Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 106 num. 12 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Strengthening publishing capacity to support academic medicine in South Africa</b>]]> <![CDATA[<b>Reviewers - the backbone of academic publishing</b>]]> <![CDATA[<b>Thank you from HMPG and the Editor</b>]]> <![CDATA[<b>The dual burden of gender-based violence and HIV in adolescent girls and young women in South Africa</b>]]> <![CDATA[<b>Willingness of tobacco smokers to contribute financially towards cessation resources</b>]]> <![CDATA[<b>HMPG in 2016</b>]]> <![CDATA[<b>30 days in medicine</b>]]> <![CDATA[<b> Maurice Aaron Kibel (14 November 1929 - 9 October 2016)</b>]]> <![CDATA[<b>Tackling child abuse and neglect in South Africa</b>]]> <![CDATA[<b>Developing an understanding of fatal child abuse and neglect: Results from the South African child death review pilot study</b>]]> Fatal child abuse is the severest consequence of violence against children. Yet, little is known about this phenomenon, as routine data do not describe it. Child death review (CDR) teams have been established to systematically review deaths from birth to adolescence as a public health response to better identify child abuse deaths, to develop policy and to improve the child protection response. This article describes the incidence of fatal child abuse and injury patterns associated with such deaths. CDR teams reviewed all child fatalities from 1 January to 31 December 2014 at two pilot sites in South Africa (SA). Data were collected on demographics, causes and circumstances of the death, and family social context. We assessed the feasibility of CDR teams in the SA setting to strengthen the identification of child abuse deaths and influence practice. A total of 707 cases were reviewed. Over half (52.4%) of the deaths were due to natural causes. A third were caused by murder, with nearly half (44%) of all murders attributed to fatal child abuse. The burden of fatal child abuse and neglect was found among the <1-year age group. Abandonment at birth was most common, followed by blunt force injuries and strangulation/asphyxiation deaths. CDR teams are effective in better identifying deaths due to child abuse and neglect via a multidisciplinary approach and regular case reviews. <![CDATA[<b>Maternal mental health and the first 1 000 days</b>]]> Even though maternal mental health receives low priority in healthcare, it is a vital component for the developing fetus and the raising of healthy children who are able to contribute meaningfully to society. This article explores risk factors for common mental illnesses and treatment options available in under-resourced settings. <![CDATA[<b>Using a child rights approach to strengthen prevention of violence against children</b>]]> Violence against children is widespread in South Africa. Much of it remains hidden, and social services are thinly stretched. This article therefore focuses on children's rights to protection and considers the implications for healthcare practice. Children's rights can be considered both a 'language of critique' and a 'language of possibility' - encouraging us to evaluate current practice from a child-centred perspective and to re-imagine ways in which we deliver healthcare services. The article outlines the nature, extent and long-term effects of violence against children, introduces a framework for conceptualising violence prevention, and considers ways in which health professionals can better respond to cases of abuse and neglect, and prevent violence against children from taking place. <![CDATA[<b>Addressing legal and policy barriers to male circumcision for adolescent boys in South Africa</b>]]> With millions of adolescents becoming infected with HIV globally, it is essential that barriers to much-needed interventions are reduced for at-risk adolescents. In this article we review the legal and policy framework in South Africa for adolescent access to male circumcision. We are of the view that the framework does confer protection for adolescent boys while enabling access to male circumcision; however, we identify ambiguities and tensions that exist between the Children's Act, regulations and national guidelines. We recommend reform to further enable access by this vulnerable group to this prevention modality. <![CDATA[<b>South African Guidelines Excellence (SAGE): Adopt, adapt, or contextualise?</b>]]> Clinical practice guideline (CPG) activities must be planned carefully for efficient use of available resources and evidence-based implementation. De novo development of CPGs may sometimes 'recreate the wheel' and delay implementation. Three innovative alternatives to de novo CPG development (adopt, contextualise or adapt) are outlined, which have greater potential than de novo development to best use the limited available resources, personnel and time in settings such as South Africa. <![CDATA[<b>The universities of Stellenbosch/Cape Town low-carbohydrate diet review: Mistake or mischief?</b>]]> A 2014 meta-analysis from the universities of Stellenbosch and Cape Town reported that diets with a lower-carbohydrate (CHO) content are no more effective for producing weight loss than are high-CHO diets, so-called isoenergetic 'balanced' diets. We have re-examined the article and found numerous errors, many material in nature. Studies were included that failed the authors' own inclusion criteria; invalid and subjective meta-analysis sub-grouping was used; and data extraction was repeatedly inaccurate. All but one error favoured the balanced diet. The article was widely publicised, highly impactful and inaccurate. This begs the question: mistake or mischief? <![CDATA[<b>Research competency and specialist registration: Quo vadis?</b>]]> The requirement of 'research completion' as necessary for specialist registration with the Health Professions Council of South Africa (HPCSA) has recently been subject to legal action, with a court order potentially shifting requirements beyond those envisaged by the HPCSA. The research requirement is congruent with National Department of Health strategy in this regard, i.e. the strengthening of research as a stated priority. While the expectation of research competency is not in itself contentious, the capacity of institutions and the ability of registrars to facilitate and complete, respectively, have brought the issue into focus. Specifically, the apparent discrepancy between a court order and a regulation needs to be resolved to ensure that specialist registration is not unduly hampered, while ensuring that a potentially important contributor to a national priority is not prejudiced. <![CDATA[<b>Revisiting an old foe: The face of psychosis in neurosyphilis</b>]]> A delusional, agitated middle-aged man presented to hospital with a tenacious psychotic episode. Upon appropriate therapy for neurosyphilis, dramatic resolution of this brief episode ensued, prompting a literature review of psychosis associated with neurosyphilis. <![CDATA[<b>A case of convergence spasms - do not be caught off-guard</b>]]> A hypertensive patient presented with complaints of headache and fluctuating double vision and deterioration in vision from 2010. She displayed symptoms associated with convergence spasms, which could be confused with sixth cranial nerve palsies. A few pointers are given to prevent clinicians from being caught off-guard when encountering this clinical condition. <![CDATA[<b>Diabetic cachectic neuropathy: An uncommon neurological complication of diabetes</b>]]> A 40-year-old female patient with diabetes of 12 years' duration, with poor drug compliance, presented with a 4-month history of rapid progressive weight loss, burning sensations in the feet, abdominal swelling, and constipation with occasional episodes of epigastric pain. On examination, she was chronically ill-looking with a body mass index of 17.1 kg/m², grossly distended abdomen (initially mistaken for gravid abdomen). Blood pressure measurements in the supine and standing positions were 200/130 mmHg and 180/100 mmHg, respectively. Neurological examination revealed stocking-pattern loss of pain, temperature, and light touch modalities. Vibration sensation was impaired up to the malleoli bilaterally, with impairment of joint position sense of both big toes. Random blood sugar level was 16.4 mmol/L; glycosylated haemoglobin was 13.2% with a haematocrit of 33.0%. Renal indices, uric acid, liver function tests and fasting lipid profile were all within normal limits. An abdominal ultrasound scan showed distended bowel loops. The vibration perception threshold average using biothesiometry was 27.3 mV. <![CDATA[<b>Safeguarding maternal and child health in South Africa by starting the Child Support Grant before birth: Design lessons from pregnancy support programmes in 27 countries</b>]]> BACKGROUND. Deprivation during pregnancy and the neonatal period increases maternal morbidity, reduces birth weight and impairs child development, with lifelong consequences. Many poor countries provide grants to mitigate the impact of poverty during pregnancy. South Africa (SA) offers a post-delivery Child Support Grant (CSG), which could encompass support during pregnancy, informed by lessons learnt from similar grants. OBJECTIVES. To review design and operational features of pregnancy support programmes, highlighting features that promote their effectiveness and efficiency, and implications thereof for SA. METHODS. Systematic review of programmes providing cash or other support during pregnancy in low- and middle-income countries. RESULTS. Thirty-two programmes were identified, across 27 countries. Programmes aimed to influence health service utilisation, but also longer-term health and social outcomes. Half included conditionalities around service utilisation. Multifaceted support, such as cash and vouchers, necessitated complex parallel administrative procedures. Five included design features to diminish perverse incentives. These and other complex features were often abandoned over time. Operational barriers and administrative costs were lowest in programmes with simplified procedures and that were integrated within child support. CONCLUSIONS. Pregnancy support in SA would be feasible and effective if integrated within existing social support programmes and operationally simple. This requires uncomplicated enrolment procedures (e.g. an antenatal card), cash-only support, and few or no conditionalities. To overcome political barriers to implementation, the design might initially need to include features that discourage pregnancy incentives. Support could incentivise service utilisation, without difficult-to-measure conditionalities. Beginning the CSG in pregnancy would be operationally simple and could substantially transform maternal and child health. <![CDATA[<b>Psychosocial risk and protective factors associated with perpetration of gender-based violence in a community sample of men in rural KwaZulu-Natal, South Africa</b>]]> BACKGROUND. Rates of gender-based violence (GBV) in South Africa (SA) are among the highest in the world. In societies where social ideals of masculinity encourage male dominance and control over women, gender power imbalances contribute to male perpetration and women's vulnerability. The drivers that cause men to perpetrate GBV and those that lead to HIV overlap and interact in multiple and complex ways. Multiple risk and protective factors for GBV perpetration by males operate interdependently at a number of levels; at the individual level, these include chronic anxiety and depression, which have been shown to lead to risky sexual behaviours. OBJECTIVES. (¿) To examine psychosocial risk factors (symptoms of anxiety and depression) as well as protective factors (social support and self-esteem) as self-reported by a cohort of males in rural KwaZulu-Natal (KZN) Province, SA; and (ii) to determine whether there are differences in anxiety, depression, social support and self-esteem between perpetrators and non-perpetrators. METHODS. A cross-sectional study using quasi-probability cluster sampling of 13 of 28 wards in Harry Gwala District, KZN. Participants were then randomly chosen from each ward proportionate to size. RESULTS. The participants were relatively young (median age 22 years); over half were schoolgoers, and 91.3% had never married. Over 43% of the sample reported clinical levels of anxiety and depressive symptoms on the Brief Symptom Inventory. Rates of GBV perpetration were 60.9%, 23.6% and 10.0% for psychological abuse, non-sexual physical violence and sexual violence, respectively. GBV perpetration was associated with higher depression, higher anxiety, lower self-esteem and lower social support. CONCLUSIONS. Interventions to address GBV need to take modifiable individual-level factors into account. <![CDATA[<b>Prevalence and correlates of violence among South African high school learners in uMgungundlovu District municipality, KwaZulu-Natal, South Africa</b>]]> BACKGROUND. Young people grow up in homes and communities where many are exposed daily to crime and antisocial behaviours. OBJECTIVE. To investigate the prevalence of violence and the demographic factors associated with such violence among South African (SA) high school learners in the uMgungundlovu District, KwaZulu-Natal, SA. METHODS. In a cross-sectional study, we used stratified random sampling to select 16 schools in uMgungundlovu District. All Grade 10 high school learners (N=1 741) completed a self-administered questionnaire (Centers for Disease Control Youth Risk Behavior Survey). Data analysis was carried out using STATA 13 statistical software (Statacorp, USA). RESULTS. Of the participants in this study, 420 (23.9%) had been bullied, 379 (21.7%) had missed school because of feeling unsafe, 468 (15.4%) had been involved in physical fights and 41 (2.4%) had carried weapons to school. There was a significant association between being in a physical fight and missing school (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.9 - 3.3; p<0.001). There were higher odds of male learners carrying weapons than female learners (OR 5.9, 95% CI 2.0 - 15.0). Among learners living in rented rooms, the OR of feeling unsafe was 2.7 (95% CI 0.8 - 3.0), in an informal settlement the OR was 0.8 (95% CI 0.3 - 2.0) and in reconstruction and development programme houses it was 2.7 (95% CI 1.0 - 5.0), compared with learners residing in Zulu homesteads. CONCLUSION. Violence among learners attending high schools in uMgungundlovu District is a major problem and has consequences for both their academic and social lives. Urgent interventions are required to reduce the rates of violence among high school learners. <![CDATA[<b>Iatrogenic medication errors in a paediatric intensive care unit in Durban, South Africa</b>]]> BACKGROUND. Iatrogenic medication errors due to calculation errors are an under-reported concern in children. OBJECTIVE. To determine the incidence and source of iatrogenic medication errors in a paediatric intensive care unit (PICU). METHODS. A prospective study was conducted in the PICU at Inkosi Albert Luthuli Hospital, Durban, South Africa, over a 3-month period in 2014. Medication-related calculation skills of medical practitioners and nurses were assessed through the voluntary anonymous completion of a questionnaire. Medication errors were recorded either spontaneously or by review of all electronic records of admissions. Errors were classified as delays in the decision to prescribe, prescribing mistakes, dispensing errors and administration issues. RESULTS. Of 25 staff members sampled, only 6 (24.0%) were able to complete all medication calculations accurately, while 44.0% (n=11) were unable to answer three or more questions correctly. Errors most frequently encountered included failure to calculate rates of infusion and the conversion of mL to mEq or mL to mg for potassium, phenobarbitone and digoxin. Of the 117 children admitted, 111 (94.9%) were exposed to at least one medication error. Two or more medication errors occurred in 34.1% of cases. Of the errors, 73.8% were detected on chart review and 26.2% by spontaneous reporting. Overall, 89.2% of errors occurred during prescribing, with 10.0% having a ¿10-fold increase or decrease in dosage calculations. Only 2.7% of medication errors were reported as resulting in adverse events. CONCLUSION. Therapeutic skills of healthcare professionals working in the PICU need to be improved to decrease iatrogenic medicationerrors. <![CDATA[<b>Risk factors for unsuccessful lumbar puncture in children</b>]]> BACKGROUND. This descriptive study provides the first information on an association between the use of sedation and a reduction in the prevalence of unsuccessful lumbar puncture (LP) in African children of all races. OBJECTIVE. Our hypothesis was that children who do not receive any procedural sedation are more likely to have unsuccessful LPs. METHODS. A cross-sectional observational study examined LPs performed from February to April 2013, including details of the procedure, sedation or analgesia used, and techniques. The setting was the Medical Emergency Unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, and the participants all children aged 0 - 13 years who had an LP in the unit during the time period. RESULTS. Of 350 children, 62.9% were <12 months of age, the median age being 4.8 months (interquartile range 1.5 - 21.7). The prevalence of unsuccessful (traumatic or dry) LP was 32.3% (113/350). Sedation was used in 107 children (30.6%) and was associated with a reduction in the likelihood of unsuccessful LP (p=0.002; risk ratio (RR) 0.5 (95% confidence interval (CI) 0.34 - 0.78)) except in those <3 months of age, where sedation did not significantly reduce the likelihood (p=0.56; RR 1.20 (95% CI 0.66 - 2.18)). CONCLUSIONS. Unsuccessful LP was common. Sedation was not routinely used, but the results suggest that it may be associated with a reduction in the rate of unsuccessful LP. Unsuccessful LP may lead to diagnostic uncertainty, prolonged hospitalisation and unnecessary antibiotic use. Whether a procedural sedation protocol would reduce the rate of unsuccessful LP requires further study. <![CDATA[<b>Evaluating point-of-care testing for glycosylated haemoglobin in public sector primary care facilities in the Western Cape, South Africa</b>]]> BACKGROUND. Diabetes mellitus contributes significantly to the burden of disease in South Africa (SA). Monitoring of glycaemic control with glycosylated haemoglobin (HbA1c) is recommended, even though current laboratory-based testing does not support immediate clinical decision-making. OBJECTIVES. To evaluate the costs and consequences for quality of care by introducing point-of-care (POC) testing for HbA1c for patients with type 2 diabetes at community health centres in Cape Town, SA. METHODS. A quasi-experimental study was conducted at two control and two intervention sites in the same sub-district. The DCA Vantage Analyzer (Siemens, Germany) for POC testing was introduced at the intervention sites for 12 months. Patients were randomly selected from the diabetes register at the intervention (n=300) and control (n=300) sites, respectively, and data were collected from patient records at baseline and 12 months. Focus group interviews were performed at the intervention sites. Technical quality and cost implications were evaluated. RESULTS. POC testing was feasible, easy to integrate into the organisation of care, resulted in more immediate feedback to patients (p<0.001) and patients appeared more satisfied. POC testing did not improve test coverage, treatment intensification, counselling or glycaemic control. There was an incremental cost of ZAR2 110 per 100 tests. Compliance with quality control was poor, although control tests showed good reliability. CONCLUSION. This study does not support the introduction of POC testing for HbA1c in public sector primary care practice in the current context. POC testing should be evaluated further in combination with interventions to overcome clinical inertia and strengthen primary healthcare. <![CDATA[<b>Socioeconomic and modifiable predictors of blood pressure control for hypertension in primary care attenders in the Western Cape, South Africa</b>]]> BACKGROUND. Low socioeconomic status is associated with the risk of hypertension. There are few reports of the effect of socioeconomic and potentially modifiable factors on the control of hypertension in South Africa (SA). OBJECTIVES. To investigate associations between patients' socioeconomic status and characteristics of primary healthcare facilities, and control and treatment of blood pressure in hypertensive patients. METHODS. We enrolled hypertensive patients attending 38 public sector primary care clinics in the Western Cape, SA, in 2011, and followed them up 14 months later as part of a randomised controlled trial. Blood pressure was measured and prescriptions for antihypertension medications were recorded at baseline and follow-up. Logistic regression models assessed associations between patients' socioeconomic status, characteristics of primary healthcare facilities, and control and treatment of blood pressure. RESULTS. Blood pressure was uncontrolled in 60% (1 917/3 220) of patients at baseline, which was less likely in patients with a higher level of education (p=0.001) and in English compared with Afrikaans respondents (p=0.033). Treatment was intensified in 48% (892/1 872) of patients with uncontrolled blood pressure at baseline, which was more likely in patients with higher blood pressure at baseline (p<0.001), concurrent diabetes (p=0.013), more education (p=0.020), and those who attended clinics offering off-site drug supply (p=0.009), with a doctor every day (p=0.004), or with more nurses (p<0.001). CONCLUSION. Patient and clinic factors influence blood pressure control and treatment in primary care clinics in SA. Potential modifiable factors include ensuring effective communication of health messages, providing convenient access to medications, and addressing staff shortages in primary care clinics. <![CDATA[<b>Awareness, perceived risk and practices related to cervical cancer and Pap smear screening: A cross-sectional study among HIV-positive women attending an urban HIV clinic in Johannesburg, South Africa</b>]]> BACKGROUND. Cervical cancer is a major cause of cancer-related deaths, especially in the context of the HIV epidemic. OBJECTIVE. To examine awareness, perceived risk and practices related to cervical cancer screening among HIV-positive women. METHODS. Interviewer-administered structured questionnaires were administered to HIV-positive women (aged >18 years) enrolled in a cervical cancer screening study at the Themba Lethu Clinic, Johannesburg, South Africa, from November 2009 to December 2011. Modified Poisson regression with robust standard errors was used to identify factors at enrolment associated with awareness, perceived risk and adequate practice related to cervical screening. Adjusted relative risks (aRRs) with 95% confidence intervals (CIs) are presented. RESULTS. Of the 1 202 women enrolled, 71.3% and 18.2% were aware of the Pap smear and HPV, respectively. Of the 1 192 participants with data evaluated, 76.5% were worried and 23.5% were not worried about cervical cancer; 28.6% of the women had adequate screening practice. Older age (40 - 49 years or >50 years v. 18 - 29 years) (aRR 1.63, 95% CI 1.12 - 2.37; aRR 2.22, 95% CI 1.44 - 3.41), higher education (tertiary v. less than grade 10) (aRR 1.39, 95% CI 1.00 - 1.93), initiation on combination antiretroviral therapy (aRR 1.36, 95% CI 1.00 - 1.85) and awareness of Pap smear screening (aRR 16.18, 95% CI 7.69 - 34.01) were associated with adequate screening practice. CONCLUSIONS. High levels of Pap smear awareness and low levels of Pap smear screening uptake were observed. However, Pap smear awareness was associated with adequate screening practice. More research into effective health education programmes to address these gaps is needed. <![CDATA[<b>Mutations of mtDNA polymerase-</b><b>γ</b><b> and hyperlactataemia in the HIV-infected Zulu population of South Africa</b>]]> BACKGROUND. Mitochondrial toxicity, particularly symptomatic hyperlactataemia or lactic acidosis (SHL/LA), has been attributed to the use of nucleoside reverse transcriptase inhibitors (NRTIs), possibly because of their capacity to impede human mitochondrial DNA polymerase-γ (POLG), which is responsible for the replication of mitochondrial DNA. OBJECTIVE. To determine whether known monogenic POLG1 polymorphisms could be linked with the unexpectedly high incidence of SHL/ LA observed in HIV-infected Zulu-speaking patients exposed to the NRTIs stavudine or zidovudine in their antiretroviral therapy. METHODS. One hundred and sixteen patients from Edendale Hospital, Pietermaritzburg, South Africa, participated in the study between March and August 2014. Fifty-nine symptomatic cases were compared with 57 non-symptomatic controls on stavudine for &gt;24 months. Among the symptomatic patients, 13 had SHL with measured lactate between 3.0 and 4.99 mmol/L, and 46 had LA with a lactate level &gt; 5 mmol/L. Genomic DNA from 113 samples was used for subsequent allelic discrimination polymerase chain reaction screening for the R964C and E1143G single-nucleotide polymorphisms of POLG1. Sequencing was performed for 40/113 randomly selected samples for confirmation of the genotyping results. RESULTS. Neither of the two known POLG1 mutations was observed. The cases presented with SHL/LA between 4 and 18 months on stavudine. Females (70.4%) were significantly (p<0.001) more likely to be cases (adjusted odds ratio 24.24, 95% CI 5.14 - 114.25) compared with males. CONCLUSION. This study has shown that our sample of the Zulu-speaking population does not exhibit a genetic predisposition to SHL/LA associated with known monogenic POLG1 mutations, indicating another possible predisposing factor for increased risk of SHL/LA. <![CDATA[<b>Screening for calreticulin mutations in a cohort of patients suspected of having a myeloproliferative neoplasm</b>]]> BACKGROUND. The discovery of calreticulin (CALR) has shown it to be the second most frequent mutation after the Janus Kinase 2 (JAK2) mutation in myeloproliferative neoplasms (MPNs). Its structure indicates various functions, of which two are to ensure calcium homeostasis and proper folding of other target proteins. Over 36 types of CALR mutations have been identified, all causing a recurrent frameshift in the C-terminal domain affecting CALR's localisation and calcium-binding function. OBJECTIVE. To screen a cohort of 89 patients suspected of having an MPN for the CALR mutations. METHODS. Capillary and gel electrophoresis were used in conjunction as confirmatory tests to screen the cohort of patients. RESULTS. Of three samples containing a type 1 CALR mutation, two were heterozygous and one homozygous for a 52-base pair deletion in CALR. CONCLUSIONS. Most studies report CALR mutations to be present only in patients with primary myelofibrosis or essential thrombocythaemia, with mutual exclusivity to JAK2 mutations. The findings of this study indicate that JAK2 and CALR mutations are no longer considered mutually exclusive. Similarly, patients with a polycythaemia vera phenotype could also carry a CALR mutation. <![CDATA[<b>The mass miniature chest radiography programme in Cape Town, South Africa, 1948 - 1994: The impact of active tuberculosis case finding</b>]]> BACKGROUNd. Tuberculosis (TB) control programmes rely mainly on passive detection of symptomatic individuals. The resurgence of TB has rekindled interest in active case finding. Cape Town (South Africa) had a mass miniature radiography (MMR) screening programme from 1948 to 1994. OBJECTIVE. To evaluate screening coverage, yield and secular trends in TB notifications during the MMR programme. METHODS. We performed an ecological analysis of the MMR programme and TB notification data from the City of Cape Town Medical Officer of Health reports for 1948 - 1994. RESULTS. Between 1948 and 1962, MMR screening increased to 12% of the population per annum with yields of 14 cases per 1 000 X-rays performed, accounting for >20% of total annual TB notifications. Concurrent with increasing coverage (1948 - 1965), TB case notification decreased in the most heavily TB-burdened non-European population from 844/100 000 population to 415/100 000. After 1966, coverage declined and TB notifications that initially remained stable (1967 - 1978) subsequently increased to 525/100 000. MMR yields remained low in the European population but declined rapidly in the non-European population after 1966, coincidental with forced removals from District 6. An inverse relationship between screening coverage and TB notification rates was observed in the non-European adult population. Similar secular trends occurred in infants and young children who were not part of the MMR screening programme. CONCLUSION. MMR of a high-burdened population may have significantly contributed to TB control and was temporally associated with decreased transmission to infants and children. These historical findings emphasise the importance of re-exploring targeted active case finding strategies as part of population TB control.