Henrik Friis

ASSOCIATION BETWEEN GENITAL SCHISTOSOMIASIS AND HIV IN RURAL ZIMBABWEAN WOMEN

Objective:To determine the association between female genital Schistosoma haematobium infection and HIV. Design and methods:A cross-sectional study with a 1-year follow-up. Gynecological and laboratory investigations were performed for S. haematobium and HIV. Sexually transmitted infections, demographic and urogenital history were analysed as confounders. The participants were 527 sexually active, non-pregnant, non-menopausal women between the ages of 20 and 49 years. The setting was a rural Zimbabwean community where S. haematobium related lesions were found in 46% of the women, HIV in 29% and herpes simplex type- 2 (HSV-2) in 65%. Results:In permanent residents (>3 years residency), HIV was found in 41% (29/70) of women with laboratory proven genital schistosomiasis as opposed to 26% HIV positive (96/375) in the schistosomal ova negative group [odds ratio (OR), 2.1; 95% confidence interval (CI), 1.2–3.5; P = 0.008. In multivariate analysis S. haematobium infection of the genital mucosa was significantly associated with HIV seropositivity (adjusted OR, 2.9; 95% CI, 1.11–7.5; P = 0.030). All seven women who became HIV positive during the study period (seroincidence 3.1%) had signs of S. haematobium at baseline. In accordance with other studies HIV was significantly associated with HSV-2 (OR, 3.0; 95% CI, 1.7–5.3; P < 0.001), syphilis and human papillomavirus. The highest HIV prevalence (45%) was found in the 25–29 years age group. Conclusion:Women with genital schistosomiasis had an almost three-fold risk of having HIV in this rural Zimbabwean community. Prospective studies are needed to confirm the association.

Choice of foods and ingredients for moderately malnourished children 6 months to 5 years of age.

There is consensus on how to treat severe malnutrition, but there is no agreement on the most cost-effective way to treat infants and young children with moderate malnutrition who consume cereal-dominated diets. The aim of this review is to give an overview of the nutritional qualities of relevant foods and ingredients in relation to the nutritional needs of children with moderate malnutrition and to identify research needs. The following general aspects are covered: energy density, macronutrient content and quality, minerals and vitamins, bioactive substances, antinutritional factors, and food processing. The nutritional values of the main food groups—cereals, legumes, pulses, roots, vegetables, fruits, and animal foods—are discussed. The special beneficial qualities of animal-source foods, which contain high levels of minerals important for growth, high-quality protein, and no antinutrients or fibers, are emphasized. In cereal-dominated diets, the plant foods should be processed to reduce the contents of antinutrients and fibers. Provision of a high fat content to increase energy density is emphasized; however, the content of micronutrients should also be increased to maintain nutrient density. The source of fat should be selected to supply optimal amounts of polyunsaturated fatty acids (PUFAs), especially n-3 fatty acids. Among multiple research needs, the following are highlighted: to identify the minimum quantity of animal foods needed to support acceptable child growth and development, to examine the nutritional gains of reducing contents of antinutrients and fibers in cereal- and legume-based diets, and to examine the role of fat quality, especially PUFA content and ratios, in children with moderate malnutrition.

The immune system in children with malnutrition--a systematic review.

Background Malnourished children have increased risk of dying, with most deaths caused by infectious diseases. One mechanism behind this may be impaired immune function. However, this immune deficiency of malnutrition has not previously been systematically reviewed. Objectives To review the scientific literature about immune function in children with malnutrition. Methods A systematic literature search was done in PubMed, and additional articles identified in reference lists and by correspondence with experts in the field. The inclusion criteria were studies investigating immune parameters in children aged 1–60 months, in relation to malnutrition, defined as wasting, underweight, stunting, or oedematous malnutrition. Results The literature search yielded 3402 articles, of which 245 met the inclusion criteria. Most were published between 1970 and 1990, and only 33 after 2003. Malnutrition is associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. Lymphatic tissue, particularly the thymus, undergoes atrophy, and delayed-type hypersensitivity responses are reduced. Levels of antibodies produced after vaccination are reduced in severely malnourished children, but intact in moderate malnutrition. Cytokine patterns are skewed towards a Th2-response. Other immune parameters seem intact or elevated: leukocyte and lymphocyte counts are unaffected, and levels of immunoglobulins, particularly immunoglobulin A, are high. The acute phase response appears intact, and sometimes present in the absence of clinical infection. Limitations to the studies include their observational and often cross-sectional design and frequent confounding by infections in the children studied. Conclusion The immunological alterations associated with malnutrition in children may contribute to increased mortality. However, the underlying mechanisms are still inadequately understood, as well as why different types of malnutrition are associated with different immunological alterations. Better designed prospective studies are needed, based on current understanding of immunology and with state-of-the-art methods.

Effects of prenatal multimicronutrient supplements on birth weight and perinatal mortality: a randomised, controlled trial in Guinea-Bissau

Objectives:To assess the effects of daily prenatal multimicronutrient supplementation on birth weight (BW) and perinatal mortality.Design:Randomised, controlled, double masked trial.Setting:Urban Guinea-Bissau, West Africa.Subjects:A total of 2100 pregnant women (22±7 weeks pregnant at entry) were recruited through antenatal clinics, of which 1670 (79.5%) completed the trial. BW was available for 1100 live born babies.Interventions:Identical-looking supplements containing one (MN-1) or two (MN-2) Recommended Dietary Allowances (RDA) of 15 micronutrients, or iron and folic acid (control).Results:Mean BW among 1100 live born infants was 3050±498 g with 11.9% being low birth weight (LBW, BW<2500 g). Perinatal mortality was 82 per 1000 deliveries (N=1670), and neonatal mortality 45 per 1000 live births (N=1599). Mean BW in MN-1 (n=360) and MN-2 (n=374) groups were 53 [−19; 125] and 95 [24; 166] g higher than controls (n=366). Proportion of LBW was 13.6% in control, and 12.0 and 10.1% in the MN-1 and MN-2 groups, respectively (P=0.33). Among anaemic women (30%), MN-2 increased BW with 218 [81; 354] g compared to controls, with a decreased risk of LBW of 69 [27; 87]%. There were apparently no differences in perinatal mortality between groups.Conclusions:Prenatal micronutrient supplementation increased BW but did not reduce perinatal mortality in this study. Multimicronutrient supplementation with two RDA should be considered in future programmes to reduce the proportion of LBW.

The contribution of hookworm and other parasitic infections to haemoglobin and iron status among children and adults in western Kenya

A cross-sectional study of 729 children and adults in western Kenya investigated the impact of infection with hookworm, Ascaris lumbricoides, Trichuris trichiura, Schistosoma mansoni and malaria on iron status. In bivariate analyses, hookworm intensities as low as 300 eggs/g of faeces were negatively related to levels of haemoglobin (Hb) and serum ferritin (SF). Malaria parasitaemia was negatively related to Hb and positively related to SF, while S. mansoni intensities were negatively related to SF. Multivariate regression analysis was done to identify predictors of Hb and SF levels. In children, age (in years) was the only predictor for Hb (B = 1.7 g/L) and only malaria parasitaemia (negative, light, moderate, heavy) was retained in the model for log10 SF (B = 0.097 microgram/L). In adults, hookworm infection and malaria parasitaemia together with age, sex, pregnancy, SF levels < 12 micrograms/L and elevated body temperature were significant predictors of low Hb. The regression coefficient for hookworm egg count (for increments of 100 eggs/g) was -1.3 g/L. Significant interactions between sex and age and between sex and malaria parasitaemia were revealed. Age and malaria parasitaemia were significant predictors only among females, with a regression coefficient for malaria parasitaemia of -6.9 g/L. The regression coefficient for hookworm did not change when SF < 12 micrograms/L was taken out of the model, indicating that the effect of hookworm cannot be explained by low iron stores alone. Using SF as the dependent variable, hookworm and S. mansoni intensities together with age and sex were retained in the model. The regression coefficients for hookworm egg count (increments of 100 eggs/g) and S. mansoni egg count (increments of 10 eggs/g) were -0.011 microgram/L and -0.012 microgram/L, respectively. Iron deficiency was a problem in this population and hookworm infections contributed significantly to this situation.

Obesity and regional fat distribution in Kenyan populations: Impact of ethnicity and urbanization

Background: Obesity is increasing rapidly in Africa, and may not be associated with the same changes in body composition among different ethnic groups in Africa. Objective: To assess abdominal visceral and subcutaneous fat thickness, prevalence of obesity, and differences in body composition in rural and urban Kenya. Subjects and methods: In a cross-sectional study carried out among Luo, Kamba and Maasai in rural and urban Kenya, abdominal visceral and subcutaneous fat thicknesses were measured by ultrasonography. Height and weight, waist, mid-upper arm circumferences, and triceps skinfold thickness were measured. Body mass index (BMI), arm fat area (AFA) and arm muscle area (AMA) were calculated. Results: Among 1430 individuals (58.3% females) aged 17–68 years, abdominal visceral and subcutaneous fat, BMI, AFA and waist circumference (WC) increased with age, and were highest in the Maasai and in the urban population. AMA was only higher with increasing age among males. The prevalence of overweight (BMI ≥ 25) (39.8% vs. 15.8%) and obesity (BMI ≥ 30) (15.5% vs. 5.1%) was highest in the urban vs. rural population. Conclusion: Abdominal visceral and subcutaneous fat thickness was higher with urban residency. A high prevalence of overweight and obesity was found. The Maasai had the highest overall fat accumulation.

Prevalence of glucose intolerance and associated risk factors in rural and urban populations of different ethnic groups in Kenya.

OBJECTIVE To assess the prevalence of glucose intolerance in rural and urban Kenyan populations and in different ethnic groups. Further, to identify associations between lifestyle risk factors and glucose intolerance. RESEARCH DESIGN AND METHODS A cross-sectional study included an opportunity sample of Luo, Kamba, Maasai, and an ethnically mixed group from rural and urban Kenya. Diabetes and IGT were diagnosed using a standard OGTT. BMI, WC, AFA, AMA and abdominal subcutaneous and visceral fat thicknesses, physical activity and fitness were measured. Questionnaires were used to determine previous diabetes diagnosis, family history of diabetes, smoking habits, and alcohol consumption. RESULTS Among 1459 participants, mean age 38.6 years (range 17-68 years), the overall age-standardized prevalence of diabetes and IGT was 4.2% and 12.0%. The Luo had the highest prevalence of glucose intolerance among the rural ethnic groups. High BMI, WC, AFA, abdominal visceral and subcutaneous fat thickness, low fitness and physical activity, frequent alcohol consumption, and urban residence were associated with glucose intolerance. CONCLUSIONS The prevalence of diabetes and IGT among different Kenyan population groups was moderate, and highest in the Luo. The role of lifestyle changes and ethnicity on the effect of diabetes in African populations needs further exploration.

Earth-eating and reinfection with intestinal helminths among pregnant and lactating women in western Kenya

We conducted a longitudinal study among 827 pregnant women in Nyanza Province, western Kenya, to determine the effect of earth‐eating on geohelminth reinfection after treatment. The women were recruited at a gestational age of 14–24 weeks (median: 17) and followed up to 6 months postpartum. The median age was 23 (range: 14–47) years, the median parity 2 (range: 0–11). After deworming with mebendazole (500 mg, single dose) of those found infected at 32 weeks gestation, 700 women were uninfected with Ascaris lumbricoides, 670 with Trichuris trichiura and 479 with hookworm. At delivery, 11.2%, 4.6% and 3.8% of these women were reinfected with hookworm, T. trichiura and A. lumbricoides respectively. The reinfection rate for hookworm was 14.8%, for T. trichiura 6.65, and for A. lumbricoides 5.2% at 3 months postpartum, and 16.0, 5.9 and 9.4% at 6 months postpartum. There was a significant difference in hookworm intensity at delivery between geophagous and non‐geophagous women (P = 0.03). Women who ate termite mound earth were more often and more intensely infected with hookworm at delivery than those eating other types of earth (P = 0.07 and P = 0.02 respectively). There were significant differences in the prevalence of A. lumbricoides between geophagous and non‐geophagous women at 3 (P = 0.001) and at 6 months postpartum (P = 0.001). Women who ate termite mound earth had a higher prevalence of A. lumbricoides, compared with those eating other kinds of earth, at delivery (P = 0.02), 3 months postpartum (P = 0.001) and at 6 months postpartum (P = 0.001). The intensity of infections with T. trichiura at 6 months postpartum was significantly different between geophagous and non‐geophagous women (P = 0.005). Our study shows that geophagy is associated with A. lumbricoides reinfection among pregnant and lactating women and that intensities built up more rapidly among geophagous women. Geophagy might be associated with reinfection with hookworm and T. trichiura, although these results were less unequivocal. These findings call for increased emphasis, in antenatal care, on the potential risks of earth‐eating, and for deworming of women after delivery.

Association of HIV and ART with cardiometabolic traits in sub-Saharan Africa: a systematic review and meta-analysis

Background Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations. Methods We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants. Results Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, −0.59; 95% CI, −0.86 to −0.31), BMI (SMD, −0.32; 95% CI, −0.45 to −0.18), SBP (SMD, −0.40; 95% CI, −0.55 to −0.25) and DBP (SMD, −0.34; 95% CI, −0.51 to −0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, −0.34; 95% CI, −0.62 to −0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits. Conclusions Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

Effects of iron and multimicronutrient supplementation on geophagy: a two-by-two factorial study among Zambian schoolchildren in Lusaka

Geophagy has been associated with iron deficiency and anaemia, but no causal relationship has been established. To clarify this, we conducted a two-by-two factorial randomised, controlled trial on the effect of iron and multimicronutrient supplementation on geophagy in Zambian schoolchildren in Lusaka, from February to December 2001. Of the 406 children, 212 (52.2%) were girls and the mean (range) age was 10.2 (7-15) years. Geophagy was reported by 302 (74.4%) and more often in girls than in boys (80.2 vs. 67.7%, P = 0.007). The mean (range) daily earth intake was 25.2 (1-200) g. Geophageous children had more often geophageous relatives than non-geophageous children (79.5 vs. 1.9%, P < 0.001). Geophageous children had lower serum ferritin (20.5 vs. 25.0 microg/l, P = 0.032) but not haemoglobin (Hb) (129.2 vs. 130.4 g/l, P = 0.59), than non-geophageous. Among those with Hb < 130 g/l, geophageous children had significantly higher prevalence (53.7 vs. 30.6%, P = 0.024) of Ascaris lumbricoides infection than non-geophageous. The prevalence of geophagy (74.4 to 51.6%) and the intake of earth (25.3 to 15.0 g/day) declined (P = 0.001 and P < 0.001, respectively) among the 220 (54.2%) children followed-up. In bivariate analysis, non-iron supplementation reduced the prevalence of geophagy more than iron supplementation did, but this was not confirmed in the multiple logistic regression analysis. Multimicronutrients had no effect on either geophagy prevalence or earth intake. Geophagy was prevalent and associated with iron deficiency, but iron supplementation had no effects on geophageous behaviour. Geophagy could be a copied behaviour and the association between geophagy and iron deficiency due to impaired iron absorption following earth eating.