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The Covid-19 pandemic and resultant disruptions to schooling presented significant challenges for many families. Well organised families have been shown to have a protective effect on adolescent wellbeing in periods of shock. At the onset of the Covid-19 pandemic, Asenze, a population-based cohort study, was conducting a third wave of data collection in peri-urban South Africa, examining risk and protective factors during adolescence. By March 2020, n = 272 adolescents and their caregivers (n = 241) in the cohort had been assessed when in-person data collection was halted by lockdown measures countrywide. During this cessation we undertook a brief telephonic qualitative sub-study to explore whether families enrolled in the cohort were able to cohabit cohesively and undertake distance learning during lockdown. A purposeful sample of 20 families (caregivers n = 20, adolescents n = 24) recently assessed in the Wave 3 of the main study, participated in semi-structured interviews. Quantitative data from Waves 1–3 of the main study was used to measure family function, adolescent cognitive function, and profile adolescent and caregivers. The quantitative and qualitative data were integrated to illustrate the dynamics of the participants’ lives before and during lockdown. We found that families classified as well-organized before lockdown, were more likely to report co-operation during lockdown. Adolescents who were self-motivated, had access to smartphones or the internet, and were supported by both family and educators, were well-placed to continue their education without much disruption. However, few schools instituted distance learning. Of the adolescents who were not assisted- some studied on their own or with peers, but others did no schoolwork, hindered by a lack of digital connectivity, and poor service delivery. The experience of adolescence and caregivers in the Asenze Cohort during lockdown highlight the importance of family functioning for adolescent wellbeing in crisis, as well as the need for access to health, mental health, and social services, communication upgrades, and enhancements to the education system during peaceful times, to make a difference to young lives in times of crisis.

Background In-home iron fortification for infants in developing countries is recommended for control of anaemia, but low absorption typically results in >80% of the iron passing into the colon. Iron is essential for growth and virulence of many pathogenic enterobacteria. We determined the effect of high and low dose in-home iron fortification on the infant gut microbiome and intestinal inflammation. Methods We performed two double-blind randomised controlled trials in 6-month-old Kenyan infants (n=115) consuming home-fortified maize porridge daily for 4 months. In the first, infants received a micronutrient powder (MNP) containing 2.5 mg iron as NaFeEDTA or the MNP without iron. In the second, they received a different MNP containing 12.5 mg iron as ferrous fumarate or the MNP without the iron. The primary outcome was gut microbiome composition analysed by 16S pyrosequencing and targeted real-time PCR (qPCR). Secondary outcomes included faecal calprotectin (marker of intestinal inflammation) and incidence of diarrhoea. We analysed the trials separately and combined. Results At baseline, 63% of the total microbial 16S rRNA could be assigned to Bifidobacteriaceae but there were high prevalences of pathogens, including Salmonella Clostridium difficile, Clostridium perfringens, and pathogenic Escherichia coli. Using pyrosequencing, +FeMNPs increased enterobacteria, particularly Escherichia/Shigella (p=0.048), the enterobacteria/bifidobacteria ratio (p=0.020), and Clostridium (p=0.030). Most of these effects were confirmed using qPCR; for example, +FeMNPs increased pathogenic E. coli strains (p=0.029). +FeMNPs also increased faecal calprotectin (p=0.002). During the trial, 27.3% of infants in +12.5 mgFeMNP required treatment for diarrhoea versus 8.3% in −12.5 mgFeMNP (p=0.092). There were no study-related serious adverse events in either group. Conclusions In this setting, provision of iron-containing MNPs to weaning infants adversely affects the gut microbiome, increasing pathogen abundance and causing intestinal inflammation. Trial registration number NCT01111864.

Background The shortage of healthcare professionals (HCP) negatively affects health services in rural areas in many parts of the world, as is the case in South Africa. Innovative programs designed to improve the recruitment strategies for health system in a rural area are essential. They need support with a scholarship and mentorship programme for young people from rural areas to study for health science degrees, with the aim that they would take up a post at the hospital in their community, once qualified. This paper reports the perceptions and experiences of the students and graduates sponsored by the foundation, and those of managers from the facilities where the students were ultimately placed, in order to gauge whether such a programme can make a sustainable contribution to address the shortage of health personnel in rural areas and to what extent this is happening. Methods The authors used qualitative methods, combining semi-structured in-depth interviews and focus groups and the data were analyzed thematically. Results The results provide information on students interviewed who appreciated the financial and socio-emotional support that they received. On the other hand, graduates value the availability of jobs in their home community on completion of their studies. The managers reported the success of the programme in increasing the number of healthcare personnel at the hospitals, and the increased range of available medical services. Since the graduates are familiar with the language and culture of their patients the managers considered that they are better able to assist them. Conclusions The system was well thought-out and achieved its goal of improving health services in an underdeveloped rural area of South Africa. More could be achieved if other government services in the area were simultaneously improved and if the system were replicated elsewhere. The students and graduates from rural areas are involved on sustaining health services in rural areas while rural managers support the programme and make suggestions for improvement and to promote the program in other regions.

While neurodevelopmental abnormalities are common in children with HIV infection, their detection can be challenging in settings with limited availability of health professionals. The aim of this study was to assess the ability to identify developmental disability among HIV positive and HIV negative children living in South Africa with an internationally used screen. This analysis uses a sample of 1,330 4-6 year old children and 1,231 of their caregivers in KwaZulu-Natal, South Africa, including administration of the Ten Questions (TQ) screen, a standardized medical history and physical examination conducted by a medical doctor, with hearing and vision screening, psychological assessment for cognition and language delay, and voluntary HIV testing. There was a high prevalence of disability among the sample. Compared to HIV negative children, HIV positive children were more likely to screen positive on at least one TQ item (59.3 vs 42.8%, p = 0.01), be delayed in sitting, standing or walking (OR 3.89, 95% CI = 2.1-7.2) and have difficulty walking or weakness in the arms or legs (OR = 2.7, 95%CI = 0.8-9.37). By medical doctor assessment, HIV positive children were more likely to be diagnosed with gross motor disability (OR = 3.5, 95%CI = 1.3-9.2) and hearing disability (OR = 2.5, 95%CI = 1.2-5.3). By independent psychological assessment, HIV positive children were more likely to have cognitive delay (OR = 2.2, 95%CI = 1.2-3.9) and language delay (OR = 4.3, 95%CI = 2.2-8.4). Among HIV positive children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 100% and 51.2%, respectively. Among HIV-negative children, the sensitivity and specificity of the TQ for serious disability (vs. no disability) was 90.2% and 63.9%, respectively. In this first report of the use of the TQ screen in the isiZulu language, it was found to have high sensitivity for detecting serious developmental disabilities in children, especially HIV positive children. The performance of the TQ in this sample indicates utility for making best use of limited neurodevelopmental resources by screening HIV positive children.

Prosocial behavior has positive social, cognitive, and physical health effects on the individual exhibiting the behavior as well as on society as a whole, and is integral to overall mental and physical wellbeing. The development of prosocial behavior is rooted in early childhood and learned through observation. As such, those spending time with children, especially their caregiver, play a critical role in their prosocial development. The current study investigates the impact of caregiver mental health on the prosocial development of young children over time. This paper presents a secondary analysis of child prosocial development in the Asenze Study, a longitudinal, population-based cohort study based in KwaZulu-Natal, South Africa. Children were followed-up over time from an average age of five to seven years along with their caregivers. Linear GEE regression analysis was used to assess whether a change in presence of a mental health disorder in a caregiver during this 2-year interval (using the Client Diagnostic Questionnaire) impacted the development of their child's prosocial behavior (using the Strengths and Difficulties Questionnaire). After adjusting for early child-care, child HIV status, SDQ child prosocial subscale, SDQ total difficulties score, and household order score (CHAOS), children whose caregivers acquired a mental health disorder had a significantly smaller increase in prosocial behavioral development compared to children whose caregivers never had a mental health disorder. Identifying contextually relevant modifiable factors such as this will help stimulate the development of interventions to promote prosocial development in childhood.

Schistosoma (S.) haematobium infection is a common cause of genital morbidity in adult women. Ova in the genital mucosal lining may cause lesions, bleeding, pain, discharge, and the damaged surfaces may pose a risk for HIV. In a heterogeneous schistosomiasis endemic area in South Africa, we sought to investigate if young girls had genital symptoms and if this was associated with urinary S. haematobium. In a cross-sectional study of 18 randomly chosen primary schools, we included 1057 schoolgirls between the age of 10 and 12 years. We interviewed assenting girls, whose parents had consented to their participation and examined three urines from each of them for schistosome ova. One third of the girls reported to have a history of genital symptoms. Prior schistosomal infection was reported by 22% (226/1020), this was associated with current genital symptoms (p<0.001). In regression analysis the genital symptoms were significantly associated both with urinary schistosomiasis (p<0.001) and water contact (p<0.001). Even before sexually active age, a relatively large proportion of the participating girls had similar genital symptoms to those reported for adult genital schistosomiasis previously. Anti-schistosomal treatment should be considered at a young age in order to prevent chronic genital damage and secondary infections such as HIV, sexually transmitted diseases and other super-infections.

Background: Evidence on the association between feeding practices, iron deficiency, anaemia, stunting, and impaired psychomotor development during infancy is limited. This study assessed the association between psychomotor development with early feeding practices, growth, iron status, and anaemia. Methods: This was cross-sectional baseline data of a randomised controlled trial which included 6-month-old infants and their mothers or primary caregivers (n = 750) in a peri-urban community in the North West province of South Africa. The Kilifi Developmental Inventory and a parent rating scale were used to assess psychomotor development. Feeding practices and anthropometric measurements were based on the World Health Organisation (WHO) guidelines. Anaemia and iron status were determined by blood sample analysis. Results: Prevalence of anaemia and stunting for the infants were 36.4% and 28.5%, respectively. Multiple regression analysis showed that birth weight was related to combined psychomotor scores (β = −3.427 (−4.603, 1.891), p < 0.001), as well as parent rating scores (β = −0.843 (−1.507, −0.180), p = 0.013). Length-for-age z-scores were associated with combined psychomotor scores (β = −1.419 (−2.466, 0.373), p = 0.008), as well as parent rating scores (β = −0.747 (−1.483, −0.010), p = 0.047). Conclusions: In this setting, with high prevalence of anaemia and stunting, important associations between lower psychomotor development scores and birthweight as well as length-for-age z-scores in 6-month-old infants were found. These findings warrant further investigation to develop a greater understanding of factors influencing the association between child growth and psychomotor development within the first 1000 days of life.

Hepcidin regulation by competing stimuli such as infection and iron deficiency has not been studied in infants and it's yet unknown whether hepcidin regulatory pathways are fully functional in infants. In this cross-sectional study including 339 Kenyan infants aged 6.0±1.1 months (mean±SD), we assessed serum hepcidin-25, biomarkers of iron status and inflammation, and fecal calprotectin. Prevalence of inflammation, anemia, and iron deficiency was 31%, 71%, 26%, respectively. Geometric mean (±SD) serum hepcidin was 6.0 (±3.4) ng/mL, and was significantly lower in males than females. Inflammation (C-reactive protein and interleukin-6) and iron status (serum ferritin, zinc protoporphyrin and soluble transferrin receptor) were significant predictors of serum hepcidin, explaining nearly 60% of its variance. There were small, but significant differences in serum hepcidin comparing iron deficient anemic (IDA) infants without inflammation to iron-deficient anemic infants with inflammation (1.2 (±4.9) vs. 3.4 (±4.9) ng/mL; P<0.001). Fecal calprotectin correlated with blood/mucus in the stool but not with hepcidin. Similarly, the gut-linked cytokines IL-12 and IL-17 did not correlate with hepcidin. We conclude that hepcidin regulatory pathways are already functional in infancy, but serum hepcidin alone may not clearly discriminate between iron-deficient anemic infants with and without infection. We propose gender-specific reference values for serum hepcidin in iron-replete infants without inflammation.

Little is known about the effects of combined micronutrient and sugar consumption on growth and cognition. In the present study, we investigated the effects of micronutrients and sugar, alone and in combination, in a beverage on growth and cognition in schoolchildren. In a 2 × 2 factorial design, children (n 414, 6–11 years) were randomly allocated to consume beverages containing (1) micronutrients with sugar, (2) micronutrients with a non-nutritive sweetener, (3) no micronutrients with sugar or (4) no micronutrients with a non-nutritive sweetener for 8·5 months. Growth was assessed and cognition was tested using the Kaufman Assessment Battery for Children version II (KABC-II) subtests and the Hopkins Verbal Learning Test (HVLT). Micronutrients decreased the OR for Fe deficiency at the endpoint (OR 0·19; 95 % CI 0·07, 0·53). Micronutrients increased KABC Atlantis (intervention effect: 0·76; 95 % CI 0·10, 1·42) and HVLT Discrimination Index (1·00; 95 % CI 0·01, 2·00) scores. Sugar increased KABC Atlantis (0·71; 95 % CI 0·05, 1·37) and Rover (0·72; 95 % CI 0·08, 1·35) scores and HVLT Recall 3 (0·94; 95 % CI 0·15, 1·72). Significant micronutrient × sugar interaction effects on the Atlantis, Number recall, Rover and Discrimination Index scores indicated that micronutrients and sugar in combination attenuated the beneficial effects of micronutrients or sugar alone. Micronutrients or sugar alone had a lowering effect on weight-for-age z-scores relative to controls (micronutrients − 0·08; 95 % CI − 0·15, − 0·01; sugar − 0·07; 95 % CI − 0·14, − 0·002), but in combination, this effect was attenuated. The beverages with micronutrients or added sugar alone had a beneficial effect on cognition, which was attenuated when provided in combination.

Schistosomiasis and soil-transmitted helminthiasis are among the most prevalent neglected tropical diseases and may lead to severe consequences. We assessed the extent of coinfection between Schistosoma haematobium and the soil-transmitted helminths (STHs) Ascaris lumbricoides and Trichuris trichiura in schoolgirls in the rural areas of KwaZulu-Natal, South Africa. We also explored if S. haematobium can serve as a predictor for soil-transmitted helminths in this area. From 15 selected schools, 726 primary schoolgirls aged 10-12 years provided both urine and stool samples. The samples were examined for the presence of eggs using the urine sedimentation technique for S. haematobium and the Kato Katz technique for STHs. Pearson's chi-square test was used to calculate the association and Spearman's rank correlation was used for the correlation analysis. There was a highly significant correlation between S. haematobium and STHs at a school level (Spearman's correlation coefficient =0.93; p<0.001). The prevalences were found to be 36.9% and 38.8% for S. haematobium and STHs, respectively. A significant association was found between S. haematobium and STHs (odds ratio =2.05; confidence interval =1.58-2.93; p<0.001). Indirect indicators of urogenital schistosomiasis (e.g. water contact and haematuria) were significantly associated with A. lumbricoides and T. trichiura infection. We have demonstrated a highly significant correlation and overall association between urogenital schistosomiasis and A. lumbricoides and T. trichiura. We cautiously suggest that all S. haematobium endemic areas should be treated for STH infections.