33 research outputs found
Malaria parasitemia among asymptomatic infants seen in a malaria endemic region of western Kenya
Background: Sustainable Development Goal number three call for complete reversal in the incidence of malaria by 2030. Malaria however remains a health priority in sub-Saharan Africa, with children under five experiencing the highest morbidity and mortality. In clinical settings, management of malaria cases has primarily been centred on case definition, giving minimal consideration to the asymptomatic individuals who remain a major reservoir since they do not seek care. In malaria endemic areas, infants are likely to remain asymptomatic since they have partial immunity acquired from the mother.Objective: To determine the proportion of infants with positive parasitemia and describe their clinical and demographic characteristics.Design: A cross-sectional study.Setting: Webuye District Hospital, Western Kenya.Subjects: Three hundred and eighty four infants.Results: Prevalence of malaria parasitemia among enrolled infants was 61%. Infants born to housewife mothers, born to mothers who attended ANC during pregnancy; those weaned late or with family history of sickle cell disease were more likely tohave malaria parasitemia with p-values of 0.031,0.015,0.007, and 0.025 respectively.Conclusion: Prevalence of malaria parasitemia among asymptomatic infants in Webuye (Western Kenya) remains high
Characteristics of HIV-infected children seen in Western Kenya
Objectives: To describe the characteristics and outcomes of children registered for care in a large HIV care programme in Western Kenya.
Design: A retrospective descriptive study.
Setting: USAID-AMPATH HIV clinics in health centres; district and sub-district hospitals; Moi Teaching and Referral Hospital in Western Kenya.
Subjects: HIV-infected children below age of 15 years seen in a network of 18 clinics in Western Kenya.
Interventions: Paediatric HIV diagnosis and care including treatment and prevention of opportunistic infections and provision of combination antiretroviral therapy (CART).
Main outcome measures: Diagnosis, clinical stage and immune status at enrollment and follow-up; hospitalisation and death. Descriptive statistical analyses and chi square tests were performed.
Results: Four thousand and seventeen HIV-infected children seen between June 2002 and April 2008. Median age at enrollment was four years (0-14.2 years), 51% girls, 25% paternal orphans, 10% total orphans and 13% maternal orphans. At enrollment, 25% had weight-for-Age Z scores (WAZ)\u3e -1 and 21% had WAZ scores \u3c 3. Orphaned children had worse WAZ scores (p=0.0001). Twenty five per cent of children were classified as WHO clinical stage 3 and 4, 56% were WHO clinical stages 1 and 2 with 19% missing clinical staging at enrollment. Cough (25%), gastroenteritis (21%), fever (15%), pneumonia (10%) were the commonest presenting features. Twenty six per cent had been diagnosed with tuberculosis and only 25% started on cotrimoxazole preventive therapy (CPT). Median CD4% at enrollment was 16% (0-64%); latest recorded values were 22% (0-64). Sixty four per cent were on cART (cART+), median age at start was 5.4 (014.4 years).The median initial CD4% among cART+ was 13 (0-62) compared to 24 (0-64) for those not on ART (cART-). Median CD4% for cART+ improved to 22% (0-59); whereas cART- was 23% (0- 64) at last appointment. During the period of follow-up, one fifth (19%) of children on cART were lost to follow-up compared to slightly over one third (37%) for those not on cART. Thirty four percent were hospitalised; 41% diagnosed with pneumonia. Six per cent of 4017 were confirmed dead.
Conclusions: HIV -infected children were enrolled in care early in childhood. Orphanhood was prevalent in these children as were gastroenteritis, fever, pneumonia and advanced immuno-suppression. Orphans were more likely to be severely malnourished. Only a quarter of children were put on cotrimoxazole preventive therapy. Children commenced on cART late but responded well to treatment. Loss to follow-up was less prevalent among those on cART
Morbidity and mortality in HIV - infected children admitted at Moi Teaching and Referral Hospital in Western Kenya
Background: HIV-infected children are at higher risk of opportunistic infections that could result in hospitalisation. The outcomes of hospitalisation are variable and depend on the admission diagnosis, the patientsâ immune status and whether or not the patient is on anti-retroviral drugs.Objective: To describe the characteristics and causes of hospitalisation and mortality for HIV infected children admitted to Moi Teaching and Referral hospital in western Kenya.Design: a retrospective study of prospectively collected data.Setting: The paediatric wards of Moi Teaching and Referral Hospital (MTRH). A Kenyan National Referral Hospital.Subjects: HIV-infected children admitted the paediatric wards.Interventions: Treatment with combination anti-retroviral therapy (cART), treatment of common opportunistic infections.Main outcome measures: Demographic and clinical data, including diagnosis, immune status, and treatment with combination anti-retroviral therapy (cART), were extracted from hospital admission records of HIV-infected children registered with the USAIDAcademic Model Providing Access to Healthcare (AMPATH) partnership. We conducted descriptive statistical analyses and used chi-square and fisherâs exact tests to assess for associations between categorical variables and each of the independent variables.Results: Between December 2006 and May 2009, 396 HIV-infected children were admitted to MTRH. Median age at admission was 2.0 years (range 0-15); 236 (59%) were male; 36 (15%) of available 236 orphan status entries were orphaned; 198 (73%) were in CDC categories B and C and 61 (16%) of available 386 had been on ART. Among 108 patients with documented immunologic status, the mean CD4 cell percentage was 16% (SD 10.8). Among the 396 children, 104 (15%) were diagnosed with pneumonia, 92 (14%) with gastroenteritis, 36 (9%) with tuberculosis and 37 (9%) with malaria. Deaths occurred in 28(7%) of the patients. The median duration of hospitalisation was seven days (range 1- 516) for discharged patients and six days (range 0-72) for those who died. A significantly higher percentage of the children who were not previously enrolled in AMPATH died, signifying 14 (15%) mortality among this population of admitted patients, p = 0.0017. Of those who died, (17%) were diagnosed with pneumonia and 22 (79%) of them were not on cART.Conclusion: The common diagnoses at hospitalisation included pneumonia, gastroenteritis, malaria and tuberculosis. Higher mortality occurred among those diagnosed with pneumonia and those not previously enrolled in the HIV care programme. Aggressive treatment and prevention of the most prevalent diseases and early enrollment into HIV care are recommended for HIV-infected children. A follow-up study to investigate the pathological causes of death in this population is recommended
Evaluating eHealth: Undertaking Robust International Cross-Cultural eHealth Research
David Bates and Adam Wright discuss the opportunities and challenges of undertaking international collaborations in eHealth evaluation research, and make recommendations for moving forward
Adherence to antiretroviral therapy in young children in Cape Town, South Africa, measured by medication return and caregiver self-report: a prospective cohort study
<p>Abstract</p> <p>Background</p> <p>Antiretroviral therapy (ART) dramatically improves outcomes for children in Africa; however excellent adherence is required for treatment success. This study describes the utility of different measures of adherence in detecting lapses in infants and young children in Cape Town, South Africa.</p> <p>Methods</p> <p>In a prospective cohort of 122 HIV-infected children commenced on ART, adherence was measured monthly during the first year of treatment by medication return (MR) for both syrups and tablets/capsules. A questionnaire was administered to caregivers after 3 months of treatment to assess experience with giving medication and self-reported adherence. Viral and immune response to treatment were assessed at the end of one year and associations with measured adherence determined.</p> <p>Results</p> <p>Medication was returned for 115/122 (94%) children with median age (IQR) of 37 (16 â 61) months. Ninety-one (79%) children achieved annual average MR adherence â„ 90%. This was an important covariate associated with viral suppression after adjustment for disease severity (OR = 5.5 [95%CI: 0.8â35.6], p = 0.075), however was not associated with immunological response to ART. By 3 months on ART, 13 (10%) children had deceased and 11 (10%) were lost to follow-up. Questionnaires were completed by 87/98 (90%) of caregivers of those who remained in care. Sensitivity of poor reported adherence (missing â„ 1 dose in the previous 3 days) for MR adherence <90% was only 31.8% (95% CI: 10.7% â 53.0%). Caregivers of 33/87 (38.4%) children reported difficulties with giving medication, most commonly poor palatability (21.8%). Independent socio-demographic predictors of MR adherence â„ 90% were secondary education of caregivers (OR = 4.49; 95%CI: 1.10 â 18.24) and access to water and electricity (OR = 2.65; 95%CI: 0.93 â 7.55). Taking ritonavir was negatively associated with MR adherence â„ 90% (OR = 0.37; 95%CI: 0.13 â 1.02).</p> <p>Conclusion</p> <p>Excellent adherence to ART is possible in African infants and young children and the relatively simple low technology measure of adherence by MR strongly predicts viral response. Better socio-economic status and more palatable regimens are associated with better adherence.</p
Multiple Measures Reveal Antiretroviral Adherence Successes and Challenges in HIV-Infected Ugandan Children
Background: Adherence to HIV antiretroviral therapy (ART) among children in developing settings is poorly understood. Methodology/Principal Findings: To understand the level, distribution, and correlates of ART adherence behavior, we prospectively determined monthly ART adherence through multiple measures and six-monthly HIV RNA levels among 121 Ugandan children aged 2â10 years for one year. Median adherence levels were 100% by three-day recall, 97.4% by 30-day visual analog scale, 97.3% by unannounced pill count/liquid formulation weights, and 96.3% by medication event monitors (MEMS). Interruptions in MEMS adherence of 48 hours were seen in 57.0% of children; 36.3% had detectable HIV RNA at one year. Only MEMS correlated significantly with HIV RNA levels (r = â0.25, p = 0.04). Multivariable regression found the following to be associated with <90% MEMS adherence: hospitalization of child (adjusted odds ratio [AOR] 3.0, 95% confidence interval [CI] 1.6â5.5; p = 0.001), liquid formulation use (AOR 1.4, 95%CI 1.0â2.0; p = 0.04), and caregiverâs alcohol use (AOR 3.1, 95%CI 1.8â5.2; p<0.0001). Childâs use of co-trimoxazole (AOR 0.5, 95%CI 0.4â0.9; p = 0.009), caregiverâs use of ART (AOR 0.6, 95%CI 0.4â0.9; p = 0.03), possible caregiver depression (AOR 0.6, 95%CI 0.4â0.8; p = 0.001), and caregiver feeling ashamed of childâs HIV status (AOR 0.5, 95%CI 0.3â0.6; p<0.0001) were protective against <90% MEMS adherence. Change in drug manufacturer (AOR 4.1, 95%CI 1.5â11.5; p = 0.009) and caregiverâs alcohol use (AOR 5.5, 95%CI 2.8â10.7; p<0.0001) were associated with 48-hour interruptions by MEMS, while second-line ART (AOR 0.3, 95%CI 0.1â0.99; p = 0.049) and increasing assets (AOR 0.7, 95%CI 0.6â0.9; p = 0.0007) were protective against these interruptions. Conclusions/Significance: Adherence success depends on a well-established medication taking routine, including caregiver support and adequate education on medication changes. Caregiver-reported depression and shame may reflect fear of poor outcomes, functioning as motivation for the child to adhere. Further research is needed to better understand and build on these key influential factors for adherence intervention development
The costâeffectiveness of prophylaxis strategies for individuals with advanced HIV starting treatment in Africa
Introduction Many HIVâpositive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhancedâprophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 <100 cells/mm3. We investigated the costâeffectiveness of this enhancedâprophylaxis package versus other strategies, including using cryptococcal antigen (CrAg) testing, in individuals with CD4 <200 cells/mm3 or <100 cells/mm3 at ART initiation and all individuals regardless of CD4 count. Methods The REALITY trial enrolled from June 2013 to April 2015. A decisionâanalytic model was developed to estimate the costâeffectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standardâprophylaxis, enhancedâprophylaxis, standardâprophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhancedâprophylaxis (CrAgâpositive) or standardâprophylaxis (CrAgânegative), the second to enhancedâprophylaxis (CrAgâpositive) or enhancedâprophylaxis without fluconazole (CrAgânegative) and the third to standardâprophylaxis with fluconazole (CrAgâpositive) or without fluconazole (CrAgânegative). The model estimated costs, lifeâyears and qualityâadjusted lifeâyears (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Results Enhancedâprophylaxis was costâeffective at costâeffectiveness thresholds of US500 per QALY with an incremental costâeffectiveness ratio (ICER) of US113 per QALY in the CD4 <100 cells/mm3 population) and increased in all individuals regardless of CD4 count (US2.30. Conclusions The REALITY enhancedâprophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is costâeffective. Efforts should continue to ensure that components are accessed at lowest available prices
Late Presentation With HIV in Africa: Phenotypes, Risk, and Risk Stratification in the REALITY Trial.
This article has been accepted for publication in Clinical Infectious Diseases Published by Oxford University PressBackground: Severely immunocompromised human immunodeficiency virus (HIV)-infected individuals have high mortality shortly after starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods: The Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children â„5 years of age with CD4 counts .1). Results: Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P < .04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P = .02). Of five late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/”L), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/”L) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/”L), but low symptom burden and maintained fat mass. The remaining groups had 4%-6% mortality. Conclusions: Clinical and laboratory features identified groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up. Clinical Trials Registration: ISRCTN43622374.REALITY was funded by the Joint Global Health Trials Scheme (JGHTS) of the UK Department for International Development, the Wellcome Trust, and Medical Research Council (MRC) (grant number G1100693). Additional funding support was provided by the PENTA Foundation and core support to the MRC Clinical Trials Unit at University College London (grant numbers MC_UU_12023/23 and MC_UU_12023/26). Cipla Ltd, Gilead Sciences, ViiV Healthcare/GlaxoSmithKline, and Merck Sharp & Dohme donated drugs for REALITY, and ready-to-use supplementary food was purchased from Valid International. A. J. P. is funded by the Wellcome Trust (grant number 108065/Z/15/Z). J. A. B. is funded by the JGHTS (grant number MR/M007367/1). The Malawi-LiverpoolâWellcome Trust Clinical Research Programme, University of Malawi College of Medicine (grant number 101113/Z/13/Z) and the Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi (grant number 203077/Z/16/Z) are supported by strategic awards from the Wellcome Trust, United Kingdom. Permission to publish was granted by the Director of KEMRI. This supplement was supported by funds from the Bill & Melinda Gates Foundation
Prevalence of pain and adequacy of analgesic prescription among children admitted at Trans Nzoia County Referral Hospital, Kenya
Objective: To determine the prevalence and severity of pain and adequacy of analgesic prescription among children admitted at Trans-Nzoia County Referral Hospital (TCRH) pediatric wards.Design: A sequential explanatory mixed method study.Setting: TCRH pediatric wards.Participants: Children aged 5-14 years admitted over a period of 6 months. Healthcare providers and managers at TCRH.Interventions: Pain assessment using the Faces Pain Scale-Revised (FPS-R).Outcome measures: Prevalence computed by those who reported pain versus the total screened population. Severity computed by levels of pain reported by the sampled population. Adequacy assessed by the dosing and choice of analgesic versus the WHO analgesic ladder.Results: Out of the 928 children screened, 764 (82.33%) had pain. Among the 384 sampled, severity reported at 35.7% mild, 49.7% moderate and 14.6% severe. Adequacy of prescription in dosing determined at 16.7% with 34.2% of prescriptions being under dose and 49.1% overdose. Adequacy in choice of analgesia as per WHO analgesic ladder was at 42.45%. Pain score was statistically significant in association with prescription adequacy (P-value < 0.001, AOR= 32 moderate pain and 69.8 severe pain, CI=5.175-183.07). Drug availability and knowledge on pediatric pain management were some of the factors determining drug prescription in the facility.Conclusion: Prevalence of pain among children admitted at TCRH is very high, occurring in 4 out of 5 children. There is low adequacy of analgesic prescription. Pain score, drug availability, staffing and pediatric pain management knowledge were the major factors associated with analgesic prescription and administration