Measles in hospitalized African children with human immunodeficiency virus

Comparative seroprevalence of measles virus immunoglobulin M antibodies in children aged 0-8 months and a control population aged 9-23 months presenting with measles-like symptoms in selected hospitals in Kaduna State

Background

Measles remains the leading cause of vaccine-preventable childhood mortality in developing countries, with its greatest incidence in children younger than 2 years of age. The aim of this study was to determine the seroprevalence of measles virus in children (aged 0–8 months) and older children (aged 9–23 months) presenting with measles-like symptoms.

Methods

A total of 273 blood samples comprising 200 from children aged 0–8 months and 73 from children aged 9–23 months were collected and analyzed for measles virus IgM antibodies by enzyme-linked immunosorbent assay.

Results

An overall prevalence of 21.2% was obtained, with a prevalence of 6.5% in children aged 0–8 months and 61.6% in children aged 9–23 months. The prevalence of measles virus increased with age in children aged 0–8 months and decreased with age in older children (aged 9–23 months), showing a significant association between measles virus and age of the child (P=0.000). A higher prevalence was found in females (27.5%) than in males (16.3%) and this difference was significant (odds ratio 1.942, P=0.025). There was no significant association with the level of parental education, parental occupation, or number of children in the family (P>0.05). With respect to children’s vaccination status and breastfeeding, there was a significant association (P<0.05). The marital status of the family, place of residence, and household size showed no significant association with the prevalence of measles virus. However, a significant association was observed in relation to maternal measles history (odds ratio 2.535, P=0.005) and maternal vaccination status (odds ratio 1.791, P=0.049), as well as between measles virus infection and all presenting symptoms, except for vomiting, malaria, typhoid, and pneumonia, which showed no significant association (P>0.05).

Conclusion

The findings of this study confirm the presence of measles virus infection in children aged 0–8 months.

Immune responses to measles and tetanus vaccines among Kenyan human immunodeficiency virus type 1 (HIV-1)-infected children pre- and post-highly active antiretroviral therapy and revaccination

BACKGROUND

: HIV-1-infected children have lower response rates after measles and tetanus immunization than uninfected children. We determined the extent to which highly active antiretroviral therapy (HAART) augments vaccine immunity and promotes responses to revaccination.

METHODS

: Previously immunized, antiretroviral-naive HIV-1-infected children were evaluated for immunity against measles and tetanus. After 6 months on HAART, children meeting CD4% criteria (>15%) who were persistently antibody negative were revaccinated and immunity was reassessed.

RESULTS

: At enrollment, among 90 children with mean age of 4.9 years, 67% had negative measles IgG and 22% negative tetanus IgG. Among 62 children completing 6 months on HAART, 17 (40%) of 43 without protective measles IgG converted and 10 (53%) of 19 positive children lost measles responses (P = 0.3). Children who lost responses had significantly lower measles antibody concentrations than those who remained measles IgG positive during follow-up (7.1 vs. 20.3 mg/mL; P = 0.003). Three (23%) of 13 children negative for tetanus IgG spontaneously seroconverted on HAART, while 15 (31%) of 49 children lost tetanus antibody (P = 0.008). There was a nonsignificant trend for an association between spontaneous measles seroconversion and lower baseline HIV-1 viral load (P = 0.06). Tetanus seroconversion was associated with older age (P = 0.03). After revaccination, positive responses were observed in 78% and 75% of children reimmunized against measles and tetanus, respectively.

CONCLUSIONS

: After 6 months of HAART, more than half of previously immunized children still lacked positive measles antibody. With increased use of HAART in pediatric populations, revaccination against measles and tetanus should be considered to boost response rates and immunization coverage.

HIV type 1 infection is a risk factor for mortality in hospitalized Zambian children with measles

BACKGROUND

Measles remains a significant cause of vaccine-preventable mortality in sub-Saharan Africa, yet few studies have investigated risk factors for measles mortality in regions of high human immunodeficiency virus type 1 (HIV-1) prevalence.

METHODS

Between January 1998 and July 2003, children with clinically diagnosed measles who were hospitalized at the University Teaching Hospital in Lusaka, Zambia, were enrolled in an observational study. Demographic and clinical information was recorded at enrollment and at discharge or death. Measles was confirmed by detection of antimeasles virus immunoglobulin M antibodies, and HIV-1 infection was confirmed by detection of HIV-1 RNA.

RESULTS

Of 1474 enrolled children, 1227 (83%) had confirmed measles and known HIV-1 infection status. Almost one-third of the HIV-1-infected children with measles were <9 months of age, the age of routine measles vaccination, compared with one-fourth of the uninfected children (P = .07). Death occurred during hospitalization in 23 (12.2%) of the HIV-1-infected children and 45 (4.3%) of the HIV-1-uninfected children (p < .001) with measles. After adjusting for age, sex, and measles vaccination status, HIV-1 infection (odds ratio, 2.5; 95% confidence interval, 1.4-4.6), < or =8 years of maternal education (odds ratio, 2.4; 95% confidence interval, 1.2-4.8), and the presence of a desquamating rash (odds ratio, 2.2, 95% confidence interval, 1.3-3.6) were significant predictors of mortality due to measles.

CONCLUSIONS

In a region of high HIV-1 prevalence, coinfection with HIV-1 more than doubled the odds of death in hospitalized children with measles. Increased mortality among HIV-1-infected children is further evidence that greater efforts are necessary to reduce transmission of the measles virus in regions of high HIV-1 prevalence.

The impact of HIV infection on childhood pneumonia: comparison between developed and developing regions

Respiratory disease is the commonest cause of morbidity and mortality in HIV-infected children. While the pattern of HIV-related pneumonia in African adults is well documented and is recognised as quite different from that which occurs among HIV-infected adults in high-income regions, less is known of the situation in children. Most children are infected by mother-to-child transmission and presentation of HIV-related pneumonia is often in infancy or early childhood, an age group in which confirmation of the cause of pneumonia is difficult. However, aetiological data are important. Poor response of the infant with severe pneumonia to standard antibiotic (such as chloramphenicol) or of the older child with chronic pneumonia to anti-tuberculosis treatment are two very common clinical dilemmas that many Malawian health workers would recognise. This review aims to present the available data relevant to Malawi, contrast with experience from the developed world and to describe common HIV-related pneumonias such as PCP and LIP. Unlike for adults, the pattern of HIV-related pneumonia in Malawian children may not be so different in cause from that described for children in developed countries prior to the use of PCP prophylaxis and anti-retroviral therapies. The most important contrast is the higher prevalence and poorer outcome.

HIV disease and respiratory infection in children

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.

Effect of highly active antiretroviral therapy on the serological response to additional measles vaccinations in human immunodeficiency virus-infected children

Children infected with human immunodeficiency virus (HIV) often lose their vaccine-induced antibody to measles virus. Before highly active antiretroviral therapy (HAART), an additional immunization against measles infrequently resulted in protective antibodies. The antibody response to an additional measles-mumps-rubella (MMR) vaccination was compared in 28 HIV-infected children who lacked protective antibody to measles virus and were undergoing HAART or non-HAART regimens. Serostatus was measured by automated enzyme-linked immunoassay. Nine (64.3%) of 14 children undergoing HAART, compared with 3 (21.4%) of 14 in the non-HAART group, had antibody to measles virus after the additional vaccination with MMR (P=.027). The groups showed no significant difference in CD4 cell values. Ten of 14 HAART patients had undetectable levels of HIV. The mean HIV load for the HAART group was 27,700 copies/mL (median, <400 copies/mL); for the non-HAART group, it was 86,000 copies/mL (median, 9000 copies/mL). Thus, HAART improves the response to an additional MMR vaccination, which is consistent with immune system reconstitution.

Disease in children infected with HIV in Abidjan, Côte d'Ivoire

OBJECTIVE

To document the range of disease in African children infected with HIV.

DESIGN

Necropsy results in consecutive children aged 1 month or more who were HIV positive and in children who were HIV negative for comparison; IgA western blots on serum samples from children under 2 years of age who were positive for HIV-1 to test the validity of routine HIV serology.

SETTING

Largest hospital in Abidjan, Côte d'Ivoire.

SUBJECTS

78 children who were HIV positive and 77 children who were HIV negative on whom a necropsy was performed; their median ages at death were 18 and 21 months respectively. 36 HIV positive children and 29 HIV negative children were 1-14 months old; 42 HIV positive and 48 HIV negative children were > or = 15 months old.

MAIN OUTCOME MEASURES

Cause of death and prevalence of diseases confirmed pathologically.

RESULTS

Respiratory tract infections were more common in HIV positive than in HIV negative children (73 (94%) v 52 (68%); P < 0.05), and were aetiologically heterogeneous. Pneumocystis carinii pneumonia was found in 11 out of 36 (31%) HIV positive children aged < 15 months, but in no HIV negative children. Among older children measles was more common in HIV positive children (8/42 (19%) v 2/48 (4%); P < 0.06). Pyogenic meningitis was present in similar proportions of HIV positive and HIV negative children aged < 15 months (7/36 (19%) and 7/29 (24%)). In HIV positive children tuberculosis (1/78), lymphocytic interstitial pneumonitis (1/78), and HIV encephalitis (2/78) were rare.

CONCLUSIONS

There is greater overlap between diseases associated with HIV infection and other common health problems in African children than there is in adults. Compared with adults, HIV positive children had a high prevalence of P carinii pneumonia and a low prevalence of tuberculosis. Measles, but not malaria, was associated with HIV infection.

Safety, tolerance, and pharmacokinetics of systemic ribavirin in children with human immunodeficiency virus infection

Eleven pediatric patients, aged 1 to 10 years and with symptomatic human immunodeficiency virus infection, were treated with 6 or 10 mg of oral ribavirin per kg of body weight daily for 60 days. Safety and pharmacokinetic parameters were monitored; five children had comprehensive pharmacokinetic evaluations. The children tolerated the drug well, and treatment was not associated with any clinically significant adverse effects. Peak concentrations in plasma of 2.5 and 3.0 microM were reached at 90 min after single oral doses of 6 and 10 mg/kg, respectively. The mean systemic availability of oral ribavirin was 42.3%. After 60 days of ribavirin administration, mean trough concentrations in plasma of 2.6 and 4.1 microM were obtained. Ribavirin penetrated well into the cerebrospinal fluid, achieving 70% of the concentration in plasma at steady state.