Predictors of Persistent Anaemia in the First Year of Antiretroviral Therapy: A Retrospective Cohort Study from Goma,the Democratic Republic of Congo

Background

Anaemia is associated with adverse outcomes including early death in the first year of antiretroviral therapy (ART). This study reports on the factors associated with persistent anaemia among HIV-infected patients initiating ART in the Democratic Republic of Congo (DR Congo).

Methods

We conducted a retrospective cohort study and analyzed data from patients receiving HIV care between January 2004 and December 2012 at two major hospitals in Goma, DR Congo. Haemoglobin concentrations of all patients on ART regimen were obtained prior to and within one year of ART initiation. A logistic regression model was used to identify the predictors of persistent anaemia after 12 months of ART.

Results

Of 756 patients, 69% of patients were anaemic (IC95%: 65.7–72.3) at baseline. After 12 months of follow up, there was a 1.2 g/dl average increase of haemoglobin concentration (P < 0.001) with differences depending on the therapeutic regimen. Patients who received zidovudine (AZT) gained less than those who did not receive AZT (0.99 g/dl vs 1.33 g/dl; p< 0.001). Among 445 patient who had anaemia at the beginning, 33% (147/445) had the condition resolved. Among patients with anaemia at ART initiation, those who did not receive cotrimoxazole prophylaxis before starting ART(AOR 3.89; 95% CI 2.09–7.25; P < 0.001) and a AZT initial regimen (AOR 2.19; 95% CI 1.36–3.52; P < 0.001) were significantly at risk of persistent anaemia.

Conclusions

More than two thirds of patients had anaemia at baseline. The AZT-containing regimen and absence of cotrimoxazole prophylaxis before starting ART were associated with persistent anaemia 12 months, after initiation of treatment. Considering the large proportion of patients with persistence of anaemia at 12 months, we suggest that it is necessary to conduct a large study to assess anaemia among HIV-infected patients in Goma.     

Prospects for Bonobo Insectivory: Lui Kotal, Democratic Republic of Congo

Chimpanzees (Pan troglodytes) are well-known to eat invertebrates, especially social insects, across Africa, but allopatric bonobos (P. paniscus) are not. Bonobo insectivory is sparsely documented and apparently sporadic. However, the availability to bonobos of social insect prey and raw materials with which to make tools to exploit them is unknown. Here, we test a set of hypotheses that relates to questions of presence, abundance, density, and distribution of taxa that Pan consume and of vegetation suitable for making extractive foraging tools. We worked at Lui Kotal, Democratic Republic of Congo, where unprovisioned bonobos live in intact forest, far from villages. We collected insect and fecal specimens, transected for prey and assessed raw materials, and monitored mounds of Macrotermes. All but 1 of the major taxa of relevant termites, ants, and (stinging) honey bees were present. The 3 main taxa of insects that chimpanzees elsewhere eat —Macrotermes (fungus-growing termites), Dorylus (Anomma; army or driver ants), and Apis (honey bees)— were abundant and widespread, and usually at densities exceeding those at well-known chimpanzee study-sites. Similarly, woody and nonwoody vegetation suitable for making fishing probes was common at mounds of Macrotermes. There is no obvious ecological reason why bonobos should not use elementary technology in extractive foraging, e.g., termite-fish, ant-fish, ant-dip, honey-dip, to obtain social insects.     

Wild Edible Plant Markets in Kisangani, Democratic Republic of Congo

Benefits from wild edible plants (WEP) are multiple for rural households as well as urban traders. To set species priorities for WEP market development and domestication, we performed an inventory of WEP species and traders in five markets and one road-side selling point in Kisangani. During four one-month sessions between September 2007 and July 2008, all WEP traders present in the target markets were interviewed. We registered 119 unique sellers, selling 15 different WEPs. The September-October period and ‘Marché Central’ were the most important for WEP trade in Kisangani. Added values and net incomes generated through WEP sales were very divergent. Four types of traders could be distinguished. Gnetum africanum trade involves the more dynamic traders. Cola acuminata, Garcinia kola and Piper guineense spices have local and international market potential. Within the wild fruits category we propose Landolphia owariensis and Tetracarpidium conophorum as priority species for local market development.     

High prevalence of Taenia solium cysticerosis in a village community of Bas-Congo, Democratic Republic of Congo

Cysticercosis results from tissue infection with the larval stage of the pig tapeworm Taenia solium. Infection of the brain may cause neurocysticercosis, the most frequent cause of acquired epilepsy in developing countries. Information on human cysticercosis in the Democratic Republic of Congo (DRC) is scarce and outdated. We believe this is the first reported study on human cysticercosis and epilepsy in a village community of DRC. The proportion of villagers seropositive by ELISA for T. solium circulating antigen was 21.6%, the highest figure reported to date. The adjusted prevalence of active epilepsy in the community was 12.7 in 1,000.     

Intestinal parasites infections in hospitalized AIDS patients in Kinshasa, Democratic Republic of Congo

To determine the prevalence and the species spectrum of intestinal parasites (IP) involved in hospitalized AIDS patients, a prospective observational and cross-sectional study was carried out in the four main hospitals in Kinshasa, Democratic Republic of the Congo. From November 2006 through September 2007, a single stool sample was collected from 175 hospitalized AIDS patients older than 15 years. Parasites were detected by light microscopy, including Ziehl-Neelsen, Fungi-Fluor, modified trichrome stains, and by immunofluorescence antibody tests and PCR for species diagnosis of microsporidia. At baseline, 19 patients (10.8%) were under antiretroviral therapy and 156 (89.2%) were eligible for ART. The main diagnosis for justifying hospitalization was intestinal infection associated with diarrhea in 87 out of 175 (49.7%). 47 out of 175 (26.9%) were found to harbor an IP, and 27 out of 175 (15.4%) were infected with at least one opportunistic IP (OIP). Prevalence rate for OIP were 9.7%, 5.1%, 1.7% and 0.6% for Cryptosporidium sp., Enterocytozoon bieneusi, Isospora belli and Encephalitozoon intestinalis respectively. Considering patients with diarrhea only, prevalence rate were 12.6%, 4.6%, 3.4% and 1.1% respectively. The other IP observed were Entamoeba histolytica/Entamoeba dispar in nine cases (5.1%), Ascoris lumbricoides in seven cases (4.0%), Giardia intestinalis in three cases (1.7%), hookworm in two cases (1.1%) and Trichiuris trichiura, Enterobius vermicularis, Schistosoma mansoni in one patient each (0.6%). No significant relationship was established between any individual IP and diarrhea. These results underline the importance of OIP in symptomatic AIDS patients regardless of diarrhea at the time of the hospitalisation, and showed that routine microscopic examination using stains designed for Cryptosporidium spp. or the microsporidia should be considered due to the absence of clinical markers.     

The phenotype and genotype of rheumatoid arthritis in the Democratic Republic of Congo

Introduction

Little is known about rheumatoid arthritis in the black, particularly in Congolese, populations. Our objective was to describe the phenotype and genotype of rheumatoid arthritis (RA) in Congolese.

Methods

All consecutive rheumatoid arthritis (RA) patients attending Kinshasa University Hospital in a three-year time period were included. Demographics, clinical features and tobacco consumption were noted. Disease Activity Score (DAS)-28 based on the erythrocyte sedimentation rate (ESR), Health Assessment Questionnaire (HAQ), anti-citrullinated peptide antibodies (CCP) antibodies and rheumatoid factor (RF) were determined. Radiographs were scored according to Sharp-van der Heijde. On a subset of patients and controls HLA-DRB1 typing was performed.

Results

A total of 114 females and 14 males aged 51.2 ± 14.9 were included. Mean duration of symptoms was four years. Moderate tobacco consumption was reported in a minority of patients. DAS-28 at first visit was >5.1 and HAQ ≥0.5 in all patients. X-rays showed joint erosions and/or joint space narrowing, mostly of a moderate grade in 55.8% of patients. Anti-CCP and/or RF were present in 48.6% of patients with available data (n = 72) and in 3.0% of controls (n = 67). Radiographic changes and nodules were more frequent in RF or anti-CCP positive patients. One copy of the shared epitope was found in 13 patients (35.1%) and 3 controls (12.5%). Two copies were found in one patient (2.7%) and in one control (4.2%).

Conclusion

Congolese patients with RA consult long after disease onset. Despite this delay, the majority presents without major damage and is RF, anti-CCP and SE negative. We put forward the hypothesis that besides different environmental factors there is probably also a particular genetic risk profile in Congolese patients, different from the HLA-DRB1 shared epitope.     

A quantitative comparison of frugivorous tephritids (Diptera: Tephritidae) in tropical forests and rural areas of the Democratic Republic of Congo

Most of the current knowledge about African tephritids originates from studies performed in agricultural areas, while information about their distribution in pristine or moderately disturbed environments is extremely scarce. This study aims at (i) describing levels of spatial variability of frugivorous tephritids in tropical forests and small rural villages of the Congo River basin and (ii) verifying if human-mediated activities, such as small-scale agriculture and trade, can affect their distribution patterns. Four locations were sampled along a 250?km stretch of the Congo River. At each location, pristine and disturbed habitats (i.e. tropical forests and small rural villages, respectively) were sampled, with three replicate sites in each combination of habitat and location. Sampling with modified McPhail traps baited with four different attractants yielded 819 tephritid specimens of 29 species from seven genera (Bactrocera, Carpophthoromyia, Ceratitis, Dacus, Celidodacus, Perilampsis, Trirhithrum). The three most abundant species sampled (Dacus bivittatus, D. punctatifrons, Bactrocera invadens) showed significant variations in abundance across locations and sites and accounted for 98.29% of the overall dissimilarity between habitats. Assemblages differed among locations and sites while they showed significant differences between pristine and disturbed habitats in two out of the four locations. This study shows that frugivorous tephritids in central Congo have remarkably patchy distributions with differences among locations and sites representing the main source of variability. Our data show that, in rural villages of central Democratic Republic of Congo, human activities, such as small-scale agriculture and local commerce, are not always sufficient to promote differences between the tephritid assemblages of villages and those of the surrounding tropical forests.     

Diet of Grauer's Gorillas in the Montane Forest of Kahuzi,Democratic Republic of Congo

We describe the diet of a semihabituated group of Grauer's gorillas (Gorilla beringei graueri) inhabiting the montane forest of Kahuzi-Biega National Park, Democratic Republic of Congo, based on direct observations, feeding remains in their fresh trails, and fecal samples collected over 9 yr. We examined fruit availability in their habitat; consumption of fruit, vegetative, and animal food; and daily intake of vegetative plant food using a transect, fruit monitoring trails, fecal analysis, and tracing of the animal's daily trails between consecutive nest sites. The fruit food repertoire of Kahuzi gorillas resembles that of western and eastern lowland gorillas inhabiting lowland tropical forests, while their vegetative food repertoire resembles that of mountain gorillas inhabiting montane forests. Among 236 plant foods (116 species), leaves, pith, and barks constitute the major parts (70.2%), with fruit making up the minor part (19.7%). About half (53.2%) of the total fecal samples included fruit remains. The gorillas used leaves, stems and other vegetative plant parts as staples. Their fruit intake was similar to that reported for mountain gorillas in Bwindi. They ate animal foods, including earthworms, on rare occasions. Variation in fruit consumption was positively associated with variation in fruit production. The gorillas ate fig fruits frequently; fig intake is positively correlated with that of other fruits, and figs were not fallback foods. They relied heavily on bamboo shoots on a seasonal basis; however, no bamboo shoots were available for several years after a major flowering event. Our results support the argument that variation in gorilla diets mostly reflects variation in vegetational composition of their habitats.     

Molecular malaria epidemiology: mapping and burden estimates for the Democratic Republic of the Congo, 2007

Background

Epidemiologic data on malaria are scant in many high-burden countries including the Democratic Republic of the Congo (DRC), which suffers the second-highest global burden of malaria. Malaria control efforts in regions with challenging infrastructure require reproducible and efficient surveillance. We employed new high-throughput molecular testing to characterize the state of malaria control in the DRC and estimate childhood mortality attributable to excess malaria transmission.

Methods and Findings

The Demographic and Health Survey was a cross-sectional, population-based cluster household survey of adults aged 15–59 years in 2007 employing structured questionnaires and dried blood spot collection. Parasitemia was detected by real-time PCR, and survey responses measured adoption of malaria control measures and under-5 health indices. The response rate was 99% at the household level, and 8,886 households were surveyed in 300 clusters; from 8,838 respondents molecular results were available. The overall prevalence of parasitemia was 33.5% (95% confidence interval [C.I.] 32–34.9); P. falciparum was the most prevalent species, either as monoinfection (90.4%; 95% C.I. 88.8–92.1) or combined with P. malariae (4.9%; 95% C.I. 3.7–5.9) or P. ovale (0.6%; 95% C.I. 0.1–0.9). Only 7.7% (95% CI 6.8–8.6) of households with children under 5 owned an insecticide-treated bednet (ITN), and only 6.8% (95% CI 6.1–7.5) of under-fives slept under an ITN the preceding night. The overall under-5 mortality rate was 147 deaths per 1,000 live births (95% C.I. 141–153) and between clusters was associated with increased P. falciparum prevalence; based on the population attributable fraction, 26,488 yearly under-5 deaths were attributable to excess malaria transmission.

Conclusions

Adult P. falciparum prevalence is substantial in the DRC and is associated with under-5 mortality. Molecular testing offers a new, generalizable, and efficient approach to characterizing malaria endemicity in underserved countries.     

Epidemiology of Schistosoma mansoni infection in Ituri Province,north-eastern Democratic Republic of the Congo

BackgroundSchistosomiasis, caused by Schistosoma mansoni, is of great significance to public health in sub–Saharan Africa. In the Democratic Republic of Congo (DRC), information on the burden of S. mansoni infection is scarce, which hinders the implementation of adequate control measures. We assessed the geographical distribution of S. mansoni infection across Ituri province in north-eastern DRC and determined the prevailing risk factors.Methods/Principal findingsTwo province–wide, community–based studies were conducted. In 2016, a geographical distribution study was carried out in 46 randomly selected villages across Ituri. In 2017, an in–depth study was conducted in 12 purposively–selected villages, across the province. Households were randomly selected, and members were enrolled. In 2016, one stool sample was collected per participant, while in 2017, several samples were collected per participant. S. mansoni eggs were detected using the Kato–Katz technique. In 2017, a point–of–care circulating cathodic S. mansoni antigen (POC–CCA) urine test was the second used diagnostic approach. Household and individual questionnaires were used to collect data on demographic, socioeconomic, environmental, behavioural and knowledge risk factors.Of the 2,131 participants in 2016, 40.0% were positive of S. mansoni infection. Infection prevalence in the villages ranged from 0 to 90.2%. Of the 707 participants in 2017, 73.1% were tested positive for S. mansoni. Prevalence ranged from 52.8 to 95.0% across the health districts visited. Infection prevalence increased from north to south and from west to east. Exposure to the waters of Lake Albert and the villages’ altitude above sea level were associated with the distribution.Infection prevalence and intensity peaked in the age groups between 10 and 29 years. Preschool children were highly infected (62.3%). Key risk factors were poor housing structure (odds ratio [OR] 2.1, 95% 95% confidence interval [CI] 1.02–4.35), close proximity to water bodies (OR 1.72, 95% CI 1.1–2.49), long-term residence in a community (OR 1.41, 95% CI 1.11–1.79), lack of latrine in the household (OR 2.00, 95% CI 1.11–3.60), and swimming (OR 2.53, 95% CI 1.20–5.32) and washing (OR 1.75, 95% CI 1.10–2.78) in local water bodies.Conclusions/SignificanceOur results show that S. mansoni is highly endemic and a major health concern in Ituri province, DRC. Infection prevalence and intensity, and the prevailing socioeconomic, environmental, and behavioural risk factors in Ituri reflect intense exposure and alarming transmission rates. A robust plan of action is urgently needed in the province.     

Ranging Patterns of Chimpanzees in a Montane Forest of Kahuzi,Democratic Republic of Congo

I studied ranging patterns of a semihabituated unit-group of chimpanzees for 60 mo at Kahuzi. They had a total home range of 12.81 km² and a mean annual home range of 7.55 km². Considering the low density of chimpanzees in the area vis-à-vis chimpanzees in arid areas, their home range is very small. Kahuzi chimpanzees used the home range in a clumped pattern, frequently visiting the core area and only rarely entering peripheral areas. The monthly range changes with fruit availability, increasing during periods of fruit scarcity. There was no consistent seasonal difference in the size of the home range. However, use of different habitat types may vary seasonally. While there was no seasonal effect in the use of primary forest, the chimpanzees showed a statistically consistent seasonal difference in their use of secondary forest, visiting it mainly during the dry season when fig trees were in fruit. Since the primary forest provides them with more food fruits, chimpanzees tended to use more frequently the small patches of primary forest in their home range. Thus, the size and distribution of small fragmented primary forests may be an important factor influencing the ranging pattern of chimpanzees at Kahuzi.     

Fruit availability and chimpanzee party size at Kahuzi montane forest,Democratic Republic of Congo

The effect of fruit availability on chimpanzee party size was investigated in the montane forest of Kahuzi. Seasonal variation in both fruit availability and party size was examined. Fruit abundance per se does not affect chimpanzee party size. However, seasonality and distribution patterns of fruits are both determinant ecological factors that control the size of chimpanzee parties at Kahuzi. There was no correlation between fruit abundance and the spatial distribution of fruits. When fruits were clumped and available in large amounts for a long period, chimpanzee party size increased, or otherwise decreased when fruits were highly available for only a limited period. Tree species that produced only a small amount of ripe fruit throughout the year did not affect the foraging party size of chimpanzees. Temporal and spatial variability in fruit abundance seems to constrain grouping patterns of chimpanzees at Kahuzi more so than in other chimpanzee habitats previously described.     

Effectiveness of Routine BCG Vaccination on Buruli Ulcer Disease: A Case-Control Study in the Democratic Republic of Congo,Ghana and Togo

Background

The only available vaccine that could be potentially beneficial against mycobacterial diseases contains live attenuated bovine tuberculosis bacillus (Mycobacterium bovis) also called Bacillus Calmette-Guérin (BCG). Even though the BCG vaccine is still widely used, results on its effectiveness in preventing mycobacterial diseases are partially contradictory, especially regarding Buruli Ulcer Disease (BUD). The aim of this case-control study is to evaluate the possible protective effect of BCG vaccination on BUD.

Methodology

The present study was performed in three different countries and sites where BUD is endemic: in the Democratic Republic of the Congo, Ghana, and Togo from 2010 through 2013. The large study population was comprised of 401 cases with laboratory confirmed BUD and 826 controls, mostly family members or neighbors.

Principal Findings

After stratification by the three countries, two sexes and four age groups, no significant correlation was found between the presence of BCG scar and BUD status of individuals. Multivariate analysis has shown that the independent variables country (p = 0.31), sex (p = 0.24), age (p = 0.96), and presence of a BCG scar (p = 0.07) did not significantly influence the development of BUD category I or category II/III. Furthermore, the status of BCG vaccination was also not significantly related to duration of BUD or time to healing of lesions.

Conclusions

In our study, we did not observe significant evidence of a protective effect of routine BCG vaccination on the risk of developing either BUD or severe forms of BUD. Since accurate data on BCG strains used in these three countries were not available, no final conclusion can be drawn on the effectiveness of BCG strain in protecting against BUD. As has been suggested for tuberculosis and leprosy, well-designed prospective studies on different existing BCG vaccine strains are needed also for BUD.