Hepatitis B infection in black children from residential care facilities in KwaZulu-Natal. Implications for adoption and foster care.

OBJECTIVES: A study was undertaken to assess the prevalence of hepatitis B infection in selected residential child care facilities in Natal. DESIGN: All residents at three facilities in the Durban and Pietermaritzburg areas of KwaZulu-Natal were tested for markers of hepatitis B infection as part of a broader health status assessment. RESULTS: One hundred and ninety-five children between the ages of 3 and 194 months (78 +/- 47) were studied. Overall 66.2% of children had evidence of past exposure to hepatitis B virus. Of these 14.9% were positive for hepatitis B surface antigen, 13.3% for hepatitis B e antigen, 47.7% for hepatitis B surface antibody and 59.5% for hepatitis B core antibody. Relative rates of infection increased with age from 18.2%, 20% and 27.8% in the 1st, 2nd and 3rd years of life respectively to 72.2% and 88.2% in the 4th and 5th years of life. Relative rates of infection increased with duration of stay from 40% by the end of the 1st year to 100% by the end of the 5th year. CONCLUSIONS: This study has demonstrated a very high rate of infection with hepatitis B virus and a high prevalence of hepatitis B surface antigenaemia in residential care facilities. It has also shown that the infection is horizontally transmitted within these facilities, that infection increases with duration of stay, that there is a dramatic increase in infection rates after the 3rd year of life, that the highest carrier rates are occurring in children between the ages of 2 and 4 years, and that the vast majority of carriers are highly infectious. These children are not only at risk themselves for the long-term complications of this disease but also constitute an important reservoir of hepatitis B infection within the larger community. There is an urgent need for uniform national guidelines for the screening and management of children in residential care facilities and children being prepared for adoption or foster care. There is also a need for a wider investigation into conditions at residential care facilities previously designated for black children in this country.

Assessment and 2-year follow-up of some factors associated with severity of respiratory infections in early childhood.

OBJECTIVE: To assess the effect of some factors on the severity of acute respiratory infection (ARI) in children. DESIGN: In a case control study, children with pneumonia were matched with controls who had upper respiratory infection. They were compared in respect of nutrition, household crowding and smoke pollution, and the presence of current viral respiratory infection. Both cohorts were followed up for 18-24 months to determine if there was a difference in subsequent respiratory sequelae. SETTING: Primary health care-based cohorts of peri-urban township children. PARTICIPANTS: Forty-eight children < 3 years of age with pneumonia (index cases) were matched by age and presentation time with controls who suffered only from upper respiratory infection. All came from underprivileged communities. Index cases were selected as they presented and the study was conducted between February 1988 and June 1991. MAIN OUTCOME MEASURE: Any difference between index cases and controls in respect of the four factors listed under 'Design'. Follow-up home visits determined whether subsequent sequelae of the two grades of ARI were different. RESULTS: The presence of current viral infection at entry to the study was evident in 21 of those with pneumonia and 12 controls (difference between groups = 19.15%, 95% confidence intervals 0.25 - 38.05, P = 0.052). Overcrowding in the home was comparable. Index homes were occupied by a mean of 3.57 (SD 1.54) children and 5.26 (SD 4.84) adults, control homes by 3.51 (SD 1.80) children and 4.36 (SD 2.02) adults. Occupancy of the room in which the child slept was also not significantly different: index group mean 4.23 (SD 1.55) and controls 4.02 (SD 1.38) (mean difference 0.21, 95% Cl 0.378 - 0.798, P = 0.485). Correlation of bedroom crowding with young age (< 1 year) or weight-for-age centiles was not significant in either cohort (r < 0.3 in all). The prevalence of viral infection was not increased by degree of crowding in either group (P = 0.636). Domestic smoke pollution was similar: cigarette smoking occurred in 75% of index homes and 69% of control homes. Wood or coal fires were used in 19% of index and 14% of control homes. The nutritional status of both groups proved to be similar. Fifteen per cent of index children and 12% of controls had weight-for-age centiles < or = 10th centile (difference = 3.26%, 95% Cl -10.72 - 17.24, P = 0.649). Two-year home follow-up visits were completed in 75% of the index and 69% of the control group. The balance were followed up for 18 months. There was no difference between index and control children in the recurrence of respiratory symptoms (P = 0.664) or need to visit a health facility (P = 0.302). CONCLUSIONS: Factors shown elsewhere to contribute to the acquisition or severity of ARI could not be demonstrated as important in this study. The children with pneumonia and their matched controls with upper respiratory infections came from equally overcrowded and smoke-filled homes, had comparable nutritional status which was not markedly poor, and had an equal incidence of current viral infection. Subsequent ill-health was not found to be greater in the pneumonia group.

Subclinical pertussis in incompletely vaccinated and unvaccinated infants.

Incidental to a phase II study of acellular and whole-cell pertussis vaccines involving 342 infants who were clinically observed from birth until the age of 9 months, subclinical pertussis was retrospectively diagnosed in 10 infants on the basis of serological evidence. IgG and IgA to filamentous haemagglutinin (FHA), pertussis toxin (PT) and agglutinogens 2 and 3 (AGG2, 3) were assayed by enzyme-linked immunosorbent assay (ELISA) in serum obtained at birth and at 2, 4, 6 and 9 months of age. All 10 infants had > or = 4-fold rises in at least two different pertussis IgG antibodies. Nine of the 10 infants had > or = 4-fold increases in all three IgG antibodies measured. One infant had > or = 4-fold increases in IgG-FHA and IgG-AGG2,3 but not IgG-PT. Seven infants had raised IgA antibodies to PT and FHA and 4 infants had raised IgA antibodies to AGG2,3. Subclinical infection provoked differing degrees of antibody production in response to multiple antigens. Subclinical infection was detected in both unvaccinated infants (4) and in infants who had been vaccinated from 2 months of age with either acellular (4) or whole-cell vaccines (2). Subjects were 8 months of age or younger and only 1 had completed primary vaccination. Other infections of infancy were commonly detected; 4 infants had upper respiratory disease about the time of subclinical pertussis. None had a household member with symptomatic pertussis. Likelihood of subclinical infection was related to significantly lower levels of maternally acquired pertussis IgG-AGG2,3 antibodies but not associated with infants' nutritional status.

Does whole-cell pertussis vaccine protect black South African infants? Assessment of post-vaccination events and antibody responses to pertussis toxin, filamentous haemagglutinin and agglutinogens 2 and 3.

The whole-cell pertussis vaccine currently used in South Africa has not been adequately evaluated for post-vaccination events and immunogenicity. A trial of this vaccine combined with diphtheria and tetanus toxoids (DTP) was undertaken in 115 black babies who received primary vaccination at 2, 4 and 6 months of age. Serological IgG responses to the major antigens of Bordetella pertussis, filamentous haemagglutinin (FHA), pertussis toxin (PT) and fimbriae (agglutinogens 2 and 3 (AGG 2 + 3), were evaluated by enzyme-linked immunosorbent assay in sera obtained at birth, and before vaccination at 2, 4 and 6 months and at 9 months. Surprisingly, after 3 doses of DTP, responses to PT and FHA were found merely to restore levels of IgG to PT and FHA to those found in cord blood. In contrast with the positive increases in these antibodies found in other series of whole-cell vaccination, the anti-PT seroconversion rate was only 19% and the anti-FHA rate only 24%. High levels of anti-AGG 2 + 3 were produced with 67.2% seroconversion. The frequency and nature of post-vaccination events were recorded. Incidences of all reactions to the vaccine were low (7.6%). Fever (3.2%) and excessive crying (2.4%) were the most frequently occurring minor events. The rate of neurological post-vaccination events (without sequelae) during the brief follow-up period was 2 hypotonic-hyporesponsive episodes (8.03/1,000 doses) and 1 convulsion (4.02/1,000 doses). Significant pertussis antibody levels were found in maternal and cord sera with levels in the latter frequently being higher.(ABSTRACT TRUNCATED AT 250 WORDS)

Loss of maternal measles antibody in black South African infants in the first year of life--implications for age of vaccination.

In order to investigate the feasibility of measles vaccination before the age of 9 months the duration of passive immunity against measles was estimated by conducting a longitudinal study of measles antibody levels in 20 black neonates delivered at term. Measles serum antibody (IgG) was measured by enzyme-linked immunosorbent assay in the mother at childbirth and on consecutive samples taken from the infants from birth until 9 months of age. Protective measles antibody level was defined as greater than 200 mIU. Unprotective levels were found in 88% (95% confidence interval (CI) 81-99%) of 6-month-old infants, while at 9 months all were susceptible. The mean antibody level was 192 mIU (CI 104-348%) at 4 months; 34 mIU (CI 15-73%) at 6 months and 13 mIU (CI 6-24%) at 9 months of age. Our data support the recent World Health Organisation recommendation to immunise children in developing countries at 6 months with the 'high titre' Edmonston-Zagreb measles vaccine, since most infants in our study had lost passive immunity against measles by this age.

Lack of efficacy of the standard potency Edmonston-Zagreb live, attenuated measles vaccine in African infants.

The efficacy of standard potency Edmonston-Zagreb (E-Z) measles vaccine was tested in a randomized trial of Black infants in a rural area of South Africa where a measles epidemic was occurring. The following immunization schedules were used: 48 infants aged 4-8.5 months who received 3.9 log 50 infectious units of E-Z vaccine (group A); 48 infants aged 4-8.5 months who received 3.28 log 50 infectious units of Schwarz vaccine (group B); and 28 infants aged greater than 9 months who received 3.28 log 50 infectious units of Schwarz vaccine and served as controls (group C). For infants aged less than 23 weeks who were given either the E-Z or Schwarz vaccine, the number of seropositives was low (28%), irrespective of the pre-vaccination level of measles antibody. There was a higher number of seropositives (68%) among those in the age range greater than 23 weeks to less than 36 weeks who received the E-Z vaccine rather than the Schwarz vaccine (36%). When administered to children aged greater than 36 weeks, the Schwarz vaccine produced a satisfactory, though suboptimal response rate (61%). There was no correlation between seropositivity and pre-vaccination measles antibody status. Use of the standard dose of E-Z vaccine may have been one of the factors for this poor response, and this supports the WHO recommendation that titres higher than the standard potency vaccine are needed if 6-month-old infants are to be successfully immunized against measles.

Lack of efficacy of the standard potency Edmonston-Zagreb live, attenuated measles vaccine in African infants

The efficacy of standard potency Edmonston-Zagreb (E-Z) measles vaccine was tested in a randomized trial of Black infants in a rural area of South Africa where a measles epidemic was occurring. The following immunization schedules were used: 48 infants aged 4-8.5 months who received 3.9 log 50 infectious units of E-Z vaccine (group A); 48 infants aged 4-8.5 months who received 3.28 log 50 infectious units of Schwarz vaccine (group B); and 28 infants aged greater than 9 months who received 3.28 log 50 infectious units of Schwarz vaccine and served as controls (group C). For infants aged less than 23 weeks who were given either the E-Z or Schwarz vaccine, the number of seropositives was low (28%), irrespective of the pre-vaccination level of measles antibody. There was a higher number of seropositives (68%) among those in the age range greater than 23 weeks to less than 36 weeks who received the E-Z vaccine rather than the Schwarz vaccine (36%). When administered to children aged greater than 36 weeks, the Schwarz vaccine produced a satisfactory, though suboptimal response rate (61%). There was no correlation between seropositivity and pre-vaccination measles antibody status. Use of the standard dose of E-Z vaccine may have been one of the factors for this poor response, and this supports the WHO recommendation that titres higher than the standard potency vaccine are needed if 6-month-old infants are to be successfully immunized against measles

Child sexual abuse and gonococcal conjunctivitis. A case report.

An unusual presentation of child sexual abuse is reported. A 6-year-old girl developed a unilateral purulent conjunctival discharge. Neisseria gonorrhoeae was isolated from conjunctival and genital swabs. Genital examination and further enquiries by social workers confirmed a diagnosis of sexual abuse.

Patterns of care in an overburdened tertiary hospital outpatients department.

King Edward VIII Hospital, Durban, is the major tertiary medical care centre for blacks in Natal and KwaZulu. Annually, there are approximately 35,000 patients who attend the Paediatric Outpatient Department for the first time. A representative sample of 280 of these records was reviewed to determine the proportion of patients who: (i) had been referred from other levels of the health service; and (ii) could have been treated in a primary care facility. A large proportion (78.5%; 95% confidence interval (CI) 73.6-83.4%) were unreferred. In addition, 42.2% (CI 36.4-48.0%) could have been medically managed in a primary care facility. More unreferred compared with referred patients could have been managed in a primary care facility (48.6% v. 18.6%; P less than 0.001). The findings suggest that an improved primary health care service in Natal and KwaZulu would reduce the number of inappropriate paediatric outpatient visits.

Aetiological factors of infantile diarrhoea: a community-based study.

A community-based study was undertaken to compare the organisms responsible for diarrhoea in children living in formal housing with indoor water supply and sanitation with those from a deprived environment. The role of "home remedies" was also assessed. Among 373 children with diarrhoea, rotavirus was detected in 15% (in 371 symptom-free controls, 9%), and proved to be the single most common causative agent. Bacterial pathogens were found in 20% of patients, with enteropathogenic Escherichia coli (EPEC) being isolated most frequently (9%; controls 3%), followed by Shigella species (4%; controls 1%), Campylobacter jejuni (4%; controls 1%), Salmonella species (2%; controls 1%) and enterotoxigenic E. coli (ETEC) (2%; controls 1%). Giardia lamblia and cryptosporidium were detected in 6% (controls 6%) and 3% (controls 1%) of patients, respectively; 7% (controls 1%) harboured more than one enteropathogen and no pathogens were detected in 58% (controls 78%). The vast majority (greater than 90%) of both patients and controls received some form of "home remedy" which included disinfectants and traditional herbs. The findings of this study therefore confirm the extremely complex nature of diarrhoea in developing communities and indicate that environmental factors are compounded by other issues.

Diarrhoea is a nutritional disease.

More hospitalised patients with diarrhoea than patients without diarrhoea were underweight for age. In a retrospective survey of patients hospitalised more than once with either diarrhoea or bronchopneumonia, the patients with diarrhoea were found to have a greater decrease in weight for age at the time of the second admission than the patients with bronchopneumonia. The malnutrition associated with diarrhoea is due to a number of factors, including decreased intake, extra losses and malabsorption of nutrients. Patients on marginal food intakes may be unable to make up lost ground after diarrhoeal episodes and become malnourished. A brief survey of health professionals' attitudes suggested a tendency to overlook the nutritional component in the management of diarrhoea. Nutritional rehabilitation during and after episodes of diarrhoea ought to receive more emphasis in teaching and practice.

Breast-feeding support.

With the objective of prolonging unsupplemented breast-feeding, three groups of breast-feeding mothers were provided with support by frequent home visits by different types of health workers (including a lay worker). A fourth group received limited support and a fifth group received no support. Significant differences were found between some of the groups, the lay worker having the greatest impact. The results indicate that a home visitation programme could be successful in promoting breast-feeding.

Breast-feeding - evaluation of a health education programme.

A health education programme which had the objective of increasing the practice of breast-feeding is evaluated. Women provided with health education are shown to have greater knowledge of the advantages of breast-feeding but unchanged behaviour as regards breast-feeding practice. A plea is made for a nation-wide effort to promote breast-feeding.

Age-specific occurrence rates of measles in urban, peri-urban, and rural environments: implications for time of vaccination.

Measles vaccination is unsatisfactory in infants less than 8 months old. To find out what proportion of children with measles in the developing world fall within this age range, a survey was conducted in Natal/Kwa Zulu. Data were collected from urban (community-based survey, infectious diseases hospital data, referral centre date), peri-urban (regional hospital and clinics), and rural (3 local hospitals and their peripheral clinics) populations. There was a positive association between population density and the percentage of measles cases aged 8 months or less. 20-45% of measles patients in urban areas, 15% in the peri-urban zone, and 6-12% in rural Kwa Zulu had the disease at or below 8 months of age. The mortality rate for measles in this age group at the referral centre was 26%. There is an urgent need for effective methods of immunizing the very young against measles in high-density regions of developing countries.