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Ngonzi J, Tibaijuka L, Mwanje Kintu T, Kihumuro RB, Ahabwe O, Byamukama O, Salongo W, Adong J, Boatin AA, Bebell LM. Prevalence and Risk Factors for Newborn Anemia in Southwestern Uganda: A Cross-Sectional Study. Anemia 2024; 2024:5320330. [PMID: 38596653 PMCID: PMC11003795 DOI: 10.1155/2024/5320330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Introduction The global prevalence of maternal anemia is about 42%, and in sub-Saharan Africa, the prevalence of newborn anemia ranges from 25% to 30%. Anemia in newborn babies may cause complications such as delayed brain maturation and arrested growth. However, there is limited data on the prevalence of newborn anemia and its risk factors in people living in resource-limited settings. Objectives We determined the prevalence and risk factors for newborn anemia and its correlation with maternal anemia in southwestern Uganda. Methods This was a cross sectional study of 352 pregnant women presenting to the Mbarara Regional Referral Hospital for delivery. We collected maternal blood in labor and umbilical cord blood from the placental vein. We measured hemoglobin using a point-of-care Hemocue machine. We used summary statistics to characterize the study participants and compared demographic characteristics and outcomes using chi-square, t-test, and Wilcoxon rank sum analyses. We defined newborn anemia as umbilical cord hemoglobin <13 g/dl and measured the relationship between maternal and umbilical cord hemoglobin using linear regression analysis. Results The prevalence of newborn anemia was 17%. Maternal parity was significantly higher for anemic than nonanemic newborns (3 versus 2, P=0.01). The mean age in years (SD) was significantly lower for participants with umbilical cord hemoglobin <13 g/dl than those ≥13 g/dl (26 years [5.6] versus 28 [6.3], P=0.01). In multivariable linear regression analysis, a 1-point decrease in maternal hemoglobin was associated with a 0.14-point decrease in umbilical cord hemoglobin (P=0.02). Each one-unit increase in parity was associated with a 0.25-point decrease in umbilical cord hemoglobin (P=0.01). Cesarean delivery was associated with a 0.46-point lower umbilical cord hemoglobin level compared with vaginal delivery (P=0.03). Conclusions We found a significant association between maternal and newborn hemoglobin, underscoring the importance of preventing and correcting maternal anemia in pregnancy. Furthermore, maternal anemia should be considered a risk factor for neonatal anemia.
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Affiliation(s)
- Joseph Ngonzi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Leevan Tibaijuka
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Timothy Mwanje Kintu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Raymond Bernard Kihumuro
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Onesmus Ahabwe
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Onesmus Byamukama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Wasswa Salongo
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Julian Adong
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adeline A. Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Lisa M. Bebell
- Harvard Medical School, Department of Medicine, Center for Global Health and Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, USA
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Gupta S, Bebell LM. When should I give corticosteroids to my patient with Pneumocystis pneumonia? Cleve Clin J Med 2024; 91:217-219. [PMID: 38561210 DOI: 10.3949/ccjm.91a.23082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Simran Gupta
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Lisa M Bebell
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Adong J, Musinguzi N, Ngonzi J, Haberer JE, Bassett IV, Siedner MJ, Roberts DJ, Hahn JA, Bebell LM. Effects of Maternal HIV Infection and Alcohol Use in Pregnancy on Birth Outcomes in Uganda. AIDS Behav 2024; 28:805-810. [PMID: 37843685 PMCID: PMC10922316 DOI: 10.1007/s10461-023-04181-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/17/2023]
Abstract
Alcohol use and HIV infection are prevalent in sub-Saharan Africa (sSA), and both are associated with low birth weight. Yet, few studies have evaluated the combined effects of maternal HIV infection and alcohol use on birth outcomes. We analyzed data from a prospective cohort study of HIV-related placental changes in Ugandan women. We defined alcohol use as self-reported alcohol use within the last year, using the AUDIT questionnaire and used linear and logistic regression to measure associations between maternal alcohol use, HIV serostatus, and birth weight. In a subsample, we measured alcohol exposure using phosphatidylethanol (PEth) in neonatal heelstick dried blood spots to confirm maternal alcohol use. Of 352 participants, 176 (50%) were women with HIV (WHIV). Three of 176 (2%) HIVuninfected women and 17/176 (10%) of WHIV self-reported alcohol use (P = 0.002). Maternal HIV infection was associated with lower birth weight (β = -0.12, 95% CI [-0.20, -0.02], P = 0.02), but self-reported alcohol use was not (β = 0.06, 95% CI [-0.15, 0.26], P = 0.54), and the interaction between HIV serostatus and alcohol use was not significant (P = 0.13). Among the PEth subsample, neither HIV status nor PEthconfirmed alcohol use were associated with low birth weight. Maternal HIV infection was associated with lower birth weight, but alcohol use was not, and there was no significant interaction between maternal HIV infection and alcohol use. Alcohol use was more prevalent in WHIV and under-reporting was common. A larger study of the effects of laboratory-confirmed alcohol and HIV exposure on birth outcomes is warranted.
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Affiliation(s)
- Julian Adong
- Mbarara University of Science and Technology, P.O.Box 1410, Mbarara, Uganda.
| | - Nicholas Musinguzi
- Mbarara University of Science and Technology, P.O.Box 1410, Mbarara, Uganda
| | - Joseph Ngonzi
- Mbarara University of Science and Technology, P.O.Box 1410, Mbarara, Uganda
| | - Jessica E Haberer
- Department of Medicine, Center for Global Health, Massachusetts General Hospital, Boston, USA
| | - Ingrid V Bassett
- Department of Medicine, Center for Global Health, Massachusetts General Hospital, Boston, USA
| | - Mark J Siedner
- Mbarara University of Science and Technology, P.O.Box 1410, Mbarara, Uganda
- Department of Medicine, Center for Global Health, Massachusetts General Hospital, Boston, USA
| | - Drucilla J Roberts
- Department of Pathology, Center for Global Health, Massachusetts General Hospital, Boston, USA
| | | | - Lisa M Bebell
- Department of Medicine, Center for Global Health, Massachusetts General Hospital, Boston, USA
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Edelson PK, Cao D, James KE, Ngonzi J, Roberts DJ, Bebell LM, Boatin AA. Maternal anemia is associated with adverse maternal and neonatal outcomes in Mbarara, Uganda. J Matern Fetal Neonatal Med 2023; 36:2190834. [PMID: 37312571 PMCID: PMC10419325 DOI: 10.1080/14767058.2023.2190834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 02/28/2023] [Accepted: 03/09/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE Maternal anemia is a significant risk factor for maternal morbidity and mortality, increasing risk of preterm birth, intrauterine growth restriction, stillbirth, and death. Moderate and severe anemia in pregnancy is defined as hemoglobin (Hb) <10 g/dl and Hb < 7 g/dl, respectively. We aimed to characterize the association of maternal anemia with maternal, neonatal, and placental outcomes in a resource-limited setting. METHODS Data were collected from a prospective cohort of 352 pregnant women at a tertiary academic Ugandan hospital. One hundred and seventy-six (50%) of women were living with HIV. Hemoglobin was measured in labor, and placentas were collected postpartum. Maternal outcomes included mode of delivery, hemorrhage, blood transfusion, intensive care unit admission, and maternal mortality. Neonatal outcomes included gestational age at delivery, birthweight, stillbirth, and neonatal mortality. Placental descriptors included weight and thickness. Categorical variables were analyzed using Chi-squared and Fisher's exact tests. RESULTS Hemoglobin < 10 g/dl, was present in 17/352 (5%) of women. Significantly more women with moderate or severe anemia were HIV-infected: 14/17 (82%) versus 162/335 (48%) (p = .006). Blood transfusions (2/17, 12% versus 5/335, 2%, p = .04) and neonatal deaths (2/17, 12% versus 9/335, 3%, p = .01) were more common in the anemia group. Placental thickness was lower in the anemia group (1.4 cm versus 1.7 cm, p = .04). CONCLUSIONS Moderate and severe anemia was associated with maternal HIV infection, maternal blood transfusion, neonatal death, and decreased placental thickness. The overall rate of moderate and severe anemia among this cohort was lower than previously reported.
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Affiliation(s)
- P. Kaitlyn Edelson
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Danni Cao
- Brandeis University, Waltham, MA, USA
| | - Kaitlyn E. James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Lisa M. Bebell
- Infectious Diseases Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Adeline A. Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
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Wiens MO, Trawin J, Pillay Y, Nguyen V, Komugisha C, Kenya-Mugisha N, Namala A, Bebell LM, Ansermino JM, Kissoon N, Payne BA, Vidler M, Christoffersen-Deb A, Lavoie PM, Ngonzi J. Prognostic algorithms for post-discharge readmission and mortality among mother-infant dyads: an observational study protocol. Front Epidemiol 2023; 3:1233323. [PMID: 38455948 PMCID: PMC10911031 DOI: 10.3389/fepid.2023.1233323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/13/2023] [Indexed: 03/09/2024]
Abstract
Introduction In low-income country settings, the first six weeks after birth remain a critical period of vulnerability for both mother and newborn. Despite recommendations for routine follow-up after delivery and facility discharge, few mothers and newborns receive guideline recommended care during this period. Prediction modelling of post-delivery outcomes has the potential to improve outcomes for both mother and newborn by identifying high-risk dyads, improving risk communication, and informing a patient-centered approach to postnatal care interventions. This study aims to derive post-discharge risk prediction algorithms that identify mother-newborn dyads who are at risk of re-admission or death in the first six weeks after delivery at a health facility. Methods This prospective observational study will enroll 7,000 mother-newborn dyads from two regional referral hospitals in southwestern and eastern Uganda. Women and adolescent girls aged 12 and above delivering singletons and twins at the study hospitals will be eligible to participate. Candidate predictor variables will be collected prospectively by research nurses. Outcomes will be captured six weeks following delivery through a follow-up phone call, or an in-person visit if not reachable by phone. Two separate sets of prediction models will be built, one set of models for newborn outcomes and one set for maternal outcomes. Derivation of models will be based on optimization of the area under the receiver operator curve (AUROC) and specificity using an elastic net regression modelling approach. Internal validation will be conducted using 10-fold cross-validation. Our focus will be on the development of parsimonious models (5-10 predictor variables) with high sensitivity (>80%). AUROC, sensitivity, and specificity will be reported for each model, along with positive and negative predictive values. Discussion The current recommendations for routine postnatal care are largely absent of benefit to most mothers and newborns due to poor adherence. Data-driven improvements to postnatal care can facilitate a more patient-centered approach to such care. Increasing digitization of facility care across low-income settings can further facilitate the integration of prediction algorithms as decision support tools for routine care, leading to improved quality and efficiency. Such strategies are urgently required to improve newborn and maternal postnatal outcomes. Clinical trial registration https://clinicaltrials.gov/, identifier (NCT05730387).
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Affiliation(s)
- Matthew O. Wiens
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- WALIMU, Kampala, Uganda
| | - Jessica Trawin
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
| | - Yashodani Pillay
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
| | | | | | - Angella Namala
- Department of Obstetrics & Gynaecology, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Lisa M. Bebell
- Department of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Center for Global Health, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - J. Mark Ansermino
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s and Women’s Hospitals, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Beth A. Payne
- Digital Health Research, BC Children’s Hospital Research Institute, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Astrid Christoffersen-Deb
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Pascal M. Lavoie
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Digital Health Research, BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science & Technology, Mbarara, Uganda
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Morton SU, Hehnly C, Burgoine K, Ssentongo P, Ericson JE, Kumar MS, Hagmann C, Fronterre C, Smith J, Movassagh M, Streck N, Bebell LM, Bazira J, Kumbakumba E, Bajunirwe F, Mulondo R, Mbabazi-Kabachelor E, Nsubuga BK, Natukwatsa D, Nalule E, Magombe J, Erickson T, Ngonzi J, Ochora M, Olupot-Olupot P, Onen J, Ssenyonga P, Mugamba J, Warf BC, Kulkarni AV, Lane J, Whalen AJ, Zhang L, Sheldon K, Meier FA, Kiwanuka J, Broach JR, Paulson JN, Schiff SJ. Paenibacillus spp infection among infants with postinfectious hydrocephalus in Uganda: an observational case-control study. Lancet Microbe 2023; 4:e601-e611. [PMID: 37348522 PMCID: PMC10529524 DOI: 10.1016/s2666-5247(23)00106-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2023] [Accepted: 03/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Paenibacillus thiaminolyticus is a cause of postinfectious hydrocephalus among Ugandan infants. To determine whether Paenibacillus spp is a pathogen in neonatal sepsis, meningitis, and postinfectious hydrocephalus, we aimed to complete three separate studies of Ugandan infants. The first study was on peripartum prevalence of Paenibacillus in mother-newborn pairs. The second study assessed Paenibacillus in blood and cerebrospinal fluid (CSF) from neonates with sepsis. The third study assessed Paenibacillus in CSF from infants with hydrocephalus. METHODS In this observational study, we recruited mother-newborn pairs with and without maternal fever (mother-newborn cohort), neonates (aged ≤28 days) with sepsis (sepsis cohort), and infants (aged ≤90 days) with hydrocephalus with and without a history of neonatal sepsis and meningitis (hydrocephalus cohort) from three hospitals in Uganda between Jan 13, 2016 and Oct 2, 2019. We collected maternal blood, vaginal swabs, and placental samples and the cord from the mother-newborn pairs, and blood and CSF from neonates and infants. Bacterial content of infant CSF was characterised by 16S rDNA sequencing. We analysed all samples using quantitative PCR (qPCR) targeting either the Paenibacillus genus or Paenibacillus thiaminolyticus spp. We collected cranial ultrasound and computed tomography images in the subset of participants represented in more than one cohort. FINDINGS No Paenibacillus spp were detected in vaginal, maternal blood, placental, or cord blood specimens from the mother-newborn cohort by qPCR. Paenibacillus spp was detected in 6% (37 of 631 neonates) in the sepsis cohort and, of these, 14% (5 of 37 neonates) developed postinfectious hydrocephalus. Paenibacillus was the most enriched bacterial genera in postinfectious hydrocephalus CSF (91 [44%] of 209 patients) from the hydrocephalus cohort, with 16S showing 94% accuracy when validated by qPCR. Imaging showed progression from Paenibacillus spp-related meningitis to postinfectious hydrocephalus over 1-3 months. Patients with postinfectious hydrocephalus with Paenibacillus spp infections were geographically clustered. INTERPRETATION Paenibacillus spp causes neonatal sepsis and meningitis in Uganda and is the dominant cause of subsequent postinfectious hydrocephalus. There was no evidence of transplacental transmission, and geographical evidence was consistent with an environmental source of neonatal infection. Further work is needed to identify routes of infection and optimise treatment of neonatal Paenibacillus spp infection to lessen the burden of morbidity and mortality. FUNDING National Institutes of Health and Boston Children's Hospital Office of Faculty Development.
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Affiliation(s)
- Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Christine Hehnly
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Kathy Burgoine
- Neonatal Unit, Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Mbale, Uganda; Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda; Busitema University, Busitema, Uganda
| | - Paddy Ssentongo
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA; Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jessica E Ericson
- Division of Pediatric Infectious Disease, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - M Senthil Kumar
- Department of Biostatistics, Harvard T H Chan School of Public Health and Department of Data Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Cornelia Hagmann
- Department of Neonatology and Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Claudio Fronterre
- Centre for Health Informatics, Computing, and Statistics, Lancaster University, Lancaster, UK
| | - Jasmine Smith
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Mercedeh Movassagh
- Department of Biostatistics, Harvard T H Chan School of Public Health and Department of Data Sciences, Dana Farber Cancer Institute, Boston, MA, USA
| | - Nicholas Streck
- Department of Pathology and Laboratory Medicine Division of Clinical Pathology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Lisa M Bebell
- Division of Infectious Diseases, Department of Medicine, Center for Global Health, and Medical Practice Evaluation Center and Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Francis Bajunirwe
- Department of Epidemiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | | | | | | | - Tim Erickson
- CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Moses Ochora
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Peter Olupot-Olupot
- Neonatal Unit, Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Mbale, Uganda; Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda; Busitema University, Busitema, Uganda
| | - Justin Onen
- CURE Children's Hospital of Uganda, Mbale, Uganda; Mulago National Referral Hospital, Makerere University, Kampala, Uganda
| | - Peter Ssenyonga
- CURE Children's Hospital of Uganda, Mbale, Uganda; Mulago National Referral Hospital, Makerere University, Kampala, Uganda
| | - John Mugamba
- CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA; Department of Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Department of Surgery, Hospital for Sick Children, University of Toronto, ON, Canada
| | - Jessica Lane
- Department of Neurosurgery, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Andrew J Whalen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Lijun Zhang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Kathryn Sheldon
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Frederick A Meier
- Department of Pathology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Julius Kiwanuka
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James R Broach
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Joseph N Paulson
- Department of Data Sciences, N-Power Medicine, Redwood City, CA, USA
| | - Steven J Schiff
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
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Ngonzi J, Tibaijuka L, Kintu TM, Kihumuro RB, Onesmus A, Onesmus B, Adong J, Salongo W, Boatin AA, Bebell LM. Prevalence and risk factors for newborn anemia in southwestern Uganda: a prospective cohort study. Res Sq 2023:rs.3.rs-3054549. [PMID: 37461715 PMCID: PMC10350226 DOI: 10.21203/rs.3.rs-3054549/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Introduction The global prevalence of anemia in pregnancy is about 42%, and in sub-Saharan Africa, the prevalence of newborn anemia ranges from 25-30%. Anemia in newborn babies may cause complications such as delayed brain maturation and arrested growth. However, there is limited data on prevalence of newborn anemia and its risk factors in people living in resource-limited settings. Objectives We determined the prevalence and risk factors for newborn anemia and its correlation with maternal anemia in southwestern Uganda. Methods This was a prospective cohort study of 352 pregnant women presenting to Mbarara Regional Referral Hospital for delivery. We collected maternal blood in labor and umbilical cord blood from the placental vein, as a proxy for newborn hemoglobin. We estimated hemoglobin using a point-of-care Hemocue machine. We used summary statistics to characterize the cohort, and compared demographic characteristics and outcomes using Chi-square, t-test, and Wilcoxon Ranksum analyses. We defined newborn anemia as umbilical cord hemoglobin < 13g/dl and estimated the relationship between maternal and umbilical cord hemoglobin using linear regression analysis, adjusting for potential confounders. Results The prevalence of newborn anemia was 17%. The average maternal parity was significantly higher for anemic and non-anemic newborns (3.5 versus 2.8, P = 0.01). Mean age [SD] was significantly lower for participants with umbilical cord hemoglobin < 13g/dl than those > = 13 g/dl, (26 [5.6] versus 28 [6.3], P = 0.01). In multivariable linear regression analysis, a 1-point decrease in maternal hemoglobin was associated with a 0.14-point decrease in umbilical cord hemoglobin (P = 0.02). Each one-unit increase in maternal parity was associated with a 0.25-point decrease in umbilical cord hemoglobin (P = 0.01). Cesarean delivery was associated with a 0.46-point lower umbilical cord hemoglobin level compared to vaginal delivery (P = 0.03). Conclusions We found a significant correlation between maternal and newborn hemoglobin levels, underscoring the importance of preventing and correcting maternal anemia in pregnancy. Furthermore, maternal anemia should be considered a risk factor neonatal anemia.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Lisa M Bebell
- Harvard Medical School, Massachusetts General Hospital
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Kelly MS, Mohammed A, Okin D, Alba GA, Jesudasen SJ, Flanagan S, Dandawate NA, Gavralidis A, Chang LL, Moin EE, Witkin AS, Hibbert KA, Kadar A, Gordan PL, Bebell LM, Hauptman M, Valeri L, Lai PS. Preferred Language Mediates Association Between Race, Ethnicity, and Delayed Presentation in Critically Ill Patients With COVID-19. Crit Care Explor 2023; 5:e0927. [PMID: 37332365 PMCID: PMC10270487 DOI: 10.1097/cce.0000000000000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023] Open
Abstract
Which social factors explain racial and ethnic disparities in COVID-19 access to care and outcomes remain unclear. OBJECTIVES We hypothesized that preferred language mediates the association between race, ethnicity and delays to care. DESIGN SETTING AND PARTICIPANTS Multicenter, retrospective cohort study of adults with COVID-19 consecutively admitted to the ICU in three Massachusetts hospitals in 2020. MAIN OUTCOME AND MEASURES Causal mediation analysis was performed to evaluate potential mediators including preferred language, insurance status, and neighborhood characteristics. RESULTS Non-Hispanic White (NHW) patients (157/442, 36%) were more likely to speak English as their preferred language (78% vs. 13%), were less likely to be un- or under-insured (1% vs. 28%), lived in neighborhoods with lower social vulnerability index (SVI) than patients from racial and ethnic minority groups (SVI percentile 59 [28] vs. 74 [21]) but had more comorbidities (Charlson comorbidity index 4.6 [2.5] vs. 3.0 [2.5]), and were older (70 [13.2] vs. 58 [15.1] years). From symptom onset, NHW patients were admitted 1.67 [0.71-2.63] days earlier than patients from racial and ethnic minority groups (p < 0.01). Non-English preferred language was associated with delay to admission of 1.29 [0.40-2.18] days (p < 0.01). Preferred language mediated 63% of the total effect (p = 0.02) between race, ethnicity and days from symptom onset to hospital admission. Insurance status, social vulnerability, and distance to the hospital were not on the causal pathway between race, ethnicity and delay to admission. CONCLUSIONS AND RELEVANCE Preferred language mediates the association between race, ethnicity and delays to presentation for critically ill patients with COVID-19, although our results are limited by possible collider stratification bias. Effective COVID-19 treatments require early diagnosis, and delays are associated with increased mortality. Further research on the role preferred language plays in racial and ethnic disparities may identify effective solutions for equitable care.
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Affiliation(s)
- Michael S Kelly
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Adna Mohammed
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Daniel Okin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - George A Alba
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Shelby Flanagan
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- New England Pediatric Environmental Health Specialty Unit, Boston, MA
| | - Nupur A Dandawate
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Alexander Gavralidis
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Leslie L Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emily E Moin
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alison S Witkin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kathryn A Hibbert
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA
| | - Patrick L Gordan
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Marissa Hauptman
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Linda Valeri
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY
| | - Peggy S Lai
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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9
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Okin D, Huang CY, Alba GA, Thompson BT, Bebell LM, Lai PS. Response. Chest 2023; 163:e287-e288. [PMID: 37295891 PMCID: PMC10244862 DOI: 10.1016/j.chest.2023.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 06/12/2023] Open
Affiliation(s)
- Daniel Okin
- Division of Pulmonary and Critical Care Medicine, Boston, MA
| | | | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Boston, MA
| | | | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Peggy S Lai
- Division of Pulmonary and Critical Care Medicine, Boston, MA.
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10
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Okin D, Alba GA, Bebell LM, Lai PS. Response. Chest 2023; 163:e291. [PMID: 37295895 PMCID: PMC10244858 DOI: 10.1016/j.chest.2023.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 06/12/2023] Open
Affiliation(s)
- Daniel Okin
- Division of Pulmonary and Critical Care Medicine, Boston, MA
| | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Boston, MA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Peggy S Lai
- Division of Pulmonary and Critical Care Medicine, Boston, MA.
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Nziza N, Jung W, Mendu M, Chen T, McNamara RP, Fortune SM, Franken KLMC, Ottenhoff THM, Bryson B, Ngonzi J, Bebell LM, Alter G. Maternal HIV infection drives altered placental Mtb-specific antibody transfer. Front Microbiol 2023; 14:1171990. [PMID: 37228375 PMCID: PMC10203169 DOI: 10.3389/fmicb.2023.1171990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction Placental transfer of maternal antibodies is essential for neonatal immunity over the first months of life. In the setting of maternal HIV infection, HIV-exposed uninfected (HEU) infants are at higher risk of developing severe infections, including active tuberculosis (TB). Given our emerging appreciation for the potential role of antibodies in the control of Mycobacterium tuberculosis (Mtb), the bacteria that causes TB, here we aimed to determine whether maternal HIV status altered the quality of Mtb-specific placental antibody transfer. Methods Antigen-specific antibody systems serology was performed to comprehensively characterize the Mtb-specific humoral immune response in maternal and umbilical cord blood from HIV infected and uninfected pregnant people in Uganda. Results Significant differences were noted in overall antibody profiles in HIV positive and negative maternal plasma, resulting in heterogeneous transfer of Mtb-specific antibodies. Altered antibody transfer in HIV infected dyads was associated with impaired binding to IgG Fc-receptors, which was directly linked to HIV viral loads and CD4 counts. Conclusions These results highlight the importance of maternal HIV status on antibody transfer, providing clues related to alterations in transferred maternal immunity that may render HEU infants more vulnerable to TB than their HIV-unexposed peers.
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Affiliation(s)
- Nadege Nziza
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
| | - Wonyeong Jung
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
| | - Maanasa Mendu
- Department of Molecular and Cellular Biology, Harvard University, Boston, MA, United States
| | - Tina Chen
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
| | - Ryan P. McNamara
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
| | - Sarah M. Fortune
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Kees L. M. C. Franken
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Tom H. M. Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Bryan Bryson
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lisa M. Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, United States
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States
| | - Galit Alter
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, United States
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12
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Symonds NE, Vidler M, Wiens MO, Omar S, English LL, Ukah UV, Ansermino JM, Ngonzi J, Bebell LM, Hwang B, Christoffersen-Deb A, Kissoon N, Payne BA. Risk factors for postpartum maternal mortality and hospital readmission in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth 2023; 23:303. [PMID: 37120529 PMCID: PMC10148415 DOI: 10.1186/s12884-023-05459-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 02/20/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND In low- and middle-income countries, approximately two thirds of maternal deaths occur in the postpartum period. Yet, care for women beyond 24 h after discharge is limited. The objective of this systematic review is to summarize current evidence on socio-demographic and clinical risk factors for (1) postpartum mortality and (2) postpartum hospital readmission. METHODS A combination of keywords and subject headings (i.e. MeSH terms) for postpartum maternal mortality or readmission were searched. Articles published up to January 9, 2021 were identified in MEDLINE, EMBASE, and CINAHL databases, without language restrictions. Studies reporting socio-demographic or clinical risk factors for postpartum mortality or readmission within six weeks of delivery among women who delivered a livebirth in a low- or middle-income country were included. Data were extracted independently by two reviewers based on study characteristics, population, and outcomes. Included studies were assessed for quality and risk of bias using the Downs and Black checklist for ratings of randomized and non-randomized studies. RESULTS Of 8783 abstracts screened, seven studies were included (total N = 387,786). Risk factors for postpartum mortality included Caesarean mode of delivery, nulliparity, low or very low birthweight, and shock upon admission. Risk factors for postpartum readmission included Caesarean mode of delivery, HIV positive serostatus, and abnormal body temperature. CONCLUSIONS Few studies reported individual socio-demographic or clinical risk factors for mortality or readmission after delivery in low- and middle-income countries; only Caesarean delivery was consistently reported. Further research is needed to identify factors that put women at greatest risk of post-discharge complications and mortality. Understanding post-discharge risk would facilitate targeted postpartum care and reduce adverse outcomes in women after delivery. TRIAL REGISTRATION PROSPERO registration number: CRD42018103955.
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Affiliation(s)
- Nicola E Symonds
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
| | - Matthew O Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Walimu, Kampala, Uganda
| | - Shazmeen Omar
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - L Lacey English
- Department of Internal Medicine and Pediatrics, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - U Vivian Ukah
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - J Mark Ansermino
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lisa M Bebell
- Infectious Diseases Division, and Center for Global Health, Massachusetts General Hospital Medical Practice Evaluation Center, Boston, MA, USA
| | - Bella Hwang
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
| | - Astrid Christoffersen-Deb
- Department of Obstetrics and Gynaecology, University of British Columbia, Rm V3-339, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Niranjan Kissoon
- The Centre for International Child Health, BC Children's Hospital, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Beth A Payne
- School of Public and Population Health, University of British Columbia, Vancouver, BC, Canada
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13
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Okin D, Huang CY, Alba GA, Jesudasen SJ, Dandawate NA, Gavralidis A, Chang LL, Moin EE, Ahmad I, Witkin AS, Hardin CC, Hibbert KA, Kadar A, Gordan PL, Lee H, Thompson BT, Bebell LM, Lai PS. Prolonged Prone Position Ventilation Is Associated With Reduced Mortality in Intubated COVID-19 Patients. Chest 2023; 163:533-542. [PMID: 36343687 PMCID: PMC9635255 DOI: 10.1016/j.chest.2022.10.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Prone position ventilation (PPV) is resource-intensive, yet the optimal strategy for PPV in intubated patients with COVID-19 is unclear. RESEARCH QUESTION Does a prolonged (24 or more h) PPV strategy improve mortality in intubated COVID-19 patients compared with intermittent (∼16 h with daily supination) PPV? STUDY DESIGN AND METHODS Multicenter, retrospective cohort study of consecutively admitted intubated COVID-19 patients treated with PPV between March 11 and May 31, 2020. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day all-cause mortality and prone-related complications. Inverse probability treatment weights (IPTW) were used to control for potential treatment selection bias. RESULTS Of the COVID-19 patients who received PPV, 157 underwent prolonged and 110 underwent intermittent PPV. Patients undergoing prolonged PPV had reduced 30-day (adjusted hazard ratio [aHR], 0.475; 95% CI, 0.336-0.670; P < .001) and 90-day (aHR, 0.638; 95% CI, 0.461-0.883; P = .006) mortality compared with intermittent PPV. In patients with Pao2/Fio2 ≤ 150 at the time of pronation, prolonged PPV was associated with reduced 30-day (aHR, 0.357; 95% CI, 0.213-0.597; P < .001) and 90-day mortality (aHR, 0.562; 95% CI, 0.357-0.884; P = .008). Patients treated with prolonged PPV underwent fewer pronation and supination events (median, 1; 95% CI, 1-2 vs 3; 95% CI, 1-4; P < .001). PPV strategy was not associated with overall PPV-related complications, although patients receiving prolonged PPV had increased rates of facial edema and lower rates of peri-proning hypotension. INTERPRETATION Among intubated COVID-19 patients who received PPV, prolonged PPV was associated with reduced mortality. Prolonged PPV was associated with fewer pronation and supination events and a small increase in rates of facial edema. These findings suggest that prolonged PPV is a safe, effective strategy for mortality reduction in intubated COVID-19 patients.
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Affiliation(s)
- Daniel Okin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Ching-Ying Huang
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - George A Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | | | - Leslie L Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Emily E Moin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Imama Ahmad
- Department of Medicine, Salem Hospital, Salem, MA
| | - Alison S Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - C Corey Hardin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Kathryn A Hibbert
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA
| | - Patrick L Gordan
- Divison of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA
| | - Hang Lee
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Peggy S Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA.
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Rahim NE, Ngonzi J, Boatin AA, Bassett IV, Siedner MJ, Mugyenyi GR, Bebell LM. Correction: The interaction between antenatal care and abnormal temperature during delivery and its relationship with postpartum care: a prospective study of 1,538 women in semi-rural Uganda. BMC Pregnancy Childbirth 2022; 22:953. [PMID: 36544105 PMCID: PMC9769070 DOI: 10.1186/s12884-022-05293-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Nicholas E. Rahim
- grid.32224.350000 0004 0386 9924Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, USA
| | - Joseph Ngonzi
- grid.33440.300000 0001 0232 6272Department of Obstetrics and Gynaecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adeline A. Boatin
- grid.32224.350000 0004 0386 9924Department of Obstetrics and Gynecology and Center for Global Health, Massachusetts General Hospital, Boston, USA
| | - Ingrid V. Bassett
- grid.32224.350000 0004 0386 9924Department of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Mark J. Siedner
- grid.32224.350000 0004 0386 9924Department of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA ,grid.33440.300000 0001 0232 6272Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey R. Mugyenyi
- grid.33440.300000 0001 0232 6272Department of Obstetrics and Gynaecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lisa M. Bebell
- grid.38142.3c000000041936754XDepartment of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Center for Global Health, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, GRJ-504, Boston, MA 02114 USA
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15
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Rahim NE, Ngonzi J, Boatin AA, Bassett IV, Siedner MJ, Mugyenyi GR, Bebell LM. The interaction between antenatal care and abnormal temperature during delivery and its relationship with postpartum care: a prospective study of 1,538 women in semi-rural Uganda. BMC Pregnancy Childbirth 2022; 22:860. [PMID: 36411419 PMCID: PMC9677695 DOI: 10.1186/s12884-022-05207-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/11/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Postnatal care (PNC) is an important tool for reducing maternal and neonatal morbidity and mortality. However, what predicts receipt and maintenance in PNC, particularly events during pregnancy and the peripartum period, is not well understood. We hypothesized that fever or hypothermia during delivery would engender greater health consciousness among those attending antenatal care, leading to greater PNC engagement after hospital discharge and our objective was to evaluate this relationship. METHODS Women were prospectively enrolled immediately postpartum at Mbarara Regional Referral Hospital (MRRH). We collected postpartum vital signs and surveyed women by telephone about PNC receipt, fever, and infection at two and six weeks postpartum. Our outcome of interest was receipt of PNC post-discharge, defined as whether a participant visited a health facility and/or was hospitalized in the postpartum period. Our explanatory variables were whether a participant was ever febrile (> 38.0˚C) or hypothermic (< 36.0˚C) during delivery stay and whether a participant attended at least 4 antenatal care (ANC) visits. We used logistic regressions to estimate the association between ANC and fever/hypothermia with PNC, including an interaction term between ANC and fever/hypothermia to determine whether there was a modifying relationship between variables on PNC. Regression models were adjusted for age, marital status, parity, HIV serostatus, Mbarara residency, and whether the participant was referred to MRRH, RESULTS: Of the 1,541 women, 86 (5.6%) reported visiting a health facility and/or hospitalization and 186 (12.0%) had an abnormal temperature recorded during delivery stay. Of those who reported at least one visit, 59/86 (68.6%) delivered by cesarean, 37/86 (43.0%) reported post-discharge fever, and 44/86 (51.2%) reported post-discharge infection. Neither ANC attendance, abnormal temperature after delivery, nor their interaction term, were significantly associated with post-discharge PNC. The included covariates were not significantly associated with the outcome. CONCLUSIONS While the overall proportion of women reporting post-discharge PNC was low, those who reported visiting a health facility and/or hospitalization had high proportions of post-discharge fever, post-discharge infection, and cesarean delivery, which suggests that these visits may have been related to problem-focused care. No significant associations between ANC and PNC were observed in this cohort. Further research assessing ANC quality and PNC visit focus is needed to ensure ANC and PNC are optimized to reduce morbidity and mortality.
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Affiliation(s)
- Nicholas E. Rahim
- grid.32224.350000 0004 0386 9924Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, USA
| | - Joseph Ngonzi
- grid.33440.300000 0001 0232 6272Department of Obstetrics and Gynaecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adeline A. Boatin
- grid.32224.350000 0004 0386 9924Department of Obstetrics and Gynecology and Center for Global Health, Massachusetts General Hospital, Boston, USA
| | - Ingrid V. Bassett
- grid.32224.350000 0004 0386 9924Department of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Mark J. Siedner
- grid.32224.350000 0004 0386 9924Department of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA ,grid.33440.300000 0001 0232 6272Mbarara University of Science and Technology, Mbarara, Uganda
| | - Godfrey R. Mugyenyi
- grid.33440.300000 0001 0232 6272Department of Obstetrics and Gynaecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lisa M. Bebell
- grid.38142.3c000000041936754XDepartment of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, Center for Global Health, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, GRJ-504, Boston, MA 02114 USA
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16
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Dolatshahi S, Butler AL, Siedner MJ, Ngonzi J, Edlow AG, Adong J, Jennewein MF, Atyeo C, Bassett IV, Roberts DJ, Lauffenburger DA, Alter G, Bebell LM. Altered Maternal Antibody Profiles in Women With Human Immunodeficiency Virus Drive Changes in Transplacental Antibody Transfer. Clin Infect Dis 2022; 75:1359-1369. [PMID: 35245365 PMCID: PMC9555842 DOI: 10.1093/cid/ciac156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-exposed, uninfected (HEU) children have a higher risk of severe infection, but the causes are poorly understood. Emerging data point to altered antibody transfer in women with HIV (WHIV); however, specific perturbations and the influence of antiretroviral therapy (ART) and HIV viremia remain unclear. METHODS We evaluated antigen-specific transplacental antibody transfer across 14 antigens in paired maternal and umbilical cord plasma from 352 Ugandan women; 176 were WHIV taking ART. We measured antigen-specific immunoglobulin G (IgG) sub-class (IgG1, 2, 3, 4) levels and antibody Fcγ receptor (FcγRn, 2a, 2b, 3a, 3b) binding profiles. We used partial least squares discrimi-nant analysis to define antigen-specific transplacental antibody transfer features. RESULTS Global antibody transfer patterns were similar by maternal HIV serostatus, pointing to effective placental function in WHIV. However, HEU umbilical cord antibody profiles were altered, driven by perturbed WHIV seroprofiles, with higher levels of herpesvirus antibodies (P < .01 for Epstein-Barr virus, herpes simplex virus) and lower levels of classic vaccine-induced antibodies (P < .01 for tetanus, polio, Haemophilus influenzae type b), suggesting that umbilical cord antibody profile differences arise from imbalanced WHIV immunity. Abnormal WHIV antibody profiles were associated with HIV viremia, lower CD4 count, and postconception ART initiation (P = .01). CONCLUSIONS Perturbed immune-dominance profiles in WHIV shift the balance of immunity delivered to neonates. Perturbed HIV-associated maternal antibody profiles are a key determinant of com-promised neonatal immunity. Maternal vaccination interventions may promote transfer of relevant, effective antibodies to protect HEU children against early-life infections.
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Affiliation(s)
- Sepideh Dolatshahi
- Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Audrey L Butler
- State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Mark J Siedner
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph Ngonzi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Andrea G Edlow
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julian Adong
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Caroline Atyeo
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts, USA
| | - Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Galit Alter
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts, USA
| | - Lisa M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
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17
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Bebell LM, Ngonzi J, Meier FA, Carreon CK, Birungi A, Kerry VB, Atwine R, Roberts DJ. Building Perinatal Pathology Research Capacity in Sub-Saharan Africa. Front Med (Lausanne) 2022; 9:958840. [PMID: 35872791 PMCID: PMC9304650 DOI: 10.3389/fmed.2022.958840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/24/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Over two million stillbirths and neonatal deaths occur in sub-Saharan Africa (sSA) annually. Despite multilateral efforts, reducing perinatal mortality has been slow. Although targeted pathologic investigation can often determine the cause of perinatal death, in resource-limited settings, stillbirths, early neonatal deaths, and placentas are rarely examined pathologically. However, the placenta is a key source of diagnostic information and is the main determinant of fetal growth and development in utero, influencing child health outcomes. Methods In 2016, our collaborative intercontinental group began investigating infectious perinatal death and adverse child health outcomes in Uganda. We developed and initiated a 4-day combined didactic/practical curriculum to train health workers in placental collection, gross placental examination, and tissue sampling for histology. We also trained a local technician to perform immunohistochemistry staining. Results Overall, we trained 12 health workers who performed gross placental assessment for > 1,000 placentas, obtaining > 5,000 formalin-fixed tissue samples for research diagnostic use. Median placental weights ranged from 425 to 456 g, and 33.3% of placentas were < 10th percentile in weight, corrected for gestational age. Acute chorioamnionitis (32.3%) and maternal vascular malperfusion (25.4%) were common diagnoses. Discussion Through a targeted training program, we built capacity at a university-affiliated hospital in sSA to independently perform placental collection, gross pathologic examination, and placental tissue processing for histology and special stains. Our training model can be applied to other collaborative research endeavors in diverse resource-limited settings to improve research and clinical capacity and competency for diagnostics and management of stillbirth, neonatal death, and child health outcomes.
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Affiliation(s)
- Lisa M. Bebell
- Division of Infectious Diseases, Department of Medicine, Medical Practice Evaluation Center and Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Lisa M. Bebell,
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Frederick A. Meier
- Department of Pathology, Wayne State University School of Medicine, Detroit, MI, United States
| | - Chrystalle Katte Carreon
- Division of Women’s and Perinatal Pathology, Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
- Department of Pathology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Abraham Birungi
- Department of Pathology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Vanessa B. Kerry
- Division of Pulmonary and Critical Care Medicine and Center for Global Health, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Seed Global Health, Boston, MA, United States
| | - Raymond Atwine
- Department of Pathology, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Drucilla J. Roberts
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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18
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Moin EE, Okin D, Jesudasen SJ, Dandawate NA, Gavralidis A, Chang LL, Witkin AS, Hibbert KA, Kadar A, Gordan PL, Bebell LM, Lai PS, Alba GA. Code status orders in patients admitted to the intensive care unit with COVID-19: a retrospective cohort study. Resusc Plus 2022; 10:100219. [PMID: 35284847 PMCID: PMC8898738 DOI: 10.1016/j.resplu.2022.100219] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose Materials and methods Results Conclusions
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Affiliation(s)
- Emily E. Moin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Okin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Leslie L. Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alison S. Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kathryn A. Hibbert
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA, USA
| | - Patrick L. Gordan
- Department of Medicine, Salem Hospital, Salem, MA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA, USA
| | - Lisa M. Bebell
- Division of Infectious Diseases, Medical Practice Evaluation Center and Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Peggy S. Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - George A. Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
- Corresponding author at: 55 Fruit Street, Bulfinch 148, Boston, MA 02114, USA.
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19
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Hehnly C, Ssentongo P, Bebell LM, Burgoine K, Bazira J, Fronterre C, Kumbakumba E, Mulondo R, Mbabazi-Kabachelor E, Morton SU, Ngonzi J, Ochora M, Olupot-Olupot P, Mugamba J, Onen J, Roberts DJ, Sheldon K, Sinnar SA, Smith J, Ssenyonga P, Kiwanuka J, Paulson JN, Meier FA, Ericson JE, Broach JR, Schiff SJ. Cytomegalovirus infections in infants in Uganda: Newborn-mother pairs, neonates with sepsis, and infants with hydrocephalus. Int J Infect Dis 2022; 118:24-33. [PMID: 35150915 PMCID: PMC9058984 DOI: 10.1016/j.ijid.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/30/2022] [Accepted: 02/04/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives: To estimate the prevalence of cytomegalovirus (CMV) infections among newborn-mother pairs, neonates with sepsis, and infants with hydrocephalus in Uganda. Design and Methods: Three populations—newborn-mother pairs, neonates with sepsis, and infants (≤3 months) with nonpostinfectious (NPIH) or postinfectious (PIH) hydrocephalus—were evaluated for CMV infection at 3 medical centers in Uganda. Quantitative PCR (qPCR) was used to characterize the prevalence of CMV. Results: The overall CMV prevalence in 2498 samples across all groups was 9%. In newborn-mother pairs, there was a 3% prevalence of cord blood CMV positivity and 33% prevalence of maternal vaginal shedding. In neonates with clinical sepsis, there was a 2% CMV prevalence. Maternal HIV seropositivity (adjusted odds ratio [aOR] 25.20; 95% confidence interval [CI] 4.43–134.26; p = 0.0001), residence in eastern Uganda (aOR 11.06; 95% CI 2.30–76.18; p = 0.003), maternal age < 25 years (aOR 4.54; 95% CI 1.40–19.29; p = 0.02), and increasing neonatal age (aOR 1.08 for each day older; 95% CI 1.00–1.16; p = 0.05), were associated risk factors for CMV in neonates with clinical sepsis. We found a 2-fold higher maternal vaginal shedding in eastern (45%) vs western (22%) Uganda during parturition (n = 22/49 vs 11/50, the Fisher exact test; p = 0.02). In infants with PIH, the prevalence in blood was 24% and in infants with NPIH, it was 20%. CMV was present in the cerebrospinal fluid (CSF) of 13% of infants with PIH compared with 0.5% of infants with NPIH (n = 26/205 vs 1/194, p < 0.0001). Conclusions: Our findings highlight that congenital and postnatal CMV prevalence is substantial in this African setting, and the long-term consequences are uncharacterized.
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Affiliation(s)
- Christine Hehnly
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Paddy Ssentongo
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, USA; Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathy Burgoine
- Neonatal Unit, Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Mbale, Uganda; Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom; Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Claudio Fronterre
- Centre for Health Informatics, Computing, and Statistics, Lancaster University, Lancaster, United Kingdom
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Joseph Ngonzi
- Department of Obstetrics and Gynaecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Moses Ochora
- Centre for Health Informatics, Computing, and Statistics, Lancaster University, Lancaster, United Kingdom
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Mbale, Uganda; Busitema University, Busitema, Uganda
| | - John Mugamba
- CURE Children's Hospital of Uganda, Mbale, Uganda
| | - Justin Onen
- Mulago National Referral Hospital, Kampala, Uganda
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, MA, USA
| | - Kathryn Sheldon
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Shamim A Sinnar
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jasmine Smith
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | | | - Julius Kiwanuka
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joseph N Paulson
- Department of Biostatistics, Product Development, Genentech Inc., San Francisco, CA, USA
| | | | - Jessica E Ericson
- Division of Pediatric Infectious Disease, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - James R Broach
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, The Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Steven J Schiff
- Center for Neural Engineering, Department of Engineering Science and Mechanics, The Pennsylvania State University, University Park, PA, USA; Center for Infectious Disease Dynamics, and Department of Physics, The Pennsylvania State University, University Park, PA, USA.
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20
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Shook LL, Bordt EA, Meinsohn MC, Pepin D, De Guzman RM, Brigida S, Yockey LJ, James KE, Sullivan MW, Bebell LM, Roberts DJ, Kaimal AJ, Li JZ, Schust D, Gray KJ, Edlow AG. Placental Expression of ACE2 and TMPRSS2 in Maternal Severe Acute Respiratory Syndrome Coronavirus 2 Infection: Are Placental Defenses Mediated by Fetal Sex? J Infect Dis 2021; 224:S647-S659. [PMID: 34293137 PMCID: PMC8344531 DOI: 10.1093/infdis/jiab335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Expression of angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2), host molecules required for viral entry, may underlie sex differences in vulnerability to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We investigated whether placental ACE2 and TMPRSS2 expression vary by fetal sex in the presence of maternal SARS-CoV-2 infection. METHODS Placental ACE2 and TMPRSS2 expression was quantified by quantitative reverse transcription polymerase chain reaction (RT-PCR) and by Western blot in 68 pregnant women (38 SARS-CoV-2 positive, 30 SARS-CoV-2 negative) delivering at Mass General Brigham from April to June 2020. The impact of fetal sex and maternal SARS-CoV-2 exposure on ACE2 and TMPRSS2 was analyzed by 2-way analysis of variance (ANOVA). RESULTS Maternal SARS-CoV-2 infection impacted placental TMPRSS2 expression in a sexually dimorphic fashion (2-way ANOVA interaction, P = .002). We observed no impact of fetal sex or maternal SARS-CoV-2 status on ACE2. TMPRSS2 expression was significantly correlated with ACE2 expression in males (Spearman ρ = 0.54, P = .02) but not females (ρ = 0.23, P = .34) exposed to maternal SARS-CoV-2. CONCLUSIONS Sex differences in placental TMPRSS2 but not ACE2 were observed in the setting of maternal SARS-CoV-2 infection, which may have implications for offspring vulnerability to placental infection.
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Affiliation(s)
- Lydia L Shook
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Evan A Bordt
- Department of Pediatrics, Lurie Center for Autism, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marie-Charlotte Meinsohn
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Pepin
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rose M De Guzman
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sara Brigida
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Laura J Yockey
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kaitlyn E James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mackenzie W Sullivan
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lisa M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, MGH Center for Global Health, and Harvard Medical School, Boston, Massachusetts, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anjali J Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Z Li
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Danny Schust
- Department of Obstetrics, Gynecology, and Women’s Health, University of Missouri, Columbia, Missouri, USA
| | - Kathryn J Gray
- Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea G Edlow
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Bordt EA, Shook LL, Atyeo C, Pullen KM, De Guzman RM, Meinsohn MC, Chauvin M, Fischinger S, Yockey LJ, James K, Lima R, Yonker LM, Fasano A, Brigida S, Bebell LM, Roberts DJ, Pépin D, Huh JR, Bilbo SD, Li JZ, Kaimal A, Schust DJ, Gray KJ, Lauffenburger D, Alter G, Edlow AG. Maternal SARS-CoV-2 infection elicits sexually dimorphic placental immune responses. Sci Transl Med 2021; 13:eabi7428. [PMID: 34664987 PMCID: PMC8784281 DOI: 10.1126/scitranslmed.abi7428] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There is a persistent bias toward higher prevalence and increased severity of coronavirus disease 2019 (COVID-19) in males. Underlying mechanisms accounting for this sex difference remain incompletely understood. Interferon responses have been implicated as a modulator of COVID-19 disease in adults and play a key role in the placental antiviral response. Moreover, the interferon response has been shown to alter Fc receptor expression and therefore may affect placental antibody transfer. Here, we examined the intersection of maternal-fetal antibody transfer, viral-induced placental interferon responses, and fetal sex in pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Placental Fc receptor abundance, interferon-stimulated gene (ISG) expression, and SARS-CoV-2 antibody transfer were interrogated in 68 human pregnancies. Sexually dimorphic expression of placental Fc receptors, ISGs and proteins, and interleukin-10 was observed after maternal SARS-CoV-2 infection, with up-regulation of these features in placental tissue of pregnant individuals with male fetuses. Reduced maternal SARS-CoV-2–specific antibody titers and impaired placental antibody transfer were also observed in pregnancies with a male fetus. These results demonstrate fetal sex-specific maternal and placental adaptive and innate immune responses to SARS-CoV-2.
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Affiliation(s)
- Evan A Bordt
- Department of Pediatrics, Lurie Center for Autism, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Lydia L Shook
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.,Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Caroline Atyeo
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA.,PhD Program in Virology, Division of Medical Sciences, Harvard University, Boston, MA 02115, USA
| | - Krista M Pullen
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Rose M De Guzman
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.,Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Marie-Charlotte Meinsohn
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Maeva Chauvin
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | | | - Laura J Yockey
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.,Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Kaitlyn James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Rosiane Lima
- Mucosal Immunology and Biology Research Center, Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02129, USA
| | - Lael M Yonker
- Mucosal Immunology and Biology Research Center, Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02129, USA
| | - Alessio Fasano
- Mucosal Immunology and Biology Research Center, Department of Pediatrics, Massachusetts General Hospital, Boston, MA 02129, USA.,European Biomedical Research Institute of Salerno (EBRIS), Salerno, Italy
| | - Sara Brigida
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.,Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - David Pépin
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jun R Huh
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA 02115, USA.,Evergrande Center for Immunologic Diseases, Harvard Medical School and Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Staci D Bilbo
- Department of Pediatrics, Lurie Center for Autism, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA.,Department of Psychology and Neuroscience, Duke University, Durham, NC 27708, USA
| | - Jonathan Z Li
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Anjali Kaimal
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Danny J Schust
- Department of Obstetrics, Gynecology, and Women's Health, University of Missouri, Columbia, MO 65201, USA
| | - Kathryn J Gray
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Douglas Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Andrea G Edlow
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.,Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA 02114, USA
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22
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Elshaboury RH, Monk MM, Bebell LM, Bidell MR, Adamsick ML, Gandhi RG, Paras ML, Hohmann EL, Letourneau AR. Remdesivir use and outcomes during the FDA COVID-19 emergency use authorization period. Ther Adv Infect Dis 2021; 8:20499361211046669. [PMID: 34589214 PMCID: PMC8474339 DOI: 10.1177/20499361211046669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/29/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Remdesivir (RDV) was approved for treatment of coronavirus disease 2019
(COVID-19), in May 2020 under US Food and Drug Administration emergency use
authorization (EUA). Clinical outcomes related to RDV use in hospitalized
patients during the EUA period are not well described. Methods: We conducted a retrospective study of patients who received RDV under EUA.
The primary outcome was clinical recovery by day 14 as determined by an
eight-category ordinal scale. Secondary outcomes included recovery and
survival to day 28, and adverse events. Recovery and survival were
calculated using a stratified log-rank Kaplan–Meier estimator and a Cox
proportional hazards model. Results: Overall, 164 patients received RDV between May and October 2020, and 153
(93.3%) had evaluable data. Most (77.1%) were hospitalized within 10 days of
symptom onset, and 79.7% started RDV within 48 hours. By days 14 and 28, 96
(62.7%) and 117 patients (76.5%) met the definition of clinical recovery,
respectively. Median time to recovery was 6 days [interquartile range (IQR)
4–12]. Mortality rates were 6.5% and 11.8% by days 14 and 28, respectively.
Age and time to start of RDV after hospital admission were predictive of
recovery and 28-day mortality. Conclusions: In this real-world experience, outcomes after 5 days of RDV therapy were
comparable to those of clinical trials. Disease severity, age, and
dexamethasone use influenced clinical outcomes. Time to RDV initiation
appeared to affect recovery and 28-day mortality, a finding that should be
explored further. Mortality rate decreased over the analysis period, which
could be related to dexamethasone use and improved management of
COVID-19.
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Affiliation(s)
- Ramy H Elshaboury
- Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street GRB-005B, Boston, MA 02114, USA
| | - Miranda M Monk
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Lisa M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Monique R Bidell
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Meagan L Adamsick
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Ronak G Gandhi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Molly L Paras
- Anti-infective Stewardship Program, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth L Hohmann
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Alyssa R Letourneau
- Anti-infective Stewardship Program, Massachusetts General Hospital, 55 Fruit Street, Division of Infectious Diseases, Cox 5, Boston, MA 02114, USA
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23
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Maswime S, Pule C, Bebell LM, Hedt-Gauthier B, Chandiwana N, Haberer JE, Pattinson R. Stillbirth rate by maternal HIV serostatus and antiretroviral use in pregnancy in South Africa: An audit. S Afr Med J 2021; 111:822-823. [PMID: 34949244 PMCID: PMC8713459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- S Maswime
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa
| | - C Pule
- Global Surgery Division, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa
| | - L M Bebell
- Massachusetts General Hospital Center for Global Health, USA; Harvard Medical School, USA
| | - B Hedt-Gauthier
- Massachusetts General Hospital Center for Global Health, USA; Harvard Medical School, USA
| | - N Chandiwana
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - J E Haberer
- Massachusetts General Hospital Center for Global Health, USA; Harvard Medical School, USA
| | - R Pattinson
- South African Medical Research Council/University of Pretoria Maternal and Infant Health Care Strategies Extramural Unit, South Africa
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24
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Gray KJ, Bordt EA, Atyeo C, Deriso E, Akinwunmi B, Young N, Baez AM, Shook LL, Cvrk D, James K, De Guzman R, Brigida S, Diouf K, Goldfarb I, Bebell LM, Yonker LM, Fasano A, Rabi SA, Elovitz MA, Alter G, Edlow AG. Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol 2021; 225:303.e1-303.e17. [PMID: 33775692 PMCID: PMC7997025 DOI: 10.1016/j.ajog.2021.03.023] [Citation(s) in RCA: 373] [Impact Index Per Article: 124.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pregnant and lactating women were excluded from initial coronavirus disease 2019 vaccine trials; thus, data to guide vaccine decision making are lacking. OBJECTIVE This study aimed to evaluate the immunogenicity and reactogenicity of coronavirus disease 2019 messenger RNA vaccination in pregnant and lactating women compared with: (1) nonpregnant controls and (2) natural coronavirus disease 2019 infection in pregnancy. STUDY DESIGN A total of 131 reproductive-age vaccine recipients (84 pregnant, 31 lactating, and 16 nonpregnant women) were enrolled in a prospective cohort study at 2 academic medical centers. Titers of severe acute respiratory syndrome coronavirus 2 spike and receptor-binding domain immunoglobulin G, immunoglobulin A, and immunoglobulin M were quantified in participant sera (n=131) and breastmilk (n=31) at baseline, at the second vaccine dose, at 2 to 6 weeks after the second vaccine, and at delivery by Luminex. Umbilical cord sera (n=10) titers were assessed at delivery. Titers were compared with those of pregnant women 4 to 12 weeks from the natural infection (n=37) by enzyme-linked immunosorbent assay. A pseudovirus neutralization assay was used to quantify neutralizing antibody titers for the subset of women who delivered during the study period. Postvaccination symptoms were assessed via questionnaire. Kruskal-Wallis tests and a mixed-effects model, with correction for multiple comparisons, were used to assess differences among groups. RESULTS Vaccine-induced antibody titers were equivalent in pregnant and lactating compared with nonpregnant women (pregnant, median, 5.59; interquartile range, 4.68-5.89; lactating, median, 5.74; interquartile range, 5.06-6.22; nonpregnant, median, 5.62; interquartile range, 4.77-5.98, P=.24). All titers were significantly higher than those induced by severe acute respiratory syndrome coronavirus 2 infection during pregnancy (P<.0001). Vaccine-generated antibodies were present in all umbilical cord blood and breastmilk samples. Neutralizing antibody titers were lower in umbilical cord than maternal sera, although this finding did not achieve statistical significance (maternal sera, median, 104.7; interquartile range, 61.2-188.2; cord sera, median, 52.3; interquartile range, 11.7-69.6; P=.05). The second vaccine dose (boost dose) increased severe acute respiratory syndrome coronavirus 2-specific immunoglobulin G, but not immunoglobulin A, in maternal blood and breastmilk. No differences were noted in reactogenicity across the groups. CONCLUSION Coronavirus disease 2019 messenger RNA vaccines generated robust humoral immunity in pregnant and lactating women, with immunogenicity and reactogenicity similar to that observed in nonpregnant women. Vaccine-induced immune responses were statistically significantly greater than the response to natural infection. Immune transfer to neonates occurred via placenta and breastmilk.
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Affiliation(s)
- Kathryn J Gray
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Evan A Bordt
- Lurie Center for Autism, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Caroline Atyeo
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA; PhD Program in Virology, Division of Medical Sciences, Graduate School of Arts & Sciences, Harvard University, Boston, MA
| | | | - Babatunde Akinwunmi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nicola Young
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aranxta Medina Baez
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lydia L Shook
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA
| | - Dana Cvrk
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kaitlyn James
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Rose De Guzman
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sara Brigida
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Khady Diouf
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ilona Goldfarb
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lisa M Bebell
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; MGH Center for Global Health, and Harvard Medical School, Boston, MA
| | - Lael M Yonker
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA; Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alessio Fasano
- Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA; Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - S Alireza Rabi
- Department of Cardiothoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michal A Elovitz
- Maternal and Child Health Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA.
| | - Andrea G Edlow
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA.
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25
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Ngonzi J, Bebell LM, Boatin AA, Owaraganise A, Tiibajuka L, Fajardo Y, Lugobe HM, Wylie BJ, Jacquemyn Y, Obua C, Haberer JE, Geertruyden JPV. Impact of an educational intervention on WHO surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda. Int J Qual Health Care 2021; 33:6352323. [PMID: 34390247 DOI: 10.1093/intqhc/mzab089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/31/2021] [Accepted: 06/05/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The World Health Organization (WHO) recommends adherence to its surgical safety checklist (SSC) to optimize patient safety and reduce cesarean surgical site infection (SSI). Educational interventions combined with audit and feedback mechanisms on the checklist use by clinicians have the potential to improve adherence and clinical outcomes. Despite the increase in cesarean delivery rates, there is a paucity of data on how such interventions can improve adherence in resource-limited settings. OBJECTIVE We performed a quality improvement project to measure the impact of an educational intervention with daily audit and feedback procedures on rates of WHO SSC adherence, including pre-operative antibiotic administration and SSI at Mbarara Regional Referral Hospital maternity ward in Uganda. METHODS The study involved chart abstraction of WHO SSC and pre-operative antibiotic use during cesarean deliveries and signs of subsequent SSI in three phases. First, we conducted a retrospective review of all charts from May to June 2018 (pre-intervention phase). Second, we instituted an educational intervention on the WHO SSC and pre-operative antibiotics use, followed by a daily audit of charts and feedback to clinicians from July to August 2018 (the intervention phase). Third, we reviewed charts from September to October 2018 (the post-intervention phase). The WHO SSC adherence, pre-operative antibiotic administration and SSI rates were measured as the proportion of the total cesarean deliveries per study phase and then compared across the three phases. RESULTS We reviewed 678 patients' charts (200 in the pre-intervention phase, 230 in the intervention phase and 248 in the post-intervention phase). The mean patient age was 25 years. The use of the WHO SSC was 7% in the pre-intervention phase compared to 92% in the intervention phase (P < 0.001), and 77% in the post-intervention phase (P < 0.001). Pre-intervention antibiotic receipt was 18% compared to 90% in the intervention phase (P < 0.001) and 84% in the post-intervention phase (P < 0.001). The documented SSI rate in the pre-intervention phase was 15% compared to 7% in the intervention phase (P = 0.02) and 11% in the post-intervention phase (P = 0.20). CONCLUSIONS An educational intervention, daily audit and feedback to clinicians increased the use of the WHO SSC and prophylactic antibiotics for cesarean delivery-although the rates waned with time. Research to understand factors influencing the checklist use and antibiotic prophylaxis including prescriber knowledge, motivation and clinical process is required. Implementation interventions to sustain usage and impact on clinical outcomes need to be explored.
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Affiliation(s)
- Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda +256
| | - Lisa M Bebell
- Massachusetts General Hospital and Harvard Medical School, 125 Nashua St, Suite 722, Boston, MA 02114, USA
| | - Adline A Boatin
- Massachusetts General Hospital and Harvard Medical School, 125 Nashua St, Suite 722, Boston, MA 02114, USA
| | - Aspihas Owaraganise
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda +256
| | - Leevan Tiibajuka
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda +256
| | - Yarine Fajardo
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda +256
| | - Henry Mark Lugobe
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O BOX 1410, Mbarara, Uganda +256
| | - Blair J Wylie
- Massachusetts General Hospital and Harvard Medical School, 125 Nashua St, Suite 722, Boston, MA 02114, USA
| | - Yves Jacquemyn
- Global Health Institute, University of Antwerp, Wilrijkstraat 10; 2650 Edegem, Antwerp, Belgium
| | - Celestino Obua
- Mbarara University of Science and Technology, P.O BOX 1410, Mbarara +256, Uganda
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, 125 Nashua St, Suite 722, Boston, MA 02114, USA
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26
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Bebell LM, Zash R. Editorial: Viral infections at the maternal-fetal interface - setting the research agenda. J Infect Dis 2021; 224:S629-S630. [PMID: 34293151 DOI: 10.1093/infdis/jiab356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lisa M Bebell
- Massachusetts General Hospital Division of Infectious Diseases and Medical Practice Evaluation Center; Harvard Medical School
| | - Rebecca Zash
- Beth Israel Deaconess Medical Center Division of Infectious Diseases, Harvard Medical School
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27
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Fai KN, Corine TM, Bebell LM, Mboringong AB, Nguimbis EBPT, Nsaibirni R, Mbarga NF, Eteki L, Nikolay B, Essomba RG, Ndifon M, Ntone R, Hamadou A, Matchim L, Tchiasso D, Abah Abah AS, Essaka R, Peppa S, Crescence F, Ouamba JP, Koku MT, Mandeng N, Fanne M, Eyangoh S, Mballa GAE, Esso L, Epée E, Njouom R, Okomo Assoumou MC, Boum Y. Serologic response to SARS-CoV-2 in an African population. Sci Afr 2021; 12:e00802. [PMID: 34095639 PMCID: PMC8164732 DOI: 10.1016/j.sciaf.2021.e00802] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/15/2021] [Accepted: 05/02/2021] [Indexed: 01/04/2023] Open
Abstract
Official case counts suggest Africa has not seen the expected burden of COVID-19 as predicted by international health agencies, and the proportion of asymptomatic patients, disease severity, and mortality burden differ significantly in Africa from what has been observed elsewhere. Testing for SARS-CoV-2 was extremely limited early in the pandemic and likely led to under-reporting of cases leaving important gaps in our understanding of transmission and disease characteristics in the African context. SARS-CoV-2 antibody prevalence and serologic response data could help quantify the burden of COVID-19 disease in Africa to address this knowledge gap and guide future outbreak response, adapted to the local context. However, such data are widely lacking in Africa. We conducted a cross-sectional seroprevalence survey among 1,192 individuals seeking COVID-19 screening and testing in central Cameroon using the Innovita antibody-based rapid diagnostic. Overall immunoglobulin prevalence was 32%, IgM prevalence was 20%, and IgG prevalence was 24%. IgM positivity gradually increased, peaking around symptom day 20. IgG positivity was similar, gradually increasing over the first 10 days of symptoms, then increasing rapidly to 30 days and beyond. These findings highlight the importance of diagnostic testing and asymptomatic SARS-CoV-2 transmission in Cameroon, which likely resulted in artificially low case counts. Rapid antibody tests are a useful diagnostic modality for seroprevalence surveys and infection diagnosis starting 5-7 days after symptom onset. These results represent the first step towards better understanding the SARS-CoV-2 immunological response in African populations.
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Affiliation(s)
| | | | - Lisa M Bebell
- Massachussetts General Hospital, Boston, United States
| | | | | | | | | | | | | | - Rene Ghislain Essomba
- National Public Health Laboratory, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Cameroon
| | | | | | - Achta Hamadou
- Public Health Emergency Operation Center, Ministry of Health, Yaoundé, Cameroon
| | | | | | | | | | - Solange Peppa
- National Public Health Laboratory, Yaoundé, Cameroon
| | | | | | | | - Nadia Mandeng
- Public Health Emergency Operation Center, Ministry of Health, Yaoundé, Cameroon
| | - Mahamat Fanne
- Public Health Emergency Operation Center, Ministry of Health, Yaoundé, Cameroon
| | | | | | - Linda Esso
- Public Health Emergency Operation Center, Ministry of Health, Yaoundé, Cameroon
| | - Emilienne Epée
- Public Health Emergency Operation Center, Ministry of Health, Yaoundé, Cameroon
| | | | - Marie-Claire Okomo Assoumou
- National Public Health Laboratory, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Cameroon
| | - Yap Boum
- Epicentre, Yaoundé, Cameroon
- Public Health Emergency Operation Center, Ministry of Health, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Cameroon
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28
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Paulson JN, Williams BL, Hehnly C, Mishra N, Sinnar SA, Zhang L, Ssentongo P, Mbabazi-Kabachelor E, Wijetunge DSS, von Bredow B, Mulondo R, Kiwanuka J, Bajunirwe F, Bazira J, Bebell LM, Burgoine K, Couto-Rodriguez M, Ericson JE, Erickson T, Ferrari M, Gladstone M, Guo C, Haran M, Hornig M, Isaacs AM, Kaaya BN, Kangere SM, Kulkarni AV, Kumbakumba E, Li X, Limbrick DD, Magombe J, Morton SU, Mugamba J, Ng J, Olupot-Olupot P, Onen J, Peterson MR, Roy F, Sheldon K, Townsend R, Weeks AD, Whalen AJ, Quackenbush J, Ssenyonga P, Galperin MY, Almeida M, Atkins H, Warf BC, Lipkin WI, Broach JR, Schiff SJ. Paenibacillus infection with frequent viral coinfection contributes to postinfectious hydrocephalus in Ugandan infants. Sci Transl Med 2021; 12:12/563/eaba0565. [PMID: 32998967 DOI: 10.1126/scitranslmed.aba0565] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 05/06/2020] [Indexed: 12/14/2022]
Abstract
Postinfectious hydrocephalus (PIH), which often follows neonatal sepsis, is the most common cause of pediatric hydrocephalus worldwide, yet the microbial pathogens underlying this disease remain to be elucidated. Characterization of the microbial agents causing PIH would enable a shift from surgical palliation of cerebrospinal fluid (CSF) accumulation to prevention of the disease. Here, we examined blood and CSF samples collected from 100 consecutive infant cases of PIH and control cases comprising infants with non-postinfectious hydrocephalus in Uganda. Genomic sequencing of samples was undertaken to test for bacterial, fungal, and parasitic DNA; DNA and RNA sequencing was used to identify viruses; and bacterial culture recovery was used to identify potential causative organisms. We found that infection with the bacterium Paenibacillus, together with frequent cytomegalovirus (CMV) coinfection, was associated with PIH in our infant cohort. Assembly of the genome of a facultative anaerobic bacterial isolate recovered from cultures of CSF samples from PIH cases identified a strain of Paenibacillus thiaminolyticus This strain, designated Mbale, was lethal when injected into mice in contrast to the benign reference Paenibacillus strain. These findings show that an unbiased pan-microbial approach enabled characterization of Paenibacillus in CSF samples from PIH cases, and point toward a pathway of more optimal treatment and prevention for PIH and other proximate neonatal infections.
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Affiliation(s)
- Joseph N Paulson
- Department of Biostatistics, Product Development, Genentech Inc., South San Francisco, CA 94080, USA
| | - Brent L Williams
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - Christine Hehnly
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Nischay Mishra
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - Shamim A Sinnar
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA.,Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Lijun Zhang
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Paddy Ssentongo
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA.,Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA 16802, USA.,Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | | | - Dona S S Wijetunge
- Department of Pathology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Benjamin von Bredow
- Department of Pathology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Ronnie Mulondo
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Julius Kiwanuka
- Department of Pediatrics, Mbarara University of Science and Technology, P.O. Box 1410 Mbarara, Uganda
| | - Francis Bajunirwe
- Department of Epidemiology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, P.O. Box 1410 Mbarara, Uganda
| | - Lisa M Bebell
- Division of Infectious Disease, Massachusetts Genereal Hospital, Harvard Medical School, 55 Fruit St, GRJ-504, Boston, MA 02114, USA
| | - Kathy Burgoine
- Neonatal Unit, Department of Paediatrics and Child Health, Mbale Regional Referral Hospital, Plot 29-33 Pallisa Road, P.O. Box 1966, Mbale, Uganda.,Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Plot 29-33 Pallisa Road, P.O. Box 1966 Mbale, Uganda.,University of Liverpool, Liverpool, L69 3BX, UK
| | - Mara Couto-Rodriguez
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Biotia, 100 6th avenue, New York, NY 10013, USA
| | - Jessica E Ericson
- Division of Pediatric Infectious Disease, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Tim Erickson
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Matthew Ferrari
- Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA 16802, USA.,Department of Biology, Pennsylvania State University, University Park, PA 16802, USA.,Department of Statistics, Pennsylvania State University, University Park, PA 16802, USA
| | - Melissa Gladstone
- Institute for Translational Medicine, University of Liverpool, Liverpool, L12 2AP, UK
| | - Cheng Guo
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Murali Haran
- Department of Statistics, Pennsylvania State University, University Park, PA 16802, USA
| | - Mady Hornig
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - Albert M Isaacs
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO 63130, USA
| | - Brian Nsubuga Kaaya
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Sheila M Kangere
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, M5G 1X8, Canada
| | - Elias Kumbakumba
- Department of Pediatrics, Mbarara University of Science and Technology, P.O. Box 1410 Mbarara, Uganda
| | - Xiaoxiao Li
- Institute for Translational Medicine, University of Liverpool, Liverpool, L12 2AP, UK
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO 63130, USA
| | - Joshua Magombe
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston MA 02115, USA
| | - John Mugamba
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - James Ng
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale Regional Referral Hospital, Plot 29-33 Pallisa Road, P.O. Box 1966 Mbale, Uganda.,Busitema University, Mbale Campus, Plot 29-33 Pallisa Road, P.O. Box 1966, Mbale, Uganda
| | - Justin Onen
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Mallory R Peterson
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA.,Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA 16802, USA
| | - Farrah Roy
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Kathryn Sheldon
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Reid Townsend
- Department of Medicine, Washington University School of Medicine , St. Louis, MO 63130, USA
| | - Andrew D Weeks
- Sanyu Research Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool L8 7SS, UK
| | - Andrew J Whalen
- Department of Mechanical Engineering, Pennsylvania State University, University Park, PA 16802, USA
| | - John Quackenbush
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Peter Ssenyonga
- CURE Children's Hospital of Uganda, Plot 97-105, Bugwere Road, P.O. Box 903 Mbale, Uganda
| | - Michael Y Galperin
- National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, MD 20894, USA
| | - Mathieu Almeida
- Université Paris-Saclay, INRAE, MGP, Jouy-en-Josas, 78350, France
| | - Hannah Atkins
- Department of Comparative Medicine, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - W Ian Lipkin
- Center for Infection and Immunity, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
| | - James R Broach
- Institute for Personalized Medicine, Department of Biochemistry and Molecular Biology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Steven J Schiff
- Center for Neural Engineering, Pennsylvania State University, University Park, PA 16802, USA. .,Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA 16802, USA.,Center for Infectious Disease Dynamics, Pennsylvania State University, University Park, PA 16802, USA.,Department of Neurosurgery, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.,Department of Physics, Pennsylvania State University, University Park, PA 16802, USA
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29
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Bowder AN, Yen CF, Bebell LM, Fernandes AR. Intravenous cephalosporin versus non-cephalosporin-based prophylaxis to prevent surgical site infections in colorectal surgery patients: A systematic review and meta-analysis. Ann Med Surg (Lond) 2021; 67:102401. [PMID: 34257956 PMCID: PMC8256185 DOI: 10.1016/j.amsu.2021.102401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Surgical site infection (SSI) is common in colorectal surgery patients and associated with morbidity and mortality. Guidelines recommend preoperative intravenous antimicrobial prophylaxis with aerobic and anaerobic coverage to reduce SSI risk. Cephalosporin based prophylaxis (CBP) regimens are recommended as first-line prophylaxis, and non-cephalosporin based are recommended as alternative prophylaxis (AP). We evaluate the efficacy of CBP versus AP in preventing surgical site infections in colorectal surgery patients. Methods A systematic review and meta-analysis was conducted of studies published between 2005 and 2020 in MEDLINE and Web of Science. Studies were excluded if intravenous antimicrobial prophylaxis was not administered, or if oral and intravenous prophylaxis were routinely co-administered. Heterogeneity was reported using the Q-statistic and I2-statistic. Publication bias was evaluated using a funnel plot and Egger test for small study effects. Statistical significance was defined as a two-sided p < 0.05. Results 11 studies met inclusion criteria. AP was not associated with increased SSI risk at 30 days compared to CBP (OR 1.01, 95% CI 0.91, 1.13; OR < 1 favors AP). There was no effect size variability in subgroup analysis comparing higher-to lower-quality studies (I2 = 99%, P = 0.17). Subgroup analysis by publication year approached a significant difference in effect size between studies published prior to 2014 and later than 2014 (I2 = 99%, P = 0.06). Conclusions Meta-analysis of 11 studies of SSI risk in adult colorectal surgery patients suggest that SSI risk is similar for patients receiving CBP or AP, subgroup analysis of studies published since 2014 suggest increased SSI risk with AP compared to CBP. Meta-Analysis found that surgical site infection risk is similar for patients receiving intravenous cephalosporin based or alternative prophylaxis. Subgroup analysis of studies published since 2014 suggest increased surgical site infection risk with alternative prophylaxis compared to cephalosporin based prophylaxis. RCT’s are needed to evaluate trends in SSI risk in cephalosporin-based prophylaxis compared to alternative prophylaxis.
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Affiliation(s)
- Alexis N. Bowder
- Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI 53226, USA
- Corresponding author. 9200 Watertown Plank, Milwaukee WI, 53222, USA. @abowder
| | - Christina F. Yen
- Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 300 Longwood Ave, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Lisa M. Bebell
- Massachusetts General Hospital, Division of Infectious Diseases, 55 Fruit St, Boston, MA 02114, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Alisha R. Fernandes
- Department of Surgery, Juravinski Hospital and Cancer Center, Hamilton, Ontario, Canada, 699 Concession St, Hamilton, ON L8V 5C2, Canada
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30
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Mandeng N, Fai KN, Bebell LM, Boum Y. Negative antigen RDT and RT-PCR results do not rule out COVID-19 if clinical suspicion is strong - Authors' reply. Lancet Infect Dis 2021; 21:1210. [PMID: 34058129 PMCID: PMC8163293 DOI: 10.1016/s1473-3099(21)00288-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/07/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Nadia Mandeng
- Centre de Coordination des Opérations d'Urgence de Santé Publique, Ministère de la Santé Publique, Yaoundé, Cameroon
| | - Karl Njuwa Fai
- Epicentre, Médecins Sans Frontières, Yaoundé BP 12069, Cameroon
| | - Lisa M Bebell
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Yap Boum
- Epicentre, Médecins Sans Frontières, Yaoundé BP 12069, Cameroon; University of Yaoundé I, Faculty of Medicine, Yaoundé, Cameroon.
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31
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Abstract
We previously demonstrated that the late gestation placental expression pattern of ACE2 (the primary SARS-CoV-2 receptor) is localized to the villous syncytiotrophoblast (ST), usually in a polarized membranous pattern at the ST base sparing the apical surface (that directly exposed to maternal blood). We found that the late gestation placental expression pattern of TMPRSS2 (the spike proteinase required for SARS-CoV-2 cellular infection), is usually absent in the trophoblast but rarely, weakly expressed in the placental endothelium. We now show the developmental protein expression patterns of ACE2 and TMPRSS2 by immunohistochemistry throughout gestation, from first through third trimester. We found TMPRSS2 expression was rarely detectable in villous endothelium and very rarely detectable in the ST across gestation. We found ACE2 expression varied during gestation with circumferential ST expression more common in early gestations and polarized expression more common in later gestation. Although this study is small, these preliminary results suggest that earlier gestation pregnancies may be more vulnerable to infection than later gestation pregnancies.
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Affiliation(s)
| | - Lisa M Bebell
- Department of Medicine, Division of Infectious Diseases, Medical Practice Evaluation Center, and Global Health Collaborative, Massachusetts General Hospital, Boston MA
| | - Andrea G Edlow
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, Massachusetts General Hospital, Boston MA
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32
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Bebell LM, Parks K, Le MH, Ngonzi J, Adong J, Boatin AA, Bassett IV, Siedner MJ, Gernand AD, Roberts DJ. Placental decidual arteriopathy and vascular endothelial growth factor A (VEGF-A) expression among women with and without HIV. J Infect Dis 2021; 224:S694-S700. [PMID: 33880547 DOI: 10.1093/infdis/jiab201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Women with HIV (WHIV) are at higher risk of adverse birth outcomes. Proposed mechanisms for the increased risk include placental arteriopathy (vasculopathy) and maternal vascular malperfusion (MVM) due to antiretroviral therapy (ART) and medical comorbidities. However, these features and their underlying pathophysiologic mechanisms have not been well characterized in WHIV. METHODS We performed gross and histologic examination and immunohistochemistry staining for vascular endothelial growth factor A (VEGF-A), a key angiogenic factor, on placentas from women with one or more MVM risk factors including: weight <5 th percentile, histologic infarct or distal villous hypoplasia, nevirapine-based ART, hypertension, and pre-eclampsia/eclampsia during pregnancy. We compared pathologic characteristics by maternal HIV serostatus. RESULTS A total of 27/41 (66%) placentas assessed for VEGF-A were from WHIV. Mean maternal age was 27 years. Among WHIV, median CD4 T-cell count was 440 cells/mm 3 and HIV viral load was undetectable in 74%. Of VEGF-A stained placentas, both decidua and villous endothelium tissue layers were present in 36 (88%). VEGF-A was detected in 31/36 (86%) with decidua present, and 39/40 (98%) with villous endothelium present. There were no differences in VEGF-A presence in any tissue type by maternal HIV serostatus (P=0.28-1.0). MVM was more common in placentas selected for VEGF-A staining (51 versus 8%, P<0.001). CONCLUSIONS VEGF-A immunostaining was highly prevalent, and staining pattern did not differ by maternal HIV serostatus among those with MVM risk factors, indicating the role of VEGF-A in placental vasculopathy may not differ by maternal HIV serostatus.
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Affiliation(s)
- Lisa M Bebell
- Massachusetts General Hospital Division of Infectious Diseases, Boston, MA, USA.,MassGeneral Global Health, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Kalynn Parks
- Department of Nutritional Sciences, Pennsylvania State University, University Park, PA, USA
| | - Mylinh H Le
- Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Ngonzi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Julian Adong
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Adeline A Boatin
- MassGeneral Global Health, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Department of Obstetrics and Gynecology, Boston, MA, USA
| | - Ingrid V Bassett
- Massachusetts General Hospital Division of Infectious Diseases, Boston, MA, USA.,Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Mark J Siedner
- Massachusetts General Hospital Division of Infectious Diseases, Boston, MA, USA.,MassGeneral Global Health, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center of Massachusetts General Hospital, Boston, MA, USA
| | - Alison D Gernand
- Department of Nutritional Sciences, Pennsylvania State University, University Park, PA, USA
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Affiliation(s)
- Yap Boum
- Epicentre, Médecins Sans Frontières, Yaoundé BP 12069, Cameroon.
| | - Lisa M Bebell
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Bordt EA, Shook LL, Atyeo C, Pullen KM, De Guzman RM, Meinsohn MC, Chauvin M, Fischinger S, Yockey LJ, James K, Lima R, Yonker LM, Fasano A, Brigida S, Bebell LM, Roberts DJ, Pépin D, Huh JR, Bilbo SD, Li JZ, Kaimal A, Schust D, Gray KJ, Lauffenburger D, Alter G, Edlow AG. Sexually dimorphic placental responses to maternal SARS-CoV-2 infection. bioRxiv 2021:2021.03.29.437516. [PMID: 33821279 PMCID: PMC8020979 DOI: 10.1101/2021.03.29.437516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
There is a persistent male bias in the prevalence and severity of COVID-19 disease. Underlying mechanisms accounting for this sex difference remain incompletely understood. Interferon responses have been implicated as a modulator of disease in adults, and play a key role in the placental anti-viral response. Moreover, the interferon response has been shown to alter Fc-receptor expression, and therefore may impact placental antibody transfer. Here we examined the intersection of viral-induced placental interferon responses, maternal-fetal antibody transfer, and fetal sex. Placental interferon stimulated genes (ISGs), Fc-receptor expression, and SARS-CoV-2 antibody transfer were interrogated in 68 pregnancies. Sexually dimorphic placental expression of ISGs, interleukin-10, and Fc receptors was observed following maternal SARS-CoV-2 infection, with upregulation in males. Reduced maternal SARS-CoV-2-specific antibody titers and impaired placental antibody transfer were noted in pregnancies with a male fetus. These results demonstrate fetal sex-specific maternal and placental adaptive and innate immune responses to SARS-CoV-2.
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35
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Boum Y, Fai KN, Nikolay B, Mboringong AB, Bebell LM, Ndifon M, Abbah A, Essaka R, Eteki L, Luquero F, Langendorf C, Mbarga NF, Essomba RG, Buri BD, Corine TM, Kameni BT, Mandeng N, Fanne M, Bisseck ACZK, Ndongmo CB, Eyangoh S, Hamadou A, Ouamba JP, Koku MT, Njouom R, Claire OM, Esso L, Epée E, Mballa GAE. Performance and operational feasibility of antigen and antibody rapid diagnostic tests for COVID-19 in symptomatic and asymptomatic patients in Cameroon: a clinical, prospective, diagnostic accuracy study. Lancet Infect Dis 2021; 21:1089-1096. [PMID: 33773618 PMCID: PMC7993929 DOI: 10.1016/s1473-3099(21)00132-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/05/2021] [Accepted: 02/19/2021] [Indexed: 12/16/2022]
Abstract
Background Real-time PCR is recommended to detect SARS-CoV-2 infection. However, PCR availability is restricted in most countries. Rapid diagnostic tests are considered acceptable alternatives, but data are lacking on their performance. We assessed the performance of four antibody-based rapid diagnostic tests and one antigen-based rapid diagnostic test for detecting SARS-CoV-2 infection in the community in Cameroon. Methods In this clinical, prospective, diagnostic accuracy study, we enrolled individuals aged at least 21 years who were either symptomatic and suspected of having COVID-19 or asymptomatic and presented for screening. We tested peripheral blood for SARS-CoV-2 antibodies using the Innovita (Biological Technology; Beijing, China), Wondfo (Guangzhou Wondfo Biotech; Guangzhou, China), SD Biosensor (SD Biosensor; Gyeonggi-do, South Korea), and Runkun tests (Runkun Pharmaceutical; Hunan, China), and nasopharyngeal swabs for SARS-CoV-2 antigen using the SD Biosensor test. Antigen rapid diagnostic tests were compared with Abbott PCR testing (Abbott; Abbott Park, IL, USA), and antibody rapid diagnostic tests were compared with Biomerieux immunoassays (Biomerieux; Marcy l'Etoile, France). We retrospectively tested two diagnostic algorithms that incorporated rapid diagnostic tests for symptomatic and asymptomatic patients using simulation modelling. Findings 1195 participants were enrolled in the study. 347 (29%) tested SARS-CoV-2 PCR-positive, 223 (19%) rapid diagnostic test antigen-positive, and 478 (40%) rapid diagnostic test antibody-positive. Antigen-based rapid diagnostic test sensitivity was 80·0% (95% CI 71·0–88·0) in the first 7 days after symptom onset, but antibody-based rapid diagnostic tests had only 26·8% sensitivity (18·3–36·8). Antibody rapid diagnostic test sensitivity increased to 76·4% (70·1–82·0) 14 days after symptom onset. Among asymptomatic participants, the sensitivity of antigen-based and antibody-based rapid diagnostic tests were 37·0% (27·0–48·0) and 50·7% (42·2–59·1), respectively. Cohen's κ showed substantial agreement between Wondfo antibody rapid diagnostic test and gold-standard ELISA (κ=0·76; sensitivity 0·98) and between Biosensor and ELISA (κ=0·60; sensitivity 0·94). Innovita (κ=0·47; sensitivity 0·93) and Runkun (κ=0·43; sensitivity 0·76) showed moderate agreement. An antigen-based retrospective algorithm applied to symptomatic patients showed 94·0% sensitivity and 91·0% specificity in the first 7 days after symptom onset. For asymptomatic participants, the algorithm showed a sensitivity of 34% (95% CI 23·0–44·0) and a specificity of 92·0% (88·0–96·0). Interpretation Rapid diagnostic tests had good overall sensitivity for diagnosing SARS-CoV-2 infection. Rapid diagnostic tests could be incorporated into efficient testing algorithms as an alternative to PCR to decrease diagnostic delays and onward viral transmission. Funding Médecins Sans Frontières WACA and Médecins Sans Frontières OCG. Translations For the French and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Yap Boum
- Epicentre, Yaoundé, Cameroon; Public Health Emergency Operation Center, Ministry of Public Health, Yaoundé, Cameroon.
| | | | | | | | - Lisa M Bebell
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Aristide Abbah
- Public Health Emergency Operation Center, Ministry of Public Health, Yaoundé, Cameroon
| | | | | | | | | | | | | | | | | | | | - Nadia Mandeng
- Public Health Emergency Operation Center, Ministry of Public Health, Yaoundé, Cameroon
| | - Mahamat Fanne
- Public Health Emergency Operation Center, Ministry of Public Health, Yaoundé, Cameroon
| | | | | | | | | | | | | | | | | | - Linda Esso
- Public Health Emergency Operation Center, Ministry of Public Health, Yaoundé, Cameroon
| | - Emilienne Epée
- Public Health Emergency Operation Center, Ministry of Public Health, Yaoundé, Cameroon
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Gray KJ, Bordt EA, Atyeo C, Deriso E, Akinwunmi B, Young N, Baez AM, Shook LL, Cvrk D, James K, De Guzman RM, Brigida S, Diouf K, Goldfarb I, Bebell LM, Yonker LM, Fasano A, Rabi SA, Elovitz MA, Alter G, Edlow AG. COVID-19 vaccine response in pregnant and lactating women: a cohort study. medRxiv 2021. [PMID: 33758889 DOI: 10.1101/2021.03.07.21253094] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Pregnant and lactating women were excluded from initial COVID-19 vaccine trials; thus, data to guide vaccine decision-making are lacking. We sought to evaluate the immunogenicity and reactogenicity of COVID-19 mRNA vaccination in pregnant and lactating women. Methods 131 reproductive-age vaccine recipients (84 pregnant, 31 lactating, and 16 non-pregnant) were enrolled in a prospective cohort study at two academic medical centers. Titers of SARS-CoV-2 Spike and RBD IgG, IgA and IgM were quantified in participant sera (N=131), umbilical cord sera (N=10), and breastmilk (N=31) at baseline, 2nd vaccine dose, 2-6 weeks post 2nd vaccine, and delivery by Luminex, and confirmed by ELISA. Titers were compared to pregnant women 4-12 weeks from native infection (N=37). Post-vaccination symptoms were assessed. Kruskal-Wallis tests and a mixed effects model, with correction for multiple comparisons, were used to assess differences between groups. Results Vaccine-induced immune responses were equivalent in pregnant and lactating vs non-pregnant women. All titers were higher than those induced by SARS-CoV-2 infection during pregnancy. Vaccine-generated antibodies were present in all umbilical cord blood and breastmilk samples. SARS-CoV-2 specific IgG, but not IgA, increased in maternal blood and breastmilk with vaccine boost. No differences were noted in reactogenicity across the groups. Conclusions COVID-19 mRNA vaccines generated robust humoral immunity in pregnant and lactating women, with immunogenicity and reactogenicity similar to that observed in non-pregnant women. Vaccine-induced immune responses were significantly greater than the response to natural infection. Immune transfer to neonates occurred via placental and breastmilk.
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Boatin AA, Ngonzi J, Wylie BJ, Lugobe HM, Bebell LM, Mugyenyi G, Mohamed S, Martinez K, Musinguzi N, Psaros C, Metlay JP, Haberer JE. Wireless versus routine physiologic monitoring after cesarean delivery to reduce maternal morbidity and mortality in a resource-limited setting: protocol of type 2 hybrid effectiveness-implementation study. BMC Pregnancy Childbirth 2021; 21:124. [PMID: 33579213 PMCID: PMC7880025 DOI: 10.1186/s12884-021-03550-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/08/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Women in sub-Saharan Africa have the highest rates of morbidity and mortality during childbirth globally. Despite increases in facility-based childbirth, gaps in quality of care at facilities have limited reductions in maternal deaths. Infrequent physiologic monitoring of women around childbirth is a major gap in care that leads to delays in life-saving interventions for women experiencing complications. METHODS We will conduct a type-2 hybrid effectiveness-implementation study over 12 months to evaluate using a wireless physiologic monitoring system to detect and alert clinicians of abnormal vital signs in women for 24 h after undergoing emergency cesarean delivery at a tertiary care facility in Uganda. We will provide physiologic data (heart rate, respiratory rate, temperature and blood pressure) to clinicians via a smartphone-based application with alert notifications if monitored women develop predefined abnormalities in monitored physiologic signs. We will alternate two-week intervention and control time periods where women and clinicians use the wireless monitoring system during intervention periods and current standard of care (i.e., manual vital sign measurement when clinically indicated) during control periods. Our primary outcome for effectiveness is a composite of severe maternal outcomes per World Health Organization criteria (e.g. death, cardiac arrest, jaundice, shock, prolonged unconsciousness, paralysis, hysterectomy). Secondary outcomes include maternal mortality rate, and case fatality rates for postpartum hemorrhage, hypertensive disorders, and sepsis. We will use the RE-AIM implementation framework to measure implementation metrics of the wireless physiologic system including Reach (proportion of eligible women monitored, length of time women monitored), Efficacy (proportion of women with monitoring according to Uganda Ministry of Health guidelines, number of appropriate alerts sent), Adoption (proportion of clinicians utilizing physiologic data per shift, clinical actions in response to alerts), Implementation (fidelity to monitoring protocol), Maintenance (sustainability of implementation over time). We will also perform in-depth qualitative interviews with up to 30 women and 30 clinicians participating in the study. DISCUSSION This is the first hybrid-effectiveness study of wireless physiologic monitoring in an obstetric population. This study offers insights into use of wireless monitoring systems in low resource-settings, as well as normal and abnormal physiologic parameters among women delivering by cesarean. TRIAL REGISTRATION ClinicalTrials.gov , NCT04060667 . Registered on 08/01/2019.
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Affiliation(s)
- Adeline A Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit Street, Founders 5, Boston, MA, USA.
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, USA.
- Program for Global Surgery and Social Change, Boston, USA.
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Blair J Wylie
- Harvard Medical School, Boston, USA
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Henry M Lugobe
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lisa M Bebell
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Godfrey Mugyenyi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sudi Mohamed
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Kenia Martinez
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nicholas Musinguzi
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Christina Psaros
- Harvard Medical School, Boston, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua P Metlay
- Harvard Medical School, Boston, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Atyeo C, Pullen KM, Bordt EA, Fischinger S, Burke J, Michell A, Slein MD, Loos C, Shook LL, Boatin AA, Yockey LJ, Pepin D, Meinsohn MC, Nguyen NMP, Chauvin M, Roberts D, Goldfarb IT, Matute JD, James KE, Yonker LM, Bebell LM, Kaimal AJ, Gray KJ, Lauffenburger D, Edlow AG, Alter G. Compromised SARS-CoV-2-specific placental antibody transfer. Cell 2021; 184:628-642.e10. [PMID: 33476549 PMCID: PMC7755577 DOI: 10.1016/j.cell.2020.12.027] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/16/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023]
Abstract
SARS-CoV-2 infection causes more severe disease in pregnant women compared to age-matched non-pregnant women. Whether maternal infection causes changes in the transfer of immunity to infants remains unclear. Maternal infections have previously been associated with compromised placental antibody transfer, but the mechanism underlying this compromised transfer is not established. Here, we used systems serology to characterize the Fc profile of influenza-, pertussis-, and SARS-CoV-2-specific antibodies transferred across the placenta. Influenza- and pertussis-specific antibodies were actively transferred. However, SARS-CoV-2-specific antibody transfer was significantly reduced compared to influenza- and pertussis-specific antibodies, and cord titers and functional activity were lower than in maternal plasma. This effect was only observed in third-trimester infection. SARS-CoV-2-specific transfer was linked to altered SARS-CoV-2-antibody glycosylation profiles and was partially rescued by infection-induced increases in IgG and increased FCGR3A placental expression. These results point to unexpected compensatory mechanisms to boost immunity in neonates, providing insights for maternal vaccine design.
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Affiliation(s)
- Caroline Atyeo
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA; PhD Program in Virology, Division of Medical Sciences, Harvard University, Boston, MA 02115, USA
| | - Krista M Pullen
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Evan A Bordt
- Department of Pediatrics, Lurie Center for Autism, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Stephanie Fischinger
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA; PhD Program in Immunology and Virology, University of Duisburg-Essen, Essen 47057, Germany
| | - John Burke
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Ashlin Michell
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Matthew D Slein
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Carolin Loos
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA; Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Lydia L Shook
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Adeline A Boatin
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Laura J Yockey
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - David Pepin
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Marie-Charlotte Meinsohn
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Ngoc Minh Phuong Nguyen
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Maeva Chauvin
- Pediatric Surgical Research Laboratories, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Drucilla Roberts
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Ilona T Goldfarb
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Juan D Matute
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Kaitlyn E James
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Lael M Yonker
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Lisa M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, MGH Global Health, and Harvard Medical School, Boston, MA 02114, USA
| | - Anjali J Kaimal
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Kathryn J Gray
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Douglas Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Andrea G Edlow
- Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA; Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA 02114, USA.
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA.
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Bebell LM, Gonzalez RG, Barczak AK, Anahtar MN. Case 1-2021: A 76-Year-Old Woman with Lethargy and Altered Mental Status. N Engl J Med 2021; 384:166-176. [PMID: 33497551 DOI: 10.1056/nejmcpc2027084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lisa M Bebell
- From the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
| | - R Gilberto Gonzalez
- From the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
| | - Amy K Barczak
- From the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
| | - Melis N Anahtar
- From the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Massachusetts General Hospital, and the Departments of Medicine (L.M.B., A.K.B.), Radiology (R.G.G.), and Pathology (M.N.A.), Harvard Medical School - both in Boston
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McDiehl RP, Boatin AA, Mugyenyi GR, Siedner MJ, Riley LE, Ngonzi J, Bebell LM. Antenatal Care Visit Attendance Frequency and Birth Outcomes in Rural Uganda: A Prospective Cohort Study. Matern Child Health J 2020; 25:311-320. [PMID: 33201450 DOI: 10.1007/s10995-020-03023-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Antenatal care (ANC) is designed to improve pregnancy outcomes by providing screening and treatment for preventable and treatable diseases. However, data are lacking on whether ANC affects stillbirth risk. We hypothesized stillbirth risk in Uganda is lower in women attending the recommended ≥ 4 ANC visits compared to those attending ≤ 3. METHODS We performed a secondary analysis of subset of 1,785 women enrolled in a prospective cohort of postpartum infection who presented to a regional referral hospital for delivery. Our primary outcome was documented stillbirth; a secondary composite poor birth outcome included stillbirth, early neonatal death, low birth weight (< 2500 g), and 5-min APGAR score < 7. We performed multivariable logistic regression analyses to identify independent correlates of stillbirth and poor birth outcome. RESULTS Of 1,785 participants, 58 (3%) pregnancies resulted in stillbirth and 198 (11%) had a poor birth outcome. Of 1,236 women attending ≥ 4 ANC visits, 31 (2.5%) had a stillbirth, compared to 27/510 (5.2%) attending ≤ 3. In multivariable analyses controlling for age, parity, distance traveled, referral status to hospital, malaria prophylaxis, and syphilis infection; attending ≥ 4 ANC visits was associated with significantly reduced odds of stillbirth (aOR 0.5, 95% CI 0.3-0.9, P = 0.02) and poor birth outcome (aOR 0.66, 95% CI 0.4-0.96, P = 0.03). Malaria prophylaxis was also independently associated with reduced odds of stillbirth (aOR 0.05, 95% CI 0.2-1.0, P = 0.04). CONCLUSIONS Attending ≥ 4 ANC visits was associated with reduced odds of stillbirth and poor birth outcomes in this Ugandan cohort, which may be related to more comprehensive infection screening, treatment, and prevention services.
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Affiliation(s)
- Rachel P McDiehl
- Emory University School of Medicine Department of Gynecology and Obstetrics, Glenn Building, 4th Floor - 412B, 69 Jesse Hill Jr Drive SE, Atlanta, GA, 30303, USA.
| | - Adeline A Boatin
- Massachusetts General Hospital Department of Obstetrics and Gynecology, 55 Fruit St, Boston, MA, 02114, USA.,Massachusetts General Hospital Center for Global Health, Suite 722, 125 Nashua St, Boston, MA, 02114, USA
| | - Godfrey R Mugyenyi
- Mbarara University of Science and Technology Department of Obstetrics and Gynaecology, P.O. Box 1410, Mbarara, Uganda
| | - Mark J Siedner
- Massachusetts General Hospital Center for Global Health, Suite 722, 125 Nashua St, Boston, MA, 02114, USA.,Massachusetts General Hospital Division of Infectious Diseases and Medical Practice Evaluation Center, 55 Fruit St and 100 Cambridge St, Boston, MA, 02114, USA
| | - Laura E Riley
- Weill Cornell Medical Center Department of Obstetrics and Gynecology, New York, NY, USA
| | - Joseph Ngonzi
- Mbarara University of Science and Technology Department of Obstetrics and Gynaecology, P.O. Box 1410, Mbarara, Uganda
| | - Lisa M Bebell
- Massachusetts General Hospital Center for Global Health, Suite 722, 125 Nashua St, Boston, MA, 02114, USA.,Massachusetts General Hospital Division of Infectious Diseases and Medical Practice Evaluation Center, 55 Fruit St and 100 Cambridge St, Boston, MA, 02114, USA
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Matias WR, Vaidya A, Brigl M, Bebell LM. A Patient with Fever and Dyspnea. N Engl J Med 2020; 383:e111. [PMID: 33211933 DOI: 10.1056/nejmimc2019378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Edelson PK, Cao D, James KE, Ngonzi J, Roberts DJ, Bebell LM, Boatin AA. 364: Maternal anemia is associated with adverse obstetric, neonatal and placental outcomes in Mbarara, Uganda. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Sutherland T, Mpirimbanyi C, Nziyomaze E, Niyomugabo JP, Niyonsenga Z, Muvunyi CM, Mueller A, Bebell LM, Nkubana T, Musoni E, Talmor D, Rickard J, Riviello ED. Widespread antimicrobial resistance among bacterial infections in a Rwandan referral hospital. PLoS One 2019; 14:e0221121. [PMID: 31443107 PMCID: PMC6707788 DOI: 10.1371/journal.pone.0221121] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/30/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Resistance among bacterial infections is increasingly well-documented in high-income countries; however, relatively little is known about bacterial antimicrobial resistance in low-income countries, where the burden of infections is high. METHODS We prospectively screened all adult inpatients at a referral hospital in Rwanda for suspected infection for seven months. Blood, urine, wound and sputum samples were cultured and tested for antibiotic susceptibility. We examined factors associated with resistance and compared hospital outcomes for participants with and without resistant isolates. RESULTS We screened 19,178 patient-days, and enrolled 647 unique participants with suspected infection. We obtained 942 culture specimens, of which 357 were culture-positive specimens. Of these positive specimens, 155 (43.4%) were wound, 83 (23.2%) urine, 64 (17.9%) blood, and 55 (15.4%) sputum. Gram-negative bacteria comprised 323 (88.7%) of all isolates. Of 241 Gram-negative isolates tested for ceftriaxone, 183 (75.9%) were resistant. Of 92 Gram-negative isolates tested for the extended spectrum beta-lactamase (ESBL) positive phenotype, 66 (71.7%) were ESBL positive phenotype. Transfer from another facility, recent surgery or antibiotic exposure, and hospital-acquired infection were each associated with resistance. Mortality was 19.6% for all enrolled participants. CONCLUSIONS This is the first published prospective hospital-wide antibiogram of multiple specimen types from East Africa with ESBL testing. Our study suggests that low-resource settings with limited and inconsistent access to the full range of antibiotic classes may bear the highest burden of resistant infections. Hospital-acquired infections and recent antibiotic exposure are associated with a high proportion of resistant infections. Efforts to slow the development of resistance and supply effective antibiotics are urgently needed.
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Affiliation(s)
- Tori Sutherland
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, United States of America
| | - Christophe Mpirimbanyi
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Elie Nziyomaze
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Jean-Paul Niyomugabo
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Zack Niyonsenga
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Claude Mambo Muvunyi
- Department of Clinical Biology, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, United States of America
| | - Lisa M. Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, MGH Global Health, and Harvard Medical School, Boston, United States of America
| | - Theoneste Nkubana
- Department of Pathology, Kigali University Teaching Hospital, Kigali, Rwanda
| | - Emile Musoni
- Department of Clinical Biology, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, United States of America
| | - Jennifer Rickard
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
- Department of Surgery, University of Minnesota, Minneapolis, United States of America
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States of America
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Ayebare A, Bebell LM, Bazira J, Ttendo S, Katawera V, Bangsberg DR, Siedner MJ, Firth PG, Boum Ii Y. Comparative assessment of methicillin resistant Staphylococcus aureus diagnostic assays for use in resource-limited settings. BMC Microbiol 2019; 19:194. [PMID: 31438852 PMCID: PMC6704615 DOI: 10.1186/s12866-019-1566-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 08/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rise of methicillin-resistant Staphylococcus aureus (MRSA) is a global health concern. Paucity of data on MRSA carriage prevalence and diagnostic methods in resource-limited settings hampers efforts to define the problem and plan an appropriate response. Additionally, high variability in cost and logistical characteristics of MRSA screening methods may impede infection control efforts. We compared the performance of locally-available chromogenic agar BD CHROMagar MRSA II and two PCR-based assays (Hain GenoQuick MRSA and Cepheid Xpert SA Complete) for the detection of asymptomatic MRSA carriage in nasal swabs. RESULTS During 2015, we enrolled 500 patients from five hospital wards at a Ugandan regional referral hospital. We found 30% prevalence of methicillin-sensitive Staphylococcus aureus (MSSA) nasal carriage, and 5.4% MRSA nasal carriage prevalence. Compared to a composite reference standard defined as a positive test result on any one of the three assays, Hain GenoQuick MRSA demonstrated the highest sensitivity (96%) followed by direct plating on CHROMagar at (70%), with the lowest sensitivity observed with Xpert SA Complete (52%). Cepheid Xpert provided the most rapid results (< 1 h) but was the most expensive (US $45-50/test). Substantially more labor was required for the Hain GenoQuick MRSA compared to Xpert SA Complete or CHROMagar tests. CONCLUSION MRSA nasal carriage prevalence rates were low, and high diagnostic sensitivity was achieved using Hain GenoQuick MRSA. Chromogenic media had significantly lower sensitivity, but may represent a viable local option given its lower cost compared to PCR-based assays.
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Affiliation(s)
- A Ayebare
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. .,Epicentre Mbarara Research Centre, Mbarara, Uganda.
| | - L M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - J Bazira
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - S Ttendo
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - V Katawera
- World Health Organization, Monrovia, Liberia
| | - D R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - M J Siedner
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - P G Firth
- Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA
| | - Y Boum Ii
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. .,Epicentre Mbarara Research Centre, Mbarara, Uganda.
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Ngonzi J, Bebell LM, Fajardo Y, Boatin AA, Siedner MJ, Bassett IV, Jacquemyn Y, Van Geertruyden JP, Kabakyenga J, Wylie BJ, Bangsberg DR, Riley LE. Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda. BMC Pregnancy Childbirth 2018; 18:270. [PMID: 29954356 PMCID: PMC6022296 DOI: 10.1186/s12884-018-1891-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 06/11/2018] [Indexed: 11/17/2022] Open
Abstract
Background There is a paucity of recent prospective data on the incidence of postpartum infections and associated risk factors in sub-Saharan Africa. Retrospective studies estimate that puerperal sepsis causes approximately 10% of maternal deaths in Africa. Methods We enrolled 4231 women presenting to a Ugandan regional referral hospital for delivery or postpartum care into a prospective cohort and measured vital signs postpartum. Women developing fever (> 38.0 °C) or hypothermia (< 36.0 °C) underwent symptom questionnaire, structured physical exam, malaria testing, blood, and urine cultures. Demographic, treatment, and post-discharge outcomes data were collected from febrile/hypothermic women and a random sample of 1708 normothermic women. The primary outcome was in-hospital postpartum infection. Multivariable logistic regression was used to determine factors independently associated with postpartum fever/hypothermia and with confirmed infection. Results Overall, 4176/4231 (99%) had ≥1 temperature measured and 205/4231 (5%) were febrile or hypothermic. An additional 1708 normothermic women were randomly selected for additional data collection, for a total sample size of 1913 participants, 1730 (90%) of whom had complete data. The mean age was 25 years, 214 (12%) were HIV-infected, 874 (51%) delivered by cesarean and 662 (38%) were primigravidae. Among febrile/hypothermic participants, 174/205 (85%) underwent full clinical and microbiological evaluation for infection, and an additional 24 (12%) had a partial evaluation. Overall, 84/4231 (2%) of participants met criteria for one or more in-hospital postpartum infections. Endometritis was the most common, identified in 76/193 (39%) of women evaluated clinically. Twenty-five of 175 (14%) participants with urinalysis and urine culture results met criteria for urinary tract infection. Bloodstream infection was diagnosed in 5/185 (3%) participants with blood culture results. Another 5/186 (3%) tested positive for malaria. Cesarean delivery was independently associated with incident, in-hospital postpartum infection (aOR 3.9, 95% CI 1.5–10.3, P = 0.006), while antenatal clinic attendance was associated with reduced odds (aOR 0.4, 95% CI 0.2–0.9, P = 0.02). There was no difference in in-hospital maternal deaths between the febrile/hypothermic (1, 0.5%) and normothermic groups (0, P = 0.11). Conclusions Among rural Ugandan women, postpartum infection incidence was low overall, and cesarean delivery was independently associated with postpartum infection while antenatal clinic attendance was protective.
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Affiliation(s)
- Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.
| | - Lisa M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Yarine Fajardo
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Adeline A Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Mark J Siedner
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Yves Jacquemyn
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | | | - Jerome Kabakyenga
- Institute of Maternal Newborn and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Blair J Wylie
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Laura E Riley
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
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Bebell LM, Oduyebo T, Riley LE. Ebola virus disease and pregnancy: A review of the current knowledge of Ebola virus pathogenesis, maternal, and neonatal outcomes. Birth Defects Res 2018; 109:353-362. [PMID: 28398679 DOI: 10.1002/bdra.23558] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/30/2016] [Accepted: 07/28/2016] [Indexed: 11/09/2022]
Abstract
The 2014 to 2016 Ebola virus disease (EVD) outbreak in West Africa devastated local health systems and caused thousands of deaths. Historical reports from Zaire ebolavirus outbreaks suggested pregnancy was associated with an increased risk of severe illness and death, with mortality rates from 74 to 100%. In total, 111 cases of pregnant patients with EVD are reported in the literature, with an aggregate maternal mortality of 86%. Pregnancy-specific data published from the recent outbreak include four small descriptive cohort studies and five case reports. Despite limitations including reporting bias and small sample size, these studies suggest mortality in pregnant women may be lower than previously reported, with five of 13 (39%) infected women dying. Optimal treatments for pregnant women, and differences in EVD course between pregnant women and nonpregnant individuals, are major scientific gaps that have not yet been systematically addressed. Ebola virus may be transmitted from mother to baby in utero, during delivery, or through contact with maternal body fluids after birth including breast milk. EVD is almost universally fatal to the developing fetus, and limited fetal autopsy data prevent inferences on risk of birth defects. Decisions about delivery mode and other obstetric interventions should be individualized. WHO recommends close monitoring of survivors who later become pregnant, but does not recommend enhanced precautions at subsequent delivery. Although sexual transmission of Ebola virus has been documented, birth outcomes among survivors have not been published and will be important to appropriately counsel women on pregnancy outcomes and inform delivery precautions for healthcare providers. Birth Defects Research 109:353-362, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Lisa M Bebell
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts.,Massachusetts General Hospital Center for Global Health, Boston, Massachusetts
| | - Titilope Oduyebo
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.,Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laura E Riley
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
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Henwood PC, Bebell LM, Roshania R, Wolfman V, Mallow M, Kalyanpur A, Levine AC. Ebola Virus Disease and Pregnancy: A Retrospective Cohort Study of Patients Managed at 5 Ebola Treatment Units in West Africa. Clin Infect Dis 2018; 65:292-299. [PMID: 28379374 PMCID: PMC5850452 DOI: 10.1093/cid/cix290] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/29/2017] [Indexed: 11/14/2022] Open
Abstract
Background. Reliable data are lacking on pregnancy outcomes during Ebola virus disease (EVD) epidemics. We aimed to characterize symptoms and outcomes among pregnant women admitted to Ebola treatment units (ETUs) with suspected and confirmed EVD to better inform obstetric management. Methods. We analyzed a retrospective cohort of reproductive-aged women presenting to 5 West African ETUs from September 2014 to September 2015. We compared clinical symptoms, risk of EVD diagnosis, and mortality between pregnant and nonpregnant women. Results. Of 729 reproductive-aged women admitted to study ETUs, 44 (6%) reported pregnancy. Thirteen of 44 pregnant women (30%) tested EVD positive; 6 of 13 (46%) died. Pregnant women were less likely than nonpregnant women to report anorexia, asthenia, diarrhea, fever, myalgias/arthralgias, nausea, or vomiting (P < .05) at admission. Pregnant women with suspected EVD had the same risk, however, of laboratory-confirmed EVD (30% vs 24%, P = .38). While pregnant women with confirmed EVD had similar Ebola viral loads on presentation to nonpregnant women, as measured by initial cycle threshold (26.4 vs 23.2, P = .16), they were less likely to have myalgias/arthralgias (P< .001) and vomiting (P = .02). Both all-cause mortality (14% vs 19%, P = .39) and EVD-specific mortality (46% vs 54%, P = .60) were not significantly different between pregnant and nonpregnant women. Two neonates born live in the ETU died within 8 days. Conclusions. We find no evidence to support a difference in the risk of death between pregnant women with suspected or confirmed EVD compared to nonpregnant women. Limited data suggest poor fetal and neonatal outcomes in EVD-affected pregnancies.
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Affiliation(s)
- Patricia C Henwood
- Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.,International Medical Corps, Los Angeles, California
| | - Lisa M Bebell
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, and Massachusetts General Hospital Center for Global Health, Boston
| | | | | | | | | | - Adam C Levine
- International Medical Corps, Los Angeles, California.,Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Lai PS, Bebell LM, Meney C, Valeri L, White MC. Epidemiology of antibiotic-resistant wound infections from six countries in Africa. BMJ Glob Health 2018; 2:e000475. [PMID: 29588863 PMCID: PMC5868442 DOI: 10.1136/bmjgh-2017-000475] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 01/07/2018] [Accepted: 01/10/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction Little is known about the antimicrobial susceptibility of common bacteria responsible for wound infections from many countries in sub-Saharan Africa. Methods We performed a retrospective review of microbial isolates collected based on clinical suspicion of wound infection between 2004 and 2016 from Mercy Ships, a non-governmental organisation operating a single mobile surgical unit in Benin, Congo, Liberia, Madagascar, Sierra Leone and Togo. Antimicrobial resistant organisms of interest were defined as methicillin-resistant Staphylococcus aureus (MRSA) or Enterobacteriaceae resistant to third-generation cephalosporins. Generalised mixed-effects models accounting for repeated isolates in a patient, potential clustering by case mix for each field service, age, gender and country were used to test the hypothesis that rates of antimicrobial resistance differed between countries. Results 3145 isolates from repeated field services in six countries were reviewed. In univariate analyses, the highest proportion of MRSA was found in Benin (34.6%) and Congo (31.9%), while the lowest proportion was found in Togo (14.3%) and Madagascar (14.5%); country remained a significant predictor in multivariate analyses (P=0.002). In univariate analyses, the highest proportion of third-generation cephalosporin-resistant Enterobacteriaceae was found in Benin (35.8%) and lowest in Togo (14.3%) and Madagascar (16.3%). Country remained a significant predictor for antimicrobial-resistant isolates in multivariate analyses (P=0.009). Conclusion A significant proportion of isolates from wound cultures were resistant to first-line antimicrobials in each country. Though antimicrobial resistance isolates were not verified in a reference laboratory and these data may not be representative of all regions of the countries studied, differences in the proportion of antimicrobial-resistant isolates and resistance profiles between countries suggest site-specific surveillance should be a priority and local antimicrobial resistance profiles should be used to guide empiric antibiotic selection.
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Affiliation(s)
- Peggy S Lai
- Division of Pulmonary/Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Africa Bureau, Mercy Ships, Cotonou, Benin
| | - Lisa M Bebell
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Linda Valeri
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Bebell LM, Ngonzi J, Siedner MJ, Muyindike WR, Bwana BM, Riley LE, Boum Y, Bangsberg DR, Bassett IV. HIV Infection and risk of postpartum infection, complications and mortality in rural Uganda. AIDS Care 2018; 30:943-953. [PMID: 29451005 DOI: 10.1080/09540121.2018.1434119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
HIV infection may increase risk of postpartum infection and infection-related mortality. We hypothesized that postpartum infection incidence and attributable mortality in Mbarara, Uganda would be higher in HIV-infected than HIV-uninfected women. We performed a prospective cohort study of 4231 women presenting to a regional referral hospital in 2015 for delivery or postpartum care. All febrile or hypothermic women, and a subset of randomly selected normothermic women were followed during hospitalization and with 6-week postpartum phone interviews. The primary outcome was in-hospital postpartum infection. Secondary outcomes included in-hospital complications (mortality, re-operation, intensive care unit transfer, need for imaging or blood transfusion) and 6-week mortality. We performed multivariable regression analyses to estimate adjusted differences in each outcome by HIV serostatus. Mean age was 25.2 years and 481 participants (11%) were HIV-infected. Median CD4+ count was 487 (IQR 325, 696) cells/mm3, and 90% of HIV-infected women (193/215 selected for in-depth survey) were on antiretroviral therapy. Overall, 5% (205/4231) of women developed fever or hypothermia. Cumulative in-hospital postpartum infection incidence was 2.0% and did not differ by HIV status (aOR 1.4, 95% CI 0.6-3.3, P = 0.49). However, more HIV-infected women developed postpartum complications (4.4% vs. 1.2%, P = 0.001). In-hospital mortality was rare (2/1768, 0.1%), and remained so at 6 weeks (4/1526, 0.3%), without differences by HIV serostatus (P = 1.0 and 0.31, respectively). For women in rural Uganda with high rates of antiretroviral therapy coverage, HIV infection did not predict postpartum infection or mortality, but was associated with increased risk of postpartum complications.
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Affiliation(s)
- Lisa M Bebell
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA
| | - Joseph Ngonzi
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Mark J Siedner
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA.,c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Winnie R Muyindike
- d Department of Medicine , Mbarara Regional Referral Hospital , Mbarara , Uganda
| | - Bosco M Bwana
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda
| | - Laura E Riley
- e Division of Obstetrics and Gynecology , Massachusetts General Hospital , Boston , MA , USA
| | - Yap Boum
- c Faculty of Medicine , Mbarara University of Science and Technology , Mbarara , Uganda.,f Epicentre Mbarara Research Centre , Mbarara , Uganda
| | - David R Bangsberg
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA.,b Massachusetts General Hospital Center for Global Health , Boston , MA , USA
| | - Ingrid V Bassett
- a Division of Infectious Diseases , Massachusetts General Hospital , Boston , MA , USA
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50
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Bebell LM, Ayebare A, Boum Y, Siedner MJ, Bazira J, Schiff SJ, Metlay JP, Bangsberg DR, Ttendo S, Firth PG. Prevalence and correlates of MRSA and MSSA nasal carriage at a Ugandan regional referral hospital. J Antimicrob Chemother 2017; 72:888-892. [PMID: 27999030 DOI: 10.1093/jac/dkw472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 10/05/2016] [Indexed: 02/06/2023] Open
Abstract
Background Despite increasing antimicrobial resistance globally, data are lacking on prevalence and factors associated with Staphylococcus aureus (SA) and MRSA carriage in resource-limited settings. Objectives To determine the prevalence of SA and MRSA nasal carriage and factors associated with carriage among Ugandan regional referral hospital patients. Methods We enrolled a cross-section of 500 adults, sampling anterior nares for SA and MRSA carriage using Cepheid Xpert SA Nasal Complete. Results Mean age was 37 years; 321 (64%) were female and 166 (33%) were HIV infected. Overall, 316 (63%) reported risk factors for invasive SA infection; 368 (74%) reported current antibiotic use. SA was detected in 29% and MRSA in 2.8%. MRSA and MSSA carriers were less likely than SA non-carriers to be female (50% and 56% versus 68%, P = 0.03) or to have recently used β-lactam antibiotics (43% and 65% versus 73%, P = 0.01). MRSA carriers were more likely to have open wounds than MSSA carriers and SA non-carriers (71% versus 27% and 40%, P = 0.001) and contact with pigs (21% versus 2% and 6%, P = 0.008). MRSA carriage ranged from 0% of HIV clinic participants to 8% of inpatient surgical ward participants ( P = 0.01). In multivariable logistic regression analysis, male sex was independently associated with SA carriage (OR 1.68, 95% CI 1.12-2.53, P = 0.01) and recent β-lactam antibiotic use was associated with reduced odds of SA carriage (OR 0.61, 95% CI 0.38-0.97, P = 0.04). Conclusions MRSA nasal carriage prevalence was low and associated with pig contact, open wounds and surgical ward admission, but not with HIV infection.
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Affiliation(s)
- Lisa M Bebell
- Infectious Diseases Division, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Massachusetts General Hospital Center for Global Health, 125 Nashua Street, Boston, MA 02114, USA
| | - Arnold Ayebare
- Epicentre Research Base, PO Box 1956, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Yap Boum
- Epicentre Research Base, PO Box 1956, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark J Siedner
- Infectious Diseases Division, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Massachusetts General Hospital Center for Global Health, 125 Nashua Street, Boston, MA 02114, USA
| | - Joel Bazira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Steven J Schiff
- Center for Neural Engineering and Center for Infectious Disease Dynamics, Departments of Engineering Science and Mechanics, Neurosurgery and Physics, The Pennsylvania State University, University Park, PA, USA
| | - Joshua P Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA
| | - David R Bangsberg
- Infectious Diseases Division, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.,Massachusetts General Hospital Center for Global Health, 125 Nashua Street, Boston, MA 02114, USA
| | - Stephen Ttendo
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Paul G Firth
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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