To the Editor: Pterygium is a wing-shaped fibrovascular growth of the conjunctiva across the limbus onto the cornea. Although a hereditary influence on pterygium formation is recognised and a report of possible genetic influence in white South Africans has been published, little is known about these factors in black African populations.
South Africa's rate of tuberculosis (TB) has increased over the last 20 years, to now having the third-highest TB burden in the world. The TB control programme has primarily focused on effective case management of passively presenting TB cases, and progress has been recorded towards international treatment targets. While outcomes for notified TB cases have improved, this strategy failed to contain the TB epidemic. South Africa has the highest per capita annual risk of TB disease of comparably sized countries globally, and its communities have extremely high TB transmission rates. The rates of TB infection of children and adolescents are now similar to those reported 100 years ago in Europe long before chemotherapy became available. High rates of HIV testing of TB patients in Cape Town allows analysis of TB notification data stratified by age, type of TB and HIV status, and a better understanding of TB epidemiology. TB infection prevalence data from Cape Town communities allow estimation of the prevailing force of TB infection and, together with TB notification and prevalence data, the effective number of secondary infections and case finding proportions can be estimated. This better understanding of the major drivers of the TB epidemic allows reasons to be identified for failure of the present strategy. New control strategies can also be identified, that must be accompanied by novel TB control targets.
This study used the Maslach Burnout Inventory to evaluate the degree of burnout among junior doctors at Red Cross War Memorial Children's Hospital (RXH), Cape Town, and the influence thereof on the retention of valuable skills in the hospital. It further considered measures that could be taken to mitigate the causes of burnout, by means of qualitative methods.
Background. The research explores the significance of burnout and the role it plays in the retention of junior doctors at RXH. There has been an increase in the migration of medical doctors worldwide, with an exodus of doctors from South Africa. Along with the effects of HIV/AIDS, this places extra strain on those who remain.
Methodology. A two-part, mixed quantitative and qualitative study consisting of a validated measure, the Maslach Burnout Inventory, was sent to 39 junior doctors at RXH. Responses were received from 23 doctors (one of which was invalid), constituting a 60% response rate. The second part consisted of four semistructured interviews.
Results. Of the 22 respondents, 100% experienced a high degree of burnout on one of the three scales of burnout, namely emotional exhaustion, depersonalisation and reduced accomplishment. Of those surveyed, 95% expressed an intention to leave RXH.
Conclusion. The degree of emotional exhaustion and depersonalisation experienced by the junior doctors at RXH was significantly higher than that in a normative sample of 1 104 doctors. Recruitment, improved management and planning, increased support, mentorship and a more empathetic administration were some of the factors suggested to mitigate the burnout experienced by the junior doctors.
The cause of cardiomyopathy in patients infected with the human immunodeficiency virus (HIV) remains largely unknown, although a number of predisposing factors have been identified. Malnutrition has been postulated to be a contributory factor, but the association of anthropometric measures of nutritional status with HIV-associated cardiomyopathy has not been established.
Method. We investigated the association between anthropometric measures of nutritional status and cardiomyopathy in HIV-positive individuals in a cross-sectional case comparison study.
Results. Seventeen cases of HIV-associated cardiomyopathy and a comparison group of 18 HIV-positive individuals without cardiomyopathy were studied. There was no significant difference between the two groups in age, gender, CD4 cell count, HIV RNA viral load or World Health Organization (WHO) clinical stage of HIV disease. Patients with HIV-associated cardiomyopathy had evidence of undernutrition compared with HIV-infected people without cardiomyopathy, as evidenced by a significantly lower body mass index (BMI) (20.9 kg/m2 v. 27.0 kg/m2, p=0.02), mid-upper arm circumference (26.2 cm v. 27.3 cm, p=0.02), and bone-free arm muscle area (26.7 cm2 v. 32.8 cm2, p=0.02). However, in a multivariate stepwise logistic regression model, a lower BMI was the only independent anthropometric risk factor for cardiomyopathy (odds ratio 0.76, 95% confidence interval 0.64 - 0.97, p=0.02).
Conclusion. A lower BMI is associated with cardiomyopathy in people who are living with HIV.
Background. While countries strengthen their health information systems, local health managers require alternative strategies to monitor their prevention of mother-to-child transmission (PMTCT) programmes to improve coverage and service delivery.
Objective. To demonstrate the use of a postpartum audit to establish PMTCT coverage and programme deficiencies at hospitals and multiple primary health care facilities.
Methods. A cross-sectional hospital-based medical chart audit of pregnant women admitted in labour to their regional hospital. Their antenatal hand-held medical records were added to a hospital-issued maternity chart that was used to record further obstetric and perinatal management during their hospital stay. Women recuperating in the postnatal wards up to 48 hours after delivery at two hospitals in KwaZulu-Natal participated. Data included their antenatal attendance, access to HIV counselling and testing (HCT), and access to nevirapine (NVP) for PMTCT.
Results. Fifty-three clinics were indirectly evaluated as a result of the postpartum audit. All clinics provided HCT and the average HIV testing rate was 91% (range 40 - 100); 15% (N=8) of these clinics with HIV testing rates of <80% were identified. The median frequency of NVP dispensing at 53 clinics was 87% (interquartile range 67 - 100); among these 30% (N=16) with NVP dispensing frequencies of <80% were identified.
Conclusion. An exit survey by trained nurses at a maternity hospital can provide health services management with a quick estimate of antenatal and PMTCT coverage of multiple primary health facilities in a specified catchment area. Challenges in the PMTCT programme at primary health clinic and hospital levels were highlighted.
Objective. To assess the immunogenicity and safety data for a pentavalent combination vaccine containing acellular pertussis, inactivated poliovirus, and Haemophilus influenzae (Hib) polysaccharide-conjugate antigens.
Methods. A DTaP-IPV//PRP~T vaccine (Pentaxim™) was given at 6, 10 and 14 weeks of age to 212 infants in South Africa. Monovalent hepatitis B vaccine was given concomitantly. Immunogenicity was assessed using seroprotection and seroconversion rates; safety was assessed by monitoring for solicited injection site and systemic adverse events, and follow-up monitoring for unsolicited adverse events and serious adverse events.
Results. Immunogenicity was high for each vaccine antigen, and similar to a reference study done in France using a similar (2, 3 and 4 months of age) administration schedule. After the third dose, 94.6% of participants had anti-PRP ≥ 0.15 µg/ml. The anti-PRP geometric mean antibody titre (GMT) was 2.0 µg/ml. The seroprotection rates for diphtheria and tetanus (≥ 0.01 IU/ml), poliovirus types 1, 2 and 3 (≥ 8 1/dil U) and hepatitis B were all 100%. Anti-polio GMTs were very high, 1 453, 1 699 and 2 398 (1/dil U) for types 1, 2 and 3, respectively. The seroconversion/vaccine response rates to pertussis antigens (4-fold increase in antibody concentration) were 97.5% for PT and 83.9% for FHA.
Conclusions. The DTaP-IPV//PRP~T vaccine was highly immunogenic at 6, 10 and 14 weeks of age in infants in South Africa, was compatible with the monovalent hepatitis B vaccine, and was well tolerated.
Background. Determining symptoms of menopause in older users of hormonal injectable contraceptives may be challenging, owing to method-induced amenorrhoea, suppression of follicle-stimulating hormone (FSH) and vasomotor symptoms.
Objective. To investigate menopausal symptoms in women aged 40 - 49 using injectable contraceptives depot-medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN) or combined oral contraceptives (COCs), compared with non-users of hormonal contraception.
Methods. Women using DMPA (N=127), NET-EN (N=102), COCs (N=106) and 161 non-hormonal contraceptive user controls were recruited. Baseline visit serum FSH was measured and information was collected on vasomotor symptoms and menstrual regularity.
Results. There was no difference in reporting of vasomotor symptoms between the groups. There was no evidence of a difference in FSH level between non-users (mean FSH 26.7 IU/ml, SD 28.7) and DMPA users (mean FSH 23.1 IU/ml, SD 27.8) (p=0.64). However, the NET-EN (mean FSH 11.0 IU/ml, SD 10.9) (p=0.003) and COC groups (mean FSH 12.5 IU/ml, SD 18.7) (p=0.001) had significantly lower FSH levels compared with the non-user group.
Conclusion. The lower FSH levels found in the NET-EN and COC users compared with controls may indicate a greater degree of suppression of FSH levels in these two methods, compared with DMPA. Measuring FSH levels may therefore be informative of menopausal status in DMPA users but not in NET-EN or COC users. Vasomotor symptoms may assist in assessing menopausal status in DMPA, NET-EN and COC users.