Paediatrics hydrocephalus in the province of KwaZulu-Natal South Africa: a study towards understanding the burden of disease and developing an integrated model aimed at improving outcomes.

Abstract

Background Paediatric hydrocephalus is a major contributor to morbidity and mortality in low- and middle income countries (LMICs), with sub-Saharan Africa disproportionately affected. In KwaZulu- Natal (KZN), South Africa, this burden is exacerbated by a high HIV prevalence, limited access to specialist neurosurgical care, and a predominance of central nervous system (CNS) infections. This thesis aimed to comprehensively investigate the epidemiology, aetiology, and treatment outcomes of paediatric hydrocephalus in KZN, with particular emphasis on HIV related infections and health service disparities. Methods A mixed-methods approach comprised a scoping review, followed by retrospective and prospective data analysis over a 20-year period (2003–2022). Data was collected from 3,325 children treated at Inkosi Albert Luthuli Central Hospital. Data was analysed to assess epidemiological trends, treatment modalities—including ventriculoperitoneal shunts (VPS) and endoscopic third ventriculostomy (ETV)—complication rates, HIV status, and outcomes, in particular, predictors of mortality. Subgroup analyses were performed to examine the role of tuberculous meningitis (TBM) and cryptococcal meningitis in HIV-infected children, as well as the effect of geographical proximity to centralised neurosurgery services on clinical outcomes. Results Post-infectious hydrocephalus (PIH) was the most common aetiology (32.7%), primarily due to TBM and pyogenic meningitis. HIV-infected children had higher complication and mortality rates, with TBM-related hydrocephalus associated with a 35.5% mortality rate. VPS procedures were the predominant treatment modality (84.2%), with an overall infection rate of 9.6%. Proximity to centralised neurosurgery services significantly impacted outcomes, with children living further away from neurosurgical services experiencing higher complication rates. Overall mortality was 7.9%, with predictors including older age, low GCS, cerebral infarcts, extra meningeal tuberculosis (TB), VPS infection, low CD4 count and hyponatraemia. Conclusions: CNS infections remain the predominant cause of paediatric hydrocephalus in KZN, with HIV infection significantly worsening outcomes. The findings highlight the urgent need for increased access to neurosurgery services and integrated public health strategies. A framework: AGILE-WIN (Antenatal care, Genetic counselling, Infection control, Localised services, Early diagnosis, Workforce improvement, Immunisation, and Networked reporting) is proposed to reduce disparities, promote early diagnosis, and improve outcomes for children with hydrocephalus in LMICs.