Integrating prevention of mother-to-child HIV transmission into antenatal care: learning from the experiences of women in South Africa

In 1999, for the first time in South Africa, a Mother-to-Child HIV Transmission (MTCT) prevention programme was implemented at the routine primary care level and not as part of a research protocol. A total of 264 women attending prenatal care in these clinics were interviewed in Xhosa using a standardized questionnaire. All had been offered HIV testing, and 95% had accepted. Women who had not been tested were four times more likely to believe that in the community families reject HIV-positive women (p<0.005). Of women who tested, 19% were HIV positive and 83% had told their partner that they had taken the test. HIV-positive women who had not disclosed testing to their partners were three times more likely to believe that, in the community, partners are violent towards HIV-positive women (p<0.005); 86% stated that they would have taken AZT if found to be HIV positive. Only 11% considered that the use of formula feeding indicated that a woman was HIV positive. In conclusion, routine prenatal HIV testing and interventions to reduce perinatal HIV transmission are acceptable to the majority of women in a South African urban township, despite an awareness of discrimination in the community towards HIV-positive women.

Sputum induction as a diagnostic tool for community-acquired pneumonia in infants and young children from a high HIV prevalence area

Sputum induction is a standard diagnostic procedure to identify pathogens in lower respiratory tract secretions in adults with pneumonia, but has rarely been studied or used in infants and young children. Our aim was to determine the usefulness of induced sputum (IS) as a diagnostic method for infants and children hospitalized with community-acquired pneumonia (CAP) in a high HIV prevalence area. Children hospitalized for CAP were prospectively enrolled over a year. IS was obtained by nebulization with hypertonic (5%) saline, physiotherapy, and suctioning. Sputum was submitted for bacterial and mycobacterial culture and P. carinii detection. Gastric lavages (GLs) were done for M. tuberculosis culture; a nasopharyngeal aspirate (NPA) was obtained for bacterial culture and P. carinii detection. IS was obtained in 210 children (median age, 7 (25th to 75th percentile, 3-18) months); 138 (66%) were HIV-infected; 148 (70%) were receiving supplemental oxygen. Bacteria were isolated from 101 (50%) IS and 141 (70%) NPA paired specimens (P < 0.001). A significantly higher rate of S. aureus, H. influenzae, M. catarrhalis, and S. pneumoniae was found in NPAs compared to IS; this pattern was particularly evident in HIV-infected children. M. tuberculosis was cultured from sputum in 19 patients (9%); GLs performed in 142 children were positive in only 9 (6%). The difference (95% confidence interval) between yields for M. tuberculosis from culture of IS compared to GL was 4.3% (95% CI, 0-5.6%; P = 0.08). P. carinii was identified from IS in 12 (5.7%) children; all corresponding NPAs were negative. Seven (3%) children could not tolerate sputum induction. Side effects included increased coughing in 4%, epistaxis in 3%, and wheezing responsive to bronchodilators in 1%. In conclusion, induced sputum is a useful and safe diagnostic procedure in infants and children with CAP from a high HIV prevalence area.

Conjugate vaccines for preventing Haemophilus influenzae type b infections

BACKGROUND

Haemophilus influenzae (H. influenzae) is an important cause of meningitis and pneumonia in children, causing an estimated three million cases of serious disease and hundreds of thousands of deaths annually worldwide. The introduction of H. influenzae type b (Hib) vaccines into routine immunisation schedules in developed countries has been followed by a rapid decline in disease occurrence, but vaccine cost is a significant barrier to use in developing countries. There is a need to determine the size of the effects of the vaccine, to enable cost-effectiveness comparisons with competing priorities in developing countries.

OBJECTIVES

1. To determine the effects of conjugate Hib vaccine in preventing Hib disease or death in children under five years.2. To determine any serious adverse outcomes.

SEARCH STRATEGY

Searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003); MEDLINE (January 1966 to April 2003), EMBASE (1990 to April 2003); and scanning of reference lists and contacting of authors of trial reports. Reports in all languages were considered.

SELECTION CRITERIA

All randomised controlled trials or quasi-randomised trials of conjugate H. influenzae type b vaccines compared with placebo or no treatment in children who were followed until at least two years of age.

DATA COLLECTION AND ANALYSIS

Two investigators independently selected eligible studies and extracted data. Differences were resolved by discussion.

MAIN RESULTS

Five studies were included in the review, and four in meta-analyses. The overall quality of the trials was good. The relative risk for invasive Hib disease was 0.20 (95% confidence interval 0.07 to 0.54; random effects model), but there was statistically significant unexplained variation (heterogeneity) in the effects of the four trials in the meta-analysis (p = 0.002). The size of the effects found in the trials did not appear to differ consistently with different vaccine types, the number of vaccine doses, age at first vaccination or use in developed vs developing countries, but the confidence intervals for the effect estimates were wide.Hib-related mortality data showed a non-significant trend towards benefit (relative risk was 0.29; 95% confidence interval 0.07 to 1.20; random effects model). The relative risk for all cause mortality in the single trial from which data were available was 1.01 (95% confidence interval 0.38 to 2.67, random effects model). No serious adverse effects were reported in any of the trials, involving a total of 257,000 infants.

REVIEWER'S CONCLUSIONS

Hib vaccine is safe and effective. The size of the effect could plausibly be anywhere between a 46% and 93% reduction in Hib invasive disease, before the effect of herd immunity is taken into account. In resource-poor settings, decisions to use the vaccine will depend on its cost, the local burden of Hib disease and competing priorities. Insufficient evidence from randomised controlled trials was identified of the effects of Hib conjugate vaccine on either Hib-specific or on all-cause mortality.

The role of nutrition and micronutrients in paediatric HIV infection

It has been postulated that micronutrients play a role in the pathogenesis of HIV disease. Though data are sparse, there is evidence that HIV-infected adults and children have a range of micronutrient deficiencies with increasing severity in advanced disease and in the presence of malnutrition. It appears that micronutrient deficiencies contribute to immune dysfunction, infectious morbidity and disease progression. Limited interventive studies suggest that vitamin and mineral supplementation is beneficial to HIV-infected adults and children; however, current, regimens are not evidence-based and there are no randomised controlled trials in children. There are a number of African studies under way addressing these issues.

Serum immunoglobulin E levels in human immunodeficiency virus-infected children with pneumonia

Elevated serum immunoglobulin E (IgE) levels have been reported in association with human immunodeficiency virus (HIV) infection in adults, but there is little information in children. The aim of the present study was to compare serum IgE levels in HIV-positive and -negative children hospitalized with pneumonia in South Africa and to investigate whether IgE may be useful as a marker of specific infections or prognosis in HIV-infected children. History, examination, blood tests, and induced sputum or bronchoalveolar lavage were carried out. Of 122 children [45% female, median age 8 months (3-20 months)], 81 were infected with HIV. A history of allergy or asthma was present in three children (two of whom were HIV positive). Serum IgE was higher in HIV-infected children [83 (33-147) vs. 29 (6-113) IU/l; p = 0.011] as was immunoglobulin G (IgG) [49 (37-63) vs. 27.5 (23-34) g/l; p < 0.001]. CD4 lymphocytes [600 (330-1,210) vs. 1,900 (1,500-3,030) cells/ micro l], percentage CD4 cells [13.6 (9.4-20.3) vs. 40.1 (31.1-44.9)] and CD4 : CD8 ratio [0.3 (0.2-0.4) vs. 2 (1.4-2.8)] were lower in HIV-positive children (p < 0.001 for all). Bacteremia occurred in 12 (10%) children; other specific pathogens identified included Mycobacterium tuberculosis in eight (7%) and Pneumocystis carinii in nine (7%). There was no correlation with CD4 count, CD4 : CD8 ratio, or the presence of specific pathogens, and IgE level. In-hospital mortality (11%) did not correlate with IgE levels. HIV-infected children with pneumonia have higher serum IgE compared with seronegative patients. In HIV-positive children, IgE levels did not correlate with the degree of immunosuppression or with outcome.

Safety and immunogenicity of TETRActHIB (a vaccine combining DTP vaccine and Haemophilus influenzae type B conjugate vaccine) administered to infants at 6, 10 and 14 weeks of age

The safety and immunogenicity of TETRActHIB (a vaccine combining diphtheria and tetanus toxoids-pertussis vaccine (DTP) with Haemophilus influenzae type b (Hib) conjugate vaccine (polyribosyl ribitol phosphate conjugated to tetanus protein) (PRP-T)) was assessed in 131 Cape Town infants immunized at 6, 10 and 14 weeks of age. Serological responses to all component antigens were measured before the first dose and at 18 weeks of age. In addition, anti-PRP antibodies were measured at 9 and 18 months of age to determine long-term immunogenicity. The vaccine was well tolerated by infants and no significant side-effects were reported. Responses to Hib at 18 weeks of age were good in that most infants achieved a level of anti-PRP antibodies > or = 0.15 microgram/ml, indicative of short-term protection, and 70% achieved a level > or = 1 microgram/ml, indicative of long-term protection. The proportions of children with protective levels > or = 0.15 microgram/ml and > or = 1 microgram/ml were similar at 9 and 18 months of age, i.e. approximately 75% and 45%, respectively. Responses to tetanus and diphtheria toxoids were excellent and all infants achieved protective serological levels. Responses to pertussis were moderate in that approximately 65% achieved 'protective' serum levels of pertussis agglutinins, i.e. titres > or = 320. In conclusion, this study has shown that the DTP/PRP-T vaccine is safe, immunogenic and well tolerated in infants immunised at 6, 10 and 14 weeks of age. TETRActHIB is therefore suitable for inclusion in the World Health Organisation Expanded Programme on Immunisation (WHO EPI) schedule.

A proposed vitamin A supplementation programme for South Africa--design, coverage and cost

BACKGROUND

A national survey of the micronutrient status of preschool children in South Africa established that vitamin A deficiency is a significant public health problem, requiring urgent attention. A number of immediate and long-term interventions were recommended, including the introduction of a vitamin A supplementation programme and a food fortification programme.

OBJECTIVES

The aim of the study was to assist in the development and implementation of a national vitamin A supplementation programme at primary health care facilities for mothers and children. This was achieved by determining the design, coverage and cost of a national primary health care facility vitamin A supplementation programme.

METHODS

Based on an extensive review of the literature, the main components of a primary health care facility vitamin A supplementation programme were identified. The annual, recurrent costs of each of the programme components were estimated for the nine provinces in South Africa. Immunisation coverage rates were used as a proxy for estimating the coverage of the programme.

RESULTS

The main components of the programme were identified as: promotion, training, purchase of vitamin A capsules, distribution of vitamin A capsules to primary health care facilities, distribution of capsules to the programme beneficiaries, and monitoring and evaluation. The programme would operate from primary health care facilities and would target all children between 6 and 24 months of age and newly delivered mothers. It was estimated that the programme would cover 74% of children and 95% of postpartum women nationally. The total annual, recurrent cost of the national programme was estimated at R16.4 million. The bulk of the costs would include personnel costs, comprising 68% of the total costs. Other costs included promotion (27%), vitamin A capsules (4%) and training (1%). The cost of the programme would vary significantly by province, but the provinces' average total cost per beneficiary would be similar.

CONCLUSION

A primary health care facility vitamin A supplementation programme has been designed and accompanied by an estimated overall cost and coverage for implementation. The findings of the study showed that the programme would be financially feasible and would reach the majority of children under 24 months of age. It is recommended that further research be undertaken to extend the programme to the more 'hard to reach' population using other strategies such as mass immunisation campaigns.

Finger clubbing in children with human immunodeficiency virus infection

We investigated the frequency of finger clubbing in 150 HIV-infected children consecutively hospitalized for acute pneumonia in South Africa and described associated clinical, laboratory and radiological features. Clubbing occurred in 30 of 150 (20%) HIV-infected children compared with one of 99 (1%) HIV-negative control patients, p < 0.001. Clubbing was associated with lower presenting heart and respiratory rates and enlarged parotid glands. Total and CD4 + lymphocytes, CD4:CD8 ratio and LDH were lower in children with clubbing, but serum protein and gammaglobulin were higher. No differences in the prevalence or type of microbial pathogens were found between the two groups. Clubbing was associated with a radiological diagnosis of LIP. Children with clubbing had a lower in-hospital mortality rate than those without clubbing (6.7% vs 24.2%, p = 0.035). In geographical areas with high HIV seroprevalence rates, the presence of clubbing in a child hospitalized for respiratory disease should raise the suspicion of HIV infection.

Aetiology and outcome of pneumonia in human immunodeficiency virus-infected children hospitalized in South Africa

To determine the aetiology and outcome of pneumonia in human immunodeficiency virus (HIV)-infected children, we prospectively investigated 250 children hospitalized with pneumonia who were known or clinically suspected to be HIV-positive, or who required intensive care support in Cape Town, South Africa. Blood culture, induced sputum or bronchoalveolar lavage, nasopharyngeal aspirate and gastric lavage were performed. Of the total, 151 children (60.4%) were HIV-infected. Pneumocystis carinii pneumonia (PCP), occurring in 19 (7.6%) children (15 HIV-positive), was the AIDS-defining infection in 20.3%. The incidence and type of bacteraemia (14.3%) were similar in HIV-positive and HIV-negative patients; S. pneumoniae (5%) and S. aureus (2%) were the predominant isolates. Sputum or BAL cultures yielded bacteria in 145 of 243 (60%) specimens; viruses were cultured in 37 (15.2%). Bacterial prevalence (including M. tuberculosis in 8%) and anti-microbial resistance did not differ by HIV status except for S. aureus which was more common in HIV-infected children. Thirty-one (20%) HIV-positive and 8 (8%) HIV-negative children died [RR 1.16 (95% CI 1.05-1.28), p=0.008]; using multiple logistic regression, PCP was the only risk factor for mortality (p = 0.03).

CONCLUSION

In South Africa, PCP is an important AIDS-defining infection in children; bacterial pathogens occur commonly and with a similar prevalence in HIV-positive and HIV-negative children hospitalized for pneumonia. HIV-infected children with pneumonia have a worse outcome than HIV-negative patients.

Pneumocystis carinii pneumonia in South African children infected with human immunodeficiency virus

BACKGROUND

Pneumocystis carinii pneumonia (PCP) has been regarded as uncommon in HIV-infected patients in Africa, but diagnostic difficulties and geographic variability may partly account for this. There is little information on the incidence of PCP in HIV-infected children in Africa.

AIM

To investigate (1) the incidence and associated features of PCP in African HIV-infected children and (2) the usefulness of sputum induction and nasopharyngeal aspirates (NPAs) for diagnosis of PCP.

METHODS

HIV-infected children hospitalized with pneumonia were prospectively enrolled in a 1-year study in South Africa. History, examination, chest radiology and blood tests (including HIV testing) were performed. Sputum induction (5% NaCl nebulization) or nondirected bronchoalveolar lavage in intubated patients was performed for P. carinii identification using immunofluorescence and silver stain; immunofluorescence was also done on nasopharyngeal aspirates (NPAs).

RESULTS

Of 151 HIV-infected children [47% female; median age, 9 (range, 3 to 23) months], 87 had been previously diagnosed with HIV whereas 64 (42.4%) were found to be HIV-positive at the time of admission. PCP occurred in 15 children (9.9%; 95% confidence interval, 5.9 to 15.5) and was the AIDS-defining infection in 13 of 64 (20.3%; 95% confidence interval, 11.8 to 31.5). Only 1 of 59 children receiving prophylaxis (1.7%) developed PCP compared with 14 of 92 (15.2%) not taking prophylaxis [relative risk, 0.11 (0.02 to 0.82), P = 0.007]. PCP-infected children were younger [3 (range, 3 to 4) vs. 10 (range, 4 to 24) months, P < 0.001] and presented with more severe pulmonary disease as indicated by a higher respiratory rate [63 (range, 60 to 73) vs. 50, (range, 40 to 60) P < 0.001], heart rate [160 (range, 136-180) vs. 140 (range, 120-152) P = 0.025] and a greater incidence of cyanosis (53% vs. 26%, P = 0.025). Clinical signs of HIV infection, occurring in 96% of children, were equally prevalent in both groups. High serum lactate dehydrogenase was the only laboratory investigation that distinguished PCP-infected from uninfected children [626 (range, 450 to 1098) vs. 307 (range, 243 to 465) units/l], P < 0.001. No radiologic features were found to be diagnostic of PCP. P. carinii was identified in 9 sputa and 6 bronchoalveolar lavage specimens, but all corresponding NPAs were negative. Seven of 15 (47%) children with PCP died while hospitalized compared with 24 of 136 (18%) without PCP [relative risk, 1.21 (range, 0.99 to 1.47), P = 0.008].

CONCLUSION

PCP is an important pathogen in HIV-infected infants in South Africa and is associated with a high mortality. Induced sputum is effective for obtaining lower respiratory tract secretions for diagnosis of PCP but an NPA is not useful.

Sputum induction for the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South Africa

BACKGROUND

Bacteriological confirmation of pulmonary tuberculosis is difficult in infants and young children. In adults and older children, sputum induction has been successfully used; this technique has not been tested in younger children.

AIMS

To investigate whether sputum induction can be successfully performed in infants and young children and to determine the utility of induced sputum compared to gastric lavage (GL) for the diagnosis of pulmonary tuberculosis in HIV infected and uninfected children.

SUBJECTS AND METHODS

149 children (median age 9 months) admitted to hospital with acute pneumonia who were known to be HIV infected, suspected to have HIV infection, or required intensive care unit support. Sputum induction was performed on enrollment. Early morning GL was performed after a minimum four hour fast. Induced sputum and stomach contents were stained for acid fast bacilli and cultured for Mycobacterium tuberculosis.

RESULTS

Sputum induction was successfully performed in 142 of 149 children. M tuberculosis, cultured in 16 children, grew from induced sputum in 15. GL, performed in 142 children, was positive in nine; in eight of these M tuberculosis also grew from induced sputum. The difference between yields from induced sputum compared to GL was 4.3% (p = 0.08). M tuberculosis was cultured in 10 of 100 HIV infected children compared to six of 42 HIV uninfected children (p = 0.46).

CONCLUSION

Sputum induction can be safely and effectively performed in infants and young children. Induced sputum provides a satisfactory and more convenient specimen for bacteriological confirmation of pulmonary tuberculosis in HIV infected and uninfected children.

Doctors' attitudes to the care of children with HIV in South Africa

A descriptive survey was conducted on the attitudes of medical staff to caring for HIV-infected children, in three teaching hospitals in Cape Town, South Africa. The study was designed to determine whether the knowledge of a patient's HIV-positive status affects the doctor's attitude and management, to determine doctors' perceived competence with regard to the management of paediatric AIDS and to identify their major concerns in the management of paediatric patients with HIV infection. The response rate was 86%, including 89% of consultants, 81% of registrars and 87% of medical officers employed at the hospitals during the period July/August 1996. The study has highlighted that doctors working in a situation where the epidemic has only recently emerged perceive themselves as being inadequate with regard to managing HIV infection in children. There are indications that doctors may be influenced by the HIV-positive status of children when making decisions regarding their medical management. One of the major concerns with regard to the management of patients with HIV, expressed by doctors in the study, was the lack of management protocols and policy guidelines.

Primary staphylococcal pneumonia in young children: a review of 100 cases

Staphylococcus aureus (S. aureus) is responsible for a small proportion of acute respiratory infections in children. Nevertheless a high index of suspicion is required because of the potential for rapid progression, the need for antibiotics different to those routinely administered in the treatment of pneumonia, and the high incidence of complications. There are few data from developing countries. The objective of this retrospective review was to document the natural history of primary staphylococcal pneumonia at Red Cross Childrens' Hospital in Cape Town over a 7-year period (1989-1995). Staphylococcal pneumonia was defined as acute pneumonia with microbiological evidence of S. aureus or with characteristic radiological features. One hundred patients were identified. The median age was 5 months, 78 patients being below one year of age. Cough and fever were present in almost all patients at the time of presentation. Tachypnoea, recession, dullness, and crepitations were commonly elicited signs. Initial chest radiographs revealed empyema, pleural effusion, or pyopneumothorax in 67 patients. A further 26 patients developed such changes on subsequent chest radiographs. Pneumatocoeles were identified in 37 patients--most of these were only noted on radiographs taken some days after admission. Microbiological confirmation was obtained in 92 cases. S. aureus was isolated in 23/98 blood cultures, 62/67 pleural aspirates, and from tracheal aspirates in 16 cases. Intercostal drains were inserted in 67 cases and 20 children underwent thoracotomy. The case fatality rate was 7 per cent. This study shows that primary staphylococcal pneumonia is chiefly a disease of infants. Symptoms and signs were similar as for other forms of acute pneumonia, although in the majority of cases chest radiographs taken at the time of admission suggested the diagnosis. Treatment with antibiotics and drainage of empyema resulted in a good outcome in the majority of cases.

Risk factors for meningococcal disease in Cape Town

OBJECTIVE

To determine the risk factors associated with meningococcal disease among children living in Cape Town.

DESIGN

A case-control study was conducted from October 1993 to January 1995.

SETTING

The study population consisted of all children under the age of 14 years who were resident in the Cape Town metropolitan region. Cases and controls were selected from Red Cross War Memorial Children's Hospital.

RESULTS

A total of 70 cases and 210 controls were interviewed. Significant risk factors for meningococcal disease included being breast-fed for less than 3 months (adjusted odds ratio (OR) 2.4); overcrowding (adjusted OR 2.3); and age less than 4 years (adjusted OR 2.3). Exposure to two or more household members who smoked was also a risk factor, but only in the presence of a recent upper respiratory tract infection (adjusted OR 5.0).

CONCLUSION

This is the first case-control study in South Africa examining risk factors for meningococcal disease. It provides further evidence for reduction of smoking, reduction of overcrowding and promotion of breast-feeding as important public health measures.