Abstracts of Poster Presentations Thursday, 19th of ...

© The Author(s) 2019. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.

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Trans R Soc Trop Med Hyg 2019; 113: S199–S245doi:10.1093/trstmh/trz090 Advance Access publication 16 September 2019

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Abstracts of Poster PresentationsThursday, 19th of September 2019

P330

PREVALENCE, HIV CO-INFECTION AND MULTI-DRUG RESIS-TANCE OF SMEAR POSITIVEPULMONARY TUBERCULOSIS INPRISON SETTINGSOF NORTHWEST ETHIOPIA

Gebrecherkos T., Belay T., Baye G.Dept. of Medical Microbiology, School of Biomedical and LaboratorySciences, University of Gondar, Gondar, Ethiopia

Introduction: In correctional settings tuberculosis is a public health con-cern in Ethiopia where there is no medical screening during admission.The incarcerated population is at greater risk for tuberculosis (TB) thanthe general population.Aim: The aim of this study was to determine the prevalence, HIV co-infection and Multi-drug resistance of smear positive pulmonary tuber-culosis and associated risk factors in prison settings.Methods: A community based cross-sectional study was conductedamong prisoners of North Gondar zone where all inmates with a historyof cough for ≥ 2 weeks were included. Socio-demographic characteristicsand potential risk factors were assessed using a structured questionnaire.Spot-morning-spot sputum samples were collected, smears wereprepared and stained with Auramine O stain and examined through Lightemitting diode- fluorescence microscope. All samples suspected for acid-fast bacilli were also further examined by GeneXpert MTB/RIF assay. Datawas analyzed using SPSS version 20. The multivariable logistic regressionanalysis was used to determine the association between risk factorsand prison tuberculosis and a P-value < 0.05 was taken as statisticallysignificant.Results: A total of 282 prison inmates suspected of PTB were enrolledin the study. The overall prevalence of smear positive PTB infection was5.3% (15/282) with point prevalence of 384.6/100,000 prison inmatepopulations and three of the smear positive TB cases were resistant torifampicin. The prevalence of HIV infection among TB suspected prisonersand TB/HIV co-infection were 6% and 27%, respectively. Moreover, smearpositive PTB disease was significantly associated with smoking status,malnutrition, number of prison inmates per cell, poor cell ventilation, anda history of contact with TB patients.Conclusion: The prevalence of smear positive pulmonary tuberculosisamong prison inmates was 2 times higher than the general popu-lation. There was a high prevalence of TB/HIV co-infection amongsmear positive PTB cases. Reducing the burden of prison inmatesin a particular cell, preventing malnutrition, establishing ventilationsystem can possibly minimize the transmission of tuberculosis amongprisoners.

References:1. Abebe D, Bjune G, Ameni G, Biffa D, Abebe F: Prevalence of pulmonarytuberculosis and associated risk factors in Eastern Ethiopian prisons.The International Journal of Tuberculosis and Lung Disease. 2011;15(5):668-732. Telisinghe L, Fielding KL, Malden JL, Hanifa Y, Churchyard GJ, Grant AD,et al: High tuberculosis prevalence in a South African prison: the need forroutine tuberculosis screening. PloS one. 2014; 9 (1).

3. Maggard KR, Hatwiinda S, Harris JB, Phiri W, Krüüner A, Kaunda K,et al: Screening for tuberculosis and testing for human immunodeficiencyvirus in Zambian prisons. Bulletin of the World Health Organization. 2015;93(2):93-101.

P331

LINKAGE TO HIV CARE AND STARTING ART IN SUB-SAHARANAFRICA: UNDERSTANDING A COMPLEX PLOBLEM THROUGH THEMETA-STUDY OF QUALITATIVE RESEARCH

Lungu N.1, Lawrence D.S.1,2, Tsholo K.2, Jarvis J.N.1,2,3

1Dept. of Clinical Research, Faculty of Infectious and Tropical Dis-eases, London School of Hygiene and Tropical Medicine, London,UK;2Botswana Harvard AIDS Institute Partnership, Gaborone,Botswana;3Botswana-UPenn Partnership, Gaborone, Botswana

Background: A major challenge to achieving the UNAIDS 90-90-90 tar-gets in sub-Saharan Africa is starting antiretroviral therapy (ART) follow-ing HIV diagnosis. Qualitative research is well placed to explore factorsimpacting an individual’s motivation and beliefs.Methods: Ten databases were searched for qualitative data from peo-ple living with HIV (PLWH) in sub-Saharan Africa, who were describingtheir reasons for engaging with care and starting ART, or not. Data wasincluded if collected in the era of established free ART, from 2012 until thepresent day. Meta-study was used to synthesise findings; methods andtheories were extracted and compared, and primary and secondary datawere extracted and subject to thematic analysis. Three researchers eachundertook all elements to derive consensus.Results: 3245 studies were identified and 23 included. There was widevariation in research methods, and few applied theoretical perspectives.Seventy themes from primary and secondary data were grouped intothree main categories, which evolved as a conceptual framework withwhich we have explained our outcomes.For PLWH, perception of the self is the most important considerationbefore engaging with care. Internal perception of the self is how someoneviews their own physical and mental health, their intimate partnership,and their roles in society. External perception of the self describes howsomeone believes others see them; their health, relationships, and socialrole. Combined with the individual’s beliefs about HIV and ART, theirexplanatory model of HIV, the potential effect is to engage with care,or not. Environmental factors such as clinic experience and geographicallocation influence engagement but are smaller concerns, represented bythe fewest data and codes.Conclusions: Engaging with HIV care is more likely when a person believesthat doing so will improve their own perception of themselves and protecthow they believe others perceive them. This is influenced by their under-standing of HIV and ART. Environmental factors are less fundamental tothe outcome of linkage to care. In the era of test-and-treat, these findingsshould be considered when developing linkage interventions and same-day ART initiation programmes.

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Poster Presentations

P334

MEDICAL IMAGING IN HOSPITALIZED PATIENTS TREATED FORTUBERCULOSIS IN A REFERENCE HOSPITAL IN RWANDA AFOCUS ON DISSEMINATION STATUS

Bitunguhari L.1,2, Manzi O.1,2, Walker T.2,3, Clerinx J.41Dept. of Internal Medicine, University Teaching Hospital, Kigali,Rwanda;2School of Medicine and Pharmacy, University of Rwanda, Kigali,Rwanda;3Faculty of Health and Medicine, University of Newcastle, Newcas-tle, Australia;4Dept. of Clinical Sciences, Institute of Tropical Medicine, Antwerp,Belgium

Introduction: Tuberculosis (TB) and HIV remain major causes of morbid-ity and mortality worldwide, Abdominal ultrasound may reveal TB diseaseand its spread in hospitalized patients with unrecognized TB.Aim: The focus of study was to assess TB multifocality and overlappingfeatures in TB dissemination and its relationship with HIV co-infection.Methods: This prospective observational cohort study included hospi-talized patients on TB treatment with or without HIV. TB was con-firmed when acid-fast bacilli were found in sputum and Xpert resultsor elsewhere, and probable when composite clinical, laboratory andradiological findings were consistent with TB disease. Disseminated TBwas defined on medical imaging criteria. HIV coinfection was a studyendpoint.Results: Of 199 patients, TB was confirmed in 80 (40%), and 125 (63%)were HIV coinfected. Chest X-ray was consistent with TB in 148/187(87%), and abdominal ultrasound in 156/183 (85%). Pulmonary TB and/orconcurrent pulmonary/extrapulmonary TB was seen in 130 (65%), andisolated extrapulmonary TB in the remaining 69 (35%) patients. Morethan one anatomical site was affected in 145 (73%), and TB was dissem-inated in 121 (61%). HIV coinfection was associated with disseminatedTB, abdominal TB and military TB, but inversely with TB pleurisy.Conclusion: Disseminated TB is predominant in hospitalized patients, andassociated with HIV coinfection. Abdominal ultrasound is essential todocument TB dissemination.

P335

MID-UPPER ARM CIRCUMFERENCE IS A PREDICTOR OF TUBER-CULOSIS WASTING

Patsche C.B.1,2, Rudolf F.2,3, Sifna A.2, Wejse C.1,2,3

1Center for Global Health, Dept. of Public Health, Aarhus Univer-sity, Aarhus, Denmark;2Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau;3Dept. of Infectious Diseases, Aarhus University Hospital, Aarhus,Denmark

Introduction: Body mass index (BMI) <18.5 is occasionally used to deter-mine nutrition therapy eligibility of patients with tuberculosis in low-resource settings. A simpler measure of nutritional status, such as mid-upper arm circumference (MUAC), which does not require literacy andnumeracy skills, is, however, desirable in low-resource settings.Aim: The objective of this study was to identify MUAC cut-offs predictingBMI <18.5 and BMI <16.Methods: A prospective observational study was conducted at the healthand demographic surveillance site located in urban Bissau, Guinea-Bissau, West Africa. Newly diagnosed adult patients with tuberculosiswere enrolled from three health centres and the national tuberculosis

reference hospital, between November 2003 and August 2017. MUACand BMI were measured at treatment initiation. Pearson’s correlation,univariate regression analysis, and receiver operating characteristics(ROC) area under the curve were used to analyze data.Results: Of 1994 enrolled adult patients with tuberculosis, 1833 patientswere eligible for this study. Exclusion criteria were: multi drug-resistancetuberculosis, pregnancy, edema, and missing MUAC and/or BMI values.MUAC were strongly correlated with BMI (r=0.76), and for each BMI unitincrease MUAC increased with 0.67cm (p<0.001). ROC area under thecurve for MUAC predicting BMI <18.5 was 0.87 and ROC area under thecurve for MUAC predicting BMI <16 was 0.89. A MUAC cut-off of 24.2 cmbest identified BMI <18.5 (SENS 79.4%, SPEC 78.8%) and a MUAC cut-offof 22.0 cm best identified BMI <16 (SENS 87.9%, SPEC 75.0%).Conclusion: MUAC is well-correlated with BMI in patients with tuberculo-sis in Guinea-Bissau and can be used as a nutritional status indicator. Thefindings suggest the possibility that MUAC can be used in place of BMI insuitable situations, such as determining nutrition therapy eligibility, if BMImeasurements propose a challenge.

P336

SEXUAL TRANSMITTED DISEASE IN PREGNANT WOMEN-KISANTU HEALTH ZONE-DEMOCRATIC REPUBLIC OF CONGO,2017

Mvumbi G.1, Okitolonda.V.1, Magazani A.1, Yassa A.1, MasisaM.1, Okitolonda W.E.2, Muyembe-Tamfum J.J.3, Lubula L.1,4,Kebela B.4

1Dept. of Epidemiology, School of Public Health/FELTP, Kinshasa;2School of Public Health, Kinshasa;3Institut National de Recherche Biomedicale, Faculté de Medecine,Université de Kinshasa, Kinshasa;4Direction de Lutte contre les maladies, Kinshasa, DRC

Background: Prenatal Chlamydia trachomatis (CT), Neisseria gonorrhoeae(NG), and Trichomonas vaginalis (TV) infections are associated withadverse birth outcomes including premature birth, low birth weight, andinfant infection. Many countries, including Democratic Republic of Congo(DRC), do not recommend prenatal CT, NG, or TV screening. As rapiddiagnostic tests become available, it is important to evaluate prenatalsexually transmitted infection (STI) prevalence and acceptability andfeasibility of prenatal screening programs.Methods: We conducted a cross-sectional study on 352 consenting preg-nant women in 4 clinics providing prenatal care in the Kisantu health zonefrom October 2016 to February 2017. Eligible women were age 18 yearsor older and less than 35 weeks pregnant.A standardized questionnaire was administered and biological samples(urine and vaginal/ endocervical swabs) were collected and analyzed,using a GeneXpert (swabs) for testing of Chlamydia trachomatis (CT),Neisseria gonorrhea (NG) and Trichomonas vaginalis (TV). We treatedboth CT-NG-infections with azithromycin (1gm oral) and TV-infection withtinidazole (2gr). We provided antibiotics for expedited partner therapy(EPT). Women returned for test-of-cure at 4-8 weeks. We calculatedscreening acceptability as the percent of eligible women screened, andtreatment feasibility as the percent of positive women treated. We mea-sured infection prevalence, symptom status, cure rates, and EPT accept-ability.Results: The majority of women (57.4%) were age 20-29 years. Themedian week of pregnancy was 28 weeks (range: 4-34 weeks). Screeningacceptability was 98.6%. STI prevalence was: CT: 3.0%, NG: 1.4%, andTV: 14.6%. Symptoms were reported among 9.1% of CT-infected women,20.0% of NG-infected women, and 15.7% of TV-infected women. Treat-ment feasibility was 97.0%. Upon first test-of-cure, 100.0% were cured

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of CT, 100.0% were cured of NG, and 51.1% were cured of TV. Of infectedwomen, 77.3% reported their partners accepted EPT.Conclusions: Prenatal STI screening had high acceptability, feasibility,and partner management. These data support continued studies todetermine the cost-effectiveness of prenatal STI screening programsto prevent adverse birth outcomes in DRC and shows us the need toimprove and expand clinical management to assess and reduce the riskof infection, transmission or spread of STIs-HIV during ANC.

P337

HIV CASE FINDING AND LINKAGE TO CARE IN ELEME LOCALGOVERNMENT AREA, RIVERS STATE: A COMPARATIVE ANALY-SIS OF FACILITY HIV SERVICES OPTIMIZATION AND COMMU-NITY BASED HIV INTERVENTION

Emenike A.3, Ekele O.D.1, Badru T.1, Agbakwuru C.1, Oladele E.1,Adedokun O.1, Owhonda G.2, Khamofu H.1, Pandey S.R.11FHI 360, Nigeria;2Rivers State Ministry of Health;3Pathfinder International, Nigeria

Background: A combination of effective and efficient approaches is nec-essary for scaling up of HIV case-identification, particularly in resource-limited settings. To increase access and coverage, communities need tobe linked to facilities via community-based interventions that seek topromote health seeking behavior.Aim: This study aims to compare the effect of community based HIVtesting services (HTS) to HTS optimization at the facility level.Methods: This is a pre-and post-intervention study conducted in Eleme,one of the priorities LGA supported by the USAID funded StrengtheningIntegrated Delivery of HIV/AIDS Services (SIDHAS) in Rivers State. The pre-intervention phase (PIP1) covers the period November 2015 – October2016 while the post intervention phase is from November 2016 – Oct2017. PIP1 involved community entry/mobilization, HIV screening in gen-eral population, referrals and linkage to care and treatment services fromthe community to the facility, while the PIP2 focused on optimizationof HIV testing services within the facilities through multipoint/ProviderInitiated Testing and Counselling[PITC], targeted testing in the commu-nities, Sexual Network and Genealogy Testing and referrals by escortto Service Delivery Points. We reviewed HTS and ART commencementdata to compare differences in positivity yield and linkage between bothphases.Results: The PIP1 had 107,813 individuals counselled, tested andreceived result, 1,406 tested HIV Positive and 964 linked to ART whilethe PIP2 had 24,078 individuals tested, 614 HIV positive and 610 linkedto ART. Findings show increase in positivity yield from 1% to 3% andlinkage from 87% to 99% in PIP1 and PIP2 respectively.Conclusion: Although community outreaches create awareness, a tar-geted approach to HTS including sexual network/genealogy testing maybe a more efficient approach. In addition, PITC in health facilities yields ahigher positivity and linkage rates, maximizes use of testing resources byfocusing on higher risk populations.

P338

HIV INCIDENCE AMONG PREGNANT WOMEN AND ASSOCIATEDRISK FACTORS IN KABAROLE DISTRICT, UGANDA

Theuring S.1, Schumann H.1, Rubagumya K.2, Rubaihayo J.2,Wanyenze R.31Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin, Berlin, Germany;

2School of Public Health, Mountains of the Moon University, FortPortal, Uganda;3School of Public Health, Makerere University, Kampala, Uganda

Introduction: It is assumed that pregnant women are particularly vul-nerable to new HIV infection due to biological, social and behaviouralreasons. At the same time, incident infection during pregnancy increasesthe risk for HIV transmission to the baby due to an acute viral load peak.Yet, HIV incidence in pregnancy is poorly investigated even in the highlyHIV-burdened regions of Sub-Saharan Africa.Aim: The aim of our study was to measure HIV incidence rates amongpregnant women in Kabarole District, Uganda and assess associated riskfactors.Methods: A cross-sectional study was conducted in three health facilitiesin the Fort Portal vicinity in 2017. We recruited pregnant and deliveringwomen who had an HIV-negative test result documented in their ANCcard dating from at least three months earlier, and who therefore under-went routine repeat HIV testing according to hospital guidelines. Inter-views were additionally conducted for information on sociodemographicbackground and potential risk behaviour. We calculated the HIV incidencerate as seroconversions per 100 women-years, and data was analysedwith regard to influencing factors.Results: In total, we recruited 1610 initially HIV-negative women. Medianage of the clients was 24 years; 85.7% were married or in a relationship.Among the partners, 20 (1.2%) were known to be HIV-positive. Repeattesting revealed 15 women had seroconverted during pregnancy, result-ing in an HIV incidence rate of 2.9 per 100 women-years. Regression anal-ysis identified living separately from the partner (RC 1.978, p-value 0.025),having multiple sex partners (RC 1.113, p-value 0.019), unprotected sexwith an unknown person (RC 2.783, p-value <0.001), alcohol abuse (RC2.789, p-value <0.001) and sex under the influence of drugs/alcohol (RC1.974, p-value 0.016) as factors independently associated with serocon-version.Conclusion: The HIV incidence rate in our study was higher compared todata from previous studies on both general and pregnant population inUganda. This confirms the hypothesis that pregnant women representa high risk group for HIV infection, requiring specific prevention andprotection strategies throughout pregnancy. Further research is neededon adequate ways of minimizing potentially involuntary risk behavioursin settings showing high levels of gender imbalance or sexual violence.

P339

TREATMENT INTERRUPTIONS AND REENGAGEMENT ON HIVCARE IN A RURAL COUNTY SERVING PASTORALIST COMMUNI-TIES IN KENYA: A RETROSPECTIVE COHORT STUDY

Yonga P.O.1,2, Kalya S.K.1, Lynen L.3, Decroo T.3,4

1Dept. of Internal Medicine, Baringo County Referral Hospital,Kabarnet, Kenya;2Dept. of Internal Medicine, Fountain Health Care Hospital, Eldoret,Kenya;3Dept. of Clinical Sciences, Institute of Tropical Medicine, Antwerp,Belgium;4Post-Doctoral research, Research Foundation Flanders, Brussels,Belgium

Introduction: In Kenya, 63% of all people living with HIV (PLHIV) areestimated to have a suppressed viral load. However, rural clinics servingpastoralist communities are known to be hard to reach. No previous studyhas assessed the magnitude of antiretroviral therapy (ART) interruptionsfollowed by reengagement in such settings.Aim: To determine the magnitude of ART interruptions followed by reen-gagement among PLHIV in Baringo County, Kenya.

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Methods: Retrospective cohort study of treatment interruptions, virologicresponse, and reengagement in care among patients who started ARTbetween 2014-2016 in Baringo County, Kenya, with 58% ART coverage.Patients two weeks late for their next appointment were consideredas having interrupted treatment, those late for 6 months or more aslost to follow-up. Predictors of reengagement after an interruption wereestimated using logistic regression.Results: Of 342 patients, 76.9% (263) experienced at least one treatmentinterruption (range: 0-7 interruptions; figure 1). In 218 patients with a viralload (VL), 78.0% had a suppressed VL. Those with a history of treatmentinterruptions were less likely to suppress their VL (p=0.002; figure 2). Sixpatients had treatment failure (two consecutive VL>1000copies/mm3),and all had interrupted treatment at least once (range: 1-5 interrup-tions). After an interruption, male patients (aOR 0.3; 95%CI: 0.2-0.6;p<0.001) and patients WHO stage category III -IV (aOR 0.3; 95%CI: 0.1-0.5; p<0.001) were less likely to reengage in care.Conclusion: Treatment interruptions in Baringo County were noted to beunacceptably high. Innovative ART delivery is required to meet the needsin pastoralist settings, which will in turn reduce interruptions, increaseviral suppression, and control HIV transmission.

P340

GENDER DIMENSIONS OF TUBERCULOSIS (TB) – EXAMININGUNDER-REPORTING AMONG MEN IN TANZANIA

Sawhney M.Dept. of Public Health Sciences, University of North Carolina, Char-lotte, USA

Introduction: Tuberculosis (TB) a highly infectious disease affects nearly10 million people (www.who.org). Till date, most of the TB researchand interventions have focused on “women and children”. The globalmale: female (M: F) ratio for TB notifications was 1.7. Among the olderpopulation (14 years +) TB incidence in Tanzania was reported to be103 for males compared to 48 for females. The higher disease burdenin men, combined with larger gaps in detection and reporting, suggeststhat strategies for improved access of health services among men arerequired to reduce disease burden from TB.Aim: (i) Ascertain depth of gender disparities in TB diagnosis, report-ing, and access to treatment, (ii) Identify, understand, and documentdeterminants of gender disparity with regard to barriers for TB diagnosis,care, treatment among the population in TB prone areas, and (iii) Assessawareness and knowledge among different stakeholders regarding theappropriate reporting of TB cases among men and women in TB proneareas.Methods: An appropriate mix of qualitative and quantitative methods areemployed for data collection and analysis. For the qualitative part, datais collected through focus groups sessions (women, men, and migrantpopulation) among population 18 years and older in and around Dar-Es-Salaam. Tailored interviews are conducted for key informants (healthcareworkers, leaders of social groups and community leaders) to examinereasons for under-reporting and barriers for seeking timely treatment.For the quantitative part, quarterly TB reports from healthcare facilitiesand laboratories are reviewed to ascertain the depth of gender disparitiesin TB diagnosis and reporting. SPSS and Atlas are used for quantitative andqualitative data analysis respectively.Results: Preliminary results highlight access to health care, social andcultural norms, occupation as some of the significant barriers for under-reporting among men to for TB related outcomes.Conclusion: Results from this study play an important role in filling thegaps in current research for under-reporting of TB among men. Anotherimportant outcome from this study is to be able to use these results in thedesign and implementation of targeted interventions to improvise timelyTB case detections among men.

P341

THE TUBERCULOSIS (TB) GENDER DIVIDE: ANALYSIS OF RECENTTB PREVALENCE SURVEYS

Sawhney M.1, Kak N.21Dept. of Public Health Sciences, The University of North Carolina,Charlotte;2University Research Co., LLC, Chevy Chase, USA

Introduction: Gender plays a large role in TB infection, access to services,and treatment outcomes for TB. Gender as a determinant of TB infectionvaries based on certain important factors; for example, while men acquiremore TB globally due to occupational and health-seeking factors, womenmay be less likely to receive appropriate diagnosis and may experiencemore and greater barriers to care than men. Till date, most of the TBresearch and interventions have focused on “women and children”. How-ever, recent TB prevalence survey/s in multiple countries highlight thattuberculosis rates are actually higher among males (Population-BasedTuberculosis Prevalence Survey from Ethiopia, Tanzania, and Vietnam).With the latest data highlighting gender differences in diagnosis, report-ing/notifications, and treatment of TB cases will impact TB preventiveprograms, policies, and funding priorities in near future.Aim: (i) Assess awareness and knowledge regarding symptoms, diagno-sis, and appropriate reporting among different stakeholders working inTB prone areas; (ii) Ascertain depth of gender disparities in TB diagnosis,reporting, access to treatment, and reducing burden of disease, and(iii) Implement gender-sensitive training programs/interventions (in closecollaborations with existing programs in the region) to increase the rateof timely diagnosis and reporting of TB cases.Methods: A mix of qualitative and quantitative methods are employedfor data collection and analysis. Qualitative methods include focus groupdiscussions among different population groups (women, men, drug users,truck drivers, and migrant populations). Quantitative methods includesurveying different stakeholders to document health systems relatedchallenges in addressing the health care needs of TB patients.Results: Preliminary results describe strong inter-linkages between bio-logical, occupational, social and other cultural considerations in describ-ing the effect of gender on TB prevalence, treatment seeking, and casereporting.Conclusion: Overall, gender an often overlooked component of TB pro-gramming includes a variety of important factors which must be elu-cidated in order to be effectively targeted for more gender-inclusiveprogramming. The results of this work establish an understanding ofgender in TB, under-reporting of TB, and low TB notifications based ongender with the goal of reducing the burden of TB through more highlyfocused TB control programs.

P342

PUBLIC-PRIVATE MIX ON QUALITY OF CARE IN PROVISION OFTUBERCULOSIS TREATMENT

Ndambuki J.N., Ondieki C.O.Dept. of medical services, Machakos Level 5 Hospital, Machakos,Kenya

Introduction: Public-private mix (PPM) for Tuberculosis (TB) entails coor-dinating activities with the various stakeholders in both the public andprivate health facilities to provide high quality services to the TB patients.In Kenya, currently PPM activities are being implemented in Machakostown and targets the service providers in the private sector through theinitiative of the Kenya Association for the Prevention of Tuberculosis andLung Diseases (KAPTLD) under the mandate of the Ministry of PublicHealth and Sanitation’s Division of Leprosy, Tuberculosis and Lung Disease

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(DLTLD). PPM activities within Machakos town advocates for the develop-ment of appropriate TB health policies, training of health care workersand the implementation of a well-resourced health programs that leadto prevention, care and control of Tuberculosis.Aim: To assess the quality of patient care in provision of TB treatmentwithin the three referral hospitals within Machakos town.Methods: This was a descriptive retrospective study of all TB patientsdiagnosed and notified in the two private and one public referral hospitalswithin Machakos town between January and December 2017.The threereferral hospitals are within a radius of one kilometre.Results: Of the 647 TB cases notified in the whole district, the 2 privatehospitals notified 14.8% while the public hospital notified 61.2%. On TBdiagnosis 63% were Bacteriologically confirmed in the public hospitalwith the private hospital having a lower proportion at 38%. The privatehospitals had treatment success rate (TSR) of 77.1% while in the publichospital it was 87.6%. Incomplete data was noted in the private facilitiesmore pronounced in the sputum follow up smears that were missinghence affecting the TSR.Conclusion: PPM Integration is evident in scaling up PPM programmes tohave continuity of care as the private hospitals continue with diagnosingand treating TB. Data accuracy and completeness plays a major rolein ensuring favourable TB treatment outcomes. This could be achievedby regular supervision by KAPLTD in collaboration with National TB pro-gramme in Kenya. Health care workers working in these facilities requirementorship and training on modern tools to ensure no major gaps arenoted in the TB data.

P343

A DESCRIPTIVE ANALYSIS OF SCREENING AND TREATMENT OFTUBERCULOSIS IN PREGNANT WOMEN IN URBAN TERTIARYCARE HOSPITALS IN PAKISTAN

Ali R.F.1, Khan M.2, Shah M.T.1, Arif D.1, Khan A.J.3, Becerra M.4,Chandir S.31Maternal and Child Health, Interactive Research & Development,Karachi, Pakistan;2Interactive Research & Development, Johannesburg, South Africa;3Interactive Research and Development, Singapore;4Global Health and Social Medicine, Harvard Medical School,Boston, USA

Introduction: Tuberculosis (TB) is the tenth leading cause of death glob-ally and is a significant contributor to non-obstetric causes of mortal-ity in women of reproductive age. The global burden of antenatal TBwas estimated at 216,500 cases in 2011. Pakistan accounts for 7% ofthe global TB burden with a prevalence of 4.3/1000. Antenatal visitsprovide an opportunity to screen women for TB who otherwise maynot access health services. The lack of national data on maternal TBprevalence coupled with the absence of TB screening prompted this pilotprogram.Aim: The program aimed to implement and assess the feasibility of TBscreening within the maternal population seeking antenatal-care, withthe eventual goal to integrate TB screening into the standard of care forthe antenatal population.Methods: Active case-finding for TB in pregnancy was phased into 6 largetertiary care centers of Karachi. The verbal symptomatic screening wasconducted on all attending pregnant women with a collection of sputumsamples in symptomatic women. GeneXpert test was performed on allthe collected samples. Sputum culture and shielded chest x-rays werealso performed at 2 of the sites. Bacteriologically confirmed TB cases werelinked to TB treatment with regular follow-ups and supervision.Results: TB symptom screening of 105,888 antenatal-cases wasconducted between April and December 2017. A total of 2,986 (2.8%)

women reported at least one symptom and 2,917 (98%) casesunderwent diagnostic evaluation. Through the multiple diagnostic tests,27 newly diagnosed cases of pulmonary TB were identified. Twelvewomen diagnosed prior to pregnancy and 9 pre-diagnosed cases ofextra-pulmonary TB were also enrolled in the study making it a totalof 48 cases. Overall, 96% of cases were put on TB treatment.Conclusion: TB screening during antenatal visits provides an appropriateopportunity to identify active cases among the maternal population andlink them to treatment. However, verbal symptomatic screening followedby Xpert-testing is likely an insufficient case-finding strategy in high TBburden settings. Therefore, a multifaceted diagnostic approach whichincludes clinical examination, TB culture, and CXRs should be investigatedand adopted.

P344

A RANDOMIZED TRIAL OF AMBISOME® MONOTHERAPY ANDCOMBINATION OF AMBISOME® AND MILTEFOSINE FOR THETREATMENT OF VL IN HIV POSITIVE PATIENTS IN INDIA

Burza S.1, Pandey K.2, Mahajan R.1, Kazmi S.1, Alexander N.3,Lasry E.4, Moreto-Planas L.4, Goyal V.5, Das V.N.R.2, Das P.21Médecins Sans Frontières, New Delhi, India;2Rajendra Memorial Research Insitute of Medical Sciences, Patna,India;3London School of Hygiene and Tropical Medicine, London, UK;4Médecins Sans Frontières, Barcelona, Spain;5Drugs for Neglected Diseases initiative, New Delhi, India

Background: Between 6-10% of adults with Visceral Leishmaniasis (VL)are co-infected with HIV in Bihar, India. We present the results of a ran-domized, parallel arm, open-label, non-comparative clinical trial to assessthe safety and efficacy of the combination of liposomal amphotericin B(AmBisome®) plus miltefosine (Impavido®) and AmBisome® alone forthe treatment of VL in HIV co-infected patients in India.Methods: 150 patients with parasitologically confirmed VL and sero-logically confirmed HIV were randomized to receiving either 40mg/kgAmBisome in 8 divided doses over 24 days or a combination of 30mg/kgin 6 divided doses over 11 days given together with 100mg miltefosinedaily for 14 days. Exclusion criteria were limited to those unwilling to usecontraception and/or those with serious underlying disease that wouldpreclude evaluation of response to study medication.All patients were initiated or continued on ART. Primary and secondaryefficacy endpoints were being alive and disease free at 6 months and12 months respectively. Safety was assessed based on clinical adverseevents and laboratory parameters during treatment and one-monthfollow-up. All results are presented in ITT analysis.Results: 84% and 88% of patients presented with CD4<200, whilst 20%and 21% of patients were additionally co-infected with tuberculosis inthe combination and monotherapy arms respectively. 99% and 92%of patients were considered ‘initial’ cure at day 29 in the combinationand monotherapy arms respectively, dropping to 96% and 85% at the6 months primary endpoint and 86% and 75% at 12 months secondaryendpoint∗. When excluding patients with tuberculosis, 6 month and 12-month effectiveness was 96.7% and 89.6% for combination and 91.5%and 85.7% for monotherapy respectively. Both arms had similar numbersof SAEs (5 vs 4), none considered related to the study drugs, and all butone related to tuberculosis.Conclusions: Both treatment regimens appear safe, however combina-tion treatment of AmBisome and Miltefosine appears to be more effectivethan Ambisome monotherapy in the treatment of VL in patients co-infected with HIV in India, while halving treatment duration. Effectivenesswas accentuated with longer follow up and particularly in patients withVL-HIV-TB co-infection, a new clinical entity.

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Ethics statement:This study was prospectively registered at the Clinical Trial Registry ofIndia (CTRI/2015/05/005807) and was approved by the Ethical ReviewBoard of MSF, London School of Hygiene and Tropical Medicine and theRMRI/ICMR Ethics Committee.∗12-month results include 114/150 complete follow ups, completion willbe in April 2019.

P345

DIAGNOSIS OF TREPONEMA PALLIDUM AND HIV INFECTIONSAND CONTACT TRACING IN THE MBYA-GUARANÍ POPULATIONOF THE PUERTO IGUAZÚ, ARGENTINA. A CROSS-SECTIONALSTUDYMarx J.1, Acosta-Soto L.2, Deschutter E.J.3, Bornay-Llinares F.2,Sotillo-Soler V.2, Ramos-Rincón J.M.41Laboratory of Clinical Analysis, “Dr. Marta T. Schwarz” Public Hos-pital, Puerto Iguazú, Misiones, Argentina;2Parasitology Area, University Miguel Hernández de Elche, Alicante,Spain;3Dept. of Microbiology, School of Exact, Chemical and NaturalSciences, National University of Misiones, Posadas, Misiones,Argentina;4Dept. of Clinical Medicine, University Miguel Hernández de Elche,Alicante, Spain

Introduction: In Argentina, there are currently 93 Mbyá Guaraní com-munities dispersed throughout the province of Misiones, representing apopulation of about 6200 people.Aim: To assess the prevalence of Treponema pallidum and HIV infectionin Mbyá Guaraní people over the age of 11 in Puerto Iguazú (Argentina)and to describe contact tracing of cases.Material: Cross-sectional study in people of the Mbyá Guaraní ethnicityin the villages of Fortín Mborore (pop. 1146; 25◦38’05.6"S 54◦33’44.3"W),Yryapú (pop. 369; 25◦36’51.9"S 54◦33’03.5"W), and Yasí Porá (pop. 149,25◦36’20.8"S 54◦32’42.2"W) in Puerto Iguazú. Participants were selectedrandomly to undertake a survey and blood testing.Results: Of the 551 participants, 48 were infected with T. pallidum (8.71%;95% confidence interval [CI] 7.38-10.04). Infection prevalence decreasedwith age, standing at 9.66% in the 11–19-year age group, 8.42% in 20–39-year-olds, and 4.54% in people aged 40 or older. There were four casesof HIV (0.72%, 95% CI 0.31–1.13). We traced 130 contacts for the 48 T.pallidum infection cases; 39/40 (97.5%) sexual contacts tested positivefor infection.Among the 90 children with infected mothers, 76 who were aged 18months or older tested negative/14 younger 18 months. Of the 14younger children, 6 had mothers who received treatment while pregnant,and these children tested VDRL negative at birth and at six months of age,so congenital syphilis was ruled out. The 8 remaining children were bornat home, and their mothers did not recall having received treatment. Allthese children were recommended for treatment. All lab controls to 18months of age showed a reduction in VDRL titers.Conclusion: Prevalence of T. pallidum infection and HIV are higher inthis indigenous community of Argentina, representing a public healthconcern.

P346

FACTORS ASSOCIATED WITH TUBERCULOSIS-HIV COINFEC-TION IN DIAGNOSIS IN THE NZANZA HEALTH ZONE FROM2012-2017

Nzuzi C., Mvumbi G., Okitolonda V., Onyamboko M.Kinshasa School of Public Health, Kinshasa, DRC

Introduction: The objective of this study is to determine the factorsassociated with the increase in the proportion of tuberculosis patientscoinfected with HIV in Kiamvu and Baobab CSDT in the Nzanza SZ, Matadi,between January 2012 and December 2017.Methodology: This was a case-control study of 187 HIV-positive TBpatients and 187 HIV-negative TB patients being followed at the TBTesting and Treatment Center (CDT) in Nzanza SZ from 1 January 2012to 31 December. December 2017. We used Pearson’s chi-square test andhomogeneity as well as logistic regression. This helped to identify factorsassociated with TUB / HIV co-infection.Results: HIV-positive TB patients had a high daily household income[OR: 2.903; p: 0.000]) than seronegatives. The majority of HIV-positiveTB patients had unprotected sex with a casual partner before diagnosis[OR, 1.82; p: 0.000]) than seronegatives. After adjustment, the intake ofalcohol [OR: 12.2; p: 0.004]) and extra pulmonary forms of tuberculosis[OR: 31.5; 0.002] were associated with increased TUB / HIV co-infection.Conclusion: Alcohol intake and extra-pulmonary forms of tuberculosiswere the factors associated with increased TUB / HIV co-infection. Aware-ness of TB patients may help reduce the risk of HIV infection.

P348

CLINICAL PATTERNS OF TETANUS AND HIV CO-INFECTION IN AREFERRAL HOSPITAL IN ETHIOPIA: A CASE SERIES

Lomencho A.AMC, Addis Ababa; MEPI Junior Scholars, University of Gondar,Gondar, Ethiopia

Introduction: Tetanus remains to be an important public health problemin developing countries. Although much has been published on the clinicalcharacteristics of tetanus patients, there is paucity of evidence on itsinteraction with HIV.Aim: To describe clinical profile of patients with tetanus in ICU.Methods: The patients are cases of tetanus – HIV co-infection admittedto Black Lion Hospital, Addis Ababa, Ethiopia. A case series study designwas utilized.Results: We presented two HIV patients who never had immunizationor post exposure prophylaxis presenting with cephalic tetanus with latergeneralization. The first was a 50-year-old male patient with CD4 38admitted with a diagnosis of WHO stage I HIV with Ableitt Grade 3generalized tetanus. The second was 41 years old male on ART for 6years with CD4 520 admitted with a diagnosis of grade III generalizedtetanus, and Stage T1 HIV. The incubation period and period of onset were10 days and 12 hours for the first and 3 days and 18 hours for the sec-ond patient respectively. Both received tracheostomy, Tetanus antitoxin,metronidazole, diazepam infusion, Chlorpromazine, and supportive care.Both patients developed dysautonomia and received Magnesium sul-phate. Both received mechanical ventilation for hospital acquired pneu-monia. The second patient was successfully weaned after 4 days whileweaning was difficult in the first. Control of spasms and dysautonomiawas very difficult in the first patient even following phenobarbitone andthiopental. He later developed Ventilator associated pneumonia and diedfrom severe sepsis. The second patient had a smooth course and wasdischarged improved. On discharge, he received 2 doses of tetanus toxoidand was enrolled into chronic care. The total ICU stay was 16 days and21 days respectively.Conclusion: The difference in the control of spasms, dysautonomia andoutcome in the two patients might indicate the variability of clinicalmanifestations and prognosis of tetanus in HIV patients depending onthe degree of immunosuppression. There is a need for further studies tocharacterize tetanus – HIV- co-infection.

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P350CLINICAL PROFILE AND OUTCOMES OF PATIENTS WITHABDOMINAL TUBERCULOSIS FROM A TERTIARY CARE CENTERFROM SOUTH INDIANawahirsha S., Gunasekaran K., Prasad J.D., Das S.,Iyyadurai R.Dept. of Medicine, Christian Medical College, Vellore, India

Introduction: Abdominal tuberculosis accounts for 5% of all TB patients.Abdominal TB includes involvement of the GI Tract, peritoneum, lymphnodes and solid organs. The diagnosis of tuberculosis in a developingcountry like ours is difficult as the histology and culture proven diagnosisisn’t available in all patients. Due to the varied clinical presentation, thereis often a diagnostic dilemma. This study aims to describe the clinicalprofile and the various modes of presentation of abdominal tuberculosisand the outcomes.Aim: This study aims to describe the clinical profile and outcomes ofpatients with abdominal tuberculosis.Methods: This was a retrospective study among patients who presentedover the last 5 years (April 2014 to July 2018) to medicine unit 5. A total of88 patients were identified to have abdominal tuberculosis, among them31 patients who completed treatment were included and analyzed.Results: There were 17 men and 14 women, the mean (SD) age was43(16.3). 27(87%) patients had loss of appetite as the presenting symp-tom and 26(83.8%) patients had fever and loss of weight respectively. 10patients had ascites, 8 had hepatomegaly and 7 had splenomegaly.5 patients had HIV infection and 4 patients had diabetes mellitus type 2.Hypoalbuminemia was seen in 22 patients and 15 patients had an ele-vated serum alkaline phosphatase. 79% of patients had lymphadenopa-thy on CT as compared to 55% on ultrasound. 55% of patients hadperitoneal thickening on CT as compared to 15% on ultrasound.Definitive tuberculosis (culture positivity) was seen in 10 patients. Theremaining 21 patients were diagnosed to have probable tuberculosisbased on nucleic acid amplification (6) and histopathology alone (15).3 patients developed drug induced hepatitis. 26 patients completedtherapy and were cured and 5 patients died. Low albumin (p=0.044, 95%CI=-2.57 to -0.39), high alkaline phosphatase (p=0.013, 95% CI = 40.48to 313.22) were associated with increased mortality.Conclusion: Abdominal involvement is one of the common presentationsof tuberculosis, presenting with loss of appetite, fever, ascites and hep-atosplenomegaly. In our study only 32% of patients had microbiologicalevidence of tuberculosis. Hypoalbuminemia and elevated alkaline phos-phatase were associated mortality.

P351“LEAVING NO ONE BEHIND”: IMPROVING TB-CARE THROUGHSOCIAL SUPPORT IN GERMANYBeyersdorff L., Prömpers M., Menzel S., Knipper M.Project “Together against Tuberculosis”, Institute for the History ofMedicine, Justus-Liebig-University, Giessen, Germany

Introduction: Germany is low incidence country for tuberculosis, yetnumbers are increasing since 2013. The majority of patients are for-eign nationals and the current epidemiological trend is related to themigration dynamics of the recent years. One major challenge is thattreatment completion rates appear to be especially low among asylumseekers. In response to this situation, “Together against Tuberculosis”was created for improving TB-care through voluntary social support toall TB-patients (independent of migration background) by undergraduatemedical students. The project is located in the host city of one of thelargest reception centres for refugees in Germany (Giessen, in the FederalState of Hesse).

Aim: Drawing on the human rights-based notion of “leaving no onebehind”, the project aims to (i) improve treatment outcomes byestablishing a supportive relationship between two medical studentsand one patient, (ii) to systematically identify barriers (qualitativeapproach) and document success rates (quantitative), (iii) to pro-vide a didactic experience for future physicians to improve social,cultural and structural competencies by getting insights into theGerman health care systems from the perspective of highly vulnerablepatients.Methods: This presentation will be the first communication of theproject philosophy, structure and preliminary results. Sampling: Amongall patients with active TB identified by the local county’s public healthdepartment between June 2017 and June 2019 (incl. MDR- and XDR-TB),support is offered to patients residing outside institutions with functioningDOT-program (e.g. reception centres). Quantitative information is basedon regular project documentation (anonymous data), qualitative datais generated by semi-structures interviews with all medical studentsparticipating in the project.Results: Quantitative results comprise numbers of TB-patients in theregion, patients receiving support, completion rates, denial and drop-out(disaggregated according to gender, age, migration background, legalstatus and further criteria). Qualitative data show how a multiplicity ofsocial, legal, cultural and economic factors, and the complex structure ofthe German health system, obstruct TB-care, yet also how to overcomethese barriers.Conclusion: In a low incidence and high income country like Germany,social support and individual commitment are crucial for achieving thatno patient is left behind.

P352TUBERCULOSIS BEHIND THE COUGHRamos V.1, García J.2, Subías C.3, García M.4, Guillamón A.E.2,Alegría I.5, Ramos J.61Home Hospitalization Unit, University Hospital of Torrevieja, Ali-cante, Spain;2Dept. of Internal Medicine, University Hospital of Torrevieja, Ali-cante, Spain;3Gambo General Rural Hospital, West-Arsi, Ethiopia;4Dept. of Internal Medicine, Vega Baja Hospital, Orihuela, Alicante,Spain;5Dept. of Pediatrics, Gambo General Rural Hospital, West-Arsi,Ethiopia;6Dept. of Internal Medicine, University General Hospital of Alicante- ISABIAL, Alicante, Spain

Introduction: Gambo Hospital is located in a rural area of Ethiopia. Thehospital serves an estimated population of 385,000 people. It operateswith limited resources and patients must pay for the services. Highincidence of tuberculosis has been described in this region.Aim: The purpose of the study is to analyze how the diagnosis of pul-monary tuberculosis (ptbc) is done.Material and Methods: This is a descriptive and cross-sectional study, inwhich data of all the patients attended in the outpatient clinic during May2018 because of respiratory symptoms and diagnosed with ptbc wereincluded.Results: 165 patients were included, but only 27 (13.8 %) had ptbc. 18were men (66.7%). 24 of them required admission. HIV screening wasdone in 22 patients and two of them had positive result. 5 patientshad been previously treated for tbc. A total of 12 patients (44.4%) werediagnosed with ptbc through culture, 7 (25.9%) with an x-ray sugges-tive of ptbc and 8 (29.6%) were diagnosed due to the lack of clinical

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improvement. The main symptom they suffered was dry cough in 55.6%,followed by productive cough in 33.3% and haemoptotic sputum in11.1%. 37% of patients had to consult a second time, due to persistenceof symptoms.Conclusion: Pulmonary tuberculosis has a high incidence in the region,but only 16.3% of the patients were diagnosed with ptbc. Most patientswere diagnosed by sputum culture, while 29% of the patients werediagnosed because of a lack of improvement, despite of negative com-plementary tests. In patients with no clinical improvement, after severalantibiotic regimes and negative complementary tests, the approach wasto initiate empirical tbc treatment. The decision was taken on the basisof the low sensitivity of sputum cultures and the lack of other resources.We conclude that ptbc is underdiagnosed. An active search of contacts isnot performed.

P353

MORTALITY PATTERNS AND PREDICTORS IN HIV POSITVEADULTS IN A FAITH-BASED HOSPITAL IN A LMIC: A TEN YEARREVIEW

Olaniyi-George J.F.O.1, Okedare O.A.1, Omoluru T.O.2,Afolabi A.C.T.31Dept. of Family Medicine, O.L.A. Catholic Hospital Oluyoro Oke Ofa,Ibadan;2Dept. of Family Medicine, General Hospital, Lagos;3ARV Unit, O.L.A. Catholic Hospital Oluyoro Oke Ofa, Ibadan, Nigeria

Introduction: Nigeria has the highest number of HIV positive adultsin the world. Current prevalence rate (2018) is 3.2% among the adultpopulation, giving an estimated HIV positive adult population of 3.4million. The majority of HIV care is given at government tertiary andsecondary care facilities with poorly managed government primarycare facilities unable to contribute much except in the way of PMTCT.Faith-based hospitals have stepped into this gap with the support ofdonors such as USAID, PEPFAR and technical assistance of partners likeCatholic Caritas and FHI-360. O.L.A Catholic Hospital is a secondarylevel faith-based hospital which started care of HIV infected/af-fected people in July 2008 and till date has cared for over 10,000patients.Aim: To understand causes and predictors of death in HIV infected adultsin resource poor settings so as to improve their care.Methods: A death register had been opened since the inception of theHIV programme of the hospital and details of the demised patients fromDecember 2008 till December 2018 were extracted from the registerand cross-checked with their care cards to ensure consistency. Relevantvariables extracted from the care cards such as bio-data (age, sex,marital status, occupation), date of initial diagnosis, date of commence-ment on ART, drug adherence patterns, regimen and switches if any,laboratory records (CD4 counts and viral load patterns), co-morbidities/co-infections.Results: With an average of 3% of patients dying during this period,we hope to describe the average duration of illness before demise ofHIV positive patients in LMIC like Nigeria and reasons for early demise.We want to identify the relationship between the initial CD4 count andresponse to ART, initial CD4 count and the course of illness, effect ofadherence and reasons for poor adherence, impact of co-morbidities onthe course of HIV, and effect of socio-demographic variables on mortalityin HIV positive adults.Conclusion: Understanding the relationship between socio-demographicfactors, person-specific disease characteristics, immunological patterns,co-morbidities and HIV infection may aid construction of useful algo-rithms to predict likelihood of death in the absence of complex investi-gations and medications that are unavailable in LMICs.

P354HIV SERVICES OFFERED TO KEY POPULATION-FEMALE SEXWORKERS IN THE NORTH WEST REGION OF CAMEROONAMIDST CRIMINALISATIONTayong G., Fokam I., Wanyoh D.Regional Technical Group HIV, Bamenda; Cameroon MedicalWomen Association, Cameroon

Introduction: Sex work is punishable in Cameroon under section 343 ofthe penal code. Despite this the HIV programme is engaged in workingwith Female sex worker (FSW) who had an HIV prevalence of 36%and 24% in the IBBS of 2009 and 2016 respectively. In the Bamendahealth District of the North West region of Cameroon, 51% of its 416808inhabitants are female with 1.96% of the female population being FSW.Aim: To show that despite the criminalisation of Sex work, FSW receivedservices.Method: Data on HIV prevention, HIV testing, treatment care and supportoffered to FSW in 2017 and 2018 in the Bamenda Health District wascollected and analysed.Results: FSW received services. 2630 and 3556 FSW received HIV pre-vention interventions in 2017 and 2018 respectively. The uptake of freetesting was 90% and 55% in 2017 and 2018 respectively. HIV positive ratewas 8% and 18% in 2017 and 2018 respectively.88% and 90% enrolmenton ART of those tested positive in 2017 and 2018. The HIV positive rateranged from 8% in 2017 to 18% in 2018. In 2017 adequate screeningof FSW was not done and positive rate could have been biased. In 2018with the introduction of micro-testing the probability that the FSW weretested increased. Viral load testing remains low at 32% and 47% in 2017and 2018 respectively. The uptake of viral load testing was very low dueto the fact that FSW had to pay for the test.

Conclusion: There is some level of administrative tolerance to FSW inCameroon. Because of the poor health seeking behaviours of FSW, freeand FSW friendly services should be provided to reduce HIV transmissionin the FSW, their clients and in the community.

Reference:1. Annual Report RTG HIV, North West

P355SOCIO-POLITICAL CRISIS IN CAMEROON: HINDRANCE TO HIVSERVICES DELIVERY AND UPTAKETayong G., Tedongmo M., Bekombo D.Regional Technical Group HIV, Bamenda, Cameroon

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CharacteristicOverall Population

VIRAL LOAD SUPPRESSED VIRAL LOAD UNSUPPRESSED p-valuePercentage Number Percentage Number

AGE GROUP <0.0001Child 4.22 369 12.16 267Adolescent 8.30 725 24.04 528Adult 87.47 7640 63.80 1401

Introduction: HIV is a public health problem in Cameroon with 3.4% ofthe population being infected. Cameroon, mainly French speaking, has 10administrative units called regions, two of which are English speaking-theNorth West and South West regions. The HIV prevalence in the North Westregion is 5.1%, higher than in 6 other regions. To effectively reduce newinfections, 39178 PLWHIV were to be place on treatment by December2018. These two English speaking regions had had serious socio-politicalcrisis and armed conflict that escalated in July 2018 leading to closure ofhealth units and displacement of the population in all 19 health districtof the region offsetting HIV service delivery.Aim: To report the effect of the armed conflict in the North West regionon the number of active users of ART.Methods: Routine data from health units offering HIV services wasreviewed from January 2016 to December 2018.Results: It was observed that the number of health units reporting HIVservices from July 2018, the time of escalation of the conflict reducedfrom 246 sites to 199 sites in December 2018.

The Number of active users of ART dropped from 36377 in June 2018 to32247 in December 2018.The number of PLWHIV newly enrolled on ART dropped from 1489 in thesecond quarter of 2018 to 704 in the 4th Quarter of 2018.

Conclusion: The socio-political crisis in Cameroon is effacing achieve-ments in HIV service delivery and uptake in the North West region. To

stop the upsurge of new HIV infections, the crisis must be resolvedimmediately through dialogue.

P357

HIV INFECTED CHILDREN ARE LEFT BEHIND IN THE NORTHWEST REGION OF CAMEROON

Tayong G.1, Kengne C.2, Bekombo D., Tedongmo M.1Regional Technical Group HIV, Bamenda;2NACC, Yaounde, Cameroon

Introduction: Viral suppression is the overall goal of antiretroviral therapyin all HIV infected person irrespective of age, sex or geographical locationof the person. In Cameroon, HIV remains a huge public health problemwith 3.4% of the population being infected. In the North West region,one of the administrative units of Cameroon, the HIV prevalence is higher,at 5.1%.Aim: Even though antiretroviral therapy coverage is less than 50% inCameroon, progress is being made to treat all persons who are living withHIV and providing good quality follow up services. With the intention tohave elements of the quality of Care both in the health facility and inthe community, viral load data for all clients who did the test in 2018was collected from the reference laboratory and analysed at programmelevel.Methods: Laboratory data for all PLWHIV tested for viral load in theNorth West region was collected and analysed. This was done to find outdifferences in virologic outcome and determine if there was a relationshipwith age and virologic outcome. Children were subjects under 10 whileadolescents were subjects 10 to 18 years and adults were persons 19years and above.Results: It was observed that the proportion with suppressed viral loadwas 87.47%, 8.3% and 4.22% in adults, adolescents and children respec-tively. While 84% of total adults tested had suppressed viral load and 57%and 58% in adolescents and children respectively. It was observed thatage was related to virologic outcome (P<.0001).Conclusion: Children and adolescent s living with HIV are more vulnerableand less likely to achieve treatment success. Special interventions to theirfavour both in the health facilities and at community level are required forthese groups of PLWHIV to obtain viral suppression. Research should bedone to identify strategies that will improve their outcome.

P359

A CASE OF DISSEMINATED HISTOPLASMOSIS WITH CONCOMI-TANT CLOSTRIDIUM DIFFICILE INFECTION, P. AERUGINOSAAND E. COLI BACTERAEMIA AND CITOMEGALOVIRUS REACTI-VATION IN HIV PATIENT IN A NON-ENDEMIC COUNTRY

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Ramirez-Hidalgo M.F.1, Cuadrat-Begue I.2, Bellés-Bellés A.3,Gros-Navés L.4 , Perez-Reyna R.5, Chavez-Parada C.5, Pericas-Pulido J.M.61Tropical Medicine Dept., Arnau de Vilanova Univesity Hospital,Lleida;2Internal Medicine Dept., Arnau de Vilanova Univesity Hospital,Lleida;3Microbiology Dept., Arnau de Vilanova Univesity Hospital, Lleida;4Lleida Rural Nord Basic Health Area, Gestió de Serveis Sanitaris,Lleida;5Haematology Dept., Arnau de Vilanova Univesity Hospital, Lleida;6Clinical director Infectious Diseases & Clinical Microbiology, Lleida,Spain

Introduction: Histoplasma capsulatum var. capsulatum (Hcc) is adimorphic fungus that may cause systemic disease in HIV patients. Itis endemic along Ohio and Mississippi river valley, Latinoamerica, Indiaand Southeast Asia. In West Africa we can found Histoplasma capsulatumvar. dubosii (Hcd) but no cases of Hcc in Mali (1). Anecdotal cases havebeen described in Europe (2).We present a patient from Mali, resident in Spain, with HIV coinfectedwith disseminated histoplasmosis, Clostridium difficile, P. aeruginosa andE. coli infection and Citomegalovirus (CMV) reactivation.Case Report: A 47-year-old man born in Mali moved to Spain 11 yearsago, recent diagnosis of HIV with an absolute CD4 count of 6 cells/uL,presented for fever, abdominal pain, vomits, bloody diarrhoea and olig-uria for 24hs. He also presented cough, haemoptysis and weight loss for 2months. He was afebrile, tachycardic with low blood pressure and oxygensaturation 98%. Physical exam revealed cachectic state, pitting oedemaon legs, skin lesions and fine crackles in lungs.Laboratories revealed creatinin 5.58 mg/dL, transaminases elevation, C-reactive protein 232.5 mg/L, lymphocyte count 260 cells/uL, haematocrit30%, platelets 98.000/uL. Clostridium difficile PCR was positive in faecesso fidaxomicin was initiated with piperacillin-tazobactam and ganciclovir.Liposomal Amphotericin B was initiated when the cytologist revealedintraneutrophil inclusions suggestive of fungal infection. A positive PCRfor Hcc and eventually grew of the fungus in blood cultures, confirmedthe diagnosis. We also revealed a positive PCR CMV in serum with 2864copies/mL and P. aeruginosa and E. coli in blood culture. Computedtomography of the chest revealed micronodular opacities in right upperand medium lobe, bilateral axillar lymphadenopathy and diffuse ground-glass changes.We obtained negative results in mycobacterial and common pathogensanalysis.Patient was discharged with posaconazole. Constitutional symptoms,pulmonary and laboratory abnormalities improved in the follow-up.Conclusion: Disseminated histoplasmosis is rare in a non-endemicarea and it is a challenge to clinicians because of the variety in theclinical presentation and the restricted range of tests. In our case,the cytological identification helped to have a clinical suspicion. Webelieve that improvement of surveillance in non-endemic countries iscrucial.

References:1. Oladele RO, Ayanlowo OO, Richardson MD, Denning DW. Histoplas-mosis in Africa: An emerging or a neglected disease?. PLoS Negl TropDis 2018; 12(1): e0006046. Available at: https://doi.org/10.1371/journal.pntd.0006046.2. Adenis AA, Aznar C, Couppié P. Histoplasmosis in HIV-Infected Patients:A Review of New Developments and Remaining Gaps. Curr Trop Med Rep2014; 1(2): 119-128.

P360

GENETIC DIVERSITY AND TRANSMITTED DRUG RESISTANCE INHIV-1 INFECTED PREGNANT WOMEN NEWLY DIAGNOSED INLUANDA, ANGOLASebastião C.S.1,2,3,4, Neto Z.2, Jesus C.S.5, Mirandela M.2,Jandondo D.2, Couto-Fernandez J.C.5, Tanuri A.6, Morais J.2,7,Brito M.4,8

1NOVA Medical School, Faculdade de Ciências Médicas, Universi-dade NOVA de Lisboa, Lisboa, Portugal;2Instituto Nacional de Investigação em Saúde, Luanda, Angola;3Instituto Superior de Ciências da Saúde, Universidade AgostinhoNeto, Luanda, Angola;4Centro de Investigação em Saúde de Angola, Luanda, Angola;5Laboratorio de AIDS & Imunologia Molecular, Instituto OswaldoCruz, Rio de Janeiro, Brazil;6Laboratório de Virologia Molecular, Departamento de Genética,Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil;7Faculdade de Medicina, Universidade Agostinho Neto, Luanda,Angola;8Health and Technology Research Center (H&TRC), Escola Superiorde Tecnologia da Saúde de Lisboa, Instituto Politécnico de Lisboa,Lisboa, Portugal

Introduction: The evaluation of HIV-1 genetic diversity and determi-nation of transmitted drug resistance associated to the antiretroviraltherapy is of paramount importance in the molecular epidemiologicalmonitoring, in guiding therapeutic regimen and prevention mother-to-child transmission.Aim: To present recent data of HIV-1 genetic diversity and prevalence ofTDR in recently diagnosed, drug naive pregnant women from Luanda, fora better understanding of current molecular epidemiology of HIV-1 inAngola and to support policies of prevention, assistance and treatmentof HIV in the country.Methods: In this study, the HIV-1 pol gene from the blood sample of34 pregnant women with a recent diagnosis and naive antiretroviraltreatment were completely amplified and sequenced with the ABI 3500Genetic Analyzer (Applied Biosystems, USA) using an in-house VirologyQuality Assurance (VQA) in-house test in Luanda, Angola.Results: The subtype C (38%) was the more prevalent, followed by sub-type F1 (18%), A1 (9%), G (9%), D (6%) and H (3%). In addition, the detec-tion of the circulating recombinants forms, CRF02_AG (6%), CRF37_cpx(3%) and the unique recombinant forms, F1/C (3%), A1/G (3%), and H/G(3%) were found. A total of 6/34 (18%) pregnant woman showed someresistance mutation to antiretroviral. Low levels of transmitted drug resis-tance were observed associated to the nucleoside reverse transcriptase(3%) and protease inhibitors (3%), however, a higher prevalence (18%)of resistance mutations was detect to the non-nucleoside reverse tran-scriptase inhibitors, mainly the mutations K103N (33%), G190A (33%),and Y181I (17%), causing different levels of resistance to the antiretroviralused in Angola.Conclusions: The high prevalence observed for non-nucleoside inhibitorsis probably due to its widespread use as part of the first-line antiretroviralregimens in Angola. However, it is necessary that surveillance studiesof resistant HIV-1 subtypes continue to be carried out in Angola toensure surveillance and to estimate the national prevalence of resistancesubtypes in the general population and to assist the Angolan Ministry ofHealth in the design of new antiretroviral regimens for the fight againstinfection in Angola.

P361ELEVATED PLASMA MATRIX METALLOPROTEINASE-8 PREDICTSSPUTUM CULTURE POSITIVITY IN PULMONARY TUBERCULOSIS

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https://doi.org/10.1371/journal.pntd.0006046


Walker N.F.1, Karim F.2, Moosa M.Y.S.3, Moodley S.2, MazibukoM.2, Khan K.2, Leslie A.2, Pym A.21TB Centre and Dept. of Clinical Research, London School ofHygiene and Tropical Medicine, London, UK;2Africa Health Research Institute, Durban, South Africa;3Dept. of Infectious Diseases, University of KwaZulu-Natal, Durban,South Africa

Introduction: Tuberculosis (TB) caused an estimated 10.0 million casesand 1.6 million deaths in 2017, disproportionately affecting low resource-settings. Despite available effective treatments, treatment success rateshave fallen to 82% globally and are 55% for multi-drug resistant TB. Iden-tifying patients who inadequately respond to treatment is a challenge,relying on sputum analysis, skilled personnel, laboratory infrastructureand time. Matrix metalloproteinases (MMPs) are host enzymes that areupregulated by Mycobacterium tuberculosis (Mtb) and are elevated inhuman TB disease.Aim: We evaluated plasma MMPs as biomarkers of TB treatmentresponse.Methods: Patients with active TB were recruited in Durban, South Africa.Sputum for mycobacterial analysis including drug susceptibility testingand plasma were collected at TB diagnosis, week 8 and month 6 followingTB treatment initiation. Plasma MMP-1, -3, -8, -9, and -10 were measuredby multiplex and procollagen III N-terminal propeptide (PIIINP), a matrixdegradation product, by ELISA.Results: 85 participants were enrolled. HIV seroprevalence was 43.5%.At enrolment, 78 (91.7%) were Mtb culture positive. At 6 months, 5(5.88%) participants were culture positive: two were fully sensitive, twohad acquired multi-drug resistance and one drug susceptibility resultwas unavailable. These were predominantly sputum smear negative(4/5, 80%). Plasma MMP-1, -8, -10 and PIIINP concentrations decreasedbetween enrolment and week 8. MMP-8 was significantly increased inMtb sputum culture positive compared to culture negative participantsat enrolment (median MMP-8 4609 pg/ml, IQR 2353-9048 vs median775 pg/ml, IQR 551-4920, p=0.019 respectively) and at month 6 (median3650, IQR 1214-3888 vs median 720, IQR 551-1321, p=0.008). By receiveroperating characteristic curve analysis, month 6 MMP-8 predicted month6 culture positivity with an area under the curve of 0.847 (95% CI 0.723-0.970, p=0.011), corresponding to a sensitivity of 100% and a specificity of65% at the optimal cut-off (>920 pg/ml).Conclusion: Plasma MMPs and PIIINP decreased with effective TB treat-ment. Elevated plasma MMP-8 is associated with sputum culture positiv-ity in smear negative patients and is a candidate biomarker for monitoringtreatment response. It is suitable for adaptation into a low-cost point-of-care tool for diagnostic and treatment interventions, warranting furthervalidation.Acknowledgements:Funding was from British Infection Association, Academy of MedicalSciences UK, National Institutes of Health (U01 AI 069924) and MedicalResearch Council South Africa. We are grateful to Vanderbilt UniversityMedical Center for assistance with this study.

P362

CHALLENGES IN TUBERCULOSIS INFECTION CONTROL IN PUB-LIC HEALTHCARE FACILITIES IN ARBA MINCH TOWN OF SOUTH-ERN ETHIOPIA – A MIXED METHODS STUDYToitole K.K.1, Vander Kelen C.2, Ejara E.D.3, Battaglioli T.21Dept. of Internal Medicine, Arba Minch General Hospital, ArbaMinch, Ethiopia;2Dept. of Public Health, Institute of Tropical Medicine, Antwerp,Belgium;3Dept. of Internal Medicine, University of Gondar, Gondar, Ethiopia

Introduction: Tuberculosis (TB) is a major public health problem inEthiopia. To control transmission in healthcare facilities, TB infectioncontrol measures (TB-IC) should be implemented. Ethiopia developedTB-IC guidelines in 2010. However, their implementation is sub-optimaland local data are limited.Aim: To explore challenges in TB-IC in three public healthcare facilities inArba Minch town, Southern Ethiopia.Methods: This mixed-method study was carried out in February and April2018. We assessed knowledge, attitude and practice (KAP) towards TB-IC among health professionals using an anonymous, self-administeredstructured questionnaire, conducted 13 In-depth interviews and six focusgroup discussions and health facility assessment. Composite scores forKAP were calculated. Logistic regression was used to identify factorsassociated with KAP above the median value of the respective compositescore. Qualitative data were analysed thematically using the SystemsEngineering Initiative for Patient Safety model.Results: No health facility had a TB-IC plan or an occupational healthrecord for staff treated for TB or a record of TB-IC training. The mediantime between positive TB symptoms screening and diagnosis was >1day in all facilities. In waiting areas, individuals with TB symptoms werenot separated. Among the 237 KAP survey respondents, 44% had beenin service for ≥5 years, 14% had been treated for TB, 29% had receivedTB-IC training; 40% thought that TB can be transmitted by sharing foodsand drinks; 76% did not know that surgical masks do not protect from TBinfection and 31% that FFP2/N95 respirators are protective. Most partici-pants (86%) worried about acquiring TB while at work; 45% thought thatcoughers should wait as others in waiting areas. At multivariate analysis,TB-IC training was found to be determinant for knowledge (adjustedodds ratio=0.4, 95%CI:0.2-0.8). Shortage of masks and respirators, lackof emphasis and monitoring of TB-IC, unsuitable facility setup, delayin diagnosis and treatment, stigma and discrimination were the mainreported challenges to TB-IC implementation.Conclusion: We found major gaps in TB-IC managerial/administrativemeasures and in knowledge among health professionals. Urgentactions are needed to strengthen TB-IC implementation in the studyarea.

P364

RESPIRATORY TRACT CRYPTOSPORIDIOSIS IS COMMON INHIV-NEGATIVE CHILDREN WITH PRIMARY GASTROINTESTINALOR RESPIRATORY CLINICAL PRESENTATIONS

Mor S.M.1, Ndeezi G.2, Ascolillo L.R.3, Tasimwa H.B.4, Charalam-pos A.1 , Nakato R.2, Namuli L.2, Tzipori S.5, Tumwine J.K.2,Griffiths J.K.31Institute for Infection and Global Health, University of Liverpool,Liverpool, UK;2Dept. of Paediatrics and Child Health, Makerere University Collegeof Health Sciences, Kampala, Uganda;3Dept. of Public Health and Community Medicine, Tufts UniversitySchool of Medicine, Boston, USA;4Dept. of Microbiology, Makerere University College of Health Sci-ences, Kampala, Uganda;5Dept. of Infectious Diseases and Global Health, Tufts Univer-sity Cummings School of Veterinary Medicine, North Grafton,USA

Introduction: Respiratory tract cryptosporidiosis (RTC) is considered anoccasional, late-stage complication of HIV/AIDS.Aim: To elucidate the clinical and epidemiological significance of RTC inchildren in Kampala, Uganda with primary gastrointestinal and respira-tory presentations.

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Methods: Children aged 9-36 months presenting to the Acute Care Unitat Mulago Hospital with 2 different chief complaints were enrolled: (A)diarrhoea, with cough (n=1935); and (B) cough or pneumonia, with orwithout diarrhoea (n=1245). Children were screened for Cryptosporidiumin stool using RT-PCR. Stool-positive children were selected for furtherdiagnostic tests, including sputum induction if eligible. In addition, 59stool-negative children in Group B were selected for sputum induction.Sputum samples were subjected to RT-PCR for Cryptosporidium, bacterialculture and sensitivity and auramine-smear for TB.Results: Prevalence of enteric cryptosporidiosis was 259/1935 (13.4%)and 74/1245 (5.9%) in Group A and B, respectively (82.2% C. hominis,15.4% C. parvum, 2.3% C. meleagridis or mixed). Of 300 stool-positivechildren that had sputum available for analysis, 79 (26.3%) had RTC(62/235 [26.4%] and 17/65 [26.2%] in Group A and B, respectively; NS).Strikingly, 8 stool-negative children in Group B, only 2 of whom haddiarrhoea, also had RTC. RTC occurred in children with C. hominis andC. parvum enteric infections, but was significantly more common in theformer (82/253 [32.4%] versus 7/46 [15.2%] enteric infections, p=0.022).No bacterial pathogens were cultured from sputum of 32/87 (36.8%)children with RTC. Of the 70 children with RTC and available HIV result,all children were HIV-negative, except for one.Conclusion: RTC is common in stool-positive children with primary gas-trointestinal and respiratory presentations in Uganda, and also occursin the absence of apparent enteric infection. C. hominis has a greaterpropensity for infection of the respiratory tract than C. parvum. HIV doesnot seem to be a determinant of RTC.

P365RISK FACTORS FOR TUBERCULOSIS (TB) TREATMENT INTER-RUPTION AMONG PATIENTS IN BARINGO COUNTY, KENYA: ARETROSPECTIVE COHORT STUDY

Yonga P.O.1,2, Rutto K.1, Rono R.3, Kalya S.K.11Dept. of Internal Medicine, Baringo County Referral Hospital,Kabarnet;2Dept. of Internal Medicine, Fountain Health Care Hospital, Eldoret;3Dept. of Preventive and Promotive Health Services, Baringo CountyGovernment, Kabarnet, Kenya

Introduction: Tuberculosis (TB) treatment success has been noted inKenya over the years, though adherence to treatment still poses a chal-lenge in Kenya, especially among the pastoralist communities.Aim: To determine factors associated with TB treatment interruption in aKenyan pastoralist community.Methods: A retrospective cohort study was conducted among adultpatients in Baringo County, Kenya with TB whose details were registeredin TIBU, a national electronic data system specifically dedicated for TBprogramming. Kaplan Meier curves were utilized for assessing time fromcommencement of treatment to treatment interruption, and multivari-ate analysis was performed using Cox proportional hazards modelling.Results: 141 patients were studied, with a male gender predominanceof 60.3% (n=85), and a TB/HIV co-infection rate of 22% (n=31). 15.6%(n=22) of the patients were documented to have interrupted TB treat-ment, with a cumulative incidence rate of 3%. Patients aged 18-60years (HR: 1.50; 95% CI: 0.50-4.56), TB/HIV co-infected patients (HR:1.42; 95% CI: 0.51-4.00), and male patients (HR: 1.07; 95% CI: 0.45-2.56) were at increased risk of interrupting treatment, though the effectswere not statistically significant. Testing for HIV at TB diagnosis (HR: 0.98;95% CI: 0.13-7.34) was noted to bea protective factor for preventing TBtreatment interruption, though this effect was not statistically significantas well.Conclusion: High rates of TB treatment interruption were noted majorlyamong young patients and TB/HIV co-infected patients. Thus, pre-

treatment counseling should be intensified among these groups, andTB/HIV integration services further strengthened to improve adherenceto TB treatment.

P366

CO-MORBIDITIES IN FILIPINO PERSONS WITH TUBERCULOSIS:A CROSS-SECTIONAL STUDY IN URBAN AND RURAL PUBLIC TB-DOTS FACILITIES

White L.V.1, Edwards T.1,2, Lee N.3, Castro M.C.4, Saludar N.R.5,Calapis R.W.6, Faguer B.N.1, Garfin C.7, Solon J.A.4, Cox S.E.1,8

1School of Tropical Medicine and Global Health, Nagasaki Univer-sity, Nagasaki, Japan;2Tropical Epidemiology Group, London School of Hygiene and Trop-ical Medicine, London, UK.;3Royal Free Hospital, London, UK;4Nutrition Center Philippines, Manila, the Philippines;5San Lazaro Hospital, Manila, the Philippines;6San Lazaro Hospital PMDT Treatment Center, Manila, thePhilippines;7National TB Programme, Manila, the Philippines;8Faculty of Population Health, London School of Hygiene and Trop-ical Medicine, London, UK

Introduction: Diabetes and undernutrition are important TB risk factors,requiring management to improve treatment outcomes, but Filipino dataare scarce.Aim: To determine the extent of co-morbidity, in particular diabetes andundernutrition, in persons enrolled at urban and rural TBDOTS facilities.Methods: All non-pregnant individuals aged ≥18 years, registeredas undergoing TB-DOTS in five participating clinics; three in MetroManila (urban) and two in Negros Occidental (rural) were invited toparticipate. Active community tracing was employed for those notregularly attending the TB-DOTs facility. Diabetes was defined asHbA1c>=6.5% (Alere Afinion AS100) from an EDTA finger-prick sample.Finger-prick haemoglobin was measured using a Hemocue 301. HIV rapidtest screening was offered to all participants and required additionalconsent.Results: Between May-September 2017, 637 persons with TB wereenrolled; 338 (53.1%) in urban and 299 (46.9%) in rural facilities. Theprevalence of moderate or severe undernutrition (BMI<17 kg/m2) was20.5% (95% CI: 17.4-23.9%) and more common in rural facilities (25%vs 17%, p=0.014). The prevalence of diabetes was 9.2% (95% CI: 7.0-11.8) with 52% previously undiagnosed. The prevalence of severe ormoderate anaemia (hemoglobin<11g/dl) was 13.6% (95% CI:11.0-16.5%). Hypertension was self-reported by 8.6% (95% CI: 6.6-11.1).Prevalence of these conditions was similar in rural and urban areas.In urban facilities, 74/303 (24%) were HIV positive, with most casesin one tertiary HIV treatment facility and 163/290 (56%) with completedata had at least one co-morbidity. HIV status was unknown for 85% ofpatients in rural facilities due to refusal, with only two cases amongstthose tested. Ignoring HIV status in rural areas, 83/261 (32%) withcomplete data had at least one comorbidity. When comparing ruraland HIV negative patients in urban areas 41% and 48% had at leastone co-morbidity and 8% and 11% had at least two comorbidities.The most frequent combination of co-morbidities was for anaemiaand undernutrition, then self-reported hypertension and diabetes andonly undernutrition and anaemia co-morbidities were observed incombination with HIV.Conclusion: Half of Filipino TB patients could require management of aco-morbid condition. There was very little overlap of co-morbidity withTB-HIV.

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P368

PERCEIVED BARRIERS AND FACILITATORS TO TUBERCULOSISCARE IN NEPAL

Dixit K.1, Aryal T.P.1, Gurung S.C.1, Dhital R.1, Caws M.2,Wingfield T.3,4,5

1Public Health Dept., Birat Nepal Medical Trust, Kathmandu,Nepal;2Dept. of Clinical Sciences, Liverpool School of Tropical Medicine,Liverpool, UK;3Dept. of Clinical Sciences and International Public Health, Liver-pool School of Tropical Medicine, Liverpool, UK;4Social Medicine, Infectious Diseases, and Migration (SIM) Group,Dept. of Public Health Sciences, Karolinska Institutet, Stockholm,Sweden;5Tropical and Infectious Diseases Unit, Royal Liverpool and Broad-green University Hospitals NHS Trust, Liverpool, UK

Introduction: Although diagnostic tests and medicine for tuberculosis(TB) are free, there are hidden barriers for patients living with TB (PLWTB)and multi-drug resistant TB (PLWMDRTB) to access and engage with care.However, evidence concerning these barriers and the optimal strategiesto combat them is limited, impairing National TB Program’s (NTP) effortsto offer holistic, patient-centred care.Aim: To characterise patients’ perspectives on risk factors for developingTB/MDR-TB disease and barriers and facilitators to care.Methods: Between August 2018 and February 2019, a mixed-methodstudy was conducted, including two focus group discussions (FGDs) withPLWTB and PLWMDRTB. Participants were people currently or recentlytreated for TB at government health facilities in four study sites in Nepal.Participants were purposively sampled to ensure diversity of socioculturaland economic position. FGDs used semi-structured questions to facilitatediscussion of risk factors for TB and barriers/facilitators to TB care. FGDswere audio recorded, transcribed in Nepali, and translated into English.Dominant FGD themes and sub-themes identified were analysed usingNVivo-12.Results: There were fourteen participants, eleven of whom were male.PLWTB and PLWMDRTB identified heavy alcohol consumption, weakimmune systems, and poor sanitation and environment in the homeor workplace as risk factors for developing TB disease; and highlightedunemployment, household economic burden, long distance to TBtreatment centres, and multiple visits to public and private healthcarefacilities as barriers to care. Barriers to care identified only by PLWMDRTBwere requirement of daily nutritional supplements, distance from familyand friends (geographically, due to admission to a hostel throughoutMDR-TB treatment and, socially, due to stigma), and discrimination fromhealthcare workers. Common facilitators to care mentioned across bothgroups included support from healthcare workers, family and peers,free medicines, and governmental reimbursement of nutrition andtransportation costs. PLWMDRTB highlighted the need for better localaccess to resistance testing on sputum samples.Conclusion: TB patients face multiple barriers while accessing TB diag-nosis and treatment in Nepal. Psychosocial and socioeconomic supportpackages integrated into routine NTP activities are required to amelio-rate these barriers, improve accessibility, and enhance patient-centredcare.

P369

PATIENT AND STAKEHOLDER PERSPECTIVES ON BARRIERS ANDFACILITATORS TO TUBERCULOSIS CARE IN NEPAL

Dixit K.1, Gurung S.C.1, Dhital R.1, Caws M.2, Wingfield T.3,4,5

1Public Health Dept., Birat Nepal Medical Trust, Kathmandu, Nepal;2Dept. of Clinical Sciences, Liverpool School of Tropical Medicine,Liverpool, UK;3Dept. of Clinical Sciences and International Public Health, Liver-pool School of Tropical Medicine, Liverpool, UK;4Social Medicine, Infectious Diseases, and Migration (SIM) Group,Dept. of Public Health Sciences, Karolinska Institutet, Stockholm,Sweden;5Tropical and Infectious Diseases Unit, Royal Liverpool and Broad-green University Hospitals NHS Trust, Liverpool, UK

Introduction: People affected by tuberculosis (TB) face multiple barriersto accessing and engaging with TB care. Identifying and addressing thesebarriers and facilitators can contribute to enhanced TB control.Aim: To explore whether perceived barriers and facilitators to TB carediffer between people with and without direct experience of TB disease.Methods: Between August 2018 and February 2019, we conducted fivefocus group discussions (FGDs) with 39 purposively selected participants.Participants included patients with TB (n=14 of which n=7 had multi-drugresistant TB) and other stakeholders without current TB diseases suchas community leaders (n=6), grass-roots community organizations (n=7),and TB health professionals (n=12), predominantly from Nepal’s NationalTB Program). Semi-structured questions were used to discuss barriers andfacilitators to TB care. Major FGD themes and sub-themes were identifiedand thematic analysis was done using NVivo-12.Results: The most common barriers collectively mentioned acrossFGDs were: increased financial burden on TB-affected householdsmainly related to transportation and nutritional requirements; multiplediagnostic visits to both public and private clinics; and discriminationfrom healthcare workers. The patient FGDs reported specific barriersincluding: unemployment and distance from family members duringtreatment. Stakeholder FGDs emphasized barriers including: geographicalbarriers and long distance to health centres; inadequate advocacy andpatient-centred care by health centres; and inadequate awarenessabout TB among TB-affected households. The most common facilitatorscollectively mentioned across FGDs were: nutritional and financialsupport for patients affected by TB; provision of free and quality TBmedicines from government; supportive behaviour of healthcare workers;community awareness raising programs; improved access to diagnosticfacilities; and mobilization of community volunteers or sputum campsfor active case finding. Stakeholders specifically mentioned the need forpolitical commitment to improve TB services.Conclusion: Economic hardship of TB-affected households, diagnosticdelays, and stigmatizing behaviour from healthcare workers are barriersto TB care in Nepal. Patient-centred care including financial and nutri-tional support could contribute to overcoming these barriers.

P371

DRUG RESISTANCE PROFILES OF HIV-1 POSITIVE PATIENTSEXPERIENCING VIROLOGICAL REBOUND ON RITONAVIR-BOOSTED DARUNAVIR MONOTHERAPY

Abdullahi A.1, Fopoussi O.M.2, Beloukas A.3, Defo V.F.2,3,Moudourou S.2, Kouanfack C.3, Torimiro J.2, Geretti A.M.11Institute of Infection and Global Health, University of Liverpool,Liverpool, UK;2Chantal Biya International Reference Centre for Researchon HIV/AIDS Prevention and Management (CIRCB), Yaoundé,Cameroon;3Hôpital Central Yaoundé, Ministry of Public Health, Yaoundé,Cameroon

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Introduction: Randomised trials investigating the use of ritonavir-boosted darunavir (DRV/r) as maintenance monotherapy have uniformlyreported an increased risk of viraemia on DRV/r monotherapy, but a lowrisk of emerging darunavir resistance-associated mutations (RAMs) usingSanger sequencing.Aim: This study characterised and compared the resistance profiles ofpatients who experienced viraemia (>60 copies/ml) on DRV/r monother-apy while taking part in a randomised clinical trial in Cameroon usingSanger sequencing in peripheral blood mononuclear cells (PBMCs) atstudy entry and ultra-deep sequencing in plasma at time of virologicalrebound.Methods: At study entry (baseline), patients were mostly female 61/81(75%) and had been on ART for a median of 7.5 years and on a PI-basedtriple combination regimen for a median of 3.1 years. Median current CD4and nadir CD4 counts were 467 and 92 cells/mm3, respectively. UsingSanger and deep sequencing, reverse transcriptase (RT) and proteaseRAMs were investigated in baseline Peripheral Blood Mononuclear Cells(n=60) and plasma at viraemia (n=21).Results: By Sanger sequencing, NRTI and NNRTI RAMs were detectedin 39/60 (65.0%) and 41/60 (68.3%) with 37/60 (61.7%) having muta-tions to both drug classes including 29/60 with ≥1 thymidine analoguemutation (TAMs) and 5/60 (8.3%) with multi-drug resistance (MDR) andmiscellaneous mutations. Three patients showed the D30N PI muta-tion. Most patients were infected with HIV-1 subtype CRF02_AG (35/60;58.3%). In plasma samples, NRTI and NNRTI RAMs occurred in 9/21(42.9%) and 5/21 (23.8%) samples respectively and 2 patients had D30NPI mutation. The D30N PI mutations showed no phylogenetic clustering.When comparing resistance profile in 18 patients with available plasmaand PBMC data, most patients (12/18) resistance profile was either fullyor partially consistent.Conclusion: Resistance testing of HIV-1 DNA should be interpreted inthe context of the patient’s full treatment and resistance history, andabsence of detection should be interpreted with caution.

P375

ISOLATED TESTICULAR TB: A RARE CASE IN A 41 YEARS OLDPATIENT

Lomencho A.1, Fantaye H.21Emerald Medical, AMC Infectious Diseases Center, Addis Ababa;2Federal Ministry of Health, Addis Ababa, Ethiopia

Introduction: Urogenital TB is one of the common presentations of TBworldwide. Isolated testicular TB is a rare finding.Aim: To describe clinical profile of a patient with urogenital TB.Methods: Case report.Results: We present a case of Testicular TB in a patient who presentedto our center for general check-up. He has no background history ofimmunosuppression and is from a good socioeconomic background.The patient had no fever, night sweats, dysuria or cough. All generalcheck-up tests including chest X – ray, ESR and ultrasound of abdomenwere normal. Four months later he came back with a month historyof swelling in his right testicle associated with scrotal erythema andlocalized abscess. Ultrasound revealed 4 x 5 cm testicular mass withcentral necrosis and fluid. FNAC from the right tests showed caseousgranulomatous necrosis suggestive for testicular TB. AFB was negative.TB culture was also done and showed growth of Mycobacterium Tuber-culosis. Repeat chest X ray, ESR, Abdominal ultrasound were normal.Patient received full course of Anti TB (2RHZE/4RH) and the swellingsubsided.Conclusion: Urogenital TB is the third most common site for TB dissem-ination. However, isolated testicular TB is a rare presentation of TB. Itpresents with painful or painless swelling, and if left untreated draining

sinus and permanent infertility. Epididymitis is the commonest feature. Itis often confused with other testicular pathologies including torsion andcancer. As with our patient, constitutional symptoms including fever andnight sweats may not be present. Isolated testicular swelling in otherwisehealthy patient living in TB endemic countries like Ethiopia should raisesuspicion of testicular TB.

P376

LAY COMMUNITY PERCEPTIONS AND TREATMENT OPTIONS FORHYPERTENSION IN RURAL NORTHERN GHANA – A QUALITATIVEANALYSIS

Nyaaba G.N.1, Masana L.2, Aikins A.D.3, Stronks K.1,Agyemang C.11Dept. of Public Health, APH Research Institute, University of Ams-terdam, University Medical Centres, Amsterdam, The Netherlands;2Barcelona Institute for Global Health (ISGlobal), University ofBarcelona, Medical Anthropology Research Centre-URV, Tarragona,Spain;3Regional Institute for Population Studies, University of Ghana,Legon, Ghana

Introduction: Adherence to hypertension treatment is a major publichealth challenge for low and middle-income countries particularly in sub-Saharan Africa. One potential reason could be the discordance betweenlay and medical explanatory models of hypertension and its treatment.Understanding community perceptions and practices may contribute toimproving hypertension control as they present insights into psychosocialand cultural factors that shape individual behaviour.Aim: We explore community perceptions regarding hypertension and itstreatment in rural northern Ghana and how they differ from medicalunderstanding.Methods: This was a multisite qualitative study using semi structuredinterviews and focus group discussions to collect data in four ruralcommunities in two regions of northern Ghana, which were analysedusing a thematic approach. We conducted 16 semi structured interviewsand 8 focus group discussions with community leaders and membersrespectively.Results: Three major themes were identified; community perceptions,treatment options and community support for people with hypertension.Community perceptions about hypertension include hypertensionperceived as excess blood in the body and as spiritual or witchcraftattacks. Traditional medicine is perceived to cure hypertension com-pletely with concurrent use of biomedical and traditional medicinesencouraged in rural communities. Community members did not considerthemselves at risk of developing hypertension and reported havinginadequate information on how to provide social support for hypertensivecommunity members which they attributed to low literacy andpoverty.Conclusion: There is a substantial mismatch between communities’ per-ceptions and medical understanding of hypertension and its treatment.These perceptions partly result from structural factors and social normsshaped by collective processes and traditions which shape lay beliefsand influence individual health behaviour. Socioeconomic factors alsothwart access to information and contribute to inadequate social supportfor persons with hypertension. These findings highlight the need for apublic health approach to hypertension control targeting families andcommunities.

P377

THE HIDDEN BURDEN OF CHRONIC RESPIRATORY DISEASE INPATIENTS ATTENDING TB CLINICS IN THE GAMBIA

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Jayasooriya S.M.1,2, Jobe A.1, Badjie S.1, Owolabi O.1, RachowA.3, Sutherland J.S.1, Kampmann B.1,4

1Vaccines and Immunity Theme, Medical Research Council UnitThe Gambia, London School of Hygiene and Tropical Medicine,Gambia;2School of Health Sciences and Related Research (ScHARR), Univer-sity of Sheffield, Sheffield, UK;3Division of Infectious Diseases and Tropical Medicine, MedicalCentre of the University of Munich, Munich, Germany;4Vaccine Centre, London School of Hygiene and Tropical Medicine,Bloomsbury, London, UK

Introduction: Seventy-two per cent of deaths worldwide are attributed tonon-communicable diseases (NCDs) and this proportion is rising. A lead-ing cause of NCD-related mortality is chronic respiratory disease, causingan estimated 3.8 million deaths in 2015. Early TB diagnosis is improvingwith the increased sensitivity of Xpert MTB/RIF® and Ultra assays oversputum microscopy in adults. Patients with GeneXpert negative sputumform an important group in LMICs. They require further diagnostic work-up as we become more confident that those who test negative are lesslikely to have active TB.Aim: Perform a pilot study, using data from routine care, to determine theaetiology of symptoms in patients with GeneXpert negative sputum at TBscreening.Methods: Patients were consecutively recruited from a TB research clinicbetween September 2017 and July 2018. A spot and early morningsputum Xpert MTB/RIF® assay were performed. Where both assays werenegative, patients were followed-up as part of routine care. All underwentHIV testing, a chest radiograph and further available investigations asclinically indicated.Results: 125 (52%) were both spot and early morning sputum XpertMTB/RIF® (n=63) or Ultra (n=62) assay negative. Of these 17 (14%) wereclassified as TB on clinical and radiological grounds. The other 108 (86%)not-TB cases, included four (3.7%) deaths and six (6%) patients lost tofollow-up. Excluding the six patients lost to follow-up, diagnoses wereestablished in 62% (63/102). The majority of patients had respiratoryconditions (48/63; 76%), followed by cardiovascular (13/63; 21%) andrenal disease (2/63; 3.2%). The diagnosis remained unknown in 32%(35/102). A high proportion of these were HIV-1-positive 34% (12/35),had a past medical history of TB 40% (14/35) and were current smokers23% (8/35).Conclusion: Models for health care provision for patients in LMICswith chronic respiratory diseases are in their infancy. These findingshighlight the potential for using existing TB clinics to capture thishidden burden of disease. It is imperative that we broaden our outlookand rethink our view of TB services, as they may prove essential inenabling us to meet the challenges of the rising NCD pandemic inLMICs.

P378THE OUTCOME OF PATIENTS ON HEMODIALYSIS AT UNIVER-SITY TEACHING HOSPITAL OF KIGALI: A RETROSPECTIVEANALYTICAL STUDY ON PATIENTS WITH ACUTE AND CHRONICRENAL FAILUREBitunguhari L.1, Twahirwa T.S.2, Murengezi E.3, Mukiza J.41Dept. of Internal Medicine, University Teaching Hospital, Kigali;2Dept. of Research and Quality Improvement, University TeachingHospital, Kigali;3Dept. of Health Insurance, Rwanda Biomedical Center, Kigali;4Dept. of Biomedical Science, University of Gitwe, Ruhango,Rwanda

Introduction: Kidney dysfunction is both a national and internationalproblem. Its incidence in the general population is increasing, mostlydue to high prevalence of diabetes, hypertension and the long-termconsequences of acute kidney injury. We conducted this Study in oneof the sub-Saharian country (Rwanda) to assess the outcome of patientunder haemodialysis.Aim: The aim of this study was to describe the demographic data and theoutcome of patients who received haemodialysis at university Teachinghospital of Kigali since the initiation of the dialysis thru 2017.Methods: Data were retrospectively collected and analyzed on 152patients treated in the hemodialysis unit at university teaching hospitalof Kigali during period of lysis service at CHUK during period of September2014 to March 2017. We report the demographic and clinical data as wellas the survival of patients who underwent hemodialysis.Results: We identified 152 patients who received hemodialysis treat-ment. Seventy-eight (51.3%) were identified to have acute kidneyinjury;74 (48.7%) were designated as chronic kidney failure. The mainrisk factors for hemodialysis treatment were hypertension 73 (48%),diabetes 71 (46.7%), eclampsia 20 (13.2%), and volume deficit 24(15.8%). Hyperkalemia, pulmonary edema, encephalopathy and otheruremic symptoms were present in 39-43% of patients and were themost common indications for hemodialysis. Seventy patients (46%)died. Encephalopathy and poor oxygen saturation were independent riskfactors for death. Most patients died within 4 months after hemodialysisinitiation. Forty-five patients (20.6%) could not afford the usual provisionof 3 sessions of hemodialysis per week and received less frequent dialysis.Conclusion: There is high mortality in patients referred for hemodialysis.Almost half of the patients have chronic renal failure and require per-manent renal replacement therapy. Many patients limit therapy due tofinancial reasons.

P380THE EFFICACY OF PROCESSED AMARANTH ON ANEMIA PREVA-LENCE AND HEMOGLOBIN LEVEL IN PRESCHOOL CHILDREN INSOUTH ETHIOPIA: A RANDOMISED CONTROLLED TRIALOrsango A.Z.1,2, Loha E.1, Lindtjørn B.2, Engebretsen I.M.S.21School of Public Health, College of Medicine and Health Sciences,Hawassa University, Hawassa, Ethiopia;2Centre for International Health, University of Bergen, Bergen,Norway

Introduction: Few studies have evaluated the impact of fortification withiron-rich foods such as amaranth grain to reduce anaemia. Amaranth isrich in micro- and macronutrients, specifically iron, but has high level ofphytate which decrease absorption of nutrients from food.Aim: To evaluate the efficacy of processed amaranth containing bread onanemia prevalence and hemoglobin level among preschool children.Method: Anemic (hemoglobin less than 11g/dl) children (N=100) wererandomly identified in a community survey and enrolled in a 1:1 cluster-randomised trial for 6months. In the intervention arm (N=50), daily 150gbread containing 70% amaranth and 30% chickpea, where the amaranthwas processed, meaning socked, germinated and fermented was given.In the control arm (N=50), daily 150g bread containing processed maizewas given. The bread was given in the mornings under direct supervisionfor the full study period. Data were collected on socioeconomic statusand dietary diversity. Hemoglobin, ferritin and C-reactive protein weremeasured using standard methods at baseline and after the end of theintervention. Descriptive statistics, generalized estimating equation (GEE),generalized liner model (GLM) and an independent sample t-test wereused to analyse data.Result: The intervention and the control groups were similar at the startof the study. The post intervention anaemia prevalence was lower in the

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intervention than in the control group (9.6% (8/83) compared to 20.5%(17/83), χ2 =4.95, p=0.026). Adjusted odds ratio (AOR) shows anaemiaprevalence was significantly higher in the control group [AOR: 2.96 (1.03,8.51)]. The mean hemoglobin level was 12.4g/dl (CI: 12.11-12.67) in theamaranth group compared with 11.84 g/dl (CI: 11.62 - 12.06) in thecontrol group. The mean hemoglobin difference was -0.55 (95%CI: -1.06to - 0.04) and it was significantly lower in the control group [AOR: 0.49(0.32, 0.78)]. The median level of ferritin in the intervention group was22.2 μg/L (IQR: 13.1- 44.5) and 22.4 μg/L (IQR: 13.3 - 33.2) in the controlgroup.Conclusion: Processed amaranth/chickpea containing bread 70:30 canbe used as food for children and may have favorable effects on thehemoglobin levels.Trial Registry number:PACTR201705002283263.

P381

MENTAL DISORDERS IN NORTHERN BURKINA FASO

Ouedraogo S.1,2, Wédraogo A.M.2, Salamon R.3, Thonneau P.11Health Dept., Senghor University, Alexandria, Egypt;2CBM International, Country Office, Ouagadougou, Burkina Faso;3ISPED, University of Bordeaux, Bordeaux, France

Introduction: Mental disorders are a major public health problem thathas been ignored in Africa. Cities and campaigns in northern BurkinaFaso are experiencing many cases of mentally ill people living on thestreets.Aim: Describe the management of patients with mental disorders andfollowed by the "Sauvons Le Reste" Association.Methods: Observational survey from 17 July to 15 August 2018. Eighteenface-to-face interviews and seventeen focus groups were conducted withpatients and their families.Results: In total, 35 patients were included in our study. Among them,twenty-seven lived in the street for 1 to 35 years. Of the 35 patientstreated by the association and taken into account in our study, theaverage age of disease occurred was 26 ± 9 years. There were 25 singlesand 29 male patients. A notion of psychoactive substance use was foundin 54% of patients. The main diagnoses were psychotic disorders (20/35)and disorders related to the consumption of psychoactive substances(11/35). For the treatment, 14 patients associated modern, traditionalmedicine and religious prayer and 12 had not received any prior to theirintegration into the « seconde chance » project (knowing that 20/35 worecomorbidities). Of the twenty-seven patients who lived in the street, fourstill do not have news of their family. Mental disorders are perceived bythe population as a "curse", a "divine punishment for serious miscon-duct", a "possession of geniuses", a "demon who dwells in Man". Theseinterpretations were a poor insertion of patients into society and manywere left in the street by their families without diagnosis or treatment.Conclusion: The diagnosis and management of mental disorders remainsinadequate in this part of Burkina Faso. The strategy of the "SauvonsLe Reste" Association is to be encouraged in collaboration with publicministries and Non-Governmental Organizations.

P382THE STATE OF PREPAREDNESS FOR INTEGRATION OF NON-COMMUNICABLE DISEASES SERVICES IN PRIMARY CARE FACIL-ITIES IN LILONGWE, MALAWIShiroya V.1,2, Nkhweliwa C.3, Safary E.1, Chaweza T.3,Mwagomba B.3, Phiri S.3, Deckert A.1, Müller O.1, Neuhann F.11Heidelberg Institute of Global Health, Heidelberg, Germany;

2Health Promotion Alliance of Kenya, Kenya;3The Lighthouse Trust, Kamuzu Central Hospital Lilongwe, Lilongwe,Malawi

Introduction: In Malawi 38% of the disease burden is due to non-communicable diseases, with hypertension being the most prevalent.Malawi adopted the WHO Package of Essential NCDs in 2012.Aim: In the context of a larger project on capacity strengthening andimplementation of evidence-based integration models for NCDs weassessed preparedness of primary care facilities to integrate NCD careand control within daily service delivery.Methods: A checklist-based survey of six out of seven public healthfacilities that provide NCD services in Lilongwe district was performedand in-depth interviews with 12 key persons including facility managers,NCD focal points were conducted. Survey questionnaires were developedbased on standardized frameworks of the WHO and the MoH Malawi.Preliminary findings: In response to overwhelming outpatient atten-dance seeking NCD services at the main referral hospitals, a policy direc-tive in 2017 initiated NCD clinics in five public primary care facilities inthe district. The facilities serve a combined catchment population of 1.07million people, in greater Lilongwe. All facilities assessed run a weeklyclinic for first line diagnosis and treatment for hypertension, diabetes andasthma. Interviewees emphasized dissatisfaction with the current statusof NCD services, citing a lack of operational guidance and support. NCDclinics met the district requirement of two personnel on paper but inpractice these clinics were not a priority due to heavy workload in otherdepartments. A discrepancy also exists between personnel who havebeen trained in NCD care versus those providing the service, with 100% ofnurses trained in NCD care reporting that they were not involved in provid-ing the services. None of the health workers interviewed had received in-service refresher training for NCD conditions in the previous 24 months. Allfacilities highlighted insufficient in-service training, unavailability of basicequipment, erratic drug supply, lack of community awareness, and weakcoordination and communication at policy level as some of the mainchallenges facing service integration for NCDs at primary level.Conclusion: The assessment reveals important gaps in translation ofMalawi’s important policy decision to improve service delivery for NCDsat primary levels to practice, thereby requiring further support.

P383

THE BURDEN OF HYPERTENSION IN HAWASSA, ETHIOPIA ANDITS PUBLIC HEALTH RESPONSE: A CROSS-SECTIONAL STUDY ONPARTICIPANTS OF A CYCLING EVENT AND SYSTEMATIC LITER-ATURE REVIEW

Lomencho A.1,2, Fantaye H.3, De Vos P.41Internal Medicine and Public Health, AMC, Addis Ababa, Ethiopia;2Addis Ababa University, MEPI Junior Scholars Project; University ofGondar, Gondar, Ethiopia;3National Blood Bank Service Agency, FMOH, Addis Ababa,Ethiopia;4Institute of Global Health and Development Queen MargaretUniversity, Edinburgh, UK

Introduction: Developing countries like Ethiopia continue to face a dou-ble burden of communicable and non-communicable diseases. There isinsufficient data to characterize the existing burden of hypertension andits associated risk factors in Hawassa, Ethiopia.Aim: The aims of this study are to systematically look into availableevidence of hypertension in Ethiopia and to obtain its approximate figurein Hawassa, Ethiopia.Methods: An annual cycling event happening at Hawassa was used toobtain data on adults with ages 18 years and above. Data was collected

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about sociodemographic characters and measurements. Analysis wasmade by STATA 14. Chi square test and odds ratios with 95% CI were cal-culated and multivariate logistic regression utilized. A systematic reviewof literature with narrative synthesis was made.Results: A total of 250 participants were included in the sample amongwhich 75.2% were men. The burden of blood pressure record in hyperten-sive range was 25.2%. Among those found to have blood pressure recordsin the hypertensive ranges, 84.1% were not aware of it. After multivariatelogistic regression, Age, BMI category (<25 or ≥25), regular physical exer-cise at least twice a week and waist circumference remained to be signif-icant risk factors for the records of blood pressure in hypertensive range.The systematic literature review resulted in an initial search of 192 articlesout of which 10 articles were included in the final synthesis. The studiesrevealed a prevalence of hypertension ranging from 16.5%-25% withurban studies reporting higher values. In all of the studies, the awarenessof hypertension was quite low. Studies reporting adherence to medica-tions revealed <70% adherence. Significant risk factors for hypertensionidentified in most of the studies included age, obesity, cigarette smoking,and lack of physical activity.Conclusion: This study revealed high burden of blood pressure recordsin hypertensive range and low awareness among the participants of thecycling event. This calls for a wider research to further characterize theburden and risk factors. The systematic review revealed a higher burdenin urban settings, low public awareness and shared risk factors.

P384

UPDATE ON THE FURTHER DEVELOPMENT OF THE SKINAPP

Jansen B.1, Mieras L.1, Veldhuijzen N.1, Mwageni N.2,Schoenmakers A.1, Kasang C.3, van Hees C.41Technical Dept., NLR, Amsterdam, The Netherlands;2Dept. of Dermatology, Catholic University of Health and AlliedSciences, Mwanza, Tanzania;3Technical Dept., German Leprosy and Tuberculosis Relief Associa-tion, Würzburg, Germany;4Dept. of Dermatology, Erasmus Medical Centre, Rotterdam, TheNetherlands

Introduction: Available data shows that more than 50% and sometimesas much as 80% of the population in resource poor settings has a skincondition1. Moreover, these regions cope with a shortage of dermatol-ogists and peripheral health workers (PHWs) often lack experience todiagnose and treat skin diseases. The gap between the prevalence ofskin conditions and the availability of capable staff in peripheral healthfacilities should be bridged. NLR developed a mobile phone applicationthat supports PHWs to diagnose and treat skin diseases. The develop-ment of the SkinApp included pilots in Nigeria and Mozambique to testthe algorithm and user-friendliness. The third version of the SkinApp iscurrently being validated.Aim: The validation study aims to evaluate the diagnostic accuracy andreproducibility of the NLR SkinApp for skin diseases, including neglectedtropical diseases presenting with skin lesions, when used by PHWs, andto determine the value of the SkinApp in clinical decision making.Methods: It is a cross-sectional study amongst patients (age>18) pre-senting with skin diseases in an outpatient dermatology clinic. The firstphase was conducted in Mwanza, Tanzania in November 2018. TwoPHWs, without any dermatology training, field-tested the applicationand assessed the value of the SkinApp in clinical decision making. Thediagnosis of two dermatologists was used as the gold standard. The aimwas to enrol at least 24 patients per disease listed in the SkinApp, takinginto account the desired sensitivity, precision and confidence levels.Results: Through observation of the PHWs using the SkinApp it becameclear that it is an easy-to-use, supporting tool during consultation. There

was a clear learning curve with a gradual increase of correct diag-noses over time during the study period. Preliminary findings are encour-aging showing that more than 75% of the people presenting with askin disease listed in the SkinApp is correctly diagnosed. The validatedprocess will be completed in Tanzania, Mozambique and Ethiopia inMay 2019.Conclusion: The preliminary findings of the first phase of the SkinApp vali-dation confirm that it is an easy to use, field-friendly tool that contributesto PHWs’ capability to diagnose skin diseases.

Reference:1. Hay R., Fuller L. The assessment of dermatological needs in resource-poor regions. Int. J. Dermatol 2011; 50, 552–557.

P385CLINICAL PROFILE OF PATIENTS PRESENTING WITH HEAVYMETAL TOXICITY PRESENTING TO A TEACHING HOSPITAL INSOUTH INDIA

Ramya Iyadurai Z.A., Abraham O.C., Thambu D., Sowmya S.,Karthik G.Dept. of Medicine, Christian Medical College, Vellore, India

Introduction: Heavy metal toxicity is due to the accumulation of heavymetals in the human body. The most common heavy metals associatedwith toxicity are mercury, arsenic and lead.Aims: To look at the clinical profile, management and outcomes ofpatients presenting to the department of medicine with heavy metaltoxicity.Materials and methods: This is a retrospective cohort study. The patientswere identified from the medical electronic database using the keywords arsenic, mercury lead and heavy metal toxicity. The patients wereincluded from January 2015 till January 2017 were included in the study.Results: Among the patients who had heavy metal screening donefrom the department of medicine 80 had elevated heavy metal levels.Among these patients 48 (60%) were males. The most common heavymetal causing toxicity was nickel, there were 19 patients who had highnickel levels, the most common clinical presentation was neuropathy18 followed by renal involvement 3 in these group of patients. Thesecond most commonly detected heavy metal was chromium who pre-sented with neuropathy 22 (63%) a renal 14 (34.7%) of patients. Therewere 11 patients with arsenic toxicity and 11 (78%) had neuropathyand 1 patient had acute arsenic toxicity with circulatory collapse andrenal failure. Lead toxicity was seen in 19 patients out of whom 15(78%) had neuropathy and 4 (22%) had renal involvement. Among allthe patients with heavy metal toxicity only 5 (6%) underwent specifictherapy. There were only 3 deaths 2 patients died due to lead toxicityand 1 patient due to acute arsenic poisoning which was an industrialaccident. Among 80 patients 22 (27%) were on using Indian system ofmedicine.Conclusions: Other than traditionally known heavy metal toxins neverheavy metal toxicity with nickel and chromium has become more com-mon. A significant number of people present with either neurological orrenal toxicity. Nearly one third of patients with heavy metal toxicity areusing Indian system of medicine.

P386EVALUATION OF THE EXPERIMENTAL SPASMOLYTIC ANDANTIULCER EFFECT OF THE FRUIT EXTRACT AND FRACTIONSOF CUCUMIS METULIFERUSIhim S.A., Okpalaeke E.E., Nworu C.S.

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Dept. of Pharmacology and Toxicology, Faculty of PharmaceuticalSciences, University of Nigeria, Nsukka, Nigeria

Introduction: The management of peptic ulcer has largely remainedsuboptimal. There has been a growing interest in the development ofalternative therapies, especially from plant sources due to their availabil-ity and lower side effect for the management of peptic ulcer.Aim: This study was undertaken to give credence to the traditional useof Cucumis metuliferus in the treatment of gastrointestinal ailmentsparticularly peptic ulcer disease.Methods: The methanol fraction of the fruit plant material was extractedsequentially using n-hexane, ethyl acetate, butanol and water yieldingHFCM, EAFCM, BFCM and WFCM respectively and evaluated for antiulcerproperties using experimental ulcer models induced by indomethacin,ethanol and hypothermic resistant stress in rats. The effects of theextracts on rodent gastrointestinal motility and contractions of isolatedintestinal tissues induced by acetylcholine and histamine were alsostudied.Results: Ethanol-induced ulcer was significantly (p<0.05) protected byMECM (100, 200 and 400 mg/kg). MECM (100, 200 and 400 mg/kg), EAFCM(200, 400 mg/kg), and WFCM (200, 400 mg/kg) exhibited dose-relatedand significant (p<0.05) protection of rats against indomethacin inducedulcers. Significant (p<0.05) gastro protective effect was shown by MECMand its fractions at all doses except EAFCM (100 mg/kg). Gastrointestinalpropulsion in mice was significantly (p<0.05) reduced in a dose depen-dent manner with MECM (400 mg/kg) and WFCM (400 mg/kg) showingthe highest level of antiperistaltic activity. The contractions evoked byacetylcholine and histamine on the rabbit jejunum were antagonized bythe extracts and fractions in a concentration dependent antispasmolyticmanner. However, MECM did not show inherent spasmogenic effect onthe intestinal Guinea pig ileum. Acute toxicity tests showed an oralLD50 greater than 5000 mg/kg in mice. Rich varieties of bioactive con-stituents in MECM include alkaloids, terpiniod, flavoniod, carbohydratesand steroids.Conclusion: These findings demonstrate that the plant, Cucumismetuliferus, possesses pharmacological properties which lend credenceto its ethnomedicinal use as an antiulcer and anti-diarrhoeal agent.

P387

ACUTE PARACETAMOL TABLET OVERDOSE – CLINICAL PROFILEFROM A TERTIARY CARE CENTRE IN SOUTH INDIA

Prasad J., Karthik G., Ramya I.Dept. of General Medicine, Christian Medical College, Vellore, India

Introduction: Paracetamol (acetaminophen) is a widely prescribed med-ication, commonly consumed by persons with the intent of self-harm.Early use of N-acetyl cysteine dramatically improves outcomes. This studydescribes patients with acute paracetamol overdose, their outcomes andcost of care.Methods: In this retrospective study, data were analysed from Jan-uary 2008 to August 2018, extracted from the inpatient medicalrecords.Results: 126 patients presented with acute paracetamol overdose. Themean age was 26 years, 69.8% were female and 23.8% were healthcareworkers. 71.4% of patients consumed more than 7.5g.46.8% of patients had vomiting and 22.2% had abdominal pain. 54% ofpatients received activated charcoal and 90.5% received N-acetyl cys-teine. 13.5% of patients had acute hepatitis and 3.2% had unconjugatedhyperbilirubinemia. 2 patients had either an isolated elevation of alkalinephosphatase or hypokalemia.Mean duration of hospital stay was 4.1 days. Mean hospital bill and N-acetyl cysteine therapy were rupees 13,442 and 2,209 respectively.

Paracetamol dose of >12g (OR = 3.416, 95% C.I. = 1.057 – 11.036, p-value = 0.040), male gender (OR = 3.831, 95% C.I. = 1.192 – 12.310, p-value = 0.024) and delay in N-acetyl cysteine therapy of more than 12hours (OR = 6.75, 95% C.I. = 2.13 - 21.37, p-value = 0.001) increasedodds of developing hepatitis. Activated charcoal use reduced the risk ofdeveloping hepatitis (OR = 0.240, 95% C.I. = 0.068 – 0.849, p-value =0.027).Conclusion: Consumption of >12g of paracetamol, male gender anddelay in initiation of N-acetyl cysteine therapy were associated withincreased risk of hepatitis. Activated charcoal use reduced the risk ofdeveloping hepatitis.

P391

COMMUNITY MANAGEMENT OF CHILDHOOD FRACTURES INGHANA. AN EXPLORATORY STUDY

Gyapong M.1, Garshong B.2, Binka C.3, Addei S.4, Manyeh A.4,Mottey B.E.1, Addo W.L.51Institute of Health Research, University of Health and Allied Sci-ences, Ho;2Research and Development Division, Ghana Health Service,Accra;3Ghana Institute of Management and Public Administration(GIMPA), Accra;4Dodowa Health Research Center, Dodowa;5AO Alliance Foundation, Accra, Ghana

Introduction: Globally, injuries are a major health problem leaving mil-lions with temporary or permanent disability. In 2010, unintentionalinjury accounted for 37 deaths per 100,000 Ghanaian children under age14. As parents are the primary responders to childhood injury, there isthe need to strengthen opportunities for pre-and post-hospital care forchildren who suffer injuries in LMICs.Aim: The aim of the study was to explore caregivers’ managementpractices of childhood fractures.Methods: This mixed methods study, conducted at the community levels,engaged, care givers of children under 14 years of age, communitymembers, in Focus Group Discussions and household surveys, and In-depth interviews with traditional bone setters in rural and urban settingsin the Ashanti and Central regions of Ghana. The main theme exploredwas the categories of treatment options for childhood fractures in thecommunity and reasons for this. Bone setters in the community were alsoasked how they managed childhood fractures. FGDs and IDIs were taperecorded and transcribed verbatim. A matrix was developed to assessconvergence. Thematic analysis was carried out based on the themesderived from objectives.Results: The study showed that generally children under five are moreprone to injuries especially the males due to their boisterous nature.Common first aid provided for childhood fracture by caregivers include,massaging the affected area with ointments, shea butter and hot waterand administration of pain killers. Caregivers seek care for children withfractures from both health facilities and traditional bonesetters depend-ing on their perception of severity. In many instances they primarily visitthe health facility to get an X-ray which is usually required by traditionalbonesetters. Due to delays in seeking care at the health facility, compli-cations occur which may lead to deformity and increased cost of care.There is no information on appropriate care on childhood fractures at thecommunity level.Conclusion: Community members perceive the bonesetter as havingskills in the management of fractures for both adults and children.As such, they adhere to the advice of bone setters. Bone setters areavailable in the community and easily accessible with flexible paymentoptions.

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P392

MENTORING AND SUPERVISION - A KEY COMPONENT TOENSURE QUALITY SERVICES IN RAJSHAHI AND NAOGAONDISTRICTS IN BANGLADESH

Akhter F.1, Ghatak S.2, Haque A.31Public Health Improvement Initiative Project, Swiss Red Cross,Bern, Switzerland;2Swiss Red Cross, Bern, Switzerland;3Development Association for Self-reliance, Communication andHealth (DASCOH), Rajpara, Bangladesh

Introduction: DASCOH, a reputed NGO in collaboration with the SwissRed Cross initiated an on-the job supervision and mentorship interventioncarried out by the relevant Government health authorities and staff toenhance the service quality of in 66 Primary Health Care facilities inBangladesh.Aim: To demonstrate that supervision and mentorship improves knowl-edge, skills and quality of care.Methods: A quantitative supervision and mentorship checklist was devel-oped and piloted together with the Government in 14 Community Clinicsand applied on a monthly basis in 46 Community Clinics, 20 UnionHealth and Family Welfare Centres in Rajshahi and Naogaon district.The checklist consists of an array of tasks from a brief history elicitingup to examination and recordkeeping, a health provider has to performduring consultation. Fulfilment of the tasks in a correct manner indicatesimproved quality of care. Data were collected and evaluated over a periodof one year.Results: 608 supervision and mentorship visits were conducted both byproject staff and government health officials over one year in 2017 andin 2018. The data of Rajshahi district indicates at community clinic level20% service improvement through supervision and mentorship visit, andat Union Health and Family Welfare centre level 6% service improvementthrough supervision and 18% through mentorship visit. In Naogaon dis-trict, at community clinic level 22% service improved through supervisionsystem, and 24% by mentorship visit, and at union health and familywelfare centre level 20% service improved through supervision and 25%by mentoring visits.Conclusion: The project proved that mentoring and supervision hasbrought about improvements in quality service in the governmenthealth facilities and demonstrated that these mechanisms can beintegrated into the primary health care system. While the supervisionand mentorship appear to be effective, it needs to be applied morerigorously and on a longer-term. More research is required to assessthe effectiveness of the supervision and mentoring process as well as toelicit other barriers for quality improvement.

P393

AN ENIGMA OF EXTRA-PONTINE MYELINOSIS IN PRIMARYADRENAL INSUFFECIENCY

Reddy S.S.1,2, H.S.S.31Dept. of Infectious and Tropical Diseases, LSHTM, London, UK;2Dept. of Internal Medicine, Brindhavvan Areion Hospital,Bengaluru, India;3Dept. of Endocrinology, Manipal Hospital Jayanagar, Bengaluru,India

Introduction: Extra-Pontine Myelinolysis (EPM) is a relatively rare, life-threatening complication with poorly understood pathophysiology,varied clinical manifestations, and uncertain treatment. This case reportdescribes a patient with neurologic manifestations and characteristic

brain imaging changes of extrapontine myelinolysis occurring inthe context of primary adrenal failure secondary to an infectiousinsult.Case Report: An elderly lady presented with altered state of senso-rium, abnormal myoclonic spasms, and posturing with recent history ofrecurrent vomiting and fatigue. Prior medical history was significant forrecurrent urinary tract infections, weight loss with decreased appetiteand fatigue. On examination, she appeared ill, agitated with severewasting and marked dehydration. She was afebrile, tachycardic with lowblood pressures. Pallor, knuckle pigmentation with dark palmer creases,hyper-pigmented oral mucosa, and a BCG vaccination scar on generalexamination. The laboratory findings were significant for anemia withleucopenia. Metabolic workup reported of low sodium (109 mmol/L),low serum osmolality with high urine spot sodium and urine osmolality.Imaging studies contributed to the findings of homogeneous T2 hyper-intensity of bilateral basal ganglia. No other significant cortical lesions,meningeal enhancement or basal exudates noted. Electroencephalo-gram was suggestive of a metabolic-encephalopathic state.Results: Hormonal assays were confirmatory for primary Addison’spathology with low serum cortisol, high Adreno-Cortico-Tropic Hormone(ACTH) level, and Synacthen stimulation test. A CECT of the abdomenrevealed moderate enlargement of the left adrenal gland with a singleupper pole hyperechoic lesion, with associated findings of left ureteralstricture with mild hydroureteronephrosis. A CT-guided biopsy of theadrenal lesion showed granulomatous lesions with central caseousnecrosis. Acid-fast bacilli were identified in serial urinary samples. Analysiswith Xpert MTB/RIF was positive for mycobacterium tubercle bacilli withsensitivity to rifampicin. The cerebrospinal fluid analysis was negativefor TBM. No other foci were detected. Hence a case of hyponatremicEPM secondary to primary adrenal insufficiency, due to genitourinaryMycobacterium tuberculosis.Conclusion: Though disseminated adrenal pathology is rarely reported,but in the right clinical context and a high index of suspicion, promptinterventions into early identification and treatment of Mycobacteriumtuberculosis in Addison’s disease, can result in favorable prognostic out-come.

P394

EXPERIENCES OF PSYCHOTHERAPISTS WORKING WITHREFUGEES: WITH A FOCUS ON EXPLANATORY MODELS AS ACHALLENGE

Asfaw B.B., Lohmann J.Heidelberg Institute of Global Health, Heidelberg University, Hei-delberg, Germany

Introduction: Despite a high burden of mental health problems amongmigrants and refugees, there is still limited knowledge about effectivemental health care provision for this group. Among the many barriers indelivering mental health care for such groups, explanatory model–clients’narration about their health, mental illness, and the healing processis one.Aim: This study, thus, aimed at narrowing such gap in knowledge byadequate description of major challenges with a focus on explanatorymodel as challenge and in-depth description of strategies used by psy-chotherapists by studying direct experiences of psychotherapists involvedin cross-cultural psychotherapy.Methods: The study used qualitative study that used semi-structuredinterviews as a data collection tool. Purposive sampling and frameworkanalysis strategies were used for selecting samples and for doing theanalysis, respectively. Strategies to improve trustworthiness includingtransparency, member checking, and documenting personal bias wereconsidered.

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Results: In the analysis process, five major themes namely, Biographicalcharacteristics, Cross-cultural experience of participants and its impli-cation to therapy, Challenges in cross-cultural psychotherapy, Strate-gies in cross-cultural psychotherapy and Lessons learned (advises fortherapists) were identified. The main challenges indicated in this studyinclude perceived ‘strange’ belief systems of clients (explanatory models),language and the use of translators. In dealing with the challenges,psychoeducation, use of professional translators, open-mindedness andcountermagic (use of clients’ illness healing rituals as resources) wereindicated as main strategies.Conclusion: Therapists’ migration and cross-cultural experiences have apositive implication to psychotherapy with refugees. Clients’ explanatorymodels or healing narratives and rituals was also pointed out as apotential resource that could be positively utilized in psychotherapy.

P395

MANAGING PAEDIATRIC TYPE 1 DIABETES IN A SUB-SAHARANREFUGEE CAMP SETTING

Siese T.F.1, Beck A.J.2, Alins Sahun Y.31General Paediatrics Dept., Derriford Hospital, Plymouth;2Diabetes and Endocrinology Dept., Derriford Hospital, Plymouth;3Consultant Paediatrician, Derriford Hospital, Plymouth, UK

Introduction: Global estimates of healthcare expenditure on Diabetesare estimated to be approximately 11% of total healthcare expenditure1.However, across the developing world, funding priorities remain biasedtowards infectious diseases, on a cost-effective basis. Insulin-dependentDiabetes remains a death sentence for most of the population livingin South Sudan due to physical and social barriers created by civil war,poverty, food insecurity, and reliance on limited NGO-run health services.Aim: As humanitarian doctors, working in a Médecins Sans Frontières(MSF) hospital in a United Nations Protection of Civilians (PoC) camp, werecount our first-hand experiences in managing two cases of paediatricdiabetes.Methods: On arrival to the hospital we encountered Case 1, a five-year-old girl who had been treated for Diabetic Ketoacidosis (DKA) withsubcutaneous Insulin injections, more than two months prior, but hadremained inpatient throughout this period. Delays in discharge wereattributed to difficulties finding an appropriate insulin/meal regime, aswell as challenges in educating staff, patient and family to managethe patient safely at home on twice daily intermediate-acting insulin(NPH) injections. Case 2, a seven-year-old girl, was admitted with feverand respiratory distress, and treated on admission for Severe Malaria.Random blood glucose was “High”, with urinary dipstick testing positivefor ketones. History from the mother revealed polyuria, polydipsia andweight loss over several weeks. She was treated for presumed DKA, withIV replacement2 followed by an adjustable Actrapid IV infusion, (0.05-0.1units/kg/hr) with empirical potassium supplementation. Stabilisation wasachieved within 48hrs and she was subsequently discharged within twoweeks on twice daily NPH, with outpatient support.Conclusion: Managing Diabetes in Sub-Saharan displaced populationscan be particularly challenging due to unstable living conditions, physicaland psychological barriers in accessing healthcare, limited healthcarehuman resources and drug availability. Such obstacles render westernstandards of care unattainable. Yet through innovative use of availableresources, setting up a facility-specific guideline and focussing uponbuilding the skills and knowledge of the child, we argue that whereverpossible we should strive to meet the basic needs of children with Dia-betes throughout the developing world.

References:1. Elrayah-Eliadarous, Hind A; Ostenson, Claes-Goran; Eltom, Mohamed;Johansson, Pia; Sparring, Vibeke; Wahlstrom, Rolf. Economic and social

impact of diabetes mellitus in a low-income country: A case-control studyin Sudan. Journal of Diabetes. 2017. Volume 9, Issue 122. NICE. Diabetic Ketoacidosis in Children and Young People. 2017.Accessed on 5th November, 2018, via https://pathways.nice.org.uk/pathways/diabetes-in-children-and-young-people#path=view%3A/pathways/diabetes-in-children-and-young-people/diabetic-ketoacidosis-in-children-and-young-people.xml&content=view-node%3Anodes-fluid-and-insulin-therapy

P3972018 MASS CAMPAIGN AND SCREENING ON HYPERTENSIONAND DIABETES - KIGALI, RWANDA: PREVALENCE, KNOWLEDGEAND RISK FACTORSZinnen V.1, Mukantagara M.2, Mukangarambe P.3,Mbarushimana A.4, Rwagasore E.2, Tihon V.1, Ndayisaba G.2,Condo J.21Enabel (Belgian development agency), Kigali;2Rwanda Biomedical Center, Kigali;3Public Health Directorate, City of Kigali, Kigali;4Rwanda NCD Alliance, Kigali, RwandaIntroduction: Non-communicable diseases (NCDs) are the leading causeof death worldwide and their increase is a major health challenge, par-ticularly in developing countries. In Rwanda, studies show an increase inNCDs like hypertension and diabetes, while many cases are still under-diagnosed due to asymptomatic nature of the diseases and lack ofawareness. Among various strategies, annual mass campaigns are orga-nized in Kigali to raise public awareness, to promote prevention and todetect risk factors, hypertension (HTA) and diabetes.Aims: The study aims to evaluate the characteristics of the populationwho participated in screening during 2018 campaign, the prevalence ofexisting risk factors, hypertension and diabetes, the knowledge aboutown status and counselling provided. The objective is to understand thescope of the campaign and to better organize next ones with increasedimpact.Methods: Screened participants were registered, and the informationneeded to meet the aims of the study was collected through a question-naire. To investigate the association between diseases and risk factors,univariate analysis was first conducted using Odd-Ratio (OR) followingwhich a multivariate logistic regression model was developed.Results: A total of 4580 participants were registered (57% male, 27%<45). Combined Body Mass Index (BMI) and Waist Circumference atrisk was present in 17%. 15% were smokers/ex-smokers and 20% hadharmful use of alcohol. 26% had HTA: 73% were unaware and 31%were sent to health facility (HF). 4% had fasting hyperglycaemia: 71%were unaware and 45% were referred. Elevated BMI was significantlyassociated with women (OR:3.0) and age≥45 (OR:2.6); HTA with age≥45(OR:3.0), overweight (OR:2.2), and alcohol (OR:2.0); Hyperglycaemia withwomen (OR:2.0), age≥45 (OR:2.7), overweight (OR:2.4) and HTA (OR:1;82).Conclusion: The campaign mobilized high number of people and con-tributed to detect unknown cases of HTA and diabetes. Findings showhigh prevalence of risk factors and HTA that called for urgent measures.This study revealed some limitations: what happened to people detectedwith abnormal values and what is the real impact? Therefore, a studyto understand the usefulness and impact of such a campaign has beenlaunched and for the next campaigns, case management will be betterensured.

P398DIETARY INTAKES, PERCEIVED QUALITY OF LIFE AND RISKFACTORS FOR METABOLIC SYNDROME AMONG MIDDLE AGEDADULTS IN GHANA: A CASE-CONTROL STUDY

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Bannerman E.K.1, Klomegah S.1, Zotor F.1, Agbozo F.1,2

1Dept. of Family and Community Health, School of Public Health,University of Health and Allied Health Sciences, Ho, Ghana;2Institute of Global Health, Medical Faculty and University Hospital,Heidelberg University, Heidelberg Germany

Introduction: Metabolic syndrome (MetS), previously uncommon in sub-Sahara African, is increasingly becoming a public health concern. It isheightened by the epidemiological transition associated with excessenergy intake, sedentary lifestyles and urbanization. MetS refers to the co-occurrence of cardiovascular risks primarily obesity, hypertension, insulinresistance and atherogenic dyslipidemia.Aim: To assess prevalence of MetS using obesity, hypertension anddiabetes as cardiovascular risks and determine the associated dietary,lifestyle and physiologic risk factors.Methods: One-to-one age and sex-matched case-control study involving152 adults aged 45-65 years. Cases were identified in the diabetic clinicof a municipal hospital in Ghana while controls were recruited in the com-munities. MetS was determined by WHO and International Diabetic Fed-eration (IDF) criteria. Lifestyle habits and physical activity were assessedusing a validated lifestyle/habits questionnaire while habitual dietaryintakes were assessed using food frequency questionnaire. Anthropom-etry, blood pressure and fasting capillary glucose were measured. Differ-ences were tested using McNemar and paired t-test tests. Crude oddsratio (COR) for MetS estimated using conditional logistic regression.Results: Mean age was 57.31±5.46 years; 95% (n=144) were females.MetS by WHO (case:67.1% vs control:1.3%) and IDF (case:85.3% vscontrol: 2.7%) criteria were 34.2% and 44.7% respectively. Amongcases and controls, lateral obesity (100% vs 60.5%), central obesity(98.7% vs 36.8%), hypertension (90.8% vs 2.6%) and diabetes (72.4% vs1.3%) differed significantly. Controls (77.6%) consumed more diversifieddiets than cases (10.5%) (p=0.001). Significant number of cases felta high risk of illness based on their physical health (73.7% vs 2.6%),exercise/fitness (88.2% vs 13.2%), nutrition and weight control (14.5% vs1.3%) and psychological health (19.7% vs 0%) but none felt sociallyunhealthy. Lower risk for MetS was found among participants withsecondary education (COR:0.17 95% CI:0.04-0.73) and peri-urbandwellers (COR:0.22 95%CI:0.09-0.53) while unemployment (COR:9.00CI:1.26-64.35) and central obesity (COR: 48.0 95%CI: 6.62-347.74) wereassociated with higher risk.Conclusion: MetS adversely affected general sense of wellbeing. Obesitywas an important predictor. Interventions to enhance weight control,quality of life and dietary diversity are crucial and should be integratedinto social support and health systems.-

P399

DOXYCYCLINE A GAME CHANGER AGAINST ACUTE UNDIFFER-ENTIATED FEBRILE ILLNESS IN THE HIMALAYAS

Kattel V.1, Sarraf D.P.2, Agrawal Y.31BPKIHS, Internal Medicine, Dharan;2BPKIHS, Clinical Pharmacology, Dharan;3BPKIHS, Pathology, Dharan, NepalIntroduction: Physician in Nepal will face two main challenges whileprescribing antibiotics against acute undifferentiated febrile illness (AUFI)other than self-limiting viral fever1. They lack epidemiological variablesand data for the endemic disease differentiation2 and insufficient expen-sive diagnostic facilities3.Aim: To compare outcome of therapeutic trial of four antibiotics(azithromycin, ceftriaxone, doxycycline and levofloxacin) as an answerfor this syndromic dilemma in Nepal.Methods: It was a prospective cohort study conducted from 1/1/2016 to31/12/2016 among adult AUFI inpatient. Endemic pathogens like malaria

and dengue were rule out with available antigen detection diagnostictest. Antibiotics were chosen on the basis of recent history of antibioticsexposure. Stable patient was given a therapeutic trail of doxycycline200mg/day or azithromycin 1gm/day or levofloxacin 750mg/day withexpected outcome as defervescence by 48 hours. Ceftriaxone 2gm/daywas added to non-responder and hemodynamically unstable patients.Antibiotics were upgraded if there was no clinical improvement by 48hours.Results: There were 111 acute undifferentiated febrile illness withoutclinical diagnosis admitted in year 2016. Around 65% patients had defer-vescence with treatment by 48 hours. Single drug treatment versescombination with ceftriaxone had defervescene rate of 62 verses 67%respectively by 48 hours. More than 75% patients treated with doxycy-cline alone or doxycycline and ceftriaxone have defervescene by 48 hoursand clinical cure with statistical significance.Conclusion: For unknown reason doxycycline had statistically significantbetter outcome than azithromycin or levofloxacin or ceftriaxone againstacute undifferentiated febrile illness in Nepal.

References:1. Feikin D R, Olack B, Bigogo G M, et al. “The Burden of Common InfectiousSyndromes at the Clinic and Household Level from Population-BasedSurveillance in Rural and Urban Kenya.” PLoS One 6 (1): 2011. e16085.2 .Joshi R, Colford JM, Jr., Reingold AL, et al. Nonmalarial acute undifferen-tiated fever in a rural hospital in central India: diagnostic uncertainty andovertreatment with antimalarial agents. The American journal of tropicalmedicine and hygiene. 2008; 78(3):393-9.3. Kanika Deshpande Koirala, François Chappuis, Kristien Verdonck, et al.Persistent febrile illnesses in Nepal: A systematic review. Indian J Med Res.2018; 148(4): 385–395.

P400PREVALENCE, ASSOCIATED FACTORS AND OUTCOME OF VENTI-LATOR ASSOCIATED PNEUMONIA AMONG PATIENTS IN INTEN-SIVE CARE UNITS AT KCMC, TANZANIANyamboto G.1, Muro F.1,2

1Kilimanjaro Christian Medical University College, Moshi;2Community Health Dept., Kilimanjaro Christian Medical Centre(KCMC), Moshi, Tanzania

Introduction: Ventilator associated pneumonia (VAP) is a nosocomialpneumonia commonly occurring in patients receiving mechanical ven-tilation 48-72hrs following endotracheal intubation. It is often a problemamong patients in intensive care units (ICUs) leading to significant mor-bidity and increased health costs. Although commonly reported, hospitalacquired infection (HAI) in pediatrics than other age groups accounts forabout 20% of all HAIs. VAP is associated with an increase in hospitalmorbidity and mortality, duration of hospitalization and high health-carecosts.Aim: To determine the prevalence, associated factors and outcomes ofVAP among the patients in intensive care units at Kilimanjaro ChristianMedical Centre, Moshi - Tanzania.Methods: A retrospective, cross-sectional hospital based study designwas used. Analysis was done using SPSS v.20 to summarize data usingmean for continuous variables and percentages for categorical variables.Multivariate logistic regression was used to express the magnitude anddirection of association.Results: Of 138 files available, 58(42.0%) were of males and the averageage of all patients was 51.81 years (SD±20). The point prevalence of VAPwas 4.1%, in which the sex specific point prevalence was 3.5% and 4.5%for male and female respectively. Tracheostomy, re-intubation frequency,length of staying in ICUs were the clinical factors associated with VAP.

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Acinobacter baumanii was microorganism significantly associated withVAP. In this study the proportion of patient dying due to VAP was 38.7%.Conclusion: VAP remains a public health problem given the observedprevalence and proportion of deaths. Re-intubation frequency and pro-longed mechanical ventilation were associated with VAP, thus effectiveintervention such as the implementation of VAP prevention bundles whichhas been proven to be effective in clinical practices are necessary incombatting this problem and thus improve patient outcome.

P402

PREVALENCE OF NON-COMMUNICABLE DISEASES RISKFACTORS ACROSS LEVEL OF EDUCATION IN RWANDANPOPULATION

Dushimiyimana V.1, Rwunganira S.2, Musabyimana J.P.1,Ndishimye P.1, Niyonsenga S.P.2, Musanabaganwa C.1,Ntaganda E.2, Nshyimiyimana L.1, Ndayisaba F.G.2, Condo U.J.21Rwanda Biomedical Center, Medical Research Center, Kigali;2Rwanda Biomedical Center, Non-Communicable Disease Division,Kigali, Rwanda

Introduction: Non-communicable diseases (NCDs) are the major causeof premature death worldwide. The speed at which NCDs have risen hascreated a gigantic global problem with predictions that by 2030 theywill overtake infectious diseases as the leading contributor to burden ofdisease in Sub Sahara Africa. Monitoring disparities in NCDs risk factorsprevalence can help to inform and target effective interventions.Aim: We measured prevalence of NCDs risk factors by education level.Method: We conducted a secondary data analysis from STEP surveydataset of 2014 in Rwanda. These STEP survey data were collected fromNovember 2012 to March 2013 through a cross-sectional study usingmultistage cluster sampling among Rwandans aged 15 to 64 years old.A total of 7200 participants were enrolled countrywide. This analysischecked association between level of education and NCDs risk factors likehypertension, obesity, alcohol consumption, cholesterol level, smokingstatus and physical activity.Result: Overall, the prevalence of hypertension was 17.5% (CI:16.24,18.8;95% CL). A proportion of 14.75% (13.84,15.71) were overweight while3.5% (2.966,4.126) were obese. An estimate of 12.91% (11.56,14.39)were heavy drinkers, 4.52% (13.48,15.63) smokers while 60% did notdo vigorous physical activities. There was a significant high prevalenceof hypertension among participants with secondary school and aboveversus primary school and below (18.1%, CI [15.4,21.1] and 17.3%,[16.11,18.71]). The prevalence of obesity, heavy drinking and raisedcholesterol was also high among the study participants with secondaryschool education and above (9.23% CI [7.3,11.5], 16.1% CI [12.4,20.7],6.33%, CI [4.6,8.5]) when comparing to participants with primaryeducation and below (2.52% CI [2.1,3.6], 12.52 %CI [11.1,14], 3.24 CI[3.1,4.3]). Level of education is significantly associated with smokingbehaviour whereby 15% of participants with primary school as thehighest level of education were smokers compared to 7% only amongthe participants who studied up to secondary school level.Conclusions: The co-existence of multiple lifestyle NCD risk factors is apublic health concern in people with secondary school education and

above. Comprehensive health-promotion interventions addressing theco-existence of multiple NCD risk factors are needed especially in highschool and tertially education school and their targeted alumni.

P404A CASE OF SEPSIS FOLLOWING DOG BITE WITH NORMALAPPEARING WOUND SITELomencho A.1, Fantaye H.2, Teame A.31Emerald Medical, AMC Infectious Diseases Center, Addis Ababa;2Federal Ministry of Health, Addis Ababa;3AMC Infectious Diseases Center, Addis Ababa, Ethiopia

Introduction: Animal bite is a common reason for outpatient visits. Thecommon consequences following bite include cellulitis, rabies, and sepsis.Aim: To describe clinical profile of sepsis following dog bite.Methods: Case report.Results: We present a case of possible Capnocytophaga Canorimor-sus sepsis following dog bite in a 45 years old male with no otherknown illness. He owns the dog which is vaccinated for rabies. He visitedhealth facility about an hour following the bite and received woundcare and prescribed cephalexin. On the third day he experienced highgrade intermittent fever, chills, rigor, lower abdominal cramps, diarrhoea,and reddish skin lesions on the trunk. Examination of the wound siterevealed clean wound with neither evidence of cellulitis nor draining fluid.Laboratory evaluation included normal liver function tests, negative bloodculture at 7 days, raised creatinine to 1.4mg/dl (Acute kidney injury) andnegative stool examination. There was no leucocytosis. He was startedon intravenous Meropenem with clinical impression of CapnocytophagaCanorimorsus sepsis following dog bite. Follow up creatinine showedvalue of 0.7. There were fever records till the third day following antibioticinitiation, which later resolved and patient was discharged improvedcompleting 7 days course of antibiotic.Conclusion: Capnocytophaga Canorimorsus, a slow growing, carbon lov-ing, facultative anaerobe, is a normal flora in dog saliva present in up to70% of dogs and an important cause of fulminant sepsis following dogbite. The drug of choice to prevent it following dog bite is Amoxicillin-Clavulanate which was not prescribed in this patient. The absence ofcellulitis at bite site together with otherwise unexplained fever and othersymptoms with negative blood culture is highly suggestive of sepsis dueto Capnocytophaga Canorimorsus. It is often overlooked and patientstend to come late with severe sepsis and end organ damage, a reasonbehind the high mortality. Sepsis from Capnocytophaga Canorimorsusshould be entertained in any patient presenting with fever shortly follow-ing dog bite. A normal appearing wound will not rule out the possibilityof fulminant sepsis. Adequate antibiotic prophylaxis needs to be givenfollowing animal bites.

P406

CAUSES OF HOSPITAL ADMISSIONS AMONG ASYLUM SEEKERSAND REFUGEES

Aro T.1, Kantele A.1-3

1Dept. of Internal Medicine, Clinicum, Medical Faculty, University ofHelsinki;2Inflammation Center, University of Helsinki and Helsinki Univer-sity Hospital, Helsinki, Finland;3Karolinska Institutet, Solna, Stockholm, Sweden

Background: Asylum seekers and refugees are a special patient groupwith diverse health issues. However, the data on causes of hospitaladmissions are scarce.

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Methods: We collected clinical data from asylum seekers and refugeesadmitted to Helsinki University Hospital between 2010–18.Results: Most of the patients were hospitalized for a non-infectious cause,one third of the admissions were related to pregnancy. One fifth ofthe patients had an infectious disease as the primary diagnosis, mostcommonly a respiratory tract infection, followed by dermatologic infec-tions, urinary tract infections and acute gastroenteritis. A more detailedanalysis of the diagnoses will be presented at the meeting.Conclusion: Our study describes the diagnoses set for asylum seekersand refugees at a tertiary hospital and emphasizes the need to supportmaternal health among refugees.

P407IMPACT OF SENSOR NETWORKS WITHIN BODY BOUNDARYTOWARDS AUGMENTING CAUSES OF DIABETESMiah M.D.1,3, Kiew Sayok A.1, Adil Samdany A.21Institute of Biodiversity and Environmental Conservation, Univer-siti Malaysia Sarawak, Malaysia;2North East Medical College & Hospital, Sylhet;3Mornington University College, Amborkhana, Sylhet, Bangladesh

Diabetes is a chronic, progressive non-communicable disease related withunusually high levels of blood glucose. Yet Medical authorities are facingthe unwanted augmenting causes of diabetes towards human body asa very important global issue for several years. The study attempts torelook at the applications of the wireless sensor networks that affecton pancreas within and around the body boundary. Qualitative andquantitative wireless sensor data were obtained from field experimentsand field surveys. Key health information tools collected from experi-mental specimens on cats and dogs and their living status challengesin risks with fundamental principles are highlighted. The study showedthat the prevalence of diabetes in specimens was in peak during thestudy period. The study represents the urine flow speed fluctuates withinfection due to misuse of wireless sensor networks. The findings reflectthe importance in diabetes through prevention and treatment that thephysicians provide, which fails to recover due to access abusing sensornetworks. The study also found the urban hospitals are in risks due toinsecure sensor technology. Scientific healthcare knowledge is essentialfor treatment with modern technological arena but such knowledgeis poorly identified while different clinical supports are still below par.Overall, the study contributes to the diabetes society through develop-ment of dynamic health care technology framework indicating effectivesolutions on free from diabetes. The study suggests future researchtrajectories of a new sophisticated alternative treatment approach to pro-mote mental health and well-being linking with Sustainable DevelopmentGoals 2030.

P408PRELIMINARY RESULTS OF A COST ANALYSIS OF ACUTEMYELOID LEUKEMIA TREATMENT AT TATA MEDICAL CENTER,KOLKATA, INDIA; 2011-2016

Smith R.D.1, Samani M.1, Mandal P.2, Ghosh A.2, Roy D.3, BhartiN.3, Ghose S.4, Datta S.5, Chandy M.6, Radhakrishnan V.61Dept. of Global Health and Social Medicine, King’s College London,London, UK;2Techno India, Salt Lake, India;3NSHM College of Technology and Management, Kolkata, India;4Dept. of Administration, Tata Medical Center, Kolkata, India;5Dept. of Palliative Care and Psycho-oncology, Tata Medical Center,Kolkata, India;

6Dept. of Haemato-oncology, Tata Medical Center, Kolkata, India

Introduction: In India, 6.2% of cancer patient households are pushedunder the poverty line due to health care expenditures.1 Acute MyeloidLeukemia (AML) is among the most expensive cancer treatments; only5% of the population is able to afford transplant2.Aims: The aim was to measure the direct costs to AML patients at TataMedical Center (TMC) to provide guidance when estimating the costs ofcurative treatments. This informs policy, resource allocation and advisespatients.Methods: This was a retrospective audit of all patients who presentedwith AML at TMC between 2011-2016. The sample consisted of 543patients who were at least 18 at diagnosis. APML subtype was excluded.Cancer registry data was used to determine which patients receivedAML treatment. Electronic Medical Records were used to stratifypatients according to the type of treatment taken. Billing data wasused to measure the direct costs of treatments. Billing data wasdivided into clinical subcategories including Blood Bank, Chemotherapy,Infection, Bone Marrow Transplant (BMT), Imaging and LaboratoryInvestigations.Results: 174 patients had undergone curative treatment. 56 of thesepatients received BMT. 23 BMT patients began treatment at TMC and 33BMT patients previously underwent treatment elsewhere. 105 non-BMTpatients began treatment at TMC and 13 patients previously underwenttreatment elsewhere. Among all patients, 50 were alive at last follow-up.The average direct cost of treatment for non-BMT patients alive at lastfollow-up was $22,000 USD. The average direct cost of treatment forBMT patients alive at last follow-up was $72,416. The percentage of totalexpenditures of patients alive at last follow-up which did not receive BMTincluded 38% of costs spent on infections, 26% blood products, 18%laboratory expenses, 16% chemotherapy and 2% imaging.Conclusion: The average direct cost of BMT patients alive at last follow-up was nearly four times that of non-BMT. The largest direct cost acrossall types of patients was infection related cost, increasing costs by 38%for BMT patients and 49% for non-BMT patients. When direct costs areestimated exclusively using treatment protocols, these estimates arenearly half of the actual direct costs of treatment.

References:1. Pramesh, C., Badwe, R., Borthakur, B., Chandra, M., Raj, E., Kannan, T.,Kalwar, A., Kapoor, S., Malhotra, H., Nayak, S., Rath, G., Sagar, T., Sebastian,P., Sarin, R., Shanta, V., Sharma, S., Shukla, S., Vijayakumar, M., Vijaykumar,D., Aggarwal, A., Purushotham, A. and Sullivan, R. (2014). Delivery ofaffordable and equitable cancer care in India. The Lancet Oncology, 15(6),pp.e223-e233.2. Chandy, M., Srivastava, A., Dennison, D., Mathews, V. and George, B.(2001). Allogeneic bone marrow transplantation in the developing world:experience from a center in India. Bone Marrow Transplantation, 27(8),pp.785-790

P409

EVALUATION OF THE PERFORMANCE OF COMMERCIALLYAVAILABLE IMMUNE-CHROMATOGRAPHIC RAPID DIAGNOSTICTESTS (RDTS) FOR THE DIAGNOSIS OF DENGUE IN INDIA

Mahajan R.1, Flevaud L.2, Periera A.1, Harshana A.1, BoelaertM.3, Goswami R.4, Burza S.11Médecins Sans Frontières, New Delhi, India;2Médecins Sans Frontières, Barcelona, Spain;3Institute of Tropical Medicine, Antwerp, Belgium;4Calcutta School of Tropical Medicine, Kolkata, India

Background: India contributes a third of the global burden of dengueinfection. Immuno-chromatographic rapid diagnostic tests (RDTs) either

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based on antigen or antibody detection facilitate early diagnosis ofdengue. However, the reliability and performance of commercial testshave yet to be independently evaluated in the Indian setting.Methods: We obtained 488 well-characterized archived serum speci-mens, including 241 dengue cases and 247 dengue negative controls.We evaluated four combined NS1/IgM RDTs commercially available inIndia: Multisure Dengue Ab/Ag Rapid Test (MP Biomedicals; MP), Den-gucheck Combo (Zephyr Biomedicals; ZB), SD BIOLINE Dengue Duo (Alere;SD), and Dengue Day 1 Test (J Mitra; JM). Sensitivities and specifici-ties were determined against the two reference standard ELISA testresults.Results: A total of 238, 226, 208, and 146 reference NS1 ELISA sampleswere tested with MP, ZB, SD, and JM tests, respectively. The RDTs demon-strated sensitivity (95% CI) of 71.8% (61.4%-80.0%) (MP), 85.1% (76.1%-91.1%) (ZB), 77.2% (66.8%-85.1%) (SD) and 80.9% (70.0%-88.5%) (JM)respectively, compared to the reference standard.Specificity (95% CI) was 90.1% (91.7%-98.2%) (MP), 92.8% (87.3%-96.1%) (ZB), 96.1% (91.3%-98.3%) (SD), and 93.6% (85.9%-97.2%)(JM) respectively. Evaluated in 287, 323, 318 and 225 reference IgMELISA samples, the RDTs showed a sensitivity (95% CI) of 40%(32.0%-49.0%) (MP), 50.3% (42.4%-58.3%) (ZB), 47.3% (39.3%-55.3%) (SD) and20.0% (13.6%-28.4%) (JM) respectively and specificity (95% CI) of 92.4%

(87.1%-95.6%) (MP), 88.6% (83.1%-92.5%) (ZB), 96.5% (92.6%-98.4%)(SD) and 92.2% (85.8%-95.8%) (JM) respectively.Considering the sample as positive when either the NS1 antigen or theIgM antibody result was positive, and negative otherwise, led to sensi-tivities (95% CI) of 87.5% (73.9%-94.5%), 82.9% (68.7%-91.5%), 93.8%(79.9%-98.3%) and 91.7% (64.6%-98.5%) respectively, and specificities(95% CI) of 75.3% (64.4%-83.8%), 73.9% (62.1%-83.0%), 76.5% (65.1%-85.0%) and 80.0%(49.0%-94.3%) respectively. Inter-reader agreementwas very good (k=0.96).Conclusion: All the RDTs evaluated here provided better sensitivities withantigen (NS1) detection component (range 71.8%-85.1%) comparedto antibody (IgM) detection component (range: 20%-50.3%) within thesame kits. Although performance was inferior to manufacturer claims,specificities for all RDTs were in the acceptable range for NS1 andIgM components. These results support the added value of combinedantigen-and antibody-based RDTs for the diagnosis of acute dengue.Ethics:This study was approved by the Ethics Review Boards of the CalcuttaSchool of Tropical Medicine, West Bengal and Medecins sans Frontieres(MSF).Conflict of interest:We declare that there are no conflicts of interests for any authors.

Table 1. Overall diagnostic sensitivity and specificities of NS1 antigen RDTs compared with reference standard NS1 ELISA

MULTISURE Dengue Ab/Ag Rapid Test Dengucheck Combo SD BIOLINE Dengue Duo Dengue day 1 testManufacturer MP biomedicals Zephyr biomedicals (ZB) SD bioline (Alare) J Mitra (JM)Total samples 238 226 208 146Sensitivity (%) 71.8 (61.4-80.2) 85.1 (76.1 -91.1) 77.2 (66.8-85.1) 80.9 (70.0-88.5)Specificity (%) 90.1 (91.7-98.2) 92.8 (87.3-96.1) 96.1 (91.3-98.3) 93.6 (85.9-97.2)

Table 2. Dagnostic sensitivity and specificities of IgM antibodies RDTs compared with reference standard IgM Capture ELISA

MULTISURE Dengue Ab/Ag Rapid Test Dengucheck Combo SD BIOLINE Dengue Duo Dengue day 1 testManufacturer MP biomedicals Zephyr biomedicals (ZB) SD bioline (Alare) J Mitra (JM)Total samples 287 323 318 225Sensitivity (%) 40.0 (32.0-49.0) 50.3 (42.4-58.3) 47.3 (39.3-55.3) 20.0 (13.6-28.4)Specificity (%) 92.4 (87.1-95.6) 88.6 (83.1-92.5) 96.5 (92.6-98.4) 92.2 (85.8-95.8)

Table 3. Diagnostic sensitivity and specificities of RDTs when NS1 antigen and IgM antibody results were combined considering a sample positiveif either assay positive.

MULTISURE Dengue Ab/Ag Rapid Test Dengucheck Combo SD BIOLINE Dengue Duo Dengue day 1 testManufacturer MP biomedicals Zephyr biomedicals (ZB) SD bioline (Alare) J Mitra (JM)Total samples 113 106 100 22Sensitivity (%) 87.5(73.9-94.5) 82.9 (68.7-91.5) 93.8 (79.9-98.3) 91.7 (64.6-98.5)Specificity (%) 75.3(64.4-83.8) 73.9 (62.1-83.0) 76.5 (65.1-85.0) 80.0 (49.0-94.3)

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P411

IMPACT OF EBOLA OUTBREAK ON PREGNANT EBOLA NEGATIVETESTED WOMEN

Guinovart S.1, Lledó P.1, Bernasconi A.2, Flevaud L.1, Segers N.3,de la Rosa O.11Médecins Sans Frontières, Barcelona, Spain;2Swiss Tropical and Public Health Institute, Basel, Switzerland;3formerly Médecins Sans Frontières, Barcelona, Spain

Introduction: Between 2014 and 2016, West Africa faced the biggestoutbreak of Ebola, resulting in 28,646 cases, 11,323 deaths and affectinga total of 10 countries in Africa, Europe and North America.International response to the Ebola Virus Disease (EVD) outbreak in WestAfrica faced great challenges and ethical dilemmas in providing safeobstetric interventions to Ebola Virus (EBOV) infected pregnant women.However little has been published concerning the challenges and out-comes that pregnant EBOV negative patients experienced.Aim: To assess the obstetric and foetal/neonatal outcomes of pregnantpatients admitted to an Ebola Treatment Centre and tested negative toEBOV.Methods: Retrospective observational study of all pregnant womenadmitted to the specialized Maternity Ebola Treatment Centre (METC)of Médecins Sans Frontières (MSF) in Hastings, Freetown (Sierra Leone)between January and September 2015.Results: Out of 48 Ebola suspected pregnant patients admitted inthe METC, 40 (83.3%) tested negative for EBOV. Signs and symptomsrecorded on admission were similar in both positive and negativegroups. 15 (37.5%) Ebola negative patients presented an obstetriccomplication. Seven of them (17.5%) needed urgent referral foremergency obstetric care, but transfer was delayed until arrival ofnegative PCR results. Four maternal deaths occurred, three of which werepotentially avoidable with timely surgery. Three stillbirths with positivefoetal heart rate on admission were reported in the EBOV negativegroup.Conclusion: Several factors hindered access to timely obstetric care forEBOV negative patients; the collapse of the health system during theepidemic in Sierra Leone, the fact that Ebola can mimic certain obstetriccomplications, the stigma pregnant women faced during the epidemic,the restrictive obstetric protocols in the METC and, often, long delaysbefore negative PCR results were available.Even if based on a small series, our analysis suggests that maternaldeaths and obstetric complications could have been avoided.Further efforts and innovations are needed to allow proper and timelyobstetric care in the event of a new Ebola epidemic.

P413

A CASE-SERIES OF THREE RETURNED TRAVELLERS WITHVACCINE-PREVENTABLE ENCEPHALITIDES

Easton A.The Encephalitis Society, Malton, UK; Dept. of Clinical Infection,Microbiology and Immunology, University of Liverpool, Liverpool,UK

Introduction: Japanese encephalitis (JE) is a mosquito-borne diseasecaused by the Flavivirus JE virus (JEV). Tick-borne encephalitis (TBE) is aflavivirus infection spread by ticks. Rabies is an infection caught from thebite or scratch of an infected animal, most often a dog.All three infections can cause encephalitis resulting in a range of mor-tality and morbidity for patients affected. All three are also vaccine-preventable.

Aim: The aim of this presentation is to present a case series of threereturned travellers to raise awareness of the severity of outcomes forpatients and families affected by the condition.Methods: This presentation describes three cases of UK nationals whocontracted a Japanese encephalitis, a tick-borne encephalitis and a rabiesencephalitis abroad during 2014 to 2018. Their clinical/neurological find-ings and diagnoses will be presented in brief along with a mix of survivorand family member remembered experiences that provide an insightinto how these encephalitides have impacted their lives, and their viewson vaccination. The descriptions are formulated from and presented viavideo, audio and written interview data provided by participants.Results: These three cases demonstrate the continuum of outcomefollowing encephalitis in returning travellers, two of whom sufferedvery poor outcome. The case studies provide insight into the significantimpact that contracting encephalitis can have psychologically, emo-tionally and physically, both on survivors, their family and extendednetworks. The presentation also touches upon their hindsight views onvaccination.Conclusion: According to a recent survey conducted in the UK, USA, India,Germany and Australia, 80% of the general public in these countriesdo not know what encephalitis is. This is perhaps in contrast to otherconditions, whose incidence is lower, but who receive much higher clinicaland public profiles. Although the risk of acquiring encephalitis duringtravel is low overall, the disease can be very severe. The insight gainedby interviewing these survivors and their family members will suggestthat travel practitioners should ensure that travellers know not only thelikelihood, but also the severity, of an unfamiliar condition, in order tomake informed decisions about their choice to vaccinate or not.

P414

CLINICAL PROFILE AND OUTCOMES OF INPATIENTS WITHINFLUENZA FROM A TERTIARY CARE CENTER IN SOUTH INDIA

Gunasekaran K., Das S., Iyyadurai R.Dept. of General Medicine unit V, Christian Medical College, Vellore,India

Introduction: Influenza is an acute viral respiratory infection that affects5%–15% of the global population. They have a varied spectrum of clinicalpresentation with milder forms presenting as Influenza like illness (ILI) toclinically severe forms such as severe acute respiratory infection (SARI).Two subtypes of influenza A currently circulate in humans: seasonal H3N2(sH3N2 emerged in 1968) and pandemic H1N1 (pH1N1 emerged in 2009).While the epidemiological characteristics of the initial wave of pH1N1have been studied in detail, less is known about its infection dynamicsduring subsequent waves or its severity relative to sH3N2.Aim: In this study we aim to study the clinical profile and outcomes ofinpatients with influenza infection.Method and Materials: This retrospective study was conducted over aperiod of 24 months (December 2015 to January 2017). The data wasextracted from the inpatient medical records and it was analysed. Alladult patients requiring admission in Medicine unit V with a diagnosisof influenza were included. A diagnosis of influenza was confirmed byreal time PCR. Descriptive statistics were obtained for all variables in thestudy and appropriate statistical tests were employed to ascertain thesignificance.Results: The cohort consists of 70 patients with 39(55.7%) femalesand aged 49.27 ± 17.17years (mean, SD). Nineteen (27.1%) patientshad predisposing lung condition and 15 (21.4) patients had diabetes.The admission SOFA score was 2.31 ± 2.01. Forty-four (62.85%) werepositive for H1N1 influenza, 14 (20%) and 12 (17%) positive for H3N2 andinfluenza B respectively. Thirteen (8.57%) required intensive care moni-toring, 20 (28.6%) required mechanical ventilation and 4 (5.7) patients

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EBOV negativesN=73

Malaria testingNegative N=42 Pf N=22 Pf/Pan N=9

Age, years (2 missing) median, IQR 25 (10-40) 35 (23-44) 11 (4-31) 7 (4.5-10)< 5 years n, % 10 (14%) 2 (5%) 6 (29%) 2 (25%)5-15 years n, % 14 (20%) 3 (7%) 6 (29%) 5 (62.5%)15-45 years n, % 36 (51%) 28 (67%) 7 (33%) 1 (12.5%)≥ 45 years n, % 11 (15%) 9 (21%) 2 (9%) 0 (0%)Male sex (3 missing) n, % 38 (54%)

required haemodialysis. The mean ± SD duration of hospital stay wasof 8.64 ± 6.16 days and 12 (18.1%) developed secondary infection. Themortality in this cohort was 14(20%).Conclusion: Seasonal influenza continues to cause significant morbidityand mortality. H1N1 continues to be the commonest strain with a recentsurge in H3N2 cases.

P416

RETROSPECTIVE ANALYSIS OF EBOLA VIRUS NEGATIVE HUMANBLOOD SAMPLES FROM BIKORO, DRC 2018

De Smet B.1, De Weggheleire A.1, Makiala-Mandanda S.2,Mbala-Kingebeni P.2, Ariën K.3, Ahuka-Mundeke S.21Dept. of Clinical Sciences, Institute of Tropical Medicine, Antwerp,Belgium;2Dept. of Virology, Institut National de Recherche Biomédicale,Kinshasa, DRC;3Dept. of Biomedical Sciences, Institute of Tropical Medicine,Antwerp, Belgium

Introduction: Early May 2018 an Ebola Virus disease (EVD) outbreak wasdeclared in DR Congo’s Equateur Province. Diagnostic laboratories wereinstalled by the Institut National De Recherche Biomédicale (INRB) inMbandaka, Itipo and Bikoro.Aim: We retrospectively investigated the etiology of acute febrile illnessin EBOV-negative patients.Methods:The first stored whole blood sample of each EVD-suspect whotested EBOV-negative by Cepheid Xpert® Ebola test in Bikoro between May11th and June 30th 2018 was included.Malaria was diagnosed by SD FK60 Malaria Antigen rapid diagnostictesting (Standard Diagnostics).Real-time reverse transcriptase PCR testing was performed with in-houseprotocols for Yellow Fever (YFV), Dengue (DENV), Chikungunya (CHIKV),Japanese Encephalitis (JEV); and Realstar® kits (Altona Diagnostics) forRift Valley fever (RVFV), Crimean Congo Haemorrhagic fever (CCHFV), Zika(ZIKV) and the Filoscreen® kit.Results: A total of 133 EVD-suspects were tested, 99 were EBOV-negative,and for 73 samples were available.Median duration of illness was 3 days (IQR 2-7). Fever (89%), generalfatigue (55%), abdominal pain (49%), nausea/vomiting (45%) and poorappetite (45%) were the most prevalent symptoms. Additional patientdemographics and malaria results are displayed in Table 1.The positive Pf result (HRP-2), found in 30% of EBOV-negative patients,indicated a recent P. falciparium infection; a positive Pf/PAN result (HRP-2 and pLDH, 12%) suggests an ongoing infection with P. falciparum onlyor multiple Plasmodium species. 29% of children <15 years had activemalaria.

All PCR analyses (Filoscreen n=70, YFV n=69, DENV n=67, CHIKV n=52,RVFV n=26, ZIKV n=69, CCHFV n=69) were negative, except for the sampleof a 20-year-old female testing DENV serotype 2 positive. Her blood wasdrawn six days after symptoms started and she presented with fever andheadache.A limitation of this study was the challenge of cold chain storage in thisemergency setting. This may have resulted in viral RNA degradation; andsub-optimal virus detection.Conclusion: Our results confirm the importance of malaria testing andtreatment during EVD outbreaks. On-site testing for other haemorrhagicviruses seems less relevant, but surveillance remains critical. Further andbroader etiological studies (including bacteria) for acute febrile illness areto be encouraged.

P418FAVIPIRAVIR EFFICACY AND SAFETY IN LASSA FEVER: A SYS-TEMATIC REVIEW

Bahaie N.S.1, Nhu Y.M.2, Tawfik G.M.3, Hassan O.G.4, KhattabE.M.5, Ba Nghia T.L.2, Mohamed H.S.6, Huy N.T.7,8,9

1Faculty of Medicine, Alexandria University, Alexandria, Egypt;2Faculty of Medicine, Vo Truong Toan University, Hau Giang,Viet Nam;3Faculty of Medicine, Ain Shams University, Cairo, Egypt;4Faculty of Medicine, South Valley University, Qena, Egypt;5Faculty of Dentistry, Al-Azhar University, Cairo, Egypt;6Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt;7Evidence Based Medicine Research Group, Ton Duc Thang Univer-sity, Ho Chi Minh City, Vietnam;8Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi MinhCity, Vietnam;9Dept. of Clinical Product Development, Institute of TropicalMedicine (NEKKEN), School of Tropical Medicine and Global Health,Nagasaki University, Nagasaki, Japan

Introduction: Lassa fever is a tropical endemic disease causing a vaguefebrile presentation that is difficult to diagnose, and eventually leadingto deadly complications. Due to its recent outbreak in Nigeria in 2018, ithas to be reconsidered in terms of control and treatment. While evidenceexists in support of the use of Favipiravir as a medication to control thesigns and symptoms of Lassa fever in a few studies, its efficacy is stillcontroversial and hence there is still no approved drug for this condition.Aim: To evaluate the efficacy and safety of Favipiravir in treating Lassahaemorrhagic fever.Methods: Thirteen electronic databases were used to identify relevantstudies. Quality assessment National Institute of Health (NIH) tools

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for observational cohort, cross-sectional, and case-control studies wereused. Descriptive analysis was done for included four studies.Results: Apparent benefit in support of Favipiravir use in treatment ofLassa fever was demonstrated in all 4 included studies in the formof 100% survival rate, a marked reduction of virus titre in blood andinternal organs, and a decrease in temperature among Lassa virus (LASV)infected cases as compared to Ribavirin and placebo control groups. Italso managed to increase the mean time to death and decrease the liverbiochemical test values of AST and ALT. No side effects were reported inany of the studies, so this remains a concern. Despite these demonstratedadvantages, it was proved that days post infection prior to administrationof the drug is a potentially significant variable. An increase in this variable,directly affects and decreases the efficacy of Favipiravir in treating theinfection.Conclusion: Our study provides an insight into the efficacy of Favipiravirand its role in improving Lassa fever through the available data thatsuggest a promising benefit to treat LASV infected cases. More futurehuman studies should help establish a stronger clinical base for thisevaluation, and aid in elucidating whether it outweighs its adverse eventsif any; that could be experienced.

P419

DESCRIPTION OF HEPATITIS B VIRAL LOADS WITHIN A UKCOHORT OF CHRONIC INFECTION

Downs L.O.1,2, Smith D.2,3, Patel M.1, McNaughton A.L.2,Salih H.4, Freeman O.4, Varnai K.3, Davies J.4, Barnes E.2,3,5,Matthews P.C.1,2,3

1Dept. of Infectious Diseases and Microbiology, Oxford UniversityHospitals NHS Foundation Trust, Oxford;2Nuffield Dept. of Medicine, University of Oxford, Oxford;3National Institutes of Health Research Health Informatics Collab-orative, NIHR Oxford Biomedical Research Centre, Oxford;4Oxford NIHR Biomedical Research Centre Clinical InformaticsGroup, Big Data Institute, University of Oxford, Oxford;5Dept. of Hepatology, Oxford University Hospitals NHS FoundationTrust, Oxford, UK

Introduction: Hepatitis B virus (HBV) DNA viral loads (VL) show largevariation within a population during chronic hepatitis B (CHB) infection.This may be dependent on factors including duration of HBV infec-tion, hepatitis B e-antigen (HBeAg) status, gender, age and HBV geno-type. HBV VL has implications for disease progression, HCC develop-ment and transmission, and is used in the algorithm for determiningtreatment eligibility, but there are few published descriptions of HBV VLdistributions.Aim: We set out to describe HBV VL distribution in a diverse UK cohort,to determine how HBV VL changes over time and to identify associatedpatient characteristics.Methods: Longitudinal HBV DNA measurements, demographic data, andother laboratory parameters were collected retrospectively via an elec-tronic pipeline supported by the National Institute for Health ResearchHealth Informatics Collaborative (NIHR-HIC) for all patients with CHB(positive HBsAg on ≥2 occasions ≥6 months apart) between 2011-2016within a large UK teaching hospital (n=505). We included only those offtreatment (n=383).Results: The average age of our cohort was 42 years with the dominantethnicity being white (29%). The majority of our cohort was HBeAgnegative (81%) and male (56%). Mean HBV VL was 3.97 log10 iU/mL whichis lower than previously described in hepatitis C virus1 and HIV2. Therewas a bimodal VL distribution with peaks at around 3 and 8 log10 iU/mL.Mean HBV DNA differed significantly between ethnicities (p=0.0045 by

one-way ANOVA) with those from South East Asia having the highestmedian HBV VL (21109 IU/mL). Those who were HBeAg positive had asignificantly higher VL than those who were HBeAg negative (p<0.0001)and males had a significantly higher VL than females (p=0.025).Conclusion: These data describe the population distribution of HBV viralloads in CHB. This is the first robust description of the bimodal distributionof HBV VL. This work adds to the body of evidence showing male, HBeAgpositive patients have higher HBV viral loads, although the reasons forthis are not known. Descriptions of HBV VL in different populations mayshed light on the evolutionary biology of HBV and help inform clinicalmonitoring.

References:1. Ticehurst, J. R., Hamzeh, F. M., & Thomas, D. L. (2007). Factors affectingserum concentrations of hepatitis C virus (HCV) RNA in HCV genotype1-infected patients with chronic hepatitis. Journal of Clinical Microbiol-ogy, 45(8), 2426–2433.2. Hollingsworth, T. D., Chapman, R., de Wolf, F., Hanage, W. P., & Fraser,C. (2007). Variation in HIV-1 set-point viral load: Epidemiological analysisand an evolutionary hypothesis. Proceedings of the National Academy ofSciences, 104(44), 17441–17446.

P420

EPIDEMIOLOGY OF HEPATITIS B AND EVALUATION OF VACCINEEFFICACY IN A CENSUS-BASED COMMUNITY SEROSURVEY OFNDIRANDE TOWNSHIP IN BLANTYRE, MALAWI

Stockdale A.J.1,2, Shawa I.1,3, Everett D.1,4, Geretti A.M.2,Gordon M.1,2

1Malawi-Liverpool-Wellcome Trust Clinical Research Programme,Blantyre, Malawi;2Institute of Infection and Global Health, University of Liverpool,Liverpool, UK;3University of Malawi College of Medicine, Blantyre, Malawi;4University of Edinburgh, Edinburgh, UK

Introduction: In sub-Saharan Africa, hepatitis B (HBV) is the principlecause of hepatocellular carcinoma and cirrhosis. In Malawi, the epi-demiology of HBV has not previously been characterised in a samplethat is representative of the general population. The infant HBV vaccine,provided at 6, 10 and 14 weeks, was introduced in 2002 and an assess-ment of vaccine impact is required. Previous reports from Malawi, pre-dominantly employing convenience sampling, estimated HBV prevalenceof 8%.Methods: We tested 6073 individuals residing in Ndirande, an urbantownship in Blantyre, Malawi, who were participants in the STRATAA study(Strategic use of Typhoid vaccines across Asia and Africa) for hepatitisB surface antigen (HBsAg) using a GPS-mapped census of the township(n=97,411), with oversampling of younger and older age groups. We useda laboratory ELISA (MONOLISA HBsAg, Bio-Rad) with repeat testing ofindeterminate samples (ratio 0.9-4). We examined effect of gender usinglogistic regression and calculated age-sex standardised prevalence usingcensus data, stratified by time of vaccine introduction.Results: Among individuals aged 0-4, 5-14, 15-34, 35-50 and >50 years,the prevalence of HBsAg was 0.4% (95% confidence interval 0.1-1.4),0.3% (0.2-0.7), 4.5% (3.6-5.6), 5.8% (4.4-7.5), and 2.7% (1.8-4.2), respec-tively. HBV infection was not associated with gender, after adjustmentfor age (odds ratio for female vs male 0.9 (95% CI 0.6–1.2, p=0.49)).Age-sex standardised HBV prevalence among individuals born before vsafter introduction of the infant HBV vaccine was 5.2% (95% CI: 4.3, 6.1)and 0.3% (0.1-0.5), p<0.0001, respectively. HBV vaccination status wasascertained for 1149/2085 (55.1%) children under 11 years; 1118/1149

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(97.3%) reported receiving 3 doses. Low HBV prevalence was observedin children regardless of HBV vaccination status: 0.2% (95% CI 0.05-0.6),0% (0% (0-11.0) and 0.5% (0.2-1.2%); p=0.33, for complete, incompleteor unknown vaccine status, respectively.Conclusions: In an urban township in Malawi, hepatitis B was of inter-mediate prevalence (5.2%) in individuals born prior to the introductionof the HBV vaccination in 2012. HBV infection prevalence was 94% lowerin children born after the introduction of the vaccine. Very high rates ofvaccination were reported.

P421

YELLOW FEVER VACCINE ASSOCIATED VISCEROTROPIC DIS-EASE IN 42 YEARS OLD MALE

Lomencho A.1, Fantaye H.21Emerald Medical, AMC Infectious Diseases Center, Addis Ababa;2Federal Ministry of Health, Addis Ababa, Ethiopia

Introduction: Yellow fever is a common viral infection in the tropics whichhas led to recommendations by WHO for routine vaccination of travellersto countries at risk.Aim: To describe clinical profile of Yellow Fever Vaccine associated disease.Methods: Case report.Result: We report the first case report of Yellow Fever Vaccine associatedviscerotropic disease in Ethiopia. A 45 years old male patient with no back-ground medical history developed fever, myalgia, arthralgia, anorexia,prostration 2 days following Yellow Fever Vaccine. Five days following thevaccine he developed yellowish discoloration of the eyes and body anddarkening of urine. He had yellow fever vaccine 10 years ago which wasuneventful. He has no history of allergy to eggs. He has no backgroundhistory of diabetes, HIV and is not on immunosuppressive treatment. Onexamination, he had stable vital signs. There was scleral icterus, and theskin was tinged yellow. There was mild right upper abdominal tenderness.Laboratory tests revealed hepatocellular pattern acute liver injury withelevated transaminases (ALT, AST) and high bilirubin. He also had mildacute kidney injury. Blood culture for bacterial infection was negative.He was admitted, received supportive care including IV fluids, avoidingof hepatotoxic medications. His liver function gradually normalized in thefollowing three weeks.Discussion: Yellow Fever Vaccine Associated Viscerotropic disease is arare syndrome resembling wild type of yellow fever with incidence of0.4 per 100,000 vaccine recipients. About 65 cases have been reportedworldwide and is said to have case fatality of 60%. Immunity provided byYellow fever vaccine is assumed to be lifelong in majority of individualsthat receive it. In 2016, WHO recommended there is no need of boosterdose every 10 years. Our patient received a booster dose with a cascadeof symptoms which temporally goes with Yellow Fever vaccine associatedviscerotropic disease. The finding in our report indicate the need ofeducating the general public on newer WHO guidelines, and a wider studyfor its risk factors. We also need active surveillance of vaccine recipientsto document incidence in Ethiopia.

P422

STATUS OF INFECTION PREVENTION AND CONTROL (IPC) ATA LASSA FEVER TREATMENT CENTER BEFORE AND AFTER THEIMPLEMENTATION OF AN INTENSIVE IPC PROGRAM DURING ASURGE IN LF OUTBREAK, 2019

Ilesanmi O.1, Ayodeji O.2, Adedosu N.2, Adeagbo A.2, AbejegahC.2, Odutayo A.2, Ayun F.21Dept. of Community Medicine, College of Medicine, University ofIbadan, Ibadan;

2Lassa Fever Infection Control and Research Centre, Federal Medi-cal Centre, Owo, Nigeria

Background: Implementation of infection prevention and control (IPC)programs is important in the control of Lassa Fever (LF) outbreak. Wereport the status of IPC at a tertiary health facility before and after theimplementation of IPC program during a surge in LF outbreak.Methods: We conducted a longitudinal observational study from Febru-ary, 2019 to May 2019. The IPC Assessment Framework (IPCAF)-a WorldHealth Organization (WHO) Guidelines on core components of IPC pro-grammes in health care facility was used. The tool has 8 core componentswith a score of 0-100 per component. The IPCAF provided a baselineassessment of the IPC programme, IPC activities areas and evaluationafter three months. During the first phase, members of the research teaminterviewed relevant unit heads and IPC committee members. During thesecond phase, we designed and implemented an IPC programs. In thethird phase, same interview like the first was conducted. The programmeinitiated included training of health care workers and provision of relevantIPC items according to identified gaps and available funding.Results: The overall IPC level score increased from 318.5 at baselineto 545 at repeat assessment 3 months later. Varied improvements inIPC were reported in all the components, with IPC education and train-ing [baseline (20) final (70)], IPC guidelines [baseline (50) final (92.5)]and monitoring/audits of IPC practices and feedback [baseline (40) final(82.5)] recording the most remarkable improvements. Health care asso-ciated infection [baseline (10) final (25)] and Built environment, materialsand equipment for IPC [baseline (43.5) final (55)] had the least improve-ment. Poor motivation to adopt recommended changes by some hospitalstaff and excess workload in some clinical areas were the leading issuespreventing improvements.Conclusions: Most aspects of the IPC core components were appropri-ately implemented. The facility should develop long-term plans for solv-ing identified challenges and further promote IPC programme activities.

P423DETERMINANTS OF HOSPITAL-WIDE ANTIMICROBIAL STEW-ARDSHIP PROGRAM IN NNAMDI AZIKIWE UNIVERSITY TEACH-ING HOSPITAL, NNEWI

Okechukwu R.C., Onyejiaka D., Elo-Ilo J.C., Ebenebe J., EgbuniweM., Obasikene C., Nri-Ezedi C.A., Ugbaja J.Centre for Community Medicine and Primary Healthcare, NnamdiAzikiwe University Teaching Hospital Nnewi, Nnewi, Nigeria

Introduction: There is global need for effective hospital-wide antimicro-bial stewardship program, (ASPs) to contain he challenges of antimicro-bial resistance. Challenges to the effective practice of ASPs in the NnamdiAzikiwe University Teaching Hospitals Nnewi have not been adequatelyresearched.Objectives: To assess the challenges to effective Antimicrobial Steward-ship Program among healthcare workers in Nnamdi Azikiwe UniversityTeaching Hospital, Nnewi.Methods: A cross sectional survey among healthcare workers in theNnamdi Azikiwe University Teaching Hospital, Nnewi using structuredself-administered questionnaire instrument. Ethical approval wasobtained from the ethical review board of the teaching hospital anddata collected were analyzed using SATA software version 12 afterethical approval. Demographic characteristics of the respondents werecomputed and tests for statistical significance were done using regressionanalysis and chi-square tests at 95% confidence interval (p value=0.05)Results: Of the 190 questionnaires distributed 162 were returned, (85.3%response). Among the respondents were 44 (27.2%) males and 118(72.8%) females; with age range 21 – 63 years: mean age; 35.2 (XXX 8.2)years; median age of 34 years; median length of service in the hospital,

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5 years. Only 6 (3.75%) of the respondents consider their knowledge andskills of antimicrobial stewardship program as excellent; 54 (33.5%) didnot think that antimicrobial resistance is a serious healthcare problem.Bivariate logistic regression analysis for the predictors of antimicrobialstewardship program were not statistically significant for respondents’knowledge of antimicrobial stewardship program within their age cate-gory (p, 0.14; OR: 1.89), gender (p, 0.76; OR: 1.12), and length of servicewithin the hospital (p, 0.17; OR: 1.64), at 95% confidence interval.Conclusion: The respondents in this study showed overall poor knowl-edge of antimicrobial stewardship program. The major challengestowards effective antimicrobial stewardship program were lack ofawareness about the program and insufficient personnel. There is need tocreate awareness through regular training and retraining of personnel inorder to have effective and functional antimicrobial stewardship programwithin our teaching hospitals.

P424

PREVALENCE OF SEXUALLY TRANSMITTED INFECTIONS ANDRISK FACTORS AMONG YOUNG PEOPLE IN A PUBLIC HEALTHCENTER IN BRAZIL: A CROSS-SECTIONAL STUDY

Peder L.D.1,4, Silva C.M.2,4, Nascimento B.L.3, Malizan J.A.4,Madeira H.S.4, Horvath J.D.5, Silva E.S.6, Teixeira J.J.V.11Post-Graduate Program in Biosciences and Physiopathology, Mar-ingá State University, Maringá;2Post-Graduate Program in Health Sciences, Maringá State Univer-sity, Maringá;3Center of Medical and Pharmaceutical Sciences, State Universityof Western Paraná, Cascavel;4Clinical Analyses Laboratory, University Center of Assis GurgaczFoundation, Cascavel;5Centro Especializado em Doenças Infecto Parasitárias, Cascavel;6Dept. of Statistics, Maringá State University, Maringá, Brazil

Introduction: Sexually transmitted infections (STI) significantly impactthe health of sexually active people, mainly youngsters, and can causesexual dysfunction, infertility, increased transmission of HIV, low self-esteem, and death1-3. We conducted a transversal study of users ofpublic health service and verified the prevalence of STI and its associatedpredictors for male and female individuals aged 13–24 years in an interiorcounty of southern Brazil.Methods: A total of 1,703 adolescents and young adults, stratified byage (13–18 and 19–24 years respectively) and sex, admitted betweenApril 1, 2012 and March 31, 2017, participated in this retrospectivestudy. Epidemiological, clinical, and laboratory data of medical recordswere analyzed using the chi-square test and odds ratio, with confidenceinterval of 95% by the Stata® 9.0 program.Results: During the study period, a total of 3,448 patients were attended,and of these, 1,703 (49.39%) were aged 13–24 years, with higher STIprevalence between those aged 19–24 years (86.56%). The prevalenceof STI among men and women, respectively, was 35.40% and 47.67%for condylomata, 8.46% and 7.00% for herpes, 26.35% and 18.80% forsyphilis, and 20.06% and 6.27% for urethral discharge syndrome. The riskfor STI acquisition was the highest in young adults (OR 1.55, 95% CI 1.17-2.06, p=0.002), female individuals (OR 1.51, 95% CI 1.14-2.00, p=0.004),those with multiple sexual partners (OR 1.62, 95% CI 1.22-2.16, p<0.001),and those not or irregularly using preservatives (OR 1.62, 95% CI 1.22-2.16, p<0.001).Conclusion: The findings revealed a significant prevalence of STI in youngpeople in public health service. The predictors associated with STI in thesepatients were being female, having multiple partners in the last year,and not using or irregular use of preservatives. These predictors confirm

the necessity to implement more aggressive strategies to prevent theoccurrence of STI in specific populations with higher disease risk andminimizing costs and damages caused by the infections.

References:1. Hartman L.B., Monasterio E., Hwang L.Y. Adolescent contracep-tion: Review and guidance for pediatric clinicians. Curr Probl PediatrAdolesc Health Care 2012; 42:221–263.2. Workowski K.A., Berman S., Centers\ignorespacesfor\ignorespacesDisease\ignorespacesControl\ignorespacesand\ignorespacesPrevention\ignorespaces(CDC). Sexually transmitted diseases treatment guide-lines, Morbidity and mortality weekly report. Recommendations andreports / Centers for Disease Control 2010; 59:1-110.3. Redmond A.M., McNamara J.F. The road to eliminate mother-to-childHIV transmission. J Pediatr (Rio J) 2015; 91:509–511.

P427

RISK FACTORS FOR DIAGNOSED NOMA IN NORTHWESTNIGERIA: A CASE-CONTROL STUDY

Farley E.1, Lenglet A.2, Ariti C.3, Jiya N.M.4, Adetunji A.S.5, vander Kam S.2, Bil K.21Médecins Sans Frontières, Sokoto, Nigeria;2Médecins Sans Frontières, Amsterdam, The Netherlands;3Centre for Medical Education, Cardiff University School ofMedicine, Cardiff, UK;4Dept. of Paediatrics, Usmanu Danfodiyo University Teaching Hos-pital, Sokoto, Nigeria;5Dept. of Surgery, Noma Children’s Hospital, Sokoto, Nigeria

Introduction: Noma rapidly disintegrates the tissue of the face and leadsto severe disfiguration and high mortality. In Sokoto, Nigeria, MédecinsSans Frontières and the Ministry of Health (MoH) run treatment andprevention programs at the Noma Children’s Hospital (NCH).Aim: Using a case-control study design, we aimed to estimate risk factorsfor diagnosed noma in Sokoto and Kebbi states to guide existing programstrategies.Methods: Cases were defined as patients <15 years old at self-reportedonset of noma, admitted to NCH in the previous year. Controls werematched to cases by village of residence, current age and sex. Caretakersprovided consent and answered questions on demographics, vaccinationhistory, nutritional habits and living conditions. Data was collected ontablets using KoboCollect. Risk factors for noma were estimated by cal-culating unadjusted and adjusted odds ratios (ORs) and respective 95%confidence intervals (CI95%) using logistic regression.Results: We included 74 cases and 222 controls (mean age 11 (SD13) and10 (SD12) respectively). Five cases (6.5%) and 36 controls (16.2%) hada vaccination card (p=0.03). Vaccination coverage for polio and measleswas below 7% in both groups. The two main reported water sources werea bore hole in the village (cases n= 27, 35.06%; controls n= 63, 28.38%;p=0.08), and a well in the compound (cases n= 24, 31.17%; controls n=102, 45.95%; p= 0.08). The risk factors for being a noma case included:the mother not being the primary caretaker (aOR 0.1; CI95%:0.05-0.4,p<0.001), the caretaker being unmarried (aOR 0.01; CI95%: 0.004-0.04,p<0.001), colostrum not being given to the baby (aOR 0.3; CI95%:0.1-1.1; p=0.004) and the child being fed maize porridge every day (aOR 5.0;CI95%:1.2-20.8; p=0.03).Conclusion: This study suggests that social conditions and infant feedingpractices are associated with being a noma case in northwest Nigeria.Our recorded vaccination coverage for all children is well below thetargets established by the MoH. Noma prevention efforts should includeincreasing access to health care and vaccinations, educating caretakersabout the benefits of colostrum and eating a varied diet and educating

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community members on identifying noma to ensure care is soughtrapidly.Ethics:The study protocol was approved by the MSF Ethical Review Board (study1710), Usmanu Danfodiyo University Teaching Hospital Health Researchand Ethics Committee in Nigeria (UDUTH/HREC/2017/No.595) and theMinistry of Health in both Sokoto (SKHREC/032/017) and Kebbi (MOH/-SUB/4027//Vol.I/14) States.Acknowledgements:We would like to thank the study team Juliana Oyemakinde Modupe,Amina Abubakar, Linda Torhee, Dalhat Bello, Victoria Agboarumi, Has-sana Abdullahi, Christiana Abuka, Jiya Hassan Abdulmalite, Hussaina Balafor all their hard work and dedication to this project; the patients andcaretakers who offered to be a part of the study; and the staff at theNoma Children’s Hospital for their assistance with the project.

P428

CHLOS-HRM: A NOVEL ASSAY TO IDENTIFY CHLORAMPHENICOL-SUSCEPTIBLE E. COLI AND K. PNEUMONIAE IN MALAWI ANDNEPAL

Williams C.T.1, Musicha P.2,3,4, Feasey N.A.2,5, Adams E.R.1,Edwards T.11Research Centre for Drugs and Diagnostics, Liverpool School ofTropical Medicine, Liverpool, UK;2Malawi-Liverpool-Wellcome Trust Clinical Research Programme,Queen Elizabeth Central Hospital, Blantyre, Malawi;3Mahidol-Oxford Tropical Medicine Research Unit, Mahidol Univer-sity, Bangkok, Thailand;4Centre for Tropical Medicine and Global Health, Nuffield Dept. ofMedicine, University of Oxford, Oxford, UK;5Dept. of Clinical Sciences, Liverpool School of Tropical Medicine,Liverpool, UK

Introduction: Severe bacterial infection with antimicrobial resistant bac-teria is an important cause of morbidity and mortality in the devel-oping world, where 3rd-generation cephalosporins are frequently bothfirst and last-line antimicrobials. With the dearth of new drugs in thepipeline, reimplementing older ‘forgotten’ drugs could provide an alter-native, cheaper treatment option. A broad-spectrum antimicrobial, chlo-ramphenicol is widely available in the developing world and could be re-introduced to treat susceptible infections.Aim: Design and evaluate a high-resolution melt (HRM)-qPCR assay,ChloS-HRM, to identify chloramphenicol-susceptible infections in a hos-pital setting.Methods: The assay was designed and evaluated using 72 wholegenomes sequenced (WGS) isolates of Escherichia coli and Klebsiellapneumoniae from Queen Elizabeth Central Hospital, Malawi. Our primersdetect 18 chloramphenicol resistance genes within 7 distinct peakscorrelating with different gene groups (catA1, catA2, catA3, catB2,catB Group 3, cmlA, floR) following HRM analysis. ChloS-HRM resultswere compared with MIC and WGS results. The assay is to be furtherevaluated against 200 clinical samples from Nepal and results comparedto susceptibility testing data.Results: The overall agreement between MIC and HRM was 96 %, withan accuracy of 88 % in identifying susceptibility (15/17) and 98 % inidentifying resistance (54/55). The single false-susceptible result had nodetectable gene by ChloS-HRM or WGS. Compared with WGS, ChloS-HRMhad 100 % sensitivity and specificity for catA (catA1-A3), cmlA and floR,and 96 % specificity for catB; sensitivity could not be estimated due to thelack of catB in the clinical sample collection. Results from the screeningof the Nepalese samples will also be presented.

Conclusion: The ChloS-HRM provides a quicker and cheaper optionfor identifying chloramphenicol-susceptible infections to guide antimi-crobial stewardship and de-escalate treatment from 3rd-generationcephalosporins. This would be valuable in resource-limited areas withchloramphenicol-susceptible MDR and XDR Enterobacteriaceae.

P429

BACTERIOLOGICAL PROFILE OF URINARY INFECTION IN ARURAL AREA IN UGANDA

Carrasco Calzada F.1,2, Pérez Tanoira R.1,3, Cuadros J.4,5, RocaBiosca D.2, Górgolas M.3, Ramos Rincón J.M.6,7

1Universidad Autónoma de Madrid, Madrid;2Fundación el Alto, Castellón;3Hospital Fundación Jiménez Díaz, Madrid;4Hospital Príncipe de Asturias, Alcalá de Henares;5Universidad de Alcalá de Henares, Alcalá de Henares;6Hospital General Universitario de Alicante, Alicante;7Universidad Miguel Hernández, Alicante, Spain

Introduction: Urinary tract infections (UTI) are frequently treated withempirical broad-spectrum antibiotics, favouring the appearance ofantimicrobial resistance. This problem is accentuated in rural areas indeveloping countries with low accessibility to medicines and lack of amicrobiological diagnosis.Aim: The objective of this study is to ascertain the viability of introducingurine culture in a rural area of Uganda for bacteriological identificationand antimicrobial susceptibility.Materials/Methods: Prospective study including 128 patients withsuspected UTI attending to Saint Joseph’s Hospital-Kitgum (Uganda)between May and July 2018. A urine sample was included if itdemonstrated pure growth (over 100.000 colonies formers units) of asingle organism in Agar Cystein Lactose Electrolit Deficient (CLED) andleukocyturia. Samples were cultured and examined by microscope. Insome cases, isolated bacteria inactivated with methanol were identifiedusing Matrix-Assisted Laser Desorption/Ionization Time-Of-Flight in Spain.The isolates were further tested for antibiotic sensitivity using Kirby-Bauer method and following the guidelines of the Clinical and LaboratoryStandards Institute.Results: The main isolated bacteria were Escherichia coli (54.3%)and Staphylococcus spp., E. coli isolates resistant to ampicillin andco-trimoxazole occurred in more than 60% of cases. Globally, themost active antibiotics were nitrofurantoin (15.6%of resistance in allisolates), amoxicillin-clavulanic acid (20.5%) and ampicillin + sulbactam(24.4%). Finally, the antibiotics less active were amoxicillin (66.2%) andciprofloxacin (44.6%).Conclusion: Empirical treatment of UTIs in rural Uganda should notinclude amoxicillin or ciprofloxacin, due to a high resistance pattern. Nitro-furantoin remains as a suitable antiseptic for not-complicated cystitis.The results of this study may guide empirical therapy in a rural areahospital where culture and susceptibility testing facilities are scarce.

P430

SEASONALITY OF BLASTOCYSTIS SPP. IN A HEALTH DEPART-MENT IN EASTERN OF SPAINNavalón-Blasco S.1, Aleixandre-Gorriz I.1, Real A.1, Ibañez L.1,Almodóvar-Fernández I.1, López-Pedrajas R.1, Gregori-Roig P.2,Navarro L.3, Domínguez-Márquez M.V.3, Sánchez-Thevenet P.11Cardenal Herrera CEU University/CEU Universities, Castellon;2La Plana University Hospital, Villarreal;

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3Health Dept. Arnau de Vilanova, Valencia, Spain

Introduction: Blastocystis spp. is an intestinal parasite. Its role as aprimary pathogen in humans is controversial and its epidemiology stillneeds to be studied, including aspects such as seasonality.Aim: The aim of this work was to study the relationship between fre-quency of occurrence of Blastocystis spp. and seasonality in a HealthDepartment of the Valencian community (eastern Spain).Methods: The frequency of positive fecal concentration for Blastocystisspp. was obtained from the Microbiology Service of the Arnau de VilanovaHospital in the province of Valencia (Spain), from October 2016 to Octo-ber 2018. The presence of the parasites in the samples (n=4664) wasconfirmed by microscopical analysis under an optical microscope at 400magnifications by health professionals of the service. The demographicand epidemiological data of the different patients were obtained fromthe database system of the hospital service.Results: 9.7% (n=222) of the analyzed samples were positive for anyparasite and 49.2% of those positive samples presented Blastocystis spp.Therefore, the analysis of fecal concentrates showed that the frequencyof parasitism by Blastocystis spp. was 4.8%. The highest number of posi-tive samples was detected during the months of January (8.9%), February(8.3%) and March (9.3%), while the months with the lowest numberof positive samples were detected in May (0.7%), June (0.3%) and July(1.5%). Lastly, we observed a significantly increase in the percentage ofpositive samples during the cold months (6.9%) in compare with thesamples for the warm period (1.3%) (p < 0.0000001). These results arenot in accordance with results obtained by other authors. We think thatthese differences are due to the temperate of this region.Conclusion: Our results show that there is an increase of the frequencyof parasitism by Blastocystis spp. in the coldest months. These results arederived from a preliminary study and more studies should be performedto better understand our findings.

P431

DIPHTHERIA IN CHILDREN WITHIN AN EMERGENCY OUTBREAKSETTING – A CLINICO-EPIDEMIOLOGICAL COMPARATIVEANALYSIS WITH ADULT PATIENTS IN BANGLADESH

Sikder E.1, Valle del Barrio B.1, Firuz W.1, Khatoon R.1, OpstrupA.1, Sagrado M.J.2, Prieto M.A.2, Lafferty N.2, Mahajan R.1,Masum R.R.1, Patti J.11Médecins Sans Frontières, Cox Bazaar, Bangladesh;

2Médecins Sans Frontières, Barcelona, Spain

Background: Diphtheria outbreaks are rare with limited evidenceon differences in clinic-epidemiological presentation and evolutionbetween children and adults, and how this might direct vaccinationstrategies. This study contrasts those treated by OCBA between 11th

December 2017 and 15th February 2018 in the Rohynga forced massdisplacement.Methods: Indicator based surveillance of diphtheria cases was collectedat presentation, during and up to 90 days post-treatment, with paediatricclassified as <15yrs. Patients met pre-defined clinical case definitions1

and treatment protocols. Clinico-epidemiological proportional outcomeswere then compared.Results: 605 from a total of 915 treated patients were <15yrs with amean age of 8.4yrs, with 14.6%(n=88) under the age of 5. 50% of childrenwere female compared to 73% of adults. Mean time of symptom onsetto admission was 2.5 days for both. PCR testing conducted in 132 casesshowed higher positivity in pediatric cases (55.3% vs 31.6%). Adult casesmaintained steady incidence through the outbreak compared to pediatricwhich followed a propagated epidemic curve (Figure 1).Although nearly all (98%) received timely antibiotics, 2.7% and 32.7%of patients fitting the WHO ´RED ´2 and ´ORANGE ´3 severity guidancefor Diphtheria Anti-Toxin (DAT) treatment received it. Overall a higherproportion of adults than children were treated with DAT (27.3% vs 14.1%,p<0.01) and received high dose steroids (28.6% vs 16.5%, p<0.01). Ahigher proportion of paediatric patients receiving DAT reported adverseevents (16.5% vs 2.3%, p<0.01).CFR at point of discharge was 0.66% in paediatric and 0% in adult cases.At 90-days post discharge, 5.6% of paediatric and 3.5% of adults werenot found; a further 3 paediatric were reported to have died, 2 within 30days, while 1.3% of patients demonstrated a long-term diphtheria relatedcomplication.Conclusion: Despite likelihood of overdiagnosis, substantial numbers ofadult cases were reported in this outbreak reflecting the combination ofa large population of non-immune adults and poor vaccination coverageamong children. A higher proportion of adults received DAT and steroidsin a context where adults were excluded from pre-emptive and reactivediphtheria vaccination. Both groups showed a low prevalence of severesymptoms, the vast majority being bullneck early in the intervention priorto DAT availability. A low correlation between those receiving DAT andWHO recommendations reflects various challenges in outbreak response,particularly lack of DAT availability. Despite this, overall outcomes weregood, with low incidence of long-term complications in both age groups,and those not receiving DAT.

Figure 1. Epidemic Curve of paediatric vs adult diphtheria patients

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Table 1. Clinical and treatment features of diphtheria cases1

PaediatricsN=604

AdultN=311

P-value

N % N %Female sex 300 49.7 227 73 <0.01

Symptoms presentFever 355 58.8 155 49.8 0.01Sore throat or difficulty of swallowing 572 94.7 305 98.1 0.02Gross lymphadenopathy 348 57.6 109 35 <0.01Pseudo-membrane 410 67.9 226 72.7 <0.16Pharyngitis 134 22.2 116 37.3 <0.01Nasal discharge 39 6.5 3 1 <0.01Skin ulcers 11 1.8 2 0.6 0.16Stridor 4 0.7 0 0 0.15Respiratory distress 4 0.7 0 0 0.15Bullneck 186 30.8 52 16.7 <0.01Shock 1 0.2 0 0 0.5SeverityFitting WHO ´RED ´ criteria for DAT2 180 29.8 44 14.1 <0.01Fitting WHO ´RED ´ criteria for DAT2 AND received DAT 6/180 3.3 0/44 0Fitted WHO ´ORANGE ´ criteria for DAT3 261 43.2 188 60.5 <0.01Fitted WHO ´ORANGE ´ criteria for DAT3 AND Received DAT 77/261 29.5 70/188 37.2MedicationDAT administered 85 14.1 86 27.7 <0.01Adverse event in patient given DAT 14/85 16.5 2/86 2.3 <0.011st ATB-Penicillins given 28 4.6 8 2.6 0.131st ATB-Macrolides given 599 99.2 306 98.4 0.08Steroids-High Dose Dexamethasone given 87 14.4 79 25.4 <0.01Steroids-Hydrocortisone or Prednisone given 13 2.2 10 3.2 0.33PCR confirmationPCR positive 52/94 55.3 12/38 31.6

Ethics Statement:Approved by Medical Director OCBA as per MSF ERB guidelines of retro-spective analysis of routinely collected data.

P432SYSTEMATIC REVIEW OF SCRUB TYPHUS STUDY LANDSCAPE:PROTOCOL AND PRELIMINARY LITERATURE SEARCH RESULTS

Saraswati K.1,2,3, Maguire B.3,4, Singh S.4, Day N.P.J.2,3,Guérin P.J.3,4

1Eijkman-Oxford Clinical Research Unit, Eijkman Institute forMolecular Biology, Jakarta, Indonesia;2Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropi-cal Medicine, Mahidol University, Bangkok, Thailand;3Centre for Tropical Medicine and Global Health, Nuffield Dept. ofMedicine, University of Oxford, Oxford, UK;4Infectious Diseases Data Observatory (IDDO), UK

Introduction: Scrub typhus is an acute febrile illness caused by Orientiatsutsugamushi reported in Asia, Northern Australia, and parts ofChile. It is estimated that 1 billion people are at risk of this disease.However, compared to its magnitude, evidence to optimise treatments

and disease control efforts are sparse. Existing data collected frompast clinical trials and longitudinal observational studies could be asource of information to address research priorities and knowledgegaps.Aim: To conduct a systematic review to assess the characteristics ofscrub typhus clinical studies and explore the feasibility to develop a scrubtyphus individual participant-level data (IPD) platform.Methods: Following PRISMA guidance, 6 databases and 2 clinical trialregistries were searched for studies conducted between 1998 andMarch 2018. Prospective clinical studies in humans with scrub typhuswhere treatment was administered and participants were followed upat least once i.e. clinical trials and longitudinal observational studieswere included. Variables for extraction include treatment tested, patientcharacteristics, diagnostic methods, geographical location, outcomemeasures, and statistical methodology. Relevant data was extracted in aREDCap database. Thematic analysis, narrative synthesis, and statisticalanalysis were performed with R.Results: The literature searches identified 5,163 citations, of which 2,647unique articles were screened by two reviewers after duplicate removal. Atotal of 95 studies (7 clinical trials and 88 observational studies) met thepre-specified inclusion criteria. The studies have been conducted in 11countries and enrolled a total of 9,010 patients, 510 (5.7%) from clinicaltrials and 8,500 (94.3%) from observational studies. 390 case series andreports were also identified.

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Conclusion: Although there were only a few scrub typhus clinical trialsfound, there are substantially more data available from observationalstudies. Meta-analysis using an IPD approach can produce a more rep-resentative secondary analysis because it facilitates the use of datafrom observational studies as well – highlighting the potential use ofIPD platform. Understanding the landscape of scrub typhus treatmentstudies allows assessment of the feasibility of addressing research ques-tions using IPD meta-analysis method and to conduct a research gapanalysis.

P434

BRUCELLOSIS IN A LOW PREVALENCE SETTING

Fordham I., O’Connor C., Riley P.Dept. of Infection, St George’s University Hospitals NHS FoundationTrust, London, UK

Introduction: Brucellosis is a zoonotic infection, usually acquired fromcontact with infected livestock and unpasteurised dairy products. Itcommonly causes persistent fever, but clinical presentations can varysignificantly and it therefore may be considered as a differential in thefebrile patient with risk factors. The cattle populations in Great Britainand Northern Ireland were declared brucellosis free in 1985 and 2015respectively1. Brucellosis remains a rare disease in the UK and infectionsdiagnosed at UK centres will be acquired from contact with livestock ordairy products from an enzootic region excepting very rare human tohuman transmission2.Aim: To investigate episodes of brucellosis at our hospital since 2001: thepresentation, methods of testing, management and outcome.Methods: Culture positive Brucella sp. episodes were identified fromarchived laboratory records from 2001 to 2018. In addition, the Brucellaserology results from hospitals submitting specimens to South WestLondon Pathology were analysed from 2001 to 2008, to investigate thefrequency of testing and positive results.Results: Four patients with Brucella bacteraemias were identified. All hadlived in enzootic areas and consumed milk regularly. All cultures grew Bru-cella melitensis species. Presentations all included fever, other featuresvaried. All patients were treated with doxycycline and rifampicin but dura-tions varied from 6 weeks to 6 months. Three patients also had gentam-icin, ranging from one to four weeks. All patients had complete recovery.Brucella serology testing at our centre has increased since 2001 andmore than 85 patients/year have been tested in recent years, costingapproximately £2000/year. The serology results have been positive in only5 patients over 18 years, including 2 patients who were also found to bebacteraemic.Conclusion: Brucella is a rare disease in the UK, and the cases describedhad contact with livestock or dairy products from enzootic regions. Inthe four bacteraemic patients, management did vary regarding antibioticchoice, dose and duration, although all patients received rifampicin anddoxycycline. Serology tests are done comparatively frequently, with fewpositive results. It may be possible to choose those patients who haveserology testing more carefully, using known risk factors, to save unnec-essary testing.

References:1. Public Health England. UK Zoonosis Report 20172. TuonFF, GondolfoRB, CerchiariN. Human-to-human transmission ofBrucella - a systematic review. Trop Med Int Health. 2017 May;22(5):539-546

P435

ANTIBIOTIC RESISTANCE PATTERN OF URINARY TRACTINFECTIONS IN A FACILITY IN ETHIOPIA: EXPERIENCE OF ACLINICIAN

Lomencho A.AMC, Addis Ababa, MEPI Junior Scholars, Addis Ababa; Universityof Gondar, Gondar, Ethiopia

Introduction: Urinary tract infection is a common outpatient medicalproblem. A knowledge of the common causative agents and their resis-tance pattern is important to come up with local recommendations. Atpresent there is lack of national data to support this and facility basedstudies are a good starting point.Aim: To see the etiologic pattern and antimicrobial resistance profile ofUrinary tract infections seen in a facility in Ethiopia.Methods: This was a retrospective observational study of all urine culturesdone for UTI over a 7 months period (January-July 2018).Results: There were a total of 75 urine cultures done over six monthsperiod out of which 65% was for female patients. The age range was from18 to 90 with a mean age of 45. 85% of the urine cultures were done foroutpatient cases. Common comorbidities seen among the participantsincluded diabetes (4%) and HIV (2%). Among the cultures done, 60%were done for a consideration of recurrent UTI. 42% (32) of the cultureresults showed growth. E. coli accounted for 68.7% of the positive cultureswhile Enterococcus fecalis accounted for 10%. The rest were klebsiellapneumoniae (9%) S. Saprophyticus (4%), citrobacter (3%) and otherorganisms.Conclusion: E. Coli accounted for a majority of urinary tract infectionsseen at our facility. The resistance pattern noted for E. Coli could be anindirect indication of widespread use of antibiotics including amoxicillin,ceftriaxone and Ciprofloxacin. The antibiotic resistance pattern notedin this study needs to be further investigated to come up with localrecommendations for empiric antibiotic use for UTI.

P438BURDEN OF IMPORTED TROPICAL DISEASE AS WORK–RELATEDHEALTH EVENTS IN THE MEDICAL SERVICE OF AN INTERNA-TIONALLY WORKING ORGANISATIONKreuzberg C.1, Wagner S.21Medical Service, Deutsche Gesellschaft für Internationale Zusam-menarbeit (GIZ) GmbH, Bonn;2Medical Service, Deutsche Gesellschaft für Internationale Zusam-menarbeit (GIZ) GmbH, Eschborn, Germany

Introduction: The Deutsche Gesellschaft für Internationale Zusamme-narbeit (GIZ) is a service provider in the field of international coopera-tion for sustainable development and international education work. Ithas more than 6500 employees plus national personal working in 120countries worldwide.The Medical Service carries out check-ups for all staff and their familiesbefore during and after foreign assignments and business trips. Consul-tations are held in order to advice those with acute conditions.Aim: The analysis was done to monitor the burden of tropical diseases aswork related health events in our organisation.Methods: We analysed all laboratory results targeting tropical diseasesof examinations done in our Medical Service in 2018.Results: In 2018 our Medical Service carried out 3125 check-upexaminations. In 680 cases we requested a serology for schistosomiasisas a screening parameter. Serology was positive in 75 cases (11% of alltested/2,4% of all examined persons). With 1740 microscopic stool exam-inations we detected 87 parasitic infestation (5% of all tested, 2,7% of allexamined). Entamoeba histolytica/dispar were most frequently found (48cases). All of them could be identified as apathogenic entameoba in PCR

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differentiation. In 16 stool samples blastocystis hominis was detected.As all persons were free of complaints no medical treatment wasgiven.A need for medical treatment was found in only 26 cases: 12 withdetection of giardia lamblia (0,3% of all persons examined) and 14 withdetection of intestinal helminths (0,4%).In emergency consultation all of the 21 rapid tests to rule out Malariawere negative.Conclusion: In all check- ups done in 2018 we detected only 101 cases(3,2%) of imported tropical diseases needing medical treatment: mainlyschistosomiasis (75 cases, 2,4%), followed by intestinal helminthiasis(14 cases, 0,5%) and lambliasis (12 cases 0,3%). In our internationallyworking organisation the burden of imported tropical diseases as workrelated health events are low.

P440CAUSES AND OUTCOME OF BLOODSTREAM INFECTIONS INCAMBODIAN ADULTS: RESULTS OF 9 YEAR SURVEILLANCEDe Vos K.1, Liesenborghs A.1, Phe T.2, Veng C.2, Jacobs J.3,Vlieghe E.1,3,4

1Faculty of Medicine and Health Sciences, University of Antwerp,Antwerp, Belgium;2Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia;3Dept. of Clinical Sciences, Institute of Tropical Medicine, Antwerp,Belgium;4General Internal Medicine, Infectious Diseases and TropicalMedicine, University Hospital Antwerp, Antwerp, Belgium

Background: Bloodstream infections (BSI) are a major cause of mortalityData from from low-resource settings are scarce. We describe outcomeand risk factors of BSI in Cambodian adults over a 9-year period.Methods: In all adults presenting between January 2009 – February 2018with signs of ‘systemic inflammatory response syndrome’ at SihanoukHospital Centre of HOPE, 20 ml of blood was cultured. From patients withproven BSI, clinical, epidemiological, treatment and outcome data wereprospectively collected. and analyzed using STATA and MS Excel. Isolateswere identified using standard microbiological techniques; antibiotic sus-ceptibilities were assessed using disk diffusion and MicroScan®, with addi-tional E-test where applicable and according to CLSI guidelines. Ethicalclearance was approved by the National Ethics Committee of Cambodiaand at the University Hospital of Antwerp.Results: A total of 2150 BSI episodes from 1911 adult patientswere included. Median age was 54 years (SD 17.3 y), 57% (xxx/xxx)were female. Half of episodes 49.3%; xxx/xxx)) had been exposed toantibiotics prior to admission. Comorbidities were found in 1565/2150(72.8%), including diabetes 506/2150 (23.5%), liver disease 305/2150(14.2%) and HIV 293/2150 (13.6%). Fever (>38.5◦C) was found in53.7% of BSI episodes. The most frequent (presumed) sources ofsepsis were gastrointestinal (42.4%), respiratory (23.0%) and urinarytract (14.5%).Top 5 clinically relevant pathogens were Escherichia coli (n=614; 28.6%),Salmonella paratyphi A (n=285; 13.3%), Burkholderia pseudomallei(n=179; 8.3%), Staphyloccocus aureus (n=150; 7.0%), Klebsiella pneumo-niae (n=121; 17.8%). Methicillin resistance was found in 51/150 (34%)of S.aureus isolates. Combined resistance to ceftriaxone, gentamycin,cotrimoxazole and ciprofloxacin was found in 199/614 (32.4%) E. coliisolates. Salmonella spp resistance to ciprofloxacin was 248/414 (59.9%).Top five empirical antibiotic treatments were ceftriaxone (n=748),amoxicillin-clavulanic acid (n=215), ceftriaxone+metronidazole (n=182),ceftriaxone+amikacin (n=157), ciprofloxacin (n=121).The overall mortality rate a hospital discharge was 16,9% (323/1911), in192 patients (8.9%) the outcome was unknown.

Conclusion: BSI in Cambodia is associated with highly resistantpathogens and important early mortality. Studies on risk factor formortality are ongoing.

P441

POINT PREVALENCE SURVEY OF ANTIMICROBIAL USE ANDRESISTANCE FROM HOSPITALS IN SUB-SAHARAN AFRICA

Kuti O.O.1, Alori S.21UNICEF Ghana, Accra, Ghana;2Lagos Laboratory Services, Pathology Section, General Hospital,Lagos, Nigeria

Introduction: The emergence and spread of antibiotic resistance is aglobal health threat especially low and middle income where a largerburden of diseases is due to infectious diseases. Antibiotic stewardshipis essential to maintain the usefulness of antibiotics in the preventionand treatment of infectious diseases. Point prevalence surveys uses localdata to monitor antimicrobial prescribing practices and identify strategyto control and reduce antibiotic resistance.Methods: A review was conducted of published data on point prevalencesurveys of and antibiotics usage and healthcare-associated infections(HAIs) from sub-saharan countries. The search was conducted with com-binations of key search terms, including “((Point Prevalence Survey [Title])AND Africa)” and “healthcare-associated infections (HAIs) and antimicro-bial use”.Results: Five studies from 4 sub Saharan African countries were foundthrough advanced search on Pubmed, Embase and Web of Science. Forfull-text review by two independent reviewers, 5 articles and 1 meetingpresentation were selected.The overall median prevalence of antimicrobial use ranges from was 36%-54%. The prevalence of antimicrobial use differed significantly accordingto area of specialty, with the highest prevalence occurring in Paediatricintensive care wards (90.7%) and surgical wards (76.4%), as comparedwith medical and obstetric patients (36%). More than half of the patients(52%) were being treated with two antibiotics.The commonest indication for prescribing antimicrobials was treatmentof a community-acquired infection (40.1%), followed by surgical prophy-laxis (33.6%) followed by treatment of HAI (21.1%). The most commoninfections treated by antimicrobials were respiratory tract infections andthe most commonly prescribed antimicrobial agents were penicillins withbeta-lactamase inhibitors.Conclusion: The PPS review shows a high rate of antimicrobial use in acutecare hospitals in sub Saharan countries. In developing initiatives, antimi-crobial stewardship programs in region should focus on identified targetsfor improvement in antimicrobial use include decreases in prescribingof broad-spectrum and parenteral antimicrobials, better adherence toguidelines, and improved documentation.

P442CURRENT PRACTICE OF INTRAPARTUM ANTIBIOTIC PREVEN-TION IN NIGERIA AND SUB SAHARAN AFRICA

Adejumo R.N.1, Nakakana U.N.21Dept. of Obstetrics and Gynaecology, Rasheed Sekoni SpecialistHospital, Dutse, Nigeria;2Medical Research Council The Gambia Unit at London School ofHygiene and Tropical Medicine, The Gambia

Introduction: Intrapartum Antibiotic Prophylaxis (IAP) is a potentially life-saving intervention for the prevention of neonatal and maternal infec-tions and sepsis. In the developed world, there are policies for screening

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based on risk and treatment of pregnant women, particularly with GroupB streptococci. In Africa, there is a high variability in the organismswhich colonise mothers and cause neonatal infections. These policies ifavailable, can significantly reduce the burden of neonatal mortality dueto sepsis.Aim: To review and appraise the practices of IAP in Sub Saharan Africa.Methods: We conducted a key word search on Pubmed with the searchterms “Intrapartum AND antibiotic∗ AND (prophylaxis OR prevention) ANDAfrica”. We also searched African Journals Online (AJOL)’. Additionally, weselected a systematic review of Intrapartum Antibiotic Chemoprophylaxispolicies for the prevention of Group B Streptococcal Disease worldwide.A short survey was conducted among Obstetric practitioners in tertiaryhealth facilities in Nigeria to ascertain the current practice of IAP inNigeria.Results: The AJOL search yielded one result, which was relevant. ThePubmed search yielded 28 results, of which 24 were relevant. SouthernAfrica reported GBS infection rates similar to the developed world, but notNigeria or the rest of Africa. One systematic review reported a prevalenceof 0.06 per 1000 livebirths. A prospective study, however found a carriagerate of 8.6% for GBS, similar to other studies in Nigeria (Range of 8% to11% prevalence). There was an antibiotic resistance to erythromycin andclindamycin in 31.6% of cases. The outcome showed a 100% efficacyof IAP in preventing neonatal sepsis. There are, no published universalpolicies on screening and Intrapartum Antibiotic Prophylaxis, possiblybecause the broad aetiologies of newborn sepsis. The survey showed thatmost tertiary health facilities in Nigeria have a policy of selective IAP,with the most common indications being PROM and chorioamnionitis ona case-by-case basis.Conclusion: There is no consistent practice of IAP in most of Sub Saha-ran Africa, in Nigeria most hospitals administer IAP on a case by casebasis, probably due to inadequate information regarding carriage ofmicroorganisms.

P443POST PARTUM FAMILY PLANNING: IS THE UNMET NEED A HIGH-INCOME COUNTRY (HIC) PROBLEM?Mulji Y.1, Park H.2, Letchworth P.11Dept. of Obstetrics and Gynaecology, Imperial College NHS Trust,London;

2Imperial Medical School, London, UK

Introduction: Globally, over 9/10 women want to avoid pregnancy for2 years after childbirth but 1 in 7 isn’t using contraception. Post Par-tum Family Planning (PPFP) is the prevention of unintended and closelyspaced pregnancies in the 12 months following childbirth. This can pre-vent 1/3 of maternal deaths and reduce child mortality. PPFP initiativeshave had a renewed emphasis with the development of the WHO PPFPCompendium in 2017, major donor projects via Gates foundation andRCOG ‘leading safe choices.’ These are focused on providing a servicein Low and middle income countries (LMIC’s) however what is needin HIC’s?Aim: Assess the unmet need for PPFP in a high-income setting.Methods: A prospective survey of women on the postnatal ward at St.Mary’s Hospital, Imperial NHS Trust between 1/12/18 – 31/12/18 wasundertaken. Patients were interviewed; hospital notes reviewed and a 13-point questionnaire completed. Data was anonymised and entered ontoMicrosoft Excel where it was analysed.Results: 125 patients were surveyed, 41/125 (33%) of pregnancies wereunplanned, of whom 15/41 (37%) had never used contraception. 25/125(20%) of women were unaware they could conceive whilst breastfeeding.44/125 (35%) of women had never used contraception in the past. Amajority of patients (51%) hadn’t yet thought about postpartum con-traception. 51/125 (41%) of women stated they would be interestedin long acting immediate post partum contraception if it were offeredat the unit. Although documentation of discussion about PPFP occurred121/125 (96.8%) most women 74/125 (59.2%) women did not recall theconversation.Conclusion: As obstetricians and midwives, we have multiple points ofimpact within the continuum of care during pregnancy and can encour-age uptake of immediate PPFP. Financial health policy can interfere withthe ability to provide services such as PPFP. Here we highlight the unmetneed for PPFP in a UK setting. Whilst global initiatives focus on womenin LMIC’s improvements in offering PPFP, is should also to be prioritisedin HICs this will prevent adverse maternal health and social outcomesassociated with short inter-pregnancy intervals and will empower thesewomen to take control over their fertility prior to hospital discharge.

P444

UPTAKE AND OUTCOMES OF IMMEDIATE POST-PLACENTALINTRAUTERINE CONTRACEPTION INSERTED AT TIME OFCAESAREAN SECTION AT DERRIFORD HOSPITAL, PLYMOUTH

Mulji Y.1, Shaylor K.2, Caukwell S.31Dept. of Obstetrics and Gynaecology, Imperial College NHS Trust,London;2Dept. of Obstetrics & Gynaecology, Torbay and South DevonHealthcare NHS Foundation Trust, Torbay;3Dept. of Obstetrics & Gynaecology, University Hospitals PlymouthNHS Trust, Plymouth, UK

Introduction: Post partum family planning (PPFP) is the prevention ofunintended pregnancies and closely spaced pregnancies through the first12 months following childbirth. Family planning can not only preventmore than 1/3 of maternal deaths, but also reduce the risk of childmortality which is highest with very short birth-to-pregnancy intervals.There was no existing routine service to offer immediate PPFP at DerrifordHospital.Aim: To offer women post placental intrauterine contraception (PPIUC)during elective caesarean sections and increase the evidence base onoutcomes of PPIUC during caesarean sections.Methods: Patient information leaflets, checklists and standard operatingprocedures for offering PPIUC were devised. All women having elective

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caesarean sections between 01/05/2016 and 31/08/2017 were offeredPPIUC. Women had the option between a copper intrauterine device (IUD)or Mirena intrauterine system (IUS).A follow up 6 week check and questionnaire was offered to all women toobtain data on acceptance, complications or any issues associated withPPIUC.Results: A total of 486 patients had elective caesarean sections duringthis period. 95/486 (20%) patients opted to for PPIUC. 79/95 (83%) ofpatients actually had PPIUC (68 Mirena IUS and 11 copper IUD). Of these,20/95 (21.1%) were unplanned pregnancies.69/79 (87%) patients were followed up. 46/69 (67%) women still hadtheir PPIUC in situ. 78.3% were happy with having PPIUC and 81.2% wouldrecommend it to a friend. The remaining 23/69 (33%) no longer had theirPPIUC in situ - 12 due to expulsions and 11 removed predominantly due tobleeding pattern concerns and discomfort. Only 12/69 (17%) of womenneeded an ultrasound scan due to missing strings.Conclusion: There is a learning curve required for inserting IUCDs attime of caesarean section such as the need for improved clarity in theinformation leaflets we provide, highlighting potential bleeding pattern,which will hopefully reduce the removal rates.PPIUC is a beneficial form of PPFP that is known to be effective and isdeemed satisfactory by patients. It should be offered routinely and mayprevent adverse outcomes of closely spaced pregnancies.

P446

THE EXPOSURE OF FOREST STAFF IN TIGER RESERVES IN CEN-TRAL INDIA TO SNAKE BITES

Trivedy C.1,2,3,4, Gadre V.11Wildlife Conservation Trust, Mumbai, India;2Emergency Medicine, Brighton and Sussex University NHS Trust,Brighton, UK;3Blizard Institute, Queen Mary University of London, London, UK;4The Tulsi Foundation, UK

Introduction: Snake bites are a major global public health problem withup to 46,000 annual deaths in India alone. Forest staff (FS) who workin remote and rural areas are at risk of snake bites but there is nodata on their exposure to this condition, their awareness regarding themanagement of snake bites or the type of health care facilities availableto them.Aim: The aim of the study was to look at the impact of snake bites in tigerreserves across Central India.Methods: FS were recruited to complete a face to face survey whichexplored their exposure to a range of medical conditions whilst workingin remote areas. The survey assessed issues such as exposure to snakebites, confidence in managing snakebites as well as access to definitivecare in the event of snake bite.Results: A total of 1,097 FS completed the survey from 14 tiger reservesacross Central India. 55 participants (5%) reported to have been bittenby a snake whilst on duty and 31% knew of someone who had beenbitten. 208 participants (19%) reported that they had provided first aid oradvised someone else in the event of a snakebite. ‘When asked regardingtheir level of confidence in managing a snakebite in rural/remote settings,24% of respondents were ‘not confident’, 57% were ‘somewhat confi-dent’ while 19% were ‘very confident’ 130 (20%) stated that they hadaccess to a health facility that could provide anti-venom. The mediandistance required to travel for definitive care varied between the surveysites ranging from 13.1-32.9Km, whilst the median distance across allsites was 27.4km.Conclusion: This study shows that although the self-reported exposureto snakebites among FS themselves is low (5%), they are more likelyto be involved in managing snakebites (19%). Low level of confidence

in ability to manage snakebites as well limited resources and accessto definitive care suggests the need for greater awareness and bettertraining in pre-hospital management, which could have a positive impacton the prognosis of snakebites in such remote settings.

P447

VERBAL AUTOPSY TOOL FOR AUDITS OF SNAKEBITE EVENTS INRESOURCE-LIMITED SETTINGS

Tianyi F.L.1,2, Agbor V.N.3, Tochie J.N.4, Kadia B.M.5,6, MedangR.2, Nkwescheu A.S.2,7,8

1Mayo Darle Sub-divisional Hospital, Mayo Darle;2Cameroon Society of Epidemiology (CASE);3Ibal Sub-divisional Hospital, Oku, North-west Region;4Faculty of Medicine and Biomedical Sciences, University ofYaoundé I, Yaoundé;5Foumbot District Hospital, Foumbot;6Grace Community Health and Development Association, Kum-ba/Yaoundé;7Laboratory of Public Health Biotechnology and Research, Biotech-nology Centre, University of Yaoundé 1, Yaoundé;8Research Foundation for Tropical Diseases and Environment(REFOTDE), Buea, Cameroon

Introduction: Snakebite envenomation is a largely unpredictable eventwhich could have severe and fatal consequences on non-expectant vic-tims. It is a major public health problem which disproportionately affectspoor rural communities. Children and farmers in remote rural areas sufferthe highest burden. Data and circumstances surrounding the death ofsnakebite victims are often difficult to come by. Routine national healthreporting systems, primarily hospital-based, grossly underestimate theactual incidence of snakebite mortality.Aim: To scale up snakebite surveillance in resource-limited settings bydesigning a simple audit tool to collect data for every case of snakebite-related death in the community.Methods: A PubMed search strategy was built using the keywords;‘Snakebite∗ OR Snake bite’ and ‘Mortality∗ OR Death∗ OR Envenomation∗’and ‘Verbal autopsy∗ OR audit∗’. The search returned 9 articles fromwhich we identified key indicators and information which could influencesnakebite managements and could describe the circumstance withinwhich the snakebite occurred. These were used to design our audit toolwhich was piloted with good results.Results: The tool presents two parts; A community-based section with28 questions which provides data on the kind of snake (as seen bythe victim or witnesses), immediate treatment, immediate signs andsymptoms and the time to arrive at the nearest health facility. A facility-based section with 27 questions which seeks to identify the kind ofenvenoming syndrome, antivenom availability and the outcome of thevictim.Conclusion: We designed a death audit-tool, which could be used byprimary care service providers for all deaths suspected to be due to snakebite envenoming. Community-based audits using our tool would providereal time data on snakebite incidence identify key intervention points tocurb snakebite mortality in high-risk rural areas.

P449SUB-OPTIMAL VACCINATION COVERAGE AMONG SOUTHAFRICAN CHILDREN: IMPLICATION FOR VACCINE-PREVENTABLE DISEASE CONTROL PROGRAMMEAdetokunboh O.O.1,2

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1Cochrane South Africa, South African Medical Research Council,Cape Town;2Division of Epidemiology and Biostatistics, Dept. of Global Health,Stellenbosch University, Cape Town, South Africa

Introduction: Vaccination of children against vaccine-preventable dis-eases is an essential public health intervention for reducing childhoodmorbidity and mortality.Aim: This study aims to analyse the trend, coverage and geographicalvariation of childhood vaccinations in the South African population perprovince.Methods: This study used data from the cross-sectional, population-based Demographic and Health Survey (DHS) conducted in differentprovinces of South Africa in 1998 and 2016. Descriptive and spatialdata analysis methods were used to determine the coverage level andgeographic variation in children aged 12-23 months who received or didnot receive basic vaccinations at any time before the survey. The 2016South African DHS collected data on coverage of vaccines among childrenborn in the three years preceding the survey.Results: The percentage of South African children age 12-23 months oldwho had received all basic vaccinations decreased from 63% in 1998to 61% in 2016 while those aged 12 months old increased from 55%in 1998 to 58% in 2016. In 1998, 2% of South African children werereported to have received no vaccinations, as compared with 5% in 2016.The vaccination coverage by province ranged from 52% in Gauteng to80% in Free State in 2016. Average vaccine coverage of Bacille Calmette-Guérin vaccine was 93%, third dose of diphtheria, tetanus, and acellularpertussis, polio, and Haemophilus influenzae type b (DTaP-IPV-Hib) vac-cines was 65% and single dose of measles vaccine was 86%. Vaccinecoverage for the third dose of hepatitis B was 65%, third dose of pneumo-coccal conjugate vaccine was 62% and second dose of rotavirus vaccinewas 70%.Conclusion: This study shows that there is sub-optimal vaccination cov-erage among South African children. The findings of this study enhancethe better understanding of the geographical variation and identificationof poor performing provinces for vaccination uptake in South Africa. This isuseful for customising intervention strategies for provinces and efficientallocation of limited resources. These findings are vital for improvingvaccination uptake and vaccine-preventable disease control programmesin South Africa.

P450

UROGENITAL INFECTIONS AMONG PREGNANT WOMEN INPEMBA ISLAND, TANZANIA

Juliana N.C.A.1, Deb S.2,3, Sazawal S.3, Morré S.A.1,4,Ambrosino E.11Institute for Public health Genomics, Cluster of Genetics & CellBiology, Research School for Oncology and Developmental Biology,Maastricht University, Maastricht, The Netherlands;2Public Health laboratory-Ivo de Carneri, Chake Chake, PembaIsland, Tanzania;3Center for Public Health Kinetics, New Delhi, India;4Laboratory of Immunogenetics, Dept. of Medical Microbiologyand Infection Control, VU University Medical Center, Amsterdam,The Netherlands

Introduction: Over 30 different microorganisms are known to causeurogenital tract infections in women. In pregnant women, such infec-tions may also cause pregnancy-related complications and newbornsmorbidity. These infections are mostly asymptomatic, thus often unrec-ognized, increasing the risk for complications. Among such infections,

the ones by Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG),Trichomonas vaginalis (TV) and Mycoplasma genitalium (MG) are mostprevalent and curable, but if untreated, they might lead to adverseoutcomes.Efforts to map the burden of these infections globally have shown a highprevalence in Sub-Saharan Africa, bearing over 40% of all reported cases.In the very same region, the prevalence of urogenital infections amongpregnant women appears to be equal to, if not greater than, malaria.Compared to its neighboring countries, Tanzania shows a rather highburden. The existing morbidity data in the country originates from themainland, whereas little is available on the importance of this problem inthe Zanzibar archipelago, where hardly any study has been conducted onthe topic so far.Aim: This retrospective study investigates the prevalence of Chlamydiatrachomatis (CT), Trichomonas vaginalis (TV) and Neisseria gonorrhoeae(NG) urogenital infections, and their correlation with maternal health andpregnancy outcomes in a subset of pregnant women in the island ofPemba, Tanzania.Methods: Vaginal swabs were collected from a cohort of pregnantwomen during the first trimester of pregnancy, along with phenotypicdata. Detection of microorganisms was performed using PCR.Results: Initial results showed a 4.46%, 6.04% and 0% prevalence of CT,TV and NG infections respectively, some were double infections. Furthertesting on samples collected at different time points, and for Mycoplasmagenitalium, Ureaplasma urealyticum and Herpes Simplex Virus infectionsare ongoing. Analysis into possible risk factors and association withpregnancy outcomes, as premature birth, will follow.Conclusion: This study represents the first effort trying to map the burdenof urogenital infections in Pemba, as it is the first to show any prevalenceof such infections in the area. Further, this effort is expected to offervaluable information on risk factors, as well as on correlation of suchinfections with pregnancy outcomes.

P451

CHANGING THE TREND OF MATERNAL AND NEWBORNMORTALITY BY BASIC GESTURES IN MADAGASCAR

Andrianaivo N.1, Rakotovao J.P.1, Razafimandimby E.21Technical Dept., Jhpiego, Antananarivo;2Management Dept., Jhpiego, Antananarivo, Madagascar

Introduction: Maternal and child mortality rates have been stagnated inMadagascar since many decades, with 478 per 100 000 live births and26 per 1000 live births respectively in 20131. It is crucial to find afford-able and practical solution by respecting WHO guidelines to tackle it. Aspecific intervention (essential and emergency maternal and newborncare training) coupled with basic equipment donation for the maternityand capacity building in data management were implemented in 573primary health centers in 16 regions of Madagascar. Specifically, thebasic activities initiated at the health centers were the 4 essential caresand newborn resuscitation, prevention of infection, systematic control ofhypertension during antenatal care for preeclampsia/eclampsia preven-tion and systematic uterotonic injection within 1 minute after birth forpostpartum haemorrhage prevention.Aim: Our objective is to evaluate the maternal and newborn mortalitytrend after the intervention.Methods: We used a retrospective observational cohort methodology.Data from dashboard of the targeted health centers completed withroutine data from October 2015 to June 2018 were used.Results: As primary outcomes, 183,567 newborn benefited the 4 ele-ments of newborn essential care (immediate drying, skin to skin, lateclamping of umbilical cord, immediate breastfeeding) from 70% in 2015to 100% in 2018 and 12,163 newborn resuscitated from 70% to 91%,

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there were 917,098 pregnant women whom blood pressure were con-trolled systematically with an increase of 33%, systematic uterotonicinjection within 1 minute after birth coverage increased from 85% to100% of 188.281women. Overall, there was a significant decrease of thematernal and newborn mortality in the targeted health centers; from 242to 20 deaths of women per 100 000 births meaning a reduction of 91.73%of maternal mortality and from 16.4 to 8.4 fresh stillbirth per 1000 birth,approximatively 50% of reduction.Conclusion: Findings suggest that basic and simple gesture of preventionof infection, eclampsia and postpartum haemorrhage can have substan-tial impact in the reduction of maternal and newborn mortality duringbirth. It is a vital finding for Madagascar and developing countries withsimilar context which have struggled to change the trend of mortalityduring birth during many decades.

Reference:1. INSTAT. Enquête nationale sur le suivi des objectifs du millénairepour le développement à Madagascar: Objectif 05. Antananarivo: InstitutNational de Statistique; 2013.125 p.

P452

TASK SHIFTING OF EMERGENCY CAESAREAN SECTION INSOUTH ETHIOPIA: ARE WE RECREATING THE BRAIN DRAIN?

Asefa A.1,2, Morgan A.2, Berhan Y.31School of Public Health, Hawassa University, Hawassa, Ethiopia;2Nossal Institute for Global Health, University of Melbourne, Mel-bourne, Australia;3Ministry of Public Health, Addis Ababa, Ethiopia

Introduction: In settings with low numbers of obstetricians, task shiftingCSs to lesser trained health workers is a strategy to increase the coverageof this life saving intervention. Between 2009 and 2013 a task shiftingintervention to train CS teams involving health officers, general practition-ers, and anaesthetic and scrub nurses was implemented in 13 hospitalsin southern Ethiopia.Aim: To assess medium-term outcomes of the task shifting program.Methods: A cross-sectional study involving review of secondary dataand supplemented with interviews with the focal persons responsiblefor the task shifting intervention was conducted. Data from deliveryand CS registers of the hospitals (for the six months before and aftertask shifting commenced) including the current workplace of each ofthe health workers trained to provide CSs services was collected. Meandifferences were computed with their respective confidence intervals toappreciate the difference between numbers of CSs conducted and totaldeliveries attended. The interviews discussed the challenges with theimplementation of task shifting of CS in the hospitals.Results: Comparing the hospitals’ performance before and after the taskshifting process demonstrated a significant increase in the number ofCSs performed (Mean difference = 43.8; 95%CI: 18.3, 69.4; p=0.003) andthe number of deliveries attended (Mean difference = 155.9; 95%CI:48.9, 263.7; p=0.02). However, non-retention of trained staff and limitedcontinuous availability of blood transfusion negatively affected imple-mentation of the task shifting; from the 41 trained surgeons, only 14(34%) were retained in the primary hospitals. There was a differencein the attrition rate with trained general practitioner obstetricians andtrained nurse anaesthetists more likely to have left. Nurses trained intheatre assisting were less likely to leave.Conclusion: While there was a significant change in the number of CSsconducted after the task shifting, this improvement is unlikely to besustained given that trained personnel move to a place they were notinitially supposed to be deployed. The factors that limit the availabilityof obstetricians in many of these hospitals are equally relevant for the

newly trained doctors who are also then able to take that skill to a bettermarketplace after the task shifting training. Better understanding of howto retain highly skilled providers is necessary.

P453

IMPROVING SURGICAL INFORMED CONSENT IN OBSTETRICAND GYNAECOLOGIC SURGERIES IN A TEACHING HOSPITALIN ETHIOPIA: A BEFORE AND AFTER STUDY

Asefa A.1,2, Wolde Z.3, Gedefaw A.3, Teshome M.31School of Public Health, Hawassa University, Hawassa, Ethiopia;2Nossal Institute for Global Health, University of Melbourne, Mel-bourne, Australia;3Dept. of Obstetrics and Gynaecology, School of Medicine, Collegeof Medicine and Health Sciences, Hawassa University, Hawassa,Ethiopia

Introduction: Even though surgical informed consent (SIC) has markedbenefits, in many settings the information is not provided appropriately.In Ethiopia, minimal attention is given to SIC.Aim: This study assesses whether an intervention designed to improveSIC in obstetric and gynaecologic surgeries is associated with receipt ofSIC components.Methods: Pre-intervention and post-intervention surveys were conductedat Hawassa University Comprehensive Specialized Hospital amongwomen who underwent obstetric or gynaecologic surgeries. Theintervention consisted of a 3-day training on standard counselling forsurgical procedures offered to health professionals. A total of 457 womenwere surveyed (230 pre-intervention, 227 post-intervention). An adjustedPoisson regression analysis was used to identify the association betweenthe intervention and the number of SIC components received.Results: The majority of participants were 25–34 years of age in boththe pre-intervention and post-intervention groups (p=0.66). 45.7%of the pre-intervention and 51.5% of the post-intervention surveyparticipants underwent elective surgery (p=0.21). Additionally, 70.4%of pre-intervention survey participants received counselling immediatelybefore surgery, compared with 62.4% of post-intervention participants(p<0.001). 5.7% of pre-intervention and 6.6% of post-intervention partic-ipants reported the belief that SIC consists entirely of signing on a pieceof paper (p=0.66). After controlling for effects of potential confounders,the number of SIC components reported by post-intervention surveyparticipants was 16% higher than what is received by pre-interventionones (adjusted coefficient=1.16 (1.06–1.28)). Having elective versusemergency surgery was not associated with the number of componentsreceived by participants in either group (adjusted coefficient=0.98(0.88–1.09)).Conclusion: Training on the delivery of standard SIC is associated withreceipt of a higher number of standard counselling components. How-ever, there is a need to evaluate whether a one-time intervention leadsto sustained improvement. A system-wide study of factors that promoteSIC is required.

P455

EXPLORING THE IMPACT OF REPRODUCTIVE LOSS IN NEAR-MISS WOMEN IN ZANZIBAR

Broerze F.M.J.1, Herklots T.1, Khamis Mzee M.2, SaadunMabrouk S.2, Franx A.1, Jacod B.31Division of Woman and Baby, University Medical Centre Utrecht,Utrecht, The Netherlands;

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2Dept. of Obstetrics & Gynaecology, Mnazi Mmoja Hospital, Zanz-ibar, Tanzania;3Dept. of Obstetrics & Gynaecology, Onze Lieve Vrouwe Gasthuis,Amsterdam, The Netherlands

Introduction: Since 2015, research into life-threatening maternal mor-bidity has been ongoing in Zanzibar’s referral hospital, with one projectaiming to gain insight in the long-term consequences. For women whohave survived such complications, so-called maternal near-misses, a keytheme when regarding their well-being is reproductive loss, referring toperinatal death and/or hysterectomy. Additionally, less tangible types ofloss can be experienced, such as loss of functioning, social status or bodilyintegrity.Aim: To assess the impact of reproductive loss on well-being and togenerate a narrative-based understanding of the concept of reproductiveloss amongst women in Zanzibar.Methods: A mixed methods study was set up with both quantitativeand qualitative approaches including maternal near-misses with(cases) and without (controls) reproductive loss was quantitativelycompared, three months after discharge from the hospital. Interviewer-administered, assessment was done of disability (WHODAS2.0), qual-ity of life (WHOQOL-BREF), signs of depression (PHQ-9), signs ofposttraumatic stress disorder (HTQ-16) and social support (PSSS).Additionally, blood pressure and haemoglobin levels were compared.In-depth interviews were performed with maternal near-misses withreproductive loss, through a pre-designed interview, inspired by relevantliterature.Results: The well-being assessment included 46 cases and 40 controls.The outcomes were inconclusive, with no statistical difference foundfor WHODAS (p-value = 0.47), WHOQOL-BREF (p-value = 0.34), PHQ (p-value = 0.42), HTQ (p-value = 0.92), PSSS (p-value = 0.29) or diastolicBP (p-value = 0.88), systolic BP (p-value = 0.21) and Hb-level (p-value =0.27). In-depth interviews, performed on 22 participants, gave profoundinsight in experiences of loss, consequences of loss and coping mecha-nisms with loss of maternal near-miss survivors dealing with reproductiveloss.Conclusion: Questionnaire-based, the well-being of maternal near-misswomen with and without reproductive loss three months after dischargedid not differ. Though, further exploration displayed how maternal near-miss women with reproductive loss were profoundly being affected bytheir loss in mental, physical, sexual and economic fields.

P456

HIGH PREVALENCE OF INTESTINAL PARASITES IN AN URBANPOPULATION OF PREGNANT WOMEN FROM BUKAVU, DEMO-CRATIC REPUBLIC OF CONGO

Mulinganya G.1,2,3, Hendwa E.3, Callens S.1, Hofkens K.4, VerweijJ.J.5, Bisimwa G.2, Levecke B.4, Cools P.41Dept. of Internal Medicine and Pediatrics, Ghent University, Ghent,Belgium;2Catholic University of Bukavu, Bukavu, Democratic Republic ofCongo;3Hôpital Provincial Général Référence de Bukavu, Bukavu, Demo-cratic Republic of Congo;4Dept. of Parasitology, Immunology and Virology, Faculty of Vet-erinary Sciences, Ghent University, Ghent, Belgium;5Laboratory for Medical Microbiology and Immunology, St. Elisa-beth Hospital, Tilburg, The Netherlands

Introduction: Soil-transmitted helminths (Ascaris lumbricoides, Trichuristrichiura and hookworms) and Schistosoma spp. are parasitic infections

that cause an enormous global burden. The population groups that sufferthe most from these infections are children and women of reproductiveage. They may become anemic and impaired in nutrient uptake (mainlydue to T. trichiura, hookworm and Schistosoma). To reduce the diseaseburden of these infections, the WHO recommends preventive chemother-apy (PC) programs, during which anthelmintic drugs are periodicallyadministered to at-risk populations. Recently, the PC coverage in childrenhas reached a level that is unprecedented in history (70%) and it isexpected to further increase. This is sharp contrast with the coverage inwomen of reproductive age which has remained very low (<25% in sub-Saharan Africa). To close this gap, a WHO advisory group on deworm-ing in women of reproductive age has recently prioritized to increasethe knowledge of epidemiology of STH and Schistosoma infections inwomen of reproductive age and the use of new diagnostics to assessthis.Aim: We aimed to assess the prevalence of STHs and Schistosoma spp.in an urban population of pregnant women from Bukavu, South Kivu,Democratic Republic of Congo using sensitive molecular tools.Methods: We collected 120 stool samples from pregnant womenbetween 16 – 20 weeks of gestation that came to seek antenatal care inthe Provincial Reference Hospital of Bukavu. DNA was extracted from stooland quantitative PCR was used for the simultaneous detection of STHsand Schistosoma sp. In addition, the presence of other intestinal parasiteswas assessed, including Hymenolepis nana, Enterobius vermicularis,Strongyloides stercoralis, Taenia spp, Cryptosporidium, Entamoebahistolytica and Giardia duodenalis.Results: More than half of women (54.2%) were infected with at leastone parasite. The most prevalent parasites were A. lumbricoides (33.3%),T. trichiura (18.3%), G. duodenalis (15.0%) and Schistosoma spp. (9.2%).Few women were infected with hookworm (1.7%), S. stercoralis (5.0%), E.histolytica (0.8%) and Taenia spp. (0.8%), and none were infected with H.nana, E. vermicularis and Cryptosporidium spp.Conclusion: We report the first prevalence data on intestinal parasites inpregnant women in Democratic Republic of Congo. The overall prevalencewas high and incorporation of parasitological examination as part of theantenatal care warrants further investigation.

P457

UPTAKE OF PROSTATE CANCER SCREENING AMONG OLDER MENIN MUKONO DISTRICT, UGANDA

Ddumba I.1,2, Mbonye E.1, Ssentamu D.2, Nyanzi H.2,Kakande B.11Dept. of Health, Mukono District Local Government, Mukono;2Dept. of Research & Documentation; African Research Center 4Ageing & Dementia, Kampala, Uganda

Background: Worldwide, prostate cancer (PC) remains the most com-mon cause of cancer-related deaths among men aged 40 years andabove. However, in sub-Saharan Africa, where the burden is becom-ing increasingly high, routine screening for PC has remained low. Thishas led to reduced detection rates, poor management, high cost ofmanaging complications and ultimately increased mortality from thedisease.Aim: The study aimed at determining the individual characteristics andhealth system factors that influence uptake of PC screening among menaged 50 years and above.Methods: The study employed a cross sectional study design with mixedmethods. A total of 385 men were randomly sampled and in-depthinterviews five Key Informants purposively selected participated in thestudy. Data collected consisted of individual characteristics and healthsystems factors. We used a backward stepwise logistic regression withsurvey estimation to determine individual and health systems factors

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that were significantly associated with uptake prostate cancer screen-ing. Qualitative data were analyzed following the six steps of thematicanalysis.Results: Only 1 in 10 (8%) of older men had screened for PC. close to6 in 10 (54.3%) of men lacked knowledge on PC screening, while morethan half (51%) were not aware of the consequences of Prostate cancer.Factors that were associated with PC screening included; self-vulnerability( Odds ratio (OR), 2.50; 95% CI; 1.06 -5.56), knowledge levels ( 0.39;95% CI; 0.17-0.91) and awareness of the consequence (OR, 2.70, 95% CI;1.09- 7.14).Conclusion: The uptake of PC screening was low. Self-vulnerability, knowl-edge levels and awareness of consequences, influence PC screening.There is need to improve community awareness through sensitization inorder to increase PC uptake.

P458MOTIVATIONS FOR PARTICIPATING IN THE USE OF MOBILESMART PHONE APP FOCUSING ON MONITORING OF HYPERTEN-SION AMONG OLDER PERSONS IN UGANDADdumba I.1, 2, Joloba S.2, Kakande B.11Dept. of Research & Documentation, African Research Center 4Ageing and Dementia (ARCAD), Kampala;2Dept. of Health, Mukono District Local Government, Mukono,Uganda

Background: Cardiovascular Disease (CVD) risk factors such as hyperten-sion and diabetes are more prevalent among the older persons. The CVDrisk factors contribute to over 60% of NCD related deaths in later years.Therefore, urgent need for strategies to optimally monitor and controlCVD risk factors is paramount in averting morbidity and mortality amongolder persons. A mobile smart phone App focusing on monitoring ofhypertension could be an innovative tool to encourage.Objectives: To explore older persons motivates for participating ineHealth monitoring of blood pressure.Design: A cross-sectional research using a qualitative approach (HTNSmartApp Study).Setting and Participants: It’s a nested study from the prospective studyof “Testing the use of Smartphone App in control of CVD risk factorsamong older persons in Uganda”. A total of 45 interview guides and4 focus group discussions were conducted. The study included olderpersons with Smart phone, diagnosed with hypertension and he/sheis on treatment. We employed semi-structured questionnaires for datacollection.Results: Eager to know about their Blood pressure numbers, benefits fromother CVD risk reduction strategies, reminder to take medications, beingfunctionally independent, daily check up their BP numbers, presenceof individual at home and being the first cohort to participate in thistrial, were some of the prominent motivators to participate in this trial.Although the design of the study could have influenced the reasons toparticipate in the trial, physical navigating of Mobile SmartApp indepen-dently could have been a great motivator.Conclusion and Implication: Individual benefits and social networksmotivated seniors to participate in this trial; such features should beput into consideration while conducting recruitment for older personsfor future trials. Additionally, maintenance of level of independence andoptimal control of hypertension emerged as a great concern among olderperson living alone.

P459RISK FACTORS OF DEPRESSION AMONG MENOPAUSAL WOMENIN SRI LANKA: A CASE-CONTROL STUDY

Dheerasinghe D.S.A.F.1, Kathriarachchi S.2, Seneviratne H.R.3,Cader M.4, Fonseka P.51National Dengue Control Unit of the Ministry of Health, Colombo;2Dept. of Psychiatry, Faculty of Medical Sciences, University of SriJayewardenepura, Sri Jayewardenepura;3Dept. of Gynaecology and Obstetrics, Faculty of Medicine, Univer-sity of Colombo, Colombo;4National Programme for Tuberculosis Control and Chest Diseases,Ministry of Health, Colombo;5Dept. of Community Medicine, Faculty of Medical Sciences, Uni-versity of Sri Jayewardenepura, Sri Lanka

Introduction: Common mental health disorders, especially depression,are increasingly identified as significant public health problems amongmiddle-aged menopausal women due to various biological and life chal-lenges faced during this period, hence this study.Aim: The aim of this study was to identify the risk factors of depressionamong middle-aged menopausal women aged 40 to 55 years.Methods: A community-based case-control study was conducted in thedistrict of Colombo, Sri Lanka,among 137 confirmed cases of depression and with an equal number ofcontrols without any psychiatric illness.Definition of “case” - A menopausal identified as having depression afteradministration of DASS-21 Sinhala and confirmed as a depressed womanafter a diagnostic clinical assessment.Definition of “control” - A menopausal woman identified as not havingdepression or anxiety or stress after administration of DASS-21 Sinhalaversion and confirmed as not having any psychiatric illness by diagnosticclinical assessment.A pre-tested interviewer-administered questionnaire by trained inter-viewers to assess risk factors of depression amongst menopausal womenwas used.Bivariate analysis and logistic regression (LR) analysis were performed.The independent risk factors for depression were identified while adjust-ing for confounding effect in the logistic regression model.Results: Of the 10 predictor variables considered in the LR analysis,5 variables were retained in the final LR model. LR analysis identifiednuclear family structure (OR=2.90, 95% CI: 1.51-5.56), presence ofmenopausal symptoms (OR=2.23, 95% CI: 1.34-4.01), presence ofpremenstrual symptoms in the past (OR= 2.01; 95% CI: 1.14-3.53),presence of stressful life events (OR=2.13; 95% CI: 1.15-3.92) and lesssocial support (OR=2.03; 95% CI: 1.16-3.54) as risk factors of depressionamong menopausal women aged 40 – 55 years.Conclusions: The risk factors specific for depression among menopausalwomen are related to the reproductive factors (presence of premenstrualsymptoms in the past and presence of menopausal symptoms), and tothe social & psychological factors (i.e. the nuclear family structure, thesocial support available and the stressful life events).The findings should be communicated to the health planners to imple-ment health and social programmes at community clinics to improvequality of life, by assessing the acceptability of the proposed programme.

P460

IT TAKES TWO TO OWN: ENGAGING STAKEHOLDERS INADDRESSING ADOLESCENTS SEXUAL AND REPRODUCTIVEHEALTH IN THE VOLTA REGION OF GHANA USING ROUTINEDISTRICT HEALTH INFORMATION AND IMPLEMENTATIONRESEARCH

Doegah P.T., Acquah E., Agordoh P., Mottey B., Ansah E.,Gyapong M.University of Health and Allied Sciences, Ho, Ghana

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Introduction: Regional performance on teenage pregnancy, shows thatthat Volta region has a high teenage pregnancy rate (14.7%) com-pared to the national rate (12%) and within the region, the Adakludistrict emerged as a district with the highest teenage pregnancy rate(19%) in 2016. The District health management team introduced ado-lescent clubs within communities as an intervention to curb the canker.However, this intervention has generated mistrust between parents andthe district health management team (DHMT). As parents perceivedthe clubs as an avenue the DHMT employs to introduce their wards tocontraceptives. There is therefore the need for the DHMT to use thedistrict health information management system (DHIMS2) to engagestakeholders through implementation research to understand the mag-nitude of teenage pregnancy within the district and find solutions to theproblem.Aim: This study aims at strengthening the capacity of district healthmanagement teams in using data from the DHIMS2 platform to engagewith key stakeholders in identifying gaps and finding solutions to theproblem of teenage pregnancy in the Volta Region of Ghana.Methods: Using an Implementation Research (IR) design which entailsthree (3) phases, the DHMT will interrogate the DHIMS2 data to workwith key stakeholders to design a study aimed at understanding theprevailing situation and needs of adolescents and other stakeholders inthe implementation of various programs. The DHMT and research teamwill engage with various stakeholders in the design and implementa-tion of best services for the adolescents. This is to curb the high rateof teenage pregnancy and rebuild the trust of the community in theDHMT and the purpose of the adolescent clubs. Phase 1 data collec-tion will be carried out between March and June 2019 with fundingby IDRC.Results: The anticipated results of phase 1 are capacity of DHMT builtto interrogate DHIMS2 data, needs of adolescents, community mem-bers and elders assessed, practical and sustainable interventions agreedupon.Conclusion: Since adolescents are unable to improve their own healthoutcomes and wellbeing without support, it is important that key stake-holders are engaged to dispel the mistrust between the community andthe DHMT.

P461UPTAKE AND ACCURACY OF CAREGIVERS TESTING CHILDRENUSING ORAL HIV TESTS IN ZIMBABWE

Dziva Chikwari C.1,2, Bandason T.2, Simms V.1, Dringus S.1,McHugh G.2, Sibanda E.3, Chikodzore R.4, Mutseta M.5, NcubeG.4, Corbett E.L.1, Ferrand R.A1,2

1London School of Hygiene and Tropical Medicine, London, UK;2Biomedical Research and Training Institute, Harare, Zimbabwe;3Health Services Dept., Bulawayo City Council, Bulawayo, Zim-babwe;4Ministry of Health and Child Care, Zimbabwe;5Population Services International, Harare, Zimbabwe

Background: HIV testing is the first step in accessing lifesaving ART.Barriers to testing have been identified particularly for children includingdistance to health facilities, travel costs, user fees and inconvenientopening times.Aim: To investigate the feasibility of caregiver testing whereby caregiverstest their own children at home using oral mucosal transudate (OMT)tests.Methods: HIV positive individuals attending 3 urban and 3 rural clinics forHIV care in Zimbabwe were offered HIV testing for children (2-18years)of unknown HIV status living in their household by either taking an OMTtest kit home (caregiver testing) or testing by a healthcare provider.

Caregivers were shown how to perform and interpret the test using avideo shown at the clinic and written instructions provided to take home.A brief competency test and questionnaire on reason for option choicewas administered by research assistant (RA). An accuracy assessmentwas conducted with the first 15 caregivers at each clinic whereby an RAobserved the caregiver performing the test, on the child, at the household.Participants were followed-up to ascertain test outcomes and to collectused test kits.Results: Overall 56 caregivers chose caregiver testing (86% female,median age 39 years IQR 36,42) and had 141 children (median age 8years, IQR 5,13) to be tested. The main reasons for choosing caregivertesting included convenience (93%) and privacy (77%). Being a biologicalparent rather than another relative/non-relative was associated withincreased odds of caregiver testing uptake (OR 1.45 95%CI 1.02-2.05,p=0.039) when compared to provider testing. All caregivers passed thecompetency assessment. Test outcomes were received for 102 (72%)children who tested HIV negative. Among caregivers who underwent anaccuracy assessment 89% performed the test on their children with noassistance and 98% accurately interpreted the test result alone. No socialharms were reported.Conclusions: Caregiver testing is a feasible method to increase uptakeof testing among children especially in rural settings where access toservices is poor and settings where clinic staff is limited. HIV yield waslow which may be indicative of PMTCT success.

P463THE IMPACT OF A MATERNAL NEAR-MISS EVENT ON THE SUR-VIVORS’ LIVES AFTER THREE MONTHSHerklots T.1, Saadun Mabrouk S.2, Khamis Mzee M.2, Meguid T.3,Franx A.1, Jacod B.41Division of Woman & Baby, University Medical Centre Utrecht, TheNetherlands;2Dept. of Obstetrics & Gynaecology, Mnazi Mmoja Hospital, Zanz-ibar, United Republic of Tanzania;3Village Health Works, Kigutu, Burundi;4Dept. of Obstetrics & Gynaecology, Onze Lieve Vrouwe Gasthuis,Amsterdam, The Netherlands

Introduction: Globally, maternal healthcare and wellbeing still needimprovement and patients’ needs should guide the policy-making.Women who suffered from and survived severe obstetric complications– maternal near-misses – carry a wealth of information, beyond the in-hospital phase. Exploring longer-term wellbeing will help to target theareas that need improvement most.Aim: To multi-dimensionally assess a maternal near-miss event’s impacton women in Zanzibar who, three months before, survived such com-plication in the region’s referral hospital Mnazi Mmoja Hospital and toexplore those areas of the maternal healthcare system in most need ofimprovement.Methods: From May 2017 – December 2018, all maternal near-misseswere prospectively identified during admission and, if consenting, 1:1matched with controls, which were women with a similar admissiondate, diagnosis on admission and delivery mode but without severecomplications. Three months after, participants were interviewedon: quality of life (WHOQOL-BREF), disability (WHODAS2.0), signs ofdepression (PHQ-9), signs of posttraumatic stress disorder (HTQ-16),social support (PSSS), urinary incontinence (ICIQ-SF) and breastfeedingself-efficacy (BSEF-SF). Additionally, history was taken on intercur-rent illness, haemoglobin and blood pressure were measured andchild(ren)’s survival, growth and school attendance of siblings wereassessed.

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Results: 125 near-misses and 121 controls had the three-month follow-up assessment. The groups were comparable at baseline, except thatnear-misses were more likely to have had no scholar education, a lowerperceived wealth and a higher rate of perinatal mortality (52.3% vs.14.0% controls) (p<0.001). Self-reported intercurrent illness was signif-icantly more prevalent in near-misses than controls, 32.8% vs. 17.4% (RR1.89; 95%-CI 1.19-3.00) as did self-reported pain, 17.6% vs. 7.4% of (RR2.37; 95%-CI 1.14-4.93); near-misses scored positive for signs of mild tomoderate depression (PHQ-9 >5) than controls, 8.5% vs. 4.3% (RR 1.95;95%-CI 0.70-5.43). Trends but no significant differences were observed inthe other domains.Conclusion: Physically and mentally, maternal near-miss survivors in thisstudy appeared to struggle, more so than women who had a relativelyuncomplicated pregnancy/childbirth. Continuation of audits of severemorbidity – with the patients as well as the health workers at the centre –should be pursued in order to conceptualize policies for effective maternalhealthcare improvement.

P464PATHOLOGICAL CHANGES IN THE BRAINS OF PERSONS WHODIED WITH NODDING SYNDROME AND OTHER FORMS OFEPILEPSY IN NORTHERN UGANDA

Hotterbeekx A.1, Onzivua S.2, Lammens M.3, Kumar-Singh S.4,Lukande R.2, Idro R.5, Akena G.6, Colebunders R.11Global health institute, University of Antwerp, Antwerp, Belgium;2Dept. of pathology, Makerere University, Kampala, Uganda;3Dept. of pathology, University hospital of Antwerp, Antwerp, Bel-gium,4Laboratory of histology, University of Antwerp, Antwerp, Belgium,5Dept. of paediatrics and child health, Makerere University, Kam-pala, Uganda,6Kitgum general hospital, Kitgum, Uganda

Introduction: Nodding syndrome (NS) is an epileptic form characterizedby repetitive forward dropping of the head, mental disability, sometimesstunted growth and/or underdeveloped secondary sexual characteristics.There is a strong epidemiological association between NS and onchocer-ciasis but the neuropathological changes and disease mechanisms linkedto NS remain to be determined.Aim: To describe the pathological changes in persons who died with NSand other forms of epilepsy.Methods: We included individuals below 30 years old who died in theKitgum and Pader districts, northern Uganda. Informed consent wasobtained from the relatives and a post-mortem exam performed within24h after death. Pathological changes were documented after exter-nal and internal examinations. The brain was fixated in 10% neutralbuffered formalin. Paraffin embedded biopsies were stained by routinehaematoxylin-eosin (H&E) staining and immunohistochemistry (IHC) tovisualize astrocytes (GFAP), macrophages (CD68) and tau-reactive neu-rofibrillary tangles (AT8). Neurofibrillary tangles were confirmed withroutine Gallyas silver staining.Results: Post-mortem exams were performed in 7 individuals with NSand 2 with generalised seizures; 6 males and 3 females, aged between16 and 23 years (median 18). Three had underdeveloped secondarysexual characteristics and 2 had burn wounds. Four were wasted withreduced subcutaneous fat and muscle and one was blind since the ageof 10. All received anti-epileptic drug treatment (sodium valproate orcarbamazepine) but 4 died during convulsions. Six had abnormalitiesin the lungs: fibrinous adhesions to the chest wall or collection offluids due to repeated aspiration of gastric contents. Macroscopic andhistological examination of the brains revealed cerebellar atrophy withloss of Purkinje cells and hyperplasia of Bergmann glia; elsewhere

there was non-systemic neuronal loss with mild gliosis and slightmeningeal lymphocytosis. Two, including one without NS, showed verylimited and 2 showed a moderate amount of tau-immunoreactiveneurofibrillary tangles and pre-tangles. The others did not show any tau-reactive staining. One individual had Burkitt lymphoma with meningealinvolvement.Conclusion: Pathological changes in the brain of persons with NS are char-acterized by loss of neurons, especially Purkinje cells with mild infiltrationof microglia. Contrary to previous research, not all cases presented tau-reactive neurofibrillary tangles.

P465

VARIATIONS IN PREVALENCE RATES OF HOUSEHOLD FOODINSECURITY AND CHILD UNDERNUTRITION IN SOUTH ETHIOPIA:A PANEL STUDY

Kabalo B.Y.1,3,4, Hagos S.2, Loha E.3, Lindtjørn B.41School of Public Health, Wolaita Sodo University, Wolaita Sodo,Ethiopia;2School of Public Health, Addis Ababa University, Addis Ababa,Ethiopia;3School of Public and Environmental Health, Hawassa University,Hawassa, Ethiopia;4Centre for International Health, University of Bergen, Bergen,Norway

Introduction: Even at times of good crop harvest, many children in theWolaita area in South Ethiopia remain undernourished. However we lackevidence on how the risk for malnutrition varies in different seasons in ayear.Aim: The objective of this study was to assess variations during differentseasons in prevalence rates of Household Food Insecurity (HFI) and childundernutrition in the rural Wolaita area in southwest Ethiopia.Methods: We did a cohort study involving 909 children less than five yearsof age and their households. Data were collected through four repeatedsurveys conducted in June 2017 (baseline), September 2017, December2017, and March in 2018. The study participants were recruited fromthree rural villages in altitude below 1600 metre above sea level and twovillages at higher altitudes. The main outcome measures were the HFI,and child wasting and stunting.Results: The mean HFI prevalence was 77.3% in June, 60.3% in Septem-ber, 76.2% in December, and 84.1% in March. September had a lessHFI risk [RD=17.1 [95% CI: 13.1-21.0] %] and March had a higher one[RD=6.7 [95% CI: 2.8-10.6] %]] compared with baseline. Thus, Septembercould be described as food plenty and March as food scarcity. The meanchild wasting rate was 9.9% in June, 9.3% in September, 10.2% inDecember, and 13.1% in March. The mean child wasting rate remainedroughly similar across June, September and December, but it was higherin March [RD=3.2 [95% CI: 0.34-6.1] %]. The HFI was not found tobe an independent predictor for child wasting, but the high peak forthe mean wasting rate was seen in a food-scarce season. The averagestunting prevalence was 32.2 [95% CI: 26.7-38.3] %. The stunting ratesdid not show any seasonal variations, but the mean stunting prevalencewas higher in the higher altitude areas [35.7 % vs. 29.3%; χ2 =17.5,P<0.001].Conclusions: The HFI and child wasting rates showed seasonal variationswhereby the mean wasting rate peaked high at a food-scarce season.

P467

PREDICTORS OF OBSTRUCTED LABOUR IN MBALE REGIONALREFERRAL HOSPITAL: A CASE CONTROL STUDY

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Musaba W.M.1, Barageine J.K.2, Ndeezi G.3, Wamono F.4, WeeksA.D.5, Wandabwa J.N.61Dept. of Obstetrics & Gynaecology, Busitema University/MbaleRegional Referral Hospital, Mbale, Uganda;2Dept. of Obstetrics & Gynaecology, School of Medicine, MakerereUniversity, College of Health Sciences, Kampala, Uganda;3Dept. of Paediatrics and Child Health, School of Medicine, Mak-erere University, College of Health Sciences, Kampala, Uganda;4School of statistics & planning, Makerere University, College ofBusiness & Management Sciences, Kampala, Uganda;5Sanyu Research Unit, University of Liverpool/Liverpool Women’sHospital, Liverpool, UK;6Dept. of Obstetrics & Gynaecology, Busitema University Faculty ofHealth Sciences, Mbale, Uganda

Introduction: In low resource settings, obstructed labour (OL) signifi-cantly contributes to maternal and perinatal morbidity and mortality.In Uganda, the utilisation of maternity services from antenatal careto Health Facility Childbirths has significantly improved over the years.Surprisingly OL and the associated adverse obstetric outcomes have notreduced significantly. Although, the risk factors for OL are known tothe Health care providers, preventable maternal and perinatal deathsattributed to it are still unacceptably high. Probably there are otherunknown context specific factors that contribute to the increased risk forOL in regional referral hospitals. We hypothesised that the utilisation ofANC services is not protective against developing OL.Aim: We aimed to identify the predictors for OL in Mbale Regional ReferralHospital.Methods: We conducted a case control study comparing sociodemo-graphic and obstetric factors of women with and without OL in a ratioof 1:1. For each case identified, two controls were immediately selectedfrom the women admitted in active labour within the same 24hourperiod. Our primary exposure variable was number of ANC visits attendedduring the current pregnancy. Data was collected using face to faceinterviews and review of relevant patient records. Univariate, bivariateand multivariate analysis was conducted using Stata 14.Results: A total of 423 respondents (141 cases and 282 controls) par-ticipated in the study over a period of seven months. After adjustingfor confounding and interaction, being a referral (adjusted Odds Ratio =7.89(4.92-12.65). Every woman had attended at least one ANC visit andalmost all in a government health facility. Compared to having no birthand complication readiness plan (BRCP), having one (adjusted Odds Ratio= 0.55(0.34-0.91). Compared to being prim para and grand multipara,being a of second to fourth gravidity (adjusted Odds Ratio =0.73(0.55- 0.91) was protective against developing OL in Mbale Regional referralhospital.Conclusion: Referral status is the main predictor for OL in Mbale RegionalReferral hospital. Having a birth and complication readiness plan is pro-tective against OL. Therefore, health care providers should invest enoughtime in ensuring that every woman comes up with one during ANC.

P468

FEEDING PRACTICES FOR VERY LOW BIRTH WEIGHT INFANTSIN NEONATAL UNITS IN NIGERIA

Tongo K.1, Nabwera H.M.2, Akindolire A.1, Ezeaka C.3, Imam Z.4,Umoru D.5, Abdulkadir I.6, Allen S.21University College Hospital, Ibadan, Nigeria;2Liverpool School of Tropical Medicine, Liverpool, UK;3Lagos University Teaching Hospital, Lagos, Nigeria;4Massey St. Children’s Hospital, Lagos, Nigeria;5Maitama District Hospital, Abuja, Nigeria;

6Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Introduction: Neonatal deaths account for 46% of under 5 mortalityand this proportion is rising. Most neonatal deaths occur in sub-SaharanAfrica and South Asia, particularly among low birth weight (LBW) infants(<2500g). Gut structure and function are immature particularly in thevery low birth weight (vLBW) infants (<1500g). Optimising early enteralnutrition has the potential to avert adverse outcomes such as sepsis andimpaired growth, but current feeding practices are unknown.Aim: To describe current feeding practices for vLBW infants among pae-diatricians in Nigeria.Methods: From May-August 2018, a feeding survey was sent to seniorpaediatricians providing care to hospitalised vLBW infants in Nigeria withsupport from the Nigerian Society of Neonatal Medicine. Data analysiswas done using Stata v15.0. Proportions were used to describe categoricaland means (standard deviations) medians (range) for continuous data.Results: Senior paediatricians from 37 neonatal units (NNUs) respondedto the survey; 29 (78%) tertiary and 8 (22%) secondary level. Only 17(49%) of NNUs had written feeding guidelines for vLBW infants. Breast-milk was universally the first choice of feed. Only half of the NNUsintroduced enteral feeds early (median 24 hours, range 0-72). The volumeof milk used at initiation of feeds (median 10ml/kg/day, range 5-40) andfor advancement of feeds (median 20ml/kg/day, range 10-40) variedmarkedly. The number of days to establishment of full enteral feeds (120ml/kg/day) also varied: median 10 days, range 3-20. Nasogastric tubefeeding was used commonly (27, 75%). Less than half of the units (18,48%) had storage facilities for expressed breastmilk; none used donorbreast milk although 12 (32%) used surrogate mothers when mother’smilk was inadequate or not accessible. Most NNUs used formula milk totop-up breast milk if insufficient (23, 78%).Conclusion: There is marked variability in all elements of feeding practicefor vLBW infants in Nigeria. There is an urgent need to generate evidenceto standardise feeding practices in sick vLBW infants to improve theiroutcomes.

P469

AN ASSOCIATION BETWEEN HIV PREVALENCE AND SOCIOE-CONOMIC FACTORS AMONG YOUNG PEOPLE IN ZAMBIA: DONEIGHBOURHOOD CONTEXTUAL EFFECTS PLAY A ROLENakazwe C.1,2,3, Michelo C.2,4, Fylkesnes M.K.1,2, Sandøy I.F.1,4

1Centre for International Health, University of Bergen, Bergen,Norway;2School of Public Health, University of Zambia, Lusaka, Zambia;3Central Statistical Office, Lusaka, Zambia;4Centre for Intervention Science in Maternal and Child Health,University of Bergen, Bergen, Norway

Introduction: Available evidence indicates that socioeconomic factorsare strongly associated with HIV infection, though the pattern of asso-ciation is mixed.Aim: The objective of the study is to examine the association of individ-ual and neighbourhood-level socioeconomic factors on HIV prevalenceamong young women and men.Methods: We analysed data from the 2013-14 Zambia Demographicand Health Survey. The analysis was restricted to young people (15–24years) with HIV serostatus results (n= 11,751). Socioeconomic factorswere measured by wealth, education and employment. We used multi-level logistic regression models to examine the effect of individual andneighbourhood level variables on HIV prevalence.Results: Overall, individual-level employment was associated with lowerodds of being infected (aOR 0.81 CI 0.69 – 0.96), however the associationwas no longer significant when stratified by sex. Conversely, wealth

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was associated with increased odds of HIV infection among young menand women (aOR 1.57 CI 1.08 – 2.29) and (aOR 2.29 CI 1.76 – 3.00),respectively). Neighbourhoods with a high proportion of employed weresignificantly associated with reduced odds of HIV infection. In contrast,high wealth and education status at neighbourhood-level were associ-ated with increased odds of HIV infection. In the final multivariate model,which included both individual and neighbourhood-level socioeconomicfactors, the pattern of association changed and neighborhood employ-ment was associated with increased odds of HIV infection. At individuallevel, an additional year of education was associated with a 5% reducedodds of HIV infection but limited to young women (aOR 0.95 (CI 0.92 –0.98)). The final multivariate model explained 50% of the variance in HIVprevalence.Conclusion: Our study indicated that individual-level socioeconomic fac-tors influence young people’s vulnerability to HIV infection in Zambiamore than community-level factors. However, our findings also highlightthe relevance of contextual factors. Though accounting for a relativelysmall proportion of explained variance, the fact that medium neigh-bourhood employment and high neighbourhood educational attainmentincrease the risk of HIV infection, indicate that there are dynamics withincommunities, possibly affecting the way people interact with each other,that can put them at increased risk.

P470

GIARDIA LAMBLIA IN UGANDAN CHILDREN AGED 9 TO 36MONTHS ATTENDING MULAGO HOSPITAL, KAMPALA: PREVA-LENCE AND ASSOCIATED FACTORS

Ndeezi G.1, Mor S.M.2, Ascolillo L.R.3, Tasimwa H.B.4, NakatoR.1, Namuli L.1, Tzipori S.5, Mukunya D.1, Griffiths J.K.3,Tumwine J.K.11Dept. of Paediatrics and Child Health, Makerere University, Col-lege of Health Sciences, Kampala, Uganda;2Institute for Infection and Global Health, University of Liverpool,Liverpool, UK;3Dept. of Public Health and Community Medicine, Tufts UniversitySchool of Medicine, Boston, USA;4Dept. of Microbiology, Makerere University, College of HealthSciences, Kampala, Uganda;5Dept. of Infectious Disease and Global Health, Tufts UniversityCummings School of Veterinary Medicine, Boston, USA

Introduction: Giardia lamblia (G. lamblia) is a common gastrointestinalpathogen in children living in low income countries. Most of the studieshave been done in school-age children while literature in the pre-schoolchildren is scanty.Aim: We carried out a study to determine the magnitude and risk factorsof infection with G. lamblia in children aged 9-36 months presenting atMulago national referral hospital with diarrhea or cough as the mainsymptoms.Methods: Information regarding demographic data and some risk fac-tors were collected from the mothers/caretakers followed by a physicalexamination. Stool was tested for G. lamblia and cryptosporidia using RealTime-PCR. Additional tests included stool microscopy for all the childrenand culture for those with diarrhea.Results: The overall prevalence of G. lamblia was 6.7% (214/3173). Inchildren whose main symptom was diarrhea the prevalence was 6.9%(134/1931) and 6.4% (80/1242) in children with cough. Of the 214children with giardia 18 (8.4%) were co-infected with cryptosporidia.Giardiasis was not associated with sex of the child, mother’s/ care-taker’s level of education, availability of safe water, child’s immunizationstatus, nutritional status and diarrhea or dehydration. Infection was

independently associated with passing mucoid stool [adjusted OddsRatio (aOR) = 2.29, 95%CI:1.11 - 4.74], age [aOR= 3.12, 95%CI: 1.82-5.33], recurrent diarrhea [aOR =2.35, 95%CI: 1.57- 3.50] and having aruminant (goat or sheep or cow) in the homestead [aOR= 1.93, 95%CI:1.27, 2.93].Conclusion: This is the first reported survey of G. lamblia in children of thisage group conducted in Uganda using high sensitivity PCR. Infection iscommon in young children and the prevalence tends to increase with age.As has been reported with other gastrointestinal pathogens co-infectionwith cryptosporidia occurs. G. lamblia should be suspected in children whohave had recurrent diarrhea and those passing mucoid stool. Preventionstrategies should be extended to this age group since infection seems tooccur early in life.

P472

NEW TECHNOLOGY FOR IMPROVEMENT OF MATERNAL, NEONA-TAL AND CHILD HEALTH CARE, THE CASE OF MUTAHO HEALTHDISTRICT IN BURUNDI

Niyibizi R.W.1, Ruhimbo M.21Gitega Provincial Health Office, Burundi Ministry of Health andHIV/AIDS Control, Gitega;2Unicef Burundi, Bujumbura, Burundi

Introduction: Burundi is an East African low-income country with a fast-growing population actually close to eleven million and a high densityup to 379 inhabitants by square kilometer. According to recent BurundiDemographic Health survey 2016-17, the under-5 mortality rate is 23 per1,000 live births and the maternal mortality ratio 334 per 100,000 livebirths.Community health workers use the mobile phone to collect the real-timedata (RapidSMS) on key maternal, neonatal and child health indicators(pregnancy until birth, and newborn until 2 years). The real-time indi-cators are recorded and the system generates automatic reminders forclinical appointments, delivery, and post-natal care visits.Aim: The objective is to assess the impact of the use of RapidSMS onmaternal and child health in MUTAHO as pilot Health District for KIRA-MAMA Project.Methods: Retrospective study was done by analyzing RapidSMS data basefrom 1 January 2017 to 31 October 2018.Results: 6,819 women were registered, 808 high risk pregnancies weredetected and 87 red alerts were delivered for emergency cases; 43,701reminders were also delivered via the system.Registered women received pregnancy monitoring in the community. Redalerts were delivered mostly for hemorrhage (18%), miscarriage (40%)whereas reminders related to vaccination appointments (43.9%); deliv-eries (32.6%); antenatal care (16.7%) and post-natal care visits (6.6%).Conclusion: The use of RapidSMS improved maternal and child healthoutcomes in MUTAHO Health district: high risk pregnancy detection atcommunity level allow health facilities and the district hospital to knowhow many labored deliveries expected in the following two weeks. Redalerts lead them to prepare for emergency cases and check if the patientarrived to the health center in real time or need help for it. Remindershelp to avoid missed appointments. Time is for scaling up nationalwide.

P474

CHILDHOOD ONSET DIABETES MELLITUS: EPIDEMIOLOGICAL,CLINICAL AND FOLLOW-UP FEATURES AT OUAGADOUGOU(BURKINA FASO)

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Sagna Y.1, Saloukou M.K.E.1, Bognounou R.1, Yanogo D.A.R.2,Bagbila A.P.3, Traoré S.1, Guira O.1, Tiéno H.4, Drabo Y.J.11Service de Médecine Interne, Centre Hospitalier Universitaire Yal-gado Ouédraogo, Ouagadougou;2Service de Médecine, Centre Hospitalier Universitaire de Tengan-dogo, Ouagadougou;3Service de Médecine Interne, Centre Hospitalier UniversitaireSouro Sanou, Bobo Dioulasso;4Service de Médecine Interne et d’Endocrinologie, Centre Hospital-ier Universitaire de Bogodogo, Ouagadougou, Burkina Faso

Introduction: The prevalence of diabetes mellitus in adults is 4.9% inBurkina Faso. Childhood onset diabetes is still poorly understood in devel-oping countries because of the lack of adequate facilities and staff inhealth care centers. Since 2013, insulin and insulin needles are freelyprovided for the management of diabetes in childhood and teenage (upto 21 years old) in the department of Internal Medicine of the CentreHospitalier Universitaire Yalgado Ouédraogo (CHU YO).Objective: to describe the epidemiological, clinical and evolutionary fea-tures of diabetes in childhood in Ouagadougou (Burkina Faso).Methods: Single-center observational study conducted between 2013 to2018 at CHU YO, a tertiary care hospital. Epidemiological, clinical andfollow-up characteristics have been described for all consecutive patientswith diabetes diagnosed before the age of 18 years.Results: Eighty-eight patients were included. The mean age at diagnosiswas 14 years [2-18] years and the sex ratio (M/F) was 0.55. 48.9% ofpatients lived within 25km of the hospital (CHU YO) and 44.3% livedmore than 100km away. 79.4% had attended school. Type 1 diabetesaccounted for 97.7% of patients and a family history of diabetes wasfound in 11.4% of cases. 11 patients had a delayed growth (12.5%) and 3(3.4%) had delayed puberty. Keto-acidosis was the main circumstance ofdiscovery of diabetes (62.5%). The mean duration of diabetes progressionwas 4 [0-20] years. 53 patients (60.2%) had a glucose meter. 66 patients(75%) had a daily dual injections regimen of mixed insulin and 22 patients(75%) had more than 2 insulin injections per day. Glycemic control wasconsidered acceptable in 47.7% of patients and the mean glycatedhemoglobin was 9.9 [6.3-15]%. We reported 2 cases of nephropathywithout renal failure, 3 cases of non-proliferative diabetic retinopathy and3 deaths.Conclusion: Keto-acidosis remains the main circumstance of discoveryof diabetes in childhood. About half of the children do not have a goodglycemic control.

P475

EPIDEMIOLOGY AND ECONOMIC IMPACT OF GIARDIASIS:STUDY AMONG PAEDIATRIC OUTPATIENTS IN EASTERN SPAIN

Saura-Carretero Z.1, Pérez-Olaso O.2, Sánchez-Thevenet P.1,Real-Fernández A.1, Aleixandre-Górriz I.1, Gregori-Roig P.21Universidad CEU Cardenal Herrera/CEU Universities, Castellón;2Hospital Universitario de La Plana, Villarreal, Spain

Introduction: Giardia is an enteric protozoan that infects a wide range ofvertebrate hosts, being considered a major causative agent of gastroin-testinal disease in humans in both developing and developed countries.Human giardiasis is a compulsory notifiable disease in Spain.Aim: The main goals of the present study were: i) to report the frequencyof occurrence of giardiasis in paediatric outpatients in the region; ii) toevaluate the association of age, seasonality, and gender whit the disease;iii) to determine its economic impact.Methods: We reviewed 219 clinical records of cases of giardiasis diag-nosed and treated from September 2012 to April 2018 at the Department

of Health 3 of the Castellón Province, Spain. All cases from outpatient14 years and younger were included in the study. We analysed socio-demographic characteristics and presentation factors. We also assessedgiardiasis treatment practices and health-related cost. Ethical approvalwas obtained.Results: 155 cases in children were diagnosed and treated during thestudy period. Five recurrent cases were registered. The male/female ratiowas 1.2, although the difference by sex was not statistically significant(P = 0.51). Local incidence rates varied from 29/105 person-year to8/105 person-year. Significant differences were obtained according toseasonality (P = 0.0002, more frequent in warm seasons) and age, with0 to 4 years old being the more affected group (P < 0.000001). Co-infections by Giardia duodenalis and Campylobacter spp. and G. duode-nalis (5.9%; 9/155) and Blastocystis spp. were the most frequent associ-ations identified (5.2%; 8/155). Diarrhea (41.0%; 62/155) and abdominalpain (37.0%; 56/155) were the most reported symptoms. The relateddirect cost of the disease was 30,286.39e.Conclusion: This study provides an updated picture of giardiasis in chil-dren in this eastern Spain region. Data presented are strongly indicativethat of the frequency of occurrence of giardiasis on this area is greaterthan that declared by formal systems. This is the first evaluation of theburden of paediatric cases of giardiasis here. Our findings contributeto expand knowledge about the epidemiology of the disease and theywould be useful for the application of more effective control strategies atlocal level.

P476

CURBING MATERNAL FETAL MORTALITY (EVIDENCE FROMRWANDA): RECOMMENDATIONS FOR SEIZING PREECLAMPSIA

Iradukunda C.1, Sawhney M.21Kibagabaga District Hospital, Kigali, Rwanda;2Dept. of Public Health Sciences, The University of North Carolina,Charlotte, USA

Introduction: Preeclampsia (PE) is among the top six causes of maternalmortality, high maternal morbidity, and adverse neonatal outcomes. InSub-Saharan Africa, the combined maternal mortality from PE is stag-gering at almost 500 deaths per 100,000 live births. In Rwanda, hyper-tensive disorders are responsible for 28.6 % of all maternal deaths.Although there seems to awareness now for this serious medical condi-tion, not enough research/data is available to understand risk factors anddeterminants.Aim: To understand the underlying risk factors and their interactions withother socioeconomic, cultural, and health determinants for PE.Methods: This was a retrospective study conducted using data accessiblethrough the Kigali University Teaching Hospital from January 2017to December 2017. Data were extracted from patient records onimportant variables such as age, parity, and hospital stay (days innumber), previous history of PE, hypertension, smoking history, familyhistory of PE, mode of child delivery, and molar pregnancy history. Dataanalysis was done using SPSSv23 to understand the risk factors andits association for outcomes such as eclampsia, stroke, and placentaabruption.Results: The most affected age group were women 26-35years (72.8%),while gestation age on admission ranged between 22-40 weeks. Only 47(51.1%) had identifiable risk factors (smoking, molar pregnancy, Familyhistory of previous preeclampsia, hypertension, and diabetes mellitus)83.7% had a history of severe features (Headache, epigastric pain, andblurred vision), and women who were of 27-37 weeks were signifi-cantly affected. 34.7% delivered preterm while complications [eclampsia,stroke, acute kidney injury (AKI), post-partum haemorrhage (PPH), andplacenta abruption) appeared in 32.6% of women with acute kidney

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injury is the most common (43.3%). The average hospital stay was 7days,97.78% were discharged home while 22% died. Though 22.2% of new-borns died, the majority had APGAR (activity, pulse, grimace, appearance,and respiration) above 8.Conclusion: A number of socio-demographic, obstetric and medical con-ditions are significant risk factors for preeclampsia/eclampsia in thisregion. Awareness and guidelines for prevention are needed. Prospectiveresearch on risk factors and the cost-effectiveness of different manage-ment approaches is recommended as well as action on the improvementof the fetal outcome.

P479

MOTIVATORS AND BARRIERS TO EXCLUSIVE BREASTFEEDINGAND DIVERSITY OF COMPLEMENTARY FEEDING IN A RAPIDLYURBANIZING SETTING IN SIERRA LEONE

Turay H.1, Sesay F.F.1, Kallon M.2, Conteh I.3, Kargbo A.A.1,Jalloh U.H.1, Hodges M.H.11Helen Keller International, Freetown;2GOAL Sierra Leone, Freetown;3District Health Management Team, Ministry of Health and Sani-tation, Cline Town, Sierra Leone

Introduction: Sub–optimal infant and young child feeding practices con-tribute to malnutrition and the high child mortality rate.Aim: To understand the barriers and motivators for optimal practices andto (re-)design appropriate interventions.Methods: A behavioral assessment identified ‘Doers’ and ‘Non-doers’ ofexclusive breastfeeding mothers (of infants 0-6 months) and diversityof complementary feeding (6-23 months) from 21 randomly selectedclusters in the Rural Western Area. Semi-structured individual interviewswere conducted to identify significant motivators and barriers to thesebehaviors.Results: Two thirds of mothers interviewed were ‘single’. For exclusivebreastfeeding, 80 Doers and 93 Non-doers were interviewed. Love forthe father and time for the infant were the strongest motivating factorsfor Doers versus Non-doers 9%/0% (p<0.001). Barriers included house-hold workload, (0%/11%) disapproval by grandmothers, mother-in-law(4%/20%) and other relatives (6%/26%) (p<0.005 each), disapprovalby partner (6%/20%), not enough breast milk (0%/6%), sore breasts(3%/12%) and traditional belief around ‘tumbu’ in breast milk or ‘banfapikin’ (that the infant becomes sick because the mother has recom-menced sexual activity) (24%/45%) (p<0.05 each).For dietary diversity, 91 Doers and 99 Non-doers were interviewed. Sig-nificant motivators were the perceived prevention of sickness (18%/2%)(p<0.005) and positive health advantages (p<0.05). Barriers includedaffordability and availability (1%/15%) (p<0.001 each) and accessibility(9%/2%) (p<0.05). Non-Doers reported approval from health workers asmotivating, despite their inability to overcome accessibility, affordability,or availability barriers.Conclusion: Mothers were less likely to exclusively breastfeed without aloving relationship with the infants’ father which implies both emotionaland financial support. Affordability, availability and accessibility of diversediets even in a densely populated, urbanizing setting were barriers todiverse complementary feeding as time and/or expense of shopping forfood affects mothers’ time, work-load and disposable income. Messagesneed to target the support-networks (partners, extended family andworkplace) to allow mothers, time and support for exclusively breast-feeding. Programmers need to scale-up reproductive health services toincrease access to modern forms of contraception and the preventionof unplanned pregnancies. Programmers also need to focus on reducingthe costs of diverse diets by increasing production and accessibility ratherthan more messages targeting mothers.

P480

DETEMINANTS OF BREASTFEEDING PRACTICE IN PUJEHUNDISTRICT, SIERRA LEONE: A MIXED-METHOD STUDY

Van Breevoort D.1, Tognon F.2, George M.G.3, Segafredo G.4,Pisani E.1, Van den Broek A.5, Putoto G.31Doctors with Africa CUAMM, Pujehun-Freetown, Sierra Leone;2Dept. for Woman and Child Health, University of Padua, Padua,Italy;3Ministry of Health and Sanitation, Pujehun district, Sierra Leone;4Doctors with Africa CUAMM, Padova, Italy;5Royal Institute of Amsterdam (KIT), Department Global Health,The NetherlandsIntroduction: In Sierra Leone, more than 10% children do not reach theage of five year. Among others, children suffer from diarrhoea and respira-tory infections. It has been well established that exclusive breastfeedingfor six months and continued breastfeeding with complementary feedingfor two years highly contributes to a decrease in child morbidity andmortality. Interventions to promote breastfeeding practice can positivelycontribute to survival, health and development of children. Multifactorialdeterminants influence the breastfeeding practice. Currently, the breast-feeding practice of and perceptions on breastfeeding in Pujehun district,Southern Sierra Leone, is not well known.Aim: This study aimed to gain understanding on the current breastfeedingpractice in Pujehun district and to explore the perception on breast-feeding in order to develop recommendations for appropriate strategiesto promote breastfeeding practice and improve child health in Pujehundistrict.Methods: This exploratory mixed-method study include a survey of 194mothers, semi-structured interviews and focus group discussions.Results: The results reveal that the exclusive breastfeeding rate is increas-ing over the years from 32% reported in 2013 to presently 63%. However,there is a sharp decrease of exclusive breastfeeding rate by age groupfrom 74% in the age group 0-1 month to 33% in the age group 4-5months. Moreover, this study describes that nurses and husbands havemajor influence on feeding practice. Enabling factors identified for bestpractice of breastfeeding are, among others, assistance during the firstbreastfeeding, receiving information on benefits of breastfeeding duringpregnancy, counselling by the nurse, support from the husband andknowing how friends and families feeding their babies. Main barriers iden-tified in this study are, no encouragement from the husband, perceptionof bad stool of the infant and perception of not having enough milkproduction.Conclusion: Although the exclusive breastfeeding rate has beenincreased over the years, there is still a gap between the practiceof breastfeeding and WHO recommendations. More effort is neededto promote exclusive breastfeeding practice for all children under sixmonths. This study identified determinants for exclusive breastfeedingwhich can be used to promote best breastfeeding practice in future healthprograms planning.

P481

ASSESSING RISK FACTORS FOR PREECLAMPSIA AND ECLAMP-SIA IN A MAIN REFERRAL MATERNITY HOSPITAL IN FREETOWN,SIERRA LEONE

Stitterich N.1, Shepherd J.2, Koroma M.M.3, Theuring S.11Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin, Berlin, Germany;2National School of Midwifery, Freetown;3Princess Christian Maternity Hospital, Freetown, Sierra Leone

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Introduction: Sierra Leone (SL) had a maternal mortality rate of1,360/100,000 births as of 2015, one of the highest in the world. One ofthe main causes for maternal death in SL is preeclampsia and eclampsia(PE/E). Knowing risk factors for PE/E could improve management ofwomen at risk, avoid severe complications and reduce hospitalizationcosts. We conducted a study on risk factors of PE/E in Princess ChristianMaternity Hospital (PCMH), which is the main referral maternity hospitalfor the entire country. In 2017, PCMH recorded 565 severe PE/E cases,which led to 14.5% of all maternal deaths.Aim: We aimed at assessing risk factors of PE/E in the catchment area ofPCMH, in order to improve management of women at risk.Methods: Between November 2018 and February 2019, we conducted anobservational case-control study among pregnant woman and womenin childbed with a 66-item questionnaire, capturing sociodemographic,obstetric, health-related, nutritional, environmental and behaviouralcharacteristics, as well as birth outcomes and disease characteristics.Data collection was conducted by four study nurses through structuredinterviews and analysis of patient charts. Pregnant or postpartum womenwho met the PE/E definition according to national guidelines wereincluded as cases, and women in childbed without PE/E as controls. Toidentify risk factors, we conducted univariate analysis and multivariatelogistic regression.Results: A total of 672 women were included in the study (214cases, 458 controls). PE/E was significantly associated with very lowfinancial power (AOR=2.66), PE/E in family history (AOR=3.15), chronichypertension (AOR=3.58), urinary tract infection (AOR=2.03), chronicdiarrhea (AOR=3.14), high mid upper arm circumflex (AOR=3.12), andinadequate fruit intake (AOR=2.65); as well as living close to a wastedeposit (AOR=2.06) and drinking untreated ground water (AOR=2.12).Among postpartum women from the case group, significantly morestillbirths, preterm births and low birth weight infants were reportedcompared to controls.Conclusion: Our findings suggest that pregnant women require bettereducation on healthy lifestyle, including nutrition and water safety aswell as prevention of gastrointestinal and urinary tract infections. Womenwith a family risk of PE/E and chronic hypertension should be screenedregularly.

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