Publications by authors named "Behzad Nadjm"

65 Publications

The Role of Nutrition in COVID-19 Susceptibility and Severity of Disease: A Systematic Review.

J Nutr 2021 May 12. Epub 2021 May 12.

Medical Research Council (MRC) Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, The Gambia.

Background: Many nutrients have powerful immunomodulatory actions with the potential to alter susceptibility to coronavirus disease 2019 (COVID-19) infection, progression to symptoms, likelihood of severe disease, and survival.

Objective: The aim was to review the latest evidence on how malnutrition across all its forms (under- and overnutrition and micronutrient status) may influence both susceptibility to, and progression of, COVID-19.

Methods: We synthesized information on 13 nutrition-related components and their potential interactions with COVID-19: overweight, obesity, and diabetes; protein-energy malnutrition; anemia; vitamins A, C, D, and E; PUFAs; iron; selenium; zinc; antioxidants; and nutritional support. For each section we provide: 1) a landscape review of pertinent material; 2) a systematic search of the literature in PubMed and EMBASE databases, including a wide range of preprint servers; and 3) a screen of 6 clinical trial registries. All original research was considered, without restriction to study design, and included if it covered: 1) severe acute respiratory syndrome coronavirus (CoV) 2 (SARS-CoV-2), Middle East respiratory syndrome CoV (MERS-CoV), or SARS-CoV viruses and 2) disease susceptibility or 3) disease progression, and 4) the nutritional component of interest. Searches took place between 16 May and 11 August 2020.

Results: Across the 13 searches, 2732 articles from PubMed and EMBASE, 4164 articles from the preprint servers, and 433 trials were returned. In the final narrative synthesis, we include 22 published articles, 38 preprint articles, and 79 trials.

Conclusions: Currently there is limited evidence that high-dose supplements of micronutrients will either prevent severe disease or speed up recovery. However, results of clinical trials are eagerly awaited. Given the known impacts of all forms of malnutrition on the immune system, public health strategies to reduce micronutrient deficiencies and undernutrition remain of critical importance. Furthermore, there is strong evidence that prevention of obesity and type 2 diabetes will reduce the risk of serious COVID-19 outcomes. This review is registered at PROSPERO as CRD42020186194.
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http://dx.doi.org/10.1093/jn/nxab059DOI Listing
May 2021

Epidemiological Characteristics, Ventilator Management, and Clinical Outcome in Patients Receiving Invasive Ventilation in Intensive Care Units from 10 Asian Middle-Income Countries (PRoVENT-iMiC): An International, Multicenter, Prospective Study.

Am J Trop Med Hyg 2021 01 11. Epub 2021 Jan 11.

Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.

Epidemiology, ventilator management, and outcome in patients receiving invasive ventilation in intensive care units (ICUs) in middle-income countries are largely unknown. PRactice of VENTilation in Middle-income Countries is an international multicenter 4-week observational study of invasively ventilated adult patients in 54 ICUs from 10 Asian countries conducted in 2017/18. Study outcomes included major ventilator settings (including tidal volume [] and positive end-expiratory pressure [PEEP]); the proportion of patients at risk for acute respiratory distress syndrome (ARDS), according to the lung injury prediction score (LIPS), or with ARDS; the incidence of pulmonary complications; and ICU mortality. In 1,315 patients included, median was similar in patients with LIPS < 4 and patients with LIPS ≥ 4, but lower in patients with ARDS (7.90 [6.8-8.9], 8.0 [6.8-9.2], and 7.0 [5.8-8.4] mL/kg Predicted body weight; = 0.0001). Median PEEP was similar in patients with LIPS < 4 and LIPS ≥ 4, but higher in patients with ARDS (five [5-7], five [5-8], and 10 [5-12] cmHO; < 0.0001). The proportions of patients with LIPS ≥ 4 or with ARDS were 68% (95% CI: 66-71) and 7% (95% CI: 6-8), respectively. Pulmonary complications increased stepwise from patients with LIPS < 4 to patients with LIPS ≥ 4 and patients with ARDS (19%, 21%, and 38% respectively; = 0.0002), with a similar trend in ICU mortality (17%, 34%, and 45% respectively; < 0.0001). The capacity of the LIPS to predict development of ARDS was poor (ROC AUC of 0.62, 95% CI: 0.54-0.70). In Asian middle-income countries, where two-thirds of ventilated patients are at risk for ARDS according to the LIPS and pulmonary complications are frequent, setting of is globally in line with current recommendations.
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http://dx.doi.org/10.4269/ajtmh.20-1177DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941813PMC
January 2021

Implementation of C-reactive protein point of care testing to improve antibiotic targeting in respiratory illness in Vietnamese primary care (ICAT): a study protocol for a cluster randomised controlled trial.

BMJ Open 2020 12 23;10(12):e040977. Epub 2020 Dec 23.

Oxford University Clinical Research Unit, Hanoi, Vietnam.

Introduction: C-reactive protein (CRP), a biomarker of infection, has been used widely in high-income settings to guide antibiotic treatment in patients presenting with respiratory illnesses in primary care. Recent trials in low- and middle-income countries showed that CRP testing could safely reduce antibiotic use in patients with non-severe acute respiratory infections (ARIs) and fever in primary care. The studies, however, were conducted in a research-oriented context, with research staff closely monitoring healthcare behaviour thus potentially influencing healthcare workers' prescribing practices. For policy-makers to consider wide-scale roll-out, a pragmatic implementation study of the impact of CRP point of care (POC) testing in routine care is needed.

Methods And Analysis: A pragmatic, cluster-randomised controlled trial, with two study arms, consisting of 24 commune health centres (CHC) in the intervention arm (provision of CRP tests with additional healthcare worker guidance) and 24 facilities acting as controls (routine care). Comparison between the treatment arms will be through logistic regression, with the treatment assignment as a fixed effect, and the CHC as a random effect. With 48 clusters, an average of 10 consultations per facility per week will result in approximately 520 over 1 year, and 24 960 in total (12 480 per arm). We will be able to detect a reduction of 12% to 23% or more in immediate antibiotic prescription as a result of the CRP POC intervention. The primary endpoint is the proportion of patient consultations for ARI resulting in immediate antibiotic prescription. Secondary endpoints include the proportion of all patients receiving an antibiotic prescription regardless of ARI diagnosis, frequency of re-consultation, subsequent antibiotic use when antibiotics are not prescribed, referral and hospitalisation.

Ethics And Dissemination: The study protocol was approved by the Oxford University Tropical Research Ethics Committee (OxTREC, Reference: 53-18), and the ethical committee of the National Hospital for Tropical Diseases in Vietnam (Reference:07/HDDD-NDTW/2019). Results from this study will be disseminated via meetings with stakeholders, conferences and publications in peer-reviewed journals. Authorship and reporting of this work will follow international guidelines.

Trial Registration Details: NCT03855215; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2020-040977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759760PMC
December 2020

Factors influencing choices of empirical antibiotic treatment for bacterial infections in a scenario-based survey in Vietnam.

JAC Antimicrob Resist 2020 Dec 10;2(4):dlaa087. Epub 2020 Nov 10.

Oxford University Clinical Research Unit, 78 Giai Phong, Hanoi, Vietnam.

Background: Antimicrobial stewardship (AMS) programmes have been implemented around the world to guide rational use of antibiotics but implementation is challenging, particularly in low- and middle-income countries, including Vietnam. Understanding factors influencing doctors' prescribing choices for empirical treatment can help design AMS interventions in these settings.

Objectives: To understand doctors' choices of antibiotics for empirical treatment of common bacterial infections and the factors influencing decision-making.

Methods: We conducted a cross-sectional survey among medical professionals applying for a postgraduate programme at Hanoi Medical University, Vietnam. We used a published survey developed for internal medicine doctors in Canada. The survey was self-administered and included four clinical scenarios: (i) severe undifferentiated sepsis; (ii) mild undifferentiated sepsis; (iii) severe genitourinary infection; and (iv) mild genitourinary infection.

Results: A total of 1011/1280 (79%), 683/1188 (57.5%), 718/1157 (62.1%) and 542/1062 (51.0%) of the participants selected combination therapy for empirical treatment in scenarios 1, 2, 3 and 4, respectively. Undifferentiated sepsis (OR 1.82, 95% CI 1.46-2.27 and 2.18, 1.51-3.16 compared with genitourinary) and severe infection (1.33, 1.24-1.43 and 1.38, 1.21-1.58 compared with mild) increased the likelihood of choosing a combination therapy and a carbapenem regimen, respectively. Participants with higher acceptable minimum threshold for treatment coverage and young age were also more likely to prescribe carbapenems.

Conclusions: Decision-making in antibiotic prescribing among doctors in Vietnam is influenced by both disease-related characteristics and individual factors, including acceptable minimum treatment coverage. These findings are useful for tailoring AMS implementation in Vietnam and other, similar settings.
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http://dx.doi.org/10.1093/jacamr/dlaa087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653509PMC
December 2020

Purchase and use of antimicrobials in the hospital sector of Vietnam, a lower middle-income country with an emerging pharmaceuticals market.

PLoS One 2020 20;15(10):e0240830. Epub 2020 Oct 20.

Wellcome Africa Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.

Introduction: Antimicrobial use is associated with emergence of antimicrobial resistance. We report hospital antimicrobial procurement, as a surrogate for consumption in humans, expenditure and prices in public hospitals in Vietnam, a lower middle-income country with a high burden of drug resistant infections.

Method: Data on antimicrobial procurement were obtained from tender-winning bids from provincial health authorities and public hospitals with detailed bids representing 28.7% (1.68 / 5.85 billion US $) of total hospital medication spend in Vietnam. Antimicrobials were classified using the Anatomical Therapeutic Chemical (ATC) Index and the 2019 WHO Access, Watch, Reserve (AWaRe) groups. Volume was measured in number of Defined Daily Doses (DDD). Antimicrobial prices were presented per DDD.

Results: Expenditure on systemic antibacterials and antifungals accounted for 28.6% (US $482.6 million/US $1.68 billion) of the total drug bids. 83% of antibacterials (572,698,014 DDDs) by volume (accounting for 45.5% of the antibacterials spend) were domestically supplied. Overall, the most procured antibacterials by DDD were second generation cephalosporins, combinations of penicillins and beta-lactamase inhibitors, and penicillins with extended spectrum. For parenteral antibacterials this was third generation cephalosporins. The average price for antibacterials was US $15.6, US $0.86, US $0.4 and US $11.7 per DDD for Reserve, Watch, Access and non-recommended/unclassified group antibacterials, respectively.

Conclusions: Antimicrobials accounted for a substantial proportion of the funds spent for medication in public hospitals in Vietnam. The pattern of antibacterial consumption was similar to other countries. The high prices of Reserve group and non-recommended/unclassified antibacterials suggests a need for a combination of national pricing and antimicrobial stewardship policies to ensure appropriate accessibility.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240830PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575121PMC
December 2020

Dexamethasone for COVID-19: data needed from randomised clinical trials in Africa.

Lancet Glob Health 2020 09 14;8(9):e1125-e1126. Epub 2020 Jul 14.

Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, PO Box 273, The Gambia.

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http://dx.doi.org/10.1016/S2214-109X(20)30318-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833918PMC
September 2020

Does sunlight drive seasonality of TB in Vietnam? A retrospective environmental ecological study of tuberculosis seasonality in Vietnam from 2010 to 2015.

BMC Infect Dis 2020 Feb 28;20(1):184. Epub 2020 Feb 28.

Oxford University Clinical Research Unit - Hanoi, National Hospital of Tropical Diseases, 78 Giai Phong, Hanoi, Vietnam.

Background: Tuberculosis (TB) is a major global health burden, with an estimated quarter of the world's population being infected. The World Health Organization (WHO) launched the "End TB Strategy" in 2014 emphasising knowing the epidemic. WHO ranks Vietnam 12th in the world of high burden countries. TB spatial and temporal patterns have been observed globally with evidence of Vitamin D playing a role in seasonality. We explored the presence of temporal and spatial clustering of TB in Vietnam and their determinants to aid public health measures.

Methods: Data were collected by the National TB program of Vietnam from 2010 to 2015 and linked to the following datasets: socio-demographic characteristics; climatic variables; influenza-like-illness (ILI) incidence; geospatial data. The TB dataset was aggregated by province and quarter. Descriptive time series analyses using LOESS regression were completed per province to determine seasonality and trend. Harmonic regression was used to determine the amplitude of seasonality by province. A mixed-effect linear model was used with province and year as random effects and all other variables as fixed effects.

Results: There were 610,676 cases of TB notified between 2010 and 2015 in Vietnam. Heat maps of TB incidence per quarter per province showed substantial temporal and geospatial variation. Time series analysis demonstrated seasonality throughout the country, with peaks in spring/summer and troughs in autumn/winter. Incidence was consistently higher in the south, the three provinces with the highest incidence per 100,000 population were Tay Ninh, An Giang and Ho Chi Minh City. However, relative seasonal amplitude was more pronounced in the north. Mixed-effect linear model confirmed that TB incidence was associated with time and latitude. Of the demographic, socio-economic and health related variables, population density, percentage of those under 15 years of age, and HIV infection prevalence per province were associated with TB incidence. Of the climate variables, absolute humidity, average temperature and sunlight were associated with TB incidence.

Conclusion: Preventative public health measures should be focused in the south of Viet Nam where incidence is highest. Vitamin D is unlikely to be a strong driver of seasonality but supplementation may play a role in a package of interventions.
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http://dx.doi.org/10.1186/s12879-020-4908-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048025PMC
February 2020

Plans for Nationwide Serosurveillance Network in Vietnam.

Emerg Infect Dis 2020 01;26(1)

In recent years, serosurveillance has gained momentum as a way of determining disease transmission and immunity in populations, particularly with respect to vaccine-preventable diseases. At the end of 2017, the Oxford University Clinical Research Unit and the National Institute of Hygiene and Epidemiology held a meeting in Vietnam with national policy makers, researchers, and international experts to discuss current seroepidemiologic projects in Vietnam and future needs and plans for nationwide serosurveillance. This report summarizes the meeting and the plans that were discussed to set up nationwide serosurveillance in Vietnam.
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http://dx.doi.org/10.3201/eid2601.190641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924907PMC
January 2020

"I can make more from selling medicine when breaking the rules" - understanding the antibiotic supply network in a rural community in Viet Nam.

BMC Public Health 2019 Nov 26;19(1):1560. Epub 2019 Nov 26.

Radboud UMC, Nijmegen, the Netherlands.

Background: As in many other low and middle income countries (LIMCs), Vietnam has experienced a major growth in the pharmaceutical industry, with large numbers of pharmacies and drug stores, and increasing drug expenditure per capita over the past decade. Despite regulatory frameworks that have been introduced to control the dispensing and use of prescription-only drugs, including antibiotics, compliance has been reported to be strikingly low particularly in rural parts of Vietnam. This qualitative study aimed to understand antibiotic access and use practices in the community from both supplier and consumer perspectives in order to support the identification and development of future interventions.

Methods: This qualitative study was part of a project on community antibiotic access and use (ABACUS) in six LMICs. The focus was Ba Vi district of Hanoi capital city, where we conducted 16 indepth interviews (IDIs) with drug suppliers, and 16 IDIs and 6 focus group discussions (FGDs) with community members. Drug suppliers were sampled based on mapping of all informal and formal antibiotic purchase or dispensing points in the study area. Community members were identified through local networks and relationships with the field collaborators. All IDIs and FGDs were audio-taped, transcribed and analysed using content analysis.

Results: We identified a large number of antibiotic suppliers in the locality with widespread infringements of regulatory requirements. Established reciprocal relationships between suppliers and consumers in drug transactions were noted, as was the consumers' trust in the knowledge and services provided by the suppliers. In addition, antibiotic use has become a habitual choice in most illness conditions, driven by both suppliers and consumers.

Conclusions: This study presents an analysis of the practices of antibiotic access and use in a rural Vietnamese setting. It highlights the interactions between antibiotic suppliers and consumers in the community and identifies possible targets for interventions.
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http://dx.doi.org/10.1186/s12889-019-7812-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880519PMC
November 2019

Analysis of the 56-kDa type specific antigen gene of Orientia tsutsugamushi from northern Vietnam.

PLoS One 2019 30;14(8):e0221588. Epub 2019 Aug 30.

Naval Medical Research Center, Silver Spring, Maryland, United States of America.

Scrub typhus has been documented since 1932 in Vietnam, however, the disease burden of scrub typhus remains poorly understood in the country. We conducted this study to describe the phylogenetic analysis of the 56-kDa type-specific antigen (TSA) gene of Orientia tsutsugamushi associated with PCR positive cases of scrub typhus. Of 116 positive samples, 65 type-specific antigen gene sequences were obtained and classified into 3 genogroups: Karp, Kato and Gilliam. The Karp genogroup was the most frequently detected phylogenetic cluster in the study with 30 samples (46%), followed by Kato and Gilliam with 20 (31%) and 15 (23%), respectively. All sequences showed 94-100% nucleotide similarity to reference sequences collected in the central part of Vietnam in 2017. Patients infected with Karp genogroup were more likely to have significant thrombocytopenia than the other genogroups. These results suggest that any scrub typhus vaccine considered for use in Vietnam should provide protection against each of these 3 genogroups.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221588PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716651PMC
March 2020

A randomised controlled trial of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) versus conventional microbiological methods for identifying pathogens: Impact on optimal antimicrobial therapy of invasive bacterial and fungal infections in Vietnam.

J Infect 2019 06 23;78(6):454-460. Epub 2019 Mar 23.

Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom; Department of Medical Microbiology, RadboudUMC, Nijmegen, The Netherlands.

Objectives: We assessed the impact of MALDITOF-MS on the timeliness of optimal antimicrobial therapy through a parallel-arm randomised controlled trial in two hospitals in Vietnam.

Methods: We recruited patients with a pathogen (bacterial or fungal) cultured from a normally sterile sample. Samples were randomly assigned (1:1) to identification by MALDITOF-MS or conventional diagnostics. The primary outcome was the proportion on optimal antimicrobial therapy within 24 h of positive culture, determined by a blinded independent review committee. Trial registered at ClinicalTrials.gov (NCT02306330).

Results: Among 1005 randomised patients, pathogens were isolated from 628 (326 intervention, 302 control), with 377 excluded as likely contaminants or discharged/died before positive culture. Most isolates were cultured from blood (421/628, 67.0%). The proportion receiving optimal antimicrobial therapy within 24 h (the primary outcome) or 48 h of growth was not significantly different between MALDITOF-MS and control arms (135/326, 41.4% vs 120/302, 39.7%; Adjusted Odds ration (AOR) 1.17, p = 0.40 and 151/326, 46.3% vs 141/302, 46.7%; AOR 1.05 p = 0.79, respectively).

Conclusions: MALDITOF-MS, in the absence of an antimicrobial stewardship programme, did not improve the proportion on optimal antimicrobial therapy at 24 or 48 h after first growth in a lower-middle income setting with high rates of antibiotic resistance.
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http://dx.doi.org/10.1016/j.jinf.2019.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529875PMC
June 2019

Clinical Manifestations and Molecular Diagnosis of Scrub Typhus and Murine Typhus, Vietnam, 2015-2017.

Emerg Infect Dis 2019 04;25(4)

Rickettsioses are endemic to Vietnam; however, only a limited number of clinical studies have been performed on these vectorborne bacteria. We conducted a prospective hospital-based study at 2 national referral hospitals in Hanoi to describe the clinical characteristics of scrub typhus and murine typhus in northern Vietnam and to assess the diagnostic applicability of quantitative real-time PCR assays to diagnose rickettsial diseases. We enrolled 302 patients with acute undifferentiated fever and clinically suspected rickettsiosis during March 2015-March 2017. We used a standardized case report form to collect clinical information and laboratory results at the time of admission and during treatment. We confirmed scrub typhus in 103 (34.1%) patients and murine typhus in 12 (3.3%) patients. These results highlight the need for increased emphasis on training for healthcare providers for earlier recognition, prevention, and treatment of rickettsial diseases in Vietnam.
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http://dx.doi.org/10.3201/eid2504.180691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6433017PMC
April 2019

Sero-Prevalence Surveillance to Predict Vaccine-Preventable Disease Outbreaks; A Lesson from the 2014 Measles Epidemic in Northern Vietnam.

Open Forum Infect Dis 2019 Mar 24;6(3):ofz030. Epub 2019 Jan 24.

Oxford University Clinical Research Unit, Wellcome Trust Asia Programme, Hanoi, Vietnam.

Background: During the first half of 2014, a severe outbreak of measles occurred in northern Vietnam, causing 15 033 confirmed cases and 146 deaths.

Methods: To evaluate the population-level seroprevalence of protection against measles in the period before the outbreak, we made use of an existing age-stratified serum bank, collected over the year before the outbreak, between November 2012 and December 2013, from 4 sites across the country (Hanoi, Hue, Dak Lak, and Ho Chi Minh City). Data from the UNICEF's Multiple Indicator Clustered Surveys (MICS), carried out in Vietnam during the first quarter of 2014, were used to assess the vaccine coverage in 6 ecological regions of Vietnam.

Results: Results revealed a large discrepancy between levels of protection, as estimated from the serology and vaccine coverage estimated by UNICEF's MICS. Variation in seroprevalence across locations and age groups corresponded with reported numbers of measles cases, most of which were among the 0-2-year-old age group and in the northern part of the country.

Conclusions: Our study presents a strong case in favor of a serosurveillance sentinel network that could be used to proactively tune vaccination policies and other public health interventions.
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http://dx.doi.org/10.1093/ofid/ofz030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405937PMC
March 2019

Geographical and temporal trends and seasonal relapse in Plasmodium ovale spp. and Plasmodium malariae infections imported to the UK between 1987 and 2015.

BMC Med 2018 11 27;16(1):218. Epub 2018 Nov 27.

Public Health England Malaria Reference Laboratory, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.

Background: Plasmodium ovale spp. and P. malariae cause illness in endemic regions and returning travellers. Far less is known about these species than P. falciparum and P. vivax.

Methods: The UK national surveillance data, collected 1987 to 2015, were collated with the International Passenger Survey and climatic data to determine geographical, temporal and seasonal trends of imported P. ovale spp. and P. malariae infection.

Results: Of 52,242 notified cases of malaria, 6.04% (3157) were caused by P. ovale spp. and 1.61% (841) by P. malariae; mortality was 0.03% (1) and 0.12% (1), respectively. Almost all travellers acquired infection in West or East Africa. Infection rate per travel episode fell fivefold during the study period. The median latency of P. malariae and P. ovale spp. was 18 and 76 days, respectively; delayed presentation occurred with both species. The latency of P. ovale spp. infection imported from West Africa was significantly shorter in those arriving in the UK during the West African peak malarial season compared to those arriving outside it (44 days vs 94 days, p < 0.0001), implying that relapse synchronises with the period of high malarial transmission. This trend was not seen in P. ovale spp. imported from East Africa nor in P. malariae.

Conclusion: In West Africa, where malaria transmission is highly seasonal, P. ovale spp. may have evolved to relapse during the malarial high transmission season. This has public health implications. Deaths are very rare, supporting current guidelines emphasising outpatient treatment. However, late presentations do occur.
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http://dx.doi.org/10.1186/s12916-018-1204-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260574PMC
November 2018

Excess direct hospital cost of treating adult patients with ventilator associated respiratory infection (VARI) in Vietnam.

PLoS One 2018 31;13(10):e0206760. Epub 2018 Oct 31.

Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.

Introduction: Ventilator associated respiratory infections (VARIs) are the most common hospital acquired infections in critical care worldwide. This work aims to estimate the total annual direct hospital cost of treating VARI throughout Vietnam.

Methods: A costing model was constructed to evaluate the excess cost of diagnostics and treatment of VARI in Vietnam. Model inputs included costs for extra lengths of stay, diagnostics, VARI incidence, utilisation of ventilators and antibiotic therapy.

Results: With the current VARI incidence rate of 21.7 episodes per 1000 ventilation-days, we estimated 34,428 VARI episodes in the 577 critical care units in Vietnam per year. The extra cost per VARI episode was $1,174.90 and the total annual excess cost was US$40.4 million. A 1% absolute reduction in VARI incidence density would save US$1.86 million annually. For each episode of VARI, the share of excess cost components was 45.1% for critical care unit stay and ventilation, 3.7% for diagnostics and 51.1% for extra antimicrobial treatment.

Conclusions: At the current annual government health expenditure of US$117 per capita, VARI represents a substantial cost to the health service in Vietnam. Enhanced infection prevention and control and antimicrobial stewardship programmes should be implemented to reduce this.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206760PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209379PMC
April 2019

Clinical characteristics, organ failure, inflammatory markers and prediction of mortality in patients with community acquired bloodstream infection.

BMC Infect Dis 2018 Oct 26;18(1):535. Epub 2018 Oct 26.

Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, 78 Giai Phong street, Dong Da district, Hanoi, Vietnam.

Background: Community acquired bloodstream infection (CABSI) in low- and middle income countries is associated with a high mortality. This study describes the clinical manifestations, laboratory findings and correlation of SOFA and qSOFA with mortality in patients with CABSI in northern Vietnam.

Methods: This was a retrospective study of 393 patients with at least one positive blood culture with not more than one bacterium taken within 48 h of hospitalisation. Clinical characteristic and laboratory results from the first 24 h in hospital were collected. SOFA and qSOFA scores were calculated and their validity in this setting was evaluated.

Results: Among 393 patients with bacterial CABSI, approximately 80% (307/393) of patients had dysfunction of one or more organ on admission to the study hospital with the most common being that of coagulation (57.1% or 226/393). SOFA performed well in prediction of mortality in those patients initially admitted to the critical care unit (AUC 0.858, 95%CI 0.793-0.922) but poor in those admitted to medical wards (AUC 0.667, 95%CI 0.577-0.758). In contrast qSOFA had poor predictive validity in both settings (AUC 0.692, 95%CI 0.605-0.780 and AUC 0.527, 95%CI 0.424-0.630, respectively). The overall case fatality rate was 28%. HIV infection (HR = 3.145, p = 0.001), neutropenia (HR = 2.442, p = 0.002), SOFA score 1-point increment (HR = 1.19, p < 0.001) and infection with Enterobacteriaceae (HR = 1.722, p = 0.037) were independent risk factors for in-hospital mortality.

Conclusions: Organ dysfunction was common among Vietnamese patients with CABSI and associated with high case fatality. SOFA and qSOFA both need to be further validated in this setting.
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http://dx.doi.org/10.1186/s12879-018-3448-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204014PMC
October 2018

C-reactive protein point of care testing in the management of acute respiratory infections in the Vietnamese primary healthcare setting - a cost benefit analysis.

Antimicrob Resist Infect Control 2018 4;7:119. Epub 2018 Oct 4.

1Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.

Aim: We assess the cost-benefit implications of C-reactive protein (CRP) testing in reducing antibiotic prescription for acute respiratory infection in Viet Nam by comparing the incremental costs of CRP testing with the economic costs of antimicrobial resistance averted due to lower antibiotic prescribing.

Findings: Patients in the CRP group and the controls incurred similar costs in managing their illness, excluding the costs of the quantitative CRP tests, provided free of charge in the trial context. Assuming a unit cost of $1 per test, the incremental cost of CRP testing was $0.93 per patient. Based on a previous modelling analysis, the 20 percentage point reduction in prescribing observed in the trial implies a societal benefit of $0.82 per patient. With the low levels of adherence to the test results observed in the trial, CRP testing would not be cost-beneficial. The sensitivity analyses showed, however, that with higher adherence to test results their use would be cost-beneficial.
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http://dx.doi.org/10.1186/s13756-018-0414-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6172744PMC
September 2019

A Systematic Review and Meta-analysis of Ventilator-associated Pneumonia in Adults in Asia: An Analysis of National Income Level on Incidence and Etiology.

Clin Infect Dis 2019 01;68(3):511-518

Oxford Clinical Research Unit Hanoi, National Hospital for Tropical Diseases, Vietnam.

Background: Ventilator-associated pneumonia (VAP) is the commonest hospital-acquired infection (HAI) in intensive care. In Asia, VAP is increasingly caused by resistant gram-negative organisms. Despite the global antimicrobial resistance crisis, the epidemiology of VAP is poorly documented in Asia.

Methods: We systematically reviewed literature published on Ovid Medline, Embase Classic, and Embase from 1 January 1990 to 17 August 2017 to estimate incidence, prevalence, and etiology of VAP. We performed a meta-analysis to give pooled rates and rates by country income level.

Results: Pooled incidence density of VAP was high in lower- and upper-middle-income countries and lower in high-income countries (18.5, 15.2, and 9.0 per 1000 ventilator-days, respectively). Acinetobacter baumannii (n = 3687 [26%]) and Pseudomonas aeruginosa (n = 3176 [22%]) were leading causes of VAP; Staphylococcus aureus caused 14% (n = 1999). Carbapenem resistance was common (57.1%).

Conclusions: VAP remains a common cause of HAI, especially in low- and middle-income countries, and antibiotic resistance is high.
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http://dx.doi.org/10.1093/cid/ciy543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336913PMC
January 2019

Community-level antibiotic access and use (ABACUS) in low- and middle-income countries: Finding targets for social interventions to improve appropriate antimicrobial use - an observational multi-centre study.

Wellcome Open Res 2017 28;2:58. Epub 2017 Jul 28.

INDEPTH Network, Accra, Ghana.

In many low- and middle-income countries (LMICs), a poor link between antibiotic policies and practices exists. Numerous contextual factors may influence the degree of antibiotic access, appropriateness of antibiotic provision, and actual use in communities. Therefore, improving appropriateness of antibiotic use in different communities in LMICs probably requires interventions tailored to the setting of interest, accounting for cultural context. Here we present the ABACUS study (AntiBiotic ACcess and USe), which employs a unique approach and infrastructure, enabling quantitative validation, contextualization of determinants, and cross-continent comparisons of antibiotic access and use. The community infrastructure for this study is the INDEPTH-Network (International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries), which facilitates health and population research through an established health and demographic surveillance system. After an initial round of formative qualitative research with community members and antibiotic suppliers in three African and three Asian countries, household surveys will assess the appropriateness of antibiotic access, provision and use. Results from this sample will be validated against a systematically conducted inventory of suppliers. All potential antibiotic suppliers will be mapped and characterized. Subsequently, their supply of antibiotics to the community will be measured through customer exit interviews, which tend to be more reliable than bulk purchase or sales data. Discrepancies identified between reported and observed antibiotic practices will be investigated in further qualitative interviews. Amartya Sen's Capability Approach will be employed to identify the conversion factors that determine whether or not, and the extent to which appropriate provision of antibiotics may lead to appropriate access and use of antibiotics. Currently, the study is ongoing and expected to conclude by 2019. ABACUS will provide important new insights into antibiotic practices in LMICs to inform social interventions aimed at promoting optimal antibiotic use, thereby preserving antibiotic effectiveness.
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http://dx.doi.org/10.12688/wellcomeopenres.11985.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5897850PMC
July 2017

PRactice of VENTilation in Middle-Income Countries (PRoVENT-iMIC): rationale and protocol for a prospective international multicentre observational study in intensive care units in Asia.

BMJ Open 2018 04 28;8(4):e020841. Epub 2018 Apr 28.

Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.

Introduction: Current evidence on epidemiology and outcomes of invasively mechanically ventilated intensive care unit (ICU) patients is predominantly gathered in resource-rich settings. Patient casemix and patterns of critical illnesses, and probably also ventilation practices are likely to be different in resource-limited settings. We aim to investigate the epidemiological characteristics, ventilation practices and clinical outcomes of patients receiving mechanical ventilation in ICUs in Asia.

Methods And Analysis: PRoVENT-iMIC (study of PRactice of VENTilation in Middle-Income Countries) is an international multicentre observational study to be undertaken in approximately 60 ICUs in 11 Asian countries. Consecutive patients aged 18 years or older who are receiving invasive ventilation in participating ICUs during a predefined 28-day period are to be enrolled, with a daily follow-up of 7 days. The primary outcome is ventilatory management (including tidal volume expressed as mL/kg predicted body weight and positive end-expiratory pressure expressed as cm HO) during the first 3 days of mechanical ventilation-compared between patients at no risk for acute respiratory distress syndrome (ARDS), patients at risk for ARDS and in patients with ARDS (in case the diagnosis of ARDS can be made on admission). Secondary outcomes include occurrence of pulmonary complications and all-cause ICU mortality.

Ethics And Dissemination: PRoVENT-iMIC will be the first international study that prospectively assesses ventilation practices, outcomes and epidemiology of invasively ventilated patients in ICUs in Asia. The results of this large study, to be disseminated through conference presentations and publications in international peer-reviewed journals, are of ultimate importance when designing trials of invasive ventilation in resource-limited ICUs. Access to source data will be made available through national or international anonymised datasets on request and after agreement of the PRoVENT-iMIC steering committee.

Trial Registration Number: NCT03188770; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2017-020841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5931304PMC
April 2018

Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: study protocol for a randomised controlled trial.

Trials 2018 Apr 4;19(1):217. Epub 2018 Apr 4.

Wellcome Trust Asia Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.

Background: Ventilator-associated respiratory infection (VARI) comprises ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Although their diagnostic criteria vary, together these are the most common hospital-acquired infections in intensive care units (ICUs) worldwide, responsible for a large proportion of antibiotic use within ICUs. Evidence-based strategies for the prevention of VARI in resource-limited settings are lacking. Preventing the leakage of oropharyngeal secretions into the lung using continuous endotracheal cuff pressure control is a promising strategy. The aim of this study is to investigate the efficacy of automated, continuous endotracheal cuff pressure control in preventing the development of VARI and reducing antibiotic use in ICUs in Vietnam.

Methods/design: This is an open-label randomised controlled multicentre trial. We will enrol 600 adult patients intubated for ≤ 24 h at the time of enrolment. Eligible patients will be stratified according to admission diagnosis (180 tetanus, 420 non-tetanus) and site and will be randomised in a 1:1 ratio to receive either (1) automated, continuous control of endotracheal cuff pressure or (2) intermittent measurement and control of endotracheal cuff pressure using a manual cuff pressure meter. The primary outcome is the occurrence of VARI, defined as either VAP or VAT during the ICU admission up to a maximum of 90 days after randomisation. Patients in both groups who are at risk for VARI will receive a standardised battery of investigations if their treating physician feels a new infection has occurred, the results of which will be used by an endpoint review committee, blinded to the allocated arm and independent of patient care, to determine the primary outcome. All enrolled patients will be followed for mortality and endotracheal tube cuff-related complications at 28 days and 90 days after randomisation. Other secondary outcomes include antibiotic use; days ventilated, in ICU and in hospital; inpatient mortality; costs of antibiotics in ICU; duration of ICU stay; and duration of hospital stay.

Discussion: This study will provide high-quality evidence concerning the use of continuous endotracheal cuff pressure control as a method to reduce VARI, antibiotic use and hospitalisation costs and to shorten stay.

Trial Registration: ClinicalTrials.gov, NCT02966392 . Registered on November 9, 2016. Protocol version: 2.0; issue date March 3, 2017.
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http://dx.doi.org/10.1186/s13063-018-2587-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883270PMC
April 2018

Reducing antibiotic overuse in rural China.

Lancet Glob Health 2018 04;6(4):e376

Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam; Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, UK. Electronic address:

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http://dx.doi.org/10.1016/S2214-109X(18)30071-8DOI Listing
April 2018

Novel genetic polymorphisms associated with severe malaria and under selective pressure in North-eastern Tanzania.

PLoS Genet 2018 01 30;14(1):e1007172. Epub 2018 Jan 30.

Pathogen Molecular Biology Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Significant selection pressure has been exerted on the genomes of human populations exposed to Plasmodium falciparum infection, resulting in the acquisition of mechanisms of resistance against severe malarial disease. Many host genetic factors, including sickle cell trait, have been associated with reduced risk of developing severe malaria, but do not account for all of the observed phenotypic variation. Identification of novel inherited risk factors relies upon high-resolution genome-wide association studies (GWAS). We present findings of a GWAS of severe malaria performed in a Tanzanian population (n = 914, 15.2 million SNPs). Beyond the expected association with the sickle cell HbS variant, we identify protective associations within two interleukin receptors (IL-23R and IL-12RBR2) and the kelch-like protein KLHL3 (all P<10-6), as well as near significant effects for Major Histocompatibility Complex (MHC) haplotypes. Complementary analyses, based on detecting extended haplotype homozygosity, identified SYNJ2BP, GCLC and MHC as potential loci under recent positive selection. Through whole genome sequencing of an independent Tanzanian cohort (parent-child trios n = 247), we confirm the allele frequencies of common polymorphisms underlying associations and selection, as well as the presence of multiple structural variants that could be in linkage with these SNPs. Imputation of structural variants in a region encompassing the glycophorin genes on chromosome 4, led to the characterisation of more than 50 rare variants, and individually no strong evidence of associations with severe malaria in our primary dataset (P>0.3). Our approach demonstrates the potential of a joint genotyping-sequencing strategy to identify as-yet unknown susceptibility loci in an African population with well-characterised malaria phenotypes. The regions encompassing these loci are potential targets for the design of much needed interventions for preventing or treating malarial disease.
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http://dx.doi.org/10.1371/journal.pgen.1007172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806895PMC
January 2018

Ventilator-associated respiratory infection in a resource-restricted setting: impact and etiology.

J Intensive Care 2017 19;5:69. Epub 2017 Dec 19.

Oxford University Clinical Research Unit, Hanoi, Vietnam.

Background: Ventilator-associated respiratory infection (VARI) is a significant problem in resource-restricted intensive care units (ICUs), but differences in casemix and etiology means VARI in resource-restricted ICUs may be different from that found in resource-rich units. Data from these settings are vital to plan preventative interventions and assess their cost-effectiveness, but few are available.

Methods: We conducted a prospective observational study in four Vietnamese ICUs to assess the incidence and impact of VARI. Patients ≥ 16 years old and expected to be mechanically ventilated > 48 h were enrolled in the study and followed daily for 28 days following ICU admission.

Results: Four hundred fifty eligible patients were enrolled over 24 months, and after exclusions, 374 patients' data were analyzed. A total of 92/374 cases of VARI (21.7/1000 ventilator days) were diagnosed; 37 (9.9%) of these met ventilator-associated pneumonia (VAP) criteria (8.7/1000 ventilator days). Patients with any VARI, VAP, or VARI without VAP experienced increased hospital and ICU stay, ICU cost, and antibiotic use ( < 0.01 for all). This was also true for all VARI ( < 0.01 for all) with/without tetanus. There was no increased risk of in-hospital death in patients with VARI compared to those without (VAP HR 1.58, 95% CI 0.75-3.33,  = 0.23; VARI without VAP HR 0.40, 95% CI 0.14-1.17,  = 0.09). In patients with positive endotracheal aspirate cultures, most VARI was caused by Gram-negative organisms; the most frequent were (32/73, 43.8%) (26/73, 35.6%), and (24/73, 32.9%). 40/68 (58.8%) patients with positive cultures for these had carbapenem-resistant isolates. Patients with carbapenem-resistant VARI had significantly greater ICU costs than patients with carbapenem-susceptible isolates (6053 USD (IQR 3806-7824) vs 3131 USD (IQR 2108-7551),  = 0.04) and after correction for adequacy of initial antibiotics and APACHE II score, showed a trend towards increased risk of in-hospital death (HR 2.82, 95% CI 0.75-6.75,  = 0.15).

Conclusions: VARI in a resource-restricted setting has limited impact on mortality, but shows significant association with increased patient costs, length of stay, and antibiotic use, particularly when caused by carbapenem-resistant bacteria. Evidence-based interventions to reduce VARI in these settings are urgently needed.
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http://dx.doi.org/10.1186/s40560-017-0266-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5738227PMC
December 2017

Strongyloides stercoralis seroprevalence in Vietnam.

Epidemiol Infect 2017 11 17;145(15):3214-3218. Epub 2017 Oct 17.

Oxford University Clinical Research Unit and Wellcome Trust Major Overseas Programme,Hanoi,Vietnam.

Strongyloidiasis is a neglected tropical disease caused by the roundworm Strongyloides stercoralis affecting 30-100 million people worldwide. Many Southeast-Asian countries report a high prevalence of S. stercoralis infection, but there are little data from Vietnam. Here, we evaluated the seroprevalence of S. stercoralis related to geography, sex and age in Vietnam through serological testing of anonymized sera. Sera (n = 1710, 1340 adults and 270 children) from an anonymized age-stratified serum bank from four regions in Vietnam between 2012 and 2013 were tested using a commercial Strongyloides ratti immunoglobulin G ELISA. Seroreactivity was found in 29·1% (390/1340) of adults and 5·5% (15/270) of children. Male adults were more frequently seroreactive than females (33·3% vs. 24·9%, P = 0·001). The rural central highlands had the highest seroprevalence (42·4% of adults). Seroreactivity in the other regions was 29·9% (Hue) and 26·0% and 18·2% in the large urban centres of Hanoi and Ho Chi Minh City, respectively. We conclude that seroprevalence of S. stercoralis was high in the Vietnamese adult population, especially in rural areas.
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http://dx.doi.org/10.1017/S0950268817002333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7116469PMC
November 2017

Long-term outcomes of patients with Streptococcus suis infection in Viet Nam: A case-control study.

J Infect 2018 02 29;76(2):159-167. Epub 2017 Sep 29.

Wellcome Trust Major Overseas Programme - Oxford University Clinical Research Unit, 78 Giai Phong, Dong Da, Ha Noi, Viet Nam; Nuffield Department of Medicine, University of Oxford, Oxford OX1 3BD, UK; Radboud UMC, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.

Objectives: Streptococcus suis is a zoonotic cause of severe meningitis and sepsis in humans. We aimed to assess the long-term outcomes in patients who survived S. suis infection, in particular the progress and impact of vestibulocochlear sequelae.

Methods: This case-control study evaluated outcomes of S. suis infection at discharge and 3 and 9 months post-discharge for 47 prospectively enrolled cases and at 11-34 months for 31 retrospectively enrolled cases. Outcomes in patients were compared to 270 controls matched for age, sex and residency.

Results: The prevalence ratio (PR) of moderate-to-complete hearing loss was 5.0(95%CI 3.6-7.1) in cases at discharge, 3.7(2.5-5.4) at 3 months, 3.2(2.2-4.7) at 9 months, and 3.1(2.1-4.4) in retrospective cases compared to controls. Hearing improvement occurred mostly within the first 3 months with a change in hearing level of 11.1%(95%CI 7.0-15.1%) compared to discharge. The PR of vestibular dysfunction was 2.4(95%CI 1.7-3.3) at discharge, 2.2(1.4-3.1) at 3 months, 1.8(1.1-2.5) at 9 months, and 1.8(1.1-2.6) for retrospective cases compared to controls. Cases also indicated more problems with mobility, self-care and usual activities.

Conclusions: Both hearing and vestibular impairment were common and persist in cases. Appropriate patient management strategies are needed to reduce the incidence and impact of these sequelae.
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http://dx.doi.org/10.1016/j.jinf.2017.09.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5790056PMC
February 2018

Determining the predictive equation for height from ulnar length in the Vietnamese population.

Asia Pac J Clin Nutr 2017;26(6):982-986

Oxford Clinical Research Unit Hanoi, National Hospital for Tropical Diseases, Hanoi, Vietnam.

Background And Objectives: Height is an essential measurement in clinical medicine. It allows the calculation of body mass index, ideal body weight, basic energy requirements and tidal volumes. In many patient groups, such as the critically ill, height cannot be measured easily and surrogate anthropometric measures are used. Regression equations estimating height are specific to ethnicity. We aimed to develop the regression equation for Vietnamese men and women to predict height from ulna length and so improve prescription of life-saving treatment in the intensive care units.

Methods And Study Design: A cross-sectional survey of patients and relatives at the National Hospital for Tropical Diseases was undertaken. Ulna length, standing height and weight were measured. The first two thirds of participants' data, stratified by sex and age, were allocated to a model training group, the subsequent participants entered the validation group. Linear regression equations were calculated for the model group by sex, then applied to the validation group and assessed for precision. Other international equations were also compared.

Results: 498 males and 496 females were recruited. There was good correlation between ulna length and height in those aged 21-64, r=0.66, p<0.001 in males and females. The regression equations were: male: height = 85.61 + (3.16 x ulna length), female: height = 85.80 + (2.97 x ulna length). Equations from other populations were less accurate.

Conclusions: The regression equations calculated for men and women aged 21-64 showed good correlation and can be used to predict height in those where direct measurement is impossible.
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http://dx.doi.org/10.6133/apjcn.012017.01DOI Listing
August 2019

Bacterial bloodstream infections in a tertiary infectious diseases hospital in Northern Vietnam: aetiology, drug resistance, and treatment outcome.

BMC Infect Dis 2017 07 12;17(1):493. Epub 2017 Jul 12.

Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam.

Background: Bloodstream infections (BSIs) are associated with high morbidity and mortality worldwide. However their aetiology, antimicrobial susceptibilities and associated outcomes differ between developed and developing countries. Systematic data from Vietnam are scarce. Here we present aetiologic data on BSI in adults admitted to a large tertiary referral hospital for infectious diseases in Hanoi, Vietnam.

Methods: A retrospective study was conducted at the National Hospital for Tropical Diseases between January 2011 and December 2013. Cases of BSI were determined from records in the microbiology department. Case records were obtained where possible and clinical findings, treatment and outcome were recorded. BSI were classified as community acquired if the blood sample was drawn ≤48 h after hospitalization or hospital acquired if >48 h.

Results: A total of 738 patients with BSI were included for microbiological analysis. The predominant pathogens were: Klebsiella pneumoniae (17.5%), Escherichia coli (17.3%), Staphylococcus aureus (14.9%), Stenotrophomonas maltophilia (9.6%) and Streptococcus suis (7.6%). The overall proportion of extended spectrum beta-lactamase (ESBL) production among Enterobacteriaceae was 25.1% (67/267 isolates) and of methicillin-resistance in S. aureus (MRSA) 37% (40/108). Clinical data was retrieved for 477 (64.6%) patients; median age was 48 years (IQR 36-60) with 27.7% female. The overall case fatality rate was 28.9% and the highest case fatality was associated with Enterobacteriaceae BSI (34.7%) which accounted for 61.6% of all BSI fatalities.

Conclusions: Enterobacteriaceae (predominantly K. pneumoniae and E. coli) are the most common cause of both community and hospital acquired bloodstream infections in a tertiary referral clinic in northern Vietnam.
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http://dx.doi.org/10.1186/s12879-017-2582-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5508750PMC
July 2017

Seroprevalence of Scrub Typhus, Typhus, and Spotted Fever Among Rural and Urban Populations of Northern Vietnam.

Am J Trop Med Hyg 2017 May;96(5):1084-1087

Center for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.

AbstractRickettsial infections are recognized as important causes of fever throughout southeast Asia. Herein, we determined the seroprevalence to rickettsioses within rural and urban populations of northern Vietnam. Prevalence of individuals with evidence of prior rickettsial infections (IgG positive) was surprisingly low, with 9.14% (83/908) testing positive to the three major rickettsial serogroups thought to circulate in the region. Prevalence of typhus group rickettsiae (TG)-specific antibodies (6.5%, 58/908) was significantly greater than scrub typhus group orientiae (STG)- or spotted fever group rickettsiae (SFG)-specific antibodies ( < 0.05). The majority of TG seropositives were observed among urban rather than rural residents ( < 0.05). In contrast, overall antibody prevalence to STG and SFG were both very low (1.1%, 10/908 for STG; 1.7%, 15/908 for SFG), with no significant differences between rural and urban residents. These results provide data on baseline population characteristics that may help inform development of serological testing criteria in future clinical studies.
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http://dx.doi.org/10.4269/ajtmh.16-0399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5417199PMC
May 2017