Infectious diseases at the paediatric isolation units of Clairwood and King Edward VIII Hospitals, Durban

Objective. Information on diseases of public health importance is scanty or  unavailable in South Africa as a result of a weak health surveillance system. Large institutional databases of common diseases can, therefore, provide useful ancillary information for planning and policy, despite unavoidable selection bias. We conducted a 12-year retrospective review (1985 - 1996) of all children admitted to the only isolation facility for the Durban metropolitan region. ·Our aim was to document changes in admissions and mortality for common childhood infectious diseases and to detect any impact of the HIV epidemic on these diseases.Results. During these years 19 037 children were admitted and annual admissions decreased by 79%. Measles accounted for the majority of admissions (58%), followed by varicella at 23%. No cases of poliomyelitis, diphtheria or cholera have been seen since 1990. Typhoid fever, mumps, tetanus and pertussis have  decreased, but remain at low endemic levels. Between 1994 and 1996, 1% of measles and 15.3% of varicella cases have been associated with illV-l infection; this has resulted in 56% of measles deaths and 75% of varicella deaths occurring in HIV co-infected children. Overall, 60% of deaths during the past 3 years have been in illV co-infected children. HIV testing based solely on clinical suspicion was performed in 11% and 29% of measles and varicella cases, respectively. Average all-disease mortality was 5.3%, a decrease of 87% over the study period, with measles accounting for most deaths (86%).Conclusions. The changing profile of childhood infectious diseases described at the paediatric isolation units is consistent with available national data. Probable reasons for these changes are the shift in emphasis to primary health care issues, and a gradual improvement in socio-economic conditions of the poor

Microbicide trials for preventing HIV/AIDS in South Africa: Phase II trial participants' experiences and psychological needs

The Microbicide Division of the Department of Medical Microbiology at MEDUNSA, South Africa, recently completed a phase II expanded safety trial of the candidate microbicide Carraguard. A microbicide is a vaginal product that women might use, if proven safe and effective, to protect themselves from HIV and possibly other sexually transmitted infections (STIs). The study participants were from Ga-Rankuwa and its neighbouring areas, an historically disadvantaged residential township near Pretoria. We conducted six focus group discussions with phase II trial participants to evaluate their experiences with trial participation and their psychological needs. Participants spontaneously talked about their experiences with the study gel and speculum examinations. They felt that they had received high quality medical care. They indicated that their personal hygiene and knowledge of the female reproductive system, HIV and other STIs had improved, which helped their families and empowered them as women. Participants valued being able to discuss their anxiety about HIV/AIDS with study staff. They felt that the study provided them with a supportive environment in which their personal problems (not necessarily restricted to HIV/AIDS) could be addressed. Some recommended that the study staff improve their professionalism and punctuality. They suggested the formation of participant support groups, and expressed a preference to remain involved in the trial. Some participants appeared to have become dependent on services provided during the trial. We have taken the results of these focus group discussions into account during planning for a phase III efficacy trial of Carraguard to be conducted in the same and other similar communities. SAHARA-J (2004) 1(2): 78-86 Keywords: HIV prevention, South Africa, microbicide, ethical challenges in microbicide trials. RÉSUMÉ La Division de Microbicide du Département de Microbiologie Médicale de l'Université Médicale d'Afrique Australe, MEDUNSA, Afrique du Sud, a récemment accompli la phase II de l' épreuve de sûreté renforcée du candidat microbicide Carraguard. Un microbicide est un produit vaginal que les femmes pourraient employer, s'il est prouvé sûr et efficace, pour se protéger elles-mêmes contre le VIH et probablement d'autres infections sexuellement transmises (STIs). Les participantes à l'étude étaient de Ga-Rankuwa et de ses environs, une banlieue noire résidentielle historiquement désavantagée près de Pretoria.Nous avons conduit des discussions en six groupes d'étude avec les participants à la phase II de l'épreuve pour évaluer leurs expériences concernant la participation à l'épreuve et leurs besoins psychologiques. Les participantes ont spontanément parlé de leurs expériences relatives aux études du gel et aux examens du speculum. Elles ont estimé qu'elles avaient reçu le soin médical de haute qualité. Elles ont indiqué que leur hygiène et connaissance personnelles du système reproducteur femelle, de VIH et de tout autre STIs s'étaient améliorées, qui ont aidé leurs familles et les ont émancipées comme femmes. Les participantes ont estimé qu'elles étaient en mesure de discuter leur inquiétude au sujet de VIH/SIDA avec le personnel de l'étude. Ils ont estimé que l'étude leur a fourni un environnement de soutien dans lequel leurs problèmes personnels (pas nécessairement limités au VIH/SIDA) pourraient être adressés. Certaines ont recommandé que le personnel d'étude améliore son professionnalisme et ponctualité. Elles ont suggéré la formation des groupes de soutien de participantes, et ont exprimé leur préférence de rester impliquées dans l'épreuve. Quelques participantes ont semblé être devenues dépendantes des services fournis pendant l'épreuve. Nous avons tenu compte des résultats de ces discussions de groupe d'étude pour la planification de la phase III de l'épreuve d'efficacité du Carraguard qui devra être conduite dans la même communauté et d'autres communautés semblables. SAHARA-J (2004) 1(2): 78-86 Mots clés: Prévention de VIH, Afrique du Sud, microbicide, défis éthiques dans des épreuves de microbicid

Evaluation of immune responses in HIV infected patients with pleural tuberculosis by the QuantiFERON® TB-Gold interferon-gamma assay

<p>Abstract</p> <p>Background</p> <p>Diagnosis of tuberculous (TB) pleuritis is difficult and better diagnostic tools are needed. New blood based interferon-gamma (IFN-γ) tests are promising, but sensitivity could be low in HIV positive patients. The IFN-γ tests have not yet been validated for use in pleural fluid, a compartment with higher level of immune activation than in blood.</p> <p>Methods</p> <p>The QuantiFERON TB^®-Gold (QFT-TB) test was analysed in blood and pleural fluid from 34 patients presenting with clinically suspected pleural TB. Clinical data, HIV status and CD4 cell counts were recorded. Adenosine deaminase activity (ADA) analysis and TB culture were performed on pleural fluid.</p> <p>Results</p> <p>The patients were categorised as 'confirmed TB' (n = 12), 'probable TB' (n = 16) and 'non-TB' pleuritis (n = 6) based on TB culture results and clinical and biochemical criteria. The majority of the TB patients were HIV infected (82%). The QFT-TB in pleural fluid was positive in 27% and 56% of the 'confirmed TB' and 'probable TB' cases, respectively, whereas the corresponding sensitivities in blood were 58% and 83%. Indeterminate results in blood (25%) were caused by low phytohemagglutinin (PHA = positive control) IFN-γ responses, significantly lower in the TB patients as compared to the 'non-TB' cases (p = 0.02). Blood PHA responses correlated with CD4 cell count (r = 0.600, p = 0.028). In contrast, in pleural fluid indeterminate results (52%) were caused by high Nil (negative control) IFN-γ responses in both TB groups. Still, the Nil IFN-γ responses were lower than the TB antigen responses (p < 0.01), offering a conclusive test for half of the patients. We did not find any correlation between blood CD4 cell count and IFN-γ responses in pleural fluid.</p> <p>Conclusion</p> <p>The QFT-TB test in blood could contribute to the diagnosis of TB pleuritis in the HIV positive population. Still, the number of inconclusive results is too high to recommend the commercial QFT-TB test for routine use in pleural fluid in a TB/HIV endemic resource-limited setting.</p

Adenosine Deaminase Activity Is a Sensitive Marker for the Diagnosis of Tuberculous Pleuritis in Patients with Very Low CD4 Counts

Background: Adenosine Deaminase Activity (ADA) is a commonly used marker for the diagnosis of tuberculous pleural effusion. There has been concern about its usefulness in immunocompromised patients, especially HIV positive patients with very low CD4 counts. The objective of this study was to evaluate the sensitivity of ADA in pleural fluid in patients with low CD4 counts. Materials and Methods: This was a retrospective case control study. Medical files of patients with tuberculous pleuritis and non-tuberculous pleuritis were reviewed. Clinical characteristics, CD4 cell counts in blood and biochemical markers in pleural fluid, including ADA were recorded. Results: One ninety seven tuberculous pleuritis and 40 non- tuberculous pleuritis patients were evaluated. Using the cut-off value of 30 U/L, the overall sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of ADA was 94%, 95%, 19, and 0.06 respectively. The mean CD4 cell counts among TB pleuritis patients was 29 and 153 cells/microL in patients with CD4 ,50 cells/microL and .50 cells/microL, (p,0.05) respectively. The corresponding mean ADA values for these patients were 76 U/L and 72 U/L respectively (p.0.5). There was no correlation between ADA values and CD4 cell counts (r =20.120, p = 0.369). Conclusion: ADA analysis is a sensitive marker of tuberculous pleuritis even in HIV patients with very low CD4 counts in a high TB endemic region. The ADA assay is inexpensive, rapid, and simple to perform and is of great value for the immediate diagnosis of tuberculous pleuritis while waiting for culture result and this has a positive impact on patient outcome

Preliminary outcomes of a paediatric highly active antiretroviral therapy cohort from KwaZulu-Natal, South Africa

BACKGROUND: Few studies address the use of paediatric highly active antiretroviral therapy (HAART) in Africa. METHODS: We performed a retrospective cohort study to investigate preliminary outcomes of all children eligible for HAART at Sinikithemba HIV/AIDS clinic in KwaZulu-Natal, South Africa. Immunologic, virologic, clinical, mortality, primary caregiver, and psychosocial variables were collected and analyzed. RESULTS: From August 31, 2003 until October 31, 2005, 151 children initiated HAART. The median age at HAART initiation was 5.7 years (range 0.3–15.4). Median follow-up time of the cohort after HAART initiation was 8 months (IQR 3.5–13.5). The median change in CD4% from baseline (p < 0.001) was 10.2 (IQR 5.0–13.8) at 6 months (n = 90), and 16.2 (IQR 9.6–20.3) at 12 months (n = 59). Viral loads (VLs) were available for 100 children at 6 months of which 84% had HIV-1 RNA levels ≤ 50 copies/mL. At 12 months, 80.3% (n = 61) had undetectable VLs. Sixty-five out of 88 children (73.8%) reported a significant increase (p < 0.001) in weight after the first month. Eighty-nine percent of the cohort (n = 132) reported ≤ 2 missed doses during any given treatment month (> 95%adherence). Seventeen patients (11.3%) had a regimen change; two (1.3%) were due to antiretroviral toxicity. The Kaplan-Meier one year survival estimate was 90.9% (95%confidence interval (CI) 84.8–94.6). Thirteen children died during follow-up (8.6%), one changed service provider, and no children were lost to follow-up. All 13 deaths occurred in children with advanced HIV disease within 5 months of treatment initiation. In multivariate analysis of baseline variables against mortality using Cox proportional-hazards model, chronic gastroenteritis was associated with death [hazard ratio (HR), 12.34; 95%CI, 1.27–119.71) and an HIV-positive primary caregiver was found to be protective against mortality [HR, 0.12; 95%CI, 0.02–0.88). Age, orphanhood, baseline CD4%, and hemoglobin were not predicators of mortality in our cohort. Fifty-two percent of the cohort had at least one HIV-positive primary caregiver, and 38.4% had at least one primary caregiver also on HAART at Sinikithemba clinic. CONCLUSION: This report suggests that paediatric HAART can be effective despite the challenges of a resource-limited setting

Evaluation of adherence measures of antiretroviral prophylaxis in HIV exposed infants in the first 6 weeks of life.

CAPRISA, 2015.Abstract available in pdf