The impact of COVID-19 on use of maternal and reproductive health services and maternal and perinatal mortality

South Africa experienced two waves of COVID-19 infection in the financial year 2020/21. This study examines the impact of these waves on maternal and perinatal mortality and their effect on the use of and access to maternal and reproductive health services. Data from the District Health Information System on maternal and perinatal deaths, births, antenatal visits, and use of contraceptive termination of pregnancy services were used, and the 2020/21 and 2019/20 financial years were compared in order to formulate national and provincial perspectives. Data on visits for initiating antenatal care, births, contraceptive prescriptions and termination-of-pregnancy services were used to assess utilisation of maternal and reproductive health services respectively; and the number and rates of maternal and perinatal deaths were examined to assess impact. A second descriptive analysis of pregnant women who had delivered after having contracted COVID-19 was performed using a separate database set up by the National Department of Health/South African Medical Research Council/University of Pretoria (NDoH/ SAMRC/UP), specifically to monitor the effects of COVID-19). The data suggest that there was a marked increase (of 40%) in maternal deaths (p<0.00001), 10% in stillbirths (p<0.00001), and 3% in (p=0.31) neonatal deaths when compared with the same period in 2019/20. There was a mean 28% increase in the institutional maternal mortality ratio in all provinces during the second wave compared with the first wave (p<0.0001), except in the Western Cape which had a decrease of 1%. Data from the National Institute for Communicable Diseases showed that the case fatality rate for pregnant women with COVID-19 was high (4.5%), as was the perinatal mortality rate (70.6 per 1 000 births), while the institutional maternal mortality ratio for South Africa was 16.94/100 000 live births. An increase of 3.6% in in-facility births in 2020/21 compared with 2019/20 was observed, with increased movement of pregnant women to the more rural provinces and districts for delivery. Antenatal care services were maintained overall, but use of reproductive health services declined (contraceptive prescriptions by 5%, and termination of pregnancy by 17% overall). The effect of the COVID-19 epidemic on pregnant women and its collateral damage is severe. Strengthening the health system to maintain essential services during a pandemic and vaccination of healthcare workers and pregnant women are key to reducing maternal and perinatal mortality.http://www.journals.co.za/content/journal/healthrObstetrics and Gynaecolog

Toward elimination of mother–to–child transmission of HIV in South Africa: how best to monitor early infant infections within the Prevention of Mother–to–Child Transmission Program

BACKGROUNDSouth Africa has utilized three independent data sources to measure the impact of its program for the prevention of mother–to–child transmission (PMTCT) of HIV. These include the South African National Health Laboratory Service (NHLS), the District Health Information System (DHIS), and South African PMTCT Evaluation (SAPMTCTE) surveys. We compare the results of each, outlining advantages and limitations, and make recommendations for monitoring transmission rates as South Africa works toward achieving elimination of mother–to–child transmission (eMTCT). METHODS HIV polymerase chain reaction (PCR) test data, collected between 1 January 2010 to 31 December 2014, from the NHLS, DHIS and SAPMTCTE surveys were used to compare early mother–to–child transmission (MTCT) rates in South Africa. Data from the NHLS and DHIS were also used to compare early infant diagnosis (EID) coverage. RESULTS The age–adjusted NHLS early MTCT rates of 4.1% in 2010, 2.6% in 2011 and 2.3% in 2012 consistently fall within the 95% confidence interval as measured by three SAPMTCTE surveys in corresponding time periods. Although DHIS data over–estimated MTCT rates in 2010, the MTCT rate declines thereafter to converge with age–adjusted NHLS MTCT rates by 2012. National EID coverage from NHLS data increases from around 52% in 2010 to 87% in 2014. DHIS data over–estimates EID coverage, but this can be corrected by employing an alternative estimate of the HIV–exposed infant population. CONCLUSION NHLS and DHIS, two routine data sources, provide very similar early MTCT rate estimates that fall within the SAPMTCTE survey confidence intervals for 2012. This analysis validates the usefulness of routine data sources to track eMTCT in South Africa.IS

Adult gonorrhea, chlamydia and syphilis prevalence, incidence, treatment and syndromic case reporting in South Africa: Estimates using the Spectrum-STI model, 1990-2017.

OBJECTIVES:To estimate trends in prevalence and incidence of syphilis, gonorrhea and chlamydia in adult men and women in South Africa. METHODS:The Spectrum-STI tool estimated trends in prevalence and incidence of active syphilis, gonorrhea and chlamydia, fitting South African prevalence data. Results were used, alongside programmatic surveillance data, to estimate trends in incident gonorrhea cases resistant to first-line treatment, and the reporting gap of symptomatic male gonorrhea and chlamydia cases treated but not reported as cases of urethritis syndrome. RESULTS:In 2017 adult (15-49 years) the estimated female and male prevalences for syphilis were 0.50% (95% CI: 0.32-0.80%) and 0.97% (0.19-2.28%), for gonorrhea 6.6% (3.8-10.8%) and 3.5% (1.7-6.1%), and for chlamydia 14.7% (9.9-21%) and 6.0% (3.8-10.4%), respectively. Between 1990 and 2017 the estimated prevalence of syphilis declined steadily in women and men, probably in part reflecting improved treatment coverage. For gonorrhea and chlamydia, estimated prevalence and incidence showed no consistent time trend in either women or men. Despite growing annual numbers of gonorrhea cases - reflecting population growth - the estimated number of first line treatment-resistant gonorrhea cases did not increase between 2008 and 2017, owing to changes in first-line antimicrobial treatment regimens for gonorrhea in 2008 and 2014/5. Case reporting completeness among treated male urethritis syndrome episodes was estimated at 10-28% in 2017. CONCLUSION:South Africa continues to suffer a high STI burden. Improvements in access and quality of maternal, STI and HIV health care services likely contributed to the decline in syphilis prevalence. The lack of any decline in gonorrhea and chlamydia prevalence highlights the need to enhance STI services beyond clinic-based syndromic case management, to reinvigorate primary STI and HIV prevention and, especially for women, to screen for asymptomatic infections

Adult gonorrhea, chlamydia and syphilis prevalence, incidence, treatment and syndromic case reporting in South Africa : estimates using the Spectrum-STI model, 1990-2017

OBJECTIVES : To estimate trends in prevalence and incidence of syphilis, gonorrhea and chlamydia in adult men and women in South Africa. METHODS : The Spectrum-STI tool estimated trends in prevalence and incidence of active syphilis, gonorrhea and chlamydia, fitting South African prevalence data. Results were used, alongside programmatic surveillance data, to estimate trends in incident gonorrhea cases resistant to first-line treatment, and the reporting gap of symptomatic male gonorrhea and chlamydia cases treated but not reported as cases of urethritis syndrome. RESULTS : In 2017 adult (15–49 years) the estimated female and male prevalences for syphilis were 0.50% (95% CI: 0.32–0.80%) and 0.97% (0.19–2.28%), for gonorrhea 6.6% (3.8–10.8%) and 3.5% (1.7–6.1%), and for chlamydia 14.7% (9.9–21%) and 6.0% (3.8–10.4%), respectively. Between 1990 and 2017 the estimated prevalence of syphilis declined steadily in women and men, probably in part reflecting improved treatment coverage. For gonorrhea and chlamydia, estimated prevalence and incidence showed no consistent time trend in either women or men. Despite growing annual numbers of gonorrhea cases − reflecting population growth − the estimated number of first line treatment-resistant gonorrhea cases did not increase between 2008 and 2017, owing to changes in first-line antimicrobial treatment regimens for gonorrhea in 2008 and 2014/5. Case reporting completeness among treated male urethritis syndrome episodes was estimated at 10–28% in 2017. CONCLUSION : South Africa continues to suffer a high STI burden. Improvements in access and quality of maternal, STI and HIV health care services likely contributed to the decline in syphilis prevalence. The lack of any decline in gonorrhea and chlamydia prevalence highlights the need to enhance STI services beyond clinic-based syndromic case management, to reinvigorate primary STI and HIV prevention and, especially for women, to screen for asymptomatic infections.S1 File. Prevalence data and biomedical assumptions. Including: A Table. Syphilis prevalence data from surveys, studies and routine ANC-based program screening, used in the Spectrum-STI estimation of adult syphilis prevalence in South Africa With references: [7, 8, 19, 46, 50, 70–97]. B Table. Spectrum assumptions on proportion of episodes symptomatic, proportions of symptomatic episodes treated, episode durations for treated and untreated episodes, and the resulting treatment coverage-weighted average episode durations. With references: [10, 19, 38]. C Table. Gonorrhea and chlamydia prevalence data used, and adjustments for diagnostic test performance and missing high-risk populations, and for chlamydia for age, in the Spectrum- STI prevalence trend estimation for 15–49 year-old adults, South Africa. With references: [32, 46, 50, 51, 72, 77, 80, 81, 86, 91–93, 95, 98–116].S2 File. Reported STI cases, and STI prevalences among women with Vaginal Discharge Syndrome, South Africa.The World Health Organization, Department of Reproductive Health and Researchhttp://www.plosone.orgam2019Medical Microbiolog