Modeling the relationship between precipitation and malaria incidence in Mpumalanga, South Africa

Climatic or weather-driven factors such as rainfall have considerable impact on vector abundance and the extrinsic cycles that parasites undergo in mosquitoes. Climate models therefore allow for a better understanding of the dynamics of malaria transmission. While malaria seasons occur regularly between October and May in Mpumalanga, there is considerable variation in the starting point, peak and magnitude of the season. The relationship between rainfall and malaria incidence may be used to better model the variation in the malaria season. As a first step, this study seeks to explore the complex association between rainfall and malaria incidence through time series methods

A randomised control trial for the restoration of functional ability in patients post total knee arthroplasty: Eccentric versus concentric cycling ergometry

Introduction: While the total knee arthroplasty procedure improves joint-specific outcomes, including pain and range of movement, functional deficits post-surgery has been noted. Movement abnormalities and quadriceps weakness of the operated limb, as well as a decrease in strength on the non-operated have been widely reported. Recovery of strength and function to normal levels is also rare, thereby predisposing patients to future disability with increasing age. The purpose of this study was to determine the effects of an eight-week eccentric cycling ergometry exercise intervention versus a concentric cycling ergometry exercise intervention in total knee arthroplasty recipients three to nine months post-surgery. This study aimed to a) investigate the change in joint kinetics, kinematics and muscle activity during the phases of gait, between the eccentric and concentric groups over time and b) To determine if an eccentric cycling exercise intervention produces greater improvements in knee function when compared to concentric cycling exercise. Methods: Eighteen participants, three to nine months post total knee arthroplasty were recruited and randomly assigned to either an eccentric or concentric cycling exercise intervention group. Participants performed three exercise sessions weekly over a progressive eight-week period on the Grucox Isokinetic Ergometer. Walking gait analyses and functional outcomes, as measured by the six-minute walk test and validated knee scores (Knee Injury and Osteoarthritis Outcome Score, SF-36 Health Survey and Tegner Activity Scale) were recorded pre- and post-intervention. Results: The concentric group knee flexion range of movement increased significantly during the swing phase of gait (p=0.021) post-intervention together with a significant increase in the peak knee flexion angle during swing (p=0.038). The concentric group showed significant differences between pre and post-rehabilitation in knee flexion range of movement during the swing phase of gait (p=0.030). Significant correlations between knee joint stiffness and the quadriceps:hamstring co-activation ratio were observed in the concentric intervention group pre-intervention: during the pre-activation phase of gait between knee joint stiffness and vastus medialis / biceps femoris (r=-0.68; p=0.042) and during load acceptance phase of gait between knee joint stiffness and vastus lateralis / biceps femoris (r=0.07; p=0.036). The eccentric group recorded neuromuscular changes post-intervention with a significant decrease in the muscle activity of the biceps femoris during load acceptance phase of gait (p=0.021). The eccentric group had significantly better functional outcomes in the overall score of Knee injury and Osteoarthritis Outcome post-intervention (p=0.008) with a significant increase in function seen in the Sports and Recreation subgroup (p=0.008) and a significant increase in the level of activity as measure by the Tegner Activity Scale post-intervention (p=0.028), despite not showing any significant changes in the knee joint kinetics and kinematics. The concentric group only reported a significant increase in the overall score of the of the SF-36 Health Survey (p=0.011) with significant increases in three of the subgroups post-intervention: Bodily pains had improved (p=0.042), the role limitations due to physical heath had improved (p=0.028) and the role limitations due to emotional health had also improved (p=0.009). The concentric group also showed significant improvement in the emotional health over the intervention in comparison to the eccentric intervention group (p=0.020). Both intervention groups reported a similar significant increase in the distance covered during the six-minute walk test post-intervention (p=0.038). Conclusion: The results of this exploratory study did not find the eccentric cycling rehabilitation intervention exclusively more effective than the concentric cycling intervention in the restoration of functional ability in patients post-TKA. The eccentric intervention did however result in neuromuscular adaptations consistent with a move towards a more typical asymptomatic gait pattern and participants reported greater functional improvements on validated knee functional assessments and levels of activity scores. The concentric intervention yielded kinematic changes and participants reported improvements in their emotional and physical health post-intervention. Eccentric training and its role in early stage post-operative rehabilitation is limited. Based on the findings from this exploratory study, the benefit of eccentric training as an adjunct to rehabilitation and its role in contributing to greater improvements in the restoration of functional ability post-TKA needs to be further explored

Assessing the effectiveness of malaria interventions at the regional level in Ghana using a mathematical modelling application

Supporting malaria control with interfaced applications of mathematical models that enables investigating effectiveness of various interventions as well as their cost implications could be useful. Through their usage for planning, these applications may improve the prospects of attaining various set targets such as those of the National Strategic Plan policies for malaria control in Ghana. A malaria model was adapted and used for simulating the incidence of malaria in various regions of Ghana. The model and its application were developed by the Modelling and Simulation Hub Africa and calibrated using district level data in Ghana from 2012 to 2018. Average monthly rainfall at the zonal level was fitted to trigonometric functions for each ecological zone using least squares approach. These zonal functions were then used as forcing functions. Subsequently, various intervention packages were investigated to observe their impact on averting malaria incidence by 2030. Increased usage of bednets but not only coverage levels, predicted a significant proportion of cases of malaria averted in all regions. Whereas, improvements in the health system by way of health seeking, testing and treatment predicted a decline in incidence largely in all regions. With an increased coverage of SMC, to include higher age groups, a modest proportion of cases could be averted in populations of the Guinea savannah. Indoor residual spraying could also benefit populations of the Transitional forest and Coastal savannah as its impact is significant in averting incidence. Enhancing bednet usage to at least a doubling of the current usage levels and deployed in combination with various interventions across regions predicted significant reductions, in malaria incidence. Regions of the Transitional forest and Coastal savannah could also benefit from a drastic decline in incidence following a gradual introduction of indoor residual spraying on a sustained basis

Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross sectional study

Background: In low-resource settings, patients’ use of multiple healthcare sources may complicate chronic care and clinical outcomes as antiretroviral therapy (ART) continues to expand. However, little is known regarding patterns, drivers and consequences of using multiple healthcare sources. We therefore investigated factors associated with patterns of plural healthcare usage among patients taking ART in diverse South African settings. Methods: A cross-sectional study of patients taking ART was conducted in two rural and two urban sub-districts, involving 13 accredited facilities and 1266 participants selected through systematic random sampling. Structured questionnaires were used in interviews, and participant’s clinic records were reviewed. Data collected included household assets, healthcare access dimensions (availability, affordability and acceptability), healthcare utilization and pluralism, and laboratory-based outcomes. Multiple logistic regression models were fitted to identify predictors of healthcare pluralism and associations with treatment outcomes. Prior ethical approval and informed consent were obtained. Results: Nineteen percent of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. A further 15% of respondents reported additional expenditure on self-care (e.g. special foods). Access to health insurance (Adjusted odds ratio [aOR] 6.15) and disability grants (aOR 1.35) increased plural healthcare use. However, plural healthcare users were more likely to borrow money to finance healthcare (aOR 2.68), and incur catastrophic levels of healthcare expenditure (27%) than non-plural users (7%). Quality of care factors, such as perceived disrespect by staff (aOR 2.07) and lack of privacy (aOR 1.50) increased plural healthcare utilization. Plural healthcare utilization was associated with rural residence (aOR 1.97). Healthcare pluralism was not associated with missed visits or biological outcomes. Conclusion: Increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Plural healthcare utilization may be an indication of patients’ dissatisfaction with perceived quality of ART care provided. Healthcare expenditure of a catastrophic nature remained a persistent complication. Plural healthcare utilization did not appear to influence clinical outcomes. However, there were potential negative impacts on the livelihoods of patients and their households.Web of Scienc

Local level inequalities in the use of hospital-based maternal delivery in rural South Africa

BACKGROUND: There is global concern with geographical and socio-economic inequalities in access to and use of maternal delivery services. Little is known, however, on how local-level socio-economic inequalities are related to the uptake of needed maternal health care. We conducted a study of relative socio-economic inequalities in use of hospital-based maternal delivery services within two rural sub-districts of South Africa. METHODS: We used both population-based surveillance and facility-based clinical record data to examine differences in the relative distribution of socio-economic status (SES), using a household assets index to measure wealth, among those needing maternal delivery services and those using them in the Bushbuckridge sub-district, Mpumalanga, and Hlabisa sub-district, Kwa-Zulu Natal. We compared the SES distributions in households with a birth in the previous year with the household SES distributions of representative samples of women who had delivered in hospitals in these two sub-districts. RESULTS: In both sub-districts, women in the lowest SES quintile were significantly under-represented in the hospital user population, relative to need for delivery services (8% in user population vs 21% in population in need; p < 0.001 in each sub-district). Exit interviews provided additional evidence on potential barriers to access, in particular the affordability constraints associated with hospital delivery. CONCLUSIONS: The findings highlight the need for alternative strategies to make maternal delivery services accessible to the poorest women within overall poor communities and, in doing so, decrease socioeconomic inequalities in utilisation of maternal delivery services. Keywords: Maternal health, Socio-economic inequalities, Access, Maternal delivery servicesWeb of Scienc

Operational research (ers) in development: Growing a new generation of operational researchers

This paper explores the theme of training operational research (OR) practitioners in South Africa by critically evaluating a Masters program in Operational Research in Development (ORD), launched in 2005 at the University of Cape Town. This program was specifically focused on applying OR to the problems of the developing world in general and Africa in particular. We describe the program and review the practical work undertaken by students participating in the program. Topics range widely across domains including health (anti-malarial drug resistance); poverty (food banking); governance (NGO management structures and monitoring of local government performance) and sustainable livelihoods (spaza shop operations). We use the review to highlight strengths and weaknesses of the program, as well as challenges faced in the OR education in South Africa at a postgraduate level

Hitting a Moving Target: A Model for Malaria Elimination in the Presence of Population Movement

South Africa is committed to eliminating malaria with a goal of zero local transmission by 2018. Malaria elimination strategies may be unsuccessful if they focus only on vector biology, and ignore the mobility patterns of humans, particularly where the majority of infections are imported. In the first study in Mpumalanga Province in South Africa designed for this purpose, a metapopulation model is developed to assess the impact of their proposed elimination-focused policy interventions. A stochastic, non-linear, ordinary-differential equation model is fitted to malaria data from Mpumalanga and neighbouring Maputo Province in Mozambique. Further scaling-up of vector control is predicted to lead to a minimal reduction in local infections, while mass drug administration and focal screening and treatment at the Mpumalanga-Maputo border are predicted to have only a short-lived impact. Source reduction in Maputo Province is predicted to generate large reductions in local infections through stemming imported infections. The mathematical model predicts malaria elimination to be possible only when imported infections are treated before entry or eliminated at the source suggesting that a regionally focused strategy appears needed, for achieving malaria elimination in Mpumalanga and South Africa

Predicting the impact of border control on malaria transmission: a simulated focal screen and treat campaign

BACKGROUND: South Africa is one of many countries committed to malaria elimination with a target of 2018 and all malaria-endemic provinces, including Mpumalanga, are increasing efforts towards this ambitious goal. The reduction of imported infections is a vital element of an elimination strategy, particularly if a country is already experiencing high levels of imported infections. Border control of malaria is one tool that may be considered. METHODS: A metapopulation, non-linear stochastic ordinary differential equation model is used to simulate malaria transmission in Mpumalanga and Maputo province, Mozambique (the source of the majority of imported infections) to predict the impact of a focal screen and treat campaign at the Mpumalanga-Maputo border. This campaign is simulated by nesting an individual-based model for the focal screen and treat campaign within the metapopulation transmission model. RESULTS: The model predicts that such a campaign, simulated for different levels of resources, coverage and take-up rates with a variety of screening tools, will not eliminate malaria on its own, but will reduce transmission substantially. Making the campaign mandatory decreases transmission further though sub-patent infections are likely to remain undetected if the diagnostic tool is not adequately sensitive. Replacing screening and treating with mass drug administration results in substantially larger decreases as all (including sub-patent) infections are treated before movement into Mpumalanga. CONCLUSIONS: The reduction of imported cases will be vital to any future malaria control or elimination strategy. This simulation predicts that FSAT at the Mpumalanga-Maputo border will be unable to eliminate local malaria on its own, but may still play a key role in detecting and treating imported infections before they enter the country. Thus FSAT may form part of an integrated elimination strategy where a variety of interventions are employed together to achieve malaria elimination