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Onyamboko MA, Olupot-Olupot P, Were W, Namayanja C, Onyas P, Titin H, Baseke J, Muhindo R, Kayembe DK, Ndjowo PO, Basara BB, Okalebo CB, Williams TN, Uyoga S, Taya C, Bamisaiye A, Fanello C, Maitland K, Day NPJ, Taylor WRJ, Mukaka M. Factors affecting haemoglobin dynamics in African children with acute uncomplicated Plasmodium falciparum malaria treated with single low-dose primaquine or placebo. BMC Med 2023; 21:397. [PMID: 37858129 PMCID: PMC10588240 DOI: 10.1186/s12916-023-03105-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Single low-dose primaquine (SLDPQ) effectively blocks the transmission of Plasmodium falciparum malaria, but anxiety remains regarding its haemolytic potential in patients with glucose-6-phopshate dehydrogenase (G6PD) deficiency. We, therefore, examined the independent effects of several factors on haemoglobin (Hb) dynamics in falciparum-infected children with a particular interest in SLDPQ and G6PD status. METHODS This randomised, double-blind, placebo-controlled, safety trial was conducted in Congolese and Ugandan children aged 6 months-11 years with acute uncomplicated P. falciparum and day (D) 0 Hbs ≥ 6 g/dL who were treated with age-dosed SLDPQ/placebo and weight-dosed artemether lumefantrine (AL) or dihydroartemisinin piperaquine (DHAPP). Genotyping defined G6PD (G6PD c.202T allele), haemoglobin S (HbS), and α-thalassaemia status. Multivariable linear and logistic regression assessed factor independence for continuous Hb parameters and Hb recovery (D42 Hb > D0 Hb), respectively. RESULTS One thousand one hundred thirty-seven children, whose median age was 5 years, were randomised to receive: AL + SLDPQ (n = 286), AL + placebo (286), DHAPP + SLDPQ (283), and DHAPP + placebo (282). By G6PD status, 284 were G6PD deficient (239 hemizygous males, 45 homozygous females), 119 were heterozygous females, 418 and 299 were normal males and females, respectively, and 17 were of unknown status. The mean D0 Hb was 10.6 (SD 1.6) g/dL and was lower in younger children with longer illnesses, lower mid-upper arm circumferences, splenomegaly, and α-thalassaemia trait, who were either G6PDd or heterozygous females. The initial fractional fall in Hb was greater in younger children with higher D0 Hbs and D0 parasitaemias and longer illnesses but less in sickle cell trait. Older G6PDd children with lower starting Hbs and greater factional falls were more likely to achieve Hb recovery, whilst lower D42 Hb concentrations were associated with younger G6PD normal children with lower fractional falls, sickle cell disease, α-thalassaemia silent carrier and trait, and late treatment failures. Ten blood transfusions were given in the first week (5 SLDPQ, 5 placebo). CONCLUSIONS In these falciparum-infected African children, posttreatment Hb changes were unaffected by SLDPQ, and G6PDd patients had favourable posttreatment Hb changes and a higher probability of Hb recovery. These reassuring findings support SLDPQ deployment without G6PD screening in Africa. TRIAL REGISTRATION The trial is registered at ISRCTN 11594437.
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Affiliation(s)
- Marie A Onyamboko
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Kinshasa, Democratic Republic of Congo
| | - Peter Olupot-Olupot
- Busitema University, P.O. Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Winifred Were
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Cate Namayanja
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Peter Onyas
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Harriet Titin
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Joy Baseke
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Rita Muhindo
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Daddy K Kayembe
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Kinshasa, Democratic Republic of Congo
| | - Pauline O Ndjowo
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Kinshasa, Democratic Republic of Congo
| | - Benjamin B Basara
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Kinshasa, Democratic Republic of Congo
| | | | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, London, SW7 2AS, UK
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Chiraporn Taya
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Adeola Bamisaiye
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Caterina Fanello
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, London, SW7 2AS, UK
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Walter R J Taylor
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Mukaka M, Onyamboko MA, Olupot-Olupot P, Peerawaranun P, Suwannasin K, Pagornrat W, Kouhathong J, Madmanee W, Were W, Namayanja C, Onyas P, Titin H, Baseke J, Muhindo R, Kayembe DK, Ndjowo PO, Basara BB, Bongo GS, Okalebo CB, Abongo G, Uyoga S, Williams TN, Taya C, Dhorda M, Dondorp AM, Waithira N, Imwong M, Maitland K, Fanello C, Day NPJ, Tarning J, White NJ, Taylor WRJ. Pharmacokinetics of single low dose primaquine in Ugandan and Congolese children with falciparum malaria. EBioMedicine 2023; 96:104805. [PMID: 37757570 PMCID: PMC10550634 DOI: 10.1016/j.ebiom.2023.104805] [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: 04/12/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND There are no pharmacokinetic data of single low dose primaquine (SLDPQ) as transmission blocking in African children with acute Plasmodium falciparum and glucose-6-phosphate dehydrogenase deficiency (G6PDd). METHODS Primaquine pharmacokinetics of age-dosed SLDPQ (shown previously to be gametocytocidal with similar tolerability as placebo) were characterised in falciparum-infected Ugandan and Congolese children aged 6 months to 11 years, treated on admission with standard 3-day dihydroartemisinin-piperaquine or artemether-lumefantrine plus SLDPQ: 6 m-<1 y: 1.25 mg, 1-5 y: 2.5 mg, 6-9 y: 5 mg, 10-11 y: 7.5 mg. LC-MS/MS-measured plasma primaquine and carboxyprimaquine (baseline, 1, 1.5, 2, 4, 8, 12, 24 h) were analysed by noncompartmental analysis. Multivariable linear regression modelled associations between covariates, including cytochrome-P450 2D6 metaboliser status, and outcomes. FINDINGS 258 children (median age 5 [interquartile range (IQR) 3-7]) were sampled; 8 (3.1%) with early vomiting were excluded. Primaquine doses of 0.10-0.40 (median 0.21, IQR 0.16-0.25) mg base/kg resulted in primaquine maximum plasma concentrations (Cmax) of 2.3-447 (median 103.0, IQR 72.1-140.0) ng/mL between 1.0 and 8.0 (median 2) hours (Tmax) and median areas under the drug concentration curves (AUC0-last) 730.2 (6 m-<1 y, n = 12), 582.8 (1-5 y, n = 126), 871.1 (6-9 y, n = 80), and 931.0 (10-11 y, n = 32) ng∗h/mL. Median elimination half-live (T½) was 4.7 (IQR 3.8-5.6) hours. Primaquine clearance/kg peaked at 18 months, plateauing at 4 y. Increasing CYP2D6 metaboliser activity score [poor (3/250), intermediate (52/250), normal (150/250), ultrarapid (5/250), indeterminate (40/250)] and baseline haemoglobin were significantly associated with a lower primaquine AUC0-last,which increased with increasing mg/kg dose and age but was independent of the artemisinin treatment used. INTERPRETATION Age-dosed SLDPQ resulted in variable primaquine exposure that depended on bodyweight-adjusted dose, age, baseline haemoglobin and CYP2D6 metaboliser status, but not on dihydroartemisinin-piperaquine or artemether-lumefantrine. These data support age-dosed SLDPQ for transmission blocking in sub-Saharan Africa. FUNDING This work was cofunded by the UK Medical Research Council, Wellcome Trust, and UK Aid through the Global Health Trials (grant reference MR/P006973/1). The funders had no role in the study design, execution, and analysis and decisions regarding publication.
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Affiliation(s)
- Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Marie A Onyamboko
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Democratic Republic of Congo
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda; Busitema University, P.O. Box 1460, Mbale, Uganda
| | - Pimnara Peerawaranun
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Kanokon Suwannasin
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Watcharee Pagornrat
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Jindarat Kouhathong
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Wanassanan Madmanee
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Winifred Were
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Cate Namayanja
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Peter Onyas
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Harriet Titin
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Joy Baseke
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Rita Muhindo
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Daddy K Kayembe
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Democratic Republic of Congo
| | - Pauline O Ndjowo
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Democratic Republic of Congo
| | - Benjamin B Basara
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Democratic Republic of Congo
| | - Georgette S Bongo
- Kinshasa School of Public Health, University of Kinshasa, Avenue Tombalbaye 68-78, Democratic Republic of Congo
| | - Charles B Okalebo
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Grace Abongo
- Mbale Clinical Research Institute (MCRI), P.O. Box 1966, Mbale, Uganda
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, SW7 2AS, United Kingdom
| | - Chiraporn Taya
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Naomi Waithira
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Mallika Imwong
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, SW7 2AS, United Kingdom
| | - Caterina Fanello
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Joel Tarning
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Walter R J Taylor
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.
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3
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Opi DH, Ndila CM, Uyoga S, Macharia AW, Fennell C, Ochola LB, Nyutu G, Siddondo BR, Ojal J, Shebe M, Awuondo KO, Mturi N, Peshu N, Tsofa B, Band G, Maitland K, Kwiatkowski DP, Rockett KA, Williams TN, Rowe JA. Non-O ABO blood group genotypes differ in their associations with Plasmodium falciparum rosetting and severe malaria. PLoS Genet 2023; 19:e1010910. [PMID: 37708213 PMCID: PMC10522014 DOI: 10.1371/journal.pgen.1010910] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 09/26/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023] Open
Abstract
Blood group O is associated with protection against severe malaria and reduced size and stability of P. falciparum-host red blood cell (RBC) rosettes compared to non-O blood groups. Whether the non-O blood groups encoded by the specific ABO genotypes AO, BO, AA, BB and AB differ in their associations with severe malaria and rosetting is unknown. The A and B antigens are host RBC receptors for rosetting, hence we hypothesized that the higher levels of A and/or B antigen on RBCs from AA, BB and AB genotypes compared to AO/BO genotypes could lead to larger rosettes, increased microvascular obstruction and higher risk of malaria pathology. We used a case-control study of Kenyan children and in vitro adhesion assays to test the hypothesis that "double dose" non-O genotypes (AA, BB, AB) are associated with increased risk of severe malaria and larger rosettes than "single dose" heterozygotes (AO, BO). In the case-control study, compared to OO, the double dose genotypes consistently had higher odds ratios (OR) for severe malaria than single dose genotypes, with AB (OR 1.93) and AO (OR 1.27) showing most marked difference (p = 0.02, Wald test). In vitro experiments with blood group A-preferring P. falciparum parasites showed that significantly larger rosettes were formed with AA and AB host RBCs compared to OO, whereas AO and BO genotypes rosettes were indistinguishable from OO. Overall, the data show that ABO genotype influences P. falciparum rosetting and support the hypothesis that double dose non-O genotypes confer a greater risk of severe malaria than AO/BO heterozygosity.
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Affiliation(s)
- D. Herbert Opi
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Immunity, Infection and Evolution, Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Carolyne M. Ndila
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Sophie Uyoga
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Alex W. Macharia
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Clare Fennell
- Centre for Immunity, Infection and Evolution, Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Lucy B. Ochola
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gideon Nyutu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bethseba R. Siddondo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - John Ojal
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mohammed Shebe
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kennedy O. Awuondo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Neema Mturi
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Norbert Peshu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Benjamin Tsofa
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gavin Band
- Wellcome Centre for Human Genetics, Oxford, United Kingdom
| | - Kathryn Maitland
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | | | - Thomas N. Williams
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - J. Alexandra Rowe
- Centre for Immunity, Infection and Evolution, Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom
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Kagucia EW, Ziraba AK, Nyagwange J, Kutima B, Kimani M, Akech D, Ng'oda M, Sigilai A, Mugo D, Karanja H, Gitonga J, Karani A, Toroitich M, Karia B, Otiende M, Njeri A, Aman R, Amoth P, Mwangangi M, Kasera K, Ng'ang'a W, Voller S, Ochola‐Oyier LI, Bottomley C, Nyaguara A, Munywoki PK, Bigogo G, Maitha E, Uyoga S, Gallagher KE, Etyang AO, Barasa E, Mwangangi J, Bejon P, Adetifa IMO, Warimwe GM, Scott JAG, Agweyu A. SARS-CoV-2 seroprevalence and implications for population immunity: Evidence from two Health and Demographic Surveillance System sites in Kenya, February-December 2022. Influenza Other Respir Viruses 2023; 17:e13173. [PMID: 37752065 PMCID: PMC10522478 DOI: 10.1111/irv.13173] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND We sought to estimate SARS-CoV-2 antibody seroprevalence within representative samples of the Kenyan population during the third year of the COVID-19 pandemic and the second year of COVID-19 vaccine use. METHODS We conducted cross-sectional serosurveys among randomly selected, age-stratified samples of Health and Demographic Surveillance System (HDSS) residents in Kilifi and Nairobi. Anti-spike (anti-S) immunoglobulin G (IgG) serostatus was measured using a validated in-house ELISA and antibody concentrations estimated with reference to the WHO International Standard for anti-SARS-CoV-2 immunoglobulin. RESULTS HDSS residents were sampled in February-June 2022 (Kilifi HDSS N = 852; Nairobi Urban HDSS N = 851) and in August-December 2022 (N = 850 for both sites). Population-weighted coverage for ≥1 doses of COVID-19 vaccine were 11.1% (9.1-13.2%) among Kilifi HDSS residents by November 2022 and 34.2% (30.7-37.6%) among Nairobi Urban HDSS residents by December 2022. Population-weighted anti-S IgG seroprevalence among Kilifi HDSS residents increased from 69.1% (65.8-72.3%) by May 2022 to 77.4% (74.4-80.2%) by November 2022. Within the Nairobi Urban HDSS, seroprevalence by June 2022 was 88.5% (86.1-90.6%), comparable with seroprevalence by December 2022 (92.2%; 90.2-93.9%). For both surveys, seroprevalence was significantly lower among Kilifi HDSS residents than among Nairobi Urban HDSS residents, as were antibody concentrations (p < 0.001). CONCLUSION More than 70% of Kilifi residents and 90% of Nairobi residents were seropositive for anti-S IgG by the end of 2022. There is a potential immunity gap in rural Kenya; implementation of interventions to improve COVID-19 vaccine uptake among sub-groups at increased risk of severe COVID-19 in rural settings is recommended.
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Affiliation(s)
| | | | | | | | | | - Donald Akech
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Maurine Ng'oda
- African Population and Health Research CenterNairobiKenya
| | | | - Daisy Mugo
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | | | - John Gitonga
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | | | | | | | - Mark Otiende
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Anne Njeri
- African Population and Health Research CenterNairobiKenya
| | | | | | | | | | - Wangari Ng'ang'a
- Presidential Policy and Strategy UnitThe Presidency, Government of KenyaNairobiKenya
| | - Shirine Voller
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | - Patrick K. Munywoki
- Division for Global Health ProtectionUS Centers of Disease Control and Prevention, Center for Global HealthNairobiKenya
| | | | | | - Sophie Uyoga
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Katherine E. Gallagher
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | - Philip Bejon
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of MedicineOxford UniversityOxfordUK
| | - Ifedayo M. O. Adetifa
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- London School of Hygiene and Tropical MedicineLondonUK
| | - George M. Warimwe
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of MedicineOxford UniversityOxfordUK
| | - J. Anthony G. Scott
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- London School of Hygiene and Tropical MedicineLondonUK
| | - Ambrose Agweyu
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- London School of Hygiene and Tropical MedicineLondonUK
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Uyoga S, Mbanya D, George EC, Maitland K. Blood transfusion for children in sub-Saharan Africa: 200 years on. Lancet Child Adolesc Health 2023; 7:525-526. [PMID: 37327800 DOI: 10.1016/s2352-4642(23)00143-8] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Sophie Uyoga
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi 80108, Kenya.
| | - Dora Mbanya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Kathryn Maitland
- Department of Infectious Disease, Imperial College, London, UK; Institute of Global Health and Innovation, Faculty of Medicine, Imperial College, London, UK
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Taylor WR, Olupot-Olupot P, Onyamboko MA, Peerawaranun P, Weere W, Namayanja C, Onyas P, Titin H, Baseke J, Muhindo R, Kayembe DK, Ndjowo PO, Basara BB, Bongo GS, Okalebo CB, Abongo G, Uyoga S, Williams TN, Taya C, Dhorda M, Tarning J, Dondorp AM, Waithira N, Fanello C, Maitland K, Mukaka M, Day NJP. Safety of age-dosed, single low-dose primaquine in children with glucose-6-phosphate dehydrogenase deficiency who are infected with Plasmodium falciparum in Uganda and the Democratic Republic of the Congo: a randomised, double-blind, placebo-controlled, non-inferiority trial. Lancet Infect Dis 2023; 23:471-483. [PMID: 36462528 DOI: 10.1016/s1473-3099(22)00658-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND WHO recommends gametocytocidal, single low-dose primaquine for blocking the transmission of Plasmodium falciparum; however, safety concerns have hampered the implementation of this strategy in sub-Saharan Africa. We aimed to investigate the safety of age-dosed, single low-dose primaquine in children from Uganda and the Democratic Republic of the Congo. METHODS We conducted this randomised, double-blind, placebo-controlled, non-inferiority trial at the Mbale Regional Referral Hospital, Mbale, Uganda, and the Kinshasa Mahidol Oxford Research Unit, Kinshasa, Democratic Republic of the Congo. Children aged between 6 months and 11 years with acute uncomplicated P falciparum infection and haemoglobin concentrations of at least 6 g/dL were enrolled. Patients were excluded if they had a comorbid illness requiring inpatient treatment, were taking haemolysing drugs for glucose-6-phosphate dehydrogenase (G6PD) deficiency, were allergic to the study drugs, or were enrolled in another clinical trial. G6PD status was defined by genotyping for the G6PD c.202T allele, the cause of the G6PD-deficient A- variant. Participants were randomly assigned (1:1) to receive single low-dose primaquine combined with either artemether-lumefantrine or dihydroartemisinin-piperaquine, dosed by bodyweight. Randomisation was stratified by age and G6PD status. The primary endpoint was the development of profound (haemoglobin <4 g/dL) or severe (haemoglobin <5 g/dL) anaemia with severity features, within 21 days of treatment. Analysis was by intention to treat. The sample size assumed an incidence of 1·5% in the placebo group and a 3% non-inferiority margin. The trial is registered at ISRCTN, 11594437, and is closed to new participants. FINDINGS Participants were recruited at the Mbale Regional Referral Hospital between Dec 18, 2017, and Oct 7, 2019, and at the Kinshasa Mahidol Oxford Research Unit between July 17, 2017, and Oct 5, 2019. 4620 patients were assessed for eligibility. 3483 participants were excluded, most owing to negative rapid diagnostic test or negative malaria slide (n=2982). 1137 children with a median age of 5 years were enrolled and randomly assigned (286 to the artemether-lumefantrine plus single low-dose primaquine group, 286 to the artemether-lumefantrine plus placebo group, 283 to the dihydroartemisinin-piperaquine plus single low-dose primaquine group, and 282 to the dihydroartemisinin-piperaquine plus placebo group). Genotyping of G6PD identified 239 G6PD-c.202T hemizygous males and 45 G6PD-c.202T homozygous females (defining the G6PD-deficient group), 119 heterozygous females, 418 G6PD-c.202C normal males and 299 G6PD-c.202C normal females (defining the non-G6PD-deficient group), and 17 children of unknown status. 67 patients were lost to follow-up and four patients withdrew during the study-these numbers were similar between groups. No participants developed profound anaemia and three developed severe anaemia: from the G6PD-deficient group, none (0%) of 133 patients who received placebo and one (0·66%) of 151 patients who received primaquine (difference -0·66%, 95% CI -1·96 to 0·63; p=0·35); and from the non-G6PD-deficient group, one (0·23%) of 430 patients who received placebo and one (0·25%) of 407 patients who received primaquine (-0·014%, -0·68 to 0·65; p=0·97). INTERPRETATION Gametocytocidal, age-dosed, single low-dose primaquine was well tolerated in children from Uganda and the Democratic Republic of the Congo who were infected with P falciparum, and the safety profile of this treatment was similar to that of the placebo. These data support the wider implementation of single low-dose primaquine in Africa. FUNDING UK Government Department for International Development, UK Medical Research Council, UK National Institute for Health Research, and the Wellcome Trust Joint Global Health Trials Scheme.
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Affiliation(s)
- Walter R Taylor
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale, Uganda; Department of Public Health, Busitema University, Mbale, Uganda
| | - Marie A Onyamboko
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Pimnara Peerawaranun
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand
| | | | | | - Peter Onyas
- Mbale Clinical Research Institute, Mbale, Uganda
| | | | - Joy Baseke
- Department of Public Health, Busitema University, Mbale, Uganda
| | - Rita Muhindo
- Mbale Clinical Research Institute, Mbale, Uganda
| | - Daddy K Kayembe
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Pauline O Ndjowo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Benjamin B Basara
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Georgette S Bongo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Grace Abongo
- Mbale Clinical Research Institute, Mbale, Uganda
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Institute of Global Health Innovation, Imperial College London, London, UK
| | - Chiraporn Taya
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand
| | - Mehul Dhorda
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Joel Tarning
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Naomi Waithira
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Caterina Fanello
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Institute of Global Health Innovation, Imperial College London, London, UK
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas J P Day
- Mahidol Oxford Tropical Medicine Clinical Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Olupot-Olupot P, Okiror W, Mnjalla H, Muhindo R, Uyoga S, Mpoya A, Williams TN, terHeine R, Burger DM, Urban B, Connon R, George EC, Gibb DM, Walker AS, Maitland K. Pharmacokinetics and pharmacodynamics of azithromycin in severe malaria bacterial co-infection in African children (TABS-PKPD): a protocol for a Phase II randomised controlled trial. Wellcome Open Res 2023; 6:161. [PMID: 37519413 PMCID: PMC10382785 DOI: 10.12688/wellcomeopenres.16968.2] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 08/01/2023] Open
Abstract
Background: African children with severe malaria are susceptible to Gram-negative bacterial co-infection, largely non-typhoidal Salmonellae, leading to a substantially higher rates of in-hospital and post-discharge mortality than those without bacteraemia. Current evidence for treating co-infection is lacking, and there is no consensus on the dosage or length of treatment required. We therefore aimed to establish the appropriate dose of oral dispersible azithromycin as an antimicrobial treatment for children with severe malaria and to investigate whether antibiotics can be targeted to those at greatest risk of bacterial co-infection using clinical criteria alone or in combination with rapid diagnostic biomarker tests. Methods: A Phase I/II open-label trial comparing three doses of azithromycin: 10, 15 and 20 mg/kg spanning the lowest to highest mg/kg doses previously demonstrated to be equally effective as parenteral treatment for other salmonellae infection. Children with the highest risk of bacterial infection will receive five days of azithromycin and followed for 90 days. We will generate relevant pharmacokinetic data by sparse sampling during dosing intervals. We will use population pharmacokinetic modelling to determine the optimal azithromycin dose in severe malaria and investigate azithromycin exposure to change in C-reactive protein, a putative marker of sepsis at 72 hours, and microbiological cure (seven-day), alone and as a composite with seven-day survival. We will also evaluate whether a combination of clinical, point-of-care diagnostic tests, and/or biomarkers can accurately identify the sub-group of severe malaria with culture-proven bacteraemia by comparison with a control cohort of children hospitalized with severe malaria at low risk of bacterial co-infection. Discussion: We plan to study azithromycin because of its favourable microbiological spectrum, its inherent antimalarial and immunomodulatory properties and dosing and safety profile. This study will generate new data to inform the design and sample size for definitive Phase III trial evaluation. Registration: ISRCTN49726849 (27 th October 2017).
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Affiliation(s)
- Peter Olupot-Olupot
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Busitema University Faculty of Health Sciences, Mbale Regional Referral Hospital, Mbale, Uganda
| | - William Okiror
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Busitema University Faculty of Health Sciences, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Hellen Mnjalla
- KEMRI Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Rita Muhindo
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Busitema University Faculty of Health Sciences, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Sophie Uyoga
- KEMRI Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Ayub Mpoya
- KEMRI Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Thomas N Williams
- KEMRI Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
| | - Rob terHeine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Britta Urban
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Roisin Connon
- MRC Clinical Trials Unit, University College London, Aviation House, 125 Kingsway, London, WC28 6NH, UK
| | - Elizabeth C George
- MRC Clinical Trials Unit, University College London, Aviation House, 125 Kingsway, London, WC28 6NH, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit, University College London, Aviation House, 125 Kingsway, London, WC28 6NH, UK
| | - A Sarah Walker
- MRC Clinical Trials Unit, University College London, Aviation House, 125 Kingsway, London, WC28 6NH, UK
| | - Kathryn Maitland
- KEMRI Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
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Lucey O, Acana S, Olupot‐Olupot P, Muhindo R, Ayikobua R, Uyoga S, Kyeyune‐Byabazaire D, Cooke G, Maitland K. High false discovery rate of the Architect anti-HCV screening test in blood donors in Uganda and evaluation of an algorithm for confirmatory testing. Vox Sang 2022; 117:1360-1367. [PMID: 36218235 PMCID: PMC10092297 DOI: 10.1111/vox.13364] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 07/09/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Adequate supplies of donor blood remain a major challenge in sub-Saharan Africa. This is exacerbated by a lack of confirmatory testing for transfusion-transmitted infections by blood transfusion services (BTS), leading to significant blood disposal owing to putatively high seroprevalence rates amongst Ugandan blood donors. We aimed to ascertain the false discovery rate of the Architect anti-hepatitis C virus (HCV) screening assay and categorize screen-reactive samples into three groups: presumed false positive, active and past infection, and develop an algorithm for confirmatory testing. MATERIALS AND METHODS A total of 470 screen-reactive HCV blood donations were retested using the Architect anti-HCV assay, an alternative antibody test (SD Biosensor) and a core antigen (cAg) test. signal-to cut-off (S/CO) ratios and pre-analytical factors (centrifugation speed, haemolysis check, time between collection and testing) were recorded. Based on the S/CO ratio evaluation, we propose a testing algorithm to guide supplemental tests. RESULTS The false discovery rate of the Architect anti-HCV assay was 0.84 as 395/470 (84%) screen-reactive samples had no evidence of HCV infection (SD Biosensor and cAg negative) (presumed false positive), 38/470 (8.1%) were antigenaemic, and 32/470 (6.8%) had evidence of past infection. The median S/CO ratios of the presumed false-positive and active infection samples were 1.8 and 17.3, respectively. The positive predictive value of HCV positivity in samples with ratios above 12 was 91.8%. On retesting, 104/470 (22.1%) samples became negative. CONCLUSION The Architect anti-HCV assay has a very high false discovery rate in Ugandan BTSs, leading to excessive blood disposal. Pre-analytical factors likely contribute to this. An introduction of confirmatory testing using an algorithm based on S/CO ratio evaluation could limit unnecessary blood wastage and donor deferral.
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Affiliation(s)
- Olivia Lucey
- Department of Infectious Disease, Division of MedicineImperial CollegeLondonUK
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Susan Acana
- Ugandan Blood Transfusion ServiceKampalaUganda
| | - Peter Olupot‐Olupot
- Busitema University Faculty of Health SciencesMbale Campus and Mbale Regional Referral HospitalMbaleUganda
- Department of PaediatricsMbale Clinical Research InstituteMbaleUganda
| | - Rita Muhindo
- Busitema University Faculty of Health SciencesMbale Campus and Mbale Regional Referral HospitalMbaleUganda
- Department of PaediatricsMbale Clinical Research InstituteMbaleUganda
| | | | - Sophie Uyoga
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeKilifiKenya
- Busitema University Faculty of Health SciencesMbale Campus and Mbale Regional Referral HospitalMbaleUganda
| | | | - Graham Cooke
- Department of Infectious Disease, Division of MedicineImperial CollegeLondonUK
| | - Kathryn Maitland
- Department of Infectious Disease, Division of MedicineImperial CollegeLondonUK
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeKilifiKenya
- Institute of Global Health and Innovation, Division of MedicineImperial CollegeLondonUK
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9
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Ojal J, Brand SPC, Were V, Okiro EA, Kombe IK, Mburu C, Aziza R, Ogero M, Agweyu A, Warimwe GM, Uyoga S, Adetifa IMO, Scott JAG, Otieno E, Ochola-Oyier LI, Agoti CN, Kasera K, Amoth P, Mwangangi M, Aman R, Ng’ang’a W, Tsofa B, Bejon P, Barasa E, Keeling MJ, Nokes DJ. Revealing the extent of the first wave of the COVID-19 pandemic in Kenya based on serological and PCR-test data. Wellcome Open Res 2022; 6:127. [PMID: 36187498 PMCID: PMC9511207 DOI: 10.12688/wellcomeopenres.16748.3] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/02/2023] Open
Abstract
Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.
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Affiliation(s)
- John Ojal
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Samuel P. C. Brand
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Vincent Were
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research programme, Nairobi, Kenya
| | - Ivy K. Kombe
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Caroline Mburu
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Rabia Aziza
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Morris Ogero
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - George M. Warimwe
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Sophie Uyoga
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Ifedayo M. O. Adetifa
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - J. Anthony G. Scott
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Edward Otieno
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Charles N. Agoti
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- School of Public Health, Pwani University, Kilifi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Wangari Ng’ang’a
- Presidential Policy & Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Benjamin Tsofa
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Philip Bejon
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Edwine Barasa
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matt J. Keeling
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
| | - D. James Nokes
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
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Affiliation(s)
- Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand; Centre for Global Health and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - James A Watson
- Centre for Global Health and Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Sophie Uyoga
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya
| | - Thomas N Williams
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya; Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Kathryn M Maitland
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya; Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, London, UK
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11
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Uyoga S, Olupot-Olupot P, Connon R, Kiguli S, Opoka RO, Alaroker F, Muhindo R, Macharia AW, Dondorp AM, Gibb DM, Walker AS, George EC, Maitland K, Williams TN. Sickle cell anaemia and severe Plasmodium falciparum malaria: a secondary analysis of the Transfusion and Treatment of African Children Trial (TRACT). Lancet Child Adolesc Health 2022; 6:606-613. [PMID: 35785794 PMCID: PMC7613576 DOI: 10.1016/s2352-4642(22)00153-5] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sickle cell anaemia (SCA) has historically been associated with high levels of childhood mortality in Africa. Although malaria has a major contribution to this mortality, to date, the clinical pathology of malaria among children with SCA has been poorly described. We aimed to explore the relationship between SCA and Plasmodium falciparum malaria in further detail by investigating the burden and severity of malaria infections among children recruited with severe anaemia to the TRACT trial of blood transfusion in Africa. METHODS This study is a post-hoc secondary analysis of the TRACT trial data, conducted after trial completion. TRACT was an open-label, multicentre, factorial, randomised controlled trial enrolling children aged 2 months to 12 years who presented with severe anaemia (haemoglobin <6·0 g/dL) to four hospitals in Africa. This secondary analysis is restricted to Uganda, where the birth prevalence of SCA is approximately 1% and malaria transmission is high. Children were classified as normal (HbAA), heterozygous (HbAS), or homozygous (HbSS; SCA) for the rs334 A→T sickle mutation in HBB following batch-genotyping by PCR at the end of the trial. To avoid confounding from SCA-specific medical interventions, we considered children with an existing diagnosis of SCA (known SCA) separately from those diagnosed at the end of the trial (unknown SCA). The outcomes considered in this secondary analysis were measures of P falciparum parasite burden, features of severe malaria, and mortality at day 28 in malaria-positive children. FINDINGS Between Sept 17, 2014, and May 15, 2017, 3944 children with severe anaemia were enrolled into the TRACT trial. 3483 children from Uganda were considered in this secondary analysis. Overall, 1038 (30%) of 3483 Ugandan children had SCA. 1815 (78%) of 2321 children without SCA (HbAA) tested positive for P falciparum malaria, whereas the prevalence was significantly lower in children with SCA (347 [33%] of 1038; p<0·0001). Concentrations of plasma P falciparum histidine-rich protein 2 (PfHRP2), a marker of the total burden of malaria parasites within an individual, were significantly lower in children with either known SCA (median 8 ng/mL; IQR 0-57) or unknown SCA (7 ng/mL; 0-50) than in HbAA children (346 ng/mL; 21-2121; p<0·0001). In contrast to HbAA children, few HbSS children presented with classic features of severe and complicated malaria, but both the frequency and severity of anaemia were higher in HbSS children. We found no evidence for increased mortality at day 28 in those with SCA compared with those without SCA overall (hazard ratios 1·07 [95% CI 0·31-3·76] for known SCA and 0·67 [0·15-2·90] for unknown SCA). INTERPRETATION The current study suggests that children with SCA are innately protected against classic severe malaria. However, it also shows that even low-level infections can precipitate severe anaemic crises that would likely prove fatal without rapid access to blood transfusion services. FUNDING UK Medical Research Council, Wellcome, and UK National Institute for Health and Care Research.
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Affiliation(s)
- Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Peter Olupot-Olupot
- Busitema University Faculty of Health Sciences, Mbale Regional Referral Hospital, Mbale, Uganda; Mbale Clinical Research Institute, Mbale, Uganda
| | - Roisin Connon
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College London, London, UK
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Kampala, Uganda
| | - Robert O Opoka
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Kampala, Uganda
| | | | - Rita Muhindo
- Mbale Clinical Research Institute, Mbale, Uganda
| | | | - Arjen M Dondorp
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College London, London, UK
| | - A Sarah Walker
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College London, London, UK
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College London, London, UK
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Department of Infectious Disease and Institute of Global Health Innovation, Division of Medicine, Imperial College London, London, UK
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Department of Infectious Disease and Institute of Global Health Innovation, Division of Medicine, Imperial College London, London, UK.
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12
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Etyang AO, Adetifa I, Omore R, Misore T, Ziraba AK, Ng’oda MA, Gitau E, Gitonga J, Mugo D, Kutima B, Karanja H, Toroitich M, Nyagwange J, Tuju J, Wanjiku P, Aman R, Amoth P, Mwangangi M, Kasera K, Ng’ang’a W, Akech D, Sigilai A, Karia B, Karani A, Voller S, Agoti CN, Ochola-Oyier LI, Otiende M, Bottomley C, Nyaguara A, Uyoga S, Gallagher K, Kagucia EW, Onyango D, Tsofa B, Mwangangi J, Maitha E, Barasa E, Bejon P, Warimwe GM, Scott JAG, Agweyu A. SARS-CoV-2 seroprevalence in three Kenyan health and demographic surveillance sites, December 2020-May 2021. PLOS Glob Public Health 2022; 2:e0000883. [PMID: 36962821 PMCID: PMC10021917 DOI: 10.1371/journal.pgph.0000883] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/12/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most of the studies that have informed the public health response to the COVID-19 pandemic in Kenya have relied on samples that are not representative of the general population. We conducted population-based serosurveys at three Health and Demographic Surveillance Systems (HDSSs) to determine the cumulative incidence of infection with SARS-CoV-2. METHODS We selected random age-stratified population-based samples at HDSSs in Kisumu, Nairobi and Kilifi, in Kenya. Blood samples were collected from participants between 01 Dec 2020 and 27 May 2021. No participant had received a COVID-19 vaccine. We tested for IgG antibodies to SARS-CoV-2 spike protein using ELISA. Locally-validated assay sensitivity and specificity were 93% (95% CI 88-96%) and 99% (95% CI 98-99.5%), respectively. We adjusted prevalence estimates using classical methods and Bayesian modelling to account for the sampling scheme and assay performance. RESULTS We recruited 2,559 individuals from the three HDSS sites, median age (IQR) 27 (10-78) years and 52% were female. Seroprevalence at all three sites rose steadily during the study period. In Kisumu, Nairobi and Kilifi, seroprevalences (95% CI) at the beginning of the study were 36.0% (28.2-44.4%), 32.4% (23.1-42.4%), and 14.5% (9.1-21%), and respectively; at the end they were 42.0% (34.7-50.0%), 50.2% (39.7-61.1%), and 24.7% (17.5-32.6%), respectively. Seroprevalence was substantially lower among children (<16 years) than among adults at all three sites (p≤0.001). CONCLUSION By May 2021 in three broadly representative populations of unvaccinated individuals in Kenya, seroprevalence of anti-SARS-CoV-2 IgG was 25-50%. There was wide variation in cumulative incidence by location and age.
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Affiliation(s)
| | - Ifedayo Adetifa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Omore
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya
| | - Thomas Misore
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya
| | | | | | - Evelyn Gitau
- African Population and Health Research Center, Nairobi, Kenya
| | - John Gitonga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Daisy Mugo
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Henry Karanja
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - James Tuju
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | | | | | - Wangari Ng’ang’a
- Presidential Policy and Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Donald Akech
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - Angela Karani
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shirine Voller
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Amek Nyaguara
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | | | | | | | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - George M. Warimwe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - J. Anthony G. Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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13
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Orangi S, Ojal J, Brand SP, Orlendo C, Kairu A, Aziza R, Ogero M, Agweyu A, Warimwe GM, Uyoga S, Otieno E, Ochola-Oyier LI, Agoti CN, Kasera K, Amoth P, Mwangangi M, Aman R, Ng'ang'a W, Adetifa IM, Scott JAG, Bejon P, Keeling MJ, Flasche S, Nokes DJ, Barasa E. Epidemiological impact and cost-effectiveness analysis of COVID-19 vaccination in Kenya. BMJ Glob Health 2022; 7:e009430. [PMID: 35914832 PMCID: PMC9344598 DOI: 10.1136/bmjgh-2022-009430] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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] [Received: 04/22/2022] [Accepted: 06/22/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND A few studies have assessed the epidemiological impact and the cost-effectiveness of COVID-19 vaccines in settings where most of the population had been exposed to SARS-CoV-2 infection. METHODS We conducted a cost-effectiveness analysis of COVID-19 vaccine in Kenya from a societal perspective over a 1.5-year time frame. An age-structured transmission model assumed at least 80% of the population to have prior natural immunity when an immune escape variant was introduced. We examine the effect of slow (18 months) or rapid (6 months) vaccine roll-out with vaccine coverage of 30%, 50% or 70% of the adult (>18 years) population prioritising roll-out in those over 50-years (80% uptake in all scenarios). Cost data were obtained from primary analyses. We assumed vaccine procurement at US$7 per dose and vaccine delivery costs of US$3.90-US$6.11 per dose. The cost-effectiveness threshold was US$919.11. FINDINGS Slow roll-out at 30% coverage largely targets those over 50 years and resulted in 54% fewer deaths (8132 (7914-8373)) than no vaccination and was cost saving (incremental cost-effectiveness ratio, ICER=US$-1343 (US$-1345 to US$-1341) per disability-adjusted life-year, DALY averted). Increasing coverage to 50% and 70%, further reduced deaths by 12% (810 (757-872) and 5% (282 (251-317) but was not cost-effective, using Kenya's cost-effectiveness threshold (US$919.11). Rapid roll-out with 30% coverage averted 63% more deaths and was more cost-saving (ICER=US$-1607 (US$-1609 to US$-1604) per DALY averted) compared with slow roll-out at the same coverage level, but 50% and 70% coverage scenarios were not cost-effective. INTERPRETATION With prior exposure partially protecting much of the Kenyan population, vaccination of young adults may no longer be cost-effective.
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Affiliation(s)
- Stacey Orangi
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
| | - John Ojal
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- The Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Samuel Pc Brand
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Cameline Orlendo
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Angela Kairu
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Rabia Aziza
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Morris Ogero
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - George M Warimwe
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sophie Uyoga
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Edward Otieno
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Lynette I Ochola-Oyier
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Charles N Agoti
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Wangari Ng'ang'a
- Presidential Policy & Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Ifedayo Mo Adetifa
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- The Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - J Anthony G Scott
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- The Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Philip Bejon
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matt J Keeling
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
- Mathematics Institute, University of Warwick, Coventry, UK
| | - Stefan Flasche
- The Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - D James Nokes
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore University, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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14
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Watson JA, Uyoga S, Wanjiku P, Makale J, Nyutu GM, Mturi N, George EC, Woodrow CJ, Day NPJ, Bejon P, Opoka RO, Dondorp AM, John CC, Maitland K, Williams TN, White NJ. Improving the diagnosis of severe malaria in African children using platelet counts and plasma PfHRP2 concentrations. Sci Transl Med 2022; 14:eabn5040. [PMID: 35857826 PMCID: PMC7613613 DOI: 10.1126/scitranslmed.abn5040] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [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: 01/15/2023]
Abstract
Severe malaria caused by Plasmodium falciparum is difficult to diagnose accurately in children in high-transmission settings. Using data from 2649 pediatric and adult patients enrolled in four studies of severe illness in three countries (Bangladesh, Kenya, and Uganda), we fitted Bayesian latent class models using two diagnostic markers: the platelet count and the plasma concentration of P. falciparum histidine-rich protein 2 (PfHRP2). In severely ill patients with clinical features consistent with severe malaria, the combination of a platelet count of ≤150,000/μl and a plasma PfHRP2 concentration of ≥1000 ng/ml had an estimated sensitivity of 74% and specificity of 93% in identifying severe falciparum malaria. Compared with misdiagnosed children, pediatric patients with true severe malaria had higher parasite densities, lower hematocrits, lower rates of invasive bacterial disease, and a lower prevalence of both sickle cell trait and sickle cell anemia. We estimate that one-third of the children enrolled into clinical studies of severe malaria in high-transmission settings in Africa had another cause of their severe illness.
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Affiliation(s)
- James A. Watson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK,Corresponding author.
| | - Sophie Uyoga
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Perpetual Wanjiku
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Johnstone Makale
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Gideon M. Nyutu
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Neema Mturi
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Elizabeth C. George
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Charles J. Woodrow
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas P. J. Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philip Bejon
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK,KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya
| | - Robert O. Opoka
- Makerere University, Department of Paediatrics and Child Health, Kampala, Uganda
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chandy C. John
- Department of Pediatrics, Indiana University, Indiana, IN, USA
| | - Kathryn Maitland
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya,Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College, London, UK
| | - Thomas N. Williams
- KEMRI Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Coast, Kilifi 80108, Kenya,Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College, London, UK
| | - Nicholas J. White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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15
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Obonyo NG, Olupot-Olupot P, Mpoya A, Nteziyaremye J, Chebet M, Uyoga S, Muhindo R, Fanning JP, Shiino K, Chan J, Fraser JF, Maitland K. A Clinical and Physiological Prospective Observational Study on the Management of Pediatric Shock in the Post-Fluid Expansion as Supportive Therapy Trial Era. Pediatr Crit Care Med 2022; 23:502-513. [PMID: 35446796 PMCID: PMC7613033 DOI: 10.1097/pcc.0000000000002968] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Fluid bolus resuscitation in African children is harmful. Little research has evaluated physiologic effects of maintenance-only fluid strategy. DESIGN We describe the efficacy of fluid-conservative resuscitation of septic shock using case-fatality, hemodynamic, and myocardial function endpoints. SETTING Pediatric wards of Mbale Regional Referral Hospital, Uganda, and Kilifi County Hospital, Kenya, conducted between October 2013 and July 2015. Data were analysed from August 2016 to July 2019. PATIENTS Children (≥ 60 d to ≤ 12 yr) with severe febrile illness and clinical signs of impaired perfusion. INTERVENTIONS IV maintenance fluid (4 mL/kg/hr) unless children had World Health Organization (WHO) defined shock (≥ 3 signs) where they received two fluid boluses (20 mL/kg) and transfusion if shock persisted. Clinical, electrocardiographic, echocardiographic, and laboratory data were collected at presentation, during resuscitation and on day 28. Outcome measures were 48-hour mortality, normalization of hemodynamics, and cardiac biomarkers. MEASUREMENT AND MAIN RESULTS Thirty children (70% males) were recruited, six had WHO shock, all of whom died (6/6) versus three of 24 deaths in the non-WHO shock. Median fluid volume received by survivors and nonsurvivors were similar (13 [interquartile range (IQR), 9-32] vs 30 mL/kg [28-61 mL/kg], z = 1.62, p = 0.23). By 24 hours, we observed increases in median (IQR) stroke volume index (39 mL/m 2 [32-42 mL/m 2 ] to 47 mL/m 2 [41-49 mL/m 2 ]) and a measure of systolic function: fractional shortening from 30 (27-33) to 34 (31-38) from baseline including children managed with no-bolus. Children with WHO shock had a higher mean level of cardiac troponin ( t = 3.58; 95% CI, 1.24-1.43; p = 0.02) and alpha-atrial natriuretic peptide ( t = 16.5; 95% CI, 2.80-67.5; p < 0.01) at admission compared with non-WHO shock. Elevated troponin (> 0.1 μg/mL) and hyperlactatemia (> 4 mmol/L) were putative makers predicting outcome. CONCLUSIONS Maintenance-only fluid therapy normalized clinical and myocardial perturbations in shock without compromising cardiac or hemodynamic function whereas fluid-bolus management of WHO shock resulted in high fatality. Troponin and lactate biomarkers of cardiac dysfunction could be promising outcome predictors in pediatric septic shock in resource-limited settings.
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Affiliation(s)
- Nchafatso G Obonyo
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
- Initiative to Develop African Research Leaders, Kilifi, Kenya
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
| | - Peter Olupot-Olupot
- Initiative to Develop African Research Leaders, Kilifi, Kenya
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
- Busitema University, Faculty of Health sciences, Mbale, Uganda
| | - Ayub Mpoya
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Martin Chebet
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
- Busitema University, Faculty of Health sciences, Mbale, Uganda
| | - Sophie Uyoga
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
- Initiative to Develop African Research Leaders, Kilifi, Kenya
| | - Rita Muhindo
- Mbale Clinical Research Institute, Department of Paediatrics, Mbale, Uganda
| | - Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- Faculty of Medicine, University of Queensland, Brisbane, VIC, Australia
| | - Kenji Shiino
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Jonathan Chan
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, VIC, Australia
- Faculty of Medicine, University of Queensland, Brisbane, VIC, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Kathryn Maitland
- Kenya Medical Research Institute, Clinical Sciences Department, Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease and Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, United Kingdom
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16
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Olupot‐Olupot P, Connon R, Kiguli S, Opoka RO, Alaroker F, Uyoga S, Nakuya M, Okiror W, Nteziyaremye J, Ssenyondo T, Nabawanuka E, Kayaga J, Williams Mukisa C, Amorut D, Muhindo R, Frost G, Walsh K, Macharia AW, Gibb DM, Walker AS, George EC, Maitland K, Williams TN. A predictive algorithm for identifying children with sickle cell anemia among children admitted to hospital with severe anemia in Africa. Am J Hematol 2022; 97:527-536. [PMID: 35147242 PMCID: PMC7612591 DOI: 10.1002/ajh.26492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/22/2021] [Revised: 01/27/2022] [Accepted: 01/29/2022] [Indexed: 01/27/2023]
Abstract
Sickle cell anemia (SCA) is common in sub-Saharan Africa where approximately 1% of births are affected. Severe anemia is a common cause for hospital admission within the region yet few studies have investigated the contribution made by SCA. The Transfusion and Treatment of severe anemia in African Children Trial (ISRCTN84086586) investigated various treatment strategies in 3983 children admitted with severe anemia (hemoglobin < 6.0 g/dl) based on two severity strata to four hospitals in Africa (three Uganda and one Malawi). Children with known-SCA were excluded from the uncomplicated stratum and capped at 25% in the complicated stratum. All participants were genotyped for SCA at trial completion. SCA was rare in Malawi (six patients overall), so here we focus on the participants recruited in Uganda. We present baseline characteristics by SCA status and propose an algorithm for identifying children with unknown-SCA. Overall, 430 (12%) and 608 (17%) of the 3483 Ugandan participants had known- or unknown-SCA, respectively. Children with SCA were less likely to be malaria-positive and more likely to have an affected sibling, have gross splenomegaly, or to have received a previous blood transfusion. Most outcomes, including mortality and readmission, were better in children with either known or unknown-SCA than non-SCA children. A simple algorithm based on seven admission criteria detected 73% of all children with unknown-SCA with a number needed to test to identify one new SCA case of only two. Our proposed algorithm offers an efficient and cost-effective approach to identifying children with unknown-SCA among all children admitted with severe anemia to African hospitals where screening is not widely available.
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Affiliation(s)
- Peter Olupot‐Olupot
- Busitema University Faculty of Health SciencesMbale Regional Referral HospitalMbaleUganda
- Mbale Clinical Research InstituteMbaleUganda
| | - Roisin Connon
- Medical Research Council Clinical Trials Unit (MRC CTU)University College LondonLondonUK
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, School of MedicineMakerere UniversityKampalaUganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, School of MedicineMakerere UniversityKampalaUganda
| | | | - Sophie Uyoga
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeKilifiKenya
| | | | | | - Julius Nteziyaremye
- Busitema University Faculty of Health SciencesMbale Regional Referral HospitalMbaleUganda
- Mbale Clinical Research InstituteMbaleUganda
| | | | - Eva Nabawanuka
- Department of Paediatrics and Child Health, School of MedicineMakerere UniversityKampalaUganda
| | - Juliana Kayaga
- Department of Paediatrics and Child Health, School of MedicineMakerere UniversityKampalaUganda
| | - Cynthia Williams Mukisa
- Department of Paediatrics and Child Health, School of MedicineMakerere UniversityKampalaUganda
| | | | | | - Gary Frost
- Section for Nutrition Research, Department of Metabolism, Digestion and ReproductionImperial CollegeLondonUK
| | - Kevin Walsh
- Section for Nutrition Research, Department of Metabolism, Digestion and ReproductionImperial CollegeLondonUK
| | - Alexander W. Macharia
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit (MRC CTU)University College LondonLondonUK
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit (MRC CTU)University College LondonLondonUK
| | - Elizabeth C. George
- Medical Research Council Clinical Trials Unit (MRC CTU)University College LondonLondonUK
| | - Kathryn Maitland
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeKilifiKenya
- Department of Surgery and Cancer, Institute of Global Health and InnovationImperial CollegeLondonUK
| | - Thomas N. Williams
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeKilifiKenya
- Department of Surgery and Cancer, Institute of Global Health and InnovationImperial CollegeLondonUK
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17
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George EC, Uyoga S, M'baya B, Kyeyune Byabazair D, Kiguli S, Olupot-Olupot P, Opoka RO, Chagaluka G, Alaroker F, Williams TN, Bates I, Mbanya D, Gibb DM, Walker AS, Maitland K. Whole blood versus red cell concentrates for children with severe anaemia: a secondary analysis of the Transfusion and Treatment of African Children (TRACT) trial. Lancet Glob Health 2022; 10:e360-e368. [PMID: 35180419 PMCID: PMC8864302 DOI: 10.1016/s2214-109x(21)00565-9] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/23/2021] [Accepted: 11/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The TRACT trial established the timing of transfusion in children with uncomplicated anaemia (haemoglobin 4-6 g/dL) and the optimal volume (20 vs 30 mL/kg whole blood or 10 vs 15 mL/kg red cell concentrates) for transfusion in children admitted to hospital with severe anaemia (haemoglobin <6 g/dL) on day 28 mortality (primary endpoint). Because data on the safety of blood components are scarce, we conducted a secondary analysis to examine the safety and efficacy of different pack types (whole blood vs red cell concentrates) on clinical outcomes. METHODS This study is a secondary analysis of the TRACT trial data restricted to those who received an immediate transfusion (using whole blood or red cell concentrates). TRACT was an open-label, multicentre, factorial, randomised trial conducted in three hospitals in Uganda (Soroti, Mbale, and Mulago) and one hospital in Malawi (Blantyre). The trial enrolled children aged between 2 months and 12 years admitted to hospital with severe anaemia (haemoglobin <6 g/dL). The pack type used (supplied by blood banks) was based only on availability at the time. The outcomes were haemoglobin recovery at 8 h and 180 days, requirement for retransfusion, length of hospital stay, changes in heart and respiratory rates until day 180, and the main clinical endpoints (mortality until day 28 and day 180, and readmission until day 180), measured using multivariate regression models. FINDINGS Between Sept 17, 2014, and May 15, 2017, 3199 children with severe anaemia were enrolled into the TRACT trial. 3188 children were considered in our secondary analysis. The median age was 37 months (IQR 18-64). Whole blood was the first pack provided for 1632 (41%) of 3992 transfusions. Haemoglobin recovery at 8 h was significantly lower in those who received packed cells or settled cells than those who received whole blood, with a mean of 1·4 g/dL (95% CI -1·6 to -1·1) in children who received 30 mL/kg and -1·3 g/dL (-1·5 to -1·0) in those who received 20 mL/kg packed cells versus whole blood, and -1·5 g/dL (-1·7 to -1·3) in those who received 30 mL/kg and -1·0 g/dL (-1·2 to -0·9) in those who received 20 mL/kg settled cells versus whole blood (overall p<0·0001). Compared to whole blood, children who received blood as packed or settled cells in their first transfusion had higher odds of receiving a second transfusion (odds ratio 2·32 [95% CI 1·30 to 4·12] for packed cells and 2·97 [2·18 to 4·05] for settled cells; p<0·001) and longer hospital stays (hazard ratio 0·94 [95% CI 0·81 to 1·10] for packed cells and 0·86 [0·79 to 0·94] for settled cells; p=0·0024). There was no association between the type of blood supplied for the first transfusion and mortality at 28 days or 180 days, or readmission to hospital for any cause. 823 (26%) of 3188 children presented with severe tachycardia and 2077 (65%) with tachypnoea, but these complications resolved over time. No child developed features of confirmed cardiopulmonary overload. INTERPRETATION Our study suggests that the use of packed or settled cells rather than whole blood leads to additional transfusions, increasing the use of a scarce resource in most of sub-Saharan Africa. These findings have substantial cost implications for blood transfusion and health services. Nevertheless, a clinical trial comparing whole blood transfusion with red cell concentrates might be needed to inform policy makers. FUNDING UK Medical Research Council (MRC) and the Department for International Development. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Elizabeth C George
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Sophie Uyoga
- Kenya Medical Research Institute, Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - Sarah Kiguli
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Uganda
| | - Peter Olupot-Olupot
- Busitema University Faculty of Health Sciences, Mbale Regional Referral Hospital, Mbale, Uganda; Mbale Clinical Research Institute, Mbale, Uganda
| | - Robert O Opoka
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Uganda
| | - George Chagaluka
- College of Medicine, Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | | | - Thomas N Williams
- Kenya Medical Research Institute, Wellcome Trust Research Programme, Kilifi, Kenya; Department of Infectious Disease, Institute of Global Health and Innovation, Imperial College London, London, UK
| | - Imelda Bates
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Dora Mbanya
- Haematology and Transfusion Service, Centre Hospitalier et Universitaire, Yaounde, Cameroon
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - A Sarah Walker
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Kathryn Maitland
- Kenya Medical Research Institute, Wellcome Trust Research Programme, Kilifi, Kenya; Department of Infectious Disease, Institute of Global Health and Innovation, Imperial College London, London, UK.
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18
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Ojal J, Brand SPC, Were V, Okiro EA, Kombe IK, Mburu C, Aziza R, Ogero M, Agweyu A, Warimwe GM, Uyoga S, Adetifa IMO, Scott JAG, Otieno E, Ochola-Oyier LI, Agoti CN, Kasera K, Amoth P, Mwangangi M, Aman R, Ng’ang’a W, Tsofa B, Bejon P, Barasa E, Keeling MJ, Nokes DJ. Revealing the extent of the first wave of the COVID-19 pandemic in Kenya based on serological and PCR-test data. Wellcome Open Res 2022; 6:127. [PMID: 36187498 PMCID: PMC9511207 DOI: 10.12688/wellcomeopenres.16748.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Accepted: 02/14/2022] [Indexed: 02/02/2023] Open
Abstract
Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.
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Affiliation(s)
- John Ojal
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Samuel P. C. Brand
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Vincent Were
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research programme, Nairobi, Kenya
| | - Ivy K. Kombe
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Caroline Mburu
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Rabia Aziza
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Morris Ogero
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - George M. Warimwe
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Sophie Uyoga
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Ifedayo M. O. Adetifa
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - J. Anthony G. Scott
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Edward Otieno
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Charles N. Agoti
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- School of Public Health, Pwani University, Kilifi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Wangari Ng’ang’a
- Presidential Policy & Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Benjamin Tsofa
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Philip Bejon
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Edwine Barasa
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matt J. Keeling
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
| | - D. James Nokes
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
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19
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Etyang AO, Lucinde R, Karanja H, Kalu C, Mugo D, Nyagwange J, Gitonga J, Tuju J, Wanjiku P, Karani A, Mutua S, Maroko H, Nzomo E, Maitha E, Kamuri E, Kaugiria T, Weru J, Ochola LB, Kilimo N, Charo S, Emukule N, Moracha W, Mukabi D, Okuku R, Ogutu M, Angujo B, Otiende M, Bottomley C, Otieno E, Ndwiga L, Nyaguara A, Voller S, Agoti CN, Nokes DJ, Ochola-Oyier LI, Aman R, Amoth P, Mwangangi M, Kasera K, Ng’ang’a W, Adetifa IMO, Wangeci Kagucia E, Gallagher K, Uyoga S, Tsofa B, Barasa E, Bejon P, Scott JAG, Agweyu A, Warimwe GM. Seroprevalence of Antibodies to Severe Acute Respiratory Syndrome Coronavirus 2 Among Healthcare Workers in Kenya. Clin Infect Dis 2022; 74:288-293. [PMID: 33893491 PMCID: PMC8135298 DOI: 10.1093/cid/ciab346] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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: 03/15/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Few studies have assessed the seroprevalence of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among healthcare workers (HCWs) in Africa. We report findings from a survey among HCWs in 3 counties in Kenya. METHODS We recruited 684 HCWs from Kilifi (rural), Busia (rural), and Nairobi (urban) counties. The serosurvey was conducted between 30 July and 4 December 2020. We tested for immunoglobulin G antibodies to SARS-CoV-2 spike protein, using enzyme-linked immunosorbent assay. Assay sensitivity and specificity were 92.7 (95% CI, 87.9-96.1) and 99.0% (95% CI, 98.1-99.5), respectively. We adjusted prevalence estimates, using bayesian modeling to account for assay performance. RESULTS The crude overall seroprevalence was 19.7% (135 of 684). After adjustment for assay performance, seroprevalence was 20.8% (95% credible interval, 17.5%-24.4%). Seroprevalence varied significantly (P < .001) by site: 43.8% (95% credible interval, 35.8%-52.2%) in Nairobi, 12.6% (8.8%-17.1%) in Busia and 11.5% (7.2%-17.6%) in Kilifi. In a multivariable model controlling for age, sex, and site, professional cadre was not associated with differences in seroprevalence. CONCLUSION These initial data demonstrate a high seroprevalence of antibodies to SARS-CoV-2 among HCWs in Kenya. There was significant variation in seroprevalence by region, but not by cadre.
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Affiliation(s)
| | - Ruth Lucinde
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Henry Karanja
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Daisy Mugo
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - John Gitonga
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - James Tuju
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Angela Karani
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Hosea Maroko
- KEMRI Center for Infectious and Parasitic Diseases Control Research, Alupe, Kenya
| | | | | | | | | | | | | | | | | | | | | | - David Mukabi
- Department of Health, Busia County, Busia, Kenya
| | | | | | | | - Mark Otiende
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christian Bottomley
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Edward Otieno
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Amek Nyaguara
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shirine Voller
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | | | - Wangari Ng’ang’a
- Presidential Policy and Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Ifedayo M O Adetifa
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Katherine Gallagher
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sophie Uyoga
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Edwine Barasa
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - J Anthony G Scott
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - George M Warimwe
- KEMRI–Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
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20
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Gilchrist JJ, Kariuki SN, Watson JA, Band G, Uyoga S, Ndila CM, Mturi N, Mwarumba S, Mohammed S, Mosobo M, Alasoo K, Rockett KA, Mentzer AJ, Kwiatkowski DP, Hill AVS, Maitland K, Scott JAG, Williams TN. BIRC6 modifies risk of invasive bacterial infection in Kenyan children. eLife 2022; 11:77461. [PMID: 35866869 PMCID: PMC9391038 DOI: 10.7554/elife.77461] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 01/31/2022] [Accepted: 07/22/2022] [Indexed: 11/23/2022] Open
Abstract
Invasive bacterial disease is a major cause of morbidity and mortality in African children. Despite being caused by diverse pathogens, children with sepsis are clinically indistinguishable from one another. In spite of this, most genetic susceptibility loci for invasive infection that have been discovered to date are pathogen specific and are not therefore suggestive of a shared genetic architecture of bacterial sepsis. Here, we utilise probabilistic diagnostic models to identify children with a high probability of invasive bacterial disease among critically unwell Kenyan children with Plasmodium falciparum parasitaemia. We construct a joint dataset including 1445 bacteraemia cases and 1143 severe malaria cases, and population controls, among critically unwell Kenyan children that have previously been genotyped for human genetic variation. Using these data, we perform a cross-trait genome-wide association study of invasive bacterial infection, weighting cases according to their probability of bacterial disease. In doing so, we identify and validate a novel risk locus for invasive infection secondary to multiple bacterial pathogens, that has no apparent effect on malaria risk. The locus identified modifies splicing of BIRC6 in stimulated monocytes, implicating regulation of apoptosis and autophagy in the pathogenesis of sepsis in Kenyan children.
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Affiliation(s)
- James J Gilchrist
- Department of Paediatrics, University of OxfordOxfordUnited Kingdom,MRC–Weatherall Institute of Molecular Medicine, University of OxfordOxfordUnited Kingdom,Wellcome Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Silvia N Kariuki
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - James A Watson
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
| | - Gavin Band
- Wellcome Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Carolyne M Ndila
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Neema Mturi
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Salim Mwarumba
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Shebe Mohammed
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Moses Mosobo
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Kaur Alasoo
- Institute of Computer Science, University of TartuTartuEstonia
| | - Kirk A Rockett
- Wellcome Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Alexander J Mentzer
- Wellcome Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Dominic P Kwiatkowski
- Wellcome Centre for Human Genetics, University of OxfordOxfordUnited Kingdom,Wellcome Sanger InstituteCambridgeUnited Kingdom
| | - Adrian VS Hill
- Wellcome Centre for Human Genetics, University of OxfordOxfordUnited Kingdom,The Jenner Institute, University of OxfordOxfordUnited Kingdom
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya,Division of Medicine, Imperial CollegeLondonUnited Kingdom
| | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya,Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial CollegeLondonUnited Kingdom
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21
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Nyagwange J, Kutima B, Mwai K, Karanja HK, Gitonga JN, Mugo D, Uyoga S, Tuju J, Ochola-Oyier LI, Ndungu F, Bejon P, Agweyu A, Adetifa IMO, Scott JAG, Warimwe GM. Comparative performance of WANTAI ELISA for total immunoglobulin to receptor binding protein and an ELISA for IgG to spike protein in detecting SARS-CoV-2 antibodies in Kenyan populations. J Clin Virol 2022; 146:105061. [PMID: 34973474 PMCID: PMC8711170 DOI: 10.1016/j.jcv.2021.105061] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/22/2021] [Indexed: 12/24/2022]
Abstract
Many SARS-CoV-2 antibody detection assays have been developed but their differential performance is not well described. In this study we compared an in-house (KWTRP) ELISA which has been used extensively to estimate seroprevalence in the Kenyan population with WANTAI, an ELISA which has been approved for widespread use by the WHO. Using a wide variety of sample sets including pre-pandemic samples (negative gold standard), SARS-CoV-2 PCR positive samples (positive gold standard) and COVID-19 test samples from different periods (unknowns), we compared performance characteristics of the two assays. The overall concordance between WANTAI and KWTRP was 0.97 (95% CI, 0.95-0.98). For WANTAI and KWTRP, sensitivity was 0.95 (95% CI 0.90-0.98) and 0.93 (95% CI 0.87-0.96), respectively. Specificity for WANTAI was 0.98 (95% CI, 0.96-0.99) and 0.99 (95% CI 0.96-1.00) while KWTRP specificity was 0.99 (95% CI, 0.98-1.00) and 1.00 using pre-pandemic blood donors and pre-pandemic malaria cross-sectional survey samples respectively. Both assays show excellent characteristics to detect SARS-CoV-2 antibodies.
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Affiliation(s)
- James Nyagwange
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya.
| | | | - Kennedy Mwai
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Parktown 2193, Johannesburg, South Africa
| | - Henry K Karanja
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - John N Gitonga
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Daisy Mugo
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - James Tuju
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | | | - Francis Ndungu
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya; Nuffield Department of Medicine, Oxford University, OX3 7BN, Oxford, United Kingdom
| | - Ambrose Agweyu
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Ifedayo M O Adetifa
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya; Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, WC1E 7HT, Keppel Street, London, United Kingdom
| | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya; Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, WC1E 7HT, Keppel Street, London, United Kingdom
| | - George M Warimwe
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya; Nuffield Department of Medicine, Oxford University, OX3 7BN, Oxford, United Kingdom
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22
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Lucinde RK, Mugo D, Bottomley C, Karani A, Gardiner E, Aziza R, Gitonga JN, Karanja H, Nyagwange J, Tuju J, Wanjiku P, Nzomo E, Kamuri E, Thuranira K, Agunda S, Nyutu G, Etyang AO, Adetifa IMO, Kagucia E, Uyoga S, Otiende M, Otieno E, Ndwiga L, Agoti CN, Aman RA, Mwangangi M, Amoth P, Kasera K, Nyaguara A, Ng’ang’a W, Ochola LB, Namdala E, Gaunya O, Okuku R, Barasa E, Bejon P, Tsofa B, Ochola-Oyier LI, Warimwe GM, Agweyu A, Scott JAG, Gallagher KE. Sero-surveillance for IgG to SARS-CoV-2 at antenatal care clinics in three Kenyan referral hospitals: Repeated cross-sectional surveys 2020-21. PLoS One 2022; 17:e0265478. [PMID: 36240176 PMCID: PMC9565697 DOI: 10.1371/journal.pone.0265478] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 09/13/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The high proportion of SARS-CoV-2 infections that have remained undetected presents a challenge to tracking the progress of the pandemic and estimating the extent of population immunity. METHODS We used residual blood samples from women attending antenatal care services at three hospitals in Kenya between August 2020 and October 2021and a validated IgG ELISA for SARS-Cov-2 spike protein and adjusted the results for assay sensitivity and specificity. We fitted a two-component mixture model as an alternative to the threshold analysis to estimate of the proportion of individuals with past SARS-CoV-2 infection. RESULTS We estimated seroprevalence in 2,981 women; 706 in Nairobi, 567 in Busia and 1,708 in Kilifi. By October 2021, 13% of participants were vaccinated (at least one dose) in Nairobi, 2% in Busia. Adjusted seroprevalence rose in all sites; from 50% (95%CI 42-58) in August 2020, to 85% (95%CI 78-92) in October 2021 in Nairobi; from 31% (95%CI 25-37) in May 2021 to 71% (95%CI 64-77) in October 2021 in Busia; and from 1% (95% CI 0-3) in September 2020 to 63% (95% CI 56-69) in October 2021 in Kilifi. Mixture modelling, suggests adjusted cross-sectional prevalence estimates are underestimates; seroprevalence in October 2021 could be 74% in Busia and 72% in Kilifi. CONCLUSIONS There has been substantial, unobserved transmission of SARS-CoV-2 in Nairobi, Busia and Kilifi Counties. Due to the length of time since the beginning of the pandemic, repeated cross-sectional surveys are now difficult to interpret without the use of models to account for antibody waning.
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Affiliation(s)
- Ruth K. Lucinde
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- * E-mail:
| | - Daisy Mugo
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christian Bottomley
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angela Karani
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Rabia Aziza
- School of Life Sciences and the Zeeman Institute for Systems Biology & Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, United Kingdom
| | | | - Henry Karanja
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - James Tuju
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Edward Nzomo
- Kilifi County Hospital, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Evans Kamuri
- Kenyatta National Hospital, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Kaugiria Thuranira
- Kenyatta National Hospital, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Sarah Agunda
- Kenyatta National Hospital, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Gideon Nyutu
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Ifedayo M. O. Adetifa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Edward Otieno
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Amek Nyaguara
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Wangari Ng’ang’a
- Presidential Policy and Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | | | | | - Oscar Gaunya
- Busia Country Teaching & Referral Hospital, Busia, Kenya
| | - Rosemary Okuku
- Busia Country Teaching & Referral Hospital, Busia, Kenya
| | - Edwine Barasa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | | | - George M. Warimwe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | - J. Anthony G. Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Katherine E. Gallagher
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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23
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Brand SPC, Ojal J, Aziza R, Were V, Okiro EA, Kombe IK, Mburu C, Ogero M, Agweyu A, Warimwe GM, Nyagwange J, Karanja H, Gitonga JN, Mugo D, Uyoga S, Adetifa IMO, Scott JAG, Otieno E, Murunga N, Otiende M, Ochola-Oyier LI, Agoti CN, Githinji G, Kasera K, Amoth P, Mwangangi M, Aman R, Ng’ang’a W, Tsofa B, Bejon P, Keeling MJ, Nokes DJ, Barasa E. COVID-19 transmission dynamics underlying epidemic waves in Kenya. Science 2021; 374:989-994. [PMID: 34618602 PMCID: PMC7612211 DOI: 10.1126/science.abk0414] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [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: 06/17/2021] [Accepted: 10/04/2021] [Indexed: 01/16/2023]
Abstract
Policy decisions on COVID-19 interventions should be informed by a local, regional and national understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. Epidemic waves may result when restrictions are lifted or poorly adhered to, variants with new phenotypic properties successfully invade, or infection spreads to susceptible subpopulations. Three COVID-19 epidemic waves have been observed in Kenya. Using a mechanistic mathematical model, we explain the first two distinct waves by differences in contact rates in high and low social-economic groups, and the third wave by the introduction of higher-transmissibility variants. Reopening schools led to a minor increase in transmission between the second and third waves. Socioeconomic and urban–rural population structure are critical determinants of viral transmission in Kenya.
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Affiliation(s)
- Samuel P. C. Brand
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Warwick, UK
- School of Life Sciences, University of Warwick, Warwick, UK
| | - John Ojal
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Rabia Aziza
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Warwick, UK
- School of Life Sciences, University of Warwick, Warwick, UK
| | - Vincent Were
- Health Economics Research Unit, KEMRI–Wellcome Trust Research Programme, Nairobi, Kenya
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute–Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ivy K Kombe
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Caroline Mburu
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - George M. Warimwe
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James Nyagwange
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Henry Karanja
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - John N. Gitonga
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Daisy Mugo
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Sophie Uyoga
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Ifedayo M. O. Adetifa
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - J. Anthony G. Scott
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Edward Otieno
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Nickson Murunga
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Mark Otiende
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Lynette I. Ochola-Oyier
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Charles N. Agoti
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - George Githinji
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Wangari Ng’ang’a
- Presidential Policy and Strategy Unit, The Presidency, Government of Kenya
| | - Benjamin Tsofa
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
| | - Philip Bejon
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matt. J. Keeling
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Warwick, UK
- School of Life Sciences, University of Warwick, Warwick, UK
- Mathematics Institute, University of Warwick, Warwick, UK
| | - D. James Nokes
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme (KWTRP), Kilifi, Kenya
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Warwick, UK
- School of Life Sciences, University of Warwick, Warwick, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI–Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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24
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Bottomley C, Otiende M, Uyoga S, Gallagher K, Kagucia EW, Etyang AO, Mugo D, Gitonga J, Karanja H, Nyagwange J, Adetifa IMO, Agweyu A, Nokes DJ, Warimwe GM, Scott JAG. Quantifying previous SARS-CoV-2 infection through mixture modelling of antibody levels. Nat Commun 2021; 12:6196. [PMID: 34702829 PMCID: PMC8548402 DOI: 10.1038/s41467-021-26452-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 04/23/2021] [Accepted: 09/17/2021] [Indexed: 11/09/2022] Open
Abstract
As countries decide on vaccination strategies and how to ease movement restrictions, estimating the proportion of the population previously infected with SARS-CoV-2 is important for predicting the future burden of COVID-19. This proportion is usually estimated from serosurvey data in two steps: first the proportion above a threshold antibody level is calculated, then the crude estimate is adjusted using external estimates of sensitivity and specificity. A drawback of this approach is that the PCR-confirmed cases used to estimate the sensitivity of the threshold may not be representative of cases in the wider population-e.g., they may be more recently infected and more severely symptomatic. Mixture modelling offers an alternative approach that does not require external data from PCR-confirmed cases. Here we illustrate the bias in the standard threshold-based approach by comparing both approaches using data from several Kenyan serosurveys. We show that the mixture model analysis produces estimates of previous infection that are often substantially higher than the standard threshold analysis.
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Affiliation(s)
- C Bottomley
- International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - M Otiende
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - S Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - K Gallagher
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - E W Kagucia
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - A O Etyang
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - D Mugo
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - J Gitonga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - H Karanja
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - J Nyagwange
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - I M O Adetifa
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - A Agweyu
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - D J Nokes
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- School of Life Sciences, University of Warwick, Coventry, UK
| | - G M Warimwe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - J A G Scott
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
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25
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Kagucia EW, Gitonga JN, Kalu C, Ochomo E, Ochieng B, Kuya N, Karani A, Nyagwange J, Karia B, Mugo D, Karanja HK, Tuju J, Mutiso A, Maroko H, Okubi L, Maitha E, Ajuck H, Mukabi D, Moracha W, Bulimu D, Andanje N, Aman R, Mwangangi M, Amoth P, Kasera K, Ng'ang'a W, Nyaguara A, Voller S, Otiende M, Bottomley C, Agoti CN, Ochola-Oyier LI, Adetifa IMO, Etyang AO, Gallagher KE, Uyoga S, Barasa E, Bejon P, Tsofa B, Agweyu A, Warimwe GM, Scott JAG. Anti-Severe Acute Respiratory Syndrome Coronavirus 2 Immunoglobulin G Antibody Seroprevalence Among Truck Drivers and Assistants in Kenya. Open Forum Infect Dis 2021; 8:ofab314. [PMID: 34660838 PMCID: PMC8519263 DOI: 10.1093/ofid/ofab314] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 05/06/2021] [Accepted: 06/09/2021] [Indexed: 11/14/2022] Open
Abstract
In October 2020, anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G seroprevalence among truck drivers and their assistants (TDA) in Kenya was 42.3%, higher than among healthcare workers and blood donors. Truck drivers and their assistants transport essential supplies during the coronavirus disease 2019 pandemic, placing them at increased risk of being infected and of transmitting SARS-CoV-2 over a wide geographical area.
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Affiliation(s)
| | | | | | - Eric Ochomo
- KEMRI Centre for Global Health Research (CGHR), Kisumu, Kenya
| | - Benard Ochieng
- KEMRI Centre for Global Health Research (CGHR), Kisumu, Kenya
| | - Nickline Kuya
- KEMRI Centre for Global Health Research (CGHR), Kisumu, Kenya
| | - Angela Karani
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - Daisy Mugo
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - James Tuju
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Agnes Mutiso
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Hosea Maroko
- KEMRI Centre for Infectious and Parasitic Diseases Control Research, Busia, Kenya
| | - Lucy Okubi
- KEMRI Centre for Infectious and Parasitic Diseases Control Research, Busia, Kenya
| | | | | | | | | | | | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Wangari Ng'ang'a
- Presidential Policy and Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Amek Nyaguara
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shirine Voller
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christian Bottomley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Ifedayo M O Adetifa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Katherine E Gallagher
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Edwine Barasa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | | | - George M Warimwe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
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26
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Uyoga S, Adetifa IMO, Otiende M, Yegon C, Agweyu A, Warimwe GM, Scott JAG. Prevalence of SARS-CoV-2 Antibodies From a National Serosurveillance of Kenyan Blood Donors, January-March 2021. JAMA 2021; 326:1436-1438. [PMID: 34473191 PMCID: PMC8414357 DOI: 10.1001/jama.2021.15265] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study examines the prevalence of SARS-CoV-2 antibodies among blood donors aged 16 to 64 years in Kenya from January to March 2021.
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Affiliation(s)
- Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christine Yegon
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
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27
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Connon R, George EC, Olupot-Olupot P, Kiguli S, Chagaluka G, Alaroker F, Opoka RO, Mpoya A, Walsh K, Engoru C, Nteziyaremye J, Mallewa M, Kennedy N, Nakuya M, Namayanja C, Nabawanuka E, Sennyondo T, Amorut D, Williams Musika C, Bates I, Boele van Hensbroek M, Evans JA, Uyoga S, Williams TN, Frost G, Gibb DM, Maitland K, Walker AS. Incidence and predictors of hospital readmission in children presenting with severe anaemia in Uganda and Malawi: a secondary analysis of TRACT trial data. BMC Public Health 2021; 21:1480. [PMID: 34325680 PMCID: PMC8323322 DOI: 10.1186/s12889-021-11481-6] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Severe anaemia (haemoglobin < 6 g/dL) is a leading cause of recurrent hospitalisation in African children. We investigated predictors of readmission in children hospitalised with severe anaemia in the TRACT trial (ISRCTN84086586) in order to identify potential future interventions. METHODS Secondary analyses of the trial examined 3894 children from Uganda and Malawi surviving a hospital episode of severe anaemia. Predictors of all-cause readmission within 180 days of discharge were identified using multivariable regression with death as a competing risk. Groups of children with similar characteristics were identified using hierarchical clustering. RESULTS Of the 3894 survivors 682 (18%) were readmitted; 403 (10%) had ≥2 re-admissions over 180 days. Three main causes of readmission were identified: severe anaemia (n = 456), malaria (n = 252) and haemoglobinuria/dark urine syndrome (n = 165). Overall, factors increasing risk of readmission included HIV-infection (hazard ratio 2.48 (95% CI 1.63-3.78), p < 0.001); ≥2 hospital admissions in the preceding 12 months (1.44(1.19-1.74), p < 0.001); history of transfusion (1.48(1.13-1.93), p = 0.005); and missing ≥1 trial medication dose (proxy for care quality) (1.43 (1.21-1.69), p < 0.001). Children with uncomplicated severe anaemia (Hb 4-6 g/dL and no severity features), who never received a transfusion (per trial protocol) during the initial admission had a substantially lower risk of readmission (0.67(0.47-0.96), p = 0.04). Malaria (among children with no prior history of transfusion) (0.60(0.47-0.76), p < 0.001); younger-age (1.07 (1.03-1.10) per 1 year younger, p < 0.001) and known sickle cell disease (0.62(0.46-0.82), p = 0.001) also decreased risk of readmission. For anaemia re-admissions, gross splenomegaly and enlarged spleen increased risk by 1.73(1.23-2.44) and 1.46(1.18-1.82) respectively compared to no splenomegaly. Clustering identified four groups of children with readmission rates from 14 to 20%. The cluster with the highest readmission rate was characterised by very low haemoglobin (mean 3.6 g/dL). Sickle Cell Disease (SCD) predominated in two clusters associated with chronic repeated admissions or severe, acute presentations in largely undiagnosed SCD. The final cluster had high rates of malaria (78%), severity signs and very low platelet count, consistent with acute severe malaria. CONCLUSIONS Younger age, HIV infection and history of previous hospital admissions predicted increased risk of readmission. However, no obvious clinical factors for intervention were identified. As missing medication doses was highly predictive, attention to care related factors may be important. TRIAL REGISTRATION ISRCTN ISRCTN84086586 .
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Affiliation(s)
- Roisin Connon
- MRC Clinical Trials Unit at University College London, 90 High Holborn, London, WC1V 6LJ, UK.
| | - Elizabeth C George
- MRC Clinical Trials Unit at University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Faculty of Health Sciences, Busitema University, PO Box 236, Tororo, Uganda
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, PO Box 7072, Kampala, Uganda
| | - George Chagaluka
- College of Medicine, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Robert O Opoka
- Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, PO Box 7072, Kampala, Uganda
| | - Ayub Mpoya
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Kevin Walsh
- Institute of Global Health and Innovation, Department of Medicine, Imperial College London, London, SW7 2AZ, UK
| | - Charles Engoru
- Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - Julius Nteziyaremye
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Faculty of Health Sciences, Busitema University, PO Box 236, Tororo, Uganda
| | - Macpherson Mallewa
- College of Medicine, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Neil Kennedy
- College of Medicine, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, UK
| | - Margaret Nakuya
- Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - Cate Namayanja
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Faculty of Health Sciences, Busitema University, PO Box 236, Tororo, Uganda
| | - Eva Nabawanuka
- Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, PO Box 7072, Kampala, Uganda
| | - Tonny Sennyondo
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Faculty of Health Sciences, Busitema University, PO Box 236, Tororo, Uganda
| | - Denis Amorut
- Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - C Williams Musika
- Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, PO Box 7072, Kampala, Uganda
| | - Imelda Bates
- Liverpool School of Tropical Medicine and Hygiene, Liverpool, UK
| | | | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Heath Park Cardiff, Cardiff, CF14 4XW, Wales
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
- Institute of Global Health and Innovation, Department of Medicine, Imperial College London, London, SW7 2AZ, UK
| | - Gary Frost
- Institute of Global Health and Innovation, Department of Medicine, Imperial College London, London, SW7 2AZ, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, 90 High Holborn, London, WC1V 6LJ, UK
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
- Institute of Global Health and Innovation, Department of Medicine, Imperial College London, London, SW7 2AZ, UK
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, 90 High Holborn, London, WC1V 6LJ, UK
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28
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Watson JA, Ndila CM, Uyoga S, Macharia A, Nyutu G, Mohammed S, Ngetsa C, Mturi N, Peshu N, Tsofa B, Rockett K, Leopold S, Kingston H, George EC, Maitland K, Day NPJ, Dondorp AM, Bejon P, Williams TN, Holmes CC, White NJ. Improving statistical power in severe malaria genetic association studies by augmenting phenotypic precision. eLife 2021; 10:e69698. [PMID: 34225842 PMCID: PMC8315799 DOI: 10.7554/elife.69698] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 04/22/2021] [Accepted: 06/22/2021] [Indexed: 12/14/2022] Open
Abstract
Severe falciparum malaria has substantially affected human evolution. Genetic association studies of patients with clinically defined severe malaria and matched population controls have helped characterise human genetic susceptibility to severe malaria, but phenotypic imprecision compromises discovered associations. In areas of high malaria transmission, the diagnosis of severe malaria in young children and, in particular, the distinction from bacterial sepsis are imprecise. We developed a probabilistic diagnostic model of severe malaria using platelet and white count data. Under this model, we re-analysed clinical and genetic data from 2220 Kenyan children with clinically defined severe malaria and 3940 population controls, adjusting for phenotype mis-labelling. Our model, validated by the distribution of sickle trait, estimated that approximately one-third of cases did not have severe malaria. We propose a data-tilting approach for case-control studies with phenotype mis-labelling and show that this reduces false discovery rates and improves statistical power in genome-wide association studies.
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Affiliation(s)
- James A Watson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Carolyne M Ndila
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Alexander Macharia
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Gideon Nyutu
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Shebe Mohammed
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Caroline Ngetsa
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Neema Mturi
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Norbert Peshu
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Benjamin Tsofa
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Kirk Rockett
- The Wellcome Sanger InstituteCambridgeUnited Kingdom
- Wellcome Trust Centre for Human Genetics, University of OxfordOxfordUnited Kingdom
| | - Stije Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Hugh Kingston
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit, University College LondonLondonUnited Kingdom
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
- Institute of Global Health Innovation, Imperial College, LondonLondonUnited Kingdom
| | - Nicholas PJ Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
| | - Philip Bejon
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-CoastKilifiKenya
- Institute of Global Health Innovation, Imperial College, LondonLondonUnited Kingdom
| | - Chris C Holmes
- Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
- Department of Statistics, University of OxfordOxfordUnited Kingdom
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol UniversityBangkokThailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of OxfordOxfordUnited Kingdom
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Adetifa IMO, Uyoga S, Gitonga JN, Mugo D, Otiende M, Nyagwange J, Karanja HK, Tuju J, Wanjiku P, Aman R, Mwangangi M, Amoth P, Kasera K, Ng'ang'a W, Rombo C, Yegon C, Kithi K, Odhiambo E, Rotich T, Orgut I, Kihara S, Bottomley C, Kagucia EW, Gallagher KE, Etyang A, Voller S, Lambe T, Wright D, Barasa E, Tsofa B, Bejon P, Ochola-Oyier LI, Agweyu A, Scott JAG, Warimwe GM. Temporal trends of SARS-CoV-2 seroprevalence during the first wave of the COVID-19 epidemic in Kenya. Nat Commun 2021; 12:3966. [PMID: 34172732 PMCID: PMC8233334 DOI: 10.1038/s41467-021-24062-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 02/19/2021] [Accepted: 05/25/2021] [Indexed: 12/17/2022] Open
Abstract
Observed SARS-CoV-2 infections and deaths are low in tropical Africa raising questions about the extent of transmission. We measured SARS-CoV-2 IgG by ELISA in 9,922 blood donors across Kenya and adjusted for sampling bias and test performance. By 1st September 2020, 577 COVID-19 deaths were observed nationwide and seroprevalence was 9.1% (95%CI 7.6-10.8%). Seroprevalence in Nairobi was 22.7% (18.0-27.7%). Although most people remained susceptible, SARS-CoV-2 had spread widely in Kenya with apparently low associated mortality.
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Affiliation(s)
- Ifedayo M O Adetifa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom.
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
| | | | - Daisy Mugo
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - James Tuju
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Wangari Ng'ang'a
- Presidential Policy & Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Charles Rombo
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Christine Yegon
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Khamisi Kithi
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Elizabeth Odhiambo
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Thomas Rotich
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Irene Orgut
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Sammy Kihara
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Christian Bottomley
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | | | - Katherine E Gallagher
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | | | - Shirine Voller
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
| | - Teresa Lambe
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Daniel Wright
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Edwine Barasa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | | | | | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - George M Warimwe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
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30
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Olupot-Olupot P, Okiror W, Mnjalla H, Muhindo R, Uyoga S, Mpoya A, Williams TN, terHeine R, Burger DM, Urban B, Connon R, George EC, Gibb DM, Walker AS, Maitland K. Pharmacokinetics and pharmacodynamics of azithromycin in severe malaria bacterial co-infection in African children (TABS-PKPD): a protocol for a Phase II randomised controlled trial. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16968.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: African children with severe malaria are susceptible to Gram-negative bacterial co-infection, largely non-typhoidal Salmonellae, leading to a substantially higher rates of in-hospital and post-discharge mortality than those without bacteraemia. Current evidence for treating co-infection is lacking, and there is no consensus on the dosage or length of treatment required. We therefore aimed to establish the appropriate dose of oral dispersible azithromycin as an antimicrobial treatment for children with severe malaria and to investigate whether antibiotics can be targeted to those at greatest risk of bacterial co-infection using clinical criteria alone or in combination with rapid diagnostic biomarker tests. Methods: A Phase I/II open-label trial comparing three doses of azithromycin: 10, 15 and 20 mg/kg spanning the lowest to highest mg/kg doses previously demonstrated to be equally effective as parenteral treatment for other salmonellae infection. Children with the highest risk of bacterial infection will receive five days of azithromycin and followed for 90 days. We will generate relevant pharmacokinetic data by sparse sampling during dosing intervals. We will use population pharmacokinetic modelling to determine the optimal azithromycin dose in severe malaria and investigate azithromycin exposure to change in C-reactive protein, a putative marker of sepsis at 72 hours, and microbiological cure (seven-day), alone and as a composite with seven-day survival. We will also evaluate whether a combination of clinical, point-of-care diagnostic tests, and/or biomarkers can accurately identify the sub-group of severe malaria with culture-proven bacteraemia by comparison with a control cohort of children hospitalized with severe malaria at low risk of bacterial co-infection. Discussion: We plan to study azithromycin because of its favourable microbiological spectrum, its inherent antimalarial and immunomodulatory properties and dosing and safety profile. This study will generate new data to inform the design and sample size for definitive Phase III trial evaluation. Registration: ISRCTN49726849 (27th October 2017).
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31
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Maitland K, Kiguli S, Olupot-Olupot P, Opoka RO, Chimalizeni Y, Alaroker F, Uyoga S, Kyeyune-Byabazaire D, M’baya B, Bates I, Williams TN, Munube D, Mbanya D, Molyneux EM, South A, Walker AS, Gibb DM, George EC. Transfusion management of severe anaemia in African children: a consensus algorithm. Br J Haematol 2021; 193:1247-1259. [PMID: 33955552 PMCID: PMC7611319 DOI: 10.1111/bjh.17429] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Received: 01/06/2021] [Accepted: 02/18/2021] [Indexed: 12/12/2022]
Abstract
The phase III Transfusion and Treatment of severe anaemia in African Children Trial (TRACT) found that conservative management of uncomplicated severe anaemia [haemoglobin (Hb) 40-60 g/l] was safe, and that transfusion volume (20 vs. 30 ml/kg whole blood equivalent) for children with severe anaemia (Hb <60 g/l) had strong but opposing effects on mortality, depending on fever status (>37·5°C). In 2020 a stakeholder meeting of paediatric and blood transfusion groups from Africa reviewed the results and additional analyses. Among all 3196 children receiving an initial transfusion there was no evidence that nutritional status, presence of shock, malaria parasite burden or sickle cell disease status influenced outcomes or modified the interaction with fever status on volume required. Fever status at the time of ordering blood was a reliable determinant of volume required for optimal outcome. Elevated heart and respiratory rates normalised irrespective of transfusion volume and without diuretics. By consensus, a transfusion management algorithm was developed, incorporating three additional measurements of Hb post-admission, alongside clinical monitoring. The proposed algorithm should help clinicians safely implement findings from TRACT. Further research should assess its implementation in routine clinical practice.
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Affiliation(s)
- Kathryn Maitland
- Department of Infectious Disease, Division of Medicine, Institute of Global Health and Innovation, Imperial College, London, UK
- Uganda Blood Transfusion Services (BTS), National BTS, Kampala, Uganda
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, Kampala
| | - Peter Olupot-Olupot
- Faculty of Health Sciences, Busitema University, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, Kampala
| | - Yami Chimalizeni
- College of Medicine, Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | | | - Sophie Uyoga
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - Imelda Bates
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas N. Williams
- Department of Infectious Disease, Division of Medicine, Institute of Global Health and Innovation, Imperial College, London, UK
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Deogratias Munube
- Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, Kampala
| | - Dora Mbanya
- Haematology & Transfusion Service, Centre Hospitalier et Universitaire, Yaounde, Cameroon
| | | | - Annabelle South
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
| | - Diana M. Gibb
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
| | - Elizabeth C. George
- Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK
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32
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Ojal J, Brand SPC, Were V, Okiro EA, Kombe IK, Mburu C, Aziza R, Ogero M, Agweyu A, Warimwe GM, Uyoga S, Adetifa IMO, Scott JAG, Otieno E, Ochola-Oyier LI, Agoti CN, Kasera K, Amoth P, Mwangangi M, Aman R, Ng’ang’a W, Tsofa B, Bejon P, Barasa E, Keeling MJ, Nokes DJ. Revealing the extent of the first wave of the COVID-19 pandemic in Kenya based on serological and PCR-test data. Wellcome Open Res 2021; 6:127. [PMID: 36187498 PMCID: PMC9511207 DOI: 10.12688/wellcomeopenres.16748.1] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 02/02/2023] Open
Abstract
Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.
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Affiliation(s)
- John Ojal
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Samuel P. C. Brand
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Vincent Were
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research programme, Nairobi, Kenya
| | - Ivy K. Kombe
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Caroline Mburu
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Rabia Aziza
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
| | - Morris Ogero
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - George M. Warimwe
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Sophie Uyoga
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Ifedayo M. O. Adetifa
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - J. Anthony G. Scott
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Edward Otieno
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Charles N. Agoti
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- School of Public Health, Pwani University, Kilifi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - Wangari Ng’ang’a
- Presidential Policy & Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Benjamin Tsofa
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
| | - Philip Bejon
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Edwine Barasa
- Health Economics Research Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matt J. Keeling
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
| | - D. James Nokes
- Kenya Medical Research Institute - Wellcome Trust Research programme, Kilifi, Kenya
- The Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research (SBIDER), University of Warwick, Coventry, UK
- School of Life Sciences, University of Warwick, Coventry, UK
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33
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Uyoga S, George EC, Bates I, Olupot-Olupot P, Chimalizeni Y, Molyneux EM, Maitland K. Point-of-care haemoglobin testing in African hospitals: a neglected essential diagnostic test. Br J Haematol 2021; 193:894-901. [PMID: 33993492 PMCID: PMC7611318 DOI: 10.1111/bjh.17431] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 01/06/2021] [Accepted: 03/02/2021] [Indexed: 11/28/2022]
Abstract
Owing to the rapid turnaround time in the assessment of haemoglobin level by point-of-care tests (POC Hb), these have grown in popularity and scope in large parts of the world. However, whilst POC testing for malaria and HIV remains has been integrated into patient management in Africa, the use of POC haemoglobin testing remains neglected by health services. The main users of transfusions (paediatric, maternity and trauma services) present largely as emergencies. Ward-based POC Hb could result in more rapid and accurate diagnosis of anaemia, contributing to saving of lives and at the same time reduce unnecessary transfusions which deplete the limited supplies of donated blood in Africa. Severe anaemia requiring transfusion is a major cause of paediatric admission in Africa. At a dissemination meeting to discuss the results of a large phase III paediatric transfusion trial and steps to implementation of the findings participants strongly recommended that one of the most pressing actions required was to prioritise the use of POC haemoglobin testing. This would facilitate implementation of the new transfusion algorithm, developed at the meeting, which refines patient management including blood transfusions. We present the rationale for the strongly recommended prioritisation of POC Hb, using paediatric transfusion as an exemplar.
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Affiliation(s)
- Sophie Uyoga
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit (MRC CTU) at University College, London, UK
| | - Imelda Bates
- Liverpool School of Tropical Medicine, Liverpool UK, Liverpool, UK
| | - Peter Olupot-Olupot
- Faculty of Health Sciences, Busitema University, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Yami Chimalizeni
- College of Medicine, Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | - Elizabeth M Molyneux
- College of Medicine, Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
| | - Kathryn Maitland
- Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Disease and Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
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34
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Uyoga S, Adetifa IMO, Karanja HK, Nyagwange J, Tuju J, Wanjiku P, Aman R, Mwangangi M, Amoth P, Kasera K, Ng'ang'a W, Rombo C, Yegon C, Kithi K, Odhiambo E, Rotich T, Orgut I, Kihara S, Otiende M, Bottomley C, Mupe ZN, Kagucia EW, Gallagher KE, Etyang A, Voller S, Gitonga JN, Mugo D, Agoti CN, Otieno E, Ndwiga L, Lambe T, Wright D, Barasa E, Tsofa B, Bejon P, Ochola-Oyier LI, Agweyu A, Scott JAG, Warimwe GM. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Kenyan blood donors. Science 2021; 371:79-82. [PMID: 33177105 PMCID: PMC7877494 DOI: 10.1126/science.abe1916] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [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: 08/20/2020] [Accepted: 11/06/2020] [Indexed: 12/13/2022]
Abstract
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Africa is poorly described. The first case of SARS-CoV-2 in Kenya was reported on 12 March 2020, and an overwhelming number of cases and deaths were expected, but by 31 July 2020, there were only 20,636 cases and 341 deaths. However, the extent of SARS-CoV-2 exposure in the community remains unknown. We determined the prevalence of anti-SARS-CoV-2 immunoglobulin G among blood donors in Kenya in April-June 2020. Crude seroprevalence was 5.6% (174 of 3098). Population-weighted, test-performance-adjusted national seroprevalence was 4.3% (95% confidence interval, 2.9 to 5.8%) and was highest in urban counties Mombasa (8.0%), Nairobi (7.3%), and Kisumu (5.5%). SARS-CoV-2 exposure is more extensive than indicated by case-based surveillance, and these results will help guide the pandemic response in Kenya and across Africa.
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Affiliation(s)
- Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Ifedayo M O Adetifa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | | | - James Tuju
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Wangari Ng'ang'a
- Presidential Policy and Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Charles Rombo
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Christine Yegon
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Khamisi Kithi
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Elizabeth Odhiambo
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Thomas Rotich
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Irene Orgut
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Sammy Kihara
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christian Bottomley
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Zonia N Mupe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Katherine E Gallagher
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | - Shirine Voller
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | - Daisy Mugo
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Edward Otieno
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Teresa Lambe
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Daniel Wright
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Edwine Barasa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | | | | | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - George M Warimwe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
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35
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Uyoga S, Adetifa IMO, Karanja HK, Nyagwange J, Tuju J, Wanjiku P, Aman R, Mwangangi M, Amoth P, Kasera K, Ng'ang'a W, Rombo C, Yegon C, Kithi K, Odhiambo E, Rotich T, Orgut I, Kihara S, Otiende M, Bottomley C, Mupe ZN, Kagucia EW, Gallagher KE, Etyang A, Voller S, Gitonga JN, Mugo D, Agoti CN, Otieno E, Ndwiga L, Lambe T, Wright D, Barasa E, Tsofa B, Bejon P, Ochola-Oyier LI, Agweyu A, Scott JAG, Warimwe GM. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Kenyan blood donors. Science 2021; 371:79-82. [PMID: 33177105 DOI: 10.1101/2020.07.27.20162693] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/06/2020] [Indexed: 05/24/2023]
Abstract
The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Africa is poorly described. The first case of SARS-CoV-2 in Kenya was reported on 12 March 2020, and an overwhelming number of cases and deaths were expected, but by 31 July 2020, there were only 20,636 cases and 341 deaths. However, the extent of SARS-CoV-2 exposure in the community remains unknown. We determined the prevalence of anti-SARS-CoV-2 immunoglobulin G among blood donors in Kenya in April-June 2020. Crude seroprevalence was 5.6% (174 of 3098). Population-weighted, test-performance-adjusted national seroprevalence was 4.3% (95% confidence interval, 2.9 to 5.8%) and was highest in urban counties Mombasa (8.0%), Nairobi (7.3%), and Kisumu (5.5%). SARS-CoV-2 exposure is more extensive than indicated by case-based surveillance, and these results will help guide the pandemic response in Kenya and across Africa.
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Affiliation(s)
- Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Ifedayo M O Adetifa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | | | - James Tuju
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Rashid Aman
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Patrick Amoth
- Ministry of Health, Government of Kenya, Nairobi, Kenya
| | | | - Wangari Ng'ang'a
- Presidential Policy and Strategy Unit, The Presidency, Government of Kenya, Nairobi, Kenya
| | - Charles Rombo
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Christine Yegon
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Khamisi Kithi
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Elizabeth Odhiambo
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Thomas Rotich
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Irene Orgut
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Sammy Kihara
- Kenya National Blood Transfusion Services, Ministry of Health, Nairobi, Kenya
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Christian Bottomley
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Zonia N Mupe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Katherine E Gallagher
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | - Shirine Voller
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | | | - Daisy Mugo
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Edward Otieno
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Teresa Lambe
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Daniel Wright
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Edwine Barasa
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | | | | | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Diseases Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - George M Warimwe
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
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Uyoga S, Macharia AW, Ndila CM, Nyutu G, Shebe M, Awuondo KO, Mturi N, Peshu N, Tsofa B, Scott JAG, Maitland K, Williams TN. Glucose-6-phosphate dehydrogenase deficiency and susceptibility to childhood diseases in Kilifi, Kenya. Blood Adv 2020; 4:5942-5950. [PMID: 33275767 PMCID: PMC7724908 DOI: 10.1182/bloodadvances.2020003015] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/09/2020] [Indexed: 01/26/2023] Open
Abstract
Few previous studies have reported the effects of glucose-6-phosphate dehydrogenase (G6PD)-deficiency on child health in Africa. We conducted a case-control study in which cases (n = 6829) were children admitted, for any reason, to Kilifi County Hospital, Kenya, while controls (n = 10 179) were recruited from the surrounding community. Cases were subclassified based on their clinical and laboratory findings at admission. We calculated the prevalence of specific diseases by G6PD c.202 genotype, the only significant cause of G6PD-deficiency in this area, then estimated the association between genotype and admission with specific conditions using logistic regression. Among neonates, the prevalence of jaundice was higher in both G6PD c.202T heterozygotes (40/88; 45.5%; P = .004) and homo/hemizygotes (81/134; 60.5%; P < .0001) than in wild-type homozygotes (157/526; 29.9%). Median bilirubin levels also increased across the groups, being highest (239 mmol/L; interquartile range 96-390 mmol/L) in G6PD c.202T homo/hemizygotes. No differences were seen in admission hemoglobin concentrations or the prevalence of anemia or severe anemia by G6PD c.202 genotype. On case control analysis, G6PD heterozygosity was negatively associated with all-cause hospital admission (odds ratio 0.81; 95% confidence interval 0.73-0.90; P < .0001) and, specifically, admission with either pneumonia or Plasmodium falciparum parasitemia; while, conversely, it was positively associated with Gram-positive bacteremia. G6PD c.202T homo/heterozygosity was positively associated with neonatal jaundice, severe pneumonia, the receipt of a transfusion, and in-patient death. Our study supports the conclusion that G6PD c.202T is a balanced polymorphism in which a selective advantage afforded to heterozygous females against malaria is counterbalanced by increased risks of neonatal jaundice, invasive bacterial infections, and anemia.
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Affiliation(s)
- Sophie Uyoga
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Alex W Macharia
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Carolyne M Ndila
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gideon Nyutu
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mohammed Shebe
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kennedy O Awuondo
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - Neema Mturi
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Norbert Peshu
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Benjamin Tsofa
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - J Anthony G Scott
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom; and
| | - Kathryn Maitland
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Faculty of Medicine, Imperial College, St Mary's Hospital, London, United Kingdom
| | - Thomas N Williams
- Department of Epidemiology and Demography, Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
- Faculty of Medicine, Imperial College, St Mary's Hospital, London, United Kingdom
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Olupot-Olupot P, Engoru C, Nteziyaremye J, Chebet M, Ssenyondo T, Muhindo R, Nyutu G, Macharia AW, Uyoga S, Ndila CM, Karamagi C, Maitland K, Williams TN. The clinical spectrum of severe childhood malaria in Eastern Uganda. Malar J 2020; 19:322. [PMID: 32883291 PMCID: PMC7470679 DOI: 10.1186/s12936-020-03390-7] [Citation(s) in RCA: 4] [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] [Received: 06/15/2020] [Accepted: 08/25/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Few recent descriptions of severe childhood malaria have been published from high-transmission regions. In the current study, the clinical epidemiology of severe malaria in Mbale, Eastern Uganda, is described, where the entomological inoculation rate exceeds 100 infective bites per year. METHODS A prospective descriptive study was conducted to determine the prevalence, clinical spectrum and outcome of severe Plasmodium falciparum malaria at Mbale Regional Referral Hospital in Eastern Uganda. All children aged 2 months-12 years who presented on Mondays to Fridays between 8.00 am and 5.00 pm from 5th May 2011 until 30th April 2012 were screened for parasitaemia. Clinical and laboratory data were then collected from all P. falciparum positive children with features of WHO-defined severe malaria by use of a standardized proforma. RESULTS A total of 10 208 children were screened of which 6582 (64%) had a positive blood film. Of these children, 662 (10%) had clinical features of severe malaria and were consented for the current study. Respiratory distress was the most common severity feature (554; 83.7%), while 365/585 (62.4%) had hyperparasitaemia, 177/662 (26.7%) had clinical jaundice, 169 (25.5%) had severe anaemia, 134/660 (20.2%) had hyperlactataemia (lactate ≥ 5 mmol/L), 93 (14.0%) had passed dark red or black urine, 52 (7.9%) had impaired consciousness and 49/662 (7.4%) had hypoxaemia (oxygen saturations < 90%). In-hospital mortality was 63/662 (9.5%) overall but was higher in children with either cerebral malaria (33.3%) or severe anaemia (19.5%). Factors that were independently associated with mortality on multivariate analysis included severe anaemia [odds ratio (OR) 5.36; 2.16-1.32; P = 0.0002], hyperlactataemia (OR 3.66; 1.72-7.80; P = 0.001), hypoxaemia (OR) 3.64 (95% CI 1.39-9.52; P = 0.008), and hepatomegaly (OR 2.29; 1.29-4.06; P = 0.004). No independent association was found between mortality and either coma or hyperparasitaemia. CONCLUSIONS Severe childhood malaria remains common in Eastern Uganda where it continues to be associated with high mortality. An unusually high proportion of children with severe malaria had jaundice or gave a history of having recently passed dark red or black urine, an issue worthy of further investigation.
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Affiliation(s)
- Peter Olupot-Olupot
- Faculty of Health Sciences, Busitema University, Mbale Campus, P.O. Box 1460, Mbale, Uganda.
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda.
| | - Charles Engoru
- Soroti Regional Referral Hospital, P.O. Box 289, Soroti, Uganda
| | - Julius Nteziyaremye
- Faculty of Health Sciences, Busitema University, Mbale Campus, P.O. Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Martin Chebet
- Faculty of Health Sciences, Busitema University, Mbale Campus, P.O. Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Tonny Ssenyondo
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Rita Muhindo
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - Gideon Nyutu
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Alexander W Macharia
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Carolyne M Ndila
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Charles Karamagi
- Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Institute of Global Health Innovation, Imperial College, Medical School Building St Mary's Campus, Imperial College, London, W2 1PG, UK
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Institute of Global Health Innovation, Imperial College, Medical School Building St Mary's Campus, Imperial College, London, W2 1PG, UK
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Uyoga S, Wanjiku P, Rop JC, Makale J, Macharia AW, Nyutu GM, Shebe M, Awuondo KA, Mturi N, Woodrow CJ, Dondorp AM, Maitland K, Williams TN. Plasma Plasmodium falciparum Histidine-Rich Protein-2 concentrations in children with malaria infections of differing severity in Kilifi, Kenya. Clin Infect Dis 2020; 73:e2415-e2423. [PMID: 32772115 PMCID: PMC8492128 DOI: 10.1093/cid/ciaa1141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/10/2020] [Indexed: 11/13/2022] Open
Abstract
Background Most previous studies support a direct link between total parasite load and the clinical severity of Plasmodium falciparum malaria infections. Methods We estimated P. falciparum parasite loads in 3 groups of children with malaria infections of differing severity: (1) children with World Health Organization–defined severe malaria (n = 1544), (2) children admitted with malaria but without features of severity (n = 200), and (3) children in the community with asymptomatic parasitemia (n = 33). Results Peripheral parasitemias were highest in those with uncomplicated malaria (geometric mean [GM] parasite count, 111 064/μL; 95% confidence interval, CI, 86 798–141 819/μL), almost 3 times higher than in those with severe malaria (39 588/μL; 34 990–44 791/μL) and >100 times higher than in those with asymptomatic malaria (1092/μL; 523–2280/μL). However, the GM P. falciparum histidine-rich protein 2 (PfHRP2) values (95% CI) increased with severity, being 7 (4–12) ng/mL in asymptomatic malaria, 843 (655–1084) ng/mL in uncomplicated malaria, and 1369 (1244–1506) ng/mL in severe malaria. PfHRP2 concentrations were markedly lower in the subgroup of patients with severe malaria and concomitant invasive bacterial infections of blood or cerebrospinal fluid (GM concentration, 312 ng/mL; 95% CI, 175–557 ng/mL; P < .001) than in those without such infections (1439 ng/mL; 1307–1584; P < .001). Conclusions The clinical severity of malaria infections related strongly to the total burden of P. falciparum parasites. A quantitative test for plasma concentrations of PfHRP2 could be useful in identifying children at the greatest clinical risk and identifying critically ill children in whom malaria is not the primary cause.
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Affiliation(s)
- Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Jesse C Rop
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | | | | | - Neema Mturi
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Charles J Woodrow
- Mahidol-Oxford Research Unit,Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health,Nuffield Department of Medicine,University of Oxford, UK
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit,Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health,Nuffield Department of Medicine,University of Oxford, UK
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Diseases, Imperial College, London, UK
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Infectious Diseases, Imperial College, London, UK
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Macharia AW, Mochamah G, Uyoga S, Ndila CM, Nyutu G, Tendwa M, Nyatichi E, Makale J, Ware RE, Williams TN. β-Thalassemia pathogenic variants in a cohort of children from the East African coast. Mol Genet Genomic Med 2020; 8:e1294. [PMID: 32394645 PMCID: PMC7336762 DOI: 10.1002/mgg3.1294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 02/03/2020] [Revised: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND β-Thalassemia is rare in sub-Saharan Africa. Previous studies have suggested that it is limited to specific parts of West Africa. Based on hemoglobin A2 (HbA2 ) concentrations measured by HPLC, we recently speculated that β-thalassemia might also be present on the East African coast of Kenya. Here, we follow this up using molecular methods. METHODS We used raised hemoglobin A2 (HbA2 ) values (> 4.0% of total Hb) to target all HbAA members of a cohort study in Kilifi, Kenya, for HBB sequencing for β-thalassemia (n = 99) together with a sample of HbAA subjects with lower HbA2 levels. Because HbA2 values are artifactually raised in subjects carrying sickle hemoglobin (HbS) we sequenced all participants with an HPLC pattern showing HbS without HbA (n = 116) and a sample with a pattern showing both HbA and HbS. RESULTS Overall, we identified 83 carriers of four separate β-thalassemia pathogenic variants: three β0 -thalassemia [CD22 (GAA→TAA), initiation codon (ATG→ACG), and IVS1-3' end del 25bp] and one β+ -thalassemia pathogenic variants (IVS-I-110 (G→A)). We estimated the minimum allele frequency of all variants combined within the study population at 0.3%. CONCLUSIONS β-Thalassemia is present in Kilifi, Kenya, an observation that has implications for the diagnosis and clinical care of children from the East Africa region.
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Affiliation(s)
| | | | - Sophie Uyoga
- KEMRI-Wellcome Trust Research ProgrammeKilifiKenya
| | | | - Gideon Nyutu
- KEMRI-Wellcome Trust Research ProgrammeKilifiKenya
| | | | | | | | - Russell E. Ware
- Cincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Thomas N. Williams
- KEMRI-Wellcome Trust Research ProgrammeKilifiKenya
- Department of MedicineImperial CollegeSt Mary’s HospitalLondonUK
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Gilchrist JJ, Uyoga S, Pirinen M, Rautanen A, Mwarumba S, Njuguna P, Mturi N, Hill AVS, Scott JAG, Williams TN. Risk of pneumococcal bacteremia in Kenyan children with glucose-6-phosphate dehydrogenase deficiency. BMC Med 2020; 18:148. [PMID: 32536341 PMCID: PMC7294654 DOI: 10.1186/s12916-020-01604-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/23/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzyme deficiency state in humans. The clinical phenotype is variable and includes asymptomatic individuals, episodic hemolysis induced by oxidative stress, and chronic hemolysis. G6PD deficiency is common in malaria-endemic regions, an observation hypothesized to be due to balancing selection at the G6PD locus driven by malaria. G6PD deficiency increases risk of severe malarial anemia, a key determinant of invasive bacterial disease in malaria-endemic settings. The pneumococcus is a leading cause of invasive bacterial infection and death in African children. The effect of G6PD deficiency on risk of pneumococcal disease is undefined. We hypothesized that G6PD deficiency increases pneumococcal disease risk and that this effect is dependent upon malaria. METHODS We performed a genetic case-control study of pneumococcal bacteremia in Kenyan children stratified across a period of falling malaria transmission between 1998 and 2010. RESULTS Four hundred twenty-nine Kenyan children with pneumococcal bacteremia and 2677 control children were included in the study. Among control children, G6PD deficiency, secondary to the rs1050828 G>A mutation, was common, with 11.2% (n = 301 of 2677) being hemi- or homozygotes and 33.3% (n = 442 of 1329) of girls being heterozygotes. We found that G6PD deficiency increased the risk of pneumococcal bacteremia, but only during a period of high malaria transmission (P = 0.014; OR 2.33, 95% CI 1.19-4.57). We estimate that the population attributable fraction of G6PD deficiency on risk of pneumococcal bacteremia in areas under high malaria transmission is 0.129. CONCLUSIONS Our data demonstrate that G6PD deficiency increases risk of pneumococcal bacteremia in a manner dependent on malaria. At the population level, the impact of G6PD deficiency on invasive pneumococcal disease risk in malaria-endemic regions is substantial. Our study highlights the infection-associated morbidity and mortality conferred by G6PD deficiency in malaria-endemic settings and adds to our understanding of the potential indirect health benefits of improved malaria control.
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Affiliation(s)
- James J Gilchrist
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK. .,Department of Paediatrics, University of Oxford, Oxford, OX3 9DU, UK.
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Matti Pirinen
- Institute for Molecular Medicine Finland (FIMM), University of Helsinki, 00014, Helsinki, Finland
| | - Anna Rautanen
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK
| | - Salim Mwarumba
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | | | - Neema Mturi
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | | | - Adrian V S Hill
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, OX3 7BN, UK.,The Jenner Institute, University of Oxford, Old Road Campus Research Building, Oxford, OX3 7DQ, UK
| | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya.,Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya. .,Department of Medicine, Imperial College, Norfolk Place, London, W2 1PG, UK.
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Maitland K, Olupot-Olupot P, Kiguli S, Chagaluka G, Alaroker F, Opoka RO, Mpoya A, Walsh K, Engoru C, Nteziyaremye J, Mallewa M, Kennedy N, Nakuya M, Namayanja C, Kayaga J, Nabawanuka E, Sennyondo T, Aromut D, Kumwenda F, Musika CW, Thomason MJ, Bates I, von Hensbroek MB, Evans JA, Uyoga S, Williams TN, Frost G, George EC, Gibb DM, Walker AS. Co-trimoxazole or multivitamin multimineral supplement for post-discharge outcomes after severe anaemia in African children: a randomised controlled trial. Lancet Glob Health 2020; 7:e1435-e1447. [PMID: 31537373 PMCID: PMC7024999 DOI: 10.1016/s2214-109x(19)30345-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 07/07/2019] [Accepted: 07/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Severe anaemia is a leading cause of paediatric admission to hospital in Africa; post-discharge outcomes remain poor, with high 6-month mortality (8%) and re-admission (17%). We aimed to investigate post-discharge interventions that might improve outcomes. METHODS Within the two-stratum, open-label, multicentre, factorial randomised TRACT trial, children aged 2 months to 12 years with severe anaemia, defined as haemoglobin of less than 6 g/dL, at admission to hospital (three in Uganda, one in Malawi) were randomly assigned, using sequentially numbered envelopes linked to a second non-sequentially numbered set of allocations stratified by centre and severity, to enhanced nutritional supplementation with iron and folate-containing multivitamin multimineral supplements versus iron and folate alone at treatment doses (usual care), and to co-trimoxazole versus no co-trimoxazole. All interventions were administered orally and were given for 3 months after discharge from hospital. Separately reported randomisations investigated transfusion management. The primary outcome was 180-day mortality. All analyses were done in the intention-to-treat population; follow-up was 180 days. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN84086586, and follow-up is complete. FINDINGS From Sept 17, 2014, to May 15, 2017, 3983 eligible children were randomly assigned to treatment, and followed up for 180 days. 164 (4%) were lost to follow-up. 1901 (95%) of 1997 assigned multivitamin multimineral supplement, 1911 (96%) of 1986 assigned iron and folate, and 1922 (96%) of 1994 assigned co-trimoxazole started treatment. By day 180, 166 (8%) children in the multivitamin multimineral supplement group versus 169 (9%) children in the iron and folate group had died (hazard ratio [HR] 0·97, 95% CI 0·79-1·21; p=0·81) and 172 (9%) who received co-trimoxazole versus 163 (8%) who did not receive co-trimoxazole had died (HR 1·07, 95% CI 0·86-1·32; p=0·56). We found no evidence of interactions between these randomisations or with transfusion randomisations (p>0·2). By day 180, 489 (24%) children in the multivitamin multimineral supplement group versus 509 (26%) children in the iron and folate group (HR 0·95, 95% CI 0·84-1·07; p=0·40), and 500 (25%) children in the co-trimoxazole group versus 498 (25%) children in the no co-trimoxazole group (1·01, 0·89-1·15; p=0·85) had had one or more serious adverse events. Most serious adverse events were re-admissions, occurring in 692 (17%) children (175 [4%] with at least two re-admissions). INTERPRETATION Neither enhanced supplementation with multivitamin multimineral supplement versus iron and folate treatment or co-trimoxazole prophylaxis improved 6-month survival. High rates of hospital re-admission suggest that novel interventions are urgently required for severe anaemia, given the burden it places on overstretched health services in Africa. FUNDING Medical Research Council and Department for International Development.
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Affiliation(s)
- Kathryn Maitland
- Department of Medicine, Imperial College London, London, UK; Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
| | - Peter Olupot-Olupot
- Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital Mbale, Mbale, Uganda
| | - Sarah Kiguli
- Department of Paediatrics, Makerere University and Mulago Hospital, Kampala, Uganda
| | - George Chagaluka
- College of Medicine, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Robert O Opoka
- Department of Paediatrics, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Ayub Mpoya
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kevin Walsh
- Nutrition Research Section, Imperial College London, London, UK
| | | | - Julius Nteziyaremye
- Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital Mbale, Mbale, Uganda
| | - Machpherson Mallewa
- College of Medicine, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Neil Kennedy
- College of Medicine, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; School of Medicine, Dentistry and Biomedical Science, Queen's University, Belfast, UK
| | | | - Cate Namayanja
- Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital Mbale, Mbale, Uganda
| | - Julianne Kayaga
- Department of Paediatrics, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Eva Nabawanuka
- Department of Paediatrics, Makerere University and Mulago Hospital, Kampala, Uganda
| | - Tonny Sennyondo
- Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital Mbale, Mbale, Uganda
| | - Denis Aromut
- Soroti Regional Referral Hospital, Soroti, Uganda
| | - Felistas Kumwenda
- College of Medicine, and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | - Imelda Bates
- Liverpool School of Tropical Medicine and Hygiene, Liverpool, UK
| | | | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Cardiff, UK
| | - Sophie Uyoga
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Thomas N Williams
- Department of Medicine, Imperial College London, London, UK; Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gary Frost
- Nutrition Research Section, Imperial College London, London, UK
| | - Elizabeth C George
- Medical Research Council Clinical Trials Unit at University College London
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London
| | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London
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Oron AP, Chao DL, Ezeanolue EE, Ezenwa LN, Piel FB, Ojogun OT, Uyoga S, Williams TN, Nnodu OE. Caring for Africa's sickle cell children: will we rise to the challenge? BMC Med 2020; 18:92. [PMID: 32340612 PMCID: PMC7187492 DOI: 10.1186/s12916-020-01557-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 03/12/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most of the world's sickle cell disease (SCD) burden is in Africa, where it is a major contributor to child morbidity and mortality. Despite the low cost of many preventive SCD interventions, insufficient resources have been allocated, and progress in alleviating the SCD burden has lagged behind other public-health efforts in Africa. The recent announcement of massive new funding for research into curative SCD therapies is encouraging in the long term, but over the next few decades, it is unlikely to help Africa's SCD children substantially. MAIN DISCUSSION A major barrier to progress has been the absence of large-scale early-life screening. Most SCD deaths in Africa probably occur before cases are even diagnosed. In the last few years, novel inexpensive SCD point-of-care test kits have become widely available and have been deployed successfully in African field settings. These kits could potentially enable universal early SCD screening. Other recent developments are the expansion of the pneumococcal conjugate vaccine towards near-universal coverage, and the demonstrated safety, efficacy, and increasing availability and affordability of hydroxyurea across the continent. Most elements of standard healthcare for SCD children that are already proven to work in the West, could and should now be implemented at scale in Africa. National and continental SCD research and care networks in Africa have also made substantial progress, assembling care guidelines and enabling the deployment and scale-up of SCD public-health systems. Substantial logistical, cultural, and awareness barriers remain, but with sufficient financial and political will, similar barriers have already been overcome in efforts to control other diseases in Africa. CONCLUSION AND RECOMMENDATIONS Despite remaining challenges, several high-SCD-burden African countries have the political will and infrastructure for the rapid implementation and scale-up of comprehensive SCD childcare programs. A globally funded effort starting with these countries and expanding elsewhere in Africa and to other high-burden countries, including India, could transform the lives of SCD children worldwide and help countries to attain their Sustainable Development Goals. This endeavor would also require ongoing research focused on the unique needs and challenges of SCD patients, and children in particular, in regions of high prevalence.
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Affiliation(s)
- Assaf P Oron
- Maternal, Newborn and Child Health, Institute for Disease Modeling, Bellevue, WA, USA
| | - Dennis L Chao
- Maternal, Newborn and Child Health, Institute for Disease Modeling, Bellevue, WA, USA
| | - Echezona E Ezeanolue
- Healthy Sunrise Foundation, Las Vegas, NV, USA
- College of Medicine, University of Nigeria, Nsukka, Nigeria
| | | | - Frédéric B Piel
- Department of Epidemiology & Biostatistics, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | | | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | | | - Obiageli E Nnodu
- Centre of Excellence for Sickle Cell Disease Research & Training, University of Abuja, Abuja, Nigeria
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Arora S, Al-Riyami A, Hutchinson T, Toly-Ndour C, Tung JP, Ji Y, Uyoga S. Young professional council with the international society of blood transfusion. Glob J Transfus Med 2020. [DOI: 10.4103/gjtm.gjtm_15_20] [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: 11/04/2022] Open
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Uyoga S, Macharia AW, Mochamah G, Ndila CM, Nyutu G, Makale J, Tendwa M, Nyatichi E, Ojal J, Otiende M, Shebe M, Awuondo KO, Mturi N, Peshu N, Tsofa B, Maitland K, Scott JAG, Williams TN. The epidemiology of sickle cell disease in children recruited in infancy in Kilifi, Kenya: a prospective cohort study. Lancet Glob Health 2019; 7:e1458-e1466. [PMID: 31451441 PMCID: PMC7024980 DOI: 10.1016/s2214-109x(19)30328-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [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: 02/16/2019] [Revised: 07/02/2019] [Accepted: 07/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sickle cell disease is the most common severe monogenic disorder in humans. In Africa, 50-90% of children born with sickle cell disease die before they reach their fifth birthday. In this study, we aimed to describe the comparative incidence of specific clinical outcomes among children aged between birth and 5 years with and without sickle cell disease, who were resident within the Kilifi area of Kenya. METHODS This prospective cohort study was done on members of the Kilifi Genetic Birth Cohort Study (KGBCS) on the Indian Ocean coast of Kenya. Recruitment to the study was facilitated through the Kilifi Health and Demographic Surveillance System (KHDSS), which covers a resident population of 260 000 people, and was undertaken between Jan 1, 2006, and April 30, 2011. All children who were born within the KHDSS area and who were aged 3-12 months during the recruitment period were eligible for inclusion. Participants were tested for sickle cell disease and followed up for survival status and disease-specific admission to Kilifi County Hospital by passive surveillance until their fifth birthday. Children with sickle cell disease were offered confirmatory testing and care at a dedicated outpatient clinic. FINDINGS 15 737 infants were recruited successfully to the KGBCS, and 128 (0·8%) of these infants had sickle cell disease, of whom 70 (54·7%) enrolled at the outpatient clinic within 12 months of recruitment. Mortality was higher in children with sickle cell disease (58 per 1000 person-years of observation, 95% CI 40-86) than in those without sickle cell disease (2·4 per 1000 person-years of observation, 2·0-2·8; adjusted incidence rate ratio [IRR] 23·1, 95% CI 15·1-35·3). Among children with sickle cell disease, mortality was lower in those who enrolled at the clinic (adjusted IRR 0·26, 95% CI 0·11-0·62) and in those with higher levels of haemoglobin F (HbF; adjusted IRR 0·40, 0·17-0·94). The incidence of admission to hospital was also higher in children with sickle cell disease than in children without sickle cell disease (210 per 1000 person-years of observation, 95% CI 174-253, vs 43 per 1000 person-years of observation, 42-45; adjusted IRR 4·80, 95% CI 3·84-6·15). The most common reason for admission to hospital among those with sickle cell disease was severe anaemia (incidence 48 per 1000 person-years of observation, 95% CI 32-71). Admission to hospital was lower in those with a recruitment HbF level above the median (IRR 0·43, 95% CI 0·24-0·78; p=0·005) and those who were homozygous for α-thalassaemia (0·07, 0·01-0·83; p=0·035). INTERPRETATION Although morbidity and mortality were high in young children with sickle cell disease in this Kenyan cohort, both were reduced by early diagnosis and supportive care. The emphasis must now move towards early detection and prevention of long-term complications of sickle cell disease. FUNDING Wellcome Trust.
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Affiliation(s)
- Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | - Gideon Nyutu
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | - John Ojal
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mark Otiende
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - Neema Mturi
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Norbert Peshu
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; Faculty of Medicine, Imperial College, St Mary's Hospital, London, UK
| | - J Anthony G Scott
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; London School of Hygiene & Tropical Medicine, London, UK; INDEPTH Network, Accra, Ghana
| | - Thomas N Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; London School of Hygiene & Tropical Medicine, London, UK; INDEPTH Network, Accra, Ghana.
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Maitland K, Ohuma EO, Mpoya A, Uyoga S, Hassall O, Williams TN. Informing thresholds for paediatric transfusion in Africa: the need for a trial. Wellcome Open Res 2019; 4:27. [PMID: 31633055 PMCID: PMC6784792 DOI: 10.12688/wellcomeopenres.15003.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Accepted: 08/05/2019] [Indexed: 01/29/2023] Open
Abstract
Background: Owing to inadequate supplies of donor blood for transfusion in sub-Saharan Africa (sSA) World Health Organization paediatric guidelines recommend restrictive transfusion practices, based on expert opinion. We examined whether survival amongst hospitalised children by admission haemoglobin and whether this was influenced by malaria infection and/or transfusion. Methods: A retrospective analysis of standardised clinical digital records in an unselected population of children admitted to a rural hospital in Kenya over an 8-year period. We describe baseline parameters with respect to categories of anaemia and outcome (in-hospital death) by haemoglobin (Hb), malaria and transfusion status. Results: Among 29,226 children, 1,143 (3.9%) had profound anaemia (Hb <4g/dl) and 3,469 (11.9%) had severe anaemia (Hb 4-6g/d). In-hospital mortality rate was 97/1,143 (8.5%) if Hb<4g/dl or 164/2,326 (7.1%) in those with severe anaemia (Hb ≥4.0-<6g/dl). Admission Hb <3g/dl was associated with higher risk of death versus those with higher Hbs (OR=2.41 (95%CI: 1.8 - 3.24; P<0.001), increasing to OR=6.36, (95%CI: 4.21-9.62; P<0.001) in malaria positive children. Conversely, mortality in non-malaria admissions was unrelated to Hb level. Transfusion was associated with a non-significant improvement in outcome if Hb<3g/dl (malaria-only) OR 0.72 (95%CI 0.29 - 1.78), albeit the number of cases were too few to show a statistical difference. For those with Hb levels above 4g/dl, mortality was significantly higher in those receiving a transfusion compared to the non-transfused group. For non-malarial cases, transfusion did not affect survival-status, irrespective of baseline Hb level compared to children who were not transfused at higher Hb levels. Conclusion: Although severe anaemia is common among children admitted to hospital in sSA (~16%), our data do not indicate that outcome is improved by transfusion irrespective of malaria status. Given the limitations of observational studies, clinical trials investigating the role of transfusion in outcomes in children with severe anaemia are warranted.
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Affiliation(s)
- Kathryn Maitland
- Department of Medicine, Imperial College London, London, W2 1PG, UK
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Eric O. Ohuma
- Nuffield Department of Medicine, Oxford University, Oxford, OX3 7BN, UK
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Sophie Uyoga
- Epidemiology and Demographic Surveillance, KEMRI Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Oliver Hassall
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Thomas N. Williams
- Department of Medicine, Imperial College London, London, W2 1PG, UK
- Epidemiology and Demographic Surveillance, KEMRI Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
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Maitland K, Kiguli S, Olupot-Olupot P, Engoru C, Mallewa M, Saramago Goncalves P, Opoka RO, Mpoya A, Alaroker F, Nteziyaremye J, Chagaluka G, Kennedy N, Nabawanuka E, Nakuya M, Namayanja C, Uyoga S, Kyeyune Byabazaire D, M'baya B, Wabwire B, Frost G, Bates I, Evans JA, Williams TN, George EC, Gibb DM, Walker AS. Immediate Transfusion in African Children with Uncomplicated Severe Anemia. N Engl J Med 2019; 381:407-419. [PMID: 31365799 PMCID: PMC7611152 DOI: 10.1056/nejmoa1900105] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The World Health Organization recommends not performing transfusions in African children hospitalized for uncomplicated severe anemia (hemoglobin level of 4 to 6 g per deciliter and no signs of clinical severity). However, high mortality and readmission rates suggest that less restrictive transfusion strategies might improve outcomes. METHODS In this factorial, open-label, randomized, controlled trial, we assigned Ugandan and Malawian children 2 months to 12 years of age with uncomplicated severe anemia to immediate transfusion with 20 ml or 30 ml of whole-blood equivalent per kilogram of body weight, as determined in a second simultaneous randomization, or no immediate transfusion (control group), in which transfusion with 20 ml of whole-blood equivalent per kilogram was triggered by new signs of clinical severity or a drop in hemoglobin to below 4 g per deciliter. The primary outcome was 28-day mortality. Three other randomizations investigated transfusion volume, postdischarge supplementation with micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. RESULTS A total of 1565 children (median age, 26 months) underwent randomization, with 778 assigned to the immediate-transfusion group and 787 to the control group; 984 children (62.9%) had malaria. The children were followed for 180 days, and 71 (4.5%) were lost to follow-up. During the primary hospitalization, transfusion was performed in all the children in the immediate-transfusion group and in 386 (49.0%) in the control group (median time to transfusion, 1.3 hours vs. 24.9 hours after randomization). The mean (±SD) total blood volume transfused per child was 314±228 ml in the immediate-transfusion group and 142±224 ml in the control group. Death had occurred by 28 days in 7 children (0.9%) in the immediate-transfusion group and in 13 (1.7%) in the control group (hazard ratio, 0.54; 95% confidence interval [CI], 0.22 to 1.36; P = 0.19) and by 180 days in 35 (4.5%) and 47 (6.0%), respectively (hazard ratio, 0.75; 95% CI, 0.48 to 1.15), without evidence of interaction with other randomizations (P>0.20) or evidence of between-group differences in readmissions, serious adverse events, or hemoglobin recovery at 180 days. The mean length of hospital stay was 0.9 days longer in the control group. CONCLUSIONS There was no evidence of differences in clinical outcomes over 6 months between the children who received immediate transfusion and those who did not. The triggered-transfusion strategy in the control group resulted in lower blood use; however, the length of hospital stay was longer, and this strategy required clinical and hemoglobin monitoring. (Funded by the Medical Research Council and Department for International Development; TRACT Current Controlled Trials number, ISRCTN84086586.).
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Affiliation(s)
- Kathryn Maitland
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Sarah Kiguli
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Peter Olupot-Olupot
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Charles Engoru
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Macpherson Mallewa
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Pedro Saramago Goncalves
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Robert O Opoka
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Ayub Mpoya
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Florence Alaroker
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Julius Nteziyaremye
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - George Chagaluka
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Neil Kennedy
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Eva Nabawanuka
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Margaret Nakuya
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Cate Namayanja
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Sophie Uyoga
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Dorothy Kyeyune Byabazaire
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Bridon M'baya
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Benjamin Wabwire
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Gary Frost
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Imelda Bates
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Jennifer A Evans
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Thomas N Williams
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Elizabeth C George
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - Diana M Gibb
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
| | - A Sarah Walker
- From the Department of Pediatrics (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the Centre for Health Economics, University of York, York (P.S.G.), the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), and the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.) - all in the United Kingdom; the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., E.N.), and the Uganda Blood Transfusion Services (BTS), National BTS (D.K.B.), Kampala, Busitema University Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and Mbale BTS (B.W.), Mbale, and the Soroti Regional Referral Hospital, Soroti (C.E., F.A., M.N.) - all in Uganda; the College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Program (M.M., G.C.). and Malawi BTS (B.M.), Blantyre, Malawi; and the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi, Kenya (K.M., A.M. S.U., T.N.W.)
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Maitland K, Olupot-Olupot P, Kiguli S, Chagaluka G, Alaroker F, Opoka RO, Mpoya A, Engoru C, Nteziyaremye J, Mallewa M, Kennedy N, Nakuya M, Namayanja C, Kayaga J, Uyoga S, Kyeyune Byabazaire D, M'baya B, Wabwire B, Frost G, Bates I, Evans JA, Williams TN, Saramago Goncalves P, George EC, Gibb DM, Walker AS. Transfusion Volume for Children with Severe Anemia in Africa. N Engl J Med 2019; 381:420-431. [PMID: 31365800 PMCID: PMC7610610 DOI: 10.1056/nejmoa1900100] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Severe anemia (hemoglobin level, <6 g per deciliter) is a leading cause of hospital admission and death in children in sub-Saharan Africa. The World Health Organization recommends transfusion of 20 ml of whole-blood equivalent per kilogram of body weight for anemia, regardless of hemoglobin level. METHODS In this factorial, open-label trial, we randomly assigned Ugandan and Malawian children 2 months to 12 years of age with a hemoglobin level of less than 6 g per deciliter and severity features (e.g., respiratory distress or reduced consciousness) to receive immediate blood transfusion with 20 ml per kilogram or 30 ml per kilogram. Three other randomized analyses investigated immediate as compared with no immediate transfusion, the administration of postdischarge micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. The primary outcome was 28-day mortality. RESULTS A total of 3196 eligible children (median age, 37 months; 2050 [64.1%] with malaria) were assigned to receive a transfusion of 30 ml per kilogram (1598 children) or 20 ml per kilogram (1598 children) and were followed for 180 days. A total of 1592 children (99.6%) in the higher-volume group and 1596 (99.9%) in the lower-volume group started transfusion (median, 1.2 hours after randomization). The mean (±SD) volume of total blood transfused per child was 475±385 ml and 353±348 ml, respectively; 197 children (12.3%) and 300 children (18.8%) in the respective groups received additional transfusions. Overall, 55 children (3.4%) in the higher-volume group and 72 (4.5%) in the lower-volume group died before 28 days (hazard ratio, 0.76; 95% confidence interval [CI], 0.54 to 1.08; P = 0.12 by log-rank test). This finding masked significant heterogeneity in 28-day mortality according to the presence or absence of fever (>37.5°C) at screening (P=0.001 after Sidak correction). Among the 1943 children (60.8%) without fever, mortality was lower with a transfusion volume of 30 ml per kilogram than with a volume of 20 ml per kilogram (hazard ratio, 0.43; 95% CI, 0.27 to 0.69). Among the 1253 children (39.2%) with fever, mortality was higher with 30 ml per kilogram than with 20 ml per kilogram (hazard ratio, 1.91; 95% CI, 1.04 to 3.49). There was no evidence of differences between the randomized groups in readmissions, serious adverse events, or hemoglobin recovery at 180 days. CONCLUSIONS Overall mortality did not differ between the two transfusion strategies. (Funded by the Medical Research Council and Department for International Development, United Kingdom; TRACT Current Controlled Trials number, ISRCTN84086586.).
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Affiliation(s)
- Kathryn Maitland
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Peter Olupot-Olupot
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Sarah Kiguli
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - George Chagaluka
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Florence Alaroker
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Robert O Opoka
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Ayub Mpoya
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Charles Engoru
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Julius Nteziyaremye
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Macpherson Mallewa
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Neil Kennedy
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Margaret Nakuya
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Cate Namayanja
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Julianna Kayaga
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Sophie Uyoga
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Dorothy Kyeyune Byabazaire
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Bridon M'baya
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Benjamin Wabwire
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Gary Frost
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Imelda Bates
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Jennifer A Evans
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Thomas N Williams
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Pedro Saramago Goncalves
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Elizabeth C George
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - Diana M Gibb
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
| | - A Sarah Walker
- From the Department of Medicine (K.M., T.N.W.) and Nutrition Research Section (G.F.), Imperial College London, and the Medical Research Council Clinical Trials Unit at University College London (E.C.G., D.M.G., A.S.W.), London, the School of Medicine, Dentistry, and Biomedical Science, Queen's University, Belfast (N.K.), the Liverpool School of Tropical Medicine and Hygiene, Liverpool (I.B.), the Department of Pediatrics, University Hospital of Wales, Cardiff (J.A.E.), and the Centre for Health Economics, University of York, York (P.S.G.) - all in the United Kingdom; Busitema University Faculty of Health Sciences, Mbale Campus, Mbale Regional Referral Hospital (P.O.-O., J.N., C.N.), and the Mbale Blood Transfusion Services (B.W.), Mbale, the Department of Pediatrics, Makerere University and Mulago Hospital (S.K., R.O.O., J.K.), and the Uganda Blood Transfusion Services, National Blood Transfusion Services (D.K.B.), Kampala, and Soroti Regional Referral Hospital, Soroti (F.A., C.E., M.N.) - all in Uganda; the Kenya Medical Research Institute-Wellcome Trust Research Program, Kilifi (K.M., A.M., S.U., T.N.W.); and the College of Medicine and the Malawi-Liverpool-Wellcome Trust Clinical Research Program (G.C., M.M., N.K.) and the Malawi Blood Transfusion Services (B.M.) - all in Blantyre, Malawi
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Houston KA, Gibb J, Olupot-Olupot P, Obonyo N, Mpoya A, Nakuya M, Muhindo R, Uyoga S, Evans JA, Connon R, Gibb DM, George EC, Maitland K. Gastroenteritis aggressive versus slow treatment for rehydration (GASTRO): a phase II rehydration trial for severe dehydration: WHO plan C versus slow rehydration. BMC Med 2019; 17:122. [PMID: 31256761 PMCID: PMC6600884 DOI: 10.1186/s12916-019-1356-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND World Health Organization rehydration management guidelines (plan C) for severe dehydration are widely practiced in resource-poor settings, but never formally evaluated in a trial. The Fluid Expansion as a Supportive Therapy trial raised concerns regarding the safety of bolus therapy for septic shock, warranting a formal evaluation of rehydration therapy for gastroenteritis. METHODS A multi-centre open-label phase II randomised controlled trial evaluated two rehydration strategies in 122 Ugandan/Kenyan children aged 60 days to 12 years with severe dehydration secondary to gastroenteritis. We compared the safety and efficacy of standard rapid rehydration using Ringer's lactate (100 ml/kg over 3 h (6 h if < 1 year), incorporating 0.9% saline boluses for children with shock (plan C) versus slower rehydration: 100 ml/kg Ringer's lactate over 8 h (all ages) without boluses (slow: experimental). The primary outcome was the frequency of serious adverse events (SAE) within 48 h including cardiovascular, respiratory and neurological complications. Secondary outcomes included clinical, biochemical and physiological measures of response to treatment by intravenous rehydration. RESULTS One hundred twenty-two eligible children (median (IQR) age 8 (6-12) months) were randomised to plan C (n = 61) or slow (n = 61), with two (2%) lost to follow-up at day 7). Following randomisation mean (SD) time to start intravenous rehydration started was 15 min (18) in both arms. Mean (SD) fluid received by 1 hour was greater in plan C (mean 20.2 ml/kg (12.2) and 33.1 ml/kg (17) for children < 1 year and >- 1 year respectively) versus 10.4 ml/kg (6.6) in slow arm. By 8 hours volume received were similar mean (SD) plan C: 96.3 ml/kg (15.6) and 97.8 ml/kg (10.0) for children < 1 and ≥ 1 year respectively vs 93.2 ml/kg (12.2) in slow arm. By 48-h, three (5%) plan C vs two (3%) slow had an SAE (risk ratio 0.67, 95% CI 0.12-3.85, p = 0.65). There was no difference in time to the correction of dehydration (p = 0.9) or time to discharge (p = 0.8) between groups. Atrial natriuretic peptide levels rose substantially by 8 hours in both arms, which persisted to day 7. Day 7 weights suggested only 33 (29%) could be retrospectively classified as severely dehydration (≥ 10% weight loss). CONCLUSION Slower rehydration over 8 hours appears to be safe, easier to implement than plan C. Future large trials with mortality as the primary endpoint are warranted. TRIAL REGISTRATION ISRCTN67518332 . Date applied 31 August 2016.
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Affiliation(s)
- Kirsty A. Houston
- Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, Norfolk Place, Imperial College, London, W2 1PG UK
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Jack Gibb
- Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, Norfolk Place, Imperial College, London, W2 1PG UK
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, PO Box 291, Mbale, Uganda
| | - Nchafatso Obonyo
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Ayub Mpoya
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Margaret Nakuya
- Soroti Regional Referral Hospital, PO Box 289, Soroti, Uganda
| | - Rita Muhindo
- Mbale Clinical Research Institute, Pallisa Road, PO Box 291, Mbale, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, PO Box 291, Mbale, Uganda
| | - Sophie Uyoga
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
| | - Jennifer A. Evans
- Department of Paediatrics, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW Wales UK
| | - Roisin Connon
- MRC Clinical Trials Unit at UCL 90 High Holborn, 2nd Floor, London, WC1V 6LJ UK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at UCL 90 High Holborn, 2nd Floor, London, WC1V 6LJ UK
| | - Elizabeth C. George
- MRC Clinical Trials Unit at UCL 90 High Holborn, 2nd Floor, London, WC1V 6LJ UK
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, Norfolk Place, Imperial College, London, W2 1PG UK
- KEMRI-Wellcome Trust Research Programme, PO Box 230, Kilifi, Kenya
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49
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Uyoga S, Mpoya A, Olupot-Olupot P, Kiguli S, Opoka RO, Engoru C, Mallewa M, Kennedy N, M'baya B, Kyeyune D, Wabwire B, Bates I, Gibb DM, Walker AS, George EC, Williams TN, Maitland K. Haematological quality and age of donor blood issued for paediatric transfusion to four hospitals in sub-Saharan Africa. Vox Sang 2019; 114:340-348. [PMID: 30838664 PMCID: PMC6563499 DOI: 10.1111/vox.12764] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 10/01/2018] [Revised: 12/28/2018] [Accepted: 01/28/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Paediatric blood transfusion for severe anaemia in hospitals in sub-Saharan Africa remains common. Yet, reports describing the haematological quality of donor blood or storage duration in routine practice are very limited. Both factors are likely to affect transfusion outcomes. MATERIALS AND METHODS We undertook three audits examining the distribution of pack types, haematological quality and storage duration of donor blood used in a paediatric clinical trial of blood at four hospitals in Africa (Uganda and Malawi). RESULTS The overall distribution of whole blood, packed cells (plasma-reduced by centrifugation) and red cell concentrates (RCC) (plasma-reduced by gravity-dependent sedimentation) used in a randomised trial was 40·7% (N = 1215), 22·4% (N = 669) and 36·8% (N = 1099), respectively. The first audit found similar median haematocrits of 57·0% (50·0,74·0), 64·0% (52·0,72·5; P = 0·238 vs. whole blood) and 56·0% (48·0,67·0; P = 0·462) in whole blood, RCC and packed cells, respectively, which resulted from unclear pack labelling by blood transfusion services (BTS). Re-training of the BTS, hospital blood banks and clinical teams led to, in subsequent audits, significant differences in median haematocrit and haemoglobins across the three pack types and values within expected ranges. Median storage duration time was 12 days (IQR: 6, 19) with 18·2% (537/2964) over 21 days in storage. Initially, 9 (2·8%) packs were issued past the recommended duration of storage, dropping to 0·3% (N = 7) in the third audit post-training. CONCLUSION The study highlights the importance of close interactions and education between BTS and clinical services and the importance of haemovigilance to ensure safe transfusion practice.
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Affiliation(s)
- Sophie Uyoga
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ayub Mpoya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale, Uganda
- Faculty of Health Sciences, Busitema University, Mbale Campus, Mbale, Ugandas
| | - Sarah Kiguli
- Department of Paediatrics, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Robert O Opoka
- Department of Paediatrics, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Charles Engoru
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Macpherson Mallewa
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Neil Kennedy
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- School of Medicine, Dentistry and Biomedical Science, Queen's University, Belfast, UK
| | | | | | | | - Imelda Bates
- Liverpool School of Tropical Medicine and Hygiene Pembroke Place, Liverpool, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Ann Sarah Walker
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Elizabeth C George
- MRC Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Thomas N Williams
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Medicine, St Mary's Campus Imperial College, London, UK
| | - Kathryn Maitland
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Medicine, St Mary's Campus Imperial College, London, UK
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50
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Uyoga S, Macharia AW, Ndila CM, Nyutu G, Shebe M, Awuondo KO, Mturi N, Peshu N, Tsofa B, Scott JAG, Maitland K, Williams TN. The indirect health effects of malaria estimated from health advantages of the sickle cell trait. Nat Commun 2019; 10:856. [PMID: 30787300 PMCID: PMC6382840 DOI: 10.1038/s41467-019-08775-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 09/06/2018] [Accepted: 01/29/2019] [Indexed: 12/01/2022] Open
Abstract
Most estimates of the burden of malaria are based on its direct impacts; however, its true burden is likely to be greater because of its wider effects on overall health. Here we estimate the indirect impact of malaria on children's health in a case-control study, using the sickle cell trait (HbAS), a condition associated with a high degree of specific malaria resistance, as a proxy indicator for an effective intervention. We estimate the odds ratios for HbAS among cases (all children admitted to Kilifi County Hospital during 2000-2004) versus community controls. As expected, HbAS protects strongly against malaria admissions (aOR 0.26; 95%CI 0.22-0.31), but it also protects against other syndromes, including neonatal conditions (aOR 0.79; 0.67-0.93), bacteraemia (aOR 0.69; 0.54-0.88) and severe malnutrition (aOR 0.67; 0.55-0.83). The wider health impacts of malaria should be considered when estimating the potential added benefits of effective malaria interventions.
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Affiliation(s)
- Sophie Uyoga
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Alex W Macharia
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Carolyne M Ndila
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Gideon Nyutu
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Mohammed Shebe
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Kennedy O Awuondo
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Neema Mturi
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Norbert Peshu
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - Benjamin Tsofa
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
| | - J Anthony G Scott
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Kathryn Maitland
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya
- Department of Medicine, Imperial College, St Mary's Hospital, London, W21NY, UK
| | - Thomas N Williams
- Department of Epidemiology and Demography, KEMRI/Wellcome Trust Research Programme, PO Box 230, Kilifi, 80108, Kenya.
- Department of Medicine, Imperial College, St Mary's Hospital, London, W21NY, UK.
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