Thorkild Tylleskär

Cassava cyanogens and konzo, an upper motoneuron disease found in Africa

Konzo is a distinct form of tropical myelopathy characterised by abrupt onset of spastic paraparesis. Epidemics in East Africa have been attributed to dietary cyanide exposure from insufficiently processed cassava but a study done in Zaire disputed such an aetiology. We investigated a konzo-affected population in rural Zaire and measured the cyanogen content of cassava flour, determined urinary thiocyanate as an indicator of cyanide intake, and compared blood cyanide concentrations in cases and controls. The affected population consumed flour made from short-soaked (one day) cassava roots and thus had high dietary cyanide exposure (urinary thiocyanate in 31 children = 757 mumol/l) compared with the unaffected population (urinary thiocyanate in 46 children = 50 mumol/l) that ate cassava that had been soaked for three days before consumption. 3 konzo patients, but only 2 of 23 controls, had blood cyanide concentrations above 4 mumol/l (p less than 0.01), although serum thiocyanate concentrations were similar. Our findings indicate a causal role in konzo of sustained high blood cyanide concentrations maintained by a deficient sulphur intake impairing cyanide to thiocyanate conversion. The underlying causes of konzo are poverty and food shortage, but a minor improvement of food processing may, as in beri-beri, be preventive.

Intimate partner violence against women in eastern Uganda: implications for HIV prevention

BackgroundWe were interested in finding out if the very low antenatal VCT acceptance rate reported in Mbale Hospital was linked to intimate partner violence against women. We therefore set out to i) determine the prevalence of intimate partner violence, ii) identify risk factors for intimate partner violence and iii) look for association between intimate partner violence and HIV prevention particularly in the context of the prevention of mother-to-child transmission of HIV programme (PMTCT).MethodsThe study consisted of a household survey of rural and urban women with infants in Mbale district, complemented with focus group discussions with women and men. Women were interviewed on socio-demographic characteristics of the woman and her husband, antenatal and postnatal experience related to the youngest child, antenatal HIV testing, perceptions regarding the marital relationship, and intimate partner violence. We obtained ethical approval from Makerere University and informed consent from all participants in the study.ResultsDuring November and December 2003, we interviewed 457 women in Mbale District. A further 96 women and men participated in the focus group discussions. The prevalence of lifetime intimate partner violence was 54% and physical violence in the past year was 14%. Higher education of women (OR 0.3, 95% CI 0.1–0.7) and marriage satisfaction (OR 0.3, 95% CI 0.1–0.7) were associated with lower risk of intimate partner violence, while rural residence (OR 4.4, 95% CI 1.2–16.2) and the husband having another partner (OR 2.4, 95% CI 1.02–5.7) were associated with higher risk of intimate partner violence. There was a strong association between sexual coercion and lifetime physical violence (OR 3.8, 95% CI 2.5–5.7). Multiple partners and consumption of alcohol were major reasons for intimate partner violence. According to the focus group discussions, women fear to test for HIV, disclose HIV results, and request to use condoms because of fear of intimate partner violence.ConclusionIntimate partner violence is common in eastern Uganda and is related to gender inequality, multiple partners, alcohol, and poverty. Accordingly, programmes for the prevention of intimate partner violence need to target these underlying factors. The suggested link between intimate partner violence and HIV risky behaviours or prevention strategies calls for further studies to clearly establish this relationship.

Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey.

BackgroundMother-to-child transmission of HIV (MTCT) accounts for over 95% of all paediatric HIV infections worldwide. Several studies have shown that male participation in the antenatal care of their spouses together with couple counselling and testing for HIV, increases use of the interventions for HIV prevention. The prevention programme of MTCT (PMTCT) was launched in Uganda in 2000 and Mbale in 2002. Less than 10% of the pregnant women accepted antenatal HIV testing at Mbale Regional Referral Hospital in 2003; couple counselling and testing for HIV was low. Therefore, we conducted the study to determine the level of male involvement and identify its determinants in the PMTCT programme.MethodsA cross-sectional survey of 388 men aged 18 years or more, whose spouses were attending antenatal care at Mbale Regional Referral Hospital, was conducted in Mbale district, Eastern Uganda. A male involvement index was constructed based on 6 questions. The survey was complemented by eight focus group discussions and five in-depth interviews.ResultsThe respondents had a median age of 32 years (inter-quartile range, IQR: 28-37). The majority (74%) had a low male involvement index and only 5% of men accompanied their spouses to the antenatal clinic. Men who had attained secondary education were more likely to have a high male involvement index (OR: 1.9, 95% CI: 1.1-3.3) than those who had primary or no formal education. The respondents, whose occupation was driver (OR: 0.3, 95% CI: 0.1-0.7) or those who had fear of disclosure of their HIV sero-status results to their spouses (OR: 0.4, 95% CI: 0.2-0.8), were less likely to have a high male involvement index. Barriers to male involvement in the PMTCT programme were related to both the poor health system, to socio-economic factors and to cultural beliefs.ConclusionsStructural and cultural barriers to mens involvement in the PMTCT programme in Mbale district were complex and interrelated. Community sensitization of men about the benefits of antenatal care and PMTCT and improving client-friendliness in the clinics needs to be prioritised in order to improve low male participation and mitigate the effect of socio-economic and cultural factors.

Low adherence to exclusive breastfeeding in Eastern Uganda: A community-based cross-sectional study comparing dietary recall since birth with 24-hour recall

BackgroundExclusive breastfeeding is recommended as the best feeding alternative for infants up to six months and has a protective effect against mortality and morbidity. It also seems to lower HIV-1 transmission compared to mixed feeding. We studied infant feeding practices comparing dietary recall since birth with 24-hour dietary recall.MethodsA cross-sectional survey on infant feeding practices was performed in Mbale District, Eastern Uganda in 2003 and 727 mother-infant (0–11 months) pairs were analysed. Four feeding categories were made based on WHOs definitions: 1) exclusive breastfeeding, 2) predominant breastfeeding, 3) complementary feeding and 4) replacement feeding. We analyzed when the infant fell into another feeding category for the first time. This was based on the recall since birth. Life-table analysis was made for the different feeding categories and Cox regression analysis was done to control for potential associated factors with the different practices. Prelacteal feeding practices were also addressed.ResultsBreastfeeding was practiced by 99% of the mothers. Dietary recall since birth showed that 7% and 0% practiced exclusive breastfeeding by 3 and 6 months, respectively, while 30% and 3% practiced predominant breastfeeding and had not started complementary feeding at the same points in time. The difference between the 24-hour recall and the recall since birth for the introduction of complementary feeds was 46 percentage points at two months and 59 percentage points at four months. Prelacteal feeding was given to 57% of the children. High education and formal marriage were protective factors against prelacteal feeding (adjusted OR 0.5, 0.2 – 1.0 and 0.5, 0.3 – 0.8, respectively).ConclusionEven if breastfeeding is practiced at a very high rate, the use of prelacteal feeding and early introduction of other food items is the norm. The 24-hour recall gives a higher estimate of exclusive breastfeeding and predominant breastfeeding than the recall since birth. The 24-hour recall also detected improper infant feeding practices especially in the second half year of life. The dietary recall since birth might be a feasible alternative to monitor infant feeding practices in resource-poor settings. Our study reemphasizes the need for improving infant feeding practices in Eastern Uganda.

Predictors of poor anthropometric status among children under 2 years of age in rural Uganda

OBJECTIVE To assess predictors of poor anthropometric status among infants and young children. DESIGN Cross-sectional survey. SETTING The rural subsistence agricultural district of Hoima, western Uganda. SUBJECTS Seven hundred and twenty children aged 0-23 months with their mothers/carers. METHODS Participants were recruited in September 2002, using a two-stage cluster sampling methodology. A structured questionnaire was administered to mothers in their home settings. Information on health, household socio-economic status, child feeding practices and anthropometric measurement was gathered. Conditional logistic regression analysis was applied taking into account the hierarchical relationships between potential determinants of poor anthropometric status. RESULTS The mean Z-score for weight-for-height was -0.2 (95% confidence interval (CI) -0.1, -0.7), for height-for-age was -1.1 (95% CI -1.2, -0.9) and for weight-for-age was -0.7 (95% CI -0.8, -0.6). Wasting was independently associated only with a history of fever in the 2 weeks prior to the survey (odds ratio (OR)=4.4, 95% CI 1.5, 13), while underweight was associated with a history of fever (OR=2.4, 95% CI 1.3, 4.4) and cough (OR=3.0, 95% CI 1.3, 6.8). Stunting was positively associated with a wider range of factors, including: history of a fever episode (OR=1.7, 95% CI 1.0, 2.9), lack of a latrine in the household (OR=2.7, 95% CI 1.5, 4.9), failure to de-worm children 12 months or older (OR=1.7, 95% CI 1.1, 2.8), and being born to a non-formally educated mother compared with mothers educated above primary school (OR=2.1, 95% CI 1.1, 4.0). CONCLUSIONS In analyses guided by the hierarchical interrelationships of potential determinants of malnutrition, wasting and underweight turned out to be independently predicted by morbidity (proximal) factors. Stunting, however, was predicted by socio-economic (distal), environmental and health-care (intermediate) factors in addition to morbidity. Strategies aimed at improving the growth of infants and young children in rural communities should address morbidity due to common childhood illness coupled with environmental and socio-economically oriented measures.

Bacteraemia among severely malnourished children infected and uninfected with the human immunodeficiency virus-1 in Kampala, Uganda

BackgroundTo establish the magnitude of bacteraemia in severely malnourished children, and describe the types of bacteria and antimicrobial sensitivity by HIV status.MethodIsolates were recovered from 76 blood specimens. Antibiotic susceptibility tests were performed using commercial antibiotic disks and demographic and clinical findings were recorded.ResultsOf the 450 children 63% were male; median age 17.0 months (inter quartile range, IQR 12–24) and 57% had oedema. 151 (36.7 %) of 411 tested HIV-positive; 76 (17.1%) of 445 blood specimens grew bacterial isolates; 58% were Gram negative – S. typhimurium (27.6%) and S. enteriditis (11.8%). Staph. aureus (26.3%) and Strep. pneumoniae (13.2%) were the main Gram positive organisms. There was no difference in the risk of bacteraemia by HIV status, age < 24 months, male sex, or oedema, except for oral thrush (OR 2.3 CI 1.0–5.1) and hypoalbuminaemia (OR 3.5 CI 1.0–12.1). Isolates from severely immuno-suppressed children (CD4% <15%) were more likely to grow Salmonella enteriditis (OR 5.4; CI 1.6 – 17.4). The isolates were susceptible (≥ 80%) to ciprofloxacin, ceftriaxone and gentamicin; with low susceptibility to chlorampenicol, ampicillin (< 50%) and co-trimoxazole (<25%). Suspicion of bacteraemia had 95.9% sensitivity and 99.2% specificity. Among bacteraemic children, mortality was higher (43.5% vs 20.5%) in the HIV-positive; OR 3.0 (95%CI 1.0, 8.6).ConclusionBacteraemia affects 1 in every 6 severely malnourished children and carries high mortality especially among the HIV-positive. Given the high level of resistance to common antibiotics, there is need for clinical trials to determine the best combinations of antibiotics for management of bacteraemia in severely malnourished children.

Male partner antenatal attendance and HIV testing in eastern Uganda: a randomized facility-based intervention trial

BackgroundThe objective of the study was to evaluate the effect of a written invitation letter to the spouses of new antenatal clinic attendees on attendance by couples and on male partner acceptance of HIV testing at subsequent antenatal clinic visits.MethodsThe trial was conducted with 1060 new attendees from October 2009 to February 2010 in an antenatal clinic at Mbale Regional Referral Hospital, Mbale District, eastern Uganda. The intervention comprised an invitation letter delivered to the spouses of new antenatal attendees, while the control group received an information letter, a leaflet, concerning antenatal care. The primary outcome measure was the proportion of pregnant women who attended antenatal care with their male partners during a follow-up period of four weeks. Eligible pregnant women were randomly assigned to the intervention or non-intervention groups using a randomization sequence, which was computer generated utilizing a random sequence generator (RANDOM ORG) that employed a simple randomization procedure. Respondents, health workers and research assistants were masked to group assignments.ResultsThe trial was completed with 530 women enrolled in each group. Participants were analyzed as originally assigned (intention to treat). For the primary outcome, the percentage of trial participants who attended the antenatal clinic with their partners were 16.2% (86/530) and 14.2% (75/530) in the intervention and non-intervention groups, respectively (OR = 1.2; 95% CI: 0.8, 1.6). For the secondary outcome, most of the 161 male partners attended the antenatal clinic; 82 of 86 (95%) in the intervention group and 68 of 75 (91%) in the non-intervention group were tested for HIV (OR = 2.1; 95% CI: 0.6 to 7.5).ConclusionsThe effect of the intervention and the control on couple antenatal attendance was similar. In addition, the trial demonstrated that a simple intervention, such as a letter to the spouse, could increase couple antenatal clinic attendance by 10%. Significantly, the majority of male partners who attended the antenatal clinic accepted HIV testing. Therefore, to further evaluate this simple and cost-effective intervention method, adequately powered studies are required to assess its effectiveness in increasing partner participation in antenatal clinics and the programme for prevention of mother to child transmission of HIV.Trial RegistrationClinicalTrials.gov Identifier: NCT01144234.

Severe malnutrition with and without HIV-1 infection in hospitalised children in Kampala, Uganda: differences in clinical features, haematological findings and CD4 + cell counts

BackgroundThe aim of this study was to describe the clinical features, haematological findings and CD4+ and CD8+ cell counts of severely malnourished children in relation to human immunodeficiency virus (HIV) infection.MethodsThe study was conducted in the paediatric wards of Mulago hospital, which is Ugandas national referral and teaching hospital. We studied 315 severely malnourished children (presence of oedema and/or weight-for-height: z-score < -3) and have presented our findings. At admission, the CD4+ and CD8+ cells were measured by the flow cytometry and HIV serology was confirmed by Enzyme linked Immunoassay for children >18 months of age, and RNA PCR was performed for those ≤18 months. Complete blood count, including differential counts, was determined using a Beckman Coulter counter.ResultsAmong the 315 children, 119 (38%) were female; the median age of these children was 17 months (Interquartile range 12–24 months), and no difference was observed in the HIV status with regard to gender or age. The children showed a high prevalence of infections: pneumonia (68%), diarrhoea (38%), urinary tract infection (26%) and bacteraemia (18%), with no significant difference with regard to the HIV status (HIV-positive versus HIV-negative children). However, the HIV-positive children were more likely to have persistent diarrhoea than the HIV-uninfected severely malnourished children (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.2–3.6). When compared with the HIV-negative children, the HIV-positive children showed a significantly lower median white blood cell count (10700 versus 8700) and lymphocyte count (4033 versus 2687). The CD4+ cell percentages were more likely to be lower in children with non-oedematous malnutrition than in those with oedematous malnutrition even after controlling for the HIV infection.The novel observation of this study is that the CD4+ percentages in both HIV-positive and HIV-negative children without oedema were lower that those in children with oedema. These observations appear to imply that the development of oedema requires a certain degree of immunocompetence, which is an interesting clue to the pathophysiology of oedema in severe malnutrition.

It is her responsibility: partner involvement in prevention of mother to child transmission of HIV programmes, northern Tanzania

BackgroundPartner involvement has been deemed fundamental in prevention of mother to child transmission (PMTCT) programmes, but is difficult to achieve. This study aimed to explore acceptability of the PMTCT programme components and to identify structural and cultural challenges to male involvement.MethodsThe study was conducted during 2007-2008 in rural and urban areas of Moshi in the Kilimanjaro region of Tanzania. Mixed methods were used, and included focus group discussions with fathers and mothers, in-depth interviews with fathers, mothers and health personnel, and a survey of 426 mothers bringing their four-week-old infants for immunization at five reproductive and child health clinics.ResultsRoutine testing for HIV of women at the antenatal clinic was highly acceptable and appreciated by men, while other programme components, notably partner testing, condom use and the infant feeding recommendations, were met with continued resistance. Very few men joined their wives for testing and thus missed out on PMTCT counselling. The main barriers reported were that women did not have the authority to request their husbands to test for HIV and that the arena for testing, the antenatal clinic, was defined as a typical female domain where men were out of place.ConclusionsDeep-seated ideas about gender roles and hierarchy are major obstacles to male participation in the PMTCT programme. Empowering women remains a huge challenge. Empowering men to participate by creating a space within the PMTCT programme that is male friendly should be feasible and should be highly prioritized for the PMTCT programme to achieve its potential.

Geographical and seasonal association between linamarin and cyanide exposure from cassava and the upper motor neurone disease konzo in former Zaire

High cyanide intake from consumption of insufficiently processed cassava has been advanced as a possible aetiology of the upper motor neurone disease konzo. However, similar neurodamage has not been associated with cyanide exposure from any other source. With an ecological study design, we compared 22 cases of konzo, 57 unaffected household members and 116 members from unaffected households, a total of 195 subjects, in konzo‐affected savanna villages with 103 subjects in adjacent non‐affected forest villages in the Paykongila area in the Bandundu Region. Zaire.