive care unit in Leeds. Of the 162, 64 (40%) were born in the unit because their mothers had received antenatal care there, 58 (36%) were born in another hospital and subsequently transferred, and 40 (25%) were transferred in utero because of potential complications. The overall mortalities for each group were 14%, 38%, and 18% respectively. These differences were significant, but when they were corrected for gestation, birth weight, and mode of delivery there was no difference in either the mortality or the incidence of intraventricular haemorrhage in the three study populations. Although there seem to be no distinct advantages of in utero transfer in terms of mortality and morbidity, there are other psychological and emotional advantages.     

Deprivation,low birth weight,and children's height: a comparison between rural and urban areas.

OBJECTIVE--To compare proportions of low birthweight babies and mean heights of schoolchildren between rural and urban areas at different levels of social deprivation. DESIGN--Cross sectional population based study classifying cases by Townsend material deprivation index of enumeration district of residence and by rural areas, small towns, and large towns. SETTING--Northumberland Health District. SUBJECTS--18,930 singleton infants delivered alive during January 1985 to September 1990 and resident in Northumberland in October 1990; 9055 children aged 5 to 8 1/2 years attending Northumberland schools in the winter of 1989-90. MAIN OUTCOME MEASURES--Odds ratios for birth weight less than 2800 g; difference in mean height measured by standard deviation (SD) score. RESULTS--Between the most deprived and most affluent 20% of enumeration districts the odds ratio for low birth weight adjusted for rural or urban setting was 1.71 (95% confidence interval 1.51 to 1.93) and the difference in mean height -0.232 SD score (-0.290 to -0.174). Between large towns and rural areas the odds ratio for low birth weight adjusted for deprivation was 1.37 (1.23 to 1.53) and the difference in mean height -0.162 SD score (-0.214 to -0.110). Results for small towns were intermediate between large towns and rural areas. CONCLUSIONS--Inequalities in birth weight and height exist in all rural and urban settings between deprived and affluent areas. In addition, there is substantial disadvantage to living in urban areas compared with rural areas which results from social or environmental factors unrelated to current levels of deprivation.     

Chromosome breakage in low birth weight newborns.

The frequency of chromosome aberrations in cells cultured from umbilical cord blood was determined for 50 low birth weight (LBW) and 50 normal birth weight (NBW) euploid newborns matched for sex, race, and maternal age. The metaphase spreads had been prepared in the course of an earlier study of frequency of aneuploidy and results are from 72-h cultures, i.e., presumably, at the second division in vitro. There were no significant differences between the two groups in the frequency of cells with chromosome breakage, chromosome gaps, or hyperdiploid cells. There was, however, a significantly higher frequency of hypodiploid cells in the LBW group. The present findings differ from those of others who have reported an increase in chromosome breakage in premature newborns.     

Patterns of low birth weight in the Bengali newborns

This paper examines the distribution of low birth weight (2500 g or less) by gestation time, sex, maternal age, parity (birth order), socioeconomic conditions, and season of birth among 5117 single live births born to Bengali mothers at the Ramakrishna Mission Seva Pratisthan Hospital in Calcutta, India. Preterm infants have low birth weight significantly more often than their full term counterparts. Female infants have low birth weights significantly more often than male infants. The infants of poor mothers have lower birth weights in higher order births more often than infants of higher orders born to well-off mothers. Teenaged mothers produce low birth weight babies significantly more often than older mothers. Although the relationship is not significant, low birth weight infants occur more often among 1st and late born infants and less often among 2nd born infants. The season of birth is not significantly associated with birth weight. Less than 10% of low birth weight infants are pre-term, while the rest are full term. The great majority of low birth weight infants are small-for-gestational-age; the minority are small due to curtailed gestational age. The proportion of infants weighing less than 2001 g is only 9%; this figure tallies closely with earlier studies of India.     

Race and the inheritance of low birth weight

This paper uses intergenerational data from the Panel Study of Income Dynamics (PSID) to address the black-white difference in propensities toward low birth weight (LBW). We determine that socioeconomic conditions account for some variation in low birth weight across race. Further, while race differences in the risk of low birth weight cannot be explained entirely, we find that the inheritance of parental birth weight status dramatically reduces the black-white gap in low birth weight. Intergenerational legacies of poor infant health explain the largest share of racial disparities in filial birth weight. We then try to assess whether this intergenerational transmission of low birth weight is indeed genetic by using grandparent-fixed effects models to factor out, to a great extent, family socioeconomic circumstances. We find that even within this framework, both father's and mother's birth weight status have an important impact on filial outcomes. However, the degree of inheritance is weaker for African Americans than for other races. Finally, we theorize that the importance of paternal birth weight status implies a genetic association that does not work through the uterine environment but rather through the fetus itself.     

Maternal and neonatal factors influencing premature birth and low birth weight in Australia

This study identified the influences of neonatal and maternal factors on premature birth and low birth weight in New South Wales, Australia. Bivariate and multivariate analyses were used to explore the association of selected neonatal and maternal characteristics with premature birth and low birth weight. The findings of this study showed that premature birth and low birth weight rate significantly varied by infant sex, maternal age, marital status, Aboriginality, parity, maternal smoking behaviour during pregnancy and maternal hypertension. First-born infants, and infants born to mothers aged less than 20 years, or who were single, separated/divorced, Aboriginal or who smoked during the pregnancy, were at increased risk of being premature or of low birth weight. This study also found that risk factors for premature births and low birth weight were similar in both singleton and multiple births. Gestational age was confirmed to be the single most important risk factor for low birth weight. The findings of this study suggest that in order to reduce the incidence of low birth weight and premature births, health improvement strategies should focus on anti-smoking campaigns during pregnancy and other healthcare programmes targeted at the socially disadvantaged populations identified in the study.     

Factors affecting birth weight of a newborn--a community based study in rural Karnataka, India

Background

Low birth weight (LBW) is a major public health problem in many developing countries, especially so in India. Although we do not know all the causes of LBW, maternal and environmental factors appear to be significant risk factors in its occurrence.

Objectives

To know the factors affecting the birth weight of a newborn and to estimate the prevalence of LBW.

Methods

The present study was carried out amongst 1138 pregnant women and their newborns residing in area covered by Kinaye Primary Health Centre in rural Karnataka, India. The study was conducted from 1^st June 2008 to 31^st December 2009.

Results

The mean birth weight of newborns was 2.6 kg with a range of 1.2 to 3.8 kg. The prevalence of LBW was 22.9%. Among the studied risk factors, 25 of them were significantly associated with the birth weight of a newborn on univariate logistic regression analysis. Maternal education [Odds Ratio (OR) 3.2], exposure to passive smoking [OR 2.3], age at first pregnancy ≥25 years [OR 3.6], birth interval <2 years [OR 2.4], previous history of LBW baby [OR 3.3], weight gain ≤4 kg during pregnancy [OR 7.0], maternal weight at last week of gestation ≤45 kg [OR 2.3], pregnancy induced hypertension [OR 3.3], high risk pregnancy [OR 3.6] and late antenatal registration [OR 3.6] emerged as significant risk factors on multivariate analysis.

Conclusion

The problem of LBW is multidimensional, and hence, we need an integrated approach incorporating medical, social, economical and educational measures to address this issue.     

Mid-arm circumference at birth as predictor of low birth weight and neonatal mortality

In Bangladesh, like other developing countries, most births occur at home or in the community, so logistic problems and taboos prevent the weighing of every newborn child. This study was performed to see whether other simpler measurements could be substituted for weight to identify neonates of low birth weight. A total of 1676 live births at the Chittagong Medical College Hospital constituted the study sample, and this showed a high correlation between mid-arm circumference and birth weight (r=0.792, p<0.000). A mid-arm circumference of <9.0 cm had the best sensitivity and specificity for identifying newborns with a birth weight of less than 2500 g. These neonates were followed up to record neonatal deaths. Neonatal mortality showed an inverse relation with mid-arm circumference. A mid-arm circumference of <9.0 cm and a birth weight of <2500 g were equally useful in predicting neonatal outcome. Mid-arm circumference is a simple, quick and reliable indicator for predicting low birth weight and neonatal outcome, and can be easily measured by medical practitioners and traditional birth attendants (TBAs) in the community of developing countries like Bangladesh.