South African Medical Journal (SAMJ)
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The incidence of incomplete abortion and the prevalence of abortion-related morbidity in South African public hospitals, 2018
Get PDFBackground. The occurrence of abortion-related morbidity indicates limited access to safe abortion. Globally, unsafe abortions remain a persistent, yet preventable, cause of maternal mortality. South Africa (SA) is internationally recognised for its progressive reproductive rights framework, supported by its Constitution and laws. However, evidence suggests that women encounter barriers to accessing safe abortions, including stigma, resistance from healthcare providers, a shortage of trained professionals and a lack of awareness of their rights. We hypothesised that, 20 years after the promulgation of the Choice on Termination of Pregnancy Act, the incidence of incomplete abortion (ICA) and the prevalence of abortion-related morbidity would change, influenced by access to safe abortion and the introduction of medication abortion. We wanted to compare our data with 2000 and 1994 survey results to assess change.
Objectives. To estimate the incidence of incomplete abortion and describe the prevalence of abortion-related morbidity in SA public hospitals in 2018.
Methods. This was a cross-sectional, retrospective study. We selected a stratified random sample of public hospitals. We extracted data from medical records of women who presented with ICA during a predetermined 21-day period in 2018. Data were captured directly into a REDCap database. To estimate the national incidence of ICA, we used population estimates for 2018, comprising 17 199 227 women aged 12 - 49 years, and 1 200 436 live births. The prevalence of ICA morbidity is reported. We compared the rates in this study with those reported from similar studies in 2000 and 1994.
Results. We found 913 medical records of women presenting with ICA in the 56 public hospitals. ICA incidence was 367 (274 - 459) per 100 000 women aged 12 - 49 years. The average age of the women was 27 years, and the majority had a previous pregnancy before the ICA. A large proportion (73.9%) of women were in the first trimester. There was no sign of infection in 92.5% of records, no organ failure in 99.1% of records and there were no deaths. There was no change in the ICA incidence when compared with the 1994 and 2000 results. Women’s mean age and having a previous pregnancy were similar in the three studies (1994, 2000 and 2018). The proportion of women presenting in the first trimester increased over time: 60.5% in 1994, 67.1% in 2000 and 73.9% in 2018. There has been a decline in the prevalence of abortion-related morbidity, demonstrated by lower levels of severity, no signs of infections and no organ failure.
Conclusion. ICA incidence has not changed, but related morbidity is declining. Various factors could explain our findings, but the lack of change in ICA incidence indicates that access to formal abortion care has not improved over the past 20 years
Addressing the limitations of the regulatory landscape in South Africa regarding advanced cell and gene therapies and related sectors involving human cells, tissues and organs
Get PDFAdvanced cell-based and gene therapy products emerged during the 1990s as new health product categories for treating and curing previously untreatable or incurable conditions. These products are complex, diverse and therapeutically specific, requiring specialised regulatory frameworks. During the last three decades, several jurisdictions have constructed specific regulatory frameworks to ensure these products’ safety, clinical efficacy and quality. As these are new and disruptive products, these frameworks are continuously evolving. However, South Africa (SA)’s regulatory frameworks for medicines, human biological materials and genetically modified organisms have not kept pace with scientific and technological developments, leaving regulatory gaps. We briefly describe these novel products and their regulatory frameworks, and propose a way forward in SA
A cross-sectional study of patients with prosthetic mitral valves at a tertiary centre in Johannesburg, South Africa
Get PDFBackground. There is a high incidence of rheumatic valvular heart disease involving the mitral valve in Soweto, Johannesburg. Many of these patients go on to have mitral valve replacement (MVR). Data regarding clinical and echocardiographic characteristics of patients with prosthetic mitral valves are scarce in South Africa.
Objective. To document the clinical and echocardiographic profiles of contemporary patients with MVR.
Methods. Clinical, electrocardiographic and echocardiographic data in these patients were collected prospectively from March 2020 to August 2021 at Chris Hani Baragwanath Academic Hospital prosthetic valve clinic.
Results. The study included 186 participants with a median (interquartile range (IQR)) age of 52 (41 - 60) years. Of these, 96% were of black African ethnicity (79% female). The median (IQR) body mass index (BMI) among participants was 27 (23.5 - 30.4) kg/m2, with 29% of participants classified as obese (BMI >30 kg/m2). Eighty-two percent of patients had New York Heart Association class 1 dyspnoea. The most common complications were atrial fibrillation (AF, 39%), heart failure (HF, 25%) and stroke (13%). There were two cases of previously documented prosthetic valve thrombosis, two cases of prosthetic valve endocarditis, two of paravalvular regurgitation and one with structural valve deterioration. Seventy percent of patients had subtherapeutic international normalised ratios (INRs), with a median (IQR) INR of 2.55 (2.03 - 2.92). Forty-seven percent of patients had a left ventricular ejection fraction (EF) of <40%. Seventy-four percent of participants were on some combination of guideline-directed medical therapy for HF with reduced EF, although only 12% were on at least three medications. Pulmonary hypertension was present in 37% of patients, with a median (IQR) pulmonary artery systolic pressure of 28.5 (17 - 41) mmHg. Tricuspid annuloplasty ring was noted in a minority (12 patients).
Conclusion. The contemporary patients with MVR were middle-aged obese females with significant AF burden, residual left ventricular dysfunction that was suboptimally managed, and subtherapeutic INR.
Real-world effectiveness of Ad26.COV2.S or BNT162b2 booster vaccines against severe COVID-19 in adults who received a primary dose of Ad26.COV2.S in South Africa during the Delta period: A retrospective cohort study using medical scheme data
Get PDFBackground. From March 2020 to June 2022, South Africa (SA) confronted successive waves of COVID‐19, each linked to emerging SARS‐CoV‐2 variants. Vaccines played a critical role in preventing severe disease and death, but as new SARS‐CoV‐2 variants emerged, with increasing breakthrough infections, questions arose about the real‐world effectiveness of first‐generation vaccines containing the ancestral strain against evolving variants including Delta and Omicron BA.1 and BA.4/5 SARS‐CoV‐2.
Objectives. To assess the real‐world effectiveness of ancestral strain booster doses (either Ad26.COV2.S or BNT162b2) in preventing severe COVID‐19 outcomes, including hospitalisation, admission to critical care and death, among essential workers in SA who received a primary dose of Ad26.COV2.S against emerging SARS‐CoV‐2 variants.
Methods. A retrospective cohort study was conducted using data from a large private health insurance scheme. Individuals who received a single dose of Ad26.COV2.S as their primary vaccination were included. Time‐varying Cox regression models were used to assess the effectiveness of boosting with either Ad26.COV2.S or BNT162b2 v. not boosting against severe COVID‐19 outcomes associated with emerging variants, adjusting for various demographic and clinical factors.
Results. By August 2021, a total of 407 961 individuals received a first dose of Ad26.COV2.S, of whom 350 688 were eligible for and 332 286 included in the vaccine effectiveness (VE) analysis. Of these, 206 359 (62%) received no further doses, while 113 957 (34%) received a second dose of Ad26.COV2.S and 11 970 (4%) received a second dose of BNT162b2 by August 2022. During the follow‐up period (November 2021 ‐ August 2022), 1 125 COVID‐19‐related hospital admissions, 198 admissions to critical care and 41 COVID‐19‐related deaths were recorded. Adjusted relative VE against severe outcomes was 34% (95% confidence interval (CI) 19 ‐ 45) for hospital admission, 51% (95% CI 22 ‐ 70) for critical care admission, and 89% (95% CI 13 ‐ 98) for COVID‐19‐ related death.
Conclusion. While most participants remained unboosted, administration of either ancestral strain Ad26.COV2.S or BNT162b2 vaccination provided protection against severe COVID‐19 outcomes among essential workers in SA during the dominance of the Omicron BA.1 and BA.4/5 variants, demonstrating cross‐strain protection
Diarrhoeal admissions among children aged
Get PDFBackground. The COVID‐19 pandemic in South Africa (SA) had several effects, including the implementation of public health and social measures (PHSM) such as mobility limitations, social (physical) distancing, mask‐wearing and hand hygiene promotion. This led to behavioural shifts, and potentially impacted the transmission dynamics of other infectious diseases, including acute diarrhoea among children.
Objective. To investigate changes in acute diarrhoea hospital admissions in children aged <5 years in Western Cape Province, SA.
Methods. We conducted a retrospective analysis of diarrhoea admissions from January 2019 to November 2021. We estimated changes in rates and trends of diarrhoea admissions during the pandemic compared with pre‐pandemic periods using interrupted time series analysis, adjusting for key characteristics.
Results. There were 17 204 children admitted for diarrhoea during the study period, of whom 54% were male, and almost half (48%) were aged <1 year. COVID‐19 PHSM were associated with a 24% step reduction in diarrhoea admissions compared with the pre‐COVID‐19 period (incidence rate ratio (IRR) 0.76, 95% confidence interval (CI) 0.69 ‐ 0.84). This was followed by an average 2% per month increase in diarrhoea admission incidence during the pandemic (IRR 1.02, CI 1.01 ‐ 1.02).
Conclusion. There was a marked reduction in diarrhoea admissions during the strictest PHSM implementation. Interventions such as hand hygiene and physical distancing likely contributed to these observed changes. This study underscores the importance of ongoing public health interventions to mitigate diarrhoeal diseases among children and prevent hospitalisation
Professor Jan H Louw: South Africa’s paediatric surgery pioneer
Get PDFProf. Jan Hendrik Louw (1915 - 1992) was a pioneering figure in paediatric and adult surgery in South Africa, and he left an indelible mark on teaching, training, research and academia. He excelled academically and graduated from the University of Cape Town medical school with distinction in 1938. He was appointed to the Chair of Surgery at UCT and Groote Schuur Hospital in 1955, transforming the department into a centre of excellence in clinical practice, research and education. He was instrumental in developing paediatric surgery as a distinct specialty at the newly inaugurated Red Cross War Memorial Children’s Hospital in 1956. Subsequent groundbreaking research with Christiaan Barnard investigating congenital intestinal atresia, which involved intrauterine fetal surgery in puppies, garnered international commendation. Known as a strict disciplinarian, his insistence on clinical excellence, rigorous academic standards and ethical responsibility became the hallmarks of surgical culture at UCT, Groote Schuur Hospital and beyond. His leadership in and contributions to medical politics were substantial, and his achievements and international reputation were affirmed by honorary fellowships from 11 international surgical colleges and the prestigious Denis Browne Gold Medal from the British Association of Paediatric Surgery. His seminal tome, In the Shadow of Table Mountain, documented from conception the history of the Medical School at UCT. His memory endures through the countless lives he touched, the surgeons he trained, and his contributions to global surgery. He retired in 1980, leaving a towering legacy in South African and international surgery
Workplace bullying and mental health of medical interns in KwaZulu-Natal Province, South Africa
Get PDFBackground. There is a silent epidemic of workplace bullying among medical doctors, with junior doctors being the most vulnerable. Little research has been conducted to establish the nature and extent of bullying of medical interns in KwaZulu-Natal (KZN) Province, South Africa.
Objectives. To describe the prevalence and types of workplace bullying, identify alleged perpetrators, and explore the association between bullying and the mental health and quality of life of medical interns in KZN.
Methods. A cross-sectional online survey was conducted across all state hospitals in KZN designated for training first- and second-year medical interns, from 1 June to 31 August 2023, using snowball sampling. Participants completed a newly designed sociodemographic, clinical and bullying questionnaire, the Negative Acts Questionnaire (NAQ), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7) scale, and the World Health Organization Quality of Life scale.
Results. Of the 270 medical interns employed in KZN, 182 responded, and 135 were included in the study. All interns were classified as having experienced bullying according to the NAQ, and 61.8% screened positive for symptoms of anxiety and/or depression on the PHQ-9 and GAD-7. The most commonly reported somatic symptoms and work-related behaviours caused by workplace bullying were recurrent headaches (42.5%), chronic lethargy (79.3%), gastrointestinal illnesses (42.7%), sleep disturbances (67.8%), loss of interest in work (81.0%) and absenteeism from work (43.5%). Most participants (61.2%) did not report the bullying to senior staff, and most of those who did report were dissatisfied with the outcome of the investigation (91.2%).
Conclusion. Medical interns in KZN have a high prevalence of anxiety and depressive symptoms, with a negative impact on their quality of life. Bullying by senior medical and nursing staff is pervasive. However, it was not possible to explore the associations between bullying and mental health, as all participants had high bullying scores on the NAQ.