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Review of the status and control of foot and mouth disease in sub-Saharan Africa.

Six of the seven serotypes of foot and mouth disease (FMD) virus (i.e. all but Asia 1) are prevalent in Africa although there are marked regional differences in distribution. Three of these serotypes are unique to Africa, namely the three South African Territories (SAT) serotypes. Serotype C may also now be confined to Africa because it has not been reported elsewhere recently. In southern Africa at least, the SAT serotypes have an intimate and probably ancient association with African buffalo (Syncerus caffer) that is instrumental in their maintenance. Within each of the six prevalent serotypes, with the possible exception of C, there are a number of different lineages with more or less defined distributions (i.e. topotypes) that in some cases are sufficiently immunologically different from one another to require specific vaccines to ensure efficient control. This immunological diversity in prevalent serotypes and topotypes, in addition to uncontrolled animal movement in most parts of the continent, render FMD difficult to control in present circumstances. This fact, together with poorly developed intercontinental trade in animals and animal products has resulted in the control of FMD being afforded a low priority in most parts of the continent, although the northern and southern regions of the continent are an exception. As a consequence, eradication of FMD from Africa as a whole is not a prospect within the foreseeable future. In southern Africa, the use of fencing and other means to strictly control the movement of wildlife and livestock as well as judicious application of vaccine has resulted in countries of the region being able to access beef and other livestock markets in Europe and elsewhere in the developed world. Significant marketing of livestock and livestock products from Africa outside the continent is unlikely to be achieved unless similar approaches can be developed for other regions of Africa. This will result in continuing under-exploitation of a valuable resource in the arid and semi-arid regions of Africa, with increasing marginalisation of human populations living there.

Africa South of the Sahara↗

Medical care on the brink: the need for re-engineering healthcare services in sub-Saharan Africa.

The sub-Saharan region of Africa is home to more of the ills of mankind than any other region on earth. Nowhere is the aggregate of disease, political turmoil, inadequate resources and a crumbling infrastructure so completely packaged in a seemingly "escape proof" pod as in sub-Saharan Africa. This continent is a kaleidoscope of people and problems derived from artificial boundaries drawn by European colonial powers, resulting in a litany of problems that have flourished for many decades. In the immediate postcolonial era, there was some oversight by the departed powers, but this has changed recently with decreasing interest in African affairs and only episodic worldwide news coverage because of other world events that overshadow Africa and its problems. The end of the cold war also eliminated the attention Africa received when the superpowers were courting nations. The American Medical Team for Africa has conducted medical missionary work throughout Africa for over a decade and, through its observations, has developed recommendations that are germane to all of sub-Saharan Africa. The organization thinks that this might warrant the attention of governments, international pharmaceutical houses, foundations, the United Nations and all international aid agencies concerned about the plight of healthcare in Africa. These recommendations should enable these countries to re-establish an affordable, efficient and sustainable infrastructure for basic hospital services so that they can diagnosis, monitor, treat and manage disease populations. In some areas, Africa needs to be retrofitted with technology from the past, while in others it needs to be fast-forwarded into the future. The purpose of this manuscript is to try putting the various healthcare challenges into one of these two categories.

Africa South of the Sahara↗

[Rheumatic diseases in black Africa].

There have been few epidemiological studies of bone and joint diseases in black Africa. Available data were generated by hospital studies which were inevitably flawed by selection bias. They found that the incidence and/or severity of rheumatoid arthritis were reduced in West Africa but not in urban areas of Southern and East Africa, as compared with industrialized countries. Ankylosing spondylitis was infrequent. The human immunodeficiency virus epidemic can be expected to increase the prevalence of spondyloarthropathies despite the fact that few black Africans are HLA B27-positive. Gout was the most common inflammatory joint disease seen in inpatients in West Africa and Equatorial Africa. Osteoarthritis of the fingers or hip and dysplasia of the hip were infrequent. The main causes of hip symptoms were sickle cell anemia and hemoglobin C disease whose manifestations include bone necrosis, osteomyelitis, and attacks of bone and joint pain. Osteoarthritis of the knee was common in West and Southern Africa, especially in obese women. Low back pain and sciatica due to disc herniation were as common as in Europe. Lumbar canal stenosis appeared more common in West Africa than in Southern Africa, with a predominance in females. Postmenopausal osteoporosis was exceedingly rare. Infectious diseases were prevalent as a result of underindustrialization and defective hygiene. The paucity of rheumatologists, young mean age of the population, and scarcity of population-based studies are sources of bias which should be taken into account when interpreting the available data on rheumatological diseases in black Africa. In the future, more rigorous studies made possible by increased access to health care will provide improved insight into the semiology and epidemiology of bone and joint diseases in this area.

Africa South of the Sahara↗

Molecular epidemiology of serotype O foot-and-mouth disease virus with emphasis on West and South Africa.

Genetic relationships of serotype O foot-and-mouth disease (FMD) viruses recovered from outbreaks of the disease in the West African countries of Niger, Burkina Faso and, Ghana (1988-1993) and those from South Africa (2000) were determined by partial VP1 gene characterization. A 581-bp fragment, corresponding to the C-terminus half of the ID (VP1 gene) region was amplified and sequenced. An homologous region of 495 nucleotides was ultimately used to determine genetic relationships of serotype O viruses from the Middle East, Europe, South America, North Africa, East Africa, southern Africa and Asia. Seven distinct type O genotypes were identified by phylogenetic reconstruction, consisting of viruses from the following geographical regions: Genotype A: Asia, the Middle East, and South Africa, Genotype B: East Africa, Genotype C: West and North Africa, Genotype D: Taiwan and Russia, Genotype E: Angola and Venezuela, Genotype F: Western Europe, and Genotype G: Europe and South America. The genotypes constitute three different evolutionary lineages (I-III), which correspond to three discrete continental regions, some of which display inter-continental distributions due to introductions. Results further indicate that the outbreaks in Burkina Faso (1992) and Ghana (1993) are part of the same epizootic and that the strain involved in a recent outbreak of the disease in South Africa is most closely related (97% sequence identity) to a 1997 Bangladesh strain.

Africa, Western↗

End-stage renal disease in sub-Saharan and South Africa.

The major health problems in Africa are AIDS, tuberculosis, malaria, gastroenteritis and hypertension; hypertension affects about 20% of the adult population. Renal disease, especially glomerular disease, is more prevalent in Africa and seems to be of a more severe form than that found in Western countries. The most common mode of presentation is the nephrotic syndrome, with the age of onset at five to eight years. It is estimated that 2 to 3% of medical admissions in tropical countries are due to renal-related complaints, the majority being the glomerulonephritides. There are no reliable statistics for ESRD in all African countries. Statistics of the South African Dialysis and Transplant Registry (SADTR) reflect the patients selected for renal replacement therapy (RRT) and do not accurately reflect the etiology of chronic renal failure (CRF), where public sector state facilities will offer RRT only to patients who are eligible for a transplant. In 1994, glomerulonephritis was recorded as the cause of ESRD in 1771 (52.1%) and hypertension in 1549 (45.6%) of patients by the SADTR. In a six-year study of 3632 patients with ESRD, based on SADTR statistics, hypertension was reported to be the cause of ESRD in 4.3% of whites, 34.6% of blacks, 20.9% mixed race group and 13.8% of Indians. Malignant hypertension is an important cause of morbidity and mortality among urban black South Africans, with hypertension accounting for 16% of all hospital admissions. In a ten-year study of 368 patients with chronic renal failure in Nigeria, the etiology of renal failure was undetermined in 62%. Of the remaining patients whose etiology was ascertained, hypertension accounted for 61%, diabetes mellitus for 11% and chronic glomerulonephritis for 5.9%. Patients with CRF constituted 10% of all medical admissions in this center. Chronic glomerulonephritis and hypertension are principal causes of CRF in tropical Africa and East Africa, together with diabetes mellitus and obstructive uropathy. The availability of dialysis and transplantation is quite variable in Africa: treatment rates in North Africa are 30 to 186.5 per million population (pmp) in countries with more established programs: Algeria 78.5; Egypt 129.3; Libya 30; Morocco 55.6; Tunisia 186.5 pmp. In South Africa, treatment rates of 99 pmp were reported; Dialysis and transplant programs in the rest of Africa are dependent on the availability of funding and donors. Services are still predominantly urban and therefore generally inaccessible to the poorer, less educated rural patient. There is not enough money for healthcare in the developing world, particularly for expensive and chronic treatment such as RRT. The goal should be to have a circumscribed chronic dialysis program, with as short a time on dialysis as possible, and to increase the availability of transplantation (both living donor and cadaver). Efforts should be made to optimize therapy of renal disease and renal failure globally and particularly in developing countries. Strategies should be developed to screen for and manage conditions such as hypertension and diabetes mellitus at the primary healthcare level in an effort to decrease the incidence of chronic renal failure. Increasingly, health is influenced by social and economic circumstances. Any improvements in health thus demand integrated, comprehensive action against all the determinants of ill health.

Africa South of the Sahara↗

HIV/AIDS situation in Africa.

The HIV/AIDS pandemic marks a severe development crisis in Africa, which remains by far the worst affected region in the world. Forty-two million people now live with HIV/AIDS of which 29.4 million (70.0%) are from sub-Saharan Africa. Approximately 5 million new infections occurred in 2002 and 3.5 million (70.0%) of these were also from sub-Saharan Africa. The estimated number of children orphaned by AIDS living in the region is 11 million. In 2002, the epidemic claimed about 2.4 million lives in Africa, more than 70% of the 3.1 million deaths worldwide. Average life expectancy in sub-Saharan Africa is now 47 years, when it would have been 62 years without AIDS. HIV/AIDS stigma is still a major problem despite the extensive spread of the epidemic. A complex interaction of material, social, cultural and behavioural factors shape the nature, process and outcome of the epidemic in Africa. However, too many partners and unprotected sex appear to be at the core of the problem, Even if exceptionally effective prevention, treatment and care programmes take hold immediately, the scale of the crisis means that the human and socio-economic toll will remain significant for many generations. Although 70% of people living with HIV/AIDS are in Africa, only 6,569 (4.7%) of the 140,736 scientific publications on HIV/AIDS, from 1981 to 2000, are directly related to Africa. Effective responses to the epidemic require a multisectoral approach, including governments, the business sector and civil society.

Acquired Immunodeficiency Syndrome↗

Parkinson's disease in Africa: A systematic review of epidemiologic and genetic studies.

Parkinson's disease (PD) occurs worldwide, but little is known about PD in Africa. We systematically reviewed publications on PD in Africa, with emphasis on epidemiologic and genetic studies. Articles published between 1944 and December 2004 were identified using several strategies. The studies emanated from 13 African countries (Kenya, Uganda, Tanzania, Ethiopia, Nigeria, Senegal, Ghana, Togo, Libya, Tunisia, Algeria, Zimbabwe, and South Africa). The publications fell into four categories: clinical series (n = 17), prevalence studies (n = 7), incidence studies (n = 1), and genetic studies (n = 3). The clinical series documented the occurrence of PD in Africa and described its clinical characteristics. The prevalence studies suggested some intracontinental geographic variation in PD prevalence. Overall, the prevalence figures and the incidence rates of PD in Africa appeared lower than those reported for European and North American populations. Few genetic studies of PD have been reported from Africa, and none in blacks. There are no case-control or cohort studies of PD reported from Africa. This review provides a summary of PD research in Africa over the past 60 years and highlights the information gaps and potential areas for future research.

Africa↗

AIDS in Africa: emerging trends.

This paper reviews the literature on AIDS in Africa. By 29 February, 1988, 9760 cases of AIDS had been reported in Africa. This review addresses the currently accepted belief in the African origin of AIDS, the distribution (cluster) of AIDS in Africa, identified modes of transmission, and changing sexual and drug use behaviors in Africa. There is no conclusive evidence to show that the AIDS virus originated in Africa. Even if the progenitor virus had a habitat in central Africa, certain high-risk sexual behaviors which were introduced in the 60s and 70s may have initiated the infectious process. The distribution pattern does not suggest a transcontinental spread; rather, it suggests a contigual and transatlantic spread. The primary mode of transmission is heterosexual activity. This paper raises a number of questions relating to heterosexual behaviors. Other issues addressed include drug use behavior, homosexuality, and high-risk sexual activities of Africans and foreigners in Africa. Other modes of transmission are transfusion of contaminated blood and blood products, use of nonsterile needles, and perinatal transmission. It is not likely that traditional (folk) medicine will contribute to the spread of AIDS. Traditional doctors use fresh razor blades for cuts and not hollow instruments such as needles. The impact of the political and socioeconomic climate in most of Africa during the 60s and early 70s is evaluated. Finally, we make suggestions for future direction, which include confirmatory testing of HIV Positive samples, conducting clinical epidemiology and social science-based research, and developing innovative education programs that are culturally relevant.

Acquired Immunodeficiency Syndrome↗

HIV prevalence and trends in sub-Saharan Africa: no decline and large subregional differences.

BACKGROUND: Expansion of HIV surveillance systems in sub-Saharan Africa is leading to downward adjustments to the size of the AIDS epidemic. However, only analysis of surveillance data from the same populations over time can provide insight into trends of HIV prevalence. We have used data from the same antenatal clinics to document recent empirical trends. METHODS: We collated data from antenatal clinics on HIV prevalence between 1997 and 2003. Data were obtained from 140?000 pregnant women attending more than 300 antenatal clinics in 22 countries in sub-Saharan Africa. Additionally, long-term trend data are available for 57 urban areas and provinces. FINDINGS: Median HIV prevalence in 148 antenatal clinic sites in southern Africa increased from 21.3% (IQR 11.5-28.2%) in 1997/98 to 23.8% (15.6-29.2%) in 2002. At more than half the sites (58%) an increase of at least one-tenth was noted, but at a fifth of sites, prevalence dropped by at least one-tenth. In eastern Africa, median HIV prevalence decreased from 12.9% (7.0-16.9%) in 1997/98 to 8.5% (5.3-13.0%) in 2002, with prevalence rising in four (7%) sites, but falling at 25 (43%) sites. In west Africa, median HIV prevalence was 3.5% (2.2-5.9%) and 3.2% (2.3-6.1%) for 1997/98 and 2002, respectively, with reductions and increases in prevalence being noted in equal proportions. The long-term trends in urban areas in sub-Saharan Africa show a similar pattern, with increasing evidence of stabilisation during the past 2-3 years compared with the previous decade. INTERPRETATION: Evidence from surveillance of mostly urban antenatal clinic attendees indicates that the growth in the AIDS epidemic in sub-Saharan Africa has levelled off since the late 1990s but only eastern Africa shows a decline in HIV prevalence. Very large differences persist between subregions. Workers planning a response to the AIDS epidemic must take more careful consideration of these variations to allow locally appropriate responses to the epidemic.

Adolescent↗

A re-examination of levels and differential in fertility in South Africa from recent evidence.

The final estimate of South Africa's population as of October 1996 from the first post-apartheid census by Statistics South Africa was lower (40.6 million) than expected (42 million). The expectation of a total population of 42 million was largely based on results of apartheid projections of South Africa's population. The results of the last apartheid census in South Africa in 1991 had been adjusted such that it was consistent with results modelling the population size of South Africa. The discrepancy between the final estimate of the 1996 census and that expected from the modelling described above, and the departure by Statistics South Africa from previous practice of adjusting the census results to be consistent with demographic models, has generated controversies regarding the accuracy of the final results from the 1996 census. This study re-examines levels and differential in fertility in South Africa from recent evidence in order to assess whether or not the fertility inputs in projections of South Africa's population during the apartheid era overestimated fertility.

Adolescent↗

The variable incidence of psoriasis in sub-Saharan Africa.

BACKGROUND: Surveys of skin disorders have previously provided information about the prevalence and incidence of psoriasis in sub-Saharan Africa; however, the geographic and ethnic trends which may be drawn from these surveys have not been fully described in previous studies, which considered only a fraction of the available data. METHODS: A critical review of clinic-based surveys of psoriasis incidence and population-based studies of psoriasis prevalence is presented. The incidence of psoriasis is adjusted, wherever possible, to factor out the widely variable incidence of infectious skin conditions seen in African skin clinics. To distinguish between genetic and environmental factors that may be responsible for the variability of psoriasis incidence, attention is drawn to climate, human leukocyte antigen (HLA) frequencies, and language groups across the regions surveyed in sub-Saharan Africa. RESULTS: Higher psoriasis incidence rates are consistently observed in eastern Africa than in western Africa, consistent with more limited data on the prevalence of psoriasis in western Africa. Neither rainfall/humidity levels nor HLA frequencies can simply account for these differences; however, the ethnicities of sub-Saharan African peoples may be observed to parallel roughly the trend in psoriasis incidence. Western African countries, such as Nigeria, Mali, Senegal, and Sierra Leone, where lower rates of psoriasis incidence have been reported (less than 1.0% of skin disorders), are populated mainly by non-Bantu-speaking ethnic groups. Bantu-speaking peoples constitute a majority in the populations of most countries in eastern and southern sub-Saharan Africa, where the incidence of psoriasis varies widely. African Americans, whose largely non-Bantu-speaking African ancestry is shared with modern western Africans, also have relatively low psoriasis incidence rates by comparison with North American Caucasians. CONCLUSIONS: Ethnic correlations both within Africa and between North America and Africa suggest that unidentified genetic factors, which differ between eastern and western sub-Saharan Africans, may govern the differential incidence of psoriasis.

Africa South of the Sahara↗

Characterization of subtype A HIV-1 from Africa by full genome sequencing.

OBJECTIVE: To improve our understanding of the genetic complexity of HIV-1 subtype A by increasing the number of subtype A isolates that have been sequenced in their entirety. METHODS: Nine HIV-1-seropositive patients from Africa living in Sweden contributed peripheral blood mononuclear cells (PBMC) for this study. Sequencing of the C2-V3 region of env had shown them to be subtype A. DNA from virus cultures was used for the amplification of virtually full-length proviral sequences, and the resulting fragment was sequenced. RESULTS: Six of the nine viral isolates were subtype A throughout the genome, or non-recombinant, and all of these were from east Africa. One virus from the Ivory Coast had the AG(IbNG) genetic form, a recombinant form common in west Africa. Two of the isolates were novel recombinants: one was an A/C recombinant and the other was A/D. Analysis of gag reveals three subclusters within the A subtype: one containing the AG(IbNG) subtype viruses, one containing the AE(CM240) viruses and one containing the non-recombinant A viruses. These genetic clusters have different geographical distributions in Africa. CONCLUSION: The prevailing view of HIV-1 subtype A forming a uniform band across the center of sub-Saharan Africa needs revision. In all probability, the most common subtype in west Africa and west central Africa is the AG recombinant, AG(IbNG), whereas in east central Africa it is the non-recombinant subtype A.

Africa↗

Characterization of and application of monoclonal antibodies against Rickettsia africae, a newly recognized species of spotted fever group rickettsia.

Rickettsia africae is a newly described species which causes African tick bite fever. Mediterranean spotted fever caused by R. conorii is endemic in the same regions of Africa as tick bite fever, and differentiation of the two syndromes by characterization of their etiological agents is important for epidemiological studies. R. africae and R. conorii are, however, difficult to distinguish, and therefore, our aim was to produce monoclonal antibodies to address this problem. Monoclonal antibodies were produced against R. africae by fusing splenocytes from BALB/C mice immunized with purified rickettsial organisms and SP2/0-Ag14 myeloma cells. A total of 355 hybridomas producing monoclonal antibodies to R. africae were identified by initial screening with six different antigens by microimmunofluorescence assay. A panel of 23 representative monoclonal antibodies were selected and subcloned. This panel was screened with a further 17 different spotted fever group (SFG) rickettsial reference antigens. Of these 23 monoclonal antibodies, 1 cross-reacted with only R. parkeri, whereas the others cross-reacted with more than two different antigens. Immunoblotting indicated that all the monoclonal antibodies were directed against the epitopes on two major high-molecular-mass heat-labile proteins, of which the molecular masses were 128 and 135 kDa, respectively. This monoclonal antibody panel was used successfully to identify R. africae in the blood culture of an infected patient, in infected cells within shell vials, and in infected ticks collected from Africa. Furthermore, the cross-reactivity of each SFG rickettsia with each of these 23 monoclonal antibodies was scored and was used to build a dendrogram of taxonomic relatedness between R. africae and the other SFG rickettsiae on the basis of Jaccard coefficients and unweighted pair group method with arithmetic mean analysis. The relatedness was generally consistent with that obtained by other methods of comparison.

Africa↗

Running on empty: sexual co-factors are insufficient to fuel Africa's turbocharged HIV epidemic.

The hypothesis that heterosexual transmission drives sub-Saharan Africa's HIV epidemics requires much faster transmission dynamics in Africa than in the US and Europe, where heterosexual transmission is arguably insufficient to maintain existing levels of HIV prevalence. Initially, experts surmised that Africans had more sexual partners; however, studies of sexual behaviour circa 1990 undermined this assumption. Next, it was supposed that the high burden of bacterial sexually transmitted disease (STD) in Africa explained greater HIV transmission efficiency; however, during the 1990s, community studies in Africa showed that STD had much less than expected impact on HIV transmission. Current attempts to explain HIV as a primarily sexual epidemic in Africa propose multiple factors, including herpes simplex virus type 2, lack of male circumcision, concurrency, and others. These factors also fail for various reasons to account for Africa's HIV epidemics: they are present also in the US and/or Europe; they do not correlate with differences in HIV prevalence across Africa; etc. While behavioural and biological variables influence personal risk for HIV acquisition, the available evidence suggests that they do not differentiate African from US and European epidemics, nor do they determine the differential HIV epidemic trajectories noted across Africa.

Africa↗

"Harnessing genomics to improve health in Africa" - an executive course to support genomics policy.

BACKGROUND: Africa in the twenty-first century is faced with a heavy burden of disease, combined with ill-equipped medical systems and underdeveloped technological capacity. A major challenge for the international community is to bring scientific and technological advances like genomics to bear on the health priorities of poorer countries. The New Partnership for Africa's Development has identified science and technology as a key platform for Africa's renewal. Recognizing the timeliness of this issue, the African Centre for Technology Studies and the University of Toronto Joint Centre for Bioethics co-organized a course on Genomics and Public Health Policy in Nairobi, Kenya, the first of a series of similar courses to take place in the developing world. This article presents the findings and recommendations that emerged from this process, recommendations which suggest that a regional approach to developing sound science and technology policies is the key to harnessing genome-related biotechnology to improve health and contribute to human development in Africa. METHODS: The objectives of the course were to familiarize participants with the current status and implications of genomics for health in Africa; to provide frameworks for analyzing and debating the policy and ethical questions; and to begin developing a network across different sectors by sharing perspectives and building relationships. To achieve these goals the course brought together a diverse group of stakeholders from academic research centres, the media, non-governmental, voluntary and legal organizations to stimulate multi-sectoral debate around issues of policy. Topics included scientific advances in genomics innovation systems and business models, international regulatory frameworks, as well as ethical and legal issues. RESULTS: Seven main recommendations emerged: establish a network for sustained dialogue among participants; identify champions among politicians; use the New Plan for African Development (NEPAD) as entry point onto political agenda; commission an African capacity survey in genomics-related R&D to determine areas of strength; undertake a detailed study of R&D models with demonstrated success in the developing world, i.e. China, India, Cuba, Brazil; establish seven regional research centres of excellence; and, create sustainable financing mechanisms. A concrete outcome of this intensive five-day course was the establishment of the African Genome Policy Forum, a multi-stakeholder forum to foster further discussion on policy. CONCLUSION: With African leaders engaged in the New Partnership for Africa's Development, science and technology is well poised to play a valuable role in Africa's renewal, by contributing to economic development and to improved health. Africa's first course on Genomics and Public Health Policy aspired to contribute to the effort to bring this issue to the forefront of the policy debate, focusing on genomics through the lens of public health. The process that has led to this course has served as a model for three subsequent courses (in India, Venezuela and Oman), and the establishment of similar regional networks on genomics and policy, which could form the basis for inter-regional dialogue in the future.

Editorial↗

MERS-CoV in the Middle East and Africa: from surveillance gaps in humans and dromedary camels to One Health frameworks for spillover, prevention, research and response preparedness.

Middle East respiratory syndrome coronavirus (MERS-CoV) remains a low-incidence but high-consequence zoonotic coronavirus threat. Since its identification in Saudi Arabia in 2012, more than 2600 laboratory-confirmed cases have been reported from 27 countries, most from the Arabian Peninsula; the reported case fatality ratio is high but probably overestimates infection fatality because mild and asymptomatic infections are under-detected. Dromedary camels across the Middle East, North Africa, East Africa, the Horn of Africa, and parts of the Sahel show extensive evidence of MERS-CoV infection or exposure, yet PCR-confirmed human disease has rarely been reported from Africa. This "Africa paradox" is one of the most important unresolved issues in MERS-CoV epidemiology. We propose a dromedary camel-centered One Health framework for the connected Middle East-Africa dromedary belt. The framework is organized around two linked barriers: an upstream barrier that detects and reduces zoonotic spillover at the camel-human interface, and a downstream healthcare barrier that prevents amplification after human infection occurs. Preparedness should include sentinel surveillance for severe acute respiratory infection and atypical pneumonia in camel-exposed populations, linked animal-human genomic surveillance, culturally respectful and occupationally practical risk reduction, rapid diagnostic pathways, healthcare infection prevention and control, mass-gathering and travel preparedness, and preapproved research platforms. A Middle East-Africa preparedness compact aligned with the International Health Regulations, One Health governance, and equitable pathogen access and benefit sharing could transform fragmented surveillance into a standing transregional system for early detection, prevention, and research-ready response.

Africa paradox↗

The impact of HIV-1 infection on mortality in children under 5 years of age in sub-Saharan Africa: a demographic and epidemiologic analysis.

OBJECTIVE: To estimate the effects of the HIV-1 epidemic on mortality in children under 5 years of age in urban and rural populations in eastern and central, and southern Africa. METHODS: A lifetable method that allows for the effects of competing causes (i.e., mortality due to HIV and other causes) was used to estimate mortality. Our calculations used published and unpublished data on HIV-1 infection in African adults and children (incidence and prevalence, vertical transmissions, transmission by blood transfusion and natural history), and typical baseline fertility and child mortality data. The results were applied to model rural and urban populations to explore the effects of parameters such as mortality in HIV-1-infected children, fertility in infected mothers and overall population growth. RESULTS: We estimate that child mortality will rise substantially because of the prevalence of HIV-1 in urban areas. There will be little difference in the absolute levels of increase in mortality between areas in eastern and central, and southern Africa with similar levels of HIV infection; however, in relative terms the effect will be more noticeable in southern Africa because of the lower baseline mortality. Towns with severe epidemics (30% adult seroprevalence) might experience a rise in child mortality of one-third in eastern and central Africa and three-quarters in southern Africa. This will cancel or reverse existing advantages in urban over rural levels of child mortality and this effect will be more pronounced in southern Africa. The exact impact of HIV-1 will vary according to mortality among HIV-1-infected children and to fertility among infected women. However, changes in age structure and population growth have relatively little impact on mortality. CONCLUSIONS: There are likely to be substantial increases in child mortality in sub-Saharan Africa as a result of HIV-1 infection. The main determinant of childhood infection is the scale of the epidemic among adults. Increases in mortality will depend on local adult seroprevalence but are hard to predict precisely because of possible variation in death rates among HIV-1-infected children. In rural areas with low seroprevalence other diseases will remain the main cause of mortality. However, in urban areas families and health services will have to face considerably increased demands from ill and dying children.

Adolescent↗

Plague in Africa from 1935 to 1949; a survey of wild rodents in African territories.

The history of plague in Africa during the period 1935-49 is reviewed. Much of the information derives from a questionnaire sent to all African territories in 1950. The annual incidence of plague in Africa declined, particularly from 1946 onwards. In 1949, under 400 cases were reported, as compared with over 6,000 in 1935. By the end of 1949, plague was still active in the Belgian Congo, Kenya and Tanganyika, Madagascar, and southern Africa. No cases were reported from Egypt, Tunisia, Algeria, Morocco, Senegal, or Uganda during 1949. A comparison of the seasonal incidence of plague with prevailing atmospheric conditions (temperature and rainfall) in African territories shows that human plague is more frequent in warm moist weather-60 degrees -80 degrees F (15 degrees -27 degrees C)-than in hot dry, or cold, weather-over 80 degrees F (27 degrees C) or under 60 degrees F (15 degrees C). The highlands of equatorial Africa and of Madagascar appear to provide the optimum environment for the persistence of plague on the domestic (murine) plane and the high-veld and Kalahari of southern Africa on the sylvatic plane. The rat (Rattus rattus) and the multimammate mouse (R. (Mastomys) natalensis) and their fleas Xenopsylla brasiliensis and X. cheopis appear to be mainly responsible for the persistence of the reservoir in the East African highlands; R. rattus and X. cheopis play this role in Madagascar. The gerbils (Tatera and Desmodillus) and their burrow fleas X. philoxera and X. piriei are the main reservoirs of plague in southern Africa. Within these areas, Pasteurella pestis finds an environment suitable for its continued survival; the conditions seem to be comparable to those defined as obtaining in endemic centres in India. Elsewhere in Africa such endemic centres do not appear to exist.

Africa↗