1
|
Marcy O, Borand L, Ung V, Msellati P, Tejiokem M, Huu KT, Do Chau V, Ngoc Tran D, Ateba-Ndongo F, Tetang-Ndiang S, Nacro B, Sanogo B, Neou L, Goyet S, Dim B, Pean P, Quillet C, Fournier I, Berteloot L, Carcelain G, Godreuil S, Blanche S, Delacourt C. A Treatment-Decision Score for HIV-Infected Children With Suspected Tuberculosis. Pediatrics 2019; 144:e20182065. [PMID: 31455612 DOI: 10.1542/peds.2018-2065] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Diagnosis of tuberculosis should be improved in children infected with HIV to reduce mortality. We developed prediction scores to guide antituberculosis treatment decision in HIV-infected children with suspected tuberculosis. METHODS HIV-infected children with suspected tuberculosis enrolled in Burkina Faso, Cambodia, Cameroon, and Vietnam (ANRS 12229 PAANTHER 01 Study), underwent clinical assessment, chest radiography, Quantiferon Gold In-Tube (QFT), abdominal ultrasonography, and sample collection for microbiology, including Xpert MTB/RIF (Xpert). We developed 4 tuberculosis diagnostic models using logistic regression: (1) all predictors included, (2) QFT excluded, (3) ultrasonography excluded, and (4) QFT and ultrasonography excluded. We internally validated the models using resampling. We built a score on the basis of the model with the best area under the receiver operating characteristic curve and parsimony. RESULTS A total of 438 children were enrolled in the study; 251 (57.3%) had tuberculosis, including 55 (12.6%) with culture- or Xpert-confirmed tuberculosis. The final 4 models included Xpert, fever lasting >2 weeks, unremitting cough, hemoptysis and weight loss in the past 4 weeks, contact with a patient with smear-positive tuberculosis, tachycardia, miliary tuberculosis, alveolar opacities, and lymph nodes on the chest radiograph, together with abdominal lymph nodes on the ultrasound and QFT results. The areas under the receiver operating characteristic curves were 0.866, 0.861, 0.850, and 0.846, for models 1, 2, 3, and 4, respectively. The score developed on model 2 had a sensitivity of 88.6% and a specificity of 61.2% for a tuberculosis diagnosis. CONCLUSIONS Our score had a good diagnostic performance. Used in an algorithm, it should enable prompt treatment decision in children with suspected tuberculosis and a high mortality risk, thus contributing to significant public health benefits.
Collapse
Affiliation(s)
- Olivier Marcy
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia;
- Centre INSERM U1219, Bordeaux Population Health, University of Bordeaux, Bordeaux, France
| | - Laurence Borand
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Vibol Ung
- Tuberculosis and HIV Department, National Pediatric Hospital, Phnom Penh, Cambodia
- University of Health Sciences, Phnom Penh, Cambodia
| | - Philippe Msellati
- UMI 233-U1175 TransVIHMI, IRD, Université de Montpellier, Montpellier, France
| | - Mathurin Tejiokem
- Service d'Epidémiologie et de Santé Publique, Centre Pasteur du Cameroun, Réseau International des Instituts Pasteur, Yaounde, Cameroon
| | - Khanh Truong Huu
- Infectious Disease Department, Pediatric Hospital Nhi Dong 1, Ho Chi Minh City, Vietnam
| | - Viet Do Chau
- Infectious Disease Department, Pediatric Hospital Nhi Dong 2, Ho Chi Minh City, Vietnam
| | - Duong Ngoc Tran
- Pediatric Department, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | | | | | - Boubacar Nacro
- Service de Pédiatrie, Centre Hospitalier Universitaire Souro Sanou, Bobo Dioulasso, Burkina Faso
| | - Bintou Sanogo
- Service de Pédiatrie, Centre Hospitalier Universitaire Souro Sanou, Bobo Dioulasso, Burkina Faso
| | | | - Sophie Goyet
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Bunnet Dim
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Polidy Pean
- Immunology Laboratory, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Catherine Quillet
- ANRS Research Site, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | | | | | - Guislaine Carcelain
- Immunologie Biologique, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, Paris, France; and
| | - Sylvain Godreuil
- Département de Bactériologie-Virologie, Hôpital Arnaud de Villeneuve, Centre Hospitalier Régional Universitaire de Montpellier, Montpellier, France
| | - Stéphane Blanche
- Unité d'Immunologie Hématologie Rhumatologie Pédiatrique, Hôpital Necker Enfants Malades and
| | | |
Collapse
|
2
|
Gelaw YA, Williams G, Soares Magalhães RJ, Gilks CF, Assefa Y. HIV Prevalence Among Tuberculosis Patients in Sub-Saharan Africa: A Systematic Review and Meta-analysis. AIDS Behav 2019; 23:1561-1575. [PMID: 30607755 DOI: 10.1007/s10461-018-02386-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
HIV associated tuberculosis (TB) morbidity and mortality is a major concern in sub-Saharan Africa. Understanding the level of HIV infection among TB patients is vital for adequate response. We conducted a systematic review and meta-analysis to estimate the prevalence of HIV in TB patients in sub-Saharan Africa. We searched PubMed, EMBASE, Web of Science and CINAHL databases. A meta-analysis with a random-effects model was performed. Potential sources of heterogeneity in the prevalence estimates were explored using meta-regression analysis. We identified 68 studies that collectively included 62,969 TB patients between 1990 and 2017. The overall estimate of HIV prevalence in TB patients was 31.8% (95% CI 27.8-36.1). There was substantial heterogeneity in the prevalence estimates in Southern, Central, Eastern, and Western sub-Saharan Africa regions (43.7, 41.3, 31.1 and 25.5%, respectively). We noted an apparent reduction in the estimate from 33.7% (95% CI 27.6-40.4) in the period before 2000 to 25.7% (95% CI 17.6-336.6) in the period after 2010. The Eastern and Southern sub-Saharan Africa region had higher prevalence [34.4% (95% CI 29.3-34.4)] than the Western and Central region [27.3% (95% CI 21.6-33.8)]. The prevalence of HIV in TB patients has declined over time in sub-Saharan Africa. We argue that this is due to strengthened HIV prevention and control response and enhanced TB/HIV collaborative activities. Countries and regions with high burdens of HIV and TB should strengthen and sustain efforts in order to achieve the goal of ending both HIV and TB epidemics in line with the Sustainable Development Goals.
Collapse
Affiliation(s)
- Yalemzewod Assefa Gelaw
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia.
- Institute of Public Health, College of Medicine and Health Science, University of Gondar, 196, Gondar, Ethiopia.
| | - Gail Williams
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
| | - Ricardo J Soares Magalhães
- UQ Spatial Epidemiology Laboratory, Faculty of Science, School of Veterinary Science, The University of Queensland, Gatton, QLD, 4343, Australia
- Children's Health and Environment Program, Faculty of Medicine, Child Health Research Centre, The University of Queensland, Brisbane, QLD, 4101, Australia
| | - Charles F Gilks
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
| | - Yibeltal Assefa
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Brisbane, QLD, 4006, Australia
| |
Collapse
|
3
|
Brent AJ, Nyundo C, Langat J, Mulunda C, Wambua J, Bauni E, Sande J, Park K, Williams TN, Newton CRJ, Levin M, Scott JAG. Prospective Observational Study of Incidence and Preventable Burden of Childhood Tuberculosis, Kenya. Emerg Infect Dis 2018; 24:514-523. [PMID: 29460738 PMCID: PMC5823335 DOI: 10.3201/eid2403.170785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
4
|
Adamu AL, Aliyu MH, Galadanci NA, Musa BM, Gadanya MA, Gajida AU, Amole TG, Bello IW, Gambo S, Abubakar I. Deaths during tuberculosis treatment among paediatric patients in a large tertiary hospital in Nigeria. PLoS One 2017; 12:e0183270. [PMID: 28817675 PMCID: PMC5560640 DOI: 10.1371/journal.pone.0183270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/01/2017] [Indexed: 11/18/2022] Open
Abstract
Background Despite availability of effective cure, tuberculosis (TB) remains a leading cause of death in children. In many high-burden countries, childhood TB is underdiagnosed and underreported, and care is often accessed too late, resulting in adverse treatment outcomes. In this study, we examined the time to death and its associated factors among a cohort of children that commenced TB treatment in a large treatment centre in northern Nigeria. Methods This is a retrospective cohort study of children that started TB treatment between 2010 and 2014. We determined mortality rates per 100 person-months of treatment, as well as across treatment and calendar periods. We used Cox proportional hazards regression to determine adjusted hazard ratios (aHR) for factors associated with mortality. Results Among 299 children with a median age 4 years and HIV prevalence of 33.4%; 85 (28.4%) died after 1,383 months of follow-up. Overall mortality rate was 6.1 per 100 person-months. Deaths occurred early during treatment and declined from 42.4 per 100 person-months in the 1st week of treatment to 2.2 per 100 person-months after at the 3rd month of treatment. Mortality was highest between October to December period (9.1 per 100 pm) and lowest between July and September (2.8 per 100 pm). Risk factors for mortality included previous TB treatment (aHR 2.04:95%CI;1.09–3.84); HIV infection (aHR 1.66:95%CI;1.02–2.71), having either extra-pulmonary disease (aHR 2.21:95%CI;1.26–3.89) or both pulmonary and extrapulmonary disease (aHR 3.03:95%CI;1.70–5.40). Conclusions Mortality was high and occurred early during treatment in this cohort, likely indicative of poor access to prompt TB diagnosis and treatment. A redoubling of efforts at improving universal health coverage are required to achieve the End TB Strategy target of zero deaths from TB.
Collapse
Affiliation(s)
- Aishatu L. Adamu
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria
- Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
- * E-mail:
| | - Muktar H. Aliyu
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Vanderbilt Institute of Global Health, Nashville, TN, United States of America
| | | | - Baba Maiyaki Musa
- Department of Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria
| | - Muktar A. Gadanya
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria
- Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Auwalu U. Gajida
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria
- Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Taiwo G. Amole
- Department of Community Medicine, College of Health Sciences, Bayero University Kano, Kano, Nigeria
- Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Imam W. Bello
- Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
- Department of Public Health and Disease Control, Kano State Ministry of Health, Nigeria
| | - Safiya Gambo
- Department of Paediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria
| | - Ibrahim Abubakar
- Institute for Global Health, University College London, London, United Kingdom
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Trend of childhood TB case notification in Lagos, Nigeria, 2011-2014. Int J Mycobacteriol 2015; 4:239-44. [PMID: 27649872 DOI: 10.1016/j.ijmyco.2015.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/22/2015] [Accepted: 05/26/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Childhood tuberculosis (TB) has been neglected by national TB programs in sub-Saharan Africa because of the emphasis on adult smear-positive TB cases. About 80,000 HIV children die from TB, and over 550,000 childhood TB cases occur annually, representing 6% of the global TB burden, making TB an important cause of morbidity and mortality in children. Thus, this study assessed the trend of childhood TB cases notified in Lagos, Nigeria from 2011 to 2014. METHODS Retrospective data review of childhood TB cases notified to the Lagos State TB and Leprosy Control Programme (LSTBLCP) between January 1, 2011 and December 31, 2014. RESULTS A total of 2396 children were treated for all forms of TB representing 6.8% of the total 35,305 TB cases notified during the study period. This constituted 1102 (46%) males and 1294 (54%) females. There was a progressive increase in the proportion of children treated for TB from 495 (5.9%) in 2011, 539 (6.4%) in 2012, 682 (7.2%) in 2013 and 680 (7.6%) in 2014. Of the total childhood TB cases notified, 16.3-20% were new sputum pulmonary smear positive; 68.2-74.6% were new sputum pulmonary smear negative; while extra-pulmonary TB accounted for 6.7-10.6%. The case notification rate (CNR) of childhood TB per 100,000 increased from 13.4 in 2011, 14.3 in 2012, 17.7 in 2013 and 17.2 in 2014. CONCLUSION There was an increase in the case notification rate of TB among children between 2011 and 2014. Efforts should be made to sustain this increasing trend.
Collapse
|
7
|
Oberhelman RA, Soto-Castellares G, Gilman RH, Castillo ME, Kolevic L, Delpino T, Saito M, Salazar-Lindo E, Negron E, Montenegro S, Laguna-Torres VA, Maurtua-Neumann P, Datta S, Evans CA. A Controlled Study of Tuberculosis Diagnosis in HIV-Infected and Uninfected Children in Peru. PLoS One 2015; 10:e0120915. [PMID: 25927526 PMCID: PMC4416048 DOI: 10.1371/journal.pone.0120915] [Citation(s) in RCA: 10] [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: 06/09/2014] [Accepted: 02/09/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diagnosing tuberculosis in children is challenging because specimens are difficult to obtain and contain low tuberculosis concentrations, especially with HIV-coinfection. Few studies included well-controls so test specificities are poorly defined. We studied tuberculosis diagnosis in 525 children with and without HIV-infection. METHODS AND FINDINGS 'Cases' were children with suspected pulmonary tuberculosis (n = 209 HIV-negative; n = 81 HIV-positive) and asymptomatic 'well-control' children (n = 200 HIV-negative; n = 35 HIV-positive). Specimens (n = 2422) were gastric aspirates, nasopharyngeal aspirates and stools analyzed by a total of 9688 tests. All specimens were tested with an in-house hemi-nested IS6110 PCR that took <24 hours. False-positive PCR in well-controls were more frequent in HIV-infection (P≤0.01): 17% (6/35) HIV-positive well-controls versus 5.5% (11/200) HIV-negative well-controls; caused by 6.7% (7/104) versus 1.8% (11/599) of their specimens, respectively. 6.7% (116/1719) specimens from 25% (72/290) cases were PCR-positive, similar (P>0.2) for HIV-positive versus HIV-negative cases. All specimens were also tested with auramine acid-fast microscopy, microscopic-observation drug-susceptibility (MODS) liquid culture, and Lowenstein-Jensen solid culture that took ≤6 weeks and had 100% specificity (all 2112 tests on 704 specimens from 235 well-controls were negative). Microscopy-positivity was rare (0.21%, 5/2422 specimens) and all microscopy-positive specimens were culture-positive. Culture-positivity was less frequent (P≤0.01) in HIV-infection: 1.2% (1/81) HIV-positive cases versus 11% (22/209) HIV-negative cases; caused by 0.42% (2/481) versus 4.7% (58/1235) of their specimens, respectively. CONCLUSIONS In HIV-positive children with suspected tuberculosis, diagnostic yield was so low that 1458 microscopy and culture tests were done per case confirmed and even in children with culture-proven tuberculosis most tests and specimens were false-negative; whereas PCR was so prone to false-positives that PCR-positivity was as likely in specimens from well-controls as suspected-tuberculosis cases. This demonstrates the importance of control participants in diagnostic test evaluation and that even extensive laboratory testing only rarely contributed to the care of children with suspected TB. TRIAL REGISTRATION This study did not meet Peruvian and some other international criteria for a clinical trial but was registered with the ClinicalTrials.gov registry: ClinicalTrials.gov NCT00054769.
Collapse
Affiliation(s)
- Richard A. Oberhelman
- Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- * E-mail:
| | - Giselle Soto-Castellares
- Asociación Benéfica Proyectos en Informatica, Salud, Medicina, y Agricultura (PRISMA), Lima, Peru
- US Naval Medical Research Unit Six, Lima, Peru
| | - Robert H. Gilman
- Asociación Benéfica Proyectos en Informatica, Salud, Medicina, y Agricultura (PRISMA), Lima, Peru
- Department of Microbiology, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Maria E. Castillo
- Infectious Diseases Service, Instituto Nacional de Salud del Niño, Lima, Peru
- Department of Pediatrics, Faculty of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Lenka Kolevic
- Infectious Diseases Service, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Trinidad Delpino
- Infectious Diseases Service, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Mayuko Saito
- Asociación Benéfica Proyectos en Informatica, Salud, Medicina, y Agricultura (PRISMA), Lima, Peru
- Department of Microbiology, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Eduardo Negron
- Department of Pediatrics, Hospital Nacional Cayetano Heredia, Lima, Peru
| | | | | | - Paola Maurtua-Neumann
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Sumona Datta
- Department of Microbiology, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru
- Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, United Kingdom
- IFHAD: Innovation For Health And Development, London, United Kingdom
| | - Carlton A. Evans
- Department of Microbiology, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru
- Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, United Kingdom
- IFHAD: Innovation For Health And Development, London, United Kingdom
| |
Collapse
|
8
|
The challenge of chronic lung disease in HIV-infected children and adolescents. J Int AIDS Soc 2013; 16:18633. [PMID: 23782483 PMCID: PMC3687079 DOI: 10.7448/ias.16.1.18633] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 04/15/2013] [Accepted: 04/16/2013] [Indexed: 11/08/2022] Open
Abstract
Until recently, little attention has been given to chronic lung disease (CLD) in HIV-infected children. As the HIV epidemic matures in sub-Saharan Africa, adolescents who acquired HIV by vertical transmission are presenting to health services with chronic diseases. The most common is CLD, which is often debilitating. This review summarizes the limited data available on the epidemiology, pathophysiology, clinical picture, special investigations and management of CLD in HIV-infected adolescents. A number of associated conditions: lymphocytic interstitial pneumonitis, tuberculosis and bronchiectasis are well described. Other pathologies such as HIV-associated bronchiolitis obliterans resulting in non-reversible airway obstruction, has only recently been described. In this field, there are many areas of uncertainty needing urgent research. These areas include the definition of CLD, pathophysiological mechanisms and common pathologies responsible. Very limited data are available to formulate an effective plan of investigation and management.
Collapse
|
9
|
A systematic review of clinical diagnostic systems used in the diagnosis of tuberculosis in children. AIDS Res Treat 2012; 2012:401896. [PMID: 22848799 PMCID: PMC3405645 DOI: 10.1155/2012/401896] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 05/09/2012] [Indexed: 11/17/2022] Open
Abstract
Background. Tuberculosis (TB) is difficult to diagnose in children due to lack of a gold standard, especially in resource-limited settings. Scoring systems and diagnostic criteria are often used to assist in diagnosis; however their validity, especially in areas with high HIV prevalence, remains unclear. Methods. We searched online bibliographic databases, including MEDLINE and EMBASE. We selected all studies involving scoring systems or diagnostic criteria used to aid in the diagnosis of tuberculosis in children and extracted data from these studies. Results. The search yielded 2261 titles, of which 40 met selection criteria. Eighteen studies used point-based scoring systems. Eighteen studies used diagnostic criteria. Validation of these scoring systems yielded varying sensitivities as gold standards used ranged widely. Four studies evaluated and compared multiple scoring criteria. Ten studies selected for pulmonary tuberculosis. Five studies specifically evaluated the use of scoring systems in HIV-positive children, generally finding the specificity to be lower. Conclusions. Though scoring systems and diagnostic criteria remain widely used in the diagnosis of tuberculosis in children, validation has been difficult due to lack of an established and accessible gold standard. Estimates of sensitivity and specificity vary widely, especially in populations with high HIV co-infection.
Collapse
|
10
|
Grant LR, Hammitt LL, Murdoch DR, O'Brien KL, Scott JA. Procedures for collection of induced sputum specimens from children. Clin Infect Dis 2012; 54 Suppl 2:S140-5. [PMID: 22403228 PMCID: PMC3297553 DOI: 10.1093/cid/cir1069] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 12/22/2011] [Indexed: 12/17/2022] Open
Abstract
In most settings, sputum is not routinely collected for microbiological diagnosis from children with lower respiratory disease. To evaluate whether it is feasible and diagnostically useful to collect sputum in the Pneumonia Etiology Research for Child Health (PERCH) study, we reviewed the literature on induced sputum procedures. Protocols for induced sputum in children were collated from published reports and experts on respiratory disease and reviewed by an external advisory group for recommendation in the PERCH study. The advisory group compared 6 protocols: 4 followed a nebulization technique using hypertonic saline, and 2 followed a chest or abdomen massage technique. Grading systems for specimen quality were evaluated. Collecting sputum from children with lower respiratory tract illness is feasible and is performed around the world. An external advisory group recommended that sputum be collected from children hospitalized with severe and very severe pneumonia who participate in the PERCH study provided no contraindications exist. PERCH selected the nebulization technique using hypertonic saline.
Collapse
Affiliation(s)
- Lindsay R Grant
- Department of International Health, Center for American Indian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA.
| | | | | | | | | |
Collapse
|
11
|
Human immunodeficiency virus and tuberculosis coinfection in children: challenges in diagnosis and treatment. Pediatr Infect Dis J 2010; 29:e63-70. [PMID: 20651637 DOI: 10.1097/inf.0b013e3181ee23ae] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The burden of childhood tuberculosis (TB) is influenced by the human immunodeficiency virus (HIV) epidemic and this dangerous synergy affects various aspects of both diseases; from pathogenesis and the epidemiologic profile to clinical presentation, diagnosis, treatment, and prevention. HIV-infected infants and children are at increased risk of developing severe forms of TB. The TB diagnosis is complicated by diminished sensitivity and specificity of clinical features and diagnostic tools like the tuberculin skin test and chest x-ray. Although alternative ways of pulmonary sampling and the development of interferon-γ assays have shown to lead to some improvement of TB diagnosis in HIV-infected children, new diagnostic tools are urgently needed. Coadministration of anti-TB treatment and antiretroviral drugs induces severe complications, and this highlights the need to define optimal treatment regimens. Practical implementation of these regimens in TB control programs should be combined with isoniazid preventive therapy in TB-exposed HIV-infected children. The risk of severe complications after Bacille Calmette-Guérin vaccination of HIV-infected children emphasizes the need for new nonviable vaccines. This article reviews the current status of pediatric HIV-TB coinfection with specific emphasis on the diagnosis and treatment.
Collapse
|
12
|
Stockdale AJ, Duke T, Graham S, Kelly J, Duke T, Kelly J. Evidence behind the WHO guidelines: hospital care for children: what is the diagnostic accuracy of gastric aspiration for the diagnosis of tuberculosis in children? J Trop Pediatr 2010; 56:291-8. [PMID: 20817689 DOI: 10.1093/tropej/fmq081] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
13
|
Wright CA, Hoek KGP, Marais BJ, van Helden P, Warren RM. Combining fine-needle aspiration biopsy (FNAB) and high-resolution melt analysis to reduce diagnostic delay in Mycobacterial lymphadenitis. Diagn Cytopathol 2010; 38:482-8. [PMID: 19894259 DOI: 10.1002/dc.21223] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Tuberculous lymphadenitis is the most common cause of extra-pulmonary tuberculosis (TB) in developing countries. Lymphadenitis caused by non-tuberculous mycobacteria (NTM) requires consideration, particularly in immunocompromised patients and children in developed countries. Fine-Needle Aspiration Biopsy (FNAB) offers a valuable specimen collection technique, but culture confirmation, mycobacterial speciation and drug resistance testing (if indicated) is often unavailable in TB endemic areas and result in unacceptable diagnostic delay. We evaluated the diagnostic value of high-resolution DNA melting (HRM) analysis in the diagnosis of mycobacterial lymphadenopathy using FNAB and an inexpensive transport medium. Specimens were collected from patients referred to the FNAB Clinic at Tygerberg Hospital (June 2007-May 2008) with clinical mycobacterial lymphadenitis. Cytology, culture, and HRM were performed on all specimens. The reference standard for disease was defined as positive cytology (morphological evidence plus mycobacterial visualization) and/or a positive culture. Specimens were collected from 104 patients and mycobacterial disease was confirmed in 54 (51.9%); 52 Mycobacterium tuberculosis, 1 Mycobacterium Bovis BCG and 1 NTM. Cytology was positive in 83.3% (45/54) and culture in 72.2% (39/54) of patients. HRM identified 57.4% (31/54) of cases. By using the defined reference standard, we recorded 94.0% specificity and 51.9% sensitivity (positive predictive value 90.3%) with HRM analysis.HRM analysis allowed rapid and species specific diagnosis of mycobacterial lymph adenitis in the majority of patients, permitting early institution of appropriate therapy. Optimization of this technique requires further study.
Collapse
Affiliation(s)
- Colleen A Wright
- Division of Anatomical Pathology, Department of Pathology, Stellenbosch University and NHLS Tygerberg, Tygerberg, South Africa.
| | | | | | | | | |
Collapse
|
14
|
Evaluation of latent class analysis and decision thresholds to guide the diagnosis of pediatric tuberculosis in a Rwandan reference hospital. Pediatr Infect Dis J 2010; 29:e11-8. [PMID: 19935116 DOI: 10.1097/inf.0b013e3181c61ddb] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SETTING A pediatric ward of a university hospital in Kigali, Rwanda, a region with a high HIV seroprevalence. OBJECTIVE To estimate the diagnostic accuracy of symptoms, signs, and paraclinical investigations for tuberculosis in children, and to propose a clinical rule based on the results. DESIGN During a 2-year period all children with cough for more than 2 weeks and/or fever for more than 2 weeks and/or reported weight loss were prospectively included. A set of clinical and paraclinical data were analyzed with latent class analysis. Comparison of post-test probability based on this analysis with a therapeutic threshold for TB was used to develop a guideline. RESULTS In the 309 children HIV prevalence was 56%, bacteriology was positive in 9%, and the tuberculin skin test (TST) was >10 mm in 20%. TB prevalence was 32%. Bacteriology and TST had a specificity of 97% and cough had a sensitivity of 91%. Decision analysis suggests treating children presenting one of the inclusion criteria, combined with positive bacteriology or TST >10 mm or contact with a TB patient. CONCLUSIONS Latent class analysis confirmed earlier identified predictors for TB and allowed development of an easy to use clinical rule, applicable in reference hospitals of countries with high HIV endemicity.
Collapse
|
15
|
Marais BJ, Graham SM, Cotton MF, Beyers N. Diagnostic and management challenges for childhood tuberculosis in the era of HIV. J Infect Dis 2007; 196 Suppl 1:S76-85. [PMID: 17624829 DOI: 10.1086/518659] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The diagnosis and management of childhood tuberculosis (TB) pose substantial challenges in the era of the human immunodeficiency virus (HIV) epidemic. The highest TB incidences and HIV infection prevalences are recorded in sub-Saharan Africa, and, as a consequence, children in this region bear the greatest burden of TB/HIV infection. The tuberculin skin test (TST), which is the standard marker of Mycobacterium tuberculosis infection in immunocompetent children, has poor sensitivity when used in HIV-infected children. Novel T cell assays may offer higher sensitivity and specificity than the TST, but these tests still fail to make the crucial distinction between latent M. tuberculosis infection and active disease and are limited by cost considerations. Symptom-based diagnostic approaches are less helpful in HIV-infected children, because of the difficulty of differentiating TB-related symptoms from those caused by other HIV-associated conditions. Knowing the HIV infection status of all children with suspected TB is helpful because it improves clinical management. HIV-infected children are at increased risk of developing active disease after TB exposure/infection, which justifies the use of isoniazid preventive therapy once active TB has been excluded. The higher mortality and relapse rates noted among HIV-infected children with active TB who are receiving standard TB treatment highlight the need for further research to define optimal treatment regimens. HIV-infected children should also receive appropriate supportive care, including cotrimoxazole prophylaxis, and antiretroviral therapy, if indicated. Despite the difficulties experienced in resource-limited countries, the management of children with TB/HIV infection could be vastly improved by better implementation of readily available interventions.
Collapse
Affiliation(s)
- B J Marais
- Desmond Tutu TB Centre, Tygerberg, South Africa.
| | | | | | | |
Collapse
|
16
|
Molyneux E. Human immunodeficiency virus infection and pediatric bacterial meningitis in developing countries. J Neurovirol 2006; 11 Suppl 3:6-10. [PMID: 16540447 DOI: 10.1080/13550280500511337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Over a million children are infected by the human immunodeficiency virus (HIV); most of whom live in the developing world. Bacterial meningitis is a serious infection of childhood that is 10 times more common in resource-constrained settings than well-resourced countries, and the outcome is worse. This paper reviews the relationship of bacterial meningitis to HIV infection and also the effect of HIV status on antibiotic sensitivity to common causes of childhood meningitis. The combined effects on outcome and long-term sequelae of meningitis are discussed and illustrated with results from Malawi and Southern Africa.
Collapse
|
17
|
Graham SM, Bell DJ, Nyirongo S, Hartkoorn R, Ward SA, Molyneux EM. Low levels of pyrazinamide and ethambutol in children with tuberculosis and impact of age, nutritional status, and human immunodeficiency virus infection. Antimicrob Agents Chemother 2006; 50:407-13. [PMID: 16436690 PMCID: PMC1366879 DOI: 10.1128/aac.50.2.407-413.2006] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recent pharmacokinetic studies that included children found that serum drug levels were low compared to those of adults for whom the same dosages were used. This study aimed to characterize the pharmacokinetics of pyrazinamide and ethambutol in Malawian children and to examine the impact of age, nutritional status, and human immunodeficiency virus (HIV) infection. We conducted a pharmacokinetic study of children treated for tuberculosis with thrice-weekly pyrazinamide (n = 27; mean age, 5.7 years) and of a separate group of children treated with thrice-weekly ethambutol (n = 18; mean age, 5.5 years) as portions of tablets according to national guidelines. Malnutrition and HIV infection were common in both groups. Blood samples were taken just prior to oral administration of the first dose, and subsequent samples were taken at intervals of 2, 3, 4, 7, 24, and 48 h after drug administration. Serum drug levels were low in all children for both drugs; in almost all cases, the maximum concentration of the drug in serum (Cmax) failed to reach the MIC for Mycobacterium tuberculosis. The Cmax of pyrazinamide was significantly lower in younger children (<5 years) than in older children. The Cmax of pyrazinamide was also lower for HIV-infected children and children with severe malnutrition, but these differences did not reach statistical significance. No differences were found for ethambutol in relation to age, HIV infection, or malnutrition, but the Cmax was <2 mg/liter in all cases. Studies of pharmacokinetic parameters and clinical outcomes obtained by using higher dosages of drugs for treatment of childhood tuberculosis are needed, and recommended dosages may need to be increased.
Collapse
Affiliation(s)
- S M Graham
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, P.O. Box 30096, Blantyre 3, Malawi.
| | | | | | | | | | | |
Collapse
|
18
|
van Kooten Niekerk NKM, Knies MM, Howard J, Rabie H, Zeier M, van Rensburg A, Frans N, Schaaf HS, Fatti G, Little F, Cotton MF. The first 5 years of the family clinic for HIV at Tygerberg Hospital: family demographics, survival of children and early impact of antiretroviral therapy. J Trop Pediatr 2006; 52:3-11. [PMID: 15947012 DOI: 10.1093/tropej/fmi047] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Family clinics address the problems of HIV-infected children and their families. The aims were to document demographics of the children and caregivers attending the Family Clinic for HIV at Tygerberg Academic Hospital (TAH) and to investigate factors affecting disease progression in children. METHODS A retrospective folder review of children and parents attending the Family Clinic at TAH between January 1997 and December 2001, a period noted for its lack of antiretroviral treatment. RESULTS Of 432 children seen for testing, 274 children, median age 16.9 months, were HIV-infected. During follow-up, 46 children died (median age 23 months) and 113 were lost to follow-up. The majority of children were malnourished. Those <2 years of age had lower weight for age Z-scores (WAZ) than older children (p<0.001). At presentation, 47 per cent were in clinical stage B and two-thirds had moderate or severe CD4+ T cell depletion. Seventeen children had received highly active antiretroviral therapy (HAART), 12 dual and 31 monotherapy. HAART was associated with improved survival compared to dual or monotherapy. Risk of death was reduced from eleven-fold for a WAZ <-4 to four-fold between -2 and -3. There was no association with immunological and clinical classification at entry and risk of mortality. Only 18 per cent of parents were evaluated in the clinic. Non-parental care was documented for 25 per cent of families. CONCLUSIONS A low WAZ is associated with poor survival in children. Nutritional status should receive more attention in HIV disease classification in children. Parent utilization of the clinic was inadequate. Even in the absence of HAART, extended survival in children is possible.
Collapse
|
19
|
O'Hare BAM, Venables J, Nalubeg JF, Nakakeeto M, Kibirige M, Southall DP. Home-based care for orphaned children infected with HIV/AIDS in Uganda. AIDS Care 2005; 17:443-50. [PMID: 16036229 DOI: 10.1080/09540120412331291779] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The primary aim of this paper is to describe an outreach programme from a main state hospital in sub-Saharan Africa, which has been running for three years. This programme is based in Mulago Hospital, Kampala, Uganda and cares for up to 200 children infected with HIV/AIDS in their home. We describe the clinic and how we meet the families and enrol them, the infrastructure of the programme and the personnel involved. Children and their families receive physical, psychological and social care and we describe each aspect of this. The knowledge base about older children with AIDS in Africa is scarce and the secondary aim of this paper is to publish observations that were made while providing care. This includes demographics and the health problems encountered among children living with HIV/AIDS in a resource-poor setting who do not receive antiretroviral medication. Finally, we discuss the strengths and weaknesses of this model of care and the prerequisites to setting up a similar model.
Collapse
Affiliation(s)
- B A M O'Hare
- Department of Paediatrics, University of Wales, Cardiff, UK.
| | | | | | | | | | | |
Collapse
|
20
|
Graham SM. Impact of HIV on childhood respiratory illness: differences between developing and developed countries. Pediatr Pulmonol 2003; 36:462-8. [PMID: 14618636 DOI: 10.1002/ppul.10343] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The main differences of the impact of HIV on childhood respiratory illness between developed and developing countries, and particularly some countries in Africa, are the scale of the problem and the lack of resources to address problems of prevention, diagnosis, and management. Recent data from HIV-infected African children are reviewed and show that the pattern of respiratory disease in these children is not markedly different to the pattern that was reported from the USA and Europe prior to the use of antiretroviral therapy and routine Pneumocystis jiroveci pneumonia (PCP) prophylaxis for HIV-exposed infants. Bacterial pneumonia is very common in all age groups. PCP and cytomegalovirus (CMV) are especially common in infants, and lymphoid interstitial pneumonitis (LIP) is common in older children. One difference is that pulmonary tuberculosis (PTB) is relatively more common in HIV-infected African children. This is likely to reflect the higher prevalence of smear-positive PTB in the region and therefore of exposure/infection compared to developed countries. Autopsy studies have provided a lot of useful data, but more prospective clinical and intervention studies from different parts of the region are needed in order to improve clinical diagnosis and management.
Collapse
MESH Headings
- Child
- Child, Preschool
- Comorbidity
- Developed Countries/statistics & numerical data
- Developing Countries/statistics & numerical data
- Global Health
- HIV Infections/epidemiology
- Humans
- Incidence
- Infant
- Lung Diseases, Interstitial/diagnosis
- Lung Diseases, Interstitial/epidemiology
- Pneumonia, Bacterial/epidemiology
- Pneumonia, Bacterial/prevention & control
- Pneumonia, Pneumocystis/diagnosis
- Pneumonia, Pneumocystis/epidemiology
- Pneumonia, Pneumocystis/prevention & control
- Pneumonia, Viral/epidemiology
- Respiratory Tract Diseases/diagnosis
- Respiratory Tract Diseases/epidemiology
- Respiratory Tract Diseases/prevention & control
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/therapy
Collapse
Affiliation(s)
- S M Graham
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme and Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.
| |
Collapse
|
21
|
Chintu C, Mudenda V, Lucas S, Nunn A, Lishimpi K, Maswahu D, Kasolo F, Mwaba P, Bhat G, Terunuma H, Zumla A. Lung diseases at necropsy in African children dying from respiratory illnesses: a descriptive necropsy study. Lancet 2002; 360:985-90. [PMID: 12383668 DOI: 10.1016/s0140-6736(02)11082-8] [Citation(s) in RCA: 222] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Accurate information about specific causes of death in African children dying of respiratory illnesses is scarce, and can only be obtained by autopsy. We undertook a study of children who died from respiratory diseases at University Teaching Hospital, Lusaka, Zambia. METHODS 137 boys (93 HIV-1-positive, 44 HIV-1-negative], and 127 girls (87 HIV-1-positive, 40 HIV-1-negative) aged between 1 month and younger than 16 years underwent autopsy restricted to the chest cavity. Outcome measures were specific lung diseases, stratified by age and HIV-1 status. FINDINGS The presence of multiple diseases was common. Acute pyogenic pneumonia (population-adjusted prevalence 39.1%, 116/264), Pneumocystis carinii pneumonia (27.5%, 58/264), tuberculosis (18.8%, 54/264), and cytomegalovirus infection (CMV, 20.2%, 43/264) were the four most common findings overall. The three most frequent findings in the HIV-1-negative group were acute pyogenic pneumonia (50%), tuberculosis (26%), and interstitial pneumonitis (18%); and in the HIV-1-positive group were acute pyogenic pneumonia (41%), P carinii pneumonia (29%), and CMV (22%). HIV-1-positive children more frequently had P carinii pneumonia (odds ratio 5.28, 95% CI 2.12-15.68, p=0.0001), CMV (7.71, 2.33-40.0, p=0.0002), and shock lung (4.15, 1.20-22.10, p=0.03) than did HIV-1-negative children. 51/58 (88%) cases of P carinii pneumonia were in children younger than 12 months, and five in children aged over 24 months. Tuberculosis was common in all age groups, irrespective of HIV-1 status. INTERPRETATION Most children dying from respiratory diseases have preventable or treatable infectious illnesses. The presence of multiple diseases might make diagnosis difficult. WHO recommendations should therefore be updated with mention of HIV-1-positive children. Improved diagnostic tests for bacterial pathogens, tuberculosis, and P carinii pneumonia are urgently needed.
Collapse
Affiliation(s)
- Chifumbe Chintu
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Over one million children world-wide are living with HIV infection and respiratory disease is the commonest cause of morbidity and mortality in these children. The initial presentation of respiratory infection is usually in infancy or early childhood. There is enormous potential to prevent childhood HIV infection that is being realised in industrialised countries but not yet elsewhere. Increasingly, therefore, the burden of HIV disease is in children living in or from non-industrialised countries. This review describes and contrasts the pattern of respiratory infection from both regions. This pattern has changed with the implementation of PCP prophylaxis and the availability of potent antiretroviral therapy for children in resource-rich countries, such as the UK. More data are required from resource-poor regions such as tropical Africa, but it is clear that the major differences reflect greater background risk for respiratory infection and very limited management options rather than specific aetiology.
Collapse
Affiliation(s)
- Stephen M Graham
- Wellcome Trust Research Laboratory and Department of Paediatrics, College of Medicine, University of Malawi, Malawi.
| | | |
Collapse
|