Pediatrics

Study achieving optimal neurodevelopmental outcomes in HIV-Infected Infants

HIV infection can result in neurodevelopmental impairment in children. We do not yet understand the extent to which effective antiretroviral therapy (ART) prevents these delays, but Global WACh researcher Dr. Sarah Benki-Nugent’s recent study, conducted in collaboration with researchers at the University of Nairobi, has provided insight to help answer this question. Their study focused on HIV-infected infants in Nairobi Kenya who received ART from the time of infancy and compared their developmental milestone attainment to HIV-unexposed infants.

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Sarah Benki-Nugent, MS, PhD, is the study’s lead investigator and Acting Assistant Professor at University of Washington Department of Global Health

Most HIV-infected infants in their study were extremely ill at the time of HIV diagnosis and many were first identified in the hospital. Unfortunately, late diagnosis continues to be common in Africa and UNAIDS has recently estimated that only about half of HIV-infected children are receiving treatment.

The study found that overall, HIV-infected infants had later age at attainment of milestones compared to unexposed infants. However, infants who had better responses to treatment had better developmental outcomes. Benki-Nugent and Kenyan research collaborator Dalton Wamalwa say, “We still don’t’ know how children will do in the long-term; however, this data suggests that effective response to ART provided some benefit, even in a group of infants who were very sick when first diagnosed.”

The study suggests that early HIV diagnosis and successful treatment are likely key factors in retaining cognitive and motor neurodevelopment in HIV-infected children. It is also likely critical, Dr. Benki-Nugent says, to provide additional strategies, such as parenting support for early childhood development alongside HIV treatment to help children reach their full potential.

Click here to read more about the researcher’s work recently featured in Infectious Disease Advisor.

Gut Health and Child Survival at ASTMH

This week, members of our enteric research team are in Atlanta, Georgia for the 65th annual meeting of the American Society of Tropical Medicine and Hygiene (ASTMH). They join approximately 4,400 other researchers, government and public health officials, practicing physicians, students, and all health care providers working in the fields of tropical medicine, hygiene, and global health.

Our Healthy Growth and Development Core is dedicated to optimizing care in young children at high risk of diarrhea-associated mortality and the ASTMH annual meeting provides our team with a unique opportunity to discuss recent findings, build inspiration for our next big projects, and re-energize our commitment to reducing the worldwide burden of tropical infectious diseases to improve health around the world.

Yesterday ASTMH heard from Rebecca Brander on correlations of drug resistance in Kenyan children with acute bacterial diarrhea. Rebecca is a MPH student at the University of Washington and completed this research in collaboration with Global WACh directors Grace John-Stewart, Patty Pavlinac, and Judd Walson. Patty Pavlinac, our Health Growth and Development director, leads the Global WACh representation at the conference.

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Rebecca’s study “Host and Environmental Correlates of Multi-Drug Resistance in Kenyan Children with Acute Bacterial Diarrhea” is a key area of research for addressing the prevalence in which bacterial diarrhea results in significant morbidity and mortality in children in sub-Saharan Africa. Antibiotic treatment can be a life-saving intervention, but the antibiotic resistance has rapidly emerged in this population of children, and now this intervention’s efficacy is limited. The study’s data pinpoints risk factors for antibiotic resistance in enteric pathogens, in order to inform diarrhea management recommendations and control resistance.

Click to read the entire study

Making strides in HIV testing and counseling

Irene Njuguna and Jill Neary are MPH Candidates in Epidemiology at the UW School of Public Health. With mentorship from Global WACh researcher Jenn Slyker and Kenyatta National Hospital VCT Director Dr. David Bukusi, they developed a new tool to track provider initiated HIV testing and counseling for children admitted to hospitals in Kenya. Read about their work below.  

In line with the World Health Organization recommendations, the Kenya National HIV testing guidelines recommend universal provider initiated HIV testing and counseling (PITC) for all children in sub Saharan Africa who come in contact with health care facilities. However, in many settings universal PITC is not routinely implemented, with ward transfers, weekend admissions, and discharges resulting in some missed testing opportunities. This results in late diagnosis of HIV infected children, who are at high risk of mortality and do not benefit fully from HIV treatment.

This project began with the intent to intervene in this cycle of unmet HIV care needs. The team looked to Kenya’s national referral hospital: Kenyatta National Hospital (KNH). Working with the PITC team at KNH, the team established an important framework for developing easy to use, acceptable tools to track and improve PITC coverage. In partnership with the KNH pediatric ward PITC counselors, a system was developed to track each individual child admitted, confirm testing completion, identify reasons any children missed testing, and flag children requiring testing.

The tool was successfully piloted in the pediatric department, and at the end of the practicum period, the PITC team recommended that the tool also be used in the adult in-patient medical wards.

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Jill Neary (left) and Irene Njuguna (right) with Ruth Andere: the leader of the Pediatric PITC team.

Congratulations Irene, Jill, and the entire KNH team for your accomplishment! We can look forward to hearing about the continued success of PITC at Kenyatta National Hospital.

Success for CATCH at Nairobi Innovation Week

Last week at Nairobi Innovation Week, members of the CATCH study team spent three days showcasing their innovative visions for pediatric HIV care. This was an important opportunity for the team to highlight the successes and findings of CATCH: Counseling and Testing for Children at Home.

The CATCH study accomplishes what’s in its name by “catching” children ages 12 and under who have fallen through the cracks in HIV diagnosis systems. CATCH offers parents infected with HIV the opportunity to have their children tested, both in clinics or in the home. HIV-infected children are then linked to an HIV care clinic of choice, which ensures that children can receive much needed care. CATCH has been working and gathering data since the start of 2014, with funding for seven different sites in Nairobi and one in Western Kenya.

Throughout the three-day event, CATCH presented posters, modeled pediatric test kits, and engaged visitors with their approaches and ideas about HIV testing in children. “There was a great amount of enthusiasm for the translation of research findings into policy, particularly from senior University of Nairobi visitors and local media,” said Anjuli Wagner, a postdoctoral fellow in the Department of Global Health and member of the study team.

Each day, members from the CATCH team, including Anjuli Wagner, Cyrus Mugo, and Verlinda Otieno spoke with over 40 individuals interested in continuing to be part of the discussion about CATCH’s work. The team also visited with nearby stands and discovered valuable new connections with other pediatric health advocates.

CATCH team members tabling at Nairobi Innovation Week

CATCH team members tabling at Nairobi Innovation Week

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We’re sending CATCH our congratulations for their engagement and innovation in Nairobi!

For more information about CATCH, take a look at this animated depiction of the project.

Global WACh Toto Bora Trial aims to reduce childhood mortality

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Toto Bora, an expression meaning “healthy baby” in Kiswahili, enrolled its first pediatric patient today in a research trial aimed at reducing childhood morbidity and mortality in the months after a hospitalization.

In sub-Saharan Africa, childhood mortality remains unacceptability high.  Children who are hospitalized and subsequently discharged are a group of children at particularly high risk, yet few interventions exist for the post-discharge period. A recent trial found that the mass drug administration of azithromycin reduced childhood mortality by half among children in Ethiopia in communities receiving the intervention.  The Toto Bora team, led by Drs. Judd Walson, MD, MPH and Patricia Pavlinac, PhD MS, believes that children being discharged from hospital represent an accessible high-risk population in which targeted use of this broad-spectrum antibiotic may have dramatic impact.

In this double-blind, placebo-controlled trial, children discharged from hospitals in Kisii and Homa Bay counties of Kenya are randomized to a 5-day course of azithromycin or placebo and followed for six months to determine the efficacy of azithromycin in reducing post-discharge morbidity and mortality. Stool, nasopharyngeal swabs, and blood samples are also being collated from children to evaluate the effect of the intervention on enteric and nasopharyngeal infections, malaria, the gut microbiome, and systematic inflammation. The emergence of antibiotic resistance among treated individuals and their primary caregivers will also be assessed and cost-effectiveness analyses performed to inform policy decisions.

The Toto Bora Trial began enrollment on June 28, 2016 and is estimated to be complete data collection in June 2019.   Congratulations to this Global WACh team for launching this important study to generate evidence on effective interventions to reduce childhood mortality in Kenya!

Read more about Toto Bora on the clinicaltrials.gov website: https://clinicaltrials.gov/ct2/show/NCT02414399

The CATCH Study Focuses on the Children Who Miss Diagnosis

Image 3The Kenya Pediatric Studies (KPS) team has been working hard on an important study called CATCH (Counseling and Testing for Children at Home). The CATCH study does just what the name says by “catching” children ages 12 and under who have fallen through the cracks in HIV diagnosis systems.

There are 3.3 million children in the world living with HIV.  Half of HIV-infected children that go untreated will die by the age of two. There are some great programs in place to help prevent mother-to-child transmission (PMTCT) during pregnancy, birth, and breastfeeding; but going through all the steps in these systems can be challenging, and medication is not always successful at preventing infection in babies.

Children born before PMTCT systems were widely available may not have had the chance to be tested. Additionally, if a mother finds out that she has HIV after her child has been born, there may be a missed opportunity to test her child. Many HIV-infected young children with a missed diagnosis are admitted to the hospital when they are already very sick and they don’t respond well to HIV treatment.  The CATCH team aims to find children who may have missed diagnosis in PMTCT and get them the care they need before it’s too late.

CATCH is working to bridge the gap by approaching parents already in treatment and asking if they have any children who have not been tested and would like to have these children tested. CATCH offers testing both in clinics and at the home for those parents who prefer not to bring their children to the clinic. HIV-infected children are then linked to an HIV care clinic of choice, which ensures that children can live happy and healthy lives because of much needed care.

One issue that the CATCH team has run into is the issue of disclosure of HIV status to children. “Telling a child they have HIV is hard because you’re also potentially exposing the parents’ status as well. Kids also have a difficult time processing the news and will sometimes talk with friends, which can lead to possible stigma for the family,” says Anjuli Wagner, a PhD candidate in the Department of Epidemiology and member of the CATCH study team. Still, studies suggest that disclosure does seem to improve outcomes for infected children.

The CATCH study originally intended to focus on all children ages 0-18, but they discovered through discussions with bioethicists and their community advisory board that adolescents have a unique set of needs that are quite different from those of younger children. With adolescents, it’s challenging to decide who can give permission for the HIV test, who should receive the results of the test, and how best to support  a young person who is gaining independence to cope with their diagnosis. To address these challenges inherent in adolescent HIV testing, another study called ‘DASH’ was created. DASH (Developing Adolescent Strategies for HIV testing) is focusing on voluntary counseling and testing for adolescents and is just another way the Kenya Pediatric Studies and Global WACh teams are making sure all the bases are covered for appropriate testing and treatment for children and adolescents.

CATCH currently has funding for 7 different sites in Nairobi and one in Western Kenya and we’re looking forward to seeing those results!