Recent Submissions

  • Women experience a better long-term immune recovery and a better survival on HAART in Lao People's Democratic Republic

    Bastard M; Soulinphumy K; Phimmasone P; Saadani AH; Ciaffi L; MSF (BioMed Central, 2013-07-10)
  • Lessons and challenges for measles control from unexpected large outbreak, Malawi

    Minetti A; Kagoli M; Katsulukuta A; Huerga H; Featherstone A; Chiotcha H; Noel D; Bopp C (2013-07-10)
    Despite high reported coverage for routine and supplementary immunization, in 2010 in Malawi, a large measles outbreak occurred that comprised 134,000 cases and 304 deaths. Although the highest attack rates were for young children (2.3%, 7.6%, and 4.5% for children <6, 6-8, and 9-11 months, respectively), persons >15 years of age were highly affected (1.0% and 0.4% for persons 15-19 and >19 years, respectively; 28% of all cases). A survey in 8 districts showed routine coverage of 95.0% for children 12-23 months; 57.9% for children 9-11 months; and 60.7% for children covered during the last supplementary immunization activities in 2008. Vaccine effectiveness was 83.9% for 1 dose and 90.5% for 2 doses. A continuous accumulation of susceptible persons during the past decade probably accounts for this outbreak. Countries en route to measles elimination, such as Malawi, should improve outbreak preparedness. Timeliness and the population chosen are crucial elements for reactive
  • Nevirapine versus efavirenz for patients co-infected with HIV and tuberculosis: a randomised non-inferiority trial

    Bonnet M; Bhatt N; Baudin E; Silva C; Michon C; Taburet AM; Ciaffi L; Sobry A (2013-07-10)
    BACKGROUND In countries with a high incidence of HIV and tuberculosis co-infection, nevirapine and efavirenz are widely used as antiretroviral therapy but both interact with antituberculosis drugs. We aimed to compare efficacy and safety of a nevirapine-based antiretroviral therapy (started at full dose) with an efavirenz-based regimen in co-infected patients. METHODS We did a multicentre, open-label, randomised, non-inferiority trial at three health centres in Maputo, Mozambique. We enrolled adults (≥18 years) with tuberculosis and previously untreated HIV infection (CD4 cell counts <250 cells per μL) and alanine aminotransferase and total bilirubin concentrations of less than five times the upper limit of normal. 4-6 weeks after the start of tuberculosis treatment, we randomly allocated patients (1:1) with central randomisation, block sizes of two to six, and stratified by site and CD4 cell count to nevirapine (200 mg twice daily) or efavirenz (600 mg once daily), plus lamivudine and stavudine. The primary endpoint was virological suppression at 48 weeks (HIV-1 RNA <50 copies per mL) in all patients who received at least one dose of study drug (intention-to-treat population); death and loss to follow-up were recorded as treatment failure. The non-inferiority margin for the difference of efficacy was 10%. We assessed efficacy in intention-to-treat and per-protocol populations and safety in all patients who received study drug. This study is registered with, number NCT00495326. FINDINGS Between October, 2007, and March, 2010, we enrolled 285 patients into each group. 242 (85%) patients in the nevirapine group and 233 (82%) patients in the efavirenz group completed follow-up. In the intention-to-treat population, 184 patients (64·6%, 95% CI 58·7-70·1) allocated nevirapine achieved virological suppression at week 48, as did 199 patients (69·8%, 64·1-75·1) allocated efavirenz (one-sided 95% CI of the difference of efficacy 11·7%). In the per-protocol population, 170 (70·0%, 63·8-75·7) of 243 patients allocated nevirapine achieved virological suppression at week 48, as did 194 (78·9%, 73·2-83·8) of 246 patients allocated efavirenz (one-sided 95% CI 15·4%). The median CD4 cell count at randomisation was 89 cells per μL. 15 patients substituted nevirapine with efavirenz and six patients substituted efavirenz with nevirapine. 20 patients allocated nevirapine (7%) had grade 3-4 increase of alanine aminotransferase compared with 17 patients allocated efavirenz (6%). Three patients had severe rash after receipt of of nevirapine (1%) but no patients did after receipt of efavirenz. 18 patients in the nevirapine group died, as did 17 patients in the efavirenz group.
  • Malaria is an uncommon cause of adult sepsis in south-western Uganda

    Auma MA; Siedner MJ; Nyehangane D; Nalusaji A; Nakaye M; Mwanga-Amumpaire J; MSF (BioMed Central, 2013-07-10)
    Background: Malaria is often considered a cause of adult sepsis in malaria endemic areas. However, diagnostic limitations can make distinction between malaria and other infections challenging. Therefore, the objective of this study was to determine the relative contribution of malaria to adult sepsis in south-western Uganda. Methods: Adult patients with sepsis were enrolled at the Mbarara Regional Referral Hospital between February and May 2012. Sepsis was defined as infection plus >=2 of the following: axillary temperature >37.5[degree sign]C or <35.5[degree sign]C, heart rate >90 or respiratory rate >20. Severe sepsis was defined as sepsis plus organ dysfunction (blood lactate >4 mmol/L, confusion, or a systolic blood pressure <90 mmHg). Sociodemographic, clinical and laboratory data, including malaria PCR and rapid diagnostic tests, as well as acid fast bacteria sputum smears and blood cultures were collected. Patients were followed until in-patient death or discharge. The primary outcome of interest was the cause of sepsis. Multivariable logistic regression was performed to assess predictors of mortality. Results: Enrollment included 216 participants who were 51% female with a median age of 32 years (IQR 27--43 years). Of these, 122 (56%) subjects were HIV-seropositive of whom 75 (66%) had a CD4+ T cell count <100 cells/muL. The prevalence of malaria was 4% (six with Plasmodium falciparum, two with Plasmodium vivax). Bacteraemia was identified in 41 (19%) patients. In-hospital mortality was 19% (n = 42). In multivariable regression analysis, Glasgow Coma Score <9 (IRR 4.81, 95% CI 1.80-12.8) and severe sepsis (IRR, 2.07, 95% CI 1.03-4.14), but no specific diagnoses were statistically associated with in-hospital mortality. Conclusion: Malaria was an uncommon cause of adult sepsis in a regional referral hospital in south-western Uganda. In this setting, a thorough evaluation for alternate causes of disease in patients presenting with sepsis is recommended.
  • Observational Bias during Nutrition Surveillance: Results of a Mixed Longitudinal and Cross-Sectional Data Collection System in Northern Nigeria

    Grellety E; Luquero FJ; Mambula C; Adamu HH; Elder G; Porten K; MSF (Epicentre, 2008-03-07)
    Background: The Sahel is subject to seasonal hungry periods with increasing rates of malnutrition. In Northern Nigeria,there is no surveillance system and surveys are rare. The objectives were to analyse possible observational bias in a sentinelsurveillance system using repeated mixed longitudinal/cross-sectional data and estimate the extent of seasonal variation. Methods Thirty clusters were randomly selected using probability proportional to size (PPS) sampling from Kazaure Local Government Area, Jigawa State. In each cluster, all the children aged 6–59 months within 20 randomly selected households had their mid-upper arm circumference measured and were tested for oedema. The surveys were repeated every 2 or 4 weeks. At each survey round, three of the clusters were randomly selected to be replaced by three new clusters chosen at random by PPS. The seasonal variation of acute malnutrition was assessed using cyclical regression. The effect of repeated visits to the same cluster was examined using general linear mixed effects models adjusted for the seasonal change. Results: There was a significant seasonal fluctuation of Global Acute Malnutrition (GAM) with a peak in October. With each repeat survey of a cluster, the prevalence of GAM decreased by 1.6% (95% CI: 0.4 to 2.7; p = 0.012) relative to the prevalence observed during the previous visit after adjusting for seasonal change. Conclusions: Northern Nigeria has a seasonal variation in the prevalence of acute malnutrition. Repeated surveys in the same cluster-village, even if different children are selected, lead to a progressive improvement of the nutritional status of that village. Sentinel site surveillance of nutritional status is prone to observational bias, with the sentinel site progressively deviating from that of the community it is presumed to represent.