ORIGINAL

Niger J Paed 2012;39 (2):67- 70

Ntia HN

HIV Infection in hospitalized under-5

children with acute watery diarrhoea in

Calabar, Nigeria

Anah MU

Eyong KI

Ikpeme OE

DOI:http://dx.doi.org/10.4314/njp.v39i2.6

Received: 8th December 2011

Accepted: 31st December 2011

Abstract: Background: The signs

and symptoms of HIV/AIDS in

children are not quite distinct be-

cause of similarities in clinical pres-

entation between HIV infection and

endemic tropical diseases. Diar-

rhoea, one of the cardinal symp-

toms of HIV/AIDS, is a common

childhood disease.

Objective: This study was con-

ducted to find the prevalence of

HIV infection among children ad-

mitted with acute watery diarrhoea

in our diarrhoea treatment and train-

ing unit.

Method: Consecutive children aged

below 5 years admitted into the unit

with diarrhoea were recruited. The

children were examined. The par-

ents were counseled before blood

was taken for HIV screening. In

addition, parents of children who

were sero-positive for HIV were

also screened.

Results: One hundred and fifty- two

who made the inclusion criteria

were studied. Eight (5.3%) were

sero-positive for HIV, five of them

being males. None of these mothers

had antenatal care and they were all

delivered at either home or tradi-

tional attendants' homes. All were

under weight and six of them pre-

sented with severe dehydration.

These factors reached statistical

significant differences between

children who were sero-positive

and those who were not. None of

these eight patients died from acute

watery diarrhoea but two of them

eventually died from complications

of persistent diarrhoea.

Anah MU⁽

Ntia HN,

)

Eyong KI, Ikpeme OE.

Department of Paediatrics,

University of Calabar Teaching

Hospital,

PMB 1278, Calabar, Nigeria.

Email:

unicalucthpaediatrics@yahoo.com

Conclusion: Children with HIV

may present with acute watery diar-

rhoea. Children with diarrhoea that

are underweight with severe dehy-

dration whose sero-status are not

known should be screened for HIV.

Introduction

Diarrhoea Training/Treatment Unit which admits acute

watery diarrhoea cases offers this opportunity.

Diarrhoea is a leading cause of morbidity_,₂and mortality

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among children in developing countries . It is also a

Few studies have examined the issue of co-morbidity of

HIV₅w_,₆_,₉i_,t₁h₀acute watery diarrhea as a clinical manifesta-

This study therefore attempts to find out the

leading cause of morbidity and mortality among HIV

3

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infected children . Diarrhoea incidence, duration and

severity are higher in HIV infected children. For in-

stance acute and persistent diarrhoea are four time₃s more

common in HIV-infected than uninfected children .

tion.

prevalence of HIV among children admitted into the

Diarrhoea Treatment and Training Unit of the University

of Calabar Teaching Hospital, Calabar, Nigeria. This

study will help in identifying children admitted with

acute watery diarrhoea who in addition also have HIV

infection. The children identified could eventually be

enrolled into the treatment programme to expand the

intervention.

Paediatric HIV infection in Nigeria is increasingly be-

coming a problem because a lot of infected children are

not identified early due to similarities in clinical presen-

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tation between HIV infection and endemic diseases .

Furthermore, financial constraints and limited or lack of

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confirmatory testing facilities are also contributory .

Selective screening based on clinical suspicion has been

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advocated for developing countries . It could be espe-

cially useful in the presence of a larger load of patients

with several morbidities that may be HIV-related, in the

face of limited resources for diagnosis and treatment.

Subjects and Methods

This prospective study was conducted in the Diarrhoea

Treatment/Training Unit (DTU) of the University of

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Calabar Teaching Hospital in the Southern tip₁of Nige-

The data were analysed using Microsoft excel. Chi-

square was calculated for contiguous variables and P

was significant at p-value ≤ 0.05.

1

ria. The unit earlier described by Ochigbo et al is a sub

-unit of the Children's Emergency Room of the Hospital

and it admits an average of 30-40 patients per month

with acute watery diarrhoea.

Ethical approval for the study was obtained from the

Ethical Committee of the University of Calabar Teach-

ing Hospital. In addition, a written consent was obtained

from the individual parent/guardian.

Result

A total of 152 patients were recruited out of a total of

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46 patients admitted during the period. There were 88

Consecutive under-5 admissions with acute watery diar-

rhea, clinically defined as passage of three or more wa-

tery stools in a day were recruited. As a departmental

policy, children less than six weeks old, malnourished

children with diarrhoea and those with persistent diar-

rhoea are admitted into other wards of the department

and were thus excluded from this study. Also excluded

in the study were children whose HIV sero-status were

known. All recruited patients' parents/guardians were

given pre- and post-counseling. Parents whose children

were sero-positive for HIV were subsequently screened.

males and 64 females giving a male: female ratio of

1.4:1. Eight were sero-positive for HIV, five of them

being males. This gives a prevalence of 5.3% among

diarrhea admissions. The youngest was three months

while the oldest was 48 months. All the mothers of our

patients were sero-positive for HIV.

The age distribution of infected children is shown in

Table 1.

Table 1: Age distribution of 152 children and frequency

of HIV among the age groups

Age in months

Number Number

sero-positive

Percent

A proforma data was opened for each child and mother

stating the age, sex, frequency and duration of diarrhea,

vomiting, fever and other symptoms. Feeding options

for infants were noted. Each child was fully examined

and degree of dehydration noted. Anthropometry was

done according to standard procedures. Social status was

assessed based on suggested classification by Olusanya

< 6

7 – 12

25

47

38

19

1

3

2

1

0

0.66

1.97

1.32

0.66

0.00

1

2

3

4

3 – 24

5-36

7-48

13

10

1

2

et al .

9-<60

Two screening tests were done using CHEMBIO STAT-

PAK Assay (CHEMBIO diagnostic systems, INC, USA)

and the Determine (Inverness Medical, Japan) to screen

for HIV 1 and 2 antibodies. The test kits were used in

strict compliance with the manufacturer's instructions.

T o t a l

152

8

5.3

Socio -economic states

These tests were done by the investigators (after receiv-

ing training) and there were cross-checked by a scientist

from the President Emergency Plan for Aids Relief

Three children were from the middle class and five

from the lower socio-economic class.

(

1

PEPFAR) Laboratory. In addition, children who were

8 months and below that were sero-positive had blood

All the eight children with HIV were underweight. Cor-

respondingly, 62 (43%) out of the 144 that were sero-

negative were underweight. There was a statistically

significant difference between these two groups, X2 =

4.38, P=0.036.

taken for polymerase chain reaction analysis through the

PEPFAR clinic. Those with confirmed infection status

were recruited into the Paediatric HIV/AIDS treatment

protocol. There was no facility to screen these diarrhea

admissions for rota virus. Stool cultures were done and

urea, electrolyte and creatinine levels were done for se-

verely dehydrated children. Children who had fever

were screened for malaria and septicaemia.

Stool frequency ranged from five to six per day, and two

had dysentery. Three progressed to persistent diarrhea.

Escherichia coli was the commonest organism isolated

in three of the patients while one culture grew Staphylo-

coccus aureus. The rest did not grow any pathogen.

Each child received appropriate treatment for the level

of dehydration ranging from oral rehydration salts to

intravenous fluid therapy. In addition, all received zinc

oxide which is routinely practised in the unit. Each pa-

tient was followed up till discharged or transfered to the

main paediatric ward when complications set in or the

diarrhea became persistent. The study spanned nine

months, from April 1st 2008 to October 30, 2008.

Nutrition History

Only one of the eight sero - positive children was exclu-

sively breast fed, others were mixed-fed from infancy.

Place of Delivery

None of the parents had antenatal care and therefore

none was screened. All of them were delivered at home,

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churches and traditional birth attendant places. Parity

ranged from one to three.

Our prevalence could have been higher if subjects with

severe malnutrition with diarrhoea were screened preva-

lence rates as high as 10₃_,-₇3_,₉0_,₁%₆_,₁₇have been recorded in

and up to 50% in Ken-

Duration of Diarrhoea

several studies in Nigeria

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ya6 , . Most of these studies involved other morbidities

Five of them presented within 48 hours of diarrhoea .

Associated illness

other _,₆_,t₇h_,₁a₆_,n₁₇_,₁₈a_. cute watery diarrhoea as in our

3

study

In a Zambian study that assessed chil-

dren 5 years and below with diarrhoea and HIV only

5% had acute diarrhoea, the remaining being chronic

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9

Three had malaria while two had acute respiratory infec-

tion in addition to acute diarrhea.

diarrhoea . It shows that a lot of children may be missed

if not screened. For instant, in a recent analysis of blood

samples of children in Kogi a prevalence of 10% was

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Past Medical History

recorded, higher above the national average .

Two had been admitted earlier for febrile illness but no

previous history of blood transfusion. None had a

chronic illness.

Our youngest patient was aged three months and at this

age it is difficult to diagnose HIV because the sero-

positive test could have come from maternal antibodies.

Also at this age most are asymptomatic. In this era that

our women preferred unorthodox places for deliveries

selected screening is necessary when these categories of

patients present themselves at health facilities.

Degree of Dehydration

Six (75%) of the eight had severe dehydration while the

remaining two had moderate dehydration. Compara-

tively only 35 of the 144 were severely dehydrated. This

difference between the two groups was statistically sig-

nificant. X2=7.48, P=0.005.

All our patients with HIV belonged to the middle and

lower social classes.

This is not surprising because these social classes do

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2,15

.

Outcome

not often avail themselves with antenatal facilities

None of our parents received antenatal care and so none

of them was screened. Since most of our women are not

screened it should now be the responsibility of practitio-

ners to adopt the provider initiated screening of HIV as

recommended by the World Health Organization in Ni-

geria to pick up those that were not screened during ante

The five who were younger than 18 months had PCR

done and were confirmed positive.

Three of these acute diarrhoea cases were complicated

with persistent diarrhoea and were subsequently trans-

ferred to the main paediatric ward where two later died.

All the other surviving patients were recruited for ARV

treatment.

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natal care .

All infected children were underweight and this was

statistically significant. This cannot be solely attribut-

able to HIV at this age because most of the patients were

of low socio-economic status. In addition, nutrition was

also not optimal as most of them were mixed -fed from

infancy. One of our selection criteria was to exclude

severely malnourished children who are readily screened

for HIV and are not usually admitted in DTU. It would

be expedient from this study to recommend screening of

underweigh₂_-t₄patients with diarrhoea for HIV so as not to

miss them.

Discussion

The prevalence of HIV infection among acute diarrhoea

admissions was 5.3%. This shows that some patients

with acute diarrhoea may also have HIV infection. This

prevalence is similar to the 5% HIV seropr₃evalence in a

1

Lagos hospital among children outpatients .

It is, however, higher than the 4.1% national sentinel

sero prevalence rate but lower than the overall HIV

prevalence of 7.1% reported for Cross River State dur-

Most of the children were severely dehydrated at presen-

tation. This agrees with the fact that diarrhoea inci-

dence, duration and severity are higher in HIV infected

children . That most of them were severely dehydrated

at presentation could have been contributed by the de-

crease immunity accompanying HIV infection.

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3

ing the National sentinel survey for 2010 . This sentinel

survey is derived from antenatal visits which is not rep-

resentative of the population since most mothers do not

book for antenatal care and even those that book deliv-

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ered at home as reported by Etuk and Etuk .

This may predispose to severity of diarrhea and vomit-

ing and therefore the severe dehydration. The presence

of co-morbid conditions in some of these children may

support the assertion that immunity decreases with HIV

infection even before HIV becomes symptomatic. It was

thus not surprising that malaria and acute respiratory

tract infections were common among these patients and

two had previous hospitalization.

The national estimates of person living with HIV/AIDS

in 2010 are 3.1 million with children constituting

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21,580 . This is a sizeable number that will increase

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the abysmally high childhood mortalities in Nigeria. All

our patients had vertical transmission from their moth-

ers. Efforts must be geared towards reduction of HIV/

AIDS in Nigeria.

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Conclusion

All the children were delivered at home or traditional

birth attendants' places. The question that arises is

whether these parents knew their sero-status before such

deliveries took place. This history, however, was not

volunteered by the mothers. If screening is made more

accessible to mothers, the prevention of transmission

from mother- to -child could be enhanced20. Stake hold-

ers need to work out modalities to reach the un-reached.

Children with acute watery diarrhoea may in addition,

also have HIV infection. High index of suspicion is nec-

essary as there were no pathognomonic symptoms and

signs of children with both conditions. We recommend

that children with acute watery diarrhoea that are under-

weight and severely dehydrated should be screened for

HIV.

Conflict of interest: None

Funding: None

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