Evaluation of the malaria case surveillance system in KwaZulu-Natal Province, South Africa, 2022: a focus on DHIS2.

BACKGROUND: South Africa set a target to eliminate malaria by 2023, with KwaZulu-Natal (KZN) Province the malaria-endemic province closest to achieving this goal. Objective two of the National Malaria Elimination Strategic Plan (NMESP) focused on strengthening surveillance systems to support the country's elimination efforts. Regular evaluations of the malaria surveillance systems against the targets of the NMESP objective are crucial in improving their performance and impact. This study aimed to assess whether the malaria surveillance system in KwaZulu-Natal Province meets the NMESP surveillance objective and goals. METHODS: A mixed-methods cross-sectional study design was used to evaluate the malaria surveillance system, focusing on the District Health Information System 2 (DHIS2). The study assessed the data quality, timeliness, simplicity, and acceptability of the system. Key personnel from KZN's Provincial malaria control programme were interviewed using self-administered questionnaires to evaluate their perception of the system's simplicity and acceptability. Malaria case data from January 2016 to December 2020 were extracted from the DHIS2 and evaluated for data quality and timeliness. RESULTS: The survey respondents generally found the DHIS2-based surveillance system acceptable (79%, 11/14) and easy to use (71%, 10/14), stating that they could readily find, extract, and share data (64%, 9/14). Overall data quality was good (88.9%), although some variables needed for case classification had low completeness and data availability. However, case notifications were not timely, with only 61% (2 622/4 329) of cases notified within 24 h of diagnosis. During the 5-year study period, the DHIS2 captured 4 333 malaria cases. The majority of cases (81%, 3 489/4 330) were categorized as imported, and predominately in males (67%, 2 914/4 333). CONCLUSION: While the malaria surveillance system in KZN Province largely met the NMESP surveillance strategic goals, it failed to achieve the overarching surveillance objective of 100% notification of cases within 24 h of diagnosis. The majority of reported cases in KZN Province were classified as imported, emphasizing the importance of complete data for accurate case classification. Engaging with healthcare professionals responsible for case notification and disseminating aggregated data back to them is needed to encourage and improve notification timeliness.

Knowledge, Attitudes, Practices, and Acceptability of Medical Male Circumcision among Males in Traditionally Circumcising Rural Communities of Alfred Nzo District, Eastern Cape, South Africa.

Male circumcision (MC) reduces HIV transmission risk by up to 60% in heterosexual men. However, uptake of medical male circumcision (MMC) is low in traditionally circumcising communities of South Africa. We assessed knowledge, attitudes, and practices to identify factors predicting acceptability of MMC among males in the Alfred Nzo District. A cross-sectional study was conducted among males aged 15-49 years in this district. Logistic regression was used to identify factors predicting acceptability of MMC. We interviewed 343 males who had a median age of 19 years (interquartile range (IQR): 16-25 years). Of these, 77% (95% confidence interval (CI): 72-82) were circumcised: 77% (95% CI: 71-82) were circumcised in a traditional setting and 21% (95% CI: 16-26) in a medical setting. The median score of knowledge about the benefits of MMC was 62.5% (IQR: 37.5-75.0), with 59% (95% CI: 53-64) demonstrating a positive attitude towards MMC and 68% (95% CI: 63-73) accepting involvement of health workers in MC. Excellent knowledge (adjusted odds ratio (aOR): 3.07, 95% CI: 0.99-9.58, p = 0.053), awareness (aOR: 3.26, 95% CI: 1.08-9.86, p = 0.037), and positive attitude towards MMC (aOR: 2.35, 95% CI: 1.30-4.25, p = 0.005) were associated with acceptability of MMC. Participants demonstrated good knowledge and acceptance of the MMC programme. Knowledge, attitude, and awareness were significant predictors of MMC acceptability.

Estimation of shedding time in laboratory-confirmed COVID-19 cases in South Africa: a population-based record linkage study, March-December 2020.

Introduction: in South Africa, COVID-19 cases are notifiable and hospitalized cases are reported on a dedicated platform. It is crucial to estimate the duration of SARS-CoV-2 shedding to inform public health interventions. We aimed to estimate viral shedding time among laboratory-confirmed COVID-19 cases in South Africa. Methods: we analyzed COVID-19 PCR results from 5 March to 31 December 2020. We included cases with at least 2 consecutive positive PCR tests and a subsequent negative test. We performed multiple linear regression to determine the association between shedding time and predictor variables (age, sex, admission status and province). We included 2752 cases that met the inclusion criteria. Results: about 39.9% (1099/2752) of participants were inpatients and 60.1% (1653/2752) were outpatients. The median shedding time was 17 days (range: 1-128). There was no difference in shedding time between males and females and between hospitalized patients and outpatients. Individuals aged 0-4 years had the lowest shedding time (median: 14 days, range: 1-72). After adjusting for age, sex and province, shedding time was shorter for hospitalized patients compared to outpatients (co-efficient: -0.14, CI: -0.24 - -0.03, P-value: 0.014). Six provinces (KwaZulu-Natal, Gauteng, Limpopo, North West, Mpumalanga, and Western Cape) had a significant association with shedding time. Conclusion: the duration of viral shedding within our population varies from 1-128 days. Although prolonged shedding might not necessarily indicate infectiousness, individual patient monitoring and management are needed for patients with prolonged shedding. Further studies are required to explore the association between comorbidities and SARS-CoV-2 shedding time.

Risk factors for breast cancer among women in Ekurhuleni Metropolitan Municipality, Gauteng province of South Africa, 2017‒2020: a case-control study.

Introduction: Breast cancer (BC) is the most common cancer among women in South Africa (SA), with an age-standardised incidence rate of 52.6 and an age-standardised mortality rate of 16.0 per 100,000 population. There is a paucity of evidence on the risk factors for BC among women of all races in SA. Given the rising prevalence of BC in SA, literature-based evidence is critical for the appropriate dissemination of preventative measures. This study aimed to identify the risk factors associated with the development of BC among women in Ekhuruleni Metropolitan Municipality. Methods: An unmatched case-control study was conducted from 1 January 2017 to 31 December 2020 using secondary data extracted from the Ekurhuleni Population-Based Cancer Registry. Unconditional multivariable logistic regression analysis was carried out using the adjusted odds ratio (aOR). The variables race, employment, human immunodeficiency virus (HIV), smoking and alcohol status were included in the multivariable logistic regression model while the model was adjusted for age. Results: A total of 2,217 cases and 851 controls were enrolled in the study. The mean age (±SD) in years was 55.7 (±15.2). The White population group, being self-employed and being HIV positive was significantly associated with reduced odds of BC development. HIV-positive women were 61% less likely to have BC than women who were HIV-negative (aOR 0.39; 95% confidence interval (CI): 0.27‒0.57). White women were 65% less likely to have BC than women of other races (aOR 0.35; 95% CI: 0.29‒0.43). Self-employed women were 59% less likely to have BC than women who were formally employed (aOR 0.41; 95% CI: 0.18‒0.97). No evidence of association was observed between tobacco smoking and BC as well as alcohol consumption and BC. Conclusion: There was a 65% reduction in BC risk among White women compared to other races. HIV-positive women demonstrated a 61% lower likelihood of BC while self-employed women showed a 59% reduced risk of developing BC. These findings suggest that being White, self-employed or HIV-positive may provide some protection against BC. However, additional research is needed to validate these results and establish the underlying reasons behind these associations.

Evaluation of the rubella surveillance system in South Africa, 2016-2018: A cross-sectional study.

BACKGROUND: Rubella is a leading vaccine-preventable cause of birth defects. We conducted this study to evaluate the rubella surveillance system in South Africa from 2016 to 2018. The rubella surveillance system had not been evaluated since its inception; therefore, a formal evaluation is necessary to assess key attributes and to ascertain the extent to which the system achieves its objectives. METHODS: We conducted a cross-sectional study to assess the usefulness, simplicity, positive predictive value, timeliness, and data quality of the rubella surveillance system from 2016 to 2018. We reviewed retrospective rubella surveillance data and conducted a survey with key stakeholders of the system. We compiled a summary report from the survey and calculated the annualized detection rate of rubella and non-rubella febrile rash, positive predictive value, the proportion of complete records, and timeliness between the surveillance steps. We compared our results with recommended performance indicators from the 2015 revised World Health Organization African regional guidelines for measles and rubella surveillance. RESULTS: The rubella surveillance system was useful but weak in terms of simplicity. The annualized detection rate of rubella febrile rash was 1.5 per 100,000 populations in 2016, 4.4 in 2017, and 2.1 in 2018. The positive predictive value was 29.1% in 2016, 40.9% in 2017, and 32.9% in 2018. The system did not meet the timeliness goal in the health facility component but met this goal in the laboratory component. The system had poor data quality, particularly in the health facility component. CONCLUSIONS: The rubella surveillance system was useful, although it was not simple to use and had low PPV, poor timeliness, and poor data quality. Efforts should be made to improve the system's simplicity, PPV, timeliness, and data quality at the facility level.

Association between preeclampsia and HIV: a case-control study in urban South Africa.

BACKGROUND: Preeclampsia is a considerable cause of maternal and infant morbidity and mortality. Although its etiology is unknown, preeclampsia has been described as a state of exaggerated maternal inflammatory response. Therefore, it has been hypothesized that preeclampsia would occur less commonly in states of immune deficiency. OBJECTIVE: This study aimed to compare the prevalence of treated and untreated HIV infections among preeclamptic cases and controls, determine infant outcomes, and evaluate the association between HIV and preeclampsia after adjusting for known predictor variables, including maternal age, gravidity, body mass index, and smoking. STUDY DESIGN: This case-control study investigated the association between preeclampsia and HIV infection using secondary data from an unrelated study. We defined preeclamptic cases as pregnant women who were normotensive until 20 weeks of gestation and thereafter had at least 1 high blood pressure measurement either before or at delivery and proteinuria, defined as protein excretion of ≥300 mg within 24 hours or >2 protein on dipstick urinalysis. The prevalence of HIV infection was compared between cases and controls. Multivariate logistic regression analysis was used to assess the association between preeclampsia and potential confounding variables and reported using odds ratios and 95% confidence intervals. RESULTS: There were 571 cases with preeclampsia and 596 normotensive controls included in this study. The median age was 27 years for cases and 26 years for controls (P=.008). Most participants (69%) had ≥2 previous pregnancies with no difference between the cases and controls (P=.176). Overall, 43% of the participants were obese, with a mean body mass index of 29 (interquartile range, 24.5-34.2), with higher proportions of women who were overweight and obese in the group with preeclampsia (P=.031). The prevalence of HIV was significantly lower in cases than in controls (24% vs 30%, respectively; P=.014). Compared with 16% of infants born preterm to normotensive controls, 48% of infants were born preterm born to women with preeclampsia (P<.001). Compared with 14% of infants born with low birthweight to normotensive controls, 53% of infants were born with low birthweight to women with preeclampsia (P<.0001). Untreated HIV infection was negatively associated with preeclampsia (unadjusted odds ratio, 0.330; 95% confidence interval, 0.197-0.552; P<.0001), whereas factors associated with preeclampsia were advanced maternal age (odds ratio, 1.673; 95% confidence interval, 1.209-2.316; P=.002) and obesity (odds ratio, 1.611; 95% confidence interval, 1.023-2.537; P=.040). After adjusting for maternal age, gravidity, smoking, and body mass index in the multivariate regression, only obesity remained significantly associated with preeclampsia (adjusted odds ratio, 1.624; 95% confidence interval, 1.024-2.575; P=.039). CONCLUSION: Before the large-scale rollout of antiretroviral therapy in a setting with a high burden of HIV and preeclampsia, untreated HIV infection was found to have a protective effect against preeclampsia. The protective effect against preeclampsia was not apparent for HIV infection treated with antiretroviral therapy.

Skin cancer risk factors among Black South Africans-The Johannesburg Cancer Study, 1995-2016.

BACKGROUND: The Black population has lower skin cancer incidence compared to White, Indian/Asian, and Mixed-race populations in South Africa; however, skin cancer still exists in the Black population. The aim of this study is to identify risk factors associated with skin cancer among Black South Africans. MATERIALS AND METHODS: A case-control study was conducted. Cases were patients with keratinocyte cancers (KCs) and/or melanoma skin cancers (MSCs) and controls were cardiovascular patients. Sociodemographic exposures, environmental health variables, smoking, and HIV status were assessed. Stepwise logistic regression was used to identify risk factors associated with KCs and MSCs. RESULTS: The KCs histological subtypes showed that there were more squamous cell carcinomas (SCCs) (78/160 in females, and 72/160 in males) than basal cell carcinomas (BCCs). The SCC lesions were mostly found on the skin of the head and neck in males (51%, 38/72) and on the trunk in females (46%, 36/78). MSC was shown to affect the skin of the lower limbs in both males (68%, 27/40) and females (59%, 36/61). Using females as a reference group, when age, current place of residency, type of cooking fuel used, smoking, and HIV status were adjusted for, males had an odds ratio (OR) of 2.04 for developing KCs (confidence interval [CI]: 1.08-3.84, p = .028). Similarly, when age, current place of residency, and place of cooking (indoors or outdoors) were adjusted for, males had an OR of 2.26 for developing MSC (CI: 1.19-4.29, p = .012). CONCLUSIONS: Differences in the anatomical distribution of KCs by sex suggest different risk factors between sexes. There is a positive association between being male, smoking, rural dwelling, and a positive HIV status with KCs and being male and rural dwelling with MSC. The rural dwelling was a newly found association with skin cancer and warrants further investigation.

Trends in RPR Seropositivity among Children Younger than 2 Years in South Africa, 2010-2019.

A positive rapid plasma reagin (RPR) result in children under the age of 2 years indicates either passive transplacental transfer of maternal antibodies or active infection with syphilis (possible congenital syphilis). We describe trends in RPR seropositivity in this population using centralized laboratory data. A secondary analysis of laboratory data collected through the National Health Laboratory Service, Corporate Data Warehouse from 2010 to 2019 was conducted. Of the 127 150 children <2 years included in the analysis, 10 969 [8.6%; 95% confidence interval (95% CI) 85-88]) were RPR seropositive. RPR seropositivity increased from 6.5% to 13.0% between 2010 and 2019. Overall, the annual rate of RPR seropositivity was relatively stable between 2010 and 2018 with a range of 89-127/100 000 live births, increasing sharply to 165/100 000 livebirths in 2019. KwaZulu-Natal and North West provinces recorded the largest increases in annual seropositivity rate, while Eastern Cape and Western Cape had the most significant declines. Although this analysis is limited to laboratory results, in the absence of major changes in testing practices, there may be a rise in the burden of antenatal syphilis exposure in utero indicating an increase in maternal syphilis and syphilis transmission in the general population. South Africa needs to intensify Mother-to-Child Transmission of syphilis elimination efforts to reach the WHO target of ≤50 cases per 100 live births by 2030.

Completeness of Reporting for Breast Cancer Data in the National Pathology-Based Cancer Registry in South Africa.

BACKGROUND: It is important for a cancer registry to have adequate coverage of the catchment area to accurately estimate the cancer burden. This study aimed to determine the pathology-based South African National Cancer Registry's (NCR's) catchment rate of breast cancer cases using a hospital-based cancer registry as reference. METHODS: Using 2 record linkage approaches, a combination of deterministic record linkage (DRL) and probabilistic record linkage (PRL), we linked a breast cancer hospital registry (n = 398) from 2015 with breast cancer registry data from the NCR (n = 16,642). Firstly, using DRL, we matched and linked records using the unique laboratory report number. Records that were not matched using DRL were linked using PRL. Manual reviews of both data sources were then performed to evaluate records that did not match using either DRL or PRL. The NCR's catchment rate was calculated using the total number of matched records from the hospital registry to the NCR breast cancer registry. RESULTS: Of 398 records from the hospital registry, 397 were matched to the NCR breast cancer registry, giving the NCR a catchment rate of 99.75%. A total of 291 records were matched with NCR records by DRL; 95, by PRL; and 11, by manual review. Only 1 record did not match. CONCLUSION: Nearly all hospital breast cancer cases were found in the NCR database. This suggests that the workflow used by the NCR for the identification, collection, and registration of breast cancer cases diagnosed histologically is adequate for this hospital.

Epidemiology of laboratory-confirmed mumps infections in South Africa, 2012-2017: a cross-sectional study.

BACKGROUND: Data on the burden of mumps in South Africa are limited and the epidemiology of mumps in this setting is not well understood. We present an analysis of mumps data in South Africa from 2012 to 2017. METHODS: This cross-sectional study included secondary data on laboratory-confirmed mumps infections from 2012 to 2017, archived at the South African National Health Laboratory Services' data repository as well as from four private laboratories. Mumps-specific immunoglobulin M (IgM) and/or viral nucleic acid positive results represented acute infections. We used age-specific mid-year population estimates for each study year as denominators when calculating annual cumulative incidence. Seasonality was based on the season that showed a peak in infections. RESULTS: Out of 48,580 records obtained from the public and private sectors, 46,713 (96.2%) were from the private sector. Over the study period, there were 7494 acute infections, 7085 (94.5%) of which were recorded in the private sector. Of these 7494 infections, 3924 (52.4%) occurred in males. The proportion of samples tested that were IgM positive was 18.6% (1058/5682) in 2012, 15% (1016/6790) in 2013, 15.8% (1280/8093) in 2014, 15.5% (1384/8944) in 2015, 13.1% (1260/9629) in 2016 and 15.8% (1496/9442) in 2017. The cumulative incidence rate per 100,000 was highest in children between one and 9 years throughout the study period. The cumulative incidence of infections was highest in the Western Cape, Gauteng and the Northern Cape. Infections peaked in June and November. CONCLUSION: Laboratory-confirmed mumps infections predominantly occurred in spring, affecting children below 10 years of age and individuals who were male. There were fewer tests performed in the public sector compared to the private sector. Since only laboratory data was analysed our results represent and underestimate of disease burden. Further studies that include clinical data are required to provide better estimates of disease burden in South Africa.

Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study.

BACKGROUND: In South Africa, 30.9% of children under five years with Severe Acute Malnutrition (SAM) died in 2018. We aimed to identify factors associated with mortality among children under five years hospitalized with SAM in Limpopo province, South Africa. METHODS: We conducted a cross-sectional study including children under five years admitted with SAM from 2014 to 2018 in public hospitals of Limpopo province. We extracted socio-demographic and clinical data from hospital records. We used logistic regression to identify factors associated with mortality. FINDINGS: We included 956 children, 50.2% (480/956) male and 49.8% (476/956) female. The median age was 13 months (inter quartile range: 9-19 months). The overall SAM mortality over the study period was 25.9% (248/956). The most common complications were diarrhea, 63.8% (610/956), and lower respiratory tract infections (LRTIs), 42.4% (405/956). Factors associated with mortality included herbal medication use (adjusted Odds Ratio (aOR): 2.2, 95% Confidence Interval (CI): 1.4-3.5, p = 0.001), poor appetite (aOR: 2.7, 95% CI: 1.4-5.2, p = 0.003), Mid-upper circumference (MUAC) <11.5 cm (aOR: 3.0, 95% CI: 1.9-4.7, p<0.001), lower respiratory tract infections (LRTIs) (aOR: 1.6, 95% CI: 1.2-2.0, p<0.001), anemia (aOR: 2.5, 95% CI: 1.1-5.3, p = 0.021), hypoglycemia (aOR: 12.4, 95% CI: 7.1-21.8, p<0.001) and human immunodeficiency virus (HIV) infection (aOR: 2.3, 95% CI: 1.6-3.3, p<0.001). INTERPRETATION: Herbal medication use, poor appetite, LRTIs, anemia, hypoglycemia, and HIV infection were associated with mortality among children with SAM. These factors should guide management of children with SAM.

Healthcare seeking behaviour for common infectious syndromes among people in three administrative regions of Johannesburg, South Africa, 2015: a cross-sectional study.

INTRODUCTION: Hospital-based surveillance programs only capture people presenting to facilities and may underestimate disease burden. We conducted a healthcare utilisation survey to characterise healthcare-seeking behaviour among people with common infectious syndromes in the catchment areas of two sentinel surveillance hospitals in Johannesburg, South Africa. METHODS: A cross-sectional survey was conducted within three regions of Johannesburg from August to November 2015. Premises were randomly selected from an enumerated list with data collected on household demographics and selected syndromes using a structured questionnaire. Fisher's exact or chi-square tests were used to determine association of characteristics among different regions. RESULTS: Of 3650 selected coordinates, 3358 were eligible dwellings and 2930 (87%) households with 9850 individuals participated. Four percent of participants (431/9850) reported influenza-like illness (ILI) in the last 30 days; equal numbers of participants (0.2%, 20/9850) reported pneumonia or tuberculosis symptoms in the last year and <1% reported diarrhoea or meningitis symptoms. Sixty eight percent (295/431) of participants who reported ILI, 75% (6/8) of children with diarrhoea and all participants who reported pneumonia (20), tuberculosis (20) or meningitis (6) sought healthcare. For all syndromes most sought care at registered healthcare providers. Of these only 10% (24/237) attended sentinel hospitals, predominantly those that lived closer to the hospitals. In contrast, of patients with meningitis, 50% (3/6) sought care at sentinel hospitals. CONCLUSION: Patterns of seeking healthcare differed by syndrome and distance from facilities. Surveillance programs are still relevant in collecting information on infectious syndromes and reflect a proportion of the hospital's catchment area.

The performance of different case definitions for severe influenza surveillance among HIV-infected and HIV-uninfected children aged <5 years in South Africa, 2011-2015.

In 2014, the World Health Organization (WHO) proposed a new severe influenza surveillance case definition, which has not been evaluated in a high human immunodeficiency virus (HIV) prevalence setting. Our study aimed to assess the performance of this proposed case definition in identifying influenza among HIV-uninfected and HIV-infected children aged <5 years in South Africa. We prospectively enrolled children aged <5 years hospitalised with physician-diagnosed lower respiratory tract infection (LRTI) at two surveillance sites from January 2011 to December 2015. Epidemiologic and clinical data were collected. We tested nasopharyngeal aspirates for influenza using reverse transcription polymerase chain reaction. We used logistic regression to assess factors associated with influenza positivity among HIV-infected and HIV-uninfected children. We calculated sensitivity and specificity for different signs and symptoms and combinations of these for laboratory-confirmed influenza. We enrolled 2,582 children <5 years of age with LRTI of whom 87% (2,257) had influenza and HIV results, of these 14% (318) were HIV-infected. The influenza detection rate was 5% (104/1,939) in HIV-uninfected and 5% (16/318) in HIV-infected children. Children with measured fever (≥38°C) were two times more likely to test positive for influenza than those without measured fever among the HIV-uninfected (OR 2.2, 95% Confidence Interval (CI) 1.5-3.4; p<0.001). No significant association was observed between fever and influenza infection among HIV-infected children. Cough alone had sensitivity of 95% (95% CI 89-98%) in HIV-uninfected and of 100% (95% CI 79-100%) in HIV-infected children but low specificity: 7% (95% CI 6-8%) and 6% (95% CI 3-9%) in HIV-uninfected and HIV-infected children, respectively. The WHO post-2014 case definition for severe acute respiratory illness (SARI-an acute respiratory infection with history of fever or measured fever of ≥ 38°C and cough; with onset within the last ten days and requires hospitalization), had a sensitivity of 66% (95% CI 56-76%) and specificity of 46% (95% CI 44-48%) among HIV-uninfected and a sensitivity of 63% (95% CI 35-84%) and a specificity of 42% (95% CI 36-48%) among HIV-infected children. The sensitivity and specificity of the WHO post-2014 case definition for SARI were similar among HIV-uninfected and HIV-infected children. Our findings support the adoption of the 2014 WHO case definition for children aged <5 years irrespective of HIV infection status.

Prevalence and risk factors contributing to antibiotic-resistant Staphylococcus aureus isolates from poultry meat products in South Africa, 2015-2016.

Staphylococcus aureus, including methicillin-resistant strains, has been detected in food products of animal origin globally. Limited data have been reported on the factors contributing to antibiotic resistance of food-borne pathogens in South Africa. The primary aim of this study was to determine the prevalence of S. aureus, including antibiotic-resistant strains, in poultry meat products as well as the evaluation of potential risk factors for contamination of poultry meat products with antibiotic-resistant S. aureus isolates. A cross-sectional investigation was conducted in municipalities located across the nine provinces of South Africa, which included abattoirs, meat processing facilities, retail outlets and cold stores at the major ports of entry into South Africa. Staphylococcus aureus isolates obtained from various poultry meat products were tested for susceptibility to 14 antibiotic compounds representing 10 antibiotic classes using the Kirby-Bauer disc diffusion method. Potential risk factors were evaluated using a logistic regression model. Of the 311 samples tested, 34.1% (n = 106) were positive for S. aureus (95% confidence interval [CI], 28.9% - 39.7%). Seventy-two of the 106 isolates were randomly selected for antibiotic sensitivity testing. Twenty-one per cent (n = 15) of the isolates selected for sensitivity testing were methicillin-resistant strains (95% CI, 12.2% - 32.0%). Multi-drug resistance was detected in 22.2% (n = 16) of these isolates tested (95% CI, 13.3% - 33.6%). Origin of the product (p = 0.160), type of meat product (p = 0.962), type of facility (p = 0.115) and facility hygiene practices (p = 0.484) were not significantly associated with contamination of poultry meat products with methicillin-resistant strains. The study provides baseline data for further studies on antibiotic resistance risk assessments for food-borne pathogens, including S. aureus, which should guide the implementation plans of the South African National Antimicrobial Resistance Strategy Framework, 2017-2024.

Cognitive and behavioural determinants of multiple sexual partnerships and condom use in South Africa: Results of a national survey.

BACKGROUND: Human immunodeficiency virus (HIV) risky behaviours including multiple sexual partnership (MSP) and non-condom use (nCU) are known to be drivers of the spread of HIV; cognitive factors including perceived susceptibility of HIV, self-efficacy and attitudes play a significant role in influencing risky sexual behaviours. OBJECTIVES: We sought to investigate personal beliefs, perceptions, thoughts and actions that are associated with MSP and nCU in South Africa. METHODS: We analysed nationally representative data from the 2012 National HIV Communication Survey (NCS) that included about 10 000 participants aged 16-55 years. Five constructs were created to measure psychosocial and cognitive determinants. Cronbach's alpha coefficient for internal consistency reliability was calculated. Multivariable logistic regression was used to determine factors associated with MSP and nCU. RESULTS: Of the 6061 sexually active respondents, 13% (95% CI: 11.47-13.12) reported MSP and 52.7% (n = 3158 of 6039) (95% CI: 51.0-53.55) nCU at last sex. Factors associated with MSP included perceived benefits, adjusted odds ratio (aOR) = 2.16 (95% CI: 1.80-2.58), perceived susceptibility to HIV, aOR = 2.22 (95% CI: 1.83-2.69) and engaging in intergenerational sex, aOR = 2.14 (95% CI: 1.78-2.56). Predictors of nCU were perceived benefits, aOR = 1.25 (95% CI: 1.09-1.43); perceived susceptibility to HIV, aOR = 1.6 (95% CI: 1.39-1.83); and personal beliefs, aOR = 1.35 (95% CI: 1.13-1.62). CONCLUSION: Cognitive and behavioural factors were found to be predictors of risky sexual behaviours for HIV. This highlights the importance of considering personal perception and reasoning when attempting to understand and influence an individual's sexual behaviour. This could be done through enhancing awareness of HIV risk in the general population and by influencing cognitive behaviour change through community mobilisation, advocacy and creating activities to improve self-esteem.

Common Mental Health Disorders among Informal Waste Pickers in Johannesburg, South Africa 2018-A Cross-Sectional Study.

Waste-picking is an income-generating opportunity for individuals living in poverty. Waste picking is associated with a range of risk factors for common mental disorders (CMD). This study aimed to determine the prevalence and factors associated with CMD among waste pickers in Johannesburg. A cross-sectional study analyzed secondary data for 365 waste pickers. A validated Self-Reporting Questionnaire (SRQ-20) was used to assess CMD. Multivariable logistic regression was fitted to identify factors associated with CMD. The overall prevalence of CMD among waste pickers was 37.3%. The odds of having CMD were 2.5 and 3.2 higher in females and cigarette smokers, respectively (p = 0.019 and p = 0.003). Life enjoyment (Adjusted odds ratio [aOR] 0.54, p = 0.02) and a good quality of life (aOR 0.34, p ≤ 0.001) were associated with lower odds of CMD. The high prevalence of CMD among waste pickers was significantly associated with cigarette smoking, being female, not enjoying life, and a poor quality of life. Mental health awareness of CMD will assist with the prevention, early detection, and comprehensive management of CMD among waste pickers.

South Africa field epidemiology training program: developing and building applied epidemiology capacity, 2007-2016.

In 2007, South Africa (SA) launched a field epidemiology training program (SAFETP) to enhance its capacity to prevent, detect, and respond to public health threats through training in field epidemiology. The SAFETP began as a collaboration between the SA National Department of Health (NDOH), National Institute for Communicable Diseases (NICD), and the University of Pretoria (UP), with technical and financial support from the U.S. Centers for Disease Control and Prevention (CDC). In 2010, the CDC in collaboration with the NICD, established a Global Disease Detection (GDD) Center in SA, and the SAFETP became a core activity of the GDD center. Similar to other FETPs globally, the SAFETP is a 2-year, competency-based, applied epidemiology training program, following an apprenticeship model of 'learn by doing'. SAFETP residents spend approximately 25% of the training in classroom-based didactic learning activities, and 75% in field activities to attain core competencies in epidemiology, biostatistics, outbreak investigation, scientific communication, surveillance evaluation, teaching others, and public health leadership. Residents earn a Master's in Public Health (MPH) degree from UP upon successfully completing a planned research study that serves as a mini-dissertation.Since 2007, SAFETP has enrolled an average of 10 residents each year and, in 2017, enrolled its 11th cohort. During the first 10 years of the program, 98 residents have been enrolled, 89% completed the 2-year program, and of these, 76 (87%) earned an MPH degree. Of those completing the program, 88% are employed in the public health sector, and work at NICD, NDOH, Provincial Health Departments, foreign health institutions, or non-governmental organizations. In the first 10 years of the program, the combined outputs of trainees included over 130 outbreak investigations, more than 150 abstracts presented at national and international scientific conferences, more than 80 surveillance system evaluations, and more than 45 manuscripts published in peer-reviewed scientific journals. The SAFETP is having an impact in building epidemiology capacity for public health in South Africa. Developing methods to directly link and measure the impact of the program is planned for the future.

Risk factors for mortality among adults registered on the routine drug resistant tuberculosis reporting database in the Eastern Cape Province, South Africa, 2011 to 2013.

INTRODUCTION: South Africa is among countries with the highest burden of drug resistant tuberculosis (DR-TB). The Eastern Cape Province reported the highest MDR-TB mortality rates in South Africa for the 2010 treatment cohorts. This study aimed to determine risk factors for mortality among adult patients registered for DR-TB treatment in the province. METHODS: We conducted a retrospective cohort study of adult patients treated for laboratory confirmed DR-TB between January 2011 and December 2013. Demographic and clinical characteristics of the patients were obtained from a web-based electronic database of patients treated for DR-TB. We applied modified Poisson regression with robust standard errors to identify risk factors for DR-TB mortality. We also stratified the analyses into multi-drug resistant TB (MDR-TB) and extensively drug resistant (XDR-TB). RESULTS: Among 3,729 patients that met the inclusion criteria, 39% (n = 1,445) died. Of the patients that died, 53% (n = 766) were male, 68% (n = 982) had MDR-TB, 72% (n = 1,038) were HIV co-infected, and median age was 37 years (Interquartile Range [IQR] 30-46). Patients were at higher risk of mortality during DR-TB treatment if they were HIV co-infected not on antiretroviral treatment (ART) (adjusted incidence risk ratio [aIRR] 3.3, 95% confidence interval [CI] 2.9-3.8), were 60 years or older (aIRR 1.7, 95%CI 1.5-2.0), had a diagnosis of XDR-TB (aIRR 1.6, 95%CI 1.5-1.7), or had been hospitalised at treatment start (aIRR 1.7, 95%CI 1.5-1.8). Among MDR-TB patients, risk of mortality was higher if patients were HIV co-infected not on ART (aIRR 3.9, 95%CI 3.3-4.6), were 60 years or older (aIRR 1.9, 95%CI 1.6-2.3), or had been hospitalised at start of MDR-TB treatment (aIRR 1.7, 95%CI 1.5-1.9). Among XDR-TB patients, risk of mortality was higher in patients who were HIV co-infected not on ART (aIRR 1.8, 95%CI 1.5-2.2), or had been hospitalised at the start of XDR-TB treatment (aIRR 1.5, 95%CI 1.3-1.8). CONCLUSION: HIV co-infected not on ART, older age, XDR-TB and hospital admission for DR-TB treatment were independent risk factors for DR-TB mortality. Integration of TB and HIV services, with focus on voluntary HIV testing and counselling of DR-TB patients with unknown HIV status, and provision of ART for all co-infected patients may reduce DR-TB mortality in the Eastern Cape.

Feasibility of using postal and web-based surveys to estimate the prevalence of tuberculosis among health care workers in South Africa.

INTRODUCTION: Health Care Workers (HCWs) are among the highest risk groups for contracting tuberculosis (TB), which is ranked the third most common occupational health disease in South Africa. Little is known about the true extent of the burden of TB among South African HCWs and current surveillance approaches are inadequate. The study aimed to determine the feasibility of using postal and web-based surveys accessed through registries of registered professionals to estimate the prevalence of TB among HCWs in South Africa. MATERIALS AND METHODS: We conducted a cross sectional survey on a sample of professional nurses and doctors (general practitioners) registered on the Medpages database platform; a subscription based registry for practising health care professionals. The survey included professionals who were actively involved in the clinical management of patients, either in public or private health care facilities. The paper based survey, including pre-paid return envelopes, was distributed via the post office and web-based surveys were distributed via e-mail through a hyperlink. Descriptive statistics were used to summarize the data and the Chi-square test to determine associations between categorical variables. Active TB was defined as any history of TB. RESULTS: Out of a total of 3,400 health care professionals contacted, 596 (18%) responses were received: 401 (67%) web-based and 195 (33%) postal. A significantly higher percentage of complete forms were from postal compared to web-based (97% [189/195] versus 87% [348/401], p<0.001). Younger (<60 years) professionals were more likely to use the web-based compared to postal (87% [236/270] versus 71% [134/189], p<0.001). Overall, the prevalence of active TB infection was 8.7%, (95%CI: 6.3%-11.7%) and there was no difference observed between doctors and nurses (10.8% [18/167] versus 7.5% [22/292], p = 0.236). CONCLUSION: This novel approach demonstrated the feasibility of using an existing registry of professionals to conduct surveys to estimate the prevalence of TB. Our findings showed a high TB prevalence; however the estimate might have been biased by the low response rate. Further research to optimise our approach could lead to a viable option in improving surveillance among health care professionals.

Conducting a secondary data analysis to estimate the incidence of congenital syphilis in South Africa, 2010 - 2016.

Analysis of existing health data is often used as a cost-effective and time-efficient means to provide evidence to inform important public health decisions. However, the accuracy of the resultant decisions largely depends on the quality of the accessible data, and how the data are processed, analyzed, interpreted and reported. This case study, based on an actual secondary data analysis that was conducted by a trainee of the South African Field Epidemiology Training Programme during April 2017, was designed to provide a classroom simulation of practical considerations that should be taken into account when planning an analysis of a secondary dataset. The case study is ideally suited to reinforce principles already covered in lectures or in background reading assignments.