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WHAT'S NEW THIS TUESDAY ON WWW.CHILDSURVIVAL.NET: PMTCT IN ANGOLA; TWO ON YAWS; POLIO ERADICATION, 2011-2012

Tuesday, 22nd of May 2012

 

• WHAT’S NEW: PMTCT IN ANGOLA; SINGLE  DOSE AZITHROMYCIN AGAINST YAWS;  YAWS ERADICATION; POLIO ERADICATION, 2011-2012; PMTCT IN ANGOLA

PLoS One. 2012;7(4):e36381. Epub 2012 Apr 30.

Effectiveness of a Prevention of Mother-to-Child HIV Transmission Programme in an Urban Hospital in Angola.

Lussiana C, Clemente SV, Ghelardi A, Lonardi M, Pulido Tarquino IA, Floridia M.

Source

Infectious Diseases Laboratory, Hospital Divina Providencia, Luanda, Angola.

Abstract below; full text is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0036381

 

BACKGROUND:

Antiretroviral therapy is effective in reducing rates of mother-to child transmission of HIV to low levels in resource-limited contexts but the applicability and efficacy of these programs in the field are scarcely known. In order to explore such issues, we performed a descriptive study on retrospective data from hospital records of HIV-infected pregnant women who accessed in 2007-2010 the Luanda Municipal Hospital service for prevention of mother-to-child transmission (PMTCT). The main outcome measure was infant survival and HIV transmission. Our aim was to evaluate PMTCT programme in a local hospital setting in Africa.

RESULTS:

Data for 104 pregnancies and 107 infants were analysed. Sixty-eight women (65.4%) had a first visit before or during pregnancy and received combination antiretroviral treatment (ART) in pregnancy. The remaining 36 women (34.6%) presented after delivery and received no ART during pregnancy. Across a median cohort follow-up time of 73 weeks, mortality among women with and without ART in pregnancy was 4.4% and 16.7%, respectively (death hazard ratio: 0.30, 95% CI 0.07-1.20, p = 0.089). The estimated rates of HIV transmission or death in the infants over a median follow up time of 74 weeks were 8.5% with maternal ART during pregnancy and 38.9% without maternal ART during pregnancy. Following adjustment for use of oral zidovudine in the newborn and exposure to maternal milk, no ART in pregnancy remained associated with a 5-fold higher infant risk of HIV transmission or death (adjusted odds ratio: 5.13, 95% CI: 1.31-20.15, p = 0.019).

CONCLUSIONS:

Among the women and infants adhering to the PMTCT programme, HIV transmission and mortality were low. However, many women presented too late for PMTCT, and about 20% of infants did not complete follow up. This suggests the need of targeted interventions that maintain the access of mothers and infants to prevention and care services for HIV.

 

‘A single oral dose of azithromycin is non-inferior to benzathine benzylpenicillin and avoids the need for injection equipment and medically trained personnel.’

 

• SINGLE DOSE AZITHROMYCIN AGAINST YAWS

 

Full text, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61624-3/fulltext

 

Abstract below:

 

Published Online: The Lancet, 11 January 2012

Single-dose azithromycin versus benzathine benzylpenicillin for treatment of yaws in children in Papua New Guinea: an open-label, non-inferiority, randomised trial

Original Text

Dr Oriol Mitjà MD a b , Russell Hays MD a, Anthony Ipai HEO a, Moses Penias HEO a, Raymond Paru BSc a, David Fagaho BSc a, Elisa de Lazzari MSc b, Quique Bassat PhD b

Background

Yaws—an endemic treponematosis and, as such, a neglected tropical disease—is re-emerging in children in rural, tropical areas. Oral azithromycin is effective for syphilis. We assessed the efficacy of azithromycin compared with intramuscular long-acting penicillin to treat patients with yaws.

Methods

We did an open-label, non-inferiority, randomised trial at Lihir Medical Centre, Papua New Guinea, between Sept 1, 2010, and Feb 1, 2011. Children aged 6 months to 15 years with a serologically confirmed diagnosis of yaws were randomly allocated, by a computer-generated randomisation sequence, to receive either one 30 mg/kg oral dose of azithromycin or an intramuscular injection of 50 000 units per kg benzathine benzylpenicillin. Investigators were masked to group assignment. The primary endpoint was treatment efficacy, with cure rate defined serologically as a decrease in rapid plasma reagin titre of at least two dilutions by 6 months after treatment, and, in participants with primary ulcers, also by epithelialisation of lesions within 2 weeks. Non-inferiority was shown if the upper limit of the two-sided 95% CI for the difference in rates was lower than 10%. The primary analysis was per protocol. This trial is registered with ClinicalTrials.gov, number NCT01382004.

Findings

We allocated 124 patients to the azithromycin group and 126 to the benzathine benzylpenicillin group. In the per-protocol analysis, after 6 months of follow-up, 106 (96%) of 110 patients in the azithromycin group were cured, compared with 105 (93%) of 113 in the benzathine benzylpenicillin group (treatment difference −3·4%; 95% CI −9·3 to 2·4), thus meeting prespecified criteria for non-inferiority. The number of drug-related adverse events (all mild or moderate) was similar in both treatment groups (ten [8%] in the azithromycin group vs eight [7%] in the benzathine benzylpenicillin group).

Interpretation

A single oral dose of azithromycin is non-inferior to benzathine benzylpenicillin and avoids the need for injection equipment and medically trained personnel. A change to the simpler azithromycin treatment regimen could enable yaws elimination through mass drug administration programmes.

Funding

International SOS and Newcrest Mining.

a Lihir Medical Centre—International SOS, Newcrest Mining, Lihir Island, Papua New Guinea

b Barcelona Centre for International Health Research, Hospital Clinic, University of Barcelona, Barcelona, Spain

Correspondence to: Dr Oriol Mitjà, Department of Medicine, Lihir Medical Center, PO Box 34, Lihir Island, NIP, Papua New Guinea

 

 

 

 

‘Renewed efforts to eradicate the disease will initially focus on 6 countries – Cameroon, Ghana, Indonesia, Papua New Guinea, the Solomon Islands and Vanuatu – starting with pilot projects in selected districts, and then expanding to other areas and countries within 2 years. In order to move towards the goal set by the roadmap, the support of the World Health Assembly would be critical. The last resolution on endemic treponematoses (yaws, bejel and pinta) was adopted in 1978 (WHA31.58).11’

 

• YAWS ERADICATION

 

Full text is at http://www.who.int/wer/2012/wer8720.pdf

 

‘The GPEI continues to face a grave shortfall of just under billion to finance the programme for 2012–2013. Lack of funds has already forced the cancellation and scaling-back of SIAs in 24 countries in the first part of 2012. A continued funding crisis will preclude the full implementation of national emergency plans and jeopardize the goal of a polio-free world.’

 

• POLIO ERADICATION, 2011-2012

 

From thw Weekly Epidemiological Record, http://www.who.int/wer/2012/wer8720.pdf

 

Editorial note

 

The most significant achievement of the GPEI during January 2011–March 2012 was the interruption of endemic WPV circulation in India, considered polio-free as of February 2012. Success in India is attributed to innovative approaches by the Indian government and partners, including the large-scale mobilization of human and financial resources to increase SIA coverage in children in high-risk endemic areas and migrant populations, introduction of bOPV, improvements in routine immunization coverage, and rapid responses to new outbreaks.8

 

India’s success proves the technical viability of global polio eradication and offers tested

solutions to many operational challenges in other countries Also, an unprecedented reduction in WPV3 cases globally has occurred since January 2011. Khyber agency in Pakistan and several northern states in Nigeria are the only areas from where WPV3 cases continue to be reported.9, 10

 

Outbreaks following importations into polio-free countries pose a continued threat to the momentum of the GPEI. Large outbreaks occurred in 2010 in the European Region11 and in the Republic of the Congo;12 outbreaks in 2011 have been small because of timely detection and prompt response SIAs. The outbreak in China in 2011 was rapidly contained through massive response SIAs, which in some areas included vaccination of all persons up to 40 years of age. Older age groups have been affected by polio with high case fatality rates in a number of recent outbreaks. Even when not affected, older children and adults appear to enhance WPV transmission. To reduce the scope and duration of any new outbreaks in polio-free areas, GPEI is recommend-ing that strong consideration be given to vaccination of

all children aged <15 years in the initial response SIAs.

 

Until WPV transmission in all areas is interrupted, the threat of outbreaks in polio-free areas will continue, requiring all countries to maintain high routine immunization coverage, sensitive AFP surveillance, and rapid detection of outbreaks, with prompt immunization response. Continued intense WPV transmission in northern Nigeria poses a significant threat of WPV importation and spread into other west and central African countries.

 

In response to the WHO Executive Board’s recognition of poliovirus eradication as a programmatic emergency for global public health1, each of the remaining countries with endemic or re-established transmission has developed an emergency action plan for interrupting wild poliovirus transmission, which includes oversight and accountability mechanisms and engaging political and health leaders at all administrative levels. National emergency plans specify strategies to vaccinate chronically missed children, improve the quality of SIAs in persistently poor performing areas and achieve levels of immunity be end 2012 that can lead to cessation of transmission. These strategies also address inadequate

micro-planning, poor selection and performance of vaccination teams, weak supervision, inadequate monitoring and refusal to accept vaccine. Special strategies were developed to access children in areas of armed conflict and insecurity. National emergency plans also outline strategies to identify, map and vaccinate children in migrant and mobile populations and to improve routine immunization services, particularly for high-risk population groups.

 

Informed by national emergency plans and in recognition of global challenges, the GPEI has developed a Global Emergency Action Plan (GEAP) 2012–2013. Key objectives of the plan are (i) to assist Afghanistan, Nigeria and Pakistan to significantly increase immunization coverage by the end of 2012 to levels that will interrupt transmission shortly thereafter, (ii) to help to sustain the momentum achieved in Chad, DRC and Angola to interrupt transmission in 2012, (iii) to further improve polio partner accountability and coordination and (iv) to close the large global funding gap. Funding requirements for the GEAP 2012–2013 are US$ 2.18 billion. The GPEI continues to face a grave shortfall of just under billion to finance the programme for 2012–2013. Lack of funds has already forced the cancellation and scaling-back of SIAs in 24 countries in the first part of 2012. A continued funding crisis will preclude

the full implementation of national emergency plans and jeopardize the goal of a polio-free world.