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Thesis (M.S.)--University of Wisconsin--Madison. / Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 24-26).

Thesis (M.D.)--Medical Society of Connecticut, 1810. / Microform version available in the Readex Early American Imprints series.

A research report submitted to the University of the Witwatersrand, Johannesburg in partial fulfillment for the requirements of the degree of Master of Medicine 2017. / Background Cryptococcal meningitis (CM) remains an ongoing and devastating disease with detrimental outcomes accounting for up to 44% of acquired immune deficiency syndrome (AIDS) related mortality. A significant portion of the cases have been attributed to recurrences, thought to be largely preventable. In the first world the recurrence rate is estimated at <5% but it is more than double that rate in developing countries. In the era of freely available antiretroviral therapy (ART) and secondary prophylaxis with fluconazole, we endeavoured to study the prevalence along with the clinical and laboratory features of patients with recurrence of CM in our setting. Objectives 1. Determine the prevalence of recurrent CM at Chris Hani Baragwanath Academic Hospital (CHBAH) for patients with the incident presentation between the years 2012-2013. 2. Determine the use of ART and fluconazole in patients with recurrent CM. The patients were divided into 4 groups reliant on whether they were on ART and fluconazole at the time of diagnosis of recurrent CM. a. Patients on ART and fluconazole. b. Patients on ART alone. c. Patients on fluconazole alone. d. Patients on no therapy. 3. Describe the clinical and laboratory features of patients with recurrent CM, as a cohort and by group. The groups were comparatively analysed. The variables studied included clinical presentation, mortality and cerebrospinal fluid (CSF) findings. Methods This was a retrospective review of adult patients presenting to Chris Hani Baragwanath Academic Hospital (CHBAH) with recurrent CM. The patients were identified using the Group for Enteric, Respiratory, and Meningeal disease Surveillance for South Africa (GERMS-SA) database. This is a nationwide network of clinical microbiology laboratories (both in the public and private sector) participating in an active laboratory-based surveillance programme for bacterial and fungal pathogens of public health importance. Specimen of patients identified to have CM are submitted to the National Institute of Communicable Diseases for confirmation and further characterisation. CHBAH is one of 25 enhanced surveillance sites where additional data including demographics, clinical findings and laboratory results were recorded. Hospital records and laboratory results were used to supplement the data. Patients with recurrent CM were identified between February 2012 and April 2014. The incident episode of CM had to have been from January 2012 to December 2013. The number of incident cases in that period was the denominator for the rate of recurrence. Results A total of 51 patients were identified from the database from an incident cohort of 658 patients with CM giving a prevalence rate for recurrent CM of 7.8%. These 51 patients had a total of 62 recurrent episodes of CM. Eight (15.7%) patients had multiple recurrences. There were 30 (58.8%) males and the median CD4 count was 85/mm3 (IQR: 3-393/mm3). The median time to recurrence was 143 days (IQR: 32-633 days). Data on the use of ART and fluconazole was available for 56 (90.3%) of recurrent episodes in 45 patients. A total of 37 (66.1%) recurrent episodes were in patients on ART and 26 (46.4%) were on fluconazole. The 56 episodes of recurrent CM were grouped as follows: 1. A total of 20 (35.7%) recurrent episodes were in patients on both ART and fluconazole. Immune reconstitution syndrome (IRIS) contributed 14 cases. 2. A total of 17 (30.4%) of recurrent episodes were in patients only on ART. 3. A total of 6 (10.7%) of the recurrent episodes were in patients on fluconazole prophylaxis only. 4. A total of 13 (23.2%) of the recurrent episodes were in patients on no therapy. The patients presented clinically with headaches (76.8%), meningism (57.1%), a Glasgow Coma Scale (GCS) <15 (30.4%) and seizures (14.3%). Twenty-seven (48.2%) cases died in hospital. Mortality was significantly higher in those with a GCS of less than 15 (82% vs. 33%, P=0.0008) and those with seizures (86% vs. 42%, P=0.0197). No statistically significant differences were noted amongst the 4 groups with respect to the clinical presentation, cerebrospinal fluid profile, the time to recurrence and mortality. Conclusion The prevalence of recurrent CM was midway between that of the developed world and a pre-ART study in Gauteng. Recurrent CM had a high mortality. The finding that one-third of patients were not on ART and that more than half were not on fluconazole at the time of diagnosis of recurrent CM, together with the high rate of multiple recurrence requires further investigation. Explicit steps need to be taken to link patients with health care facilities to ensure reliable provision of fluconazole and the initiation of ART. / MT2017

Master of Public Health - MPH / Meningitis is a common opportunistic infection and an important cause of mortality among people living with HIV and AIDS globally. This study investigated meningitis in adults living with HIV and AIDS admitted to the medical wards of Livingstone tertiary hospital in Port Elizabeth in 2018 and determined the prevalence of its aetiological types, clinical presentations, diagnostic challenges, treatment outcomes and predictors of prognosis.

Background. Internationally, infectious diseases remain the greatest cause of morbidity among young children. Infectious disease burden is particularly high in low-to-mid income countries (LMIC). South Africa has a high prevalence of bacterial meningitis (BM), especially in children under the age of five. BM is also one of the commonest causes of acquired hearing loss in children. Given the fluctuating and transient nature of BM-related hearing loss, there is a need for an effective audiological protocol to facilitate timeous and appropriate audiological management. There is currently no universally accepted protocol for the audiological referral and management of children diagnosed with BM. Consequently, there is a need for an evidence-based protocol that will ensure timely referral and audiological testing of all children diagnosed with BM. Early identification of BM-related hearing loss in children will allow for timeous, appropriate audiological management and associated benefits, such as an option for placement in mainstream schooling. Objectives. This study aimed to explore the audiological management of children diagnosed with BM at a tertiary hospital in the Western Cape, South Africa, with reference to: patterns of referral for audiological assessment following a diagnosis of BM; current audiological protocols for the management of children diagnosed with BM. It was anticipated that this study would generate evidence that could potentially be used to develop appropriate protocols for the audiological management of children diagnosed with BM in LMICs, specifically South Africa. Methods. A retrospective record review was conducted using patient folders of children between 0 and 6 years who were treated for BM between May 2016 and May 2018. Data collection took place at Red Cross War Memorial Children's Hospital, which has a paediatric infectious diseases unit and an audiology department. Demographic and audiological data were recorded on a self-developed data abstraction form and data were analysed descriptively. Results. A total of 291 patient folders were accessed for review in this study. Of those, 40 (13.7%) met the inclusion criteria for the study and were selected for review. The majority of excluded folders were for patients not referred for audiological testing post-BM diagnosis. For those children referred to audiology, average referral time was 15 days (SD = 24 days) and each patient attended an average of only 2 audiology appointments. Otoacoustic emissions testing and tympanometry were the most commonly performed audiological tests in all children. BM-related hearing loss developed in 2/19 of these patients. All patients who were diagnosed with BM-related hearing loss were subsequently fitted with hearing aids – one of whom was fitted unilaterally with a hearing aid and the other, a cochlear implant candidate, was lost to follow-up. Conclusions. The key challenge experienced in this study was low referral rates to audiology (16%), which was followed by poor adherence to follow-up appointments – both of which were found to impede effective audiological management. Effective management and prevention of BM-related hearing loss pose challenges in LMICs. This study highlights the need for a well-defined referral pathway and an evidence-based protocol for the audiological management of children with BM within the South African health care setting. If this could be achieved, the early identification of hearing loss in these children has the potential to provide them with developmental, scholastic, and working opportunities in line with those of children with normal hearing.

Meningococcal meningitis is a burden in the African meningitis belt. Before 2010, Neisseria meningitidis serogroup A (N. meningitidis A) was the predominant pathogen causing deathly epidemics. MenAfriVac® vaccine protects against N. meningitidis A. It was introduced in 2010 into highest meningitis risk health districts. There was limited data on the effects of MenAfriVac®, mainly on the degree of relationship between N. meningitidis A and the MenAfriVac® immunization. The social ecological model was used as a theoretical framework for this study. The purpose of this quantitative study was to assess the effectiveness of MenAfriVac® from 2010 to 2017 in 21 out of 26 countries of the African meningitis belt. The four research questions contributed to establishing the effects of MenAfriVac®. An interrupted time series design and nonprobability sampling were used. Secondary data were retrieved from World Health Organization database. The binomial negative regression and Pearson’s Chi-Square tests were used. The study found that after the MenAfriVac® introduction there were 39% decline of incidence rate of the meningitis suspected cases (IRR 0.61, 95% CI 0.48 – 0.79, p < .001), a high degree of relationship between N. meningitidis A and MenAfriVac® immunization (χ2 (1) = 11039.49, p = 0.000, Phi = 0.657, P=0.000), 99% decline of the risk of N. meningitidis A (RR 0.01, 95% CI 0.08-0.013), and 99.6% decline of risk of epidemic due to N. meningitidis A (RR 0.004, 95% CI 0.001-0.016). The study demonstrated that high MenAfriVac® coverage and enhanced surveillance are pivotal to reduce the meningitis burden. Results will be used to inform policy and public health practice to reduce the meningitis cases and improve quality of live in the community.

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