- ItemThe effect of covid-19 lockdown on healthcare utilisation and hospital mortality in children < 5 years of age in a large Cape Town District, South Africa(Stellenbosch : Stellenbosch University, 2023-03) Elmi, Noradin; Smit, Liezl; Rabie, Helena; Wessels, Thandi; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: Background: Lockdown policies resulted in a de-escalation of non-COVID-19 healthcare services during the COVID-19 pandemic. The aim of this study was to investigate the effect of these lockdown measures on health care utilization and in-hospital mortality in children < 5 years of age in Metro East, a large Cape Town district in South Africa. Methods: A retrospective cross-sectional study was done to compare routinely collected child health data from 1 January – 31 December 2020, the first wave of the COVID-19 pandemic, with similar time periods in 2018 and 2019. Secondary data from the Standard Information Jointly Assembled by Networked Infrastructure (SINJANI) and the Child Healthcare Problem Identification Programme (CHPIP) databases for all Metro East primary healthcare clinics (PHC) and Hospitals were included in the data analysis. Results: During hard lockdown levels, primary healthcare visits across Metro East showed a 1.8 times decline compared to the same time period in 2019 (p<0.05). A 1.2 times decline in the provision of the first dose of measles with a 1.4 times decline in the number of fully immunised children at 1 year of age were seen (p=0.84). Total hospital emergency care visits were 35.7% less in 2020 (16 368) compared to 2019 (25 446). Total hospital admissions across Metro East decreased in 2020 (9 810) compared to 2019 (10 247) and 2018 (11 698) (p<0.01), with a sharp decrease when lockdown was instituted; recording 384 admissions in April 2020 compared to 1 168 in 2019 and 1 330 in 2018. In contrast to previous years, acute gastro-enteritis [27%; 2 675/9 810] accounted for a higher proportion of hospital admissions than acute respiratory infections [22%; 2 141/9 810] in 2020. Although fewer total deaths were reported in hospitals across Metro East in 2020 (119), the in-hospital mortality rate increased from 2.3% [96/4 163] in 2019 to 3.8% [95/2 498] (p<0.01) in 2020 in Tygerberg Hospital, where 80% (95/119) of deaths were recorded. Conclusion: Measures instituted during the COVID-19 pandemic in 2020 disrupted the access to, and provision of, healthcare services for children. This resulted in an immediate, and potential future, indirect effect on child morbidity and mortality in Cape Town.
- ItemShort-term outcomes of children with multisystem inflammatory syndrome in children (MIS-C) in South Africa : a prospective cohort study(Stellenbosch : Stellenbosch University, 2023-03) Lishman, Juanita; Rabie, Helena; Abraham, Deepthi Raju; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: Background: Despite the life-threatening presentation of MISC in children, the overall prognosis is favourable in centers with access to appropriate supportive care. In this study we investigate the short-term outcomes in children with MIS-C in Cape Town, South Africa. Methods: This prospective observational cohort study in children <13 years who fulfilled the World Health Organization (WHO) case definition of MIS-C and were admitted to Tygerberg Hospital in Cape Town between 1 June 2020 and 31 October 2021. Clinical features were recorded at baseline and at followup at cardiology and rheumatology-immunology clinics respectively. Findings: Fifty-three children with a median age of 7.4 years (interquartile range (IQR) 4.2-9.9) MIS-C were included. There was a slight male predominance (30/53; 56,6%) and the majority was of mixed-race (28/53; 52,83%) or black African ancestry (24/53; 45,3%). Fourteen children (14/53; 26,4%) had comorbid disease. The median length of hospital stay was 8 days (IQR 6-10). All children had an echocardiogram performed at baseline of which 39 were abnormal (39/53; 73,6%). The majority had elevated markers of inflammation, lymphopenia, anaemia, renal impairment, hyponatremia, and elevated cardiac enzymes during the acute phase. All children were discharged alive. The median days from discharge to cardiology follow-up was 39 days (IQR 33.5-41.5) and for rheumatology immunology clinic was 70.5 days (IQR 59.5-85.0). Eleven children (11/41; 26,8%) had a persistently abnormal echocardiogram at cardiology follow-up. Systemic inflammation and organ dysfunction resolved in most. Interpretation: Although the short-term outcomes of MIS-C in our cohort were generally good, the cardiac morbidity needs further characterization and follow-up.
- ItemThe impact of BCG non-vaccination on TBM severity in a TBM-endemic setting, Cape Town : a case-controlled study(Stellenbosch : Stellenbosch University, 2023-03) Barday, Mish-Al; Solomons, Regan; Van Toorn, Ronald; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: Introduction: BCG (Bacille Calmette-Guérin) is a live-attenuated vaccine that is routinely administered at birth to all infants in the Western Cape Province of South Africa, consistent with World Health Organization (WHO) guidelines. The protective effects of BCG against tuberculous meningitis (TBM) and miliary tuberculosis (TB) was highlighted following a global BCG vaccine supply shortage in 2015 which resulted in a marked increase in the number of TBM cases in children under the age of 2 years at our institution. It is not known whether the BCG shortage also impacted on TBM disease severity. Objective: The study aimed to describe the clinical, cerebrospinal fluid (CSF) and radiological parameters in children diagnosed with TBM, with and without BCG vaccination, during two time periods: 1985-2015 and 2019-2020 at Tygerberg Hospital in Cape Town, South Africa. Design: A retrospective (1985-2015) and prospective (2019-2020) hospital-based observational cohort study. Results: 518 children with TBM were included in the study. Of the 480 consecutive TBM children in the retrospective study, 183/480 (38%) were not BCG-vaccinated, while in the prospective study of 38 consecutive TBM children, 18/38 (47%) did not receive the BCG vaccine. In the prospective group, unvaccinated TBM patients were younger (median 24.0 months, interquartile range (IQR) 12.5-36.0) compared to those who were vaccinated, median 27.5 months, IQR 19.0-48.0, however when comparing means statistical significance was not obtained; p=0.12. Age of onset was higher in the retrospective group, median 32.0 months, IQR 19.0-59.0. in both studies, non-BCG vaccination was associated with increased TBM disease severity i.e. advanced TBM stage (odds ratio (OR) 2.50: 95% confidence interval (CI) 1.53-4.10; p<0.01), depressed level of consciousness, GCS<15 (OR 2.45: 95% CI 1.50-4.01; p<0.01) and cranial nerve palsy (OR 1.65: 95% CI 1.10-2.47; p<0.01) in the retrospective study, and hemiparesis (OR 6.07: 95% CI 1.49-24.76; p<0.01) and extraneural mycobacteriological confirmation as evidence of disseminated TB (OR 6.14: 95% CI 1.10-32.21; p=0.03) in the prospective study. Furthermore, in the retrospective study BCG vaccination was associated with raised intracranial pressure, but with a weaker significance value (OR 0.62: 95% CI 0.39-0.99; p=0.04) Conclusion: In the prospective group, BCG non-vaccination was associated with hemiparesis and extraneural mycobacteriological confirmation. Retrospectively, BCG non-vaccination was associated with advanced stage TBM, depressed level of consciousness and cranial nerve palsy. The global BCG shortage in 2015 has contributed to an increase in TBM severity in the ensuing 4 years as demonstrated by the prospective association with hemiparesis.
- ItemThe contribution of the initial chest X-ray to the management of very low birth weight neonates admitted with respiratory distress in a resource limited tertiary hospital neonatal unit(Stellenbosch : Stellenbosch University, 2023-01) Johaar, Rizqah; Holgate, Sandi; Hassan, Haseena; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: Introduction: Respiratory distress (RD) is the most common reason for admission into a neonatal unit and current guidelines recommend non-invasive ventilation (NIV) such as high flow nasal cannula (HFNC) or nasal continuous positive airway pressure (nCPAP) as the preferred method of support. Respiratory distress syndrome (RDS), a common cause of RD, is predominantly seen in premature neonates with the risk increasing with decreasing gestational age. If commenced early, nCPAP can reduce the need for surfactant replacement in 50% of cases of RDS, however, if surfactant is needed, administration within 2 hours is recommended. The use of nCPAP has changed the classic radiographic features of RDS thus the usefulness of the CXR in very low birth weight (VLBW, ≤ 1500 g) neonates was explored. Methods: The management of inborn VLBW neonates with RD at Tygerberg Hospital, Cape Town, South Africa (1 January 2019 - 31 December 2019) was analysed retrospectively. Timing of the CXR, clinician reported CXR findings and the need for, and timing of surfactant administration was described. Main results: Of the 617 included VLBW neonates, 75 % (463/617) had a CXR done and 30 % (189/617) required surfactant. Significantly more neonates requiring a fraction of inspired oxygen (Fi02) > 0.30, or with grade III/IV RDS, received surfactant compared to those needing a Fi02 < 0.3 (74 vs 14 %) or with grade I/II RDS (78 vs 19 %). Neonates waited a median of 3 hours and 19 minutes (interquartile range [IQR] = 2 hours 31 minutes – 4 hours 46 minutes) for their initial CXR to be done. The median time to surfactant replacement therapy (SRT) was 4 hours 43 minutes (IQR = 2 hours 30 minutes – 11 hours 30 minutes), with 43 % receiving their first dose of surfactant after 6 hours of age. Those that did not have a CXR were more likely to get their surfactant in under 2 hours after birth (P = < 0.001). No additional pathology, e.g. pneumothorax, was detected on the initial CXR. Conclusion: Surfactant administration was delayed beyond 2 hours in neonates where CXR was performed. Clinical criteria, such as FiO2 requirement, seemed as useful as CXR in predicting who would need surfactant. No additional pathology was detected by CXR, suggesting it would be safe to omit x-rays in these neonates on admission and beneficial in optimizing timing of SRT and reducing radiation exposure.
- ItemOutcomes of children with malignant extracranial germ cell tumours at Tygerberg hospital(Stellenbosch : Stellenbosch University, 2023-03) Louw, Byron; Kruger, M., (Mariana); Van Zyl, Anel; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: INTRODUCTION: The objective of this study was to document the outcome of patients with malignant extracranial germ cell tumours (MEGCTs) at a paediatric oncology unit in Cape Town in the Western Cape province of South Africa. METHODS: All children diagnosed with an MEGCT between 2003 and 2018 at Tygerberg Hospital were included in the study. Data collected included demographic data, histology, tumour site, and stage, alpha-fetoprotein (AFP) level at diagnosis, treatment modalities and outcome. The data were analysed with Stata version 16.1 following a three-step analytical approach for descriptive statistics and correlational and survival analysis. RESULTS: Seventeen children were included; none were excluded. The median age was 18 months with a mean of 53.9 months (interquartile range (IQR) 8-102; standard deviation (SD) 53.8). The male-to-female ratio was 1:2.4. Seven children (41.2%) had ovarian tumours (granulosa cell tumour n=2; immature teratoma n=2; mixed germ cell tumour n=2; germinoma n=1), and four had testicular tumours (yolk sac tumour n=3; granulosa cell tumour n=1). Five patients had a sacrococcygeal yolk sac tumour and one had a pelvic immature teratoma. Nine children had only surgery, while the other eight had chemotherapy in addition to surgery. The event-free survival rate was 88.2%. One child with relapsed disease survived after successful treatment with second-line chemotherapy. Only one child, with metastatic sacrococcygeal yolk sac tumour, died. This small cohort's overall survival (OS) was excellent, with 94.1% (95% CI 71.3 - 99.9%) surviving. CONCLUSION: The outcome of this small cohort of children with MEGCT treated at Tygerberg Hospital was excellent. The one child who died had metastatic disease, supporting the importance of early diagnosis of this rare childhood cancer.