The initial impact of the COVID-19 pandemic on the diagnosis of new cancers at a large pathology laboratory in the public health sector, Western Cape Province, South Africa.

BACKGROUND: The COVID-19 pandemic has disrupted cancer diagnostic services. A decline in the number of new cancers being diagnosed over a relatively short term implies a delay in diagnosis and subsequent treatment. This delay is expected to have a negative effect on cancerrelated morbidity and mortality. The impact of the pandemic on the number of new cancer diagnoses in our setting is unknown. OBJECTIVES: To assess the impact of COVID-19 on the number of new cancers diagnosed at our institution in the first 3 months following the implementation of lockdown restrictions, by focusing on common non-cutaneous cancers. METHODS: A retrospective laboratory-based audit was performed at a large anatomical pathology laboratory in Western Cape Province, South Africa. The numbers of new diagnoses for six common cancers (breast, prostate, cervix, large bowel, oesophagus and stomach) from 1 April 2020 to 30 June 2020 were compared with the corresponding period in 2019. RESULTS: Histopathological diagnoses for the six cancers combined decreased by 192 (-36.2%), from 531 new cases in the 2019 study period to 339 in the corresponding period in 2020. Substantial declines were seen for prostate (-58.2%), oesophageal (-44.1%), breast (-32.9%), gastric (-32.6%) and colorectal cancer (-29.2%). The smallest decline was seen in cervical cancer (-7%). New breast cancers diagnosed by cytopathology declined by 61.1%. CONCLUSIONS: The first wave of the COVID-19 pandemic and the associated response resulted in a substantial decline in the number of new cancer diagnoses, implying a delay in diagnosis. Cancer-related morbidity and mortality is expected to rise as a result, with the greatest increase in mortality expected from breast and colorectal cancer.

Testing the effectiveness of a transdiagnostic treatment approach in reducing violence and alcohol abuse among families in Zambia: study protocol of the Violence and Alcohol Treatment (VATU) trial.

BACKGROUND: Violence against women and girls (VAWG) is an urgent global health problem. Root causes for VAWG include the individual- and family-level factors of alcohol abuse, mental health problems, violence exposure, and related adverse experiences. Few studies in low- and middle-income countries (LMIC) have assessed the effectiveness of psychological interventions for reducing VAWG. This randomized controlled trial, part of the What Works to Prevent Violence Against Women and Girls consortium, examines the effectiveness of a common elements treatment approach (CETA) for reducing VAWG and comorbid alcohol abuse among families in Zambia. METHODS/DESIGN: Study participants are families consisting of three persons: an adult woman, her male husband or partner, and one of her children aged 8-17 (if available). Eligibility criteria include experience of moderate-to-severe intimate partner violence by the woman and hazardous alcohol use by her male partner. Family units are randomized to receive CETA or treatment as usual. The primary outcome is VAWG as measured by the Severity of Violence Against Women Scale, assessed along with secondary outcomes at 24 months post-baseline. Interim assessments are also conducted at 4-5 months (following CETA completion) and 12 months post-baseline. CONCLUSIONS: This ongoing trial is one of the first in sub-Saharan Africa to evaluate the use of an evidence-based common elements approach for reducing VAWG by targeting a range of individual- and family-level factors, including alcohol abuse. Results of this trial will inform policy on what interventions work to prevent VAWG in LMIC with local perspectives on scale up and wider implementation.

A systematic review of prediction models for prevalent pulmonary tuberculosis in adults.

A systematic review was conducted to describe the quality and characteristics of prediction models for prevalent pulmonary tuberculosis (PTB) in adults at routine TB care settings. A prediction model was defined as the combination of two or more clinical predictors designed to estimate the probability of having TB. Studies using culture-confirmed PTB as reference standard were included. Models for in-patients, children or specific patient populations were excluded. PubMed, Scopus and the Cochrane Library and abstracts from the International Union Against Tuberculosis and Lung Disease, American Thoracic Society and European Respiratory Society conferences were searched. The CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) checklist was used for data extraction and quality assessment. From 13 671 identified records, six were included for data extraction; three assessed smear-negative, culture-positive PTB as outcome and three focused on human immunodeficiency virus infected individuals only. Reporting of model development, performance and evaluation was poor. In four studies, predictive performance was evaluated using the development data set (apparent performance), one study did an internal validation and one study did an external validation. Results were not pooled due to heterogeneity. Existing prediction models for estimating prevalent PTB in adults at primary care level are poorly reported and validated and are not useful for TB screening. The World Health Organization symptom screen is recommended.

Process and implementation of Audio Computer Assisted Self-Interviewing (ACASI) assessments in low resource settings: a case example from Zambia.

BACKGROUND: Studies from low- and middle-income countries (LMIC) indicate that the use of audio computer-assisted self-interviewing (ACASI) is associated with more accurate reporting of sensitive behaviors (e.g. substance use and sexual risk behaviors) compared with interviewer-administered questionnaires. There is a lack of published information on the process of designing, developing, and implementing ACASI in LMIC. In this paper we describe our experience implementing an ACASI system for use with a population of orphans and vulnerable children in Zambia. METHODS: A questionnaire of mental health, substance use, and HIV risk behaviors was converted into an ACASI system, tested in pilot and validity studies, and implemented for use in a randomized controlled trial. Successes, barriers, and challenges associated with each stage in the development and implementation of ACASI are described. RESULTS: We were able to convert a lengthy and complex survey into an ACASI system that was feasible for use in Zambia. Lessons learned include the importance of: (1) piloting the written and electronic versions; (2) proper and extensive training for study assessors to use ACASI and for those doing voice recordings; and (3) attention to logistics such as appropriate space, internet, and power. CONCLUSIONS: We found that ACASI was feasible and acceptable in Zambia with proper planning, training, and supervision. Given mounting evidence indicating that ACASI provides more accurate self-report data and immediate data download compared with interview-administered measures, it may be an effective and economical alternative for behavioral health research studies in LMIC.

Routine programmatic delivery of isoniazid preventive therapy to children in Cape Town, South Africa.

SETTING: Fourteen primary health care facilities in Cape Town, South Africa. OBJECTIVE: To determine the proportion and characteristics of infectious adult tuberculosis (TB) cases that identify children aged <5 years who qualify for isoniazid preventive therapy (IPT), and to determine the proportion of children who initiate and complete IPT. DESIGN: A retrospective clinical record review conducted as a stratified cluster survey. RESULTS: Of 1179 records of infectious adult cases, 33.3% had no documentation of contacts. Of the remaining 786 records, 525 contacts aged <5 years were identified, representing 0.7 child contacts per infectious adult case. Older age, male, human immunodeficiency virus (HIV) positive, smear-negative and retreatment TB cases were all associated with no documentation of contacts. Of the 525 child contacts identified, less than half were screened for TB, 141 initiated IPT and 19 completed it. CONCLUSION: Less than 67% of infectious TB case records had documentation of contacts. Younger, female, HIV-negative and new smear-positive TB cases were more likely to have had contacts identified. Less than 14% of children already initiated on IPT completed 6 months of treatment.

Tuberculosis contact investigation in a high-burden setting: house or household?

SETTING: A high tuberculosis (TB) burden setting, South Africa. Two frequently used definitions for 'household' are 1) 'all dwellings on the same plot of land that share the same residential address'; and 2) 'a group of persons who live together in the same dwelling unit and who have the same eating arrangements'. OBJECTIVE: To characterise a household and the outcome of investigations in household child contacts using definition 1 compared to definition 2 during a TB contact investigation. DESIGN: Access to a household (definition 1) was gained via an adult TB case. Children were assessed for TB infection and disease. RESULTS: Household enumeration indicated 25 members of three families living in a main house and a fourth family living in an adjacent structure. Three children were diagnosed with TB and two referred for isoniazid preventive therapy. Families living in the main house shared the main kitchen, while the yard house family used its own kitchen. This household would have been classified as two separate households if definition 2 had been used, and children with TB disease and infection would have been missed. CONCLUSION: The definition of household in TB contact investigation should provide a framework that is broad enough to capture the majority of children at risk.

Environmental tobacco smoke exposure increases Mycobacterium tuberculosis infection risk in children.

BACKGROUND: Data on the association between exposure to environmental tobacco smoke (ETS) and Mycobacterium tuberculosis infection in children are limited. OBJECTIVE: To examine the dose-response effect of ETS exposure on the risk of M. tuberculosis infection in children in a high tuberculosis (TB) burden setting. METHODS: This cross-sectional study included healthy South African children from impoverished urban communities. Data were collected on household ETS and M. tuberculosis exposure, demographics, socio-economic and anthropometric data, M. tuberculosis infection, human immunodeficiency virus and TB disease status. RESULTS: Among 196 children (median age 6.8 years, range 0.3-15.9), 97 (49.5%) were M. tuberculosis - i nfected (tuberculin skin test [TST] ≥ 10 mm) and 128 (65.3%) reported ETS exposure; of these, 81/128 (63.3%) were exposed to ≥ 2 household smokers. The presence of ≥ 2 household smokers was associated with M. tuberculosis infection in univariate analysis, irrespective of TST cut-off point. In analysis adjusting for M. tuberculosis exposure, socio-economic status, age and previous TB treatment, ETS exposure remained associated with M. tuberculosis infection. In univariate and multivariate analysis, pack-years of exposure were associated with risk of TB infection. DISCUSSION: Exposure to ETS is associated with M. tuberculosis infection in children after adjustment for multiple variables, with a dose-response relationship between the degree of ETS exposure and risk of infection. Public health interventions to reduce exposure to tobacco smoke among children in high TB burden settings are urgently needed.

Consulting private health care providers aggravates treatment delay in urban South African tuberculosis patients.

SETTING: An urban primary health care facility in Khayelitsha, South Africa. OBJECTIVES: To determine the difference in total tuberculosis (TB) treatment delay in patients who initially seek care at National TB Control Programme (NTP) facilities after the onset of TB-related symptoms, compared to patients who initially seek care from non-NTP health care practitioners (HCP); and to describe the relative contributions of diagnostic, treatment initiation, patient and health system (HS) delay. DESIGN: A cross-sectional study of adult TB patients treated by the NTP. RESULTS: A total of 210 patients (median age 31 years) were enrolled from May to December 2009: 46% were male, and 58% were human immunodeficiency virus (HIV) infected. The median duration of total delay was 31 days, diagnostic delay 26, treatment initiation delay 0, patient delay 8 and HS delay 17 days. Initial visit to a non-NTP HCP was independently associated with total (P = 0.007), HS (P = 0.014) and diagnostic delays (P = 0.012). HIV infection was an independent risk factor for total (P = 0.047) and HS delay (P = 0.021); 27% of patients reported first going to a non-NTP HCP. CONCLUSION: Initial care sought from non-NTP HCP was the main determinant of total, HS and diagnostic delays. Engagement and education of private HCPs is recommended.

The use of light-emitting diode fluorescence to diagnose mycobacterial lymphadenitis in fine-needle aspirates from children.

BACKGROUND: Fine-needle aspiration biopsy (FNAB) is a simple, safe and effective method for investigating suspected mycobacterial lymphadenitis in children. Fluorescence microscopy can provide rapid mycobacterial confirmation. Light-emitting diodes (LEDs) provide a cheap and robust excitation light source, making fluorescence microscopy feasible in resource-limited settings. OBJECTIVE: To compare the diagnostic performance of LED fluorescence microscopy on Papanicolaou (PAP) stained smears with the conventional mercury vapour lamp (MVL). METHODS: FNAB smears routinely collected from palpable lymph nodes in children with suspected mycobacterial disease were PAP-stained and evaluated by two independent microscopists using different excitatory light sources (MVL and LED). Mycobacterial culture results provided the reference standard. A manually rechargeable battery-powered LED power source was evaluated in a random subset. RESULTS: We evaluated 182 FNAB smears from 121 children (median age 31 months, interquartile range 10-67). Mycobacterial cultures were positive in 84 of 121 (69%) children. The mean sensitivity with LED (mains-powered), LED (rechargeable battery-powered) and MVL was respectively 48.2%, 50.0% and 51.8% (specificity 78.4%, 86.7% and 78.4%). Inter-observer variation was similar for LED and MVL (κ = 0.5). CONCLUSION: LED fluorescence microscopy provides a reliable alternative to conventional methods and has many favourable attributes that would facilitate improved, decentralised diagnostic services.

Recording isoniazid preventive therapy delivery to children: operational challenges.

Despite recommendations to provide isoniazid preventive therapy (IPT) to eligible children aged <5 years who are in close contact with an infectious tuberculosis (TB) case, IPT delivery in high-burden settings remains poor. To evaluate the current system supporting IPT delivery to children in an urban community, South Africa, we reviewed the recording practices of a local clinic regarding management of children exposed to a current adult TB case. No standardised IPT management tools existed. Only 21% of children eligible for IPT had documentation of IPT delivery. There is a need to implement systems that support IPT recommendations in high-burden settings.

Support for nurses directly involved with women who chose to terminate a pregnancy.

Research conducted by Poggenpoel, Myburgh and Gmeiner (1998:2-8) on "One voice regarding the legalization of abortion: Nurses who experience discomfort" indicated that the nurses were in favour of the fact that nurses should volunteer to participate in terminating a pregnancy of a woman. From our observations in clinics where nurses voluntarily participate in providing reproductive health services, including termination of pregnancy, it became clear that supporting these nurses may be essential. To be able to provide support, it is necessary to identify, explore and describe nurses' experience of being directly involved with women who terminate their pregnancy. To enable us to address the identified problems, a qualitative research strategy was implemented in which respondents were included in the sample through purposive sampling. Phenomenological interviews were conducted individually. Data was analyzed by means of Tesch's descriptive approach. Thereafter, guidelines for operationalization were inferred from the results and a literature control completed to verify and enrich guidelines. Measures to ensure trustworthiness have been applied in the research and ethical measures have been strictly adhered to regarding this sensitive issue.

[Support for the psychiatric nurse specialist and the psychiatric community nurse in their interactions with the psychiatric patient. Part II]. / Ondersteuningsbenadering aan psigiatriese gemeenskapsverpleegkundiges in interaksie met psigiatriese pasiënte. Deel II.

In this article the research is described that had as goal to generate a supportive approach for the psychiatric nurse specialist to the psychiatric community nurse in interaction with the psychiatric patient, to promote, maintain and restore their mental health as an integral part of health. Guidelines for operationalisation of this supportive approach by the psychiatric nurse specialist, are also described. The research design utilised a qualitative, descriptive and contextual design. The exploratory field work was done in phase one of this research (as described in part I of these articles) and consisted of phenomenological interviews and focus groups. Trustworthiness was ensured by utilising Guba's model for trustworthiness.

[The psychiatric community nurse's experience about her interaction with the psychiatric patient]. / Die psigiatriese gemeenskapsverpleegkundige se belewenis van haar interaksie met die psigiatriese pasiënt: Deel 1.

The experiences of psychiatric community nurses with regard to their interaction with psychiatric patients were explored and described. A qualitative, exploratory, descriptive and contextual design was used. Phenomenological semi-structured interviews were conducted with a purposefully selected sample population. Trustworthiness was ensured by using Lincoln & Guba's (1985) model. A literature control was conducted as well. Results indicated that healthier support is needed for the psychiatric nurse to facilitate therapeutic interaction between the psychiatric patient and the community psychiatric nurse.

[Service experience of community psychiatric nurses: 1]. / Die belewing van die psigiatriese verpleegkundiges van hul dienslewering in die gemeenskap: deel 1.

Since psychiatric community services were legalised by the promulgation of the Mental Health Act no 18 of 1973 shift to primary mental Health Care has occurred. This change resulted in an increase in psychiatric patients within the community, and because of this increase the workload of the psychiatric community nurse became heavier. This higher expectation might cause pressure for the psychiatric community nurse and therefore influence her therapeutic relationship with her patient negatively. It was therefore important that the work experience of the psychiatric community nurse should be explored and described in order to formulate guidelines to mobilise resources to promote, maintain and restore the mental health of the psychiatric community nurse. A exploratory, descriptive contextual study was done with the aim of achieving insight into the internal environment experiences of the psychiatric community nurse working in the psychiatric community. In depth exploration was achieved by way of the phenomological method of interviewing to obtain data.