SAMJ Vol 105, No 3 (2015) by HMPG

MARCH 2015

VOL. 105 NO. 3

‘Over-servicing’, ‘underservicing’ and ‘abandonment’: What is the law?

181

Care and prevention of congenital disorders

186

Dementia in rural South Africa

189

Two-dose HPV vaccination is sufficient

191

Traumatic brain injury, the hidden pandemic

195

Kidney disease in methamphetamine users

199

Emergency care research priorities CME: Diagnosis and management of chronic kidney disease

202 232-238

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MARCH 2015

VOL. 105 NO. 3

FROM THE EDITOR

EDITOR Janet Seggie, BSc (Hons), MD (Birm), FRCP (Lond), FCP (SA)

160 The ch in children stands for cherish J Seggie 162

EDITOR EMERITUS Daniel J Ncayiyana, MD (Groningen), FACOG, MD (Hon), FCM (Hon)

EDITOR’S CHOICE

CONSULTING EDITOR JP de V van Niekerk, MD, FRCR

CORRESPONDENCE 164

Conflict of interest and regulatory authorities R Jobson, A Gray

164

Inaugural International Association of Student Surgical Societies Symposium N Rich

IZINDABA 165 168 169 170

Eastern Cape treatment dysfunction boosts virulent new XDR-TB strain Will Basson come out on top? Zuma’s legal advisors ‘led him astray’, turned healthcare professionals into criminals The risky lives of South Africa’s children: Why so many die or are traumatised

OBITUARIES/HULDEBLYKE 172 Ajay Makanjee 172 Alewyn Petrus Rossouw

DEPUTY EDITOR Bridget Farham, BSc (Hons), PhD, MB ChB SCIENTIFIC EDITOR Ingrid Nye, BSc TECHNICAL EDITORS Emma Buchanan, BA Paula van der Bijl, BA, HDipLib NEWS EDITOR Chris Bateman | Email: chrisb@hmpg.co.za CEO AND PUBLISHER Hannah Kikaya HEAD OF PUBLISHING Robert Arendse

SAMJ FORUM

PRODUCTION MANAGER Emma Jane Couzens

173

CLINICAL PRACTICE Carbohydrate loading in the preoperative setting L T Hill, M G A Miller

ART DIRECTOR Brent Meder

175

CLINICAL ALERT Recommendations for the treatment and prevention of malaria: Update for the 2015 season in South Africa L H Blumberg

ONLINE MANAGER Gertrude Fani

179

Chronic pancreatitis, depression and substance use disorders: A not uncommon combination C Y Jeppe, C P Szabo, M D Smith

181

MEDICINE AND THE LAW ‘Over-servicing’, ‘underservicing’ and ‘abandonment’: What is the law? D J McQuoid-Mason

EDITORIALS 183 The Global Status Report on Violence Prevention 2014: Where to for the South African health sector? C L Ward, G Lamb 185

Prevention of Liver Fibrosis and Cancer in Africa: The PROLIFICA project – a collaborative study of hepatitis B-related liver disease in West Africa J Howell, N G Ladep, M Lemoine, S Nayagam, P S Toure, M M Diop, J A Daveiga, A S Sall, G Lo, M M E Crossey, M R Thursz, S D Taylor-Robinson, M M Ka

186

Need for services for the care and prevention of congenital disorders in South Africa as the country’s epidemiological transition evolves H L Malherbe, A L Christianson, C Aldous

189

Dementia in rural South Africa: A pressing need for epidemiological studies C A de Jager, J A Joska, M Hoffman, K E Borochowitz, M I Combrinck

RESEARCH 191

The Vaccine and Cervical Cancer Screen project 2 (VACCS 2): Linking cervical cancer screening to a two-dose HPV vaccination schedule in the South-West District of Tshwane, Gauteng, South Africa L C Snyman, G Dreyer, C Visser, M H Botha, F H van der Merwe

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March 2015, Vol. 105, No. 3

DTP & DESIGN Carl Sampson

DISTRIBUTION MANAGER Edward Macdonald | Tel. 021-681-7085 HEAD OF SALES AND MARKETING Diane Smith | Tel. 012-481-2069 Email: dianes@samedical.org PROFESSIONAL ADVERTISING Bronlyne Granger | Tel. 021-681-7000 E-mail: bronlyne.granger@hmpg.co.za HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Dr M J Grootboom, Mrs H Kikaya, Adv. Y Lemmer, Prof. E L Mazwai, Dr M Mbokota, Mr G Steyn, Dr G Wolvaardt ASSOCIATE EDITORS Q Abdool Karim, A Dhai, N Khumalo, R C Pattinson, A Rothberg, A A Stulting, J Surka, B Taylor, M Blockman ISSN 0256-9574 Publisher website: www.hmpg.co.za SAMA website: www.samedical.org Journal website: www.samj.org.za

195

Traumatic brain injury, the hidden pandemic: A focused response to family and patient experiences and needs J Webster, A Taylor, R Balchin

199

Hypertension, end-stage renal disease and mesangiocapillary glomerulonephritis in methamphetamine users E S W Jones, B L Rayner

202

Emergency care research priorities in South Africa* D J van Hoving, B K Barnetson, L A Wallis

209

Oral v. pulse intravenous cyclophosphamide: A retrospective analysis of adverse events in a setting with a high burden of infectious disease* E Pretorius, M R Davids, R du Toit

Members of the Association receive the SAMJ only on request, as part of their membership benefit.

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Prevalence and causes of thrombocytopenia in an academic state sector laboratory in Soweto, Johannesburg, South Africa* J L Vaughan, J Fourie, S Naidoo, N Subramony, T Wiggill, N Alli

Subscriptions: Tel. 012-481-2071 E-mail: members@samedical.org

220

228

An investigation of fingerstick blood collection for point-of-care HIV-1 viral load monitoring in South Africa* T J Maiers, N Gous, M Nduna, S M McFall, D M Kelso, M J Fisher, K M Palamountain, L E Scott, W S Stevens

CONTINUING MEDICAL EDUCATION

232

GUEST EDITORIAL Chronic kidney disease A M Meyers

233

REVIEW Significance, definition, classification and risk factors of chronic kidney disease in South Africa A M Meyers

236

ARTICLES Diagnostic approach to chronic kidney disease* I P Naiker, A G Assounga, A M Meyers

237

Management of patients with chronic kidney disease* T Gerntholtz, G Paget, P Hsu, A M Meyers

237

Clinical aspects of chronic kidney disease* B van Rensburg, A M Meyers

List of contributors to the articles and information compiled by the National Kidney Foundation of South Africa† F du Toit

*Abstract only, full article available online. Available online only.

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The SAMJ is published monthly by the Health and Medical Publishing Group (Pty) Ltd, Co. registration 2004/0220 32/07, a subsidiary of SAMA. 28 Main Road (Cnr Devonshire Hill Road), Rondebosch, 7700 Tel. (021) 681-7200. E-mail: publishing@hmpg.co.za Website: www.samedical.org Please submit all letters and articles for publication online at www.samj.org.za © Copyright: Health and Medical Publishing Group (Pty) Ltd, a subsidiary of the South African Medical Association Use of editorial material is subject to the Creative Commons Attribution – Noncommercial Works License. http://creativecommons.org/licenses/bync/3.0 Plagiarism is defined as the use of another’s work, words or ideas without attribution or permission, and representation of them as one’s own original work. Manuscripts containing plagiarism will not be considered for publication in the SAMJ. For more information on our plagiarism policy, please visit http://www.samj.org.za/ index.php/samj/about/editorialPolicies Printed by Creda Communications

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March 2015, Vol. 105, No. 3

FIRST PUBLISHED IN 1884

The ch in children stands for cherish But South Africa (SA) does not cherish her children, in spite of their right to care and protection, enshrined in our Constitution’s Bill of Rights. Of course this failure occurs in a milieu of social tolerance of use of force and violence in the country as a whole, with high levels of family violence in the home, violence in the community, and violence at the hands of police and in schools (with frequent resort to corporal punishment[1]). Children from poorer households and from rural areas are particularly affected.[2] An editorial in this issue of SAMJ[3] informs us of the SA position in relation to other countries around the world in the Global Status Report on Violence Prevention 2014,[4] jointly released by the World Health Organization (WHO), the United Nations Development Programme and the United Nations Office on Drugs and Crime. Izindaba[5] features the harsh lives of SA’s children in this issue. ‘The risky lives of South Africa’s children: Why so many die or are traumatised’ reveals that 80% of children live in informal settlements (‘danger-filled environments’), and because of the widespread, tragic absence of the most effective risk-mitigating factor possible – their biological parents – they are highly vulnerable. Children need adults who will cherish them and on whom they can depend for love, care and, most of all, protection. But many of SA’s children are not raised within the conventional nuclear family … 14.6 million of our 18.5 million children have both parents known to be alive, according to Statistics South Africa’s General Household Survey of 2010,[1] only 6.0 million (one in three) aged under 18 years live with both their mother and father, 2.3 million have a mother alive but father deceased or unknown, 0.7 million have father alive but mother deceased or unknown, and 0.9 million have both parents either deceased or unknown. Of 12.4 million children in single-parent homes, the majority live with their mother, a fraction with their father, and the remainder with neither parent. Daily, thousands of children experience physical, sexual and/or psychological abuse. It is no comfort to learn that the scourge is a global one and rife in so-called sophisticated, developed countries such as the USA and the UK. In the USA, with a population of 360 million, 1 500 children (2012 statistics) die as a result of abuse.[6] SA, with a population of 55 million, a sixth of that of the USA, achieves the same: three children a day (1 200 a year) are murdered.[7] In the UK, sexual abuse (defined by the WHO as ‘the involvement of a child in a sexual activity that he or she does not fully comprehend, is unable to give consent to, or for which the child is not developmentally prepared and cannot give consent’) is rife, as recent news bulletins and the Home Office Secretary confirm, with one in 20 children subject to sexual abuse despite rigorous legal sanctions against perpetrators.[8] Everywhere, the youngest are most vulnerable.[2] The Teddy Bear Clinic in Johannesburg has dealt with cases of sexual abuse in very young children,[2] and there are statistics of rapes of children aged between 1 and 3 years.[9] Of female victims of rape, 85% had been raped when aged between 10 and 14 years.[10] Boys are not exempt – 3.5% of young men report having been raped by a man.[11] The perpetrator is typically known to the victim – a friend, a teacher,[12] or worse, a relative or household member, with sexual assault typically occurring in the child’s home.[7] Jewkes et al.[11] point out that ‘The numerous experiences of sexual harassment by male teachers (and male learners) confirm that it is a major problem in schools. The greatest concern is the teachers’ abuse of their power over the schoolgirls to gain sexual access to them. The teachers’ conspiracy to support each other is an indication of its pervasiveness. These experiences diminish the educational chances of girls.’

160

On rare, widely publicised occasions children are the perpetrators, but the Teddy Bear Clinic Constitutional Court case[13] decriminalised sexual conduct between adolescent consenting children aged under 16 years and placed a moratorium on the reporting duties of doctors and others. SA appears, in large measure, to have become inured to the horrors perpetrated against her children, and even seeks to rationalise that poverty is the cause. Why, invoking the lyric ‘I’m depraved on account of I’m deprived!’ (an exclamation by one of the youths serenading Officer Krupke in Leonard Bernstein and Stephen Sondheim’s ‘West Side Story’[14]), should deprivation be an excuse for depravity? Around the world poverty – in our own country resulting from high levels of parental unemployment – is one possible explanation, but child abuse occurs across all socioeconomic levels. Beyond poverty and unemployment, a look at the ‘ecology’ of SA’s communities reveals a multiplicity of adverse factors that render the neighbourhoods in which children live dangerous, and make crime and sexual violence easy for the perpetrator: failure of electricity and hence poor lighting; poor access to water, with children spending long hours collecting water and exposed along the route; the proliferation of shebeens in townships, and high levels of alcohol and substance abuse. The long-term mental, physical and social consequences of child abuse can be intuited:[6] damage to the eyes, brain and spinal cord resulting from shaken-baby syndrome; rib and long bone fractures; impaired mental development, depression and withdrawal; psychiatric illness (including depression, anxiety, anger, post-traumatic stress disorder and eating disorders); and academic underachievement, perhaps because of a greater tendency to attention deficit and/or hyperactivity disorder. A third of abused and neglected children develop chronic health disorders as adults, being more prone to suffer from allergies, arthritis, asthma, bronchitis, high blood pressure and ulcers, in addition to physical disabilities caused by the abuse. Add to these antisocial behaviours and a tendency to perpetrate (often violent) crime, which leads to arrest in youth and adulthood, and abuse of alcohol and drugs, with a majority of adults in drug treatment programmes having been abused as children. Abused children are more likely to experience teen pregnancy. A vicious cycle is established … abused and neglected children tend to go on to abuse their own children. The cost (estimated at USD124 billion annually in the USA[6]) to the SA fiscus is huge, as the editorial by Ward and Lamb[3] affirms. According to a KPMG report, violence against women alone costs the SA economy between R28.4 and R42.2 billion per year (0.9 1.3% of the GDP), before adding the costs of child welfare and protection, special-needs education, and demands on the health system and on law enforcement, the courts and prisons. There is hope … that ‘at the southern tip of the continent of Africa, a rich reward in the making … will and must be measured by the happiness and welfare of the children, at once the most vulnerable citizens in any society and the greatest of our treasures.’[15] A survey in progress has ‘massive potential to inform the design and delivery of inter ventions to reduce child maltreatment’.[3] Janet Seggie Editor

janet.seggie@hmpg.co.za

March 2015, Vol. 105, No. 3

FROM THE EDITOR

1. Statistics South Africa. General household survey 2010. Statistical release P0318. http://www.statssa. gov.za/publications/p0318/p0318june2010.pdf (accessed 5 January 2015). 2. Department of Social Development/Department of Women, Children and People with Disabilities/ UNICEF. Violence against children in South Africa. http://www.cjcp.org.za/uploads/2/7/8/4/27845461/ vac_final_summary_low_res.pdf (accessed 5 January 2015). 3. Ward CL, Lamb G. The Global Status Report on Violence Prevention 2014: Where to for the South African health sector? S Afr Med J 2015;105(3):183-184. [http://dx.doi.org/10.7196/SAMJ.9305] 4. World Health Organization. Global Status Report on Violence Prevention 2014. Geneva: WHO, 2014. (SA profile p. 195.) http://www.undp.org/content/dam/undp/library/corporate/Reports/UNDP-GVAviolence-2014.pdf (accessed 5 January 2015). 5. Bateman C. The risky lives of SA’s children: Why so many die or are traumatised. S Afr Med J 2015;105(3):170-171. [http://dx.doi.org/10.7196/SAMJ.9462] 6. Childhelp. https://www.childhelp.org/child-abuse-statistics/Childhelp (accessed 5 January 2015). 7. Mathews S, Abrahams N, Jewkes R, Martin LJ, Lombard C. Child homicide patterns in South Africa: Is there a link to child abuse? http://www.mrc.ac.za/policybriefs/childhomicide.pdf (accessed 5 January 2015). 8. National Society for the Prevention of Cruelty to Children. http://www.nspcc.org.uk/preventingabuse/child-abuse-and-neglect/child-sexual-abuse/sexual-abuse-facts-statistics/ (accessed 5 January 2015). 9. Vetten L, Jewkes R, Fuller R, Christofides N, Loots L, Dunseith O. Tracking Justice: The Attrition of Rape Cases through the Criminal Justice System in Gauteng. Johannesburg: Tshwaranang Legal

Advocacy Centre, Medical Research Council, Centre for the Study of Violence and Reconciliation. http://www.csvr.org.za/docs/tracking_justice.pdf (accessed 5 January 2015). 10. Jewkes R, Levin J, Mbananga N, Bradshaw D. Rape of girls in South Africa. Lancet 2002;359(9303):319321. [http://dx.doi.org/10.1016/S0140-6736(02)07530-X] 11. Jewkes R, Abrahams N, Mathews S, et al. Preventing rape and violence in South Africa: Call for leadership in a new agenda for action. MRC Policy Brief, November 2009. www.mrc.ac.za/gender/ prev_rapedd041209.pdf (accessed 5 January 2015). 12. Abrahams N, Mathews S, Ramela P. Intersections of ‘sanitation, sexual coercion and girls’ safety in schools’. Trop Med Int Health 2006;11(5):751-756. [http://dx.doi.org/10.1111/j.13653156.2006.01600.x] 13. McQuoid-Mason DJ. The Teddy Bear Clinic Constitutional Court case: Sexual conduct between adolescent consenting children aged under 16 years decriminalised and a moratorium on the reporting duties of doctors and others. S Afr Med J 2014;104(4):275-276. [http://dx.doi.org/10.7196/SAMJ.7653] 14. Officer Krupke in Leonard Bernstein and Stephen Sondheim’s ‘West Side Story’. https://www.youtube. com/watch?v=pq28qCklEHc (accessed 5 January 2015). 15. Nobel Lecture Acceptance and Nobel Lecture. Nelson Mandela’s Nobel Peace Prize acceptance speech, 10 December 1993. http://www.nobelprize.org/nobel_prizes/peace/laureates/1993/mandela-lecture_ en.html (accessed 5 January 2015).

S Afr Med J 2015;105(3):160-161. DOI:10.7196/SAMJ.9452

EDITOR’S CHOICE

Recognising and diagnosing chronic kidney disease: Part 1

For many reasons, general physicians find renal disease difficult to diagnose, understand and treat. The terms ‘chronic kidney disease’ (CKD) and ‘glomerular filtration rate’ – representing the renal function equation – have been introduced to clarify some of these difficulties. Unfortunately, these pivotal concepts are often poorly understood. CKD risks being unrecognised because there are no specific symptoms, and it is often not diagnosed or only diagnosed at an advanced stage. Tests for CKD are, however, simple and freely available. CKD and advancing chronic renal failure (CRF) are underdiagnosed generally, particularly in rural areas. At the same time, there is an alarming rise in the incidence of serious CRF. From global estimates, we can suppose that 5 million South Africans over the age of 20 have CKD, and the figure is almost certainly higher among black South Africans. In South Africa (SA), hypertension and diabetes, both diseases that are markedly influenced by lifestyle choices, are by far the main causes of CKD and CRF. This being so, the potential for prevention by early diagnosis and proper treatment to slow or minimise the progression of functional deterioration is huge. The annual cost of renal replacement therapy is approximately ZAR200 000 per patient for dialysis and about ZAR300 000 in the first year, and ZAR160 000 - 180 000 in subsequent years, for transplantation. The March CME is the first of a two-part series of articles derived from the National Kidney Foundation of South Africa guidelines for the diagnosis and management of CKD. April will carry the second part of these guidelines. The intention is to help generalists be aware of this heterogeneous condition, diagnose and manage it to the best of their ability, and mitigate the burden of disease that CKD represents.

Effects of methamphetamine abuse on the kidneys and blood pressure

Methamphetamine abuse has risen dramatically in SA, particularly in the Western Cape Province and by young people of lower socioeconomic status and educational level. Methamphetamine is relatively easy and inexpensive to produce, making it readily accessible. A closely related amphetamine, known as Ecstasy, initially used as an appetite suppressant, rapidly became a recreational drug used in dancing clubs and was found to cause hyperthermia, dehydration and rhabdomyolysis, and an increased risk of acute renal failure. The toxic effects of amphetamines include cardiomyopathy, ischaemic heart disease, aneurysm formation, seizures, psychosis, hallucinations, stroke, hyperthermia, rhabdomyolysis, pulmonary hypertension, systemic hypertension, acute renal failure and hepatocellular damage. There have been isolated reports of adverse renal effects, including necrotising renal vasculopathy, an exaggerated decline in renal function over a 15-year follow-up of patients who used methamphetamines, a higher serum creatinine level 1 year after transplant in recipients from donors who had used methamphetamines, and early graft loss of two kidneys from donors who had used methamphetamines. The chronic effects of methamphetamine abuse on the kidneys and blood pressure have not been documented. Jones and Rayner[1] reviewed patients referred for evaluation of kidney disease and/or hypertension who had been abusing methamphetamines and whose mean age was just 29 years, and concluded that methamphetamine use is associated with severe hypertension, half of the subjects fulfilling criteria for malignant hypertension and mesangiocapillary glomerulonephritis that rapidly evolves to end-stage renal disease.

Preventing liver fibrosis and cancer in Africa

As is well recognised, hepatitis B virus (HBV) infection is endemic in sub-Saharan Africa (SSA), and the HBV-related disease burden is high.

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The lifetime risk of HBV infection is >60%, and >8% of those infected remain chronic HBV carriers who are at risk of progressive liver disease and HBV-related hepatocellular carcinoma (HCC). SSA has one of the highest HBV-related liver cancer rates in the world, as it is the most common cancer among males and third most common among females. Unfortunately, HCC is usually a highly aggressive tumour with limited treatment options, particularly in resource-poor settings, such as SSA. Furthermore, HBV-related HCC affects patients in their working and reproductive years. The achievements of a collaborative research project, the PROLIFICA project, are outlined in an editorial entitled ‘Prevention of Liver Fibrosis and Cancer in Africa: The PROLIFICA project – a collaborative study of hepatitis B-related liver disease in West Africa’.[2] So far the project has succeeded in achieving capacity building in each of the three countries (The Gambia, Sénégal and Nigeria) involved in the study. Local health infrastructure has benefited from new technologies, such as the Fibroscan to assess liver fibrosis using ultrasound-based transient elastography, a mass spectroscopy system in The Gambia for local biomarker research, and the development of in-house laboratory assays, as well as skills transference for improved liver cancer healthcare, in West Africa. Local nursing, medical and laboratory staff have benefited from training, education and employment opportunities. Procedures and training in effective and secure data management and ethical research practices have been a central part of the PROLIFICA platform. Local researchers have availed themselves of specialised academic mentorship at each of the three sites involved in the study to obtain higher research degrees and academic publications. Finally, community education on HBV infection, mode of transmission and prevention is also likely to have had a positive impact on HBV awareness, at both community and political levels. Above all, the PROLIFICA platform has facilitated the development of strong relationships for future research collaborations and a deeper under standing of the barriers to improved healthcare delivery in Africa.

The Vaccine and Cervical Cancer Screen project 2

This issue of SAMJ carries the third in the series of articles dealing with HPV and cervical cancer, ‘The Vaccine and Cervical Cancer Screen project 2 (VACCS 2): Linking cervical cancer screening to a two-dose HPV vaccination schedule in the South-West District of Tshwane, Gauteng, South Africa’.[3] This study again provided the opportunity to investigate the outcome of cervical cancer screening in mothers and guardians by linking this to the vaccination of the girls in their care. Female parents and guardians of primary school girls were invited to take part in self-administered HPV screening, the screen kit consisting of a sample collector with user instructions available as an Evalyn brush. Linking self-testing HPV screening to HPV vaccination proved a promising alternative to the current screening policy, although greater uptake rates are required. Given the effective communication of results via the school system and using mobile phone technology, large numbers of women can potentially be screened without impacting on the over-burdened primary care services.

Dementia in rural SA: A pressing need for epidemiological studies

With older age being a major risk factor for dementia, the increasing numbers of older adults worldwide will increase demand for services to diagnose, treat and care for people with dementia. Little is known about the prevalence of dementia or its impact on older adults living in low- and middle-income countries (LMICs) in Africa, including SA. Furthermore, research into the aetiology and risk factors in LMICs is scant. The need for studies to investigate these factors in SA is therefore critical, say De Jager et al. [4]

March 2015, Vol. 105, No. 3

EDITOR’S CHOICE

Alzheimer’s disease is the most common form of dementia in older adults and possibly contributes to 60 - 70% of cases. Other major varieties include vascular dementia, dementia with Lewy bodies and frontotemporal dementia. In SA, disorders associated with neurodegeneration such as traumatic brain injury (TBI), alcohol dependence and HIV infection are affecting increasing numbers of older adults. There is also a growing burden of disease from non-communicable diseases such as diabetes, heart disease and obesity resulting from increasingly unhealthy lifestyles and diet, which contribute to dementia risk.

TBI: The hidden pandemic

Few resources are available for the rehabilitation of TBI patients in SA, and access to rehabilitation facilities in the public sector is limited. TBI can require a long and arduous recovery process, and many survivors are left with permanent physical, emotional and cognitive disabilities. Perhaps unsurprisingly, TBIs from interpersonal violence are largely inflicted by right-handed perpetrators, which results in frontal lobe and/or left temporal lobe injuries. The neurocognitive and behavioural sequelae of frontal lobe injuries include poor judgement, impaired problem-solving ability and loss of the ability to think abstractly, poor organisational skills, loss of inhibition and impulsive behaviour, aggression, personality changes, depression, anxiety and reduced social skills. Left temporal lobe injuries can result in communication difficulties due to disorders of language (receptive aphasia), including loss of the ability to comprehend speech. These deficits have a disabling effect on survivors’ ability to cope with activities of daily living and with constructive engagement within their families and communities. Poor impulse control and weak social skills result in dangerous situations for survivors and for those around them. The experiences of TBI survivors and their family members as outlined by Webster et al.[5] served to inform the development of simple, integrated coping strategies, namely two ‘S-Plan’ tools, one for survivors and their

families/caregivers, and the other for care workers, in conjunction with counselling and support-group processes. The S-Plan constitutes a discharge resource to inform patients and their carers. Successful TBI support will not only benefit survivors and their family units, but can also contribute towards a reduction in future violent acts perpetrated by TBI survivors. The ComaCARE Trust is a non-profit organisation based at Groote Schuur Hospital in Cape Town. ComaCARE has been addressing the needs of survivors and families since 2005 by providing a psychosocial service that employs community caregivers in the acute-care setting. In 2012, recognising that TBI survivors are usually discharged into the care of an unprepared family unit, ComaCARE developed a brain injury prevention and family support service in Khayelitsha. This HeadsUP! Hub provides supportive intervention for families that involves counselling by social workers and training for families (to know what to do if their relative displays disruptive behaviour at school or the workplace, aggression, memory problems, anxiety, depression or sleep disturbances). For the next phase of this research, these integrated tools will be piloted from 2015 as part of a longitudinal research project to be conducted in under-resourced communities in Cape Town. JS 1. Jones ESW, Rayner BL. Hypertension, end-stage renal disease and mesangiocapillary glomerulonephritis in methamphetamine users. S Afr Med J 2015;105(3):199-201. [http://dx.doi.org/10.7196/SAMJ.8731] 2. Howell J, Ladep NG, Lemoine M, et al. Prevention of Liver Fibrosis and Cancer in Africa: The PROLIFICA project – a collaborative study of hepatitis B-related liver disease in West Africa. S Afr Med J 2015;105(3):185-186. [http://dx.doi.org/10.7196/SAMJ.8880] 3. Snyman LC, Dreyer G, Visser C, Botha MH, van der Merwe FH. The Vaccine and Cervical Cancer Screen project 2 (VACCS 2): Linking cervical cancer screening to a two-dose HPV vaccination schedule in the South-West District of Tshwane, Gauteng, South Africa. S Afr Med J 2015;105(3):191194. [http://dx.doi.org/10.7196/SAMJ.8888] 4. De Jager CA, Joska JA, Hoffman M, Borochowitz KE, Combrink MI. Dementia in rural South Africa: A pressing need for epidemiological studies. S Afr Med J 2015;105(3):189-190. [http://dx.doi. org/10.7196/SAMJ.8904] 5. Webster J, Taylor A, Balchin R. Traumatic brain injury, the hidden pandemic: A focused response to family and patient experiences and needs. S Afr Med J 2015;105(3):195-198. [http://dx.doi. org/10.7196/SAMJ.9014]

UNIVERSITY OF OXFORD, ENGLAND

OXFORD NUFFIELD MEDICAL FELLOWSHIP 2015/16 Applications are invited for an award under the Scheme for Oxford Nuffield Medical Fellowships normally to be held in a department within the Medical Science Division of the University. This prestigious fellowship carries an allowance of £41 564 (plus any cost of living increases). This allowance is subject to UK tax. The Trustees will also pay direct, economy class return air fares for the appointee, his/her spouse and children up to the age of 18 years. A generous baggage allowance is also provided. Applicants should have graduated from one of the universities listed below and should either hold a medical qualification or have appropriate research experience. There is no limit as to age or status. The fellowship is tenable for two years in the first instance, with the possibility of an extension for a third year. Fellows are expected to return to South Africa at the end of the fellowship to continue to do work of a similar nature. The award is available from 1 October 2015 or, subject to consultation with the University’s Medical Sciences Office and the department concerned, from such other later date as may be agreed. The next round of Nuffield Medical Fellowship for South Africa will be in 2016/17. If the fellow requires a visa to come to the UK, a Tier 5 Temporary Worker Visa (http://www.admin.ox.ac.uk/personnel/permits/tier5/ temporaryworkers/) will be sponsored by the University to allow the fellow to undertake Collaborative Research (only). Supplementary employment (such as clinical work) might be permitted only if the specialty is listed by the UKBA as a shortage occupation (Medical practitioners – 2211) (see http://www.ukba.homeoffice.gov.uk/sitecontent/documents/workingintheuk/shortageoccupationlistnov11. pdf ). Please note that the visa regulations are constantly updated by the UK Border Agency.

Participating universities University of Cape Town, University of Limpopo, University of KwaZulu-Natal, University of the Free State, University of Pretoria, Stellenbosch University h, University of the Witwatersrand. Further information may be obtained from Ms Nandie Makatesi (nandie.makatesi@uct.ac.za). Details of the research interests of those departments in which the fellowship may be held may be obtained at the website http://www.ox.ac.uk/divisions/medical_sciences.html

Candidates must provide a letter describing their plans and proposed work at the University of Oxford (prior contact with suitable academic hosts at the University is highly recommended), as well as a full curriculum vitae and the names of at least three contactable referees. These should be sent, only via e-mail, to Ms Nandie Makatesi at nandie.makatesi@uct.ac.za by

no later than 31 May 2015.

CORRESPONDENCE

Conflict of interest and regulatory authorities

To the Editor: Parrish and Blockman[1] make excellent points about conflict of interest (COI), particularly in the context of ‘medical leadership’. As key opinion leaders themselves (both are members of the National Essential Medicines List Committee (2013 - 2015), as is the second signatory to this letter – the term does not imply membership of an advisory panel to any for-profit vendor of healthrelated goods or services), the authors are well placed to make comments. An aspect of COI not considered in their article relates to regulatory authorities. Managing COI effectively is a regulatory concern internationally.[2,3] The most explicit legislation about COI, of all the Acts controlling statutory health councils, is the Medicines and Related Substances Act.[4] Section 6 of this Act has the heading ‘Disqualifications, vacation of office, filling of vacancies and declaration of interest’. Subsection 1(d) unequivocally states that ‘No person shall be appointed as a member of the council – who is employed in the pharmaceutical industry.’ Parrish and Blockman point out the shortcomings of ‘disclosure’ as an intervention for dealing with COI. The Medicines Act goes further than disclosure, and demands, in sub-section 6(4), that a Council or Committee member ‘shall recuse’ themselves ‘from any discussion or decision-making to which the said interests relate or may relate’[4] (our emphasis). Unfortunately these clear directives do not appear in the Medicines and Related Substances Amendment Act, 2008 (Act 72 of 2008), or in the Medicines and Related Substances Amendment Bill (Bill 6 of 2014). Once brought into effect, these legislative instruments will replace the Medicines Control Council with a South African Health Products Regulatory Authority (SAHPRA). Section 34, the ‘preservation of secrecy’ clause, remains, as do deficiencies in the description of the roles of advisory committees; and whether their advice to the authority will routinely be made public (with the necessary redaction of commercially sensitive information). It is vital that the employees of this new authority should not have any commercial interests related to the pharmaceutical, foods, cosmetics, medical devices or in vitro diagnostics industries. The members of ‘expert committees’ envisaged for the new authority should not be employed by these industries. Apart from declaring their interests, members of such committees should recuse themselves from ‘any discussion or decision-making to which the said interests relate or may relate’. Whether or not such members actually leave the room for the duration of such discussion should be a policy decision of SAHPRA. How transparently declarations of COI are shared publicly also requires careful consideration.

Inaugural International Association of Student Surgical Societies Symposium

To the Editor: A noteworthy event for global undergraduate surgical education took place when the University of Cape Town Student Surgical Society successfully hosted the inaugural International Association of Student Surgical Societies (IASSS) Symposium. The IASSS is a recently established global surgical society with the objectives of creating an international movement to represent the needs of surgical societies, developing partnerships between these societies across the globe, and facilitating surgical open education, surgical electives and undergraduate research. While students run the society, the IASSS is fortunate to be able to call on the mentorship of patrons Profs Del Kahn (UCT) and Georges Azzie (University of Toronto). The symposium was held at UCT on 7 - 10 July 2014, and had an exceptional turnout of 115 undergraduate delegates from five continents and 15 countries. The theme of the symposium was ‘Pioneering in surgery’, and delegates were treated to a programme filled with engaging talks by world-renowned speakers, practical workshops, a high-quality research competition and an intriguing debate on surgical training in developing v. developed countries. Some highlights of the programme included talks on ‘The scope of ENT surgery’ (which included a live endoscopic cadaver dissection) by Dr Darlene Lubbe and ‘The brains for neurosurgery’ by Prof. Anathony Figaji, and a workshop on FATE (focused assessment with trans-thoracic echocardiography) and eFAST (extended focused assessment with sonography for trauma). The symposium afforded the perfect forum for networking with tomorrow’s leaders in surgery, fostering collaboration between societies and sharing of ideas. This was illustrated by a student-led transcontinental multicentre research study that is currently in process. Among many guests, the symposium hosted Prof. Sats Pillay, Treasurer of the International Surgical Society (ISS/SIC), which has endorsed the IASSS as being ‘in line with the ISS/SIC endeavours’. With an official IASSS surgical journal, the Journal of Surgical Sciences, established and the next symposium already being planned, the future looks bright for the IASSS and student surgical education. Medical Student, University of Cape Town, and Treasurer, IASSS and UCT Surgical Society, 2014 10nicholas.rich@gmail.com

Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, Durban, South Africa

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Nicholas Rich

Roy Jobson

Dr George Mukhari Academic Hospital and Sefako Makgatho Health Sciences University, Medunsa campus, Ga-Rankuwa, Gauteng, South Africa royjobson@gmail.com

Andy Gray

1. Parrish A, Blockman M. Who will guard the guards? Medical leadership and conflict of interest in South African healthcare. S Afr Med J 2014;104(11):757-758. [http://dx.doi.org/10.7196/SAMJ.8546] 2. Watson R. European Medicines Agency is accused of weakening its conflict of interest policy. BMJ 2014;349:g7431. [http://dx.doi.org/10.1136/bmj.g7431] 3. EMA. European Medicines Agency policy on the handling of declarations of interests of scientific committees’ members and experts. EMA/626261/2014. http://www.ema.europa.eu/docs/en_GB/ document_library/Other/2014/11/WC500177253.pdf (accessed 17 December 2014). 4. Medicines and Related Substances Act, 1965 (Act No. 101 of 1965). http://www.mccza.com/ genericDocuments/Act_101_of_1965_published_2003.pdf (accessed 17 December 2014).

S Afr Med J 2015;105(3):164. DOI:10.7196/SAMJ.8892

March 2015, Vol. 105, No. 3

IZINDABA

Eastern Cape treatment dysfunction boosts virulent new XDR-TB strain At least half of all known drug-resistant tuberculosis (DR-TB) patients in the Port Elizabeth area (and possibly the entire Eastern Cape) are being treated with too few drugs, fuelling the spread of extensively drug-resistant (XDR)-TB and condemning them to death. Similar dynamics, though not quite as alarming, pertain in KwaZulu-Natal and to a lesser extent in the Western Cape. An atypi cal (Beijing) strain of multiple-drug-resis tant (MDR)-TB, first detected by researchers at Stellenbosch University 2 years ago, is being created via a ‘one-size-fits-all’ system of de centralised, nurse-led TB clinics with an insufficient array of drugs and wholly inadequate expertise. In the Eastern Cape, the situation is being worsened by a woeful lack of local political will and/or understanding – resulting in a virulent, ‘export-ready’ budgetcrippling potential domestic time bomb. Researchers spoken to by Izindaba say that patients carrying this ‘aberrant’ pre-XDR MDR strain and/or the ensuing full-blown XDR are being detected in significant numbers in the Western Cape metropole, the primary destination for the Eastern Cape’s huge migrant worker population. The Beijing strain is one mutation away from XDR and is being driven by treatment with an insufficient array of drugs. Izindaba has reliably learnt that the National Health Laboratory Service (NHLS) in Port Elizabeth conducted a Line Probe Assay (using the latest Hain LifeSciences technology) on two locally predominant MDR-TB strains, one in particular (Beijing) described as ‘pre-programmed to become XDR’. The conclusion of their lab technicians? The Port Elizabeth (PE) metropole, in parti cular, has a ‘real problem’.

In the Eastern Cape, the situation is being worsened by a woeful lack of local political will and/ or understanding – resulting in a virulent, ‘export-ready’ budgetcrippling potential domestic time bomb.

When slower is better

‘It appears to be fuelled by our patients being put onto a standard regimen of treatment in which very few drugs are effective,’ one

source said. An infectious diseases doctor working in the Eastern Cape explained that nurses could wait for up to 6 weeks for culture results to confirm the DR strain. This ‘archaic’ confirmation followed the 2-hours-or-less GeneXpert result confirming rifampicin resistance. While the samples were at the laboratory to confirm or identify additional resistance markers by culture, nurses and doctors were ‘blindly’ putting patients onto standard MDR-TB treatment – inadequate to treat many of the circulating strains and thus amplifying resistance. Médecins Sans Frontières (MSF) is strengthening its MDR drug regimen in the Western Cape, leading the way in combating this new pre-XDR strain. (National policy on TB treatment is to get as many patients onto treatment as soon as possible and to refer patients, but some experts believe there is insufficient emphasis on, and education about, the multiple complexities of drug resistance.) The national guidelines encourage NGOs and provincial clinics to promote nurse-initiated DR-TB treatment based on single GeneXpert results. However, most healthcare workers, including many doctors, do not understand how to tailor MDR treatment based on mutational analysis, resulting (in the case of the Beijing strain) in the rough equivalent of pouring petrol onto a veld fire, the Izindaba sources claim.

First doing more harm …

One as yet unpublished research paper on the aberrant MDR-TB strain shows that 25% of the PE laboratory samples examined are pre-XDR and 25% are full-blown XDR – clearly demonstrating that half of all the cases scrutinised are being inadequately/ incorrectly treated. A doctor source at the coalface explained that ‘essentially treatment has selected this strain out – the issue here is the current system not dealing with the current problem’. He said that infrastructure issues, misguided provincial budget allocation, insufficient training and staff, and a general lack of MDR treatment knowledge on the part of both nurses and doctors aggravated matters. The latest available data from the Jose Pearson TB Hospital in PE show that in 2011, just 35% of MDR TB patients who completed 24 months of treatment remained cured after a year, while only 12% of XDR-TB patients who

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completed 24 months of treatment remained cured a year later. In 2012, this treatment ‘success’ for MDR patients dropped to 29% and for XDR patients to 9%. This is roughly in line with much of the published data. (The implication is that the remainder have died, will die or have been lost to follow-up, unless the debilitated survivors can quickly access the latest drugs now coming on line – bedaquiline and linezolid.) According to the treatment register at the Jose Pearson TB Hospital, there were 24 confirmed cases of XDR-TB (of which 17 were HIV-positive) in the last quarter of last year. The number of patients started on treatment in the first quarter of 2014 was 48. The hospital sees up to 15 new cases of XDRTB per month, draining a huge area in the western part of the province – from Graaff Reinet to Port Alfred and from Humansdorp to Kareedouw. The clinicians emphasised that this probably represents the ‘tip of the iceberg’ in terms of actual MDR/XDR-TB prevalence. Many TB sufferers never make it to a clinic or present too late, having ignored the initial night sweats or the persistent cough. ‘TB is a classic for presenting too late. Active case finding needs to be drastically addressed,’ says Prof. Rob Warren, associate professor in the Department of Medical Biochemistry at Stellenbosch University, whose team first identified the aberrant preXDR-TB Beijing strain at the heart of the latest development.

Prof. Rob Warren, associate professor in the Department of Medical Biochemistry at Stellen bosch University.

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IZINDABA

‘A tide … when taken at the flood …’

The Eastern Cape coalface doctor warned: ‘We’re at a crossroads. If we don’t have a complete revamp of how we approach this problem, we’ll lose a golden opportunity to really make a difference. We have a threshold; something needs to be done now. If we continue blindly on, we’ll expand resistance to the new drugs we have ...’ Chief among the solutions, he believes, is a centralised system to allow the appropriate use of new drugs in a regulated manner based on better diagnostics with good monitoring and follow-up (at least until better training and systems are in place to allow more widespread use of the new drug resources). He said patients needed to be put on the correct therapy as soon as possible, with much-improved case-finding and follow-up.

Eastern Cape a TB treatment ‘black hole’

One doctor typified the Eastern Cape (when compared with the other high-TB-burden provinces of the Western Cape and KwaZuluNatal) as ‘a black hole – it’s left up to poorly trained people to implement a very difficult programme’. The historical/political context is showing. The other two provinces have ‘a lot of academic research going on and use their resources more efficiently. In the Eastern Cape programmes are poorly applied and badly implemented – to the point where they don’t work. My sense is that things are getting worse.’ Eastern Cape doctors said that staff shortages and a lack of ongoing monitoring have rendered contact tracing and follow-up wholly ineffective. Warren’s team found that the Beijing MDR/XDR-TB strain was causing a huge amount of primary transmission, not only within a specific HIV-positive cohort of patients, but across the board. His team’s research centres on novel strategies to reduce the time-to-detection period of both drugsensitive and DR-TB – and to understand the causative agents of the disease better. Their goal is to ‘develop a foolproof diagnostic method that can be used by anyone, anywhere’.

TB diagnosis ‘behind the research curve’

The current TB diagnostic method remains an arduous process that requires the patient to present to the health facility for screening, diagnosis and treatment. Sputum samples are sent to a peripheral laboratory for GeneXpert testing and to a central laboratory for drug susceptibility testing. The patient is therefore not present when the results arrive. Up to 20% of patients do not return at all for their results, and even top government TB Directorate

XDR-TB on the increase nationally

Prof. Keertan Dheda, Head of Pulmonology, Uni versity of Cape Town and Groote Schuur Hospital.

officials admit that the systems for tracing them are weak. On testing, Warren observed: ‘The tools are out there. There’s the first-line probe and then the probe for second-line drugs – if we implemented the second-line test, we could probably reduce the [laboratory test] turn-around time from around 50 days to 3 days.’ The test is not perfect yet (a reason given for its low use in spite of its being approved by the World Health Organization (WHO)), but it picks up over 80% of secondline resistance (both are Hain LifeSciences assays). Warren emphasised that in the South African (SA) TB ‘outbreak’ context, the success rate would probably be much higher because outbreaks generally contain the same mutations, making identification much easier.

Assuming proper adherence to national DR-TB management guidelines, the current per patient cost of XDR-TB is ZAR303 508 (USD26 392), four times greater than MDR-TB at ZAR77 878 (USD6 772), and 103 times greater than drug-sensitive TB at ZAR2 955 (USD257). An Izindaba canvassing of some top TB res earchers revealed that they do not necessarily have ‘the ear’ of the National Department of Health (NDoH). Said Warren: ‘Unfortunately there isn’t good liaison between research, and policy and practice. Things filter slowly through the academic journals into their expert group discussions where they may or may not take on an idea and put it forward.’

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Between 2007 and 2012, SA’s recorded cases of MDR-TB (i.e. resistant to at least two of the primary drugs used to combat standard TB) almost doubled. SA has the highest incidence of TB among the 22 high-burden countries (860/100 000), and when adjusted for population, it outdoes India and China. According to 2012 government figures, just 42% of patients diagnosed with MDR-TB began treatment. Observes Dr Gilles van Cutsem, MSF’s medical co-ordinator for SA and Lesotho: ‘We have in SA one of the only rising epidemics of drug-sensitive TB and DR-TB. And we’re not doing very well at detecting it and treating it.’ In a highly cited paper[1] co-authored by Prof. Keertan Dheda, Head of the Lung Infection and Immunity Unit in the University of Cape Town’s Lung Institute, the budgetary implications of not responding appropriately to the DR-TB challenge are daunting. Assuming proper adherence to national DR-TB management guidelines, the current per patient cost of XDR-TB is ZAR303 508 (USD26 392), four times greater than that of MDR-TB at ZAR77 878 (USD6 772), and 103 times greater than drug-sensitive TB at ZAR2 955 (USD257). Despite DR-TB’s comprising only 2.2% of the case burden, it consumed 32% of the total estimated 2011 national TB budget of ZAR2.5 billion (USD218 million). A frightening 45% and 25% of the DR-TB costs were attributed to anti-TB drugs and hospitalisation, respectively. XDR-TB consumed 28% of the total DR-TB diagnosis and treatment costs. Laboratory testing and anti-TB drugs comprised the majority (71%) of MDR-TB costs, while hospitalisation and anti-TB drug costs comprised the majority (92%) of XDR-TB costs. A decentralised XDRTB treatment programme could potentially reduce costs by ZAR79 695 (USD6 930) (26%) per case and reduce the total amount spent on DR-TB by 7%, the authors conclude.[1]

Dr Norbert Ndjeka, head of the National MDRTB Directorate.

IZINDABA

Dr Lindiwe Mvusi, National TB Directorate chief.

SA’s TB control ‘a comedy of errors’

Both Warren and Dheda have emphasised that unless the drug-susceptible ‘TB tap’ is turned off, DR-TB will continue to grow. Dheda’s work currently centres on creating an effective new combination regimen for DR-TB. In a paper published in the South African Respiratory Journal,[2] Warren and his co- authors bluntly say that their review of TB statistics ‘suggests that the current National Tuberculosis Control Programme is unable to curb the emergence and spread of this difficult-to-treat epidemic’. The country’s TB control history was ‘a comedy of errors’, which more modern technology could have helped avoid. ‘It is therefore essential that we learn from these mistakes and use current knowledge to design diagnostic algorithms and treatment guidelines that prevent acquisition of resistance and ensure improved treatment outcomes,’ they conclude.[2] Warren emphasised that he was not blaming anyone in the current national TB Directorate, but merely pointing to the treatment mistakes of the past that they were now saddled with. Neither Dr Norbert Ndjeka, head of the MDR-TB Directorate, nor Dr Lindiwe Mvusi, National TB Directorate chief, had seen the PE NHLS research paper – but they were eager to study it. Ndjeka said the national guidelines ‘clearly stated’ that the standard ised regimen was for newly diagnosed MDRTB patients only. MDR-TB patients exposed to second-line drugs, pre-XDR-TB and XDR-TB were treated with an ‘individualised regimen’ (however, Izindaba established that this was only after drug susceptibility results were made available after a wait that could take 6 weeks – again, it is in this time that patients are being ‘undertreated’). Ndjeka denied that many clinicians lacked sufficient knowledge, describing them as ‘well trained, and educated’. He said he was

due to hold a workshop with his provincial staff and clinicians in Johannesburg in midto late February – and invited Izindaba to bring Warren and its other sources to address them. He described the Jose Pear son Hospital MDR/XDR figures cited as ‘another gross inaccuracy’, saying last year’s WHO Global Tuberculosis Report had SA’s 2011 cohort analysis and that the 2012 report was still incomplete, but due for finalisation this April. Ndjeka said that SA was a ‘very high’ MDR-TB country, and his directorate had consulted the ‘best brains in the country’ on this issue. ‘We cannot work with each and everybody, though the top ones are in constant communication with us – I can provide proof of this,’ he asserted. He said that describing the country’s TB control history as a ‘comedy of errors’ was ‘malicious’. ‘We need experts who provide solutions, given the little existing evidence,’ he added. Mvusi conceded that the Hain Line Probe Assay, version 2, would ‘help greatly in reducing the waiting time for confirmatory first- and second-line drug suscep tibility testing because the patient could then be switched to the appropriate regimen earlier’. Ndjeka said that linezolid and bedaquiline were being introduced ‘in a very responsible manner’ in the public sector, SA being the first TB programme in the world to introduce new agents in about 40 years.

In the Eastern Cape, the situation is being worsened by a woeful lack of local political will and/ or understanding - resulting in a virulent, ‘export-ready’ budgetcrippling potential domestic time bomb.

Eastern Cape admits there’s a problem – but it’s ‘being addressed’

An Eastern Cape health department spokes man revealed that bedaquiline had already been ‘responsibly’ introduced at the Jose Pearson Hospital (and a few other selected hospitals nationwide), and ‘so far no adverse events have been reported’. TB clinicians across the country had just met to discuss the scale-up of linezolid and bedaquiline. The Jose Pearson Hospital ‘performance figures’ quoted by Izindaba were ‘acknowledged’, but the data were ‘currently being cleaned up to April this year before being submitted as final to the WHO’. He said that the province had a very high MDR-TB burden and admitted

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that treatment outcomes were poor – but a ‘lot of progress’ in managing the disease had been made in recent years. The NHLS had produced evidence that positive GeneXpert rifampicin-resistant cases were more likely to be MDR-TB, ‘hence our guidelines recommend starting MDR-TB treatment, taking a sample for confirmatory test through the Line Probe Assay or conventional drug susceptibility testing’. He repeated the NDoH assertion that MDR-TB patients exposed to second-line TB drugs, pre-XDR TB patients and XDR-TB patients were treated with an individualised drug regimen. An expert provincial MDR-TB committee met every quarter to review and discuss complicated cases and facilitate/regulate access to the new drugs. The reported increase in DR-TB in the province between 2007 and 2012 was actually an indication of intensified case finding and better diagnostic technology. Active steps to address the challenges inclu ded partnering with the NHLS to improve the response to positive DR-TB results with rapid follow-up diagnostics. The DR-TB decentralisation programme involved ten hospitals, with intensive training of health care workers on MDR-TB management being accelerated, while outreach vehicles had been hired to address late presentation of patients and improve case finding and contact tracing. Four hospitals were either under construction or renovation to comply with national infection prevention and control guidelines. Although Izindaba did not source its most alarming data directly from the PE laboratory, technicians there received a stern warning: ‘Permission is required to conduct research or make use of departmental data/ information – this being granted only on condition that these findings are shared with provincial health management before being presented on any platform.’ Izindaba has chosen to withhold the names of some of its Eastern Cape sources, who said they fear becoming targets of angered local officialdom – historically a common anxiety among that province’s many deeply committed healthcare workers. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2015;105(3):165-167. DOI:10.7196/SAMJ.9475 1. Pooran A, Pieterson E, Davids M, Theron G, Dheda K. What is the cost of diagnosis and management of drug resistant tuberculosis in South Africa? PLoS One 2013;8(1):e54587. [http://dx.doi.org/10.1371/journal.pone.0054587] 2. Warren RM, Hoek K, Sirgel F, et al. Emergence and treatment of drug resistant tuberculosis: A comedy of errors. South African Respiratory Journal 2011;16(4):112-116.

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IZINDABA

Will Basson come out on top? The seasoned legal team of apartheid-era chemical warfare expert and top cardiologist Dr Wouter Basson will within a fort night ask the Medical and Dental Prof essions Board (MDPB) committee that found him guilty of violating basic medical ethics to recuse itself entirely.

Prof. Jannie Hugo.

This follows their having secured a High Court injunction on 19 January to halt Basson’s professional conduct sentencing hearing so they could prepare an application to the committee to recuse itself, claiming that its two members signed or approved of at least one of about 30 petitions calling for Basson to be struck from the medical register of the Health Professions Council of South Africa (HPCSA). The MDPB (one of the many HPCSA boards) committee last year found Basson guilty of unprofessional conduct, saying that he ‘defiled the unique and sacred position of doctors’ by actively furthering warfare via the production, distribution and use of teargas and drugs against the apartheid regime’s enemies some 30 years ago. The HPCSA, charged with ‘guiding the professions and protecting the public’, has taken 7 years to get to this point, in a roller-coaster ride of legal technicalities and procedural delays. Now there is the possibility that should Jaap Cilliers, SC, the veteran legal counsel of several high-profile right-wing court victories, succeed in getting the committee to reluctantly recuse itself, the entire hearing will have to start from scratch – either that, or new committee appointees will have to pick up the hearing where it left off in January (i.e. witnesses testifying in aggravation of sentence, the central theme of which was Basson’s demonstrable lack of any remorse for

his actions). On 12 and 13 March, Basson’s legal team will try to provide compelling evidence to committee chairperson Prof. Jannie Hugo and committee member Prof. Eddie Mhlanga (both advised by retired former Judge President Fritz Eloff) that they signed or approved of any one of the many petitions calling for Basson to be struck from the medical register. The defence team have also argued that Hugo’s and Mhlanga’s ‘conduct’ after it asked them whether they were members of any organisation that signed an anti-Basson petition is a telling factor in support of their recusal application. The unspoken threat of yet another Cilliers High Court application will perforce focus the minds of the committee. In his response to the successful High Court defence application, Hugo admitted that he was a member of the Rural Doctors Association of South Africa and the South African Medical Association, both of which circulated strongly worded petitions calling for Basson to be struck from the medical roll. However, he denied ever signing any petition or taking part in formulating any of them. He said that the reason was simple: ‘I could not allow myself to be influenced by and/or participate in processes relevant to the issues to be determined in the proceedings, which were occurring outside the hearings.’ Mhlanga did not submit anything to the High Court about membership of any of the organisations that circulated ‘anti-Basson’ petitions, but Hugo testified that Mhlanga had informed him that his response was identical to his own. Judge A J Bam said that both Hugo and Mhlanga were constitutionally obliged to furnish a proper explanation of their possible involvement and/or knowledge of the petition to Cilliers. Their refusal to do so was not justified, and was irregular. Judge Bam ordered the HPCSA to pay the costs of the application.

Walk-out drama precedes High Court intervention

The impending recusal move is without precedent in the HPCSA’s history of professional conduct hearings, and may well lay bare its often controversial and sometimes dysfunctional processes – at least as much as whether its professional conduct committee conducted itself towards Basson with any historical bias. There was drama during the January hearing when the pro forma complainant (the HPCSA) called a fresh witness in aggravation of sentence. Cilliers stood up and asked that proceedings be adjourned to enable him to prepare a recusal application, explaining why. Hugo refused, saying that proceedings should continue. Cilliers walked out of the hearing in protest, filing his

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High Court application. Basson, in testimony prior to his earlier acquittal on multiple charges of murder, fraud and drug dealing in his 2002 criminal trial (which earned the professionally highly regarded Durbanville cardiologist the moniker ‘Dr Death’), and the State’s subsequent failed appeal bids to the Supreme Court and the Constitutional Court (ending in 2005), has insisted that his conduct came within the context of war and conflict and that no proof was ever obtained that he caused harm or death. However, the professional conduct committee found that the ethical values of ‘beneficence, non-malificence, justice and autonomy’ had not changed since the time of his ethical offences, and that medical ethics were especially important in times of war and conflict. Hugo found that Basson had contravened both the Geneva Declaration of 1948 and the UN convention on the prohibition of and stockpiling of dangerous weapons. No doctor could claim ignorance of their expected professional behaviour, he added. Basson, while project officer of the 1980s and early 1990s secret ‘Project Coast’ and its military front teargas and drugs manufacturing company Delta G, co-ordinated the largescale production and stockpiling of Mandrax, ecstasy and teargas and provided ‘disorientating substances for cross-border kidnapping’. He also supplied cyanide suicide capsules to apartheid undercover operatives for use when captured – something the committee heard caused an agonising death, not the quick and painless demise of spy novels.

Cilliers’ colourful court career

Cilliers, regarded as one of the more able senior counsels by his peers, took on the so-called ‘generals case’ in the mid-1990s when former defence minister Magnus Malan and 20 senior military officers stood trial for murdering 13 people, some of them children, in the Kwa Makhutha township massacre of 1987. All were acquitted in a 1996 ruling that polarised black and white South Africa. Besides getting Basson acquitted of the criminal charges, Cilliers less successfully took on the case of Jewell Crossberg, the Limpopo farmer given a 20-year sentence for shooting dead a Zimbabwean farmworker, and that of the ‘Waterkloof Four’, young Pretoria men sentenced to 12 years for ‘cruelly’ murdering and assaulting a homeless black man. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2015;105(3):168. DOI:10.7196/SAMJ.9463

IZINDABA

Zuma’s legal advisors ‘led him astray’, turned healthcare professionals into criminals President Jacob Zuma’s legal advisors ‘led him astray’, resulting in him ‘irrationally’ signing into existence a law that crimin alised the provision of healthcare services in South Africa and flouted several provisions of the Constitution. That is the nub of the Constitutional Court’s 27 January finding after Zuma, his Minister in the Presidency Jeff Radebe, Minister of Health Dr Aaron Motsoaledi and National Health Director-General (DG) Precious Malebona Matsoso applied to have the controversial Certificate of Need (CoN) provisions deproclaimed.

‘Irrational’ – President Jacob Zuma on the CoN.

The earlier and premature proclamation brought into effect sections 36 - 40 of the National Health Act from April 2014, forcing tens of thousands of healthcare providers to apply to Matsoso for a CoN within a very narrow time frame (2 years), and making it impossible for her department to properly process and decide on the ‘appropriate’ geographical placement of each practitioner, or for her to consult widely before drafting appropriate regulations. It was always a nonstarter – in spite of the health department’s brave assertions to the contrary as multiple and furious healthcare organisations protested. Penalties for non-compliance included a jail term of up to 5 years.

CoN: not dead, just sleeping …

The law is not dead. It will be re-proclaimed, probably in toto, once a more pragmatic time frame has been written up, almost certainly leading to another High Court or

Constitutional Court application, this time by its adversaries. One or several of the more bold, cash-fluid healthcare bodies will probably argue that the CoN is a blunt instrument, giving almost unfettered power to the Health DG to restrict and control the placement of healthcare practices – or even effectively close them down, with unintended consequences including accelerating the overseas migration of newly qualified healthcare professionals, thus undermining the very National Health Insurance scheme the CoN intends to support. Government’s embarrassing legal somer sault brings into serious question the quality and competence of Zuma’s top legal advisors and the health department’s own legal architects, and/or the quality of communication between them and the country’s health policy implementers. It was left up to the South African Dental Association (SADA) to properly examine the ‘teeth’ of the legal provisions and warn the presidency that they were effectively criminalising all healthcare provision in the country (SADA and the Hospital Association of South Africa were cited as co-respondents in the Constitutional Court application, having brainstormed with several other healthcare bodies, including the South African Medical Association and the SA Private Practitioners Forum). All agree with government that better access to healthcare is vital and are willing to help address the geographical mismatch of services and patients – but differ strongly on the use of the CoN to do this.

Trust us, this is no ‘Con’

The protestors see the certificate as arbitrary and dictatorial, in spite of Motsoaledi’s and the DG’s repeated reassurances that they won’t use it to crowbar healthcare prof essionals in an over-served area out of their current practices. Motsoaledi is even on record as saying that the law will merely be used ‘incrementally’ to prevent new practitioners buying into already well-staffed practices in adequately served geographical areas. However, unlike several similar pieces of overseas legislation, it goes well beyond that, enabling any less enlightened future DG to strong-arm healthcare prof

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Director-General of Health, Precious Malebona Matsoso.

essionals, arguably in defiance of several Constitutional provisions. In agreeing with the government’s admission that its CoN proclamation was premature and irrational, the Constitutional Court judges said that the poor timing resulted in a failure to respect, promote and fulfil fundamental tenets of the Bill of Rights, including the right to life, the right of access to healthcare and the right to transparency and accountability. Zuma’s actions were described as ‘untenable and unintended’, and ‘ill-advised, irrational and thus invalid’. He was led astray by his legal advisors, who gave him mistaken counsel. Zuma didn’t know at the time that signing the proclamation into law was fruitless because nobody could apply for a certificate without the vital regulations being in place, nor could the regulations be drafted without widespread consultation. He was unable to withdraw the proclamation because the date for its commencement had long since passed and there was no mechanism contained in the Act itself to remedy the situation. The judges said that the other remedy – taking the parliamentary legislative amendment route – would be ‘lengthy and burdensome’ and would fail to address the ‘precarious position the health service industry finds itself in’. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2015;105(3):169. DOI:10.7196/SAMJ.9468

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The risky lives of South Africa’s children: Why so many die or are traumatised Of the 18.5 million children under the age of 18 in South Africa (SA), 8% have no fathers, 23% do not live with their biological parents, and 60% live in poverty – frightening figures that top local epidemiologists and clinicians agree help explain why the risk of a child dying here is ten times higher than in Europe.

Prof. Sebastian van As.

These figures emerged with the release of the annual South African Child Gauge report by the Children’s Institute at the Uni versity of Cape Town (UCT) in November 2014, and from an Izindaba interview with Prof. Sebastian van As, chief paediatric surgeon at Red Cross War Memorial Children’s Hospital in Cape Town, the only dedicated children’s hospital in the country. Since 1991, Red Cross Hospital has built up the world’s single largest data base on child trauma. The experts at both institutions agree that poverty and the widespread, tragic absence of the most effective risk-mitigating factors possible – one or both of a child’s biological parents – render the 8% of SA’s children living in urban informal areas the most vulnerable as they roam danger-filled environments, many bordered by highways, train routes or bodies of water. HIV/AIDS in the

pre-antiretroviral (ARV) era has left SA with one of the world’s largest orphan populations (3% being double orphans and 8% having no father). According to Katharine Hall, project leader of the Child Poverty Programme at UCT’s Children’s Institute, a major contributor to the Child Gauge, the overall orphan count rose dramatically from the early 1990s, with the graph currently levelling off (an indicator of how dramatically the introduction of ARVs has impacted on mortality). Hall emphasised that household survey data continued to show that children who were not living with their biological parents were ‘overwhelmingly in the care of other kin’ – a legacy of migrant labour and urban housing shortages. This was ‘not something that poor households can easily resolve’. An aggravating risk factor is that even those children lucky enough to have working parents or guardians are often left unsupervised as their primary minders leave in the early hours to eke out a living, and return home in darkness. Van As told Izindaba that a child younger than 6 years of age was insufficiently deve loped neurologically to properly assess the dangers around him or her, with the lack of sufficient child-minding facilities and crèches in the townships a major problem. He feels so strongly about this that he believes it should a criminal offence to allow a child to wander alone unsupervised: ‘If you let a dog roam free without a licence, you can be fined – but there’s no legal protection for kids.’ Asked about the ten times greater risk of an SA child dying v. a European one, Van As said this came from a World Health Organization country-by-country child mortality comparison. Three years ago his own unit had compared the relative risk of a child ending up in a Cape Town hospital v. a child being admitted to Birmingham Hospital in the UK. The data showed that there was a 25 times greater chance locally.

Ten times as many children die in accidents as are abused

SA was ‘anything but a child-centred society’, and the media attention on violence against children disguised the ‘true numbers’, which showed that ten times as many children died from accidental injuries as were violated.

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Just 5% (or 500) of the 10 000 children seen at Red Cross Hospital annually were physically or sexually abused. (According to Western Cape Health Department policy, Red Cross Hospital admits only children 13 years old and younger). Van As and his Red Cross team of two trauma and three orthopaedic consultants (backed by an average of 10 paediatric registrars) admit 3 000 children annually, 1 000 suffering from burns and 2 000 from a mixture of other injuries, the biggest overall killer being motor vehicle accidents. He said that poverty also drove malnutrition, which impeded neurological development, further hampering less-privileged children from reaching their full potential. The country’s violent past and the generational passing on of violent behaviour, aggravated by widespread poverty, meant that ‘we are world champions at killing children’, he observed. In the hour Izindaba spent interviewing him, Van As treated a child with 32 fractures (as a result of domestic violence between adults with the child being used as a ‘shield’, a common cause of severe trauma) and watched another die after the upper part of her torso had been kept alive for two days. Hit by a heavy-duty truck while walking on a township road, she had literally been torn in two.

The experts at both institutions agree that poverty and the widespread, tragic absence of the most effective riskmitigating factors possible – one or both of a child’s biological parents – render the 8% of SA’s children living in informal urban areas highly vulnerable as they roam danger-filled environments, many bordered by highways, train routes or bodies of water.

Violence learnt and passed on

The 2014 Child Gauge report, entitled Preven ting Violence against Children: Breaking the Inter-generational Cycle, found that over half of SA’s children frequently experience some

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form of violence from a very early age. This had long-term consequences that could be avoided by investing in prevention initiatives. While there was a paucity of systematic research on the extent and range of violent experiences, population-based prevalence studies showed that over half of children experience physical violence at the hands of a caregiver, teacher or relative. Incidents of sexual violence were under-reported – a ‘disturbing reality’ when considering that half of the 45 230 ‘contact crimes’ against children reported in the 2013/2014 crime statistics were sexual offences (an average of 62 cases per day). A two-province study found that one-third of participating children experienced emotional abuse. Emotional violence and neglect, and corporal and humiliating punishment of children, were ‘common in the home’, where abuse and neglect especially of young children could result in death. Physical punishment at schools was still ‘pervasive’ in spite of being banned for almost 20 years. Shanaaz Mathews, director of the Child ren’s Institute and lead editor of the 2014 Child Gauge report, said that these experiences hampered a child’s development, learning ability, self-esteem and emotional security and had long-term consequences for employment prospects and life expectancy. Hervé Ludovic de Lys, UNICEF’s SA representative, said that the current epidemic of violence undermines the fabric of society, affecting productivity, well-being and prosperity. ‘The good news is that it is possible to see a dramatic reduction in violence against children in a relatively short time by implementing the right strategies, allocating enough resources and mobilising the highest political will,’ he added brightly. Mathews said that the impact of violence went beyond physical scars. Research showed that an intergenerational cycle of violence was created when children were exposed to violence in their early years, with these children more likely to become perpetrators or victims of violence when they were older because of neurological and psychological damage.

resolution skills to deal with peer pressure, substance abuse and social norms that promoted violence between young men and between them and their partners. Within the social development services there was currently too much focus on response services instead of prevention and early intervention measures. Lucy Jamieson of the Children’s Institute said that nonprofit organisations, which delivered the bulk of services on behalf of government, were ‘not fairly compensated’, resulting in a funding crisis that was hampering services to children and families in need. Dena Lomofsky of the research consultancy Southern Hemisphere said that while multi ple intersectoral committees had been set up to strengthen collaboration between government departments and civil society, each structure tended to focus on ‘a specific issue with little collaboration between them to address children’s needs holistically’. This led to a fragmented response to a com plex problem that required strong leader ship from within government. Joan van Niekerk of Childline South Africa said that the National Department of Health could play a key role by identifying caregivers and children at risk and referring them to social services – but this was ‘neglected in both policy and practice’.

Parenting and lifeskills programmes essential

Violence ‘normalised’ in SA

Parenting programmes could play a major role in providing essential support to families ravaged by poverty, intimate partner violence and substance abuse, while lifeskills programmes for young people could help develop communication and conflict

In the hour Izindaba spent interviewing him, Van As treated a child with 32 fractures (as a result of domestic violence between adults with the child being used as a ‘shield’, a common cause of severe trauma) and watched another die after the upper part of her torso had been kept alive for two days. Hit by a heavyduty truck while walking on a township road, she had literally been torn in two.

The Child Gauge report states that due to the ‘normalisation of violence’ in SA’s past, there was now a widespread tolerance of it that would require ‘a great deal of work’, including engendering an attitude that ‘preventing violence is everybody’s business’.

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Red Cross Hospital is home to one of the world’s oldest child-safety NGOs. Started in 1978 by its renowned former head of peadiatric surgery, Prof. Sid Cywes, when he noticed that he was doing more operations on children hurt in accidental injuries than on those suffering from all other diseases combined, Child Safe SA is aimed at promoting awareness through research, interventions (e.g. educating caretakers, crèche managers and teachers), and advocacy – based on hard data. A pre fabricated ‘home’ on the hospital grounds highlights all the potential dangers in every room of the house, including things like dangling electric kettle cords (responsible for a disproportionate number of nearfatal burns in toddlers), containers with water, and age-specific posters on ‘Living safely’ and ‘Travelling safely’. The NGO won a global award at the 2008 World Safety conference in Mexico.

Gun law improvements – 70% fewer child gunshot admissions

A manifestation of the violence referred to in the Child Gauge report, and a shining example of basic interventions, can be seen in how Child Safe SA tackled a virtual epidemic of child gunshot wounds in 2000. That year the hospital’s trauma unit treated 50 children with firearmrelated injuries, mainly ‘collateral injuries’ resulting from adults intending to harm other adults (most children were hit by stray bullets) – a ‘morbid’ measurement of how many bullets were fired in Cape Flats communities, sparking an evidence-based campaign supporting the NGO ‘GunFree South Africa’. A petition demanding stricter gun laws was delivered after a march on Parliament, resulting in a new firearm bill being adopted in 2002 that requires a gun-handling safety competency certificate, raises the minimum age requirement for possessing a firearm from 16 to 21, and declares ‘gun-free zones’ (e.g. places of worship, schools, hospitals). After these changes in the law, there was an ‘astonishing’ 70% decrease in admissions of children with gunshot wounds to Red Cross Hospital. ‘We cannot make it better, we have to go out there and prevent,’ Van As stressed. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2015;105(3):170-171. DOI:10.7196/SAMJ.9462

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OBITUARIES/HULDEBLYKE Ajay Makanjee

This tribute to Dr Ajay Makanjee, general surgeon and founding member of the KwaZulu-Natal Specialist Network, was extracted from a eulogy at his memorial service. Ajay was born in Durban to Jaymati and Amaratlal Makanjee on 13 November 1959. He matriculated at the Gandhi Desai School in Durban and then attended medical school at the University of Natal, graduating in 1982. At medical school, his habit of questioning his teachers whenever he saw a reason to challenge their views raised the ire of many. He also refused to attend lectures that he considered mundane, preferring to study those subjects on his own. He was a master

Alewyn Petrus Rossouw

Dit is met innige leedwese dat ek verneem het van Alewyn se dood. Op 27 Januarie 2015 sou hy 79 jaar oud geword. Alewyn kom vanaf Lydenburg, waar sy vader ’n gesinsdokter was. Sy moeder was ’n sjarmante dame vanaf Nederland, maar het goed hier ingeburger. Alewyn se ouer broer, Braam, was ook ’n algemene praktisyn en sy suster, Corrie, was getroud met ds. Punt Janson, wat later ’n parlementslid geword het. Alewyn se ouers het op Graskop afgetree en ons het as koshuis-studente gereeld piesangs, lietsjies en pynappels vanaf hul plaas ontvang. Hierdie ‘eksotiese’ vrugte was ’n eienaardigheid vir ons Vrystaters met ons waatlemoene, pruime, kersies en perskes! Alewyn was ’n briljante student. In sy eerste jaar het dr. B Cholnoky (plantkunde) rondgeloop met Alewyn se antwoordstel en verklaar: ‘Hier is nou ’n papier’, tewyl hy ander gewaarsku het: ‘Menere, julle sal sak soos bakstene!’.

brag and table-tennis player, and spent many hours in the medical school sports hall honing his skills. Ajay had a strong intuitive sense of ethics, and when the United Nations promulgated International Woman’s Day to highlight the plight of women, Ajay wrote a letter to request that they also found an International Youth Day. In 1990 he qualified as a general surgeon. With a special interest in diseases of the breast, he was a founding member and remained actively involved in the metropolitan breast oncology team in Durban. Such was his dedication to this team that he attended his last clinic the day before his sudden illness. Known for his formidable intellect and irreverent sense of humour, Ajay was happiest in the company of his family and friends or immersed in a book, Sudoku or a crossword puzzle while listening to jazz. His love of golf was matched only by his passion for soccer, and he shared both with his son Amar and daughter Deeya. He and his wife Vasie also had a younger son named Arjun and an older daughter, Veena. Described as a loving son, father and brother, with a heart of gold, Ajay was quite an adventurer. He hiked the peaks of the Drakensberg to train for his successful ascents of Mount Kilimanjaro and Machu Picchu. He had to abandon his Otter Trail trek on the penultimate day, when he dislocated his

kneecap while climbing a rocky precipice along the Southern Cape coast. Despite this, he stayed on to greet his fellow hikers at the Storms River mouth with a six-pack of Black Label beer to celebrate their accomplishment. Ajay also enjoyed regular fishing with the Medics Angling Club, resulting in many a tall fishing tale that will be told for years to come! Fiercely loyal, infuriatingly resolute and abundantly generous, Ajay stepped to the beat of his own drum. He sought the truth at all costs and claimed no easy victories. The measure of his life lies in the simplicity, humility and nobility of spirit for which he will always be remembered. He was a vocal member of the KZN Specialist Network, where his incisive questions and challenges at our academic meetings and annual general meetings will be very much missed. He was ever prepared to criticise the board of directors, and never spared any advice or recommendations to make the KZNSN a better organisation. Ajay will be sorely missed by all our members, by his colleagues, and by the staff he worked with at Ethekwini Hospital in Durban. His indomitable spirit will forever live on in our midst. Rest in peace, Ajay.

Die eerste ses jaar van ons studie het maar redelik roetinegewys verloop. Ek en Alewyn was kamermaats vir ’n hele aantal jare. Hy was besonder belese en kon interessant gesels oor etiek en filosofie. Hy was versot op O Henry en Damon Runyon se kortverhale en het later John Steinbeck bewonder en gelees. Sy ware potensiaal het gou na sy huis dokterjare te voorskyn gekom en hy het kliniese assistent in neurologie geword. Hy het baie hoofstukke in akademiese boeke geskryf, bv. saam met prof. Ben Meyer (fisiologie). Hy was ’n gesogte mentor vir kliniese assistente in neurologie. Sover ek weet, was hy die eerste magisterstudent wat hierdie graad met lof geslaag het by Pretoria se Fakulteit Geneeskunde. Ironies genoeg is hy gediagnoseer met motorneuronsiekte, wat hom gou afgetakel het. Hy was vir baie jare in vennootskap met dr. C Guldenpfennig (‘Pennie’) en het betreklik onlangs sy kliniese deel van die praktyk vaarwel geroep. Daarna het hy waardevolle werk

gedoen as kundige met betrekking tot mediesgeregtelike neurologies-verwante gevalle. Alewyn was ’n betroubare mens vir wie ek grenslose agting gehad het. Hy het onbaatsugtige diens aan sy medemens verskaf. Hy was ook minsaam, met ’n wonderlike humorsin. Ons klasmaats, met wie ons op dieselfde verdieping in die mediese koshuis gebly het, sluit in Frik Booysen en Johan van Wyk, internasionaal bekende lewerchirurg. Johan was ook later hoof van die Departement Chirurgie by Tygerberg Akademiese Hospitaal. Alewyn was getroud met Elna de Villiers en hulle het drie kinders gehad. Sy was oorspronklik ’n plaasnooi – ook uiters intelligent – en ’n steunpilaar in sy lewe. Ons harte gaan uit na Elna, sy gesin en sy familie. Ons sal Alewyn nie vergeet nie.

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Executive Committee, KZN Specialist Network KwaZulu-Natal, South Africa info@kznspecialist.co.za

Prof. Ben Smit 2de Laan 22, Melkbosstrand, Wes-Kaap, Suid-Afrika bensmit@sonicwireless.co.za

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CLINICAL PRACTICE

Carbohydrate loading in the preoperative setting L T Hill, M G A Miller Lauren Hill is a critical care dietitian with a PhD in physiology and 20 years’ experience as a clinical dietitian, academic and researcher. Her special interest, knowledge and expertise is in nutritional support of critically ill adults, trauma patients and difficult-to-treat patients who have undergone surgery to the gastrointestinal tract. Malcolm Miller is a specialist anaesthetist and intensivist in clinical and academic practice at the University of Cape Town/Groote Schuur Hospital, South Africa. Nutritional support of the critically ill is among his interests. Both authors are affiliated to the Division of Critical Care and Department of Anaesthesia, Faculty of Health Sciences, University of Cape Town.

Nutrition support is an evolving field, and modern clinical nutrition practice should actively incorporate strategies to enhance various clinical outcomes. In surgical patients, clinical benefits can be maximised by nutritional support protocols that minimise and manage the perioperative fasting period. This approach, which includes the perioperative provision of clear carbohydrate-containing fluids, has been shown to be safe, is evidence based, and is supported by many professional societies. Such a strategy has been shown to aid the anaesthetic process and maintain an optimal metabolic state, including improved insulin sensitivity and blunted muscle catabolic activity. Some important consequences of this improved metabolic control include shorter hospital stay and fewer postoperative complications. A proactive multidisciplinary team approach is essential to use this nutrition support strategy with success across a hospital’s surgical service. S Afr Med J 2015;105(3):173-174. DOI:10.7196/SAMJ.8746

The past decade has seen an evolution in clinical practices and protocols governing perioperative fast ing for elective surgical procedures. Various pro fessional associ ations for both surgery (Enhanced Recovery After Surgery (ERAS)) and anaesthesiology (Canadian, American, European, and South African (SA) society guide lines) (Table 1) support more modern nil per mouth guidelines of 6 hours for solids and only 2 hours for clear fluids, even in some instances for some patient subgroups known to have delayed gastric emptying. It has been suggested that minimising the preoperative fasting period, by allowing the consumption of oral carbohydrate-containing clear fluids with or without protein, has a number of clinical advantages, including more stable hae modynamics during induction of anaesthesia, greater glycaemic stability, reduced lean tissue catabolism, and a more positive patient experience.

Nevertheless, consistent compliance of anaesthetists with the updated recommendations to allow carbohydrate-containing clear fluids in the immediate preoperative period is low.[1] This short review addresses the issues of permitting preoperative free fluids in view of lack of associated risk, and actively encouraging preoperative consumption of carbohy drate-containing free fluids due to the associated clinical benefits.

Aspiration risk

The main rationale for maintaining patients in a preoperative fasted state is the purported risk of pulmonary aspiration upon induction of anaesthesia. In fact, the incidence of aspiration is very low – perhaps 1/45 000 elective anaesthetics in stable, otherwise healthy patients – and clinically important consequences of such an event are even rarer. It has been shown that gastric residual volume is a very poor marker of

Table 1. Summary of professional association guidelines for preoperative fasting Professional body

Current guideline

European Society of Anaesthesiologists

Adults and children should be encouraged to drink clear fluids (including water, pulp-free juice and tea or coffee without milk) up to 2 hours before elective surgery (including caesarean section).

ERAS

Preoperative clear fluid intake (exclusions from free intake according to national guidelines): 800 ml carbohydrate-rich drink the evening before surgery, and 400 ml 2 hours before anaesthesia.

Association of Anaesthetists of Great Britain and Ireland

Intake of water up to 2 hours before induction of anaesthesia. A minimum preoperative fasting time of 6 hours for food (solids, milk and milk-containing drinks).

European Society for Parenteral and Enteral Nutrition

Patients undergoing surgery who are considered to have no specific risk for aspiration may drink clear fluids until 2 hours before anaesthesia. Solids are allowed until 6 hours before anaesthesia. Use preoperative carbohydrate loading (the night before and 2 hours before surgery) in most patients undergoing major surgery.

American Society of Anesthesiologists

Fast from intake of clear fluids (water, fruit juices without pulp, carbonated beverages, clear tea, coffee) at least 2 hours before anaesthesia. Fast from intake of light solids and non-human milk 6 hours before anaesthesia. Fast for 8 hours following fatty meals.

Canadian Anesthesiologists’ Society

Before elective anaesthesia, duration of fasting should be 8 hours after a meal including meat or fatty foods, 6 hours after light solid meals, and 2 hours after clear fluids.

South African Society of Anaesthesiologists

Fasting guidelines of 6 hours for solids and 2 hours for clear fluids should be applied.

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FORUM

aspiration risk, and that, with the exception of meals with a high fat content, intake of non-particulate meals such as carbohydrate-based drinks has no relevant bearing on increasing gastric residual volume. In fact, the opposite may be true: judicious use of appropriate oral fluids during the preoperative hours may actually reduce volume residue in the stomach.[2] The emphatic, traditional practice of prolonged preoperative fasting as a risk-reduction approach is therefore unnecessary and is a dogma not founded upon good evidence.

The metabolic response to surgery

The typical physiological response to surgery includes a well-described stress hormone- and cytokine-induced hyperglycaemic and catabolic metabolic profile. This occurs in part as a result of poor movement of GLUT4 glucose transporters to the cell membrane, leading to insulin resistance, along with low muscle glycogen synthetase activity, leading to poor glycogen storage, in a counter-regulatory hormonal environment that enhances muscle protein degradation due to glucoeneogenesis. The response can persist for days to weeks after surgery, and its amplitude is influenced by the magnitude and duration of the surgery and the extent of intraoperative blood loss.[3] Both nutritional compromise going into surgery and the fasting state worsen the response, owing to underlying glycogen and lean tissue depletion. In the SA clinical setting, poor nutritional status of surgical patients is common. It is generally advocated that purposive nutritional support of such patients in the pre- and perioperative period is of clinical benefit. However, the intentional use of nutrition-providing clear fluids in the acute preoperative phase, regardless of nutritional status, may not be practised as uniformly. This is despite the support for such practice by both the American and European societies for parenteral and enteral nutrition, as outlined in their guidelines.[4,5]

The carbohydrate loading concept

Control of the metabolic response is understood to improve clinical outcomes. One of the recommended methods of control is the provision of isotonic, carbohydrate-containing clear fluids until 2 hours preoperatively, so that patients enter surgery in a fed rather than fasted state. This has been called ‘carbohydrate loading’. The principle of the approach is the provision of an energy-containing liquid meal, which will result in insulin secretion necessary to alter the fasted metabolic state.[6] Since fat and hypertonic fluids inhibit gastric emptying, for safety reasons the preferred energy source is carbohydrate in an isotonic solution. An amount of 50 g is sufficient to produce an insulin response similar to that of a mixed solid meal. Recommendations for preoperative carbohydrate loading have therefore been based around this amount and include 100 g carbohydrate on the evening prior to surgery and a further 50 g 2 hours prior to induction of anaesthesia.[7] There is now more than one commercially available sip drink oral supplement that can provide this amount in the form of complex carbohydrate polymers without providing excessive fluid or producing a hyperosmolar product. The isotonic nature of the sip drink is important, as hyperosmolar solutions may delay gastric emptying or provoke other gastrointestinal symptoms such as diarrhoea. Several thousand patients in clinical trials and several million patients in routine clinical practice worldwide have used these commercial carbohydrate-rich drinks without adverse events. The use of such products is therefore safe. Both carbohydrate and protein produce the desired insulin response. It has therefore been postulated that the addition of protein to carbohydrate-rich sip drinks would enhance the clinical benefits of carbohydrate loading. Importantly, by using non-particulate, fatfree, lactose-free protein sources, carbohydrate drinks containing medical nutrition therapy-grade protein still meet the characteristics of a ‘clear’ fluid.

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Clinical benefits

Benefits of the above approach to preoperative fasting are both physiological and patient orientated. The physiological consequences of intake of carbohydrate-rich sip drinks up to 2 hours before surgery are an up to 50% reduction in insulin resistance, which in turn shortens hospital stay and reduces postoperative complications;[6,8] lower muscle catabolism;[9-11] improved intraoperative haemodynamic stability, particularly in children, as a result of more favourable fluid balance status; reduced days to discharge fitness; and superior handgrip strength, a sensitive marker of early muscle protein loss. Perrone et al.,[12] in a small study in 2011, showed that the addition of whey protein to a carbohydrate drink further improved insulin sensitivity and reduced acute-phase markers compared with carbohydrate alone. In addition, benefits on various aspects of patient comfort (such as thirst and anxiety), co-operation, compliance and overall subjective satisfaction have been reported.

Conclusion

There has been a distinct shift in the clinical approach to optimally preparing patients for surgery. There is mixed but good evidence that preoperative oral carbohydrate delivery up to 2 hours before induction should be part of this optimising, and improves outcomes. This practice is widely supported by professional societies for nutrition, surgery and anaesthesiology, and therefore requires co-operative participation from the relevant members of the clinical team. However, it appears that compliance may not be ideal. A change in culture is still necessary so that practice is based on evidence rather than the beliefs or fears of individual practitioners working defensively. Better implementation may depend not only on increasing awareness of modern fasting guidelines but also on packaging nutrition interventions like this one into audit bundles in order to incentivise compliance through a systems-based approach. The time has come for consistent metabolic preparation of patients in the preoperative period through delivery of carbohydrate loading in order to improve surgical outcomes. Disclosures. LH received an unrestricted writing grant from Nestlé Healthcare, SA. 1. Bosse G, Breuer JP, Spies C The resistance to changing guidelines – what are the challenges and how to meet them. Best Pract Res Clin Anaesthesiol 2006;20(3):379-395. [http://dx.doi.org/10.1016/j. bpa.2006.02.005] 2. Maltby JR. Fasting from midnight – the history behind the dogma. Best Pract Res Clin Anaesthesiol 2006;20(3):363-378. [http://dx.doi.org/10.1016/j.bpa.2006.02.001] 3. Nygren J. The metabolic effects of fasting and surgery. Best Pract Res Clin Anaesthesiol 2006;20(3):429438. [http://dx.doi.org/10.1016/j.bpa.2006.02.004] 4. McClave SA, Martindale RG, Vanek VW, et al.; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009;33(3):277-316. [http://dx.doi.org/10.1177/0148607109335234] 5. Weimann A, Braga M, Harsanyic L, et al. ESPEN guidelines on enteral nutrition: Surgery including organ transplantation. Clin Nutr 2006;25(2):224-244. [http://dx.doi.org/10.1016/j.clnu.2006.01.015] 6. Ljungqvist O. Modulating postoperative insulin resistance by preoperative carbohydrate loading. Best Pract Res Clin Anaesthesiol 2009;23(4):401-409. [http://dx.doi.org/10.1016/j.bpa.2009.08.004] 7. Kratzing C. Pre-operative nutrition and carbohydrate loading. Proc Nutr Soc 2011;70(3):311-315. [http://dx.doi.org/10.1017/S0029665111000450] 8. Sato H, Carvalho G, Sato T, Lattermann R, Matsukawa T, Schricker T. The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab 2010;95(9):4338-4344. [http://dx.doi.org/10.1210/jc.2010-0135] 9. Donatelli F, Corbella D, Di Nicola M, et al. Preoperative insulin resistance and the impact of feeding on postoperative protein balance: A stable isotope study. J Clin Endocrinol Metab 2011;96(11):E1789-E1797. [http://dx.doi.org/10.1210/jc.2011-0549] 10. Henriksen MG, Hessov I, Dela F, et al. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand 2003;47(2):191-199. [http://dx.doi.org/10.1034/j.1399-6576.2003.00047.x] 11. Yuill KA, Richardson RA, Davidson HI, et al. The administration of an oral carbohydratecontaining fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively – a randomised clinical trial. Clin Nutr 2005;24(1):32-37. [http://dx.doi.org/10.1016/j. clnu.2004.06.009] 12. Perrone F, da-Silva-Filho AC, Adôrno IF, et al. Effects of preoperative feeding with a whey protein plus carbohydrate drink on the acute phase response and insulin resistance: A randomized trial. Nutr J 2011;10:66. [http://dx.doi.org/10.1186/1475-2891-10-66]

Accepted 11 August 2014.

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CLINICAL ALERT

Recommendations for the treatment and prevention of malaria: Update for the 2015 season in South Africa L H Blumberg Lucille Blumberg is an infectious diseases specialist and microbiologist, and Head of the Division of Public Health Surveillance and Response at the National Institute for Communicable Disease, Johannesburg, South Africa. She has compiled this article for the South African Malaria Elimination Committee (SAMEC), the national malaria advisory group to the National Department of Health, Pretoria, South Africa, in her capacity as chairperson. Corresponding author: Lucille Blumberg (lucilleb@nicd.ac.za)

Notified malaria cases in South Africa (SA) decreased significantly over the past 14 years, from over 60 000 in the 1999/2000 malaria season to less than 13 000 in 2013/2014. However, the past two seasons have seen increases in both local and imported cases. Mozambique contributes the highest number of imported cases in SA. This update provides recommendations for malaria treatment and prevention (in travellers and residents) for 2015. S Afr Med J 2015;105(3):175-178. DOI:10.7196/SAMJ.9407

Management of malaria

Key components of successful management are early and accurate diagnosis (Table 1) and prompt treatment with effective drugs. Treatment should ideally be based on confirmed parasitological diagnosis.[1,2] Microscopy of Giemsa-stained thick and thin blood smears remains the diagnostic mainstay.[3] Rapid antigen detection diagnostic tests (RDTs) are more widely accessible than expert microscopy, provide prompt results and are adequately sensitive for Plasmodium falciparum infections. However, RDTs cannot quantify parasite density (so do not detect hyperparasitaemia that indicates severe malaria) and are less sensitive for non-falciparum species than for falciparum infections. RDTs are unsuitable for monitoring treatment response because of antigen persistence.[4] A negative (rapid or microscopy) test does not exclude malaria; repeat testing within 8 - 24 hours, without attempting to coincide with fever peak timing, is mandatory until a positive result or an alternative definitive diagnosis is achieved. Blood smears should be checked for malaria whenever thrombocytopenia is unexpectedly identified. Test any patient with unexplained fever for malaria, even in the absence of a travel history. Occasionally, infected mosquitoes are transported from endemic areas in suitcases and vehicles (Odyssean malaria).[5] All malaria cases must be notified to local health authorities.

Treatment of malaria

The choice and route of treatment depends primarily on disease severity, which is often underestimated. Uncomplicated malaria is symptomatic infection without signs of severity or evidence of vital organ dysfunction. Persistent vomiting, clinical jaundice, change in mental state or increase in respiratory rate constitutes severe malaria (Table 2).[6,7] Treat uncomplicated malaria with artemether-lumefantrine (Coartem) (Table 3).[2] For optimal absorption it must be taken with milk or fat-containing food. Adequate fluids, temperature control with paracetamol, and careful follow-up are important. Avoid non-steroidal anti-inflammatory agents. Patients should respond clinically and parasitologically within 24 - 48 hours. Consider poor compliance, misdiagnosis and possible drug resistance if no significant improvement occurs within 72 hours. Artemetherlumefantrine remains efficacious in South Africa (SA),[8,9] with no reports of artemisinin resistance in Africa as yet. In the rare event of artemether-lumefantrine treatment failure despite full compliance, give a full directly observed 7-day course of oral quinine (plus doxycycline or clindamycin) in hospital. Oral quinine, combined with 7 days of doxycycline, remains an alternative to artemether-lumefantrine (Table 4), but compliance is poor. In pregnancy or children aged <8 years, substitute clindamycin for doxycycline (Table 4). Doxycycline or clindamycin add no early

Table 1. Diagnosis of malaria Keep a high index of suspicion for malaria in travellers to, or residents of, malaria transmission areas presenting with fever or other ’flu-like illness, irrespective of the time of year, intensity of transmission or use of chemoprophylaxis. Always take an adequate travel history. Typical presentation: paroxysms of fever and rigors in adults, also headache, myalgia, loss of appetite, nausea and vomiting. In young children, fever, lethargy, poor feeding, vomiting and diarrhoea are most common. Important differential diagnoses: meningitis, African tick-bite fever, typhoid, viral haemorrhagic fever, trypanosomiasis. Progression to severe disease may be rapid, particularly in non-immune and immune-compromised persons, young children and pregnant women. Often missed in patients with comorbid disease. Frequently misdiagnosed in pregnancy, requiring differentiation from pregnancy complications including intrauterine and urinary tract infections.

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treatment benefit, so are started only once symptoms improve, as gastrointestinal side-effects may exacerbate those of quinine.

Second and third trimesters. Artemether-lumefantrine is con sidered safe and efficacious.

Drug interactions

Large adults

Concomitant use of certain other drugs (e.g. efavirenz, rifampicin) may alter blood concentrations of artemether-lumefantrine and quinine. There is no evidence of the clinical significance of these interactions, but full adherence and fat co-administration is advised, and response to treatment should be monitored particularly carefully.

Pregnancy

First trimester. Supervised 7-day course of oral quinine plus clindamycin.

Table 2. Clinical and laboratory criteria for severe malaria (any one or combination of these criteria applies) Clinical Impaired consciousness, multiple convulsions Respiratory distress, acidotic breathing, pulmonary oedema

Artemether-lumefantrine is registered in SA only for use in patients weighing ≤65 kg. Minimal pharmacokinetic data exist for larger patients; one study suggests a trend towards increased risk of treatment failure in patients >80 kg.[10] Again, adequate adherence and fat co-administration is important, with careful monitoring of response. If adherence is assured, consider administering the same total dose over 5 days (dosing at 0, 8, 24, 48, 72 and 96 hours).

Recommendations for non-falciparum malaria

Malaria species should be confirmed by a reliable laboratory. Nonfalciparum infections are usually uncomplicated, but occasionally produce severe illness. Use artemether-lumefantrine for initial therapy of uncomplicated P. vivax and P. ovale infections. To prevent relapses, this should be followed by a course of primaquine after excluding glucose-6-phosphate dehydrogenase (G6PD) deficiency. Table 3. Dosing schedule for artemether-lumefantrine (Coartem) Time of dosing (hours) and number of tablets

Circulatory collapse Jaundice Bleeding Prostration Laboratory Hypoglycaemia (blood glucose <2.2 mmol/L) cidosis (plasma bicarbonate <15 mmol/L or serum lactate A >5 mmol/L) Hepatic transaminases >3 times normal enal impairment (serum creatinine >265 µmol/L or rapidly R rising creatinine or urine output <400 mL/day in an adult) Haemoglobin <5 g/L Parasitaemia ≥5% ≥5% neutrophils contain malaria pigment Presence of schizonts of P. falciparum in peripheral blood smear

Body weight (kg)

8 - 12

5 - 14

15 - 24

25 - 34

≥35

Table 4. Dosing schedule for oral quinine with doxycycline or clindamycin Drug

Schedule

Oral quinine

10 mg/kg 8-hourly for 7 days

Doxycycline

200 mg stat, thereafter 100 - 200 mg once daily, or 3.5 mg/kg once daily for 7 days

Clindamycin

10 mg/kg bd for 7 days

Table 5. Dosing schedule and adverse effects for mefloquine, doxycycline and atovaquone-proguanil Chemoprophylactic

Schedule

Adverse effects

Mefloquine (Lariam, Mefliam)

Weekly, starting 1 - 2 weeks before travel, weekly while there and continue for 4 weeks after Adults: 250 mg weekly Children: 5 mg/kg weekly Not recommended for children <3 months or <5 kg

Gastrointestinal, headache, dizziness, imbalance, mood changes, insomnia, nightmares, and rarely, psychosis. Increased risk of eye disorders Contraindications: epilepsy, neuropsychiatric disorders, those who require fine motor co-ordination, divers and pilots

Doxycycline (daily)

Daily, starting 1 day before travel, daily while there and continue for 4 weeks after Adults: 100 mg daily Not recommended for children <8 years

Skin photosensitivity, oesophagitis, upper gastrointestinal symptoms, vaginal candidiasis or diarrhoea (normal flora disruption)

Atovaquone-proguanil (Malanil, Numal)

Daily, starting 1 day before travel, daily while there and continue for 1 week after Adults: 1 tablet daily Children >11 kg: Malanil Paediatric at prescribed dose per body weight

Adverse reactions uncommon; include headache, nausea, vomiting, abdominal pain, diarrhoea

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Table 6. Drug choice according to patient factors Patient factor

Mefloquine

Doxycycline

Atovaquone-proguanil

Pregnancy â&#x20AC;&#x201C; avoid travel to malaria areas.

Now recommended for all trimesters[12,13] if travel is necessary.

Contraindicated

Contraindicated owing to lack of data.

Young children â&#x20AC;&#x201C; avoid taking children <5 years to high-risk areas.

Can be used in children >3 months or >5 kg. Generally well tolerated by children.

Use only in children >8 years.

Paediatric tablets can be given to children >11 kg. Breaking of tablets is not recommended.

Persons requiring long-term prophylaxis

Can be used for up to 3 years. Longer-term use may be justified by risk of malaria.

Can be safely used for up to 2 years. Longer term use may be justified by risk of malaria.

Can be used confidently for up to 1 year. Longer-term use may be justified by risk of malaria.

HIV-positive (on ARVs)

Best option

ARVs = antiretrovirals.

Fig. 1. Malaria risk map for SA (adopted 2014).

The recommended dose in children is 0.25 - 0.3 mg/kg daily for 14 days, and that for adults is 15 mg daily for 14 days. Currently primaquine is only available on a named-patient basis with Section 21 MCC approval.

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Severe malaria (Table 5)

Severe malaria is a medical emergency requiring prompt parenteral treatment, intensive nursing care, and careful monitoring and management of complications.[6.7] Intravenous artesunate (2.4 mg/kg

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at 0, 12 and 24 hours, then daily until the patient is able to tolerate oral treatment) is preferred treatment, but is currently unregistered and only available on a named-patient basis with Section 21 MCC approval.[2,11] When intravenous artesunate is not promptly available, intravenous quinine (with an initial loading dose of 20 mg/kg and then maintenance doses of 10 mg/kg, each dose slowly infused over at least 4 hours) is initiated urgently and given 8-hourly until oral treatment is tolerated. Follow with a complete course of artemetherlumefantrine.[2] Reassess frequently to ensure that all complications are promptly detected and optimally managed.

Critical issues in management of severe malaria

Hypoglycaemia. Urgently exclude (or administer empiric glucose) if there is a depressed level of consciousness or convulsions. Repeat glucose monitoring 4-hourly. Renal failure. This is a frequent, early complication in adults. Severe malaria requires careful fluid management, with frequent measurement of renal function (urea, electrolytes and creatinine), ongoing monitoring of urine output and judicious fluid administration. Strictly avoid overhydration, as the acute respiratory distress syndrome is a common and difficult-to-treat complication, particularly in pregnancy.

Prevention of malaria

Prevention of mosquito bites is the mainstay of malaria prevention. Malaria-transmitting mosquitoes generally bite at night, so people in malaria-endemic areas should ideally remain indoors from dusk to dawn, and sleep under insecticide-treated bednets in rooms with screened windows and doors. Fig. 1 shows endemic areas in SA; residents and travellers in these areas should take necessary precautions to avoid mosquito bites. Effective repellents contain DEET (diethyl toluamide). Use products containing 20 - 50% DEET for long-lasting protection for adults and children aged >2 months. Products containing >50% DEET have no additional benefit. Avoid applying to eyes or mouth.

Additionally, travellers to malaria-endemic areas should use chemoprophylaxis depending on the malaria risk assessment. Three similarly effective chemoprophylactic agents are currently registered in SA (Table 5), all requiring a doctor’s prescription. Selection should be based on patient factors (Table 6) and which option is likely to be best tolerated for optimal adherence.

Scope of protection

Chemoprophylactics are most effective against parasite asexual blood stages. While they will prevent initial illness caused by all species, they will not prevent relapses due to P. vivax and P. ovale. 1. World Health Organization. Guidelines for the Treatment of Malaria. 2nd ed. Geneva: WHO, 2010. http://www.who.int/malaria/publications/atoz/9789241547925/en/ (accessed 14 January 2015). 2. South African National Department of Health. Guidelines for the Treatment of Malaria in South Africa. Pretoria: NDoH, 2010. 3. Payne D. Use and limitations of light microscopy for diagnosing malaria at primary health care level. Bull World Health Organ 1988;66(5):621-626. 4. Bell DR, Wilson DW, Martin LB. False-positive results of a Plasmodium falciparum histidinerich protein 2-detecting malaria rapid diagnostic test due to high sensitivity in a community with fluctuating low parasite density. Am J Trop Med Hyg 2005;73(1):199-203. 5. Frean J, Brooke B, Thomas J, Blumberg L. Odyssean malaria outbreaks in Gauteng Province, 20072013. S Afr Med J 2014;104(5):335-338. [http://dx.doi.org/10.7196/SAMJ.7684] 6. World Health Organization. Management of Severe Malaria – a Practical Handbook. 3rd ed. Geneva: WHO, 2013. http://www.who.int/malaria/publications/atoz/9789241548526/en/ (accessed 14 January 2015). 7. World Health Organization. Severe malaria. Trop Med Int Health 2014;19(Suppl 1):1-131. [http:// dx.doi.org/ 10.1111/tmi.12313_2] 8. Barnes KI, Durrheim DN, Little F, et al. Effect of artemether-lumefantrine policy and improved vector control on malaria burden in KwaZulu-Natal, South Africa. PloS Med 2005;2:e330. [http://dx.doi. org/10.1371%2Fjournal.pmed.0020330] 9. Vaughan-Williams CH, Raman J, Raswiswi E, et al. Assessment of the therapeutic efficacy of artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in northern KwaZulu-Natal: an observational cohort study. Malar J 2012;11:434. [http://dx.doi. org/10.1186/1475-2875-11-434] 10. Leykin Y, Miotto L, Pellis T. Pharmacokinetic considerations in the obese. Best Pract Res Clinical Anesthesiol 2011;25(1):27-36. [http://dx.doi.org/10.1016/j.bpa.2010.12.002] 11. Kift EV, Kredo T, Barnes KI. Parenteral artesunate access programme aims at reducing malaria fatality rates in South Africa. S Afr Med J 2011;101(4):240-241. 12. Schlegenhauf P, Blumentals WA, Suter P, et al. Pregnancy and fetal outcomes after exposure to mefloquine in the pre- and periconception period and during pregnancy. Clin Infect Dis 2012;54(11):e124-131. [http://dx.doi.org/10.1093/cid/cis215] 13. Centers for Disease Control and Prevention. CDC Update: New recommendations for mefloquine use in pregnancy. http://www.cdc.gov/malaria.new_info/2011.mefloquine_pregnancy.html (accessed 14 January 2015).

Accepted 26 January 2015.

This month in the SAMJ ... Maud Lemoine* is a clinical senior lecturer and honorary consultant in hepatology at St Mary’s Hospital, Imperial College London. She completed her medical degree and a PhD in physiology and physiopathology in Paris, France, where she also graduated in political sciences from the Institute of Political Studies. She worked at the Medical Research Council laboratories in The Gambia, West Africa, running the PROLIFICA (Prevention of Liver Fibrosis and Cancer in Africa) project (EU-FP7) on hepatitis B virus and liver cancer. She is also leading a study on HIV/hepatitis C virus co-infection in Vietnam, funded by the ANRS (the French research agency on HIV/AIDS and viral hepatitis), and is co-investigator in a forthcoming pilot study on sofobuvir/ribavirinbased, interferon-free therapy in Cameroon, Côte d’Ivoire and Sénégal. She is a member of the World Health Organization scientific advisory board for the development of hepatitis C guidelines and of the ANRS. * Howell J, Ladep NG, Lemoine M, et al. Prevention of Liver Fibrosis and Cancer in Africa: The PROLIFICA project – a collaborative study of hepatitis B-related liver disease in West Africa. S Afr Med J 2015;105(3):185-186. [http://dx.doi.org/10.7196/SAMJ.8880]

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Chronic pancreatitis, depression and substance use disorders: A not uncommon combination C Y Jeppe, C P Szabo, M D Smith Cara Yvonne Jeppe is a research facilitator in the Hepatopancreatobiliary Unit in the Department of Surgery at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. She has a professional background as a medical technologist and her interests include social determinants of disease and the outcomes of their surgical management. Prof. Christopher Paul Szabo is Head of the Department of Psychiatry, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, and Head of the Department of Psychiatry at Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg. His areas of special interest include eating disorders and ethics. Adjunct Prof. Martin Derrick Smith is Head of the Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, and Head of the Department of Surgery at Chris Hani Baragwanath Academic Hospital. He has a special interest in hepatopancreatobiliary surgery. Corresponding author: C P Szabo (christopher.szabo@wits.ac.za)

Chronic pancreatitis (CP) is a progressive and debilitating disease. A potentially important consideration is the relationship between CP, depression and substance use disorders, which seems to be circular and multiplicative. Pain management is a critical component of intervention, and it would seem that in the context of chronic illness this requires a biopsychosocial approach aiming for a tailored intervention that strikes an appropriate therapeutic balance. S Afr Med J 2015;105(3):179-180. DOI:10.7196/SAMJ.8885

Chronic pancreatitis (CP), a progressive and debili tating disease that usually presents with pain, is frequently attributed to alcohol misuse. Patients generally present for treatment in their fourth decade after recurring absenteeism and job loss; some have become (or have always been) indigent. There is a need for prevention. A potentially important consideration is the relationship between CP, depression and substance use disorders (SUDs), which seems to be circular and multiplicative.

Pain, depression and substance abuse

Compared with people in good health, ‘depression is approximately two to three times more common in people with a chronic physical health problem’.[1] In their article discussing the neurobiology and clinical presentation of pain and its synergies with SUD, Savage et al.[2] stated: ‘Pain and substance abuse co-occur frequently, and each can make the other more difficult to treat’; ‘each may reinforce components of the other’; and ‘depression is the most common psychiatric symptom seen among pain patients’. They found that clinicians’ fear that patients might develop SUD with opioid treatment for pain compromised effective treatment.[2] Mavandadi et al.[3] found that pain ‘may hinder or minimize treatment-related improvements in depressive symptoms’. Concerns about substance dependence resulting from opioid use may therefore contribute to inadequate pain relief and also lead to suboptimal response to treatment of depression, while potentially contributing towards depressive symptoms. The interplay of these factors has clear implications for the management of CP and calls for a multidisciplinary approach to optimise outcome.

Diagnosis of depression

Depression is frequently undetected and untreated. While poor socioeconomic status can predispose people to depression, which can begin in childhood or adolescence, it can also make diagnosis and treatment less likely. Other risk factors for a depressive disorder include alcohol abuse, stressful life events, adverse childhood experiences, job

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loss, close personal relationship problems, poverty, and a family history of depression. Severe pain is a major contributor to depression, and pain amelioration can improve collaborative care interventions for depression. In 1985 David Goldberg[4] identified five main reasons why patients failed to have their psychiatric conditions diagnosed by physicians: they would not be asked directly about their psychological conditions; only somatic symptoms would be discussed; privacy during consultations would be lacking; there would be an exclusive focus on organic causes of symptoms; and physicians lacked confidence in their ability to make psychiatric assessments. Ideally, consultants should have knowledge of the culture of origin of patients with depression, within a holistic biopsychosocial approach to disease management. Knowledge of the social environment of such patients is critical for determining what measures can be taken to improve their circumstances and thus contribute to amelioration of depression. Social workers from the community are well placed to facilitate such measures.

Depression and physical illness

Objective evidence on the incidence and severity of depression in com bination with chronic physical health problems is not available.[1] Somatic symptoms of the latter can occur with, and mask, the symptoms of the former, making distinction between the two problematic.[1] The simultaneous presence of both increases the likelihood and extent of functional, social and occupational disabilities, and may lead to shorter life expectancies. Depression worsens medical prognosis and may play an aetiological role in SUD and CP. In 2000, DiMatteo et al.[5] found that depressed patients with physical illness were ‘three times more likely to be non-compliant with treatment recommendations’. Although active treatment for depression may have a lesser beneficial effect for severe pain, and may not improve length of survival, it improves quality of survival.

Chronic pancreatitis, substance abuse and depression

Depression and low self-esteem arising from poor education and unemployment are associated with high-risk behaviours such as

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substance abuse, while SUD can be both the cause and effect of depression. Wehler et al.[6] lamented the lack of knowledge about poor mental health in patients with CP and noted that a substantially increased risk for onset of major depressive disorders arises from alcohol abuse. Such a causal link has also been suggested by Fergusson et al.[7] Drug addiction has been cited as a complication of depressive disorders, and dependence on opioids can result from their use as prescribed treatment for CP pain. Unemployment may be a predictor of abuse of prescription opioids and vice versa, while both increase dependence on disability grants.

Chronic pancreatitis, surgery and pain management

The Frey procedure (local resection of the pancreatic head with lateral pancreaticojejunostomy) undertaken at the Hepatopancreato biliary (HPB) Unit in the Department of Surgery at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa, between 2002 and 2009 improved quality of life and functioning and reduced symptoms in 32 patients with painful CP.[8] The median duration of pain before surgery was 72 months (range 10 - 264). There was no significant correlation between preoperative pain duration and the pain score or pain intensity of the 32 patients. The traditional view that with time there is ‘burn-out’ of pain has been invalidated,[8-10] and deferment of surgery in anticipation of future ‘burn-out’ is therefore not appropriate. Rather, deferment of surgery increases the risk of dependence on opioids. In a later unpublished study from the same authors, 35 patients treated between 2009 and 2012 answered a structured interview before and after the Frey procedure in the HPB Unit. All patients answered questions relating to hopelessness and pain, as measured on a visual analogue scale from 0 to 10. The use of prescribed opioids was recorded at both interviews. The duration of postoperative follow-up was a mean of 27.5 months (standard deviation 24.9). Before surgery, 68.6% of the patients felt hopeless, 100% had a pain score of ≥5, and 38.2% were using prescribed opioids. After surgery, at the last recorded visit, 34.3% felt hopeless, 54.5% had pain ≥5, and there was an increase in the use of prescribed opioids to 64.7% of the sample. The increasingly liberal prescribing of opioids has raised concern about dependence and deleterious side-effects.[11] Misuse of opioids for the relief of depression can lead to behaviours that exaggerate pain in order to increase the amount of opioids prescribed. In a rare study on interventions for alcohol abuse in patients with

alcohol use disorders and painful pancreatitis, a reduction in alcohol consumption and a decreased need for analgesics was achieved by a multidisciplinary group of pancreatic surgeons and addiction and pain specialists.[12]

Conclusion

The use of adequate analgesia is a key component in preventing depressive symptoms, but may promote substance dependence and abuse. The clinician is therefore caught in a double bind. Pain management in the context of chronic illness requires a bio psychosocial approach aiming for a tailored intervention that strikes an appropriate therapeutic balance. Surgeons, pain and addiction clinicians working in collaboration with nurses, social workers, psychologists and psychiatrists can contribute to improved quality of life for patients with CP, and raise professional and public awareness at all levels of healthcare. 1. National Collaborating Centre for Mental Health. Depression in adults with a chronic physical health problem. In: Depression in Adults with a Chronic Physical Health Problem: The NICE Guideline on Treatment and Management. Chap. 2. British Psychological Society and Royal College of Psychiatrists, 2010:15-27. http://www.nice.org.uk/guidance/cg91/evidence/cg91-depression-with-a-chronic-physicalhealth-problem-full-guideline2 (accessed 30 January 2015). 2. Savage SR, Kirsh KL, Passik SD. Challenges in using opioids to treat pain in persons with substance use disorders. Addict Sci Clin Pract 2008;4(2):4-25. [http://dx.doi.org/10.1151/ascp08424] 3. Mavandadi S, Ten Have TR, Katz IR, et al. Effect of depression treatment on depressive symptoms in older adulthood: The moderating role of pain. J Am Geriatr Soc 2007;55(2):202-211. [http://dx.doi. org/10.1111/j.1532-5415.2007.01042.x] 4. Goldberg D. Identifying psychiatric illness among general medical patients. BMJ 1985;291(6489):161162. [http://dx.doi.org/10.1136/bmj.291.6489.161] 5. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160(14):2101-2107. [http://dx.doi.org/10.1001/archinte.160.14.2101] 6. Wehler M, Nichterlein R, Fischer B, et al. Factors associated with health-related quality of life in chronic pancreatitis. Am J Gastroenterol 2004;99(1):138-146. [http://dx.doi.org/10.1111/j.15720241.2004.04005.x] 7. Fergusson DM, Boden JM, Horwood J. Tests of causal links between alcohol abuse or depen dence and major depression. Arch Gen Psychiatry 2009;66(3):260-266. [http://dx.doi.org/10.1001/ archgenpsychiatry.2008.543] 8. Jeppe CY, Becker P, Smith MD. Post-Frey procedure quality of life in South African patients with painful chronic pancreatitis. J Pancreas (Online) 2013;14(1):21-30. [http://dx.doi.org/10.6092/15908577/933] 9. Mullady DK, Yadav D, Amann ST, et al. Type of pain, pain-associated complications, quality of life, disability and resource utilization in chronic pancreatitis: A prospective cohort study. Gut 2011;60(1):77-84. [http://dx.doi.org/10.1136/gut.2010.213835] 10. Liu LS, Shenoy M, Pasricha PJ. Substance P and calcitonin gene related peptide mediate pain in chronic pancreatitis and their expression is driven by nerve growth factor. J Pancreas (Online) 2011;12(4):389-394. 11. Sehgal N, Colson J, Smith HS. Chronic pain management with opioid analgesics: Benefits versus harms of long-term therapy. Expert Review of Neurotherapeutics 2013;13(11):1201-1220. [http://dx.doi.org /10.1586/14737175.2013.846517] 12. Lang MB, Segersvard R, Grundsten M, et al. Management of alcohol use disorders in patients with chronic pancreatitis. J Pancreas (Online) 2012;13(6):654-659. [http://dx.doi.org/10.6092/15908577/1037]

Accepted 8 September 2014.

This month in the SAMJ ... Greta Dreyer* is a gynaecological oncologist at Steve Biko Academic Hospital, Pretoria, where she heads the clinical and research units in the Department of Obstetrics and Gynaecology at the University of Pretoria. She is a founder member of the South African HPV Advisory Board and its research fund and of the University of Pretoria and Netcare Familial Cancer Centre, and established the Southern African Journal of Gynaecological Oncology, of which she is still Editor-in-Chief. She holds a doctorate in basic research and clinical cancer genetics for work done on the PTEN gene in gynaecological cancer. Her research efforts in oncology are currently mostly aimed at the control of lower genital tract cancer via immunisation and screening, the recognition, diagnosis and prevention of familial cancer, and surgical treatment of women’s cancer. She established the Vaccine and Cervical Cancer Screen (VACCS) study group in 2009, consisting of clinicians and academics from various South African universities. The group has completed two multicentre projects aiming to improve vaccination against and screening for cervical cancer in South Africa and the developing world. * Snyman LC, Dreyer G, Visser C, Botha MH, van der Merwe FH. The Vaccine and Cervical Cancer Screen project 2 (VACCS 2): Linking cervical cancer screening to a twodose HPV vaccination schedule in the South-West District of Tshwane, Gauteng, South Africa. S Afr Med J 2015;105(3):191-194. [http://dx.doi.org/10.7196/SAMJ.8888]

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MEDICINE AND THE LAW

‘Over-servicing’, ‘underservicing’ and ‘abandonment’: What is the law? D J McQuoid-Mason David McQuoid-Mason is Professor of Law at the Centre for Socio-Legal Studies, University of KwaZulu-Natal, Durban, South Africa, and publishes and teaches in medical law. Corresponding author: D J McQuoid-Mason (mcquoidm@ukzn.ac.za)

The Ethical Rules and Policy Document of the Health Professions Council of South Africa (HPCSA) do not define ‘over-servicing’, ‘underservicing’ and ‘abandonment’. The HPCSA Guidelines on Over-servicing, Perverse Incentives and Related Matters define ‘over-service’ only. The converse of this definition can be used to define ‘underservicing’. The courts do not refer to these concepts, but apply general rules regarding professional negligence and malpractice based on what a reasonably competent doctor in the same position would do. In deciding the standard to be adopted, the courts may consult the ethical rules of the medical profession, but are not bound to take them into account. S Afr Med J 2015;105(3):181-182. DOI:10.7196/SAMJ.9141

The Health Professions Council of South Africa (HPCSA) rules[1] mention ‘over-servicing’ and ‘underservicing’ of patients in terms of fees and over-charging (rule 7(3)). However, ‘over-servicing’ and ‘underservicing’ are not defined, and they are silent on ‘abandonment’ of patients. The Guidelines on Over-servicing, Perverse Incentives and Related Matters[2] define ‘over-servicing’ but not ‘underservicing’ or ‘abandonment’ of patients. The definition of ‘over-servicing’ in the Guidelines can assist in defining a meaning for ‘underservicing’. ‘Abandonment’ of patients may sometimes be linked to ‘underservicing’. The legal standard of care required of doctors is often influenced by the ethical rules of the profession, but the courts are not bound by them. As South Africa (SA) has no ethical guidelines for practitioners defining ‘underservicing’ and ‘abandonment’ of patients, the courts will apply the general principles of legal liability for professional negligence and malpractice.

treating patients.[4] In a sense, ‘underservicing’ is the opposite of ‘overservicing’. The converse of the Guidelines definition of ‘over-servicing’ could therefore be used to define ‘underservicing’.

What is the meaning of ‘underservicing’?

What does ‘over-servicing’ mean?

‘Underservicing’ generally means failing to provide a patient with the standard of care that a reasonably competent doctor in a similar situation and in the same field of medical practice would be expected to provide.[5] This definition can be refined by formulating one that is the converse of the ‘over-servicing’ definition in the Guidelines[2] (para 2.14), which could read as follows: The failure to supply, provide, administer, use or prescribe any treatment or care (including diagnostic and other testing, medicines and medical devices) which are medically and clinically indicated, necessary or appropriate under the circumstances or which is in accordance with the recognised treatment protocols and procedures, without due regard to the patient’s financial and health interests.

They also state that healthcare practitioners shall not ‘[p]rovide a service or perform or direct certain procedures to be performed on a patient that are neither indicated nor scientific or have been shown to be ineffective, harmful or inappropriate through evidence-based review’. The same principle applies to referrals to another healthcare practitioner for a service or a procedure that is not indicated or unscientific, or that evidence-based review has shown to be ineffective, harmful or inappropriate. The HPCSA Policy Document on Undesirable Business Practices[3] provides that ‘[i]ncentives may not be used to encourage either “over” or “under” servicing of patients’ and that ‘[a]ppropriate care should be provided at all times’ (para 4.8), but does not define the terms. The Guidelines and Policy Document are consistent with the law, which requires doctors to act with reasonable skill and care when

This definition could also be incorporated into the Guidelines, as could the converse of the two examples of ‘over-servicing’ in the Guidelines (para 2.1.4). The latter could be used to indicate that healthcare practitioners should not ‘underservice’ patients by ‘failing to provide a service or perform or direct certain procedures to be performed on a patient that are indicated or have been shown to be effective and appropriate’, or by ‘failing to refer a patient to another healthcare practitioner for a service or a procedure that is indicated or has been shown to be effective and appropriate’. These definitions and examples of ‘underservicing’ are consistent with the law[5] and could be used to guide the courts. The treatment of cancer patients in the USA is a good example of ‘underservicing’. Research concluded that the ‘slow pace of adoption of early palliative care for patients with serious cancer is a tragic under service of health care, leading to much unnecessary suffering’.[6] This is because many hospitalised patients receive ‘aggressive care’ instead of hospice services,[6] which indicates that ‘underservicing’ may sometimes be linked to ‘over-servicing’. Unnecessary interventions in terminally ill cancer patients, causing patients to suffer needless expense and pain, are examples of ‘over-servicing’. The use of unnecessary treatment in futile situations is also unethical and unlawful.[7]

The HPCSA Guidelines[2] define ‘over-servicing’ as: ‘[T]he supply, provision, administration, use or prescription of any treatment or care (including diagnostic and other testing, medicines and medical devices) which is medically and clinically not indicated, unnecessary or inappropriate under the circumstances or which is not in accordance with the recognised treatment protocols and procedures, without due regard to both the financial and health interests of the patient.’

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Continual ‘underservicing’ of patients by medical practitioners may also constitute ‘abandonment’ if this forces patients to terminate their doctor’s services.

What constitutes ‘abandonment’?

‘Abandonment’ of a patient occurs when a doctor unilaterally ceases treatment before the patient has recovered or terminates the patient’s contract,[8] without giving adequate notice or referring the patient to another practitioner.[9] ‘Abandonment’ may include doctors: (i) closing their practices without proper notice; (ii) denying the doctor-patient relationship; (iii) refusing to see a patient previously seen; (iv) failing to visit a hospitalised patient; (v) failing to provide follow-up care; and (vi) failing to provide a competent substitute when away from practice[10] or closing their practice. Where doctors continually ‘underservice’ their patients, so that they must seek healthcare from somebody else, this may amount to ‘constructive abandonment’ because it forces the patients to terminate the doctor-patient relationship. These definitions and examples are consistent with the law regarding professional negligence and malpractice in situations where the doctor’s conduct amounts to an actionable omission.

The law regarding ‘over-servicing’, ‘underservicing’ and ‘abandonment’ of patients

Doctors are expected to exercise the same degree of skill and care as reasonably competent practitioners in their branch of the profession.[4] Although the courts usually follow what the medical profession regards as reasonable professional conduct, they are not bound to follow this.[5] When deciding the level of skill and care required, the courts may take into account the ethical rules of the profession where they are consistent with statute or common law.[5] Failure by practitioners to measure up to the expected standard of skill and care may result in legal action by patients for professional negligence or malpractice.[4] In deciding whether the harm suffered by a patient was caused by ‘over-servicing’, ‘underservicing or ‘abandonment’, the courts must decide whether the doctor failed to measure up to the standard of a reasonably competent doctor in the same field of practice.[4] The courts may refer to the HPCSA’s Ethical Rules,[1] the Policy Document[3] and the ethical Guidelines[2] regarding ‘over-servicing’ and ‘underservicing’ of patients. However, they will rely on what they consider to be professional negligence or malpractice according to the law[4] – which may or may not be based on what the medical profession considers to be ‘underservice’, ‘over-service’ or ‘abandonment’.

Overservicing

There are few reported court cases on ‘over-servicing’. The former SA Medical Council disciplined doctors who engaged in such practices, especially when they charged excessive fees, e.g. removing teeth surgically instead of by ordinary extraction, unnecessary house calls by a general practitioner, and having unnecessary tests done.[11] The Council also disciplined practitioners in cases where the procedures were unnecessary, e.g. unnecessary X-rays and the needless amputation of toes.[11] In these circumstances, according to the common law, the patients could refuse to pay the healthcare practitioner’s fees for the services not required. They could also claim damages in a civil action provided they could prove to have suffered harm as a result of such over-service. These definitions and examples in the Guidelines[2] could assist the courts in deciding whether there was ‘over-servicing’.

Underservicing

The law does not mention ‘underservicing’, but it usually takes the form of an actionable omission based on a failure to treat a according to good

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medical practice.[12] Many cases of ‘underservicing’ have come before the courts, usually involving the failure to provide follow-up treatment and postoperative care,[13] e.g. the patient is not informed by the doctor when test results after discharge from a hospital indicate that further diagnosis or treatment is necessary, or the doctor does not advise the patient to return if abnormal symptoms are experienced after treatment.[12] In these situations the test is whether a reasonably competent practitioner in the same position would have exercised the same degree of skill and care as the practitioner concerned.[5] This is inherent in the suggested definition and examples of ‘underservicing’, which could assist the courts but would not be binding on them.

‘Abandonment’

A patient is abandoned ‘when a doctor interrupts a course of necessary treatment without proper notice and referral to another practitioner’.[14] A doctor who causes harm by such action will be liable for damages.[8] Once a doctor engages in treating a patient, treatment may not be abandoned if this would harm the patient – unless the patient makes treatment by the doctor impossible.[15] In SA law, ‘abandonment’ is generally not mentioned by the courts, as it is treated as an actionable omission (as in the case of ‘underservicing’) under the general principles of liability for professional negligence or malpractice. Professional negligence or malpractice resulting from failure to provide follow-up treatment and postoperative care usually involves: ‘(a) A complete and unreasonable refusal to look after a patient after the completion of the immediate treatment; (b) withdrawal from the doctor/ patient relationship at a critical stage and without the consent of the patient and without reasonable notice … to the patient; [and] (c) the premature discharge of a patient’.[16] In the USA the courts have found doctors liable for ‘abandonment’ of their patients where they terminated their professional relationship at an unreasonable time or without affording the patient an opportunity to find an equally qualified replacement.[17] The former SA Medical Council also disciplined practitioners for refusing to treat patients after being requested to do so, not visiting a patient in hospital who subsequently died, and failing to treat a patient in labour after he had treated her from the beginning of her preg nancy.[11] The courts are likely to take a similar approach – provided the patient can prove harm as a result of such ‘abandonment’. The decisions of the courts will be based on the principles of professional negligence and malpractice.[18] The above definitions and examples could provide useful guidelines for the courts when deciding whether the doctors concerned had abandoned their patients.[11] 1. Ethical and Professional Rules of the Health Professions Council of South Africa. GN R717 in Government Gazette 29079 of 4 August 2006, as amended by GN R68 in Government Gazette 31825 of 2 February 2009. 2. Health Professions Council of South Africa. Guidelines on Over-servicing, Perverse Incentives and Related Matters. Pretoria: HPCSA, 2008. 3. Health Professions Council of South Africa. Policy Document on Undesirable Business Practices. Pretoria: HPCSA, 2005. 4. Castell v De Greeff 1993 (3) SA 501 (C). 5. Van Wyk v Lewis 1924 AD 438. 6. Wiencke MC. Cancer care: ‘Tragic underservice’. Dartmouth Medicine, Spring 2011. http://www. dartmed.dartmouth.edu/spring11/html/disc_cancer.php (accessed 3 November 2014). 7. Cf. Airedale NHS Trust v Bland [1993] 1 All ER 821 (HL). 8. McQuoid-Mason D, Dada M. A-Z of Medical Law. Cape Town: Juta, 2011:1. 9. USLegal. Patient Abandonment Law & Legal Definition. http://definitions.uslegal.com/p/patientabandonment/ (accessed 16 October 2014). 10. Segen’s Medical Dictionary. http:// medical-dictionary.thefreedictionary.com/abandonment (accessed 3 November 2014). 11. Verschoor T. Verdicts of the Medical Council. Pretoria: Digma, 1990:95-96. 12. Carstens P, Pearman D. Foundational Principles of South African Medical Law. Durban: LexisNexis, 2007:815-816. 13. Cf. Webb v Isaac 1915 EDL 273. 14. Dube v Administrator, Transvaal 1963 (4) SA 260 (W). 15. Boumil MM, Elias C. The Law of Medical Liability. St Paul, Minn.: West Publishing Co., 1995:17. 16. Strauss SA. Doctor, Patient and the Law. 3rd ed. Pretoria: JL van Schaik, 1993:3. 17. Hill v Midlantic Health Care Group 33 A.2d 314 (D.C. 2007). http://definitions.uslegal.com/p/patientabandonment/ (accessed 16 October 2014). 18. Classen NJB, Verschoor T. Medical Negligence in South Africa. Pretoria: Digma, 1992:38-39.

Accepted 12 November 2014.

March 2015, Vol. 105, No. 3

EDITORIAL

The Global Status Report on Violence Prevention 2014: Where to for the South African health sector? The World Health Organization (WHO), the United Nations Development Programme and the United Nations Office on Drugs and Crime jointly released the first Global Status Report on Violence Prevention[1] on 10 December 2014. The report reviews how governments around the world, including in South Africa (SA), are attempting to curb interpersonal violence. There is some good news in the report. In common with many other countries, SA’s homicide rate has declined over the past decade: it was 40.3/100 000 in 2004/5, and 32.2/100 000 in 2012/2013.[2] Across the five types of interpersonal violence assessed in the report – child maltreatment, youth violence, intimate partner violence, sexual violence and elder abuse – SA has national action plans for all but two, namely youth violence and elder abuse (and in these two cases, some provinces have action plans). But manifestly it is not all good news. Homicide levels in SA are fluctuating around 32/100 000, and over the past 4 years, the lowest level achieved was 30.9/100 000 (in 2011/2012).[2] Homicide is a robust indicator of the prevalence of other forms of violence,[3,4] so this demonstrates that SA is struggling to reduce violence below the horizon achieved in 2011/2012. That rate is in itself exceedingly high: in 2012, the African Region as a whole had a rate of 10.9/100 000, making SA one of the most lethally violent African countries for which data are available.[1] This is a health sector issue for several reasons. First, the injuries and deaths caused by interpersonal violence place a considerable burden on the health sector. Second, evidence-based public health approaches to preventing violence are increasingly demonstrating their effectiveness.[1,3,5] The Global Status Report on Violence Prevention addresses several key areas for violence prevention: action plans, laws and policies, prevention programmes and services for victims of violence, and data on violence, and the SA health sector has a role to play in each. There are two key policy-level public health interventions that are likely to reduce all forms of violence: limiting access to firearms and to alcohol.[1,3] In terms of firearms control, SA has a comprehensive legal system in place to restrict firearm proliferation and misuse. However, recent experiences of trauma surgeons (A Nicol, A B van As, oral communication, 22 October 2014) and high-profile firearm murders suggest that firearm homicides are increasing after an initial drop.[6] In March 2015, the SA parliament will initiate a national Firearm Summit to review the state of the country’s firearm controls with a view to improving them.[7] This review will need evidence – evidence best obtained through injury surveillance in trauma centres and mortuaries. With the National Non-Natural Mortality Surveillance System[8] we are well placed to record deaths due to firearms: we now urgently need surveillance of injuries across trauma centres to complete the picture, as injuries tend to be more frequent than deaths and so provide a more complete picture of the role of firearms in violence.[9] Alcohol control geared towards reduction presents a more complicated picture, especially with SA’s history of alcohol abuse dating back to colonial times.[10] The government taxes most forms of alcohol in order to discourage excessive consumption. Nonethe less, a large proportion of South Africans binge drink, which carries a number of possible serious health consequences, including an

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increased risk of being both a perpetrator and a victim of violence.[1] There is a plethora of policy-level interventions that can reduce this, such as increasing taxes on alcohol and restricting hours of sale, and collaboration between health professionals, law enforcement and communities to develop and implement appropriate policies, as well as treatment and prevention programmes.[11] Most recently, Minister of Health Aaron Motsoaledi is to be commended for his call for a ban on alcohol advertising:[12] the rest of the health sector should support him in this. SA laws to prevent interpersonal violence are progressive and comprehensive in most areas. The only gaps are laws providing for victim compensation and legal representation, and in the area of child maltreatment, prevention (such as banning female genital mutilation, and a comprehensive ban on corporal punishment).[1] But the real problem is lack of enforcement. At best our laws are only partially enforced, and most are applied in a very limited way.[1] A case in point is the banning of corporal punishment in schools: data from national surveys conducted by the Centre for Justice and Crime Prevention (CJCP) reveals that 49.8% of SA children still suffer corporal punishment at the hands of teachers.[13] Violence in schools has serious consequences for children, including increasing the likelihood that they will go on to commit violent acts.[14] Health professionals, such as educational psychologists, urgently need to roll out evidence-based programmes to provide teachers with skills for non-violent discipline. Of course, it takes considerable resources to implement large-scale interventions, but countries with similar circumstances to SA, such as Brazil, Colombia, El Salvador, Mexico and India, are faring much better in this regard.[1] Similarly, there are a number of violence prevention programmes across the country that address each form of violence and services for victims, but these are typically provided in a very limited way and not on the large scale that can meaningfully address the problem. Notable exceptions include programmes that train children to recognise and avoid sexually abusive situations, preschool enrichment programmes, life-skills training for young people, and anti-bullying policies.[1] However, an investigation 10 years ago found that youth violence prevention programmes in SA were typically not evidence based and had not been rigorously evaluated,[15] and a more recent survey of parenting programmes had similar findings,[16] suggesting that there is not yet a culture of evidence-based intervention and evaluation in prevention programming in SA. There is therefore very little to give us confidence that programmes implemented here are effective – yet globally there is mounting evidence about effective programmes that could be applied in SA.[5] In addition, SA’s victim services are less developed in comparison with countries with similar challenges of violence in the Americas and South-East Asia.[1] This too needs attention, within the health sector and elsewhere. Supporting victims can prevent them both from becoming victims again and from becoming perpetrators.[17,18] If policies and programmes are to be effective, they need to be driven by relevant and accurate data. Compared with most other low- to middle-income countries, SA is data rich, and has national statistics on youth violence, intimate partner violence and sexual violence.[1] A survey that will give us the first-ever nationally representative data on child maltreatment is in progress, and is being led by researchers at CJCP and the University of Cape Town and funded by the UBS Optimus Foundation. These data will be released

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EDITORIAL

in mid-2015, and have massive potential to inform the design and delivery of interventions to reduce child maltreatment where they are needed the most. Elder abuse, however, remains under-researched in SA (as in many other countries). We need to continue to uphold these high standards, and expand on and use the data we have to design evidence-based interventions. Reducing violence is of course important from a human rights and safety perspective, but it will also contribute to national development. First, violence costs the economy a great deal. Patching up injuries, physical rehabilitation, conducting autopsies, treating mental health problems, prosecuting and incarcerating perpetrators, and putting children in foster care are all enormously costly things to do. According to a recent report from KPMG Human and Social Services, violence against women in SA alone costs the economy between R28.4 and R42.2 billion per year – 0.9 - 1.3% of the gross domestic product.[19] That would build many, many houses, and one of the recommendations of the Global Status Report on Violence Prevention is good housing design to reduce concentrated poverty, an area in which SA is failing.[1] Second, violence prevention programmes typically do not only prevent violence but also promote other good outcomes. Parenting programmes that aim to reduce child maltreatment, for instance, not only reduce child abuse and neglect but also teach parents the skills that promote child wellbeing more broadly. From the prevention perspective, their children are less likely to use drugs, to become HIVpositive, or to begin lives of crime. From the promotion perspective, their children are more likely to stay in school, and to have the skills to hold down a job and hence to contribute to the economy.[20] Reducing violence should therefore be a national priority, both to promote the rights of citizens to lives free from fear, and to release more funding for national development. Violence prevention initiatives that follow the public health approach can be effective. Since early calls to take this approach,[21] SA has established a solid foundation of relevant data and policy. Now is the time to build on this base by acting on the World Health Assembly Resolution[22] passed earlier this year, and implement the recommendations of the World Report on Violence and Health,[3] namely: • Create, implement and monitor a national action plan for violence prevention. • Enhance capacity for collecting data on violence. • Define priorities for, and support research on, the causes, consequences, costs and prevention of violence. • Promote primary prevention responses. • Strengthen responses for victims of violence. • Integrate violence prevention into social and educational policies, and thereby promote gender and social equality. • Increase collaboration and exchange of information on violence prevention. • Promote and monitor adherence to international treaties, laws and other mechanisms to protect human rights.

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• Seek practical, internationally agreed responses to the global drugs trade and the global arms trade. Catherine L Ward Department of Psychology, Faculty of Humanities, University of Cape Town, South Africa, and Safety and Violence Initiative, University of Cape Town Guy Lamb Safety and Violence Initiative, University of Cape Town, South Africa Corresponding author: C L Ward (catherine.ward@uct.ac.za, cathy.ward.sa@gmail.com) 1. World Health Organization. Global Status Report on Violence Prevention 2014. Geneva: WHO, 2014. (SA profile p. 195.) http://www.undp.org/content/dam/undp/library/corporate/Reports/UNDP-GVAviolence-2014.pdf (accessed 17 December 2014). 2. South African Police Service. Crime Categories: Figures and Ratios. Pretoria: South African Police Service, 2014. http://www.saps.gov.za/resource_centre/publications/statistics/crimestats/2014/crime_ stats.php (accessed 17 December 2014). 3. Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World Report on Violence and Health. Geneva: World Health Organization, 2002. 4. Matzopoulos R, Bhalla K, Harrison J. Homicide. In: Donnelly PD, Ward CL, eds. The Oxford Textbook of Violence Prevention: Epidemiology, Evidence and Policy. Oxford: Oxford University Press, 2015:11-18. 5. Donnelly PD, Ward CL, eds. The Oxford Textbook of Violence Prevention: Epidemiology, Evidence and Policy. Oxford: Oxford University Press, 2015. 6. Matzopoulos RG, Thompson ML, Myers JE. Firearm and nonfirearm homicide in 5 South African cities: A retrospective population-based study. Am J Public Health 2014;104(3):455-460. [http://dx.doi. org/10.2105/AJPH.2013.310650] 7. Merrington Z. Parliament to host gun control summit next year [television broadcast]. South African Broadcasting Corporation, 6 November 2014. 8. Butchart A, Peden M, Matzopoulos R, et al. The South African National Non-Natural Mortality Surveillance System – rationale, pilot results and evaluation. S Afr Med J 2001;91(5):408-417. 9. Schuurman N, Cinnamon J, Matzopoulos R, Fawcett V, Nicol A, Hameed SM. Collecting injury surveillance data in low- and middle-income countries: The Cape Town Trauma Registry pilot. Glob Public Health 2011;6(8):874-889. [http://dx.doi.org/ 10.1080/17441692.2010.516268] 10. Mager A. ‘White liquor hits black livers’: Meanings of excessive liquor consumption in South Africa in the second half of the twentieth century. Soc Sci Med 2004;59(4):735-751. [http://dx.doi.org/ doi:10.1016/j.socscimed.2003.12.005] 11. Parry CDH, Dewing S. A public health approach to addressing alcohol-related crime in South Africa. Afr J Drug Alcohol Stud 2006;5(1):41-56. 12. Makuyana I. Motsoaledi says no alcohol adverts. The New Age [newspaper on the Internet], 12 September 2013. http://www.thenewage.co.za/106998-1056-53-Motsoaledi_says_no_alcohol_ adverts/?switcher=1 (accessed 17 December 2014). 13. Burton P, Leoschut L. School Violence in South Africa: Results of the 2012 National School Violence Study. Cape Town: Centre for Justice and Crime Prevention, 2013. 14. Souverein F, Ward CL, Visser I, Burton P. Serious, violent young offenders in South Africa: Are they life-course persistent offenders? J Interpers Violence (in press). 15. Farr V, Dawes A, Parker Z. Youth violence prevention and peace education programmes in South Africa: A preliminary investigation of programme design and evaluation practices. Cape Town: Children’s Institute, University of Cape Town, 2003. 16. Wessels IM. Child maltreatment prevention programmes in South Africa: Investigating design and evaluation practices. MA thesis. Cape Town: University of Cape Town, 2012. 17. Hawkridge S, Berg A, Seedat S. The consequences of violence: Mental health issues. In: Donnelly PD, Ward CL, eds. The Oxford Textbook of Violence Prevention: Epidemiology, Evidence and Policy. Oxford: Oxford University Press, 2015:97-104. 18. Feder G, Sardinha L. Preventing intimate partner violence thorugh advocacy and support programmes. In: Donnelly PD, Ward CL, eds. The Oxford Textbook of Violence Prevention: Epidemiology, Evidence and Policy. Oxford: Oxford University Press, 2015:193-200. 19. KPMG Human and Social Services. Too costly to ignore – the economic impact of gender-based violence in South Africa. Johannesburg: KPMG, 2014. 20. Hawkins JD, Catalano RF, Arthur MW. Promoting science-based prevention in communities. Addict Behav 2002;27(6):951-976. [http://dx.doi.org/10.1016/S0306-4603(02)00298-8] 21. Kruger J, Butchart A, Seedat M, Gilchrist A. A public health approach to violence prevention in South Africa. In: Van Eeden R, Wentzel M, eds. The Dynamics of Aggression and Violence in South Africa. Pretoria: Human Sciences Research Council, 1998:399-424. 22. World Health Organization. Resolution WHA67.15. Strengthening the role of the health system in addressing violence, in particular against women and girls, and against children. 67th World Health Assembly, Geneva, 19-24 May 2014. Documentation WHA67: main documents, information documents, diverse documents, resolution. Geneva: WHO, 2014.

S Afr Med J 2015;105(3):183-184. DOI:10.7196/SAMJ.9305

March 2015, Vol. 105, No. 3

EDITORIAL

Prevention of Liver Fibrosis and Cancer in Africa: The PROLIFICA project – a collaborative study of hepatitis B-related liver disease in West Africa Hepatitis B and hepato cellular carcinoma in subSaharan Africa (SSA)

Achievements of the PROLIFICA project so far

Hepatitis B virus (HBV) infection causes a spectrum of acute and chronic liver disease ranging from inactive chronic carrier status to progressive chronic hepatitis, culminating in end-stage cirrhosis and liver cancer.[1] In SSA, HBV infection is endemic and the HBV-related disease burden is high. The lifetime risk of HBV infection is over 60%, and more than 8% of the population remain chronic HBV carriers who are at risk of progressive liver disease and HBV-related hepatocellular carcinoma (HCC). SSA has one of the highest HBV-related liver cancer rates in the world,[2] and it is the most common cancer among males and third most common among females.[3,4] Unfortunately, HCC is usually a highly aggressive tumour with limited treatment options, particularly in resource-poor settings such as SSA.[5] Furthermore, HBV-related HCC affects patients in their working and reproductive years.[5] HBV therefore represents a threat to health on the African continent. Early detection and treatment of HBV infection reduces HCC incidence and mortality (primary prevention).[6,7] Furthermore, HCC survival is improved by early detection of potentially treatable HCC by screening of patients at risk.[8] However, limited access to affordable medical care is a major limiting factor in hepatitis and liver cancer management in SSA. Routine HBV and HCC screening and surveillance programmes for the general population are virtually nonexistent, and there is a lack of infrastructure to support channelling of screened patients into long-term treatment programmes.[9] Safe and effective treatments for HBV exist, but in SSA treatment access is severely limited. Despite highly effective nucleoside analogues such as tenofovir being available in most countries in SSA at a generic price for the treatment of HIV infection, very few African countries offer publicly funded HBV treatment.[9]

Prevention of hepatitis B-related liver fibrosis and cancer in Africa: The PROLIFICA study

Against this sombre backdrop of HBV-related liver disease in SSA, the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) project was established in 2011 to address some of the urgent HBV research needs in West Africa. This is an ongoing 5-year translational research project funded by the European Union Framework 7[10] and represents a collaboration between Imperial College, London; the Medical Research Council (The Gambia Unit) in Fajara, The Gambia; the International Agency for Research on Cancer, Lyon, France; Le Dantec University Hospital, Dakar, and University of Thiès, Sénégal; and Jos University Teaching Hospital, Jos, Nigeria. The overall aim of the project is to reduce the incidence of HBVrelated HCC in West Africa. The three specific aims of the project are demonstrating the feasibility of widespread screening for HBVrelated liver disease; establishing whether treatment of HBV with nucleoside analogues is a cost-effective method to reduce the burden of HBV-related liver disease and liver cancer in West Africa; and developing novel biomarkers to predict and diagnose HBV-related liver fibrosis and HCC.

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To date, the PROLIFICA study has provided important insights into HBV-related HCC in West Africa, including identification of novel metabonomic biomarkers that may prove useful for HCC diagnosis in resource-poor settings;[11,12] identification of genomic determinants of HCC and epidemiological insights into risks for more severe HBVrelated liver disease;[13] validation of point-of-care tests for HBV (manuscript in submission) and the optimal use of the Fibroscan to measure liver stiffness[14] as a surrogate imaging marker for liver fibrosis; and the non-invasive aspartate aminotransferase-to-platelet ratio (APRI score) to determine the severity of liver cirrhosis from simple blood tests (manuscript in submission). Importantly, the PROLIFICA platform has resulted in crucial capacity building in each of the three countries involved in the study. Local health infrastructure has benefited from new technologies, such as the Fibroscan to assess liver fibrosis using ultrasound-based transient elastography, a mass spectroscopy system in The Gambia for local biomarker research and the development of in-house laboratory assays, as well as skills transference to build capacity for improved liver cancer healthcare in West Africa. Local nursing, medical and laboratory staff have benefited from training, education and employment opportunities. Procedures and training in effective and secure data management and ethical research practices have also been a central part of the PROLIFICA platform. Local researchers have availed themselves of specialised academic mentorship at each of the three sites involved in the study to obtain higher research degrees and produce highly regarded academic publications. Finally, community education on HBV infection, mode of transmission and prevention is likely to have had a positive impact on HBV awareness, both at the community and political level. Above all, the PROLIFICA platform has facilitated the development of strong relationships for future research collaborations and a deeper understanding of the barriers to improved healthcare delivery in Africa. All centres have benefited equally from the experience and knowledge shared between the investigating teams. Arguably these are the greatest achievements of the project. International collaborative projects between academic institutions in Africa and the rest of the world are a fantastic opportunity to share ideas, specialised expertise and new technologies and foster a united approach to solving some of the greatest public health challenges in Africa today. Collaborations also provide a stronger international voice to raise global awareness of the importance of liver disease in Africa among governments, the pharmaceutical industry and the international community. Acknowledgements. All the authors are grateful to the UK National Institute for Health Research Biomedical Facility at Imperial College London for infrastructure support. MMEC is supported by a Fellowship grant from the Sir Halley Stewart Foundation (Cambridge, UK). All the authors are participant workers in the European Union Framework 7-funded PROLIFICA project in West Africa, which aims to diagnose, treat and follow up a cohort of hepatitis B-positive patients in The Gambia, Sénégal and Nigeria (EC FP7, P34114; www.prolifica.eu). JH is supported by an NHMRC Early Career Post Doctoral fellowship.

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Jessica Howell Department of Medicine, Imperial College London, UK, Centre for Population Health, Macfarlane-Burnet Institute, Victoria, Australia, and Department of Medicine, University of Melbourne, Victoria Nimzing G Ladep Department of Medicine, Imperial College London, UK, and Department of Medicine, Jos University Teaching Hospital, Plateau State, Nigeria Maud Lemoine Department of Medicine, Imperial College London, UK, and Medical Research Council (The Gambia Unit), Fajara, The Gambia Shevanthi Nayagam Department of Medicine, Imperial College London, UK Papa Souleymane Toure Magatte Madoky Diop Joao Armindo Daveiga UFR Santé, Thiès University, Thiès, Sénégal Amina Sow Sall Gora Lo Laboratoire de Bacteriologie Virologie, Le Dantec Hospital, Dakar, Sénégal Mary M E Crossey Mark R Thursz Simon D Taylor-Robinson Department of Medicine, Imperial College London, UK

Mamadou Mourtalla Ka UFR Santé, Thiès University, Thiès, Sénégal Corresponding author: J Howell (j.howell@imperial.ac.uk) 1. European Association for the Study of the Liver. EASL clinical practice guidelines: Management of chronic hepatitis B virus infection. J Hepatol 2012;57(1):167-185. [http://dx.doi.org/10.1016/j. jhep.2012.02.010] 2. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005;55(2):74108. [http://dx.doi.org/10.3322/canjclin.55.2.74] 3. Parkin DM, Sitas F, Chirenje M, Stein L, Abratt R, Wabinga H. Part I: Cancer in indigenous Africans – burden, distribution, and trends. Lancet Oncol 2008;9(7):683-692. [http://dx.doi.org/10.1016/S14702045(08)70175-X] 4. Kirk GD, Lesi OA, Mendy M, et al. The Gambia Liver Cancer Study: Infection with hepatitis B and C and the risk of hepatocellular carcinoma in West Africa. Hepatology 2004;39(1):211-219. [http:// dx.doi.org/10.1002/hep.20027] 5. European Association for the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: Management of hepatocellular carcinoma. J Hepatol 2012;56(4):908-943. [http://dx.doi.org/10.1016/j.jhep.2011.12.001] 6. Robotin MC, Kansil MQ, George J, et al. Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: Effects on health services utilisation. BMC Health Serv Res 2010;10:215. [http://dx.doi.org/10.1186/1472-6963-10-215] 7. Liaw YF, Sung JJ, Chow WC, et al. Lamivudine for patients with chronic hepatitis B and advanced liver disease. N Engl J Med 2004;351(15):1521-1531. [http://dx.doi.org/10.1056/NEJMoa033364] 8. Lopez PM, Villanueva A, Llovet JM. Systematic review: Evidence-based management of hepatocellular carcinoma – an updated analysis of randomized controlled trials. Aliment Pharmacol Ther 2006;23(11):1535-1547. [http://dx.doi.org/10.1111/j.1365-2036.2006.02932.x] 9. World Health Organization.Global policy report on the prevention and control of viral hepatitis in WHO Member States. http://www.who.int/csr/disease/hepatitis/global_report/en/ (accessed 21 April 2014). 10. European Union Framework 7. www.prolifica.eu (accessed August 2014). 11. Shariff MI, Ladep NG, Cox IJ, et al. Characterization of urinary biomarkers of hepatocellular carcinoma using magnetic resonance spectroscopy in a Nigerian population. J Proteome Res 2010;9(2):10961103. [http://dx.doi.org/10.1021/pr901058t] 12. Ladep NG, Dona AC, Lewis MR, et al. Discovery and validation of urinary metabotypes for the diagnosis of hepatocellular carcinoma (HCC) in West Africans. Hepatology 2014;60(4):1291-301. [http://dx.doi.org/10.1002/hep.27264] 13. Shimakawa Y, Yan HJ, Tsuchiya N, Bottomley C, Hall AJ. Association of early age at establishment of chronic hepatitis B infection with persistent viral replication, liver cirrhosis and hepatocellular carcinoma: A systematic review. PLoS One 2013;8(7):e69430. [http://dx.doi.org/10.1371/journal. pone.0069430] 14. Lemoine M, Shimakawa Y, Njie R, et al. Food intake increases liver stiffness measurements and hampers reliable values in patients with chronic hepatitis B and healthy controls: The PROLIFICA experience in The Gambia. Aliment Pharmacol Ther 2014;39(2):188-96. [http://dx.doi.org/10.1111/apt.12561]

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Need for services for the care and prevention of congenital disorders in South Africa as the country’s epidemiological transition evolves The lack of prioritisation of congenital disorders (CDs) in health care, and the limited resources allocated to prevention and to the care of those affected, is an issue of global concern. This is especially true in low- and middle-income countries (LMICs), where over 90% of CDs currently occur, resulting in 95% of CD deaths worldwide.[1,2] In 2010 the World Health Organization’s World Health Assembly (WHA) prioritised services for the care and prevention of CDs, particularly in LMICs, by passing Resolution WHA63.17.[2] This recognised the importance of CDs as a cause of stillbirths and neonatal deaths, their contribution to under-5 mortality, and their contribution to failure to attain Millennium Development Goal 4 (MDG4). WHA63.17 urged member states to recognise and address CDs as a public health issue. It also highlighted the lack of accurate epidemiological data available for many LMICs.[2] CDs are often undiagnosed or misdiagnosed and the cause of death wrongly attributed. Collectively, this prevents policy decision-makers from correctly assessing the burden of CDs in these LMICs.[3]

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In South Africa (SA), the constitutional, legal and regulatory framework exists to promote the development of services for the care and prevention of CDs. It is the government’s responsibility to provide such services. To understand the renewed need for these services, it is important to consider, contemplate and review the epidemiological transition that has occurred in SA over the last 25 years.

Epidemiology of CDs in SA

Modelled data of genetic causes of CDs[1] and an estimate of teratogenic causes (A L Christianson, personal communication, 2014) indicate that a minimum of 6.8% of births, representing one in every 15 live births in SA, is affected by a CD. Of these, 80.5% are genetic or partially genetic in cause, while 19.5% are caused by teratogens. The latter is higher than the 10 - 15% expected, owing to the high prevalence of fetal alcohol syndrome.[1] With 26.2% of CDs diagnosable in the first day of life, over 18 000 cases annually should be identified and reported in SA.[4] However, in 2012 only 2 174 CDs were reported via the Birth Defects Collection Tool administered by the National Department of Health (NDoH) (V Mtyongwe,

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personal communication, 2013). This indicates under-reporting of 88%! Although serious CDs can be life threatening or result in longterm disability, up to 70% can be prevented, cured or ameliorated by appropriate care.[1,5] Many interventions are relatively inexpensive and low-tech, including surgery for congenital malformations and community-based preventive measures (e.g. iodine and folic acid fortification of staple foods).[1]

Epidemiological transition

Epidemiological transition is the term for the change in population health statistics and pattern of diseases of a country or region, consequent on change in socioeconomic, education, infrastructure and healthcare development.[1] Omran’s three-stage model of epi demiological transition[6] has been used extensively to describe this process, particularly in industrialised nations. During this transition, infant and child mortality rates decrease and longevity rises, communicable diseases are controlled and eradicated, and noncommunicable and degenerative diseases emerge. Most high-income or industrialised countries completed the first two stages of epidemiological transition decades ago. Stage one, the ‘age of pestilence and famine’, is characterised by high fluctuating mortality rates, a low life expectancy at birth, and epidemics, famine and war as the main causes of death. This is followed by stage two, the ‘age of receding pandemics’, when mortality starts to decrease and is accompanied by a marked increase in life expec tancy, although high levels of communicable disease re main.[6] By controlling infectious diseases, reducing malnutrition and improving healthcare (including maternal) services, industrialised countries moved into stage three, the ‘age of degenerative and man-made diseases’.[1,6] Deaths from CDs remain invisible during this process of transition – ‘buried’ among deaths caused by communicable diseases – to emerge only as the latter are adequately controlled. CDs then become proportionately more significant in overall neonatal, infant and child mortality.

CDs attained public health significance in industrialised nations as they moved into the third stage of epidemiological transition in the early 1960s.[1] Since 85 - 90% of CDs have a genetic cause, their birth prevalence and resulting mortality remained high,[1] causing them to emerge and persist as a leading cause of child death in industrialised nations. A comparative study of death rates in England and Wales for 1901 and 1971 demonstrates this: a 68% reduction in non-communicable diseases occurred between 1901 and 1971, but the number of deaths caused by CDs remained unchanged.[1]

Epidemiological transition and CDs in SA

SA, like many LMICs, has not followed the classic model of epidemiological transition experienced by industrialised nations, as a result of the HIV/AIDS and TB epidemics.[7] Fig. 1 plots the under-5 mortality rate (U5MR), infant mortality rate (IMR) and life expectancy at birth (longevity) data for SA over the past 25 years. From 1960, a clear trend of decreasing infant and under-5 mortality and increasing longevity continued until 1992, when life expectancy at birth peaked at 62.33 years. In 1993, both the U5MR and the IMR were at an all-time low of 58.2/1 000 live births and 45.1/1 000 live births, respectively. At this point it appeared as if SA would follow the three classic stages of epidemiological transition, approaching the early phases of transition from stage two of the ‘age of receding pandemics’ to stage three, the ‘age of degenerative and man-made diseases’.[6] As a result of this falling childhood mortality in the early 1990s, CDs began to emerge as a public health issue. The Policy Guidelines for the Management and Prevention of Genetic Disorders, Birth Defects and Disabilities were published by the NDoH in 2001.[8] These outlined goals, objectives, strategies and delivery of clinical and laboratory services appropriate for the care and prevention of CDs. In 2004, the National Guidelines for the Care and Prevention of the Most Common Genetic Disorders, Birth Defects and Disabilities[9]

35.0

Deaths, n /1 000 live births

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70 25.0

60 50

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1988 1989 1990 199119921993 1994 1995 1996 1997 1998 1999 2000 20012002 2003 2004 2005 2006 20072008 2009 2010 2011 2012 2013

MDG set

U5MR

IMR

Longevity

HIV prevalence (% of pregnant women infected)

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ARV roll-out

Fig. 1. Epidemiological transition in SA over the past 25 years, as demonstrated by data for childhood mortality,[18] longevity[19] and the HIV epidemic.[20]

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were published, targeting primary healthcare providers, describing common CDs and strategies for their care and prevention. However, progress in epidemiological transition was dramatically interrupted and reversed in the mid-1990s with the advent of the concomitant HIV/AIDS and TB epidemics (Fig. 1). Over a 10-year period, HIV prevalence in pregnant women soared from 7.6% in 1994 to 29.5% in 2004. Child mortality rose dramatically, with the U5MR peaking at 80.8/1 000 live births in 2003 and the IMR at 53.2/1 000 in 2002. Life expectancy dropped to 51.56 years in 2005, an all-time low since the 1960s. SA was no longer following the sequential stages of transition as HIV/AIDS caused the resurgence of TB, adding a stage to Omran’s concept known as the ‘age of emergent and re-emergent infections’.[7,10,11] Combined with the simultaneously increasing burden of non-communicable diseases in the population, this has led to a ‘double burden of disease’.[11] In 2004, the prevalence of HIV infection among pregnant women plateaued at 30% and the U5MR started to reduce as a result of scaledup prevention of mother-to-child transmission and expanded rollout of antiretroviral (ARV) therapy.[12] The 2002 IMR of 53.2/1 000 live births dropped to 33.5 in 2012 (Fig. 1). This is lower than the all-time best IMR of 45/1 000 live births in 1993 prior to the HIV/ AIDS epidemic. However, since 2011 both the IMR and U5MR have stagnated without significant further reductions.[13] A major effect of the HIV/AIDS and TB epidemics was to ‘bury’ the issue of CDs. As services for HIV/AIDS developed, funding and attention were diverted away from tertiary medical genetic services. If child mortality, including neonatal deaths, is to decrease further, control of these ongoing epidemics cannot be at the expense of other child healthcare needs.[12] Services for the care and prevention of CDs in SA are now at a lower base than in 2001. The 2003 recommendations for human capacity requirements to be trained and in-post by 2010 to meet the expected, and now increased, health needs remain unful filled.[14] Personnel levels are similar to, or lower than, those in 2001, with 11 medical geneticists today compared with four in 2001 and the 20 recommended by 2010.[14] Of the nine genetic counsellors in posts today, only four are in the state system (T Wessels, personal communication, 2014), compared with approximately 20 in 2001, and the 80 recommended.[14] Budget cuts have compromised medical genetic diagnostic laboratory services countrywide. In 2013, SA was reported as the only country of eight emerging economies evaluated where positive development in improving med ical genetic service structures had ceased and indeed regressed.[3] This decline will take time to reverse, and the dire state of these services, including the lack of policy addressing childhood disability, must be recognised by those in authority and urgently rectified.

Conclusion

While SA has missed attaining MDG4, it has significantly reduced the U5MR and IMR under difficult circumstances. The previous negative epidemiological transition, premised on the HIV/AIDS epidemic, has reversed and is once again positive with an IMR of 33/1 000 live births.[7] SA must now confront the issue of developing services for the care and prevention of CDs to reduce the stagnating child mortality rates.[13] The current IMR is now below 40/1 000 live births, at which point countries recognise the coming health needs of CDs and strive to implement appropriate services.[15] The proportion of deaths from CDs in SA under-5s was 4% in 2008,[3] and may be expected to rise as childhood deaths from CDs increasingly emerge

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as a leading cause of death in children while deaths from infections, particularly HIV/AIDS, decrease. Legislation entitles those affected and living with CDs, including those disabled as a result, to the ‘best possible patient care’ in the prevailing circumstances, and provides for access to prevention by appropriate interventions.[16] With the global focus, including that of SA, shifting to non-communicable diseases, CDs must be contextualised as the first non-communicable disease experienced by people. CDs deserve to be prioritised, in accordance with WHA Resolution WHA63.17, to ensure the human dignity and constitutionally and legally enshrined human rights of those affected and their families.[2,17] H L Malherbe School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa, and National Chair, Southern African Inherited Disorders Association A L Christianson Division of Human Genetics, National Health Laboratory Service and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa C Aldous School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: H L Malherbe (helen@hmconsult.co.za) 1. Christianson A, Howson CP, Modell B. March of Dimes: Global Report on Birth Defects, the Hidden Toll of Dying and Disabled Children. White Plains, NY: March of Dimes Birth Defects Foundation, 2006:85. 2. World Health Organization. Sixty-Third World Health Assembly – Birth Defects. Geneva: WHO, 2010. http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R17-en.pdf (accessed 11 September 2013). 3. Nippert I, Christianson A, Gribaldo L, et al. Genetic Testing in Emerging Economies (GenTEE) Summary Report. Ispra, Italy: Joint Research Centre, European Commission, 2013:176. 4. Venter P, Christianson A, Hutamo C, Makhura M, Gericke G. Congenital anomalies in rural black South African neonates – a silent epidemic? S Afr Med J 1995;85(1):15-20. 5. Czeizel AE, Intôdy Z, Modell B. What proportion of congenital abnormalities can be prevented? BMJ 1993;306(6876):499-503. [http://dx.doi.org/10.1136/bmj.306.6876.499] 6. Omran AR. The epidemiologic transition: A theory of the epidemiology of population change. Milbank Mem Fund Q 1971;49(4):509-538. [http://dx.doi.org/10.2307/3349375] 7. Kahn K, Garenne ML, Collinson MA, Tollman SM. Mortality trends in a new South Africa: Hard to make a fresh start. Scand J Public Health Suppl 2007;35(69):26-34. [http://dx.doi. org/10.1080/14034950701355668] 8. Department of Health. Policy Guidelines for the Management and Prevention of Genetic Disorders, Birth Defects and Disabilities. Pretoria: Department of Health, 2001. 9. Department of Health. National Guidelines for the Care and Prevention of the Most Common Genetic Disorders, Birth Defects and Disabilities. Pretoria: Department of Health, 2004. 10. Smallman-Raynor M, Phillips D. Late stages of epidemiological transition: Health status in the developed world. Health Place 1999;5(3):209-222. [http://dx.doi.org/10.1016/S1353-8292(99)00010-6] 11. Agyei-Mensah S, de-Graft Aikins A. Epidemiological transition and the double burden of disease in Accra, Ghana. J Urban Health 2010;87(5):879-897. [http://dx.doi.org/10.1007/s11524-010-9492-y] 12. Kerber KJ, Lawn JE, Johnson LF, et al. South African child deaths 1990-2011: Have HIV services reversed the trend enough to meet Millennium Development Goal 4? AIDS 2013;27(16):2637-2648. [http://dx.doi.org/10.1097/01.aids.0000432987.53271.40] 13. Dorrington R, Bradshaw D, Laubscher, R. Rapid Mortality Surveillance Report 2012. Cape Town: South African Medical Research Council, 2012. http://www.mrc.ac.za/bod/ RapidMortalitySurveillanceReport2012.pdf (accessed 29 October 2014) 14. Department of Health. Strategic Framework for the Modernisation of Tertiary Hospital Services. Discussion Document. Pretoria: Department of Health, 2003. 15. Modell M, Kuliev A. The history of community genetics: The contribution of the haemoglobin disorders. Community Genet 1998;1(1):3-11. [http://dx.doi.org/10.1159/000016129] 16. World Health Organization, World Alliance of Organizations for the Prevention of Birth Defects. Services for the Prevention and Management of Genetic Disorders and Birth Defects in Developing Countries (Report of a Joint WHO/WAOPBD Meeting, The Hague, 5-7 January 1999). Geneva: WHO, 1999. 17. Christianson AL. Attaining human dignity for people with birth defects: A historical perspective. S Afr Med J 2013;103(12):1014-1019. [http://dx.doi.org/10.7196/samj.7277] 18. UN Inter-agency Group for Child Mortality Estimation (IGME). Child mortality estimates. www. childmortality.org (accessed 3 November 2014). 19. World Bank. Life expectancy at birth total (years). http://data.worldbank.org/indicator/SP.DYN.LE00. IN (accessed 2 November 2014). 20. Health Systems Trust. 2012 National Antenatal Sentinel HIV & Herpes Simplex Type-2 Prevalence Survey. www.hst.org.za/publications/2012-national-antenatal-sentinel-hiv-herpes-simplex-type-2prevalence-survey (accessed 4 November 2014).

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Dementia in rural South Africa: A pressing need for epidemiological studies Dementia is a growing public health concern globally, with total estimated worldwide costs per year at USD604 billion in 2010.[1] With older age being a major risk factor for dementia, the increasing numbers of older adults worldwide will increase demand for services to diagnose, treat and care for people with dementia (PWD). Little is known about the prevalence of dementia or its impact on older adults living in low- and middle-income countries (LMICs) in Africa, including South Africa (SA). Furthermore, there has been little research into the aetiology and risk factors in LMICs. The need for studies to investigate these factors in SA is therefore critical. Primary dementia is a non-communicable disease (NCD) or syndrome, usually of a chronic or progressive nature, caused by neurodegeneration in the brain that affects a range of cognitive domains including memory, language, orientation and executive functions. As a result, behaviour, mood and the ability to perform everyday activities are affected. Although dementia mainly affects older people, it is not a normal part of ageing. Alzheimer’s disease (AD) is the most common form of dementia in older adults and possibly contributes to 60 - 70% of cases.[2] Other major varieties include vascular dementia, dementia with Lewy bodies and frontotemporal dementia. In SA, disorders associated with neurodegeneration such as traumatic brain injury, alcohol dependence and HIV infection are affecting increasing numbers of older adults. There is also a growing burden of disease from NCDs such as diabetes, heart disease and obesity resulting from increasingly unhealthy lifestyles and diet, which contribute to dementia risk.[3] Dementia causes a loss of independence and is overwhelming for individuals living with the condition, their carers and their families. Comorbidities and frailty become increasingly common as dementia progresses, requiring more health, social and home/community care services.

Worldwide prevalence

Recent estimates are that there are approximately 44 million PWD worldwide, with 60% of these living in LMICs. This percentage is predicted to rise to 71% by 2050,[4] with expected increases between 134% and 146% in Latin America, North Africa and the Middle East. Projected increases for sub-Saharan Africa are between 70% and 90%. This relatively modest increase is consistent with limited demographic ageing owing to high child and adult mortality and the HIV epidemic.[2] Estimated age-standardised dementia prevalences for individuals aged >60 years have been reported for 21 Global Burden of Disease regions,[1] with a four-fold variation in prevalence from 2.1% to 8.5%. The 10/66 Dementia Research Group conducted a multicentre study in ten LMICs that included Nigeria but not SA. The dementia prevalence using Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria was 3.9% for persons aged over 60 years.[5] With the 10/66 screening algorithm, prevalences were higher, ranging from 5.6% to 11.7%, being lowest in rural China and India and highest in Cuba. The difference in prevalence with different diagnostic criteria was reportedly due to lack of sensitivity of the DSM-IV for less severe cases. Cases of dementia generally progress in severity over time, which calls for earlier detection. Research on dementia conducted in sub-Saharan Africa indicates a higher prevalence in urban v. rural areas. The prevalence ranges from 2 - 3.7% in rural Nigeria and Benin to 6 - 7.6% in cities in

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Central Africa.[6] The differing prevalence ranges may reflect the methods employed in the studies, or differences in genetic, familial, environmental, cultural or educational factors in the regions studied. AD risk due to the ApoE4 allele is weaker for Yoruba Nigerians than for African Americans,[7] and it is not known how genetic risk varies among other African populations. Moreover, milder dementia may be underdetected in LMICs because of low awareness, the high levels of support routinely provided to older people, and reluctance to report social and occupational failings to outsiders. These factors all contribute to difficulties in establishing a diagnosis.

Dementia prevalence in SA

There is a paucity of published research on the prevalence of dementia in SA.[8] A survey of individuals aged >60 years in residential homes found 7.9% with dementia; this was not, however, a population prevalence study. The University of the Free State, with the 10/66 Group, investigated dementia in an urban black community and reported a higher than expected preliminary prevalence of approximately 6% in a small sample of 200 older persons.[9]

Prevalence of HIV-associated dementia

There is potentially a growing epidemic of dementia in older South Africans, especially among those with HIV infection. The prevalence of HIV-associated dementia (HAD) is 15 - 30% in untreated populations with late-stage disease, presenting with neurocognitive impairments, emotional disturbances, and motor dysfunction.[10] The prevalence in individuals receiving highly active antiretroviral therapy (HAART) is 10%, with an annual incidence of 1%. The prevalence of less severe forms of HIV-associated neurocognitive disorder (HAND) is 20 - 30%.[11] Prevalences are higher among people accessing HIV care in sub-Saharan African countries with a high HIV seroprevalence. Prevalences of 42% for HAND and 25% for HAD were reported among individuals starting HAART in primary care centres in Cape Town,[12] with all study participants being in later stages of HIV infection. Cognitive disorder in HIV is particularly important in view of associations with poor adherence to HAART, faster disease progression and mortality.[12] It is difficult to quantify the impact of numbers of people with dementia and of the age distribution of dementia cases in the region. Given an adult HIV seroprevalence of 15 - 25% in southern African countries, it is conceivable that most patients with dementia in the region are likely to have HAD.[10]

Services for PWD in SA

It is anticipated that by 2030 the proportion of the SA population aged >60 years will have increased to 11%,[13] with a concomitant rise in cases of dementia. However, the level of awareness and preparedness for the detection and costs of dementia care in the country is low, particularly in rural areas. In 2011, SA had fewer than ten geriatricians and fewer than five specialists in old-age psychiatry for a population of 3.8 million persons aged >60 years.[14] Basic curricula for training of health professionals in screening and diagnosis of dementia, and of social workers and other practitioners in management and care options for PWD, are limited. Dementia is often unrecognised by primary care practitioners, with signs and symptoms often ascribed simply

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to old age. As in many LMICs, primary level healthcare concentrates on treatable diseases. Health and social services often fail to meet the needs of older persons, especially those with mental health problems and dementia.[15] In rural areas, the burden of HIV cases on the health system results in limited access to good treatment for PWD.[1] Dementia drugs to improve cognitive function and treat underlying depression and/or behavioural disorders are expensive and unavailable on the Essential Drug List, and are therefore beyond the reach of the majority of older persons. A great need for family support and care services for problems encountered with daily living and behaviour has been identified. A study in Cape Town found that 79% of a memory clinic’s clients were being cared for by family members, some of whom had given up their jobs to do so.[16] Caregiver stress is highlighted as an important factor in dementia care in LMICs, even in traditional cultures where family care is regarded as the norm.[15] There are problems with access to care for older persons in urban areas, but the situation is worse in rural areas, where more than 40% of the SA population live and where service provision is fragmented and often severely underresourced. If dementia and its associated behavioural symptoms are poorly understood in rural communities, there is the risk that individuals with dementia may be stigmatised, with their symptoms ascribed to witchcraft, ostracised and subject to abuse. The policy on ageing in SA promotes deinstitutionalisation and limits statesubsidised residential care, so that no more than 2% of frail older persons who are in need of 24-hour nursing care are catered for.[17] The national dementia associations, Alzheimer’s SA and Dementia SA, both non-governmental organisations (NGOs), do provide informal education and support for carers and pursue activist roles to improve both policy and services. Similarly, a few other NGOs, including religious groups, provide services for older people. The paucity of epidemiological data in SA makes it difficult to advocate for improved services or prioritisation of funding for dementia studies. Research on prevalence and risk factors pertinent to the local population is needed to estimate the public health burden of dementia. Increased knowledge about dementia will enable earlier detection and diagnosis of this NCD. Thereafter, healthcare, interventions and support can be implemented and improved. This is particularly relevant at the present time in SA, as the government plans to introduce a National Health Service with National Health Insurance, and it would be timely to ensure that services for older persons are incorporated. The following are needed now to address dementia in SA: • Robust prevalence data using culture-fair screening tests • Earlier diagnosis and intervention options • Destigmatisation and increased awareness • Increased preparedness and service provision • Integration of older persons’ needs and rights into national health policies across all sectors, e.g. health and justice, adequate protection of vulnerable PWD from abuse and neglect • Prioritised research funding • Education at all levels, including communities, to better manage PWD and enable them to live meaningful and purposeful lives • Training and skills development for healthcare providers

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• Career advancement for professionals in geriatric medicine and related disciplines. Celeste A de Jager Divisions of Geriatric Medicine and Neurology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa John A Joska Division of Neuropsychiatry, Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa Margaret Hoffman School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa Karen E Borochowitz Dementia SA, Cape Town, South Africa Marc I Combrinck Divisions of Geriatric Medicine and Neurology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: C A de Jager (celeste.dejager@uct.ac.za) 1. World Health Organization. Dementia: A Public Health Priority. Geneva: WHO, 2012. http:// www.who.int/mental_health/publications/dementia_report_2012/en/ (accessed 31 January 2015). 2. Alzheimer’s Association. Alzheimer’s disease facts and figures. Alzheimers Dement 2012;8(2):131-168. [http://dx.doi.org/10.1016/j.jalz.2012.02.001] 3. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw D. The burden of noncommunicable diseases in South Africa. Lancet 2009;374(9693):934-947. [http://dx.doi.org/10.1016/ S0140-6736(09)61087-4] 4. Ferri CP, Prince M, Brayne C, et al; Alzheimer’s Disease International. Global prevalence of dementia: A Delphi consensus study. Lancet 2005;366(9503):2112-2117. [http://dx.doi.org/10.1016/S01406736(05)67889-0] 5. Prince M, Acosta D, Chui H, et al. Dementia diagnosis in developing countries: A cross-cultural validation study. Lancet 2003;361(9361):909-917. [http://dx.doi.org/10.1016/S0140-6736(03)12772-9] 6. Guerchet M, Mouanga AM, M’belesso P, et al. Factors associated with dementia among elderly people living in two cities in Central Africa: The EDAC multicentre study. J Alzheimers Dis 2012;29(1):15-24. [http://dx.doi.org/10.3233/JAD-2011-111364] 7. Hendrie HC, Murrell J, Baiyewu O, et al. APOE ε4 and the risk for Alzheimer disease and cognitive decline in African Americans and Yoruba. Int Psychogeriatr 2014;26(6):977-985. [http://dx.doi. org/10.1017/S1041610214000167] 8. Olayinka OO, Mbuyi NN. Epidemiology of dementia among the elderly in sub-Saharan Africa. Int J Alzheimers Dis 2014;2014:195750. [http://dx.doi.org/10.1155/2014/195750] 9. Radebe M. Media release, Media Liaison. http://www.ufs.ac.za/templates/archive. aspx?news=1871&cat=1 (accessed 31 January 2015). 10. Grant I. Neurocognitive disturbances in HIV. Int Rev Psychiatry 2008;20(1):33-47. [http://dx.doi. org/10.1080/09540260701877894] 11. Valcour VG, Shikuma CM, Walters MR, et al. Cognitive impairment in older HIV-1-seropositive individuals: Prevalence and potential mechanisms. AIDS 2004;18(Suppl 1):S79-S86. 12. Joska JA, Westgarth-Taylor J, Myer L, et al. Characterization of HIV-associated neurocognitive disorders among individuals starting antiretroviral therapy in South Africa. AIDS Behav 2011;15(6):1197-1203. [http://dx.doi.org/10.1007/s10461-010-9744-6] 13. United Nations, Department of Economic and Social Affairs, Population Division. World Mortality Report. New York: UN, 2013. 14. Kalula S, Petros G. Responses to dementia in less developed countries with a focus on South Africa. Global Aging 2011;7(1):31-40. 15. Patel V, Prince M. Ageing and mental health in a developing country: Who cares? Qualitative studies from Goa, India. Psychol Med 2001;31(1):29-38. 16. Kalula SZ, Ferreira M, Thomas KGF, de Villiers L, Joska JA, Geffen LN. Profile and management of patients at a memory clinic. S Afr Med J 2010;100(7):449-451. 17. Follentine S. Ageing in South Africa: An overview. Bold 2006;16(4):7-16.

S Afr Med J 2015;105(3):189-190. DOI:10.7196/SAMJ.8904

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The Vaccine and Cervical Cancer Screen project 2 (VACCS 2): Linking cervical cancer screening to a two-dose HPV vaccination schedule in the SouthWest District of Tshwane, Gauteng, South Africa L C Snyman,1 MB ChB, MPraxMed, MMed (O&G), FCOG (SA); G Dreyer,1 MB ChB, MMed (O&G), MCOG (SA), PhD; C Visser,1 BSc (Hons), MSc; M H Botha,2 MB ChB, MMed (O&G), FCOG (SA), PhD; F H van der Merwe,2 MB ChB, MMed (O&G), FCOG 1 2

ynaecological Oncology Unit, Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of Pretoria, South Africa G Unit for Gynaecological Oncology, Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa

Corresponding author: L C Snyman (leon.snyman@up.ac.za)

Background. Cervical cancer is a preventable disease with a high prevalence in South Africa (SA), where screening is opportunistic. Primary prevention is now possible through HPV vaccination. In VACCS 1 the feasibility of linking cervical cancer with HPV vaccination was demonstrated. Objectives. To investigate the feasibility of linking HPV self-testing with a two-dose HPV vaccination schedule and to compare results with VACCS 1. Methods. The project was conducted in five schools in the South-West District of Tshwane, Gauteng, SA. Leaflet information on cervical cancer and screening was provided, with requests for consent and assent for a two-dose HPV vaccination of schoolgirls. Female caregivers were invited to take part in HPV self-screening. Results. Of 965 girls invited for vaccination, 519 (53.7%) had full consent and 518 (99.8%) received at least one vaccine dose. The invited uptake rate was 53.7% and 495 girls received both doses, giving a completion rate of 95.4% v. 82.6% in VACCS 1. Of 1 135 self-screen kits handed out, 560 (49.3%) were not returned. The mean age (standard deviation) of the 160 women who participated in self-screening was 38.7 (7.7) years. HPV testing was negative in 116 women (72.5%), 15 women (9.4%) tested positive for HPV 16 and/or 18, and 27 (16.9%) were positive for non-16/18 oncogenic HPV. Conclusion. Data from the VACCS projects suggest that school-based vaccine programmes can be successfully implemented. A two-dose schedule allowed for higher completion rates. Linking self-collected HPV screening to HPV vaccination is feasible, is a promising and viable screening strategy, and reached the appropriate age group for screening. S Afr Med J 2015;105(3):191-194. DOI:10.7196/SAMJ.8888

Cervical cancer incidence rates in South Africa (SA) have reached epidemic proportions, where cervical cancer accounts for 18.0/100 000 of deaths (age-standardised rate). Cancer of the cervix is the leading cause of cancer-related death in Africa.[1] HIV infection increases the risk of developing cervical cancer and lowers the age at diagnosis.[2] Although the disease is largely preventable through screening programmes aimed at treatment of detected cancer precursor lesions, successful screening programmes have not been implemented anywhere in the developing world.[3] Fortunately effective vaccines are registered and available against the viral cause of the disease, namely human papillomavirus (HPV).[4] Before 2014, these vaccines were not yet introduced into the national vaccine programme in SA – the Expanded Program on Immunization (EPI). During 2014, a two-dose vaccination programme was introduced in some schools for girls in grade 4 in SA. The vaccines are available for private healthcare users, but are underutilised in this sector as well. It is predicted that in the future cervical cancer vaccination will be a more cost-effective and much more effective strategy than screening for this disease.[5] HPV vaccines were originally tested in a three-dose regimen in adult women and found to be highly immunogenic and effective in preventing cervical cancer precursor lesions. Recently new data

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have demonstrated that vaccination with two doses of the same vaccine in younger girls (aged 9 - 14 years) also provides high levels of antibodies. Indeed, the antibody response was demonstrated to be non-inferior to the immunogenicity obtained with a two-dose schedule in females aged 15 - 25 years. A similar safety profile was also demonstrated when compared with the three-dose group.[6,7] Countries in the developed and developing world are increasingly opting to provide two doses of HPV vaccine as part of their national policy in response to these preliminary data. This method of bridging to efficacy data is a well-established approach in vaccinology. It is proposed that introduction of the HPV vaccine into the EPI programme in SA will be greatly facilitated by providing only two doses (at months 0 and 6) to primary school girls, while immunogenicity will be uncompromised because of the young age of the recipients.[7] Herd immunity will depend upon high uptake and completion rates, while affordability and success of the programme will also depend upon resources needed as well as direct and indirect programme costs. The first arm of the Vaccine and Cervical Cancer Screen (VACCS) project (VACCS 1) showed that cervical cancer screening of women with self-testing can be successfully linked to implementation of an HPV vaccination programme at the schools attended by their daughters. In this trial, the conventional three-dose regimen was used and more than 1 000 girls were vaccinated.[8]

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The current study, done in the same district as VACCS 1, aimed to investigate the feasibility of linking two-dose vaccination of eligible primary school girls with HPV self-testing of their female caregivers. In addition, this study compared some differences in methodology and outcomes with the first VACCS project. Screening uptake and outcomes were also investigated and compared with the outcomes achieved in VACCS 1. The major differences in study methods between VACCS 1 and 2 included the invitation to female parents and guardians to take part in self-screening, the two-dose vaccination schedule, and the collection and testing of HPV DNA. HPV tests were sent with the girls attending school and, unlike with VACCS 1, there were no additional information events in the form of an oral presentation presented by a doctor.

Methods

As with the first VACCS project, this national study was conducted in Gauteng and Western Cape provinces with the approval of the national and provincial departments of Basic Education and Health. The method and results of the Gauteng part of the study are described here. Five primary schools neighbouring those in which girls had been vaccinated in VACCS 1 were identified in the South-West District of Tshwane. After obtaining consent from the governing body and princiÂ pal of each school, study packs containing printed leaflet information, informed consent and assent forms and self-screen kits were handed out to all the girls in grades 4 - 7 (aged â&#x2030;Ľ9 years) to take home. The printed leaflet contained information about cervical cancer and its symptoms, accurate and complete information about the safety and efficacy of the HPV vaccine for primary prevention of cervical cancer, and information on screening for the disease. Parents and guardians of eligible girls were requested to provide informed consent for a two-dose HPV vaccine schedule, while all eligible girls were requested to provide assent for vaccination. Two bivalent vaccine doses donated by the manufacturing company were administered to the consented girls, 6 months apart, by a team of registered nurses during school hours. Female parents and guardians of eligible girls were invited to take part in self-administered HPV screening. The screen kit consisted of a sample collector with user instructions available as an Evalyn brush. Specimens together with personal information were returned to the school in sealed containers. DNA was extracted from the Evalyn brush and tested using Roche Cobas 4800.[9] HPV DNA results were reported as positive for HPV 16, HPV 18 and other high-risk HPV (hrHPV) types (31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68) or negative for oncogenic HPV. HPV test results were interpreted as positive if DNA of any of the 15 high-risk viral types was found, and were interpreted as invalid if no DNA amplification occurred as tested by the internal control. Women who screened positive were informed of the results via the school system and by making use of mobile phone technology, and invited

to the gynaecology department at Kalafong Hospital for treatment or requested to visit their own healthcare provider with the screen results.

Definitions

The invited cohort (IC) was defined as all female learners enrolled in the selected schools in grades 4 - 7 and the consented cohort (CC) as participants with written consent from the parent or guardian as well as assent from the learner. Girls whose parents or guardians had given consent but who did not attend vaccine events were included in the CC. The vaccinated cohort (VC) comprised all girls who received at least one vaccine dose. Vaccine uptake rates were calculated in a number of ways in order to allow comparison with other published HPV vaccine reports and with VACCS 1. The consented uptake rate (CUR) was calculated as VC/CC and the invited uptake rate (IUR) as VC/IC. Vaccine completion rates (VCRs) were determined using the vaccine cohort as a denominator. The VCR was calculated using all girls who received both vaccine doses, while the insufficiently vaccinated rate (IVR) used the number of girls who received only one vaccine dose. The study was approved by the Research Ethics Review Committee of the Faculty of Health Sciences, University of Pretoria (90/2013).

Results

Vaccination data

In the five schools selected for the project, the IC consisted of 965 girls. The CC consisted of 519 girls (53.7%) of whom 518 received the first vaccine dose (VC), giving a consented uptake rate of 99.8%. The IUR was 53.7%. Four hundred and ninety-five girls received both doses and 23 received only one dose, resulting in an IVR of 4.4%. The VCR was 95.4% for two doses. The vaccination uptake and completion rates for the five different schools are shown in Table 1. One adverse event was reported as a rash developing a few hours after vaccination in a girl known to be allergic to various substances, but could not be confirmed to be related to the vaccine.

Screening

A total of 1 135 self-screen kits were handed out to eligible girls attending the five schools, to be passed on to their female parents and guardians. Female staff members at the schools also requested selfscreen kits, which accounts for the difference between the numbers of tests handed out and the IC. Of the 1 135 self-screen kits handed out, 378 (33.3%) were returned unused and undamaged, 37 (3.3%) were unused but damaged, and 560 (49.3%) were not returned. Unused but damaged kits were not tested for the presence of HPV DNA. One hundred and sixty women participated in self-screening. The return rate as a proportion of tests distributed was 14.1%. Screening uptake was 16.6% when calculated as a proportion of the IC (160 from 965) and 30.8% when calculated as a proportion of the CC (160 from 519). The proportion of the CC was calculated to compare with similar

Table 1. Vaccination uptake and completion rates for the different schools School

IC, n

CC, n

VC, n

IUR, %

CUR, %

Received 2 doses, n

VCR, %

Received 1 dose, n

IVR, %

351

156

44.4

100.0

149

95.5

4.5

203

136

135

66.5

99.3

128

94.1

5.2

226

120

53.1

100.0

113

94.2

5.8

64.0

100.0

0.0

160

56.8

100.0

97.8

2.2

Total

965

519

518

53.7

99.8

495

95.4

4.4

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Discussion

Reported vaccine uptake differs widely and is influenced by many factors such as social, religious, cultural and awareness aspects.[10] School-based vaccination programmes also tend to be more effective than other pro grammes.[11] In this study, informed consent from parents as well as assent from the girls were prerequisites for inclusion in the vaccine cohort. A vaccine uptake rate of 53.7%, calculated as a proportion of all girls eligible for vaccination, compares well with reports from other parts of the world. It is lower than the 64.0% overall uptake reported for VACCS 1[12] and can be attributed to the modification in information transfer. In VACCS 1 the vaccine uptake was 51.7% for girls whose parents or guardians did not attend the information sessions and 87.5% for those whose parents or guardians attended. Although such information events result in higher uptake rates, they are not sustainable during a mass vaccine roll-out programme. Higher vaccine uptake rates can be accomplished by introducing an opt-out programme combined with assent from girls. Several studies have confirmed the noninferiority of two vaccine doses compared with three doses.[6,7] The VCR of 95.4% achieved during this study compares favourably with other published data from SA[13] and with the sufficiently vaccinated

year during VACCS 1.[8] A vaccine programme in which two doses are administered should

rate (two doses 6 months apart) of 94.5% in Gauteng schools vaccinated in one calendar

Table 2. Comparison of different screen uptake rates for VACCS 1 and VACCS 2 Participation rates

VACCS 1, %

VACCS 2, %

Return rate: Self-test kits returned used/self-test kits distributed

31.8

14.1

Participation rate: IC

15.3

16.6

Participation rate: CC

23.9

30.8

Table 3. Comparison of HPV screen outcomes for VACCS 1 and 2 HPV self-screen

VACCS 1 (Roche Linear Array and tampons), %

VACCS 2 (Cobas and Evalyn samplers), %

Invalid tests

3.6

1.3

hrHPV-negative

66.7

72.5

Any hrHPV

29.6

26.3

HPV 16- and/or 18-positive

9.1

9.4

Non-16/18 hrHPV-positive

20.6

16.9

70 60 Participants, n

uptake rates calculated in VACCS 1.[8] A comparison of the different screen uptake rates is presented in Table 2. When calculating screening uptake, the size of the true target population needs to be clarified. Although not investigated in the current study, data from the questionnaires administered to a similar population during the VACCS 1 study suggested that at least 52.6% of women were in need of a screening test (‘had last test >10 years ago’). Using these data, the true target population in VACCS 2 is 538 women, corresponding to an uptake of 29.7%. The mean (standard deviation) age of women participating in self-screening was 38.7 (7.7) years (range 20 - 67). The age distri bution for this population is shown in Fig. 1. Of the 160 women tested, 2 (1.3%) had invalid tests and 116 (72.5%) tested negative for hrHPV. Fifteen women (9.4%) tested positive for HPV 16 and/or 18 and 27 (16.9%) tested positive for non-16/18 hrHPV (Fig. 2). Of the 15 women who tested positive for HPV 16/18, 3 had only HPV 16 and 1 had only HPV 18. Eleven women tested positive for both HPV 16 and 18. These screening results per age group are shown in Fig. 2. The comparative data from VACCS 1 are shown in Table 3.

40 30 21

20 10

13 8

0 Unknown

≤29

30 - 39

40 - 49

≥50

Age, years

Fig. 1. Age distribution of women participating in self-screening.

1.3%

9.4% HPV 16- and/or 18-positive 16.9% Non-16/18 hrHPV-positive 72.5%

hrHPV-negative

Invalid

Fig. 2. HPV self-testing screen results.

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Participants, n

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90.0

HPV 16- and/or 18-positive

80.0

Non-16/18 hrHPV-positive

70.0

hrHPV-negative

60.0 50.0 40.0 30.0 20.0 10.0 0.0 ≤29

30 - 39

40 - 49

References

≥50

Age, years

Fig. 3. Age distribution of participants.

be less complicated to implement and more cost-effective, and results in the vaccination of more individuals.[7] Screening for cervical cancer using conven tional cytology has had limited success in SA[1] despite being effective and having been available for more than 50 years. It is therefore vital to investigate alternative screening options and screening opportunities. Selftesting for HPV as a screening tool for cervical cancer has been well documented and can be implemented even in resource-poor settings. [14-16] Both VACCS 1 and 2 investigated the feasibility of implementing HPV self-screening in an urban population without making use of the health system. The method followed in the current study of inviting female parents and guardians to participate in screening and to distribute information about the vaccination of their children in an information package delivered at home via the children is a realistic, feasible and cost-effective alternative compared with a strategy that has not been widely implemented. The screened population falls largely into the ideal age group of women requiring screening (Fig. 1). In this study, screening uptakes compared favourably with similar calculations from VACCS 1 despite the different methods of providing information. In VACCS 1, self-test kits were distributed to women after they had attended lectures at information events, while in VACCS 2 self-test kits were distributed to all female parents and guardians together with written information about cervical cancer, screening and vaccination. In comparable studies conducted on European non-respon ders via a mailed invitation, compliance rates varied between 6.4% (UK) and 31.3% (Netherlands), with most groups reporting uptake rates around 30%.[17] Screening uptakes achieved during this study of 30.8% (CC) and 29.7% (unscreened cohort) compare favourably with these data.

When comparing the results, it is important to note that the screening methodology used in VACCS 1 and VACCS 2 differed in two important aspects: (i) VACCS 1 employed tampon-based self-screening transported in a buffer solution, while Evalyn brushes were used for self-collection and transported dry in VACCS 2; and (ii) different HPV testing technology was used: Roche linear array in VACCS 1, and Roche Cobas 4800 in VACCS 2.

Conclusion

Data from the VACCS project suggest that school-based vaccine programmes can be implemented successfully in suburban areas. A two-dose vaccine schedule yields higher VCRs and will also allow for more girls to be vaccinated. Results from the current study support the SA Department of Health HPV vaccination programme. Screening uptake and results in this study confirm the feasibility of HPV screening in this population. Linking self-testing HPV screening to HPV vaccination is a promising alternative to the current screening policy. The screening method used in this study was successful in reaching the appropriate target population, uptake rates were acceptable, and results were effectively communicated via the school system and mobile phone technology. Screening options other than conventional population-based cervical cytology are promising and should be further investigated and implemented. Acknowledgements. The assistance of the follow ing groups and persons that enabled the successful completion of this project is gratefully acknowledged. Financial support was received from the Cancer Research Initiative of South Africa, a national collaborative research programme supported by the South African Medical Research Council and the Cancer Association of South Africa, and from First for Women Insurance for screening and

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treatment of screen-positive women and investigator support. Funding for this study was provided by GlaxoSmithKline Biologicals SA (117280). GlaxoSmithKline Biologicals SA was provided the opportunity to review a preliminary version of this manuscript for factual accuracy, but the authors are solely responsible for final content and interpretation. The authors received no financial support or other form of compensation related to the development of the manuscript. Teams of registered nurses handled vaccine processes, and Dr Karin Richter managed the laboratory screening data.

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1. ICO (Institut Català d’Oncologia) Information Centre on HPV and Cancer. South Africa. Human papillomavirus and related cancers, fact sheet 2013. http://www.hpvcentre.net/statistics/reports/ZAF_ FS.pdf (accessed 17 April 2014). 2. Parkin DM, Sitas F, Chirenje M, Stein L, Abratt R, Wabinga H. Part I: Cancer in indigenous Africans – burden, distribution, and trends. Lancet Oncol 2008;9(7):683-692. [http://dx.doi.org/10.1016/S14702045(08)70175-X] 3. Gakidou E, Nordhagen S, Obermeyer Z. Coverage of cervical cancer screening in 57 countries: Low average levels and large inequalities. PLoS Med 2008;5(6):e132. [http://dx.doi.org/10.1371/journal. pmed.0050132] 4. Harper DM, Franco EL, Wheeler CM, et al. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: Follow-up from a randomised control trial. Lancet 2006;367(9518):1247-1255. [http://dx.doi. org/10.1016/S0140-6736(06)68439-0] 5. Villa LL, Costa RL, Petta CA, et al. High sustained efficacy of a prophylactic quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up. Br J Cancer 2006;95(11):1459-1466. [http://dx.doi.org/10.1038/ sj.bjc.6603469] 6. Dobson SR, McNeil S, Dionne M, et al. Immunogenicity of 2 doses of HPV vaccine in younger adolescents vs 3 doses in young women: A randomized clinical trial. JAMA 2013;309(17):1793-802. [http:// dx.doi.org/10.1001/jama.2013.1625] 7. Romanowski B, Schwarz TF, Ferguson LM, et al. Immune response to the HPV-16/18 AS04-adjuvanted vaccine administered as a 2-dose or 3-dose schedule up to 4 years after vaccination: Results from a randomized study. Hum Vaccine Immunother 2014;10(5):1155-1165. [http://dx.doi.org/10.4161/hv.28022] 8. Snyman LC, Dreyer G, Botha MH, van der Merwe, FH, Becker PJ. The Vaccine and Cervical Cancer Screen (VACCS) project: Linking cervical cancer screening to HPV vaccination in the SouthWest District of Tshwane, Gauteng, South Africa. S Afr Med J 2015;105(2):115-120. [http://dx.doi.org/10.7196/SAMJ.8418] 9. Heideman DA, Hesselink AT, Berkhof J, et al. Clinical validation of the cobas 4800 HPV test for cervical screening purposes. J Clin Microbiol 2011;49(11):3983-3985. [http://dx.doi.org/10.1128/ JCM.05552-11] 10. Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: A theory-informed, systematic review. Prev Med 2007;45(2-3):107114. [http://dx.doi.org/10.1016/j.ypmed.2007.05.013] 11. Brotherton JM, Murray SL, Hall MA, et al. Human papillomavirus vaccine coverage among female Australian adolescents: Success of the school-based approach. Med J Aust 2013;199(9):614-617. [http:// dx.doi.org/10.5694/mja13.10272] 12. Botha MH, van der Merwe FH, Snyman LS, Dreyer G. The Vaccine and Cervical Cancer Screen (VACCS) project: Acceptance of human papillomavirus vaccination in a school-based programme in two provinces of South Africa. S Afr Med J 2015;105(1):40-43. [http:// dx.doi.org/10.7196/SAMJ.8419] 13. Moodley I, Mubaiwa V, Tathiah N, Denny L. High uptake of Gardasil vaccine among 9 - 12-year-old schoolgirls participating in an HPV vaccination demonstration project in KwaZuluNatal Province. S Afr Med J 2013;103(5):318-321. [http://dx.doi. org/10.7196/SAMJ.6414] 14. Mnisi EF, Dreyer G, Richter KL, Horton A, Snyman LC. Human papillomavirus DNA testing on self-collected vaginal tampon samples as a cervical cancer screening test in a Gauteng population. S Afr J Gynaecol Oncol 2013;5(2):S15-S20. 15. Richter KL. Understanding and incorporating human papillomavirus testing in cervical cancer screening: A South African perspective. S Afr J Gynaecol Oncol 2011;3(1):9-14. 16. Cuzick J, Arbyn M, Sankaranarayanan R, et al. Overview of human papillomavirus-based and other novel options for cervical cancer screening in developed and developing countries. Vaccine 2008;26(Suppl 10):K29-K41. [http://dx.doi.org/10.1016/j. vaccine.2008.06.019] 17. Racey CS, Withrow DR, Gesink D. Self-collected HPV testing improves participation in cervical cancer screening: A systematic review and meta-analysis. Can J Pub Health 2013;104(2):e159-e166. [http://www.ncbi.nlm.nih.gov/pubmed/23618210]

Accepted 12 January 2015.

RESEARCH

Traumatic brain injury, the hidden pandemic: A focused response to family and patient experiences and needs J Webster,1 MA (Sociology, Philosophy); A Taylor,2 MB BCh, FCS (Neurosurgery), MMed; R Balchin,3 BSocSci, MA (Neuropsychology), PhD (Neuropsychology) ComaCARE Trust, Groote Schuur Hospital, Cape Town, South Africa Division of Neurosurgery, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa 3 Department of Psychology, Faculty of Humanities, University of Cape Town, South Africa 1 2

Corresponding author: A Taylor (allan.taylor@uct.ac.za)

Introduction. Traumatic brain injury (TBI) has many potential cognitive, behavioural and psychological consequences, and contributes significantly to the national burden of disease and to ongoing violent behaviour. Few resources are available for the rehabilitation of patients with TBI in South Africa, and access to rehabilitation facilities in the public sector is limited. Consequently, it is the families impacted on by TBI that ultimately carry the care and rehabilitation burden once survivors are discharged from hospital. Families are generally ill equipped to cope with the complex and potentially long-term disabilities that accompany brain injury. Methods. Reviewing interviews with 175 family members and 354 patients recovering from TBI helped identify the key challenges that the survivors of TBI and their families face. Results. Nine problem areas were identified that formed the basis for development of a discharge resource, the S-Plan, which serves to inform patients and carers and provide practical solutions for the problems they face. Conclusion. The experiences of TBI survivors and their family members served to inform the development of simple, integrated coping strategies, namely two S-Plan tools, one for survivors and their families/caregivers and the other for care workers, in conjunction with counselling and support group processes. The S-Plan constitutes a discharge resource to inform patients and carers and provide practical solutions for the problems they face in caring for family members who have suffered TBI. S Afr Med J 2015;105(3):195-198. DOI:10.7196/SAMJ.9014

The context of trauma

In South Africa (SA), the high prevalence of violence contributes to the national burden of disease.[1] In the Western Cape Province in 2009, 7% of deaths (n=3 217) were caused by intentional injuries, which also accounted for 9.7% of years of life lost (YLL) – a total of 79 653 YLL.[2]

Traumatic brain injury (TBI) upstream factors and injury profile

In 2009, an internal audit conducted at Groote Schuur Hospital (GSH), Cape Town, Western Cape, revealed that of the total of 10 046 trauma patients admitted that year, approximately 24% were classified as head-injury patients, with 654 having a moderate to severe TBI. The direct cost of these patients to the tertiary service in 2009 was R17 448 756 (T King, Coma Care Trust audit, 2010 – unpublished). This audit also identified that 82% of assault-related head trauma was experienced by young black and coloured men, and that the average length of stay in hospital for a patient receiving neurosurgical intervention was 10.2 days. This brief slice of the patient’s life in the acute-care setting is usually preceded by an upstream reality involving poverty, unemployment, poor community infrastructure, high rates of alcohol consumption and a weakened family unit.

Downstream impact of TBI

TBI can require a long and arduous recovery process. Many survi vors are left with permanent physical, emotional and cognitive disabilities. TBIs that are caused by interpersonal violence are inflicted largely by right-handed perpetrators, and typically result in frontal lobe and/or left temporal lobe injuries. The neurocognitive and behavioural sequelae of frontal lobe injuries are severe and

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include poor judgement, impaired problem-solving ability and loss of the ability to think abstractly, poor organisational skills, loss of inhibition and impulsive behaviour, aggression, personality changes, depression, anxiety and reduced social skills.[3-5] Left temporal lobe injuries can result in communication difficulties due to disorders of language (receptive aphasia), including loss of the ability to comprehend speech.[3-6] These deficits have a disabling effect on survivors’ ability to cope with activities of daily living and with constructive engagement within their families and communities. Poor impulse control and weak social skills result in dangerous situations for survivors and for those around them. The link between TBI and criminal behaviour is internationally well evidenced. In a Finnish study, adolescent TBI survivors were found to have committed crimes significantly more often than adolescents without a TBI (53.8% v. 14.7%, respectively).[7] In addition, the prevalence of both violent crimes (42.9% v. 9.1%), and non-violent crimes (29.4% v. 6.8%) was also higher in the TBI group. Similarly, in a study of 186 young offenders in the UK, the frequency of self-reported TBI was associated with more convictions; three or more self-reported TBIs were associated with greater violence in the offences that were committed.[8] The rehabilitation of TBI survivors is therefore not only a health issue for survivors and their families, but also a critical violence prevention strategy for SA.

The current rehabilitation response

In SA, there is limited access to rehabilitation facilities in the public sector. The consequence for TBI survivors is that very few receive adequate rehabilitation services; only 16 of the 654 survivors in the 2009 GSH audit were admitted to a public rehabilitation facility. Over a 5-year period (2008 - 2012), TBI survivors made up less

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than 9% of the Western Cape Rehabilitation Centre (WCRC)’s intake (Dr Jenny Hendry, personal communication, 2014). The WCRC is a 240-bed rehabilitation centre and the only dedicated rehabilitation service available to public patients. In addition, a TBI may include an initial period of post-traumatic amnesia and usually involves a slow recovery period, yet candidates for rehabilitation centres are expected to behave appropriately and recover in a 6 12-week period. This means that few survivors receive the necessary re habilitation support, and the majority are instead discharged to unprepared families who typically become their main support structure. This ultimately negatively affects caregiver wellness and family resilience.[9,10] Outpatient rehabilitation is also very limited, and most patients receive no more than 30 minutes of physio therapy or occupational therapy per week at their community healthcare centre.

Addressing the need

The ComaCARE Trust is a non-profit organisation based at GSH. ComaCARE has been addressing the needs of survivors and families since 2005 by providing a psychosocial service that employs community caregivers in the acute-care setting. In 2012, recognising that TBI survivors are usually discharged into the care of an unprepared family unit, ComaCARE developed a brain injury prevention and family support service in Khayelitsha, one of the Western Cape’s hot spots for interpersonal violence as identified through injury mortality surveillance data.[2] This HeadsUP! Hub provides supportive intervention for families that involves counselling by social workers and training to know what to do if their relative displays any of the sequelae of TBI (e.g. disruptive behaviour at school or in the workplace, aggression, memory problems, anxiety, depression and sleep disturbances).

Objectives

To faciliate the provision of relevant and sustainable TBI services, this study had two primary objectives: (i) to examine in a systematic way the key challenges that survivors of brain injury and their family members face; and (ii) to create tools as guides in helping families and care workers to manage and cope with the consequences of brain injury in under-resourced settings.

Methods

This was an applied, exploratory study. The approach to data collection was qualitative, as the interview data collected were analysed thematically to extract and highlight the topics that emerged. Participants (families of TBI survivors and the survivors themselves) were identified using purposive sampling. The overall study design had two distinct phases: (i) the process of identifying the key problems faced by survivors of TBI and their families through interviews gathered from various sources (see below); and (ii) the process of creating the content for tools to serve as guides in assisting families and care workers to manage and cope with the consequences of brain injury. This second phase was dependent on the data collected during phase one, which served to inform the content and structure of the tools created. The experiences of 175 family members and 354 survivors were recorded. These interview data were collected between 2008 and 2013 from: (i) the acute-care hospital support service offered by ComaCARE at GSH; (ii) intake interviews for the HeadsUP! survivor care programme; (iii) bimonthly outpatient support service clinics linked to the Division of Neurosurgery at GSH; and (iv) HeadsUP! support groups. In both the individual and the group sessions, survivors and family members were interviewed separately, thereby

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enabling each group to express themselves freely. Feedback from all sources was recorded in written notes, which were subsequently analysed thematically to extract and highlight the common topics that emerged.

Results

Phase 1: Family and survivor feedback

Several critical factors emerged from the data collection process to aid the provision of better services for TBI survivors and their families. Lack of accessible information In general, it was evident that there was initially a communication problem between family members and medical professionals in the acute-care setting. Family members felt that they had not been adequately informed by medical professionals about TBI and its potential consequences. When they did receive feedback, it was often too complex to be understood, families lacking a frame of reference to be able to contextualise any knowledge received. Families related that in their traumatised state, they were unable to absorb spoken information and then convey it to other family members. Family feedback also identified the clear lack of information regarding the longer-term requirements of recovery and possible strategies to cope with cognitive impairments, personality changes and behavioural issues. Content of required information The key themes that emerged from families, and the areas where information is desperately needed, included coping with personality changes, how to manage aggressive behaviour, issues regarding memory, issues regarding motivation, sleep disturbances, language and communication problems, sexual disinhibition and/or disinterest, depression and safety concerns. Family members reported that their own mental health was adversely affected as a result of the stress of having to look after survivors; depression, fatigue, utter frustration and burnout were commonly reported. The issues most commonly reported by the TBI survivors (who often revealed a lack of insight into their neurocognitive and behavioural problems) were the need for a social life and meaningful activity, sensitivity to noise, difficulty sleeping, depression, anxiety and headaches. Some survivors also reported that family members no longer had the time or patience to engage and listen to them, and consequently failed to understand their problems, their needs and their frustrations. The issues of depression, aggressive behaviour, headaches and anxiety were probed through further questioning in order to establish whether there were any triggers that preceded these experiences. Type of information and support Families stated that at the acute stage of injury, verbal information alone was not adequate, given that they needed time to review information and to share it with family members. On the survivor’s return home, families reported that their information needs changed, as survivors’ behavioural issues only became apparent as new challenges presented over time. Families therefore needed written information that could be consulted at different stages of the recovery process, and that could be used to help the survivor to take part in his/her own rehabilitation process wherever possible. In addition, both families and survivors expressed the need for access to advisors and counsellors, and wanted to counter their feelings of isolation in fora where people could understand and relate to their problems.

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Finding practical solutions Some of the more experienced family members interviewed described their coping strategies to avoid and manage the most distressing survivor behaviours, noting that, as with parenting a child, survivors needed to have a balanced and structured day to ensure a sense of wellbeing and safety, and that they needed regular sleep, a healthy diet, stimulation and friendship. The problems experienced, and the strategies that families employed, were then analysed and compiled under nine central topics/themes based on words starting with ‘S’ (Fig. 1). This decision to incorporate the key topics identified under headings that all began with the same letter (in English) was made in order to make them easier to remember and to provide a framework for the varied information from the often very different sources available. English was chosen as the language of written communication, as many of the participants refused to accept written information in isiXhosa, despite its being their home language.

Phase 2: The development of the S-Plan process

Survivors and families identifying challenges Two sets of posters were designed (one with images of adults and the other of children) in order to allow for both survivors and family members to have each of the elements of the poster explained to them by a care worker who speaks English and also their home language. In their use, the care worker explains the behaviours and challenges that families may experience on the road to recovery, or that trigger, or are triggered by, difficult emotions or symptoms. Family members and survivors are then asked whether they are currently facing difficulties in any of these areas. If one of the ‘S issues’ is identified through this process, the care worker will interview the family member and survivor separately using the questionnaires pertaining to the relevant component of the S-Plan. Next, in discussion with both parties, the care worker will support them in choosing one or two areas to focus on in the coming weeks. Support with written material, counselling and engagement in support groups After an agreed issue to work on has been identified, an S-Plan guide booklet is given to the family member and survivor. This guide contains an introduction and also covers all nine topics, with each of the sections including information under the following headings: ‘What is the problem?’,

Fig. 1. The S-Plan.

‘When it is likely to happen’, ‘What it looks like’, ‘What can make things worse?’, ‘How does this make life difficult for survivors?’, ‘How it might make you feel as a caregiver’, ‘What you can do to help’, and ‘Who can help further?’. These guides are currently used with family units, and at the three HeadsUP! support groups that were established in 2012. Posters for teaching and training purposes have also been designed to accompany these S-Plan guides. The posters include spaces for the nine words starting with ‘S’ to be translated when necessary. In the future, the guides will be translated into isiXhosa/ English and Afrikaans/English versions.

Discussion

SA faces many healthcare challenges, including a high burden of physical trauma with few rehabilitation services. Funding limitations and the demand for additional acute-care services mean that it is unlikely that new rehabilitation services will be added in the near future, and patients will continue to be discharged home from acutecare settings. While this study focused on TBI patients treated in Cape Town, it is likely that TBI patients and their families throughout SA face the same, or worse, difficulties. Inpatient admission times are typically short (10 days on average) and

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acute rehabilitation during this time is limited, with many families having to take on the burden of looking after a person with impairments such as hemiparesis, dysphasia, confusion and aggression. No local studies have surveyed outcomes for TBI survivors who are discharged early into a setting with limited outpatient rehabilitation, although the outcomes of stroke patients discharged in similar circumstances in Cape Town have been examined. One of the findings from a study examining survival, disability and functional outcomes of stroke patients following discharge was that patients requiring nasogastric feeding did particularly poorly at home, indicating that their caregivers were not equipped to deal with the complexity of the care required.[11] It is evident that TBI is a huge problem globally, and that families ultimately bear the burden of care provision, yet there is little available literature from underresourced communities regarding the needs of families of survivors and the problems they face.[12] Studies (mainly in developed countries) that have looked at families’ needs (both met and unmet) and the problems they face in relation to TBI have identified high levels of stress, lack of education regarding TBI, lack of information on how to prepare for the

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future, behavioural problems and problems at school on the part of the TBI survivor, and survivors’ loss of interest in activities, anxiety, memory problems and aggressive temperament.[12-16] Commonly reported needs, which like the reported problems can change over time, include the need for social/instrumental care, emotional care and healthcare; the need for professional and financial support and information; the need for access to relevant information regarding TBI and its consequences; and the need to be actively involved with the care of the TBI survivor.[12-15] Successful TBI support will not only benefit survivors and their family units, but can also contribute towards a reduction in future violent acts perpetrated by TBI survivors. In SA, as in many other parts of the world, inadequate information and support, along with the lack of appropriate rehabilitation facilities, places a massive care burden on unprepared family members and community care workers. The participants in this study identified a multitude of complex daily challenges when survivors returned to their homes and communities. These challenges cover a wide spectrum, ranging from survivors’ behavioural and memory problems to depression and sleep disturbances. Caregivers’ own mental health is negatively affected, with depression, fatigue, stress and frustration all reported. Consequently, the ability of families to cope is often compromised, adversely affecting TBI recovery. The S-Plan tools (the family guide, posters and questionnaires) have been created to compensate for the lack of resources that are necessary to respond to the hidden pandemic that is TBI. The provision of these tools aims to empower families, survivors and healthcare professionals by offering a structured and interactive approach to identifying and then addressing the specific challenges that each TBI survivor and their family members face. The S-Plan has been developed to educate families and survivors about the need for a balanced, structured day, and will help families to reflect on the triggers of disruptive behaviour and to plan the survivor’s rehabilitation process. It also raises taboo subjects such as sexuality, substance abuse and security, and enables conversation about concerns and fears around such subjects. The questionnaires have been designed with specific emphasis on: (i) helping to identify the perceptions of survivors and families about their behaviours; (ii) revealing where there is a disabling lack of insight, sometimes from both parties; and (iii) helping survivors and families to decide together on priority areas for goal setting. The ComaCARE Trust acknowledges families as the experts in this process, and hopes to strengthen their advocacy role in exposing the hidden epidemic of TBI and the dangers inherent in failing to provide adequate rehabilitation services that can impact favourably on family wellness and violence prevention. Further research will be conducted in communities in the Western Cape in order to systematically investigate the efficacy of the new S-Plan tools. This will involve an iterative research process, testing

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separate elements of the S-Plan tools based on families’ and care workers’ firsthand experience of their effectiveness, with the aim of improving them.

Conclusion

The experiences of TBI survivors and their family members have served to inform the development of simple, integrated coping strategies (S-Plan tools in conjunction with counselling and support group processes). One S-Plan tool is for survivors and their families/ caregivers, and the other is for care workers. For the next phase of this research, these integrated tools will be piloted from 2015 onwards as part of a longitudinal research project to be conducted in underresourced communities in Cape Town. Acknowledgements. JW thanks the Nussbaum Foundation, the Norwegian Centre for Human Rights and the Western Cape Department of Social Development for their support of this research. RB sincerely thanks the Claude Leon Foundation for their funding and support of this research. References 1. Matzopoulos R, Bowman B, Mathews S, Myers J. Applying upstream interventions for interpersonal violence prevention: An uphill struggle in low- to middle- income contexts. Health Policy 2010;97(1):62-70. [http://dx.doi.org/10.1016/j.healthpol.2010.03.003] 2. Groenewald P, Bradshaw D, Msemburi W, et al. Western Cape Mortality Profile 2009. Cape Town: South African Medical Research Council, 2012. http://www.mrc.ac.za/bod/ WesternCapeMortalityProfile2009.pdf (accessed 9 October 2014). 3. Walsh K, Darby EJ. Neuropsychology: A Clinical Approach. 4th ed. Edinburgh: Churchill Livingstone, 1999. 4. McDonald BC, Flashman LA, Saykin AJ. Executive dysfunction following traumatic brain injury: Neural substrates and treatment strategies. NeuroRehabilitation 2002;17(4):333-344. 5. Kolb B, Whishaw IQ. Fundamentals of Human Neuropsychology. 5th ed. Alberta: Worth Publishers, 2003. 6. Stuss DT. Traumatic brain injury: Relation to executive dysfunction and the frontal lobes. Curr Opin Neurol 2011;24(6):584-589. [http://dx.doi.org/10.1097/WCO.0b013e32834c7eb9] 7. Luukkainen S, Riala K, Laukkanen M, Hakko H, Räsänen P. Research Reports – Association of traumatic brain injury with criminality in adolescent psychiatric inpatients from Northern Finland. Psychiatry Res 2012;200(2-3):767-772. [http://dx.doi.org/10.1016/j.psychres.2012.04.018] 8. Williams WH, Cordan G, Mewse AJ, Tonks J, Burgess CN. Self-reported traumatic brain injury in male young offenders: A risk factor for re-offending, poor mental health and violence? Neuropsychol Rehabil 2010;20(6):801-812. [http://dx.doi.org/10.1080/09602011.2010.519613] 9. Chesnut RM, Carney N, Maynard H, et al. Evidence Report on Rehabilitation of Persons with Traumatic Brain Injury. Rockville, Md: Agency for Health Care Policy and Research, 1998. http://www. ncbi.nlm.nih.gov/books/NBK32897/ (accessed 9 October 2014) 10. Carney N, du Coudray H, Davis-O’Reilly C, et al. Rehabilitation for Traumatic Brain Injury in Children and Adolescents. Evidence Report No. 2, Supplement. Rockville, Md: Agency for Health Care Policy and Research, 1999. http://www.ncbi.nlm.nih.gov/books/NBK32918/ (accessed 9 October 2014). 11. De Villiers L, Badri M, Ferreira M, Bryer A. Stroke outcomes in a socio-economically disadvantaged urban community. S Afr Med J 2011;101(5):345-348. 12. Hassan STS, Khaw WF, Rosna AR, Husna J. Traumatic brain injury: Caregivers’ problems and needs. J Nepal Med Assoc 2011;51(181):53-55. 13. Rotondi AJ, Sinkule J, Balzer K, Harris J, Moldovan R. A qualitative needs assessment of persons who have experienced traumatic brain injury and their primary family caregivers. J Head Trauma Rehabil 2007;22(1):14-25. [http://dx.doi.org/10.1097/00001199-200701000-00002] 14. Arango-Lasprilla JC, Quijano MC, Aponte M, et al. Family needs in caregivers of individuals with traumatic brain injury from Colombia, South America. Brain Inj 2010;24(7-8):1017-1026. [http:// dx.doi.org/10.3109/02699052.2010.490516] 15. Hawley CA. Reported problems and their resolution following mild, moderate and severe traumatic brain injury amongst children and adolescents in the UK. Brain Inj 2003;17(2):105-129. [http://dx.doi. org/10.1080/0269905021000010131] 16. Hall KM, Karzmark P, Stevens M, Englander J, O’Hare P, Wright J. Family stressors in traumatic brain injury: A two-year follow-up. Arch Phys Med Rehabil 1994;75(8):876-884. [http://dx.doi. org/10.1016/0003-9993(94)90112-0]

Accepted 20 October 2014.

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Hypertension, end-stage renal disease and mesangiocapillary glomerulonephritis in methamphetamine users E S W Jones, MB BCh, PhD, FCP (SA), Cert Nephrol (SA); B L Rayner, MB ChB, FCP (SA), MMed, PhD Department of Medicine, Faculty of Health Sciences, University of Cape Town, and Renal Unit, Groote Schuur Hospital, Cape Town, South Africa Corresponding author: E S W Jones (eswjones@gmail.com)

Background. Methamphetamine abuse has risen dramatically in South Africa. The chronic effects of abuse on the kidneys and blood pressure have not been documented. This study reviewed patients referred for evaluation of kidney disease and/or hypertension, who had been abusing methamphetamines. Methods. The records of patients referred to the renal unit between 2005 and 2013 who had been using methamphetamines were retrospectively reviewed. Patient demographics, biophysical parameters, blood pressure, renal function, renal ultrasound and biopsy findings, complications of chronic kidney disease and comorbidities were recorded. Results. Forty-seven patients were included in the study. Their mean age was 29 years. Hypertension was present in 42 (89.4%) of patients, with malignant hypertension in 21 (44.7%). Forty-five (95.7%) had chronic kidney disease (CKD), and 26 (55.3%) had end-stage renal disease. Renal biopsies were performed in 24 patients. Twelve (50.0%) of the biopsies showed hypertensive changes and 14 (58.3%) mesangiocapillary glomerulonephritis type 1, with deposition of IgM and C3 complement. Conclusion. Methamphetamine use is associated with severe hypertension, mesangiocapillary glomerulonephritis and CKD. S Afr Med J 2015;105(3):199-201. DOI:10.7196/SAMJ.8731

South Africa (SA) is experiencing a dramatic rise in the use of methamphetamines, particularly in the Western Cape Province.[1] The drug is commonly used by young people of mixed ancestry,[2] and particularly those of lower socioeconomic status and educational level.[3] A closely related amphetamine, known as Ecstasy, was initially used as an appetite suppressant but rapidly became a recreational drug used in dancing clubs, where it was found to cause hyperthermia, dehydration and rhabdomyolysis, and an increased risk of acute renal failure.[4] Methamphetamine is relatively easy and inexpensive to produce, making it readily accessible.[5] The use of amphetamines is associated with significant adverse physical effects. The toxic effects include cardiomyopathy,[6] ischaemic heart disease, aneurysm formation, seizures, psychosis, hallucinations, stroke,[7] hyperthermia, rhabdomyolysis, pulmonary hypertension, systemic hypertension, acute renal failure[8] and hepatocellular damage.[9] A review of the histopathological findings in drug users does not mention any renal effects in amphetamine users.[10] There have been isolated reports of adverse renal effects including necrotising renal vasculopathy,[8] an exaggerated decline in renal function over 15-year follow-up of patients who used methamphetamines,[11] an increased serum creatinine level 1 year after transplant in recipients of kidneys from donors who had used methamphetamines,[12] and early graft loss of two kidneys from donors who had used methamphetamines.[13] In Africa there is even less information on the health outcomes of methamphetamine use. What literature there is addresses the dental, psychiatric and social impact of drug use in SA, particularly in the Western Cape.[14-16] This study reviewed patients attending a single tertiary hospital with hypertension and/or chronic kidney disease (CKD) and who reported the use of methamphetamines.

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Methods

Patients with a history of methamphetamine use who were referred to the Division of Nephrology and Hypertension at Groote Schuur Hospital, Cape Town, for evaluation were retrospectively studied from their medical records from 2005 to 2013. Patient demographics, biophysical parameters, blood pressure, renal function, renal ultrasound and biopsy findings, complications of CKD defined in terms of the Kidney Disease: Improving Global Outcomes guidelines,[17] and comorbidities were recorded. The estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula (Table 1). Hypertensive retinopathy was graded 1 - 4 according to the presence of silver wiring, arteriovenous nipping, haemorrhages/exudates or papill足 oedema, respectively.[18] Malignant hypertension on fundoscopy was defined as grade 3 - 4 hypertensive retinopathy. Left ventricular hyper足 trophy (LVH) was defined by Sokolow-Lyon criteria of >35 mm.[19] Renal biopsy was performed in patients with impaired renal function of unknown cause and/or proteinuria >3 g/d in the presence of normal-sized kidneys. Malignant hypertension on histology was defined as the presence of fibrinoid necrosis and onion-skinning of the arterioles associated with crenation of the glomerular basement membrane. The study was approved by the University of Cape Town Research Ethics Committee (HREC REF: 573/2011).

Results

Forty-seven patients were identified, of whom 40 (85.1%) were male. Their mean (standard deviation (SD)) age was 29 (8) years. Table 1 shows the baseline demographics. Five patients (10.6%) were black Africans and the remainder (89.4%) of mixed ancestry. At the time of data collection, 11 patients had died, all of whom had endstage renal disease (ESRD) at presentation and were not eligible for chronic dialysis in terms of the criteria for long-term dialysis and

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Table 1. Patient demographics

Patients, N

Mean (SD)

Age (years)

29.4 (8.0)

Systolic BP (mmHg)

183 (37)

Diastolic BP (mmHg)

114 (24)

BMI (kg/m )

24.6 (4.4)

Creatinine (µmol/l)

716 (623)

Urea (mmol/l)

31.4 (20.1)

Potassium (mmol/l)

4.6 (0.88)

UPCR (g/mmol)

0.52 (0.44)

Haemoglobin (g/dl)

9.9 (2.7)

MCV (fl)

85 (6)

Albumin (g/l)

32 (9)

Cholesterol (mmol/l)

5.9 (2.8)

SD = standard deviation; BP = blood pressure; BMI = body mass index; UPCR = urinary protein-creatinine ratio; MCV = mean cell volume.

transplantation in the Western Cape; all died as a consequence of chronic renal failure. At presentation, 42 (89.4%) of the patients were hypertensive, with evidence of malignant hypertension (defined by grade 3 or 4 hypertensive retinopathy and/or evidence on renal biopsy) in 21 (44.7%). The mean (SD) blood pressure was 183 (37)/114 (24) mmHg. Significant target organ damage (TOD) as a result of hypertension was evident in 34 patients (72.3%). Of the 37 patients (78.7%) who had documentation of electrocardiographic findings, LVH was found in 26 (70.3%). Findings on fundoscopy were recorded in 26 patients (55.3%): stage 1 hypertensive retinopathy was seen in 2 (7.7%) patients, stage 2 in 5 (19.2%), stage 3 in 11 (42.3%) and stage 4 in 7 (26.9%). CKD was found in 45 patients (95.7%). On ultrasound, 24 patients (51.1%) had evidence of CKD (i.e. small kidneys in 10, loss of corticomedullary differentiation in 4, increased echogenicity in 19). The mean (SD) urine protein-creatinine ratio was 0.52 (0.44) g/mmol. Twenty-six patients (55.3%) had stage 5 CKD, 4 (8.5%) stage 4, 4 (8.5%) stage 3, 5 (10.6%) stage 2, and 6 (12.8%) stage 1; only 2 (4.3%) had no evidence of CKD. Renal biopsy was performed in 24 patients (51.1%). Hypertensive changes were found in 12 biopsies (50.0%) with 6 (25.0%) showing malignant changes (Fig. 1, E and F). Six (25.0%) showed ESRD. Mesangiocapillary glomerulonephritis (MCGN) type 1 was found in 14 biopsy cases (58.3%) (Fig. 1, A and B), all of which were positive for IgM and C3 complement (Fig. 1, C and D). In addition, 9 (37.5%) showed staining for IgG and 7 (29%) for IgA. One individual (2.1%) tested positive for HIV, and 2 (4.3%) for syphilis. The HIV-positive patient underwent renal biopsy, the histological findings showing hypertensive changes only. No patients were positive for hepatitis B or C, or had infective endocarditis or systemic lupus erythematosus. All the patients in this study had been using methamphetamines, but in only a few cases was the length of drug use documented. Some patients used other recreational drugs, methaqualone in 10 cases (21.3%) and cocaine in 3 (6.4%); no patient used intravenous drugs. All three patients using cocaine had malignant hypertension and ESRD. Two of these patients underwent renal biopsy, which showed hypertensive changes and ESKD in both cases, but no evidence of MCGN. Of the patients who had used methaqualone, 7 underwent renal biopsies; 6 had hypertensive changes and 5 had MCGN.

[20]

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Fig. 1. Light microscopic features of kidney changes seen in methamphet amine users. A: Lobular glomerulus with thickened GBM (H&E); B: Glomerulus showing split GBM (JMS); C: Immunohistochemistry for C3 and D, IgM subendothelial deposits; E: Concentric myointimal thickening (‘onion skinning’) (H&E); F: Ischaemic retraction of glomeruli with corrugation of the GBM (JMS). (GBM = glomerular basement membrane; H&E = haematoxylin and eosin; JMS = Jones methenamine silver.)

Discussion

This study investigated the association between hypertension and/ or CKD and methamphetamine use in patients referred to a single large tertiary hospital in Cape Town for evaluation of CKD and/or hypertension between 2005 and 2013. The major findings were the presence of severe hypertension, with 44.7% of cases complicated by malignant hypertension; CKD (stage 4 or 5 in 64%) was present in in 95.7%. The unexpected and novel finding was the presence of MCGN in 58.3% of the 24 biopsies performed. The association of methamphetamine use with hypertension is not unexpected, as the drug has vasoconstrictive properties causing increased systemic vascular resistance and raised blood pressure. However, the severity of the hypertension is remarkable. The mean (SD) blood pressure was 183 (37)/114 (24) mmHg, and 44.7% had malignant hypertension. TOD was commonly seen: 70.3% had LVH and 96.2% hypertensive retinopathy. On renal biopsy of hypertensive methamphetamine users, there were vascular changes of hypertension in 12 with evidence of malignant hypertension in 6. The prevalence of CKD in this group of patients was 95.7%, with 63.8% of patients having very severe disease (CKD stages 4 and 5). In the cohort, 41 cases of CKD were related to hypertension on clinical grounds, and this was confirmed by renal biopsy in 12 cases. The unexpected finding in this study was that not all cases of CKD were

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a consequence of hypertension. MCGN was found to be the cause in 14 cases (58.3% of biopsies and 29.7% of the entire group). Idiopathic MCGN is the most common biopsy finding in Cape Town[21] and in other areas of SA the second most common,[22] although it is declining in incidence in developed countries.[23] Known associations with MCGN did not explain the link between methamphetamine use and MCGN. All the biopsies that showed MCGN had IgM and C3 deposits, supporting chronic antigenaemia as a possible cause. Hepatitis C virus, hepatitis B virus, HIV, malaria and infective endocarditis are common infectious agents associated with MCGN, but these were excluded on clinical and serological grounds in all except one patient, who was HIV-positive. This patient had hypertensive changes on renal biopsy without evidence of MCGN. The two patients who tested positive for syphilis did not undergo renal biopsy. MCGN is thought to result from chronic antigenaemia with defects in elimination or clearing of foreign antigen.[24] It is possible that people who use methamphetamines are exposed to multiple infectious antigens through the sharing of drugs and devices to inhale the drug. Another possible means of exposure to infectious antigens is through close physical contact between people during the process of taking the drug. It is also possible that methamphetamines alter self-proteins, making them immunogenic or creating haptens. However, these explanations are highly speculative. On renal biopsy, MCGN and hypertension were fairly equally repres ented (14 and 12 cases, respectively). MCGN has a poor prognosis, with 50% of patients progressing to ESRD within 5 years.[24] Severe hyper tension (affecting 37 patients (78.7%)) also results in ESRD. Seven patients (14.9%) had isolated hypertension without ESRD. This suggests that there are at least two pathways to ESRD for patients using methamphetamines. MCGN has been associated with intravenous drug use, especially of heroin.[25] However, it is unlikely that intravenous drug use was relevant in this group of patients; no such drug use was reported, and no patient was hepatitis B- or C-positive. Only one patient was found to be HIVpositive. The prevalence of HIV in the mixed-ancestry community it is ~5.5 - 6.6%[26] and in SA overall ~8.5%,[27] considerably higher figures than in this study. Similarly, hepatitis B prevalence is high in SA (~8%).[28]

Study limitations

The limitations of this study are that it is purely observational of the presence of hypertension, MCGN and ESRD in patients using methamphetamines. In addition, there is no clear pathophysiological pathway linking methamphetamine abuse to MCGN. Further studies, while difficult in the setting of illicit substances, are clearly required.

Conclusion

The abuse of methamphetamines appears to be associated with severe hypertension and MCGN, both of which can lead to ESRD and death. In a resource-limited setting, this has important implications for the management of these young patients. Strategies to prevent exposure to this easily accessible drug need to be implemented. Acknowledgements. This research was initiated by Dr Nazier Khan, who tragically died before he could complete the project.

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References 1. Peltzer K, Ramlagan S, Johnson BD, Phaswana-Mafuya N. Illicit drug use and treatment in South Africa: A review. Subst Use Misuse 2011;45(13):2221-2243. [http://dx.doi.org/10.3109/10826084.201 0.481594] 2. Matsha TE, Yako YY, Rensburg MA, Hassan MS, Kengne AP, Erasmus RT. Chronic kidney diseases in mixed ancestry South African populations: Prevalence, determinants and concordance between kidney function estimators. BMC Nephrol 2013;14(1):75-84. [http://dx.doi.org/10.1186/1471-236914-75] 3. Plüddemann A, Flisher AJ, McKetin R, Parry C, Lombard CJ. Methamphetamine use, aggressive behavior and other mental health issues among high school students in Cape Town, South Africa. Drug Alcohol Depend 2010;109(1-3):14-19. [http://dx.doi.org/10.1016/j.drugalcdep.2009.11.021] 4. Fahal IH, Sallomi DF, Yaqoob M, Bell GM. Acute renal failure after ecstasy. BMJ 1992;305(6844):29. [http://dx.doi.org/10.1136/bmj.305.6844.29] 5. Plüddemann A, Myers B, Parry C. Fact sheet – Methamphetamine. Cape Town: Medical Research Council, 2007:1-3. 6. Ito H, Yeo K-K, Wijetunga M, Seto TB, Tay K, Schatz IJ. A comparison of echocardiographic findings in young adults with cardiomyopathy: With and without a history of methamphetamine abuse. Clin Cardiol 2009;32(6):E18-E22. [http://dx.doi.org/10.1002/clc.20367] 7. Ances BM, Vaida F, Cherner M, et al. HIV and chronic methamphetamine dependence affect cerebral blood flow. J Neuroimmune Pharmacol 2011;6(3):409-419. [http://dx.doi.org/10.1007/s11481-0119270-y] 8. Bingham C, Beaman M, Nicholls AJ, Anthony PP. Necrotizing renal vasculopathy resulting in chronic renal failure after ingestion of methamphetamine and 3,4-methylenedioxymethamphetamine (‘ecstasy’). Nephrol Dial Transplant 1998;13(10):2654-2655. [http://dx.doi.org/10.1093/ndt/13.10.2654] 9. Albertson TE, Derlet RW, van Hoozen BE. Methamphetamine and the expanding complications of amphetamines. West J Med 1999;170(4):214-219. 10. Milroy CM, Parai JL. The histopathology of drugs of abuse. Histopathology 2011;59(4):579-593. [http://dx.doi.org/10.1111/j.1365-2559.2010.03728.x] 11. Vupputuri S, Batuman V, Muntner P, et al. The risk for mild kidney function decline associated with illicit drug use among hypertensive men. Am J Kidney Dis 2004;43(4):629-635. [http://dx.doi. org/10.1053/j.ajkd.2003.12.027] 12. Inouye DS, Kickertz K, Wong LL. Methamphetamine use in deceased kidney donors impairs one-yr graft function. Clin Transplant 2007;21(5):643-650. [http://dx.doi.org/10.1111/j.13990012.2007.00703.x] 13. De Ligny BH, El Haggan W, Comoz F, et al. Early loss of two renal grafts obtained from the same donor: Role of ecstasy? Transplantation 2005;80(1):153-156. [http://dx.doi.org/10.1097/01. TP.0000158713.70266.06] 14. Meade CS, Watt MH, Sikkema KJ, et al. Methamphetamine use is associated with childhood sexual abuse and HIV sexual risk behaviors among patrons of alcohol-serving venues in Cape Town, South Africa. Drug Alcohol Depend 2012;126(1-2):232-239. [http://dx.doi.org/10.1016/j. drugalcdep.2012.05.024] 15. Wechsberg WM, Luseno WK, Karg RS, et al. Alcohol, cannabis, and methamphetamine use and other risk behaviours among black and coloured South African women: A small randomized trial in the Western Cape. Int J Drug Policy 2008;19(2):130-139. [http://dx.doi.org/10.1016/j.drugpo.2007.11.018] 16. Jones HE, Browne FA, Myers BJ, et al. Pregnant and nonpregnant women in Cape Town, South Africa: Drug use, sexual behavior, and the need for comprehensive services. Int J Pediatr 2011;2011:353410. [http://dx.doi.org/10.1155/2011/353410] 17. Stevens PE, Levin A. Clinical guidelines. Evaluation and management of chronic kidney disease: Synopsis of the Kidney Disease: Improving Global Outcomes 2012 Clinical Practice Guideline. Ann Intern Med 2013;158(11):825-831. [http://dx.doi.org/10.7326/0003-4819-158-11-201306040-00007] 18. Talley NJ, O’Connor S. Clinical Examination. 3rd ed. Talley NJ, O’Connor S, eds. Eastgardens, NSW, Australia: Blackwell Science, 1996. 19. Romhilt DW, Bove KE, Norris RJ, et al. A critical appraisal of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy. Circulation 1969;40(2):185-195. [http://dx.doi. org/10.1161/01.CIR.40.2.185] 20. Swanepoel CR, Wearne N, Duffield MS, Okpechi IG. The evolution of our knowledge of HIVassociated kidney disease in Africa. Am J Kidney Dis 2012;60(4):668-678. [http://dx.doi.org/10.1053/j. ajkd.2012.04.034] 21. Okpechi I, Swanepoel C, Duffield M, et al. Patterns of renal disease in Cape Town South Africa: A 10year review of a single-centre renal biopsy database. Nephrol Dial Transplant 2011;26(6):1853-1861. [http://dx.doi.org/10.1093/ndt/gfq655] 22. Van Rensburg BWJ, van Staden AM, Rossouw GJ, Joubert G. The profile of adult nephrology patients admitted to the renal unit of the Universitas Tertiary Hospital in Bloemfontein, South Africa from 1997 to 2006. Nephrol Dial Transplant 2010;25(3):820-824. [http://dx.doi.org/10.1093/ndt/gfp535] 23. Simon P, Ramée MP, Autuly V, et al. Epidemiology of primary glomerular diseases in a French region. Variations according to period and age. Kidney Int 1994;46(4):1192-1198. [http://dx.doi.org/10.1038/ ki.1994.384] 24. Floege J, Johnson RJ, Feehally J. Section IV: Glomerular disease. In: Floege J, Johnson RJ, Feehally J, eds. Comprehensive Clinical Nephrology. 4th ed. St Louis: Elsevier Saunders, 2010:193-358. [http://dx.doi.org/10.1016/B978-0-323-05876-6.00015-0] 25. Jaffe JA, Kimmel PL. Chronic nephropathies of cocaine and heroin abuse: A critical review. Clin J Am Soc Nephrol 2006;1(4):655-667. [http://dx.doi.org/10.2215/CJN.00300106] 26. Connolly C, Shisana O, Colvin M, Stoker D. Epidemiology of HIV in South Africa – results of a national, community-based survey. S Afr Med J 2004;94(9):776-781. 27. Lehohla P. Mid-Year Population Estimates 2013. Pretoria: Statistics South Africa, 2013:1-17. 28. Kew MC. Epidemiology of chronic hepatitis B virus infection, hepatocellular carcinoma, and hepatitis B virus-induced hepatocellular carcinoma. Pathol Biol 2010;58(4):273-237. [http://dx.doi. org/10.1016/j.patbio.2010.01.005]

Accepted 13 October 2014.

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Emergency care research priorities in South Africa D J van Hoving, MB ChB, Dip PEC (SA), MMed (Em Med), MScMedSci (Clin Epi); B K Barnetson, MB ChB; L A Wallis, MB ChB, FCEM, MD Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town, South Africa Corresponding author: D J van Hoving (nvhoving@sun.ac.za)

Background. Emergency care research is rarely undertaken in low- and middle-income countries. A manageable ‘road map’ for research in South African (SA) emergency care is needed to address research gaps. Objective. To identify, collate and prioritise research topics from identified knowledge gaps in emergency care in SA. Methods. Seventy-six individuals were invited to participate in a modified Delphi study. Participants were requested to suggest important research topics before rating them. Consensus was achieved when >75% of participants strongly agreed or disagreed. Participants then ranked the agreed statements before selecting the most appropriate methodology relating to study design, funding and collaboration. Results. Three hundred and fifty topics were suggested by 31 participants. Topics were collated into 123 statements before participants rated them. Consensus was achieved for 39 statements. The highest-ranked priority in the prehospital group was to determine which prehospital interventions improve outcomes in critically ill patients. The competence of emergency care providers in performing common lifesaving skills was deemed the most important in clinical emergency care. Implementing and reviewing quality improvement systems scored the highest under general systems and safety management. Only 22 statements achieved consensus regarding study design. The National Department of Health was the preferred funding source, while private organisations and emergency care societies were identified as possible collaborative partners. Conclusion. This study provides expert consensus on priority research areas in emergency care in SA as a guide for emergency care providers to ensure evidence-based care that is relevant to the SA population. S Afr Med J 2015;105(3):202-208. DOI:10.7196/SAMJ.8967

Health research has a high value to society and has resulted in a noteworthy improvement in healthcare. South Africa (SA) has a quadruple burden of disease that is being addressed by the strate g ic priorities of the National Department of Health (NDoH).[1] A continuous reduction in morbidity and mortality can only be guaranteed if research is ongoing, if the efficacy and adverse effects of medical interventions are continuously monitored, and by ensuring that research is relevant to a specific patient population.[2] High-quality healthcare implies practice that is consistent with the current best evidence.[3] It is essential to know which interventions work and which do not, and which are likely to be harmful. This becomes vitally important in settings with a mismatch between the burden of disease and available resources. While healthcare professionals in low- and middle-income countries (LMICs) should use evidence-based decisions in day-today patient care, implementing evidence-based medicine remains difficult.[4] Since the majority of studies are done in high-income countries for high-income countries relating to health conditions important to high-income countries,[5] their limited applicability and transferability to LMICs creates a knowledge vacuum in LMICs, including SA.[4] Research in the field of emergency care specifically related to LMICs is sparse. A single consensus study related to clinical research priorities, emergency centre management and administration exists,[6] but there are no lists or identified gaps for any aspects of emergency or acute care specific to SA. Research related to emergency care in SA demands a manageable ‘road map’ to address the research gaps. This study aimed to identify, collate and prioritise research topics from identified knowledge gaps in emergency care in SA.

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Methods

Study design

A three-phase modified Delphi study was undertaken from 1 March 2012 to 5 April 2013. The Delphi study design was modified in that each phase was limited to only two or three rounds (Fig. 1). Ethics approval was obtained from the Human Research Ethics Committee, Stellenbosch University, Tygerberg, Cape Town (Reference S12/02/034).

Study population

Seventy-six participants were invited to represent the expert panel (Appendix 1). They included doctors, nurses, prehospital care providers, and policy makers from all the provinces in SA. Invited panel members were given the option of appointing a representative in their place.

Data collection and management

All potential panel members were invited by e-mail, and partici pation implied consent. An online survey tool (SurveyMonkey) was used to facilitate the process. The views of all participating panellists were given equal weight. Participants were given 4 weeks to complete each round; weekly reminders were sent by e-mail until a response was received or the 4 weeks had expired. All panel members were invited to participate in rounds 1 and 2 of phase 1 and re-invited for the first round of phases 2 and 3. In phase 1 (identifying research topics), participants were requested to suggest important research topics in five categories of emergency care (adult emergency care, paediatric emergency care, prehospital emergency care, emergency nursing care, and a ‘general’ section for any other area related to emergency care). An example was provided for each category, and categories were randomised to avoid question order bias. The suggested research topics were then collated

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Phase 1. Identifying research topics

•

Round 1: Submission of free-text suggestions regarding important research needed in emergency care

• •

Round 2: Rate agreement of proposed research statements Round 3: Determine consensus on research statements

Phase 2. Prioritising research topics

• •

Round 1: Ranking of agreed research statements Round 2: Determine consensus on ranking of statements

Phase 3. Best approach to prioritised research topics

• •

Round 1: Select the most appropriate method to address the research statements related to study design, funding and collaboration Round 2: Determine consensus regarding most appropriate study design

Fig. 1. The Delphi process used to attain a coherent list of research topics for emergency care in SA.

Table 1. Examples to determine rank order of research statements Ranked value Participant A

Participant B

Participant C

Average per statement

Ranking

Statement A

N/A

1.5

Statement B

N/A

2.5

Statement C

3.3

Statement D

Statement E

N/A

3.5

N/A = not applicable.

into 123 research statements. Participants were then asked to rate their agreement that each statement was a priority for research in emergency care in SA. A 10-point Likert scale was used, and consensus was achieved when >75% of participants strongly agreed (scores 8 - 10) or strongly disagreed (scores 1 - 3). The mean score for each statement was calculated, while statements completed as ‘not applicable’ were excluded. Surveys were then individualised, and participants were presented with all non-consensus statements. Both the participant’s rating score and the mean rating score for each nonconsensus statement were provided to allow participants to consider an alternative rating score. In phase 2 (prioritising research topics), consensus statements from phase 1 were regrouped into three new categories: (i) prehospital; (ii) clinical; and (iii) general systems and safety. Panellists were asked to rank the statements in each category in order of importance. Categories per se and statements within each category were randomised to prevent question order bias. Participants could exclude statements by indicating them as ‘not applicable’ to their area of expertise. Submission was blocked until all statements were either ranked or excluded. The overall rank order per category was subsequently determined. For each participant, the first ranked statement (i.e. most important) was given a value of 1. The lowestranked or least important statement received the value of the number of statements in that category less the number of statements selected as ‘not applicable’. An average ranking score was calculated for every

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statement by adding the values given by all participants, and dividing that by the number of participants that ranked that specific statement; the top ranking statement would therefore have the lowest average score (Table 1). The ranked statements were presented to the participants. The categories were randomised, but the statements in each category were presented in the order of the average ranking scores achieved. Both the participant’s ranking score and the mean ranking score were provided to allow participants to consider an alternative ranking score. For the final phase (best approach to prioritised research topics), participants were requested to choose one or more study design options. Participants were also given the option of using free text to suggest funding and collaboration options for each statement. Participants were again allowed to select ‘not applicable’ to exclude themselves from that statement if they considered the topic out of their area of expertise. Only the study design options for each research statement were redistributed to determine consensus. Collected data were transferred to and analysed on a passwordprotected electronic spreadsheet (Microsoft Office Excel 2010, Microsoft Corporation, USA).

Results

Seventy-six panel members were invited to participate in the study. Two medical and three nursing panel members appointed

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Delphi process used to determine consensus regarding the ranking of the research state ments was completed by 19 participants (65%). Tables 2, 3 and 4 provide the final consensus ranking order of consensus priority statements in each category. The response rate for suggesting study design options was 28% (n=21); only three statements initially achieved consensus. The last round of the study (reconsidering study design options) was completed by 15 partici pants (71%). An additional 22 statements achieved consensus regarding the most appropriate study design to use (Tables 2 - 4). One to three suggestions per statement for funding options were received for 32 (84%) of the 38 statements. The NDoH (n=26) and private organisations (n=12) were most often indicated as potential funding sources. One to two collaboration suggestions per statement were provided for 29 statements (76%). Private organisations (n=7) and emergency care-related societies (n=7) were considered as options with which to do collaborative work.

representatives in their place. The response statistics for all study phases are summarised in Fig. 2. Three hundred and fifty research topics were suggested by 31 participants (41%). The suggested topics were collated into 123 research statements. Seventy-five of the original 76 panel members were invited to rate their agreement of the proposed collated research statements as a priority for research in emergency care in SA (one panel member was unintentionally not invited). Thirty-one (41%) responded, and consensus was achieved for 11 statements. The remaining statements were resent for re-rating. Consensus was achieved for 39 statements after 25 participants (81%) changed their initial scores. These statements were then grouped into the three categories as described under ‘Methods’. One of the statements was only identified late in the study and was subsequently not included. The consensus statements were ranked by 29 panel members (39%). Statements were re-ordered according to their average ranking scores achieved. The

Response rates, % of total invitees

100

Unresponded

Unknown

Prehospital

Policy makers

Nursing

Medical

40 30 20 10

)

sig n

ig n

es -su gg es

yd ud st

Thirty-nine statements related to emergency care were identified as high priorities for the SA setting.

Prehospital emergency care

Prehospital interventions on patient outcomes were ranked first among prehospital research priorities. The need to substantiate clinical care by evidence and to use clinically relevant performance measures was echoed by studies from Europe and the USA, including both adult and child populations.[7-9] There have been substantial international debates regarding the scope of prehospital care, and it is clear that the issue has not been resolved. The SA emerg ency medical services system has adopted the Anglo-American system, which minimises on-scene time (as opposed to the FrancoGerman model, which includes prehospital physicians with an extensive scope of practice and very advanced technology).[10] A prolonged on-scene time, usually as a result of additional prehospital interventions, has been shown to be detrimental to patient outcomes (especially in trauma); it is therefore important to ensure that only the necessary interventions, backed by substantial evidence, are performed.[11] Appropriate management strategies ranked second in the prehospital group. Any pre hospital system faces challenges with the acquisition and appropriate allocation of assets and resources, including human resources.[12] SA has been losing significant numbers of prehospital practitioners with advanced training over the past decade.[13] Poor working conditions, physical security and economic considerations were identified as some of the main ‘push’ factors.[13] Govender et al.[14] also hinted that current measures are inadequate to actively manage the shortages of prehospital practitioners with advanced training and their migration out of SA.

Re 2

Clinical emergency care

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2. 2

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gg es

im po

r ta

nc e

)

1) /3 25 rta im po

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Re 3 1.

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Discussion

All phases rounds (respondents, n/invitees, n)

Fig. 2. Summary of response statistics for all study phases.

Emergency care (prehospital, medical and nursing) is a procedure-orientated field that

Table 2. Ranked research priority topics related to prehospital emergency care Rank

Research statement

Study design

Determine which prehospital interventions improve outcomes in trauma or critically ill patients

Randomised controlled trial

Determine the most appropriate prehospital management strategies in southern Africa

Systematic review ± meta-analysis

Tie 3rd

Optimise the use of resources in terms of transfers and transport in emergency medical services

Non-consensus

Tie 3rd

Compile evidence-based guidelines for the critical care transfer of patients

Systematic review ± meta-analysis

Determine the outcomes of prehospital drug-facilitated intubations

Non-consensus

Determine an appropriate mass casualty system for southern Africa

Systematic review ± meta-analysis

Implications of the abuse of ambulance services to transport non-emergency cases

Descriptive study

Define the role of aeromedical transport in rural areas

Descriptive study

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Table 3. Ranked research priority topics related to clinical emergency care Rank

Research statement

Study design

Determine how competent emergency care providers are in performing common lifesaving skills within their scope of practice

Non-consensus

Determine whether emergency care providers are competent in recognising and handling a failed airway

Descriptive study

Determine the burden of disease and patient conditions that present to the emergency centre

Descriptive study

Determine how competent emergency nurses are in recognising critically ill patients

Descriptive study Systematic review ± meta-analysis

Determine markers of severity in the trauma or critically ill patient

Determine how competent emergency care providers are in providing paediatric critical care

Descriptive study

Develop effective pain management strategies for all acute-care patients

Systematic review ± meta-analysis

Determine the knowledge and utilisation of non-invasive ventilation by emergency care providers

Descriptive study

Determine the efficacy of nurse-led triage

Non-consensus

Determine the need for a national poison information centre

Descriptive study

Determine appropriate spinal immobilisation techniques in the SA context

Non-consensus

Determine whether paediatric seizures are managed appropriately by all emergency care providers

Descriptive study

Determine whether toxicological cases are appropriately managed by all emergency care providers

Non-consensus

Determine whether paediatric febrile illnesses are managed appropriately

Descriptive study

Determine the impact of low-dose digital X-ray (LODOX) machines on emergency trauma patient management

Non-consensus

Table 4. Ranked research priority topics related to general systems and safety management Rank

Research statement

Study design

Implement and review quality improvement systems

Non-consensus

Determine whether evidence-based healthcare is adhered to in providing emergency care

Descriptive study

Develop strategies to reduce child and infant morbidity and mortality

Systematic review ± meta-analysis

Comparison of the different acute-care systems in order to improve understanding and implement integrated care pathways

Systematic review ± meta-analysis

Tie 5th

Determine whether lifesaving equipment is checked before commencing duty

Systematic review ± meta-analysis or descriptive study

Tie 5th

Determine the cost-effectiveness of providing emergency care

Systematic review ± meta-analysis

Determine the true implication of prolonged length of stay in emergency centres

Non-consensus

Determine the impact of National Health Insurance on emergency care

Non-consensus

Determine efficacy of infection control measures in various acute-care settings

Non-consensus

Determine valid and reliable assessment methods for emergency care educational examinations

Non-consensus

Determine the efficacy of hospital case load policies

Non-consensus

Determine whether informed consent is appropriately undertaken in the emergency care setting

Descriptive study

Determine whether adequate emergency centre discharge instructions are given to patients

Descriptive study

Determine how emergency care trainees perceive their future in emergency care in southern Africa

Descriptive study

Determine the impact of occupation-specific dispensation on recruitment and retention of emergency centre staff

Descriptive study

requires adequate knowledge and skills to diagnose and manage acute aspects of illnesses and injuries.[15] Overcrowding and prolonged length of patient stay mean that the management of critically ill and trauma patients frequently extends beyond initial stabilisation in the emergency centre when intensive care unit capacity is limited (and exhausted). The consequences were reflected in the research priorities related to clinical emergency care, where statements relating to competence in managing critically ill patients featured repeatedly.

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However, SA-trained healthcare providers have always been sought after internationally owing to the high quality and standard of their medical education and their hands-on experience.[16] The focus on competence is also in stark contrast to other international studies, which highlighted clinical outcomes as their top research priorities.[17,18] Emergency medicine is still a relatively young specialty in SA, with the focus on competence revealing that it is still establishing its place in the broader medical field.

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The burden of disease and patient conditions presenting to emergency centres ranked third in the clinical emergency care section. Knowing the acuity mix of patients presenting to emergency centres is essential to plan service delivery accurately. The efficient deployment of staff relative to temporal patterns of patient presentations and developing strategies for dealing with non-referred minor cases has been highlighted previously.[19] This information can also help in identifying key areas to optimise patient flow from as early as the initial presentation to the emergency medical service, so that emergencies can be dealt with promptly and appropriately.[19] The emergency medicine setting is a unique environment of high patient volumes, brief clinical encounters, and patients from all age groups representing a spectrum of acuity. Risk stratification is the initial step towards a personalised patient care plan to ensure that patients are safely managed and appropriately investigated. Although the identification of appropriate markers of severity (5th-ranked statement) was identified as an international priority,[17] it would be just as useful, or even more useful, in resource-limited settings. The early identification of disease severity and subsequent focused management of high-risk patients is therefore as important from a healthcare economics point of view as from a morbidity and mortality perspective.

General systems and safety management

The expectation and requirement to deliver safe and highquality emergency care have never been greater. Healthcare systems are not as reliable as has been thought, and highquality care is often lacking.[20,21] Cost-effectiveness of emergency medical interventions and quality assurance are considered global priorities.[6,21] According to the Institute of Medicine in the USA, a healthcare system should aim to be safe, effective, efficient, patient-centred, timely and equitable.[20] Components of emergency care that can improve quality and patient safety include well-trained and motivated staff, appropriate physical structures, effective processes to enable high-quality care, co-ordinated clinical pathways supported by best evidence-based practice, and monitoring objective outcome measures to reflect continuous quality improvement (e.g. diagnostic errors, mortality and morbidity rates, etc.).[22]

Study limitations

Purposeful sampling was used for the panel selection, the criteria being that experts were identified by their specialist qualification and roles as leaders in their fields or heads of academic institutions or societies. Policymakers remained largely non-contactable, limiting the knowledge gained pertaining to policies and resource allocation at provincial or national levels. Participants in a Delphi study have an interest and involvement in the question being examined. Researcher and subject bias is a known limitation, but the wide range of panellists should offset this. The opinion of a subset of experts with special interests in certain aspects of emergency care (e.g. paediatric emergency care) may have been under-represented. The lack of participant discussion may have prevented participants from changing their views and responding according to the majority opinion.

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Collating free text statements was undertaken in an effort to reduce the number of statements to avoid panel fatigue and attrition. Abstraction may have led to omission of details and potential oversimplification of suggested priority topics. The response rate and consensus thresholds (75%) mean that final agreement is not implied; guidelines for further research were essentially identified.

Conclusion

This study provides expert consensus on the current priority research areas in emergency care in SA. It can ultimately guide emergency care providers to serve the SA population with evidence-based emergency medical care that is relevant. Acknowledgement. We thank Ms Rachel Allgaier for her input on the initial proposal. References 1. Department of Health (South Africa). NSDA: A Long and Healthy Life for All South Africans. Pretoria: Department of Health, 2013. http://www.hst.org.za/sites/default/files/NSDA_booklet.pdf (accessed 24 July 2014). 2. Wallis LA. Knowing and doing: Negotiating resource constraints through research. African Journal of Emergency Medicine 2013;3(4):151. [http://dx.doi.org/10.1016/j.afjem.2013.08.002] 3. Guyatt GH, Meade MO, Jaeschke RZ, Cook DJ, Haynes RB. Practitioners of evidence based care. BMJ 2000;320(7240):954-955. [http://dx.doi.org/10.1136/bmj.320.7240.954] 4. Lowe M. Evidence-based medicine – the view from Fiji. Lancet 2000;356(9235):1105-1107. [http:// dx.doi.org/10.1016/S0140-6736(00)02743-4] 5. Chinnock P, Siegfried N, Clarke M. Is evidence-based medicine relevant to the developing world? PLoS Med 2005;2(5):e107. [http://dx.doi.org/10.1371/journal.pmed.0020107] 6. Hodkinson PW, Wallis LA. Emergency medicine in the developing world: A Delphi study. Acad Emerg Med 2010;17(7):765-774. [http://dx.doi.org/10.1111/j.1553-2712.2010.00791.x] 7. Fevang E, Lockey D, Thompson J, Lossius HM. The top five research priorities in physician-provided pre-hospital critical care: A consensus report from a European research collaboration. Scand J Trauma Resusc Emerg Med 2011;19(1):57. [http://dx.doi.org/10.1186/1757-7241-19-57] 8. Snooks H, Evans A, Wells B, et al. What are the highest priorities for research in emergency prehospital care? Emerg Med J 2009;26(8):549-550. [http://dx.doi.org/10.1136/emj.2008.065862] 9. Foltin GL, Dayan P, Tunik M. Priorities for pediatric prehospital research. Pediatr Emerg Care 2010;26(10):773-777. [http://dx.doi.org/10.1097/PEC.0b013e3181fc4088] 10. Al-Shaqsi S. Models of international emergency medical service (EMS) systems. Oman Med J 2010;25(4):320-323. [http://dx.doi.org/10.5001/omj.2010.92] 11. Seamon MJ, Doane SM, Gaughan JP, et al. Prehospital interventions for penetrating trauma victims: A prospective comparison between advanced life support and basic life support. Injury 2013;44(5):634638. [http://dx.doi.org/10.1016/j.injury.2012.12.020] 12. Institute of Medicine. Challenges facing the prehospital system. In: Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary. Washington, DC: National Academies Press, 2011. http://www.ncbi.nlm.nih.gov/books/NBK62391/ (accessed 31 July 2014). 13. Govender K, Grainger L, Naidoo R, MacDonald R. The pending loss of advanced life support paramedics in South Africa. African Journal of Emergency Medicine 2012;2(2):59-66. [http://dx.doi. org/10.1016/j.afjem.2011.11.001] 14. Govender K, Grainger L, Naidoo R. Developing retention and return strategies for South African advanced life support paramedics: A qualitative study. African Journal of Emergency Medicine 2013;3(2):59-66. [http://dx.doi.org/10.1016/j.afjem.2012.11.005] 15. Emergency Medicine Society of South Africa. Practice guideline EM001 – Definition of emergency medicine. 2008. http://emssa.org.za/documents/em001.pdf (accessed 31 July 2014). 16. Bezuidenhout M, Joubert G. Reasons for doctor migration from South Africa. S Afr Fam Pract 2009;51(3):211-215. 17. Eagles D, Stiell IG, Clement CM, et al. International survey of emergency physicians’ priorities for clinical decision rules. Acad Emerg Med 2008;15(2):177-182. [http://dx.doi.org/10.1111/j.15532712.2008.00035.x] 18. Keijzers G, Thom O, Taylor D, Knott J, Taylor DM. Clinical research priorities in emergency medicine. Emerg Med Australas 2014;26(1):19-27. [http://dx.doi.org/10.1111/1742-6723.12141] 19. Hodkinson PW, Wallis LA. Cross-sectional survey of patients presenting to a South African urban emergency centre. Emerg Med J 2009;26(9):635-640. [http://dx.doi.org/10.1136/emj.2008.063362] 20. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001. http://www.nap.edu/books/0309072808/html/ (accessed 14 August 2014). 21. Lutge E, Friedman I, Mbatha T. A review of health research in South Africa from 1994 to 2007. In: Barron P, Roma-Reardon J, eds. South African Health Review 2008. Durban: Health Systems Trust, 2008. 22. Lecky F, Mason S, Benger J, Cameron P, Walsh C. Framework for quality and safety in the emergency department. International Federation for Emergency Medicine, 2012. http://www.ifem.cc/site/ DefaultSite/filesystem/documents/Policies%20and%20Guidelines/Framework%20for%20Quality%20 and%20Safety%20in%20the%20Emergency%20Department%202012.doc.pdf (accessed 18 August 2014).

Accepted 20 October 2014.

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RESEARCH

Appendix 1 Invited panel list Group

Panel member

Position

Emergency medicine academic programme head

Prof. Efraim Kramer

University of the Witwatersrand

Emergency medicine academic programme head

Prof. Dries Engelbrecht

University of Pretoria

Emergency medicine academic programme head

Prof. Lee Wallis

Stellenbosch University/University of Cape Town

Emergency medicine academic programme head

Dr William Lubinga

University of Limpopo

Emergency medicine academic programme head

Dr Darryl Wood

University of KwaZulu-Natal

Selected other medical doctors

Dr Hein Lamprecht

Head: Continuous Quality Improvement, Western Cape EMS

Selected other medical doctors

Dr Roger Dickerson

SA College of Emergency Medicine

Selected other medical doctors

Dr Basil Bonner

Emergency physician (private sector)

Selected other medical doctors

Dr Tim Hardcastle

Trauma surgeon

Selected other medical doctors

Dr Steve Holt

Emergency physician (private sector)

Selected other medical doctors

Dr NiĂŤl van Hoving

Emergency physician

Selected other medical doctors

Dr P H Hargovan

University of KwaZulu-Natal

Selected other medical doctors

Dr Baljit Cheema

Paediatric emergency physician

Selected other medical doctors

Dr Charl van Loggerenberg

Medical Director: International SOS

Selected other medical doctors

Dr Mike Wells

Emergency physician

Selected other medical doctors

Dr Wayne Smith

Head: Disaster Medicine (Western Cape)

Selected other medical doctors

Dr Heike Geduld

Head: Education (Western Cape)

Emergency medicine-related society

Dr Jonathan Witt for Prof. Walter Kloeck

Head: Research task force team at Resuscitation Council of South Africa

Emergency medicine-related society

Dr Melanie Stander

Emergency Medicine Society of South Africa

Emergency medicine-related society

Dr Elmin Steyn

Trauma Society of South Africa

Academic nursing institutions

Ms Jean Augustyn

Medi-Clinic

Academic nursing institutions

Ms Tanya Heyns on behalf of Prof. Mulder

Senior lecturer: Emergency Nursing at University of Pretoria

Academic nursing institutions

Ms S Schmollgruber for Prof. L Maree

Head: Nursing Education, University of the Witwatersrand

Academic nursing institutions

Prof. S Duma

University of Cape Town

Academic nursing institutions

Mande Toubkin

Netcare

Academic nursing institutions

Prof. B Ncama

University of KwaZulu-Natal

Academic nursing institutions

Janet Bell on behalf of Prof. Marina Clarke

Stellenbosch University

Academic nursing institutions

Dr Doriccah Peu

University of Pretoria

Academic nursing institutions

Dr Carin Maree

University of Pretoria

Academic nursing institutions

Theo Lighthelm

School for Military Health Training

Other nursing professionals

Prof. Petra Bryciewicz

Professional emergency care nurse

Emergency medicine-related society

Lynette Thomas

Emergency care education

Emergency medicine-related society

Kathy Bodmer

Emergency Nurses Society of South Africa

Emergency medicine-related society

Yolande Magerman

Emergency Nurses Society of South Africa

Dr Cleeve Robertson

Western Cape, EMS Director

Medical

Nursing

Policy makers Prehospital directors

Continued ...

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March 2015, Vol. 105, No. 3

RESEARCH

Prehospital directors

Mr N Sithole

KwaZulu-Natal, EMS Director

Prehospital directors

Mr AK Munilal

Free State, EMS Director

Prehospital directors

Mr A Dhai

Northern Cape, EMS Director

Prehospital directors

Mr T Dludlu

Gauteng, EMS Director

National government

Mr Peter Fuhri

National EMS, EMS Director

National government

Dr Charles Theu

DoH National EMS Director

Provincial government

Dr Beth Engelbrecht

Western Cape: Deputy-Director General Health

Provincial government

Dr Samuel Beja

Chief Directorate: Clinical Support, Eastern Cape

Provincial government

Dr Theys

Head: Health, Northern Cape

Provincial government

Dr Moji

Deputy Director-General, Free State

Provincial government

Dr Nomonde Xundu

Head: Health, Gauteng

Provincial government

Dr Sibongiseni Dlomo

MEC Health, KZN

Provincial government

Dr Sibongile Zungu

Head: Health, KZN

Provincial government

Dr Clifford Mkasi

MEC Health, Mpumalanga

Provincial government

Dr Lydia Sebego

Head: Health, North West

Provincial government

Dr Aggrey Morake

Head: Health and Social Development, Limpopo