Diagnosis of paediatric tuberculosis using sputum induction in Botswana: programme description and findings.

SETTING: Four public hospitals in Botswana, a high tuberculosis (TB) burden setting. OBJECTIVES: To assess the feasibility and utility of sputum induction in the diagnosis of paediatric TB. DESIGN: From 2008 to 2010, children aged ≤18 years referred for suspected pulmonary TB underwent sputum induction. Confirmed TB was defined as the presence of at least one of the signs and symptoms suggestive of TB and positive Mycobacterium tuberculosis culture. Information on TB-associated symptoms (cough, fatigue, night sweats, low appetite, chest pain, weight loss, haemoptysis and contact with a TB case) was collected for three risk groups: human immunodeficiency virus (HIV) positive children, HIV-negative children aged <3 years and HIV-negative children aged ≥3 years. RESULTS: The median age of the 1394 subjects who underwent sputum induction was 3.8 years (IQR 1.3-8.4); 373 (27%) were HIV-positive, 419 (30%) were HIV-negative and 602 (43%) had unknown HIV status. TB was confirmed in 84 (6.0%); cases were more likely to have weight loss, chest pain or TB household contacts. There were no serious complications attributable to sputum induction during and after the procedure; only 0.8% (9/1174) of patients reported minor complications. CONCLUSIONS: In Botswana, paediatric sputum induction was feasible, safe and assisted bacteriological confirmation in a subgroup of children treated for TB.

Echocardiographic findings in Eldoret: retrospective study.

Echocardiographic (ECHO) findings in 211 consecutive examinations performed at Eldoret Medical Services from August 1992 to May 1994 were analysed. Most patients were referred by physicians from Eldoret and from the surrounding hospitals for assessment of heart failure or a heart murmur. Thirty three echocardiograms were judged as being normal and 177 abnormal. Of the abnormal ECHOs, congenital heart disease accounted for 38.4% while rheumatic heart disease accounted for 40.7%: Of the 68 patients with congenital defects, 21 (30.1%) had ventricular septal defects; 19 (27.9%) persistent ductus arteriosus; five (7.5%) mitral valve; four (5.9%) tetralogy of Fallot; and three (4.4%) atrial septal defects. In addition, there were two (3.0%) patients each with complete atrio-ventricular septal defects, tricuspid atresia, complete transposition of the great arteries, truncus arteriosus, single ventricle and bicuspid aortic valve. Of the 67 patients with uncomplicated rheumatic heart disease, mitral valve involvement alone was seen in 39 (58.2%), mitral and aortic in 26 (38.8%) and aortic valve alone in two (3.0%). Rheumatic heart disease was complicated by bacterial endocarditis in five patients. Nine patients had pericardial effusion. The possible role of colour-flow ECHO as a feasible, non-invasive and, in the long term, cost-effective means of allowing for early detection and timely institution of secondary prophylaxis while rheumatic heart disease is still asymptomatic is highlighted.

Prevalence of asthma, allergic rhinitis and dermatitis in primary school children in Uasin Gishu district, Kenya.

Three thousand and eighteen children aged 13-14 years were studied using a standard questionnaire developed and field tested by the International Study of Asthma and Allergies in Children(ISAAC) steering committee between January and April 1995 to establish the prevalence and severity of asthma, rhinitis and eczema. 58 rural primary schools were randomly selected from which 3018 children filled out the written (WQ) and the video (VQ)questionnaires. There were 1471 (48.7%) males and 1547 (51.3%) females. On the written questionnaire the cumulative prevalence for wheezing, rhinitis, itchy eyes and skin rashes was 21.2%, 32.4%, 11.8% and 23.8% respectively, with respective 12 month period prevalence rates of 10.2%, 25.3% and 14.4% for wheezing, rhinitis and itchy rashes. On the video questionnaire the cumulative prevalence rates were 11.4%, 12.3%, 5.0%, 16.3% and 3.6% for wheezing, exercise induced wheezing, nocturnal wheezing, nocturnal cough and difficulty in breathing associated with wheezing respectively. The video questionnaire prevalence rates are lower than those of the written questionnaire possibly due to difficulties the children encountered in correlating the symptoms and the disease. The prevalence of severe symptoms for rhinitis, eczema and wheezing of 10.1%, 6.8% and 5.8% respectively are lower than those reported for developed countries. These results compare with those of a previous study in Estonia using the same ISAAC questionnaire and support the hypothesis that although the prevalence of asthma and allergic diseases are on the increase worldwide, it is more so in the developed than the developing countries.

Community health assessment index content and face validation studies.

The objective of the study was to evaluate content and face validity of Community Health Assessment Index (CHAI). Two independent groups of experts convened in Dar-es-salaam and Eldoret after having had a chance to study CHAI for two or more weeks in order for them to make written evaluations on the index. Twelve and 11 experts representing a broad range of interest in community health in the African context convened in Dar-es-salaam and Eldoret respectively. Most of these were nominated by their respective institutions, namely, ministries of health, academic and research institutions and non-governmental and multilateral organisations. The findings of the two groups of experts were very similar. The consensus was that CHAI has face and content validity. However, both groups suggested that (i) total adult mortality instead of male adult mortality be used; and (ii) that a 5 km rather than 10 km radius be used to define accessibility to health care. Regarding to questionnaire the consensus was that (a) the questions were both clear and culturally appropriate; (b) apart from the part which concerns a description of health services policy and community participation, the questionnaire could be administered by literate primary health care workers after appropriate training and translation; and (c) in addition to generating CHAI scores, the data gathered with this instrument could be used for planning and evaluation at the local community level. Overall the questionnaire was judged as "good" by 19 while the remaining 4 judged it as being "very good". Several suggestions in wording were made. Also a few additional questions were suggested. This evaluation provides justifications for further studies to assess the remaining measurement properties of this index.

Prevalence of heart disease in school children in rural Kenya using colour-flow echocardiography.

In a survey using colour-flow echocardiography and a portable generator, of one thousand one hundred fifteen children, three had clinical and echocardiographic evidence of rheumatic heart disease giving a prevalence rate of 27/1000. Sixty nine (6.2%) of the children examined had trivial mitral regurgitation (TMR). Of these, three had associated trivial aortic regurgitation. Isolated trivial aortic regurgitation was not seen. Four children had isolated mild-moderate regurgitation of the pulmonary valve. Congenital heart disease (CHD) was found in two children-one with secundum atrial septal defect and one with a ventricular septal defect and pulmonary stenosis, giving a prevalence of 1.8/1000. One child had a bicuspid aortic valve and two persistent left superior vena cava. It is feasible to carry out an echocardiographic survey using a portable generator in schools where electricity is not available. The prevalence of rheumatic heart disease (RHD) is higher than previously found in Kenya. The prevalence of TMR is surprisingly high. This was associated with familial clustering reminiscent of RHD. The importance of these findings must await the results of further investigation.

A randomised controlled trial to assess the relative efficacy of chloroquine, amodiaquine, halofantrine and Fansidar in the treatment of uncomplicated malaria in children.

A randomised controlled trial was carried out to determine the relative efficacy of four commonly used antimalarial drugs in children aged three to twelve years presenting with uncomplicated malaria at the Eldoret District Hospital, Kenya. One hundred and eighty eight children were studied between July 1993 and July 1994. There were no significant baseline differences between treatment groups with respect to age, sex, weight, ethnicity, haemoglobin, white blood cell (WBC) counts, parasite counts, previous exposure to malaria and prior treatment. Of the 188 patients, eleven were lost to follow-up while twelve were discontinued from the study due to poor clinical response. Most of the latter (eight out of twelve) were in the chloroquine group. By day seven, there were significant differences (p = 0.004) in parasite clearance between groups. There were no significant statistical differences between the groups (p = 0.12) with regard to the fever clearance time. However, there was a significant statistical difference (p = 0.00003) between the treatment groups in the cure rates. Halofantrine was the most efficacious drug with 82% of the cases cured followed by fansidar(R)(62%), amodiaquine (55%) and chloroquine (29%). RI and RII resistance were observed in all the treatment groups, i.e. halofantrine (18%), fansidar (38%), amodiaquine (45%) and chloroquine (67%) while RIII resistance was only observed in the chloroquine group(3%).

Clinical presentation of atopic dermatitis in Negroid children.

Clinical findings in 54 consecutive negroid children with atopic dermatitis (AD) are presented. The age range was 0.25 to 10.25 years. Male:Female ratio was 1.2:1. Time of onset range between 1 week and 8 years with onset before the age of 1 year in 81.1%. Facial and flexural involvement were observed in 81.5% and 70.4% of patients respectively. The latter was more common after the age of two years. Keratosis pilaris, repeated skin infections and ichthyosis were observed in 72, 45, and 40 per cent of the children. Allergic conjunctivitis was present in 11.8%. The findings suggest that the clinical presentation of AD in Negroid children is similar to that in white children.

Anthropometric measurements in children with congenital heart disease at Kenyatta National Hospital (1985-1986).

Heights, weights, skinfold thicknesses as well as head, chest, and mid upper arm circumferences of 175 children with congenital heart disease, aged 0-12 years, attending the paediatric cardiology clinic at Kenyatta National Hospital between February, 1985 and January, 1986 were taken. The results were compared to those of normal children matched for age, sex and socio-economic status. The heights of 164/175 (93.7%), the weights of 156/175 (89.1%), both heights and weights of 150/175 (85.7%) patients were all below control values. The mid upper arm circumferences of 142/175 (81.1%), the skinfold thicknesses of 136/175 (77.7%) and the chest circumferences of 124/175 (70.9%) were all below controls. 110/175 (62.9%) patients had smaller head circumferences compared to normal controls. The differences in value between the test and control groups were statistically significant in all parameters except for head circumference.

Effects of skin contactants on evolution of atopic dermatitis in children: a case control study.

There is little published literature on the effects of skin contactants during early infancy on eventual development of atopic dermatitis (AD). The purpose of this study was to determine whether or not a relationship exists between the use of skin care products in early infancy and the subsequent development of AD. We studied a group of 54 Kenyan children with AD and 63 age and sex matched controls. Emollients had been used to lubricate the skin during early infancy in a similar proportion of children in both groups (odds ratio = 0.33; 95% CI = 0.14, 0.80). Similarly, no association was found between the use of toilet soaps or laundry detergents in early infancy and development of AD. These findings suggest that baby soaps and vaseline petroleum jelly can safely be used in the skin care of AD susceptible individuals.

Epidemiology of rheumatic heart disease among primary school children in western Kenya.

A community survey was conducted to determine the prevalence of rheumatic heart disease in Kenyan children in all primary schools in 2 sublocations in Western Kenya. In total, 3631 children (97% school attendance) aged from 5 to 15 years were examined by one experienced physician and 2 cardiologists between September and December 1985. Six children were found to have evidence of rheumatic heart disease, giving a prevalence rate of 1.7/1000. As all cases occurred in the age group between 10 and 15 years, the rate was calculated for this group as 2.4/1000. None of these patients had previously been diagnosed as having rheumatic fever. There were 3 males and 3 females. Four patients had mitral regurgitation, one had aortic regurgitation and one had mitral stenosis. Three had electrocardiographic evidence of left atrial abnormality and one showed findings of left ventricular hypertrophy but two patients had normal tracings. Half were symptomatic with dyspnoea on exertion and two gave a history of fleeting polyarthritis. The socio-economic status (peasant), family size (mean = 6 siblings) and the number of children sleeping per room were the same in both the cases with rheumatic heart disease and their controls. The health workers achieved low scores (mean 26%) with regard to the clinical diagnosis, treatment and prevention of rheumatic fever at the level of primary health care. Rheumatic heart disease, nonetheless, was relatively insignificant in the overall picture of health care of school children in Western Kenya.

Comparison of two dosage schedules of sodium stibogluconate in the treatment of visceral leishmaniasis in Kenya.

The efficacy and safety of a single daily dose of sodium stibogluconate, 20 mg/kg body weight, given by deep intramuscular injection was compared with the conventional dose of 10 mg Sb/kg body weight in a randomised trial in Kenyan children and adults with visceral leishmaniasis. Splenic aspiration proved a safe and simple method for assessing parasitological response to treatment. In children the higher dose was associated with a faster clinical and parasitological response, and 100% were cured within 4 weeks, compared with 60% receiving the lower dosage. This difference is statistically significant by life-table analysis (x2 = 4.41, p less than 0.05). The superiority of the higher dose was not, however, seen in adults. In both children and adults the higher dose given daily for 2--4 weeks and in one patient for up to 7 weeks was found to be safe and well tolerated. It is likely, but not proven, that the use of sodium stibogluconate in a dose of 20 mg/kg bw daily for 4 weeks will reduce the relapse-rate in Kenyan children with visceral leishmaniasis.