Factors Associated with Survival to Discharge of Newborns in a Middle-Income Country

Clinical and mortality audit is an essential part of quality improvement in health care; information obtained in this process is used to develop targeted interventions to improve outcome. This study aimed to determine predictors of short-term survival in neonates. An existing neonatal database was reviewed. A total of 5018 neonates > 400 g admitted to a tertiary hospital (Johannesburg South Africa) between 1 January 2013 and 31 December 2015 were analysed. Mean birth weight was 2148 g (standard deviation [SD]: 972) and mean gestational age was 34.2 weeks (SD: 4.8). Overall survival was 85.6% (4294/5018). The most common causes of death were prematurity (46.2%), hypoxia (19.5%) and infection (17.2). The strongest predictors of survival were birth weight (OR 1.0; 95% confidence intervals (CI): 1.0–1.01) and gestational age (OR = 1.1, 95% CI: 1.05–1.17). Other predictors of survival included metabolic acidosis (OR = 0.14, 95% CI: 0.09–0.20), hyperglycemia (OR = 0.31, 95% CI: 0.23–0.41), mechanical ventilation (OR = 0.35, 95% CI: 0.28–0.46), major birth defect (OR = 0.12, 95% CI: 0.08–0.18), resuscitation at birth (OR = 0.39, 95% CI: 0.31–0.49) and Caesarean section (OR = 1.8, 95% CI: 1.44–2.25). In conclusion, resources need to be focused on improved care of VLBW infants

Incidence and predictors of recovery from anaemia within an HIV-infected South African Cohort, 2004-2010

Introduction: Anaemia is one of the most frequent haematological complications in HIV-infected  persons. Understanding factors associated with recovery from anaemia during ART is vital in improving clinical outcomes since anaemia is a strong predictor of mortality.Methods: Cohort study of 12,441 HIV-infected adults initiating ART between 2004- 2010 in Johannesburg, South Africa. A further 2,489 patients with prevalent anaemia at ART initiation were examined to  determine the incidence and predictors of recovery from anaemia. Cox proportional hazards models were fitted to investigate predictors of recovery from anaemia.Results: Of the 2,489 patients with prevalent anaemia, most patients (n=2,225, 89.4%) recovered from anaemia. Median time to anaemia recovery was 3.9 months (IQR: 3.22-6.20) and incidence rate was 180 per 100person years (95% CI: 172-187). In univariate analysis, sex, CD4 count, BMI, WHO stage,  employment status, smoking status and presence of tuberculosis at initiation of ART were significant  predictors of recovery from anaemia. However in multivariate analysis, predictors of recovery from  anaemia were: male sex- HR: 1.43 (95% CI: 1.29-1.59) p< 0.001, advanced WHO stage III/IV - HR: 1.17 (95% CI: 1.07-1.29) p=0.001). There was no significant association with CD4 count in multivariate  analysis.Conclusion: A large proportion of HIV infected patients with anaemia at baseline recover early during the course of ART. Females and those with less advanced WHO stage seem to be at higher risk of poor  recovery from anaemia. Understanding the predictors for poor recovery from anaemia would allow closer follow-up and more targeted interventions thus reducing excess anaemia and mortality burden.Key words: Haemoglobin, human immunodeficiency virus, AIDS, Themba Lethu clinical cohort, antiretroviral therap

Treatment Gaps Found in the Management of Type 2 Diabetes at a Community Health Centre in Johannesburg, South Africa

Aims. The management of cardiometabolic goals or “ABCs” (HbA1c, blood pressure (BP), and cholesterol) ultimately determines the morbidity and mortality outcomes in patients with type 2 diabetes mellitus (T2DM). We sought to determine if patients with T2DM attending an urbanized public sector community health centre (CHC) were having their ABCs measured, were treated with appropriate cardioprotective agents and finally, were achieving guideline-based targets. Methods and Results. A cross-sectional record review of 519 patients was conducted between May and August 2015. The mean age was 54 years (SD: ±11.5) and 54% (n=280) were females. Testing of ABCs occurred in 68.8% (n=357) for HbA1c, 95.4% (n=495) for BP, and 58.6% (n=304) for LDL-C. Achievement of ABC targets was as follows: 19.3% (HbA1c < 7%), 22.0% (BP < 140/80 mmHg), and 56.3% (LDL-C < 2.5 mmol/l). Conclusion. There were a significant number of patients who were not tested nor received adequate pharmacotherapy or achieved their ABC targets. This places these patients at an increased risk for the development of diabetes-related complications. Although the realities of resource constraints exist in South Africa’s public sector settings, a wider implementation of evidence-based guidelines must be instituted in order to ensure better patient outcomes

HIV Disease Progression Among Antiretroviral Therapy Patients in Zimbabwe: A Multistate Markov Model.

Background: Antiretroviral therapy (ART) impact has prolonged survival of people living with HIV. We evaluated HIV disease progression among ART patients using routinely collected patient-level data between 2004 and 2017 in Zimbabwe. Methods: We partitioned HIV disease progression into four transient CD4 cell counts states: state 1 (CD4 ≥ 500 cells/μl), state 2 (350 cells/μl ≤ CD4 < 500 cells/μl), state 3 (200 cells/μl ≤ CD4 < 350 cells/μl), state 4 (CD4 < 200 cells/μl), and the absorbing state death (state 5). We proposed a semiparametric time-homogenous multistate Markov model to estimate bidirectional transition rates. Covariate effects (age, gender, ART initiation period, and health facility level) on the transition rates were assessed. Results: We analyzed 204,289 clinic visits by 63,422 patients. There were 24,325 (38.4%) patients in state 4 (CD4 < 200) at ART initiation, and 7,995 (12.6%) deaths occurred by December 2017. The overall mortality rate was 3.9 per 100 person-years. The highest mortality rate of 5.7 per 100 person-years (4,541 deaths) was from state 4 (CD4 < 200) compared to other states. Mortality rates decreased with increase in time since ART initiation. Health facility type was the strongest predictor for immune recovery. Provincial or central hospital patients showed a diminishing dose-response effect on immune recovery by state from a hazard ratio (HR) of 8.30 [95% confidence interval (95% CI), 6.64-10.36] (state 4 to 3) to HR of 3.12 (95% CI, 2.54-4.36) (state 2 to 1) compared to primary healthcare facilities. Immune system for male patients was more likely to deteriorate, and they had a 32% increased mortality risk (HR, 1.32; 95% CI, 1.23-1.42) compared to female patients. Elderly patients (45+ years) were more likely to immune deteriorate compared to 25-34 years age group: HR, 1.35; 95% CI, 1.18-1.54; HR, 1.56; 95% CI, 1.34-1.81 and HR, 1.53; 95% CI, 1.32-1.79 for states 1 to 2, state 2 to 3, and states 3 to 4, respectively. Conclusion: Immune recovery was pronounced among provincial or central hospitals. Male patients with lower CD4 cell counts were at a higher risk of immune deterioration and mortality, while elderly patients were more likely to immune deteriorate. Early therapeutic interventions when the immune system is relatively stable across gender and age may contain mortality and increase survival outcomes. Interventions which strengthen ART services in primary healthcare facilities are essential

Infant mortality in South Africa - distribution, associations and policy implications, 2007: an ecological spatial analysis

<p>Abstract</p> <p>Background</p> <p>Many sub-Saharan countries are confronted with persistently high levels of infant mortality because of the impact of a range of biological and social determinants. In particular, infant mortality has increased in sub-Saharan Africa in recent decades due to the HIV/AIDS epidemic. The geographic distribution of health problems and their relationship to potential risk factors can be invaluable for cost effective intervention planning. The objective of this paper is to determine and map the spatial nature of infant mortality in South Africa at a sub district level in order to inform policy intervention. In particular, the paper identifies and maps high risk clusters of infant mortality, as well as examines the impact of a range of determinants on infant mortality. A Bayesian approach is used to quantify the spatial risk of infant mortality, as well as significant associations (given spatial correlation between neighbouring areas) between infant mortality and a range of determinants. The most attributable determinants in each sub-district are calculated based on a combination of prevalence and model risk factor coefficient estimates. This integrated small area approach can be adapted and applied in other high burden settings to assist intervention planning and targeting.</p> <p>Results</p> <p>Infant mortality remains high in South Africa with seemingly little reduction since previous estimates in the early 2000's. Results showed marked geographical differences in infant mortality risk between provinces as well as within provinces as well as significantly higher risk in specific sub-districts and provinces. A number of determinants were found to have a significant adverse influence on infant mortality at the sub-district level. Following multivariable adjustment increasing maternal mortality, antenatal HIV prevalence, previous sibling mortality and male infant gender remained significantly associated with increased infant mortality risk. Of these antenatal HIV sero-prevalence, previous sibling mortality and maternal mortality were found to be the most attributable respectively.</p> <p>Conclusions</p> <p>This study demonstrates the usefulness of advanced spatial analysis to both quantify excess infant mortality risk at the lowest administrative unit, as well as the use of Bayesian modelling to quantify determinant significance given spatial correlation. The "novel" integration of determinant prevalence at the sub-district and coefficient estimates to estimate attributable fractions further elucidates the "high impact" factors in particular areas and has considerable potential to be applied in other locations. The usefulness of the paper, therefore, not only suggests where to intervene geographically, but also what specific interventions policy makers should prioritize in order to reduce the infant mortality burden in specific administration areas.</p

Developmental outcome of very low birth weight infants in a developing country

BACKGROUND: Advances in neonatal care allow survival of extremely premature infants, who are at risk of handicap. Neurodevelopmental follow up of these infants is an essential part of ongoing evaluation of neonatal care. The neonatal care in resource limited developing countries is very different to that in first world settings. Follow up data from developing countries is essential; it is not appropriate to extrapolate data from units in developed countries. This study provides follow up data on a population of very low birth weight (VLBW) infants in Johannesburg, South Africa. METHODS: The study sample included all VLBW infants born between 01/06/2006 and 28/02/2007 and discharged from the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Bayley Scales of Infant and Toddler Development Version 111 (BSID) 111 were done to assess development. Regression analysis was done to determine factors associated with poor outcome. RESULTS: 178 infants were discharged, 26 were not available for follow up, 9 of the remaining 152 (5.9%) died before an assessment was done; 106 of the remaining 143 (74.1%) had a BSID 111 assessment. These 106 patients form the study sample; mean birth weight and mean gestational age was 1182 grams (SD: 197.78) and 30.81 weeks (SD: 2.67) respectively. The BSID (111) was done at a median age of 16.48 months. The mean cognitive subscale was 88.6 (95% CI: 85.69 - 91.59), 9 (8.5%) were < 70, mean language subscale was 87.71 (95% CI: 84.85 - 90.56), 10 (9.4%) < 70, and mean motor subscale was 90.05 (95% CI: 87.0 - 93.11), 8 (7.6%) < 70. Approximately one third of infants were identified as being at risk (score between 70 and 85) on each subscale. Cerebral palsy was diagnosed in 4 (3.7%) of babies. Factors associated with poor outcome included cystic periventricular leukomalacia (PVL), resuscitation at birth, maternal parity, prolonged hospitalisation and duration of supplemental oxygen. PVL was associated with poor outcome on all three subscales. Birth weight and gestational age were not predictive of neurodevelopmental outcome. CONCLUSION: Although the neurodevelopmental outcome of this group of VLBW infants was within the normal range, with a low incidence of cerebral palsy, these results may reflect the low survival of babies with a birth weight below 900 grams. In addition, mean subscale scores were low and one third of the babies were identified as "at risk", indicating that this group of babies warrants long-term follow up into school going age

Prevalence and Risk Factors for Trachoma in Central and Southern Malawi

BACKGROUND: Trachoma, one of the neglected tropical diseases is suspected to be endemic in Malawi. OBJECTIVES: To determine the prevalence of trachoma and associated risk factors in central and southern Malawi. METHODOLOGY/PRINCIPAL FINDINGS: A population based survey conducted in randomly selected clusters in Chikwawa district (population 438,895), southern Malawi and Mchinji district (population 456,558), central Malawi. Children aged 1-9 years and adults aged 15 and above were assessed for clinical signs of trachoma. In total, 1010 households in Chikwawa and 1016 households in Mchinji districts were enumerated within 108 clusters (54 clusters in each district). A total of 6,792 persons were examined for ocular signs of trachoma. The prevalence of trachomatous inflammation, follicular (TF) among children aged 1-9 years was 13.6% (CI 11.6-15.6) in Chikwawa and 21.7% (CI 19.5-23.9) in Mchinji districts respectively. The prevalence of trachoma trichiasis (TT) in women and men aged 15 years and above was 0.6% (CI 0.2-0.9) in Chikwawa and 0.3% (CI 0.04-0.6) in Mchinji respectively. The presence of a dirty face was significantly associated with trachoma follicular (TF) in both Chikwawa and Mchinji districts (P10%), and warrants the trachoma SAFE control strategy to be undertaken in Chikwawa and Mchinji districts

The prevalence of human papillomavirus infections and associated risk factors in men-who-have-sex-with-men in Cape Town, South Africa

Abstract Background We investigated the prevalence of human papillomavirus (HPV) infection and associated behavioural risk factors in men-who-have-sex-with-men (MSM) attending a clinical service in Cape Town, South Africa. Methods MSM were enrolled at the Ivan Toms Centre for Men’s Health in Cape Town. A psychosocial and sexual behavioral risk questionnaire was completed for each participant and urine, oro-pharyngeal and anal swabs were collected for HPV testing using the Linear Array HPV Genotyping Test. Logistic regression analyses were performed to determine sexual risk factors associated with HPV infection at the three anatomical sites. Results The median age of all 200 participants was 32 years (IQR 26-39.5), of which 31.0 % were black, 31.5 % mixed race/coloured and 35.5 % white. The majority of the participants (73.0 %) had completed high school, 42.0 % had a tertiary level qualification and 69.0 % were employed. HPV genotypes were detected in 72.8 % [95 % CI: 65.9–79.0 %], 11.5 % [95 % CI: 7.4–16.8 %] and 15.3 % [95 % CI: 10.5–21.2 %] of anal, oro-pharyngeal and urine specimens, respectively. Prevalence of high-risk (HR)-HPV types was 57.6 % [95 % CI: 50.3–64.7 %] in anal samples, 7.5 % [95 % CI: 4.3–12.1 %] in oro-pharyngeal samples and 7.9 % [95 % CI: 4.5–12.7 %] in urine, with HPV-16 being the most common HR-HPV type detected at all sites. HPV-6/11/16/18 was detected in 40.3 % [95 % CI: 33.3–47.6 %], 4.5 % [95 % CI: 2.1–8.4 %] and 3.2 % [95 % CI: 1.2–6.8 %] of anal, oro-pharyngeal and urine samples, respectively. Multiple HPV types were more common in the anal canal of MSM while single HPV types constituted the majority of HPV infections in the oropharynx and urine. Among the 88 MSM (44.0 %) that were HIV positive, 91.8 % [95 % CI: 83.8–96.6 %] had an anal HPV infection, 81.2 % [95 % CI: 71.2–88.8 %] had anal HR-HPV and 85.9 % [95 % CI: 76.6–92.5 %] had multiple anal HPV types. Having sex with men only, engaging in group sex in lifetime, living with HIV and practising receptive anal intercourse were the only factors independently associated with having any anal HPV infection. Conclusions Anal HPV infections were common among MSM in Cape Town with the highest HPV burden among HIV co-infected MSM, men who have sex with men only and those that practiced receptive anal intercourse. Behavioural intervention strategies and the possible roll-out of HPV vaccines among all boys are urgently needed to address the high prevalence of HPV and HIV co-infections among MSM in South Africa

Competing risk of mortality on loss to follow-up outcome among patients with HIV on ART: a retrospective cohort study from the Zimbabwe national ART programme.

OBJECTIVE: To determine the loss to follow-up (LTFU) rates at different healthcare levels after antiretroviral therapy (ART) services decentralisation among ART patients who initiated ART between 2004 and 2017 using the competing risk model in addition to the Kaplan-Meier and Cox regressions analysis. DESIGN: A retrospective cohort study. SETTING: The study was done in Zimbabwe using a nationwide routinely collected HIV patient-level data from various health levels of care facilities compiled through the electronic patient management system (ePMS). PARTICIPANTS: We analysed 390 771 participants aged 15 years and above from 538 health facilities. OUTCOMES: The primary endpoint was LTFU defined as a failure of a patient to report for drug refill for at least 90 days from last appointment date or if the patient missed the next scheduled visit date and never showed up again. Mortality was considered a secondary outcome if a patient was reported to have died. RESULTS: The total exposure time contributed was 1 544 468 person-years. LTFU rate was 5.75 (95% CI 5.71 to 5.78) per 100 person-years. Adjustment for the competing event independently increased LTFU rate ratio in provincial and referral (adjusted sub-HRs (AsHR) 1.22; 95% CI 1.18 to 1.26) and district and mission (AsHR 1.47; 95% CI 1.45 to 1.50) hospitals (reference: primary healthcare); in urban sites (AsHR 1.61; 95% CI 1.59 to 1.63) (reference: rural); and among adolescence and young adults (15-24 years) group (AsHR 1.19; 95% CI 1.16 to 1.21) (reference: 35-44 years). We also detected overwhelming association between LTFU and tuberculosis-infected patients (AsHR 1.53; 95% CI 1.45 to 1.62) (reference: no tuberculosis). CONCLUSIONS: We have observed considerable findings that 'leakages' (LTFU) within the ART treatment cascade persist even after the decentralisation of health services. Risk factors for LTFU reflect those found in sub-Saharan African studies. Interventions that retain patients in care by minimising any 'leakages' along the treatment cascade are essential in attaining the 90-90-90 UNAIDS fast-track targets

Loss to Follow-Up Risk among HIV Patients on ART in Zimbabwe, 2009-2016: Hierarchical Bayesian Spatio-Temporal Modeling

Loss to follow-up (LTFU) is a risk factor for poor outcomes in HIV patients. The spatio-temporal risk of LTFU is useful to identify hotspots and guide policy. Secondary data on adult HIV patients attending a clinic in provinces of Zimbabwe between 2009 and 2016 were used to estimate the LTFU risk in each of the 10 provinces. A hierarchical Bayesian spatio-temporal Poisson regression model was fitted using the Integrated Nested Laplace Approximation (INLA) package with LTFU as counts adjusting for age, gender, WHO clinical stage, tuberculosis coinfection and duration on ART. The structured random effects were modelled using the conditional autoregression technique and the temporal random effects were modelled using first-order random walk Gaussian priors. The overall rate of LTFU was 22.7% (95%CI: 22.6/22.8) with Harare (50.28%) and Bulawayo (31.11%) having the highest rates. A one-year increase in the average number of years on ART reduced the risk of LTFU by 35% (relative risk (RR) = 0.651; 95%CI: 0.592-0.712). In general, the provinces with the highest exceedance LTFU risk were Matabeleland South and Matabeleland North. LTFU is one of the drawbacks of HIV prevention. Interventions targeting high-risk regions in the southern and northern regions of Zimbabwe are a priority. Community-based interventions and programmes which mitigate LTFU risk remain essential in the global HIV prevention campaign