Development and evaluation of a new paediatric blood transfusion protocol for Africa.

Severe anaemia is a common childhood emergency in developing countries. Practical evidence-based guidance on when to transfuse, volume of transfusion and ideal duration of transfusion is lacking. The aim of this study is to develop a paediatric transfusion protocol for use in under-resourced environments and evaluate its usability in a busy African hospital setting. A paediatric transfusion protocol based on the WHO Guidelines was developed for the Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi. On the basis of simple bedside clinical features of respiratory, cardiovascular and neurological compromise, the protocol allocates children with severe anaemia (haemoglobin

Genital ulcers and transmission of HIV among couples in Zimbabwe.

Seventy-five married men found to be positive for HIV-1 in Harare, Zimbabwe, were interviewed in order to define behaviours associated with acquisition of infection and to determine factors associated with transmission of infection to their wives. The majority of infected men reported sexual intercourse with multiple heterosexual partners and female prostitutes, and gave a history of sexually transmitted diseases (STDs). All subjects denied homosexual activity and parenteral drug abuse. Serological testing of the wives of seropositive men showed that 45 (60%) were HIV-antibody-positive. Wives of men with AIDS and AIDS-related complex (ARC) and wives of men who gave a history of genital ulcer disease were more likely to be seropositive. The study demonstrates that HIV-1 infection in Zimbabwe occurs through heterosexual intercourse and is associated with other STDs. In addition, the study shows that male to female transmission of HIV-1 is facilitated by the presence of genital ulcers in infected men.

PIP: As part of a prospective cohort study of Zimbabweans seropositive for human immunodeficiency virus (HIV) infection, the factors associated with HIV transmission from husband to wife were analyzed in 75 couples. The mean age of the infected men was 32.1 years; all had been married for at least 1 year and 53 had at least 1 child. None of the men acknowledged a history of homosexual practices or intravenous drug use. All 75 had received injections, but only at reputable health care facilities, and none had been blood transfusion recipients. 4 men (5%) were asymptomatic, 40 (53%) had persistent generalized lymphadenopathy, 24 (32%) had acquired immunodeficiency syndrome (AIDS)-related complex (ARC), and 7 (9%) had full-blown AIDS. Of the 75 wives tested, 45 (60%) were seropositive for HIV-1 infection. Seropositivity was significantly more common among women married to men with ARC (71% infection rate) and AIDS (86% infection rate). Comparison of concordant (both seropositive) and discordant (husband only seropositive) couples indicated no significant differences in terms of age, duration of marriage, number of children, oral contraceptive use by the wife, husband's contact with prostitutes, or sexual activity on the part of the husband with multiple partners in the preceding 3 years. In addition, there was no significant difference between groups in terms of history of sexually transmitted diseases. However, men who reported a history of genital ulcer disease were significantly more likely to have a wife who was seropositive (relative risk, 1.94; 95% confidence interval, 1.62-15.13). This difference persisted even when the male's stage of disease was controlled. Thus, it appears that HIV-1 infected men with genital ulcers are likely to transmit the infection through vaginal intercourse.

Sexual behavior and risk factors for HIV infection in a group of male factory workers who donated blood in Harare, Zimbabwe.

Zimbabwe has experienced a rapid rise in HIV seroprevalence in recent years. As many as 1 million people (10% of the population) are predicted to become seropositive by 2000. We examined social and behavioral factors associated with HIV infection in a case-control study among male factory workers who donated blood before the launching of the AIDS Awareness Campaign. There were 188 subjects: 69 were HIV-positive and 119 were HIV-negative. High-risk behavior was common in both groups. Among seronegative men, 73.1% reported a sexually transmitted disease (STD), 55.5% reported cash payment for sex, and 73.1% had outside girlfriends. Nonetheless, HIV-positive men were more likely to report a history of STD (OR = 3.9; 95% CI = 1.5-11.9), particularly genital ulcers (OR = 2.4; 95% CI = 1.2-4.8), and extramarital partners (OR = 2.8; 95% CI = 1.1-7.1). HIV-positive men reported more lifetime partners (16.5 vs. 12; p less than 0.05) and were less likely to live with their wives (OR = 0.51; 95% CI = 0.23-1.15). Our findings support the importance of genital ulcer as a risk factor and suggest widespread high-risk sexual behavior among urban working-class men.

Clinical and laboratory characteristics of HIV-1 infection in Zimbabwe.

To define the impact of human immunodeficiency virus (HIV) infection in Africa, clinical and laboratory investigations were conducted on 265 HIV-seropositive outpatients in Zimbabwe. Twenty-four of the study subjects were asymptomatic (ASX), 124 had persistent generalized lymphadenopathy (PGL), and 117 had AIDS-related complex (ARC). HIV infection was assessed by commercial ELISA, Western blots, synthetic peptide ELISA, and measurement of p24 antigen. Serum immunoglobulins, lymphocyte mitogen responses, and CD4+ cell numbers were obtained in 54 sequential patients. Compared to seronegative subjects, mean CD4+ cell numbers were decreased and serum immunoglobulins, particularly IgM and IgG, were increased in all groups of seropositive subjects. Lymphocyte proliferative responses to phytohemagglutinin and concanavalin A decreased progressively in ASX, PGL, and ARC patients and were significantly lower in PGL and ARC patients compared to seronegative controls. Generalized lymphadenopathy was present in 234/265 (88%) of patients. Lymph node biopsies in 100 patients demonstrated follicular hyperplasia in 97 and Mycobacterium tuberculosis in 3. Of 165 patients followed for a median of 6 months, 5 developed the acquired immune deficiency syndrome (AIDS). Symptoms of ARC, low CD4+ cell number, and p24 antigen were predictive of the development of AIDS in Zimbabwe.

Guillain-Barré syndrome associated with human immunodeficiency virus infection in Zimbabwe.

We studied the clinical features and human immunodeficiency virus (HIV) serology of 32 consecutive adults with inflammatory demyelinating polyneuropathy (IDP) admitted to the teaching hospitals in Harare, Zimbabwe. Twenty-nine of the IDP patients had Guillain-Barré syndrome (GBS), and the other three had chronic IDP. Sixteen of 29 (55%) GBS patients were HIV-seropositive, a higher frequency of HIV infection than in blood donors drawn from the population served by these hospitals. All three chronic IDP patients were HIV-seronegative. In all HIV-seropositive patients, GBS was the initial illness that brought the patient to medical attention and led to the diagnosis of HIV infection. Compared with seronegative patients, the HIV-seropositive GBS patients were more likely to have generalized lymphadenopathy, CSF pleocytosis, coexistent CNS disturbance, and prior sexually transmitted disease. GBS in this region of Africa is frequently associated with HIV infection.

Risk of hepatitis B infection among medical and paramedical workers in a general hospital in Zimbabwe.

To evaluate the addition of hepatitis vaccine to health schemes for hospital workers in Zimbabwe we undertook a cross sectional study of viral markers in 226 hospital workers and compared the results with 97 volunteer blood donor controls. One hundred and thirty one (58%) hospital workers had hepatitis markers compared with 45 (46%) of the donor group. Racial group was the strongest risk factor. Blacks were 70% more likely to have markers than whites. This racial difference was not explained by job status or patient contact. Our data suggest that work in a district general hospital does not constitute a clinically important hazard for hepatitis B infection. Because of the high cost of the vaccine, additional studies to assess the risk of hospital work in other settings in Zimbabwe are required before health policy regarding routine hepatitis B vaccination is determined.

Pooling of sera for human immunodeficiency virus (HIV) testing: an economical method for use in developing countries.

To determine whether donated blood samples in African countries could be pooled, then tested for the presence of human immunodeficiency virus (HIV) antibodies with a single test without loss of accuracy, a single test on five pooled samples was used, followed by individual testing of positive pools. This resulted in no loss of either sensitivity or specificity. Pooling 10 samples resulted in a loss of sensitivity for low antibody titre specimens. Pooling reduced the costs of screening by 70% and time needed for analysis. It is concluded that pooling of five samples for HIV screening may result in a substantial reduction in costs; in countries where the prevalence of HIV is higher than the 2-3% found in Zimbabwean donors, however, savings may not be as great.

PIP: The pooling of donated blood samples, followed by a single test for the presence of human immunodeficiency virus (HIV), has the potential of saving both time and money in developing countries; however, it is essential that such a procedure not compromise accuracy. To evaluate this possibility, a single test on 5 pooled samples from Zimbabwe was used, followed by individual testing of positive pools. This exercise was performed on 440 sera, or 88 pools of 5 and 44 pools of 10 sera. 17 positive results were identified through the individual testing of all sera. All 17 positive sera were also identified in the pools of 5, but 2 specimens were missed in the pools of 10 due to the loss of sensitivity for low antibody titer specimens. In addition to reducing the time needed for laboratory analysis, pooling reduces the costs of screening by 5% in settings where seroprevalence is 15% and by 70% when seroprevalence is 2%. In Zimbabwe, the cost of screening kits with this technique is 1/3 of what it would be if sera were tested individually. In general, the technique of pooling 5 sera seems cost-effective only when the prevalence of HIV seropositivity is 10% or less. The ability to declare specimens seronegative in lots of 5 also reduces the time that must be spent on record keeping as well as screening.

Pulmonary diseases in patients infected with the human immunodeficiency virus in Zimbabwe, Central Africa.

During the 11 month period up to 30 September 1987, 37 patients (26 male, 11 female, mean age 27 years) with respiratory symptoms who were human immunodeficiency virus (HIV) positive, were studied prospectively on 40 occasions to determine the cause of any pulmonary complications. HIV was heterosexually transmitted. Predominant symptoms were cough (89%), fever (89%), weight loss (83%), and dyspnoea (60%). Transnasal fibre-optic bronchoscopy (with bronchoalveolar lavage, bronchial brushings and transbronchial lung biopsies) was performed on 35 patients, twice on 3 patients. 'Tru-cut' lung biopsies were obtained from 2 patients who died before bronchoscopy. Pulmonary tuberculosis was the commonest disease, being found in one-third of the patients (12 of 37). Mycobacterium tuberculosis was cultured from 4; the remainder of the plates were contaminated. Pneumocystis carinii was present in 8 patients: as the sole pathogen in 3, with Streptococcus pneumoniae in 4, Staphylococcus aureus in 2, and one also had tuberculous lymphadenitis. Endobronchial Kaposi's sarcoma was seen in 6 of 7 patients with skin nodules. Bacterial pathogens isolated included Staph. aureus (5), S. pneumoniae (5), Klebsiella pneumoniae (2), Haemophilus influenzae (2), H. parainfluenzae (1) and Pseudomonas aeruginosa (1). Invading Aspergillus fumigatus was diagnosed by lung biopsy in one. No diagnosis was reached for 8 patients. It is concluded that in Central Africa pulmonary complications in AIDS patients are similar to those in Europe and North America but the incidence of different pathogens depends on the prevalence of pathogens in the community. M. tuberculosis is probably the commonest pathogen. This study has confirmed that P. carinii pneumonia does occur, but occurs less frequently.

Pneumocystis carinii pneumonia in patients with AIDS in Central Africa.

Over a period of 11 months, 37 patients infected with the Human Immunodeficiency Virus (HIV) presenting with symptoms of bronchopulmonary disease were investigated. Patients presented with cough, weight loss, fever and dyspnoea. Investigations included fibreoptic bronchoscopy with bronchoalveolar lavage and transbronchial biopsy. In eight patients (22%) Pneumocystis carinii was found. Pulmonary infiltrates were found on chest radiographs of six patients, while in the remaining two patients chest radiographs showed clear lung fields. P. carinii was found in two patients with pulmonary Kaposi's sarcoma. Infection with P. carinii often occurred with other pathogens: Streptococcus pneumoniae was found in four patients, Staphylococcus aureus in two and tuberculosis in two. P. carinii pneumonia does occur in patients with HIV infection in Africa and the diagnosis is relatively simple to make provided that transbronchial biopsy and bronchoalveolar lavage are carried out through a fibreoptic bronchoscope and specimens examined after appropriate staining. However, the prevalence of P. carinii in patients with HIV infection in Africa appears to be lower than that found in patients with HIV infection in Europe and North America.

HLA frequencies in black Zimbabweans.

One-hundred-and-nineteen normal Black Zimbabweans were typed for HLA antigens. We found a close similarity between the HLA antigen frequencies in Zimbabweans and Black South Africans (Xhosa), another Bantu-speaking group. The only significant differences noted were for HLA-Aw36, -Bw53, -Cw6, -DR4 and -DQw3 (p less than 0.01). The most common HLA haplotypes in significant positive linkage disequilibrium in the two groups were different. The differences that were noted may be due to gene flow from the San to the Black South Africans, since it is thought that the Zimbabweans had little if any contact with the San.

Blood safety.

Since blood is a biologic product, it is unlikely that the risk for transfusion-transmitted infection will ever be reduced to zero. The approach to emerging infections associated with transfusion of blood and blood products includes assessing the transmissibility of the agent by this route; developing effective prevention strategies, including screening tests and donor deferral policies; improving viral and bacterial inactivation procedures; and surveillance for known, as well as emerging and poorly characterized, transfusion-transmitted agents. Vigilance is needed to help ensure proper balance between safety and the availability of blood. Finally, vigilance needs to extend to the developing world, where the basic elements to reduce transfusion-transmitted infections and systems of disease surveillance are often not available.