Assessment of the quality of the acute flaccid paralysis (AFP) reporting system, Mpumalanga, South Africa

The WHO member countries undertook to eliminate poliomyelitis globally by the year 2000. Acute flaccid paralysis (AFP) surveillance finds paralytic cases of polio so that swift action can be taken and shows that wild poliovirus has been eliminated when polio cases no longer occur. Mpumalanga Province, a rural province in the north-east of South Africa, developed a rapid reporting system where infection control nurses at the public and private sector hospitals report weekly to the AFP surveillance Officer, including zero reporting, on 9 infectious disease syndromes that require rapid action on clinical presentation alone. This system was implemented in 1998 and included AFP. The non-polio AFP reporting rate increased from 0.37 in 1997 to 0.55 during 1998 with more than 80% of the units reporting weekly. The binomial exact confidence intervals however include 1. A hospital record review of all paediatric admissions revealed that only 2 AFP cases were missed by the system. The AFP reporting rate remains below the international standard of 1 per 100 000 children under 15 years of age despite an adequate reporting system. The role of chance variation, particularly in small geographical areas, has not been discussed in official polio-eradication guidelines but it is . imperative that population size be taken into account when judging the rate of AFP case detection. With the low international reference rate and play of chance variation it is possible that regions with relatively small populations, low non-polio AFP detection rates and no cases of polio detected for an extended period may have adequate surveillance systems supporting polio free certification. In these areas additional criteria for determining the adequacy of the surveillance system should also be considered.Dissertation (MMed)--University of Pretoria, 2006.School of Health Systems and Public Health (SHSPH)Unrestricte

Bovine brucellosis in Gauteng, South Africa : seroprevalence amongst cattle handlers and variables associated with seropositive cattle herds, 2014–2016

In South Africa, the prevalence of cattle handler exposure to Brucella on cattle farms is unknown and risk factors and cattle symptoms associated with infected cattle herds are unavailable. To address this gap, a case-control study of cattle herds was conducted in Gauteng province and farm workers and veterinary officials were tested for exposure to Brucella. Seroprevalence amongst farm workers exposed to case herds ranged from 4.0% (BrucellaCapt®) to 16.7% (IgG ELISA®), compared to those exposed to control herds, where seroprevalence ranged from 1.9% (BrucellaCapt®) to 5.7% (IgG ELISA®). Seroprevalence amongst veterinary officials was significantly greater compared to farm workers exposed to case herds for the outcome RBT+ IgM- IgG+ (OR = 11.1, 95% CI: 2.5–49.9, p = 0.002) and RBT- IgM- IgG+ (OR = 6.3, 95% CI: 2.3–17.3, p < 0.001). Risk factors associated with being an infected herd were: being a government-sponsored farm vs. private farm (OR 4.0; 95% CI: 1.4–11.3; p = 0.009), beef vs. dairy herd (OR 7.9; 95% CI: 1.4–44.9; p = 0.020), open vs. closed herd (OR 3.3; 95% CI: 1.1–10.4; p = 0.038) and the presence of antelope on the farm (OR 29.4; 95% CI: 4.0–218.2; p = 0.001). Abortions (OR = 5.1; 95% CI: 2.0–13.3; p < 0.001), weak calves in the herd (OR = 8.0; 95% CI: 2.6–24.4; p < 0.001), reduction in number of calves born (OR = 9.0; 95% CI: 2.1–43.6; p < 0.001), reduction in conception rate (OR = 3.9; 95% CI: 0.8–18.3; p = 0.046), hygromas in cattle (p = 0.011) and farmers reporting brucellosis-like symptoms in their farm workers or in him/herself (OR = 3.4; 95% CI: 1.3–8.7; p = 0.006) were more likely to be associated with Brucella infected herds than control herds. This evidence can be used in strategic planning to protect both human and herd health.The University of Pretoria Animal and Zoonotic Diseases Institutional Research Theme (AZD IRT) and by the South African Health and Welfare Sector Education and Training Authority (HWSETA). The APC was funded by University of Pretoria.https://www.mdpi.com/journal/pathogensam2022Centre for Veterinary Wildlife StudiesProduction Animal StudiesSchool of Health Systems and Public Health (SHSPH

Knowledge of brucellosis, health-seeking behaviour, and risk factors for Brucella infection amongst workers on cattle farms in Gauteng, South Africa

Brucellosis in humans is under-detected and underreported in sub-Saharan Africa. Risk factors associated with Brucella infection and health seeking behaviour in response to brucellosis-like symptoms, amongst cattle farm workers and veterinary officials in South Africa, are unknown. Farm workers and veterinary officials (N = 230) were screened for brucellosis using commercial Rose Bengal Test (RBT®), IgM Enzyme-linked Immunoassay (ELISA)®, IgG ELISA® and the BrucellaCapt® test. Knowledge of brucellosis and risk factors for exposure to Brucella were also investigated. Seroprevalence varied according to test used: 10.1% (RBT®), 20.9% (IgG ELISA®) and 6.5% (BrucellaCapt®). Only 22.2% (6/27) of veterinary officials opt to visit a clinic, doctor, or hospital in response to selfexperienced brucellosis-like symptoms, compared to 74.9% (152/203) of farm workers (p < 0.001). Of the BrucellaCapt® seropositive participants, 53% (7/15) did not visit a clinic in response to brucellosislike symptoms. Weak evidence of an association between the handling of afterbirth or placenta and infection of a short evolution (RBT®, IgM ELISA® and IgG ELISA® seropositive) was found (OR = 8.9, 95% CI: 1.0–81.1, p = 0.052), and strong evidence of an association between this outcome and the slaughter of cattle (OR = 5.3, 95% CI: 1.4–19.6, p = 0.013). There was strong evidence of a positive association between inactive/resolved infection and veterinary officials vs. farm workers exposed to seropositive herds (OR = 7.0, 95% CI: 2.4–20.2, p < 0.001), with a simultaneous negative association with the handling of afterbirth or placenta (OR = 3.9, 95% CI: 1.3–11.3, p = 0.012). Findings suggest a proportion of undetected clinical cases of brucellosis amongst workers on cattle farms in Gauteng.Data Availability Statement: Data are available on request from the Gauteng Department of Agriculture and Rural Development.The University of Pretoria Animal and Zoonotic Diseases Institutional Research Theme (AZD IRT) and by the South African Health and Welfare Sector Education and Training Authority (HWSETA).https://www.mdpi.com/journal/pathogensam2022Centre for Veterinary Wildlife StudiesProduction Animal StudiesSchool of Health Systems and Public Health (SHSPH

Household living conditions and individual behaviours associated with malaria risk : a community-based survey in the Limpopo River Valley, 2020, South Africa

AVAILABILITY OF DATA AND MATERIALS : The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.BACKGROUND : Over the past decade, implementation of multiple malaria control strategies in most countries has largely contributed to advance the global malaria elimination agenda. Nevertheless, in some regions, seasonal epidemics may adversely affect the health of local populations. In South Africa, Plasmodium falciparum malaria is still present, with the Vhembe District experiencing an incidence rate of 3.79 cases/1000 person-years in 2018, particularly in the Limpopo River Valley, bordering Zimbabwe. To elucidate the complexity of the mechanisms involved in local regular malaria outbreaks, a community-based survey was implemented in 2020 that focused on the relationship between housing conditions and malaria risky behaviours. METHODS : The community-based cross-sectional survey was conducted among the population of three study sites in the Vhembe District, which were selected based on malaria incidence rate, social and health characteristics of inhabitants. The household survey used a random sampling strategy, where data were collected through face-to-face questionnaires and field notes; to described the housing conditions (housing questionnaire), and focus on individual behaviours of household members. Statistical analyses were performed combining hierarchical classifications and logistic regressions. RESULTS : In this study, 398 households were described, covering a population of 1681 inhabitants of all ages, and 439 adults who participated in community-based survey. The analysis of situations at risk of malaria showed that the influence of contextual factors, particularly those defined by the type of habitat, was significant. Housing conditions and poor living environments were factors of malaria exposure and history, regardless of site of investigation, individual preventive behaviours and personal characteristics of inhabitants. Multivariate models showed that, considering all personal characteristics or behaviours of inhabitants, housing conditions such as overcrowding pressures were significantly associated with individual malaria risk. CONCLUSIONS : The results showed the overwhelming weight of social and contextual factors on risk situations. Considering the Fundamental Causes Theory, malaria control policies based on health behaviour prevention, should reinforce access to care or promoting health education actions. Overarching economic development interventions in targeted geographical areas and populations have to be implemented, so that malaria control and elimination strategies can be efficiently and effectively managed.The “GeoPal” project leading to this publication has received funding from the A*Midex Foundation of Aix-Marseille University, funded by socio-economic partners.https://malariajournal.biomedcentral.comhj2023School of Health Systems and Public Health (SHSPH)UP Centre for Sustainable Malaria Control (UP CSMC

Measles outbreak in South Africa: epidemiology of laboratory-confirmed measles cases and assessment of intervention, 2009-2011

BACKGROUND: Since 1995, measles vaccination at nine and 18 months has been routine in South Africa; however, coverage seldom reached .95%. We describe the epidemiology of laboratory-confirmed measles case-patients and assess the impact of the nationwide mass vaccination campaign during the 2009 to 2011 measles outbreak in South Africa. METHODS: Serum specimens collected from patients with suspected-measles were tested for measles-specific IgM antibodies using an enzyme-linked immunosorbent assay and genotypes of a subset were determined. To estimate the impact of the nationwide mass vaccination campaign, we compared incidence in the seven months pre- (1 September 2009–11 April 2010) and seven months post-vaccination campaign (24 May 2010–31 December 2010) periods in seven provinces of South Africa. RESULTS: A total of 18,431 laboratory-confirmed measles case-patients were reported from all nine provinces of South Africa (cumulative incidence 37 per 100,000 population). The highest cumulative incidence per 100,000 population was in children aged ,1 year (603), distributed as follows: ,6 months (302/100,000), 6 to 8 months (1083/100,000) and 9 to 11 months (724/100,000). Forty eight percent of case-patients were $5 years (cumulative incidence 54/100,000). Cumulative incidence decreased with increasing age to 2/100,000 in persons$40 years. A single strain of measles virus (genotype B3) circulated throughout the outbreak. Prior to the vaccination campaign, cumulative incidence in the targeted vs. non-targeted age group was 5.9-fold higher, decreasing to 1.7 fold following the campaign (P,0.001) and an estimated 1,380 laboratoryconfirmed measles case-patients were prevented. CONCLUSION: We observed a reduction in measles incidence following the nationwide mass vaccination campaign even though it was conducted approximately one year after the outbreak started. A booster dose at school entry may be of value given the high incidence in persons .5 years.Our acknowledgements go to the Department of Health South Africa, National, provincial and districts, the South African Field Epidemiology and Laboratory Training Programme (SAFELTP), for ongoing support in surveillance and outbreak activities; Division of Epidemiology (Tsakani Nkuna, Kelebogile Lebogang Motsepe) and Virology (Londiwe Mahlaba, Mduduzi Buthelezi, Nomfundo Radebe, Muzi Hlanzi, Wayne Howard) at the NICD-NHLS for data management and laboratory testing support respectively and Private Laboratories for their support and referring specimens to the NICD.www.plosone.orgam201

Factors predicting 6-month retention among people with opioid use disorders accessing outpatient methadone maintenance therapy in Tshwane, South Africa

BACKGROUND. In South Africa (SA), increasing illicit opioid use and associated health challenges can be managed with opioid substitution therapy (OST), such as methadone, if the recommended dose and duration of use are prescribed. The Community Oriented Substance Use Programme (COSUP) provides free methadone to patients with opioid use disorder in Tshwane, SA, on need-based criteria. OBJECTIVES. To determine selected sociodemographic and substance use treatment factors associated with retention for at least 6 months among participants receiving methadone as part of OST in COSUP. METHODS. This was a retrospective cohort study using secondary data of patients treated with methadone at 8 COSUP sites. The factors associated with at least 6 months’ retention for 575 participants from December 2016 to September 2018 were analysed. RESULTS. There were 91.3% males, 86.4% South Africans and 85.9% black Africans, with a median age of 30 years. At baseline, the majority were injecting heroin (55.5%) and were provided with free methadone (59.3%). The median dose of methadone at 6 months or on leaving the programme was 20 mg; 38.4% of participants were retained for at least 6 months. Of those not retained, the median duration on methadone was 56 days, whereas for those retained for at least 6 months, the median number of days on methadone were 254. After adjusting for sex and age, participants receiving methadone doses <50 mg had lower odds of being retained (0 - 20 mg: adjusted odds ratio (aOR) 0.25; p=0.002; 95% confidence interval (CI) 0.10 - 0.61; >20 - 40 mg: aOR 0.20; p<0.001; 95% CI 0.08 - 0.49) than those administered ≥50 mg. Participants who received free methadone had 3.75 the odds of being retained than those buying it themselves (p<0.001; 95% CI 2.47 - 5.70). Participants treated in the inner city had 5.19 the odds of being retained than those in a suburban setting (p<0.001; 95% CI 2.99 - 9.03). Compared with black African participants, white participants had 3.39 the odds of being retained (p=0.001; 95% CI 1.64 - 7.00). Injecting heroin users had 0.63 the odds of being retained (p=0.032; 95% CI 0.41 - 0.96). CONCLUSIONS. To maximise retention on OST, methadone should be free, with maintenance doses >50 mg. Reasons for lower retention among participants from periurban settings, those who inject and those from previously disadvantaged racial groups need to be explored, and findings used to inform programming.http://www.samj.org.zaam2021Family MedicineSchool of Health Systems and Public Health (SHSPH

Sero-prevalence of bovine brucellosis in the Bojanala Region, North West Province, South Africa 2009–2013

Bovine brucellosis affects food safety, food security and human health in rural communities in the North West Province, South Africa. The World Organisation for Animal Health suggests routine sero-surveillance and vaccination of cattle for control and to prevent zoonotic transmission. Although sero-surveillance and subsidised vaccination have been in place for decades, data from Bojanala have not previously been analysed. The aim of this study was to retrospectively analyse historical data on routine sero-surveillance of bovine brucellosis and state subsidised vaccination, in communal, commercial and dairy cattle in the study area. This was a descriptive, cross-sectional retrospective analysis of records from all adult cows bled by the state veterinary services during routine sero-surveillance for bovine brucellosis, in the Bojanala Region, North West Province, between 2009 and 2013. Fewer communal (N = 11 815) and dairy (N = 6696), than commercial beef (N = 28 251) cows, were tested. Overall herd prevalence (33.33%), differed significantly from individual prevalence (3.18%) in all groups. Communal herds had both the highest herd prevalence (38.8%) and the highest individual prevalence (5.2%). Both herd and individual sero-prevalence were lowest in dairy cattle, possibly because registered dairy herds are routinely tested. Over the 5-year study period, only 24 086 (7.15%) of the 342 500 cows eligible for free vaccination, were vaccinated. The annual number of cattle tested was highly variable. Dairy cattle that were regularly tested had a significantly lower herd and individual prevalence. Herd prevalence would be useful for spatial mapping, whilst individual prevalence could better reflect the risk of zoonotic transmission.The State Veterinary Services of the North West Province in South Africa and the the National Research Foundation.http://www.jsava.co.zaam2020School of Health Systems and Public Health (SHSPH

Rubella in South Africa : an impending Greek tragedy?

BACKGROUND: The incidence of congenital rubella syndrome (CRS) is unknown in South Africa. There is evidence that it may be significant and largely undetected, particularly in the upper socio-economic group. This may be due to incomplete routine administration of MMR vaccine in infancy and a build-up of susceptible females reaching the childbearing age group who could be exposed to the extensive reservoir of virus in the unimmunised public sector of the population. OBJECTIVE: To assess the extent of the immunity gap to rubella by testing for protective IgG antibodies and the incidence of rubella infection by testing for IgM antibodies in sera. The data obtained would also be used to model the extent of CRS. DESIGN: Residual laboratory serum specimens from public and private laboratories were serologically tested for rubella IgG antibodies to investigate the immunity gap in the population and IgM antibodies in sera collected from the measles rashlike illness surveillance programme. Modelling exercises calculated the force of infection and the predicted incidence of CRS in South Africa. RESULTS: The serological immunity gap was significantly greater in the private sector specimens compared with the public sector - 10.7% versus 5.4%, respectively. In most years rubella caused much more rash-like illness than measles, with a significant number (5.1 - 9.6%) of rubella-positive IgM specimens occurring in women of childbearing age. CONCLUSION: Modelling of the data suggests that the extent of CRS may be grossly underestimated in South Africa. Approximately 654 cases are calculated to occur every year. It is suggested that selective immunisation of girls before puberty should be instituted together with a routine rubella immunisation programme of infants to forestall a possible future outbreak of CRS, as occurred in Greece in 1993

Molecular epidemiological investigation of a typhoid fever outbreak in South Africa, 2005 : the relationship to a previuos epidemic in 1993

In 2005, over 600 clinically diagnosed typhoid fever cases occurred in South Africa, where an outbreak had been previously described in 1993. Case-control and molecular investigations, including Salmonella enterica serovar Typhi (S. Typhi) isolates from that area from 1993, 2005 and later, were undertaken. Controls were significantly older than cases (P=0.003), possibly due to immunity from previous infection, and a significantly larger proportion had attended a gathering (P=0.035). Exposure to commercial food outlets and person-to-person transmission was not significant. Pulsed-field gel electrophoresis and multi-locus tandem repeat analysis revealed common clusters of S. Typhi strains identified in 1993 and 2005 as well as in 2007 and 2009. This outbreak probably occurred in a non-immune population due to faecally contaminated water. S. Typhi strains appeared to be related to strains from 1993; failure to address unsafe water may lead to further outbreaks in the area if the current population immunity wanes or is lost.This work was supported by a grant by the K. H. Keddy and others NHLS Research Trust

Part V. Surveillance activities

The critical importance of robust antimicrobial resistance (AMR) surveillance in South Africa cannot be overemphasised. Without knowing what the resistance situation is, it is impossible to develop appropriate antibiotic treatment guidelines and associated essential drug lists (EDLs) and to create and update evidence-based policies both at institutional and national levels. The broader benefits of AMR surveillance data include: • Determining incidence rates of hospital-acquired infections (HAIs) and identifying the associated causative organisms and their AMR profile to feed into hospital guidelines and more appropriate treatment for infected patients. This in turn allows early interventions by infection prevention and control (IPC) so as to minimise further spread of AMR organisms. • Profiling local or regional AMR patterns to inform selection of AMR screening practices in specific health care facilities (HCFs). • Educating health care staff about the impact of AMR and about issues in antibiotic use and misuse. • Monitoring trends over time to signal whether interventions are having the desired effect. • Comparing South Africa with other countries in the region and around the world to facilitate sharing intervention experience. South Africa has a good start at AMR surveillance, but it can and must be improved. For most AMR infections, surveillance data are laboratory and therefore organism centred, which limits the ability to differentiate between colonisation and infection with AMR organisms. It is also not possible to determine the clinical impact of AMR. A major shortcoming is that AMR surveillance is currently limited to a minority of HCFs, which does not reflect the extent of AMR across South Africa. The very limited profiling of AMR in the community needs to be addressed. Finally, the variability of surveillance methodology used makes it impossible to compare rates and trends across institutions.http://www.samj.org.zaam2017School of Health Systems and Public Health (SHSPH