Healthcare Gazette - 2015 Nov/Dec

healthcare gazette

NOVEMBER/DECEMBER 2015 • ISSN 2078-9750

Natives grow paler waiting for the NHI White Paper

PG 6

New hope for early Alzheimer’s patients PG 18 20

32

FEATURE

Heartache of unhealthy lifestyles – what it costs us in lives

52

NEWS

Grim toll of kidney donor and dialysis machine shortages

57

FOCUS

Collaboration on Ebola vaccine changes R & D forever

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5 www.hmpg.co.za

RESEARCH

Digoxin – tried and tested?

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Contents | 03

Co nt ent s FEATURES

NEWS

06

Natives grow paler waiting for the NHI White Paper

29

Marketers of unhealthy foods exploit our ‘survival’ DNA

PROFILES

42 force

Glenda Gray: A formidable

RESEARCH

56

More evidence against antibacterial soaps

56

Atmospheric carbon dioxide concentrations and zinc deficiency

14

32

Rendering a dangerous healthcare ocean safer

Grim toll of kidney donor and dialysis machine shortages

45

Surfing the genome wave – Dr Craig Venter

FOCUS

18

34

New hope for early Alzheimer’s patients

Using cutting-edge science to tackle NCDs?

20

The heartache of unhealthy lifestyles – what it costs us in lives

36

High-tech exercise medicine boosts healthcare

38

Don’t measure who died and why – it’s confidential!

24

SA’s debilitating ‘diabesity’ pandemic threatens healthcare delivery

48

Surgeons bicker as penis recipient impregnates girlfriend

52

Collaboration on Ebola vaccine changes R & D forever

39

Is SA’s NHI ready for ‘health tourism’?

– a cautionary tale

40

Gauteng’s negligence continues, major overhaul underway

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57

58

Digoxin – tried and tested?

HPV vaccination and pregnancy outcomes

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HAS THE EXPERIENCE AND RESOURCES TO GIVE YOUR PRACTICE THE EDGE IT NEEDS

Ed’s Letter | 05

Ed’s Letter EDITOR Chris Bateman

C h r i s B at e m a n

CONTRIBUTORS Taryn Springhall, Anne Hahn & Bridget Farham SUB-EDITOR Diane de Kock

Dishing up some ‘lifestyle-gevaar’

T

he tsunami of

in what one American researcher calls

non-communicable

a ‘food swamp’ and are biologically

diseases (NCDs) which

wired to pay more attention to food

threaten to engulf our

than other things in our environment

hard-pressed, under-

and at the mercy of ubiquitous,

staffed and often dysfunctional public

cheap and aggressive marketing of

healthcare facilities has put the

unhealthy food items. Heave some

spotlight firmly on the sea of change

unhelpful cultural attitudes, fuelled by

needed in our lifestyles. We know

our horrific HIV/AIDS legacy, into the

what’s required across all income

world’s highest Gini coefficient, and fat

groups and geographical areas – but

suddenly becomes a fatal attraction,

it’s the harnessing of political will and

wrongly signalling physical and financial

the means of achieving this that will

wellbeing. A few innovative (private)

ultimately prove pivotal.

healthcare funders are on the money

This, the second-ever edition

(literally) when it comes to using

Published by the Health and Medical Publishing Group (HMPG) CEO AND PUBLISHER Hannah Kikaya EDITOR-IN-CHIEF Janet Seggie EXECUTIVE EDITOR Bridget Farham MANAGING EDITOR Ingrid Nye 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

of the Healthcare Gazette, carries

ubiquitous technology and behavioural

a raft of stories outlining what our

economics to ‘nudge’ people into

grossly unhealthy lifestyles cost us

appropriate exercise and nutrition;

individually and as a society – and

but they reach mostly the privileged

some of the more innovative solutions

few. Law-making takes time (we have a

being proposed. Take a look at the

batch around smoking and salt content,

numbers, which you’d think would spur

with others in the pipeline), so maybe

every activist and advocacy group,

it’s high time government tried making

government and the private sector into

some ‘white propaganda’ as all-

unified action; 70% of all South African

pervasive as killer fast-food marketing.

women and 45% of men (over 35) are

Speaking of legislation, we also

overweight or obese, while 12% of all

highlight clumsy law-making where the

Printed by Paarl Print

of us are either pre-diabetic or living

Health Department is taking on Home

Publisher website: www.hmpg.co.za

with full-blown diabetes. Premature

Affairs at the SA Law Commission,

deaths caused by heart and blood

ironically to enable us to continue

vessel diseases (CVDs) in those of

finding out just what South Africans

us of working age (35 - 64 years) are

are dying of, so we can craft and build

expected to increase by 41% between

interventions more effectively. It’s an

2000 and 2030. It’s all because we live

interesting old world! Enjoy.

CUSTOMER SERVICE & ONLINE SUPPORT Gertrude Fani | +27 (0)72 635 9825 | publishing@hmpg.co.za FINANCE AND ADMINISTRATION Tshepiso Mokoena | +27 (0)12 481 2140 | tshepisom@hmpg.co.za LAYOUT AND DESIGN Tenfour Media

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

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Natives grow paler waiting for the NHI White Paper You know South Africa’s (SA’s) healthcare system is terminally ill when one medical scheme covers, in full, a claim of R16.5 million which represents one patient’s 20-day hospital stay.

T

By Marika Sboros and Chris Bateman he claim (which

date). In the vacuum, the NHI

Discovery Medical Scheme

detractors grow. Sceptics say just

paid) wasn’t for high-tech

untangling the complexities of hospital

(or any) surgery, smart

standards to apply the national Health

cancer drugs, stem cells,

Department’s draft regulations on

cloning, or anything one might expect

minimum standards across both

modern medicine’s practitioners to

private and public sectors will prove

dream up to justify such an exorbitant

nightmarish. Enforcing them equally

(some might call it obscene) bill. It was

would prove the ultimate litmus test.

for haemophilia, a rare, life-threatening condition in which the blood doesn’t clot properly.

The claim’s financial blood-letting

landscape permanently and has fuelled

Here are the NHI fault lines …

One cannot wish away existing “fault

could have killed off a smaller scheme,

ongoing, even wild, speculation in

lines”, says Prof. Laetitia Rispel,

or seriously destabilised its risk pool. It

the media and healthcare fraternity.

University of the Witwatersrand’s newly

is more proof, if any were needed, that

It’s probably a little dog-eared in its

appointed head of Public Health.

SA’s healthcare system is a ‘sick-care’

nineteenth version, which Motsoaledi

Delivering her inaugural address on

system in urgent need of life-saving

doesn’t see as untoward. England

campus this September, Rispel says

intervention.

“have been annually fine-tuning theirs

these faults have mired the NHI in

Sceptics say just untangling the complexities of hospital standards to apply the national Health Department’s draft regulations on minimum standards across both private and public sectors will prove nightmarish National Health Insurance (NHI),

for the past 67 years”, he told the

controversy and effectively undermined

first mooted six years ago, could be the

Healthcare Gazette in an exclusive

“progressive and far-reaching

prescription. Whether it will be is crystal

pre-release interview.

health policies in SA, leadership and

ball stuff, despite the eternal optimism

Speaking on 5 October, Motsoaledi

management”. Among the yawning

of the government’s irrepressible

insisted he was “not pulling the

cracks Rispel identified:

National Health Minister Dr Aaron

wool over anyone’s eyes”. He was

• Corruption, and tolerance for

Motsoaledi – and the tantalising

“just waiting for the next available

ineptitude and leadership, management

White Paper on Universal Health

opportunity to brief cabinet – if they

and governance failures

Care Coverage he’s dangled before

call me I’ll go running” (consulting

• Lack of a fully functional district health

expectant stakeholders, only to snatch

a calendar with Healthcare Gazette

system, which is the main vehicle for the

it away again. The anxiously awaited

he picked out 20 October as the

delivery of primary healthcare

document will alter the healthcare

earliest available cabinet briefing

• The health workforce crisis.

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Feature | 07

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There is also the vexed question of

driver of these “unusually high costs”

an NHI financial scaffold.

was because some haemophilia cases

Rispel pointed out that SA spends

require treatment with “an extremely

8.5% of its gross domestic product

high-cost medication, NovoSeven” (a

on healthcare – around R332 billion in

licence for Novo Nordisk to print money

monetary terms – but with half spent

if ever there were one).

in the private sector, catering for “the

High-cost medications are clearly

socioeconomic elite”. The remaining

a driver of healthcare crises globally.

84% of the population, who carry a far

Broomberg told us that Discovery

greater burden of disease, depend on

Health Medical Scheme data on

the under-resourced public sector,” she stressed.

Dr Jonathan Broomberg, CEO of Discovery Health

Many earlier gains and

cost and use of specialty, high-cost medicines showed a four-fold increase in the number of claimants since 2008,

improvements were compromised by

accuracy”. Instead of asking whether

with each patient costing in excess

an ineffective national response to the

SA could afford an NHI, the question

of R500 000 a year. “This is as much

country’s quadruple disease burden:

was “whether we can afford not to”,

as 80 times higher than the average

communicable disease (especially

Motsoaledi said.

cost of other claims for medicine,” he

HIV, AIDS and tuberculosis), non-

Prof. Ian Sanne, a specialist physician

said, “and Discovery Health Medical

communicable diseases (NCDs, also

and professor of internal medicine and

Scheme’s high-cost medicines spend

called chronic diseases of lifestyle, such

infectious disease at the University of the

reached R1.1 billion in 2014.” This

as obesity, hypertension and diabetes),

Witwatersrand, agreed, adding: “We

value was predicted to double in the

maternal, neonatal and child deaths, and

don’t have a choice. We can’t afford

next five years, especially considering

deaths from injuries and violence.

not to implement an NHI, and we have

current local and global trends, the

“Globally there was a significant shift in healthcare systems towards value-based reimbursement models that better align incentives for efficiency, effectiveness and quality of care” Broomberg At the Hospital Association of

to increase expenditure.” Where will

increasing NCD burden, and other

South Africa (HASA) late-September

that money come from? Speaking in

demand-side factors, Broomberg said.

conference, Motsoaledi reiterated

his personal capacity to the Healthcare

that he would be appointing a five-

Gazette, Sanne, who is also CEO and

say it could resolve disproportionate

person public/private National Health

director of the HIV NGO Right to Care,

cost-benefit ratios. So too could

Commission, headed by an expert

said expenditure on education for

the Competition Commission’s

academic with the President and himself

Services SETA (Sector Education and

comprehensive review of SA’s

second and third in command.

Training Authority) was leading to an ill-

healthcare system that began in 2012,

defined output. He would replace that

looking inter alia into “hospital and

with NHI funding.

specialist costs showing dramatic

It has become a cliché these days to talk of healthcare costs spiralling

increases which cannot be justified on economic grounds”. The Commission

He derided those who “want us to

into the stratosphere. That situation

also began a Market Inquiry into the

cost the NHI down to the last cent”,

will only worsen with time, even though

private healthcare sector in January

saying this futuristic speculation was

Discovery’s highest claim cost for

2014, to probe high prices in private

“an exercise in futility”. Nobody could

another patient in 2014 – R6.97 million

healthcare, the “general state of

have predicted that antiretroviral drugs

(also a haemophiliac who underwent

competition in this sector”, and to

for HIV/AIDS would drop from R314 per

12 months treatment) – appears (to the

see what can be done to achieve

person in 2009 to just R89 per person

healthcare ‘elite’) relatively cheap at

accessible, affordable, high-quality and

two years later. A decade ago, one HIV

the price. That worked out at just over

advanced private healthcare in SA. Final

positive patient costs R10 000 to treat

R583 000 a month, a doddle compared

recommendations and findings are

per annum; today it costs less than

with more than R800 000 a day for

expected towards the end of this year.

R1 000, he said. Every cost calculation

the originally cited 2010 R16-million

was based on “serious assumption – it

claim. According to Discovery Health

had been too much “fact-free” debate

cannot be done with any measure of

CEO Jonathan Broomberg, the main

about the drivers of high healthcare

Broomberg said historically there

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Photo: Chris Bateman

.

Not having an NHI is unaffordable – Motsoaledi

Fans of a workable, sustainable NHI

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Minister of Health, Dr Aaron Motsoaledi

“Doctors seemed unwilling to accept that RWOPS was taking seasoned specialists and physicians away from vital mentoring and training responsibilities in the public sector to earn extra money in the private sector.” Motsoaledi costs. The inquiry would create “an

running private healthcare facilities

with all of this and put up something

objective and comprehensive evidence

once the highly controversial law was

that is sustainable.”

base” that would “allow informed

reproclaimed. “If you want a licence to

debate and discussion on the real

run a private hospital… do we just give

drivers of cost” and what could be done

you a licence, or do we put conditions?

about them.

We’ll give you a list of needs, if you want

Forever altering the healthcare landscape

to run this hospital – you can operate, for

“It will be like abolishing Bantustans and

example, if you immunise so many kids,

coming up with a new country; some

check so many children’s eyesight and

were not happy, but unfortunately that

hearing… screen them. You cannot just

has to happen.”

Motsoaledi’s White Paper lays out

open – we’ll say: ‘If you open here, these

specific conditions under which all new

are the services that are needed’.”

healthcare practices and facilities may

As profound as “abolishing Bantustans’’

Motsoaledi said there was not a

Citing the 2011-launched national schools healthcare programme aimed at 12 million learners, of all income

operate so that patients in desperate

single healthcare organisation that

levels – which he described as “one of

need of preventive and curative services

would not be deeply affected by the

the most important programmes in the

can finally access them. Motsoaledi said

White Paper, ranging from deeply

re-engineering of primary healthcare”

a Register of Needs in a reproclaimed

contested medical scheme rules to

– he said State health screening of

Certificate of Needs (CoN) law would be

the Board of Healthcare Funders (BHF)

28 000 children in the poorer quintiles

a pillar of any Universal Health Coverage

and the Health Professions Council

had shown that one-third had

dispensation. Admitting outright that

(HPCSA). “There will be no more

eyesight, hearing, speech or oral

the timeline for healthcare practitioners

papering of cracks in the wall like the

hygiene problems. “So what do I do?

to apply for a CoN was untenable in

Prescribed Minimum Benefits war

I have to seek out audiologists, speech

the recently withdrawn, poorly scripted

around Regulation 8 (pricing of medical

therapists and optometrists – and the

legislation, Motsoaledi said specific

services). “That was zama-zama (try, try).

only way I can address this is to go to

conditions would be attached to

When we put in the NHI, it will do away

the private sector.”

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Feature | 11 For the CoN, he would need a

workers’ crisis, and the contention that

training advisory task team (increasing

well-defined Register of Needs by

doctors were leaving SA in droves.

bedside experience to supplement

geographical area. His researchers

Motsoaledi said migration of doctors,

academic study) and was studying a

initially went “very deep to research

even between developing countries,

report by the deans of medical schools

and try and geographically map the

was a global phenomenon. The South

on remunerative work outside the Public

availability of healthcare in KwaZulu-

African Development Countries (SADC)

Service (RWOPS). “When I compare

Natal (a pilot probe)”. They found, via

had agreed not to poach healthcare

myself with some of the newly qualified

‘geo-informatics’ that this province’s

workers from one another, yet an influx

medical interns, I believe I was better

healthcare provision, with the exception

of neighbouring country doctors into SA

trained,” he added.

of Pietermaritzburg (the capital) lay

continued. When his SADC healthcare

almost entirely along the coast. “If you

partners complain that SA is a major

map clinics and other facilities, surgeons,

culprit, Motsoaledi’s response is to

gynaes, paediatricians – they’re all sitting

advise them to “speak to the private

along the coast. There’s nothing in the

sector; that’s where most of them go”.

middle; how do you provide universal health coverage to people away from the coast, especially if you don’t sit down with healthcare providers, whether

Healthcare workers – nowhere to run to on NHI

RWOPS abuse a big deal – Motsoaledi He said doctors seemed unwilling to accept that RWOPS was taking seasoned specialists and physicians away from vital mentoring and training responsibilities in the public sector to earn extra money in the private

Addressing concerns that doctors,

sector. “They are abandoning medical

uncertain and insecure in the six-year

students,” he charged, repeating a

fundamental features of our healthcare

vacuum since an NHI was first mooted,

theme he has raised repeatedly, and

system that need intervention: the fee-for-

Motsoaledi said they would “vote

which his provincial counterparts have

service payment system and fragmented

with their feet”. The United Nations

been probing, even threatening criminal

silo-structure in which doctors, hospitals

General Assembly had long adopted

charges. When asked to respond to

and all other providers work. “Numerous

universal health coverage as the most

the same healthcare survey which found

studies in the USA and elsewhere show

effective tool to deliver more equitable

that 81% of doctors had yet to take

clearly that these features not only

healthcare to more people. “So when

the necessary steps to ensure ease of

add to costs, but may compromise

those youngsters I spoke to in 2009 told

integration into the new NHI model

patient experience and quality of care.

me that the moment I implement an NHI

(once implemented) Motsoaledi shot

Globally there is a significant shift in

they’ll pack their bags and go… I said,

back: “It’s all in their minds – the White

healthcare systems towards value-based

and still say, to them: There’s no place to

Paper is not out yet”.

reimbursement models that better align

run to, everyone is doing it!”

private or public?”

Broomberg highlights other

incentives for efficiency, effectiveness

Sanne agreed that migration

Sanne said that there was recognition within the healthcare

and quality of care. This includes a

of medical personnel was a global

sector that the population in SA had

big shift away from fee for service

phenomenon, adding that he believed

doubled in last 20 years, yet the output

reimbursement towards other payment

the issue in SA had been “blown

of training institutions in the healthcare

models, such as capitation, fixed fees

out of proportion”. Of doctors in his

sector had remained stable. “Part of the

and other risk-sharing contracts with

medical school class, more than 50%

revitalisation of healthcare in SA includes

healthcare providers.”

were practising outside the country:

plans for medical, nursing and pharmacy

“It’s ongoing, my own organisation is

schools to increase, if not double their

attracting qualified doctors back, and

output,” he said.

Pay doctors for cost-efficiency – Broomberg

“Claims data from Discovery Health

overall I do not believe this (exodus) is due to NHI.” A 2014 survey of 500 SA doctors,

Turning to the rising tide of NCDs or diseases of lifestyle, Motsoaledi said if the Council for Medical Schemes

Medical Scheme shows significant

which showed a confidence level of

(CMS) told him a nationwide response

opportunity to increase remuneration for

43% in the future of the healthcare

was needed to the ever-escalating costs

healthcare professionals by improving

system over the next five years, singled

of hypertension he would “go to the

quality of care and patient outcomes

out doctor and nurse training and

root of the problem”, not build more

and eliminating some associated spend

moonlighting by State-employed

hospitals. In this vein, he warned the

in control of the treating doctor,”

specialists as major issues. Asked for

tobacco industry that SA’s reputation

Broomberg said.

a response, Motsoaledi said he was

for strong anti-smoking laws was about

working with the vice-chancellors of

to be significantly enhanced via further

several universities to form a nurse

legislation. He said the World Health

Another perennial debate at medical conferences is the health

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

health ministers were invited, that a concept known as leap frogging, which takes full advantage of speedily evolving technology, would enable implementation of NHI schemes in developing countries. “It might have taken 100 years to lay underwater communication cables in Europe and more than that to reach every single household, but cellphones arrived and simply leap-frogged that.” The use of technology, changing business models (something Motsoaledi suspected spoke “very loudly” to his HASA-delegate audience) and behaviour change Prof. Laetitia Rispel, head of Public Health at the University of the Witwatersrand

were essential requirements for “leapfrogging”, but speed, and doing things

Organization (WHO) had warned this

the fee-for-service payment system and

April that the global tidal wave of NCDs

the fragmented silo-structure in which

would render any health minister who

doctors, hospitals and all other providers

did not take drastic steps “incapable of

work,” Broomberg said. Numerous

presenting a credible health budget’’.

studies in the USA and elsewhere

on a mass scale were vital.

NHI critical – so keep faith and be accountable

had clearly shown that these features

In concluding her inaugural address,

not only added to costs, but could

Rispel said she had painted a bleak

compromise the patient experience and

picture of the SA health system,

the quality of care. Globally there was

and fault lines seemed more like

a significant shift in healthcare systems

huge cracks requiring radical

CM

Broomberg remains upbeat about

towards value-based reimbursement

treatment. However, these were “not

MY

both the NHI and the future of open

models that better align incentives for

an inevitability”. A “metaphorical

medical schemes. “SA faces a number

efficiency, effectiveness and quality

repair” of fault lines would ensure

of challenges in rising healthcare

of care, he says. “This includes a

success of the proposed NHI system.

costs, which we share with most global

big shift away from fee-for-service

This would require “political will,

healthcare systems,” he observed.

reimbursement towards other payment

leadership and stewardship at all

“Increasing costs are driven by a

models, such as capitation, fixed fees

levels, meritocratic appointments of

combination of supply- and demand-

and other risk-sharing contracts with

public service managers with the right

side factors.” Demand-side factors

healthcare providers. “Claims data

skills, competencies, ethics and value

included the volume of healthcare

from Discovery Health Medical Scheme

systems, effective governance at all

services consumed each year, including

show there is a significant opportunity

levels of the health system to enforce

an ageing insured population, as well as

to increase remuneration for healthcare

laws, appropriate management

the rapid increase in chronic diseases of

professionals by improving the quality

systems, and citizen involvement

lifestyle. “This growing demand typically

of care and patient outcomes and

and advocacy to hold public officials

adds an additional 4-5% each year to

eliminating some of the associated

accountable”. Existing evidence

healthcare inflation, over and above any

spend that is in the control of the

suggested that a high-performing

increases in tariffs charged by healthcare

treating doctor,” Broomberg said.

public health sector was “one of

Discovery confident about strong open medical schemes

professionals and other providers,” Broomberg said. Supply factors referred to issues such as the number of healthcare professionals, hospitals and other service providers, how these are

Technologically “leap frogging” the staff shortage crisis

the most redistributive mechanisms to reduce health inequalities”, Rispel said.

Change in the status quo was “not optional, but a critical necessity”,

Earlier this year, World Bank president

and NHI-envisaged reforms provided

cost and rapid entry of new medicines

Dr Jim Yong Kim told the World

“exciting opportunities for health system

and technologies. “Our healthcare

Economic Forum in Davos, Switzerland,

change in SA, rarely available in most

system has two fundamental features,

where Motsoaledi and five other global

countries”.

organised and paid, as well as the high

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

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CMY

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ASSESSMENT

COURSE OBJECTIVES To enable health professionals to dispense and ensure the quality use of medicines prescribed to the patient.

At the end of the course the participants will be able to: • Identify and apply ethical, legal and therapeutic considerations in all facets of dispensing.

• Evaluate prescription and assess patient profile.

• Dispense the prescription.

• Manage the procurement and storage of medicines.

• Advise patients to ensure quality use of medicines and improve health status.

CERTIFICATION

Participants will be assessed through: • Portfolio of evidence • Written questionnaire • Dispensing Practical Exam - scheduled on a specific date

Successful participants will receive a Course Certificate of Completion from the Health Science Academy should they successfully complete the assessment process. This certificate must then be submitted in terms of regulation 18 of Act 101 of 1965, as amended. The course is accredited through FPD for 30 CPD points.s

COURSE STRUCTURE

COURSE FEE

The Dispensing course leads to a certificate of completion at a National Qualifications Framework (NQF) level 6.

To obtain the certificate a minimum of 30 credits must be obtained. Each credit represents about 10 notional learning hours. The course is taught through distance education, training workshops are provided on request.

R2 300 (Inclusive of all VAT and taxes where applicable) the course fee includes all study material, assessment, practical examination and certification.

ENTRANCE REQUIREMENTS All Medical Practitioners.

STUDY MATERIAL Participants will receive a comprehensive ‘resource guide’ covering all the study units and annexure containing ‘additional’ information which may be required. You will also receive an ‘assessment documentation guide’, consisting of learning activities, multiple choice and short questions that need to be completed.

A member of SAIHCM

The practical examination will be scheduled on a specific day, participants will be notified about the date, venue and time. A minimum group of 20 participants will be needed to schedule a practical examination.

Study material will be posted as soon as full payment has been received.

REGISTRATION TSHEPO GAOFETOGE Tel: 012 816 9100 Fax: 086 567 0340 Email: tshepog@foundation.co.za Address: P.O. Box 75324, Lynnwood Ridge, 0040 Website: www.foundation.co.za

Foundation for Professional Development (Pty) Ltd, Registration number 2000/002641/07 Registered with the Department of Education as a Private Institution of Higher Education under the higher education act, 1997. Registration number 2002/HE07/013 H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

A member of the SAMA Group

Rendering a dangerous healthcare ocean safer Take a tidal wave of patients, a trickle of specialists and a small shoal of medical students eager to palpate, probe and prick (at the very least) and mix them together in the public sector sea for several consecutive years. No CPD points for guessing the range of adverse events that can, and will, inevitably follow.

T

By Chris Bateman he reality is that

don’t regularly call on specialists

to encounter, let alone perfect. The

these ongoing ratios

to teach and supervise certain

UCT/GSH academic complex takes a

cost provincial health

procedures – that’s still a pragmatic,

Pan-African view on skills development,

authorities billions of

but now lower-impact, necessity.

and the versatile laboratory (all bulk

rand in litigation pay-

outs every year, never mind – in a best-case professional scenario – a

An 11-year journey…

equipment on wheels to enable 15-minute, discipline-specific set-up) buzzes with French, Dutch and English

Begun in 2004, the Clinical Skills

accents (the majority of African origin),

of overworked and under-supervised

Centre has grown exponentially via

testimony to the global ubiquity of

doctors and nurses.

progressive budgeting and tailored

medical training.

debilitating knock to the confidence

Yet one single, carefully considered

specialist equipment-company funding.

When it comes to undergraduate

cross-disciplinary intervention that

Today it has a simulation laboratory

correctly trains under- and post-graduate

with traditional simulation equipment,

to build skills longitudinally. Take

medical professionals – without

a ‘patient-less’ simulated ward and a

Emergency Medicine training for

harming anyone or repeatedly invading

health and rehabilitation laboratory – all

medical students; while first-year

the privacy of patients – is making a

organised according to functions, not

students do basic life support as taught

difference at Groote Schuur Hospital

disciplines – in what Weiss describes as

to lay people, third-years progress

(GSH), and far wider afield.

“an important ideological step towards

to intermediate life support using a

programmes, simulation is scaffolded

The University of Cape Town

integrated, multidisciplinary training”.

bag-mask device and automated and

(UCT)’s public and privately funded

A generalist who has swum the seas of

manual defibrillators. Fourth-years are

simulation hub, spread across three

public sector hospitals, private practice

taught how to intubate a patient during

spaces in the hospital, populated

and occupation medicine, Weiss has

resuscitation and to work with different

with high- and low-fidelity manikins

helped source private sector funding

kinds of drugs (e.g. cardiac resuscitation

and equipment, and staffed by

for two young anaesthesiologists

drugs) and advanced treatment

several full- and part-time experts

who have a passion for developing

algorythms, building skill toward difficult

(both generalist and specialist) is an

simulation-based education. Today

intubations and IV access (central and

enviable hybrid teaching model. Dr

this journalist is watching post-grad

other forms of vascular access). By fifth

Rachel Weiss, director of the UCT

students acquire endoscopy skills,

year they’re pacing and ‘cardioverting’

Clinical Skills Centre and an expert

guiding instruments past life-like

patients with deadly slow and fast heart

in curriculum design and education,

swollen airways, down burnt throats and

rates. “We also teach the so-called ‘soft

puts it succinctly: “Here you can give

past tumours, not to mention doing a

skills’: how to work as a team around

standardised teaching to everyone,

needle cricothyroidotomy (aka ‘crike’ or

a bed, function as a team leader and

without harming patients or imposing

emergency airway procedure) – basically

communicate effectively in high stress

a major teaching burden on busy

a range of airway problems that in a

environments, so by sixth year they are

specialists”. That’s not to say they

clinical patient setting might take years

able to run a full resuscitation scenario

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Feature | 15

Anaesthesiologist, Dr Andrie Alberts, leads colleague Dr Ulla Plenge through a procedure

Anaesthesiologists and UCT Simultation Lab instructors, Dr Rowan Duys (left) and Dr Ross Hofmeyr, flank registrar Dr Lara Veronese, as she practices a procedure H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

by themselves, taking responsibility for

blood cultures or learn how to create a

manageable conditions (mild cardiac

keeping somebody alive until more

sterile field while suturing.” It is not only

failure or hypertension) to simulate

competence arrives.” Weiss says she

the patient who is at risk in a hospital;

situations and help teach medical

had to learn all this on the job 30 years

healthcare workers have a high risk of

students how to communicate by

ago; “today these guys learn it all

contracting TB from infected patients

giving them feedback. Weiss says the

right here”.

or blood-borne diseases such as HIV

more junior the doctor, “the more

and hepatitis during needle stick

they tend to palpate the patient’s liver

injuries. The Centre fits and supplies

repeatedly to learn” – not ideal for

every student with TB respirators in

tertiary in-patients lying vulnerably in

the wards and works with activism

a ward. “We did a study in 2011 and

lab is an expensive (but ultimately cost-

group TB PROOF to break the silence

found that patients are completely

effective) exercise; an advanced life

around occupational TB. A partnership

disempowered. They sometimes get

support casualty manikin costs R140 000

with Becton Dickenson, manufacturers

students coming up to them five times

while the price tag for a programmable,

of safety needles, actively promotes

a day to practise on them – and they

wireless theatre manikin is close to

awareness and ensures that students

still say yes! Patients become de-

R1 million – “we wouldn’t let third-years

receive intense, small-group,

personalised. They also told us they

near him,” quips Weiss. The useful

supervised practicals with a range of

didn’t really want to be repeatedly

life-span of a manikin is five years, while

different safety devices. Simulation-

examined, but that they understood

all machines need constant calibration.

based training provides opportunities

students had to learn, which is quite

“People don’t always appreciate the

to standardise care; instead of ‘see

sad,” she adds. Her five-year plan is to

behind-the-scenes support required

one, do one, teach one’ in the ward,

secure about R200 000 per annum to

to run a simulation lab effectively and

students can, for example, insert inter-

appoint a coordinator who recruits and

cost-efficiently,” says Weiss. Opening a

costal drains on pork ribs or manikins

systematically trains a team of patient

door on a bank of built-in cupboards,

repeatedly until they get it right.

partners who can even be ‘shared’

she pulls out a small clear plastic box

Here’s where the real diamonds on the

across institutions and programmes,

Costly but hugely effective

Setting up and maintaining a simulation

Setting up and maintaining a simulation lab is an expensive (but ultimately cost-effective) exercise; an advanced life support ‘casualty’ manikin costs R140 000 while the price tag for a programmable, wireless ‘theatre’ manikin is close to R1 million – “we wouldn’t let third-years near him,” quips Weiss of equipment with its contents list

training sea-bed lie; simulation means

thus gradually creating programme

neatly taped on the lid – stock-taking

less risk to patients, students speedily

sustainability. She intends paying these

and student discipline here are non-

improving hand-to-eye coordination

patients, citing models used in the USA

negotiable, while recycling plays a major

skills, and more people taught in less

where payment is standard practice

part in keeping the consumables budget

time. “You can stop and correct errors

even though an ethic of volunteerism is

manageable.

and re-do things. We see them making

far more entrenched. “We have a lot of

a mistake and we stop that before

patients here who cannot work because

it gets ingrained. It’s optimal and

of their condition, so this would be job

project that is either currently adding

repeated practice. As a student you

creation and they’d replace the patients

major value to the teaching programme

may never get a chance to do this stuff

in the actual wards. Our in-hospital

or soon will be via cyber-reach believe

before your internship. Here you learn,

patients are really ill – so it’s actually a

in getting the basics right. “Patient

so that one day when you end up in a

human rights issue,” she adds.

safety is our first priority; for example,

deep rural hospital, people don’t die

to inculcate a lifelong respect for

from preventable errors.”

Weiss and her anaesthesiology colleagues, each of whom has a pet

infection control, second-year students start with hand-washing (a talk from an infection control nurse whose favourite trick is to put students’ hands under

Giving patients their humanity back

Dr Rowan Duys, an anaesthetist and recent Fellow in Simulation and Education (partially funded by Draeger, who also donated R10 million in medical equipment to the Centre), takes time off from leading a simulation to tell me

One of her dreams is to start a

that as far back as second year, he can

many bugs they’re carrying), while our

patient-partner programme, recruiting

remember wondering what the point

third-years prepare sterile trolleys for

a small group of jobless people with

was of learning to “look after the patient

a ‘glitter-bug’ light to show just how

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

in front of you when the system around you is broken”.

Anaesthesiologist applies his life lessons

Mitigation in a dysfunctional system

R30 000 grant they’re using in-house programming skills and a bank of cardiology electrocardiograms (ECGs)

His colleague Dr Ross Hofmeyr, the

to create an online learning platform

Storz Fellow in Airway and Thoracic

to plug a major learning gap – the

Anaesthesia (predominantly funded

interpretation of ECGs. “We got

What stuck from his internship at

by Stortz, manufacturers of endoscopy

complaints from people teaching sixth-

George Mukhari Hospital, north of

equipment), has tellingly similar

years, saying that students don’t retain

Pretoria, was “the amazing individual

motives: “If I’m a highly skilled

their third-year ECG interpretation

clinicians but a real lack of leadership

anaesthetist working in a dysfunctional

theory.” Online exercises now enable

and training”, while his community

system, my patients will get poor care,

students from third to sixth year to not

service at Hlabisa Hospital in northern

no matter how good I am! You can try

only interpret ECGs, but to assess their

KwaZulu-Natal helped hone his

and tackle that from a management

own knowledge levels. The programme

survival skills. Subsequent work in the

point of view or a political point of view,

allows Viljoen and Weiss to identify

NHS in the UK first exposed him to

but I want to tackle it from a training

where any individual or a cohort of

simulation training and taught him

and education angle,” he asserts. As far

students is struggling and respond

that minimum standards there were

as he knows, he and Duys are the only

appropriately. “It’s the perfect tool for

far better protected and that the UK

Cape Metropole consultants (across

cardiology registrars just before their

“holes in the net” for patient care

disciplines) taking up either part- or

exam – and the template is the same

were far smaller than locally. His more

full-time educational roles. Hofmeyr

whether you’re an undergraduate or a

recent registrar time here left him

says that while anaesthesia is generally

postgraduate student.” They’re busy

painfully aware of the stark differences

very safe, it has a zero tolerance for

with a quality assurance test, having

in skills levels between UK nurses and

adverse outcomes. “Nobody ever

recruited 15 interns from GSH and

their local counterparts – and the

got better because of anaesthesia –

surrounding hospitals for a pilot study

differences in training methodology.

everything we do places the patient at

which involves a pre-test exposure to

“Here you can give standardised teaching to everyone, without harming patients or imposing a major teaching burden on busy specialists” “I developed a real passion for

risk, yet there are low-frequency, high-

the online test, and a post-test. After

developing nursing education and

risk events which we don’t see often,

some software tweaks, it will be rolled

skills levels and finding innovative

but they have dire consequences.”

out to 600, fourth- to sixth-year UCT

ways to train people better,” he

It is here that simulation can avoid

medical students next year as part of

says, explaining a journey that led

things like anaphylaxis, malignant

Viljoen’s PhD research, and thereafter

him to approach Draeger to fund

hyperthermia, major haemorrhage

to a wider audience. She says that

his current post from August this

or difficult intubation. “You hardly

research studies both internationally

year. Nearly five years ago he began

ever get to practise these, but you’re

and locally suggest that “most doctors,

training a short course in anaesthesia

supposed to be good at managing

unless they are cardiologists, suck

to GSH (and other) nurses using the

them,” he adds. His ‘extra value-add’ to

at ECGs” and this bolstered her

simulation lab for scenario-based

the Clinical Skills Centre is developing

proposal and subsequent funding.

training. He believes simulation

a utilitarian e-learning platform for

“We concluded it was essential to have

and communications technology

nurses by creating and tailoring

some kind of method or platform for

are the greatest tools available in

modules on the internet, working with

ongoing ECG practice and feedback,

medical education. In simulation he

a Dutch university. Duys is developing

with modules tailored to the level of the

sees three major areas: technical

a similar algorithm-based e-learning

student – in diagnosing a third degree

skills, crew resource management

platform that can be adapted by any

block, for example, you could have easy

(team interaction, leadership and

medical student to his or her skills

or very difficult variations.”

communication skills), and systems

and knowledge levels. Weiss is no

testing and development, which can

slouch in this department either:

UCT’s world-class Clinical Skills Centre

lead to identifying a latent risk or

drawing on expertise and resources

will increasingly reverberate across the

adverse event during simulation that

from the Division of Cardiology, she’s

country and the continent, as medical

one can report as a real-time human

collaborating with a senior registrar,

professionals emerge more proficient

event – one of the more hidden

Charl Viljoen, who wants to super-

than ever before – with commensurate

life-saving benefits.

specialise in cardiology. With a small

huge savings in lives and money.

What is certain is that the effect of

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

New hope for early Alzheimer’s patients

By Chris Bateman

S

cientists appear to

have broken a decadeslong deadlock in the battle against Alzheimer’s disease

Tests show 30% slower decline in memory

given at an earlier stage – something that might be expected given that it apparently had no effect for patients

However, when scientists analysed the

with more serious dementia. “It’s

data more closely, they found that in

entirely possible you’ll show an even

for the first-ever drug that appears to

the 1 300 patients with mild dementia,

bigger benefit if people are given

slow the pace of mental decline.

after announcing trial results

those who had been placed on the drug

solanezumab earlier on,” said Karran.

Says Dr Eric Karran, director of

showed a roughly 30% slower decline in

Scientists said the results also

research at Alzheimer’s Research UK:

memory and cognitive tests than those

support the idea that sticky plaques in

“This is the first evidence of something

who had taken a placebo during the

the brain – the most visible hallmark of

genuinely modifying the disease

18-month trial. This was a fairly small

the disease – are what causes mental

process by delaying cognitive decline

difference from the perspective of the

decline. The drug is an antibody that

in patients in the first stages of the

patients who had not yet suffered the

works by disassembling the building

disease. I think we’re on the verge of

devastating memory loss or profound

blocks that make up the plaques, slowly

a radical breakthrough”. He added

changes to personality that follow later.

causing them to disintegrate. Explained

that in the past 30 years there had

However, the result hinted that the drug

Karran: “What these results validate is

been more than 100 failed Alzheimer’s

could work as long as it was given early

that one of the common hypotheses we

drug trials, with only a few medicines

enough. Questions remained about

have for what causes Alzheimer’s, called

emerging to ease the symptoms of

whether the drug was simply treating

the amyloid cascade hypothesis… that

the disease, but nothing that slowed

the symptoms – improving a patient’s

this is probably correct. And what is

or halted it. “It’s a breakthrough in

mood or concentration – rather than

important about that is that we have a

my mind. The history of medicine

actually delaying the loss of neurons in

number of different mechanisms that

suggests that once you get through

the brain, which drives memory loss. So

are targeting this hypothesis that are

that door you can explore further

to test this, Eli Lilly switched the half of

in clinical development right now, and

therapeutic opportunities much more

the 1 300 patients who had been on the

it could well be that they will succeed

aggressively. It makes us less helpless.”

placebo on to the drug as well – and the

and we may be able to combine

entire group was given solanezumab

therapies later on and get even more

was shown to stave off memory loss

for a further two years. If the drug was

benefit for patients”. Until now, drugs

in patients with mild Alzheimer’s over

just treating the symptoms, the placebo

that targeted the plaques have not

the course of several years. The effects

group would be expected to catch up

appeared to have any effect, leading

would have been barely discernible

over time. The results, unveiled in July

some to question whether some other

to patients or their families, scientists

this year at the Alzheimer’s Association

biological process in Alzheimer’s was

said, and it is no cure. But the wider

International Conference in Washington

the real root of the disease.

implications of the results are hugely

DC, showed that the differences

significant because it is the first time

between the two groups were still

positive, it is likely to be several

any medicine has slowed the rate at

there – a sign that the drug had made

years before the drug would become

which the disease damages the brain.

a genuine impact on the progression of

available on Britain’s NHS – and

The drug, developed by the American

the disease.

further afield. Another phase-three

The drug, called solanezumab,

company Eli Lilly, had previously

“It deflected the course of the

Even if further trial results are

trial is due to report next year and

been tested in a larger group of

disease in an irrevocable manner,” said

patients with both mild and moderate

Karran, who previously worked for Eli

through regulatory approval and

dementia and this trial had appeared

Lilly. The company is now looking to see

be shown to be of sufficient benefit

to end in yet another failure in 2012.

whether the drug is more effective when

to patients.

then the drug would need to go

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Feature | 19

The wider implications of the results have been hailed as hugely significant because it is the first time any medicine has slowed the rate at which the disease damages the brain H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

The heartache of unhealthy lifestyles – what it costs us in lives Premature deaths caused by heart and blood vessel diseases in South Africans of working age (35 – 64 years) are expected to increase by 41% between 2000 and 2030, according to a review of research by Prof. Krisela Steyn of the University of Cape Town (UCT). By Chris Bateman

P

rof. Steyn, of UCT’s

of a heart attack, while about 60 per

Although most heart attacks, heart

Department of Medicine

day died because of a stroke. For every

failures and other chronic diseases

and a former director of the

woman that died of a heart attack,

usually only occurred in middle-aged

Chronic Diseases of Lifestyle

two men died, while about 37 people

and older people, the influences

(CDL) Unit at the Medical

died per day because of heart failure.

of risk factors could start before

Research Council (MRC), believes the

Despite the high death rates caused by

birth and have an effect throughout

negative economic effect of this will

AIDS in SA, the rate of chronic diseases,

life. Therefore, the processes for

be “enormous”. Her review shows that

including heart disease, was increasing

prevention and management of heart

the highest death rates for heart and

rapidly. No data existed on the number

disease “must start early and be

blood vessel diseases, or cardiovascular

of heart attacks or strokes that South

present throughout life”.

diseases (CVDs) in South Africa (SA) are

Africans suffered from daily. However,

She emphasised that in people

found in Indian people, followed by

there was a rule of thumb suggesting

who have several risk factors, the

coloured people, while white and black

that for one death caused by a heart

chance of suffering a heart attack grew

African people have the lowest rates.

attack or stroke, three persons would

exponentially with each additional

Although white and black Africans have

survive such an attack.

factor. This principle could be

similar rates for these diseases, their

Steyn said that research models

illustrated by considering a person

patterns differ considerably. White

suggested that chronic-disease

with three risk factors. The chance

people mainly reflect a pattern of death

deaths increased from 565 per

of suffering a heart attack did not

caused by heart attacks, while black

day in 2000 to 666 per day in 2010

increase by 3 + 3 + 3 = 9, but by 3

people reflect that of death caused by

– and were continuing to climb.

x 3 x 3 = 27, thus the risk increased

stroke, diseases of the heart muscle

More than half the deaths caused

exponentially with multiple risk factors.

and high blood pressure. Her research

by chronic diseases, including heart

To assess the true heart attack risk

review also reveals that between 1997

disease, occurred before the age of

level, the effect of all the risk factors

and 2004, 195 people died per day

65. These were premature deaths

present needed to be assessed. Such

in SA because of some form of CVD.

which affected the workforce and

absolute risk assessment considered

About 33 people died daily because

had a major effect on the economy.

the multiplication effect of risk factors

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Feature | 21

About 33 people died daily because of a heart attack, while about 60 per day died because of a stroke. For every woman that died of a heart attack, two men died, while about 37 people died per day because of heart failure.

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

to identify those who were at highest

Heart failure is caused by the

when the artery lumens appear normal

risk. This implied that the risk for a heart

inability of the heart to pump blood

attack in a person with modest levels

efficiently around the body. This occurs

of many risk factors could be higher

because of damage to the heart

diseases of the heart muscle. In

than that in a person who had only

muscle as a result of various diseases.

cardiomyopathy, the heart muscle

one risk factor at a very high level. The

Circulation becomes slow, causing

becomes enlarged or abnormally thick

known risk factors for a heart attack

excess fluid to be retained in the body.

or rigid, resulting in the inability of the

were present in all South Africans,

A stroke, also known as

on angiography.

Cardiomyopathy refers to

heart to function as an effective pump

and effective prevention of heart

acerebrovascular accident (CVA),

disease should start early and continue

occurs when the blood flow to the

throughout life, targeting the entire

brain is interrupted. This could either

when the arteries that supply blood to

population. Every media opportunity

happen when a blood vessel to the

the heart muscle (the coronary arteries)

and regulation needed to be embraced

brain ruptures, causing bleeding, or

become hardened and narrowed,

to maintain healthy, lifelong lifestyles,

becomes blocked by a blood clot.

caused by a build-up of fatty deposits

while early detection of signs and

The affected brain cells then start

(atheroma) in the cells lining the wall

symptoms was vital to avoid serious

to die because of a lack of oxygen

of the coronary arteries. As these fatty

for blood to the body.

Coronary artery disease occurs

The risk for a heart attack in a person with modest levels of many risk factors can be higher than that in a person who has only one risk factor at a very high level long-term complications. A full 75%

and other nutrients. The severity of a

deposits build-up gradually, the insides

of heart attacks or strokes occurred in

stroke varies from a passing weakness

of the coronary arteries get narrower

5 - 10% of people who had suffered a

or tingling in a limb to a profound

and less blood can flow through them.

previous event or had many risk factors.

paralysis, coma or death.

Eventually, blood flow to the heart

People should be motivated to seek an

Angina is chest pain or discomfort

muscle is significantly reduced, and,

absolute heart attack risk assessment,

that occurs when the heart muscle

because blood carries much-needed

which includes looking at a person’s

does not get enough blood. This may

oxygen, the heart muscle is not able to

age, gender, smoking status, blood

feel like pressure or a crushing pain

receive the amount of oxygen it needs.

pressure level, diabetes status and total

in the chest, which may also occur

This process leads to ischaemic heart

blood cholesterol level.

in the shoulders, arms, neck, jaw, or

disease, which causes damage to the

back. Angina is a symptom usually

heart muscle.

The many ways in which the heart (and brain) can suffer

CVD refers to any disease of the heart and blood vessels. The most common

aggravated by exercise and is caused

Rheumatic heart disease is

when insufficient blood reaches the

a condition in which permanent

heart muscle. This occurs when plaque

damage to heart valves between the

builds up in the arteries of the heart,

chambers of the heart occurs. The

and is called atherosclerosis.

heart valve is damaged by a disease

Atherosclerosis is a slow,

process called rheumatic fever that

involve the heart muscle, stroke, heart

progressive disease that may start in

begins with a throat infection caused

attack, heart failure and heart disease

childhood, and can eventually impede

by Streptococcus bacteria. These

caused by high blood pressure. A heart

the blood flow through the arteries of

malfunctioning heart valves eventually

attack is also known as a myocardial

the brain, heart, kidneys, and the arms

place stress on the heart muscle and

infarction (MI). When the diseased-

and legs. In the worst-case scenario

a person may require an operation to

roughened arteries of the heart become

the blood flow to these organs can be

replace the diseased heart valve.

too narrow or a clot forms, blood flow to

blocked off entirely.

the heart muscle is restricted. The heart

In ischaemic heart disease the

The Heart and Stroke Foundation,

muscle is left without oxygen, causing

coronary arteries supply blood to the

South Africa. Heart Disease in

death of a segment of the muscle

heart muscle and no alternative blood

SouthAfrica. Media data document

and leaving the heart unable to pump

supply exists, so a blockage in the

compiled by Professor Krisela Steyn,

sufficient blood to the rest of the body.

coronary arteries reduces the supply

Department of Medicine, University

Symptoms include sudden severe chest

of blood to the heart muscle. Most

ofCape Town & Chronic Diseases

pain which could spread down one or

ischaemic heart disease is caused by

of LifestyleUnit, Medical Research

both arms and to the neck.

atherosclerosis, usually present even

Council.Ed. Jean M Fourie, 2007.

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SA’s debilitating ‘diabesity’ pandemic threatens healthcare delivery With 12% of all South Africans either pre-diabetic or living with full-blown diabetes, and 70% of all women and 45% of men (over 35) overweight or obese,1 radical lifestyle changes, better prevention and earlier diagnoses are vital if our overburdened health system is to cope. By Chris Bateman

S

cientific estimates

Indian population in SA (11 - 13%),

much-reduced fertility and a growing

vary, but it’s safe to say that

as this group has a strong genetic

proportion of the population above

between two and three

predisposition for diabetes. This is

60 years. In parallel with unfolding

million South Africans

followed by 8 - 10% in the coloured

urbanisation, the population burden

are living with diabetes

community, 5 - 8% among blacks and

of vascular risk factors namely

4% among whites.

hypertension, hypercholesterolaemia,

and at least another five million are pre-diabetic, many without even

A closer look at the historical

diabetes and obesity has increased.

being aware of it, the latter ignorance

prevalence curve of claimants per

The top researchers agree: the scale

leading to inadequate treatment and

1 000 members registered on

of CVD burden poses a threat to the

a host of complications. It takes on

Discovery Health’s chronic illness

health system and calls for timely

average seven years for a person to

benefits shows hypertension claimants

intervention.

get diagnosed with type 2 diabetes,

up from 76 in 2008 to 96 last year. This

meaning that an estimated 30% of

is followed by hypercholesterolaemia,

data is based on the Council for

people present for treatment with

which rose from 40 to 50 claimants

Medical Schemes (CMS) chronic

already developed complications,

per 1 000 members over the same

disease list (CDL) of 27 conditions (now

directly contributing to an increased

period while diabetes mellitus claims

including HIV/AIDS), meaning that it

prevalence of heart disease, stroke,

rose from 19 per 1 000 members to

only shows members who registered in

blindness – about 55% of people

27 members over the same time.

terms of the CDL. While admittedly a

with diabetes are likely to suffer from

Cardiovascular disease (CVD) almost

small snapshot of a much wider trend

diabetic retinopathy, with diabetes

‘flat-lined’ at nearly 11 claimants per

nationally and globally, these three

being the third leading cause of

1 000 members to 12 between these

top-claiming diseases illustrate the

blindness in South Africa (SA), with

years, in spite of CVD increasing

outcomes of poor lifestyle choices by

retinopathy and cataracts accounting

among all age groups and being

South Africans generally. According

for 8 000 new cases of vision

predicted to become the prime

to Dr Noluthando Nematswerani,

impairment every year – amputations

contributor to overall morbidity and

head of Discovery’s Clinical Policy

and kidney failure. Diabetes mellitus is

mortality in people over 50 years

Unit, the tidal wave of chronic NCDs

the fourth largest underlying cause of

old. According to a review of the

(of lifestyle) currently engulfing SA

natural death (by age and sex) in SA.3

top CVD literature, several factors

is because, “we’re forever in a rush,

Tuberculosis and influenza/pneumonia

are contributing to the CVD fatality

eating convenient fast foods and

are numbers one and two, with

shift – an epidemiological transition,

with those less privileged going for

cerebrovascular and other forms of

which has seen a rise in chronic

sugary beverages because they assign

heart disease lying third.3 The highest

non-communicable disease (NCD)

a certain status to them. In most

prevalence of diabetes is among the

and a demographic transition with

canteens, cafeterias and restaurants

2

The Discovery claims prevalence

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Feature | 25

It takes on average seven years for a person to get diagnosed with type 2 diabetes, meaning that an estimated 30% of people present for treatment with already-developed complications, directly contributing to an increased prevalence of heart disease, stroke, blindness, amputations and kidney failure H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

the less healthy stuff is cheaper. It’s more expensive to get a salad than say, ‘slap’ chips or a bunny chow.

Access to healthy stuff is limited”.

She says that when a lack of physical activity is added to this poor nutrition, “you get more and more people becoming obese with attendant noncommunicable diseases”.

Meaning well, but doing it wrong “Then you also have the stress levels in just making ends meet and long hours at work. We all have good intentions, but if you don’t pack your own lunch, the likelihood of you eating unhealthily is pretty high,” she added.

This was highlighted recently by Dr Deborah Cohen, a senior scientist at RAND Corp, a top US-based research organisation, and author of A Big Fat Crisis: The Hidden Influences behind the Obesity Epidemic and How We Can End It. Addressing a Discovery doctor seminar on NCDs in Johannesburg on 6 August this year, she described society generally as a “food swamp” in which we wallow, biologically wired to pay more attention to food than other things in our environment and at the mercy of ubiquitous, cheap and

and nutrition technology and how

them. Teachers and other staff are also

aggressive marketing. This drove a

to themselves “walk the talk” (which

included in the rewards-based lifestyle

global obesity epidemic which in SA

research had shown resulted in better

improvement programme. Then we

sees more than 70% of women above

patient compliance).

have ‘park runs’ – free weekly 5 km

35 years old and 45% of men above 35 years overweight or obese. The World 1

Health Organization (WHO) attributes 82% of deaths in developing and emerging economies to NCDs.

timed runs across the country, where

Investing in children to secure SA’s future

Active Kids report is drawn up annually

Asked how her company made

by a specific country’s research working

anybody can enter every weekend,” she said. The globally-used Healthy

interventions with a social impact

group, in SA comprising of 23 experts

Health was “pushing hard” on ways

wider than just on their higher-

in physical education, nutrition, sport

to make early diagnoses by using

income subscribers, she said they

science, public health and journalism.

their impressive wellness database,

ran multiple social responsibility

It is based on a systematic review of

and sending staff and equipment to

projects. These included, for example,

peer-reviewed literature (previous five

companies where employees were

using Discovery’s Vitality programme

years), dissertations, and non-peer-

properly assessed and screened for

at schools in and around Gauteng

reviewed reports (‘grey’ literature)

glucose and body mass indexes,

in partnership with the City of

dealing with the physical activity and

asked searching questions about their

Johannesburg. “We do things like

nutritional status of South African

physical and nutritional lifestyles and

improving what’s in their tuckshops

children and youths aged between

interventions proposed. Other projects

and using the issues identified in

6 and 18 years. In the context of what

involved assertively educating doctors

the latest Healthy Active Kids report

is now widely-termed ‘diabesity’ (so

on user-friendly high-tech fitness

to design a holistic programme for

strong is the link between obesity and

Nematswerani said Discovery

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diabetes), its findings are fundamental

2030. There are currently 14.7 million

and the diabetes drugs, so it is difficult

to SA’s healthcare planning. The group

diabetics in Africa; however, according

to control both diseases.”

looked at how much children play,

to the IDF around 78% of Africans

how much fast food they eat, how

with diabetes are undiagnosed. The

have to focus their attention on

much TV they watch and how much

main causes for the dramatic rise

primary prevention, raising public

support they get for healthy choices

in diabetes on this continent are

awareness, building capacity for

Kapur says governments will

at home and school. Here are some of

urbanisation and obesity. Millions of

healthcare programmes and offering

the alarming findings around physical

people are migrating from rural to

diabetes services at primary care,

activity and nutrition:

urban areas in pursuit of work and

ensuring patients can receive self-

•A t least half of South African

better opportunities. In a short time

care education and support. They

children are active for less than an

their lifestyles change dramatically:

need to promote breastfeeding (as

hour a day. This is not nearly enough

they adopt a westernised diet high

it is a good prevention of obesity in

and gives SA children a D for

in fat, sugar and salt, and get far

both mother and child) and identify

physical activity.

less exercise than they were used to.

women with gestational diabetes.

• L ess than half the children in SA

Cultural beliefs also play a big role.

Diabetes during pregnancy could

cities take part in an organised sport

According to dietician Suna Kassier,

cause serious complications and

or recreational activity. This is a C.

many Africans still see weight gain as

increase the risk of both mother and

•M ost children spend almost three

a sense of achievement. “It signifies

child developing diabetes later in

hours a day watching TV during

dignity and respect, and shows that

life. “People often say that treating

“People often say that treating diabetes is expensive. I disagree.

It is not providing this care that is very expensive – most of the high costs of diabetes come from treating its complications” the week and even more over

you’re enjoying wealth and a good

diabetes is expensive. I disagree. It

weekends. We got an F on

life. Being thin is also associated with

is not providing this care that is very

sedentary behaviours.

hardship, trouble at home and serious

expensive – most of the high costs

illnesses such as TB or HIV/AIDS.”

of diabetes come from treating its

children continues to increase; the

This weight gain leads to overweight

complications. Prevention, early

intake of sugary drinks plays a major

and obesity, which is a great precursor

identification and offering proper

role. Our previous grade of C– has

for type 2 diabetes.

basic care are both essential and

•O verweight and obesity among

dropped to a D. •M ore than two-thirds of youngsters eat fast food at least three times a week. That’s an F.

No disease is an island …

affordable. But not enough is being done to address this.”

Ironically, there are links between

1. Bradshaw B, Steyn K, Levitt N,

diabetes and HIV/AIDS and TB.

Nojilana B. Non-Communicable

According to Dr Anil Kapur, managing

Diseases – A Race Against Time.

director of the World Diabetes

Burden of Disease Research Unit,

recommendations on salt intake,

Foundation (WDF), few people know

South African Medical Research

giving us a D.

that in Africa, more than on any other

Council. Chronic Disease Initiative

continent, there are interactions

for Africa, Department of Medicine,

between these three conditions and

University of Cape Town, 2015.

their various treatments.

2. Hofman KJ, Cook C, Levitt N.

•O nly 50% of children eat enough fruit and vegetables – we get a C–.

• L ess than half of children meet the

•F or regulations on food advertising to children SA scored an F–.

We definitely have some work to do in this area.

Taking a macro-view, globally, 366

“Patients who receive antiretroviral

Preventing diabetic blindness: A

drugs are at a higher risk of developing

priority for South Africa. S Afr Med J

diabetes, as some of the drugs cause

2014;104(10):661-662. [http://dx.doi.

million people have diabetes. The

glucose intolerance as one of the

org/10.7196/samj.8580]

International Diabetes Federation

side-effects. People with diabetes

3. Republic of South Africa. Mortality

(IDF) predicts that this number will

have a greater risk of developing TB as

and Causes of Death in South

rise to 552 million by 2030, with the

diabetes reduces the body’s immunity.

Africa, 2012: Findings from Death

greatest increase expected to be

In addition, the interaction between

Notification. Pretoria: Statistics South

in Africa – where the incidence of

drugs to treat diabetes and TB reduces

Africa, 2012. www.statssa.gov.za/

diabetes will have almost doubled by

the effectiveness of both the TB drugs

publications/P03093/P030932012.pd

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

News | 29

Marketers of unhealthy foods exploit our ‘survival’ DNA

By Chris Bateman

W

e have allowed

tion (WHO) attributes 82% of deaths in

Can End It. She was one of several

our society to

developing and emerging economies to

ground-breaking researchers who

become a

non-communicable diseases (NCDs).

spoke at the 6 August Discovery

‘food swamp’ in which we

wallow, biologically wired to pay more attention to food than other things in our environment and at the mercy of ubiquitous, cheap and aggressive marketing.

This drives a global obesity epidemic

This ‘survival/obesity’ link thesis

Healthcare doctor seminar aimed at

was recently posited by Dr Deborah

increasing awareness and involvement

Cohen, a senior scientist at RAND

in containing the global NCDs, held

“I’m not advocating telling people what not to eat but rather preventing businesses from putting people at risk”

which in South Africa sees more than

Corp, a top US-based research

at the Wanderers Cricket Ground in

70% of women above 35 years old and

organisation and author of A Big Fat

Johannesburg.

45% of men above 35 years overweight

Crisis: The Hidden Influences behind

or obese. The World Health Organiza-

the Obesity Epidemic and How We

1

Cohen said we use non-cognitive processing for most of our usual activ-

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

ities (outside of planning and thinking about the future) and we are automatically wired to the survival imperative.

“We’re biologically wired to pay more attention to food than other things in our environment. It can make us feel hungry even if we’re full. When food is everywhere, that capacity is killing us,” she said.

The food industry knows how important it is to capture people’s attention: “The more we look at it, the more likely we are to buy it”. Placement and product design are built around this imperative. End-aisle displays sell 50% better, and if junk food is placed there, that is what people buy. Increased product variety encourages “decision fatigue”, making it more difficult for low-income earners who end up making “trade-offs” resulting in poor and unhealthy decision-making. Cohen said that restaurants and supermarkets are also acutely aware that when people are served or offered more than they need, they eat more than they should.

Tasty and unhealthy temptation everywhere

“We’re biologically wired to pay more attention to food than other things in our environment. It can make us feel hungry even if we’re full. When food is everywhere, that capacity is killing us.” our innate inability to multi-task. The

research conducted in the USA. Giving

assertion that obesity is the result of

the example of her own hypertensive,

Simply “taking personal responsibil-

a person’s own conscious choice and

dentist father who suffered from heart

ity” for one’s weight is no solution

that willpower controls weight flies

disease, she said he was a hard-work-

and highly impractical in the face of

in the face of the existing obesity

ing war veteran, punctual to a fault,

such overwhelming temptation and

epidemic – and more than a decade of

worked six days a week and raised In South Africa the National Department of Health has promulgated mandatory salt regulations, beginning in 2016.

This will save an estimated total of 6 400 lives from stroke, 4 300 from non-fatal stroke, and cut hospitalisation costs by R300 million annually. Similarly, a potential SA tax on sugary drinks would cut the number of obese people by 220 000 in three years.

Occasionally, industry and not government sets the precedent … Tesco, a leading food retailer in the UK, has banned junk food from its checkout aisles.

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

News | 31

Senior scientist at RAND Corp, Dr Deborah Cohen

three children. “How does an other-

In the 1820s in the USA there were no

traded on consumer “choice fatigue”.

wise responsible person eat too much?

cars and we were losing breadwin-

By restricting impulse marketing and

It’s survival behaviour, reflexive and au-

ners to alcohol with a lot of domestic

junk food promotion, plus introducing

tomatic – there is no conscious control.

abuse thrown in”. The ‘demon drink’

counter-advertising reminding people

Eating is like breathing. Sometimes we

led to the Temperance Movement

just how much they were being manip-

can control our gut, but if we did it all

with Prohibition “going a bit too far”.

ulated, the obesity pandemic could be

the time we wouldn’t be able to do an-

However, this was where the conversa-

pushed back.

ything else! Most of our behaviours are

tion needed to start, she said, dis-

automatic. If we eat a bowl of popcorn

playing a slide of how alcohol control

-State? No. Actually I don’t know why

while watching TV, we only realise it

policies restricted access – pointing

nannies have such a bad name, they

when there’s nothing left. When eating

the way to how to address the obesity

look after our interests. Look at Mary

we’re more likely to pay attention to

epidemic via public health standards

Poppins in The Sound of Music; she

our dinner companion or our kids. We

and regulations – especially when it

recommended a spoonful of sugar and

don’t do it (pay conscious attention to

came to the retail environment. “I’m

that’s better than six!” she joked. Co-

food) because we don’t have to. We

not advocating telling people what not

hen rounded up by questioning wheth-

have better things to do.”

to eat but rather preventing business-

er 30 million South Africans could all

Cohen said that historically, the

es from putting people at risk,” she

be making the same mistake. “Instead

1970’s and 1980’s saw the initiation of

stressed. Recent examples of this in

we have to prepare an environment

hyper-sophisticated food marketing

the USA included standardising the

that takes into account what human

strategies, including the buying of

quality and quantity of school meals,

nature is. We wouldn’t have an obesity

shelf space in stores. What is needed

private hospitals refusing to carry sug-

epidemic if we didn’t live in a food

today is a public health solution, she

ary foods, sweets or drinks and soda

swamp.”

said, citing the evolution of liquor

taxes in the city of Berkley. However,

control in her home country. Two

regulation needed to go beyond

Bradshaw D, Steyn K, Levitt N, Nojilana

centuries ago liquor marketing was

taxes, Cohen said. What are needed

B. Non-Communicable Diseases – A

“ubiquitous”, with Americans having a

are standardised portions and restric-

race against time. Parow: South African

reputation as a “nation of drunkards”.

tions on “bargain combo meals” which

Medical Research Council, 2010.

“Am I recommending a Nanny

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News | 33

The grim toll of kidney donor and dialysis machine shortages An estimated 10 000 South African (SA) men and women of all ages die of kidney disease or failure every year because they do not have access to dialysis or a kidney transplant – while only 300 kidney transplants are performed annually. By Chris Bateman

T

his is according to

at private clinics. In the public health

dialysis treatment. Does the patient’s

both the National Kidney

system, the agonising decision about

house have running water, sanitation

Foundation (NKF) and

who will receive ongoing dialysis until

and electricity in case the patient has

the South African Renal

a donor kidney might be found, and

to perform some kind of home dialysis?

Society (SARN), the latter

who doesn’t, is forced upon hospitals

Does he or she have a good social sup-

of which says people wait on average

by sheer lack of resources. For every

port network? Factors working against

three to five years, with some of the

individual who gets a place in a state-

being included in a state dialysis

more complicated cases waiting up to

run dialysis programme, there are

programme and receiving an eventual

10 years to get a new kidney. President

many more that don’t.

transplant should a donor become

of the SARN, Ms Sarala Naicker, says

Selection criteria include: whether

available include substance abuse by

thousands of people with kidney failure

a patient has dependants and other

the patient, smoking, consumption of

in SA remain untreated and are unable

important responsibilities, the degree

alcohol and, often, obesity.

to access dialysis because of a shortage

to which a patient is able to be educat-

of machines. “All of the facilities are

ed and have insight into the illness and

new kidney patients in SA has soared.

oversubscribed so it’s very difficult to

whether a patient is sufficiently moti-

Kidney failure in SA adults is mainly

put new people on treatment,” she

vated to follow the necessary regimen

due to inherited hypertension

explained, adding that the country has

(for example, the degree to which he

(60 - 65%) or type 2 diabetes (another

actually seen a decline in kidney donors.

or she is compliant in terms of taking

20 - 25%). Kidney failure in the black

If SA were to increase transplanting

medication regularly). Age is also a

population is four times higher than

numbers, more patients would be

consideration. The national guideline

in other groups, due to the high

able to access life-saving dialysis. The

indicates that state hospital patients

incidence of high blood pressure.

Department of Health aims to increase

must be under the age of 60 to qualify

Some of the luckier ones, who meet

the transplant rate five-fold and to

to be admitted to a provincial hospital

the criteria, are able to undergo

double dialysis treatment numbers

dialysis programme.

dialysis at home while awaiting a new

over the next 10 years which will have

In the Western Cape, Groote Schuur

Over the past years, the number of

kidney. Each night, they connect them-

a significant effect on the transplant

and Tygerberg are the only two institu-

selves to a loaned dialysis machine

waiting list and the waiting times. South

tions that offer dialysis, and their cut-off

via a catheter in their stomachs. The

Africa currently provides treatment to

age is 55, unless the person is diabetic,

machine removes waste fluid and tox-

about 8 000 renal failure patients. The

then the patient has to be younger than

ins from their systems, just like normal

Department of Health hopes to increase

50. Other criteria include the extent to

kidneys would, while they sleep. For

this number to about 14 000 by 2025.

which the patient’s domestic circum-

those less lucky there are more sleep-

Most South Africans with kidney

stances support the lifestyle changes

less than restful nights, as they pray

which are necessary to complement the

and ponder their fate.

disease can’t afford to pay for dialysis

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Using cutting-edge science to tackle NCDs

By Chris Bateman

S

trategically using

phones with fitness applications and/

behavioural economics

or wear fitness devices with the internet

and the explosion in

being ubiquitous. “We’re faced with an

medical technology to

entirely different world, measuring and

understand what motivates

monitoring our heart rates, steps per

people is pivotal to helping reduce a

day … how we sleep at night. This all

non-communicable diseases (NCDs)

leads to vast amounts of data which we

epidemic responsible for 68% of

can analyse and use in massive quanti-

deaths worldwide.

ties far quicker than ever before. People

This was Discovery Health CEO Dr Jonathan Broomberg’s key message to hundreds of doctors attending an NCD health summit featuring global and local leaders in genomics, biochemistry, obesity and disruptive technology, held at the Wanderers

are also forming teams and friendship/ Dr Jonathan Broomberg

High-impact interventions will save “billions”

family groups – creating the whole idea of social organisations around exercise – this self-measurement and the ensuing big data are leading to major new insights on what motivates people,” he said. Financial nudging or incentives

The cost to the global economy of

– extensively used in Discovery’s glob-

Citing the “deeply disturbing” recent

continuing a business as usual

al Vitality programme – was a highly

World Health Organization (WHO)

approach versus implementing

effective tool in helping people make

report that attributes 82% of deaths in

high-impact healthcare interventions

better choices in an unhealthy culture

Cricket Ground on 6 August this year.

When it came to metabolic risk factors, obesity was responsible for 3.4 million deaths while high blood pressure topped the charts at 9.4 million deaths

and environment that was “built upon the pleasure of the moment”.

“We know that the human brain is far from rational. It has immediate reactions, reflexes and slow and fast thinking. Our brains need to be tricked into doing

developing and emerging economies

came to USD7 trillion (R89 trillion)

things if we really want to do them. We

to NCDs, Broomberg said this posed

versus USD11 billion (R139.9 billion),

tend to discount future risk (as in not

the biggest challenge yet to the

creating an overwhelming case for

wearing seat belts or dismissing the

global healthcare community. Poor

mobilising citizens, society and the

chances of a heart attack via a continued

lifestyle choices were the key driver

healthcare professions. “It makes you

poor diet). We understand the risks, but

of the pandemic, compounding any

wonder why we’re not tackling this

when you ask yourself what you do to

pre-existing genetic predispositions.

more aggressively,” Broomberg added.

counter them, the answer is generally

Global estimates for behavioural risk

Reflecting on the historical trajectory of

nothing (or very little),” said Broomberg.

factors put poor nutrition’s contri-

the science of wellness, he said it had

Advertising that pleads with mothers to

bution to NCD deaths at 1.7 million

moved from merely treating diseases in

buy healthy food for their children simply

and insufficient physical activity at 2.3

the 1980s to more aggressive screening

does not work; however, it has been

million deaths. When it came to meta-

in the late 1990s (leading to earlier de-

shown that offering a 15% discount on

bolic risk factors, obesity was respon-

tection of cardiovascular and hyperten-

certain foods resulted in a 6% increase

sible for 3.4 million deaths while high

sive conditions) to a massive explosion

in the healthy foods in their supermarket

blood pressure topped the charts at

in technology in the last five to seven

baskets, the correlation improving as

9.4 million deaths.

years. Today most people carry mobile

discounts increased.

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High-tech exercise medicine boosts healthcare With exercise medicine about to be elevated to specialty status in South Africa, doctors should begin working with their patients to design technology-based, comprehensive lifestyle interventions that both parties can monitor to achieve major health improvements. By Chris Bateman

T

his was the core

NCD risk factor for global morbidity,

Committee had banded together with

prevention message from

with heart disease, stroke, diabetes and

the UN General Assembly and the

Stellenbosch University

cancers contributing to more than three

World Health Organization (WHO) to

sports science and

million preventable deaths annually.

declare NCDs “a catastrophe waiting

medicine researcher,

Sixty percent of premature deaths

to happen”.

Prof. Wayne Derman, to 210 doctors

from NCDs occurred in developing

attending the Discovery Health Non-

countries, with the Lancet’s 2012 special

Low CR fitness causes most NCDrelated deaths

Communicable Diseases (NCDs)

edition describing physical inactivity

Summit in Gauteng on 6 August this

alone as a “pandemic with far-reaching

year. Warning delegates that unless they

health, economic, environmental and

kept up with cutting-edge healthcare

social consequences’’. Delivering his

study of more than 40 000 men and

technology they could end up delivering

talk entitled ‘Disruptive Change; Using

12 000 women published in the British

sub-optimal care, Derman said physical

Innovation in the Prevention of NCD’s’,

Journal of Sports Medicine (BJSM) he

inactivity was now the fourth leading

Derman said the International Olympic

said low cardiorespiratory fitness (LCRF)

Citing the 2009 findings of a three-month

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News | 37

Prof. Wayne Derman, Stellenbosch University sports science and medicine researcher, at the NCD summit

outstripped obesity, smoking, hyper-

more evidence, there is piles of it. What

Stockholm, Norway, were painted black

tension, high cholesterol and diabetes

we need is commitment (by doctors

and white to look like piano keys with

in ‘all-cause’ deaths data – accounting

and patients to interventions),” said

movement detectors linked to musical

for 16% of men and 17% of women. He

Derman. He again turned to the BJSM

notes so pedestrians could actually ‘play

said there were three choices everyone

to earmark overarching interventions

them’: a ‘before and after’ study found

needed to make on a daily basis that

which researchers outlined graphically

that 66% more people than normal

would predict whether they developed

in what they termed “the population

chose the stairs over the escalator. Col-

cardiovascular disease, diabetes, cancer

prevention pyramid” divided into ter-

leagues of his in London had redesigned

or a chronic respiratory illness. These

tiary, secondary and primary sections.

the London Underground map to show

were: “Whether you smoke, what you

These included public education

how many steps commuters took be-

put into your mouth on any given day

(embracing mass media), the built

tween the various stations. He referred

There were three choices everyone needed to make on a daily basis that would predict whether they developed cardiovascular disease, diabetes, cancer or a chronic respiratory illness. These were: “Whether you smoke, what you put into your mouth on any given day and whether you’re going to exercise”. and whether you’re going to exercise”. It

environment, transit modes and systems,

was also possible to predict who would

settings such as schools and commu-

Exercise as Medicine and www.ideo.org,

die and who would live, simply by mon-

nities and sport-for-all, plus healthcare

a free toolkit in design thinking, guiding

itoring their sedentary behaviour over

professionals and/or hospitals.

behaviour change and designing a prac-

a long period. “If you sit for more than three hours per day it appears to cut your life short by two years – even among

Redesigning the environment

delegates to several websites, including

tice according to a patient’s needs. “You might get swamped and end up doing nothing. In that case just choose two

Elaborating, he said some cycling lanes

physical activity apps, two nutrition apps

shortens life expectancy by the same

were bigger than car lanes in Europe,

and two mindfulness apps and learn to

degree as smoking. We don’t need

while stairs alongside escalators in

use them,” he added.

individuals who exercise regularly. This

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Don’t measure who died and why – it’s confidential!

By Chris Bateman

T

he Director General

Germany of census records to kill Jews

(DG) of Health is to

during World War II and an alleged

recommend counter-

raid by Israel on Palestinian census

measures to the South

records in order to “kill, maim and

African Law Commission

arrest” its enemies.

to prevent an amendment to the Birth

The Western Cape Department

and Death Registration Act, making

of Health has developed (from 2000

the cause of death confidential to

onwards) a sophisticated home-grown

all but Statistics South Africa (Stats

mortality data system, working with the

SA) officials. The amendment, as it

City of Cape Town, the University of

stands, effectively torpedoes mortality

Cape Town and the SAMRC to glean

surveillance for public health planning

detailed public health information not

countrywide, even though this is only

available from national vital statistics.

currently happening to any real effect

The province used this vital information

in the Western Cape. The longterm harm of sealing off ‘cause of

DG of Health, Precious Malebona Matsoso

to develop appropriately placed programmes to reduce diarrhoea deaths

The long-term harm of sealing off ‘cause-of-death’ data in death certificates lies in epidemiologists being unable to geographically pin-point where deaths are occurring and why death’ data in death certificates lies

ly and citing the media’s controversial

among children, and evaluate HIV-ART

in epidemiologists being unable to

accessing of the health records of the

and cervical cancer screening pro-

geographically pin-point where deaths

late Minister of Health Dr Manto Tsha-

grammes. By January 2014, the City of

are occurring and why – effectively

balala-Msimang as an example of a

Cape Town had developed an IT system

causing healthcare planners to operate

violation of the doctor-patient relation-

that was capturing deaths by residen-

blind – contributing to even more

ship. He said this “sacrosanct princi-

tial suburb within weeks of the date of

deaths. Life-saving interventions such

ple” held equally true for the dead.

death, automatically coding the under-

as vaccination, prevention messaging

Questioning why it was necessary to

lying cause of death in 70% of cases.

and distribution of resources become

wait for a death before interventions

The rapid availability of specific detail

extremely difficult.

were put in place, Lehohla said stats

of where people died and cause of

drawn from health records (i.e. living

death painted a much richer and clearer

one of the most pragmatic incumbents

patient consultations) could help build

picture of the public health action

in recent years, called in her lawyers

disease profiles. Anonymity was “a fun-

required to address the problems faced

after reading about the effect the new

damental qualifier” to the aggregates

by those communities. That all came to

law will have in the Healthcare Ga-

StatsSA produced on any phenom-

an abrupt end when the Department

zette’s sister journal, the SA Medical

ena of public interest. “Even with an

of Home Affairs (DHA) in an attempt to

Journal (Izindaba) earlier this year.

application of the most sophisticated

streamline its processing and maintain

Informed of the objections (initially by

algorithm, such aggregates cannot be

individual confidentiality suddenly

the SA Medical Research Council –

decomposed (sic) to reveal the specific

last February, introduced a new death

DG Precious Malebona Matsoso,

SAMRC), Statistician General Mr Pali

individual to whom the phenomenon

notification form with the cause of death

Lehohla took a hard line, claiming the

of public interest relates,” he added.

page sealed and only Stats SA legally

Western Cape had been acting illegal-

Lehohla cited the abuse by Nazi

empowered to open it.

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News | 39

Is SA’s NHI ready for ‘health tourism’? – a cautionary tale

By Chris Bateman

A

Nigerian woman identified as 37-year-old

Bimbo Ayelabola and her quins

Bimbo Ayelabola has been let off a R2.9 million (£145 000) bill by a British

National Health Service (NHS) hospital after delivering quintuplets there. The news report in the UK’s Telegraph newspaper is concentrating the minds of South Africa’s (SA’s) universal healthcare budgetary architects, with at least 1.7 million foreign nationals currently estimated to be living in this country – and dismal patient fee collection already costing tens of millions of rand every year in most provinces.

Ayelabola underwent a complex caesarean section in 2011, but failed to pay any of the cost of the operation

Photo: News Group Newspapers Ltd

and neonatal care for her five babies.

Constitutional and medical ethical imperatives on treatment hold serious budgetary implications once the local NHI system gets underway

According to the Telegraph, Homerton

for almost two weeks after the birth of

pletely unacceptable that people living

University Hospital in East London will

two boys, and three identical girls, in

outside the UK think they can abuse

not chase Ayelabola for the outstand-

April 2011. Although her visa had report-

our NHS. We expect and are support-

ing bill. The hospital claims that it sent

edly expired, she continued living in her

ing the NHS to make every effort to

one request for payment, more than six

sister’s apartment with the children and

reclaim money owed to it”.

months after she left the hospital, and

did not return home until February 2013.

did not take any further action when

Ayelabola recently spoke to London’s

that there were 1 692 242 people – or

this was returned unpaid. The mother of

The Mail newspaper, saying: “What is it

3.3% of South Africa’s population – who

five, who is a make-up artist, has since

that’s my fault? I don’t understand. They

were not citizens in 2011. Similar figures

returned to Lagos and claims she never

blamed me that I came to the UK and I

were recorded the year following the

The 2011 South African census found

received her bill. “I have never received

just came to use the system, which I did

census (in the 2012 General Household

my bill. If I had it, I would pay it,” she

not do. If it (health tourism) is a problem

Survey) and experts are on record as

is reported as saying. Ayelabola’s story

in the UK, you should talk to the NHS. I

saying it is unlikely this number has

follows claims by NHS whistle-blowers

have never received my bill. If I had it, I

increased significantly. Tough new SA

that managers are instructing them

would pay it.”

immigration regulations declare a person

to turn a blind eye to health tourists,

The UK Telegraph reports that

undesirable if they overstay their granted

because it is too much trouble to chase

Ayelabola is separated from her

period, banning them from returning

them for money.

wealthy husband, Ohi Nasir Ilavbare,

for increasingly lengthy periods linked

but that he is involved in the lives of

to their illegal stay. However, constitu-

a visitor’s visa after discovering she was

his children. She is also believed to

tional and medical ethical imperatives

pregnant in 2010, and stayed with her

have been banned from returning to

on treatment hold serious budgetary

younger sister in the UK early in her

Britain for five years. A Department of

implications once the local NHI system

pregnancy. She remained in the hospital

Health spokesman said: “It is com-

gets underway.

Ayelabola is said to have obtained

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40 | News

Gauteng’s negligence continues, major overhaul underway

By Chris Bateman

M

edical lawsuits

(Democratic Alliance), Mahlangu said

R5.758 billion was irregularly spent pri-

against Gauteng’s

the department had lost 168 cases

marily by the Gauteng education, roads

Health Department

in court. While she did not have “the

and transport and human settlement

increased by over

correct information” about how many

departments. This was more than the

R4 billion between

cases had been won, Mahlangu said

R3.751 billion irregularly spent in the

April last year and March this year – and

eight were settled out of court. “Part of

2013/14 financial year and the R4.688

now stand at R13.1 billion. Claimants

the strategy is to engage more with the

billion irregularly spent in the 2012/13

hoping for financial redress to deal

patients and families. All the hospitals

financial year. Tellingly, the irregular

with whatever pain and suffering

have mechanisms now; they’re called

expenditure related mostly to non-com-

they’re facing are in for a long wait; the

... redress committees. Where we know

pliance with supply-chain management

province paid out just R544 million in

that we’ve wronged the family or pa-

rules and regulations, a long-standing

damages and settlements for medical

tient, we’re able to engage with them

charge made by independent health

claims between January 2010 and the

much more and admit guilt. We’ve also

advocacy and activist groups. In terms

current 2014/15 financial year. Moves

introduced a dispute resolution mech-

of fruitless and wasteful expenditure,

are afoot, however, to stem the tide of

anism,” she said. Until recently the de-

a total of R415.6m was wasted in the

claims and to speed up pay-outs.

partment fought cases in court, but she

2014/15 financial year, primarily by

had instructed her officials to do things

the Health and Roads and Transport

provincial health department’s annual

differently. “We are going to look at all

departments. Mahlangu also revealed,

report, tabled in the Gauteng legisla-

the merits of all cases and on the basis

in answer to a written question from

ture in early September and in answer

of that settle where we need to settle

Bloom, that the Charlotte Maxeke

to questions posed to its Health MEC,

– but also negotiate with the families.”

Johannesburg Academic Hospital had

Qedani Mahlangu. The province’s

Bloom welcomed the department’s

been unable to do a single gall-bladder

health department failed to receive

readiness to negotiate with victims but

operation since March last year be-

clean overall financial audits for the third

slammed Mahlangu for obfuscating on

cause of broken laparoscopy equip-

financial year in a row, mainly due to un-

how many cases her department had

ment. Fifty-one patients were currently

paid patient fees, reported Mahlangu’s

won since January 2010, adding: “Well,

waiting for gall-bladder operations at

colleagues, Premier David Makhura and

I can tell you how many, zero, nothing.

the hospital. Normally, some six gall-

Finance MEC, Barbara Creecy.

They’ve lost every single one,” he said,

bladder operations were done every

adding that the R544 million was “an

month, so the backlog was now more

Mabona, said there were currently 1

astounding figure” that could have

than eight months because of the bro-

780 medico-legal claims at various

gone to improving hospital facilities.

ken equipment, Bloom said. Mahlangu

These figures emerged from the

Departmental spokesperson, Steve

stages in court, dating back to 2010, most of them emanating from Chris Hani Baragwanath, Tembisa, Charlotte Maxeke and Pholosong hospitals.

Irregular spending up 18.6% since 2012/13

promised new laparoscopic equipment within eight weeks and said prospective gall-bladder surgery patients were in the meantime being referred to the

Makhura and Creecy revealed that

Helen Joseph Hospital. Other broken

ing the department by meeting with

more than R5 billion in public money

equipment at the flagship hospital

clinical managers and other healthcare

had been irregularly spent by Gauteng

this year includes the mammography

professionals to advise on record-

government departments and agencies

machine, lifts, air-conditioning units in

keeping and identification of potential

in the 2014/15 financial year. Speaking

operating theatres and a sterilising

claims. Replying to a question in the

on 1 September at a media briefing

machine – leading to an ongoing

Gauteng legislature from Jack Bloom

at the provincial legislature, they said

shortage of clean linen.

Retired judge Neels Claassen was help-

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42 | Profiles

Glenda Gray: A formidable force

By Leverne Gething

N

ational Research

HIV. Her research into post-exposure

only saved lives of many children, but

Foundation A-rated

prophylaxis for prevention of mother-

also improved the quality of life for

scientist Glenda Gray

to-child transmission (PMTCT) led

many others with HIV and AIDS.”

was recently appointed

to the development of clinical

president of the South

guidelines that have been adopted

African Medical Research Council

(MRC). With a distinguished academic

background in paediatrics and HIV, Gray intends to maintain her ongoing research

internationally.

Garlanded in awards

Game-changing interventions In her new role Glenda’s single-

minded determination to develop game-changing interventions to end

Her expertise has been garlanded in

SA’s TB and HIV epidemics remains

awards. In 2002 Glenda received the

unfettered. “From discovery to clinic

director and co-founder of the Perinatal

Nelson Mandela Health and Human

– bench to bed – funding for research

HIV Research Unit of the University

Rights Award for her work on mother-

is critical. I am interested in ensuring

of the Witwatersrand, based at

to-child transmission of HIV-1. In

we do both blue-sky research and

Chris Hani Baragwanath Hospital in

2003 she received the International

translational research and that we

Soweto, and a member of the Vaccine

Association of Physicians in Aids Care

fund throughout the value chain of

and Infectious Diseases Unit at the

‘Hero of Medicine’ award.

disease. We are also interested in

commitments throughout her tenure.

As professor of Paediatrics and

Fred Hutchinson Cancer Research

In June 2012 she received a DSc

funding the next-generation scientists

Center in Seattle, USA, she has a long

(honoris causa) from Simon Fraser

and funding black African scientists

pedigree in key research. This includes

University, Vancouver, and in the

and to develop research capacity in

the development of HIV vaccine

same year was admitted into the

historically disadvantaged institutions.

trials in South Africa and ongoing

American Academy of Microbiology.

assessment of efficacy of microbicides

In 2013 she received South Africa’s

research – from discovery (bench) to

as preventive HIV therapy. She is co-

highest honour, the Order of the

clinical (bed) – we must be involved in

principal investigator of the US National

Mapungubwe, granted by the

all aspects of research to find solutions.

“We must do cradle-to-the-grave

Institutes of Health-funded HIV Vaccine

President for: “Her excellent life-

I want to grow medical science in

Trials Network (HVTN) and director of

saving research in mother-to-child

South Africa so that we become a

HVTN International Programmes.

transmission of HIV and AIDS that has

formidable force,” she says. “I want to

changed the lives of people in South

foster discoveries that change lives,

Africa and abroad. Her work has not

and I hope that the HIV vaccines we are

Dr Gray’s research has contributed significantly to the understanding of

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developing countries could feed their infants formula to avoid transmitting the virus through breastmilk. Global health leaders were recommending that women in developing countries shouldn’t use formula, arguing that the risk of babies dying from contaminated water outweighed that of contracting HIV. Glenda wanted to educate women so that they could make a choice; she found that women in Soweto were able to use formula safely. The reaction from activists who had led previous boycotts against baby formula makers was harsh.

Everything about that presentation testing now show us the way to more

age of six. Unusual for a pupil from

was quintessential Glenda: the drive

effective regimens for the future.”

the local high school she gained a

to save lives, the willingness to buck

place to study medicine at Wits, and

convention, and her insistence on

just not enough funding: “I need at

went on to carve a path in paediatrics.

asking the community – her patients –

least three times the budget I have

Around this time, the late 1980s,

However, she says that there is

to be truly effective, to fund diverse

South Africa was in the grip of the

research. We have the vision but not

emerging HIV/AIDS epidemic. As

the means to be world-class medical

a young physician Gray was drawn

researchers – even though we have

into HIV activism, working in an

the ability and the scientists.”

underground organisation opposed

R30 million has already been

to the apartheid government. Her

what they wanted.

In 2015 her approach hasn’t changed

She speaks of promise for the future.

“In my own research, I hope that

“I want to foster discoveries that change lives, and I hope that the HIV vaccines we are testing now show us the way to more effective regimens for the future” awarded by the MRC to previously

portfolio was to work in townships

the HIV vaccines that we are testing

under-resourced universities to

with healthcare workers in the field

over the next few years show us the

fund research into the prevention,

of HIV, and to organise emergency

way to developing more and more

reduction and control of disease in

medical teams to treat people injured

effective HIV vaccines. Promise is

South Africa. With the Department

during anti-government protests.

being shown that we are on the

of Health and the private sector, the

By the time Glenda qualified as

path to eradicating paediatric HIV in

MRC is also facilitating the National

a paediatrician, every third child at

children in South Africa, that at long

Health Scholars programme, worth

Baragwanath Hospital was HIV-positive,

last women and child health are on

R36.2 million, to support 1 000 PhD

and HIV was the most common cause

the political agenda, and that intimate

graduates over the next 10 years.

of death in children admitted.

partner violence and child murder are

If Glenda’s sheer energy and

Glenda had planned to be a doctor,

receiving the attention they deserve.

“In the real world, I want to make

determination are anything to go by,

not a researcher, but the crisis propelled

her goals will be attained.

her to be both, and she began looking

a difference by increasing the funding

for affordable ways to prevent mother-

to young scientists, to assist in making

to-child HIV transmission.

universities that previously were not so,

Carving a path in paediatrics

In 1996 Glenda presented her first

to be research active. I want to grow

Gray was the fifth of six children

research paper to an international

medical science in South Africa so we

brought up in the mining town of

AIDS meeting – and walked straight

become a formidable force in Africa

Boksburg, east of Johannesburg, and

into a tempest. The subject was

and beyond. I want discoveries that

wanted to become a doctor from the

whether or not HIV-positive women in

change the lives of South Africans.”

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Profiles | 45

Surfing the genome wave – Dr Craig Venter

By Chris Bateman

A

1960s Newport

via advances in genome sequencing

on human genotypes – and is now

Beach surfer, Vietnam

and engineering.

working on synthetic methods to

war veteran and self-

Having achieved the quickest

rewrite genetic codes. The latter work

confessed adrenalin

PhD in Californian history, Dr Craig

stands to transform energy production

junkie who belatedly

Venter, named by Time Magazine (in

(for example, recycling carbon instead

began an illustrious medical career, is

2007 and 2008) as one of the globe’s

of burning it into the atmosphere),

on the verge of revolutionising global

100 most influential people, built the

food production and manufacturing.

health, agriculture and manufacturing

world’s most comprehensive database

His scientific team’s work in

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One of the globe’s 100 most influential people, Venter built the world’s most comprehensive database on human genotypes – and is now working on synthetic methods to rewrite genetic codes epigenetics has led to precision medicine that can tailor highly effective

health and life insurance industries.

corresponding factors in ourselves that

“Our company’s name is Human

regulate all kinds of processes – and all

therapies to individual patients and

Longevity. We’re not trying to directly

of this is contained in a linear genetic

predict diseases up to 20 years in

increase the length of a lifetime. In fact

code. Five years ago we built the first

advance. Addressing the Discovery

it’s very similar to Discovery’s Vitality

genetic chromosome (synthetic). While

Health Non-Communicable Diseases

Programme – promoting a healthy

the human genome is the most complex

(NCDs) summit in Johannesburg via

lifestyle. There’s no one disease we’re

part of all of it, we’re excited about

video-link on 6 August this year, Venter

focused on or interested in. If we get

applications across the entire space,” he

said that his company’s work would

new preventive medicines, that’s great.

told a fascinated audience of hundreds

usher in a “transformative era” for the

Epigenetics is a new field looking at

of doctors. His company is also making

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Profiles | 47

are mutated and which drugs will work.

disease. He revealed that the cost

We have very specific RNA vaccines

of sequencing genomes in Europe

that are individualised and very precise.

was currently no more than $1 000, a

Within a couple of weeks of getting the

quantum drop from a decade ago.

tissue from the patients we have precise

“Also, the more knowledge you

quantitative information versus guessing

have of your own life, the more chance

blindly like most medicine today. We

you have of changing your own life

understand the programming. It’s clear

outcomes. We all have a pre-existing

from the patient’s DNA in his genome

condition to something in our genetic

why he or she got cancer in the first

code. That will be useful in getting the

place – and that they would probably

right policy to the right people and the

have got it sooner or later. In healthy

right risk factors to the right people.”

individuals cancer doesn’t appear if

In the future, exercise patterns, dietary

you have a good immune system, but if

patterns and pharmaceutical patterns

you have a suppressed immune system

could be examined for each type of

because it’s under stress or genetically

change in the genetic code. With

suppressed, you greatly increase your

over half of all our genes contributing

risk of cancer.”

to functions of our brain, it was also

His team found 25 000 mutations

highly feasible that predicting what

in a tumour that were different from

type of memory a person would have

the patient’s genome. “From those

would become possible. He described

protein changes, we come up with

autism (for example) as “not a single

unique drugs that we know will work

disease. Every single child has a

on that person’s biochemical pathways

different set of mutations of genes

with these mutations,” he explained. In

affecting the brain”.

future physicians would become much

Venter said prevention was the

more like “team captains helping their

ultimate goal of his entire scientific

patients navigate through all this new

approach. “If we can prevent disease

information – the goal is for all of us to

(in patients) at the earliest stages

try and prevent diseases by detecting

of their lives, they can live longer,

them early”.

healthier lives.” Every human being

Human Longevity’s goal was

has 1 trillion human cells, but 200

to sequence 1 million genomes by

trillion bacterial cells, called our

2020 and the challenge now is to get

microbiome. This determines most of

sufficient diversity of patient samples

our metabolism and health outcomes.

and diseases. “The more knowledge

Human beings have “500 or so”

you have, the more lives you can

major chemicals circulating in their

individualised RNA vaccines and can

save,” Venter added. Key for all health

bloodstream, 60% from the human

now predict dementia 20 years before

is socioeconomic conditions while

metabolism and 30% from the different

the first symptoms show, preventing the

poor diet or high stress environments

animals they have eaten.

advancement of Alzheimer’s disease

are aggravators. People in poor

versus trying to treat it after it has

socioeconomic regions have much

now only from the human genetic

already begun to manifest.

shorter lifespans and a greater risk for

code. In the future we’ll have a greater

infectious diseases.

understanding of how the chemicals

Cancer from genes and mutations

Venter singles out sanitation

“We can’t predict all of this right

in the food affect us in different ways. I believe we can totally prevent disease at the early stages in people’s lives.

Describing cancer as a “100% genetic

However, he laser-beamed in on

President Barack Obama talks about

disease” Venter said it was, however,

improving sanitation, saying this

the era of precision medicine; well it

not literally inherited from parents, but

would increase human longevity more

was individualised before that. We

came from accumulated mutations

than anything else, followed by diet

believe we’re doing individualised,

within ourselves. “We know which genes

and understanding the risk for heart

precision medicine,” Venter said.

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Surgeons bicker as penis recipient impregnates girlfriend The world’s first recipient of a transplanted penis is still thriving 22 months later, reportedly having successfully impregnated his girlfriend, who is now in her final trimester.

However, peers of his transplant team have begun questioning the long-term benefits of the operation. By Chris Bateman

D

r Elmi Muller,

patient, whose identity has been

unlike a solid organ transplant,

a former head of

jealously guarded by the clinicians, is

involve multiple tissues, resulting

the South African

one of 250 annual formerly hopeless

in a complex immunogenicity.

Transplantation Society

known penile amputees across

While microsurgical problems were

and head of Groote

the country: victims of failed ritual

overcome several years ago, one of

Schuur Hospital’s Transplantation

circumcision, with several reported to

the main obstacles which prevent

Services, queries whether the operation

have contemplated suicide, so powerful

the expansion of composite tissue

will ultimately prove worthwhile, given

is the cultural stigma. The intervention

transplantation worldwide is the

the long-term effects of the high-dose

is arguably particularly apt in South

immunological effect of these grafts

immunological suppression required.

Africa, where the prevalence of penile

on the recipients. Dr Muller said:“The

Citing abundant literature on difficulties

loss is way above the international

true challenge is weighing up the

faced by hand-transplant recipients,

average, especially in Xhosa-speaking

long-term risk of immunosuppression

she also openly ponders whether the

regions of the Eastern Cape. A

and opportunistic infection

21-year-old patient, from the rural

snapshot of the only available hospital

against the functional ability of

Eastern Cape, fully appreciated these

admission data for life-threatening

the transplanted organ”. The

“The true challenge is weighing up the long-term risk of immunosuppression and opportunistic infection against the functional ability of the transplanted organ” inherent longer-term risks beforehand.

post-ritual circumcision complications

risk of rejection was of particular

While conceding that the impact on

in that province stood at 200 patients

concern when the transplanted

the quality of life of the recipient might

in December 2001 alone, with 11

tissue contained skin and lymphoid

be excellent, she says “a few important

mutilations.

tissue that elicited a strong immune

questions” need answering by the Tygerberg Hospital transplantation team, led by urology chief Dr Andre van der Merwe.

It might work, but will it last?

response. Without appropriately strong immunosuppression, the potential for acute rejection and

Writing in a paper submitted to

irreversible destruction of the

the South African Medical Journal

donated tissue was high. Citing the

a multidisciplinary team at Tygerberg

(SAMJ) this August, Dr Muller

composite tissue transplantation

Hospital on 11 December 2014. The

said composite tissue transplants,

experience gained from 50 patients

The operation was performed by

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Focus | 49

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Plastic surgeon, Prof. Frank Graewe, urologist, Prof. Andre van der Merwe and immunologist Prof. Rafique Moosa

in 36 centres, who underwent hand transplantations worldwide, she said the desirable health outcome and expected quality of life years gained was reported to be “questionable” when weighed up against the risks of immunosuppressive therapy.

“Penis transplantation is a life-

To illustrate her point, Dr Muller said that with uterus transplantation the (transplanted) uterus is removed after two pregnancies so that the patient will not be exposed to lifelong immunosuppression acceptance of a physician’s opinion,

risks but it should also consider the

enhancing rather than life-saving

even by sophisticated patients, “what

emotional effect of such a graft.

therapy and therefore the side

amount of risk should an individual

Another reason why composite tissue

-effects of these drugs remain of

be advised to accept for a non-life

transplantation remains limited in

particular concern as they contribute

threatening condition? Is a young male

many countries is because of limited

to significant morbidity with chronic

patient who lost his penis in a ritualistic

donor availability (from brain-dead

use,” she writes.

procedure able to weigh up his sexual

donors). South African organ donation

ability and normality with his long-term

rates are currently among the lowest

health in general?”

in the world and many cultural and

Uterus transplantation: discard after use

She said that protocols in hand

religious barriers exist which prevent

transplantation required very strict

families from consenting to organ

To illustrate her point, Dr Muller said

entry criteria based on physical as well

donation. The country’s public

that with uterus transplantation the

as emotional assessment. It is for this

education programmes were also

(transplanted) uterus is removed

reason that finger transplantation,

seriously lacking.

after two pregnancies so that the

for instance, is not taking place, as

patient will not be exposed to lifelong

the risks are judged to outweigh the

immunosuppression.

benefit of a single finger. Not only

Dr Muller also said that given

should the informed consent of the

the existing cultural and language

recipient include information on the

barriers and the general unquestioning

immunosuppression and physical

Culturally a penis is not easily donated Muller said it was “interesting to

note” that the family of the local

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Focus | 51 penis donor insisted on a penis

full Tygerberg psychiatric department

procedure would be delivered to the

reconstruction after death. “It seems

(in addition to the research ethics

people who needed it most by being

a strange request if the family was

expert used previously) for future

on offer in state facilities to vulnerable

completely comfortable with this

assessments, but the availability

groups that were unable to afford or

donation. Asking donor families for a

of plastic surgeons remains at a

access state-of-the-art healthcare.

part of the deceased person’s body

premium. He said it is difficult to

that has strong associations with body

schedule a transplant as “these things

success was the culmination of 4 years

identity has the potential to put them

come in as emergencies and the

of clinical and ethical preparation,

off transplantation completely and

donor is never planned”. His team

intensive laboratory work on cadavers,

this could negatively impact on organ

had hoped that the international

frustration in finding willing donors,

donation rates for solid organs in

publicity would lead to an additional

and careful groundwork to ensure that

South Africa,” she added.

funding boost from national

the procedure and its concomitant

Van der Merwe said the transplant

Responding to the criticisms,

government to the provincial health

lifelong immune suppressant

Van der Merwe conceded that they

authority, but this had not emerged.

treatment were replicable and

had encountered an immunological

His transplant group had been

affordable to all.

suppression complication in the

invited to submit a full paper to the

form of an atypical infection of the

prestigious Lancet medical journal in

of Tygerberg Hospital, emphasised

patient’s foot some months after the

the UK. This would include not just

that the procedure was not an

transplant. While it “gave us grey

the case support for their operation

answer to the ongoing loss of life

hairs” the infection had responded

but all of the difficulties and problems

and reproductive organs caused by

successfully to ciprofloxacin and

they encountered.

inexpert ritual male circumcision.

some creams and the patient was soon back at work. The only other post-transplantation problems were a urethral leak and a stricture problem, which were relatively easily resolved

Recipient “impeccably” briefed beforehand

Dr Dimitri Erasmus, chief executive

“While hugely significant, this is a life-changing, not a lifesaving procedure. The focus should remain on preventive efforts,” he said. The nine-hour operation was conducted

Dr Muller said composite tissue allo-

by a team led by Prof. Van der Merwe,

his patient had fully appreciated

transplantation for the restoration of

head of SU’s Division of Urology, with

the relative risks and benefits of the

congenital or acquired deformities

his university counterpart in plastic

operation, Van der Merwe replied:

was not new. Not only hand, but

surgery, Prof. Frank Graewe and SU’s

“Well, he made his partner pregnant

face, knee, trachea, uterus and

Department of Medicine chief and

very quickly after the transplant, so

oesophagus allografts had so far

transplant immunologist, Prof. Rafique

that probably shows that he does

been transplanted successfully.

Moosa, in attendance.

via a second operation. On whether

understand the longer-term risks.

The Tygerberg advance gives

A similar transplant procedure

The allegation that he may not have

hope to victims of botched ritual

was performed in Guangzhou General

understood is a bit paternalistic,”

circumcisions, survivors of penile

Hospital in China in 2006, involving

he added.

cancer and potentially even to men

a 44-year-old recipient who lost his

with severe erectile dysfunction. The

penis in an accident, but surgeons

long-standing critic who was “less

pre-and postoperative transplant

had to remove the organ two weeks

than supportive”, revealing that

team included Dr Nicola Barsdorf,

later when skin problems resulted in

provincial health authorities had

Head of Health Research Ethics at

an aesthetic setback. Graewe said

declined them permission to continue

Stellenbosch University (SU), who said

the Chinese used a very different

with transplants (there were nine

that the research team addressed the

approach, warming the donor penis

candidates). However, he stressed

issue of therapeutic misconception

up with an infrared lamp post-

that this had nothing to do with Dr

(i.e. the risk that a research participant

operatively, which had increased

Muller’s reservations but was the

may not fully understand the

the metabolic requirements instead

result of an all-inclusive cost analysis

experimental nature of the treatment)

of increasing the blood supply as

showing the transplantation to have

“impeccably”. The patient had

they had. However, the crucial

cost R300 000. After several months

been counselled repeatedly over an

difference appeared to have been

the province reversed its decision and

extended period about the potential

inadequate psychological work-up,

had since reinstated the programme.

risks and benefits. The transplant

he stressed, adding that the

The interdisciplinary team has more

team’s partnership with local public

recipient’s girlfriend had strongly

recently gained the backing of the

health structures also meant that the

objected to the result.

He described Dr Muller as a

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Collaboration on Ebola vaccine changes R & D forever

By Chris Bateman

A

vaccine that is

which by the end of this August had

100% protective

claimed 11 300 lives, infecting 28 073

against the Ebola

people in Guinea, Liberia and Sierra

virus took less than

Leone. The death tally included 513

12 months of field

health workers among the 881 health

trials before scientists were confident

worker infections, a frighteningly high

enough to vaccinate all people at risk

proportion of heroic men and women

after close contact with an infected

professionals and lay workers who put

person – marking a turning point in the

themselves directly and repeatedly

history of research and development.

in harm’s way. In stark contrast to the

According to Børge Brende, Minister

speedy vaccine collaboration, only

of Foreign Affairs in Norway (one of

when isolated Ebola carriers popped

The death tally included 513 health workers among the 881 health worker infections, a frighteningly high proportion of heroic men and women professionals and lay workers who put themselves directly and repeatedly in harm’s way the vaccine’s major funders), if the

future outbreaks. He called the trial

up in Britain, Spain and America –

current results hold up, it may prove

outcome a “sensational result”, and

prompting near hysteria in the media

to be the silver bullet against Ebola,

put it down to an extra-ordinary

(particularly in America) – did the

helping to bring the current outbreak

and rapid collaborative effort driven

under-funded and poorly prepared

to zero and enabling control of all

by the urgency of the Ebola crisis,

World Health Organization (WHO) and

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

S AM F

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Prescrib

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Blood-For

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Divis Medica ical Associatio d n a h lt d Hea ican Me outh Afr for the S ublishers

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The ESSENTIAL MEDICAL REFERENCE for every healthcare professional!

The convenient pocket-sized design enables you to fit it comfortably into your hospital bag or coat pocket, so it can always be at hand for ready reference. South African Medicines Formulary (SAMF), a joint initiative of the University of Cape Town’s Division of Clinical Pharmacology and the Health and Medical Publishing Group, publishers for the South African Medical Association, provides easy access to the latest, scientifically accurate information, including full drug profiles, clinical notes and special prescriber’s points. The thoroughly updated 12th edition of SAMF is your essential reference to the rational, cost-effective and safe use of medicines.

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Email: dianes@hmpg.co.za NO VEMBER/D E C EMBER 2 0 1 5 Tax invoice to be posted on dispatch of order

The WHO declared Liberia free of Ebola virus transmission in the human population this August – having previously declared the country Ebola free in May – only to see the deadly virus resurface six weeks later How it works

explains Dr Feinberg. “So the vaccine

The vaccine used in the Guinea study

will likely be used in at-risk communities

is called VSV-EBOV, which the WHO

where and when it is required. However,

vaccine went from initial testing in

describes as a good microorganism that

it will also hopefully provide an

humans to demonstration of vaccine

has borrowed the guise of the Ebola

important additional approach to help

efficacy and safety in a large Phase III

virus but does not contain the virus. It

protect health workers who care for

study in Guinea in less than 12 months

tricks the body of the vaccinated person

Ebola-infected patients. We are doing

– a record time. “Normally, it takes

and triggers an immune defence against

additional research on the vaccine

about a decade or more for a vaccine

the Ebola virus, protecting the person if

to provide a comprehensive set of

to come to this point,” explained

they come into contact with someone

data to inform licensure decisions by

Prof. Peter Smith, an epidemiologist

who is infected. Mark Feinberg MD,

regulatory agencies and to facilitate

and specialist in vaccine trials from

of Merck Vaccines (which provides the

the development and implementation

the London School of Hygiene and

vaccine), says it works in a similar way to

of policy decisions by key international

Tropical Medicine and a key advisor.

live, attenuated vaccines against other

and national authorities,” he added. A

viral infections. He said the ability of

drawback of the current formulation of

Paule Kieny, who leads the Ebola

this vaccine to elicit prompt immune

the vaccine is that it must be kept very

Research and Development (R & D)

responses against the Ebola virus

cold in a tropical country with sparse

effort at the WHO, said that the work

following administration of a single

electricity. Future work will be needed

marked a turning point in the history

dose represented a vital attribute.

to develop a more thermo-stable

of research and development. “We

After VSV-EBOV is further studied and

formulation.

now know that the urgency of saving

licensed by regulatory authorities,

lives can accelerate R & D – we will

Merck plans to produce enough doses

assembled, embracing scientists,

harness this positive experience to

to control future outbreaks, stockpiling

physicians, epidemiologists and experts

develop a global R & D preparedness

them for other Ebola emergencies. At

from the WHO, Norway, Canada,

framework so that if another major

this point, the vaccine will not be used

Guinea, Doctors without Borders,

disease outbreak ever happens again,

like common vaccines such as those for

universities of Florida, Maryland and

for any disease, the world can act

polio and measles (which are routinely

Bern, and the London School of Hygiene

quickly and efficiently to develop and

administered). “Ebola is not a common

and Tropical Medicine. Says Dr John-

use medical tools and prevent a large-

infectious disease, and outbreaks arise

Arne Røttingen, head of infectious

scale tragedy.

in sporadic and unpredictable ways,”

disease control at the Norwegian

individual nations respond with slow but growing efficacy.

The clinical development of the

Assistant Director-General Marie-

A massive vaccine trial team was

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Focus | 55 Institute of Public Health and chair of

minimise the time necessary to gather

that for a prolonged initial period

the trial’s steering group: “We knew it

more conclusive evidence needed for

seemed out of control, with the world

was a race against time and that the

eventual licensure of the product”.

seemingly looking on helplessly. The

trial had to be implemented under

The trial will now include 13- to

virus is spread among humans via the

the most challenging circumstances.”

17-year-olds, and possibly children

bodily fluids of recently deceased

Funding came from the Wellcome Trust,

from age six, on the basis of new

victims, and carriers with symptoms

Norway, Canada, the WHO and Doctors

evidence of the vaccine’s safety.

including vomiting, diarrhoea and –

without Borders. Merck scientists, along

Crucially, the vaccine has also been

in the worst cases – massive internal

with those from New Link Genetics

given to 1 200 frontline health workers,

and external bleeding. A country is

Corporation, an early developer of the

laboratory staff, cleaning staff and

considered free of Ebola transmission

vaccine, also gave detailed technical

burial teams.

once two 21-day incubation periods

support to field trial staff on the vaccine and its administration.

Virus ‘fenced in’ by vaccinating all contacts

Dr Bertrand Draguez, who has

have passed since the last known case

been leading Doctors without Borders

tests negative for a second time. WHO

efforts to find new tools to combat

declared Liberia free of Ebola virus

Ebola, said more data were needed –

transmission in the human population

for example, on how long the vaccine

this August, having previously declared

offers protection – but that the results

the country Ebola free in May, only to

From early this August the researchers

suggest a “unique breakthrough”

see the deadly virus resurface in six

began using a ‘ring’ strategy – based

in fighting the disease. “Even if the

weeks. The United Nations agency said

on that used in smallpox eradication

sample size is quite small and more

the country had now entered a 90-day

in the 1970s – to test the vaccine’s

research and analysis is needed,

period of heightened surveillance, and

effectiveness. “The premise is that by

the enormity of the public health

saluted Liberia’s “successful response”

vaccinating all people who have come

emergency should lead us to continue

to the recent re-emergence, when six

into contact with an infected person

using this vaccine right now to protect

people were infected, including two

you create a protective ‘ring’ and stop

those who might get exposed to the

who died. “Liberia’s ability to effectively

the virus from spreading further,” said

disease: contacts of infected patients

respond to the latest outbreak is due

Røttingen. Using the ring approach, when the Ebola epidemic in Guinea dispersed into smaller local outbreaks, the vaccinators and the trial team were able to move with it. It allowed the trial to continue and at the same time

A country is considered free of Ebola transmission once two 21-day incubation periods have passed since the last known case tests negative for a second time

contribute seamlessly to the control of

and frontline workers,” he emphasised.

to intensified vigilance and rapid

the Ebola outbreak. In some cases, the

Because the virus was concentrated in

response by the government and

clusters were whole villages. In others,

hot spots across the region, it made

multiple partners,” the WHO said.

the clusters were smaller sections of

more sense to focus on vaccinating

Liberia was the hardest hit in the West

towns and cities. By the first week in

those close to infected patients and

African Ebola outbreak, which began in

September, more than 4 000 close

frontline workers than to embark on

December 2013. Experts have warned

contacts of almost 100 Ebola patients,

a mass vaccination campaign, he

that even after 42 days have passed

including family members, neighbours

confirmed. “Health workers have

the danger is not over, considering that

and co-workers, had voluntarily

been fighting an unfair battle against

some Ebola cases are still surfacing in

participated in the trial. Until then, half

the Ebola [virus] and for the first time

neighbouring Guinea and Sierra Leone.

were vaccinated three weeks after the

there is a prospect of a tool that could

identification of an infected patient

protect lives and break chains of

after the very first outbreak, the number

and others straightaway, to allow

transmission,” said Draguez.

of cases was doubling every three

for comparison of the results. It was found that within 10 days the vaccine protected against the Ebola virus for

MSF heroEs initially ‘out in the cold’

By November last year, eight months

weeks, overwhelming thinly equipped facilities, with rotting bodies lying in the streets and countryside. However,

both groups. The randomisation was

Doctors without Borders were the first

10 months later (September this year)

stopped in early September for obvious

international organisation to treat and

case incidence had plateaued at

ethical reasons, with the WHO saying

follow-up Ebola patients in Guinea,

between 20 and 30 cases per week, for

it was “to allow for all people at risk to

putting them at the forefront of what

eight consecutive weeks, vastly boosting

receive the vaccine immediately and to

has been a torrid and fearful outbreak

the new vaccination programme.

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Atmospheric carbon dioxide concentrations and zinc deficiency

T

he global

at ambient CO2 concentrations

consequences

(375 - 384 ppm) using food

More evidence against antibacterial soaps

of increasing

balance sheet data for 2003

By Bridget Farham

By Bridget Farham

carbon dioxide

- 2007 from the Food and

concentration

Agriculture Organisation. They

H

and washing is known to be

in terms of climate change are

used previously published

now generally well known and

data from free air CO2

accepted. What is probably

enrichment and open-top

less well known is the effect

chamber experiments to

of increasing carbon dioxide

model zinc intake at raised CO2

concentrations on the zinc

concentrations (550 ppm, which

content of important food

is the expected concentration

crops such as barley, wheat,

by 2050). The difference

rice, soya and field peas. These

between the population at

most common. In the light of concerns over the safety

are an important source of zinc

risk at elevated and ambient

and efficacy of antibacterial products, the US Food and

in the diet for billions of people

CO2 concentrations – the

Drug Administration (FDA) introduced a ruling that

around the world.

population at new risk of zinc

Adequate zinc intake is the cornerstone of maternal and

the single most effective way to prevent the spread of infection. Largely through successful marketing, antibacterial soaps are widely believed to be particularly

effective and have proliferated on supermarket shelves.

The label ‘antibacterial’ means that the soap contains ingredients with antimicrobial activity, and triclosan is the

manufacturers need to show that antibacterial soap is

deficiency – was the measure

more effective than plain soap and water. Researchers from

of impact.

Korea chose to focus specifically on triclosan to look at the

What emerged was that

efficacy of antibacterial soaps containing this ingredient.

to a paper recently published

the total number of people

Triclosan is known to be effective against bacteria,

in The Lancet Global Health,

estimated to be placed at risk

fungi and some viruses, but adverse effects such as

roughly 17% of the world’s

of new zinc deficiency by 2050

allergy have been reported. And there is also the

population were estimated to

was 138 million, with most of

problem of promoting antibiotic resistance.

be at risk of zinc deficiency in

those affected living in Africa

2011. Zinc deficiency increases

and South Asia – nearly

in vitro and in vivo. The soaps were exposed to 20

the risk of premature delivery

48 million in India alone.

bacterial strains, recommended by the FDA and

child health and, according

and reduces growth and weight

This model highlights a

Researchers compared two types of soap both

tested under conditions that replicate normal hand

gain in infants and young

previously unquantified effect

washing behaviour. Both products contained identical

children, while the mineral

on human health of increased

ingredients, but the antibacterial version contained

is also important in immune

CO2 emissions and should

0.3% triclosan. Results showed no significant difference

function. The global burden

be used to guide possible

in bactericidal activity between plain and antibacterial

of disease attributed to zinc

interventions.

soap when used for normal hand-washing. In vitro experiments did show significantly greater antibacterial

deficiency is high, with more than 100 000 deaths annually

Myers SS. Effect of increased

effects of the soap containing triclosan, but only after

from diarrhoea and pneumonia

concentrations of atmospheric

9 hours of exposure.

in children younger than 5 years

carbon dioxide on the global

attributable to zinc deficiency.

threat of zinc deficiency:

Use plain soap and water!

A modelling study. Lancet

Kim SA, Moon H, Lee K, Rhee MS. Bactericidal

estimated per capita per

Glob Health 2015. [http://

effects of triclosan in soap both in vitro and in vivo.

day bioavailable zinc for the

dx.doi.org/10.1016/S2214-

J Antimicrob Chemoth 2015;dkv275. [http://dx.doi.

populations of 188 countries,

109X(15)00093-5]

org/10.1093/jac/dkv275]

In this study, the authors

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

Research | 57

Digoxin – tried and tested?

By Bridget Farham of observational and controlled data, including all studies published from 1960 to July 2014 that examined treatment with digoxin compared with placebo or no treatment. The objective was to clarify the impact of digoxin on death and clinical outcomes across all randomised controlled trials.

There were 52 studies systematically reviewed, made up of 621 845 patients. In general those using digoxin were older and sicker than the controls.

They had a lower ejection fraction, more diabetes and greater use of diuretics and anti-arrhythmic drugs.

The meta-analysis included 75 study analyses, with a combined total of 4 006 21 patient years of followup. What was noticeable was that the baseline differences between treatment groups had a significant

D

effect on the mortality associated with digoxin, including markers of heart failure severity such as the use of diuretics. igoxin has been

consistent with these findings, showing

Studies with better methods and lower

in use since around

that digoxin improves symptoms and

risk of bias were more likely to report

1785, when it was

prevents clinical deterioration. However,

a neutral association of digoxin with

first introduced to

no such experimental trial data exist

mortality, and across all study types there

cardiology by William

for atrial fibrillation, and confusion

was a small but significant reduction

Withering. It is widely used for its positive

about whether digoxin is truly linked

in the all-cause hospital admission risk

inotropic effect in cardiac failure and

to adverse prognosis has led to the

among those using digoxin.

for its negative chronotropic effect

downgrading of digoxin in clinical

in atrial fibrillation – and, of course,

practice guidelines. Furthermore, the

digoxin? There are many who argue

the two conditions often go together.

finding that beta-blockers have no

against it, particularly because of its

However, its use has declined, partially

prognostic effect on patients with heart

narrow therapeutic index. But, particularly

because of concerns about safety after

failure and concomitant atrial fibrillation

in the sick elderly, its side-effects seem to

observational studies reported increased

has again led to questions as to what

be far more tolerable than more modern

mortality with digoxin. However, the

alternatives clinicians have available.

anti-arrhythmics. This analysis seems to

largest randomised controlled trial of

There is therefore a clear imperative to

suggest that there is still a place for this

digoxin in heart failure (the DIG trial)

define the place of digoxin in the clinical

commonly used drug.

showed neutral effects on mortality

management of both heart failure and

and a reduction in admissions to

atrial fibrillation and to guide physicians

Ziff OJ, Lane DA, Samra M, et al.

hospital compared with placebo,

and patients with an indication for

Safety and efficacy of digoxin:

as well as a decrease in mortality

treatment with digoxin.

Systematic review and meta-analysis of

among those with low serum digoxin

This study, published recently

So, should we or should we not use

observational and controlled trial data.

concentrations. There were also several

in the British Medical Journal, is a

BMJ 2015;351:h4451. [http://dx.doi.

smaller randomised trials that were

systematic review and meta-analysis

org/10.1136/bmj.h4451]

H EALT H CARE GAZE TTE | NO VEMBER/D E C EMBER 2 0 1 5

HPV vaccination and pregnancy outcomes

By Bridget Farham

V

accination against the human papillomavirus (HPV) has very rapidly become part of the recommended vaccinations in the schedules of many countries, with millions of women receiving either the bivalent vaccine

against HPV types 16 and 18 or the quadrivalent vaccine against types 6, 11, 16 and 18. So far there are no major safety concerns for either vaccine, either from pre- or postlicensure studies or in reports from major drug and health bodies worldwide.

However, as pointed out in a recent article in the British Medical Journal, in 2010 the data safety monitoring board of the randomised bivalent HPV vaccination Costa Rica HPV Vaccine Trial (CVT) raised concerns about the effect of the vaccination on the risk of miscarriage in the parallel PApilloma TRIal against Cancer In young Adults (PATRICIA).

In a pooled analysis of the two trials, Wacholder and colleagues found no evidence supporting an increased risk of miscarriage for pregnancies conceived at least 90 days after vaccination using the bivalent HPV vaccine.

Their observation of an imbalance in miscarriage rates for pregnancies conceived within 90 days from vaccination in the bivalent HPV vaccination arm compared with the control arm did not allow investigators to “completely rule out the possibility of an increased risk among pregnancies conceived within three months of vaccination�.

This study was an observational long-term follow-up of a randomised double-blind trial combined with an independent unvaccinated population-based cohort in a single centre in Costa Rica. There were 7 466 women in the trial and 2 836 women in the unvaccinated cohort.

Women in the trial were assigned to receive three

pregnancies conceived less than 90 days from vaccination.

There was, however, an increased risk estimate for

doses of bivalent HPV vaccine (n=3 727) or the control

miscarriages in a subgroup of pregnancies conceived

hepatitis A vaccine (n=3 739). A crossover bivalent HPV

any time after vaccination, which may be an artifact of a

vaccination occurred in the hepatitis A vaccine arm at the

thorough set of sensitivity analyses, but since a genuine

end of the trial. Women in the unvaccinated cohort

association cannot totally be ruled out, this should

(n=2 836) received no vaccine. The main outcome was

nevertheless be explored further in existing and

the risk of miscarriage, defined as fetal loss within

future studies.

20 weeks’ gestation, in pregnancies exposed to bivalent HPV vaccine in less than 90 days and any time from

Panagiotou OA, Befano BL, Gonzalez P, et al. Effect of

vaccination compared with pregnancies exposed to

bivalent human papillomavirus vaccination on pregnancy

hepatitis A and pregnancies in the unvaccinated cohort.

outcomes: Long term observational follow-up in the Costa

The results showed that there is no evidence that the

Rica HPV Vaccine Trial. BMJ 2015;351:h4358 [http://dx.doi.

bivalent HPV vaccination affects the risk of miscarriage for

org/10.1136/bmj.h4358]

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ADDED VALUE References: 1. IMS, August 2015. 2. Duphalac Syrup Package insert S0 Duphalac Syrup®. Composition: Each 5ml of Duphalac Syrup contains 3,3 g lactulose. Reg.No. K/11.5/180. Pharmacological Classification: A. 11.5 Laxatives. Name and business address of license holder: Abbott Laboratories S.A. (Pty) Ltd. Abbott Place, 219 Golf Club Terrace, Constantia Kloof, 1709.

Tel: (011) 858 2000. Reg No. 1940/014043/07. For full prescribing information refer to package insert approved by the Medical Regulatory Authority.

Date of publication of this promotional material: October 2015. Promotional Material Reference Number: Duphalac - ZAEDULAC140215. www.duphalac.com

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S2 ALLERWAY 5. Each film-coated tablet contains levocetirizine dihydrochloride 5 mg. Reg. No. 43/5.7.1/0815 Please refer to detailed package insert for full prescribing information.

References: 1. Seema Rani, M.C. Gupta, Prem Verma, Dalbir Singh. A Comparative Study of Clinical Efficacy And Tolerability Of Second Generation (Cetirizine) and Third Generation (Levocetirizine) Antihistaminics in Seasonal Allergic Rhinitis. Available at: http://www.scopemed.org/?mno=30140. (Accessed 23/03/2015 2. Garg G, Thami GP. Comparative efficacy of cetirizine and levocetirizine in chronic idiopathic urticaria.

The journal of dermatological treatment 2007; 18(1):23-4. 3. Kapp A, Demarteau N. Cost Effectiveness of Levocetirizine in Chronic Idiopathic Urticaria. Clin Drug Invest. 2006;26 (1):1-11. Accessed via Medscape 01/06/2014. Available at: http://www.medscape.com/viewarticle/521307 4. Passalacqua G ,Canonica GW. A review of the evidence from comparative studies of levocetirizine and desloratadine for the symptoms of allergic rhinitis. Erratum in.Clin Ther.2005 Oct:27(10):1669 ZA/05/2015/Allerway/001

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