Karen Zwi

Prevention of vertical transmission of HIV: analysis of cost effectiveness of options available in South Africa.

Abstract Objective: To assess the cost effectiveness of vertical transmission prevention strategies by using a mathematical simulation model. Design: A Markov chain model was used to simulate the cost effectiveness of four formula feeding strategies, three antiretroviral interventions, and combined formula feeding and antiretroviral interventions on a cohort of 20 000 pregnancies. All children born to HIV positive mothers were followed up until age of likely death given current life expectancy and a cost per lifeyear gained calculated for each strategy. Setting: Model of working class, urban South African population. Results: Low cost antiretroviral regimens were almost as effective as high cost ones and more cost effective when formula feeding interventions were added. With or without formula feeding, low cost antiretroviral interventions were likely to save lives and money. Interventions that allowed breast feeding early on, to be replaced by formula feeding at 4 or 7 months, seemed likely to save fewer lives and offered poorer value for money. Conclusions: Antiretroviral interventions are probably cost effective across a wide range of settings, with or without formula feeding interventions. The appropriateness of formulafeeding was highly cost effective only in settings with high seroprevalence and reasonable levels of child survival and dangerous where infant mortality was high or the protective effect of breastfeeding substantial. Pilot projects are now needed to ensure the feasibility of implementation

Paediatric hospital admissions at a South African urban regional hospital: the impact of HIV, 1992-1997.

Rates of infection by the human immunodeficiency virus (HIV) have been increasing rapidly in South Africa over the last decade. This study documents the changes over time in prevalence of HIV infection amongst hospitalized children, and its effects on the profile of disease and in-hospital mortality over the period 1992-1997. Admissions to the paediatric medical wards between January 1992 and April 1997 were obtained from the routine computerized database held in the Department of Paediatrics at Chris Hani Baragwanath Hospital. HIV tests were performed on clinical indications only. Over the study period there were 22,633 admissions involving 19,918 children. Total annual admissions increased by 23.6% between 1992 and 1996. Prevalence of HIV infection increased from 2.9% in 1992 to 20% in 1997. HIV-infected children had a younger age distribution, longer median length of stay and more readmissions (p < 0.001) compared with HIV-negative and untested children. HIV-infected children accounted for the increased number of admissions for pneumonia, gastro-enteritis, malnutrition and tuberculosis, and the rise in in-hospital mortality by 42% from 4.3% in 1992 to 6.1% in 1997. Paediatric HIV infection has changed the profile of paediatric admission diagnoses and increased in-hospital mortality in the relatively short time between 1992 and 1997. Over the same period, HIV-negative children showed declining rates of malnutrition, vaccine-preventable diseases and admission to the intensive care unit.

Health service delivery for newly arrived refugee children: A framework for good practice

Aim:  To propose a framework for good practice to promote improved access, equity and quality of care in service delivery for newly arrived refugee children.

HIV infection and in-hospital mortality at an academic hospital in South Africa

AIM To document the impact that rapid increases in HIV infection in hospitalised children at Chris Hani Baragwanath Hospital has had on in-hospital mortality. METHODS Hospital discharge summaries from January 1992 to the end of 1996 were reviewed. RESULTS There were 20 733 admissions in the five year period; 7985 (39%) were tested for HIV. In tested admissions above 15 months of age, 4.9% were HIV infected in 1992, increasing to 35% in 1996. Under 15 months of age, 9% of tested admissions were positive in 1992, increasing to 46% in 1996. The proportion of all hospital deaths occurring in children considered HIV infected (ELISA testing together with clinical features if 15 months or younger) increased from 6.7% in 1992 to 46.1% in 1996 (p < 0.001). In-hospital mortality for all children increased by 21% from 4.3% in 1992 to 5.2% in 1996. Mortality rates declined in uninfected children from 5.4% in 1992 to 4.5% in 1996 (χ2 trend 3.3; p = 0.06). CONCLUSION The mortality rate of children has increased at Chris Hani Baragwanath Hospital as a result of HIV infection. Almost half the deaths were HIV related in 1996. HIV infection is threatening the advances that have been made on child survival in South Africa over the last few decades.

Use of risperidone in a paediatric population: an observational study.

Objective:  To evaluate the impact of risperidone on functional impairment in a paediatric sample and to document the range of adverse drug reactions.

Patterns of injury in children and adolescents presenting to a South African township health centre

OBJECTIVES: To describe the patterns and causes of childhood injury presenting to a South African township health centre in 1991. DESIGN: Retrospective review of clinic held case notes. SETTING: Typical South-African urban township within Greater Johannesburg. SUBJECTS: 695 subjects aged 0-19 years presenting as a direct result of injury. RESULTS: Overall rates of presentation for injury were 6297/100,000/year (95% confidence interval 5463 to 7131); 35% of injuries were caused by violence, 14% by traffic, and 51% by other unintentional causes (such as falls and sport injuries). Males had higher rates of presentation than females for violent (p < 0.001) and unintentional injuries (p < 0.01), but rates were similar for traffic injuries. The highest rates were for injuries caused by violence in 15-19 year-old males and were 9319/100,000/year. CONCLUSIONS: Rates are lower than in more developed countries. However, they appear to represent the more severe end of the spectrum of injury severity. The rates are similar for those below age 10 years and higher for those above age 10 years compared with severe injury rates in other studies. These data are likely to underestimate true rates. The risk of injuries caused by violence increase with age and these injuries are more serious than those due to other causes. Males are at higher risk for all types of injury except traffic injury.

Towards better health for refugee children and young people in Australia and New Zealand: The Royal Australasian College of Physicians perspective.

Working Party Dr Karen Zwi, Chairperson of Working Party, Community Paediatrician & Senior Lecturer, Sydney Children’s Hospital and University of New South Wales, New South Wales (NSW). Dr Shanti Raman, Area Community Paediatrician: Child Protection, Sydney South West Area Health Service, NSW. Dr David Burgner, Paediatric Infectious Disease Physician, School of Paediatrics and Child Health, University of Western Australia and Princess Margaret Hospital, Western Australia. Dr Shola Faniran, Trainee Representative, NSW. Dr Lesley Voss, Paediatric Infectious Disease Physician, Starship Children’s Hospital, Auckland, New Zealand. Dr Bijou Blick, Child Health Medical Officer, Northern Beaches Child and Family Health Service, Sydney, NSW. Ms Mary Osborn, Senior Policy Officer, Royal Australasian College of Physicians (RACP), Sydney, NSW. Mr Colin Borg, Senior Executive Officer, Paediatrics & Child Health Division, RACP, Sydney, NSW. Dr Mitchell Smith, Public Health Physician, NSW Refugee Health Service, NSW.

Human rights and child health

Abstract:  Human rights are those basic standards without which people cannot live in dignity.

School-Based Education Programs for the Prevention of Child Sexual Abuse: A Cochrane Systematic Review and Meta-Analysis.

Objective: To assess evidence of the effectiveness of school-based education programs for the prevention of child sexual abuse (CSA). The programs deliver information about CSA and strategies to help children avoid it and encourage help seeking. Methods: Systematic review including meta-analysis of randomized controlled trials (RCTs), cluster RCTs, and quasi-RCTs. Results: Twenty-four studies with 5,802 participants were included. Child self-protective skills, odds ratio = 5.71, confidence interval = [1.98, 16.51]; factual, standardized mean difference (SMD) = 0.61 [0.45, 0.78]; and applied knowledge, SMD = 0.45 [0.24, 0.65], increased in the intervention group, and knowledge gains were retained at 6 months, SMD = 0.69 [0.51, 0.87]. There were no differences in anxiety or fear, SMD = −0.08 [0.22, 0.07], and findings regarding disclosure of abuse were inconclusive. Conclusion: Children’s self-protective skills and knowledge can be increased by participation in school-based sexual abuse prevention programs. However, it is unknown whether gains in skills and knowledge actually decrease the likelihood of CSA.

Cheaper antiretrovirals to treat AIDS in South Africa: They are at their most cost effective in preventing mother to child transmission

Many countries in sub-Saharan Africa are overwhelmed by a pandemic of HIV and AIDS that is reducing life expectancy by two decades, reversing gains made in infant mortality and increasing the burden on health resources that are already overstretched. South Africa is no exception. The government, AIDS activists, healthcare professionals, and communities are desperate to find a universal solution or “magic bullet.” Triple combination therapy has dramatically widened the gulf in peoples experience of HIV and AIDS, depending on whether they live in the North or the South. Not surprisingly, activists, both local and international, have persistently called for a substantial lowering of the prices of antiretroviral and other expensive drugs needed to treat people with AIDS. What would reducing the price of antiretrovirals mean for South Africa in its battle against HIV and AIDS? It is important to distinguish between using antiretroviral drugs to prevent mother to child transmission and to treat adults infected with HIV. Interventions to reduce vertical transmission are highly effective in preventing …