The Clinical Spectrum and Financial Burden of HIV Infected Children in a Regional Hospital in South Africa

Background: HIV infection has become a common risk factor for hospital admission and a major contributor to childhood morbidity in South Africa. There remains a paucity of data describing the cost of hospitalisation of HIV-infected children in South Africa. The aim of this study was to describe basic demographics and clinical patterns as well as cost implications of the hospitalisation of HIV-infected children in the Karl Bremer Hospital; Cape Town; South Africa. Methods: A prospective descriptive longitudinal study of HIV-positive paediatric admissions; matched with HIV-negative controls; was conducted. Patients were matched according to age; socio-demographic area and presenting symptoms. Questionnaires were used to elicit demographic and clinical information. Worksheets were used to record any costs incurred; which were calculated at rates applicable to 2001. This was done daily during admission. Data was statistically analysed in MS Excel and MS Access. Thirty HIV-positive children were identified; of which 23 could be matched with 23 HIV-negative children. HIV-positive children had a higher admission rate (2.09 versus 0.26 previous admissions; p = 0.000) and were also younger at the time of first admission to hospital (7.52 versus 13.78 months; p = 0.005). There is a statistically significant difference in duration of hospitalisation in the HIV-positive group when compared to the control group - duration of hospitalisation being longer in the HIV-positive group (7.91 versus 4.96 days; p = 0.005). Despite being treated for the same condition; there is a statistically significant difference in the cost incurred by children in the HIV-positive group (R6 203.16) when compared to the HIV-negative group (R3 901.96); p = 0.000. Conclusion: This study shows a clear and statistically significant difference between the HIV-positive group and HIV-negative control group of children with regard to admission rate; age at first admission; duration of hospitalisation and cost incurred during hospitalisation. HIV-infected children in the pre-HAART (highly active anti-retroviral therapy) era were hospitalised more frequently and for longer periods than their HIV-uninfected counterparts. These findings seem to suggest that the cost of hospitalising HIV-positive children is significantly more than HIV-negative controls; which will increase the financial burden on already restricted health resources

Informed consent and participant perceptions of influenza vaccine trials in South Africa.

BACKGROUND AND OBJECTIVES: There are few insights from sub-Saharan Africa on research participants' experiences of the informed consent process, particularly in the context of randomised controlled trials, where issues of randomisation and the use of placebos may be confusing concepts for participants. This study investigated the knowledge and perceptions of the informed consent process among individuals participating in influenza vaccine trials in two disadvantaged communities in South Africa. METHOD: Four to 12 months after completion of the trials, participants were contacted to return to participate in the informed consent study. The semistructured questionnaire administered to assess recall of trial procedures and the informed consent process covered key issues including: purpose of the study; awareness that the study was not part of routine treatment; voluntary nature of participation and freedom to withdraw; randomisation; placebos; and remuneration. RESULTS: A total of 334 participants (93% of the original vaccine trial sample; mean age 68 years, median level of education grade 8, 69% women) completed the questionnaire. Only 21% were able to recall that they were allocated randomly to the different treatment arms. Only 19% of those involved in the placebo controlled study had interpreted the concept of placebo as an inactive medication. CONCLUSION: Although a good general recall of trial concepts was demonstrated, only a small proportion of the participants correctly interpreted and recalled the concepts of randomisation and placebos. Informed consent in this and similarly disadvantaged communities may often be inadequate and new ways to improve understanding of the research process should be explored.

Nosocomial adenovirus infection in a paediatric respiratory unit.

We report a nosocomial outbreak due to adenovirus in a paediatric respiratory unit serving a poor socio-economic community. Of 207 children admitted during an eight-month period, 24% were neonates; the median age of the remainder was 10 months. Thirty-two cases were found to be infected with adenovirus and of these 67% died. Nine were already infected with adenovirus when admitted. Twenty-three acquired the infection after admission, giving an incidence of nosocomial acquisition of 12% with a 91% mortality rate. All but one of the adenovirus infected children were being ventilated and had an endotracheal tube in place. Nosocomial spread was likely to have been from the hands of attendants, especially those manipulating suction catheters and endotracheal tube or ventilator connections. Risk factors for acquiring nosocomial infection were young age: all but two were < 1 year of age, and a relatively prolonged ward stay necessitated by the nature of the primary condition (pneumonia, bronchiolitis, laryngotracheo bronchitis, tetanus). The measures that were taken to control spread of the virus are described. Despite these, primary cases of adenovirus infection re-introduced the virus regularly over the study period. The genome analysis showed adenovirus types to be 7c2 and 7c.

Normal values for simple lung function tests in South African Asian children.

Normal lung function values have frequently been shown to be racially specific. This study of 1072 boys and girls establishes normal standards for peak expiratory flow rate, forced expiratory volume in 1 s, and forced vital capacity in Asian (Indian) children aged 5-14 years. These values are compared with those of American white and black children and of Indian and British Asians.

Tetanus in children: an 11-year review.

One hundred and three cases of tetanus in children 1-12 years of age were reviewed. Sixty-six per cent had severe disease, half of whom required management with total muscle paralysis and intermittent positive pressure ventilation (IPPV), and 70% in this group developed signs of sympathetic overactivity (SOA). Control of SOA with morphia 0.5-1 mg/kg/dose given 1-4 times a day appears to have decreased the mortality rate from this complication of severe tetanus. There was a relative resistance to drug control of SOA in the youngest children. High output renal failure developed in two children, an incidence much the same as reported in severely affected adults. The overall mortality rate of this series was 14.5%: all the deaths were amongst those severely affected. The cause of death could be attributed to tetanus in half, while in the remainder it resulted from complications of intensive therapy. Tetanus in children resembles the disease in adults.

Morphine in tetanus--the management of sympathetic nervous system overactivity.

Morphine was administered intravenously in bolus doses 6-hourly to 10 patients; 9 developed signs of sympathetic overactivity and required increased morphine dosage. The mean daily morphine dosage was 103 +/- 36 mg and the maximum daily dosage was 170 +/- 65 mg. In all cases morphine decreased the mean arterial blood pressure (mean 18%; P less than 0.01) and heart rate (mean 7%; P less than 0.01). In 7 cases the cardiac output fell minimally (mean 7%; P = 0.07), while the systemic vascular resistance decreased (mean 12%; P less than 0.01) in 8 cases. Nine patients survived, 1 died from renal failure and septicaemia. There were no apparent problems with either opiate withdrawal or addiction. No patient required either alpha- or beta-adrenergic blockers and the consequent simplified management constitutes a significant improvement in control of these patients.

Nasotracheal intubation versus tracheostomy for intermittent positive pressure ventilation in neonatal tetanus.

Fifty-two neonates with tetanus who required muscle paralysis and IPPV were managed alternatively with naso-tracheal intubation or tracheostomy. The complications of the two techniques were compared. Planned extubation caused less problems in the intubated than in the tracheostomized children, and secondary infection occurred less often. Accidental extubation, however, was a significant hazard in the intubated child.

Renal function in tetanus.

In twenty-eight patients suffering from tetanus, renal function was evaluated from admission for a period of 2 weeks. Investigations included daily blood urea, osmolality and creatinine and urinary osmolality and sodium. Free water clearance (CH2O) was calculated. The patients were divided into those requiring tracheostomy and sedation alone (Group I) and those with more severe tetanus requiring total muscle paralysis and IPPV (Group II). The latter group also had evidence of sympathetic nervous overactivity (SOA). Daily blood urea, serum creatinine and osmolality showed no significant difference between the two groups except during the phase of uremia. Mean urinary sodium was significantly different between the two groups (p less than 0.001). Four patients in Group II developed an abnormal plasma urea (Group IIb). In one patient the rise in urea followed resuscitation from cardiac arrest and the remaining three patients had in common severe cardiovascular instability associated with SOA. All four patients were non-oliguric during the phase of uremia. Only one patient with renal failure survived, compared with a 75% survival in the patients with SOA without renal failure and a 100% survival in Group I. Tetanus complicated by renal failure has a poor prognosis.

Labetalol in tetanus. The treatment of sympathetic nervous system overactivity.

The cardiovascular instability in some cases of severe tetanus is due to increased circulating catecholamines. In 15 patients with this complication of tetanus, labetalol, a drug with alpha- and beta-peripheral adrenergic blocking properties, was used in management. The drug was administered orally, by i.v. bolus or by continuous infusion. Wide variation in dosage was needed both from case to case and in the same patient during the course of his disease. In most cases the pulse and blood pressure were reduced by labetalol, although their variability was not much improved. The effect on the cardiac output and systemic vascular resistance ranged from modest reduction in both, to marked effect on cardiac output without any change in systemic vascular resistance. The alpha-adrenergic blockage of labetalol is known to be less powerful than the beta-blocking effect, and this property could be a disadvantage in the management of sympathetic overactivity in tetanus.

Legionnaires' disease in Durban. A case report.

An isolated case of Legionnaires' disease occurring in Durban is described. The patient presented with bilateral extensive pneumonia. Diagnosis was made by the indirect immunofluorescent antibody test, which showed a fourfold rise in titre from 1 : 128 to 1 : 512. Awareness of the fact that Legionnaires' disease occurs here should result in early recognition and appropriate management of this disease.

Continuous positive pressure ventilation in children with bronchopneumonia.

The application of a small end-expiratory pressure of 5 cmH2O to the assisted ventilation of nineteen children (mean age 19 months) with bronchopneumonia was compared with intermittent positive pressure ventilation. Within 1 h of introducing continuous positive pressure ventilation the alveolar-to-arterial oxygen gradient was reduced in most patients, with an increase in functional residual capacity and a decrease in total pulmonary blood shunt. Physiological dead space was also reduced, a feature not observed in other studies, and the significance of this finding is discussed. The use of continuous positive pressure ventilation in broncho-pulmonary infection was shown to be effective even at small pressures, and can be recommended especially for patients requiring long-term ventilation.

Severe measles-associated pneumonia treated with assisted ventilation.

Measles-associated pneumonia, which was severe enough to require mechanical ventilation, caused a mortality of 64%. The main indications for special respiratory care were severe infection and hypoxaemia. Complications of the disease occurred in 78% of the patients. The commonest were anaemia, enteritis and cardiac failure, and they contributed to the grave prognosis. Viral pneumonia was present in most of the patients who died; superinfection was rare. The characteristics of measles virus was present in 30% and of adenovirus in no less that 40%.