Thesis (MPhil (Communicable Diseases)) (Dept of Interdisciplinary Health Sciences. Community Health))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: Global control of the tuberculosis (TB) epidemic remains one of the greatest health challenges of the 21st century, despite the availability of effective treatment over the past 50 years. The rising incidence of transmitted (primary) drug resistant TB threatens the very fabric of conventional TB control efforts, which are already strained by a rampant human immunodeficiency virus (HIV) epidemic. Ongoing transmission of Mycobacterium tuberculosis is a key factor that sustains the TB epidemic in endemic areas such as the socio-economically deprived townships of Cape Town, South Africa. My research explores the disease context, or social terrain, of TB in this endemic setting. It is primarily concerned with how the social terrain of endemic TB may contribute to ongoing transmission and the potential that it holds for enhancing TB control efforts. Analyses of qualitative data from eight township research sites in and around Cape Town show that pragmatic and novel approaches are required to pierce through the enormity of TB as a political and economic problem. Broadening the current biomedical focus on treating individual patients, to include more holistic community-based interventions, can and should be developed. Data were collected as part of qualitative pre-intervention community surveys conducted in 2005 and 2006 for a public health intervention trial (ZAMSTAR) performed in Zambia and South Africa. Twenty-four communities were selected as research sites and this study draws on the survey data collected in the trial’s eight South African sites. Although the data were collected for the ZAMSTAR trial, the aims and analyses presented in this study - which seek to improve our understanding of how the social terrain is meaningful for TB control - remain independent of ZAMSTAR. Through a retrospective analysis of the South African data, I inductively present three distinctive ways in which the social terrain is meaningful for TB control. First, the interaction between social cohesion and social diversity may be an important variable that predicts community response to public health interventions aimed at reducing the prevalence of TB in these endemic areas. This is demonstrated by triangulating ZAMSTAR’S adaptation of a social systems model with further analysis of the research sites. Second, the study identifies a common discourse running through the sites that stigmatizes TB as both a dirty and HIV-related disease. It is argued that this may be significantly contributing to TB diagnostic delay and I call for more holistic approaches to TB control that can reduce perceived marginalization and TB-HIV stigma. Third, congregate settings emerge as noteworthy visible features of social terrain that clearly have the potential to facilitate TB transmission within communities. The pre-intervention surveys qualitatively described public spaces within each research site and the use thereof. Basic principles of TB transmission are applied to these descriptions, developing a novel method of mapping the relative transmission risk possibly posed. Innovative use of similar approaches could identify likely transmission “hot spots” that may serve as focal points for targeted interventions, such as adjustments that increase ventilation or encourage TB suspects to seek urgent medical diagnosis and treatment. / AFRIKAANSE OPSOMMING: Die beheer van tuberkulose (TB) bly steeds een van die grootste gesondheids uitdagings van die 21ste eeu, ten spyte van die beskikbaarheid van effektiewe behandeling vir die afgelope 50 jaar. Die stygende insidensie van oorgedraagde (primêre) middelweerstandige TB bedreig die wese van konvensionele TB kontrole programme, wat reeds gebuk gaan onder die oorweldigende impak van die menslike immuungebrek virus (MIV) epidemie. Ononderbroke oordrag van Mycobacterium tuberculosis is ‘n kardinale faktor wat die epidemie onderhou in areas soos die sosioekonomies agtergeblewe dele van Kaapstad, Suid-Afrika. My navorsing ondersoek sosiale terrein (konteks) van TB in hierdie hiperendemiese konteks. Dit is primêr gemoeid met die moontlike bydrae van die sosiale terrein tot voortgaande TB oordrag en die potensiaal wat dit mag inhou om TB kontrole te verbeter. Analise van kwalitatiewe data van agt agtergeblewe gemeenskappe in en om Kaapstad wys dat nuwe en pragmatiese benaderings benodig word om die volle omvang van TB as ‘n politieke en ekonomiese problem aan te spreek. Data is versamel as deel van kwalitatiewe pre-intervensie gemeenskapsopnames wat gedoen is gedurende 2005 en 2006 vir ‘n publieke gesondheid intervensie studie (ZAMSTAR) in Zambië en Suid-Afrika. Die studie sou poog om die TB prevalensie betekenisvol te verlaag in gemeenskappe wat erg geaffekteer word deur MIV. Vir navorsings doeleindes is vier-en-twintig gemeenskappe geselekteer, waaronder agt Suid-Afrikaanse gemeenskappe. My studie analiseer kwalitatiewe data wat versamel is in hierdie agt gemeenskappe, wat verskeie observasie en deelnemende tegnieke ingespan het. Die studie poog om algemene begrip te verbeter van hoe die sosiale terrein betekenisvol kan wees in TB kontrole; dit is my eie werk en is totaal onafhanklik van die groter ZAMSTAR studie. Induktiewe retrospektiewe analise van data identifiseer drie voorbeelde wat illustreer hoe die sosiale terrein betekenisvol mag wees vir TB kontrole. Eerstens, die interaksie tusses sosiale kohesie en sosiale diversiteit mag ‘n belangrike verandelike wees wat gemeenskapsrespons tot publieke gesondheidsintervensies voorspel. Dit word geïllustreer deur die toepassing van ‘n sosiale sisteme model (soos aangepas deur ZAMSTAR) en analise van ander aanvullende data. Tweedens, identifiseer die studie ‘n gemeenskaplike diskoers in alle navorsings gemeenskappe wat TB stigmatiseer as beide ‘n vuil en MIV-verwante siekte. Dit word geargumenteer dat hierdie verskynsel moontlik betekenisvol bydra tot vertraging van TB diagnose en die nodigheid vir meer holistiese benaderings wat marginalisasie en TB-HIV stigma kan verminder word uitgewys. Derdens blyk dit dat openbare vergaderplekke ‘n belangrike deel van die sosiale terrein vorm en duidelik die potensiaal het om TB oordrag binne gemeenskappe te fasiliteer. Die pre-intervensie opnames het alle openbare vergaderplekke sorgvuldig beskryf en basiese beginsels van TB oordrag is gebruik om vergaderplekke geografies te kaart volgens die moontlike transmissie risiko wat dit mag inhou. Innoverende gebruik van GIS-gebasseerde benaderings, soortgelyk aan die metode wat gebruik is om potensiële “transmission hot spots” te kaart, mag bydra om intervensies beter te fokus, deur bv. verbeterde ventilasie te verskaf of mense met simptome van TB aan te moedig om dringend mediese hulp te soek.

Thesis (MMed)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Introduction: The morbidity and mortality associated with tuberculosis (TB) disease is of grave consequences for the health and employment of afflicted individuals. Healthcare workers are identified amongst high risk groups in communities. The prevalence/incidence of TB is dependent on the presence of associated risk factors which varies in diversity and intensity in different communities and workplaces. Understanding the risk factors operating in any given environment is indispensable to any tuberculosis control programme. Objective: The objective of this study was to describe the occurrence and trends of TB disease as well as to determine the risk factors associated with the disease among Tygerberg hospital employees. Method: A cross-sectional descriptive study design with a nested case-control component was used to determine the occurrence (and trends) and risk factors of TB disease respectively. Occurrence and trends of tuberculosis: The frequencies, distribution and trends of TB disease from 2008 to 2011 were obtained by calculating and comparing the annual incidence rates for each variable. Cases were identified from the occupational health clinic TB register, while the various denominator data were obtained from the Human Resource database. Determination of risk factors: Cases were recruited from the occupational health clinic TB register and controls were randomly selected from unaffected workers during the study period. Self-administered risk factor questionnaires were completed by both cases and controls. Multivariate logistic regression analysis was used to determine the association between known and suspected risk factors and the occurrence of TB disease amongst employees. Results: Sixty six cases of TB disease occurred in the workforce during the study period resulting in an annual average incidence rate of 397/100,000 population (95% CI: 307/100,000-505/100,000). Twenty three (34.8%) of the 66 cases occurred in Housekeeping staff, making them the most affected sub-group [1181/100,000 population (95% CI: 747/100,000-1768/100,000)]. The rate of TB disease in nurses was 1.7 times (95%CI: 1.4-2.0) that of doctors. Workers in the 40-49 years age-group experienced the highest incidence [490/100,000 population (95%CI: 329.6/100,000-706.8/100,000)] of TB disease compared to the other age-groups. There was no obvious difference in gender occurrences. Disease rates varied among different racial groups, with the highest rate in black employees [1473/100,000 population, (95%CI: 924/100,000-1981/100,000)]. Distribution of TB disease in the institution was widespread, with security department being the most affected [2500/100,000 population (95%CI: 311/100,000- 9262/100,000)]. There was a downward but statistically insignificant (annual range 9-23; p=0.28) trend in the rate of disease occurrence over the study period. No previous training on TB prevention (OR: 2.97, 95% CI: 1.15 - 7.71), HIV (OR: 67.08, 95% CI: 7.54 – 596.64) and working without knowledge of TB risk profile of the workplace (OR: 8.66, 95% CI: 1.10 – 67.96) were associated with TB disease occurrence. Conclusion: Occurrence of TB disease among Tygerberg hospital employees was low compared to that of the general population of its drainage areas. Disease occurrence in the facility was wide and varied with respect to occupational groups, workplaces and time. Well-established risk factors for TB infection (and disease) were found to be determinants of disease occurrence in the facility.

KwaZulu-Natal is the province worst affected by the disease burden of HIV and AIDS with 38.7% of pregnant women attending antenatal clinics (ANC) testing positive for HIV in 2008 (South Africa National Department of Health, 2008; Horwood et al, 2010). The lack of male partner involvement has been recognized as a contributing factor to poor programme adherence by women initiated into the prevention of mother-to-child-transmission (PMTCT) programme in South Africa (Peltzer et al, 2011a). Increasing male partner involvement in the services, therefore, has been acknowledged as one of the strategies that may have an impact in the success of the programme (DOH, 2008; Peltzer et al., 2011a; Reece et al, 2010; Vika et al, 2010) This study aimed to explore and describe male partner involvement in PMTCT services in a selected primary health care facility in KwaZulu-Natal. Five areas were investigated: demographic factors; knowledge; socio-cultural factors; programmatic factors; and the interrelationship between demographic factors, knowledge, socio-cultural factors and programmatic factors on male involvement in PMTCT. A quantitative exploratory descriptive design was conducted in November 2012 at a selected primary health care facility in KwaZulu-Natal. Questionnaires were issued to 90 men. The study revealed some association between certain variables of interest and male involvement. The study recommended that PMTCT programmes need to boost their awareness strategies as a means of increasing male involvement in the services. / Theses (M.N.)-University of KwaZulu-Natal, Durban, 2013.

Thesis (MMed (Occupational Medicine))--Stellenbosch University, 2013. / Introduction Exposure incidents involving blood and body fluids represent a major hazard for medical undergraduates. Every medical teaching university experiences the problem of undergraduate medical students sustaining such incidents. Although Post Exposure Prophylaxis (PEP) is readily available and accessible to medical undergraduates following an incident, continuity and quality of care extends beyond the provision of PEP. This includes follow up consultations after receiving PEP according to protocol. Study Design This study was performed at the Tygerberg Campus of Stellenbosch University in Cape Town, South Africa to assess compliance with follow up consultations following an exposure incident. The study base consisted of all the medical undergraduates who reported an exposure incident at the Campus Health clinic. Cases were defined as medical undergraduate students of Stellenbosch University who had reported an exposure incident between January 2007 and December 2011. They were identified using the clinic database and records. Influential factors associated with the exposure incident, including compliance regarding follow up consultations were obtained from standardised reporting forms and medical records. The data was analysed in 2 sections, a cross sectional component (descriptive and analytical) and a retrospective cohort component. Two student cohorts were retrospectively followed from the beginning of their 3rd year to the end of their medical curriculum (6th year). Results There were 280 exposure incidents reported in the study period, of which 174 were low risk and were 106 high risk incidents for which PEP was prescribed (37.86% used PEP). For those who had high risk exposures, 90.57% (n=96) attended the 6-week follow up consultation, 48.11% (n=51) attended the 3 month visit and 34.91% (n=37) attended the 6 month follow up visit. There was an increase in the number of exposure incidents from 2010 (n=43) to 2011 (n=76). Internal medicine accounted for the most number of incidents (n=68), followed by Surgery (n=51), Obstetrics and Gynaecology (n=44), and Paediatrics (n=42). Drawing blood was the most common reported activity associated with exposures. Of notable importance was recapping, disposing of needles and insertion of blood into sample tubes. These activities accounted for 63 of the 280 exposure incidents. The 4th year students were the least at risk for exposure incidents compared to 3rd, 5th, 6th years. The annual average cumulative risk of having an exposure incident was found to be 5.7% (95%CI=4%-8%) and 6.8% (95%CI=5%-9%) amongst the 2 student cohorts over the duration of 4 years (clinical exposure time). Recommendations There is an urgent need for the number of exposure incidents to be reduced, e.g. needle recapping and disposal, and insertion of blood in sample tubes cause numerous preventable incidents. Various other strategies can be implemented in order to reduce the number of incidents across all undergraduate years of study. It is envisaged that by reducing the number of exposure incidents, there will be a subsequent decrease in the number of individuals requiring PEP. The importance of ensuring compliance with regard to follow up consultations needs to be emphasized. Factors that lead to noncompliance need to be investigated in a separate study.