Factors Associated with Early Mortality in HIV-Positive Men and Women Investigated for Tuberculosis at Ethiopian Health Centers
Identifieur interne : 003821 ( Ncbi/Merge ); précédent : 003820; suivant : 003822Factors Associated with Early Mortality in HIV-Positive Men and Women Investigated for Tuberculosis at Ethiopian Health Centers
Auteurs : Anton Reepalu [Suède] ; Taye Tolera Balcha [Suède, Éthiopie] ; Sten Skogmar [Suède] ; Nuray Güner [Suède] ; Erik Stureg Rd [Suède] ; Per Björkman [Suède]Source :
- PLoS ONE [ 1932-6203 ] ; 2016.
Abstract
Despite increasing access to antiretroviral treatment (ART) in low-income countries, HIV-related mortality is high, especially in the first months following ART initiation. We aimed to evaluate the impact of TB coinfection on early mortality and to assess gender-specific predictors of mortality in a cohort of Ethiopian adults subjected to intensified casefinding for active TB before starting ART.
Prospectively recruited ART-eligible adults (n = 812, 58.6% female) at five Ethiopian health centers were followed for 6 months. At inclusion sputum culture, Xpert MTB/RIF, and smear microscopy were performed (158/812 [19.5%] had TB). Primary outcome was all-cause mortality. We used multivariate Cox models to identify predictors of mortality.
In total, 37/812 (4.6%) participants died, 12 (32.4%) of whom had TB. Karnofsky performance score (KPS) and mid-upper arm circumference (MUAC) were associated with mortality in the whole population. However, the associations were different in men and women. In men, only MUAC remained associated with mortality (adjusted hazard ratio [aHR] 0.71 [95% CI 0.57–0.88]). In women, KPS <80% was associated with mortality (aHR 10.95 [95% CI 2.33–51.49]), as well as presence of cough (aHR 3.98 [95% CI 1.10–14.36]). Cough was also associated with mortality for TB cases (aHR 8.30 [95% CI 1.06–65.14]), but not for non-TB cases.
In HIV-positive Ethiopian adults managed at health centers, mortality was associated with reduced performance score and malnutrition, with different distribution with regard to gender and TB coinfection. These robust variables could be used at clinic registration to identify persons at increased risk of early mortality.
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DOI: 10.1371/journal.pone.0156602
PubMed: 27272622
PubMed Central: 4896420
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type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4896420</idno><idno type="RBID">PMC:4896420</idno><idno type="doi">10.1371/journal.pone.0156602</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000424</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000424</idno><idno type="wicri:Area/Pmc/Curation">000424</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Curation">000424</idno><idno type="wicri:Area/Pmc/Checkpoint">000729</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Checkpoint">000729</idno><idno type="wicri:Area/Ncbi/Merge">003821</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Factors Associated with Early Mortality in HIV-Positive Men and Women Investigated for Tuberculosis at Ethiopian Health Centers</title><author><name sortKey="Reepalu, Anton" sort="Reepalu, Anton" uniqKey="Reepalu A" first="Anton" last="Reepalu">Anton Reepalu</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden</addr-line></nlm:aff><country xml:lang="fr">Suède</country><wicri:regionArea>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö</wicri:regionArea><wicri:noRegion>Malmö</wicri:noRegion></affiliation></author><author><name sortKey="Balcha, Taye Tolera" sort="Balcha, Taye Tolera" uniqKey="Balcha T" first="Taye Tolera" last="Balcha">Taye Tolera Balcha</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden</addr-line></nlm:aff><country xml:lang="fr">Suède</country><wicri:regionArea>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö</wicri:regionArea><wicri:noRegion>Malmö</wicri:noRegion></affiliation><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Ministry of Health, Addis Ababa, Ethiopia</addr-line></nlm:aff><country xml:lang="fr">Éthiopie</country><wicri:regionArea>Ministry of Health, Addis Ababa</wicri:regionArea><wicri:noRegion>Addis Ababa</wicri:noRegion></affiliation></author><author><name sortKey="Skogmar, Sten" sort="Skogmar, Sten" uniqKey="Skogmar S" first="Sten" last="Skogmar">Sten Skogmar</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden</addr-line></nlm:aff><country xml:lang="fr">Suède</country><wicri:regionArea>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö</wicri:regionArea><wicri:noRegion>Malmö</wicri:noRegion></affiliation></author><author><name sortKey="Guner, Nuray" sort="Guner, Nuray" uniqKey="Guner N" first="Nuray" last="Güner">Nuray Güner</name><affiliation wicri:level="1"><nlm:aff id="aff003"><addr-line>Region Skåne Competence Center, Skåne University Hospital, Lund, Sweden</addr-line></nlm:aff><country xml:lang="fr">Suède</country><wicri:regionArea>Region Skåne Competence Center, Skåne University Hospital, Lund</wicri:regionArea><wicri:noRegion>Lund</wicri:noRegion></affiliation></author><author><name sortKey="Stureg Rd, Erik" sort="Stureg Rd, Erik" uniqKey="Stureg Rd E" first="Erik" last="Stureg Rd">Erik Stureg Rd</name><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>Medical Microbiology, Department of Laboratory Medicine, Malmö, Lund University, Lund, Sweden</addr-line></nlm:aff><country xml:lang="fr">Suède</country><wicri:regionArea>Medical Microbiology, Department of Laboratory Medicine, Malmö, Lund University, Lund</wicri:regionArea><wicri:noRegion>Lund</wicri:noRegion></affiliation></author><author><name sortKey="Bjorkman, Per" sort="Bjorkman, Per" uniqKey="Bjorkman P" first="Per" last="Björkman">Per Björkman</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden</addr-line></nlm:aff><country xml:lang="fr">Suède</country><wicri:regionArea>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö</wicri:regionArea><wicri:noRegion>Malmö</wicri:noRegion></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Introduction</title><p>Despite increasing access to antiretroviral treatment (ART) in low-income countries, HIV-related mortality is high, especially in the first months following ART initiation. We aimed to evaluate the impact of TB coinfection on early mortality and to assess gender-specific predictors of mortality in a cohort of Ethiopian adults subjected to intensified casefinding for active TB before starting ART.</p></sec><sec id="sec002"><title>Material and Methods</title><p>Prospectively recruited ART-eligible adults (n = 812, 58.6% female) at five Ethiopian health centers were followed for 6 months. At inclusion sputum culture, Xpert MTB/RIF, and smear microscopy were performed (158/812 [19.5%] had TB). Primary outcome was all-cause mortality. We used multivariate Cox models to identify predictors of mortality.</p></sec><sec id="sec003"><title>Results</title><p>In total, 37/812 (4.6%) participants died, 12 (32.4%) of whom had TB. Karnofsky performance score (KPS) and mid-upper arm circumference (MUAC) were associated with mortality in the whole population. However, the associations were different in men and women. In men, only MUAC remained associated with mortality (adjusted hazard ratio [aHR] 0.71 [95% CI 0.57–0.88]). In women, KPS <80% was associated with mortality (aHR 10.95 [95% CI 2.33–51.49]), as well as presence of cough (aHR 3.98 [95% CI 1.10–14.36]). Cough was also associated with mortality for TB cases (aHR 8.30 [95% CI 1.06–65.14]), but not for non-TB cases.</p></sec><sec id="sec004"><title>Conclusions</title><p>In HIV-positive Ethiopian adults managed at health centers, mortality was associated with reduced performance score and malnutrition, with different distribution with regard to gender and TB coinfection. 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Westreich</name></author><author><name sortKey="Sanne, I" uniqKey="Sanne I">I Sanne</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cornell, M" uniqKey="Cornell M">M Cornell</name></author><author><name sortKey="Lessells, R" uniqKey="Lessells R">R Lessells</name></author><author><name sortKey="Fox, Mp" uniqKey="Fox M">MP Fox</name></author><author><name sortKey="Garone, Db" uniqKey="Garone D">DB Garone</name></author><author><name sortKey="Giddy, J" uniqKey="Giddy J">J Giddy</name></author><author><name sortKey="Fenner, L" uniqKey="Fenner L">L Fenner</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bassett, I V" uniqKey="Bassett I">I V Bassett</name></author><author><name sortKey="Chetty, S" uniqKey="Chetty S">S Chetty</name></author><author><name sortKey="Wang, B" uniqKey="Wang B">B Wang</name></author><author><name sortKey="Mazibuko, M" uniqKey="Mazibuko M">M Mazibuko</name></author><author><name sortKey="Giddy, 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Sciences</subject><subj-group><subject>Infectious Diseases</subject><subj-group><subject>Bacterial Diseases</subject><subj-group><subject>Tuberculosis</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Tropical Diseases</subject><subj-group><subject>Tuberculosis</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Immunology</subject><subj-group><subject>Vaccination and Immunization</subject><subj-group><subject>Antiviral Therapy</subject><subj-group><subject>Antiretroviral Therapy</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Immunology</subject><subj-group><subject>Vaccination and 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Symptoms</subject><subj-group><subject>Coughing</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Microbiology</subject><subj-group><subject>Virology</subject><subj-group><subject>Co-Infections</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Mucus</subject><subj-group><subject>Sputum</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Mucus</subject><subj-group><subject>Sputum</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Physiology</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Mucus</subject><subj-group><subject>Sputum</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Physiology</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Mucus</subject><subj-group><subject>Sputum</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Microbiology</subject><subj-group><subject>Medical Microbiology</subject><subj-group><subject>Microbial Pathogens</subject><subj-group><subject>Viral Pathogens</subject><subj-group><subject>Immunodeficiency Viruses</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pathology and Laboratory Medicine</subject><subj-group><subject>Pathogens</subject><subj-group><subject>Microbial Pathogens</subject><subj-group><subject>Viral Pathogens</subject><subj-group><subject>Immunodeficiency Viruses</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Organisms</subject><subj-group><subject>Viruses</subject><subj-group><subject>Viral Pathogens</subject><subj-group><subject>Immunodeficiency Viruses</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Organisms</subject><subj-group><subject>Viruses</subject><subj-group><subject>Immunodeficiency Viruses</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and life sciences</subject><subj-group><subject>Organisms</subject><subj-group><subject>Viruses</subject><subj-group><subject>RNA viruses</subject><subj-group><subject>Retroviruses</subject><subj-group><subject>Lentivirus</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Microbiology</subject><subj-group><subject>Medical Microbiology</subject><subj-group><subject>Microbial Pathogens</subject><subj-group><subject>Viral Pathogens</subject><subj-group><subject>Retroviruses</subject><subj-group><subject>Lentivirus</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pathology and Laboratory Medicine</subject><subj-group><subject>Pathogens</subject><subj-group><subject>Microbial Pathogens</subject><subj-group><subject>Viral Pathogens</subject><subj-group><subject>Retroviruses</subject><subj-group><subject>Lentivirus</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Organisms</subject><subj-group><subject>Viruses</subject><subj-group><subject>Viral Pathogens</subject><subj-group><subject>Retroviruses</subject><subj-group><subject>Lentivirus</subject><subj-group><subject>HIV</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Immunology</subject><subj-group><subject>Immune Suppression</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Immunology</subject><subj-group><subject>Immune Suppression</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Diagnostic Medicine</subject><subj-group><subject>Signs and Symptoms</subject><subj-group><subject>Immune Suppression</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pathology and Laboratory Medicine</subject><subj-group><subject>Signs and Symptoms</subject><subj-group><subject>Immune Suppression</subject></subj-group></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Factors Associated with Early Mortality in HIV-Positive Men and Women Investigated for Tuberculosis at Ethiopian Health Centers</article-title><alt-title alt-title-type="running-head">Factors Associated with Early Mortality</alt-title></title-group><contrib-group><contrib contrib-type="author"><contrib-id contrib-id-type="orcid" authenticated="false">http://orcid.org/0000-0003-1690-8921</contrib-id><name><surname>Reepalu</surname><given-names>Anton</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib><contrib contrib-type="author"><name><surname>Balcha</surname><given-names>Taye Tolera</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Skogmar</surname><given-names>Sten</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Güner</surname><given-names>Nuray</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Sturegård</surname><given-names>Erik</given-names></name><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Björkman</surname><given-names>Per</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Ministry of Health, Addis Ababa, Ethiopia</addr-line></aff><aff id="aff003"><label>3</label><addr-line>Region Skåne Competence Center, Skåne University Hospital, Lund, Sweden</addr-line></aff><aff id="aff004"><label>4</label><addr-line>Medical Microbiology, Department of Laboratory Medicine, Malmö, Lund University, Lund, Sweden</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Pacheco</surname><given-names>Antonio Guilherme</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>FIOCRUZ, BRAZIL</addr-line></aff><author-notes><fn fn-type="conflict" id="coi001"><p><bold>Competing Interests: </bold>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con" id="contrib001"><p>Conceived and designed the experiments: AR TTB SS PB. Performed the experiments: AR TTB. Analyzed the data: AR NG. Contributed reagents/materials/analysis tools: ES PB. Wrote the paper: AR TTB SS PB.</p></fn><corresp id="cor001">* E-mail: <email>anton.reepalu@med.lu.se</email></corresp></author-notes><pub-date pub-type="epub"><day>7</day><month>6</month><year>2016</year></pub-date><pub-date pub-type="collection"><year>2016</year></pub-date><volume>11</volume><issue>6</issue><elocation-id>e0156602</elocation-id><history><date date-type="received"><day>15</day><month>1</month><year>2016</year></date><date date-type="accepted"><day>17</day><month>5</month><year>2016</year></date></history><permissions><copyright-statement>© 2016 Reepalu et al</copyright-statement><copyright-year>2016</copyright-year><copyright-holder>Reepalu et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:href="pone.0156602.pdf"></self-uri><abstract><sec id="sec001"><title>Introduction</title><p>Despite increasing access to antiretroviral treatment (ART) in low-income countries, HIV-related mortality is high, especially in the first months following ART initiation. We aimed to evaluate the impact of TB coinfection on early mortality and to assess gender-specific predictors of mortality in a cohort of Ethiopian adults subjected to intensified casefinding for active TB before starting ART.</p></sec><sec id="sec002"><title>Material and Methods</title><p>Prospectively recruited ART-eligible adults (n = 812, 58.6% female) at five Ethiopian health centers were followed for 6 months. At inclusion sputum culture, Xpert MTB/RIF, and smear microscopy were performed (158/812 [19.5%] had TB). Primary outcome was all-cause mortality. We used multivariate Cox models to identify predictors of mortality.</p></sec><sec id="sec003"><title>Results</title><p>In total, 37/812 (4.6%) participants died, 12 (32.4%) of whom had TB. Karnofsky performance score (KPS) and mid-upper arm circumference (MUAC) were associated with mortality in the whole population. However, the associations were different in men and women. In men, only MUAC remained associated with mortality (adjusted hazard ratio [aHR] 0.71 [95% CI 0.57–0.88]). In women, KPS <80% was associated with mortality (aHR 10.95 [95% CI 2.33–51.49]), as well as presence of cough (aHR 3.98 [95% CI 1.10–14.36]). Cough was also associated with mortality for TB cases (aHR 8.30 [95% CI 1.06–65.14]), but not for non-TB cases.</p></sec><sec id="sec004"><title>Conclusions</title><p>In HIV-positive Ethiopian adults managed at health centers, mortality was associated with reduced performance score and malnutrition, with different distribution with regard to gender and TB coinfection. These robust variables could be used at clinic registration to identify persons at increased risk of early mortality.</p></sec></abstract><funding-group><award-group id="award001"><funding-source><institution>the Swedish Civil Contingency Agency</institution></funding-source><principal-award-recipient><name><surname>Björkman</surname><given-names>Per</given-names></name></principal-award-recipient></award-group><award-group id="award002"><funding-source><institution>the Swedish International Development Cooperation Agency</institution></funding-source><principal-award-recipient><name><surname>Björkman</surname><given-names>Per</given-names></name></principal-award-recipient></award-group><award-group id="award003"><funding-source><institution>the Swedish Medical Society</institution></funding-source><principal-award-recipient><name><surname>Björkman</surname><given-names>Per</given-names></name></principal-award-recipient></award-group><award-group id="award004"><funding-source><institution>the Crafoord Foundation</institution></funding-source><principal-award-recipient><name><surname>Björkman</surname><given-names>Per</given-names></name></principal-award-recipient></award-group><funding-statement>This work was supported by the Swedish Civil Contingency Agency (<ext-link ext-link-type="uri" xlink:href="http://www.msb.se">www.msb.se</ext-link>), the Swedish International Development Cooperation Agency (<ext-link ext-link-type="uri" xlink:href="http://www.sida.se">www.sida.se</ext-link>), the Swedish Medical Society (<ext-link ext-link-type="uri" xlink:href="http://www.sls.se">www.sls.se</ext-link>), and the Crafoord Foundation (<ext-link ext-link-type="uri" xlink:href="http://www.crafoord.se">www.crafoord.se</ext-link>). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement></funding-group><counts><fig-count count="2"></fig-count><table-count count="3"></table-count><page-count count="13"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>All relevant data are within the paper and its Supporting Information files. The raw data are available in both electronic and paper form.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>All relevant data are within the paper and its Supporting Information files. The raw data are available in both electronic and paper form.</p></notes></front></pmc><affiliations><list><country><li>Suède</li><li>Éthiopie</li></country></list><tree><country name="Suède"><noRegion><name sortKey="Reepalu, Anton" sort="Reepalu, Anton" uniqKey="Reepalu A" first="Anton" last="Reepalu">Anton Reepalu</name></noRegion><name sortKey="Balcha, Taye Tolera" sort="Balcha, Taye Tolera" uniqKey="Balcha T" first="Taye Tolera" last="Balcha">Taye Tolera Balcha</name><name sortKey="Bjorkman, Per" sort="Bjorkman, Per" uniqKey="Bjorkman P" first="Per" last="Björkman">Per Björkman</name><name sortKey="Guner, Nuray" sort="Guner, Nuray" uniqKey="Guner N" first="Nuray" last="Güner">Nuray Güner</name><name sortKey="Skogmar, Sten" sort="Skogmar, Sten" uniqKey="Skogmar S" first="Sten" last="Skogmar">Sten Skogmar</name><name sortKey="Stureg Rd, Erik" sort="Stureg Rd, Erik" uniqKey="Stureg Rd E" first="Erik" last="Stureg Rd">Erik Stureg Rd</name></country><country name="Éthiopie"><noRegion><name sortKey="Balcha, Taye Tolera" sort="Balcha, Taye Tolera" uniqKey="Balcha T" first="Taye Tolera" last="Balcha">Taye Tolera Balcha</name></noRegion></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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