*The percentages and right hand values represent the level of conformance to Regulation 918 amongst all the hospices sampled (n=10).
Kitchen facility design and food handling practices in hospices around Central South Africa.
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
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Using these techniques, scientists obtain information about the crystal structure and chemical and physical properties of materials. Nowadays, different techniques are based on observing the scattered intensity of an X-ray beam hitting a sample as a function of incident and scattered angle, polarization, and wavelength.\nThis book is intended to give overviews of the relevant X-ray scattering techniques, particularly about inelastic X-ray scattering, elastic scattering, grazing-incidence small-angle X-ray scattering, small-angle X-ray scattering, and high-resolution X-ray diffraction, and, finally, applications of X-ray spectroscopy to study different biological systems.",isbn:"978-953-51-2888-5",printIsbn:"978-953-51-2887-8",pdfIsbn:"978-953-51-4120-4",doi:"10.5772/62609",price:119,priceEur:129,priceUsd:155,slug:"x-ray-scattering",numberOfPages:228,isOpenForSubmission:!1,isInWos:1,hash:"af21d4ead14637fcfa5f919430ec45f5",bookSignature:"Alicia Esther Ares",publishedDate:"January 25th 2017",coverURL:"https://cdn.intechopen.com/books/images_new/5371.jpg",numberOfDownloads:14433,numberOfWosCitations:15,numberOfCrossrefCitations:12,numberOfDimensionsCitations:22,hasAltmetrics:1,numberOfTotalCitations:49,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 9th 2016",dateEndSecondStepPublish:"March 30th 2016",dateEndThirdStepPublish:"July 4th 2016",dateEndFourthStepPublish:"October 2nd 2016",dateEndFifthStepPublish:"November 1st 2016",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7,8",editedByType:"Edited by",kuFlag:!1,editors:[{id:"91095",title:"Dr.",name:"Alicia Esther",middleName:null,surname:"Ares",slug:"alicia-esther-ares",fullName:"Alicia Esther Ares",profilePictureURL:"https://mts.intechopen.com/storage/users/91095/images/system/91095.jpg",biography:"Alicia Esther Ares is a professor of Materials Science at the Chemical Engineering Department, School of Sciences (FCEQyN), National University of Misiones (UNaM), Posadas, Misiones, Argentina, since December 2013. She is also an independent researcher at the National Scientific and Technical Research Council (CONICET), Argentina, since January 2015. Previously, she has been a research associate at CONICET (2008–2014) and an associate professor at UNaM (2007–2013). She has also been an assistant professor at UNaM (1989–2007). She graduated at the University of Misiones in 1992 and completed a PhD degree in Materials Science at the Institute of Technology 'Jorge Sabato,” UNSAM–CNEA, Buenos Aires, Argentina. Later, she made a postdoctoral stays at the following institutions: Faculdade de Engenharía Mecânica, Departamento de Engenharía de Materiais, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil (2001 and 2005–2006); Department of Materials Science and Engineering, University of Florida, Gainesville, Florida, United States (2002–2003); and Faculty of Sciences, National University of Misiones, Posadas, Misiones, Argentina (2003–2004).\r\nShe has a 30-year teaching experience both at the undergraduate and at the graduate level. Her research interests lie in the following areas: Solidification thermal parameters, mechanical properties, and corrosion resistance of different alloys and composite materials; Solidification structures and properties of alloys for hard tissue replacement; Metallic materials selection for the management of biofuels; Synthesis and characterization of nanostructured coatings, membranes, and templates of aluminum and zinc oxides; Fabrication and characterization of nanostructured titanium and iron oxide coatings for water treatment systems based on advanced oxidative and reductive processes; and Natural products as corrosion inhibitors of metallic materials. 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Ashraf",coverURL:"https://cdn.intechopen.com/books/images_new/8268.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"199287",title:"Dr.",name:"Ghulam Md",middleName:null,surname:"Ashraf",slug:"ghulam-md-ashraf",fullName:"Ghulam Md Ashraf"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},ofsBook:{item:{type:"book",id:"9536",leadTitle:null,title:"Education at the Intersection of Globalization and Technology",subtitle:null,reviewType:"peer-reviewed",abstract:"
\r\n\tOur rapidly shrinking, interconnected world is experiencing an unprecedented change in the face of digital innovation and emerging globalization. As the world’s population spirals beyond 7.7 billion, international economies are becoming more integrated and mutually dependent upon one other. These interconnected economies are subject to political, social, and cultural expectations unimagined in past decades. Employee skill sets that were in high demand only a few decades ago are now considered obsolete and unnecessary. New occupations are evolving in the face of digital advancement only to be quickly replaced by other emerging occupations more suitable to satisfying transitioning expectations. The changes are endless. Educational systems can no longer educate for today’s jobs. They must educate for tomorrow’s jobs. They must empower the future of their national economies while remaining mindful of the needs of tomorrow’s global economy. They stand at the intersection of globalization and technology. The only thing certain is change.
\r\n\r\n\tThis book is intended to examine the educational issues encountered in such an environment. The book aims to afford a fresh examination of theory, research, and practice into this field of study and to provide the reader with an insight into the challenges, successes, and opportunities encountered by today’s educational institutions.
",isbn:"978-1-83962-470-4",printIsbn:"978-1-83962-469-8",pdfIsbn:"978-1-83962-471-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"0cf6891060eb438d975d250e8b127ed6",bookSignature:"Dr. Lee Waller, Dr. Sharon Waller, Dr. Vongai Mpofu and Dr. Mercy Kurebwa",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9536.jpg",keywords:"Global Skill Sets, Career Development, International Networking, Adult Education, World Education Culture, Modernization, International Standards, Educator Preparation, Educational Technology, Educational Impact, Curriculum Development, Sociocultural Issues",numberOfDownloads:613,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 10th 2020",dateEndSecondStepPublish:"July 1st 2020",dateEndThirdStepPublish:"August 30th 2020",dateEndFourthStepPublish:"November 18th 2020",dateEndFifthStepPublish:"January 17th 2021",remainingDaysToSecondStep:"7 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Prof. Lee Waller completed a Ph.D. in Higher Education Administration from the University of North Texas, he spent 17 years in the American community college system and served for 9 years at Texas A&M University-Commerce before joining the AURAK family.",coeditorOneBiosketch:"Dr.Sharon Waller spent 13 years at a Sherman Independent School District where she served as an educational diagnostician, curriculum coordinator, and teacher, her teaching and research focus on special education, strategic educational leadership, and effective assessment of student learning.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"263301",title:"Dr.",name:"Lee",middleName:null,surname:"Waller",slug:"lee-waller",fullName:"Lee Waller",profilePictureURL:"https://mts.intechopen.com/storage/users/263301/images/system/263301.png",biography:"Prof. Lee Waller completed a Ph.D. in Higher Education Administration from the University of North Texas. He earned his BS in Education and MS in Mathematics from Stephen F. Austin State University in Nacogdoches, Texas. Prof. Lee spent 17 years in the American community college system and served for 9 years at Texas A&M University Commerce before joining the AURAK family. Prof. Waller’s teaching and research focus on digital learning, strategic educational leadership, and effective assessment of student learning. Prof. Waller was recently awarded (2014) the Effective Practice Award for Excellence in the Utilization of Emerging Technology by the Online Learning Consortium (formerly Sloan-C). He was also awarded (2012) the Excellence in Teaching Award by Sigma Alpha Pi, The National Society of Leadership and Success.",institutionString:"American University of Ras Al Khaimah",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:{id:"263302",title:"Dr.",name:"Sharon",middleName:null,surname:"Waller",slug:"sharon-waller",fullName:"Sharon Waller",profilePictureURL:"https://mts.intechopen.com/storage/users/263302/images/system/263302.png",biography:"Dr. Sharon Waller completed a Ph.D. in Special Education from the Texas Woman’s University in Denton, Texas. She earned her Master of Education in Special Education from the University of North Texas and her BBA from Texas Woman’s University. Both institutions are located in Denton, Texas. Dr. Sharon spent 13 years a Sherman Independent School District where she served as an educational diagnostician, curriculum coordinator, and teacher. She joined the AURAK family as Manager of Counseling, Testing, and Disability Services in 2105. Dr. Waller’s teaching and research focus on special education, strategic educational leadership, and effective assessment of student learning.",institutionString:"American University of Ras Al Khaimah",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:null},coeditorTwo:{id:"299343",title:"Dr.",name:"Vongai",middleName:null,surname:"Mpofu",slug:"vongai-mpofu",fullName:"Vongai Mpofu",profilePictureURL:"https://mts.intechopen.com/storage/users/299343/images/system/299343.jpg",biography:"Dr. Vongai Mpofu is a seasoned Science teacher educator with a strong background in school leadership and science teaching. She holds a Ph. D. in Science Education from the University of Witswatersrand in South Africa and have twelve years of University teaching experience at Bindura University of Science Education (BUSE). She joined University service at BUSE with a wealth of experience of heading several high schools in Zimbabwe. She has been in university leadership as a chairperson of the Department of Science and Mathematics Education as well as the acting Dean of the Faculty of Science Education. Dr. Vongai has a good record for teaching, research, and community engagement as well as qualities of good leadership. She is also engaged in journal editorship and peer reviews. She is actively involved in research and leadership related events inclusive of presenting conference papers and facilitating in research and leadership events. Her school management experiences have been enhanced by several professional development courses in leadership she has attended.",institutionString:"Bindura University of Science Education",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Bindura University of Science Education",institutionURL:null,country:{name:"Zimbabwe"}}},coeditorThree:{id:"324485",title:"Dr.",name:"Mercy",middleName:null,surname:"Kurebwa",slug:"mercy-kurebwa",fullName:"Mercy Kurebwa",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002x7lPRQAY/Profile_Picture_1592997052286",biography:"Mercy Kurebwa is a Full Professor in Education. She is a goal-getter, hardworking and committed individual who has worked as a teacher in the Primary schools and a Senior Assistant Registrar, Registrar and Lecturer in Universities. Her work experience spans over 34 years. Currently, she is working in the Zimbabwe Open University’s Faculty of Education and Department of Educational Studies teaching courses in Educational management at both Bachelors and Masters levels. Mercy Kurebwa holds a Certificate in Education (Morgenster Teachers College), Bachelor’s Degree in Educational Administration, Planning and Policy Studies and a Master’s Degree in Administration, Planning and Policy Studies (University of Zimbabwe) and a Doctor of Philosophy Degree in Education (Zimbabwe Open University). Mercy Kurebwa has published 53 journal articles and has also presented over 20 papers at local and international conferences. The focus of the publications and presentations was on Assessment, Open and Distance Learning (ODel), Early Childhood Education, issues in schools, leadership and a few social issues. Mercy supervises Doctorate candidates, participates in university committees; has written and reviewed modules, reviewed journal articles and is an internal and external examiner for Doctorate candidates. 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As in any domestic setting, the safety and quality of food served in a hospice depend on the kitchen design, storage conditions, and food preparation practices of the food handlers. Micro-organisms in such areas can become airborne when droplets are generated while cleaning, cooking, preparing food, speaking, coughing, sneezing or vomiting. Most residential and hospice kitchens do not normally use air-filtration systems as it is the situation in hospitals. This means that the principal factors governing the levels of airborne particles indoor are: indoor sources, outdoor particle levels, the deposition rate of particles on indoor surfaces, and the air exchange rate (Nazaroff, 2004). Exposure of building occupants to certain micro-organisms, and elevated concentrations of environmental organisms, could result in allergenic reactions, irritant responses, toxicosis, respiratory illness and other ill effects.
\n\t\t\tThis is especially important in a hospice environment that accommodates patients with compromised immune systems due to infection with the human immunodeficiency virus (HIV). Tuberculosis (TB) is an archetypal example of a disease that is transmitted by airborne route. Primary pulmonary TB is caused by the inhalation of droplet nuclei carrying the causative agent, Mycobacterium nuclei (MTB). For hardy bacteria such as mycobacterium TB, only a single organism is needed to cause disease (Haas, 2006). TB acts synergistically with HIV and increases the risk of primary TB infection developing into the active disease by a hundred fold (Davies, 1999). The world-wide occurrence of TB is high, with approximately one third of the world’s population thought to be infected with MTB (Miller, 1996). Globally, TB is estimated to cause the deaths of three million people annually, and this figure is predicted to rise to five million by the year 2050 (Davies, 1999). Nosocomial infections similar to TB are a very real problem in healthcare facilities, with approximately one in 10 patients acquiring an infection during a hospital stay (Schulgen, et al., 2000).
\n\t\t\tAlthough most nosocomial infections are generally associated with person-to-person contact, evidence is mounting that they are mostly transmitted via aerosol route. Unlike formal healthcare facilities that generally boast air filtration systems, informal healthcare facilities like hospices have none. With patients suffering from a plethora of diseases associated with a compromised immune system, contaminated air only serves to aggravate the problem. It is therefore essential at these establishments to limit the prevalence of food-borne and airborne causative agents in the food preparation areas and through preventative measures limiting the chances for secondary infections. Therefore, the aim of this study was to quantify the microbial load of indicator microorganisms and associated environmental factors in the air (outside and inside) of a typical hospice environment. Subsequently, the relationship between environmental factors and microbial concentration was established and compared with normal breathable air in the same environment. It is expected that minimising food-borne contaminants associated with aerosols in HIV/AIDS hospices will improve the safety of food, being a considerable contributor to the food-borne contamination levels. It is envisaged that this study will contribute to the scientific knowledge of microbial contaminants associated with HIV/AIDS hospices in South Africa.
\n\t\tSamples of breathable air were collected at ten registered hospices in two provinces in central South Africa, namely the Eastern Cape and Free State. The sampling campaigns were conducted during the southern-hemisphere winter (dry months, April-September). Samples were collected in duplicate at each hospice in the morning (before and after food preparation) and also at lunchtime (before and after food preparation), both inside and outside the hospice kitchen for both sessions.
\n\t\t\tAll microbial samples were collected 1.5 metres above the floor on 65 mm RODAC plates by means of impaction on soft agar. The (SAS) Super-90 surface air sampler (PBI International, Milan, Italy) was used for this purpose. The air sampler was calibrated at an airflow rate of 0.03 m3.min-1 and all detachable parts were sterilised with 70% ethanol before use and between sampling runs (Venter et al., 2004). Plate count agar (PCA) was used for the isolation of total viable aerobic count (Merck, SA). Samples were then placed in a cooler box and immediately transported to the laboratory. Subsequent incubation of the plates was done at temperatures of between 25 and 37 °C for periods ranging from 24 to 72 hours. All colonies were enumerated using the positive hole correlation method and expressed as colony-forming units per cubic meter of air sampled. Subsequent replica plating was performed using a replica plating device and sterile velveteen cloth to quantify the following micro-organisms: Staphylococcus aureus, Pseudomonas spp., Bacillus spp., coliform and total coliform.
\n\t\t\tAssessment of the kitchen design and setting was done by means of visual observations and note taking. Simultaneous observation of safe food handling and storage practices was also conducted. (See table 2.1)
\n\t\t\tThe extrinsic environmental factors capable of influencing the survival of micro-organisms, i.e. temperature (area heat stress monitor, Questemp, SA) and relative humidity (whirling psychrometer, Airflow Instrumentation, SA), were measured, as were the factors that could influence the distribution of the assessed microbiota (Chang, et al., 2001), namely airflow (airflow anemometer – LCA 6000 VT, Airflow Instrumentation, SA) and airborne particle (dust) concentrations (hand-held aerosol monitor - 1005/1060, PPM Enterprises, Inc) (Venter, et al., 2004). Positive and negative controls were included and all analysis and assays were repeated at least in duplicate according to Venter, et al., (2004).
\n\t\t\tThe results obtained from the technical investigations are presented in Table 1. From this, it is apparent that most hospices with the exception of a few e.g. Ons plek and Bethlehem, complied with the requirements of good preparation and handling practices of food.
\n\t\t\t\t\n\t\t\t\t\t\t\t\tOccurrence\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t%\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\t|
\n\t\t\t\t\t\t\t\tKitchen facility design\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t | |
Ceiling | \n\t\t\t\t\t\t\t60 | \n\t\t\t\t\t\t|
Ventilation through natural moving air | \n\t\t\t\t\t\t\t60 | \n\t\t\t\t\t\t|
Air bricks with filters | \n\t\t\t\t\t\t\t50 | \n\t\t\t\t\t\t|
\n\t\t\t\t\t\t\t\tFood handling practices\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t | |
Cleanliness/neatness of the food handler | \n\t\t\t\t\t\t\t70 | \n\t\t\t\t\t\t|
Wearing of suitable protective clothing | \n\t\t\t\t\t\t\t50 | \n\t\t\t\t\t\t|
Availability of hand washing facilities | \n\t\t\t\t\t\t\t60 | \n\t\t\t\t\t\t|
Storage space for hygienic storage of food | \n\t\t\t\t\t\t\t50 | \n\t\t\t\t\t\t|
Availability of easy to clean refuse containers | \n\t\t\t\t\t\t\t50 | \n\t\t\t\t\t\t|
Regular washing of hands before/after food preparation | \n\t\t\t\t\t\t\t60 | \n\t\t\t\t\t\t|
\n\t\t\t\t\t\t\t\tOverall cleanliness of the kitchen\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t | |
Environment conducive for cooking/preparing food | \n\t\t\t\t\t\t\t50 | \n\t\t\t\t\t\t
*The percentages and right hand values represent the level of conformance to Regulation 918 amongst all the hospices sampled (n=10).
Kitchen facility design and food handling practices in hospices around Central South Africa.
The lack of air filtration systems due to financial constraints, may have contributed to the presence of bio-aerosol indoors. The majority of the investigated kitchens were also not designed to provide required barriers against moisture, temperature, pests, dust and associated microbes. Therefore limited control over the quality and safety of the food stored under the noted conditions would be expected.
\n\t\t\tThe extrinsic factors that influence the viability and distribution of micro-organisms that prevail in various hospice kitchens are listed in figure 1. From these results, it is evident that on average, the hospice kitchens provide an environment that would sustain microbial viability concomitant to proliferation, given that a suitable substrate and sufficient time is available. The transport and the ultimate setting of a bio aerosol are affected by its physical properties and the environmental parameters that it encounters. These physical characteristics are size, density, and shape of droplets or particles; the environmental factors include magnitude of a relative humidity and temperature, which determine the capacity to be airborne. Bioaerosols generated from suspensions undergo desiccation, whereas those generated as dusts or powders partially rehydrate. The presence of moulds as an example indicates a problem with water penetration or high humidity indoors (Goel and Goel 2009).
\n\t\t\t\tThe persistence of micro-organisms, the presence and density of pathogens and the potential spread of microbial contamination from contaminated food in the household Kitchen have been extensively studied and re-examined. These studies indicated that domestic kitchen sites have been found to be repeatedly contaminated with a variety of bacterial contaminants, including Listeria monocytogens (Beumer, et al., 1996), Escherichia coli and Enterobacter cloacae (Speirs, et al., 1995). It is well known that dampness and other excess moisture accumulation in buildings are closely connected to observation of mould, mildew, or other microbial growth. Microbial growth has also been associated with building characteristics. In residences measures of microbial contamination have been found to be positively correlated with indoor temperature and humidity, age and size of buildings, use of wood stoves and fireplaces and absence of mechanical ventilation (Dharmage, et al., 1999). From this study it became evident that the evaluated kitchens boasted levels of relative humidity of 60 ± inside as compared to the average of 40 ± outside.
\n\t\t\t\tThe relative humidity (RH) in one of the hospices was 100% and the dominant bacterial specie was Bacillus cereus, therefore showing an increase associated with an increase in RH. The average temperatures were below 20 °C outside and 15 °C inside (Figure 2); hence the prevalence of Pseudomonas\n\t\t\t\t\taeruginosa (Fig 1) due to their ability to survive at low temperatures (Forsythe, 2000). The average airflow for the assessed kitchen was 0.4 m.s-1 outside compared to the average of 0.2 m.s-1 inside. It is also interesting to note that the low airflow inside correlated with a high concentration of airborne particulates inside which was 8.04 mg.m-3.
\n\t\t\tThe presence of undesirable bio-aerosols is often associated with sick building syndrome (SBS) and building-related illnesses. Sources include furnishing and building materials, fungal contamination within wall and gaps at structural joints (Jay, 2000). Inadequacies in the building design and improper ventilation may contribute to poor indoor air quality. For purposes of this study, micro-organisms indicative of poor food manufacturing practices are defined as indicator organisms. In the formal food industry, the presence of Escherichia\n\t\t\t\t\tcoli is indicative of faecal contamination, while the presence of Staphylococcus\n\t\t\t\t\taureus points to extensive human handling, and total viable aerobic organisms is a sign of poor process hygiene. The presence of these organisms in the breathable air of the various hospice kitchens could also be attributed to the aforementioned practices, as food processing is the core business of the kitchens in this setting.
\n\t\t\t\tThe Environmental factors quantified outside (1) and within (2) hospice kitchens
In this scenario, the presence of E.\n\t\t\t\t\tcoli could be due to faecal contaminants from the hands of food handlers, or from contaminated working surfaces and utensils. Therefore, it is of the utmost importance to observe proper personal hygiene, particularly with regard to hand-washing after visiting the toilet, in order to prevent contamination. However, three of the hospices that were investigated are without hand-washing facilities and are located in rural areas. As noted in figure 1 the average airborne particulates were 7.90 mg.m-3 inside as compared to 8.0 mg.m-3 outside. These results are comparable to those observed by Hargreaves et al., 2003. The presence of Bacillus spp was also noted in the presence of these conspicuous airborne particulates which were dominant throughout the sampling period. This could be due to the fact that these are spore formers and bacteria in many cases are attached to larger airborne particles.
\n\t\t\t\tAccording to Moir et al., 2002 these spores can endure a wide range of extreme environmental stresses while retaining the capacity to return to vegetative growth almost immediately once the nutrient returns to the environment. It was therefore assumed that airflow in and outside the hospice kitchens were sufficient to carry dust particles as well as different bacterial population (Figure 1). In general, the average bacterial counts varied between 1 x 101 to 1x 102 cfu.m-3. Compared to the literature these counts were fairly low and apart from being possible allergens they are also associated with decreased lung function, increased respiratory symptoms such as cough, shortness of breath and asthma attacks (WHO, 2002). From the observed results it is apparent that the kitchens in question boast a resident bio-aerosol population that is not significantly influenced by the noted environmental parameters. Though the source of the bio-aerosols assayed is not clear, S.\n\t\t\t\t\taureus probably results from aerosols dispersed by the food handlers in the kitchens. It should also be noted that although microbial counts were low, the kitchens provided an environment conducive to microbial survival as aerosolised particles and subsequently as food contaminants. In general the kitchens had a lower temperature, increased RH, and higher airborne particle count.
\n\t\t\tIndoor air pollution is usually caused by the accumulation of contaminants from various indoor sources. The generation of pollutants within the indoor environment may come from primary sources such as fuel combustion for cooking, as well as emissions from fireplaces, stoves, cleaning products and chemicals stored in the home. It is therefore safe to assume that since all these factors were present at the study sites, they all contributed to the indoor air pollution discovered. Factors such as heating, ventilation, air-conditioning and household activities, e.g. cooking and cleaning, all play a crucial role in the wellbeing of a building’s occupants. In a setting such as a hospice, where proper food storage and handling is not always possible due to lack of infrastructure, it is essential that special care is taken regarding the type of food stored and the packaging material used. Micro-organisms detected in the indoor air of the hospice kitchens included in this study could be derived from the hospice occupants, but may also emanate from the outside environment. One such example would be Bacillus cereus, which is a common air- and dust-borne contaminant that readily multiplies in meat products. These organisms are able to withstand unfavourable conditions such as low temperature and heat due to their ability to form spores (Whyte et al., 2001). A study by Nel et al., 2003, reported rapidly increasing levels of B. cereus when a product was exposed to poor handling and processing procedures. A hospice, where patients are provided with accommodation, food and care, would be a typical example of this setting.
\n\t\t\tFrom the results it can be concluded that certain food preparation and storage facilities in the hospices studied are, according to the technical data, not suitable for this purpose. However, it appeared that some of the extrinsic factors influencing microbial viability were being governed. Specific attention should be given to the upgrading of the kitchen infrastructure – for example, it would be ideal to have separate rooms for the preparation of raw and cooked food, as well as a room used only for food storage purposes. The results presented in this chapter further identified the hospice occupants as possible sources of the organisms found in the hospice kitchens and surrounding environments, since the occupants were in some cases also responsible for preparing the food, while moving continuously between the kitchen, bathroom and bedroom. In terms of residency, it would thus be ideal to separate the patients from the food preparation facilities, including the kitchen.
\n\t\t\tCompanies that regularly donate food to the hospices are further cautioned to avoid donating foodstuffs that are past their sell-by date, as the inability of the assessed kitchens to control humidity fluctuations only exacerbates the problem with regard to food safety and proliferation of microbial load. It was further noted that in South Africa, unlike in more humid countries, the facility design and geographical localisation have a limited effect on the resident bio-aerosol profiles. In order to address and verify the concerns raised in this chapter, it is recommended that the ability of micro-organisms to proliferate on the foods (high-risk) provided to the hospices should be assessed and the menus adjusted in accordance to season- associated changes in the extrinsic factors that would influence microbial viability and growth. It should further be noted that the occupants of the hospices concerned have very little knowledge of proper food storage and handling practices and are to a large extent not aware of the threats posed to them by the resident microbiota. This problem could be alleviated by providing the patients and food handlers with educational training in respect of proper food safety (storage and handling).
\n\t\tDue to a lack of empirical data, aerosol transmission of influenza is often questioned and its relationship with other airborne microbiota such as bacteria and fungi still requires further research to establish their impact on food and people indoors (Blachere et al., 2007).
\n\t\tAcquired immune deficiency syndrome (AIDS) is a disease caused by a retrovirus known as human immunodeficiency virus (HIV) [1]. HIV/AIDS remains one of the world’s most significant public health challenges, particularly in low- and middle-income countries [2]. Children constitute a segment of the population affected by the virus. HIV contributes to illness and death of children and is the commonest cause for pediatric hospital admission [3].
\nOf the total 1.8 million children living with HIV, an estimated 110,000 die of AIDS-related illnesses each year which means 290 children die of AIDS-related illnesses every day. Nearly 90% of HIV-infected children live in sub-Saharan Africa (SSA) [4]. In Ethiopia it is estimated that 65,088 children are living with HIV. In 2016, over 3100 children died due to AIDS-related illness [5].
\nThe introduction of antiretroviral therapy (ART) presented an enormous opportunity in terms of reducing morbidity and mortality due to AIDS, worldwide. Ethiopia has been engaged in the scale-up of ART access to its people since 2005 [6]. It has been shown that the improvement in access to ART improves the quality of life and survival of children [7, 8].
\nStudies show that early access to ART could prevent 25% of HIV-related deaths [7, 8, 9]. Therefore, to reduce child mortality attributed to HIV/AIDS, the provision of comprehensive treatment, care, and support for HIV-infected children is very important.
\nEthiopia has adopted the World Health Organization’s (WHO) recommendations for ART where “regardless of their CD4 cell count, all HIV-infected individuals should start treatment to reduce morbidity and mortality associated with HIV infection” [3]. The number of sites providing ART service in Ethiopia, including both public and private facilities, has increased from 3 to over 1000, and persons initiated on treatment has increased from 24,000 to 308,000 during the period 2006–2016 with more than 23,400 children under the age of 15 taking antiretroviral drugs [10].
\nSurvival of HIV-positive children in Ethiopia and other similar settings has improved as a result of increased access to ART; however, it is still low in the first 6 months after initiation of ART [11]. Reports from Kenya, Zambia, and Malawi show that death among HIV-positive children following ART initiation remains high, ranging from 7.5 to 15% [12, 13, 14]. This contrasts the substantially higher survival probability among HIV-positive children initiated on ART in developed countries [15]. Findings from other studies elsewhere in Africa and other low-income countries show that ART programs have resulted in decreased mortality among children on ART [16, 17, 18]. Available evidences also depicted that the survival of the children is not only affected by the care delivered by ART programs but also more fundamentally influenced by low CD4 count, advanced disease according to WHO staging, low hemoglobin (Hgb) level, and opportunistic infections (OIs) like bacterial pneumonia and tuberculosis [19, 20, 21]. However, as far as our search of the available literature has revealed, little is known about the effect of factors like viral load, nutritional status, co-trimoxazole (CTZ) preventive therapy (CPT), and isoniazid (INH) preventive therapy (IPT) on survival status of children below 15 years of age. Therefore, this study intended to estimate the survival time and identify associated factors by including viral load, nutritional status, CPT, and IPT among HIV-infected children initiated on ART in public health facilities in Arba Minch town, Southern Ethiopia.
\nStudy area and period: We conducted the study in Arba Minch town from March 20, 2017 to April 10, 2017. Arba Minch town is located about 495 km southwest of the capital city Addis Ababa and about 275 km from Hawassa, the capital of the Southern Nations, Nationalities, and Peoples’ Region (SNNPR). Arba Minch town has one general hospital and one public health center, which provide ART service. Arba Minch Hospital was among the first few public hospitals to start ART in Ethiopia in August 2003. Arba Minch Health Center started ART service at the end of 2007. According to the Gamo Gofa Zone Health Department (ZHD) report, the Arba Minch Hospital and Arba Minch Health Center provide HIV/AIDS interventions, including free diagnostic, treatment, and monitoring services. Since August 2003, ART has been provided to children living with HIV regardless of CD4 count and WHO clinical stage, with financial support from the Norwegian Lutheran Mission. Data from ZHD show that a total of 664 children with HIV/AIDS were enrolled on chronic HIV care at the hospital and the health center since January 2009, but only 608 started ART (460 children at Arba Minch General Hospital and 148 children at Arba Minch Health Center) [22].
\nStudy design: A health facility-based retrospective cohort study.
\nSource populations: All children living with HIV who were enrolled on first-line ART at the center.
\nStudy populations: All children living with HIV who were enrolled on first-line ART at the center and who fulfill the inclusion criteria.
\nInclusion criteria: Those who were aged <18 years and enrolled on first-line ART and have follow-up at Arba Minch General Hospital and Health Center.
\nSample size determination: The sample size was calculated by applying a two-population proportion formula using Epi-Info version 7. Co-trimoxazole preventive therapy, tuberculosis (TB) co-infection at baseline, and anemia were considered, and taking the most significant predictors of the three variables, anemia was used [17] with the following assumptions: 95% CI, power 80%, ratio of unexposed to exposed 1:1, parameter outcome in exposed hemoglobin (Hgb) < 10 gm/dl = 14.7%, outcome in unexposed Hgb ≥ 10 gm/dl = 5.8%, and hazard ratio (HR) = 2.5. This resulted in sample size of 412 children. As there were a total of 421 children in the study area who fulfilled the inclusion criteria, we included all 421 in this study.
\nSampling procedure and sampling technique: A total of 608 children who started ART during the study period were identified in the two ART clinics. Charts were organized according to the hospital card number, in a chronological order, with each chart representing one child. As some of the charts in the hospital were not arranged in numerical order, the investigator assigned new numbers for all those registered between 2009 and 2016, starting from 1 to 608. Of these, the investigator drew 421 samples which fulfilled the inclusion criteria after reviewing the information transcribed to the pre-structured data abstraction form; 187 individuals did not fulfill the inclusion criteria; therefore, those charts were excluded from the study. Children ≤14 years of age and on ART registered for chronic care at public health institutions of Arba Minch town from 1 January 2009 to 30 December 2016 were included in the study. Those whose cards were incomplete with information on baseline CD4 count, WHICH staging and date of ART start and current status were excluded from the study.
\nDependent variable: The response (outcome) variable in this study was “survival time” of HIV-infected children after starting ART.
\nIndependent variables: The predictor variables included five continuous covariates (age, hemoglobin level, weight, height, and CD4 count) and nine categorical variables (gender, co-trimoxazole prophylaxis, TB co-infection status, isoniazid prophylaxis, functional status, clinical stage of the disease according to WHO scaling, type of ART drug, adherence to ART, and year of ART initiation).
\nCensored: includes lost to follow-up, transfer out, and live beyond the study time.
\nAdherence to ART: assessed by counting the number of tablets the children miss within the first 3 months after starting ART.
\nSurvival: absence of experience of death.
\nSurvival time: the length of time in months a child was followed up from the time the child started ART until death, was lost to follow-up, or was still on follow-up.
\nA structured interviewer-administered questionnaire was used to collect the data [23, 24, 25]. The questionnaire was primarily developed in English and then translated into Amharic language for simplicity of data collection. Then Amharic version was also back-translated to English language for its consistency by two different language experts. The data collection tool has four sections. Pretesting of the data collection tool was done on 17 individuals who were selected from Berber Health Center that were not included in the actual study. Based on the pretest, a data collection tool was corrected to ensure logical sequence, clarity, and skipping patterns. Data was collected by eight trained health professionals and supervised by two bachelor degree health professionals. All data collectors and supervisors were trained for 2 days and performed practical exercises to be familiar with the questionnaire. Exit interview was done. The participants’ weight was measured in kilograms with 0.2 kg increments using standard beam balance, and the scale was checked at zero during measurement. The study participant was removing their heavy outer clothes and shoes. The participant height was measured using the standard measuring scale to the nearest 0.5 cm. The participants were asked to take off their shoes, stand erect, and look straight in vertical plain. The data collectors were regularly supervised for proper data collection as well as checked for completeness and consistency throughout data collection period.
\nData processing and analysis: The completeness and consistency of the data was checked, coded, and double entered into Epi-info version 7 and exported to Statistical Package for Social Sciences (SPSS) version 20 for analysis. Exploratory data analysis was carried out to check the levels of missing values and presence of influential outliers. Descriptive statistics such as mean (standard deviation), frequencies, and proportions were used to describe the characteristics of the cohort. Kaplan-Meier survival curve together with log-rank test was used to assess survival experience of an individual at specific times and to compare survival between different independent variables.
\nThe analysis was conducted in several steps. First, univariate Cox proportional hazard regression model was performed for each independent variable and outcome of interest to identify potentially significant variables for consideration in the multivariable Cox proportional hazards regression model. Based on the univariate analysis, variables were selected for the multivariable analysis. Variables whose univariate significance test results were below p-value <0.25 were included in the multivariable regression model. In addition, context and findings of previous studies were considered in the identification of candidate variables for multivariable analysis.
\nMultivariable analysis was started with a model containing all of the selected variables. The model was built through a stepwise regression procedure, which added variables successively (the most significant at each step) until no variable added significant information and compared by likelihood ratio test and Harrell’s concordance statistic test. Interactions and confounders were tested and the cutoff point of beta change greater than 20% was used. The results of the final model were expressed in terms of hazard ratio with 95% confidence intervals (CI) and interpreted accordingly. Kaplan-Meier survival curve together with log-rank test was used to check for the existence of any significant differences in survival between the various categories of variables considered in this study. Statistical significance was declared if the p-value was less than 0.05.
\nEthical considerations: Ethical approval was obtained from the ethical review committee of Arba Minch University, College of Medicine and Health Sciences, with reference number CMHS/4268/09. Following the approval, an official letter of cooperation was written to concerned bodies by the Department of Public Health of Arba Minch University. Permission was granted from the Hospital and Health Center Administration as per the recommendation letter from the department. Personal identifiers were excluded during data extraction; rather codes were used. Considering the study was being conducted on secondary data, obtaining informed consents from the participants was not possible. However, the confidentiality of information was maintained by not recording their name from the chart, and the recorded data were not accessed by a third person except by the principal investigator.
\nBaseline characteristics of the study participant: A total of 421 study participants (children under 15 years old) were included in the study. The sample is comprised of 241 (57.2%) males and 180 (42.8%) females. The ages of the cohort at ART initiation ranged from 3 to 168 months with a median age of 72 (IQR = 33–108) months. Based on WHO clinical staging, 196 (47%) children initiated ART at an advanced stage of the disease, i.e., WHO clinical stage III or IV. During the ART initiation, 139 (33%) children were affected by one or more opportunistic illness, of which 41 children were found to have died at the end of the study. Sixty (14.3%) had history of TB at the start of ART, and 36 died during the follow-up time. At the initiation of ART, mean (SD) value for weight of children was 18.6 (±9.65) kg, and mean (SD) value for height of the cohort was 110.8 (±32.19) cm. The baseline median value for Hgb was 10.9 (IQR = 8.8–12.3) g/dl, and 181 (43.1%) of the children had absolute CD4 count below threshold for immune deficiency at initiation of ART.
\nAmong the reviewed participants, 410(97.4%) were on first-line ART regimen, while the rest were started on second line. Concerning the type of ART regimens, around 61% of children were taking D4T-based drug regimens when they started the treatment (Table 1).
\nVariables | Categories | Frequency | Percent |
---|---|---|---|
Sex | Male | 241 | 57.2 |
Female | 180 | 42.8 | |
Age category | <1 year | 30 | 7.1 |
1–4 years | 169 | 40.1 | |
5–14 years | 222 | 52.7 | |
Primary caregiver | Parents | 268 | 63.7 |
Relatives | 119 | 28.3 | |
Guardian/orphan | 34 | 8.0 | |
Parental status | Both parents are alive | 260 | 61.8 |
Maternal orphan | 45 | 10.9 | |
Paternal orphan | 31 | 7.4 | |
Double orphan | 84 | 19.9 | |
WHO clinical staging at entry | Stage I | 91 | 21.6 |
Stage II | 135 | 32.1 | |
Stage III | 147 | 34.9 | |
Stage IV | 48 | 11.4 | |
TB at baseline | Yes | 60 | 14.3 |
No | 361 | 85.7 | |
Hemoglobin level at baseline | <10 gm/dl | 78 | 18.5 |
≥10 gm/dl | 343 | 81.5 | |
Absolute CD4 at baseline | CD4 above threshold | 239 | 56.9 |
CD4 below threshold | 181 | 43.1 | |
ART adherence status | Good | 335 | 79.6 |
Fair | 33 | 7.8 | |
Poor | 53 | 12.6 | |
CTZ prophylaxis | Yes | 314 | 74.6 |
No | 107 | 25.4 | |
INH prophylaxis | Yes | 302 | 71.7 |
No | 119 | 28.3 |
Demographic and clinical characteristics and chemoprophylaxis status among children on antiretroviral treatment at Arba Minch Hospital and Health Center, Southern Ethiopia, 2017.
After initiation of ART, children were followed up for a minimum of 1 and maximum of 95 months with median follow-up period of 50 (IQR = 24–80) months. At the end of follow-up, 261 (62%) of the children were alive, 43 (10.2%) were lost to follow-up, 52 (12.4%) were transferred out to other facilities, and 65 (15.4%) were reported dead. The overall mean estimated survival time after ART initiation of children in the study was 82.3 (95% CI = 79.48–85.14) months.
\nThere is a significantly different survival time between different factors considered in this study. Females have relatively lower survival time of 79.3 months than males with 84.6 months. Children 1–4 years of age had higher survival time of 86.8 months than those less than 1 and 5–14 years of age who had a mean survival time of 69.3 and 80.8 months, respectively.
\nThe overall Kaplan-Meier survivor function estimate showed that most of the deaths occurred in the earlier months of ART initiation, which declined in the later months of follow-up. Most of the graphs did not show differences between different categories. However, relatively larger gaps are observed in covariates such as WHO clinical stage, TB co-infection, low Hgb level (<10gm/dl), and CTZ and INH prophylaxes (Figures 1 and 2).
\nThe plot of the overall estimate of Kaplan-Meier survivor function among children on ART at public health facilities of Arba Minch town, Southern Ethiopia, 2017.
Survival curves for children on ART by WHO clinical stage, hemoglobin level, and TB co-infection after start on ART at public health facilities in Arba Minch town, 2017.
One important predictor of low survival time in univariable Cox regression analysis was advanced WHO staging. The risk of low survival chance in individuals with advanced disease according to WHO staging at baseline was nearly 4 times higher than that of those at the mild stage of the disease (P < 0.001). The risk of surviving a shorter time in individuals who had severe acute malnutrition (SAM) at baseline was nearly 2.5 times higher when compared to those with no malnutrition (P < 0.006). Patients with baseline opportunistic infections (OIs) survive nearly three 3 times shorter than those without OIs (P < 0.001), and children with TB co-infection were nearly 11 times more likely to survive shorter when compared to those without TB co-infection (P < 0.001). The risk of surviving at short duration was significantly higher with low hemoglobin level (CHR = 7.3, 95% CI = 4.47–11.9, P = 0.001) and CD4 count below the threshold (CHR = 1.7, 95% CI = 1.02–2.74, P = 0.041) when starting ART compared to their counterparts. CTZ and INH had preventive effect against surviving for short duration (CHR = 0.2, 95% CI = 0.10–0.27 P = 0.001) and (CHR = 0.1, 95% CI = 0.07–0.20 P = 0.001) when compared to their counterparts throughout the follow-up period, respectively (Table 2).
\nCovariate/factor | Categories | CHR | P-values |
---|---|---|---|
Sex | Male | ||
Female | 1.617 | 0.053* | |
Age group | <1 year | ||
1–4 years | 1.259 | 0.336 | |
5–14 years | 0.655 | 0.069* | |
Nutritional status | Normal | ||
Underweight | 1.903 | 0.010* | |
Anemia | No | ||
Yes | 2.702 | 0.001* | |
Absolute CD4 count | Above threshold | ||
Below threshold | 1.293 | 0.041* | |
INH prophylaxis | No | ||
Yes | 0.408 | 0.001* | |
CTZ prophylaxis | No | ||
Yes | 0.348 | 0.001* | |
ART adherence on follow-up | Good | ||
Fair | 6.256 | 0.001* | |
Poor | 5.937 | 0.001* | |
WHO clinical staging at entry | Stage I and II | ||
Stage III | 2.360 | 0.009* | |
Stage IV | 10.412 | 0.001* | |
Functional status | Working | ||
Ambulatory | 1.302 | 0.350 | |
Bedridden | 1.375 | 0.392 | |
ART regimens at entry | D4t-based regimen | 0.294 | 0.420 |
AZT-based regimen | 0.513 | 0.290 | |
TDF-based regimen | 0.562 | 0.404 | |
Second-line ART | |||
Evidence of TB during follow-up | Yes | 1.383 | 0.050* |
No |
Univariable Cox regression analysis of sociodemographic characteristics and clinical and immunological status among children who were started on ART at public health facilities of Arba Minch town, 2017.
Note: CTZ, Cotrimoxazole; ART, antiretroviral therapy; INH, isoniazid; TB, tuberculosis; OI, opportunistic Infections, *p < 0.25 which are candidate for Multivariate Cox regression model.
In multivariable Cox regression analysis, children with CD4 count below threshold for immunodeficiency at ART initiation were 2.3 times (AHR = 2.26, 95% CI = 1.32–3.88, P = 0.003) more likely to survive at shorter duration as compared to those with CD4 count above threshold. Children with low weight for age (underweight) at ART initiation were almost 4 times (AHR = 4.1, 95% CI = 2.41–6.9, P = 0.001) more likely to survive at shorter duration as compared to those with normal weight. Children that were presented for treatment with fair ART adherence and poor ART adherence were on follow-up 3.4 times (AHR = 3.4, 95% CI = 1.66–6.9, P = 0.001) and 3.3 times (AHR = 3.3, 95% CI = 1.73–6.23, P = 0.001) and more likely to survive at shorter duration, respectively, as compared to those with good adherence on follow-up. Estimated AHR for children on INH prophylaxis and CTZ prophylaxis were 0.4 (95% CI = 0.21–0.65, P = 0.001) and 0.3 (95% CI = 0.14–0.44, P = 0.001); short duration survival hazard among children who took INH prophylaxis was 63% and CTZ prophylaxis 75% (Table 3).
\nCovariate | Categories | AHR | P-values |
---|---|---|---|
Nutritional status | Normal | 1 | |
Underweight | 4.08 | 0.001 | |
Absolute CD4 count | Above threshold | 1 | |
Below threshold | 2.26 | 0.003 | |
INH prophylaxis | No | 1 | |
Yes | 0.37 | 0.001 | |
CTZ prophylaxis | No | 1 | |
Yes | 0.25 | 0.001 | |
ART adherence on follow-up | Good | 1 | |
Fair | 3.39 | 0.001 | |
Poor | 3.28 | 0.001 |
Multivariable Cox regression analysis of sociodemographic characteristics and clinical and immunological status among children on ART at public health facilities of Arba Minch town, 2017.
In this study the overall mean survival time was 82.3 months (95% CI: 79.48–85.14). The cumulative probability of survival of children on ART was 82.9% after 5 years (95% CI: 78.2%–86.7%). The major factors that affect the survival time of children with HIV/AIDS and on ART are nutritional status, absolute CD4 count below threshold, and poor/fair adherence to ART. Isoniazid prophylaxis and co-trimoxazole prophylaxis were preventive factors.
\nMean survival time in our cohort was 82.3 months (95% CI = 79.48–85.14). This was in line with the finding of a study conducted in Southwest Ethiopia [83 months (95% CI = 79–87)] [26]. However, our finding was higher when compared with study conducted in Northwest Ethiopia, which reported a survival time of 56.5 months [20]. This difference might be associated with the high proportion (74.3%) of children in this study taking CTZ prophylaxis as compared to the finding of the study conducted in Northwest Ethiopia (52.3–70.4%), and the difference might also be associated with increased access to ART services.
\nThe cumulative probability of survival of children on ART in our study was 82.9% after 5 years (95% CI: 78.2–86.7%). This was comparable with the report of a study conducted in Felege Hiwot Referral Hospital, Bahir Dar, Northern Ethiopia (83%) [27] and another one in Northwest Ethiopia (83%) [20]. However the cumulative survival probability from our study was much lower than that of the reports from Adama Referral Hospital and Medical College, Central Ethiopia (91.6%) [19], and Wolaita zone health facilities, Southern Ethiopia (92%) [20]. These variations between our study and those from central and Southern Ethiopia may have something to do with the variation in the quality of care provided at different institutions.
\nIn this study we found that having CD4 cell count below the threshold level was significantly associated with an increased probability of having short duration of survival among the children. This concurs with the findings of different studies previously done in Ethiopia [20, 28]. The similarity might be related to the fact that children, in our series, with absolute CD4 counts below the threshold level are more prone to OIs like TB. Another possible explanation could be ART was initiated in an advanced HIV stage (stages III and IV) where immunity of the children was already compromised.
\nAnother covariate that had a significant effect on survival time was adherence to ART. The HR for poor adherence was 2.1 times, and the HR for fair adherence was 2.2 times more likely to result in short duration of survival compared to children with good adherence. This finding was supported by studies conducted in Northwest Ethiopia [28] and Wolaita zone health facilities [20]. The poor adherence might be due to insufficient counseling and education of caregiver/patient.
\nThe initiation of CTZ and INH at the start of ART in our cohort was associated with a longer duration of survival. This finding concurred with that of the studies conducted in Felege Hiwot Referral Hospital, Northern Ethiopia [20], and rural Mozambique [29]. The possible reason for higher risk of shorter survival time among children who did not receive CTZ at ART initiation could be due to occurrence of OIs such as Pneumocystis pneumonia, toxoplasmosis, bacterial pneumonia, sepsis, and diarrhea. Co-trimoxazole prophylaxis should be given at the initiation of ART to reduce OI and associated short duration survival among HIV-positive children on ART, thereby improving their survival.
\nThe hazards of short survival time for children on INH prophylaxis was 0.38, which means that, in those children who take INH prophylaxis, the hazard of short duration of survival was reduced by 62%. This finding corroborates the finding of the study conducted in Mizan-Aman General Hospital, in Southern Ethiopia [26], and that of a double blinded, placebo-controlled trial on INH efficacy among HIV children infected in Cape Town, South Africa [30]. A possible reason could be INH prophylactic therapy (IPT) prevented the occurrence of TB.
\nThere are some strengths and limitations of this study. The strengths of this study are the use of standard measurements which enabled to make the comparison of findings with other national and international literatures to be valid. In addition, considering long duration of follow-up period of children on ART and the inclusion of important predictors like CTZ, INH and nutritional status also add to the strength to this study. Since our study is retrospective based on available records, excluding those with incomplete information, survival time might be underestimated.
\nIn general, this study showed that the probability of survival of children on ART was 73.9% after 96 months and the overall mean survival time was 82.3 months. The main independent predictors of the survival time were nutritional status, absolute CD4 count below threshold, poor/fair adherence to ART, and absence of INH prophylaxis and CTZ prophylaxis. However, sex, age, advanced disease according to WHO clinical stage, and presence of TB at baseline were not predictors of survival time. Therefore, children living with HIV should be encouraged to take prophylaxis drugs like CTZ and INH. This could be achieved by collective efforts of all concerned bodies on high-risk groups such as children with OI especially TB after initiation of ART and a careful monitoring and follow-up of the children.
\nWe would like to say thank you very much to the health facilities administrator of the hospital and health center, health professionals, and data collectors who contributed to this work.
\nThe authors declare that there was no competing interest in connection to this research and its result.
NB conceived and designed the study, developed data collection instruments, and supervised data collection. NB and SH participated in the testing and finalization of the data collection instruments and coordinated study progress. NB and SH performed the statistical analysis; SH wrote all versions of the manuscript. All authors read and approved the final manuscript.
\nART | antiretroviral therapy |
AHR | adjusted hazard rate |
AIDS | acquired immune deficiency syndrome |
CPT | co-trimoxazole preventive therapy |
FMOH | Federal Ministry of Health |
HIV | human immune virus |
NNRT | nonnucleated reverse transcripts |
SAM | severe acute malnutrition |
UNICEF | United Nations Children’s Fund |
WHO | World Health Organization |
IntechOpen implements a robust policy to minimize and deal with instances of fraud or misconduct. As part of our general commitment to transparency and openness, and in order to maintain high scientific standards, we have a well-defined editorial policy regarding Retractions and Corrections.
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\\n\\n1. RETRACTIONS
\\n\\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
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\\n\\nPublishing of a Retraction Notice will adhere to the following guidelines:
\\n\\n1.2. REMOVALS AND CANCELLATIONS
\\n\\n2. STATEMENTS OF CONCERN
\\n\\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\\n\\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\\n\\n3. CORRECTIONS
\\n\\nA Correction will be issued by the Academic Editor when:
\\n\\n3.1. ERRATUM
\\n\\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\\n\\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n3.2. CORRIGENDUM
\\n\\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n4. FINAL REMARKS
\\n\\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\\n\\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\\n\\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\\n\\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\\n\\nPolicy last updated: 2017-09-11
\\n"}]'},components:[{type:"htmlEditorComponent",content:'IntechOpen’s Retraction and Correction Policy has been developed in accordance with the Committee on Publication Ethics (COPE) publication guidelines relating to scientific misconduct and research ethics:
\n\n1. RETRACTIONS
\n\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\n\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\n\nPublishing of a Retraction Notice will adhere to the following guidelines:
\n\n1.2. REMOVALS AND CANCELLATIONS
\n\n2. STATEMENTS OF CONCERN
\n\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\n\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\n\n3. CORRECTIONS
\n\nA Correction will be issued by the Academic Editor when:
\n\n3.1. ERRATUM
\n\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\n\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n3.2. CORRIGENDUM
\n\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n4. FINAL REMARKS
\n\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\n\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\n\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\n\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\n\nPolicy last updated: 2017-09-11
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