SAMJ Vol 106, No 11 (2016) by HMPG

NOVEMBER 2016

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CME Sexual violence IN PRACTICE Isoniazid preventive therapy – obstacles to success CASE REPORT Migraine treatment and epilepsy RESEARCH Barriers to obstetric care among maternal near-misses Medical waste disposal – are we getting it right?

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FROM THE EDITOR 5

ACTING EDITOR Bridget Farham, BSc (Hons), PhD, MB ChB

The doors of learning … B Farham

EDITORS EMERITUS Daniel J Ncayiyana, MD (Groningen), FACOG, MD (Hon), FCM (Hon) JP de V van Niekerk, MD, FRCR

EDITOR’S CHOICE CORRESPONDENCE

Preliminary results of allograft use from the South African skin bank H Rode, R Martinez, A D Rogers, R Moore, N L Allorto

We need more prospective studies for Kounis syndrome I Akbas, M Emet

The dilemma of age estimation of children and juveniles in South Africa M Tiemensma, V M Phillips

First report of Wohlfahrtiimonas chitiniclastica bacteraemia in South Africa R Hoffmann, F Fortuin, M Newton-Foot, S Singh

HMPG CEO AND PUBLISHER Hannah Kikaya | Email: hannahk@hmpg.co.za MANAGING EDITORS Ingrid Nye Claudia Naidu TECHNICAL EDITORS Emma Buchanan Paula van der Bijl

IZINDABA 16 18 20

ASSOCIATE EDITORS Q Abdool Karim, A Dhai, N Khumalo, R C Pattinson, A Rothberg, A A Stulting, J Surka, B Taylor, M Blockman, J M Pettifor

Counting the public healthcare litigation bill New findings say ‘never take a TB cure for granted’ A fond and grateful farewell

PRODUCTION MANAGER Emma Jane Couzens

CME

DTP AND DESIGN Clinton Griffin

GUEST EDITORIAL The epidemic of sexual violence in South Africa K Joyner

CHIEF OPERATING OFFICER Diane Smith | Tel. 012 481 2069 Email: dianes@hmpg.co.za

ARTICLES Understanding the intergenerational transmission of violence N Woollett, K Thomson

Current approaches to the management of adult survivors of sexual offences M Tiemensma

Physical and sexual violence against children A B van As

ISSUES IN PUBLIC HEALTH Health system challenges: An obstacle to the success of isoniazid preventive therapy E I Okoli, L Roets

NON-COMMUNICABLE DISEASES Addressing tobacco smoking in South Africa: Insights from behavioural science G Ganz

MEDICINE AND THE LAW When are doctors legally obliged to stop and render assistance to injured persons at road accidents? D McQuoid-Mason

Managing the remains of fetuses and abandoned infants: A call to urgently review South African law and medicolegal practice L du Toit-Prinsloo, C Pickles, G Saayman CASE REPORTS A report of three patients in whom the surgical closure of terminal branches of the external carotid arteries for treatment of migraine resulted in significantly reduced frequency of epileptic attacks E Shevel Polyarteritis nodosa presenting as a bladder outlet obstruction M Borkum, H Y Abdelrahman, R Roberts, A A Kalla, I G Okpechi

RESEARCH 48

Is South Africa advancing towards National Health Insurance? The perspectives of general practitioners in one pilot site* R Surender, R van Niekerk, L Alfers

ONLINE SUPPORT Gertrude Fani FINANCE Tshepiso Mokoena

IN PRACTICE

JOURNAL ADVERTISING Charles William Duke Reneé Hinze Ladine van Heerden Azad Yusuf Kenni Gambo

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HMPG BOARD OF DIRECTORS Prof. M Lukhele (Chair), Dr M R Abbas, Dr M J Grootboom, Mrs H Kikaya, Prof. E L Mazwai, Dr M Mbokota, Dr G Wolvaardt ISSN 0256-9574 SAMA website: www.samedical.org Journal website: www.samj.org.za

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Medical waste disposal at a hospital in Mpumalanga Province, South Africa: Implications for training of healthcare professionals* R R Makhura, S F Matlala, M P Kekana

A cross-sectional study of peripartum blood transfusion in the Eastern Cape, South Africa* K van den Berg, E M Bloch, A S Aku, M Mabenge, D V Creel, G J Hofmeyr, E L Murphy

Barriers to obstetric care among maternal near-misses* P Soma-Pillay, R C Pattinson

A review of the peri-operative management of paediatric burns: Identifying adverse events* H Rode, C Brink, K Bester, M P Coleman, T Baisey, R Martinez

The state of methamphetamine (‘tik’) use among youth in the Western Cape, South Africa* E H Weybright, L L Caldwell, L Wegner, E Smith, J J Jacobs

Intimate partner violence at a tertiary institution* K Spencer, M Haffejee, G Candy, E Kaseke

Tonsillectomy rates in the South African private healthcare sector* P Douglas-Jones, J J Fagan

An analysis of inter-healthcare facility transfer of neonates in the eThekwini Health District of KwaZulu-Natal, South Africa* P Askokcoomar, R Naidoo *Full article available online only.

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CME Sexual violence

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IN PRACTICE Isoniazid preventive therapy – obstacles to success CASE REPORT Migraine treatment and epilepsy RESEARCH Barriers to obstetric care among maternal near-misses Medical waste disposal – are we getting it right?

NOVEMBER 2016

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FROM THE EDITOR

The doors of learning … As I write this, our universities are in crisis – a crisis that has been coming since last year when the first protests about fees started. These prompted a zero fee increase for 2016, which has crippled most of our institutions of higher learning, already struggling with falling government funding. Between 1994 and 2014, the number of students in public universities more than doubled. During the same period the proportion of black students at universities increased from 52% to 81% of the student population. However, as an open letter from 1 200 university academics to president Jacob Zuma and higher education minister Blade Nzimande in August this year (2016) says, this increase in student numbers has not been matched by adequate funding.[1] In fact, every year has seen a decrease in real terms of government funding to public universities. The letter goes on to say that ‘our public universities can in fact barely be called public, with national government subsidies to university budgets falling from an already low 49% in 2000 to 40% in 2012’. At the same time, employment of full-time staff has not matched increases in student numbers, potentially decreasing the quality of teaching and adding to the administrative burden on full-time academic staff. The situation in our medical schools is arguably even worse, with frozen posts in the public hospitals that provide much of our medical teaching. The current protests are about an allowed 8% fee increase for 2017 – only for certain groups of students. The poorest will still get at least some government subsidy, including their fees paid. As I write, the University of Cape Town is closed, with no idea when it will open again. The University of the Witwatersrand is open, but if the level of violence associated with the recent protests on its campuses continues or escalates, it seems that its chances of finishing the 2016 academic year are slim. The University of KwaZulu-Natal is once again being subjected to violent protests, and the academic programme is also in serious danger. The University of Limpopo closed 2 weeks ago, and its 2016 academic programme appears to have been abandoned. Reading the comments on the social media pages of Wits and UCT is instructive. While the majority of students desperately want to finish the year, there is a vocal, persistent and often violent group who simply want to close the universities until their demand for free education is met – however long that takes, and whatever the consequences. This group of students is managing to hold our universities to ransom because of the violence of their protest action,

which is not only endangering those who remain on campus but has also (including the 2015 protests) so far cost the country around ZAR600 million in damage to university property. If the medical classes of 2016 do not graduate at the end of this year, there will be no intake of interns in 2017 and that cohort of community service doctors will also be lost. Our public health services are heavily dependent on these junior medical staff. So far, no one has been prepared to say exactly what the consequences will be, although minister of health Aaron Motsoaledi has been heard to say that the lack of interns will be disastrous. The prospect for final-year medical students is bleak – and many of them may well not manage to find the funds to repeat the year. A 2012 estimate by Moneyweb[2] put the cost of educating a single doctor in South Africa (SA) at ZAR250 000 a year – more than ZAR1.5 million for the whole degree. Yes, tertiary education in SA needs to be more easily accessible to those who cannot directly finance their own studies – ‘free’, if you like. But nothing is ‘free’ – someone pays, somewhere. Our government’s response to this crisis would be laughable if it were not so tragic. The president and the higher education minister together are leaving the universities to bear the brunt of anger that should be directed at government. Until our elected parliamentary representatives step up and take responsibility for their actions, we are likely to see the collapse of some of the finest academic institutions on the continent, and indeed in the world. Bridget Farham Acting Editor ugqirha@iafrica.com 1. Govender P. More than 1 200 academics plead with government to address funding crisis. Mail & Guardian, 15 August 2016. http://mg.co.za/article/2016-08-15-00-more-than-1-200-academics-pleadwith-government-to-address-funding-crisis (accessed 11 October 2016). 2. Carte D. The cost of medical education: And why our doctors emigrate. Moneyweb, 2 November 2012. http://www.moneyweb.co.za/archive/the-cost-of-medical-eductation/ (accessed 11 October 2016).

S Afr Med J 2016;106(11):1058. DOI:10.7196/SAMJ.2016.v106i11.12102

November 2016, Print edition

EDITOR’S CHOICE

CME: Sexual violence

Clinicians need to be fortified with knowledge and skills to meet the challenge of caring for individuals who have suffered or are at risk of gender-based violence (GBV). This issue of CME focuses on sexual violence, which involves a continuum that is far broader than sexual assault and has reached epidemic proportions in South Africa (SA). A recent human rights review identified entrenched stigma against persons based on their sexual or gender orientation, gender identity or bodily diversity, highlighting such persons’ ongoing experience of harassment, discrimination and sexual and physical violence. In addition, irregular migrants, trafficked and refugee women, orphans and other vulnerable girls such as those living with disabilities face an increased risk of GBV. Health professionals need to remain mindful of the inherent dignity of each patient, particularly those who are marginalised and neglected by mainstream society.

Barriers to obstetric care among maternal near-misses

Obstetric emergencies may occur in women with known risk factors or be caused by pregnancy itself, gestational hypertension or obstetric haemorrhage. A significant proportion of serious complications occur in women with no recognisable risk factors. A serious complication may progress rapidly to a life-threatening situation, so access and timely referral to appropriate emergency obstetric care are important. The World Health Organization estimates that about 88 - 98% of maternal deaths can be avoided with timely access to existing emergency obstetric intervention. However, there is increasing evidence that the majority of women classified as near-miss cases in developing countries arrive at referring hospitals in a critical condition. In a study of 100 maternal near-misses from Steve Biko Academic Hospital in Pretoria,[1] one or more factors causing a delay in accessing care were identified in 83% of cases, an unacceptably high rate. Delay in patient admission, referral and treatment and substandard care were important barriers identified for near-miss cases related to haemorrhage, hypertension and medical disease in pregnancy.

Peripartum blood transfusion in the Eastern Cape Province, SA

In SA, as is the case globally, obstetric haemorrhage (OH) remains a leading contributor to maternal mortality and morbidity. Delayed recognition of risk factors for OH and failure to provide effective peripartum care directly and adversely affect maternal outcomes. This is most notable in resource-poor settings, particularly where rural geography, ineffective referral and transportation systems compound risk associated with obstetric emergencies. Consequently, OH and high rates of blood transfusion prescribed for OH are frequent. Specific to SA, postpartum haemorrhage continued to contribute significantly to maternal deaths over the last reported triennium (2011 - 2013). Van den Berg et al.[2] assessed the incidence of peripartum transfusion at three large regional hospitals in the Eastern Cape in 2013. The overall rate was 3.2%, with significant variability by hospital. The number of red blood cell units per transfused patient and per delivery also varied significantly. This confirms a high rate of transfusion in SA, despite rates of OH that approximate those in high-income countries, suggesting that national transfusion guidelines are not being followed.

Medical waste disposal – are we getting it right?

Nurses, medical doctors, and dental and allied health staff are healthcare professionals (HCPs) who generate various types of hazardous hospital waste. Hospital waste is classified as medical waste, chemical waste, radioactive waste, cytotoxic waste, pharmaceutical waste and general

waste. The focus of this article by Makhura et al.[3] is on medical waste, which includes sharps, laboratory waste, human tissue and cadavers used for research purposes. Each waste category must be disposed of correctly according to specific guidelines to protect HCPs, ward cleaners, laundry workers and patients from needlestick injuries and biological hazards. The authors looked at how HCPs in a hospital in Mpumalanga Province both understood and applied guidelines around the disposal of medical waste. A high proportion of HCPs did not have adequate knowledge but nevertheless disposed of medical waste appropriately. While knowledge and practices were not associated with age, gender or years of experience, there was an association between professional category and knowledge and practices.

Methamphetamine (‘tik’) use among youth in the Western Cape Province, SA

Methamphetamine (MA) use in SA, especially in Cape Town and its surrounding areas, has been increasing at alarming rates. Recent evidence suggests that MA is second only to marijuana as the primary substance of abuse in patients seeking treatment. Weybright et al.[4] focused on grade 8 learners from 54 Western Cape secondary schools and showed that an alarming 5% had used tik in their lifetime, and of these 65% had used it in the past month or week. Risk factors for use were male gender, not having a present or partially present mother, not living in an apartment/flat/brick house, alcohol and tobacco use, and having a same-sex partner. The need for comprehensive prevention initiatives is highlighted.

GPs’ perspectives of National Health Insurance (NHI)

The launch of the long-awaited NHI White Paper in December 2015 heralded a new stage in SA’s advancement towards universal health coverage – arguably the most radical health reform in the country’s history. In order to achieve this transformation, the proposals intend a complete reconfiguration of the necessary funding and service delivery mechanisms. Part of this initiative is the contracting of public and private hospital specialists and GPs to deliver services free of charge at the point of use. Surender et al.[5] report on the views and experiences of GP providers tasked with implementing the reforms at one pilot site, Tshwane District in Gauteng Province, providing an insight into the practical challenges the NHI scheme faces in implementation. The overall experiences of the GPs exposed a number of problems with the pilot. These included frustration with lack of appropriate infrastructure and equipment in NHI facilities, difficulties integrating into the facilities and lack of professional autonomy, as well as unhappiness with contracting arrangements. Despite strong support for the idea of NHI, there was general scepticism that private doctors would embrace the scheme on the scale required, suggesting that the current pilots are still a long way from the vision of a single, integrated health system. BF 1. Soma-Pillay P, Pattinson RC. Barriers to obstetric care among maternal near-misses. S Afr Med J 2016;106(11):1110-1113. DOI:10.7196/SAMJ.2016.v106i11.10726 2. Van den Berg K, Bloch EM, Aku AS, Mabenge M, Creel D, Hofmeyr GJ, Murphy EL. A crosssectional study of peripartum blood transfusion in the Eastern Cape, South Africa. S Afr Med J 2016;106(11):1103-1109. DOI:10.7196/SAMJ.2016.v106i11.10870 3. Makhura RR, Matlala SF, Kekana MP. Medical waste disposal at a hospital in Mpumalanga Province, South Africa: Implications for training of healthcare professionals. S Afr Med J 2016;106(11):10961102. DOI:10.7196/SAMJ.2016.v106i11.10689 4. Weybright EH, Caldwell LL, Wegner L, Smith E, Jacobs JJ. The state of methamphetamine (‘tik’) use among youth in Western Cape, South Africa. S Afr Med J 2016;106(11):1120-1123. DOI:10.7196/ SAMJ.2016.v106i11.10814 5. Surender R, van Niekerk R, Alfers L. Is South Africa advancing towards National Health Insurance? The perspectives of general practitioners in one pilot site. S Afr Med J 2016;106(11):1092-1095. DOI:10.7196/SAMJ.2016.v106i11.10683

November 2016, Print edition

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CORRESPONDENCE

Preliminary results of allograft use from the South African skin bank

To the Editor: In 2013, Rogers et al.[1] highlighted the desperate need for a skin bank in this country. Earlier this year, Allorto et al.,[2] in a letter to this journal, reported the establishment of South Africa (SA)’s first skin bank, and advocated for increased donation, as well medical and lay education to increase tissue donation to meet the enormous need. The primary motivation for this initiative is to have a ready supply of deceased donor (cadaver) allograft for use as a biological temporary skin substitute. In the context of major burn injury, allograft is used as a temporary wound cover after excision of deep partial thickness and full thickness burns prior to autografting, or as physical protection and a scaffold over widely meshed autografts. Allograft is the best possible test of the capacity for a wound bed to accommodate subsequent autografting, especially in the context of a major burn with limited donor sites, but is also invaluable following the management of wound infection, necrosis or other conditions that may compromise take. Excellent results have also been reported in the context of exfoliative disorders of the skin or as part of reconstructive surgeries to create a dermal scaffold (referred to as alloderm or allodermis). Burns exceeding 40% of the total body surface area (TBSA) have inadequate donor skin available to cover the excised burn eschar. Temporary alternatives to autografts include synthetic skin substitutes or deceased donor allograft. Allografts can be sourced from organ donor patients, hospital or state mortuaries, private institutions or (rarely) living donors. Using restrictive guidelines for its use, at least 25 patients per month with major burns would benefit from allograft use as part of their burn care in SA. The establishment of a national skin bank attached to the Tshwane University of Technology ensures the availability of a legal, secure and readily available source of quality allograft. The bank was officially opened in April 2016 and is supported by the Department of Health and the SA Tissue Bank (SAtiBA). Similar to the European skin bank, allograft preservation is through an inexpensive process of glycerolisation. Once deglycerolised, the product functions as a valuable temporary skin cover, undergoing the phases of graft take not unlike autograft (plasmatic imbibition, inosculation and neovascularisation). Tissue compatibility between donor and recipient is not required, although rejection is inevitable if skin is left on for more than 2 weeks, resulting in epidermolysis. The skin is commercially available at R11/cm2 and can be stored for at least 2 years at 4°C. We present our preliminary results from eight paediatric patients managed at the Red Cross War Memorial Children’s Hospital using glycerolised allografts obtained from the skin bank. The mean age was 3.6 years (range 10 months to 8 years). Seven sustained flame burns and one a deep scald injury. The indications for allograft use in all eight were cover following burn eschar excision and wound preparation, and to enhance epithelialisation after micrografting in five patients. The mean TBSA burn was 49% (range 11 - 86%). Allografts were placed immediately after early excision, typically on day 3 (range 1 - 9 days). Autograft take following allograft wound preparation was greater than 90% in all cases. The TBSA grafted with allograft in these eight children was 35.9%; this was a total of 12 100 cm2 allograft. All the children survived and were discharged, following shorter average hospitals stays than before. We used allograft to optimise wound bed preparation after excision, contributing to excellent outcomes after removal of the micrograft sheets on the seventh postoperative day. Having allograft

available at both of these critical phases has undoubtedly resulted in shorter hospital lengths of stay (less than 1.5 days per percentage burn), and increased the lethal dose, 50% (LD50) of major burns in this unit to over 70% TBSA, a statistic unprecedented in low- and middle-income countries. Another paediatric burn unit in SA, Chris Hani Baragwanath Hospital, also started using skin bank allograft recently, where it was applied to four children with burns between 30 and 50% TBSA as part of temporary skin cover after initial excision. The skin bank has changed the landscape for the management of major burns in SA. H Rode, R Martinez

Red Cross War Memorial Children’s Hospital and Division of Paediatric Surgery, Department of Surgery, Faculty of Health Sciences, University of Cape Town, South Africa heinz.rode@uct.ac.za

A D Rogers

Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre; and Division of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Toronto, Canada

R Moore

Chris Hani Baragwanath Hospital Johnson and Johnson Burns Unit, Faculty of Surgery, University of Witwatersrand, Johannesburg, South Africa

N L Allorto

Edendale Hospital Burn Service, Pietermaritzburg; and Department of Surgery, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 1. Rogers AD, Allorto NL, Adams S, Adams KG, Hudson DA, Rode H. Isn’t it time for a cadaver skin bank in South Africa? Ann Burns Fire Disasters 2013;26(3):142-146. 2. Allorto NL, Rogers AD, Rode H. ‘Getting under our skin’: Introducing allograft skin to burn surgery in South Africa. S Afr Med J 2016;106(9):865-866. DOI:10.7196/samj.2016.v106i9.10852

S Afr Med J 2016:106(11):1059. DOI:10.7196/SAMJ.2016.v106i11.12096

We need more prospective studies for Kounis syndrome

To the Editor: We read the article[1] about Kounis syndrome published in an earlier issue of your journal with great interest. This letter is intended both to correct a mistake in the article and to emphasise its importance by sharing our own clinical experiences. Kounis syndrome, which is a myocardial ischaemia picture accompanying allergic cases, was first described in 1991.[2] Though not rare, Kounis syndrome is among the diseases less commonly found in literature, and one of the least known and most underdiagnosed diseases by clinicians.[3] Actual incidence of the disease is not exactly known, because of poor reliability in reporting and misdiagnosis.[3,4] The incidence of the disease was indicated to be between 4.3 and 9.6 per 100 000 in retrospective studies.[5,6] Only one study shows the prospective incidence of Kounis syndrome,[3,7] conducted in our institution. In this study, Akoz et al.[7] found the incidence of the disease to be 19.4/100 000.[7] This incidence is high compared with retrospective studies, indicating that the syndrome is actually more common than estimated. Unfortunately, this prospective study was mistakenly stated to be retrospective in the letter published in your journal.[1] Although Kounis syndrome is found in all races and age groups across the world,[1] the number of the reported cases from southern European countries is relatively high.[5] Factors such as genetic predisposition, similar climatic and environmental conditions, inaccuracies in drug use and higher clinician awareness of the disease in that region may contribute to the differences in geographical distribution.[5] With this letter, we particularly want to thank the respected scientist Dr Kounis, who contributed to awareness of the

November 2016, Print edition

An open letter to South Africa’s healthcare service providers

Thank you… As a healthcare professional, you protect the health and wellbeing of thousands of patients, and many of those whom you tirelessly care for are members of GEMS. Thank you for the many new lives you have brought into the world and into the GEMS family in the past decade. Thank you for guiding and nurturing thousands of GEMS babies through their formative years and the childhood illnesses that are part of growing up. Thank you for being the helping hand that dispenses care to our older members in their twilight years. Thank you for being the voice that offers hope to those afflicted by dreaded diseases and terminal illness. Our commitment to you… As healthcare practitioners you are a scarce and precious resource, you are the backbone of our healthcare delivery system. Without you we could not provide accessible, affordable quality care to our members. We want you to know that we acknowledge and appreciate your tireless efforts in ensuring that our members receive quality healthcare.

A word of concern… It is with great concern that we have noted an increasing trend among a small group of seemingly unscrupulous healthcare practitioners who do not view healthcare as a precious resource, often using the funds that are at the disposal of our members in a wasteful and abusive manner. This is done without due consideration to the sustainability of GEMS or that of the broader South African healthcare industry.

Tough action from GEMS… In honouring the true ethos of this proud profession and the sacrosanct doctor/patient relationship, we caution the small minority of healthcare practitioners who are responsible for such wasteful practices. Those who abuse member and Scheme funds are guilty of the unacceptable practice of fraud.

If this describes you, you may stop reading now, unless you are so committed to your profession that you, yourself, would want to assist us to bring to book those who are bringing our proud profession into disrepute.

There is a smaller group of individuals who do not uphold the values of their profession, do not care for our members as we do and do not uphold the sanctity of life. These are individuals who are motivated by greed. The sustainability of the South African healthcare industry carries little weight in their hearts and minds.

For these reasons, in the coming months, the Scheme will be introducing a number of additional managed care and forensic interventions and will be taking a tough stance on waste, misuse of member benefits and particularly fraud.

Yours in health Dr Gunvant (Guni) Goolab Principal Officer: GEMS

Working towards a healthier you

GEMS107

In line with our values of honesty and transparency we thought it fair to alert those who are abusing GEMS’s resources to desist from any practice that will endanger the sustainability of the Scheme, thereby harming our members, our valued healthcare professionals and the greater South African healthcare system.

CORRESPONDENCE

syndrome among clinicians. Along with an increase in publications about Kounis syndrome, it is possible that there will be an increase in reported cases of the disease in African countries. Symptoms and/or findings of systemic allergic response accompanying electrocardiographic or laboratory findings of myocardial ischaemia should remind us of the possibility of Kounis syndrome.[8] However, sometimes Kounis syndrome can be observed without classic clinical findings of hypersensitivity such as skin lesion (urticaria, angiooedema, mucosal involvement) or hypotension.[7] The diagnosis of the syndrome is made primarily via symptoms and signs, electrocardiographic and laboratory features, and echocardiographic and angiographic changes in patients.[3] Our prospective study showed that cardiac magnetic resonance imaging (MRI) can also be used as an alternative to these methods,[7] especially in patients who have contrast allergy or who need to be careful about radiation exposure. Cardiac MRI is successful in the early diagnosis of the syndrome, making the disease diagnosable in individuals whose electrocardiogram and troponin are normal, distinguishing between ischaemic and non-ischaemic cases.[7] Although cardiac MRI use is not common in emergency services, we want to remind again that it has a place in the diagnosis of Kounis syndrome. There are three variants of Kounis syndrome, depending on whether there is a lesion in the coronary artery or if there is a drugeluting stent in the patient.[3] In the treatment stage, although there are some differences in the variants, it is difficult to know which exact type of Kounis syndrome the patient has during the first evaluation of an individual at emergency services. Thus, early patient treatment should include management of acute coronary syndrome and alleviation of the allergic symptoms.[9] In conclusion, we believe that doctors in Africa will increasingly diagnose Kounis syndrome in the future, as current experience in dark-skinned patients is very low. I Akbas, M Emet

Department of Emergency Medicine, Faculty of Medicine, University of Ataturk, Erzurum, Turkey mucahitemet@gmail.com 1. Kounis NG, Grapsas N, Lianas D, Soufras GD, Patsouras N. Kounis syndrome: Aspects of incidence and epidemiology. S Afr Med J 2016;106(5):426. DOI:10.7196/samj.2016.v106i5.10680 2. Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: The concept of allergic angina. Br J Clin Pract 1991;45(2):121-128. 3. Kounis NG. Kounis syndrome: An update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med 2016;54(10):1545-1559. DOI:10.1515/cclm-2016-0010 4. Scherbak D, Lazkani M, Sparacino N, Loli A. Kounis syndrome: A stinging case of ST-elevation myocardial infarction. Heart Lung Circ 2015;24(4):e48-e50. DOI:10.1016/j.hlc.2014.11.026 5. Kounis NG, Mazarakis A, Tsigkas G, Giannopoulos S, Goudevenos J. Kounis syndrome: A new twist on an old disease. Future Cardiol 2011;7(6):805-824. DOI:10.2217/fca.11.63 6. Helbling A, Hurni T, Mueller UR, Pichler WJ. Incidence of anaphylaxis with circulatory symptoms: A study over a 3-year period comprising 940,000 inhabitants of the Swiss Canton Bern. Clin Exp Allergy 2004;34(2):285-290. DOI:10.1111/j.1365-2222.2004.01882.x 7. Akoz A, Tanboga HI, Emet M, et al. A prospective study of Kounis syndrome: Clinical experience and cardiac magnetic resonance imaging findings for 21 patients. Acta Medica 2013;29:811. 8. Fourie P. Kounis syndrome: A narrative review. S Afr J Anaesth Analg 2016;22(2):72-80. DOI:10.108 0/22201181.2016.1154309 9. Gunaydin ZY, Bektas O, Akgedik R, Kaya A, Acar T. Recurrent Kounis syndrome. How should be the long-term treatment of Kounis syndrome? Int J Cardiol 2014;177(3):1042-1043. DOI:10.1016/j. ijcard.2014.11.048

S Afr Med J 2016;106(11):1060. DOI:10.7196/SAMJ.2016.v106i11.11190

The dilemma of age estimation of children and juveniles in South Africa

To the Editor: Requests for medical practitioners to perform age estimations in children and juveniles without formal documentation in South Africa (SA) are usually made by the courts or social workers in line with the provisions of the Child Justice Act.[1] The involved individuals may be undocumented SA children – possibly abandoned or in conflict with the law, or, more commonly,

unaccompanied or separated foreign minors with no proof of their chronological age. Age defines the relationship between an individual and the state and, in turn, the protection and/or support to which an individual may be entitled.[2] The possible ramifications of age estimations are quite serious and may, and do, often infringe on the involved individual’s rights, including the possibility that a child will not receive support from the state if deemed an adult. There may be no protection for a child from detention or their wrongful incarceration with adults. Conversely, an adult, incorrectly assessed to be a child, may expose children to risk when placed in a children’s environment.[2] There is no consistency in the practice of age estimation throughout the world and it may consist of non-medical methods only (i.e. an interview and/or review of documentation), various medical methods (skeletal assessment, dental assessment with or without dental radiography, skeletal radiographic assessment, physical assessment or psychological assessment), or a combination of these methods.[2-4] In SA, it is stated in section 13 of the Child Justice Act that if, during an assessment of a child, the age of the child is uncertain, the probation officer must make an age estimation. It further states that the probation officer can use certain information such as previous age determinations, statements by the parents or the child, school documents, baptism or other religious certificates, or age estimations by medical practitioners. The probation officer must submit the age estimation on a prescribed form to the inquiry magistrate and the estimation can be changed before the child is sentenced, if more information regarding the child’s age arises.[1] No further guidance with regard to the experience or qualifications of the medical practitioner or how and where these assessments should be done is provided. This leaves the procedure open for individual and subjective interpretation and the application thereof. There is no consistency in this practice across SA. In Cape Town, when children and juveniles are referred to medical practitioners for an age estimation, these assessments are usually done by clinical forensic practitioners, and consist of a physical examination and completion of a set form: Form 7 – Medical report and age assessment of child in terms of section 48(2) of the Children’s Act, 2005 (Act no. 38 of 2005). Requests for age estimations are increasing with regard to the increased number of immigrants. From January to June 2016, 37 children were referred for age estimations to the Clinical Forensic Unit at Victoria Hospital, Cape Town. No published data are available on the estimated number of foreign undocumented children in SA. According to the United Nations High Commissioner for Refugees (UNHCR) September 2015 factsheet, there are 112 192 refugees and an estimated 463 940 asylum seekers in SA, Lesotho and Swaziland, with the majority originating from Zimbabwe, Somalia, Ethiopia, Democratic Republic of the Congo, Rwanda and Burundi.[5] These age estimations are often complicated by various factors such as non-availability of collateral information, language barriers, children fearful of providing any information because of the dread of deportation, and a lack of population-specific charts to use to compare anthropometric measurements. Despite these complicating factors, the court expects the medical practitioner to come to a ‘scientific’ conclusion regarding an approximate or even an exact date of birth or chronological age, and will in most cases accept the estimated age without question. Age estimation is especially difficult when it comes to the assessment of young persons (aged 15 years to early 20s) where physical maturity does not necessarily equate to being an adult.[2]

November 2016, Print edition

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CORRESPONDENCE

The difficulties and ethical dilemmas underlying these assessments have been recognised internationally and led to controversial debates and attempts to address these concerns, particularly in the context of increasing human migration, and it is clear that more discussions are needed to determine what is ‘ethically and morally acceptable in terms of the error margin in assessing age’.[2,3] It is recommended that age assessment is only employed as a last resort, and if it is performed, a holistic approach is recommended.[2,3] In the SA milieu, discussions between the various role players (Department of Health, including dentists, paediatricians and clinical forensic practitioners, immigration control, SA Police Service, Department of Justice and Department of Social Development) and further research and training are urgently indicated to protect the rights of the affected individuals. A holistic and multidisciplinary approach, with clear guidelines for the management of these vulnerable individuals, should be established, taking into account the inherent margins of error in these medical assessments, and ensuring that the assessments are done in a safe child- and gender-sensitive manner,[6] by experienced and trained role players. M Tiemensma

Clinical Forensic Unit, Victoria Hospital, Cape Town, South Africa marianne.tiemensma@westerncape.gov.za

V M Phillips

Fig. 1. Right shoulder soft tissue infection was the most likely source of W. chitiniclastica bacteraemia in this patient.

Department of Forensic Medicine and Toxicology, Faculty of Health Sciences, University of Cape Town, South Africa 1. South Africa. Child Justice Act No. 75 of 2008. www.justice.gov.za/legislation/acts/2008-075_ childjustice.pdf (accessed 1 August 2016). 2. Aynsley-Green A, Cole TJ, Crawley H, et al. Medical, statistical, ethical and human rights considerations in the assessment of age in children and young people subject to immigration control. Br Med Bull 2012;102(1):17-42. DOI:10.1093/bmb/lds014 3. Smith T, Brownlees L. Age Assessment Practices: A Literature Review and Annotated Bibliography. New York: United Nations’ Children’s Fund, 2011. www.unicef.org/protection/Age-AssessmentPractices_2010.pdf (accessed 26 July 2016). 4. Separated Children in Europe Programme (SCEP). Review of current laws, policies and practices relating to age assessment in sixteen European countries. www.separated-children-europeprogramme.org/separted_children/publications/reports/index.html (accessed 26 July 2016). 5. United Nations High Commissioner for Refugees. 2015. UNHCR operation in South Africa, Lesotho and Swaziland – September 2015 factsheet. http://www.unhcr.org (accessed 11 August 2016). 6. United Nations High Commissioner for Refugees. Guidelines on policies and procedures on dealing with unaccompanied children seeking asylum, February 1997. http://www.unhcr.org/3d4f91cf4.pdf (accessed 27 September 2016).

S Afr Med J 2016;106(11):1061. DOI:10.7196/SAMJ.2016.v106i11.11407

First report of Wohlfahrtiimonas chitiniclastica bacteraemia in South Africa

To the Editor: The first reported case of Wohlfahrtiimonas chitiniclastica infection in South Africa presented as a soft-tissue infection and the organism was cultured from pus.[1] We describe, to our knowledge, the first case in South Africa of W. chitiniclastica bacteraemia. The case occurred in a 17-year-old male patient who was admitted to the orthopaedic department of Tygerberg Hospital, Cape Town after sustaining a degloving injury to his right shoulder. He presented with a history of his upper arm being caught in a wood press. The patient lives in a house with running water, electricity and proper ablution facilities. He had no history of excessive alcohol abuse or smoking. The patient was haemodynamically stable with a degloving injury of his right upper arm and shoulder. Contamination of the wound with foreign material was minimal. No compartment syndrome was evident. The patient had decreased deltoid and bicep function but distally the wrist and hand were neurovascularly intact. His leucocyte count was 7.93 × 103 cells/µL and creatinine level 61 µmol/L.

An aerobic blood culture grew W. chitiniclastica. The isolate was identified by matrix-assisted laser desorption ionisation-time of flight mass spectrometry (MALDI-TOF MS). 16S rRNA sequencing confirmed the isolate as W. chitiniclastica based on 100% sequence identity to W. chitiniclastica strain DZ2015 (GenBank: KU301339.1) over the 724 bp sequence.[2] Antimicrobial drug susceptibility testing was performed using the Kirby Bauer method and interpreted according to CLSI 2016 criteria for Enterobacteriaciae. The isolate was sensitive to all drugs tested, except for cotrimoxazole, which tested resistant. The patient was discharged after a course of ceftriaxone 1 g intravenously daily and successful skin grafts to the affected area. The most likely source of the W. chitiniclastica bacteraemia in this patient was the wood-related soft-tissue infection, although maggots were never observed in his wound. W. chitiniclastica is a gram-negative, facultative anaerobic gammaproteobacterium.[3] It was first isolated from the larvae of the Wohlfahrtia magnifica fly.[4] This fly has been reported as the cause of myiasis in live vertebrates in Spain, France, Hungary, Turkey, Egypt, Iran, and Korea.[5] This report should help increase clinicians’ awareness of this rare zoonotic pathogen and alert diagnostic microbiology laboratories that the bacteria can currently only be identified using mass spectrometry technology and molecular methods. Acknowledgement. We gratefully acknowledge the assistance of Dr Mischka Moodley at AmPath Laboratories in identifying the isolate.

R Hoffmann

November 2016, Print edition

CORRESPONDENCE

F Fortuin

Division of Orthopaedic Surgery, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

M Newton-Foot, S Singh

Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, Cape Town; and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa 1. Smith M, Kularatne R, Bhagoobhai B, Perovic O. First case report of a zoonotic pathogen, Wohlfahrtiimonas chitiniclastica in South Africa. Poster presentation, 6th FIDSSA Congress, 5-8 November 2015, Drakensberg, KwaZulu-Natal, South Africa. 2. Bosshard PP, Zbinden R, Abels S, Böddinghaus B, Altwegg M, Böttger EC. 16S rRNA gene sequencing verses the API 20 NE system and the VITEK 2 ID-GNB card for identification of non-

fermenting gram-negative bacteria in the clinical laboratory. J Clin Microbiol 2006;44(4):13591366. DOI:10.1128/jcm.44.4.1359-1366.2006 3. Nogi M, Bankowski MJ, Pien FD. Wohlfahrtiimonas chitiniclastica infections in 2 elderly patients, Hawaii, USA. Emerg Infect Dis 2016;22(3):567-568. DOI:10.3201/eid2203.151701 4. Tóth EM, Schumann P, Borsodi AK, Kéki Z, Kovács AL, Márialigeti K. Wohlfahrtiimonas chitiniclastica gen. nov.,sp.nov., a new gammaproteobacterium isolated from Wohlfahrtia magnifica (Diptera: Sarcophagidae). Int J Syst Evol Microbiol 2008;58(4):976-981. DOI:10.1099/ijs.0.65324-0 5. Hall MJR, Adams ZJO, Wyatt NP, Testa JM, Edge W, Nikolausz M. Morphological and mitochondrial DNA characters for identification and phylogenetic analysis of the myasiscausing flesh fly Wohlfahrtia magnifica and its relatives, with a description of Wohlfahrtia monegrosesnis sp.n.Wyatt & Hall. Med Vet Entomol 2009;23(Suppl 1):59-71. DOI:10.1111/j.13652915.2008.00779.x

S Afr Med J 2016;106(11):1062. DOI:10.7196/SAMJ.2016.v106i11.11449

Conﬁdence Through Clinical and Real World Experience1-3 #1 NOAC prescribed by Cardiologists* Millions of Patients Treated Across Multiple Indications4 References: 1. Patel M.R., Mahaffey K.W., Garg J. et al. Rivaroxaban versus warfarin in non-valvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91. 2. Tamayo S., Peacock W.F., Patel M.R., et al. Characterizing major bleeding in patients with nonvalvular atrial fibrillation: A pharmacovigilance study of 27 467 patients taking rivaroxaban. Clin Cardiol. 2015;38(2):63–8. 3. Camm A.J., Amarenco P., Haas S. et al. XANTUS: A Real-World, Prospective, Observational Study. 4. Calculation based on IMS Health MIDAS, Database: Monthly Sales December 2015. For full prescribing information, refer to the package insert approved by the Medicines Regulatory Authority (MCC). S4 XARELTO ® 10 (Film-coated tablets). Reg. No.: 42/8.2/1046. Each film-coated tablet contains rivaroxaban 10 mg. PHARMACOLOGICAL CLASSIFICATION: A.8.2 Anticoagulants. INDICATION: Prevention of venous thromboembolism (VTE) in patients undergoing major orthopaedic surgery of the lower limbs. S4 XARELTO ® 15 and XARELTO ® 20 (Film-coated tablets). Reg. No.: XARELTO ® 15: 46/8.2/0111; XARELTO ® 20: 46/8.2/0112. Each film-coated tablet contains rivaroxaban 15 mg (XARELTO ® 15) or 20 mg (XARELTO ® 20). PHARMACOLOGICAL CLASSIFICATION: A.8.2 Anticoagulants. INDICATIONS: (1) Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (SPAF); (2) Treatment of deep vein thrombosis (DVT) and for the prevention of recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE); (3) Treatment of pulmonary embolism (PE) and for the prevention of recurrent pulmonary embolism (PE) and deep vein thrombosis (DVT). HCR: Bayer (Pty) Ltd, Reg. No.: 1968/011192/07, 27 Wrench Road, Isando, 1609. Tel: 011 921 5044 Fax: 011 921 5041. L.ZA.MKT.GM.01.2016.1265 *Impact RX Data Oct - Dec 2015 NOAC: Non Vitamin K Oral Anticoagulant

November 2016, Print edition

Outcome of TORS to tongue base and epiglottis in patients with OSA intolerant of conventional treatment Asit Arora1 • Bhik Kotecha3 • George Garas1 • Ashik Amlani1 • Ara Darzi2 • Neil S Tolley1 • Konstantinos Chaidas1 - From the International Journal of the Science and Practice of Sleep Medicine Abstract Purpose Transoral robotic surgery (TORS) of

p = 0.005). Quality of life showed a sustained improvement 3 months following surgery (p = 0.01).

the tongue base with or without epiglottoplasty

No major complications occurred.

represents a novel treatment for obstructive sleep apnea (OSA). The objective was to evaluate the

Conclusions TORS of the tongue base with or

clinical eﬃcacy of TORS of the tongue base with

without epiglottoplasty represents a promising

or without epiglottoplasty in patients who had not

treatment option with minimal morbidity for

tolerated or complied with conventional treatment

selected patients with OSA. Long-term prospective

(continuous positive airway pressure or oral

comparative valuation is necessary to validate the

appliance).

ﬁndings of this study.

Methods Four-year prospective case series.

Keywords: Transoral • Robotic Surgery •

The primary outcome measure was the apnea-

Obstructive sleep apnea • Epiglottoplasty •

hypopnea index (AHI) in combination with the

Tongue base reduction

Epworth Sleepiness Score (ESS). Mean oxygen saturation levels (SaO2) before and after TORS

For original copies please email - * Asit Arora:

on respective sleep studies were also recorded.

asitarora@doctors.org.uk

Secondary outcome measures included operative time and complications. Patient reported outcome measures (PROMs) assessed included voice, swallow and quality of life.

Results Fourteen patients underwent TORS for tongue base reduction with ten having additional wedge epiglottoplasty. A 64% success rate was achieved with a normal post-operative sleep study in 36% of cases at 6 months. There was a 51% reduction in the mean AHI (36.3±21.4 to 21.2±24.6,

Fig. 1 TORS set-up using the da Vinci system ®.

p = 0.02) and a sustained reduction in the mean Epworth Sleepiness Score (p = 0.002). Mean SaO2

A indicates 12mm 30° up dual channel endoscope, B

signiﬁcantly increased after surgery compared

laser ﬁbre is inserted, C indicates 5mm long tip Maryland

to pre-operative values (92.9±1.8 to 94.3±2.5,

Dissector forceps and M indicates patient’s mouth.

indicates laser introducer through which a 273-μm thulium

Transoral Robotic Surgery (TORS) da Vinci Transoral Robotic Surgery (TORS) is a minimally invasive alternative to open surgery and full-dose chemoradiation therapy for diseases of the head and neck.

TORS allows surgeons to operate through the mouth, avoiding mandibulotomy. It features a magniﬁed 3D high-deﬁnition vision system (3DHD®) and special wristed instruments (EndoWrist ®) that bend and rotate far greater than the human wrist can, allowing for greater precision and improved quality of reconstruction.

routine and making new procedures possible.

Patient beneﬁts include: • Avoidance of disﬁguring mandibulotomy • Minimisation or elimination of the need for chemoradiation therapy • Quicker return to normal speech, swallowing and a full recovery • Less blood loss and fewer transfusions • Minimal scarring

This sophisticated robotic system dramatically

• Avoidance of tracheostomy

expands the surgeon’s capabilities and oﬀers state-

• Less risk of infection

of-the-art, minimally invasive major surgery with

• Signiﬁcantly less pain

improved outcomes by making diﬃcult operations

• Shortened hospital stay

da Vinci Surgery is performed at the following SA hospitals: GAUTENG

WESTERN CAPE

The Urology Hospital, Pretoria

Netcare Christiaan Barnard Memorial Hospital, CPT

Netcare Waterfall City Hospital, Midrand

Mediclinic Durbanville, Durbanville

KWAZULU-NATAL

For info contact Dean Fossett:

Netcare Umhlanga Hospital, Umhlanga

dean@pinnaclesurgical.co.za

+27 12 423 4000 +27 11 304 6600

+27 31 560 5500

+27 21 480 6262 +27 21 980 2100

+27 (0) 61 031 0618

www.pinnaclesurgical.co.za

These open-access articles are distributed under Creative Commons licence CC-BY-NC 4.0.

IZINDABA

Counting the public healthcare litigation bill In addition to the cost in grief and trauma to families and the shattered confidence of under-resourced, under-supervised and over-worked doctors, South Africa (SA)’s nine provincial health departments face a ZAR24 billion patient litigation bill (2010 - 2014, with ZAR500 million paid). This startling financial indicator of patient risk in our under-resourced public hospitals came from Dr Terence Carter, deputy director-general of hospitals in the National Department of Health (NDoH), in a presentation to the Rural Doctors Association of South Africa (RuDASA) in Grahamstown on 6 August this year. He said the claims figure had risen to ZAR37 billion by last year. Citing province-by-province litigation statistics, he told of an unnamed Limpopo hospital where clinical negligence and resource constraints had combined to result in the birth of a headless baby in May last year. Illustrating why protocol adherence, supervision and clinical governance were so vital in reducing patient death and injury, Carter did, however, emphasise that resource constraints ‘could be a cop-out’ for those who failed to adhere to existing available clinical guidelines.

Horrific case study

Carter said that after a lawyer’s phone call to health minister Dr Aaron Motsoaledi a full year after the headless baby incident, it emerged that the relevant hospital chief, his district manager and the district clinical specialist had no knowledge of it. A woman, 38 weeks pregnant and suffering from severe hypertension, was referred to the local district hospital from a clinic, where she was correctly given magnesium sulphate. The most senior hospital clinical manager on call was given the file, noted that her blood pressure had dropped, and prescribed appropriate additional drugs before she was taken back to her ward and ‘simply left’. Having had a previous caesarean section, she should have delivered her baby within 24 hours, Carter said. Instead, she went into labour at 2 am, several days after admission. The nurses tried in vain to deliver what was a footling breech infant, realising after several attempts that it had died. The doctor arrived at 7 am and his attempts (allegedly) ‘decapitated the baby’, with the mother being sent on to theatre to deliver the head. During the ensuing

C-section, it was found that the woman’s uterus had ruptured. She was referred to a tertiary hospital for a hysterectomy, where the attending gynaecologist found that her ovaries were damaged beyond repair.

Too many nurses and doctors thought clinical protocols were ‘optional’, treating them ‘like multiple-choice questions’. Medical litigation history in South Africa illustrated that there was little defence if a healthcare worker did not follow protocols. Resource constraints, however, were a viable defence, ‘because you can’t expect the impossible’. Carter said that when he confronted the relevant head of department at the tertiary hospital, he professed ignorance, nor had he tried to find out what had gone wrong and why. ‘There is no way maternal mortality in that province is going to be brought down. Nothing was done, all the way down [the management line], so the question of clinical governance is crucial when it comes to litigation,’ he said. Too many nurses and doctors thought clinical protocols were ‘optional’, treating them ‘like multiplechoice questions’. Medical litigation history in SA illustrated that there was little or no defence if a healthcare worker did not follow protocols. Resource constraints, however, could be a viable defence, ‘because you can’t expect the impossible’. He said doctors made life-and-death decisions on a daily basis, based on available resources, but were being ‘hung out to dry’. ‘They have to decide who gets to ICU and theatre and who doesn’t. It’s true that doctors are usually on their own when these tough decisions are made, based on human resource constraints. [However,] when you make them, make sure they’re in good faith and you’re adhering to available protocols,’ he advised his audience. Turning to the climate of hierarchal fear among junior clinicians, reported recently in the lay media, he said he found it ‘astounding’ that some doctors did not know there was a law protecting whistle-blowers. ‘Even the SABC

November 2016, Print edition

case demonstrated this recently,’ Carter observed, referring to the July court order reinstating four journalists fired by maverick CEO Hlaudi Motsoaneng for questioning his censoring of violent service delivery protests.

Whistle-blowers ‘vital’ – Carter

Healthcare workers thought of officials as more powerful than the law and the courts, often because there was a general state of fear and victimisation. ‘Even if other people know (or share a complaint), they won’t come forward to support you.’ In an interview with Izindaba later, Carter said he had in mind the much-publicised case of Addington Hospital intern Yumna Moosa, told by her consultant seniors to destroy an orthopaedic block logbook feedback entry in which she had noted that their ‘racist and sexist’ remarks were unwelcome. Her head of department refused to sign off her internship, bringing charges of clinical incompetence that the Health Professions Council of South Africa (HPCSA) overturned after she easily passed an observed test at another hospital. Her secret taping of her seniors’ comments went viral among junior doctors, with her fatherin-law, RuDASA veteran and head of family medicine at the University of Cape Town, Prof. Steve Reid, making an unsuccessful bid to mediate with the hospital CEO. At the time of writing, Moosa’s CCMA hearing remained set down for 5 October. Reid told Izindaba at the RuDASA conference that ‘this vindictive intimidation is completely out of place – they’ve dug a big hole for themselves’. Carter said the matter had been referred to the KwaZulu-Natal premier, who had assured him that there would be an independent probe. He said he hoped it would ‘encourage whistle-blowers to know their rights’. Asked to cite the most dramatic examples of hospitals failing to deliver an acceptable service owing to shortages of healthcare workers and expertise, Carter named Rob Ferriera Hospital in Nelspruit, Mpumalanga, and Universitas Hospital in Bloemfontein, Free State. He said that Rob Ferriera was once a ‘premier’ tertiary hospital but had haemorrhaged competent and experienced medical officers and specialists because of ‘significant instability’ at senior management and leadership level (last November), narrowly escaping losing its HPCSA intern training accreditation. A new head of depart-

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IZINDABA

ment had recently been appointed, however, and things had begun to improve. ‘Once you’ve had a drop in standards it’s really difficult to recover,’ he added.

Taking small bites of the elephant

Interventions aimed at addressing the overall healthcare delivery crisis were nevertheless ‘well advanced’, with ex-UCT dean of medicine Prof. Marion Jacobs’s Academy of Leadership and Management underpinning Motsoaledi’s earlier hospital CEO competence and skills audit. The audit overhauled the national hospital leadership cadre, retrenching or redeploying dozens of CEOs, moving away from qualifications towards competence and individual and system performances, ‘or basically just the simple ability to do their work’. The Office for Healthcare Standards (OHCS), a pre-National Health Insurance (NHI) quality assurance inspectorate and support body, recently found that less than 10% of public hospitals were compliant with their minimum required standards. Carter said the target was 80% or greater compliance, with the bar set at different levels for ‘extreme, vital, essential and developmental’ interventions. The OHCS also took into account the sustainable development goals, especially when it came to maternal, neonatal and infant mortality. ‘Every manager must make a contribution to achieve these targets. It’s not about whether you passed your

MBA, cum laude. It’s about your hospital performing.’ A recent health infrastructure audit also showed there was ‘some serious work that needs doing’. The NDoH was moving away from prioritising new facilities to stopping older facilities from becoming run down. Linked to that was ‘fit-for-purpose’ technology that complied with international standards, and securing maintenance and service contracts with reputable companies. The hospital supply chain also needed improvement, and his department was working with National Treasury to introduce transversal contracts instead of the piecemeal procurement system currently in place. On human resources, Carter said the annual output of doctors, nurses and clinical associates was slowly improving, with the interim mass training of SA doctors in Cuba proving the catalyst for broadening current medical campuses to accommodate more students locally. He said the envisaged massive pre-NHI reorganisation of the healthcare system was premised on a primary healthcare model based on the promotion of health and the prevention of diseases instead of the current hospicentric ‘rescue’ model. Rehabilitation and palliative care would also be increasingly emphasised. ‘We want to introduce the concept of health-promoting hospitals, not just curative. It’s totally wrong for an orthopaedic surgeon to only know how to replace a hip and knee. What about overweight patients? The orthopod should ensure preventive and

rehabilitative care. It’s also not enough to just do a gastroscopy when the patient is also smoking – or treat diabetes when you’re not focused on lifestyle,’ he said. Healthcare services were fragmented and curative, with ‘rampant, uncontrolled commercialism’.

Citing province-by-province litigation statistics, he told of an unnamed Limpopo hospital where clinical negligence and resource constraints combined to result in the birth of a headless baby in May last year. Topping the accumulated litigation claims charts from 2010 to 2014 was Johannesburg, Gauteng Province (ZAR14 019 billion). It was followed by Durban, KwaZulu-Natal (ZAR5 477 billion) and Mthatha, East London and Port Elizabeth in the Eastern Cape (total ZAR3.53 billion). Bloemfontein in the Free State was ranked fourth at ZAR780 million, while Cape Town in the Western Cape lay fifth at ZAR562 million. The province with the lowest litigation costs was the Northern Cape (Kimberley), at a ‘mere’ ZAR47.83 million. Chris Bateman chrisb@hmpg.co.za S Afr Med J 2016;106(11):1063-1064. DOI:10.7196/SAMJ.2016.v106i11.12059

New findings say ‘never take a TB cure for granted’ Stellenbosch University (SU) research findings published online in Nature Medicine in September[1] show that that 86% of HIVnegative ‘cured’ tuberculosis (TB) patients examined still had actively inflamed lung lesions, while a third of them had new or exacerbated lesions. The surprising findings highlight how important it is for healthcare workers to retain a high index of suspicion even if a smear test at the end of a TB treatment course is negative, Dr Stephanus Malherbe, of SU’s Immunology Research Group, told Izindaba. ‘We’re working on better tools to monitor treatment response, but this [study of 99 HIVnegative, TB-diagnosed and ‘cured’ patients]

Lungs of a patient at baseline (A) and after 1 (B) and 6 months (C) of TB treatment.

shows that TB almost goes back into a latent subclinical phase after treatment,’ he said. The findings would be a catalyst for further tests around immune therapy and immune modulation, but they already emphasised

November 2016, Print edition

the importance of improved counselling and advanced testing. Advanced imaging accurately showing the sites of inflammation during and after treatment revealed that only 14% of the study group had no remaining

Master of Philosophy (MPhil) in Cancer Science The African Cancer Institute at the Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa invites you to apply for the above postgraduate degree commencing 2017. The African Cancer Institute (ACI) is the coordinating and directive institution for research and training in the field of cancer at Stellenbosch University dedicated to improving prevention, early detection and diagnosis, and management of cancer in Africa. The SAQA accredited Master of Philosophy (MPhil) in Cancer Science is a new programme that offers postgraduate training to all cadres of health personnel including those with a basic science background in South Africa and from other African Countries who wish to broaden their understanding into the complexities around cancer and pursue cancer or cancer-related research. The programme is intended to deliver theoretical and practical insights needed to mould a skills set designed to advance current knowledge and address the increasing burden of cancer. Postgraduate students from Africa are encouraged to register for the degree and undertake the research component of this programme in their home country making the research relevant to one’s own environment. The first semester will comprise of 5 modules with the remaining 4 modules of a specialist nature being undertaken in the second semester. Year 2 will comprise of the research assignment. The minimum time for completion of the degree is 18 months. Modules offered in this program: • Molecular Basis of Cancer and Tumour Physiology • Infections and Cancer • Biostatistics • Nutrition and Cancer • Cancer Epidemiology • Public Health and the Environment • Principles of Cancer Therapy • Research Proposal Writing and Grantsmanship • Research Methodology • Research Assignment

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inflammation in the lung after treatment was completed. SU worked in collaboration with the Catalysis Foundation of Health, Rutgers New Jersey Medical School, Stanford University School of Medicine and the US National Institutes of Health. Malherbe said the findings point to the crucial role of the body’s immune response in suppressing or eradicating any residual

live bacteria after treatment. Any treatment aimed at boosting the immune response should improve outcomes. Instead of ‘patting a patient on the back’ once their smear was negative, healthcare workers who saw anything vaguely suspicious should send them for an X-ray and arrange a followup appointment, counselling them to eat healthily and to avoid smoking or drinking.

Chris Bateman chrisb@hmpg.co.za S Afr Med J 2016;106(11):1065. DOI:10.7196/SAMJ.2016.v106i11.12060 1. Malherbe ST, Shenai S, Ronacher K, et al. Persisting positron emission tomography lesion activity and Mycobacterium tuberculosis mRNA after tuberculosis cure. Nat Med 2016; published online 5 September 2016. doi:10.1038/nm.4177

A fond and grateful farewell After 16 years of discovery, excitement, and getting to know some of the best scientific and medical hearts and minds in this country (in many cases, the world), I am leaving Izindaba to take up a freelance career in the healthcare field. Journalism tends not to favour the salaried soul, and a graceful confluence of events has given me the impetus I need to propel me outwards and hopefully upwards. It’s been a huge privilege being privy to some of the quiet machinations of major medicopolitical players, scientific advances, AIDS denialism/ heroism, dysfunction, and triumphs against all odds by inspirational men and women. It’s the ones who refuse to accept impossibility who will linger longest in my affections – their shared attributes being a big heart, compassion for their fellow man, singleminded determination and a vision of ‘how it could be’.

first, respects individual context and confronts issues. One of the greatest gifts of journalism is the perspective you get in chatting to so many different people about a single issue. I’m glad I could bring six journalism awards, mainly for commentary and analysis, to the SAMJ over the years, but I am also very aware that the journal title opened doors. I had three amazing mentors, all with great integrity, knowledge and experience, to support and guide me: Profs Dan Ncayiyana, JP van Niekerk and Janet Seggie. If I have any advice for my successor, it will be never to break a trust, to check back for accuracy (only), and to stand firm on solid ground.

I must have brought something to the party, or I guess not so many of my sources would have confided in me – or trusted me to represent their views in a way that puts readers

November 2016, Print edition

Chris Bateman chrisb@hmpg.co.za S Afr Med J 2016;106(11):1066. DOI:10.7196/SAMJ.2016.v106i11.11475

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CME

GUEST EDITORIAL

The epidemic of sexual violence in South Africa Sexual violence in South Africa (SA) has reached epidemic proportions. Clinicians need to be fortified with knowledge and skills to meet the challenge of caring for those who have suffered or are at risk of gender-based violence (GBV). This issue of CME focuses on sexual violence as the second of three special editions on violence against women and children in SA. Sexual violence involves a continuum that is far broader than sexual assault, mirroring the complex phenomenon of sexuality itself. Our recent human rights review identified entrenched stigma against persons based on their sexual or gender orientation, gender identity or bodily diversity, highlighting such persons’ ongoing experience of harassment, discrimination and sexual and physical violence.[1] In addition, irregular migrants, trafficked and refugee women, orphans and other vulnerable girls such as those living with disabilities, face increased risk of GBV.[2] Health professionals need to remain mindful of the inherent dignity of each patient, particularly those marginalised and neglected by mainstream society. The United Nations Special Rapporteur’s report[2] on her visit to SA in December 2015 acknowledges our progressive constitution, legislation and policies to deal with GBV, as well as our commitment to international agreements such as the Convention on the Elimination of all Forms of Discrimination Against Women. But she states unequivocally that GBV is unacceptably pervasive, revealing systematic violation of women and children’s human rights within SA.[2] Her report is extensive and revealing. For example, regarding the extreme levels of sexual violence experienced by girls commuting to school, and during school by teachers and classmates, she points to the ‘culture of silence’ as a fundamental obstacle to holding educators accountable. Reference is also made to the lack of knowledge on reporting mechanisms, such as Section 54(1) of the Criminal Law (Sexual Offences and Related Matters) Amendment Act No. 32 of 2007, which makes it a crime for anyone who knows about a sexual offence against a child not to report it.[3] In response she recommends that the Department of Basic Education and the SA Council of Educators jointly discipline educators who have perpetrated such acts, and implement disciplinary sanctions against teachers and principals who fail to report cases. Furthermore, a list of sexual offending educators should be made available to all public and private schools, and a nationwide programme on sexual violence and human rights be implemented. Overall, the development (via an inclusive consultative process) and adoption of a National Strategic Plan on GBV with clear strategic priorities and core measurable goals is her primary recommendation. Adequately funded, this could either be led by an independent multisectoral oversight and accountability mechanism to monitor progress in implementation or disseminated and implemented at provincial and district levels. Šimonović[2] also advocates the establishment of provincial femicide watches, where each case is analysed to ascertain any failure of protection to improve and develop further preventive measures. She recommends that the Gender Equality Commission compile combined provincial data and take responsibility for a national femicide watch.[2]

Returning to our specific theme of sexual violence, a 2011 Gauteng study found that only one in 13 women raped by a non-partner reported the matter to the police. When raped by their partners, only one in 25 women report the offence.[4] Clearly the categories of sexual violence and intimate partner violence are far from discreet. Women and girls are at far higher risk of sexual and other violations from men they know, thereby disproving the prevalent stranger danger myth. Woollett and Thomson[5] dwell on such intersections by asking why it is that those who experience violence early in life are likely to repeat and re-experience it; and why it is so difficult to change this trajectory. Mapping practice onto theory, they offer specialised guidance on how to improve clinical care, including a comprehensive range of inspired, yet practical, clinical recommendations. Tiemensma’s[6] systematic article aims to refresh health professionals’ knowledge about current approaches to care for adult survivors of sexual offences. Addressing the double responsibility of attending to healthcare and medicolegal needs of the survivor, she provides a detailed, step-wise guideline to collection of evidence, medical management and treatment. Van As[7] sensitively addresses the complex challenges involved in attending to sexually and/or physically abused children. His article prepares health professionals to select the most appropriate and comfortable management for this patient population. These practical sets of recommendations make the care of those who have suffered from GBV, as well as those who are at risk, feasible within our SA context. Kate Joyner Division of Nursing, Department of Interdisciplinary Health Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa katejoyner.kj@gmail.com

1. Human Rights Committee. Concluding observations on the initial report of South Africa. 2016. http:// www.ccprcentre.org/country/south_africa (accessed 7 October 2016). 2. Šimonović D. Report of the Special Rapporteur on violence against women, its causes and consequences on her mission to South Africa (4 - 11 December 2015). 2016. www.ohchr.org/EN/HRB/ HRC/.../A_HRC_32_42_Add.2_en.docx (accessed 21 August 2016). 3. Centre for Applied Legal Studies. Sexual Violence by Educators in South African Schools: Gaps in Accountability. Johannesburg: CALS, 2014. 4. Machisa M, Jewkes R, Lowe-Morna C, Rama K. The War at Home. Johannesburg: Genderlinks, 2011. 5. Woollett N, Thomson K. Understanding the intergenerational transmission of violence. S Afr Med J 2016;106(11):1068-1070. DOI:10.7196/SAMJ.2016.v106i11.12065 6. Tiemensma M. Current approaches to the management of adult survivors of sexual offences. S Afr Med J 2016;106(11):1071-1074. DOI:10.7196/SAMJ.2016.v106i11.12064 7. Van As AS. Physical and sexual violence against children. S Afr Med J 2016;106(11):1075-1078. DOI:10.7196/SAMJ.2016.v106i11.12069

S Afr Med J 2016;106(11):1067. DOI:10.7196/SAMJ.2016.v106i11.12097

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This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

CME

Understanding the intergenerational transmission of violence N Woollett,1 MA (Psychology, Art Therapy); K Thomson,2 MA (Social Work) 1 2

School of Clinical Medicine and School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: N Woollett (woollettn@gmail.com)

Intimate partner violence is a major public health and human rights issue in South Africa. This violence tends to run in families and generations, with little change over time and devastating consequences at individual, family and community levels. Understanding the mechanisms for intergenerational transmission of violence may offer important clues for prevention and intervention to halt this recurrence. Health professionals are well placed to identify patients at risk and intervene in families characterised by interpersonal violence. S Afr Med J 2016;106(11):1068-1070. DOI:10.7196/SAMJ.2016.v106i11.12065

How does violence beget violence?

Intimate partner violence (IPV) is one of the most common forms of violence against women and children worldwide.[1] Violence against children, adolescents and women has similar consequences for physical health, mental health and social functioning. Experiencing multiple forms of violence in childhood and adolescence (e.g. child maltreatment, exposure to IPV, bullying, dating violence) raises the risk of trauma and other negative health and social outcomes compared with experiencing just one form.[2] But why is it that those who experience violence early in life are likely to repeat and re-experience it, and why is it so difficult to change this trajectory?

Pertinent theories and concepts

Bandura’s social learning theory[3] has often been applied to studying the intergenerational transmission of family violence and IPV.[4-6] This theory posits that behaviours are often learnt from one’s environment, and that the family system plays a pivotal role in tutoring. Children inevitably mimic and learn interpersonal skills from their parents, and this theory explains why children who grow up witnessing and experiencing IPV are more likely to be either perpetrators or victims later in their own relationships.[4] Children in these situations learn that violence is normal, appropriate, inescapable and inevitable in intimate relationships. Conflict tends to result in violence, aggression is rewarded, and strong rationalisations for violent behaviour tend to develop. The skills of effective and safe conflict resolution are not acquired and violent conflict resolution is likely to be repeated with no prosocial alternatives. Bowlby’s attachment theory[7] emphasises that the initial relationship between infant and caregiver serves as the foundation for an infant’s mental health and all future attachment and relationships in life. For children growing up in violent households, expectations of security are shattered, as their protectors become their attackers and there is nowhere to turn for help. If parents are not only the source of external danger but are simultaneously absent in their duty to protect, those you love become those you fear. This leads to great distress and an inability to regulate overwhelming emotion.[8] People with a history of child abuse expect others to be hostile, rejecting, and unavailable, and they therefore respond to others in a way that is consistent with their expectations or they behave in a manner that elicits these

familiar responses in others.[7] This experience is the result of early attachment relationships with abusive caregivers, as the parent-child attachment relationship is the prototype for later relationships.[9] As Bowlby states, ‘hurt people hurt people’. Attachment theory holds that individuals who have experienced maltreatment or attachmentrelated difficulties are more likely to report problems with regard to trust and closeness in subsequent relationships, and to express hostility and anger towards others in a variety of ways.[10] The mental health aspects of experiencing this violence should not be underestimated. Those who are consistently exposed to violence are likely to suffer from depression and post-traumatic stress disorder (PTSD).[11,12] The concepts of re-enactment or repetition compulsion are implicated in the intergenerational transmission of trauma, which is the consequence of violence. Trauma tends to be repeated on behavioural, emotional, physiological and neuro-endocrinological levels and many traumatised people expose themselves, seemingly compulsively, to situations reminiscent of the original trauma.[13] These behavioural re-enactments are rarely consciously understood to be related to earlier life experiences. Freud thought that the aim of repetition was to gain mastery over the original trauma(s), but clinical experience has shown that this rarely happens. Instead, repetition causes further suffering for victims and/or for people in their surroundings.[13] Reiker and Carmen[14] point out that confrontations with violence challenge one’s most basic assumptions about the self as invulnerable and intrinsically worthy, and about the world as orderly, safe and just. After abuse, the victim’s view of the self and the world can never be the same again: it must be reconstructed to incorporate the abuse experience. Assuming responsibility for the abuse/violence (‘it was my fault’) allows feelings of helplessness to be replaced with an illusion of control. Children are even more likely to blame themselves when they experience violence at the hands of their loved ones. Anger directed against the self or others is typically a central problem in the lives of people who have been violated. Reiker and Carmen[14] conclude that this ‘acting out’ is seldom understood by either victims or clinicians as being a repetitive re-enactment of real events from the past. These issues are framed by the concept of displaced aggression (Fig. 1). Displaced aggression can occur when someone cannot aggress towards the source of incitements or provocation, and instead takes it out on some-

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CME

Fig. 1. Displaced aggression (courtesy of Kweykway Consulting, Canada).

thing/someone else and behaves aggressively towards another individual who had nothing to do with the initial conflict. In other words, when a violent partner with more power and control aggresses towards you and you are not able to meet that aggression in an equal manner, you take your anger to where you have significant power and control and repeat what was done to you. These cycles of aggression are typical in homes defined by IPV. Victims become perpetrators through frustration, with inadequate conflict resolution skills, the inability to express anger in prosocial ways and have legitimate and strong aggressive impulses. All these concepts should be comprehended within a context of continuous traumatic stress, which is described as the experience of repeated traumatic events (e.g. IPV) against a background of ongoing danger (e.g. community violence); therefore, the threat is current and real; safety is difficult to establish; there is a lack of trust in state systems of protection and help; and there is a threat to family and community networks and systems.[15,16] Violent events are understood within this social construct and there is an expectation that trauma is part of life as opposed to an ‘unexpected’ event.[17] The threat and ongoing reality of trauma affect how people live and cope, both individually and collectively. Violence and trauma are therefore not only about the set of events experienced, but are deeply ingrained in a person’s history, identity, values and traditions.[18]

Clinical recommendations

Parents/caregivers are the primary socialisation agents involved in children’s emotional and social development. Children learn by watching their parents/caregivers and imitating their behaviour from infancy through young adulthood. Poor parenting skills are a key risk factor for child maltreatment. Parenting programmes that help parents negotiate and learn safer discipline strategies and conflict resolution skills are

indicated. Parents need alternatives to be better role models for their children and ‘unlearn’ unhealthy behaviours. There is a growing body of evidence to suggest that these programmes are sustainable, feasible and acceptable in low- and middle-income contexts.[19] Parenting programmes also contribute to reducing family stress and maternal mental ill-health,[20] and improve parentchild attachment and relationships.[21] Exploring mother-infant prenatal attachment is an important focus in understanding the intergenerational consequences of trauma. Expectant mothers with a history of interpersonal trauma report significantly lower prenatal attachment development with their unborn child than expectant mothers with no such history.[22] Screening for violence during pregnancy and intervening in antenatal environments would have a great impact on curbing the intergenerational transmission of violence and improving attachment between mother and infant. There is evidence of a direct relationship between maternal functioning and child behavioural functioning.[6] Therefore, interventions that decrease maternal mental health problems can be expected to have a secondary effect on the mental and behavioural functioning of their children. As mothers learn to improve coping strategies, so do their children. Interestingly, this is a bi-directional relationship, with recent evidence suggesting that cognitive behaviour therapy for child PTSD is directly related to improvements in maternal depressive symptoms.[23] Research indicates that in the context of IPV, interventions for children are more effective when their focus is on the dyad of mother and child, instead of child alone.[24] As such, treatment needs to be focused on the maternal-child dyad for optimum results, and improved attachment for both. Mental healthcare for those experiencing violence is highly recommended, especially trauma-focused cognitive behaviour therapy that is recognised as the gold standard in trauma treatment.[25] Gaining control over one’s current life, rather than repeating trauma in action, mood or somatic states, is the goal of treatment. In addition, helping patients consider ‘novel’ situations of safety in a relationship is a treatment goal, recognising that for many of them novel stimuli can cause heightened arousal and for those already living in states of heightened hyperarousal (those with PTSD) this is to be avoided to manage their anxiety. High arousal causes people to engage in familiar behaviour, regardless of the rewards. Many victims unconsciously choose partners that are considered ‘normal’ to their experience to avoid managing this dynamic.

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The ongoing risk of IPV is a formidable obstacle to effective treatment of victims. When psychological treatment is provided after the traumatic situation no longer exists, the goals of treatment involve placing the traumatic experience into perspective by helping a person gain control over the overwhelming emotions evoked by the memory of the event, and achieving a differentiation between remembering and reliving by stressing differences between past and present circumstances and increasing the person’s awareness of the current, safer surroundings. These goals are not realistic and may be counterproductive when conditions of violence leading to traumatic stress responses are ongoing, as hypervigilance and other traumatic responses may be adaptive but costly mechanisms to increase personal safety. When providing medical or psychological treatment, it is important to ask about familial and community contexts. The primary focus in these situations should be on conditions that increase safety and reduce risk. This focus promotes progress towards another key goal of fostering an increased capacity to respond realistically to threat.[8] Family violence in childhood, whether through witnessing or direct experience, may trigger a cycle of adversities, including re-victimisation, mental health problems and other life difficulties.[10] It is clear that in the South African (SA) context, experience of IPV is strongly linked to incident HIV infection;[26] therefore, treating IPV may have benefits to HIV incidence and prevalence. Early detection and treatment of violence against young people and children have the potential to interrupt and prevent the recurrences of violence, incident HIV in high-risk groups, and adverse psychological impacts for children and adolescents. The transmission of interpersonal violence takes shape as adolescents begin to experiment within their own relationships as they get older. Adolescents are at high risk of IPV.[27] Their young age and relative inexperience can limit their power in relationships and incur risk, particularly for females involved with older men.[27] Abuse during this time can also set young women on a trajectory for future violence and sexual risk behaviour. This age group is open to change and is flexible in trying new things. This developmental opportunity offers a window for alternative relationships and personal reflection that adults need to recognise. Interventions levelled at this patient population are urgently required. Health infrastructures designed for youth must recognise and actively anticipate that their patient populations will incur victims.

CME

Prevention strategies directed towards violence experienced by couples and children/adolescents should be integrated into public health and primary care planning. If a woman, for example, is identified as experiencing IPV, an opportunity also exists to identify a maltreated child and vice versa. Also, mental health problems identified should alert health professionals to the possibility of violence in the family or in the teen relationship because of their potential association with history for such violence. Asking a potential victim directly about these issues should be part of routine clinical practice. Educational programmes that target both genders to discuss gender inequality in public and private spheres and how violence leads to unhealthy outcomes for all are required. While gender socialisation starts at birth, early adolescence is a critical point of intensification in personal gender attitudes, as puberty reshapes male and female self-perceptions as well as social expectations from others (e.g. family members, peers). Early adolescence is therefore seen as a unique time to address gender attitudes before they become more solidified.[28] An opportunity to do this exists at different healthcare levels. Another key focus should be men, as they are more likely to be violent offenders and men of all ages play a significant role in tolerating IPV, thereby perpetuating intergenerational transmission.

Conclusion

Healthcare facilities are key points of contact in the community. They provide services and are influenced by events and experiences of the individuals and communities they serve. Health professionals are therefore powerfully placed to identify and address issues of violence in patients. Historically, violence against women and that against children sectors have worked in isolation. Violence affects the entire community, and its impact on physical and mental health is evident. For better health outcomes, greater recognition of the similarities in violence outcomes, shared risk factors and intergenerational effects for populations is needed. A closer collaboration of sectors would lead to a more meaningful and integrated policy response and healthcare service. Partnership across sectors is highly recommended.[2] 1. Devries KM, Kishor S, Johnson H, et al. Intimate partner violence during pregnancy: Analysis of prevalence data from 19 countries. Reprod Health Matters 2010;18(36):158-170. DOI:10.1016/s09688080(10)36533-5 2. Guedes A, Bott S, Garcia-Moreno C, Colombini M. Bridging the gaps: A global review of intersections of violence against women and violence against children. Glob Health Action 2016;9:1-15. DOI:10.3402/gha.v9.31516

3. Bandura AJ. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall, 1977. DOI:10.1177/ 105960117700200317 4. Islam TM, Tareque I, Tiedt AD, Hoque H. The intergenerational transmission of intimate partner violence in Bangladesh. Glob Health Action 2014;7:1-11. DOI: 10.3402/gha.v7.23591 5. Mandal M, Hindin MJ. Keeping it in the family: Intergenerational transmission of violence in Cebu, Philippines. Matern Child Health J 2015;19(3):598-605. DOI:10.1007/s10995-014-1544-6 6. McFarlane J, Symes L, Binder BK, Maddoux J, Paulson R. Maternal-child dyads of functioning: The intergenerational impact of violence against women and children. Matern Child Health J 2014;18(9):2236-2243. DOI:10.1007/s10995-014-1473-4 7. Bowlby J. Attachment and Loss. Vol. 3. New York: Basic Books, 1980. DOI:10.1017/s0021932000013596 8. Lieberman A. Ghosts and angels: Intergenerational patterns in the transmission and treatment of the traumatic sequelae of domestic violence. Inf Mental Health J 2007;28(4):422-439. DOI:10.1002/imhj.20145 9. Hines DA, Saudino KJ. Intergenerational transmission of intimate partner violence: A behavioral genetic perspective. Trauma Violence Abuse 2002;3(3):210-225. DOI:10.1177/15248380020033004 10. Jirapramukpitak T, Harpham T, Prince M. Family violence and its â&#x20AC;&#x2DC;adversity packageâ&#x20AC;&#x2122;: A common survey of family violence and adverse mental outcomes among young people. Soc Psychiatry Psychiatr Epidemiol 2011;46(9):825-831. DOI:10.1007/s00127-010-0252-9 11. Devries KM, Mak JY, Bacchus LJ, et al. Intimate partner violence and incident depressive symptoms and suicide attempts: A systematic review of longitudinal studies. PLoS Med 2013;10(5):e1001439. DOI:10.1371/journal.pmed.1001439 12. Bennice JA, Resick PA, Mechanic M, Austin M. The relative effects of intimate partner physical and sexual violence on post-traumatic stress disorder symptomatology. Violence Vict J 2003;18(1):87-94. DOI:10.1891/vivi.2003.18.1.87 13. Van der Kolk B. The compulsion to repeat the trauma: Reenactment, revictimization and masochism. Psych Clin N Am 1989;12(2):389-411. 14. Reiker PP, Carmen E. The victim to patient process: The disconfirmation and transformation of abuse. Am J Orthopsychiatry 1986;56(3):360-370. DOI:10.1111/j.1939-0025.1986.tb03469.x 15. Murphy M. When the trauma goes on. Child Care Prac 2004;10(2):185-191. DOI:10.1080/1357527 0410001693394 16. Kaminer D, Eagle G, Crawford-Browne S. Continuous traumatic stress as a mental and physical health challenge: Case studies from South Africa. J Health Psych 2016;21(1):1-12. DOI:10.1177/1359105316642831 17. Thomson K. Exploring the experience of community health workers operating in contexts where trauma and its exposure are continuous. MA thesis. Johannesburg: University of the Witwatersrand, 2014. 18. Higson-Smith C. Supporting Communities Affected by Violence. Oxford, UK: Oxfam, 2002. DOI:10.3362/9780855988579 19. Knerr W, Gardner F, Cluver L. Improving positive parenting skills and reducing harsh and abusive parenting in low- and middle-income countries: A systematic review. Prev Sci 2013;14(4):352-363. DOI:10.1007/s11121-012-0314-1 20. Barlow J, Smailagic N, Huband N, Rollof V, Bennet C. Group-based parenting programmes for improving parental psychosocial health. Cochrane Database Syst Rev 2012;(6):CD002020. DOI:10.1002/14651858.cd002020.pub3 21. Cooper P, Tomlinson M, Swartz L, et al. Improving quality of mother-infant relationship and infant attachment in a socio-economically deprived community in South Africa. BMJ 2009;338:b974. DOI:10.1136/bmj.b1858 22. Schwerdtfeger KM, Nelson Goff BS. Intergenerational transmission of trauma: Exploring the motherinfant prenatal attachment. J Traum Stress 2007;20(1):39-51. DOI:10.1002/jts.20179 23. Neill EL, Weems CF, Scheeringa MS. CBT for child PTSD is associated with reductions in maternal depression: Evidence for bidirectional effects. J Clin Child Adolesc Psychol 2016:1-11. DOI:10.1080/ 15374416.2016.1212359 24. Graham-Bermann SA, Miller-Graff LE, Howell KH, Grogan-Kaylor A. An efficacy trial of an intervention program for children exposed to intimate partner violence. Child Psychol Hum Dev 2015;46(6):927-939. DOI:10.1007/s10578-015-0532-4 25. Foa EB, Keane TM, Friedman MJ, Cohen, JA, eds. Effective Treatments for PTSD: Practical Guidelines from the International Society for Traumatic Stress Studies. 2nd ed. New York: Guildford Press, 2009: 491-507. DOI:10.1002/pon.660 26. Li Y, Marshall CM, Rees HC, et al. Intimate partner violence and HIV infection among women: A systematic review and meta-analysis. J Int AIDS Soc 2015;17(1):1-12. DOI:10.7448/ias.17.1.18845 27. Decker MR, Peitzmeier S, Olumide A, et al. Prevalence and health impact of intimate partner violence and non-partner sexual violence among female adolescents aged 15 - 19 years in vulnerable urban environments: A multi-country study. J Adolesc Health 2014;55(6):s58-s67. DOI:10.1016/j. jadohealth.2014.08.022 28. Kagesten A, Gibbs S, Blum RW, et al. Understanding factors that shape gender attitudes in early adolescence globally: A mixed methods systematic review. PLoS ONE 2016;11(6):e0157805. DOI:10.1371/journal.pone.0157805

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Current approaches to the management of adult survivors of sexual offences M Tiemensma, MB ChB, Dip For Path (SA), FC For Path (SA), MMed (For Path), DOH, AHMP Clinical Forensic Unit, Victoria Hospital, Cape Town, South Africa Corresponding author: M Tiemensma (marianne.tiemensma@westerncape.gov.za)

The adequate management of survivors of sexual offences is vital to ensure that both the healthcare and medicolegal needs of survivors are met. This article provides step-wise guidelines on current approaches to the management of adult survivors of sexual offences, which include the collection of evidence, medical management and treatment. S Afr Med J 2016;106(11):1071-1074. DOI:10.7196/SAMJ.2016.v106i11.12064

Recently, a number of sexual crimes committed in South Africa (SA) raised alarm both locally and internationally. The cases of Anene Booysen[1] and Sinoxolo Mafevuka[2] come to mind, as well as newspaper headings such as ‘Rape victim turned away from hospital’. All of these contribute to the emotional discussions reverberating from these continued crimes, and emphasise the need for the proper management of survivors of sexual offences. Dedicated clinical forensic centres, such as Thuthuzela centres,[3] are available across SA; however, in many settings, there are no dedicated service centres, and survivors are seen in provincial day hospitals and emergency departments, among, and competing with, other patients waiting to receive medical care. Often, the attending clinician is an inexperienced junior doctor, who may not have received specific training in the management of survivors of sexual offences.

Objective

This article aims to provide clear guidelines to the attending clinician when managing adult survivors of alleged sexual offences. These include the dual responsibility of attending to the healthcare and medicolegal needs of the survivor.[4]

Definitions

It is helpful for the clinician to understand the legal definitions of sexual offences, as contained in the Criminal Law (Sexual Offences and Other Related Matters) Amendment Act No. 32 of 2007 (Table 1).[5] However, it is imperative that the clinician should realise that rape is not a medical, but a legal definition and that the clinician can never testify or confirm whether ‘rape’ occurred or not. The clinician can collect evidence and give testimony on what was found during the physical examination, and merely present and explain the objective evidence to court.

It is vital to understand that in many instances no injuries are present, which does not exclude the possibility that forced penetration could have occurred. It is the role of the judge or magistrate to decide, after reviewing all available evidence and testimonies, whether a sexual crime was committed or not.

Approaches to survivors of alleged sexual offences

Anyone who reports an alleged sexual offence should be attended to in a non-judgemental way, ensuring the best outcome of the medicolegal investigation, while preventing secondary trauma. Survivors should be advised how to preserve DNA evidence prior to examination, especially if they are transferred to be seen, or while awaiting examination (Table 2). Table 2. General comments for survivors with regard to DNA evidence collection • Advise the survivor not to wash/change clothing. In cases where the clothes and underwear were changed, these garments can be brought to the healthcare facility for possible collection if they have not been washed • Survivors should be encouraged to hand over contaminated clothing, condoms, bedsheets, etc. from the crime scene to the investigating officers • Avoid eating, smoking, drinking, chewing bubblegum and brushing teeth where oral penetration has taken place • Avoid defecation, if possible • Avoid wiping the vulva after urination in case there is an urge. The nursing staff should be reminded to tell the patient that toilet paper should not be used to wipe the vulva after the patient has given a urine sample for pregnancy testing

Table 1. Legal definitions Genital organs

Includes the whole or part of the male and female genital organs, and includes surgically constructed or reconstructed genital organs

Sexual penetration

Any act which causes penetration to any extent whatsoever by: • The genital organs of one person into or beyond the genital organs, anus, or mouth of another person • Any other part of the body of one person, or any object, including any part of the body of the animal, into or beyond the genital organs or anus of another person • The genital organs of an animal, into or beyond the mouth of another person

Rape

Any person (A) who unlawfully and intentionally commits an act of sexual penetration with a complainant (B), without the consent of B, is guilty of the offence of rape

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Different scenarios

A survivor may present to a healthcare facility under various circumstances, and management should be guided by the presenting history and wishes of the survivor. In most cases, a survivor will report to a police station first, in which case a detective from the Family Violence, Child Protection and Sexual Offences (FCS) unit of the SA Police Service (SAPS) should be contacted. The detective should assist the survivor to open a case and arrange examination and evidence collection, if applicable, at the relevant healthcare facility. The examination and evidence collection are time sensitive, with a general cut-off of 120 hours since the time of the alleged incident for the evidence collection, and 72 hours for the provision of post-exposure prophylaxis against HIV.

General comments

A mentally competent adult survivor has a choice to lay a charge with the police or not. If the survivor wishes to lay a charge, but reports to a healthcare facility first, the attending clinician should contact SAPS/ FCS to request an officer to attend to the survivor at the healthcare facility. This avoids sending the survivor back to the police station first to report the incident. The Independent Police Investigative Directorate (IPID) should be contacted should the alleged perpetrator be a police official. The SAPS/IPID official has to supply the relevant medicolegal documentation (SAP 308 form, Affidavit 212 form), the J88 form, and sealed, unopened sexual assault evidence collection kit(s) (SAECK(s)).

Survivor presents with severe injuries

If a survivor is admitted with severe injuries or is in a serious medical condition, the following guidelines apply: • Forensic examination and evidence collection should be done only after stabilisation of the patient’s condition. • If a survivor has to be referred to the next level of care, ensure that the necessary information (such as forensic evidence that has not been collected yet) is communicated to the next facility and advise that, where possible, the survivor must not be bathed/washed prior to evidence collection. • Collect any removed clothes/items from the scene that may be with the survivor, and hand these over to the investigating officer, or keep these in a safe and locked cupboard until collected by the investigating officer.

Survivor presents ≤120 hours after the alleged incident and wishes to lay a charge with the police

Give the case priority as an emergency, and attend to the survivor as soon as reasonably possible. Provide the survivor with the necessary privacy. The clinician is responsible for the following: Step 1. Arrange containment counselling if available. Prepare the patient and obtain informed consent to proceed with the examination and evidence collection (SAP 308 form and consent form inside the evidence collection kit to be signed by the complainant/guardian, investigating officer and clinician). Step 2. Take a detailed history, following the information requested on the J88 form, and add clinical notes in the hospital folder. Step 3. Conduct a medical examination and collect evidence (guided by the details of the sexual offence) in the presence of a chaperone, who is preferably of the same sex as the survivor (more details on evidence collection are given below). If available and applicable, arrange or perform photographic recording of injuries. Step 4. Carefully document findings in an objective and understandable manner on the J88 form, and sign and complete the Affidavit 212 form. Take care to describe the injuries, using accurate wound terminology.

Step 5. Perform medical tests (see Medical management below). Step 6. Provide medical treatment (see Medical management below). Step 7. Arrange follow-up visits at the appropriate healthcare facility, as indicated, at 1 week, 6 weeks and 3 months. Step 8. Offer the survivor a comfort pack (if available) and bath/ shower if facilities are available. Step 9. Hand over the completed medicolegal documentation (original) to the investigating officer and keep copies in the survivor’s file, in a secure location as per local facility arrangement.

Survivor presents >120 hours after the alleged incident and wishes to lay a charge with the police

The same steps are to be followed as above, except: • There should be no collection of evidence (except in the case of termination of pregnancy after alleged rape, where the products of conception should be retained for DNA analysis, using the appropriate Tissue Collection Kit to be provided by the FCS unit). • HIV prophylaxis is prescribed up to 72 hours after the alleged incident. • Emergency contraception should be provided, if indicated, up to 120 hours after the alleged incident.

Survivor does not wish to lay a charge with the police, but requests medical advice and treatment

A survivor does not forfeit her/his right to medical advice and treatment when no case is opened with the police.[6] Explain to the survivor that it may be of value to proceed with evidence collection if within the 120-hour period after the alleged incident in case s/he changes her/his mind about laying a charge. Obtain informed consent and proceed with the procedure in the same order as before, according to the time passed since the alleged incident. If the survivor consents, evidence may be collected (SAECK obtained from the FCS unit) and kept at the healthcare facility in a locked cupboard for 30 days in case the survivor changes her/his mind. Document your findings carefully in the survivor’s clinical notes.

Evidence collection

Evidence collection is to be guided by the history and details of the alleged sexual offence. SAECKs are provided by the investigating officer. Never accept SAECKs if the seals are broken or any evidence of tampering is evident, and maintain the chain of evidence. Previously, a single box that contained all the various steps/packages for forensic evidence collection was provided. This has been changed to separate evidence collection kits, which are to be used according to the type of assault.[7] Consider the detailed history of the sexual assault and request the necessary and appropriate kits before starting with your examination of the survivor and evidence collection (Table 3).

Medical management

The medical management, similar to the evidence collection, is guided by the presenting history and the time elapsed since the alleged incident.

Investigations

The following investigations should be performed: • pre- and post-HIV-test counselling and a rapid HIV test • baseline rapid plasma reagin (RPR) test (for syphilis) • urine pregnancy test • further testing for sexually transmitted infections (STIs), if indicated • screening for hepatitis B if the immunisation status of the individual is unknown.

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Table 3. Evidence collection*[7] In most cases, samples are only collected from the genital area of the survivor Swabs are usually collected from the external genitalia (vulva/scrotum); vagina/penile shaft and glans; or perianal area (D1 or D7)

Collect when indicated by the type of rape/sexual assault Anorectal (D1) Oral (D2) Any area with body fluids (D2)

Collect reference specimens for DNA analysis and to compare hair samples Blood (D2) Pulled pubic hair (D3) Pulled head hair (D3) Buccal sample (DB)

Collect, if present Underwear, clothing (D1, D5) Fingernail debris (D2) Sanitary pad/tampon (D1) Loose pubic hair (D3) Loose head hair (D3) Debris (D2) Condoms Wipes/towels if used after the incident

D1 = adult SAECK; D7 = use this kit if the survivor is <12 years of age. *Numbers and letters in brackets refer to the relevant evidence collection kits.

Table 4. Prophylaxis and medication[8] Prophylaxis

Medication

STI prophylaxis (provide within 72 hours after the alleged incident if there is a history or signs of penetration)

Ceftriaxone 250 mg intramuscularly as a single dose, metronidazole 2 g orally as a single dose, and azithromycin 1 g orally as a single dose

Antiretroviral prophylaxis (provide within 72 hours after the alleged incident)

Rapid HIV test non-reactive Tenofovir 300 mg + emtricitabine 200 mg: 1 tablet once a day for 28 days OR Zidovudine 300 mg + lamivudine 150 mg: 1 tablet 12-hourly for 28 days AND Add a protease inhibitor in all cases Lopinavir/ritonavir 200/50 mg: 2 tablets 12-hourly for 28 days OR Atazanavir/ritonavir 300/100 mg daily Note: Give the first dose of antiretroviral medication as soon as possible General comments Tenofovir is contraindicated in renal disease or with concomitant use of nephrotoxic medicines, e.g. aminoglycosides (check baseline creatinine clearance first if this is to be prescribed) Where tenofovir is contraindicated, switch to the second choice If zidovudine is not tolerated, consult or refer to a specialist HIV clinic for further management Lopinavir/ritonavir often causes diarrhoea. If lopinavir/ritonavir is not tolerated, switch to atazanavir/ritonavir If the perpetrator is known to be HIV-positive, consult an HIV specialist for advice on postexposure prophylaxis, or phone the HIV hotline for advice: 0800 212 506 HIV test reactive (confirmed) Refer for counselling and HIV care and management at the closest appropriate healthcare facility

Emergency contraception (provide as soon as possible and not >120 hours after the alleged incident)

Emergency contraceptive pills[9] First choice: Escapelle (levonorgestrel 1.5 mg) 1 tablet orally as a single dose, or, if not available, Ovral (ethinyl oestradiol and norgestrel) 2 tablets stat and 2 tablets 12 hours later, or Norlevo (levonorgestrel) 2 tablets stat Add an anti-emetic and repeat dose if vomiting occurs within 2 hours after ingestion of medication For women already using enzyme-inducing drugs, including antiretrovirals; or within 30 days of discontinuing them, the dose should be increased by 50%, e.g. Escapelle 2 tablets stat or Norlevo 3 tablets stat or Ovral 3 tablets stat and 3 tablets 12 hours later Copper-bearing intrauterine contraceptive device Alternative option to emergency contraceptive pills

Other

Anti-emetic medication Metoclopramide 10 mg orally, 8-hourly; take 30 minutes before a meal Simple analgesics If necessary and no contraindications exist (paracetamol 500 mg orally, or ibuprofen 200 mg orally with or after a meal)

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Treatment

Treat all acute injuries evident on presentation, and provide antitetanus toxoid 0.5 mL intramuscularly if: (i) open wounds are present; (ii) the last vaccination was >10 years ago; or (iii) the vaccination status is unknown. Treat any other physical injuries as appropriate, or refer for further treatment if indicated. Treat established complications, such as infections or pregnancy, as applicable.

Prophylaxis and medication

Information on prophylaxis and medication is given in Table 4.

Follow-up visits

Document whether the survivor experiences any post-traumatic stress syndrome symptoms at each visit, and give advice regarding medication and blood results. Ensure that arrangements for counselling are in place. A repeat examination is only required if there was significant injury, and documentation regarding healing is required. Follow up blood results on hepatitis B serology (if this was indicated) and manage accordingly. Repeat the HIV and RPR tests at 6 weeks and 3 months. Enquire about menstruation and a repeat pregnancy test, if indicated, at 6 weeks and 3 months. Treat STIs if indicated. If the survivor became pregnant as a result of rape, and wishes to terminate the pregnancy, she should be referred to an

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appropriate facility for a safe termination of pregnancy as soon as possible.

Conclusion

As the prevalence of rape and sexual assault in SA is vast, clinicians can expect to be faced with providing relevant care for survivors of alleged sexual offences in an array of clinical settings. Meticulous and appropriate management of these survivors is paramount to assist their healing and the best possible judicial outcomes. 1. Eyewitness News. 2013. http://ewn.co.za/2013/10/31/The-Anene-Booysen-Stor (accessed 12 April 2016). 2. News24. 2016. http://www.news24.com/SouthAfrica/News/family-of-murdered-teen-sinoxolo-angrywith-cops-20160.11 (accessed 12 April 2016). 3. The National Prosecuting Authority of South Africa. 2016. https://www.npa.gov.za/node/4 (accessed 10 April 2016). 4. Jina R, Jewkes R, Munjanja SP, et al. Report of the FIGO Working Group on Sexual Violence/ HIV: Guidelines for the management of female survivors of sexual assault. Int J Gynaecol Obstet 2010;109(2):85-92. DOI:10.1016/j.ijgo.2010.02.001 5. South Africa. Criminal Law (Sexual Offences and Other Related Matters) Amendment Act No. 32 of 2007. http://www.justice.gov.za/legislation/acts/2007-032.pdf (accessed 8 April 2016). 6. South Africa. National Health Act of 2003. Regulations: Rendering of clinical forensic services. Government Gazette No. 33655, 2010. (Published under Government Notice R929.) http://www.gov. za/sites/www.gov.za/files/33655_929.pdf (accessed 22 April 2016). 7. Manta Forensic. 2016. Collection kits. http://www.mantakits.co.za/?page_id=3753 (accessed 11 April 2016). 8. National Department of Health. Standard Treatment Guidelines and Essential Medicines List for South Africa – Primary Health Care Level. 5th ed. Pretoria: NDoH, 2014. 9. Western Cape Government. Circular H33/2016. Provincial Contraceptive Guidelines. Cape Town, DoH, 2016.

Physical and sexual violence against children A B van As, MB ChB, MMed, MBA, FCS (SA), PhD

Trauma Unit, Division of Paediatric Surgery, Red Cross War Memorial Children’s Hospital, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: A B van As (sebastian.vanas@uct.ac.za)

Violence against children represents a sobering reality for South African health professionals. Dealing with violence against children can easily take a heavy toll on health professionals’ health, often resulting in compassion fatigue, or secondary traumatic stress, which is characterised by a blunted response to patients’ suffering, in turn causing them secondary traumatisation. This article prepares health professionals in choosing the most appropriate and comfortable management for these unfortunate young victims of violence. S Afr Med J 2016;106(11):1075-1078. DOI:10.7196/SAMJ.2016.v106i11.12069

All health professionals are responsible for the detection, treatment, and reporting of child abuse. Most severe (including lethal) abuse occurs in children <3 years old. Africa’s homicide rate for under-5 children is more than six times the incidence in Western countries.[1] Unfortunately, the magnitude of the problem has been obscured by differing legal and cultural definitions of abuse and poor reporting and recording of cases. According to the World Health Organization, ‘Child abuse or maltreatment constitutes all forms of physical and/or emotional illtreatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power’.[2]

appropriate treatment for injuries sustained; and (iv) report cases to the appropriate authorities. Treatment varies from analgesics to extensive surgical procedures and placement in institutions. Apart from medical treatment for the child, support for the patient and family should be provided. To take an adequate history can be very complicated, as parents or caregivers are often in an anxious state. It might be very difficult to establish whether the injury was accidental or non-accidental. However, the health professional’s role is to provide an accurate diagnosis, not to play detective. The diagnosis might be very difficult, but a number of circumstances should raise suspicion of child abuse (Table 1).

Role of the healthcare worker in child abuse

Physical abuse (non-accidental injury) denotes deliberate infliction of injury. Child sexual abuse is the use of a child for sexual gratification. This also includes (i) touching, fondling, or other inappropriate contact with a child’s genitals or breasts; (ii) masturbation of a child

Health professionals should (i) recognise child abuse; (ii) accurately document all clinical findings (physical and/or psychological); (iii) provide

Types of violence against children

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by an adult or vice versa, and masturbation of an adult in the presence of a child; (iii) body contact with an adult’s genitals; (iv) exhibitionism; and (v) pornography, including photography and erotic talk. Note that most of these types of violence against children will leave no physical signs. Failure to thrive due to nutritional deprivation most commonly occurs within the first 2 years of life. Approximately 50% of all failure to thrive in this age category is due to parental neglect. Intentional drugging or poisoning refers to giving a prescribed drug that was not intended for the child. Medical care neglect occurs when a child’s disease worsens owing to parental ignorance of the condition. Safety neglect refers to a lack of supervision, especially in younger age categories. Emotional abuse occurs when the child is repeatedly blamed, criticised or rejected by parents and/or caregivers. It includes verbal abuse, which is common and difficult to prove. Finally, organised abuse is a form of organised crime, often involving multiple victims and perpetrators. Paedophilic and pornographic rings are major contributors, but it also includes cult-based abuse, with spiritual or social objectives.

Physical violence against children

Child abuse commonly causes childhood death, second only to sudden infant death syndrome in babies <6 months old. Although culture or socioeconomic status may be associated with child abuse, many studies indicate that abuse occurs among all income categories and all cultures.[3] The younger the child, the bigger the risk. Younger children are at greatest risk because they are more demanding, defenceless, and non-verbal. One-third of physical abuse occurs in children <6 months of age, another third in those between 6 months and 3 years of age, and the remaining third in those >3 years of age. At particular risk are male children, those born prematurely, and stepchildren.[3] Non-accidental injury results from a deliberate action by a person who intentionally threatens, attempts, or inflicts physical harm on another. Accidental injuries result from unforeseen events that cause external trauma to the body, without the intent to cause harm. The exact circumstances surrounding assault are often unclear. Some cases involve the so-called shielding phenomenon. This encompasses a broad spectrum, from the child sustaining injuries as an innocent bystander to cases where an adult positions the child in self-defense against an attacker.[4] Injuries such as stab wounds are particularly suggestive of shielding, because it is unlikely that anyone would deliberately assault a child with a weapon. Most children admitted with firearm-related injuries are victims of ‘stray bullets’.[5]

Causes of child abuse and predisposing factors

financial need, unemployment, intimate partner violence, being a single parent, and substance abuse. There is also an intergenerational factor, as >90% of abusing parents may have been a victim of violence during their own childhood.[6]

Diagnosing child abuse

There are many ways to establish a diagnosis of non-accidental injury in children. The first is when the child readily cites a particular adult as the assailant. The complaint must be taken very seriously, and every case thoroughly investigated. Unexplained injury should prompt a consideration of child abuse, particularly when parents are reluctant to explain the nature of the accident. For instance, parents might claim that they ‘just found the child like that’, or ‘the child might have fallen down’, or ‘someone else might have hit the child’. The majority of the parents know to the minute where and when the child was hurt. A changing or discrepant history of how the trauma occurred is also suggestive of child abuse. The suspicion of child abuse increases when the history provided does not explain the severity of the physical injuries. For instance, a child who fell from a bed and yet is covered with bruises is unlikely to have suffered such injuries from the stated mechanism. Another is a parental claim that the child ‘bruises so easily’, which is usually misleading, especially when no new bruises appear during hospitalisation. Claims of self-infliction in children should be treated with suspicion; for example, reporting that a young baby has ‘rolled over her arm and fractured it’. Similarly, shifting the blame for the injury to a third party (often absent and untraceable) may also indicate child abuse. Delayed presentation is a common feature of abuse injuries. Normally parents bring their child to hospital within 24 hours of an injury. After child abuse, however, a delay is rather common. Finally, repetitive injuries in a child may indicate child abuse. Skin lesions Skin lesions can occur everywhere. Bruises on the buttocks and lower back may relate to corporal punishment, and bruises on the face are often secondary to being hit. Other typical findings are grip marks, pinch marks, and circumferential bruises. Defining the exact age of the injuries can be controversial. Most light skin lesions initially display a red colour, followed by a reddish-purple period within 24 hours, which then gradually progresses to a predominantly purple lesion (often referred to as blue) over the next week. Discoloration to yellow/green/brown is due to degradation of haemoglobin and occurs over 1 - 3 weeks.

Research indicates that >90% of abusive parents have no psychological problems or a criminal nature. Instead, they tend to be lonely, unhappy, and angry adults under tremendous stress. Additional stressful factors include a breakdown of family structure, poverty,

Burns Approximately 10% of physical abuse involves burns. Typical lesions found in child abuse are cigarette burns and so-called stocking/glove injuries from immersing toddlers in hot water.[7]

Table 1. Circumstances that could raise suspicion of violence against children

Head injuries The incidence of abusive head injury ranges from 17/100 000 to 40/100 000. Infants 0 - 3 months of age are the largest group.[8] Approximately one-third of abusive head injuries are not recognised at the initial visit to a healthcare institution. Although non-accidental head trauma in children <3 years of age is difficult to diagnose, one should maintain a high index of suspicion. The spectrum of head injury can range from skull fractures to severe lethal intracranial bleeding and brain atrophy. Subdural haematomas may also be the result of shaking. The rapid acceleration and deceleration of the shaking head appear to tear bridging veins, with resulting bleeding and subdural haematomas, often bilaterally. Another common finding is

Unexplained injuries Discrepant histories Delay in seeking medical care Alleged self-inflicted injuries Alleged third-party-inflicted injuries Repeated injuries Sexualised behaviour Sexually transmitted infection

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diffuse cerebral brain swelling with loss of normal grey-white matter differentiation and retinal haemorrhages.[9] Skeletal injuries Fractures in small children are rare. In all patients <3 years old, the occurrence of a fracture without an adequate history should prompt suspicion of child abuse. Approximately one-quarter of physical abuse cases involve skeletal injury. The long bones are involved in two-thirds of fractures, which can be spiral or transverse. Certain fractures are almost pathognomonic of child abuse, such as a chip fracture (corner or bucket-handle fracture) of the long bones (Fig. 1). This injury occurs owing to avulsion of the corner of the metaphysis from the periosteum during wrenching injuries to the long bones. Approximately 10 days after the injury, calcification of the subperiosteal bleeding creates the classic double cortex line. In all cases of suspected child abuse, a skeletal survey should be obtained. This comprises a combination of radiographs of the chest, skull and extremities, only in the anteroposterior direction. Repeated abuse may manifest as old rib fractures with callus formation in different phases of healing (Fig. 2). A radionuclear bone scan is a more sensitive method to detect old injuries, but is unreliable in children <1 year of age.

Differential diagnosis

Certain conditions may be mistaken for abuse (and vice versa), including (i) birth trauma: should be evident from the birth history; (ii) congenital syphilis: chronic periosteal reaction combined with metaphyseal widening and positive blood tests; (iii) osteogenesis imper fecta: multiple fractures, blue sclerae, osteopenia; (iv) rickets: renal disease, bowed long bones, blood abnormalities; (v) scurvy: poor wound healing, bleeding gums, petechiae; (vi) bleeding disorders: haemophilia, meningococcaemia; and (vii) skin diseases: impetigo, chickenpox, scaled skin syndrome, which may mimic burns. Genuine accidental trauma may also present, which can be diagnosed by the history, pattern of injury, and interaction with parents or caregivers.

Management of injuries

The initial stabilisation of the physically assaulted child uses an ABC approach, as with any injured child.[10] It consists of (i) primary survey with resuscitation; (ii) secondary survey with emergency treatment; and (iii) transfer to definitive care, where the abused child can receive integrated and holistic treatment. This includes medical treatment, the necessary medicolegal investigations and psychological support. This is crucial to avoid unnecessary (and traumatic) repetitive physical examination and/or repetitive taking of the medical history. While treatment is the key priority, be careful to minimise interference with any forensic evidence on the child’s clothes or skin. The primary survey consists of ABCDE: Airway with cervical spine control; Breathing with ventilatory support; Circulation with haemorrhage control; Disability with prevention of secondary insult; and Exposure. Useful adjuncts at this stage include chest and pelvic radiographs, initial blood tests (including a cross-match sample), an oro- or nasogastric tube, and a urinary catheter. The initial priority is resuscitation and treatment of immediate life-threatening problems, followed by the secondary survey, in which the child undergoes a thorough head-totoe examination. Physically abused children often have evidence of older injuries, which must be documented accurately. The final stage of emergency management is transfer to definitive care. This involves appropriate preparation for transfer – either within the hospital or to another unit – and handover to the receiving staff. Accurate handover is essential in cases of suspected or proven physical abuse. Accurate notes facilitate continuity of care.

Fig. 1. Metaphyseal lesion as a result of physical child abuse. (A) Lateral radiograph of the left tibia showing a distal metaphyseal corner fracture (arrow). (B) Frontal radiograph of the same left tibia showing that with a different obliquity the metaphyseal fracture appears as a crescentic fragment (arrows), the so-called bucket-handle fracture.

Fig. 2. Rib fractures from physical abuse. (A) Frontal chest radiograph showing healing fractures of the right posterior 8th, 10th and 11th ribs (arrows). (B) Frontal chest radiograph showing healing fractures of the right posterior 5th, 6th, 7th and 8th ribs (arrows).

Sexual violence against children

Abuse should be suspected in any child presenting with perineal injuries or infection. In girls, sexual abuse can be chronic (without signs of fresh injuries, but with absent hymen) or acute (often with fresh physical injuries). Small children often present with a bruised perineum. In the majority of cases, the perpetrator is well known to the child and may be a family member, family friend or neighbour.[11] Clinicians should be alert to symptoms and signs of child sexual abuse. Recurrent abdominal pain is common in a child unable to express the nature of the injury. Many children are referred only after someone noticed their altered gait or discomfort in walking or sitting. Nearly all children who are sexually abused are threatened (often with their life) not to disclose and are therefore often reluctant to identify the perpetrator. Children may present with a history of painful micturition and recurrent urinary tract infections, while the cause of the infection is sexual violence. Other modes of presentation are faecal soiling and/or retention. Young children presenting with discharge from penis or vagina should be investigated thoroughly and the possibility of sexual violence should be seriously considered. Abnormal wide dilatation of either the vagina or anus is very suspicious, particularly in the presence of genital laceration or bruising. Many abused girl children present to the medical care facility with the single symptom of vaginal bleeding, without any

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CME

further explanation. All children presenting with sexually transmitted infections should be assumed to be abused until proven otherwise (congenital infections).

Guidelines for examination after abuse

Examination of a sexually abused child must be sensitively performed under optimal circumstances to prevent secondary trauma. Examination should always be done by a qualified health professional. A designated private area is required and a third person (preferably mother or nurse) should be present. It is very important to explain the procedure to the caregiver and child in advance. It is mandatory to perform a full general examination, including weight, height, and nutritional status. The genital examination should only occur once. The overriding principle of physical examination is that the child should be relaxed and co-operative. In cases where this cannot be achieved (and in all cases where surgical repair is required owing to the extent of the injury), an examination under anaesthesia is warranted to determine the exact nature of the injury. Owing to the discrepancy in size between the sexual organs of the perpetrator and those of the victim, penetration rarely occurs in sexually abused children. However, forced penetration in small children can cause a mutilating injury. Absence of penetration does not rule out abuse. In a local study, one-third of the paediatric sexual assault victims had no physical injuries.[12] Bruises and first- and second-degree tears can usually be repaired primarily. However, when there is violation and laceration of the anal sphincter or the rectovaginal septum, a diverting colostomy with washout is needed. When all signs of infection have subsided (usually between 6 weeks and 3 months), the definitive repair can be performed. The recommended routine investigations for all cases of sexual abuse are the following: (i) full blood count and platelets, international normalised ratio and partial thromboplastin time to exclude a bleeding disorder; (ii) vaginal or penile swab where a discharge is present – send for microscopy, culture, and sensitivity; (iii) blood for a venereal disease research laboratory (VDRL) test; (iv) HIV serology – post-exposure prophylaxis is continued only for those who test HIV-negative; and (v) photographic documentation for legal purposes. Digital photographs have to be printed, dated, and signed immediately to be useful as evidence in court. The child should be checked for syphilis (VDRL test) and HIV/AIDS. If available, antiretroviral therapy should be initiated. Do not routinely start children on antibiotics, but wait for the results of laboratory tests. Involve social workers from the outset, and contact the child protection unit (police).

Reporting cases of suspected child abuse and court testimony

The numerous pitfalls in dealing with suspected child abuse include (i) relying on the history provided by caregivers or parents regarding the mechanism of injury; (ii) not undressing and examining the whole child; (iii) not being able to mask emotional display while examining

the injured child; (iv) insufficient experience in examining children, requiring the child to be re-examined; (v) blaming the caregivers and/or parents instead of supporting them; and (vi) omission of prophylactic antiretroviral therapy after sexual assault. To be accused of child abuse is an extremely painful experience. Some parents react aggressively if medical staff probe the possibility. Parents or caregivers regularly threaten legal action. However, South African (SA) law protects those who report suspected child abuse in good faith. Even though the investigator must be firm to conduct a thorough investigation, due recognition must be given to the possibility that the accused may be innocent. To be as thorough as possible regarding the medical report, an affidavit must be written within 24 hours of severe abuse cases, which might be litigated by court. This will assist doctors considerably at a later stage. Cases often take years to reach court. If the abuse was not well documented or data are missing, the perpetrator nearly always evades justice. All child sexual abuse cases should be investigated by the police. Yet, only 30% of perpetrators end up in court, and only ~7% face prosecution.[12] Importantly, child sexual abuse cases cannot be withdrawn, unlike adult sexual abuse cases, where the victim can change her or his mind.

Conclusion

Violence against children contributes greatly to the burden of disease among children in Africa, who have the unenviable distinction of the highest unintentional injury death rates in the world. In SA, we need to focus on creating and maintaining awareness about the magnitude, risk factors, and preventability of child injuries among policy makers, donors, practitioners, and parents/caregivers.[13] It is high time that the SA government publicly acknowledges the problem of sexual violence against children, establishes systems of reporting and expertise, and ensures a system that protects those who report offences, while swiftly dispensing justice to offenders.[14] 1. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R. World Report on Violence and Health. Geneva: World Health Organization, 2002. 2. World Health Organization. Report of the Consultation on Child Abuse Prevention, 29 - 31 March 1999. Geneva: WHO, 1999. 3. Van As AB, Naidoo S, eds. Paediatric Trauma and Child Abuse. Cape Town: Oxford University Press, 2006. 4. Fieggen AG, Wiemann M, Brown C, van As AB, Swingler GH, Peter JC. Inhuman shields – children caught in the crossfire of domestic violence. S Afr Med J 2004;94(4):293-296. 5. Campbell NM, Colville JG, van der Hayde Y, van As AB. Firearm injuries to children in Cape Town, South Africa: Impact of the 2004 Firearms Control Act. S Afr J Surg 2013;51(3):92-96. DOI:10.7196/ SAJS.1220 6. Egeland B. A history of abuse is a major risk factor for abusing the next generation. In: Gelles RJ, Loseke DR, eds. Current Controversies on Family Violence. London: Sage, 1993. 7. Pawlik MC, Kemp A. Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries. Child Abuse Neglect 2016;55:52-61. DOI:10.1016/j.chiabu.2016.03.006 8. Tingberg B, Falk AC, Flodmark O, Hygge BM. Evaluation of documentation in potential abusive head injury of infants in a paediatric emergency department. Acta Paediatr 2009;98(5):777-781. DOI:10.1111/j.1651-2227.2009.01241.x 9. Pressel DM. Evaluation of physical abuse in children. Am Fam Phys May 2000. http://www.aafp.org/ afp/2000/0515/p3057.html (accessed 5 October 2016). 10. Advanced Life Support Group. Advanced Paediatric Life Support: The Practical Approach. London: BMJ Books, 2005. 11. Barker J, Hodes D. The Child in Mind. A Child Protection Handbook. London: Routledge, 2004. 12. Van As AB, Whithers M, Millar AJW, Rode H. Child rape – patterns of injury, management and outcome. S Afr Med J 2001;91(12):1035-1038. 13. Peden M, Hyder AA. Time to keep African kids safer. S Afr Med J 2009;99(1):36-37. 14. Jewkes R. Preventing sexual violence: A rights-based approach. Lancet 2002;360(9339):1092-1093. DOI:10.1016/S0140-6736(02)11135-4

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ISSUES IN PUBLIC HEALTH

Health system challenges: An obstacle to the success of isoniazid preventive therapy E I Okoli,1 MBBS, PG Dip HIV/AIDS Management, MPhil (HIV/AIDS Management), MPH; L Roets,2 PhD 1 2

Department of Internal Medicine, Dr George Mukhari Academic Hospital, Garankuwa, Pretoria, South Africa Department of Health Studies, College of Human Sciences, University of South Africa, Pretoria

Corresponding author: E I Okoli (docokoli@yahoo.com) Background. The researchers identified infection with HIV as the strongest risk factor in the reactivation of latent tuberculosis (TB) infection or progression to active disease. Isoniazid preventive therapy (IPT) is one of the interventions recommended by the World Health Organization and the South African (SA) National Department of Health to prevent progression to active TB disease in people living with HIV. Adherence to IPT is therefore the responsibility of healthcare clients and clinicians. Objectives. To describe the incidence of TB among clients who received IPT, rates of completing and not completing IPT among those who started it, and the reasons for non-completion. Methods. A quantitative, non-experimental, descriptive retrospective cohort study was undertaken. The clinic records of 104 HIV-positive adults receiving care at a clinic in SA who started IPT between 1 July 2010 and 30 November 2011 were analysed. Results. Sixty-six of 104 study respondents (63.5%) completed the IPT course. None of the respondents who completed IPT was diagnosed with TB, and 86.8% of the respondents who did not complete the programme did so because of the poor quality of healthcare they received, and not by their own choice. Conclusion. The study results strengthened the findings of similar local and international studies that IPT is advantageous in the prevention of TB. The finding that so many patients did not complete the programme as a result of drug dispensing or prescription problems is alarming, and revealed a major shortcoming in the healthcare system. S Afr Med J 2016;106(11):1079-1081. DOI:10.7196/SAMJ.2016.v106i11.10741

With an estimated 5.6 million people living with HIV in 2011, South Africa (SA)â&#x20AC;&#x2122;s epidemic remains the largest in the world.[1] SA is also the country with the third-highest tuberculosis (TB) burden globally, and is only lagging behind countries such as China and India that have significantly larger populations.[2] TB is also the most common cause of morbidity and mortality in the HIV-infected population in SA, and studies have shown that TB accelerates the progression of HIV/AIDS.[3] Since 1993, when the World Health Organization (WHO) declared TB a global public health emergency because of 7 - 8 million recorded cases, the spread of TB increased to about 9 million new cases in 2011. [4] TB is the second leading cause of death from an infectious disease worldwide after HIV, and accounted for an estimated 1.4Â million deaths in 2011.[4] This includes an estimated 430 000 deaths from TB among people living with HIV (PLHIV).[4] HIV is the strongest risk factor recognised so far in reactivating latent Mycobacterium tuberculosis infection to active TB disease, or increasing susceptibility to new infection.[5] The risk of active TB increases soon after HIV seroconversion and doubles by the end of the first year of HIV infection.[6] Isoniazid preventive therapy (IPT) is one of the interventions that the World Health Organization (WHO) and the SA National Department of Health (NDoH) recommend to prevent progression to active TB disease in PLHIV. The WHO, with a high quality of evidence, strongly recommends that these individuals receive IPT irrespective of their degree of immunosuppression. The protective effect of TB preventive therapy is expected to last for approximately 18 months, so the therapy should be given once during

this period.[4] The lifetime risk of an infected but immunocompetent individual developing active TB disease is around 10%, with the highest risk in the first 2 years following infection. [7] The risk increases to around 10% per year in an individual living with HIV.[8] In addition to high rates of reactivation TB, HIV-infected individuals have increased susceptibility to new exogenous infection and rapidly progressive primary disease. HIV-positive individuals who are co-infected with TB are about 21 - 24 times more likely to develop active TB disease than those who are HIV-negative.[5] From a public health perspective, IPT is cost-effective, extends life expectancy, reduces the incidence of TB, and promotes savings in medical and social costs for adults with HIV, especially those who are tuberculin skin test (TST)-positive.[5] While individuals who are eligible for antiretroviral therapy (ART) should start it, all PLHIV in whom active TB has been excluded should be started on IPT, with the exception of those who abuse alcohol or have an increased likelihood of side-effects, in which case the NDoH states that counselling should precede IPT. Notwithstanding the absence of definitive evidence from randomised controlled trials on the optimal duration of IPT in HIV-infected patients, data from several observational studies demonstrate that IPT is cost-effective and beneficial because it combats low bacillary load latent TB, which serves as a reservoir for recurrent disease.

Methods

A quantitative non-experimental descriptive retrospective cohort study was performed in a clinic in an industrial area adjacent to a

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IN PRACTICE

formal urban settlement in the iLembe Health District, KwaZuluNatal Province (KZN), SA. The clinic provides the full complement of HIV/AIDS/TB management to the inhabitants of the area. Using a consecutive sampling method, the researchers collected data between July 2010 and November 2011. They used the daily clinic attendance register to obtain 441 applicable records for the study, and 104 HIV-infected adult clients met the eligibility criteria and formed the sample. The criteria for inclusion were evidence that the patient tested HIV-positive, was >18 years of age and had commenced IPT. The cut-off enrolment month of November 2011 applied because the researchers followed the records of the patients for 15 - 30 months to ascertain whether they developed active TB disease after using IPT. They screened the files of all the subjects for TB prior to commencing intake of IPT. Twelve subjects also had their sputum tested for acid-fast bacilli before starting ART. The sputum testing was done because they answered in the affirmative to at least one of the questions in the screening tool and were diagnosed with TB prior to IPT treatment. The researchers also developed a data-capturing instrument based on the objectives of the study and pretested it to gather the required data.

Ethical considerations

Ethical approval was obtained from the research ethics committee of the University of South Africa (ref. no. HSHDC/92/2012), the Department of Health (KZN) (ref. no. HRKM 011/13) and the iLembe Health District (ref. no. DM2012/09/2289). In order to maintain anonymity and confidentiality, the files were coded but names and file numbers were not entered.

Statistical analysis

Data were analysed using the SPSS statistical software program, version 21 (IBM, USA). Descriptive statistics were used to describe the demographic characteristics, and analytical statistics using the χ2 test to measure the associations between gender and age distributions of the subjects and those who completed IPT at 6 and 9 months. The 95% level of confidence (95% confidence interval) and a probability of p<0.05 were used as the definition of significance while comparing the groups.

Results

One hundred and four clinic records of HIV-positive adults receiving care at a clinic and meeting the inclusion criteria were abstracted for

5 (13.2%) Drug not prescribed

7 (18.4%) 26 (68.4%)

Drug out of stock Lost to follow-up

analysis. Of these, 63.5% (n=66) were female and 36.5% (n=38) male (Table 1). There was no statistical significance between female and male respondents who completed IPT at 9 months (p=2.699). Of the subjects, 31.7% (n=33) completed IPT within 6 months and 63.5% (n=66) within 9 months. Some could not collect their medication because of the unavailability of isoniazid; however, they did complete IPT within 9 months. The reasons for 36.5% of subjects (n=38) not completing the IPT course were identified as unavailability of drugs (18.4%, n=7), loss to follow-up (13.2%, n=5) and, most importantly, 68.4% (n=26) to whom IPT was not prescribed (Fig. 1). The clinical records of the affected patients did not state the exact reasons for this. None of the 66 respondents who completed IPT at the end of 9 months was diagnosed with TB at the conclusion of data gathering. The study findings confirmed the results of other studies that IPT for at least 6 months or up to 9 months was successful in preventing TB. Incidence rates of 0.80 per 100 person-years[9] and 2.3 per 100 person-years[10] have been reported elsewhere. Only 5 (13.2%) of the subjects who did not complete IPT were responsible for not doing so. The other 33 (86.5%) did not complete IPT because isoniazid was either not prescribed or out of stock.

Discussion

It is a cause for concern that IPT was either not prescribed or unavailable in so many cases, since the study results confirm the findings of other studies that IPT for at least 6 months and up to 9 months successfully prevented TB. To ensure quality healthcare, the required drugs must be available. The current national treatment guidelines in SA[11] recommend the use of a TST before commencing IPT. This practice should be standardised to ensure that the appropriate duration of IPT can be adhered to in order to implement research evidence, thus promoting evidence-based practice in healthcare delivery. Healthcare workers need to take responsibility for the quality of the healthcare they deliver, including the procurement of drugs to ensure the availability of IPT. Performance appraisal should include aspects such as timely ordering of medication, accountability for negligence to order medication, and attending workshops and continuing professional development sessions. Healthcare professionals who do not meet their responsibilities in providing quality healthcare as stipulated in their job descriptions should be held accountable for poor quality of healthcare, and the necessary actions should be taken against them. It was evident that IPT for at least 6 months successfully prevented TB. It therefore remains a serious concern that inadequate healthcare or possible incompetence of healthcare providers were the main reasons for patients not completing IPT despite positive evidence of its effectiveness. It is, however, important to note that the study was conducted in the catchment area of one clinic in one health district, and cannot be generalised to other contexts. Author contributions. EIO conducted the research, wrote the initial reports and funded the study. LR contributed to writing the proposal,

Fig. 1. Reasons for not completing IPT (N=38).

Table 1. Gender distribution of subjects who completed IPT at 9 months Completed at 9 months Yes No Total

Females, n (%) 28 (42.4) 38 (57.6) 66 (100.0)

Males, n (%) 10 (26.3) 28 (73.7) 38 (100.0)

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Total, n (%) 38 (36.5) 66 (63.5) 104 (100.0)

IN PRACTICE

research design and instrument development, data interpretation and writing the report. 1. National Department of Health, South Africa. National Antenatal Sentinel HIV and Syphilis Prevalence Survey in South Africa, 2011. Pretoria: NDoH, 2012. 2. National Department of Health, South Africa. Management of Drug-resistant Tuberculosis: Policy Guidelines. Pretoria: NDoH, 2011. 3. National Department of Health, South Africa. Clinical Guidelines for the Management of HIV & AIDS in Adults and Adolescents. Pretoria: NDoH, 2010. 4. World Health Organization. Global Tuberculosis Report 2012. Geneva: WHO, 2012. 5. World Health Organization. Guidelines for Intensified Tuberculosis Case-finding and Isoniazid Preventive Therapy for People Living with HIV in Resource-Constrained Settings. Geneva: WHO, 2011. 6. Granich R, Akolo C, Gunneberg C, Getahun H, Williams P, Williams B. Prevention of tuberculosis in people living with HIV. Clin Infect Dis 2010;50(S3):S215-S222. DOI:10.1086/651494

7. Foundation for Professional Development. The Integrated Management of TB, HIV & STI in the Primary Healthcare Setting. Pretoria: FPD, 2010. 8. Wilson D, Cotton M, Bekker L, Meyers T, Venter F, Maartens G, eds. Handbook of HIV Medicine. 2nd ed. Cape Town: Oxford University Press, 2008:36. 9. Golub JE, Pronyk P, Mohapi L, et al. Isoniazid preventive therapy, HAART and tuberculosis risk in HIV-infected adults in South Africa: A prospective cohort. AIDS 2009;23(5):631-636. DOI:10.1097/ QAD.0b013e328327964f 10. Rangaka MX, Wilkinson RJ, Boulle A, et al. Isoniazid plus antiretroviral therapy to prevent tuberculosis: A randomised double-blind, placebo-controlled trial. Lancet 2014;384(9944):682-690. DOI:10.1016/S0140-6736(14)60162-8 11. National Department of Health, South Africa. National Consolidated Guidelines for the Prevention of Mother-to-Child Transmission of HIV (PMTCT) and the Management of HIV in Children, Adolescents and Adults. Pretoria: NDoH, 2014.

Accepted 18 March 2016.

NON-COMMUNICABLE DISEASES This open-access article is distributed under CC-BY-NC 4.0.

Addressing tobacco smoking in South Africa: Insights from behavioural science

G Ganz, MSocSci candidate Department of Psychology, Faculty of Humanities, University of Cape Town, South Africa Corresponding author: G Ganz (garyganz@gmail.com)

Behavioural risk factors such as tobacco smoking contribute significantly to the global and local disease burden. This article surveys three behavioural science interventions that could reduce rates of tobacco smoking in South Africa. S Afr Med J 2016;106(11):1082-1083. DOI:10.7196/SAMJ.2016.v106i11.12003

In 2000, tobacco smoking contributed to 8% of mortality and 3.7% of disability-adjusted life-years in South Africa (SA).[1] The most recent study of prevalence found that 17.6% of South Africans smoke tobacco.[2] The social and economic costs of tobacco smoking are significant, and the importance of multipronged efforts to reduce rates of smoking cannot be overstated. Alone, public education campaigns which raise awareness of the health risks associated with smoking are unlikely to have a significant impact – this is because, more so than effortful thinking, health behaviours and decisionmaking are strongly determined by unconscious cognitive biases and heuristics.[3] Indeed, in the past decade there has been a rise in the use of behavioural science to address issues of public health.[4] Given that behavioural risk factors, such as smoking, contribute significantly to the global and local disease burden, evidence-based behavioural interventions have much to contribute to public health.[5] This article surveys three potentially cost-effective behavioural interventions that could reduce rates of tobacco smoking in SA.

Social norms

Perceived norms – what I think everyone else does and thinks – are a significant predictor of human behaviour.[6-8] An important finding from norms research is that we often overestimate the prevalence of and support for antisocial behaviours and underestimate those of pro-social behaviours.[8] Moreover, these misperceived norms often drive behaviour. For example, students at five schools in the USA significantly overestimated both how much bullying took place and how many people condoned bullying behaviour at their school.

Increased misperception was correlated with increased bullying. An intervention that disseminated the accurate rates of prevalence and support reduced rates of bullying significantly.[9] Another social norms intervention in the USA significantly reduced rates of youth smoking initiation.[10] Since a minority (17.6%) of South Africans smoke tobacco, researchers could examine the actual and perceived norms of smoking, and construct interventions accordingly. These interventions could use nationally representative data such as the South African National Health and Nutrition Examination Survey[2] and disaggregate it into smaller areas in order to tap into salient social identities to disseminate relevant tobacco smoking norms. For example, a campaign could emphasise the fact that the vast majority of people in a particular area do not smoke, and that most people think smoking is unappealing.

Defaults

Default options refer to ‘an option that will obtain if the chooser does nothing’.[11] Apart from cases where choice is mandated, default options are pervasive. Behavioural science research suggests that default options strongly influence choice outcomes in favour of the default.[3] For example, when a large corporation in the USA switched from voluntary (opt-in) to automatic (opt-out) enrolment in a retirement savings plan, the number of enrolled employees rose by 50%.[12] The influence of defaults is attributed to a number of factors. Firstly, defaults are often seen as normative, or the recommended option.[8,11] Secondly, it takes effort to fill out forms or answer

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questions in order to make a decision. Thirdly, even when it does not take much physical effort, people tend to avoid making active decisions as they can be mentally taxing and cause unease.[13,14] The default effect has an important application to the way in which we treat tobacco dependence. In SA, the treatment guidelines for tobacco dependence are as follows: ‘(i) identifying all smokers, alerting them to the harms of smoking and benefits of quitting; (ii) assessing readiness to initiate an attempt to quit; (iii) assessing the physical and psychological dependence to nicotine and smoking; (iv) determining the best combination of counselling/support and pharmacological therapy; (v) setting a quit date and providing suitable resources and support; (vi) frequent follow-up as often as possible via text/telephone or in person; (vii) monitoring for sideeffects, relapse and ongoing cessation; and (viii) if relapse occurs, providing the necessary support and encouraging a further attempt when appropriate’. [15] These guidelines are the norm in many countries around the world. Richter and Ellerbeck[14] point out that this particular treatment guideline deviates from the treatment of most chronic health conditions (including substance abuse) in that it is an opt-in treatment. In contradistinction, when a doctor diagnoses a patient with diabetes they do not assess the patient’s readiness before initiating treatment – that is to say, ordinarily we take an opt-out approach to treatment. Shifting the treatment default for tobacco cessation from an opt-in to an opt-out system could have significant positive benefits for public health. The authors of a meta-analysis of tobacco smoking cessation interventions conclude that ‘the evidence is sufficiently clear to recommend that doctors should offer support for cessation much more commonly that is currently the case, and prior assessment of willingness to quit excludes many who would have taken up the offer of assistance if offered it directly’.[16]

Packaging

In the same way that emotions are used by marketers and advertisers to attract consumers to a particular brand of cigarettes, they can also be used to discourage cigarette consumption.[4] Plain packaging coupled with graphic health warnings, which elicit disgust, provide another avenue to reduce tobacco smoking in SA. Australia’s implementation of plain packaging and graphic health warnings in 2012 provides an important case study. A 1-year follow-up study found an increase in rates of intention to quit,[17] and another study found a 0.55% decrease in prevalence at 34 months post intervention.[18] Perhaps most noteworthy, a study found post-intervention decreases in the appeal of cigarettes packs to youth.[19] The SA government – which ratified the World Health Organization’s Framework Convention on Tobacco Control in 2005 – has already expressed support for the introduction of plain packaging.[20]

Conclusion

Social norms, defaults, and packaging are three examples of the way in which behavioural science can contribute to issues of public health in SA. Behavioural interventions of this kind are amenable to testing in randomised controlled trials, which can help to determine their impact at scale and thereby influence policy. Researchers and policy-makers should focus their efforts on the role that behavioural science can play in developing cost-effective and evidence-based interventions to issues of public health in SA.

1. Groenewald P, Vos T, Norman R, et al. Estimating the burden of disease attributable to smoking in South Africa in 2000. S Afr Med J 2007;97(8):674-681. 2. Reddy P, Zuma K, Shisana O, Jonas K, Sewpaul R. Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey. S Afr Med J 2015;105(8):648-655. DOI:10.7196/SAMJnew.7932 3. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus & Giroux, 2013. 4. Roberto CA, Kawachi I. Behavioral Economics and Public Health. Oxford: Oxford University Press, 2015. 5. Murray CJ, Lopez AD. Measuring the global burden of disease. N Engl J Med 2013;369(5):448-457. DOI:10.1056/nejmra1201534 6. Cialdini RB, Kallgren CA, Reno RR. A focus theory of normative conduct: A theoretical refinement and reevaluation of the role of norms in human behaviour. Adv Exp Soc Psychol 1990;24(20):201-234. DOI:10.1016/s0065-2601(08)60330-5 7. Cialdini RB, Demaine LJ, Sagarin BJ, Barrett DW, Rhoads K, Winter PL. Managing social norms for persuasive impact. Soc Influence 2006;1(1):3-15. DOI:10.1080/15534510500181459 8. Tankard ME, Paluck EL. Norm perception as a vehicle for social change. Soc Issues Policy Rev 2016;10(1):181-211. DOI:10.1111/sipr.12022 9. Perkins HW, Craig DW, Perkins JM. Using social norms to reduce bullying: A research intervention among adolescents in five middle schools. Group Process Intergr Relat 2011;14(5):703-722. DOI:10.1177/1368430210398004 10. Linkenbach J, Perkins HW. Most of us are tobacco free: An eight-month social norms campaign reducing youth initiation of smoking in Montana. In: Perkins HW, ed. The Social Norms Approach to Preventing School and College Age Substance Abuse: A Handbook for Educators, Counselors, and Clinicians. San Francisco: Jossey-Bass, 2003:224-234. 11. Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth and Happiness. London: Penguin Books; 2009:93. 12. Madrian BC, Shea DF. The power of suggestion: Inertia in 401(k) participation and savings behavior. Q J Econ 2001;116(4):1149-1187. DOI:10.1162/003355301753265543 13. Johnson EJ, Goldstein D. Do defaults save lives? Science 2003;302(5649):1338-1339. DOI:10.1126/ science.1091721 14. Richter KP, Ellerbeck EF. It’s time to change the default for tobacco treatment. Addiction 2015;110(3):381-386. DOI:10.1111/add.12734 15. Van Zyl-Smit RN, Allwood B, Stickells D, et al. South African tobacco smoking cessation clinical practice guideline [Abstract]. S Afr Med J 2013;103(11):869-876. DOI:SAMJ.7484 16. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: A systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction 2012;107(6):1066-1073. DOI:10.1111/j.1360-0443.2011.03770.x 17. Durkin S, Brennan E, Coomber K, Zacher M, Scollo M, Wakefield M. Short-term changes in quitting-related cognitions and behaviours after the implementation of plain packaging with larger health warnings: Findings from a national cohort study with Australian adult smokers. Tob Control 2015;24(S2):ii26-ii32. DOI:10.1136/tobaccocontrol-2014-052058 18. Australian Government Department of Health. Post-Implementation Review: Tobacco Plain Packaging, 2016. https://ris.govspace.gov.au/files/2016/02/Tobacco-Plain-Packaging-PIR.pdf (accessed 20 August 2016). 19. White V, Williams T, Wakefield M. Has the introduction of plain packaging with larger graphic health warnings changed adolescents’ perceptions of cigarette packs and brands? Tob Control 2015;24(S2):ii42-ii49. DOI:10.1136/tobaccocontrol-2014-052084 20. News24.com. SA set to join global plain cigarette packaging trend. News24, 26 May 2016. http://www. news24.com/SouthAfrica/Local/Coastal-Weekly/sa-set-to-join-global-plain-cigarette-packagingtrend-20160525 (accessed 18 August 2016).

Accepted 19 September 2016.

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IN PRACTICE

MEDICINE AND THE LAW

When are doctors legally obliged to stop and render assistance to injured persons at road accidents? D J McQuoid-Mason, BComm, LLB, LLM, PhD Centre for Socio-Legal Studies, University of KwaZulu-Natal, Durban, South Africa Corresponding author: D J McQuoid-Mason (mcquoidm@ukzn.ac.za)

Unlike the USA, South Africa (SA) does not have ‘Good Samaritan’ laws that oblige doctors to stop at road accidents. In SA, the conduct of doctors in such situations is governed by the common law. Doctors coming across injured people at a road accident should stop and render assistance, unless they are likely to be exposed to personal danger or injury, they are mentally or physically incapable of assisting, or other medical or paramedical practitioners are at the scene. Where there is the threat of personal danger to the doctor, they must immediately report the accident to the police, advise the police to send protection and call for urgent ambulance assistance. Doctors should remain in a safe place near the scene until the police and ambulance arrive and check that paramedics are available to stabilise the injured before departing. Where there is the threat of danger, if doctors are mentally or physically unable to assist or if other medical or paramedical practitioners are at the scene, doctors may or may not be required to stop. S Afr Med J 2016;106(6):575-577. DOI:10.7196/SAMJ.2016.v106i6.10503

Most states in the USA have ‘Good Samaritan’ laws that oblige doctors to stop and render emergency treatment under certain circumstances, without incurring legal liability even if they are negligent.[1] South Africa (SA) has no such laws, and the duty of doctors to assist at road accidents is governed by the common law. The question arises whether doctors in SA are legally required to stop and render assistance to injured people at road accidents. When there is a public announcement calling for a doctor in situations such as during a movie, doctors usually have no difficulty in responding. When it comes to road accidents, it seems that doctors are more reluctant to stop and render assistance, particularly when they feel that they may be exposed to danger. In order to answer the question whether doctors are legally obliged to stop and render assistance at road accidents under the common law, it is necessary to consider the following: (i) When is there a general legal duty on people to act? (ii) When are doctors legally required to render assistance to injured persons at road accidents? (iii) What standard of care is expected of doctors who render assistance at road accidents? and (iv) When are doctors not legally required to render assistance at road accidents?

When is there a legal duty to act?

As a general rule in SA there is no legal duty to act unless the law imposes a legal duty to do so.[2] Traditionally the law imposed a legal duty to act in situations, inter alia, where a person has a special relationship with another person or a statute imposes a legal duty to act.[3] These situations were regarded as useful indicators, but were replaced by a more general boni mores (good morals) approach based on the ‘legal convictions of the community’.[2] If the legal convictions of the community would regard the omission as wrongful, the law would impose legal liability on the person concerned.[2] With the advent of the Constitution, the courts have tended to impose liability for failure to act according to the values in the Constitution, rather than the legal convictions of the community.[4]

When are doctors legally required to render assistance to injured persons at motor accidents?

Doctors should offer assistance where people who are not their patients require medical assistance. This applies to situations where

their safety is not threatened and where they can render first aid to stabilise patients until they can be handed over to other healthcare practitioners.[5] This often occurs in non-controversial situations when doctors in cinemas or theatres or travelling as passengers in aircraft respond to calls for medical assistance.

Ethical considerations

In 1978, the SA Medical and Dental Council ruled that that ‘in cases of emergency a practitioner is obliged to render assistance in all circumstances’, and it was suggested that this could be ‘interpreted broadly to mean that a doctor may not deliberately ignore an emergency situation such as a road accident’.[5] It has therefore been said that ‘where persons are in a situation where their life or health will be seriously endangered unless they receive immediate medical treatment, a practitioner who is available may not ethically refuse to attend such patients unless there are compelling circumstances that prevent the doctor from acting’.[6] In Australia, a Medical Board tribunal found a doctor guilty of improper and unprofessional conduct for failing to stop at an accident and instead driving to the police station to report it.[7] The tribunal found that the doctor’s conduct was unprofessional because she failed to stop without checking on the occupants of the car in question to determine whether there were any injuries and whether she could help. If she could not have helped, she should have ascertained the extent and nature of the injuries so that they could be reported to the emergency services. The tribunal stated: ‘It matters not that there is no existing professional relationship between a medical practitioner and the persons involved in the accident.’[7] In the UK, ‘off-duty doctors are not legally obliged to offer assistance if they come upon a medical emergency, but a failure to assist in an emergency might prompt disciplinary action by the General Medical Council’.[8] The Council guidelines state: ‘In an emergency, wherever it may arise, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care.’[8] Although the ethical rules of the medical profession are not binding on the courts, the courts may often find such rules useful in determining whether or not a doctor has acted reasonably by not stopping at a road accident.

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Legal considerations

Unlike SA, the UK does not have constitutional provision that states that nobody may be refused emergency medical treatment. [9] The decision of the SA courts regarding the wrongfulness of the doctor’s conduct will be based on the values in the Constitution.[4] Both the Constitution[9] and the National Health Act[10] provide that nobody shall be refused emergency medical treatment. It is submitted that the right not to be refused emergency medical treatment in the constitution can be interpreted to include providing medical assistance at road accident scenes even when a doctor has not been requested to provide it. A doctor is still obliged to stop and render emergency medical treatment where no other medically qualified person is available, where there is no threat to the doctor’s personal safety, and when the doctor is mentally and physically able to assist. This is because persons injured in road accidents are clearly envisaged as the type of individuals that the provision in the Constitution seeks to protect. The Constitutional Court has defined ‘emergency medical treatment’ as occurring where a person ‘suffers a sudden catastrophe that calls for immediate medical attention’,[11] which clearly applies to injured road accident victims. The traditional indicators for when there is a duty to act and the boni mores approaches to actionable omissions may also be used to underpin the values in the Constitution. For example, it could be argued that doctors who come across a road accident involving injured people, who may die or suffer permanent serious injury if they are not provided with immediate medical attention, have a ‘special relationship’ with injured people in emergency situations – even if they are not their patients.[7] In this regard, the Australian Medical Board Tribunal has observed that ‘saving human life and healing sick and injured people is a core purpose and ethic of the medical profession’.[7] Furthermore, ‘a medical practitioner’s conduct may be “in pursuit of the practitioner’s profession” even where it does not occur in the carrying out of medical practice, provided there is a sufficiently close link or nexus between the conduct and the profession of medicine’. Such a close link exists where a doctor comes across a road accident where there are injured people who require immediate medical assistance.[7] In terms of the ‘legal convictions of the community’ boni mores approach,[2] it could be argued that the legal convictions of the community would be ‘outraged’ if a doctor, who is not in any danger and has the capacity to render assistance and save lives, drives past a road accident scene without checking that the injured are being attended to medically.[7] Prior to the present Constitution, it was suggested that in determining whether or not a doctor ought to have rendered assistance in emergency situations, the courts should take into account, inter alia, the following: (i) the doctor’s actual knowledge of the patient’s condition; (ii) the seriousness of the patient’s condition; (iii) the professional ability of the doctor to do what is asked; (iv) the physical state of the doctor (e.g. the doctor may be physically exhausted); (v) the availability of other doctors, nurses or paramedics; and (vi) considerations of professional ethics’.[5] To these must now be added the provision in the Constitution stating that nobody may be refused emergency medical treatment.[9] The above factors apply generally to emergency situations where doctors are requested to assist, and it is submitted can apply equally to situations where doctors come across road accidents.

What standard of care is expected of doctors who render assistance at road accidents?

The Health Professions Council of South Africa’s rules of professional conduct state that except in emergencies, practitioners shall only

perform professional acts for which they are ‘adequately educated, trained and sufficiently experienced’ and ‘under proper conditions and in appropriate surroundings’.[12] Road accidents clearly give rise to emergencies in which doctors are not able to work ‘under proper conditions’ and ‘in appropriate surroundings’. In emergency situations, the courts will judge the doctor’s conduct by how a reasonably competent practitioner faced with similar situation would have acted. In cases of emergencies the same degree of care and skill that is used in a hospital situation may not be required, depending on the circumstances.[13] For instance, the English courts have observed that ‘[a]n emergency may overburden resources, and, if an individual is forced by circumstances to do too many things at once, the fact that he does one of them incorrectly should not lightly be taken as negligence’.[14] It is likely that the SA courts would adopt a similar approach.

When are doctors not legally required to render assistance at road accidents?

The list is not exhaustive, but doctors are not legally required to render assistance at road accidents, for example, when there is a threat to the doctor’s personal safety, the doctor is mentally or physically incapable of rendering assistance, or other medical or paramedical practitioners are already at the scene of the accident. Even then doctors may not always simply drive past and do nothing – it depends on the particular circumstances.

Threat to the doctor’s safety

The threat to the doctor’s safety must be real rather than apparent, for example a hostile crowd of onlookers or a place notorious for car hijacking. Even in such circumstances the doctor must do something if no medical assistance is present at the scene. He or she may not simply drive past. The doctor should call the police and advise them to send protection and call for urgent ambulance assistance. The doctor should remain near the scene in a safe place until the police arrive. After the arrival of the police, if an ambulance is not yet on the scene, the doctor should assist to stabilise patients until the emergency services arrive to take over. Even though the doctor does not have a trauma kit available, he or she should render basic first aid personally and if necessary direct the police or onlookers on how to assist using triage. Once an ambulance arrives, the doctor should check that paramedics are able to stabilise the injured before departing.

Doctor mentally or physically incapable of rendering assistance

Doctors may not be in a fit state to assist injured persons at accident scenes if they are mentally or physically incapable of rendering assistance, for example if intoxicated or physically exhausted while being driven in a third party’s vehicle. In such situations – provided the doctors are mentally capable of making such requests – they should ask the persons accompanying them to call the police. If doctors are not mentally capable of making such requests, they cannot be held legally liable for failing to act.

Other medical or paramedical practitioners present

Where other medical or paramedical practitioners are at the road accident scene, it is not necessary for doctors to stop and render assistance, depending on the circumstances. If, for example, it appears that the emergency services are coping with the situation, it is not necessary to stop. If it is clear that large numbers of injured people are involved and the attending practitioners may be overwhelmed, doctors should stop and inquire whether the victims need assistance.

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Conclusions

Generally, doctors who are the first to come across injured people at a road accident should stop and render assistance unless they may be exposed to personal danger or injury if they stop, are mentally or physically incapable of rendering assistance, or other medical or paramedical practitioners are already present. Where there is the threat of personal danger to the doctors they must immediately report the accident to the police and advise them to send protection and call for urgent ambulance assistance. They should remain near the scene until the police and ambulance arrive and check that paramedics are available to stabilise the injured before departing. Where there is the threat of danger, doctors are mentally or physically unable to assist or other medical or paramedical practitioners are at the scene, doctors may or may not be required to stop â&#x20AC;&#x201C; depending on the circumstances.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Boumil MM, Elias CE. The Law of Medical Liability. St. Paul, Minn.: West Publishing Co, 1995:146-151. Minister van Polisie v Ewels 1975 3 SA 590 (A). Neethling J, Potgieter JM, Visser PJ. Law of Delict. 4th ed. Durban: Butterworths, 2001:69,73. Cf. S v Makwanyane 1995 (3) SA 391 (CC). Strauss SA. Doctor, Patient and the Law. 4th ed. Pretoria: JL van Schaik, 1991:25. McQuoid-Mason DJ. The medical profession and medical practice. In: Joubert WA, Faris JA, eds. The Law of South Africa. 2nd ed. Durban: LexisNexis, 2008:para 30. Medical Board of Australia v Dekker [2013] WASAT 182. http://www.austli.edu.au/au/cases/wa/ WASAT/2013/182.html (accessed 30 December 2015). Jackson E. Medical Law: Text, Cases and Materials. 2nd ed. Oxford: Oxford University Press, 2010:126. Section 27(3) of the Constitution of the Republic of South Africa, 1996. Section 5 of the National Health Act No. 61 of 2003. Soobramoney v Minister of Health, KwaZulu-Natal 1998 1 SA 765 (CC). 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: rule 21. McQuoid-Mason DJ. The medical profession and medical practice. In: Joubert WA, Faris JA, eds. The Law of South Africa. 2nd ed. Durban: LexisNexis, 2008:para 44. Wilsher v Essex Area Health Authority [1987] 1 QB 730.

Accepted 14 January 2016.

MEDICINE AND THE LAW

This open-access article is distributed under CC-BY-NC 4.0.

Managing the remains of fetuses and abandoned infants: A call to urgently review South African law and medicolegal practice

L du Toit-Prinsloo,1 MB ChB, DipForMed (SA) Path, FCForPath (SA), MMed (Path) (Forens); C Pickles,2 LLB, LLM, LLD; G Saayman,1 MB ChB, MMed (Med Forens), FCForPath (SA) 1 2

Department of Forensic Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa South African Institute for Advanced Constitutional, Public, Human Rights and International Law, University of Johannesburg, South Africa

Corresponding author: L du Toit-Prinsloo (lorraine.dutoit@up.ac.za)

This article reviews South African (SA) law and its impact on the medicolegal management of fetal remains emanating from elective and therapeutic termination of pregnancies, stillbirths and miscarriages and the remains of abandoned or exposed infants. It was found that remains are treated differently, some constituting medical waste while others have sufficient status in law to allow for burial. This approach results in some women or couples being denied a choice with regard to disposal via culturally relevant practices, and is insensitive to the fact that all remains ultimately constitute human remains. The article argues that SA law is in urgent need of reform, and turns to foreign law and forensic practice to shed light on possible alternative approaches that could assist with developing the SA position and thereby improve the practical management of fetal and infant remains in SA. S Afr Med J 2016;106(6):578-581. DOI:10.7196/SAMJ.2016.v106i6.10347

Current South African (SA) legislation and common law principles leave many questions pertaining to the management of fetuses and infants in clinical and forensic pathology practice. The application of different legislation to different areas of medical practice results in different status being assigned to fetal and/or infant remains. Some women or couples are denied a choice with regard to disposal of fetal remains via culturally relevant practices such as burial or cremation. Current legislation also compromises effective investigation into problematic areas such as the illegal disposal of fetal remains or infants by members of the public. This article considers the SA law relevant to fetal and infant remains and reveals a number of inconsistencies and concerns. It then turns to foreign law and forensic practice to inform possible changes to the SA position with the aim of improving the practical management of fetal and infant remains in SA.

Legislation pertaining to the management of fetal remains in SA

In SA, the fetus is not vested with any constitutional rights and is primarily viewed as being part of the body of a pregnant woman.[1] This position is accepted by the authors. However, the authors assert that legislative provisions relating to the management of fetal and infant remains should be clear and consistent, providing appropriate guidance for all reasonably foreseeable outcomes. Legislative provisions should specifically also cater for the subjective need for respectful and sensitive management of all forms of human remains, including those of fetuses and abandoned infants. It is not possible to accommodate this stance in practice because of the approach currently adopted by the law.

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Choice on Termination of Pregnancy Act 92 of 1996[2]

The Choice on Termination of Pregnancy Act[2] (Choice Act) is primarily concerned with ensuring access to safe termination of pregnancy (TOP) services and the regulation of the provision of these services. Section 1 of the Act defines a TOP as ‘the separation and expulsion, by medical or surgical means, of the contents of the uterus of a pregnant woman’. The term ‘contents’ is not defined, and it can be taken to broadly include fetal matter, placenta, and any other tissue and blood material removed from a woman’s uterus. Once removed, section 3(1)(i) of the Choice Act requires that the products of conception must be managed, but aside from requiring facilities to have ‘access to safe waste disposal infrastructure’ the Act and regulations do not deal with this issue. The Act does not define ‘waste’ or ‘disposal’. According to regulation 2(xxxv) of the Gauteng Health Care Waste Management Regulations,[3] in terms of the Environment Conservation Act 73 of 1989,[4] the definition of ‘pathological waste’ includes ‘human fetuses’. Consequently, all fetal remains derived from TOP are afforded the status of medical waste and are disposed of in such a manner as to not pose a risk to public health. This position presumes that all fetal remains stemming from TOP procedures are equally of no value, and all are accorded the status of pathological waste without any meaningful consideration of parties involved (including the mother/father). The presumption stands regardless of whether the TOP is an elective or therapeutic procedure, or whether the pregnancy is viable or non-viable. This hampers the development of alternative methods of disposal and denies choice with regard to disposal methods. The fact is that even pregnancies that are deliberately terminated can be considered a loss by women or couples.[5] The current approach is devoid of respect and sensitivity.

Births and Deaths Registration Act 51 of 1992[6]

Miscarriages and stillbirths are both serious complications of pregnancy that result in loss of the pregnancy and produce fetal remains. The dividing line between miscarriage and stillbirth pivots on the viability or ability to survive of a fetus. Dorland’s Medical Dictionary defines a miscarriage as ‘a popular term for spontaneous abortion’, spontaneous abortion as ‘abortion occurring naturally; popularly known as miscarriage’, and stillbirth as ‘the delivery of a dead child’.[7-9] Many countries have legislation pertaining to the registration of stillbirths, with a specified gestational age attached to the definition. However, the conceptualisation of fetal viability in law is problematic, since the term generally fails to capture the essence of what viability means in a clinical setting. This failure relates to the fact that the law primarily relies on gestational age as an indicator of the ability to survive, while research indicates that viability is context sensitive, making the consideration of gestational age inconclusive when considered in isolation.[10] In SA, the Births and Deaths Registration Act[6] regulates the registration of births and deaths. Section 1 of the Act also defines ‘burial’ as ‘burial in the earth or the cremation or any other mode of disposal of a corpse’. This legislation is also applicable to the management of fetal remains emanating from a stillbirth or miscarriage, as it specifies what remains qualify for registration of ‘deaths’ and later burial, but uses gestational age alone as an indicator of whether one is dealing with a stillbirth or miscarriage. The provisions relevant to the registration of deaths relate to ‘persons’ and those who are ‘stillborn’, indicating that the option of burial is limited to a particular ‘person’ or ‘stillborn child’. ‘Person’ is not defined in the Act, but in SA, the legal concept of person

does not include the unborn.[11] Furthermore, section 1 of the Act narrowly defines ‘stillbirth’ or ‘stillborn’ as involving a ‘child’ that ‘has had at least 26 weeks of intra-uterine existence but showed no sign of life after birth’. Consequently, not all fetal remains originating from pregnancy complications can be buried. Should a pregnancy of less than 26 weeks’ gestation come to an end, the fetal remains will be assigned the status of pathological waste. This Act[6] treats fetal remains emanating from pregnancy complications differently to remains emanating from TOP, especially TOP at a later gestational age (see the example below). The differentiation in status and resulting implications with regard to disposal methods cannot be justified and are insensitive to the position of individuals who experience these situations. The differences in legal status assigned to a stillborn fetus in terms of the Choice Act[2] and the Births and Deaths Registration Act[6] can be illustrated by the following example. If a woman is 32 weeks pregnant and a stillborn fetus is born, the parents will be issued with a death notification form in terms of the Births and Deaths Registration Act[6] and can bury or cremate the fetus. If the same woman is informed that continuation of her 32-week pregnancy will result in a severely abnormal infant, and she decides to terminate the pregnancy in terms of the Choice Act,[2] the stillborn fetus has to be treated as pathological waste. ‘Viability’ is not defined by SA legislation, but in case law. S v Mshumpa[11] accepted that a fetus is capable of independent survival at 25 weeks’ gestation. However, in S v Molefe[12] the court ruled that fetal viability occurred at 28 weeks’ gestation for purposes of the crime of concealment of birth. The court came to this conclusion without taking into consideration any expert medical evidence, relying on outdated case law from Zimbabwe and Venda. The distinction imposed by the Births and Deaths Registration Act[6] is not only founded on an ill-established legal premise of viability, but it is used as the basis to determine the status of fetal remains and whether the family has the right to bury those remains.

Medicolegal management of remains emanating from abandoned fetuses or infants

This part of the article considers the general social disregard of fetal or infant remains more broadly and takes its cue from the poor management of fetal remains in the realms of the criminal justice system. Here, the management of fetal or infant remains involves cases in which they are ‘inappropriately’ disposed of in places not approved of by current legislation and regulations, such as in public toilets, dumps, dustbins or fields or alongside pathways.[13,14] These remains generally originate from unlawful TOP, concealed births or abandoned infants who have died from exposure. Section 113 of the General Law Amendment Act 46 of 1935[15] criminalises concealment of birth. It provides that a person commits this offence if he or she disposes of a body of a newly born child without a lawful burial order, and does so with the intention of concealing its birth. The offence stands regardless of whether the child was born alive or died before, during or after birth. The Act does not define ‘child’. However, S v Molefe[12] provides that ‘child’ refers to a fetus that has reached at least 28 weeks’ gestation. One will therefore not commit this crime if one’s conduct involves a fetus of less than 28 weeks’ gestation. The common-law crime of ‘exposing’ an infant is the unlawful and intentional exposure and abandonment of a liveborn infant in circumstances that are likely to lead to its death.[16] Prosecutions are rare, and if prosecution is pursued, individuals are usually charged with murder.[16] However, the crime of murder can only be committed against

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a ‘person’, i.e. one who is born alive.[11] According to section 239(1) of the Criminal Procedure Act 51 of 1977,[17] breathing is sufficient evidence of live birth for purposes of criminal prosecution. The discovery of discarded fetal or infant remains clearly requires investigation into a number of issues before a criminal charge can be anticipated. When such fetal material or deceased infants are found, the South African Police Service and the Forensic Pathology Service are contacted and the case is usually investigated under the Inquests Act 58 of 1959.[18] An inquest docket is opened and a medicolegal postmortem examination is conducted to establish gestational age, whether the fetus had lived outside the mother, and the cause of death or stillbirth.[19] Since the crimes of murder or exposure are only applicable to those who are born alive, only viable or sufficiently developed fetuses, who were able to breathe, would constitute the subject of a criminal investigation. However, in respect of all possible criminal offences (concealment of birth, exposure or murder), postmortem examination of remains can be very challenging and even rendered fruitless as a result of decomposition, postmortem trauma or predation.[19,20] A criminal charge may not follow simply because essential forensic evidence could not be objectively established. This discussion demonstrates that not all abandoned remains receive adequate attention in law, despite the fact that all constitute human remains. The dividing line rests on the notion of viability or ability to survive and sufficient evidence thereof. While criminal law provisions and regulatory frameworks appear to provide reasonably clear directions, their application can therefore be difficult in a practical setting. When the required essential characteristics of the remains cannot be established, no legal consequences ensue and perpetrators are not held accountable. It is not unusual practice for fetal remains (or products of conception) that have undergone medicolegal examination to be disposed of as human waste or incinerated. This implies that the remains are worthless. This conclusion is supported by the fact that not all discovered remains are recorded, and statistics relating to the inappropriate disposal of fetal and infant remains are not readily available. According to Jacobs et al.,[21] ‘no research was found that specifically investigates the phenomenon of dumping babies and fetuses’. Discussions on improving criminal/statutory provisions and social support systems cannot be meaningfully engaged in as long as fetal and infant remains are deemed pathological waste. The current legal situation results in acts of abandonment remaining invisible and unaddressed. The extent of abandonment, factors facilitating that behaviour and the underlying social reasons are likely to remain unknown. Accordingly, effective regulatory or criminal law provisions will not be developed and meaningful social reform will not take place. Overall, fetal remains hold an unfortunate position in SA, and the reason for this is not clear. There is no legislation or directives indicating what should be done with fetal remains in practice. The management and method of disposal of the remains should not cause offence, and should advance dignity without compromising the health of the public.

Alternative positions on the management of fetal remains emanating from obstetric practice

There are approaches that can be adopted to develop a sensitive position regarding the management of fetal remains emanating from obstetric practice. These approaches may be policy based or statute based. Each provides various options for methods of disposal, but also provides decisional space that allows for individualised choices.

The UK adopts a policy-based approach. Methods of disposal of fetal remains were contemplated in the Polkinghorne report.[22] This report proposed that ‘on the basis of its potential to develop into a human being, a fetus is entitled to respect, according it a status broadly comparable to that of a living person’.[22] The report questioned the ethical validity of treating pre-viable and viable fetuses differently. Debates concerning the disposal of fetal remains followed, with subsequent formulation of policies and guidelines. One of the issues arising from these debates was the fact that only stillborn infants could be buried, ‘stillborn infant’ being defined as a fetus of at least 24 weeks’ gestation, born without showing any signs of life.[23] Any loss of pregnancy before 24 weeks could not be registered as a death, and no burial of the remains was possible. [24] The Human Tissue Authority’s[25] best practice guidelines on the storage and disposal of human organs and tissues now encourages respectful disposal of remains emanating from a pregnancy loss before 24 weeks’ gestation: ‘pregnancy loss should always be handled sensitively. The needs of the woman or couple should be paramount and disposal policies should reflect this.’[25] Issues surrounding viability, pre-viability, or distinguishing between TOP or various pregnancy complications are therefore no longer relevant for the purposes of sensitive disposal of fetal remains. Even though the Human Tissue Authority’s[25] code of practice is not law, it has been well received. The Cardiff and Vale University Health Board’s Policy for the Management of Fetal Remains, Stillbirth and Neonatal Death[26] states that ‘women/couples should have choices, regardless of pregnancy gestation and it acknowledges that the death of a baby for some individuals, irrelevant of gestation can be as significant as any bereavement ... staff will ensure that care meets personal, cultural, spiritual, religious and holistic individual requirements’. The Royal College of Nursing acknowledges that ‘sometimes parents don’t recognise their loss at the time, but may return months or even years later to enquire about the disposal arrangements. Therefore it is important to respect the wishes of parents who may not want to be involved, but to ensure that sensitive and dignified disposal is carried out.’[27] Common to all guidelines is the need to dispose of fetal remains sensitively and that disposal should be governed primarily by the wishes of those affected. The guidelines assert that remains should not be categorised as ‘medical waste’, regardless of how the remains came to be. All directives merely constitute guides, and different institutions or organisations in the healthcare sector each still draft their own guidelines, resulting in inconsistencies between different guidelines and implementation more generally.[28] Furthermore, since guidelines serve as guides only, their authority and weight beyond the clinical setting are limited and they therefore cannot be imposed on those institutions or medical personnel functioning under other legal instruments such as burial and cremation laws. When burial or cremation laws are not aligned with the various health sectors’ guidelines, the intention to dispose of fetal remains sensitively may therefore be frustrated. In fact, the authority and weight of guidelines is even questionable in clinical settings, since reports have recently emerged that fetal remains emanating from TOP procedures were being used to ‘heat UK hospitals’ and that patients were not consulted about what would happen to the remains of their fetuses.[29] The Canadian province of Alberta takes a different approach, adopting a statute-based system that secures respectful and sensitive management of fetal remains. According to the Vital Statistics Act 2007,[30] every birth must be registered. The term ‘birth’ is not limited to specific gestational age; instead, any sign of life after complete expulsion or extraction will suffice. A stillbirth is defined as the complete expulsion or extraction, after at least 20 weeks’ gestation

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or the attainment of at least 500 g, of a fetus that shows no signs of life when delivered. All stillbirths must be registered, but registration takes place as if there has been a birth followed by a death. The death of a person must be registered, and upon receipt of the death registration document, a burial permit must be issued. No person may dispose of a body without such a permit.[30] While there seems to be a gap in respect of burial options for dead pre-viable fetuses, the Alberta Cemeteries Act RSA 2000 CC-3[31] offers support in this regard. The Act authorises the development of regulations that allow for ‘the disposal of fetuses and the bodies of newborn infants who have died, subject in each case to the parents’ or guardians’ request, and defining a newborn infant for the purposes of the regulations’.[31] Regulation 8 of the General Regulation 249/1998[32] provides that in the case of death of a fetus, the remains need not be disposed of in accordance with the burial requirements specified for a deceased human body, but it specifies that the manner of disposal is subject to the ‘parents’ or guardian’s’ request. It further specifies that disposal must not cause public offence. In the case of death of a fetus or newborn infant in a hospital, the hospital may dispose of the remains, but the manner of disposal is subject to the parents’ or guardian’s request and such disposal may not cause public offence.[32] No distinction is made between remains emanating from elective or therapeutic TOP, or those resulting from pregnancy complications.[32,33]

Alternative positions regarding forensic (medicolegal) management of the remains of abandoned fetuses and infants

A review of practices in the medicolegal management of the remains of abandoned fetuses and infants proved difficult, to the extent that no clear alternatives for managing these cases have been defined. There are troublesome gaps in the available data. The World Health Organization has indicated that globally an estimated 20 million pregnancies are unsafely terminated each year.[34] While it is accepted that the products of illegally performed early TOPs may not be recognisable and are therefore easily disposed of, there must be laterterm TOPs that do not result in viable births but produce remains that are more difficult to dispose of because of their recognisability and size. From a medicolegal perspective, there are few or no data concerning the finding and management of remains emanating from these practices. Finally, in many countries there is a seemingly endless record of cases of neonaticide and infanticide. Schulte et al.[35] reported that in Germany there were 150 cases of suspected neonaticide from 1993 to 2007, with 45% remaining unsolved. Herman-Giddens et al.,[36] writing on experiences from North Carolina, USA, stated that ‘at least 201 per 100 000 newborns are known to be killed or left to die per year’, and although they did not review the outcomes of all the cases prosecuted, the sentences varied from none to 25 years’ imprisonment. No research is available on the outcomes of such cases in SA.

Conclusions

SA urgently needs to review the current legislation pertaining to the management of the remains of abandoned fetuses and infants, TOPs and miscarriages. Law reform will allow for improved, sensitive clinical practice. In the context of clinical management, these changes should strive to allocate the same status to all remains, regardless of how the pregnancies ended. Development in this area should provide people with the opportunity to bury remains appropriately regardless of the gestational age, since it is well known that this assists the

grieving process. It should be emphasised that this option should be permissive in nature, rather than an obligation to dispose of a fetus in a culturally relevant way. Where no choice is exercised, disposal should nevertheless be sensitive and respectful. There appear to be wide variations in reported incidences of abandoned fetuses and infants. Sadly, this is a glaring global concern. Clear frameworks and informative legal guidelines are needed, specifically with regard to medicolegal investigation protocols when handling the remains of abandoned fetuses and infants. Protocols should demonstrate and inculcate respect for fetuses or infants, since these remains are human in nature, and this should stand regardless of whether prosecution is possible or not. This approach will also assist in developing much-needed statistics on the prevalence of illegal TOP and abandonment of infants. Although all fetal remains are similar, especially in the medicolegal environment, why are they treated so differently? 1. Pickles C. Approaches to pregnancy under the law: A relational response to the current South African position and recent academic trends. De Jure 2014;47(1):20-41. 2. Republic of South Africa. Choice on Termination of Pregnancy Act 92 of 1996. Government Gazette, 1996. http://www.gov.za/documents/choice-termination-pregnancy-amendment-act (accessed 7 March 2016). 3. Gauteng Health Care Waste Management Regulations. www.validus.co.za/ValidusImages/ HCW13DEC11.pdf (accessed 17 June 2015). 4. Republic of South Africa. Environment Conservation Act 73 of 1989. Government Gazette, 1989. http://www.acts.co.za/environment-conservation-act-1989/ (accessed 7 March 2016). 5. Meyers AJ, Lohr PA, Pfeffer N. Disposal of foetal tissue following elective abortion: What women think. J Fam Plann Reprod Health Care 2015;41(2):84-89. DOI:10.1136/jfprhc-2013-100849 6. Republic of South Africa. Births and Deaths Registration Act 51 of 1992. Government Gazette, 1992. www.gov.za/sites/www.gov.za/files/a51_1992.pdf (accessed 7 March 2016). 7. Dorland’s Illustrated Medical Dictionary. 31st ed. Philadelphia: Saunders Elsevier, 2007:1186. 8. Dorland’s Illustrated Medical Dictionary. 31st ed. Philadelphia: Saunders Elsevier, 2007:5. 9. Dorland’s Illustrated Medical Dictionary. 31st ed. Philadelphia: Saunders Elsevier, 2007:1179. 10. Pickles C. Personhood: Proving the significance of the born-alive rule with reference to medical knowledge of foetal viability. Stellenbosch Law Review 2013;24(1):146-164. 11. S v Mshumpa 2008 1 SACR 126 (E). 12. S v Molefe 2012 (2) SACR 574 (GNP) at 578. 13. Jooste B. Cape’s dumped baby shame. IOL News, 16 August 2010. http://www.iol.co.za/news/southafrica/cape-s-dumped-baby-shame-1.673089 (accessed 15 March 2015). 14. Child K, Hosken G. Born to be dumped. Times Live, 28 May 2012. http://www.timeslive.co.za/ local/2012/05/29/born-to-be-dumped (accessed 15 March 2015). 15. General Law Amendment Act 46 of 1935. http://www.gov.za/documents/general-law-amendmentact-14-may-1935-0000 (accessed 6 May 2016). 16. Snyman CR. Criminal Law. Durban: LexisNexis Butterworths, 2008:428-429. 17. Criminal Procedure Act 51 of 1977. www.justice.gov.za/legislation/acts/1977-051.pdf (accessed 6 May 2016). 18. Inquests Act 58 of 1959. www.justice.gov.za/legislation/acts/1959-58.pdf (accessed 6 May 2016). 19. Knight B, Saukko P. Knight’s Forensic Pathology. 3rd ed. New York: Oxford University Press, 2004:439-450. 20. Byard RW. Sudden Death in the Young. 3rd ed. New York: Cambridge University Press, 2010:539-547. 21. Jacobs R, Hornsby N, Marais S. Unwanted pregnancies in Gauteng and Mpumalanga provinces, South Africa: Examining mortality data on dumped aborted fetuses and babies. S Afr Med J 2014;104(12):864-869. DOI:10.7196/SAMJ.8504 22. Polkinghorne J. Review of the Guidance on the Research Use of Fetuses and Fetal Material. London: Her Majesty’s Stationery Office, 1989. 23. Births and Deaths Registration Act 1953. http://www.legislation.gov.uk/ukpga/Eliz2/1-2/20/contents (accessed 22 June 2015). 24. Forster R. Disposal of remains of fetus of under 24 weeks’ gestation. BMJ 2003;326(7384):338. DOI:10.1136/bmj.326.7384.338/b 25. Human Tissue Authority. https://www.hta.gov.uk/policies/hta-guidance-sensitive-handling-pregnancyremains (accessed 6 May 2016). 26. Cardiff and Vale University Health Board. Policy for Management of Fetal Remains, Stillbirth and Neonatal Death. 2013. http://www.cardiffandvaleuhb.wales.nhs.uk/opendoc/238496 (accessed 26 August 2015). 27. Royal College of Nursing. RCN Gynaecology Nursing Forum Working Group. Sensitive Disposal of all Foetal Remains: Guidance for Nurses and Midwives. London: Royal College of Nursing, 2007. https:// www2.rcn.org.uk/__data/assets/pdf_file/0020/78500/001248.pdf (accessed 6 May 2016). 28. Cameron M, Penney G. Are national recommendations regarding examination and disposal of products of miscarriage being followed? A need for revised guidelines? Hum Reprod 2005;20(2):531535. DOI:10.1093/humrep/deh617 29. Knapton S. Aborted babies incinerated to heat UK hospitals. The Telegraph, 24 March 2014. http:// www.telegraph.co.uk/news/health/news/10717566/Aborted-babies-incinerated-to-heat-UKhospitals.html (accessed 11 February 2015). 30. Vital Statistics Act 2007. www.qp.alberta.ca/documents/Acts/V04P1.pdf (accessed 6 May 2016). 31. Province of Alberta. Alberta Cemeteries Act RSA 2000 CC-3. www.qp.alberta.ca/documents/Acts/ C03.pdf (accessed 26 August 2015). 32. Province of Alberta. General Regulation 249/1998. www.qp.alberta.ca/documents/Regs/1998_249.pdf (accessed 17 June 2015). 33. Alberta Health Services. Caring for the remains of your miscarriage. http://www.albertahealthservices. ca/services/Page3814.aspx (accessed 15 March 2015). 34. World Health Organization. Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008. 6th ed. Geneva: WHO, 2008. 35. Schulte B, Rothschild MA, Vennemann M, Banaschak S. Examination of (suspected) neonaticides in Germany: A critical report on a comparative study. Int J Legal Med 2013;127:621-625. DOI: 10.1007/ s00414-013-0841-8 36. Herman-Giddens PA, Smith JB, Mittal M, Butts JD. Newborns killed or left to die by a parent: A population-based study. JAMA 2003;289(11):1425-1429. DOI:10.1001/jama.289.11.1425

Accepted 7 February 2016.

November 2016, Print edition

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

IN PRACTICE

CASE REPORT

A report of three patients in whom the surgical closure of terminal branches of the external carotid arteries for treatment of migraine resulted in significantly reduced frequency of epileptic attacks E Shevel, BDS, Dip MFOS, MB BCh The Headache Clinic and Specialist Migraine Centre, Johannesburg, South Africa Corresponding author: E Shevel (drshevel@headclin.com)

Three patients under treatment for grand mal epilepsy, and who were also suffering from chronic migraine, underwent vascular surgery for their migraine. A serendipitous benefit from the successful vascular surgery for migraine was a significant reduction in the frequency of their grand mal seizures. S Afr Med J 2016;106(11):1084-1085. DOI:10.7196/SAMJ.2016.v106i11.10866

This is the first report of a reduction in the frequency of grand mal attacks in patients who underwent surgical cauterisation of terminal branches of the external carotid artery to treat their migraine headaches.[1] An unexpected consequence of the surgery was that all three patients experienced not only a dramatic reduction of their migraines, but also a significant reduction in the number of epileptic attacks. All three patients were under treatment for epilepsy at the time. The treatment of choice at The Headache Clinic in Johannesburg for intractable migraine where the pain has been positively diagnosed to originate in the terminal branches of the external carotid artery is permanent surgical closure of the relevant vessels.[1] Three patients diagnosed with migraine pain originating in the dilated terminal branches of the external carotid arteries, and who were also under treatment for grand mal epilepsy, underwent surgical cauterisation of the relevant vessels. All three reported that following the surgery, not only did they no longer suffer from previously refractory migraine, but that there had also been an immediate and dramatic reduction in the number of seizures that they experienced.

Case reports and results Case 1

A 28-year-old woman presented in May 2011 with refractory chronic migraine that had started approximately 5 years earlier. She had also been under treatment for grand mal epilepsy for the previous 15Â years. Her epilepsy was currently being treated at the neurology unit of a local hospital. Brain imaging showed no intracranial mass lesions. Her current medication was carbamazepine controlled release 400 mg qid and lamotrigine 50 mg bd, but she continued to experience an average of one grand mal seizure per day. The seizures were at times, but not always, triggered when she suffered a particularly severe migraine attack. The migraine pain was diagnosed as originating in the painfully dilated terminal branches of the external carotid artery. Consequently, the superficial temporal, frontal and occipital arteries bilaterally were surgically cauterised. The first surgical intervention was carried out on 9 May 2011, when the frontal arteries were cauterised. As the patient continued

to experience headache pain, further surgery was carried out. On 31Â May 2011, the superficial temporal and occipital arteries bilaterally were cauterised. She reported thereafter that she no longer suffered from headache pain. At follow-up on 9 February 2012, she reported that since the surgical intervention on 31 May 2011 she had not suffered a single seizure despite reducing her intake of carbamazepine to 200 mg bd and lamotrigine to 50 mg bd. As of 3 December 2015, 4 years later, she has remained free of seizures.

Case 2

A 32-year-old man presented in October 2012 with refractory chronic migraine that had started some time in his teens. He was also under treatment by a neurologist for grand mal epilepsy, which had started after surgery in 2000 for removal of an arachnoid cyst. On several occasions after the surgery he had had lumbar punctures and adjustments to his ventriculoperitoneal shunt, none of which had ever indicated increased intracranial pressure. He was on topiramate 75 mg bd, clonazepam 1 mg bd, sodium valproate 1 200Â mg bd, carbamazepine 400 mg bd and escitalopram 20 mg daily. On this regimen he was experiencing an average of one seizure a week. Immediately following surgical cauterisation of the superficial temporal and occipital arteries bilaterally in October 2012, his seizures stopped. By the end of 2015, 3 years later, he had experienced no further seizures. His medication regimen remained the same.

Case 3

A 54-year-old woman presented in October 2014 with refractory chronic migraine, which had proved refractory to medication. The pain was bilateral, parietal and occipital, and also affected the vertex. When it was severe, it was accompanied by dizziness, nausea, photophobia, phonophobia and blurred vision. She was also under treatment by a neurologist for grand mal epilepsy, which had started 5 years previously. Her epilepsy medication consisted of sodium valproate controlled release, 500 mg in the morning and 1 000 mg at night, and levetiracepam 500 mg bd. Her epilepsy was poorly controlled on this regimen and she was experiencing an average of 10 seizures a day. Following surgical cauterisation of the superficial

November 2016, Print edition

IN PRACTICE

temporal and occipital arteries bilaterally, the frequency of her seizures dropped to three per week. At follow-up on 7 September 2015, she reported that she was still experiencing an average of three seizures per week. Her medication regimen remained unchanged.

Discussion

The internal carotid artery is unique in that a large outflow tract, the external carotid artery, is situated just at its origin. This disposition renders flow in the internal carotid dependent to a certain extent on flow characteristics of the external carotid arterial bed.[2] It is possible that by reducing the blood flow to the extracranial tissues, there may be a resultant increase in blood flow to the intracranial tissues, due to shunting from the cauterised terminal branches of the external carotid to the internal carotid. This hypothesis is supported by the literature. Bearing in mind that the results of animal studies cannot always be reliably extrapolated to humans, the reactivity of the neural vasculature in dogs is subordinate to that of the extraneural vasculature.[3] In the

Asian monkey, there is a similar phenomenon, in that internal carotid blood flow is determined to a certain extent by the tonus in the external carotid tree.[4] Of greater relevance though, is that bilateral external carotid ligations in both man and monkey have been shown to result in an increase in flow through the internal carotid arteries.[2] The results presented in this article suggest that this surgery carried out in migraineurs with extracranial vascular pain may also be of benefit in some cases of epilepsy. 1. Shevel E. Vascular surgery for chronic migraine. Therapy 2007;4(4):451-456. DOI:10.2217/14750708.4.4.451 2. Abraham J, Shetty G, Chandy J. Preliminary observation on the hemodynamics of the internal carotid artery following bilateral external carotid ligation in the monkey. J Neurosurg 1971;35(2):192-196. DOI:10.3171/jns.1971.35.2.0192 3. Abraham J, Margolis G, O’Loughlin JC, MacCarty WC, Jr. Differential reactivity of neural and extra-neural vasculature. I. Role in the pathogenesis of spinal cord damage from contrast media in experimental aortography. J Neurosurg 1966;25(3):257-269. DOI:10.3171/jns.1966.25.3.0257 4. Chandra R, Abraham J. Modification of neurotoxicity of methylglucamine diatrizoate (hypaque 75 per cent) by intra-arterial instillation of vasoactive drugs. Indian J Med Res 1969;57(7):1316-1324.

Accepted 19 July 2016.

CASE REPORT This open-access article is distributed under CC-BY-NC 4.0.

Polyarteritis nodosa presenting as a bladder outlet obstruction

M Borkum,1 MB ChB, FCP (SA), MMed; H Y Abdelrahman,2 MSc, MRCP, MRCP (Rheum), Cert Rheum (SA); R Roberts,3 MB ChB, MMed, FCPath (SA) Anat; A A Kalla,2 MB ChB, PhD; I G Okpechi,1 FWACP, PhD, Cert Nephrol (SA) Phys Division of Nephrology and Hypertension, Faculty of Health Sciences, University of Cape Town, South Africa Division of Rheumatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 3 Division of Anatomical Pathology, Faculty of Health Sciences, University of Cape Town; and National Health Laboratory Service, Cape Town, South Africa 1 2

Corresponding author: M Borkum (mborkum@gmail.com) Polyarteritis nodosa (PAN) of the urinary tract is rare. An unusual case of systemic PAN involving the bladder neck is described. A 27-year-old man, with known diastolic hypertension diagnosed 2 years earlier, was admitted with chronic urinary obstruction complicated by hydronephrosis. He had symptoms of myalgia and weight loss, was afebrile but had an elevated erythrocyte sedimentation rate and acute-on-chronic renal impairment. All virological and serological tests including hepatitis B and anti-neutrophil cytoplasmic antibody were negative. A computed tomography scan of the brain revealed small-vessel disease. A bladder neck mass was visualised on cystoscopy. Histological examination of this demonstrated a medium-sized necrotising vasculitis with small-vessel fibrinoid necrosis suggestive of PAN. At least six of the American College of Rheumatology criteria for PAN were met. The patient was treated with pulses of intravenous cyclophosphamide and oral corticosteroids with a good clinical response. S Afr Med J 2016;106(11):1086-1087. DOI:10.7196/SAMJ.2016.v106i11.11083

Polyarteritis nodosa (PAN) was first described by Kussmaul and Maier[1] in 1866. The annual incidence is <1/million/year, while an incidence of 77/million/year has been recorded in hepatitis B virus (HBV)-endemic areas, with a male/female ratio of 2 - 3:1. [2] The Chapel Hill Consensus Conference in 1994 defined PAN as ‘necrotizing inflammation of medium sized or small arteries without glomerulonephritis or vasculitis in arterioles, capillaries or venules’. [3] PAN can be primary or secondary to viral infection (e.g.

HBV).[4] Antineutrophil cytoplasmic antibody (ANCA) testing is usually negative, which essentially differentiates it from microscopic polyangiitis.[4] The disease often presents with vague and nonspecific signs and symptoms such as: myalgia, arthralgia, fever, headaches, neuropathy and features of chronic kidney disease, and can manifest with symptoms of transient ischaemic attacks.[3] If left untreated, PAN is usually fatal as a result of progressive renal failure or gastrointestinal complications.[3]

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IN PRACTICE

The urological manifestations of PAN documented in the literature include ureteric stenosis and orchitis.[5,6] We present a case of systemic PAN involving the bladder in a man presenting with a bladder outlet obstruction due to a mass.

Case report

A 27-year-old man was admitted to a urology ward with chronic urinary obstruction and hydronephrosis diagnosed on an ultrasound scan. This was accompanied by severe myalgia, loss of weight (approximately 10 kg over 6 months) and suprapubic pain. His past history included only hypertension, diagnosed in 2010, which was never investigated for a possible secondary cause. He was afebrile and a complete physical examination was unremarkable. Diastolic blood pressure readings were noted to be consistently elevated (>90 mmHg). Laboratory tests showed marked renal impairment (serum creatinine level 1 096 µmol/L), with a normocytic anaemia, an elevated erythrocyte sedimentation rate (105 mm/h) and an elevated C-reactive protein level of 65 mg/L. All virological and serological investigations, including HIV, hepatitis B surface antigen, hepatitis C virus antibodies, antinuclear antibodies, rheumatoid factor, a VDRL test, and perinuclear and cytoplasmic ANCA were negative. Complement levels (C3 and C4) were normal. Further investigations including a chest radiograph, electrocardiogram and echocardiogram were all normal. A cystoscopy and bladder neck resection were carried out for the urinary outlet obstruction. Histological examination of a specimen from the bladder neck revealed medium-vessel vasculitis suggestive of PAN (Fig. 1). An uncontrasted brain computed tomography (CT) scan revealed age-inappropriate atrophy with multiple lacunar infarcts due to significant small-vessel disease. CT angiography was not performed, as contrast media could not be used because of the patient’s significantly impaired renal function. The patient met 6 of the 10 American College of Rheumatology 1990 criteria for the classification of PAN, including weight loss

Fig. 1. (A) Sections of a medium-sized artery show luminal fibrin thrombi (white arrow). An adjacent small artery shows fibrinoid necrosis of the vessel wall (black arrowhead) (H&E, 100× magnification). (B) Sections of a medium-sized artery show transmural neutrophilic infiltrates and fibrinoid necrosis of the vessel wall (black arrows) (H&E, 400× magnification). (C) Sections of a small artery show fibrinoid necrosis of the vessel wall (black arrowheads) (H&E, 400× magnification). (D) Histochemical stain highlights fibrin deposition and fibrinoid necrosis of the vessel wall (black arrow) (Martius Scarlet Blue, 400× magnification).

>4 kg, diffuse myalgia, diastolic BP >90 mmHg, elevated creatinine, appropriate histological findings and arteriographic abnormalities demonstrated on CT of the head.[7] The Birmingham Vasculitis Activity Score (BVAS) was calculated at 13.[8] Oral prednisone (1 mg/kg) was commenced after excluding active and latent tuberculosis on sputum tests, chest radiography and Mantoux testing. Initial therapy with corticosteroids was, however, complicated by Klebsiella septicaemia, identified on blood culture and treated with appropriate antibiotics. On resolution of the sepsis, he was commenced on intravenous (IV) cyclophosphamide with mercaptoethane sulphonate Na (MESNA) according to the CYCLOPS protocol.[5] The dose of cyclophosphamide given was 10 mg/kg, reduced for renal function, every 2 weeks for 3 doses and then every 3 weeks for 3 doses. Oral prednisone was tapered after the first month by 5 mg every 2 weeks down to a dose of 20 mg, then by 2.5 mg monthly to a dose of 10 mg. The patient responded well to treatment. His renal function improved without requiring dialysis and the urinary outlet obstruction resolved. He was discharged with follow-up visits at the rheumatology, renal and urology outpatient clinics. At 6-month follow-up the serum creatinine level was down to 526 µmol/L and his BVAS score was 2.

Discussion

This case reflects an unusual presentation of systemic PAN diagnosed incidentally on bladder neck resection specimens. Testicular involvement in systemic PAN is common, with a prevalence of up to 85%. [6] We identified an isolated study in the literature, evaluating the radiographic findings of abdominal PAN, where extrarenal PAN (urethral, bladder) was found in 2 of the 7 patients studied. [5] However, to our knowledge, PAN involving the urinary tract (especially the urethra and bladder neck) is not well described in the literature. PAN is a potentially remitting disease with a lower relapse rate than granulomatosis with polyangiitis and microscopic polyangiitis. [3] The symptoms of PAN can be nonspecific in the early stages. A high index of suspicion is therefore required to achieve an early diagnosis and prompt treatment with immunosuppressive therapy. While the most common cause of renal impairment is related to vasculitis of the renal vessels, this case demonstrates the unusual possibility of a ‘postrenal’ cause for renal failure in PAN. The patient was treated successfully with pulses of IV cyclophosphamide. Compared with oral cyclophosphamide, this regimen offers the potential advantage of a lower cumulative dose and the likelihood of lower rates of adverse effects.[5] Prolonged follow-up of the patient is needed to determine final outcomes. 1. Watts RA, Scott DGI. Polyarteritis nodosa. In: Watts RA, Scott DGI, eds. Vasculitis in Clinical Practice. London: Springer Verlag, 2010:95-106. DOI:10,1007/978-1-84996-247-6_10 2. Lhote F, Guillevin L. Polyarteritis nodosa, microscopic polyangiitis and Churg-Strauss syndrome: Clinical aspects and treatment. Rheum Dis Clin North Am 1995;21(4):911-947. 3. Guillevin L, Lhote F. Polyarteritis nodosa and microscopic polyangiitis. Clin Exp Immunol 1995;101(Suppl 1):22-23. DOI:10.1111/j.1365-2249.1995.tb06157.x 4. Sato O, Cohn DL. Polyarteritis and microscopic polyangiitis. In: Klippel JH, Dieppe PA, eds. Rheumatology. St Louis: Mosby, 2003. 5. Fraenkel-Rubin M, Ergas D, Sthoeger ZM. Limited polyarteritis nodosa of the male and female reproductive systems: Diagnostic and therapeutic approach. Ann Rheum Dis 2002;61(4):362-364. DOI:10.1136/ard.61.4.362 6. Jee KN, Ha HK, Lee IJ, et al. Radiologic finding of abdominal polyarteritis nodosa. AJR Am J Roentgenol 2000;174(6):1675-1679. DOI:10.2214/ajr.174.6.1741675 7. Luqmani RA, Bacon PA, Moots RJ, et al. Birmingham vasculitis activity score (BVAS) in systemic necrotizing vasculitis. Q J Med 1994;87(11):671-678. 8. De Groot K, Harper L, Jayne DRW, et al. Pulse versus daily oral cyclophosphamide for induction of remission in antineutrophil cytoplasmic antibody-associated vasculitis: A randomised trial. Ann Intern Med 2009;150(10):670-680. DOI:10.7326/0003-4819-150-10-200905190-00004

Accepted 30 June 2016.

November 2016, Print edition

These open-access articles are distributed under Creative Commons licence CC-BY-NC 4.0.

RESEARCH

Is South Africa advancing towards National Health Insurance? The perspectives of general practitioners in one pilot site R Surender,1 PhD; R van Niekerk,2 PhD; L Alfers,2 PhD 1 2

Department of Social Policy and Intervention, Social Sciences Division, Oxford University, UK Institute of Social and Economic Research, Faculty of Humanities, Rhodes University, Grahamstown, South Africa

Corresponding author: R Surender (rebecca.surender@gtc.ox.ac.uk)

Background. The launch of the National Health Insurance (NHI) White Paper in December 2015 heralded a new stage in South Africa’s advancement towards universal health coverage. The ‘contracting in’ of private sector general practitioners (GPs), though only one component of the overall reformed system, is nevertheless crucial to address staff shortages and capacity, and also to realise the broader vision of a single unified, integrated system. Objective. To report on the views and experiences of GP providers tasked with implementing the reforms at one pilot site, Tshwane District in Gauteng Province, providing an insight into the practical challenges the NHI scheme faces in implementation. Methods. The study was qualitative in nature, using a combination of convenience and purposeful sampling to recruit participants. A thematic analysis of the data was conducted using Nvivo 10 software. Results. The overall experiences of the GPs exposed a number of problems with the pilot. These included frustration with lack of appropriate infrastructure and equipment in NHI facilities, difficulties integrating into the facilities and lack of professional autonomy, as well as unhappiness with contracting arrangements. Despite strong support for the idea of NHI, there was general scepticism that private doctors would embrace the scheme on the scale required. Conclusion. The study suggests that the current pilots are still a long way from the vision of a single, integrated health system. While it may be argued that the pilots are not themselves the completed NHI, the findings suggest that it will take much longer to establish than the timeline envisaged by government. S Afr Med J 2016;106(11):1092-1095. DOI:10.7196/SAMJ.2016.v106i11.10683

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.10683

Medical waste disposal at a hospital in Mpumalanga Province, South Africa: Implications for training of healthcare professionals R R Makhura, MPH; S F Matlala, DLitt et Phil (Health Studies); M P Kekana, MPH Department of Public Health, Faculty of Health Sciences, University of Limpopo, Sovenga, South Africa Corresponding author: S F Matlala (france.matlala@ul.ac.za)

Background. Healthcare professionals (HCPs) produce various types of waste in the course of rendering healthcare services. Each classification of waste must be disposed of according to the prescribed guidelines. Incorrect disposal of waste may pose a danger to employees, patients and the environment. HCPs must have adequate knowledge of the disposal of medical waste. Objectives. To determine the knowledge and practices of HCPs with regard to medical waste disposal at a hospital in Mpumalanga Province, South Africa. Methods. A quantitative cross-sectional research approach was used. The study respondents included nurses, medical doctors, dental health staff and allied health staff. Data were collected through self-administered questionnaires and analysed using IBM SPSS version 22.0. Results. A high proportion of HCPs did not have adequate knowledge regarding the disposal of medical waste, but nevertheless disposed of medical waste appropriately. While the knowledge and practices of HCPs with regard to medical waste disposal were not associated with age, gender or years of experience, there was an association between professional category and knowledge and practices.

November 2016, Print edition

RESEARCH

Conclusions. Disposal of medical waste is the responsibility of all HCPs. All categories of HCPs should receive regular training to improve their knowledge regarding disposal of medical waste and to minimise the risks associated with improper waste management. This will further increase compliance with the guidelines on disposal of medical waste. S Afr Med J 2016;106(11):1096-1102. DOI:10.7196/SAMJ.2016.v106i11.10689

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.10689

A cross-sectional study of peripartum blood transfusion in the Eastern Cape, South Africa K van den Berg,1 MB ChB, MMedSci; E M Bloch,2,3 MD, MS; A S Aku,4,5 MBBS, MPhil, MCH; M Mabenge,6,7 MB ChB, MMed; D V Creel,8 MS; G J Hofmeyr,7,9-12 DSc; E L Murphy,3,13 MD, MPH Medical Division, South African National Blood Service, Johannesburg, South Africa Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Md, USA 3 Blood Systems Research Institute, San Francisco, Calif, USA 4 Department of Obstetrics and Gynaecology, Cecilia Makiwane Hospital, Mdantsane, South Africa 5 Department of Obstetrics and Gynaecology, Frere Hospital, East London, South Africa 6 Department of Obstetrics and Gynaecology, Dora Nginza Hospital, Port Elizabeth, South Africa 7 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Walter Sisulu University, East London, South Africa 8 RTI International, Rockville, Md, USA 9 Effective Care Research Unit, East London, South Africa 10 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Arica 11 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Fort Hare University, Alice, South Africa 12 Eastern Cape Department of Health, East London, South Africa 13 Departments of Laboratory Medicine and Epidemiology/Biostatistics, University of California, San Francisco, Calif, USA 1 2

Corrresponding author: K van den Berg (karin.vandenberg@sanbs.org.za)

Background. Obstetric haemorrhage (OH) remains a major contributor to maternal morbidity and mortality. Blood transfusion is critical in OH management; yet, data on peripartum transfusion are lacking. A pilot study reported high rates of peripartum transfusion in a sample of South African (SA) hospitals, which was independently associated with HIV status. Objectives. To assess the incidence of peripartum transfusion in a sample of Eastern Cape, SA hospitals to evaluate generalisability of preceding study findings. Methods. Hospital chart reviews were conducted of all deliveries at three large regional hospitals from February to June 2013. Additional clinical data were collected for patients who sustained OH and/or were transfused. Results. A total of 7 234 women were enrolled in the study; 1 988 (27.5%) were HIV-positive. Of the 767 HIV-positive women with a CD4 count <350 cells/ÂľL, 86.0% were on full antiretroviral therapy and 9.9% received drugs for prevention of mother-to-child transmission. The overall transfusion rate was 3.2%, with significant variability by hospital: Frere Hospital (1.5%), Dora Nginza Hospital (3.8%) and Cecilia Makiwane Hospital (4.6%). The number of red blood cell units per transfused patient and per delivery varied significantly by hospital. Bivariate analysis showed significant association between transfusion and HIV status. In a multivariate analysis, controlling for OH, age, mode of delivery, gestational age, parity and birthweight, this association (odds ratio 1.45; 95% confidence interval 0.78 - 2.71) was no longer significant. Conclusion. These findings confirm high rates of peripartum transfusion in SA. While this can be possibly ascribed to variability in practice and patient profile, variation in care and improvement in HIV treatment should be considered. S Afr Med J 2016;106(11):1103-1109. DOI:10.7196/SAMJ.2016.v106i11.10870

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.10870

November 2016, Print edition

RESEARCH

Barriers to obstetric care among maternal near-misses P Soma-Pillay,1 MB ChB, Dip (Obst) SA, MMed (OetG), Cert Maternal and Fetal Medicine (SA); R C Pattinson,2 MD, FRCOG, FCOG (SA) 1 Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa 2 South African Medical Research Council Maternal and Infant Health Care Strategies Unit, Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of Pretoria, South Africa

Corresponding author: P Soma-Pillay (priya.somapillay@up.ac.za) Background. There are several factors in the healthcare system that may influence a woman’s ability to access appropriate obstetric care. Objective. To determine the delays/barriers in providing obstetric care to women who classified as a maternal near-miss. Methods. This was a descriptive observational study at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. One hundred maternal near-misses were prospectively identified using the World Health Organization criteria. The ‘three-delays model’ was used to identify the phases of delay in the health system and recorded by the doctor caring for the patient. Results. One or more factors causing a delay in accessing care were identified in 83% of near-miss cases. Phase I and III delays were the most important causes of barriers. Lack of knowledge of the problem (40%) and inadequate antenatal care (37%) were important first-phase delays. Delay in patient admission, referral and treatment (37%) and substandard care (36%) were problems encountered within the health system. The above causes were also the most important factors causing delays for the leading causes of maternal near-misses – obstetric haemorrhage, hypertension/pre-eclampsia, and medical and surgical conditions. Conclusions. Maternal morbidity and mortality rates may be reduced by educating the community about symptoms and complications related to pregnancy. Training healthcare workers to identify and manage obstetric emergencies is also important. The frequency of antenatal visits should be revised, with additional visits in the third trimester allowing more opportunities for blood pressure to be checked and for identifying hypertension. S Afr Med J 2016;106(11):1110-1113. DOI:10.7196/SAMJ.2016.v106i11.10726

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.10726

A review of the peri-operative management of paediatric burns: Identifying adverse events H Rode,1 MB ChB, FCS (SA), MMed, FRCS (Edin); C Brink,1 MB ChB; K Bester,2 MB ChB, DA, FCA (SA); M P Coleman,3 Medical student; T Baisey,3 Medical student; R Martinez,1 MB ChB Department of Paediatric Surgery, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa 2 Division Paediatric Anaesthesia, Department of Anaesthesia and Peri-operative Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 3 University of North Carolina at Chapel Hill, NC, USA 1

Corrresponding author: H Rode (heinz.rode@uct.ac.za)

Background. Burn injuries are common in poverty-stricken countries. The majority of patients with large and complex burns are referred to burn centres. Of the children who qualify for admission, according to burn admission criteria, about half require some kind of surgical procedure to obtain skin cover. These range from massive full-thickness fire burns to skin grafts for small, residual unhealed wounds. Burn anaesthetic procedures are of the most difficult to perform and are known for high complication rates. Reasons include peri-operative sepsis, bleeding, issues around thermoregulation, the hypermetabolic state, nutritional and electrolyte issues, inhalation injuries and the amount of movement during procedures to wash patients, change drapes and access different anatomical sites. The appropriate execution of surgery is therefore of the utmost importance for both minor and major procedures. Objective. To review the peri-operative management and standard of surgical care of burnt children.

November 2016, Print edition

RESEARCH

Methods. This was a retrospective review and analysis of standard peri-operative care of burnt children at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. A total of 558 children were operated on and supervised by the first author. Factors that could adversely affect surgical and anaesthetic outcomes were identified. Results. There were 257 males and 301 females in this study, with an average age of 50.1 months and average weight of 19.5 kg. The total body surface area involved was 1 - 80%, with an average of 23.5%. Inhalational injury was present in 11.3%, pneumonia in 13.1%, wound sepsis in 20.8%, and septicaemia in 9.7%, and organ dysfunction in more than one organ was seen in 6.1%. The average theatre temperature during surgery was 30.0°C. Core temperatures recorded at the start, halfway through and at completion of surgery were 36.9°C, 36.8°C and 36.5°C, respectively. The average preoperative and postoperative haemoglobin levels were 11.28 g/dL and 9.64 g/dL, respectively. Blood loss was reduced by the use of clysis from 1.5 mL/kg/% burn to 1.4 mL/kg/% burn. Adverse intraoperative events were seen in 17.6% of children. Conclusion. Burn surgery is a high-risk procedure and comorbidities are common. Anaesthesia and surgery must be well planned and executed with special reference to temperature control, rapid blood loss, preceding respiratory illnesses and measures to reduce blood loss. S Afr Med J 2016;106(11):1114-1119. DOI:10.7196/SAMJ.2016.v106i11.10938

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.10938

The state of methamphetamine (‘tik’) use among youth in the Western Cape, South Africa E H Weybright,1 PhD; L L Caldwell,2 PhD; L Wegner,3 PhD; E Smith,4 PhD; J J Jacobs,5 MS Department of Human Development, College of Agricultural, Human, and Natural Resource Sciences, Washington State University, Pullman, Washington, USA 2 Department of Recreation, Park, and Tourism Management, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania, USA; HIV and AIDS Programme, University of the Western Cape, Cape Town, South Africa; and School of Biokinetics, Recreation and Sport Sciences, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa 3 Department of Occupational Therapy, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa 4 Bennett Pierce Prevention Research Center for the Promotion of Human Development, The Pennsylvania State University, University Park, Pennsylvania, USA; and HIV and AIDS Programme, University of the Western Cape, Cape Town, South Africa 5 HIV and AIDS Programme, University of the Western Cape, Cape Town, South Africa 1

Corresponding author: E H Weybright (elizabeth.weybright@wsu.edu)

Background. Methamphetamine use among youth in the Western Cape Province of South Africa has increased at alarming rates over the past decade. Although current estimates of youth use exist, they range from 2 - 12%. Objectives. To identify (i) the prevalence of methamphetamine use in Western Cape youth and (ii) the association between use and known risk factors for methamphetamine use. Methods. Data were obtained from 10 000 Western Cape Province Grade 8 learners in 54 secondary schools (mean age 14.0 years). Prevalence was descriptively reported while risk factors for past-month use were modelled in a hierarchical logistic regression with demographic, socioeconomic status, substance use, sexual activity and relationship predictors. Results. Approximately 5% (n=496) of learners had used methamphetamine within their lifetime. Of these users, 65% (n=322) had used in the past month or week. Compared to never users, past-month users were more likely to be male, less likely to have a present or partially present mother, less likely to live in an apartment/flat/brick house, more likely to have used alcohol and tobacco and more likely to report having a same-sex partner. Conclusion. Results replicate previously known methamphetamine risk factors and highlight the need to address methamphetamine use in comprehensive prevention initiatives. S Afr Med J 2016;106(11):1125-1128. DOI:10.7196/SAMJ.2016.v106i11.10814

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.10814

November 2016, Print edition

RESEARCH

Intimate partner violence at a tertiary institution K Spencer,1 MB BCh; M Haffejee,1 MB BCh, FCS (Urol); G Candy,2 MSc, PhD; E Kaseke,3 BA, PhD Department of Urology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Department of Social Work, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa 1 2

Corresponding author: K Spencer (doctorkspencer@gmail.com) Background. Intimate partner violence (IPV) is actual or threatened physical, sexual, psychological, emotional or stalking abuse by an intimate partner. Despite the high prevalence of IPV in South Africa (SA), there is a paucity of data on university students training in fields where they are likely to have to manage the after-effects of such events in their personal capacity in the future. Objectives. To ascertain the prevalence of IPV in an SA tertiary institution population with a diverse demographic profile. Methods. Students from the faculty of health sciences and the faculty of humanities, social work department, completed an anonymous questionnaire. Students were made aware of psychological counselling available to them. Results. Responses were obtained from 1 354 of 1 593 students (85.0%) (67.8% female, 45.9% black, 32.7% white, 16.6% Indian, 4.8% coloured). Of the respondents, 53.0% indicated that they were in a relationship. The prevalence of any type of IPV (sexual, physical or emotional abuse) among all respondents was 42.6%. Emotional abuse was reported by 54.9% of respondents, physical abuse by 20.0% and sexual abuse by 8.9%. Thirty-five females (6.5% of respondents who had suffered IPV) indicated that they had been emotionally, physically and sexually abused. Fourteen percent identified themselves as perpetrators of abuse, but only three perpetrators of sexual abuse reported having also been victims of sexual abuse. Most respondents (58.7%) knew where to get help. Conclusion. The extent of IPV among the medical and social work students sampled was found to be unacceptably high, both as victims and as perpetrators. As a result of their exposure to IPV, these individuals may have difficulty in managing patients who have been subjected to abuse. S Afr Med J 2016;106(11):1129-1133. DOI:10.7196/SAMJ.2016.v106i11.12013

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.12013

Tonsillectomy rates in the South African private healthcare sector P Douglas-Jones, MB ChB; J J Fagan, MB ChB, MMed, FCORL Division of Otorhinolaryngology, Faculty of Health Sciences, University of Cape Town, South Africa Corresponding author: P Douglas-Jones (pdouglasjones@gmail.com)

Background. Adeno-/tonsillectomy is a commonly performed procedure with internationally standardised and recognised indications. Despite this, there exists considerable international (190 - 850/100 000 people ≤19 years of age) and regional variation in rates. This cannot be accounted for by differences in clinical need or regional morbidity. Objectives. To describe the adeno-/tonsillectomy rate in the South African (SA) private healthcare sector and regional variations thereof. To compare local rates with international rates and assess trends in adeno-/tonsillectomy practice. Methods. Analysis of 2012 and 2013 adeno-/tonsillectomy data provided by the largest SA private healthcare funder, accounting for 30% of the medical scheme market. Rates are expressed per 100 000 people ≤19 years of age. Results. The tonsillectomy rate in the SA private healthcare sector was 1 888/100 000 people ≤19 years of age in 2012. In 2013, the rate dropped significantly (p<0.001) to 1 755/100 000. This is more than double the highest national tonsillectomy rate reported in the literature. There was also considerable regional variation in this rate within SA.

November 2016, Print edition

RESEARCH

Discussion. The SA tonsillectomy rate is very high when compared with international trends and varies regionally within the country. The literature does not support an increased burden of disease as the reason behind this. Rather, it is differences in training and clinical practice of clinicians, as well as social and family factors, that have been implicated. Conclusion. The adeno-/tonsillectomy rate in the SA private healthcare sector is substantially higher than international norms. The reasons for this discrepancy require further consideration. S Afr Med J 2016;106(11):1134-1140. DOI:10.7196/SAMJ.2016.v106i11.10842

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i11.10842

An analysis of inter-healthcare facility transfer of neonates within the eThekwini Health District of KwaZulu-Natal, South Africa P Ashokcoomar,1,2 MTech Emergency Medical Care; R Naidoo,1 MSc (Cardiol), MSc (Med) 1 2

Department of Emergency Medical Care and Rescue, Durban University of Technology, South Africa KwaZulu-Natal Emergency Medical Services, Durban, South Africa

Corresponding author: P Ashokcoomar (pradeep.ashokcoomar@gmail.com)

Objectives. To investigate delays in the transfer of neonates between healthcare facilities and to detect any adverse events encountered during neonatal transfer. Methods. A prospective study was conducted from December 2011 to January 2012. A quantitative, non-experimental design was used to undertake a descriptive analysis of 120 inter-healthcare facility transfers of neonates within the eThekwini Health District (Durban) of KwaZulu-Natal Province, South Africa. Data collection was via questionnaire. Data collection was restricted to the Emergency Medical Services (EMSs) of eThekwini Health District, which is the local public ambulance provider. Results. All transfers were undertaken by road ambulances: 83 (62.2%) by frontline ambulances; 35 (29.2%) by the obstetric unit; and 2 (1.7%) by the planned patient transport vehicles. Twenty-nine (24.2%) transfers involved critically ill neonates. The mean (standard deviation (SD)) time to complete an inter-healthcare facility transfer was 3 h 49 min (1 h 57 min) (range 0 h 55 min - 10 h 34 min). Problems with transfer equipment were common due to poor resource allocation, malfunctioning equipment, inappropriate equipment for the type of transfer and dirty or unsterile equipment. The study identified 10 (8.3%) physiologically related adverse events, which included 1 (0.8%) death plus a further 18 (15.0%) equipment-related adverse events. Conclusions. EMS is involved in transporting a significant number of intensive care and non-intensive care neonates between healthcare facilities. This study has identified numerous factors affecting the efficiency of inter-facility transfer of neonates and highlights a number of areas requiring improvement. S Afr Med J 2016;106(5):514-518. DOI:10.7196/SAMJ.2016.v106i5.8554

Full article available online at http://dx.doi.org/10.7196/SAMJ.2016.v106i5.8554

November 2016, Print edition

CAREERS & CLASSIFIEDS Tel: 012 481 2121 | E-mail: ladinev@hmpg.co.za We accept credit card payments - Visa or MasterCard.

MEDICAL OFFICER Standards and Governance About Liberty

Lady Pohamba Private Hospital is a pure Namibian-owned, state-of-the-art hospital. We are seeking the professional services of a: • Neurosurgeon • Neonatologist • Physician • Cardiologist • Gynaecologist and obstetrician

Submit an application via email to:

hannelie.botha@lpph.com.na

Liberty is a progressive African wealth management group which, for more than fifty years, has delivered innovative long-term solutions that assist customers to achieve financial stability in their chosen lifestyles and throughout their life cycles. As a group of companies Liberty offers an extensive, market-leading range of products and services to help customers build and protect long-term wealth. These include life and health-related insurance, investment management and retirement income facilitation. Customers have flexible choices and the input provided by Liberty’s advisers equips them with the knowledge and expert advice they need to make the right decisions with confidence, no matter what their stage of life. “Our vision is to lead by being the most trusted insurance and investment company in Africa.”

Overview A very exciting opportunity is available for a business oriented medical officer in the Individual Arrangements Standards and Governance team. This team is primarily responsible for positioning the Liberty risk product proposition as the leader in the industry, both from a sales and risk management perspective. A key part of this is the effective translation of cutting edge clinical knowledge into optimal decision making.

Key Responsibilities: The candidate will be responsible for the following: • Specifying, developing, prioritizing and leading projects to improve: • Efficiency of the underwriting and claims process • Consistency of underwriting and claims decisions reached • Margins associated with the retail risk business. • In particular, close attention needs to be paid to automation opportunities • Interaction with sales force, medical professionals, Liberty staff across various business units, and reinsurers. • Providing consultant type support to operational matters on an as and when basis for both underwriting and claims teams. • Responsible for projects relating to Standards and Governance function of developing and implementing practice guides across the Fulfilment business unit. • Assisting the Standards and Governance team with any medical input that they maybe require on their projects. • Assisting to maintain practices across the Fulfilment business unit that adapt to competitive trends, new medical developments, and feedback from distribution force while continuing to maintain and improve risk management. • ECG interpretation skills will be a plus • Medical and technical training of both underwriters and claims assessors • Insurance medical examinations on insurance applicants

Qualifications: Medical Degree A diploma in occupational medicine would be preferable

Experience: • •

At least 5 years general medical experience At least 2 years medical advisory experience in an insurance environment would be preferable

Competencies: • Building strong teams • Conceptual thinking • Communication • Customer Service and quality focused • Influential and motivational • Innovative • Planning and organising If you meet the requirements and are interested in applying for this position, please send your CV to Melanie.Rossouw@liberty.co.za. The closing date for the applications is the 30th November 2016.

Liberty Group Ltd – an Authorised Financial Services Provider in terms of the FAIS Act (Licence No. 2409).

CAREERS & CLASSIFIEDS

Ophthalmology Practice for Sale Established full-time ophthalmology private practice in Durban

For enquiries contact: Yolandé: 031 207 3470 E-mail: alrow@saol.com

PRAKTYK TE KOOP Gevestigde praktyk in Lutzville, Wes-Kaap. Sal persoon pas met beroepsgesondheidkwalifikasie (of iemand wat bereid is om kursus te doen). Sluit tans beroepsgesondheid, mediese fonds, privaat praktyk en ook staats-sessies in.

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CLINICAL MICROBIOLOGIST/ANATOMICAL PATHOLOGIST VEREENIGING/NAMIBIA

We are a dynamic, cutting edge, purpose driven and values based Pathology and Diagnostic laboratory, caring for the health of patients, while offering support and expertise to medical professionals. We have an opportunity for a Clinical Microbiologist to work at our Vereeniging branch as well as a vacancy for an Anatomical Pathologist to work at our Namibia branch. If you are a creative, dynamic and passionate professional who adopts a customer-centric approach, is respectful and accountable and possesses a well-developed work ethic, while working with diverse groups of people and excelling within a multi-cultural environment then this opportunity could be what you are looking for.

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• M.Med or FC Pathology (SA) • Current registration with the HPCSA as a Pathologist or willingness to register with the HPCNA as a Pathologist • Relevant working experience • High level of ethics and integrity

Closing date for applications is Thursday, 15th December 2016

CPD

NOVEMBER 2016

The CPD programme for SAMJ is administered by Medical Practice Consulting. CPD questionnaires must be completed online at www.mpconsulting.co.za.

True (A) or false (B): SAMJ Medical waste disposal at a hospital in Mpumalanga Province, SA 1. Laboratory waste, which includes body fluids, human tissue and cultures, can be disposed of through incineration or chemical disinfection. 2. There was no association between knowledge and practice of waste disposal and age, gender or years of experience. A cross-sectional study of peripartum blood transfusion in the Eastern Cape Province, South Africa (SA) 3. In SA, as is the case globally, obstetric haemorrhage remains a leading contributor to maternal mortality and morbidity. 4. Significantly increased transfusion rates were noted with increased parity. Barriers to obstetric care among maternal near-misses 5. The most important obstetric causes for a maternal near-miss were obstetric haemorrhage, medical and surgical disorders, and complications of hypertension and pre-eclampsia in pregnancy. 6. Phase III delays were significant barriers encountered by patients with obstetric haemorrhage. The state of methamphetamine (‘tik’) use among youth in the Western Cape Province, SA 7. Risk factors for regular tik use include being male and having a same-sex partner.

CME Understanding the intergenerational transmission of violence 11. Expectant mothers with a history of interpersonal trauma report significantly lower prenatal attachment development with their unborn child than expectant mothers with no interpersonal trauma history. 12. Interventions that decrease mothers’ mental health problems can be expected to have a secondary effect on the mental and behavioural functioning of their children. Current approaches to the management of adult survivors of sexual offences 13. Emergency contraception is provided up to 72 hours after an alleged sexual offence. 14. A survivor has to lay a charge with the police in order to have access to medical advice and treatment after an alleged sexual offence. 15. It is safe to prescribe tenofovir in combination with aminoglycosides. 16. Rape is a legal, and not a medical, definition. Physical and sexual violence against children 17. Fractures are common in infants and young children <3 years of age. 18. It is the duty of the doctor to identify the perpetrator. 19. Safety issues are not the concern of the doctor. 20. The majority of child abusers have no major psychological abnormalities.

Tonsillectomy rates in the SA private healthcare sector 8. The rate of tonsillectomy reported in this study in 2013 was comparable to international norms. A review of the perioperative management of paediatric burns (online only) 9. Critical theatre variables in the management of paediatric burns include environmental temperature control, availability of consumables and staff experience. 10. There are frequent contraindications to surgery in the management of paediatric burns.

Readers please note: articles may appear in summary/abstract form in the print edition of the Journal, with the full article available online at www.samj.org.za

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November 2016, Print edition

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