BACKGROUND:More than half of people diagnosed with human immunodeficiency virus-associated cryptococcal meningitis are antiretroviral therapy (ART)-experienced. The impact of recent ART initiation (≤14 days) on outcomes from cryptococcal meningitis, and how to optimally manage ART in this patient population, are unknown. METHODS:We analyzed data from the recent Ambisome Therapy Induction Optimisation (AMBITION) trial to (1) examine whether patients diagnosed with cryptococcal meningitis within 14 days of ART initiation are at higher risk of mortality and (2) determine the impact of ART interruption at diagnosis of cryptococcal meningitis. Combined data from the AMBITION trial and the earlier Antifungal Combinations for Treatment of Cryptococcal Meningitis in Africa trial were analyzed to describe baseline characteristics of patients according to ART status. RESULTS:Among the 810 AMBITION participants, adjusted 2-week mortality risk was 20.8% (95% confidence interval [CI]: 11.5-30.2; 26/120) in those on ART for 14 days or less at presentation, 10.4% (95% CI: 3.6-17.2; 18/130) on ART for >2 weeks to 2 months, 7.1% (95% CI: 0-14.9; 7/92) on ART for >2 months to 6 months, and 13.0% (95% CI: 8.5-17.6; 50/307) in those on ART for more than 6 months compared to 12.4% (95% CI: 9.2-15.5; 111/707) among individuals not on ART. In the combined dataset, baseline fungal burdens were lower and baseline CD4 counts were higher with increasing ART duration. Among individuals on ART for ≤14 days at presentation, 2-week mortality was 35% (8/23) in those continuing ART versus 14% (7/49) in those discontinuing ART. CONCLUSIONS:Mortality from cryptococcal meningitis was higher in recent ART initiators. ART interruption in this group may lead to improved outcomes.

Background Despite strong evidence-based strategies for prevention and management, global efforts to reduce deaths from postpartum haemorrhage (PPH) have failed, and it remains the leading cause of maternal mortality. We conducted a detailed review of all maternal deaths from 33 facilities in Malawi to identify health system weaknesses leading to deaths from PPH.Methods Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi. Deaths occurring from August 2020 to December 2022 were reviewed by multidisciplinary facility-based teams who compiled case narratives from clinical notes and then subsequently reviewed by obstetricians to confirm the cause of death according to international criteria. Data were summarised using proportions/frequencies, comparisons made using χ2 or Wilcoxon rank sum tests, and logistic regression conducted to calculate ORs with CIs.Results PPH was the cause of 20.4% of maternal deaths. Most deaths from PPH occurred within 24 hours of birth (80.0%), among women who had been referred to a higher-level facility (57.0%) and were admitted in stable condition (60.0%). Vacuum births carried an increased risk of death from PPH (OR 4.25 (95% CI 1.15 to 20.13, p=0.039)). Detailed reviews identified that deaths from PPH were more likely to be associated with factors such as ‘lack of obstetric lifesaving skills’ (26.7% vs 10.1%, p<0.001), ‘inadequate monitoring’ (51.5% vs 40.7%, p=0.012) and ‘communication problems between facilities’ (11.5% vs 6.2%, p=0.019) than deaths from other causes.Conclusions Our analysis represents the largest published review of maternal deaths from PPH. We demonstrate that key health system weaknesses are contributing to these preventable maternal deaths. Case reviews conducted by multidisciplinary facility-based teams identified common and recurrent avoidable factors associated with deaths from PPH. Global efforts must now be focused on strategies that address these weaknesses, strengthening health systems and empowering healthcare workers to reduce maternal deaths from PPH.

Background Multimorbidity is a growing global concern, affecting patient outcomes and healthcare costs. In low- and middle-income countries, data on multimorbidity in primary care beyond prevalence is limited. Our study explored the demographic and clinical characteristics of multimorbidity among older people attending primary health care in Malawi. Methods We conducted a cross-sectional analysis on medical records from 15,009 older patients aged ≥50 years across three hospitals in Malawi (one tertiary, two district). Data from 2019-2021 was analyzed using R statistical software to examine patterns of multimorbidity (two or more chronic conditions). Outcome estimates were adjusted for sex, age, location, and year of clinic visit. Results The overall prevalence of multimorbidity, defined across 17 recorded chronic conditions, was 19.6%. Among the 2,941 cases of multimorbidity, 2,708 (92.0%) involved two chronic conditions, while 233 (8.0%) involved three. While most conditions increased steadily in prevalence with age, diabetes followed a different pattern, with higher prevalence among individuals aged 50–59 years (53.9%) and 60–69 years (52.4%) compared to those 70 years and older (40.3%). After adjusting for clinic visit year, gender, and study location, individuals aged 70 years and older were significantly less likely to have multimorbidity compared to those aged 50–59 years (AOR = 0.57, 95% CI: 0.52–0.62, p < 0.001). Conclusion The study revealed a wide range of multimorbidity combinations among older people attending primary health care. Strategies to address multimorbidity in older people should include efforts to identify other, less common clusters of chronic conditions.

Background: Undiagnosed HIV and Schistosomiasis are highly prevalent among fishermen in the Great Lakes region of Africa. We investigated whether combined HIV and Schistosomiasis services offered through beach clinics can reduce the prevalence of Schistosomiasis and increase uptake of antiretroviral therapy (ART) and voluntary male medical circumcision (VMMC) compared to invitation to beach clinics only.Methods: A cluster-randomized trial in 45 lakeside “boat-teams” (clusters) between March 2022-January 2023. Random allocation (1:1:1) to: 1) enhanced standard of care (SOC), with beach clinics offering HIV testing and referral, and Schistosomiasis presumptive treatment (Praziquantel) by leafleting; 2) peer-educator (PE), a peer-nominated fisherman promoting services; or 3) peer-distributor-educator (PDE), PEs additionally distributed oral HIV self-test (HIVST) kits. Co-primary outcomes: composite self-reported ART initiation, or booked for voluntary male medical circumcision (VMMC); and ³1 S. haematobium egg seen on light microscopy from 10 ml urine (“egg-positive”).Findings: Of the 5207 eligible fishermen: eSOC had 1745 (87·6%); PE had 1687 (81·9%) and PDE had 1775 (89·5%). Mean age was 33y (standard deviation: 12·3), 3032 (58·3%) were literate, 5·9% (308) reported taking ART, and 44% were egg-positive at baseline. ART initiation or VMMC booking was higher in the PE arm compared to eSOC (RD:3·44; 95%CI:1·01;5·86; p=0·01) whereas the PDE arm was associated with significant reduction in active Schistosomiasis compared to eSOC (RD:-3·15; 95%CI:-5·50;-0·81; p=0·01).Interpretation: There was weak evidence that peer-educators increased uptake of ART and VMMC and strong evidence that the addition of HIVST reduced the prevalence of active Schistosomiasis suggesting high potential for scale-up.Trial Registration: ISRCTN, trial ID: ISRCTN14354324.Funding: This research was funded in part, by the Wellcome Trust (Grant Number: 216458_Z_19_Z) and the National Institute for Health Research, UK.Declaration of Interest: ELC reports grants from London School of Hygiene & Tropical Medicine during the conduct of the study. There is no competing interest to declare for ATC, KLD, SK, DFC, AB, ALB, JRS, WK, MMK, JJ, PM, KF, ND.Ethical Approval: The study was approved by the College of Medicine Research Ethics Committee (approval number: P·03/20/2975) and the Liverpool School of Tropical Medicine Ethics Committee (approval number: 20-027). All participants provided written informed consent (or a witnessed thumbprint if illiterate) for study participation.

BACKGROUND:Undiagnosed HIV and schistosomiasis are highly prevalent among fishermen in the African Great Lakes region. We aimed to evaluate the efficacy of lakeside interventions integrating services for HIV and male genital schistosomiasis on the prevalence of schistosomiasis, uptake of antiretroviral therapy (ART) for HIV, and voluntary male medical circumcision (VMMC) among fishermen in Malawi. METHODS:We conducted a three-arm, cluster-randomised trial in 45 lakeshore fishing communities (clusters) in Mangochi, Malawi. Clusters were defined geographically by their home community as the place where fishermen leave their boats (ie, a landing site). Eligible participants were male fishermen (aged ≥18 years) who resided in a cluster. Clusters were randomly allocated (1:1:1) through computer-generated random numbers to either enhanced standard of care (SOC), which offered invitation with information leaflets to a beach clinic offering HIV testing and referral, and presumptive treatment for schistosomiasis with praziquantel; peer education (PE), in which a nominated fisherman was responsible for explaining the study leaflet to promote services to his boat crew; or peer distribution education (PDE), in which the peer educator explained the leaflet and distributed HIV self-test kits to his boat crew. The beach clinic team and fishermen were not masked to intervention allocation; however, investigators were masked until the final analysis. Coprimary composite outcomes were the proportion of participants who had at least one Schistosoma haematobium egg observed on light microscopy from 10 mL of urine filtrate and the proportion who had self-reported initiating ART or scheduling VMMC by day 28. Outcomes were analysed by intention to treat; multiple imputation for missing outcomes was done; random-effect binomial models adjusting for baseline imbalance and clustering were used to compute unadjusted and adjusted risk differences, risk ratios (RRs) and 95% CIs, and intracluster correlation coefficients for each outcome. This trial is registered with ISRCTN, ISRCTN14354324. FINDINGS:Between March 1, 2022, and Jan 29, 2023, 45 (65·2%) of 69 clusters assessed for eligibility were enrolled in the trial, with 15 clusters per arm. Of the 6036 fishermen screened at baseline, 5207 (86·3%) were eligible for participation: 1745 (87·6%) of 1991 in the enhanced SOC group, 1687 (81·9%) of 2061 in the PE group, and 1775 (89·5%) of 1984 in the PDE group. Compared with the prevalence of active schistosomiasis in the enhanced SOC group (292 [16·7%] of 1745), 241 (13·6%) of 1775 fishermen in the PDE group (adjusted RR 0·80 [95% CI 0·69-0·94]; p=0·0054) and 263 (15·6%) of 1687 fishermen in the PE group (0·92 [0·79-1·07]; p=0·28) had schistosomiasis at day 28. 230 (13·2%) in the enhanced SOC group, 281 (16·7%) in the PE group, and 215 (12·1%) in the PDE group initiated ART or were scheduled for VMMC. ART initiation or VMMC scheduling was not significantly increased with the PDE intervention (0·88 [0·74-1·05); p=0·15) and was marginally increased with the PE intervention (1·16 [0·99-1·37]; p=0·069) when compared with the enhanced SOC group. No serious adverse events were reported in this trial. INTERPRETATION:We found weak evidence for the use of peer education to increase uptake of ART and VMMC, but strong evidence for the added distribution of HIV self-test kits to promote high engagement with services and reduce the prevalence of active schistosomiasis, suggesting a high potential for scale-up in hard-to-reach communities across Malawi. FUNDING:Wellcome Trust and the UK National Institute for Health Research.

Background: Over two-thirds of global maternal deaths occur in Sub-Saharan Africa (SSA), with more than 200,000 deaths per year. Maternal sepsis causes 10% of these deaths, twice the proportion observed in high-income countries. In SSA, limited access to diagnostic microbiology facilities poses difficulties in promptly identifying and managing maternal infection and sepsis. This protocol describes a systematic review and meta-analysis that aims to summarize available data on the main bacterial agents causing maternal infections and their antibiotic susceptibility in SSA. Methods: Three electronic databases will be searched: MEDLINE, Embase and African Journals Online. Our search strategy will combine terms relating to laboratory-confirmed bacterial infection, pregnancy, postnatal period and SSA. We will include observational studies describing maternal bacterial infection's aetiology and antimicrobial resistance patterns in SSA. Two authors will perform study selection, data extraction and quality assessment. A third author will be consulted to resolve disagreements if they arise.We will summarize the proportion (and 95% confidence intervals) of samples testing positive for the most common bacteria and, depending on the data's availability and heterogeneity, examine results by country and/or region. If possible, we will describe trends over time and differentiate aetiological organisms and resistance/sensitivities by maternal infection sources. We will also undertake subgroup analyses based on HIV status, the invasive and non-invasive status of the infection, SSA sub-regions and mortality if there is adequate information to make such subgroup analysis feasible. Discussion: Data on the microbiologic outcomes for maternal infections in SSA are likely fragmented and not fully representative due to the limited availability of microbiology diagnostics and geographical differences in clinical and laboratory practices. If this is the case, policies and programme strategies to guide treatment and identify antimicrobial resistance threats in SSA settings will be challenging to target. Our systematic review aims to provide a comprehensive summary of the available data, describe the main organisms causing maternal infection and their sensitivities, and identify areas that require further research. Prospero ID: CRD42021238515

Climate change poses a significant threat to women's health in sub-Saharan Africa, yet the impact of climate change on maternal health is rarely reported in the region. Using an existing Maternal Surveillance Platform (MATSurvey), we estimated the immediate impact of Cyclone Freddy on maternal health care service indicators in Malawi. We analysed facility-level data for pregnant women up to 42 weeks post-partum using the national MATSurvey database. We compared incidences of service utilisation before (1 January to 19 February 2023) and after (20 February to 30 March 2023) the cyclone using a negative binomial regression approach. Between 1 January and 30 March 2023, a total of 37,445 live births, 50,048 antenatal clinic attendances, 23,250 postnatal clinic attendances, 84 maternal deaths, and 1,166 neonatal deaths were recorded by 33 facilities in the MatSurvey database. There was an immediate reduction in service utilisation in the post-cyclone period, including the postnatal attendance per week (pre-cyclone median: 355.0 [IQR 279.0-552.0], post-cyclone median: 261.0 [IQR 154.3-305.5], RR 0.56 [95% CI 0.44-0.71, p <0.001]) and the antenatal attendance per week (pre-cyclone median: 860.0 [IQR 756.5-1060.0], post-cyclone median: 656.5 [IQR 486.5-803.3], RR 0.66 [95% CI 0.55-0.78, p <0.001]). Stratified analyses by geographical zones revealed a stronger reduction in postnatal clinic attendance in the Southwest (RR 0.50 [95% CI 0.29-0.85, p = 0.010]) and the North (RR 0.29 [95% CI 0.15-0.56, p <0.001]). Cyclone Freddy resulted in an immediate decline in utilisation of maternal health services in cyclone-affected regions in Malawi. We observe evidence of catastrophic climate events impacting on the healthcare of women and their babies. Policymakers, researchers, and health systems need to ensure that essential women's health services are maintained during these events and improve measures to support service resilience in the face of climate change.

Background Caesarean section (CS) is the most common major surgery conducted globally, with rates rising. CS also contributes to maternal morbidity and mortality, with increased risks in low-resource settings. We conducted a detailed review of maternal deaths from 2020 to 2022 in Malawi to determine the burden of deaths related to CS, avoidable health system factors, and causes of death associated with this procedure. Methods Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi, alongside facility-level aggregated birth data. Maternal deaths were reviewed by facility-based multidisciplinary teams with subsequent confirmation of cause of death by obstetricians according to international criteria. Logistic regression was applied to estimate the odds of associations of leading causes of death with CS while adjusting for potential confounders. Results Despite a low national CS rate, most deaths occurred following CS (51.8%, 276/533). Women who delivered by CS were five times (OR 5.60, 95% CI 4.74 to 6.67) more likely to die than women who delivered vaginally. The leading causes of death following CS were postpartum haemorrhage (26.0%, 68/277), eclampsia (15.6%, 41/277) and infection (14.1%, 37/277). Deaths from pregnancy-related infection were more often associated with CS (OR 2.03, 95% CI 1.12 to 3.72). Health system factors more frequently associated with deaths following CS than vaginal birth included ‘prolonged abnormal observations without action’ (p=0.006), ‘delay in starting treatment’ (p=0.006) and ‘lack of blood transfusion’ (p=0.03). Conclusions We found a high burden of maternal death following CS in this low-resource setting. Until now, international attention and many clinical trials have been focused on improving the safety of vaginal birth. Our findings highlight the need to ensure the safe and appropriate use of this potentially life-saving intervention to reduce maternal deaths. To avoid the high burden of death following CS we highlight, there is urgent need to develop and trial CS-specific interventions.

Early identification of genetic risk factors for complex diseases can enable timely interventions and prevent serious outcomes, including mortality. While the genetics underlying many Mendelian diseases have been elucidated, it is harder to predict risk for complex diseases arising from the combined effects of many genetic variants with smaller individual effects on disease aetiology. Polygenic risk scores (PRS), which combine multiple contributing variants to predict disease risk, have the potential to influence the implementation for precision medicine. However, the majority of existing PRS were developed from European data with limited transferability to African populations. Notably, African populations have diverse genetic backgrounds, and a genomic architecture with smaller haplotype blocks compared to European genomes. Subsequently, growing evidence shows that using large-scale African ancestry cohorts as discovery for PRS development may generate more generalizable findings. Here, we (1) discuss the factors contributing to the poor transferability of PRS in African populations, (2) showcase the novel Africa genomic datasets for PRS development, (3) explore the potential clinical utility of PRS in African populations, and (4) provide insight into the future of PRS in Africa.

Although the COVID-19 pandemic has left no country untouched there has been limited research to understand clinical and immunological responses in African populations. Here we characterise patients hospitalised with suspected (PCR-negative/IgG-positive) or confirmed (PCR-positive) COVID-19, and healthy community controls (PCR-negative/IgG-negative). PCR-positive COVID-19 participants were more likely to receive dexamethasone and a beta-lactam antibiotic, and survive to hospital discharge than PCR-negative/IgG-positive and PCR-negative/IgG-negative participants. PCR-negative/IgG-positive participants exhibited a nasal and systemic cytokine signature analogous to PCR-positive COVID-19 participants, predominated by chemokines and neutrophils and distinct from PCR-negative/IgG-negative participants. PCR-negative/IgG-positive participants had increased propensity for Staphylococcus aureus and Streptococcus pneumoniae colonisation. PCR-negative/IgG-positive individuals with high COVID-19 clinical suspicion had inflammatory profiles analogous to PCR-confirmed disease and potentially represent a target population for COVID-19 treatment strategies.

Over the past few years, meta-analysis has become popular among biomedical researchers for detecting biomarkers across multiple cohort studies with increased predictive power. Combining datasets from different sources increases sample size, thus overcoming the issue related to limited sample size from each individual study and boosting the predictive power. This leads to an increased likelihood of more accurately predicting differentially expressed genes/proteins or significant biomarkers underlying the biological condition of interest. Currently, several meta-analysis methods and tools exist, each having its own strengths and limitations. In this paper, we survey existing meta-analysis methods, and assess the performance of different methods based on results from different datasets as well as assessment from prior knowledge of each method. This provides a reference summary of meta-analysis models and tools, which helps to guide end-users on the choice of appropriate models or tools for given types of datasets and enables developers to consider current advances when planning the development of new meta-analysis models and more practical integrative tools.

Introduction Understanding mother-to-infant transmission of Group B Streptococcus (GBS) is vital to the prevention and control of GBS disease. We investigated the transmission and phylogenetic relationships of mothers colonised by GBS and their infants in a peri-urban setting in The Gambia. Methods We collected nasopharyngeal swabs from 35 mother-infant dyads at weekly intervals from birth until six weeks post-partum. GBS was isolated by conventional microbiology techniques. Whole-genome sequencing was performed on GBS isolates from one mother-infant dyad (dyad 17). Results We recovered 85 GBS isolates from the 245 nasopharyngeal swabs. GBS was isolated from 16.33% and 18.37% of sampled mothers and infants, respectively. In 87% of cultured swabs, the culture status of an infant agreed with that of the mother (Kappa p-value <0.001). In dyad 17, phylogenetic analysis revealed within-host strain diversity in the mother and clone to her infant. Conclusion GBS colonisation in mothers presents a significant risk of colonisation in their infants. We confirm vertical transmission from mother to child in dyad 17, accompanied by within-host diversity.

Mass drug administration (MDA) with azithromycin is a corner-stone of trachoma control however it may drive the emergence of antimicrobial resistance. In a cluster-randomized trial (Clinical trial gov NCT00792922), we compared the reduction in the prevalence of active trachoma in communities that received three annual rounds of MDA to that in communities that received a single treatment round. We used the framework of this trial to carry out an opportunistic study to investigate if the increased rounds of treatment resulted in increased prevalence of nasopharyngeal carriage of macrolide-resistant Staphylococcus aureus. Three cross-sectional surveys were conducted in two villages receiving three annual rounds of MDA (3 × treatment arm). Surveys were conducted immediately before the third round of MDA (CSS-1) and at one (CSS-2) and six (CSS-3) months after MDA. The final survey also included six villages that had received only one round of MDA 30 months previously (1 × treatment arm).

In West Africa, the carriage of Group B Streptococcus (GBS), among infants is poorly characterised. We investigated co-carriage of GBS with other respiratory pathogens in the infants’ nasopharynx in The Gambia.

Background: Intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated bed nets (ITNs) can reduce the morbidity and mortality associated with malaria in pregnancy. Although the coverage for both IPTp and ITN use have been described in Malawi, the analysis of factors associated with IPTp receipt and ITN use is lacking. This analysis was conducted to assess IPTp and ITN use and predictors of use by women of child-bearing age (WOCBA).Methods: A two-stage cluster-sample cross-sectional survey was conducted April 16-30, 2009 in eight districts across Malawi. Information on receipt of two or more doses of IPTp, ITN ownership, and ITN use the night before the survey was collected. Multivariate logistic regression was used to assess predictors of IPTp and ITN use.Results: Data were collected from 7407 households containing 6985 WOCBA and 3213 recently pregnant women (women who reported a completed pregnancy in the 2 years before the survey). Most recently pregnant women (96 %) had at least one antenatal care (ANC) clinic visit; 91 % reported receiving at least one dose of IPTp, and 72 % reported receiving two or more doses of IPTp. Women in Phalombe, Rumphi, and Lilongwe were more likely to receive two doses of IPTp than those in Blantyre [adjusted odds ratio (aOR) 2.5 (95 % CI 1.5-4.5), 2.5 (95 % CI 1.5-4.3), and 2.0 (95 % CI 1.2-3.1), respectively]. Educated women were more likely to have received IPTp compared to women with no education [aOR 1.6 (95 % CI 1.0-2.6) for those who completed primary school, aOR1.9 (95 % CI 1.1-3.3) for some secondary school, and aOR 4.1 (95 % CI 1.9-8.7) for completed secondary school or above], and women in the poorest socioeconomic status quintile were less likely to receive IPTp than those in the least poor quintile [aOR 0.68 (95 % CI 0.48-0.97)]. In all, 53 % of WOCBA used an ITN the previous night. Women in Nkhotkhota and Phalombe were less likely to have slept under an ITN the previous night compared to those in Blantyre [aOR 0.52 (95 % CI 0.39-0.69) and aOR 0.67 (95 % CI 0.47-0.95), respectively]. In addition, age [aOR 0.61 (95 % CI 0.45-0.83) for women 15-19 years old], and either being currently pregnant [aOR 1.5 (95 % CI 1.2-2.0)] or having been pregnant in the previous 2 years [aOR 2.4, (95 % CI 2.1-2.8)] were associated with ITN use.Conclusion: In Malawi in 2009, IPTp and ITN use in WOCBA fell short of national and international goals. Adoption of new guidelines encouraging administration of IPTp at every scheduled ANC visit might increase IPTp use. Increasing health promotion activities to encourage earlier attendance at ANC clinics and create demand for IPTp and ITNs might improve overall IPTp and ITN use.

OBJECTIVE:To measure mortality and its risk factors among children discharged from a health centre in rural Gambia. METHODS:We conducted a cohort study between 12 May 2008 and 11 May 2012. Children aged 2-59 months, admitted with suspected pneumonia, sepsis, or meningitis after presenting to primary and secondary care facilities, were followed for 180 days after discharge. We developed models associating post-discharge mortality with clinical syndrome on admission and clinical risk factors. FINDINGS:One hundred and five of 3755 (2.8%) children died, 80% within 3 months of discharge. Among children aged 2-11 and 12-59 months, there were 30 and 29 deaths per 1000 children per 180 days respectively, compared to 11 and 5 respectively in the resident population. Children with suspected pneumonia unaccompanied by clinically severe malnutrition (CSM) had the lowest risk of post-discharge mortality. Mortality increased in children with suspected meningitis or septicaemia without CSM (hazard ratio [HR] 2.6 and 2.2 respectively). The risk of mortality greatly increased with CSM on admission: CSM with suspected pneumonia (HR 8.1; 95% confidence interval (CI) 4.4 to 15), suspected sepsis (HR 18.4; 95% CI 11.3 to 30), or suspected meningitis (HR 13.7; 95% CI 4.2 to 45). Independent associations with mortality were: mid-upper arm circumference (MUAC) of 11.5-13.0 cm compared to >13.0 cm (HR 7.2; 95% CI 3.0 to 17.0), MUAC 10.5-11.4 cm (HR 24; 95% CI 9.4 to 62), and MUAC <10.5 cm (HR 44; 95% CI 18 to 108), neck stiffness (HR 10.4; 95% CI 3.1 to 34.8), non-medical discharge (HR 4.7; 95% CI 2.0 to 10.9), dry season discharge (HR 2.0; 95% CI 1.2 to 3.3), while greater haemoglobin (HR 0.82; 0.73 to 0.91), axillary temperature (HR 0.71; 95% CI 0.58 to 0.87), and oxygen saturation (HR 0.96; 95% CI 0.93 to 0.99) were associated with reduced mortality. CONCLUSION:Gambian children experience increased mortality after discharge from primary and secondary care. Interventions should target both moderately and severely malnourished children.

Background We conducted an ancillary study among individuals who had participated in a PCV-7 trial in rural Gambia, to determine the influence of season on the prevalence of pneumococcal carriage. Methods 636 individuals above 30 months of age were followed from 4 to 20 months after vaccination with PCV-7 or meningococcal-conjugate-vaccine. Nasopharyngeal swabs were collected periodically between November 2006 and June 2008. Overall, 4,495 NPS were collected. Results Prevalence of pneumococcal nasopharyngeal carriage in the study subjects (median age 11 years) was 55.0%; this prevalence decreased linearly with increasing age (p = 0.001). Prevalence of carriage was significantly higher during the dry than the rainy season for any pneumococcal carriage [57.6% versus 47.8% (p<0.001)], pneumococcal vaccine serotype carriage [10.3% versus 6.5% (p< 0.001)] and non-vaccine serotype carriage [49.7% versus 42.7% (p<0.001)]. Differences remained significant in the adjusted analysis. Conclusions In areas of Africa with marked variation in rainfall, seasonality of pneumococcal carriage needs to be considered when interpreting carriage data.

Results: The result of the study showed the preponderance of certain characteristics among diabetics such as Type 2 DM (93.8%), positive family history (77.8%), female (63.8%), middle age -30 and 60 years (76.1%) and poverty (67%). While 60.1% of participants had at least one complication, the common complications are lower extremity disorders (54.8%) visual disorders (46.3%), heart failure (3.2% and renal failure (2.5%). Furthermore, the predictors of having complications were being female (aOR= 5.1; p=0.0172), co-exiting hypertension (aOR=10.78; p=0.0029), duration (1-5years) of DM (aOR=2.3; p=0.0125), poor treatment compliance (aOR=3.8; p=0.0094) and physical inactivity (aOR=6.78; p=0.0039). Limited therapeutic options are available in our study setting - 45% of participants were on Glibencliamide and Metformin while 38.7% of participants were on Insulin therapy. Also the median duration of switch from Oral Hypoglycemic Agents to Insulin was 18months among this study population. 84.2% of participants had at least one episode of interrupted supply of medication within the last 6months. Conclusion The study has provided opportunities for policy makers and researchers to combat the damaging impacts of DM on public health and the economy as insights into the clinical characteristics, socio-demographics, predictors of complications and therapeutic challenges identified, can be used, as suggested in the paper, to map out interventions capable of mitigating the impacts of DM burden in The Gambia, and SSA at large. Strength of the paper 1. The only study that has investigated the clinical characteristics, socio-demographics, predictor of complications and therapeutic options among diabetics in The Gambia. 2. We abstracted clinical data such as Type of DM, symptoms at presentation, complications, co-morbidities and medications from the participants’ records- this galvanised/augmented the data from direct interviews via questionnaire administration. 3. Findings from our study suggest that the earlier prediction of a shift in epidemic of DM from the elderly to the younger age group may not be far-fetched as 76% of the patients were between 30 and 60 years 4. Essentially, our study findings were consistent with previous reports-preponderance of type 2, delayed or late diagnosis, 72% of patients first presented to a traditional healer with symptoms suggestive of DM while positive family history and obesity were found to be independent risk factors. However, we found few contrary results as DM is commoner among people of lower socioeconomic status (67%) while there was also a significant gender difference- female being more likely to have DM (63.8% vs 36.2%; p<0.001) 5. There is limited drug options (OHA), high rate of non-compliance to oral hypoglyacemic agent (93.4%), frequent interruption of insulin supply – all these contribute to poor management outcome. 6. As seen in other spheres (51), e-Health strategies such as the use of short messages systems (SMS) by health professionals to remind patients to take their medicines can also be a useful strategy to improve compliance in our setting. Limitations of the study 1. Though, pockets of diabetics do patronise other health care providers (orthodox and non-orthodox) and may not have been represented, however, the study participants were recruited from the lone tertiary health facility (only referral centre) in The Gambia, where majority of the general population seek specialist treatments. 2. The majority of our study participants have little or no western education, therefore understanding of the questionnaires (written in English) were heavily dependent on the interpretations given by the interviewers, and consequently, responses from participants may be prone to both misrepresentation (of respondents) and translation bias. However, this drawback is limited or minimised owing to the fact that the interviewers were trained indigenous nurses.

OBJECTIVE:To establish haematological and biological reference values for Gambian infants.METHODS:Basic haematological and biochemical indices were analysed in blood samples obtained from healthy infants from Sukuta in the Western Division of The Gambia. The 2.5 and the 97.5 centiles for these indices were estimated.RESULTS:Reference ranges for haematological and biochemical indices were determined. Haemoglobin, total white cell count (WBC) and platelet levels decreased with age (P < 0.001), whereas most of the white cell count subsets except monocytes did not vary with age. Potassium and alkaline phosphatase fell significantly with increasing age (P < 0.001; P < 0.001), whereas urea and creatinine rose with increasing age (P = 0.002; P < 0.001, respectively).CONCLUSION:Our set of haematological and biochemical reference values for healthy infants in The Gambia differs from values in other settings, thus underscoring the importance of establishing region-specific paediatric reference ranges to ensure optimal patient management and evaluate the impact of interventions in clinical research.