Christopher Lemoh

Isolated core antibody hepatitis B in sub‐Saharan African immigrants

Chronic hepatitis B virus (HBV) infection is a major health problem in sub‐Saharan Africa, where prevalence is ≥8%, and is increasingly seen in African immigrants to developed countries. A retrospective audit of the medical records of 383 immigrants from sub‐Saharan Africa attending the infectious diseases clinics at the Royal Melbourne Hospital was performed from 2003 to 2006. The HBV, human immunodeficiency virus (HIV) and hepatitis C virus (HCV) serological results are reported, with a focus on the isolated core antibody HBV pattern (detection of anti‐HBc without detection of HBsAg or anti‐HBs). Two‐thirds (118/174, 68%) of those tested had evidence of HBV infection with detectable anti‐HBc. Chronic HBV infection (serum HBsAg detected) was identified in 38/174 (22%) and resolved HBV infection (both serum anti‐HBs and anti‐HBc detected) in 45/174 (26%). The isolated core antibody pattern was identified in 35/174 (20%), of whom only 1/35 (3%) had detectable serum HBV DNA on PCR testing, indicating occult chronic HBV (OCHB). Only 8/56 (14%) patients with negative anti‐HBc had serological evidence of vaccination (serum anti‐HBs detected). HIV infection was detected in 26/223 (12%). HCV antibodies were detected in 10/241 (4%), of whom 8 (80%) had detectable HCV RNA. Viral co‐infection was detected in only 2/131 (1.5%) patients tested for all three viruses. The isolated core antibody HBV pattern was common among sub‐Saharan African patients in our study. These patients require assessment for OCHB infection and monitoring for complications of HBV. J. Med. Virol. 80:1565–1569, 2008.

Delayed diagnosis of HIV infection in Victoria 1994 to 2006.

BACKGROUND The identification of factors associated with delayed diagnosis of HIV infection in Victoria, Australia was the aim of the present study. METHODS Demographic and epidemiological characteristics of cases notified to the Victorian HIV surveillance database between 1 January 1994 and 31 December 2006 were analysed. Delayed diagnosis was defined as: CD4 count below 200 cells mm(-3) at HIV diagnosis or diagnosis of AIDS earlier than 3 months after HIV diagnosis. RESULTS Diagnosis of HIV was delayed in 627 (22.6%) of 2779 cases. Of these, 528 (84.2%) had either a high-risk exposure or were born in a high-prevalence country. The most common exposure was male homosexual contact in 64.3% of cases. Independent risk factors for delayed diagnosis were: older age at diagnosis (30-39 years odds ratio [OR] 2.15, > or = 50 years OR 7.50, P < 0.001), exposure via routes other than male homosexual sex or injecting drug use (heterosexual sex OR 2.51, P < 0.001, unknown/other route OR 4.24, P < 0.001); birth in Southern/Eastern Europe (OR 2.54), South-east Asia (OR 2.70) or the Horn of Africa/North Africa (OR 3.71, P < 0.001), and male gender (OR 0.47 for females, P < 0.001). CONCLUSION Delay in the diagnosis of HIV infection is common in Victoria, but potentially avoidable in the majority of cases. Most people with delayed diagnosis had a history of male homosexual contact, injecting drug use, birth in a high-prevalence country or sexual contact with such individuals. An accurate sexual history, together with knowledge of their country of birth, should identify most individuals who should be offered an HIV test.

Working with West African migrant communities on HIV prevention in Australia

Department of Medicine, The University of Melbourne, 4th Floor, Clinical Sciences Building, Royal Melbourne Hospital, Parkville, Vic. 3050, Australia. Centre for Population Health, Burnet Institute, 85 Commercial Road, Melbourne, Vic. 3004, Australia. Centre for Clinical Research Excellence in Infectious Diseases, 9 North, 9 Floor, City Campus, Main Block, Royal Melbourne Hospital, Grattan Street, Parkville, Vic. 3050, Australia. Corresponding author. Email: c.lemoh@pgrad.unimelb.edu.au

African Australians living with HIV: a case series from Victoria

BACKGROUND This research aimed to describe the characteristics of African-born Victorians living with HIV, identify associations with delayed HIV diagnosis and describe their response to combination antiretroviral therapy (cART). METHODS A case series of African-born adults living with HIV in Victoria was conducted. Data was collected in interviews and reviews of case notes. Associations with delayed HIV diagnosis (CD4 below 200 cells microL(-1) at diagnosis and/or AIDS within 3 months of HIV diagnosis) were explored using univariate regression. AIDS-defining illnesses and response to cART were described. RESULTS Fourteen males and six females were included. Ten were born in the Horn of Africa (nine in Ethiopia). Sixteen had sexual exposure (12 heterosexual; four male-to-male sex). Seven reported acquiring HIV in Australia. Median CD4 count at diagnosis was 145 cells microL(-1). Ten had delayed HIV diagnosis, of whom eight were born in the Horn of Africa. Delayed HIV diagnosis was associated with birth in the Horn of Africa (odds ratio: 11.56). Nine had a diagnosis of AIDS, including three cases of tuberculosis, three of Pneumocystis jiroveci pneumonia and two of cerebral toxoplasmosis. Eighteen had received cART, of which 16 achieved virological suppression and 15 achieved a CD4 count above 200 cells microL(-1). Clinical failure and virological failure occurred in seven and five cases, respectively. CONCLUSIONS HIV prevention strategies for Victorias African communities should address HIV exposure in Australia. Ethiopian-born Victorians with HIV appear to be at particular risk of delayed diagnosis. Response to cART in this series was comparable to that observed in other industrialised countries.

Acquisition of HIV by African-Born Residents of Victoria, Australia: Insights from Molecular Epidemiology

African-born Australians are a recognised “priority population” in Australias Sixth National HIV/AIDS Strategy. We compared exposure location and route for African-born people living with HIV (PLHIV) in Victoria, Australia, with HIV-1 pol subtype from drug resistance assays and geographical origin suggested by phylogenetic analysis of env gene. Twenty adult HIV positive African-born Victorian residents were recruited via treating doctors. HIV exposure details were obtained from interviews and case notes. Viral RNA was extracted from participant stored plasma or whole blood. The env V3 region was sequenced and compared to globally representative reference HIV-1 sequences in the Los Alamos National Library HIV Database. Twelve participants reported exposure via heterosexual sex and two via iatrogenic blood exposures; four were men having sex with men (MSM); two were exposed via unknown routes. Eight participants reported exposure in their countries of birth, seven in Australia, three in other countries and two in unknown locations. Genotype results (pol) were available for ten participants. HIV env amplification was successful in eighteen cases. HIV-1 subtype was identified in all participants: eight both pol and env; ten env alone and two pol alone. Twelve were subtype C, four subtype B, three subtype A and one subtype CRF02_AG. Reported exposure location was consistent with the phylogenetic clustering of env sequences. African Australians are members of multiple transnational social and sexual networks influencing their exposure to HIV. Phylogenetic analysis may complement traditional surveillance to discern patterns of HIV exposure, providing focus for HIV prevention programs in mobile populations.

Understanding of latent tuberculosis, its treatment and treatment side effects in immigrant and refugee patients

BackgroundIsoniazid treatment of latent tuberculosis infection (LTBI) is commonly prescribed in refugees and immigrants. We aimed to assess understanding of information provided about LTBI, its treatment and potential side effects.MethodsA questionnaire was administered in clinics at a tertiary hospital. Total Knowledge (TKS) and Total Side Effect Scores (TSES) were derived. Logistic regression analyses were employed to correlate socio-demographic factors with knowledge.ResultsFifty-two participants were recruited, 20 at isoniazid commencement and 32 already on isoniazid. The average TKS were 5.04/9 and 6.23/9 respectively and were significantly associated with interpreter use. Approximately half did not know how tuberculosis was transmitted. The average TSES were 5.0/7 and 3.5/7 respectively, but were not influenced by socio-demographic factors.ConclusionsThere was suboptimal knowledge about LTBI. Improvements in health messages delivered via interpreters and additional methods of distributing information need to be developed for this patient population.

A binational cohort study of ventilator-associated pneumonia in Denmark and Australia

The objective was to determine the incidence and prognosis of ventilator-associated pneumonia (VAP) in intensive care units (ICUs) in Melbourne (29-bed ICU), Australia and Aarhus and Aalborg (22-bed unit and 8-bed ICU, respectively), Denmark and to characterize participating ICUs with regard to prevalence of nosocomial type bacterial pathogens, antibiotic resistance and antibiotic consumption. In this prospective cohort study 25 patients in Melbourne and 32 patients in Aarhus + Aalborg had a first episode of VAP. The incidence of VAP per 1000 ventilator d was 6.2 in Melbourne and 9.5 in Aarhus + Aalborg. Case fatality during hospital admission was 28% and 59%, respectively (unadjusted odds ratio (OR) 0.3, 95% confidence interval (CI) 0.1–0.8). OR adjusted for age and APACHE II score was 0.2 (95% CI 0.1–1.0). Nosocomial type pathogens including methicillin resistant Staphylococcus aureus were more prevalent in Melbourne, and antibiotic consumption per VAP patient was 35% higher in Melbourne than in Aarhus + Aalborg. To judge from the present data, there seems to be a complicated interrelationship between prognosis on the 1 hand and antibiotic consumption and resistance on the other. A more favourable prognosis was found in Melbourne, where levels of antibiotic consumption and antimicrobial resistance were higher than in Aarhus + Aalborg.

Development and Validation of an Instrument to Assess the Risk of Developing Viral Infections in Australian Travelers During International Travel

BACKGROUND Questionnaires are widely used for data collection in travel medicine studies, but there are no validated instruments that are available to researchers in this field. Our objective was to develop and validate a questionnaire to be used in a prospective study designed to estimate the risk of three viral infections in Australian travelers to Asia. METHODS Qualitative nonexperimental cognitive methods, including cognitive review, task analysis, and cognitive interviews, were selected. A pilot study was performed to assess the instrument in the target population. RESULTS Recalling dates related to travel or health events was observed and reported to be the most difficult task for travelers. The use of cues embedded into items and provision of memory prompts such as calendars improves the recall of dates during travel. There is a wide spectrum of accommodation, activities, and travel experiences, and item responses that were constructed as lists were useful as memory triggers, particularly for travelers with long and complicated itineraries. Cognitive interviews provided a valuable insight into how travelers used inferential and direct memory to recall travel events and their confidence in the accuracy of these processes. CONCLUSIONS The development and validation of questionnaires improve the accuracy of the data collected and should be considered an integral part of the methodology of travel-related studies.

Immunochromatographic antigen testing alone is sufficient to identify asymptomatic refugees at risk of severe malaria presenting to a single health service in Victoria

Summary Current screening guidelines for malaria in new refugees include a combination of thick and thin film examination and immunochromatographic antigen test (ICT). However, as the prevalence of malaria in our population has decreased due to changing refugee demographics, we sought to determine if an ICT alone can reliably exclude malaria in our asymptomatic refugee population. A retrospective analysis was conducted of all investigations for malaria performed from 1 August 2011 to 31 July 2013, including thick and thin blood film examination, BinaxNOW ICT, and external morphological and polymerase chain reaction (PCR) validation where applicable. Malaria was diagnosed in 45 of 1248 (3.6%) patients investigated, all of whom were symptomatic and the majority (71.1%) returned travellers. All 599 asymptomatic refugees screened were negative. Overall, 42 of 45 malaria cases were detected by the ICT; sensitivity 93.3% (95% CI 80.7–98.3%) and negative predictive value (NPV) 99.8% (99.2–99.9%). All 21 cases of Plasmodium falciparum and 20 of 22 cases of Plasmodium vivax were detected, giving a sensitivity of 100% (80.8–100%) and 90.9% (69.4–98.4%) respectively. Too few cases of Plasmodium malariae and no cases of Plasmodium ovale or Plasmodium knowlesi were diagnosed for adequate assessment to be carried out. These data suggest that full malaria screening in all asymptomatic refugees with the combination of thick and thin blood films and rapid antigen test may not be warranted. Alternative screening approaches should be considered, including the use of ICT alone, or limiting screening of asymptomatic refugees to only those originating from countries with high incidence of malaria.

Asymptomatic refugee malaria screening - implications of using a rapid immunochromatographic antigen test only: retrospective analysis of 1248 patients

Background: Current screening guidelines for malaria in new refugees include a combination of thick and thin film examination and immunochromatographic antigen test (ICT).1 However, as the prevalence of malaria in our population has decreased due to changing refugee demographics,2,3 an immunochromatographic antigen test (ICT) alone may be sufficient to exclude malaria in asymptomatic patients. Aim: To determine if an ICT alone can reliably exclude malaria in our asymptomatic refugee population. Methods: A retrospective analysis was conducted of all investigations for malaria performed from 01/08/2011 to 31/07/2013, including external morphological and PCR validation where applicable. Results: 45 of 1248 (3.6%) patients investigated were diagnosed with malaria, all cases were in symptomatic patients. Overall 42/45 malaria cases were detected by the BinaxNOW ICT; sensitivity (95%CI) 93.3% (80.7–98.3%) and negative predictive value (NPV) 99.8% (99.2–99.9%). All 21 cases of Plasmodium falciparum were detected; sensitivity and NPV of 100% (80.8–100%) and 100% (99.6–100%), respectively. ICT detected 18/20 cases of P. vivax; sensitivity and negative predictive value of 90.9% (69.4%–98.4%) and 99.8% (99.3%–100%), respectively. Too few cases of P. malariae and no cases of P. ovale or P. knowlesis were diagnosed for adequate assessment. Discussion: These data suggest that an ICT alone may be sufficient for malaria screening in our asymptomatic refugee population.