For debate. AIDS surveillance in Africa: a reappraisal of case definitions.
Authors: K M De Cock, R M Selik, B Soro, H Gayle, R L Colebunders
Journal: BMJ (1991)

Disease surveillancethe ongoing systematic collection, analysis, interpretation, and dissemination of data concerning particular diseases-is essential for setting public health priorities, for providing a rational basis for health policy, and for implementing and evaluating interventions.'In few epidemics has surveil- lance played such an important role as in the AIDS epidemic.Although increasing emphasis is now placed on surveillance for infection with human immunodeficiency virus,23 which can precede AIDS by 10 years or more," the counting of AIDS cases remains important in all national efforts to monitor the epidemic.Surveil- lance for AIDS provides a measure of severe morbidity and mortality caused by HIV which would not be assessed by reporting of HIV infections.Reporting of HIV infections may be influenced by self selection of those tested, whereas reporting of AIDS cases includes Projet RETRO-CI, only people with severe symptomatic illness, who come 01 BP 1712, Abidjan, C6te into contact more uniformly with the health care d'Ivoire system.Estimates of AIDS cases and deaths allow Kevin M De Cock, MD, evaluation of the social, economic, and human costs of director this epidemic in terms understood by the public, the Division of HIV-AIDS, media, and decision makers.National Center for AIDS reporting in the United States is relatively Infectious Diseases, complete, capturing an estimated 70-90% of deaths Centers for Disease related to HIV infection.7In contrast, the World Control, Atlanta, Georgia Health Organisation estimates that not more than 10% 30333, USA of AIDS cases in Africa are reported,8 although this Richard M Selik,MD, region includes some of the most heavily affected medical epidemiologist countries in the world.HeleneGayle,MD, chief, This paper reviews problems of surveillance for AIDS in Africa and suggests modifications to the Institut National de Sante provisional clinical case definition for AIDS in adults Publique, Abidjan, Cote proposed by WHO in 1986.9The proposed case d'Ivoire definition is intended primarily for epidemiological Benoit Soro, MD, medical surveillance and may not be adequate for clinical work.epidemiologist For the care of individual patients a simple staging system of HIV infection and disease'" will be more Royal Institute of Tropical useful than a surveillance case definition.Medicine, Antwerp, Belgium Robert L Colebunders, MD, Limitations of the WHO clinical case definition for senior lecturer AIDS in Africa Correspondence to: The surveillance case definition for AIDS that was Dr De Cock.introduced by the Centers for Disease Control" was generally inapplicable in Africa because of limited Reprint requests to: facilities for diagnosing HIV infection and associated International Activity, indicator diseases.For this reason the WHO intro-Division of HIV/AIDS, duced a clinical case definition for AIDS (box).9Mail-Stop E-50, Center for By combining symptoms and signs common in AIDS Infectious Diseases, Centers t c c for Disease Control, this clinical case definition has been used for AIDS 1600 Clifton Rd NE, surveillance in many countries, without depending on Atlanta, GA 30333, USA.laboratory tests.For diagnosing HIV infection in hospital patients in Kinshasa, Zaire, this definition had BMJ 1991;303:1185-8 a sensitivity of 59%, a specificity of 90%, and positive World Health Organisation clinical case definition of AIDS for use in Africa9 AIDS in an adult is defined by the existence of at least two major signs associated with at least one minor sign in the absence of known causes of immunosuppression such as cancer or severe malnutrition or other recog- nised aetiologies Major signs * Weight loss > 10% body weight * Chronic diarrhoea >1 month * Prolonged fever >1 month constant) (intermittent or Minor signs * Persistent cough >1 month * Generalised pruritic dermatitis * Recurrent herpes zoster * Oropharyngeal candidiasis * Chronic progressive and disseminated herpes simplex infection * Generalised lymphadenopathy