Jane Davies

Favourable one-year ART outcomes in adult Malawians with hepatitis B and C co-infection

BACKGROUND Few studies have investigated the impact of chronic hepatitis B and C infection on antiretroviral therapy (ART) outcomes in sub-Saharan Africa. Hepatotoxicity may be a particular concern in co-infected patients taking nevirapine-stavudine-lamivudine. METHODS We conducted a prospective cohort study of 300 Malawian adults starting ART and describe one-year ART outcomes according to viral hepatitis status. RESULTS At baseline, patients had advanced HIV disease (29.3% were in WHO stage 4; mean CD4 = 157 cells/microL; mean log(10)HIV-1 RNA = 5.24 copies/ml). Co-infection with hepatitis B, C and B + C were present in 6.7%, 5.7% and 1.7% respectively. At 50 weeks, all-cause mortality was 43 (14.3%). Sixteen (5.3%) had transferred to another unit. Eight (2.7%) were lost to follow up. Sixteen (5.3%) had stopped ART. 217 (72.3%) were alive on ART, of whom 82.5% had an HIV-1 RNA <400 copies/ml at week 50. During the first 50 weeks of ART, severe hepatotoxicity (liver enzyme values >5 times upper level of normal) occurred in 9%, but did not result in any ART discontinuations. Clinical hepatitis or jaundice was not observed. There were no significant differences in occurrence of hepatotoxicity, other side effects, mortality, severe morbidity, immune reconstitution or virological failure between hepatitis B and/or C co-infected patients and those who were not. Viral hepatitis co-infection was not associated with severe hepatotoxicity, mortality, severe morbidity or virological failure in multivariate analyses. CONCLUSION Our data suggest that screening for viral hepatitis B and C and liver enzyme monitoring may not require high priority in ART programmes in sub-Saharan Africa.

Impact of Results of a Rapid Staphylococcus aureus Diagnostic Test on Prescribing of Antibiotics for Patients with Clustered Gram-Positive Cocci in Blood Cultures

ABSTRACT In tropical northern Australia, approximately 20% of Staphylococcus aureus bacteremia is caused by methicillin-resistant Staphylococcus aureus (MRSA). We prospectively evaluated the impact on clinician antibiotic prescribing of the results obtained from performing the GeneXpert MRSA/SA test on 151 positive blood cultures with clustered Gram-positive cocci. The GeneXpert result led to earlier appropriate prescription of vancomycin for 54% of patients with MRSA; 25% of patients avoided vancomycin, and 16% of patients had all antibiotics ceased.

The molecular epidemiology of hepatitis B in the Indigenous people of northern Australia

The hepatitis B surface antigen was first described in the blood of an Indigenous Australian man, yet little is known about its molecular epidemiology in this population, in which it is endemic. The study aimed to determine the clinical and molecular epidemiology of hepatitis B virus (HBV) in Indigenous people from northern Australia.

Low level ivermectin coverage and the transmission of onchocerciasis

Regular collections of biting Simulium damnosum s.l. were carried out during a community-based trial of doses of ivermectin every 6 months for onchocerciasis in Sierra Leone. Over 64,000 blackflies were caught at 4 sites close to treated villages and one site near an untreated village. More than 17,000 of these blackflies were dissected during the 31 months of the study and 5 doses of ivermectin were distributed to about 30% of the human population in the treated villages. High annual biting rates (about 100,000 bites per year) and transmission potentials (about 5000 larvae per year) were found at all catching sites. Approximately 30% of parous blackflies carried Onchocerca volvulus larvae, and 8% had infective stage larvae. None of these indices appeared to be affected by the distribution of ivermectin. However, the mean number of larvae per infected blackfly fell from 8.7 to 5.8 during the study period in the treated villages, equivalent to a 21% decrease per year. No such reduction was seen in the control village. This study demonstrates that in areas where high capacity vectors predominate, the effect on transmission of even a low coverage of the human population with repeated doses of ivermectin may be detectable using the sensitive entomological index of intensity of infection in infected flies. Statistical analysis of onchocerciasis transmission data is a complex issue and ways of improving the design of trials and applying appropriate statistical methods are discussed.

Onchocerciasis transmission levels and Simulium damnosum complex biting activity at riverside and rice field sites in Sierra Leone.

ABSTRACT. Biting densities of the Simulium damnosum Theobald complex of blackflies and their levels of parasitism by Onchocerca volvulus (Leuckart) were compared at two ecologically contrasted sites in the Southern Province of Sierre Leone, West Africa: by the Tabe riverside close to Gbaiima village where onchocerciasis is hyperendemic (63.1% positive skin‐snips) and in open rice fields 2 km from the mesoendemic (54.9%) village of Senehun.

Reliability of rapid testing for hepatitis B in a region of high HIV endemicity

Hepatitis B (HBV) and HIV co-infection is common in resource-poor settings. A recent study from Malawi revealed poor correlation between hepatitis B surface antigen (HBsAg) point-of-care tests and reference tests in patients co-infected with HIV. We studied a cohort of 300 Malawian adults entering a treatment programme for HIV. Sera were tested for HBsAg first using the Determine rapid test and re-tested using a commercial enzyme immunoassay (EIA). All tests were done under optimal conditions in Liverpool, UK. Sera from all 25 patients positive for HBsAg using the rapid test and from 50 who were negative, were re-tested using the EIA, with complete concordance of results. The kappa correlation was 1, specificity 100% (93-100%) and sensitivity 100% (86-100%) compared to the reference test. Patients had advanced immune suppression (mean CD4=175 cells x 10(6)/l). In a non-field setting, the results of point-of-care Determine rapid hepatitis B tests appear reliable in patients with HIV-1 co-infection.

Onchocerciasis in Sierra Leone I. Studies on the prevalence and transmission at Gbaiima village

A longitudinal survey--parasitological, clinical, immunological and entomological--of onchocerciasis is being conducted in Gbaiima village in Sierra Leone. The estimated Annual Transmission Potential (ATP) is 5863. More than 80% of the annual transmission occurs between October and December. Four species of the Simulium damnosum complex are known to breed in a nearby river. The relative role of these species as vectors has yet to be determined. The total population (598 persons) aged one year and over were examined. Based on microfilarial and nodular rates the prevalence of onchocerciasis was 68.6%. In persons above 15 years of age this prevalence was 88.9%. Microfilarial and nodular rates were related to age. Severe skin lesions occurred in 1.0% of persons. 24 adults (7.5%) were blind (but the cause of the blindness was not determined).

Molecular virology of hepatitis B virus, sub‐genotype C4 in northern Australian Indigenous populations

Indigenous Australians experience a significant health burden from chronic hepatitis B infection; however, the strain of hepatitis B virus (HBV) found among Indigenous Australians has not been well characterized. Blood samples were collected from 65 Indigenous Australians with chronic HBV infection from across the Top End of Australias Northern Territory. Phylogenetic analysis of HBV from these samples revealed that 100% of the isolates were genotype C, sub‐genotype C4, expressing the serotype ayw3. This strain is a divergent group within the HBV/C genotype, and has only been described in Indigenous Australians. Evidence of recombination was suggested by discordant phylogenetic clustering of the C4 sequences when comparing the full genome to the surface region and confirmed by recombination analysis which showed the surface gene region to be most closely related to genotype J, while the remaining regions of the genome were most similar to genotype C sequences. Mutational analysis revealed the presence of multiple mutations that have been linked with more rapid liver disease progression and an increased risk of hepatocellular carcinoma. These mutations were detected in the majority of sequences examined. Variants associated with vaccine failure were detected as the predominant viral quasi‐species in 3/35 samples. In summary, the HBV C4 variant found in this population has a high potential to cause advanced liver disease and to escape vaccination programs. Further in vitro functional and natural history studies are warranted in order to determine the clinical and public health consequences of infection with the HBV C4 variant in these communities. J. Med. Virol. 86:695–706, 2014.

Only your blood can tell the story--a qualitative research study using semi-structured interviews to explore the hepatitis B related knowledge, perceptions and experiences of remote dwelling Indigenous Australians and their health care providers in northern Australia.

BackgroundHepatitis B is endemic in the Indigenous communities of the Northern Territory of Australia and significantly contributes to liver-related morbidity and mortality. It is recognised that low health literacy levels, different worldviews and English as a second language all contribute to the difficulties health workers often have in explaining biomedical health concepts, relevant to hepatitis B infection, to patients. The aim of this research project was to explore the knowledge, perceptions and experiences of remote dwelling Indigenous adults and their health care providers relating to hepatitis B infection with a view to using this as the evidence base to develop a culturally appropriate educational tool.MethodsThe impetus for this project came from health clinic staff at a remote community in Arnhem Land in the Northern Territory, in partnership with a visiting specialist liver clinic from the Royal Darwin Hospital. Participants were clinic patients with hepatitis B (n = 12), community members (n = 9) and key informants (n = 13); 25 were Indigenous individuals.A participatory action research project design was used with purposive sampling to identify participants. Semi-structured interviews were undertaken to explore: current understanding of hepatitis B, desire for knowledge, and perspectives on how people could acquire the information needed. All individuals were offered the use of an interpreter. The data were examined using deductive and inductive thematic analysis.ResultsLow levels of biomedical knowledge about Hepatitis B, negative perceptions of Hepatitis B, communication (particularly language) and culture were the major themes that emerged from the data. Accurate concepts grounded in Indigenous culture such as “only your blood can tell the story” were present but accompanied by a feeling of disempowerment due to perceived lack of “medical” understanding, and informed partnerships between caregiver and patient. Culturally appropriate discussions in a patient’s first language using visual aids were identified as vital to improving communication.ConclusionsHaving an educational tool in Indigenous patient’s first language is crucial in developing treatment partnerships for Indigenous patients with hepatitis B. Using a culturally appropriate worldview as the foundation for development should help to reduce disempowerment and improve health literacy.

Hookworm in the Northern Territory: down but not out

Objectives: To determine the prevalence and trends of human hookworm infection (HWI) in the Northern Territory over the past 10 years, and to assess the influence of the community childrens deworming program (CCDP).