The role of new hepatitis B vaccines in South Africa

Vaccination is key to eliminating hepatitis B virus infection in South Africa (SA). Despite introducing immunisation in 1995, as part of the expanded programme of immunisation (EPI), hepatitis B virus infection remains endemic, and EPI vaccine coverage is incomplete. In addition to infants, non-immune adults at risk of infection through their occupation or with behavioural risk factors should receive vaccination. SA has many individuals with diabetes mellitus (a prevalence of almost 13%), obesity, HIV (8.45 million) or older age (5 million >60 years old), associated with a poorer vaccine response. Recently two new hepatitis B vaccines have been licensed: HEPLISAV-B includes an adjuvant that improves immunogenicity and has shown improved vaccine response in individuals with HIV, old age or diabetes mellitus. PreHevbrio, which includes three hepatitis B surface protein domains, instead of one, may also be more immunogenic, although clinical study data are still limited. These two novel vaccines have not yet been investigated in children and licensed in SA. Should HEPLISAV-B become available in SA, it may be particularly valuable to target high-risk groups in the country, such as people living with HIV, who show a poor response to the currently licensed vaccine.

Clinical standards for drug-susceptible TB in children and adolescents

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

The prognostic impact of Wilms tumor-1 polymorphism (rs16754) and human myeloid inhibitory C-type lectin-like receptor expression in cytogenetically normal-acute myeloid leukemia

Background

There are several genetic mutations that carry prognostic and predictive values in acute myeloid leukemia (AML). They are also implicated in disease pathogenesis and patient outcome. They can be a target of novel therapies for AML. The aim of the current study was to investigate prognostic value of Wilms’ tumor-1 (WT1) genotypes and human myeloid inhibitory C-type lectin-like (hMICL) receptor expression in normal-cytogenetic group of patients with AML. Genotyping of WT1 mutations was done by Rotor Gene real-time polymerase chain reaction (PCR) while hMICL expression was detected using phycoerythrin (PE)-conjugated mouse monoclonal anti-human (MoAbs) by flow cytometry.

Results

Sixty-three patients with cytogenetically normal AML (CN-AML) were included in the study. The alternate allele of WT1 single nucleotide polymorphism (SNP) rs16754 was found in 26.89%. At day 28 of therapy, complete remission was achieved in 100% of cases harboring mutant AG plus GG genotypes but only in 6.38% of cases harboring wild genotype (AA). After 6 months, 88.23% of patients harboring WT1 mutant genotype maintained complete remission, while only 23.40% of patients with wild type showed complete remission. The overall survival in patients harboring mutant WT1 genotypes was significantly longer than in those who carried the wild type gene (P-value, 0.001). Additionally, hMICL was overexpressed in approximately 87.3% of AML cases and inversely related to complete response. Similarly, overall survival was significantly shorter in patients with positive hMICL (P-value, 0.001).

Conclusion

Mutant WT1 genotypes (SNP rs16754) were conversely, associated with complete response, and hMICL overexpression had poor prognostic value in AML.

Janus Kinase-2 Mutation Associated Portal Vein Thrombosis Complicating Liver Cirrhosis and Hepatocellular Carcinoma

Background:

Portal vein thrombosis (PVT) might be a catastrophic event complicating liver cirrhosis and hepatocellular carcinoma (HCC).

Aim:

role of JAK2 RS V617F mutation as a risk factor for PVT development in liver cirrhosis and HCC.

Methods:

A case control study conducted on 100 PVT patients (76 HCC and 24 liver cirrhosis) additionally, 100 healthy individuals used as a control group. PVT was diagnosed incidentally by Doppler ultrasound during routine follow-up HCC screening. ProthrombinG20210A mutation, MTHFR mutation, Factor V Leiden mutation (VFL), antithrombin III (ATIII), protein C, S, and antiphospholipid antibodies, along with JAK2 RS V617F mutation by real-time polymerase chain reaction all were analyzed.

Results:

Patients with PVT were significantly older (p<0.001), thrombocytopenic (p<0.001), with high alkaline phosphatase (p<0.001). JAK2 RS V617F mutation was found in 28/100 (28%) in idiopathic PVT complicating liver cirrhosis and hepatocellular carcinoma. Cases with positive JAK2 rs V617F mutation were significantly accompanied by protein S deficiency (P 0.03), LA absence (p 0.06), and high frequency of ascites (P 0.03). While, the MTHFR heterozygous mutation (p0.001), ATIII (P 0.02), and VFL (P 0.01) were more frequent with negative JAK2 rs V617F mutation. The comparison between demographic data and thrombophilic parameters in PVT cases revealed that no significant differences were recorded except for male gender, Diabetes Mellitus, splenomegaly significantly increased among HCC cases (p<0.05).

Conclusions:

JAK2 rs V617F mutation must be considered in any case of PVT with liver cirrhosis and hepatocellular carcinoma without identified thrombophilic risk factors, with potential considerations of evolving myeloproliferative disorders. New diagnostic and therapeutic implications are still awaited.

COVID-19 response in low- and middle-income countries: Don't overlook the role of mobile phone communication

Estimates of health capacities in the context of the coronavirus disease 2019 (COVID-19) pandemic indicate that most low- and middle-income countries (LMICs) are not operationally ready to manage this health emergency. Motivated by worldwide successes in other infectious disease epidemics and our experience in Sub-Saharan Africa, we support mobile phone communication to improve data collection and reporting, communication between healthcare workers, public health institutions, and patients, and the implementation of disease tracking and subsequent risk-stratified isolation measures. Programmatic action is needed for centrally coordinated reporting and communication systems facilitating mobile phones in crisis management plans for addressing the COVID-19 pandemic in LMICs. We summarize examples of worldwide mobile phone technology initiatives that have enhanced patient care and public health outcomes in previous epidemics and the current COVID-19 pandemic. In addition, we provide an overview of baseline conditions, including transparency about privacy guarantees, necessary for the successful use of mobile phones in assisting in the fight against COVID-19 spread.

Horizontal HIV transmission to children of HIV-uninfected mothers: A case series and review of the global literature

BACKGROUND

Vertical transmission is the predominant route for acquisition of HIV infection in children, either in utero, intrapartum or postnatally through breast feeding. Less frequently, children may acquire HIV by horizontal transmission. Horizontal transmission may be healthcare-associated (infusion of HIV-contaminated blood products, use of contaminated needles, syringes and medical equipment, or through ingestion of HIV in expressed breastmilk). Community-acquired HIV transmission to children may occur following surrogate breastfeeding, pre-mastication of food, and sexual abuse.

METHODS

Children with suspected horizontally acquired HIV infection were identified by retrospective folder review of existing patients (2004-2014) and by prospective interview and examination of new patients (from 2009 onwards), at a hospital-based paediatric antiretroviral clinic in Cape Town, South Africa. The global literature on horizontal HIV transmission to children (1 January 1986-1 November 2019) was reviewed, to contextualize the local findings.

RESULTS

Among the 32 children with horizontal HIV transmission (15 identified retrospectively and 17 prospectively), the median age at first diagnosis was 79 months (interquartile range 28.5-91.5); most children (90.6%) had advanced HIV disease at presentation. HIV transmission was considered healthcare-associated in 15 (46.9%), community-associated in ten (31.3%), possibly healthcare or community-associated in five (15.6 %); and unknown in two children (6.3%).

CONCLUSION

Horizontal HIV transmission to children is an important public health issue, with prevention efforts requiring intervention at healthcare facility- and community-level. Greater effort should be made to promptly identify and comprehensively investigate each horizontally HIV-infected child to establish possible routes of transmission and inform future prevention strategies.

The Circulating Micro-RNAs (-122, -34a and -99a) as Predictive Biomarkers for Non-Alcoholic Fatty Liver Diseases

BACKGROUND

It remains essential for patient safety to develop non-invasive diagnostic tools to diagnose non-alcoholic fatty liver rather than invasive techniques.

AIM

Our case-control study was to address the value of circulating miRNAs as a potential non-invasive biomarker for the diagnosis of non-alcoholic fatty acid diseases (NAFLD) and monitoring of disease progression.

METHODS

Routine clinical assessment, laboratory tests, anthropometric study, and liver biopsy results reported for 210 patients with NAFLD (124 patients of simple steatosis (SS) and 86 of non-alcoholic steatohepatitis (NASH)). Apparently matched for age and gender, healthy participants (n= 90) were enrolled as a control group. Serum samples were tested for micro-RNAs (-122, -34a and -99a) by quantitative-PCR.

RESULTS

By histopathology, 124 of the NAFLD group were of SS and 86 patients were of NASH. Compared with the control subjects, both mi-RNA-122 and -34a levels were increased in NAFLD (p< 001) and at a cut-off = 1.261, mi-RNA-122 had 92% sensitivity, 85% specificity to differentiate NAFLD from healthy controls, while mi-RNA-99a were significantly decreased in NAFLD patients with an observed decrease in disease severity, and at a cut-off = 0.46, miRNA-99a had 94% sensitivity and 96% specificity to discriminate SS from NASH.

CONCLUSION

The integration of a circulating mi-RNA panel to diagnose NAFLD cases and to discriminate between SS and NASH. Large-scale study is still needed to verify the other mi-RNA profiles and their role in NAFLD pathogenesis and targeting therapy.

Effect of topical ofloxacin on bacterial biofilms in refractory post-sinus surgery rhino-sinusitis

Bacterial biofilms have been shown to play a major role in many chronic infections, in addition, there is growing evidence that bacterial biofilms may play a role in some forms of refractory CRS that persists despite proper surgery and culture directed antibiotic therapy. The objective is to determine the effect of application of topical ofloxacin on nasal and sinus mucosa in patients with proven existence of bacterial biofilms and persistent chronic sinusitis after FESS. The study design is a prospective controlled study. The study included a total of 12 patients who had refractory CRS in spite of undergoing FESS for that specific reason (study group), and control group (involved 25 patients), for whom FESS was done, with complete improvement postoperatively in 15 of them, and persistence of symptoms in the other ten. Topical ofloxacin eye drops (0.3 %) tds for 12 weeks were prescribed for (study group), culture and sensitivity and scanning electron microscopy were done for middle meatal mucosal specimens for all patients and controls, all of them were followed up for a minimum of 9 months (range 9-18 months). Of the study group, 80 % showed marked improvement in the structure of the mucosa, with the regaining of normal respiratory epithelium, with complete disappearance of the biofilm surface, and the remaining 20 % showed only reduction in the number of inflammatory cells and regaining cilia with scattered patches of very thin biofilm. Biofilms formation plays an active role in perpetuating inflammation in CRS patients and enhanced the recurrence and resistance in those patients, we found a statistically significant improvement in patients' group (P < 0.001), after 12 weeks of topical ofloxacin (without any evidence of any side effects). So, we concluded that topical ofloxacin seems to be an effective, tolerable, convenient, cheap and even safe mode of treatment of refractory CRS after FESS due to biofilms' formation. Thus, we recommend such modality of treatment postoperatively especially in refractory cases of CRS.

Management of upper respiratory tract infections in children

Upper respiratory tract infection (URTI) occurs commonly in both children and adults and is a major cause of mild morbidity. It has a high cost to society, being responsible for absenteeism from school and work and unnecessary medical care, and is occasionally associated with serious sequelae. URTIs are usually caused by several families of virus; these are the rhinovirus, coronavirus, parainfluenza, respiratory syncytial virus (RSV), adenovirus, human metapneumovirus, influenza, enterovirus and the recently discovered bocavirus. This review will mainly focus on the rhinovirus, where significant advances have been made in understanding the epidemiology, natural history and relationship with other pathogens.

Managing the HIV-infected neonate: A rural doctor’s perspective

No Abstract Available

Paediatric ART outcomes in a decentralised model of care in Cape Town, South Africa

Background. Although subSaharan Africa faces the world’s largest paediatric HIV epidemic, only 1 in 4 children has access to combination antiretroviral therapy (ART). A decentralised approach to HIV care is advocated, but programmes in resource-limited settings encounter many challenges to community-initiated paediatric ART implementation. Methods.  A retrospective cohort analysis of 613 children receiving ART between 2004 and 2009 was performed in seven physician-run primary healthcare (PHC) clinics in Cape Town. Baseline characteristics, serial CD4+, viral load (VL) levels and status at study closure were collected. Results. Two subgroups were identified: children who were initiated on ART in a PHC clinic (n=343) and children who were down-referred from tertiary hospitals (n=270). The numbers of children initiated on ART in PHC increased sevenfold over the study period. Down-referred children were severely ill at ART initiation, with higher VLs, lower CD4+ counts and higher rates of tuberculosis co-infection (25.3% v. 16.9%; p=0.01). Median time to virological suppression was 29 weeks in PHC-ART initiates and 44 weeks in children down-referred (p<0.0001). Children down-referred to PHC either maintained or gained virological suppression. Longitudinal cohort analysis demonstrated sustained VL suppression >80%, high rates of immune reconstitution and low mortality.Conclusions. Increasing numbers of children are initiated on ART in PHC settings and achieve comparable immunological, virological and survival outcomes, suggesting successful decentralisation of paediatric HIV care. Down-referral of children with adherence-related virological failure may assist with attainment of virological suppression and sparing use of second-line medications.

Early antiretroviral treatment reduces risk of bacille Calmette-Guérin immune reconstitution adenitis

SETTING

Two centres in Soweto and Cape Town, South Africa.

OBJECTIVE

To assess the effects of timing of initiation of antiretroviral treatment (ART) and other factors on the risk of bacille Calmette-Guérin (BCG) related regional adenitis due to immune reconstitution inflammatory syndrome (BCG-IRIS) in human immunodeficiency virus (HIV) infected infants.

DESIGN

HIV-infected infants aged 6-12 weeks with CD4 count ≥25% enrolled in the Children with HIV Early Antiretroviral Therapy (CHER) Trial received early (before 12 weeks) or deferred (after immunological or clinical progression) ART; infants with CD4 count <25% all received early ART. All received BCG vaccination after birth. Reactogenicity to BCG was assessed prospectively during routine study follow-up.

RESULTS

Of 369 infants, 32 (8.7%) developed BCG-IRIS within 6 months of starting ART, 28 (88%) within 2 months after ART initiation. Of the 32 cases, 30 (93.8%) had HIV-1 RNA > 750 000 copies/ml at initiation. Incidence of BCG-IRIS was 10.9 and 54.3 per 100 person-years (py) among infants with CD4 count ≥25% at enrolment receiving early (at median age 7.4 weeks) vs. deferred (23.2 weeks) ART, respectively (HR 0.24, 95%CI 0.11-0.53, P < 0.001). Infants with CD4 count <25% receiving early ART had intermediate incidence (41.7/100 py). Low CD4 counts and high HIV-1 RNA at initiation were the strongest independent risk factors for BCG-IRIS.

CONCLUSIONS

Early ART initiation before immunological and/or clinical progression substantially reduces the risk of BCG-IRIS regional adenitis.

TB and HIV in children - advances in prevention and management

The human immunodeficiency virus (HIV) epidemic has had a major impact on the age and gender profile of adult tuberculosis (TB) patients, resulting in increased exposure of HIV-infected and uninfected children at a very young age. Young and/or HIV-infected children are extremely vulnerable to develop severe forms of TB following recent exposure and infection. There is an urgent need to implement safe and pragmatic strategies to prevent TB in children, especially in TB endemic areas where they suffer the greatest burden of disease. The management of TB in HIV-infected children poses multiple challenges, but recent advances in the implementation of prevention of mother to child transmission (PMTCT) strategies and HIV care of infants offer hope. These include HIV testing and access to PMTCT for all pregnant women, routine testing of all HIV exposed infants and rapid initiation of antiretroviral treatment irrespective of clinical or immunological disease staging. In addition, careful scrutiny for TB exposure should occur at every health care visit, with provision of isoniazid preventive therapy (IPT) following each documented exposure event. Knowing the HIV infection status of child TB suspects is essential to optimize case management. Although multiple difficulties remain, recent advances demonstrate that the management of children with TB and/or HIV can be vastly improved by well focused interventions using readily available resources.

A case of congenital measles during the 2010 South African epidemic

Congenital measles is a well recognised but uncommon transplacental infection in the post-vaccine era. A 4-day-old infant is described who presented with uncomplicated congenital measles during the 2010 South African measles outbreak. Clinicians working in regions affected by measles outbreaks should be mindful of waning vaccine-induced measles immunity where infections among pregnant women may result in a resurgence of congenital measles.

Tragal cartilage augmentation in repair of cleft palate, a new technique and its clinical implications

BACKGROUND

Cleft palate is one of the most common congenital anomalies of the head and neck worldwide. In addition to the evident feeding and growth problems, patients are involved with and suffer from speech, hearing and dental problems. Many surgical techniques and modifications have been advocated to improve functional outcome and aesthetic results, aiming at normal speech, minimizing growth disturbances, and establishing a competent velopharyngeal sphincter. Despite the variety of techniques described for repair of the clefts, there is still a relatively high incidence of postoperative fistula reaching up to 35%. This is mainly related to type and degree of the defect, and type of surgical repair.

OBJECTIVES

To evaluate the efficacy of placement of tragal cartilage free graft between the oral and nasal mucosal layers of the neo-palate in improving success rates, and anatomical and functional outcomes in repair of cleft palate with reduction of the extent of dissection.

PATIENTS AND METHODS

Fourteen patients were managed by our technique, only in large cases minimal von Langenbeck lateral release incisions were made. In all cases a tragal cartilage graft was interpositioned and fixed to the muscle layer of the neo-palate, 2-3 extramucosal trans-muscle sutures were placed for 3-4 weeks if needed, and the patients were followed up for a minimum of 12 months during which functional and anatomical assessments were done.

RESULTS

Results, including both anatomical and functional outcomes, were favorable with no gross failures, permanent significant fistula formations (one case with minor non-significant fistula), nor donor site co morbidities.

CONCLUSION

The use of tragal cartilage free graft to augment the area at the junction between the hard and soft palate appears to be a safe and effective method in repair of cleft palate that reduces the incidence of postoperative palatal fistulae, without donor site comorbidities.

Attention deficit hyperactivity and oppositional defiance disorder in HIV-infected South African children

OBJECTIVE

To determine the prevalence of attention deficit-hyperactivity disorder (ADHD) and oppositional defiance disorder (ODD) in HIV-infected South African children.

METHODS

Swanson, Nolan and Pelham (SNAP-IV) questionnaires were used to determine ADHD and ODD severity and a draw-a-person (DAP) test was used to screen for developmental disorders. Associations between behavioural subtypes, psychological functioning, demographic and health variables were investigated.

RESULTS

The SNAP-IV caregiver questionnaires showed a 26% prevalence of ADHD inattentive type; 38% hyperactive type and 24% combined type. The prevalence of ODD was 12% on parent questionnaires and 9.5% on teacher's questionnaires.

CONCLUSIONS

Parents/caregiver-only SNAP-IV questionnaires indicate a high prevalence of significant ADHD (all subtypes) and ODD in HIV-infected children. No significant differences were found between the severity of HIV disease and the presence of a behavioural disorder. The SNAP IV questionnaires and DAP test may prove valuable screening tools in HIV children with behavioural problems.

A window into a public program for prevention of mother to child transmission of HIV: evidence from a prospective clinical trial

OBJECTIVES: To evaluate efficacy of the antenatal, intra-partum and post-natal antiretroviral components of a public service Prevention of Mother to Child (MTCT) program in infants. DESIGN: Analysis of prospectively collected screening data of demographic and MTCT-related interventions and HIV-infection status of infants identified through HIV-specific DNA polymerase chain reaction. SETTING: Tygerberg Children's Hospital, Western Cape Province, South Africa. SUBJECTS: HIV-infected women and their infants identified through participation in a public service MTCT program were referred for possible participation in a prospective study of isoniazid prophylaxis. INTERVENTIONS: Key components of the Program include voluntary counselling and testing, zidovudine to the mother from between 28 and 34 weeks gestation and to the newborn infant for the first week, single dose nevirapine to the mother in labour and the newborn shortly after birth and free formula for 6 months. MAIN OUTCOME MEASURES: Number and percentage of HIV-infected infants and extent of exposure to antenatal, intrapartum and post-natal antiretrovirals. RESULTS: Of 656 infants with a median age of 12.6 weeks, screened between April 1(st) 2005 through May 2006, 39 were HIV-infected giving a transmission rate of 5.9% (95% CI: 4.4% - 8.0%). Antenatal prophylaxis was significantly associated with reduced transmission (OR: 0.43 (95% CI: 0.21 - 0.94)) as opposed to intrapartum and postpartum components (p=0.85 and p=0.84, respectively). In multivariable analysis the antenatal component remained significant (OR=0.40 (95% CI 0.19 - 0.90)). CONCLUSIONS: The antenatal phase is the most important antiretroviral component of the MTCT program, allowing most opportunity for intervention.

Otorrhoea is a marker for symptomatic disease in HIV-infected children

BACKGROUND

Chronic otorrhoea occurs commonly in HIV-infected children. However, there are few data on incidence and severity.

OBJECTIVE

To document the prevalence of otorrhoea in the clinic attendees.

METHODS

A retrospective chart review was done of all HIVI infected children seen at the Family Clinic for HIV from 1 February 1997 to 31 December 2001, a period preceding widespread availability of antiretrovirals. Otorrhoea was classified into two groups, viz. group 1 (mild): an episode lasting less than 1 month, and group 2 (severe): an episode lasting more than 1 month or more than 1 episode of otorrhoea. The clinical and immune stages of the children were noted.

RESULTS

Of 326 children seen during the study period, 104 (32%) had otorrhoea. Forty-five (13.8%) had mild and 59 (18.1%) severe otorrhoea. Two hundred and eighty-eight (88.6%) had either Centers for Disease Control stage B or C disease. The median CD4 percentage in children with otorrhoea was 17.5% (8.3-23%) versus 21% (14-28%) in those without otorrhoea (p=0.004). The odds ratio (OR) of children in stage B or C not having severe otorrhoea was 0.1 (0.01 - 0.72, p = 0.013). The OR for immune class 2 or 3 without severe otorrhoea was 0.39 (0.18 - 0.85, p = 0.021).

CONCLUSIONS

Otorrhoea contributes to the morbidity of HIV infection in children. It is a marker for symptomatic disease and CD4 depletion and should be included in clinical classifications.

Mass needle stick injury in children from the Western cape

Illegal dumping of contaminated medical waste occurs commonly in South Africa. There is little information on the management and outcome of the children exposed to and injured by medical waste. On 15 September 1999, 54 children where involved in a mass exposure incident. 44 presented the same evening and 10 following day. Used needles and syringes were discarded on their soccer field. Children gave one another injections and played darts with the discarded needles. Parents were counselled and blood was drawn for HIV and Hepatitis B virus (HBV) serology. All were given HBV vaccination (HBVV). Stat doses of zidovudine (ZDV) and lamivudine (LMV) were given to all with visible wounds or history of percutaneous injury. Younger children were given prophylaxis as we considered their histories unreliable. Further visits were conducted at the community clinic for patient convenience. Children were reviewed at weeks 1 and 3 for drug adherence and side effects. At week 4, the second HBVV was given. At 3 months and 6 months HIV and HBV serology were repeated. 18/44 (40 per cent) had entry wounds. 44/54 (81 per cent) were given antiretroviral treatment (ART). Initial screening for HIV was negative in all, 6 had antibodies to HBV surface antigen, and 2 were HBV surface antigen positive. At week 1 all patients on ART were seen but at week 3 only 30 (55 per cent) attended. 41 (75 per cent) attended at 4 weeks, 8 non-attendees being located by primary healthcare workers. At 3 months, none of the 35 (64 per cent) children had seroconverted for either virus. 44 (81 per cent) attended at 6 months and all serology was negative. All were also Hepatitis C negative. The exposure incident sensitized the community to HIV. Follow up of patients after mass exposure is difficult and time-consuming. Adherence to ART was poor and should be carefully monitored. ZDV was probably adequate for this incident. In a non-mobile community a 3 month visit unnecessary.

The first 5 years of the family clinic for HIV at Tygerberg Hospital: family demographics, survival of children and early impact of antiretroviral therapy

BACKGROUND

Family clinics address the problems of HIV-infected children and their families. The aims were to document demographics of the children and caregivers attending the Family Clinic for HIV at Tygerberg Academic Hospital (TAH) and to investigate factors affecting disease progression in children.

METHODS

A retrospective folder review of children and parents attending the Family Clinic at TAH between January 1997 and December 2001, a period noted for its lack of antiretroviral treatment.

RESULTS

Of 432 children seen for testing, 274 children, median age 16.9 months, were HIV-infected. During follow-up, 46 children died (median age 23 months) and 113 were lost to follow-up. The majority of children were malnourished. Those <2 years of age had lower weight for age Z-scores (WAZ) than older children (p<0.001). At presentation, 47 per cent were in clinical stage B and two-thirds had moderate or severe CD4+ T cell depletion. Seventeen children had received highly active antiretroviral therapy (HAART), 12 dual and 31 monotherapy. HAART was associated with improved survival compared to dual or monotherapy. Risk of death was reduced from eleven-fold for a WAZ <-4 to four-fold between -2 and -3. There was no association with immunological and clinical classification at entry and risk of mortality. Only 18 per cent of parents were evaluated in the clinic. Non-parental care was documented for 25 per cent of families.

CONCLUSIONS

A low WAZ is associated with poor survival in children. Nutritional status should receive more attention in HIV disease classification in children. Parent utilization of the clinic was inadequate. Even in the absence of HAART, extended survival in children is possible.

Bacille Calmette-Guérin vaccine-induced disease in HIV-infected and HIV-uninfected children

BACKGROUND

Bacille Calmette-Guérin (BCG)--a live, attenuated vaccine--is routinely given to neonates in settings where tuberculosis is endemic, irrespective of human immunodeficiency virus (HIV) exposure. HIV-infected infants and other immunodeficient infants are at risk of BCG-related complications. We report the presentation, treatment, and mortality of children who develop BCG disease, with emphasis on HIV-infected children. In addition, we present a revised classification of BCG disease in children and propose standard diagnostic and management guidelines.

METHODS

This retrospective, hospital-based study was conducted in the Western Cape Province, South Africa. Mycobacterium tuberculosis complex isolates recovered from children aged <13 years during the period of August 2002 through January 2005 were speciated by polymerase chain reaction to confirm Mycobacterium bovis BCG. Clinical data were collected through medical file review. BCG disease was classified according to standard and revised disease classifications. Mortality was assessed at the end of the study period.

RESULTS

BCG disease was diagnosed in 25 children; 22 (88%) had local disease, and 8 (32%) had distant or disseminated disease; 5 children (20%) had both local and distant or disseminated disease. Seventeen children were HIV infected; 2 children had other immunodeficiencies. All 8 children with distant or disseminated disease were immunodeficient; 6 were HIV infected. The mortality rate was 75% for children with distant or disseminated disease.

CONCLUSIONS

BCG vaccination poses a risk to infants perinatally infected with HIV and to other primary immunodeficient children. The proposed pediatric BCG disease classification reflects clinically relevant disease categories in HIV-infected children. The suggested diagnostic and treatment guidelines should improve existing case management and surveillance. Prospective evaluation of management strategies for BCG disease in HIV-infected and HIV-uninfected children is essential.

Unexplained HIV-1 infection in children--documenting cases and assessing for possible risk factors

BACKGROUND

In the year 2000 we reported possible horizontal transmission of HIV-1 infection between two siblings. An investigation of three families, each with an HIV-infected child but seronegative parents, permitted this finding. Sexual abuse and surrogate breast-feeding were thought unlikely. The children had overlapping hospitalisation in a regional hospital. Since then several cases of unexplained HIV infection in children have been reported. A registry was established at Tygerberg Children's Hospital for collection of data on the extent of horizontal or unexplained transmission of HIV in children.

STUDY DESIGN

Retrospective chart review.

RESULTS

Fourteen children were identified, 12 from the Western Cape and 1 each from the Eastern Cape and KwaZulu-Natal. Thirteen (92%) had been hospitalised previously. In the Western Cape, children had been hospitalised in 8 hospitals. Ten of 13 (77%) were admitted as neonates and 9 of 13 (69%) had 2 or more admissions. Intravascular cannulation and intravenous drug administration occurred in all but 2 children before HIV diagnosis.

CONCLUSION

We have confirmed HIV infection in a number of cases where the source of infection has been inadequately explained. Circumstantial evidence supports but does not prove nosocomial transmission. Further studies and identification of medical procedures conducive to the spread of HIV are urgently needed.

Postnatal zidovudine in prevention of vertical HIV-1 transmission in a service setting

We sought to determine the efficacy of a 4-6 week course of zidovudine (ZDV) in a group of infants exposed to HIV-1. A retrospective chart review was conducted on HIV-1-exposed neonates identified from February 1998 to August 1999. These infants received ZDV and their mothers were counselled regarding the risks and benefits of breastfeeding. After informed consent was obtained, the HIV-1-status of the infant was determined by RNA-PCR after 1 month of age. Thirty-three HIV-1-exposed neonates were identified; seven infants were excluded, five because of insufficient data and two because of maternal ZDV administration. In all but three, the diagnosis was suspected because of maternal illness, 19 of 26 mothers having either stage 3 or 4 disease. The transmission rate was 15.4 per cent (4 of 26). Errors in ZDV administration were detected in 20 neonates of whom four were infected (p = 1; Fischer's exact test). Antenatal diagnosis of HIV-1 status was associated with fewer medication errors in HIV-1-exposed neonates (p = 0.017, Fisher's exact test). It was concluded that a transmission rate of 15.4 per cent in symptomatic mothers suggests efficacy. Under similar circumstances, transmission rates varying between 37 and 67 per cent have been reported. Antenatal diagnosis is significantly associated with compliance to the regimen. Early identification of at-risk neonates and familiarity with the regimen may improve the outcome.