Background: Surveillance of notifiable medical conditions (NMCs) is vital for a prompt, appropriate response. In South Africa, studies have demonstrated under-reporting of NMCs despite it being mandatory. Emergency departments (EDs) are often the first point of contact for patients with NMCs. Objectives: This study aimed to assess ED clinicians’ knowledge, attitudes, and practices regarding the reporting of conditions that are relevant to the ED, and the use of the new mobile application for reporting. Method: A cross-sectional survey was conducted between November 2024 and April 2025, including 99 doctors at three public hospital EDs in Gauteng. The study assessed knowledge, attitudes and practices regarding NMCs and the use of the recently launched National Institute for Communicable Diseases (NICD) mobile application. Results: The overall mean knowledge score was 61% (standard deviation [s.d.] 11.2). Knowledge accuracy of category 1 NMCs (mean 72%) exceeded that of category 2 NMCs (mean 56%; p 0.001). Although 95% of respondents were aware that reporting NMCs is mandatory, 49% acknowledged under-reporting. Barriers to reporting included high workload, forgetfulness, and difficulty in locating the paper notification booklet. While 81% of respondents knew about the NICD mobile application, 68% had used it, and 17% had received formal training. Preference for the application versus the paper-based system was expressed by 78% of respondents. Conclusion: Under-reporting persists primarily because of high workload. A significant knowledge gap exists, particularly concerning category 2 NMCs. While the mobile application was preferred, a lack of formal training hinders its adoption. Staff training, feedback and reminders would improve the timely notification of these conditions. Contribution: This study identifies under-reporting of NMCs and offers recommendations to strengthen the disease surveillance system and encourages the use of digital technology for reporting.
Fungal keratitis is a vision-threatening corneal infection, most commonly caused by Fusarium and Aspergillus. We report a rare case of keratitis caused by Colletotrichum coccodes in an elderly patient with a chronic corneal ulcer refractory to fluconazole. Initial corneal scrapings were negative, delaying diagnosis. Repeat deep biopsy, fungal culture and pan-fungal polymerase chain reaction confirmed C. coccodes. The patient was managed with intensive topical amphotericin B and voriconazole, alongside a glycerol-preserved corneal patch graft to provide tectonic support. Contribution: This case highlights the diagnostic and therapeutic challenges of chronic fungal keratitis and illustrates the limitations of empiric antifungal therapy in the absence of culture-based guidance.
Background: The coronavirus disease 2019 (COVID-19) pandemic created ethical and legal tension for healthcare workers (HCWs), who had to balance professional obligations with personal safety, family responsibilities and resource limitations. The concept of ‘duty to care’ re-emerged as a contested ethical construct during periods of workforce vulnerability and healthcare scarcity. Aim: This article examines the ethical and juridical dimensions of HCWs’ duty of care during the COVID-19 pandemic, focusing on the South African constitutional framework, occupational health obligations and professional regulation, and whether this duty is absolute or subject to reasonable limits. Setting: The discussion is situated within South Africa’s healthcare response to the COVID-19 pandemic and the ethical expectations placed on clinicians in high-risk and emergency settings. Method: A narrative review was conducted using PubMed, Google Scholar and grey literature. Sources included peer-reviewed ethical analyses, legal frameworks and policy documents. A thematic synthesis analysed moral theory, legal duty, reciprocity and public health ethics. Results: The duty of care is substantial but not limited. South African law supports coexistence of rights rather than hierarchical obligations. Ethical analysis shows that proportionality, reciprocity and reasonable risk mitigation conditions professional duty. Employers must ensure adequate protection, transparent triage systems and psychosocial support. Failure to ensure reciprocity risks moral coercion and workforce attrition. The pandemic highlighted the need to define the thresholds where professional obligation yields to legitimate self-protection. Conclusion: The duty of care should be reconceptualised as a conditional, relational obligation grounded in constitutional values and public health ethics, with clear risk thresholds and enforceable reciprocal protections. Contribution: This article contributes to post-COVID-19 pandemic ethics literature by clarifying between the duty to treat, care and serve, proposing a Decatrad of operational reforms, reframing the duties as conditional, reciprocal and legally bounded.
Mpox is a zoonotic orthopoxvirus infection historically linked to being in endemic regions, travel and close physical contact, including within men who have sex with men (MSM) communities. We report a case of severe mpox in a heterosexual man with advanced human immunodeficiency virus (HIV) disease and no travel history to endemic areas. The patient developed extensive cutaneous disease and transmitted mpox to household contacts, illustrating non-sexual transmission. Management included supportive care and tecovirimat under Section 21 authorisation (a regulatory mechanism in South Africa permitting access to an unregistered medicine) with good clinical response. Contribution: This case highlights the changing epidemiology of mpox, the risk of severe disease in immunocompromised patients, household and non-sexual transmission. We also emphasise the importance of early diagnosis, infection control and antiviral therapy when indicated.
A 44-year-old woman with human immunodeficiency virus (HIV), chronic kidney disease and chronic diarrhoea presented with worsening gastrointestinal symptoms and renal impairment. Despite reported adherence, she had HIV viraemia and atypical hepatitis B serology (absence of hepatitis B core antibody and co-existence of hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody) with high hepatitis B virus DNA. Whole genome sequencing of hepatitis B virus was performed using Oxford Nanopore Technologies sequencing on the Oxford Nanopore Technologies GridION (ONT, Oxford, United Kingdom). Genotype A infection with HBsAg immune escape mutations D144G/G145E was identified, without drug-resistance mutations. Contribution: Findings are most consistent with hepatitis B virus reactivation following prior natural infection and subsequent loss of immune control.
Primary infection with Varicella-Zoster virus causes varicella (chickenpox). Thereafter, following reactivation after a period of latency, it can cause zoster (shingles). Simultaneous occurrence of varicella and zoster is rare, particularly in children. Contribution: We describe an 11-year-old girl, HIV-positive, but not receiving antiretrovirals, who presented with contemporaneous varicella and zoster, with the possibility of disseminated zoster also considered.
Background: Candidozyma auris has emerged as a nosocomial pathogen in South Africa, characterised by multidrug resistance and environmental persistence. Objectives: This study aimed to describe the prevalence, disease patterns, and antifungal susceptibility patterns of C. auris isolates recovered from public-sector healthcare facilities in the greater Pretoria region from 2021 to 2024. Method: A retrospective laboratory-based surveillance study was conducted using data from the National Health Laboratory Service Tshwane Academic Division laboratory. Isolates were classified as invasive or non-invasive based on specimen source. Temporal trends in antifungal minimum inhibitory concentrations (MICs) were analysed using interval-censored regression. Results: A total of 592 C. auris isolates were identified. Blood cultures were the most frequent specimen source overall, comprising 237 isolates (40.03%). Intravascular catheter tip isolates predominated in 2023 and 2024, with 48 and 72 isolates, respectively. The proportion of invasive isolates declined from 56.8% to 40.8% over the study period. Among tested isolates, fluconazole resistance exceeded 99%. Resistance to amphotericin B and echinocandins was uncommon, with eight total isolates identified. Decreasing MIC trends were observed for amphotericin B (β = −0.059 per year; p = 0.012) and micafungin (β = −0.081 per year; p = 0.026). Conclusion: Candidozyma auris remains established in the public-sector within the greater Pretoria region. There is a shift from invasive bloodstream infections towards non-invasive, device-associated isolates. Fluconazole resistance remained high while amphotericin B and echinocandins retained good in vitro activity. Contribution: This study contributes to the knowledge of C. auris in the greater Pretoria region, providing insight into epidemiology and antifungal susceptibility.
Background: Mycoplasma and Ureaplasma species are understudied opportunistic pathogens that infect humans, animals and plants. These infections are often asymptomatic, which, together with fastidious growth requirements, makes them challenging to detect. Aim: The review aimed to provide a bibliometric analysis of available literature to reflect and assess trends, progress and knowledge gaps in this field. Setting: This article is a literature review. Method: A bibliometric analysis of 19 486 documents from 1992 to 2022 was conducted using the Web of Science database and in-depth analyses on RStudio. Results: China and the United States produced a high number of publications and citations. South Africa, the first most-cited African country, contributed 685 publications, ranking 24th globally with 2031 citations. Veterinary Microbiology was the highest performing journal with 448 papers and 10 036 citations. The most frequent keywords were ‘infection’ and ‘Ureaplasma urealyticum’. Conclusion: Research on Mycoplasma and Ureaplasma infections has progressed over time, but mainly in developed countries. The restricted publications and moderate citations in South Africa suggest research gaps in understanding the true burden and impacts of these infections. Contribution: This study provides a comprehensive bibliometric overview of Mycoplasma and Ureaplasma infections and reports the global and local progress in this field. The overall moderate, steady growth highlights the need for broader international collaboration and expanded research efforts in low-resource countries to address existing research gaps. This expansion is essential, particularly in clinical research, for strengthening both surveillance and treatment guidelines.
Background: The burden of infections in dialysis facilities continues to rise worldwide. Due to the invasive procedures associated with haemodialysis (HD), patients undergoing HD in dialysis facilities are at high risk of acquiring bloodstream-related infections. Objective: The present study explored the practices of dialysis practitioners regarding the prevention of HD bloodstream-related infections at selected dialysis facilities in the City of Tshwane, Gauteng province, in South Africa. Methods: An exploratory-descriptive contextual qualitative study was conducted in five dialysis facilities utilising semi-structured interviews. Purposive sampling was conducted until data saturation was reached from 10 in-depth semi-structured interviews conducted with dialysis practitioners. Results: Data analysis was conducted concurrently with data collection using a qualitative thematic analysis approach, whereby Tesch’s eight-step method was used to analyse the data. One theme, infection prevention challenges of dialysis practitioners, emerged with three subthemes: (1) in-service training, (2) shortage of resources and (3) colleagues’ behaviors and practices. Conclusion: A lack of staffing, training and resources hinders the implementation of infection prevention and control (IPC) to ensure optimal care in dialysis facilities. These findings suggest that enhancing training programmes and promoting a culture of compliance with IPC protocols are crucial for improving patient safety and outcomes in dialysis settings. Contribution: This study highlights contextual insights into the infection prevention challenges faced by dialysis practitioners in South African dialysis facilities, highlighting critical gaps in training, resources and staff compliance that inform targeted interventions to reduce bloodstream infections.
Background: There is a paucity of data on gastrointestinal colonisation with Klebsiella pneumoniae (KPn) in African adults, although it is a known risk factor for developing KPn invasive disease (KPn-ID). Objectives: We investigated the risk factors for KPn gastrointestinal colonisation among a cohort of hospitalised adults without KPn-ID in South Africa, and described their clinical outcomes. Method: A cohort of hospitalised adults without KPn-ID was enrolled between 15 May 2023 to 14 May 2024 across three hospitals in Johannesburg, South Africa. Study participants had rectal swab cultures performed once, at enrolment, to determine the presence or absence of KPn gastrointestinal colonisation, and were followed up until in-hospital death or discharge. Results: Among the cohort of hospitalised adults without KPn-ID (n = 651), the rate of KPn gastrointestinal colonisation was 34.4% (224/651). Risk factors for KPn colonisation were peptic ulcer disease (adjusted odds ratio [aOR] 7.75; 95% confidence interval [CI]: 1.34-44.78), a central venous catheter (aOR 3.07; 95% CI: 1.00-9.40), a presumed healthcare-associated infection (pHAI) (aOR 3.13; 95% CI: 1.06-9.28), and length of stay more than seven days prior to enrolment (aOR 1.84; 95% CI: 1.23-2.75). There was no difference in in-hospital case fatality risk (CFR) between participants with (3.1%; 7/224) and without (3.0%; 13/427, p = 0.955) KPn colonisation. Conclusion: KPn gastrointestinal colonisation rates among hospitalised adults without KPn-ID were higher than that of high-income settings and also varied between study sites. Length of hospital admission prior to swabbing and pHAI were associated with KPn colonisation, suggesting that infection prevention control measures play a significant role in KPn colonisation. Contribution: Large prospective cohort studies and community surveillance studies are required in settings such as ours to further investigate KPn colonisation dynamics and explore preventive strategies against KPn-ID.
We describe a case of a 22-year-old woman living with human immunodeficiency virus (HIV) who presented with classical features of secondary syphilis. Initial Rapid Plasma Reagin (RPR) testing was unexpectedly non-reactive; however, repeat RPR testing with serum dilution yielded a reactive result, illustrating the prozone phenomenon. Contribution:The prozone phenomenon is uncommon. We aim to encourage clinician-laboratory communication when there is a high pretest probability of syphilis, with serological discordance, to facilitate prompt diagnosis and treatment.
Background: A functional national adverse events following immunisation (AEFI) surveillance system is vital for guiding vaccination policies and sustaining public confidence. The system helps ensure safe immunisation delivery, thereby maintaining high delivery vaccine coverage and reducing vaccine-preventable diseases (VPDs). Optimising these systems remains a critical public health priority. Objectives: This novel study reviews and evaluates Zimbabwe's AEFI surveillance system from 1998-2024, including updates on coronavirus disease 2019 (COVID-19) vaccine safety to identify strengths, weaknesses and opportunities for improvement. Method: We conducted an in-depth analysis of all AEFI reports received from 1998-2024, assessing reporting trends, overall system performance AEFI investigation, causality assessment and feedback to reporters using the World Health Organization (WHO) Global Benchmarking Tool (GBT). Duplications were excluded, and reports with evidence of AEFI(s) after vaccination were included. Results: The findings show a steady increase in AEFI reports per annum, especially from 2006-2024, with substantial increases in 2023 and 2024, reaching rates of 64 and 82 reports per 100 000 surviving infants. The reporting rate exceeded the WHO-recommended minimum AEFI reporting rate in 13 years (50%) out of the 26 years. The COVID-19 vaccination programme generated 519 AEFI reports (23%) between 2021-2023, with reporting rates of 2.1, 0.1 and 1.1 per 100 000 population, respectively. Conclusion: A strong partnership between the immunisation programme and regulatory authority has enhanced AEFI surveillance. However, incomplete AEFI case investigations and delays in AEFIs detection remain key. System improvements should incorporate digital tools to enhance reporting investigation and signal detection, including postmortem examinations for serious AEFIs. Contribution: The unique Zimbabwe AEFI publication contributes to the scientific knowledge, challenges and potential signals to heed to enhancing vaccine safety systems.
Background: The hepatitis C virus (HCV) testing algorithm used in South African laboratories involves two tests; a serology test to detect anti-HCV antibodies and a confirmatory test to detect the presence of HCV ribonucleic acid (RNA). These tests usually require consecutive blood samples taken at more than one hospital visit, leaving patients with inconclusive diagnosis for weeks. Objectives: This study aimed to describe the prevalence and proportion of HCV seropositive cases where diagnostic opportunities were missed among patients who attended public healthcare facilities in Johannesburg, South Africa. Method: This descriptive study was conducted as a retrospective analysis of laboratory data from the Department of Medical Virology, National Health Laboratory Service, Johannesburg, South Africa. Patients for whom HCV diagnosis were requested from 2017 to 2021 were included in the study. Results: Over the five-year period, a total of 212 670 patients were tested for HCV antibodies and 8575 (4.04%) tested positive. The HCV seropositivity was recorded for 74.8% (6421/8575) of males compared to females (23.6%; 2030/8575; p 0.001). Only 25% (2183/8575) of HCV seropositive patients had a linked HCV RNA quantitative PCR test result. Conclusion: Despite an overall HCV seroprevalence of 4% in this study, only one quarter received a definitive diagnosis. This highlights that most patients are lost to follow-up because of the two-step diagnostic process, which requires them to return to the health facility for confirmatory tests. Contribution: The study highlights the need to adopt HCV reflex testing as the standard in South Africa to meet the 2030 elimination targets.
A South African woman receiving tenofovir, lamivudine and dolutegravir (TLD) with good adherence, developed virological failure with the integrase mutation R263K. Viral suppression was achieved after rapid intensification to dolutegravir 50 mg twice daily combined with atazanavir with ritonavir (ATV/r), with continuation of the nucleoside backbone (dual-anchor regimen). This case highlights the need for earlier resistance testing and specialist-guided salvage therapy for subtype C in resource-limited settings. Contribution: Archived nucleoside reverse transcriptase inhibitor (NRTI) resistance may render the background drugs functionally inactive, creating functional DTG monotherapy that can select for R263K in HIV-1 subtype C. Swift escalation to salvage therapy may mitigate viraemia. Algorithms should be formulated to warrant earlier genotyping and promote rapid efforts to limit resistance accumulation in patients with documented adherence.
Background:There are limited data on antimicrobial prescribing quality in paediatric wards in African hospitals. Objectives:This study aimed to assess the quality of antimicrobial prescribing. Method:We conducted weekly point prevalence surveys (PPSs) (15 March 2025 - 05 April 2025), assessing antimicrobial use and prescribing quality in neonatal and paediatric medical wards at Tygerberg Hospital, Cape Town, South Africa. Inpatients with active antimicrobial prescriptions at 08:00 on PPS days were included, collecting data on demographics, antimicrobials, prescription quality and time to administration (hangtime) using electronic surveys. Results:We reviewed 842 prescription charts, of which 237 (28.1%) included antimicrobial agents (23.3% neonates vs 34.4% paediatric patients; p < 0.001). Antimicrobial use was highest in the neonatal intensive care unit (58.5%) and lowest in neonatal wards (20.0%). Most antimicrobial therapy was empiric (89.0%), with pneumonia (49.2%) leading in paediatric patients and sepsis (43.2%) in neonates. Ceftriaxone (20.9%) dominated paediatric use, while ampicillin (20.4%) and meropenem (16.7%) predominated in neonates. Overall, 49.8% of agents were 'Access', 49.3% 'Watch' and 0.9% 'Reserve' from the World Health Organization 'AWaRe' classification. The intravenous route of administration predominated (79.0%). Median treatment duration was 5 days (interquartile range [IQR] 5-7 days). In patients with sepsis, the median hangtime was 109 min (IQR 30 min - 205 min), with only 23.2% initiated within 60 min. Prescription quality was suboptimal: allergies were documented in 37.1%, infection source in 29.0% and stop dates in 38.0%. Conclusion:Antimicrobial prescribing in these neonatal and paediatric wards showed frequent use of broad-spectrum agents, delayed administration and incomplete documentation. Contribution:The findings highlight the need for improved stewardship practices to promote timely, appropriate and well-documented antimicrobial use.
Background:The emergence of the novel coronavirus disease 2019 (COVID-19), in late 2019 in Wuhan City, has led to a global outbreak of COVID-19, culminating in the declaration of a pandemic by the World Health Organization. Objectives:The aim of the study was to evaluate the factors predicting the outcome in patients with COVID-19 infection. Method:This was a retrospective study using secondary data of patients admitted with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) results at Pietersburg Hospital between 01 March 2020 and 31 March 2021, which were extracted from DATCOV portal. Results:There were 444 eligible study participants, of which 225 (50.7%) were female and 219 (49.3%) were male patients. Their median age was 57 years. A total of 159 (36%) in-hospital deaths related to COVID-19 infection were reported. Using the logistic regression model, two predictor variables, age and intensive care unit (ICU) admission were independently associated with mortality. An increase in patient's age per year, increased the odds of dying. The ICU admission had a three-fold odds for non-survival. In-hospital mortality was associated with shorter length of hospitalisation because of disease severity and late patient presentation, with a median duration of 4 days (interquartile range [IQR] 2.0-9.0). Conclusion:Age and ICU admission were significantly related to non-survival, with hypertension being the common factor in all deaths reported. Contribution:The study emphasises the importance of pandemic preparedness and strengthening healthcare services to protect vulnerable groups such as the elderly population.
This Table of Contents reflects the print compilation of peer-reviewed articles published in the journal. Each article listed was originally published online under the journal’s open access model and remains individually accessible and citable. This compilation has been created solely for print distribution, reference, and archival purposes. No new research content is introduced. The publisher affirms that all articles included in this compilation have undergone the journal’s standard editorial and peer-review processes.
Background: Marburg virus disease (MVD) poses an emerging threat to Nigeria, particularly following the 2022 outbreak in neighbouring Ghana. With Nigeria already managing Lassa fever and Mpox outbreaks, assessing healthcare workers’ preparedness at viral haemorrhagic disease reference centres is crucial for effective outbreak response. Objectives: This study aimed to assess healthcare workers’ knowledge, attitudes and preparedness regarding MVD at Nigeria’s primary viral haemorrhagic fever reference centre. Method: A cross-sectional study was conducted at Irrua Specialist Teaching Hospital, from May 2024 to October 2024. Healthcare workers were recruited using simple random sampling and data collected via semi-structured questionnaires. Descriptive and inferential statistics were analysed using Stata 17. Results: Of the 216 participants, 126 (58.3%) were doctors and 90 (41.7%) were nurses. Doctors demonstrated significantly higher knowledge of MVD symptoms (65.9% vs 46.7%, p 0.001) and risk factors, with fever being the most recognised symptom (68.0%). Only 19.1% of doctors and 10.0% of nurses had received formal MVD training. Confidence in hospital preparedness was paradoxically lower among doctors (32.5%) than nurses (65.6%, p 0.001). Most participants felt inadequately equipped with personal protective equipment, with only 38.1% of doctors and 48.9% of nurses reporting adequate protection. Conclusion: Significant gaps exist in MVD health literacy and outbreak preparedness among Nigerian healthcare workers at a major viral haemorrhagic disease centre. Contribution: Enhanced training programmes, improved resource allocation and systematic preparedness protocols are urgently needed to strengthen Nigeria’s capacity for MVD outbreak response.
Background: Carbapenem-resistant Enterobacterales (CRE) pose a critical threat to public health, marked by limited therapeutic options, high mortality rates and significant pressure on healthcare systems. Despite the growing global burden, our region remains under-represented in national surveillance efforts, with a notable absence of local data. Objectives: This study aims to describe the epidemiological, clinical and microbiological characteristics, as well as patient outcomes, of CRE bacteraemia at Universitas Academic Hospital in Bloemfontein, South Africa, over a 5-year period. Method: A retrospective file review was performed for all adult in-patients with confirmed CRE bacteraemia admitted between 2019 and 2023. Data collected included patient demographics, comorbidities and clinical data pertaining to admission, microbial characteristics and clinical outcomes. Results: Ninety-four episodes of CRE bacteraemia were identified in 88 patients. Prior antibiotic exposure was present in 90.9%, while 79.5% had comorbidities and 61.4% acute renal impairment. Klebsiella pneumoniae (84%) and Enterobacter cloacae (9.6%) were the predominant organisms cultured, with oxacillinase-48 (OXA-48) (78.4%) and New Delhi metallo-β-lactamase (NDM) (6.7%) being the most common carbapenemase genes detected. Only 13.8% of OXA-48-positive episodes received recommended first-line antibiotics. In-hospital mortality reached 56.8%, with immunosuppressive therapy significantly associated with death (p = 0.0165). Conclusion: Mortality in our setting was substantially higher than national and international reports. Suboptimal treatment and limited access to effective antimicrobials likely contributed to these poor outcomes. Contribution: This is the first outcome-focused CRE study in this region, highlighting an urgent need for improved diagnostic capacity, antimicrobial access and targeted intervention strategies in under-resourced healthcare settings.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked disorder that increases red blood cell susceptibility to oxidative damage. While haemolysis is common, methaemoglobinaemia is a rare complication. A 39-year-old man developed both conditions, triggered by Salmonella typhi infection. Diagnosis was supported by Heinz bodies and blister cells on blood smear. Methylene blue and high-dose ascorbic acid were relatively contraindicated because of ongoing haemolysis and renal dysfunction. Contribution: This case highlights the importance of considering methaemoglobinaemia in G6PD deficiency during infections and adapting treatment when standard therapies are unsuitable.
