Background: Ventilator Associated Pneumonia (VAP) is a common hospital acquired infection in children leading to an increase in morbidity and mortality. A study conducted in our PICU in 2013, showed that VAP rates decreased dramatically after implementation of a VAP bundle and appointing a VAP coordinator, to 4/1000 ventilator days. As part of a “Plan, Do, Study, Act” cycle, it was necessary to evaluate the efficacy of these interventions. Objectives: To evaluate the VAP rate in the PICU over a two year period from 2017 - 2018, and secondly to describe the causative organisms and antibiotic sensitivity/resistance patterns during this period. Methods: This was a retrospective, descriptive study using the existing PICU VAP database to identify cases. Additional information was retrieved from the PICU admission database as well as clinical folders. Results: Over the 2 years, 31 VAP cases were identified. The VAP rate in 2017 was 4.0 /1000 ventilator days and 5.4 /1000 ventilator days in 2018. Compliance with the VAP bundle was 68% in 2017 and 70% in 2018. The median(IQR) duration of ventilation in 2017 was 9 (6-12) days and 15 (11-28) days in 2018. The median(IQR) length of PICU stay in 2017 was 11 (8 – 22) days and 25 (17-37) days in 2018. The most common cultured organism was an ESBL Klebsiella pneumoniae sensitive to Amikacin and carbapenems. Conclusion: Our VAP rate has not decreased further since 2013. The VAP rate was slightly higher in 2018, and it is imperative that we improve compliance with the VAP bundle, in order to reduce VAP rates. Klebsiella pneumoniae and Pseudomonas aeruginosa were the commonest organisms causing VAPs and empiric use of Piptazobactam and Amikacin is still appropriate.

Includes bibliographical references. / Background: Intrapartum complications contribute to nearly half of all avoidable maternal and perinatal deaths nationally. Inadequate understanding of the labour process by midwives, poor documentation of labour monitoring and inadequate systemlevel support may lead to wrong diagnosis, incorrect management, and the potential for missed opportunities to prevent mortality. Aim: To evaluate the effect of an intervention package of training and clinical facilitation on the quality of clinical management in labour by registered midwives in primary level public sector health facilities in rural South Africa. Methods: Research design : Pragmatic cluster randomised trial with 12 month follow-up. Setting and participants : Seventeen clusters stratified by geo-political region and size of service; 1020 labour records (60 per cluster / site; systematic random sample); and 154 registered midwives employed in the study sites during the study period. Participants were not blinded. Intervention : A package of clinical faclitation training for selected experienced midwife clinicians / managers, and an intrapartum educational update for midwives. Intervention and control sites continued receiving routine communication, all clinical guidelines and scheduled outreach activities. Main outcome measures : Primary outcome - clinical practice measuring partograph utilisation, using a modified partograph checklist, the testing of which is described in this study. Secondary outcome - midwives’ knowledge and skills, measured by written and clinical tests. Outcomes were analysed at the individual level using regression methods that allowed for clustering. The evaluator was blinded to the study allocation. Findings: The mean scores for the total partograph were not statistically significantly different between arms; the mean difference was 1.55 points out of a possible score 47 (95% CI: -1.18 to 4.28) p= 0.27. At a score of 27 the estimated absolute difference was 13.6% (95% CI : 0.16 to 0.25) p = 0.026. The total score for midwives’ knowledge and skills was 7 points (out of a possible 119) higher in the intervention arm (95% CI : 2.1 to 12.3), p=0.006. Conclusions: Although there was no difference in the quality of the overall completion of the partograph, there was a statistically significant difference in those of better quality completions in the intervention arm. Midwives’ knowledge and skills were higher in the intervention arm and those in the control arm deteriorated over time. This difference was statistically significant. Recommendations and implications for practice: This indicates a critical need to provide continuing professional education to midwives and to arrange midwifery staffing that optimises clinical practice in settings where intrapartum care is offered. In addition to regular, sustainable programmes to enhance partograph utilisation and midwife knowledge and skills, barriers to the utilisation of the partograph need to be investigated and addressed.

The study aimed to evaluate the nutritional status of pre-school children (0-6 years), and the activities of a local CBNP serving these children, in the Ngwaritsi health district of the Northern Province. The following objectives were identified: o To determine the anthropometric status of children 0-6 years o To determine the dietary intake of children 0-6 years o To evaluate the nutrition services offered to these children by a local CBNP o To make recommendations, based on these findings, for improving existing strategies to address malnutrition in the area.

Includes bibliographical references (leaves 75-85). / The aim of this study was to determine how Swazi mothers initially respond when their children develop diarrhoea and the factors that could influence their response.

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a progressive form of inherited heart muscle disease characterized by ventricular arrhythmias and sudden cardiac death. Often the pathogenesis is linked to deleterious mutations in the desmosomal gene plakophilin-2 (PKP2). We extended investigations of the pathogenic PKP2 c.1162C>T founder mutation which had previously been reported to occur within four 'unrelated' probands (6.2%) who selfidentified as Afrikaners and who also carried a common haplotype. Common evolutionary history suggests common haplotypes are linked to a common founder and today the Afrikaner populations are a unique ethnic group in South Africa identified with various founder effects for a range of heritable disorders. Aim: This study aimed to identify the common founder using genealogical and molecular methods for the PKP2 c.1162C>T mutation in ARVC families of Afrikaner descent in South Africa. Methods and results: DNA was collected from 46 participants (7 probands and 39 relatives) from the ARVC Registry of South Africa. Probands and relatives were screened for the PKP2 c.1162C>T mutation using High Resolution Melt and Sanger sequencing. The genetic results indicated that 65.2% (30/46) of the family members harbored this mutation. High Resolution Melt, Sanger sequencing and microsatellite typing were used to create a haplotype which encompassed the c.1162C>T mutation and three microsatellite markers (M1, D12S1692 and M2) spanning the PKP2 gene. A common haplotype emerged that segregated amongst all of the affected members of the seven Afrikaner families. Genealogical tracing went back, through multiple generations, into the implicated ancestral lines of the present day Afrikaner families. Four of the seven families attained their 17th century progenitors. Through genealogical analyses of the two largest families, ACM 19 and ACM 38, we identified 116 couples which we reduced to ten candidate South African founder couples who were then subjected to further analyses. After the ACM 12 family was added to the analysis there were five candidate founder couples. Unfortunately, the ACM 71 family did not progress past the 20th century due to tracing difficulties associated with poor record keeping of mixed ancestry data in South Africa and hence, could not be linked back to any other family tree without finding ACM71.5's grandparents. Additionally, ACM 8 and 57 families were recent finds and completion of their genealogical tracing still has to done. Conclusions: Our genetic data showed that not only were 30/46 individuals positive for the PKP2 c.1162C>T mutation but that all 30 individuals also shared the same common haplotype. Our preliminary genealogy tracing data suggests that the PKP2 c.1162C>T mutation segregates at a higher frequency in the Afrikaner population possibly due to a founder effect. The genealogical evidence supports the hypothesis that the PKP2 c.1162C>T mutation is a founder mutation and that descendants of the common founders are at risk of developing ARVC. At least three more families need to be recruited to make a clear conclusion and achieve genealogical evidence based saturation, ideally, a common founder.

Includes bibliographical references (leaves 54-59). / Central nervous system involvement contributes significantly to the morbidity and mortality of paediatric HIV infection. The spectrum of CNS morbidity varies from minor developmental disabilities to severe, progressive encephalopathy. Therefore regular developmental evaluation should be regarded as an essential component of the overall care of HIV-infected children. Antiretroviral therapy may arrest or even reverse neurocognitive and motor deficits associated with HIV infection.

This study was undertaken to assess HIV-prevalence, uptake of HIV-care, general clinical characteristics and risk factors among a population visiting a mental health clinic in a rural Malawian district hospital.

Includes bibliographical references. / TB was declared a priority disease in South Africa ten years ago. Despite efforts to manage this illness, South Africa ranks as one of 22 high burden countries globally. TB is an important cause of childhood morbidity and mortality, but much of the emphasis of the NTP is on smear positive (adult) TB, as this is perceived to be the greater public health problem. The presence of HIV infection exacerbates both the incidence of TB, and the progress of TB from infection to the development of disease in both children and adults. The diagnosis of childhood TB has proved to be difficult and continues to challenge clinicians, despite technological advances in various spheres of medicine. Several guidelines and recommendations are available for diagnosing TB in children, including combinations of clinical criteria, special investigations, laboratory methods and score systems, but no gold standard exists.It is not clear how well the SANTCP guidelines for diagnosis of childhood TB are being implemented at Emmaus Hospital, or whether these guidelines are still appropriate within the context of high HIV prevalence. Not enough is known about the epidemiology of childhood TB in the Okhahlamba local municipal area surrounding Emmaus hospital to guide optimal management of children. Given the likely magnitude of the problem of childhood TB in this rural area and the difficulties of diagnosis, research into the epidemiology and diagnosis of childhood TB in this context is necessary.

Bibliography: leaves 112-123. / Cervical cancer is integrally associated with the problems of poverty in the developing world. It is the most common cancer cause of death among women in these regions. In South Africa, the lifetime risk for black African women developing this cancer is 1 in 26. Rates for white women are 1 in 80. Cervical cancer is largely preventable by screening for its precursor stages. However, cervical cancer screening in low-resource settings has only rarely been initiated and sustained. There are many barriers to the establishment of mass, organised screening programmes. This study focuses on one aspect of the screening process: the clients' receiving of their screening results. For the most part, health providers in resource-poor settings rely on the clients themselves to return to the health service to receive their results and consequent arrangements for further care. Understanding those factors that impact upon clients' returning is therefore crucial to the success of the screening. The Khayelitsha Cervical Cancer Screening Project (KCCSP) was established in 1996 to evaluate alternative screening tests to cytology. In addition, the Project has evaluated alternative screening algorithms to the traditional approach of cytology, colposcopy, biopsy and treatment, specifically, a "screen and treat" approach. This approach is expected to overcome some of the many barriers to women participating in screening programmes. This study aims to investigate the phenomenon of the high spontaneous return rate in the setting of the KCCSP. Motivating and deterring factors are sought, both logistical and psychological, in the clients' personal contexts, as well as those related to their experiences of the Project. Exploratory study in the interpretive research paradigm located in a peri-urban informal settlement outside Cape Town, South Africa. Volunteer sample of women enrolled in the KCCSP returning for their first set of screening results. Four focus groups were conducted in Xhosa, facilitated by a Xhosa-speaking social worker from Khayelitsha who has experience in focus group work. Discussion guidelines were followed. The discussions were tape recorded and later transcribed before being translated into English by the facilitator. Analysis of the data draws on elements of both the grounded theory and the systems theory paradigms. The findings reveal that, for the most part, women present to the KCCSP in order to have general gynaecological problems addressed. Returning for results represents an extension of this need. Obstacles to returning include problems with access to the clinic, the need to care for dependents at home and the competing priorities of housework and generating income. Factors that promote the returning for results are the imperative to understand the cause of, and have treatment for pre-existing gynaecological symptoms which cause high levels of anxiety. Related to this, women are motivated to have confirmed or refuted the diagnosis of a fatal disease, including cancer and HIV. Certain qualities and design features of the KCCSP facilitate women returning fOr their results. These include the perceived superior quality of interpersonal communication between Project staff and clients and the efficient manner in which results are made available to clients. Other promotive or obstructive factors that playa role in cervical screening service utilisation include; client attitudes towards traditional healers, a prevalent fear of hysterectomy, concern about privacy and gossip and a suspicious attitude toward caring health workers. Women enrolled in the KCCSP have a personal health agenda with a different focus to that of the Project. Chronic gynaecological problems are frequently experienced and give rise to levels of anxiety about their being signs of serious pathology. Women have not had these fears or the symptoms adequately addressed at other health services. The need to have these issues properly managed represents a large enough motivating force to overcome many of the practical and psychological obstacles to utilisation of the KCCSP. The Project represents for women a general women's health service.

Includes abstract. / Includes bibliographical references. / Child abuse in different forms, ranging from domestic violence against children to sexual abuse, is a worldwide phenomenon with a dramatic influence on the future of the abused child. In African countries, the number of reported cases is rising which may be a result of increased awareness amongst medical staff and parents. In sub-Saharan Africa, outside South Africa, there has been limited research on child abuse, in particular on child sexual abuse, and little is known about the extent of health services offered to the victims.