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Background Coronavirus (COVID-19) was officially declared a pandemic in March 2020 and has had a major impact on global healthcare services, including radiology. However, little is known about the full impact of COVID-19 on the utilization of diagnostic imaging in Africa's public healthcare sector. Objectives The objective of this study was to compare public sector diagnostic imaging utilization by modality for the whole Western Cape Province (WCP) of South Africa (SA), as well as its metropolitan and rural areas, in 2019 and 2020 in terms of the absolute number of investigations and investigations per 1000 people. Method We performed a retrospective analysis of Western Cape Government Department of Health and Wellness and Stats SA District Council 2021 Mid-Year Population Estimates data. All diagnostic imaging investigations performed in 2019 and 2020 were collated and stratified by imaging modality, geographic region (metropolitan/rural), and calendar year. Data are presented as the total number of investigations and investigations per 1000   people. We calculated mammography utilization for women aged 40-70 years and compared data for 2019 and 2020. Results Between 2019 and 2020, the provincial population increased by 1.9%, while total imaging investigations and investigations per 1000 people decreased by 19% (1,384,941 vs. 1,123,508, -261,433) and 20% (262/10 3 vs. 208/10 3 ), respectively. Total numerical decline was highest in plain radiographs (1,005,545 vs. 800,641, -204,904), accounting for more than three-quarters (78%) of the total reduction. Percentage decline was most pronounced for mammography, as utilization was almost halved (15.7/10 3   vs.  8.9/10 3 , -43%), whereas computed tomography was the least impacted (17.9/10 3   vs.  16.7/10 3 , -12%) with the remaining modalities decreasing between approximately one-quarter and one-fifth (magnetic resonance imaging = 26%, fluoroscopy = 25%, general radiographs = 23%, ultrasound = 16%, chest radiographs = 18%). Proportional metropolitan (-18.7%) and rural decreases (-19.3%) were similar. Conclusion COVID-19 had a substantial impact on WCP imaging services, decreasing overall radiological investigations by almost one-fifth. The greatest impact was on elective investigations, particularly mammography. Although the proportional impact was similar for the metropolitan and rural areas, COVID-19 nonetheless exacerbated existing discrepancies in imaging utilization between the geographical regions. The medium- and long-term clinical impacts of decreased imaging are still to be defined., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Teuteberg et al.)

Background: Disparities in MR access between different countries and healthcare systems are well documented. Determinants of unequal access within the same healthcare system and geographical region are poorly understood., Objective: An analysis of public sector MR utilisation in South Africa's Western Cape province (WCP)., Methods: A retrospective study of WCP MR and population data for 2013 and 2018. MR units/10 6 people, studies, and studies/10 3 people were calculated for each year, for the whole province and the 'western' and 'eastern' referral pathways, stratified by age (0-14 years, > 14 years)., Results: Between 2013 and 2018, the WCP population increased 8% (4.63 vs 5.08 × 10 6 people) while MR resources were unchanged ('western' = 2 units; 'eastern' = 1), equating to decreasing access (units/10 6 people) for the province (0.65 vs 0.59; -9.2%), the 'western' (0.97 vs 0.9; -7.2%) and 'eastern' (0.39 vs 0.35; -10.3%) pathways. In 2013, 40% (4005/10 090) of studies were in the 'eastern' pathway serving 55% (2 066 079/4 629 051) of the population. Between 2013 and 2018 'eastern' population growth ( n = 286 781) exceeded 'western' ( n = 168 469) by 70% ( n = 118 312). By 2018, 38% (7939/12 848) of studies were performed in the 'eastern' pathway, then serving 56% (2 849 753/5 084 301) of the population. Among 0-14-year-olds, 'western' utilisation (studies/103 people) exceeded 'eastern' by a factor of approximately 2.4 throughout. In patients > 14 years, the utilisation differential increased from 1.78 to 1.98 in the review period., Conclusion: Ensuring equitable services on the same healthcare platform requires ongoing surveillance of resource and population distribution. MR access can serve as a proxy for equity in highly specialised services., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2022. The Authors.)

Objectives: The objective was to compare COVID-19 outcomes in the Omicron-driven fourth wave with prior waves in the Western Cape, assess the contribution of undiagnosed prior infection to differences in outcomes in a context of high seroprevalence due to prior infection and determine whether protection against severe disease conferred by prior infection and/or vaccination was maintained., Methods: In this cohort study, we included public sector patients aged ≥20 years with a laboratory-confirmed COVID-19 diagnosis between 14 November and 11 December 2021 (wave four) and equivalent prior wave periods. We compared the risk between waves of the following outcomes using Cox regression: death, severe hospitalisation or death and any hospitalisation or death (all ≤14 days after diagnosis) adjusted for age, sex, comorbidities, geography, vaccination and prior infection., Results: We included 5144 patients from wave four and 11,609 from prior waves. The risk of all outcomes was lower in wave four compared to the Delta-driven wave three (adjusted hazard ratio (aHR) [95% confidence interval (CI)] for death 0.27 [0.19; 0.38]. Risk reduction was lower when adjusting for vaccination and prior diagnosed infection (aHR: 0.41, 95% CI: 0.29; 0.59) and reduced further when accounting for unascertained prior infections (aHR: 0.72). Vaccine protection was maintained in wave four (aHR for outcome of death: 0.24; 95% CI: 0.10; 0.58)., Conclusions: In the Omicron-driven wave, severe COVID-19 outcomes were reduced mostly due to protection conferred by prior infection and/or vaccination, but intrinsically reduced virulence may account for a modest reduction in risk of severe hospitalisation or death compared to the Delta-driven wave., (© 2022 The Authors Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Background: Although global use of medical imaging has increased significantly, little is known about utilisation trends in low- and middle-income countries (LMICs)., Objectives: To evaluate changes over a decade in public sector diagnostic imaging utilisation at provincial level in a middle-income country., Method: A retrospective analysis of medical imaging utilisation in the Western Cape Province of South Africa in 2009 and 2019. Use of conventional radiography, ultrasonography (US), fluoroscopy, CT, MRI, digital subtraction angiography (DSA) and whole-body digital radiography was assessed by total studies and studies/10 3 people, for the whole province, the rural and metropolitan areas. Mammography utilisation was calculated for every 10 3 females aged 40-70 years., Results: The provincial population and total imaging investigations increased by 25% and 32%, respectively, whilst studies/10 3 people increased by 5.5% (256 vs 270/10 3 ), with marked variation by modality. Provincial US, CT and MRI utilisation/10 3 people increased by 111% (20 vs 43/10 3 ), 78% (10 vs 18/10 3 ) and 32% (1.9 vs 2.5/10 3 ) respectively, whilst use of fluoroscopy (3.6 vs 3.7/10 3 ) and mammography (14.2 vs 15.9/10 3 women aged 40-70 years) was steady and plain radiography decreased by 20% (216 vs 196/10 3 ). For CT, mammography and fluoroscopy, percentage utilisation increases/10 3 people were higher in the rural than metropolitan areas., Conclusion: Population growth is the main driver of overall imaging utilisation in our setting. The relatively constant imaging workload per 1000 people, albeit with increasing ultrasound, CT and MR utilisation, and decreasing use of plain radiography, reflects improved provincial imaging infrastructure, and appropriate use of available resources., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2021. The Authors.)