Missed opportunities for immunisation in health facilities in the Western Cape metro

Background: Childhood immunisations are a cost effective public health intervention for prevention of infectious diseases. Immunisation coverage, however, is still sub-optimal which may result in disease outbreaks. Immunisation at every contact with a health facility is a strategy developed by the World Health Organization (WHO) in order to improve immunisation coverage. Objectives: The aim of this study was to estimate the prevalence of missed opportunities for immunisation at different levels of healthcare in the Western Cape and assess factors associated with missed opportunities. Methods: The study included a health-facility based cross-sectional exit survey of caregivers with children up to 5 years of age, followed by a qualitative exploration of staff attitudes towards immunisation. Results: The prevalence of missed opportunities for immunisation was 4.6%; 81.3% of caregivers brought Road-To-Health- Booklets (RTHB's) to consultations. Overall, 56.0% of health workers requested to see the RTHB's during consultations. Children attending primary level facilities were significantly more likely to have their RTHB's requested than children attending a tertiary level facility. Lack of training, resources and heavy workloads were the main challenges reported at secondary/tertiary level facilities

Marginalized People in a collection of short stories in Karkalam

Short story has a special place in today’s literary world. Short stories show the quality of life of the people in the society. Su.Venugopal is one of the best writers who tells the quality of life of the lower class people through short stories. In his Karkalam collection of short stories, he has clearly recorded the condition of the people who are oppressed and living on the margins of the society. The short story collection showcases the marginalized people like the economically backward and abandoned. Economic crises make these people very depressed. The life struggles of people in such a marginal position have been going on for generations. Although the social and economic changes caused by scientific developments are reflected in the lives of these people, the marginal life remains a series of problems

The Social Contract and India's Right to Education

India's 2009 Right of Children to Free and Compulsory Education (RTE) Act presents an idealized social contract which assigns roles to multiple actors to uphold a mutual duty, or collective responsibility, to secure children's access to a quality school education. This article explores how the social contract assumed by the RTE Act misrepresents the conditions required to enact mutual responsibilities as well as actors’ agreement to do so. Qualitative data from Bihar and Rajasthan show how state actors, parents, community groups and teachers negotiate and contest the RTE Act norms. The analysis illuminates the unequal conditions and ever-present politics of accountability relations in education. It problematizes the idealization of the social contract in education reform: it proposes that if the relations of power and domination through which ‘contracts’ are entered into remain unaddressed, then expressions of ‘mutual’ responsibility are unlikely to do other than reproduce injustice. It argues that policy discourses need to recognize and attend to the socially situated contingencies of accountability relations, and that doing so would offer an alternative pathway towards addressing structural inequalities and their manifestations in education

Treatment outcomes among adults with HIV/non-communicable disease multimorbidity attending integrated care clubs in Cape Town, South Africa.

Funder: Wellcome TrustBackgroundThe growing burden of the HIV and non-communicable disease (NCD) syndemic in Sub- Saharan Africa has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs. However, there is paucity of literature on treatment outcomes for multimorbid patients attending integrated care. We describe 12-month treatment outcomes among multimorbid patients attending integrated antiretroviral treatment (ART) and NCD clubs in Cape Town, South Africa.MethodsAs part of an integrated clubs (IC) model pilot implemented in 2016 by the local government at two primary health care clinics in Cape Town, we identified all multimorbid patients who were enrolled for IC for at least 12 months by August 2017. Mean adherence percentages (using proxy of medication collection and attendance of club visits) and optimal disease control (defined as the proportion of participants achieving optimal blood pressure, glycosylated haemoglobin control and HIV viral load suppression where appropriate) were calculated at 12 months before, at the point of IC enrolment and 12 months after IC enrolment. Predictors of NCD control 12 months post IC enrolment were investigated using multivariable logistic regression.ResultsAs of 31 August 2017, 247 HIV-infected patients in total had been enrolled into IC for at least 12 months. Of these, 221 (89.5%) had hypertension, 4 (1.6%) had diabetes mellitus and 22 (8.9%) had both diseases. Adherence was maintained before and after IC enrolment with mean adherence percentages of 92.2% and 94.2% respectively. HIV viral suppression rates were 98.6%, 99.5% and 99.4% at the three time points respectively. Retention in care was high with 6.9% lost to follow up at 12 months post IC enrolment. Across the 3 time-points, optimal blood pressure control was achieved in 43.1%, 58.9% and 49.4% of participants while optimal glycaemic control was achieved in 47.4%, 87.5% and 53.3% of participants with diabetes respectively. Multivariable logistic analyses showed no independent variables significantly associated with NCD control.ConclusionMultimorbid adults living with HIV achieved high levels of HIV control in integrated HIV and NCD clubs. However, intensified interventions are needed to maintain NCD control in the long term

To Study the Hemodynamic Changes from Supine to Prone Position in Asa II and III Patients Undergoing Major Spine Surgery in Prone Position using Flo Trac Sensor: An Observational Study

OBJECTIVES: This observational study assessed the hemodynamic changes that occurred in ASA II and III patients undergoing major elective spine surgery on changing position from supine to prone using the Flo Trac sensor. Additionally, it observed the effect of 10ml/kg of crystalloid fluid administered as a bolus before turning prone. METHODS: Twenty-nine patients were prospectively studied. Patients with valvular heart disease, chronic obstructive pulmonary disease, renal dysfunction and arrhythmia were excluded .After establishing venous access, radial arterial cannulation was undertaken and the Flotrac transducer was connected. Other routine monitors were connected. Induction was carried out with fentanyl, propofol and vecuronium; patients were intubated and mechanical ventilation established with tidal volumes of at least 8ml/kg. Anaesthesia was maintained with air /oxygen and Isoflurane titrated to a MAC of 0.8. Variables measured were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), stroke volume variation (SVV), pulse pressure variation (PPV), cardiac output (CO) and cardiac index(CI).Variables were measured after induction in the supine position (T1) and every 5 minutes after turning prone up to 15 minutes (T2-T4). All patients received fluid bolus of 10ml/kg of crystalloids before change of position. A fall in cardiac index by more than 20% from baseline (T1) warranted treatment with crytalloids upto 10ml/kg and/or boluses of vasopressors. Failure to respond to these warranted starting inotropic agents. Statistical analysis was performed using SPSS software. A General Estimating Equations (GEE) analysis was performed to analyze the change in variables across the time points (T2-T4) along with the significance of change (p value), with T1 as the reference. A paired t-test analysis was additionally done between time points T1 and T4. Correlation between variables (PPV and CO, SVV and CO and PPV and SVV) were assessed in the prone position at two time points using Pearson correlation test. Levene's test for Equality of Variance was used to analyse the difference in variables among patients on differing prone supports and among diabetic versus non-diabetic patients. RESULTS: There was a significant change in SBP (p=0.025), SVV (p=0.002) and PPV(p=0.02) 5 minutes after change of position to prone. However, there was no significant fall (p>0.05) in CO or CI during this time. There was a significant change in all hemodynamic variables (HR: p<0.001, SBP p<0.001, MAP p=0.014, PPV:p=0.024, SVV p=0.002, CO p<0.001, CI: p=0.003) except DBP 15 minutes after turning prone. A strong positive correlation was found to exist between SVV and PPV at T2 (r=0.835; p=<0.001) and T4 (r=0.75; p<0.001) while CO correlated weakly with SVV and PPV. Type of support (Relton-Hall vs. bolsters) and presence of diabetes did not significantly affect PPV and SVV. In conclusion, there was a statistically significant change in all hemodynamic variables 15 minutes after turning prone. There was no significant fall in CO or CI 5 minutes after turning prone; whether this can be attributed to the fluid bolus administered before change in position cannot be established at present

Factors associated with increased blood loss during delivery

Background: The present study was done to assess the blood loss during delivery even after active management of third stage of labor with oxytocin and the maternal outcomes of PPH.Methods: We studied 100 pregnant women were either in spontaneous labor or admitted for induction of labor, underwent vaginal delivery or caesarean section in our institute. Active management of third stage of labor in all 100 cases included 10 IU intramuscular oxytocin or 10 to 20 IU intravenous in 500 ml of Ringer’s Lactate. Blood loss in all cases was noted.Results: Of the included cases, 27 had to be given extra-uterotonics for atonic uterus, of which 12 parturient still had PPH. Atonic uterus was the cause of PPH in 11 of the 12 cases, while one case was of atonic uterus plus trauma. Half of all PPH cases responded to medical management alone, five cases had to undergo tamponade/stepwise devascularization and one case had to undergo obstetric hysterectomy. Blood loss was significantly higher in women aged more than 35 years, primigravida, not in labor, oligohydramnios or post-datism, elective LSCS, scarred uterus in and had more than 1 high risk factor. Among various high-risk conditions, significantly higher blood loss was observed in patients with chronic hypertension, gestational hypertension, pre-gestational diabetes mellitus, multipara with prior PPH, placenta previa, preeclampsia and sickle cell trait.Conclusions: Fifteen women avoided PPH by using a reliable method of blood loss measurement and initiating interventions early. Organized PPH management protocol morbidity and mortality of the mother and neonate can be prevented

The validity of routine individuated programmatic data in HIV surveillance assessed over a 10-year period.

Objectives In the Western Cape, South Africa, public-sector individual-level routine data are consolidated from multiple non-EMR sources through the Provincial Health Data Centre (PHDC).  This enables the description of temporal changes in population-wide antenatal HIV sero-prevalence. We evaluated the validity of these data compared to aggregated program data and sentinel surveys. Approach We conducted a retrospective cohort analysis of all pregnancies consolidated in the PHDC from January 2011 to December 2020. Evidence of antenatal and HIV care from electronic platforms (each with its own multi-source phenotype algorithm) were linked using a unique patient identifier. HIV prevalence estimates were triangulated with available sentinel national and provincial antenatal survey estimates as well as aggregated programmatic data from registers as recorded in the District Health Information System. Provincial, district-level and age-group HIV prevalence estimates were compared between data systems using correlation coefficients, absolute differences and trend analysis. Results In total, 982,914 pregnancies were ascertained with a median maternal age of 26.9 years. Between 2011–2013, PHDC HIV prevalence estimates were widely disparate from aggregate and survey data (due to incomplete electronic data) whereas, from 2014 onwards, estimates were more closely correlated to aggregate data estimates (r=0.83; p=0.02) with an average absolute prevalence difference of 0.97%. In keeping with survey and aggregate data trends, PHDC data show a relatively stable provincial HIV prevalence from 17.0 (95%CI 16.8%–17.2%) in 2015 to 18.9% (95%CI 18.7–19.1%) in 2020. The highest HIV prevalence was in the Cape Metro district (20.6%; 95%CI 20.4%–20.9%). Prevalence estimates by age group were comparable between sentinel surveys and PHDC from 2014 onwards with an average absolute prevalence difference of 1.6%. Conclusion This study is the first to compare sentinel sero-prevalence surveys with both register-based aggregate data and consolidated individuated administrative data. We show that in this setting linked individuated data may be reliably used for HIV surveillance and provide more granular estimates with greater efficiency

Utility of digitising point of care HIV test results to accurately measure, and improve performance towards, the UNAIDS 90-90-90 targets.

INTRODUCTION: High rates of pre-treatment loss to care among persons diagnosed with HIV persist. Linkage to care can be improved through active digitally-based surveillance. Currently, record-keeping for HIV diagnoses in South Africa is paper-based. Aggregated testing data are reported routinely, and only discordant findings result in a specimen being tested at a laboratory and digitised. The Western Cape Province in South Africa has a Provincial Health Data Centre (PHDC) where person-level routine electronic data are consolidated in a single database, leveraging the existence of a unique patient identifier. To facilitate improved HIV surveillance, a pre-carbonated point-of-care test (PoCT) form was piloted, where one copy was routed to a central point and digitised for PHDC inclusion. METHODS: We evaluated the utility of the intervention using cross-sectional and retrospective cohort analyses, as well as comparisons with aggregate data. Data were linked to the Patient Master Index of the PHDC using unique identifiers. Prior evidences of HIV within the PHDC were used to differentiate newly diagnosed patients and those retesting, as well as linkage to care and treatment. RESULTS: From May 2017 to June 2018, 11337 digitised point-of-care HIV testing records were linked to the PHDC. Overall, 96% of records in the aggregate dataset were digitised, with 97% linked to the PHDC. Of those tested, 79% were female (median age 27 years). Linkage demonstrated that 51.3% (95% CI 48.4-54.1%) of patients testing HIV-positive were retesting. Of those newly diagnosed, 81% (95% CI 77.9-84.3%) were linked to HIV care and 25% (95% CI 21.6-28.7%) were initiated on antiretroviral therapy immediately. CONCLUSION: Digitisation of PoCT results provides individuated HIV testing data to assist in linkage to care and in differentiating newly diagnosed patients from positive patients retesting. Actionable and accurate data can improve the measurement of performance towards the UNAIDS 90-90-90 targets

Pathogenesis and shedding of Usutu virus in juvenile chickens

Usutu virus (USUV; family: Flaviviridae, genus: Flavivirus), is an emerging zoonotic arbovirus that causes severe neuroinvasive disease in humans and has been implicated in the loss of breeding bird populations in Europe. USUV is maintained in an enzootic cycle between ornithophilic mosquitos and wild birds. As a member of the Japanese encephalitis serocomplex, USUV is closely related to West Nile virus (WNV) and St. Louis encephalitis virus (SLEV), both neuroinvasive arboviruses endemic in wild bird populations in the United States. An avian model for USUV is essential to understanding zoonotic transmission. Here we describe the first avian models of USUV infection with the development of viremia. Juvenile commercial ISA Brown chickens were susceptible to infection by multiple USUV strains with evidence of cardiac lesions. Juvenile chickens from two chicken lines selected for high (HAS) or low (LAS) antibody production against sheep red blood cells showed markedly different responses to USUV infection. Morbidity and mortality were observed in the LAS chickens, but not HAS chickens. LAS chickens had significantly higher viral titers in blood and other tissues, as well as oral secretions, and significantly lower development of neutralizing antibody responses compared to HAS chickens. Mathematical modelling of virus-host interactions showed that the viral clearance rate is a stronger mitigating factor for USUV viremia than neutralizing antibody response in this avian model. These chicken models provide a tool for further understanding USUV pathogenesis in birds and evaluating transmission dynamics between avian hosts and mosquito vectors.This work was supported by National Science Foundation [grant number: 1813011]; Virginia Polytechnic Institute and State University [grant number: Data and Decisions Proposal, VMCVM Internal Research Competition].S