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PubMed1996

The emergence of HIV/AIDS in Africa.

The recent spread of HIV/AIDS in Africa must be seen in the broader context of emerging infectious diseases, whose epidemiology results from changes in the equilibrium between the agent, the host, and the environment. For sexually transmitted agents such as HIV, epidemic spread requires a high basic reproductive rate (number of secondary cases generated by one primary case), which is itself dependent on the rate of change of sex partners, the transmissibility of the agent, and the duration of infectiousness. Factors relating to the agent which may have influenced the spread of HIV in Africa are viral types (HIV-1, HIV-2) and subtypes, of which at least 9 exist for the main group of HIV-1. Major host factors include sexual behaviour and sexual networks, commercial sex, sexually transmitted diseases, condom use, and circumcision status in males. Most difficult to study are environmental factors in the broadest sense, such as behavioral norms, poverty, migration, and HIV/AIDS prevention efforts. Any model attempting to explain HIV/AIDS emergence must account for the extreme heterogeneity of the epidemic within the African continent, and must be relevant to the application of more effective interventions. Although descriptive and analytic epidemiology remain necessary, intervention-oriented research on HIV/AIDS is now the priority in Africa.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Fundamentals of modern telemedicine in Africa.

The FOMTA (Fundamentals of Modern Telemedicine in Africa) project aims to promote the development of indigenous regional networks between R&D centres and universities of the Developing Countries (DCs) and their European counterparts. While FOMTA prepares the way for the use of broadband technology in Africa, it will also associate the DCs with the generation of knowledge, innovative and appropriate technologies needed to solve some of the specific problems, in order to achieve a sustainable economic development. Designed to eliminate the time-delaying lack of infrastructure, FOMTA will embark on the simulation of the integrated Service Digital Network infrastructure. FOMTA will adopt measures to increase the awareness and stimulate the participation of the DCs in the telemedicine and health care telematics projects through demonstrations, pilot projects, workshops, training and exchange activities. This will demonstrate the feasibility of telemedicine services in the DCs, including trial of services in real-life circumstances, and will provide training possibilities for researchers in the use of methods and tools for advanced communication technologies and telematics. Undoubtedly, telediagnosis, teleconsultation and other areas of telemedicine would thrive in Africa both as remote testing grounds and fields of practical applications.

Africa↗
PubMed1997

The epidemiology of incomplete abortion in South Africa. National Incomplete Abortion Reference Group.

OBJECTIVE: To describe the epidemiology of incomplete abortion (spontaneous miscarriage and illegally induced) in South Africa. DESIGN: Multicentre, prospective, descriptive study. SETTING: Fifty-six public hospitals in nine provinces (a stratified, random sample of all hospitals treating gynaecological emergencies). PATIENTS: All women of gestation under 22 weeks who presented with incomplete abortion during the 2-week study period. MAIN OUTCOME MEASURES: Incidence of, morbidity associated with and mortality from incomplete abortion. MAIN RESULTS: An estimated 44686 (95% CI 35633-53709) women per year were admitted to South Africa's public hospitals with incomplete abortion. An estimated 425 (95% CI 78-735) women die in public hospitals from complications of abortion. Fifteen per cent (95% CI 13-18) of patients have severe morbidity while a further 19% (95% CI 16-22) have moderate morbidity, as assessed by categories designed for the study which largely reflect infection. There were marked inter-provincial differences and inter-age group differences in trimester of presentation and proportion of patients with appreciable morbidity. CONCLUSIONS: Incomplete abortions and, in particular, unsafe abortions are an important cause of mortality and morbidity in South Africa. The methods used in this study underestimate the true incidence for reasons that are discussed. A high priority should be given to the prevention of unsafe abortion.

Abortion, Incomplete↗
PubMed1997

[Suppurative intracranial infections in Africa].

The purpose of this study was to review recent African literature on suppurative intracranial infection and its implications for neurosurgery. In order of decreasing frequency the main lesions are brain abscess, subdural empyema, and epidural abscess. Despite progress in diagnostic imaging and availability of antibiotic therapy, these lesions still cause disturbingly high morbidity and mortality especially in sub-Saharan Africa where diagnosis is often delayed. The male-to-female ratio was 3.6:1 and 70 to 80% of patients were under the age of 20 years. Spread from the paranasal sinus or ear was the most common mechanism of infection. Hematogenous processes accounted for 22% of cases and the origin was undetermined in 11% to 26% of cases. Staphylococcus aureus and enteric gram-negative bacilli were the most common bacteria identified but cultures were reported as sterile in 30% to 50% of cases. While ultrasonography can be useful in newborns with an open fontanelle, arteriography is often the only feasible procedure for diagnosis in Black Africa. The diagnostic modality of choice is computed tomography which allows precise mapping prior to neurosurgery. Introduction of computed tomography in some African cities has led to a decrease in mortality ranging from 4.7% to 43%. The most effective treatment is a combination of appropriate antimicrobial therapy and surgical decompression of expanding lesions. The main procedures are aspiration through burr holes and craniotomy. Use of this combined strategy requires close cooperation between the neurosurgeon, infectious disease specialist, and microbiologist. Therapeutic indications are discussed within the context of Black Africa.

Adult↗
PubMed1997

Impact of HIV on tuberculosis in sub-Saharan Africa: a regional perspective.

SETTING: The relative magnitude of the recent rise in tuberculosis (TB) in sub-Saharan Africa and the proportion of excess TB cases attributable to the human immunodeficiency virus (HIV) have not been evaluated from a regional perspective. METHODS: For each of 10 countries in mainland sub-Saharan Africa, we used reported TB case data from 1975-1993 to calculate annual excess TB cases after 1985, by subtracting the number of TB cases that would have been expected had pre-1985 trends continued from the number of reported cases for each year from 1985-1993. Using HIV seroprevalence rates from the literature for TB patients and the general population, we estimated the number of HIV-attributable TB cases in each country from 1985-1994. RESULTS: Excess TB cases accounted for a mean of 34% (range, 0-72%) of reported cases post-1985. HIV seropositivity in TB patients was a mean of 3.5 times (range, 1.8-6.1 times) higher than in the general population. The percentage of excess TB cases attributable to HIV increased as the HIV seroprevalence among TB patients increased, with HIV-attributable cases equalling or exceeding the number of excess TB cases in four of the six countries where > or = 50% of TB patients were estimated to be seropositive in 1992. CONCLUSION: Approximately one-third of TB cases in sub-Saharan Africa after 1985 would not have occurred had pre-1985 trends continued. The dramatic interaction of HIV and TB in the region was underscored by the high rates of HIV infection among TB patients and the high proportion of excess TB morbidity attributable to HIV.

AIDS-Related Opportunistic Infections↗
PubMed1997

Tuberculosis care in community care organizations in sub-Saharan Africa: practice and potential.

SETTING: Community care organizations in sub-Saharan Africa. OBJECTIVES: To evaluate current tuberculosis (TB) care in community health care organizations in sub-Saharan Africa, to assess their potential contribution to tuberculosis care, and to develop a model for expanded community participation in effective TB control. DESIGN: Quantitative assessment of tuberculosis care and cross-sectional assessment of qualitative measures in 14 community care organizations in Uganda, Zambia, South Africa and Malawi. RESULTS: The community care organizations assessed mainly provided care for human immunodeficiency virus (HIV) and aquired immune deficiency syndrome (AIDS) patients, and received funding from non-governmental organizations. Shortcomings in tuberculosis care included delays in diagnosis (which was often not based on sputum examination), drug shortages, low completion rates, high default rates, inadequate recording, little interaction with government tuberculosis programmes, and inadequate training of staff. However, one organization that provided primarily tuberculosis care and collaborated closely with the district tuberculosis programme and hospital attained a high treatment completion rate. The strong points of the community care organizations that favour a potential role of community participation in tuberculosis care were accessibility and staff motivation. CONCLUSION: Despite most community care organizations' shortcomings in tuberculosis care, they do have the potential to improve the care of tuberculosis patients, thus reducing the load on overstretched health facilities. Their potential impact on tuberculosis control depends on their population coverage and sustainability. HIV/AIDS community care organizations with strengthened management of tuberculosis care could serve as a model for expanded community participation in tuberculosis control. Operational research is needed to assess the feasibility and cost-effectiveness of community-based TB care.

AIDS-Related Opportunistic Infections↗
PubMed1997

The causes of childhood blindness in South Africa.

OBJECTIVES: 1. To ascertain the causes of severe visual impairment and blindness in children in schools for the blind in South Africa. 2. To determine the major avoidable causes. 3. To determine causation by ethnic group. DESIGN: A cross-sectional survey, undertaken at 15 of the 16 schools for the blind in South Africa, during May-September 1996, using standard WHO methodology. SUBJECTS: Children less than 16 years of age on May 1996. RESULTS: Of 1,615 eligible children, 1,311 were examined. According to WHO categories of visual impairment, using the corrected visual acuity in the better eye, 30.4% of children were blind (< 3/60, BL), 12.6% had severe visual impairment (< 6/60-3/60, SVI), 42.3% were visually impaired (< 6/18-6/60), and 12.0% had no impairment (6/18 or better). The anatomical sites of SVI/BL in 564 children were: retina 38.5%; optic nerve 15.2%; cornea/phthisis bulbi 11.0% and glaucoma 6.7%. Aetiological categories of SVI/BL were: hereditary diseases 33.0%; intra-uterine factors 0.9%; perinatal conditions 13.1%; acquired conditions of childhood 11.5%. In 41.5% the underlying cause could not be determined. In 38.8% of children with SVI/BL the cause was avoidable, i.e. preventable or treatable. The main causes varied between ethnic groups, the major difference being the higher proportion of retinopathy of prematurity in white and Indian children. CONCLUSIONS: The study suggests that 38.8% of causes of SVI or blindness in children in schools for the blind in South Africa are avoidable, and that specific control measures need to be targeted at different ethnic groups.

Animals↗
PubMed1998

Understanding the epidemic of HIV in South Africa. Analysis of the antenatal clinic survey data.

OBJECTIVES: To investigate the magnitude and the time course of the HIV epidemic in the provinces of South Africa from the antenatal clinic HIV surveys. DESIGN: We analysed the data on the provincial prevalences of HIV infection from 1990 to 1996 using maximum likelihood methods to determine the intrinsic growth rate and probable asymptotic prevalence of HIV among women attending antenatal clinics. SUBJECTS: Women attending antenatal clinics and included in the national HIV prevalence surveys conducted by the Department of Health. RESULTS: 1. In KwaZulu-Natal the epidemic is likely to peak at a prevalence of about 23% (95% confidence interval (CI) 19-36%). 2. The intrinsic doubling time does not differ significantly among the provinces. 3. The average length of the intrinsic doubling time is 12.0 months (95% CI 11.3-12.8 months). 4. The force of infection is approximately 1.00/year at age 16 years and declines at a rate of about 5% per year of age above 16 years. CONCLUSIONS: South Africa is likely to experience one of the worst HIV epidemics in Africa. The lack of statistically significant differences between the growth rates of the epidemic in the various provinces constrains the possible explanations that can be advanced to explain the time course of the epidemic and may in part be a consequence of migrancy. The intrinsic growth rate is higher than previous estimates and it is possible that in those provinces where the prevalence is still low it will eventually reach the same levels as in KwaZulu-Natal.

Acquired Immunodeficiency Syndrome↗
PubMed1998

The development of passive health surveillance by a sentinel network of family practitioners in South Africa.

OBJECTIVE: For the South African Sentinel Practitioner Research Network (SASPREN), a volunteer network of family practitioners in South Africa, to develop a health surveillance system through the surveillance of important health events. MOTIVATION: The incidence of important preventable diseases and the burden of disease are not reliably known in South Africa, both in the public and private sector. Incidence rates determined at primary care level could help with planning and delivery of appropriate health services and monitoring of the impact of intervention programmes. METHODS: Altogether 183 sentinel practitioners were recruited in nine provinces, from 2,478 doctors invited to participate. Of these 120 were active in reporting all their new cases of 13 selected health events to the study centre on mailed postcards. After data-capturing, incidence rates were calculated for defined periods. Feedback was given to the sentinels through a newsletter and personalised reports. RESULTS: A network of sentinel family practitioners has been established in South Africa, and can provide incidence rates for both diseases and interventions through a simple and cheap surveillance system. The calculated rates demonstrated periodic trends for certain events, as well as inter-provincial, -gender and -population group differences. CONCLUSIONS: As the validity of the dataset and its generalisation to the whole population is uncertain, its usefulness as point estimates of incidence rates is unknown. This information serves as an important pointer for further research. The trends of these rates may provide a valuable tool for monitoring the impact of public health policies.

Age Distribution↗
PubMed1998

[Malaria control in tropical Africa. 1956].

Although spraying with insecticides has caused a spectacular regression in malaria in many parts of Africa, it cannot be said that the transmission of the disease has been definitely interrupted in any large area on the mainland. There is therefore some uneasiness regarding the methods so far adopted and doubts as to whether the very considerable expenditure involved is justified. There is, moreover, acute anxiety about the possible development of resistance to insecticides by the vector anopheles. Fortunately, so far there does not appear to be any in Africa, and the author considers that logical aim should be complete eradication of malaria before resistance does appear to the powerful insecticides now available. Control measures must inevitably be continued indefinitely, but if the aim of eradication is achieved, operations could cease and it would be possible for anopheles to co-exist with man without transmitting malaria. The author points out that before any continent-wide campaign can be begun, there are, in addition to the problem of funds, a number of other problems which must be carefully studied. Among these are the lack of trained specialized staff at all levels, transport difficulties, shortage of water over vast areas in the dry season and floods during the rains, the differing habits of the various African populations, and the biology of the vector mosquitos. Despite these problems, however, the time for concerted action to achieve eradication in Africa draws nearer with each succeeding day.

Africa↗
PubMed1998

Selected gastrointestinal pathologies in tropical sub-Saharan Africa.

Doctors need to be well informed about differences in the presentation of certain diseases in tropical and temperate climates. In this article the characteristics of some gastrointestinal diseases, as they recur in sub-Saharan Africa, are briefly reviewed. Diseases of the stomach--including ulcertaion and cancer--are uncommon in Africa, although duodenal ulcer is common all over the tropics. In contrast, colorectal cancer is an extremely rare illness in sub-Saharan Africa, while hepatocellular carcinoma is much commoner than in Europe or North America and the very high incidence of this tumour in tropical countries is cause for concern.

Africa↗
PubMed1998

Evolution of malaria in Africa for the past 40 years: impact of climatic and human factors.

Different malarial situations in Africa within the past 40 years are discussed in order to evaluate the impact of climatic and human factors on the disease. North of the equator, more droughts and lower rainfall have been recorded since 1972; and in eastern and southern Africa, there have been alternating dry and wet periods in relation to El Niño. Since 1955, the increase in human population from 125 to 450 million has resulted in both expansion of land cultivation and urbanization. In stable malaria areas of West and Central Africa and on the Madagascar coasts, the endemic situation has not changed since 1955. However, in unstable malaria areas such as the highlands and Sahel significant changes have occurred. In Madagascar, cessation of malaria control programs resulted in the deadly epidemic of 1987-88. The same situation was observed in Swaziland in 1984-85. In Uganda, malaria incidence has increased more than 30 times in the highlands (1,500-1,800 m), but its altitudinal limit has not overcome that of the beginning of the century. Cultivation of valley bottoms and extension of settlements are in large part responsible for this increase, along with abnormally heavy rainfall that favored the severe epidemic of 1994. A similar increase in malaria was observed in neighboring highlands of Rwanda and Burundi, and epidemics have been recorded in Ethiopia since 1958. In contrast, in the Sahel (Niayes region, Senegal), stricken by droughts since 1972, endemic malaria decreased drastically after the disappearance of the main vector, Anopheles funestus, due to the destruction of its larval sites by cultivation. Even during the very wet year of 1995. An funestus did not reinvade the region and malaria did not increase. The same situation was observed in the Sahelian zone of Niger. Therefore, the temperature increase of 0.5 degree C during the last 2 decades cannot be incriminated as a major cause for these malaria changes, which are mainly due to the combination of climatic, human, and operational factors.

Africa South of the Sahara↗
PubMed1998

Contemporary treatment of tuberculosis in HIV prevalent countries in sub-Saharan Africa.

The HIV pandemic has been worst felt in sub-Saharan Africa. Tuberculosis is an opportunistic disease in the course of HIV infection and in the region, where the prevalence of both M. tuberculosis and HIV are very high, tuberculosis has become a major complication of HIV infection. The annual risk of tuberculosis infection remains high (1.5 to 2.5%) which is more than fifty times compared to the rates in Western Europe and the prevalence of HIV infection in tuberculosis patients ranges between 18 to 67%. More than 35% of the cases in most countries of sub-Saharan Africa are attributed to HIV. The tuberculosis treatment programmes in sub-Saharan Africa are overwhelmed with increasing number of clinical TB. This trend requires re-examination of the treatment strategy used in the region. There is need to replace streptomycin and thiacetazone in treatment regimens; provide effective short-course chemotherapy for all patients irrespective of their HIV status; use more of ambulatory treatment and expand the use of supervised intermittent therapy.

AIDS-Related Opportunistic Infections↗
PubMed1998

Review of tsetse flies and trypanosomosis in South Africa.

The history of tsetse flies and nagana (trypanosomosis) in South Africa, and especially in Zululand, is reviewed. Four valid tsetse fly species have been recorded from South Africa. Glossina morsitans morsitans disappeared from the most northerly parts of South Africa during the rinderpest epizootic between 1896-1897. Of the three remaining species that occurred in Zululand, now part of KwaZuluNatal Province, G. pallidipes was the most common vector of nagana in cattle, but was eradicated from this area in 1954. G. brevipalpis and G. austeni remained but were responsible for only a few sporadic cases of nagana up until 1990. A widespread outbreak occurred in 1990 where cattle served by 61 diptanks were found infected with Trypanosoma congolense and T. vivax. Dipping of cattle in a pyrethroid plus the therapeutic treatment of infected animals brought the disease under control. The outbreak also led to a trial to control G. brevipalpis from the most northerly parts of the Hluhluwe/Umfolozi Game Reserve making use of target technology as for savannah species. The results were not satisfactory and the trial was discontinued until further research could provide a more appropriate system for the control of this species. A Tsetse Research Station was established at Hellsgate near St. Lucia Lake where research on G. brevipalpis and G. austeni is conducted into ways and means of monitoring and controlling these species.

Animals↗
PubMed1998

What is the infant mortality rate in South Africa? The need for improved data.

OBJECTIVE: To review recent infant mortality and birth registration data in South Africa and to investigate geographical differences. OUTCOME MEASURES: Estimates of infant mortality rates, proportion of births not registered, and proportion of births recorded in health services. METHODS: 1. Published infant mortality data for South Africa were collated. Demographic data from national household surveys (1993 and 1994 October Household Surveys and the 1993 Poverty Survey by the Southern African Labour and Development Research Unit (SALDRU) at UCT) were analysed using the indirect method developed by Brass. 2. Birth registration data were analysed and compared with the estimated number of births to identify regions with greater under-registration. The number of births recorded in the health services was analysed by province in order to assess and explore alternatives within health authorities that could complement the existing system. RESULTS: 1. Published estimates of infant mortality for the period from 1990 range from 40 to 71/1,000 births and estimates based on national household surveys conducted in this period from 11 to 81/1,000 births. 2. Completeness of birth registration in the nine provinces ranges from less than 10% in the Eastern Cape, North West and Northern Province to 60% in the Western Cape. An overall improvement from 19% to 60% could be achieved if births recorded through the health services were included in the vital registration system. CONCLUSIONS: The infant mortality rate in South Africa is not known with any certainty. The extent of completeness of the birth registration system was 19%, which indicates a need for urgent improvement in order to provide key health status indicators. This study indicates that there is some potential for improving the extent of birth registration if it could be facilitated through the health service. However, this alone would not achieve complete registration. RECOMMENDATIONS: Surveys will have to be relied upon until such time as routinely available statistics are accurate. The October Household Survey conducted annually by the Central Statistical Service as potentially an important source of health status information. It is imperative that either the design of the birth history questionnaire be improved or that it be replaced by a less frequent but more specialised demographic and health survey.

Female↗
PubMed1989

Nutrition and the commoditization of food in sub-Saharan Africa.

During the past decade, Africa, more than any other continent, has been associated with famine and malnutrition. The Sahelian drought of the early 1970s, the Wollo and Karamoja famines and most recently, mass starvation in Ethiopia, have followed one another in rapid succession. The term 'food crisis' continually crops up in the popular and academic press. An increasing number of researchers probe possible causes; many seek a systemic reason for the present situation. One working hypothesis is that increasing commoditization of food has undermined Africa's food systems. This paper does not purport to prove or disprove this. Less ambitiously, its aim is to draw attention to inter-relationships between commoditization and physical and social aspects of African food systems, tracing their possible effects on the nutritional status of the African population. In so doing, some of the complexities of developing food production and consumption in the transition from peasant societies to more urban-based national economies become evident. The paper is divided into three main parts: a discussion of conceptual categories and general background information about sub-Saharan African food zones and commodity and factor markets; a review of literature on rural food availability and nutrition; and a review of urban food availability and nutrition.

Africa, Central↗
PubMedDate not supplied

Royal Society of Tropical Medicine and Hygiene Meeting at Manson House, London, 12 December 1996. HIV and pneumococcal infection in Africa. Microbiological aspects.

By the 1930s several studies had shown that Streptococcus pneumoniae was an important pathogen in Nairobi (Kenya) and various risk factors for infection were recognized, including seasonally cold conditions, overcrowding and recent arrival in the city. Research into pneumococcal disease declined with the arrival of penicillin but recently interest has been rekindled by recognition of the pneumococcus as a human immunodeficiency virus (HIV)-associated pathogen and by the emergence of antibiotic resistance. The pneumococcus and its association with HIV were studied during the course of the Wellcome Trust/Kenya Medical Research Institute HIV Programme in Nairobi (1988-1993). There were generally high rates of pneumococcal disease. The pneumococcus (with tuberculosis and salmonellosis) was a major HIV-related pathogen. One study showed HIV seropositivity to confer a relative risk of 17.8 for pneumococcal infection. Recurrent infection accounted for a large proportion (25%) of disease episodes in a longitudinally studied cohort of HIV patients. There were higher pneumococcal carriage rates in HIV-positive than in HIV-negative patients (28% vs. 16%, P = 0.003). High rates of resistance were found to penicillin (25%). Molecular characterization of penicillin-resistant strains identified 11 separate clones, showing great genetic diversity in a small sample of isolates, and there was evidence of horizontal spread of penicillin-binding protein genes between separate lineages. Molecular characterization of isolates from patients with recurrent disease suggested that both relapse and reinfection might occur. There was molecular evidence of transfer of capsular genes between clones (serotype switching). The overall spectrum of serotypes resembled those reported elsewhere, most serotypes being included in the 23-valent vaccine. Higher numbered serotypes were associated with respiratory tract source and antibiotic resistance. Various methods were used to show 82% concordance between pernasal and blood isolates in pneumonia cases. HIV-seropositive patients were more prone to infection with penicillin- and tetracycline-resistant organisms than seronegative patients (penicillin, 27% vs. 7%; tetracycline, 40% vs. 17%), a difference reflected by different serotype profiles in the 2 groups. These studies highlight the importance of the pneumococcus as an HIV-related pathogen in one part of Africa. The high rates of antibiotic resistance are a cause of concern. There should be continued monitoring of resistance patterns, and assessments of the significance of pneumococcal disease made elsewhere in Africa are to be encouraged.

Cohort Studies↗
PubMed1987

Human immunodeficiency virus type 2 infection associated with AIDS in West Africa.

We recently reported the isolation of a new retrovirus, termed human immunodeficiency virus type 2 (HIV-2), from two West African patients with the acquired immunodeficiency syndrome (AIDS). This virus is related to but distinct from the well-characterized AIDS retrovirus, human immunodeficiency virus type 1 (HIV-1). We report here evidence of infection with HIV-2 in 30 patients, almost all from West Africa. Seventeen of them had a clinical syndrome indistinguishable from AIDS (7 of these 17 died). Others had either the AIDS-related complex or no HIV-related symptoms. All patients had serum antibodies reacting with HIV-2 in an indirect immunofluorescence assay. All serum tested contained antibodies reacting with the envelope glycoprotein of the virus in an immunoprecipitation assay. Cross-reactivity of serum antibodies with HIV-1 was detected in a minority of patients and varied according to the assay used. Retroviral isolates were obtained from the blood lymphocytes of 11 patients and were all identified as HIV-2 by nucleic acid hybridization; none hybridized with an HIV-1 probe. These findings indicate that some cases of AIDS in West Africa may be caused by HIV-2, but the extent of the spread of this virus and its clinical correlates will require careful epidemiologic investigation.

AIDS-Related Complex↗