Una E. MacIntyre

The Economic Burden of Diarrheal Disease in a Tertiary Level Hospital, Gauteng, South Africa

BACKGROUND Diarrheal disease remains one of the major causes of morbidity and mortality in young children in South Africa. Although a rotavirus vaccine will reduce rotavirus diarrheal morbidity and mortality, its introduction and sustainability will incur considerable costs. The aim of this study was to estimate the costs associated with diarrheal disease of all etiologies in children <5 years of age at Dr George Mukhari Hospital, a tertiary level hospital in Gauteng, South Africa. METHODS Cost data were obtained by a review of systematically selected records of patients admitted for diarrhea during 2004 and the prospective recording of the treatment of consecutive inpatients admitted for diarrhea from February through June 2005. Data on hospital stay, medications, nondrug orders, and diagnostic tests were abstracted using standardized recording forms. Costs were calculated using 2004 and 2005 prices. Carers were interviewed using a standard interview schedule to determine out-of-pocket expenses. Stool samples were tested for rotavirus by the Medical Research Council Diarrheal Pathogens Unit. RESULTS The review sample comprised 86 (20 rotavirus positive) patient records. The prospective sample comprised 77 inpatients (25 rotavirus positive). The mean duration (+/- standard deviation [SD]) of hospital stay was 4.6 +/- 3.4 days and 5.7 +/- 4.7 days for the review and prospective samples, respectively. The mean total inpatient cost (+/-SD) was R5963 +/- R4070 (review sample) and R7256 +/- R5599 (prospective sample; P > .05). Although mean total costs did not differ significantly between rotavirus-negative and -positive samples, mean facility and antibiotic costs were significantly higher for the rotavirus-negative sample (P < .05) in the prospective sample. Mean out-of-pocket expenses (+/-SD) were R100.00 +/- R112 for inpatients. CONCLUSION Although total inpatient costs did not differ significantly between the rotavirus-negative and -positive patients, costs for the rotavirus-negative patients tended to be higher. Although a rotavirus vaccine will reduce the burden of diarrheal disease, it is imperative that measures for reducing the incidence and severity of diarrheal disease due to other pathogens are strengthened.

Short-Term Micronutrient Supplementation Reduces the Duration of Pneumonia and Diarrheal Episodes in HIV-Infected Children

The duration of pneumonia and of diarrhea is reported to be longer in HIV-infected than in uninfected children. We assessed the effect of a multi-micronutrient supplement on the duration of hospitalization in HIV-infected children. In a double-blind, randomized trial, HIV-infected children (4-24 mo) who were hospitalized with diarrhea or pneumonia were enrolled (n = 118) and given a daily dose of a multi-micronutrient supplement (containing vitamins A, B complex, C, D, E, and folic acid, as well as copper, iron, and zinc at levels based on recommended daily allowances) or a placebo until discharge from the hospital. Childrens weights and heights were measured after enrollment and micronutrient concentrations were measured before discharge. On recovery from diarrhea or pneumonia, the children were discharged and the duration of hospitalization was noted. Anthropometric indices and micronutrient concentrations did not differ between children who received supplements and those who received placebos. Overall, the duration of hospitalization was shorter (P < 0.05) among children who were receiving supplements (7.3 +/- 3.9 d) (mean +/- SD) than in children who were receiving placebos (9.0 +/- 4.9); this was independent of admission diagnosis. In children admitted with diarrhea, the duration of hospitalization was 1.6 d (19%) shorter among children receiving supplements than in those receiving placebos, and hospitalization for pneumonia was 1.9 d (20%) shorter among children receiving supplements. Short-term multi-micronutrient supplementation significantly reduced the duration of pneumonia or diarrhea in HIV-infected children who were not yet receiving antiretroviral therapy and who remained alive during hospitalization.

Dietary assessment methodology for adolescents: a review of reproducibility and validation studies

Abstract Aim: The aim of this review is to explore the validity and/or reproducibility of dietary assessment methods used to assess food and nutrient intakes of adolescents. Method: A detailed literature search was undertaken to trace articles reporting on the validity and/or reproducibility of food records, food frequency questionnaires (FFQs) and 24-hour recalls for the dietary assessment of adolescents, especially among South Africans, in the following databases: Medline, Science Direct, Academic Search Premier, Health Source, PubMed and the South African e-publications database (SAE). Original studies published between 1990 and 2009, and relevant original articles published before 1990, were included. Of these, only three were South African-based studies reporting testing for reproducibility and/or validity. Results: Results indicated that adolescents comply better with estimated food records than with weighed food records. However, energy intake was underestimated in adolescents (by 18–42%) when using food record methods. The relative validity of FFQs among adolescents was moderate, with correlation coefficients of > 0.3 for most measured nutrients and food items. Reproducibility was fair to good among female adolescents (0.3–0.83) for most nutrients and foods, but was lower in a South African Tswana-speaking group. The 24-hour recall method showed the least over- and underestimation of all the reviewed methods. When comparing the 24-hour recall method to an observed intake method among adolescents, < 11% underestimation of energy intake was found, while < 4% underestimation was found when the 24-hour recall method was tested against the doubly labelled water method. Conclusion: Based on these outcomes it was concluded that FFQs and 24-hour recalls are valid and reproducible dietary assessment methods that can be used when collecting dietary data from adolescents. Factors to consider when choosing the best suitable method should include the gender and ethnicity of the population as well as the time frame for the collection of dietary data.

Improved appetite after multi-micronutrient supplementation for six months in HIV-infected South African children.

The aim of the study was to assess the effect of multi-micronutrient supplementation on the appetite of HIV-infected children. HIV-infected children (6-24 months) who had previously been hospitalized were enrolled into a double-blind randomized trial, and given daily multi-micronutrient supplements or placebos for six months. Appetite tests were performed at enrollment and after three and six months. Appetite was measured as ad libitum intake of a commercial cereal test food served after an overnight fast according to standardized procedures. Body weights and total amount of test food eaten were measured. In total, 99 children completed the study (50 on supplements and 49 on placebos). Amounts eaten per kilogram body weight in the supplement group at enrollment and after six months were 36.7+/-17.7 g/kg (mean+/-SD) and 41.3+/-15.0 g/kg respectively, while the amounts in the placebo group were 47.1+/-14.9 g/kg and 45.7+/-13.1g/kg respectively. The change in amount eaten per kilogram body weight over six months was significantly higher in the supplement group (4.7+/-14.7 g/kg) than in the placebo group (-1.4+/-15.1g/kg). Multi-micronutrient supplementation for six months seems to significantly improve the appetite of HIV-infected children.

Measuring micronutrient intakes at different levels of sugar consumption in a population in transition: the Transition and Health during Urbanisation in South Africa (THUSA) study

Abstract Objective: The objective was to investigate the absolute micronutrient intake and the possibility of micronutrient dilution of added sugar in the diets of an African population in nutritional transition. Design: A cross-sectional, comparative, population-based design was used. Respondents who consumed sugar were divided into four quartiles of percentage of added sugar intake. Setting: The setting was 37 randomly selected rural and urban areas of the North West province. Subjects: The subjects were 1 742 adult volunteers (739 men and 1 003 women), aged between 15–65 years. After exclusion of low-energy reporters, the sample comprised 1 045 subjects (472 men and 573 women). Outcome measures: The outcomes measures were the macronutrient and micronutrient intakes of subjects in different quartiles of added sugar intake and body mass index (BMI). Results: The average intake of added sugar was 10.01% of total energy (67.12 g) in men and 11.2% total energy (67.10 g) in women. Respondents who consumed the most added sugar had significantly lower mean intakes of alcohol, but higher intakes of energy, macronutrients and most micronutrients. The diets of those in the highest sugar intake group contained significantly less thiamine, riboflavin, niacin, vitamin B12, pantothenic acid, biotin, magnesium, phosphorus and zinc per 4.18 MJ. At every level of added sugar consumption, the mean intakes of fibre (men only), folate, ascorbic acid and calcium (men and women) did not meet the dietary reference intakes [estimated average requirements (EAR)] and pantothenic acid and biotin (women only) did not meet the adequate intake. There were no significant differences in mean BMI across the quartiles of added sugar intakes in men, but the mean BMI of women who consumed the most added sugar was significantly higher than that of those who consumed less sugar. Respondents who consumed the most added sugar had significantly higher intakes of fruit (men only), bread and soft drinks, and lower intakes of maize meal and alcohol (men and women). Conclusion: Absolute intakes of most micronutrients were significantly higher in consumers with a high sugar intake [Quartile (Q) 4] compared with the lowest consumers of sugar (Q1). The lowest percentages of participants whose micronutrient intakes fell below the EAR were in Q4 and Q3. However, expression of micronutrient intake per 4.18 kJ (micronutrient dilution) revealed significantly less of most micronutrients per 4.18 MJ for men and women who consumed the most added sugar, compared with those who consumed the least.

Stunting among young black children and the socio-economic and health status of their mothers/caregivers in poor areas of rural Limpopo and urban Gauteng – the NutriGro Study

Abstract Objectives. To determine the prevalence and immediate and underlying causes of stunting in black children aged 12 - 24 months living in rural and urban South Africa. Design. A cross-sectional survey. Setting. Two poor rural villages in Limpopo and two poor urban informal settlement areas in Atteridgeville, Gauteng. Population. All households with mothers/caregivers (M/Cs) of children aged 12 - 24 months in the selected areas. All households meeting the inclusion criteria in the urban areas ( N = 380) and in the two rural villages ( N = 156) were included in the sample. Methods. Trained interviewers collected data using a standardised socio-demographic questionnaire. Heights and weights of M/Cs and their children were measured. Stunting was defined as a z-score less than -2 for height for age. Body mass index (BMI) values were calculated for the M/C. Data were analysed using a stepwise logistical regression analysis. Results. A stunting rate of 18% was documented in the rural areas, with a difference of 8% between the two villages, and 19% in the urban areas. Statistically significant associations were found between low birth weight and stunting ( p = 0.0073). Households with stunted children were significantly larger than households with non-stunted children ( p = 0.0156). Stunted children were introduced to solid foods significantly earlier than nonstunted children ( p = 0.0415). Conclusions and recommendations. Similar prevalences of stunting were found in the urban and rural areas. Of the multifactorial causes of stunting, low birth weight, early complementary feeding and large household size were significantly associated with stunting. The data collected during this phase of the NutriGro Study will be the focus for all future community-based nutrition interventions.

Calcium intake and knowledge among white adolescent girls in Gauteng, South Africa

Abstract Objectives. To determine the knowledge and intake of calcium among white adolescent girls in Gauteng, South Africa. Design. A quantitative study using a questionnaire interview conducted over 13 months (1 June 2000 - 31 July 2001). Settings. Sixteen randomly selected private and state schools in the Gauteng area. Subjects. Adolescent white girls aged between 15 and 17 years. Outcome measures. Calcium intake and knowledge using a food frequency questionnaire (FFQ) and 7-day weighed records (WRS). Results. Mean calcium intake according to the FFQ was 811 mg/day (adequate intake (AI) 1 300 mg/day). Fiftyone per cent of participants had not been given any information relating to calcium and its benefits. Teachers and parents are the most noted sources of information and 31% of the participants knew that adolescence was the most important period for calcium absorption and bone building. Conclusions. Adolescents have low intakes of calcium compared with what is recommended. It is important to develop intervention programmes that target children, adolescents, teachers and mothers alike. It is also imperative to develop awareness of the importance of calcium consumption during childhood and adolescence in order to minimise the possibility of osteoporosis in later life.

Psychosocial and economic determinants of infant feeding intent by pregnant HIV infected women in Tshwane/Pretoria

Objectives . To determine the extent to which stigma, disclosure, coping and socio-economic factors would affect infant feeding choices made antenatally by pregnant HIV-positive women after the routine prevention of mother-to-child transmission counselling process. Patients and methods. The antenatal feeding choices and determinants of these choices of HIV-infected women were studied at four antenatal clinics in two Tshwane townships, between June 2003 and December 2005. Results . Seventy-four per cent of the 293 study participants intended to formula feed their babies, while 26% planned to breastfeed or mixed feed. The women who intended to breastfeed had lower active coping ability (adjusted odds ratio (AOR) 0.88, 95% confidence interval (CI) 0.82 - 0.94), were less likely to have disclosed their status to partners or husbands (AOR 0.54, 95% CI 0.30 - 0.99), were twice as likely to be married (AOR 2.06, 95% CI 1.03 - 4.12) and were twice as knowledgeable about HIV transmission through breastfeeding (AOR 2.11, 95% CI 1.14 - 3.90). Conclusion . Counselling on infant feeding choices among HIV-infected women should be sensitive to the numerous internal and external factors that influence the decision. The support that HIV-infected women need in making their infant feeding decisions will entail psychosocial, community-wide interventions, and frequent counselling sessions to assist them in coping with and disclosing their status.

Combating Protein-Energy-Malnutrition in a Rural/ Peri-Urban Southern African Black Population

ROTEIN-ENERGY-malnutrition (PEM) is a major cause of morbidity and mortality in young children in Africa. In South Africa, in 1987, to help combating and preventing PEM in the rural black population, the Gold Fields Nutrition Unit was inaugu rated at the Medical University of Southern Africa. In 1987-9, 442 patients (rural/peri-urban) plus their mothers or child carers were admitted, and 406 attended as outpatients. Average age was 15.4 ± 7.6 months, weight 7.0 ± 1.6kg, stay in hospital, 12 ± 10.8 days, and daily weight gain during treatment was 31 ± 48g. Mothers mainly were young and unmarried. Primary causative factors were infections, ignorance, and insufficiency of food. Since results from rehabili tation are usually poor, mothers and carers were taught how best to prepare meals using local foodstuffs. The interventions included teaching and demonstrations of how to grow vegetables, maintain an orchard, a fowl-run, and improve kitchen and laundry facilities. In 1990, in a follow-up of 73 patients, no deaths had occurred within a 12 month period. This far better than usual outcome is being furthered by setting up satellite nutrition clinics.

Duration of hospitalization and appetite of HIV‐infected South African children

Human immunodeficiency virus (HIV)-infected children generally show poor growth. Episodes of diarrhoea and pneumonia in HIV-infected children are thought to be more severe than in HIV-uninfected children. The objective of this study was to compare duration of hospitalization, appetite and nutritional status of HIV-infected children with that of uninfected children. A cross-sectional study was performed on children (2-24 months) admitted with diarrhoea or pneumonia to the university hospital. Children were tested for HIV, and the duration of hospitalization was noted for 189 children. Follow-up for blood analysis (n=154) and appetite measurement (n=48) was performed 4-8 weeks after discharge. Appetite was measured as ad libitum intake of a commercial infant cereal using highly standardized procedures. Hospitalization (in days) was significantly longer in HIV-infected children; among children admitted with diarrhoea (5.9 ± 1.9 vs. 3.8 ± 1.5) (mean ± standard deviation) and with pneumonia (9.0 ± 2.5 vs. 5.9 ± 1.9). Serum zinc, iron and transferrin concentrations, and haemoglobin levels were significantly lower in HIV-infected children compared with uninfected children. Appetites [amounts eaten (g) per kg body weight] of HIV-infected children were significantly poorer than those of HIV-uninfected children (18.6 ± 5.8 vs. 25.2 ± 7.4). The eating rates (g min(-1) ) of HIV-infected children were also slower (17.6 ± 6.2 vs. 10.1 ± 3.7) Mean Z-scores for length-for-age were significantly lower among HIV-infected children compared with HIV-uninfected children. Weight-for-length Z-scores were not significantly different. In summary, HIV-infected children had a 55% longer duration of hospitalization and a 21% lower appetite.