Reasons for hospitalization in HIV-infected children in West Africa

Introduction

Current knowledge on morbidity and mortality in HIV-infected children comes from data collected in specific research programmes, which may offer a different standard of care compared to routine care. We described hospitalization data within a large observational cohort of HIV-infected children in West Africa (IeDEA West Africa collaboration).

Methods

We performed a six-month prospective multicentre survey from April to October 2010 in five HIV-specialized paediatric hospital wards in Ouagadougou, Accra, Cotonou, Dakar and Bamako. Baseline and follow-up data during hospitalization were recorded using a standardized clinical form, and extracted from hospitalization files and local databases. Event validation committees reviewed diagnoses within each centre. HIV-related events were defined according to the WHO definitions.

Results

From April to October 2010, 155 HIV-infected children were hospitalized; median age was 3 years [1–8]. Among them, 90 (58%) were confirmed for HIV infection during their stay; 138 (89%) were already receiving cotrimoxazole prophylaxis and 64 children (40%) had initiated antiretroviral therapy (ART). The median length of stay was 13 days (IQR: 7–23); 25 children (16%) died during hospitalization and four (3%) were transferred out. The leading causes of hospitalization were WHO stage 3 opportunistic infections (37%), non-AIDS-defining events (28%), cachexia and other WHO stage 4 events (25%).

Conclusions

Overall, most causes of hospitalizations were HIV related but one hospitalization in three was caused by a non-AIDS-defining event, mostly in children on ART. HIV-related fatality is also high despite the scaling-up of access to ART in resource-limited settings.     

Prevention of infectious diseases in the drepanocytic child

Children with sickle cell anemia are more exposed to infection than healthy children. Indeed, infections are the major cause of morbidity and mortality in children with sickle cell anemia, especially those aged 6 months to 5 years. Phagocytosis is reduced in these children. Polynuclear neutrophils reveal various poorly understood irregularities and are associated with a reduction of phagocytic power: zinc deficiency, reduced post-phagocytic oxidative metabolism, and a prevalence of neutrophils not forming red sheep-like globule carriers of immunoglobulin H. The power of the antibody which renders germs susceptible to phagocytosis in the serum is reduced in sickle cell patients. This may be tied to a disorder in the alternate complementary route with reduction of C3 and properdin. Sequestration of sickle cell-shaped red blood cells, splenic congestion, and short circuits of important functional territories contribute to spleen dysfunction, which occurs early. Common pathogens attacking sickle cell patients are pneumococci, salmonella species, and Haemophilus influenzae. They cause very grave infections (e.g., septicemia and purulent meningitis). Prevention of infections dwells on three perspectives: early screening for sickle cell anemia and for spleen dysfunction, preventive penicillin therapy, and vaccination. In Benin, vaccination is the only means to prevent infections. Essential vaccinations for children with sickle cell anemia include BCG, diphtheria-pertussis-tetanus, polio, and Rouvax. Strongly recommended vaccinations are Pneumovax 23, HEVAC B, TAB, vaccine against H. influenzae, and vaccine against mumps. A vaccine calendar for children with sickle cell anemia guides health workers when they must administer the vaccines and their boosters over a six year period. It is not yet universal in health facilities in Benin. A short- and long-term evaluation of the calendar's efficacy would allow one to appreciate its real impact on reducing morbidity and mortality in children with sickle cell anemia.