SAMJ: South African Medical Journal

The elephant in the room

Will global warming undo the hard-won gains of prevention of mother-to-child transmission of HIV?

South Africa's first national vaccination coverage survey since 1994

Refusal by surgical registrars to administer or recommend blood transfusions for religious reasons

Frank Dieter Snyckers, 10 June 1940 - 23 December 2018

Derek Montagu (Monty) Brink, 10 November 1957 - 10 March 2019

In a Time of Plague: Memories of the 'Spanish' Flu Epidemic of 1918 in South Africa

Why South Africa urgently needs to support the development of pregnancy exposure registries

**Life-threatening Listeria meningitis: Need for revision of South African acute bacterial meningitis treatment guidelines**

BACKGROUND: The recent listeriosis outbreak in South Africa (SA) received widespread attention in the media. More than 1 000 laboratory-confirmed cases of listeriosis occurred during an 18-month period, with a case fatality rate of 28%. Acute bacterial meningitis due to listeriosis was extremely rare at Steve Biko Academic Hospital in Pretoria until 2017/18, when we saw two very sick adults with this condition during the listeriosis outbreak.OBJECTIVES: To describe the presentation, treatment and outcome of these patients to raise awareness of this potentially fatal but treatable infection that does not respond to empirical third-generation cephalosporinsCASE REPORTS: Case 1: A 60-year-old man collapsed at home after being discharged from hospital for treatment of Listeria meningitis. On readmission he had neck stiffness and a depressed level of consciousness with right-sided hemiparesis. A computed tomography (CT) scan of the brain showed possible subarachnoid haemorrhage, but on CT angio- and venograms, extensive thrombosis of the superior sagittal, right transverse and bilateral sigmoid sinuses extending into the right internal jugular vein was noted. Patient 2: A 55-year-old HIV-positive hypertensive man on highly active antiretroviral therapy and antihypertensives visited the emergency department complaining of a new-onset headache. He was discharged on pain medication, but was readmitted the next day with a depressed level of consciousness, neck stiffness, low-grade fever and generalised tonic-clonic convulsions. A lumbar puncture revealed active cerebrospinal fluid that was culture-positive for L. monocytogenes. The patients received ampicillin and gentamicin for 3 weeks; the cerebral venous thrombosis was treated with unfractionated heparin. In both cases, the course of the disease was complicated. The first patient remained confused and suffered from psychotic episodes for 5 weeks. He was finally discharged after 6 weeks in hospital and continued to improve to the extent that he was able to return to work. The second patient needed intubation and ventilation and was treated in the intensive care unit. He improved over the next week and was finally discharged home with no residual neurological sequelaeCONCLUSIONS: Our two cases demonstrate that the listeriosis outbreak should change the way we view bacterial meningitis in SA: according to the National Institute for Communicable Diseases, empirical treatment for meningitis should include ampicillin and gentamicin in all adult patients with features of meningitis. There may be a need for an updated meningitis treatment guideline in SA

Measuring quality outcomes across hospital systems: Using a claims data model for risk adjustment of mortality rates

Healthcare delivery systems around the world are designing care through value-based models where value is defined as a function of quality of care outcomes and cost. Mortality is a sentinel outcome measure of quality of care, of fundamental importance to patients and providers. Discovery Health (DH), an administrative funder of healthcare in South Africa (SA), uses service claims data of client medical schemes to examine standardised mortality rates (SMRs) at condition level across hospital systems for the purpose of healthcare system improvement. To accurately examine and contrast variation in condition-level SMRs across acute hospital systems, this outcome metric needs to be risk-adjusted for patient characteristics that make mortality more, or less, likely to occur. This article describes and evaluates the validity of risk-adjustment methods applied to service claims data to accurately determine SMRs across hospital systems. While service claims data may have limitations regarding case risk adjustment, it is important that we do not lose the important opportunity to use claims data as a reliable proxy to comment on the quality of care within healthcare systems. This methodology is robust in its demonstration of variation of performance on mortality outcomes across hospital systems. For the measurement period January 2014 - December 2016, the average risk-adjusted SMRs across hospital systems where DH members were hospitalised for acute myocardial infarction, stroke, pneumonia and coronary artery bypass graft procedures were 9.7%, 8.0%, 5.3% and 3.2%, respectively. This exercise of transparently examining variation in SMRs at hospital system level is the first of its kind in SAs private sector. Our methodological exercise is used to establish a local pattern of variation of SMRs in the private sector as the base off which to scrutinise reasons for variation and off which to build quality of care improvement strategies. High-performing healthcare systems must seek out opportunities for learning and continuous improvement such as those offered by examining important quality of care outcome measures across hospitals.

Asthma treatment in children: A guide to screening for and management of hypothalamic-pituitary-adrenal axis suppression

A recently published approach to paediatric asthma management neither recommended screening for nor suggested any management of hypothalamic-pituitary-adrenal axis suppression in asthmatic children treated with corticosteroids. The existing literature on this topic was therefore reviewed and the quality of the evidence assessed. Recommendations for diagnosis, screening and management are made utilising the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Tuberculosis transmission in a hospitalised neonate: Need for optimised tuberculosis screening of pregnant and postpartum women

A recent fatal case of confirmed nosocomial tuberculosis (TB) transmission to a neonate in a kangaroo mother care (KMC) unit highlighted the infection risk to hospitalised neonates in South Africa, a high-burden TB setting. The index case was a 9-week-old infant who presented to another hospital's intensive care unit with severe respiratory distress shortly after discharge from the KMC unit. Contact tracing identified that the infant had been exposed to a postpartum woman with undiagnosed pulmonary TB while in the KMC unit. Molecular testing confirmed nosocomial transmission between the index case and the presumed source case in the KMC unit. We describe the subsequent process of tracing other TB-exposed infants and mothers, the difficulty in confirming TB infection/disease in pregnancy, and the provision of isoniazid preventive therapy in this cohort. We discuss the practical implementation of TB screening approaches in maternity and neonatal wards in high-burden TB settings.

Hepatitis A seroprevalence in Western Cape Province, South Africa: Are we in epidemiological transition?

BACKGROUND: Hepatitis A virus (HAV) is the most common cause of viral hepatitis worldwide. Hepatitis A vaccine is not included in the Expanded Programme on Immunisation in South Africa (EPI-SA), as the country is considered to be highly endemic for hepatitis AOBJECTIVES: To determine the seroprevalence of hepatitis A infection in Western Cape Province (WCP), South AfricaMETHODS: We conducted a cross-sectional seroprevalence study in the 1 - 7-year age group in WCP. Our samples (N=482) were blood specimens left over after laboratory testing obtained from referral hospitals between August and October 2015. A Siemens enzyme immunoassay was used to test for total hepatitis A antibodies. We also analysed hepatitis A immunoglobulin G antibody results from the National Health Laboratory Service (NHLS) DisaTab database at Groote Schuur Hospital from 2009 to 2014, and included 2009 - 2014 acute hepatitis A (immunoglobulin M-positive) surveillance data from the National Institute for Communicable Diseases to look at trends in notified acute infections over the same periodRESULTS: Our cross-sectional study showed 44.1% seroprevalence in the 1 - 7-year age group. Hepatitis A data from the NHLS database indicated a seroprevalence of <90% up to age 10 years, indicating intermediate endemicity. The surveillance data showed that a substantial number of symptomatic hepatitis A infections occurred in the 7 - 40-year age group, suggesting that an increasing proportion of the population is susceptible to HAV infectionCONCLUSIONS: These results suggest an urgent need for detailed evidence-based considerations to introduce hepatitis A vaccine into the EPI-SA

Immunisation after hepatitis B polyvalent vaccination among children in South Kivu Province, Democratic Republic of the Congo

BACKGROUND: The World Health Organization recommends the integration of vaccination against hepatitis B virus (HBV) into the national immunisation programmes of all highly endemic countries. Protective efficacy, defined as a hepatitis B surface antibody (HBsAb) level >10 mIU/mL, is ideally obtained in >90 - 95% of immunised children. The Democratic Republic of the Congo (DRC) implemented this recommendation in 2007 by introducing administration of hepatitis B vaccine in a combined formulation OBJECTIVES: To assess the rate of seroprotection in children who received hepatitis B vaccine in the DRC context METHODS: This descriptive cross-sectional study was conducted during routine postnatal consultations at the General Hospital of Bukavu in South Kivu Province, DRC. A total of 200 infants aged 6 - 12 months and their mothers were consecutively enrolled. All the infants received the three-dose regimen of hepatitis B vaccine 6, 10 and 14 weeks after birth. The mothers were tested for hepatitis B surface antigen and HIV, while HBsAb levels were measured in the infants to determine immune response RESULTS: Seroprotection was achieved in 84.5% of the infants. No maternal (age, parity, duration of pregnancy, HIV and HBV status) or infant (sex, weight at birth) factors were found to be associated with absence of immunological response CONCLUSIONS: The study demonstrated that the rate of seroprotection in the current vaccination programme against HBV in DRC was lower than desirable but comparable to rates reported in some other African countries. Further studies are needed to assess this finding and to evaluate ways to optimise the seroprotection rate

Acquisition of tolerance to egg and peanut in African food-allergic children with atopic dermatitis

BACKGROUND: There are no previous data on tolerance development in children with atopic dermatitis (AD) and concomitant food allergy in low- and middle-income settingsOBJECTIVES: To determine the rate of tolerance acquisition to egg and peanut 5 years after diagnosing food allergies in South African (SA) children with AD, and to explore factors influencing tolerance acquisitionMETHODS: Five years after first diagnosing food allergy in 37 SA children with egg and/or peanut allergy, they were reassessed for their allergies by questionnaire, skin-prick tests (SPTs) and ImmunoCAP-specific IgE (sIgE) tests (Thermo Fisher Scientific/Phadia, Sweden) to egg white, ovomucoid, peanut and Arachis hypogaea allergen 2 (Ara h 2), and incremental food challengesRESULTS: Eighteen of 25 originally egg-allergic patients and 19 of 24 originally peanut-allergic children were followed up at a median age of 8 years and 3 months and 9 years and 6 months, respectively. A high percentage of children (72.2%) outgrew their egg allergy, and 15.8% outgrew their peanut allergy. Allergic comorbidity remained high, with asthma increasing over time, and AD remaining moderate in severity in the cohort overall. At diagnosis, sIgE egg white <9.0 kU/L and sIgE ovomucoid <2.0 kU/L were associated with tolerance development to egg 5 years later. At follow-up, sIgE egg white <0.70 kU/L, sIgE ovomucoid <0.16 kU/L, SPT egg-white extract <1 mm and SPT fresh egg <5 mm were associated with tolerance. At diagnosis, sIgE Ara h 2 <1.7 kU/L and SPT peanut <10 mm were associated with tolerance development to peanut 5 years later. At follow-up, sIgE peanut <0.22 kU/L, sIgE Ara h 2 <0.18 kU/L and SPT peanut <5.5 mm were associated with toleranceCONCLUSIONS: Egg allergy was outgrown in 72.2% and peanut allergy in 15.8% of SA children 5 years after diagnosis of AD. This is in keeping with findings derived from studies in higher socioeconomic settings, and can help to guide the counselling of patients with allergies to these foods of high nutritional value

Evidence for high sugar content of baby foods in South Africa

BACKGROUND: Early-life exposure to excess sugar affects eating behaviour and creates a predisposition to non-communicable diseases (NCDs). While reducing sugar consumption has been high on the public health agenda, little is known about the sugar content of baby foodsOBJECTIVES: To describe and analyse the sugar content of baby foods in South Africa (SAMETHODS: A cross-sectional study was conducted to analyse the sugar content of baby foods. The study sample included commercially available baby foods targeted at children aged <12 months, sold in supermarkets and by other major retailers in SA. Primary data were obtained from the packaging, and sugar content was compared with recommended intake guidelines. Bivariate analyses were conducted to determine whether there were any associations between the sugar content, added sugar and the characteristics of foodsRESULTS: Over 70% of products were sweet in taste, with one in four containing added sugars. Sugar content was high in 78% of the foods sampled. Over 80% of cereals and pureed desserts contained added sugar. Fewer than 10% of pureed composite meal and pureed fruit and vegetable categories contained added sugar. Most products adhered to SA labelling standards, but none had front-of-pack nutritional informationCONCLUSIONS: The SA baby food market is characterised by products with a high sugar content, promoting an environment that encourages development of sweet-taste preferences and in the long term contributing to the rising burden of NCDs. There is an urgent need for mandatory regulation of sugar in baby foods

Healthcare utilisation patterns for respiratory and gastrointestinal syndromes and meningitis in Msunduzi municipality, Pietermaritzburg, KwaZulu-Natal Province, South Africa, 2013

BACKGROUND: Public health facilities are used by the majority of South Africans, and healthcare utilisation surveys have been a useful tool to estimate the burden of disease in a given areaOBJECTIVES: To describe care-seeking behaviour in a periurban site with a high prevalence of HIV infection, as well as barriers to seeking appropriate healthcareMETHODS: We conducted a cross-sectional household survey in 22 wards of the Msunduzi municipality in KwaZulu-Natal Province, South Africa, from October to December 2013 using a simple random sample of households selected from a 2011 census enumeration. A primary caregiver/adult decision-maker was interviewed regarding demographic data as well as health status and recent self-reported episodes of selected illnesses and healthcare utilisationRESULTS: Of the 2 238 eligible premises visited, 1 936 households (87%) with a total of 9 733 members were enrolled in the study. Of these, 635 (7%) reported one or more episodes of infectious illness during the study period. Public health clinics were most frequently consulted for all illnesses (361/635, 57%). Private healthcare (general practitioner, private clinic, private hospital) was sought by 90/635 of individuals (14%), only 13/635 (2%) reported seeking care from traditional healers, religious leaders or volunteers, and 71/635 (11%) did not seek any medical care for acute illnesses. Individuals in the lowest income group were more likely to seek care at public health facilities than those in the highest income group (70% v. 32%CONCLUSIONS: Public health facility-based surveillance may be representative of disease patterns in this community, although surveillance at household level shows that high-income individuals may be excluded because they were more likely to use private healthcare, and the proportion of individuals who died at home would have been missed by facility-based surveillance. Data obtained in such surveys may be useful for public health planning

Prospective case-series analysis of haematological malignancies in goldmining areas in South Africa

BACKGROUND: South Africa (SA) has a long history of goldmining that has resulted in locally high levels of environmental contamination from uranium and its decay products (radium-226 and radon-222) from the mine tailings. Populations living around mine tailings of the Witwatersrand goldfields may be exposed through various pathways, raising concern about potential health risks associated with haematological malignancies (HMs), for which evidence is inconclusiveOBJECTIVES: We designed a prospective case-series study of HMs at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, the major public hospital in the area, to describe demographic and clinical characteristics, lifetime residential history and potential environmental uranium exposure pathwaysMETHODS: All patients, male and female, aged >18 years and newly diagnosed with any form of leukaemia, lymphoma or myeloma at the CHBAH Haematology Unit in 2014 and 2015 were considered for inclusion in the study. Information on uranium exposure pathways and lifetime residential history was recorded from interviewer-administered questionnaires. These characteristics were described overall and according to subtypes of HMRESULTS: Of 556 patients with HMs diagnosed in 2014 and 2015 at CHBAH, 189 patients aged 18 - 90 years were interviewed, mainly with non-Hodgkin's lymphoma (NHL) (37.6%), leukaemia (32.8%) and Hodgkin's lymphoma (HL) (13.8%). HIV status was positive for 39.2% of the patients, mostly with NHL and HL. Potential environmental uranium exposure pathways were identified. Working on goldmines was reported by 12 patients (6.3%). Consumption of soil (geophagia) was a habit of 51 patients (27.0%), particularly during pregnancy. Drinking water was mainly piped water (76.6% in childhood and 97.9% in adulthood). Animal products and vegetables were most frequently obtained from stores (82.0% and 68.7%, respectively, in childhood and 96.3% and 83.6% in adulthood). Patients were referred to CHBAH by government clinic doctors (44.4%), referral hospitals (24.3%) and private doctors (20.1%). Most participants had been born and lived in Gauteng Province and Soweto (94.7% and 58.2%, respectively), and reported two lifetime places of residence on average and living at their current residence for >20 years (49.2%CONCLUSIONS: We identified potential environmental uranium exposure pathways (occupational, lifestyle related and domestic) among patients with HMs that could have resulted in increased uranium exposure. HIV is common among patients with HMs. Together with the results from a previous retrospective case series of HMs at CHBAH (2004 - 2013), our findings suggest that further research on environmental uranium exposure in mining areas and HM risk in residents is warranted

Screening and managing a low-risk pregnant population using continuous-wave Doppler ultrasound in a low-income population: A cohort analytical study

BACKGROUND: In South Africa (SA), the largest category of perinatal deaths is unexplained stillbirths. Two-thirds of these occur in the antenatal period and most fetuses are macerated, but at antenatal clinics the mothers were generally regarded as healthy, with low-risk pregnancies. Innovative methods are urgently required to detect fetuses at risk of stillbirth and manage the mothers appropriatelyOBJECTIVES: To determine the prevalence of raised resistance indices (RIs) of the umbilical artery in a low-risk, low-income population and ascertain whether use of this information can prevent perinatal deathsMETHODS: A descriptive study was performed in Mamelodi township, east of Pretoria, SA, on pregnant women attending antenatal clinics draining to two community health centres (CHCs). These women, classified as having low-risk pregnancies, were screened for placental insufficiency using a continuous-wave Doppler ultrasound apparatus (Umbiflow) between 28 and 32 weeks' gestation. When a raised RI was detected, the mother was referred to a high-risk clinic and managed according to a standard protocol. A cohort analytical study compared women who attended antenatal care at the same clinics as the Umbiflow group but did not have an Umbiflow test with those who had an Umbiflow test. The outcomes of all the deliveries in Mamelodi were recorded. The prevalences of abnormal RIs, absent end-diastolic flow (AEDF), stillbirths and neonatal deaths were the main outcome measuresRESULTS: An Umbiflow RI was performed in 2 868 women, and pregnancy outcome was available for 2 539 fetuses (88.5%); 297 fetuses (11.7%) were regarded as at high risk. AEDF was found in 1.5% of the population screened with an outcome. There were 29 perinatal deaths in the Umbiflow group (low risk n=18, high risk n=11). The perinatal mortality rate for 12 168 women attending the CHCs and the antenatal clinics draining to the CHCs who did not have an RI was 21.3/1 000 births, significantly higher than that in the Umbiflow group (11.4/1 000 births) (risk ratio 0.58, 95% confidence interval 0.42 - 0.81CONCLUSIONS: The prevalence of AEDF in this low-risk population is ~10 times higher than that previously recorded. Use of the information prevented a number of perinatal deaths, most of which would have been macerated stillbirths. Screening a low-risk pregnant population using continuous-wave Doppler ultrasound may substantially reduce the prevalence of unexplained stillbirths in SA

Protecting participants in health research: The South African Material Transfer Agreement

The need to transfer human biological materials (HBMs) across national boundaries has become increasingly important in view of increased biobank and commercial activities globally. In light of South Africa (SA)'s history of colonisation and racial discrimination, coupled with well-known instances of exploitation of research participants in the developing world, it is critical that the management of HBMs from and to other jurisdictions is explored and regulated. Material transfer agreements (MTAs) represent an important point of departure in such a process. This article explores the need for a uniform MTA in SA and discusses some aspects of the recently gazetted national MTA, which provides a framework that can serve as a safeguard for cross-border transfer of HBMs in the absence of the National Health Act's chapter 8 regulations in this regard.