Seasonal prevalence and incidence of Cryptosporidium spp. and Giardia duodenalis and associated diarrhoea in children attending pre-school in Kafue, Zambia

Prevalence, incidence and seasonal variation of Cryptosporidium and Giardia duodenalis were studied over a 12-month period in 100 children from four pre-schools in Kafue, Zambia. Questionnaire data and a single stool sample were collected monthly from each child. Samples were processed using a commercial kit (Meridian Diagnostics Inc., USA) and oo(cysts) visualised by immunofluorescence microscopy. Cryptosporidium was detected in 30.7% (241/786; 95% CI = 27.5-33.9) while G. duodenalis was detected in 29.0% (228/786; 95% CI = 25.8-32.2). A total of 86% experienced one or more episodes of cryptosporidiosis while 75% had giardiasis. Cumulative incidence per 100 children was 75.4 for Cryptosporidium and 49.0 for G. duodenalis. Both infections were significantly more common in the wet compared to the dry season (34.8%, 162/466 vs. 24.7%, 79/320, P = 0.003 and 35.2%, 164/466 vs. 20.0%, 64/320, P < 0.001, respectively). Thus, risk ratios (RR) were 1.41 (95% CI = 1.13-1.77) and 1.76 (95% CI = 1.38-2.27) for Cryptosporidium and Giardia, respectively. Diarrhoea was significantly associated with cryptosporidiosis (RR = 1.23, 95% CI = 1.03-1.47; P = 0.029) but not with giardiasis (RR = 1.12, 95% CI = 0.91-1.53; P = 0.26). We conclude that gastro-intestinal protozoal infections are highly prevalent among children attending pre-school in peri-urban Zambia highlighting the need for further studies of risk factors.     

Second‐line treatment in the Malawi antiretroviral programme: high early mortality,but good outcomes in survivors,despite extensive drug resistance at baseline*

Objectives

The Malawi antiretroviral therapy (ART) programme uses the public health approach to identify ART failure. Advanced disease progression may occur before switching to second‐line ART. We report outcomes for patients evaluated and initiated on second‐line treatment in Malawi.

Methods

Patients meeting Malawi immunological or clinical criteria for ART failure in two large urban ART clinics were evaluated for virological failure (viral load >400 HIV‐1 RNA copies/mL) and, if failure was confirmed, initiated on second‐line ART (zidovudine/lamivudine/tenofovir/lopinavir/ritonavir). Patients were seen monthly and laboratory evaluations were performed quarterly and as needed. We performed logistic regression modelling to identify factors associated with mortality, mortality or new HIV illnesses, and virological suppression at 12 months.

Results

Of the 109 patients with confirmed virological failure, five patients died prior to initiation, three declined switching and 101 patients initiated second‐line treatment. Over 12 months, 10 additional patients died, 34 patients experienced 45 HIV‐related events, and 19 patients experienced grade 3 or 4 toxicities. Among survivors, 85.2% had HIV‐1 RNA<400 copies/mL at 12 months. While power to distinguish differences was limited, response rates were similar regardless of baseline resistance level. The median CD4 count increase was 142 cells/μL. World Health Organization clinical failure at baseline [odds ratio (OR) 3.47; 95% confidence interval (CI) 1.14–10.59] and body mass index <18.5 (OR 4.43; 95% CI 1.15–17.12) were risk factors for death. Baseline CD4 count <50 cells/μL was associated with increased risk for death or morbidity at 12 months (OR 2.57; 95% CI 1.01–6.52).

Conclusions

Second‐line treatment in Malawi was associated with substantial mortality, morbidity and toxicity but, among survivors, virological outcomes were favourable.     

Growth response to antiretroviral treatment in HIV‐infected children: a cohort study from Lilongwe,Malawi

Objective Malnutrition is common in HIV‐infected children in Africa and an indication for antiretroviral treatment (ART). We examined anthropometric status and response to ART in children treated at a large public‐sector clinic in Malawi. Methods All children aged <15 years who started ART between January 2001 and December 2006 were included and followed until March 2008. Weight and height were measured at regular intervals from 1 year before to 2 years after the start of ART. Sex‐ and age‐standardized z‐scores were calculated for weight‐for‐age (WAZ) and height‐for‐age (HAZ). Predictors of growth were identified in multivariable mixed‐effect models. Results A total of 497 children started ART and were followed for 972 person‐years. Median age (interquartile range; IQR) was 8 years (4–11 years). Most children were underweight (52% of children), stunted (69%), in advanced clinical stages (94% in WHO stages 3 or 4) and had severe immunodeficiency (77%). After starting ART, median (IQR) WAZ and HAZ increased from ?2.1 (?2.7 to ?1.3) and ?2.6 (?3.6 to ?1.8) to ?1.4 (?2.1 to ?0.8) and ?1.8 (?2.4 to ?1.1) at 24 months, respectively (P < 0.001). In multivariable models, baseline WAZ and HAZ scores were the most important determinants of growth trajectories on ART. Conclusions Despite a sustained growth response to ART among children remaining on therapy, normal values were not reached. Interventions leading to earlier HIV diagnosis and initiation of treatment could improve growth response.     

Prevalence and indicators of HIV and AIDS among adults admitted to medical and surgical wards in Blantyre,Malawi

Despite high seroprevalence there are few recent studies of the effect of human immunodeficiency virus (HIV) on hospitals in sub-Saharan Africa. We examined 1226 consecutive patients admitted to medical and surgical wards in Blantyre, Malawi during two 2-week periods in October 1999 and January 2000: 70% of medical patients were HIV-positive and 45% had acquired immune deficiency syndrome (AIDS); 36% of surgical patients were HIV-positive and 8% had AIDS. Seroprevalence rose to a peak among 30-40 year olds; 91% of medical, 56% of surgical and 80% of all patients in this age group were HIV-positive. Seropositive women were younger than seropositive men (median age 29 vs. 35 years, P < 0.0001). Symptoms strongly indicative of HIV were history of shingles, chronic diarrhoea or fever or cough, history of tuberculosis (TB), weight loss and persistent itchy rash (adjusted odds ratios [AORs] all > 5). Clinical signs strongly indicative of HIV were oral hairy leukoplakia, shingles scar, Kaposi's sarcoma, oral thrush and hair loss (AORs all > 10). Of surgical patients with 'deep infections' (breast abscess, pyomyositis, osteomyelitis, septic arthritis and multiple abscesses), 52% were HIV-positive (OR compared with other surgical patients = 2.4). Severe bacterial infections, TB and AIDS caused 68% of deaths. HIV dominates adult medicine, is a major part of adult surgery, is the main cause of death in hospital and affects the economically active age group of the population.