The interface between SARS-CoV-2 and non-communicable diseases (NCDs) in a high HIV/TB burden district level hospital setting, Cape Town, South Africa.

BACKGROUND: COVID-19 experiences on noncommunicable diseases (NCDs) from district-level hospital settings during waves I and II are scarcely documented. The aim of this study is to investigate the NCDs associated with COVID-19 severity and mortality in a district-level hospital with a high HIV/TB burden. METHODS: This was a retrospective observational study that compared COVID-19 waves I and II at Khayelitsha District Hospital in Cape Town, South Africa. COVID-19 adult patients with a confirmed SARS-CoV-2 polymerase chain reaction (PCR) or positive antigen test were included. In order to compare the inter wave period, clinical and laboratory parameters on hospital admission of noncommunicable diseases, the Student t-test or Mann-Whitney U for continuous data and the X2 test or Fishers' Exact test for categorical data were used. The role of the NCD subpopulation on COVID-19 mortality was determined using latent class analysis (LCA). FINDINGS: Among 560 patients admitted with COVID-19, patients admitted during wave II were significantly older than those admitted during wave I. The most prevalent comorbidity patterns were hypertension (87%), diabetes mellitus (65%), HIV/AIDS (30%), obesity (19%), Chronic Kidney Disease (CKD) (13%), Congestive Cardiac Failure (CCF) (8.8%), Chronic Obstructive Pulmonary Disease (COPD) (3%), cerebrovascular accidents (CVA)/stroke (3%), with similar prevalence in both waves except HIV status [(23% vs 34% waves II and I, respectively), p = 0.022], obesity [(52% vs 2.5%, waves II and I, respectively), p <0.001], previous stroke [(1% vs 4.1%, waves II and I, respectively), p = 0.046]. In terms of clinical and laboratory findings, our study found that wave I patients had higher haemoglobin and HIV viral loads. Wave II, on the other hand, had statistically significant higher chest radiography abnormalities, fraction of inspired oxygen (FiO2), and uraemia. The adjusted odds ratio for death vs discharge between waves I and II was similar (0.94, 95%CI: 0.84-1.05). Wave I had a longer average survival time (8.0 vs 6.1 days) and a shorter average length of stay among patients discharged alive (9.2 vs 10.7 days). LCA revealed that the cardiovascular phenotype had the highest mortality, followed by diabetes and CKD phenotypes. Only Diabetes and hypertension phenotypes had the lowest mortality. CONCLUSION: Even though clinical and laboratory characteristics differed significantly between the two waves, mortality remained constant. According to LCA, the cardiovascular, diabetes, and CKD phenotypes had the highest death probability.

Socioeconomic status significantly impacts childhood cancer survival in South Africa.

BACKGROUND AND AIMS: Significantly discrepant survival rates have been documented in single disease childhood cancer cohorts in South Africa; those from higher socioeconomic groups were shown to have a significantly lower risk of death than those from less affluent households. This study aimed to determine the impact of socioeconomic status (SES) on childhood cancer survival using pooled South African data. METHODS: Five databases spanning January 2000 to December 2021 were interrogated. SES status was assigned based on a public sector annual household income classification. H0 households (formally unemployed) received free healthcare. H1, H2 and H3 (annual income > United States Dollar [USD] 19,000) households paid for healthcare relative to their income. The Spearman test assessed correlations between SES and disease stage in patients with solid tumours. Hazard ratios were determined using Cox regression modelling. The Kaplan-Meier procedure estimated overall survival (OS). RESULTS: A total of 1598 children were eligible for analysis; 1269 had a solid tumour with a negative correlation between SES and stage (Spearman rho = -.178; p < .001). Patients with solid tumours and lower SES showed proportionately higher numbers of stage III and IV disease (p < .01). This proportion decreased with higher SES categories. In the multivariate analyses adjusted for sex, age, tumour type and stage, higher SES was associated with lower mortality risk (p < .001), indicating that the impact of SES on survival was in excess of any effect that could be explained by lower stage disease alone. There was a strong positive correlation between race and SES (Fisher's exact tests, p < .001) across all groups and all SES strata. Five-year OS was 85.3% in children from H3 households versus 46.3% in children from H0 households (p < .001). CONCLUSION: SES significantly impacts childhood cancer survival for children with solid tumours in South Africa. SES is a robust surrogate for race in South Africa as a prognostic metric of disease outcome in childhood cancer. Advocacy to increase social support for impoverished patients is essential to achieve equitable improvements in outcomes treated with standardised national treatment guidelines.

Epidemiology and outcomes of SARS-CoV-2 infection associated with anti-nucleocapsid seropositivity in Cape Town, South Africa.

Background: In low- and middle-income countries where SARS-CoV-2 testing is limited, seroprevalence studies can characterise the scale and determinants of the pandemic, as well as elucidate protection conferred by prior exposure. Methods: We conducted repeated cross-sectional serosurveys (July 2020 - November 2021) using residual plasma from routine convenient blood samples from patients with non-COVID-19 conditions from Cape Town, South Africa. SARS-CoV-2 anti-nucleocapsid antibodies and linked clinical information were used to investigate: (1) seroprevalence over time and risk factors associated with seropositivity, (2) ecological comparison of seroprevalence between subdistricts, (3) case ascertainment rates, and (4) the relative protection against COVID-19 associated with seropositivity and vaccination statuses, to estimate variant disease severity. Findings: Among the subset sampled, seroprevalence of SARS-CoV-2 in Cape Town increased from 39.2% in July 2020 to 67.8% in November 2021. Poorer communities had both higher seroprevalence and COVID-19 mortality. Only 10% of seropositive individuals had a recorded positive SARS-CoV-2 test. Antibody positivity before the start of the Omicron BA.1 wave (28 November 2021) was strongly protective for severe disease (adjusted odds ratio [aOR] 0.15; 95%CI 0.05-0.46), with additional benefit in those who were also vaccinated (aOR 0.07, 95%CI 0.01-0.35). Interpretation: The high population seroprevalence in Cape Town was attained at the cost of substantial COVID-19 mortality. At the individual level, seropositivity was highly protective against subsequent infections and severe COVID-19. Funding: Wellcome Trust, National Health Laboratory Service, the Division of Intramural Research, NIAID, NIH (ADR) and Western Cape Government Health.

Matching study using health and police datasets for characterising interpersonal violence in the community of Khayelitsha, South Africa 2013-2015.

OBJECTIVES: The Cardiff Model of data sharing for violence prevention is premised on the idea that the majority of injury cases presenting at health facilities as a result of interpersonal violence will not be reported to the police. The aim of this study was to determine the concordance between violent crimes reported to the police with violence-related injuries presenting at health facilities in Cape Town, South Africa. METHODS: We conducted a retrospective analysis of secondary cross-sectional health and police data, from three health facilities and three police stations in the community of Khayelitsha, Cape Town. 781 cases of injuries arising from interpersonal violence seen at health facilities were compared with 739 violence-related crimes reported at police stations over five separate week-long sampling periods from 2013 to 2015. Personal identifiers, name and surname, were used to match cases. RESULTS: Of the 708 cases presenting at health facilities, 104 (14.7%) were matched with police records. The addition of non-reported cases of violence-related injuries from the health dataset to the police-reported crime statistics resulted in an 81.7% increase in potential total violent crimes over the reporting period. Compared with incidents reported to the police, those not reported were more likely to involve male patients (difference: +47.0%; p<0.001) and sharp object injuries (difference: +24.7%; p<0.001). Push/kick/punch injuries were more frequent among reporting than non-reporting patients (difference: +17.5%; p<0.001). CONCLUSION: These findings suggest that the majority of injuries arising from interpersonal violence presenting at health facilities in Khayelitsha are not reported to the police. A data-sharing model between health services and the police should be implemented to inform violence surveillance and reduction.

Characterization and Comparison of the Divergent Metabolic Consequences of High-Sugar and High-Fat Diets in Male Wistar Rats.

Diet-induced obesity (DIO) in laboratory rodents can serve as a model with which to study the pathophysiology of obesity, but obesogenic diets (high-sugar and/or high-fat) are often poorly characterised and simplistically aimed at inducing metabolic derangements for the purpose of testing the therapeutic capacity of natural products and other bioactive compounds. Consequently, our understanding of the divergent metabolic responses to different obesogenic diet formulations is limited. The aim of the present study was to characterise and compare differences in the metabolic responses induced by low-fat, medium-fat/high-sugar and high-fat diets in rats through multivariate statistical modelling. Young male Wistar rats were randomly assigned to CON (laboratory chow, low-fat), OB1 (high-sugar, medium-fat) or OB2 (high-fat) dietary groups (n = 24 each) for 17 weeks, after which metabolic responses were characterised. Projection-based multivariate analyses (principal component analysis (PCA) and orthogonal partial least squares-discriminant analysis (OPLS-DA)) were used to explore the associations between measures of body composition and metabolism. Furthermore, we conducted a systematic literature survey to examine reporting trends in rat dietary intervention studies, and to determine how the metabolic responses observed in the present study compared to other recently published studies. The OB1 and OB2 dietary regimens resulted in distinct metabolic profiles, with OB1 characterised by perturbations in insulin homeostasis and adipose tissue secretory function, while OB2 was characterised by altered lipid and liver metabolism. This work therefore confirms, by means of direct comparison, that differences in dietary composition have a profound impact on metabolic and pathophysiological outcomes in rodent models of DIO. However, through our literature survey we demonstrate that dietary composition is not reported in the majority of rat dietary intervention studies, suggesting that the impact of dietary composition is often not considered during study design or data interpretation. This hampers the usefulness of such studies to provide enhanced mechanistic insights into DIO, and also limits the translatability of such studies within the context of human obesity.

Determining antenatal medicine exposures in South African women: a comparison of three methods of ascertainment.

BACKGROUND: In the absence of clinical trials, data on the safety of medicine exposures in pregnancy are dependent on observational studies conducted after the agent has been licensed for use. This requires an accurate history of antenatal medicine use to determine potential risks. Medication use is commonly determined by self-report, clinician records, and electronic pharmacy data; different data sources may be more informative for different types of medication and resources may differ by setting. We compared three methods to determine antenatal medicine use (self-report, clinician records and electronic pharmacy dispensing records [EDR]) in women attending antenatal care at a primary care facility in Cape Town, South Africa in a setting with high HIV prevalence. METHODS: Structured, interview-administered questionnaires recorded self-reported medicine use. Data were collected from clinician records and EDR on the same participants. We determined agreement between these data sources using Cohen's kappa and, lacking a gold standard, used Latent Class Analysis to estimate sensitivity, specificity and positive predictive value (PPV) for each data source. RESULTS: Between 55% and 89% of 967 women had any medicine use documented depending on the data source (median number of medicines/participant = 5 [IQR 3-6]). Agreement between the datasets was poor regardless of class except for antiretroviral therapy (ART; kappa 0.6-0.71). Overall, agreement was better between the EDR and self-report than with either dataset and the clinician records. Sensitivity and PPV were higher for self-report and the EDR and were similar for the two. Self-report was the best source for over-the-counter, traditional and complementary medicines; clinician records for vaccines and supplements; and EDR for chronic medicines. CONCLUSIONS: Medicine use in pregnancy was common and no single data source included all the medicines used. ART was the most consistently reported across all three datasets but otherwise agreement between them was poor and dependent on class. Using a single data collection method will under-estimate medicine use in pregnancy and the choice of data source should be guided by the class of the agents being investigated.

One in five South Africans are multimorbid: An analysis of the 2016 demographic and health survey.

Multimorbidity is a global research priority, yet relatively little is known about it in low and middle income countries. South Africa has the largest burden of HIV worldwide but also has a growing burden of non-communicable diseases; potentially leading to uncommon disease combinations. Information about the prevalence of multimorbidity and factors associated with it can assist in healthcare planning and targeting groups of people for interventions. This study aimed to determine the prevalence of multimorbidity by age and sex, as well as factors associated with multimorbidity in people 15 years and older. This study analyses the nationally representative 2016 South African Demographic Health Survey. The sample included 10 336 people who participated in the Adult Health questionnaire and approximately 7 961 people who provided biomarkers. Multivariate logistic regression was used to measure the association of multimorbidity with age, sex, living in an urban or rural area, education level, wealth level, employment status, body mass index, current alcohol or tobacco use. All analyses were conducted using STATA 15. Multimorbidity was present in 20.7% (95% CI: 19.5%- 21.9%) of participants; in 14.8% (95% CI: 13.4% - 16.3%) of males and 26.2% (95% CI: 24.7-27.7%) of females. Multimorbidity increased with age; with the highest odds in the 55-64 years old age group (OR: 24.910, 95% CI: 14.901-41.641, p < 0.001) compared to those aged 15-24 years. The odds of multimorbidity was also higher in young females compared to young males (OR: 2.734, 95% CI: 1.50-4.99, p = 0.001). Possessing tertiary education (OR: 0.722, 95% CI: 0.537-0.97, p = 0.031), being employed (OR: 0.813, 95% CI: 0.675-0.979, p = 0.029) or currently using alcohol (OR: 0.815, 95% CI: 0.686-0.968, p = 0.02) was protective against multimorbidity. Multimorbidity is prevalent within the South African population, with females and older adults being most affected. However, multimorbidity is also observed in younger adults and most likely driven by the high prevalence of HIV and hypertension.

Multimorbidity Patterns in a National HIV Survey of South African Youth and Adults.

Introduction: Information pertaining to multimorbidity is frequently informed by studies from high income countries and it is unclear how these findings relate to low and middle income countries, where the burden of infectious disease is high. South Africa has a quadruple burden of disease which includes a high HIV prevalence and a growing burden of non-communicable diseases. This study aimed to analyse the prevalence and patterns (disease classes or clusters) of multimorbidity in South Africa. Methods: A secondary analysis of individuals over the age of 15 years who participated in the Fifth South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2017 (SABSSM 2017) was done. Six disease conditions were identified in the analysis (cancer, diabetes, heart disease, hypertension/high blood pressure, tuberculosis, and HIV). Chi-square tests were used to test for the differences in disease prevalence by sex. Common disease patterns were identified using a latent class analysis. Results: The sample included 27,896 participants, of which 1,837 had comorbidity or multimorbidity. When taking population-weighting into account, multimorbidity was present in 5.9% (95% CI: 5.4-6.4) of the population The prevalence of multimorbidity tended to be higher among females and increased with age, reaching 21.9% in the oldest age group (70+). The analyses identified seven distinct disease classes in the population. The largest class was "Diabetes and Hypertension" (36.3%), followed by "HIV and Hypertension" (31.0%), and "Heart disease and Hypertension" (14.5%). The four smaller classes were: "HIV, Diabetes, and Heart disease" (6.9%), "TB and HIV" (6.3%), "Hypertension, TB, and Cancer" (2.8%), and "All diseases except HIV" (2.2%). Conclusion: As the South African population continues to age, the prevalence of multimorbidity is likely to increase which will further impact the health care system. The prevalence of multimorbidity in the population was relatively low but reached up to 20% in the oldest age groups. The largest disease cluster was the combination of diabetes and hypertension; followed by HIV and hypertension. The gains in improving adherence to antiretrovirals amongst treatment-experienced people living with HIV, should be expanded to include compliance with lifestyle/behavioral modifications to blood pressure and glucose control, as well as adherence to anti-hypertension and anti-diabetic medication. There is an urgent need to improve the early diagnosis and treatment of disease in the South African population.

Explaining population trends in cardiovascular risk: protocol for a comparative analysis of health transitions in South Africa and England using nationally representative survey data.

INTRODUCTION: Cardiovascular diseases (CVD) are the leading cause of death globally and share determinants with other major non-communicable diseases. Risk factors for CVD are routinely measured in population surveys and thus provide an opportunity to study health transitions. Understanding the drivers of health transitions in countries that have not followed expected paths compared with those that exemplified models of 'epidemiologic transition', such as England, can generate knowledge on where resources may best be directed to reduce the burden of disease. This study aims to examine the notions of epidemiological transition by identifying and quantifying the drivers of change in CVD risk in a middle-income African setting compared with a high-income European setting. METHODS AND ANALYSIS: This is a secondary joint analysis of data collected within the scope of multiple population surveys conducted in South Africa and England between 1998 and 2017 on nationally representative samples of the adult population. The study will use a validated, non-laboratory risk score to estimate and compare the distribution of and trends in total CVD risk in the population. Statistical modelling techniques (fixed-effects and random-effects multilevel regression models and structural equation models) will be used to examine how various factors explain the variation in CVD risk over time in the two countries. ETHICS AND DISSEMINATION: This study has obtained approval from the University of Greenwich (20.5.6.8) and Stellenbosch University (X21/09/027) Research Ethics Committees. It uses anonymised microdata originating from population surveys which received ethical approval from the relevant bodies, with no additional primary data collection. Results of the study will be disseminated through (1) peer-reviewed articles in open access journals; (2) policy briefs; (3) conferences and meetings; and (4) public engagement activities designed to reach health professionals, governmental bodies, civil society and the lay public. A harmonised data set will be made publicly available through online repositories.

Malignant extracranial germ cell tumours: A first national report by the South African Children's Cancer Study Group.

OBJECTIVE: To determine the overall survival (OS) and prognostic factors influencing outcomes in children and adolescents with malignant extracranial germ cell tumours (MEGCTs) in preparation for the development of a harmonised national treatment protocol. METHODS: A retrospective folder review was undertaken at nine South African paediatric oncology units to document patient profiles, tumour and treatment-related data and outcomes for all children with biopsy-proven MEGCTs from birth up to and including 16 years of age. RESULTS: Between 1 January 2000 and 31 December 2015, 218 patients were diagnosed with MEGCTs. Female sex (hazard ratio [HR] 0.284, p = .037) and higher socio-economic status (SES) (HR 0.071, p = .039) were associated with a significantly lower risk of death. Advanced clinical stage at diagnosis significantly affected 5-year OS: stage I: 96%; stage II: 94.3%; stage III: 75.5% (p = .017) and stage IV (60.1%; p < .001). There was a significant association between earlier stage at presentation and higher SES (p = .03). Patients with a serum alpha-fetoprotein (AFP) level of more than 33,000 ng/ml at diagnosis had significantly poorer outcomes (p = .002). The use of chemotherapy significantly improved survival, irrespective of the regimen used (p < .001). CONCLUSIONS: The cohort demonstrated a 5-year OS of 80.3% with an event-free survival (EFS) of 75.3%. Stage, the use of chemotherapy and an elevated serum AFP level of more than 33,000 ng/ml were independently predictive of outcome. The relationship between SES and outcome is important as the implementation of the new national protocol hopes to standardise care across the socio-economic divide.

Multimorbidity patterns in South Africa: A latent class analysis.

Introduction: South Africa has the largest burden of HIV worldwide and has a growing burden of non-communicable diseases; the combination of which may lead to diseases clustering in ways that are not seen in other regions. This study sought to identify common disease classes and sociodemographic and lifestyle factors associated with each disease class. Methods: Data were analyzed from the South African Demographic and Health Survey 2016. A latent class analysis (LCA) was conducted using nine disease conditions. Sociodemographic and behavioral factors associated with each disease cluster were explored. All analysis was conducted in Stata 15 and the LCA Stata plugin was used to conduct the latent class and regression analysis. Results: Multimorbid participants were included (n = 2 368). Four disease classes were identified: (1) HIV, Hypertension and Anemia (comprising 39.4% of the multimorbid population), (2) Anemia and Hypertension (23.7%), (3) Cardiovascular-related (19.9%) and (4) Diabetes and Hypertension (17.0%). Age, sex, and lifestyle risk factors were associated with class membership. In terms of age, with older adults were less likely to belong to the first class (HIV, Hypertension and Anemia). Males were more likely to belong to Class 2 (Anemia and Hypertension) and Class 4 (Diabetes and Hypertension). In terms of alcohol consumption, those that consumed alcohol were less likely to belong to Class 4 (Diabetes and Hypertension). Current smokers were more likely to belong to Class 3 (Cardiovascular-related). People with a higher body mass index tended to belong to Class 3 (Cardiovascular-related) or the Class 4 (Diabetes and Hypertension). Conclusion: This study affirmed that integrated care is urgently needed, evidenced by the largest disease class being an overlap of chronic infectious diseases and non-communicable diseases. This study also highlighted the need for hypertension to be addressed. Tackling the risk factors associated with hypertension could avert an epidemic of multimorbidity.

Prevalence of Anaemia, Iron Deficiency, and Iron Deficiency Anaemia in Women of Reproductive Age and Children under 5 Years of Age in South Africa (1997-2021): A Systematic Review.

Using a systematic review method, the prevalence of anaemia, iron deficiency (ID), and iron deficiency anaemia (IDA) in women of reproductive age (WRA) and children under 5 years of age was obtained to inform priorities in health planning and policy in South Africa. We searched electronic databases for articles published between 1997 and 2021. A total of 713 articles were identified, of which 14 articles comprising 9649 WRA and 4085 children were included. Since most of the included studies were of low quality, we did not pool data in a meta-analysis due to heterogeneity (I2 > 75%). In WRA, anaemia prevalence ranged from 22.0% to 44.0%; ID from 7.7% and 19.0%; and IDA from 10.5% to 9.7%. The prevalence of anaemia in pregnancy was 29.0% to 42.7%; and 60.6% to 71.3% in HIV-infected pregnant women. Three national surveys reported anaemia in children at 28.9%, 10.7%, and 61.3%, respectively. Overall, among the children under 5 years old, anaemia was more prevalent in 1-year-olds (52.0%) compared to the other age groups. Between 2005 and 2012, ID increased by 3.8% and IDA decreased by 83.2% in children. Anaemia in WRA and children under 5 years in South Africa was a moderate public health concern. Therefore, interventions addressing anaemia should be intensified, and policies on iron supplementation and food fortification need to be revised and aligned to the WHO multiple micronutrient supplementation recommendations.

Bayesian modelling of population trends in alcohol consumption provides empirically based country estimates for South Africa.

BACKGROUND: Alcohol use has widespread effects on health and contributes to over 200 detrimental conditions. Although the pattern of heavy episodic drinking independently increases the risk for injuries and transmission of some infectious diseases, long-term average consumption is the fundamental predictor of risk for most conditions. Population surveys, which are the main source of data on alcohol exposure, suffer from bias and uncertainty. This article proposes a novel triangulation method to reduce bias by rescaling consumption estimates by sex and age to match country-level consumption from administrative data. METHODS: We used data from 17 population surveys to estimate age- and sex-specific trends in alcohol consumption in the adult population of South Africa between 1998 and 2016. Independently for each survey, we calculated sex- and age-specific estimates of the prevalence of drinkers and the distribution of individuals across consumption categories. We used these aggregated results, together with data on alcohol production, sales and import/export, as inputs of a Bayesian model and generated yearly estimates of the prevalence of drinkers in the population and the parameters that characterise the distribution of the average consumption among drinkers. RESULTS: Among males, the prevalence of drinkers decreased between 1998 and 2009, from 56.2% (95% CI 53.7%; 58.7%) to 50.6% (49.3%; 52.0%), and increased afterwards to 53.9% (51.5%; 56.2%) in 2016. The average consumption from 52.1 g/day (49.1; 55.6) in 1998 to 42.8 g/day (40.0; 45.7) in 2016. Among females the prevalence of current drinkers rose from 19.0% (17.2%; 20.8%) in 1998 to 20.0% (18.3%; 21.7%) in 2016 while average consumption decreased from 32.7 g/day (30.2; 35.0) to 26.4 g/day (23.8; 28.9). CONCLUSIONS: The methodology provides a viable alternative to current approaches to reconcile survey estimates of individual alcohol consumption patterns with aggregate administrative data. It provides sex- and age-specific estimates of prevalence of drinkers and distribution of average daily consumption among drinkers in populations. Reliance on locally sourced data instead of global and regional trend estimates better reflects local nuances and is adaptable to the inclusion of additional data. This provides a powerful tool to monitor consumption, develop burden of disease estimates and inform and evaluate public health interventions.

Is South Africa closing the health gaps between districts? Monitoring progress towards universal health service coverage with routine facility data.

BACKGROUND: South Africa is committed to advancing universal health coverage (UHC). The usefulness and potential of using routine health facility data for monitoring progress towards UHC, in the form of the 16-tracer WHO service coverage index (SCI), was assessed. METHODS: Alternative approaches to calculating the WHO SCI from routine data, allowing for disaggregation to district level, were explored. Data extraction, coding, transformation and modelling processes were applied to generate time series for these alternatives. Equity was assessed using socio-economic quintiles by district. RESULTS: The UHC SCI at a national level was 46.1 in 2007-2008 and 56.9 in 2016-2017. Only for the latter period, could the index be calculated for all indicators at a district level. Alternative indicators were formulated for 9 of 16 tracers in the index. Routine or repeated survey data could be used for 14 tracers. Apart from the NCD indicators, a gradient of poorer performance in the most deprived districts was evident in 2016-2017. CONCLUSIONS: It is possible to construct the UHC SCI for South Africa from predominantly routine data sources. Overall, there is evidence from district level data of a trend towards reduced inequity in relation to specific categories (notably RMNCH). Progress towards UHC has the potential to overcome fragmentation and enable harmonisation and interoperability of information systems. Private sector reporting of data into routine information systems should be encouraged.

Sex Cord Stromal Tumors in Children and Adolescents: A First Report by The South African Children's Cancer Study Group (1990-2015).

OBJECTIVES: Pediatric sex cord stromal tumors (SCSTs) are extremely rare and there are no reported data from Africa. The authors evaluated the outcomes of children and adolescents with biopsy-proven SCSTs in preparation for the introduction of a national protocol. MATERIALS AND METHODS: Retrospective data were collated from 9 South African pediatric oncology units from January 1990 to December 2015. Kaplan-Meier analysis was performed to estimate overall survival (OS) and event-free survival. RESULTS: Twenty-three patients were diagnosed with SCSTs, 3 male and 20 female individuals, during the study period. Histologies included 1 thecoma, 9 Sertoli-Leydig cell tumors, and 13 juvenile granulosa cell tumors. Stage I tumors predominated (n=14; 60.9%), with 2 stage II (8.7%), 5 stage III (21.7%), and 2 stage IV tumors (8.7%). The upfront resection rate was 91.3% with no reported surgical morbidity or mortality and an OS of 82.1%. Chemotherapy approaches were not standardized. Most children (81.8%), except 2, had recognized platinum-based regimens. Chemotherapy-related toxicity was minimal and acceptable. Assessment of glomerular filtration rate and audiology assessments were infrequent and not standardized. Three patients were lost to follow-up. CONCLUSIONS: Although the numbers in this cohort are small, this study represents the first national cohort in Africa. The 5-year OS of 82.1% was encouraging. Standardized management of rare tumors like SCSTs is critical to improve ensure OS and address potential long-term sequelae.

Blood pressure trajectories during pregnancy and associations with adverse birth outcomes among HIV-infected and HIV-uninfected women in South Africa: a group-based trajectory modelling approach.

BACKGROUND: High blood pressure (BP) late in pregnancy is associated with preterm delivery (PTD); BP has also been associated with HIV and antiretroviral therapy (ART), but whether the relationship between BP assessed longitudinally over pregnancy and PTD and low birthweight (LBW) is modified by HIV/ART is unclear. We hypothesise the presence of distinctive BP trajectories and their association with adverse birth outcomes may be mediated by HIV/ART status. METHODS: We recruited pregnant women at a large primary care facility in Cape Town. BP was measured throughout pregnancy using automated monitors. Group-based trajectory modelling in women with ≥3 BP measurements identified distinct joint systolic and diastolic BP trajectory groups. Multinomial regression assessed BP trajectory group associations with HIV/ART status, and Poisson regression with robust error variance was used to assess risk of PTD and LBW. RESULTS: Of the 1583 women in this analysis, 37% were HIV-infected. Seven joint trajectory group combinations were identified, which were categorised as normal (50%), low normal (25%), high normal (20%), and abnormal (5%). A higher proportion of women in the low normal group were HIV-infected than HIV-uninfected (28% vs. 23%), however differences were not statistically significant (RR 1.27, 95% CI 0.98-1.63, reference category: normal). In multivariable analyses, low normal trajectory (aRR0.59, 0.41-0.85) was associated with decreased risk of PTD, while high normal (aRR1.48, 1.12-1.95) and abnormal trajectories (aRR3.18, 2.32-4.37) were associated with increased risk of PTD, and abnormal with increased risk of LBW (RR2.81, 1.90-4.15). CONCLUSIONS: While HIV/ART did not appear to mediate the BP trajectories and adverse birth outcomes association, they did provide more detailed insights into the relationship between BP, PTD and LBW for HIV-infected and uninfected women.

Predictors of silicosis and variation in prevalence across mines among employed gold miners in South Africa.

BACKGROUND: The stated intention to eliminate silicosis from the South African goldmining industry as well as current programmes to find and compensate ex-miners with silicosis require an understanding of variation in silicosis prevalence across the industry. We aimed to identify the predictors of radiological silicosis in a large sample of working miners across gold mines in South Africa. METHODS: Routine surveillance chest radiographs were collected from 15 goldmine "clusters" in a baseline survey undertaken in preparation for a separate tuberculosis isoniazid prophylaxis trial. All images were read for silicosis by a health professional experienced in using the International Labour Organisation (ILO) classification. Profusion thresholds of > 1/0 and > 1/1 were used. Demographic and occupational information was obtained by questionnaire. Predictors of silicosis were examined in a multivariable logistic regression model, including age, gender, racial ascription, country of origin, years since starting mine employment, mine shaft, skill category, underground work status and tuberculosis. RESULTS: The crude silicosis prevalence at ILO > 1/1 was 3.8% [95% confidence interval (CI) 3.5-4.1%]. The range across mine shafts was 0.8-6.9%. After adjustment for covariates, the interquartile range across shafts was reduced from 2.4 to 1.2%. Black miners [adjusted odds ratio (aOR) 2.8; 95% CI 1.1-7.2] and miners in full-time underground work (aOR 2.1; 95% CI 1.3-3.4) had substantially elevated odds of silicosis, while workers from Mozambique had lower odds (aOR 0.54; 95% CI 0.38-0.77). Silicosis odds rose sharply with both age and years since starting in the industry (p for linear trend < 0.005), with 95.5% of affected miners having > 15 years since first exposure and 2.2% < 10 years. CONCLUSIONS: In surveillance of silicosis in working gold miners time since first exposure remains a powerful predictor. Age appears to be an independent predictor, while the detection of radiological silicosis in short-service miners requires attention. Public risk reporting by mines should include factors bearing on silicosis prevalence, specifically dust concentrations, with independent verification. Studies of silicosis and tuberculosis in ex-miners are needed, supported by an accessible electronic database of the relevant medical and dust exposure records of all gold miners.

Association between perinatal depressive symptoms and suicidal risk among low-income South African women: a longitudinal study.

PURPOSE: The aim of this study was to assess the association between depressive symptoms and suicidal risk over time among perinatal women at risk for depression antenatally, and assess modifying effects of age, perinatal stage and depressive symptom trajectory. METHODS: A total of 384 adult pregnant women were recruited from two antenatal clinics in an informal settlement near Cape Town, South Africa, and followed up at eight months gestation, and at 3- and 12-month postpartum. The MINI 6.0 Suicidality module and the Hamilton Depression Rating Scale (HDRS) were used to measure suicidal risk and depression, respectively. Generalised Estimating Equations were used to assess the association between change in depressive symptoms from one assessment to the next (predictor) and change in suicide score or change in suicidal risk (score ≥ 9) (outcomes). RESULTS: HDRS scores were positively correlated with suicide score (95% CI 0.35, 0.78; p < 0.001), and with odds of being at moderate risk for suicide, after controlling for risk of suicide at the previous assessment (adjusted odds ratio = 1.15; 95% CI 1.09, 1.22; p < 0.001). Age was a significant effect modifier: change in HDRS scores was not associated with change in suicide scores among participants aged 35-45 years. Secondary analyses indicated that a decrease in HDRS score was associated with a decrease in suicide scores, but an increase in HDRS score was not associated with change in suicide score. CONCLUSIONS: Depression and suicide are overlapping but relatively independent phenomena, especially among older or more chronically depressed perinatal women.

Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36 months.

PURPOSE: Latent modelling was used to identify trajectories of depressive symptoms among low-income perinatal women in South Africa. Predictors of trajectories and the association of trajectories with child outcomes were assessed. METHODS: This is a secondary analysis of data collected among women living in Cape Town settlements (N = 446). Participants were eligible if pregnant and 18 years or older, and included in the analysis if allocated to the control arm (routine perinatal care). Participants were excluded in case of non-singleton birth and baby death. Follow-up assessments were at 2 weeks, 6-, 18-, and 36-month postpartum. Trajectories of depressive symptoms were based on the Edinburgh Postnatal Depression Scale scores until 18-month postpartum, using latent class growth analysis. Child physical, cognitive, socio-emotional, and behavioural outcomes were assessed at 18 and/or 36 months. Univariate and multivariate regressions were used to identify predictors of trajectories and differences in child outcomes. RESULTS: Four trajectories were identified: chronic low (71.1%), late postpartum (10.1%), early postpartum (14.4%), and chronic high (4.5%). Low social support, unwanted pregnancy, and risky drinking were associated with the chronic high trajectory; unemployment and HIV-positive status with the early postpartum trajectory; and intimate partner violence with the late postpartum trajectory. Weight-to-length and weight-for-age z-scores at 18 months, and weight-for-age z-scores, length-for-age z-scores, emotional symptom, and peer problem scores at 36 months differed across trajectories. CONCLUSIONS: Severe depressive symptoms in postpartum period have a lasting effect on child physical and socio-emotional outcomes. Multiple screening throughout pregnancy and 1-year postpartum is essential.

Antihypertensive treatment and blood pressure trends among South African adults: A repeated cross-sectional analysis of a population panel survey.

BACKGROUND: Recent findings suggest a decline in mean blood pressure and prevalence of uncontrolled hypertension in the South African adult population in the last decade, in contrast with the increase previously observed. This study aimed at quantifying the contribution of antihypertensive treatment to this decline. METHODS: We used data from the four waves of the National Income Dynamics Study between 2008 and 2015 and analysed changes in systolic (SBP) and diastolic blood pressure (DBP) and prevalence of uncontrolled hypertension among South African adults (15 years and above). We compared the observed changes with a counterfactual scenario in which the impact of antihypertensive treatment was estimated by censored regression and removed, with and without adjustment for BMI, waist circumference, alcohol use and smoking. RESULTS: During the study period, the prevalence of antihypertensive treatment rose from 13.1% to 17.6% among women and from 5.3% to 8.2% among men. Concurrently-despite worsening trends in major biobehavioural risk factors for elevated blood pressure-mean SBP decreased in both genders, DBP decreased among women and was stable among men. The odds of uncontrolled hypertension decreased by 4%/year among women and 1%/year among men. After removing the treatment effect, the downward trend in the odds of uncontrolled hypertension was reduced to 1%/year among women and completely offset among men. Among those 55 years and older, but not among younger subjects, treatment effects also explained most of the observed decreases in mean SBP and DBP. CONCLUSIONS: Among South African adults, we infer that diffusion of antihypertensive treatment contributed substantially to the downward trend in the prevalence of uncontrolled hypertension observed between 2008 and 2015. The marked decrease in SBP and uncontrolled hypertension found among younger participants could not be explained by treatment nor by the changing distribution of the measured risk factors available in this study, and requires further investigation.