title: High incidence of tuberculosis among HIV-infected infants: evidence from a South African population-based study highlights the need for improved tuberculosis control strategies.
abstract: BACKGROUND
  There are limited population-based estimates of tuberculosis incidence among human immunodeficiency virus (HIV)-infected and HIV-uninfected infants aged < or =12 months. We aimed to estimate the population-based incidence of culture-confirmed tuberculosis among HIV-infected and HIV-uninfected infants in the Western Cape Province, South Africa.
  
  
  METHODS
  The incidences of pulmonary, extrapulmonary, and disseminated tuberculosis were estimated over a 3-year period (2004-2006) with use of prospective representative hospital surveillance data of the annual number of culture-confirmed tuberculosis cases among infants. The total number of HIV-infected and HIV-uninfected infants was calculated using population-based estimates of the total number of live infants and the annual maternal HIV prevalence and vertical HIV transmission rates.
  
  
  RESULTS
  There were 245 infants with culture-confirmed tuberculosis. The overall incidences of tuberculosis were 1596 cases per 100,000 population among HIV-infected infants (95% confidence interval [CI], 1151-2132 cases per 100,000 population) and 65.9 cases per 100,000 population among HIV-uninfected infants (95% CI, 56-75 cases per 100,000 population). The relative risk of culture-confirmed tuberculosis among HIV-infected infants was 24.2 (95% CI, 17-34). The incidences of disseminated tuberculosis were 240.9 cases per 100,000 population (95% CI, 89-433 cases per 100,000 population) among HIV-infected infants and 14.1 cases per 100,000 population (95% CI, 10-18 cases per 100,000 population) among HIV-uninfected infants (relative risk, 17.1; 95% CI, 6-34).
  
  
  CONCLUSIONS
  This study indicates the magnitude of the tuberculosis disease burden among HIV-infected infants and provides population-based comparative incidence rates of tuberculosis among HIV-infected infants. This high risk of tuberculosis among HIV-infected infants is of great concern and may be attributable to an increased risk of tuberculosis exposure, increased immune-mediated tuberculosis susceptibility, and/or possible limited protective effect of bacille Calmette-Guérin vaccination. Improved tuberculosis control strategies, including maternal tuberculosis screening, contact tracing of tuberculosis-exposed infants coupled with preventive chemotherapy, and effective vaccine strategies, are needed for infants in settings where HIV infection and tuberculosis are highly endemic.
authors.affiliation: Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, PO Box 19063, Tygerberg, South Africa. annekeh@sun.ac.za
authors.forename: A C
authors.initials: AC
authors.lastname: Hesseling
authors.forename: M F
authors.initials: MF
authors.lastname: Cotton
authors.forename: T
authors.initials: T
authors.lastname: Jennings
authors.forename: A
authors.initials: A
authors.lastname: Whitelaw
authors.forename: L F
authors.initials: LF
authors.lastname: Johnson
authors.forename: B
authors.initials: B
authors.lastname: Eley
authors.forename: P
authors.initials: P
authors.lastname: Roux
authors.forename: P
authors.initials: P
authors.lastname: Godfrey-Faussett
authors.forename: H S
authors.initials: HS
authors.lastname: Schaaf
mesh_terms: D015658:HIV Infections / Q000150:complications*; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D013019:South Africa / Q000453:epidemiology; D014376:Tuberculosis / Q000453:epidemiology*