Childhood Cancers in Zimbabwe: A 10 year review of the Zimbabwe National Cancer Registry data

OBJECTIVE

To document the pattern of cancer in children (0-14 years) registered in the Zimbabwe National Cancer Registry from 2000-2009.

DESIGN

Retrospective descriptive analysis.

METHODS

Analysis of data from the Zimbabwe National Cancer Registry for the period 2000-2009.

SETTING

The Zimbabwe National Cancer Registry.

RESULTS

Childhood Cancer constituted 3.8% of all malignancies recorded at the cancer registry during the study period. The common cancers were: Wilm's Tumour 286 (16.2%), Kaposi Sarcoma 277 (15.7%), Retinoblastoma 231 (13.1%), Non- Hodgkins lymphoma 182 (10.3%), leukemia 158 (8.9%), brain and nervous tissue 107 (6.1%), connective tissue 105 (5.9%), bone 97 (5.5%), Hodgkins lymphoma 57 (3.2%), Non-melanoma skin 33 (1.9%). All the other remaining cancers were 233 (13.2%). Burkits lymphoma constituted only 2% of all cancers. The noted pattern of cancers in this study were compared to patterns from other countries and similarities and differences are discussed.

CONCLUSION

This study showed high incidence rates of Nephroblastoma, Retinoblastoma and Kaposi sarcoma. In contrast to high income countries leukemia and brain tumours are more prevalent in older age group. Compared to other countries in Africa, Burkits lymphoma was rare. Further research is required to identify factors that influence relative frequencies in childhood cancers in Zimbabwe. Findings from this study provide baseline data for future studies.

Rhabdomyosarcoma of the orbit in a four months old infant in Zimbabwe: A case report

Infants younger than one year of age with Rhabdomyosarcoma appear to have worse prognosis compared to older children due partly to high rates of local failure. We report a 4 months old infant with orbital rhabdomyosarcoma with poor outcome. Reluctance to use aggressive local control measures and suboptimal chemotherapy dosing are significant contributory factors. Call is made for need for more studies to determine appropriate local therapy in infants with rhabdomyosarcoma.

Patterns of Retinoblastoma in Zimbabwe: 2000-2009

OBJECTIVE

To document the pattern of retinoblastoma in children in Zimbabwe for the period 2000-2009.

DESIGN

Retrospective study.

METHODS

Analysis of data from the Zimbabwe National Cancer registry and records of patients admitted to the Paediatric Oncology unit. Data collected from cancer registry were basis of diagnosis, age and gender. Data from the patients medical records included clinical presentation, time to diagnosis and treatment.

SETTINGS

The Zimbabwe National Cancer Registry and Paediatric Oncology Unit at Parirenyatwa Tertiary Hospital.

RESULTS

196 patients with retinoblastoma were registered at the cancer registry over the study period. The diagnosis was confirmed histologically on 89% of the cases and in 7% the diagnosis was based on clinical grounds. The age ranged from less than one month to 7 years with median age of 24 months. Males were 111 (56%) with male:female ratio of 1.3:1. Forty three patients (84%) had unilateral and 8 (16%) bilateral disease. Medical records were retrieved from only 54 /196 cases (27.5%). The commonest clinical presentation was proptosis 35/54 (65%). Leucocoria was present in 14/54 (26%). Time interval between first symptoms and diagnosis ranged from less than one month to 24 months with mean duration of 7.7 months (SD = 6.9). Enucleation was performed on 33/ 54 (61%), exenteration on 20/54 (37%) chemotherapy was given to 34/54 (63%) and only 6/54 (11%) received radiotherapy.

CONCLUSION

Retinoblastoma is the third commonest registered malignancy of childhood in Zimbabwe, characaterised by late presentation and poor access to therapy.

Breaking the silence: an HIV-related educational intervention for medical students in Zimbabwe

PROBLEM

A culture of silence surrounding HIV is a major contributor to continued HIV transmission and poor care for people living with HIV/AIDS.

AIM

To encourage medical leadership in addressing stigma and fear related to HIV at individual and community levels

OBJECTIVE

To pilot a mini-course for final year medical students in Zimbabwe that demonstrates stigma-reduction knowledge and skills needed to communicate information about HIV to patients, to address ethical implications of testing versus not testing for HIV, to increase awareness of the medical and preventive benefits of knowing one's HIV status and showing people how to cope with the emotional burden of dealing with HIV everyday.

DESIGN

Methods of proven effectiveness for training medical students in ethics and communication skills were used such as presentations by well respected role models and opinion leaders, role-playing, small group discussions, accompanied by materials indicating local resources, in three afternoon teaching sessions.

SETTING

University of Zimbabwe College of Medicine.

PARTICIPANTS

60 medical students, six lecturers, two facilitators and a group of actors.

MAIN OUTCOME MEASURES

Evaluation of the course by students showed appreciation of the course as measured on a scale of one to five for content and usefulness with requests for further inputs into the curriculum; model of mini-course that can be used by other medical schools in the southern Africa region and other areas of emerging HIV epidemics.

CONCLUSIONS

A brief educational intervention can help medical students to cope with the extraordinary challenge of providing care in high HIV prevalence countries and may contribute towards better leadership in addressing HIV epidemics.

A randomized control trial of an Ultra-Short zidovudine regimen in the prevention of perinatal HIV transmission in rural Zimbabwe

OBJECTIVE

To assess the practicality and effectiveness of an Ultra-Short zidovudine regimen for prevention of perinatal HIV transmission in rural Zimbabwe.

DESIGN

Double-blinded placebo-controlled randomized clinical trial.

SETTING

The Salvation Army Howard Hospital, a district hospital in rural Zimbabwe.

SUBJECTS

222 HIV positive pregnant women presenting for antenatal care prior to 36 weeks were randomized. Twenty nine women were lost to follow up.

INTERVENTION

In the Thai regimen, mothers received zidovudine (300 mg po bid) from 36 weeks gestation until labour, and zidovudine (300 mg po q3h) during labour, and the neonates received a placebo. In the Ultra-Short regimen, the mothers received a placebo from 36 weeks to labour, then zidovudine (300 mg po q3h) in labour. The neonates received zidovudine (2 mg/kg po qid) for the first three days of life.

MAIN OUTCOME MEASURE

Infant HIV RNA status at six weeks of life.

RESULTS

Results were available for 90 infants from the Thai group and 89 infants from the Ultra-Short group. Infant HIV seroconversion rates at six weeks of life were 18.9% (95%CI 10.8 to 27.0) with the Thai regimen, and 15.7% [95% Confidence Interval (CI) 8.1 to 23.4] with the Ultra-Short regimen. The upper bound of seroconversion in the Ultra-Short group was lower than the 25% seroconversion boundary that was specified to show equivalence.

CONCLUSIONS

Although the Ultra-Short regimen has equivalent efficacy to the Thai regimen, it also has many practical advantages. Ultra-Short is thus a preferable protocol.

Antibiotic use in infants hospitalised with HIV-related pneumonia in Harare, Zimbabwe

OBJECTIVE

To describe the clinical features of infants admitted with HIV-related pneumonia and to describe antibiotic use in relation to recommended treatment guidelines.

DESIGN

Case series.

SETTING

Paediatric medical wards of two University Teaching Hospitals, Parirenyatwa and Harare Central Hospitals.

SUBJECTS

100 infants aged one to 12 months admitted with HIV-related pneumonia.

MAIN OUTCOME MEASURES

Mortality and antibiotic use in the two hospitals.

METHODS

Records of 100 infants admitted for 48 hours or more with features of HIV-related pneumonia were analysed for clinical features and antibiotic use.

RESULTS

77% of patients were in the first six months of life with a peak age of two months and a median of four months (Q1 = 2, Q3 = 6). The median age of children admitted to Parirenyatwa hospital was 5.5 months (Q1 = 3, Q3 = 7) and in Harare hospital it was three months (Q1 = 2, Q3 = 6). The difference was statistically significant, p = 0.035. Fifty four percent of cases received penicillin, aminoglycoside and cotrimoxazole and overall only 30% of prescriptions complied with Essential Drug List of Zimbabwe (EDLIZ) recommendations for treatment of severe pneumonia in children with HIV infection. The overall mortality was 27.0%. The mortality in Harare Central Hospital was 40.4% and 15.7% in Parirenyatwa. The difference was statistically significant p = 0.005.

CONCLUSION

The difficulties in establishing the cause of the pneumonia in infants with HIV infection was a contributory factor to lack of adherence to standard treatment guidelines. In countries with a high prevalence of HIV infection and with limited resources, a clinical case definition for Pneumocystis carinii pneumonia (PCP) is required as a measure to provide treatment for infants with HIV related pneumonia which is evidence based. This approach will also promote rational antibiotic prescribing and will contain cost.

The costs of HIV/AIDS care at government hospitals in Zimbabwe

According to official figures, HIV infection in Zimbabwe stood at 700 000-1 000 000 in 1995, representing 7-10% of the population, with even higher expected numbers in 2000. Such high numbers will have far reaching effects on the economy and the health care sector. Information on costs of treatment and care of HIV/AIDS patients in health facilities is necessary in order to have an idea of the likely costs of the increasing number of HIV/AIDS patients. Therefore, the present study estimated the costs per in-patient day as well as per in-patient stay for patients in government health facilities in Zimbabwe with special emphasis on HIV/AIDS patients. Data collection and costing was done in seven hospitals representing various levels of the referral system. The costs per in-patient day and per in-patient stay were estimated through a combination of two methods: bottom-up costing methodology (through an in-patient note review) to identify the direct treatment and diagnostic costs such as medication, laboratory tests and X-rays, and the standard step-down costing methodology to capture all the remaining resources used such as hospital administration, meals, housekeeping, laundry, etc. The findings of the study indicate that hospital care for HIV/AIDS patients was considerably higher than for non-HIV/AIDS patients. In five of the seven hospitals visited, the average costs of an in-patient stay for an HIV/AIDS patient were found to be as much as twice as high as a non-HIV/AIDS patient. This difference could be attributed to higher direct costs per in-patient day (medication, laboratory tests and X-rays) as well as longer average lengths of stay in hospital for HIV/AIDS patients compared with non-infected patients. Therefore, the impact on hospital services of increasing number of HIV/AIDS patients will be enormous.

Paralytic poliomyelitis associated with live oral poliomyelitis vaccine in child with HIV infection in Zimbabwe: case report

OBJECTIVE

To describe a complication of oral vaccination with live, attenuated poliomyelitis virus in a child infected with HIV.

DESIGN

Case report.

SETTING

Teaching hospital in Harare, Zimbabwe.

SUBJECTS

A boy of 41/2 years and his mother.

MAIN OUTCOME MEASURES

Results of clinical and laboratory investigations.

RESULTS

Two weeks after receiving the second dose of oral poliomyelitis vaccine during national immunisation days the child developed paralysis of the right leg. He had a high titre of antibodies against poliovirus type 2, as well as antibodies against HIV-1, a low CD4 count, a ratio of CD4 to CD8 count of 0.47, and hypergammaglobulinaemia. He did not have any antibodies against diphtheria, tetanus, or poliovirus types 1 and 3, although he had been given diphtheria, tetanus, and pertussis and oral polio vaccines during his first year and a booster of the diphtheria, tetanus, and pertussis vaccine at 24 months. He had no clinical symptoms of AIDS, but his mother had AIDS and tuberculosis.

CONCLUSION

Paralytic poliomyelitis in this child with HIV infection was caused by poliovirus type 2 after oral poliomyelitis vaccine.

Seroprevalence of human immunodeficiency virus type 1 infection in childhood malignancy in Zimbabwe

OBJECTIVES

To determine the association between malignancy and the Human Immunodeficiency Virus type 1 (HIV-1) infection in children.

DESIGN

Case series.

SETTING

The Paediatric Oncology Unit at Parirenyatwa Teaching Hospital.

SUBJECTS

76 consecutive newly diagnosed cases of malignancy between May 15 and November 15 1997.

MAIN OUTCOME MEASURES

HIV serostatus.

RESULTS

27 out of 64 children were HIV seropositive, giving a seroprevalance rate of 42.2% (95% CI 30.1 to 54.3%). The four commonest diagnosed malignancies were non-Hodgkin's lymphoma (22.4%), acute lymphoblastic leukemia (19.7%), Wilm's tumour (19.7%) and Kaposi's sarcoma (15.8%). These tumours accounted for 77.6% of all malignancies. Nine of a total of 17 patients with non-Hodgkin's lymphoma were HIV positive and all 12 patients with Kaposi's were also HIV positive. No cases of Burkitt's lymphoma were seen. Although there was increased incidence of non-Hodgkin's lymphoma (NHL) compared to previous years, there was no significant association with the HIV serostatus. A significant association between Kaposi's sarcoma (KS) and HIV serostatus was observed (p < 0.001). Children with KS were more likely to be HIV seropositive. Children with acute lymphoblastic leukemia (ALL) and Wilm's tumours (WT) were 83 and 88% less likely to be HIV seropositive, respectively.

CONCLUSIONS

HIV has transformed the pattern of childhood malignancy in Zimbabwe. The two tumours mostly affected are NHL and KS.

Bacillary angiomatosis in an HIV positive child. First case report in Zimbabwe

Bacillary angiomatosis is a recently recognised condition that is seen mainly in adult patients with the acquired immunodeficiency syndrome (AIDS). Its importance lies in the fact that it can be confused with Kaposi's sarcoma which is now the commonest malignant condition in male adult patients in this country. Unlike Kaposi's sarcoma however, it is curable. Ours is the first reported case of bacillary angiomatosis in Zimbabwe.

Cor pulmonale in children with human immunodeficiency virus infection

A cross-sectional echocardiographic study of 50 black Zimbabwean children with clinical human immunodeficiency virus (HIV) infection was carried out. The median age was 9 months. Seventy per cent had chronic cough, 60% respiratory distress and 40% cyanosis. Sixty per cent had pericardial effusion and 48% right ventricular hypertrophy (RVH) and dilation. However, the clinical diagnosis of heart failure was difficult as most of these children (80%) had hepatomegaly. These findings suggest that respiratory disease plays a role in the causation of RVH in these children. As cardiac causes of RVH were absent, this was presumed to be due to cor pulmonale. HIV-infected children presenting with respiratory distress may have clinically unapparent cor pulmonale. Early and appropriate management may by beneficial.

Haematologic features of the human immunodeficiency virus (HIV) infection in Black children in Harare

Forty six Black Zimbabwean children aged between three months and seven years who were admitted into Parirenyatwa Central Hospital with serologically positive and symptomatic HIV infection were investigated for their haematologic profiles. Tests done included full blood counts, manual white cell differential counts, coagulation screening tests and bone marrow aspiration in clinically indicated cases. Anaemia was found in 84 pc, leucocytosis in 60 pc and thrombocytopaenia in 30 pc of the cases. In contrast to reports in adults leucopaenia or neutropaenia were not seen. Coagulation profiles were mostly normal but presumptive diagnosis of circulating coagulation inhibitor was made in one case. Morphological changes suggestive of myeloid dysplasia and in particular dysgranulopoiesis were commonly seen. Bone marrow aspirates examined in eight of the children all showed hyper or normal cellularity with adequate and productive megakaryocytes.

Acute poisoning in a paediatric intensive care unit in Harare

Forty two cases of acute poisoning were studied retrospectively over a two year period (1990 to 1991, inclusive) in the paediatric Intensive Care Unit (ICU), at Parirenyatwa Hospital in Harare. This formed 8.6 pc of the total admissions into the unit over the same period. The four commonest types of poisons were organophosphates, 38.1 pc; paraffin, 26.2 pc; traditional medicines (muti), 14.3 pc and miscellaneous drugs, such as chloroquine, aspirin, chloropromazine, diazepam and gama-benzene, 9.5 pc. The results suggest poor living conditions, local beliefs, customs and ignorance of the dangers of chemicals, as the risk factors associated with acute poisoning. Eighty eight pc of all admissions were children below the age of five years. The mortality rate in this series was 21 pc. Compared to the overall mortality rate of all ICU admissions of 30.9 pc over the same period, death due to acute poisoning was 1.8 pc of all ICU deaths.