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Rabie H, Goussard P. Tuberculosis and pneumonia in HIV-infected children: an overview. Pneumonia (Nathan) 2016; 8:19. [PMID: 28702298 PMCID: PMC5471701 DOI: 10.1186/s41479-016-0021-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023] Open
Abstract
Pneumonia remains the most common cause of hospitalization and the most important cause of death in young children. In high human immunodeficiency virus (HIV)-burden settings, HIV-infected children carry a high burden of lower respiratory tract infection from common respiratory viruses, bacteria and Mycobacterium tuberculosis. In addition, Pneumocystis jirovecii and cytomegalovirus are important opportunistic pathogens. As the vertical transmission risk of HIV decreases and access to antiretroviral therapy increases, the epidemiology of these infections is changing, but HIV-infected infants and children still carry a disproportionate burden of these infections. There is also increasing recognition of the impact of in utero exposure to HIV on the general health of exposed but uninfected infants. The reasons for this increased risk are not limited to socioeconomic status or adverse environmental conditions—there is emerging evidence that these HIV-exposed but uninfected infants may have particular immune deficits that could increase their vulnerability to respiratory pathogens. We discuss the impact of tuberculosis and other lower respiratory tract infections on the health of HIV-infected infants and children.
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Affiliation(s)
- Helena Rabie
- Department of Pediatrics and Child Health, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa.,Childrens Infectious Diseases Clinical Research Unit (KidCRU), University of Stellenbosch, Cape Town, South Africa.,Division of Infectious Diseases, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000 South Africa
| | - Pierre Goussard
- Department of Pediatrics and Child Health, University of Stellenbosch and Tygerberg Academic Hospital, Cape Town, South Africa
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Abstract
In 2015, the World Health Organization (WHO) declared tuberculosis (TB) to be responsible for more deaths than any other single infectious disease. The burden of TB among children has frequently been dismissed as relatively low with resulting deaths contributing very little to global under-five all-cause mortality, although without rigorous estimates of these statistics, the burden of childhood TB was, in reality, unknown. Recent work in the area has resulted in a WHO estimate of 1 million new cases of childhood TB in 2014 resulting in 136,000 deaths. Around 3% of these cases likely have multidrug-resistant TB and at least 40,000 are in HIV-infected children. TB is now thought to be a major or contributory cause of many deaths in children under five years old, despite not being recorded as such, and is likely in the top ten causes of global mortality in this age group. In particular, recent work has shown that TB is an under-lying cause of a substantial proportion of pneumonia deaths in TB-endemic countries. Childhood TB should be given higher priority: we need to identify children at greatest risk of TB disease and death and make more use of tools such as active case-finding and preventive therapy. TB is a preventable and treatable disease from which no child should die.
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Affiliation(s)
- Helen E. Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, MA 02118 USA
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Grønborg HL, Jespersen S, Hønge BL, Jensen-Fangel S, Wejse C. Review of cytomegalovirus coinfection in HIV-infected individuals in Africa. Rev Med Virol 2016; 27. [PMID: 27714898 DOI: 10.1002/rmv.1907] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/25/2016] [Accepted: 08/26/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection among HIV-infected individuals may cause end-organ disease, which is an AIDS-defining condition. Evidence from high-income countries suggests that CMV may alter the outcome of HIV infection, other than causing end-organ diseases. We reviewed literature on HIV and CMV coinfection in Africa. METHODS Systematic review of published studies on HIV and CMV coinfection in Africa using the PubMed database. RESULTS High CMV seroprevalence was found throughout Africa, exceeding 90% in most populations. Retinitis, pneumonia, and colitis were the most commonly reported CMV manifestations in HIV-infected individuals. Among patients with pulmonary symptoms, the prevalence of CMV pneumonitis varied from 20% to over 60%, whereas CMV was found in 0% to 14% of patients with gastrointestinal manifestations. Cytomegalovirus retinitis was found in 0% to 2.6% of examined HIV-infected individuals. The diagnostics of CMV end-organ diseases were found complex and difficult to interpret in African settings. Cytomegalovirus viremia was correlated with significantly lower CD4 cell count and increase in activated and apoptosis vulnerable T-lymphocytes. Also, CMV coinfection was found to be associated with increased transmission and progression of HIV infection. Moreover, detectable CMV DNA was an independent predictor of HIV transmission and mortality among HIV-infected individuals. CONCLUSIONS Cytomegalovirus is highly prevalent in Africa and a common cause of disease manifestations in HIV-infected individuals among all age groups. Cytomegalovirus coinfection in HIV-infected individuals in Africa is associated with increased transmission and mortality of HIV, but it is a neglected area of research.
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Affiliation(s)
- Helene Ladefoged Grønborg
- GloHAU, Department of Public Health, Global Health, Aarhus University, Aarhus N, Denmark.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Sanne Jespersen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Bo Langhoff Hønge
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Department of Clinical Immunology, Aarhus University Hospital, Aarhus N, Denmark
| | - Søren Jensen-Fangel
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark
| | - Christian Wejse
- GloHAU, Department of Public Health, Global Health, Aarhus University, Aarhus N, Denmark.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.,Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
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Affiliation(s)
- Stephen Gordon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre; and Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephen Graham
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre; and Liverpool School of Tropical Medicine, Liverpool, UK
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Bates M, Shibemba A, Mudenda V, Chimoga C, Tembo J, Kabwe M, Chilufya M, Hoelscher M, Maeurer M, Sinyangwe S, Mwaba P, Kapata N, Zumla A. Burden of respiratory tract infections at post mortem in Zambian children. BMC Med 2016; 14:99. [PMID: 27363601 PMCID: PMC4929772 DOI: 10.1186/s12916-016-0645-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/14/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Autopsy studies are the gold standard for determining cause-of-death and can inform on improved diagnostic strategies and algorithms to improve patient care. We conducted a cross-sectional observational autopsy study to describe the burden of respiratory tract infections in inpatient children who died at the University Teaching Hospital in Lusaka, Zambia. METHODS Gross pathology was recorded and lung tissue was analysed by histopathology and molecular diagnostics. Recruitment bias was estimated by comparing recruited and non-recruited cases. RESULTS Of 121 children autopsied, 64 % were male, median age was 19 months (IQR, 12-45 months). HIV status was available for 97 children, of whom 34 % were HIV infected. Lung pathology was observed in 92 % of cases. Bacterial bronchopneumonia was the most common pathology (50 %) undiagnosed ante-mortem in 69 % of cases. Other pathologies included interstitial pneumonitis (17 %), tuberculosis (TB; 8 %), cytomegalovirus pneumonia (7 %) and pneumocystis Jirovecii pneumonia (5 %). Comorbidity between lung pathology and other communicable and non-communicable diseases was observed in 80 % of cases. Lung tissue from 70 % of TB cases was positive for Mycobacterium tuberculosis by molecular diagnostic tests. A total of 80 % of TB cases were comorbid with malnutrition and only 10 % of TB cases were on anti-TB therapy when they died. CONCLUSIONS More proactive testing for bacterial pneumonia and TB in paediatric inpatient settings is needed.
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Affiliation(s)
- Matthew Bates
- HerpeZ, University Teaching Hospital, Lusaka, Zambia. .,University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia. .,Department of Infection, Division of Infection and Immunity, University College London, and NIHR Biomedical Research centre at UCL Hospitals, London, UK.
| | - Aaron Shibemba
- Department of Pathology & Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Victor Mudenda
- Department of Pathology & Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Charles Chimoga
- HerpeZ, University Teaching Hospital, Lusaka, Zambia.,University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia
| | - John Tembo
- HerpeZ, University Teaching Hospital, Lusaka, Zambia.,University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia.,Institute for Infectious Diseases, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mwila Kabwe
- HerpeZ, University Teaching Hospital, Lusaka, Zambia.,University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia
| | - Moses Chilufya
- HerpeZ, University Teaching Hospital, Lusaka, Zambia.,University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | - Markus Maeurer
- Therapeutic Immunology, Department of Laboratory Medicine, Department of Microbiology, and Department of Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Sylvester Sinyangwe
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Peter Mwaba
- University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia.,Ministry of Health, Lusaka, Zambia
| | - Nathan Kapata
- University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia.,National Tuberculosis Control Programme, Ministry of Community Development, Maternal and Child Health, Lusaka, Zambia
| | - Alimuddin Zumla
- University of Zambia and University College London Medical School (UNZA-UCLMS) Research and Training Programme, University Teaching Hospital, Lusaka, Zambia.,Department of Infection, Division of Infection and Immunity, University College London, and NIHR Biomedical Research centre at UCL Hospitals, London, UK
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Costenaro P, Massavon W, Lundin R, Nabachwa SM, Fregonese F, Morelli E, Alowo A, Nannyonga Musoke M, Namisi CP, Kizito S, Bilardi D, Mazza A, Cotton MF, Giaquinto C, Penazzato M. Implementation and Operational Research: Implementation of the WHO 2011 Recommendations for Isoniazid Preventive Therapy (IPT) in Children Living With HIV/AIDS: A Ugandan Experience. J Acquir Immune Defic Syndr 2016; 71:e1-8. [PMID: 26761275 DOI: 10.1097/qai.0000000000000806] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intensified tuberculosis (TB) case finding and isoniazid preventive therapy (IPT) are strongly recommended for children who are HIV infected. Data are needed to assess the feasibility of the WHO 2011 intensified tuberculosis case finding/IPT clinical algorithm. METHODS Children who are HIV infected and attending Nsambya Home Care at Nsambya Hospital, Uganda, were screened for TB following WHO recommendations. IPT was given for 6 months after excluding TB. Factors associated with time to IPT initiation were investigated by multivariate Cox proportional hazard regression. Health care workers were interviewed on reasons for delay in IPT initiation. RESULTS Among the 899 (49% male) children with HIV, 529 (58.8%) were screened for TB from January 2011 to February 2013. Children with active TB were 36/529 (6.8%), 24 (4.5%) were lost to follow-ups and 280 (52.9%) started IPT, 86/280 (30.7%) within 3 months of TB screening and 194/280 (69.3%) thereafter. Among the 529 children screened for TB, longer time to IPT initiation was independently associated with cough at TB screening (hazard ratio 0.62, P = 0.02, 95% confidence interval: 0.41 to 0.94). Four children (1% of those starting treatments) interrupted IPT because of a 5-fold increase in liver function measurements. In the survey, Health care workers reported poor adherence to antiretroviral therapy, poor attendance to periodic HIV follow-ups, and pill burden as the 3 main reasons to delay IPT. CONCLUSION In resource-constrained settings, considerable delays in IPT initiation may occur, particularly in children with HIV who are presenting with cough at TB screening. The good safety profile of isoniazid in antiretroviral-therapy-experienced children provides further support to IPT implementation in this population.
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Affiliation(s)
- Paola Costenaro
- *Department of Mother and Child Health, University of Padova, Padova, Italy;†Nsambya Home Care of St. Raphael of St. Francis Hospital, Kampala, Uganda;‡Research Center of Montreal University Health Center (CRCHUM)-Global Health, Montreal, Québec, Canada;§Associazione Casa Accoglienza alla Vita Padre Angelo, Trento, Italy;‖Department of Paediatrics and Child Health, Tygerberg Children's Hospital and Stellenbosch University, Tygerberg, South Africa; and¶MRC Clinical Trials Unit at UCL, London, United Kingdom
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Detection of Pneumocystis jirovecii by Quantitative PCR To Differentiate Colonization and Pneumonia in Immunocompromised HIV-Positive and HIV-Negative Patients. J Clin Microbiol 2016; 54:1487-1495. [PMID: 27008872 DOI: 10.1128/jcm.03174-15] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/14/2016] [Indexed: 01/01/2023] Open
Abstract
Pneumocystis jirovecii pneumonia (PCP) is an acute and life-threatening lung disease caused by the fungus Pneumocystis jirovecii The presentation of PCP in HIV-positive patients is well-known and consists of a triad of dyspnea, fever, and cough, whereas the presentation of PCP in HIV-negative patients is atypical and consists of a sudden outbreak, O2 desaturation, and a rapid lethal outcome without therapy. Despite the availability of direct and indirect identification methods, the diagnosis of PCP remains difficult. The cycle threshold (CT) values obtained by quantitative PCR (qPCR) allow estimation of the fungal burden. The more elevated that the fungal burden is, the higher the probability that the diagnosis is pneumonia. The purposes of the present study were to evaluate the CT values to differentiate colonization and pneumonia in a population of immunocompromised patients overall and patients stratified on the basis of their HIV infection status. Testing of bronchoalveolar lavage (BAL) fluid samples from the whole population of qPCR-positive patients showed a mean CT value for patients with PCP of 28 (95% confidence interval [CI], 26 to 30) and a mean CT value for colonized patients of 35 (95% CI, 34 to 36) (P < 10(-3)). For the subgroup of HIV-positive patients, we demonstrated that a CT value below 27 excluded colonization and a CT value above 30 excluded PCP with a specificity of 100% and a sensitivity of 80%, respectively. In the subgroup of HIV-negative patients, we demonstrated that a CT value below 31 excluded colonization and a CT value above 35 excluded PCP with a specificity of 80% and a sensitivity of 80%, respectively. Thus, qPCR of BAL fluid samples is an important tool for the differentiation of colonization and pneumonia in P. jirovecii-infected immunocompromised patients and patients stratified on the basis of HIV infection status with different CT values.
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Abstract
BACKGROUND Chest radiography is increasingly used to diagnose pneumonia in low-income and middle-income countries. Few studies examined whether chest radiographic findings predict outcomes of children with clinically suspected pneumonia in these settings. METHODS This is a hospital-based, prospective cohort study of children 1-23 months of age meeting clinical criteria for pneumonia in Botswana. Chest radiographs were reviewed by 2 pediatric radiologists to generate a consensus interpretation using standardized World Health Organization criteria. We assessed whether final chest radiograph classification was associated with our primary outcome, treatment failure at 48 hours, and secondary outcomes. RESULTS From April 2012 to November 2014, we enrolled 249 children with evaluable chest radiographs. Median age was 6.1 months, and 58% were male. Chest radiograph classifications were primary endpoint pneumonia (35%), other infiltrate/abnormality (42%) or no significant pathology (22%). The prevalence of endpoint consolidation was higher in children with HIV infection (P = 0.0005), whereas endpoint pleural effusions were more frequent among children with moderate or severe malnutrition (P = 0.0003). Ninety-one (37%) children failed treatment, and 12 (4.8%) children died. Primary endpoint pneumonia was associated with an increased risk of treatment failure at 48 hours (P = 0.002), a requirement for more days of respiratory support (P = 0.002) and a longer length of stay (P = 0.0003) compared with no significant pathology. Primary endpoint pneumonia also predicted a higher risk of treatment failure than other infiltrate/abnormality (P = 0.004). CONCLUSIONS Chest radiograph provides useful prognostic information for children meeting clinical criteria for pneumonia in Botswana. These findings highlight the potential benefit of expanded global access to diagnostic radiology services.
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du Plessis D, Poonsamy B, Msimang V, Davidsson L, Cohen C, Govender N, Dawood H, Karstaedt A, Frean J. Laboratory-based surveillance of Pneumocystis jiroveciipneumonia in South Africa, 2006–2010. S Afr J Infect Dis 2016. [DOI: 10.1080/23120053.2015.1118828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Wampande EM, Mupere E, Jaganath D, Nsereko M, Mayanja HK, Eisenach K, Boom WH, Gagneux S, Joloba ML. Distribution and transmission of Mycobacterium tuberculosis complex lineages among children in peri-urban Kampala, Uganda. BMC Pediatr 2015; 15:140. [PMID: 26424324 PMCID: PMC4588907 DOI: 10.1186/s12887-015-0455-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 09/14/2015] [Indexed: 11/15/2022] Open
Abstract
Background To gain insight into the transmission of tuberculosis (TB) in peri-urban Kampala-Uganda, we performed a household contact study using children as a surrogate for recent transmission of Mycobacterium tuberculosis (MTB). Using this approach, we sought to understand M. tuberculosis complex (MTBC) lineage diversity, distribution and how these relate to TB transmission to exposed children. Method MTBC isolates from children aged ≤ 15 years, collected from 2002 to 2010 in a household-contact study, were analyzed using a LightCycler RT-PCR SNP genotyping assay (LRPS). The resultant genotypic data was used to determine associations between MTBC lineage and the children’s clinical and epidemiological characteristics. Results and discussion Of the 761 children surveyed, 9 % (69/761) had culture-positive TB an estimate in the range of global childhood TB; of these 71 % (49/69) were infected with an MTBC strain of the “Uganda family”, 17 % (12/69) infected with MTBC lineage 4 strains other than MTBC Uganda family and 12 % (8/69) infected with MTBC lineage 3, thereby disproportionately causing TB in the study area. Overall the data showed no correlation between the MTBC lineages studied and transmission (OR = 0.304; P-value = 0.251; CI: 95 %; 0.039-2.326) using children a proxy for TB transmission. Conclusions Our findings indicate that MTBC Uganda family strains are the main cause of TB in children in peri-urban Kampala. Furthermore, MTBC lineages did not differ in their transmissibility to children.
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Affiliation(s)
- Eddie M Wampande
- Department of Medical Microbiology, College of Health Sciences, Makerere University, P.O box 7072, Kampala, Uganda. .,Department of Bio-molecular Resources and Biolab Sciences, College of Veterinary Medicine, Animal Resources and Bio Security, Makerere University, Kampala, Uganda.
| | - Ezekiel Mupere
- Department of Pediatrics and Child Health College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Devan Jaganath
- The Johns Hopkins School of medicine, Department of Pediatricss, Baltimore, USA.
| | - Mary Nsereko
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda.
| | - Harriet K Mayanja
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda. .,Department of Medicine College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Kathleen Eisenach
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
| | - W Henry Boom
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda. .,Tuberculosis Research Unit, School of Medicine, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, Ohio, USA.
| | - Sebastien Gagneux
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Moses L Joloba
- Department of Medical Microbiology, College of Health Sciences, Makerere University, P.O box 7072, Kampala, Uganda. .,Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda.
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Prevalence of tuberculosis in post-mortem studies of HIV-infected adults and children in resource-limited settings: a systematic review and meta-analysis. AIDS 2015; 29:1987-2002. [PMID: 26266773 PMCID: PMC4568896 DOI: 10.1097/qad.0000000000000802] [Citation(s) in RCA: 258] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Objectives: Tuberculosis (TB) is estimated to be the leading cause of HIV-related deaths globally. However, since HIV-associated TB frequently remains unascertained, we systematically reviewed autopsy studies to determine the true burden of TB at death. Methods: We systematically searched Medline and Embase databases (to end 2013) for literature reporting on health facility-based autopsy studies of HIV-infected adults and/or children in resource-limited settings. Using forest plots and random-effects meta-analysis, we summarized the TB prevalence found at autopsy and used meta-regression to explore variables associated with autopsy TB prevalence. Results: We included 36 eligible studies, reporting on 3237 autopsies. Autopsy TB prevalence was extremely heterogeneous (range 0–64.4%), but was markedly higher in adults [pooled prevalence 39.7%, 95% confidence interval (CI) 32.4–47.0%] compared to children (pooled prevalence 4.5%, 95% CI 1.7–7.4%). Post-mortem TB prevalence varied by world region, with pooled estimates in adults of 63.2% (95% CI 57.7–68.7%) in South Asia (n = 2 studies); 43.2% (95% CI 38.0–48.3) in sub-Saharan Africa (n = 9 studies); and 27.1% (95% CI 16.0–38.1%) in the Americas (n = 5 studies). Autopsy prevalence positively correlated with contemporary estimates of national TB prevalence. TB in adults was disseminated in 87.9% (82.2–93.7%) of cases and was considered the cause of death in 91.4% (95% CI 85.8–97.0%) of TB cases. Overall, TB was the cause of death in 37.2% (95% CI 25.7–48.7%) of adult HIV/AIDS-related deaths. TB remained undiagnosed at death in 45.8% (95% CI 32.6–59.1%) of TB cases. Conclusions: In resource-limited settings, TB accounts for approximately 40% of facility-based HIV/AIDS-related adult deaths. Almost half of this disease remains undiagnosed at the time of death. These findings highlight the critical need to improve the prevention, diagnosis and treatment of HIV-associated TB globally.
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Pitcher RD, Beningfield SJ, Zar HJ. The chest X-ray features of chronic respiratory disease in HIV-infected children--a review. Paediatr Respir Rev 2015; 16:258-66. [PMID: 25736908 DOI: 10.1016/j.prrv.2015.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 01/16/2015] [Indexed: 11/24/2022]
Abstract
Several features of human immunodeficiency virus (HIV) infection contribute to the development of chronic respiratory disease in children. These include the frequency and severity of acute chest infections, as well as the increased risk of pulmonary tuberculosis, aspiration, cardiovascular disease, lymphocytic interstitial pneumonitis or pulmonary neoplasia. The chest radiograph (CXR) remains the most accessible investigation for respiratory disease and plays an important role in the baseline assessment and follow-up. This review focuses on the CXR abnormalities of HIV-related chronic respiratory disease in children. The most commonly documented chronic CXR abnormalities are homogeneous opacification and pulmonary nodules, with pulmonary tuberculosis and lymphocytic interstitial pneumonitis the leading respective causes. Deficiencies in radiographic reporting methodology and relative paucity of radiographic data contribute to current limitations in knowledge and understanding of this field. The review highlights the need for standardised terminology and systematic reporting methodology in future studies. Prospective research on the natural history of lymphocytic interstitial pneumonitis, response to anti-tuberculous therapy, the impact of anti-retroviral therapy and HIV-associated bronchiectasis are needed.
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Affiliation(s)
- Richard D Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa.
| | - Stephen J Beningfield
- Division of Radiology, Department of Radiation Medicine, New Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Abstract
BACKGROUND Tuberculosis (TB) contributes significantly to child morbidity and mortality. This study aimed to estimate the minimum community-based incidence rate of TB among children <3 years of age in Southern Mozambique. METHODS Between October 2011 and October 2012, in the Manhiça District Health and Demographic Surveillance System, we enrolled prospectively all presumptive TB cases younger than 3 years of age through passive and active case finding. Participants included all children who were either symptomatic or were close contacts of a notified adult smear-positive pulmonary TB. Children were clinically evaluated at baseline and follow-up visits. Investigation for TB disease included chest radiography, HIV and tuberculin skin testing as well as gastric aspirate and induced sputum sampling, which were processed for smear, culture and mycobacterial molecular identification. RESULTS During the study period, 13,764 children <3 years contributed to a total of 9575 person-year. Out of the 789 presumptive TB cases enrolled, 13 had TB culture confirmation and 32 were probable TB cases. The minimum community-based incidence rate of TB (confirmed plus probable cases) was 470 of 100,000 person-year (95% confidence interval: 343-629 of 100,000). HIV co-infection was present in 44% of the TB cases. CONCLUSION These data highlight the huge burden of pediatric TB. This study provides one of the first prospective population-based incidence data of childhood tuberculosis and adds valuable information to the global effort of producing better estimates, a critical step to inform public health policy.
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Kroidl I, Clowes P, Reither K, Mtafya B, Rojas-Ponce G, Ntinginya EN, Kalomo M, Minja LT, Kowuor D, Saathoff E, Kroidl A, Heinrich N, Maboko L, Bates M, O'Grady J, Zumla A, Hoelscher M, Rachow A. Performance of urine lipoarabinomannan assays for paediatric tuberculosis in Tanzania. Eur Respir J 2015; 46:761-70. [PMID: 26113682 DOI: 10.1183/09031936.00003315] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/09/2015] [Indexed: 12/15/2022]
Abstract
We evaluated the diagnostic performance of two tests based on the release of lipoarabinomannan (LAM) into the urine, the MTB-LAM-ELISA assay and the Determine TB-LAM-strip assay, in children with suspected tuberculosis (TB) in a high TB/HIV-prevalence setting.In a prospective study, 132 children with suspected active TB were assigned to diagnostic subgroups. Urine samples were subjected to testing by both assays to ascertain sensitivity and specificity. Host factors associated with positive LAM results were investigated and LAM excretion monitored after antituberculous treatment initiation.18 (13.6%) children had culture-confirmed pulmonary TB. The assays' sensitivity was higher in HIV-positive versus HIV-negative children: 70% (95% confidence interval 35-93%) versus 13% (0-53%) for MTB-LAM-ELISA and 50% (19-81%) versus 0% (0-37%) for Determine TB-LAM. In 35 (27%) children with excluded active TB, both assays showed a specificity of 97.1% (85-100%). Proteinuria and low body mass index were independently associated with LAM positivity. In most patients, LAM excretion declined to zero during or at conclusion of antituberculous treatment.HIV/TB co-infected children might benefit from LAM-based tests to aid early TB diagnosis and subsequent positive impact on morbidity and mortality. Using LAM as a rule-in and treatment-monitoring tool may also show further potential.
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Affiliation(s)
- Inge Kroidl
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Germany National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania Both authors contributed equally
| | - Petra Clowes
- National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania Both authors contributed equally
| | - Klaus Reither
- Medical Services and Diagnostic, Swiss Tropical and Public Health Institute, Basel, Switzerland Medical Services and Diagnostic (Swiss TPH), University of Basel, Basel, Switzerland
| | - Bariki Mtafya
- National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Gabriel Rojas-Ponce
- National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Elias N Ntinginya
- National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Mariam Kalomo
- Dept for Paediatrics and Child Health, Mbeya Referral Hospital, Mbeya, Tanzania
| | - Lilian T Minja
- National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania Medical Services and Diagnostic, Swiss Tropical and Public Health Institute, Basel, Switzerland Medical Services and Diagnostic (Swiss TPH), University of Basel, Basel, Switzerland Ifakara Health Institute, Bagamoyo, Tanzania
| | - Dickens Kowuor
- National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Elmar Saathoff
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Germany German Centre for Infection Research (DZIF), partner site Munich, Germany
| | - Arne Kroidl
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Germany German Centre for Infection Research (DZIF), partner site Munich, Germany National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Norbert Heinrich
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Germany German Centre for Infection Research (DZIF), partner site Munich, Germany
| | - Leonard Maboko
- National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Matthew Bates
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia Division of Infection and Immunity, University College London, London, UK NIHR Biomedical Research Centre, University College London Hospitals, London, UK
| | - Justin O'Grady
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia Division of Infection and Immunity, University College London, London, UK NIHR Biomedical Research Centre, University College London Hospitals, London, UK
| | - Alimuddin Zumla
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia Division of Infection and Immunity, University College London, London, UK NIHR Biomedical Research Centre, University College London Hospitals, London, UK
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Germany German Centre for Infection Research (DZIF), partner site Munich, Germany National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Andrea Rachow
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Germany German Centre for Infection Research (DZIF), partner site Munich, Germany National Institute for Medical Research-Mbeya Medical Research Centre, Mbeya, Tanzania
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Bates M, Mudenda V, Shibemba A, Kaluwaji J, Tembo J, Kabwe M, Chimoga C, Chilukutu L, Chilufya M, Kapata N, Hoelscher M, Maeurer M, Mwaba P, Zumla A. Burden of tuberculosis at post mortem in inpatients at a tertiary referral centre in sub-Saharan Africa: a prospective descriptive autopsy study. THE LANCET. INFECTIOUS DISEASES 2015; 15:544-51. [PMID: 25765217 DOI: 10.1016/s1473-3099(15)70058-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with subclinical tuberculosis, smear-negative tuberculosis, extrapulmonary tuberculosis, multidrug-resistant tuberculosis, and asymptomatic tuberculosis are difficult to diagnose and may be missed at all points of health care. We did an autopsy study to ascertain the burden of tuberculosis at post mortem in medical inpatients at a tertiary care hospital in Lusaka, Zambia. METHODS Between April 5, 2012, and May 22, 2013, we did whole-body autopsies on inpatients aged at least 16 years who died in the adult inpatient wards at University Teaching Hospital, Lusaka, Zambia. We did gross pathological and histopathological analysis and processed lung tissues from patients with tuberculosis through the GeneXpert MTB/RIF assay to identify patients with multidrug-resistant tuberculosis. The primary outcome measure was specific disease or diseases stratified by HIV status. Secondary outcomes were missed tuberculosis, multidrug-resistant tuberculosis, and comorbidities with tuberculosis. Data were analysed using Pearson χ(2), the Mann-Whitney U test, and binary logistic regression. FINDINGS The median age of the 125 included patients was 35 years (IQR 29-43), 80 (64%) were men, and 101 (81%) were HIV positive. 78 (62%) patients had tuberculosis, of whom 66 (85%) were infected with HIV. 35 (45%) of these 78 patients had extrapulmonary tuberculosis. The risk of extrapulmonary tuberculosis was higher among HIV-infected patients than among uninfected patients (adjusted odds ratio 5·14, 95% CI 1·04-24·5; p=0·045). 20 (26%) of 78 patients with tuberculosis were not diagnosed during their life and 13 (17%) had undiagnosed multidrug-resistant tuberculosis. Common comorbidities with tuberculosis were pyogenic pneumonia in 26 patients (33%) and anaemia in 15 (19%). INTERPRETATION Increased clinical awareness and more proactive screening for tuberculosis and multidrug-resistant tuberculosis in inpatient settings is needed. Further autopsy studies are needed to ascertain the generalisability of the findings. FUNDING UBS Optimus Foundation, EuropeAID, and European Developing Countries Clinical Trials Partnership (EDCTP).
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Affiliation(s)
- Matthew Bates
- Department of Infection, Division of Infection and Immunity, University College London, London, UK; University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Victor Mudenda
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Aaron Shibemba
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka, Zambia
| | - Jonas Kaluwaji
- University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - John Tembo
- University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Mwila Kabwe
- University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Charles Chimoga
- University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Lophina Chilukutu
- University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Moses Chilufya
- University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Nathan Kapata
- National Tuberculosis Control Programme, Ministry of Community Development, Maternal and Child Health, Lusaka, Zambia
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich, Munich, Germany
| | - Markus Maeurer
- Therapeutic Immunology, Department of Laboratory Medicine, Department of Microbiology, and Department of Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Peter Mwaba
- University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Alimuddin Zumla
- Department of Infection, Division of Infection and Immunity, University College London, London, UK; University of Zambia and University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia; National Institute for Health Research Biomedical Research Centre, University College London Hospitals, London, UK.
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Lalwani S, Mathur P, Tak V, Janani S, Kumar SI, Bagla R, Misra MC. Diagnosis of ventilator-associated pneumonia: comparison between ante-mortem and post-mortem cultures in trauma patients. Indian J Med Microbiol 2015; 32:294-300. [PMID: 25008824 DOI: 10.4103/0255-0857.136572] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE To evaluate the diagnostic utility of ante-mortem tracheal aspirates for diagnosis of ventilator-associated pneumonia (VAP). Trauma victims represent an otherwise healthy population, who are on multiple invasive life-support devices, which predispose them to severe infections like VAP. The diagnosis of VAP is challenging, due to the difficulty in obtaining a representative sample from lungs. We studied the diagnostic utility of tracheal aspirates by comparing its results with the post-mortem lung cultures. MATERIALS AND METHODS A total of 106 fatal trauma patients were included in the study. Lung samples and cardiac blood were taken for culture at the time of autopsy. The results of ante-mortem and post-mortem cultures were compared. RESULTS Septicemia was the cause of death in 51 (48%) of the fatal cases and VAP was identified in 36 (34%) cases. A total of 96 (90.5%) cases had pathogens isolated from lung samples. In 62 (58%) cases, the same organism was isolated from ante-mortem and post-mortem respiratory samples. CONCLUSIONS Culture results of a properly collected tracheal aspirate should be taken into consideration along with Centre for Disease Control and Prevention (CDC's) diagnostic criteria to maximise the diagnosis of VAP.
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Affiliation(s)
| | - P Mathur
- Departments of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
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Church JA, Fitzgerald F, Walker AS, Gibb DM, Prendergast AJ. The expanding role of co-trimoxazole in developing countries. THE LANCET. INFECTIOUS DISEASES 2015; 15:327-39. [PMID: 25618179 DOI: 10.1016/s1473-3099(14)71011-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Co-trimoxazole is an inexpensive, broad-spectrum antimicrobial drug that is widely used in developing countries. Before antiretroviral therapy (ART) scale-up, co-trimoxazole prophylaxis reduced morbidity and mortality in adults and children with HIV by preventing bacterial infections, diarrhoea, malaria, and Pneumocystis jirovecii pneumonia, despite high levels of microbial resistance. Co-trimoxazole prophylaxis reduces early mortality by 58% (95% CI 39-71) in adults starting ART. Co-trimoxazole provides ongoing protection against malaria and non-malaria infections after immune reconstitution in ART-treated individuals in sub-Saharan Africa, leading to a change in WHO guidelines, which now recommend long-term co-trimoxazole prophylaxis for adults and children in settings with a high prevalence of malaria or severe bacterial infections. Co-trimoxazole prophylaxis is recommended for HIV-exposed infants from age 4-6 weeks; however, the risks and benefits of co-trimoxazole during infancy are unclear. Co-trimoxazole prophylaxis reduces anaemia and improves growth in children with HIV, possibly by reducing inflammation, either through direct immunomodulatory activity or through effects on the intestinal microbiota leading to reduced microbial translocation. Ongoing trials are now assessing the ability of adjunctive co-trimoxazole to reduce mortality in children after severe anaemia or severe acute malnutrition. In this Review, we discuss the mechanisms of action, benefits and risks, and clinical trials of co-trimoxazole in developing countries.
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Affiliation(s)
- James A Church
- Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, UK
| | | | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit at University College London, London, UK
| | - Andrew J Prendergast
- Centre for Paediatrics, Blizard Institute, Queen Mary University of London, London, UK; MRC Clinical Trials Unit at University College London, London, UK; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.
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68
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Oliwa JN, Karumbi JM, Marais BJ, Madhi SA, Graham SM. Tuberculosis as a cause or comorbidity of childhood pneumonia in tuberculosis-endemic areas: a systematic review. THE LANCET RESPIRATORY MEDICINE 2015; 3:235-43. [PMID: 25648115 DOI: 10.1016/s2213-2600(15)00028-4] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 11/19/2014] [Indexed: 11/30/2022]
Abstract
Pneumonia is a major cause of morbidity and mortality in infants and children worldwide, with most cases occurring in tuberculosis-endemic settings. Studies have emphasised the potential importance of Mycobacterium tuberculosis in acute severe pneumonia in children as a primary cause or underlying comorbidity, further emphasised by the changing aetiological range with rollout of bacterial conjugate vaccines in high mortality settings. We systematically reviewed clinical and autopsy studies done in tuberculosis-endemic settings that enrolled at least 100 children aged younger than 5 years with severe pneumonia, and that prospectively included a diagnostic approach to tuberculosis in all study participants. We noted substantial heterogeneity between studies in terms of study population and diagnostic methods. Of the 3644 patients who had culture of respiratory specimens for M tuberculosis undertaken, 275 (7·5%) were culture positive, and an acute presentation was common. Inpatient case-fatality rate for pneumonia associated with tuberculosis ranged from 4% to 21% in the four clinical studies that reported pathogen-related outcomes. Prospective studies are needed in high tuberculosis-burden settings to address whether tuberculosis is a cause or comorbidity of childhood acute severe pneumonia.
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Affiliation(s)
- Jacquie N Oliwa
- KEMRI Wellcome Trust Research Programme, Department of Public Health Research, Nairobi, Kenya.
| | - Jamlick M Karumbi
- KEMRI Wellcome Trust Research Programme, Department of Public Health Research, Nairobi, Kenya
| | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases and Biosecurity and The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology and National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen M Graham
- Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia; International Union Against Tuberculosis and Lung Disease, Paris, France
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69
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Chatterjee D, Pramanik AK. Tuberculosis in the African continent: A comprehensive review. ACTA ACUST UNITED AC 2015; 22:73-83. [PMID: 25620557 DOI: 10.1016/j.pathophys.2014.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/27/2014] [Accepted: 12/30/2014] [Indexed: 02/01/2023]
Abstract
Tuberculosis continues to be a major global health problem, causing an estimated 8.8 million new cases and 1.45 million deaths annually. New drugs in the 1940s made it possible to beat the disease, and consequently, the number of cases reduced drastically. Fast-forward a few decades, drugresistant strains of varied virulence are reported consistently, disease is again on the rise and the treatment has not kept pace. Tuberculosis is the leading cause of death among HIV-infected persons in many resource-constrained settings however, it is curable and preventable. The unprecedented growth of the tuberculosis epidemic in Africa is attributable to several factors, the most important being the HIV epidemic. Analysis of molecular-based data have shown diverse genetic backgrounds among both drug-sensitive and MDR TB isolates in Africa presumably due to underlying genetic and environmental differences. The good news is that there have been important advances recently in TB drugs and diagnostics. Despite the availability of revolutionary tests that allow for faster diagnosis and of new drugs and regimens that offer better and safer treatment it is now becoming clearer that national efforts on TB control should be enhanced and focus on improving the quality of prevention, diagnosis, treatment and care services; strengthening program management, implementation and supervision. This review is an assessment of the trend in TB in Africa.
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Affiliation(s)
- Delphi Chatterjee
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523-1682, USA.
| | - Arun K Pramanik
- Department of Pediatrics/Neonatology, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71103-4228, USA
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Auld AF, Tuho MZ, Ekra KA, Kouakou J, Shiraishi RW, Adjorlolo-Johnson G, Marlink R, Ellerbrock TV. Tuberculosis in human immunodeficiency virus-infected children starting antiretroviral therapy in Côte d'Ivoire. Int J Tuberc Lung Dis 2014; 18:381-7. [PMID: 24670690 DOI: 10.5588/ijtld.13.0395] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING In Côte d'Ivoire, more than 2000 human immunodeficiency virus (HIV) infected children aged <15 years were started on antiretroviral therapy (ART) during 2004-2008. OBJECTIVES To estimate tuberculosis (TB) incidence and determinants among ART enrollees. DESIGN A nationally representative retrospective cohort study among 2110 children starting ART during 2004-2008 at 29 facilities. RESULTS At ART initiation, the median age was 5.1 years; 82% had World Health Organization Stage III/IV, median CD4% was 11%, 42% were severely undernourished (weight-for-age Z-score [WAZ] <-3), and 150 (7%) were taking anti-tuberculosis treatment. Documentation of TB screening before ART declined from 63% to 46% during 2004-2008. Children taking anti-tuberculosis treatment at ART enrollment had a lower median CD4% (9.0% vs. 11.0%, P = 0.037) and a higher prevalence of WAZ <-3 (59% vs. 40%, P < 0.001). Among children considered TB-free at ART enrollment, TB incidence was 6.28/100 child-years during days 0-90 of ART, declining to 0.56/100 child-years after 180 days. Children with one unit higher WAZ at ART enrollment had 13% lower TB incidence (adjusted HR 0.87, 95%CI 0.77-1.00, P= 0.047). CONCLUSIONS Ensuring clinician compliance with TB screening before ART and ensuring earlier ART initiation before children suffer from advanced HIV disease and nutritional compromise might reduce TB morbidity during ART.
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Affiliation(s)
- A F Auld
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - M Z Tuho
- Ministry of Health, National Programme for Medical Care of Persons Living with HIV/AIDS, Abidjan, Côte d'Ivoire
| | - K A Ekra
- Division of Global HIV/AIDS, CDC, Abidjan, Côte d'Ivoire
| | - J Kouakou
- Division of Global HIV/AIDS, CDC, Abidjan, Côte d'Ivoire
| | - R W Shiraishi
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | | | - R Marlink
- Elizabeth Glaser Pediatric AIDS Foundation, Los Angeles, California, USA
| | - T V Ellerbrock
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
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Carrascosa MF, Mones JC, Salcines-Caviedes JR, Román JG. A man with unsuspected marine eosinophilic gastritis. THE LANCET. INFECTIOUS DISEASES 2014; 15:248. [PMID: 25467651 DOI: 10.1016/s1473-3099(14)70892-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Miguel F Carrascosa
- Department of Internal Medicine, Hospital of Laredo, Laredo, Cantabria, Spain.
| | | | | | - Javier Gómez Román
- Molecular Biology Laboratory, Pathology Department, University Hospital Marqués de Valdecilla, Faculty of Medicine, Santander, Cantabria, Spain
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Walters E, Duvenhage J, Draper HR, Hesseling AC, Van Wyk SS, Cotton MF, Rabie H. Severe manifestations of extrapulmonary tuberculosis in HIV-infected children initiating antiretroviral therapy before 2 years of age. Arch Dis Child 2014; 99:998-1003. [PMID: 24938535 DOI: 10.1136/archdischild-2013-305509] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early initiation of antiretroviral therapy (ART) in HIV-infected infants reduces mortality and opportunistic infections including tuberculosis (TB). However, young HIV-infected children remain at high risk of TB disease following mycobacterial infection. We document the spectrum of TB disease in HIV-infected children <2 years of age on ART. METHODS Retrospective cohort study; records of children <2 years of age initiating routine ART at Tygerberg Children's Hospital, Cape Town, January 2003-December 2010 were reviewed. Clinical data at ART initiation (baseline) and TB episodes after ART initiation, to June 2012, were recorded. TB immune reconstitution syndrome (TB-IRIS) and incident TB were defined as TB diagnosed within 3 months, and >3 months after, ART initiation respectively. Baseline characteristics were compared in children with TB-IRIS and those with incident TB. RESULTS In 494 children, median follow-up time on ART was 10.7 months. Fifty-five TB treatment episodes occurred after ART initiation: 23 (42%) TB-IRIS (incidence 21.9/100 person years (py)) and 32 (58%) incident TB (incidence 3.9/100 py). Children with TB-IRIS and those with incident TB had similar baseline characteristics. Eight of 10 cases of extrapulmonary TB were severe: 4 IRIS (2 meningitis, 1 disseminated, 1 pericarditis) and 4 incident cases (1 each miliary, meningitis, pericarditis and spinal). Fifty-one children (10%) died (mortality rate 5.96/100 py). Starting ART at <1 year of age approached significance as a risk factor for TB-IRIS (adjusted OR (AOR) 8.64, p=0.06); weight-for-age Z score <-2 predicted death (AOR 6.37, p<0.001). CONCLUSIONS Severe TB manifestations were observed among young HIV-infected children on ART.
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Affiliation(s)
- Elisabetta Walters
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Joanie Duvenhage
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Heather R Draper
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Anneke C Hesseling
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Susan S Van Wyk
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Mark F Cotton
- Department of Paediatrics and Child Health, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health, Tygerberg Academic Hospital, Stellenbosch University, Cape Town, South Africa
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Tembo J, Kabwe M, Chilukutu L, Chilufya M, Mwaanza N, Chabala C, Zumla A, Bates M. Prevalence and risk factors for betaherpesvirus DNAemia in children >3 weeks and <2 years of age admitted to a large referral hospital in sub-Saharan Africa. Clin Infect Dis 2014; 60:423-31. [PMID: 25352585 DOI: 10.1093/cid/ciu853] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Betaherpesviruses are established causes of morbidity and mortality in immunosuppressed patient groups but have been little studied in sub-Saharan Africa, the epicenter of the human immunodeficiency virus (HIV) pandemic. In this region, primary infections with human cytomegalovirus (HCMV) and human herpesvirus type 6 (HHV-6) type 6 are endemic in infancy, but the clinical impact of these infections among pediatric inpatient groups is poorly characterized and assumptive, based largely on data from Western populations. METHODS We used TaqMan polymerase chain reaction to screen sera from a group of 303 pediatric inpatients aged between 3 weeks and 2 years, at the University Teaching Hospital in Lusaka, Zambia. We report the prevalence of DNAemia and viral loads within this patient group, and evaluate possible clinical associations/risk factors for betaherpesvirus infections in these hospitalized children. RESULTS We detected betaherpesvirus DNAemia in 59.1% (179/303) of children. HCMV was the most prevalent (41.3%), followed by HHV-6B (20.5%), HHV-7 (20.1%), and HHV-6A (0.3%). HIV infection (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.37-3.90; P = .002), being underweight (OR, 1.82; 95% CI, 1.06-3.12; P = .03), and an admission diagnosis of suspected meningitis (OR, 5.72; 95% CI, 1.07-30.5; P = .041) were independently associated with an increased odds of HCMV DNAemia. Conversely, HHV-6B and HHV-7 DNAemia were not associated with HIV, underweight, or admission diagnosis. Median HCMV viral load was moderately but significantly higher in HIV-infected children. CONCLUSIONS Highly prevalent HCMV DNAemia was independently associated with HIV infection and being underweight across all age groups, and was also associated with meningitis, with previously underappreciated implications for the health and development of African children.
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Affiliation(s)
- John Tembo
- University of Zambia - University College London Medical School Research and Training Programme HerpeZ, University Teaching Hospital, Lusaka, Zambia Institute for Infectious Diseases, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mwila Kabwe
- University of Zambia - University College London Medical School Research and Training Programme HerpeZ, University Teaching Hospital, Lusaka, Zambia
| | - Lophina Chilukutu
- University of Zambia - University College London Medical School Research and Training Programme HerpeZ, University Teaching Hospital, Lusaka, Zambia
| | - Moses Chilufya
- University of Zambia - University College London Medical School Research and Training Programme HerpeZ, University Teaching Hospital, Lusaka, Zambia
| | - Nyaxewo Mwaanza
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Chishala Chabala
- Department of Paediatrics and Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Alimuddin Zumla
- University of Zambia - University College London Medical School Research and Training Programme Division of Infection and Immunity, University College London National Institute for Health Research Biomedical Research Centre, University College London Hospitals, United Kingdom
| | - Matthew Bates
- University of Zambia - University College London Medical School Research and Training Programme HerpeZ, University Teaching Hospital, Lusaka, Zambia Division of Infection and Immunity, University College London
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Marais BJ, Rabie H, Schaaf SH, Cotton MF. Common opportunistic infections in HIV infected infants and children Part 1—respiratory infections. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2006.10873487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Jenkins HE, Tolman AW, Yuen CM, Parr JB, Keshavjee S, Pérez-Vélez CM, Pagano M, Becerra MC, Cohen T. Incidence of multidrug-resistant tuberculosis disease in children: systematic review and global estimates. Lancet 2014; 383:1572-9. [PMID: 24671080 PMCID: PMC4094366 DOI: 10.1016/s0140-6736(14)60195-1] [Citation(s) in RCA: 220] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Multidrug-resistant tuberculosis threatens to reverse recent reductions in global tuberculosis incidence. Although children younger than 15 years constitute more than 25% of the worldwide population, the global incidence of multidrug-resistant tuberculosis disease in children has never been quantified. We aimed to estimate the regional and global annual incidence of multidrug-resistant tuberculosis in children. METHODS We developed two models: one to estimate the setting-specific risk of multidrug-resistant tuberculosis among child cases of tuberculosis, and a second to estimate the setting-specific incidence of tuberculosis disease in children. The model for risk of multidrug-resistant tuberculosis among children with tuberculosis needed a systematic literature review. We multiplied the setting-specific estimates of multidrug-resistant tuberculosis risk and tuberculosis incidence to estimate regional and global incidence of multidrug-resistant tuberculosis disease in children in 2010. FINDINGS We identified 3403 papers, of which 97 studies met inclusion criteria for the systematic review of risk of multidrug-resistant tuberculosis. 31 studies reported the risk of multidrug-resistant tuberculosis in both children and treatment-naive adults with tuberculosis and were used for evaluation of the linear association between multidrug-resistant disease risk in these two patient groups. We identified that the setting-specific risk of multidrug-resistant tuberculosis was nearly identical in children and treatment-naive adults with tuberculosis, consistent with the assertion that multidrug-resistant disease in both groups reflects the local risk of transmitted multidrug-resistant tuberculosis. After application of these calculated risks, we estimated that around 999,792 (95% CI 937,877-1,055,414) children developed tuberculosis disease in 2010, of whom 31,948 (25,594-38,663) had multidrug-resistant disease. INTERPRETATION Our estimates underscore that many cases of tuberculosis and multidrug-resistant tuberculosis disease are not being detected in children. Future estimates can be refined as more and better tuberculosis data and new diagnostic instruments become available. FUNDING US National Institutes of Health, the Helmut Wolfgang Schumann Fellowship in Preventive Medicine at Harvard Medical School, the Norman E Zinberg Fellowship at Harvard Medical School, and the Doris and Howard Hiatt Residency in Global Health Equity and Internal Medicine at the Brigham and Women's Hospital.
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Affiliation(s)
- Helen E Jenkins
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Arielle W Tolman
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Courtney M Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jonathan B Parr
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA
| | - Salmaan Keshavjee
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA
| | - Carlos M Pérez-Vélez
- Partners In Health, Boston, MA, USA; Banner Good Samaritan Medical Center, The University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Marcello Pagano
- Department of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Mercedes C Becerra
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA.
| | - Ted Cohen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
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Anderson ST, Kaforou M, Brent AJ, Wright VJ, Banwell CM, Chagaluka G, Crampin AC, Dockrell HM, French N, Hamilton MS, Hibberd ML, Kern F, Langford PR, Ling L, Mlotha R, Ottenhoff THM, Pienaar S, Pillay V, Scott JAG, Twahir H, Wilkinson RJ, Coin LJ, Heyderman RS, Levin M, Eley B. Diagnosis of childhood tuberculosis and host RNA expression in Africa. N Engl J Med 2014; 370:1712-1723. [PMID: 24785206 PMCID: PMC4069985 DOI: 10.1056/nejmoa1303657] [Citation(s) in RCA: 264] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Improved diagnostic tests for tuberculosis in children are needed. We hypothesized that transcriptional signatures of host blood could be used to distinguish tuberculosis from other diseases in African children who either were or were not infected with the human immunodeficiency virus (HIV). METHODS The study population comprised prospective cohorts of children who were undergoing evaluation for suspected tuberculosis in South Africa (655 children), Malawi (701 children), and Kenya (1599 children). Patients were assigned to groups according to whether the diagnosis was culture-confirmed tuberculosis, culture-negative tuberculosis, diseases other than tuberculosis, or latent tuberculosis infection. Diagnostic signatures distinguishing tuberculosis from other diseases and from latent tuberculosis infection were identified from genomewide analysis of RNA expression in host blood. RESULTS We identified a 51-transcript signature distinguishing tuberculosis from other diseases in the South African and Malawian children (the discovery cohort). In the Kenyan children (the validation cohort), a risk score based on the signature for tuberculosis and for diseases other than tuberculosis showed a sensitivity of 82.9% (95% confidence interval [CI], 68.6 to 94.3) and a specificity of 83.6% (95% CI, 74.6 to 92.7) for the diagnosis of culture-confirmed tuberculosis. Among patients with cultures negative for Mycobacterium tuberculosis who were treated for tuberculosis (those with highly probable, probable, or possible cases of tuberculosis), the estimated sensitivity was 62.5 to 82.3%, 42.1 to 80.8%, and 35.3 to 79.6%, respectively, for different estimates of actual tuberculosis in the groups. In comparison, the sensitivity of the Xpert MTB/RIF assay for molecular detection of M. tuberculosis DNA in cases of culture-confirmed tuberculosis was 54.3% (95% CI, 37.1 to 68.6), and the sensitivity in highly probable, probable, or possible cases was an estimated 25.0 to 35.7%, 5.3 to 13.3%, and 0%, respectively; the specificity of the assay was 100%. CONCLUSIONS RNA expression signatures provided data that helped distinguish tuberculosis from other diseases in African children with and those without HIV infection. (Funded by the European Union Action for Diseases of Poverty Program and others).
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Two year mortality and associated factors in a cohort of children from rural Uganda. BMC Public Health 2014; 14:314. [PMID: 24708689 PMCID: PMC4234345 DOI: 10.1186/1471-2458-14-314] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 03/31/2014] [Indexed: 11/10/2022] Open
Abstract
Background As part of site development for clinical trials in novel TB vaccines, a cohort of infants was enrolled in eastern Uganda to estimate the incidence of tuberculosis. The study introduced several mortality reduction strategies, and evaluated the mortality among study participants at two years. The specific of objective of this sub-study was to estimate 2 year mortality and associated factors in this community-based cohort. Methods A community based cohort of 2500 infants was enrolled from birth up to 8 weeks of age and followed for 1–2 years. During follow up, several mortality reduction activities were implemented to enhance cohort survival and retention. The verbal autopsy process was used to assign causes of death. Results A total of 152 children died over a median follow up period of 2.0 years. The overall crude mortality rate was 60.8/1000 or 32.9/1000 person years with 40 deaths per 1000 for children who died in their first year of life. Anaemia, malaria, diarrhoeal diseases and pneumonia were the top causes of death. There was no death directly attributed to tuberculosis. Significant factors associated with mortality were young age of a mother and child’s birth place not being a health facility. Conclusion The overall two year mortality in the study cohort was unacceptably high and tuberculosis disease was not identified as a cause of death. Interventions to reduce mortality of children enrolled in the cohort study did not have a significant impact. Clinical trials involving infants and young children in this setting will have to strengthen local maternal and child health services to reduce infant and child mortality.
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78
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Hailu D, Abegaz WE, Belay M. Childhood tuberculosis and its treatment outcomes in Addis Ababa: a 5-years retrospective study. BMC Pediatr 2014; 14:61. [PMID: 24581267 PMCID: PMC3944801 DOI: 10.1186/1471-2431-14-61] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 02/21/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a significant public health problem leading to high morbidity and mortality both in adults and children. Reports on childhood TB and its treatment outcome are limited. In this retrospective study, we analyzed the epidemiology and treatment outcomes of TB among children in Addis Ababa. METHODS Children registered for TB treatment over 5 years (2007 to 2011) were included in the analysis. Demographic and clinical data including treatment outcomes were extracted from TB unit registers of 23 health centers in Addis Ababa. Multivariate logistic regression was used to identify predictors of poor treatment outcomes. RESULTS Among 41,254 TB patients registered for treatment at the 23 health centers, 2708 (6.6%) were children. Among children with TB, the proportions of smear positive PTB, smear negative PTB and EPTB were 9.6%, 43.0% and 47.4%, respectively. Treatment outcomes were documented for 95.2% of children of whom 85.5% were successfully treated while rates of mortality and defaulting from treatment were 3.3% and 3.8%, respectively. The proportion of children with TB tested for HIV reached 88.3% during the final year of the study period compared to only 3.9% at the beginning of the study period. Mortality was significantly higher among under-five children (p < 0.001) and those with HIV co-infection (p < 0.001). On multivariate logistic regression, children 5-9 years [AOR = 2.50 (95% CI 1.67-3.74)] and 10-14 years [AOR = 2.70 (95% CI 1.86-3.91)] had a significantly higher successful treatment outcomes. On the other hand, smear positive PTB [AOR = 0.44 (95% CI 0.27-0.73), HIV co-infection (AOR = 0.49(95% CI 0.30-0.80)] and unknown HIV sero-status [AOR = 0.60 (95% CI 0.42-0.86)] were predictors of poor treatment outcomes. CONCLUSION The proportion of childhood TB in this study is lower than the national estimate. The overall treatment success rate has met the WHO target. Nonetheless, younger children (< 5 years), children with smear positive PTB and those with HIV co-infection need special attention to reduce poor treatment outcomes among children in the study area.
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Affiliation(s)
- Dereje Hailu
- Addis Ababa Health and Research Laboratory, P.O.Box 30738, Addis Ababa, Ethiopia
| | - Woldaregay Erku Abegaz
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P.O.Box 1176, Addis Ababa, Ethiopia
| | - Mulugeta Belay
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P.O.Box 1176, Addis Ababa, Ethiopia
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79
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Gray D, Zar HJ. Management of community-acquired pneumonia in HIV-infected children. Expert Rev Anti Infect Ther 2014; 7:437-51. [DOI: 10.1586/eri.09.14] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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80
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Morrow BM, Samuel CM, Zampoli M, Whitelaw A, Zar HJ. Pneumocystis pneumonia in South African children diagnosed by molecular methods. BMC Res Notes 2014; 7:26. [PMID: 24410938 PMCID: PMC3892044 DOI: 10.1186/1756-0500-7-26] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 01/03/2014] [Indexed: 12/02/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) is an important cause of hospitalization and mortality in HIV-infected children. However, the incidence of PCP has been underestimated due to poor sensitivity of diagnostic tests. The use of polymerase chain reaction (PCR) for pneumocystis has enabled more reliable diagnosis. This study describes the incidence, clinical features and outcome of PCP in South African children diagnosed using PCR. Methods A prospective study of children hospitalised in South Africa with suspected PCP was done from November 2006 to August 2008. Clinical, laboratory and radiological information were collected. Lower respiratory tract specimens were obtained for PCP immunofluorescence (IF), real- time PCR for pneumocystis, bacterial and mycobacterial culture. Nasopharyngeal aspirates were taken for immunofluorescence (IF), real-time PCR for pneumocystis and PCR for respiratory viruses. A blood specimen for bacterial culture and for cytomegalovirus PCR was taken. Children were followed for the duration of their hospitalisation and the outcome was recorded. Results 202 children [median (interquartile range, IQR) age 3.2 (2.1– 4.6) months] were enrolled; 124 (61.4%) were HIV infected. PCP was identified in 109 (54%) children using PCR, compared to 43 (21%) using IF and Grocott staining (p < 0.0001). Most PCP cases (88, 81%) occurred in HIV-infected children. All 21 cases (19%) occurring in HIV- negative children had another risk factor for PCP. On logistic regression, predictive factors for PCP were HIV infection, lack of fever, high respiratory rate and low oxygen saturation whilst cotrimoxazole prophylaxis was protective (OR 0.24; 95% CI 0.1 to 0.5; p < 0.002). The case fatality of children with PCP was higher than those without PCP (32.1% versus 17.2%; relative risk 1.87; 95% confidence interval (CI) 1.11 – 3.15). Amongst HIV-infected children, a CD4 less than 15% was the only independent predictor of mortality. Conclusions The diagnostic yield for PCP is more than 2.5 times higher on PCR than other detection methods. PCP is a very common cause of severe hypoxic pneumonia and is associated with high mortality in HIV-infected African infants.
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Affiliation(s)
- Brenda M Morrow
- Department of Paediatics and Child Health, Red Cross War Memorial Children's Hospital (RCWMCH), University of Cape Town, 5th Floor Institute of Child Health Building, Klipfontein Road, Rondebosch 7700, Cape Town, South Africa.
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81
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Venturini E, Turkova A, Chiappini E, Galli L, de Martino M, Thorne C. Tuberculosis and HIV co-infection in children. BMC Infect Dis 2014; 14 Suppl 1:S5. [PMID: 24564453 PMCID: PMC4016474 DOI: 10.1186/1471-2334-14-s1-s5] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes. Paediatric tuberculosis and HIV have overlapping clinical manifestations, which could lead to missed or late diagnosis. Although every effort should be made to obtain a microbiologically-confirmed diagnosis in children with tuberculosis, in reality this may only be achieved in a minority, reflecting their paucibacillary nature and the difficulties in obtain samples. Rapid polymerase chain reaction tests, such as Xpert MTB/RIF assay, are increasingly used in children. The use of less or non invasive methods of sample collection, such as naso-pharyngeal aspirates and stool samples for a polymerase chain reaction-based diagnostic test tests and mycobacterial cultures is promising technique in HIV negative and HIV positive children. Anti-tuberculosis treatment should be started immediately at diagnosis with a four drug regimen, irrespective of the disease severity. Moreover, tuberculosis disease in an HIV infected child is considered to be a clinical indication for initiation of antiretroviral treatment. The World Health Organization recommends starting antiretroviral treatment in children as soon as anti-tuberculosis treatment is tolerated and within 2- 8 weeks after initiating it. The treatment of choice depends on the child's age and availability of age-appropriate formulations, and potential drug interactions and resistance. Treatment of multidrug resistant tuberculosis in HIV-infected children follows same principles as for HIV uninfected children. There are conflicting results on effectiveness of isoniazid preventive therapy in reducing incidence of tuberculosis disease in children with HIV. CONCLUSION Data on HIV/TB co-infection in children are still lacking. There are on-going large clinical trials on the prevention and treatment of TB/HIV infection in children that hopefully will help to guide an evidence-based clinical practice in both resource-rich and resource-limited settings.HIV is the top and tuberculosis is the second leading cause of death from infectious disease worldwide, with an estimated 8.7 million incident cases of tuberculosis and 2.5 million new HIV infections annually. The World Health Organization estimates that HIV prevalence among children with tuberculosis, in countries with moderate to high prevalence, ranges from 10 to 60%. The mechanisms promoting susceptibility of people with HIV to tuberculosis disease are incompletely understood, being likely caused by multifactorial processes.
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Affiliation(s)
- Elisabetta Venturini
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Anna Turkova
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Trust, London, United Kingdom
| | - Elena Chiappini
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Luisa Galli
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Claire Thorne
- Centre of Paediatric Epidemiology and Biostatistics, University College London Institute of Child Health, London, WC1N 1EH, United Kingdom
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Bwakura-Dangarembizi M, Kendall L, Bakeera-Kitaka S, Nahirya-Ntege P, Keishanyu R, Nathoo K, Spyer MJ, Kekitiinwa A, Lutaakome J, Mhute T, Kasirye P, Munderi P, Musiime V, Gibb DM, Walker AS, Prendergast AJ. A randomized trial of prolonged co-trimoxazole in HIV-infected children in Africa. N Engl J Med 2014; 370:41-53. [PMID: 24382064 PMCID: PMC4264559 DOI: 10.1056/nejmoa1214901] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Co-trimoxazole (fixed-dose trimethoprim-sulfamethoxazole) prophylaxis administered before antiretroviral therapy (ART) reduces morbidity in children infected with the human immunodeficiency virus (HIV). We investigated whether children and adolescents receiving long-term ART in sub-Saharan Africa could discontinue co-trimoxazole. METHODS We conducted a randomized, noninferiority trial of stopping versus continuing daily open-label co-trimoxazole in children and adolescents in Uganda and Zimbabwe. Eligible participants were older than 3 years of age, had been receiving ART for more than 96 weeks, were using insecticide-treated bed nets (in malaria-endemic areas), and had not had Pneumocystis jirovecii pneumonia. Coprimary end points were hospitalization or death and adverse events of grade 3 or 4. RESULTS A total of 758 participants were randomly assigned to stop or continue co-trimoxazole (382 and 376 participants, respectively), after receiving ART for a median of 2.1 years (interquartile range, 1.8 to 2.3). The median age was 7.9 years (interquartile range, 4.6 to 11.1), and the median CD4 T-cell percentage was 33% (interquartile range, 26 to 39). Participants who stopped co-trimoxazole had higher rates of hospitalization or death than those who continued (72 participants [19%] vs. 48 [13%]; hazard ratio, 1.64; 95% confidence interval [CI], 1.14 to 2.37; P = 0.007; noninferiority not shown). There was no evidence of variation across ages (P=0.93 for interaction). A total of 2 participants in the prophylaxis-stopped group (1%) died, as did 3 in the prophylaxis-continued group (1%). Most hospitalizations in the prophylaxis-stopped group were for malaria (49 events, vs. 21 in the prophylaxis-continued group) or infections other than malaria (53 vs. 25), particularly pneumonia, sepsis, and meningitis. Rates of adverse events of grade 3 or 4 were similar in the two groups (hazard ratio, 1.20; 95% CI, 0.83 to 1.72; P=0.33), but more grade 4 adverse events occurred in the prophylaxis-stopped group (hazard ratio, 2.04; 95% CI, 0.99 to 4.22; P=0.05), with anemia accounting for the largest number of events (12, vs. 2 with continued prophylaxis). CONCLUSIONS Continuing co-trimoxazole prophylaxis after 96 weeks of ART was beneficial, as compared with stopping prophylaxis, with fewer hospitalizations for both malaria and infection not related to malaria. (Funded by the United Kingdom Medical Research Council and others; ARROW Current Controlled Trials number, ISRCTN24791884.).
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Affiliation(s)
- Mutsawashe Bwakura-Dangarembizi
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Lindsay Kendall
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Sabrina Bakeera-Kitaka
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Patricia Nahirya-Ntege
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Rosette Keishanyu
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Kusum Nathoo
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Moira J Spyer
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Adeodata Kekitiinwa
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Joseph Lutaakome
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Tawanda Mhute
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Philip Kasirye
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Paula Munderi
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Victor Musiime
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Diana M Gibb
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - A Sarah Walker
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
| | - Andrew J Prendergast
- University of Zimbabwe, College of Health Sciences, Harare (M.B.-D., K.N., T.M.); the Medical Research Council Clinical Trials Unit at University College London (L.K., M.J.S., D.M.G., A.S.W., A.J.P.) and Centre for Paediatrics, Blizard Institute, Queen Mary, University of London (A.J.P.), London; and the Paediatric Infectious Diseases Clinic of Baylor Uganda, Mulago Hospital (S.B.-K., A.K., P.K.), and Joint Clinical Research Center (R.K., V.M.), Kampala, and the Medical Research Council and Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe (P.N.-N., J.L., P.M.) - all in Uganda
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Djawe K, Daly KR, Levin L, Zar HJ, Walzer PD. Humoral immune responses to Pneumocystis jirovecii antigens in HIV-infected and uninfected young children with pneumocystis pneumonia. PLoS One 2013; 8:e82783. [PMID: 24386119 PMCID: PMC3873266 DOI: 10.1371/journal.pone.0082783] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 10/28/2013] [Indexed: 02/02/2023] Open
Abstract
Background Humoral immune responses in human immunodeficiency virus (HIV)-infected and uninfected children with Pneumocystis pneumonia (PcP) are poorly understood. Methods Consecutive children hospitalized with acute pneumonia, tachypnea, and hypoxia in South Africa were investigated for PcP, which was diagnosed by real-time polymerase chain reaction on lower respiratory tract specimens. Serum antibody responses to recombinant fragments of the carboxyl terminus of Pneumocystis jirovecii major surface glycoprotein (MsgC) were analyzed. Results 149 children were enrolled of whom 96 (64%) were HIV-infected. PcP occurred in 69 (72%) of HIV-infected and 14 (26%) of HIV-uninfected children. HIV-infected children with PcP had significantly decreased IgG antibodies to MsgC compared to HIV-infected patients without PcP, but had similar IgM antibodies. In contrast, HIV-uninfected children with PcP showed no change in IgG antibodies to MsgC, but had significantly increased IgM antibodies compared to HIV-uninfected children without PCP. Age was an independent predictor of high IgG antibodies, whereas PcP was a predictor of low IgG antibodies and high IgM antibodies. IgG and IgM antibody levels to the most closely related MsgC fragments were predictors of survival from PcP. Conclusions Young HIV-infected children with PcP have significantly impaired humoral immune responses to MsgC, whereas HIV-uninfected children with PcP can develop active humoral immune responses. The children also exhibit a complex relationship between specific host factors and antibody levels to MsgC fragments that may be related to survival from PcP.
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Affiliation(s)
- Kpandja Djawe
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Kieran R. Daly
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Research Service, Veterans Affairs Medical Center, Cincinnati, Ohio, United States of America
| | - Linda Levin
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Heather J. Zar
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Peter D. Walzer
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Research Service, Veterans Affairs Medical Center, Cincinnati, Ohio, United States of America
- * E-mail:
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84
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Modi S, Chiu A, Ng’eno B, Kellerman SE, Sugandhi N, Muhe L. Understanding the contribution of common childhood illnesses and opportunistic infections to morbidity and mortality in children living with HIV in resource-limited settings. AIDS 2013; 27 Suppl 2:S159-67. [PMID: 24361625 PMCID: PMC4648290 DOI: 10.1097/qad.0000000000000080] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration. DESIGN AND METHODS Literature review of peer-reviewed articles and abstracts combined with expert opinion and operational experience. RESULTS Morbidity and mortality due to opportunistic infections has decreased in both developed and resource-limited countries. However, the burden of HIV-related infections remains high, especially in sub-Saharan Africa, where the majority of HIV-infected children live. Limitations in diagnostic capacity in resource-limited settings have resulted in a relative paucity of data on opportunistic infections in children. Additionally, the reliance on clinical diagnosis means that opportunistic infections are often confused with common childhood illnesseswhich also contribute to excess morbidity and mortality in these children. Although several preventive interventions have been shown to decrease opportunistic infection-related mortality, implementation of many of these interventions remains inconsistent. CONCLUSIONS In order to reduce opportunistic infection-related mortality, early ART must be expanded, training for front-line clinicians must be improved, and additional research is needed to improve screening and diagnostic algorithms.
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Affiliation(s)
- Surbhi Modi
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Geogia, USA
| | - Alex Chiu
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Geogia, USA
- The CDC Experience Applied Epidemiology Fellowship, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Bernadette Ng’eno
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Nairobi, Kenya
| | | | | | - Lulu Muhe
- World Health Organization, Geneva, Switzerland
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Abstract
PURPOSE OF REVIEW According to the WHO, lower respiratory tract infections are one of the most prevalent causes of death in Africa. Estimates based on verbal autopsies are inaccurate compared with the gold standard for determining cause of death, the anatomical postmortem. Here, we review all respiratory postmortem data available from Africa and assess disease prevalence by HIV status in both adults and children. RECENT FINDINGS Pulmonary and extrapulmonary tuberculosis was detected in over 50% of HIV-infected adults, four to five-fold more prevalent than in HIV-uninfected cases. Overall tuberculosis was less prevalent in children, but was more prevalent in HIV-uninfected compared with HIV-infected children. Bacterial pneumonia was more prevalent in children than adults and was relatively unaffected by HIV status. Pneumocystis jirovecci and human cytomegalovirus pneumonia were detected almost exclusively in HIV-infected mortalities, twice as prevalent in children as in adults. Coinfections were common and correlation with premortem clinical diagnoses was low. SUMMARY Respiratory tract infections are important causes of mortality in Africa. Of the 21 reviewed studies, only four studies (all adults) were undertaken in the last decade. There is hence an urgent need for new postmortem studies to monitor cause of death in new and emerging patient groups, such as those on antiretroviral therapy and HIV exposed uninfected children.
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86
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Hsiao NY, Zampoli M, Morrow B, Zar HJ, Hardie D. Cytomegalovirus viraemia in HIV exposed and infected infants: Prevalence and clinical utility for diagnosing CMV pneumonia. J Clin Virol 2013; 58:74-8. [DOI: 10.1016/j.jcv.2013.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 04/16/2013] [Accepted: 05/05/2013] [Indexed: 10/26/2022]
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Cowan J, Greenberg Cowan J, Barnhart S, Demamu S, Fiseha D, Graham W, Melese E, Reason L, Tefera Asfaw F, Feleke G, Feleke B. A qualitative assessment of challenges to tuberculosis management and prevention in Northern Ethiopia. Int J Tuberc Lung Dis 2013; 17:1071-5. [PMID: 23735536 DOI: 10.5588/ijtld.12.0240] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To elicit Ethiopian health care providers' understanding of challenges to effectively preventing, diagnosing and treating tuberculosis (TB). DESIGN Qualitative data were collected via in-depth interviews and focus group discussions with 73 providers, including physicians, nurses, pharmacists and laboratory technicians, in five hospitals in the Northern Ethiopian regions of Amhara and Tigray. There was no intervention. RESULTS Focus groups and interviews shared a number of prominent common themes. Respondents identified numerous challenges associated with active case identification, infection control practices, diagnostics, including the absence of TB culture and drug susceptibility testing capacity, and the lack of infrastructure for diagnosing and treating multidrug-resistant TB. Pharmacists noted a need for improved procurement practices and pediatric dosages for TB medications. Providers shared concerns regarding isoniazid preventive therapy, health workforce challenges and the risk of contracting TB in the workplace. CONCLUSIONS Health care providers in the Northern Ethiopian regions of Tigray and Amhara identified many challenges to effectively preventing, diagnosing and treating TB. These challenges are complicated by severe resource constraints and challenges in attracting and retaining providers in government hospitals in centers outside Addis Ababa.
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Affiliation(s)
- J Cowan
- Department of Infectious Disease, The University of Washington, Seattle, Washington 98195, USA.
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88
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Kapata N, Chanda-Kapata P, O'Grady J, Bates M, Mwaba P, Janssen S, Marais B, Cobelens F, Grobusch M, Zumla A. Trends in childhood tuberculosis in Zambia: a situation analysis. J Trop Pediatr 2013; 59:134-9. [PMID: 23243079 DOI: 10.1093/tropej/fms065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To ascertain childhood tuberculosis (TB) trends, human immunodeficiency virus (HIV) co-infection rates and multi-drug resistant TB (MDR-TB) prevalence rates in Zambia. METHODS A retrospective review of Zambian annual TB notification data and National TB Programme reports for a 7 year period (2004-2011). TB trends were stratified by age and HIV status. RESULTS The total number of children notified during this period with all forms of TB was 40 976. A total of 2670 of 40 976 (6%) were smear-positive cases. Notification rates of all forms of childhood TB show a decline in trends from 135 per 100 000 population in 2004, to 69 per 100 000 population in 2011. CONCLUSIONS Childhood TB is an important but neglected problem in Zambia highlighted by the fact that no data exists on HIV co-infection and MDR-TB. Strengthening of the National TB Programme and diagnostics services/algorithms are required to accurately define the TB burden, HIV co-infection and MDR-TB rates in children in Zambia.
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Marais BJ, Graham SM, Maeurer M, Zumla A. Progress and challenges in childhood tuberculosis. THE LANCET. INFECTIOUS DISEASES 2013; 13:287-9. [DOI: 10.1016/s1473-3099(13)70031-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gomes VF, Andersen A, Lemvik G, Wejse C, Oliveira I, Vieira FJ, Carlos LJ, Vieira CDS, Aaby P, Gustafson P. Impact of isoniazid preventive therapy on mortality among children less than 5 years old following exposure to tuberculosis at home in Guinea-Bissau: a prospective cohort study. BMJ Open 2013; 3:bmjopen-2012-001545. [PMID: 23535699 PMCID: PMC3612806 DOI: 10.1136/bmjopen-2012-001545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE In a cohort of children less than 5 years old exposed to adult intrathoracic tuberculosis (TB) in 1996-1998, we found 66% increased mortality compared with community controls. In 2005, we implemented isoniazid preventive therapy (IPT) for children exposed to TB at home, and the present study evaluates the effect of this intervention on mortality. SETTING This prospective cohort study was conducted in six suburban areas included in the demographic surveillance system of the Bandim Health Project in Bissau, the capital city of Guinea-Bissau. PARTICIPANTS All children less than 5 years of age and living in the same house as an adult with intrathoracic TB registered for treatment in the study area between 2005 and 2007 were evaluated for inclusion in the IPT programme. MAIN OUTCOME MEASURES (END POINTS): The all-cause mortality rate ratio (MRR) between exposed children on IPT, exposed without IPT and unexposed community control children. RESULTS A total of 1396 children were identified as living in the same houses as 416 adult TB cases; of those, 691 were enrolled in the IPT programme. Compared with community controls, the IPT children had an MRR of 0.30 (95%CI 0.1 to 1.2). The MRR comparing exposed children with and without IPT was 0.21 (0.0 to 1.1). The relative mortality in IPT children compared with community controls in 2005-2008 differed significantly from the relative mortality of exposed untreated children compared with the community controls in 1996-1998 (test of interaction, p=0.01). CONCLUSIONS In 2005-2008, exposed children on IPT had 70% lower mortality than the community control children, though not significantly. Relative to the community control children, the mortality among TB-exposed children on IPT in 2005-2008 was significantly lower than the mortality among TB-exposed children not on IPT in 1996-1998.
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Affiliation(s)
- Victor Francisco Gomes
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Andreas Andersen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Grethe Lemvik
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Center for Global Health, School of Public Health, Aarhus University, Denmark
| | - Christian Wejse
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Center for Global Health, School of Public Health, Aarhus University, Denmark
| | - Ines Oliveira
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Fina J Vieira
- Hospital de Pneumologia ‘Raoul Follereau’, Bissau, Guinea-Bissau
| | | | | | - Peter Aaby
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark
| | - Per Gustafson
- Department of Clinical Sciences, Infectious Diseases Research Group, Lund University, Malmö, Sweden
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Marais BJ, Lönnroth K, Lawn SD, Migliori GB, Mwaba P, Glaziou P, Bates M, Colagiuri R, Zijenah L, Swaminathan S, Memish ZA, Pletschette M, Hoelscher M, Abubakar I, Hasan R, Zafar A, Pantaleo G, Craig G, Kim P, Maeurer M, Schito M, Zumla A. Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts. THE LANCET. INFECTIOUS DISEASES 2013; 13:436-48. [PMID: 23531392 DOI: 10.1016/s1473-3099(13)70015-x] [Citation(s) in RCA: 200] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.
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Affiliation(s)
- Ben J Marais
- Sydney Emerging Infections and Biosecurity Institute, and The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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van Dijk JH, Sutcliffe CG, Hamangaba F, Bositis C, Watson DC, Moss WJ. Effectiveness of efavirenz-based regimens in young HIV-infected children treated for tuberculosis: a treatment option for resource-limited settings. PLoS One 2013; 8:e55111. [PMID: 23372824 PMCID: PMC3555823 DOI: 10.1371/journal.pone.0055111] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 12/19/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Antiretroviral treatment (ART) options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV). Using available pharmacokinetic data, an EFV dosing schedule was developed for young co-infected children and implemented as the standard of care at Macha Hospital in Southern Province, Zambia. Treatment outcomes in children younger than 3 years of age or weighing less than 10 kg receiving either EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP) ART were compared. METHODS Treatment outcomes were measured in a cohort of HIV-infected children seeking care at Macha Hospital in rural Zambia from 2007 to 2010. Information on the diagnosis and treatment of tuberculosis was abstracted from medical records. RESULTS Forty-five children treated for tuberculosis initiated an EFV-based regimen and 69 children initiated a NVP-based regimen, 7 of whom also were treated for tuberculosis. Children receiving both regimens were comparable in age, but children receiving EFV started ART with a lower CD4(+) T-cell percentage and weight-for-age z-score. Children receiving EFV experienced increases in both CD4(+) T-cell percentage and weight-for-age z-score during follow-up, such that levels were comparable to children receiving NVP after two years of ART. Cumulative survival after 12 months of ART did not differ between groups (NVP:87%;EFV:80%;p = 0.25). Eleven children experienced virologic failure during follow-up.The adjusted hazard ratio of virologic failure comparing EFV to NVP was 0.25 (95% CI:0.05,1.24) and 0.13 (95% CI:0.03,0.62) using thresholds of 5000 and 400 copies/mL, respectively.Five children receiving EFV were reported to have had convulsions after ART initiation compared to only one child receiving NVP (p = 0.04). CONCLUSIONS Despite poorer health at ART initiation, children treated for tuberculosis and receiving EFV-based regimens showed significant improvements comparable to children receiving NVP-based regimens. EFV-based regimens should be considered for young HIV-infected children co-infected with tuberculosis in resource-limited settings.
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Affiliation(s)
- Janneke H. van Dijk
- Macha Research Trust, Macha Hospital, Choma, Zambia
- Department of Immunology and Infectious Diseases, Erasmus University, Rotterdam, The Netherlands
| | - Catherine G. Sutcliffe
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | | | - Christopher Bositis
- Greater Lawrence Family Health Center, Lawrence, Massachusetts, United States of America
| | - Douglas C. Watson
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - William J. Moss
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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Fanny ML, Beyam N, Gody JC, Zandanga G, Yango F, Manirakiza A, Rigouts L, Pierre-Audigier C, Gicquel B, Bobossi G. Fine-needle aspiration for diagnosis of tuberculous lymphadenitis in children in Bangui, Central African Republic. BMC Pediatr 2012; 12:191. [PMID: 23234495 PMCID: PMC3538580 DOI: 10.1186/1471-2431-12-191] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 12/07/2012] [Indexed: 12/14/2022] Open
Abstract
Background Tuberculosis (TB) is a major cause of childhood morbidity and mortality in developing countries. One of the main difficulties is obtaining adequate specimens for bacteriological confirmation of the disease in children. The aim of this study is to evaluate the adequacy of fine-needle aspiration (FNA) for the diagnosis of TB. Methods In a prospective study conducted at the paediatric hospital in Bangui in 2007–2009, we used fine-needle aspiration to obtain samples for diagnosis of TB from 131 children aged 0–17 years with persistent lymphadenitis. Results Fine-needle aspiration provided samples that could be used for bacteriological confirmation of TB. Ziehl-Neelsen staining for acid-fast bacilli was positive in 42.7% of samples, and culture identified TB in 67.2% of cases. Of 75 samples that were stain-negative, 49 (65.3%) were culture-positive, while 12 stain-positive samples remained culture-negative. Ten of the 12 stain-positive, culture-negative samples were from patients who had received previous antimicrobial therapy. With regard to phenotypic drug susceptibility, 81/88 strains (91.1%) were fully susceptible to isoniazid, rifampicin, ethambutol and streptomycin, six (6.8%) were resistant to one drug, and one multidrug-resistant strain was found. Conclusions Fine-needle aspiration is simple, cost-effective and non-invasive and can be performed by trained staff. Combined with rapid molecular diagnostic tests, fine-needle aspirates could improve the diagnosis of TB and provide valuable information for appropriate treatment and drug resistance.
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Affiliation(s)
- Minime-Lingoupou Fanny
- Laboratoire des Mycobactéries, Institut Pasteur de Bangui, Bangui, Central African Republic, CAR.
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Dodd LE, Wilkinson RJ. Diagnosis of paediatric tuberculosis: the culture conundrum. THE LANCET. INFECTIOUS DISEASES 2012; 13:3-4. [PMID: 23134696 DOI: 10.1016/s1473-3099(12)70290-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Lori Elizabeth Dodd
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases Division of Clinical Research, 6700B Rockledge Drive MSC 7630 Bethesda, MD 20892-7609, USA
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Bates M, O'Grady J, Maeurer M, Tembo J, Chilukutu L, Chabala C, Kasonde R, Mulota P, Mzyece J, Chomba M, Mukonda L, Mumba M, Kapata N, Rachow A, Clowes P, Hoelscher M, Mwaba P, Zumla A. Assessment of the Xpert MTB/RIF assay for diagnosis of tuberculosis with gastric lavage aspirates in children in sub-Saharan Africa: a prospective descriptive study. THE LANCET. INFECTIOUS DISEASES 2012; 13:36-42. [PMID: 23134697 DOI: 10.1016/s1473-3099(12)70245-1] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rapid and accurate diagnosis of pulmonary tuberculosis in children remains challenging because of difficulties in obtaining sputum samples and the paucibacillary nature of the disease. The Xpert MTB/RIF assay is useful for rapid diagnosis of childhood tuberculosis with sputum and nasopharyngeal samples. We assessed this assay for the detection of tuberculosis and multidrug resistant (MDR) tuberculosis with gastric lavage aspirate (GLA) samples in children admitted to hospital. METHODS We did a prospective study to assess the sensitivity and specificity of the Xpert MTB/RIF assay with GLA samples for the detection of pulmonary tuberculosis and MDR tuberculosis in new paediatric inpatient admissions at the University Teaching Hospital, Lusaka, Zambia. Children aged 15 years or younger were recruited between June, 2011, and May, 2012. GLA and sputum were analysed by standard smear-microscopy, mycobacterial growth indicator tube (MGIT) culture, MGIT drug-susceptibility testing, and the Xpert MTB/RIF assay. Sensitivity of the Xpert MTB/RIF assay was assessed with the Pearson χ(2) or Fishers exact test. FINDINGS Of 930 children, 142 produced sputum and GLA was obtained from 788 non-sputum producers. Culture-positive tuberculosis was identified in 58 (6·2%) of 930 children: ten from sputum producers and 48 from GLA of non-sputum producers. The sensitivity and specificity of the Xpert MTB/RIF assay were similar: sensitivity was 68·8% (95% CI 53·6-80·9) for GLA versus 90·0% (54·1-99·5; p=0·1649) for sputum samples; specificity was 99·3% (98·3-99·8) for GLA and 98·5% (94·1-99·7; p=0·2871) for sputum samples. The Xpert MTB/RIF assay detected an extra 28 tuberculosis cases compared with smear microscopy and was significantly more sensitive than smear microscopy for both sputum (90·0% [54·1-99·5] vs 30·0% [8·1-64·6], p=0·01) and GLA (68·8% [53·6-80·9] vs 25·0% [14·1-40·0], p<0·0001). The assay load did not differ significantly by sample type (p=0·791). 22 children were infected with HIV and tuberculosis and significant differences in assay performance could not be detected when stratifying by HIV status for either sample type. The Xpert MTB/RIF assay detected rifampicin resistance in three GLA samples: two confirmed as MDR tuberculosis and one false positive. INTERPRETATION Analyses of GLA samples with the Xpert MTB/RIF assay is a sensitive and specific method for rapid diagnosis of pulmonary tuberculosis in children who cannot produce sputum. The single site nature of our study invites caution. FUNDING European Commission, European Developing Countries Clinical Trials Partnership, and UBS Optimus Foundation.
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Affiliation(s)
- Matthew Bates
- Department of Infection, Division of Infection and Immunity, University College London, London, UK
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Rutherford ME, Hill PC, Triasih R, Sinfield R, van Crevel R, Graham SM. Preventive therapy in children exposed to Mycobacterium tuberculosis: problems and solutions. Trop Med Int Health 2012; 17:1264-73. [PMID: 22862994 DOI: 10.1111/j.1365-3156.2012.03053.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Young children living with a tuberculosis patient are at high risk of Mycobacterium tuberculosis infection and disease. WHO guidelines promote active screening and isoniazid (INH) preventive therapy (PT) for such children under 5 years, yet this well-established intervention is seldom used in endemic countries. We review the literature regarding barriers to implementation of PT and find that they are multifactorial, including difficulties in screening, poor adherence, fear of increasing INH resistance and poor acceptability among primary caregivers and healthcare workers. These barriers are largely resolvable, and proposed solutions such as the adoption of symptom-based screening and shorter drug regimens are discussed. Integrated multicomponent and site-specific solutions need to be developed and evaluated within a public health framework to overcome the policy-practice gap and provide functional PT programmes for children in endemic settings.
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Affiliation(s)
- Merrin E Rutherford
- Centre for International Health, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand Department of Pediatrics, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia Mersey Deanery, Liverpool, UK Department of Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands Centre for International Child Health, University of Melbourne, Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Vic., Australia
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98
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Lucas S, Andronikou S, Goussard P, Gie R. CT features of lymphobronchial tuberculosis in children, including complications and associated abnormalities. Pediatr Radiol 2012; 42:923-31. [PMID: 22644456 DOI: 10.1007/s00247-012-2399-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 12/15/2011] [Accepted: 01/13/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lymphobronchial tuberculosis (TB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children. OBJECTIVE To describe CT findings of lymphobronchial TB in children, the parenchymal complications and associated abnormalities. MATERIALS AND METHODS CT scans of children with lymphobronchial TB were reviewed retrospectively. Lymphadenopathy, bronchial narrowing, parenchymal complications and associations were documented. RESULTS Infants comprised 51% of patients. The commonest site of lymphadenopathy was the subcarinal mediastinum (97% of patients). Bronchial compression was seen in all children (259 bronchi, of these 28% the bronchus intermedius) with severe or complete stenosis in 23% of affected bronchi. Parenchymal complications were present in 94% of patients, including consolidation (88%), breakdown (42%), air trapping (38%), expansile pneumonia (28%), collapse (17%) and bronchiectasis (9%), all predominantly on the right side (63%). Associated abnormalities included ovoid lesions, miliary nodules, pleural disease and intracavitary bodies. CONCLUSION Airway compression was more severe in infants and most commonly involved the bronchus intermedius. Numerous parenchymal complications were documented, all showing right-side predominance.
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Affiliation(s)
- Susan Lucas
- Department of Radiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2001, South Africa.
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Pefura Yone EW, Evouna Mbarga A, Kuaban C. [The impact of HIV infection on childhood tuberculosis in Yaounde, Cameroon]. Rev Mal Respir 2012. [PMID: 23200581 DOI: 10.1016/j.rmr.2012.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To define the prevalence of HIV infection in childhood tuberculosis and investigate its impact on the clinical presentation, radiographic findings and outcomes among children suffering from tuberculosis in Yaounde. METHODS The medical records of 101 children aged less than 15years, hospitalized with tuberculosis in the chest clinic of the Yaounde Jamot Hospital between January 2005 and June 2010, were retrospectively reviewed. RESULTS Twenty-five (24.8%) of the 101 patients were HIV positive. The occurrence of concomitant intrathoracic and extrathoracic tuberculosis was more frequently observed in HIV infected children (P=0.021). Parenchymal pulmonary lesions were bilateral in 20 (90.9%) of the HIV infected children against 31 (56.1%) in the non-infected children (P=0.003). Cavitating lesions were present in 49.1% of the cases in HIV negative group versus 13.6% in HIV positive group (P=0.004), but sub-group analysis restricted to those with confirmed tuberculosis no longer showed a significant difference. The success rate of treatment was 78.9% among HIV negative patients and 56% among HIV positive patients (P=0.024). CONCLUSION HIV infection modifies the clinical presentation and radiographic features of tuberculosis in children. The treatment success rate is lower in HIV positive children, indicating a stricter medical supervision of these children and more targeted education of their parents.
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Affiliation(s)
- E W Pefura Yone
- Service de pneumologie, hôpital Jamot de Yaoundé, BP 4021 Yaoundé, Cameroun.
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Rose MV, Kimaro G, Nissen TN, Kroidl I, Hoelscher M, Bygbjerg IC, Mfinanga SG, Ravn P. QuantiFERON®-TB gold in-tube performance for diagnosing active tuberculosis in children and adults in a high burden setting. PLoS One 2012; 7:e37851. [PMID: 22808002 PMCID: PMC3395691 DOI: 10.1371/journal.pone.0037851] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 04/27/2012] [Indexed: 11/18/2022] Open
Abstract
AIM To determine whether QuantiFERON®-TB Gold In-Tube (QFT) can contribute to the diagnosis of active tuberculosis (TB) in children in a high-burden setting and to assess the performance of QFT and tuberculin skin test (TST) in a prospective cohort of TB suspect children compared to adults with confirmed TB in Tanzania. METHODS Sensitivity and specificity of QFT and TST for diagnosing active TB as well as indeterminate QFT rates and IFN-γ levels were assessed in 211 TB suspect children in a Tanzanian district hospital and contrasted in 90 adults with confirmed pulmonary TB. RESULTS Sensitivity of QFT and TST in children with confirmed TB was 19% (5/27) and 6% (2/31) respectively. In adults sensitivity of QFT and TST was 84% (73/87) and 85% (63/74). The QFT indeterminate rate in children and adults was 27% and 3%. Median levels of IFN-γ were lower in children than adults, particularly children <2 years and HIV infected. An indeterminate result was associated with age <2 years but not malnutrition or HIV status. Overall childhood mortality was 19% and associated with an indeterminate QFT result at baseline. CONCLUSION QFT and TST showed poor performance and a surprisingly low sensitivity in children. In contrast the performance in Tanzanian adults was good and comparable to performance in high-income countries. Indeterminate results in children were associated with young age and increased mortality. Neither test can be recommended for diagnosing active TB in children with immature or impaired immunity in a high-burden setting.
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Affiliation(s)
- Michala V Rose
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.
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