Onyango Fe

Hypoxaemia in young Kenyan children with acute lower respiratory infection

OBJECTIVES--To determine the prevalence, clinical correlates, and outcome of hypoxaemia in acutely ill children with respiratory symptoms. DESIGN--Prospective observational study. SETTING--Paediatric casualty ward of a referral hospital at 1670 m altitude in Nairobi, Kenya. SUBJECTS--256 Infants and children under 3 years of age with symptoms of respiratory infection. MAIN OUTCOME MEASURES--Prevalence of hypoxaemia, defined as arterial oxygen saturation < 90% determined by pulse oximetry, and condition of patient on the fifth day after admission. RESULTS--Over half (151) of the children were hypoxaemic, and short term mortality was 4.3 times greater in these children. In contrast, the relative risk of a fatal outcome in children with radiographic pneumonia was only 1.03 times that of children without radiographic pneumonia. A logistic regression model showed that in 3-11 month old infants a respiratory rate > or = 70/min, grunting, and retractions were the best independent clinical signs for the prediction of hypoxaemia. In the older children a respiratory rate of > or = 60/min was the single best clinical predictor of hypoxaemia. The presence of hypoxaemia predicted radiographic pneumonia with a sensitivity of 71% and specificity of 55%. CONCLUSIONS--Over half the children presenting to this referral hospital with respiratory symptoms were hypoxaemic. A group of specific clinical signs seem useful in predicting hypoxaemia. The clear association of hypoxaemia with mortality suggests that the detection and effective treatment of hypoxaemia are important aspects of the clinical management of acute infections of the lower respiratory tract in children in hospital in developing regions.

Clinical predictors of low CD4 count among HIV-infected pulmonary tuberculosis clients: A health facility-based survey

OBJECTIVES The study aimed to determine the clinical and laboratory predictors of a low CD4+ cell count (<200 cells/microl) in HIV-infected patients with pulmonary tuberculosis (PTB). DESIGN AND SETTING A prospective cohort study on HIV-positive patients with smear-positive PTB attending an outpatient clinic in Zimbabwe. PARTICIPANTS Consecutively consenting HIV-positive adults, aged 18 years and over, who had positive sputum smears for acid-fast bacilli and were naïve to both antituberculosis drugs and ART. INTERVENTIONS Baseline CD4+ cell count, full blood count, functional status using the Karnofsky Performance Status (KPS) score and body mass index (BMI, kg/m2) were determined for all participants. Univariate and multiple logistic regression analyses of the data were done. RESULTS Of the 97 participants recruited, 59 (61%) were females. The overall mean age was 34 years (standard deviation (SD) 8). The median CD4+ cell count was 104.5 cells/microl (intraquartile range (IQR) 41-213 cells/microl). Patients with pleuritic chest pain were less likely to have a low CD4+ cell count than patients who did not (odds ratio (OR) 0.2; confidence interval (CI) 0.03-0.8). The following were statistically significant predictors of a CD4+ cell count of <200 cells /microl: BMI<18 kg/m2 (OR 3.8; CI 1.2-12), KPS<54.4 (OR 3; CI 1.1-12) and haemoglobin concentration<8 g/dl (OR 13; CI 1.8 - 533). CONCLUSIONS HIV-infected sputum-positive PTB patients presenting with a BMI<18, KPS<54.4% and haemoglobin concentration<8 g/dl should have early initiation of ART since they are more likely to have a low CD4+ cell count, whereas those presenting with pleuritic pain are less likely to have a low CD4+ cell count.

Effect of Breastfeeding and Formula Feeding on Transmission of HIV-1: A Randomized Clinical Trial

CONTEXT Transmission of human immunodeficiency virus type 1 (HIV-1) is known to occur through breastfeeding, but the magnitude of risk has not been precisely defined. Whether breast milk HIV-1 transmission risk exceeds the potential risk of formula-associated diarrheal mortality in developing countries is unknown. OBJECTIVES To determine the frequency of breast milk transmission of HIV-1 and to compare mortality rates and HIV-1-free survival in breastfed and formula-fed infants. DESIGN AND SETTING Randomized clinical trial conducted from November 1992 to July 1998 in antenatal clinics in Nairobi, Kenya, with a median follow-up period of 24 months. PARTICIPANTS Of 425 HIV-1-seropositive, antiretroviral-naive pregnant women enrolled, 401 mother-infant pairs were included in the analysis of trial end points. INTERVENTIONS Mother-infant pairs were randomized to breastfeeding (n = 212) vs formula feeding arms (n = 213). MAIN OUTCOME MEASURES Infant HIV-1 infection and death during the first 2 years of life, compared between the 2 intervention groups. RESULTS Compliance with the assigned feeding modality was 96% in the breastfeeding arm and 70% in the formula arm (P<.001). Median duration of breastfeeding was 17 months. Of the 401 infants included in the analysis, 94% were followed up to HIV-1 infection or mortality end points: 83% for the HIV-1 infection end point and 93% to the mortality end point. The cumulative probability of HIV-1 infection at 24 months was 36.7% (95% confidence interval [CI], 29.4%-44.0%) in the breastfeeding arm and 20.5% (95% CI, 14.0%-27.0%) in the formula arm (P = .001). The estimated rate of breast milk transmission was 16.2% (95% CI, 6.5%-25.9%). Forty-four percent of HIV-1 infection in the breastfeeding arm was attributable to breast milk. Most breast milk transmission occurred early, with 75% of the risk difference between the 2 arms occurring by 6 months, although transmission continued throughout the duration of exposure. The 2-year mortality rates in both arms were similar (breastfeeding arm, 24.4% [95% CI, 18.2%-30.7%] vs formula feeding arm, 20.0% [95% CI, 14.4%-25.6%]; P = .30). The rate of HIV-1-free survival at 2 years was significantly lower in the breastfeeding arm than in the formula feeding arm (58.0% vs 70.0%, respectively; P = .02). CONCLUSIONS The frequency of breast milk transmission of HIV-1 was 16.2% in this randomized clinical trial, and the majority of infections occurred early during breastfeeding. The use of breast milk substitutes prevented 44% of infant infections and was associated with significantly improved HIV-1-free survival.