School of child & adolescent health

Title: LUNG FUNCTION IN HIV- INFECTED ADOLESCENTS ON ANTIRETROVIRAL THERAPY IN CAPE TOWN, SOUTH AFRICA
Authors: Githinji L¹, Gray D¹, Hlengwa¹ S, Zar HJ¹
Affiliation: ¹ Department of Paediatrics and Child Health, University of Cape Town and MRC Unit, Child and Adolescent Health

Background:

Over 90% of HIV infected children live in Sub-Saharan Africa. Although lung disease is very common, there is limited information on the spectrum of chronic lung disease in HIV-infected adolescents and the impact of antiretroviral therapy (ART). Lung function offers an objective method for measuring this.

Objective:

To investigate lung function in HIV infected adolescents on ART in Cape Town, South Africa in a prospective longitudinal cohort, the Cape Town Adolescent Anti-retroviral cohort (CTAAC).

Methods:

Adolescents aged 9 to 14 years who were stable on ART for at least 6 months, were enrolled in CTAAC and underwent baseline lung function testing. Lung function measures included spirometry, bronchodilator testing, six minutes’ walk test and single breath carbon monoxide diffusion test. A sample of HIV negative age, sex and ethnically matched controls were also tested.

Results:

520 HIV-infected adolescents and 110 HIV negative controls were enrolled. The mean (SD) age was 12 (1.6) years; 52% were male.

Outcome measures	Cases(HIV infected) n=520	Controls(HIV negative) n=110	P value
FEV1(L)	1.6(0.45)	1.9(0.51)	<0.001
FVC(L)	1.8(0.48)	2.0(0.56)	<0.001
FEV1/FVC (%)	89(8.7)	93(6.3)	<0.001
TLCO(mlCO/min/mmHg)	16.6(3.4)	18.1(4.2)	<0.001
KCO(mlCO/min/mmHg)/L	5.9(0.8)	5.8(0.9)	0.088
Distance covered(m)in 6 min	433.7(57.0)	443.5(60.5)	0.138

Values are mean (SD)
Conclusion:

Lung function abnormalities are common in HIV-infected adolescents. HIV infected adolescents on ART have significantly lower lung function than matched HIV negative adolescents.

Funding: NIHR01HD074051 Ethics approval number: REC Ref: 051/2013

Title: Risk factors for Bordetella pertussis disease in hospitalised children
Authors: Rudzani Muloiwa¹, Felix S. Dube², Mark P. Nicol^{2, 3,} Gregory D Hussey⁴, Heather J. Zar¹
Affiliation: ¹Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa; ²Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town; ³National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa; ⁴Vaccines for Africa Initiative, Division of Medical Microbiology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa


Background:

Despite its resurgence in high-income countries, risk factors for pertussis in children in low and middle-income countries (LMIC) are poorly understood.  This study assesses risk factors for confirmed pertussis in African children with severe LRTI.

Methods:

Bordetella pertussis infection was confirmed by PCR (IS481+/hIS1001-) on respiratory samples collected from inpatient children at a South African hospital in Cape Town, over a one-year period. Clinical details were gathered.

Results:

Bordetella pertussis infection was confirmed in 32/460 (7.0%) children aged 8 (IQR 4-18) months. Risk of confirmed pertussis was significantly increased in infants younger than two months [aRR 2.37(95% CI 1.03-5.42)]. Children with HIV exposure [aRR 3.53(95% CI 1.04-12.01)] or HIV- infection [aRR 4.35(95% CI 1.24-15.29)] were at increased risk. Mild [aRR 2.27(95% CI 1.01-5.09)] or moderate [aRR 2.70(95% CI 1.13-6.45)] under-nutrition respectively were associated with higher risks. The highest risk was seen in children whose caregivers had B. pertussis nasal infection [aRR 13.82(95% CI 7.76-24.62)]. Completion of the primary vaccine schedule was protective [aRR 0.28(95% CI 0.10-0.75). Risk of pertussis was not associated with household air pollutants.

Conclusions:

HIV exposure or infection as well as maternal nasal infection with B. pertussis and poor nutrition are associated with increased risk of pertussis in African children, especially in young infants. Completed primary vaccine schedule was associated with reduced risk of confirmed pertussis. There is an urgent need to improve primary pertussis vaccine coverage in LMIC and scale it up to include pregnant women, especially those with HIV infection.

Title: Every Child Counts – Lessons from the South African Child Death Review Pilot 
Authors: Shanaaz Mathews, Lorna J Martin, David Coetzee and Chris Scott 

Under-five mortality has declined from 56 deaths per 1,000 live births in 2009 to 41 per 1,000 live births in 2011, yet most of these deaths are preventable. There are limited published data on child mortality in older children, but vital registration data indicate that deaths from injuries increase as children get older. Child death review teams have been established in high income settings to systematically review child deaths as a public health model of identifying preventable deaths and improving child protection systems.

CDR teams have been established at two pilot sites (Western Cape and KZN) in South Africa to test the efficacy of the approach to better identify fatal child abuse and to better understand the how child deaths can be prevented. All child deaths are reviewed at the two sites for the period 1st January to 31st December 2014. Data was collected on the demographics of the child, cause of death, circumstances of the death and social context of the family. In addition the modifiable factors were also identified. 
For the period January to December 2014 the two CDR teams reviewed 711 cases at both sites. Just over half (53%) of all the child deaths were due to natural causes and 43% due to unnatural causes.  Most of the natural deaths (95%) occurred in the under-5 year age group with the majority of these deaths in infancy and associated with prematurity. There was a variation between the two sites with more natural deaths seen at the Western Cape site. Overall LRTI was the leading cause of death followed by homicide and road traffic injuries.  A total of 110 child murders were reviewed by the team with just under half (47%) of these deaths linked to child abuse. Over three quarter (78%) of these deaths were under 5 year olds. 
The CDR pilot illustrates how large numbers of children continue to die both as a result of natural and non-natural deaths in South Africa. Introducing a systematic inquiry into circumstances surrounding sudden unexpected deaths and non-natural child deaths has provided invaluable insights into why and how children die at the two sites. This enquiry has also enabled the collaborative management of child deaths and potential opportunities for prevention of these deaths. 
Title: DESCRIPTIVE STUDY EVALUATING THE USE OF THE ROAD TO HEALTH CARD BY DOCTORS IN A TERTIARY PAEDIATRIC HOSPITAL SETTING
Author: Jodi Wiles

Objective:

This study aimed to describe the level of possession of the Road to Health Card (RTHC) by a sample of caregivers of patients admitted to Red Cross War Memorial Children’s Hospital (RCWMCH), and in this sample, to assess the extent and accuracy of doctors’ transfer of clinical information between the RTHC and hospital records. 

Methods:

A prospective cross-sectional study was conducted in four general paediatric wards at RCWMCH. Consecutive patients were enrolled at discharge during office hours over a six week period. Data were extracted from a photograph of the RTHC and the participant’s hospital record (HR). The presence or absence of selected items of information on the RTHC and the HR were recorded – the primary outcome was the transfer of the specified information between records. The outcomes are presented as proportions, with Clopper-Pearson binomial confidence intervals.

Results:

One hundred and thirty-three (81%) of the eligible participants were in possession of a RTHC. One hundred and twenty-seven participants were included in the final study sample. Variables such as the child’s perinatal information, immunisation record and weight for age chart were well-documented on the RTHC prior to hospital admission and well-transferred to the HR during admission, with the exception of the full immunisation record (transfer proportion 44%). However, the presence of the most recent age-appropriate immunisation was noted in the majority of HRs (transfer proportion 85% with 95% CI 76 - 91%). In general, the new information that was recorded in the participant’s HR during their stay was poorly transferred to the RTHC on discharge. The transfer proportions of the participant’s weight for age, diagnosis and treatment were 31% (95% CI 23 - 41%), 63% (95% CI 54 - 72%) and 48% (95% CI 39 - 57%) respectively.

Conclusion:

The possession rate of RTHCs by caregivers within the study sample was within an acceptable range. Although doctors generally made use of the RTHC as a reference source when assessing the patient’s health, their recording of new clinical information on the RTHC was poor, missing the opportunity to use it as a communication tool for continuity of care.

Title: An evaluation of the impact of outreach and support child health services on level 2 and level 3 facilities
Presenter: Willie Breytenbach

Introduction:

Children from the Eden and Central-Karoo districts needing secondary and tertiary care are referred to George Regional Hospital, (GRH) in Eden and from there to Red Cross War Memorial Children’s Hospital, (RCWMCH) the tertiary hospital in Cape Town. In 1997 the paediatric department at GRH started with outreach and support (O&S) to some of the surrounding district hospitals. This O&S has grown through the years with regular 2 monthly visits to the bigger district hospitals, and less often to the smaller hospitals. The focus has been ward rounds, outpatients clinics, combined with lectures and bedside teaching together with local doctors. One aim has been the improvement of referral pathways and access to facilitate and enable prompt, timely and appropriate referrals and admissions. Our experience is that O&S leads to an increase in patient-load and referrals to GH and RCWMCH. 

Objectives:

To conduct a retrospective descriptive audit of the amount of patients referred to RCWMCH during the period 2000 to 2014 at 3 to 5 year intervals and GH in 2011 and 2014 to show the impact of O&S on level 2 and 3 child health services.

Methods:

Data was collected from the ambulance and patient transport services. The number of paediatric transfers and outpatient visits from Eden and Central-Karoo to RCWMCH were compared for the years 1999, 2005&6, 2011 and 2014. 

Results:

Preliminary data shows an increase in outpatient visits from Eden and Central-Karoo to RCWMCH from 277 in 2006 to 988 children in 2011.  

George Hospital admitted 722 children from the district in 2014.
Conclusion:

A number of factors may have led to increased referrals from the districts to GRH and RCWMCH. These include increased O&S, increased population numbers and improved district hospital care and training. Capacity at regional and tertiary level is needed to maintain and accommodate the increased amount of referrals. 

Title: FAECAL CARRIAGE OF EXTENDED-SPECTRUM BETA-LACTAMASE- AND CARBAPENEMASE-PRODUCING ENTEROBACTERIACEAE IN HEALTHY INFANTS AND THEIR MOTHERS, SOUTH AFRICA
Authors: R. I. Manenzhe¹, C. Moodley¹, S. Africa¹, H. J. Zar¹, M. P. Nicol¹, M. Kaba¹
Affiliation: ¹University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa


Objectives:

The prevalence of extended-spectrum beta-lactamase (ESBL)- and carbapenemase-producing Enterobacteriaceae in healthy humans in the community is largely unknown.  We aimed to determine the prevalence and genetic characteristics of ESBL- and carbapenemase-producing Enterobacteriaceae in stools from healthy infants and their mothers, and to determine the risk factors associated with their acquisition. 

Methods:

Maternal faecal samples (n= 90) and infants meconium (n= 90) were collected at birth from participants in the Drakenstein Child Health Study, a birth cohort in a semi-rural region of Western Cape, South Africa. Samples were screened using ChromID ESBL and ChromID CARBA media. Identification of suspect ESBL/carbapenemase-producing isolates and antibiotic susceptibility were determined using the Vitek 2 system. ESBL production was confirmed using the combination disc test, and that of carbapenemase using the modified hodge test. Selected ESBL and carbapenemase genes were evaluated by PCR and Sanger sequencing. Risk factors were assessed using univariate analysis. 

Results:

Carriage of ESBL-producing organisms was found in 4.4% (95% CI: 1.2% - 11%) of both mothers and infants. ESBL genes were detected in four E. cloacae (blaSHV-12/5), three K. pneumoniae (blaCTX-M-15) and one E. coli (blaCTX-M-14) isolates. Carbapenemase-producing isolates were not detected in this study. One mother-infant pair was ESBL-positive at birth with SHV-12- producing E. cloacae. Being born to HIV-positive mother, being born via elective caesarean section and administration of medication before discharge were positively associated with infant ESBL faecal carriage at birth. In contrast, breastfeeding prior to discharge was negatively associated with infant ESBL faecal carriage.

Conclusions:

This is the first study to detect ESBL-producing bacteria in human meconium samples and raises questions on source of such isolates and implications for community transmission. 

The study was approved by the Faculty of Health Sciences (FHS) Human Research Ethics Committee
(HREC) of the University of Cape Town, South Africa (HREC reference number: 738/2013).
Title: The Drakenstein Child Health Study: investigating the early determinants of child health in South Africa

Authors: HJ Zar,¹ W Barnett,¹  A Stadler^1,2, E von Delft², S Budree¹, A Vanker¹, N Koen³, S Lubbe⁴, L Myer,⁵  DJ Stein,³ MP Nicol⁶  on behalf of the *Drakenstein child health study team. 

Affiliation: ¹ Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and MRC Unit on Child & Adolescent Health, University of Cape Town, ² Department of Paediatrics, Paarl Hospital, ³ Department of Psychiatry and Mental Health, Groote Schuur Hospital and MRC Unit on Anxiety & Stress Disorders, University of Cape Town, ⁴ Department of Statistical Sciences, University of Cape Town; ⁵ Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, ⁶ University of Cape Town, Department of Clinical Laboratory Sciences, University of Cape Town, South Africa

*The Drakenstein child health study team who contributed to this: C Abrahams, M Arendse, A Arnold, F Bailey, F Bantom, H Claassen, E Caesar, M Cyster, K Donald, F Dube, S Erasmus, J Fourie, N Frans, D Gray, L Gunya, C Jacobs, D le Roux,  M Kaba, S Koopowitz, L Kohlakalo, M Mbovu, M Michaels, B Mnyazi, B Myers, P Nduru, N Nyakutira, D Pietersen, R Pietersen, A Revelle, D Simpson, L Stemmet, K Tshangela, L Valentine,  S van der Westhuizen, L Willemse 

Correspondence: [e-mail]

The Drakenstein Child Health Study is a unique, multidisciplinary, South African birth cohort, to investigate the impact of antenatal and early life exposures on child health.  A core focus of the study is on the incidence, risk factors, aetiology and long term impact of early pneumonia on child health.  Other focus areas include maternal health, child growth, nutrition, neurodevelopment, non-respiratory illnesses, the maternal, child and environmental microbiome and emerging non-communicable diseases. Study visits are conducted at Paarl Hospital and at TC Newman and Mbekweni clinics, which provide a strong primary health care program.
Methods:

Pregnant women from a poor, peri-urban community in Paarl with high exposure to infectious diseases and environmental risk factors were enrolled in the second trimester at 2 clinics – TC Newman (serving a mixed ancestry population) and Mbekweni (serving a Black African population).  Women were followed through pregnancy and child birth (all at Paarl hospital); mother-child pairs are followed until children are at least 5 years. Biomedical, environmental, psychosocial, and demographic risk factors are longitudinally measured.  Environmental exposures are measured using monitors placed at home visits; tobacco smoke exposure is investigated using urine cotinine measures.  Maternal and paternal physical and psychosocial health are longitudinally assessed; follow-up of children is synchronized with routine primary care visits. Active surveillance for pneumonia is done; microbiologic investigations including microbiome and multiplex PCR measures are done longitudinally and at each pneumonia episode; a case control analysis is done to investigate aetiology. Child growth, nutrition and neurodevelopmental outcomes are longitudinally assessed. Lung function is measured in children at 6 weeks, annually and during LRTI episodes.

Results:

1100 mothers were enrolled; all births have occurred and over 1300 child years of

follow up have been accrued with high cohort retention. The population is poor (with the Mbekweni population relatively poorer than that from TC Newman), mostly single mothers and 20% of mothers were HIV-infected. Rates of tobacco smoke exposure are very high,  approximately a third of pregnant women were active smokers. At birth, 56% of neonates had cotinine levels indicative of exposure, while 18% had levels of active smokers; at 6 weeks of age 53% infants tested positive for exposure. Women had a high prevalence of depression (21%), lifetime trauma (67%) or intimate partner violence (32%). Antenatal depression was strongly associated with decreased infant weight-for-age (WAZ) and head circumference-for-age (HCAZ) z-scores at birth; maternal trauma exposure was also significantly associated with a reduction in HCAZ at birth. Black African infants had higher birth weight compared to mixed race infants (median WFAZ -0.4 vs. -0.7, p<0.001) and remained heavier and taller throughout infancy. Stunting occurred in 17% at 2 months of age, declining to 13% by 12 months with a higher prevalence among mixed race than Black African children. Exclusive breastfeeding was unusual. Immunization coverage for the EPI schedule was high. By May 2015 there were 509 pneumonia cases (264 ambulatory and 112 hospitalized; pneumonia incidence 0.29 episodes per child year; e/cy). The highest incidence occurred in children 1-6 months of age (0.57 e/cy).  Organisms most strongly associated with pneumonia were B. pertussis [OR 11.1; 95% CI 1.3-92.5], RSV [OR 8.1; 95% CI 4.2-15.4] and influenza virus [OR 4.1; 95% CI 2.1-8.3]; bocavirus, parainfluenza virus, adenovirus or CMV were also associated with pneumonia. Three children had MDR TB. The pneumonia case fatality rate was 1%.
Conclusion:

There are high rates of exposures to several risk factors that may impact on child health; many of these are amenable to preventative interventions. There is a strong association between maternal health, birth outcomes and subsequent child health. Despite high levels of immunization, pneumonia is common in infants; RSV is the predominant pathogen. The study provides data on areas in which known interventions to prevent or ameliorate illness may be strengthened and also identifies novel areas that require development of new interventions.  

Acknowledgements: We thank the study staff in Paarl, the study data team and lab teams, the clinical and administrative staff of the Western Cape Government Health Department at Paarl Hospital and at the clinics for support of the study. We acknowledge the advice from members of the study International Advisory Board and thank our collaborators.  We thank the families and children who participated in this study.  
Funding: Bill and Melinda Gates Foundation [OPP 1017641]; the National Institutes of Health (H3Africa 1U01AI110466-01A1), Wellcome Trust, MRC South Africa, National Research Foundation, South Africa.  
Title: Streptococcus pneumoniae nasopharyngeal colonization, serotype distribution and Impact of vaccination during the first year of life: A South African birth cohort study
Authors: Felix S. Dube¹, Jordache Ramjith³, Sugnet Lubbe², Lourens Robberts¹, Nicole Wolter^{7, 8}, Suzan P. Van Mens⁶, Heather J. Zar⁵, Mark P. Nicol^{1, 4}
Affiliation: ¹Division of Medical Microbiology, Faculty of Health Science, University of Cape Town, South Africa, ²Department of Statistical Sciences, University of Cape Town, South Africa, ³Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, South Africa ⁴National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa, ⁵Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital  and MRC unit on Child & Adolescent Lung Health, University of Cape Town, South Africa ⁶Department of Medical Microbiology & Immunology, St Antonius Hospital Nieuwegein, the Netherlands. ⁷Centre for Respiratory Diseases and Meningitis (CRDM), National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa, ⁸School of Pathology, Faculty of Health Sciences, University of the Witswatersrand, Johannesburg, South Africa

Background:

Childhood vaccination against Streptococcus pneumoniae prevents invasive disease, including pneumonia, blood stream infections and meningitis. S. pneumoniae colonization of the nasopharynx precedes the development of invasive disease. A better understanding of the effects of serotype-specific vaccination on the dynamics of S. pneumoniae colonization is needed for monitoring vaccine efficacy and potential serotype replacement. We aim to describe longitudinal S. pneumoniae colonization and serotype distribution during the first year of life in a birth cohort (Drakenstein Child Health Study) of South African infants receiving PCV13 immunization.

Methods:

S. pneumoniae isolates were obtained from nasopharyngeal (NP) swabs collected biweekly from 137 infants from birth through their first year of life. Infants received PCV13 at 6, 14 and 36 weeks according to South African childhood vaccination program. Isolates obtained were subjected to sequetyping employing nucleic acid amplification and sequencing of the wzh regulatory gene within the capsular biosynthesis gene cluster. Results were confirmed by Quellung.

Result:

S. pneumoniae was isolated from 51% (1,594/3151) of NP swabs; yielding a point prevalence of 2% at birth and reaching a maximum prevalence of 40% at 14 weeks of age. Of the 1,594 isolates 84% (1334/1594) were successfully sequetyped, 16% (260/1,594) failed sequetyping amplification of which 67% (175/260) were non-typeable by Quellung. The median time to first S. pneumoniae acquisition was 64 days (95% CI 56 – 91 days), with no difference observed between vaccine-type (VT)  and non-vaccine-types (NVT)  (p = 0.698). Serotype-specific acquisition rates ranged from 0.0075 to 0.8827 episodes/child year, whereas the average carriage duration for all 48 different serotypes detected was between 0.04 and 22.6 days. The most frequently encountered NVT were 15b/15c, 21, 10a, 16f, 35b, 9n and 15a, while VT serotypes include 19f, 9v, 19a and 6a.

Conclusion:

In this population, the rate of S. pneumoniae acquisition and duration of carriage is serotype-specific. Most serotypes encountered during the first year of life were non-PCV13 vaccine serotypes, as expected in a population with high vaccine coverage. 

Title: LUNG FUNCTION IN THE FIRST YEAR OF LIFE IN AFRICAN INFANTS: EFFECT OF EARLY LIFE PNEUMONIA
Authors: Diane Gray¹, Lauren Willemse¹, Lidija Turkovic², Ane Visagie¹, Aneesa Vanker¹, Dan Stein³, Peter D. Sly⁴, Graham L. Hall², Heather J. Zar¹
Affiliation: ¹Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa; ²Telethon Kids Institute, University of Western Australia, Perth, Australia; ³Department of Psychiatry, University of Cape Town, Cape Town, South Africa; ²Children’s Lung, Environment and Asthma Research, Child Health Research Centre, Unviversity of Queensland, Brisbane, Australia; ⁴Queensland Children's Medical Research Institute, Brisbane, Australia


Background:

Early life lung function is associated with increased risk of respiratory disease in later life. Identifying factors that impact lung function in the first years of life is important if we are to develop strategies to strengthen paediatric respiratory health.

Aim:

To investigate the impact of early life exposures, including pneumonia on lung function during the first year.

Method:

Infants enrolled in the Drakenstein Child Health birth cohort had lung function tested at 6 weeks and 1 year of age. Testing, done during quiet natural sleep, included tidal breathing (TBFVL), exhaled nitric oxide (eNO) and SF6 multiple breath washout (MBW) measures. Early life information was collected by questionnaire at schedule study visit. Study staff examined infants at the time and 4-6 weeks after a pneumonia episode. 

Results:

Of 389 eligible infants, 304 children were tested both at 6 weeks and 1 year; 279 (70%) TBFVL, 266 (68%) eNO and 262 (66%) MBW tests were successful with good quality results. Lung function tracked strongly from 6 weeks through to 1 year. Pneumonia during the first year of life was independently associated with decreased tidal volume (average -3.6 mL lower, 95%CI -6.6 to -0.5; p=0.02) and increased respiratory rate at 1 year (6% higher, 95%CI 1.01 to 1.10; p=0.01). This effect was stronger if the infant required hospitalization. Repeat episodes of pneumonia further increased respiratory rate (5% higher, 95%CI 1.02 to 1.08; p=0.001), decreased tidal volume (-2.5 mL lower, 95%CI -4.7 to -0.3; p=0.02) and were associated with increased lung clearance index (0.2 turnovers, 95%CI 0.00 to 0.26; p=0.05). 

Conclusions:

Early life pneumonia lowers lung function achieved at 1 year, an effect independent of baseline lung function. This data provides evidence that preventing early life pneumonia is an important factor in optimising early lung growth and function and strengthening respiratory health in later childhood.

HREC REF: 423/2012
Contact presenting author: [e-mail]

 

Title: INCIDENCE OF CHILDHOOD PNEUMONIA: FACILITY-BASED SURVEILLANCE ESTIMATE COMPARED TO MEASURED INCIDENCE IN A SOUTH AFRICAN BIRTH COHORT STUDY

Authors: David M le Roux^{1, 2}, Landon Myer³, Mark P Nicol⁴, Heather J Zar¹

Affiliation: ¹Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and MRC Unit on Child and Adolescent Health ,University of Cape Town; ²Department of Paediatrics , New Somerset Hospital, ³School of Public Health, University of Cape Town; ⁴Division of Medical Microbiology, University of Cape Town;

Introduction:

Pneumonia is the leading cause of childhood mortality and a major contributor to childhood morbidity, but accurate measurement of pneumonia incidence is challenging. We compared pneumonia incidence using a facility-based surveillance system to estimates from a cohort study conducted contemporaneously in the same community in Cape Town, South Africa.

Methods:

A surveillance system was developed in 6 public sector primary care clinics and in a regional referral hospital to detect childhood pneumonia cases. Nurses recorded all children presenting to facilities who met World Health Organisation case definitions of pneumonia, and hospital records were reviewed. Estimates of pneumonia incidence and severity were compared with incidence rates based on active surveillance in the Drakenstein Child Health Study. Ethics approval was obtained from the University of Cape Town Human Research Ethics Committee (HREC REF REF 401/2009 and REF 651/2013)

Results:

From June 2012 until September 2013, the surveillance system detected 306 pneumonia episodes in children under 1 year, an incidence of 0.20 episodes per child year (e/cy) (95% CI 0.17 – 0.22 e/cy). The incidence in the cohort study from the same period was 0.27 e/cy (95% CI 0.23 – 0.32 e/cy). Pneumonia incidence in the surveillance system was almost 30% lower than in the birth cohort; rate ratio 0.72 (95% CI 0.58 – 0.89). In the surveillance system 18% percent were severe pneumonia, compared to 23% in the birth cohort, rate ratio 0.81 (95% CI 0.55 –1.18).

Conclusion:

In this setting facility-based pneumonia surveillance detected fewer cases of pneumonia, and fewer severe cases, compared to the corresponding cohort study. Facility pneumonia surveillance using data collected by local health care workers provides a useful estimate of the epidemiology of childhood pneumonia but may underestimate incidence and severity.

Funding: Bill and Melinda Gates Foundation (OPP 1017641); South African Thoracic Society; Federation of Infectious Diseases Societies of South Africa; UCT research associateship; South African Medical Research Council
[e-mail]

Title: The spatial distribution of injury mortality of children in the western geographic service area, City of Cape Town (2011-2015)
Authors: Zulfah Albertyn ¹, David Coetzee ², Shanaaz Mathews¹
Affiliation: ¹University of Cape Town, Children’s Institute, Cape Town, South Africa. ²University of Cape Town, Department of Public Health and Family Medicine, Cape Town, South Africa.

Child mortality is a global public health burden, and child deaths under the age of five far exceed deaths in the older age groups. The pattern of cause of death for children differ somewhat by age. The leading cause of death in children is still due to natural causes with; communicable diseases namely, lower respiratory track infection (LRTI), diarrheal disease commonly afflicting children under-five while older children are more likely to die as a result of injury deaths such as homicide or road traffic injury, yet both are preventable. Resources to prevent child deaths are primarily focused on the under-five age group, even though the injury burden of children increases with age. It is therefore important to strengthen the monitoring and tracking of child mortality in South Africa for all age groups over time to inform preventative measures. In addition, geographic information system (GIS) tools can describe and visualize patterns of disease burden relative to the socioeconomic and community (including environmental) proximate determinants of health. This PhD study aims to retrospectively facilitate the monitoring and tracking of injury mortality in children using mortuary data over the period of 2011 to 2015 across the western geographic service area of the City of Cape Town; by investigating the pattern of injury burden of children followed by developing a spatial analytical model to highlight where the high- and low-areas of risk (clusters) and when RTIs have taken place, as well as, potential exposures that influence these clusters.

Title: DYNAMICS OF THE NASOPHARYNGEAL MICROBIOME PRECEDING AND AT THE ONSET OF PNEUMONIA IN INFANTS: A PILOT STUDY

Authors: Shantelle Claassen*1, Elloise du Toit1, Sugnet Lubbe2, Heather J. Zar3,4, Mark P.Nicol1,5,6

Affiliation: 1Division of Medical Microbiology, Department of Clinical Laboratory Science, University of Cape Town, Cape Town, South Africa; 2Department of Statistical Sciences, Faculty of Science, University of Cape Town, Cape Town, South Africa; 3Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa; 4MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa; 5Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; 6National Health Laboratory Service of South Africa, Groote Schuur Hospital, Cape Town, South Africa

Introduction:

Pneumonia is the primary cause of mortality in children under the age of five years. African children, in particular, have the highest burden of pneumonia incidence and severity. To date, target-based studies have identified the role of bacteria such as Streptococcus pneumoniae and Haemophilus influenzae type b in pneumonia aetiology. High-throughput sequencing studies are increasingly demonstrating the importance of a “community-wide” microbiota profile in health and disease. Despite the advances in techniques to study human microbiomes, only a few studies have focused on profiling the nasopharyngeal (NP) microbiome in children with pneumonia in comparison to healthy controls. Moreover, no studies have longitudinally profiled the microbiome of children in the period immediately preceding pneumonia.

Objective:

Using a unique birth cohort design, we therefore aim to investigate the role of infant NP bacterial profiles in infants with pneumonia by comparing bacterial profiles of NP specimens collected at six two-weekly intervals prior to the onset of pneumonia and at the time of pneumonia, together with NP bacterial profiles from their age-matched controls.

Methods:

The study is nested within a South African birth cohort study, the Drakenstein Child Health Study. Nucleic acid will be extracted from NP specimens using the automated QIAsymphony® SP instrument. Illumina MiSeq sequencing will be performed targeting the V4 region of the bacterial 16S rRNA gene. We will describe changes in the composition of the NP microbiome of cases and controls using relative abundance of taxonomically classified operational taxonomic units (OTUs), Shannon diversity and Bray Curtis dissimilarity indices. Multivariate statistical methods will be used to describe statistical differences in the NP bacterial profiles from cases and controls and these will be graphically represented with log ratio biplots.

Results:

We will present results for this pilot study drawn from studying a subset of infants (eight pneumonia cases and their age-matched controls) at the Department of Paediatrics and Child Health Research Days 2015.

Next steps: We aim to expand this pilot study to include 400 age-matched case-control pairs.

Funding: Bill and Melinda Gates Foundation (OPP1017641); National Institutes of Health (NIH) (1UO1AI110466-01A1); Medical Research Council (MRC) South Africa, Collaborating centre for TB and/or HIV/AIDS: TB-CHILD; and the Oppenheimer Memorial Trust.
Ethics approval number: 585/2015

Title: FEASIBILITY OF PULSE OXIMETRY PRE-DISCHARGE SCREENING IMPLEMENTATION FOR DETECTING CRITICAL CONGENITAL HEART LESIONS IN NEWBORNS IN A SECONDARY LEVEL MATERNITY HOSPITAL IN THE WESTERN CAPE, SOUTH AFRICA - THE “POPSICLE”STUDY
Authors: AM van Niekerk¹, RM Cullis¹, LL Linley¹, L Zühlke²
Affiliation: ¹Division of Neonatal Medicine, School of Child and Adolescent Health, University of Cape Town Mowbray Maternity Hospital, Western Cape, South Africa; ²Department of Paediatrics, Red Cross War Memorial Children’s Hospital and University of Cape Town, South Africa


Background:

Early detection of Critical Congenital Heart Disease(CCHD) through newborn pulse- oximetry(POx) screening is an effective strategy for reducing paediatric morbidity and mortality rates and has been adopted by much of the developed world.

Objectives:

We aimed to document the feasibility of implementing pre-discharge POx screening in well babies born at Mowbray Maternity Hospital, a government hospital in Cape Town, South Africa. Parent and staff acceptability was also assessed.

Methods:

We conducted a prospective study of pre-discharge POx screening in a post-natal ward, following informed consent from parents.

Results:

During the study period, 1017 of 2256(45%) babies discharged were offered POx screening and 1001 screened. Ninety four percent (94%) of tests took less than three minutes to perform, 4.3% between three and five and 1.7% longer than five minutes. Eighteen patients needed second screens and three required third screens. Only 3% protocol errors were made, all without consequence. The vast majority (91.6%) of nursing staff reported insufficient time to perform the study screening in addition to their daily tasks. Over 98% of the mothers had positive comments. Two babies failed screening, and required echocardiograms. One was diagnosed with CCHD, the other with neonatal sepsis. The sensitivity and specificity was 50% (95% C.I. 1.3-98.7%) and 99.9 % (95% C.I. 99.4- 100%) respectively with a percentage correct of 99.8%.

Conclusions:

POx screening was supported and accepted by staff and parents. Given additional staff, it could be implemented successfully without an excess of false positives, errors or an additional burden to cardiology services.

HREC REF: 661/2013

Title: KNOWLEDGE AND EXPERIENCES OF PARENTS WITH CHILDREN AFFECTED BY SICKLE CELL DISEASE IN CAPE TOWN
Authors: Katryn Fourie, Jantina de Vries, Nakita Laing, Ambroise Wonkam
Sickle Cell Disease (SCD) is an autosomal recessively inherited blood disorder that leads to a debilitating systemic illness. Although the disease was initially found predominantly in tropical and subtropical regions, SCD has now become a global health problem, due to migration of people from various countries with a high burden thereof. Consequently, the incidence of SCD in South Africa has increased dramatically over the last decade.
This study, which constitutes a minor dissertation in fulfilment of an MSc (Med) Genetic Counselling degree, aimed to explore the knowledge and understanding of SCD among parents of affected children in Cape Town as well as identify burdens associated with caring for a child with SCD. Furthermore, the study assessed opportunities to improve genetic counselling services available to parents and explored their attitude to preventive policies.
A phenomenological approach was used to conduct this research. Seventeen semi-structured interviews were conducted with the biological parent of a child attending the Red Cross War Memorial Children's Hospital Haematology Clinic. Participants were selected using both purposive and convenience sampling methods. Data collected during these interviews were analysed using thematic content analysis.
Themes and relevant sub-themes were identified and grouped into three categories: knowledge and understanding; experiences and burdens; and attitude toward preventative policies. While the majority of participants had some knowledge of SCD, several misconceptions were discovered, often relating to participants’ prior knowledge of the disease. A number of burdens experienced by participants were revealed, with both practical and psychosocial implications. Finally, it was found that the majority of participants supported all methods of screening for SCD, regardless of whether they would make use of the screening services themselves.
Findings of this study provide valuable insights on the subject of experiences of parents of children affected with SCD as well as the potential role of genetic counselling services. This study contributes towards improving understanding and subsequent services provided to individuals raising a child affected with Sickle Cell Disease.

Title: PREVALENCE OF EIGHT MUTATIONS IDENTIFIED BY TARGETED EXOME SEQUENCING AMONGST AUTOSOMAL RECESSIVE NON-SYNDROMIC HEARING LOSS PATIENTS FROM CAMEROON
Authors: Kamogelo Lebeko¹, Jean Jacques N. Noubiap², Collet Dandara¹, Richard Smith³, Ambroise Wonkam¹
Affiliation: ¹ Division of Human genetics, Faculty of health Sciences University of Cape Town; ² Faculty of Medicine and biomedical Sciences University of Yaoundé, Cameroon; ³ University of IOWA, USA.


Introduction:

Hearing loss is the most common communication disorder affecting about 3 IN 500 births in developing countries. Up to 50% is attributed to genetic factors with nonsyndromic hearing loss being the most common form of hearing loss. The most common mode of inheritance is autosomal recessive accounting for up to 70% of these cases. Connexins are the most prevalent genes associated with autosomal recessive nonsyndromic hearing loss accounting for up to 75% of ARNSHL cases in European Caucasian patients. However, no significant association between connexin mutations and hearing loss was reported in our cohort. Targeted exome sequencing was used to uncover causative mutations amongst 10 consanguineous families with at least 2 affected siblings. This data revealed 12 novel causative mutations.

Objectives:

Uncover the frequency of mutations previously identified by Targeted exome sequencing amongst ARNSHL patients in sub-Saharan Africa.

Methodology:

100 patients with ARNSHL and 200 matched control sample were screened for 8 single nucleotide polymorphisms (SNPs) using SNaPshot PCR. Bioinformatics on the interactions of genes and reported secondary variants was performed as well as obtaining pathogenicity scores for the causative mutations uncovered.

Results:

We have screened the controls and found the mutations to be in low frequencies; >1%. We are in the process of genotyping our patient samples in order to uncover the frequency of these mutations. Our bioinformatics show that the mutations are indeed pathogenic and are enough to explain hearing loss in the families.

Conclusion:

The results from this project will give be the first data showing the prevalence of these novel mutations as well as the first study to present data on ARNSHL from Targeted exome sequencing data. This is the first step towards identifying the most prevalent genes and associated mutations in sub-Saharan patients, hopefully leading towards a diagnostic panel specific to this population.

Title: FACTORS INFLUENCING THE PROVISION OF MOTHERS' OWN BREAST MILK FOR PRETERM INFANTS IN A SOUTH AFRICAN TERTIARY NEONATAL UNIT



Authors: Kunda Mutesu-Kapembwa; Shukri Raban and Yaseen Joolay

Affiliation: Groote Schuur Hospital, Department of Neonatal Medicine

Background:
The health outcomes of preterm infants fed breast milk exclusively are superior to those who are fed infant formula. Mothers of preterm infants are known to struggle to provide adequate breast milk for their infant’s nutritional needs.
Objectives:

1. 
   To determine the proportion of Mothers’ Own breast Milk (MOM) consumed by very low birth weight (VLBW) and extreme low birth weight (ELBW) infants in our neonatal unit.
   
2. 
   To explore potential maternal barriers to the provision of MOM to VLBW infants in our unit.
   

Methods:
We conducted a prospective cross sectional study of 104 dyads with a birth weight < 1500g, admitted to Groote Schuur Hospital neonatal unit between January and May of 2015. An interviewer administered a structured questionnaire to participating mothers within the first 3 days of their infant’s birth with a follow-up questionnaire when the infant had reached 14 days old. The folders of the infants were reviewed for gestational age, weight, mode of delivery, state of health, feeding status and the proportion of MOM given for Days 1, 7 and 14.
Results:

The mean birth weight of infants was 1123g (Range 630-1490g, SD 231g). Only three (2,9%) infants did not receive any MOM on Day 1. Most of the infants received < 25% of their enteral nutrition as MOM on Day 1 of life. Infants’ born to hypertensive mothers were more likely to receive this low proportion of MOM than non-hypertensive mothers (96% vs 80% p=0.016). These infants were also more likely to receive lower proportions (< 75% of enteral nutrition as MOM) on Day 7 (65% vs 36% p=0.002). Only 62% of all the infants in the study received a high proportion ( > 75% of their milk as MOM) by Day 14 of life. Infants of mothers’ younger than 30 consumed a high proportion (at least 75%) MOM of on Day 7 (71% vs 31% p=0.001 ) and on Day 14 (69% vs 47%). Infants born to mothers’ who had more than 3 living children were less likely to consume a high proportion of MOM on Day 7 (25% vs 66% p=0.011) and Day 14 (25% vs 67% p=0.009). There were no significant differences in MOM provision in patients delivered by vaginal or caesarean section. The proportion of mothers who reported having received breastfeeding counselling at admission was 62%, however MOM provision was not different to those who had reported no counselling at admission. MOM provision was not associated with income or distance of the hospital to patients’ home.

Conclusion:

Mother’s own breast milk consumption at 2 weeks was low despite high initiation rates. Maternal hypertension, age, family size was identified as potential factors influencing maternal breast milk provision in preterm infants. As breast-feeding counselling did not influence breast milk provision in this study, the effectiveness of current counselling methods may need to be examined and improved.

Approved by UCT Faculty of Health Sciences Human Research Ethics Committee HREC REF: 725/2014

Title: A review of the literature on health assessment training in nursing programs
Presenter: Lauren Rees


Background to study:

The University of Cape Town (UCT) Post Graduate Diploma in Critical Care Child and Child Nursing Science has trained professional nurses over the past decade to conduct full health assessments of children within a family-centered paradigm. Health assessment training has been central to nursing education curricula worldwide for many decades but its effectiveness has been questioned.

Aim:

To review the international literature on the effectiveness of health assessment training in nursing programs.

Methods:

A scope search of selected medical databases using pre-specified selection criteria will be performed. A narrative summary of the included studies will be undertaken.

Conclusion:

A summary of the designs and characteristics of evaluation studies of health assessment training in nursing programs worldwide will be provided for a better understanding of the factors that promote effectiveness. The review will guide the design of a proposed evaluation of the health assessment training component of the UCT Post-Graduate Diploma programme in Critical Care Child and Child Nursing Science.