Sentinel surveillance of sexually transmitted infections in South Africa: a review

OBJECTIVES

To review studies of sexually transmitted infection (STI) prevalence in South Africa between 1985 and 2003 in selected sentinel populations. To examine how STI prevalence varies between populations and to identify the limitations of the existing data.

METHODS

Studies of the prevalence of syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, gonorrhoea, chlamydia, trichomoniasis, bacterial vaginosis, candidiasis, and herpes simplex virus type 2 (HSV-2) were considered. Results were included if they related to women attending antenatal clinics or family planning clinics, commercial sex workers, individuals in the general population (household surveys), patients with STIs, patients with genital ulcer disease (GUD), or men with urethritis.

RESULTS

High STI prevalence rates have been measured, particularly in the case of HSV-2, trichomoniasis, bacterial vaginosis and candidiasis. The aetiological profile of GUD appears to be changing, with more GUD caused by HSV-2 and less caused by chancroid. The prevalence of gonorrhoea and syphilis is highest in "high risk" groups such as sex workers and attenders of STI clinics, but chlamydia and trichomoniasis prevalence levels are not significantly higher in these groups than in women attending antenatal clinics.

CONCLUSIONS

The prevalence of STIs in South Africa is high, although there is extensive variability between regions. There is a need for STI prevalence data that are more nationally representative and that can be used to monitor prevalence trends more reliably.

STD care in the South African private health sector

OBJECTIVES

To establish the accessibility and quality of sexually transmitted disease (STD) care provided by private general practitioners (GPs) and workplace health services in South Africa.

DESIGN

Structured telephone interviews were conducted with a random national sample of 120 GPs and 244 occupational health nurses (OHNs) between May and July 1997. The interview schedules covered indicators of access (including utilisation) and processes (drug treatment, partner management, counselling and condom promotion) of STD care.

RESULTS

An estimated 5 million STD-related visits were made to private general practices in 1997. Reported treatment of STDs was assessed for effectiveness using well-established syndromic case management guidelines. Only 28% of GPs reported effective treatment for urethral discharge. This dropped to 14% for genital ulcer and 4% for pelvic inflammatory disease. Fifty-five per cent of the OHNs interviewed indicated that their workplace clinics provided STD care. Nurses provided this care, with or without the support of doctors, in 87% of clinics. Reported urethral discharge and genital ulcer treatment regimens were assessed as effective in 34% and 14% of responses, respectively.

CONCLUSIONS

The private sector is a major provider of STD care and is key to national efforts to achieve better STD control, thereby preventing the spread of HIV. However, the results of the research suggest that the poor quality of STD care may be undermining attempts to control these epidemics in our society. Although a complex task, strategies need to be found to improve the quality of care provided within the private sector.

Ascospore aggregation and oxylipin distribution in the yeast Dipodascopsis tothii

Upon cultivation of the yeast Dipodascopsis tothii in its sexual stage, small ascospores are released individually from the ascus tip, which then assemble in sheathed cluster balls. In contrast to Dipodascopsis uninucleata, this yeast produced smooth bean shaped ascospores with sheath-like appendages that assemble in a disordered sheathed ball of ascospores outside the ascus. Strikingly, upon release, the ascus tip contained 3-hydroxy oxylipins, while the released ascospore clusters contained little or no 3-hydroxy oxylipins as indicated by immunofluorescence microscopy. In D. uninucleata, these oxylipins are concentrated on the spore surface and interspore matrix, but not on the ascus tip.

A novel oxylipin-associated 'ghosting' phenomenon in yeast flocculation

Research on the distribution of oxylipins (3-hydroxy fatty acids) in flocculant strains of the yeast Saccharomyces cerevisiae led to the uncovering of a novel 'ghosting' phenomenon observed during assumed lectin-mediated aggregation. We found that intracellular oxylipin-containing osmiophilic layers migrate through yeast cell walls in a 'ghostlike' fashion without visually affecting the cell wall structure or the layers. This migration resulted in the binding of these layers to cell walls of adjacent cells. Consequently, 'ghosting' seems a prerequisite for flocculation to occur. However, 'ghosting' alone may not be sufficient to ensure flocculation.

An isolation procedure for arachidonic acid producing Mortierella species

Malt extract agar and an incubation temperature of 5 degrees C were used to selectively isolate representatives of the genus Mortierella from soil. Fungi in a soil sample from mountain grassland able to grow under these conditions, amounted to a total of 2640 colony forming units per gram soil. Circa 94% of the total fungal isolates represented Mortierella subgenus Mortierella. The rest of the colony-forming units consisted of Mucor isolates (6.0%) and higher fungi (1.5%). All the Mortierella isolates produced arachidonic acid.

An acetylsalicylic acid-sensitive aggregation phenomenon in Dipodascopsis uninucleata

Aggregation of ascospores has been discovered in the yeast Dipodascopsis uninucleata. When this yeast is cultivated to reach the sexual reproductive stage, small ascospores are individually released from the tip of a sac-like ascus which then aggregate in orderly clusters. Acetylsalicylic acid (ASA) inhibited ascospore release and subsequent ordered aggregation process. We suggest that novel ASA-sensitive oxidised fatty acids (3R-hydroxy-oxylipins) and small hooks located on the surface of these ascospores, are involved.

Oxylipin formation in fungi: biotransformation of arachidonic acid to 3-hydroxy-5,8-tetradecadienoic acid by Mucor genevensis

The soil fungus Mucor genevensis was shown to convert exogenous arachidonic acid to the oxylipin 3-hydroxy-5Z,8Z-tetradecadienoic acid (3-HTDE) as determined by gas chromatography/mass spectrometry. This metabolite was only found in the aqueous supernatant together with free linoleic acid, but not in the final fungal biomass. In contrast, the corresponding primary arachidonic acid metabolite (3R)-hydroxy-(5Z,8Z,11Z,14Z)-eicosatetraenoic acid (3-HETE), which has been earlier shown to be produced by the yeast Dipodascopsis uninucleata, could not be detected. These observations may be plausibly explained by a retroconversion by M. genevensis of arachidonic acid to linoleic acid before the latter is metabolised to 3-HTDE.

Screening for sexually transmitted diseases in rural South African women

OBJECTIVE

This paper reports on a study undertaken in a rural area of South Africa, to develop a non-laboratory tool to screen for sexually transmitted diseases (STDs) among family planning clients.

METHODS

A cross sectional study was performed of 249 consecutive women attending a family planning service between November and December 1994. A questionnaire was administered, and a clinical examination and laboratory tests conducted. Sociodemographic, clinical, and other non-laboratory variables that were significantly associated with laboratory evidence of infection were combined to produce non-hierarchical scoring systems for three "syndromes": gonococcal and/or chlamydial cervical infection, trichomoniasis, and cervical infection and/or trichomoniasis combined. The sensitivity, specificity, and predictive values of the scoring systems as a screening tool were assessed against the gold standard of laboratory tests.

RESULTS

The prevalence of reproductive tract infections among the study participants was as follows: Chlamydia trachomatis 12%, Neisseria gonorrhoeae 3%, Trichomonas vaginalis 18%, and bacterial vaginosis 29%. Although vaginal discharge and other symptoms were frequently reported, symptoms bore no relation to the presence of infection. The following independent associations with gonococcal/chlamydial cervical infection were found: age less than 25 years and cervical mucopus and/or friability. Abnormal discharge on examination, visible inflammatory changes of the cervix (increased redness), no recent travel, and unemployment were associated with trichomoniasis. The combination of trichomonas and/or cervical infection ("STD syndrome") was associated with cervical mucopus/friability, unemployment, lack of financial support, and increased redness of the cervix. Of the three scoring systems developed on the basis of these associations, that of the "STD syndrome" achieved the best performance characteristics as a screening tool, with a sensitivity of 62%, specificity of 74%, and positive predictive value of 48%.

CONCLUSION

STDs are common in a population of rural, sexually active women attending a family planning service. In resource poor settings, non-laboratory screening tools could play some role in identifying and treating infections in these women, especially since the majority would not otherwise have been reached. However, such screening tools cannot be viewed as the only way to identify STDs and should be considered as part of an overall strategy of STD control that includes, for example, good management of symptomatic individuals and their partners.

Production of 3R-hydroxy-polyenoic fatty acids by the yeast Dipodascopsis uninucleata

Various fatty acids were fed to the yeast Dipodascopsis uninucleata UOFS Y 128, and the extracted samples were analyzed for the accumulation of 3-hydroxy metabolites with the help of electron impact gas chromatography-mass spectrometry. Fatty acids containing of 5Z,8Z-diene system (5Z,8Z,11Z-eicosatrienoic, 5Z,8Z,11Z,14Z-eicosatetraenoic, and 5Z,8Z,11Z,14Z,17Z-eicosapentaenoic acids) yielded the corresponding 3-hydroxy-all-Z-eicosapolyenoic acids. Moreover, linoleic acid (9Z,12Z-octadecadienoic acid) and 11Z,14Z,17Z-eicosatrienoic acid were converted to the 3-hydorxylated metabolites of shorter chain length, e,g., 3-hydroxy-5Z,8Z-tetradecadienoic acid and 3-hydroxy-5Z,8Z,11Z-tetradecatrienoic acid, respectively. In contrast, no accumulation of a 3-hydroxy metabolite was observed with oleic acid (9Z-octadecenoic acid), linolelaidic acid (9E,12E-octadecadienoic acid), gamma-linolenic acid (6Z,9Z,12Z-octadecatrienoic acid), and eicosanoic acid as substrate. These findings pinpoint that the 3-hydroxylation of a fatty acid in Dipodascopsis uninucleata requires a 5Z,8Z-diene system either directly or following initial incomplete beta-oxidation. Following analysis of the enantiomer composition, the arachidonic acid metabolite was identified as 3R-hydroxy-5Z,8Z,11Z,14Z-eicosatetraenoic acid, which rules out a normal beta-oxidation as biosynthetic route to this new class of oxylipins.

The value of lipid composition in the taxonomy of the Schizosaccharomycetales

In this study, the lipid fractions i.e. neutral (NL), phospho-(PL) and glycolipids (GL) with associated fatty acids (FAs) of 54 strains, representing the Schizosaccharomycetales, were analyzed during stationary growth phase and compared. Trace amounts of linoleic acid (18:2) were present in most of the strains representing Schizosaccharomyces. An increased percentage 18:2 was observed in the PL fraction when compared to the NL fraction. This is possibly related to membranes requiring polyunsaturated FAs for fluidity. On the basis of the percentage oleic acid (18:1) and 18:2 FAs in the different lipid fractions, the Schizosaccharomycetales can clearly be divided into two groups i.e. Group 1 (represented by the genus Hasegawaea) comprising strains producing relatively large amounts of 18:2 and relatively low amounts of 18:1 when compared to Group 2 (represented by the genus Schizosaccharomyces comprising Schizosaccharomyces octosporus and Schizosaccharomyces pombe). These results are in accordance with 18S and 26S rRNA base sequence analyses and emphasize the difference between the genera Hasegawaea and Schizosaccharomyces. Utilizing gas chromatography-mass spectrometry analyses, it was found that these strains were all capable of producing gamma-linolenic acid. This further emphasizes the uniqueness of this order in the Dikaryomycota.

The production of gamma-linolenic acid by selected members of the Dikaryomycota grown on different carbon sources

In this study, seven fungal strains, representing different phylogenetic groups within the Dikaryomycota, were tested for the presence of gamma-linolenic acid [18:3(omega 6)], when grown in synthetic liquid media devoid of fatty acids, on a series of 40 different carbon sources. The fungal strains represented the species Dipodascopsis uninucleata, Eurotium rubrum, Galactomyces geotrichum, Neurospora crassa, Saccharomyces cerevisiae, Spongipellis unicolor and Talaromyces flavus. Cultures were periodically harvested during growth and the fatty acids in the total lipids analysed as methyl esters, using gas chromatography and mass spectrometry. It was found that 18:3(omega 6) is present in E. rubrum CBS 350.65, S. unicolor CBS 117.16 and in T. flavus CBS 310.38NT, when these strains were grown on certain carbon sources. No correlation between the growth phase of the organism and the presence of 18:3(omega 6) could be detected. In order to confirm the production of 18:3(omega 6), the lipid metabolism of two unrelated dikaryomycotan fungi (S. unicolor CBS 117.16 and E. rubrum CBS 350.65) grown on two different carbon sources each, was examined. Cultures of E. rubrum CBS 350.65 were grown on glucose and sorbose and cultures of S. unicolor CBS 117.16 on glucose and sucrose in synthetic liquid media with a C:N ratio of 50:1 (w/w). The total lipids of these cultures were fractionated and the fatty acids in the fractions analysed as methyl esters, using gas chromatography and mass spectrometry. The lipid metabolism of both E. rubrum CBS 350.65 and S. unicolor CBS 117.16 differed on the two carbon sources used. The ab initio production of 18:3(omega 6) by E. rubrum CBS 350.65 in synthetic liquid media was confirmed. In contrast, the ab initio production of 18:3(omega 6) by S. unicolor CBS 117.16 in synthetic liquid media could not be confirmed.

Physiological properties and fatty acid composition in Mucor circinelloides f. circinelloides

Sporangiospores of Mucor circinelloides f. circinelloides CBS108.16 could germinate and grow on a wide variety of carbon sources in synthetic liquid media. Growth was supported by aldoses which have the same configuration at carbon atom number two as glucose. Di- and trisaccharides consisting of D-glucopyranosyl moieties were assimilated, while polysaccharides like inuline and starch were also utilised. Various alcohols and organic acids could be assimilated, while the phenolic compounds tested could not support aerobic growth. The fungus was able to ferment carbohydrates consisting of D-glucopyranosyl moieties, grow in the absence of vitamins and in the presence of cycloheximide. It also liquefied gelatin and produced lipases and cellulolytic enzymes. It was found that the highest percentages polyunsaturated fatty acids were produced when acetic acid, glucose, mannitol, soluble starch or trehalose was used as carbon source. The absence of vitamins in the medium lowered the percentage of these fatty acids.

Nutritional status of children in Alexandra township. Clinic-based data and a community survey

A community-based survey of the nutritional status of children aged 12-23 months was conducted. A cluster sampling technique was used. The weight and height of 426 children were measured. Compared with clinic-based growth-monitoring data, which showed that 5.5% of the children were below the 3rd percentile of weight for age, this survey revealed that 17.7% of boys and 9.3% of girls were below the 3rd percentile of weight for age. This may indicate that the health centre is not reaching those in greatest need. In respect of height for age, 44.3% of boys and 44.1% of girls were below the 3rd percentile while less than 4% of boys and girls were below the 3rd percentile of weight for height; this indicated a high percentage of stunting but no acute malnutrition. Growth monitoring may be an important component of a child health programme. However, unless growth is measured accurately and appropriate action implemented, growth monitoring alone is of little value. Thus before continuing with the programme of growth monitoring, the Alexandra Health Centre should ensure that health workers are adequately trained and that appropriate interventions are implemented to reduce the risks associated with children who fail to gain weight at the expected rate. Once implemented, a regular evaluation of all aspects should be undertaken.

A vaccination survey using the EPI methodology ot evaluate the impact of a child health outreach programme in an urban area of South Africa

A community-based survey of the vaccination status of children aged 12-23 months was conducted to evaluate the impact of a child health outreach programme on vaccination coverage in Alexandra township, South Africa. The EPI cluster sampling technique was adapted for this purpose. The sample size, including the number of clusters and the number of units per cluster, was increased to permit stratification of the data and comparison of the results with those obtained in a study conducted prior to the introduction of the outreach services in 1988. At the time of the survey interview, 67% of the children were fully vaccinated (78% against measles) and by 1 year of age, 58% were fully vaccinated (69% against measles). The increase in coverage since the introduction of the programme was statistically significant only for measles (Student's t-test, P < 0.01). A total of 75% of children living in formal dwellings, compared with 51% living in informal dwellings, were fully vaccinated by interview (Fisher's exact test, two tailed, P < 0.0001). Mothers from informal dwellings had a 1.88 times greater chance of not knowing about the outreach services (P < 0.001). Children whose mothers knew where vaccinations were given, attended postnatal clinics, used the outreach services, possessed a road-to-health card from the Alexandra Health Centre, and who resided in a formal dwelling all had a higher chance of being vaccinated.

Evidence for, and taxonomic value of, an arachidonic acid cascade in the Lipomycetaceae

By using specific inhibitors of the lipoxygenase and cyclo-oxygenase pathways, arachidonic acid metabolites with similar sensitivities towards these inhibitors as in humans, were detected in Dipodascopsis uninucleata. The taxonomic value of aspirin sensitive arachidonic acid metabolites in the Lipomycetaceae was next assessed. No metabolites of which the production is inhibited by aspirin were detected in strains representing the following species: Lipomyces starkeyi, Lipomyces kononenkoae, Lipomyces tetrasporus, Myxozyma melibiosi, Myxozyma mucilagina, Myxozyma kluyveri, Waltomyces lipofer, Zygozyma oligophaga and Zygozyma arxii. The detection of such aspirin sensitive arachidonic acid metabolites in representative strains of Lipomyces anomalus and the genus Dipodascopsis, emphasises the isolated position of these taxa in the genus Lipomyces and the family Lipomycetaceae, respectively. Finally using long chain fatty acid analyses, electrophoretic karyotyping and other phenotypic characters, a phylogenetic scheme is proposed for some genera in the Lipomycetaceae.

Child abuse in Alexandra. A clinic-based study and a community programme

During a 21-month period 140 cases of child abuse were seen at the Alexandra Health Centre and University Clinic. The most common form of abuse was sexual abuse (81.5%), followed by physical abuse (9.3%) and neglect (7.1%). Combined abuse was seen in 2.1% of cases. Age, sex, presentation and perpetrator are discussed and a community programme recommended.

Isolation of a novel arachidonic acid metabolite 3-hydroxy-5,8,11,14-eicosatetraenoic acid (3-HETE) from the yeast Dipodascopsis uninucleata UOFs-Y128

When arachidonic acid (AA) is added to the yeast Dipodascopsis uninucleata UOFS Y128, one of the major metabolites isolated and purified with the help of thin layer chromatography (TLC) and high performance liquid chromatography (HPLC) is 3-hydroxy-5,8,11,14-eicosatetraenoic acid (3-HETE). The structure of this new AA metabolite was elucidated mainly by electron impact (EI) mass spectrometry (MS). Strikingly, the formation of this new metabolite was found to be inhibited by aspirin.

Simultaneous occurrence of heritable t(3;7) and t(14;21) in two sibs

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The Martin-Bell syndrome in South Africa

A national screening programme was introduced in 1980 when the first cases with the Martin-Bell syndrome were diagnosed in South Africa. This survey includes patients from all the major population groups in South Africa. One thousand patients, who include 354 relatives of 21 index cases, were investigated cytogenetically. About 75% of the 354 relatives were either affected males or obligate or possible carriers. The segregation pattern of the fragile site was investigated in 271 offspring of 58 carrier women. At least 30% of the carriers were mildly mentally retarded with most expressing the fragile site. Various other investigations, such as measurements of testes, speech, verbal and IQ evaluations and hormone studies were done on several affected males. No fragile site could be demonstrated in 57 unselected autistic children. The results of this programme show that this syndrome is a common cause of mental retardation and that prevention of mental retardation is possible if all the involved families could be identified.