Attachment stability and change in early childhood and associated moderators

This thesis examined attachment stability and change in parent-child relationships in the first child-specific meta-analysis and the first measurement in an Australian sample. Employing novel statistical methods, this thesis demonstrated the existence of publication bias, a low degree of attachment stability, and the importance of parental sensitivity on developmentally significant attachment transition

Haematological complications of HIV Infection

South Africa is in the midst of the world’s largest human immune deficiency virus (HIV) epidemic with an estimated 5.6 million people infected. Haematological manifestations of HIV are common and diverse, occurring at all stages of infection. Haematological emergencies occurring in this setting include the high-grade lymphomas, particularly Burkitt lymphoma, and thrombotic thrombocytopenic purpura (TTP). Immune thrombocytopenic purpura (ITP), opportunistic infections and drug side-effects are also frequent causes of cytopenias. A bone marrow biopsy has a high diagnostic utility in HIV patients presenting with unexplained cytopenias and/or fevers. It is not widely realised that HIV is also a prothrombotic state with an increased incidence of thromboembolic disease. Highly active antiretroviral therapy (HAART) is now widely available in South Africa and is a crucial adjunct to therapy of haematological complications. Medical professionals across all disciplines need to be alert to the haematological complications of HIV infection

The burden of imported malaria in Cape Town, South Africa

BACKGROUND: The Western Cape Province of South Africa (SA) is not malaria endemic; however, a considerable number of patients present with malaria to our healthcare services. OBJECTIVES: To establish the frequency of patients presenting with malaria at Groote Schuur Hospital (GSH), Cape Town, SA, and to describe their demographics, clinical outcomes and laboratory findings. METHODS: An observational, retrospective, descriptive study was conducted, which included all patients presenting with smear-positive malaria to GSH over a 4-year period between 1 April 2008 and 31 March 2012. RESULTS: During the study period, 134 malaria patients presented to GSH for management; 85% (n=114) were male, median age was 27 years. Of the total smear-positive tests, 96% (n=128) were Plasmodium falciparum, 3% (n=4) P. ovale, and in 1% (n=2) the species was not identified. The number of malaria patients increased markedly, from 6 cases in 2008 to 50 cases in 2012. Of the patients, 48.3% (n=57) were from Somalia, 8.5% (n=10) from SA and 29% (n=30) from other African countries. One SA patient acquired transfusion-transmitted malaria from a pooled platelet product, and the other SA patients had travelled to malaria-endemic areas. The remaining cases were from countries outside of Africa, including 13% (n=15) from Bangladesh. Almost two-thirds (62%; n=72) were admitted to hospital with a median length of stay of 3 days (range 1 - 32). Clinical outcomes were good with only one death and the remaining patients being discharged. CONCLUSION: Imported malaria is imposing a significant burden on health resources. The costs of medical care for the emergency treatment of foreign nationals needs to be recognised, and adequately budgeted for

The burden of imported malaria in Cape Town, South Africa

Background. The Western Cape Province of South Africa (SA) is not malaria endemic; however, a considerable number of patients present with malaria to our healthcare services.Objectives. To establish the frequency of patients presenting with malaria at Groote Schuur Hospital (GSH), Cape Town, SA, and to describe their demographics, clinical outcomes and laboratory findings. Methods. An observational, retrospective, descriptive study was conducted, which included all patients presenting with smear-positive malaria to GSH over a 4-year period between 1 April 2008 and 31 March 2012.Results. During the study period, 134 malaria patients presented to GSH for management; 85% (n=114) were male, median age was 27 years. Of the total smear-positive tests, 96% (n=128) were Plasmodium falciparum, 3% (n=4) P. ovale, and in 1% (n=2) the species was not identified. The number of malaria patients increased markedly, from 6 cases in 2008 to 50 cases in 2012. Of the patients, 48.3% (n=57) were from Somalia, 8.5% (n=10) from SA and 29% (n=30) from other African countries. One SA patient acquired transfusion-transmitted malaria from a pooled platelet product, and the other SA patients had travelled to malaria-endemic areas. The remaining cases were from countries outside of Africa, including 13% (n=15) from Bangladesh. Almost two-thirds (62%; n=72) were admitted to hospital with a median length of stay of 3 days (range 1 - 32). Clinical outcomes were good with only one death and the remaining patients being discharged.Conclusion. Imported malaria is imposing a significant burden on health resources. The costs of medical care for the emergency treatment of foreign nationals needs to be recognised, and adequately budgeted for.

Initiating the dialogue between infant mental health and family therapy: a qualitative inquiry and recommendations

This qualitative study explores infant-family mental health experts' perspectives and experiences regarding the inclusion of infants in the family therapy setting. Infant socioemotional development is relational in nature and evolves in the context of both dyadic attachment relationships and broader multi-person co-parenting systems. Given this, we sought to understand why family therapy interventions involving families with infants rarely include the infant in a triangular or family systemic approach. Interviews were completed by clinical and/or research experts whose work integrates tenets of both infant mental health (IMH) and family theory and therapy. All interviewees brought at least 5 years of expertise and were actively engaged in the field. Interviewees expressed consistent beliefs that infants have a rightful and helpful place in family therapy approaches. They maintained that infants' innate social drive and communicative capacities position them to make meaningful and clinically significant contributions within family and systemic psychotherapy contexts. Noting that infants have remained on the periphery of these practices, experts advocated expansion and greater integration between IMH and family therapy, while preserving each field's distinctive identity. Experts reported that the interplay between IMH and family therapy fields has been uni-directional as family systems concepts are embedded within IMH approaches, but few IMH premises are incorporated in mainstream family therapy practices. The disconnect was attributed to multiple factors, including graduate and professional training and theoretical, clinical, research, and sociocultural barriers, which were mutually reinforcing. Experts also identified clinical gains for both infants and family members when infants were meaningfully included in family interventions. Common ground was identified between the disciplines, with a belief that relationally distressed young children and parents are best served by clinical engagement with their network of relationships. Results call for greater collaboration between disciplines to challenge existing traditions and to more fully include infants in mainstream family therapy. Recommendations for integration of family therapy and IMH in clinical, theoretical, research, training, and sociocultural domains are offered

Allergic reactions to the Ad26.COV2.S vaccine in South Africa

BACKGROUND : The Janssen-Ad26.COV2.S vaccine is authorized for use in several countries, with more than 30 million doses administered. Mild and severe allergic adverse events following immunization (AEFI) have been reported. OBJECTIVE : We sought to detail allergic reactions reported during the Sisonke phase 3B study in South Africa. METHODS : A single dose of the Ad26.COV2.S vaccine was administered to 4,77,234 South African health care workers between February 17 and May 17, 2021. Monitoring of adverse events used a combination of passive reporting and active case finding. Telephonic contact was attempted for all adverse events reported as “allergy.” Anaphylaxis adjudication was performed using the Brighton Collaboration and National Institute of Allergy and Infectious Disease case definitions. RESULTS : Only 251 (0.052%) patients reported any allergic-type reaction (<1 in 2000), with 4 cases of adjudicated anaphylaxis (Brighton Collaboration level 1, n = 3) (prevalence of 8.4 per million doses). All anaphylaxis cases had a previous history of drug or vaccine-associated anaphylaxis. Cutaneous allergic reactions were the commonest nonanaphylatic reactions and included self-limiting, transient/localized rashes requiring no health care contact (n = 92) or isolated urticaria and/or angioedema (n = 70; median onset, 48 [interquartile range, 11.5-120] hours postvaccination) that necessitated health care contact (81%), antihistamine (63%), and/or systemic/topical corticosteroid (16%). All immediate (including adjudicated anaphylaxis) and most delayed AEFI (65 of 69) cases resolved completely. CONCLUSIONS : Allergic AEFI are rare following a single dose of Ad26.COV, with complete resolution in all cases of anaphylaxis. Although rare, isolated, delayed-onset urticaria and/or angioedema was the commonest allergic AEFI requiring treatment, with nearly half occurring in participants without known atopic disease.The Sinsonke Study is funded by the South African Medical Research Council. J.P.’s research is supported by a career development award and financial support from the National Institutes of Health; the European Developing Clinical Trials Partnership (EDCTP2 Program supported by the European Union; and the SA Medical Research Council and National Research Foundation.https://www.sciencedirect.com/journal/journal-of-allergy-and-clinical-immunology-globalhj2023Paediatrics and Child HealthSchool of Health Systems and Public Health (SHSPH

Safety evaluation of the single-dose Ad26. COV2.S vaccine among healthcare workers in the Sisonke study in South Africa : a phase 3b implementation trial

Real-world evaluation of the safety profile of vaccines after licensure is crucial to accurately characterise safety beyond clinical trials, support continued use, and thereby improve public confidence. The Sisonke study aimed to assess the safety and effectiveness of the Janssen Ad26.COV2.S vaccine among healthcare workers (HCWs) in South Africa. Here, we present the safety data.Funding for the Sisonke Study was provided by: The National Department of Health through baseline funding to the South African Medical Research Council; the Solidarity Response Fund NPC; The Michael & Susan Dell Foundation; the ELMA Vaccines and Immunization Foundation; the ELMA Vaccines and Immunization Foundation; and the Bill & Melinda Gates Foundation.https://journals.plos.org/plosmedicinedm2022Paediatrics and Child HealthSchool of Health Systems and Public Health (SHSPH

Effectiveness of the Ad26.COV2.S vaccine in health-care workers in South Africa (the Sisonke study) : results from a single-arm, open-label, phase 3B, implementation study

DATA SHARING : Individual participant data will not be made available. Study protocol, statistical analysis plan, and analytical code will be available from the time of publication in response to any reasonable request to the corresponding author.BACKGROUND : We aimed to assess the effectiveness of a single dose of the Ad26.COV2.S vaccine (Johnson & Johnson) in health-care workers in South Africa during two waves of the South African COVID-19 epidemic. METHODS : In the single-arm, open-label, phase 3B implementation Sisonke study, health-care workers aged 18 years and older were invited for vaccination at one of 122 vaccination sites nationally. Participants received a single dose of 5 x 10¹⁰ viral particles of the Ad26.COV2.S vaccine. Vaccinated participants were linked with their person-level data from one of two national medical insurance schemes (scheme A and scheme B) and matched for COVID-19 risk with an unvaccinated member of the general population. The primary outcome was vaccine effectiveness against severe COVID-19, defined as COVID-19-related admission to hospital, hospitalisation requiring critical or intensive care, or death, in health-care workers compared with the general population, ascertained 28 days or more after vaccination or matching, up to data cutoff. This study is registered with the South African National Clinical Trial Registry, DOH-27-022021-6844, ClinicalTrials.gov, NCT04838795, and the Pan African Clinical Trials Registry, PACTR202102855526180, and is closed to accrual. FINDINGS : Between Feb 17 and May 17, 2021, 477 102 health-care workers were enrolled and vaccinated, of whom 357 401 (74·9%) were female and 119 701 (25·1%) were male, with a median age of 42·0 years (33·0–51·0). 215 813 vaccinated individuals were matched with 215 813 unvaccinated individuals. As of data cutoff (July 17, 2021), vaccine effectiveness derived from the total matched cohort was 83% (95% CI 75–89) to prevent COVID-19-related deaths, 75% (69–82) to prevent COVID-19-related hospital admissions requiring critical or intensive care, and 67% (62–71) to prevent COVID-19-related hospitalisations. The vaccine effectiveness for all three outcomes were consistent across scheme A and scheme B. The vaccine effectiveness was maintained in older health-care workers and those with comorbidities including HIV infection. During the course of the study, the beta (B.1.351) and then the delta (B.1.617.2) SARS-CoV-2 variants of concerns were dominant, and vaccine effectiveness remained consistent (for scheme A plus B vaccine effectiveness against COVID-19-related hospital admission during beta wave was 62% [95% CI 42–76] and during delta wave was 67% [62–71], and vaccine effectiveness against COVID-19-related death during beta wave was 86% [57–100] and during delta wave was 82% [74–89]). INTERPRETATION : The single-dose Ad26.COV2.S vaccine shows effectiveness against severe COVID-19 disease and COVID-19-related death after vaccination, and against both beta and delta variants, providing real-world evidence for its use globally.National Treasury of South Africa, the National Department of Health, Solidarity Response Fund NPC, The Michael & Susan Dell Foundation, The Elma Vaccines and Immunization Foundation, and the Bill & Melinda Gates Foundation.http;//thelancet.comam2023Paediatrics and Child HealthSchool of Health Systems and Public Health (SHSPH

My Early Relational Trust-Informed Learning (MERTIL) for Parents: A study protocol for a brief, universal, online, preventative parenting program to enhance relational health.

BackgroundEarly relational health is a key determinant of childhood development, while relational trauma in the parent-infant dyad can instigate a cascading pattern of infant risk. Fortunately, early relational trauma is detectable and modifiable. In 2018, Australian Maternal and Child Health (MCH) nurses participated in MERTIL (My Early Relational Trauma-Informed Learning), a program to identify and prevent relational trauma. Program evaluations revealed nurses felt competent and confident to identify and respond to relational trauma; however, response capacity was inhibited by inadequate parent referral options. In response, MERTIL for Parents (My Early Relational Trust-Informed Learning) was developed, which is an online, evidence-based, self-paced parenting program that focuses on enhancing parental knowledge of relational trust and its significance for infant development. This low-cost, accessible prevention resource targets emerging relational concerns to reduce later service system engagement. The potential for universal preventative online programs that target parental and relational wellbeing remains under-explored. This paper reports on a protocol for implementing a MERTIL for Parents pilot study describing practitioners' and parents' perspectives on program feasibility and efficacy.MethodsThis study is a mixed methods, parallel armed, uncontrolled, repeated measures design. We aim to recruit 48 Australian MCH practitioners from the states of Victoria and New South Wales. These professionals will in turn recruit 480 parents with a child aged 0-5 years. All parents will receive MERTIL for Parents, which entails a 40-minute video, tipsheets, posters, and support resources. Parent data will be obtained at three periods: pre-program, program exit, and program follow-up. Practitioner data will be collected at two periods: pre-parent recruitment and program follow-up. Data collection will occur through surveys and focus groups. Primary parent outcomes will be socioemotional assessments of program efficacy. Practitioners and parents will each report on program feasibility.DiscussionThis protocol describes the feasibility and efficacy of a new online parenting program, MERTIL for Parents, with pilot field studies commencing in March 2023. We anticipate that this resource will be a valuable addition to various child and family services, for use in individual support and group work

Nesting Ecology of the Hawaiian Stilt (Himantopus mexicanus knudseni) on O‘ahu

The Hawaiian Stilt (Himantopus mexicanus knudseni) is an endangered subspecies of the Black-necked stilt (Himantopus mexicanus) that inhabits wetlands throughout the Hawaiian Islands. Depredation of eggs and chicks by introduced predators is a major threat to Hawaiian Stilt populations. Where and when a bird decides to nest may impact the likelihood of egg or chick depredation. Nesting in close proximity to water may decrease depredation rates by mammals, as water can act as a barrier to mammalian predators, does not hold scent, and provides an obstacle-free escape route for chicks. Alternatively, some mammalian predators may be attracted to water, and a number of aquatic species have been identified as predators of Hawaiian Stilt chicks, including the American Bullfrog (Lithobates catesbeianus). Vegetation height is also an important factor for egg and chick survival, as taller vegetation may help conceal nests and chicks from predators, particularly aerial species. Additionally, depredation is often not constant across the breeding season due to changes in parental activity, nest and chick abundance, or habitat characteristics. The Hawaiian Stilt nests from February to September across the Hawaiian Islands. The nesting season coincides with a seasonal decline in precipitation, which may alter habitat characteristics and thus impact depredation rates. Further, management tools, such as mammal-exclusion fencing, are currently in use and may greatly increase egg and chick survival. The objectives of this project were to: 1) identify habitat characteristics important for nest-site selection and chick habitat use; 2) identify factors that impact hatching and fledging success. We found that stilts preferred to nest in shorter vegetation than what was available and preferred Pickleweed (Batis maritima) rather than other available plant species. However, nest-site characteristics, such as vegetation height and distance to water, did not have an impact on egg depredation risk. Early nests had a higher chance of hatching than late nests. The number of depredated nests peaked later in the nesting season, following a peak in nest initiation. Introduced mammals were the primary egg predators and included rats (Rattus spp.), feral cats (Felis catus), and Small Indian Mongooses (Herpestes auropunctatus). The number of eggs laid, as well as hatching success, was greater inside the mammal exclusion fence at Honouliuli Wetland, compared to a nearby site without a fence, Waiawa Wetland, where mammalian predators are only excluded via trapping. The average home range size for 12 tracked pre-fledglings was 0.94 ± 1.42 acres, and most chicks were observed using vegetated mudflats near open water. Of the 20 chicks that were tracked in this study, 7 fledged (35%), 6 had unknown fates (30%), 4 died due to unknown causes (20%), 2 were depredated by a feral cat (10%), and 1 died due to emaciation (5%). Our results suggest that management of predators, particularly mammals, is key to improving stilt hatching success, as preferred nest-site characteristics do not reduce the likelihood of egg depredation. Tall, invasive vegetation, such as California Grass (Brachiaria mutica), should continue to be controlled, as it was rarely used for nesting. More desirable vegetation, such as Pickleweed, should be made available throughout wetlands to encourage larger spacing between nesting pairs, which may help to reduce egg depredation pressure. Increasing mammalian predator control later in the nesting season may also increase hatching success of later nesters. Alternatively, mammal-exclusion fencing may provide year-round protection from mammalian predators, increasing both egg and chick survival. More data is needed to form conclusions regarding home range and survival of Hawaiian Stilt chicks. Improved detection methods and radio-tagging attachment styles will be used in the 2020 nesting season, which will reduce uncertainties and improve statistical power of analyses