Prevalence of comorbid disease and associated risk factors among homeless people living in temporary shelters during the COVID-19 lockdown in Tshwane, South Africa.

BACKGROUND: People experiencing homelessness are among the most socially and medically vulnerable populations. OBJECTIVES: To assess the prevalence of comorbid disease and associated risk factors among homeless people admitted to temporary shelters in the City of Tshwane during levels 4 and 5 of the COVID-19 national lockdown in South Africa. METHODS: A descriptive cross-sectional study design was used. The sample was drawn from secondary data on all individuals placed in temporary shelters constructed by Tshwane during levels 4 and 5 of the COVID-19 lockdown (26 March - 31 May 2020). Descriptive statistics were used to summarise data, and a multivariable logistic regression model was applied to determine factors associated with comorbid disease. RESULTS: The overall prevalence of comorbid disease among homeless people in temporary shelters in Tshwane was 28.8% (95% confidence interval (CI) 26.9 - 30.8). There was no significant difference in the prevalence of comorbid disease by illicit substance use (29.9% for users v. 29.5% for non-users; p=0.871). In adjusted analyses, being South African (adjusted odds ratio (aOR) 2.06; 95% CI 1.10 - 3.88; p=0.024), being female (aOR 3.73; 95% CI 1.85 - 7.53; p<0.001), being black (aOR 3.43; 95% CI 1.12 - 10.54; p=0.031) or white (aOR 6.11; 95% CI 1.55 - 24.0; p=0.01), and injecting substances (aOR 1.68; 95% CI 1.19 - 2.37; p=0.003) were significantly associated with having comorbid disease. CONCLUSION: The study found a 28.8% prevalence of comorbid disease among homeless people placed in temporary shelters in Tshwane. In adjusted analysis, being South African, being female, black and white race, and injecting substances were associated with having comorbid disease. Strengthening of public health interventions such as needle and syringe exchange programmes, family planning and access to primary care with health education could improve the healthcare of people experiencing homelessness.

Cochrane Corner: The use of anticoagulants in patients hospitalised with COVID-19.

Background: In this Cochrane Corner, we highlight the main findings of a Cochrane Review by Flumignan et al. entitled 'Anticoagulants for people hospitalised with COVID-19' and discuss the implications of these findings for research and practice in South Africa. In particular, we underscore the need for additional, high-quality, randomised controlled trials comparing different intensities of anticoagulation in patients with COVID-19 illness. Individuals in the intensive care unit and those hospitalised with another illness who are incidentally found to be infected with SARS-CoV-2 should still only be treated with prophylactic-dose low-molecular-weight heparin. Contributions of the study: This Cochrane Corner summarises findings in a recent systematic review on the use of anticoagulation in people hospitalised with COVID-19, and provides insights on the implications of these findings for implementation by clinicians in South Africa. It highlights the need for clinicians to balance the benefits and harms of providing an anticoagulant, while considering the patients underlying risk for bleeding and thromboembolism.

Factors that influence parental and caregiver acceptance of routine childhood vaccination: Summary of a qualitative evidence synthesis.

We summarise a Cochrane review of qualitative evidence that explored parents' views and practices around routine childhood vaccination, and provide implications for research and practice that are relevant to the South African (SA) context. Many public health interventions to encourage vaccination are informed by an assumption that vaccine hesitancy is due to a lack of knowledge or irrational forms of thinking. The findings from this review suggest that childhood vaccination views and practices are complex social processes that are shaped by multiple factors and carry a variety of meanings. As such, we suggest that biomedical approaches must be supplemented by more nuanced and sociopolitically informed strategies for enhancing and sustaining childhood vaccination practices in SA.

Factors predicting 6-month retention among people with opioid use disorders accessing outpatient methadone maintenance therapy in Tshwane, South Africa.

BACKGROUND: In South Africa (SA), increasing illicit opioid use and associated health challenges can be managed with opioid substitution therapy (OST), such as methadone, if the recommended dose and duration of use are prescribed. The Community Oriented Substance Use Programme (COSUP) provides free methadone to patients with opioid use disorder in Tshwane, SA, on need-based criteria. OBJECTIVES: To determine selected sociodemographic and substance use treatment factors associated with retention for at least 6 months among participants receiving methadone as part of OST in COSUP. METHODS: This was a retrospective cohort study using secondary data of patients treated with methadone at 8 COSUP sites. The factors associated with at least 6 months' retention for 575 participants from December 2016 to September 2018 were analysed. RESULTS: There were 91.3% males, 86.4% South Africans and 85.9% black Africans, with a median age of 30 years. At baseline, the majority were injecting heroin (55.5%) and were provided with free methadone (59.3%). The median dose of methadone at 6 months or on leaving the programme was 20 mg; 38.4% of participants were retained for at least 6 months. Of those not retained, the median duration on methadone was 56 days, whereas for those retained for at least 6 months, the median number of days on methadone were 254. After adjusting for sex and age, participants receiving methadone doses <50 mg had lower odds of being retained (0 - 20 mg: adjusted odds ratio (aOR) 0.25; p=0.002; 95% confidence interval (CI) 0.10 - 0.61; >20 - 40 mg: aOR 0.20; p<0.001; 95% CI 0.08 - 0.49) than those administered ≥50 mg. Participants who received free methadone had 3.75 the odds of being retained than those buying it themselves (p<0.001; 95% CI 2.47 - 5.70). Participants treated in the inner city had 5.19 the odds of being retained than those in a suburban setting (p<0.001; 95% CI 2.99 - 9.03). Compared with black African participants, white participants had 3.39 the odds of being retained (p=0.001; 95% CI 1.64 - 7.00). Injecting heroin users had 0.63 the odds of being retained (p=0.032; 95% CI 0.41 - 0.96). CONCLUSIONS: To maximise retention on OST, methadone should be free, with maintenance doses >50 mg. Reasons for lower retention among participants from periurban settings, those who inject and those from previously disadvantaged racial groups need to be explored, and findings used to inform programming.

The prevalence and characteristics of moderate- to high-risk regulated and unregulated substance use among patients admitted to four public hospitals in Tshwane, South Africa.

BACKGROUND: Alcohol, tobacco and unregulated substance use contributes to the global burden of disease. Admission to hospital provides an opportunity to screen patients for substance use and offer interventions. OBJECTIVES: To determine the prevalence and nature of substance use and treatment as well as interest in harm reduction among inpatients from four hospitals in the City of Tshwane, South Africa. METHODS: In a cross-sectional study, sociodemographic and substance use data were collected from 401 patients using the World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test. Demographic characteristics were analysed using descriptive statistics. Bivariate and multivariate analyses of moderate- to high-risk tobacco and unregulated substance use in relation to demographic characteristics were also done. RESULTS: Most patients were South African (88%) and black African (79%), over half were female (57%), and they were relatively young (median age 38 years). Most (82%) lived in formal housing. Over half (56%) had completed high school, and 33% were formally employed. Bivariate analysis found substance use-related admission to be higher where scores for tobacco and unregulated substance use were moderate to high (13% v. 0.3%, p<0.05). A notably higher (p<0.1) proportion of participants with no/low tobacco and unregulated substance use had completed high school, were employed and were cohabiting/married compared with those with moderate to high scores. Across the hospitals, 32% (129/401) of the participants had moderate- to high-risk use of at least one substance: tobacco (28%, 111/401), alcohol (10%, 40/401), cannabis (7%, 28/401), opioids (2%, 9/401) and sedatives (2%, 9/401). Of these 129 participants, 10% had accessed professional help, many (67%, 78/129) wanted to learn more about harm reduction, and most (84%, 108/129) said that they were willing to participate in a community-based harm reduction programme. Multivariate analysis found moderate- to high-risk tobacco and unregulated substance use to be positively associated with male sex (adjusted odds ratio (aOR) 7.9, 95% confidence interval (CI) 2.9 - 21.5), age <38 years (aOR 3.3, 95% CI 1.2 - 8.9), moderate- to high-risk alcohol use (aOR 3.1, 95% CI 1.1 - 8.4; p=0.027) and being admitted to Tshwane District Hospital (aOR 3.6, 95% CI 1.1 - 12.2). It was negatively associated with employment (aOR 0.2, 95% CI 0.1 - 0.6). CONCLUSIONS: Moderate- to high-risk substance use is an undetected, unattended comorbidity in the hospital setting in Tshwane, particularly among young, single, unemployed men. Clinicians should identify and respond to this need. Further research is required on the implementation of in-hospital substance use screening and treatment interventions.