Gina Joubert

Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial

Abstract Objectives To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics. Design Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation. Setting 40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa. Participants 1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics). Intervention Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials. Main outcome measures Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections. Results All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38). Conclusions Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings. Trial registration Current controlled trials ISRCTN13438073.

Socioeconomic status and prevalence of allergic rhinitis and atopic eczema symptoms in young adolescents

Environmental factors are known to influence the development of allergic rhinitis and atopic eczema in genetically susceptible individuals. Socioeconomic status (SES) may be an important indicator of risk for these conditions. The International Study of Asthma and Allergies in Childhood (ISAAC) Phase 1 written questionnaire was used to determine the prevalence and severity of allergic rhinoconjunctivitis and atopic eczema symptoms in 4947 pupils aged 13–14 years attending 30 schools in socioeconomically diverse areas of Cape Town. Home addresses were used to stratify participants into five SES bands. Relationships between symptom prevalence and severity, and SES, recent urbanization and upward socioeconomic mobility were examined. Logistic regression was used to generate odds ratios (OR) and 95% confidence intervals (CI) in order to assess overall trends by SES. The prevalences of self‐reported allergic rhinitis symptoms and recurrent itchy rash in the past year were 33.2% and 11.9% respectively. Girls had a significantly higher prevalence of all symptoms than boys. The prevalence of allergic rhinitis symptoms increased from lowest to highest SES (overall OR for rhinitis symptoms in past year = 1.16, 95% CI 1.11–1.21). There was no significant trend in reported eczema symptoms by SES other than for the question, ‘Have you ever had eczema’ (OR = 0.88, 95% CI 0.83–0.93). Longer period of urbanization was weakly associated only with recurrent itchy skin rash (OR = 1.05, 95% CI 1.01–1.09). ‘Socially mobile’ pupils, i.e. those resident in the lowest SES areas but attending highest SES schools showed significantly higher prevalences of eczema and some rhinitis symptoms than pupils attending lowest SES schools. These findings may reflect differences in reporting related to language, culture and access to medical care rather than real differences in prevalence.

Allelic frequencies of host genetic variants influencing susceptibility to HIV-1 infection and disease in South African populations.

ObjectivesLimited information is available on the prevalence in African populations of host genetic polymorphisms conferring resistance to HIV-1 infection and disease. The objective of this study was to determine the allelic frequencies in South African populations of the chemokine receptor gene variants CCR5Δ32, CCR5m303 and CCR2b-64I and the CXCR4 ligand gene variant SDF1-3′A. MethodCross-sectional study to determine the prevalence of these gene variants in South African subjects of African and European descent. ResultsThe CCR5Δ32 genetic variant is rare in individuals of African origin, having an allelic frequency of 0.1% (n = 1247) compared with 9.8 % (n = 144) in Caucasians. The CCR5m303 mutation was not detected in Africans (n = 687), whereas an allelic frequency of 0.9% (n = 145) was identified in Caucasians. The frequency of CCR2b-64I allele was 13.1% (n = 180) in Africans, which was significantly higher that the 7.2% (n = 146) detected in Caucasians. Finally the allelic frequency of the SDF1-3′A gene variant was only 1.0% (n = 198) in Africans compared with 19.8% (n = 145) in Caucasians. ConclusionsThese results indicate that genetic polymorphisms conferring resistance to HIV-1 infection are rare in the South African Black population. Except for the CCR2b-64I gene variant, individuals of African origin also had a much lower prevalence of genetic variants associated with prolonged disease progression.

Correlation among total lymphocyte count, absolute CD4+ count, and CD4+ percentage in a group of HIV-1-infected South African patients

Depletion of CD4+ T cells is one of the hallmarks of progression of HIV-1 infection. However, measurement of the CD4+ T-cell count is expensive and often unavailable in less developed areas. Previous studies have suggested that the total lymphocyte count (TLC) can be used to predict a low absolute CD4+ T-cell count. To determine the relationship between TLC and CD4+ T-cell count in HIV-1-infected South African patients, 2777 HIV-1-seropositive patients visiting the Immunology clinic at the Pelonomi Hospital in Bloemfontein, South Africa from April 1991 to April 1997 were included in the study. In total, 3237 observations were used to determine sensitivity, specificity, and likelihood ratios, with 95% confidence intervals, of various cutpoints of the TLC to predict an absolute CD4+ T-cell count of <200 cells/mm3, CD4+ percentage <20%, and CD4+ percentage <15%. Spearman rank correlations were calculated between TLC and CD4+ T cells, CD4+ percentage and CD8+ T cells, as well as between CD4+ and CD8+ T cells. Results demonstrated that a TLC of 2 x 10(9)/L or less had a sensitivity of 90.3% to detect patients with a CD4+ T-cell count of <200 cells/mm3, but a specificity of only 53.7%. When the TLC cutoff value was lowered, specificity increased but sensitivity decreased. For the observations as a group, a correlation (r = 0.704) between CD4+ T-cell count and TLC was demonstrated, but if the patients were divided into three groups according to their CD4+ T-cell count, this correlation weakened considerably. Therefore, although TLC shows a correlation with CD4+ T-cell count, it is not a good predictor of the CD4+ T-cell count in this population and should preferably not be used in the clinical care of HIV/AIDS patients.

Consent for Participation in the Bloemfontein Vitamin A Trial: How Informed and Voluntary?

According to international regulatory authorities1 and local institutional guidelines,2 informed consent is a prerequisite for participation in every clinical trial. Consent implies that participation is voluntary. Furthermore, the participant must know the implications of participation.3 Even if a participant has signed an informed consent form, the participant does not necessarily understand what the participation will entail, and consent thus may not be informed.4 On the other hand, a study conducted in a South African hospital found that patient consent for HIV testing was informed but not truly voluntary.5 The aim of this study was to investigate whether the consent for HIV testing and subsequent participation in a randomized, double-blind, placebo-controlled trial investigating the effect of vitamin A on mother-to-child transmission of HIV6 was informed and voluntary. Participants’ knowledge about HIV and AIDS and the trial was used to measure how informed their consent was, and participants’ perceptions about their willingness to participate, about their ability to withdraw, and about whether they would no longer receive good medical care if they withdrew were used to measure how voluntary their consent was. The trial was conducted from September 1997 to December 2000 in Bloemfontein, Free State, South Africa. In 1997, in the annual survey of the South African Department of Health of women attending public health antenatal clinics, 20% of the Free State women were found to be HIV positive, with the national figure being 17%.7 Despite these figures, no routine intervention has been aimed at preventing vertical transmission in South Africa.

Prevalence of Helicobacter pylori antibodies in children in Bloemfontein, South Africa

BACKGROUND An association of H. pylori infection with chronic gastritis, peptic ulceration and gastric cancer is known. METHODS Prevalence of IgG antibodies to Helicobacter pylori in children in the Bloemfontein, South Africa area was studied. Children attending the general pediatric outpatient department at Pelonomi Hospital in Bloemfontein were grouped according to age. A minimum of 100 children was investigated in each age group. Baseline demographic and socioeconomic data were collected. RESULTS The study showed a high prevalence of H. pylori antibodies. Prevalence increased with age: 13.5% in children 3 months-2 years, 48.5% at 2-5 years, 67.3% at 5-10 years and 84.2% at 10-15 years. Investigation of the socioeconomic data in relation to the prevalence of H. pylori was inconclusive. CONCLUSIONS This high prevalence needs further study.

Application of the new ADA criteria for the diagnosis of diabetes to population studies in sub‐Saharan Africa

Aims To examine the implications for epidemiological studies of the American Diabetes Association (ADA) recommendation that the fasting blood glucose at a lowered level becomes the main diagnostic test for diabetes on cross‐sectional‐based data from sub‐Saharan Africa.

The impact of a nutrition education programme on the anthropometric nutritional status of low-income children in South Africa

OBJECTIVE The study determined the impact of a community-based nutrition education programme, using trained community nutrition advisors, on the anthropometric nutritional status of mixed-race children aged between 2 and 5 years. DESIGN AND SETTING The programme was implemented over two years in four study areas in the Free State and Northern Cape Provinces. Two control areas were included to differentiate between the effect of the education programme and a food aid programme that were implemented simultaneously. Weight-for-age, height-for-age and weight-for-height were summarised using standard deviations from the NCHS reference median. For each of the indicators, the difference in the percentage of children below minus two standard deviations from the reference NCHS median in the initial and follow-up surveys was determined. SUBJECTS Initially 536 children were measured and, after two years of intervention, 815. RESULTS Weight-for-age improved in all areas, but only significantly in boys and girls in the urban study area, and in boys in one rural study area. No significant improvement in height-for-age occurred in any area. Weight-for-height improved significantly in the urban study area. CONCLUSION The education programme in combination with food aid succeeded in improving the weight status of children, but was unable to facilitate catch-up growth in stunted children after two years of intervention.

A prospective clinical and urodynamic study of bladder function during and after pregnancy.

Abstract: The aim of the study was to determine whether clinical and/or urodynamic changes in bladder function occur during pregnancy. Assessment consisted of a urinary symptom questionnaire, urogynecological examination and urodynamic investigations, which were repeated 6 weeks after pregnancy. Sixty-six patients had the initial and 40 the follow-up assessments. Statistical analysis was done by 95% confidence intervals (95% CI). Nocturia, frequency, dysuria, urgency and stress incontinence occurred significantly more frequently during pregnancy. Urinary tract infection was diagnosed in 18% of patients during pregnancy and asymptomatic bacteriuria in 9%. Genuine stress incontinence was diagnosed in 12% during pregnancy and in none after pregnancy (95% CI 1% to 24%). An unstable detrusor was diagnosed in 23% of patients during pregnancy and in 15% after pregnancy (95% CI –8% to 23%). Strong desire to void, urgency, maximum cystometric capacity, maximum flow rate and average flow rate were all statistically significantly decreased during pregnancy. It is concluded that significant changes occur in bladder function during pregnancy.

Knowledge, attitudes and practices of rural women in South Africa regarding the Pap smear

Cancer of the cervix is the second most common form of cancer amongst South African women and the most common cause of cancer mortality among black South African women. The high incidence is complicated by late presentation for treatment as well as misconceptions. The national South African and provincial Eastern Cape policy guidelines on cervical cancer screening encourages all women to have at least three Pap smears in a lifetime. At present 18 out of the 24 primary health care clinics in the Hewu sub-district of the Eastern Cape have facilities to offer cervical cancer screening but due to lack of manpower this is not done routinely. The aim of this study was to ascertain the knowledge practices and attitudes regarding the Pap smear among women in a typical rural setting. (excerpt)