Lorna Renner

SIOP PODC: Recommendations for supportive care of children with cancer in a low-income setting†

These supportive care recommendations were prepared to guide doctors who practice in areas with significantly limited resources but who have sufficient infrastructure and training to treat children with cancer with curative intent. The success of any cancer treatment regimen depends largely on the availability and quality of supportive care and this also determines the intensity of treatment that can be delivered. We present practical recommendations on how to prevent infections, general nursing care, management of febrile neutropenia, nutritional assessment and support, treatment of co‐infections and the social support to help prevent failure to complete treatment in resource poor settings. Pediatr Blood Cancer 2013; 60: 899–904.

The Collaborative Wilms Tumour Africa Project; baseline evaluation of Wilms tumour treatment and outcome in eight institutes in sub-Saharan Africa.

AIM Reported survival of Wilms tumour in sub-Saharan Africa is below 50%. A published International Society of Pediatric Oncology (SIOP) Pediatric Oncology in Developing Countries (PODC) consensus adapted treatment guideline is implemented as a multi-centre prospective clinical trial at eight centres in sub-Saharan Africa. A baseline evaluation has been done to help decide on priorities to improve outcome and to assess improvements over time. METHODS A retrospective chart review was performed of patients admitted with Wilms tumour in the three years (2011-2013) preceding the collaborative trial. Patient outcome at the end of treatment was documented for all patients diagnosed in 2011 and 2012. Outcome was classified as (1) alive, no evidence of disease; (2) alive with disease; (3) died during treatment and (4) incomplete treatment. Details on treatment facilities, staff and estimated cost of treatment are documented. RESULTS Every year 114-130 patients are diagnosed. The mean survival at end of treatment is 39% (69/176) ranging from 11% to 61%. Incomplete treatment is the most common cause of treatment failure with 31% (54/176), ranging from 14% to 48% between centres. Twenty-six percent (46/176) of patients died during treatment, ranging from 13% to 37%. Estimated cost of treatment for parents ranged from 100 US

Clinical trials to improve childhood cancer care and survival in sub-Saharan Africa

to 1100 US

Comparative trial of oral versus intramuscular chloroquine in children with cerebral malaria

and was considered an important cause of failure to complete treatment. CONCLUSION Overall two year survival is estimated at 25%. Prevention of incomplete treatment is possible and will positively affect outcome. Sharing similar local challenges in this regional collaborative project helps to identify and implement feasible, sustainable and successful strategies.

Effect of Age at Antiretroviral Therapy Initiation on Catch-up Growth Within the First 24 Months Among HIV-infected Children in the IeDEA West African Pediatric Cohort

Over 80% of children with cancer live in low and middle-income countries where survival rates are much lower than high-income countries. Challenges to successful treatment of paediatric cancers in these countries include late presentation, malnutrition, failure to complete treatment and less-intense supportive care leading to increased treatment-related mortality and the need to reduce the intensity of treatment. Clinical trials can contribute to improved care and survival by providing objective information on the number of patients treated, accuracy of diagnosis, causes of treatment failure and the efficacy of specific interventions. Clinical trials can also help to build capacity (salary support and training), improve facilities (equipment) and fund treatment or essential associated costs (social support, nutritional support and follow-up care). In this article, we discuss our experience with clinical trials in Malawi and sub-Saharan Africa with emphasis on the treatment of children with Wilms tumour.

Introduction Of haemophilus Influenzae Type B Conjugate Vaccine Into Routine Immunization In Ghana And Its Impact On Bacterial Meningitis In Children Younger Than Five Years

One hundred and thirteen children aged 12 years or less with cerebral malaria in Accra, Ghana were treated with chloroquine either with a low dose regime of 3.5 mg/kg 8-hourly intramuscularly, or orally by nasogastric tube, in a standard regime, both to a total of 25 mg/kg body weight. There was no obvious difference in outcome in the 2 treatment groups. The overall mortality of 5.3% (5.9% and 4.4% in the oral and intramuscular treatment groups respectively) was similar to that seen 10 years ago in this hospital. The average parasite clearance time had increased to 61 h, compared to 41 h noted 10 years ago. The incidence of hypoglycaemia (3%) was very low compared to studies in other malaria endemic areas. The reason for this is not clear but it could have contributed to the low mortality. Neurological deficits were seen on day 14 in 7.8% of patients. Parasitaemia recurred within 14 d in 22% of surviving patients, confirming the presence of RI/RII chloroquine resistance in Accra.

Safety Monitoring of a New Pentavalent Vaccine in the Expanded Programme on Immunisation in Ghana

Background: We described malnutrition and the effect of age at antiretroviral therapy (ART) initiation on catch-up growth over 24 months among HIV-infected children enrolled in the International epidemiologic Databases to Evaluate Aids West African paediatric cohort. Methods: Malnutrition was defined at ART initiation (baseline) by a Z score <−2 standard deviations, according to 3 anthropometric indicators: weight-for-age (WAZ) for underweight, height-for-age (HAZ) for stunting and weight-for-height/BMI-for-age (WHZ/BAZ) for wasting. Kaplan–Meier estimates for catch-up growth (Z score ≥−2 standard deviations) on ART, adjusted for gender, immunodeficiency and malnutrition at ART initiation, ART regimen, time period and country, were compared by age at ART initiation. Cox proportional hazards regression models determined predictors of catch-up growth on ART over 24 months. Results: Between 2001 and 2012, 2004 HIV-infected children <10 years of age were included. At ART initiation, 51% were underweight, 48% were stunted and 33% were wasted. The 24-month adjusted estimates for catch-up growth were 69% [95% confidence interval (CI): 57–80], 61% (95% CI: 47–70) and 90% (95% CI: 76–95) for WAZ, HAZ and WHZ/BAZ, respectively. Adjusted catch-up growth was more likely for children <5 years of age at ART initiation compared with children ≥5 years for WAZ, HAZ (P < 0.001) and WHZ/BAZ (P = 0.026). Conclusions: Malnutrition among these children is an additional burden that has to be urgently managed. Despite a significant growth improvement after 24 months on ART, especially in children <5 years, a substantial proportion of children still never achieved catch-up growth. Nutritional care should be part of the global healthcare of HIV-infected children in sub-Saharan Africa.

SANKOFA: a multisite collaboration on paediatric HIV disclosure in Ghana.

This report shows the impact of a pentavalent vaccine that includes Haemophilus influenzae type b (Hib) conjugate vaccine on bacterial meningitis in children younger than 5 years in Ghana. A review of the first 3 years of a pediatric bacterial meningitis surveillance program, started in August 2001 in Accra, Ghana, was undertaken. There was a significant reduction, P = 0.042 and 0.017, in percentage of purulent meningitis in children younger than 1 year, comparing the first year when the vaccine was introduced, to the second and third years, respectively.

Anaemia and zidovudine-containing antiretroviral therapy in paediatric antiretroviral programmes in the IeDEA Paediatric West African Database to evaluate AIDS

AbstractBackground and objective: Safety monitoring of vaccines used in expanded programmes on immunisation is important in all countries, including those with limited resources. As the rates of target diseases decrease, parents become less accepting of even minor common adverse events. Identification, detection, prevention and appropriate communication of adverse events following immunisation (AEFI) are therefore essential to preserve the integrity of immunisation programmes and protect public health. The objective of this study was to document the occurrence of common minor AEFI associated with a newly introduced pentavalent vaccine for routine immunisation in Ghana’s expanded programme on immunisation. Methods: A prospective descriptive study on AEFI associated with the administration of a pentavalent diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B (DTP-hepatitis B vaccine/Hib vaccine) vaccine that is part of the Expanded Programme on Immunisation was carried out in four locations in Accra, Ghana. These locations were the nation’s premier teaching hospital (the Korle-Bu Teaching Hospital) two urban polyclinics (the Mamprobi and Ussher Town polyclinics) and a community immunisation centre (the Zongo Junction Immunisation Centre).A total of 406 infants were recruited for the study. Upon receipt of signed informed consent from the parents/guardians of the infants, the parents/guardians were supplied with a pink card that functioned as a pseudo-diary for recording AEFI that occurred at home and for measuring and noting the sizes of any injection-site swellings that might occur. It also enabled each participant to obtain free medical care at the Department of Child Health, Korle-Bu Teaching Hospital for the duration of the study (from September 2003 to December 2004) and until the child was 12 months old. Information about the occurrence of AEFI was actively solicited during each visit for immunisation and also at a visit 4 weeks after administration of the last dose of pentavalent vaccine, when participants were asked to report to the respective immunisation centres for the specific purpose of reporting any AEFI which might have occurred in the intervening period. These AEFI were analysed separately from those reported to the dedicated hospital unit at the Department of Child Health, Korle-Bu Teaching Hospital, since the AEFI reported to that unit were all verified and recorded by trained physicians. Results: Of the 406 infants, 368 completed the study, whereas 38 defaulted or were lost to follow-up. There were 104 attendances to report cases of suspected AEFI requiring physician attention at the Department of Child Health, Korle-Bu Teaching Hospital. These attendances were made by 74 patients who reported 190 events; notable among these were cough (26.3% of all AEFI reported to the hospital), fever (17.4%), common cold (12.1%), vomiting (7.4%) and diarrhoea (6.8%). Three of these visits involved AEFI that were classified as ‘serious’, since they required hospitalisation, but all three were considered to be unlikely to be related to vaccine administration. In addition, actively solicited information on AEFI following immunisation from 921 individual interviews with the parents/guardians of immunised infants during the follow-up visits resulted in reports of 259 events being reported, the most common, according to crude incidence rates, being fever (14.7%), common cold (3.8%), crying (3%) and cough (2.8%). Conclusion: The results of this study show agreement with safety studies on vaccines containing identical or similar antigens performed elsewhere and indicate the safety and tolerability of the pentavalent DTP-hepatitis B vaccine/Hib vaccine in Ghanaian children.

Time to and Predictors of CD4+ T-Lymphocytes Recovery in HIV-Infected Children Initiating Highly Active Antiretroviral Therapy in Ghana.

With the scale-up of effective antiretroviral therapy in resource-limited settings, many HIV-infected children are now able to survive into adulthood. To achieve this potential, children must navigate normative developmental processes and challenges while living with an unusually complex, stigmatizing, potentially fatal chronic illness and meeting the demands of treatment.Yet many of these children, especially preadolescents, do not know they are HIV-infected. Despite compelling evidence supporting the merits of informing children of their HIV status, there has been little emphasis on equipping the childs caregiver with information and skills to promote disclosure, particularly, when the caregiver faces a variety of sociocultural barriers and is reluctant to do so. In this study, we present the background, process and methods for a first of its kind collaboration that is examining the efficacy of an intervention developed to facilitate the engagement of caregivers in the process of disclosure in a manner suitable to the sociocultural context and developmental age and needs of the child in Ghana. We also report preliminary data that supported the design of the intervention approach and currently available domains of the data system. Finally, we discuss challenges and implications for future research.