World Health Organization Clinical Case Research Articles

Symptoms and risk factors for long COVID in non-hospitalized adults

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is associated with a range of persistent symptoms impacting everyday functioning, known as post-COVID-19 condition or long COVID. We undertook a retrospective matched cohort study using a UK-based primary care database, Clinical Practice Research Datalink Aurum, to determine symptoms that are associated with confirmed SARS-CoV-2 infection beyond 12 weeks in non-hospitalized adults and the risk factors associated with developing persistent symptoms. We selected 486,149 adults with confirmed SARS-CoV-2 infection and 1,944,580 propensity score-matched adults with no recorded evidence of SARS-CoV-2 infection. Outcomes included 115 individual symptoms, as well as long COVID, defined as a composite outcome of 33 symptoms by the World Health Organization clinical case definition. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) for the outcomes. A total of 62 symptoms were significantly associated with SARS-CoV-2 infection after 12 weeks. The largest aHRs were for anosmia (aHR 6.49, 95% CI 5.02–8.39), hair loss (3.99, 3.63–4.39), sneezing (2.77, 1.40–5.50), ejaculation difficulty (2.63, 1.61–4.28) and reduced libido (2.36, 1.61–3.47). Among the cohort of patients infected with SARS-CoV-2, risk factors for long COVID included female sex, belonging to an ethnic minority, socioeconomic deprivation, smoking, obesity and a wide range of comorbidities. The risk of developing long COVID was also found to be increased along a gradient of decreasing age. SARS-CoV-2 infection is associated with a plethora of symptoms that are associated with a range of sociodemographic and clinical risk factors.

Long-Term COVID 19 Sequelae in Adolescents: the Overlap with Orthostatic Intolerance and ME/CFS.

Purpose of ReviewTo discuss emerging understandings of adolescent long COVID or post-COVID-19 conditions, including proposed clinical definitions, common symptoms, epidemiology, overlaps with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and orthostatic intolerance, and preliminary guidance on management.Recent FindingsThe recent World Health Organization clinical case definition of post-COVID-19 condition requires a history of probable or confirmed SARS-CoV-2 infection, with symptoms starting within 3 months of the onset of COVID-19. Symptoms must last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms of the post-COVID-19 condition include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction. These symptoms generally have an impact on everyday functioning. The incidence of prolonged symptoms following SARS-CoV-2 infection has proven challenging to define, but it is now clear that those with relatively mild initial infections, without severe initial respiratory disease or end-organ injury, can still develop chronic impairments, with symptoms that overlap with conditions like ME/CFS (profound fatigue, unrefreshing sleep, post-exertional malaise, cognitive dysfunction, and orthostatic intolerance).SummaryWe do not yet have a clear understanding of the mechanisms by which individuals develop post-COVID-19 conditions. There may be several distinct types of long COVID that require different treatments. At this point, there is no single pharmacologic agent to effectively treat all symptoms. Because some presentations of post-COVID-19 conditions mimic disorders such as ME/CFS, treatment guidelines for this and related conditions can be helpful for managing post-COVID-19 symptoms.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40124-022-00261-4.

Diphtheria Antitoxin Administration, Outcomes, and Safety: Response to a Diphtheria Outbreak in Cox's Bazar, Bangladesh.

BackgroundDiphtheria has re-emerged over the past several years. There is a paucity of data on the administration and safety of diphtheria antitoxin (DAT), the standard treatment for diphtheria. The 2017–2018 outbreak among Rohingya refugees in Bangladesh was the largest in decades. We determined the outcomes of DAT-treated patients and describe the occurrence and risk factors associated with adverse reactions to DAT.MethodsWe conducted a retrospective study at the Médecins Sans Frontières Rubber Garden Diphtheria Treatment Center from December 2017–September 2018. Diphtheria was diagnosed based on the World Health Organization clinical case criteria. High-acuity patients were eligible for DAT. Safety precautions were meticulously maintained. We calculated the presence of adverse events by age, duration of illness, and DAT dosage using bivariate comparisons.ResultsWe treated 709 patients with DAT; 98% (n = 696) recovered and were discharged. One-fourth (n = 170) had at least 1 adverse reaction. Common reactions included cough (n = 115, 16%), rash (n = 66, 9%), and itching (n = 37, 5%). Three percent (n = 18) had severe hypersensitivity reactions. Five patients died during their DAT infusion or soon afterwards, but no deaths were attributed to DAT.ConclusionsOutcomes for DAT-treated patients were excellent; mortality was <1%. Adverse reactions occurred in one-quarter of all patients, but most reactions were mild and resolved quickly. DAT can be safely administered in a setting with basic critical care, provided there is continuous patient monitoring during the infusion, staff training on management of adverse effects, and attention to safety precautions.

Diagnostic accuracy of Sultan's scoring criteria in confirmed cases of measles

World Health Organization (WHO) clinical case definition for the diagnosis of measles lacks diagnostic accuracy. We thus propose two separate scoring criteria for the diagnosis of acute and post measles cases. This study was conducted to determine the diagnostic accuracy of scoring criteria in confirmed cases of measles. This cross-sectional validation study was conducted in the Department of Paediatrics Unit-I, King Edward Medical University, Lahore, Pakistan, from March-August 2009. Sixty-one cases fulfilling the WHO clinical case definition of measles were included in the study, and divided into Group A (Acute measles) and Group B (Post measles). A separate criterion was used for each. Positive Serology (IgM) was taken as confirmed cases. At scores ≥ 3, ≥ 4 and ≥ 5, the sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated. Appropriate statistical tests were applied. In Group A, out of 36 cases, 28 (78%) had total score ≥ 4, whereas IgM was positive in 24 (67%). The scoring criteria had sensitivity, specificity, PPV and NPV of 100%, 66.7%, 86% and 100% respectively. In Group B, out of 25 cases, 23 (92%) had a total score ≥ 4 whereas IgM was positive in 22 (88%) cases. The scoring criteria had sensitivity, specificity, PPV and NPV of 100%, 66.7%, 96% and 100% respectively. The measure and strength of association were statistically significant for both Groups. At scores ≥ 3 and ≥ 5, sensitivity, specificity and predictive values were not statistically significant in either group. This study has shown that the criteria for the diagnosis of acute and post measles cases at a score ≥ 4 are valid to make a clinical diagnosis.

Cholera Epidemic in Guinea-Bissau (2008): The Importance of “Place”

BackgroundAs resources are limited when responding to cholera outbreaks, knowledge about where to orient interventions is crucial. We describe the cholera epidemic affecting Guinea-Bissau in 2008 focusing on the geographical spread in order to guide prevention and control activities.Methodology/Principal FindingsWe conducted two studies: 1) a descriptive analysis of the cholera epidemic in Guinea-Bissau focusing on its geographical spread (country level and within the capital); and 2) a cross-sectional study to measure the prevalence of houses with at least one cholera case in the most affected neighbourhood of the capital (Bairro Bandim) to detect clustering of households with cases (cluster analysis). All cholera cases attending the cholera treatment centres in Guinea-Bissau who fulfilled a modified World Health Organization clinical case definition during the epidemic were included in the descriptive study. For the cluster analysis, a sample of houses was selected from a satellite photo (Google Earth™); 140 houses (and the four closest houses) were assessed from the 2,202 identified structures. We applied K-functions and Kernel smoothing to detect clustering. We confirmed the clustering using Kulldorff's spatial scan statistic. A total of 14,222 cases and 225 deaths were reported in the country (AR = 0.94%, CFR = 1.64%). The more affected regions were Biombo, Bijagos and Bissau (the capital). Bairro Bandim was the most affected neighborhood of the capital (AR = 4.0). We found at least one case in 22.7% of the houses (95%CI: 19.5–26.2) in this neighborhood. The cluster analysis identified two areas within Bairro Bandim at highest risk: a market and an intersection where runoff accumulates waste (p<0.001).Conclusions/SignificanceOur analysis allowed for the identification of the most affected regions in Guinea-Bissau during the 2008 cholera outbreak, and the most affected areas within the capital. This information was essential for making decisions on where to reinforce treatment and to guide control and prevention activities.

Response to treatment in a prospective cohort of patients with large ulcerated lesions suspected to be Buruli Ulcer (Mycobacterium ulcerans disease).

BackgroundThe World Health Organization (WHO) advises treatment of Mycobacterium ulcerans disease, also called “Buruli ulcer” (BU), with a combination of the antibiotics rifampicin and streptomycin (R+S), whether followed by surgery or not. In endemic areas, a clinical case definition is recommended. We evaluated the effectiveness of this strategy in a series of patients with large ulcers of ≥10 cm in longest diameter in a rural health zone of the Democratic Republic of Congo (DRC).MethodsA cohort of 92 patients with large ulcerated lesions suspected to be BU was enrolled between October 2006 and September 2007 and treated according to WHO recommendations. The following microbiologic data were obtained: Ziehl-Neelsen (ZN) stained smear, culture and PCR. Histopathology was performed on a sub-sample. Directly observed treatment with R+S was administered daily for 12 weeks and surgery was performed after 4 weeks. Patients were followed up for two years after treatment.FindingsOut of 92 treated patients, 61 tested positive for M. ulcerans by PCR. PCR negative patients had better clinical improvement than PCR positive patients after 4 weeks of antibiotics (54.8% versus 14.8%). For PCR positive patients, the outcome after 4 weeks of antibiotic treatment was related to the ZN positivity at the start. Deterioration of the ulcers was observed in 87.8% (36/41) of the ZN positive and in 12.2% (5/41) of the ZN negative patients. Deterioration due to paradoxical reaction seemed unlikely. After surgery and an additional 8 weeks of antibiotics, 98.4% of PCR positive patients and 83.3% of PCR negative patients were considered cured. The overall recurrence rate was very low (1.1%).InterpretationPositive predictive value of the WHO clinical case definition was low. Low relapse rate confirms the efficacy of antibiotics. However, the need for and the best time for surgery for large Buruli ulcers requires clarification. We recommend confirmation by ZN stain at the rural health centers, since surgical intervention without delay may be necessary on the ZN positive cases to avoid progression of the disease. PCR negative patients were most likely not BU cases. Correct diagnosis and specific management of these non-BU ulcers cases are urgently needed.

Epidemiological characteristics of pertussis in Estonia, Lithuania, Romania, the Czech Republic, Poland and Turkey-1945 to 2005.

Pertussis epidemiology was examined in selected Central and Eastern European countries andTurkey (CEEs) from 1945 to 2005. Epidemiology and immunisation coverage data were collected fromNational Health Departments and Epidemiology Institutes. Pertussis diagnosis was made by the World Health Organization (WHO) clinical criteria, laboratory confirmation and/or epidemiological link, except for Romania (WHO clinical case definition used). In the pre-vaccine era, pertussis incidence (except Turkey) exceeded 200/100,000 (range180-651/100,000), with 60-70% of cases occurring in pre-school children. Until 2007, a second-year booster was givenin Estonia, Lithuania and Turkey, and an additional pre-school booster elsewhere. During 1995-2005, immunisation coverage by the age of 2 years exceeded 80% (range 80-98%) and, excluding Estonia, pertussis incidence was <3/100,000. Age-specific incidence rates rose in 5-14 year olds in Poland, Estonia and the Czech Republic. Incidence rates in children <1 year of age remained unchanged. There were two age distribution patterns. In the Czech Republic and Estonia, 16% of cases occurred in pre-school children and 17% and 22% in children >15 years of age, respectively; in Romania, Turkey and Lithuania, 51%, 71% and 73%, respectively, occurred in pre-school children and <7% in children aged >15 years.Pertussis infection persists, despite high immunisation coverage. Compared with the pre-vaccine era, the age distribution changed differentially in CEEs, with an apparent shift towards older children.

The 2001 dengue epidemic in Chennai.

Dengue is emerging as a serious public health problem in Tamil Nadu. The present surveillance system is unlikely to generate proper information on the epidemiology of the disease, which is essential for planning and development of relevant control/preventive measures against dengue. Between November 2001 and January 2002, a descriptive study was undertaken on children with clinical dengue attending Kanchi Kamakoti Child Trust Hospital (KKCTH, a major private referral pediatric hospital in Tamil Nadu, India) to define the magnitude of dengue burden, the natural history of this disease in terms of clinical presentation, and outcome of the infections in hospitalized children (< 15) with clinical dengue. The sera collected from patients analyzed for dengue specific IgM and IgG antibodies by IgM, IgG antibody capture enzyme linked immunosorbent assay (ELISA) using alternatively two commercial kits. World Health Organization clinical case definition was adopted to categorize the dengue confirmed children. Dengue was diagnosed in 74.5% (143) of the 192 hospitalized children with clinical dengue. A considerable proportion (20%) of the total dengue infections were constituted by infants less than 1 yr of age. DF [dengue fever], DHF [dengue hemorrhagic fever] and DSS [dengue shock syndrome] were diagnosed in 65%, 11.2% and 23.8% of 143 dengue confirmed patients respectively. Though severe dengue (DSS + DHF) was present in 35% of the patients, the mortality rate was low during the study period due to timely diagnosis and clinical management of the patients. In developing countries like India, building of laboratory capacity for diagnosis and combat-mode ready preparedness for the management of dengue cases in emergency situation may reduce dengue-related mortality. This can be achieved in a wider scale through an integrated approach through the community, professionals and the public health departments.

Predictors of HIV/AIDS among individuals with tuberculosis: health and policy implications.

The purpose of this report was retrospectively to assess the application of clinical predictors (i.e. signs and symptoms) for the diagnosis of the human immunodeficiency virus (HIV) infections, including the acquired immunodeficiency syndrome (AIDS), among tuberculosis (TB)-positive subjects enrolled within an urban heterosexual sero-discordant couple (one partner HIV-positive and the other HIV-negative) cohort study at an HIV prevention and research centre in Lusaka, Zambia. Available medical, clinical and laboratory records from 1994 to mid-1998 were reviewed, with follow-up visits to the local chest clinics and sputum analyses laboratories instituted as additional quality assurance measures. A nested case-control study was employed. The World Health Organization clinical case definition for HIV/AIDS (WHOCCDA) was observed to be significantly more likely to predict HIV/AIDS among TB-positive HIV-positive subjects than TB-positive HIV-negative subjects. Therefore, this report documents the relative effectiveness of the WHOCCDA in predicting HIV/AIDS cases and discusses the health and policy implications, especially for the developing world which accounts for a significant proportion and impact of HIV/AIDS. Further research studies based on prospective randomized controlled trails or other rigorous evaluation strategies are warranted to substantiate these findings.

HIV disease: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

HIV disease: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Evaluation of the WHO Clinical Case Definition of AIDS in the Indian Context: Suggesting a Prediction Rule

Objective: To test the statistical significance of the existing World Health Organization (WHO) clinical case definition for the diagnosis of acquired immunodeficiency syndrome (AIDS) in areas where diagnostic resources are limited in India, and frame a prediction rule that is sensitive and specific for the clinical diagnosis of AIDS. Methodology and Results: In a case-load study, we evaluated the WHO clinical case definition of AIDS in 162 patients, the training set (58 seropositives) at the All India Institute of Medical Sciences, New Delhi. This definition had a sensitivity of about 29%, specificity of about 29%, positive predictive value of about 19% and negative predictive value of about 42%. We analyzed the clinical data of these 162 patients using stepwise logistic regression analysis. Generalized lymphadenopathy, oropharyngeal candidiasis, presumptive esophageal candidiasis, herpes zoster in the last 5 years and a total lymphocyte count of less than 1,000 × 10⁹/l emerged as important predictors. A prediction rule for the diagnosis of AIDS in the Indian context was then developed empirically using the coefficients of these predictors. We further tested the rule prospectively in 50 patients, the test set (11 seropositives) and found it to have a sensitivity of 81.8%, specificity of 97.4%, positive predictive value of 90%, and a negative predictive value of 95%. Conclusion: The WHO definition was not significant statistically for clinical use in India. The new prediction rule may help in AIDS surveillance in India.

Clinical findings in Bordetella pertussis infections: results of a prospective multicenter surveillance study.

To study the clinical presentation of culture-confirmed pertussis in children and their contacts with cough illnesses in an outpatient setting. In conjunction with a large pertussis vaccine efficacy trial in Germany, a central laboratory to isolate Bordetella species from nasopharyngeal specimens was established in Erlangen in October 1990. Pediatricians in private practices in southern Germany, the Saar region, and Berlin were encouraged to obtain nasopharyngeal specimens and clinical characteristics from patients with cough illnesses >/=7 days' duration. Bordetella species were isolated by use of calcium alginate swabs, Regan-Lowe agar, and modified Stainer-Scholte broth. Clinical characteristics were determined by initial and follow-up questionnaires. From October 1990 to September 1996, 20 972 specimens were submitted, and B pertussis was isolated in 2592 instances (12.4%). Of the culture-proven cases, 50.7% were female, and the age range was 6 days to 41 years, with a mean and median of 4.3 years and 4.1 years, respectively. The following characteristics were noted. Only 4% of the patients had received pertussis vaccine. Of unvaccinated patients, 90.2% had paroxysmal cough, 78.9% demonstrated whooping, and 53.3% presented with posttussive vomiting; 5.7% had fever >/=38 degrees C. The duration of cough was </=4 weeks in 37.9% and </=3 weeks in 17.4%. Leukocytosis and lymphocytosis (values above the age-specific mean) were observed in 71.9% and 75.9% of unvaccinated patients, respectively. The overall complication rate was 5.8%, and pneumonia (29%) was the most frequent complication. In infants <6 months of age, the rate of complications was 23.8%. One death in a 7-month-old infant occurred. Typical symptoms of pertussis were observed in the great majority of patients regardless of age group. However, the duration of cough was surprisingly short in one sixth of the patients. These short illness cases would not be classified as pertussis according to the World Health Organization clinical case definition, which requires >/=21 days of spasmodic cough.

Impact of the 1994 expanded World Health Organization AIDS case definition on AIDS surveillance in university hospitals and tuberculosis centers in Côte d'Ivoire.

To assess the impact of the 1994 expanded World Health Organization (WHO) AIDS case definition on AIDS surveillance in Côte d'Ivoire. Prospective AIDS case surveillance. From March 1994 through December 1996, passive AIDS case surveillance was conducted at the three university hospitals in Abidjan, and active AIDS case surveillance was conducted at the eight tuberculosis (TB) centers in Côte d'Ivoire. Standardized questionnaires were administered and blood samples for HIV serologic testing were collected from the patients evaluated. The numbers of persons who met the modified 1985 WHO clinical AIDS case definition (Bangui definition) and the 1994 expanded WHO AIDS case definition were determined, and the clinical characteristics of these patients were assessed. Of 8648 university hospital patients, 3658 (42.3%) met the clinical and/or the expanded case definition: 744 (20.3%) HIV-seropositive persons met only the expanded definition, 44 (1.2%) HIV-seropositive persons met only the clinical definition, 2334 (63.8%) HIV-seropositive persons met both definitions, and 536 (14.7%) HIV-seronegative persons met only the clinical definition. Of 18,661 TB center patients, 9664 (51.8%) met the clinical and/or the expanded definition: 5685 (58.8%) HIV-seropositive persons met only the expanded definition, none of the HIV-seropositive persons met only the clinical definition (by definition), 2625 (27.2%) HIV-seropositive persons met both definitions, and 1354 (14.0%) HIV-seronegative persons met only the clinical definition. Because of the inclusion of multiple severe HIV-related illnesses into the expanded definition, the number of reportable AIDS cases in HIV-seropositive patients increased 31.3% in the university hospitals, and 217% in the TB centers. The inclusion of HIV seropositivity as a criterion for the expanded definition also enhanced the specificity of AIDS case reporting, eliminating 536 cases in the university hospitals and 1354 cases in the TB centers in HIV-seronegative patients who had clinical signs of AIDS. The use of the 1994 expanded definition for surveillance purposes should be encouraged in areas of the developing world where HIV serologic testing is available.

Tropical Pyomyositis

Tropical pyomyositis (TP), a suppurative disease caused predominantly by Staphylococcus aureus, is responsible for 3% to 4% of surgical admissions in some hospitals in certain tropical countries. This study describes the clinical features of 35 patients with TP (20 males, 15 females; mean +/- SD age 28.3 +/- 14.1 years) admitted to our hospital during a 1-year period and analyzes the causal association between ancylostomiasis, human immunodeficiency virus (HIV) infection, and TP. Concerning the supposed etiologic association between Ancylostoma duodenale infection and TP, among the 35 patients with TP the stool examination of 22 (62.8%) revealed the presence of eggs of A. duodenale. In a control group of 100 asymptomatic subjects the prevalence of ancylostomiasis was 55%. The Odds ration between the two groups is 1.38 (exact 95% confidence limits = 0.59 < OR < 3.34). Furthermore, the pus from all TP abscesses (41 in 35 patients) was carefully collected and examined microscopically, but nematode larvae were not detected in any of the specimens. Hence these results do not support an association between ancylostomiasis and TP. With the aim of correlating TP with HIV infection, I carried out a case-control comparison of HIV seroprevalence among the patients affected by TP and an age- and sex-matched control group of healthy subjects. Eleven patients with TP were HIV antibody-positive (seroprevalence 31.42%), as were two controls (seroprevalence 5.71%). The matched analysis produced a Mantel-Haenszel matched Odds ratio of 5.50 and a maximum likelihood estimate of OR (MLE) of 5.50 (exact 95% confidence limits for MLE: 1.20 < OR < 51.07). Among the 11 patients HIV-seropositive, 9 (81.8%) fulfilled the World Health Organization clinical case definition (CCD) for AIDS, compared with 1 of 24 (4.1%) HIV-negative subjects. The chi-square test for difference in fulfilling the CCD for AIDS between patients with TP seropositive and seronegative result was statistically significant (p < 0.0001). It is concluded that TP is a bacterial infection highly significantly associated with HIV infection and thus must be considered a strong sign of stage III-IV of HIV disease.

Surveillance of Acquired Immunodeficiency Syndrome in Africa

In order to improve public health efforts to combat the HIV pandemic a system for surveillance of HIV and AIDS is needed. Definitions used for case reporting are at the heart of such a system. In many parts of Africa however facilities for diagnosing HIV infection and its subsequent complications are unavailable and the definition developed by the US Centers for Diseases Control and Prevention (CDC) for use in developed countries is often impractical in Africa. The World Health Organization (WHO) in early 1985 therefore proposed using a provisional case definition of AIDS based principally upon clinical criteria. Developing a clinical definition of AIDS in Africa however is also complicated. The nonspecific nature of many of the signs and symptoms of HIV infection as well as the clinical redundancy between HIV and other epidemic health problems make definitive identification of any single disease problematic. Evaluation of the surveillance definition of AIDS in Africa is complicated by the lack of an accepted standard for comparison. Most studies in the field have used HIV serology as the standard while others have employed the CDC definition for AIDS giving the evaluations a certain relativity. This paper reviews available information on the WHO definition and other clinical definitions for AIDS in Africa in order to analyze their various field evaluations and explore the use of such definitions in the African context. Sections discuss surveillance clinical case definitions for African AIDS in adult and pediatric populations clinical case definitions of African AIDS in adult and pediatric populations sensitivity and specificity the WHO clinical case definition for HIV epidemiologic survey clinical definitions for AIDS in clinical practice and working toward the improvement of the clinical definition of AIDS.

General and HIV-1-associated morbidity in a rural Ugandan community.

The AIDS epidemic in sub-Saharan Africa affects whole communities, adding to the already high burden of morbidity. Reports of AIDS cases are usually from hospital attenders, often diagnosed using the World Health Organization (WHO) clinical case definition. Little is known about the extent of HIV-associated morbidity in the general population. The objectives of this study were to describe the prevalence of (1) markers of general morbidity and (2) the criteria of the WHO clinical case definition for AIDS and (3) to determine the association between these markers and HIV-1 serostatus in a rural Ugandan community. A survey was conducted among the adult population (aged > or = 13 years) of 15 neighbouring villages in Masaka District, south-west Uganda. The survey included medical history, physical examination and testing for HIV-1 antibodies. The HIV-1 seroprevalence among 4175 out of 5278 (79%) eligible adults was 8.2%. Current health problems were reported by 57.6% of adults, with increased rates in HIV-1-positive subjects, women and older people. Five of the 10 most common complaints showed significant associations with HIV-1 status, as did reported genital ulcer and vaginal discharge. The crude HIV-1 attributable disease burden in the population was 1.2% for current illness, 4.3% for previous serious illness and 9.9% for illness leading to hospital admission. Overall, 11 (3.3%) of the HIV-1-positive and nine (0.2%) of the HIV-1-negative subjects had AIDS as defined by the clinical case definition. The positive and negative predictive values and specificity were 55.0, 92.0%, and 99.8%, respectively. Against a background of high general morbidity, we observed a relatively small population attribution of HIV-1-associated morbidity. The results indicate that the clinical AIDS case definition may provide a useful tool for population surveys.

High HIV seroprevalence and increased HIV-associated mortality among hospitalized patients with deep bacterial infections in Dar es Salaam, Tanzania

To correlate deep bacterial infections with HIV infection and evaluate the influence of HIV on clinical picture and outcome in patients with meningitis, pneumonia or pyomyositis. Case-control comparison of HIV seroprevalence between patients and an age- and sex-matched control group in a prospective cross-sectional study of hospitalized patients. One hundred and sixty-five patients admitted to hospital with either purulent meningitis, pneumonia or pyomyositis and 165 age- and sex-matched controls from orthopaedic/trauma wards. University Hospital, Dar es Salaam, Tanzania. Differences in HIV seroprevalence and mortality. Of 78 patients with purulent meningitis, 19 (24%) were HIV-seropositive, compared with 13 (17%) in the control group (P = 0.345). Of 36 patients with meningitis seen before a meningococcal epidemic affected Dar es Salaam, there was a statistically significant association with HIV infection (P = 0.013). Ten out of 19 (53%) HIV-seropositives died, compared with nine out of 59 (15%) seronegatives (P = 0.028). Of patients with pneumococcal meningitis, five out of six (83%) seropositives died, compared with two out of 12 (17%) seronegatives (P = 0.013). Fifteen out of 45 (33%) patients with pneumonia were HIV-seropositive, compared with four (9%) in the control group (P = 0.001). There was no difference in mortality between seropositive and seronegative patients with pneumonia. HIV seroprevalence was 62% among 42 patients with pyomyositis and 12% among 42 controls (P less than 0.0001). Eighteen out of 25 (72%) seropositive patients with pyomyositis fulfilled the World Health Organization (WHO) clinical case definition for AIDS. Response to recommended antibiotic treatment was satisfactory among patients with pneumonia and pyomyositis. These results show a strong association between pyomyositis, pneumonia and HIV infection. They also indicate an increased mortality associated with HIV infection in patients with pyogenic meningitis, especially pneumococcal meningitis. Pyomyositis should be considered an indicator of stage III HIV disease in the proposed WHO clinical staging system.

Predictors of Mortality among HIV-infected Women in Kigali, Rwanda

To better characterize the natural history of disease due to human immunodeficiency virus (HIV) infection in African women. Prospective cohort study over a 2-year follow-up period. A total of 460 HIV-seropositive women and a comparison cohort of HIV-seronegative women recruited from prenatal and pediatric clinics in Kigali, Rwanda in 1988. Clinical signs and symptoms of HIV disease, AIDS, and mortality. Follow-up data at 2 years were available for 93% of women who were still alive. At enrollment, many seropositive women reported symptoms listed in the World Health Organization (WHO) clinical case definition of AIDS, but these were nonspecific and often improved over time. The 2-year mortality among HIV-infected women by Kaplan-Meier survival analysis was 7% (95% CI, 5% to 10%) overall, and 21% (CI, 8% to 34%) for the 40 women who fulfilled the WHO case definition of AIDS at entry. In comparison, the 2-year mortality in women not infected with HIV was only 0.3% (CI, 0% to 7%). Independent baseline predictors of mortality in seropositive women by Cox proportional hazards modeling were, in order of descending risk factor prevalence: a body mass index of 21 kg/m2 or less (relative hazard, 2.3; CI, 1.1 to 4.8), low income (relative hazard, 2.3; CI, 1.1 to 4.5), an erythrocyte sedimentation rate exceeding 60 mm/h (relative hazard, 4.9; CI, 2.2 to 10.9), chronic diarrhea (relative hazard, 2.6; CI, 1.1 to 5.7), a history of herpes zoster (relative hazard 5.3; CI, 2.5 to 11.4), and oral candida (relative hazard, 7.3; CI, 1.6 to 33.3). Human immunodeficiency virus disease was the cause of death in 38 of the 39 HIV-positive women who died, but only 25 met the WHO definition of AIDS before death. Human immunodeficiency virus disease now accounts for 90% of all deaths among child-bearing urban Rwandan women. Many symptomatic seropositive patients may show some clinical improvement and should not be denied routine medical care. Easily diagnosed signs and symptoms and inexpensive laboratory tests can be used in Africa to identify those patients with a particularly good or bad prognosis.

Prevalence of HIV-1 Infection and Symptomatology of AIDS in Severely Malnourished Children in Dar Es Salaam, Tanzania

In Dar es Salaam, Tanzania, 200 children with severe malnutrition and controls matched for age, sex, and area of residence were screened for serological evidence of infection with the human immunodeficiency virus type 1 (HIV-1) over 5 months in 1988. The prevalence of HIV-1 antibodies in the malnourished group was 25.5% (51 of 200) compared with 1.5% (three of 200) in the controls. The seroprevalence rate was equally high in malnourished children above the age of 18 months (26 of 102; 25.5%), as in those below this age (25 of 98; 25.5%). The prevalence rate was higher in children with marasmus (38.2%) as compared to children with marasmic-kwashiorkor (12.3%) or kwashiorkor (12.2%). The prevalence of clinical features known to be associated with AIDS was higher in the HIV seropositive malnourished children as compared to the seronegative children. The modified World Health Organization clinical case definition of AIDS in children was also evaluated and found to have a low sensitivity and positive predictive value (62.8 and 57.1%, respectively) but a fairly high specificity (83.9%). It is recommended to routinely rule out HIV infection in malnourished children, especially those with marasmus.

The clinical and parasitological presentation of Plasmodium falciparum malaria in Uganda is unaffected by HIV-1 infection

The relation between Plasmodium falciparum malaria and symptomatic human immunodeficiency virus 1 (HIV-1) infection was investigated in paediatric and adult patients in Kampala, Uganda, from 1987 to 1989. Both infections contributed largely to hospital morbidity. Of 1527 clinically suspicious in-patients, 61% were positive for HIV-1 infection. 52% of patients with positive HIV-1 serology fulfilled the World Health Organization clinical case definition for acquired immune deficiency syndrome (AIDS) in Africa. No association could be found between HIV-1 infection and malaria either in paediatrics or in adults. P. falciparum parasitaemia was present in 18% of all patients and no differences in prevalence of malaria infection or in parasite density could be demonstrated between HIV-1 positive and HIV-1 negative patients. The comparison of clinical symptoms showed typical differences in AIDS-related morbidity but no difference in malaria-specific morbidity. Also, the response to malaria treatment was the same in HIV-1 positive and HIV-1 negative patients. P. falciparum malaria does not appear to act as an opportunistic agent in AIDS patients in Uganda.