People living with HIV (PLHIV) have an increased risk of tuberculosis (TB) and severe COVID-19. TB and COVID-19 present with overlapping symptoms and co-infection can lead to poor outcomes. We assessed the frequency of SARS-CoV-2 positive serology and SARS-CoV-2 infection and the risk of mortality at 6 months in PLHIV with TB disease and SARS-CoV-2 infection. This multi-country, prospective, observational study, conducted between 7th September 2020 and 7th April 2022, included ambulatory adult PLHIV investigated for TB (with symptoms of TB or advanced HIV disease) in Kenya, Uganda, and South Africa. Testing included CD4 cell count, Xpert MTB/RIF Ultra assay (sputum), Determine TB LAM Ag assay (urine), chest X-ray, blood SARS-CoV-2 serology test and SARS-CoV-2 PCR (only if TB or COVID-19 symptoms). Individuals were followed for 6 months. Among 1254 participants, 1204 participants had SARS-CoV-2 serology (54% women, median CD4 344 cells/µL [IQR 132–673]), and 487 had SARS-CoV-2 PCR. SARS-CoV-2 serology positivity was 27.0% (325/1204), lower in PLHIV with CD4 counts <200 cells/µL (19.9%, 99/497) than in those with CD4 counts ≥200 cells/µL (31.6%, 222/703), p<0.001. SARS-CoV-2 PCR positivity was 8.6% (42/487) and 27.7% (135/487) had probable or confirmed SARS-CoV-2 infection. Among PLHIV with symptoms of TB or of COVID-19, 6.6% (32/487) had SARS-CoV-2 infection and TB disease. In multivariable analyses, the risk of death was higher in PLHIV with both SARS-CoV-2 infection and TB compared to those with only SARS-CoV-2 infection (adjusted hazard ratio [aHR] 8.90, 95%CI 1.47-53.96, p=0.017), with only TB (aHR 3.70, 95%CI 1.00-13.72, p=0.050) or with none of them (aHR 6.83, 95%CI 1.75-26.72, p=0.006). These findings support SARS-CoV-2 testing in PLHIV with symptoms of TB, and SARS-CoV-2 vaccination, especially for those with severe immunosuppression. PLHIV with COVID-19 and TB have an increased risk of mortality and would benefit from comprehensive management and close monitoring.
Tuberculosis (TB) among hospitalized patients is underdiagnosed. This study assessed systematic TB-screening, followed by an enhanced TB-diagnostic package for hospitalized patients implemented by trained lay health workers in KwaZulu-Natal, South Africa. In this before-and-after study we included patients ≥ 18 years. The intervention consisted of systematic clinical screening for TB, HIV and diabetes mellitus by lay health workers and provision of an enhanced TB-diagnostic package including sputum Xpert MTB/Rif Ultra, urine lateral-flow lipoarabinomannan assay (LF-LAM), chest x-ray, and sputum culture. We compared TB case findings with people hospitalized one year preceding the intervention. In the pre-intervention phase, 5217 people were hospitalized. Among 4913 (94.2%) people not on TB treatment, 367 (7.5%) were diagnosed with TB. In the intervention phase, 4015 eligible people were hospitalized. Among 3734 (93.0%) people not on TB treatment, 560 (15.0%) were diagnosed with TB. The proportion of patients diagnosed with TB was higher in the intervention phase (15.0% vs. 7.5%, p < 0.001). Overall in-hospital mortality was lower in the intervention phase [166/3734(4.5%) vs. 336/4913(6.8%), p < 0.001]. Lay health worker-led implementation of systematic TB-screening, coupled with provision of an enhanced TB-diagnostic package significantly improved TB case detection and mortality among hospitalized adults.
Clinical trials are considered to be the largest contributor to pharmaceutical development costs. However, public disclosure of the costs of individual clinical trials is rare. Médecins Sans Frontières (MSF) sponsored a phase 2b-3 randomised controlled trial (TB-PRACTECAL), which identified a new treatment regimen for drug-resistant TB. We aimed to analyse the costs of undertaking a pivotal clinical trial conducted in relatively low-resource health settings and to demonstrate the feasibility of reporting clinical trial costs. TB-PRACTECAL trial costs were analysed using MSF accounting documents. Costs were broken down by cost category, year, and trial site. Total costs for TB-PRACTECAL were €33.9 million and the average cost per patient was €61,460. Twenty-six percent of total costs represented central activities (e.g. trial planning, trial management) and 72% represented trial site activities, with 2% uncategorizable. Within trial site costs, personnel costs were the largest cost (43%) followed by external diagnostic services (11%), medicines (9%), and other medical consumables (7%). Cost variation across trial sites was driven by different varying levels of pre-existing trial infrastructure. A review of previous studies yielded a wide range of cost estimates for clinical trials (ranging US$7–221 million/trial for pharmaceutical phase 2 and 3 trials). Nearly all previous estimates derive from industry reporting that is neither standardized nor auditable; to our knowledge, this is the first published comprehensive analysis of direct expenditures of a specific clinical trial including detailed cost breakdowns. The €34 million cost of TB-PRACTECAL included investments in developing clinical trial infrastructure, the complexity of managing six sites across three health systems, and medical expenditures that are not typical of standard clinical trials. Greater transparency in drug development costs can inform medicine pricing negotiations and is a key element in the design and implementation of more equitable systems of biomedical research and development.
- A 1-day symposium brought together over 100 individuals with lived experience of noma, expertise in neglected tropical diseases, and public health, including researchers, health advocates, and clinicians. The involvement of noma survivors was invaluable and added an important perspective in defining the research agenda.
- The most pressing research needs identified were:
- Clear case definition of noma
- Early case detection and robust surveillance
- Psychosocial and economic impact of noma
- Decision support for diagnosing acute necrotizing gingivitis and associated antibiotic regimen(s) with treatment duration
- Deeper understanding of risk factors and social determinants
- Identification of effective information, education, and communication strategies
- Effectiveness of surgical services
- Testing decentralized follow-up for patients
- An important conclusion was that noma research and control activities must be integrated across sectors and disciplines, such as neglected tropical diseases, oral health, nutrition, and child health programs including immunization.
BACKGROUND
The global epidemic of Mycoplasma genitalium (MG) is marked by its widespread prevalence, varied resistance patterns, and significant impact on sexual health. This study aimed to understand the prevalence and interaction of MG infections with other sexually transmitted infections (STIs) in a low-resource setting, as well as the implications for routine STIs care.
METHODS
This nested cross-sectional study was conducted from July 2022 to April 2023 across six outpatient care sites in Shiselweni, Eswatini. Participants completed a self-questionnaire, underwent syndromic case management, and provided urine samples for parallel molecular-based testing using the Cepheid GeneXpert® platform for MG, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV). The proportion of MG mono-infection and coinfections were calculated. Multivariable logistic regression models identified predictors of symptomatic MG mono-infections, which could be used to streamline at-risk patients for MG testing.
RESULTS
Among 735 participants, the median age was 27 (interquartile range 23—34) years, 65.9% were women, and 9.5% were HIV-positive. MG infection was detected in 10.5% (n = 77) of clients, with 45.5% (n = 35) coinfected with any of CT/NG/TV, and one case (0.1%) showing macrolide resistance. Among women with vaginal discharge syndrome (28.1%, n = 136), 0.7% (n = 1) had MG mono-infection, and 10.3% (n = 14) had MG and CT/NG/TV coinfections. Among men with male urethral syndrome (31.9%, n = 80), 3.8% (n = 3) had MG mono-infection, and 2.5% (n = 2) had MG and CT/NG/TV coinfections. Most MG-positive cases (66.2%, n = 51) did not receive antibiotic therapy, despite 68.6% (n = 35) reporting symptoms of STIs. Of treated cases, 26.0% (n = 20) received azithromycin monotherapy, 6.5% (n = 5) doxycycline monotherapy, and 1.3% (n = 1) both drugs. Of 305 individuals reporting STIs symptoms but tested negative for CT/NG/TV, 23 (7.5%) had symptomatic MG mono-infections. Unemployment and never having been tested for HIV were identified as risk factors. Streamlining 108/305 (35.4%) at-risk individuals for molecular-based MG testing would identify 14.8% (16/108) as positive, capturing 69.6% (16/23) of all symptomatic MG mono-infections.
CONCLUSIONS
MG was common among outpatients and frequently co-occurred with CT, NG, and TV infections. Syndromic case management often misclassified MG infections, leading to ineffective treatment. Expanding molecular-based MG testing could enhance antibiotic stewardship, crucial for preventing the spread of drug-resistant strains.
This case report presents a rare instance of concomitant splenic tuberculosis (TB), Epstein–Barr virus (EBV)-related T-cell leukemia/lymphoma, and malaria in a 28-year-old pregnant woman at a Médecins Sans Frontières-supported hospital in South Sudan. The patient was admitted with splenomegaly, anorexia, weakness, and transfusion-refractory anemia. She tested positive for malaria and was treated appropriately. Because of ongoing consumptive anemia, cachexia, and weakness severely impacting her quality of life, the patient underwent splenectomy. A diagnosis of TB was ultimately confirmed post-splenectomy through histopathological analysis and molecular testing. Gross findings from the pathologic analysis of a splenic sample revealed miliary deposits, necrotizing granulomas, and atypical lymphocytic infiltrates consistent with TB and EBV-associated leukemia/lymphoma. Despite temporary improvement post-operatively and the initiation of TB therapy, the patient discontinued treatment and was lost to follow-up, likely resulting in mortality. This report presents an unusual combination of concomitant pathologies that underscore the diagnostic challenges and complexity of managing overlapping infectious and hematological disorders in resource-limited settings.
BACKGROUND
Bangladesh has the second highest burden of child labour in South Asia. The informal sector employs most of the children however, data on health including injuries and place of work for children are limited. As the deadline for the Sustainable Development Goals to end child labour is upon us, it is paramount to document the impact of child labour on health. This study aims to contribute to this knowledge gap by presenting medical data from occupational health clinics (OHCs) set up by Médecins Sans Frontières (MSF) in a peri-urban area of Dhaka, Bangladesh.
METHODS
We did a retrospective analysis of health care records of children attending MSF OHCs between February 2014 and December 2023. We stratified the analysis by sex and age (< 14 years and ≥ 14- < 18 years). We looked at morbidities according to type of factory, whether children reported working with machinery, and examined nutritional and mental health (2018–2023) status.
RESULTS
Over the study period, there were 10,200 occupational health consultations among children < 18 years, of which 4945 were new/first time consultations. The average age of children attending their first consultation was 14.7 years, of which 61% were male. Fifteen percent reported living inside the factory. Children worked in all prohibited categories of the informal sector. Almost all children reported operating machinery. Musculoskeletal (26%) and dermatological (20%) were the most identified conditions, and 7.5% of consultations were for work-related injuries. A higher proportion of male children had injuries (11% vs 2.5% in girls). Children working in metal factories accounted for most injuries (65%). Mood-related disorders accounted for 86% of the 51 mental health consultations. Half of all children were malnourished with higher levels in boys and those < 14 years.
CONCLUSIONS
Findings suggest that children face hazardous realities; engaged in the worst form of labour, bearing important morbidity and injury burden, with vulnerabilities varying by sex and age. Despite their economic contributions to the informal sector, they remain largely invisible and exploited. This study highlights the urgent need for child rights-based research and cross-sectoral approaches that actively involve children to develop sustainable, targeted solutions to eliminate child labour.
BACKGROUND
Since 2016, the World Health Organization (WHO) has recommended a minimum of eight antenatal care (ANC) contacts during pregnancy, replacing the previous recommendation of four focused ANC visits. In Mali and Burkina Faso, the four ANC visits are still recommended and their coverage remains low or insufficient. To anticipate possible obstacles to the implementation of the new recommendations, this study aimed to identify the individual determinants of ANC attendance in two study districts, with a representative sample of women recruited from the community.
METHODS
Data were collected in June 2022 through a three-stage household survey with a representative sample of women who delivered in the previous 12 months in the health districts of Kangaba (Mali) and Boussé (Burkina Faso). Country-specific analyses were performed using self-reported data. Women’s sociodemographic and clinical characteristics, as well as attitudes towards ANC attendance, were described to account for clustering. Multivariable logistic regression models using generalized estimating equations were used to identify the determinants of four or more ANC uptakes. A p-value < 0.05 was considered statistically significant in the adjusted model.
RESULTS
Overall, 1590 women participated (780 in Mali; 810 in Burkina Faso) in the study. Women in Burkina Faso were older and less educated than women in Mali. The proportions of women with at least four ANC visits were 80% and 54%, and that of ANC in the first trimester was 38.7% and 43.8% in Burkina Faso and Mali respectively. Factors significantly associated with a greater probability of women attending ANC4 + visits were found only in Mali: a history of stillbirth and time spent at ANC. Factors reducing the use of ANC4 + were the lack of transportation/distance in Burkina Faso, travel time of less than 1 h to reach the maternity clinic, women’s nonrecognition of the importance of ANC visits, and the perceived high cost of the ANC visit in both countries.
CONCLUSION
ANC was lower in Mali than in Burkina Faso. Health policies aimed at achieving the WHO recommendation of 8 ANC contacts should prioritize health information and sensitization of pregnant women to improve their knowledge of the importance of attending ANC several times.
TRIAL REGISTRATION
Retrospectively registered on August 11th, 2022 registration # PACTR202208844472053. Protocol v4.0 dated September 04, 2023.
Scabies is a dermatological parasitic infestation prevalent in many regions worldwide. Classified as a neglected disease by World Health Organization (WHO) since 2017, it is often associated with poor living conditions and overcrowding. Towards the end of 2021, unusual high numbers of scabies cases in outpatient consultations were observed in two Médecins Sans Frontières’ (MSF) Primary Healthcare Centers (PHCs) in Rohingya refugee camps in Cox’s Bazar, Bangladesh. Here, we aimed to describe the epidemiological and clinical characteristics of patients with scabies consulting the clinics from July 2022–November 2023. A cross-sectional study using routinely collected data from scabies’ consultations at two MSF clinics located in camp 14 and 15 (total population 91,241 in 2023) was conducted. We retrospectively analyzed programmatic data of patients of all ages attending outpatient consultations and clinically diagnosed as scabies. Data were extracted from MSF clinical routine monitoring databases and descriptive statistics were reported. During the 16-month period, a total of 178,922 scabies consultations were recorded, amongst whom 57.7% were women and 42.3% men. Children <5 years constituted 20.5% of the cases, age-groups 6-14, 36.6%, and ≥15 years, 42.9%. Camp 15 had the highest number of cases (39.4%), followed by other camps (29.7%), and then camp 14 (24.4%). Most cases were simple scabies (79.5%); one in five were scabies with secondary infection cases. Patients were mainly treated with oral ivermectin (71.2%) and topical permethrin (24.3%); 19.5% of patients also received antibiotics. Our findings indicate that scabies is a significant health concern in the Cox’s Bazar refugee camp. This study recorded over 178000 cases in the above period. The scale of this outbreak warrants further actions, including a prevalence survey, quality implementation of mass drug administration, and multidisciplinary interventions related to camps’ living conditions such as water and sanitation.