Pulmonary manifestations in HIV seropositivity and malnutrition in Zimbabwe

Prediction of acute respiratory infections using machine learning techniques in Amhara Region, Ethiopia

Many studies have shown that infectious diseases are responsible for the majority of deaths in children under five. Among these children, Acute Respiratory Infections is the most prevalent illness and cause of death worldwide. Acute respiratory infections continue to be the leading cause of death in developing countries, including Ethiopia. In order to predict the main factors contributing to acute respiratory infections in the Amhara regional state of Ethiopia, a machine learning technique was employed. This study utilized data from the 2016 Ethiopian Demographic and Health Survey. Seven machine learning models, including logistic regression, random forests, decision trees, Gradient Boosting, support vector machines, Naïve Bayes, and K-nearest neighbors, were employed to forecast the factors influencing acute respiratory infections. The accuracy of each model was assessed using receiver operating characteristic curves and various metrics. Among the seven models used, the Random Forest algorithm demonstrated the highest accuracy in predicting acute respiratory infections, with an accuracy rate of 90.35% and Area under the Curve of 94.80%. This was followed by the Decision Tree model with an accuracy rate of 88.69%, K-nearest neighbors with 86.35%, and Gradient Boosting with 82.69%. The Random Forest algorithm also exhibited positive and negative predictive values of 92.22% and 88.83%, respectively. Several factors were identified as significantly associated with ARI among children under five in the Amhara regional state, Ethiopia. These factors, included families with a poorer wealth status (log odds of 0.18) compared to their counterparts, families with four to six children (log odds of 0.1) compared to families with fewer than three living children, children without a history of diarrhea (log odds of -0.08), mothers who had occupation(log odds of 0.06) compared mothers who didn't have occupation, children under six months of age (log odds of -0.05) compared to children older than six months, mothers with no education (log odds of 0.04) compared to mothers with primary education or higher, rural residents (log odds of 0.03) compared to non-rural residents, families using wood as a cooking material (log odds of 0.03) compared to those using electricity. Through Shapley Additive exPlanations value analysis on the Random Forest algorithm, we have identified significant risk factors for acute respiratory infections among children in the Amhara regional state of Ethiopia. The study found that the family's wealth index, the number of children in the household, the mother's occupation, the mother's educational level, the type of residence, and the fuel type used for cooking were all associated with acute respiratory infections. Additionally, the research emphasized the importance of children being free from diarrhea and living in households with fewer children as essential factors for improving children's health outcomes in the Amhara regional state, Ethiopia.

Empowering child health: Harnessing machine learning to predict acute respiratory infections in Ethiopian under-fives using demographic and health survey insights

BACKGROUND

A dearth of studies showed that infectious diseases cause the majority of deaths among under-five children. Worldwide, Acute Respiratory Infection (ARI) continues to be the second most frequent cause of illness and mortality among children under the age of five. The paramount disease burden in developing nations, including Ethiopia, is still ARI.

OBJECTIVE

This study aims to determine the magnitude and predictors of ARI among under-five children in Ethiopia using used state of the art machine learning algorithms.

METHODS

Data for this study were derived from the 2016 Ethiopian Demographic and Health Survey. To predict the determinants of acute respiratory infections, we performed several experiments on ten machine learning algorithms (random forests, decision trees, support vector machines, Naïve Bayes, and K-nearest neighbors, Lasso regression, GBoost, XGboost), including one classic logistic regression model and an ensemble of the best performing models. The prediction ability of each machine-learning model was assessed using receiver operating characteristic curves, precision-recall curves, and classification metrics.

RESULTS

The total ARI prevalence rate among 9501 under-five children in Ethiopia was 7.2%, according to the findings of the study. The overall performance of the ensemble model of SVM, GBoost, and XGBoost showed an improved performance in classifying ARI cases with an accuracy of 86%, a sensitivity of 84.6%, and an AUC-ROC of 0.87. The highest performing predictive model (the ensemble model) showed that the child's age, history of diarrhea, wealth index, type of toilet, mother's educational level, number of living children, mother's occupation, and type of fuel they used were an important predicting factor for acute respiratory infection among under-five children.

CONCLUSION

The intricate web of factors contributing to ARI among under-five children was identified using an advanced machine learning algorithm. The child's age, history of diarrhea, wealth index, and type of toilet were among the top factors identified using the ensemble model that registered a performance of 86% accuracy. This study stands as a testament to the potential of advanced data-driven methodologies in unraveling the complexities of ARI in low-income settings.

Prevalence and predictors of acute respiratory infection among children under-five years in Tigray regional state, northern Ethiopia: a cross sectional study

BACKGROUND

Acute respiratory infection is still one of the leading causes of child morbidity and mortality worldwide. Developing countries, especially in Sub-Saharan Africa including Ethiopia continue to share an overburden of this infection. Studies showed that different predictor factors were associated with the occurrence of childhood acute respiratory infection. Therefore, the main aim of this study was to assess the prevalence and associated predictor factors of acute respiratory infection among children under-five years in the Tigray Regional State, northern Ethiopia.

METHODS

A retrospective cross-sectional study design was done from January 18, 2016, to June 27, 2016. A total of 986 children under-five years were selected for this study. The logistic regression model analysis was employed to examine the predictor factors of childhood acute respiratory infection. Both bi-variable and multivariable data analysis was performed using STATA version 14.0.

RESULTS

Overall, the study showed that the two weeks prevalence of acute respiratory infection among children under-five years was 16.10% [95%CI: 13.80-18.40]. According to the multivariable logistic regression model analysis, children aged (24-60) months (AOR: 0.59, 95%CI: 0.352-0.98), rich wealth index of households (AOR: 0.60, 95%CI: 0.378-0.959), diarrhea status of children (AOR: 3, 95%CI: 1.97-4.73), and mothers smoking cigarettes (AOR: 4, 95%CI: 1.15-16.50), were significant predictors of acute respiratory infection.

CONCLUSION

The prevalence of ARI displays that Tigray regional state was experiencing a higher ARI rate than the national level. The current study identified the low wealth index of households, children aged (24-60 months), mothers smoking cigarettes, and diarrhea status of the children as crucial predictor factors for ARI. Interventions should be improved to these modifiable major predictor factors that significantly decrease the ARI problem among under-five children.

Determinants of pneumonia among under-five children at Hiwot Fana specialized hospital, Eastern Ethiopia: unmatched case-control study

BACKGROUND

Globally, pneumonia is a serious public health issue. Clear evidence is necessary for the early detection and treatment of pneumonia's causes. Yet, there is limited data on this issue in the current study area. Thus, this study aimed to pinpoint the determinants of pneumonia among under-five children at Hiwot Fana Specialized Hospital, Eastern Ethiopia.

METHODS

A hospital-based unmatched case-control study was conducted among a sample of 348 (116 cases and 232 controls) children at Hiwot Fana Specialized Hospital from October 1 to November 30, 2022. A consecutive sampling technique was employed, and data were collected with a pre-tested interviewer-administered questionnaire. The data was entered into Epi-Data version 3.1 and analyzed using SPSS version 25 software. Bivariate and multivariate binary logistic regression analyses were fitted. Variables with a 95% confidence interval having a p-value < 0.05 were considered statistically significant.

RESULTS

An overall total of 347 (115 cases and 232 controls) among under-five children was included in this study. Factors such as hand washing before child feeding [AOR: 3.11 (1.74-5.57)], birth to 6 months breastfeeding [AOR: 2.76 (1.35-5.25)], zinc supplementation [AOR: 2.5 (1.33-4.40)], diarrhea in the last 2 weeks [AOR: 4.7 (2.64-8.33)], and Upper Respiratory Tract Infections in the last 2 weeks [AOR: 5.46 (3.21-10.92)] were found to be determinants of pneumonia.

CONCLUSIONS

This study pointed out that the under-five pneumonia was relatively large. Factors such as hand washing before child feeding, birth to 6 months of breastfeeding, zinc supplementation of the child, diarrhea in the last 2 weeks, and Upper Respiratory Tract Infections in the last 2 weeks were determinants of under-five pneumonia. In this study, the primary risk factors for pneumonia may be preventable with no or minimal cost. Therefore, we advise suitable and sufficient health education addressing the prevention and management of pneumonia.

Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa

BACKGROUND

Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV) infected individuals in South Africa. Despite the implementation of HIV/TB integration services at primary healthcare facility level, the effect of HIV on TB treatment outcomes has not been well investigated. To provide evidence base for TB treatment outcome improvement to meet End TB Strategy goal, we assessed the effect of HIV status on treatment outcomes of TB patients at a rural clinic in the Ugu Health District, South Africa.

METHODS

We reviewed medical records involving a cohort of 508 TB patients registered for treatment between 1 January 2013 and 31 December 2015 at rural public sector clinic in KwaZulu-Natal province, South Africa. Data were extracted from National TB Programme clinic cards and the TB case registers routinely maintained at study sites. The effect of HIV status on TB treatment outcomes was determined by using multinomial logistic regression. Estimates used were relative risk ratio (RRR) at 95% confidence intervals (95%CI).

RESULTS

A total of 506 patients were included in the analysis. Majority of the patients (88%) were new TB cases, 70% had pulmonary TB and 59% were co-infected with HIV. Most of HIV positive patients were on antiretroviral therapy (ART) (90% (n = 268)). About 82% had successful treatment outcome (cured 39.1% (n = 198) and completed treatment (42.9% (n = 217)), 7% (n = 39) died 0.6% (n = 3) failed treatment, 3.9% (n = 20) defaulted treatment and the rest (6.6% (n = 33)) were transferred out of the facility. Furthermore, HIV positive patients had a higher mortality rate (9.67%) than HIV negative patients (2.91%)". Using completed treatment as reference, HIV positive patients not on ART relative to negative patients were more likely to have unsuccessful outcomes [RRR, 5.41; 95%CI, 2.11-13.86].

CONCLUSIONS

When compared between HIV status, HIV positive TB patients were more likely to have unsuccessful treatment outcome in rural primary care. Antiretroviral treatment seems to have had no effect on the likelihood of TB treatment success in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients emphasizing the need for enhanced integrated management of HIV/TB in rural South Africa through active screening of TB among HIV positive individuals and early access to ART among HIV positive TB cases.

Severe Recurrent Bacterial Pneumonia Among Children Living With HIV

BACKGROUND

Bacterial pneumonia imparts a major morbidity and mortality burden on children living with HIV, yet effective prevention and treatment options are underutilized. We explored clinical factors associated with severe recurrent bacterial pneumonia among children living with HIV.

METHODS

Children enrolled in the TREAT Asia Pediatric HIV Observational Database were included if they started antiretroviral therapy (ART) on or after January 1st, 2008. Factors associated with severe recurrent bacterial pneumonia were assessed using competing-risk regression.

RESULTS

A total of 3,944 children were included in the analysis; 136 cases of severe recurrent bacterial pneumonia were reported at a rate of 6.5 [95% confidence interval (CI): 5.5-7.7] events per 1,000 patient-years. Clinical factors associated with severe recurrent bacterial pneumonia were younger age [adjusted subdistribution hazard ratio (aHR): 4.4 for <5 years versus ≥10 years, 95% CI: 2.2-8.4, P < 0.001], lower weight-for-age z-score (aHR: 1.5 for <-3.0 versus >-2.0, 95% CI: 1.1-2.3, P = 0.024), pre-ART diagnosis of severe recurrent bacterial pneumonia (aHR: 4.0 versus no pre-ART diagnosis, 95% CI: 2.7-5.8, P < 0.001), past diagnosis of symptomatic lymphoid interstitial pneumonitis or chronic HIV-associated lung disease, including bronchiectasis (aHR: 4.8 versus no past diagnosis, 95% CI: 2.8-8.4, P < 0.001), low CD4% (aHR: 3.5 for <10% versus ≥25%, 95% CI: 1.9-6.4, P < 0.001) and detectable HIV viral load (aHR: 2.6 versus undetectable, 95% CI: 1.2-5.9, P = 0.018).

CONCLUSIONS

Children <10-years-old and those with low weight-for-age, a history of respiratory illness, low CD4% or poorly controlled HIV are likely to gain the greatest benefit from targeted prevention and treatment programs to reduce the burden of bacterial pneumonia in children living with HIV.

Prevalence of culture positive Tuberculosis and utility of a clinical diagnostic tool for the diagnosis of Tuberculosis among HIV Infected Children attending HIV/AIDS Care and Treatment in Dodoma Municipality, Central Tanzania

OBJECTIVE

To evaluate the performance of the modified Keith Edwards TB clinical diagnostic tool among HIV infected children.

METHODS

Cross sectional study of 252 HIV infected children < 15 years old suspected with TB at four HIV/AIDS Care Clinics in Dodoma, Tanzania from November 2018 - March 2019. The modified Keith Edwards TB clinical diagnostic tool was compared to gastric aspirates, lymphnode aspirates or sputum gene x-pert MTB/RIF and TB culture. Sensitivity, specificity, negative and positive predictive value of the clinical tool were determined. Data was analyzed using SPSS version 25.

RESULTS

Out of 252 children evaluated, 13.5% (34/252) had TB using the clinical diagnostic tool and 5.2% (13/252) had culture positive TB. The sensitivity of the clinical tool was 76.9%, specificity of 90%. Culture positive TB predictors were lymphadenopathy (AOR 13.74, 95%CI (3.86 - 48.86) p value < 0.001), weight loss (AOR 3.19,95%CI (1.38 - 7.36) p value 0.007), and difficulty breathing (AOR 7.25, 95%CI (1.54 - 34.16) p value 0.012).

CONCLUSION

The utility of the modified Keith Edwards clinical diagnostic tool for Tuberculosis diagnosis among HIV infected children is limited, calling for further validation. HIV infected children with lymphadenopathy, failure to thrive and difficulty in breathing are at high risk of Tuberculosis.

AIDS-defining causes of death from autopsy findings for HIV-positive individuals in sub-Saharan Africa in the pre- and post-ART era: A systematic review and meta-analyses

Background: The lack of representative data on causes of death in sub-Saharan Africa (SSA) hampers our understanding of the regional burden of HIV and impact of interventions. In spite of the roll-out of antiretroviral therapy (ART) programs, HIV-infected individuals are still dying from complications of AIDS in SSA. We reviewed autopsy findings in SSA to observe whether the prevalence of 14 AIDS-defining illnesses changed from the pre-ART era to the post-ART era. Methods: We conducted a systematic review of autopsy findings in SSA using Medline, CINAHL, Evidence Based Medicine, EMBASE, Scopus, Web of Science, and abstracts from the Conference on Retroviruses and Opportunistic Infections, for literature published between January 1, 1990 and September 30, 2018. We focused on 14 AIDS-defining illnesses as causes of death. Results: In total, 33 studies were identified, including 9 from South Africa, 4 from the Ivory Coast, and the rest from eastern regions of sub-Saharan Africa. Of these, 18 studies were included in the meta-analyses for each of the AIDS-defining illnesses for adults. A ‘mixed group’ of studies that included adults and children was used for separate meta-analyses. Most opportunistic infections (OIs) showed a decrease in prevalence, with the notable exception of tuberculosis (TB), which showed a 13% increase in adult deaths and a 5% increase in mixed population group deaths. Kaposi’s sarcoma and non-Hodgkin’s lymphoma both showed a notable increase in prevalence, and liver disease showed a 10% increase in prevalence in the adult group. Conclusions: Even though ART has reduced the contribution of OIs to causes of death for people infected with HIV in SSA, targeted and strategic efforts are needed in order to strengthen existing prevention, diagnosis, and treatment of TB. More research is required to understand the complex role ARTs have on liver and kidney diseases.

Spatial distribution and determinants of acute respiratory infection among under-five children in Ethiopia: Ethiopian Demographic Health Survey 2016

Background

Childhood acute respiratory infection remains the commonest global cause of morbidity and mortality among under-five children. In Ethiopia, it remains the highest burden of the health care system. The problem varies in space and time, and exploring its spatial distribution has supreme importance for monitoring and designing effective intervention programs.

Methods

A two stage stratified cluster sampling technique was utilized along with the 2016 Ethiopian Demographic and Health Survey (EDHS) data. About 10,006 under-five children were included in this study. Bernoulli model was used to investigate the presence of purely spatial clusters of under-five acute respiratory infection using SaTScan.ArcGIS version 10.1 was used to visualize the distribution of pneumonia cases across the country. Mixed-effect logistic regression model was used to identify the determinants of acute respiratory infection.

Result

In this study, acute respiratory infection among under-five children had spatial variations across the country (Moran’s I: 0.34, p < 0.001). Acute respiratory infection among under-five children in Tigray (p < 0.001) and Oromia (p < 0.001) National Regional States clustered spatially. History of diarrhoea (Adjusted Odds Ratio (AOR) = 4.71, 95% CI: (3.89–5.71))), 45–59 months of age (AOR = 0.63, 95% CI: (0.45–0.89)), working mothers (AOR = 1.27, 95% CI: (1.06–1.52)), mothers’ secondary school education (AOR = 0.65; 95% CI: (0.43–0.99)), and stunting (AOR = 1.24, 95% CI: (1.00–1.54)) were predictors of under-five acute respiratory infection.

Conclusion and recommendation

In Ethiopia, acute respiratory infection had spatial variations across the country. Areas with excess acute respiratory infection need high priority in allocation of resources including: mobilizing resources, skilled human power, and improved access to health facilities.

Isoniazid for preventing tuberculosis in HIV-infected children

BACKGROUND

Tuberculosis (TB) is an important cause of illness and death in HIV-positive children living in areas of high TB prevalence. We know that isoniazid prophylaxis prevents TB in HIV-negative children following TB exposure, but there is uncertainty related to its role in TB preventive treatment in HIV-positive children.

OBJECTIVES

To summarise the effects of TB preventive treatment versus placebo in HIV-positive children with no known TB contact on active TB, death, and reported adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, Embase and two trial registers up to February 2017.

SELECTION CRITERIA

We included trials of HIV-positive children with and without known TB exposure, randomized to receive TB preventive treatment or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently used the study selection criteria, assessed risk of bias, and extracted data. We assessed effects using risk, incidence rate and hazard ratios and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included three trials, involving 991 participants, below the age of 13 years, from South Africa and Botswana. Children were randomized to isoniazid prophylaxis or placebo, given daily or three times weekly. The median length of follow-up ranged from 5.7 to 34 months; some were on antiretroviral therapy (ART).In HIV-positive children not on ART, isoniazid prophylaxis may reduce the risk of active TB (hazard ratio (HR) 0.31, 95% confidence interval (CI) 0.11 to 0.87; 1 trial, 240 participants, low certainty evidence), and death (HR 0.46, 95% CI 0.22 to 0.95; 1 trial, 240 participants, low certainty evidence). One trial (182 participants) reported number of children with laboratory adverse events, which was similar between the isoniazid prophylaxis and placebo groups. No clinical adverse events were reported.In HIV-positive children on ART, we do not know if isoniazid prophylaxis reduces the risk of active TB (risk ratio (RR) 0.76, 95% CI 0.50 to 1.14; 3 trials, 737 participants, very low certainty evidence) or death (RR 1.45, 95% CI 0.78 to 2.72; 3 trials, 737 participants, very low certainty evidence). Two trials (714 participants) reported number of clinical adverse events and three trials (795 participants) reported number of laboratory adverse events; for both categories, the number of adverse events were similar between the isoniazid prophylaxis and placebo groups.

AUTHORS' CONCLUSIONS

Isoniazid prophylaxis given to all children diagnosed with HIV may reduce the risk of active TB and death in HIV-positive children not on ART in studies from Africa. For children on ART, no clear benefit was detected. .

Cytomegalovirus infection in HIV-infected versus non-infected infants and HIV disease progression in Cytomegalovirus infected versus non infected infants early treated with cART in the ANRS 12140-Pediacam study in Cameroon

Background

The outcome of CMV/HIV co-infection in infants treated early with combined antiretroviral therapy (cART) in resource-limited settings has not been described.

We aimed to estimate the prevalence and identify factors associated with early CMV infection in HIV-infected and non-infected infants included in a study in Cameroon, and to compare HIV disease progression and survival after 1 year of early cART, following infants’ CMV status.

Methods

HIV-infected infants followed from birth or from HIV diagnosis before 7 months old and HIV-uninfected infants born to HIV-infected or uninfected mothers were tested for CMV at a median age of 4.0 months [Interquartile range (IQR): 3.4–4.9]. Multivariable logistic regression was performed to identify factors associated with CMV infection. Early cART was offered to HIV-infected infants: mortality, immunological and virological outcomes were assessed.

Results

Three hundred and sixty-nine infants were tested. The proportion of infants infected with CMV at baseline was significantly higher in HIV-infected than in HIV-uninfected groups (58.9% (86/146) vs 30.0% (67/223), p < 0.001). At baseline, median CMV viral load was higher in HIV-infected (3.7 log copies/ml [IQR; 3.1–4.3]) than in HIV-uninfected infants (2.8 log copies [IQR; 2.1–3.4], p < 0.001). cART was initiated in 90% of HIV-infected infants (132/146) at a median age of 4.0 months (IQR; 3.2–5.9); in this sub-group CMV infection was independently associated with being followed from the time of HIV diagnosis rather than from birth (aOR = 3.1, 95%CI [1.2–8.0]), born to a non-single mother (aOR = 3.4[1.4–8.1]), and breastfeeding (aOR = 7.3 [2.7–19.4]). HIV-infected infants were retested after a median of 7.1 months [4.8–9.5]: CMV was undetectable in 37 of the 61 (60.7%) initially CMV-infected cases and became detectable in 8 of the 38 (21.1%) initially CMV-negative cases. After 1 year of cART, the probability of death (0.185 vs 0.203; p = 0.75), the proportion of cases with HIV RNA viral load <400 copies/ml (75.5% vs 61.5%; p = 0.17) and the mean CD4 percentage increase (10.97% vs 6.88%; p = 0.15) did not differ between CMV+ and CMV- infants.

Conclusions

We observed a high prevalence of CMV infection among HIV-infected infants. Early initiation of cART may have limited the negative impact of CMV even in the absence of specific anti-CMV treatment.

Prevalence of tuberculosis in post-mortem studies of HIV-infected adults and children in resource-limited settings: a systematic review and meta-analysis

Objectives:

Tuberculosis (TB) is estimated to be the leading cause of HIV-related deaths globally. However, since HIV-associated TB frequently remains unascertained, we systematically reviewed autopsy studies to determine the true burden of TB at death.

Methods:

We systematically searched Medline and Embase databases (to end 2013) for literature reporting on health facility-based autopsy studies of HIV-infected adults and/or children in resource-limited settings. Using forest plots and random-effects meta-analysis, we summarized the TB prevalence found at autopsy and used meta-regression to explore variables associated with autopsy TB prevalence.

Results:

We included 36 eligible studies, reporting on 3237 autopsies. Autopsy TB prevalence was extremely heterogeneous (range 0–64.4%), but was markedly higher in adults [pooled prevalence 39.7%, 95% confidence interval (CI) 32.4–47.0%] compared to children (pooled prevalence 4.5%, 95% CI 1.7–7.4%). Post-mortem TB prevalence varied by world region, with pooled estimates in adults of 63.2% (95% CI 57.7–68.7%) in South Asia (n = 2 studies); 43.2% (95% CI 38.0–48.3) in sub-Saharan Africa (n = 9 studies); and 27.1% (95% CI 16.0–38.1%) in the Americas (n = 5 studies). Autopsy prevalence positively correlated with contemporary estimates of national TB prevalence. TB in adults was disseminated in 87.9% (82.2–93.7%) of cases and was considered the cause of death in 91.4% (95% CI 85.8–97.0%) of TB cases. Overall, TB was the cause of death in 37.2% (95% CI 25.7–48.7%) of adult HIV/AIDS-related deaths. TB remained undiagnosed at death in 45.8% (95% CI 32.6–59.1%) of TB cases.

Conclusions:

In resource-limited settings, TB accounts for approximately 40% of facility-based HIV/AIDS-related adult deaths. Almost half of this disease remains undiagnosed at the time of death. These findings highlight the critical need to improve the prevention, diagnosis and treatment of HIV-associated TB globally.

Tuberculosis as a cause or comorbidity of childhood pneumonia in tuberculosis-endemic areas: a systematic review

Pneumonia is a major cause of morbidity and mortality in infants and children worldwide, with most cases occurring in tuberculosis-endemic settings. Studies have emphasised the potential importance of Mycobacterium tuberculosis in acute severe pneumonia in children as a primary cause or underlying comorbidity, further emphasised by the changing aetiological range with rollout of bacterial conjugate vaccines in high mortality settings. We systematically reviewed clinical and autopsy studies done in tuberculosis-endemic settings that enrolled at least 100 children aged younger than 5 years with severe pneumonia, and that prospectively included a diagnostic approach to tuberculosis in all study participants. We noted substantial heterogeneity between studies in terms of study population and diagnostic methods. Of the 3644 patients who had culture of respiratory specimens for M tuberculosis undertaken, 275 (7·5%) were culture positive, and an acute presentation was common. Inpatient case-fatality rate for pneumonia associated with tuberculosis ranged from 4% to 21% in the four clinical studies that reported pathogen-related outcomes. Prospective studies are needed in high tuberculosis-burden settings to address whether tuberculosis is a cause or comorbidity of childhood acute severe pneumonia.

The immune system in children with malnutrition--a systematic review

BACKGROUND

Malnourished children have increased risk of dying, with most deaths caused by infectious diseases. One mechanism behind this may be impaired immune function. However, this immune deficiency of malnutrition has not previously been systematically reviewed.

OBJECTIVES

To review the scientific literature about immune function in children with malnutrition.

METHODS

A systematic literature search was done in PubMed, and additional articles identified in reference lists and by correspondence with experts in the field. The inclusion criteria were studies investigating immune parameters in children aged 1-60 months, in relation to malnutrition, defined as wasting, underweight, stunting, or oedematous malnutrition.

RESULTS

The literature search yielded 3402 articles, of which 245 met the inclusion criteria. Most were published between 1970 and 1990, and only 33 after 2003. Malnutrition is associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. Lymphatic tissue, particularly the thymus, undergoes atrophy, and delayed-type hypersensitivity responses are reduced. Levels of antibodies produced after vaccination are reduced in severely malnourished children, but intact in moderate malnutrition. Cytokine patterns are skewed towards a Th2-response. Other immune parameters seem intact or elevated: leukocyte and lymphocyte counts are unaffected, and levels of immunoglobulins, particularly immunoglobulin A, are high. The acute phase response appears intact, and sometimes present in the absence of clinical infection. Limitations to the studies include their observational and often cross-sectional design and frequent confounding by infections in the children studied.

CONCLUSION

The immunological alterations associated with malnutrition in children may contribute to increased mortality. However, the underlying mechanisms are still inadequately understood, as well as why different types of malnutrition are associated with different immunological alterations. Better designed prospective studies are needed, based on current understanding of immunology and with state-of-the-art methods.

Pneumocystis pneumonia in South African children diagnosed by molecular methods

Background

Pneumocystis pneumonia (PCP) is an important cause of hospitalization and mortality in HIV-infected children. However, the incidence of PCP has been underestimated due to poor sensitivity of diagnostic tests. The use of polymerase chain reaction (PCR) for pneumocystis has enabled more reliable diagnosis. This study describes the incidence, clinical features and outcome of PCP in South African children diagnosed using PCR.

Methods

A prospective study of children hospitalised in South Africa with suspected PCP was done from November 2006 to August 2008. Clinical, laboratory and radiological information were collected. Lower respiratory tract specimens were obtained for PCP immunofluorescence (IF), real- time PCR for pneumocystis, bacterial and mycobacterial culture. Nasopharyngeal aspirates were taken for immunofluorescence (IF), real-time PCR for pneumocystis and PCR for respiratory viruses. A blood specimen for bacterial culture and for cytomegalovirus PCR was taken. Children were followed for the duration of their hospitalisation and the outcome was recorded.

Results

202 children [median (interquartile range, IQR) age 3.2 (2.1– 4.6) months] were enrolled; 124 (61.4%) were HIV infected. PCP was identified in 109 (54%) children using PCR, compared to 43 (21%) using IF and Grocott staining (p < 0.0001). Most PCP cases (88, 81%) occurred in HIV-infected children. All 21 cases (19%) occurring in HIV- negative children had another risk factor for PCP. On logistic regression, predictive factors for PCP were HIV infection, lack of fever, high respiratory rate and low oxygen saturation whilst cotrimoxazole prophylaxis was protective (OR 0.24; 95% CI 0.1 to 0.5; p < 0.002). The case fatality of children with PCP was higher than those without PCP (32.1% versus 17.2%; relative risk 1.87; 95% confidence interval (CI) 1.11 – 3.15). Amongst HIV-infected children, a CD4 less than 15% was the only independent predictor of mortality.

Conclusions

The diagnostic yield for PCP is more than 2.5 times higher on PCR than other detection methods. PCP is a very common cause of severe hypoxic pneumonia and is associated with high mortality in HIV-infected African infants.

Deaths due to respiratory tract infections in Africa: a review of autopsy studies

PURPOSE OF REVIEW

According to the WHO, lower respiratory tract infections are one of the most prevalent causes of death in Africa. Estimates based on verbal autopsies are inaccurate compared with the gold standard for determining cause of death, the anatomical postmortem. Here, we review all respiratory postmortem data available from Africa and assess disease prevalence by HIV status in both adults and children.

RECENT FINDINGS

Pulmonary and extrapulmonary tuberculosis was detected in over 50% of HIV-infected adults, four to five-fold more prevalent than in HIV-uninfected cases. Overall tuberculosis was less prevalent in children, but was more prevalent in HIV-uninfected compared with HIV-infected children. Bacterial pneumonia was more prevalent in children than adults and was relatively unaffected by HIV status. Pneumocystis jirovecci and human cytomegalovirus pneumonia were detected almost exclusively in HIV-infected mortalities, twice as prevalent in children as in adults. Coinfections were common and correlation with premortem clinical diagnoses was low.

SUMMARY

Respiratory tract infections are important causes of mortality in Africa. Of the 21 reviewed studies, only four studies (all adults) were undertaken in the last decade. There is hence an urgent need for new postmortem studies to monitor cause of death in new and emerging patient groups, such as those on antiretroviral therapy and HIV exposed uninfected children.

A 54 year analysis of articles from Mpilo Central Hospital, Bulawayo, Zimbabwe--168 articles cited 999 times

PubMed and Google Scholar were searched to obtain articles originating from Mpilo Central Hospital, Bulawayo, Zimbabwe--1958 to August 2011 (54 years). 168 articles cited 999 times were retrieved giving about 6 citations per article. Analysis of publication trends over time as well as publication avenues is made. The full research dataset for this study is shared. This study adds to the body of knowledge on teaching hospital research performance assessment particularly in low-income settings, a topic with few studies. Africa needs data on research.

Systematic review on the etiology and antibiotic treatment of pneumonia in human immunodeficiency virus-infected children

BACKGROUND

Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality in human immunodeficiency virus (HIV)-infected children.

OBJECTIVES AND METHODS

A systematic review of studies that were published between January 1990 and February 2009 on the etiology and antimicrobial or adjunctive systemic management of CAP in HIV-infected children.

RESULTS

Pneumocystis jirovecii had the strongest association with HIV infection, with a summary odds ratio of 10.1 (95% confidence interval [CI], 17.7-62.1) and 9.1 (95% CI, 2.5-33.1) in antemortem and postmortem studies, respectively. Cytomegalovirus was strongly associated with HIV positivity among fatal cases of pneumonia (summary odds ratio = 14.4 [95% CI, 6.7-30.8]). There was a trend toward a greater prevalence of Staphylococcus aureus (odds ratio, 2.5; 95% CI, 0.95-6.4) in HIV-infected children. Major limitations identified included substantial methodological heterogeneity across studies, limited sensitivity of assays for diagnosing bacterial pneumonia, and studies primarily being undertaken in the absence of antiretroviral treatment or cotrimoxazole prophylaxis. No a priori-planned randomized controlled trials on antimicrobial management of CAP in HIV-infected children were identified.

CONCLUSIONS

A World Health Organization panel used this review as well as analysis of risks and benefits to revise recommendations for antimicrobial treatment of CAP. Ampicillin plus gentamicin or ceftriaxone is now recommended as first-line empiric regimens for treating severe and very severe CAP in HIV-infected children. In addition, treatment with cloxacillin or vancomycin is recommended in settings with a high incidence of methicillin-resistant S. aureus, and particularly if clinical or microbiological evidence of S. aureus pneumonia exist. Further studies in HIV-infected children on CAP etiology and antibiotic treatment are required in the era of antiretroviral treatment.

Cost-effectiveness analysis of diagnostic options for pneumocystis pneumonia (PCP)

Background

Diagnosis of Pneumocystis jirovecii pneumonia (PCP) is challenging, particularly in developing countries. Highly sensitive diagnostic methods are costly, while less expensive methods often lack sensitivity or specificity. Cost-effectiveness comparisons of the various diagnostic options have not been presented.

Methods and Findings

We compared cost-effectiveness, as measured by cost per life-years gained and proportion of patients successfully diagnosed and treated, of 33 PCP diagnostic options, involving combinations of specimen collection methods [oral washes, induced and expectorated sputum, and bronchoalveolar lavage (BAL)] and laboratory diagnostic procedures [various staining procedures or polymerase chain reactions (PCR)], or clinical diagnosis with chest x-ray alone. Our analyses were conducted from the perspective of the government payer among ambulatory, HIV-infected patients with symptoms of pneumonia presenting to HIV clinics and hospitals in South Africa. Costing data were obtained from the National Institutes of Communicable Diseases in South Africa. At 50% disease prevalence, diagnostic procedures involving expectorated sputum with any PCR method, or induced sputum with nested or real-time PCR, were all highly cost-effective, successfully treating 77–90% of patients at $26–51 per life-year gained. Procedures using BAL specimens were significantly more expensive without added benefit, successfully treating 68–90% of patients at costs of $189–232 per life-year gained. A relatively cost-effective diagnostic procedure that did not require PCR was Toluidine Blue O staining of induced sputum ($25 per life-year gained, successfully treating 68% of patients). Diagnosis using chest x-rays alone resulted in successful treatment of 77% of patients, though cost-effectiveness was reduced ($109 per life-year gained) compared with several molecular diagnostic options.

Conclusions

For diagnosis of PCP, use of PCR technologies, when combined with less-invasive patient specimens such as expectorated or induced sputum, represent more cost-effective options than any diagnostic procedure using BAL, or chest x-ray alone.

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.

Impact of HIV on standard case management for severe pneumonia in children

It is estimated that 2 million children under 5 years of age die from pneumonia each year and that half of these deaths occur in sub-Saharan Africa. Over 85% of the more than 2.3 million children living with HIV worldwide reside in sub-Saharan Africa. HIV infection is likely to have a major impact on current recommendations for the standard case management of pneumonia in children and is the rationale for undertaking this review of published studies. The studies identified indicate an overall sixfold (range 2.5-13.5-fold) increase in pneumonia-related fatality in HIV-infected compared with HIV-uninfected African infants and children. They are more likely to have disease due to mixed infection and from a wider range of pathogens including Pneumocystis pneumonia, TB and cytomegalovirus. Scaling-up of the implementation of strategies that prevent HIV and Pneumocystis pneumonia remains an important strategy to reduce the burden of HIV-related pneumonia in the region. Research is urgently required to address the most effective pneumonia case management strategy in HIV-infected infants and children.

Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics

This report updates and combines into one document earlier versions of guidelines for preventing and treating opportunistic infections (OIs) among HIV-exposed and HIV-infected children, last published in 2002 and 2004, respectively. These guidelines are intended for use by clinicians and other health-care workers providing medical care for HIV-exposed and HIV-infected children in the United States. The guidelines discuss opportunistic pathogens that occur in the United States and one that might be acquired during international travel (i.e., malaria). Topic areas covered for each OI include a brief description of the epidemiology, clinical presentation, and diagnosis of the OI in children; prevention of exposure; prevention of disease by chemoprophylaxis and/or vaccination; discontinuation of primary prophylaxis after immune reconstitution; treatment of disease; monitoring for adverse effects during treatment; management of treatment failure; prevention of disease recurrence; and discontinuation of secondary prophylaxis after immune reconstitution. A separate document about preventing and treating of OIs among HIV-infected adults and postpubertal adolescents (Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents) was prepared by a working group of adult HIV and infectious disease specialists. The guidelines were developed by a panel of specialists in pediatric HIV infection and infectious diseases (the Pediatric Opportunistic Infections Working Group) from the U.S. government and academic institutions. For each OI, a pediatric specialist with content-matter expertise reviewed the literature for new information since the last guidelines were published; they then proposed revised recommendations at a meeting at the National Institutes of Health (NIH) in June 2007. After these presentations and discussions, the guidelines underwent further revision, with review and approval by the Working Group, and final endorsement by NIH, CDC, the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Disease Society (PIDS), and the American Academy of Pediatrics (AAP). The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of the evidence supporting the recommendation so readers can ascertain how best to apply the recommendations in their practice environments. An important mode of acquisition of OIs, as well as HIV infection among children, is from their infected mother; HIV-infected women coinfected with opportunistic pathogens might be more likely than women without HIV infection to transmit these infections to their infants. In addition, HIV-infected women or HIV-infected family members coinfected with certain opportunistic pathogens might be more likely to transmit these infections horizontally to their children, resulting in increased likelihood of primary acquisition of such infections in the young child. Therefore, infections with opportunistic pathogens might affect not just HIV-infected infants but also HIV-exposed but uninfected infants who become infected by the pathogen because of transmission from HIV-infected mothers or family members with coinfections. These guidelines for treating OIs in children therefore consider treatment of infections among all children, both HIV-infected and uninfected, born to HIV-infected women. Additionally, HIV infection is increasingly seen among adolescents with perinatal infection now surviving into their teens and among youth with behaviorally acquired HIV infection. Although guidelines for postpubertal adolescents can be found in the adult OI guidelines, drug pharmacokinetics and response to treatment may differ for younger prepubertal or pubertal adolescents. Therefore, these guidelines also apply to treatment of HIV-infected youth who have not yet completed pubertal development. Major changes in the guidelines include 1) greater emphasis on the importance of antiretroviral therapy for preventing and treating OIs, especially those OIs for which no specific therapy exists; 2) information about the diagnosis and management of immune reconstitution inflammatory syndromes; 3) information about managing antiretroviral therapy in children with OIs, including potential drug--drug interactions; 4) new guidance on diagnosing of HIV infection and presumptively excluding HIV infection in infants that affect the need for initiation of prophylaxis to prevent Pneumocystis jirovecii pneumonia (PCP) in neonates; 5) updated immunization recommendations for HIV-exposed and HIV-infected children, including hepatitis A, human papillomavirus, meningococcal, and rotavirus vaccines; 6) addition of sections on aspergillosis; bartonella; human herpes virus-6, -7, and -8; malaria; and progressive multifocal leukodystrophy (PML); and 7) new recommendations on discontinuation of OI prophylaxis after immune reconstitution in children. The report includes six tables pertinent to preventing and treating OIs in children and two figures describing immunization recommendations for children aged 0--6 years and 7--18 years. Because treatment of OIs is an evolving science, and availability of new agents or clinical data on existing agents might change therapeutic options and preferences, these recommendations will be periodically updated and will be available at http://AIDSInfo.nih.gov.

Validation of 2006 WHO prediction scores for true HIV infection in children less than 18 months with a positive serological HIV test

Introduction

All infants born to HIV-positive mothers have maternal HIV antibodies, sometimes persistent for 18 months. When Polymerase Chain Reaction (PCR) is not available, August 2006 World Health Organization (WHO) recommendations suggest that clinical criteria may be used for starting antiretroviral treatment (ART) in HIV seropositive children <18 months. Predictors are at least two out of sepsis, severe pneumonia and thrush, or any stage 4 defining clinical finding according to the WHO staging system.

Methods and Results

From January 2005 to October 2006, we conducted a prospective study on 236 hospitalized children <18 months old with a positive HIV serological test at the national reference hospital in Kigali. The following data were collected: PCR, clinical signs and CD4 cell count.

Current proposed clinical criteria were present in 148 of 236 children (62.7%) and in 95 of 124 infected children, resulting in 76.6% sensitivity and 52.7% specificity. For 87 children (59.0%), clinical diagnosis was made based on severe unexplained malnutrition (stage 4 clinical WHO classification), of whom only 44 (50.5%) were PCR positive. Low CD4 count had a sensitivity of 55.6% and a specificity of 78.5%.

Conclusion

As PCR is not yet widely available, clinical diagnosis is often necessary, but these criteria have poor specificity and therefore have limited use for HIV diagnosis. Unexplained malnutrition is not clearly enough defined in WHO recommendations. Extra pulmonary tuberculosis (TB), almost impossible to prove in young children, may often be the cause of malnutrition, especially in HIV-affected families more often exposed to TB. Food supplementation and TB treatment should be initiated before starting ART in children who are staged based only on severe malnutrition.

Diagnostic and management challenges for childhood tuberculosis in the era of HIV

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.

Pneumocystis jiroveci pneumonia and other pulmonary infections in TB smear-negative HIV-positive patients with atypical chest X-ray in Ethiopia

Pneumocystis pneumonia (PCP) has been considered a rare disease in sub-Saharan Africa. However, a rising prevalence has been noted recently. The objective of this study was to determine the relative prevalence of PCP and other pulmonary opportunistic diseases in patients infected with HIV in Ethiopia. 131 consecutive patients with respiratory symptoms and atypical chest X-ray, who were sputum smear-negative for AFB and seroreactive for HIV, underwent clinical evaluation and investigation for Pneumocystis jiroveci and Mycobacterium tuberculosis from sputum and bronchoalveolar lavage (BAL), and fungal and bacterial pathogens from BAL alone. Bacterial infections, Pneumocystis pneumonia (PCP) and pulmonary tuberculosis (PTB) occurred in 44 (33.6%), 39 (29.7%) and 31 (23.7%) patients, respectively. Pulmonary Kaposi sarcoma and non-specific interstitial pneumonitis occurred in 4 patients each. In a multivariate regression model, predictors of PCP were typical chest X-ray and low CD4 count while purulent sputum predicted bacterial infection. The sensitivity of physicians and chest X-ray diagnosis was particularly low for PTB and bacterial infections. We conclude that chronic bacterial infection and Pneumocystis pneumonia are important differential diagnoses in HIV-infected, smear-negative PTB patients presenting with atypical chest X-ray. We therefore need to escalate the use of preventive and highly active antiretroviral (HAART) treatment in order to prevent a PCP epidemic.

Estimating the number of vertically HIV-infected children eligible for antiretroviral treatment in resource-limited settings

BACKGROUND

With the gradual roll-out of antiretroviral therapy (ART) to delay progression of HIV disease in children in programmes across sub-Saharan Africa and resource-limited settings elsewhere, reliable information on the number of vertically infected children eligible for such treatment is urgently required.

METHODS

We present a model to estimate the number of vertically HIV-infected children by age who have progressed to moderate to severe disease (MSD) and as such are eligible for ART on the basis of clinical disease, allowing for: antenatal HIV prevalence, use of interventions to prevent mother-to-child transmission (PMTCT), infant feeding policies and availability of co-trimoxazole to prevent opportunistic infections that may hasten the onset of serious disease. The model assumptions were informed by published evidence and expert opinion; rates of progression to serious disease were inferred from mortality of infected and uninfected children of HIV-infected mothers; and mortality among children treated with ART was based on a study of treated children in Abidjan. To allow widespread use the model has been developed using the Excel spreadsheet software.

RESULTS

With South Africa as a hypothetical example, published antenatal prevalence and demographic data, and assuming PMTCT coverage with single dose nevirapine of 11%, all exposed and infected children receive co-trimoxazole, and various infant feeding policy scenarios, estimated numbers of children eligible for ART are presented.

CONCLUSIONS

This model is easy to implement and flexible and can be used in ART programmes at national and local level.

Contribution of bacterial sepsis to morbidity in infants born to HIV-infected Haitian mothers

BACKGROUND

Haiti is a country with a heavy burden of HIV infection in childbearing women. Previous studies have shown that early infant deaths are common in children of HIV-infected women. This study was designed to define the rates of and risk factors for systemic bacterial and mycobacterial infection in such children and to identify the causative agents.

METHODS

A cohort of 120 children born to HIV-infected mothers between May 2001 and December 2003 were prospectively observed to 15 months of age. They received comprehensive pediatric care at the GHESKIO Centers. Children were assigned to being HIV-infected by serology, RNA detection, and/or defining clinical illnesses. Blood cultures were obtained before giving antibiotics in children who were febrile or chronically ill. Blood cultures also were obtained at selected visits on well children.

RESULTS

The mortality rate in the first 15 months was high, 22 of 106 (207/1,000 live births) in these children. Sixteen (70%) deaths were within 6 months of birth. Fourty-eight blood cultures had clinically significant organisms of which 38 were Staphylococcus aureus. Blood cultures were more likely to be positive in symptomatic and in HIV-infected children.

CONCLUSIONS

Despite perinatal HIV treatment, mortality in children born to HIV-infected mothers remained high. Bacteremia, particularly with Staphylococcus aureus, is a partial explanation for excess illness.

Cotrimoxazole prophylaxis for opportunistic infections in children with HIV infection

BACKGROUND

The majority of children with HIV infection live in low-income countries without access to antiretroviral drugs. The prevention and early treatment of opportunistic infections are the mainstay of their medical management. Cotrimoxazole is cheap and effective against a wide range of organisms, including Pneumocystis jiroveci pneumonia (PCP), which is an important cause of death and illness in the first year of life. It is safe with relatively few side effects. Diagnosis of HIV in children is complicated by the presence of maternal antibodies in early life. Providing prophylaxis based initially on maternal status is one possible solution. However, routine prophylactic treatment is difficult to deliver in low-resource settings, and could also lead to increased resistance to the drug.

OBJECTIVES

To assess the effects of routinely administered cotrimoxazole on death and illness episodes in children with HIV infection, and in infants of HIV-infected mothers.

SEARCH STRATEGY

We searched the Cochrane HIV/AIDS registry, MEDLINE, the Cochrane Controlled Trials Register, LILACS, AIDSLINE, AIDSTRIALS and AIDSDRUGS databases, and proceedings and abstracts from AIDS and TB conferences (search date Feb 2005). We checked reference lists of pertinent articles, and contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing routinely administered cotrimoxazole versus placebo or no treatment in children (age less than 15 years) with HIV infection, or children less than 18 months with HIV infected mothers.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality. Where data were incomplete or unclear trial authors were contacted for further details.

MAIN RESULTS

One study was identified that fulfilled the inclusion criteria. It studied 534 children with HIV infection in Lusaka, Zambia. The study was conducted in an area of high bacterial resistance to cotrimoxazole (60-80%). A reduction in mortality of 33% was seen in the cotrimoxazole group as compared to placebo, relative risk 0.67 (95% CI 0.53 - 0.85). There was also a beneficial effect on hospitalisation, relative risk 0.77 (95% CI 0.62 - 0.96). There was no difference in adverse events between groups, and the beneficial effect was seen across all ages and CD4%.

AUTHORS' CONCLUSIONS

A single trial has shown a beneficial effect from the use of cotrimoxazole prophylaxis in HIV infected children in Zambia. It must be decided whether this can be extrapolated to other resource-poor settings.

HIV infection among paediatric in-patients in Blantyre, Malawi

To investigate the impact of HIV infection on hospital admission and death we studied children admitted to paediatric medical and surgical wards in Blantyre, Malawi, in March 2000. Unselected children whose parents or guardians consented to HIV testing of the child were recruited and HIV infection was determined by serology, with confirmation in children aged 15 months or less by PCR. We assessed the prevalence of HIV infection by age, clinical diagnosis and outcome of admission. Of 1064 admissions, 991 were tested for HIV infection, and 187 (18.9%) were infected. HIV was most common in children aged less than six months, 53 of 166 (32%). Parents of HIV-infected children were better educated, and more likely to have died, than those of uninfected children. Clinical symptoms and signs were not adequately sensitive or specific to be used for diagnosis of HIV. HIV was common in children with malnutrition (prevalence 40%), lower respiratory tract infection (29%) and sepsis (28%), and less prevalent among children with malaria (11%) or surgical admissions (11%). Almost 30% of HIV-infected children died, compared with 8.9% of uninfected children, and HIV-infected children constituted over 40% of in-patient deaths.

Pneumocystis carinii in children with severe pneumonia at Mulago Hospital, Uganda

The prevalence of Pneumocystis carinii pneumonia (PCP), its clinical and radiological features and the outcome in 121 children aged 2-60 months presenting with severe pneumonia over a 2-month period at Mulago Hospital, Kampala are described. Children presenting with severe pneumonia had sputum induction using 3% hypertonic saline. The sputum was stained using PCP monoclonal antibodies and viewed with fluorescent microscopy. Twenty children with confirmed PCP were compared with 101 without PCP. The prevalence of PCP was 16.5%, and 12 (60%) were < 6 months of age. Eighteen (42%) of 43 children infected with HIV had PCP and two of 78 not infected with HIV. The outcome in children with PCP was poor with a case fatality rate of 40% compared with 20% in those without HIV. Radiological findings were non-specific. Clinical features associated with PCP included: HIV-positive infants with a small head circumference, AIDS, a clear chest on auscultation and elevated LDH levels. PCP occurs in one in six children < 5 years with severe pneumonia in Mulago Hospital. In developing countries where investigations for PCP are not routinely available, infants suspected of PCP should be treated as an emergency.

Bacterial infections in children with HIV/AIDS

HIV/AIDS affects over 850,000 children in Africa. Bacterial infections are frequent in this group of children. Pneumonia, meningitis and septicaemia are especially common, recurrent and most often caused by Streptococcus pneumoniae. Salmonella spp are the most frequently isolated causative agent of septicaemia in malarial areas. Soft tissue, eye and oral infections have a higher incidence in HIV-infected than uninfected children. In all instances the causative agents are not dissimilar from those that cause disease in HIV-uninfected children, but the mortality is greater. Increased bacterial resistance to first line antibiotics has been reported and the use of cotrimoxazole prophylaxis may further influence the resistance pattern of common bacteria.

Current epidemiology of Pneumocystis pneumonia

Changes in incidence of PCP, groups at risk for PCP, and possible trends in the disease are discussed.

Pneumocystis pneumonia (PCP) has historically been one of the leading causes of disease among persons with AIDS. The introduction of highly active antiretroviral therapy in industrialized nations has brought about dramatic declines in the incidence of AIDS-associated complications, including PCP. In the adult population, the incidence of PCP has significantly decreased, but it remains among the most common AIDS-defining infections. Similar declines have been documented in the pediatric population. In much of the developing world, PCP remains a significant health problem, although its incidence among adults in sub-Saharan Africa has been debated. This review discusses the epidemiology of PCP during the current era of the AIDS epidemic. Although fewer cases of PCP occur in industrialized countries, increasing drug-resistant HIV infections, possible drug-resistant PCP, and the tremendous number of AIDS cases in developing countries make this disease of continued public health importance.

Tuberculosis in children: considerations for children from developing countries

Although accurate data are scarce for children, tuberculosis (TB) represents one of the most common infectious causes of morbidity and mortality worldwide. TB case rates have declined among children in the United States in the last decade, but they remain high among children from low-income countries and racial or ethnic minorities. Establishing the definitive diagnosis of TB in a child remains difficult and frequently relies on a constellation of history, clinical findings, and bacteriology. Recently, updated national and international treatment recommendations have been published. Contact investigation and treatment using directly observed therapy are important components of the optimal case detection and management of TB in children.

Towards an integrated approach to lung health in adolescents in developing countries

The World Health Organization strategies, Integrated Management of Childhood Illness and Practical Approach to Lung health provide assessment and management guidelines for health workers in developing countries. We reviewed issues important to lung health in adolescents to highlight whether differences in factors such as adolescent behaviour have consequences for the development of case management guidelines, to form a bridge between guidelines for younger children and for adults and to make suggestions for further study. Pneumonia, asthma and tuberculosis are the leading lung health problems in adolescents. As countries industrialise, the importance of asthma mortality and morbidity increases as that of pneumonia and pulmonary tuberculosis decreases. Guidelines for managing pneumonia and asthma in children and adults in developing and developed countries should be adaptable for use in adolescents in developing countries, although more information is needed on predictors of severity such as respiratory rate cut-offs, level of fever, hypotension, malnutrition and level of consciousness. The effectiveness of low-cost treatment for asthma should be explored further. HIV and the global resurgence of tuberculosis pose significant challenges for improving adolescent lung health, and prevention of smoking initiation during adolescence is a priority goal of any integrated approach to improving lung health.

Pneumonia in HIV-infected and HIV-uninfected children in developing countries

PURPOSE OF REVIEW

Pneumonia is a leading cause of illness and death in children younger than 5 years in developing countries, accounting for approximately 20% of childhood deaths. The HIV epidemic has sharply increased the incidence, severity, and mortality of childhood pneumonia in the developing world, particularly in sub-Saharan Africa. This article reviews recent findings on the epidemiology, clinical features, and management of HIV-infected and -uninfected children with pneumonia in developing countries.

RECENT FINDINGS

Bacterial infection remains a major cause of pneumonia mortality; in HIV-infected children, a broader spectrum of pathogens including gram-negative infections and Pneumocystis jiroveci occurs. Mycobacterium tuberculosis is an important cause of acute pneumonia among children from high tuberculosis prevalence areas. Use of case management guidelines substantially reduces neonatal, infant, and under-5 mortality and pneumonia-specific mortality in developing countries. New advances in therapy include the use of short-course antibiotics and high-dose amoxicillin twice daily for ambulatory treatment of HIV-negative children with pneumonia. New preventive interventions include the development of conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae, but these are not widely affordable nor available in developing countries. Despite a lower efficacy in HIV-infected children, these vaccines still protect against disease in a significant proportion of children. Available preventive interventions including micronutrient supplementation with zinc and vitamin A, and immunization as contained in the WHO Expanded Program of Immunization can substantially reduce the burden of childhood pneumonia.

SUMMARY

Urgent measures to implement existing available, effective interventions for prevention and treatment of childhood pneumonia and achieve high coverage rates in developing countries are needed.

Impact of HIV on childhood respiratory illness: differences between developing and developed countries

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.

HIV and respiratory infections in children

Respiratory disease is a frequent cause of morbidity and mortality in children infected with human immunodeficiency virus (HIV). This review highlights recent data and developments that relate to the impact of HIV on respiratory infections particularly in African children. Autopsy and clinical studies continue to show that bacterial pneumonia and Pneumocystis jiroveci pneumonia (PCP) are common respiratory infections and causes of death in regions where antiretroviral therapy and PCP prophylaxis are not routinely practiced. Recent studies of Zambian and South African children showed that pulmonary tuberculosis is more common in HIV-infected children than was previously recognized. The trial of bacterial conjugate vaccines in Johannesburg will provide important information of efficacy in an HIV endemic population. Prospective clinical descriptive and intervention studies are needed from different regions to guide clinical management and prevention of respiratory infections in HIV-infected children living in resource-poor countries.

Effect of supplementing a high-fat, low-carbohydrate enteral formula in COPD patients

OBJECTIVE

One of the goals in treating patients with chronic obstructive pulmonary disease (COPD) who suffer from hypoxemia, hypercapnia, and malnutrition is to correct the malnutrition without increasing the respiratory quotient and minimize the production of carbon dioxide. This 3-wk study evaluated the efficacy of feeding a high-fat, low-carbohydrate (CHO) nutritional supplement as opposed to a high-carbohydrate diet in COPD patients on parameters of pulmonary function.S METHODS: Sixty COPD patients with low body weight (<90% ideal body weight) were randomized to the control group, which received dietary counseling for a high-CHO diet (15% protein, 20% to 30% fat, and 60% to 70% CHO), or the experimental group, which received two to three cans (237 mL/can) of a high-fat, low-CHO oral supplement (16.7% protein, 55.1% fat, and 28.2% CHO) in the evening as part of the diet. Measurements of lung function (forced expiratory volume in 1 s or volume of air exhaled in 1 s of maximal expiration, minute ventilation, oxygen consumption per unit time, carbon dioxide production in unit time, and respiratory quotient) and blood gases (pH, arterial carbon dioxide tension, and arterial oxygen tension) were taken at baseline and after 3 wk.

RESULTS

Lung function measurements decreased significantly and forced expiratory volume increased significantly in the experimental group.

CONCLUSION

This study demonstrates that pulmonary function in COPD patients can be significantly improved with a high-fat, low-CHO oral supplement as compared with the traditional high-CHO diet.

Pathology and causes of death in a series of human immunodeficiency virus-positive and -negative pediatric referral hospital admissions in Botswana

BACKGROUND

Little is known about causes of death among children seriously affected by the AIDS epidemic in southern African countries.

METHODS

Autopsies were performed on 47 children 1 month to 13 years of age in Francistown, Botswana, between July 1997 and July 1998.

RESULTS

Median age was 10 months; 68% were HIV-positive. The leading cause of death was respiratory infection, accounting for 29 of 35 (83%) deaths among HIV-positive and 8 of 12 (67%) deaths among HIV-negative children. Among HIV-positive children, Pneumocystis carinii pneumonia (PCP) was responsible for 31% of all deaths and for 48% of deaths in infants < or =1 year. Among children < or =2 years with cough and dyspnea, age < or =1 year, interstitial infiltrate and HIV positivity were highly predictive of PCP (sensitivity, 100%; specificity, 63%).

CONCLUSION

Respiratory disease accounted for most deaths in HIV-positive children. Children < or =1 year who are known or suspected to be HIV-positive and who have cough, dyspnea and pulmonary infiltrates should be treated presumptively for PCP.

Pneumocystis carinii pneumonia in patients in the developing world who have acquired immunodeficiency syndrome

We review Pneumocystis carinii pneumonia (PCP) in patients in the developing world (i.e., Africa, Asia, the Philippines, and Central and South America) who have acquired immunodeficiency disease (AIDS). During the first decade of the AIDS pandemic, PCP rarely occurred in African adults. More recent reports have noted that PCP comprises a significantly greater percentage of cases of pneumonia than it did in the past. This trend dramatically contrasts with that observed in industrialized nations, where a reduction in the number of cases of PCP has occurred as a result of the widespread use of primary P. carinii prophylaxis and highly active antiretroviral therapy. Throughout the developing world, the rate of coinfection with Mycobacterium tuberculosis and PCP is high, ranging from 25% to 80%. Initiation of treatment when PCP is in an advanced stage may account for the high mortality rates (20%-80%) associated with pediatric PCP in the developing world.

Cotrimoxazole prophylaxis for opportunistic infections in children with HIV infection

BACKGROUND

The prevention and early treatment of infections are the mainstay of the medical management of the majority of children with HIV infection, who live in low income countries without access to antiretroviral drugs. Cotrimoxazole is cheap and effective against a wide range of organisms, including Pneumocystis carinii pneumonia (PCP) which is an important cause of death and illness in the first year of life. It is safe with relatively few side-effects. Diagnosis of HIV in children is complicated by the presence of maternal antibodies in early life and providing prophylaxis based initially on maternal status is one possible solution. However routine prophylactic treatment is difficult to deliver in low-resource settings, and could also lead to increased resistance to the drug.

OBJECTIVES

To assess the effects of routinely administered cotrimoxazole on death and illness episodes in children with HIV infection, and in infants of HIV infected mothers.

SEARCH STRATEGY

We searched the Cochrane HIV/AIDS registry, MEDLINE, the Cochrane Controlled Trials Register, LILACS, AIDSLINE, AIDSTRIALS and AIDSDRUGS databases, and proceedings and abstracts from AIDS and TB conferences (search date July 2001). We checked reference lists of pertinent articles, and contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

Randomised or quasi randomised trials comparing routinely administered cotrimoxazole versus placebo or no treatment in children (age less than 13 years) with HIV infection, or children less than 18 months with HIV infected mothers.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial eligibility and quality.

MAIN RESULTS

No studies were found that fulfilled the selection criteria.

REVIEWER'S CONCLUSIONS

No evidence from controlled trials was found of the effect of cotrimoxazole prophylaxis in HIV-infected children.