Implementation of a PMTCT programme in a high HIV prevalence setting in Johannesburg, South Africa: 2002-2015.

BACKGROUND: Great strides have been made in decreasing paediatric human immunodeficiency virus (HIV) infections, especially in sub-Saharan Africa. In South Africa, new paediatric HIV infections decreased by 84% between 2009 and 2015. This achievement is a result of a strong political will and the rapid evolution of the country's prevention of mother-to-child transmission (PMTCT) guidelines. OBJECTIVES: In this paper we report on the implementation of a large PMTCT programme in Soweto, South Africa. METHODS: We reviewed routinely collected PMTCT data from 13 healthcare facilities, for the period 2002-2015. Antiretroviral therapy (ART) coverage among pregnant women living with HIV (PWLHIV) and the mother-to-child transmission (MTCT) rate at early infant diagnosis were evaluated. RESULTS: In total, 360 751 pregnant women attended the facilities during the review period, and the HIV prevalence remained high throughout at around 30%. The proportion of PWLHIV presenting with a known HIV status increased from 14.3% in 2009 when the indicator was first collected to 45% in 2015, p < 0.001. In 2006, less than 10% of the PWLHIV were initiated on ART, increasing to 88% by 2011. The MTCT rate decreased from 6.9% in 2007 to under 1% from 2013 to 2015, p < 0.001. CONCLUSION: The achievements in decreasing paediatric HIV infections have been hailed as one of the greatest public health achievements of our times. While there are inherent limitations with using routinely collected aggregate data, the Soweto data reflect progress made in the implementation of PMTCT programmes in South Africa. Progress with PMTCT has, however, not been accompanied by a decline in HIV prevalence among pregnant women.

The impact of differences in plasma glucose between glucose oxidase and hexokinase methods on estimated gestational diabetes mellitus prevalence.

We evaluated the extent of measurement discordance between glucose oxidase and hexokinase laboratory methods and the effect of this on estimated gestational diabetes mellitus (GDM) prevalence in a routine clinical setting. 592 consecutive urban African women were screened for GDM. Paired venous specimens were submitted to two independent calibrated laboratories that used either method to measure plasma glucose concentrations. World Health Organisation diagnostic criteria were applied. GDM prevalence determined by the glucose oxidase and hexokinase methods was 6.9% and 5.1% respectively. The overall GDM prevalence was 9%. Only 34% of GDM positive diagnoses were common to both laboratory methods. Bland Altman plots identified a bias of 0.2 mmol/l between laboratory methods. Plasma glucose concentrations measured by the glucose oxidase method were more platykurtic in distribution. Low diagnostic agreement between laboratory methods was further indicated by a Cohen's kappa of 0.48 (p < 0.001). Reports of GDM prevalence using either the glucose oxidase or hexokinase laboratory methods may not be truly interchangeable or directly comparable.

Accuracy of five plasma calibrated glucometers to screen for and diagnose gestational diabetes mellitus in a low resource clinic setting.

AIMS: We investigated the clinical and analytic accuracy of five plasma calibrated glucometers, the use of which is advocated by the World Health Organisation and the International Federation of Gynaecology and Obstetrics, to screen for and diagnose gestational diabetes mellitus (GDM) in low resource settings. METHODS: 592 consecutive black African women underwent a 75 g oral glucose tolerance test (OGTT) at 24-28 weeks gestation at an urban South African community health clinic. Capillary glucose was measured by one of five glucometer brands, each paired with a routine laboratory hexokinase method of plasma glucose measurement. The laboratory results served as the gold standard reference test for GDM diagnosis. World Health Organisation GDM diagnostic thresholds were applied to glucometer and laboratory results. RESULTS: Glucometer and laboratory determined GDM prevalence was 75/592 (12.7%) and 30/592 (5.1%) with an elevated fasting glucose diagnostic in 64/75 (85%) and 24/30 (80%) of cases respectively. The proportion of glucometer results fulfilling ISO 15197:2013 recommended analytic accuracy at fasting, 60, and 120 min of the OGTT was 92.4%, 49.8% and 61.5%, with Bland Altman method revealing a positive glucometer bias of 0.22 mmol/l (-0.69-1.12 mmol/l), 0.96 mmol/l (-0.65-2.56 mmol/l) and 0.73 mmol/l (-0.73-2.19 mmol/l) respectively. Only three of the glucometer brands evaluated fulfilled ISO 15197:2013 analytic accuracy requirements and this was only achieved at fasting. All glucometers tested were inaccurate at one and two hours of the OGTT. CONCLUSIONS: Not all glucometers may be suitable for GDM screening as only three were accurate compared to the reference test and then only at fasting of the OGTT. Importantly, laboratory fasting glucose was diagnostic of GDM in 80% of cases in this study population.

Reliability and validity of last menstrual period for gestational age estimation in a low-to-middle-income setting.

AIM: Gestational age estimation by ultrasonography is the gold standard for dating pregnancies. However, the availability of prenatal ultrasonography in low-to-middle-income countries is limited. This study aimed to assess the reliability and validity of last menstrual period (LMP) as a gestational age dating method among women in Johannesburg, South Africa. METHODS: A total of 741 pregnant women were enrolled into a longitudinal study (June 2013 to July 2016). Gestational age was determined by LMP and ultrasonography. Differences in ultrasound-based and LMP-based gestational age estimates were assessed according to the American College of Obstetrics and Gynecologists' guidelines and women were classified as having discrepant results or not. Multiple statistical analyses determined the level of agreement between the two methods and validity of LMP estimates. RESULTS: Compared to ultrasound, dating by LMP assessed gestational age as 0.2 days longer. Women with discrepant results were of significantly lower weight and household socioeconomic status than those without discrepancies. While there was a substantial agreement (k = 0.64; 95% confidence interval, CI: 0.54, 0.71, P < 0.001) between the two methods, LMP only had a 29.0% (95% CI: 14.2, 48.0) sensitivity in identifying late-term neonates and a 33.3% (95% CI: 4.33, 77.7) sensitivity in identifying post-term neonates. CONCLUSION: In the absence of ultrasound, LMP is a reliable alternative for gestational age dating during early pregnancy. However, it is not sensitive in identifying late- and post-term pregnancies and should not be relied upon to make clinical decisions regarding elective cesarean section or induction of labor for supposed prolonged pregnancies.

Trends in maternal deaths in HIV-infected women, on a background of changing HIV management guidelines in South Africa: 1997 to 2015.

INTRODUCTION: As work begins towards the Sustainable Development Goal target of reducing the global maternal mortality ratio (MMR) to less than 70 deaths per 100,000 live births by 2030, much needs to be done in ending preventable maternal deaths. After 1990, South Africa experienced a reversal of gains in decreasing maternal mortality, with an increase in HIV-related maternal deaths. In this study, we assessed trends in maternal mortality in HIV-infected women, on a background of an evolving HIV care programme. METHODS: This was a cross-sectional, retrospective record review of maternal deaths in the obstetrics unit at Chris Hani Baragwanath Academic Hospital, in Johannesburg, South Africa, a referral hospital in a high HIV prevalence setting where the prevalence among pregnant women has plateaued around 29.0% for the past decade. Trends in HIV diagnosis and management in pregnancy, and causes of maternal deaths in HIV-infected women were analysed over different time periods (1997 to 2003, 2004 to 2009, 2010 to 2012, and 2013 to 2015) reflecting major guideline changes. RESULTS: From January 1997 to December 2015, there were 692 maternal deaths in the obstetrics unit. Of the 490 (70.8%) maternal deaths with a documented HIV status, 335 (68.4%) were HIV-infected. A Chi-squared test for trends showed that the institutional MMR (iMMR) in women known to be HIV-infected peaked in the period 2004 to 2009 at 380 (95% CI 319 to 446) per 100,000 live births, with a decline to 267 (95% CI 198 to 353) in 2013 to 2015, p = 0.049. This decrease coincided with changes in the South African HIV management guidelines, mainly increased availability of antiretroviral therapy (ART). Non-pregnancy related infections were the leading cause of death throughout the review period, accounting for 61.5% (206/335) of deaths. Only 23.3% (78/335) of the women who died were on ART at the time of death, this in the context of advanced immune suppression and an overall median CD4 count of 136 cells/µl (interquartile ranges (IQR) 45 to 301). CONCLUSION: In this 19-year review of maternal deaths in Johannesburg, South Africa, there was evidence of a decrease in the iMMR among HIV-infected women, but it remains unacceptably high. Efforts to address drivers of mortality and barriers to accessing ART need to be accelerated if we are to see substantial decreases in maternal mortality.

Submicron Matrices Embedded in a Polymeric Caplet for Extended Intravaginal Delivery of Zidovudine.

In this study, an intravaginal delivery system able to deliver an anti-HIV-1 agent for the purpose of potentially reducing HIV-1 transmission acting over an extended duration was successfully formulated. This delivery system was a composite polymeric caplet comprising zidovudine-loaded polyethylene glycol enclatherated pectin-mucin submicron matrices embedded within a poly (D,L-lactide), magnesium stearate, Kollidon® SR, and Carbopol® 974P NF-based polymeric caplet matrix. A three-factor and three-level Box-Behnken statistical design was utilized to optimize the polymeric caplet. The optimized directly compressed composite polymeric caplet hardness was 22.1 ± 0.3 N and the matrix resilience was 62.4 ± 0.6%. The swelling- and diffusion-controlled fractional zidovudine (AZT) release from the optimized caplet was 0.74 ± 0.01 in simulated vaginal fluid (SVF), which increased to 0.81 ± 0.21 in phosphate-buffered saline (PBS) simulating seminal fluid, over 30 days. Caplet matrix swelling was directly related to the percentage Carbopol 974P NF composition. An intravaginal system for AZT delivery was tested in the pig model over 28 days. X-ray analysis depicted delivery system swelling with matrix contrast fading over time as vaginal fluid permeated the matrix core. Plasma, vaginal fluid swab eluates, and tissue AZT concentrations were measured by gradient ultra-performance liquid chromatography (UPLC)-tandem photodiode array detection. Vaginal tissue and vaginal fluid swab eluate AZT concentrations remained above effective levels over 28 days and were higher than plasma AZT concentrations, availing a system with reduced systemic toxicity and more effective inhibition of viral replication at the site of entry.

A systematic review of maternal near miss and mortality due to postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) is the principal direct cause of maternal mortality worldwide. Analysis of maternal near miss could increase understanding of survival among women with life-threatening PPH. OBJECTIVES: To determine the near-miss ratio and maternal mortality index for PPH globally. SEARCH STRATEGY: A prevalence systematic review was conducted of English-language articles published from 1995 to 2014. Suitable articles were identified from the Scopus, PubMed, Embase, and Grey Literature databases. The main search terms used were "maternal near-miss" and "severe acute maternal morbidity." SELECTION CRITERIA: Near-miss studies and audits describing the severe maternal outcome rate for PPH were included. DATA COLLECTION AND ANALYSIS: Data were extracted from eligible publications. Quantitative analysis and narrative synthesis were used. MAIN RESULTS: For 26 included studies, the median near-miss ratio for PPH was 3 per 1000 live births. The mortality index for PPH was 6.6% (range 0.0%-40.7%). The mortality index was highest in low-income countries and lower middle-income countries. Overall, PPH was the most frequent contributor to obstetric hemorrhage, with atonic uterus identified as the main cause. CONCLUSIONS: Women in low-income countries and lower middle-income countries have an increased likelihood of severe PPH and of dying from PPH-related consequences.

Neutrophil gelatinase-associated lipocalin as a diagnostic marker of acute kidney injury in pre-eclampsia.

AIM: Neutrophil gelatinase-associated lipocalin (NGAL) is an emerging biomarker for early diagnosis of acute kidney injury (AKI). This study investigated the use of urinary NGAL as a marker of AKI in women with pre-eclampsia. METHODS: Urine and serum samples were collected over 24 h from 78 healthy and 109 pre-eclamptic women, with baseline samples taken at admission to the maternity unit; NGAL was assayed in serial urine samples. RESULTS: Baseline neutrophil gelatinase-associated lipocalin did not differ significantly between women who were healthy, those with pre-eclampsia, or with AKI (P = 0.55 for trend). When the pre-eclamptic group was divided into those with eclampsia (median, 60.5 ng/mL; IQR, 23.4-173 ng/mL; n = 19), uncomplicated pre-eclampsia (median, 18.8 ng/mL; IQR, 7.5-52.8 ng/mL; n = 48; P < 0.05 vs eclampsia), imminent eclampsia (median, 30.7 ng/mL; IQR, 13.9-49.3 ng/mL; n = 22) and pre-eclampsia with acute kidney injury (median, 60.3 ng/mL; IQR, 23.5-159 ng/mL, n = 14), however, NGAL level did differ. On multivariate regression analysis, the only significant correlate of NGAL level was the presence of eclampsia (beta = 0.22, P < 0.05). On receiver operating characteristic curve analysis, baseline NGAL did not discriminate between subjects with or without AKI (area under the curve, 0.61; 95%CI: 0.43-0.78; P = 0.12). CONCLUSION: Neutrophil gelatinase-associated lipocalin level at baseline and over a 24-h period does not provide a suitable diagnostic test for AKI in pre-eclamptic subjects.

Preventing deaths from complications of labour and delivery.

The process of labour and delivery remains an unnecessary and preventable cause of death of women and babies around the world. Although the rates of maternal and perinatal death are declining, there are large disparities between rich and poor countries, and sub-Saharan Africa has not seen the scale of decline as seen elsewhere. In many areas, maternity services remain sparse and under-equipped, with insufficient and poorly trained staff. Priorities for reducing the mortality burden are provision of safe caesarean section, prevention of sepsis and appropriate care of women in labour in line with the current best practices, appropriately and affordably delivered. A concern is that large-scale recourse to caesarean delivery has its own dangers and may present new dominant causes for maternal mortality. An area of current neglect is newborn care. However, innovative training methods and appropriate technologies offer opportunities for affordable and effective newborn resuscitation and follow-up management in low-income settings.

Causes and avoidable factors in maternal death due to cesarean-related hemorrhage in South Africa.

OBJECTIVE: To describe risk factors, clinical events, and avoidable factors in cases of maternal death due to bleeding during and after cesarean delivery. METHODS: A retrospective study was undertaken of the clinical records of women who delivered in seven hospitals in Johannesburg, South Africa, between January 2013 and December 2014. Maternal deaths due to cesarean-related hemorrhage during or within 42days of cesarean delivery at 24weeks or more were selected. Case records were audited using quantitative techniques to determine the events leading up to death. RESULTS: There were 123 251 deliveries and 17 maternal deaths due to bleeding during or after cesarean (3.2 deaths per 10 000 deliveries). Risk factors included previous cesarean delivery, preoperative anemia, and placental abruption. Uterine atony and surgical trauma were the main causes of bleeding. Five (29%) women died before the cause of bleeding was found. Avoidable factors included delays in the recognition and management of shock. Thirteen (76%) women died within 48hours of the cesarean procedure. CONCLUSION: Deaths due to bleeding during and after cesarean have multifactorial causation. Maternal healthcare systems must be strengthened, with attention to the knowledge and skills of health workers. This requires increased clinical vigilance, a rapid effective response to obstetric hemorrhage and shock, and overall health system strengthening.

A study of fresh stillbirths weighing 2500g or more at three academic hospitals in South Africa.

OBJECTIVE: To determine the frequency of fresh stillbirths weighing 2500g or more, to assess the risk factors and direct obstetric causes, and to describe avoidable factors in terms of substandard intrapartum management. METHODS: A prospective, cross-sectional, descriptive study was conducted at three obstetric teaching units in Johannesburg, South Africa. Data were consecutively collected for 6months at each of the hospitals, leading to an 18-month data collection period from May 1, 2011, to October 31, 2012. The study population was hospital-born, singleton fresh stillbirths weighing 2500g or more. RESULTS: Overall, 52 fresh stillbirths were eligible. Intrapartum catastrophic events were recorded in 30 (58%) cases (16 placental abruption, 7 cord prolapse, 4 ruptured uterus, and 3 entrapment of aftercoming head during breech delivery). Intrauterine fetal death was recorded on arrival at hospital in 15 (29%) cases. Twenty-two (42%) women underwent cardiotocography monitoring; 15 (29%) had no fetal monitoring. Among 25 cases in which the emergency was recognized, the median time from recognition of emergency to delivery was 182minutes (range 13-360). CONCLUSION: There appears to be a failure to detect or respond to evidence of fetal distress even in facilities with skilled staff and available resources.

Serotype-Specific Cell-Mediated Immunity Associated With Clearance of Homotypic Group B Streptococcus Rectovaginal Colonization in Pregnant Women.

We investigated the association between group B Streptococcus (GBS) serotype-specific capsular polysaccharide cellular immunity, measured with enzyme-linked immunospot (ELISPOT) interferon γ release assay at 20 weeks gestation in pregnant women, and its effect on rectovaginal serotype-specific GBS colonization up to 37 weeks gestation. Among women colonized by serotype III at enrollment, interferon γ ELISPOT positivity was more common in those in whom colonization was cleared (44.4%) than in those in whom colonization persisted (7.4%; P = .008), with a similar trend observed for serotype Ia. Presence of serotype-specific capsular polysaccharide cell-mediated immunity contributes to the clearance of GBS rectovaginal colonization.

Poly(ethylene glycol) enclatherated pectin-mucin submicron matrices for intravaginal anti-HIV-1 drug delivery.

This paper explores the potential of polyethylene glycol enclatherated pectin-mucin (PEG-encl-PEC:MUC) submicron matrices (SMMs) as an intravaginal drug delivery system capable of delivering an anti-HIV-1 agent (zidovudine; AZT) over a prolonged duration. A three factor and three level (3(3)) Box-Behnken statistical design was employed to optimize the SMMs. Optimized PEG-encl-PEC:MUC SMMs prepared as a stable W/O emulsion (determined by the degree of reversible colloidal phenomena) were spherical with a mean particle size of 270.6 ± 5.533 nm and mean zeta potential of -34.4 ± 0.539 mV. The microencapsulation of AZT and the hydrogen bonding mediated shielding of AZT by SMMs was confirmed by Fourier Transform Infrared (FTIR) analysis. The thermochemical (differential scanning calorimetry and thermogravimetric analysis) data proposed that Ca(2+)-based macromolecular ionic crosslinking as well as the intermolecular interactions may be responsible for the thermal stability of the delivery system. The partially amorphous nature of drug-loaded SMMs, as confirmed by X-ray diffraction patterns, further strengthened the matricization of AZT into the pectin-mucin matrix. In vitro drug release studies from the SMMs showed approximately 91% zidovudine release in simulated vaginal fluid (SVF) and 94% in phosphate buffered saline (PBS) in 24h. The mean dissolution time (MDT) of zidovudine from the SMMs was 5.974 h. The attainment of required dimensional structure and drug release profiles from SMMs highlights the potential of their inclusion into a secondary carrier system for extended and controlled intravaginal stay.

Infant feeding knowledge, perceptions and practices among women with and without HIV in Johannesburg, South Africa: a survey in healthcare facilities.

BACKGROUND: South Africa has a history of low breastfeeding rates among women with and without Human Immunodeficiency Virus (HIV). In this study, we assessed infant feeding knowledge, perceptions and practices among pregnant and postpartum women with and without HIV, in the context of changes in infant feeding and Prevention of Mother-to-Child Transmission of HIV (PMTCT) guidelines. METHODS: This was a cross-sectional survey conducted from April 2014 to March 2015 in 10 healthcare facilities in Johannesburg, South Africa. A total of 190 pregnant and 180 postpartum women (74 and 67, respectively, were HIV positive) were interviewed using a semi-structured questionnaire. Multiple regression analyses assessed factors associated with an intention to exclusively breastfeed, and exclusive breastfeeding of infants less than six months of age. RESULTS: Women with HIV had better overall knowledge on safe infant feeding practices, both in general and in the context of HIV infection. There were however gaps in knowledge among women with and without HIV. Information from healthcare facilities was the main source of information for all groups of women in the study. A greater percentage of women without HIV 80.9% (93/115), reported an intention to exclusively breastfeed, compared to 64.9% (48/74) of women with HIV, p = 0.014. Not having HIV was positively associated with a reported intention to breastfeed, Adjusted Odds Ratio (AOR) 3.60, 95% CI 1.50, 8.62. Other factors associated with a reported intention to exclusively breastfeed were prior breastfeeding experience and higher knowledge scores on safe infant feeding practices in the context of HIV infection. Among postpartum women, higher scores on general knowledge of safe infant feeding practices were positively associated with reported exclusive breastfeeding, AOR 2.18, 95% CI 1.52, 3.12. Most women perceived that it was difficult to exclusively breastfeed and that cultural factors were a barrier to exclusive breastfeeding. CONCLUSIONS: While a greater proportion of women are electing to breastfeed, HIV infection and cultural factors remain an important influence on safe infant feeding practices. Healthcare workers are the main source of information, and highlight the need for accurate and consistent messaging for both women with and without HIV.

Scaling Up Family Planning to Reduce Maternal and Child Mortality: The Potential Costs and Benefits of Modern Contraceptive Use in South Africa.

INTRODUCTION: Family planning contributes significantly to the prevention of maternal and child mortality. However, many women still do not use modern contraception and the numbers of unintended pregnancies, abortions and subsequent deaths are high. In this paper, we estimate the service delivery costs of scaling up modern contraception, and the potential impact on maternal, newborn and child survival in South Africa. METHODS: The Family Planning model in Spectrum was used to project the impact of modern contraception on pregnancies, abortions and births in South Africa (2015-2030). The contraceptive prevalence rate (CPR) was increased annually by 0.68 percentage points. The Lives Saved Tool was used to estimate maternal and child deaths, with coverage of essential maternal and child health interventions increasing by 5% annually. A scenario analysis was done to test impacts when: the change in CPR was 0.1% annually; and intervention coverage increased linearly to 99% in 2030. RESULTS: If CPR increased by 0.68% annually, the number of pregnancies would reduce from 1.3 million in 2014 to one million in 2030. Unintended pregnancies, abortions and births decrease by approximately 20%. Family planning can avert approximately 7,000 newborn and child and 600 maternal deaths. The total annual costs of providing modern contraception in 2030 are estimated to be US$33 million and the cost per user of modern contraception is US$7 per year. The incremental cost per life year gained is US$40 for children and US$1,000 for mothers. CONCLUSION: Maternal and child mortality remain high in South Africa, and scaling up family planning together with optimal maternal, newborn and child care is crucial. A huge impact can be made on maternal and child mortality, with a minimal investment per user of modern contraception.

Increased risk for group B Streptococcus sepsis in young infants exposed to HIV, Soweto, South Africa, 2004-2008(1).

Although group B Streptococcus (GBS) is a leading cause of severe invasive disease in young infants worldwide, epidemiologic data and knowledge about risk factors for the disease are lacking from low- to middle-income countries. To determine the epidemiology of invasive GBS disease among young infants in a setting with high maternal HIV infection, we conducted hospital-based surveillance during 2004-2008 in Soweto, South Africa. Overall GBS incidence was 2.72 cases/1,000 live births (1.50 and 1.22, respectively, among infants with early-onset disease [EOD] and late-onset [LOD] disease). Risk for EOD and LOD was higher for HIV-exposed than HIV-unexposed infants. GBS serotypes Ia and III accounted for 84.0% of cases, and 16.9% of infected infants died. We estimate that use of trivalent GBS vaccine (serotypes Ia, Ib, and III) could prevent 2,105 invasive GBS cases and 278 deaths annually among infants in South Africa; therefore, vaccination of all pregnant women in this country should be explored.

Serotype-specific acquisition and loss of group B streptococcus recto-vaginal colonization in late pregnancy.

BACKGROUND: Maternal recto-vaginal colonization with Group B Streptococcus (GBS) and consequent vertical transmission to the newborn predisposes neonates to early-onset invasive GBS disease. This study aimed to determine the acquisition and loss of serotype-specific recto-vaginal GBS colonization from 20-37+ weeks of gestational age. METHODS: Vaginal and rectal swabs were collected from HIV-uninfected women at 20-25 weeks of gestation age and at 5-6 weekly intervals thereafter. Swabs were cultured for GBS and isolates were serotyped by latex agglutination. Serologically non-typable isolates and pilus islands were characterized by PCR. RESULTS: The prevalence of recto-vaginal GBS colonization was 33.0%, 32.7%, 28.7% and 28.4% at 20-25 weeks, 26-30 weeks, 31-35 weeks and 37+ weeks of gestational age, respectively. The most common identified serotypes were Ia (39.2%), III (32.8%) and V (12.4%). Of 507 participants who completed all four study visits, the cumulative overall recto-vaginal acquisition rate of new serotypes during the study was 27.9%, including 11.2%, 8.2% and 4.3% for serotypes Ia, III and V, respectively. Comparing the common colonizing serotypes, serotype III was more likely to be associated with persistent colonization throughout the study (29%) than Ia (18%; p = 0.045) or V (6%; p = 0.002). The median duration of recto-vaginal GBS colonization for serotype III was 6.35 weeks, which was longer than other serotypes. Pilus island proteins were detected in all GBS isolates and their subtype distribution was associated with specific serotypes. CONCLUSION: South African pregnant women have a high prevalence of GBS recto-vaginal colonization from 20 weeks of gestational age onwards, including high GBS acquisition rates in the last pregnancy-trimesters. There are differences in specific-serotype colonization patterns during pregnancy.

Exploration of the biomacromolecular interactions of an interpenetrating proteo-saccharide hydrogel network at the mucosal interface.

The relationship between mucin (MUC) and pectin (PEC) was explored in an attempt to understand the biomacromolecular interactions that occur at mucosal surfaces when mucus membranes are exposed to PEC-based materials. These interactions were explored through techniques, such as attenuated total reflection Fourier transform infrared (ATR-FTIR) spectroscopy, SEM imagery of lyophilized MUC-PEC blends, thermodynamic analysis, rheology investigations, and in silico static lattice atomistic simulations using a molecular mechanics energy relationships (MMER) approach. Three types of PEC that had different degrees of esterification and degrees of amidation were investigated at different MUC-PEC mass ratios (1:0, 1:1, 1:4, 1:9, and 0:1). The effect PEG 400 and Ca(2 +) in the MUC-PEC interactions were also studied. ATR-FTIR spectroscopy revealed broadening and strengthening of FTIR peaks at 3363 cm(-1) and between 3000-3650 cm(-1) due to stretching vibrations of the -OH, -COOH groups on MUC and PEC as well as the -N-H group on MUC. This suggested significant intra- and inter-molecular H-bonding. Morphologically, MUC-rich scaffolds were porous, thin, and multidirectional compared with the smooth, rigid, and unidirectional PEC-rich scaffolds. The Flory-Huggins interaction parameter (χ12 ) for all MUC-PEC mass ratios was negative, thus confirming MUC-PEC miscibility and interactions. UV absorbance increased with increasing relative concentration of PEC in the aqueous MUC-PEC dispersions. Furthermore, rheology investigations demonstrated synergistic enhancement in viscosity (η) and dynamic moduli upon the addition of PEG 400 and Ca(2 +) . MMER analysis revealed several key MUC-PEC interactions that corroborated well with the experimental data. Notably, higher esterification and larger mass ratios of PEC yielded greater MUC-PEC interactions.

Evaluation of Trans-Vag broth, colistin-nalidixic agar, and CHROMagar StrepB for detection of group B Streptococcus in vaginal and rectal swabs from pregnant women in South Africa.

Maternal vaginal colonization with group B streptococcus (GBS) is a major risk factor for invasive GBS infection in newborns. The CDC-recommended method for detecting GBS colonization is to culture vaginal and rectal swabs in a selective broth followed by subculture on blood agar or a selective medium. A high incidence of antimicrobial resistance in the fecal microflora can compromise the recovery of GBS from the selective broth. Here, we compared CHROMagar StrepB (CA), Columbia colistin-nalidixic agar (CNA), and Trans-Vag selective broth enrichment for the isolation of GBS from 130 vaginal and 130 rectal swabs from pregnant women. The swabs were randomized for plating first on either CA or CNA, and they then were inoculated in Trans-Vag broth. GBS was cultured from 37.7% of the vaginal swabs and 33.1% of the rectal swabs. There were no differences in the detection rates for the vaginal swabs between CA (31.5%), CNA (26.2%), and the selective broth (30.0%). The sensitivities in relation to a composite score were 83.7%, 69.4%, and 79.6%, respectively. However, recovery of GBS from the rectal swabs was significantly higher from CA (29.2%; P<0.0001) and CNA (23.8%; P=0.002) than from the selective broth (9.2%). The sensitivities were 88.4%, 72.1%, and 27.9%, respectively. The order of plating on the solid medium was significant (P=0.003), with GBS detection rates of 30.8% and 24.6% when swabs were plated first and second, respectively. These findings show that a selective broth is not suitable for the recovery of GBS from rectal swabs in settings such as ours, due to masking of the GBS colonies by persistent microflora.