ABSTRACT
Background: Botswana has a high prevalence of women living with HIV (WLHIV) and experienced a severe nationwide COVID-19 epidemic in 2021. We evaluated adverse birth outcomes among women routinely tested for COVID-19 by HIV status, during a period when few women had access to COVID-19 vaccination. Methods: The Tsepamo Study performs birth outcomes surveillance at government hospitals throughout Botswana. We analyzed data from 13 Tsepamo sites that performed routine COVID-19 screening at delivery with rapid antigen or PCR testing between Sept 1, 2020 and Sept 30, 2021 (start dates differed by site). This analysis includes singleton deliveries with known HIV status and a COVID-19 screening test between 14 days prior and 3 days after delivery. Outcomes included maternal death, preterm delivery (PTD), very preterm delivery (VPTD), small for gestational age (SGA), very small for gestational age (VSGA), stillbirth, and neonatal death. Differences in outcomes by COVID-19 and HIV status were assessed using log binomial regression adjusted for maternal age. Results: A total of 17,627 deliveries occurred at the included sites during COVID-19 screening, and 11,149 (63.3%) were screened for COVID-19;among 10,090 (99.7%) with a known HIV status, 530 (5.3%) COVID-19 tests were positive, including 141/2129 (6.6%) among WLHIV and 389/7961 (4.9%) among women without HIV (aRR 1.32, 95% CI 1.09, 1.60). Maternal deaths were reported in 19 (3.8%) women with COVID-19 and 11 (0.12%) women without COVID-19 (aRR 30.5, 95% CI 14.6, 63.7), and did not differ by HIV status. Adverse birth outcomes (any) were more common among infants born to women with COVID-19 (34.3% vs. 26.3%;aRR 1.32, 95% CI 1.16,1.49), including PTD (21.2% vs. 13.3%;aRR 1.60, 95% CI 1.34,1.90) and stillbirth (5.5% vs. 2.8%;aRR 1.89, 95% CI 1.30,2.75), and there was a trend for higher neonatal mortality (2.0% vs. 1.4%, aRR 1.5, 95% CI 0.79, 2.85). Most adverse birth outcomes were highest among infants exposed to both COVID-19 and HIV (Figure 1). Conclusion: Infants born to women with COVID-19 experienced more adverse birth outcomes than other infants, including a 2-fold risk for stillbirth. Those exposed to both COVID-19 and HIV had the highest risk for most adverse outcomes. Further research is warranted to understand the biological interaction between COVID-19, HIV infection, and adverse birth outcomes, and whether some associations were impacted by challenges in care delivery during the height of the COVID-19 epidemic in Botswana.
ABSTRACT
Background. Although CRE are a global threat, data in low- and middle-income countries are scarce. Colonization data are vital for informing antibiotic resistance strategies. We characterized the colonization prevalence of CRE in various settings in Botswana. Methods. This study was conducted in 3 districts in Botswana (1 hospital and 2 clinics per district). Adult inpatients and clinic patients were randomly selected for enrollment. Community subjects were enrolled by inviting each enrolled clinic subject to refer up to 3 adults. Each adult clinic or community subject was also asked to refer their children. All subjects had rectal swabs obtained and inoculated on selective chromogenic media for preliminary identification of CRE. Final identification and susceptibility testing were performed using MALDI-TOF MS and VITEK-2, respectively. CRE underwent genotyping for carbapenemase genes. Results. Subjects were enrolled from 1/15/20-9/4/20 with a pause from 4/2/20-5/21/20 due to a countrywide COVID lockdown. Of 5,088 subjects approached, 2,469 (49%) participated. Enrollment by subject type was: hospital - 469 (19%);clinic - 959 (39%);community adult - 477 (19%);and community child - 564 (23%). Of 2,469 subjects, the median (interquartile range) age was 32 years (19-44) and 1,783 (72%) were female. 42 (1.7%) subjects were colonized with at least one CRE;10 subjects were colonized with multiple strains. E. coli (n=17), K. pneumoniae (n=20), and E. cloacae complex (n=11) were most common. CRE colonization prevalence was 6.8% for hospital subjects, 0.7% for clinic subjects, 0.2% for adult community subjects, and 0.5% for child community subjects (p< 0.001)). CRE prevalence varied across regions (Figure 1) and was significantly higher pre- vs post-lockdown (Figure 2). VIM and NDM were the most common carbapenemase genes (Figure 3). Conclusion. CRE colonization was significantly higher in hospital vs community settings in Botswana. CRE prevalence varied by region and decreased significantly following a countrywide lockdown. With CRE prevalence still modest, elucidating risk factors for CRE colonization holds promise in developing strategies to curb further emergence of CRE. Additional investigation of the CRE isolates without identified resistance genes is warranted.
ABSTRACT
Background. Although ESCrE are a global challenge, data on ESCrE in low- and middle-income countries are limited. In particular, colonization data are critical for larger antibiotic resistance efforts. We characterized the colonization prevalence of ESCrE in various settings in Botswana. Methods. This study was conducted in 3 hospitals and 6 clinics located in 3 districts in Botswana. In each hospital, we conducted surveillance of adult patients. Adult clinic patients were also randomly selected for participation. Finally, we enrolled community subjects by inviting each enrolled clinic subject to refer up to 3 adults. Each adult clinic or community subject was also allowed to refer their children. All subjects had rectal swabs obtained which were inoculated onto chromogenic media for preliminary identification of ESCrE. Final identification and susceptibility testing were performed using MALDI-TOF MS and VITEK-2, respectively. Genotyping was done for identification of extended-spectrum beta-lactamase (ESBL) genes. Results. Enrollment occurred from 1/15/20-9/4/20 but paused from 4/2/20-5/21/20 due to a countrywide COVID lockdown. Of 5,088 subjects approached, 2,469 (49%) participated. Enrollment by subject type was: hospital - 469 (19%);clinic - 959 (39%);community adult - 477 (19%);and community child - 564 (23%). Of 2,469 subjects, the median (interquartile range) age was 32 years (19-44) and 1,783 (72%) were female. 759 (31%) subjects were colonized with at least one ESCrE;130 subjects were colonized with multiple strains. E. coli (n=663) and K. pneumoniae (n=121) were most common. ESCrE colonization prevalence was 43% for hospital subjects, 31% for clinic subjects, 24% for adult community subjects, and 26% for child community subjects (p< 0.001)). ESCrE prevalence varied significantly across regions (Figure 1) and was significantly higher pre-lockdown vs post-lockdown (Figure 2). CTX-M was the most common ESBL gene (Figure 3). Conclusion. ESCrE colonization was common in both healthcare and community settings in Botswana. Colonization prevalence varies by region and clinical setting and decreased following a countrywide lockdown. These findings provide important clues regarding potential drivers of ESCrE that might serve as targets for intervention.