Background. Women accessing the public health system in Gauteng province, South Africa are largely unscreened for cervical cancer and have a high background prevalence of human immunodeficiency virus (HIV) infection.
Objectives. This cross-sectional study describes the age-specific prevalence of human papillomavirus (HPV) infection and cytological abnormalities among this urban and peri-urban population.
Method. Over the period March 2009 - September 2011, 1 524 women attending public sector primary healthcare clinics were invited to participate in a cervical cancer screening study. All participants were screened with conventional cytology and HPV testing undertaken using the HPV linear array genotyping kit (Roche Molecular Systems).
Results. Of 1 472 women with valid cytology results, abnormalities were detected in 17.3% (n=255), of which 9.1% (n=134) were high-grade squamous intraepithelial lesions, and 0.5% (n=8) suggestive of squamous carcinoma. Of the 1 445 women with complete data, the overall and high-risk HPV DNA prevalences were 74.6% (n=1 078) and 54.3% (n=784), respectively. HPV type 16 and/or 18 were detected in 19.5% (n=282) of women. Age-specific prevalence of HPV showed a plateau-shaped curve.
Conclusions. The prevalences of HPV infection and abnormal cytology were much higher than previously reported in general populations in South Africa and elsewhere. Higher age-specific prevalence and similar plateau-like age-specific epidemiological curves have previously only been described in studies among HIV-positive women. These findings have implications for planning and development of cervical screening programmes in developing countries with largely unscreened populations with a high background prevalence of HIV.
Background. Cervical cancer is linked to infection of the cervix by oncogenic human papillomavirus (HPV) subtypes. The quadrivalent Gardasil vaccine (against HPV types 6, 11, 16, 18), recommended in girls 9 - 12 years of age, has been shown to be safe, immunogenic and efficacious, with minimal or no side-effects.
Aim. To demonstrate the capacity of school health teams to carry out vaccinations within a school environment.
Objectives. To assess the uptake of 3 doses of the vaccine, document lessons learnt and provide recommendations for a national rollout of school-based HPV vaccination for learners.
Methods. Female learners (age 9 - 12 years) from 31 primary schools in Nongoma and Ceza districts (KwaZulu-Natal province, South Africa) were identified for inclusion in the vaccination programme. The 3 doses of vaccine were administered by existing school health teams. Education and training sessions were held with all stakeholders: provincial departments of health and education; school health teams; primary healthcare nurses; hospital doctors and nurses; private practitioners; school principals, teachers and governing bodies; parents; and community and traditional leaders.
Results. The overall uptake of the vaccine was found to be high: 99.7%, 97.9% and 97.8% for the first, second and third doses respectively (N=963). No adverse events were attributed to the HPV vaccine.
Conclusion. This project demonstrated the successful implementation of HPV vaccination among learners (ages 9 - 12 years) using school health teams.
Background. Stevens-Johnson syndrome (SJS) is an acute life-threatening condition often elicited by drugs. The government's indecisiveness in deciding to stop the use of nevirapine (NVP) in HIV-infected pregnant women owing to the increase of SJS among this population group in South Africa prompted this investigation.
Objectives. To investigate if pregnancy is a risk factor for SJS among HIV-infected women taking NVP-containing regimens and registered within the Medunsa National Pharmacovigilance Centre database.
Methods. A matched case-control study with 5:1 matching was conducted. Women with SJS (cases) taking NVP-containing regimens were matched with women without SJS (controls) taking NVP-containing regimens. Controls were randomly selected and matched to cases by hospital, age, treatment duration and CD4 count. Conditional logistic regression was used to determine if pregnancy was a risk factor for SJS.
Results. Six SJS cases were identified and 30 controls selected. The median age of both cases and controls was 29 years and the average CD4 counts were 237 and 234 cells/µl respectively. Subjects were on NVP treatment for 18 - 31 days before the onset of SJS. Controls did not develop SJS after treatment of between 1 and 365 days. Pregnancy increased the chances of developing SJS 14-fold (OR 14.28, p=0.006, 95% CI 1.54 - 131.82).
Conclusions. NVP-containing ARV regimens taken during pregnancy increase the risk of developing SJS. Healthcare workers are advised to offer informed consent to patients and recommend effective contraception methods if NVP treatment is considered. In the light of our findings, further studies of the association between NVP, pregnancy and SJS are necessary before general conclusions can be reached.
Background. Disseminated tuberculosis (TB) is a life-threatening condition which is often a challenge to diagnose. When to use bone marrow biopsies to diagnose disseminated TB in paediatrics is always a dilemma, from both a clinical and laboratory perspective, as there are no clear guidelines. Our study primarily aims to evaluate the role of routine bone marrow biopsies, and to compare peripheral blood cultures to aspirate cultures in the diagnosis of disseminated TB, in a paediatric population at Tygerberg Hospital. In addition, we set out to assess the morphology of bone marrow biopsies in this study.
Methods. A prospective study, consisting of 35 paediatric patients, was conducted from October 2007 to November 2008. Bone marrow aspirate and trephine biopsies were performed on all patients and examined. Granulomas with Ziehl-Neelsen (ZN) positivity were sought on the trephine biopsy for the presence of acid-fast bacilli (AFB).
Results. Of the 35 children in this study, 25 were eventually diagnosed with TB on the basis of a multitude of clinical and laboratory parameters. The remaining 10 had alternative diagnoses. Peripheral blood TB cultures were positive in less than 1%. Bone marrow aspirate cultures were positive in less than 5%. Bone marrow trephine biopsies showed granulomas with ZN positivity in 11% of the 35 patients.
Conclusion. Our results, generally, agree with the current evidence. Bone marrow biopsies in children should be performed if there is a strong clinical suspicion of disseminated TB, when no alternative non-invasive confirmatory test is available.
Objective. Hepatitis B virus (HBV) and HIV are endemic infections in many African countries. The objectives of this study were to determine the levels of exposure to, and protection from, HBV, as well as the prevalence of HIV/HBV co-infection and the response of HBV to highly active anti-retroviral therapy (HAART) in a cross-section of HIV-infected patients in north-eastern South Africa.
Study design. This was a laboratory-based, unmatched study. Three hundred and eighty patients were screened by ELISA for HBsAg, anti-HBc and anti-HBs. Samples non-reactive for HBsAg but reactive for anti-HBc were examined for occult HBV infection. Response to HAART was assessed by measuring HBV viral loads, seroconversion from HBeAg to anti-HBe, and levels of aminotransferase.
Results. Of the study population of 380, 60% (95% CI 54.8 - 64.9) were exposed to HBV based on HBsAg, anti-HBs or anti-HBc; 20% (95% CI 16.1 - 24.4) had active HBV infection, based on HBsAg serology, and 30% (95% CI 25.2 - 35.2) were protected, based on anti-HBs levels ≥10 IU/l. Of 181 HBsAg-negative individuals, 61 had HBV occult infection (33.7%, 95% CI 26.9 - 41.1). The differences in prevalence were not statistically significant when gender, marital status and CD4+ cell counts were considered. Of 21 patients analysed, 80% showed adequate response to the first-line HAART regimen (stavudine/lamivudine/efavirenz or nevirapine) after 12 months of use.
Conclusion. The study confirms the higher level (60%) of exposure to HBV in HIV patients in Limpopo Province, as well as the high (20%) prevalence of HBsAg positivity and occult hepatitis B (33.7%). However, further studies are warranted to corroborate the benefit of lamivudine-containing HAART regimens, as HIV/HBV co-infected patients have a higher liver-related mortality if hepatitis B is not treated.
Hepatitis B remains a significant yet preventable health issue in South Africa. The introduction of the hepatitis B vaccine into the country some 18 years ago has demonstrated benefit, but the exposure to, and prevalence of chronic HBsAg positivity remain unacceptably high. Those with chronic hepatitis B virus infection have an elevated risk of developing cirrhosis with end-stage liver disease and a markedly elevated risk of hepatocellular carcinoma, independent of the presence of cirrhosis.
The challenge in South Africa remains prevention through the universal vaccination coverage of all children and the identification of those with chronic hepatitis B virus infection. Over the last decade our understanding of hepatitis B and its behaviour and natural history in those with chronic infection has significantly improved. This understanding is key to identifying those who warrant further evaluation and therapy. A number of global societies have updated their guidelines in recent years. This document draws on these guidelines and serves to contextualise, for South Africa, practice guidelines for the management of chronic hepatitis B.