Tuberculosis and HIV infection in children in Abidjan, Côte d'Ivoire

Tuberculosis and HIV co-infection in Congolese children: risk factors of death

Introduction

Human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading causes of death from infectious disease worldwide. The prevalence of HIV among children with TB in moderate to high prevalence countries ranges between 10% and 60%. This study aimed to determine the prevalence of HIV infection among children treated for TB in Directly Observed Treatment Short-Course (DOTS) clinics in Lubumbashi and to identify risk of death during this co-infection.

Methods

This is a cross-sectional study of children under-15, treated for tuberculosis from January 1, 2013 to December 31, 2015. Clinical, paraclinical and outcome data were collected in 22 DOTS of Lubumbashi. A statistical comparison was made between dead and survived HIV-infected TB children. We performed the multivariate analyzes and the significance level set at p-value <0.05.

Results

A total of 840 children with TB were included. The prevalence of HIV infection was 20.95% (95% CI: 18.34-23.83%). The mortality rate was higher for HIV-infected children (47.73%) compared to HIV-uninfected children (17.02%) (p<0.00001). Age <5 years (aOR=6.50 [1.96-21.50]), a poor nutritional status (aOR=23.55 [8.20-67.64]), and a negative acid-fast bacilli testing (aOR=4.51 [1.08-18.70]) were associated with death during anti-TB treatment.

Conclusion

TB and HIV co-infection is a reality in pediatric settings in Lubumbashi. High mortality highlights the importance of early management.

HIV Prevalence Among Tuberculosis Patients in Sub-Saharan Africa: A Systematic Review and Meta-analysis

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.

The impact of HIV and antiretroviral therapy on TB risk in children: a systematic review and meta-analysis

BACKGROUND

Children (<15 years) are vulnerable to TB disease following infection, but no systematic review or meta-analysis has quantified the effects of HIV-related immunosuppression or antiretroviral therapy (ART) on their TB incidence.

OBJECTIVES

Determine the impact of HIV infection and ART on risk of incident TB disease in children.

METHODS

We searched MEDLINE and Embase for studies measuring HIV prevalence in paediatric TB cases ('TB cohorts') and paediatric HIV cohorts reporting TB incidence ('HIV cohorts'). Study quality was assessed using the Newcastle-Ottawa tool. TB cohorts with controls were meta-analysed to determine the incidence rate ratio (IRR) for TB given HIV. HIV cohort data were meta-analysed to estimate the trend in log-IRR versus CD4%, relative incidence by immunological stage and ART-associated protection from TB.

RESULTS

42 TB cohorts and 22 HIV cohorts were included. In the eight TB cohorts with controls, the IRR for TB was 7.9 (95% CI 4.5 to 13.7). HIV-infected children exhibited a reduction in IRR of 0.94 (95% credible interval: 0.83-1.07) per percentage point increase in CD4%. TB incidence was 5.0 (95% CI 4.0 to 6.0) times higher in children with severe compared with non-significant immunosuppression. TB incidence was lower in HIV-infected children on ART (HR: 0.30; 95% CI 0.21 to 0.39). Following initiation of ART, TB incidence declined rapidly over 12 months towards a HR of 0.10 (95% CI 0.04 to 0.25).

CONCLUSIONS

HIV is a potent risk factor for paediatric TB, and ART is strongly protective. In HIV-infected children, early diagnosis and ART initiation reduces TB risk.

TRIAL REGISTRATION NUMBER

CRD42014014276.

Changing trends in childhood tuberculosis

Several changes have been observed in the epidemiology, clinical manifestations, diagnostic modalities and treatment of tuberculosis. Emergence of HIV epidemic and drug resistance have posed significant challenges. With increase in the number of diseased adults and spread of HIV infection, the infection rates in children are likely to increase. It is estimated that in developing countries, the annual risk of tuberculosis infection in children is 2.5%. Nearly 8-20% of the deaths caused by tuberculosis occur in children. Extra pulmonary tuberculosis has increased over last two decades. HIV infected children are at an increased risk of tuberculosis, particularly disseminated disease. In last two decades, drug resistant tuberculosis has increased gradually with emergence of MDR and XDR-TB. The rate of drug resistance to any drug varied from 20% to 80% in different geographic regions. Significant changes have occurred in TB diagnostics. Various diagnostic techniques such as fluorescence LED microscopy, improved culture techniques, antigen detection, nucleic acid amplification, line probe assays and IGRAs have been developed and evaluated to improve diagnosis of childhood tuberculosis. Serodiagnosis is an attractive investigation but till date none of the tests have desirable sensitivity and specificity. Tests based on nucleic acid amplification are a promising advance but relatively less experience in children, need for technical expertise and high cost are limiting factors for their use in children with tuberculosis. Short-course chemotherapy for childhood tuberculosis is well established. Directly observed treatment strategy (DOTS) have shown encouraging result. DOTS plus strategy has been introduced for MDR TB.

Addressing Tuberculosis in the Context of Malnutrition and HIV Coinfection

Background

Tuberculosis is the second leading cause of infectious disease mortality (1.8 million/year), after HIV/AIDS. There are more than 9 million new cases each year. One-third of the world's population, and 50% of adults in sub-Saharan Africa, South Asia, and South-East Asia, are infected, representing an enormous pool of individuals at risk for developing the disease. The situation is complicated by the HIV/AIDS pandemic, widespread undernutrition, smoking, diabetes, increased mobility, and emergence of multi- and extensively drug-resistant tuberculosis.

Objective

To review the scientific evidence about the interactions among tuberculosis, nutrition, and HIV coinfection.

Results

HIV infection and malnutrition lower immunity, increasing the risk of reactivation tuberculosis and primary progressive disease. Having either tuberculosis or HIV infection causes weight loss. Malnutrition markedly increases mortality among both tuberculosis and HIV/AIDS patients and should be treated concurrently with treatment of the infections. Tuberculosis treatment is a prerequisite for nutritional recovery, in addition to intake of nutrients required for rebuilding tissues, which is constrained in food-insecure households. Additional pharmaceutical treatment to reduce the catabolic impact of inflammation or promote growth may be needed. Specific nutrients can contribute to faster sputum smear clearance, which is important for reducing transmission, as well as faster weight gain when combined with an adequate diet. Adequate nutrition and weight gain in undernourished populations might reduce the incidence of tuberculosis.

Conclusions

The many risk factors for the development of tuberculosis need to be addressed simultaneously, especially HIV/AIDS and food insecurity and undernutrition. For stronger evidence-based guidelines, existing recommendations and clinical applications need to be more widely applied and evaluated.

[Child tuberculosis at the teaching hospital of Brazzaville from 1995 to 2003]

In the paediatric service of the teaching hospital of Brazzaville, 582 files of children hospitalized were studied from January 1995 to December 2003. To determine tuberculosis frequency among sickle cell children and estimate the clinical and paraclinical aspects, a case-control study of tubercular patients with HIV negative serology was carried out by comparing at the same time a cohort of 75 sickle cell patients versus 125 patients without sickle cell disease. The results of these studies are as follows. The main assessment is the high frequency of tuberculosis. In 1995 the tuberculosis rate reaches 8%, in 2003 it was up to 13.6%, and 20.6% in 2000 due to the serious consequences of the recurrent wars between 1993 and 1999. Another cause of that high frequency is the rate of HIV/aids patients with a frequency of 2.5% of hospitalization ranging from 1.6 to 3.2%, among them 35% of the tubercular patients were seropositive. The tuberculosis prevalence was 7.4% among sickle cell patients versus 14.2% among control patients. Infection was more often identified in control patients (51.2%) than in sickle cell patients (24%). 68% of the parents were really poor and 18.5% of the children were evicted from their home by war. The pulmonary localizations were prevailing in groups of patients with sickle cell disease as well as in group of control patients. Pleuritis was observed in 8% of the patients with sickle cell disease versus 16.8% for control patients (P = 0.02). No patient with sickle cell disease had a miliary. Anergia to tuberculin test was reported in 35.8% sickle cell patients versus 10.4% for the control patients (P = 0.001). Tuberculosis prevalence is higher among control patients than in sickle cell patients. The high proportion of clinical and paraclinical data of tuberculosis did not significantly differ from the two groups. Evolution was good for 98% of the patients, 1.4% of them died; 74% of deceased patients were affected by HIV/aids.

Diagnosed tuberculosis during the follow-up of a cohort of human immunodeficiency virus-infected children in Abidjan, Côte d'Ivoire: ANRS 1278 study

INTRODUCTION

Most data on tuberculosis in human immunodeficiency virus (HIV)-infected children in Africa come from hospital-based and cross-sectional studies.

OBJECTIVES

To estimate the incidence of tuberculosis in HIV-infected children participating in an observational cohort.

METHODS

HIV-infected children in Abidjan, Côte d'Ivoire, are followed in a prospective cohort. At enrollment, all children had a physical examination, CD4 lymphocyte counts, chest radiograph and a tuberculin test. Quarterly follow-up visits are organized. All patients with suspected tuberculosis undergo specific investigations including gastric aspiration and culture. All isolates are tested for susceptibility.

RESULTS

From October 2000 to December 2003, 129 girls and 153 boys were recruited. Of children without a current or previous diagnosis of tuberculosis, 6.5% (13 of 199) had a tuberculin test result of >5 mm, compared with 17.5% of children (10 of 57) with current or previous tuberculosis (P < 0.02). Forty-eight children (17%) had a history of treated tuberculosis, and 27 children were being treated for tuberculosis at enrollment or during the first month of follow-up. Eleven children were diagnosed with tuberculosis after the first month of follow-up, and the diagnosis of mycobacterial infection was confirmed in 7 cases. Of 5 tested isolates of Mycobacterium tuberculosis, 3 were resistant to at least 1 antitubercular drug. Cumulative incidence of tuberculosis was 2060/100,000 at 12 months, 3390/100,000 at 2 years and 5930/100,000 at 3 years. The 3-year risk was 12,400/100,000 in immunocompromised children (CD4 <15%) and 3300/100,000 in other children (P < 0.0001).

CONCLUSION

The risk of tuberculosis among HIV-infected children in Côte d'Ivoire is strongly associated with the degree of immunodeficiency in HIV infection.

[Tuberculosis and HIV co-infection among children hospitalized in Bangui (Central African Republic)]

INTRODUCTION

Tuberculosis associated with HIV-infection in children makes the diagnosis of tuberculosis more complicated since it is already difficult to establish because clinically based in low-income countries, and worsens its outcome under treatment. We report our experience from the paediatric clinics of Bangui, Central African Republic.

PATIENTS AND METHODS

Our retrospective study analyzed 18-month -to 15-year-old children treated for tuberculosis from April 1998 to June 2000. Diagnosis and outcome data were abstracted from patient medical reports and we compared seropositive and seronegative patients.

RESULTS

Globally, 284 cases have been analyzed. HIV-infection rate was 25.7% (95% CI: 20.7-31.2%). Pulmonary tuberculosis and mixed forms rates were 94.4% (N = 268). Extrapulmonary tuberculosis was essentially lymphadenopathies which have been restricted only to seronegative patients. Tuberculosis microbiological findings were significantly lower in seropositive patients compared with seronegative ones, for microscopy (8.2 vs 24.6%) and for culture (35.6 vs 58.5%) (P-value < 0.05). On 28 seropositive and 72 seronegative children for which outcomes were registered, mortality rate was higher in seropositive than in seronegative patients (57.1 vs 19.4% respectively, P-value < 0.05).

CONCLUSION

The authors suggest that diagnosis of tuberculosis should be strengthened by blood or lymph node puncture culture particularly for HIV-infected children and that the treatment outcomes could be improved by diagnosis and treatment of other opportunistic infections.

The impact of HIV/AIDS on the control of tuberculosis in India

Epidemics of HIV/AIDS have increased the tuberculosis (TB) case-load by five or more times in East Africa and southern Africa. As HIV continues to spread, warnings have been issued of disastrous AIDS and TB epidemics in "new-wave" countries, including India, which accounts for 20% of all new TB cases arising in the world each year. Here we investigate whether, in the face of the HIV epidemic, India's Revised National TB Control Program (RNTCP) could halve TB prevalence and death rates in the period 1990-2015, as specified by the United Nations Millennium Development Goals. Using a mathematical model to capture the spatial and temporal variation in TB and HIV in India, we predict that, without the RNTCP, HIV would increase TB prevalence (by 1%), incidence (by 12%), and mortality rates (by 33%) between 1990 and 2015. With the RNTCP, however, we expect substantial reductions in prevalence (by 68%), incidence (by 41%), and mortality (by 39%) between 1990 and 2015. In India, 29% of adults but 72% of HIV-positive adults live in four large states in the south where, even with the RNTCP, mortality is expected to fall by only 15% between 1990 and 2015. Nationally, the RNTCP should be able to reverse the increases in TB burden due to HIV but, to ensure that TB mortality is reduced by 50% or more by 2015, HIV-infected TB patients should be provided with antiretroviral therapy in addition to the recommended treatment for TB.

Directly observed treatment for tuberculosis

Directly Observed Treatment-Short Course (DOTS) has been a successful strategy in the global control of tuberculosis (TB) in adults. However, reports of implementation are scantily available in pediatric context. Present article reviews diagnostic uncertainties of TB in children commonly faced by physicians on account of the vague clinical presentations, unreliable tuberculin tests or TB score charts, non-specific hematological, biochemical or radiological evidence, difficulty in sputum expectoration and non-availability or ill-affordability of specialised tests. It also describes therapeutic problems arising due to the physician's inexpertise, child's incomprehensibility and parental anxiety. DOTS was found to be highly effective in 930 Indian children having TB over the 6-year study period, during which, a rise in number of cases with adult pattern of disease was also noted. The trend change in pediatric TB scenario is thought to have taken place due to malnutrition so widely prevalent in this country. Irrespective of the changing trend, DOTS strategy was found to be effective for all types of pediatric TB. A need, therefore, exists for quick resolution of the programme issues related to pediatric drug dispensing, physicians' reservations about acceptance of strategy in this age-group, service-utilisation of DOTS providers for the selected cases unable to visit DOTS centres and giving executional priority to children during ongoing expansion of Revised National TB Control Programme (RNTCP) in country.

Impact of human immunodeficiency virus 1 infection on clinical presentation, treatment outcome and survival in a cohort of Ethiopian children with tuberculosis

BACKGROUND

Childhood tuberculosis (TB) is difficult to diagnose reliably because signs and symptoms are nonspecific and sputum for direct microscopy is difficult to obtain, especially in very young children. This diagnostic dilemma is thought to have increased with the HIV pandemic. Few studies on treatment outcome of dually infected children in high endemic countries have been reported. This study examines the impact of HIV infection on clinical presentation, diagnostic criteria and treatment outcome of TB in Ethiopian children.

METHODS

A prospective cohort study of children with TB diagnosed in Addis Ababa from December 1995 to January 1997 in which HIV-positive children were compared with HIV-negative children with regard to medical history, signs and symptoms, nutritional status, chest radiography, tuberculin skin test, response to TB treatment and final outcome. Mycobacterium tuberculosis was cultured in children with pulmonary manifestations.

RESULTS

HIV-positive children were younger, were underweight and had a 6-fold higher mortality than HIV-negative children. The tuberculin skin test was less sensitive and chest radiography was less specific in HIV-infected patients. Adherence to treatment was high (96%), and the cure rate was 58% for HIV-positive and 89% for HIV-negative TB patients.

CONCLUSION

HIV-positive children are at risk of diagnostic error as well as delayed diagnosis of TB. TB manifestations are more severe and progression to death is more rapid than in HIV-negative children. Weight for age may be used to identify children at high risk of a fatal outcome.

Lung diseases at necropsy in African children dying from respiratory illnesses: a descriptive necropsy study

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.

Risk factors for human immunodeficiency virus infection in Ethiopian children with tuberculosis

BACKGROUND

Separate risk factors for HIV infection and for tuberculosis (TB) are well-studied, but it is unclear whether these risk factors still apply in the new epidemiologic situation of dual infection. This study examines risk factors associated with seropositivity for HIV in Ethiopian children with clinical TB.

METHODS

A prospective, controlled study of children with TB diagnosed in Addis Ababa from December 11, 1995, to January 28, 1997, in which HIV-positive children were compared with HIV-negative children with regard to sociodemographic background, previous medical history and vaccination.

RESULTS

HIV prevalence among children with clinical TB was 11.2%. High educational status of mothers, low age, loss of one or two parents and earlier Calmette-Guérin bacillus (BCG) vaccination of the child were factors independently related to HIV infection.

CONCLUSION

Factors associated with HIV infection among children with clinical TB include higher education of parents, higher income and better living conditions. The HIV epidemic might thus modify traditional risk factors for tuberculosis. It might also decrease the overall effect of BCG vaccination given that BCG did not provide protection in children infected with HIV. An expected increase of dually infected children who are younger, more in need of hospitalization and often lacking one or both parents will put an additional burden on the Ethiopian health care system.

Adult tuberculosis overview: African versus Western perspectives

Tuberculosis is currently an enormous global health problem. In industrialized countries in Western Europe and North America, tuberculosis case rates are low and an increasing proportion of cases now occur in foreign-born individuals and in marginalized populations, including the homeless, prisoners, drug users, and persons with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS). In contrast, the burden of tuberculosis in sub-Saharan Africa continues to grow, largely fueled by the HIV pandemic and poor public health infrastructure. Use of the World Health Organization's (WHO) directly observed therapy, short course (DOTS) strategy has been successful in improving outcomes and preventing the emergence of acquired drug resistance in several African countries; however, case rates are increasing throughout most of the region. It is clear that control of tuberculosis in Africa is closely linked to control of HIV and AIDS. Substantial external donor support and innovative approaches to enhance interactions between HIV/AIDS prevention and treatment efforts and tuberculosis control programs will be needed to improve the current tuberculosis situation in Africa. The purpose of this review is to provide a synopsis of recent developments in these areas and to serve as a reference source for interested readers.

The tuberculosis pandemic: implications for health in the tropics

Among infectious diseases, tuberculosis is the leading cause of death, killing around 3 million people each year. Most cases occur in young adults but it is also a major cause of illness and death in children. The problem has been exacerbated in recent years by the HIV pandemic and by the emergence of multidrug resistance. Co-infection with HIV greatly enhances the risk of overt tuberculosis and in 1999 it is expected that tuberculosis will account for 30% of the predicted 2.5 million AIDS-related deaths. By inducing clinically and radiologically atypical forms of tuberculosis, and by increasing pressure on diagnostic facilities by sheer numbers, serious diagnostic difficulties are increasingly occurring in both adults and children in the tropics. At the present time, 2% of all cases of tuberculosis are multidrug resistant but, as the treatment of such cases is often grossly inadequate in many tropical countries, their frequency will doubtless grow. There are no simple solutions to the global emergency of tuberculosis: clearly there is a need for better use of available control measures but there is also a need to reach a much clearer understanding of the underlying immune phenomena in this disease so as to develop more effective vaccines and therapeutic agents. Finally, it cannot be ignored that tuberculosis is a disease of poverty--95% of cases and 98% of deaths due to it occur in the developing nations--and thus a major control measure is a resolution of the gross inequities in health care provision both between and within nations.

Tuberculous meningitis and co-infection with HIV

The clinical, laboratory and radiological features of 30 children with clinically diagnosed tuberculous meningitis (TBM) who were HIV-seronegative were compared with those of ten HIV-infected children with TBM. Such comparative data are not currently available in the literature and so are an important addition to our knowledge of the HIV-TB co-infection epidemic. In comparison with the HIV-negative children, those infected with HIV were younger, had a shorter duration of symptoms and were more often Mantoux-negative (HIV-positive 23% vs HIV-negative 70%; p = 0.01). On presentation, all children in both groups were in MRC TBM stages II or III. Clinical features were similar in both groups but computed tomography of the brain showed more ventricular enlargement (HIV-positive 80% vs HIV-negative 63%), gyral enhancement (HIV-positive 60% vs HIV-negative 17%; p = 0.01) and cerebral atrophy (HIV-positive 40% vs HIV-negative 17%). Outcome was considerably worse in the HIV-positive children, of whom 30% died (vs HIV-negative 0/30; p = 0.01) and the remainder were moderately (HIV-positive 30% vs HIV-negative 24%) or severely (HIV-positive 30% vs HIV-negative 19%) handicapped at the end of treatment. While clinical features were not markedly different in HIV-infected and uninfected children with TBM, abnormal radiological findings were more common in the HIV-infected group and outcome was considerably worse. Co-existing HIV encephalopathy and diminished immune competence undoubtedly contributed to the more severe clinical and neuro-radiological features.

Impact of HIV infection on the development, clinical presentation, and outcome of tuberculosis among children in Abidjan, Côte d'Ivoire

OBJECTIVE

To assess the impact of HIV infection upon the development, clinical presentation, and outcome of tuberculosis (TB) among children.

DESIGN

Case-control study and prospective cohort study.

METHODS

From March 1994 to November 1995, children aged 0-9 years with newly diagnosed TB were enrolled at the two outpatient TB centers and the two principal university hospitals in Abidjan, Côte d'Ivoire. Children were examined, blood samples were collected for HIV serology and lymphocyte phenotyping, chest radiography was performed, and gastric aspirates and sputum samples were collected for acid-fast bacilli smear and culture. Children were then followed every 2 months during a standard 6-month course of anti-TB therapy. To examine risk factors for TB, age- and sex-matched healthy control children were enrolled from among the siblings of children referred for TB skin testing.

RESULTS

Overall, 161 children with TB were enrolled, including 39 (24%) with culture-confirmed pulmonary TB, 80 (50%) with clinically diagnosed pulmonary TB, and 42 (26%) with extrapulmonary TB. Children with TB were significantly more likely than 161 control children to be HIV-seropositive (19 versus 0%), to have a past TB contact (55 versus 16%) and to live in very low socioeconomic status housing (24 versus 6%). No significant differences between HIV-seropositive and seronegative children were found in the distribution of radiologic abnormalities for pulmonary TB or in the site of extrapulmonary TB. The mortality rate in HIV-seropositive children was significantly higher than in seronegative children (23 versus 4%; relative risk, 3.6; 95% confidence interval, 2.0-6.6), and all deaths in HIV-seropositive children with available lymphocyte subtyping results occurred in those with a CD4 percentage of < 10%.

CONCLUSIONS

This study documents the importance of HIV infection as an independent risk factor for the development of TB in children, and demonstrates that HIV-related immunosuppression is a critical risk factor for mortality in this population.

Pulmonary manifestations in HIV seropositivity and malnutrition in Zimbabwe

Over a 10 month period 184 children, aged 5 years or less, who died at home had their nutritional status and HIV serostatus established; necropsies were also carried out. The HIV antibody test was positive in 122/184 (66%). Of the HIV seropositive children Pneumocystis carinii pneumonia was present in 19 (16%), cytomegalovirus pneumonia in nine (7%), and lymphoid interstitial pneumonitis in 11 (9%). Opportunistic infection was therefore seen in 28/122 (23%) of the seropositive cases but in none of the seronegative cases. Tuberculosis was present in 8/184 (4%): 6/122 (5%) in HIV seropositive and 2/62 (3%) in seronegative children. Lung aspirate showed positive bacterial isolates in 106/ 122 (86%) of HIV seropositive and 46/62 (74%) of seronegative children with Gram negative organisms predominating in both groups. Malnutrition was common and affected 106/184 (58%); positive growth was obtained in 98 (92%) of the malnourished children irrespective of their HIV serostatus. Malnutrition was significantly associated with bacterial lung infection after adjustment for the confounding effect of HIV status. No association was found between HIV serostatus and bacterial lung infection that could not be attributed to malnutrition at the time of death. The importance of adequate nutrition in reducing the risk of bacterial infection in HIV infected children is apparent.

Tuberculosis in Africa: clinical presentation and management

In the last decade, sub-Saharan Africa has experienced an explosive increase in tuberculosis (TB) cases, largely as a result of the co-epidemic of human immunodeficiency virus (HIV) infection. This article reviews the essential background epidemiology of TB in sub-Saharan Africa. The clinical features and diagnostic problems of pulmonary/extrapulmonary TB in adults and children are discussed, particularly in relation to HIV infection. Different treatment regimens, their cost, adverse reactions, the ways in which HIV infection influences treatment response and the extent of drug resistance are reviewed. The recommended approaches to TB control in Africa, including methods used to prevent TB through Bacillus Calmette-Guerin and chemoprophylaxis are examined. The success achieved by good National TB Control Programmes in some African countries allows cautious optimism that this epidemic can be controlled.

Effects of the human immunodeficiency virus on tuberculosis in children

SETTING

Human immunodeficiency virus (HIV) infection has altered the epidemiological and clinical profile of tuberculosis (TB) worldwide. In children however, unlike in adults, very little has been documented about the interaction between the two diseases.

OBJECTIVE

To examine the clinical features and response to TB treatment in children with TB and HIV, and compare them with those with TB alone.

DESIGN

A prospectively enrolled case study with systematically selected controls was conducted between 1992 and 1994 at King George V tuberculosis hospital, in Durban. Forty children with TB and HIV (Group A) were compared with 40 children with TB alone (Group B). The diagnosis of TB was made in accordance with established criteria. Measures of comparison between the groups included: history of contact with a TB case, clinical presentation on admission, presence of bacille Calmette-Guérin (BCG) scar, reaction to tuberculin test, clinical response to anti-tuberculosis treatment (mean weight gain per month, improved appetite, resolution of chest signs, decreasing size of visceromegaly), radiological response to treatment (assessed according to an objective score on admission, at 6 months and on discharge), other associated diseases, nosocomial infections and survival.

RESULTS

The mean age of the children in Group A was 25 months and in Group B 31 months. The clearest differences between the groups on admission were clinical features and response to tuberculin testing. Group A were more frequently anergic to tuberculin testing (P < 0.0001) and more often had symptoms and signs suggestive of TB (P = 0.002). Clinical response to treatment on discharge was worse in Group A than in Group B (P = 0.005). Radiological response to treatment at six months and on discharge was poorer in Group A than in Group B (P = 0.46; P = 0.006, respectively). Six children in group A and none in group B died (P = 0.012). The mean duration of treatment (and therefore period until discharge) was 8.9 months in Group B and 8.5 months in Group A for those who survived. History of contact, evidence of BCG inoculation and nosocomial infections were similar in both groups.

CONCLUSION

HIV infection adversely affects the outcome of TB in children as assessed by response to treatment and survival.

Human immunodeficiency virus infection in children with tuberculosis in Santo Domingo, Dominican Republic: prevalence, clinical findings, and response to antituberculosis treatment

We studied human immunodeficiency virus (HIV)-seroprevalence among children with clinically diagnosed tuberculosis (TB) and compared the clinical features and response to short-term anti-TB therapy of children with and without HIV infection in Santo Domingo, Dominican Republic. Children aged 18-59 months with new-onset, clinically diagnosed TB were tested for HIV antibodies, their clinical features were recorded and their response to a standard 6-month regimen of daily isoniazid and rifampicin with daily streptomycin and pyrazinamide for the first 2 months was assessed. To increase the number of HIV-infected children with TB available for study, we also included children previously known to be HIV infected who developed new-onset TB. Eleven (5.8%) of 189 consecutively enrolled children with clinically diagnosed TB were HIV infected. Fifteen other children with previously documented HIV infection and new-onset TB were available for study, yielding 26 HIV-positive and 178 HIV-negative children with TB. Of these 204 children with clinically diagnosed TB, 25 HIV-positive and 156 HIV-negative children were successfully followed for 6 months or until death. The proportion of HIV-positive children who failed treatment was 6 (29%) of 21 as compared with only 5 (3%) of 156 HIV-negative children [relative risk = 8.9; 95% confidence interval (CI) 2.9, 26.6; p = 0.0004]. HIV-infected children with clinically diagnosed TB are substantially more likely to fail standard treatment for TB than are HIV-uninfected children. If standard treatment regimens are used in such children, response to treatment must be monitored very closely and appropriate changes in the regimen must be made expeditiously.

Clinical spectrum of human immunodeficiency virus disease in children in a west African city. Project RETRO-CI

OBJECTIVES

To determine the prevalence of HIV infection in children and to compare diagnostic syndromes and outcomes in HIV-positive and HIV-negative children.

METHODS

Consecutive children hospitalized in Abidjan's three university hospitals were examined, tested for HIV infection and followed to discharge. Admission or discharge diagnoses and outcome (survived or died) were compared in HIV-positive and HIV-negative children.

RESULTS

The prevalence of HIV infection in the 4480 children hospitalized for the first time was 8.2%; the highest age-specific rate (11.2%) was in children ages 15 to 23 months. Six clinical syndromes accounted for more than 80% of admissions in HIV-positive and -negative children (all ages combined): respiratory infection; malnutrition; malaria; anemia; diarrhea; and meningitis. The dominant syndromic diagnoses in HIV-positive children were respiratory infection (26.1%) and malnutrition (25.8%); in HIV-negative children they were malaria (30.4%) and respiratory infection (19.1%). The overall mortality rate in HIV-positive children was 20.8%, compared with 8.7% in HIV-negative children (relative risk, 2.4; 95% confidence interval, 1.9 to 3.1); the highest death rate (28.1%) was in children younger than 15 months.

CONCLUSIONS

Clinical syndromes associated with HIV infection in African children are difficult to recognize without access to HIV serology. Respiratory infection and malnutrition were the dominant clinical syndromes in HIV-positive children in Abidjan. Greater overlap exists between the clinical presentations of HIV-associated disease and other common health problems in African children than in adults.

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.