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School Attendance as a Risk Factor for Incident TB among HIV-infected Children in Western Kenya
P Braitstein1,2,3, C Yiannoutsos1, A Mwangi3,4, R Vreeman1, Kara Wools-Kaloustian*1, J Sidle1,2,3, B Musick1, S Ayaya2,3, J Carter4, and W Nyandiko2,3
1Indiana Univ, Indianapolis, US; 2Moi Univ, Eldoret, Kenya; 3Moi Teaching and Referral Hosp, Eldoret, Kenya; and 4Brown Univ, Providence, RI, US
Background: We describe the incidence of TB among children
enrolled in a large network of HIV clinics in western Kenya and identify its risk factors.
Methods: The Academic Model for the Prevention and
Treatment of HIV/AIDS (AMPATH) is Kenya’s largest HIV/AIDS care system. This
analysis included all HIV-infected children aged 0 to 13 years attending an
AMPATH clinic. The primary outcome was any TB. No standardized case definition
was used, but based on the Keith Jones scoring criteria (cough >2 weeks, household
contact with TB, X-ray findings, malnutrition, failure to thrive), a score
>5 triggered TB treatment initiation. Sociodemographics, abnormally low weight
for height (z score ≤–3 vs >–3), CD4 percetnage at enrolment, and ever
having attended school were examined. Incidence rates (IR) (95% confidence
intervals, CI), descriptive and multivariate statistics were done using standard
methods.
Results: There were 6301 HIV-infected children, aged 0 to 13
years, eligible for analysis: 50.1% were female; 234 (3.6%) had TB at
enrolment and were subsequently excluded. There were 765 events in 4368.0
person-years of follow-up for an incidence rate of 17.5 (16.3 to 18.8)/100
person-years . Those with incident TB were more likely to be orphans (24% vs
10%, p <0.001), to have abnormally low weight for height (28% vs 17%,
p <0.001), to be attending an urban clinic (59% vs 54%, p = 0.007),
to have ever attended school (46% vs 20%, p <0.001), to have a lower
CD4 percentage (median 15, IQR 9 to 23 vs 20, IQR 13 to 28, p <0.001),
and to be older (years) (median 4.5, IQR 2.0 to 7.8 vs 0.82, IQR 0.16 to 3.9; p
<0.001). In multivariate analysis, having ever attended school (Adjusted
Hazard Ratio, AHR 3.09, 95%CI 2.54 to 3.76), being an orphan (AHR 1.44, 95%CI
1.18 to 1.76), being abnormally low weight for height (AHR 1.56, 95%CI 1.41 to 1.73),
and attending an urban clinic (AHR 1.45, 95%CI 1.21 to 1.74) were all
independent risk factors for incident TB among children.
Conclusions: These data suggest a high incidence of TB
among these HIV-infected children, with school attendance, orphan status, low
weight for height, and an urban environment being key risk factors. Schools and
other places of congregation may be important sites of TB acquisition and
should be targeted for TB screening and prevention.
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