[Hospital care for a child living with HIV in Dakar. What is the cost for the family?]. / Hospitalisation d'un enfant vivant avec le VIH à Dakar. Quel coût pour la famille ?

In sub-Saharan Africa, hospitalization is one of the main gateway for testing and care of children living with the HIV. The aim of this study is to estimate the direct costs of the hospitalization of children living with the HIV in Dakar (Senegal). The various expenses were collected daily with the medical file and by interview from the accompanying persons in 30 children. Median age was 9 years (1-17) with a sex ratio of 1.3. Siteen children were orphan and 7 died during the sur- vey. The median duration of the hospitaization was 20 days (3-71). Children older than 5 years had longer hospitalization duration than those under 5 years (p = 0.0001). The average full cost was 175,701 FCFA (268 €), distributed as follow: cost in the hospital 36%, cost of drugs 31%, cost of medical care 20% other non-medical expenses 13%. This survey explores an underdocumented aspect of HIV pediatric care : cost of hospitalization. It also addresses the issue of non-medical expenses resulting from the hospitalization, with regards to the families' income.

[Diagnostic and evolutionary aspects of hemorrhagic syndromes of the newborn in Dakar]. / Aspects diagnostique et évolutif des syndromes hémorragiques du nouveau-né à Dakar.

BACKGROUND: Hemorrhage is a common and serious symptom in the neonatal period. In developing countries, means of exploration are insufficient. Our purpose was to describe the epidemiological, diagnostic, therapeutic, and evolutionary aspects of hemorrhagic syndromes of the newborn in Dakar, Senegal, to identify the risk factors and diseases associated with them in order to propose recommendations for their management. METHODS: We conducted a case-control study of 82 newborns with 41 cases of hemorrhagic syndromes and 41 controls. We first described the epidemiological, diagnostic, therapeutic, and evolutionary parameters of the group that submitted a hemorrhagic syndrome and compared their diagnostic data with those of the control group to highlight the risk factors associated with the occurrence of hemorrhagic syndrome. RESULTS: The prevalence of hemorrhagic syndrome among hospitalized newborns was 9.2%, the sex-ratio (M/F) was 1.9. Preterm infants accounted for 26.8%. We often found early onset of bleeding (46.4% before 72h of life). Visceral bleeding was predominant, especially respiratory (34.1%), digestive (31.7%), and cerebral (17%), followed by cutaneous hemorrhages (26.8%). The risk factors identified were respiratory distress, shock, and a stained amniotic fluid. The concomitant diagnoses were dominated by neonatal infection (58.5%), hemorrhagic disease of the newborn (21.9%), and disseminated intravascular coagulation (19.5%). The mortality rate was high (34.1%), most often associated with disseminated intravascular coagulation. CONCLUSION: This study reveals the high mortality due to hemorrhagic syndromes caused by these three diseases for which prevention must be stressed.

[Moving from prevention to elimination of mother-to-child transmission of HIV before 2015, an unrealistic objective? Social stakes in Senegal]. / Passer de la prévention de la transmission mère-enfant du VIH à son élimination avant 2015 : un objectif irréaliste ? Enjeux sociaux au Sénégal.

In 2010, international agencies began to promote the elimination of mother-to-child HIV transmission (EMTCT) in 2015 by proposing a new preventive strategy based on the extensive use of antiretrovirals. For a country like Senegal where the epidemic is considered to be concentrated, since prevalence is beyond 1%, and where the prevention program was fully applied to only 7 to 15% of children exposed to HIV, the objective is ambitious. The pharmacological efficacy of antiretrovirals will not be sufficient if the experience of actors in the field about the social aspects and the acceptability of the program to women are not considered. The aim of this article is to describe the social issues on the basis of two studies conducted in the region of Dakar (an exploratory study of the effects of the new prevention strategies and a study of the experience of patients receiving antiretroviral treatment for 10 years). The results reveal the main issues: community prevention showed its limits at the stage of access to the program and test, which suggests the importance of strategies to promote awareness and prevention that are focused on women; retention depends highly on the attitudes of health workers and on the role of peer counselors, but the integration of HIV testing and treatment in reproductive health services is not fully established; ambivalent perceptions of antiretrovirals complicate adherence; and finally, the organization of health services hinders a family approach of prevention. These results are innovative, since most publications on this topic concern southern and east Africa.

[Epidemiological and clinical aspects of paediatric HIV infections in Albert-Royer Paediatric Hospital (Dakar, Senegal)]. / Aspects épidémiologiques et cliniques de l'infection à VIH de l'enfant au centre hospitalier national d'enfants Albert-Royer à Dakar.

UNLABELLED: Human Immunodeficiency Virus (HIV) infection prevalence rate is estimated at 1.4% in Senegal, and about 3,000 children could be infected. HIV positive children are followed up since 2000 in Albert Royer Hospital (Dakar, Senegal). OBJECTIVES: To describe clinical and epidemiological aspects of HIV paediatric infection, and to evaluate the implementation of high active antiretroviral therapy in HIV positive children in our country. POPULATION AND METHODS: Over a period of three years, the medical reports of 98 infected patients have been collected, 96% with HIV 1 infection. RESULTS: Most of the patients had a maternally transmitted HIV infection (99%). At their enrollment, the median age was 60 months; malnutrition (79%), persistent lymphadenopathy (65%) and skin lesions (64%) were the common clinical manifestations. Thirty-nine percent of the patients were in class C (CDC) and 81% had CD4 cell count< or =25%. Median viral load were 421,852 copies/ml at presentation. Seven infants had a rapid progressive disease with encephalopathy. Thirty-six patients received high active antiretroviral therapy with high observance and good tolerance. CONCLUSION: This study allowed to define clinical and biological profile of paediatric HIV infection in our country and to update the implementation of high active antiretroviral therapy.

[Management of children with sickle cell disease in Africa: experience in a cohort of children at the Royal Albert Hospital in Dakar]. / Prise en charge de la drépanocytose chez l'enfant en Afrique: expérience de la cohorte de l'Hôpital d'enfants Albert Royer de Dakar.

Management of major sickle hemoglobinopathies in industrialized countries has improved significantly over the last few years thanks to strict application of the preventive and curative measures developed as a result of a better understanding of the underlying pathophysiological mechanisms. However patients in Africa have benefited little from progress in the field due to the lack of human and physical resources in sharp contrast with the high prevalence of the disease. The purpose of this study was to analyze problems involved in management of childhood sickle cell disease in Africa based on our experience in a cohort of 556 cases treated over a period of 12 years. The main problems were the same as those encountered in other black African nations, i.e., delayed diagnosis due to a lack of routine neonatal diagnostic screening, difficulty implementing anti-infectious prophylaxis due not only to the high cost of recommended vaccinations not covered by the Expanded Program on Immunization but also to poor compliance with antiobioprophylaxis, and insufficient transfusion facilities hindering application of long-term transfusion protocols when indicated. In addition the high prevalence of digestive-tract parasitosis and malaria raise the need to combine standard preventive measures with routine parasiticidal treatment and malarial prophylaxis adapted to each geographical area. The high frequency of associated iron deficiency requires systematic laboratory testing to identify and treat resulting manifestations during follow-up. An important prerequisite for widespread implementation of appropriate preventive and curative measures in Africa is recognition of sickle cell disease as a priority in public health care policy.

[Management problems of malignant hemopathies among children in Senegal]. / Problèmes posés par la prise en charge des hémopathies malignes chez l'enfant au Sénégal.

Malignant hemopathies are not considered as public health priority in Senegal because of their infrequency in comparison with infections and malnutrition. However they remain usually lethal instead of a great improvement of their prognosis in suitable therapeutic conditions. The objective of this study was to determine the epidemiologic and evolutionnal profile of these pathologies, and identify practical management problems in a reference public pediatric service in Senegal. We retrospectively analysed hospitals registers and records of all patients followed up in Albert Royer Children Hospital of Dakar from january 1989 to december 1998. During this ten years period 25 cases of malignant hemopathies were diagnosed among 32,789 hospitalised children, representing an hospital prevalence of 0.08 per cent. Mean age at the desease diagnosis was 9.5 years and sex ratio 2.57 (18 boys and 7 girls). The malignant type was acute leukemia (AL) in 11 cases (44%) including 9 cases of of acute lymphoblastic leukemia (ALL) and 2 cases of acute myeloblastic leukemia (AML); chronic myeloid leukemia (CML) in 2 cases (8%), Hodgkin's desease (HD) in 9 cases (36%) and non hodgkinian lymphoma (NHL) in 3 cases. NHLwere Burkitt type in 2casesand lymphoblastic type in 1 case. Their was no maxillary or facial localisation in Burkitt type lymphoma. The mean duration between the first clinical symptomes and the diagnosis of the disease was 4 months and delayed diagnosis was mainly due to delayed transfer from peripheral health services to hospital. Among 19 patients whose records were available, 17 were subjected to chemotherapy. However reference protocols were completely applyed in only 2 cases, one with HD and an other with lymphoblastic lymphoma. Transfusion managementwas not sufficient because of the lack of blood derived products (packed platelets or leucocytes) when needed. Thirteen patients died while followed up and mean survival after first hospitalisation in these cases was 120 days in ALL, 38 days in AML, 2.5 years in HD and 18 months in NHL The other patients were lost of sight and presumed to be dead at home. Eventually, this study showed that, in our hospital, children with malignant hemopathies did not derive benefit of therapeutic progress enregistered long time ago in developed countries, since they remain constantly lethal. The main factors of lethality could be delayed transfer to hospital because of lack of knowledge about these pathologies in the peripheral health services and poor therapeutic conditions in reference hospitals. Creation of specialised clinical haematology department could enable us to improve the prognosis of these affections by an optimal use of available human and material ressources.

[Acute encephalic manifestations in Senegalese children with sickle cell disease]. / Manifestations encéphaliques aiguës chez l'enfant drépanocytaire sénégalais.

The course of sickle cell disease (SCD) may be complicated by neurologic events, mainly bactérial meningitidis and stroke. We retrospectively studied all cases with acute encephalic manifestations (AEM) in a cohort of 461 children and adolescents with SCD followed at Albert Royer Children Hospital of Dakar (Senegal) from january 1991 to december 2000 (ten years). Among them 438 had sickle cell anemia (SCA), 19 SC disease and 4 S-beta thalassemia (3 S-beta+, 1 S-beta0). Seven patients, all with SCA, presented antecedents of AEM revealed by flacid and proportionnal hemiplegia evoking stroke. Prevalence of these AEM was 1.5 per cent among patients with SCD and 1.6 per cent among those with SCA. They were 4 girls and 3 boys (sex ratio = 0.75) aged 4 to 8.5 years when occurred the first accident. We observed no clinical or biological distinctive characteristic of SCA in these patients compared to those without crebrovascular accident. Recurrence was observed once in a boy after a 12 months interval and twice in a girl after 20 and 60 months intervals successively. No transfusionnal program was applied to prevent recurrent stroke because of insufficient conditions for long-term transfusion. Stroke appears to be rare in senegalese children with SCD. However it poses in our context the major problem of applicability of transfusionnal program which constitute the only therapy universally recognised to be effective to prevent recurrence. Nevertheless hydroxyurea could be a satisfactory alternative.

[A home nutritional rehabilitation trial for severly malnourished children]. / Essai de réhabilitation nutritionnelle à domicile d'enfants sévèrement malnutris.

A nutritional rehabilitation trial for severely malnourished children aged 6 to 36 months (weight/height index using Z-score of less than -3 as the reference mean) was conducted in the poor suburban areas of Dakar, Senegal. Its purpose was to determine the effectiveness of a rehabilitation programme delivered in the home as compared to one provided in a nutritional recovery center (CREN). Ninety-seven children benefited from rehabilitation at home and 51 at the CREN. At the end of two months of rehabilitation and after five months of charting their weight, the average weight gain was better in the group followed at home, but it still remained well under the 50 g/day recommended by WHO. Within the two groups, all of the children stayed underweight, with an average weight/height index Z-score of less than -2.5 in the group followed at home, and a Z-score of less than -2.9 in the other group. The dropouts and the death rates in the two groups were comparable. The presence and availability of the mother as well as health education sessions adapted to each specific case through interpersonal communication seem to be the elements favouring the most effective rehabilitation being in the home.

[Sickle cell disease in children in Dakar, Senegal]. / Les syndromes drépanocytaires majeurs en pédiatrie à Dakar (Sénégal).

AIM OF THE STUDY: To determine the socioeconomic, clinical and biological aspects of sickle cell disease (SCD) in Senegalese children and adolescents, we retrospectively analysed all records of follow-up attending patients in the Albert Royer Children Hospital of Dakar (Senegal). RESULTS: Homozygous sickle cell (SS) was the most frequent genotype (307 cases). Sickle cell hemoglobin C (13 cases) and sickle cell beta-thalassemia (three cases) were uncommon. Patients were aged from five months to 22 years (mean age: eight years). Most of them came from poor families. The mean number of children was five in patients' families, with at least two cases of SCD in 60% of them. Immunization against hepatitis B virus (10.2%), Haemophilus influenzae b (8.4%), Salmonella (8.7%) and Streptococcus pneumoniae (21.4%) was insufficiently performed, because of its relatively high cost. Only 30% of the patients had received a blood transfusion. Painful crises occurred less than three times a year in 74% of the cases. Complications such as acute chest syndrome (1%), stroke (1%), cholelithiasis (9%), meningitis (0.4%), septicemia (2%) and osteomyelitis (6%) were rare. Mean steady state hemoglobin (Hb) and hemoglobin F(HbF) levels were 8.27 +/- 1.36 g/dL and 6.8 +/- 5.9% respectively among SS patients. No correlations were found neither between Hb and HbF nor between these parameters and the frequency of complications. Eleven patients (1.1% per year of follow-up) died, and infection was the main cause of death (73%). CONCLUSION: In comparison with published data, SCD seems to have mild severity in Senegalese children and adolescents in spite of poor follow-up conditions. In addition to genetic factors, environmental factors might have an important role in disease tolerance.

[Cholelithiasis and homozygote drepanocytosis in children in Dakar (Senegal)]. / Lithiase biliaire et drépanocytose homozygote en pédiatrie à Dakar (Sénégal).

BACKGROUND: Cholelithiasis is a well recognized complication of sickle-cell anemia (SCA) because of chronic hemolysis. It is usually asymptomatic but may result in acute cholecystitis or cholangitis. The aim of this study was to assess prevalence of cholelithiasis and its associated factors among Senegalese children and adolescents with SCA. PATIENTS AND METHODS: We analyzed the follow-up records and results of systematic clinical, biological and ultrasonographic examinations in 106 patients with SCA aged 11 months to 22 years (median: 10 years, 6 months), followed up in the Albert-Royer Children's Hospital (Dakar). RESULTS: Cholelithiasis was detected in 9.4% of the patients. Gender, ethnic group, geographic origin and socioeconomic conditions did not have any association with cholelithiasis frequency. The youngest patient with cholelithiasis was 7 years old, and prevalence of cholelithiasis increased with age. The mean age at the beginning of SCA follow-up was higher among patients with cholelithiasis. They were more frequently transfused and tended to present more frequent pain crises and other complications of SCA. We found no spontaneous clinical manifestations attributed to cholelithiasis. Nevertheless, provoked right upper quadrant pain was more frequently observed in patients with cholelithiasis. Fetal hemoglobin, steady-state hemoglobin, reticulocytes count, serum bilirubin, alkaline phosphatase and transaminase levels were not significantly different in these patients, compared to the others. However, those with cholelithiasis had significantly higher mean red cell volume. CONCLUSION: Prevalence of cholelithiasis appears relatively low in Senegalese patients with SCA, probably owing to the tolerance of the Senegal haplotype. Advanced age and severe chronic hemolysis are etiologic factors in evidence. We recommend systematic abdominal ultrasound at least once a year for patients older than 5 years, or when right upper quadrant pain is observed. Cholecystectomy should be performed in cases of cholelithiasis in order to prevent complications.

Pleuresies purulentes de l'enfant

122 cas de pleuresies purulentes de l'enfant sont rapportes. L'age moyen est de 3 ans. 33 pour cent des cas sont survenus sur un terrain de malnutrition proteino-calorique. 60 pour cent des enfants avaient un epanchement de grande abondance et 56 pour cent une pneumopathie associee. Le Staphylococcus aureus (51 pour cent) et le Streptococcus pneumoniae (18 pour cent) ont domine la bacteriologie du liquide pleural. Le taux de deces est de 6;5 pour cent. Le drainage pleural est pratique chez 53 pour cent des patients. L'exploration fonctionnelle n'a retrouve que des anomalies mineures. Le traitement de choix des pleuresies purulentes de l'enfant doit comprendre outre le drainage pleural; une association d'antibiotiques comportant un anti-staphylococcique

[Low birth weight: rate and risk factors in the Guédianwaye district (suburb of Dakar, Senegal)]. / Les faibles poids de naissance: fréquence et facteurs de risque dans le district de Guédiawaye (Banlieue de Dakar-Sénégal).

The authors report the results of a six months survey about the low weight of birth (L.W.B.) in the district of Guédiawaye, suburb of Dakar. The purpose is to determine the rate of L.W.B. in two main maternity hospitals of that locality and the associated risk factors. It is a survey with a control group. This survey results in a 10.7% rate, according to the data of another retrospective survey in the same maternity hospitals in 1992 (10.03%). The risk factors are mainly: celibacy, primiparity, an associated pathology with the pregnancy, the physical strain of mothers correlated to the income and to the previous L.W.B.

[Place on information in health services use by mothers in Guediawaye]. / Place de l'information dans l'utilisation des services de santé par les mères à Guédiawaye.

The authors report the results of a survey in a suburban healthcare structure. The purpose was to evaluate the knowledge of mothers about the healthcare delivered through a childhood and maternal healthcare program in Senegal. 244 women were selected at random. The consultant mothers came more for their children than for themselves (79% of consultations were for their children, 49% for themselves). 60% to 80% of women are unaware of basic notions currently teached through the "Information-Education-Communication (I.E.C)" program. All that requires to elaborate with these women healthcare strategies, which are in adequacy with their needs in these peripheral healthcare structures, and which are supported by an adequate and regularly evaluated I.E.C.

[Purulent pleurisy in the child]. / Pleurésies purulentes de l'enfant.

We studied 122 cases of empyema in children. The mean age was 3 years. We found malnutrition in 33% of the patients. 60% of them had large pleural effusion and 56% associated pneumonia. Staphylococcus aureus (51%) and Streptococcus pneumoniae (18%) were the most frequently isolated bacterias in pleural fluid. The mortality rate was 6.5%. 53% of the children had closed chest tube drainage. There were minor abnormalities in pulmonary function tests. The best treatment of empyema in children is closed chest tube drainage and an antimicrobial therapy with antistaphylococcus antibiotic.

[Esophago-tracheal fistulas: report of a case]. / Fistules oesotrachéales: à propos d'une observation.

The authors report the first case in Senegal of an esophagotracheal fistula isolated in a suckling child 1,1/2 months old, and stress: the clinical profile and the rarity of this deformity; the difficulties of providing for such patients in view of the close medico-surgical collaboration required.

[Epidemiological study of diarrhea in children 0-5 yr of age]. / Etude épidémiologique des diarrhées chez les enfants de 0 à 5 ans.

The authors use an investigation carried out at Pikine Social Paediatric Institute on children consulting for diarrhoea to underline the epidemiological factors of this affliction in Dakar suburbs: the average age of the children is 14 months; almost half the children came from families with low or irregular incomes; coprologic examination showed parasitic germs in 26.7% of the cases, rotavirus in 24.4%, and bacteria in 17.6%.