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Symptom-based screening of child tuberculosis contacts: improved feasibility in resource-limited settings.
Pediatrics. 2008 Jun; 121(6):e1646-52.OBJECTIVE: National tuberculosis programs in tuberculosis-endemic countries rarely implement active tracing and screening of child tuberculosis contacts, mainly because of resource constraints. We aimed to evaluate the safety and feasibility of applying a simple symptom-based approach to screen child tuberculosis contacts for active disease. METHODS: We conducted a prospective observational study from January through December 2004 at 3 clinics in Cape Town, South Africa. All of the children <5 years old in household contact with an adult tuberculosis source case were assessed by documenting current symptoms and tuberculin skin test and chest radiograph results. RESULTS: During the study period, 357 adult tuberculosis cases were identified; 195 cases (54.6%) had sputum smear and/or culture positive results and were in household contact with children aged <5 years. Complete information was available for 252 of 278 children; 176 (69.8%) were asymptomatic at the time of screening. Tuberculosis treatment was administered to 33 (13.1%) of 252; 27 were categorized as radiologically "certain tuberculosis," the majority (n = 22) of which had uncomplicated hilar adenopathy. The negative predictive value of symptom-based screening varied according to the case definition used, with 95.5% including all of the children treated for tuberculosis and 97.1% including only those with radiologically "certain tuberculosis." CONCLUSIONS: Our findings support current World Health Organization recommendations, demonstrating that symptom-based screening of child tuberculosis contacts should improve feasibility in resource-limited settings and seems to be safe.
Safety of switching to nevirapine-based highly active antiretroviral therapy at elevated CD4 cell counts in a resource-constrained setting [letter]
Journal of Acquired Immune Deficiency Syndromes. 2007 Aug 15; 45(5):598-600.The World Health Organization recommends the use of generic nevirapine (NVP)/efavirenz (EFV)-based highly active antiretroviral therapy (HAART) regimens as first-line therapy in the management of HIV in resource-limited settings. Initiating NVP-based HAART at elevated CD4 cell counts can lead to liver toxicity. Short-term risk of liver toxicity has been reported in men with CD4 counts greater than 400 cells/mL and in women with CD4 counts greater than 250 cells/mL. Hence, clinicians are advised to monitor the results of liver chemistry tests closely in the first 18 weeks of therapy because of the potential to develop life-threatening hepatic events. Mocroft et al showed that initiating NVP therapy at elevated CD4 levels may be safe for use in antiretroviral-experienced patients. Little is known about short-term adverse consequences and clinical outcome at elevated CD4 cell counts in a resource-limited setting. (author's)
The prognostic value of the World Health Organisation staging system for HIV infection and disease in rural Uganda.
AIDS. 1999; 13(18):2555-62.The objective was to assess whether the WHO staging classification for HIV provides prognostically valuable and applicable information in rural Uganda. Data were obtained from a population-based cohort of 232 HIV-infected individuals. Clinical information was obtained using a detailed questionnaire and ascertained by physical examination. Participants were seen routinely every 3 months and when they were sick. A computer algorithm based on clinical history, examination and laboratory findings was used to stage HIV-positive participants at each routine visit. Kaplan-Meier survival estimates and the Cox proportional hazard model were used to assess the prognostic strength of the clinical and laboratory categories of the system. An attendance rate of 81% and 799 person-years of follow-up were achieved. Survival probability estimates at 6 years from being seen in clinical stages 1, 2, 3, and 4 were 63%, 46%, 24%, and 6%, respectively. When staging was revised to incorporate lymphocyte categories, the survival probabilities were 73%, 62%, 39%, and 6%, respectively. Unexplained prolonged fever and severe bacterial infection had survival probabilities closer to stage 2 conditions, mucocutaneous herpes simplex virus infection for more than 1 month and cryptosporidiosis with diarrhea for more than 1 month closer to stage 3 and oral candidiasis closer to stage 4 conditions. Even without the laboratory markers, the clinical category of the WHO staging system is useful for predicting survival in individuals with HIV disease. This is important for areas with limited access to laboratory markers. A simple rearrangement of a few clinical conditions could improve the prognostic significance of the WHO system. (author's)
Classification of HIV infection and disease in women from Rwanda. Evaluation of the World Health Organization HIV staging system and recommended modifications.
ANNALS OF INTERNAL MEDICINE. 1995 Feb 15; 122(4):262-70.In Rwanda, health workers followed 412 HIV infected women attending prenatal and pediatric outpatient clinics in Kigali for 4 years. Researchers used these findings to evaluate WHO's HIV Staging System and predictors of mortality and to produce an HIV staging system for sub-Saharan Africa. The 36-month cumulative mortality was 9% for women originally in stage I, 15% for those in stage II, and 25% for those in stage III, and 27% for those in stage IV (p = 0.001). Significant predictors of mortality at 36 months were oral candidiasis, a low body mass index (=or< 19 kg/sq. m), a history of oral or genital ulcers (especially chronic ulcers), a low hematocrit (<0.38), and a high erythrocyte sedimentation rate (>65 mm/h) (p < 0.001). 12 of the 96 women who died by 36 months had developed pulmonary or extrapulmonary tuberculosis (TB). The researchers revised the WHO system by adding oral candidiasis, chronic oral or genital ulcers, and pulmonary TB to clinical stage IV (severe HIV disease). In the laboratory axis of the system, they replaced lymphocyte count with hematocrit and erythrocyte sedimentation rate. Using the modified laboratory axis, the 36-month mortality rate was 10% for women with normal laboratory results (stage A) and 33% for those with low hematocrit and a high erythrocyte sedimentation rate (stage B). Based on the proposed single staging system, the 36-month mortality rate was 7% for women in stage I, 10% for those in stage II, 29% for those in stage III, and 62% for those in stage IV (p < 0.001). The researchers used these results to propose a staging system that is relevant for sub-Saharan Africa, considers the extent of HIV-related outcomes, requires only inexpensive and available laboratory tests, and has clear prognostic significance. Both clinicians and researchers can use this modified staging system.