Trends and determinants of the incidence and mortality of cervical cancer in South Africa (1994-2012)

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Science in the field of Epidemiology and Biostatistics. Johannesburg, June 2017Cervical cancer (CC) is the leading cause of female cancer morbidity and mortality in South Africa, despite the introduction of preventive programs. However, there is a paucity of information on current CC rates and trends in South Africa. This study aimed to evaluate the national trends and determinants of CC over a 19 year period (1994-2012). We conducted temporal analyses of age-standardised incidence rates (ASIR) from 1994 to 2009 and age-standardised mortality rates (ASMR) from 2004 to 2012 using data from the National Cancer Registry and Statistics South Africa, respectively. We also evaluated a novel surrogate measure (complement of MR: IR ratio) to calculate five-year relative survival rates of CC (2004-2009). Temporal analyses were stratified by the province of residence, histological type, population- and age-groups, while linear regression models were fitted to determine the average annual percent change (AAPC) of the time trends. Spatial distribution was conducted by utilising the GIS coordinates of SA to map the provincial ASMR. Unconditional logistic regression analyses were carried out for three casecontrol studies using data from the hospital-based Johannesburg Cancer Case-Control Study (JCCCS) (1995-2010), to evaluate the effect of HIV infection; tobacco smoking and alcohol abuse and sexual and reproductive behaviours on the risk CC in Black South Africans. The cases were participants with CC while controls were other female cancer participants that had no known association with CC and its risk factors. There were 75,099 incident cases and 25,101 mortalities from CC in the periods studied with women below 50 years accounting for 43.1% of the cases and 35.7% deaths. The ASIR was 22.1/100,000 in 1994 and 23.3/100,000 in 2009 and there was an average annual decrease in incidence of 0.9% (AAPC=-0.9%, P-value<0.001). The ASMR decreased slightly from 13.9/100,000 in 2004 to 13.1/100,000 in 2012 (AAPC = -0.6%, P-value < 0.001). Based on current trends, the ASIR and ASMR were predicted to increase to 26.3/100,000 and 14.6/100,000 in 2030, respectively. From 2004 to 2012, five provinces had increased mortality rates (AAPC: 1.2 – 8.3, P-value<0.001) while four provinces had decreased mortality rates (AAPC: -16.6 - -1.0, P-value<0.001). In 2012, the ASMR in Black population group was 5.7-fold higher than in the White population group. The highest mortality was recorded in Mpumalanga Province (19.8/100,000) and the least in the Eastern Cape Province (8.9/100,000). From 2000 to 2009, the ASIR of adenocarcinoma of the cervix was relatively low (2.00 to 2.6 per 100,000 women) and stable, while the incidence of squamous cell carcinoma was high (17.0 to19.0 per 100,000 women) and the rate increased by 1.4% annually. The relative survival rates were higher in White and Indians/Asian women (60-80%) than in Blacks and Coloureds (40- 50%). The results of the JCCCS studies showed that the association between CC and HIV infection increased from two-fold (adjusted odds ratio, (adjOR) =1.98; 95% CI: 1.34-2.92) during the pre-anti-retroviral therapy (ART) era (1995-2003) to three-fold (adjOR=2.94 95%CI: 2.26- 3.83) in the ART era (2004-2010). Current tobacco smoking (adjOR=2.1, 95%CI: 1.10-4.01) and snuff use (adjOR=1.3, CI: 1.08-1.61) increased the likelihood of CC among Black women in South Africa. The risk of CC increased with prolonged use of hormonal contraceptives (P-value for trend = 0.003) and high parity (>6) (adjOR=4.5, 95%CI: 2.85- 7.25). The incidence and mortality of CC are probably underestimated due to underreporting of cancer in the country. South Africa had minimal changes in overall CC rates between 1994 and 2012, despite the initiation of a population-based CC screening program in 2000 and the nationwide roll out of ART in 2004. There was a marked disparity in CC rates by population group, age and province. HIV-infected women and those who use tobacco are more likely to develop CC, therefore targeted programs should be introduced to inform women about risk factors for CC. Maternal and child health initiatives should also involve CC control activities since a considerable number of women of the reproductive age (15 – 49 years) were affected.MT201

A cohort study of the relationship between anaemia, mean corpuscular volume and mortality among a CKD population in South Africa

Background: The burden of chronic kidney disease is increasing globally and prompt identification, coupled with improved management of CKD patients have increased the population of pre-dialysis patients. We, therefore, aimed to evaluate the predictors of survival among pre-dialysis CKD patients in South Africa. Methods: We conducted a cohort study of 256 consecutive consenting Black non-dialysis requiring CKD patients attending the renal outpatient clinic of a tertiary Hospital in South Africa from 1st June 2016 to 1st December 2016. Socio-demographic and clinical information of the participants were obtained. Descriptive statistics, Kaplan-Meier curves and Cox proportional hazard regression analyses were conducted to evaluate factors affecting the survival of the participants. Results: The mean age of the participants was 52.8±14.3 years and 48.0% were females, 52% were males. The death rate increased with worsening haemoglobin level from 0.96 among patients with mild anaemia to 4.29 per 100-person years among patients with severe anaemia. Anaemic patients with GFR &lt; 30mls/min had significantly increased risk of death (HR 11.51, 95% CI 1.62–78.32, P &lt; 0.001). Conclusion: Mortality in pre-dialysis CKD patients was associated with anaemia and hyperphosphatemia. Clinical interventions targeted at preventing these conditions may improve outcomes among this group of CKD patients. Keywords: Chronic kidney disease; mortality anaemia; outcomes, survival

Prevalence and Factors Associated with Parvovirus B19 Infection among Blood Donors: A Hospital‑Based Study in South‑West, Nigeria

Background: Parvovirus B19 (B19V) is a transfusion transmissible infection that can result in severe consequences in vulnerable population that includes pregnant women, immunocompromised and chronic hemolytic anemia patients. The aim of this study was to determine the prevalence and factors associated with B19V infection amongst blood donors in South–West Nigeria. Materials and Methods: We conducted a comparative cross‑sectional study to determine the seroprevalence of B19V immunoglobulin M (IgM) antibody among 183 blood donors at the blood bank of a tertiary hospital. The results were analyzed with SPSS 23 software, prevalence and associated factors were determined using frequencies and logistic regression, respectively. Results: The prevalence of B19V IgM was 7.1% (95% confidence interval: 4–11) with a higher prevalence among male donors compared to females (84.6% vs. 15.4%, P = 0.54). There was a statistically significant difference in the seropositivity of B19V IgM amongst the ethnic groups with the Yoruba ethnic group having a higher proportion of B19V IgM‑positive participants P = 0.04. Ethnicity, gender, and steady employment were also associated with increased odds of infection, while increasing age appeared to be protective; though none of these factors were statistically significant. Conclusion: This study has shown that there is still high exposure to transfusion transmissible B19V infection. Keywords: Blood donor, parvovirus immunoglobulin M antibody, sickle cell anaemi

Police Brutality, Human Rights Violations and the 2020 #EndSARS Protests in Lagos, Nigeria.

This study examines the factors responsible for the outbreak of the #EndSARS protest in Lagos, Nigeria. Relying on primary sources of data (questionnaires and Focus Group Discussions), correlation, regression and content analysis were employed to establish (i) relationship between human rights violations and protest outbreak; (ii) relationship between repressive response of government to protest and protest transformation from peaceful to violent one as well as manifestation of criminality. The results show that there exist a strong positive relationship between human rights violations and protest outbreak and between repressive response of state’s security agencies and protest transformation

Persistent hypertension up to one year postpartum among women with hypertensive disorders in pregnancy in a low-resource setting:A prospective cohort study

BACKGROUND: Hypertensive disorders in pregnancy (HDPs) are associated with lifelong cardiovascular disease risk. Persistent postpartum hypertension in HDPs could suggest progression to chronic hypertension. This phenomenon has not been well examined in low- and middle-income countries (LIMCs), and most previous follow-ups typically last for maximally six weeks postpartum. We assessed the prevalence of persistent hypertension up to one year in women with HDPs in a low resource setting and determined associated risk factors. METHODOLOGY: A prospective cohort study of women conducted at eight tertiary health care facilities in seven states of Nigeria. Four hundred and ten women with any HDP were enrolled within 24 hours of delivery and followed up at intervals until one year postpartum. Descriptive statistics were performed to express the participants’ characteristics. Univariable and multivariable logistic regressions were conducted to identify associated risk factors. RESULTS: Of the 410 women enrolled, 278 were followed up to one year after delivery (follow-up rate 68%). Among women diagnosed with gestational hypertension and pre-eclampsia/eclampsia, 22.3% (95% CI; 8.3–36.3) and 62.1% (95% CI; 52.5–71.9), respectively, had persistent hypertension at six months and this remained similar at one year 22.3% (95% CI; 5.6–54.4) and 61.2% (95% CI; 40.6–77.8). Maternal age and body mass index were significant risk factors for persistent hypertension at one year [aORs = 1.07/year (95% CI; 1.02–1.13) and 1.06/kg/m(2) (95% CI; 1.01–1.10)], respectively. CONCLUSION: This study showed a substantial prevalence of persistent hypertension beyond puerperium. Health systems in LMICs need to be organized to anticipate and maintain postpartum monitoring until blood pressure is normalized, or women referred or discharged to family physicians as appropriate. In particular, attention should be given to women who are obese, and or of higher maternal age

Metabolic syndrome following hypertensive disorders in pregnancy in a low-resource setting:A cohort study

Objectives: Hypertensive disorders in pregnancy (HDPs) are associated with risk of future metabolic syndrome. Despite the huge burden of HDPs in sub-Saharan Africa, this association has not been adequately studied in this population. Study design: This was a prospective cohort study on pregnant women recruited between August 2017 - April 2018 and followed up to one year after their deliveries and evaluated for presence of metabolic syndrome at delivery, nine weeks, six months and one year. Main outcome measures: Prevalence of metabolic syndrome Results: A total of 488 pregnant women were included: 410 and 78 with HDPs and normotensive, respectively. None of the normotensive had metabolic syndrome until one year (1.7% = 1 out of 59 observations), while among those with HDPs were 17.4% (71 of 407), 8.7% (23 of 263), 4.7% (11 of 232) and 6.1% (17 of 278), at delivery, nine weeks, six months and one year postpartum, respectively. High BMI and blood pressure were the drivers of metabolic syndrome in this population. The incidence rate in HDPs versus normotensive at one year were, respectively, 57.5/1000 persons’ year (95%CI; 35.8 – 92.6) and 16.9/1000 persons’ years (95%CI; 2.4-118.3), with incidence rate ratio of 3.4/1000 person's years. Only parity significantly predicted the presence of metabolic syndrome at one year [(aOR= 3.26/delivery (95%CI; 1.21-8.79)]. Conclusion: HDPs were associated with a higher incidence of metabolic syndrome up to one year postpartum. Women with HDPs should be routinely screened for metabolic syndrome within the first year postpartum to reduce cardiometabolic risks.</p

Intravenous versus oral iron for iron deficiency anaemia in pregnant Nigerian women (IVON): study protocol for a randomised hybrid effectiveness-implementation trial

Background Anaemia in pregnancy is highly prevalent in African countries. High-dose oral iron is the current recommended treatment for pregnancy-related iron deficiency anaemia (IDA) in Nigeria and other African countries. This oral regimen is often poorly tolerated and has several side effects. Parenteral iron preparations are now available for the treatment of IDA in pregnancy but not widely used in Africa. The IVON trial is investigating the comparative effectiveness and safety of intravenous ferric carboxymaltose versus oral ferrous sulphate standard-of-care for pregnancy-related IDA in Nigeria. We will also measure the implementation outcomes of acceptability, feasibility, fidelity, and cost-effectiveness for intravenous ferric carboxymaltose. Methods This is an open-label randomised controlled trial with a hybrid type 1 effectiveness-implementation design, conducted at 10 health facilities in Kano (Northern) and Lagos (Southern) states in Nigeria. A total of 1056 pregnant women at 20–32 weeks’ gestational age with moderate or severe anaemia (Hb < 10g/dl) will be randomised 1:1 into two groups. The interventional treatment is one 1000-mg dose of intravenous ferric carboxymaltose at enrolment; the control treatment is thrice daily oral ferrous sulphate (195 mg elemental iron daily), from enrolment till 6 weeks postpartum. Primary outcome measures are (1) the prevalence of maternal anaemia at 36 weeks and (2) infant preterm birth (<37 weeks’ gestation) and will be analysed by intention-to-treat. Maternal full blood count and iron panel will be assayed at 4 weeks post-enrolment, 36 weeks’ gestation, delivery, and 6 weeks postpartum. Implementation outcomes of acceptability, feasibility, fidelity, and cost will be assessed with structured questionnaires, key informant interviews, and focus group discussions. Discussion The IVON trial could provide both effectiveness and implementation evidence to guide policy for integration and uptake of intravenous iron for treating anaemia in pregnancy in Nigeria and similar resource-limited, high-burden settings. If found effective, further studies exploring different intravenous iron doses are planned. Trial registration ISRCTN registry ISRCTN63484804. Registered on 10 December 2020. Clinicaltrials.govNCT04976179. Registered on 26 July 2021 The current protocol version is version 2.1 (080/080/2021)

Intravenous versus oral iron for iron deficiency anaemia in pregnant Nigerian women (IVON): study protocol for a randomised hybrid effectiveness-implementation trial.

BACKGROUND: Anaemia in pregnancy is highly prevalent in African countries. High-dose oral iron is the current recommended treatment for pregnancy-related iron deficiency anaemia (IDA) in Nigeria and other African countries. This oral regimen is often poorly tolerated and has several side effects. Parenteral iron preparations are now available for the treatment of IDA in pregnancy but not widely used in Africa. The IVON trial is investigating the comparative effectiveness and safety of intravenous ferric carboxymaltose versus oral ferrous sulphate standard-of-care for pregnancy-related IDA in Nigeria. We will also measure the implementation outcomes of acceptability, feasibility, fidelity, and cost-effectiveness for intravenous ferric carboxymaltose. METHODS: This is an open-label randomised controlled trial with a hybrid type 1 effectiveness-implementation design, conducted at 10 health facilities in Kano (Northern) and Lagos (Southern) states in Nigeria. A total of 1056 pregnant women at 20-32 weeks' gestational age with moderate or severe anaemia (Hb < 10g/dl) will be randomised 1:1 into two groups. The interventional treatment is one 1000-mg dose of intravenous ferric carboxymaltose at enrolment; the control treatment is thrice daily oral ferrous sulphate (195 mg elemental iron daily), from enrolment till 6 weeks postpartum. Primary outcome measures are (1) the prevalence of maternal anaemia at 36 weeks and (2) infant preterm birth (<37 weeks' gestation) and will be analysed by intention-to-treat. Maternal full blood count and iron panel will be assayed at 4 weeks post-enrolment, 36 weeks' gestation, delivery, and 6 weeks postpartum. Implementation outcomes of acceptability, feasibility, fidelity, and cost will be assessed with structured questionnaires, key informant interviews, and focus group discussions. DISCUSSION: The IVON trial could provide both effectiveness and implementation evidence to guide policy for integration and uptake of intravenous iron for treating anaemia in pregnancy in Nigeria and similar resource-limited, high-burden settings. If found effective, further studies exploring different intravenous iron doses are planned. TRIAL REGISTRATION: ISRCTN registry ISRCTN63484804 . Registered on 10 December 2020 Clinicaltrials.gov NCT04976179 . Registered on 26 July 2021 The current protocol version is version 2.1 (080/080/2021)

Prevalence and factors associated with female sterilization in Rwanda: evidence from the demographic and health survey data (2019–2020)

Abstract Background Female sterilization is a safe and effective surgical procedure of achieving contraception. There is disparity in the prevalence of female sterilization globally, with high income countries having higher rates than low- and middle-income countries. However, current evidence of the uptake of female sterilization in Rwanda is not known. We therefore evaluated the prevalence and factors associated with female sterilization among women of reproductive age in Rwanda. Methodology This was a secondary data analysis of 14,634 women of reproductive age (15–49) in Rwanda. The data utilized was from the Rwanda Demographic Health and Survey (RDHS) 2019/2020. The predictors of female sterilization were determined using multivariable binary logistic regression analysis. Results We found that the prevalence of female sterilization was 1.1% among women of reproductive age in Rwanda. Women older than 35 years had about 8 times higher chance of being sterilized as compared to younger women (aOR: 7.87, 95% CI: 4.77–12.99). Women living with their partners had higher odds of being sterilized as compared to never married women (aOR: 19.23, 95% CI: 4.57–80.82), while women from minority religion are more likely to be sterilized as compared to those of the catholic religion (aOR: 2.12, 95% CI: 1.03–4.37). Women from rich household had a higher chance to be sterilized as compared to their counterparts from poor households (aOR: 3.13, 95% CI: 1.94–5.03). Women from the Western region were more likely to accept sterilization compared to women from Kigali (aOR: 2.025, 95% CI: 1.17–3.49) and women who had more than 5 children had higher odds when compared to women who had 5 or less children (aOR: 1.49, 95% CI: 1.06–2.10). Conclusion The overall prevalence of sterilization among Rwandan women of reproductive age was 1.1%, which was very low as compared to India (29%), China (14.1%) and United States of America (13.7%). The age, marital status, religion, household wealth quintile, region and children ever born were associated with the uptake of female sterilization among Rwandan women. Public awareness campaign on the advantages of female sterilization should be done to improve uptake

Sociodemographic predictors of endometrial cancer mortality in South Africa (1997 to 2015): a case-control study

South Africa is currently undergoing epidemiological and health transition that may impact on the risk factors of endometrial cancer mortality. We evaluated the sociodemographic characteristics of women that died from endometrial cancer in South Africa from 1997 to 2015. An unmatched case control study was conducted to compare the sociodemographic characteristic of women that died from endometrial cancer cases (n = 3,955) with the characteristics of women that died from other cancers (controls, n = 66,202) using the population-based mortality data from Statistics South Africa. Unconditional binary logistic regression modelling was conducted. The Mean age of women that died from endometrial cancer was 66.7 ± 11.9 years. The odds of death from endometrial cancer among women aged ≥50 years was about 4-fold as compared to women younger than 50 years (AOR = 3.98 95% CI: 3.14 − 5.03; p value: <.001). Conversely, high school leavers (AOR = 0.79 95% CI: 0.66 − 0.94; p value: .009), smokers (AOR= 0.53 95% CI: 0.43 − 0.65; p value: <.001), and divorced women (AOR= 0.73 95% CI: 0.59 − 0.89; p value: .002) had lesser odds of endometrial cancer mortality. This study provides information to guide Public Health control program on endometrial cancer in South Africa.Impact statement What is already known on this subject? The prevalence of endometrial cancer is increasing in low and middle income countries. After the abolition of Apartheid in South Africa, the country commenced a multi-racial government that provided socio-economic empowerment to the majority of the country. Thus, South Africa is currently undergoing epidemiological and health transition that may impact on the risks of endometrial cancer in the country. What do the result of the study add? This study is the first in South Africa to evaluate the sociodemographic characteristics of women that died from endometrial cancer using a large population-based data. Age, educational status, smoking status are some identified risk factors of mortality from endometrial cancer in South Africa What are the implications of these findings for clinical practice and/or further research? The highlighted risk factors that are associated with endometrial mortality will help in guiding health policies that will help reduce the prevalence of endometrial cancer. The study recommends a targeted national prevention program for endometrial cancer as the burden appears to be worsening with each passing year