Nicolai Lohse

Diabetes in Sub Saharan Africa 1999-2011: Epidemiology and public health implications. a systematic review

BackgroundDiabetes prevalence is increasing globally, and Sub-Saharan Africa is no exception. With diverse health challenges, health authorities in Sub-Saharan Africa and international donors need robust data on the epidemiology and impact of diabetes in order to plan and prioritise their health programmes. This paper aims to provide a comprehensive and up-to-date review of the epidemiological trends and public health implications of diabetes in Sub-Saharan Africa.MethodsWe conducted a systematic literature review of papers published on diabetes in Sub-Saharan Africa 1999-March 2011, providing data on diabetes prevalence, outcomes (chronic complications, infections, and mortality), access to diagnosis and care and economic impact.ResultsType 2 diabetes accounts for well over 90% of diabetes in Sub-Saharan Africa, and population prevalence proportions ranged from 1% in rural Uganda to 12% in urban Kenya. Reported type 1 diabetes prevalence was low and ranged from 4 per 100,000 in Mozambique to 12 per 100,000 in Zambia. Gestational diabetes prevalence varied from 0% in Tanzania to 9% in Ethiopia. Proportions of patients with diabetic complications ranged from 7-63% for retinopathy, 27-66% for neuropathy, and 10-83% for microalbuminuria. Diabetes is likely to increase the risk of several important infections in the region, including tuberculosis, pneumonia and sepsis. Meanwhile, antiviral treatment for HIV increases the risk of obesity and insulin resistance. Five-year mortality proportions of patients with diabetes varied from 4-57%. Screening studies identified high proportions (> 40%) with previously undiagnosed diabetes, and low levels of adequate glucose control among previously diagnosed diabetics. Barriers to accessing diagnosis and treatment included a lack of diagnostic tools and glucose monitoring equipment and high cost of diabetes treatment. The total annual cost of diabetes in the region was estimated at US

Gestational diabetes mellitus: results from a survey of country prevalence and practices

67.03 billion, or US

Improving the Immunogenicity of Pneumococcal Conjugate Vaccine in HIV-Infected Adults with a Toll-Like Receptor 9 Agonist Adjuvant: A Randomized, Controlled Trial

8836 per diabetic patient.ConclusionDiabetes exerts a significant burden in the region, and this is expected to increase. Many diabetic patients face significant challenges accessing diagnosis and treatment, which contributes to the high mortality and prevalence of complications observed. The significant interactions between diabetes and important infectious diseases highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.

Demographics of HIV-1 infection in Denmark: results from the Danish HIV Cohort Study.

Objective: The association between gestational diabetes mellitus (GDM), perinatal complications and long-term morbidity is gaining increased attention. However, the global burden of GDM and the existing responses are not fully understood. We aimed to assess country prevalence and to summarize practices related to GDM screening and management. Methods: Data on prevalence and country practices were obtained from a survey administered to diabetologists, obstetricians and others working on GDM in 173 countries. Results: GDM prevalence estimates range from <1% to 28%, with data derived from expert estimates, and single-site, multi-site and national prevalence assessments. Seventy-four percent of countries that completed the survey have national GDM guidelines or recommendations. Countries use a variety of screening approaches. In the countries where universal screening is recommended, the percentage of pregnant women screened ranges from 10% to >90%. Conclusions: We found large variations in estimated GDM prevalence, but direct comparison between countries is difficult due to different diagnostic strategies and subpopulations. Many countries do not perform systematic screening for GDM, and practices often diverge from guidelines. Countries need to carefully assess the cost and health impact of scaling up GDM screening and management in order to identify the best policy option for their population.

Hospitalization for Pneumonia among Individuals With and Without HIV Infection, 1995–2007: A Danish Population-Based, Nationwide Cohort Study

BACKGROUND Persons infected with human immunodeficiency virus (HIV) are often hyporesponsive to immunization, including pneumococcal vaccines. We hypothesized that adding CPG 7909, a toll-like receptor 9 (TLR9) agonist and vaccine adjuvant, to 7-valent pneumococcal conjugate vaccine (7vPnC) would increase its immunogenicity in HIV-infected adults. METHODS We performed a double-blind, placebo-controlled, phase 1b/2a trial randomizing HIV-positive patients to receive double doses of 7vPnC (Prevnar) at 0 and 3 months and 1 dose of 23-valent pneumococcal polysaccharide vaccine (PPV-23; Pneumo Novum) at 9 months, with experimental patients receiving 1 mg of CPG 7909 added to each of their 3 vaccine doses; control patients had phosphate-buffered saline added instead. Immunogenicity and safety were evaluated for up to 10 months. The primary end point was the proportion of vaccine high responders at 9 months, defined as a 2-fold increase in IgG levels to > or = 1 microg/mL for at least 5 of 7 of the 7vPnC serotypes. RESULTS Ninety-seven participants were included in the study. The proportion of vaccine high responders was higher in the experimental group (n = 48) than among controls (n = 49; 48.8% vs 25.0%; P = .02) at 9 months. Greater proportions of high responders were also observed at 3 (51.1% vs 39.6%; P = .26), 4 (77.3% vs 56.3%; P = .03), and 10 months (87.8% vs 51.1%; P < .001). Mild systemic and injection site reactions to 7vPnC were more common in the experimental group than the control group (100% vs 81.3%; P = .002). CPG 7909 did not increase non-7vPnC IgG levels after PPV-23 immunization. No adverse effects on CD4(+) cell count or organ functions occurred in either group. CONCLUSIONS The addition of a TLR9 agonist to 7vPnC significantly enhanced the proportion of vaccine high responders. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00562939 .

Validation of spontaneous abortion diagnoses in the Danish National Registry of Patients

We used a population-based cohort study design to describe the demographic characteristics of the HIV-infected population in Denmark and their variation over time. HIV treatment in Denmark is restricted to 9 centres, and all 3941 HIV-1 infected patients more than 15 y old seen at these centres in 1995–2003 were included. We found an estimated HIV prevalence of 70 per 100,000, and a mean annual incidence rate of 5.1 per 100,000 persons. The number of newly infected individuals was stable with a median of 231 per y (period 1995–2002), whereas the number of deaths decreased from 166 in 1995 to 50 in 2000 (p=0.000) and remained stable thereafter. Of the enrolled patients, 75% were males, 80% were Caucasian, 13% were black African, and the primary risk behaviour was male-to-male sexual contact (44%), heterosexual contact (36%), and injection drug use (11%). During the y 1995–2003 we found an increase in age at diagnosis (p=0.000), and no major changes in gender, race, mode of infection, or baseline CD4+ cell count and viral load, neither overall not within subgroups of patients. In this period 14.5% had AIDS at the time of HIV diagnosis. Our data do not confirm concerns about unmonitored evolution in the HIV epidemic in Denmark.

Declining risk of triple-class antiretroviral drug failure in Danish HIV-infected individuals.

BACKGROUND Human immunodeficiency virus (HIV)-infected individuals with high CD4(+) cell counts may have increased susceptibility to other infections. We compared incidence rates of pneumonia among individuals with and without HIV infection and explored risk factors for pneumonia in the HIV-infected population. METHODS This was an observational cohort study conducted during 1995-2007. Each member of a Danish population-based nationwide cohort of HIV-infected individuals was matched with up to 99 control individuals from the general population. Data on age, mortality, emigration, and hospital discharge diagnoses from 1977 onward were obtained from nationwide administrative databases. Individuals without previous hospitalization for pneumonia were observed from the date of HIV diagnosis until the first hospitalization to treat pneumonia (excluding pneumonia attributable to Pneumocystis jiroveci). Risk factors were assessed by Poisson regression. RESULTS The study included 3516 persons with HIV infection and 328,738 persons without HIV infection, which provided 23,677 person-years and 2,944,760 person-years of observation, respectively. Incidence rates of pneumonia in HIV-infected individuals decreased from 50.6 hospitalizations per 1000 person-years (95% confidence interval [CI], 42.9-59.7 hospitalizations per 1000 person-years) during 1995-1996 to 19.7 hospitalizations per 1000 person-years (95% CI, 16.2-23.8 hospitalizations per 1000 person-years) during 2005-2007. Compared with control individuals, incidence rate ratios were 34.6 (95% CI, 28.4-41.8) during 1995-1996; 6.3 (95% CI, 5.1-7.7) during 2005-2007; and 5.9 (95% CI, 4.2-7.6) during 2005-2007 for the subgroup with a CD4(+) cell count >500 cells/microL. Injection drug use, low current CD4(+) cell count, nadir CD4(+) cell count, increasing age, and no current receipt of highly active antiretroviral therapy increased the risk of pneumonia. CONCLUSIONS The risk of pneumonia in persons with HIV infection has decreased substantially since the introduction of highly active antiretroviral therapy, but HIV infection remains a strong risk factor for the need for hospitalization to treat pneumonia, even in persons with high CD4(+) cell counts.

The cost-effectiveness of gestational diabetes screening including prevention of type 2 diabetes: application of a new model in India and Israel

Purpose The purpose of this study is to validate the diagnosis of spontaneous abortion (SA) recorded in the Danish National Registry of Patients (DNRP). Methods We randomly selected patients registered in the DNRP with a diagnosis of SA between 1980 and 2008 from hospitals in the county of North Jutland and searched for their discharge records in hospital files. We estimated positive predictive value (PPV) of the DNRP diagnosis and stratified the analysis by period (1980–1994 versus 1995–2008), hospital type (regional versus local), and International Classification of Diseases revisions (ICD-8 versus ICD-10). Results We could identify hospital files of 117/174 (67%) sampled registration records. Of those, the diagnosis was confirmed in 114 patients, yielding a PPV of 97.4% (95% confidence interval = 92.7%–99.5%). The PPV did not markedly vary by period, hospital type, or ICD revision. Among the three patients with available data who did not fulfill the criteria for SA, one had an induced abortion and two had threatened abortion but did not miscarry. Conclusion Registration of SA in the DNRP accurately reflects the diagnoses recorded in medical charts. The DNRP is a suitable source of data on SAs for epidemiologic research.

Development of a model to assess the cost-effectiveness of gestational diabetes mellitus screening and lifestyle change for the prevention of type 2 diabetes mellitus

Objectives:To analyse the incidence, prevalence, and predictors for development of triple-class antiretroviral drug failure (TCF) in individuals infected with HIV. Design:Population-based observational cohort study from 1 January 1995 to 31 December 2003, focusing on all 2722 recipients of highly active antiretroviral therapy (HAART) in Denmark. Methods:We used person-years analysis, Kaplan–Meier survival curves and Cox regression analysis. TCF was defined as a minimum of 120 days with viral load > 1000 copies/ml on treatment with each of the three major drug classes. Results:We observed 177 TCFs, yielding a crude incidence rate (IR) of 1.8 per 100 person-years [95% confidence interval (CI), 1.6–2.1]. Seven years after initiation of HAART, 17.2% (95% CI, 14.5–20.5) of antiretroviral (ART)-experienced patients, but only 7.0% (95% CI, 4.3–11.2) of ART-naive patients were estimated to have failed. After an initial rise, the IR from the third to the sixth year of HAART declined significantly for ART-experienced patients [incidence rate ratio (IRR), 0.80 per year (95% CI, 0.66–0.97); P = 0.022], and non-significantly for ART-naive patients [IRR, 0.79 per year (95% CI, 0.53–1.18); P = 0.255]. The IR for all patients being followed each year declined from 1997 to 2003 [IRR, 0.88 (95% CI, 0.81–0.96); P = 0.002]. The prevalence of TCF remained stable at less than 7% after 2000. Predictors of TCF at commencement of HAART were a CD4 cell count below 200, a previous AIDS-defining event, previous antiretroviral exposure, earlier year of HAART initiation, and young age. Conclusions:The risk of TCF is declining in Denmark and the prevalence remains stable.

T-cell dysfunction in HIV-1-infected patients with impaired recovery of CD4 cells despite suppression of viral replication.

Abstract Objective: Gestational diabetes mellitus (GDM) is associated with elevated risks of perinatal complications and type 2 diabetes mellitus, and screening and intervention can reduce these risks. We quantified the cost, health impact and cost-effectiveness of GDM screening and intervention in India and Israel, settings with contrasting epidemiologic and cost environments. Methods: We developed a decision-analysis tool (the GeDiForCE™) to assess cost-effectiveness. Using both local data and published estimates, we applied the model for a general medical facility in Chennai, India and for the largest HMO in Israel. We computed costs (discounted international dollars), averted disability-adjusted life years (DALYs) and net cost per DALY averted, compared with no GDM screening. Results: The programme costs per 1000 pregnant women are