Detection of drug resistant Mycobacterium tuberculosis by high-throughput sequencing of DNA isolated from acid fast bacilli smears.

BACKGROUND: Drug susceptibility testing for Mycobacterium tuberculosis (MTB) is difficult to perform in resource-limited settings where Acid Fast Bacilli (AFB) smears are commonly used for disease diagnosis and monitoring. We developed a simple method for extraction of MTB DNA from AFB smears for sequencing-based detection of mutations associated with resistance to all first and several second-line anti-tuberculosis drugs. METHODS: We isolated MTB DNA by boiling smear content in a Chelex solution, followed by column purification. We sequenced PCR-amplified segments of the rpoB, katG, embB, gyrA, gyrB, rpsL, and rrs genes, the inhA, eis, and pncA promoters and the entire pncA gene. RESULTS: We tested our assay on 1,208 clinically obtained AFB smears from Ghana (n = 379), Kenya (n = 517), Uganda (n = 262), and Zambia (n = 50). Coverage depth varied by target and slide smear grade, ranging from 300X to 12000X on average. Coverage of ≥20X was obtained for all targets in 870 (72%) slides overall. Mono-resistance (5.9%), multi-drug resistance (1.8%), and poly-resistance (2.4%) mutation profiles were detected in 10% of slides overall, and in over 32% of retreatment and follow-up cases. CONCLUSION: This rapid AFB smear DNA-based method for determining drug resistance may be useful for the diagnosis and surveillance of drug-resistant tuberculosis.

Spondyloarthritis in sub-Saharan Africa.

Spondyloarthritis (SpA) is generally uncommon in sub-Saharan Africa, in part because of the rarity of HLA-B27 in this region. However, the relationship between HLA-B27 and SpA, particularly ankylosing spondylitis (AS), is complex. Despite the HLA-B 27:05 risk allele occurring in some West African populations, associated AS is not seen. In fact, most patients with AS are HLA-B27-negative, although there is emerging evidence that another class I HLA molecule, HLA-B 14:03, is associated with AS in black Africans. The Assessment of SpondyloArthritis International Society criteria for detecting early axial disease are of limited value in sub-Saharan Africa, because of both the rarity of HLA-B27 and very limited access to magnetic resonance imaging. Reactive arthritis (ReA), psoriatic arthritis, and undifferentiated SpA are seen mainly in the context of HIV infection, although the exact effect of the virus in the pathogenesis of arthritis is unclear. In Zambia, ReA is associated with the HLA-B*57:03 allele, which is paradoxically also associated with slow progression of HIV infection. HIV-associated ReA has a more protracted and aggressive course than standard ReA. Enthesitis-related arthritis is more common in children infected with HIV by vertical mother-to child transmission. Use of TNF inhibitors for axial disease is problematic, mainly because of cost, but also because of potential safety problems, especially reactivation of tuberculosis.

Progress made towards enhancement of rheumatology education and practice in Zambia: review of an ILAR-supported project.

The burden of non-communicable diseases such as musculoskeletal diseases in the developing world is often overshadowed by the more prevalent infectious diseases. Generally, there is gross underestimation of the burden of rheumatologic disease in the backdrop of scanty or indeed non-existent rheumatology services in these countries. Local studies conducted in the last two decades in Zambia have documented the increasing burden of rheumatologic conditions in the country. There are unfortunately negligible rheumatology services in the country both at tertiary or primary health-care facility levels. There is thus an urgent need to build capacity for these services so as to improve the care and management of rheumatic conditions. Here, we review progress made by an International League of Associations for Rheumatology (ILAR)-supported project that has run for the past 2 years (2012-2013) with the objective of enhancing paediatric and adult rheumatology education and practice so as to stimulate positive change in practice and related care services in Zambia. During this short time of the project, substantial progress has been made in the areas of paediatric and adult rheumatology services enhancement at the University Teaching Hospital, Lusaka: streamlining of referrals and follow-ups of rheumatology patients, laying foundations for short- and long-term medical education in rheumatology and raising public awareness of rheumatic diseases. The progress made by this grant underscores the suitability of the ILAR mission statement "think global, act local" demonstrating that even with minimum resources and networking, improvement of rheumatology care in developing countries is attainable.

Clinical patterns of juvenile idiopathic arthritis in Zambia.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is a heterogeneous group of disorders with different disease manifestations among various populations. There are few reports of JIA among indigenous Africans especially sub-Saharan Africa. We present herein the clinical patterns of JIA encountered at a tertiary hospital in Lusaka, Zambia. METHOD: Hospital records of patients with a diagnosis of chronic arthritis with onset at the age of 16 years or less presenting to University Teaching Hospital, Lusaka, Zambia for the periods 1994-98 and 2006-2010 were retrospectively reviewed and reclassified as Juvenile Idiopathic Arthritis (JIA) based on the International League of Associations for Rheumatology (ILA R) JIA diagnostic criteria. RESULTS: In total, 126 patients with chronic arthritis of onset at age 16 years or less were evaluated over these periods at the hospital. Of these, 85 could further be analyzed by ILAR JIA criteria but 7 (8.24%) were HIV seropositive and were assessed separately. The average age at disease onset among the 78 JIA patients was 8.70 years (range: 1-15 years) with average age at first visit to hospital being 11.3 years (range: 2 to 25 years) and with a female to male ratio of 1.2:1. Polyarticular rheumatoid factor negative JIA, at 34.62%, was the most frequent type of chronic arthritis encountered. Oligoarthritis was found in 32.05% while 11.54% and 14.10% were polyarticular rheumatoid factor positive and systemic JIA, respectively. Enthesitis-related arthritis was found in 6.41% and only 1.28% were determined to have psoriatic arthritis among this population. CONCLUSION: JIA is predominantly a polyarticular rheumatoid factor negative disease in Zambia. Late presentation is an issue with major implications for educational input and resource acquisition. There is need to elucidate the genetics and environmental factors of JIA in this region.

Improving performance of Zambia Defence Force antiretroviral therapy providers: evaluation of a standards-based approach.

BACKGROUND: The Zambia Defence Force (ZDF) has applied the Standards-Based Management and Recognition (SBM-R®) approach, which uses detailed performance standards, at some health facilities to improve HIV-related services offered to military personnel and surrounding civilian communities. This study examines the effectiveness of the SBM-R approach in improving facility readiness and provider performance at ZDF facilities. METHODS: We collected data on facility readiness and provider performance before and after the 2010-2012 intervention at 4 intervention sites selected for their relatively poor performance and 4 comparison sites. Assessors observed whether each facility met 16 readiness standards and whether providers met 9 performance standards during consultations with 354 returning antiretroviral therapy (ART) clients. We then calculated the percentages of criteria achieved for each readiness and performance standard and conducted bivariate and multivariate analyses of provider performance data. RESULTS: Facilities' ART readiness scores exceeded 80% before the intervention at both intervention and comparison sites. At endline, scores improved on 4 facility readiness standards in the intervention group but on only 1 standard in the comparison group. Multivariate analysis found that the overall provider performance score increased significantly in the intervention group (from 58% to 84%; P<.01) but not in the comparison group (from 62% to 70%). The before-and-after improvement in scores was significantly greater among intervention sites than among comparison sites for 2 standards-initial assessment of the client's condition and nutrition counseling. CONCLUSION: The standards-based approach, which involved intensive and mutually reinforcing intervention activities, showed modest improvements in some aspects of providers' performance during ART consultations. Further research is needed to determine whether improvements in provider performance affect client outcomes such as adherence to ART.

Influence of HLA-B*5703 and HLA-B*1403 on susceptibility to spondyloarthropathies in the Zambian population.

OBJECTIVE: To analyze the distribution of HLA-B alleles and to investigate their contribution in the susceptibility to spondyloarthropathies (SpA) in a sample population from Zambia, in order to determine a relationship between some HLA-B alleles and development of ankylosing spondylitis (AS), reactive arthritis (ReA), or undifferentiated SpA (uSpA). METHODS: . We selected 72 patients with SpA and found that 46 had uSpA, 23 ReA, and 3 AS. We also selected 92 matched controls; 55 of these had human immunodeficiency virus type I (HIV-I) infection. RESULTS: We found a significant increase in the rate of uSpA and ReA with features of Reiter's syndrome (RS) in HIV-positive individuals who carried the HLA-B*5703 allele (pc < 0.0001 and pc < 0.001, respectively). Among the significant new findings identified were the presence of B*1403 in 2 of the 3 AS patients (pc < 0.05, OR 47), confirming previous data in the Togolese population. CONCLUSION: The presence of B*5703 and HIV infection may not affect susceptibility to AS and ReA, but they do show an important influence in uSpA and RS. Our findings confirm that HLA-B*1403 is the only factor to increase the risk of AS in a sub-Saharan African population, whereas HLA-B27 was virtually absent in patients with AS.

Sexual risk-taking and HIV testing among health workers in Zambia.

Health workers (N=692) in five Zambian hospitals were interviewed to assess HIV/AIDS risk-taking and status awareness. They comprised of physicians, nurses, clinical officers and paramedics. Only 33% had been tested for HIV and only 24% said their partner had been tested. 26 percent of sexually active respondents had multiple partners; thirty-seven percent of these had not used condoms. Only 60% of respondents believed condoms were effective in preventing HIV. Women were less likely to trust or use condoms even in high-risk relationships. The data suggest a need to develop HIV/AIDS programs for health workers, with emphasis towards gender-based obstacles hampering safer behaviors.

Soft tissue rheumatic lesions and HIV infection in Zambians.

OBJECTIVE: To explore the relationship between human immunodeficiency virus (HIV) infection and soft tissue rheumatic lesions in HIV-positive black Zambians. METHODS: We performed a prospective study of all patients over 18 years of age attending a rheumatic clinic in a teaching hospital. All patients underwent routine blood tests, and radiographs were performed when indicated. HIV status was determined by ELISA, and clinical staging was determined by World Health Organization criteria. Patients with isolated sacroiliac pain, enthesitis, or a soft tissue lesion were selected for analysis. For HIV-positive patients, only those in clinical stage 1 (asymptomatic or persistent generalized lymphadenopathy) were selected. RESULTS: Our study cohort comprised 120 patients (41 men, 79 women, age 23-70 yrs). Diagnosis and number (% HIV positive) were distributed as follows: sacroiliitis, 14 (100%); heel pain, 14 (100%); costochondritis, 3 (100%); polyenthesitis (> or = 4 sites), 20 (100%); carpal tunnel syndrome, 8 (63%); rotator cuff syndrome, 18 (30%); tendinitis, 8 (25%); sciatica/cervical spondylosis, 12 (16%); sacroiliac strain, 7 (0%); and de Quervain's tenosynovitis, 16 (0%). HIV seroprevalence was 54% overall, 74% in those under 45 years of age, and 17% in those over 45 years of age. Population prevalence of HIV in Lusaka is about 30% in the 30-40-year age range. Mean erythrocyte sedimentation rate (ESR) in 65 patients positive for HIV was 80 mm/h and in 55 patients negative for HIV, 18 mm/h. Within each subgroup the mean ESR was significantly higher in HIV-positive patients. CONCLUSION: A young age and a raised ESR are both good indications of HIV infection in Zambian patients with soft tissue lesions. Enthesitis is a distinct HIV-related phenomenon, either an early form or a forme fruste of HIV-related spondyloarthropathy.

Human immunodeficiency virus related reactive arthritis in Zambia.

OBJECTIVE: To characterize the clinical, radiological, and diagnostic features of reactive arthritis (ReA) in indigenous Black Zambians with human immunodeficiency virus (HIV) infection. METHODS: Consecutive patients attending an arthritis clinic over a 5-year period were studied prospectively. Those who satisfied diagnostic criteria for ReA were analyzed. RESULTS: In total, 170 patients satisfied the ESSG criteria for ReA; 71 (45 men, 26 women) had one or more extraarticular manifestations; 30% had enteroreactive and 14% uroreactive disease. Only 59% of patients had the diagnostic features of ReA at presentation. The initial diagnosis was undifferentiated spondyloarthropathy (uSpa) in 20%, other ReA in 14%, and "arthritis alone" in 7%. Of 65 (42 men, 23 women) patients tested, 94% were HIV-positive (91% men, 100% women). In those with HIV, the arthritis was predominantly polyarticular, lower limb-predominant, and progressive; 58% of 33 with persistent disease had erosions of foot and/or hand joints (average disease duration, 24.4 mo); 6 of 10 showed early radiological spine or sacroiliac joint changes (average duration 47.7 mo). Anterior uveitis occurred in 33% of patients, while keratoderma blenorrhagicum and stomatitis occurred in 14.3% and 9.5%, respectively, of patients with enteroreactive ReA. Uroreactive ReA was more common in women. There were no significant differences in the clinical, diagnostic, or radiographic features between men and women or between those with or without a known preceding trigger. CONCLUSION: HIV associated ReA in Black Zambians frequently follows an accelerated course with a strong tendency to relapse, develop early erosions and joint deformity, and become chronic. The clinical, diagnostic, and radiographic features are indistinguishable from those described in the conventional (HLA-B27 related) disease, although our HIV-positive patients have a high overall frequency of uveitis, keratoderma, and onycholysis.