Healthcare Gazette - 2016 Mar/Apr

HEALTHCARE GAZETTE

MARCH/APRIL 2016 • ISSN 2078-9750

WITBANK OBS/GYNAE SURGEON GETS OFF LIGHTLY

PG 07

ZIKA: THE GLOBAL THREAT HITS OUR SHORES – BUT NO CAUSE FOR ALARM PG 34 17

21

NEWS

New radiation therapy drastically reduces treatment time

23

RESEARCH Overtreatment – again

32

FEATURE

Lending disabled babies a miraculous helping hand

H EALT H CARE G A ZE TTE | J A NU A RY 2 0 1 6 WWW.HMPG.CO.ZA

FOCUS

Chasing the ghost of an ever-changing flu virus

Contents | 03

Co nt ent s 17

21

NEWS

RESEARCH

07 Witbank obs/gynae surgeon gets off lightly

20 Increased risk of suicide in chronic fatigue syndrome

08 Practice make-overs reduce risk, improve income

20 E-cigarettes and stopping smoking

09 Vaccines: SA’s immunisation programme debunked

20 Male and female mortality from tobacco in China – contrasts

10 DNA technology could speed up diagnosis of resistance

20 Adjunctive dexamethasone of little value in HIV treatment

10 My advice was evidence based – Noakes

21 Overtreatment – again

11 Managing the dark side of paediatric care burn-out 12 Behavioural therapy works as well as antidepressants 13 STI stigma poses major HIV dangers 13 Meditation may ease trauma pain 14 PE hospital turmoil: CEO leaves, nurses snore in patient-beds 14 HIV+? Even moderate drinking is harmful 15 Budget squeeze: Cutting clinicians hurts patients 17 New radiation therapy drastically reduces treatment time 19 Enter the Ferrari of glucose monitoring devices

21 Atypical glandular cells and cervical cancer screening 21 Antiretroviral drug resistance after failure of WHO first-line regimens 21 Incidence of dementia declining

FEATURES 23 Lending disabled babies a miraculous helping hand 28 ‘Screen and treat’ solution for cervical cancer close to reality

FOCUS 32 Chasing the ghost of an everchanging flu virus 36 Zika: The global threat hits our shores – but no cause for alarm

PROFILE 40 SA’s first female trauma surgeon

22

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THE COLD NEVER BOTHERED THEM ANYWAY…

oliticians, by their very nature, tend to put the best spin on any controversy. So it is with the “frozen posts” debate, with Health Minister Dr Aaron Motsoaledi, promising to personally intervene and place any candidate for any available public sector-funded clinical post. He said this after speaking to his nine provincial counterparts, who vehemently deny they are freezing clinical posts.

What is undeniable is that they are all anxiously manipulating ever-shrinking health budgets by any means possible – and human resources is always the biggest cost.

At least one independent analyst from who studies provincial budgeting says he’s seeing deliberately slow admin and authorisation systems that effectively repel any time-constrained applicant.

armacies

CONTRIBUTORS Toni Younghusband, Melanie Gosling, Marika Sboros, Bridget Farham

There are obviously many creative ways to cost-kill a cat without freezing it to death, enabling the curious political semantics we’re seeing. What’s really needed is definitive policy guidance from the national treasury and health departments on how to define and fund critical posts. The Eastern Cape’s Dora Nginza Hospital debacle which we cover in this issue is revealing. When we put the overworked and burnt-out obs/gynae clinicians complaints to the hospital’s head office, the spokesman denied any moratorium on filling posts existed, saying the procedure was to identify a critical post and then write a motivation to the Cost Containment Committee, which sat weekly. He stressed that the post needed to already have had funding allocated to it.

Elsewhere in this edition we look at the Zika virus outbreak in South

America, put the spotlight on how improved high care infrastructure will help Red Cross War Memorial Children’s Hospital’s paediatricians manage ubiquitous caregiver burn-out, feature a former Limpopo physiotherapist’s ground-breaking disability movement assistance device and examine how new DNA technology stands to speed up the vital early diagnosis of local drug-resistant TB. Then, we look at the failings in our much-lauded vaccination programme, which makes for sobering reading. We also highlight research on how early warning testing for potential cervical cancer will almost certainly save thousands of women’s lives. That’s just a taste of an eclectic, wide-ranging Healthcare Gazette, which we hope you agree is improving with every edition.

Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EXECUTIVE EDITOR Bridget Farham MANAGING EDITORS Ingrid Nye Claudia Naidu TECHNICAL EDITORS Emma Buchanan, Paula van der Bijl PRODUCTION AND ADMINISTRATION MANAGER Emma Jane Couzens HEAD OF SALES AND MARKETING Diane Smith | +27 (0) 12 481 2069 | sales@hmpg.co.za SALES REPRESENTATIVES Charles Duke Renee van der Ryst Azad Yusuf Benru de Jager Ladine van Heerden CUSTOMER SERVICE & ONLINE SUPPORT Gertrude Fani | +27 (0)21 532 1281 | publishing@hmpg.co.za FINANCE AND ADMINISTRATION Tshepiso Mokoena | +27 (0)12 481 2140 | tshepisom@hmpg.co.za LAYOUT AND DESIGN Tenfour Media Printed by Paarl Print Publisher website: www.hmpg.co.za HG online issues: https://issuu.com/ hmpg/stacks The Health and Medical Publishing Group is a wholly owned subsidiary of the South African Medical Association (www.samedical.org).

For information on subscribing to Healthcare Gazette, please contact sales@hmpg.co.za.

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News | 07

WITBANK OBS/GYNAE SURGEON GETS OFF LIGHTLY

Graham Howarth

Dr Graham Howarth ASTRONOMICAL INSURANCE cover and potential huge payments are a real threat to the continued practice of obstetricians and gynaecologists in South Africa.

Paddy Daya, one of three obstetric care providers in Witbank, today practices only as a gynaecologist after a 4-year ordeal that ended in February cost him over R2 million. A child he delivered, now 8 years old, ended up as a spastic quadriplegic with cerebral palsy.

In spite of what he says are strong, collegially backed assertions that he took reasonable care, Daya can count himself lucky to have got off so lightly.

According to expert opinion on similar cases pooled at a Medical Protection Society (MPS) workshop in Gauteng on 10 November last year, had he not entered into precourt negotiations and settled with the parents of Altin

Kleinhans, born in May 2008 at a Life Cosmos Hospital in Witbank and with NatMed, his initially reluctant insurers, a negligence ruling could have cost far more. His lawyers estimate costs could have been R15 million (before legal fees and/or a costs ruling). The total negligence claim, against Daya and Witbank’s Life Cosmos Hospital (which settled for an undisclosed amount), was for R22 million.

According to papers served at the Pretoria High Court, Altin Kleinhans will never recover and will need around-the-clock care.

Daya agreed to pay the parents R2.8 million while denying negligence. He managed to recoup just under half of this after a legal wrangle with NatMed, who initially refused to cover him, claiming he’d not reported the matter timeously for his claims-based membership.

The parents, who live in Barberton in Mpumalanga, claimed neither the mother nor the unborn child were properly monitored before birth. The mother gave birth naturally and said that the child was delivered in an “asphyxiated and compromised condition”.

HOW IT’S CHANGED ME – DAYA

The wrangle had changed Daya’s world view and he now practices gynaecology defensively, having given up obstetrics until he hears whether his new application to the MPS will be approved. With 18 months to pay out the Kleinhans couple, the R60 000 monthly obstetrics MPS subscription, while more expensive (but with better

prospects than NatMed where he was for 15 years), is a burden he’s willing to shoulder.

CLAIMS-BASED V. OCCURRENCE-BASED CLAIMS EXPLAINED The MPS says it is not unusual for (settled) cases to exceed R20 million while special damages for loss of future earnings and care and medical and hospital expenses had increased “considerably”, especially in high-value catastrophic claim cases.

However, in response to Healthcare Gazette’s attempts to extract an estimate of total specialist litigation costs, plus total damages awarded annually in South Africa, Dr Graham Howarth, MPS Head of Medical Services (Africa), declined to reveal MPS figures, claiming they were “commercially sensitive”.

He said that MPS had tried to mitigate costs for private obstetricians and gynaecologists in 2014 by introducing a choice in professional protection for those who manage pregnancies after 24 weeks gestation. This was called claims-made protection and required a member to be in membership at the time the incident happened, when it was reported to MPS, and during the intervening years – and to report the adverse incident as soon as they became aware of it. This was opposed to (the more expensive) occurrence-based protection in which members could seek help with a complaint or claim arising from an adverse incident that took place during their MPS membership – even if it was brought years later, or if the member had long since left the MPS. Howarth said determining obstetric risk posed considerable challenges, and providing affordable protection on an occurrence basis was becoming increasingly unsustainable, because the nature of obstetric claims means that there could be a time difference of up to 30 years before a claim was made. Inevitably, this had a significant impact on the final value of the claim, especially if claims inflation had risen significantly in that time. He said that in the current climate of rising clinical negligence costs, it was more important than ever for healthcare professionals to put appropriate arrangements in place in case of a claim for clinical negligence.

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

PRACTICE MAKE-OVERS REDUCE RISK, IMPROVE INCOME Dr Mia’s reconstructed ID

WHEN MANAGING YOUR PRACTICE: DO n Get involved in the day-to-day running of your practice. n Use electronic reporting systems. n Train your staff in risk management and how to best represent you. n Ensure your equipment runs optimally and profitably. n Consider outsourcing your continuing professional development (CPD) management. n Spend money on streamlining your operation (for between R1 000 and R5 000 per month a consultancy can virtually run your practice, collect debt and offer legal advice). n Segregate staff duties, insist on dual sign-offs. n Consider installing cameras; you can monitor your practice 24/7 by cellphone anywhere in the world. n Consider registering your ID with one of three fraud prevention services, enabling a cellphone alert anytime somebody does a bureau enquiry on your ID. This and similar measures are standard practice for retail chains. n Get an external provider to do your payroll service.

DON’T n Charge VAT if you’re not registered to do so (it’s illegal). n Ever give out your username and password. n Leave all your admin to one person (a US survey found that 80% of practices experienced theft within a 5-year period; 60% of culprits were women aged 43 (on average) who worked alone, 33% had a gambling problem and 87% had no prior theft record.

Two years ago a 60-year-old Nelspruit practice manageress pilfered R1.4 million.

Sources: Selwyn Gardiner, consultant to Rosstone Consulting; Nicolene Voget, product manager, Bidvest Medical, and Kevin Hogan, fraud risk manager for Investec Bank

Phishing email BUSY DOCTORS WHO RELY ON a few staff to run their books and manage their practices are prime targets for ubiquitous cyber-crime, identity theft and in-house thieving.

South Africa (SA) is ranked third globally for citizens who fall victim to phishing emails.

Physicians tend to run their businesses sub-optimally, getting on with what they were trained to do, and ignoring effective technology and behaviour that could save millions in bad debt, and increase income by making their skill or speciality known.

So say two top practice management consultants and a fraud risk manager for Investec Bank, whose clients include 40% of local doctors. Kevin Hogan, Investec’s fraud risk manager, says SA jumped from being ranked 67 in the world for cyber-crime in December 2014 to 22 in December 2015, with doctors’ high credit ranking making them prime targets.

Police often declined to investigate because no geographical crime location could be established.

A favourite is “spear-phishing” where the likelihood of clicking on a cyber link is estimated by USA statisticians at 89%, because the con-artist knows your passions/ hobbies (ex Twitter, Facebook

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

and LinkedIn). For example, if you’re a keen golfer, he’ll offer a 35% discount on tailor-made clubs, plus a free round with Ernie Els, asking you to register a valid email address, followed by a link to a fake log-on screen from your email provider which asks for your username and password.

Identity document (ID) theft and reverse deposit rip-offs are equally popular. The former requires an insider to copy your ID, enabling the pasting on of another’s photo, and providing a payslip with your account number.

Hogan has pictures of a syndicate runner taking delivery of a BMW. The latter involves a prospective patient (no medical aid) calling to say his clerk overpaid (in advance, by cheque) and asking for a refund.

Proffering internet payment “proof” is another.

To reduce internal staff fraud, Hogan and marketing manager to Rosstone Consultants, Selwyn Gardiner, recommend segregation of duties, dual signoff processes and multiple-user access systems. Bidvest Medical (20 established radiology practices) also helps manage practice information, optimal use of hightech equipment and electronic reporting systems.

News | 09

VACCINES: SA’S IMMUNISATION PROGRAMME DEBUNKED CLINICAL STAFF RESPONSIBLE for vaccinations need to routinely check required refrigeration temperature ranges, vial expiry dates and maintain good stock records if our massive R1.4 billion supplies of vaccines are to remain cost effective and prevent disease outbreaks.

This emerged from a Healthcare Gazette probe into South Africa (SA)’s high-priority, under-funded Expanded Programme on Immunisation (EPI), which shows it to be understaffed and almost rudderless, with inaccurate data collection on vaccine coverage and efficacy.

National EPI leadership hardly exists. The top national EPI managers resigned in August and December last year, taking with them large chunks of institutional memory and invaluable expertise. SA remains in the top five underperforming EPI African countries (according to World Health Organization standards), for the third year running. According to Johann van den Heever, national EPI manager for the last 11 years, a lack of leadership vision, a R1.4 billion national budget which provides exclusively for vaccine purchase, and a critical lack of human resources, social mobilisation and surveillance, supervision, and monitoring and evaluation led to his resignation in December 2015.

The frustration of inaccurate, unscientific data collection, understaffing and lack of a pragmatic operational budget, proved too much. His national senior specialist, Dr Ntombenhle Ngcobo resigned last August followed by their chief data collector. None of them had been replaced by early March. According to van den Heever, six of the

original 13 national EPI posts (since 1994) remain, all relatively junior incumbents, aggravating basic data quality audits and rendering the immunisation evaluation inaccurate. Mr Sim Langa, the national cold chain manager responsible for vaccine supply from the Biovac Consortium (supplier to the EPI since 2003), and for quality control, said his small staff was able to check up on between 5 - 10% of all vaccination facilities.

Prof. Shabir Madhi, Deputy Chairperson of the National Advisory Group on Immunisation, said that without a national audit of vaccine storage and immunisation compliance at all facilities it was impossible to estimate coverage or vaccine-related mortality and morbidity. Van den Heever says it is“absolutely imperative” for any national health system to have an electronic register of its target population (starting with infants), followed by a national EPI coverage survey to provide a performance measurement baseline. By having an immunisation register linked to procurement of vaccines, the country would save millions of rands. In the meantime, vaccination efficacy remains up to coal-face clinicians.

VITAL TIPS FOR VACCINATORS n Always check the status of a child’s immunisation in their Road to Health booklet. n Ensure sufficient, well-functioning fridges with properly maintained back-up power. n Avoid a nursing assistant taking responsibility for the pharmacy/dispensary. Insist on a qualified pharmacy assistant. n Dedicate a diligent and responsible person to stock control, temperature monitoring and keeping of records. n Check incoming stock for potency and, whenever possible, work on progressively ironing out problems with the emergency ordering system – at the very least ensure one is in place.

Have a reliable back-up of vaccine supply and a solid plan for when stock-outs occur. n When vaccinating, always check both the vaccine vial monitor tag and expiry date (discard if either is out). n Ensure cooler boxes are covered and doing their job during vaccinations. n Monitor and record vaccine fridge temperature twice a day (i.e. ensure it remains within the 2 - 8°C range). n Keep a safety box for disposal of used syringes and needles. n Always wash your hands before touching sterile syringes and only touch the safe parts. Clean client skin with soap and water, not alcohol or spirits. n Never prefill syringes with vaccines for later use. n Never leave the needle and syringe in a vial.

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DNA TECHNOLOGY COULD SPEED UP DIAGNOSIS OF RESISTANCE

Prof. Keertan Dheda USE OF DNA TECHNOLOGY to diagnose multiple and extensive drug-resistant (DR) tuberculosis could provide results up to eight times faster than existing methods, according to researchers from the University of Oxford, UK, who helped lead a global collaborative study.

South Africa was the first country in the world to record a case of extensively drug-resistant tuber-

culosis (XDR-TB), and battles to control the disease. It is still rolling out GeneExpert rapid TB diagnosis, which diagnoses resistance in a couple of hours, but is limited to one type of resistance (rifampicin).

Dr Louise Pankhurst, the study co-author, explained that while whole genome sequencing was previously used in TB research, this was the first time the technology was applied in real-world scenarios. Its chief benefit is that, by sequencing the entire genome from a cultured isolate, it can at a single “hit” tell laboratory technicians about the drug resistance profiles.

In addition to facilitating faster and more targeted treatment of people with TB, the speedier diagnosis means scientists are able to detect and respond to potential outbreaks.

Dr Jenny Hughes, an experienced TB doctor working for Médecins Sans Frontières in Khayelitsha, Western Cape, said doing one test to see what drugs a patient was resistant to is “amaz-

ing” and enables clinicians to handpick medications for each patient.

However, local clinicians treated DR-TB mostly on a population basis, which requires a routine drug regimen. The DNA technology might work in a high-resource country, “but in a real-world setting people don’t always have the information available, or the time, and you need laboratory and genome sequencing facilities close to where you treat patients,” she added.

The new technology could eventually play a valuable role “down the treatment line so we can maybe modify our regimen”.

Prof. Keertan Dheda, an international authority on drug-resistant TB and Head of the Lung Infection and Immunity Unit in the University of Cape Town’s Lung Institute, said that more work is needed to understand how the technology can be integrated into the management of patients with TB. The researchers had not described actually treating patients based on the test results.

MY ADVICE WAS EVIDENCE BASED – NOAKES

By Marika Sboros

THE HEALTH PROFESSIONS Council of SA (HPCSA) this February closed its case against University of Cape Town emeritus professor Tim Noakes on a charge of unprofessional conduct, and will resume with cross examination of the controversial A-rated scientist on 17 October this year.

Noakes was allegedly unprofessional in giving unconventional, non-evidencebased advice to a breastfeeding mother on a social network.

The charge follows two tweets Noakes made to breastfeeding mother Pippa Leenstra on 4 February 2014 saying that good first foods for infant weaning are LCHF (lowcarbohydrate, high-fat).

Johannesburg dietitian Claire Julsing Strydom, then President of the Association for Dietetics in SA, responded to Leenstra on Twitter, lodging a complaint with the HPCSA on 5 February. The HPCSA formally charged Noakes in September 2014.

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The HPCSA‘s last expert witness at the February hearing was Stellenbosch psychiatry professor Willie Pienaar, a part-time bioethics lecturer.

At the earlier November 2015 session, the HPCSA called Julsing Strydom as a factual witness and heard testimony by retired North-West University nutrition professor Este Vorster, North-West University nutrition professor Salome Kruger, Medical Research Council Unit Head and paediatric professor Muhammed

News | 11

MANAGING THE DARK SIDE OF PAEDIATRIC CARE BURN-OUT

By Melanie Gosling

WORKING DAILY WITH critically ill and dying children is emotionally exhausting, and dealing with burnout is essential if paediatrics is to remain an effective discipline.

This is the view of the Head of the Red Cross Children’s War Memorial Hospital paediatric intensive care unit (PICU), Prof.

Andrew Argent, who calls this phenomenon the “dark side” of paediatrics. A major upgrade to the hospital is planned to help improve facilities and working conditions.

“Some of the challenges of the dark side relate to medical staff constantly dealing with critically ill children, and some burn-out is from dealing with dying children,” Argent explained. He’s acutely aware of burnout among paediatric intensive care staff, highlighting it in his inaugural speech at the University of Cape Town (UCT).

He said the profession had to start understanding what it was

that made people burn-out if it was to sustain the discipline. One recent major tonic for clinicians (besides ongoing counselling and debriefing), is the R100million expansion and upgrade of their PICU. This will not only help save the lives of thousands of sick children from across the continent – but dramatically improve staff facilities and working conditions.

While an upgraded building cannot remove the effects of working with ill or dying children, improved facilities such as better sleeping accommodation could reduce work environment stress.

Currently there is one sleeping area shared by two doctors, which doubles as an office during the day. Louise Driver, CEO of the fundraising Children’s Hospital Trust, said when doctors worked 28-hour shifts, the room was used as a sleeping area and office. “With five new sleep areas for doctors on call, they’ll be able to get the rest they need to work optimally.” PICU

Ali Dhansay, and HPCSA legal officer Nkagiseng Madube.

Vorster, Kruger, Dhansay and Pienaar suggested that Noakes was in a doctor-patient relationship with Leenstra and that the advice he gave was unconventional because it was not evidence based.

Madube contended that the HPCSA followed due process in charging him, which Noakes’ legal team strongly contested.

Noakes himself began testifying on 10 February to the HPCSA Professional Conduct Committee, chaired

by Pretoria advocate Joan Adams. He denies that he was

in a doctor-patient relationship with Leenstra, saying he had not practiced medicine for more than 10 years. As a scientist, his main concern was to give people evidence-based information from which they could make up their own minds. His testimony lasted nearly 40 hours and was supplemented by 4 000 pages and 900 slides with study references to suggest that his advice was evidence based.

Noakes stressed that his advice was only “unconventional” to anyone who failed to study the evidence. The case is being heard in Newlands, Cape Town.

nurses, who now have only one small room to rest and socialise, will get two rooms. The tiny changing room for both sexes will be demolished to make rooms for each gender, with more showers.

Argent added: “The data show that taking naps helps people doing shift work. We want support staff at the PICU to feel their efforts are valued.

This is a message that what they are doing is important and taken seriously. This improves morale and helps compassion fatigue.”

Prof. Tim Noakes meets a European author of a book on the evils of sugar

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

BEHAVIOURAL THERAPY WORKS AS WELL AS ANTIDEPRESSANTS WHAT IS COGNITIVE BEHAVIOURAL THERAPY?

Cognitive behavioural therapy (CBT) is a common type of talk therapy (psychotherapy).

You work with a mental health counsellor (psychotherapist or therapist) in a structured way, attending a limited number of sessions.

CBT helps you become aware of inaccurate or negative thinking so you can view challenging situations more clearly and respond to them in a more effective way. Not everyone who benefits from CBT has a mental health condition. It can be an effective tool to help anyone learn how to better manage stressful life situations.

CBT is a useful tool to address emotional challenges. For example, it may help you to: n Manage symptoms of mental illness n Prevent a relapse of mental illness symptoms n Treat a mental illness when medications aren’t a good option n Learn techniques for coping with stressful life situations n Identify ways to manage emotions n Resolve relationship conflicts and learn better ways to communicate n Cope with grief or loss n Overcome emotional trauma related to abuse or violence n Cope with a medical illness n Manage chronic physical symptoms.

Mental health disorders that may improve with CBT include: n Sleep disorders n Sexual disorders n Depression n Bipolar disorders n Anxiety disorders n Phobias n Obsessive-compulsive disorder n Eating disorders n Substance use disorders n Schizophrenia n Post-traumatic stress disorder Source: The Mayo Clinic

COGNITIVE BEHAVIOURAL therapy (CBT) might be as effective for treating major depression as drugs are, according to a North American study published in December last year.

However, according to local experts, CBT is vastly under-used and undertaught to students of psychology in South Africa (SA).

The new study concludes that there is no difference in treatment effects of second generation antidepressants and CBT, either alone or in combination, for patients Professor Crick Lund with major depressive disorder. CBT is a widely recognised type of psychological colleagues at the University of support that works to solve North Carolina and the Research problems and change unhelpful Triangle Institute International, thinking and behaviour. Given analysed the results of 11 that patients may have personal randomised controlled trials. preferences for one first-line Each trial compared secondtreatment over the other, the generation antidepressants and researchers say both treatments CBT for the initial treatment of “should be made accessible, major depressive disorder, and either alone or in combination, to involved 1 511 patients. The team primary-care patients with major found no statistically significant depressive disorder”. difference in effectiveness Major depressive disorder is between second-generation the most common and disabling antidepressants and CBT for form of depression in North response, remission or change in America, affecting more than depression score.

32 million people. In SA, mental Prof. Crick Lund, director illness affects one in six people of the Alan J Flisher Centre for and costs the country 2.2% of Public Mental Health at the its annual GDP. According to University of Cape Town, was the South African Depression unaware of similar local research. and Anxiety Group (SADAG) the Calling for more rigorous largest local NGO of its kind, adaptation and application there are 23 known suicides daily of CBT in SA, where it was with 11% of all non-natural deaths less widely used than other in the country due to suicide. modalities, he said CBT was not A team led by Gerald very widely taught, which he Gartlehner at Danube University, described as “concerning” given supported by Halle Amick and its robust evidence base.

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

News | 13

STI STIGMA POSES MAJOR HIV DANGERS SURVEILLANCE FOR SEXUALLY transmitted infections (STIs), in the context of South Africa (SA)’s HIV pandemic and the use of every single presenting opportunity to offer STI testing is critical if the ongoing success of the expanded antiretroviral treatment roll-out is to be sustained.

This is according to Prof. Salim Karim, a top clinical infectious diseases epidemiologist based at the University of KwaZulu-Natal in Durban where he heads the Centre for AIDS Programme Research (Caprisa). Karim said patients with STIs often preferred not to be diagnosed because STDs were associated with stigma, “so we have to use every opportunity when a patient presents to offer an HIV test and test for STDs, such as when they come in to get contraception”.

SA has among the world’s highest levels of undiagnosed and untreated cases of STIs, including chlamydia, and this drives the HIV pandemic in which it is crucial to “turn off the tap” of new infections.

Karim was responding to an Australian study that found that one in five sexually active young Australians do not get tested for chlamydia after a request from their GP. Very few similar SA studies exist. He said the social stigma around STIs in Australia, driving this testing avoidance, paled into insignificance when compared with the rates of STIs and HIV/AIDS infections in SA – although the underpinning driver was universal.

Prof. Jane Hocking from the University of Melbourne’s School of Population and Global Health told the Medical Journal of Australia

that this test drop-off trend was concerning because “the people that failed to test are also the people who are at higher risk for infection – so we’re potentially missing a lot of cases of chlamydia”.

A syndromic and microbiological surveillance study conducted among Gauteng miners seven years ago illustrates Karim’s contention. It found that a sustained high incidence of genital ulcerative disease was followed by a rapid increase in HIV prevalence and changes in the aetiology of the STI syndrome. The study contributed to better understanding of the epidemiological determinants fuelling the rapid spread of HIV in southern Africa.

Prof. Salim Karim

MEDITATION MAY EASE TRAUMA PAIN PSYCHOLOGICALLY BASED trauma relief exercises and therapy can have a salutary effect on chronic pain, especially in a country such as South Africa (SA), where high levels of violence cause widespread physical and emotional distress. The traumarelief exercises may even have a protective effect for people about to be exposed to high levels of daily stress, according to recent overseas research put to a local SA expert in late February this year.

Dr Simon Whitesman, a codirector of the Mindfulness-Based Stress Reduction Programme at the Cape Town Mediclinic and Chairperson of the Institute for Mindfulness in SA, says the high levels of undiagnosed, untreated and diagnosed all-cause trauma in SA, plus post traumatic stress disorder (PTSD), predisposes people to developing chronic pain conditions. While there were many

other causes of trauma besides SA’s societal violence, mindfulness was a way to reduce people’s trauma.

“Trauma needs a psychological intervention – the data on antidepressants in PTSD are relatively moderate,” he added.

HOW IT WORKS

Elaborating on the exercises, Whitesman said the simplest way to explain them was that chronic pain “is in the brain, even though your pain might be on the peripheries”.

Unfortunately SA does not have sufficient resources for people to go to individual counsellors. A 2014 parliamentary question revealed that SA suffers from a major shortage of mental health professionals, with many provinces filling less than a third of their psychologist and psychiatrist posts. With medical school graduate outputs remaining the same, this is unlikely to change.

US MILITARY VETERANS SPEARHEADING SELF-HELP RESEARCH

The overseas research centred on military veterans returning to their homes in the USA, with multiple types of trauma, and suffering one of the highest rates of chronic pain of any population. Veterans who practised meditation reported a 20% reduction in pain intensity. The study came out of Washington DC’s Veteran Affairs Medical Centre.

Whitesman said that the US military was also using a mindfulness-based programme for soldiers before they entered combat zones as a way of increasing resilience and managing stressful and traumatic Dr Simon Whitesman situations.

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

PE HOSPITAL TURMOIL: CEO LEAVES, NURSES SNORE IN PATIENT BEDS LONG-STANDING critical staff shortages in the maternity unit at Port Elizabeth’s Dora Nginza Hospital came to a head in Nurses protest at Dora Nginza Hospital Courtesy PE Herald mid-February with a 3-day nurses strike, the enforced departure of the CEO and nearly burnt-out doctors being prevented from doing ward rounds by strikers.

Official documents in the possession of the Healthcare Gazette (HG) reveal doctor allegations of leadership autocracy, major staff shortages, non-appointment of consultants to available posts, outstanding overtime payments and a lack of academic support and burn-out.

Combined, the doctors claim these conditions have led to patient care being compromised, which the nurses strike, from 10 -

12 February aggravated. At least one pregnant mother died during the strike, although HG could not establish whether this was owing to strike-compromised care or not. Eight doctors per shift were covering a 60-bed antenatal ward, a 70-bed postnatal ward, a 43-bed gynaecological ward, an 18-bed high-care unit, a 9-bed labour ward, a 4-bed observation ward and a teeming outpatient clinic – around the clock. The unresolved issues led to differences between the maternity unit chief, Dr Mfundo Mabenge, a member of the national Saving Mothers, Saving Babies Committee, and his CEO, Dr Nthombi Quangule.

These came to head, said HG sources in Bisho (the provincial health department head office), and at the hospital, when Quangule sent an ambulance to fetch Mabenge from his home after he took a few days off to relieve burn-out.

Then, just days before the strike, Quangule, in an unannounced late-night medical ward inspection, surprised eight nurses – the entire ward nursing complement – asleep in unoccupied patient beds. A disciplinary hearing was pending at the time of going to print. The Eastern Cape’s health department also probed Quangule’s “autocratic” behaviour and her alleged lack of response to doctor complaints. She was temporarily relieved of her post amid fears for her safety. All the worker unions involved (Nehawu, Hospersa and Denosa) called for Quangule’s sacking after a highlevel Bisho delegation and a local parliamentary portfolio committee visited the hospital. Doctors said the stalled appointment of senior doctors in the obstetrics and gynaecology unit also led to seniors being overburdened with caesarean sections.

HIV+? EVEN MODERATE DRINKING IS HARMFUL MODERATE ALCOHOL consumption is more harmful to people with HIV than uninfected individuals, raising the risk of both mortality and other negative health effects, Yale researchers found this February. Their study is the first to demonstrate the increased harm among patients who have suppressed HIV with modern antiretroviral treatment (ART).

Their findings raised a mildly curious eyebrow in Prof. Salim Karim, Director of the Centre for the AIDS Programme of Research in South Africa (CAPRISA), and

Vice-Chancellor (Research) at the University of KwaZulu-Natal in Durban. He told Healthcare Gazette that he knew of no equivalent local research, but emphasised that many ART drugs were metabolised in the liver. “Alcohol is known to induce liver enzymes, so it can certainly influence the way these drugs are metabolised. We recommend that patients on ART avoid alcohol altogether. Of course, the other very real problem is that people who drink forget to take their ART and treatment is compromised,” he added.

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

The Yale research also showed that it takes fewer drinks for a person with HIV to feel the effects. However, most prior studies were done on HIV-positive individuals who had detectable viral load.

The Yale-led team set out to determine whether the risks associated with alcohol were higher among current patients who are more likely to have the infection under control with ART. The researchers analysed data on HIV-positive and -uninfected patients from the

News | 15

BUDGET SQUEEZE: CUTTING CLINICIANS HURTS PATIENTS IN THE PAST 3 YEARS THE ranks of senior public healthcare administrators swelled by 12% as opposed to a 3.5% growth in the number of physicians, pharmacists and pathologists. This previously unpublicised skewed progression has further bolstered appeals by healthcare professional groups to stop the wide-scale, debilitating freezing of clinical posts.

The Healthcare Gazette (HG)’s extraction a review of national public healthcare staff data brings some context to ongoing political rhetoric over whether clinical posts are being frozen or not in the current severely constrained economic climate. The South African Medical Association (SAMA) and the Rural Health Advocacy Project (RHAP) claim health minister, Dr Aaron Motsoaledi, is playing political semantics, by denying that his provincial healthcare counterparts are “freezing” posts, asking him and Treasury Minister

Veterans Aging Cohort Study (VACS), a large population of individuals receiving care from the Veterans Health Administration, between 2008 and 2012. They examined the association between alcohol consumption and mortality and other signs of physiological injury and found that HIV-positive individuals were more likely to experience physiological harm and die from alcohol consumption than uninfected individuals. Even consumption of one to two drinks per day was associated with increased risk for people with HIV. The finding was particularly notable because it held true for individuals with suppressed viral load.

Pravin Gordhan to address the “real issue” of funding and protecting critical healthcare posts.

The HG review lends credence to long-standing speculation that hard-pressed provincial chief financial managers are panicking at their shrinking budgets, particularly after unions (mainly the National Education and Health Workers Union) won a 10% wage increase totalling R69 billion over the 2015/16 financial year (part of a three-year settlement).

The implications for healthcare delivery are dire.

The widespread blocking or closing down of critical clinical service delivery posts from December last year through January (when most doctors and nurses were seeking them), is “dangerously short-sighted”, says SAMA chairperson, Dr Mzukisi Grootboom. Not only would it hurt the most vulnerable patient populations and increase existing

billion rand litigation claims, but it would aggravate work pressures as clinical staff were stretched to breaking point after colleagues leave, creating a “domino effect” and leading to the potential collapse of untenably staffed Dr Mzukisi Grootboom public health facilities.

In spite of an overall national increase of 18 701 clinical staff in September 2012 to 19 352 (3.5% increase) in September 2015, the clinical staff component suddenly plummeted by 327 members (−1.7%) from March to September last year, when financial austerity measures were introduced. National health staff figures show that as of September last year there were 511 senior managers (directors up to Director’s General), up from 457 in September 2012 (a 12% increase), with a gradual upward creep every year in between.

The effect of alcohol on one’s liver function can change the way ART drugs are metabolised.

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

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News | 17

NEW RADIATION THERAPY DRASTICALLY REDUCES TREATMENT TIME A NEW RADIATION THERAPY machine that drastically reduces treatment session times by delivering a constant base of radiation while rotating around the patient has been introduced at the Vincent Pallotti Hospital’s Oncology Centre in Pinelands, Cape Town.

Called the Novalis Tx Radio Surgery System, the machine rotates around the patient to deliver treatment beams anywhere in the body from virtually any angle, delivering highly precise, painless treatment while avoiding surrounding healthy tissue.

According to an independent private radiation oncologist, Dr Conrad Jacobs, what sets the machine apart from existing equipment is the speed at which it can operate and its built-in manoeuvrability. However, he said manoeuvrability was not unique to the Novalis system; existing machines used special add-on equipment to perform the same function and delivered outcomes “every bit as good”.

The new machine – also soon to be installed be installed by Life Healthcare at the Eugene Marais Hospital in Pretoria, Gauteng, and the Hilton Private Hospital in KwaZulu-Natal – uses in-built image guidance and motion management tools to provide doctors with detailed information about the shape, size and position of the tumour, and guide the setup, positioning, monitoring of the body, and tumour motion during treatment.

Jacobs drew an analogy with robotic surgery: “It is still surgery but just a different method of administering it. It’s nice to have (because of the speed and agility), but it comes at a cost. If

Oncology Centre – radiation machine you look at the current situation in South Africa, you simply can’t afford that in every cancer unit’’.

He explained that with other radiation equipment such as that used in stereo body radiation surgery and stereotactic brain surgery, radiographers had to constantly switch the machine on and off to ensure the radiation field was correct as they scanned. However, “at the end

of the day you won’t get a better outcome,’’ he said.

The equipment has been in existence overseas for about 4 years, he said. Jacobs said the average time for pre-existing radiation machine treatment was around 20 minutes, something the Novalis machine can reduce by half by delivering a constant base of radiation as it moves over the body.

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

CHOOSE THE

YO U KNOW Over 10 years real-life experience managing diabetes*

* L antus 速 was launched in S outh Africa in 20 0 3

SCHEDULING STATUS: S3 PROPRIETARY NAME AND DOSAGE FORM: LANTUS 速 (solution for injection). COMPOSITION: Each ml of the solution for injection contains 3.64 mg of the active ingredient insulin glargine, corresponding to 100 U human insulin, 2.7 mg of the preservative metacresol and 0.0626 mg of zinc chloride as stabiliser. 10 ml vial contains 0.02 mg polysorbate 20 as additional stabiliser. REGISTRATION NUMBER: 34/21.1/0248. NAME AND BUSINESS ADDRESS OF THE APPLICANT: sanofi-aventis south africa (pty) ltd, 2 Bond Street, Midrand, 1685. Tel: 011 256 3700. Reg. No. 1996/10381/07.

ZA.GLU.11-05-15

News | 19

ENTER THE FERRARI OF GLUCOSE MONITORING DEVICES

Prof. Larry Distiller AN AUTOMATIC 14-DAY glucose level measuring device the size of a R5 coin attached to a diabetic patient’s upper arm is set to vastly improve clinical decision making. It’s been labelled a “game changer” by Prof. Larry Distiller, the founder of the Centre for Diabetes and Endocrinology (CDE) in Johannesburg.

Launched commercially in Gauteng early this March, the device takes a reading every 15 minutes, allowing for up to 1 344 glucose readings over the 2-week period via a small filament inserted just under the skin that measures interstitial fluid. Distiller said the dense glucose data, downloaded in the doctor’s office using a reader, provides a comprehensive visual report of the patient’s ambulatory glucose profile. “What sets it apart from other devices that record continuously for 5 days and are bulkier, less comfortable and more expensive, is that it calibrates automatically and has brilliant software that interprets the data,” says Distiller. He described the device as the 2016 Ferrari of glucose monitoring devices, adding: “The 1990 VW

Prof. Distiller, Carte Blanche TV presenter, Devi Sankaree Govender and Dr Cranston at the device launch on 4 March.

Beetle can also get you to where you’re going, but this is far more advanced”.

Other devices (worn on the stomach) require twice or even four times-a-day calibration by the patient and use a tiny needle and sensor. Called the FreeStyle Libre Pro System, the device costs R650 (per fortnight) and enables predictive clinical decision making, facilitating better patient education. Distiller says physicians who have patients whose diabetes was not as well controlled as it should be – or who had hypoglycaemia – could see “exactly what’s going on” and adjust dosages.

Up to 4.5 million South Africans have diabetes, with numbers

growing daily through rapid cultural and social changes, longevity, movement from rural to urban environments, and a rising prevalence of unhealthy behaviours, including poor diet and lack of exercise.

The only way to prevent or reduce morbidity and mortality is meticulous control of glycaemia, blood pressure and dyslipidaemia, plus regular examinations to avoid complications.

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BITE-SIZED SUMMARIES OF THE LATEST SCIENTIFIC ADVANCES Male and female mortality from tobacco in China – contrasts E-cigarettes and stopping smoking

Increased risk of suicide in chronic fatigue syndrome THERE IS UNCERTAINTY about the mortality associated with chronic fatigue syndrome, but now there is a study showing that, although all-cause mortality is not increased in the syndrome, there is a substantial increase in mortality from suicide – a factor to be aware of.

DO E-CIGARETTES help people to stop smoking? Not according to this study. A systematic review and meta-analysis of 38 studies showed quite the opposite – e-cigarettes are associated with significantly less quitting among smokers.

CHINESE MEN NOW smoke more than one third of the world’s cigarettes.

But Chinese women now smoke far less than in previous generations. This Lancet study shows that smoking will cause about 20% of all adult male deaths in China during the 2010s. The tobaccoattributed proportion is increasing in men, but low, and decreasing, in women.

Although overall adult mortality rates are falling, as the adult population of China grows and the proportion of male deaths due to smoking increases, the annual number of deaths in China caused by tobacco will rise from about 1 million in 2010 to 2 million in 2030 and to 3 million in 2050, unless there is widespread cessation.

Adjunctive dexamethasone of little value in HIV treatment

ADULT PATIENTS WITH HIV-associated cryptococcal meningitis from many different areas, including Uganda and Malawi, were treated with dexamethasone to attempt to reduce mortality. The trial was stopped early – dexamethasone not only did not reduce mortality but was associated with more adverse events.

Kalkhoran S, Glantz SA. E-cigarettes

Chen Z, Peto R, Zhou M, et al.

and smoking cessation in real-world

Contrasting male and female trends in

and clinical settings: A systematic

tobacco-attributed mortality in China:

Beardsley J, et al. Adjunctive

Roberts E, Wessely S, Chalder

review and meta-analysis. Lancet

Evidence from successive nationwide

dexamethasone in HIV: Associated

T, et al. Lancet 2016; S0140-

Respir Med 2016;4(2):116-128.

prospective cohort studies.

cryptococcal meningitis.

6736(15)01223-01224. DOI:10.1016/

DOI:10.1016/S2213-2600(15)00521-

Lancet 2015;386(10002):1447-1456.

N Engl J Med 2016;374:542-554.

S0140-6736(15)01223-4

00524

DOI:10.1016/S0140-6736(15)00340-2

DOI:10.1056/NEJMoa1509024

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

Research | 21

Atypical glandular cells and cervical cancer screening Overtreatment – again ROUTINELY COLLECTED health data and subsequent randomised controlled trials seem to give different answers from each other on the same clinical questions.

This may lead to substantial over-estimates of treatment effects, requiring caution in clinical decision making.

ATYPICAL GLANDULAR cells (AGCs) found at cervical screening are associated with a high and persistent risk of cervical cancer for up to 15 years, particularly for cervical adenocarcinoma and women with AGC aged 30 - 39. Compared with the reduction in risk of cancer seen after high-grade squamous intraepithelial lesion (HSIL) management, management of AGCs seems to have been suboptimal in preventing cervical cancer.

Research to optimise management is needed, and a more aggressive assessment strategy is warranted.

Incidence of dementia declining Antiretroviral drug resistance after failure of WHO firstline regimens

Those taking part in the Framingham Heart Study have been under surveillance for dementia since 1975. You might expect that the incidence is rising, but you would be wrong.

THIS GLOBAL ASSESSMENT of drug resistance after virological failure with firstline tenofovir-containing antiretroviral treatment showed that tenofovir resistance was highest in sub-Saharan Africa.

Overall, the authors recorded a high proportion of patients with this type of virological failure across low- and middleincome countries.

TenoRes Study Group. Global epidemiology of drug resistance after

Among participants in the Framingham Heart Study, the incidence of dementia has declined over the course of three decades.

The factors contributing to this decline have not been completely identified.

failure of World Health Organization

Hemkens LG. Agreement of treatment effects for mortality

Wang J, Andrae B, Sundström K,

(WHO) recommended first-line regimens

Satizabal C L. Incidence of

from routinely collected data and

et al. Risk of invasive cervical cancer

for adult HIV-1 infection: A multicentre

dementia over three decades in the

subsequent randomized trials:

after atypical glandular cells in cervical

retrospective cohort study. Lancet Infect

Framingham Heart Study.

Meta-epidemiological survey. BMJ

screening: Nationwide cohort study. BMJ

Dis 2016; S1473-3099(15)00536-00538.

N Engl J Med 2016;374:523-532.

2016;352:i493. DOI:10.1136/bmj.i493

2016;352:i276. DOI:10.1136/bmj.i276

DOI:10.1016/S1473-3099(15)00536-8

DOI:10.1056/NEJMoa1504327

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

THE SELF-INITIATED PRONE-POWERED CRAWLER

Feature | 23

Finn test drives the SIPPC

LENDING DISABLED BABIES A MIRACULOUS HELPING HAND Dr Thubi A Kolobe has developed a groundbreaking skateboardlike device, linked to a computer, that promises to enhance life prospects for disabled infants.

IMAGINE SWINGING YOUR DISABLED infant on a sling, sliding them around on a blanket or manipulating their little body to try to develop some core strength to enable independent movement and develop vitally required early neural pathways.

This is how parents and physiotherapists the world over have, until very recently, treated infants with cerebral palsy and others with profound disabilities.

Neuroscience and research now shows that this treatment often has very little outwardly visible effect for infants who are cognitively impaired. Enter to centre stage a former physiotherapist from Limpopo-

turned professor in Rehabilitation Sciences at the University of Oklahoma, Dr Thubi A Kolobe. She has conceived the SelfInitiated Prone-Powered Crawler (SIPPC), a skateboard-like device that miraculously enhances the physical abilities of disabled infants, particularly those with cerebral palsy (CP). She has also co-invented a mobile device that “teaches” disabled infants how to crawl, transforming existing cognition, early mobility and life prospects.

A subset of these children would otherwise never acquire the basic motor skills so fundamental to all future potential learning. The ground-breaking device was displayed at the Smithsonian Innovation

“

There is a window of very high synaptic connections in the brain at between 2 and 9 months old, a critical period for neural development

Peter Pidcoe (co-inventor) with the SIPPC

Dr Thubi Kolobe

“

Kolobe is using a neural feedback net to investigate the real-time activity in babies’ brains ... while Pidcoe is working to refine the design

Festival at the National Museum of American History in Washington DC, in September last year where Kolobe was honoured for her creative thinking. The device teaches infants born with disabilities not just to crawl, but to experience and enjoy independent movement.

Kolobe became frustrated with what she saw as the limitations of existing therapies, some of which do not necessarily reinforce neural pathways.

Research has shown that when babies try to move but do not get the desired effects, their brains prune off that particular motor pathway, leaving them forever disabled.

By stratifying five groups of infants and testing them weekly at 6 months, 9 months, 12 months, 3 years and 5 years, she and her colleagues were able to track the trajectories of those who ended up with cerebral palsy and those who did not.

They discovered that a developmental gap opened up even before term age (birth), becoming dramatic by 3 - 4 months old.

Kolobe explains that there is a window of very high synaptic connections in the brain at between 2 and 9 months old, a critical period for neural development, during which neurologists and paediatricians had previously adopted a “wait and see” strategy. “My frustration was that the age gap was widening even at this early stage.”

NUDGING THE INFANT BRAIN INTO ACTION

Although babies generally don’t crawl before 9 months, introducing the idea of crawling early enough facilitates brain connections and enhances the child’s innate compulsion to move. “We were waiting until they failed at 9 months,” Kolobe observes. The solution was to intervene early to enable the formation of lasting skills – so she turned to technology.

“I thought there must be a way to support these babies, to bypass those constraints on them and still enable them to drive themselves to move and explore.

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

Feature | 25

I wanted something that could harness a baby’s early independent movements, to keep them going and convert them into functional use.” So, in 2003, she sought out Peter Pidcoe, a former Chicago colleague, who runs a “peculiar” laboratory at Richmond’s Virginia Commonwealth University (VCU). People come to him, a physical therapist and engineer, when they need help creating a therapy tool that doesn’t yet exist. A “tinker” of note, Pidcoe fiddles away in a garage in the basement of VCU’s West Hospital, constructing devices; from electronic fatigue monitors to predict potential ankle sprains, to prosthetic limbs. Kolobe and her colleagues wrote algorithms incorporated into the electronically powered motorised SIPPC, with sensors that respond to babies’ little kicks and weight shifts, rewarding them with an extra boost. The baby lies directly on the cushioned board, secured in place with soft neoprene straps, and his/her arms and legs connect to sensors attached to computers. Later versions of the SIPPC now have a “onesie mode”, a shirt with embedded sensors to fine-tune directional detection, so that even babies who cannot generate much force would be reinforced by forward, lateral or backward motion.

“There is sophisticated measurement of the movement of a child’s arms and legs, and the SIPPC uses that to identify patterns we want to reward,” Pidcoe explains. “You direct the reward to the activities you’re trying to achieve.”

AN ILLUSTRATIVE CASE

One of her earliest patient successes was Kara Ellis, a twin born at 25 weeks who failed to thrive, living on and off ventilators and eating badly, whose determined mother, a nurse, came to her for help when her child started making odd movements and scissoring her fingers. Kolobe had by then developed, with colleagues in Chicago, an assessment called the ‘Test of Infant Motor Performance’ to identify infants most at risk of CP. She drew on her research of how brain growth affects motor development in very young children. At just a few months old, Kara was diagnosed with CP and other motor development

Stimulating an infant to move

delays, a result of her mother’s determination and internet searching.

CP nearly always affects muscle control and is often undiagnosed until the child is a year or more old, when it’s often too late for effective treatment. The baby has already passed through the stages of learning how to move: rolling, sitting, crawling, cruising and toddling. Random kicks and wiggles of a normal 3-monthold baby do important work by forming crucial neural connections that lead to advanced motor skills, such as walking or writing with a pencil. Putting a colourful toy just out of Kara’s reach was enough to stimulate her to reach for it, to attempt to lurch in its direction. Kara was rewarded when her effort resulted in movement towards the toy. Eventually, with more and more practice, Kara learnt to quickly move and grab the toy, because her developing brain reinforced the neural connections that control that skill. Tragically, the reverse is also true, with infants’ brains having a ruthless “use it or lose it” policy; if a baby tries to move and doesn’t get the desired effect, the brain eventually prunes off that motor pathway.

Monica Ellis said of her daughter: “Initially she would just lie there on her belly, unmotivated to participate. She sucked her fingers and watched as we tried to entice her to play. To get her moving, we’d pop her fingers out of her mouth, and she’d get mad”. They then got Kara’s attention with a toy. The first time she

H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

“

Even if a child was shown to have very little potential to move on its own after ongoing therapy; “if this device can help give them just the pleasure of the tiniest movement, that’s what it’s all about”

reached for an object on her own, Ellis and Kolobe cheered. “It flipped a switch,” Ellis says. “She’d turn her head and look at us like ‘Oh, you like this?’ That positive response really helped her to learn to start doing things on her own.” With help and reinforcement from the SIPPC, Kara learned how to crawl. Today, an active 4 year old in preschool with her sister, Kara walks, talks and runs. She has officially been discharged from physical therapy.

Ellis says if it weren’t for the SIPPC, the small obstacles of Kara’s infancy would have been infinitely more challenging to overcome. “Even as a little preemie, she let everyone do everything for her because she couldn’t do it by herself,” Ellis says. Kolobe, too, is driven to show that even very young infants are highly capable of making huge gains in the face of a potential disability: “This is what can happen when we harness and multiply the little capabilities that they have so that they can be successful, and only technology can allow us to do that. As a scientist, there are so many questions to be answered, and I feel we haven’t even scratched the surface with what we can learn from this”.

FIVE YEARS TO PUBLIC LAUNCH

Longitudinal Development:

Prof. Kolobe helps an infant test the crawler

LONGITUDINAL DEVELOPMENT: BY RISK GROUP

By Risk Group 180 160 140

LONGITUDE longitudASSIG group assig GROUP

120 100

full full term term

80

low preterm low risk risk preterm

60

very birthright very low low birthweight

40

bpd bpd

20

cns cns

0 -60

-20

20

60

100

POST-TERM AGE AT TESTING IN DAYS

post-term age at testing in days

140

Kolobe and Pidcoe continue to work on the SIPPC in their respective labs, but in slightly different capacities. Kolobe is using a neural feedback net to investigate the real-time activity in babies’ brains as they navigate with the SIPPC, while Pidcoe is working to refine the design in the hope that it will be commercially available to parents and therapists at a relatively affordable price. The versions, on display at the Smithsonian Institute, currently cost between R3 320 and R5 000 to produce.

Ultimately, Kolobe sees versions that can be driven with a cellphone, laptop or iPad-based application. Pidcoe describes the outcome as a classic example of how clinical and engineering tools can blend.

Pidcoe and Kolobe patented the SIPPC in January 2015. Although still a prototype, the goal is to miniaturise it, putting all the electronics into a small app, enabling it to be easily stored and transported. Kolobe hopes that within 5 years they will be ready for Federal Drug Administration (FDA)

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Feature | 27

approval and licensing, with a device that can be used twice a day at home, 5 days a week (currently in use twice a week owing to it’s relatively cumbersome nature). All the infants’ movements and distance and direction travelled are coded, and the less they access the “assist” function, the greater the success. A former University of KwaZulu-Natal graduate in the politically troubled early 1970s, Kolobe is determined that cost should not become a barrier to access: “It’s important to me that the device cost no more than $500 (approx. R7 500),” she says.

INVENTOR’S EMPATHIC JOURNEY

Ironically, a temporary disability of her own set her off on her unique academic journey.

“In matric I ended up in Baragwanath Hospital after a car crash in which a piece of the steering wheel cost me my voice.

The physios would visit my speech therapist during my sessions and I was fascinated by the work they did. My brother, a medical technologist at a research institute, took me to see two of them in action and that was that.” After graduating, she was the first and only black physiotherapist at the 1 200-bed Kalafong Hospital – and the only physiotherapist when Attridgeville and Mamelodi erupted into violence in 1976 (making travel to the hospital too dangerous for her 11 white colleagues).

“During that time, I did everything, including ICU, out of which came intense reading of foreign journals, which ultimately led to my applying for the Fullbright Scholarship, which at that time was unprecedented for healthcare professionals, from the American Consulate.”

LOCALLY APPLICABLE? AN INDEPENDENT PROFESSIONAL VIEW

Ms Marlette Burger, a physiotherapy lecturer at Stellenbosch University who specialises in paediatric neurology, said the real test of the invention would be whether it resulted in children continuing to independently move their limbs without the device.

With so few pilot tests, it obviously has some way to go. However, if it could evolve into a portable “take-home” device

for twice daily use, and could be imported cheaply enough to make it accessible for already budget constrained parents of disabled children, the electrically sensed movement assistance would be a valuable complementary tool to existing gold standard therapy. She explained that physiotherapists and occupational therapists currently used their hands to facilitate movement patterns in disabled children to achieve similar results. “For example, if the child is lying on its back, you use your hands to roll them over using their pelvis. The baby needs to do the work with the upper part of their trunk and arms and legs.” Therapists focused on trunk control and core stability to get the trunk to support the head and legs so that the child could hopefully learn to sit, and later stand up independently. Burger emphasised that a child’s motivation was crucial for success and said this was critically linked to their cognitive function and ability. “If they have severe cognitive disability, the prognosis is not so good.”

She said the device – which introduced a new kind of stimulation – sparked her curiosity. “I am interested in how quickly she saw in her research on those various age groups, that the device actually helps translate into independent movement patterns in the baby.” A fan of modern technology, she said it was currently “way under-used” in the disability field. Even if a child was shown to have very little potential to move on its own after ongoing therapy, “if this device can give them just the pleasure of the tiniest movement, that’s what it’s all about”.

Dr Ina Diene, a senior part-time lecturer at Stellenbosch University, private physiotherapy consultant and President of the South African Physiotherapy Association, said the device was “wonderful news for rehabilitation”. Its general application in South Africa was highly relevant. While wanting to see more evidence on the device teaching disabled infants to crawl, she said that other than its costs, the device “could work very well”, even in rural areas where there was a scarcity of rehabilitation therapists.

It seems more children’s futures stand to be transformed – simply because one passionate therapist refused to give up.

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Thubi Kolobe invented a Self-Initiated Prone Progressive Crawler (SIPPC) to help motorchallenged babies learn to inch themselves around

‘SCREEN AND TREAT’ SOLUTION FOR CERVICAL CANCER CLOSE TO REALITY Africa has the highest burden of cervical cancer in the world, with more that 60 000 African women dying from the disease annually.

“

If you remove those cells that are shown to be abnormal, you have a very high chance of preventing that woman from ever developing cervical cancer”

E

VEN THOUGH CERVICAL CANCER is preventable by screening through a Pap smear, around 6 000 women in South Africa (SA) develop this disease every year – and over 80% of these women are black. The life work of gender and health activist, renowned health researcher and gynaecologist at the University of Cape Town(UCT), Prof. Lynette Denny, focuses on preventing cervical cancer in low-resource settings. Her team is now very close to a workable intervention that could affect millions.

Denny describes cervical cancer as a “beautiful” example of inequity in access to health services: “The reason that cervical cancer is so common in poor countries is that they simply cannot afford to initiate or sustain mass cervical cancer screening programmes – so women do not

get screened, and because they don’t get screened, they are getting cervical cancer.”

However, cervical cancer is preventable because it has a precancerous phase.

“The natural history of cervical cancer is that a woman’s cervix becomes infected with certain high-risk types of human papillomavirus (HPV), particularly types 16 and 18. If her body is unable to clear this infection, it enters a dysplastic phase or precancer phase, which at one point may convert itself into cancer. However, if you can detect that precancer or dysplastic phase with a Pap smear and remove those abnormal cells, you can prevent it from developing into cervical cancer.

“This is a very expensive process. It needs a woman to go for a Pap smear, someone to take that smear, and transfer the smear to the laboratory, where it is interpreted by specially trained technicians

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Cervix with inflammatory changes, so-called ligneous cervicitis.

Invasive squamous cell carcinoma.

Hairy-cell leukaemia involving the cervix uteri.

and pathologists. The result goes back to the clinician and the patient is then referred for colposcopy, a highly specialised examination of the cervix during which it is illuminated and magnified with the application of 5% acetic acid, which shows up the abnormal cells. If you remove those cells that are shown to be abnormal, you have a very high chance of preventing that woman from ever developing cervical cancer.”

An alternative is testing the cervix for infection with certain high risk types of HPV (especially types 16 and 18) as the virus is believed to set off the chain of events that cause cervical cancer. HPV testing to date has been laboratory based and expensive.

“It could also lead to over-treatment, since it also identifies women infected with HPV but who do not have a precancer. You are treating women who possibly would clear the infection spontaneously.”

Denny stresses the need for a strong healthcare system to sustain cervical cancer screening with Pap smears. “In the UK in the 1980s they recognised that they were not having a real impact on cervical cancer, so GPs were actually paid to do Pap smears, and the coverage increased to over 85%. Only then did the incidence of cervical cancer really reduce. Achieving that required an injection of about £185 million to sustain that system.”

Her work for the last 20 years has been on finding an alternative to the Pap smear, where you could screen a woman at a primary healthcare clinic (PHC), give her the result and offer her treatment at the same visit – what she calls “screen and treat”.

“Our unit has been working in collaboration with Columbia University in New York and with funding from the Gates

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We found that women that underwent HPV testing followed by cryotherapy had a 75% reduction in cervical cancer precursors at year 3”

Prof. Lynette Denny

BIOGRAPHY Prof. Lynette Denny has published over 100 peer-reviewed papers and received numerous awards. She is Chair and professor of obstetrics and gynaecology, and a registered sub-specialist in gynaecological oncology at Groote Schuur Hospital and the University of Cape Town (UCT), and a full member of the Institute of Infectious Diseases and Molecular Medicine at UCT. She was named Distinguished Scientist for Improving the Quality of Life of Women by the South African Department of Science and Technology in 2006, and is rated a B2 scientist by the National Research Foundation of SA. Prof. Denny was the first recipient of the Shoprite Checkers SABC 2 Women of the Year award for Science and Technology in 2004. In 2012 she received the

South African Medical Association award for Extraordinary Service to Medicine, and was given a fellowship ad eudeum to the Royal College of Obstetrics and Gynaecology in the UK. She was presented with the British Society for Colposcopy and Cervical Pathology’s Founders’ Medal at the 15th World Congress for Cervical Pathology and Colposcopy in London in 2014. In 2015 she was presented with the International Federation of Gynaecology and Obstetrics Award in Vancouver, Canada.

In February 2015 the South African Medical Research Council announced its creation and support of a Gynaecological Cancer Research Centre, in partnership with UCT and headed

by Prof. Denny.

Foundation. Our first two cross-sectional studies in 1996 and 1998 showed that in a low-resource setting, in an unscreened population of older women

(35 - 65 years), a Pap smear and visual inspection with acetic acid (VIA) performed almost equally in detecting precancerous lesions. However, doing VIA means just passing a speculum into a woman’s vagina, washing it with vinegar, immediately looking for a result, and if positive treating her at that same visit.

“In 2000 we embarked on a trial where we randomly assigned 7 000 women aged 35 - 65 years to HPV DNA testing, if she had a positive test, or to VIA, or to no treatment regardless of screening test (after excluding all potential cancers by taking a photo of every woman’s cervix).

Every woman underwent a colposcopy at every single visit, which allows you to take a biopsy of the cervix – the gold standard to determine whether a woman has cervical cancer or not – and we saw them for 36 months. None had been screened before.

“What we showed was that if you screen a woman with HPV DNA testing and if she was randomised to receive treatment because of a positive test, nursing sisters could be trained to use a cryotherapy

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probe which goes onto the cervix and freezes and destroys the abnormal cells.

This was a radical change, since up till this point the whole domain of cervical disease had been in the hands of specialists.

Now it is in the hands of nursing sisters at PHC level. We found that women that underwent HPV testing followed by cryotherapy had a 75% reduction in cervical cancer precursors at year 3, compared with those receiving no treatment at all, whereas those that underwent VIA had a 48% reduction. HPV testing was thus much more effective than VIA.” In this study the women were given a 2 - 6-day grace period for ethical and research reasons; this simulated as if screening and treating were being done. The women came back within 2 - 6 days of being screened.

“This finding flew in the face of the previous study showing that VIA was just as effective as HPV testing and cytology.

A very good colleague of mine repeated the study in India with 100 000 women, and had exactly the same results; not only that, but in the ‘HPV testing and treat’

group represented a statistically significant reduction in deaths from cervical cancer.”

Even given this dramatic result, Denny and her team were “pretty depressed”, because although they had shown that screen and treat worked, there was no way any African country would be able to afford it while it was laboratory based.

Fortunately, things were to change.

“Now where we are with our research is that we have a new test that can give the result within an hour. A woman can come to the clinic, be tested for HPV, get her result within an hour through incredible technology, and if positive be treated at the same visit with cryotherapy by a nurse.

If she is not suitable for that (about 10% of cases), she is referred to the next level of care.

“If you can take the service to the woman at PHC level, you can screen and treat her at the same visit, and have – we know from the work my group has done – an excellent result. We needed a radical solution to the issue of cervical cancer – and now we are very close to it.”

“

Now where we are with our research is that we have a new test that can give the result within an hour”

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THE INFLUENZA VIRUS H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6

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CHASING THE GHOST OF AN EVER-CHANGING FLU VIRUS N o v _ D e c 2 0 1 4 | R E S E A R C H N E W S | 10

Two further publications (see below) from the School

of Public Health at Wits and the NICD have demonstrated PCVs to be effective in preventing

pneumococcal disease among South African children in conditions of routine vaccine use. The first paper

generated estimates of pneumococcal conjugate

vaccine effectiveness in HIV-uninfected and -infected children which is an important aspect of monitoring

vaccine performance in routine use. Dr Cheryl Cohen, lead author of this paper, is a clinical epidemiologist

at the NICD and senior lecturer in the School of

Public Health at Wits. An additional paper by Dr Claire von Mollendorf, a PhD student registered in

the School of Public Health at Wits, showed that HIV-

Medical epidemiologists and vaccine manufacturers fight an annual battle to stay one step ahead of ever-mutating flu viruses so that the protection they offer can be as effective as possible – with high HIV prevalence in South Africa complicating the picture. infected

children

and

HIV-exposed-uninfected

children are at substantially increased risk of pneumococcal disease. This is important as it

highlights the potential for this vaccine to reduce health disparities in these vulnerable groups.

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1. Von Gottberg A, de Gouveia L, Tempia S, Quan V, Meiring S, von Mollendorf C, Madhi SA, Zell ER, Verani JR, O'Brien KL, Whitney CG, Klugman KP, Cohen C. Effects of vaccination on invasive pneumococcal disease in South Africa. N Engl J Med 2014; 371:1889-99.

CCORDING TO DR Cheryl Cohen, a medical epidemiologist and Head of the Centre for Respiratory Diseases and Meningitis at the National Institute for Communicable Diseases (NICD), HIV prevalence boosts local flu-related mortality by about 30%. Over half of all patients with flu-associated lower respiratory tract infections in public sector hospitals are HIV-positive. This makes HIV the

2. Cohen C, von Mollendorf C, de Gouveia L, Naidoo N, Meiring S, Quan V, Nokeri V, Fortuin-de Smidt M, Malope-

most important condition hospitalised Kgokong B, Moore D,risk Reubenson G, Moshefor M, Madhi SA, Eley B, Hallbauer U, Kularatne R, Conklin L, O'Brien KL, Zell flu ER, in Klugman this country, changing the classic risk K, Whitney CG, von Gottberg A. Effectiveness of 7-Valent Pneumococcal Conjugate Vaccine Against profile of flu patients entirely from those Invasive Pneumococcal Disease in HIV-Infected and Uninfected Children in South A Matched Casein northern Europe andAfrica: northern America Control Study. Clin Infect Dis 2014; 59:808-18. where mostly the elderly and young children 3. Von Mollendorf C, Cohen C, de Gouveia L, Naidoo N, Meiring S, Quan V, Lindani S, Moore D, Reubenson (immature immune systems) are at risk.G, Moshe M, Eley B, Hallbauer UM, Finlayson H, Madhi SA, Conklin L, Zell ER, Klugman KP, Whitney CG, von Gottberg In other countries, people aged A. Risk Factors for Invasive Pneumococcal Disease among Children less 5 Years Age in a are High HIV-Prevalence between 25Than and 45ofyears seldom Setting, South Africa, 2010 to 2012. Pediatr Infect Dis J admitted to hospital, but in South Africa 2014.

Dr Cheryl Cohen (SA) the advent of HIV has completely Photograph (top to bottom): Dr Claire von Mollendorf, Dr changed that. On the positive side Anne von Gottberg and Dr Cheryl Cohen.

WITS | HEALTH SCIENCES

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Over half of all patients with flu-associated lower respiratory tract infections in public sector hospitals are HIVpositive

(although there is a paucity of local research), the huge improvement in prevention-of-mother-to-child-transmission (PMTCT) (now below 2%), and the increased availability of highly active antiretroviral therapy (HAART), almost certainly means that fewer high-flu-risk infants and children under 5 years old are dying. Cohen says this is intuitively based on research in the USA showing that mortality has dropped significantly in the era of HAART. She said local research estimates that between 6 734 and 11 619 people die of seasonal influenza-associated illness in SA every year.

Approximately 5% of these deaths are in children under 5 years old, while among people 5 years or older, an estimated 50% of influenza-associated deaths are in the elderly, with approximately 30% in HIV-infected individuals.

The highest rates of influenzaassociated hospitalisation were in those aged 65 years or older, HIV-infected individuals and children under 5 years old. Asked about last year’s delay in the delivery of a quickly modified flu vaccine and speculation that this had boosted flu prevalence, she said there were no such clouds on this year’s manufacturing horizon. “Yes, they’ve modified the vaccine again to be more appropriate to the strains circulating but they tell me there are no delays expected.” She explained that flu mutation makes it a real challenge to appropriately adapt the vaccine every season, because it takes a full 6 months to

make a new vaccine. “It’s always evolving.

Each year the strains are similar, but slightly different. One factor can cause change; people become immune and this pushes the virus to change – this is also why you can get flu many times.” Scientists keep up by holding two disease surveillance meetings annually, one in the northern hemisphere and one in the southern, pooling their findings to come up with effective vaccines. Her advice was that it was always better to get your flu shot than not, even if this resulted in only moderate protection. She was responding to a mismatch in the US flu vaccine and the flu strain circulating there during their 2014/2015 season, which resulted in the vaccine proving to be only 23% effective.

“If we get it (the vaccine) too late, it can be a real challenge for healthcare workers to get the vaccine into people in time. We just have to do our best to estimate it (development and production), but we cannot predict the future,” she emphasised. She said the World Health Organization did its level best to make predictions based on surveillance data, but in some years “it just happens that the strain that comes around is different to the vaccine that’s being circulated”. It was particularly difficult when a new strain got into circulation when there was little or no community immunity. “It’s a mystery, but we’re working on it all the time. It’s an intrinsic property of the virus to mutate and cause disease,” she added.

IMMUNE HISTORY COMPLICATES ROAD TO UNIVERSAL FLU VACCINE An in-depth view into people’s immune responses to the pandemic 2009 H1N1 vaccine reveals that past exposure to influenza can potentially reduce a person’s ability to launch a broadly protective antibody response to the virus. The findings, made in December last year, could complicate efforts to develop a universal flu vaccine.

The constantly evolving influenza virus often returns a different strain each season, causing mild to serious illness and even death. A protein on the surface of the virus called haemagglutinin (HA), which is composed of a globular head and stalk, allows influenza to bind to and invade cells. Most flu vaccines activate antibodies that target the virus’s HA globular head, a region highly prone to mutating, offering protection only from specific strains. Antibodies directed at the HA stalk, which remains largely constant across strains, are known to help produce long-term immunity.

To better understand how immune memory influences

immunity to influenza, Sarah Andrews and colleagues from the Department of Medicine at the University of Chicago analysed the antibody response to the 2009 pandemic H1N1 strain over time in vaccinated individuals. They found that subjects with low levels of H1N1-specific antibodies prior to vaccination mounted a broadly protective immune response against the HA stalk. However, those with high levels of pre-existing H1N1-specific antibodies largely targeted the HA head, leading to a weaker immune response. These subjects tended to be older and have therefore encountered a wider range of H1N1 strains over their lifetime.

The findings suggest that prior exposure to influenza, including in vaccines, may actually leave one with fewer broadly protective immune cells, presenting an additional hurdle to developing a universal flu vaccine independent of a person’s immune history.

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FLU DRUG SHORTENS HOSPITAL TIME FOR EXPECTANT MOTHERS A new study has highlighted the importance of the flu vaccination and early treatment for expectant mothers, a high-risk group.

P

regnant women are at higher risk for serious illness and complications, including death, from influenza. For expectant mothers hospitalised with flu, early treatment with the influenza antiviral drug oseltamivir may shorten their time in the hospital, especially in severe cases, suggests a new study published early this year.

The findings also underscore the importance of the flu vaccination for this risk group.

“Treating pregnant women who have influenza with antiviral drugs can have substantial benefit in terms of reducing length of stay in the hospital,” said Dr Sandra S Chaves, of the US Centers for Disease Control and Prevention (CDC) and senior author of the study. The CDC recommends treatment of suspected cases of flu among pregnant women with antiviral drugs as soon as possible, without waiting for test results to confirm influenza. “The earlier you treat, the better chances you have to modify the course of the illness.”

Past studies have suggested that flu antiviral therapy is safe and beneficial for pregnant women. The current study, based on data from a nationwide flu surveillance network including 14 states, focused on pregnant women hospitalised with laboratoryconfirmed flu over four recent flu seasons, from 2010 to 2014. During the study period, 865 pregnant women were hospitalised with flu. Sixty-three of these patients, or about 7%, had severe illness. After adjusting for underlying medical conditions, vaccination status and pregnancy trimester, the

researchers found that early treatment with the antiviral drug oseltamivir was associated with a shorter hospital stay. Among pregnant women with severe flu who were treated early – within two days of the start of symptoms – the median length of stay was about five days shorter compared with hospitalised pregnant women with severe flu who were treated later (2.2 days v. 7.8 days). Pregnant women hospitalised with less severe illness who were treated early also had a shorter hospital stay than those treated later, but the difference was not as great.

In the study, pregnant women hospitalised with severe flu were half as likely to have been vaccinated as women hospitalised with milder illness (14% v. 26%). The CDC recommends an annual flu vaccination for everyone 6 months of age and older, including pregnant women during any trimester of their pregnancy. Earlier studies have suggested that immunisation during pregnancy may protect not only the mother from flu, but also her newborn baby during the first 6 months of life.

A related editorial commentary by Drs Alan TN Tita and William W Andrews of the University of Alabama at Birmingham, said: “Overall, considering the accumulating evidence of fetal benefit and safety, influenza vaccination of pregnant and postpartum women should be a public health priority.

Prompt initiation of antiviral therapy if infection occurs, preferably within two days of suspected or confirmed influenza infection, is encouraged.”

WHO SHOULD BE INOCULATED? n Women who would be in their second or third trimester of pregnancy during the influenza season. Pregnant women with medical conditions that place them at risk for influenza complications should be immunised at any stage of pregnancy. n Adults and children over 6 months old with a chronic health condition (e.g. diabetes, respiratory disorder) or with a weakened immune system (e.g. HIV/AIDS).

n Everyone aged 65 and older n Residents of long-term care facilities n Caregivers of babies and young children n Children on long-term aspirin therapy n Anyone who is likely to come into regular, close contact with people in these high-risk categories n People who have one or more medical conditions that places them at increased risk for serious flu complications.

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ZIKA: THE GLOBAL THREAT HITS OUR SHORES – BUT NO CAUSE FOR ALARM With South Africa confirming on 19 February that a visiting Columbian businessman was infected with the mosquito-borne Zika virus, the dire global implications, especially for pregnant women, have set emergency bells ringing.

T

HE UNIDENTIFIED businessman (who fully recovered) is believed to have contracted the disease in Columbia, which is experiencing a major outbreak, before travelling to South Africa (SA). Health Minister Aaron Motsoaledi, however, assured South Africans that there is no threat of an outbreak locally because the mosquito species currently causing the epidemic, Aedes aegypti, does not exist

locally. The disease has most alarmingly been linked to microcephaly, a condition that causes babies to be born with abnormally small heads and, in most cases, irreversible brain damage.

By early March 2016, Zika had been linked to 4 000 new cases of microcephaly in Brazil where it was first detected in May last year. Neighbouring Columbia’s National Health Institute reported 2 100 pregnant women infected with Zika by 27 February, with authorities appealing

“

By early March 2016 Zika had been linked to 4 000 new cases of microcephaly in Brazil where it was first detected in May last year

ZIKA LINK IN EYE ABNORMALITIES Vision-threatening eye abnormalities in infants in Brazil with microcephaly (a birth defect characterised by an abnormally small head) may be associated with presumed intrauterine infection with the Zika virus, according to a Brazilian study published earlier this year.

An epidemic of the Zika virus began in Brazil in April 2015.

Six months after the onset of the Zika outbreak there was an unusual increase in newborns with microcephaly. Dr Rubens Belfort Jr of the Federal University of São Paulo, Brazil and co-authors evaluated the ocular findings of 29 infants with microcephaly (head circumference less than or equal to 32 cm) with a presumed diagnosis of congenital Zika virus.

The study was conducted during December 2015 and all the children and their mothers were evaluated at the Roberto Santos General Hospital in Salvador,

Brazil. Of the 29 mothers, 23 (79.3%) reported suspected Zika virus signs and symptoms during pregnancy, including rash, fever, arthralgia (joint pain), headache and itch. Among the 23 mothers who reported symptoms during pregnancy, 18 or 78.3% reported Zika virus symptoms during the first trimester of pregnancy, according to the report. Abnormalities of the eye were observed in 10 of the 29 infants (34.5%) with microcephaly; of the 20 eyes in 10 children, 17 eyes (85%) had ophthalmoscopic abnormalities.

Bilateral abnormalities were found in 7 of the 10 infants (70%) presenting with ocular lesions, the most common of which were focal pigment mottling of the retina and chorioretinal atrophy in 11 of the 17 eyes with abnormalities (64.7%). There were optical nerve abnormalities in eight eyes (47.1%), along with other findings.

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Analysts and epidemiologists predict the virus could infect up to 5 million people in North, Central and South America

TREATMENT DO’S AND DON’TS n There is no vaccine or specific prophylactic treatment. n Differential clinical diagnoses should be considered as well as co-infection with other mosquito-borne diseases such as dengue fever, chikungunya and malaria. n The treatment is symptomatic and mainly based on pain relief, fever reduction and antihistamines for pruritic rash. n Treatment with acetylsalicylic acid and non-steroidal antiinflammatory drugs is discouraged because of a potential increased risk of haemorrhagic syndrome reported with other Flaviviruses as well as the risk of Reye’s syndrome after treatment with aspirin in young children.

to women not to fall pregnant – even though the causal link to the virus has yet to be proven. SA’s National Institute of Communicable Diseases (NICD) Head, Prof.

Lucille Bloomberg, said that SA’s Aedes aegypti mosquitoes had not been shown to be competent vectors, adding that any local spread was “very unlikely”. In spite of this, her institute and the Department of Health were monitoring events closely.

Joe Maila, a spokesman for Motsoaledi, explained that the virus was present in the blood of a patient typically for less than 7 days, meaning that a person carrying the virus would have to be bitten by a correct subtype of an Aedes aegypti mosquito during this time for the virus to be transmitted to the next person through a bite from the same mosquito.

The Aedes mosquito that transmitted the Zika virus in South America also transmitted dengue fever and yellow fever, yet these viruses are not found in SA. Maila said this strongly indicated that the local Aedes mosquito does not contribute to the spread of the Zika virus. He added, however, that given the frequency of travel between SA and a number of countries currently experiencing Zika outbreaks, it was likely that other sporadic imported cases would be seen here, as has been the experience in a number of countries.

MILLIONS AT RISK

Analysts and epidemiologists predict the virus could infect up to 5 million people in North, Central and South America and, as with Ebola in West Africa (which killed 10 000 people via a very different vector, human-to-human bodily fluids), the race is now on to develop a vaccine with the World Health Organization (WHO) declaring Zika an international public health emergency and responding far more rapidly than it did to Ebola (for which a vaccine was belatedly developed).

Four conditions need to apply for the WHO to declare a Public Health Emergency of International Concern (PHEIC). These are: n the outbreak must have a serious public health impact n it must be unexpected n it must have the potential to spread

n it must have the potential to lead to travel and trade restrictions.

In late February 2016 the WHO convened an emergency Zika meeting to coordinate and streamline its multi-country response, while the Pan American Health Organization convened a research indaba inviting the world’s top experts to identify current gaps in the scientific knowledge of the Zika virus, its impact on humans and it public health implications. By 1 March the virus had spread to 23 countries and territories in South America, with some 40 cases reported in North America, all of them travellers from the pandemic regions. Major airlines routing to and from the Americas were either offering re-bookings or refunds for tickets to areas affected by the virus, or giving pregnant women the opportunity to change their reservations to another destination or to delay travel. Meanwhile WHO assistant director, Bruce Aylward, said developing a safe and effective vaccine could take a year, while it could take 6 - 9 months to confirm whether Zika is the actual cause of the birth defects, or whether the two are just associated.

The Aedes aegypti mosquito thrives in the warm, humid, increasingly dense urban areas of Latin America – and climate change has been making these places warmer and wetter. According to one WHO report, the related dengue disease infected people 30 times more frequently in 2013 than it did in the 1960s, making it the planet’s most rapidly spreading mosquito-borne virus.

Researchers have successfully bred a strain of male Aedes with a single modified gene which programmes its offspring for selfdestruction. Millions of mutant males were released last year in Brazil’s south-eastern Piracicaba city (a high dengue infection area) while Zika was still relatively unknown.

According to the latest reported data, the “friendly” insects reduced the wild Aedes population there by 82%. On 19 January 2016 a new mosquito-making factory, thirty times larger than the existing plant, began construction in the city. Other Brazilian municipalities are now clamouring for the authorities to approve a licence that will allow the “manufacturing” company to sell its product commercially.

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HISTORY, SPREAD AND SYMPTOMS

ZIKA VIRUS INFECTION IS A MOSQUITOborne pathogen that has widened its geographic range from Africa and Asia to the Pacific Islands and the Americas in the last decade. Before 2007, viral circulation and a few outbreaks were documented in tropical Africa and in some areas in South East Asia. Since 2007, several islands of the Pacific region have experienced outbreaks.

Last year, disease outbreaks were reported in South America for the first time. The virus disease is now considered globally as an emerging infectious disease. Currently, there is a large and ongoing outbreak in the Americas, and the local circulation of the Zika virus is widely established in over

23 North American regions. The incubation period is typically 3 - 12 days, and infections caused by the virus are mostly asymptomatic. If symptomatic, it presents as a mild to moderate illness characterised by rash, fever, arthritis or arthralgia and conjunctivitis, with symptoms lasting 7 - 10 days. The rash is typically maculopapular, with a median duration of 6 days (range 2 - 14) and arthralgia lasts for about 3 days.

Other reported symptoms include headache, myalgia, retro-orbital pain and vomiting. There is no prophylaxis, treatment or vaccine to protect against infection, so preventative personal measures are recommended to avoid bites.

INFECTION CONTROL AND PREVENTION The following activities support the reduction of mosquito breeding sites in outdoor and/or indoor areas by draining or discarding sources of standing water at the community level, and can include: n Removal of all open containers with stagnant water surrounding houses on a regular basis (flower plates and pots, used tyres, tree holes and rock pools) or, if that is not possible, treatment with larvicides. n Tight coverage of water containers, barrels, wells and water storage tanks. n Wide use of window and/or door screens. n During an outbreak, elimination of adult mosquitoes through aerial spraying with insecticides.

n Using personal protection measures during the day because that’s when the aedes mosquitoes bite. Other measures to avoid bites should be applied when in risk areas by: • using appropriate mosquito repellents and wearing longsleeved shirts and long trousers, especially during the hours of highest mosquito activity • sleeping or resting in screened or air-conditioned rooms, otherwise use insecticidal treated mosquito nets, even during the day.

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It presents as a mild to moderate illness characterised by rash, fever, arthritis or arthralgia and conjunctivitis, with symptoms lasting 7 - 10 days

SA’S FIRST FEMALE TRAUMA SURGEON

By Toni Younghusband

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A cold, pale organ when suddenly perfused in the recipient’s body, magically starts to function within minutes.

This amazes me every time I do a kidney transplant”

A

SLEW OF FIRSTS characterises Dr Elmin Steyn’s career in medicine.

The first female trauma surgeon in South Africa (SA); the first female head of an academic surgical department; the first female surgeon in private practice in Cape Town; the first female president of both the Trauma Society of SA and the Transplant Society of SA, and so on.

She also has her helicopter pilot’s licence, has co-edited a definitive textbook on trauma and heads up the biggest private renal transplant programme in Cape Town.

Yet for someone first in line when achievements were handed out, she is surprisingly low-key and there is frustratingly little in the headlines about the private life of the woman behind the scalpel. That is the way she likes it.

She may be a pre-eminent achiever but the basics of good medicine still excite her, not the media attention that springs from success.

“A cold, pale organ when suddenly perfused in the recipient’s body, magically starts to function within minutes. This amazes me every time I do a kidney transplant,” she says.

It was during her first job at Ga-Rankuwa Hospital near Pretoria that she first experienced the thrill of transplant surgery and that thrill has never waned. “I played a small part in the development of the first cadaver donor transplant programme in SA that offered life-saving transplants to black patients, under the leadership of Prof. Johan van Wyk. “This was the mid-eighties and it was generally believed that for cultural reasons black families would not accept the concept of brain death and would not donate the organs of their loves ones. We disproved this.”

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CHALLENGING GENDER PREJUDICE

Challenging myths and prejudice is an Elmin Steyn hallmark. Indeed, she believes she may well have chosen a medical career precisely because an ultra-conservative male schoolteacher told her medicine was “not for women”. She went on to become one of the first women in the country to qualify as a general surgeon, and in the process became an enthusiastic proponent of patients’ rights too.

“Many years ago when treating trauma cases was the least popular aspect of general surgery and generally relegated to junior trainees, I realised that even the most hardened gangster was just another victim of the system and deserved the same level of care as everyone else. I feel very strongly that we should respect (and teach medical trainees to respect) patients’ rights. The patient is our first priority.”

Inequality in medical care is a major frustration. “In big cities in SA, Africa and in many parts of the world, we have world-class medical care with access to chronic treatment modalities like dialysis, transplantations, high-tech interventions and life-saving emergency care.

“In rural areas, despite the efforts of a few heroic individual healthcare providers, limited access to medical care places people at risk of dying of eminently treatable and often preventable conditions.”

Steyn has an exceptional track record in outreach and community upliftment projects, says Ken Boffard, Prof. Emeritus of the University of the Witwatersrand (Wits) and trauma director of Netcare Milpark Hospital, who has known her since 1990.

“In some ways she has been a role model as to how a surgeon should care about people, her patients and those around her,” he says.

Those students that learn from her in her new role as Head of the Department of Surgery at Stellenbosch University and Tygerberg Hospital will experience Steyn’s intense passion for all facets of her craft.

PREVENTION BETTER THAN CRISIS INTERVENTION

While many surgeons are content to devote their energies to the theatre alone, Steyn has used her experience to influence all aspects of trauma and transplant surgery, from improving the rate of organ procurement to the prevention of traumatic injuries.

Steyn established a major injury prevention programme for the Trauma Society of SA, has worked with injury prevention groups and has been instrumental in establishing highly regarded injury and advocacy websites.

In addition, she has been very active in increasing organ donor awareness. She established many of these initiatives at her own expense and they have involved a huge commitment in time and energy.

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“

She went on to become one of the first women in the country to qualify as a general surgeon, and in the process became an enthusiastic proponent of patients’ rights too

“

What we need is very simple and realistic – a commitment from administrators of all hospitals in SA to institute a protocol of compulsory referral of all potential organ donors to transplant coordinators”

She firmly believes that health professionals should actively participate in the societies in which they work, especially in influencing behavioural change towards better health outcomes. “Preventable injuries such as interpersonal violence and road traffic-related injuries are a huge financial burden on the healthcare system and the tax payer.

“The causes are complex and multiple but I strongly believe that we should not complacently continue to treat the consequences of the mayhem; as health professionals we should be advocates for change in behaviour, law enforcement and mindset,” she says.

While she aims to continue Stellenbosch University’s tradition of surgical training excellence, she also hopes to impact organ procurement at Tygerberg Hospital to benefit the hundreds of patients waitlisted for transplants.

“Improving organ donation is about education – not only of the public, but also of the medical profession and health administrators,” she says. “What we need is very simple and realistic – a commitment from administrators of all hospitals in SA to institute a protocol of compulsory referral of all potential organ donors to transplant coordinators.”

TRAUMA TRAGICALLY A GROWING DISCIPLINE In countries where trauma has had little

impact in the past (few traffic injuries and low levels of interpersonal violence) there is renewed interest in developing trauma skills.

As terrorist threats grow and more military surgeons are deployed with peacekeeping forces in troubled parts of the world, and with SA’s reputation as experts in trauma management, Steyn has been invited to teach trauma surgery all over the world.

“Dr Steyn is highly regarded as a surgical educator, both here and abroad,” says Prof. Boffard. “I have had the privilege of watching her teach and she has the knack of embracing and involving her audience, and stimulating audience participation.

Where there have been assessments by participants, these have consistently shown her to have the highest ratings.”

Steyn quickly adds how reliant she is on the team collective, the importance of being part of a team in her job and how much she is looking forward to working with her new team at the university.

When not saving lives or teaching others, Steyn collects art and hikes, especially in areas where there is no cellphone reception. “I also love all aspects of aviation and flying, and obtained my helicopter pilot’s licence some years ago, but sadly there isn’t much time to fly.”

She may not take to the skies very much anymore but there is no doubt that Elmin Steyn will give wings to those Stellenbosch students who have the privilege of learning from her.

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5th Annual

OUTBREAK CONTROL AND PREVENTION AFRICA CONFERENCE

CPD ACCREDITED

Dates: 20 & 21 April 2016

Venue: Indaba Hotel, Fourways, Johannesburg

CONFIRMED SPEAKER FACULTY Dr Chika Asomugha Senior Medical Advisor for Public Health and the Communicable Diseases Programmes GAutenG DepArtment oF HeAltH professor Stella Anyangwe Honorary Professor of Epidemiology unIVerSItY oF pretorIA Dr Salim parker President SoutH AFrICAn SoCIetY oF trAVel meDICIne mandla Zwane Deputy Director - Health mpumAlAnGA DepArtment oF HeAltH Dr lourens robberts ‎Clinical & Public Health Microbiologist unIVerSItY oF CApe toWn

Dr Jacob Sheehama Deputy Associate Dean SCHool oF meDICIne - unIVerSItY oF nAmIBIA Dr lesego Bogatsu Senior Manager-Aviation Medicine SoutH AFrICAn CIVIl AVIAtIon AutHorItY Thulisa Mkhencele Epidemiologist nAtIonAl InStItute For CommunICABle DISeASeS thomas Dlamini Epidemiologist & Researcher eAStern CApe DepArtment oF HeAltH professor Bethabile lovely Dolamo Professor: Health Services Management and Leadership DepArtment oF HeAltH StuDIeS - unIVerSItY oF SoutH AFrICA

Diana Chebet Microbiologist & Infection Control Unit Team Leader pHArmAKen ltD - KenYA

PRACTICAL CASE STUDY WORKSHOP

Godwill mlambo Assistant Malaria Control Manager tFm proJeCt DemoCrAtIC repuBlIC oF ConGo CPD Accredited: Level 1 – 10 Clinical Points (1pt per hr) 10 Speaker points (per instance)

• • • •

DISCuSSInG tHe InternAtIonAl reSponSe pArADIGm to pAnDemIC DISeASe Control In AFrICA AnD tHe nexuS WItH peACeKeepInG reSponSe meCHAnISmS In tHe lIGHt oF tHe WeSt AFrICAn eBolA outBreAK Andre Juan roux Conflict Management, Peacekeeping and Peacebuilding Expert

Sp e o CIA reg FFer l del i s rec egateter 5 eiv s del e the and e th Fr gate 6 ee

KEY STRATEGIES TO BE DISCUSSED

Analysing the effects of outbreak pandemics on developing countries within Africa Collaborating with national multi-sectoral outbreak response teams managing outbreaks at a national and global level Examining the role of medical and health innovation to prevent and treat deadly infectious diseases

• • • •

Formulating solutions to enhance airport preparedness guidelines for outbreaks of communicable disease Improving the management and control of outbreaks in hospitals and public health centres Discussing the management and control of Tuberculosis within confined spaces Investigating cases of Malaria and providing prevention and control strategies ItC is a proud member of:

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For easy registration contact Therisha +27 (0) 11 326 2501 or email bookings@intelligencetransferc.co.za

ItC IS etDp SetA ACCreDIteD & AorleVel 1 B-BBee CompAnY or fax: +27 (0) 11 326 2960 visit: www.intelligencetransferc.co.za H EALT H CARE GA ZE TTE | MA RC H /A PR I L 2 0 1 6