Browsing by Author "Muloiwa, Rudzani"

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    A systematic review of the epidemiology of hepatitis A in Africa
    (2019-07-22) Patterson, Jenna; Abdullahi, Leila; Hussey, Gregory D; Muloiwa, Rudzani; Kagina, Benjamin M
    Abstract Background Hepatitis A, caused by the hepatitis A virus (HAV), is a vaccine preventable disease. In Low and Middle-Income Countries (LMICs), poor hygiene and sanitation conditions are the main risk factors contributing to HAV infection. There have been, however, notable improvements in hygiene and sanitation conditions in many LMICs. As a result, there are studies showing a possible transition of some LMICs from high to intermediate HAV endemicity. The World Health Organization (WHO) recommends that countries should routinely collect, analyse and review local factors (including disease burden) to guide the development of hepatitis A vaccination programs. Up-to-date information on hepatitis A burden is, therefore, critical in aiding the development of country-specific recommendations on hepatitis A vaccination. Methods We conducted a systematic review to present an up-to-date, comprehensive synthesis of hepatitis A epidemiological data in Africa. Results The main results of this review include: 1) the reported HAV seroprevalence data suggests that Africa, as a whole, should not be considered as a high HAV endemic region; 2) the IgM anti-HAV seroprevalence data showed similar risk of acute hepatitis A infection among all age-groups; 3) South Africa could be experiencing a possible transition from high to intermediate HAV endemicity. The results of this review should be interpreted with caution as the reported data represents research work with significant sociocultural, economic and environmental diversity from 13 out of 54 African countries. Conclusions Our findings show that priority should be given to collecting HAV seroprevalence data and re-assessing the current hepatitis A control strategies in Africa to prevent future disease outbreaks.
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    An exploration of disclosure and non-disclosure patterns in HIV-infected children in Cape Town, South Africa
    (2018) Shea, Robert F; Muloiwa, Rudzani
    A cross-sectional, descriptive study combining with open-ended (qualitative) interview questions with quantitative component was conducted to explore disclosure experiences of mothers and caregivers of HIV-infected children. The study was conducted with 102 parents and caregivers at a tertiary hospital in Cape Town delivering care to 303 HIV-infected paediatric patients. The study sample included 102 participants, ranging in age from 16 years to 71 years. The sample included 73 mothers (72%), six fathers (6%), 11 foster-mothers (11%), and 12 caregivers or grandmothers (12%). The median age of participants’ children was 4 (IQR 2-8) years and ranged from five months to 16 years. Only 48 (47%) were old enough for disclosure to be possible. Disclosure or disclosure delay was associated with several factors, including the child’s age or ability to understand, anxiety and guilt about being blamed for infecting the child, fear of exposing the child to stigma, discrimination and social exclusion related to the child disclosing to others, and the hope that the child would be adherent if they understood their illness and the way in which the medication could improve their health outcomes. Only 16 (33%) of 48 participants actually disclosed the child’s HIV status. The results indicate that HIV-disclosure remains a challenging, emotionally-charged experience for mothers and caregivers. The findings of this research, and similar studies, point to the value of integrating disclosure support and planning into routine care for children and adolescents, as well as their parents and caregivers.
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    Descriptive analysis of routine childhood immunisation timelines in the Western Cape, South Africa
    (2021) Blose, Ntombifuthi J; Amponsah-Dacosta, Edina; Kagina, Benjamin M; Muloiwa, Rudzani
    Background: Adherence to the recommended age-specific immunisation schedules is critical in ensuring vaccine effectiveness against vaccine preventable diseases (VPDs). Delays in the uptake of routine childhood immunisations lead to an increase in children susceptible to VPDs. Catch-up vaccination campaigns are strategies aimed at minimising the time at risk of VPDs and alleviating missed immunisation opportunities. However, there is limited data on immunisation timeliness in the Western Cape to contribute to developing effective catch-up vaccination campaigns. Therefore, this study sought to assess the timeliness of age-specific routine childhood immunisation within the Western Cape province of South Africa. Methods: We reviewed 709 participant records from a prospective health-facility based study conducted between 2012 and 2016 in Cape Town, South Africa. The primary outcome of interest was receiving age-specific immunisations ≥ 4 weeks (28 days) of that recommended for age as per the South African Expanded Programme on Immunisation (EPI) schedule. Using secondary data, the prevalence of delayed uptake of immunisations and time-at-risk for each vaccine was determined using proportions and medians and interquartile range (IQR). Multivariable logistic regression (p< 0.05) was used to determine the association between potential socio-economic risk factors and delayed uptake of routine childhood immunisations. Results: A total of 652/709 (91.9%) participants with a median age of 11 [IQR 4.5 – 28.0] months were eligible for analysis in this study. A trend of decreasing immunisation coverage with increasing age was observed among study participants. Notably, a trend of increasing delay in the uptake of routine vaccines and an increasing median time-at-risk of VPDs in age-specific immunisations was observed with increasing age. The highest delay in the uptake of vaccine doses was observed among the 3rd dose of the DTP3 vaccine 163 (34.6%), while the lowest was seen among the birth doses [(BCG – 40 (6.5%) and OPV – 43 (7%)]. The longest median time-at-risk of VPDs, was with the 2nd dose of the measles vaccine dose [12.9 (IQRs 6.7-38.6) weeks] and the lowest was OPV birth dose [6.3 (5.3-9.1) weeks]. Multivariable logistic regression analysis showed that participants who attended pre-school or creche compared to those who did not, were protected against delaying uptake of the 3 rd dose of the Hepatitis B vaccine and 2nd dose of the measles vaccine. While those who had adult caregivers compared to those who had adolescent caregivers, were protected against delaying the uptake of the 1 st rotavirus vaccine dose. Participants from households of low and upper-middle socio-economic IQR compared to high socio-economic status (SES) based on SES scores calculated from household data (i.e., availability and sources of amenities such as water, fuel, toilets, and level of maternal education) were more likely to delay uptake of the 3 rd does of the Pneumococcal Conjugate Vaccine and the 1 st dose of the measles vaccine, respectively. Conclusion: Using DTP3 coverage as proxy for national immunisation coverage, immunisation coverage in this population fell below the recommended 95% immunisation coverage rate. Additional population delays in the uptake of vaccine doses increases the time during which infants and children are susceptible to potential fatal VPDs. The observed increase in delayed immunisation and increased time-at-risk of VPDs, calls for an urgent need to address timing of vaccination particularly in late infancy and in the second year of life. There is an urgent need to develop strategies aimed at mitigating factors associated with delay in uptake of routine childhood vaccines in the Western Cape Province. Since creche attendance conferred protection against the delay in uptake of vaccines, mitigation strategies implemented upstream by the department of basic education, as well as health and immunisation service providers should strengthen collaborations to ensure that timely vaccine uptake among creche attendees is regularly monitored. Where delays are identified, catch-up strategies can be implemented at educational facilities or referrals to immunization clinics. It is important that this strategy is coupled with caregiver and healthcare worker vaccine education on the importance of timely immunisation uptake. Education about timely vaccine uptake will aid in the provision of informed council from healthcare providers to – not only adult caregivers - but adolescent caregivers as well, with the aim to reduce delayed uptake of vaccine amongst those raised by adolescent caregiver. The health system and the Expanded Programme of Immunisation on South Africa (EPISA) should couple these interventions with effective mobile reminder systems. These reminder systems will particularly serve the purpose to remind those caregivers whose delay uptake of vaccines as a result of a busy schedule. This could improve adherence to the recommended childhood immunisation schedule. Generally, for such interventions to work, effective monitoring and surveillance of immunisation services and vaccines is critical in achieving a high immunisation coverage and timely uptake of vaccines. Future studies should continuously monitor immunisation coverage and timeliness data in the Western Cape Province and South Africa as a whole to support evidence-based strengthening of provincial and national immunisation services.
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    Determinants of vaccine hesitancy in Africa: a systematic review
    (2017) Paone, Alexander; Kagina, Benjamin M; Muloiwa, Rudzani; Hussey, Gregory D
    This MPH dissertation is a systematic review of the factors contributing to vaccine hesitancy in Africa. The dissertation comprises of the following three parts: The research protocol (Part A) outlines the background and proposed methods of the research. The protocol outlines the search strategy used to identify research eligible for this review according to defined criteria. The objective of this research was to identify determinants of vaccine hesitancy in Africa. The protocol describes data collection methods and the analysis plan of this research in order to address the objective. The literature review (Part B) provides a summary and interpretation of the current literature on barriers to vaccination, specifically vaccine hesitancy and its impacts on immunisation programs. The literature review identifies discord among literature in defining vaccine hesitancy and evaluating its presence and impact on varying populations, and reviews the attempts for standardisation by the Strategic Advisory Group of Experts Working Group on Vaccine Hesitancy. Lastly, the literature review identifies gaps in the literature, and suggests filling them ideally with a standardised metric. The manuscript (Part C) is presented in a format suitable for Vaccine journal submission. The manuscript includes a background, a description of the methods used, and a presentation and discussion of the results of the systematic review.
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    Environmental and occupational respiratory diseases - 1040. Associations between asthma and bronchial hyper-responsivness with allergy and atopy phenotypes in urban black South African teenagers
    (BioMed Central Ltd, 2013) Levin, Michael; Muloiwa, Rudzani; Motala, Cassim
    Epidemiological studies in South Africa show increasing prevalence rates of asthma and allergic sensitisation in both urban and rural Black African communities, and narrowing of the urban-rural gradient. There is a paucity of current data on bronchial hyper-responsiveness (BHR) in urban Black African children, associations between asthma and BHR and the relationship between BHR, allergen sensitisation and other atopic diseases.
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    Epidemiology of leptospirosis in Groote Schuur Hospital
    (2021) Mteshana, Ziningi Charity; Dlamini, Sipho; Muloiwa, Rudzani; Naicker, Preneshni
    Background The burden of leptospirosis in sub-Saharan Africa remains unclear although it is accepted that this infection is widely spread in this region. The global estimated number of cases is one million with 58 900 deaths attributable to leptospirosis annually. Objective To describe the profile of patients with suspected leptospirosis and to compare their in hospital outcomes. Methods & Material We performed a retrospective study at a tertiary referral hospital in South Africa. All adults with suspected leptospirosis who had a laboratory request for leptospirosis ELISA IgM testing between 2005 and 2015 were included. Clinical and laboratory findings at presentation were correlated with the patient's subsequent clinical course and ELISA IgM status. Results During the study period 223 patients who had ELISA IgM test requests were enrolled. Leptospirosis ELISA IgM was positive in 45 (20%) patients. Enrolled patients had a median age of 38 (IQR 31 – 53) years, 147/223 (66%) were males and 80/223 (36%) were HIV positive. There were 12/45 (27%) HIV-positive patients in the IgM-positive group compared to 68/178 (38%) in the IgM-negative group, p=0.22. Compared to IgM-negative patients, patients with positive IgM were more likely to present with jaundice 37/45 (82%) vs. 82/178 (46%), p <0.01, and acute kidney injury (AKI) 34/45 (76%) vs.102/178(57%), p=0.06. The median length of hospital stay was 13 days (IQR 8-22 days) for IgM-positive compared to 10 days (IQR 6-21 days) in IgM-negative patients, p= 0.10. A total of 11/45 (24%) IgMpositive patients required ICU admission compared to 41/178 (23%) of IgM-negative patients, p=0.84 and the median length of ICU stay was 7 days (IQR 4-11) for IgM-positive compared to 6 days (IQR 3-9.5) for IgM-negative patients, p=0.51. There were 13/45 (29%) IgM-positive patients who needed dialysis compared to 42/178 (24%) of IgM-negative patients, p= 0.46. The mortality rate was 7/45 (16%) in IgM-positive compared to 52/178 (29%) in IgM-negative patients, p=0.07. Conclusion Patients with positive IgM presented predominantly with jaundice and AKI. There was no statistically significant difference in HIV status and outcomes between the two groups of patients
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    Evidence-based vaccinology: supporting evidence-informed considerations to introduce routine hepatitis A immunization in South Africa
    (2023) Patterson, Jenna; Kagina, Benjamin; Cleary Susan; Muloiwa, Rudzani; Hussey, Gregory; Silal, Sheetal
    Hepatitis A is a vaccine preventable disease caused by the Hepatitis A Virus (HAV). Currently, South Africa is classified by the World Health Organization (WHO) as a high hepatitis A endemic region where 90% of children are assumed to be “naturally immunised” following HAV exposure before the age of 10 years old. In high hepatitis A endemic settings, routine vaccination against HAV is not necessary due to high rates of “natural immunization”. Recent data suggest a possible shift from high to intermediate HAV endemicity may be occurring in South Africa. Countries with intermediate HAV endemicity and no routine hepatitis A vaccination program have a high risk of experiencing hepatitis A outbreaks and high costs associated with care. Currently, there is no routine vaccination program against HAV in South Africa. The aim of this PhD was to generate evidence for decision making on whether a routine vaccination program against HAV should be considered for introduction into the South African Expanded Program on Immunizations (EPI-SA). The objectives included gathering context-specific evidence on the epidemiologic features of hepatitis A, clinical characteristics of the disease, hepatitis A vaccine characteristics and cost of case management. Using this evidence, the PhD estimated the future epidemiology of hepatitis A and impacts of routine hepatitis A vaccination scenarios in the country. The PhD's overall methods were informed by the principles of Evidence-Based Vaccinology for developing vaccine recommendations. The project included a mixed-methods approach: systematic reviews, a retrospective clinical folder review, mathematical modelling, and economic evaluation. A dynamic transmission model was built to forecast the future epidemiology of hepatitis A and to simulate the impacts of several different childhood hepatitis A vaccination strategies in South Africa. Selected findings have been published in relevant peer-reviewed journals. In addition, a technical dossier was prepared to submit to the South African National Advisory Group on Immunization (NAGI) on behalf of the Hepatitis A Working Group for considerations of introducing hepatitis A vaccination into the South African EPI.
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    Factors associated with increased mortality in a predominantly HIV-infected population with Stevens Johnson syndrome and toxic epidermal necrolysis
    (Public Library of Science, 2014) Knight, Lauren; Muloiwa, Rudzani; Dlamini, Sipho; Lehloenya, Rannakoe J
    Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening drug reactions with a higher incidence in HIV-infected persons. SJS/TEN are associated with skin and mucosal failure, predisposing to systemic bacterial infection (BSI), a major cause of death. There are limited data on risk factors associated with BSI and and mortality in HIV-infected people with SJS/TEN. METHODS: We conducted a retrospective study of patients admitted to a university hospital with SJS/TEN over a 3 year period. We evaluated their underlying illnesses, eliciting drugs, predictive value of bacterial skin cultures and other factors associated with mortality and BSI in a predominantly HIV-infected population by comparing characteristics of the patients who demised and those who survived. RESULTS: We admitted 86 cases during the study period and 67/86(78%) were HIV-infected. Tuberculosis was the commonest co-morbidity, diagnosed in 12/86(14%) cases. Skin cultures correlated with BSI by the same organism in 7/64(11%) cases and 6/7 were Gram-negative. Two of the 8 cases of Gram-negative BSI had an associated Gram-negative skin culture, although not always the same organism. All 8 fatalities had >30% epidermal detachment, 7 were HIV-infected, 6 died of BSI and 6 had tuberculosis. CONCLUSIONS: Having >30% epidermal detachment in SJS/TEN carries an increased risk of BSI and mortality. Tuberculosis and BSI are associated with higher risk of death in SJS/TEN. Our data suggests there may be an association between Gram-negative BSI and Gram-negative skin infection.
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    Incidence of anxiety and depression in a predominantly HIV-infected population with severe adverse drug reactions
    (BioMed Central Ltd, 2014) Zitha, Eddy; Chiliza, Bonga; Muloiwa, Rudzani; Lehloenya, Rannakoe
    Little is known on the short-term or medium-term psychological and psychiatric sequelae following Stevens Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and drug reaction with eosinophilia and systemic symptoms (DRESS). Based on this we did a prospective study designed to assess anxiety and depression in patients with severe cutaneous adverse drug reactions by indicating higher Hospital anxiety and depression scale (HADS).
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    Klebsiella pneumoniae bloodstream infections at a South African children’s hospital 2006–2011, a cross-sectional study
    (BioMed Central, 2016-10-17) Buys, Heloise; Muloiwa, Rudzani; Bamford, Colleen; Eley, Brian
    Background: Klebsiella pneumoniae (KP) is a significant paediatric bloodstream pathogen in children. There is little data from Africa. In this study we describe the epidemiology of multi-drug resistant Klebsiella pneumoniae bloodstream infection (KPBSI) at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. Methods: We conducted a retrospective cross-sectional study of KPBSI from 1 January 2006 to 31 December 2011 using conventional descriptive and inferential statistical methods. Results: Of 410 hospitalised children with laboratory confirmed KPBSI, 339 (83 %) were caused by extendedspectrum β-lactamase (ESBL) producing isolates. The median age (IQR) was 5.0 (2–16) months, 212 (51.7 %) were male, 82 (20 %) were HIV-infected, and 241 (58.8 %) were moderately or severely underweight. The infection was hospital-acquired or healthcare-associated in 389 (95 %) children and community-acquired in 21 (5 %) children. Significant risk factors for ESBL-KPBSI included cephalosporin exposure in the 12 months prior to the KPBSI, adjusted risk ratio (aRR) 1.18 (95 % CI: 1.06–1.31); HIV infection, aRR 1.14 (1.04–1.25), and intravenous infusions for more than 3 days before the KPBSI, aRR 1.15 (95 % CI: 1.04–1.28). A total of 109 (26.6 %) children died within 30 days of the KPBSI, their median age was four (IQR 1–11) months. The median (IQR) time between KPBSI and death was three (1–9) days. HIV-infection, aRR 2.44(95 % CI: 1.59–3.74); skin erosions at the time of KPBSI, aRR 2.15 (95 % CI: 1.54–3.00); being in PICU at the time of the KPBSI, aRR 1.64 (95 % CI: 1.03–2.61) or needing PICU admission after developing KPBSI, aRR 1.72 (95 % CI: 1.10–2.70) were significant risk factors for death. Conclusion: ESBL-producing KP is an important cause of laboratory confirmed bloodstream infection in hospitalised children and is associated with high mortality.
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    Laboratory findings that occur in Klebsiella pneumoniae blood stream infection in HIV-infected children compared to HIV uninfected children, at a South African children's hospital, Cape Town, 2006–2011: a nested-descriptive cross-sectional study
    (2022) Shapaka, Johanna Tekla; Buys, Heloise; Muloiwa, Rudzani
    Background: Bloodstream infection (BSI) caused by Klebsiella pneumoniae (KP), is a leading cause of hospitalassociated childhood mortality. There are limited data on how poor outcomes of KPBSI can be predicted in poorly resourced areas. This study aimed to assess if the profile of differential counts from full blood counts (FBC) taken at two time points in children <13 years with KPBSI could be used to predict the risk of death. Methods We conducted a retrospective study of a cohort of children admitted to hospital between 2006-2011 with KPBSI. FBC collected within 48 hours (T1) of blood culture and 5-14 days later (T2), were reviewed. Differential counts were classified as abnormal if they were higher or lower than laboratory ranges for normal results. The risk of death was assessed for each category of differential counts. Risk ratios adjusted (aRR) for potential confounders were used to estimate the effect of cell counts on risk of death using multivariable analysis. Data were stratified by HIV status. Results: Of 296 children included, median age 5 (IQR:2-13) months, 82 were HIV -infected. Ninety-five (32%) of the children with KPBSI died. Mortality in HIV-infected and uninfected children was 39/82 (48%) and 56/214 (26%), respectively (p <0.001). Independent associations with mortality were observed with leucopenia, neutropenia and thrombocytopenia. Risk of mortality in children with thrombocytopenia at T1 and T2 was aRR 2.5 (95% CI: 1.34-4.64) and 3.18 (95% CI: 1.31-7.73) respectively in the HIV-uninfected group, whereas the risk for mortality in the HIV-infected group with thrombocytopaenia at T1 and T2 was aRR 1.99 (95% CI: 0.94-4.19) and 2.01 (95% CI: 0.65-5.99) respectively. Neutropenia in the HIV-uninfected group at T1 and T2, showed aRR 2.17 (95% CI: 1.22- 3.88) and 3.70 (95% CI 1.30-10.51) respectively, while in the HIV-infected group, they were aRR 1.18 (95% CI 0.69-2.03) and 2.05 (0.87-4.85) at similar time points. Risk of mortality related to leucopenia at T2 was associated with mortality in HIV-uninfected and HIV-infected patients was aRR 3.22 (95%CI 1.22-8.51) and 2.34 (1.09-5.04) respectively. Persistently high band cell percentage at T2 in HIVinfected children indicated a risk of mortality of aRR 2.91 (95% CI 1.20-7.06). Conclusion Abnormal neutrophil counts and thrombocytopenia are independently associated with significant mortality in children with KPBSI. In resource-limited countries haematological markers have the potential to predict KPBSI mortality.
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    Narcolepsy associated with Pandemrix influenza vaccine: A systematic review and meta-analysis
    (2021) Lakoma, Leif; Muloiwa, Rudzani; Abdullahi, Leila; Engel, Mark
    This systematic review and meta-analysis forms the mini-dissertation part of the primarily coursework degree of Master of Public Health at the University of Cape Town. The review is divided into three separate parts. The first part constitutes the research protocol which outlines the proposed methods and scope of the review. The second part is a structured literature review further elaborating on the research topic and current knowledge of it. The final third part constitutes the manuscript-ready part of the review. The aim of the review is to systematically explore the current scientific literature regarding the association between narcolepsy and the Pandemrix pandemic influenza vaccine. This particular association has been one of the most studied presumed vaccine adverse effects of the last decade and it has greatly affected the discussion on vaccine safety and vaccine hesitancy still to this date. Despite several studies having been published investigating the association, no systematic review of these studies had been performed prior to the beginning of this this review.
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    Patterns of Detectable Viral Load in a cohort of HIV-infected adolescents on antiretroviral therapy
    (2018) Sher, Rebecca Yael Nthabiseng; Muloiwa, Rudzani; Dlamini, Sipho
    Background Despite improved treatment and access to care, adolescent AIDS deaths are decreasing more slowly than in any other age group. There is lack of longitudinal data around adolescent adherence and the dynamics of viraemia over time. We aimed to describe patterns of detectable viral load in a cohort of adolescents attending an antiretroviral clinic in Cape Town, South Africa. Methods We conducted a retrospective cohort study of all patients on ART aged 10-19 years. Participants were included if they underwent at least two HIV viral load (VL) measurements and attended the Groote Schuur Hospital HIV Clinic for at least 24 months between 2002 and 2016. The primary outcome was two consecutive VL >100 copies/ml, in line with the lower limit of detection of assays in use over the follow-up period. Results Of 482 screened subjects, 327 met inclusion criteria. Most subjects were vertically infected (n= 314; 96%), and 170 (52%) were male. Overall, 203 episodes of confirmed detectable VL involving 159 (49% [95% CI 43%–54%]) subjects were experienced during the follow-up period. A total of 111 (34%) subjects never experienced detectable VL, while 16 (5%) never suppressed throughout the follow-up period. Median age at first detectable VL was 14 (IQR 11-16) years. Of the 159 subjects who experienced detectable VL, 102 (64%) re-suppressed, of which 38 (37%) had a subsequent detectable VL. Six subjects had genotyped resistance to protease inhibitors. Four of these never suppressed, while two suppressed on salvage regimens. Total follow-up time was 1723 person years (PY), of which 880 (51%) were contributed by the 159 subjects who experienced detectable VL. Overall time with detectable VL was 370 PY. This comprised 22% of total follow-up time, but 42% of the follow-up time contributed by those who experienced detectable VL. The rate of detectable VL was 11.8 (95% CI 10.3–13.5) episodes per 100 PY. The risk increased by 24% for each year of increasing age (RR 1.24 [95% CI 1.17-1.31]; p< 0.0001). Neither prevalence, duration nor rate of detectable VL was influenced by gender. Conclusion Detectable VL was seen in nearly half of adolescents, with the rate increasing with age. Viraemia was not a static process, and adolescents moved in and out of this state as adolescence progressed. Further study is warranted to correlate these findings with risks and clinical outcomes.
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    Patterns of mortality in children presenting to a tertiary paediatric emergency unit in Sub-Saharan Africa: a cross sectional study
    (2020) Josephs, Tracey; Buys, Heloise; Masu, Adelaide; Muloiwa, Rudzani
    Background Pneumonia, diarrhoea and perinatal factors are the foremost killers of South African children as in other low- and middle-income countries. Poverty, poor access to care and pre-hospital care are reported major pre-hospital factors and lack of triage, poor skills, delays, poor adherence to treatment protocols and inadequate emergency care determining mortality have been reported to increase in-hospital mortality. Objectives To describe the clinical presentation and management of children admitted via the medical emergency unit (MEU) of the Red Cross War Memorial Children's Hospital (RCWMCH) who subsequently died. Methods We did a retrospective study undertaking a cross-sectional review of children who died following admission via RCWMCH MEU in 2008. Demographic information, clinical data, time factors and mortality data were reviewed and summarised by descriptive and inferential statistics. The unit utilised the WHO Emergency Triage Assessment and Treatment (ETAT) triage tool, categorising children into Red (emergency), orange (priority) and Green (non-urgent). Patient management was assessed by means of ETAT and the Integrated Management of Childhood Illness (IMCI) tools, which is used to identify severity of illness and strategize treatment plans accordingly. Results A total of 135 children met the inclusion criteria. The crude mortality rate was of 6.25 per 1000 admissions. Of the 135 children who died, 119 (88%) were under five years of age, 33(24%) were HIV-infected, of whom (88%) were under 5 years old. In 67 (50%), a chronic medical condition could be identified while 67 (50 %) were moderately or severely malnourished. There were 29 (22%) deaths within 24 hours of arrival at the MEU. Fifty-five (41%) presented after hours. Community health centres referred 65 (48%) patients, general practitioners referred 20 (15%) and 38 (28%) were self-referred. Ambulance services provided pre-hospital transport to 69 (51%). The two top presenting illnesses in 88 (65%) of the children were acute respiratory illness and acute gastroenteritis. Prior to referral, oxygen was not provided in 57 (59%) children, 35 (71%) with suspected sepsis did not receive antibiotics and glucose was not checked in 39 (80%) with depressed level of consciousness. The median time to ward transfer was 3.23 (IQR: 2.12-4.92) hours. Twelve deaths (9%) occurred in the MEU, 57 (42%) in PICU, 56 (42%) in medical wards and 10 (7%) in specialist wards. The five most common causes of death were acute respiratory infections in 45 (33%), acute gastroenteritis in 27 (20%), septicaemia 22 (16%), meningitis in 13 (10%) and cardiac conditions in 12 (9%) children. Conclusion The top causes of mortality in this hospital cohort in 2008 were pneumonia, acute gastroenteritis, and septicaemia. Using the IMCI and ETAT standard of care, suboptimal management was identified in pre-hospital management, as well as MEU management. Appropriate training and protocol implementation to improve morbidity and mortality should be undertaken.
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    Prevalence of anxiety and depression in a predominantly HIV-infected population with severe cutaneous adverse drug reactions
    (2016) Zitha, Eddy; Lehloenya, Rannakoe J.; Muloiwa, Rudzani; Chiliza, Bonginkosi
    Background: There is limited data on anxiety and depression in subjects with severe cutaneous adverse drug reactions (SCADR), in a predominantly HIV - infected population. The aim of the study was to prospectively investigate the prevalence of anxiety and depression and quality of life in patients with SCADR. Methods: In this prospective study, SJS, SJS - TEN, TEN and DRESS patients were assessed for anxiety and depression using validated scoring systems, the Hospital Anxiety and Depression Scale (HAD S), and the Dermatology Life Quality Index (DLQI). This was done at six weeks post discharge and again at six months follow - up. Results: Forty - eight patients with SCADR were enrolled at six weeks and 37/48 (77%) completed the study at six months. The populations were similar demographically at six weeks and six months. At six weeks anxiety or borderline anxiety symptoms/caseness was identified in 25/48 (52%) SCADR patients and depression or borderline depression symptoms/caseness in 24/48 (50%). Of those with symptoms, 18 were assessed as having co - morbid anxiety and depression with only 2 cases of pure anxiety and 4 of pure depression. At six months only 37 patients with SCADR returned for follow - up. Four of them had died in the interim while the other seven relocated. Of the cases of pure anxiety; one resolved and one was lost to follow - up. Of the cases of pure depression; one resolved, one persisted, one converted to comorbid anxiety and depression and one was lost to follow - up. Of those with co - morbid anxiety and depression 10 persisted, 2 converted to pure depression, 3 normalised and 2 were lost to follow - up. One previously normal patient developed anxiety symptoms and one case developed comorbid anxiety and depression. In 9/13 (69%) of the patients with SJS, SJS - TEN and TEN, co - morbid anxiety and depression persisted from week six to 6 months. In contrast in only 1/5 (20%) of the patients with DRESS, co - morbid anxiety and depression persisted from week six to 6 months. The cases of pure anxiety and depression were too small for meaningful comment. The overall SJS, SJS - TEN and TEN had median DLQI 8.4 relative to DRESS (DLQI 7.5) at six weeks. However, TEN (DLQI 14) had a greater impact on the quality of life compared to SJS (DLQI 3) and DRESS (DLQI 7.5). This pattern was maintained at six months. Conclusion: Anxiety and depression in patients with SCADR in a predominantly HIV - infected population is present. In the majority of cases, depression and anxiety coexist in patients with SCADR. These are sustained for at least 6 months post discharge. SCADR has a negative impact on quality of life. Our findings should help to improve the awareness of the impact of severe cutaneous adverse drug reactions on mental health especially as this may impact on future treatment adherence.
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    The prevalence of liquid chromatography-tandem mass spectrometry confirmed paediatric poisoning at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
    (2021-01-18) Washaya, Norbertta; Evans, Alicia; Muloiwa, Rudzani; Smith, Peter; Buys, Heloise
    Background Paediatric poisoning is a common presentation to emergency departments worldwide. There is a paucity of data on the role of liquid chromatography-tandem mass spectrometry (LC-MS/MS), in the management of paediatric poisoning in low-and middle-income countries (LMICs). In high-income countries, most studies are retrospective, and few include children. Objective The study describes the prevalence of liquid chromatography-tandem mass spectrometry confirmed paediatric poisoning at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. Methods Children admitted with suspected poisoning between 1 January 2017 and 31 December 2017, were recruited. All patients had a urine and/or blood sample sent for LC-MS/MS toxicology. Data collected included demographic data, clinical features, investigations, management, outcome and social interventions. Results One hundred fifty-two children, with median age of 39 (IQR 25–61) months were enrolled of which 128 (84%) were poisoning cases. Of the 128 poisoning cases, 88 (69%) presented with a history of ingesting a known substance, 16 (12%) an unknown substance and 24 (19%) were cases of occult poisoning. LC-MS/MS was able to identify a substance in 92% of the cases of occult poisoning. In those who had presented with a seemingly known substance, LC-MS/MS found a different substance in 15 cases. LC-MS/MS was also able to detect multiple drugs in 40 patients. Of the poisoning cases, six (5%) cases were attempted homicide cases and 5 (4%) cases were attempted suicide cases. No children died. Individualized social interventions were instituted in poisoning cases. Emergency placement safety reasons was required in 6 children. Conclusion When the limitations are known, LC-MS/MS is useful in identifying cases of occult poisoning, identifying patients who have ingested multiple substances and/or an unknown substance and when targeted towards child protection. As LC-MS/MS is an expensive test, it should be used judiciously in LMICs.
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    A retrospective review of the prevalence and management of anaemia in children in at Red Cross War Memorial Children's Hospital
    (2015) Wege, Martha Helena; Hartley, Patricia; Muloiwa, Rudzani
    Introduction Childhood anaemia is a major public health problem, iron deficiency being most common. WHO estimates anaemia to occur in 24.1% of pre-school South African children. Our study describes prevalence and management of anaemia in children aged 6 - 36 months presenting to a children's hospital. Methods In a retrospective cross-sectional study, laboratory data were used to estimate prevalence of anaemia in children aged 6 - 36 month presenting to medical emergency or ambulatory services of Red Cross Children's Hospital in 2012. A random sample of 50% of anaemic children was sampled for detailed review. Results 2661 subjects were included. Anaemia (H b < 10.5) was found in 40.8 % (1088/2661. Children presenting to medical emergency had a higher prevalence of anaemia compared to those presenting to ambulatory services ( 42.7% vs. 34.9 % ; p=0.001 ). Anaemia prevalence increased with decreasing age with RR 1.25 (95% CI 1.10 - 1.43) and RR 1.15 (95% CI 1.02 - 1.31) in children aged 6 - 11 months and 12 - 23 months respectively compared to children aged 24 - 36 months. Microcytosis was found in 51.3% (558/1088) of anaemic children and in 19.3% (n=303/1573) of children without anaemia ; p<0.001 Folders were reviewed i n 502 children with anaemia , 36.1% had mild anaemia (Hb 10 - 10.5g/dl), while moderate ( Hb 8 - 10 g/dl ) and severe ( Hb < 8 g/dl ) anaemia was found in 52.5% and 11.4% respectively. Breastfeeding for longer than six months was associated with higher risk of microcytic anaemia [RR 1.26 (95%CI 1.08 - 1.47)]. Only 12.2 % (31 /254) of children with microcytic anaemia received adequate iron therapy, 50.0 % (127/254) received no iron therapy. Conclusions Prevalence of anaemia in children presenting to hospital is higher than predicted for well children in South Africa. The risk is higher in younger and acutely sick children. Prolonged breasting is associated with increased risk of microcytosis. Most children with suspected iron deficiency anaemia did not receive appropriate treatment.
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    RSV infection in children hospitalised with severe lower respiratory tract infection at the Red Cross War Memorial Children's Hospital (2012-2013)
    (2023) Morgan, Nicole; Muloiwa, Rudzani; Ascott Heloise
    Objectives: Low- and middle-income countries carry the largest burden of Respiratory syncytial virus (RSV) disease, with most deaths occurring in these settings. This study aimed to investigate the burden of RSV disease in South African children hospitalised with lower respiratory tract infection (LRTI), with specific reference to incidence, risk factors, and co26 infections. Results: RSV was detected in 142 (30.9%; 95%CI 26.7-35.3) of the included 460 study children with LRTI. The median age of RSV-positive children was 4.6 (IQR 2.4-9.7) months compared to RSV-negative children of 10.5 (IQR 4.4-21.3) months, P = <0.001. Most cases occurred in autumn and winter with 126 (89%) cases over this period. IS demonstrated greater sensitivity for RSV diagnosis with 135 cases (95.1%) detected on IS and 57 cases (40.1%) identified on NP; P<0.001. The median length of hospital stay was 3.3 (SD 4.2) days in the RSV positive group and 2.7 (SD 3.3) days in the RSV negative group; P<0.001. The number of detected viral pathogens was a median of 1 (IQR 0-2) in RSV positive children (when RSV was excluded from the count) compared to 2 (IQR 2-3) in RSV negative children; P<0.001. The presence of RSV was independently associated with a reduction in the frequency of most viruses tested for on PCR. Conclusions: RSV is common in children hospitalised with LRTI and mainly affects younger children. There is an urgent need to find an effective vaccine to prevent RSV pneumonia in children worldwide, especially in LMICs that carry the greatest burden of disease.
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    School based versus supplemental vaccination strategies in the delivery of vaccines to 5-19 year olds in Africa - a systematic review
    (2017) Haddison, Christiana Eposi; Kagina, Benjamin M; Abdullahi, Leila H; Muloiwa, Rudzani; Hussey, Gregory D
    Background: Some vaccine preventable diseases still remain a public health burden in many African countries. The occurrence of vaccine preventable diseases in all age groups has led to the realization of the need to extend routine immunisation services to school age children and adolescents. Supplemental immunisation activities (SIAs) and school based vaccination (SBV) are two common strategies used to complement the EPI in vaccine delivery. Therefore, this review aimed to assess the effectiveness of SIAs compared to SBV in the administration of vaccines to 5-19 year olds in Africa. Methods and findings: Systematic review methods (protocol number CRD42017057475) were used to address our study aim. Electronic databases were searched up to March 30, 2017 for primary studies investigating the delivery of vaccines via SIAs or SBV to 5-19 year olds. To be included in the review, studies must have reported any of the following outcomes: vaccination coverage, cost of the vaccination strategy or effect of the strategy on routine immunisation. During the search, no restriction was placed on language or the study period. The search was complemented by browsing reference lists of potential studies. Out of the 4938 studies identified, 31 studies met our inclusion criteria. Both SIAs and SBV showed high vaccination coverage. This result should be interpreted with caution due to the high heterogeneity observed across the included studies. The SIAs reported a higher coverage of 91% (95% CI: 84%, 98%) than SBV which had a coverage of 75% (95% CI: 67%, 83%). In most settings, SBV was reported to be more expensive than SIAs. The SIAs were found to negatively affect routine immunisation services. Conclusions: Both SIAs and SBV are routinely used to complement the EPI in the delivery of vaccines in Africa. In settings where school enrolment is suboptimal as is the case in many African countries, our results show SIAs may be more effective in reaching school age children and adolescents than SBV. The SBV has only been tested in the delivery of two or three dose HPV vaccine to adolescent girls, whereas SIAs have been tested in the delivery of different types of vaccines. Our results re-iterate the importance of systematic evidence to best inform African authorities on the optimal delivery strategies of vaccines targeting school age children and adolescents into their immunisation programme.
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    Stevens Johnson Syndrome and toxic epidermal necrolysis: maternal and foetal outcomes in twenty-two consecutive pregnant HIV infected women
    (Public Library of Science, 2015) Knight, Lauren; Todd, Gail; Muloiwa, Rudzani; Matjila, Mushi; Lehloenya, Rannakoe J
    Introduction Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) form a spectrum of a rare and life-threatening cutaneous drug reaction. SJS/TEN in pregnancy poses largely unknown risk factors and outcomes for both the mother and foetus compared to the general population. METHODS: We conducted a study of consecutive pregnant women admitted to single tertiary referral centre in South Africa with SJS/TEN over a 3 year period. They were all managed by the same medical team using the same protocols. We evaluated their underlying illnesses, offending drugs and the course of pregnancy and outcomes to determine factors influencing maternal and foetal outcomes. RESULTS: We identified twenty-two women who developed SJS/TEN while pregnant, all of them HIV-infected. Their median age was 29 years. The majority 16/22 (73%) had SJS, the milder variant of the disease affecting < 10% body surface area. Nevirapine was the offending drug in 21/22 (95%) cases. All 22 of the mothers survived with 3/22 (14%) developing postpartum sepsis. Pregnancy outcomes were known in 18/22 women and 9/18 (50%) babies were delivered by caesarean section. There were 2 foetal deaths at 21 and 31 weeks respectively and both were associated with post-partum sepsis. Postnatal complications occurred in 5 cases, 3 involving the respiratory system and the other two being low birth weight deliveries. Eight placentae and one foetus were sent for histology and none showed macroscopic or microscopic features of SJS/TEN. On follow-up, only 12/20 children were tested for HIV at 6 weeks post-delivery and none of them were HIV-infected. All had received prophylactic ARVs including nevirapine. CONCLUSIONS: TEN, the severe form of the disease, was associated with poorer foetal outcomes. SJS/TEN-associated mortality is not increased in HIV-infected pregnant women. Maternal SJS/TEN does not seem to commonly manifest in the foetus.