Occurrence and causes of occupational asthma in South Africa - results from SORDSA's occupational asthma registry, 1997 - 1999

Objective. To present results for the first 3 years of the occupational asthma registry of the Surveillance of Workrelated and Occupational Respiratory Diseases in South Africa (SORDSA) programme, ending December 1999.Design. Surveillance was accomplished by collecting voluntary reports of occupational asthma cases from pulmonologists, occupational medicine practitioners and occupational health nurses.Setting. Medical and occupational health referral centres in the nine provinces of South Africa.Subjects. Patients diagnosed with new-onset occupational asthma with latency or irritant-induced asthma, reported to SORDSA during 1997 - 1999. Outcome measures. Frequencies of cases, causative agents, industries causing exposure and diagnostic methods. Average annual incidence rates by province and by occupation.Results. During this period 324 cases of occupational asthma were reported. The average annual incidence rate of occupational asthma was estimated in the three bestreporting provinces, namely Gauteng, KwaZulu-Natal and the Western Cape, as 17.5 per million employed people annually. This rate was highest in the Western Cape (25.1 per million). Semi-skilled operators had the highest incidence rate of 68.7 per million annually in the three provinces. Isocyanates and latex were the most common agents. Low molecular weight causative agents predominated (68.8%) over high molecular weight agents. Health care was the most frequently reported workplace for occupational asthma (OA) development. Serial peak flow testing was the method most often used for diagnosis. One fifth of the cases were still occupationally exposed to the  causative agent at time of diagnosis.Conclusion. Despite underreporting, SORDSA's estimate of the occupational asthma incidence rate was similar to that of the UK. SORDSA has also demonstrated that surveillance programmes in a developing country can provide useful information on which to base prevention activities

Pathogenic lower genital tract organisms in HIV-infected and uninfected women, and their association with postpartum infectious morbidity

Objectives. To determine the prevalence of vaginal pathogens during pregnancy and their impact on postpartum infectious morbidity among antiretroviral-naïve HIV-infected, and HIVuninfected, women. Methods. Vaginal swabs were obtained during early labour by speculum examination prior to digital vaginal examination, and sent for microscopy and culture. Women were assessed for infectious complications within 24 - 72 hours of delivery, and up to 2 weeks postpartum. Results. Laboratory results were available for 801 women who delivered vaginally (418 HIV infected and 383 uninfected). The baseline characteristics of the two groups were comparable, and the median CD4 count for HIV-infected women (N=391) was 416/μl. Fifty-five per cent (54.8%) of women had positive cultures (439/801), more among those who were HIV infected than uninfected (60% v. 49.1%, p=0.002). Women with positive cultures had slightly higher rates of infectious morbidity than those without (20.5% v. 15.2%, p=0.052). Trichomonas vaginalis and group B streptococci were significantly associated with sepsis (p=0.023 and <0.001, respectively), whereas the presence of Candida species seemed to be protective (relative risk 0.69, p=0.014). Conclusion. The study shows that a high proportion of pregnant women have pathogenic organisms in the lower genital tract that are associated with development of postpartum infectious morbidity

Procedure for prolapsed haemorrhoids vs excisional haemorrhoidectomy: A systematic review and meta-analysis

Background. The procedure for prolapse and haemorrhoids (PPH) was introduced to address the postoperative pain following excisional haemorrhoidectomy (EH). Objective. To assess the efficacy of both procedures to treat haemorrhoids. Data sources. Literature review using MEDLINE. Articles addressing PPH and EH were included. Study selection. RCTs comparing EH and PPH with ≥20 patients. Data extraction. Primary endpoints were pain, operative time, hospital stay, satisfaction with procedure and time to return to normal activity. Secondary endpoints such as recurrence and complications were collated for descriptive analysis. A metaanalysis was performed using the random effects model on studies reporting ‘mean' and SD or SEM. Data synthesis. PPH was associated with less postoperative pain, less operative time, shorter hospital stay and earlier return to normal activities compared with EH. There appears to be no significant difference in satisfaction with the procedure. There was no difference between the two procedures in terms of complications. There were more recurrences after PPH. Conclusion. Compared with EH, PPH is associated with less postoperative pain, reduced operative time and hospital stay and earlier return to normal activity, and a trend towards improved patient satisfaction. The rate of recurrence appears higher with PPH. South African Medical Journal Vol. 99 (1) 2009: pp. 43-5

Will graduating medical students prefer to practise in rural communities?

Background: The shortage of doctors and their maldistribution between urban and rural areas contribute to inequitable health care delivery. Strategies are being sought by the government and universities to address these challenges. At the Nelson R Mandela School of Medicine of the University of KwaZulu-Natal the admissions policy ensures greater access to rural students and curricular interventions have been introduced to increase an awareness of the plight of vulnerable communities. This study attempted to ascertain the career intentions of final-year medical students and the influence of area of origin and gender on the location of their proposed future practice.Methods: The 2005 final-year cohort was surveyed by means of an anonymous questionnaire. Demographic information, area of origin and career intentions were canvassed. Students of rural origin were identified as those who matriculated from rural schools and lived more than 200 km from the nearest city. The data were analysed descriptively.Results: Female and rural students accounted for 63% and 11% of the sample respectively. Women were less likely than men to practise in rural areas. Thirty-five per cent indicated a preference for a public government service career as opposed to a private medical (26%) career. Slightly more than 13.7% (n = 26) of the cohort wished to pursue practice or  postgraduate careers overseas. Nearly 62% (n = 90) of the students in the current cohort received government subsidies for their studies.Conclusions: The increased intake of students from rural origin and curricular attempts to increase social awareness of vulnerable rural communities are inadequate to alter the perceptions of medical graduates towards rural practice. While government initiatives and medical schools are starting to work together to service rural communities, alternative strategies need to be explored to entice physicians to rural practice

Lactic acidosis, risk factors and predictive laboratory markers: a nested case control study in South Africa

Background: The incidence of antiretroviral therapy (ART)-induced lactic acidosis and its associated mortality may be reduced by appropriate  dosing, risk stratification and early detection.Objectives: To describe the epidemiology of lactic acidosis, define the risk factors and identify predictive laboratory markers in the context of the roll-out of ART in South Africa.Design: A nested case control study. Risk factor analysis was adjusted for the established risk factors of weight and gender.Setting and subjects: Persons commenced on stavudine-containing  therapy between 2004 and 2007 at Port Shepstone Hospital in  KwaZulu-Natal were included. Persons with a body weight above 60 kg received Stavudine 40 mg twice daily, and those with a body weight below 60 kg, 30 mg twice daily.Outcome measures: Assessed risk factors included weight, gender, age, alanine transaminase (ALT), urea, creatinine, albumin, cholesterol, triglyceride (TG) levels, CD4 counts and viral loads.Results: Lactic acidosis occurred in 79 (17 per 1 000 person-years) of 1 762 people living with HIV on ART. Significant factors were being female [adjusted odds ratio (AOR) of 5.4] and increased body weight (adjusted OR of 1.1 per kg). The risk of lactic acidosis increased 6.6, 6.9 and 95 times (adjusted ORs) as weight increased from a baseline weight of < 60 kg to 60-69 kg, 70-79 kg or > 80 kg, respectively. Six months into therapy, predictors of developing lactic acidosis were an ALT > 50 IU/l (adjusted OR of 11.1) and a higher TG (adjusted OR of 8.8 per mmol/l). No associations were found with regard to age, CD4 count, viral load, and creatinine or albumin levels.Conclusion: Obese females are at greatest risk of lactic acidosis, with an exponential increase in risk above 80 kg. The 30-mg dose may be preferable, given that a sharp increase in risk occurred at 60 kg, was most likely dose related, and that 30 mg has been shown to provide adequate virological suppression. Additional risk factors for lactic acidosis include a high ALT and TG levels at treatment

Setting the scene for SORDSA - the importance of occupational respiratory disease surveillance in South Africa

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Investigating the association between diabetes mellitus, depression and psychological distress in a cohort of South African teachers

Background. Diabetes mellitus (DM) may increase the risk of depression as a result of a sense of threat of debilitating complications or because of associated lifestyle changes. Depression may increase the risk of type 2 diabetes as a result of poor health behaviours.Objective. To determine the association between diabetes mellitus, depression and psychological  distress in a cohort of South African (SA) teachers.Methods. Teachers from 111 public schools in the Metro South District of the Cape Metropolitan area,  SA, were invited to participate in this study. The Center for Epidemiologic Studies Depression Scale  (CES-D) and the Kessler Psychological Distress Scale (K10) were used to assess depression and psychological distress, respectively. A professional nurse completed a physical examination and  collected blood for measurement of glucose, cholesterol and serum creatinine.Results. Of the 388 teachers who completed the questionnaires, 67.5% were female and the average age  was 46.2 years (standard deviation 8.7). Psychological distress was identified in 28.1% of the cohort and depression in 15.5%, and 7.7% were found to fulfil criteria for DM. A diagnosis of DM was associated with an increased risk of depression (adjusted odds ratio (AOR) 3.90; 95% confidence interval (CI) 1.33 - 11.37) and psychological distress (AOR 3.62; 95% CI 1.31 - 10.00).Conclusion. The high prevalence of obesity and DM in this cohort of SA teachers is of concern. A  diagnosis of DM was strongly associated with an increased risk of depression and psychological distress

Recognition of infants at high risk for vertical HIV transmission at delivery in rural Western Cape Province, South Africa

Background. Despite South Africa’s substantial reduction in vertical HIV transmission (VHT), national paediatric HIV elimination is not yet attained. National and Western Cape Province (WC) HIV guidelines recommend enhanced postnatal prophylaxis for infants at high risk for VHT, identified in the WC 2015/2016 guidelines by any single high-risk criterion (maternal antiretroviral therapy (ART) <12 weeks, absent/ unsuppressed maternal HIV viral load (HIV-VL) <12 weeks before/including delivery, spontaneous preterm labour, prolonged rupture of membranes, chorioamnionitis). Accuracy of high-risk infant identification is unknown. Objectives. Primarily, to determine the proportion of infants at high risk for VHT, the accuracy of labour-ward risk classification, the criteria determining high-risk statuses and the criteria missed among unrecognised high-risk infants; secondarily, to determine maternal factors associated with high-risk infants. Methods. Infants born to women living with HIV at a rural regional hospital (May 2016 - April 2017) were retrospectively evaluated using data from the labour ward VHT register, standardised maternity case records, National Health Laboratory Service database and WC Provincial Health Data Centre. The study-derived risk status for each infant was determined using documented presence/absence of risk criteria and compared with labour ward assigned risk to determine accuracy. Proportions of high-risk and unrecognised high-risk infants with each high-risk criterion were determined. Maternal characteristics associated with having a high-risk infant were evaluated using multivariable logistic regression. Results. For liveborn infants, labour ward assigned risk classifications were 40% (n=75/188) high risk, 50% (n=94/188) low risk and 10% (n=19/188) unclassified. Study-derived risk was high risk for 69% (n=129/188) and low risk for 31% (n=59/188), yielding a high-risk classification sensitivity of 51% (95% confidence interval (CI) 42 - 60) and specificity of 69% (95% CI 56 - 80). Absent/unsuppressed HIVVL 4 antenatal visits (38% v. 81%, p<0.01) and first antenatal visit <20 weeks’ gestation (57% v. 77%, p=0.01). Only the number of antenatal visits remained associated with having a high-risk infant after adjusting for gestation at first visit and timing of HIV diagnosis and ART initiation: each additional antenatal visit conferred a 39% (95% CI 25 - 50) reduction in the odds of having a high-risk infant. Conclusion. Labour ward risk classification failed to recognise half of high-risk infants. Infant high-risk status as well as non-detection thereof were driven by suboptimal maternal HIV-VL monitoring. Reinforcing visit frequency later in pregnancy may improve antenatal HIV-VL monitoring, and point-of-care HIV-VL monitoring at delivery could improve recognition of virally unsuppressed mothers and their high-risk infant

Dual and triple therapy to prevent mother-to-child transmission of HIV in a resource-limited setting – lessons from a South African programme

Objective. To determine outcomes of pregnant women and their infants at McCord Hospital in Durban, South Africa, where dual and triple therapy to reduce HIV vertical transmission have been used since 2004 despite national guidelines recommending simpler regimens. Method. We retrospectively examined records of all pregnant women attending McCord Hospital for their first antenatal visit between 1 March 2004 and 28 February 2007. Uptake of HIV testing and HIV prevalence were determined, and clinical, immunological and virological outcomes of HIV-positive women and their infants, followed through to 6 months after delivery, were described. Results. The antenatal clinic was attended by 5 303 women; 4 891 (92%) had an HIV test, and 703 (14%) were HIV positive. The HIV-positive women were subsequently followed up: 653 (93%) received antiretroviral therapy or prophylaxis, including 424 (60%) who received triple therapy. Of the 699 live babies delivered, 661 (94%) received prophylaxis. At 6 weeks 571 babies (82%) were brought back for HIV testing; 16 (2.8%) were HIV positive. After 6 months, only 150 women (21%) were receiving follow-up care at the adult HIV clinic. Conclusion. Where a tailored approach to prevention of motherto-child transmission (PMTCT) is used, which attempts to maximise available technology and resources, good short-term transmission outcomes can be achieved. However, longer-term follow-up of mothers&rsquo; and babies&rsquo; health presents a challenge. Successful strategies to link women to ongoing care are crucial to sustain the gains of PMTCT programmes

High risk of malnutrition associated with depressive symptoms in older South Africans living in KwaZulu-Natal, South Africa: a cross-sectional survey

Background: Malnutrition contributes to functional and cognitive decline in older adults, which results in decreased quality of life and loss of independence. This study aimed to identify determinants of nutritional risk among community-dwelling adults in KwaZulu-Natal, South Africa. Methods: A cross-sectional survey was undertaken in 1008 subjects aged 60 years and over who were randomly selected by systematic sampling. Demographics, socioeconomic data and self-reported history of medical conditions were recorded. The Mini Nutritional Assessment-Short Form (MNA-SF) was used to screen for nutritional risk, and the Centre for Epidemiologic Studies Depression scale was administered to all subjects. Descriptive statistics and the Pearson chi-square and Kruskal-Wallis tests were used for statistical analysis. Logistic regression modelling determined predictors of nutritional risk. Results: Of the 984 participants (mean age = 68.8 \ub1 7.4 years; range 60\u2013103 years) who completed the MNA-SF, 51 % were classified as having a normal nutritional status, 43.4 % at risk for malnutrition and 5.5 % classified as malnourished. Men were more likely to be either at risk for malnutrition or be malnourished than women (p = 0.008), as were subjects with a monthly household income of 64R1600 per month (~133 USD) (p = 0.003). In logistic regression models, depressed people were 2.803 (p &lt; 0.001) times more likely to be at risk or be malnourished than those not depressed. Conclusion: A high prevalence of risk of malnutrition was identified in older South Africans living in an urban area with poor infrastructure. Further investigations are warranted to determine whether the higher prevalence of depressive symptomatology in nutritionally at risk individuals is a determinant or a consequence of malnutrition, in order to develop targeted nutritional interventions in this age group