Human immunodeficiency virus status disclosure and education for children and adolescents in Papua New Guinea.

AIM: How to provide human immunodeficiency virus (HIV) disclosure and awareness for children and young people has not been studied in Papua New Guinea or Pacific Island countries. We aimed to determine the current practices of HIV disclosure and evaluate whether an incremental disclosure education model, as recommended by World Health Organization (WHO), would increase children's knowledge about their condition and improve adherence to antiretroviral therapy (ART). METHODS: We enrolled HIV-infected children on ART whose parents consented, and we identified whether they were aware that they were HIV positive or not. An incremental education model was used to teach the children about their illness and to disclose their HIV status if that was the parents' wishes. Knowledge of HIV and adherence to ART before and following education sessions was assessed. RESULTS: A total of 138 children HIV-positive children were recruited. Only 7% had previously been made aware of their HIV test results; the mean disclosure age was 12.7 years. By 10 years of age, 25 of 34 participants (74%) had not been told they had HIV. The common reasons caregivers gave for not disclosing were that the child was too young and the potential psychosocial impacts on the child and the family. Using an education model of HIV disclosure, children's knowledge of HIV increased significantly, and ART adherence, which was good at 95%, increased to 99% an average of 9 months after education. CONCLUSION: There is a low rate of disclosure for HIV-infected children in Papua New Guinea. This study underlines the importance and value of incorporating age-appropriate HIV education within HIV services.

Evaluation of Xpert MTB/RIF assay in children with presumed pulmonary tuberculosis in Papua New Guinea.

BACKGROUND: The Gene Xpert MTB/ RIF assay (Xpert) is used for rapid, simultaneous detection of Mycobacterium tuberculosis (MTB) and rifampicin resistance. This study examined the accuracy of Xpert in children with suspected pulmonary tuberculosis (PTB). METHODS: Children admitted to Port Moresby General Hospital with suspected PTB were prospectively enrolled between September 2014 and March 2015. They were classified into probable, possible and TB-unlikely groups. Sputum or gastric aspirates were tested by Xpert and smear microscopy; mycobacterial culture was undertaken on a subset. Children were diagnosed with TB on the basis of standard criteria which were used as the primary reference standard. Xpert, smear for acid-fast bacilli (AFB) and the Edwards TB score were compared with the primary reference standard. RESULTS: A total of 93 children ≤14 years with suspected PTB were enrolled; 67 (72%) were classified as probable, 21 (22%) possible and 5 (5.4%) TB-unlikely. Eighty were treated for TB based on the primary reference standard. Xpert was positive in 26/93 (28%) MTB cases overall, including 22/67 (33%) with probable TB and 4/21 (19%) with possible TB. Three (13%) samples identified rifampicin resistance. Xpert confirmed more cases of TB than AFB smear (26 vs 13, p = 0.019). The sensitivity of Xpert, AFB smear and an Edwards TB score of ≥7 was 31% (25/80), 16% (13/80) and 90% (72/80), respectively, and the specificity was 92% (12/13), 100% (13/13) and 31% (4/13), respectively, when compared with the primary reference standard. CONCLUSION: Xpert sensitivity is sub-optimal and cannot be relied upon for diagnosing TB, although a positive result is confirmatory. A detailed history and examination, standardised clinical criteria, radiographs and available tests remain the most appropriate way of diagnosing TB in children in resource-limited countries. Xpert helps confirm PTB better than AFB smear, and identifies rifampicin resistance. Practical guidelines should be used to identify children who will benefit from an Xpert assay.

Epidemiology of bacterial meningitis in children admitted to Gondar University Hospital in the post pneumococcal vaccine era.

INTRODUCTION: Community acquired bacterial meningitis (CABM) is responsible for high mortality and disabling sequelae. Introduction of pneumococcal conjugate vaccine (PCV-10) and haemophilus influenzeatype b (Hib) has changed the epidemiological and clinical features of patients presenting with CABM as it is shown in different literatures over the last decade. The aim of this study was to assess the clinical and epidemiologic features and outcomes of CABM after the introduction of PCV-10 in Gondar University Hospital (GUH). METHODS: This is a retrospective study among children between 2 months and 14 years of age discharged from Gondar University Hospital. All patient records discharged with a diagnosis of meningitis at GUH were reviewed from September 2011 - September 2013. The data was collected using a structured questionnaire from the patient record charts and analysis was done using SPSS-20. RESULTS: 80 cases (1.6%) of CABM out of 4996 admissions were identified. There were 60 (75%) cases of CABM using WHO criteria of cerebrospinal fluid leukocytosis (CSF) > 100cells/mm3, or 10-100cells/mm3 with either hypoglycorrhea or increased protein; and 20 (25%) with culture confirmation. S. Pneumoniae was the most frequent pathogen identified in 14 (70%) children. The most common age group were infants 2-12 month old (n = 32, 40%). Children with adverse outcomes had shown a higher frequency of being older children (p = 0.045), loss of consciousness (p = 0.046), seizure at admission (p < 0.01), and a positive CSF culture (p = 0.03). CONCLUSION: Introduction of PCV-10 has shown a decreased admission rate, mortality, and neurologic sequelae due to CABM.

Holistic care of complicated tuberculosis in healthcare settings with limited resources.

In recent years, most of the focus on improving the quality of paediatric care in low-income countries has been on improving primary care using the Integrated Management of Childhood Illness, and improving triage and emergency treatment in hospitals aimed at reducing deaths in the first 24 hours. There has been little attention paid to improving the quality of care for children with chronic or complex diseases. Children with complicated forms of tuberculosis (TB), including central nervous system and chronic pulmonary TB, provide examples of acute and chronic multisystem paediatric illnesses that commonly present to district-level and second-level referral hospitals in low-income countries. The care of these children requires a holistic clinical and continuous quality improvement approach. This includes timely decisions on the commencement of treatment often when diagnoses are not certain, identification and management of acute respiratory, neurological and nutritional complications, identification and treatment of comorbidities, supportive care, systematic monitoring of treatment and progress, rehabilitation, psychological support, ensuring adherence, and safe transition to community care. New diagnostics and imaging can assist this, but meticulous attention to clinical detail at the bedside and having a clear plan for all aspects of care that is communicated well to staff and families are essential for good outcomes. The care is multidimensional: biomedical, rehabilitative, social and economic, and multidisciplinary: medical, nursing and allied health. In the era of the Sustainable Development Goals, approaches to these dimensions of healthcare are needed within the reach of the poorest people who access district hospitals in low-income countries.

Severe malnutrition in children in Papua New Guinea: effect of a multi-faceted intervention to improve quality of care and nutritional outcomes.

BACKGROUND AND AIMS: Severe malnutrition remains a major problem in Papua New Guinea; it is associated with 11% of paediatric hospital admissions and 33% of all child deaths, with a case fatality rate around 20%. This article aims to evaluate the effectiveness of a multi-faceted intervention for improving care for children with severe malnutrition. METHODS: Severe malnutrition was defined as weight-for-age (WFA) <-3 Z-scores with severe wasting or mid upper arm circumference <115 mm or generalised oedema owing to malnutrition. The intervention included training for health-care workers on WHO guidelines for severe malnutrition, ward-round checklists, posters and support for nurses to provide better patient nutrition. Three point prevalence surveys were conducted; one before the intervention and two afterwards at 3-month intervals. The main outcomes were weight change since admission, energy intake and the proportion of the calculated required energy intake in the previous 24 hours. Each stage of the WHO guidelines for severe malnutrition management was assessed for adherence. RESULTS: There were significant improvements in the WHO steps for the management of severe malnutrition. At pre-intervention baseline, children received a median of 356 ml/day (IQR 178-450): 31% (95% CI 21-48) of their estimated daily energy requirements for weight. In the first follow-up survey, children received a median of 820 (IQR 600-1110) ml/day: 98% (95% CI 67-100) of daily energy requirements; and in the second follow-up survey they received 780 (IQR 480-900) ml/day: 86% (95% CI 46-100%) of daily requirement (P<0.001 both for volume received and percentage of energy requirements). Median weight gain prior to the intervention was 1.55 g/kg/day (IQR -4.3-6.0) which increased to 5.56 g/kg/day (IQR -3.7-12.0) and 10.19 g/kg/day (IQR 0-16.0) in the first and second follow-up surveys, respectively (P=0.013). CONCLUSION: Implementation of a multi-faceted intervention to improve the management of children with severe malnutrition was associated with improved quality of care and improved weight gain.

Correlation of Clinical Outcomes With Multiplex Molecular Testing of Stool From Children Admitted to Hospital With Gastroenteritis in Botswana.

BACKGROUND: Diarrheal disease is a leading cause of death for young children. Most pediatric gastroenteritis is caused by viral pathogens; consequently, current recommendations advocate against routine antibacterial therapy if children present without bloody stools. METHODS: In this prospective cohort study, we enrolled children with severe acute gastroenteritis admitted to hospital in Botswana. Details of presenting history, physical examination, and course in the hospital were recorded. Stool samples were characterized using a 15 pathogen polymerase chain reaction assay. RESULTS: There were 671 participants with a median age of 8.3 months; 77 (11%) had severe acute malnutrition. Only 74 children had bloody stools, of whom 48 (65%) had a detectable bacterial pathogen, compared to 195 of 592 (33%) of those without. There were 26 deaths (3.9%). Covariates associated with death in multivariable logistic regression were the detection of any of Campylobacter/Shigella/enterotoxigenic Escherichia coli (odds ratio [OR] 2.57, 95% confidence interval [CI] 1.07-6.17), severe acute malnutrition (OR 4.34, 95% CI 1.79-10.5), and antibiotic therapy (OR 8.82, 95% CI 2.03-38.2). There was no significant association between bloody stools and death, and the effect of Campylobacter/Shigella/enterotoxigenic E. coli infection on death was not modified by the presence of bloody stools. CONCLUSIONS: Detection of bacterial enteropathogens is associated with increased mortality in children in sub-Saharan Africa. Unfortunately, most children with these infections do not have bloody stools, and bloody dysentery was not found to be associated with worse outcomes. Clinical trials evaluating outcomes associated with more aggressive diagnostic strategies in children presenting with severe acute gastroenteritis in sub-Saharan Africa should be undertaken.

Hospital-based surveillance for rotavirus gastroenteritis using molecular testing and immunoassay during the 2011 season in Botswana.

We describe rotavirus testing and clinical characteristics for children admitted with acute gastroenteritis during Botswana's 2011 rotavirus season. The rotavirus season extended from June to October with rotavirus-specific case fatality being 2.8%. Using molecular testing as reference, the immunochromatographic test had a sensitivity of 76.5% and specificity of 68.0%. Rotavirus vaccine may significantly reduce childhood morbidity and mortality in Botswana.

Lumbar puncture and cerebrospinal fluid analysis.

Examination of the CSF is the gold standard for the diagnosis of meningitis. There are a number of laboratory tests. in addition to CSF cell count, glucose concentration, Gram's stain, and bacterial culture, that are useful in identifying the organism and differentiating between bacterial and viral meningitis. These laboratory tests can be used in combination with the clinical presentation to determine which patient should be treated for bacterial meningitis while awaiting the result of CSF Gram's stain and bacterial culture.

Laparoscopic removal of a symptomatic rudimentary uterine horn in a perimenarchal adolescent.

An adolescent patient with a symptomatic, noncommunicating, rudimentary uterine horn is described. Diagnosis was suggested by ultrasonography and treatment was by laparoscopic resection. A review of other pediatric cases as well as the adult literature gives evidence that laparoscopic resection is worth considering in such cases.

Técnicas para el diagnóstico de laboratorio del tifo y otras rickettsiasis

On the occasion of the first Inter-American Typhus Meeting held in Mexico on October 1945, the Pan American Typhus Commission discussed the methods for the diagnosis of typhus and advised that a preliminary test should be recommended using Castaneda's blue X-19 antigen and after this preliminary test the serum be sent to special laboratories for a differential test by complement fixation, using murine and classic rickettsial suspensions as antigens. Because of the necessity of uniform results, the X-19 antigen has to be prepared and delivered by the Typhus Laboratory of Mexico, until reliable laboratories take over the production. In case that it is produced elsewhere, samples of each lot must be sent to Dr. M. Ruiz Castaneda who shall inform periodically about the conditions of the antigen in order to discontinue its use in case of deterioration

The OX-19 antigen is a suspension containing approximately 100 billion organisms per ml. which are stained in blue to facilitate the observation of positive tests in mixtures of blood and antigen. It is titrated in order to produce a visible agglutination only when the agglutinin content of the blood is above 1:100. Non-significant tests are, therefore, ruled out

The preliminary test is usually negative until the 5th or 6th day of the disease and becomes positive from the 5th to the 7th day on. A positive test after one or more negatives is of ...(AU)

Técnicas para el diagnóstico de laboratorio del tifo y otras rickettsiasis

On the occasion of the first Inter-American Typhus Meeting held in Mexico on October 1945, the Pan American Typhus Commission discussed the methods for the diagnosis of typhus and advised that a preliminary test should be recommended using Castaneda's blue X-19 antigen and after this preliminary test the serum be sent to special laboratories for a differential test by complement fixation, using murine and classic rickettsial suspensions as antigens. Because of the necessity of uniform results, the X-19 antigen has to be prepared and delivered by the Typhus Laboratory of Mexico, until reliable laboratories take over the production. In case that it is produced elsewhere, samples of each lot must be sent to Dr. M. Ruiz Castaneda who shall inform periodically about the conditions of the antigen in order to discontinue its use in case of deterioration

The OX-19 antigen is a suspension containing approximately 100 billion organisms per ml. which are stained in blue to facilitate the observation of positive tests in mixtures of blood and antigen. It is titrated in order to produce a visible agglutination only when the agglutinin content of the blood is above 1:100. Non-significant tests are, therefore, ruled out

The preliminary test is usually negative until the 5th or 6th day of the disease and becomes positive from the 5th to the 7th day on. A positive test after one or more negatives is of ...(AU)

Traducido del inglés de la obra "Diagnostic Procedures & reagents," 2a. ed., pp. 232-246 por la OPS