Mitchells Plain Research Articles

Molecular characterisation of hepatitis A in the Western Cape province, South Africa in 2023

In 2023, passive laboratory-based surveillance showed an increase in hepatitis A virus (HAV) infection. We investigated hepatitis A incidence using the notifiable medical condition surveillance system (NMCSS) data and molecularly characterised positive blood samples from the Western Cape province for 2023. All HAV IgM seropositive cases from the NMCSS from 1 January to 31 October 2023 in South Africa were investigated. HAV RNA from blood samples that had tested positive for HAV IgM from Western Cape was amplified in the VP1/P2B junction and sequenced (3500Xl Genetic Analyser). Sequences were assembled, aligned (Sequencher) and analysed (Aliview 1.27 and MEGA11). Statistical analysis was performed using Excel and the CuSum2 Threshold to determine suspected outbreaks. In 2023, the incidence of HAV IgM was 6.28/100,000 in South Africa, with the highest incidence in Western Cape province (15.86/100,000). Children aged 5 to 14 years were affected the most in the Western Cape. The positive cases in the Western Cape were above the CuSum2 threshold from January to May 2023, with the highest incidence observed in the City of Cape Town Metropolitan (14.8/100,000). Genotyping was successfully performed on 92.7% (139/150) of serum samples, for which the IB sub-genotype was detected. Three primary mutations R63K, R71S and M104I were observed in more than 49% of the samples. Most of the samples sequenced belonged to patients residing in areas close to each other within the City of Cape Town Southern, Western, and Mitchells Plain sub-districts. The CuSum2 threshold method allowed the identification of suspected HAV outbreaks in the districts within the Western Cape in 2023 while genotyping identified clusters of sub-genotype IB. Genotyping could assist with determining the common source of infection during an outbreak, especially if coupled with epidemiological and geographical data. Further active surveillance can assist in investigating the HAV risk factors for targeted public health responses.

'I am afraid the news is not good' - Breaking bad news in the time of COVID: Experiences from a field hospital.

The COVID-19 Pandemic had profound effects on healthcare systems around the world. In South Africa, field hospitals, such as the Mitchell's Plain Field Hospital, managed many COVID patients and deaths, largely without family presence. Communicating with families, preparing them for death and breaking bad news was a challenge for all staff. This study explores the experiences of healthcare professionals working in a COVID-19 field hospital, specifically around having to break the news of death remotely. A150-bed Mitchells Plain Field Hospital (MPFH) in Cape Town. A qualitative exploratory design was utilised using a semi-structured interview guide. Four themes were identified: teamwork, breaking the news of death, communication and lessons learnt. The thread linking the themes was the importance of teamwork, the unpredictability of disease progression in breaking bad news and barriers to effective communication. Key lessons learnt included effective management and leadership. Many families had no access to digital technology and linguo-cultural barriers existed. We found that in the Mitchell's Plain Field Hospital, communication challenges were exacerbated by the unpredictability of the illness and the impact of restrictions on families visiting in preparing them for bad news. We identified a need for training using different modalities, the importance of a multidisciplinary team approach and for palliative care guidelines to inform practice.Contribution:Breaking the news of death to the family is never easy for healthcare workers. This article unpacks some of the experiences in dealing with an extraordinary number of deaths by a newly formed team in the COVID era.

An initiative to reduce psychiatric boarding in a Cape Town emergency department.

Psychiatric boarding in Emergency Departments (ED) is a global challenge which results in long ED length of stays (LOS) with significant consequences on patient care and staff safety. This study investigated the impact of an initiative to reduce psychiatric boarding on LOS and readmission rate, as well as explored the relationship between boarding times and LOS. This study was conducted at Mitchells Plain Hospital, a large district-level hospital in Cape Town. This cross-sectional study collected data for 24 months, which included a 9-month period prior to the initiative and 16 months thereafter. Data were collected retrospectively from official electronic patient registries. The initiative comprised of inpatient hallway boarding as a full-capacity protocol with the accompanying capacitation of psychiatric wards to accommodate the additional burden. The initiative was associated with a decrease of 95% (p < 0.001) in boarding time, 13% (p < 0.001) in ward LOS and 25% (p < 0.001) in hospital LOS. Ward LOS were found to be independent of ED boarding times. The readmission rate increased from 12% to 18% post intervention. The initiative resulted in a sustainable improvement in boarding times and LOSs. The observational nature of this study precludes concrete conclusions and further investigations into psychiatric inpatient hallway boarding are recommended. Inpatient hallway boarding could be a feasible option to reduce the risk. Psychiatric boarding times in the ED are independent of ward LOS, rendering it devoid from any value from a lean and economic perspective.

The value of shock index, modified shock index and age shock index to predict mortality and hospitalisation in a district level emergency centre

IntroductionTriage is the most important step in patients’ journey through an Emergency Centre (EC) and directly impacts time to critical actions. Triage tools, like the South African Triage Scale, are however not designed to predict patient outcomes. The shock index (SI), modified shock index (MSI) and age shock index (ASI) are clinical markers derived from vital signs and correlate with tissue perfusion in critically ill patients. This study aimed to assess the value of SI, MSI and ASI to predict mortality and the need for hospitalisation in all adult patients presenting to a district level emergency centre in South Africa. MethodsThis diagnostic study was performed as a retrospective observational study, using data from an existing electronic registry at a district level hospital emergency centre over a period of 24 months. All adult patients who presented to Mitchells Plain Hospital were eligible for inclusion. Sensitivity, specificity and likelihood ratios were calculated for each variable as a predictor of mortality and hospitalisation with pre-determined thresholds. ResultsDuring the study period of 24 months, a total of 61 329 patients ≥ 18 years old presented to the EC with 60 599 included in the final sample. A red SATS triage category (+LR = 7.2) and SI ≥1.3 (+LR = 4.9) were the only two predictors with any significant clinical value. The same two markers performed well for both patients with and without trauma and specifically for patients who died while under the care of the emergency centre. DiscussionThe study demonstrated that patients with a SI≥1.3 at triage have a significantly higher likelihood to die or require hospitalisation, whether the presenting complaint is trauma related or not, especially to predict mortality while under the care of the EC. Incorporating this marker as a triage alert could expedite the identification of patients requiring time critical interventions and improve patient throughput in the emergency centre.

Routine investigations for patients with mental and behavioural disturbances.

The process of medical clearance aims to exclude a general medical condition as an underlying cause for mental and behavioural disorders and involves routine screening with special investigations. Current evidence, however, suggests that clinician gestalt should guide the need for special investigations and that there is no benefit to routine screening. This study aimed to determine the effectiveness of and adherence to the Western Cape (WC) provincial guidelines for routine investigations of adult patients with behavioural disturbances. This study was conducted at Mitchells Plain Hospital in Cape Town, South Africa. This descriptive study was conducted at Mitchells Plain Hospital in Cape Town, South Africa. Data were collected from existing electronic registries over a 6-month period. Adult mental healthcare users were risk stratified into the probability of having a general medical condition and the results of their special investigations were described against their outcome. Of the 688 patients included in this study, 66% had abnormal vital signs and of the 312 patients who received special investigations, 56% were abnormal, including 18% who were clinically significantly abnormal. Abnormal special investigations changed the clinical outcome for 3 (<1%) patients. Adherence to the guidelines was reasonable (82%) but non-adherence resulted in unnecessary investigations. The results of this study support the existing evidence that clinical assessment and clinician gestalt should guide the need for special investigations and that there is no benefit to routine screening in the emergency centre (EC). The results also demonstrate that non-adherence rarely changed patient outcomes. This study provides information on the value of routine screening investigations in ECs.

Acute angioedema in Cape Town emergency centres and a suggested algorithm to simplify and improve management.

Angioedema is the most common acute allergic presentation to emergency centres (EC), with hospitalisation rates increasing in high-income countries. Angioedema can complicate with life-threatening laryngeal obstruction. There are no local data; therefore, we aimed to characterise acute angioedema cases presenting to ECs and develop a simple management algorithm. To characterise the clinical presentation, management and outcomes of acute angioedema cases presenting to ECs. Based on these findings, we developed a management algorithm for acute angioedema to improve the care of acute angioedema in South Africa (SA). We conducted a retrospective folder review of all patients admitted to Groote Schuur Hospital (tertiary) and Mitchells Plain District Hospital (secondary) ECs from 1 June 2018 to 31 June 2020. Using ICD-10 coding, folders of adults ≥18 years with possible angioedema presenting to the ECs were screened. An allergist extracted demographics, medical history, management and outcome data for each angioedema event. A total of 142acute angioedema episodes were included, with a median (interquartile range) age of 42 (28- 58) years, and 62% of patients were female. The majority (124/142, 87%) of acute angioedema EC presentations involved swelling above the shoulders, with airway involvement in 20(14%) patients, with two patients requiring intubation. Nineteen (13%) patients required admission, with five (26%) admitted to high care/intensive care. Drug-induced angioedema was the most common cause, with 64/142 (45%) linked to a known offending drug, 42/64 (65.6%) being angiotensin-converting enzyme inhibitor (ACE-I). Critical information to guide angioedema management, including past personal/family allergy history, and duration of angioedema prior to EC visit, was not recorded in 64.7% and 37.8% of EC records, respectively. Unnecessary treatment with corticosteroids or antihistamines occurred in 19/53 (36%) and 16/53 (30%) cases with bradykinin-mediated angioedema ACE-I angioedema and hereditary angioedema). Overall, only 36/142 (25%) of angioedema patients were connected to allergy care. Angioedema is the most common allergy presentation to two ECs in Cape Town, SA. Bradykinin-mediated angioedema secondary to ACE-I therapy is the single most common offender, and was not appropriately managed in more than a third of cases. Based on these findings, we have developed a management algorithm that easily stratifies patients into bradykinin or mast cell-mediated angioedema with a step-by-step management approach that is applicable to the SA context. Ongoing awareness and education on allergy emergencies are required to ensure accurate diagnosis of less common causes of angioedema (particularly bradykinin-mediated angioedema) and linkage to allergy specialist care.

Paediatric procedural sedation and analgesia in a South African emergency centre: a single-centre, descriptive study

BackgroundProcedural sedation and analgesia are considered a core competency in emergency medicine as patients present to the emergency centre on an unscheduled basis, often with complex complaints that necessitate emergent management. Previous evidence has consistently shown that procedural sedation and analgesia in the emergency centre in the paediatric population, even the very young, are safe if appropriate monitoring is performed and appropriate medications are used. The aim of the study was to describe the indications for procedural sedation and analgesia, the fasting status of paediatric patients undergoing procedural sedation and analgesia and the complications observed during procedural sedation and analgesia in the paediatric population at a single emergency centre in Cape Town, South Africa.MethodsA retrospective, descriptive study was conducted at Mitchells Plain Hospital, a district-level hospital situated in Mitchells Plain, Cape Town. All paediatric patients younger than 13 years of age who presented to the emergency centre and received procedural sedation and analgesia during the study period (December 2020–April 2021) were included in the study. Data was extracted from a standardised form, and simple descriptive statistics were used.ResultsA total of 113 patients (69% male) were included: 13 infants (< 1 year of age), 47 young children (1–5 years of age) and 53 older children (5–13 years of age). There was only 1 (0.9%) complication documented, which was vomiting and did not require admission. The majority of patients received ketamine (96.5%). The standardised procedural sedation and analgesia form was completed in 49.1% of cases. Indications included burns debridement (11.5%), suturing (17.7%), fracture reduction (23.9%), lumbar punctures (31.9%) and others (15.0%). The indications for procedural sedation and analgesia varied between the different age groups. The majority of patients in this study did not have their fasting status documented (68.1%), and 18.6% were not appropriately fasted as per American Society of Anaesthesiology guidelines. Despite this, there was an extremely low rate of documented complications of 0.9%.ConclusionThe study findings are in accordance with previous international literature reporting low complication rates. Although fasting status was unknown in the majority of patients, there was an extremely low rate of documented complications and no interventions required. Safe, timely procedural sedation and analgesia with minimal pain and unnecessary suffering can become the norm in emergency medicine practice in South Africa.

Pathways to water resilient South African cities – from mono-functional to multi-functional stormwater infrastructure

In light of rapid population growth and climate-change pressures on water resources, there is an urgent need in many African cities to shift to more resilient, decentralised, nature-based approaches. In response, the City of Cape Town's Water Strategy document proposes various alternative water supply sources. One is Managed Aquifer Recharge (MAR) using the Cape Flats Aquifer (CFA). Overlying the CFA are a significant number of stormwater ponds that were originally designed solely to prevent flooding. These ponds could be retrofitted to infiltrate stormwater run-off, recharging the aquifer and serving a water treatment function using nature-based approaches. Many of these mono-functional ponds are in neighbourhoods that are socio-economically disadvantaged through former apartheid spatial planning. These ponds are frequently litter-filled, used for dumping rubble and, on occasion, occupied with informal housing. It is in this context that the conversion of engineered single-purpose stormwater ponds into multi-functional space is proposed using a demonstration site in Mitchells Plain, Cape Town. The ‘Pathways to water resilient South African cities (PaWS)’ project is a collaboration between the Future Water Institute at the University of Cape Town (UCT) and University of Copenhagen (UCPH), funded through DANIDA. This research is revealing how maximum benefit could be derived from these water management systems by adopting low-cost, easy to install blue-green interventions that rely on nature-based approaches. The findings from the research have relevance across Southern Africa where several large cities have existing stormwater ponds designed for flood control or as passive open green spaces. It offers valuable strategies for how these single-purpose ponds can be transformed into multifunctional blue-green spaces in ways that build resilience while addressing the environmental injustice that is a legacy of South Africa's ‘green apartheid’.

Managing stormwater in South African neighbourhoods: When engineers and scientists need social science skills to get their jobs done

Abstract Stormwater harvesting via managed aquifer recharge in retrofitted infrastructure has been posited as a method for resource augmentation in Cape Town. However, the existing guidelines on stormwater retrofits are technically inclined, occidental, and generally misaligned with the realities and socio-economic contexts of developing nations like South Africa. Water and urban practitioners from developing nations cannot just 'copy and paste' existing guidelines as different socio-economic dimensions and colonial histories typically hinder 'traditional' approaches. This paper assesses how a transdisciplinary team navigated these realities in a case study of a retrofitted pond in Mitchells Plain, Cape Town. A decolonial thinking framework was applied for reflection and thematic content analysis. The framework was used to unpack how the team encountered, addressed, and learned from the challenges during the retrofit process. The research team found that the retrofit process within a context of under-resourced South African communities can be viewed as developmental work with a strong emphasis on continuous community engagement. Thus, it is suggested that in the South African context, water practitioners should consider, at the fore, interaction with local communities, including awareness of racialised histories, to ensure projects are successfully implemented and completed.

How do we get the community gardening?: grassroots perspectives from urban gardeners in Cape Town, South Africa

ABSTRACT Urban agriculture offers numerous environmental, economic, and social benefits. However, it is often hampered by limited engagement in cities of the global South. This article offers bottom-up perspectives on how to increase the uptake of urban agriculture activities. It draws on urban gardeners’ perspectives in the low-income neighbourhood of Mitchells Plain, Cape Town. The mixed-methods approach combined a questionnaire survey, semi-structured interviews with urban gardeners, and interviews with civil society actors and a state official. The results indicate that climate and soil conditions are major deterrents to urban agriculture. However, community dialogues about urban agriculture’s social and environmental benefits could play a crucial role in increasing uptake and in facilitating conversations about urban agriculture and food more generally. The paper offers recommendations for future interventions seeking to promote urban agriculture and support actors in low-income neighbourhoods in Cape Town and other African cities.

Knowledge, attitudes, practices and intention to get vaccinated against COVID-19: results from a cross-sectional survey in three peri-urban communities in South Africa.

South Africa has the largest number of confirmed cases of COVID-19 in Africa. Data to inform public health strategies to mitigate the spread of new variants and severity of disease is needed, including information on knowledge, attitudes and practices (KAP) regarding COVID-19, factors associated with intention to get vaccinated, and viewpoints on reliable sources of data. we investigated these topics as part of the COVID-19 healthcare utilization and seroprevalence (HUTS) cross-sectional survey in three communities in South Africa: Mitchell´s Plain (Western Cape Province), Pietermaritzburg (KwaZulu-Natal Province) and Klerksdorp (North West Province) during and after the second wave of COVID-19 prior to vaccine availability. primary caregivers from 5799 households participated in the study, 41.1% from Pietermaritzburg, 34.2% from Klerksdorp and 24.7% from Mitchells Plain. Two-thirds and 94.7% of respondents had correct knowledge on the cause and spread of COVID-19, respectively. Knowledge measures were significantly associated with age less than 65 years, the highest level of education and site (Mitchells Plain). Desired preventive behaviors were associated with higher socio-economic status. While 64.7% of people intended to get vaccinated, those over 64 years of age were more likely to intend to vaccinate (aOR: 1.25, 95% CI: 1.06-1.47). Vaccine intention related to protection of self (58.4%) and family (40.0%). The most trusted source of COVID-19 information was television (59.3%) followed by radio (20.0%). these data can be used to design targeted public health campaigns for the current COVID-19 and future epidemics, ensuring that socio-economic constraints and preference for trusted information are considered.

Access to acute stroke care: A retrospective descriptive analysis of stroke patients' journey to a district hospital.

The burden of stroke in Africa has increased in the last two decades, with the population undergoing a rapid epidemiological transition, with a rise in the incidence of stroke risk factors together with the gradual aging of the population. Evidence-based guidelines for acute stroke care are often not feasible in resource challenged settings but even when resources are available, considerable delays to definitive care exists. This study aims to describe the factors that influence time from symptom onset to hospital arrival in patients that present to a district level hospital Emergency Centre with confirmed ischaemic strokes. A descriptive analysis was performed using a retrospective folder and database review. All adult patients with a confirmed ischaemic stroke, on Computed Tomography (CT) scan, presenting to Mitchells Plain Hospital Emergency Centre during the study period of 12 months (1st of January 2019 to 31st of December 2019), were eligible for inclusion. Data were collected from existing electronic patient databases and the time from onset of symptoms to hospital arrival was extracted from the clinical notes. A total of 730 (2%) patients presented with a diagnosis of stroke, of which 381 (52%) were included (CT confirmed ischaemic strokes). Only 48 (13%) presented within 4.5h of symptom onset and the median time from onset of symptoms to presentation to the hospital was 24h (IQR 12-72h). The majority of patients (31%) arrived via a primary public emergency medical service (EMS) call, while 29% presented directly to the hospital as self-referrals with private transport. Primary public EMS calls had the shortest call-to-hospital-arrival time (1 hour and 31 minutes), even though the median time from symptom onset to hospital arrival was still 16h. The median time from symptom onset to hospital arrival for patients with stroke symptoms is much longer than what evidence-based guidelines suggest. The chain of survival for emergency stroke care is only as strong as its weakest link and the data from this study suggest that improvement campaigns should target stroke education and access to care.

Emergency clinician output in a district hospital emergency centre: a cross-sectional analysis.

Appropriate and efficient staffing is a cornerstone of emergency centre performance. There is however a paucity of literature describing clinician output in low- and middle-income countries with current staffing models based on anecdotal evidence. This study aimed to assess clinician output at a district level emergency centre, and how it varied depending on shift, clinician, and workload factors. We conducted a retrospective cross-sectional study using an existing electronic patient registry, to determine the patients consulted per hour (PPH) during each clinician shift and how this is affected by various clinician, shift, and workload factors. Data was collected over three non-contiguous randomly selected four-week cycles from Mitchells Plain Hospital's electronic patient registry. Associations between PPH and various factors were assessed using ANOVA with post-hoc adjustments where appropriate. The correlation between PPH and workload metrics was calculated with the Pearson's Rank correlation test. Statistical significance was defined as p<0.05. A total of 1 289 clinician shifts were analysed with an overall PPH of 0.7. A significant association between PPH and shift type (p=0.021), clinician category (p<0.001) and cumulative shifts (p<0.001) were shown. There was a decline in clinician output during a shift and output was significantly decreased by the number of boarders in the emergency centre but increased with higher numbers of patients waiting at the start of the shift. This study describes a relatively low clinician output as compared to evidence from high-income countries and has highlighted several associations with various shift, clinician, and workload factors. The results from this study will form the basis of quality improvement interventions to improve patient throughput and will inform staff scheduling and surge planning strategies.

Temporal changes in trauma according to alcohol sale restrictions during the South African national COVID-19 lockdown.

IntroductionThe South African government enforced various alcohol sale restrictions during the COVID-19 lockdown in order to reduce hospital admissions related to alcohol-associated injuries. A cross-sectional study was performed to describe the temporal changes in trauma according to alcohol sale restrictions during the South African national COVID-19 lockdown.MethodsData from all trauma-related patients presenting to the emergency centre of Mitchells Plain Hospital from 01/03/2020 till 29/9/2020 and corresponding periods during 2019 were exported from an existing database. The relationship between variables was determined with the χ2-test, Fisher's exact test, independent samples median test or t-test. A sub-analysis compared similar 2020 lockdown levels when a second alcohol ban were instituted while most business were allowed to operate (level 3b – alcohol banned versus level 3 – alcohol restricted).ResultsTotal number of trauma presentations were 539 (14.6%) less in 2020 (n = 3160) than in 2019 (n = 3699); the mean number decreased by 2.5 per day (95% CI −2.9 to −2.1). Lockdown levels with an alcohol ban had on average 4.8 less patients per day than corresponding periods in 2019 (p < 0.001). No significant difference was observed in lockdown levels with alcohol sale restrictions (mean difference per day −0.4, p = 0.195). Trauma presentations increased significantly (mean difference per day 7.0 (95% CI 6.5 to 7.5)) from 2020 lockdown levels with alcohol sales ban (mean per day 11.4) to 2020 lockdown levels with alcohol sale restrictions (mean per day 18.4). Significantly less patients (mean −3.2 (95% CI −3.9 to −2.5)) presented during 2020 lockdown level 3b (alcohol sales banned, mean 13.9) compared to level 3 (alcohol sales restricted, mean 17.1).ConclusionTemporal changes in trauma were observed according to alcohol sale restrictions during South Africa's COVID-19 lockdown periods. Significantly less trauma cases presented during periods with an alcohol ban compared to periods where alcohol sales were only restricted.

Tourism Competitiveness and Sustainability Indicators in the Context of Surf Tourism: The Case of Cape Town

Sport tourism has experienced considerable growth in the last decades, either from the sport events perspective or considering an active sport tourism approach. Therefore, some emergent market niches like surf tourism have been developed in numerous coastal destinations to attract sustainability-sensitive tourists due to the ongoing environmental challenges and the socio-economic crisis. Cape Town is positioned in a prominent place in terms of competitiveness, with a considerable variety of beaches and surf spots facing multiple issues. The aim of this study is to try to identify the most competitive beaches and subdistricts in terms of sustainability and to suggest criteria for surf-tourism-related indicators to obtain an overview about this space, using weighting indicators, and applying geography and political economy lenses. The results reveal that Strand, Table View, and Surfers’ Corner are the most competitive beaches. Additionally, beaches located in some underprivileged areas such as Mitchells Plain and Khayelitsha are potentially interesting from a socio-economic development point of view, although they show a lack of accommodation infrastructures. These results seem to indicate that those areas should be closely monitored, and destination managers should focus their attention and finance there to obtain a more sustainable surf tourism development.

A Retrospective observational cohort study of the effect of antenatal influenza vaccination on birth outcomes in Cape Town, South Africa, 2015-2016.

BackgroundThere are conflicting data concerning the impact of antenatal influenza vaccination on birth outcomes including low birthweight (LBW), preterm birth, small for gestational age (SGA), and stillbirth.MethodsWe conducted a retrospective observational cohort study of infants born to women residing in Mitchells Plain, Cape Town. Infants were born at 4 health facilities during May 28 – December 31, 2015 and April 15 – December 31, 2016. We performed crude and multivariable logistic regression, propensity score (PS) matching logistic regression, and inverse probability of treatment weighted (IPTW) regression to assess vaccine effectiveness (VE) against LBW, preterm birth, SGA, and stillbirth adjusting for measured confounders.ResultsMaternal vaccination status, antenatal history, and ≥1 birth outcome(s) were available for 4084/5333 (76.6%) pregnancies, 2109 (51.6%) vaccinated, and 1975 (48.4%) unvaccinated. The proportion LBW was lower in vaccinated (6.9%) vs. unvaccinated (12.5%) in multivariable [VE 0.27 (95% CI 0.07‐0.42)], PS [VE 0.30 (95% CI 0.09‐0.51)], and IPTW [VE 0.24 (95% CI 0.04‐0.45)]. Preterm birth was less frequent in vaccinated (8.6%) than unvaccinated (16.4%) in multivariable [VE 0.26 (0.09‐0.40)], PS [VE 0.25 (95% CI 0.09‐0.41)], and IPTW [VE 0.34 (95% CI 0.18‐0.51)]. The proportion SGA was lower in vaccinated (6.0%) than unvaccinated (8.8%) but not in adjusted models. There were few stillbirths in our study population, 30/4084 (0.7%).ConclusionsUsing multiple analytic approaches, we found that influenza vaccination was associated with lower prevalence of LBW (24‐30%) and preterm birth (25‐34%) in Cape Town during 2015‐2016.

Adolescents and substance abuse: the effects of substance abuse on parents and siblings

ABSTRACT This study aimed to describe the adverse effects that adolescent substance abuse has on the levels of care giving and well-being of families. The researchers used a qualitative case study design which focused on an issue of concern (such as adolescent substance abuse) and thus selected one case to elucidate the issue, i.e., a single case study. The case would be the family members of substance abusing adolescents in Mitchells Plain, a township in Cape Town, as an exemplar for the study. Purposive sampling was used to select 12 participants, seven parents (mothers) and five siblings. Individual semi-structured interviews were utilized for data collection through the use of interview schedules. The data were analysed in the form of qualitative thematic analysis where four themes emerged, which focused on the various effects (for example, financial, physical, emotional, and distrust) on family well-being resulting from living with a substance-abusing adolescent.

Assessment of sludge management strategies in wastewater treatment systems using a plant-wide approach

The objective of this paper is to use plant-wide modeling to assess the net impacts of varying sludge management strategies. Special emphasis is placed on effluent quality, operational cost and potential resource recovery (energy, nutrients). The study is particularly focused on a centralized bio-solids beneficiation facility (BBF), which enables larger, more capital intensive sludge management strategies. Potential barriers include the ability to process reject streams from multiple donor plants in the host plant. Cape Flats (CF) wastewater treatment works (WWTW) (Cape Town, South Africa) was used as a relevant test case since it is currently assessing to process sludge cake from three nearby facilities (Athlone, Mitchells Plain and Wildevoelvlei). A plant-wide model based on the Benchmark Simulation Model no 2 (BSM2) extended with phosphorus transformations was adapted to the CF design / operational conditions. Flow diagram and model parameters were adjusted to reproduce the influent, effluent and process characteristics. Historical data between January 2014 and December 2019 was used to compare full-scale measurements and predictions. Next, different process intensification / mitigation technologies were evaluated using multiple criteria. Simulation values for COD, TSS, VSS/TSS ratio, TN, TP, NH4+/NH3, HxPO43-x, NOx alkalinity and pH fall within the interquartile ranges of measured data. The effects of the 2017 severe drought on influent variations and biological phosphorus removal are successfully reproduced for the entire period with dynamic simulations. Indeed, 80% of all dynamically simulated values are included within the plant measurement uncertainty ranges. Sludge management analysis reveals that flow diagrams with thermal hydrolysis pre-treatment (THP) result in a better energy balance in spite of having higher heat demands. The flow diagram with THP is able to i) increase biodegradability/solubility, ii) handle higher sludge loads, iii) change methanogenic microbial population and iv) generate lower solids volumes to dispose by improving sludge dewaterability. The study also reveals the importance of including struvite precipitation and harvesting (SPH) technology, and the effect that pH in the AD and the use of chemicals (NaOH, MgO) may have on phosphorus recovery. Model-based results indicate that the current aerobic volume in the water line (if properly aerated) would be able to handle the returns from the sludge line and the contribution of a granular partial nitritation/Anammox (PN/ANX) reactor on the overall nitrogen removal would be marginal. However autotrophic N denitrification generates a much lower sludge production and therefore increases AD treatment capacity. The study shows for the very first time in Africa how the use of a (calibrated) plant-wide model could assist water utilities to decide between competing plant layouts when upgrading a WWTW.

Low prevalence of atrial fibrillation in ischaemic stroke: Underestimating a modifiable risk factor.

IntroductionCerebrovascular disease remains one of the leading causes of morbidity and mortality globally. In South Africa, it was the fourth leading cause of death in 2016, responsible for 5.1% of all deaths - the leading cause of death in individuals 65 years and older. Atrial fibrillation accounts for 15% of all strokes and 25% are diagnosed when patients present with a stroke. We set out to determine the prevalence of atrial fibrillation in patients with confirmed ischaemic strokes in a district level hospital in the Western Cape, South Africa.MethodsThis descriptive study was conducted at Mitchells Plain Hospital in Cape Town and data was collected over a one-year period. Patients diagnosed with a stroke were identified from an electronic patient register and relevant radiology and clinical data were sourced retrospectively. The diagnosis of ischaemic stroke was confirmed by a CT scan report and ECGs were independently screened by two Emergency Physicians. Ethical approval was granted by the University of Cape Town Human Research Ethics Committee [790/2018].ResultsThe proportion of adult patients with a stroke diagnosis was 2%. Of the included cases, 80% had ischaemic strokes and 11% had haemorrhagic strokes. 11% of all patients with ischaemic strokes had atrial fibrillation, 67% of those presumed new. A total of 60 (15%) of all patients with ischaemic stroke were aged 45 years or younger. The inpatient mortality rate was statistically higher in patients who had atrial fibrillation (26% vs 7%, p < 0.001).ConclusionWith the increasing population life expectancy, and prevalence of cardiovascular disease the prevalence of atrial fibrillation and its complications will increase. Since the risk of stroke related to atrial fibrillation can be reduced significantly by oral anticoagulation, further studies should aim to explore barriers and challenges to effective screening.

A descriptive analysis of the effect of the national COVID-19 lockdown on the workload and case mix of patients presenting to a district-level emergency centre in Cape Town, South Africa

The global COVID-19 pandemic caused many countries to institute nationwide lockdowns to limit the spread of the disease. To describe the effect of the national COVID-19 lockdown in South Africa (SA) on the workload and case mix of patients presenting to a district-level emergency centre. The electronic patient tracking and registration database at Mitchells Plain Hospital, a district-level hospital in Cape Town, was retrospectively analysed. The 5-week lockdown period (27 March - 30 April 2020) was compared with a similar period immediately before the lockdown (21 February - 26 March). A comparison was also made with corresponding time periods during 2018 and 2019. Patient demographics, characteristics, diagnoses and disposition, as well as process times, were compared. A total of 26 164 emergency centre visits were analysed (8 297 in 2020, 9 726 in 2019, 8 141 in 2018). There was a reduction of 15% in overall emergency centre visits from 2019 to 2020 (non-trauma 14%, trauma 20%). A 35% decrease was seen between the 2020 lockdown period and the 5-week period before lockdown (non-trauma 33%, trauma 43%), and the reduced number of visits stayed similar throughout the lockdown period. The median age increased by 5 years during the 2020 lockdown period, along with an 8% decrease in patients aged &lt;12 years. High-acuity patients increased by 6% and the emergency centre mortality rate increased by 1%. All process times were shorter during the lockdown period (time to triage -24%, time to consultation -56%, time to disposition decision -29%, time in the emergency centre -20%). The SA national COVID-19 lockdown resulted in a substantial decrease in the number of patients presenting to the emergency centre. It is yet to be seen how quickly emergency centre volumes will recover as lockdown measures are eased.