Immunization manual for medical and nursing students \u27\u27Hepatitis B Disease\u27\u27

Approximately 350 – 400 million people worldwide are chronically infected with the hepatitis B virus (HBV ), and approximately 1 million die annually of HBV -related disease. The worldwide prevalence of hepatitis B virus ranges from 0.1% to 20%). This wide range is largely due to differences in age at the time of infection. Following acute HBV infection, the risk of developing chronic infection varies inversely with age: 90% for perinatal infection, 25–35% for infection at age 1–5 years and less than 10% for adults. About 45% of the world population live in areas where chronic HBV is highly endemic (≥8% of the population are hepatitis B surface antigen (HBsAg) positive), 43% live in intermediate-endemicity areas (2–7% HBsAg-positive) and 12% live in low-endemicity areas (0.6% to \u3c2% HBsAg-positive). In the WHO European Region the HBsAg sero-prevalence ranges from 0.3% to 12% with up to 3.5 million carriers. Central Asian republics and parts of Eastern Europe are high endemic areas. Intermediately endemic areas include eastern and southern Europe and the Russian Federation, while northern and Western Europe are low endemic areas. More than 2 000 million people alive today have been infected with HBV at some time in their lives. Three quarters of the world’s population live in areas where there are high levels of infection. Every year there are over 4 million acute clinical cases of HBV , and about 25% of carriers, 1 million people a year, die from chronic active hepatitis, cirrhosis or primary liver cancer. In developing countries the majority of Hepatitis B Virus (HBV ) infection is acquired in early infancy or childhood. The acute infection often goes unrecognized and most of the morbidity and mortality from this disease occurs many years later. This has resulted in failure of appreciation of the full impact of this disease. Currently, effective, affordable treatment for Hepatitis B disease is not available. Immunization is the mainstay for prevention and control of the disease

Prevalence of vitamin D deficiency in exclusively breastfed infants at a tertiary healthcare facility in Nairobi, Kenya

Objective: To determine the prevalence of vitamin D deficiency (VDD) in exclusively breastfed infants at the Aga Khan University Hospital Nairobi, Kenya (AKUHN). The relationships between 25-hydroxyvitamin D; 25OHD, parathyroid hormone (PTH), maternal vitamin D supplementation, and sunlight exposure were also determined. Subjects and methods: Blood from 98 infants was assayed for 25OHD, calcium, phosphate, and PTH. Socio-demographic and clinical characteristics were analyzed using descriptive statistics and inferential analysis (p \u3c 0.05). Results: The prevalence of VDD (25OHD \u3c12 ng/mL), vitamin D insufficiency (VDI, 25OHD 12-20 ng/mL) and vitamin D sufficiency (VDS, 25OHD \u3e20 ng/mL) was 11.2% (95% CI 8.0%-14.4%), 12.2% (95% CI 8.9%-15.5%), and 76.5% (95% CI 72.3%-80.8%) respectively. There was no difference in the mean age, head circumference, length, or weight of infants in VDD, VDI, and VDS groups. PTH was elevated when 25OHD was \u3c12 ng/mL and normal when 25OHD was between 12-20 ng/mL. 25OHD and PTH were normal in infants whose mothers received vitamin D supplements. Infants who received \u3c30 minutes/day of exposure to sunlight were 5 times more likely to have VDI than infants who received ≥30 minutes/day (p = 0.042). Conclusions: The prevalence of VDD in exclusively breastfed infants at AKUHN is low. The current national policy that recommends exclusive breastfeeding of infants in the first 6 months of life appears to be effective in staving off vitamin D deficiency but those infants with \u3c 30 minutes sunlight exposure may benefit from low dose supplemental vitamin D during times of low sunlight exposure

Hospital-acquired malnutrition in children at a tertiary care hospital

Objectives: This study sought to investigate the incidence and factors associated with hospital-acquired malnutrition in children. Design: A hospital-based longitudinal survey carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: One hundred and seventy children who met the inclusion criteria were included in the study. Outcome measures: Anthropometry was done at admission and discharge. Incidence of hospital-acquired malnutrition was estimated from the total number of children showing a decrease in weight-for-height/length (WFH) or Body Mass Index (BMI) z-scores from the time of admission to discharge. Logistic regression analysis was performed to determine associations between selected variables and weight loss during hospitalisation. Results: Albeit a borderline level of significance, a decrease in calculated z-scores occurred in 60.6% (Confidence Interval (CI) 53.1–67.6%) of children during hospitalisation with a mean weight decrease of 0.5 kg (Standard Deviation (SD) ± 3.37, p = 0.055). Children ≤ 60 months of age demonstrated a mean decrease in weight-for-height/length z-score of 0.145 (SD ± 0.73, p = 0.042); and those \u3e 60 months, a mean decrease in BMI z-score of 0.152 (SD ± 0.39, p = 0.004). The majority with weight loss had been admitted with a diagnosis of gastroenteritis (81.2%), gastritis (64.3%) and pneumonia (55.6%). Weight loss was associated with duration of admission: 3 - 5 days (Odds Ratio (OR) 2.43, CI 1.46–4.03), 5 - 7 days (OR 4.67, CI 1.34–16.24), and \u3e 7 days (OR 2.75, CI 0.88–8.64); score test for trend of odds is OR 1.37 (95% CI 1.11–1.69, p = 0.003). Conclusion: This study found a high incidence of hospital-acquired malnutrition in children. The most affected were those with gastroenteritis, gastritis and pneumonia. Hospital-acquired malnutrition was associated with an increased duration of hospitalisation

Pre-albumin as a marker for predicting weight loss in hospitalised children

Objectives: This study sought to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Design: A hospital-based longitudinal survey was carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: A total of 170 children aged 29 days to 15 years who met the inclusion criteria were included in the study. Outcome measures: Serum pre-albumin levels and weight were measured at admission and repeated after 48–96 h. Sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Results: Of the 170 children studied, 57% and 60% had a drop in serum pre-albumin level and weight within the first four days of hospitalisation respectively. A drop in pre-albumin occurred in 68% of the 103 patients who had weight loss (p \u3c 0.001). Using a serum pre-albumin cut off point of \u3c 0.15 g/l at admission, sensitivity and specificity of serum pre-albumin in predicting weight loss were 76.7% and 29.0% (negative predictive value = 42.9%; positive predictive value = 64.2%). Positive and negative likelihood ratios were low at 1.08 and 0.8. The majority of the patients (72.3%) were already at risk of malnutrition as determined by the pre-albumin risk stratification on admission. Conclusion: Serum pre-albumin is not an accurate surrogate for weight loss during hospitalisation. It is, however, useful in identifying patients at risk of malnutrition on admission and during hospitalisation

Short term clinical outcome of children with rotavirus infection at Kenyatta National Hospital, Nairobi

Background: Rotavirus infection is the single most common cause of acute gastroenteritis in children under five years of age. Rotavirus gastroenteritis has a high morbidity and mortality in children in Kenya. Objectives: To determine the short term clinical outcome for children admitted to Kenyatta National Hospital with rotavirus gastroenteritis and the correlates of poor outcome. Design: Short longitudinal survey. Setting: Kenyatta National Hospital from February to May 2008. Subjects: Five hundred children were screened using a rapid antigen detection kit and ELISA. Results: Of the 191 children who tested positive for rotavirus in stool; 172 children were recruited into the study. Eighty eight per cent of the patients were discharged within one week, 8.1% stayed for more than seven days while 4.1% died. Children who had co-morbidities such as malnutrition, rickets and pneumonia had worse outcomes. Conclusion: Rotavirus gastroenteritis has a long hospital stay and a high mortality. Children in shock on admission and those with co-morbid conditions should get priority for they have a poor outcome

Pre-albumin as a marker for predicting weight loss in hospitalised children

Objectives: This study sought to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Design: A hospital-based longitudinal survey was carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: A total of 170 children aged 29 days to 15 years who met the inclusion criteria were included in the study. Outcome measures: Serum pre-albumin levels and weight were measured at admission and repeated after 48–96 h. Sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Results: Of the 170 children studied, 57% and 60% had a drop in serum pre-albumin level and weight within the first four days of hospitalisation respectively. A drop in pre-albumin occurred in 68% of the 103 patients who had weight loss (p < 0.001). Using a serum pre-albumin cut off point of < 0.15 g/l at admission, sensitivity and specificity of serum pre-albumin in predicting weight loss were 76.7% and 29.0% (negative predictive value = 42.9%; positive predictive value = 64.2%). Positive and negative likelihood ratios were low at 1.08 and 0.8. The majority of the patients (72.3%) were already at risk of malnutrition as determined by the pre-albumin risk stratification on admission. Conclusion: Serum pre-albumin is not an accurate surrogate for weight loss during hospitalisation. It is, however, useful in identifying patients at risk of malnutrition on admission and during hospitalisation

Effectiveness of sequential v. standard triple therapy for treatment of Helicobacter pylori infection in children in Nairobi, Kenya

Background: Once the diagnosis of Helicobacter pylori is confirmed, treatment requires at least two antibiotics and an acid inhibitor for a minimum of seven days. Unfortunately, treatment failures are being frequently reported. Treatment regimens that include sequential administration of antibiotics with acid inhibitors have been developed to try and increase the rate of eradication. Objective: To determine the effectiveness of a novel 10-day sequential therapy compared with the standard 10-day triple therapy for treatment of H. pylori infection in children. Methods: A double-blinded, randomised, controlled trial was conducted. Children under the age of 16 years with recurrent abdominal pain associated with dyspepsia and diagnosed with H. pylori by histology were randomly allocated either to a 10-day sequential treatment regimen or to a 10-day conventional triple therapy. Analysis of the outcome of this study was based on clinical improvement and confirmed H. pylori eradication based on stool H. pylori antigen detection and/or repeat endoscopy. Results: Of the 71 patients included in the analysis, 45 (63.4%) were given the 10-day conventional treatment while 26 (36.6%) received the 10-day sequential treatment. There was no difference in clinical improvement after treatment in the two therapies. However, there was a significant difference in the eradication of H. pylori between the conventional v. sequential regimens (48.8% v. 84.6%, respectively; p=0.02, odds ratio 0.19). Conclusion: The sequential treatment had a significantly higher H. pylori eradication rate than the conventional treatment

Prevalence and genetic diversity of rotavirus infection in children with acute gastroenteritis in a hospital setting, Nairobi Kenya in post vaccination era: a cross-sectional study

Introduction: Rotavirus is the leading cause of severe diarrhoea among infants and young children. Each year more than 611 000 children die from rotavirus gastroenteritis, and two million are hospitalized, worldwide. In Kenya, the impact of recent rotavirus vaccinations on morbidities has not been estimated. The study aimed at determining the prevalence and identity of rotavirus strains isolated from rotavirus-associated diarrhoea in vaccinated children presenting with acute gastroenteritis.Methods: Two hundred and ninety eight specimen from children presented at Gertrude Childrens’ Hospital from January to June 2012 were tested by EIA (Enzyme-linked Immunosorbent Assay) for rotavirus antigens. Molecular characterization was conducted on rotavirus-positive specimens. Extracted viral RNA was separated by polyacrylamide gel electrophoresis (PAGE) and the specific rotavirus VP4 (P-types) and VP7 (G-types) determined.Results: The prevalence rate of rotavirus was 31.5% (94/298). Of the rotavirus dsRNA, 57 (60.1%) gave visible RNA profiles, 38 (40.4%) assigned long electropherotypes while 19 (20.2%) were short electropherotypes. The strains among the vaccinated were G3P [4], G12P [6], G3P [6], G9P [4], G mixed G9/3P [4] and G1/3P [4]. Specifically, the G genotypes were G9/3 (5.3%), G9 (4.3%), G3 (4.3%), G12 (2.1%) and mixed G1/3 (1.1%). The P genotypes detected were P [4] (5.3%) and P [6] (5.3%). Conclusion: The present study demonstrates diversity in circulating genotypes with emergence of genotypes G3, G9, G12 and mixed genotypes G9/3 and recommends that vaccines should be formulated with a broad range of strains to include G9 and G12

Effectiveness of sequential v. standard triple therapy for treatment of Helicobacter pylori infection in children in Nairobi, Kenya

Background. Once the diagnosis of Helicobacter pylori is confirmed, treatment requires at least two antibiotics and an acid inhibitor for a minimum of seven days. Unfortunately, treatment failures are being frequently reported. Treatment regimens that include sequential administration of antibiotics with acid inhibitors have been developed to try and increase the rate of eradication.Objective. To determine the effectiveness of a novel 10-day sequential therapy compared with the standard 10-day triple therapy for treatment of H. pylori infection in children. Methods. A double-blinded, randomised, controlled trial was conducted. Children under the age of 16 years with recurrent abdominal pain associated with dyspepsia and diagnosed with H. pylori by histology were randomly allocated either to a 10-day sequential treatment regimen or to a 10-day conventional triple therapy. Analysis of the outcome of this study was based on clinical improvement and confirmed H. pylori eradication based on stool H. pylori antigen detection and/or repeat endoscopy. Results. Of the 71 patients included in the analysis, 45 (63.4%) were given the 10-day conventional treatment while 26 (36.6%) received the 10-day sequential treatment. There was no difference in clinical improvement after treatment in the two therapies. However, there was a significant difference in the eradication of H. pylori between the conventional v. sequential regimens (48.8% v. 84.6%, respectively; p=0.02, odds ratio 0.19). Conclusion. The sequential treatment had a significantly higher H. pylori eradication rate than the conventional treatment.

World Allergy Organization (WAO) diagnosis and rationale for action against Cow\u27s milk allergy (DRACMA) guidelines update – X – breastfeeding a baby with cow\u27s milk allergy

Cow’s milk allergy is rare in exclusively breastfed infants. To support the continuation of breastfeeding an infant after diagnosis with a cow’s milk allergy, it is critical to examine the evidence for and against any form of cow’s milk elimination diet for lactating mothers. In this narrative review, we highlight the lack of high-quality evidence, hence subsequent controversy, regarding whether the minuscule quantities of cow’s milk proteins detectable in human milk cause infant cow’s milk allergy symptoms. Current clinical practice recommendations advise a 2–4 week trial of maternal cow’s milk dietary elimination for: a) IgE-mediated cow’s milk allergy only if the infant is symptomatic on breastfeeding alone; b) non-IgE-mediated associated symptoms only if the history and examination strongly suggest cow’s milk allergy; and c) infants with moderate to severe eczema/ atopic dermatitis, unresponsive to topical steroids and sensitized to cow’s milk protein. There should be a clear plan for home reintroduction of cow’s milk into the maternal diet for a period of 1 week to determine that the cow’s milk elimination is responsible for resolution of symptoms, and then subsequent reoccurrence of infant symptoms upon maternal cow’s milk reintroduction. The evidence base to support the use of maternal cow’s milk avoidance for the treatment of a breastfed infant with cow’s milk allergy is of limited strength due to a lack of high-quality, adequately powered, randomised controlled trials. It is important to consider the consequences of maternal cow’s milk avoidance on reducing immune enhancing factors in breast milk, as well as the potential nutritional and quality of life impacts on the mother. Referral to a dietitian is advised for dietary education, along with calcium and vitamin D supplementation according to local recommendations, and a maternal substitute milk should be advised. However, for most breastfed infants with cow’s milk allergy maternal cow’s milk dietary elimination will not be required, and active support of the mother to continue breastfeeding is essentia