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PubMed2006

Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa.

BACKGROUND: The epidemics of HIV-1 and tuberculosis in South Africa are closely related. High mortality rates in co-infected patients have improved with antiretroviral therapy, but drug-resistant tuberculosis has emerged as a major cause of death. We assessed the prevalence and consequences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis in a rural area in KwaZulu Natal, South Africa. METHODS: We undertook enhanced surveillance for drug-resistant tuberculosis with sputum culture and drug susceptibility testing in patients with known or suspected tuberculosis. Genotyping was done for isolates resistant to first-line and second-line drugs. RESULTS: From January, 2005, to March, 2006, sputum was obtained from 1539 patients. We detected MDR tuberculosis in 221 patients, of whom 53 had XDR tuberculosis. Prevalence among 475 patients with culture-confirmed tuberculosis was 39% (185 patients) for MDR and 6% (30) for XDR tuberculosis. Only 55% (26 of 47) of patients with XDR tuberculosis had never been previously treated for tuberculosis; 67% (28 of 42) had a recent hospital admission. All 44 patients with XDR tuberculosis who were tested for HIV were co-infected. 52 of 53 patients with XDR tuberculosis died, with median survival of 16 days from time of diagnosis (IQR 6-37) among the 42 patients with confirmed dates of death. Genotyping of isolates showed that 39 of 46 (85%, 95% CI 74-95) patients with XDR tuberculosis had similar strains. CONCLUSIONS: MDR tuberculosis is more prevalent than previously realised in this setting. XDR tuberculosis has been transmitted to HIV co-infected patients and is associated with high mortality. These observations warrant urgent intervention and threaten the success of treatment programmes for tuberculosis and HIV.

Adult↗

PubMed2000

Effect of human immunodeficiency virus infection on episodes of diarrhea among children in South Africa.

BACKGROUND: Infection with HIV is increasing among children in South Africa. Diarrhea is a common cause of morbidity and mortality in Africa, and some studies have shown that HIV-infected children have episodes of severe diarrhea with higher mortality than HIV-uninfected children. OBJECTIVES: To compare the severity, pathogens and outcome of diarrhea in HIV-infected and uninfected children. METHODS: We studied 181 children ages 3 months to 4 years admitted for gastroenteritis to the Chris Hani Baragwanath Hospital in Soweto, South Africa. Demographic details of the children were recorded, as were the details of the episode of diarrhea. Stools specimens were collected and sent for microbiologic evaluation. The clinical course of the child's admission was recorded. Children were diagnosed as being infected with HIV if they tested positive by HIV enzyme-linked immunosorbent assay (ELISA) and were >15 months of age, or if they were ELISA-positive, were < 15 months of age and had clinical signs of HIV infection. RESULTS: Of the 176 children with an HIV ELISA result, 31 (17.6%) were classified as HIV-infected. More HIV-infected children were malnourished (80.6% vs. 39.5%, P < 0.001) and more likely to have had prolonged diarrhea (16.1% vs. 5.9%, P = 0.07) compared with HIV-uninfected children. HIV-infected children had a higher rate of a codiagnosis of pneumonia (43.3% vs. 9.2%, P < 0.0001) and were more likely to require a hospital stay of >4 days (prevalence odds ratio, 5.11; 95% confidence interval, CI 1.49 to 17.52). There were no significant differences in stool pathogens or in the level of dehydration on admission between the HIV-infected and uninfected children. CONCLUSION: HIV-infected children have the same spectrum of enteric pathogens as uninfected children but require more attention because of malnutrition and comorbidity.

Breast Feeding↗

PubMed2003

Molecular investigation of two possible cases of accidental HIV-1 transmission in South Africa.

HIV-1 sequences from two possible transmission cases in South Africa were examined for evidence of genetic linkage. HIV-1-seropositive blood samples were obtained from a donor and recipient within 8 months following a blood transfusion and from a healthcare worker and her patient within 10 months following a needle-stick injury. A 700-bp region in env and 550-bp region in gag were analyzed. All sequences were phylogenetically associated with HIV-1 subtype C, the predominant HIV-1 subtype in South Africa. The nucleotide sequences from the blood transfusion case grouped together significantly with a bootstrap value of 100%. These samples were 98% and 100% identical in the predicted amino acid sequences of env and gag, respectively. In contrast, sequences from the needle-stick case showed only 67% and 80% amino acid identity in env and gag, respectively, and were separated on a phylogenetic tree. Molecular analysis suggested that HIV transmission occurred in the blood transfusion case but not in the case of the needle-stick injury. These data emphasize the need for molecular investigation of epidemiologically linked cases of HIV transmission.

Adult↗

PubMed2005

Tissue banking in South Africa: a 19-year history.

The establishment of a Tissue Bank and the science of Tissue Banking in South Africa started in the 1960s and is still developing. This article describes the development and growth of Tissue Banking in South Africa. The current emphasis is to supply viable bone products that have been produced under the best possible quality controlled circumstances; with the collaboration between different Organ Donation Organisations. Through collaboration, a dramatic increase in the number of donors was noted over the years. Concurrently, there was a dramatic increase in the usage of different allograft products and now necessitates the development of new graft materials for expanding patient options. As an ongoing concern, the Tissue Bank in South Africa experienced an ever increase in costs to enhance quality/safety controls: increase in historical patient information, documentation and serological testing in a population struggling to control HIV. To date, the South African Tissue Bank has not experienced any untoward patient incidence since the 1960s and currently is getting over 500 donors per year.

History, 20th Century↗

PubMed2001

Characterization of full-length HIV type 1 subtype C sequences from South Africa.

Four full-length genome subtype C sequences from South Africa, three of which are being used for vaccine development, were characterized. Three isolates were obtained from recently infected individuals in KwaZulu/Natal: Du151, Du422, and Du179. A fourth isolate, CTSc2, was obtained from an individual residing in Cape Town. All four strains used the CCR5 coreceptor, although Du179 also used CXCR4. The four isolates clustered within subtype C, but the three Du isolates formed a subcluster with a bootstrap value of 100%, with CTSc2 outside the subcluster. None of the strains showed evidence of intersubtype recombination, as expected from the predominance of subtype C in South Africa. All 4 isolates had a 16-amino acid truncation on the 3' end of the Rev protein, identified in other subtype C isolates. Like many other subtype C strains, Du151, Du422, and Du179 had three NF-kappa B-binding sites in the LTR; however, CTSc2 had only two.

Genome, Viral↗

PubMed2001

Active case finding: understanding the burden of tuberculosis in rural South Africa.

SETTING: The Agincourt demographic and health surveillance site in South Africa's rural Northern Province. OBJECTIVES: To accurately assess the true burden of tuberculosis in a rural sub-district with a known high prevalence of human immunodeficiency virus. DESIGN: Data on hospital registrations of tuberculosis were combined with data from an ongoing demographic health and surveillance system to accurately describe the burden of tuberculosis in a well-defined community. Undiagnosed active cases of sputum-positive disease in the community were detected among chronic coughers identified by heads of household during a single-pass census interview. RESULTS: The incidence of hospitalised tuberculosis among the permanently resident population (n = 56 566) was 212/100,000 person-years during 1999. The average point prevalence of detected tuberculosis (all forms) among patients aged over 10 years was 133/100,000, and 81/100,000 for sputum-positive pulmonary disease. This compares with a point prevalence of 16/100,000 cases of sputum-positive disease detected through active case finding. CONCLUSION: For every nine cases of sputum positive pulmonary tuberculosis being treated at any one time, there are two cases of undiagnosed disease in the community. This study demonstrates a modest burden of undiagnosed tuberculosis among residents in a rural sub-district in South Africa.

Adolescent↗

PubMed2004

Suicide trends in South Africa, 1968--90.

AIMS: A study was undertaken to investigate suicide rates and proportional mortality trends in South Africa from 1968 to 1990. METHODS: Suicide rates per 100,000 population per year and suicide proportional mortality rates per year were calculated. The analyses were stratified by race, sex, and age group. Trends were interpreted using graphs depicting smoothed sex/race-specific suicide rates and proportional mortality rates over time. Regression models for suicide rates were fitted within specific age groups to test the effects of race, sex, and time. Further analysis was done within the specific age and race groups, if any interaction was found with time. RESULTS: There were increases in suicide rate in the young (particularly for white males) and for whites aged 65 years and above (particularly for males). CONCLUSIONS: The finding that suicide among the young and elderly in South Africa is increasing suggests that preventive efforts are indicated, especially for white males. Trends for young South Africans mirror those in Europe and the USA, and attention to trends in these countries may predict future trends in youth suicide in South Africa.

Adolescent↗

PubMed1994

The consequences of drunken driving in South Africa.

With the increase of alcohol use and abuse in South Africa, there has been an increase in the frequency of drunken driving offences. The community has become increasingly irate at the horrendous damage and loss of life which are occasioned by these offences. The courts have therefore been forced to take not of public opinion, and the penalties have consequently become more stringent and punitive. This article focuses primarily on the recurrent conflict between medical treatment and the imposition of punishment when the court is confronted by a person who has been driving whilst exceeding the legal blood alcohol limit. The courts are faced with having to differentiate between those persons who have an alcohol dependency and those who have merely behaved irresponsibly. What do they do? If the law deals with both cases in the same manner, it would not be achieving anything. The legal system in South Africa needs to differentiate between those persons who have an addiction and subsequently need treatment, and those who need education. The legal system needs, therefore, to make provision for proper independent professional diagnostic assessment. This article suggests alternative options which the courts could adopt in order to deal with these offences in a more flexible and effective manner.

Accidents, Traffic↗

PubMed2002

The HIV-1 epidemic in South Africa.

The first reported cases of HIV-1 infection in South Africa occurred in 1982. Two distinct HIV-1 epidemic patterns were recognized. Initially the infection was prevalent in white males who had sex with males. The HIV-1 clade B was associated with this group. By 1989, the second epidemic was recognized primarily in the black population. Infections in this case were mainly heterosexual in origin. The HIV-1 clade involved was mainly C. The national HIV-1 sero-prevalence in antenatal attendees was less than 1% in 1990 and by 1994 this figure had risen to 7.5%. The most recent antenatal surveillance for HIV-1 sero-prevalence in 1999 revealed the following. The national prevalence rate for 1999 was 22.4% compared with the 1998 rate of 22.8%. The data highlighted the profound effect the epidemic had and will have on the disease burden in South Africa and by extension on the social and economic fronts. This view was emphasised by the impact HIV-1 infection had on tuberculosis. For example, sentinel surveys have attributed 44% of tuberculosis cases to HIV-1 infection. Moreover, the high prevalence of sexually transmitted infections will certainly exacerbate the HIV-1 epidemic.

AIDS-Related Opportunistic Infections↗

PubMed2000

Ethics in South Africa: new challenges.

One of the reasons why ethics is so much spoken about nowadays is that the moral certainties of previous times no longer exist. Recent events in South Africa have called into question many of the values and principles formerly adhered to. Formerly, we had confidence in the moral consensus that was shared by our families, religious organizations, educational institutions, professional associations and judicial system. Nowadays we have pluralism, and we live in a society with many competing moralities. Whereas in traditional societies, there is considerable agreement on values, in pluralistic societies, such as South Africa, individuals are subject to a clash of values and have the difficult task of deciding which should prevail. Euthanasia and assistance in suicide are currently hot issues in South Africa. Ethical conduct of medical practitioners dealing with cases of AIDS is an ongoing task. New issues like Telemedicine and the ethics involved therein, are a concept in South Africa and will receive much attention in this year.

Attitude to Health↗

PubMed2001

The epidemiology of human immunodeficiency virus in South Africa.

We review the epidemiology of human immunodeficiency virus (HIV) in South Africa where the prevalence of HIV infection is among the highest in the world. The epidemic reached South Africa relatively recently but the prevalence of infection has increased rapidly and there are significant differences among provinces. Although few 15-year-old people are infected the prevalence increases rapidly with age thereafter, especially among women. The prevalence of herpes simplex virus type 2 exceeds that of HIV and curable sexually transmitted infections are common. 'Circular migration' may help to explain the high rates and rapid spread of HIV in the region. The incidence of tuberculosis has increased dramatically as a result of the HIV epidemic. Antiretroviral therapy for the prevention of vertical transmission has been shown to be effective in local conditions but transmission through breast-feeding remains problematical. While some epidemiological models have been developed, much more needs to be done in this regard in order to plan, coordinate and evaluate an effective response to the epidemic. We conclude by discussing some of the research that is needed and steps that could be taken to reduce the continued spread of the infection.

Adolescent↗

PubMed2000

Barriers to implementing South Africa's Termination of Pregnancy Act in rural KwaZulu/Natal.

INTRODUCTION: South Africa's Termination of Pregnancy Act, the most liberal abortion law in Africa, took effect early in 1997. In spite of the anticipated benefits to women's health, however, public reaction has been mixed. In the country's most populous province, KwaZulu/Natal, opposition is strong and most health care providers have refused to provide the service. This study explored attitudes and beliefs about abortion and the Termination of Pregnancy Act among primary care nurses and community members in a rural district in order to better understand barriers to implementation of the new law. METHODS: As part of a community survey on women's reproductive health (n = 138), questions on knowledge, attitudes and beliefs about abortion were asked, as well as awareness of the provisions of the Termination of Pregnancy Act. To better understand the perspectives of health care workers, a survey among primary care nurses on duty (n = 25) was also conducted. In-depth interviews were conducted with both nurses and women in the community to further pursue issues raised in the two surveys. RESULTS: Support for the Act was low (11%) among both community members and nurses, and few supported abortion on request (18 and 6%, respectively). Within each group, however, a clear hierarchy of support was observed: a majority of nurses (56%) and community members (58%) supported abortion in the case of rape or incest, or if the continued pregnancy would endanger a woman's health (61 and 56%, respectively), but few supported abortion for social or economic reasons. In-depth interviews revealed that abortion is seen as contrary to prevailing community norms; nurses were poorly informed about the Termination of Pregnancy Act and felt confused in their professional responsibilities. CONCLUSIONS AND RECOMMENDATIONS: Legalization alone cannot ensure implementation of abortion services. In South Africa, extensive media coverage prior to passage of the law ensured almost universal awareness of the Act, but little public education took place at the same time. In spite of general opposition to the law, however, there is an encouraging level of support for abortion in some circumstances. These findings suggest that abortion services can be implemented, even in conservative rural areas, but that a process of information dissemination and community consent prior to implementation is essential. Locating abortion within broader reproductive health services could be an effective way to improve access and acceptability.

Abortion, Legal↗

PubMed2004

Dental caries in six, 12 and 15 year old Venda children in South Africa.

BACKGROUND: Oral diseases is still a major problem in most developing countries. Within the Republic of South Africa, there remains areas where few or no studies have been done on the oral health status. The emerging district health system with decentralisation of health services to address past inequity in health care in South Africa also provides compelling case for data collection at regional levels. OBJECTIVES: To assess the prevalence and severity of dental caries of school children; determine the caries patterns of the study population and to provide useful data for the planning of oral health services in this region. DESIGN: Descriptive analytical study. SETTING: School children in the Donald Fraser Health District, Venda in the Northern province, Republic of South Africa. SUBJECTS/METHODS: A total of 519 school children in the age groups 6, 12 and 15 years were examined by a calibrated examiner for dental caries using WHO diagnostic criteria. Both the schools, which were divided into rural and peri-urban locations and the children that participated were randomly selected. RESULTS: A mean dmft(sd) of 2.68(3.29) in six year olds and a mean DMFT (sd) scores of 0.61(1.50) and 1.26 (2.18) were recorded in the 12 and 15 year olds respectively. In the six year olds the upper anterior teeth showed highest susceptibility to caries, clearly indicating that black children suffer from early infant caries. At ages of 12 and 15 the mandibular molars were the teeth most affected. The decayed component constituted the main part of the dmft and DMFT scores. Ninety-nine percent of these lesions were untreated and the restorative care was almost nil. CONCLUSION: An important finding was the doubling of the mean DMFT from the 12-year-olds to 15-year olds and the caries levels for all age groups was higher than the provincial average. The treatment required were mostly extractions and simple fillings, the majority of which could be managed by dental auxiliaries using the Atraumatic Restorative Treatment Technique. This study indicates that preventive oral health measures should be implemented on the younger age groups in order to control dental caries.

Adolescent↗

PubMed2003

A study on the incidence of suicide by hanging in the sub-region of Transkei, South Africa.

BACKGROUND: Transkei is a former black homeland in South Africa. It is a historical place and well known for spearheading the freedom fight of South Africa because most of the African National Congress leaders are from this region. It was therefore deprived of development by the apartheid government and is now a poverty stricken area. Transkei is characterized by the lack of infrastructure, and hence a, high rate of unemployment. The majority of individuals are dependent on either the income of migrant mineworkers or subsistence farming at home. OBJECTIVE: To estimate the incidence of suicides in the sub-region of Transkei. METHOD: This is a retrospective record review of deaths due to hanging during the period of January 1993-December 2000 at the Umtata General Hospital. All medico-legal autopsies were recorded in a register at the mortuary. The names, addresses, age, and causes of deaths are found recorded in the register. The catchment areas of these autopsies are Umtata and Nqgeleni magisterial areas which have a population of about 300,000. All autopsy records were collected and analyzed manually. RESULTS: There has been an increasing trend of hanging since 1993, with an overall suicidal death rate increasing from 23.7 per 100,000 in 1993 to 38.6 per 100,000 in 2000. It is observed to be higher in November 32 (13%) and least in September 12 (5%). Over half the deaths 32 (51%) due to hanging were young adults (16-30 years) and 8 (13%) adolescents less than 15 years of age. Twelve (19%) deaths were 31-45 year olds and 5 (7%) were over 61 years. CONCLUSION: There is increasing incidence of deaths due to hanging in Transkei. Nearly two-thirds of them were young adults less than 30 years. RECOMMENDATION: Suicidal tendency in terms of young adults is emerging as an important mental health issue that needs to be addressed. There is need of a well-planned prospective study to be carried out in Transkei.

Journal Article↗

PubMed1998

What is the infant mortality rate in South Africa? The need for improved data.

OBJECTIVE: To review recent infant mortality and birth registration data in South Africa and to investigate geographical differences. OUTCOME MEASURES: Estimates of infant mortality rates, proportion of births not registered, and proportion of births recorded in health services. METHODS: 1. Published infant mortality data for South Africa were collated. Demographic data from national household surveys (1993 and 1994 October Household Surveys and the 1993 Poverty Survey by the Southern African Labour and Development Research Unit (SALDRU) at UCT) were analysed using the indirect method developed by Brass. 2. Birth registration data were analysed and compared with the estimated number of births to identify regions with greater under-registration. The number of births recorded in the health services was analysed by province in order to assess and explore alternatives within health authorities that could complement the existing system. RESULTS: 1. Published estimates of infant mortality for the period from 1990 range from 40 to 71/1,000 births and estimates based on national household surveys conducted in this period from 11 to 81/1,000 births. 2. Completeness of birth registration in the nine provinces ranges from less than 10% in the Eastern Cape, North West and Northern Province to 60% in the Western Cape. An overall improvement from 19% to 60% could be achieved if births recorded through the health services were included in the vital registration system. CONCLUSIONS: The infant mortality rate in South Africa is not known with any certainty. The extent of completeness of the birth registration system was 19%, which indicates a need for urgent improvement in order to provide key health status indicators. This study indicates that there is some potential for improving the extent of birth registration if it could be facilitated through the health service. However, this alone would not achieve complete registration. RECOMMENDATIONS: Surveys will have to be relied upon until such time as routinely available statistics are accurate. The October Household Survey conducted annually by the Central Statistical Service as potentially an important source of health status information. It is imperative that either the design of the birth history questionnaire be improved or that it be replaced by a less frequent but more specialised demographic and health survey.

Female↗

PubMed2002

Regional clustering of shared neutralization determinants on primary isolates of clade C human immunodeficiency virus type 1 from South Africa.

Clade C is one of the most prevalent genetic subtypes of human immunodeficiency virus type 1 (HIV-1) in the world today and one of the least studied with respect to neutralizing antibodies. Most information on HIV-1 serology as it relates to neutralization is derived from clade B. Clade C primary isolates of HIV-1 from South Africa and Malawi were shown here to resemble clade B isolates in their resistance to inhibition by soluble CD4 and their sensitivity to neutralization by human monoclonal antibody immunoglobulin G1b12 and, to a lesser extent, 2F5. Unlike clade B isolates, however, all 16 clade C isolates examined resisted neutralization by 2G12. Infection with clade C HIV-1 in a cohort of female sex workers in South Africa generated antibodies that neutralized the autologous clade C isolate and T-cell-line-adapted (TCLA) strains of clade B. Neutralization of clade B TCLA strains was much more sensitive to the presence of autologous gp120 V3 loop peptides compared to the neutralization of clade C isolates in most cases. Thus, the native structure of gp120 on primary isolates of clade C will likely pose a challenge for neutralizing antibody induction by candidate HIV-1 vaccines much the same as it has for clade B. The autologous neutralizing antibody response following primary infection with clade C HIV-1 in South Africa matured slowly, requiring at least 4 to 5 months to become detectable. Once detectable, extensive cross-neutralization of heterologous clade C isolates from South Africa was observed, suggesting an unusual degree of shared neutralization determinants at a regional level. This high frequency of cross-neutralization differed significantly from the ability of South African clade C serum samples to neutralize clade B isolates but did not differ significantly from results of other combinations of clade B and C reagents tested in checkerboard assays. Notably, two clade C serum samples obtained after less than 2 years of infection neutralized a broad spectrum of clade B and C isolates. Other individual serum samples showed a significant clade preference in their neutralizing activity. Our results suggest that clades B and C are each comprised of multiple neutralization serotypes, some of which are more clade specific than others. The clustering of shared neutralization determinants on clade C primary HIV-1 isolates from South Africa suggests that neutralizing antibodies induced by vaccines will have less epitope diversity to overcome at a regional level.

Amino Acid Sequence↗

PubMed2005

Riding the wave: South Africa's contribution to ethnopharmacological research over the last 25 years.

South Africa is a country with both rich floral biodiversity and cultural diversity. Traditional herbal medicines form an important part of the healthcare of most South Africans, and relies heavily on the use of indigenous plants. This article briefly describes the role South Africa has played in recent years, in contributing to the worldwide increase in research in the field of ethnopharmacology.

Ethnopharmacology↗

PubMed1992

Estimations of the total size of the HIV and hepatitis B epidemics in South Africa.

The total number of people infected with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in South Africa was estimated from a number of sources of seroprevalence for each of these viruses. A total figure of 122,951 HIV-infected individuals in South Africa was arrived at for January 1991; 69% (85,247) were from the urban black population and 20% (24,474) from the rural black population. The male homosexual population constituted some 7% (8,175) of the total, 94% of whom were white; however, this probably represented a substantial underestimation of the size of this population. A total of 1,475,223 carriers of HBV virus was calculated for South Africa from data obtained from 1986 to 1990. Of these, 88% (1,302,741) came from the rural black population and 8% (114,118) from the urban black population. Extrapolations from small sample numbers and often with broad assumptions are subject to considerable error. Nevertheless, estimated total figures do provide a vivid picture of the extent of these two epidemics.

Acquired Immunodeficiency Syndrome↗