Thesis (MCurr)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Child mortality is a worldwide problem and, according to the World Health Organization (WHO), 8,1 million children under the age of five years die each year. The Millennium Development Goals focus on the worldwide reduction in child mortality by two-thirds between 2000 and 2015. Several studies show that worldwide Community Integrated Management of Childhood Illness (CIMCI) interventions by community care workers (CCWs) have a positive effect on child health. The goal of this study was to determine the factors influencing CIMCI in the rural areas of the West Coast District in the Western Cape of South Africa. The objectives for this study were to determine the factors influencing CIMCI carried out in rural areas by the CCWs, which were identified as: • having working hours that are adequate for such a comprehensive service package; • being adequately trained; • having adequate knowledge of the “16 Key Family Practices” of CIMCI; • having equipment that is adequate for the execution of their daily duties; • being able to cope with the challenges of working in rural and remote areas; and • receiving adequate supervision and support related to CIMCI. A descriptive, non-experimental exploratory research design with a quantitative approach was applied. The target population (N = 270) consisted of CCWs who are funded by the Provincial Government of the Western Cape (PGWC) in the West Coast District. For this study a response rate of 257 (95,18%) was obtained. Data was collected personally by the researcher with a self-administered questionnaire. The data was analysed with the assistance of a statistician and are presented in histograms and frequency tables. The participants were tested on their knowledge of CIMCI, and more than half of them achieved an average score that was not satisfactory. Statistically significant correlations were found between the participants’ total score achieved and highest school grade passed (p < 0. 01); their level of Expanded Public Works Programme (EPWP) training (p < 0.01); their attendance of the CIMCI five-day course (p < 0.00); and if they had done a refresher course on CIMCI (p < 0.00). The total score was also shown by the Mann-Whitney U test (p < 0.01) to have a direct relationship with whether they had received any health-related training after school. The conclusion that can be drawn is that the higher the level of education of the CCWs, the better their knowledge of CIMCI. This could also improve their work performance. The recommendations arising from this study include that CIMCI training should be standardised to ensure that the CCWs have adequate knowledge. The current policy on community-based services (CBS) of the Provincial Government Western Cape Department of Health should also be standardised to ensure adequate working hours, training, equipment and supervision, and to take into consideration the challenges of working in rural areas. In conclusion, should these recommendations be implemented, CIMCI will have a huge, positive impact on child morbidity and mortality. CCWs will be ensured adequate working hours in relation to their workload, and will receive adequate training, equipment and supervision. This will reduce the challenges CCWs face and strengthen their services in rural areas. / AFRIKAANSE OPSOMMING: Kindersterftes is wêreldwyd ’n probleem en volgens die Wêreldgesondheidsorganisasie sterf 8,1 miljoen kinders onder die ouderdom van vyf jaar elke jaar. Die Millenniumontwikkelings-doelwitte fokus daarop om kindersterftes tussen 2000 en 2015 met twee-derdes te verminder. Verskeie studies toon dat intervensies deur middel van Gemeenskapsgeïntegreerde Bestuur van Kindersiektes deur gemeenskapsorgwerkers die wêreld oor ’n positiewe effek op kindergesondheid het. Die doel van hierdie studie was om die faktore te bepaal wat Gemeenskapsgeïntegreerde Bestuur van Kindersiektes in die landelike gebiede van die Weskusdistrik in die Wes-Kaap van Suid-Afrika beïnvloed. Die doelwitte vir hierdie studie was om die faktore te bepaal wat beïnvloed hoe Gemeenskapsgeïntegreerde Bestuur van Kindersiektes in die landelike gebiede deur gemeenskapsorgwerkers uitgevoer word, wat soos volg uiteengesit is: • werksure wat voldoende is vir die omvattende pakket dienste wat aangebied word; • dat hulle voldoende opgelei is; • dat hulle voldoende kennis het van die “16 Sleutel Familiepraktyke” van Gemeenskapsgeïntegreerde Bestuur van Kindersiektes; • dat hulle die nodige toerusting besit wat voldoende is vir die uitvoer van hulle daaglikse pligte; • dat hulle raad weet met die uitdagings van werk in landelike en afgeleë gebiede; en • dat hulle voldoende toesig en ondersteuning met betrekking tot Gemeenskapsgeïntegreerde Bestuur van Kindersiektes ontvang. ’n Beskrywende, nie-eksperimentele verkennende navorsingsontwerp met ’n kwantitatiewe benadering is gebruik. Die teikenbevolking (N = 270) het bestaan uit gemeenskapsorgwerkers wat deur die Provinsiale Regering van die Wes-Kaap in die Weskusdistrik befonds word. Vir hierdie studie is ’n responstempo van 257 (95,18%) verkry. Die data is persoonlik deur die navorser deur middel van ’n selftoepastoets ingesamel. Die data is met behulp van ’n statistikus geanaliseer en word deur middel van histogramme en frekwensietabelle voorgestel. Die deelnemers is getoets op grond van hulle kennis van Gemeenskapsgeïntegreerde Bestuur van Kindersiektes, en meer as die helfte het ’n gemiddelde telling behaal wat nie bevredigend is nie. Statisties beduidende korrelasies is verkry tussen die deelnemers se totale telling en die hoogste skoolgraad behaal (p < 0.01); hulle vlak van Expanded Public Works Programme (EPWP) opleiding (p < 0.01); hulle bywoning van die vyfdaagse Gemeenskapsgeïntegreerde Bestuur van Kindersiektes kursus (p < 0.00); en of hulle ’n opknappingskursus oor Gemeenskapsgeïntegreerde Bestuur van Kindersiektes gedoen het (p < 0.00). Die totale telling is deur die Mann-Whitney U-toets (p < 0.01) gewys om ’n direkte verwantskap te hê met of hulle enige gesondheidsverwante opleiding ná skool ondergaan het. Die gevolgtrekking is dat hoe hoër die gemeenskapsorgwerkers se vlak van opvoeding, hoe beter hulle kennis van Gemeenskapsgeïntegreerde Bestuur van Kindersiektes. Dit sou ook hulle werkverrigting kon verbeter. Die aanbevelings wat uit hierdie studie spruit, sluit in dat Gemeenskapsgeïntegreerde Bestuur van Kindersiektes-opleiding gestandaardiseer moet word om te verseker dat gemeenskapsorgwerkrs voldoende kennis het. Die huidige beleid van die Provinsiale Regering van die Wes-Kaap oor gemeenskapsgebaseerde dienste moet ook gestandaardiseer word om te verseker dat hulle toereikende werksure, opleiding, toerusting en toesig het, en om die uitdagings van werk in landelike gebiede in ag te neem. Ter afsluiting: sou hierdie aanbevelings geïmplementeer word, sal Gemeenskapsgeïntegreerde Bestuur van Kindersiektes ‘n groot, positiewe impak op kindermorbiditeit en kindersterftes hê. Gemeenskapsorgwerkers sal van voldoende werksure met betrekking tot hulle werklas verseker wees, en sal voldoende opleiding, toerusting en toesig ontvang. Dit sal die uitdagings verminder waarvoor hulle te staan kom en hulle dienste in landelike gebiede versterk.

Thesis (MScSportSc)--University of Stellenbosch, 2002. / ENGLISH ABSTRACT: Numerous studies have shown that coronary artery disease (CAD) has its origin in childhood. Several risk factors that increase a person's risk for the development of CAD are prevalent amongst children. South African statistics concerning the prevalence of these risk factors are limited. Research has shown that early intervention to eliminate risk factors can decrease the risk for the development of CAD. The purpose of this study was to determine the prevalence of certain coronary risk factors amongst children aged 11 to 13 years in certain Western Cape schools. Certain selected factors were tested. These included obesity, lack of physical activity, hypertension, low physical fitness (V02max), a family history associated with an increased risk, exposure to cigarette smoke, prevalence of diabetes mellitus and an unhealthy diet. The sample consisted out of 288 children and was made up by 154 boys and 134 girls. Certain anthropometrical measurements (stature, weight, skinfoids, waist and hip circumferences) were taken. Activity levels, family history, exposure to cigarette smoke, prevalence of diabetes mellitus and diet, were measured by means of questionnaires. Physical fitness (V02max) was tested with a three-minute step-test. A sphygmomanometer was used to measure blood pressure. Depending on the circumference of the child's arm, a paediatric or adult size cuff was used. The results of the study showed that 22.01% of the boys and 59.7% of the girls had a percentage body fat so high that it was considered a coronary risk factor. Physical fitness levels were considered risk factors in 2.6% of the boys and 9% of the girls. A very high percentage of the children tested had a family history associated with an increased risk for the development of CAD (73.38% of the boys and 78.36% of the girls). Systolic hypertension was prevalent among 22.01% of the boys and 23.13% of the girls. Diastolic hypertension was only prevalent among 5.19% of the boys and 5.97% of the girls. Low activity levels were considered a risk factor in 31.17% of the boys and 39.55% of the girls. Out of all the subjects, 32.47% of the boys and 37.31% of the girls were exposed to cigarette smoke on a daily basis. The results of this study shows that certain coronary risk factors are quite common amongst children. Prevention programmes that focuses on elimination of coronary risk factors, such as hypertension, inactivity and obesity, is essential for the prevention of subsequent coronary artery disease in adults. / AFRIKAANSE OPSOMMING: Verskeie studies het al bewys dat koronêre hartvatsiekte (KHS) reeds sy ontstaan het in kinders van baie jong ouderdomme. Verskeie risikofaktore wat tot die latere ontstaan van KHS lei kom ook onder jong kinders voor. Statistiek ten opsigte van die voorkoms van hierdie risikofaktore onder kinders in Suid-Afrika is egter baie beperk. Verskeie navorsing toon dat vroeë intervensie kan lei tot "n verlaging in risiko vir die ontwikkeling van KHS op "n latere stadium. Die doel van die studie was om die voorkoms van sekere koronêre risikofaktore in kinders in Suid-Afrika te ondersoek. Sekere risikofaktore is ondersoek, dit het ingesluit, obesiteit, lae fisieke aktiwitietsvlakke, hipertensie, lae fisieke fiksheid (V02maks), 'n familie geskiedenis wat geassosieer word met "n verhoogte risiko, blootstelling aan sigaret rook, die voorkoms van diabetes mellitus en "n swak dieet. Die steekproef het bestaan uit 288 kinders waarvan 134 meisies en 154 seuns was. Verskeie antropometriese meetings (lengte, massa, velvoue, middel- en heup omtrekmates) is geneem. Aktiwiteitsvlakke, familiegeskiedenis, blootstelling aan sigarette rook, voorkoms van diabetes mellitus en dieet is deur middel van vraelyste vasgestel. Fisieke fiksheid (V02maks) is deur middel van "n drie-minuut-opstaptoets vasgestel. Bloeddruk is met "n sfigmomanometer gemeet. Afhangend van die omtrek van die kind se arm is "n pediatries- of volwasse-grootte drukband gebruik. Persentasie liggaamsvet was by 22.01% van die seuns en 59.7% van die meisies so hoog dat dit as "n risikofaktor beskou kan word. Fisieke fiksheidsvlakke kan by 2.6% van die seuns en 9% van die meisies as "n risikofaktor beskou word. "n Baie hoë persentasie van die kinders het "n familiegeskiedenis gehad wat geassosieer word met "n verhoogde risiko vir die ontwikkeling van KHS (73.38% van die seuns en 78.36% van die meisies). Sistoliese hipertensie het onder 22.01% van die seuns en 23.13% van die meisies voorgekom. Diastoliese hipertensie het baie minder voorgekom as sistoliese hipertensie (5.19% van die seuns en 5.97% van die meisies). Lae aktiwiteitsvlakke het onder 31.17% van die seuns en 39.55% van die meisies voorgekom. 'n Redelike hoë persentasie van die kinders word daagliks aan sigaretrook van hulouers of oppassers blootgestel (32.47% van die seuns en 37.31% van die meisies.) Die resultate van die studie dui aan dat daar 'n redelike hoë voorkoms van sekere koronêre risikofaktore onder kinders is. Ondersoek moet ingestel word na moontlike, goed gestruktureerde intervensieprogramme.

Dissertation submitted in partial compliance with the requirements for a Masters Degree in Technology: Homoeopathy, Durban University of Technology, 2009. / INTRODUCTION The aim of this study was to evaluate the efficacy of homoeopathic simillimum in the treatment of attention-deficit/hyperactivity disorder (AD/HD) in schoolgoing children aged 6-11 years. AD/HD affects approximately 3-5% of children worldwide. It is thus a highly prevalent childhood disorder characterised by hyperactivity, impulsivity and restlessness. There are 3 subtypes of the condition, namely combined type, predominantly inattentive type and predominantly hyperactive-impulsive type (DSM-IV-TR, 2000 pg 90). OBJECTIVE The objective of the study was to determine the efficacy of homoeopathic simillimum in the treatment of this disorder, and thus promote homoeopathy as a safe alternative to conventional AD/HD treatments. METHODOLOGY The study was conducted as a double-blind placebo-controlled study. The sample group consisted of 30 participants. There was an experimental group of 16, which was compared to a placebo control group of 14. Participants were recruited from the greater Durban area. They had to satisfy clear inclusion and exclusion criteria. Participants and parents/guardians were required to attend 3 consultations with the researcher at The Homoeopathic Day Clinic over a 2-month period. The ADHD Rating Scale-IV Home and School Versions (Appendices B and C) had to be completed by the participant’s parent/guardian and teacher respectively. One was filled in at the initial consultation to serve as a baseline reading, and thereafter, every month. Remedies were dispensed at the first 2 consultations and these remedies were decided upon after thorough case-taking, use of Radar 9.0 Homoeopathic Software and discussion with 1 of 2 selected clinicians. Those on placebo were given free treatment at the end of the study. RESULTS Statistical analysis was conducted on the ADHD Rating Scales-IV Home and School Versions (Appendices B and C), completed by the parent/guardian and teacher respectively. Improvement was based on a decrease in the rating scale score. On analysis, the results (Table 4.8, 4.9 and 4.10) showed no statistically significant effect of treatment (i.e. no difference between treatment and placebo group), but across the whole trial and within each group (particularly the treatment group) subjects had significant reductions in symptoms (i.e. the reductions in symptoms were large enough that there was less than 5% chance that they were random fluctuations/effects). This was seen in both the treatment and placebo groups, as indicated by Table 4.11, 4.12 and 4.13, but more significant reductions were seen in the treatment group, indicated by Table 4.14. As discussed in Chapter 5, this by no means rules out the efficacy of homoeopathic simillimum for the treatment of AD/HD. CONCLUSIONS A large number of parents, teachers and doctors are seeking a safe, effective way to treat this highly prevalent disorder (Soreff & Chang, 2008) and, although the study did not satisfy the hypothesis that homoeopathic simillimum is an effective treatment for AD/HD in schoolgoing children, it did aid in creating awareness of the use of homoeopathy as a treatment option for this condition and highlighted the need for more extensive research to be undertaken for this treatment option. It is the researcher’s opinion that larger, longer duration studies, employing quantitative analysis, as well as qualitative analysis would yield more significant results. / M

Glomerulonephritis as an extra hepatic manifestation of chronic HBV infection has now been well documented [1,2,3,4,5]. HBV-associated nephropathy has been described in areas of both high and low endemicity [6]. In Africa HBV-associated nephropathy has been reported from the southern, central and northern regions [7,8,9,10,11]. In the southern African continent the prevalence of HBV-associated nephropathy appears to be higher than the rest of the continent [12]. In KwaZulu/Natal, South Africa, the prevalence of hepatitis B surface antigenaemia (HbsAg) in urban, rural and institutionalised children was reported to be 6.3%, 18.5% and 35.4% and the HBV exposure rates, as shown by the presence of any marker of HBV infection, 19.5%, 65.1% and 70.1% respectively amongst black children [13]. Prior experience of nephrotic syndrome (NS) and its association with HBV in black children, already published in a series of reports, showed HBV-associated nephropathy to be the commonest form of nephrotic syndrome among black patients in KwaZulu/Natal; membranous nephropathy (MN) being the commonest histological type reported [7,14]. The only other large series of HBV-associated nephropathy in southern Africa was from Cape Town of a large cohort of children, mainly of mixed ancestory (coloured), with a small number of black children [8]. There have been no other large studies of this condition amongst black children in Africa. We therefore undertook a series of studies to delineate the spectrum of this disease in black children with regard to the following: clinical presentation, laboratory findings, natural history, biosocial background, genetics (using HLA Class I and II antigens) as well as the impact of treatment and prevention by immunisation. We commenced these studies by reviewing our 20-year experience of 636 children with NS in Durban, South Africa for the period 1976- - 1995. Three hundred and six (48.2%) were blacks, 307 (48.2%) Indians and 23 (3.6%) were a mixed group (coloured); 91 (14.3%) could not be categorised and were excluded from the analysis. In black children, membranous nephropathy accounted for 43% of all cases of NS; 86.2% of these 306 children were associated with hepatitis B virus antigens [15]. This contrasts with the 2% - 5% prevalence of idiopathic membranous nephropathy reported in western countries [16]. We then proceeded to document the clinical features of this disease in black children. One hundred and thirty-three children with NS positive for HBV carriage were studied. In 70 patients the histological type was membranous; 46 of these 70 patients were followed up for a mean of 3.4 years (range 1-11). Spontaneous elimination of both HBsAg and HBeAg occurred in 10 (21.7%) of the 46 patients; 16 (34.8%) cleared HBeAg alone. Co-existing liver disease occurred in 18 (25.7%); hypocomplementaemia (low C3 and C4) in 22 (47.8%) and 5 (10.9%) of these 46 children respectively. Sixty-five (92.9%) of the 70 patients had normal renal function; 1(1.4%) impaired renal function; 3 (4.3%) chronic renal insufficiency and 1(1.4%) end stage renal disease at last hospital visit. Twelve (17.1%) of the 70 patients were in remission; all having cleared HBeAg. HBVMN was clinically indistinguishable from 24 children with idiopathic MN although biochemical characteristics were different. There were 23 patients with histological lesions other than MN. Forty patients with clinical, biochemical and serological findings similar to those with HBVMN and the other histological types, were unbiopsied. This report delineates the natural history of HBV infection in black South African children with NS, the majority of whom have MN. Disease remission in HBVMN parallels elimination of HBV antigens, particularly HBeAg. Comparison of HBVMN with idiopathic MN revealed clinically indistinguishable characteristics but unexplained biochemical differences [14]. Little is understood of the biosocial context in which HBV-associated nephropathy (particularly MN) develops. In the next two studies we evaluated HBV status and proteinuria in family members and household contacts of index children with HBVMN to test the hypothesis that HBV carriage and asymptomatic proteinuria are closely linked and may be causally associated. In the first of these two studies, thirty-one black children with biopsy-proven HBVMN were the index cases. One hundred and fifty-two family members and 43 black household contacts were the subjects of this study. We assessed HBV carrier status by testing for HBV antigens and antibodies using enzyme-linked immunosorbent assays (ELISA) and for HBV DNA by using slot-blot hybridisation and nested polymerase chain reaction. Sequencing of the precore HBV region of HBV was done in a subset of both index cases and subjects. Proteinuria was assessed by measuring the urinary protein: creatinine ratio. Seventy-two (37%) of the 197 family members and household contacts were HBV carriers, and 53 (27%) had a protein: creatinine ratio greater than the physiological limit (protein: creatinine ratio <0.2). Abnormal proteinuria was defined by a protein: creatinine ratio 0.2. Continuous data was compared using analysis of variance. Categorical data were compared using Chi-square test or Fisher’s exact test where appropriate. A probability of <0.05 was considered significant. The frequency of abnormal proteinuria was not significantly different in those with [22 (30.5%) of 72] or without [33 (32%) of 104] HBV carriage. This lack of association remained when carriers were classified into those who were HBsAg positive only and those with active viral replication (HBsAg and/or HBeAg and/or HBV DNA; p = 0.01). Family members were more predisposed to HBV carriage than household contacts, but abnormal proteinuria was present with equal frequency (p = 0.48). Age had a significant impact on proteinuria, with children less than five years being more likely to have abnormal proteinuria (p = 0.008). The prevalence of abnormal proteinuria in family members and household contacts of the index cases was more than in community-based controls. The 10 index HBVMN cases and 14 family members and household contacts that were tested all had HBV of genotype A. The results suggest that the family members and household contacts of children with HBVMN are at very high risk of HBV carriage; they also have asymptomatic proteinuria at a significantly higher rate than community-based controls. The HBV carrier status was not associated with proteinuria. This lack of association was a finding supported by peak prevalences of proteinuria in those under five years but no corresponding peak of HBV carriage. Proteinuria may indicate glomerular basement membrane dysfunction. Environmental and social factors may underpin development of these two disorders, but are insufficient to account for the index cases of HBVMN. The emergence of children with HBVMN from such households additionally depends on unidentified and possibly genetic factors [17]. In the second study of the biosocial background in which the HBV carrier-state with MN develops, we used the same subjects. One hundred and twenty-three unrelated individuals from the communities of the index cases, negative for HBV, served as controls. In this study, proteinuria was assessed using sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) and protein: creatinine ratios. Patterns of proteinuria on SDS-PAGE were classified as glomerular, tubular or mixed; IgG and haptoglobulin were suggestive of MN. Seventy-two (36.9%) of the 195 family members and household contacts were HBV carriers; 21 (29.2%) of these carriers had evidence of proteinuria using SDS-PAGE. Twenty-eight (41.2%) of the sixty-eight members of the study group who were HBV negative and 26.8% of the controls also showed proteinuria on SDS-PAGE. This lack of association between HBV carriage and proteinuria remained when controlled for gender and family relationship. Also, HBV was not protective against the development of proteinuria. Age was associated directly with a glomerular pattern of proteinuria (p = 0.007). Those having a pattern of proteinuria suggestive of MN were more likely to have an abnormal protein: creatinine ratio (p = 0.001). Ten (59%) subjects with a membranous pattern of proteinuria and 19 (47.5%) with a non-membranous pattern of proteinuria had microscopic haematuria. Such a pattern of proteinuria was not significantly different between subjects and community based controls (8.7% vs. 6.5%, p = 0.5). Environmental exposures in these subjects may be responsible for the proteinuria, which probably reflects underlying glomerular basement membrane damage. Discordance between the HBV carrier-state and patterns of proteinuria in the study group suggest that interaction between specifically vulnerable individuals and HBV group suggest HBV and MN may not be causally related or that it reflects exceptional interaction between specifically vulnerable individuals and HBV [18]. From the above two studies we inferred that the pathogenetic mechanisms by which individuals with chronic HBV infection develop MN are probably dependent on interactions between viral, host and environmental factors; some evidence suggests a genetic predisposition. We therefore undertook another two studies to explore HLA associations in black children with HBVMN. In the first of these two studies, thirty black children, age range 2 to 16 years, with biospy-proven HBVMN, were the subjects of this study. HLA A, B and C antigens were determined using a two-stage lymphocytotoxic test. HLA DRB1* and DQB1* typing was done using sequence-specific primers. HLA class I and II antigen frequencies of the study subjects were compared to controls that were randomly chosen healthy blood donors from the same population. HLA DQB1*0603 was increased in patients with HBVMN compared to controls (chi-square 13.65, RR 4.3). DRB1*07 and DQB1*02 were increased in frequency in the study subjects but failed to reach statistical significance. There was no significant difference in the frequencies of class I antigens in the study group compared to controls. This study is the first report of HLA associations in black patients with HBVMN in whom Class I and II antigens were determined using molecular methodology. It shows a high frequency of DQB1*0603 in black children with HBVMN compared to controls suggesting a possible genetic predisposition to the development of HBVMN [19]. Following our findings of an HLA Class II association in black children with HBVMN, we proceeded to determine if HLA DQB1*0603 predisposes to HBV carriage and development of abnormal proteinuria in the second study. We studied 70 family members of 14 children with HBVMN positive for HLA DQB1*0603 selected from the first study. Associations of HLA DQB1*0603 to HBV carriage and abnormal proteinuria were determined using the mean probability ratio (LOD scores). Forty-seven of the 70 (67%) family members were positive for HBV infection. Nineteen (27%) had abnormal range proteinuria. LOD scores in the study subjects with DQB1*0603 who were HBV negative vs. those with DQB1*0603 who were HBV positive was not significant (anti-log sum = 2.0559 and average 0.23). When a similar calculation was done for abnormal proteinuria, there were no significant findings (anti-log sum = 3.8587 and average 0.43). This lack of association between HLA DQB1*0603 with either HBV carriage or abnormal proteinuria in family members suggests that additional factors may play a role in predisposing children to chronic HBV carriage and the development of MN. We therefore conclude that the main effect of HLA DQB1*0603 which distinguishes HBVMN from family members is the degree of proteinuria which is a reflection of the severity of glomerular basement membrane damage in the latter [20]. In the next study we proceed to investigate the efficacy of Interferon alpha 2b (INTRON A ®) in the treatment of HBV-associated nephropathy in black children. Twenty-four black children with biopsy-proven HBV-associated nephropathy were recruited into the study during the period April 1997 to June 1999. Five defaulted treatment and were excluded from the primary analysis. IFN 2b was administered for 16 weeks. Response to treatment was defined as loss of HBeAg, decrease in proteinuria, and prevention of deterioration in renal and liver function. A control group of 20 patients was followed up for the same period. Ten (52.6%) of the treated children responded with clearance of HBeAg by 40 weeks. None cleared HBsAg. All responders showed remission of proteinuria, 90% maintained normal renal function and 1 (10%) showed improvement of renal function. HBV DNA levels decreased in this group. Nine patients did not clear HBeAg; none showed remission of proteinuria, 2 showed deterioration of renal function. Liver enzymes rose during treatment but subsequently declined irrespective of response to therapy. No serious side effects were encountered. Only 5% of controls showed spontaneous clearance of HBeAg, and none had remission of proteinuria. Black children with HBV-associated nephropathy show accelerated clearance of HBeAg with remission of proteinuria following treatment with IFN 2b. IFN 2b was well-tolerated [21]. We then went on to investigate the impact of HBV vaccination in South Africa over 6 years on HBV-associated MN. HBV vaccine has resulted in a decline in the incidence of HBV carriage and hepatocellular carcinoma in South East Asia. Vaccine efficacy in Africa has not been adequately assessed. King Edward VIII Hospital, Durban, South Africa, is the only tertiary referral centre for the province of KwaZulu/Natal for children with renal diseases. HBV vaccine was introduced into the Extended Programme on Immunisation (EPI) in April 1995; vaccine coverage rates between 1995-2001 for children for the first, second and third doses were 85.4%, 78.2% and 62.0% respectively. HBV status was determined using radioimmunoassay (1984 – 1991) or ELISA. MN was confirmed on renal biopsy. The hospital average annual incidence of HBVMN was compared pre and post-vaccination, and according to age groups. Between 1984 and 2001 there were 119 children with HBVMN; the mean age was 7 years (range 1 to 14 years) and 101(85%) were males. The average annual rate ratio (aRR) per 105 child population was 0.25. The aRR of 0.03 for the years 2000-2001, was significantly lower than the aRR of 0.22 during the pre-immunisation period (1984 – 1994) [p = 0.003; RR = 0.12 (95% CI: 0.03 – 0.5)]. The aRR in 2000-2001 for children 0 – 4 years (0.00) and 5 – 10 years (0.09) were significantly lower than in the pre-vaccination years (0.16 and 0.46, p = 0.01 and 0.02 respectively). Thus, HBV vaccine, even at low coverage for the full EPI schedule, reduced the hospital incidence of HBVMN by six years [22]. From this series of studies we concluded that prior to the introduction of the HBV vaccine into the Expanded Programme on Immunisation in Children, HBV-associated nephropathy, particularly MN was the commonest form of NS in black children. Several studies have suggested on the basis of epidemiological, clinical and immunological evidence a causal association between chronic HBV carriage and the development of nephropathy. In our present series of studies we have findings that lend further support to the causal association between HBV carriage and development of nephropathy, particularly MN, in black children. We have shown that genetic and other environmental factors may also play a role in determining the degree of proteinuria. Those children with abnormal range proteinuria less than the nephrotic range show no association with HBV carriage or genetic factors with regard to HLA linkage. The efficacy of interferon treatment in elimination of the HBV and abrogation of proteinuria following clearance of the virus (particularly the HBeAg) as well as the impact of routine HBV immunisation in preventing HBV carriage and subsequent development of nephropathy lends further support to our findings. The impact of viral load has yet to be investigated. / Thesis (Ph.D.)-University of Natal, Durban, 2002.

CAPES / Esta tese propõe uma metodologia baseada em Ontologias e técnicas de Inteligência Artificial para apoio ao diagnóstico e ao processo de ensino-aprendizagem em Fisioterapia Neuropediátrica. Nesta área são escassas as medidas objetivas que permitam quantificar o diagnóstico e a evolução de um paciente. O diagnóstico é limitado a informar em quais meses do desenvolvimento motor normal um paciente pode ser classificado, baseando-se na experiência subjetiva do fisioterapeuta. Neste trabalho foram utilizados métodos formais para a aquisição e representação do conhecimento de especialistas da área. Conflitos de opiniões foram tratados sistematicamente e o conhecimento foi representado por uma Ontologia. Esta gerou um conjunto de regras de classificação a partir do qual três abordagens foram desenvolvidas: um sistema especialista crisp, um fuzzy e um baseado em modelos determinísticos. O primeiro teve um desempenho não condizente com a realidade do problema. O segundo se mostrou também inadequado. A abordagem com modelos determinísticos se mostrou adequada para classificar um paciente com diferentes graus de pertinência a múltiplos meses do desenvolvimento motor. Os resultados utilizando esta metodologia sugerem que o mesmo é capaz de simular objetivamente o diagnóstico fornecido por especialistas ao analisarem casos reais, em 90% dos casos. Uma extensão do trabalho foi a utilização da Ontologia em uma ferramenta de suporte ao processo de ensino-aprendizagem deste conteúdo em Fisioterapia. Esta abordagem mostrou resultados satisfatórios, tendo sido utilizada tanto por profissionais quanto por alunos, mostrando o seu potencial como recurso multimídia de ensino. 85% dos profissionais entrevistados concordaram fortemente sobre o potencial da ontologia para se tornar uma nova forma de contribuição ao processo de ensino-aprendizagem deste conteúdo. As principais contribuições desta tese são: a gestão eficiente do conhecimento em um domínio cuja característica é a fraca sistematização e a subjetividade; metodologias para apoio à quantificação do diagnóstico do paciente neuropediátrico; e o desenvolvimento de uma ferramenta para suporte ao ensino baseado em uma Ontologia. / This thesis proposes a new methodology based on ontologies and artificial intelligence techniques to support the diagnosis and the teaching-learning process in neuropediatric physiotherapy. In this area, standardized and objective measurements to quantify the diagnosis are difficultly found. The diagnosis is limited to inform in which months of the normal motor development a patient can be classified, based upon only on the subjective experience of the physiotherapist. In this work formal methods for knowledge acquisition and representations were used. Possible divergences of opinions between experts were systematically treated, and the acquired knowledge was represented as an ontology. Such ontology generated a set of classification rules from which three different approaches for diagnosis were developed: a crisp expert system, a fuzzy system, and another approach based on deterministic models. The crisp expert system did not accomplish to the problem. The fuzzy approach was not adequate too. The last approach was shown to be adequate for classifying a given patient with different degrees of membership to several months of the motor development. Results using this methodology suggested that it is capable of simulating objectively the diagnosis from human experts when analyzing real-world cases, in 90% of the cases. An extension of this work is the use of the developed ontology in a tool to support the teaching-learning process of neuropediatric physiotherapy. Such approach revealed fairly satisfactory. It was tested by professionals and students, and both found it promising as a multimedia educational resource. 85% strongly agreed about the ontology potential to be used as a tool for teaching-learning process. Overall, the main contributions of this thesis are: efficient knowledge management in a domain with weak standardization and high subjectivity of expert knowledge; methodologies for supporting the quantification of the diagnosis of a neuropediatric patient; and the development of an ontology-based multimedia tool for educational purposes.

Malgré l’existence de différents vaccins protecteurs à l’égard des infections par B. pertussis, la coqueluche reste une maladie infectieuse fréquente et est encore actuellement responsable de 300.000 décès par an dans le monde. Une meilleure compréhension des réponses immunitaires induites par les principaux facteurs de virulence de B. pertussis est donc importante afin d’optimaliser la vaccination. Alors que le rôle des anticorps dans la protection contre la coqueluche est reconnu depuis de nombreuses années, celui des réponses d’immunité cellulaire a été identifié mais est moins bien caractérisé. <p>Dans ce travail, nous avons analysé différents aspects des réponses d’immunité cellulaire induites par deux antigènes majeurs de B. pertussis, l’hémagglutinine filamenteuse (FHA) et la toxine pertussique (PT) chez des nourrissons. Nous avons étudié la persistance des réponses spécifiques des antigènes de B. pertussis après la primo vaccination des nourrissons et caractérisé différents facteurs qui modulent ces réponses, nous permettant ainsi de comprendre l’hétérogénéité des réponses d’immunité cellulaire observées tant qualitativement que quantitativement. <p>Nous avons montré que les réponses immunitaires spécifiques de la FHA et de la PT pouvaient persister jusqu’à neuf mois après la dernière administration du vaccin contre la coqueluche. Ces réponses immunitaires sont caractérisées par une production d’interféron-gamma (IFN-&61543;) par les cellules sanguines circulantes (PBMC), par une prolifération lymphocytaire ainsi que par une production d’anticorps. Bien que les lymphocytes T CD8+ participent à la sécrétion spécifique d’IFN-&61543; leur participation semble quantitativement moins importante que celle des lymphocytes T CD4+ et dépendante de ces derniers. Cependant, les PBMC de certains enfants vaccinés ne produisent pas ou peu d’IFN-&61472;&61543; après stimulation in vitro par les antigènes de B. pertussis. Cette inhibition, voire absence, de réponse immunitaire de type Th1 spécifique est associée à une sécrétion constitutive d’IL-10 par les monocytes ou à la présence de lymphocytes T CD8+. Enfin, étant donné que la FHA est inductrice d’IL-10 dans un modèle in vitro murin, nous avons analysé son effet sur la production in vitro de cette cytokine par les cellules dendritiques humaines (DCs). Nous avons montré que la FHA induit bien une production d’IL-10 par les DCs mais également les productions d’IL-12p70, d’IL-6 et d’IL-23, cytokines impliquées dans la différenciation des lymphocytes T naïfs en lymphocytes T effecteurs Th1 ou Th17. Parallèlement, nous avons testé une forme tronquée de FHA, la FHA 44 qui est également protectrice dans un modèle murin d’infection par B. pertussis. Nous avons montré que cette FHA tronquée n’induit pas de production d’IL-10 tout en induisant une production d’IL-12p70 et d’IL-23 par les DCs. La forme moléculaire de FHA présente dans les vaccins joue donc un rôle déterminant sur le type de réponses immunitaires induites et le remplacement de la FHA native dans les vaccins acellulaires par la FHA 44 devrait potentiellement permettre une meilleure réponse IFN-& / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

The differentiation, in an infant with cholestasis, between extrahepatic biliary atresia (EHBA) and the neonatal hepatitis syndrome (NHS) is important in that laparotomy is always indicated in EHBA but is undesirable in NHS. This differentiation is particularly difficult in those infants with complete cholestasis. Hepatobiliary scintigraphy is a commonly used investigation in infants with obstructive jaundice. The scintigraphic demonstration of excretion into the gut excludes extrahepatic obstruction, however, absence of excretion may be due to EHBA, severe cholestasis with patent extrahepatic bile ducts or poor uptake of the agent, and is therefore not diagnostic. This study has examined the quantitative measurement of the hepatic uptake of p-butyl IDA and Sn colloid, and an estimation of liver shape, in a group of patients with complete cholestasis in whom conventional scan interpretation, based on excretion into the-gut, would not be useful. The scans were recorded as dynamic studies and the resultant time-activity curves were subjected to curve fitting to calculate a rate constant for uptake of radiopharmaceutical. Liver shape was determined from the anterior static image of the colloid scan. The results show a significant difference between the EHBA and the NHS patients in the rate of uptake of p-butyl IDA, in the ratio of the rate of uptake of p-butyl IDA/the rate of uptake of colloid and in the measurements used to express liver shape. Using this method of scan interpretation, a diagnostic accuracy of 85% was achieved in this study of patients who clinically, and on scan, had no evidence of bile flow. Hepatic scintigraphy is therefore a useful investigation in the diagnostic work-up of infants presenting with obstructive jaundice even when bile flow is completely absent.

BACKGROUND: Ethiopia adopted a new strategy called integrated community case management to address common childhood illness (ICCM). This strategy has been introduced in some rural districts of Bale zone. It has multiple functions, involving assessment of sick children at community health post levels. Despite this, the efficacy of this strategy has not been investigated. Aim: This study aimed to assess the level of ICCM service utilisation and factors influencing this at health posts in Agarfa district. METHODS: Cross sectional and phenomenological methodologies were employed in this study. Data were collected from 401 mothers using questionnaires and 29 participants using in-depth interviews. Quantitative data were analysed using both descriptive and inferential statistical approaches. Thematic analysis was used for the qualitative data. RESULT: The utilsation of ICCM services is limited among caregivers in rural communities. There is a range of factors responsible for the limited utilisation. Examples of these include absence of health extension workers at health posts, caregivers’ negative perception of ICCM service, socio-cultural factors, level of education and household finance. The most common childhood illnesses noted were diarrhoea, followed by fever and cough. Caregivers seek help from HEWs at health posts two or more days after idenfying signs and symptoms of these illnesses. CONCLUSION: Behavioural messages to address prevailing negative attitudes and socio-economic barriers to accessing health care would help improve uptake of ICCM services / Health Studies / M.A. (Public Health)

The aim of this study was to describe mothers’ knowledge, attitudes and practices regarding malaria in children under five years old. A descriptive cross-sectional study design was used. A structured questionnaire was administered by face-to-face interviews during data collection. The study population of this research composed of mothers of children under five years old suffering from malaria in Thyolo district. Economic-demographic characteristics that were significantly associated with mothers’ knowledge were age (p=0.018), formal education (p=0.001), income (p=0.005), and type of a house (p=0.002). Sources of malaria information that were significantly associated with mothers’ knowledge included television (p=0.004), radio (p=o.005), and posters (p=o.00019). Treatment-seeking behaviour was significantly associated with education (p=0.017). Treatment prior to hospitalisation was significantly associated with mothers’ education (p=0.0001), number of children that passed away (p=0.015), distance to the health facility (p=0.013), lack of money (p=0.019), and time taken at the hospital to get treatment (p=0.016). Recommendations were made to improve mothers’ malaria knowledge for further research / Health Studies / M.A. (Public Health)

Submitted in fulfilment of the requirements for the Degree in Masters of Technology in Nursing, Durban University of Technology, 2013. / South Africa is one of 12 countries where the under-five child mortality rate has increased. In response to this challenge, the WHO and UNICEF in the 1990s developed Integrated Management of Childhood Illness (IMCI), a strategy to reduce child mortality and morbidity. IMCI training was launched in South Africa in 1998. Health care workers trained in IMCI face many challenges when applying the new integrated case management approach. Training settings tend to differ from the actual work environment. Simulation is practiced in an enclosed environment and certain assessments are not possible for example chest in drawing, level of consciousness, oedema amongst others. In South Africa, there has been limited research on IMCI in-service and pre-service training and no research has been conducted regarding the training of student nurses on IMCI and follow up of these learners in the clinical field. Purpose of the study The purpose of this study was to evaluate the IMCI training of learners in the use of IMCI Guidelines in the KwaZulu-Natal College of Nursing (KZNCN). Methodology This study followed a descriptive quantitative approach and evaluates the training of the learners and the facilitation and training of lecturers with regards to IMCI in the KZNCN campuses. Data was collected using questionnaires for facilitators and learners on the three campuses. Results The findings of this study revealed that teaching and learning approaches used to facilitate IMCI were adequate except for clinical practice and theory which was reported to be insufficient.