MPH / Department of Public Health / See the attached abstract below

Thesis (MPA.) -- University of Limpopo, 2018 / Background: Cancer of the cervix is the fourth most common cancer affecting women worldwide and is currently considered as a sexually transmitted cancer. This type of cancer is caused in most cases by a viral infection, Human Papilloma Virus (HPV) strains 16 and 18. Cervical screening aims to prevent invasive cervical carcinoma by detection and treatment of its precursors cervical intraepithelial neoplasia grade 2 (CIN2) and, particularly, grade 3 (CIN3). The current study aimed at determining the distribution of cervical cancer and the association of cervical cancer with HIV infection in Limpopo Province. Methods: The current study used quantitative retrospective method to systematically review the available data on Papanicolaou (Pap) smears from National Health Laboratory Services at Polokwane hospital from the year 2013 to 2015. The data was kept anonymously by not using the names of the patients and ethical clearance was received from the Turfloop Research Committee of University of Limpopo in consideration of section 14, 15, 16, and 17 of National Health Act 61 of 2004. The data was exported to excel spreadsheet and cleaned before exported into SPSS 23.0 software which was used for data analysis. Results: The findings from the current study show a decline of 33% in the number of Pap smears that were submitted for cytology between 2013 (82 041) and 2015 (23 527) in Limpopo province. However, the study revealed that there is an increase in prevalence of cervical cancer from 16.7% in 2013 to 19.2% in 2015 in Limpopo Province. In the same period this rural province already demonstrates a high burden of cervical cancer among the middle aged women. The positive cervical smears were classified as cervical intraepithelial neoplasia (CIN) I, II, or III and therefore, 78.5% were CIN I, 21% CIN II and 0,5% CIN III. HIV infections have been found to be associated with cervical cancer as the prevalence of cervical cancer among HIV positive women was found to be 25% and most of the affected women are the middle aged group. vi Conclusion: The screening coverage for cervical cancer has decreased in Limpopo Province but the prevalence of cervical cancer has increased by 2.5% therefore, this translates to the need for community awareness about prevention of cervical cancer. Majority of the cases were classified as CIN 1 at 78.5% which can be cured if treatment started early. The Limpopo Province should therefore strengthen strategies to integrate HIV and cervical cancer services as it was found that there is a strong association between the HIV and cervical cancer.

Cervical cancer remains the leading cause of cancer mortality among women worldwide, a burden in the developing countries and commonly detected through symptoms at later invasive stages. The study aimed at establishing knowledge and awareness of the importance of cervical cancer screening in the Makhuduthamaga Sub-district by exploring the perceptions of women and professional nurses and through the review of the National Cervical Cancer Screening Policy (2013). Recommendations to address the gap in knowledge and to inform the National Cervical Cancer Screening Policy were developed based on the study findings. A mixed-method approach was used in this study through a sequential explanatory design, which is quantitatively driven was used. Quantitative data were obtained by using a researcher developed checklist. The checklist was developed from variables stated in the National Cervical Cancer Screening Policy and was used to review its implementation. Qualitative data was obtained through in-depth interviews with individual women and focus group discussions with professional nurses. The study was conducted in ten randomly selected clinics of Makhuduthamaga Sub-district. Purposive sampling was done to obtain qualitative data. An average score of 9.7 was obtained for all ten clinics that participated in the study with regard to the evaluation of the implementation of the National Cervical Cancer Screening Policy. Only 6 (60%) clinics implemented the policy whereas 4 (40%) clinics did not implement the policy. Women and professional nurses perceived cervical cancer screening as important. Lack of knowledge among women regarding cervical cancer screening contributed to the majority of women not screening for cervical cancer. Lack of resources, the 10 year interval of normal cervical cancer screening, the use of disposable vaginal speculums and brushes, lack of standardized cervical cancer screening training, centralization of cytology laboratories came out as factors that negatively influence the uptake of cervical cancer screening. Cervical cancer screening awareness campaigns, availability of resources and standardized in-service trainings on cervical cancer screening were recommended to enhance the cervical cancer screening uptake. / Health Studies / D. Litt. et Phil. (Health Studies)

MCur / Department of Advanced Nursing Science / Cervical cancer remains one of the major public health problems globally, despite the fact that it is preventable and curable if identified at an early stage. Currently, cervical cancer is the leading cause of death among women in Sub-Saharan Africa where the knowledge about the disease is scarce among the affected population. Methods A quantitative cross-sectional survey was conducted in Thulamela Municipality of Limpopo Province. The purpose of the study was to assess the knowledge of cervical cancer prevention among women in four villages in Thulamela Municipality. The population of the study was composed of all women aged above 30 in the villages Malamulele, Mhinga, Muledane and Phiphidi. A sample of one thousand five hundred and forty-six (1546) was drawn using random sampling. Quantitative data were collected using a twenty-six-item questionnaire. The data were coded and then processed using the Statistical Package for Social Sciences to produce frequency tables and descriptive statistics such as chi-square and correlation. Results A number of findings were made in this study. The majority of the women in this study had little or no knowledge about cervical cancer, human papilloma virus and vaccines. The majority of the women had little or no knowledge on cervical cancer risk factors and how the disease is spread. These findings were confirmed by chi-squared values at p<0.05 and showed significant association between variables: that young women were likely to be aware of cervical cancer compared to elderly women, educated women were more likely to be knowledgeable about cervical cancer than those with low education attainment, elderly women were more likely to be not worried about cervical cancer compared to young women. Correlation, Pearson rho scores at p<0.05 showed significant correlations knowledge of cervical cancer and age (negative), knowledge and education (positive). The findings signified the need for cervical cancer prevention education in Vhembe District, and the need for primary health care nurses to promote access to such services through robust health education. vi Recommendations The study made a number of practical recommendations likely to educate women about cervical cancer, human papilloma virus and its prevention. These include: The possibility of large hospitals having their own small broadcasting stations that will frequently disseminate information throughout the local municipalities, road shows and use of informal sector like politicians and traditional healers in disseminating information.

MPH / Department of Public Health / Despite the availability of the South African cervical cancer screening guidelines at clinics, women are still seen in the out-patient department of selected rural district hospital in Thulamela Municipality, referred from Primary Health Care (PHC) facilities with no cervical cancer screening results. Thus, cervical cancer screenings are done at a hospital and results often came back positive for cervical cancer. Such practices pose a risk of delayed cervical cancer diagnoses and its discovery at an advanced stage, increasing cervical cancer mortality rates. The purpose of this study was to investigate the compliance of professional nurses at primary health care facilities to the South African cervical cancer screening guidelines in Thulamela Municipality. This study adopted a qualitative approach as it aimed to get a better understanding on compliance of professional nurses regarding South Africa’s cervical cancer screening guidelines. Nonprobability sampling was used to select primary health care facilities including interested participants who were judged to possess the information that was required to answer the research question of this study. The sample size of the study was determined by data saturation. Trustworthiness was ensured by four criteria of Guba and Linclon, namely credibility, transferability, dependability and confirmability. A digital recorder was used to log individual responses during interview sessions. Data from the digital recordings were transcribed verbatim. Results were analysed and interpreted thematically. This study established that clinic professional nurses are non –compliance to the South African cervical cancer screening guidelines; nurses face several challenges such as inadequate knowledge of the cervical cancer screening guidelines, shortage of resources and shortage of staff. Recommendations that emanated from the discussion of the findings and the conclusion of this study are likely to have implications and applications for supporting and advancing the cervical cancer screenings. / NRF

MCur / Department of Advanced Nursing Science / Historically, cancer is regarded as a disease with very devastating effects on human beings because it leads to many deaths across the world, compared to AIDS, tuberculosis and malaria collectively. Cancer diagnosis has impacted negatively on patients and their immediate families and has caused unbearable consequences. Unlike other chronic diseases, cancer patients undergo different types of treatments which affect their well-being and as a result they tend to have different experiences to those of other chronic diseases sufferers. The study design used was a quantitative cross sectional survey. The purpose was to investigate the impact of cancer diagnosis on cancer patients in Vhembe district. The target population included all patients in the Vhembe District of Limpopo, South Africa who have been diagnosed with cancer in the past six months. Using a probability simple random, a sample of 207 patients diagnosed with cancer, from seven selected hospitals in Vhembe District were selected as respondents and a self -administered questionnaire was used to collect data. Data was analysed using a software package for descriptive statistics (SPSS version 23). Graphs, tables and charts were used to display the results visually and chi-square to compare variables. Ethical principles of privacy, anonymity, informed consent were considered. The findings revealed that cancer diagnosis has negative outcomes as patients experience physical hardship, psychological stress, financial difficulties, as well as interference with family and social life. The study recommended that cancer patients and their families, be supported through the cancer journey. / NRF

MSc (Microbiology) / Department of Microbiology / BACKGROUND: Human papillomavirus (HPV) is a common sexually transmitted virus known to be a causative agent of cervical cancer (CC), one of the most frequent cancers in women worldwide. HPV is a double stranded DNA virus of approximately 7,900 bp; belonging to Papillomaviridae family. To date, about 202 low risk (LR) and high risk (HR) HPV genotypes have been identified. However, available vaccines against HPV infection are designed based on the most common known genotypes. Therefore, it is critical to understand the scope and diversity of HPV genotypes in all geographical locations which can help to inform the design and development of future vaccines. OBJECTIVE: The objective of this study was to describe the burden and diversity of HPV genotypes in a cohort of women in routine care in northern South Africa. METHODS: Eighty seven women consented to participate in the study and each provided a specimen for analysis. With the help of qualified health care practitioners, Aptima Cervical Specimen Collection and Transport Kit (Hologic, San Diego, CA) was used to collect cervical specimens from each study participant following the manufacturer’s procedure. Total DNA was purified from the cervical pellet using QIAamp DNA mini kit (Qiagen, Hilden, Germany) according to the manufacturer’s instructions. The purified DNA was then subjected to a single round conventional PCR in a reaction volume of 100 μl to amplify HPV L1 gene comprising of approximately 450 bp. A portion of each PCR amplicon from each participant was denatured, hybridized and genotyped using the Linear Array HPV genotyping Test Kit (Roche Molecular Systems, Inc. Branchburg, NJ USA). The kit is designed to detect 37 HPV genotypes (genotypes 6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73, 81, 82, 83, 84, IS39 and CP6108). To detect the HPV genotypes, the Linear Array (LA) reference guide was used for results interpretation following the manufacturer’s instructions. The other portion of each of the amplicons was subjected to next generation sequencing (NGS) using the Illumina MiniSeq platform. Using the Nextera XT DNA Library preparation kit, an initial input of 1ng genomic DNA was tagmented, cleaned up, normalized and pooled. The pooled library was then denatured with 0.1 N NaOH and diluted into a final volume of 500 μl at 1.8 pM then sequenced using the Local Run Manager option following the manufacturer’s instructions. The generated sequence data was downloaded into fastaQ format and analysed using Genious 11.0.5 software. RESULTS: Of the 87 participants, the overall proportion of women harbouring HPV DNA by linear array (LA) PCR was 23% (n=20). Of the 20, 16 (80%) were living with HIV. However, this difference was not significant (p=0.077). Genotyping data generated by Roche LA method was successful for all the 20 positive amplicons. In this study, 27 (73%) of the 37 HPV genotypes incorporated in the Roche Linear Array method were detected. The detected genotypes include: types 84, 83, 81, 73, 72, 71, 70, 69, 68, 66, 62, 61, 59, 54, 53, 52, 51, 45, 42, 39, 35, 26, 18, 16, 6, IS39 and CP6108. Most women (15/20;75%) harboured multiple infections compared to single infection. In terms of genotypes distribution, the most frequent genotypes detected LR HPV types in increasing order of frequency included HPV type 61 and 83 (12%), 62 (36%) and 81 (43%). On the other hand, HPV type 66, 53, 52, 51, 18 and 16 were the most common genotypes detected HR HPV types. In contrast, although genotyping data was successfully generated from 15 of 20 women (75%), NGS technology was seen to be more sensitive compared to Roche LA method. Nearly all the detected genotypes identified by the commercial kit were detected by NGS. In addition, NGS detected 10 namely: HPV types 11, 31, 33, 40, 55, 56, 58, 64, 67, and 82 that were not detected by the LA yet incorporated in the kit. Moreover, it was observed that NGS identified additional 6 HPV types including HPV types 2, 27, 30, 35, 85 and 102 not incorporated in the Roche LA kit. A similar distribution of HPV multiple infections was observed in the study population, however, high frequency of 93% (14 of 15) was detected by NGS. The proportion of women harbouring one or more of the 22 LR HPV types was 100% (n=15).The most frequent LR genotypes in increasing order of frequency was HPV type 62 and 70 (27%), 6 (40%) and 11 (47%). HPV types 40, 42, 54, 72, 64, and 81 were the least detected genotypes with n=1 (7%) each. Furthermore, the common combination observed among the participants was type 6 and 11. In contrast, the most frequent detected genotypes in the study population by NGS under the HR HPV types in increasing order of frequency include type 35 (21%), 39, 56 and 82 (29%), 68 (36%) and 51 (50%). In addition, HPV types 26, 31, 45, 53, 56, 58 and 66 were the least detected genotypes n=1 (7%) in the study population. HPV 39 and 68 were observed as the common combination detected under HR HPV types. Following genotyping by LA and NGS, the demographic and clinical data of all the 20 positive subjects by PCR were subjected to statistical analysis to determine the association between HPV positive DNA status and associated risk factors. Smoking status (p=0.000), age at first sexual intercourse (p=0.011), vaccination status (p=0.000), gender of sexual partner (p=0.000), highest level of education (p=0.004), marital status (p=0.008) and number of sexual partners (p=0.000) were found to be having a positive statistical association. CONCLUSION: Amplification of targeted HPV DNA from cervical specimens demonstrated the presence of HPV infection in the study cohort, with a proportion of 23%. The findings illustrate that there is a diversity of HPV genotypes prevalent in the study population as shown by Roche LA and NGS methods. However, the NGS method was observed to be more sensitive than Roche LA in detecting HPV genotypes. Furthermore, NGS identified 6 additional HPV types not incorporated in the Roche LA. Thus, there are genotypes that may be present in the study population that the Roche commercial kit may fail to detect. Therefore, is it imperative to use both genotyping methods to confirm HPV genotypes. / NRF