Introduction: A screening program has been implemented in SA with intervals of 10 years after a normal cytological result. There are no studies which evaluate repeat screening at a shorter interval in SA. Aim: This study aims to find the incidence of cytological abnormalities on a repeat test after a report of normal cytology or an inadequate pap smear. The factors associated with an abnormal cytology on repeat testing will also be explored. Methods: This is a secondary data analysis of the information obtained in a trial investigating the use of the diaphragm in the prevention of HIV infection between 2004 and 2006. Women were offered a Papanicolaou (Pap) smear at the enrolment visit and again at the end of the trial. The incidence of abnormal cytology after a normal or inadequate cytology was obtained. Demographic factors, history, clinical findings and tests for STI were compared amongst women with a normal and abnormal Pap smear on repeat testing after a normal Pap smear. Results: The incidence of cytological abnormalities was 6.48 % per annum in women with a previously normal Pap and 11.71% per annum in women with an inadequate smear result. (Log rank test for difference significant (p=0.03)). The incidence of cytological abnormalities in women with either an inadequate Pap smear or a normal Pap smear was 7.33%. However, the incidence of a high grade lesion was less than 0.5%. Factors associated with abnormal cytology in the multivariate analysis were a history of ectopic pregnancy [OR=9.25 (CI-1.78-48.03), p=0.01], number of male partners [0R=1.12 (CI-1.03-1.22),p=0.01], number of times a women was treated for an STI [OR=6.59 (1.54-28.19), p=0.01], history of vaginal discharge [OR=13.95 (1.18-164.47), p=0.00], and HIV infection [OR=6.58 (1.14-38.16),p=0.04]. Conclusion: The incidence of significant cervical lesions is low, but it would be prudent to continue to repeat those Pap smears that are found to be inadequate with the present interval of 10 years. In women with a normal Pap smear, a repeat Pap smear after 1-2 years should only be performed if clinically indicated.

M.Fam.Med., Faculty of Health Sciences, University of the Witwatersrand, 2011

MPH, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Introduction: Cervical cancer is caused by persistent infection with high-risk Human Papilloma Virus (HPV) and is a leading cause of cancer deaths in South African women aged 15-65years. We estimated prevalence of abnormal (Atypical squmous cells of unknown significance to invasive cervical cancer) cervical cytology and associated cofactors in 18-35-year old women who tested negative for Human Immuno deficiency Virus (HIV). Method: This cervical lesion study was secondary analysis of data collected during a Microbicide Feasibility Study (MFS). MFS recruited 1100 women from public health care facilities. Women were interviewed and socio-demographic, sexual behaviour and clinical information was collected. If HIV negative, cervical and vaginal swabs were collected for Pap smear and laboratory testing for sexually-transmitted infections (STI). For the cervical lesion study, 808 women were eligible and 752 were enrolled in the study. Associations with abnormal cervical cytology were analysed using multiple logistic regression, and were reported as adjusted odds ratio (AOR) with a 95% confidence interval (CI). Results: We analysed 570 cytology specimens. Prevalence of abnormal cervical cytology was 6.7% (95% CI 4.8-9.0). Women who had an abnormal cervical cytology result were more likely than those with normal cytology results to report abnormal vaginal discharge (OR 2.33; 95% CI 1.07-5.06; p=0.03). They were also more likely to have more than one child (OR 2.21; 95% CI 1.00-4.87; p=0.05). v Discussion and conclusion: Our study showed that LSIL is common in this younger age group. Because HPV infection and thus abnormal cervical cytology are high among the younger population, this result is not unexpected. Since most LSIL regress naturally, our data support the current South African screening protocol for cervical cancer.

Thesis (M Med.(Obstetrics and Gynaecology))--University of Limpopo, 2010. / STUDY RATIONALE: Cervical cancer is the most common cancer of women on the African continent and the second most common cancer of women worldwide and in South Africa ’. It has been estimated in 1997 that, among women who received no cervical screening in South Africa, 1 in 26 women were likely to develop cervical cancer . Screening will probably decrease the incidence of cervical cancer by 60% or more . There is a direct relationship between the number of women screened by Pap smears and the decreased incidence of cervical cancer. In Iceland, where more than 90% of women were screened in that time, the incidence decreased by 80%. In Norway, where only 5% of the women were screened, the incidence only decreased by 10% . In South Africa, it is estimated that Pap smears were taken in 18.8% of white women and only 2.6% of black women in 2002 . Real-world obstacles to successful cervical cancer prevention in develo- ping countries involve people more than technologies 3. This can be ma- naged by focusing on system quality management 3. The root causes of poor quality must be examined. Suba et al 3 found causes such as obso- 7 lete supplies, poorly maintained microscopes, insufficient training and suboptimal working conditions. Successful follow-up for screen-positive women has been achieved through the allocation of budgets for dedicated personnel to recontact women with positive test results 3. Human Papillomavirus (HPV) infection is known to cause cervical can- cer. Human Papillomavirus (HPV) infection is also regarded as the most common sexually transmitted infection worldwide, with an estimated life- time risk of 79% for women to contract at least one infection between the ages of 20 and 79 years . Although some men have anal or genital lesions associated with HPV 16 and 18, most men serve as vectors of oncogenic HPV. Male partners may be important contributors to their female partners’ risk of cervical cancer . The 15 HPV types, which are classified as high risk virus types, cause 95 % of all cervical cancer. The High Risk HPV Genotypes are: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 and 82. HPV 16 and 18 together cause around 70 % of all cervical cancer ’. Squamous cell cervical cancer constitutes approximately 80% of cervical cancers . Adenocarcinoma is the second most common histological type and shows a rising incidence, even in developed countries . 8 There is geographical variation in type-specific HPV prevalence 9. HPV16 is the most common type associated with adenocarcinomas, except in Southeast-Asia, where the prevalence of HPV 18 exceeds that of HPV 16. HPV 16, 18, 35, 45and 59 are present in 96% of adenocarci- nomas of the cervix 10. A pooled analysis by Clifford et al 9 showed that the prevalence of high risk HPV types is around 18 % in sub-Saharan Africa, with HPV 16 and HPV 35 present in 8% of women. HPV 31 and HPV 33 were present in 7% of women and HPV 18 was present in 4% of women. Sub- Saharan Africa had the highest prevalence of all HPV types and Europe the lowest. The variation in prevalence of HPV 16 across regions was smaller for HPV 16 than for the other high-risk types. The next common high- risk types were HPV 33 and HPV 56 in Asia, HPV 58 in South America and HPV 31 in Europe 9. This study’s rationale was to ascertain the HPV types prevalent in pa- tients with abnormal Pap smears seen at the Gynaecological Outpatients Clinic at Dr. George Mukhari Hospital, the Gynaecological Oncology Clinic at Dr. George Mukhari Hospital, the Tshepang Clinic at Dr. George Mukhari Hospital and the Setshaba Research Centre of the University of Limpopo – Medunsa Campus in Soshanguve. 9 This study can also act as a pilot study for future studies to test the ef- fectiveness of using high risk HPV types screening as a primary screening method, instead of Pap smears, to identify patients who are at a higher risk to develop cervical cancer and who need further investigations such as Colposcopically directed biopsies.

MMed(Obstetrics and Gynaecology) / Introduction Against the high background rate of HIV among our antenatal clinic attendees, 30.3% in Gauteng in 2007, and the importance of cancer of the cervix as a health issue; this study was undertaken to determine the rate of abnormality found in cervical smears performed on HIV positive women attending the postnatal clinic at Johannesburg Hospital. The degree of abnormality and where possible its management, was reviewed. Secondly it was determined whether the immune status, namely the WHO clinical stage, CD4 cell count and viral load, correlated with the Pap smear results. Lastly patients were also analyzed according to the treatment received for HIV and their Pap smear results. Patients and Methods The study is a retrospective record review. All the patients who attended the postnatal clinic (PNC) between October 2005 and the end of July 2006, who had a Pap smear, were included. Follow-up test results were collected to the end of June 2007. A total of 324 patients attended the clinic in the study time period, of which 248 (76.5%) had a Pap smear done and 76 (23.5%) did not. iv Results The main results of interest were as follows – 131 patients (52.8%) had normal Pap smears, 64(25.8%) had LGSIL, 32 (12.9%) had HGSIL, 10 (4.0%) had ASCUS and 11 (4.4%) had Pap smears that could not be classified. In total 47.2% of the Pap smears were abnormal. There was one case of malignancy developing after an abnormal Pap smear. Patients with abnormal Pap smears tended to have a lower mean CD4 cell count while the viral load and WHO Stage did not appear to have an impact on the final analysis of the Pap smears. Conclusion The rates of cervical abnormality in HIV sero-positive patients attending the Johannesburg Hospital postnatal clinic are much higher (47.2%) than would be expected in the general population (10%), with a significant portion requiring follow-up investigation and management. It is however preferable to deal with cervical cytological abnormalities comprehensively during the screening phase rather than trying to manage a potential increase in cervical cancer cases.

Thesis (M. Med. Sc.)--University of Hong Kong, 2005.

This observational study of 100 dogs naturally infected with Babesia rossi determined whether severity of parasitaemia was associated with outcome of infection and documented the relative distribution of parasitised red blood cells (pRBC) in capillary and venous circulation. The association between increased parasitaemias and outcome with a clinically compromised circulation was also investigated. Outcome was defined as either hospitalisation with death, or hospitalisation with eventual recovery or treatment as an outpatient. Dogs were enrolled if large babesias were found on stained thin capillary blood smears made from an ear prick. Thin venous smears were prepared from jugular or cephalic blood. Parasitaemias were manually counted and expressed as the percent pRBC. Ten dogs died, 50 recovered after hospitalisation and 40 were treated as outpatients. Venous sampling site did not affect venous parasitaemia (P = 0.6). Both capillary and venous parasitaemias of dogs that died were significantly higher than those of dogs that recovered after hospitalisation (P = 0.002) and dogs that were treated as outpatients (P < 0.0001). When assessing the whole group, capillary parasitaemia (median 0.61%, range <0.05-71.6%, interquartile range (IQR) 0.22-3.75%) was significantly higher than venous parasitaemia (median 0.14%, range 0-30.6%, IQR 0.046–0.52%) with P < 0.0001. The 21 dogs with a clinically compromised circulation were more likely to die (P <0.0001) and had significantly higher capillary (median 5.98%, range 0.09-71.6%, IQR 2.44-19.41%) and venous (median 2.81%, range <0.05-30.6%, IQR 0.17-9.03%) parasitaemias than the 79 dogs with a clinically normal circulation (capillary median parasitaemia 0.38%, range <0.05-12.87%, IQR 0.16-1.42%; venous median parasitaemia 0.096%, range 0-6.13%, IQR <0.05-0.33%; P < 0.0001). This study shows that high parasitaemia is significantly associated with death in B rossi infected dogs. Unfortunately, there was a wide overlap in the parasitaemias of the three outcome groups with the result that neither capillary nor venous parasitaemias appear prognostically useful. The previous clinical suspicion that capillary parasitaemias are usually higher than venous parasitaemias is confirmed. Thus capillary samples are the most appropriate diagnostic samples. Prior observations that a clinically compromised circulation is associated with death are confirmed. This association provides a rapid means of identifying patients in need of intensive monitoring and treatment. Despite the highly significant association between compromised circulation and higher parasitaemia, it is thought unlikely that parasite burden is the sole trigger for circulatory collapse. Copyright 2006, University of Pretoria. All rights reserved. The copyright in this work vests in the University of Pretoria. No part of this work may be reproduced or transmitted in any form or by any means, without the prior written permission of the University of Pretoria. Please cite as follows: Bohm, M 2006, The comparative assessment of capillary and venous Babesia rossi parasitaemias on thin blood smears and their association with disease manifestation, MMedVet dissertation, University of Pretoria, Pretoria, viewed yymmdd < http://upetd.up.ac.za/thesis/available/etd-05042007-154527 / > / Dissertation (Master of Veterinary Medicine (Small Animal Medicine))--University of Pretoria, 2006. / Companion Animal Clinical Studies / unrestricted

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Medicine in Family Medicine. / Introduction South Africa has more people living with HIV than any other country in the world.1 Women infected with HIV have a high risk in the development of cervical dysplasia and cancer of the cervix more so than women who are not infected.2,3 Methods A cross-sectional descriptive study was carried out by reviewing cervical smears of HIV positive women in a district hospital. Three hundred and ninety cervical Pap smears were classified according to the Bethesda system. Adherence was measured by the patient’s report and viral load. Data was collected through the use of self administered questionaire and data capture sheet. Results The prevalence of abnormal Pap smears was 57 per cent and LSIL was the commonest abnormality seen (142/390, 36%). Eighty-four per cent (328/390) had stage 1 WHO-HIV classification. WHO stage 3 participants seemed to be three times more likely to have abnormal Pap smears than those with WHO stage 1 (OD 3.3, STD. error 1.70, p=0.018, 95% CI 1.23-9.04). Abnormal pap smears were seen more in participants with CD4 cell count ≤ 350 cells/μL as compared to participants with CD4 cell count ≥ 500 cells/μL { 122/172, (71.00 %) vs 48/117, (41.03%), p-0.000, 95% CI : 0.09-0.37}. Similarly, participants who did not use HAART had more abnormal results as compared to those who used HAART {42/60(70.00%) vs 180/330 (55.00%), p-0.028, 95% CI 0.28-0.93}.Adherence to HAART did not show any link with abnormal smears. Conclusion The more immune-suppressed a woman is, the higher the risk of developing cervical cancer precursors. The high risk group in this study was found to be the participants with the CD4 cell count of ≤ 350 cells/μL and the viral load ≥1000 copies/mm3. The self-reported adherence level did not show any impact.

OBJECTIVE: The incidence of endocervical adenocarcinoma has increased steadily over the past two decades. Since the Bethesda System was introduced, the diagnosis of atypical glandular cells of undetermined significance (AGUS) has also risen and now accounts for 0.461.83% of all cervical (Pap) smears. The purpose of this study was to evaluate the significance of a diagnosis of A GUS using cytohistologic correlation. STUDY DESIGN: A retrospective review of archival material from 1993 through 1996 identified 64 patients who had smears diagnosed as AGUS and had a subsequent surgical biopsy. The smears were reviewed and cytologic features analyzed and correlated with the histologic diagnosis. RESULTS: On biopsy, 3 (5%) of the 64 cases showed endocervical adenocarcinoma in situ (AIS) (1 case with invasive adenocarcinoma also), 14 (22%) had a benign glandular lesion (endocervical polyp, tubal metaplasia, microglandular hyperplasia, reactive changes), 35 (54%) had squamous intraepithelial lesion (SIL) (15 diagnosed on the original smear), and 12 (19%) had no abnormality. Among the cytologic criteria evaluated, feathering (P = .01), palisading (P < .001) and chromatin clearing (P = .002) were shown to have a significant association with the histopathologic diagnosis of AIS/adenocarcinoma. These features were also useful in distinguishing AIS/adenocarcinoma from SIL and benign glandular changes from AIS/adenocarcinoma but not benign/reactive glandular changes from SIL. CONCLUSION: A diagnosis of AGUS correlated with a clinically significant lesion in the majority of cases. Squamous dysplasia (SIL) was the most common lesion identified. The presence of feathering, nuclear palisading and chromatin clearing increased the likelihood of a histologic diagnosis of AIS/adenocarcinoma.

Excerpt: Use of a nylon brush (Cytobrush and others) with spatula to obtain Papanicolaou (Pap) smears from pregnant women is more likely to obtain sufficient endocervical cells, without adverse consequence for the mother or for the fetus.