1
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Sturgeon JP, Tome J, Dumbura C, Majo FD, Ngosa D, Mutasa K, Zyambo K, Besa E, Chandwe K, Kapoma C, Mwapenya B, Nathoo KJ, Bourke CD, Ntozini R, Chasekwa B, Smuk M, Bwakura-Dangarembizi M, Amadi B, Kelly P, Prendergast AJ. Inflammation and epithelial repair predict mortality, hospital readmission, and growth recovery in complicated severe acute malnutrition. Sci Transl Med 2024; 16:eadh0673. [PMID: 38416844 PMCID: PMC7615785 DOI: 10.1126/scitranslmed.adh0673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/07/2024] [Indexed: 03/01/2024]
Abstract
Severe acute malnutrition (SAM) is the most high-risk form of undernutrition, particularly when children require hospitalization for complications. Complicated SAM is a multisystem disease with high inpatient and postdischarge mortality, especially in children with comorbidities such as HIV; however, the underlying pathogenesis of complicated SAM is poorly understood. Targeted multiplex biomarker analysis in children hospitalized with SAM (n = 264) was conducted on plasma samples, and inflammatory markers were assessed on stool samples taken at recruitment, discharge, and 12 to 24 and 48 weeks after discharge from three hospitals in Zimbabwe and Zambia. Compared with adequately nourished controls (n = 173), we found that at baseline, complicated SAM was characterized by systemic, endothelial, and intestinal inflammation, which was exacerbated by HIV infection. This persisted over 48 weeks despite nutritional recovery and was associated with children's outcomes. Baseline plasma concentrations of vascular endothelial growth factor, glucagon-like peptide-2, and intestinal fatty acid-binding protein were independently associated with lower mortality or hospital readmission over the following 48 weeks. Following principal components analysis of baseline biomarkers, higher scores of a component representing growth factors was associated with greater weight-for-height z score recovery and lower mortality or hospital readmission over the 48 weeks. Conversely, components representing higher gut and systemic inflammation were associated with higher mortality or hospital readmission. These findings highlight the interplay between inflammation, which damages tissues, and growth factors, which mediate endothelial and epithelial regeneration, and support further studies investigating interventions to reduce inflammation and promote epithelial repair as an approach to reducing mortality and improving nutritional recovery.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
| | - Joice Tome
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Benjamin Mwapenya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kusum J Nathoo
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Melanie Smuk
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Paul Kelly
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, E1 2AT, UK
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2
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Chabala C, Jacobs TG, Moraleda C, Ndaferankhande JM, Mumbiro V, Passanduca A, Namuziya N, Nalwanga D, Musiime V, Ballesteros A, Domínguez-Rodríguez S, Chitsamatanga M, Cassia U, Nduna B, Bramugy J, Sacarlal J, Madrid L, Nathoo KJ, Colbers A, Burger DM, Mulenga V, Buck WC, Mujuru HA, te Brake LHM, Rojo P, Tagarro A, Aarnoutse RE. First-Line Antituberculosis Drug Concentrations in Infants With HIV and a History of Recent Admission With Severe Pneumonia. J Pediatric Infect Dis Soc 2023; 12:581-585. [PMID: 37843384 PMCID: PMC10687595 DOI: 10.1093/jpids/piad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/14/2023] [Indexed: 10/17/2023]
Abstract
Optimal antituberculosis therapy is essential for favorable clinical outcomes. Peak plasma concentrations of first-line antituberculosis drugs in infants with living HIV receiving WHO-recommended dosing were low compared with reference values for adults, supporting studies on increased doses of first-line TB drugs in infants.
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Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Lusaka, Zambia
- University Teaching Hospital, Children’s Hospital, Lusaka, Zambia
- HerpeZ, Lusaka, Zambia
| | - Tom G Jacobs
- Department of Pharmacy, Radboudumc Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cinta Moraleda
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - John M Ndaferankhande
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Vivian Mumbiro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Alfeu Passanduca
- Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
| | - Natasha Namuziya
- University Teaching Hospital, Children’s Hospital, Lusaka, Zambia
| | - Damalie Nalwanga
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Victor Musiime
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Joint Clinical Research Centre, Kampala, Uganda
| | - Alvaro Ballesteros
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - Sara Domínguez-Rodríguez
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | | | - Uneisse Cassia
- Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
| | - Bwendo Nduna
- Arthur Davidson Children’s Hospital, Ndola, Zambia
| | - Justina Bramugy
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Jahit Sacarlal
- Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
| | - Lola Madrid
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- London School of Hygiene and Tropical Medicine (LMC), London, UK
| | - Kusum J Nathoo
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Angela Colbers
- Department of Pharmacy, Radboudumc Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboudumc Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Veronica Mulenga
- University of Zambia, School of Medicine, Lusaka, Zambia
- University Teaching Hospital, Children’s Hospital, Lusaka, Zambia
| | - W Chris Buck
- Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - Hilda A Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Lindsey H M te Brake
- Department of Pharmacy, Radboudumc Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pablo Rojo
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
- Pediatric Service, Hospital Universitario 12 de Octubre, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
| | - Alfredo Tagarro
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- Pediatric Service, Infanta Sofia University Hospital, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
- Universidad Europea de Madrid, Madrid, Spain
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboudumc Institute for Medical Innovation (RIMI), Radboud University Medical Center, Nijmegen, The Netherlands
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Bwakura-Dangarembizi M, Dumbura C, Ngosa D, Majo FD, Piper JD, Sturgeon JP, Nathoo KJ, Amadi B, Norris S, Chasekwa B, Ntozini R, Wells JC, Kelly P, Prendergast AJ. Fat and lean mass predict time to hospital readmission or mortality in children treated for complicated severe acute malnutrition in Zimbabwe and Zambia. Br J Nutr 2023; 130:1024-1033. [PMID: 36573378 PMCID: PMC10442795 DOI: 10.1017/s0007114522004056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022]
Abstract
HIV and severe wasting are associated with post-discharge mortality and hospital readmission among children with complicated severe acute malnutrition (SAM); however, the reasons remain unclear. We assessed body composition at hospital discharge, stratified by HIV and oedema status, in a cohort of children with complicated SAM in three hospitals in Zambia and Zimbabwe. We measured skinfold thicknesses and bioelectrical impedance analysis (BIA) to investigate whether fat and lean mass were independent predictors of time to death or readmission. Cox proportional hazards models were used to estimate the association between death/readmission and discharge body composition. Mixed effects models were fitted to compare longitudinal changes in body composition over 1 year. At discharge, 284 and 546 children had complete BIA and skinfold measurements, respectively. Low discharge lean and peripheral fat mass were independently associated with death/hospital readmission. Each unit Z-score increase in impedance index and triceps skinfolds was associated with 48 % (adjusted hazard ratio 0·52, 95 % CI (0·30, 0·90)) and 17 % (adjusted hazard ratio 0·83, 95 % CI (0·71, 0·96)) lower hazard of death/readmission, respectively. HIV-positive v. HIV-negative children had lower gains in sum of skinfolds (mean difference -1·49, 95 % CI (-2·01, -0·97)) and impedance index Z-scores (-0·13, 95 % CI (-0·24, -0·01)) over 52 weeks. Children with non-oedematous v. oedematous SAM had lower mean changes in the sum of skinfolds (-1·47, 95 % CI (-1·97, -0·97)) and impedance index Z-scores (-0·23, 95 % CI (-0·36, -0·09)). Risk stratification to identify children at risk for mortality or readmission, and interventions to increase lean and peripheral fat mass, should be considered in the post-discharge care of these children.
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Affiliation(s)
- Mutsa Bwakura-Dangarembizi
- University of Zimbabwe, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- University of Witwatersrand, Johannesburg, South Africa
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Joe D. Piper
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Jonathan P. Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Kusum J. Nathoo
- University of Zimbabwe, Faculty of Medicine and Health Sciences, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Shane Norris
- University of Witwatersrand, Johannesburg, South Africa
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jonathan C. Wells
- Population Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
- Blizard Institute, Queen Mary University of London, London, UK
| | - Andrew J. Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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4
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Sturgeon JP, Mufukari W, Tome J, Dumbura C, Majo FD, Ngosa D, Chandwe K, Kapoma C, Mutasa K, Nathoo KJ, Bourke CD, Ntozini R, Bwakura-Dangarembizi M, Amadi B, Kelly P, Prendergast AJ. Risk factors for inpatient mortality among children with severe acute malnutrition in Zimbabwe and Zambia. Eur J Clin Nutr 2023; 77:895-904. [PMID: 37553508 PMCID: PMC10473959 DOI: 10.1038/s41430-023-01320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND/OBJECTIVES Malnutrition underlies 45% of deaths in children under-5 years annually. Children hospitalised with complicated severe acute malnutrition (SAM) have unacceptably high mortality. We aimed to identify variables from early hospital admission (baseline factors) independently associated with inpatient mortality in this cohort to identify those most at risk. SUBJECTS/METHODS Observational study of 745 children aged 0-59 months admitted with complicated SAM at three hospitals in Zimbabwe/Zambia. Children underwent anthropometry and clinical assessment by a study physician within 72 h of enrolment, and caregivers provided sociodemographic data. Children were followed-up daily until discharge/death. A multivariable survival analysis identified the baseline factors independently associated with mortality. RESULTS 70/745 (9.4%) children died in hospital. Age between 6-23 months [aHR 6.53, 95%CI 2.24-19.02], higher mid-upper arm circumference [aHR 0.73, 95%CI 0.59-0.89], presence of oedema [aHR 2.22, 95%CI 1.23-4.05], shock [aHR 8.18, 95%CI 3.79-17.65], sepsis [aHR 3.13, 95%CI 1.44-6.80], persistent diarrhoea [aHR 2.27, 95%CI 1.18-4.37], lack of a toilet at home [aHR 4.35, 95%CI 1.65-11.47], and recruitment at one Harare site [aHR 0.38, 95%CI 0.18-0.83] were all independently associated with inpatient mortality. Oedematous children had a significantly higher birthweight [2987 g vs 2757 g, p < 0.001] than those without oedema; higher birthweight was weakly associated with mortality [aHR 1.50 95%CI 0.97-2.31]. CONCLUSIONS Children with oedema, low MUAC, baseline infections, shock and lack of home sanitation had a significantly increased risk of inpatient mortality following hospitalisation for complicated SAM. Children with high-risk features may require additional care. A better understanding of the pathophysiology of SAM is needed to identify adjunctive interventions.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe.
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Wadzanai Mufukari
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Joice Tome
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Kusum J Nathoo
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
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5
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Jacobs TG, Mumbiro V, Chitsamatanga M, Namuziya N, Passanduca A, Domínguez-Rodríguez S, Tagarro A, Nathoo KJ, Nduna B, Ballesteros A, Madrid L, Mujuru HA, Chabala C, Buck WC, Rojo P, Burger DM, Moraleda C, Colbers A. Suboptimal lopinavir exposure in infants on rifampicin treatment receiving double-dosed or semi-superboosted lopinavir/ritonavir: time for a change. J Acquir Immune Defic Syndr 2023; 93:42-46. [PMID: 36724434 PMCID: PMC10069754 DOI: 10.1097/qai.0000000000003168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/17/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND While super-boosted lopinavir/ritonavir (LPV/r; ratio 4:4 instead of 4:1) is recommended for infants living with HIV and receiving concomitant rifampicin, in clinical practice many different LPV/r dosing strategies are applied due to poor availability of paediatric separate ritonavir formulations needed to super-boost. We evaluated LPV pharmacokinetics in infants with HIV receiving LPV/r dosed according to local guidelines in various sub-Saharan African countries with or without rifampicin-based tuberculosis (TB)-treatment. METHODS This was a 2-arm pharmacokinetic sub-study nested within the EMPIRICAL trial (#NCT03915366). Infants aged 1-12 months recruited into the main study were administered LPV/r according to local guidelines and drug availability either with or without rifampicin-based TB-treatment; during rifampicin co-treatment they received double-dosed (ratio 8:2) or semi-superboosted LPV/r (adding a ritonavir 100mg crushed tablet to the evening LPV/r dose). Six blood samples were taken over 12 hours after intake of LPV/r. RESULTS In total, 14/16 included infants had evaluable pharmacokinetic curves; 9/14 had rifampicin co-treatment (5 received double-dosed and 4 semi-superboosted LPV/r). The median (IQR) age was 6.4 months (5.4-9.8), weight 6.0kg (5.2-6.8) and 10/14 were male. Of those receiving rifampicin, 6/9 (67%) infants had LPV C trough <1.0mg/L compared to 1/5 (20%) in the control arm. LPV apparent oral clearance was 3.3-fold higher for infants receiving rifampicin. CONCLUSION Double-dosed or semi-superboosted LPV/r for infants aged 1-12 months receiving rifampicin resulted in substantial proportions of subtherapeutic LPV levels. There is an urgent need for data on alternative antiretroviral regimens in infants with HIV/TB co-infection, including twice-daily dolutegravir.
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Affiliation(s)
- T G Jacobs
- Radboud university medical center, Department of Pharmacy, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - V Mumbiro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - M Chitsamatanga
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - N Namuziya
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - A Passanduca
- Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique
| | - S Domínguez-Rodríguez
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - A Tagarro
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- Pediatric Service. Infanta Sofia University Hospital, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
- Universidad Europea de Madrid
| | - K J Nathoo
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - B Nduna
- Arthur Davidson Children's Hospital, Ndola, Zambia
| | - A Ballesteros
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
| | - L Madrid
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- London School of Hygiene and Tropical Medicine (LMC), London UK
| | - H A Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - C Chabala
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
- University of Zambia, School of Medicine, Lusaka, Zambia
| | - W C Buck
- Universidade Eduardo Mondlane Faculdade de Medicina, Maputo, Mozambique
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, United States
| | - P Rojo
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- Pediatric Service, Hospital Universitario 12 de Octubre, Servicio Madrileño de Salud (SERMAS), Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
| | - D M Burger
- Radboud university medical center, Department of Pharmacy, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - C Moraleda
- Pediatric Unit for Research and Clinical Trials (UPIC), Hospital 12 de Octubre Health Research Institute (i+12), Biomedical Foundation of Hospital Universitario 12 de Octubre (FIB-H12O), Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
| | - A Colbers
- Radboud university medical center, Department of Pharmacy, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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6
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Amuge P, Lugemwa A, Wynne B, Mujuru HA, Violari A, Kityo CM, Archary M, Variava E, White E, Turner RM, Shakeshaft C, Ali S, Nathoo KJ, Atwine L, Liberty A, Bbuye D, Kaudha E, Mngqibisa R, Mosala M, Mumbiro V, Nanduudu A, Ankunda R, Maseko L, Kekitiinwa AR, Giaquinto C, Rojo P, Gibb DM, Turkova A, Ford D. Once-daily dolutegravir-based antiretroviral therapy in infants and children living with HIV from age 4 weeks: results from the below 14 kg cohort in the randomised ODYSSEY trial. Lancet HIV 2022; 9:e638-e648. [PMID: 36055295 PMCID: PMC9646993 DOI: 10.1016/s2352-3018(22)00163-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Young children living with HIV have few treatment options. We aimed to assess the efficacy and safety of dolutegravir-based antiretroviral therapy (ART) in children weighing between 3 kg and less than 14 kg. METHODS ODYSSEY is an open-label, randomised, non-inferiority trial (10% margin) comparing dolutegravir-based ART with standard of care and comprises two cohorts (children weighing ≥14 kg and <14 kg). Children weighing less than 14 kg starting first-line or second-line ART were enrolled in seven HIV treatment centres in South Africa, Uganda, and Zimbabwe. Randomisation, which was computer generated by the trial statistician, was stratified by first-line or second-line ART and three weight bands. Dispersible 5 mg dolutegravir was dosed according to WHO weight bands. The primary outcome was the Kaplan-Meier estimated proportion of children with virological or clinical failure by 96 weeks, defined as: confirmed viral load of at least 400 copies per mL after week 36; absence of virological suppression by 24 weeks followed by a switch to second-line or third-line ART; all-cause death; or a new or recurrent WHO stage 4 or severe WHO stage 3 event. The primary outcome was assessed by intention to treat in all randomly assigned participants. A primary Bayesian analysis of the difference in the proportion of children meeting the primary outcome between treatment groups incorporated evidence from the higher weight cohort (≥14 kg) in a prior distribution. A frequentist analysis was also done of the lower weight cohort (<14 kg) alone. Safety analyses are presented for all randomly assigned children in this study (<14 kg cohort). ODYSSEY is registered with ClinicalTrials.gov, NCT02259127. FINDINGS Between July 5, 2018, and Aug 26, 2019, 85 children weighing less than 14 kg were randomly assigned to receive dolutegravir (n=42) or standard of care (n=43; 32 [74%] receiving protease inhibitor-based ART). Median age was 1·4 years (IQR 0·6-2·0) and median weight 8·1 kg (5·4-10·0). 72 (85%) children started first-line ART and 13 (15%) started second-line ART. Median follow-up was 124 weeks (112-137). By 96 weeks, treatment failure occurred in 12 children in the dolutegravir group (Kaplan-Meier estimated proportion 31%) versus 21 (48%) in the standard-of-care group. The Bayesian estimated difference in treatment failure (dolutegravir minus standard of care) was -10% (95% CI -19% to -2%; p=0·020), demonstrating superiority of dolutegravir. The frequentist estimated difference was -18% (-36% to 2%; p=0·057). 15 serious adverse events were reported in 11 (26%) children in the dolutegravir group, including two deaths, and 19 were reported in 11 (26%) children in the standard-of-care group, including four deaths (hazard ratio [HR] 1·08 [95% CI 0·47-2·49]; p=0·86). 36 adverse events of grade 3 or higher were reported in 19 (45%) children in the dolutegravir group, versus 34 events in 21 (49%) children in the standard-of-care group (HR 0·93 [0·50-1·74]; p=0·83). No events were considered related to dolutegravir. INTERPRETATION Dolutegravir-based ART was superior to standard of care (mainly protease inhibitor-based) with a lower risk of treatment failure in infants and young children, providing support for global dispersible dolutegravir roll-out for younger children and allowing alignment of adult and paediatric treatment. FUNDING Paediatric European Network for Treatment of AIDS Foundation, ViiV Healthcare, UK Medical Research Council.
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Affiliation(s)
- Pauline Amuge
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | | | - Ben Wynne
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Hilda A Mujuru
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | | | - Moherndran Archary
- Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Ebrahim Variava
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | - Ellen White
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Rebecca M Turner
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Clare Shakeshaft
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Shabinah Ali
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Kusum J Nathoo
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Afaaf Liberty
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | - Dickson Bbuye
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | | | - Rosie Mngqibisa
- Department of Paediatrics and Children Health, King Edward VIII Hospital, University of KwaZulu-Natal, Durban, South Africa
| | - Modehei Mosala
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | - Vivian Mumbiro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | | | - Lindiwe Maseko
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | | | - Carlo Giaquinto
- Department of Women and Child Health, University of Padova, Italy; Penta Foundation, Padova, Italy
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit, Hospital 12 de Octubre, Madrid, Spain
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Deborah Ford
- Medical Research Council Clinical Trials Unit at University College London, London, UK.
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7
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Bwakura‐Dangarembizi M, Dumbura C, Amadi B, Chasekwa B, Ngosa D, Majo FD, Sturgeon JP, Chandwe K, Kapoma C, Bourke CD, Robertson RC, Nathoo KJ, Ntozini R, Norris SA, Kelly P, Prendergast AJ. Recovery of children following hospitalisation for complicated severe acute malnutrition. Maternal & Child Nutrition 2022; 18:e13302. [PMID: 34939325 PMCID: PMC8932709 DOI: 10.1111/mcn.13302] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
Nutritional recovery and hospital readmission following inpatient management of complicated severe acute malnutrition (SAM) are poorly characterised. We aimed to ascertain patterns and factors associated with hospital readmission, nutritional recovery and morbidity, in children discharged from hospital following management of complicated SAM in Zambia and Zimbabwe over 52‐weeks posthospitalization. Multivariable Fine‐Gray subdistribution hazard models, with death and loss to follow‐up as competing risks, were used to identify factors associated with hospital readmission; negative binomial regression to assess time to hospitalisation and ordinal logistic regression to model factors associated with nutritional recovery. A total of 649 children (53% male, median age 18.2 months) were discharged to continue community nutritional rehabilitation. All‐cause hospital readmission was 15.4% (95% CI 12.7, 18.6) over 52 weeks. Independent risk factors for time to readmission were cerebral palsy (adjusted subhazard ratio (aSHR): 2.96, 95% CI 1.56, 5.61) and nonoedematous SAM (aSHR: 1.64, 95%CI 1.03, 2.64). Unit increases in height‐for‐age Z‐score (HAZ) (aSHR: 0.82, 95% CI 0.71, 0.95) and enrolment in Zambia (aSHR: 0.52, 95% CI 0.28, 0.97) were associated with reduced subhazard of time to readmission. Young age, SAM at discharge, nonoedematous SAM and cerebral palsy were associated with poor nutritional recovery throughout follow‐up. Collectively, nonoedematous SAM, ongoing SAM at discharge, cerebral palsy and low HAZ are independent risk factors for readmission and poor nutritional recovery following complicated SAM. Children with these high‐risk features should be prioritised for additional convalescent care to improve long‐term outcomes. One‐in‐six children managed for SAM were readmitted into hospital over the first year after discharge and one‐in‐eight remained undernourished by 52 weeks of follow‐up. Nonoedematous SAM, ongoing SAM at the time of discharge and underlying cerebral palsy were independent risk factors for hospital readmission and poor nutritional recovery. Low HAZ was a risk factor for hospital readmission and poor nutritional recovery. Postdischarge care should focus on children with disability, nonoedematous SAM at initial hospitalisation and have ongoing SAM at the time of discharge. Stunting should be considered in the management of children with SAM.
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Affiliation(s)
- Mutsa Bwakura‐Dangarembizi
- University of Zimbabwe College of Health Sciences Harare Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- University of Witwatersrand Johannesburg South Africa
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | - Jonathan P. Sturgeon
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
| | - Claire D. Bourke
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Ruairi C. Robertson
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
| | - Kusum J. Nathoo
- University of Zimbabwe College of Health Sciences Harare Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
| | | | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia Lusaka Zambia
- Blizard Institute, Queen Mary University of London London UK
| | - Andrew J. Prendergast
- Zvitambo Institute for Maternal and Child Health Research Harare Zimbabwe
- Blizard Institute, Queen Mary University of London London UK
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8
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Bwakura-Dangarembizi M, Dumbura C, Amadi B, Ngosa D, Majo FD, Nathoo KJ, Mwakamui S, Mutasa K, Chasekwa B, Ntozini R, Kelly P, Prendergast AJ. Risk factors for postdischarge mortality following hospitalization for severe acute malnutrition in Zimbabwe and Zambia. Am J Clin Nutr 2021; 113:665-674. [PMID: 33471057 PMCID: PMC7948837 DOI: 10.1093/ajcn/nqaa346] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Children discharged from hospital following management of complicated severe acute malnutrition (SAM) have a high risk of mortality, especially HIV-positive children. Few studies have examined mortality in the antiretroviral therapy (ART) era. OBJECTIVES Our objectives were to ascertain 52-wk mortality in children discharged from hospital for management of complicated SAM, and to identify independent predictors of mortality. METHODS A prospective cohort study was conducted in children enrolled from 3 hospitals in Zambia and Zimbabwe between July 2016 and March 2018. The primary outcome was mortality at 52 wk. Univariable and multivariable Cox regression models were used to identify independent risk factors for death, and to investigate whether HIV modifies these associations. RESULTS Of 745 children, median age at enrolment was 17.4 mo (IQR: 12.8, 22.1 mo), 21.7% were HIV-positive, and 64.4% had edema. Seventy children (9.4%; 95% CI: 7.4, 11.7%) died and 26 exited during hospitalization; 649 were followed postdischarge. At discharge, 43.9% had ongoing SAM and only 50.8% of HIV-positive children were receiving ART. Vital status was ascertained for 604 (93.1%), of whom 55 (9.1%; 95% CI: 6.9, 11.7%) died at median 16.6 wk (IQR: 9.4, 21.9 wk). Overall, 20.0% (95% CI: 13.5, 27.9%) and 5.6% (95% CI: 3.8, 7.9%) of HIV-positive and HIV-negative children, respectively, died [adjusted hazard ratio (aHR): 3.83; 95% CI: 2.15, 6.82]. Additional independent risk factors for mortality were ongoing SAM (aHR: 2.28; 95% CI: 1.22, 4.25), cerebral palsy (aHR: 5.60; 95% CI: 2.72, 11.50) and nonedematous SAM (aHR: 2.23; 95% CI: 1.24, 4.01), with no evidence of interaction with HIV status. CONCLUSIONS HIV-positive children have an almost 4-fold higher mortality than HIV-negative children in the year following hospitalization for complicated SAM. A better understanding of causes of death, an improved continuum of care for HIV and SAM, and targeted interventions to improve convalescence are needed.
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Affiliation(s)
- Mutsa Bwakura-Dangarembizi
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kusum J Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Simutanyi Mwakamui
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
- Blizard Institute, Queen Mary University of London, London, UK
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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9
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Mujuru HA, Burnett E, Nathoo KJ, Ticklay I, Gonah NA, Mukaratirwa A, Berejena C, Manangazira P, Rupfutse M, Chavers T, Weldegebriel GG, Mwenda JM, Parashar UD, Tate JE. Cost estimates of diarrhea hospitalizations among children <5 years old in Zimbabwe. Vaccine 2020; 38:6735-6740. [PMID: 32873405 DOI: 10.1016/j.vaccine.2020.08.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Diarrhoea is a leading killer of children <5 years old, accounting for 480,000 deaths in 2017. Zimbabwe introduced Rotarix into its vaccination program in 2014. In this evaluation, we estimate direct medical, direct non-medical, and indirect costs attributable to a diarrhea hospitalization in Zimbabwe after rotavirus vaccine introduction. METHODS Children <5 years old admitted to Harare Central Hospital from June 2018 to April 2019 with acute watery diarrhea were eligible for this evaluation. A 3-part structured questionnaire was used to collect data by interview from the child's family and by review of the medical record. A stool specimen was also collected and tested for rotavirus. Direct medical costs were the sum of medications, consumables, diagnostic tests, and service delivery costs. Direct non-medical costs were the sum of transportation, meals and lodging for caregivers. Indirect costs are the lost income for household members. RESULTS A total of 202 children were enrolled with a median age of 12 months (IQR: 7-21) and 48 (24%) had malnutrition. Children were sick for a median of 2 days and most had received outpatient medical care prior to admission. The median monthly household income was higher for well-nourished children compared to malnourished children (p < 0.001). The median total cost of a diarrhea illness resulting in hospitalization was $293.74 (IQR: 188.42, 427.89). Direct medical costs, with a median of $251.74 (IQR: 155.42, 390.96), comprised the majority of the total cost. Among children who tested positive for rotavirus, the median total illness cost was $243.78 (IQR: 160.92, 323.84). The median direct medical costs were higher for malnourished than well-nourished children (p < 0.001). CONCLUSION Direct medical costs are the primary determinant of diarrhea illness costs in Zimbabwe. The descriptive findings from this evaluation are an important first step in calculating the cost effectiveness of rotavirus vaccine.
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Affiliation(s)
- Hilda A Mujuru
- Harare Central Hospital, Harare, Zimbabwe; Department of Paediatrics and Child Health, University of Zimbabwe, Zimbabwe.
| | - Eleanor Burnett
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kusum J Nathoo
- Harare Central Hospital, Harare, Zimbabwe; Department of Paediatrics and Child Health, University of Zimbabwe, Zimbabwe
| | - Ismail Ticklay
- Department of Paediatrics and Child Health, University of Zimbabwe, Zimbabwe; Parirenyatwa Group Hospitals, Harare, Zimbabwe
| | | | | | | | - Portia Manangazira
- Epidemiology and Disease Control, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | - Tyler Chavers
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Jason M Mwenda
- World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Jacqueline E Tate
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
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10
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Mujuru HA, Burnett E, Nathoo KJ, Ticklay I, Gonah NA, Mukaratirwa A, Berejena C, Manangazira P, Rupfutse M, Weldegebriel GG, Mwenda JM, Yen C, Parashar UD, Tate JE. Monovalent Rotavirus Vaccine Effectiveness Against Rotavirus Hospitalizations Among Children in Zimbabwe. Clin Infect Dis 2020; 69:1339-1344. [PMID: 30590488 DOI: 10.1093/cid/ciy1096] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 12/19/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Rotavirus is a leading cause of mortality among children <5 years old. We evaluated monovalent rotavirus vaccine effectiveness (VE) under conditions of routine use at 2 surveillance sites in Harare, Zimbabwe, after vaccine introduction in May 2014. METHODS Children aged <5 years hospitalized or treated in the accident and emergency department (A&E) for acute watery diarrhea were enrolled for routine surveillance. Copies of vaccination cards were collected to document vaccination status. Among children age-eligible to receive rotavirus vaccine, we estimated VE, calculated as 1 - odds ratio, using a test-negative case-control design. RESULTS We included 903 rotavirus-positive cases and 2685 rotavirus-negative controls in the analysis; 99% had verified vaccination status. Rotavirus-positive children had more severe diarrhea than rotavirus-negative children; 61% of cases and 46% of controls had a Vesikari score ≥11 (P < .01). Among cases and controls, 31% and 37%, respectively, were stunted for their age (P < .01). Among children 6-11 months old, adjusted 2-dose VE against hospitalization or treatment in A&E due to rotavirus of any severity was 61% (95% confidence interval [CI], 21%-81%) and 68% (95% CI, 13%-88%) against severe rotavirus disease. Stratified by nutritional status, adjusted VE was 45% (95% CI, -148% to 88%) among stunted infants and 71% (95% CI, 29%-88%) among infants with a normal height for age. CONCLUSIONS Monovalent rotavirus vaccine is effective in preventing hospitalizations due to severe rotavirus diarrhea among infants in Zimbabwe, providing additional evidence for countries considering rotavirus vaccine introduction that live, oral rotavirus vaccines are effective in high-child-mortality settings.
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Affiliation(s)
- Hilda A Mujuru
- Harare Central Hospital, University of Zimbabwe, Harare.,Department of Paediatrics and Child Health, University of Zimbabwe, Harare
| | - Eleanor Burnett
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kusum J Nathoo
- Harare Central Hospital, University of Zimbabwe, Harare.,Department of Paediatrics and Child Health, University of Zimbabwe, Harare
| | - Ismail Ticklay
- Department of Paediatrics and Child Health, University of Zimbabwe, Harare.,Parirenyatwa Group Hospitals, Harare
| | - Nhamo A Gonah
- Chitungwiza Central Hospital, Ministry of Health and Child Care
| | | | - Chipo Berejena
- National Virology Laboratory, Ministry of Health and Child Care
| | | | | | | | - Jason M Mwenda
- WHO Regional Office for Africa1, Brazzaville, Republic of Congo
| | - Catherine Yen
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Umesh D Parashar
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacqueline E Tate
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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11
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Bwakura-Dangarembizi M, Amadi B, Bourke CD, Robertson RC, Mwapenya B, Chandwe K, Kapoma C, Chifunda K, Majo F, Ngosa D, Chakara P, Chulu N, Masimba F, Mapurisa I, Besa E, Mutasa K, Mwakamui S, Runodamoto T, Humphrey JH, Ntozini R, Wells JCK, Manges AR, Swann JR, Walker AS, Nathoo KJ, Kelly P, Prendergast AJ. Health Outcomes, Pathogenesis and Epidemiology of Severe Acute Malnutrition (HOPE-SAM): rationale and methods of a longitudinal observational study. BMJ Open 2019; 9:e023077. [PMID: 30782694 PMCID: PMC6361330 DOI: 10.1136/bmjopen-2018-023077] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 10/25/2018] [Accepted: 11/07/2018] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Mortality among children hospitalised for complicated severe acute malnutrition (SAM) remains high despite the implementation of WHO guidelines, particularly in settings of high HIV prevalence. Children continue to be at high risk of morbidity, mortality and relapse after discharge from hospital although long-term outcomes are not well documented. Better understanding the pathogenesis of SAM and the factors associated with poor outcomes may inform new therapeutic interventions. METHODS AND ANALYSIS The Health Outcomes, Pathogenesis and Epidemiology of Severe Acute Malnutrition (HOPE-SAM) study is a longitudinal observational cohort that aims to evaluate the short-term and long-term clinical outcomes of HIV-positive and HIV-negative children with complicated SAM, and to identify the risk factors at admission and discharge from hospital that independently predict poor outcomes. Children aged 0-59 months hospitalised for SAM are being enrolled at three tertiary hospitals in Harare, Zimbabwe and Lusaka, Zambia. Longitudinal mortality, morbidity and nutritional data are being collected at admission, discharge and for 48 weeks post discharge. Nested laboratory substudies are exploring the role of enteropathy, gut microbiota, metabolomics and cellular immune function in the pathogenesis of SAM using stool, urine and blood collected from participants and from well-nourished controls. ETHICS AND DISSEMINATION The study is approved by the local and international institutional review boards in the participating countries (the Joint Research Ethics Committee of the University of Zimbabwe, Medical Research Council of Zimbabwe and University of Zambia Biomedical Research Ethics Committee) and the study sponsor (Queen Mary University of London). Caregivers provide written informed consent for each participant. Findings will be disseminated through peer-reviewed journals, conference presentations and to caregivers at face-to-face meetings.
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Affiliation(s)
- Mutsa Bwakura-Dangarembizi
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Claire D Bourke
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Benjamin Mwapenya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kapula Chifunda
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Florence Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Pamela Chakara
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Nivea Chulu
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Faithfull Masimba
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Idah Mapurisa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Simutanyi Mwakamui
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | | | - Jean H Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Amee R Manges
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Kusum J Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
- Blizard Institute, Queen Mary University of London, London, UK
| | - Andrew J Prendergast
- Blizard Institute, Queen Mary University of London, London, UK
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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12
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Chimhuya S, Mbuwayesango B, Aagaard EM, Nathoo KJ. Development of a neonatal curriculum for medical students in Zimbabwe - a cross sectional survey. BMC Med Educ 2018; 18:90. [PMID: 29720167 PMCID: PMC5932895 DOI: 10.1186/s12909-018-1194-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 04/20/2018] [Indexed: 05/20/2023]
Abstract
BACKGROUND Calls have been made to reassess the curricula of medical schools throughout the world to adopt competence-based programs that address the healthcare needs of society. Zimbabwe is a country characterized by a high neonatal mortality rate of 24 per 1000 live births. The current research sought to determine the content and appropriate teaching strategies needed to guide the development of an undergraduate neonatal curriculum map for medical students at the University of Zimbabwe College of Health Sciences. METHODS We surveyed faculty (n = 8) and non-faculty pediatricians (n = 5), senior resident medical officers (N = 26) using a self-administered questionnaire, and completed one focus group discussion with midwives (n = 11). We asked respondents their expectations regarding knowledge, psychomotor skills, competencies, and teaching strategies in a basic newborn curriculum for medical students. Relevant policy and curricula documents were reviewed to assess newborn health needs and the current training. A group of faculty educationists (n = 11) collated and finalized the findings from the document review, survey, and focus group using descriptive statistics and thematic analysis. RESULTS The document review revealed three key neonatal health objectives according to the current national maternal and neonatal health road map. These objectives are to be met using a four tier approach comprising (i) family planning (ii) focused antenatal care (iii) clean and safe delivery and (iv) basic and comprehensive emergency obstetric & neonatal care. Existing curriculum has 15 newborn topics taught in lecture style during the pediatric rotations, and five newborn care skills to be learned through observation. The existing curriculum is silent on desired competencies. In the current study 19 cognitive areas, 17 psychomotor skills and six competency domains were identified for an ideal neonatal curriculum for undergraduate students. A combination of teaching strategies including classroom, simulation and a clinical rotation were recommended. CONCLUSION This study revealed a significant gap between the existing neonatal curriculum and the ideal curriculum as recommended by broad stakeholders in the context of national health care needs. Next steps are to complete the development and implementation of the proposed curriculum map to better align with the ideal state.
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Affiliation(s)
- Simbarashe Chimhuya
- Department of Pediatrics and Child Health, University of Zimbabwe College of Health Sciences, P.O.Box A178, Mazoe Street, Avondale, Harare, Zimbabwe
| | - Bothwell Mbuwayesango
- Department of Surgery, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Eva M. Aagaard
- Department of Medicine, Division of General Internal Medicine at the University of Colorado School of Medicine, Aurora, CO USA
| | - Kusum J. Nathoo
- Department of Pediatrics and Child Health, University of Zimbabwe College of Health Sciences, P.O.Box A178, Mazoe Street, Avondale, Harare, Zimbabwe
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Hakim JG, Chidzonga MM, Borok MZ, Nathoo KJ, Matenga J, Havranek E, Cowan F, Abas M, Aagaard E, Connors S, Nkomani S, Ndhlovu CE, Matsika A, Barry M, Campbell TB. Medical Education Partnership Initiative (MEPI) in Zimbabwe: Outcomes and Challenges. Glob Health Sci Pract 2018; 6:82-92. [PMID: 29602867 PMCID: PMC5878082 DOI: 10.9745/ghsp-d-17-00052] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 09/25/2017] [Indexed: 11/21/2022]
Abstract
The 5-year medical education and research strengthening initiative in Zimbabwe increased faculty retention and student enrollment, improved information technology infrastructure, provided mentoring for postgraduates and clinical training in specialty areas, instituted a competency-based curriculum reform process, and created new departments and centers to institutionalize health education and research implementation. A comprehensive review of the curriculum is still underway and uptake of technology-assisted teaching has been slower than expected. Background: Sub-Saharan Africa has an inadequate number of health professionals, leading to a reduced capacity to respond to health challenges, including HIV/AIDS. From 2010 to 2015, the Medical Education Partnership Initiative (MEPI)—sponsored by the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH)—was enthusiastically taken up by the University of Zimbabwe College of Health Sciences (UZCHS) and 12 other sub-Saharan African universities to develop models of training to improve medical education and research capacity. In this article, we describe the outcomes and challenges of MEPI in Zimbabwe. Methods: UZCHS in partnership with the University of Colorado, Denver; Stanford University; University of Cape Town; University College London; and King's College London designed the Novel Education Clinical Trainees and Researchers (NECTAR) program and 2 linked awards addressing cardiovascular disease and mental health to pursue MEPI objectives. A range of medical education and research capacity-focused programs were implemented, including faculty development, research support, mentored scholars, visiting professors, community-based education, information and technology support, cross-cutting curricula, and collaboration with partner universities and the ministries of health and education. We analyzed quantitative and qualitative data from several data sources, including annual surveys of faculty, students, and other stakeholders; workshop exit surveys; and key informant interviews with NECTAR administrators and leaders and the UZCHS dean. Findings: Improved Internet connectivity and electronic resource availability were early successes of NECTAR. Over the 5-year period, 69% (115 of 166) of faculty members attended at least 1 of 15 faculty development workshops. Forty-one faculty members underwent 1-year advanced faculty development training in medical education and leadership. Thirty-three mentored research scholars were trained under NECTAR, and 52 and 12 in cardiovascular and mental health programs, respectively. Twelve MEPI scholars had joined faculty by 2015. Full-time faculty grew by 36% (122 to 166), annual postgraduate and medical student enrollment increased by 61% (75 to 121) and 71% (123 to 210), respectively. To institutionalize and sustain MEPI innovations, the Research Support Center and the Department of Health Professions Education were established at UZCHS. Conclusion: MEPI has synergistically revitalized medical education, research capacity, and leadership at UZCHS. Investments in creating a new research center, health professions education department, and, programs have laid the foundation to help sustain faculty development and research capacity in the country.
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Affiliation(s)
- James G Hakim
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
| | - Midion M Chidzonga
- Dean's Office, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Margaret Z Borok
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Kusum J Nathoo
- Department of Pediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Jonathan Matenga
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Edward Havranek
- Division of Cardiology, University of Colorado, Aurora, Denver, CO, USA
| | - Frances Cowan
- Research Department of Infection and Population Health, University College London, London, UK
| | - Melanie Abas
- Institute of Psychiatry, King's College London, London, UK
| | - Eva Aagaard
- Division of General Internal Medicine, University of Colorado, Aurora, Denver, CO, USA
| | - Susan Connors
- Evaluation Center, School of Education and Human Development, University of Colorado, Aurora, Denver, CO, USA
| | - Sanele Nkomani
- NECTAR Office, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Chiratidzo E Ndhlovu
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Antony Matsika
- NECTAR Office, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Michele Barry
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Thomas B Campbell
- Division of Infectious Diseases, University of Colorado, Aurora, Denver, CO, USA
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Chimhuya S, Nathoo KJ, Rusakaniko S. Non-adherence to highly active antiretroviral therapy in children attending HIV treatment clinic at harare Children's Hospital, Zimbabwe. Cent Afr J Med 2013; 59:63-70. [PMID: 29144622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Non-adherence reduces the effectiveness of antiretroviral therapy. Knowledge of factors associated with non-adherence would assist clinicians and program planners to design and implement interventions to improve adherence and therefore treatment outcomes. OBJECTIVE To determine the prevalence and factors associated with non-adherence to Highly Active Antiretroviral Therapy (HAART) in children less than 10 years of age. METHODS A cross-sectional study of 216 caregivers and children less than 10 years of age who had received HAART for at least 60 days prior to this study. Non-adherence was defined as taking less than 95% of prescribed doses. Caregiver self-reports of missed doses in the 30 days preceding a clinic visit, and clinic based pill counts were used to determine non-adherence. RESULTS Of the 228 children selected, 216 (94.7%) study participants were assessed using the self-report method. Pill count assessment was done on only 96 (44%) participants who produced unused pills on their review dates. Caregiver self-reports (n=216) estimated the prevalence of non-adherence to be 7.4% (95%: CI 3.90 10.90) whereas clinic-based pill counts (n=96) yielded a higher estimate of 18.8% (95% CI 10.94 26.56). In a regression analysis based on pill count, two or fewer siblings (OR=6.26, 95% CI 1.64-23.95) or adults (OR=3.73, 95% CI: 1.01-13.78) in the household were independently associated with non-adherence to HAART. Of the 16 participants who were non adherent by pill count the reasons for missing doses were, attending gatherings (funeral, church), caregiver forgetting to give dose, medication running out, not understanding dosing instructions, concurrently taking other medicines such as anti tuberculosis drugs and cotrimoxazole, child visiting relatives during school vacation, and inconsistent supply of drugs in the hospital. CONCLUSION The prevalence of non adherence using pill count method was high at this clinic. Caregiver reports of missed doses underestimated the prevalence of non-adherence to HAART. Having fewer siblings or adults in the household to assist with dosing are strongly associated with non-adherence to HAART in this population of children.
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Dondo V, Mujuru HA, Nathoo KJ, Chirehwa M, Mufandaedza Z. Renal abnormalities among HIV-infected, antiretroviral naive children, Harare, Zimbabwe: a cross-sectional study. BMC Pediatr 2013; 13:75. [PMID: 23663553 PMCID: PMC3654941 DOI: 10.1186/1471-2431-13-75] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 05/02/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Data on the prevalence of renal and urine abnormalities among HIV-infected children in Sub-Saharan Africa are limited. We set out to determine the prevalence of proteinuria; low estimated glomerular filtration rate (eGFR), urinary tract infection and associated factors among HIV-infected antiretroviral therapy (ART) naive children, aged 2-12 years, attending the paediatric HIV clinic at a tertiary hospital in Harare. METHODS Consecutive ART naive children attending the clinic between June and October 2009 were recruited. Detailed medical history was obtained and a complete physical examination was performed. Children were screened for urinary tract infection and for significant persistent proteinuria. Serum creatinine was used to estimate GFR using the modified Counahan-Barratt formula. The Student's t-test was used to analyse continuous variables and the chi-square or Fisher's exact test was used to analyse categorical data. Logistic regression was performed to assess the relationship between study factors and urine abnormalities, persistent proteinuria and the eGFR. RESULTS Two hundred and twenty children were enrolled into the study. The median age was 90 months (Q1=65.5; Q3=116.5). The prevalence of urinary tract infection was 9.5%. Escherichia coli was the predominant organism. There was uniform resistance to cotrimoxazole. Persistent proteinuria (urine protein to creatinine ratio greater than 0.2, a week apart) was found in 5% of the children. Seventy-five children (34.6%) had mild to moderate renal impairment shown by a low eGFR (30 to <90 ml/min/1.73 m2). Persistent proteinuria was more likely to be found in children who were wasted, weight-for-height (WHZ) z-score <-2 (p=0.0005). Children with WHO clinical stage 4 were more likely to have a low eGFR than children with less advanced stages (OR 2.68; CI 1.24-5.80). Urine abnormalities were more likely to be observed in children with WHO clinical stages 3 and 4 (OR 2.20; CI 1.06-4.60). CONCLUSION There is significant renal impairment among HIV-infected, ART naive children aged 2-12 years attending the outpatient paediatric HIV clinic at Harare Central Hospital. The abnormalities are more likely to occur in children with advanced HIV/AIDS. Screening for renal impairment and urinary tract infections in HIV-infected children before initiation of ART and regularly thereafter would be helpful in their management. KEYWORDS HIV, renal disease, persistent proteinuria, glomerular filtration rate, urinary tract infection.
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Affiliation(s)
- Vongai Dondo
- Department of Paediatrics and Child Welfare, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Hilda A Mujuru
- Department of Paediatrics and Child Welfare, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Kusum J Nathoo
- Department of Paediatrics and Child Welfare, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Maxwell Chirehwa
- Department of Community Medicine, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
| | - Zivanai Mufandaedza
- Department of Medical Laboratory Sciences, University of Zimbabwe, College of Health Sciences, Avondale, Harare, Zimbabwe
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Nathoo KJ, Rusakaniko S, Tobaiwa O, Mujuru HA, Ticklay I, Zijenah L. Clinical predictors of HIV infection in hospitalized children aged 2-18 months in Harare, Zimbabwe. Afr Health Sci 2012; 12:259-67. [PMID: 23382738 DOI: 10.4314/ahs.v12i3.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In Africa without antiretroviral treatment more than half of the HIV infected children die by 2 years. The recommended HIV virological testing for early infant diagnosis is not widely available in developing countries therefore a presumptive diagnosis is made in infants presenting with symptoms suggestive of HIV disease. OBJECTIVES To identify presenting signs and symptoms predictive of HIV infection in hospitalized children aged between 2- 18 months at Harare Hospital, Zimbabwe. METHODS In a cross sectional study the baseline clinical information was collected and HIV infection confirmed using DNA PCR. Multiple logistic regression analysis was used to identify significant predictors of symptomatic HIV infection. Diagnostic parameters (sensitivity, specificity) and their 95% confidence intervals were calculated. RESULTS 355 children with an overall median age of 6 months (IQR: 3, 10.5 months) of whom 203 (57.2%) were HIV DNA PCR positive. Clinical signs independently predictive of HIV infection were cyanosis, generalized lymphadenopathy, oral thrush, weight for age z-score <-2 and splenomegaly. The sensitivity of these signs ranged from 43-49% with a higher specificity (ranging from 72.3-89.5%). CONCLUSION Clinical identification using individual signs for probable HIV infection in hospitalized children below 18 months would provide an opportunity for early diagnosis, treatment.
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Bwakura-Dangarembizi M, Musesengwa R, Nathoo KJ, Takaidza P, Mhute T, Vhembo T. Ethical and legal constraints to children's participation in research in Zimbabwe: experiences from the multicenter pediatric HIV ARROW trial. BMC Med Ethics 2012; 13:17. [PMID: 22818109 PMCID: PMC3521203 DOI: 10.1186/1472-6939-13-17] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 07/05/2012] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Clinical trials involving children previously considered unethical are now considered essential because of the inherent physiological differences between children and adults. An integral part of research ethics is the informed consent, which for children is obtained by proxy from a consenting parent or guardian. The informed consent process is governed by international ethical codes that are interpreted in accordance with local laws and procedures raising the importance of contextualizing their implementation. FINDINGS In Zimbabwe the parental informed consent document for children participating in clinical research is modeled after Western laws of ethics and requires that the parent or legally authorized representative provide consent on behalf of a minor. This article highlights the experiences and lessons learnt by Zimbabwean researchers in obtaining informed consent from guardians of orphaned children participating in a collaborative HIV clinical trial involving the Medical Research Council, United Kingdom and four centers, three of which are in Uganda. Researchers were faced with a situation where caregivers of orphaned children were not permitted to provide informed consent for trial participation. The situation contrasted with general clinical practice where consent for procedures on orphans is obtained from their caregivers who are not legal guardians. CONCLUSION The challenges faced in obtaining informed consent for orphans in this clinical trial underscores the need for the Zimbabwe ethics committee to develop an ethical and legal framework for pediatric research that is based on international guidelines while taking into account the cultural context. The Medical Research Council of Zimbabwe has since started the process that is expected to involve critical stakeholders namely the community including children, ethicists, the legal fraternity and researchers.
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Affiliation(s)
- Mutsa Bwakura-Dangarembizi
- Department of Pediatrics and Child Health, University of Zimbabwe College of Health Sciences, Box A178, Avondale, Harare, Zimbabwe
| | - Rosemary Musesengwa
- Medical Research Council of Zimbabwe, P.O. Box CY489, Causeway, Harare, Zimbabwe
| | - Kusum J Nathoo
- Department of Pediatrics and Child Health, University of Zimbabwe College of Health Sciences, Box A178, Avondale, Harare, Zimbabwe
| | - Patrick Takaidza
- Medical Research Council of Zimbabwe, P.O. Box CY489, Causeway, Harare, Zimbabwe
| | - Tawanda Mhute
- University of Zimbabwe Clinical Research Centre, P.O. Box A1578, Avondale, Harare, Zimbabwe
| | - Tichaona Vhembo
- University of Zimbabwe Clinical Research Centre, P.O. Box A1578, Avondale, Harare, Zimbabwe
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Hargrove JW, Humphrey JH, Mahomva A, Williams BG, Chidawanyika H, Mutasa K, Marinda E, Mbizvo MT, Nathoo KJ, Iliff PJ, Mugurungi O. Declining HIV prevalence and incidence in perinatal women in Harare, Zimbabwe. Epidemics 2011; 3:88-94. [PMID: 21624779 DOI: 10.1016/j.epidem.2011.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 12/10/2010] [Accepted: 02/23/2011] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In several recent papers it has been suggested that HIV prevalence and incidence are declining in Zimbabwe as a result of changing sexual behavior. We provide further support for these suggestions, based on an analysis of more extensive, age-stratified, HIV prevalence data from 1990 to 2009 for perinatal women in Harare, as well as data on incidence and mortality. METHODOLOGY/PRINCIPAL FINDINGS Pooled prevalence, incidence and mortality were fitted using a simple susceptible-infected (SI) model of HIV transmission; age-stratified prevalence data were fitted using double-logistic functions. We estimate that incidence peaked at 5.5% per year in 1991 declining to 1% per year in 2010. Prevalence peaked in 1998/9 [35.9% (CI95: 31.3-40.7)] and decreased by 67% to 11.9% (CI95: 10.1-13.8) in 2009. For women <20y, 20-24y, 25-29y, 30-34y and ≥35y, prevalence peaked at 25.4%, 34.2%, 47.1%, 44.0% and 33.5% in 1993, 1996, 1997, 1998 and 1999, respectively, declining thereafter in every age group. Among women <25y, prevalence peaked in 1994 at 28.8% declining thereafter by 69% to 8.9% (CI95: 6.8-11.5) in 2009. CONCLUSION/SIGNIFICANCE HIV prevalence declined substantially among perinatal women in Harare after 1998 consequent upon a decline in incidence starting in the early 1990s. Our model suggests that this was primarily a result of changes in behavior which we attribute to a general increase in awareness of the dangers of AIDS and the ever more apparent increases in mortality.
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Humphrey JH, Marinda E, Mutasa K, Moulton LH, Iliff PJ, Ntozini R, Chidawanyika H, Nathoo KJ, Tavengwa N, Jenkins A, Piwoz EG, Van de Perre P, Ward BJ. Mother to child transmission of HIV among Zimbabwean women who seroconverted postnatally: prospective cohort study. BMJ 2010; 341:c6580. [PMID: 21177735 PMCID: PMC3007097 DOI: 10.1136/bmj.c6580] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To estimate the rates and timing of mother to infant transmission of HIV associated with breast feeding in mothers who seroconvert postnatally, and their breast milk and plasma HIV loads during and following seroconversion, compared with women who tested HIV positive at delivery. DESIGN Prospective cohort study. SETTING Urban Zimbabwe. PARTICIPANTS 14 110 women and infants enrolled in the Zimbabwe Vitamin A for Mothers and Babies (ZVITAMBO) trial (1997-2001). MAIN OUTCOME MEASURES Mother to child transmission of HIV, and breast milk and maternal plasma HIV load during the postpartum period. RESULTS Among mothers who tested HIV positive at baseline and whose infant tested HIV negative with polymerase chain reaction (PCR) at six weeks (n=2870), breastfeeding associated transmission was responsible for an average of 8.96 infant infections per 100 child years of breast feeding (95% CI 7.92 to 10.14) and varied little over the breastfeeding period. Breastfeeding associated transmission for mothers who seroconverted postnatally (n=334) averaged 34.56 infant infections per 100 child years (95% CI 26.60 to 44.91) during the first nine months after maternal infection, declined to 9.50 (95% CI 3.07 to 29.47) during the next three months, and was zero thereafter. Among women who seroconverted postnatally and in whom the precise timing of infection was known (≤90 days between last negative and first positive test; n=51), 62% (8/13) of transmissions occurred in the first three months after maternal infection and breastfeeding associated transmission was 4.6 times higher than in mothers who tested HIV positive at baseline and whose infant tested HIV negative with PCR at six weeks. Median plasma HIV concentration in all mothers who seroconverted postnatally declined from 5.0 log(10) copies/mL at the last negative enzyme linked immunosorbent assay (ELISA) to 4.1 log(10) copies/mL at 9-12 months after infection. Breast milk HIV load in this group was 4.3 log(10) copies/mL 0-30 days after infection, but rapidly declined to 2.0 log(10) copies/mL and <1.5 log(10) copies/mL by 31-90 days and more than 90 days, respectively. Among women whose plasma sample collected soon after delivery tested negative for HIV with ELISA but positive with PCR (n=17), 75% of their infants were infected or had died by 12 months. An estimated 18.6% to 20.4% of all breastfeeding associated transmission observed in the ZVITAMBO trial occurred among mothers who seroconverted postnatally. CONCLUSIONS Breastfeeding associated transmission is high during primary maternal HIV infection and is mirrored by a high but transient peak in breast milk HIV load. Around two thirds of breastfeeding associated transmission by women who seroconvert postnatally may occur while the mother is still in the "window period" of an antibody based test, when she would test HIV negative using one of these tests. Trial registration Clinical trials.gov NCT00198718.
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Piwoz EG, Humphrey JH, Tavengwa NV, Iliff PJ, Marinda ET, Zunguza CD, Nathoo KJ, Mutasa K, Moulton LH, Ward BJ. The impact of safer breastfeeding practices on postnatal HIV-1 transmission in Zimbabwe. Am J Public Health 2007; 97:1249-54. [PMID: 17538064 PMCID: PMC1913077 DOI: 10.2105/ajph.2006.085704] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We assessed the association between exposure to an educational intervention that emphasized safer breastfeeding practices and postnatal HIV transmission among 437 HIV-positive mothers in Zimbabwe, 365 of whom did not know their infection status. METHODS Mothers were tested for HIV and were encouraged--but not required--to learn their HIV status. Intervention exposure was assessed by a questionnaire, Turnbull methods were used to estimate postnatal HIV transmission, and multivariate Cox proportional hazard models were constructed to assess the association between intervention exposure and postnatal HIV transmission. RESULTS Cumulative postnatal HIV transmission was 8.2%; each additional intervention contact was associated with a 38% reduction in postnatal HIV transmission. HIV-positive mothers who were exposed to both print and video materials were 79% less likely to infect their infants compared with mothers who had no exposure. These findings were similar for mothers who did not know their HIV status. CONCLUSIONS The promotion of exclusive breastfeeding has the potential to reduce postnatal HIV transmission among women who do not know their HIV status, and child survival and HIV prevention programs should support this practice.
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Affiliation(s)
- Ellen G Piwoz
- Center for Nutrition, Academy for Educational Development, Washington, DC, USA
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Marinda E, Humphrey JH, Iliff PJ, Mutasa K, Nathoo KJ, Piwoz EG, Moulton LH, Salama P, Ward BJ. Child mortality according to maternal and infant HIV status in Zimbabwe. Pediatr Infect Dis J 2007; 26:519-26. [PMID: 17529870 DOI: 10.1097/01.inf.0000264527.69954.4c] [Citation(s) in RCA: 245] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND HIV causes substantial mortality among African children but there is limited data on how this is influenced by maternal or infant infection status and timing. METHODS Children enrolled in the ZVITAMBO trial were divided into 5 groups: those born to HIV-negative mothers (NE, n = 9510), those born to HIV-positive mothers but noninfected (NI, n = 3135), those infected in utero (IU, n = 381), those infected intrapartum (IP, n = 508), and those infected postnatally (PN, n = 258). Their mortality was estimated. RESULTS Two-year mortality was 2.9% (NE infants), 9.2% (NI), 67.5% (IU), 65.1% (IP), and 33.2% (PN). Between 8 weeks and 6 months, mortality in IU infants quintupled (from 309 to 1686/1000 c-y). The median time from infection to death was 208, 380, and >500 days for IU, IP, and PN infants, respectively. Among NI children, advanced maternal disease was predictive of mortality. Acute respiratory infection was the major cause of death. CONCLUSIONS Perinatally infected infants are at particular risk of death between 2 and 6 months: cotrimoxazole prophylaxis and early pediatric HAART should be scaled up. Uninfected infants of infected mothers have at least twice the mortality risk of infants born to uninfected mothers: all HIV-exposed infants should be targeted with child survival interventions. HIV-positive mothers with more advanced disease are not only more likely to infect their infants, but their infants are more likely to die, whether infected or not: provision of antiretroviral treatment to pregnant and lactating women is an urgent need for both mothers and their children.
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Kasvosve I, Gomo ZAR, Nathoo KJ, Matibe P, Mudenge B, Gordeuk VR. Reference intervals of serum transferrin receptors in pre-school children in Zimbabwe. Clin Chim Acta 2007; 382:138-41. [PMID: 17493600 DOI: 10.1016/j.cca.2007.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 03/21/2007] [Accepted: 03/21/2007] [Indexed: 10/23/2022]
Abstract
In laboratory medicine an observed value of a biological analyte may be compared with previously observed values from an appropriate reference population. A reference range for serum transferrin receptor concentration has not been established for Zimbabwean children. We prospectively studied 208 children aged 3-60 months who were residents of Harare, a non-malaria and non-hookworm endemic area, and who attended a well-child clinic. Anthropometric measurements were calculated, complete blood counts performed and serum concentrations of ferritin and transferrin receptors determined. A final group of 83 pre-school children with no apparent illness was used to determine the serum transferrin receptor concentration reference interval after excluding individuals with abnormal clinical and laboratory investigations. The central 95 percentile interval for transferrin receptors after eliminating factors that are known to affect serum transferrin receptors was 3.9-9.5 mg/L. Children, aged < or =24 months had a lower reference range than children >24 months old. This study provides an estimate of the serum transferrin receptor reference intervals in African children using the Ramco Laboratories, Stafford, TX assay kit.
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Affiliation(s)
- Ishmael Kasvosve
- Department of Chemical Pathology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
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Tavengwa NV, Piwoz EG, Iliff PJ, Moulton LH, Zunguza CD, Nathoo KJ, Hargrove JW, Humphrey JH. Adoption of safer infant feeding and postpartum sexual practices and their relationship to maternal HIV status and risk of acquiring HIV in Zimbabwe. Trop Med Int Health 2007; 12:97-106. [PMID: 17207153 DOI: 10.1111/j.1365-3156.2006.01758.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the relationships between maternal knowledge and concern about HIV status, adoption of preventive practices and risk of acquiring HIV in Zimbabwe. METHODS Knowledge and behavioural data were collected via interview from 2595 mothers enrolled in ZVITAMBO, a randomized trial of postpartum vitamin A supplementation that also offered education on safer infant feeding and sexual practices. Mothers were tested for HIV at delivery; those uninfected at baseline were retested during study follow-up. Logistic regression methods were used to identify variables associated with adoption of preventive behaviours and, for HIV-negative mothers, their relationship to risk of acquiring HIV post-delivery. RESULTS A total of 518 mothers (20%) reported practicing safer sex and 289 mothers (11%) reported modifying their feeding behaviour because of HIV. Fear of transmitting HIV (50.4%) and protecting the baby's health (30.9%) were the most frequently cited reasons for behaviour change. Forty-nine HIV-negative mothers acquired HIV during the first postpartum year. After taking into account other significant covariates, mothers who were concerned about their own HIV status were 1.9 times more likely (95% CI: 1.05-3.52; P = 0.03), and those reporting safer sex practices were 58% less likely to become infected (adjusted odds ratio: 0.42; 95% CI: 0.17-1.04; P = 0.06). Married women who reported practicing abstinence to prevent HIV were 3.2 times more likely to become infected than non-abstaining mothers (P = 0.01), while there were no new HIV infections among abstaining single mothers. CONCLUSIONS Greater emphasis should be given to safer sex practices among women who test negative in mother-to-child HIV prevention programmes.
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Humphrey JH, Nathoo KJ, Hargrove JW, Iliff PJ, Mutasa KE, Moulton LH, Chidawanyika H, Malaba LC, Zijenah LS, Zvandasara P, Ntozini R, Zunguza CD, Ward BJ. HIV-1 and HIV-2 prevalence and associated risk factors among postnatal women in Harare, Zimbabwe. Epidemiol Infect 2007; 135:933-42. [PMID: 17217549 PMCID: PMC2870654 DOI: 10.1017/s0950268806007709] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Studies of antenatal women form the predominant source of data on HIV-1 prevalence in Africa. Identifying factors associated with prevalent HIV is important in targeting diagnostic services and care. Between November 1997 and January 2000, 14,110 postnatal women from Harare, Zimbabwe were tested by ELISAs reactive to both HIV-1 and HIV-2; a subset of positive samples was confirmed with assays specific for HIV-1 and HIV-2. Baseline characteristics were elicited and modelled to identify risk factors for prevalent HIV infection. HIV-1 and HIV-2 prevalences were 32.0% (95% CI 31.2-32.8) and 1.3% (95% CI 1.1-1.5), respectively; 4% of HIV-1-positive and 99% of HIV-2-positive women were co-infected. HIV-1 prevalence increased from 0% among 14-year-olds to >45% among women aged 29-31 years, then fell to <20% among those aged>40 years. In multivariate analyses, prevalence increased with parity, was lower in married women than in single women, divorcees and widows, and higher in women with the lowest incomes and those professing no religion. Adjusted HIV-1 prevalence increased during 1998 and decreased during 1999. Age modified the effects of parity, home ownership and parental education. Among older women, prevalence was greater for women who were not homeowners. Among younger women, prevalence increased with parity and low parental education. None of these factors distinguished women co-infected with HIV-2 from those infected with HIV-1 alone. Prevalent HIV-1 infection is associated with financial insecurity and weak psychosocial support. The ZVITAMBO study apparently spanned the peak of the HIV-1 epidemic among reproductive women in Harare.
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Affiliation(s)
- J H Humphrey
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Zvandasara P, Hargrove JW, Ntozini R, Chidawanyika H, Mutasa K, Iliff PJ, Moulton LH, Mzengeza F, Malaba LC, Ward BJ, Nathoo KJ, Zijenah LS, Mbizvo M, Zunguza C, Humphrey JH. Mortality and morbidity among postpartum HIV-positive and HIV-negative women in Zimbabwe: risk factors, causes, and impact of single-dose postpartum vitamin A supplementation. J Acquir Immune Defic Syndr 2006; 43:107-16. [PMID: 16885772 DOI: 10.1097/01.qai.0000229015.77569.c7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Vitamin A deficiency is common among women in resource-poor countries and is associated with greater mortality during HIV. METHODS Fourteen thousand one hundred ten mothers were tested for HIV and randomly administered 400,000 IU vitamin A or placebo at less than 96 hours postpartum. The effects of vitamin A and HIV status on mortality, health care utilization, and serum retinol were evaluated. RESULTS Four thousand four hundred ninety-five (31.9%) mothers tested HIV positive. Mortality at 24 months was 2.3 per 1000 person-years and 38.3 per 1000 person-years in HIV-negative and HIV-positive women, respectively. Vitamin A had no effect on mortality. Tuberculosis was the most common cause of death, and nearly all tuberculosis-associated deaths were among HIV-positive women. Among HIV-positive women, vitamin A had no effect on rates of hospitalization or overall sick clinic visits, but did reduce clinic visits for malaria, cracked and bleeding nipples, pelvic inflammatory disease, and vaginal infection. Among HIV-negative women, serum retinol was responsive to vitamin A, but low serum retinol was rare. Among HIV-positive women, serum retinol was largely unresponsive to vitamin A, and regardless of treatment group, the entire serum retinol distribution was shifted 25% less than that of HIV-negative women 6 weeks after dosing. CONCLUSIONS Single-dose postpartum vitamin A supplementation had no effect on maternal mortality, perhaps because vitamin A status was adequate in HIV-negative women and apparently unresponsive to supplementation in HIV-positive women.
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Affiliation(s)
- Partson Zvandasara
- Department of Obstetrics and Gynaecology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
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Kasvosve I, Gomo ZA, Nathoo KJ, Matibe P, Mudenge B, Loyevsky M, Nekhai S, Gordeuk VR. Association of serum transferrin receptor concentration with markers of inflammation in Zimbabwean children. Clin Chim Acta 2006; 371:130-6. [DOI: 10.1016/j.cca.2006.02.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Revised: 02/25/2006] [Accepted: 02/25/2006] [Indexed: 10/24/2022]
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Humphrey JH, Hargrove JW, Malaba LC, Iliff PJ, Moulton LH, Mutasa K, Zvandasara P, Nathoo KJ, Mzengeza F, Chidawanyika H, Zijenah LS, Ward BJ. HIV incidence among post-partum women in Zimbabwe: risk factors and the effect of vitamin A supplementation. AIDS 2006; 20:1437-46. [PMID: 16791019 DOI: 10.1097/01.aids.0000233578.72091.09] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test whether post-partum vitamin A supplementation can reduce incident HIV among post-partum women and identify risk factors for HIV incidence. DESIGN Randomized, placebo-controlled trial METHODS Between November 1997 and January 2001, 14,110 women were randomly administered 400,000 IU vitamin A or placebo within 96 h post-partum. HIV incidence was monitored among 9562 HIV-negative women. RESULTS Cumulative incidence was 3.4% [95% confidence interval (CI), 3.0-3.8] and 6.5% (95% CI, 5.7-7.4) over 12 and 24 months post-partum, respectively. Vitamin A supplementation had no impact on incidence [hazard ratio (HR), 1.08; 95% CI, 0.85-1.38]. However, among 398 women for whom baseline serum retinol was measured, those with levels indicative of deficiency (< 0.7 micromol/l, 9.2% of those measured) were 10.4 (95% CI, 3.0-36.3) times more likely to seroconvert than women with higher concentrations. Furthermore, among women with low serum retinol, vitamin A supplementation tended to be protective against incidence (HR, 0.29; 95% CI, 0.03-2.60; P = 0.26), although not significantly so, perhaps due to limited statistical power. Severe anaemia (haemoglobin < 70 g/l) was associated with a 2.7-fold (95%CI, 1.2-6.1) greater incidence. Younger women were at higher risk of HIV infection: incidence declined by 5.7% (2.8-8.6) with each additional year of age. CONCLUSION Among post-partum women, a single large-dose vitamin A supplementation had no effect on incidence, although low serum retinol was a risk factor for seroconversion. Further investigation is required to determine whether vitamin A supplementation of vitamin-A-deficient women or treatment of anaemic women can reduce HIV incidence.
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Affiliation(s)
- Jean H Humphrey
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA.
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Humphrey JH, Iliff PJ, Marinda ET, Mutasa K, Moulton LH, Chidawanyika H, Ward BJ, Nathoo KJ, Malaba LC, Zijenah LS, Zvandasara P, Ntozini R, Mzengeza F, Mahomva AI, Ruff AJ, Mbizvo MT, Zunguza CD. Effects of a single large dose of vitamin A, given during the postpartum period to HIV-positive women and their infants, on child HIV infection, HIV-free survival, and mortality. J Infect Dis 2006; 193:860-71. [PMID: 16479521 DOI: 10.1086/500366] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 09/28/2005] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Low maternal serum retinol level is a risk factor for mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV). Multiple-large-dose vitamin A supplementation of HIV-positive children reduces mortality. The World Health Organization recommends single-large-dose vitamin A supplementation for postpartum women in areas of prevalent vitamin A deficiency; neonatal dosing is under consideration. We investigated the effect that single-large-dose maternal/neonatal vitamin A supplementation has on MTCT, HIV-free survival, and mortality in HIV-exposed infants. METHODS A total of 14,110 mother-infant pairs were enrolled < or =96 h after delivery, and both mother and infant, mother only, infant only, or neither received vitamin A supplementation in a randomized, placebo-controlled trial with a 2 x 2 factorial design. All but 4 mothers initiated breast-feeding. A total of 4495 infants born to HIV-positive women were included in the present analysis. RESULTS Neither maternal nor neonatal vitamin A supplementation significantly affected postnatal MTCT or overall mortality between baseline and 24 months. However, the timing of infant HIV infection modified the effect that supplementation had on mortality. Vitamin A supplementation had no effect in infants who were polymerase chain reaction (PCR) positive [corrected] for HIV at baseline. In infants who were PCR negative at baseline and PCR positive at 6 weeks, neonatal supplementation reduced mortality by 28% (P=.01), but maternal supplementation had no effect. In infants who were PCR negative at 6 weeks, all 3 vitamin A regimens were associated with ~2-fold higher mortality (P< or =.05). CONCLUSIONS Targeted vitamin A supplementation of HIV-positive children prolongs their survival. However, postpartum maternal and neonatal vitamin A supplementation may hasten progression to death in breast-fed children who are PCR negative at 6 weeks. These findings raise concern about universal maternal or neonatal vitamin A supplementation in HIV-endemic areas.
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Affiliation(s)
- Jean H Humphrey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Kasvosve I, Gomo ZAR, Nathoo KJ, Matibe P, Mudenge B, Loyevsky M, Gordeuk VR. Effect of ferroportin Q248H polymorphism on iron status in African children. Am J Clin Nutr 2005; 82:1102-6. [PMID: 16280445 DOI: 10.1093/ajcn/82.5.1102] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Iron deficiency is common in African children, but genetic variations affecting susceptibility have not been identified. The Q248H mutation in ferroportin, a cellular iron exporter regulated by iron status and inflammation, may be associated with high iron stores in African adults. OBJECTIVE The study examined the prevalence of iron deficiency in African children in an area where malaria transmission is low to absent and investigated whether ferroportin Q248H provides protection from iron deficiency. DESIGN Complete blood counts, serum markers of iron status and inflammation, and ferroportin Q247H were measured in 208 preschool children in Harare, Zimbabwe. Iron deficiency was defined by serum ferritin and C-reactive protein (CRP) concentrations (definition 1) or by ferritin and the ratio of transferrin receptor to log10 ferritin (definition 2). RESULTS Q248H was present in 40 children (38 heterozygotes, 2 homozygotes), elevated CRP was present in 26 (12.5%), and iron deficiency was present in 50 (24.0%) (definition 1) or 55 (26.4%) (definition 2). The interaction between ferroportin Q248H and CRP was significant for ferritin concentrations (P = 0.027) in a 2-factor analysis of variance model. With elevated CRP, the estimated geometric mean (SE range) ferritin concentration was 74 (52-106) microg/L for Q248H heterozygotes but 24 (20-30) microg/L for wild-type subjects (P = 0.016). With normal CRP, the ferritin concentration was 16 (14-19) microg/L whether or not the mutation was present. After adjustment for age and weight-for-height z score, the odds ratio (OR) for iron deficiency in Q248H heterozygotes was not significant according to definition 1 (OR: 0.53; 95% CI: 0.18, 1.40; P = 0.222) or definition 2 (OR: 0.39; 95% CI: 0.14, 1.07; P = 0.068). CONCLUSIONS Any effect of Q248H in protecting against iron deficiency may be observable in children exposed to repeated inflammatory conditions. Further studies of iron status and ferroportin Q248H in African children are needed.
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Affiliation(s)
- Ishmael Kasvosve
- Department of Chemical Pathology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
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Zijenah LS, Tobaiwa O, Rusakaniko S, Nathoo KJ, Nhembe M, Matibe P, Katzenstein DA. Signal-boosted qualitative ultrasensitive p24 antigen assay for diagnosis of subtype C HIV-1 infection in infants under the age of 2 years. J Acquir Immune Defic Syndr 2005; 39:391-4. [PMID: 16010158 DOI: 10.1097/01.qai.0000158401.59047.84] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The gold standard for diagnosis of HIV-1 infection in infants under the age of 2 years is DNA or reverse transcriptase polymerase chain reaction. However, these tests are expensive and therefore not available in resource-limited countries. With the increasing availability of antiretroviral drugs for prevention of mother-to-child transmission of HIV and treatment of AIDS in resource-poor countries, there is an urgent need to develop cheaper, alternative, and cost-effective laboratory methods for early diagnosis of infant HIV-1 infection that will be useful in identifying infected infants who may benefit from early cotrimoxazole prophylaxis or commencement of antiretroviral therapy. We evaluated an alternative method, the enzyme-linked immunosorbent assay-based qualitative ultrasensitive p24 antigen assay for diagnosis of subtype C HIV-1 infection in infants under the age of 2 years using DNA polymerase chain reaction as the reference method. The assay showed a sensitivity of 96.7% (95% CI: 93.0-100) for detection of HIV-1 infection among infants 0-18 months of age with a specificity of 96.1% (95% CI: 91.7-100). These evaluated parameters were not statistically different between infants aged 0-6 and 7-18 months. The ultrasensitive p24 antigen assay is a useful diagnostic test for detection of HIV-1 infection among infants aged 0-18 months.
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Affiliation(s)
- Lynn S Zijenah
- Department of Immunology, Division of Infectious Diseases, College of Health Sciences, University of Zimbabwe, Harare.
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Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, Moulton LH, Ward BJ, Humphrey JH. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005; 19:699-708. [PMID: 15821396 DOI: 10.1097/01.aids.0000166093.16446.c9] [Citation(s) in RCA: 357] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The promotion of exclusive breastfeeding (EBF) to reduce the postnatal transmission (PNT) of HIV is based on limited data. In the context of a trial of postpartum vitamin A supplementation, we provided education and counseling about infant feeding and HIV, prospectively collected information on infant feeding practices, and measured associated infant infections and deaths. DESIGN AND METHODS A total of 14 110 mother-newborn pairs were enrolled, randomly assigned to vitamin A treatment group after delivery, and followed for 2 years. At baseline, 6 weeks and 3 months, mothers were asked whether they were still breastfeeding, and whether any of 22 liquids or foods had been given to the infant. Breastfed infants were classified as exclusive, predominant, or mixed breastfed. RESULTS A total of 4495 mothers tested HIV positive at baseline; 2060 of their babies were alive, polymerase chain reaction negative at 6 weeks, and provided complete feeding information. All infants initiated breastfeeding. Overall PNT (defined by a positive HIV test after the 6-week negative test) was 12.1%, 68.2% of which occurred after 6 months. Compared with EBF, early mixed breastfeeding was associated with a 4.03 (95% CI 0.98, 16.61), 3.79 (95% CI 1.40-10.29), and 2.60 (95% CI 1.21-5.55) greater risk of PNT at 6, 12, and 18 months, respectively. Predominant breastfeeding was associated with a 2.63 (95% CI 0.59-11.67), 2.69 (95% CI 0.95-7.63) and 1.61 (95% CI 0.72-3.64) trend towards greater PNT risk at 6, 12, and 18 months, compared with EBF. CONCLUSION EBF may substantially reduce breastfeeding-associated HIV transmission.
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Piwoz EG, Iliff PJ, Tavengwa N, Gavin L, Marinda E, Lunney K, Zunguza C, Nathoo KJ, Humphrey JH. An education and counseling program for preventing breast-feeding-associated HIV transmission in Zimbabwe: design and impact on maternal knowledge and behavior. J Nutr 2005; 135:950-5. [PMID: 15795468 DOI: 10.1093/jn/135.4.950] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
International guidance on HIV and infant feeding has evolved over the last decade. In response to these changes, we designed, implemented, and evaluated an education and counseling program for new mothers in Harare, Zimbabwe. The program was implemented within the ZVITAMBO trial, in which 14,110 mother-baby pairs were enrolled within 96 h of delivery and were followed at 6 wk, 3 mo, and 3-mo intervals. Mothers were tested for HIV at delivery but were not required to learn their test results. Infant feeding patterns were determined using data provided up to 3 mo. Formative research was undertaken to guide the design of the program that included group education, individual counseling, videos, and brochures. The program was introduced over a 2-mo period: 11,362, 1311, and 1437 women were enrolled into the trial before, during, and after this period. Exclusive breast-feeding was recommended for mothers of unknown or negative HIV status, and for HIV-positive mothers who chose to breast-feed. A questionnaire assessing HIV knowledge and exposure to the program was administered to 1996 mothers enrolling after the program was initiated. HIV knowledge improved with increasing exposure to the program. Mothers who enrolled when the program was being fully implemented were 70% more likely to learn their HIV status early (<3 mo) and 8.4 times more likely to exclusively breast-feed than mothers who enrolled before the program began. Formative research aided in the design of a culturally sensitive intervention. The intervention increased relevant knowledge and improved feeding practices among women who primarily did not know their HIV status.
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Zijenah LS, Katzenstein DA, Nathoo KJ, Rusakaniko S, Tobaiwa O, Gwanzura C, Bikoue A, Nhembe M, Matibe P, Janossy G. T lymphocytes among HIV-infected and -uninfected infants: CD4/CD8 ratio as a potential tool in diagnosis of infection in infants under the age of 2 years. J Transl Med 2005; 3:6. [PMID: 15683549 PMCID: PMC549040 DOI: 10.1186/1479-5876-3-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Accepted: 02/01/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Serologic tests for HIV infection in infants less than 18 months do not differentiate exposure and infection since maternally acquired IgG antibodies may be detected in infants. Thus, the gold standard for diagnosis of HIV-1 infection in infants under the age of 2 years is DNA or reverse transcriptase polymerase chain reaction. There is an urgent need to evaluate alternative and cost effective laboratory methods for early diagnosis of infant HIV-1 infection as well as identifying infected infants who may benefit from cotrimoxazole prophylaxis and/or initiation of highly active antiretroviral therapy. METHODS: Whole blood was collected in EDTA from 137 infants aged 0 to 18 months. DNA polymerase chain reaction was used as the reference standard for diagnosis of HIV-1 infection. T-cell subset profiles were determined by flow cytometry. RESULTS: Seventy-six infants were DNA PCR positive while 61 were negative. The median CD4 counts of PCR negative infants were significantly higher than those of the PCR positive infants, p < 0.001. The median CD4/CD8 ratio and the %CD4 of the PCR positive infants were both significantly lower than those of the negative infants, p < 0.001. The CD4/CD8 ratio had a >98% sensitivity for diagnosis of HIV-1 infection and a specificity of >98%. CONCLUSION: The CD4/CD8 ratio appears useful in identifying HIV-infected infants. The development of lower cost and more robust flow cytometric methods that provide both CD4/CD8 ratio and %CD4 may be cost-effective for HIV-1 diagnosis and identification of infants for cotrimoxazole prophylaxis and/or highly active antiretroviral therapy.
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Affiliation(s)
- Lynn S Zijenah
- Department of Immunology, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - David A Katzenstein
- Division of Infectious Diseases and AIDS Research, Stanford University Medical School, Stanford, California, USA
| | - Kusum J Nathoo
- Department of Paediatrics, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - Simbarashe Rusakaniko
- Department of Community Medicine, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - Ocean Tobaiwa
- Department of Immunology, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - Christine Gwanzura
- Department of Haematology, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - Arsene Bikoue
- Department of Immunology and Molecular Pathology, Royal Free and University College Medical School, London, UK
- Department of Flow Cytometry, MFN International, Asmara, Eritrea
| | - Margaret Nhembe
- Department of Paediatrics, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - Petronella Matibe
- Department of Paediatrics, College of Health Sciences University of Zimbabwe, Harare, Zimbabwe
| | - George Janossy
- Department of Immunology and Molecular Pathology, Royal Free and University College Medical School, London, UK
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Malaba LC, Iliff PJ, Nathoo KJ, Marinda E, Moulton LH, Zijenah LS, Zvandasara P, Ward BJ, Humphrey JH. Effect of postpartum maternal or neonatal vitamin A supplementation on infant mortality among infants born to HIV-negative mothers in Zimbabwe. Am J Clin Nutr 2005; 81:454-60. [PMID: 15699235 DOI: 10.1093/ajcn.81.2.454] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Young infants are at risk of vitamin A deficiency. Supplementation of breastfeeding mothers improves the vitamin A status of their infants, but there are no data regarding its effect on infant mortality, and data on the effect of directly supplementing infants during the first few weeks of life are conflicting. OBJECTIVE The objective was to measure the effect on infant mortality of supplementing neonates and their HIV-negative mothers with single, large doses of vitamin A during the immediate postpartum period. DESIGN A randomized, placebo-controlled, 2-by-2 factorial design trial was conducted in 14,110 mothers and their infants; 9208 of the mothers were HIV-negative at delivery, remained such during the postpartum year, and were retained in the current analysis. The infants were randomly assigned within 96 h of delivery to 1 of 4 treatment groups: mothers and infants received vitamin A (Aa), mothers received vitamin A and infants received placebo (Ap), mothers received placebo and infants received vitamin A (Pa), and both mothers and infants received placebo (Pp). The vitamin A dose in the mothers was 400,000 IU and in the infants was 50,000 IU. The mother-infant pairs were followed to 12 mo. RESULTS Hazard ratios (95% CI) for 12 mo mortality among infants in the maternal-supplemented and infant-supplemented groups were 1.17 (0.87, 1.58) and 1.08 (0.80, 1.46), respectively. Hazard ratios (95% CI) for the Aa, Ap, and Pa groups compared with the Pp group were 1.28 (0.83, 1.98), 1.27 (0.82, 1.97), and 1.18 (0.76, 1.83), respectively. These data indicate no overall effect. Serum retinol concentrations among a subsample of women were similar to reference norms. CONCLUSION Postpartum maternal or neonatal vitamin A supplementation may not reduce infant mortality in infants of HIV-negative women with an apparently adequate vitamin A status.
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Affiliation(s)
- Lucie C Malaba
- Department of Nutrition, University of Zimbabwe, Harare, Zimbabwe
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Gwanzura L, Pasi C, Nathoo KJ, Hakim J, Gangaidzo I, Mielke J, Robertson VJ, Heyderman RS, Mason PR. Rapid emergence of resistance to penicillin and trimethoprim-sulphamethoxazole in invasive Streptococcus pneumoniae in Zimbabwe. Int J Antimicrob Agents 2003; 21:557-61. [PMID: 12791469 DOI: 10.1016/s0924-8579(03)00052-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Pneumococcal pneumonia and meningitis are common infectious disease problems in people who are HIV seropositive in southern Africa. For many years two inexpensive antibiotics, penicillin and trimethoprim-sulphamethoxazole (TMP-SMX) had been effective in treatment, but recently resistance to these agents has been reported from many parts of the world. This study was designed to determine the antimicrobial resistance patterns in invasive pneumococci from hospital patients in Harare, Zimbabwe. A total of 160 isolates of Streptococcus pneumoniae from blood cultures and CSF cultures were examined. The isolates came from adults and children in hospital in Harare between 1994 and 2000. The majority of isolates came from HIV positive adults (74%) and children (75%). Isolates of pneumococci with an MIC of 1.0 mg/l or more were first seen in 1997 and by 2000 they made up 35% of all isolates. Significantly more isolates from HIV seropositive patients (50%) showed reduced susceptibility to penicillin compared with isolates from HIV seronegative patients (16%), and high level resistance (MIC 1.0 mg/l or higher) was found in 16% isolates from HIV positive patients compared with 6% isolates from HIV seronegative patients. Resistance to TMP-SMX was common, with more than 50% isolates from HIV positive and HIV negative patients having reduced susceptibility to this antibiotic combination.
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Affiliation(s)
- Lovemore Gwanzura
- Department of Medical Laboratory Science, University of Zimbabwe Medical School, PO Box A178 Avondale, Harare, Zimbabwe
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Mtombeni S, Mahomva A, Siziya S, Sanyika C, Doolabh R, Nathoo KJ. A clinical evaluation of children under the age of five years who are household contacts of adults with sputum positive tuberculosis in Harare, Zimbabwe. Cent Afr J Med 2002; 48:28-32. [PMID: 12971154 DOI: 10.4314/cajm.v48i3-4.51677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the prevalence and risk factors for transmission of tuberculosis in children under five years of age who are household contact of sputum smear positive tuberculosis adults in Harare, Zimbabwe. DESIGN Cross sectional study. SETTING City Health Infectious Diseases Hospital Outpatient Department. SUBJECTS 174 children in contact with 102 index cases. MAIN OUTCOME MEASURES TB infection status in children according to modified WHO classification of tuberculosis. METHODS Under five year old contacts of sputum smear positive TB adults were recruited over a three month period. A coded questionnaire was used to document the following: socio-demographic profile of caregivers, duration of stay with the index case and presenting complaints. Contacts were evaluated by clinical examination, Mantoux testing, HIV antibody testing and chest radiographs. RESULTS Of the 174 children in contact with 102 index cases evaluated, 109 (62.6%) were Mantoux positive (> or = 10 mm), 42% had abnormal chest X-ray, with hilar lymphadenopathy being the commonest abnormality. Forty nine percent of the children evaluated had probable TB, 28% had suspected TB and 23% had no TB. High alcohol acid fast load (AAFB) in the index case was independently associated with probable and suspected TB (OR 2.27 95% CI (1.05 to 4.87). CONCLUSION The documented high transmission rate among under five years contacts in the study justifies the need for strengthening contact tracing and appropriate therapeutic management of identified children.
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Affiliation(s)
- S Mtombeni
- Department of Paediatrics and Child Health, University of Zimbabwe, Medical School, PO Box A178, Avondale, Harare, Zimbabwe
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Mazengera LR, Nathoo KJ, Rusakaniko S, Zegers BJ. Serum IgG subclasses levels in paediatric patients with pneumonia. Cent Afr J Med 2001; 47:142-5. [PMID: 12201019 DOI: 10.4314/cajm.v47i6.8604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the IgG subclass levels of patients admitted to Harare Central Hospital paediatric wards with pneumonia. DESIGN A cross sectional study. SETTING Harare Central Hospital, Departments of Immunology and Paediatrics, University of Zimbabwe; Department of Paediatric Immunology, University of Utrecht, The Netherlands. SUBJECTS 56 paediatric patients. MAIN OUTCOME MEASURES IgG subclass profiles of children with pneumonia. RESULTS Of the 56 children tested, 40 (71%) had antibodies to human immunodeficiency virus (HIV). The levels of IgG1 and IgG3 subclasses were significantly higher in HIV antibody positive children (p < 0.001, p < 0.01 respectively) than in those without detectable HIV antibodies in their sera. There was no significant relationship between IgG subclass levels and the presence of HIV p24 antigen. Furthermore, age and gender also had no significant influence on the levels of IgG subclasses in this population. CONCLUSION High levels of IgG1 and IgG3, but not IgG2 and IgG4, occur frequently in children with pneumonia and are associated with the presence of HIV antibodies.
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Affiliation(s)
- L R Mazengera
- Department of Immunology, University of Zimbabwe Medical School, P O Box A178, Avondale, Harare, Zimbabwe
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Nathoo KJ, Gondo M, Gwanzura L, Mhlanga BR, Mavetera T, Mason PR. Fatal Pneumocystis carinii pneumonia in HIV-seropositive infants in Harare, Zimbabwe. Trans R Soc Trop Med Hyg 2001; 95:37-9. [PMID: 11280062 DOI: 10.1016/s0035-9203(01)90325-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Lung biopsies taken post mortem from 24 HIV-seropositive children who died of pneumonia in Harare Hospital (Zimbabwe) during 1995 were examined for pathogens using histology, culture, microscopy and polymerase chain reaction (PCR). Pneumocystis carinii was detected in 16 (67%) children, in 5 of whom bacterial pathogens were also detected. There were 2 cases of cytomegalovirus infection. On the basis of histology and PCR, none of the children had tuberculosis. These data add to the evidence that P. carinii pneumonia may be a significant cause of death in HIV-infected children in southern Africa. Policies on treatment for severe pneumonia, and on prophylaxis for children born to HIV-seropositive mothers need to be re-examined.
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Affiliation(s)
- K J Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe Medical School, P.O. Box A178, Avondale, Harare, Zimbabwe.
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Abstract
Administration of oxygen via a tube held close to the nose prevented hypoxemia during breastfeeding in 15 of 20 infants with bronchopneumonia.
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Affiliation(s)
- J P Brady
- Department of Pediatrics, University of Zimbabwe, Harare, Zimbabwe
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Nathoo KJ, Mabuzane E, Munyoro M, Shearley A, Manyame B, Beillik R. Progress towards polio eradication in Zimbabwe. Cent Afr J Med 1999; 45:330-5. [PMID: 10941412 DOI: 10.4314/cajm.v45i12.8511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- K J Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe Medical School, Avondale, Harare
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Abstract
OBJECTIVE To determine levels of serum immunoglobulins IgG, IgM and IgA in patients admitted with pneumonia to Harare Central Hospital paediatric wards. DESIGN A cross sectional pilot study. SETTING Harare Central Hospital, Department of Immunology, University of Zimbabwe; Department of Paediatrics, University of Zimbabwe; Immunology Laboratory, University of Utrecht (The Netherlands). SUBJECTS 71 paediatric patients. MAIN OUTCOME MEASURES Immunoglobulin profiles for children with pneumonia. RESULTS Of the 71 children tested, 43 had high IgG levels of between two and half and five times the upper end of the normal age-matched reference range. While the same 43 children with high IgG had similarly elevated levels of IgM, only 25 of them had elevated IgA levels. Of this group of 43 children with hypergammaglobulinaemia, all but one, had antibodies to human immunodeficiency virus (HIV), 50% of whom had detectable levels of p24 antigen in their sera. A small minority, 4% of the 71 patients, had very low levels of total immunogloblins. CONCLUSIONS High levels of total immunoglobulins occur frequently in children with pneumonia and are associated with the presence of HIV 1/2 antibodies and also p24 antigen.
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Affiliation(s)
- L R Mazengera
- Department of Immunology, University of Zimbabwe Medical School, Avondale, Harare, Zimbabwe
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Nathoo KJ, Bannerman CH, Pirie DJ. Pattern of admissions to the paediatric medical wards (1995 to 1996) at Harare Hospital, Zimbabwe. Cent Afr J Med 1999; 45:258-63. [PMID: 10823229 DOI: 10.4314/cajm.v45i10.8496] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To document the pattern of disease and outcome of medical paediatric admissions at Harare hospital. DESIGN Cross sectional study from 1 June 1995 to 30th May 1996. SETTING Medical paediatric wards, Harare Central Hospital. SUBJECTS All admissions below the age of nine years. MAIN OUTCOME MEASURES Socio-demographic features, nutritional status, clinical diagnoses, duration of hospital stay and mortality. RESULTS A total of 8,826(90.0%) of the admissions were assessed. The majority(51.8%) of the patients were one year and below. "Road to Health" cards, available for 94.4% children, showed 88.0% had appropriate immunizations for age. Forty nine percent had lower respiratory tract infection either as only, or concurrent with other diagnoses, with an overall fatality rate of 16.2%. Acute diarrhoea was the second most frequent condition (21.0%) with an associated case fatality rate of 11.3%. Mortality rates for neonatal sepsis and bacterial meningitis were 12.3% and 32.8% respectively. Severe malnutrition defined as less than 60% of the expected weight for age, was present in 12.5% with an associated fatality rate of 28.7%. Based on clinical suspicion 23.2% of the total children were tested for HIV antibodies and 82.0% were positive. Overall case fatality among the inpatients was 17.8% and 36.7% of the total deaths occurred within 24 hours of admission. CONCLUSION There is a need to re-evaluate our management strategies for common conditions including those with HIV infection. Standardization of case management is an important and essential step towards reduction in mortality both at the primary and referral health institutions.
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Affiliation(s)
- K J Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe Medical School, Avondale, Harare
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Iliff PJ, Humphrey JH, Mahomva AI, Zvandasara P, Bonduelle M, Malaba L, Nathoo KJ. Tolerance of large doses of vitamin a given to mothers and their babies shortly after delivery. Nutr Res 1999. [DOI: 10.1016/s0271-5317(99)00101-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Nathoo KJ, Porteous JE, Siziya S, Wellington M, Mason E. Predictors of mortality in children hospitalized with dysentery in Harare, Zimbabwe. Cent Afr J Med 1998; 44:272-6. [PMID: 10910572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES To document the pattern of complications and identify risk factors for subsequent mortality in a hospitalized paediatric population during a Shigella dysenteriae type 1 epidemic. DESIGN Hospital based prognostic study. SETTING Paediatric wards in Harare and Parirenyatwa tertiary referral hospitals. SUBJECTS All children aged one month to 12 years admitted to the wards with a history of bloody diarrhoea between January 1993 to June 30 1994 were included in the study (n = 312). MAIN OUTCOME MEASURES Patterns of complications and predictors of mortality. RESULTS The peak age group of the patients was 12 to 23 months. Ninety five children died giving an overall case fatality rate (CFR) of 30.4% (95% CI, 25.3 to 35.6). One third (n = 107) had haemolytic uraemic syndrome (HUS), among whom the CFR was 43%. Other complications included altered consciousness (35%), seizures (12%), coma (4.5%), severe dehydration (14%), abdominal distention (17%), rectal prolapse (5%) and ileus (6%). In a multivariate analysis, temperature < 36 degrees C (OR 2.12; 95% CI, 1.33 to 3.39), severe dehydration (OR, 1.70; 95% CI, 1.15 to 2.53), hyperkalemia (> 5.5 mmol/L) (OR, 1.74; 95% CI, 1.01 to 1.97), hyponatremia (< 120 mmol/L) (OR, 1.57; 95% CI, 1.17 to 2.11), urea (> 8 mmol/L) (OR, 1.74; 95% CI, 1.29 to 2.36), and abdominal distention (OR, 1.67; 95% CI, 1.16 to 2.41) were found to be predictors of mortality. CONCLUSION Some of the major clinical and laboratory features allowing the early identification of children at increased risk of dying during dysentery outbreaks have been delineated. The high fatality associated with complicated dysentery highlights the need for preventive strategies which are sustainable in the region.
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Affiliation(s)
- K J Nathoo
- Department of Community Medicine, University of Zimbabwe Medical School, Harare, Zimbabwe
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Borok MZ, Nathoo KJ, Gabriel R, Porter KA. Clinicopathological features of Zimbabwean patients with sustained proteinuria. Cent Afr J Med 1997; 43:152-8. [PMID: 9431741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To describe clinico-pathological features of patients admitted with significant proteinuria. DESIGN Hospital based prospective survey conducted from 1982 to 1987. SETTING Paediatric and medical wards at both tertiary referral hospitals in Harare. SUBJECTS 119 patients who presented with significant proteinuria were investigated. RESULTS Of the primary nephritides, diffuse mesangial proliferative glomerulonephritis was the most common finding (25/119); IgM was the dominant or sole immunoglobulin identified in 17/25. Minor glomerular abnormalities were common (19/119); there were 11 patients with minimal change disease and this number accounted for 42% of the children aged three to 12 years who were nephrotic. This incidence is higher than previously reported from Africa. Diffuse membranous nephropathy was frequent (18/119); hepatitis B surface antigen was present in only five of these patients. Focal sclerosing glomerulo-sclerosis was as frequent as diffuse membranous nephropathy (18/119) and appeared to be idiopathic. Diffuse mesangiocapillary glomerulonephritis (membranoproliferative) was present in 15/119 patients; no causal association was made. CONCLUSION The pattern of primary glomerulonephritis is described from 1982 to 1987. We describe a slightly higher number of patients with minimal change disease and minor glomerular abnormalities than previously reported and a surprisingly small number of patients with diffuse endocapillary glomerulonephritis. In common with other African series, no patient with IgA nephropathy was found.
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Affiliation(s)
- M Z Borok
- Department of Medicine, University of Zimbabwe Medical School, Harare, Zimbabwe
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Ticklay IM, Nathoo KJ, Siziya S, Brady JP. HIV infection in malnourished children in Harare, Zimbabwe. East Afr Med J 1997; 74:217-20. [PMID: 9299820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A descriptive study was undertaken to compare the pattern of socio-demographic features, nutritional profile and presenting features of HIV infected and uninfected children with malnutrition. A total of 140 children aged above 15 months admitted to the paediatric wards, Harare Hospital from December 1993 to February 1994 were studied. Sixty eight (48.6%) children were found to be HIV seropositive and 72 negative. The socio-demographic features were similar in both groups. Marasmus and marasmic kwashiorkor were predominant in the HIV infected children, whilst the majority (64%) of the children in the HIV uninfected group had kwashiorkor (p = 0.001). Pneumonia, lymphadenopathy, chronic discharging ears and oral thrush were significantly more frequent in the HIV infected than in the non HIV infected children (p < 0.01). Factors predictive of HIV infection were marasmus (OR 2.72, 95% CI 1.04-8.10), generalised lymphadenopathy (OR 2.77, 95% CI 1.16-6.64), oral thrush (OR 2.72, 95% CI 1.16-6.37) and discharging ears (OR 6.05, 95% CI 1.89-19.42) with a sensitivity of 57.6% (95% CI 45.7%-69.5%), specificity of 71.4% (95% CI 60.8% 82.0%). The high prevalence of HIV infection among the malnourished children emphasises the impact of the HIV epidemic on childhood nutritional morbidity.
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Nathoo KJ. Shigella dysenteriae type 1 in Zimbabwe. Afr Health 1997; 19:9-10. [PMID: 12292400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
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Abstract
BACKGROUND HIV infection is common in mothers and their children in Zimbabwe, and HIV-infected children are particularly susceptible to bacterial infections. There is little information on the etiology and outcome of HIV-related bacteremia in African children. METHODS Blood cultures from 309 hospitalized children in Zimbabwe, of whom 168 were diagnosed as having HIV, were examined for pathogens. The association among significant bacteremia, HIV infection and mortality was assessed in these children. RESULTS The most common isolates were coagulase-negative staphylococci (31 children, 25 clinically significant), Staphylococcus aureus (22 children) and Streptococcus pneumoniae (20 children). Nontyphoidal Salmonella (10 children), Escherichia coli (4 children) and Klebsiella sp. (4 children) were the most frequent Gram-negative bacteria. Two children had Rhodococcus equi pneumonia. HIV-infected children showed increased risk of bacteremia (odds ratio (OR) = 2.68), especially if younger than 18 months of age (OR = 2.94), and high risk of enterobacteremia (OR = 15.76). There was no significant association of bacteremia with nutritional status. Mortality was 17% overall but was higher in HIV-infected children up to 6 months of age (OR = 2.81) and in bacteremic children of any age (OR = 2.03). CONCLUSIONS Prompt recognition of pathogens and early administration of appropriate antimicrobials is important in reducing the morbidity and mortality associated with bacteremia in HIV-infected children in Africa.
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Affiliation(s)
- K J Nathoo
- Department of Paediatrics, University of Zimbabwe Medical School, Harare Central Hospital, PRM
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Brady JP, Nathoo KJ. Hypoxaemia and bronchopneumonia in infants less than six months of age. Cent Afr J Med 1996; 42:163-5. [PMID: 8870312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the association of both oxygen saturation (SaO2) in high levels of inspired oxygen (FiO2) and the rate of desaturation in air among survivors and non survivors (death within 7 days of admission) in infants with bronchopneumonia. DESIGN Hospital based prognostic study. SETTING Tertiary level Paediatric ward, Harare Hospital. SUBJECTS Total of 40 infants aged less than six months with pneumonia were studied. INTERVENTIONS Oxygen saturation was measured with a pulse oximeter and F1O2 with an analyser. F1O2 was increased until the SaO2 reached maximal values, SaO2 was recorded for five minutes: three in O2 (oxygen) and two in air and the rate of desaturation calculated. MAIN OUTCOME MEASURES Mortality within seven days of admission. RESULTS Eleven died within seven days of admission. Mortality was not associated with age, weight for age, severity of pneumonia, or SaO2 in high oxygen (99pc versus 95pc). It was related to the rate of oxygen desaturation in air; 8pc/minute versus 24pc/minute in survivors and non survivors, respectively (p < 0.001). CONCLUSION This study suggests that current nursing procedures and feeding practices may need to be modified in these very ill infants.
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Affiliation(s)
- J P Brady
- Department of Paediatrics, Harare Central Hospital, Zimbabwe
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van Gool T, Luderhoff E, Nathoo KJ, Kiire CF, Dankert J, Mason PR. High prevalence of Enterocytozoon bieneusi infections among HIV-positive individuals with persistent diarrhoea in Harare, Zimbabwe. Trans R Soc Trop Med Hyg 1995; 89:478-80. [PMID: 8560514 DOI: 10.1016/0035-9203(95)90073-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Infection with the microsporidian parasite Enterocytozoon bieneusi may be a major cause of prolonged diarrhoea in individuals also infected with human immunodeficiency virus (HIV). The parasite has been reported from Europe, Australia and the Americas, with a prevalence of 7-29%. Faecal specimens were obtained from 202 adults and 106 children in Harare, Zimbabwe, all of whom were in hospital and had diarrhoea. HIV serology was available for 119 adults: 106 were HIV seropositive. There were clinical grounds for suspecting HIV infection in 23 of the remaining patients. E. bieneusi was identified in specimens from 13/129 patients (10%) for whom HIV infection was indicated by serology and/or clinical signs, 1/60 patients (2%) of uncertain HIV status, and 0/13 seronegative patients. 18/106 children were HIV seropositive and 12 were not; HIV serology was not available for the remainder, but 19 were strongly suspected of being infected with HIV on clinical criteria. E. bieneusi was not detected in samples from any child. As is common in Zimbabwe, the prevalence of other parasites in faecal specimens was low and, amongst patients with proven or suspected HIV infection, E. bieneusi was the most prevalent parasite identified, particularly in patients with diarrhoea of over 4 weeks duration.
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Affiliation(s)
- T van Gool
- Department of Medical Microbiology, University of Amsterdam, The Netherlands
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