Haroon Saloojee

The prevention and management of congenital syphilis: an overview and recommendations

The continued occurrence of congenital syphilis is an indictment of the inadequate antenatal care services and poor quality of programmes to control sexually transmitted infections. More than 1 million infants are born with congenital syphilis each year. Despite national policies on antenatal testing and the widespread use of antenatal services, syphilis screening is still implemented only sporadically in many countries, leaving the disease undetected and untreated among many pregnant women. The weak organization of services and the costs of screening are the principal obstacles facing programmes. Decentralization of antenatal syphilis screening programmes, on-site testing and immediate treatment can reduce the number of cases of congenital syphilis. Antenatal syphilis screening and treatment programmes are as cost effective as many existing public health programmes, e.g. measles immunization. Diagnosis of congenital syphilis is problematic since more than half of all infants are asymptomatic, and signs in symptomatic infants may be subtle and nonspecific. Newer diagnostic tests such as enzyme immunoassays, polymerase chain reaction and immunoblotting have made diagnosis more sensitive and specific but are largely unavailable in the settings where they are most needed. Guidelines developed for better-resourced settings are conservative and err on the side of overtreatment. They are difficult to implement in, or inappropriate for, poorly-resourced settings because of the lack of investigative ability and the pressure on health facilities to discharge infants early. This paper offers recommendations for treating infants, including an approach based solely on maternal serological status and clinical signs of syphilis in the infant.

Supplementary feeding with either ready-to-use fortified spread or corn-soy blend in wasted adults starting antiretroviral therapy in Malawi: randomised, investigator blinded, controlled trial.

Objective To investigate the effect of two different food supplements on body mass index (BMI) in wasted Malawian adults with HIV who were starting antiretroviral therapy. Design Randomised, investigator blinded, controlled trial. Setting Large, public clinic associated with a referral hospital in Blantyre, Malawi. Participants 491 adults with BMI <18.5. Interventions Ready-to-use fortified spread (n=245) or corn-soy blend (n=246). Main outcome measures Primary outcomes: changes in BMI and fat-free body mass after 3.5 months. Secondary outcomes: survival, CD4 count, HIV viral load, quality of life, and adherence to antiretroviral therapy. Results The mean BMI at enrolment was 16.5. After 14 weeks, patients receiving fortified spread had a greater increase in BMI and fat-free body mass than those receiving corn-soy blend: 2.2 (SD 1.9) v 1.7 (SD 1.6) (difference 0.5, 95% confidence interval 0.2 to 0.8), and 2.9 (SD 3.2) v 2.2 (SD 3.0) kg (difference 0.7 kg, 0.2 to 1.2 kg), respectively. The mortality rate was 27% for those receiving fortified spread and 26% for those receiving corn-soy blend. No significant differences in the CD4 count, HIV viral load, assessment of quality of life, or adherence to antiretroviral therapy were noted between the two groups. Conclusion Supplementary feeding with fortified spread resulted in a greater increase in BMI and lean body mass than feeding with corn-soy blend. Trial registration Current Controlled Trials ISRCTN67515515.

Reduced effectiveness of Haemophilus influenzae type b conjugate vaccine in children with a high prevalence of human immunodeficiency virus type 1 infection

Background. Haemophilus influenzae type b (Hib) conjugate vaccines have successfully reduced the burden of invasive Hib disease in developed countries; however, their effectiveness in countries with a high incidence of pediatric HIV-1 is unknown. Methods. The effectiveness of Hib conjugate vaccine was prospectively evaluated in South African children. The burden of invasive Hib disease in children <1 year old was compared in 2 cohorts. The first cohort included 22 000 African children born in 1997 [969 (4.45%) of whom were estimated to be HIV-1-infected] who were not vaccinated with Hib conjugate vaccine. This group was compared with 19 267 children [1162 (6.03%) of whom were estimated to be HIV-1-infected] vaccinated at 6, 10 and 14 weeks of age with an Hib conjugate vaccine [TETRAMUNE (polyribosylribitol phosphate-CRM197-diphtheria-tetanus toxoids-whole cell pertussis)] between March, 1998, and June, 1999. Results. The estimated burden of invasive Hib disease in nonimmunized HIV-1-infected children <1 year of age was 5.9-fold [95% confidence interval (95% CI), 2.7 to 12.6] higher than in HIV-1-uninfected children. The overall estimated effectiveness of Hib conjugate vaccine in fully vaccinated children <1 year of age was 83.2% (95% CI 60.3 to 92.9). Vaccine effectiveness was significantly reduced in HIV-1- infected [43.9% (95% CI −76.1 to 82.1)] compared with uninfected children [96.5% (95% CI 74.4 to 99.5);P < 10−5]. Among three of the fully vaccinated HIV-1-infected children who developed invasive Hib disease, the anti-Hib polyribosylribitol phosphate serum antibody concentrations were 0.23, 0.25 and 0.68 &mgr;g/ml. Conclusion. Although the Hib conjugate vaccine was less effective among HIV-1-infected than among uninfected children, it was 83% effective in preventing overall invasive Hib disease and therefore should be considered for inclusion in the routine vaccination schedule by other African countries.

Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa

OBJECTIVE To investigate the problems, benefits, feasibility, and sustainability of implementation of WHO guidelines on management of severe malnutrition. METHODS A postal survey invited staff from 12 African hospitals to participate in the study. Five hospitals were evaluated and two were selected to take part in the study: a district hospital in South Africa and a mission hospital in Ghana. At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation. FINDINGS Malnutrition management practices improved at both hospitals. Measures against hypoglycaemia, hypothermia, and infection were strengthened. Early, frequent feeding was established as a routine practice. Some micronutrients for inclusion in the diet were not locally available and needed to be imported. Problems were encountered with monitoring of weight gain and introducing a rehydration solution for malnutrition. CONCLUSION Implementation of the main principles of the WHO guidelines on severe malnutrition was feasible, affordable, and sustainable at two African hospitals. The guidelines could be improved by including suggestions on how to adapt specific recommendations to local situations. The guidelines are well supported by experience and published reports, but more information is needed about some components and their impact on mortality.

Lower respiratory tract infections associated with influenza A and B viruses in an area with a high prevalence of pediatric human immunodeficiency type 1 infection.

Background. Despite the high burden of pediatric HIV-1 infection in developing countries, there are few data on the clinical course of influenza virus-associated lower respiratory tract infection (LRTI) in these children. Objective. To define and compare the clinical course of HIV-1-infected and -uninfected African children hospitalized with influenza virus associated severe LRTI. Methods. Children with severe LRTI were prospectively recruited between March, 1997, and March, 1999, as part of a broader study evaluating the etiology and outcome of this condition in hospitalized HIV-1-infected and -uninfected children. The results of children in whom influenza A or B virus was identified by immunofluorescent antibody staining after shell vial culture are reported. Viruses isolated were typed by hemagglutination inhibition assays. Results. Twenty-five (21.6%) of the 116 children hospitalized with severe LRTI in whom influenza A or B virus was identified were HIV-1-infected. HIV-1-infected children were older than uninfected children (mean age ± sd 17.4 ± 10.8 months vs. 10.2 ± 8.9 months;P = 0.002). HIV-1-infected children were more likely to have an underlying medical illness (in addition to HIV-1 infection) predisposing them to more severe LRTI (32.0%vs. 13.2%;P = 0.03). HIV-infected children were also more likely to have indirect evidence of bacterial coinfection, including chest radiographic evidence of confluent alveolar consolidation (78.9%vs. 35.1%, P = 0.006), and were less likely be wheezing (8.0%vs. 31.9%, P = 0.01). However, there was no difference in the clinical outcome of HIV-1-infected and -uninfected children. The duration of hospitalization [median (range) 5 (2 to 33) days vs. 4 (0 to 21) days, P = 0.08] and the mortality rates (8.0%vs. 2.2%, P = 0.20) were similar between HIV-1-infected and -uninfected children. Conclusion. HIV-1-infected children hospitalized with severe LRTI associated with influenza virus have an outcome similar to that of HIV-1-uninfected children even in the absence of antiretroviral or anti-influenza virus treatment.

What’s new? Investigating risk factors for severe childhood malnutrition in a high HIV prevalence South African setting

Aim: To identify risk factors for severe childhood malnutrition in a rural South African district with a high HIV/AIDS prevalence. Design: Case-control study. Setting: Bushbuckridge District, Limpopo Province, South Africa. Participants: 100 children with severe malnutrition (marasmus, kwashiorkor, and marasmic kwashiorkor) were compared with 200 better nourished (>-2 SD weight-for-age) controls, matched by age and village of residence. Bivariate and multivariate analyses were conducted on a variety of biological and social risk factors. Results: HIV status was known only for a minority of cases (39%), of whom 87% were HIV positive, while 45% of controls were stunted. In multivariate analysis, risk factors for severe malnutrition included suspicion of HIV in the family (parents or children) (OR 217.7, 95% CI 22.7—2091.3), poor weaning practices (OR 3.0, 95% CI 2.0—4.6), parental death (OR 38.0, 95% CI 3.8—385.3), male sex (OR 2.7, 95% CI 1.2—6.0), and higher birth order (third child or higher) (OR 2.3, 95% CI 1.0—5.1). Protective factors included a diverse food intake (OR 0.53, 95% CI 0.41—0.67) and receipt of a state child support grant (OR 0.44, 95% CI 0.20—0.97). A borderline association existed for family wealth (OR 0.9 per unit, 95% CI 0.83—1.0), father smoking marijuana (OR 3.9, 95% CI 1.1— 14.5), and history of a pulmonary tuberculosis contact (OR 3.2, 95% CI 0.9—11.0). Conclusions: Despite the increasing contribution of HIV to the development of severe malnutrition, traditional risk factors such as poor nutrition, parental disadvantage and illness, poverty, and social inequity remain important contributors to the prevalence of severe malnutrition. Interventions aiming to prevent and reduce severe childhood malnutrition in high HIV prevalence settings need to encompass the various dimensions of the disease: nutritional, economic, and social, and address the prevention and treatment of HIV/AIDS.

Iron deficiency and impaired child development.

Papers p 1389 Iron deficiency affects 20% to 50% of the worlds population, making it the most common nutritional deficiency.1 In developing countries about half of all cases of anaemia in women and children result from iron deficiency, but other important and often coexisting contributors include malaria, hookworm infestation, HIV, and deficiencies in other nutrients such as vitamin A and folates. 2 3 Conversely, anaemia is just one manifestation of iron deficiency, and there are forms of mild to moderate iron deficiency in which anaemia is absent but tissue function is impaired. In children iron deficiency develops slowly and produces few acute symptoms. As the deficiency worsens children become pale and weak, eat less, and tire easily. They gain weight poorly, have frequent respiratory and intestinal infections, and may develop pica. The most worrying association is that between iron deficiency and impaired development in behaviour, cognition, and psychomotor skills. Over the past three decades many studies have confirmed this relation, but whether iron deficiency is the sole …

Clinical outcomes of severe malnutrition in a high tuberculosis and HIV setting

Objective Case death rates for severe childhood malnutrition remain stubbornly elevated in high HIV prevalence settings, despite the implementation of WHO guidelines. This study examined case death and other clinical outcomes in malnourished children with and without HIV infection. Methods A prospective, observational study was undertaken at three tertiary hospitals in Johannesburg, South Africa. All severely malnourished children had their HIV status established, and anthropometric, clinical and diagnostic findings and admission outcomes were analysed. Findings Just over half (51%) of the 113 severely malnourished children were HIV infected, but 31/58 (54%) of these children had their positive status diagnosed only after admission. Marasmic children were significantly more likely to be HIV infected (OR 9.7, 95% CI 3.5 to 29.1). Tuberculosis (TB) was strongly suspected and treated in 27 children (24%) although confirmed in only five (4%). The overall case death rate was 11.5%. HIV infection, pallor and shock were significant predictors of death. HIV-infected children were six times more likely to die compared with HIV-negative children (19% vs 3.6%, OR 6.2, 95% CI 1.2 to 59). HIV-‘affected’ children (HIV negative but exposed) and HIV-negative children had similar outcomes. Conclusion HIV infection significantly increases severe malnutrition case death. WHO guidelines for the management of severe malnutrition in high HIV prevalence settings need to be modified to include routine HIV and TB testing and offer guidance on the criteria and timing of TB treatment and highly active antiretroviral therapy initiation.

Nutritional status of Malawian adults on antiretroviral therapy 1 year after supplementary feeding in the first 3 months of therapy

Objective  To test the hypothesis that individuals on antiretroviral therapy (ART) for 3 months with a greater body mass index (BMI) as a result of supplementary feeding with ready‐to‐use fortified spread would maintain a higher BMI 9 months after the feeding ended.

Infant feeding practices in a high HIV prevalence rural district of KwaZulu-Natal, South Africa

Abstract Aim: To describe infant feeding practices at birth and at 14 weeks post-partum in the Ugu-North Health District, KwaZulu-Natal, South Africa. Methods: A prospective, cohort study design was used. Mothers who delivered over a one-month period were interviewed at birth and 14 weeks later. Results: Initially, 168 mothers were interviewed within 24 hours of delivery, of whom 117 (70%) were contactable at 14 weeks post-partum. The vast majority (96%) initiated breast-feeding at birth. At birth, less than one-third (55/168 [32.7%]) of mothers declared an intention to both breast and formula (mix) feed in the next 14 weeks, but by the 14th week post-partum over three-quarters (89/117 [76.1%]) actually practised mixed feeding. At 14 weeks, the prevalence of exclusive breast-feeding was 18%: 52% of infants were offered water and 73% solids. The majority (20/23 [87%]) of HIV infected mothers chose to breastfeed their infants at birth. Nevertheless, they were significantly more likely to formula feed their infants compared to HIV negative mothers (3/23 [13.0%] vs 2/145 [1.4%], OR 10.73, 95% CI 1.34 – 99.16, p = 0.02). By 14 weeks, only 11% of HIV positive mothers were still exclusively breast-feeding, while almost two-thirds (12/19 [63%]) practised mixed feeding. This change was mainly ascribed to their need to return to school (40%) or to work (20%). Conclusions: Most infants were fed inappropriately by 14 weeks of age. The failure to maintain exclusive breast-feeding, despite high initiation rates, is of greatest concern. Routine prevention of mother-to-child transmission of HIV services was ineffective in influencing mothers to follow any feeding regimen exclusively.AbstractAim: To describe infant feeding practices at birth and at 14 weeks post-partum in the Ugu-North Health District, KwaZulu-Natal, South Africa.Methods: A prospective, cohort study design was used. Mothers who delivered over a one-month period were interviewed at birth and 14 weeks later.Results: Initially, 168 mothers were interviewed within 24 hours of delivery, of whom 117 (70%) were contactable at 14 weeks post-partum. The vast majority (96%) initiated breast-feeding at birth. At birth, less than one-third (55/168 [32.7%]) of mothers declared an intention to both breast and formula (mix) feed in the next 14 weeks, but by the 14th week post-partum over three-quarters (89/117 [76.1%]) actually practised mixed feeding. At 14 weeks, the prevalence of exclusive breast-feeding was 18%: 52% of infants were offered water and 73% solids. The majority (20/23 [87%]) of HIV infected mothers chose to breastfeed their infants at birth. Nevertheless, they were significantly more likely to formula feed their inf...