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Mweemba C, Mutale W, Masiye F, Hangoma P. Why is there a gap in self-rated health among people with hypertension in Zambia? A decomposition of determinants and rural‒urban differences. BMC Public Health 2024; 24:1025. [PMID: 38609942 PMCID: PMC11015612 DOI: 10.1186/s12889-024-18429-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. METHODS We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. RESULTS Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap. CONCLUSIONS Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.
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Affiliation(s)
- Chris Mweemba
- Department of Health Policy and Management, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, P.O. Box 50110, Zambia.
| | - Wilbroad Mutale
- Department of Health Policy and Management, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, P.O. Box 50110, Zambia
| | - Felix Masiye
- Department of Economics, School of Humanities and Social Science, Great East Road Campus, Lusaka, P.O Box 32379, Zambia
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, P.O. Box 50110, Zambia
- Chr. Michelson Institute (CMI), Bergen, Norway
- Bergen Center for Ethics and Priority Setting in Health, University of Bergen, Bergen, Norway
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Mweemba C, Mutale W, Masiye F, Hangoma P. Why is there a gap in self-rated health among people with hypertension? A decomposition of determinants and rural-urban differences. RESEARCH SQUARE 2023:rs.3.rs-3111338. [PMID: 37461663 PMCID: PMC10350196 DOI: 10.21203/rs.3.rs-3111338/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Background Hypertension affects over one billion people globally and is one of the leading causes of premature death. The low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from the more affluent and urban population towards the poorer and rural communities. Our study examined inequalities in self-rated health among people with hypertension and whether there is a rural-urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. Methods We utilized the Zambia Household Health Expenditure and Utilization Survey for the data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from a previous study. The linear probability model provided a preliminary assessment of the association between self-rated health and independent variables. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. Results Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (62%), district HIV prevalence (26%) and household expenditure (12%) being the most important determinants that explain the health gap. Conclusions Urban hypertension patients have better SRH than rural patients in Zambia. Educational interventions, financial protection schemes and strengthening hypertension health services in rural areas can significantly reduce the health gap between the two regions.
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Affiliation(s)
- Chris Mweemba
- Department of Health Policy and Management, School of Public Health, P.O. Box 50110, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Wilbroad Mutale
- Department of Health Policy and Management, School of Public Health, P.O. Box 50110, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Felix Masiye
- Department of Economics, School of Humanities and Social Science, P.O Box 32379, Great East Road Campus, University of Zambia, Lusaka, Zambia
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, P.O. Box 50110, Ridgeway Campus, University of Zambia, Lusaka, Zambia
- Chr. Michelson Institute (CMI), Bergen, Norway
- Bergen Center for Ethics and Priority Setting in Health, University of Bergen, Bergen, Norway
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Sebilo M, Ledibane NRT, Takuva S. Incidence of cardiometabolic diseases in a Lesotho HIV cohort: Evidence for policy decision-making. South Afr J HIV Med 2021; 22:1246. [PMID: 34230861 PMCID: PMC8252144 DOI: 10.4102/sajhivmed.v22i1.1246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background Antiretroviral treatment (ART) has been associated with the development of certain cardiometabolic diseases (CMDs). The burden of CMDs amongst ART-experienced patients in sub-Saharan Africa was unknown. Objective We quantified the burden of CMDs and identified the associated risk factors in a large treatment cohort on ART at a high-volume facility in Lesotho. Methods In this retrospective cohort study, we extracted data from the daily dispensing electronic system and routine clinical records of 785 adults on ART between 2011 and 2015 in Maseru, Lesotho. CMD was defined as a diagnosis of hypertension, diabetes mellitus or dyslipidaemia (singly or collectively). Descriptive statistics were used to describe the disease burden; Kaplan–Meier curves and cause-specific Cox proportional hazards models were fitted to examine the impact of the ART regimen and identify the risk factors associated with the occurrence of CMD. Results Of the 785 participants, 473 (60%) were women. The median age of the group was 42 years, interquartile range (IQR), 36–51 years. The overall incidence of CMD was 5.6 (95% confidence interval [CI] = 4.4–7.1) per 100 person-months of follow-up. The median time to onset of CMD was 16.6 months (IQR = 7.4–23.4). ART was not associated with the occurrence of CMD (cause-specific hazard ratio [CHR] = 1.55; 95% CI = 0.14–16.85; P = 0.72). Higher body mass index (BMI) was associated with the occurrence of diabetes mellitus (CHR = 1.19; 95% CI = 1.14–1.38; P = 0.026). Conclusion The incidence of CMD in this relatively young patient population is low yet noteworthy. We recommend that patients living with HIV and AIDS should be routinely screened for CMD. Higher BMI is generally associated with the occurrence of CMD.
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Affiliation(s)
- Motlalepula Sebilo
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Neo R T Ledibane
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Simbarashe Takuva
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Odukoya O, Badejo O, Sodeinde K, Olubodun T. Behavioral risk factors for hypertension among adults living with HIV accessing care in secondary health facilities in Lagos State, Nigeria. J Family Med Prim Care 2020; 9:3450-3457. [PMID: 33102312 PMCID: PMC7567202 DOI: 10.4103/jfmpc.jfmpc_544_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/26/2020] [Accepted: 05/11/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Excess risk for cardiovascular disease, especially hypertension, may exist among human immunodeficiency virus infection (HIV)-positive persons. This study was carried out to assess the prevalence of the behavioral risk factors for hypertension, including their awareness of these factors and their attitudes toward them. Methods: This descriptive cross-sectional study was conducted among 400 HIV-infected adults who accessed care in nine secondary health facilities in Lagos State, Nigeria. Respondents were selected by multistage sampling and data elicited using a structured, interviewer-administered questionnaire. Blood pressure (BP) was measured thrice and a respondent was considered as having raised BP if the mean of the last two measurements is ≥140 mm Hg (systolic BP) or ≥90 mm Hg (diastolic BP) or if respondents are currently taking anti-hypertensive. Results: Prevalence of key behavioral risk factors for hypertension was high. For instance, 82.0% of the respondents were physically inactive. Stress and physical inactivity were the two most known risks of hypertension, identified by 87.3% and 70.5% of the respondents, respectively. Majority (66.0%) had positive attitudes toward hypertension risk factors and 26.7% of them had raised BP. Lower age, that is, 30 years and below (OR = 2.89, 95% CI = 1.26–6.64), BMI of less than 25 (OR = 1.87, 95 CI = 1.16–3.01), and being diagnosed of HIV for 5 years and less (OR = 1.62, 95% CI = 1.006–2.62) were significantly associated with normal BP measurements among respondents. Conclusion: The proportion of people living with HIV/AIDS who show known behaviors that place them at risk for hypertension is high. Measures to address these risk factors among them are warranted.
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Affiliation(s)
- Oluwakemi Odukoya
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos State, Nigeria.,Department of Community Health and Primary Care, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
| | | | - Kolawole Sodeinde
- Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
| | - Tope Olubodun
- Department of Community Health and Primary Care, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
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Kemal A, Teshome MS, Ahmed M, Molla M, Malik T, Mohammed J, Abate KH. Dyslipidemia and Associated Factors Among Adult Patients on Antiretroviral Therapy in Armed Force Comprehensive and Specialized Hospital, Addis Ababa, Ethiopia. HIV AIDS (Auckl) 2020; 12:221-231. [PMID: 32753977 PMCID: PMC7342468 DOI: 10.2147/hiv.s252391] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Background The development of antiretroviral drugs and subsequent access to combined antiretroviral therapy contributed to the decline in morbidity and mortality rates associated with acquired immune deficiency syndrome, resulting in an increased life expectancy and improved quality of life for people living with human immunodeficiency virus. However, a cluster of metabolic derangements such as dyslipidemia is increasing, especially for those on antiretroviral therapy. Limited studies were done on the prevalence of dyslipidemia and its associated factors among adult patients on antiretroviral therapy in Ethiopia which demand the conduct of the present investigation entitled on the prevalence of dyslipidemia and its associated factors among adult patients on antiretroviral therapy in Armed Force Comprehensive and Specialized Hospital Addis Ababa, Ethiopia, 2018. Methods Institution-based cross-sectional study design was employed between March and April 2018. Systematic sampling method was used to select 353 study participants. Pretested stepwise approach of the World Health Organization questionnaire (WHO Stepwise), document review, anthropometric measurements, and laboratory analysis were used to collect data on different variables under the study. Collected data were entered in Epidata version 3 and analyzed by SPSS version 21. Results The prevalence of dyslipidemia among study participants was 74.8%. Female participants were twice and half at risk of developing dyslipidemia compared to males (AOR= 2.38; 95% CI: 1.15, 3.66). Similarly, compared to those attended college level of education, not attended formal education (AOR=0.19; 95% CI: 0.05, 0.66), and having primary/secondary educational level (AOR= 0.33; 95% CI: 0.16, 0.66) showed lower odds to develop dyslipidemia. Furthermore, WHO clinical stage II (AOR= 0.35; 95% CI: 0.14,0.92), stage III (AOR=0.25; 95% CI:0.10,0.64), duration on ART (AOR= 1.01; 95% CI: 1.001,1.02), and BMI (AOR =1.13; 95% CI: 1.06,1.23) were significantly associated with dyslipidemia. Conclusion There exists a high prevalence of dyslipidemia among study participants. Sex, educational status, WHO clinical stage, duration on ART, and BMI were significantly associated factors for dyslipidemia. Intervention strategies including the identified factors are demanded in the setting.
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Affiliation(s)
- Adnan Kemal
- Department of Public Health, College of Health Science, Defense University, Addis Ababa, Ethiopia
| | | | - Mohammed Ahmed
- Department of Public Health, College of Health Science, Woldia University, Woldia, Ethiopia
| | - Meseret Molla
- Department of Public Health, College of Health Science, Defense University, Addis Ababa, Ethiopia
| | - Tabarak Malik
- Department of Biochemistry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Jemmal Mohammed
- Department of Ophthalmology, Jimma University, Jimma, Ethiopia
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Roozen G, Vos AG, Tempelman HA, Venter W, Grobbee DE, Scheuermaier K, Klipstein-Grobusch K. Cardiovascular disease risk and its determinants in people living with HIV across different settings in South Africa. HIV Med 2019; 21:386-396. [PMID: 31852030 PMCID: PMC7318654 DOI: 10.1111/hiv.12831] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/21/2019] [Accepted: 10/31/2019] [Indexed: 01/24/2023]
Abstract
Objectives Socio‐economic factors and lifestyle are known to differ across geographies and populations, which may result in distinct risk profiles for cardiovascular disease (CVD). This study assessed carotid intima‐media thickness (CIMT), a proxy for CVD, and its determinants in two groups of people living with HIV (PLHIV) in two different settings in South Africa. Methods A cross‐sectional analysis was conducted comparing data from the Ndlovu Cohort Study in the Limpopo Province (group 1) and from three clinical trials in Johannesburg (group 2). The association between demographics, conventional CVD risk factors, HIV‐related factors and CIMT in groups 1 and 2 was analysed with two separate multivariable linear regression models. Results Group 1 consisted of 826 participants (mean age 42.2 years) and mean (± standard deviation) CIMT was 0.626 ± 0.128 mm. In this group, sex, age, body mass index (BMI), cholesterol, glucose and antiretroviral therapy (ART) duration (β = 0.011 mm per 5 years; P = 0.02) were associated with higher CIMT. There were positive interactions between age and ART duration and age and cholesterol. Group 2 consisted of 382 participants (mean age 39.5 years) and mean (± standard deviation) CIMT was 0.560 ± 0.092 mm. In this group, only sex, education level, BMI and cholesterol were associated with higher CIMT, albeit with weaker associations than in group 1. Conclusions Conventional CVD risk factors were the main drivers of CIMT. The impact of some of these risk factors appeared to increase with age. Differences in sample size, age and viral suppression might explain why an effect of ART was observed in group 1 but not in group 2.
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Affiliation(s)
- Gvt Roozen
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A G Vos
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Infectious Disease, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - H A Tempelman
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,Ndlovu Care Group, Groblersdal, South Africa
| | - Wdf Venter
- Ezintsha, Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - D E Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - K Scheuermaier
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Ginsenoside Rb1 Blocks Ritonavir-Induced Oxidative Stress and eNOS Downregulation through Activation of Estrogen Receptor-Beta and Upregulation of SOD in Human Endothelial Cells. Int J Mol Sci 2019; 20:ijms20020294. [PMID: 30642080 PMCID: PMC6358897 DOI: 10.3390/ijms20020294] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/04/2019] [Accepted: 01/09/2019] [Indexed: 02/07/2023] Open
Abstract
We have previously shown that ritonavir (RTV), a highly active anti-retroviral therapy (HAART) drug, can cause endothelial dysfunction through oxidative stress. Several antioxidants including ginsenoside Rb1, a compound with antioxidant effect, can effectively block this side effect of RTV in endothelial cells. In the current study, we explored a mechanism by which ginsenoside Rb1 could protect these cells via binding of estrogen receptors (ERs). We found that several human endothelial cell lines differentially expressed ER-β and had very low levels of ER-α. RTV treatment significantly increased the production of reactive oxygen species (ROS) and decreased the expression of endothelial nitric oxidase synthase (eNOS) and superoxide dismutase (SOD) in HUVECs, while Rb1 effectively blocked these effects of RTV. These effects of Rb1 were effectively inhibited by silencing ER-β, indicating that ginsenoside Rb1 requires ER-β for its antioxidant activity in inhibiting the deleterious effect of RTV in human endothelial cells. Furthermore, Rb1 specifically activated ER-β transactivation activity by ER-β luciferase reporter assay. Rb1 competitively bound to ER-β, which was determined by the high sensitive fluorescent polarization assay.
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Masyeni S, Sintya E, Megawati D, Sukmawati NMH, Budiyasa DG, Aryastuti SA, Khairunisa SQ, Arijana I, Nasronudin N. Evaluation of antiretroviral effect on mitochondrial DNA depletion among HIV-infected patients in Bali. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2018; 10:145-150. [PMID: 30104903 PMCID: PMC6072679 DOI: 10.2147/hiv.s166245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Nucleoside reverse transcriptase inhibitors (NRTIs) are the cornerstone of highly active antiretroviral therapy combination regimens for HIV infection. Unfortunately, NRTIs have been noticeably associated with many adverse effects related to mitochondrial toxicity leading to mitochondrial deoxyribonucleic acid (mtDNA) depletion. However, similar mitochondrial dysfunction has recently been found even in antiretroviral therapy-naïve patients, suggesting HIV itself could contribute to this abnormality. In this study, we determine whether mtDNA depletion was present in either antiretroviral therapy-naïve or NRTI-treated patients at Sanjiwani Hospital, Bali, Indonesia. Patients and methods A cross-sectional study was conducted from the peripheral blood mononuclear cells of HIV patients. Specifically, the relative content of mtDNA (mtRNR1 gene) to nuclear DNA (ASPOLG gene) was determined by real-time polymerase chain reaction. Data were analyzed with SPSS 16.0 software and GraphPad Prism 7.02. Results A total of 84 samples (67 on NRTIs and 17 HIV-naïve) were suitable for analysis. We identified 21.4% of the samples (18/84) with mtDNA:nDNA ratio <1. Although it was not significant (P=0.121), the median mtDNA:nDNA ratio of HIV-naïve group was slightly higher (median 1.8; interquartile range [IQR]: 1.1-2.1) than NRTI-treated patients (median 1.5; IQR: 1.3-2.85). Tenofovir-based NRTI was more frequently used (73.13%) than zidovudine-based NRTI (26.86%). The period for which NRTI was used probably contributed to the ratio of mtDNA:nDNA. The median ratio of mtDNA:nDNA zidovudine-treated patients was slightly lower (median 1.2; IQR: 1.08-1.98) when compared to tenofovir-based NRTI (median 1.6; IQR: 1.05-2.10), with the median period of former treatment being significantly longer (P<0.001). Although these data overall indicate that NRTI treatment had no effect on mtDNA:nDNA ratios, patients who undergo more than 12 months of NRTIs treatment show a decrease in the ratio; however, further study is required. Conclusion Almost one-fourth of the samples showed a lower mtDNA:nDNA ratio. The decreasing of the ratio mtDNA:nDNA was most likely present after 12 months of NRTI treatment.
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Affiliation(s)
- Sri Masyeni
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Erly Sintya
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Dewi Megawati
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | | | - Dewa Ga Budiyasa
- Internal Medicine Department, Sanjiwani Hospital, Gianyar, Bali, Indonesia
| | - Sri Agung Aryastuti
- Faculty of Medicine and Health Sciences, University of Warmadewa, Denpasar, Bali, Indonesia,
| | - Siti Qamariyah Khairunisa
- Indonesia-Japan Collaborative Research Center for Emerging and Reemerging Infectious Diseases, Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
| | - Igkn Arijana
- Histology Department of Faculty of Medicine, Udayana University, Denpasar, Bali, Indonesia
| | - N Nasronudin
- Indonesia-Japan Collaborative Research Center for Emerging and Reemerging Infectious Diseases, Institute of Tropical Disease, Airlangga University, Surabaya, Indonesia
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