National HIV surveillance in South Africa--1993-1995.

OBJECTIVE: To determine the point prevalence of HIV infection by serological examination which, performed consistently over several years, serves to monitor the distribution and trend of the HIV epidemic in South Africa. DESIGN: Annual cross-sectional surveys conducted nationally, in October/November. SETTING: South Africa, including areas that used to be known as self-governing and independent national states. SUBJECTS: Pregnant women in the age group 15-49 years who attend antenatal clinic services provided by the public health services. OUTCOME MEASURES: HIV positivity as determined serologically. RESULTS: The rising trend found previously continues: HIV positivity in South Africa was found to be 4.25% in 1993, 7.57% in 1994 and 10.44% in 1995. In 1995 the highest rate was recorded in KwaZulu-Natal (18.23%) and the lowest in the Western Cape (1.66%). On the basis of certain assumptions it is estimated that these rates are indicative of 1.7 million sexually active adults having been infected with HIV by October/November 1995, plus a cumulative total of 40,000 infants. Women in their 20s had the highest age-specific prevalence rates, viz. 13.12% (20-24 years) and 11.03% (25-29 years). HIV positivity in pregnant teenagers was 9.5%. CONCLUSIONS: The HIV epidemic is firmly established in South Africa with a wide variation in provincial prevalence rates. Of particular public health significance is the finding of a high and rising prevalence rate in pregnant teenagers. The observed prevalence rate for 1995 is lower than expected, giving rise to guarded hope that provinces with the highest recorded rates are moving away from the exponential growth found hitherto.

The South African HIV epidemic, reflected by nine provincial epidemics, 1990-1996.

OBJECTIVES: To determine by serological examination the annual point prevalence rates of infection with the human immunodeficiency virus (HIV) in representative samples of subjects in the nine provinces of South Africa, 1990-1996. DESIGN: Annual cross-sectional point prevalence surveys conducted in October/November of each year. SETTING: South Africa, including areas that used to be known as self-governing and independent National States. SUBJECTS: Pregnant women in the age group 15-49 years who attend antenatal clinic services provided by the public health services, and who act as an indicator group of the HIV epidemic among the heterosexually active population. OUTCOME MEASURES: HIV positivity as determined serologically; done consistently over several years, this serves to monitor the distribution and trend of the HIV epidemic in each of the nine provinces of South Africa. RESULTS: Empirical data gained from seven annual, consecutive countrywide surveys demonstrate a wide geographical variation in the point prevalence rates of HIV infection. In October/November 1996 the point prevalence rates (%) were as follows: Western Cape 3.09, Northern Cape 6.57, Northern Province 7.96, Eastern Cape 8.10, Gauteng 15.49, Mpumalanga 15.77, Free State 17.49, KwaZulu-Natal 19.90 and North West 25.13. The weighted national average was 14.17%. There are indications that some of the provinces (KwaZulu-Natal and possibly Mpumalanga) might have passed a point of inflection suggesting deceleration in their specific rates of increase. These results are, however, counterbalanced by the exponential growth still being experienced in provinces with large populations such as Gauteng and the Eastern Cape. It is concluded that the net effect of these divergent trends currently affects the national figure only marginally. A major deflection from the exponential growth patterns seen hitherto can be anticipated only once all or most of the highly populated provinces have traversed their respective points of inflection. The exponential model significantly explains the HIV epidemics in the provinces. The combination of these provincial epidemics describes the initial exponential phase of the epidemic.

A population-based seroprevalence study in South Africa as a tool in the polio eradication initiative.

A seroprevalence study for poliomyelitis was carried out on a sample of sera from a serum bank used for a vitamin A study. Vaccination coverage was satisfactory (80% or more) in five of nine provinces, although a prevalence of antibody to polio of 80% or more was found in all provinces. Serologic immunity (i.e., the prevalence of neutralizing antibodies) exceeded vaccination coverage, suggesting secondary spread of vaccine virus. However, whether or not water was supplied through a piped system was not associated with secondary spread of vaccine virus to nonvaccinated children. Seroprevalence studies are a valuable adjunct to acute flaccid paralysis surveillance, which is the standard surveillance instrument for the poliomyelitis eradication initiative. The use of available and suitable serum banks for seroprevalence investigations is a relatively cheap monitoring option that can yield very valuable information for the eradication initiative.

National HIV surveillance--South Africa, 1990-1992.

The findings of three annual surveys of women attending antenatal clinics (at the end of 1990, 1991 and 1992) are presented here. These surveys form part of the National HIV Surveillance Programme. This programme is probably the most useful means of monitoring the trend and distribution of the epidemic. In all strata, a consistent rise in the HIV prevalence rate was found; it doubled almost every 12 months. The point prevalence rate in antenatal clinic attenders in South Africa increased from 0.76% in 1990 to 1.49% in 1991 and 2.69% in 1992. The prevalence rate was found to vary widely geographically: Natal/KwaZulu formed the spearhead of the epidemic with a 4.77% rate of HIV infection in 1992. Venda and the Cape appeared to be the least affected with rates of 0.64% and 0.66% respectively.

Poliomyelitis outbreak in Natal/KwaZulu, South Africa, 1987-1988. 2. Immunity aspects.

An extensive poliomyelitis outbreak due to type 1 poliovirus took place in Natal/KwaZulu, South Africa, in 1987-1988, causing 412 paralytic cases. This epidemic differed from a previously described outbreak in Gazankulu, South Africa, in 1982 in that it occurred against a background of relatively good immunity. Thus, only 12% of patients lacked antibodies to types 2 and 3, indicating lack of previous immunization, and 76% of healthy children sampled in the epidemic area had serological immunity to all 3 types of poliovirus. The occurrence of extensive outbreaks in relatively well-immunized communities emphasizes the need to maximize herd immunity and reduce reservoirs of infection in the gut and in the environment, which can be achieved only with oral polio vaccine.

Poliomyelitis outbreak in Natal/KwaZulu, South Africa, 1987-1988. 1. Epidemiology.

An epidemic of type 1 poliomyelitis occurred in Natal/KwaZulu in the eastern part of South Africa between December 1987 and November 1988. 412 poliomyelitis cases were reported, of whom 74% were younger than 5 years. The case-fatality rate was 8%. It is suggested that massive floods, experienced in the area 2 months earlier, triggered the outbreak.

Maternal glycosylated haemoglobin values after delivery of large infants and unexplained stillbirths.

Glycosylated haemoglobin (Hb A1) values were estimated immediately after delivery in 29 patients who had given birth to a large infant, in 25 who had delivered a macerated stillborn infant, and in 31 controls matched for age and parity. No difference in mean Hb A1 values was found between mothers of normal-sized and of large infants. The mean Hb A1 level for the mothers who had delivered a macerated stillborn infant was higher than that for the control group (8,26% v. 7,65%). Although this was not statistically significant, there were 5 patients with a raised Hb A1 value and a normal glucose tolerance test result; this may suggest gestational diabetes.

Breast-feeding - evaluation of a health education programme.

A health education programme which had the objective of increasing the practice of breast-feeding is evaluated. Women provided with health education are shown to have greater knowledge of the advantages of breast-feeding but unchanged behaviour as regards breast-feeding practice. A plea is made for a nation-wide effort to promote breast-feeding.

Carbohydrate metabolism in twin pregnancy.

Carbohydrate metabolism was evaluated in 26 women with a twin pregnancy and 26 women with a singleton pregnancy. The groups were similar in respect of age, parity and gestational age. Each woman had an oral glucose tolerance test. No significant differences in venous blood sugar values or insulin responses were found between singleton and twin pregnancies.

Trichomonas infection in pregnancy--does it affect perinatal outcome?

Antenatal patients free of Trichomonas vaginalis vaginal infection were compared with infected patients, half of whom were treated and half left untreated. The treated group was given benzoylmetronidazole 50 ml (2 g metronidazole equivalent) as a single dose. The mode of treatment was found to be very palatable and highly effective. The birth weights and gestational age at delivery were similar in all three groups.

Serological diagnosis of syphilis in pregnancy. Experiences at King Edward VIII Hospital, Durban.

Three different serological screening tests for syphilis were performed at the 'booking' visit of 500 antenatal patients at the King Edward VIII Hospital, Durban. The prevalence of active syphilis was 7,4%. The rapid plasma reagent test not only had a high biological false-positive rate at 11,8%, but also failed to detect 18,9% of the 37 patients diagnosed as having syphilis by means of the IgM-specific fluorescent treponemal antibody absorption (FTA-ABS) test. The Treponema pallidum haemagglutination (TPHA) test had a similarly high biological false-positive rate of 15,8%, but did not miss any of the 37 cases of active syphilis. The TPHA test is therefore advocated for screening patients for syphilis.

Breast-feeding practices in a Black community.

Our study was designed to obtain information about the prevalence of breast-feeding among rural and urban Blacks, to determine whether the number of women providing early supplementary feeding has increased over a 4-year period, and to discover groups at particular risk of failure to breast-feed optimally. Women attending child health clinics were interviewed. Over 95% had commenced breast-feeding, but only 50% were still doing so after 5--8 weeks. Women uncertain of whether or not to breast-feed and those unsuccessful on a previous occasion are as likely to commence breast-feeding as are other groups, but are likely to introduce early supplementation. Improvements in hospital and clinic practice as regards a greater emphasis on health education, early suckling and the avoidance of supplementary feeding in neonates may have contributed to the slight improvement in breast-feeding practices seen over the 4-year period studied.

The 'unbooked' mother at King Edward VIII Hospital, Durban.

'Unbooked' status is associated with excessive perinatal mortality at King Edward VIII Hospital, Durban. A survey was therefore conducted to characterize the unbooked mother and to identify important factors contributing to her unbooked status. The unbooked mother was found to come more frequently from a background of unstable relationships and to have poor financial and emotional support. Unwanted babies and inadequate parenting arrangements were more frequent in this group. One factor contributing to unbooked status was the inaccessibility of peripheral services, which too often also offer a low standard of care. Another was the lack of commitment of private practitioners (visited 67% of the study group) to a concept of antenatal care which is cumulative and includes the planning of the timing, mode and place of delivery. Factors which did not influence the booking status of the mother included the use of traditional healers (Umthandazo and Nyanga) and the incidence of previous operative deliveries. Various recommendations arising from these findings are made.

Intrauterine-pressure studies in African nulliparae: normal labour progress.

Uterine activity was measured in 29 nulliparous African women, who were in the active phase of spontaneous labour, and who were delivered vaginally without supplementary oxytocin. A fluid-filled intrauterine catheter, an external strain gauge and a pressure-curve integrator were used to quantitate uterine activity. The rate of dilatation of the cervix from entry to the study to full dilatation of the cervix was greater than 1 cm/h; this constituted normal labour progress. In nulliparous African women the minimum level of uterine activity likely to be associated with a cervical dilatation rate of 1 cm/h was 1200 kPas/15 min and the median uterine activity level in the active phase of normal labour was 1824 kPas/15 min.

Intrauterine-pressure studies in African nulliparae: delay, delivery and disproportion.

Uterine activity was measured in 43 African nulliparae who were in the active phase of spontaneous labour and in whom delay in cervical dilatation had occurred. Details of labour were recorded on a partogramme, on which an alert and an action line had been drawn, and which were 2 h apart. Delay was defined as a cervical dilatation rate of less than 1 cm/h. Uterine activity was measured with a fluid-filled intrauterine catheter, an external strain gauge and a pressure-curve integrator. The uterine activity levels which were observed in association with delay are considerably less than those associated with normal labour progress. The uterine activity levels that were associated with pitocin augmentation after the action line and which resulted in vaginal delivery have been analysed. They were similar to the levels observed in normal labour. The uterine activity levels which were associated with 'failure to progress in labour' beyond the action line have also been analysed. It is argued that a minimum uterine activity level of 1800 kPas/15 min is required to fully test the cephalopelvic relation.

Female sterilization - a follow-up report.

A retrospective study of 1204 patients who made use of a free sterilization service is reported. The mean length of follow-up was 21 months. Of the patients, 95% were satisfied with the results of the procedure and only 0,25% wanted a reversal. The rate of hysterectomies performed subsequent to sterilization was 1,2%. Sterilization did not adversely influence the menstrual pattern or menstrual discomfort.

Comparison of amniotic fluid optical density and foam stability test in predicting fetal lung maturity.

The ability of optical density measurements and the foam stability test to predict the L/S ratio of amniotic fluid (AF) was examined. Optical density measurements and the foam test predicted the L/S ratio with a similar degree of accuracy; neither was able to replace biochemical measurement of the L/S ratio because both gave false negative and false positive predictions. Optical density measurements and the foam test did not combine to increase the accuracy of prediction.