Etiology and risk factors of meningitis in patients admitted at a Central Hospital in Harare

OBJECTIVE

To determine etiology and risk factors of meningitis in patients admitted a tertiary referral Hospital in Harare.

DESIGN

Cross-Sectional Study.

SETTING

Urban Referral Health Facility.

SUBJECTS

Patients suspected of having Meningitis admitted at Parirenyatwa Hospital were consecutively consented and recruited into the study until sample size accrual.

MAIN OUTCOME MEASURES

Prevalence of pathogens associated with Meningitis. Risk factors of meningitis.

RESULTS

Two Hundred and Ninety Six (296) clinically suspected meningitis patients were recruited into the study, 51.7 %( n=115) were male. Meningitis was confirmed in 20.6% (n=61) cases with the following pathogen proportions, C. neoformans - 45.9 %( n=28), S. pneumoniae – 27.9 % (n=17), TBM – 4.9 %( n=3), probable viral meningitis – 6.6% (n=4 and other bacteria- 14.8% (n=9). Patients from crowded households were also more likely to suffer from meningitis than those from sparsely populated households (p<0.001).

CONCLUSION

The use of Latex agglutination increases the proportion of detected pathogens both fungal and bacterial when used in conjunction with CSF gram stain and culture. Cryptococcus neoformans and S. pneumoniae are the leading causes of meningitis in patients admitted at Parirenyatwa Hospital.

Optimization of the oligonucleotide ligation assay for the detection of nevirapine resistance mutations in Zimbabwean Human Immunodeficiency Virus type-1 subtype C

An oligonucleotide ligation assay (OLA) designed to detect Human Immunodeficiency Virus type-1 (HIV)-drug-resistance to the nevirapine (NVP) selected mutations K103N, Y181C, V106M and G190A was used to evaluate 200 archived dried blood spots (DBS) from infected infants participating in the Zimbabwean Early Infant Diagnosis (EID) Program. Consensus sequencing of specimens with indeterminate OLA results was performed to identify genetic sequence polymorphisms that appeared to compromise performance of the OLA. When consistent patterns of polymorphisms were observed the probes were redesigned, and DBS specimens with indeterminate OLA results were retested with the new Zimbabwe-specific (ZW) probes. OLA results obtained in Zimbabwe were compared to repeat testing in a US reference laboratory. 188/200 (94%) DBS yielded polymerase chain reaction (PCR) amplification of HIV pol. ZW probes reduced indeterminate OLA results from 5.2% to 2.8% of codons evaluated (p=0.02), with 98.2% concordance between results obtained in the Zimbabwean and US laboratories. Optimization of OLA probes to accommodate polymorphisms in regional HIV variants improved OLA performance, and comparison to the USA results showed successful implementation of the OLA in Zimbabwe for detection of NVP resistance mutations in DBS specimens.

Antimicrobial susceptibility patterns amongst group B streptococci from women in Harare, Zimbabwe

As part of a larger study of vaginal pathogens in women in Harare, we have examined the antimicrobial susceptibility patterns of 130 isolates of group B streptococci (GBS). These organisms are important because of their association with preterm labour, premature rupture of membranes and neonatal sepsis. All of the isolates in Harare were fully sensitive to beta-lactams, with an MIC(90) for ampicillin of 0.38 mg/l, but five isolates were resistant in vitro to erythromycin, and each of these had an MIC >4 mg/l. Seven isolates showed resistance to clindamycin. Some isolates showed an intermediate sensitivity to gentamicin, but the great majority were resistant to this antibiotic. Studies in developed countries have shown that an intervention strategy, using intrapartum chemoprophylaxis, is effective in reducing the incidence of complications of GBS colonization in pregnant women. Our data suggest that ampicillin would be a suitable antibiotic for use in an intervention programme of intrapartum chemoprophylaxis in Harare.

The effects of genital schistosoma haematobium on human papillomavirus and the development of cervical neoplasia after five years in a Zimbabwean population

BACKGROUND

High-risk human papillomavirus (HPV) is responsible for cervical cancer and genital Schistosoma haematobium infection has been hypothesized to be an additional co-factor or even an independent risk factor for cervical neoplasia. The present study aimed to investigate the impact of schistosomiasis on HPV persistence and development of cell atypia in a group of rural Zimbabwean women with confirmed high-risk HPV.

METHODS

A five-year follow-up was done among women previously included in a study on genital schistosomiasis. Women who had high-risk HPV at baseline were invited after 5 years for examination of cell atypia, genital schistosomiasis, and high-risk HPV. Both vaginal lavage samples (low-cost) and cervix brush samples (high-cost) were obtained for further analysis.

RESULTS

Thirty-seven women were re-examined. Genital Schistosoma haematobium of a minimum of five years' duration was associated with the development high-grade squamous intraepithelial neoplasia, but not with persistent high-risk HPV. There was a high concordance between the brush and vaginal lavage (96.3% agreement, kappa 0.93); however, the number of beta-globin negative vaginal lavage samples was unacceptably high.

CONCLUSIONS

Findings warrant an exploration in a larger longitudinal study where a vaginal swab should be explored.

Human immunodeficiency virus, smoking and self-rated health in Harare, Zimbabwe

SETTING

Twenty-two urban factories in Harare.

OBJECTIVE

To determine the relationship between the human immunodeficiency virus (HIV), smoking and self-rated health in a high HIV prevalence urban workforce.

DESIGN

Cross-sectional survey.

RESULTS

Of 7482 employees, 6111 (82%) consented to interview and anonymous HIV serology; 88% were male; median age was 34 years. HIV prevalence was 19%. Current (median 6 cigarettes per day) and former smoking were reported by 17% and 7%, respectively. Smoking (current or former) was more common among HIV-positive (27%) than -negative participants (17%; P < 0.001). Factors significantly associated with being a smoker on multivariate analysis were being HIV-infected (OR 1.5, 95% CI 1.4-1.7), older age (P < 0.001), non-Christian (OR 1.6, 95% CI 1.2-2.2) and manual job (OR 1.4, 95% CI 1.2-1.6). Women (OR 0.05, 95% CI 0.03-0.11) and the better educated (OR 0.7, 95% CI 0.5-0.9) were significantly less likely to smoke. HIV-positive smokers had the highest risk of reporting poor health (adjusted OR compared to HIV-negative non-smokers 3.4, 95% CI 2.3-5.0).

CONCLUSIONS

Smoking was significantly more common among HIV-positive than -negative employees in this predominantly male workforce. There was evidence of a combined effect on self-rated poor health, a variable shown to be a strong independent predictor of mortality in industrialised countries. Interventions to encourage smoking cessation may be an important component of HIV care in Southern Africa.

Chlamydia trachomatis in symptomatic and asymptomatic men: detection in urine by enzyme immunoassay

BACKGROUND

Infection with Chlamydia trachomatis is known to be a common cause of urethritis and cervicitis. The standard methods of detection require the collection of intra-urethral and/or cervical swabs, which may be submitted for culture, antigen detection or nucleic acid amplification. The collection of swabs is suitable only within the context of a health care facility. Recent reports have indicated that antigen detection can be used with urine specimens, and because these can be self-collected, this may be particularly useful for the detection of asymptomatic carriage.

OBJECTIVE

To determine the sensitivity and specificity of urine antigen assays in the detection of chlamydial infection in men.

SETTING

Two groups of men were investigated; men with urethritis attending clinics or private practitioners, and healthy adult men enrolled into either urban or rural HIV prevention projects.

METHODS

Urine samples from men in both groups were collected and assayed for the presence of chlamydial antigen using a commercial enzyme immunoassay (EIA) kit. For symptomatic men an intra-urethral swab was also collected and assayed for antigen detection using a commercial EIA. For asymptomatic men, a ligase chain reaction was carried out on the same urine sample.

RESULTS

The prevalence of chlamydial antigen in symptomatic men was 15% (39/257), and in asymptomatic men was 4% (15/349). The sensitivity and specificity of urine EIA for symptomatic men was 87% and 83% respectively. For asymptomatic men, the sensitivity of urine EIA was 86%, and the specificity was 100%.

CONCLUSION

Urine EIA is a relatively inexpensive method for the detection of chlamydial infections in men. The true specificity in symptomatic men may be higher, as the "gold standard" that we used may give false negative results. Antigen EIA for examination of urine specimens from community surveys of asymptomatic men may be particularly useful because of the low cost of assays, and because urine samples can be self-collected without discomfort to study subjects. The prevalence of C. trachomatis that we describe here is consistent with other studies of chlamydial epidemiology in Zimbabwe.

Asymptomatic bacteriuria among outpatients with diabetes mellitus in an urban black population

OBJECTIVE

To determine the prevalence of asymptomatic bacteriuria (ASB) in individuals afflicted by Diabetes mellitus; the antibiotic susceptibility of the microbial isolates and the association of host factors with ASB.

DESIGN

This was a prospective cross sectional study.

SETTING

Attendants of outpatient polyclinics at three main tertiary hospitals; namely, Harare, Chitungwiza and Parirenyatwa Hospitals.

SUBJECTS

176 participants.

MAIN OUTCOME MEASURES

Patients attending the polyclinics between 6.30 am and 9.30 am from Monday to Friday were randomly selected. Demographic data was obtained at enrollment using a standardized questionnaire. Fasting venous blood was withdrawn from the participants for glucose analysis. Clean-catch midstream urine samples from all men and women were cultured and the causal organisms were isolated and identified by standard microbiological methods. Antibiotic susceptibility testing was performed using a disc diffusion method. Potential host factors included age, type of diabetes, duration of diabetes, glucosuria and leukocyturia.

RESULTS

The prevalence of ASB was 32% in the diabetics and 11% in nondiabetic participants. The commonest bacterial organism isolated in participants afflicted by Diabetes mellitus was Escherichia coli (26%) followed by Staphylococcus aureus (21%), Streptococcus group B (14%), Streptococcus group D and non-lactose fermenting coliforms (7% respectively). Other isolates were Micrococcus and Pseudomonas (5% respectively), Klebsiella and Proteus (2% respectively). Gentamicin, nitrofurantoin, ampicillin and nicene were the most effective antimicrobials in the majority of isolates. Certain isolates exhibited some bacterial resistance to conventional antibiotics. Of the host factors, an association was found between bacteriuria and glucosuria (p < 0.001) and between leukocyturia and bacteriuria (p = 0.005).

CONCLUSION

The prevalence of ASB is increased in diabetes and the rather high blood glucose levels exhibited by these individuals may further complicate this condition. As some bacterial species exhibited resistance to some common antimicrobials, these results raise questions regarding future clinical reliability of some conventional antimicrobials when considering therapy for asymptomatic bacteriuria.

The prevalence of Herpes simplex virus type-2 infection in blood donors in Harare, Zimbabwe

OBJECTIVE

To determine the prevalence of HSV-2 infections in a population of blood donors.

DESIGN

Cross sectional study.

SETTING

Harare Blood Transfusion Service (BTS) Centre.

SUBJECTS

314 serum specimens of voluntary blood donors.

MAIN OUTCOME MEASURES

HSV-2 sero-prevalence.

RESULTS

The median age (Q1, Q3) of the blood donors was 18 (17,27) years and 65% of them were males. HSV-2 infection was detected in 29 (9.7%) of the 299 specimens that were analyzed. There was a strong association between age of blood donors and HSV-2 seropositivity (p < 0.001). Older blood donors tended to be positive while younger donors tended to be negative for HSV-2 antibodies. Though not as strong, there was also an association between HSV-2 and HIV seropositivity (p = 0.048).

CONCLUSION

The prevalence of HSV-2 infections in blood donors in Harare is high, considering the nature of the population studied. Therefore, the testing for HSV-2 in the serum of prospective blood donors should be included in the screening profiles used at the BTS centre in Harare, Zimbabwe to improve blood and blood products.

Enzyme immunoassay for urogenital trichomoniasis as a marker of unsafe sexual behaviour

Enzyme immunoassay (EIA) was used to detect antibodies to Trichomonas vaginalis in sera from Zimbabwe. The EIA showed a sensitivity of 95 and 94% when compared with vaginal swab culture among women attending a family planning clinic (FPC) and female commercial sex workers (CSW) respectively. The specificity was 85 and 77% in the two groups. Culture-negative FPC women were sub-divided into high risk or low risk of exposure to trichomoniasis. The seroprevalence was 10% (6/61) among low risk women, 21% (10/48) among high risk women and 23% (9/39) among culture negative CSW. The EIA was positive in 46% (18/39) men with genital discharge but only 5% (2/37) healthy blood donors. None of 31 sera from prepubescent children was positive. The EIA may be useful for community surveys of trichomoniasis. Because T. vaginalis is a common sexually transmitted disease, the test may indicate behaviour that increases the risk of STD transmission.

Fatal Pneumocystis carinii pneumonia in HIV-seropositive infants in Harare, Zimbabwe

Lung biopsies taken post mortem from 24 HIV-seropositive children who died of pneumonia in Harare Hospital (Zimbabwe) during 1995 were examined for pathogens using histology, culture, microscopy and polymerase chain reaction (PCR). Pneumocystis carinii was detected in 16 (67%) children, in 5 of whom bacterial pathogens were also detected. There were 2 cases of cytomegalovirus infection. On the basis of histology and PCR, none of the children had tuberculosis. These data add to the evidence that P. carinii pneumonia may be a significant cause of death in HIV-infected children in southern Africa. Policies on treatment for severe pneumonia, and on prophylaxis for children born to HIV-seropositive mothers need to be re-examined.

Antibiotic sensitivity and plasmid profiles of Pseudomonas aeruginosa

OBJECTIVE

To determine the susceptibility of Pseudomonas aeruginosa to commonly used antibiotics and to study the relationship between antibiotic resistance and the plasmid profiles of the organism.

DESIGN

Cross sectional study

SETTING

Samples of burns, wound pus, urine, blood, sputum, stool and aspirates were obtained from Harare Hospital (n = 120) and Parirenyatwa Hospital(n = 80).

SUBJECTS

Male and female patients either admitted or attending clinics.

MAIN OUTCOME MEASURES

P. aeruginosa isolates obtained were resistant to commonly used antibiotics in this environment. The resistance may be plasmid-dependent.

RESULTS

P. aeruginosa is prevalent in burns (76.7%) and wounds (67.5%) and in their respective hospital wards. The isolates of P. aeruginosa were resistant to gentamicin (65.5%); carbenicillin (61.9); polymyxinb (53.0%); ciprofloxacin (61.1%) and ceftriazone (70.8%); but showed high sensitivity to tazocin (89.4%) and nalidixic acid (59.3%) and cotrimoxazole (54.9%). All the isolates resistant to the antibiotics tested possessed plasmid DNA. Strains with four plasmids of molecular weight of approximately, 1.5 x 10(6), 1.8 x 10(6), 2.9 x 10(6) and 7.4 x 10(6) Da showed multiple resistance to the drugs that were tested.

CONCLUSION

This study reveals an emergence of multiple antibiotic-resistant strains of P. aeruginosa. The traditional drugs gentamicin, carbenicillin, ciproflaxacin, and polymyxin-b used for treatment of P. aeruginosa infections may no longer be reliable. Therefore, a newer drug such as tazocin and other rarely used drugs such as nalidixic acid should be considered for P. aeruginosa antibiotic therapy.

Relationship of human herpesvirus 8 peripheral blood virus load and Kaposi's sarcoma clinical stage

OBJECTIVE

To determine the relationship between human herpesvirus 8 (HHV-8 or Kaposi's sarcoma-associated herpesvirus) peripheral blood virus load and Kaposi's sarcoma (KS) clinical stage.

DESIGN

Blinded, cross-sectional analysis of peripheral blood HHV-8 DNA levels in persons with AIDS-related KS in Harare, Zimbabwe.

METHODS

Subjects were stratified by KS clinical stage. The amount of HHV-8 DNA in plasma and peripheral blood mononuclear cells (PBMC) was determined by quantitative real-time PCR amplification of the HHV-8 open reading frame 26.

RESULTS

Thirty-one HIV-1/HHV-8-coinfected persons were studied: 26 subjects had histologically confirmed KS (one stage II, 11 stage III and 14 stage IV) and five subjects had antibodies to HHV-8 but did not have KS. The age, CD4 lymphocyte count and plasma HIV-1 RNA levels were similar in all groups. HHV-8 DNA was detected in the plasma of all HHV-8-infected subjects (range < 2.4 to 5.2 log10 copies/ml), but plasma HHV-8 DNA levels were not associated with KS disease stage. In contrast, the amount of HHV-8 DNA in PBMC (range < 0.7 to 4.5 log10 copies/microg) was strongly associated with KS clinical stage (P = 0.005). Among stage IV KS cases, there was a linear relationship between plasma and PBMC HHV-8 DNA levels (r2 = 0.42; P = 0.01).

CONCLUSION

The strong association observed between the extent of KS disease and the levels of HHV-8 DNA in PBMC provides further evidence for a relationship between HHV-8 virus load and KS pathogenesis.

Detection of Kaposi's sarcoma-associated herpesvirus in oral and genital secretions of Zimbabwean women

Kaposi's sarcoma-associated herpesvirus (KSHV) in oral and genital secretions of women may be involved in horizontal and vertical transmission in endemic regions. Nested polymerase chain reaction assays were used to detect KSHV DNA sequences in one-third of oral, vaginal, and cervical specimens and in 42% of peripheral blood mononuclear cell (PBMC) specimens collected from 41 women infected with human immunodeficiency virus type 1 who had Kaposi's sarcoma (KS). KSHV DNA was not detected in specimens from 100 women without KS, 9 of whom were seropositive for KSHV. A positive association was observed between KSHV DNA detection in oral and genital mucosa, neither of which was associated with KSHV DNA detection in PBMC. These data suggest that KSHV replicates in preferred anatomic sites at levels independent of PBMC viremia. Detection of genital-tract KSHV only among relatively immunosuppressed women may provide an explanation for infrequent perinatal transmission of KSHV.

Effect of intravaginal practices on the vaginal and cervical mucosa of Zimbabwean women

OBJECTIVES

Lesions on the vaginal and cervical mucosa may facilitate transmission of HIV and other sexually transmitted diseases (STDs). We evaluated the relationship between intravaginal practices and the presence of colposcopic lesions in Zimbabwean women.

METHODS

Users and nonusers of intravaginal practices were seen at enrollment, and at 1 and 6 months. Interviewing, counseling, and pelvic and colposcopic examinations were performed at each study visit. Specimens were collected at enrollment and 6 months.

RESULTS

Colposcopic lesions were found at least once in 83% of the participants (n = 162), and in 66% of all exams (n = 430). Most lesions were classified as related to infection with human Papillomavirus (HPV) (58%) or another pathogen (20%), but 11% of lesions could have been caused by intravaginal practices (signal lesions). Intravaginal practices were not associated with an increased incidence in signal lesions (95 and 124 lesions per 100 person-years of follow-up for users and nonusers respectively; p = .290), nor with the presence of signal lesions in multivariate baseline (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.37-4.72; p = .666) and six month transition models (OR, 1.67; 95% CI, 0.59-4.70; p = .333).

CONCLUSIONS

No associations between intravaginal practices and colposcopic lesions were found in this study. However, the potential effect of intravaginal practices on the cervical and vaginal mucosa, and on subsequent HIV and STD transmission, warrants further study. The usefulness of colposcopy as a research tool in areas with high prevalences of HIV and HPV is questioned.

Intravaginal practices, vaginal flora disturbances, and acquisition of sexually transmitted diseases in Zimbabwean women

One hundred sixty-nine Zimbabwean women were studied to determine whether the use of intravaginal practices (cleaning with the fingers, wiping the vagina, and inserting traditional substances) are associated with disturbances of vaginal flora and acquisition of sexually transmitted diseases (STDs). Subjects were interviewed and received counseling and a pelvic examination at enrollment, 1 month, and 6 months, and vaginal specimens were collected at enrollment and at 6 months. Users were more likely than nonusers to have vaginal flora disturbances but were not more likely to acquire an STD (relative risk [RR], 2.15; P=.188). Certain vaginal flora disturbances were associated with increased STD incidence and HIV prevalence. The absence of lactobacilli from the vaginal flora was associated with being positive for human immunodeficiency virus in baseline (odds ratio [OR], 0.24; P=.001) and 6-month transition multivariate models (OR, 0.39; P=.025). The presence of clue cells at baseline was associated with a higher incidence of STDs (RR, 1. 94; P=.025).

Syphilis serology and HIV infection in Harare, Zimbabwe

OBJECTIVE

To determine the reliability of serological tests in detecting syphilis in a factory worker cohort and examine the impact of concurrent HIV infection on serological tests for syphilis.

METHOD

Reactions to non-treponemal and treponemal antigens were tested using sera from a cohort of 3401 factory workers in Harare, Zimbabwe. The participants consented to regular testing for syphilis, by VDRL, and HIV using two ELISAs. All sera from men who were VDRL positive, and a random sample of VDRL negative sera, were tested by RPR, TPHA, and where appropriate FTA-Abs. From the results, men were defined as having no syphilis, active syphilis, incident syphilis, historic syphilis, or giving biological false positive reactions.

RESULTS

709 sera were examined from 580 men. There were 78 cases of active syphilis in the cohort, giving a prevalence of 2.3%, and the seroincidence was 0.25 per 100 person years of follow up. The prevalence of HIV in the cohort was 19.8%. There was a strong association between syphilis, whether active, incident or historic, and HIV seropositivity. With both HIV positive and negative sera the negative predictive values of VDRL and RPR were > 99.9% while the positive predictive value for VDRL (30%) was lower than for RPR (39%). Biological false positive reactions were detected in 0.5% of the cohort, with in most cases a transient rise in VDRL titres up to < 1/16. Higher false positive titres occurred in five men, each of whom was HIV positive.

CONCLUSIONS

The VDRL is reliable in detecting possible cases of syphilis even in a community with a high prevalence of heterosexually transmitted HIV. There is need, however, for confirmatory tests. The prevalence of syphilis in this cohort is very low in comparison with other countries in southern Africa, but is consistent with recent data from Harare. Despite a strong association between syphilis and HIV it was clear that syphilis could not be counted as a major factor fueling the HIV epidemic in Zimbabwe.

Prevalence and incidence of herpes simplex virus type 2 infection among male Zimbabwean factory workers

Stored sera from a cohort of 2397 male factory workers in Harare, Zimbabwe, were screened for herpes simplex virus type 2 (HSV-2)-specific antibodies, to estimate the prevalence and incidence of genital herpes infection and to assess the relation between HSV-2 and human immunodeficiency virus (HIV) acquisition. The prevalence of HSV-2 at enrollment was 39.8%. Correlates of HSV-2 seropositivity were HIV seropositivity, marital status, history of sexually transmitted disease (STD), older age, and higher income. The incidence of HSV-2 seroconversion during follow-up was 6.2/100 person-years. Correlates of HSV-2 seroconversion were enrollment while HIV-positive or seroconversion during follow-up, reported genital ulcer, history of STD, and number of sex partners. No evidence was found that HSV-2 infection was more likely to precede HIV or vice versa. HSV-2 and HIV seropositivity are strong markers for high-risk sexual behavior. Improved interventions targeted to populations in which the incidence of either viral infection is high are needed.

Risk factors for gonococcal and chlamydial cervical infection in pregnant and non-pregnant women in Zimbabwe

OBJECTIVE

To identify demographic, behavioural and clinical characteristics of symptomatic and asymptomatic women with gonococcal and/or chlamydial cervicitis a study was conducted among women attending antenatal clinics and primary care clinics in Harare, Zimbabwe.

DESIGN

Cross sectional study.

SETTING

Primary care clinics and antenatal clinics in Harare.

SUBJECTS

467 women with vaginal discharge and 1,189 asymptomatic pregnant women.

MAIN OUTCOME MEASURES

Behavioural and clinical correlates of gonococcal and chlamydial cervical infection.

RESULTS

The mean age of symptomatic women was 26.11 +/- 6.84 years (range: 15 to 52 years) and that of asymptomatic pregnant women was 24.67 +/- 5.43 years (range: 15 to 45 years). Gonococcal and/or chlamydial cervical infection was found in 69 of 1,189 (5.8%) pregnant women and in 77 of 467 (16.5%) non-pregnant women. Logistic regression analysis identified the following predictors of gonococcal or chlamydial infection in women with vaginal discharge: being separated from the partner for a month or more (p = 0.002), having had sex with a new partner in the last three months (p = 0.002), current use of condoms (p = 0.011), and the finding on examination of a purulent vaginal discharge (p = 0.004). Amongst these women an increasing educational level was inversely associated with cervical infection (p = 0.007). Amongst asymptomatic pregnant women the following were identified as predictors of cervical infection: the patient admitting to having a vaginal discharge on direct questioning (p = 0.004), and the finding of a purulent vaginal discharge on examination (p = 0.001).

CONCLUSIONS

Amongst symptomatic and asymptomatic women certain behavioural factors and some clinical findings are associated with cervical gonococcal or chlamydial infection. Women with multiple partners and with partners who are currently using condoms with them and those women with a purulent vaginal discharge are likely to be infected. The age and marital status of subjects was not associated with cervical infection. These findings are useful in providing appropriate care for women with overt or minimal symptoms.

Adolescent pregnancy in Zimbabwe: distribution by socio-demographic factors

We conducted a further analysis of the Zimbabwe 1994 demographic health survey data to determine demographic and social factors associated with adolescent pregnancies in Zimba notbwe. Out of a total of 1486 female adolescents sampled, 12 did not provide information on whether they had begun child bearing, and were therefore excluded from the analysis. Significantly elevated odds ratios (OR) were noted for age (OR=2.27,95% confidence interval (CI) 2.01-2.58) and having primary or no education (OR=1.58, 95%CI 1.35,1.87). Watching television every week was protective (OR=0.69, 95%CI 0.57-0.83). Heads of households with less than 25 years of age were 2.10 (95%CI 1.54-2.87) times more likely to have adolescents who were pregnant when compared with heads of households of age 35 years or more. We conclude that electronic media should be continued to be used to deliver sex education messages to adolescents in order to curb the adolescent pregnancy epidemic.

Association between human immunodeficiency virus and herpes simplex virus type 2 seropositivity among male factory workers in Zimbabwe

To determine the seroprevalence of herpes simplex virus type 2 (HSV-2), to identify correlates of infection, and to describe the correlation with human immunodeficiency virus (HIV) seropositivity, 224 HIV-negative and 191 HIV-positive male factory workers in Zimbabwe were screened for HSV-2-specific antibodies. HSV-2 seroprevalence was 35.7% among HIV-negative subjects and 82.7% among HIV-positive subjects. The weighted estimate of HSV-2 seroprevalence in this population is 44.6%. The correlation between HIV and HSV-2 remained significant after controlling for multiple sex partners, paying for sex, and history of sexually transmitted disease (adjusted odds ratio, 8.0; 95% confidence interval, 4.8-13.1). If the association between HSV-2 and HIV is causal, then the high seroprevalence of HIV and HSV-2 suggests that suppressive HSV-2 treatment should be considered as a strategy to reduce HIV transmission in this population. HSV-2 seroconversion may be a suitable surrogate end point to evaluate HIV prevention interventions.

Polymerase chain reaction detection of Haemophilus ducreyi DNA

OBJECTIVES

To develop a polymerase chain reaction (PCR) method to detect Haemophilus ducreyi DNA in cultured isolates and clinical material.

METHODS

Primers specific to the H ducreyi 16s rRNA gene were synthesised. PCR conditions were optimised and products were verified by restriction endonuclease digestion and agarose gel electrophoresis.

RESULTS

The method was able to detect all 28 H ducreyi strains tested; specificity was demonstrated using lysates of 12 related organisms. Applied to clinical samples from genital ulcer swabs obtained in Harare, Zimbabwe, H ducreyi DNA was detected in repeated assays in 35 clinical samples.

CONCLUSION

PCR amplification using primers from the 16s rRNA gene may be a useful alternative to culture for the detection of H ducreyi and the diagnosis of chancroid.

Antimicrobial resistance in gonococci isolated from patients and from commercial sex workers in Harare, Zimbabwe

The objective is to compare antibiotic resistance amongst gonococci isolated from different patient groups in Harare, Zimbabwe. Antimicrobial susceptibilities of Neisseria. gonorrhoeae were determined by disc sensitivity tests. The MICs for penicillin, kanamycin, ceftriaxone, norfloxacin and ciprofloxacin were determined using E-test strips. There were 147 isolates from symptomatic men, 47 isolates from symptomatic women, 29 isolates from asymptomatic women and 41 isolates from female commercial sex workers. A total of 119 (45%) isolates were PPNG and 23 (16%) non-PPNG isolates had a penicillin MIC > 0.64 mg/l. Over 90% of isolates were resistant to TMP/SMX and 16% were resistant to tetracycline. Resistance was uncommon against kanamycin (6%), erythromycin (2%) or ceftriaxone ( < 1%). For kanamycin, the MIC90 was 32 mg/l, for ceftriaxone the MIC90 was < 0.032 mg/l for non-PPNG and < 0.064 mg/l for PPNG. For norfloxacin and ciprofloxacin the MIC90 was < 0.064 mg/l for both PPNG and non-PPNG. Isolates from the commercial sex workers showed a significantly increased prevalence of PPNG, of penicillin-tolerant non-PPNG and of tetracycline resistance. Four of the 41 isolates from sex workers showed multiple resistance (to penicillin, TMP/SMX, tetracycline and kanamycin) compared to 1/223 isolates from other groups (OR = 24.0). Antimicrobial resistance is common amongst gonococci in Harare, especially with isolates from commercial sex workers. In order for STD treatment to be implemented as an effective strategy in HIV control, continued monitoring of resistance patterns is essential.

Genetic diversity in human-derived Pneumocystis carinii isolates from four geographical locations shown by analysis of mitochondrial rRNA gene sequences

The opportunistic fungal pathogen Pneumocystis carinii is a frequent cause of pneumonia in immunocompromised hosts. In this study, we have compared the DNA sequences of a portion of the mitochondrial large-subunit rRNA gene of P. carinii (an informative locus showing up to 27% differences among isolates of P. carinii from human-, rat-, mouse-, ferret-, rabbit-, and horse-infected lungs) obtained from human-derived isolates from widely disparate geographical areas, including Britain, the United States, Brazil, and Zimbabwe. A single-base polymorphism which varied among samples was identified. Apart from this nucleotide, the DNA sequences of all samples were identical. The sequences of the British samples were shown to be stable over a period of 4 years. These data suggest that there is relatively low genetic diversity among isolates of human-derived P. carinii from different global regions.

Severe Klebsiella infection as a cause of mortality in neonates in Harare, Zimbabwe: evidence from postmortem blood cultures

Postmortem blood cultures were taken from 105 neonates dying at Harare Hospital during a 1-year period. The infants were characterized by prematurity (63% < 37 weeks gestation), low birth weight (60% < 2500 g) and low Apgar score at 1 min (43% < 3). More than one-half of the infants died within 48 hours of admission. Positive blood cultures within 10 minutes of death occurred in 44% of infants, and Klebsiella sp. were by far the most common isolates. Positive blood cultures were associated with very low birth weight (< 1500 g), and with babies who survived for > 48 hours. Antibodies to human immunodeficiency virus type 1 were found in 40% of the infants, and a high proportion of these had Klebsiella bacteremia. Nearly all the infants had received antibiotic therapy, usually penicillin and gentamicin. Very few babies who had received a cephalosporin had a positive blood culture, and in vitro tests showed that although many organisms were resistant to penicillin and the aminoglycosides, very few showed resistance to the cephalosporins. Our findings suggest that cephalosporins may be useful in treating severe neonatal sepsis, particularly when there is no response to more standard therapy.

HIV and other sexually transmitted diseases at a rural hospital in Zimbabwe

OBJECTIVE

To define the epidemiological characteristics of STD patients attending an outpatient clinic in rural Zimbabwe, to examine the aetiologic agents causing infection and to determine their relationship with HIV infection.

SUBJECTS

319 men and 146 women, making a sample of about 7% all patients attending an STD clinic during the 3 month study period. Microbiological data were collected from 104 men and 72 women selected randomly from these. Pregnant women were excluded and patients who had received antibiotics within the previous 14 days were excluded from the microbiology sub-sample.

SETTING

An outpatient STD clinic at a District Hospital on a major truck route about 300 km north of the capital, Harare.

METHODS

All new patients attending the clinic during a 3 month period were enrolled for clinical and epidemiological investigations using a standard procedure. Specimens for microbiological investigation were taken from every second patient seen on the first three days of each week.

RESULTS

The typical patient was male (m:f ratio 2.2) aged 20-29 years (68% patients), not married (56% men) and in paid employment (66% men vs. 27% for the district). In men the most common presenting feature was genital ulceration, while in women, discharges were more common. Genital warts were noted frequently in both sexes. In the sub-sample examined microbiologically, H ducreyi was isolated from 46% ulcers clinically diagnosed as chancroid, and motile spirochaetes were detected in 25% painless ulcers. Neither of these were detected in ulcers in women, but HSV antigen was found as frequently in ulcers from men (19%) as from women (17%). In patients with genital discharges, gonococcal infection occurred in 64% men and 17% women, while T vaginalis was isolated from 39% women and only 8% men. Over 60% gonococcal isolates were PPNG, and 18% showed in vitro resistance to tetracycline. Yeasts, mainly C albicans were isolated from 42% women with a discharge and 25% women with ulcers. In men the presence of yeasts was associated with superficial ulceration and itchiness of the glans. Positive HIV-1 serology was found in 64% patients. There was no statistical association with current genital ulcers, though there was an association with previous STD episodes and particularly with serological evidence of syphilis. Apart from yeasts, there was no association between positive HIV-1 serology and the presence of pathogens in the genital tract.

CONCLUSIONS

The high prevalence of HIV-1 antibodies in STD patients in Karoi suggests integration of STD and AIDS control programmes to be a necessity. Since paid employment was a common feature of both STD clinic attendance and HIV-1 seropositivity, these programmes may be effectively directed through the work place.

The use of monoclonal antibodies to identify mycobacteria grown in culture in Zimbabwe

Monoclonal antibodies (Mabs) were used in an ELISA system to identify 462 mycobacterial isolates from clinical specimens in Zimbabwe. Cultures of mycobacteria were either sonicated or mechanically homogenised and used to coat the wells of microtitre plates. The mouse Mabs used reacted to lipoarabinomannan, an antigen common to all species of mycobacteria, to a 16 kDa protein specific to members of the Mycobacterium tuberculosis complex, to a glycolipid found in the cell wall of M. kansasii and to a glycolipid found in the cell wall of members of the M. avium-intracellulare complex. On the basis of serologic reactivity 443/462 (94%) isolates were identified as M. tuberculosis, 6/462 (1%) were identified as M. avium-intracellulare and 7/462 (2%) were identified as M. kansasii. The remaining 16 isolates gave negative reactions with each of the monoclonals, except that reactive with lipoarabinomannan. On the basis of biological tests on the 13 of the isolates that were available, 6 were identified as M. tuberculosis and 3 as M. bovis. In each of these the optical densities in the ELISA with at least one of the Mabs directed against the 16 kDa protein, was within 0.2 units of the cut off value. 4 isolates were not identifiable using biological tests in our laboratory. Each of the available isolates identified serologically as M. avium-intracellulare or M. kansasii gave biological reactions consistent with this identification. This study has shown Mab-ELISA to be a reliable means of rapidly identifying large numbers of mycobacterial isolates in a reference laboratory in Zimbabwe.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurocysticercosis: experience with diagnosis by ELISA serology and computerised tomography in Zimbabwe

Over a three-year period, 646 sera from 630 patients with signs and symptoms compatible with neurocysticercosis were investigated for antibodies to cysticercal antigens using an ELISA test. Overall, 12 pc specimens were positive. The sensitivity of the ELISA, when compared with a limited number of computerised tomography investigations, was over 70 pc. False negative serology was associated with HIV infection in some patients. The positive predictive value was 87 pc and the negative predictive value was 85 pc when patients with active infection, potentially amenable to chemotherapy, were considered. The specificity, determined from serological tests of patients with a variety of trematode, cestode and other infections, was over 90 pc. Three of 11 patients with intestinal taeniasis, and each of two patients with hydatid disease were seropositive. The results suggest the value of ELISA serology as a more cost-effective diagnostic method for all patients with suspected cysticercosis.

Reduced lymphocyte responses to mitogens in natural and experimental trichomoniasis

Proliferative responses to mitogens were determined by using peripheral blood mononuclear cells from women with active trichomoniasis, with serological evidence of past infection with Trichomonas vaginalis, and with no evidence of current or past infection. Even after the human immunodeficiency virus antibody status of the patients was taken into account, cells from women with active trichomoniasis showed reduced responses to phytohemagglutinin, concanavalin A, pokeweed mitogen, and bacterial lipopolysaccharide. Similar findings were obtained by using spleen cells from mice inoculated subcutaneously with live trichomonads. Reduction in proliferative responses by these cells could be detected 3 days after inoculation. There was some evidence to suggest that more-pathogenic strains of the parasite induced a greater degree of immunosuppression. The responses of spleen cells from mice inoculated with trichomonad-free culture supernatants were within normal limits, indicating that live trichomonads were needed to induce suppression. Support for this was gained from studies with cells from women who were treated successfully. Cells from these women rapidly regained normal lymphoproliferative function. Interleukin-2 (IL-2) production by spleen cells from infected mice was determined from measurements of mitochondrial activity in an IL-2-dependent T-cell line following incubation with stimulated spleen cell culture supernatants. These tests demonstrated lower IL-2 activity in supernatants from cell cultures from infected mice than in those from uninfected mice. The reduction in IL-2 activity did not, however, appear to correlate with the degree of reduction of mitogen-induced lymphoproliferation. Suppression of T-cell-mediated immunity may be one of the mechanisms by which T. vaginalis is able to evade host responses to infection.

Genital infections in women attending a genito-urinary clinic in Harare, Zimbabwe

One hundred women attending a sexually transmitted diseases clinic in Harare were examined for presenting features and genital infections. The most common presenting symptoms were of discharge, lower abdominal pain and dysuria, and on examination signs of discharge, inflammation, haemorrhage or ulcers/erosions were noticeable in all women. Fourteen women had genital warts. Pathogens were detected in 95% of patients. Gonococcal infection occurred in 19 women, with 60% of the strains isolated being penicillinase producing. Yeasts were detected in specimens from 25 women while chlamydial infection appeared to be rare, evidence of infection being detected in only eight women. Sera from 44 women were positive by the RPR test and sera from 33 women were positive by TPHA. Gardnerella vaginalis was isolated from 48 women, Group B streptococci from 37 women, and Trichomonas vaginalis from 32 women.

Pneumocystis carinii pneumonia in patients with AIDS in Central Africa

Over a period of 11 months, 37 patients infected with the Human Immunodeficiency Virus (HIV) presenting with symptoms of bronchopulmonary disease were investigated. Patients presented with cough, weight loss, fever and dyspnoea. Investigations included fibreoptic bronchoscopy with bronchoalveolar lavage and transbronchial biopsy. In eight patients (22%) Pneumocystis carinii was found. Pulmonary infiltrates were found on chest radiographs of six patients, while in the remaining two patients chest radiographs showed clear lung fields. P. carinii was found in two patients with pulmonary Kaposi's sarcoma. Infection with P. carinii often occurred with other pathogens: Streptococcus pneumoniae was found in four patients, Staphylococcus aureus in two and tuberculosis in two. P. carinii pneumonia does occur in patients with HIV infection in Africa and the diagnosis is relatively simple to make provided that transbronchial biopsy and bronchoalveolar lavage are carried out through a fibreoptic bronchoscope and specimens examined after appropriate staining. However, the prevalence of P. carinii in patients with HIV infection in Africa appears to be lower than that found in patients with HIV infection in Europe and North America.

Antimicrobial susceptibility of Neisseria gonorrhoeae in Harare, Zimbabwe. Relationship to serogroup

The authors investigated one hundred fifty-four isolates of Neisseria gonorrhoeae obtained from men, women, and infants in Harare, Zimbabwe, for in vitro susceptibility to various antibiotics and for reactivity with serogrouping antisera. The authors found sixty-four (42%) isolates to be WI serogroup and 90 (58%) to be WII/III. One hundred three isolates were penicillinase-producing N. gonorrhoeae (PPNG); although all of these showed resistance to penicillin, 14 isolates had an MIC to penicillin of less than 10 mg/L. All of these 14 isolates were WI serogroup. Twenty-seven of the 51 non-PPNG showed in vitro resistance to penicillin (MIC greater than 1.25 mg/L). All but one of these chromosomally resistant isolates were WII/III serogroup. With cefuroxime, tetracycline, and erythromycin, 10-15% of isolates had MICs greater than accepted breakpoints. Most isolates were susceptible to thiamphenicol, and all were susceptible to ciprofloxacin, kanamycin, and spectinomycin. The authors noted that WI isolates, whether PPNG or not, were consistently more susceptible to antibiotics than WII/III isolates. Only with kanamycin and spectinomycin were the MICs of the two serogroups similar.

Antimicrobial susceptibility of Neisseria gonorrhoeae isolated from maternal and child infections in Harare. The Puerperal Sepsis Study Group

The in vitro antimicrobial susceptibilities of 29 PPNG and 26 non-PPNG isolated from women and neonates in Zimbabwe were investigated. There was evidence of chromosomal resistance to penicillin in many of the non-PPNG strains, with over 60 percent of all isolates having an MIC greater than 1 mg/litre. Reduced susceptibility to tetracycline was evident in about 20 percent of PPNG strains, particularly those containing the 4.4Md plasmid, while over 10 percent of non-PPNGs showed partial resistance to cefuroxime. Less than half of the strains were susceptible to erythromycin (MIC50 greater than 0.5 mg/litre) while all were susceptible to kanamycin and spectinomycin. PPNG containing the 3.2 Md plasmid were very susceptible to thiamphenicol (MIC50 0.25 mg/litre), while other strains were only moderately susceptible (MIC50 2 mg/litre). These findings suggest that penicillin, tetracycline or erythromycin may no longer be relied on for the successful treatment of gonococcal infection in women and babies. Thiamphenicol, Blactamase stable cephalosporins, kanamycin or spectinomycin may be useful alternatives, effective against most strains of both PPNG and non-PPNG. Continued surveillance is recommended to monitor changes in this susceptibility pattern.

Characterisation by plasmid profiles, serogroups, and auxotypes of Neisseria gonorrhoeae from Harare, Zimbabwe

(ABSTRACTOne hundred and fifty five strains of Neisseria gonorrhoeae were regrown from 216 freeze dried cultures originally isolated in Zimbabwe. The gonococci were from men (61 strains) and women (39 strains) attending a referral sexually transmitted diseases (STD) clinic, from women presenting for delivery at hospital with signs of sepsis (22 strains) or with an asymptomatic infection (16 strains), and from babies with ophthalmia neonatorum (17 strains). Seventy five of the 100 isolates from STD clinic patients and 29 of the 55 isolates from hospital patients were penicillinase producing N gonorrhoeae (PPNG). Two thirds of all PPNG strains contained the 24.5 megadalton conjugative plasmid. The 3.2 megadalton resistance plasmid, usually associated with PPNG strains originating in Africa, was present in only one third of the PPNG strains. The 2.6 megadalton cryptic plasmid was present in all strains. Prototrophic and proline requiring auxotypes predominated in both PPNG and non-PPNG strains. Arginine requiring auxotypes were found in four of the 16 isolates from asymptomatic women, whereas three of the 22 strains from women with puerperal sepsis and four of the 61 strains from men with urethritis required both proline and arginine. Fifty eight out of 66 PPNG strains with the 4.4 megadalton plasmid required proline compared with 22/38 PPNG strains with the 3.2 megadalton plasmid and 20 of the 51 non-PPNG strains. Three quarters (38/51) of non-PPNG strains belonged to serogroup WII/III as did 42/66 PPNG strains with the 4.4 megadalton plasmid but only 10/38 PPNG strains with the 3.2 megadalton plasmid. In all, 23 different strain types could be recognized on the basis of plasmid content, auxotype, and serogroup. There was, however, a high degree of homogeneity between PPNG and non-PPNG isolates.

Management of gonococcal ophthalmia neonatorum with single-dose kanamycin and ocular irrigation with saline

Two hundred nineteen neonates with gonococcal ophthalmia neonatorum, including 40 infected with penicillinase-producing strains, were treated as outpatients with a single intramuscular injection of 100 mg of kanamycin and hourly ocular irrigation with saline. Neisseria gonorrhoeae was isolated from three (1.4%) of the 212 babies attending for follow-up, and post-gonococcal conjunctivitis developed in 22 (10.4%) of those who returned for follow-up.

Mouse spleen cell responses to trichomonal antigens in experimental Trichomonas vaginalis infection

Subcutaneous inoculation of live T. vaginalis into mice caused splenomegaly, particularly when using strains of parasites with low pathogenicity. The proliferative responses of spleen cells from uninfected mice, as measured by [3H] TdR uptake, showed that trichomonal antigens, whether from strains with high or low pathogenicity, have no mitogenic activity. Spleen cells from mice infected with trichomonads of low pathogenicity showed a proliferative response to trichomonal antigens that was maximal after 4 days incubation. The proliferative response of spleen cells from mice infected with trichomonads of high pathogenicity continued for at least 6 days in the presence of the antigen. Moreover, in the latter case there was a significantly greater uptake of [3H] TdR when cells were incubated with antigens of a highly pathogenic strain. These results support the view that although many antigens are common to strains with differing levels of pathogenicity, some antigens are more closely associated with strains that are more highly pathogenic. The strong proliferative response to these antigens may then be related to the clinical presentation of infection with these strains.