Seroprevalence of viral hepatitis in Tanzanian adults.

In a cross-sectional study in Dar es Salaam, Tanzania, we determined the seroprevalence of markers for hepatitis A, B, C and E viruses and examined associated risk markers. Among 403 healthy adults, the seroprevalence of antibodies to hepatitis A virus was 99.0% (95% confidence interval: 97.5-99.7). Prior exposure to hepatitis C and E viruses was rare (hepatitis C: 0.7% (0.2-2.1); hepatitis E: 0.2% (< 0.1-1.4)). The prevalence of all markers of hepatitis B was 70.7% (66.0-75.1). Hepatitis B surface antigen was identified in 6.0% (3.9-8.7) of subjects. Independent predictors of hepatitis B infection identified by logistic regression included older age, male gender, Muslim religion and type of abode. Given the high prevalence of hepatitis B and the low prevalence of hepatitis C, the majority of chronic viral hepatitis is likely to be associated with hepatitis B. Control efforts should focus primarily on hepatitis B.

Delayed-type hypersensitivity testing in Tanzanian adults with HIV infection.

Delayed-type hypersensitivity (DTH) testing and total lymphocyte counts as measures of cell-mediated immune function were assessed for medical patients in Dar es Salaam, Tanzania. DTH testing was performed with the Multitest CMI device which simultaneously administers seven antigens. Of 201 patients completing DTH testing, 90 were HIV seropositive. Anergy occurred more frequently among HIV-seropositive patients (39 of 90) as compared with HIV-seronegative patients (17 of 111). DTH skin test reactivity, measured by anergy, the number of positive antigens, and the combined DTH response induration, was significantly related to the clinical stage of HIV disease. Median total lymphocyte counts were significantly lower in HIV-seropositive patients than in HIV-seronegative patients (1,130 vs. 1,680 lymphocytes x 10(6)/L). Total lymphocyte counts decreased with increasing severity of HIV disease. In multivariable analysis, the number of positive antigens in DTH testing and lymphopenia significantly predicted HIV infection. The findings suggest that DTH testing and total lymphocyte counts may be useful, inexpensive tests of immune function in African patients with HIV disease.

International health and internal medicine residency training: the Duke University experience.

OBJECTIVE: To evaluate the impact of the Duke University Medicine Residency International Health Program (IHP) on program participants and to evaluate the relationship of the IHP to the residency program. SUBJECTS AND METHODS: The Duke University Medicine Residency Program classes of 1988 to 1996 participated in a questionnaire-based survey. All program participants (n = 59), a group of nonparticipants (n = 138), and residents who had not yet had an opportunity to participate (preparticipants; n = 106). RESULTS: The overall response rate to the questionnaire was 93%. Participation exceeded expectations and had a strongly positive impact on personal and professional lives of the majority of the participants. Participants reported a significant positive impact on their training in internal medicine and their knowledge of tropical medicine. A minority of nonparticipants identified a positive effect in these areas due to conferences and interactions with their participating colleagues. Participants who changes career plans during residency tended to move toward areas of general internal medicine or public health, in contrast to nonparticipants who tended to change areas of subspecialty or chose private practice. The IHP was identified as a significant factor for selection of the Duke Medicine Residency by 42% of the preparticipant group. Nearly all of the respondents (99%) indicated that the IHP should be continued. CONCLUSION: The IHP has a measurable positive impact on the participants, as well as on the Medicine Residency Program.

Diagnosis and screening of HIV/AIDS using clinical criteria in Tanzanian adults.

The clinical utility of the World Health Organization (WHO) clinical case definition (CCD) of acquired immune deficiency syndrome (AIDS) in Africa, several proposed modifications of the WHO CCD, and two proposed screening algorithms for human immunodeficiency virus (HIV) infection were examined in adult medical inpatients in Dar es Salaam, Tanzania. Sensitivity, specificity, and positive and negative predictive values were determined for the CCDs and screening algorithms. Multivariable analysis identified factors with high accuracy for HIV infection. Of 223 patients enrolled in the study, 95 were seropositive for HIV infection. The WHO CCD and the modified CCDs had low sensitivities (14.7-32.6%) but high specificities (95.3-99.2%) and positive predictive values (83.8-94.7%). The screening algorithms had moderate sensitivities (66.3-77.9%) and poor specificities (46.1-79.7%). Multivariable analysis consistently identified oral candidiasis and lymphadenopathy as the best predictors of HIV infection. Although patients with asymptomatic or early HIV infection may be missed by clinical criteria, in a high prevalence population, AIDS may be diagnosed accurately clinically because of the effect of prevalence on the positive predictive values of the CCDs. Furthermore, selection of patients for HIV serologic testing may be guided by simple combinations of clinical features.

Tuberculous pericarditis in Tanzanian patients with and without HIV infection.

SETTING: Large academic medical center in Tanzania. OBJECTIVES: To determine the etiologies and outcomes of large pericardial effusions in HIV-infected and uninfected patients. DESIGN: Prospective cohort study of patients admitted with new large pericardial effusions, confirmed echocardiographically. Patients had pericardial biopsies and drainage with extensive analysis of tissue and fluid specimens, and were followed with clinical and echocardiographic examinations. RESULTS: Of 28 patients with large pericardial effusions, 19 were infected with HIV-1. 22 had invasive diagnostic procedures: 14 of 14 HIV-infected patients, but only 4 of 8 non-HIV-infected patients, had tuberculous pericarditis (P = 0.01). All but 1 of the HIV-infected patients had strongly positive tuberculin skin tests, and short-term outcomes were similar in the 2 groups. CONCLUSION: TB is the predominant cause of large pericardial effusion in HIV-infected patients in this setting; non-HIV-infected patients are more likely to have other etiologies. These patients were at an early stage of HIV infection and responded well to treatment. In settings where microbiological studies are not routinely available, HIV-infected patients with large pericardial effusions may be treated empirically for tuberculosis and monitored for improvement. If improvement does not follow within 2-4 weeks further studies are indicated. HIV-negative patients should undergo diagnostic evaluation initially.

Severe cutaneous hypersensitivity reactions during treatment of tuberculosis in patients with HIV infection in Tanzania.

Concurrent infection with HIV-1 and Mycobacterium tuberculosis is increasingly common in East Africa. In the past, a drug regimen consisting of 2 months of intramuscular streptomycin plus 12 months of isoniazid and thiacetazone has been used in tuberculosis control programs with acceptable efficacy and low incidence of adverse reactions. Anecdotal reports of increasing cases of Stevens-Johnson syndrome prompted a 2 month prospective search for cases of severe cutaneous hypersensitivity reactions at Muhimbili Medical Centre in Dar es Salaam, Tanzania. Five such patients were admitted to a single ward during this time, 4 of whom were HIV-seropositive and all of whom were being treated with isoniazid and thiacetazone. These findings have implications for the management of tuberculosis in East Africa and perhaps other countries with high prevalence of both HIV-1 and tuberculosis.

PIP: Concurrent infection with HIV-1 and Mycobacterium tuberculosis (TB) is increasingly common in East Africa. In HIV-infected individuals, pulmonary TB tends to occur before the onset of opportunistic infections. A common treatment regimen in developing countries is two months of intramuscular streptomycin combined with twelve months of isoniazid and thiacetazone. TB control programs have found this approach to be of acceptable efficacy with a low incidence of adverse reactions. Anecdotal reports of increasing cases of Stevens-Johnson syndrome, however, prompted a two-month prospective search for cases of severe cutaneous hypersensitivity reactions at Muhimbili Medical Center in Dar es Salaam, Tanzania. Five such patients were admitted to an hospital ward over the two-month period, four of whom were HIV-seropositive and all of whom were being treated with isoniazid and thiacetazone. Two were also receiving streptomycin. Four had extensive mucosal involvement of the eyelids, lips, and mouth, consistent with Stevens-Johnson syndrome. The remaining patient had bullous skin lesions, without mucosal involvement, consistent with an exfoliative dermatitis. On admission, medications were discontinued and patients underwent routine management, including the administration of steroids. Four patients were discharged from the hospital 3-7 weeks after admission with improved conditions. One patient died suddenly after five weeks of hospitalization due to unknown causes. These patients give extra support to observations that thiacetazone is associated with the increased incidence of severe cutaneous hypersensitivity syndrome in people infected with HIV-1. Further studies are needed to quantify the excess morbidity and mortality resulting from this treatment regimen.

Pericardial disease and human immunodeficiency virus in Dar es Salaam, Tanzania.

The number of patients admitted to Muhimbili Medical Centre, Tanzania, with pericardial effusions rose after the epidemic of acquired immunodeficiency syndrome (AIDS) began. To investigate a possible relation all patients with suspected pericardial disease admitted between Oct 1, 1987, and March 31, 1989, were studied. 28 of 42 patients (67%) were seropositive for human immunodeficiency virus (HIV). 28 of 39 patients (72%) with pericardial effusion were HIV-seropositive compared with 0 of 3 without effusion. More HIV-seronegative than HIV-seropositive patients were receiving antituberculous chemotherapy and had ascites at enrollment. Only 5 of 28 HIV-seropositive patients had clinical signs of AIDS. 9 of 14 HIV-seropositive patients tested had positive Mantoux tests. There were no significant differences between the HIV-seropositive and seronegative groups in the duration of symptoms, laboratory results, X-ray or ultrasound findings, frequency of tamponade, or mortality. 38 patients were treated for tuberculosis. Pericardial effusion is strongly associated with, and an early manifestation of, HIV infection in Tanzania.

PIP: The number of patients admitted to Muhimbili Medical Center, Tanzania, with pericardial effusions rose after the epidemic of acquired immunodeficiency syndrome (AIDS) began. To investigate a possible relation all patients with suspected pericardial disease admitted between October 1, 1987 and March 31, 1989, were studied. 28 of 42 patients (67%) were seropositive for human immunodeficiency virus (HIV). 28 of 39 patients (72%) with pericardial effusion were HIV-seropositive compared with 0 of 3 without effusion. More HIV-seronegative than HIV-seropositive patients were receiving anti-tuberculous chemotherapy and had ascites at enrollment. Only 5 of 28 HIV-seropositive patients had clinical signs of AIDS. 9 of 14 HIV-seropositive patients tested had positive Mantoux tests. There were no significant differences between the HIV-seropositive and seronegative groups in the duration of symptoms, laboratory results, X-ray or ultrasound findings, frequency of tamponade, or mortality. 38 patients were treated for tuberculosis. Pericardial effusion is strongly associated with, and an early manifestation of, HIV infection in Tanzania. (Author's).

Efficacy of immune therapy in early experimental Naegleria fowleri meningitis.

Naegleria fowleri meningoencephalitis is usually fatal in humans despite treatment. As a new approach, we tested intracisternal passive immune therapy in rabbits with amebic meningoencephalitis by using antinaegleria immune serum, an immunoglobulin G fraction, and a newly developed monoclonal antibody to N. fowleri. Both the immune serum and an immunoglobulin G fraction isolated from it by affinity chromatography provided a consistent, although temporary, protective effect, shown by prolongation of survival (P = 0.001). Multiple doses of immune serum further prolonged survival (P = 0.005). The protective effect of serum was retained after heating to 56 degrees C. We then developed a monoclonal antibody to N. fowleri which provided similar protection. Passive intracisternal antibody therapy might serve as an adjunctive component in the treatment of amebic meningoencephalitis.