Staphylococcus aureus epidemic in a neonatal nursery: a strategy of infection control

The risk of nosocomial infection due to Staphylococcus aureus in fullterm newborns is higher under hospital conditions where there are overcrowded nurseries and inadequate infection control techniques. We report on an outbreak of skin infection in a Maternity Nursery (May 21, 2000) and the measures undertaken to bring the epidemic under control. These measures included: separating neonates already present in the nursery on August 23, 2000 from ones newly arriving by creating two different cohorts, one of neonates born before this date and one of neonates born later; restricting healthcare workers caring for S. aureus- infected infants from working with non-infected infants; disallowing carrier healthcare workers from caring for patients; introducing contact and droplet precautions (including the routine use of gowns, gloves, and mask); ensuring appropriate disinfection of potential sources of contamination. A representative number of isolates were typed by genomic DNA restriction length polymorphism analysis by means of pulsed-field gel electrophoresis (PFGE). Among the 227 cases of skin lesions, microbiological laboratory analyses confirmed that 175 were staphylococcal infections. The outbreak showed a gradual reduction in magnitude when the overcrowding of the Nursery was reduced by separating the newborns into the two different Nurseries (two cohorts). The genotyping of the strains by PFGE confirmed the nurse-to-newborn transmission of S. aureus. The measures adopted for controlling the S. aureus outbreak can, in retrospect, be assessed to have been very effective.     

Spread of methicillin‐resistant Staphylococcus aureus USA300 in a neonatal intensive care unit

Background: Reports of community‐associated methicillin‐resistant Staphylococcus aureus (CA‐MRSA) in neonatal intensive care units (NICU) and in otherwise healthy patients without obvious risk factors have been increasing in frequency. Described herein is a cluster of cases of CA‐MRSA USA300 strains in an NICU affecting infants, health‐care workers and the health‐care workers’ families. Methods: Infants and health‐care workers with infection and colonization due to MRSA between 1 January 2004 and 30 June 2005 in a tertiary care center NICU in San Antonio, TX were studied. Antimicrobial susceptibility testing and polymerase chain reaction detection of the mecA gene characterized the MRSA isolates. All MRSA cases were reviewed for clinical severity of infection and outcome. Results: During the 18 months studied, a total of four (0.6%) of 676 infants had CA‐MRSA bacteremia or colonization. One infant with necrotizing pneumonia died and three health‐care workers who directly cared for the infected infants developed soft‐tissue infections caused by CA‐MRSA. Four family members of two health‐care workers subsequently developed soft‐tissue infections. All of the analyzed isolates (eight of nine) belonged to pulsed‐field type USA300 and possessed Panton–Valentine leukocidin genes, which have been associated with severe skin and soft‐tissue infections, and necrotizing pneumonia. Conclusions: It is likely that the CA‐MRSA USA300 strain can be transmitted between NICU patients to health‐care workers and their family members. The CA‐MRSA cases reported here reinforce the virulence of CA‐MRSA USA300 strains and emphasize the need to embrace infection control practices designed to protect hospitalized patients, health‐care workers and their family members.     

Impaired early growth of infants perinatally infected with human immunodeficiency virus: Correlation with viral load

Objective: To evaluate the effect of viral load on the early growth of infants infected with human immunodeficiency virus (HIV).Methods: Plasma concentrations of p24-antigen and HIV ribonucleic acid were measured retrospectively and correlated with growth parameters for the` first 18 months of life in a cohort of 47 term infants born to HIV-infected mothers prospectively enrolled in a study of perinatal HIV transmission. Comparisons of the mean weight and length of the 18 HIV-infected and 29 uninfected infants for each interval and across intervals were made. Viral load was correlated with standard deviation scores. Infants were stratified by high and low viral load during the first 6 months of life.Results: At birth, no difference in weight and length was observed between HIV-infected and uninfected infants. Between birth and 6 months of age, the infected infants grew less rapidly than the uninfected infants, a finding temporally associated with an exponential increase in HIV viremia. The linear growth of infected infants remained consistently less than that of the uninfected infants after 6 months of life, although the differences were no longer statistically significant and tended to decrease with age in parallel with declines in viral load. The median plasma concentration of HIV ribonucleic acid was significantly higher at 3, 6, 12, and 18 months in infected infants in whom growth failure developed. Infants who had a high viral load in the first 6 months of life were significantly more likely to have severe growth failure. Though the mean SD for weight of the infected infants was always less than that of the uninfected infants, the differences were small and not significant.Conclusions: Our results confirm the observation that stunting is an early frequent finding in perinatal HIV infection. The deleterious effect of HIV on linear growth appears to be correlated with the level of postnatal HIV viremia, although the exact mechanism of this association remains to be elucidated.(J Pediatr 1997; 130:915-22)     

In vitro immunoglobulin response of fetal B-cells is influenced by perinatal infections and antibiotic treatment: a study in preterm infants

The aim of our study was to analyse the influence of perinatal infections and administration of antibiotics on B-cell activity in blood cell cultures of preterm infants. We studied spontaneous and Escherichia coli induced immunoglobulin (Ig) secretion in 148 infants of 24 to 36 weeks of gestation: 53 healthy infants (Group I), 40 healthy infants receiving prophylactically antibiotics (Group II), 14 infants with intra-uterine infection (Group III) and 41 with nosocomial infection (Group IV). Spontaneous Ig secretion was significantly lower in neonates with intra-uterine infection (Group III) than in healthy infants of Group I. Nosocomial infections in Group IV increased spontaneous Ig synthesis, but only in the first days after birth. E. coli stimulation of peripheral blood mononuclear cells significantly increased Ig synthesis in healthy infants of Group I, whereas induced minimal Ig production in infected infants of Groups III and IV. Antibiotics given as prevention to Group II decreased Ig production in cell cultures as compared to healthy infants (Group I). Conclusion The results indicate that perinatal infections and administration of antibiotics depress immunoglobulin secretion in cell cultures. We suggest that in vivo B-cell activity in infected preterm infants, and infants prophylactically receiving antibiotics, could also be depressed and result in decreased immunoglobulin production in these infants. Received: 8 April 1997 / Accepted in revised form: 24 November 1998     

Rate of mother to child transmission of HIV and factors associated among HIV exposed infants in Oromia Regional State,Ethiopia: Retrospective study

Background

Mother to Child Transmission of HIV (MTCTH) is a major public health challenge in Ethiopia. Monitoring and evaluation of the rate of HIV transmission among infants born to HIV positive mothers is the major indicator to understand the performance of a national HIV control program. However, this is not well documented in Oromia Regional State, Ethiopia.

Sputum induction for the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South Africa

BACKGROUND—Bacteriological confirmation of pulmonary tuberculosis is difficult in infants and young children. In adults and older children, sputum induction has been successfully used; this technique has not been tested in younger children.
AIMS—To investigate whether sputum induction can be successfully performed in infants and young children and to determine the utility of induced sputum compared to gastric lavage (GL) for the diagnosis of pulmonary tuberculosis in HIV infected and uninfected children.
SUBJECTS AND METHODS—149 children (median age 9 months) admitted to hospital with acute pneumonia who were known to be HIV infected, suspected to have HIV infection, or required intensive care unit support. Sputum induction was performed on enrolment. Early morning GL was performed after a minimum four hour fast. Induced sputum and stomach contents were stained for acid fast bacilli and cultured for Mycobacterium tuberculosis.
RESULTS—Sputum induction was successfully performed in 142 of 149 children. M tuberculosis, cultured in 16 children, grew from induced sputum in 15. GL, performed in 142 children, was positive in nine; in eight of these M tuberculosis also grew from induced sputum. The difference between yields from induced sputum compared to GL was 4.3% (p = 0.08). M tuberculosis was cultured in 10 of 100HIV infected children compared to six of 42 HIV uninfected children (p = 0.46).
CONCLUSION—Sputum induction can be safely and effectively performed in infants and young children. Induced sputum provides a satisfactory and more convenient specimen for bacteriological confirmation of pulmonary tuberculosis in HIV infected and uninfected children.

     

Clinical manifestations and management of pediatric HIV infection

HIV infection has emerged as a colossal problem with epidemic proportions. According to an estimate from UNAIDS about 36.1 million people all over the world are infected at present. In India about 3.5 million people are infected. The infection has evolved into phase II process of disease evolution, spreading from high-risk population to the general population. The antenatal HIV seropositivity has shown a steady increase from 0.1% to 2% in some tertiary care hospitals in Mumbai. Pediatric HIV infection presents with diverse clinical manifestations. In developing countries like India, diagnosis of infection during first year of life in perinatally exposed infants poses a problem due to lack of easy accessibility and increased cost of diagnostic facilities like HIV-PCR, CD4/CD8 counts and viral cultures. Moreover, lack of adequate drugs and exorbitant cost of sustaining antiretroviral therapy complicates the management issues. An assortment of antiretovirals is available in USA and other developed countries. In India drugs like zidovudine, lamivudine, stavudine, nevirapine and indinavir are available and are used in symptomatic patients. CDC has defined definite treatment guidelines for pediatric population recently. These guidelines need to be modified in our set up. At the present juncture in India the emphasis remains on the prevention and treatment of opportunistic infections like tuberculosis and pneumocystis carinii and on prevention of perinatal transmission with zidovudine. This brief review deals with various clinical manifestations as relevant in a developing country like India and recent advances in antiretroviral therapy.     

Infections in neonates delivered at term are associated with increased serum levels of ICAM-1 and E-selectin

All newborn infants consecutively admitted to the Neonatal Intensive Care Unit (NICU) at the University Hospital of Trondheim during 1993 were eligible to participate in the study. In total, 241 neonates were included, for whom anamnestic, clinical and laboratory characteristics were recorded. Peripheral blood was retrieved at admittance, and serum levels of soluble intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin were determined. Newborn infants were classified as infected or non-infected according to selected criteria, and 24 newborn infants fulfilled the criteria of having an infection, whereas 168 newborn infants were classified as non-infected. ICAM-1, VCAM-1 and E-selectin were detected in all neonatal samples. Serum concentrations of E-selectin varied by gestational age (GA), higher levels were found in non-infected term (GA ≥ 37 weeks) neonates (n= 53) than in those (n= 115) delivered prematurely (GA < 37 weeks) without infection (p < 0.0001), whereas ICAM-1 and VCAM-1 concentrations did not differ between groups of non-infected term and preterm newborn infants. Similarly, newborn infants delivered at term (n= 16) demonstrated higher levels of E-selectin than premature infants (n= 8) in association with infection (p < 0.001). Both ICAM-1 and E-selectin were increased in term newborn infants with infection (n= 16) compared to the non-infected term group (n= 53)(both p < 0.01), whereas VCAM-1 concentrations did not differ between the two groups. In the premature groups of infected (n= 8) and non-infected (n= 115) neonates, no differences in ICAM-1, VCAM-1 and E-selectin concentrations were observed. The use of ICAM-1 concentration (cut-off level: 250 μg 1^-1) as a diagnostic test for infection in term neonates yielded a sensitivity of 80% and a specificity of 61%, whereas a sensitivity of 70% and a specificity of 79% were found when E-selectin concentration (cut-off level: 150 μ 1^-1was used. Conclusively, increased shedding of soluble ICAM-1 and E-selectin is one component of infection-induced neonatal immune response after full-time pregnancies. Our data suggest that the ability of increased shedding of soluble ICAM-1 and E-selectin molecules is developed during the final weeks of pregnancy. Assessment of ICAM-1 and E-selectin concentrations may be used as diagnostic tools with a high sensitivity and a moderate specificity in term neonates suspected of infection.     

Impaired neutralizing activity by transplacental measles antibodies in infants born to HIV‐1‐infected mothers

Aim: Growing numbers of newborns are saved from HIV infection through increased access to mother‐to‐child transmission prevention programmes. The maternally derived humoral immunity of these children might be impaired, both in terms of quantity and in terms of quality, with consequences for the timing of immunization against measles. Methods: A cell‐ELISA technique compared the neutralizing activity on Edmonston strain measles virus of sera from 1‐ to 4‐month‐old infants. Ten serum specimens came from noninfected infants of HIV‐infected mothers and another 10 from infants of healthy mothers. The sera were matched for the level of conventional ELISA measles antibodies. Results: Reflecting infection of the Vero cells by non‐neutralized virus, optical density values were significantly higher for the sera from the children of the HIV‐infected mothers than for those of the noninfected mothers (p < 0.001). Conclusion: Maternally derived protection against measles may be impaired by the mother’s HIV infection, relating to the quality rather than to the quantity of transplacental antibodies. Selective, early immunization with live attenuated measles vaccine should be evaluated in noninfected children of HIV‐1‐infected mothers.     

Transfusion-acquired human immunodeficiency virus infection in twelve neonates: epidemiologic, clinical and immunologic features

Twelve neonates in 3 cohorts received blood transfusions from two donors who were infected with human immunodeficiency virus (HIV). All 12 infants developed laboratory and/or clinical evidence of HIV infection, usually in the first year of life. Ten of 12 infants had serum antibody to HIV when tested between 9 and 42 months of age. The two seronegative infants were severely hypogammaglobulinemic when they were tested. Nine infants developed a variety of illnesses attributable to HIV infection, but only 2 fulfilled criteria for the diagnosis of acquired immunodeficiency syndrome. In follow-up ranging from 2 1/2 to 4 years 5 patients (42%) have died. Four patients had HIV-associated illnesses but recovered and now have few if any symptoms attributable to HIV infection. Three children have never had signs or symptoms attributable to HIV. Immunologic abnormalities were present in all patients; the most consistent finding was a decrease in the proportion of T helper cells. Three patients had severe panhypogammaglobulinemia. The hypogammaglobulinemic infants had significantly lower numbers and percentages of T helper cells compared to the remaining patients (P less than 0.01). We conclude that exposure to HIV via transfusion in the neonatal period results in an extremely high rate of infection with substantial mortality and morbidity, but clinical recovery occurs in some patients. Also hypogammaglobulinemia may be more common in infants with HIV infection than previously appreciated.     

Epidemiological and clinical aspects of paediatric HIV infections in Albert-Royer Paediatric Hospital (Dakar, Senegal)]

Human Immunodeficiency Virus (HIV) infection prevalence rate is estimated at 1.4% in Senegal, and about 3,000 children could be infected. HIV positive children are followed up since 2000 in Albert Royer Hospital (Dakar, Senegal). OBJECTIVES: To describe clinical and epidemiological aspects of HIV paediatric infection, and to evaluate the implementation of high active antiretroviral therapy in HIV positive children in our country. POPULATION AND METHODS: Over a period of three years, the medical reports of 98 infected patients have been collected, 96% with HIV 1 infection. RESULTS: Most of the patients had a maternally transmitted HIV infection (99%). At their enrollment, the median age was 60 months; malnutrition (79%), persistent lymphadenopathy (65%) and skin lesions (64%) were the common clinical manifestations. Thirty-nine percent of the patients were in class C (CDC) and 81% had CD4 cell count< or =25%. Median viral load were 421,852 copies/ml at presentation. Seven infants had a rapid progressive disease with encephalopathy. Thirty-six patients received high active antiretroviral therapy with high observance and good tolerance. CONCLUSION: This study allowed to define clinical and biological profile of paediatric HIV infection in our country and to update the implementation of high active antiretroviral therapy.     

Demonstration of mother-to-infant transmission ofStaphylococcus aureus by pulsed-field gel electrophoresis

We assessed mother-to-infant transmission ofStaphylococcus aureus. Anterior nares swabs of 466 pregnant women, vaginal swabs of 305 of these women and anterior nares swabs of 305 6-day-old infants were examined for the presence ofS. aureus. The results showed that 7.5% of the vaginal swabs from the pregnant women and 10.1% of the anterior nares swabs from the infants were positive forS. aureus. Six of the 466 pregnant women (1.3%) and 12 of the 305 infants (3.9%) carried methicillin-resistantS. aureus (MRSA) in the anterior nares site, but none of the vaginal specimens were positive for MRSA. Analysis ofSmaI digested chromosomal DNA analysis using pulsed-field gel electrophoresis (PFGE) showed that methicillin-sensitiveS. aureus (MSSA) strains obtained from four pairs of pregnant women and their infants were completely identical, which strongly suggesting mother-to-infant transmission ofS. aureus.Conclusion This study elucidated the prevalence ofS. aureus carriage among pregnant women and newborn infants. Mother-to-infant infection ofS. aureus was demonstrated phenotypically and genetically. PFGE is a useful tool to detect infection routes including mother-to-infant-infection.     

Clinical manifestations of HIV infected children

Objective : Heterosexual contact is the predominant mode of transmission among adults in India with an increasing number of women of childbearing age becoming infected with HIV. Consequently, children in India increasingly getting infected, primarily from vertical transmission. A retrospective review of the profile of HIV infected children attending an HIV clinic in South India is reported.Methods : All HIV-infected children under 15 years of age at the time of first presentation and managed at this center between June 1996 and June 2000 are included in this report. Socio-demographic characteristics and clinical manifestation were collected in a precoded proforme. A complete physical examination and baseline laboratory investigations were performed at entry into the clinic and at subsequent follow-up.Results : Fifty-eight HIV-infected children were included: thirty-nine (67.2%) were male with mean age 4 years. Perinatal transmission was the predominant mode of HIV acquisition (67%). Common clinical manifestations in these children at presentation included oral candidiasis (43%), pulmonary tuberculosis (35%), recurrent respiratory infections (26%), bacterial skin infection (21%), papulo-pruritic dermatitis (19%), hepatosplenomegaly and lymphadenopathy (14%) each and chronic diarrhea (7%).Conclusion : An understanding of the epidemiology of pediatric HIV infection may reveal opportunities to reduce and perhaps eliminate perinatal transmission. Knowledge of clinical manifestations in this setting will help physicians meet the management challenges presented by HIV infected children.     

PRIMARY AND SECONDARY MATERNAL CYTOMEGALOVIRUS INFECTIONS AND THEIR RELATION TO CONGENITAL INFECTION

ABSTRACT. 4382 new mothers were examined retrospectively with the enzymelinked immunosorbent assay (ELISA) for IgG activity to cytomegalovirus (CMV) during pregnancy. Some of them were also studied with the indirect immunofluorescence (IIF) test for CMV-IgM antibodies. All the infants had been studied for CMV excretion within the first week of life. Nineteen of them had been shown to be congenitally infected with CMV. 1218 (28 %) women lacked CMV-IgG activity at their first antenatal visit (usually in months III-IV). Fourteen of them seroconverted before parturition (primary infection). Thirteen of the seroconverters were shown to develop CMV-IgM activity. In 6 (43 %) cases the primary infection was transmitted to the offspring. The remaining 13 congenitally infected infants were born to mothers with a positive IgG-test at their first antenatal control. Only one of these mothers had a clearly positive IgM-test. She was shown to lack CMV-antibodies before conception (primary infection during the first trimester). Preconceptional sera were obtained from further 4 of the 13 seropositive mothers of congenitally infected infants; all 4 had CMV antibodies before pregnancy (secondary infection during pregnancy). The combined studies of the mothers and infants revealed that 21–63 % of the congenital infections could have been caused by secondary maternal infections. Prospectively performed, the study would only have disclosed one of the three fetal CMV infections that resulted in neurological sequelae.     

Epidemiology, clinical characteristics and natural history of vertically transmitted human immunodeficiency virus-1 infection in Japan

Abstract Background : According to the Ministry of Health and Welfare AIDS Surveillance Committee's report on vertically transmitted human immunodeficiency virus (HIV) infection, there have been eight children with acquired immune deficiency syndrome (AIDS) and 18 children with HIV infection in Japan, totalling 26 in all as of February 1997. A search of the literature fails to reveal any report that deals with many cases of vertically transmitted HIV infection in Japan. Methods: A primary questionnaire survey was taken of the main medical institutions across the country, followed by a secondary questionnaire survey of physicians and pediatricians who treated the disease. A clinical review was made of 19 children with vertically transmitted HIV infection (including eight AIDS children) according to the 1994 Revised Classification System for HIV Infection in Children. Results : The mean age at diagnosis was 14.5 months and the diagnosis was made at less than 18 months of life in approximately 70% of infected children. In the mean observation period of 16 months, six of eight AIDS children (75%), and one child of group B died. The mean period of observation for the seven dead children was 7 months, and six of seven children died by 36 months of life. The survival period after the diagnosis of AIDS was 15 months. The diagnosis of HIV infection was made based on the clinical symptoms of all children with AIDS. Of 11 children, six (45%) presented with symptoms of HIV infection by 6 months of life, and 10 of 11 children (91%) presented with symptoms by 26 months of life. The noteworthy clinical findings included hepatomegaly, splenomegaly, recurrent respiratory tract infection, lymph node swelling, oral candidiasis, hepatitis, wasting syndrome, HIV encephalopathy and severe pneumonia. The favored age for the start of complications and the magnitude of decrease in the HIV helper cell count varied with each case of complications of HIV infection (wasting syndrome, HIV encephalopathy) or opportunistic infections (cytomegalovirus infection, Mycobacterium avium complex infection). Anti-HIV drugs (mainly zidovudine) had been used in five of eight children with AIDS and were effective in two long survivors alone. Conclusions : Children who are diagnosed with HIV infection, based on their clinical symptoms, carry a poor prognosis. In this respect, early diagnosis and progress in anti-HIV therapy are necessary.     

GB virus C/hepatitis G virus infection in HIV infected patients with haemophilia despite treatment with virus inactivated clotting factor concentrates

AIM—To determine the frequency of GB virus C (GBV-C)/hepatitis G virus (HGV) infection before and after switch to the use of virus inactivated concentrates in haemophiliac patients infected with human immunodeficiency virus (HIV).
PATIENTS AND METHODS—Initial and follow up sera from 49 children with haemophilia were analysed for the presence of GBV-C/HGV RNA and antibodies to HGV (anti-HGV). All patients had been infected with HIV while receiving concentrates without virus inactivation before 1984and were subsequently treated with virus inactivated concentrates.
RESULTS—In the first available serum sample (1987 or later), two of 49 patients were GBV-C/HGV RNA positive and two further patients were anti-HGV positive. During follow up (mean, 6 years), 14 patients developed markers of GBV-C/HGV infection. Eleven of these had received no blood products except clotting factor concentrates that had been prepared with virus inactivation.
CONCLUSIONS—Despite being treated with virus inactivated clotting factor concentrates, HIV positive patients with haemophilia are at an increased risk of manifesting GBV-C/HGV infection. We hypothesise that GBV-C/HGV is transmitted by these clotting factor concentrates. However, we cannot rule out the emergence of markers of GBV-C/HGV infection as a result of the progression of immune impairment in the course of HIV infection.

     

Maternal HIV is associated with reduced growth in the first year of life among infants in the Eastern region of Ghana: the Research to Improve Infant Nutrition and Growth (RIING) Project

Children of HIV‐infected mothers experience poor growth, but not much is understood about the extent to which such children are affected. The Research to Improve Infant Nutrition and Growth (RIING) Project used a longitudinal study design to investigate the association between maternal HIV status and growth among Ghanaian infants in the first year of life. Pregnant women in their third trimester were enrolled into three groups: HIV‐negative (HIV‐N, n = 185), HIV‐positive (HIV‐P, n = 190) and HIV‐unknown (HIV‐U, n = 177). Socioeconomic data were collected. Infant weight and length were measured at birth and every month until 12 months of age. Weight‐for‐age (WAZ), weight‐for‐length (WLZ) and length‐for‐age (LAZ) z‐scores were compared using analysis of covariance. Infant HIV status was not known as most mothers declined to test their children's status at 12 months. Adjusted mean WAZ and LAZ at birth were significantly higher for infants of HIV‐N compared with infants of HIV‐P mothers. The prevalence of underweight at 12 months in the HIV‐N, HIV‐P and HIV‐U were 6.6%, 27.5% and 9.9% (P < 0.05), respectively. By 12 months, the prevalence of stunting was significantly different (HIV‐N = 6.0%, HIV‐P = 26.5% and HIV‐U = 5.0%, P < 0.05). The adjusted mean ± SE LAZ (0.57 ± 0.11 vs. ?0.95 ± 0.12; P < 0.005) was significantly greater for infants of HIV‐N mothers than infants of HIV‐P mothers. Maternal HIV is associated with reduce infant growth in weight and length throughout the first year of life. Children of HIV‐P mothers living in socioeconomically deprived communities need special support to mitigate any negative effect on growth performance.     

Bacterial meningitis among children under the age of 2 years in a high human immunodeficiency virus prevalence area after Haemophilus influenzae type b vaccine introduction

Aim: The aim of this study was to describe bacterial causes of meningitis among children < 2 years in a high human immunodeficiency virus (HIV) prevalence area after introduction of routine Haemophilus influenzae type b vaccination. Methods: Data collected between April 2003 and December 2008 were extracted from a surveillance database and medical records of children < 2 years admitted in Mbarara Hospital, Uganda with suspected bacterial meningitis. HIV infection was confirmed using rapid tests and polymerase chain reaction and bacterial meningitis by using cerebrospinal fluid culture. Results: Between April 2003 and December 2008, 1464 children under 5 years were admitted with suspected bacterial meningitis of which 1235 (84.4%) had cerebrospinal fluid collected; 894 (72.4%) of these samples were from children < 2 years. Of the 894 samples, 64 (7.2%) grew an organism including Streptococcus pneumoniae (26; 41%), Salmonella species (20; 31%), H. influenzae (6; 9%) and coliforms (7; 11%), and five (8%) grew contaminants that are all coagulase negative Staphylococcus. Of the 894 children, 468 (52.3%) were tested for HIV; 16.7% were positive. Fifty‐one children had a pathogenic isolate and a treatment outcome, and 23 (45%) died; 13 (56.6%) deaths were due to S. pneumoniae, eight (34.8%) were due to Salmonella spp., one (4.3%) was due to H. influenzae and one (4.3%) was due to coliforms. HIV infection was associated with a threefold increase in mortality, increased likelihood of a bacterial isolate and decreased likelihood of malaria parasitaemia. Conclusion: Following H. influenzae type b vaccine introduction, S. pneumoniae and Salmonella spp. are the major causes of bacterial meningitis among children < 2 years in Uganda. Pneumococcal conjugate vaccines and reduction in mother to child transmission of HIV could reduce the observed mortality.     

Elimination of HIV infection in infants in Europe--challenges and demand for response

Effective interventions for the prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) infection now exist and where these are fully implemented, MTCT rates of 1-2% are achievable. Virtual elimination of HIV in infants by 2010 has therefore been set as a goal for European region. There are, however, many challenges. The eastern European and central Asian countries are facing the fastest growing HIV epidemic in the world with a dramatic increase in numbers of HIV-positive pregnancies and new HIV infected infants. Nevertheless, the prevalence of HIV among pregnant women is still relatively low and the high coverage with antenatal care provide an opportunity to decrease the number of new HIV cases among infants to minimal level. The challenge is to move national strategies for prevention of HIV infection among infants from a disease-focused vertical approach towards effective preventive interventions integrated into mother-child health (MCH) and reproductive health services. The scaling up of prevention interventions among those most at risk and hard-to-reach women are key priority actions. This goes beyond clinical care and needs to include a range of care and protection issues, both in health institutions and in the community. The WHO Regional Office for Europe, together with other UNAIDS co-sponsors, has developed a regional strategic framework for prevention of HIV infection in infants. The strategic framework promotes a comprehensive approach comprising the four interrelated elements: (1) primary prevention of HIV infection; (2) prevention of unintended pregnancies among HIV-infected women; (3) prevention of HIV transmission from HIV-infected women to their children; (4) provision of care and support to HIV-infected women, their infants and families. Implementation of all four pillars of the strategic framework would help European countries to achieve the goal of virtual elimination of HIV infection in infants.     

A PROSPECTIVE STUDY ON THE INCIDENCE AND SIGNIFICANCE OF CONGENITAL CYTOMEGALOVIRUS INFECTION

Abstract. Screening of 3060 neonates for congenital cytomegalovirus (CMV) infection by virus excretion in the urine showed an overall incidence of 0.4%. The incidence was about 1 % for mothers between 16 and 25 years and only 0.2% for mothers between 25 and 35. No mothers over 35 years of age gave birth to congenitally infected infants. The percentage of women in the child-bearing age susceptible to CMV infection was estimated by the absence of CMV complement-fixing antibodies in cord sera and ranged from 48% to 33% with increasing age. None of the infected infants showed obvious signs of congenital CMV infection at birth. At follow-up, two infants showed slight, but transient symptoms compatible with a foetal infection; a pair of premature twins exhibited retarded physical and psychomotor development, but this could just as well be ascribed to the prematurity itself. None of the infants had detectable CMV-IgM antibodies in cord sera, but a trend towards elevated total IgM concentration in cord sera and elevated virus excretion titres appeared in the infants with symptoms. With the very low incidence and no signs of sensomotor sequelae the preliminary conclusion is that foetal CMV infection in our population by no means has a significance to deserve routine screening or a vaccination programme.