University of Zambia Medical Library

HIV/STD/TB Infection in Children and Paediatric AIDS (AIDS in Zambia Bibliography #36-52)

(#36) "Sexually Transmitted Diseases in Children"
Ratnam, A.V., Haworth, A., Hira, S.K. (1983) East African Medical Journal, Vol. 60, pp 636-639.
Geographical area: Lusaka; Keywords: onorrhoea, paediatrics; Location: UNZA Medical Library

Results of clinical surveillance of 26 children under the age of 15 presenting at an STD clinic over a 20 month period. 16 of the 19 patients under 10 were female; 5 of the 7 older children were male. 8 of the 18 female patients were considered victims of sexual assault whilst the remaining 10 acquired their infection through sexual experimentation with adolescent or preadolescent males. 15 of the females were reported to have intact hymens. Secondary syphilis was diagnosed in 17 patients (65.4 per cent), trichomoniasis in nine, gonorrhoea in five and genital warts in four. [Editor's note: this paper is contextualised in Richens, J. (1994) Sexually transmitted diseases in children in developing countries, Genitourinary Medicine, Vol 70, No. 4, pp 278-283].

(#37) Kaposi's sarcoma in Zambian children
Rolfe, M., Wels, K.H.G. (1987) AIDS, Vol 1, pp 259-260. Geographical area: Copperbelt; Key words: Kaposi's Sarcoma, paediatrics; Location: UNZA Medical Library

Objective:
To document the existence of Kaposi's sarcoma (KS) in Zambian children. Methods: Clinical observation of children admitted and seen in the Copperbelt region of Zambia. Since 1985, 8 African children have been seen with histologically proven KS on lymph node biopsy.

Results:

• They were all seropositive for anti-HIV antibodies using ELISA tests (Wellcozyme, Elavia, Hoffman-La Roche).
• All had generalised lymphadenopathy which was sometimes massive and occasionally painful. Three patients had abnormal chest radiographs and one developed skin lesions but no oral or conjunctival lesions were observed.
• The male-to-female ratio was 3:1 and the mean age at diagnosis was 3.4 years (range 1.8-5.2 years).
• Three patients died, with a mean survival of 3 months from diagnosis (range 1 months). Four patients were still alive, with a mean survival of 6.5 months from diagnosis (range 4-12 months) and one has been lost to follow-up.
• Four patients benefitted with reduction in glandular size following treatment with vincristine and actinomycin-D.
• Seven children had seropositive mothers whilst one child had Sickle-cell anaemia and had received several blood transfusions.
• One mother was herself found to have KS on lymph-node biopsy. As the child was aged 1 year 9 months at presentation it is possible that transplacental spread of KS occurred. However, the presence of HIV infection plus other unknown cofactors in both patients remain the more likely aetiological factors. Conclusions: Paediatricians in central Africa should be aware that KS occur in children as a manifestation of AIDS and is likely to become more prevalent as the epidemic spreads.

(#38) Tuberculosis in Children
Nabulyato, A. (1989) unpublished
Geographical area: Lusaka; Keywords: TB, paediatric AIDS, BCG; Location: unknown

Tuberculosis is a common and prevalent disease in Zambia. This study records the incidence and manifestation of TB and 20 per cent of these had protein energy malnutrition. Among the extrapulmonary lesions was cervical lymphadenitis, meningitis and miliary TB. Five of the patients had pulmonary tuberculosis associated with the human immuno-deficiency virus (HIV). The BCG immunisation at birth proved not protective in 22 children.

(#39) The Effects Of Human Immunodeficiency Virus on Child Development
Shilalukey, M., Ruzibiza, J. (1990) unpublished
Geographical area: Lusaka; Key words: Paediatric AIDS; Location: unknown

Paediatric AIDS and HIV infection is mainly diagnosed clinically in Zambia with minimal laboratory aid, viz antibody testing. The focus has been on the physical illness in children. The physical, emotional and psychological effects of HIV infection in children, as they are emerging in Zambia are illustrated in this case study with particular reference to the deleterious effect on development of nursing HIV in a busy neonatal intensive care unit.

(#40) The impact of HIV infection on malnutrition in a Zambian rural Community
Chela, C., Nseluke, M., Campbell, I., Rader, A., Siankanga, Z. (1990) Poster presented at the VIth International Conference on AIDS, San Francisco, June, 1990.
Geographical area: Chikankata, Southern Province; Key words: Malnutrition, paediatric AIDS; Location: UNZA Medical Library, UNICEF

Objective:

• To describe the management of seropositive children presenting with malnutrition.
• To determine the impact of HIV on nutrition rehabilitation.
• To assess the advantages of community based care.

Method:
A retrospective analysis of 120 records of severely malnourished children who had been tested for HIV was done, covering a period from January 1987 to January 1990. The files comprised of 60 HIV-negative and 60 HIV-positive children. All patients studied were suspected to have HIV infection clinically and were tested using the Wellcozyme ELISA test. Patients were classified in three groups for easy follow up and analysis of results.

• Group 1: Less than 15 months at time of diagnosis to date of study (Jan. 1990)
• Group 2: Greater than 15 months from time of diagnosis to date of study (Jan. 1990)
• Group 3: Greater than 15 months at time of diagnosis.

Results:

• The average age of presentation with malnutrition did not differ significantly between the HIV seropositive and HIV seronegative children. The same can be said abut the sex of the subjects.
• Marasmus accounted for 54 per cent of all patients with 63 per cent of these being infected; Kwashiorkor accounted for 27 per cent of all patients with 34 per cent being infected; Subnutrition accounted for 12 per cent of all patients and 35 per cent of these being infected.
• Marasmus-kwashiorkor accounted for 7.5 per cent of all patients and 33 per cent being HIV infected.
• HIV infection presents commonly as marasmus in the paediatrics age group.
• Mortality is 53 per cent in HIV infected children while it is 4.8 per cent in those free of infection.
• Readmissions are greater in HIV infected children (18 per cent) compared to those free of infection (10 per cent).

Conclusions:

• Morbidity and mortality for HIV infected children suffering from malnutrition is increased.
• Since there is no weight gain and mortality is increased, admission into the established rehabilitation centre is likely to be depressing to mothers and, therefore, counterproductive.
• An alternative method of care for such children is home based care which contains opportunities for preventative counselling of families and communities.

(#41) HIV Infection Among Hospitalised Children at the University Teaching Hospital, Lusaka: diagnosis and risk of transmission through therapeutic practices
Luo, C. (1991) unpublished
Geographical area: Lusaka; Keywords: Blood transfusion, paediatrics, case definition; Location: UNZA Medical Library

The aim of this study is to identify whether medical practices outside hospital may be responsible for HIV transmission in children with seronegative parents. The objectives were to estimate the rate of seropositivity amongst hospitalised children; to evaluate WHO clinical case definition for AIDS diagnosis in children and to evaluate the role of hospitalisation, medical injections and clarification therapy in HIV transmission. 5 mls of blood was obtained in 10 mls containers by venipuncture from each mother and child. Blood was processed at the Immunology laboratory at the UTH. The samples were centrifuged and the serum collected in ml aliquot serum containers (sastarol tubes, West Germany.) The HIV test was done using two ELISA Systems employing different principles (Elavia AC-AB-AK1, Wellcozyme HIV Recombinant). Any sera that was undeterminant was subjected to Western blot for confirmation of results (New LAV IAC - AB-AK). Most of the children in the study acquired HIV infection by vertical transmission from their HIV-positive mothers. A few children, 8 out of 247 (3.7 per cent) who had seronegative mothers may have acquired the infection through other means. The study recommends that the effectiveness of health education efforts must be evaluated; screening of all blood transfusion in hospitals and that diagnosis in Zambia should be based on the Zambia criteria which should be supported by a positive laboratory test

(#42) Cytomegalovirus Ileitis Presenting Massive Rectal Bleeding in Infancy Kawimbe, B.
ArcHIVes of diseases of Childhood; Vol.66(7);1991; pp 883-4
Geographical area: unknown; Keywords: Cytomegalovirus, AIDS-related complex; Location: UNZA Medical Library

Two Zambian infants presented with massive rectal bleeding caused by cytomegalovirus ileitis. The first was seropositive for HIV and the second seronegative, though her mother was seropositive. Both infants died.

(#43) Clinical presentation of HIV/AIDS in the high risk neonate in Zambia
Shilalukey-Ngoma, M.P., Mushanga, A., Wang, X., Watanabe, M. (1992) Early Human Development, 29 pp 221-224
Geographical area: Lusaka; Key words: Paediatric AIDS, diarrhoea; Location: UNZA Medical Library

A prospective case study series was conducted between January and October 1991 on 108 neonates admitted to NICU, Lusaka. 90 patients satisfied inclusion criteria, 45 cases and 45 controls. Symptomatic seropositive babies born to seropositive mothers presented with failure to thrive, fever, persistent or recurrent thrush, severe sepsis and large liver. Tendency to prematurity among cases was high, diarrhoea, sepsis and haemolytic anaemia appear to be terminal signs. Neonates suffer the most aggressive form of HIV/AIDS, with symptomatic cases dying 3-4 weeks of onset of symptoms. Over one quarter of the mothers were symptomatic. Congenital malformations and lymphadenopathy were not significantly associated. Microcephaly occurred in association with failure to thrive and was not an isolated finding.

(#44 ) Polymerase Chain Reaction for the Diagnosis of Paediatric Tuberculosis
Godfrey-Faussett, P. (1992) On going clinical study
Geographical area: Lusaka; Keywords: TB; Location: UNZA Medical Library

The pattern of individual cases of tuberculosis has been altered by the impact of HIV. More cases are extrapulmonary and fewer positive sputum smears are found among the pulmonary cases. Rising rates of infection are also leading to increased numbers of paediatric cases. New diagnostic methods that are rapid, sensitive and specific are therefore urgently needed. The polymerase chain reaction (PCR) is a molecular technique for amplifying minute amounts of DNA from a particular organism to levels where it can be detected. It is hoped that, because of its widespread application other more commercial fields of study, the costs of equipment and reagents will continue to fall and will reach levels that would no longer make it inappropriate for developing countries.

(#45) Evaluation of clinical diagnosis criteria of paediatric AIDS in Zambia
Malek, A., Chintu, C., Nyumbu, M., Mukelabai, K., Luo, N. (1992) Paper presented to the VIIIth International Conference on AIDS, Amsterdam, 1992.
Geographical area: Lusaka; Key words: Paediatric AIDS, case definition, diarrhoea, evaluation; Location: UNZA Medical Library

Objectives:
To evaluate the usefulness of the clinical diagnostic criteria of paediatric AIDS in Zambia.

Methods:
All in-patient infants and children, admitted to one of the paediatric units at the University Teaching Hospital, Lusaka, over a specified period (two weeks) were enrolled in this study. Each patient had a physical examination and his caretaker was interviewed by means of a standard questionnaire, which covered all parts of the clinical diagnostic criteria of paediatric AIDS in Zambia. Interviews and examination were carried out by two different paediatricians, who were unaware of HIV antibody status of the patient. In all patients serological studies for HIV antibodies were done, using ELISA and Serdia Fujirbo Kit, Wellcozyme in one third. Patients with disseminated Kaposi's sarcoma (KS) or cryptococcal meningitis were excluded.

Results:
Completed questionnaires, findings of physical examination, and serum samples were available from 170 out of 179 patients (94.9 per cent), one with KS and one with cryptococcal meningitis were excluded from the study. In the remaining 168, the mean age was 19 months, the male/female ratio 1.1:1 and serum samples from 37 (22 per cent) patients were HIV-positive. The criteria had a high specificity (92.4 per cent) and positive predictive value (73.7 per cent) for the diagnosis of HIV infection in children, with a sensitivity of 75.7 per cent. In the major criteria, the most common was persistent fever for more than one month 81.0 per cent (30 of 37). In the minor criteria, progressive weight loss 94.6 per cent (35 of 37), and chronic diarrhoea 91.9 per cent (34 of 37) were the most common.

Conclusions:
The clinical diagnostic criteria of paediatric AIDS in Zambia is very useful for surveillance. It is of diagnostic value, especially in areas with limited facilities for laboratory diagnosis.

(#46)Case definitions for paediatric AIDS: the Zambian experience
Chintu, C., Malek, A., Nyumbu, M., Luo, C., Masona, J., et al. (1993) International Journal of STDs and AIDS, 1993, 4, pp 83-85
Geographical area: Lusaka; Key words: Case definition, paediatric AIDS; Location: UNZA Medical Library

For the purpose of surveillance of the acquired immunodeficiency syndrome (AIDS) in developing countries, the World Health Organisation (WHO) has recommended criteria for the clinical case definition of AIDS in adults and children. In a preliminary examination of children in Zambia a number of patients with obvious AIDS did not fit the published WHO case definition for paediatric AIDS. Based on this the Zambia National AIDS Surveillance Committee designed local criteria for the clinical case definition of paediatric AIDS. We compared the Zambian criteria with the WHO criteria for the diagnosis of paediatric cases through studying 134 consecutively admitted children to one of the paediatric wards at the University Teaching Hospital in Lusaka. Twenty nine of the patients were HIV-1 seropositive and 105 were HIV seronegative. Among the 29 HIV seropositive patients, the Zambian criteria identified 23, and the WHO criteria identified 20 children has having AIDS. The 105 HIV-seronegative children were classified as having AIDS in 9 cases by the Zambian criteria and in 38 cases by the WHO criteria. These results give the Zambian criteria for the diagnosis of AIDS a sensitivity of 79.3 per cent, a specificity of 91.4 per cent and a positive predictive value of 86.8 per cent compared to a sensitivity of 69 per cent, specificity of 64 per cent and a positive predictive value of 38 per cent for the WHO criteria. The current WHO criteria are inadequate for the diagnosis of paediatric AIDS. The need to refine the WHO criteria for the diagnosis of paediatric AIDS is discussed.

(#47) Cutaneous hypersensitivity reactions due to thiacetazone in the treatment of tuberculosis in Zambian children infected with HIV-1
Chintu, C., Luo, C., Bhat, G., Raviglione, M., DuPont, H., et al. (1993) ArcHIVes of Diseases in Childhood, Vol 68, pp 665-668
Geographical area: Lusaka; Key words: TB; Location: UNZA Medical Library

Tuberculosis is one of the most common infections in Zambian adults and children infected with HIV. In Africa, cutaneous hypersensitivity reactions attributed to thiacetazone during treatment of TB in adults infected with HIV-1 have been well documented. This study monitored adverse drug reactions during treatment for TB over an 18 month period (1990-1) in 237 children with a clinical diagnosis of TB (125 boys and 112 girls: 88/237 (37 per cent) infected with HIV-1) and 242 control children (149 boys and 93 girls; 26/242 (11 per cent) infected with HIV-1). 22 (9 per cent) of the 237 children with TB developed hypersensitivity skin reactions during the course of treatment.

Adverse skin reactions were seen more often in children infected with HIV than those who were not (OR 11.65, 95 per cent confidence interval 3.07 to 34.88). These represented 19 (21 per cent) of 88 children infected with HIV and three (2 per cent) of 149 children not infected with HIV. These skin reactions occurred after a period of treatment ranging between two and four weeks among 14 children receiving the HST (isoniazid, streptomycin, thiacetazone) regimen and eight children receiving the HSTR (isoniazid, streptomycin, thiacetazone, rifampicin) regimen. Twelve (55 per cent) of the 22 children who reacted adversely to treatment developed the Stevens-Johnsons syndrome. All 12 of these children with Stevens-Johnsons syndrome were infected with HIV. The mortality among these children who developed Stevens-Johnsons syndrome was 91 per cent (11 out of 12 died within three days of the onset of the reaction). No further reactions were observed in the 11 children who recovered from the cutaneous hypersensitivity reactions after thiacetazone was discontinued over a period of six months of further treatment for TB.

The results of this study were in part responsible for the recommendations put forward by the WHO to avoid the use of thiacetazone in the treatment of TB in children infected with HIV.

(#48) Seroprevalence of human immunodeficiency virus type 1 infection in Zambian children with tuberculosis
Chintu, C., Bhat, G., Luo, C., Raviglione, M., Diwan, V., et al. (1993) Paediatric Infections Diseases Journal, 1993:12 pp 499-504
Geographical area: Lusaka; Key words: TB, BCG; Location: UNZA Medical Library

Descriptions in the medical literature of human immunodeficiency virus type 1 (HIV-1) in children with tuberculosis (TB) are scanty. This study determined the seroprevalence of HIV-1 in 237 hospitalised children between the ages of 1 month and 14 years with clinical diagnosis of TB (125 males and 112 females) and in 242 control children (149 males and 93 females). The overall HIV-1 seroprevalence rate in patients with TB was 37 per cent (88 of 237) compared with 10.7 per cent (26 of 242) among the control group (p<0.00001:odds ratio 5.37, 95 per cent confidence interval = 3.21 < 5.37 < 9.47). HIV-1 seropositivity in children with TB ranged from 53 per cent (31 of 58) in the 12 to 18 month age group to 14 per cent (9 of 61) in the 10 to 14 year olds.

The risk of TB attributable to HIV infection was 29 per cent. The predominant clinical presentation in both seronegative (84.6) and seropositive (89.7) groups was that of pulmonary TB and there were no significant differences in clinical presentation between the two groups of patients. Only 54.8 per cent of the patients attended follow-up within 3 months. Bacillus Calmette-Guerin (BCG) vaccination coverage was 87.3 per cent among TB patients and 90.5 per cent in the controls. No significant differences in BCG vaccination rates between the seronegative and seropositive children were seen. Coinfection with HIV and TB in children is now one of the major public health problems in Zambian children.

(#49) HIV, BCG and TB in children: a case control study in Lusaka, Zambia
Bhat, G.J., Diwan, V.K., Chintu, C., Kabika, M., Masona, J. (1993) Journal of Tropical Paediatrics (1993) 39, 4, pp 219-223
Geographical area: Lusaka; Key words: TB, BCG; Location: UNZA Medical Library

In this hospital study in Lusaka, Zambia in 1991, 77 per cent of 116 TB cases had BCG scars compared with 88 per cent of 154 controls; 36 of the TB cases were HIV-positive children compared with 18 of the controls. BCG gave a 59 per cent protective effect in HIV-negative children but was not associated with altered risk in HIV-positive children. HIV-positive children are suggested to have an eight-fold higher risk of TB.

(#50) Paediatric HIV seropositivity in an urban community of Lusaka
Muyanga, J. (1994) unpublished
Geographical area: Lusaka; Keywords: Paediatric infection, surveillance; Location: UNZA Medical Library

Objectives:
To look at HIV-1 serostatus among children in a peri-urban community in Lusaka. To determine possible risk factors in horizontal transmission of HIV.

Methods:
A pre-tested questionnaire was distributed to a number of people in a peri-urban area of Lusaka. Blood/sera was also collected from 581 children aged between 0-15 years. After collecting the blood it was tested to determine the serostatus of the respondents.

Results:

• 32 (5.5 per cent) of the blood samples tested positive with prevalence rates higher in infants. After the age of six, there were almost no cases of HIV except for isolated cases.
• 28 of the positive children had their mothers test positive for HIV-1.
• 91 mothers who were positive had children who tested seronegative.
• Four of the children who were positive had mothers who were negative for HIV-1 antibodies.

Conclusions:
The distribution of HIV in the paediatric age group in the community was found to be quite high (5.5 per cent). The higher prevalence rate in infants also reflected the high seropositive rate of their mothers and women in the child-bearing age indicating that the seropositivity of the infants was due to perinatal transmission.

(#51) Prevalence of HIV in Children in an Urban Community Virology Laboratory, UTH
(1995) Viral infections in Zambia, Vol. 2: Activities of the Virology Laboratory, pp 45-46.
Geographical area: Lusaka; Key words: Surveillance; Location: UNZA Medical Library

Objectives:
To define the prevalence of HIV antibody in children of urban community of Lusaka.

Methods:

• Age group: children aged 10-15 years.
• Study design: house to house survey in one urban community of Lusaka.
• Sample collection: blood was collected on filter paper from children and their mothers.
• Samples were screened for HIV using Serodia HIV (PHA test), and positive samples were confirmed by Western Blot.

Results:
The prevalence of HIV antibody in mothers was 23.3 per cent (115/516). The prevalence in children aged 1-4 years was 4.1 per cent (11/268). In the age group of less than one year, prevalence was 18-22 per cent.

(#52) Influence of the HIV Epidemic on the Incidence of Kaposi's Sarcoma in Zambian Children
Athale, U.H., Patil, P.S., Chintu, C. and Elem, B. (1995) Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 8: pp 96-100
Geographical area: Lusaka; Key words: Kaposi's sarcoma, paediatrics, blood transfusion, AIDS- related complex; Location: UNZA Medical Library

Acquired immunodeficiency syndrome-associated Kaposi's sarcoma (KS) is well documented in adults. However, very little information is available about KS in the paediatric age group. A retrospective study was undertaken at the University Teaching Hospital (UTH), Lusaka, Zambia, to define the incidence and clinical profile of KS in Zambian children over the last 13 years and to determine the inclusion, if any, of the current human immunodeficiency virus (HIV) epidemic on the pattern of paediatric KS. All the histopathological records from 1980 to 1992 were reviewed and all cases of KS along with the total number of malignancies, both in children and adults, were analysed. Along with this, 17 of 23 case files of paediatric KS patients treated at the UTH since 1984 were retrieved and clinical details recorded.

Of a total of 915 cases of KS, 85 (9.25 per cent) were in children <14 years of age. The age ranged from 7 months to 14 years with an average of 5.62 years; the male/female ratio was 1.76:1. A significant increase in the incidence of paediatric KS has been recorded since 1987 (p > 0.001). This coincides with the advent of the HIV epidemic in the country. The disease was aggressive and fulminant in paediatric patients. More than 80 per cent HIV seropositivity was detected. Children with blood transfusion-related HIV infection had cutaneous or lymphocutaneus disease, indicating that the mode of acquisition of HIV infection may influence the clinical appearance of KS. Thus, HIV-associated KS in children in becoming a common entity in Zambia. An urgent prospective epidemiologic study is needed to address this problem in HIV-affected regions.

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