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Background Tetanus is a potentially life-threatening neurologic disorder caused by the toxin-producing bacterium Clostridium tetani. Primary prevention is achieved through vaccination, typically administered during infancy, however, breakthrough cases of tetanus in fully immunized individuals, especially in pediatric populations have been noted posing unique challenges for diagnosis and management. Uganda currently does not provide tetanus booster doses beyond infancy. The World Health Organisation (WHO) recommends 3 dose Tetanus Toxoid (TT) booster doses at ages 12–23 months, 4–7 years and 9–15 years whereas the US-Centers for Disease control (CDC) recommends 3 additional doses at 15–18 months, 4–6 months and at 11–12 years. This case report represents an unusual occurrence of tetanus an 11-year-old male who had completed the standard infant vaccines recommended in Uganda but still manifested with symptoms consistent with the disease. Case presentation An 11-year-old male Muganda was referred to Mulago National Referral Hospital's Acute Care Unit from a peripheral health facility with worsening backache, trismus, difficulty swallowing, and heightened sensitivity to touch and noise. On admission, he presented with severe pain, an arched back, and frequent muscle spasms indicative of tetanus, despite receiving the standard recommended infant vaccines in Uganda. The patient received intravenous metronidazole, alternate diazepam, and chlorpromazine, leading to a steady improvement in symptoms after which he was discharged on day 29. Conclusion This case underscores the critical necessity of remaining vigilant for tetanus, even in individuals with a documented history of complete immunization at infancy. Additionally, this scenario highlights the pressing need for reviews of vaccination policies in regions where the recommended booster doses are not currently integrated into routine immunization schedules. Emphasizing adherence to these booster doses is key to enhancing tetanus immunity throughout childhood and adolescence.

High mortality is associated with initiation of antiretroviral therapy for HIV. In this report from sub-Saharan Africa, enhanced prophylaxis with isoniazid, fluconazole, azithromycin, and albendazole was associated with decreased mortality at 24 and 48 weeks.

Despite the great strides that have been made in prevention of mother to child transmission (PMTCT), children continue to acquire HIV. The reduction in transmission is variable, for example in Africa, great gains have been made in Eastern and Southern Africa, but critical gaps remain in West and Central Africa. These gaps are also observed in the treatment of children living with HIV. Although there is increased access to lifesaving antiretroviral therapy (ART), management of pediatric HIV infection continues to be a challenge to clinicians in low-income countries where the disease burden is disproportionately high. On the contrary, recent advances in ART drug types and formulations provide great hope. In this narrative review, we present key updates in HIV care and promising ART research among children and adolescents living with HIV. We particularly highlight the dolutegravir (DTG) research which informed the change of the World Health Organization (WHO) ART guidelines in this age group. Significant gaps remain around management of children presenting with advanced disease to minimize mortality and in the long-term care and treatment of adolescents living with HIV. Research to address these sensitive areas is crucial for the realization of global, regional, and national pediatric HIV targets.

One-third of people with HIV in sub-Saharan Africa start antiretroviral therapy (ART) with advanced disease. We investigated associations between immune biomarkers and mortality in participants with advanced HIV randomised to cotrimoxazole or enhanced antimicrobial prophylaxis in the Reduction of Early Mortality in HIV-Infected Adults and Children Starting Antiretroviral Therapy (REALITY) trial (ISRCTN43622374). Biomarkers were assayed using ELISA and Luminex. Associations between baseline values and all-cause 24-week mortality were analysed using Cox models, and for cause-specific mortality used Fine & Gray models, including prophylaxis randomisation, viral load, CD4, WHO stage, age, BMI, and site as covariates; and weighted according to inverse probability of selection into the substudy. Higher baseline CRP, IFN-γ, IL-6 and IP-10 were associated with higher all-cause mortality; and higher IL-23, IL-2 and RANTES with lower all-cause mortality. Associations varied by cause of death: tuberculosis-associated mortality was most strongly associated with higher CRP and sST2, and cryptococcosis-associated mortality with higher IL-4 and lower IL-8. Changes in I-FABP ( p  = 0.002), faecal alpha-1 antitrypsin ( p  = 0.01) and faecal myeloperoxidase ( p  = 0.005) between baseline and 4 weeks post-ART were greater in those receiving enhanced versus cotrimoxazole prophylaxis. Our findings highlight how the immune milieu shapes outcomes following ART initiation, and how adjunctive antimicrobials can modulate the gut environment in advanced HIV. In this study, by analysing immune biomarkers in a cohort of people with advanced HIV, the authors show that elevated levels of some biomarkers at baseline were associated with either increased (CRP, IFN-ƴ, IL-6 and IP-10) or decreased (IL-23, IL-2 and RANTES) likelihood of all-cause mortality.

Children living with perinatally acquired HIV (CLWH) survive into adulthood on antiretroviral therapy (ART). HIV, ART, and malnutrition can all lead to low bone mineral density (BMD). Few studies have described bone health among CLWH in Sub-Saharan Africa. We determined the prevalence and factors associated with low BMD among CLWH switching to second-line ART in the CHAPAS-4 trial (ISRCTN22964075) in Uganda. BMD was determined using dual-energy X-ray Absorptiometry (DXA). BMD Z-scores were adjusted for age, sex, height and race. Demographic characteristics were summarized using median interquartile range (IQR) for continuous variables and proportions for categorical variables. Logistic regression was used to determine the associations between each variable and low BMD. A total of 159 children were enrolled (50% male) with median age (IQR) 10 (7-12) years, median duration of first -line ART 5.2(3.3-6.8) years; CD4 count 774 (528-1083) cells/mm3, weight-for-age Z-score -1.36 (-2.19, -0.65) and body mass index Z-score (BMIZ) -1.31 (-2.06, -0.6). Low (Z-score≤ -2) total body less head (TBLH) BMD was observed in 28 (18%) children, 21(13%) had low lumbar spine (LS) BMD, and15 (9%) had both. Low TBLH BMD was associated with increasing age (adjusted odds ratio [aOR] 1.37; 95% CI: 1.13-1.65, p = 0.001), female sex (aOR: 3.8; 95% CL: 1.31-10.81, p = 0.014), low BMI (aOR 0.36:95% CI: 0.21-0.61, p<0.001), and first-line zidovudine exposure (aOR: 3.68; 95% CI: 1.25-10.8, p = 0.018). CD4 count, viral load and first- line ART duration were not associated with TBLH BMD. Low LS BMD was associated with increasing age (aOR 1.42; 95% CI: 1.16-1.74, p = 0.001) and female sex: (aOR 3.41; 95% CI: 1.18-9.8, p = 0.023). Nearly 20% CLWH failing first-line ART had low BMD which was associated with female sex, older age, first-line ZDV exposure, and low BMI. Prevention, monitoring, and implications following transition to adult care should be prioritized to identify poor bone health in HIV+adolescents entering adulthood.

Background Severe pneumonia remains the leading cause of morbidity and mortality among children worldwide. Severe pneumonia causes death during hospitalization, and survivors are prone to malnutrition after discharge from the hospital. The World Health Organization and United Nations International Children’s Fund recommend ‘continued’ feeding following a severe pneumonia illness without specific recommendations on nutritional support. This recommendation could influence health workers’ and caregivers’ nutritional practices. This study aimed to explore the perspectives and practices of health workers and caregivers for mitigating malnutrition among children with severe pneumonia. Methods We conducted a cross-sectional qualitative study between June and November 2021 among health workers and caregivers of children hospitalized with severe pneumonia at Mulago National Referral Hospital in Kampala, Uganda. The data were collected via focus group discussions involving 17 caregivers and key informant interviews with 12 health workers and were analyzed via the content-thematic analysis approach. Both manual coding and Atlas Ti software were used to support the analysis. Results Health workers and some caregivers were aware that severe pneumonia predisposes children to malnutrition to various degrees, citing reduced appetite, difficulty breathing, persistent vomiting, and increased metabolic demands as pathways. Caregivers increased breastfeeding and utilized nutrient-rich foods to prevent malnutrition, while health workers applied caregiver education and tailored pneumonia management strategies, including following available guidelines and working with nutritionists. Conclusion Severe pneumonia is recognized among health workers and some caregivers as a risk factor for malnutrition. However, mitigating strategies are not uniformly practiced by caregivers and could be enhanced by effective health education and sensitization. More specific guidelines could further reinforce the beneficial practices of health workers managing children with severe pneumonia who are not severely malnourished, and improve treatment outcomes.

Type 1 Diabetes Mellitus is one of the most common chronic diseases in children, yet data from low-income countries remains scarce. Recent reports suggest a rising global incidence of new-onset T1DM, projected to double by 2045. The COVID-19 pandemic is believed to have further influenced T1DM onset and severity at presentation, with several studies reporting increased incidence and higher rates of diabetic ketoacidosis (DKA). This study aimed to assess the impact of COVID-19 pandemic on paediatric type 1 diabetes mellitus onset. We conducted a retrospective review of medical records for children aged 6 months to 19 years diagnosed with new-onset T1DM between March 2017 and February 2023 at Mulago and Nsambya hospital's paediatric diabetes clinics. Clinical and demographic characteristics were compared between the pre-COVID- 19 (March 2017-February 2020) and COVID-19 (March 2020-February 2023) periods using Chi-square and Fisher's exact tests. Trends in new onset type 1 diabetes were analyzed using interrupted time series with 12 six-month intervals. STATA 17.0 was used for the analysis. A total of 245 children were included. The mean age at diagnosis was 10.9 years (SD ± 4.5), with 56% being female. More cases were diagnosed during the COVID-19 period (60.4%, n = 148) compared to the pre-COVID-19 period (39.6%, n = 97), representing a 52% increase, although it was not statistically significant (p = 0.1997). Overall, 66% (n = 162) presented with DKA at diagnosis, with similar proportions in both periods (pre-COVID: 61%, COVID-19: 69%). There was a rising trend in T1DM among Ugandan children at Mulago and Nsambya pediatric diabetic clinics, from 2.7 new cases/month during pre-COVID to 4.1/month during the pandemic.

Despite global efforts to eliminate mother-to-child-transmission of HIV (MTCT), many children continue to become infected. We determined the prevalence of HIV among children with severe acute malnutrition (SAM) and that of their mothers, at admission to Mwanamugimu Nutrition Unit, Mulago Hospital, Uganda. We also assessed child factors associated with HIV-infection, and explored factors leading to HIV-infection among a subset of the mother-child dyads that tested positive. We conducted a cross-sectional evaluation within the REDMOTHIV (Reduce mortality in HIV) clinical trial that investigated strategies to reduce mortality among HIV-infected and HIV-exposed children admitted with SAM at the Nutrition Unit. From June 2021 to December 2022, we consecutively tested children aged 1 month to 5 years with SAM for HIV, and the mothers who were available, using rapid antibody testing upon admission to the unit. HIV-antibody positive children under 18 months of age had a confirmatory HIV-DNA PCR test done. In-depth interviews (IDIs) were conducted with mothers of HIV positive dyads, to explore the individual, relationship, social and structural factors associated with MTCT, until data saturation. Quantitative data was analyzed using descriptive statistics and logistic regression in STATAv14, while a content thematic approach was used to analyze qualitative data. Of 797 children tested, 463(58.1%) were male and 630(79.1%) were ≤18months of age; 76 (9.5%) tested positive. Of 709 mothers, median (IQR) age 26 (22, 30) years, 188(26.5%) were HIV positive. Sixty six of the 188 mother-infant pairs with HIV exposure tested positive for HIV, an MTCT rate of 35.1% (66/188). Child age >18 months was marginally associated with HIV-infection (crude OR = 1.87,95% CI: 1.11-3.12, p-value = 0.02; adjusted OR = 1.72, 95% CI: 0.96, 3.09, p-value = 0.068). The IDIs from 16 mothers revealed associated factors with HIV transmission at multiple levels. Individual level factors: inadequate information regarding prevention of MTCT(PMTCT), limited perception of HIV risk, and fear of antiretroviral drugs (ARVs). Relationship level factors: lack of family support and unfaithfulness (infidelity) among sexual partners. Health facility level factors: negative attitude of health workers and missed opportunities for HIV testing. Community level factors: poverty and health service disruptions due to the COVID-19 pandemic. In this era of universal antiretroviral therapy for PMTCT, a 10% HIV prevalence among severely malnourished children is substantially high. To eliminate vertical HIV transmission, more efforts are needed to address challenges mothers living with HIV face intrinsically and within their families, communities and at health facilities.

Background Prevention of mother to child transmission (PMTCT) has lowered the incidence of paediatric HIV globally. The risk of mother-to-child transmission of HIV (MTCT) remains high in Africa, where there is a high prevalence of pregnancy and poor health-seeking behaviour among young girls and women. Methods In this cross-sectional, mixed-methods study, we evaluated the utilization of PMTCT services and associated factors among adolescent and young postpartum mothers aged 15 to 24 years at a public urban referral hospital in Uganda. Both HIV-positive and HIV-negative participants were recruited. Utilization of PMTCT services was defined as use of the PMTCT cascade of services including ever testing for HIV, receiving HIV test results; If tested negative, subsequent retesting up to 14 weeks; If tested positive, Antiretroviral drugs (ARVs) for the mother, ARVs and septrin prophylaxis for infant, safe delivery, safer infant feeding, early infant diagnosis within 6 weeks, and linkage to treatment and care. Optimal utilization of PMTCT was defined as being up to date with utilization of PMTCT services for reported HIV status at the time of being interviewed. The overall proportion of participants who optimally utilized PMTCT services was determined using descriptive statistics. Qualitative data was analyzed manually using the content thematic approach. Results Of the 418 participants, 65 (15.5%) were HIV positive. Overall, only 126 of 418 participants (30.1%) had optimally utilized PMTCT services. However, utilization of PMTCT services was better among HIV positive mothers, with 83% (54/65) having utilized the services optimally, compared to only 20% (72/353) of the HIV negative mothers (OR 18.2 (95% CI; 9.0–36.7)). The benefits of knowing ones HIV status, health of the unborn child, and counseling and support from health workers and peers, were the major factors motivating adolescent and young mothers to utilize PMTCT services, while stigma, financial constraints, non-disclosure, and lack of partner and family support were key demotivating factors. Conclusion Utilization of PMTCT services by these adolescent and young mothers was suboptimal. Special consideration should be given to adolescents and young women in the design of elimination of mother to child transmission (EMTCT) programs, to improve the utilization of PMTCT services.

Co-trimoxazole is effective in preventing opportunistic infections in persons with advanced HIV infection. In this trial in southern Africa, prolonged co-trimoxazole therapy (>96 weeks after initiation of ART) was shown to have continued benefit beyond CD4 T-cell recovery. Co-trimoxazole (fixed-dose trimethoprim–sulfamethoxazole) is commonly used in sub-Saharan Africa because of its low cost, wide availability, and broad-spectrum antimicrobial activity. Despite high levels of resistance to co-trimoxazole, prophylaxis with this drug combination before antiretroviral therapy (ART) reduces mortality, morbidity, and rates of hospitalization among human immunodeficiency virus (HIV)–infected adults 1 – 6 and children, 7 , 8 predominantly by reducing rates of pneumonia, diarrhea, and malaria. 1 – 8 The increasing availability of ART in sub-Saharan Africa has considerably reduced morbidity and mortality among HIV-infected children. 9 World Health Organization (WHO) guidelines 10 recommend daily co-trimoxazole prophylaxis for HIV-infected children younger than 2 years of age and for . . .