Lung diseases cause a large proportion of childhood illnesses and hospital admissions in sub-Saharan Africa. Diagnosis is difficult with limited resources and is often based on pragmatic guidelines. To improve the accuracy of these recommendations, researchers at University College London and Lusaka’s University Teaching Hospital (UTH) used autopsy to discover common causes of lung disease in Zambian children.

They performed autopsy on the chest cavity of 137 boys and 127 girls aged one month to 16 years who died from respiratory diseases at UTH. Of these, 180 had HIV; 84 did not. The study showed that:

• Almost half of HIV-positive children and a third of HIV-negative children had more than one disease.
• Overall, 39 per cent had acute pyogenic pneumonia, 28 per cent had Pneumocystis carinii pneumonia (PCP), 20 per cent cytomegalovirus infection (CMV) and 19 per cent had tuberculosis (TB).
• In children without HIV, the most common findings were acute pyogenic pneumonia (50 per cent), TB (26 per cent) and insterstitial pneumonitis (18 per cent).
• In the HIV-positive group, the most common diagnoses were acute pyogenic pneumonia (41 per cent), PCP (29 per cent) and CMV (22 per cent).

Autopsy is the most accurate way to obtain information about disease rates at death. In this study it showed that most of these children died from preventable or treatable infectious illnesses. Clarity and consensus are needed in guidelines for the management of childhood respiratory diseases in developing countries. The authors recommend that policy-makers addressing this huge problem in sub-Saharan Africa should:

• attempt to bring back routine autopsy within health services for the surveillance of killer diseases
• focus more attention on the neglected issue of TB in children
• develop cheap, rapid, practical, sensitive and specific tests for the causes of diseases such as TB and PCP
• update World Health Organisation (WHO) recommendations to include specific advice on HIV-positive children
• define regional patterns of antibiotic resistance among common bacterial infections to provide more evidence for treatment guidelines
• incorporate these recommendations into the WHO integrated management of childhood infections framework.

The authors also discuss extending the recommended range of co-trimoxazole prophylaxis to older HIV-positive children who are at risk of PCP. This might also protect against other bacterial infections. However, co-trimoxazole resistance may already be widespread in Africa and more data is needed to address this issue.

Source(s):
‘Lung diseases at necropsy in African children dying from respiratory illnesses: a descriptive necropsy study’, The Lancet 360: 985-990, by C. Chintu, et al., 2002 Full document.
'Identification of Pneumocystis carinii DNA in oropharyngeal mouth washes from AIDS children dying of respiratory illnesses', AIDS16 (6):932-934, by K. Lishimpi et al., 2002

Funded by: UK Department for International Development

id21 Research Highlight: 17 March 2003

Further Information:
Alimuddin Zumla
Centre for Infectious Diseases and International Health
University College London
Windeyer Institute of Medical Sciences, Room G41
46 Cleveland Street
London
W1T 4JF
UK

Contact the contributor: a.zumla@ucl.ac.uk

University College London

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