The social epidemiology of tuberculosis in South Africa: a multilevel analysis

Increased risk of tuberculosis is widely recognized to be associated with increased poverty, yet there have been few analyses of the social determinants of tuberculosis, particularly in high-burden settings. We conducted a multilevel analysis of self-reported tuberculosis disease in a nationally representative sample of South Africans based on the 1998 Demographic and Health Survey (DHS). Individual and household-level demographic, behavioral and socioeconomic risk factors were taken from the DHS; data on community-level socioeconomic status (including measures of absolute wealth and income inequality) were derived from the 1996 national census. Of the 13,043 DHS respondents, 0.5% reported having been diagnosed with tuberculosis disease in the past 12 months and 2.8% reported having been diagnosed with tuberculosis disease in their lifetime. In a multivariate model adjusting for demographic and behavioral risk factors, tuberculosis diagnosis was associated with cigarette smoking, alcohol consumption and low body mass index, as well as a lower level of personal education, unemployment and lower household wealth. In a model including individual- and household-level risk factors, high levels of community income inequality were independently associated with increased prevalence of tuberculosis (adjusted odds ratio for lifetime tuberculosis comparing the most unequal quintile to the middle quintile of inequality: 2.37, 95% confidence interval: 1.59-3.53). These results provide novel insights into the socioeconomic determinants of tuberculosis in developing country settings, although the mechanisms through which income inequality may affect tuberculosis disease require further investigation.     

Inequities in under-five child malnutrition in South Africa

OBJECTIVES: To assess and quantify the magnitude of inequalities in under-five child malnutrition, particularly those ascribable to socio-economic status and to consider the policy implications of these findings. METHODS: Data on 3765 under-five children were derived from the Living Standards and Development Survey. Household income, proxied by per capita household expenditure, was used as the main indicator of socio-economic status. Socio-economic inequality in malnutrition (stunting, underweight and wasting) was measured using the illness concentration index. The concentration index was calculated for the whole sample, as well as for different population groups, areas of residence (rural, urban and metropolitan) and for each province. RESULTS: Stunting was found to be the most prevalent form of malnutrition in South Africa. Consistent with expectation, the rate of stunting is observed to be the highest in the Eastern Cape and the Northern Province - provinces with the highest concentration of poverty. There are considerable pro-rich inequalities in the distribution of stunting and underweight. However, wasting does not manifest gradients related to socio-economic position. Among White children, no inequities are observed in all three forms of malnutrition. The highest pro-rich inequalities in stunting and underweight are found among Coloured children and metropolitan areas. There is a tendency for high pro-rich concentration indices in those provinces with relatively lower rates of stunting and underweight (Gauteng and the Western Cape). CONCLUSION: There are significant differences in under-five child malnutrition (stunting and underweight) that favour the richest of society. These are unnecessary, avoidable and unjust. It is demonstrated that addressing such socio-economic gradients in ill-health, which perpetuate inequalities in the future adult population requires a sound evidence base. Reliance on global averages alone can be misleading. Thus there is a need for evaluating policies not only in terms of improvements in averages, but also improvements in distribution. Furthermore, addressing problems of stunting and underweight, which are found to be responsive to improvements in household income status, requires initiatives that transcend the medical arena.     

The epidemiology of rape and sexual coercion in South Africa: an overview

During 1999 the issue of rape in South Africa was debated at the highest levels. The epidemiology of rape has become an issue of considerable political importance and sensitivity, with President Mbeki demanding an answer to the question: how much rape is there in South Africa? The purpose of this paper is both to summarise and synthesise the findings of research to provide an overview of the epidemiology of rape of women in South Africa and to show how difficult it is to answer the President's question. The review begins by considering why rape is so difficult to research. Data available shows that rape reported to the police (240 incidents of rape and attempted rape per 100,000 women each year) represents the tip of an ice berg of sexual coercion. Representative community-based surveys have found, for example, that in the 17-48 age group there are 2070 such incidents per 100,000 women per year. Non-consensual sex in marriage and dating relationships is believed to be very common but is usually not well reported in surveys. Forced sexual initiation is reported by almost a third of adolescent girls. In addition coerced consensual sex is a common problem in schools, workplaces and amongst peers. Knowledge of causal and contributory factors influencing the high levels of rape are also discussed. We conclude that the rape statistic for the country is currently elusive but levels of non-consensual and coerced sex are clearly very high. International comparison needs to be approached with caution because most developing countries lack the infrastructure for accurate crime reporting and do not have such a substantial body of survey data.     

Molecular genotyping and epidemiology of equine piroplasmids in South Africa

Recently reported substantial genetic diversity within Theileria equi 18S rRNA gene sequences has led to the identification of five genotypes A, B, C, D, and E, complicating molecular and serological diagnosis. In addition, T. haneyi has lately been reported as a species closely related to the T. equi 18S rRNA genotype C (Knowles et al., 2018). Theileria spp. of this group have a monophyletic origin and are therefore referred to as Equus group to distinguish them from the remaining Theileria lineages (Jalovecka et al., 2019). In this study, we report on the development of genotype-specific quantitative real-time PCR assays capable of detecting and distinguishing between each parasite genotype. Alignment of complete 18S rRNA sequences available on GenBank allowed for the design of a single primer pair and five TaqMan minor groove binder (MGB™) probes specific for each genotype (A–E). The assays, evaluated as qPCR simplex and two qPCR multiplex formats (Multiplex EP–ABC and Multiplex EP–DE), were shown to be both efficient and specific in the detection of T. equi genotypes. The developed qPCR assays were used to study (i) the intra-specific diversity of parasite genotypes within horse and zebra, (ii) the inter-specific differences in parasite genotype diversity in horses as compared to zebra, and (iii) the geographic distribution of T. equi 18S rRNA genotypes in South Africa. In addition, (iv) the presence of T. haneyi in South Africa was evaluated. An assessment of 342 equine field samples comprising 149 field horses, 55 racehorses, and 138 wild zebra confirmed the previously reported presence of T. equi 18S rRNA genotypes A, B, C, and D, and absence of genotype E in South African equids. Theileria equi genotypes A, B, C, and D, were detected in zebra, whereas only genotypes A, C and D, could be identified in field horses, and only genotypes A and C in racehorses. Genotypes B and D were the dominant genotypes identified in zebra in South Africa, while horses were predominantly infected with T. equi genotypes A and C. The greater diversity of T. equi genotypes in zebra suggests that it is an ancestral host for this piroplasmid lineage. Importantly, evidence is presented that each identified T. equi genotype segregates independently in each of the three studied equid populations reinforcing the notion that they represent individual separate entities corresponding to species. Preliminary investigations of the relationship between T. equi genotype C infections and Theileria haneyi, suggest that in addition to the five currently known T. equi genotypes, South African equids are also infected with T. haneyi.     

The epidemiology of AIDS in Africa

A substantial proportion of the Acquired Immune Deficiency Syndrome (AIDS) patients reported in Europe were native Africans who did not have any of the identified risk factors for developing the disease. Most of these patients, who came from the French-speaking countries of Central Africa, came to medical attention primarily in France, Belgium, and Switzerland. The cases were not simply in proportion to the distribution of African populations in Europe. The fact that Africans make up about 7% of the total, male/female ratio is markedly different than the European cases and the vast majority of the African cases had none of the known risk factors. The primary studies conducted to document the presence of AIDS in Africa provided the impetus for the next step, i.e., widespread epidemiologic studies designed to determine the geographic scope and intensity of the problem, the risk factors and modes of transmission in the African context, and attention to the political, economic, social, and cultural issues and initiatives that will necessarily make up part of the local and international response to this epidemic. Some of the most comprehensive epidemiological data comes from Kinshasa, where a multinational research effort is in place. Seroprevalence data was published on over 5000 people through 1985. The bimodal curve shows peaks in seroprevalence among infants under 1 year, among adult women 15-29, and among adult men 30-39. The number of infected adults vastly exceeds the number of infected children. Preliminary data indicated that from 1/3 to 2/3 of the positive tests among infants are due to passive transfer of maternal antibody and not true HIV infection of the infant. Overall, 6% of adults had specific antibody against HIV. Overall incidence of AIDS in Kinshasa is approximately 176/million population, but as most cases occur in adults, this translates into 380/million adults over 20 years old per year. Another study examined the natural history among a cohort of healthy but seropositive hospital workers over time for the development of HIV-related disease, in comparison to matched seropositive controls. 1.3%/year progressed to AIDS; 10.4%/year progressed to Aids-Related Conditions or to different lymphadenopathy. This was 15 times the rate of progression of the control group. As this data comes from Kinshasa, a city of 2 million people, it cannot be taken to represent Africa as a whole or even Zaire as a whole.     

Anticipating rotavirus vaccines: epidemiology and surveillance of rotavirus in South Africa

Rotavirus infection is associated with acute infantile gastroenteritis in infants and young children globally. In South Africa, rotavirus infection has been shown to be associated with approximately one-quarter of all diarrhoeal admissions to hospital. Rotavirus infection predominantly occurs in infants less than 12 months of age (75%) and has a peak of shedding during the cooler, drier months of the year. A secondary peak during the spring has been observed. Multiple infections with rotavirus and at least one other microbial agent are common. The circulating VP7 serotypes and VP4 genotypes have been determined in various regions of South Africa and show a geographic specific distribution. A decade previously, P[8]G1 or G4 strains predominated, and P[4]G2 strains occurred in an epidemic pattern in one region. More recently, rotavirus strains with P[6] genotype have become common and novel VP7/VP4 genotype combinations are occurring across the country. G9 strains have been reported from Cape Town to Vendaland. The circulating rotavirus types observed in this study add to the knowledge of the natural history of rotavirus infection and provide the groundwork to consider future vaccine strategies.     

The epidemiology of yellow fever in Western Africa

Observations made during the epidemics in Côte d''Ivoire (1982), Burkina Faso (1983), Nigeria (1986 and 1987) and Mali (1987), together with studies conducted in the last 10 years, particularly in Côte d''Ivoire, now make it possible, without calling into question the dynamics of yellow fever virus circulation in space and time, to redefine some features of the pattern suggested in 1977 and refined on a number of occasions up to 1983. The endemicity area is still the region of epizootic and enzootic sylvatic circulation, and contains the natural focus and the endemic emergence zone. --The natural focus is no longer confined to the forest alone, now that transovarial transmission has been demonstrated. --The endemic emergence zone is tending to become conterminous with the endemicity area on account of increasing deforestation. Emergence in forest regions, due to Aedes africanus, is still few and isolated, unlike that observed in savanna regions where A. furcifer is the major vector. The different behaviour of these two vectors and their population dynamics determine the quality of the man-vector contact and are responsible for these two patterns of emergence. --The emergence front limits the endemicity area in the north. Its position varies and depends on annual rainfall patterns. The epidemicity area, where the virus does not circulate before an epidemic and where the immunity status of unvaccinated populations is low, is geographically heterogeneous. It consists of regions to the north of the emergence front and of towns anywhere. It is characterized by high potentials for the development of A. aegypti populations. Only man can introduce the virus into this area. Three types of epidemic are distinguished, depending on the vectors: --Urban epidemics resulting from transmission by a domestic vector. These epidemics always occur within the epidemicity area, either in dry savanna (rural subtype) or in towns (urban subtype). The virus is introduced into the ecosystem by man. Transmission is always strictly interhuman. --Intermediate epidemics consist of two successive phases: first of all there is a series of endemic emergences, followed by interhuman transmission involving A. aegypti. These epidemics can only occur in the endemicity area. --Sylvatic epidemics occur in villages, but only involve the sylvatic vectors. They result from a conjunction of a very large number of emergences for which A. furcifer is almost always mainly responsible, and occur in the endemicity area, usually close to the emergence front. Transmission is never strictly interhuman, as the same vector populations are responsible for epizootic and epidemic transmission.(ABSTRACT TRUNCATED AT 400 WORDS)     

The epidemiology of trachoma blindness in Southern Africa

Twenty five years ago medical scientists working in Southern Africa clarified the natural history of trachoma and how it affected vision impairment and eventual blindness in rural communities. After this, doctors attempted to take appropriate actions against the disease. Initial surveys indicated a blindness prevalence rate of 760/100,000 among rural Africans compared to 100/100,000 among the white population. Trachoma was found to be the main cause of blindness. It was found mostly among children under 15 years to a very high degree and seemed to start soon after birth. Vaccine development failed and mass treatment was started. Control measures which did not reach the community, the population at risk, and which did not affect ways of living were found to be ineffective. Community health programmes were thus started but only in a few areas. Further, it was found that non-medical control strategies would be more effective and efficient. Improvement of living standards is one such strategy.     

Living resiliently: The voices of a group of child protection social workers in South Africa

Child protection social workers (CPSWs) do critical work protecting vulnerable children. Given the demanding nature of this work, CPSWs are reportedly at great risk for negative outcomes, such as burnout and depression. Another outcome is often unsatisfactory service delivery by CPSWs, leaving vulnerable children exposed to continued maltreatment. Understanding how some CPSWs do well, despite the demanding nature of their work, is important to inform future interventions that could potentially promote CPSW resilience and improve CPSW service delivery. While some research on the resilience of CPSWs exists, very little is known about resilience in South African CPSWs. The aim of this qualitative study was to contribute to the ongoing conversation of CPSW resilience, by exploring resilience among CPSWs in Gauteng, South Africa. Participants shared their lived experiences of workplace adversity and resilience. In this paper, we report only on the findings related to their resilience, which was analysed using thematic analysis. Findings reveal that participants’ resilience was informed by a safe and appealing space away from work; drawing strength from religion; relaxation and self-care as healing modalities; a passion for CPSW; the positive influence of personal background; supportive care systems; self-efficacy and personal agency; and a positive outlook. The resilience of these CPSWs, although dependent on supportive and responsive ecologies, was mostly self-directed since they appeared fundamentally accountable to procure support.     

The epidemiology of dementia in Africa: a review

Very few of the 100 studies of the prevalence of dementia have been carried out in Africa. Much of the early work concerned small hospitalised samples. However, a series of studies from Ibadan, Nigeria, have produced consistently low rates for dementia, especially for Alzheimer's Disease. The most recent studies reveal rather higher rates, but still lower than surveys carried out elsewhere. The possible reasons for these findings are considered: differential survival rates, the hiding of cases by relatives because of stigma, reluctance to seek medical assistance as inappropriate, poor access to medical care, the feeling that the old person has come to the end of his useful life and defective case-finding techniques. The need for further research is emphasised.     

The epidemiology of hepatitis B virus infection in HIV-infected and HIV-uninfected pregnant women in the Western Cape,South Africa

Objectives

Persistent hepatitis B virus (HBV) infection is a major cause of morbidity and mortality in sub-Saharan Africa. The HIV epidemic has the potential to affect its biology. Immunisation protocols established in the pre-HIV era are based upon data showing predominantly horizontal infant transmission. This study aimed to determine whether HIV co-infection will change the epidemiology of HBV both by increasing infectivity and by favouring the escape of viruses bearing phenotypically altered HBsAg.

Methods

This retrospective cross-sectional study used antenatal samples from the 2008 Antenatal Sentinel HIV and Syphilis Prevalence Survey in the Western Cape, South Africa. All HIV-infected women were age and race-matched to HIV-uninfected women. Samples were tested for serological markers of HBV and HDV infection. HBV viral load, consensus sequencing and genotyping were performed. Luminex technology was used to determine HBsAg phenotype. All samples from HIV-infected women were tested for traces of antiretroviral drugs by mass spectrometry.

Results

This study showed a trend toward loss of immune control of HBV in HIV-infected women with 3.4% of samples containing HBsAg, 18.9% contained HBeAg. In contrast, 2.9% of samples from HIV-uninfected women contained HBsAg and 17.1% of these HBeAg. The median HBV load in the HIV-infected group was 9.72 × 10⁷ IU/ml and in the HIV-uninfected group 1.19 × 10⁶ IU/ml. Genotyping showed 63/68 samples belonged to genotype A and the remainder genotype D. Mutations in the precore region were found in 35% and 33% of samples from HIV-infected and HIV-uninfected respectively. Although no major epitope ablation was found, marked variation in HBsAg profiles in HIV-infected group was demonstrated. No HDV infection was detected.

Conclusion

HIV-HBV co-infected women exhibit a degree of immune escape. One in six HBV-infected pregnant women, irrespective of HIV status is HBeAg seropositive. HBV immunization of newborns in sub-Saharan Africa should be implemented.     

Caregivers in South Africa: The Challenge

Caring In early intervention is an important issue for caregivers as South Africa is increasingly becoming culturally diverse. Caring like leadership plays a central part in understanding individual and group behaviour, for it is the caregiver who usually provides the direction toward goal attainment for the families and children. Therefore, a more culturally appropriate capability should be valuable in improving caregivers' roles. This paper discusses the role confusion that a caregiver is likely to face, by trying to explain why disciplinary counselling must be distinguished from developmental counselling. It shows that to a large extent, it is how a caregiver manages the relationship that determines whether children's developmental goals will be achieved. Describes how a black caregiver (counsellor) could become an effective developer of children by being optimistic about the ability of children to grow. The most pressing need for future research is to examine the cultural context of parenting and the influence of childhood poverty in the development of children.     

The state of psychiatry in South Africa today

The very idea/philosophy behind the South African government's policy of Apartheid (separation), is insulting and humiliating to the black people and tends to incite arrogance and a sense of superiority, even omnipotence, in the whites. Personality development is skewed along racial lines. The mental effects of malnutrition and certain physical diseases, both of which are widespread in South African blacks, especially among their children, are well known. The torture to which security-police detainees have been subjected has resulted in thousands of cases of mental ill-health, as well as physical ill-health, and about 100 deaths, in the past 30 years. Authoritative reports about the in-patient psychiatric facilities for blacks have shocked the world medical, psychiatric and lay communities, and out-patient services for blacks are only sparsely existent, especially in the rural areas (the so-called 'independent homelands' and 'self-governing national states'). The socio-political climate makes interracial therapy, necessary because of the paucity of trained black professionals, particularly difficult. This fact, and the psychological implications of Apartheid, have, until very recently, hardly ever been addressed by psychiatrists and psychologists practising in South Africa. The United Nations and its agency, the World Health Organization, have taken unequivocally oppositional stands for decades but the (West-oriented) World Medical Association and the (mostly-Western) World Psychiatric Association have yet to speak out on this issue, like they have on those involving the Soviet Union and other Eastern Bloc countries.     

The high burden of injuries in South Africa

OBJECTIVE: To estimate the magnitude and characteristics of the injury burden in South Africa within a global context. METHODS: The Actuarial Society of South Africa demographic and AIDS model (ASSA 2002) - calibrated to survey, census and adjusted vital registration data - was used to calculate the total number of deaths in 2000. Causes of death were determined from the National Injury Mortality Surveillance System profile. Injury death rates and years of life lost (YLL) were estimated using the Global Burden of Disease methodology. National years lived with disability (YLDs) were calculated by applying a ratio between YLLs and YLDs found in a local injury data source, the Cape Metropole Study. Mortality and disability-adjusted life years' (DALYs) rates were compared with African and global estimates. FINDINGS: Interpersonal violence dominated the South African injury profile with age-standardized mortality rates at seven times the global rate. Injuries were the second-leading cause of loss of healthy life, accounting for 14.3% of all DALYs in South Africa in 2000. Road traffic injuries (RTIs) are the leading cause of injury in most regions of the world but South Africa has exceedingly high numbers - double the global rate. CONCLUSION: Injuries are an important public health issue in South Africa. Social and economic determinants of violence, many a legacy of apartheid policies, must be addressed to reduce inequalities in society and build community cohesion. Multisectoral interventions to reduce traffic injuries are also needed. We highlight this heavy burden to stress the need for effective prevention programmes.     

Trachoma in South Africa

Trachoma remains the most common cause of preventable blindness in certain areas of the northern Transvaal region of South Africa. Results of epidemiological studies in the area indicate that trachoma is a familial disease with young children acting as the main source of infection within the family. Elderly women who have lived in these areas for long periods of time are at greater risk of blindness and impaired vision from the disease. Genital tract carriage of Chlamydia trachomatis is relatively infrequent in these trachoma-endemic areas and no evidence of eye-to-eye transmission of oculo-genital serotypes of C. trachomatis could be demonstrated.