SAMJ Vol 107, No 4 (2017) by HMPG

APRIL 2017

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GUEST EDITORIAL Evidence-based decision-making for primary care CORRESPONDENCE Death by maladministration CME Prevention of childhood injuries (part 2) IN PRACTICE Presenting features of tuberous sclerosis complex CASE REPORT Lead poisoning in shooting-range workers RESEARCH Contraception coverage in South African women Wound infection secondary to snakebite Hip and knee arthroplasty waiting lists

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APRIL 2017 PRINT EDITION

FROM THE EDITOR 3

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

Cry, the beloved country ... B Farham

GUEST EDITORIAL 4

Evidence-based decision-making for primary care: The interpretation and role of pragmatic trials L R Fairall, O Mahomed, E D Bateman

EDITOR’S CHOICE CORRESPONDENCE

Death by maladministration: An important category of patient mortality D J Stein, C Chambers, I Daniels, B Patel, C Sunkel, J White, Z Wilson, C Lund

Targeting mothers and selling men what they do not want: A response to ‘Missed opportunities for circumcision of boys’ D Sidler, B D Earp, A A van Niekerk, K Moodley, S Kling

What is the nature of a conflict of interest in a scientific publication? L London

Patients in whom surgical closure of terminal branches of external carotid arteries for migraine treatment resulted in reduced frequency of epileptic attacks I Derakhshan

IZINDABA 16

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HMPG CEO AND PUBLISHER Hannah Kikaya Email: hannahk@hmpg.co.za MANAGING EDITORS Ingrid Nye Claudia Naidu TECHNICAL EDITORS Emma Buchanan Kirsten Morreira Naadia van der Bergh Paula van der Bijl PRODUCTION MANAGER Emma Jane Couzens

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

OBITUARIES Denise Anne Campbell White Oliver Raynham

GUEST EDITORIAL Prevention of childhood injuries (part 2) A B van As, A van Niekerk

ARTICLES Energy poverty, shack fires and childhood burns D K Kimemia, A van Niekerk

SALES MANAGER (CAPE TOWN) Azad Yusuf JOURNAL ADVERTISING Charles William Duke Reneé Hinze Ladine van Heerden Makhadzi Mulaudzi Charmalin Simpson Ismail Davids ONLINE SUPPORT Gertrude Fani

Promote buckling up and save a child’s life Y Ferreira, A B van As

FINANCE Tshepiso Mokoena

IN PRACTICE 28

CLINICAL UPDATE Tuberous sclerosis complex in the Western Cape, South Africa: The clinical presentation features E Kija, B Schlegel, P Samia, M Wessels, J M Wilmshurst

CASE REPORTS Systemic lupus erythematosus: A possible cause of non-alcoholic Wernicke’s encephalopathy M T L Nyo, D Magazi, M M T M Ally

Lead poisoning in shooting-range workers in Gauteng Province, South Africa: Two case studies A Mathee, P de Jager, S Naidoo, N Naicker

Mammary analogue secretory carcinoma: A rare salivary gland tumour B S Jackson, T L Pratt, A van Rooyen

RESEARCH 39

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, W Edridge, R P Abratt

DTP AND DESIGN Clinton Griffin Travis Arendse

30 days in medicine B Farham

CONTINUING MEDICAL EDUCATION

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

Contraception coverage and methods used among women in South Africa: A national household survey M F Chersich, N Wabiri, K Risher, O Shisana, D Celentano, T Rehle, M Evans, H Rees

April 2017, Print edition

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

Wound infection secondary to snakebite M Wagener, M Naidoo, C Aldous

Pulmonary scar carcinoma in South Africa N Jenkins, E M Irusen, C F N Koegelenberg

Hip and knee arthroplasty waiting list – how accurate and fair? T Kavalier, M Nortje, R N Dunn

The benefit of pharmacological venous thromboprophylaxis in foot and ankle surgery* N P Saragas, P N F Ferrao, B F Jacobson, E Saragas, A Strydom

Available data sources for monitoring non-communicable diseases and their risk factors in South Africa* M Wandai, J Aagaard-Hansen, C Day, B Sartorius, K J Hofman

Perceptions of healthcare professionals regarding their own body weight in selected public hospitals in Mpumalanga Province, South Africa* M C Phetla, L Skaal

Cross-sectional evaluation of the Bronchitis Severity Score in Egyptian children: A move to reduce antibiotics* E M I Moawad, M A E Haron, R M A Maher, E A A Abdallah, H Hussein, N M Badawy, M E A El-Rheem

Prevalence of hepatitis B, hepatitis C and human immunodeficiency viruses, and evaluation of risk factors for transmission: Report of a population screening in Nigeria* U C Okonkwo, H Okpara, A Otu, S Ameh, Y Ogarekpe, H Osim, M Inyama

Problematic alcohol and other substance use among patients presenting to emergency services in South Africa: Who is ready for change?* K Sorsdahl, D J Stein, T Naledi, E Breuer, B Myers *Abstract only, full article available online. CAREERS AND CLASSIFIEDS

ONLINE CONTENTS LISTED IN Index Medicus (Medline) Excerpta Medica (EMBASE) Biological Abstracts (BIOSIS) Science Citation Index (SciSearch) Directory of Open Access Journals (DOAJ) Current Contents/Clinical Medicine SAMJ SUBSCRIPTION RATES Local subscriptions ZAR1 488.00 p.a. Foreign subscriptions ZAR3 408.00 p.a. Single copies ZAR124.00 local, ZAR284.00 foreign Members of the South African Medical Association receive the SAMJ only on request, as part of their membership benefit. Subscriptions: Tel. 012 481 2071 Email: members@samedical.org The SAMJ is published monthly by the Health and Medical Publishing Group (Pty) Ltd, Co. registration 2004/0220 32/07, a subsidiary of SAMA. HEAD OFFICE Health and Medical Publishing Group (Pty) Ltd Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext. 3, Pretoria, 0181 Tel. 012 481 2069 Email: dianes@hmpg.co.za EDITORIAL OFFICE Suite 11, Lonsdale Building, Lonsdale Way, Pinelands, 7405 Tel. 021 532 1281 | Cell. 072 635 9825 Email: publishing@hmpg.co.za Please submit all letters and articles for publication online at http://www.editorialmanager.com/samj

CPD QUESTIONS

ERRATUM CPD question 13, March 2017

Use of editorial material is subject to the Creative Commons Attribution – Non-commercial Works Licence. https://creativecommons.org/licenses/bync/4.0 Printed by TANDYM PRINT

APRIL 2017

Background photo: South African patients at the TB centre in Khayelitsha, Cape Town, wait to see doctors on the eve of World TB day | Alexander Joe, Gallo Images/AFP Box photos: Buckle up | George Doyle; Exposure of tendons in a necrotic septic snakebite wound after debridement | Wagener et al.; Preparing for hip replacement surgery | snoofek

April 2017, Print edition

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

FROM THE EDITOR

Cry, the beloved country ... Towards the end of last year (2016), around 1 300 psychiatric patients were moved over a period of several months from Life Esidimeni, a specialised private facility, to care homes run by charities. Esidimeni means ‘place of dignity’, and the private company delivers healthcare services to indigent patients under contract to national and provincial departments of health and social development, and has done for five decades. The end result reverberated around the country, and indeed the world – at least 100 deaths in truly appalling circumstances. The moves were made in the face of appeals by family members, psychologists and advocacy groups that this would be dangerous for patients. They pleaded with Qedani Mahlangu, then Gauteng provincial health minister, to stop the move. They even went to court. The move went ahead. Mahlangu has resigned – an unusual move among South African politicians – but too little, too late. As Dan Stein and colleagues[1] point out so well in this issue of the SAMJ, this is ‘death by maladministration’. The patients were moved to NGOs that ‘jostled’ over which patients they wanted in what the health ombudsman’s report described as a ‘cattle auction’.[2] Some sent pick-up trucks to collect them. Patients essentially died of neglect. These people are the ‘vulnerable and voiceless’ in society that Stein et al. rightly describe as serving as the ‘canary in the coal mine’. That they died at all is more than shocking. It is reminiscent of what was quietly happening in Nazi Germany in the late 1930s under Hitler’s regime. It reflects a growing lack of concern worldwide for people who cannot speak for themselves, be they the mentally ill, the elderly and frail, or the refugees who are being hounded around Europe because, quite simply, no one wants them. What is particularly distressing about this tragedy is that people tried to cover it up. The risks were known before the patients were moved, and Mahlangu and her administration simply watched as the tragedy unfolded. Mahlangu only admitted to the deaths after being quizzed by the shadow minister for health in Parliament – at the time the death toll stood at 77. Patients were dying even as Parliament heard of the debacle. Esidimeni was ignored during the chaotic State of the Nation address, except by one DA MP who unsuccessfully called for a minute’s silence to honour the dead. In the past week, our deputy president and minister of health have been doing some fancy

footwork in the name of damage limitation – cynically, this appears to be more about saving face than saving lives. So far, it appears that 27 psychiatric patients have been moved, with the consent of their families, to the Solomon Stix Morewa Private Hospital in Johannesburg.[3] But since there is little or no public knowledge of the fates of the rest of the patients who were moved, it is possible that there are still patients at risk of neglect in unsuitable, but cheap, NGO facilities. The ‘canary in the coal mine’ analogy is apt. We can no longer close our eyes to the corruption and wilful neglect of our public services, and indeed our people, by a government that is increasingly desperate to hold on to power, and through it access to the public purse. The imminent crisis around the distribution of social grants on 1 April this year is another case in point. If this distribution fails, lack of these grants will cause massive hardship, and quite possibly illness and death, for yet another group of voiceless and vulnerable people. Across the world, humanity is losing its compassion. The events around refugees and asylum seekers in Europe are one example. The hate speech and crimes that are increasing in the UK (and other parts of Europe) and the USA with the rise of the far right are another. Greed and selfishness are becoming acceptable. We must not let this happen. Bridget Farham Editor ugqirha@iafrica.com 1. Stein DJ, Chambers C, Daniels I, et al. Death by maladministration: An important category of patient mortality. S Afr Med J 2017;107(4):280. https://doi.org/10.7196/SAMJ.2017.v107i4.12389 2. Makgoba MW. The report into the ‘circumstances surrounding the deaths of mentially ill patients: Gauteng Province’. 2017. http://politicsweb.co.za/documents/the-life-esidimeni-disaster-the-makgobareport (accessed 13 March 2017). 3. Eye Witness News. Motsoaledi confirms move of Esidimeni patients to other facilities. http://ewn. co.za/2017/03/03/motsoaledi-confirms-move-of-esidimeni-patients-to-other-facilities (accessed 13 March 2017).

S Afr Med J 2017;107(4):277. DOI:10.7196/SAMJ.2017.v107i4.12460

April 2017, Print edition

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

GUEST EDITORIAL

Evidence-based decision-making for primary care: The interpretation and role of pragmatic trials In the era of evidence-based medicine, health authorities are obligated to base policies on solid evidence. The gold standard of evidence-based medicine is the randomised controlled trial (RCT) in which participants fulfil strict criteria for inclusion, and the ecology of care – i.e. factors other than the intervention that could influence the outcome are controlled.[1] However, evidence supporting systems interventions in health services that involve multiple changes in the delivery of services is complex and requires the synthesis of evidence from multiple sources. Not surprisingly, such evidence is scarcest in the resource-constrained settings that need it most, where issues of prioritisation and cost-effectiveness are of paramount importance. This dilemma facing health authorities is well illustrated by circumstances surrounding the adoption of Adult Primary Care (APC) by the National Department of Health for use in primary care facilities in South Africa (SA), which forms part of the Ideal Clinic initiative.[2] APC is the new name for Primary Care 101 (PC101), developed by the Knowledge Translation Unit at the University of Cape Town Lung Institute, after more than a decade of formative research. APC is a comprehensive clinical management guide and training approach for frontline clinicians (in SA, usually nurses), providing simple algorithms for the integrated management of multiple conditions; in fact the majority of reasons for which adult patients attend primary care facilities, including preventive, curative and chronic care.[3] What evidence might the health authorities have considered in adopting the APC approach, particularly in the face of the recent publication, in a high-impact journal, of a large pragmatic randomised trial conducted in 38 clinics in the Eden and Overberg districts of SA, which failed to show significant improvement in the management of three non-communicable diseases (NCDs) and case detection of depression following the introduction of PC101?[4] What other factors might the health authorities have considered in making this decision? First, it should be noted that the decision predated the availability of the results of the PC101 trial. We argue that there are at least three reasons why the decision remains appropriate: (i) methodological issues in pragmatic controlled trials such as the PC101 trial; (ii) additional evidence supporting the effectiveness of PC101; and (iii) the role of evidence in shaping health system reform. In the continuum of research methods from observational studies to randomised trials, the pragmatic trial comes close to ‘reallife’ conditions while retaining the advantages of randomisation and preservation of internal validity. Explanatory RCTs, where interventions are tested under tightly controlled conditions, are useful to decision-makers when they produce negative results, as interventions that do not work under ideal conditions are unlikely to be effective when applied in real-world settings, and so can be abandoned. When they produce positive findings, questions arise as to whether they will yield similar results under routine circumstances where, for example, adherence is usually far lower than what was achieved in the trial. Conversely, positive pragmatic trials provide compelling evidence of usefulness and should prompt adoption. When negative, further research remains an option, particularly if, as in the PC101 trial, there is no evidence of harm.[5] The PC101 trial was ambitious in its pragmatic orientation and affected by the unpredictable impact of real-life conditions. It focused on the intensification of prescribing for three NCDs –

hypertension, diabetes and chronic respiratory diseases – and case detection of depression, while adopting a ‘hands-off ’ approach to assessing the validity of correct diagnosis, eligibility for treatment intensification, underlying disease severity, or patient adherence to treatment. Furthermore, factors external to the trial played a role. For example, during the trial, the district health authorities, in part inspired by a renewed focus on NCDs that accompanied PC101, implemented a Chronic Disease Season to encourage recognition and treatment of NCDs in all clinics, including 17 control clinics in the Eden district. These and other issues described in the main publication probably accounted for the negative results for the primary endpoints. However, notably, analysis of prespecified subgroups – patients with poor control of diabetes and those with highest blood pressures – benefited significantly from the intervention.[4] The challenges of designing and performing pragmatic controlled trials of complex interventions such as PC101, together with the scarcity or small size of positive outcomes, explain their rarity, particularly in low-income settings. But the PC101 trial is the latest of a succession of research reported by the Knowledge Translation Unit in more than 30 publications over 12 years. This research includes three other pragmatic randomised trials that showed consistent, reproducible improvements in both process and health outcomes, particularly for infectious diseases.[6-8] The PC101 trial must therefore be seen in the context of a growing experience of integrated nurseled primary care, in what has recently been described as a Learning Health System approach.[9] The Learning Health System is one that aims ‘to integrate delivery of health services with the generation of new knowledge about the effectiveness of these services’. Since the first version of PC101 (initially called the Practical Approach to Lung Health in South Africa – PALSA), results from studies of varying design – observational, qualitative, cost-effectiveness, and pragmatic randomised controlled trials – have been used to improve and expand the clinical guide and training methods. Further trials are underway in North West Province, SA (testing a strengthened mental health component of APC) and in Brazil (testing a Brazilian adaptation). The utility and role of APC should therefore not be invalidated by the results of one negative trial. Finally, how might health authorities weigh evidence from various sources in their important policy decisions? An evidence hierarchy should place pragmatic trials performed in the target health facilities and embedded in usual practice as the highest level of evidence. Sadly, because pragmatic trials are complex and their results often challenging to interpret, decision-makers rely on findings from less robust research designs such as before-and-after observational studies. Supportive evidence from research by an independent party provides further assurance for decision-makers. PC101 was subjected to a controlled before-and-after study with a limited survey of impact on nurse knowledge and quality of care in 42 clinics in three health districts of SA. Findings were broadly positive across a range of process outcomes. Furthermore, since quality care can only be delivered by trained and motivated staff, qualitative research and audit confirming the rapid and enthusiastic uptake and rollout among healthcare workers of the APC approach, including most recently among undergraduate doctors, also serve as validation of the approach.

April 2017, Print edition

GUEST EDITORIAL

What other factors require consideration? Cost and competing priorities are major factors in decision-making. Although a formal cost-consequence analysis of PC101 has not been completed, previous research results point to little if any additional cost, other than that relating to treatment related to improved detection of infectious disease.[10] The attractiveness of the approach in implementing APC is that it utilises existing staff and staff trainers, and simply involves standardisation of clinical management and healthcare worker training. The training programme employs adult learning principles that increase confidence and strengthen self-perceived efficacy of healthcare workers. Furthermore, regular updates of the clinical management guide avoid the confusion of outdated guidelines and policies. The lack of alternatives to address the heavy load and multimorbidity faced by frontline clinicians, reflecting the collision of SA’s infectious disease and NCD epidemics, supports the adoption and implementation of APC. More than 80% of this load is borne by nurses in primary care in SA, a burden for which they often feel ill equipped. APC is designed around their needs and scope of practice, customised for their use in the clinic and compliant with all policies, and, importantly, harmonises conflicting instructions in different official guidelines. Health systems research is a challenging but vital component of healthcare delivery, especially in resource-constrained settings, in which bad choices are both wasteful and deny care to those who need it. Results of a single well-conducted pragmatic controlled trial are of unquestionable value, but the evidence gap is best addressed by a Learning Health System – a continuous programme of research designed to generate and apply best evidence and then rigorously evaluate its effectiveness. Such a programme requires long-term collaborations between researchers, healthcare system and authorities ‘to drive the process of discovery as a natural outgrowth of patients’ care; and to ensure innovation, quality, safety and value in health care’.[11] Lara R Fairall Knowledge Translation Unit, University of Cape Town Lung Institute, and Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa lara.fairall@uct.ac.za

Ozayr Mahomed Discipline of Public Health Medicine, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

Eric D Bateman Knowledge Translation Unit, University of Cape Town Lung Institute, South Africa 1. Price D, Bateman ED, Chisholm A, et al. Complementing the randomized controlled trial evidence base: Evolution not revolution. Ann Am Thorac Soc 2014;11(Suppl):S92-S98. https://doi.org/10.1513/ AnnalsATS.201308-276RM 2. Ideal Clinic South Africa. Ideal Clinic Manual Version 16. Pretoria: National Department of Health, South Africa, October 2015. 3. Mash B, Fairall LR, Adejayan O, et al. A morbidity survey of South African primary care. PLoS One 2012;7(3):e32358. https://doi.org/10.1371/journal.pone.0032358 4. Fairall LR, Folb N, Timmerman V, et al. Educational outreach with an integrated clinical tool for nurseled non-communicable chronic disease management in primary care in South Africa: A pragmatic cluster randomized controlled trial. PLoS Med 2016;13(11):e1002178. https://doi.org/10:1371/journal. pmed.1002178 5. Sackett DL. Clinician-trialist rounds: Mind your explanatory and pragmatic attitudes! Part 1: What. Clin Trials 2013;10(3):495-498. https://doi.org/10.1177/1740774513484395 6. Fairall LR, Zwarenstein M, Bateman ED, et al. Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: Pragmatic cluster randomised controlled trial. BMJ 2005;331:750. https://doi.org/10.1136/bmj.331.7519.750 7. Zwarenstein M, Fairall LR, Lombard C, et al. Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial. BMJ 2011;342:d2022. https://doi.org/10.1136/bmj.d2022 8. Fairall LR, Bachmann MO, Lombard C, et al. Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): A pragmatic, parallel, cluster-randomised trial. Lancet 2012;380(9845):889-898. https://doi.org/10.1016/S0140-6736(12)60730-2 9. English M, Irimu G, Agweyu A, et al. Building Learning Health Systems to accelerate research and improve outcomes of clinical care in low- and middle-income countries. PLoS Med 2016;13(4):e1001991. https://doi.org/10.1371/journal.pmed.1001991 10. Fairall L, Bachmann MO, Zwarenstein M, et al. Cost-effectiveness of educational outreach to primary care nurses to increase tuberculosis case detection and improve respiratory care: Economic evaluation alongside a randomised trial. Trop Med Int Health 2010;15(3):277-286. https://doi.org/10.1111/j.13653156.2009.02455.x 11. Olsen L, Aisner D, McGinnis JM. The Learning Healthcare System: Workshop Summary (IOM Roundtable on Evidence-Based Medicine). Washington, DC: National Academies Press, 2007.

S Afr Med J 2017;107(4):278-279. DOI:10.7196/SAMJ.2017.v107i4.12413

April 2017, Print edition

EDITOR’S CHOICE

CME: Prevention of childhood injuries (part 2)

Trauma and violence are major contributors to the burden of disease globally, and low- and middle-income countries (LMICs) bear the brunt of this scourge. Unfortunately, in South Africa (SA), attempts to mitigate the devastating effects of trauma and violence on our young population are not a top priority of policy makers and health practitioners. Two very important reference points guide the programmes that promote child safety in SA. The Convention on the Rights of the Child, as promoted by the United Nations, has been adopted in its entirety in SA. These values are also entrenched in our Constitution. It would, therefore, seem that our country is serious about and committed to promoting the rights of children to survival and health, development, and protection from trauma and abuse. Reality paints a starkly different picture, however, with the obligation of the health and social development sectors to protect children’s rights remaining feeble and without a commitment to a clear proactive course of action. Furthermore, child health comprises far more than the absence of disease. Striving for a healthy child population should include the goal of promoting child safety, and prioritising focused and appropriate assessment of childhood trauma, injury risk and resilience factors. This issue of CME makes a crucial contribution to child safety with regard to two major issues – child burns, and child safety in motor vehicles through child restraints.

Contraception coverage and methods used among women in SA: A national household survey

Contraception has profound benefits for women and society, including reduced maternal and infant mortality and morbidity, empowerment of women to make informed choices about fertility, economic advancement, and a reduction in the number of children infected with HIV. In recent decades, contraceptive use has risen markedly worldwide, although at a much slower pace in sub-Saharan Africa than elsewhere. About a quarter of women in sub-Saharan Africa currently use modern contraceptive methods, with levels highest in southern Africa. In SA, for example, estimates of the proportion of women of reproductive age who are protected against unplanned pregnancies, using modern contraceptive methods, have increased steadily from 26.3% in 2002/2003 to 37.3% in 2013/2014. These figures are drawn from a district health information system covering the public sector, while population-level end-user data have yielded somewhat different estimates. For example, the 2003 Demographic and Health Survey, the most recent available national report, found a contraceptive prevalence of 64.7%, similar to more recent modelling estimates. Regardless of which figures are correct, the continued rise in the number of terminations of pregnancy in SA among all age groups suggests that substantial deficiencies remain in accessing family planning services. Using data from the 2012 SA National HIV Prevalence, Incidence and Behaviour Survey, this analysis by Chersich et al.[1] assesses the extent of unmet contraceptive need, and estimates the overall contraception coverage and methods used. The authors also aimed to identify underserved populations through examining the demographic factors and sexual behaviours associated with contraceptive use. In addition to providing updated figures on key family planning indicators, they sought to identify the areas that need to be addressed to strengthen family planning services in SA and similar settings. Conclusions were not encouraging. Even though levels appear to be rising slowly over time, less than half of SA women were using a modern contraceptive method in 2012. Women with only primary

school education and of lower socioeconomic status were less likely to report contraceptive use. In the light of high unintended pregnancy rates and contraceptive failure noted in this study, it is hoped that SA’s new contraceptive policy and clinical guidelines will be fully implemented as a national health priority.

Hip and knee arthroplasty waiting list – how accurate and fair?

Orthopaedic surgery is an expensive procedure with high patient demand for reconstructive service. This mismatch between patient demand and available service results in the requirement for surgical waiting lists. Hip and knee joint replacement surgery (arthroplasty) is life changing in terms of pain reduction and functional improvement, but patients can wait months to years for the procedure. This is not unique to SA, but local challenges of high and competing trauma and infection, and burden of disease exacerbate the problem. Surgical waiting lists are frequently used to determine demand and access by hospital managers and provincial planners. It is therefore necessary to understand the waiting list system and assess how accurately it reflects patient demand. At Groote Schuur Hospital (GSH), despite performing >250 hip and knee joint replacements per year, there is an extensive and growing waiting list. Traditionally, waiting lists have been personally maintained by the surgeons involved, using a variety of paper-based and electronic methods. Recently, GSH developed a hospital-based electronic waiting list system for arthroplasty, requiring the interaction of administration and clinical staff. This has brought about many unforeseen challenges. Waiting lists are necessary to improve fair access to healthcare such as high-cost surgical procedures. They should ensure the optimal use of time for healthcare workers and patients. Ideally, patients should be stratified by means of a predetermined scoring system to match needs, skills and outcomes. However, many waiting lists are poorly managed, and anecdotal experience suggests that fairness to access is impeded by difficulty in contacting patients due to inaccurate contact details and the surgeons’ practice of calling in the last-seen patient when there is a last-minute cancellation. However, clinicians and services are increasingly being assessed by their waiting periods and lists, especially by increasing numbers of hospital management staff. Patients waiting >6 months for their surgery have been shown to experience greater preoperative anxiety, depression and dissatisfaction than those waiting <6 months. Generally, neither pain nor function seemed to worsen for patients waiting <6 months for knee or hip replacements.

Available data sources for monitoring non-communicable diseases and their risk factors in SA

The importance of quality data in health service delivery, programme planning, monitoring and evaluation is widely acknowledged. The concept of data availability for decision-making has been promoted with a view to improving evidence-based public health programming for better health outcomes. Quality data are also critical to the pathway to universal health coverage, enabling better understanding of budget allocation in the organisation of health services, including an integrated approach for those in need. A World Health Organization (WHO) report showed that in many LMICs, data for monitoring indicators of major non-communicable diseases (NCDs) such as cancer are at best only partially quantifiable. In SA, health information systems for major infectious diseases function relatively better than those for NCDs. The electronic tuberculosis register (ETR.net), designed for TB/HIV surveillance,

April 2017, Print edition

EDITOR’S CHOICE

programme monitoring and evaluation, and the Three Interlinked Electronic Registers (TIER.net), which keep patient records on HIV and tuberculosis, while not perfect, have been implemented by most public health facilities. In contrast, in common with those of most LMICs, SA data sources for monitoring NCDs are rudimentary. These diseases were previously mostly associated with affluence in LMICs,[14] so they received little attention, leading to this paucity of reliable health information systems for NCDs. The High-Level Meeting of the 66th session of the United Nations General Assembly in 2011 and the WHO’s Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013 - 2020, which had as one of six objectives ‘to monitor the trends and determinants of noncommunicable diseases and evaluate progress in their prevention and control’, combined to give new momentum to NCD monitoring efforts. In 2012, the SA National Department of Health developed a National Strategic Plan for the Prevention and Control of NonCommunicable Diseases 2013 - 17 (NCD Strategic Plan) followed by the 2015 Strategy for the Prevention and Control of Obesity in South Africa 2015 - 2020. The NCD Strategic Plan outlined priority health conditions and set out goals and targets to be achieved by the year 2020 for various indicators. Wandai et al.[2] set out to: (i) describe data sources currently available to monitor NCD prevalence, risk conditions and risk factors in SA; (ii) assess the range, quality, regularity and comparability of results from these sources and identify gaps; and (iii) suggest improvements to data producers. The recommendation is that available SA data sources for NCDs and their risk conditions and factors be harmonised and in certain areas strengthened, eliminating gaps and providing a sound basis of data quality, definitions and categories used and timeliness to facilitate monitoring progress of the NCD Strategic Plan.

Cross-sectional evaluation of the Bronchitis Severity Score in Egyptian children: A move to reduce antibiotics

Despite evidence of limited benefit of antibiotics in acute bronchitis, most paediatric patients are prescribed them. A high incidence of infectious diseases and frequent use of antibiotics are reported from

LMICs, where resistant bacteria spread rapidly owing to factors such as overcrowding, poor sanitation and a warm, humid climate. Moawad et al.[3] evaluated the validity of the Bronchitis Severity Score (BSS) in assessing the clinical response to treatment of acute bronchitis, and determined whether clinical data and basic laboratory measurements can be used to guide antibiotic prescription. The BSS, first described in 1996 by Haidvogl et al.,[4] is a clinical assessment scale based on physician-assessed items in conjunction with subjective feedback from the patient. It was designed to be used by primary healthcare practitioners to assess the clinical status of a patient with acute bronchitis at various points of time, i.e. baseline and follow-up visits. The study confirmed that the diagnosis of acute bronchitis is influenced by variables such as cough, purulent sputum and the presence of abnormal chest findings on examination. Overall, the results are consistent with previously published research on childhood acute bronchitis, with a predominance of acute cough in all cases. Twenty-eight percent of the participants had a productive cough with purulent sputum, also consistent with other studies, in which >50% of parents described the cough as dry, the remainder reporting it to be productive or of a mixed type. As has been reported by others, the authors found that the colour of the sputum had no predictive value for the diagnosis of bacterial bronchitis or for differentiating between pneumonia and bronchitis. The BSS was identified as a simple and practical clinical scoring system for evaluating disease severity and monitoring disease resolution in acute bronchitis, and may help to reduce the inappropriate use of antibiotics and combat antibiotic resistance. BF 1. Chersich MF, Wabiri N, Risher K, et al. Contraception coverage and methods used among women in South Africa: A national household survey. S Afr Med J 2017;107(4):307-314. https://doi.org/10.7196/ SAMJ.2017.v107i4.12141 2. Wandai M, Aagaard-Hansen J, Day C, Sartorius B, Hofman KJ. Available data sources for monitoring non-communicable diseases and their risk factors in South Africa. S Afr Med J 2017;107(4):331-337. https://doi.org/10.7196/SAMJ.2017.v107i4.11438 3. Moawad CEMI, Haron MAE, Maher RMA, et al. Cross-sectional evaluation of the Bronchitis Severity Score in Egyptian children: A move to reduce antibiotics. S Afr Med J 2017;107(4):342-345. https://doi. org/10.7196/SAMJ.2017.v107i4.11428 4. Haidvogl M, Schuster R, Heger M. Akute Bronchitis im Kindesalter. Multicenter-Studie zur Wirksamkeit und Vertraglichkeit des Phytotherapeutikums Umckaloabo. Z Phytother 1996;17(5):300-313.

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Death by maladministration: An important category of patient mortality

B Patel South African Federation of Mental Health, Johannesburg, South Africa

To the Editor: South Africa (SA) has witnessed regular protest actions in recent years. These involve major political issues including quality education, service delivery, state capture, and other crucial matters. Despite their large contribution to the national burden of disease, including morbidity and mortality, mental health issues have received much less attention from the public and from the press. And the fate of the most severely impacted, such as those with intellectual disability, appears to be of particularly little interest. Yet the quality of life of those who are the most vulnerable and voiceless in society often serves as the proverbial canary in the coal mine. Disregard for such individuals is a marker of deep dysfunction in health systems. This has been tragically illustrated through the recent debacle at the Gauteng Department of Health, where administrators demanded the discharge of around 2 000 patients with mental illness from the Life Esidimeni facility, leading to the death of at least 94.[1] If we are to learn one lesson from the international experience of deinstitutionalisation over the last 50 years, it is that it should never be pursued as a cost-saving strategy. The funds should always follow the patients into the community. Well-resourced community-based mental health services can provide high-quality care for people living with mental illness, within a human rights framework. Indeed, this approach is strongly endorsed by the World Health Organization.[2] In effect, administrative decisions which override such considerations constitute an important category of patient morbidity and even mortality. Sustainable development, so sorely needed by our country, is crucially dependent on functional health systems.[3] In the case of HIV, death by maladministration was exemplified in the failure to roll out antiretrovirals, which severely impacted our economic growth. Analogously, deinstitutionalisation of psychiatric services without adequate community care has previously been proposed locally, but fails to provide health or save funds over the long term.[4] Not only is there no health without mental health,[5-8] but arguably there is no sustainable development without mental health; the data continuously indicate that it is less expensive for countries to treat mental illness than to ignore it.[7] We are heartened that health professionals (including the Society of Psychiatrists of SA) and civil society (including the SA Depression and Anxiety Support Group, and the SA Federation of Mental Health) joined to vigorously oppose the Gauteng Department of Health, and by the independence demonstrated by both the courts and the Health Ombud on this matter. We call for immediate action to implement the National Mental Health Policy Framework and Strategic Plan (2013 - 2020) in provinces, and for adequate community-based care for people living with mental illness.[8] D J Stein Department of Psychiatry and Mental Health, Medical Research Council Unit on Risk & Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa dan.stein@uct.ac.za

C Chambers South African Depression and Anxiety Support Group (SADAG), Johannesburg, South Africa

I Daniels Cape Mental Health, Cape Town, South Africa

C Sunkel South African Federation of Mental Health, Johannesburg, South Africa

J White School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Z Wilson South African Depression and Anxiety Support Group (SADAG), Johannesburg, South Africa

C Lund Department of Psychiatry and Mental Health, Medical Research Council Unit on Risk & Resilience in Mental Disorders, University of Cape Town, Cape Town, South Africa 1. Makgoba M. Report into the ‘Circumstances Surrounding the Deaths of Mentally Ill Patients: Gauteng Province’. 2017:60. http://www.ohsc.org.za/images/documents/FINALREPORT.pdf (accessed 1 February 2017). 2. World Health Organization. Organization of Services for Mental Health. Mental Health Policy and Service Guidance Package. Geneva: WHO, 2003. 3. Izutsu T, Tsutsumi A, Minas H, et al. Mental health and wellbeing in the Sustainable Development Goals. Lancet Psychiatry 2015;2(12):1052-1054. http://dx.doi.org/10.1016/S2215-0366(15)00457-5 4. Stein DJ, Allwood C, Emsley RA. Community care of psychiatric disorders in South Africa - lessons from research on deinstitutionalisation. S Afr Med J 1999;89(9):942-943. 5. Prince M, Patel V, Saxena S, et al. No health without mental health. Lancet 2007;370(9590):859-877. 6. Lund C, Stein DJ, Corrigall J, et al. Mental health is integral to public health: A call to scale up evidencebased services and develop mental health research. S Afr Med J 2008;98(6):444-446. 7. Lund C, Myer L, Stein DJ, Williams DR, Flisher AJ. Mental illness and lost income among adult South Africans. Soc Psychiatry Psychiatr Epidemiol 2013;48(5):845-851. 8. Stein DJ. A new mental health policy for South Africa. S Afr Med J 2014;104(2):115-116.

S Afr Med J 2017;107(4):280. DOI:10.7196/SAMJ.2017.v107i4.12389

Targeting mothers and selling men what they do not want: A response to ‘Missed opportunities for circumcision of boys’

To the Editor: Millard et al.[1] state in their editorial in the SAMJ January issue that medical male circumcision (MC) in South Africa (SA) peaked in 2013, only to decline in subsequent years despite improved surgical infrastructure and ‘high-level marketing’. They attach great hope to ‘demand creation’, which they state is supported by the Bill and Melinda Gates Foundation and the Clearinghouse on Male Circumcision. ‘Demand creation is trying to sell something that many men don’t want’, they state. Elucidating MC statistics, the authors report that ‘45% of all 2014 circumcisions were among boys <15 years of age.’ According to them, ‘it is time for SA to change gears and orient marketing and programmes to males of all ages’, but particularly to boys of this age range. In addition, they compare MC of boys to successful ‘immunisation’ and suggest that ‘mothers are an influential but neglected target of circumcision promotion’, since they will presumably motivate their boys to be circumcised and spread the word about MC to their friends. Their conclusion is that ‘the time to change course is now’. Adult MC as a form of partial prophylaxis against female-to-male, heterosexually transmitted HIV, where valid, informed consent has been acquired, has its supporters and there are legitimate arguments to be made in its defence. Even then, the scope of information required for consent to be valid is a matter of serious concern. For example, have the functions, sensitivity and other anatomical properties of the foreskin been fully communicated and understood?[2,3] Are the ongoing ethical and medical controversies regarding MC at least

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mentioned in the process of obtaining consent?[4] Such matters are not mere technicalities; for consent to be ethically valid, it must be fully informed – not solicited by emphasising only the benefits of a procedure, as in the case of a ‘marketing’ campaign. There has been repeated criticism of the idea that MC of boys can be compared with immunisation.[5] Immunisation involves a needle-prick to the skin and can prevent serious conditions that pose a current risk to the child, and which are easily transmittable to other children through incidental contact. MC, by contrast, involves the irreversible excision of healthy genital tissue, to reduce the risk of potential diseases to which the child may one day be exposed. Vaccination is uniformly supported by mainstream medical associations; MC is, however, a source of sustained controversy among qualified experts. The creation of an artificial ‘demand’ through ‘high-level marketing’ and ‘targeting mothers’ – for a surgical procedure that removes healthy tissue from a minor individual in the absence of actual pathology – raises serious ethical questions. To ‘target’ mothers as a means to an end smacks of manipulation, undermines parental autonomy, and may be a misuse of medical authority and the power differential between doctor and patient. The authors’ admission of medical interference with cultural rituals also raises serious concerns regarding medical patronising. It is also problematic that no reference is made to the Children’s Act (Act No. 38 of 2005), which stipulates that a boy to be circumcised must be 16 years of age and must provide his own informed consent. It may only be performed after counselling and in accordance with the regulations to the Act (s 12(9)(a) - (c)). Circumcision of any male child under the age of 16 is prohibited except when it is performed for religious purposes in accordance with the practices of the religion concerned, or for medical reasons on the recommendation of a medical practitioner (s 12(8)). Contravention of s 12(8) is rendered a criminal offence by s 305(1)(a)). Given a situation as controversial and complex as MC of minors for intended risk-reduction of HIV transmission, an attitude of caution is surely warranted. Medical programmes implemented without due ethical regard for the decision-making autonomy of boys and their parents run the risk of accumulating ‘so much power, that they become immune to their own mistakes’.[6] If MC is something ‘many men don’t want’, we should listen to them and take seriously their perspectives. This could be attained via community engagement and community consultation initiatives. Simply bypassing them and pressing the procedure onto more vulnerable commodified ‘targets’ represents a ‘missed opportunity’ to learn from its intended beneficiaries. More importantly, the missed opportunities to educate patients on matters of genital hygiene, safe sex and other HIV preventive measures are blatant in many HIV clinics in public hospitals where patients sit in waiting rooms for hours with minimal educational or motivational input from healthcare workers. High school education in SA is yet another missed opportunity, with life orientation classes often spending minimal time on education around sexually transmitted diseases, including HIV. Simply applying a biomedical fix to a complex multifactorial sociobehavioural medical crisis in the context of extreme poverty, marginalisation and disenfranchisement has not worked and will not work. D Sidler Division of Paediatric Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children’s Hospital, Cape Town, South Africa ds2@sun.ac.za

B D Earp Yale-Hastings Program in Ethics and Health Policy, Yale University, USA; and Research Fellow, Oxford Uehiro Centre for Practical Ethics, University of Oxford, UK

A A van Niekerk Centre for Applied Ethics, Stellenbosch University, Cape Town, South Africa

K Moodley Centre for Medical Ethics and Law, World Health Organization Collaborating Centre in Bioethics; and Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

S Kling Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Children’s Hospital, Cape Town, South Africa 1. Millard P, Goldstuck N. Missed opportunities for circumcising boys. S Afr Med J 2017;107(1):19. https://doi.org/10.7196/SAMJ.2017.v107i1.12177 2. Earp BD. Infant circumcision and adult penile sensitivity: Implications for sexual experience. Trends Urol Mens Health 2016;7(4):17-21. https://doi.org/10.1002/tre.531 3. Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83(S1):34-44. 4. Parker R, Aggleton P, de Camargo, KR Jr. Circumcision and HIV prevention: Emerging debates in science policies and programmes. Global Public Health 2015;10(5-6):549-551. https://doi.org/10.10 80/17441692.2015.1015705 5. Lyons B. Male infant circumcision as a ‘HIV vaccine’. Public Health Ethics 2013;6(1):90-103. https:// doi.org/10.1093/phe/phs039 6. Harari YN. Homo Deus, A Brief History of Tomorrow. London: Harvil Secker, 2016:167.

S Afr Med J 2017;107(4):281. DOI:10.7196/SAMJ.2017.v107i4.12406

What is the nature of a conflict of interest in a scientific publication?

To the Editor: The use, misuse and, sometimes, failure to recognise conflict of interest (CoI) is a growing problem in medical publications.[1] The critique by Harcombe and Noakes[2] published in the December 2016 SAMJ, purporting to find many weaknesses in the so-called ‘Universities of Stellenbosch/Cape Town low-carbohydrate review’[3] is somewhat disturbing, not specifically because of the content of their critique, to which the authors of the systematic review have replied, but because of how Harcombe and Noakes have recruited questions of bias and implied CoI to support their views. Harcombe and Noakes imply bias on the part of the authors of the original systematic review by suggesting it is a ‘reasonable question’ to ask ‘what is the chance that … all the errors … disadvantaged the low-CHO [carbohydrate]’ diet … when many of the authors … are on public record as being vigorously opposed to lower- or lowCHO diets and those who promote such eating plans.’ Indeed, their ‘Opinion’ title goes further by suggesting there might have been ‘mischief.’ Does going on public record opposing or promoting a scientific position mean anything with regard to the likely validity of the findings of a subsequent peer-reviewed paper? If so, the same arguments could be made about Harcombe and Noakes, who have been far more public in their advocacy for a particular interpretation of the low-CHO diet question. Should we read any bias into their analysis simply because they have invested so much time and effort in claiming benefits for a low-CHO diet? Clearly, Harcombe and Noakes would argue that it would be rather unscientific to take such a position. The claim that scientists who have held a particular position in a public debate are likely to be biased in any future engagement on that issue is one of a number of strategies used by corporations to discredit scientists whose research has found that corporate products or activities are health-harming.[4] These industry arguments posit that because a particular scientist has previously held a public

April 2017, Print edition

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Lagoon Beach Hotel, Cape Town Saturday, 6 May 2017 OVERVIEW Doctors: For speaker topics please see the programme on www.sasawesterncape.co.za Nurses: For speaker topics please see the programme on www.sasawesterncape.co.za COST SASA Members: Early Registration: R250.00 • Late Registration: R350.00 Non-SASA Members: Early Registration: R1 000.00 • Late Registration: R1 200.00 Nurses: Early Registration: R450.00 • Late Registration: R500.00 CPD The Update Meeting will be accredited REGISTRATION Early registration closes 22 April 2017 To register please visit our website: www.sasawesterncape.co.za Date: Venue:

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position on a scientific finding of public health importance, they have a CoI no different to that of a scientist employed by an industry with financial interests in the outcome of a research investigation into their product or activity. I have personally experienced such arguments in engaging with industry-employed scientists in the field of pesticide hazards.[5] Using this argument, industry interests seek to neutralise science that produces findings critical of its operations by widening the scope of CoI so unreasonably as to include simply holding a public opinion. In that construction, because everyone has an opinion, everyone must have a CoI, so CoI becomes irrelevant for assessing the validity of a study. Yet the CoI declared by Harcombe and Noakes appears quite limited. Listed are a number of statements pertaining to financial interests (or non-interests of the authors). But strangely, nowhere in the declaration is it mentioned that Prof. Noakes is facing a disciplinary hearing by the Health Professions Council of South Africa in which the validity of his claims regarding the low-CHO diet is relevant to the question of his professional behaviour. No matter what one believes about whether the charges are groundless or justified, it is undeniable that a systematic review that produces evidence that contradicts his public claims is obviously highly damaging to his case, and a published critique of the systematic review would be of direct help to defend himself at the hearing. Yet this interest is not mentioned at all in the declaration. CoI in the context of publication needs to be understood not as a matter of holding strong opinions, but as a situation in which an individual’s interests diverge from their scientific responsibilities such that they may be seen to achieve unusual personal advantage from the publication of the article.[6] The World Health Organization defines CoI as occurring when the ‘ability to exercise judgement in one role is impaired by his or her obligations in another role or by the existence of competing interests,’ which could ‘create a risk of a tendency towards bias in favour of one interest over another or that the individual would not fulfil his duties impartially’.[7] This could take the form of a financial or material advantage, as most commonly framed by CoI statements, but also includes nonfinancial interest – including the arena of litigatory or regulatory advantages. Just as corporations try to generate pseudoscience that they can advance in defending themselves from claims in court, individuals who might benefit in a litigatory context from a particular publication are also in a position of CoI. Readers need to know that when they interpret a particular set of findings emerging from a publication. CoI statements should not be used to discount results of a particular paper, but to give readers the opportunity to understand how CoI may have been present in the interpretation and to ‘judge the paper in a more informative way’.[8] Managing CoI in publications is not easy, and deciding what constitutes a non-financial CoI is not always obvious. For example, different sources cite academic commitments, personal relationships or favours, political or religious beliefs, relationships to the journal editor or institutional affiliations as non-financial conflicts of interest.[6,7,9,10] The International Committee of Medical Journal Editors’ form for disclosure of potential CoIs lists a very broadly inclusive frame of ‘other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work’.[11] However, a recent survey of 117 ‘core’ clinical journals noted that non-financial CoI criteria used by journals were most commonly issues related to ‘personal relationship’, ‘professional relationships’ and ‘academic associations’, and that ‘personal opinion’ and author-

ship of original studies or editorials on the same subject were regarded as constituting CoI in only three journals (less than 5% of all responding journals).[12] This signals the difficulties in managing CoI in health scientific publications. But unless we make a start by reflecting carefully on what it is, what it is not and how it should be handled, we risk allowing the notion to be recruited for partisan reasons in contentious debates, and subordinating science to vested interests. With major public health policies looming in South Africa, such as legislation on alcohol advertising, the National Health Insurance, regulation of e-cigarettes and the adoption of sugar-sweetened beverage taxes, we can anticipate intense lobbying by vested interests to shape public opinion as to what really is the best evidence. We desperately need clear CoI provisions unambiguously executed to ensure that vested interests are not allowed to use our journals to benefit some interests at the expense of science. L London School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa leslie.london@uct.ac.za 1. United Nations Educational, Scientific and Cultural Organization. Growing concern about conflict of interest in scientific journals. In: UNESCO Science Report 2010. Paris: UNESCO, 2010;48. 2. Harcombe Z, Noakes TD. The universities of Stellenbosch/Cape Town low-carbohydrate diet review: Mistake or mischief? S Afr Med J 2016;106(12):1179-1182. https://doi.org10.7196/SAMJ.2016.v106. i12.12072 3. Naude CE, Schoonees A, Senekal M, Young T, Garner P, Volmink J. Low carbohydrate versus isoenergetic balanced diets for reducing weight and cardiovascular risk: a systematic review and metaanalysis. PLoS One 2014;9(7):e100652. https://doi.org/10.1371/journal.pone.0100652 4. Michaels D. Doubt is their product: How industry’s assault on science threatens your health. Oxford: Oxford University Press, 2008. 5. London L, Coggon D, Moretto A, Westerholm P, Wilks MF, Colosio C. The ethics of human volunteer studies involving experimental exposure to pesticides: Unanswered dilemmas. Environmental Health 2010;9:50. hhttps://doi.org/10.1186/1476-069X-9-50 6. World Association of Medical Editors. Conflict of Interest in Peer-Reviewed Medical Journals. http:// wame.org/about/conflict-of-interest-in-peer-reviewed-medical (accessed 4 February 2017). 7. Roll Back Malaria Partnership. Conflict of Interest Policy and Procedure. Geneva: World Health Organization, 2006. http://archiverbm.rollbackmalaria.org/partnership/secretariat/docs/ RBMconflictOfIinterestPolicy.pdf (accessed 4 February 2017). 8. Ruff K. Scientific journals and conflict of interest disclosure: What progress has been made? Environ Health 2015;30;14-45. https://doi.org/10.1186/s12940-015-0035-6 9. Wager E, Kleinert S. Responsible research publication: International standards for authors. A position statement developed at the 2nd World Conference on Research Integrity, Singapore, 22 - 24 July 2010. In: Mayer T, Steneck N, eds. Promoting Research Integrity in a Global Environment. Singapore: Imperial College Press/World Scientific Publishing, 2011:309-316. 10. Macklin R. Conflict of interest and bias in publication. Indian J Med Ethics 2016;1(4):219-222. 11. International Committee of Medical Journal Editors. ICMJE Form for Disclosure of Potential Conflicts of Interest. http://icmje.org/conflicts-of-interest/ (accessed 4 February 2017). 12. Khaled Shawwa K, Kallas R, Koujanian S, et al. Requirements of clinical journals for authors’ disclosure of financial and non-financial conflicts of interest: A cross-sectional study. PLoS ONE 11(3):e0152301. https://doi.org/10.1371/journal.pone.015230

S Afr Med J 2017;107(4):282-283. DOI:10.7196/SAMJ.2017.v107i4.12411

Patients in whom surgical closure of terminal branches of external carotid arteries for migraine treatment resulted in reduced frequency of epileptic attacks

To the Editor: I read the recent case report by Shevel[1] with regard to three cases of migralepsy with great interest. The author described postoperative improvement in migraine after surgical bilateral closure of terminal branches of external carotid arteries, which in every case was associated with marked reduction in occurrences of epilepsy in the same patients. I would like to point out that migralepsy (i.e. migraine-related epilepsy) is a common entity, affecting ~50% of people suffering from essential headaches (migraine and other nondescript headaches).[2-5] The veracity of the author’s finding is attested to by a similar dramatic improvement in migraine-related

April 2017, Print edition

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seizures after headaches are brought under adequate control, using daily scheduled maintenance therapy with opioids, employing dosetitrating methodology. This may require up-titrating the dose to very high levels in some patients.[6] Iraj Derakhshan University of Cincinnati, Cincinnati, and Case Western Reserve University, Cleveland, Ohio, USA idneuro@hotmail.com 1. Shevel EI. 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. S Afr Med J 2016;106(11):1084-1085. https://doi.org/10.7196/SAMJ.2016.v106i11.10866

2. Wilner AN, Sharma BK, Thompson AR, Krueger A. Analgesic opioid use in a health-insured epilepsy population during 2012. Epilepsy Behav 2016;57:126-132. https://doi.org/10.1016/j. yebeh.2016.01.033 3. Derakhshan I. Analgesic opioid use in a health-insured epilepsy population during 2012: Consider migralepsy. Epilepsy Behav 2016;60:238. https://doi.org/10.1016/j.yebeh.2016.04.013 4. Wilner AN, Sharma BK, Thompson AR, Krueger A. Analgesic opioid use in a health-insured epilepsy population during 2012: Response to Derakhshan. Epilepsy Behav 2016;60:239. https://doi. org/10.1016/j.yebeh.2016.04.016 5. Harnod T, Wang YC, Kao CH. High risk of developing subsequent epilepsy in young adults with migraine: A nationwide population-based cohort study in Taiwan. QJM 2015;108(6):449-455. https:// doi.org/10.1093/qjmed/hcu215 6. Spierings EL, Volkerts ER, Heitland I, Thomson H. A randomized, rater-blinded, crossover study of the effects of oxymorphone extended release, fed versus fasting, on cognitive performance as tested with CANTAB in opioid-tolerant subjects. Pain Med 2014;15(2):264-271. https://doi.org/10.1111/pme.12307

S Afr Med J 2017;107(3):172. DOI:10.7196/SAMJ.2017.v107i3.12280

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 fi brillation. 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 fi brillation: 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. S4 XARELTO ® 15: Each film-coated tablet contains rivaroxaban 15 mg. Reg. No: 46/8.2/0111; Namibia S2 : 12/8.2/0006; Botswana S2 : BOT1302296 S4 XARELTO ® 20: Each film-coated tablet contains rivaroxaban 20 mg. Reg. No: 46/8.2/0112; Namibia S2 : 12/8.2/0007; Botswana S2 : BOT1302297 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, Co. Reg. No.: 1968/011192/07, 27 Wrench Road, Isando, 1609. Tel: +27 (0) 11 921 5044 Fax: +27 (0) 11 921 5041. For full prescribing information, refer to the package insert approved by the Medicines Regulatory Authority (MCC). L.ZA.MKT.GM.01.2016.1265 © Bayer January 2016 *Impact RX Data Oct - Dec 2015 NOAC: Non Vitamin K Oral Anticoagulant

April 2017, Print edition

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IZINDABA

30 days in medicine Vitamin D supplementation and acute respiratory tract infections

Acute respiratory tract infections (ARTIs) are responsible for 10% of visits to doctors in the USA and important causes of morbidity and mortality globally. Observational studies report consistent independent associations between low serum vitamin D levels and susceptibility to ARTI. A systematic review and meta-analysis from randomised controlled trials[1] published recently in the BMJ suggests that vitamin D supplementation is safe and protects against ARTI, the effect being particularly marked in those who were very deficient in the vitamin. However, a linked editorial[2] questions the validity of the data, saying that clinical practice should probably not be changed – yet. The authors point out that the primary result is a reduction from 42% to 40% in the proportion of participants experiencing at least one ARTI. Also, the definition of ARTI varied between studies, consisting of a mixture of diverse conditions such as acute otitis media, laboratory-confirmed influenza, self-reported colds or chest infections and radiograph-confirmed pneumonia. The jury is still out. 1. Martineau R, Joliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent acute respiratory tract infections: Systematic review and meta-analysis of individual participant data. BMJ 2017;356:i6583. https://doi.org/10.1136/bmj.i6583 2. Bolland MJ, Avenell A. Do vitamin D supplements help prevent respiratory tract infections? BMJ 2017;356:j456. https://doi.org/10.1136/bmj.j456

Anti-clotting drugs linked to bleeding near brain

A large Danish study has found that antithrombotic drug use, particularly use of a vitamin K antagonist, increases the risk of subdural haematoma. Researchers identified 10 000 patients with a first-ever subdural haematoma from 2000 to 2015, who were matched to more than 400 000 people from the general population. Among those with a subdural haematoma, 47% were taking antithrombotic medication. The highest odds of subdural haematoma were associated with using a vitamin K antagonist such as warfarin. Low-dose aspirin was associated with a slightly increased risk of subdural haematoma, while clopidogrel and a direct oral anticoagulant were associated with a moderately higher risk. The highest risk was found in concurrent use of clopidogrel and a vitamin K antagonist. Overall, women were at higher risk than men with all antithromobotic drugs. This study adds to the complexity of the risk-benefit equation of antithrombotic drug use. Gaist D, Rodriguez LAG, Hellfritzsch M. Association of antithrombotic drug use with sub-dural haematoma risk. JAMA 2017;317(8):836-846. https://doi.org/10.1001/jama.2017.0639

Ask two simple questions to predict depression in the elderly

Complex screening tools are no more effective than asking two simple questions to diagnose depression in older people, according to a review of clinical studies. The prevalence of depression in older people is 10 - 20%. Early detection and treatment will improve prognosis, but traditional screening is difficult because many somatic symptoms such as weight loss and disturbed sleep are common physical problems associated with ageing.

Researchers identified 133 studies evaluating 16 diagnostic tools in a total of 46 651 patients aged 60 - 87 years. Most studies used the Geriatric Depression Scale, but six used the Two Question Screen asking about symptoms in the past month: ‘Have you been troubled by feeling down, depressed or hopeless?’, and ‘Have you experienced little interest or pleasure in doing things?’. The results, reported in the British Journal of Psychiatry, showed that the Two Question Screen diagnosed depression as effectively as other screening instruments. Tsoi KKF, Chan JYC, Hirae HW, et al. Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: Systematic review and meta-analysis. Br J Psychiatry 2017, bjp.bp.116.186932. https://doi.org/10.1192/bjp.bp.116.186932

Widespread use of pneumococcal conjugate vaccine in low- and middleincome countries safe

This study, recently published in Lancet Global Health, shows that the local introduction in 2011 of the 13-valent pneumococcal conjugate vaccine (PCV13) using a 2 + 1 schedule is safe and effective in both HIV-infected and HIV-uninfected children. PCV13 was designed to include disease-causing serotypes that are important in low- and middle-income countries. In this study, cases of invasive pneumococcal disease in children aged ≤5 years were identified through national laboratory-based surveillance and isolates were stereotyped. Age-matched, HIV status-matched in-hospital controls were sought for every case, aiming for four controls for every HIV-uninfected case and six controls for every HIV infection. Between January 2012 and December 2014, children aged ≥16 weeks were enrolled: 240 were cases not infected with HIV, 75 were cases with HIV infection, 1 118 were controls not infected with HIV, and 283 were controls with HIV infection. The effectiveness of two or more doses of PCV13 against PCV13-serotype invasive pneumococcal disease was 85% among 11 case-control sets of children not infected with HIV and 91% among three case-control sets of children with HIV infection. PCV13 effectiveness among 26 case-control sets of children not infected with HIV was 52% against all-serotype invasive pneumococcal disease and 94% (44 100%) for serotype 19A. Vaccine effectiveness against PCV7-serotype invasive pneumococcal disease was 87% in children exposed to HIV but uninfected and 90% (53 - 98%) in malnourished children not infected with HIV. The results indicate that PVC13 in a 2 + 1 schedule is effective for preventing vaccine-type pneumococcal infections in young children not infected with HIV, including those who are malnourished or have been exposed to HIV. These findings support the recommendation for widespread use of pneumococcal conjugate vaccine in low- and middle-income countries. Cohen C, von Mollendord C, de Gouveia L, et al. for the South African IPD Case-Control Study Group. Effectiveness of the 13-valent pneumococcal conjugate vaccine against invasive pneumococcal disease in South African children: A case-control study. Lancet Glob Health 2017;5(3):e359-e369. https://doi. org/10.1016/S2214-109X(17)30043-8

B Farham Editor ugqirha@iafrica.com

April 2017, Print edition

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IZINDABA

OBITUARY Denise Anne Campbell White

News of the death of Denise White on 9 March in London, in the care of her beloved daughters, will have hit her colleagues extremely hard. Denise graduated from the University of Cape Town. Addressing her fellow retirees in 2009, she recalled that when she had been a student in the 1960s there were no black Africans in her class, and coloured and Indian colleagues were not allowed to go near white patients at Groote Schuur Hospital. She observed that she and her fellow medical retirees had been privileged to have been part of a momentous passage from apartheid to democracy, and had seen the Faculty of Health Sciences at UCT becoming fully integrated. As was typical, she challenged fellow retirees ‘not to go home and feel sorry for yourself ’, but to continue making contributions, as the need for their services was so great. The immensity of her contributions to the South African medical scene, chiefly through her work in the South African Medical Association and the Health Professions Council of South Africa, has been well documented.[1] In 2009, Denise was appointed to the Medical and Dental Professions Board of the HPCSA. There she served two 5-year terms, retiring only in 2016, and was appointed to several subcommittees dealing with matters of professional conduct as well as serving on

the Health Committee (assessing and ruling on ‘impaired’ practitioners). A life member of SAMA, she chaired the Academic Doctors Association and later the Public Sector Doctors Committee and for many years led the staff association of Groote Schuur Hospital, being succeeded by Prof. Mark Sonderup. Denise was an effective communicator and natural leader, and often found herself leading in turbulent times. Her view was that there was no point in being ‘timid or naive – you have to don an asbestos shield to deflect the heat of a crisis and remain cool’.[1] In the era of AIDS denialism, as vicechairperson of SAMA in 2005, Denise engaged in a campaign against natural health approaches, in particular as they related to AIDS, and issued a statement on behalf of SAMA directly attacking micronutrients in the prevention and treatment of HIV/ AIDS. And, soon after her assumption of the chairmanship of the Association in 2009 in the hard days of the junior doctors’ strike (the first in the country), she found herself in the roiled waters of medical politics … in her own words, ‘SAMA’s titanic struggle’ aimed at achieving the Occupation-Specific Dispensation for public sector doctors.[2] As testament to her extraordinary commitment and her philosophy as expressed in ‘if you have the ability to serve, you should’, and despite diagnosis of the disease that was to cause her death, and the grievous sudden loss of her husband in 2015, Denise agreed to serve as president of SAMA for the 2015/2016 term. She devoted her term as president to raising awareness of mental health, which, as she expressed it, ‘is unfortunately the Cinderella of the healthcare professions – always the Oliver Twist’. She would have been appalled to learn of the recent Esidimeni crisis. Her advice regarding implementation of effective mental healthcare in this country, involving multiprofessional teams and task shifting to mental health workers in community clinics,[1] would be well taken. Denise was a superb clinical psychiatrist. She was chief clinician in the Emergency

April 2017, Print edition

Psychiatric Unit at GSH until her promotion to professor and head of psychiatry at Lentegeur Hospital. Legions of psychiatrists trained under her. Following her retirement, and having set up her own private practice, she continued to offer mentorship and advice by persuading these young colleagues, typically in solo private practice, to meet weekly in her rooms to participate in a journal club. In the course of our responsibilities for convening undergraduate and postgraduate training in our respective departments, my counterparts and I frequently called upon Denise to come to the aid of junior, and indeed some senior, colleagues who were dealing with depression and distress of one kind or another. A phone call was all it took to enlist instant assistance. As an academic and researcher, Denise was a highly sought-after speaker at international psychiatric conferences, having gained a national and international reputation for her early research focusing on the cause and management of the neuroleptic malignant syndrome. She (and colleague Dr Ashley Robbins) identified the link between administration of neuroleptic drugs to patients with a catatonic illness and evolution of the syndrome. Her later work concerned the links between HIV and psychiatric illness, half of all patients living with HIV/AIDS suffering some form of mental illness. She was also frequently called upon to address issues of women’s health. Fittingly, in 2016 she received the Distinguished Service Award from the South African Society of Psychiatrists. Denise White was a very precious friend and colleague to many, and will be sorely missed. Janet Seggie University of Cape Town, South Africa janet.seggie@uct.ac.za 1. Bateman C. SAMA president, medicopolitical veteran, psychiatrist and treatment pioneer. S Afr Med J 2015;105(12):1003-1004. https://doi.org/10.7196/SAMJ.2015.v105i12.10301 2. White D. The South African Medical Association (SAMA) – poised on the perimeter of change. S Afr Med J 2010;100(1):20-21.

IZINDABA

OBITUARY Oliver Raynham

Dr Oliver Raynham with patient Seth Gordon, about to go into theatre (photo by Sue Gordon).

Dr Oliver Raynham was killed in a boating accident in the early evening of 29 December 2016 at the age of 47. He was sailing his Hobie catamaran up the Klein River outside Stanford when its mast hit power lines crossing the river and he was electrocuted. On board with him were three 11-year-old boys, participants in the annual Hermanus Camp, where Oliver was volunteering as the camp doctor (as he had done for several years) and as a group leader. The boys escaped physically unharmed. They reported that just before the accident they had been sharing biscuits and enjoying the beauty of the evening, and Oliver’s last words were about how grateful and blessed they were to share such a wonderful moment. The way he died was typical of him – always living life to the full, out on an adventure, and surrounded by young people, with whom he had a natural affinity. Oliver was born on 28 June 1969 in Cape Town, the youngest of four children, his father a well-known surgeon in the city, and grew up in the Southern Suburbs. He attended Western Province Preparatory School, Westerford High School, Abbott’s College and Rhodes University before being conscripted into the army, where he worked as a medic and was inspired to

study medicine. Gaining entry into medical school was not easy, but he was determined, and overcame many disappointments before his acceptance into Stellenbosch University. After being awarded his MB ChB he went to Brighton, UK, to study further, gaining Membership of the Royal College of Surgeons of England and the Diploma in Otolaryngology Head and Neck Surgery. He then returned to Cape Town, joined the ENT Department at the University of Cape Town to specialise, and achieved his FCS (SA) (ORL) through the Colleges of Medicine of South Africa. During his specialist training circumstances led Oliver to work at Red Cross War Memorial Children’s Hospital, and it would appear that this experience nurtured his love for and understanding of children and allowed him to develop a special interest in paediatric airway pathologies. Once he had specialised, Oliver was posted to the ENT department at New Somerset Hospital in Green Point, which he ran for a number of years before committing himself to full-time private practice at the Life Vincent Pallotti Hospital. He had been running his popular practice for 6 years before his accident. Oliver kept his hand in the world of academic medicine; he continued to do sessions at Red Cross, which were funded by UCT, and these allowed him to achieve his potential as a teacher, both of UCT 5th-year medical students doing their ENT rotation and the registrars specialising in ENT through that facility. Oliver demonstrated clinical excellence and great patience in teaching, and enjoyed sharing his knowledge. Also of note was his genuine rapport with the young patients and their families – he had an enviable ‘bedside manner’. A father of four, he had a relaxed and natural manner with children generally. He would frequently pick up a small nervous child and give them a hug and a smile that inevitably put them at ease, and parents were confident in his ability and grateful for the time he took to

April 2017, Print edition

explain clearly what was going on and the best way forward. A testament to this was the number of medical doctors who brought their children to be seen by him. Among his professional colleagues, Oliver, with his light-hearted and gregarious nature, was always a pleasure to be around. He participated actively in the academic realms of the ENT profession in South Africa, and had recently presented at the national ENT congress as well as authoring a scientific paper he intended to publish. He also took on responsibility in the South African ENT society, had just been elected onto the management committee, and was earmarked to contribute significantly in fee negotiations on behalf of the society. Oliver was a proud father and a loving, committed husband. He and Maria had four children, Joshua, 17, Thomas, 13, Peter, 9, and Sophie, 7. They spent many family holidays out camping, exploring nature; Oliver had a passion for outdoor life. He provided an excellent role model for his children and would gladly relate their successes to anyone who wanted to know. He sought balance and measure in his professional and family life in the form of a passion for mountain biking – some days he was awake in the early hours of the morning cycling on the slopes of Devil’s Peak with his mates. He participated in many mountain biking challenges and had a regular group of friends with whom he enjoyed the camaraderie, the trials and tribulations, and the sheer humour associated with these events. As husband, father, son, brother, doctor, friend and colleague, Oliver played his roles well. It has been said that it is not length of life that is important, but depth of life. Oliver jumped into life and never touched the bottom. He will be missed tremendously. Graeme Copley Red Cross War Memorial Children’s Hospital, Cape Town, South Africa gjcopley@yahoo.com

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

CME

GUEST EDITORIAL

Prevention of childhood injuries (part 2) Trauma and violence are major causes of the burden of disease globally, and low- and middle-income countries bear the brunt of this scourge.[1] Unfortunately, in South Africa (SA), attempts to mitigate the devastating effects of trauma and violence on our young population are not a top priority of policy makers and health practitioners. Two very important reference points guide our programmes that promote child safety in SA. The Convention on the Rights of the Child, as promoted by the United Nations, has been adopted in its entirety in SA.[2] These values are also entrenched in our constitution. It would, therefore, seem that our country is serious and committed to promoting the rights of children to survival and health, development, and protection from trauma and abuse. Reality paints a starkly different picture, however, with the obligation of the health and social development sectors to protect children’s rights remaining feeble and without a commitment to a clear proactive course of action.[3] Furthermore, child health comprises far more than the absence of disease. Striving for a healthy child population should include the goal of promoting child safety, and prioritising focused and appropriate assessment of childhood trauma, injury risk and resilience factors.[4] This issue of CME makes a crucial contribution to child safety with regard to two major issues. The first article[5] identifies energy poverty, prevalent in underresourced communities, as a key contributor to the problem of child burns. The authors argue that prevention interventions are required, which should include access for impoverished families to clean, safe, and sustainable energy technologies. In the absence of grid electricity, a reality for many thousands of people in SA, the distribution of proven alternative domestic energy technologies, such as liquefied petroleum gas and solar power, is a long-term safety and energy priority. The second article[6] assesses the use of child restraints in motor vehicles, as reflected by admissions to a dedicated paediatric trauma unit over more than a quarter of a century. The results of this study are rather disappointing – it seems we are not learning from our mistakes.

It is high time that our medical and surgical fraternity takes cognisance of these disastrous preventable causes of childhood morbidity and mortality. The time to get involved and spring into preventive action is now. A B van As Childsafe, Cape Town; and Trauma Unit, Red Cross War Memorial Children’s Hospital and Division of Paediatric Surgery, Faculty of Health Sciences, University of Cape Town, South Africa sebastian.vanas@uct.ac.za

A van Niekerk South African Medical Research CouncilUniversity of South Africa’s Violence, Injury and Peace Research Unit, Cape Town; and Institute for Social and Health Sciences, University of South Africa, Johannesburg, South Africa 1. Van As AB. Global factors affecting child trauma and the need for ongoing child advocacy. Vulnerable Child Youth Studies 2011;6(4):277-283. https://doi.org/10.1080/17450128.2011.603395 2. United Nations International Children’s Emergency Fund. Convention on the Rights of the Child. Geneva: UNICEF, 1989. 3. Hyder AA, Peden M, Krug E. Child health must include injury prevention. Lancet 2009;373(9658):102. https://doi.org/10.1016/s0140-6736(08)61736-5 4. Van As AB, Stein DJ. Child safety: A neglected priority. World J Pediatr 2010;6(4):293-295. https://doi. org/10.1007/s12519-010-0229-5 5. Kimemia DK, van Niekerk A. Energy poverty, shack fires and childhood burns. S Afr Med J 2017;107(4):289291. https://doi.org/10.7196/SAMJ.2017.v107i4.12436 6. Ferreira Y, van As AB. Promote buckling up and save a child’s life. S Afr Med J 2017;107(4):292-294. https://doi.org/10.7196/SAMJ.2017.v107i4.12433

S Afr Med J 2017;107(4):288. DOI:10.7196/SAMJ.2017.v107i4.12432

April 2017, Print edition

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

CME

Energy poverty, shack fires and childhood burns D K Kimemia, PhD; A van Niekerk, PhD South African Medical Research Council-University of South Africa’s Violence, Injury and Peace Research Unit, Cape Town; and Institute for Social and Health Sciences, University of South Africa, Johannesburg, South Africa Corresponding author: D K Kimemia (david.kimemia@mrc.ac.za)

Burn injuries are a persisting challenge in South Africa. Energy poverty, prevalent in under-resourced communities, is a key contributor to the problem. The energy-poor rely on solid fuels and flammable hydrocarbons, such as paraffin, for energy services. The fuels are burnt in inefficient, leaky and unstable appliances, leading to health losses from pollutant emissions, burns, and conflagrations. Within cramped informal home settings, using flammable fuels and risky combustion technologies, the situation can become devastating, especially for young children. Those who survive fiery incidents have to contend with trauma and property losses that may lead to further impoverishment. Proactive intervention strategies are required and should include the broadening of access to safe and sustainable energy. We advocate greater enforcement of home appliance standards and targeted support for the distribution of proven alternative energy technologies, such as liquefied petroleum gas and solar power. Support and advocacy from professional and citizen groups would be necessary to ensure that government prioritises the safe energy requirements of poor citizens. S Afr Med J 2017;107(4):289-291. DOI:10.7196/SAMJ.2017.v107i4.12436

Deepening of energy poverty in South Africa

Energy poverty, i.e. the lack of access to modern energy, is a key driver of burn injury in South Africa (SA). Energy poverty is prevalent in dense low-income settlements in developing countries, including SA.[1-4] The dirty fuels that the energy-poor depend on are burnt in inefficient and risky combustion devices, leading to health losses – from pollutant emissions to burn injuries.[5,6] Globally, about 2.7 billion people lack clean and safe cooking facilities and 1.2 billion have no access to electricity.[7] The majority – 95% of these people – reside either in sub-Saharan Africa or developing Asia. Household air pollution leads to the deaths of ~4 million people every year, while burns cause ~265 000 deaths, including ~100 000 children.[8] A key intervention for reducing energy poverty and its consequences is the promotion of access to clean and safe energy technologies for domestic use. The access to modern energy is a prerequisite for human wellbeing, with the human development index, a measure of wellbeing, shown to increase monotonically with extra units of modern energy accessed.[9] Various definitions of energy poverty are used by different organisations involved in this sector. The SA Department of Energy profiles energy poverty among SA households using three approaches: (i) the energy poverty ratio that categorises an energy-poor household as one that ‘spends more than 10% of their net income on energy procurement’; (ii) a subjective approach (based on household experiences and difficulty with the costs of their basic energy requirements); and (iii) an approach based on the thermal comfort levels of households relative to social needs, i.e. the physical state of dwellings that contribute to thermal efficiency.[3] The expenditure-based definition classified 47% of the SA population as experiencing energy poverty in 2012, while the subjective measure cited a figure of 42% and a thermal efficiency measure of 22%.[3] The United Nations defines energy poverty as an ‘inability to cook with modern cooking fuels and the lack of a bare minimum of electric lighting to read or for other household and productive activities after sunset’.[10] The Asian Development Bank has a somewhat

richer definition of energy poverty and regards it as ‘the absence of sufficient choice in accessing adequate, affordable, reliable, highquality, safe and environmentally benign energy services to support economic and human development’.[11]

Shack fires and child burn injuries

The impact of informal settlement shack fires on individuals and communities has received significant attention, with nearly 5 000 informal settlement fires reported between 2009 and 2012.[12] The effect of such fires typically results in significant economic losses and a reduced quality of life for the affected community, and often the loss of lives. Fires kill thousands of people every year, with many more disabled or seriously injured, resulting in untold and often lifelong misery and entrenched poverty.[13] These deaths are mainly categorised as owing to flame burns, although in informal settlements liquid and food burns are also a significant cause of burn injury and hospitalisation. In SA, children are a vulnerable population, because of their more limited risk appraisal capacities and physiology. Burns may leave disabling scars to the skin or body of the child, and may also inflict notable psychological, educational and social impairment. The consequent physical and psychological adjustments may be worsened by the circumstances, severity and site(s) of the injury, the child’s personality, and the access to supportive social relationships.[14] The highest childhood burn mortality and hospitalisation rates are reported in the first 3 years of a child’s life, with rates thereafter decreasing until adolescence, when burn mortality rates again start to increase.[15] The highest concentrations of burn injury are reported in informal settlements or low-cost-housing neighbourhoods.[16] Informal settlements are particularly vulnerable to communitywide conflagrations owing to the density of such areas, the composition of home structures and flammable building materials, the storage and use of paraffin or kerosene, the use of portable stoves and homemade bottle lamps, the overcrowded conditions in many such dwellings, and the lack of water or a restricted water supply.[16] In such settings, the proximity of flammable material to heating sources is enhanced, with many low-income families using paraffin as their

April 2017, Print edition

34 42 (4) 2

20 (4)

25 20 (4)

8 (0)

40 (4)

38 (4)

27 20 (4) 73 (0) 4

4 4

main fuel source owing to its lower cost and ease of accessibility.[17] The use of unsafe energy sources and the unsafe handling of these appliances may cause a fire or burn injury. These dangerous practices include, for example, the lighting of matches before turning on an appliance, or leaving pot handles to face outward on the stove while in use. While paraffin stoves, wood, and candles have been implicated in most flame burn injuries, electricity is associated with the bulk of liquid and food burns. Therefore, even clean energy sources must be accompanied by safe conversion technology and awareness education on its safe uses and the emergency responses. However, despite the prioritisation of electrification in SA, it is anticipated that low-income families will continue to rely on paraffin stoves for cooking and heating tasks, because of the cost of both electricity and safe essential electrical appliances.[18]

[20]

Paraffin appliances failures: Towards alternative energy From Kimemia D and Van Niekerk A.

*Rank scores (in parentheses) signify the level of improvement: 0 = poor; 1 = fair; 2 = good; 3 = better; 4 = best.

79.0 (0) 1 800 (2) LPG

1.85 (4) 0.01 (4)

Ethanol gel

60 (4)

0.06 (2)

2 2

3 9.0 (4)

8.3 (4) 0.11 (0)

0.15 (0)

260 (0)

1 900 (2)

70 (4)

45 (4)

1.03 (1)

0.83 (0)

0.72 (4)

1.29 (4)

Methanol

0 3 6.0 (4) 150 (0) 44 (3) 1.20 (4) Kerosene

1.29 (2)

Toxicity, mg/m3

Stove

Fire power, kW

Energy efficiency, %

0.04 (3)

Stove price, USD

Controllability, rank score

Durability, rank score

Temperature of touchable parts, ˚C Fuel availability, rank score

Fig 1. (A) New paraffin stove – note the fuel leak. (B) In-use stove, with a damaged self-extinguishing mechanism and flame snuffer.

CO emissions, g/mJ

Table 1. Values and rank scores for key stove and fuel attributes

Fuel cost, USD/mJ

Average attribute values and rankings*

Mechanical stability angle, Ɵ˚

Total rank scores, maximum possible: 44

CME

The most hazardous of common energy appliances in use in SA is the nonpressure paraffin stove, which is also the main cause of fires and burn injuries. The SA Bureau of Standards (SABS) in 2006 enacted a national standard for non-pressure paraffin stoves and heaters (SANS1906:2012 Ed 3.1), which was subsequently declared a compulsory specification.[19] The compulsory specification notice declares that ‘the

April 2017, Print edition

homologation granted in respect of an appliance type pursuant to the Specification may be withdrawn if the requirements in the Specification have not been maintained’.[19] Since then, a few wick-type paraffin stoves have been approved for manufacturing and distribution in SA. However, although these stoves may carry the SABS mark of approval, designating them as safe for domestic use, their design is reported as wanting in terms of stability, fuel leaks, flame control and general quality.[20] Despite these concerns, such stoves continue to be manufactured and distributed with an SABS stamp. A key requirement of SANS1906:2012 Ed 3.1 is for approved stove designs to have a self-extinguishing mechanism, which ensures that the flame is extinguished if the appliance is tilted beyond the stability limit. Although the culprit stove designs do have such a mechanism in place, it is prone to malfunction and failure within a few days to weeks of use. The reservoir tank for approved stoves is meant to be leak proof; however, recent characterisations of in-use stoves show that leaks are commonplace, even in a new, outof-the-box stove (Fig. 1).[20] The requirement to have a steady, non-stuttering flame and sturdy construction is equally not adhered to, as shown in recent laboratory tests. These shortcomings added to overall poor construction, and short durability makes these types of stove a ‘time bomb’.[21] With regard to safety, the energy-poor are exposed to harm on a continuing basis despite the paraffin stove standard and a national statutory regulator. The technology for energy services that can provide cooked food, comfortable indoor

CME

temperatures and illumination in a clean, safe, and cost-effective manner does exist. The two most practical and scalable alternatives are liquefied petroleum gas (LPG) for cooking and heating, and solar power for off-grid lighting. Regarding cooking needs, a recent analysis highlights that LPG is currently the most feasible and practical clean and safe cooking technology among improved cook stove alternatives in SA (Table 1). Because of the inherent advantages, LPG has been promoted successfully as a replacement for paraffin and biomass in Senegal, India, and Indonesia.[22-24] LPG has been piloted in selected SA communities with some success; however, there have been cost barriers, and efforts at upscaling have not been forthcoming. A dedicated policy for LPG diffusion requires serious consideration and support, with the required budgets and prioritised timelines.

Conclusions and recommendations

There is a discernible and disconcerting relationship between energy poverty and burn injury trauma. Without improving poor people’s access to safe and sustainable energy, burn injuries will remain a challenge in SA. Various efforts could be activated to address energy impoverishment. Government is required to prioritise and enable modern energy access within its broader poverty eradication commitments in poor communities. However, all concerned citizens could play an active role in catalysing such a transition by demanding this greater policy focus and the required funding support for safe community energisation. We therefore urge the national and provincial governments to enact the required legislation to support the expansion of safe, healthy and efficient energy alternatives, in particular LPG and solar coverage. The relatively higher acquisition and running costs for the suggested alternatives could be overcome by means of targeted social safety nets, such as issuing a free LPG kit (stove, heater and filled cylinder) and recurring monthly subsidies on gas refills. Neighbourhoods with a high reliance on paraffin should be prioritised, with clear indications of the requisite budgets, implementation targets, and roll-out timelines. We furthermore propose that the use of paraffin as a household fuel should concurrently be actively discouraged and eventually phased out. The multiple environmental risks that relate to dwellings in makeshift, unserviced settlements, however, require a broader strategy that enables the upgrading of infrastructural arrangements and service delivery to informal settle-

ments, including the reduction of housing density and provision of materials for better energy-efficient dwellings. 1. Kaygusuz K. Energy services and energy poverty for sustainable development. Renew Sustain Energ Rev 2011;15(2):936-937. https://doi.org/10.1016/j.rser.2010.11.003 2. Nussbaumer P, Brazilian M, Modi V. Measuring energy poverty: Focusing on what matters. Renew Sustain Energ Rev 2012;16(1):231-243. https://doi.org/10.1016/j.rser.2011.07.150 3. Department of Energy (South Africa). A Survey of Energy-related Behaviour and Perceptions in South Africa: The Residential Sector. Pretoria: Department of Energy, 2012. 4. Sustainable Energy Africa. Tackling Urban Energy Poverty in South Africa. Cape Town: SEA, 2014. 5. Kimemia D, Vermaak C, Pachauri S, Rhodes B. Burns, scalds and poisonings from household energy use in South Africa: Are the energy poor at greater risk? Energ Sustain Dev 2014;18(1):1-8. https://doi. org/10.1016/j.esd.2013.11.011 6. Schwebel DC, Swart D, Hui S, et al. Paraffin-related injury in low-income South African communities: Knowledge, practice and perceived risk. Bull World Health Organ 2009;87(9):700-706. https://doi.org/10.2471/ BLT.08.057505 7. International Energy Agency. Role of Sustainable Energy in Ending Poverty. Paris: IEA, 2017. http://iea. org/topics/energypoverty/ (accessed 20 February 2017). 8. World Health Organization. Household Air Pollution and Burns: Key Facts. Geneva: WHO, 2016. http:// who.int/mediacentre/factsheets/fs292/en/ (accessed 21 February 2017). 9. Goldemberg J, Johansson T, Reddy A, Williams R. A global cooking fuel initiative. Energ Sustain Dev 2004;8(3):5-12. https://doi.org/10.1016/S0973-0826(08)60462-7 10. Modi V, McDade S, Lallement D, Saghir J. Energy and the Millennium Development Goals. New York: United Nations Development Programme, 2006:9. 11. Sumiya B. Energy poverty in context of climate change: What are the possible impacts of improved modern energy access on adaptation capacity of communities? Int J Environ Sci Develop 2016;7(1):7379. https://doi.org/10.7763/IJESD.2016.V7.744 12. Fire Protection Association of Southern Africa. SA National Fire Statistics 2014. Johannesburg: FPASA, 2014:40. http://fpasa.co.za/journals/sa-national-fire-statistics (accessed 6 March 2017). 13. Matzopoulos R, Prinsloo M, Pillay-van Wyk V, Gwebushe N, Mathews M, Martin LJ. Injury-related mortality in South Africa: A retrospective descriptive study of post-mortem investigations. Bull World Health Organ 2015;93(5):303-313. https://doi.org/10.2471/BLT.14.145771 14. Bakker A, Maertens KJP, van Son MJM, van Loey NEE. Psychological consequences of pediatric burns from a child and family perspective: A review of the empirical literature. Clin Psychol Rev 2013;33(3):361371. https://doi.org/10.1016/j.cpr.2012.12.006 15. Van Niekerk A, Laubscher R, Laflamme L. Demographic and circumstantial accounts of fatal burn injuries in Cape Town. A register based cross-sectional study. BMC Public Health 2009;9:374. https:// doi.org/10.1186/1471-2458-9-374 16. Van Niekerk A, Reimers A, Laflamme L. Area characteristics and determinants of childhood burn injury in Cape Town. Public Health 2006;120(2):115-124. https://doi.org/10.1016/j.puhe.2005.08.015 17. Gevaart-Durkin A, Swart D, Chowdhury Z. A study of energy-related injuries from hospital admissions among children and adults in South Africa. Burns 2014;40(6):1209-1218. https://doi.org/10.1016/j. burns.2013.12.014 18. Sustainable Energy Africa. State of energy report for Cape Town. 2003. http://sustainable.org.za/SEED (accessed 6 March 2017). 19. Department of Trade and Industry, South Africa. Compulsory specification for non-pressure kerosene stoves and heaters. Government Gazette No. 29338:1091. 2006. 20. Kimemia D, van Niekerk A. Cookstove options for safety and health: Comparative analysis of technological and usability attributes. Energ Pol 2017;(epub ahead of print). https://doi.org/10.1016/j. enpol.2017.03.022 21. Abahlali baseMjondolo. Warning on ‘time bomb’ paraffin stoves. 2007. http://abahlali.org/node/2821/ (accessed 27 February 2017). 22. Andadari R, Mulder P, Rietveld P. Energy poverty reduction by fuel switching: Impact evaluation of the LPG conversion program in Indonesia. Ener Pol 2014;66(1):436-449. https://doi.org/10.1016/j. enpol.2013.11.021 23. Budya H, Arofat M. Providing cleaner energy access in Indonesia through the megaproject of kerosene conversion to LPG. Ener Pol 2011;39(12):7575-7586. https://doi.org/10.1016/j.enpol.2011.02.061 24. Natarajan M. Differences between intentional and non-intentional burns in India: Implications for prevention. Burns 2014;40(5):1033-1039. https://doi.org/10.1016/j.burns.2013.12.002

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Promote buckling up and save a child’s life Y Ferreira,1 MB ChB, DipPEC, DipForMed (Clin); A B van As,2 MB ChB, MMed, MBA, FCS (SA), PhD Trauma Unit, Red Cross War Memorial Children’s Hospital, and Division of Paediatric Surgery, Faculty of Health Sciences, University of Cape Town, South Africa 2 Childsafe South Africa, Cape Town; Trauma Unit, Red Cross War Memorial Children’s Hospital, and Division of Paediatric Surgery, Faculty of Health Sciences, University of Cape Town, South Africa 1

Corresponding author: A B van As (sebastian.vanas@uct.ac.za)

Road traffic crash (RTC) injuries are the leading cause of child mortality and morbidity in South Africa for children between the ages of 1 and 18 years. The World Health Organization’s Global Status Report on Road Safety 2015 rated the African continent’s roads the world’s most dangerous. After pedestrian injuries, passenger injuries are the most lethal. There is no doubt that a seat belt is the single most effective feature in a vehicle to reduce the severity of injury to the vehicle’s occupants; wearing a seat belt reduces the risk of fatal injury by up to 50% and 75% for front seat and rear seat occupants, respectively. Children have specific anatomical and physiological limitations that render them more vulnerable to serious injury, but the prevention of childhood RTC injuries has unfortunately not received the deserved attention by the medical fraternity. There is currently ample evidence that the use of seat belts and appropriate child restraint seats has led to a significant reduction in RTC fatalities and injuries. It is, therefore, the duty of every healthcare worker to lead by example by using child restraints correctly, and actively encouraging the use of these devices for all their clients and patients. S Afr Med J 2017;107(4):292-294. DOI:10.7196/SAMJ.2017.v107i4.12433

Road traffic crash statistics in Cape Town

RTC injuries are the leading cause of death in 5 - 14-year-old children in Cape Town.[5] RCWMCH is a public institution that serves as a referral paediatric hospital for children <13 years of age in the greater Cape Metropole. Pedestrian RTCs are the most commonly observed mechanism in RTC injuries in all age groups seen at RCWMCH (71%), with a male predominance of 64%.[1] The second most commonly observed mechanism of road trafficrelated injury is unrestrained vehicle passengers (11%). Children <1 year of age are particularly at risk (35%).[1] Of the 4 517 documented passengers in RTCs seen over a 25-year period, only 27% (n=1 222) were restrained

(Fig. 1). Despite a quarter of a decade’s campaigning to promote road safety, this number has not improved significantly from 1991 to 2015 (Fig. 2).[6]

Seat belts and child restraints

A seat belt is the single most effective feature in a vehicle that can reduce the severity of the occupants’ injuries resulting from RTCs. Per

Restrained 1 222 (27.0%)

Excluded 464 (9.3%)

Unrestrained 3 295 (73%)

Included 4 517 (90.7%)

Fig. 1. Distribution of passengers in RTC cases (n=4 981) at RCWMCH over a 25-year period (1991 - 2016).

Passengers, %

Behind each health statistic is a human being, a family, and a community. This is especially true with regard to the devastating road traffic crash (RTC) toll on South African (SA) roads. RTC injuries are the leading cause of childhood trauma-related mortality and morbidity in SA. Up to 40% of children who present to Red Cross War Memorial Children’s Hospital (RCWMCH), Cape Town, SA with RTC injuries required admission owing to the severity of their injuries. Low- and middle-income countries exhibit a disproportionately higher burden of RTC injuries and deaths, but have a relative lack of analytical data.[1] In 2010, 1.3 million deaths worldwide were caused by RTCs.[2] Twentyone percent of these deaths occurred among children.[3] Increasing motorisation has led to a higher number of crashes and injuries to vehicle occupants, particularly in low- and middle-income countries. In the last two decades there was a 46% increase in deaths due to RTCs.[2] The World Health Organization (WHO)’s Global Status Report on Road Safety 2015 rated Africa’s roads the world’s deadliest. SA’s road fatalities were 25.1/100 000 population, a little below the African average of 26.6/100 000. This is, however, well above the 9.2/100 000 population for Europe and the worldwide estimate of 17.4/100 000.[4]

90 80 70 60 50 40 30 20 10 0

1990 -1995

1996 - 2000

Restrained

2001 - 2005

2006 - 2010

2011 - 2015

Unrestrained

Fig. 2. Comparison between restrained and unrestrained passengers according to year of injury.

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the WHO’s Global Status Report on Road Safety 2015, wearing a seat belt reduces the risk of fatal injury by up to 50% and 75% for front seat and rear seat occupants, respectively.[4] The seat belt was invented by an English engineer, George Cayley, in the late 1800s. The purpose of these belts was to help keep pilots inside their gliders.[7] The three-point lap/shoulder belt, as we know the seatbelt today, was invented by the Swedish engineer and inventor, Nils Bohlin, in 1958. The 1959 Volvo was the first car to be fitted with the three-point lap/shoulder belt as standard equipment. Before 1959, only two-point lap belts were available in motor vehicles.[8] Since 1959, engineers have worked to enhance the three-point belt, but the basic design remains Bohlin’s. Volvo made the new seat belt design available to other motor vehicle manufacturers free, in the interest of public safety. When Bohlin passed away in 2002, Volvo had estimated that the seat belt had saved more than one million lives in the four decades since its introduction.[8] Since the Vienna Convention on Road Traffic of 1968, the wearing of safety belts has been compulsory for drivers and passengers of motor vehicles, unless domestic legislation granted exception. Legislation for the compulsory wearing of seat belts was first introduced globally by the Government of the State of Victoria, Australia, in 1970.[9] SA only introduced seat belt legislation in 1973 and updated it in the National Road Traffic Act No. 93 of 1996.[10] The three-point lap/shoulder seat belt aims to: • prevent the occupant from being ejected from the vehicle upon impact • prevent ejection, i.e. ejection from a vehicle results in a 5 - 8 times higher chance of death compared with a non-ejected occupant • reduce the risk of contact with the interior of the vehicle, i.e. prevent the occupant from being flung forward and hitting the steering wheel, dashboard, or the seat in front of them • prevent injury to other occupants. Unrestrained rear-seated passengers can be flung forward and hit other occupants • distribute the forces of a crash over the strongest parts of the human body, thereby reducing the risk of internal injury.[11] The three-point lap and diagonal seat belt was designed for adults. In the case of children of varying size and weight, and the different relative proportions of their bodies, adult seat belts are not optimally effective at preventing ejection and injury.[11] Children have specific anatomical and physiological limitations that render them vulnerable to serious injury. A smaller portion of a child’s abdomen is covered by the pelvis and rib cage, leaving it unprotected and at higher risk of injury. A child’s rib cage is also more

likely to bend rather than break, resulting in energy from the collision being transferred to the internal viscera.[11] At birth, an infant’s head is approximately a quarter of their total length and about one-third of their body weight. Furthermore, children’s skulls are pliable up to the age of 24 months. Even low-energy forces can result in cranial deformity and brain injury. The smaller the child, the lower the force needed.[11] Adult passengers often hold infants and young children in their arms, believing that they will keep them safe in the event of a collision. This is physically impossible and a dangerous myth. During impact, the weight and velocity of an adult body can magnify into a potentially lethal force, crushing the child to death. Infants and children therefore need a child restraint system that accommodates their size and weight, and can adapt to the different phases in their development.[6] Correctly applied, child restraints reduce the likelihood of a fatal crash by ~70% among infants (<1 year of age) and between 54% and 80% among young children (1 - 4 years old).[4,12,13] Unrestrained children in RTCs are found to have a higher injury severity and are more likely to need urgent medical intervention compared with children who were properly restrained.[13] Failing to apply adequate child restraints is a major risk factor for injury to young children in RTCs. Despite extraordinary success in reducing deaths and serious injuries, the rate of use of appropriate child restraints in motor vehicles in SA remains dismal. Rates as low as 10% have been observed by Kling et al.[14] in 2011.

The National Road Traffic Act

The SA law on seat belts is set out in Regulation 213 of the National Road Traffic Act (NRTA) No. 93 of 1996. The law is very clear – all adult occupants (>14 years of age or >1.5 m in height) are obliged to wear seat belts if they are in a vehicle, including the driver of the vehicle and front and rear seat passengers. It is the driver’s legal responsibility to ensure that the persons travelling in the vehicle wear a seat belt.[10] Since 1 May 2015, children <3 years old are also permitted to travel in a car only if they are secured in a car seat. Motorists with unrestrained children <3 years old in their vehicle can be fined. This was a long-awaited and welcome addendum to the NRTA. This provision does, however, not apply in the case of a minibus, midibus or bus operated for reward, which creates problematic loopholes in the legislation to the detriment of the children it is supposed to protect.[15] For children between the ages of 3 - 14 years (or <1.5 m in height) the law is unfortunately not clear. These children are obliged to

Table 1. Arrive Alive car seat information Rearward-facing infant car seat

Forward-facing child seat

Booster seat

Booster cushion

Birth - 1 year

9 months - 4 years

4 - 6 years

6 - 12 years

Up to 13 kg

9 - 18 kg

15 - 25 kg

22 - 36 kg

Never put an infant car seat on the front seat, especially if there is a passenger airbag

Can be used until the child’s weight exceeds 18 kg

Booster seats have a back and can provide additional protection in the case of a side impact

Booster cushions do not have an integral harness to hold the child in place

Use until the three-point lap/ shoulder seat belt fits the child properly

The adult seat belt must be used and adjusted correctly

Keep child in rearward-facing seat for as long as possible

Can be used until the child grows too tall for the height of the adjustable harness

Move to forward-facing seat if the child has exceeded the maximum weight for the infant seat or if the top of their head is higher than the top of the seat

Typically use when the child reaches a height of ~145 cm

April 2017, Print edition

Children who are tall enough to wear an adult seat belt should be in the back seat until they are 13 years old

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utilise seat belts only when these are present in a vehicle. The NRTA therefore does render it lawful for children to travel in a vehicle without any form of restraint.[10] According to the WHO’s Global Status Report on Road Safety 2015, 105 countries have seat belt laws in place that cover both front and rear seat passengers, while 53 countries have a child restraint law in place (based on age, weight or height) that restricts children from sitting in the front seat.[4] The Arrive Alive campaign has published very useful car seat suggestions to clarify this dilemma (Table 1).[16] Sadly, the impact of legislation on fatalities is often minimal. For instance, the Japanese road traffic law regarding compulsory child restraint seats for all children aged 0 - 5 years was implemented in April 2000. However, this legislation failed to result in a statistically significant reduction in child RTC occupant fatalities or injuries, as shown by Desapriya et al.[17] Numerous efforts have to be made to increase compliance of the use of car restraint seats. Information and educational programmes for the public, safety seat loaner programmes and reward-based programmes are some of the options.[18] SA is a developing country. Mobility in any shape and form is valuable, i.e. a bicycle is better than walking and a car represents prosperity. This is even more significant in rural areas, where people expose themselves to risks to travel to work, school or hospital. One of such situations is passengers on goods vehicles (e.g. travelling on the back of a bakkie). In November 2016, the government published two amendments to the NRTA in the Government Gazette No. 40420, which will be effective from 12 May 2017:[19] • Regulation 247 of the NRTA No. 93 of 1996 permits the conveying of passengers in the goods compartment of a vehicle if the sides of the vehicle are enclosed to a height of at least 350 mm above the seating surface or 900 mm above the surface on which the person is standing.[19] Therefore, roughly the length of a ruler is offered as protection and there is no need for a roof covering. • Regulation 250 of the NRTA No. 93 of 1996 states that ‘No person shall on a public road carry any person for reward in the goods compartment of a motor vehicle’.[19] Neither of these regulations forbids the conveyance of persons in the goods compartment of a bakkie, regardless of whether they are children or not. Only if the conveyance is for reward, will it be prohibited.

Medical practitioner’s obligation

Childhood trauma is a major cause of mortality and morbidity. The WHO expects that by 2020 it may be the primary disease globally.[20] Most countries, including SA, define RTC injuries as the responsibility of the Department of Transport. Medical practitioners are responsible for dealing with the consequences of RTCs, but not for the prevention of injury. Worldwide there was remarkable success in changing lifestyle health concerns, such as smoking and obesity.[5] Every healthcare worker, whether general practitioner, paediatri-

cian or member of a nursing team, will fail our children by not emphasising the value of seat belts and the necessity of proper child restraints, and actively promoting the new legal requirements.

Conclusion

The prevention of RTC injuries has long been neglected by the medical profession. There is ample evidence that the use of seat belts and appropriate child restraint seats has led to a significant reduction in RTC fatalities and injuries. Every healthcare worker should lead by example by using child restraints properly, as well as actively encouraging the use of these devices. As per Arrive Alive South Africa: ‘Buckling up is the simplest way to save a life’.[16]

1. Kihurani I, van Niekerk A, van As AB. Child road traffic crash injuries at the Red Cross War Memorial Children’s Hospital in Cape Town, South Africa in 1992, 2002 and 2012. Int J Inj Contr Saf Promot 2014;22(4):352-358. https://doi.org/10.1080/17457300.2014.912236 2. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2095-2128. https://doi.org/10.1016/S0140-6736(12)61728-0 3. Hyder AA, Labinjo M, Muzafar SSF. A new challenge to child and adolescent survival in urban Africa: An increasing burden of road traffic injuries. Traffic Inj Prev 2006;7(4):381-288. https://doi. org/10.1080/15389580600942965 4. World Health Organization. Global Status Report on Road Safety 2015. Geneva: WHO, 2015. http:// who.int/violence_injury_prevention/road_safety_status/2015/en/ (accessed 15 February 2017). 5. Groenewald P, Bradshaw D, Daniels J, et al. Cause of death and premature mortality in Cape Town, 2001 - 2006. Cape Town: South African Medical Research Council, 2008. http://westerncape.gov.za/ Text/2008/11/cause_of_death_and_premature_mortality_in_cape_town_5_november_2008.pdf (accessed 15 February 2017). 6. Childsafe South Africa. Red Cross War Memorial Children’s Hospital, 1991 - 2016. http://childsafe.org (accessed 6 March 2017). 7. Manby F. Clunk, click – an invention that saved lives for 50 years. Yorkshire Post, 24 August 2009. http://yorkshirepost.co.uk/clunk-click-an-invention-that-s-saved-lives-for-50-years-1-2296965 (accessed 15 February 2017). 8. O’Grady S. The man who saved a million lives: Nils Bohlin – inventor of the seatbelt. The Independent, 18 August 2009. http://independent.co.uk/life-style/motoring/features/the-man-who-saved-a-millionlives-nils-bohlin-inventor-of-the-seatbelt-1773844.html (accessed 15 February 2017). 9. McDermott FT, Hough DE. Reduction in road fatalities and injuries after legislation for compulsory wearing of seat belts: Experience in Victoria and the rest of Australia. Br J Surg 1979;66(7):518-521. https://doi.org/10.1002/bjs.1800660721 10. South Africa. National Road Traffic Act No. 93 of 1996. http://gov.za/sites/gov.za/files/25484_0.pdf (accessed 15 February 2017). 11. Sinclair M. The promotion of road safety by healthcare professionals in South Africa. S Afr Med J 2013;103(9):614-615. https://doi.org/10.7196/SAMJ.7335 12. Kool B, Ryan R, Radice K, et al. A child restraint for every child on every trip. NZ Med J 2014;127(1388):61-65. 13. Recicar J, Barczyk A, Duzinski S, et al. Does restraint status in motor vehicle crash with rollover predict the need for trauma team presence on arrival? An ATOMAC study. J Pediatr Surg 2016;51(2):319-322. https://doi.org/0.1016/j.pedsurg.2015.10.041 14. Kling J, Nicholls T, Ntambeka P, van As AB. Restraint use for child passengers in South Africa. S Afr Med J 2011;101(3):146. 15. South Africa. National Road Traffic Act No. 93 of 1996. Regulation 231(6A). http://ndmc.gov.za/ Documents/Regulations/tabid/298/ctl/ (accessed 15 February 2017). 16. Arrive Alive. Child restraints and road safety. https://arrivealive.co.za/ (accessed 15 February 2017). 17. Desapriya E, Fujiwara T, Scime G, et al. Compulsory child restraint seat law and motor vehicle child occupant deaths and injuries in Japan 1994 - 2005. Int J Inj Contr Saf Promot 2008;15(2):93-97. https:// doi.org/10.1080/17457300802080602 18. Roberts MC, Turner DS. Preventing death and injury in childhood: A synthesis of child safety seat efforts. Health Educ Q 1984;11(2):181-193. 19. South Africa. National Road Traffic Act No. 93 of 1996. Regulations: School children and persons not to be conveyed in goods compartment of a motor vehicle for reward. Government Gazette No. 40420, 2016. (Published under Government Notice R188.) 20. Van As AB. Paediatric trauma care. Afr J Paediatr Surg 2010;7(3):129-133. https://doi.org/10.4103/01896725.70409

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IN PRACTICE

CLINICAL UPDATE

Tuberous sclerosis complex in the Western Cape, South Africa: The clinical presentation features E Kija,1,2 MMed; B Schlegel,1 FCP; P Samia,1,3 MPhil; M Wessels,1 MMed; J M Wilmshurst,1 MD Department of Paediatric Neurology, Red Cross War Memorial Childrenâ&#x20AC;&#x2122;s Hospital, University of Cape Town, South Africa Department of Paediatrics, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania 3 Department of Paediatrics, Medical College, Aga Khan University, Nairobi, Kenya 1 2

Corresponding author: J M Wilmshurst (jo.wilmshurst@uct.ac.za)

Tuberous sclerosis complex (TSC) is a genetic neurocutaneous condition, which affects multiple organ systems. This study aimed to determine the presenting features of children with TSC in Cape Town, South Africa. A cross-sectional study was conducted at a TSC clinic, and clinical features at presentation were prospectively collected. Thirty-nine children (23 boys; median age 10 (range 1 - 26) years; median diagnosis age 16 (0 - 153) months) were recruited. Twenty-one (54%) children presented with focal seizures. Seven (18%) children had epileptic spasms. Skin manifestations led to a diagnosis in 13 (33%) and neuroimaging in 22 (56%) children. Antenatal screening detected cardiac rhabdomyomas in 3 children. One child had a positive family history. In the paediatric service, TSC diagnosis usually followed neuroimaging, whereas at the neurology service skin manifestations indicated TSC. In conclusion, most children with TSC presented as emergency cases with seizures. Health practitioner awareness of the common TSC clinical signs was lacking, with the diagnosis often delayed. S Afr Med J 2017;107(4):295-298. DOI:10.7196/SAMJ.2017.v107i4.12040

Tuberous sclerosis complex (TSC) is a genetically inherited condition that manifests with benign non-invasive hamartomas in multiple organ systems and is associated with varied clinical presentations.[1,2] The prevalence of TSC worldwide is reported as 1 in 6 000 newborns.[1-4] Equivalent data from Africa are lacking. In Africa, the burden of disease is dominated by infectious aetiologies. People with non-communicable disorders, especially of genetic origin, have access to scarce resources and are managed as low-priority cases. This results in disparate outcomes, e.g. in well-resourced settings awareness of TSC is more likely to lead to early diagnosis, whereas in Africa management is reactive, and limited resources and poor awareness lead to delayed diagnosis and intervention. Red Cross War Memorial Childrenâ&#x20AC;&#x2122;s Hospital (RCWMCH), Cape Town, South Africa (SA) is unique in that it provides a dedicated TSC service in the paediatric neurology department. The service was established >15 years ago and has, during this period, managed 45 affected children. Based on international prevalence figures, this number is less than expected for the region and raises concerns that only a proportion of affected children access the service. The referral pattern and disease demographics of the service were examined to identify remedial factors to improve diagnosis and service delivery.

Objective

The objective of this study was to document the phenotype of SA children with TSC, identifying clinical features at presentation, which could lead to improvements in diagnosis in our setting.

Methods

RCWMCH is a university teaching hospital located in the Western Cape, SA. For children with TSC a dedicated multidisciplinary service operates in the paediatric neurology department, in line with international management guidelines. Patients are referred to our

hospital by local health practitioners, based on concerns that arise from the complications of TSC. As such, the understanding of referral patterns was considered important to develop interventions to promote earlier identification of affected children, which would facilitate preventive rather than reactive interventions. All children attending the service between October 2013 and August 2016 were prospectively recruited. Patient demographics were recorded and compared with international data (Table 1).[5-7] Age at presentation, referral sources and reason for referral were also documented. Ethical clearance to conduct the study was granted by the Faculty of Health Sciences Research Ethics Committee, University of Cape Town (ref. no. 020/2013). Written consent was obtained from caregivers.

Results

Over the 33-month period, consent was obtained for 39 children (23 males, 16 females; median 10 (range 1 - 26) years), who fulfilled the international diagnostic criteria for TSC, to be part of the study. From the original cohort attending the service (n=45), 5 children had been referred to adult services, and 1 child died because of complications unrelated to his TSC diagnosis. Sixteen children were of indigenous black African ancestry, 9 were white, 13 of mixed ancestry and 1 was Arabic. Median age at diagnosis was 16 (0 - 153) months (Table 1). Twenty-one (54%) children were referred to the general neurology service owing to focal seizures, where TSC was diagnosed. Diagnosis was delayed in four children. Two were mislabelled on neuroimaging, specifically with neurocysticercosis in one child and congenital cytomegalovirus in another. TSC was diagnosed following identification of hypopigmented skin lesions in the former child and after persistent hypertension and identification of renal angiomyolipomas in the latter. A third child suffered recurrent

April 2017, Print edition

IN PRACTICE

Table 1. Demographics of children attending the TSC service from October 2013 to August 2016 compared with those of other similar paediatric cohort studies[5-7] Variable

Current study, N=39

Yates et al., N=114

Datta et al.[6] (infants only), N=41

Male:female

23:16

62:63

24:17

[5]

Erol et al.,[7] N=20 10:10

Age at presentation (months), median

1.5

Subependymal giant cell astrocytomas,* n (%)

10 (26)

5 (4)

4 (10)

1 (5)

Epilepsy, n (%)

34 (87)

17 (85)

Focal epilepsy, n (%)

21 (54)

7 (35)

Epileptic spasms (3 focal epilepsy and epileptic spasms), n (%)

7 (18)

7 (35)

Cortical tubers,* n (%)

31 (79)

93 (89)

35 (85)

16 (80)

Subependymal nodules,* n (%)

36 (92)

76 (73)

37 (90)

16 (80)

Intellectual disability, n (%)

23 (59)

75 (85)

5/8 (63)

Angiomyolipoma,* n (%)

17 (44)

13 (12)

6 (15)

1 (5)

Cardiac rhabdomyoma,* n (%)

8 (20)

51 (58)

35 (85)

Facial angiofibroma,* n (%)

19 (49)

24 (29)

8 (40)

>3 hypomelanotic macules,* n (%)

27 (69)

80 (65)

21 (51)

17 (85)

Shagreen patch,* n (%)

10 (28)

30 (24)

30 (73)

2 (10)

1 (0.02)

3 (2)

Ungual and periungual fibroma,* n (%) *International diagnostic criteria.

[2]

pancreatitis, and her skin lesions were initially thought to be due to a fungal infection. She eventually underwent a brain magnetic resonance imaging (MRI) scan and the skin lesions were re-examined. A fourth child was resident in a rural part of the country. His learning and behavioural problems were well known to his caregivers, but he attended the health service only when he was 12 years and 9 months of age, with poorly controlled seizures. Seven (18%) children had epileptic spasms, 4 at presentation, and 3 with focal seizures later developed spasms. The median lag time from onset of epileptic spasms to diagnosis and intervention was 3 (2 - 8) months. Skin manifestations led to referral in 13 (33%) children, who were already being managed for seizures. Neuroimaging as part of routine screening for seizures resulted in confirmation of TSC in a further 22 (56%) children. Three children with cardiac rhabdomyomas were identified antenatally, and one child with a positive family history was also diagnosed antenatally. Most children were referred to the general neurology service as emergency cases with prolonged convulsive seizures, and a smaller proportion were referred from the medical outpatient service with brief seizures. The hospital location of the child at the time of diagnosis was distributed as follows: medical outpatients (n=9), paediatrics (n=9), neurology (n=15), antenatal obstetric service (n=3), and 1 each for genetics, gastroenterology and dermatology services. The key marker that led to the diagnosis of TSC was predominantly based on neuroimaging findings after routine investigation for seizures in children managed in the medical outpatient service, and after the identification of skin lesions for children managed in the neurology service. Comparison between these diagnostic markers for medical outpatients compared with neurology outpatients demonstrated a trend, but it was not statistically significant on Fisherâ&#x20AC;&#x2122;s exact test (p=0.058). Prior to 2007, the median value for the number of new children with TSC who were referred to the service was 1 per year; from 2007, this number increased to a median value of 3 per year.

Discussion

This study illustrated that awareness of TSC in SA health services is poor. TSC was suspected in only a few children, based on the presence of skin lesions; their referral to the neurology service was typically because of recurrent seizures. Most of the remaining children presented after acute presentations with seizures, and the diagnosis of TSC was made following admission for emergency management. Children in our cohort presented later than those reported in international studies (Table 1). As found in our study and in large international studies, the presenting features of TSC can be diverse â&#x20AC;&#x201C; prior to their diagnosis a proportion of our children were under direct management in the genetics, gastroenterology and dermatology services.[4] The skin manifestations of two of the patients were detected, but incorrectly interpreted. In settings where conditions such as neurocysticercosis are prevalent, erroneous assumptive diagnoses based on neuroimaging findings may also occur, as illustrated in this study. Hypomelanocytic macules may be present at birth, and other skin manifestations such as facial angiofibroma and shagreen patches appear later during the first decade of life.[2] In this study, even though hypomelanocytic macules were found in 69% of patients, the diagnosis of TSC was suspected at referral in only 33% of cases (Table 1). The 2012 international guidelines on the diagnosis and management of TSC emphasise the importance of early diagnosis to improve the outcome of affected children.[1] Epileptic spasms are common during the first year of life in children with TSC. These children may also have focal seizures, which may occur either before or after onset of epileptic spasms. Corticosteroids are the recommended treatment for infants with epileptic spasms who do not have TSC, while vigabatrin is the most effective intervention in infants with TSC.[8] Delayed recognition of TSC can lead to suboptimal intervention for epileptic encephalopathy. The guidelines recommend presymptomatic electroencephalography (EEG) in the age group at risk of epileptic spasms.[2,5]

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While this is a viable intervention at our centre, patients in this study typically had already evolved seizures as a presenting complaint. Furthermore, EEG is a scarce resource in low- and low-middleincome countries in Africa and many centres struggle to access such testing. Epileptic spasms were identified in 18% of the children in our study, which is similar to the percentage in other studies.[9] The guidelines have similar recommendations for renal monitoring to screen for angiomyolipomas. Even though this is also a rational recommendation, it is unlikely to be fullfilled in many parts of subSaharan Africa.[1,2,10] In our group, 3 patients presented with cardiac rhabdomyomas, and 5 had lesions identified after TSC was diagnosed. It is possible that these additional cases reflected limited antenatal assessment, and further highlights the difficulties of early detection in our setting.[11] The challenges illustrated here highlight the need for these children to be managed in a tertiary setting, where adequate multidisciplinary care can be provided, and the drain on already stretched secondary and primary healthcare services can be avoided. The study by Yates et al.[5] reported similar presentation triggers and phenotypic features as in our cohort, but in a population in the UK. One hundred and fourteen children in this study met the criteria for TSC and 17% were diagnosed in the antenatal period, compared with 8% of our patients.[5] Thirty children (24%) in the UK study presented before the onset of seizures, which affected 77 (62%) of the group.[5] In our population, the diagnosis of TSC before neuroimaging for new onset of seizures occurred less often than in the Yates et al.[5] study, but the proportion of children presenting with seizures was comparable (62% in the UK study v. 56% in the current study). The UK study also found an increasing number of children presenting prenatally or in early infancy, which reflected both the increased awareness of TSC and appropriate resources available to identify affected patients.[5] The international TSC guidelines also recommend early neurodevelopmental screening to optimise performance outcomes. This would permit appropriate school placement and learning support to be initiated. There are challenges to such implementation in our setting, especially where there are additional compounding factors of poor socioeconomic structure, and layering effects from other comorbidities, such as HIV and tuberculosis. In most parts of Africa, there is limited access to developmental intervention, with few skilled health practitioners and long waiting lists. Subependymal giant cell astrocytomas (SEGAs) are some of the more serious complications of TSC. International guidelines recommend regular monitoring and awareness of early symptoms and signs to facilitate early intervention.[1] The current study found a higher proportion of children with SEGAs compared with the UK, USA and Turkey.[5-7] This may reflect disease behaviour, whereby only the most symptomatic patients access healthcare services in our setting. In SA, there is no effective structure for routine screening of asymptomatic children for TSC. Genetic testing is useful to confirm the diagnosis of TSC and for family counselling.[5] Currently, genetic testing is not routinely available in SA and fulfilment of clinical criteria is used to confirm a diagnosis of TSC. However, the service does have access to genetic counsellors, who provide families with support. A previous study[12] showed that caregivers, who despite regular attendance at the clinic, often failed to understand the condition and benefited when provided with written information, preferably in their home language or language of choice. This study highlights that there is a great need to raise awareness of TSC in our setting. Based on service referral patterns, opportunities to achieve this could be by promoting TSC teaching in undergraduate curricula, in community projects, and by

raising awareness in primary healthcare clinics. Informative posters could be placed in strategic settings, such as primary healthcare clinics and community centres. In SA, a national TSC non-governmental organization is yet to be established, but there are other routes of support, such as Rare Diseases SA (http://rarediseases.co.za/) and Epilepsy SA (http://epilepsy.org.za). Many of the patients were incidentally diagnosed by neuroimaging performed as part of evaluation of their seizure disorder. In our setting, neuroimaging is not usually performed unless there is concern of focal pathology. Further, in our experience seizures are often erroneously assumed to be generalised, also reducing the likelihood of performing neuroimaging. This highlights the need for extracting a good clinical seizure semiology and performing a careful clinical examination, as the majority of affected children have skin manifestations. Since 2007, the RCWMCH TSC service has actively promoted awareness of common clinical markers for TSC within the hospital structure â&#x20AC;&#x201C; a tertiary care facility. The median annual referral rate has tripled. While this is a positive trend, heightened awareness needs to be facilitated at primary and secondary facilities as the next stage. Based on the apparent scarcity of recognition and limited awareness of TSC in SA, which, compared with other parts of Africa, has greater access to resources, it is likely that the challenges of diagnosing TSC are even more pronounced in the rest of the continent. The late diagnosis of TSC in adulthood is associated with greater complications.[13]

Conclusion

In this study, most children with TSC presented as emergency cases with seizures. Awareness of the common clinical markers at presentation is lacking. We aimed to gain insight into the referral patterns of children with TSC to a specialised service to identify ways to improve early identification of and intervention with regard to the condition. The next stage will be an intervention study to observe if the recruitment can be improved by raising awareness in the key locations where these children present, inclusive of primary healthcare clinics, community bases, and school healthcare clinics. TSC prevalence is estimated internationally at 1 in 6 000 newborns, and based on our population of 2.14 million children <19 years of age in the Western Cape, some 357 children in this region may have TSC.[14] The majority of affected children in our area and potentially sub-Saharan Africa are probably not diagnosed. This highlights the need to raise awareness of such common clinical markers to promote early referral to specialist centres to reduce complications.

Acknowledgements. The authors would like to thank the patients, parents and carers for agreeing to participate in this study. Author contributions. EK, MW and PS assisted with the data collection; EK drafted the manuscript; BS identified patients for study inclusion, assisted with consent and contributed to the manuscript content; and JW designed and conceived the study and revised the final manuscript. Conflict of interest. JW and BS are members of the SA Tuberous Sclerosis Complex advisory committee, which was established with funding support from Novartis.

1. Krueger DA, Northrup H. International Tuberous Sclerosis Complex Consensus G. Tuberous sclerosis complex surveillance and management: Recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference. Pediatr Neurol 2013;49(4):255-265. https://doi.org/10.1016/j. pediatrneurol.2013.08.002 2. Northrup H, Krueger DA, Group ITSCC. Tuberous sclerosis complex diagnostic criteria update: Recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference. Pediatr Neurol 2013;49(4):243-254. https://doi.org/10.1016/j.pediatrneurol.2013.08.001

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3. Rentz AM, Skalicky AM, Liu Z, et al. Tuberous sclerosis complex: A survey of health care resource use and health burden. Pediatr Neurol 2015;52(4):435-441. https://doi.org/10.1016/j.pediatrneurol.2014.11.013 4. Kothare SV, Singh K, Hochman T, et al. Genotype/phenotype in tuberous sclerosis complex: Associations with clinical and radiologic manifestations. Epilepsia 2014;55(7):1020-1024. https://doi.org/10.1111/ epi.12627 5. Yates JR, Maclean C, Higgins JN, et al. The Tuberous Sclerosis 2000 Study: Presentation, initial assessments and implications for diagnosis and management. Arch Dis Child 2011;96(11):1020-1025. https://doi.org/10.1136/adc.2011.211995 6. Datta AN, Hahn CD, Sahin M. Clinical presentation and diagnosis of tuberous sclerosis complex in infancy. J Child Neurol 2008;23(3):268-273. https://doi.org/10.1177/0883073807309250 7. Erol İ, Savaş T, Şekerci S, et al. Tuberous sclerosis complex: Single center experience. Turk Pediatri Ars 2015;50(1):51-60. 8. Friedman D, Bogner M, Parker-Menzer K, Devinsky O. Vigabatrin for partial-onset seizure treatment in patients with tuberous sclerosis complex. Epilep Behav 2013;27(1):118-120. https://doi.org/10.1016/j. yebeh.2012.12.033 9. Kothare SV, Singh K, Chalifoux JR, et al. Severity of manifestations in tuberous sclerosis complex in relation to genotype. Epilepsia 2014;55(7):1025-1029. https://doi.org/10.1111/epi.12680

10. Ouzaid I, Autorino R, Fatica R, et al. Active surveillance for renal angiomyolipoma: Outcomes and factors predictive of delayed intervention. BJU Int 2014;114(3):412-417. https://doi.org/10.1111/bju.12604 11. Shen Q, Shen J, Qiao Z, Yao Q, Huang G, Hu X. Cardiac rhabdomyomas associated with tuberous sclerosis complex in children: From presentation to outcome. Herz 2015;40(4):675-678. https://doi. org/10.1007/s00059-014-4078-1 12. Samia P, Donald KA, Schlegel B, Wilmshurst JM. Parental understanding of tuberous sclerosis complex. J Child Neurol 2015;30(10):1281-1286. https://doi.org/10.1177/0883073814558121 13. Seibert D, Hong CH, Takeuchi F, et al. Recognition of tuberous sclerosis in adult women: Delayed presentation with life-threatening consequences. Ann Intern Med 2011;154(12):806-813. https://doi. org/10.7326/0003-4819-154-12-201106210-00008 14. Statistics South Africa. 2014. http://statssa.gov.za/publications/P0302/P03022014 (accessed 19 January 2017).

Accepted 7 December 2016.

CASE REPORT

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

Systemic lupus erythematosus: A possible cause of non-alcoholic Wernicke’s encephalopathy

M T L Nyo,1 MB ChB, FCP (SA) Cert Rheum (Phys); D Magazi,2 MB BCh, MMed (Neuro), FCP (Neuro) (SA); M M T M Ally,3 MB BCh, FCP (SA), PhD Division of Rheumatology, Department of Medicine, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa Department of Neurology, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa 3 Division of Rheumatology, Department of Internal Medicine, Faculty of Health Sciences, University of Pretoria, South Africa 1 2

Corresponding author: M T L Nyo (mtlnyo@gmail.com)

We report a young woman with systemic lupus erythematosus (SLE) and an acute cerebellar ataxia. A history of poor appetite and vomiting preceded the inco-ordination. Ataxia in SLE has been well described, but is nevertheless uncommon. The clinical triad of mild confusion, ataxia and ophthalmoplegia also raised the possibility of Wernicke’s encephalopathy (WE). The diagnosis of WE was further supported by the magnetic resonance imaging features. Owing to overlapping causal factors, this case illustrates the complexity of diagnosing and managing neuropsychiatric syndromes in a patient with SLE. The limited published literature on SLE-related cerebellar syndromes adds to the challenge. Gastrointestinal manifestations of SLE are described as being common in SLE, with nausea and vomiting occurring in >50% of cases in some series. Poor eating habits and vomiting are well-described causes of non-alcoholic WE. This is the first description of gastrointestinal SLE as a possible cause of WE. S Afr Med J 2017;107(4):299-301. DOI:10.7196/SAMJ.2017.v107i4.12053

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disorder, with neurological manifestations being common. Attribution of neurological features to SLE is often a challenging process that requires a thorough clinical evaluation, relevant laboratory investigations and imaging studies. Acute cerebellar ataxia has been described in SLE, although little has been published in this regard. Wernicke’s encephalopathy (WE) is a neurological complication of thiamine deficiency. Poor eating habits and vomiting are well-described causes of non-alcoholic WE. Gastrointestinal manifestations commonly occur, with nausea and vomiting reported in >50% of cases in some series. It is important that WE is considered in patients with SLE and ataxia, as it is treatable and carries a significant morbidity and mortality without appropriate treatment.

Case report

A 24-year-old black female patient was referred to the rheumatology clinic at Dr George Mukhari Academic Hospital, a tertiary hospital

in Pretoria, South Africa, with suspected SLE. Dermatologists had been treating her for a biopsy-proven bullous lupus for a few months. The initial consultation at the rheumatology clinic confirmed the diagnosis of SLE, based on the presence of acute cutaneous lupus, non-scarring generalised alopecia, haemolytic anaemia, positive antinuclear antibody, positive anti-Smith antibody, a weakly positive lupus anticoagulant test, and a low level of serum complement 3 (C3), unequivocally fulfilling the Systemic Lupus International Collaborating Clinics classification criteria for SLE.[1] Although her bullous lesions had healed, she had an active interarticular rash on her fingers and haemolytic anaemia, with a haemoglobin of 6.4 g/dL, confirming the presence of active disease. She received 2 U of blood and was treated with oral prednisone and oral azathioprine. Five weeks later, she presented again, complaining of intermittent vomiting and nausea of ~3 weeks’ duration. She also reported weight loss and vertigo. A physical examination revealed sinus tachycardia, drowsiness, mild confusion, nystagmus, dysarthria, truncal and limb

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ataxia and bilateral partial 6th cranial nerve palsies. Her haemoglobin was 11.4 g/dL. All other laboratory tests for detecting active SLE in various organ systems were normal, except for hypoalbuminaemia, with a serum albumin of 26 g/L. Her renal function test was normal and there was no proteinuria. Hypoalbuminaemia seemed to reflect the severity of vomiting and possibly the negative acute-phase response. Typical features of SLE-related protein-losing enteropathy, such as diarrhoea, profound pitting oedema and effusions in serous cavities, were absent. Barium studies and gastroscopy did not show any abnormalities to explain the reasons for her vomiting, suggesting that SLE itself was the likely cause. SLE activity was thought to be the cause of sinus tachycardia, as other causes such as thyrotoxicosis, lung diseases, pulmonary embolism and myocarditis were excluded. With regard to her neurological symptoms and signs, the possibility of SLE-related cerebellar syndrome was initially considered in view of active SLE. A computed tomography scan of the brain revealed cerebral atrophy, which is not an infrequent finding in patients with SLE. Subsequently, a lumbar puncture and analysis of the cerebrospinal fluid were normal, except for slightly elevated protein at 0.72 g/L; infection-related meningitis was excluded. Magnetic resonance imaging (MRI) scanning revealed signal hyperintensity in the thalami, midline cerebellum and cerebellar hemispheres (Fig. 1). The clinical triad of mild confusion, ataxia and ophthalmoplegia in the presence of suggestive MRI findings led to the diagnosis of non-alcoholic WE. It was, however, considered an atypical presentation, as the patient had a pancerebellar syndrome involving the trunk and the limbs, rather than the typical midline cerebellar syndrome of WE that involves mainly the trunk. Dysarthria is also not a common clinical feature of WE.[2]

Case management

The patient was initially treated with intravenous fluid and empiric intravenous antibiotics. In view of the likelihood of gastrointestinal SLE, the low exclusion probability of SLE-related cerebellar syndrome, and low probability of sepsis, she was initially given three doses of intravenous methylprednisolone over 3 days at 750 mg/dose, followed by oral prednisone. Vomiting stopped after a few days. The patient was then started on high-dose intravenous thiamine for 2 weeks,

Fig. 1. Brain MRI fluid-attenuated inversion-recovery (FLAIR) images and diffusion-weighted images (DWI). (A) FLAIR image shows hyperintensity in cerebellar hemispheres (white arrows). (B) FLAIR image shows hyperintensity in cerebellar vermis and paravermis (black arrow head). (C) DWI shows hyperintensity in cerebellar hemispheres (void arrows). (D) DWI shows hyperintensity in the thalami (black arrows).

followed by oral thiamine. Two weeks after the initiation of high-dose thiamine treatment, she was found to have some residual ataxia and confusion. Every 2 weeks six intravenous cyclophosphamide pulses at 500 mg/dose were added to her treatment.

Outcome and follow-up

At the completion of all six pulses of cyclophosphamide, the patient was assessed as being in remission from SLE, with no residual neurological features, except for mild forgetfulness reported by the patient. At her most recent follow-up visit about 1 year later, she remained in remission, with full neurological recovery.

Discussion

A major challenge in the diagnosis and management of the index patient was the decision to attribute her cerebellar ataxia to the SLE as opposed to an SLE-unrelated cause. This is not an uncommon challenge in the setting of neurological manifestations of SLE owing to an overlap in presentation. The main alternative diagnostic consideration in this case was non-alcoholic WE. The process of attributing a neuropsychiatric event to SLE usually involves: (i) exclusion of secondary causes; (ii) assessment of the type of event and its timing in relation to the onset of SLE; (iii) assessment of risk factors for SLE-related events v. SLE-unrelated events; (iv) special investigations, often including neuroimaging and analysis of cerebrospinal fluid; and (v) assessment of clinical response to treatment.[3] Secondary causes such as drugs, a paraneoplastic phenomenon and metabolic abnormalities causing cerebellar ataxia were excluded and no source of infection was identified. Regarding the type of event, it has been shown that major occurrences, such as an acute confusion state, refractory seizures, myelopathy, optic neuritis, acute psychosis, polyneuropathy and stroke, are more likely to be attributable to SLE than minor events, such as mild depression, anxiety, headaches, mild cognitive dysfunction and polyneuropathy without electrophysiological evidence.[4] However, there is a scarcity of information about SLE-related cerebellar ataxia in the published literature. The American College of Rheumatology described 19 neuropsychiatric syndromes in 1999[5] â&#x20AC;&#x201C; one of these is movement disorders. Cerebellar ataxia together with chorea and hemiballismus are categorised as movement disorders. In 1988, Singh et al.[6] reported three women with SLE and cerebellar ataxia, who responded favourably to treatment with moderate doses of prednisone. In 1996, Manto et al.[7] reported a 27-year-old woman with SLE, who presented with a subacute pancerebellar syndrome. Her brain MRI scan showed cerebellar atrophy and the cerebellar ataxia improved markedly following corticosteroid administration. In 2000, Yaginuma et al.[8] described a 28-year-old woman with active SLE involving digestive tract, skin and kidneys, who developed acute cerebellar ataxia, a paresis of the right inferior rectus muscle, left abducens paralysis and left facial palsy, which seemed to be consistent with a brainstem lesion visible on MRI. This lesion disappeared within 9 days of corticosteroid treatment. In 2008, Appenzeller et al.[9] reported 3 women with SLE and acute cerebellar ataxia, who were successfully treated with intravenous corticosteroids and an immunosuppressant. Most recently, in 2014, Ghosh et al.[10] described a 22-year-old girl with active SLE, who presented with lupus nephropathy and subacute pancerebellar syndrome. Her brain MRI scan showed cerebellar atrophy. Treatment of lupus nephropathy with oral corticosteroids and mycophenolate mofetil prevented further deterioration of her cerebellar syndrome. Regarding the timing of the event, an SLE-related neuropsychiatric event tends to occur at the onset of SLE or within the first 2 years after the diagnosis.[3] Our patient seemed to fall into the latter category.

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Major risk factors for SLE-related events include generalised SLE activity or damage, history of previous or concurrent major SLErelated neuropsychiatric events and presence of antiphospholipid antibodies.[3] Our patient had a weakly positive lupus anticoagulant test. The following features may have suggested active SLE in this patient: sinus tachycardia, hypoalbuninaemia, low serum C3 level and possible gastrointestinal SLE. MRI findings of our patient were not typical for an SLE-related neuropsychiatric event. There was no evidence of ischaemia, as would have resulted from a vasculitis or vasculopathy. The involvement of the vermis, the paravermis together with the medial aspects of both thalami, has been described by some researchers as specific for nonalcoholic WE.[11,12] The involvement of the cerebellar hemispheres, albeit atypical, has been described in WE.[13] Gastrointestinal manifestations are described as being common in SLE, with nausea and vomiting occurring in >50% of cases in some series.[14] In our patient, the acute cerebellar syndrome, together with the MRI features, was suggestive of WE. Poor eating habits and vomiting are well-described causes of non-alcoholic WE.[15] WE is a neurological complication of thiamine (vitamin B1) deficiency.[2] It is an acute syndrome requiring emergent treatment to prevent death and neurological morbidity. Women appear to be more susceptible to the condition than men. Although chronic alcoholism accounts for most cases of WE, it can be associated with other conditions such as anorexia nervosa, dieting, starvation, gastrointestinal surgery or hyperemesis gravidarum. The classic triad of encephalopathy, oculomotor dysfunction/ophthalmoplegia and gait ataxia may not be present in all patients; hence, a high index of suspicion is necessary to recognise and treat the condition early. Ataxia of the legs or arms and dysarthria or scanning speech are thought to be uncommon, although some literature suggests that the lower limbs are typically involved. Diagnosis is primarily clinical because the specific diagnostic laboratory tests (e.g. red blood cell thiamine) are often not readily available. A brain MRI scan typically shows signal hyperintensities in the periaqueductal area, medial thalamus, dorsal medulla, tectal plate and mamillary bodies. Treatment of WE is essentially with high-dose intravenous thiamine, followed by oral thiamine. Response to thiamine replacement is usually very good and improvement in ocular signs and confusion can be seen within hours to days, while gait ataxia may start improving only in the second week.

Conclusion

Owing to overlapping causal factors, this case illustrates the complexity of diagnosing and managing neuropsychiatric syndromes in patients with SLE. The limited published literature on SLE-related cerebellar syndrome further contributes to the diagnostic dilemma.

Ataxia is not common in SLE; when it occurs, WE is an important consideration because it is treatable and carries a significant mortality rate, should it be ignored.[16] In our case, given the clinical presentation, which was suggestive of WE owing to gastrointestinal SLE, we instituted treatment for both conditions, with a satisfactory outcome. This is the first description of gastrointestinal SLE as a possible cause of non-alcoholic WE.

Teaching points

• Diagnosing and managing neuropsychiatric syndromes in patients with SLE is a challenging process, requiring a multidisciplinary approach. • Poor eating habits and vomiting are well-described causes of nonalcoholic WE. • Gastrointestinal manifestations, such as vomiting, are common in SLE. • Gastrointestinal SLE is a possible cause of non-alcoholic WE. • WE is an important consideration in a patient with SLE and acute cerebellar ataxia. 1. Petri M, Orbai AM, Alarcón GS, et al. Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012;64(8):2677-2686. https://doi.org/10.1002/art.34473 2. Yuen T. Wernicke encephalopathy. In: Aminoff MJ, ed. UpToDate 2015. http://uptodate.com/contents/ wernicke-encephalopathy?source=search_result&search=wernicke%20encephalopathy&selectedTitle=1~45 (accessed 16 February 2017). 3. Fanouriakis A, Boumpas DT, Bertsias GK. Pathogenesis and treatment of CNS lupus. Curr Opin Rheumatol 2013;25(5):577-583. https://doi.org/10.1097/BOR.0b013e328363eaf1 4. Ainiala H, Hietaharju A, Loukkola J, et al. Validity of the new American College of Rheumatology criteria for neuropsychiatric lupus syndromes: A population-based evaluation. Arthritis Rheum 2001;45(5):419-423. https://doi.org/10.1002/1529-0131(200110)45:5<419::AID-ART360>3.0.CO;2-X 5. American College of Rheumatology. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum 1999;42(4):599-608. https://doi. org/10.1002/1529-0131(199904)42:4<599::AID-ANR2>3.0.CO;2-F 6. Singh RR, Prasad K, Kumar A, et al. Cerebellar ataxia in systemic lupus erythematosus: Three case reports. Ann Rheum Dis 1988;47(11):954-956. https://doi.org/10.1136/ard.47.11.954 7. Manto MU, Rondeaux P, Jacquy J, et al. Subacute pancerebellar syndrome associated with systemic lupus erythematosus. Clin Neurol Neurosurg 1996;98(2):157-160. https://doi.org/10.1016/0303-8467(96)00013-3 8. Yaginuma M, Suenaga M, Shiono Y, et al. Acute cerebellar ataxia of a patient with SLE. Clin Neurol Neurosurg 2000;102(1):37-39. https://doi.org/10.1016/S0303-8467(99)00078-5 9. Appenzeller S, Cendes F, Costallat LT. Cerebellar ataxia in systemic lupus erythematosus. Lupus 2008;17(12):1122-1126. https://doi.org/10.1177/0961203308093071 10. Ghosh K, Chatterjee A, Ghosh S, et al. Cerebellar ataxia in a young patient: A rare path to lupus. J Neurosci Rural Pract 2014;5(Suppl 1):S75-S76. https://doi.org/10.4103/0976-3147.145212 11. Fei GQ, Zhong C, Jin L, et al. Clinical characteristics and MRI features of nonalcoholic Wenicke encephalopathy. Am J Neuroradiol 2008;29(1):164 -169. https://doi.org/10.3174/ajnr.A0827 12. Roh JH, Kim JH, Koo Y, et al. Teaching neuroimage: Diverse MRI signal intensities with Wernicke encephalopathy. Neurology 2008;70(15):e48. https://doi.org/10.1212/01.wnl.0000308951.21103.49 13. Kim JE, Kim TH, Yu IK, et al. Diffusion-weighted MRI in recurrent Wernicke’s encephalopathy: A remarkble cerebellar lesion. J Clin Neurol 2006;2(2):141-145. https://doi.org/10.3988/jcn.2006.2.2.141 14. Xu D, Yang H, Lai CC, et al. Clinical analysis of systemic lupus erythematosus with gastrointestinal manifestations. Lupus 2010;19(7):866-869. https://doi.org/10.1177/0961203310365883 15. Galvin R, Brathen G, Ivashynka A, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol 2010;17(12):1408-1448. https://doi.org/10.1111/j.14681331.2010.03153.x 16. Pearce J. Wernicke-Korsakoff encephalopathy. Eur Neurol 2008;59(1-2):101-104. https://doi.org/ 10.1159/000109580

Accepted 13 January 2017.

April 2017, Print edition

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

IN PRACTICE

CASE REPORT

Lead poisoning in shooting-range workers in Gauteng Province, South Africa: Two case studies A Mathee,1,2,3 PhD, MSc; P de Jager,2,4 MB ChB, DCH (SA), MMed (PHM), FCPHM (SA), MSc (HEPM); S Naidoo,2 MB ChB; N Naicker,1,2,4 PhD, MB ChB, MMed Environment and Health Research Unit, South African Medical Research Council, Johannesburg, South Africa School of Public Health, Department of Community Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Department of Environmental Health, Faculty of Health Sciences, University of Johannesburg, South Africa 4 Epidemiology and Surveillance Unit, National Institute for Occupational Health, National Health Laboratory Service, Johannesburg, South Africa 1 2

Corresponding author: A Mathee (amathee@mrc.ac.za) Background. Lead exposure constitutes a major public health concern globally. Relative to developed nations, lead exposure is understudied and poorly addressed in Africa, and there is a dearth of information available to inform lead poisoning prevention strategies, even in highrisk groups such as workers in shooting ranges who are potentially exposed to lead daily. Methods. Two workers at a private shooting range in Gauteng, South Africa (SA), had blood lead levels and exposure histories taken. Results. Workers had highly elevated blood lead levels and clinical symptoms associated with elevated blood lead levels. Conclusion. Workers in private SA shooting ranges are vulnerable to lead exposure and poisoning, and scaled-up action is required to protect them and their families, as well as shooting-range users, from lead and the related health risks. S Afr Med J 2017;107(4):302-303. DOI:10.7196/SAMJ.2017.v107i4.12176

Its many useful properties have resulted in lead being widely used in modern life. However, research has revealed lead to be highly toxic and associated with a wide range of detrimental health effects, including impaired cognitive function,[1] hearing deficits, behavioural abnormalities, aggressive behaviour,[2] anaemia and other clinical effects, as well as a range of nonspecific effects, such as joint pain, headaches, weight loss, abdominal pain and in severe cases, muscular paralysis, coma and death.[3] While lead exposure is a recognised public health concern in Africa,[4] there is a paucity of research information available to describe the levels and pathways of exposure to lead in the general public, as well as in specific high-risk settings. Shooting ranges, for example, have been established to be a setting of high risk for lead exposure elsewhere in the world,[5-7] but little information is available, to our knowledge, on the lead exposure situation in South African (SA) shooting ranges. Here, two case studies of elevated lead exposure in workers at a private shooting range in Gauteng Province are described.

Methods

In 2014, blood lead analyses were undertaken in two workers at a private indoor shooting range in greater Johannesburg. Blood lead levels were determined using a LeadCare II (Magellan Diagnostics, USA) portable testing system, with a 50 μL aliquot of whole blood obtained from a finger prick following the thorough washing of hands with soap and water. Ethical approval for this work, which was part of a broader cross-sectional survey of the blood lead levels of users of indoor shooting ranges, was obtained from the Human Research Ethics Committee of the SA Medical Research Council. Written, informed consent was obtained from all participants prior to enrolling them in the study.

Results Case 1

A 63-year-old

woman living in an informal settlement on the periphery of Johannesburg had a laboratory-confirmed blood lead level of 42.8 μg/dL. She had been employed at the indoor shooting range as a cleaner for the previous 22 years, before which she had been employed as a domestic worker. She was responsible for cleaning the entire range and collecting spent ammunition, which the shooting-range owner sold for lead recycling. The range was poorly ventilated and not fitted with air filtration devices. The walls in the shooting range were padded with a rippled, spongy material in an effort to reduce noise, and some of the floors were carpeted. Both these materials serve as traps for dust present in the range, and the spongy material, originally yellowish in colour, had deeply blackened over time. She cleaned the range predominantly using a dry duster, dry broom and ordinary domestic vacuum cleaner, and was not provided with personal protective equipment. She neither hunted nor practised gun shooting, and had no other identifiable source of lead exposure. She reported long-standing type 2 diabetes mellitus, essential hypertension and rheumatoid arthritis, for which she was receiving treatment. She described her general health as fair, but complained of paraesthesiae in her hands and feet, and experienced occasional abdominal cramps. She had been pregnant five times, and one had ended in a miscarriage in 2000.

Case 2

A 27-year-old man living in a suburban area south-east of Johannesburg had a laboratory-confirmed blood lead level of 60.0 μg/ dL. He had been employed at the indoor shooting range for the previous 3 years, where he worked as an administrator and instructor. He

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IN PRACTICE

had been shooting for 9 years, and practised on a weekly basis for around 30 minutes. Most often he used a handgun, but on occasion would also use a shotgun or rifle. He mainly used nonjacketed (lead head) bullets. He was not a hunter. He always used hearing protection, sometimes eye protection but no other personal protective equipment. He sometimes placed bullets in his mouth and often ate at the range. He reported always washing his hands after shooting. He was a tobacco smoker and smoked at the range. He was unaware of any other sources of exposure to lead outside his work environment. He reported no major health concerns, but during the previous 2 years he and his family had observed changes in his mood and difficulty controlling anger. He also reported abdominal cramps and paraesthesiae in his hands and feet.

Discussion

The case studies presented here raise concerns over the potential for high levels of exposure to lead among workers in privately owned SA shooting ranges. Both workers had highly elevated blood lead levels, and no evidence of alternative sources of exposure. The blood level lead of case 2 (60 µg/dL) was sufficiently elevated to require removal from his duties or workplace in terms of lead regulations promulgated under the umbrella of the SA Occupational Health and Safety Act No. 83 of 1993. Yet, for both of the cases, despite long periods of work in a high lead-exposure setting (case 1 had worked at the range for 22 years), this was the first occasion on which they had undergone a blood lead test, indicating the need for a higher level of occupational health monitoring and vigilance in this vulnerable group of workers. Both workers reported symptoms, for example paraesthesia in extremities, consistent with lead poisoning. Observations at the range revealed concerns regarding the inadequate design of the infrastructure (such as the absence of effective ventilation systems), floor and wall surfaces that could trap dust and that were not easy to clean (such as carpeted floors and spongy wall finishes), poor hygiene facilities and practices (disposable towels and soap were not provided) and poor housekeeping (the range was being cleaned with ordinary domestic brooms and dry cloths, rather than wet cleaning and the use of a high-efficiency particulate air vacuum cleaner). In addition, the workers’ knowledge of lead hazards was weak, as has been shown to be the case more broadly in SA.[8] Apart from the direct exposure to lead in shooting-range workers, there is also concern over the indirect exposure to lead among their family or household members. Lead particles may be transported from the range, via the skin, hair, clothing and footware of the workers, into their homes, thus indirectly causing others

to be exposed to lead. Workers’ clothing was also being washed together with that of their household members, constituting another potential indirect pathway of lead exposure for their families. In the interests of workers and their families, it is therefore imperative that the health, labour and industrial/commercial sectors join forces to ensure that measures are put in place to eliminate or significantly reduce lead exposure in shooting-range workers. These might include lead hazard awareness campaigns, the institution of shooting-range monitoring and surveillance programmes, and the development of guidelines or standards for the design and fitting of private shooting ranges in South Africa.

Conclusion

This study has shown highly elevated worker exposure to lead at an SA shooting range, with one of the two workers having a blood lead level that requires removal in terms of SA lead regulations. Numerous opportunities for lowered lead exposure were identified, including improved ventilation, personal hygiene, lead hazard awareness, improved housekeeping, worker monitoring and surveillance programmes at ranges and the drafting of guidelines or standards for the design and fitting of shooting ranges. Funding. Funding for this study was provided by the SA Medical Research Council. Acknowledgements. The shooting range manager/owner and the workers included in the study are thanked, and the assistance of Mirriam Mogotsi, Louise Renton, Thandi Zwane, Patricia Albers, Reaford Beldon, Felicia Mpiti and Tahira Kootbodien is appreciated. 1. Bellinger D, Dietrich KN. Low-level lead exposure and cognitive function in children. Pediatr Ann 1994;23(11):600-605. https://dx.doi.org/10.3928/0090-4481-19941101-08 2. Needleman HL, McFarland C, Ness RB, Fienberg SE, Tobin MJ. Bone lead levels in adjudicated delinquents. A case control study. Neurotoxicol Teratol 2002;24(6):711-717. https://dx.doi. org/10.1016/s0892-0362(02)00269-6 3. Tong S, von Schirnding YE, Prapamontol T. Environmental lead exposure: A public health problem of global dimensions. Bull World Health Organ 2000;78(9):1068-1077. 4. Nriagu JO, Blankson ML, Ocran K. Childhood lead poisoning in Africa: A growing public health problem. Sci Total Environ 1996;181(2):93-100. https://dx.doi.org/10.1016/0048-9697(95)04954-1 5. Fayiga A, Saha U. Soil pollution at outdoor shooting ranges: Health effects, bioavailability and best management practices. Environ Pollut 2016;216:135-145. https://dx.doi.org/10.1016/j. envpol.2016.05.062 6. Abudhaise B, Alzoubi M, Rabi A, Alwash R. Lead exposure in indoor firing ranges: Environmental impact and health risk to the range users. Int J Occup Med Environ Health 1995;9(4):323-329. 7. Beaucham C, Page E, Alarcon WA, Calvert GM, Methner M, Schoonover TM. Indoor firing ranges and elevated blood lead levels – United States, 2002 - 2013. Morb Mortal Wkly Rep 2014;63(16):347-351. 8. Haman T, Mathee A, Swart A. Low levels of awareness of lead hazards among pregnant women in a high risk Johannesburg neighbourhood. Int J Environ Res Public Health 2015;12(12):15022-15027. https://dx.doi.org/10.3390/ijerph121214968

Accepted 23 November 2016.

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IN PRACTICE

CASE REPORT

Mammary analogue secretory carcinoma: A rare salivary gland tumour B S Jackson,1 MB BCh, MMed (Surg); T L Pratt,1 MB ChB; A van Rooyen,2 MB ChB, MMed (Path) 1 2

Department of Surgery, Kalafong Hospital and Faculty of Health Sciences, University of Pretoria, South Africa National Health Laboratory Services and Department of Anatomical Pathology, Faculty of Health Sciences, University of Pretoria, South Africa

Corresponding author: B S Jackson (drbrandonjackson@gmail.com)

Mammary analogue secretory carcinoma (MASC) is a rare and recently described tumour of the salivary glands. MASC has similar histomorphological and immunohistochemical features of secretory carcinoma of the breast. MASC can be mistaken for other salivary gland tumours, especially acinic cell carcinoma. A 28-year-old man was diagnosed with a rare salivary gland tumour in Pretoria, South Africa (SA). To our knowledge, a report of MASC in SA has not previously been published. The surgeons dealing with salivary gland tumours should be aware of the clinical presentation. Current treatment is similar to that of other salivary gland malignancies. S Afr Med J 2017;107(4):304-306. DOI:10.7196/SAMJ.2017.v107i4.12228

Salivary gland malignancy is rare, with a global annual incidence of 3 per 100 000 people.[1,2] A rare salivary gland tumour, mammary analogue secretory carcinoma (MASC), has only recently been described.[3] The few reports and studies concerning MASC have been published in several pathology journals. We report a case of a MASC of the right parotid salivary gland. Ethics approval was obtained from the University of Pretoria Faculty of Health Sciences Research Ethics Committee (ref. no. 384/2016).

Case report

A 28-year-old man presented to Kalafong Hospital, Pretoria, South Africa, with a 1-year history of a slow-growing right cheek mass. The mass was not painful and there was no history of trauma to the face. Clinically, the patient was well, with a non-tender, firm, mobile 4 Ă&#x2014; 3 cm parotid tumour. The right facial nerve was intact. The patient tested negative for HIV. Fine needle aspiration biopsy showed the features to be characteristic of a pleomorphic adenoma. The patient underwent a superficial parotidectomy. Macroscopically, a tan-white homogeneous nodule of 0.8 cm was present in the lateral aspect of the parotid gland. Histological examination of sections from the superior aspect showed apparently normal parotid salivary gland tissue. Examination of the lateral aspect showed a relatively circumscribed area with a lobulated architecture traversed by thick fibrous septa (Fig. 1). Microcystic growth with dilated areas and papillary-cystic growth patterns with papillary projections were seen (Fig. 2). Tumour islands punctuated by microcysts were scattered within the sclerosed stroma. The papillae were lined by bland cells with abundant eosinophilic to vacuolated cytoplasm. Some cells had a hobnail appearances and low-grade vesicular round-to-ovoid nuclei, with finely granular chromatin and conspicuous nucleoli (Fig. 3). The wall appeared markedly hyalinised and sclerosed. A chronic lymphocytic inflammatory infiltrate was present in the wall. Partial infiltration into the salivary gland was seen in areas. No necrosis or mitotic figures were present. Inspissated secretions and abundant eosinophilic homogeneous secretory material were present. Immunohistochemistry showed strong diffuse staining with the keratin marker CK7 and patchy positivity with S-100 protein. DOG-1

Fig. 1. MASC: multinodular tumour separated by fibrous bands (arrow).

Fig. 2. Area with papillary growth (arrows).

and P63 were negative. Intracytoplasmic and intraluminal mucus was highlighted with periodic acid-Schiff (PAS) (Fig. 4). The histological features were compatible with the rare, recently described MASC. There were no projections of the tumour toward the deep lobe of the parotid gland. The patient underwent adjuvant radiotherapy. At 8 months post excision, he was well with no signs of recurrence.

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Fig. 3. Area with microcystic pattern and prominent intraluminal secretions (arrow head). Nuclei with finely granular chromatin and conspicuous nucleoli (arrows).

Discussion

In 2010, Skálová et al.[3] published a description of 16 cases of salivary gland tumours, which were reminiscent of secretory (juvenile) carcinoma of the breast, and subsequently proposed MASC to describe the tumours.[4] Secretory carcinoma is a rare tumour of the breast with a characteristic histological appearance.[5] Breast and salivary gland tissues are derived from the same ectodermal embryonic origin.[2] Salivary and mammary gland tissue have identical ductulo-acinar architecture. Both tumours consist of microcystic and solid areas with abundant vacuolated colloid-like PAS-positive secretions within the microcystic spaces.[6,7] Both tumours are triple (ER/PR/Her-2)-negative. Breast secretory carcinomas are clinically slow growing, recur locally, occur mainly in young females and generally have a favourable outcome.[4] MASC can be clinically slow growing or have an aggressive pattern with metastases and increased mortality.[3] MASC can be mistaken for acinic cell carcinoma; however, MASC does not have acinar cells with cytoplasmic PAS-positive, zymogen-like granules.[3] The majority of MASC cases were previously diagnosed as ‘zymogen-poor’ acinic cell carcinoma, but also have similar features to low-grade cribiform cystadenocarcinoma, adenocarcinoma not otherwise specified, and low-grade muco-epidermoid carcinoma.[9,10] Acinic cell carcinoma of the breast is composed of cells arranged in microcystic, solid and microglandular areas, and resembles acinic cell carcinoma of the salivary glands. The immunohistochemical and clinicopathological findings of salivary acinic cell carcinoma are similar to those of breast secretory carcinomas.[3] MASC is rubbery and has a white-to-grey surface when cut. Microscopically, the tumour is a circumscribed (but not encapsulated) multinodular mass divided by fibrous septa with microcystic, glandular and solid growth patterns.[4,8] Tumour cells are relatively uniform.[11] The tumour can invade within the salivary gland and can extend into the surrounding structures.[3,8] The tumour cells have low-grade vesicular nuclei, finely granular chromatin and a distinctive centrally located nucleolus. The nucleus is surrounded by pale eosinophilic granular or vacuolated cytoplasm.[3,4] Mitotic rates are usually 0 - 1 mitotic figures/10 high-powered fields.[12] Immunohistochemical studies show positive staining with vimentin, mammaglobin, cytokeratin 7 and S-100 protein.[3,8] Mammaglobin and S-100 protein can also be positive in polymorphous lowgrade adenocarcinomas and some adenoid cystic carcinomas.[13] Immunohistochemical stains are negative for DOG-1 and p63.[14] Skálová et al.[3] showed that MASCs are associated with a recurrent chromosomal translocation t(12;15) (p13;q25), which results in

Fig. 4. Secretions are highlighted with PAS stain (arrow).

a fusion gene between the ETV6 gene (chromosome 12) and the NTRK3 gene (chromosome 15). This ETV6-NTRK3 gene encodes for a chimeric tyrosine kinase.[3,4,7,15] Secretory carcinoma of the breast also has a recurrent chromosomal translocation t(12;15) (p13;q25), which also occurs some cases of myelogenous leukaemia, infantile fibrosarcoma and congenital mesoblastic nephroma.[12] Currently, salivary MASC is the only salivary gland tumour to harbour the recurrent chromosomal translocation t(12;15) (p13;q25).[4] ETV6-NTRK3 gene fusion definitively diagnoses MASC, but not all laboratories are equipped to perform this highly specialised test. The reported cases of MASC are diagnosed in the major salivary glands; the majority in the parotid gland. These tumours also occur in the minor salivary glands of the oral cavity. MASC has been documented in the lip, soft palate, hard palate, base of tongue and buccal mucosa.[2,12,16] The reported cases are usually in males, with a male:female ratio of 1.5:1.[2,4,17] According to a retrospective study from 1990 to 2012 by Min et al.,[8] the average age of diagnosis is 46 years, with a usual range of 14 - 77 years.[2,8] The youngest reported case occurred in a 5-year-old girl.[18] The size of MASC ranges from 1.77 to 2.5 cm.[3,8,10] MASCs in the oral cavity are usually smaller (mean 0.9 cm) than those in the major salivary glands.[12,19] MASC is considered to be a low-grade carcinoma that is slowgrowing, painless and with a relatively favourable prognosis.[7,12] It does not usually infiltrate surrounding structures, and perineural and vascular invasion is unusual.[12] MASCs have a 15% risk of local recurrences, especially if incompletely excised.[7] Simple enucleation of the tumour has a higher risk of local recurrence compared with excision.[7] MASCs have a 20% risk of lymph node metastases and 5% risk of distant metastases. Local recurrence usually occurs before distant metastases or tumour-related death.[7] High-grade transformation is associated with an accelerated clinical course and poor outcome. Skálová et al.[3] reported on three patients with high-grade transformed MASC who received parotidectomy. Two of the three received postoperative radiotherapy, the third patient’s condition being too poor to complete radiotherapy. All three died of metastatic disease within 2 - 6 years of diagnosis.[7] Clinical stage at diagnosis is the most accurate predictor of prognosis. Treatment recommendations are tentative, as there has been a limited number of cases of MASC with published follow-up data.[20] The role of adjuvant radiotherapy has not been assessed in patients with MASC. However, in the presence of high-grade transformed MASC, radical surgery with neck dissection followed by adjuvant radiotherapy is advised.[7] The optimal follow-up period for MASC is also not currently determined.

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Some ETV6-NTRK3-positive leukaemias respond to tyrosine inhibitors. MASC may therefore also respond favourably by targeting the ETV6–NTRK3 translocation, as a potential therapy, especially for the high-grade transformation MASC.[12] 1. Parkin DM, Ferlay J, Curado MP, et al. Fifty years of cancer incidence: CI5 I-IX. Int J Cancer 2010;127(12):2918-2927. https://doi.org/10.1002/ijc.25517 2. Cooper D, Burkey B, Chute D, et al. Mammary analogue secretory carcinoma of the soft palate: A report of two cases. Int J Otolaryngo Head Neck Surg 2013;2(5):174-178. https://doi.org/10.4236/ ijohns.2013.25037 3. Skálová A, Vanecek T, Sima R, et al. Mammary analogue secretory carcinoma of salivary glands containing the ETV6-NTRK3 fusion gene: A hitherto undescribed salivary gland tumor entity? Am J Surg Pathol 2010;34(5):599-608. https://doi.org/10.1097/pas.0b013e3181d9efcc 4. Laco J, Svajdler Jr M, Andrejsc J, et al. Mammary analog secretory carcinoma of salivary glands: A report of 2 cases with expression of basal/myoepithelial markers (calponin, CD10 and p63 protein). Path Res Pract 2013;209(3):167-172. https://doi.org/10.1016/j.prp.2012.12.005 5. McDivitt RW, Stewart FW. Breast carcinoma in children. JAMA 1966;195(5):388-390. https://doi. org/10.1001/jama.195.5.388 6. Petersson F, Lian D, Chau Y, et al. Mammary analogue secretory carcinoma: The first submandibular case reported including findings on fine needle aspiration cytology. Head Neck Pathol 2012;6(1):135139. https://doi.org/10.1007/s12105-011-0283-x 7. Skálová A, Vanecek T, Majewska H, et al. Mammary analogue secretory carcinoma of salivary glands with high-grade transformation. Report of 3 cases with the ETV6-NTRK3 gene fusion and analysis of TP53, B-catenin, EGFR, and CCND1 genes. Am J Surg Pathol 2014;38(1):23-33. https://doi. org/10.1097/pas.0000000000000088 8. Min JJ, Joon SS, Sang YK, et al. Finding and characterizing mammary analogue secretory carcinoma of the salivary gland. Korean J Pathol 2013;47(1):36-43. https://doi.org/10.4132/ koreanjpathol.2013.47.1.36 9. Majewska H, Sang YK, Soon YN, et al. Mammary analogue secretory carcinoma of salivary glands: A new entity associated with ETV6 gene rearrangement. Virchows Arch 2015;466(3):245-254. https:// doi.org/10.1007/s00428-014-1701-8 10. Chiosea SI, Griffith C, Assaad A, et al. Clinicopathological characterization of mammary analogue secretory carcinoma of salivary glands. Histopathol 2012;61(3):387-394. https://doi.org/10.1111/ j.1365-2559.2012.04232.x

11. Inaba T, Fukumura Y, Saito T, et al. Cytological Features of mammary analogue secretory carcinoma of the parotid gland in a 15-year-old girl: A case report with review of the literature. Case Rep Pathol 2015;2015:1-6. https://doi.org/10.1155/2015/656107 12. Bishop JA. Unmasking MASC: Bringing to light the unique morphologic, immunohistochemical and genetic features of the newly recognized mammary analogue secretory carcinoma of salivary glands. Head Neck Pathol 2013;7(1):35-39. https://doi.org/10.1007/s12105-013-0429-0 13. Patel KR, Solomon IH, El-Mofty SK, et al. Mammaglobin and S-100 immunoreactivity in salivary gland carcinomas other than mammary analogue secretory carcinoma. Hum Pathol 2013;44(11):25012508. https://doi.org/10.1016/j.humpath.2013.06.010 14. Hijazi N, Rahemtulla A, Zhou C, et al. An FNA pitfall: Mammary analogue secretory carcinoma mistaken for acinic cell carcinoma due to cytoplasmic granules. Hum Pathol Case Rep 2014;1(4):5861. https://doi.org/10.1016/j.ehpc.2014.09.008 15. Abe M, Inakia R, Kannoa Y, et al. Molecular analysis of a mammary analogue secretory carcinoma in the upper lip: Novel search for genetic and epigenetic abnormalities in MASC. Int J Surg Case Rep 2015;9:8-11. https://doi.org/10.1016/j.ijscr.2015.02.011 16. Helkamaa T, Rossib S, Mesimäkia K, et al. Mammary analogue secretory carcinoma of minor palatal salivary glands: A case report and review of the literature. J Oral Maxillofac Surg Med Pathol 2015;27(5):698-702. https://doi.org/10.1016/j.ajoms.2015.02.005 17. Griffith C, Seethala R, Chiosea SI. Mammary analogue secretory carcinoma: a new twist to the diagnostic dilemma of zymogen granule poor acinic cell carcinoma. Virchows Arch 2011;459(1):117118. https://doi.org/10.1007/s00428-011-1098-6 18. Keisling M, Bianchi M, Pascasio JM. Mammary analogue secretory carcinoma of salivary gland in a 5 year old: Case report. Int J Pediatr Otorhinolaryngol 2014;9(4):163-165. https://doi.org/10.1016/j. pedex.2014.09.003 19. Kratochvil FJ III, Stewart JCB, Moore SR. Mammary analogue secretory carcinoma of salivary glands: A report of 2 cases in the lips. Oral Maxillofac Pathol 2012;114(5):630-635. https://doi.org/10.1016/j. oooo.2012.07.480 20. Gupta R, Balasubramanian D, Clark JR. Salivary gland lesions: Recent advances and evolving concepts. Oral Maxillofac Pathol 2015;119(6):661-674. https://doi.org/10.1016/j.oooo.2015.02.481

Accepted 8 December 2016.

April 2017, Print edition

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

RESEARCH

Contraception coverage and methods used among women in South Africa: A national household survey M F Chersich,1 MB BCh, PhD; N Wabiri,2 MSc, MBA, PhD; K Risher,3 MHS; O Shisana,4 MA, ScD; D Celentano,3 MHS, ScD; T Rehle,2,5 MD, PhD; M Evans,6 MA; H Rees,1,7 MB BChir, MA, MRCGP Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Human Sciences Research Council, Cape Town, South Africa 3 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 4 Evidenced Based Solutions, Cape Town; and Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa 5 Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa, 6 Department of Anthropology, Faculty of Graduate Studies, York University, Toronto, Canada 7 London School of Hygiene and Tropical Medicine, University of London, UK 1 2

Corresponding author: M F Chersich (mchersich@wrhi.ac.za) Background. Globally, family planning services are being strengthened and the range of contraceptive choices expanded. Data on contraceptive coverage and service gaps could help to shape these initiatives. Objective. To assess contraception coverage in South Africa (SA) and identify underserved populations and aspects of programming that require strengthening. Methods. Data from a 2012 SA household survey assessed contraception coverage among 6 296 women aged 15 - 49 years and identified underserved populations. Results. Two-thirds had an unintended pregnancy in the past 5 years, a quarter of which were contraceptive failures. Most knew of injectable (92.0%) and oral contraception (89.9%), but fewer of intrauterine devices (56.1%) and emergency contraception (47.3%). Contraceptive prevalence was 49.1%, and 41.8% women used modern non-barrier methods. About half had ever used injectable contraception. Contraception was lower in black Africans and younger women, who used a limited range of methods. Conclusion. Contraception coverage is higher than many previous estimates. Rates of unintended pregnancy, contraceptive failure and knowledge gaps, however, demonstrate high levels of unmet need, especially among black Africans and young women. S Afr Med J 2017;107(4):307-314. DOI:10.7196/SAMJ.2017.v107i4.12141

Contraception has profound benefits for women and society, including reduced maternal and infant mortality and morbidity, empowerment of women to make informed choices about fertility, economic advancement, and a reduction in the number of children infected with HIV.[1,2] In recent decades, contraceptive use has risen markedly worldwide, although at a much slower pace in sub-Saharan Africa than elsewhere.[3] About a quarter of women in sub-Saharan Africa currently use modern contraceptive methods, with levels highest in southern Africa.[4,5] In South Africa (SA), for example, estimates of the proportion of women of reproductive age who are protected against unplanned pregnancies, using modern contraceptive methods, have increased steadily from 26.3% in 2002/2003 to 37.3% in 2013/2014.[6] These figures are drawn from a district health information system covering the public sector, while population level end-user data have yielded somewhat different estimates. For example, the 2003 Demographic and Health Survey,[7] the most recent available national report, found a contraceptive prevalence of 64.7%, similar to more recent modelling estimates.[8] Regardless of which figures are correct, the continued rise in the number of terminations of pregnancy in SA among all age groups suggests that substantial deficiencies remain in accessing family planning services.[6] Increasing the range of contraception choices available is a key component of ensuring access for women, their partners and couples

to the most effective method they wish to use. Global policymakers and policy advocates have placed particular emphasis on increasing access to long-acting reversible contraception (LARC) methods, including intrauterine devices and subdermal implants. These are highly effective, and markedly diminish the need for user adherence and contact with health workers. Many providers in SA are, however, still unfamiliar with these methods.[9-11] In SA, as throughout subSaharan Africa, the injectable progestins depot-medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN) are the most popular contraceptive methods,[4] and their use has continued to rise over time.[12] Nationally, about 5.8 million doses of DMPA are administered annually.[6] By contrast, in most high-income countries, use of injectable contraceptives is rare, aside from in marginalised groups, such as poor, African American or aboriginal women.[13-16] The popularity of injectables in sub-Saharan Africa is ascribed to its convenience for providers and women, cost effectiveness, and high acceptability among women and health providers.[2] Method discontinuation and contraceptive failure, however, frequently occur with this method.[17,18] Using data from the 2012 SA National HIV Prevalence, Incidence and Behaviour Survey,[19] this analysis assesses the extent of unmet contraceptive need, and estimates the overall contraception coverage and methods used. We also aimed to identify underserved populations through examining the demographic factors and sexual behaviours

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RESEARCH

associated with contraceptive use. In addition to providing updated figures on key family planning indicators, the study seeks to identify the areas that need to be addressed to strengthen family planning services in SA and similar settings.

Methods

Survey sampling, field and laboratory procedures

The fourth SA National HIV Prevalence, Incidence and Behaviour Survey[19] took place from January to November 2012. This population-based survey applied multistage stratified sampling by province; locality (urban formal, urban informal, rural formal including commercial farms, and rural informal or tribal authority areas); and predominant racial groups. Sampling frames were based on enumerator areas (EA) used in the national census, updated in 2007 to reflect changes in the sociodemographic profile of the country since 2001. In total, 1 000 EAs were selected from a database of 86 000 EAs as the primary sampling units, 15 households within each EA constituted the secondary sampling unit (15 000 households), and all persons in the selected households were eligible for the survey. Additional details of the survey methodology, including fieldwork procedures and quality control measures, are described elsewhere.[19] Dried blood spot specimens collected by finger prick were tested in a laboratory for HIV antibodies using a testing algorithm with three different immunoassays. All HIV testing was anonymous and unlinked to personal identifiers. Individuals were given an opportunity to access their HIV test results 8 weeks after testing at designated facilities, using bar codes to preserve anonymity. The study protocol was approved by the Human Sciences Research Council’s Research Ethics Committee (ref. no. 5/17/11/10) and the Human Subjects Review from the Centers for Disease Control and Prevention’s Global AIDS Programme. Only women in the reproductive age group (15 - 49 years) who had ever had sex were included in this analysis.

Study measures

Data were drawn from face-to-face questionnaires, which elicited detailed information on demographic and socioeconomic characteristics, contraception use, sexual behaviours and other risk factors for HIV infection. In a multiple-response question, women were asked if they ever had used or were currently using a contraceptive method, specifically injectable or oral contraception, an intrauterine device (IUD), female or male sterilisation, or natural family planning. In a separate question, women reported condom use at last sex and consistent condom use with their last partner. Injectable contraception referred to the use of either DMPA or NET-EN, as women were not asked to differentiate between these methods. Contraceptive prevalence was defined as the percentage of women aged 15 - 49 years, who were using (or whose partner was using) a contraceptive method at the time of the interview.[20] Contraceptive methods consisted of injectable and oral hormones, IUDs, female and male sterilisation, emergency contraception, and other (consistent condom use with last partner, natural family planning, or withdrawal). The indicator only includes women who were sexually active (had sex in previous 12 months), and not pregnant or amenorrhoeic. Injectable and oral hormones, IUDs, and female or male sterilisation were considered modern contraception. Condoms were excluded from this definition as biases inherent in its measurement may both under- and overestimate its use for contraception, hampering interpretation.[21] We used unintended pregnancy as a proxy indicator of unmet need for contraception. Socioeconomic quartiles were derived from measures of household living standards captured in the household questionnaire:

infrastructure and housing characteristics (source of drinking water, access to electricity, main source of energy for cooking and type of toilet used) and household ownership of durable assets (presence of a working refrigerator, radio, television, cellphone and landline phone). Details of how quartiles were generated and the rationale for using quartiles, rather than the commonly used quintiles, are provided elsewhere.[22,23]

Data management and analysis

After double data entry, data validity was verified using the Census and Survey Processing System (CSPro) (US Census Bureau, USA).[24] Data were analysed using Stata version 14.0 (Stata Corporation, USA), taking into account the complex multilevel sampling design (by age, race group and province) and participant non-response. Summary indices for descriptive analysis are weighted percentages, and unweighted counts are provided. Descriptive analyses were conducted to investigate whether use of any contraception or individual method was associated with demographic, social or economic characteristics, or pregnancy history. We also determined whether sexual behaviour, condom use, HIV risk perception and HIV status varied between women using different contraceptive methods. In descriptive and bivariate analyses, associations were identified using the Rao-Scott F statistic to determine p-values.

Results

Unmet need for contraception

Among the 8 482 women aged 15 - 49 years who had ever had sex, 81.1% reported being sexually active in the past year (Table 1). These figures were lowest among women 35 - 49 years (75.1%) compared with 83.0% in those 15 - 19 years, and about 85% among the other age groups (p<0.001). Age was also associated with unintended pregnancy among the 3 538 women who reported a pregnancy in the past 5 years. Overall, a third of these women (33.5%) had desired to become pregnant at the time of their last pregnancy; this was reported by only 10.1% of women 15 - 19 years of age and 20.9% of those 20 - 24 years of age (p<0.001). At the time of the pregnancy, about half of women 15 - 19 years (51.2%) and 20 - 24 years (48.5%) had not wanted to have a child. In older women, these levels were 41.3% for women 25 - 34 years and 44.9% for those 35 - 49 years. Among the 276 women who were pregnant at the time of the survey, only half (50.6%) had wanted to become pregnant. About a quarter (24.0%) of all women who reported a pregnancy in the past 5 years had been using a contraceptive method at the time of their pregnancy. These levels were only 12.8% in 15 - 19-year-olds compared with 19.7% in 20 - 24-year olds and 26.1% in women ≥25 years (p<0.01).

Contraceptive knowledge and prevalence

Of women who had ever had sex, almost all (92.0%) were aware of injectable contraception, with similarly high levels of knowledge of oral contraception (89.9%) and female sterilisation (73.3%; Table 2). Only about half, however, had heard of IUDs, emergency contraception or male sterilisation (56.1%, 47.3%, and 45.3%, respectively). Levels of knowledge among women aged 15 - 19 years were lower than those of older women for each contraceptive method. Most notably, only 30.9% of 15 - 19-year-olds knew of IUDs and 36.2% of emergency contraception, considerably lower than for other women. On average, women had heard of 4 - 5 contraceptive methods in total. Just under half of the 8 245 women responding to questions about lifetime contraception use (women who had ever had sex) reported having ever used injectable contraception (46.2%) and a quarter had ever used oral contraception (25.6%). Aside from the ‘other contra-

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ceptive’ category, ever use of all other methods (IUD, female sterilisation, male sterilisation, and emergency contraception) was <10%. Overall, current contraceptive prevalence was 49.1%, and 41.8% of women were using modern, non-barrier methods (Table 3). Injectable contraception was by far the most common method, used by 25.0% of women. Other methods were several-fold less common and only a negligible portion were using an IUD (1.6%). Among injectable contraception users, the majority had obtained this method of contraception at a clinic or community health centre (70.8%), while other methods were much less likely to have been provided at these facilities (<50% for all). A notably higher proportion of oral and emergency contraception users, and female and male sterilisation users, acquired their contraception from a private facility or doctor (23.0%, 21.3%, 26.5% and 41.5% respectively), while a considerable proportion of IUDs were obtained from a pharmacy (27.3%).

Table 1. Indices of unmet need for contraception in different age groups, SA, 2012 Variable

Prevalence

p-value

83.0 84.6 85.7 75.1

<0.001

6.6 6.1 8.1 1.7

<0.001

Sexually active past 6 months, age (years)* 15 - 19 (n=659) 20 - 24 (n=1 489) 25 - 34 (n=2 772) 35 - 49 (n=3 576) Currently pregnant, age (years)† 15 - 19 (n=500) 20 - 24 (n=1 197) 25 - 34 (n=2 235) 35 - 49 (n=2 587)

Sociodemographic factors and contraception use

Intended to become pregnant, age (years)‡ 15 - 19 (n=216) 20 - 24 (n=805) 25 - 34 (n=1 613) 35 - 49 (n=904)

10.1 20.9 37.4 42.1

<0.001

51.2 48.5 41.3 44.9

<0.001

12.8 19.7 26.1 26.1

<0.01

Table 3 shows the distribution of contraceptive methods among the 6 296 sexually active women, stratified by sociodemographic groups. Only about a third of women aged 15 - 19 years were using modern contraception, only 5.0% were using oral contraception, and 0.4% an IUD. Compared with their younger counterparts, more women aged 20 - 34 or 35 - 49 years were using modern contraception (42.7% and 41.8%, respectively). A considerable proportion of women 35 - 49 years old had been sterilised (16.4%), but their use of injectables (16.2%) was much lower than that of women aged 15 - 19 years (26.1%) and those 20 - 34 years (30.5%). Contraceptive coverage was highest in the Western Cape (54.0%), Eastern Cape (50.7%) and KwaZulu-Natal (50.1%), and lowest in the Northern Cape (42.2%) and Mpumalanga (45.0%). Prevalence of any contraceptive use differed by race, ranging from 47.2% in black Africans, 52.4% in coloureds, 61.1% in Indians/Asians, to 61.9% in whites (p<0.001). While 27.5% of black African and 23.8% of coloured women were using injectables, the method is only used by 6.8% of Indians/Asians, and 4.8% of whites (p<0.001). Oral contraception, on the other hand, was more likely to be reported by white and Indian/Asian women (22.8% and 22.5%, respectively). IUDs were also relatively more common among whites (6.0%) and Indians/Asians (3.8%). Female sterilisation among Indian/Asian

Did not want to have a child, age (years)‡ 15 - 19 (n=216) 20 - 24 (n=805) 25 - 34 (n=1 613) 35 - 49 (n=904) Used contraception at time of pregnancy, age (years)‡ 15 - 19 (n=214) 20 - 24 (n=800) 25 - 34 (n=1 610) 35 - 49 (n=906) *

Among women who had ever had sex (n=8 482). Among sexually active women. Among women who were pregnant in past 5 years.

† ‡

Table 2. Contraceptive method awareness, prevalence and access point of SA women, 2012 Variable (unweighted n)

Injectable contraception, %

Oral contraception, %

IUD, %

Female sterilisation, %

Male sterilisation, %

Emergency contraception, %

Other, %†

Knows of method (n=8 507)

92.0

89.9

56.1

73.3

45.3

47.3

61.8

Ever used method (n=8 245)

46.2

25.6

4.5

8.2

1.9

5.7

18.7

Currently used method (n=6 296)*

25.0

8.6

1.6

8.1

2.3

0.8

11.4

Where obtained method

Hospital (n=567)

10.2

8.3

8.4

34.8

25.6

19.7

9.1

Clinic or CHC (n=1 935)

70.8

42.3

48.5

24.0

19.9

40.6

48.9

Mobile clinic (n=124)

3.5

1.9

1.5

1.0

0.1

7.3

0.8

Family planning clinic (n=345)

8.3

10.9

3.6

4.5

1.2

1.5

4.3

Private facility (n=177)

1.1

1.0

2.9

23.5

38.7

0.0

2.1

Private doctor (n=283)

1.9

22.0

5.3

3.0

2.8

21.3

14.0

Pharmacy (n=179)

2.3

10.7

27.3

2.6

6.6

0.5

3.6

Other (n=332)

1.8

2.7

2.4

6.7

5.0

9.2

17.2

CHC = community health centre. *Among those who reported sexual activity in the past year. † Consistent condom use with last partner, natural family planning or withdrawal.

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Table 3. Demographic characteristics of current contraceptive users among sexually active women, SA, 2012 Variable (unweighted n)

Any Modern Injectable Oral conFemale steri- Male sterili- Emermethod, % method, %† method, % traception, % IUD, % lisation, % sation, % gency, %

Others, Not % using, %

Total (n=6 296)

49.1

41.8

25.0

Age (years)

8.6

1.6

8.1

2.3

0.9

11.4

50.9

***

15 - 19 (n=490)

43.7

34.1

26.1

5.0

0.4

3.6

2.2

0.6

12.5

56.3

20 - 34 (n=3 362)

50.3

42.7

30.5

9.3

1.5

3.5

1.1

1.0

11.7

49.7

35 - 49 (n=2 444)

48.3

41.8

16.2

8.4

1.9

16.4

4.3

0.6

10.7

51.7

***

Black African (n=3 982)

47.2

39.7

27.5

6.8

1.1

6.3

1.3

0.9

11.8

52.8

White (n=512)

61.9

51.3

4.8

22.8

6.0

16.6

13.0

1.4

14.8

38.1

Coloured (n=1 122)

52.4

47.6

23.8

9.7

1.9

12.3

2.8

0.2

7.0

47.6

Indian/Asian (n=670)

61.1

58.3

6.8

22.5

3.8

27.9

1.4

0.2

5.3

38.9

***

Western Cape (n=820)

54.0

49.3

23.8

7.2

2.6

15.6

5.5

0.1

8.5

46.0

Eastern Cape (n=725)

50.7

43.4

34.6

3.4

0.9

5.7

0.6

0.8

10.1

49.3

Northern Cape (n=480)

42.2

39.5

24.8

7.1

1.7

6.0

2.7

0.0

4.3

57.8

Free State (n=459)

52.6

44.2

29.7

12.0

3.1

7.0

1.5

3.2

15.8

47.4

KwaZulu-Natal (n=1 499) 50.1

45.8

32.5

7.2

1.4

5.8

1.1

0.5

6.2

49.9

North West (n=460)

46.3

35.1

21.2

7.7

1.1

6.7

0.8

0.5

14.4

53.7

Gauteng (n=876)

48.1

39.0

18.4

11.1

1.7

9.7

3.3

0.9

13.1

51.9

Mpumalanga (n=470)

45.0

38.8

21.2

11.8

0.7

6.2

3.4

1.7

13.3

55.0

Limpopo (n=507)

46.3

34.9

21.3

9.1

1.1

5.9

0.6

0.7

18.4

53.7

***

Grade 0 - 3 (n=112)

37.3

33.2

23.8

4.8

2.2

6.4

0.0

0.3

8.5

62.7

Grade 4 - 7 (n=576)

44.0

37.6

28.6

3.6

0.4

7.1

0.8

0.9

8.8

56.0

Grade 8 - 11 (n=2 207)

51.0

44.8

30.2

6.8

1.4

8.4

1.7

0.8

11.3

49.0

Grade 12 (n=2 149)

49.8

41.2

24.1

10.5

1.3

7.1

2.0

0.5

12.5

50.2

Tertiary (n=611)

53.3

43.2

14.9

14.5

3.4

11.2

4.2

2.4

12.8

46.7

***

Quartile 1 (n=1 204)

48.2

41.7

33.2

5.7

1.0

4.4

0.2

0.6

10.5

51.8

Quartile 2 (n=1 300)

48.3

40.5

30.4

5.6

1.1

5.2

0.8

0.5

11.7

51.7

Race

Province

Education status

Socioeconomic status

Quartile 3 (n=1 953)

47.5

40.0

23.1

9.6

1.2

8.7

2.3

1.0

12.3

52.5

Quartile 4 (n=1 763)

53.7

46.0

12.9

13.9

3.4

15.7

6.1

1.3

10.8

46.3

45.3

26.8***

8.9

1.5

9.5***

2.4

0.7

11.0

47.9***

Ever pregnant (n=5 049) 52.1***

Sexually active = sex in past year. * p=0.01 - 0.05, **p=0.01 - 0.001, ***p<0.001. † Injectable contraception, oral contraception, IUD or sterilisation.

women (27.9%) was considerably more frequent than in other races, while 16.6% of white women had been sterilised, as had 13.0% of their male partners. Compared with the poorest quartile, women in the two highest socioeconomic quartiles were much less likely to use injectable hormonal contraceptives (for QIII: odds ratio (OR) 0.60, 95% confidence interval (CI) 0.46 - 0.78; and for QIV: OR 0.30, 95% CI 0.22 - 0.41). However, the opposite associations were observed with all other contraceptive methods, higher socioeconomic quartiles being associated with increased odds of contraceptive use. Associations between educational level and contraceptive method mirrored those of socioeconomic status (SES). For example, the method mix for women with

tertiary education differed considerably from others: 14.5% were using oral contraception and 2.4% had used emergency contraception – much higher than in other groups.

Women’s sexual behaviour and HIV risk by type of contraception

Table 4 shows the distribution of sexual behaviour by contraceptive method. Overall, of all sexually active women, most reported ≤3 lifetime sexual partners (75.0%), and only 5.3% had had >1 partner over the past year. Close to 40.0% of participants mentioned having had age-disparate sex partners (partners ≥5 years older than the woman). About a third used a condom at last sex (38.5%) and reported consistent condom

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Table 4. Sexual behaviour and HIV status by current contraceptive use among sexually active women in SA, 2012 Variable (unweighted n)

Total population, %

Injectable method, %

Oral contraception, %

Lifetime sexual partners, n

IUD, %

Female sterilisation, %

Male sterilisation, %

Emergency, %

Others, %

Not using, %

1 (n=2 162)

31.9

31.5

35.2

33.3

38.3

34.9

26.3

23.9

30.9

2 - 3 (n=2 495)

43.1

45.0

36.5

29.1

40.5

38.5

28.1

43.8

43.1

4 - 6 (n=2 495)

20.3

20.1

23.2

27.1

17.9

26.0

45.1

23.5

21.0

≥7 (n=279)

4.6

3.3

5.1

10.6

3.3

0.6

0.4

8.9

4.9

94.7

95.3

96.4

97.3

95.9

94.9

92.5

91.7

93.9

Partners in past year, n 1 (n=5 961) ≥2 (n=298)

5.3

4.7

3.6

2.7

4.1

5.1

7.5

8.3

6.1

No (n=80)

56.1

58.2

82.4

39.7

48.6

0.0

51.4

59.7

56.0

Yes (n=75)

43.9

41.8

17.6

60.3

51.4

100

48.6

40.3

44.0

Concurrent partners†

Intergenerational sex

No (n=3 885)

60.4

59.9

64.0

69.8

49.0

42.8

56.7

66.1

60.4

Yes (n=2 321)

39.6

40.1

36.0

30.2

51.0

57.2

43.3

33.9

39.6

Condom use at last sex

No (n=4 066)

61.5

63.8

67.5

70.9

76.7

81.3

47.3

34.4

60.1

Yes (n=2 094)

38.5

36.2

32.5

29.1

23.3

18.7

52.7

65.6

39.9

***

Inconsistent or none (n=4 519)

69.6

72.5

80.2

76.3

80.8

77.0

52.8

50.5

67.3

Yes (n=1 687)

30.4

27.5

19.8

23.7

19.2

23.0

47.2

49.5

32.7

***

Low risk (n=4 425)

65.4

57.2

74.1

71.4

79.8

87.7

56.9

59.4

66.5

High risk (n=1 820)

34.6

42.8

25.9

28.6

20.2

12.3

43.1

40.6

33.5

Negative (n=3 968)

73.3

72.2

80.6

89.6

83.3

82.6

78.1

71.1

71.6

Positive (n=1 083)

26.7

27.8

19.4

10.4

16.7

17.4

21.9

28.9

28.4

Consistency of condom use

Perceived risk of HIV infection

HIV status

Sexually active = sex in past year. * p=0.01 - 0.05, **p=0.01 - 0.001, ***p<0.001. † Among those with multiple sexual partners in past year.

use (30.4%). Sexual behaviours among women using injectables were broadly similar to those of other women. For oral contraceptive users, however, 11.0% of whites reported consistent condom use compared with 25.1% of black Africans. These patterns were similar in women who had been sterilised (11.7% of white women reporting consistent condom use compared with 26.7% of black African women). Those not using any method of contraception were more likely to have multiple sexual partners in the past year (6.1%) than other women, but otherwise had similar behaviours as contraceptive users. Younger women (aged 15 - 19 years) who used modern contraception were less likely to report multiple sexual partners in the past year than non-users (4.2% among users v. 8.0% among non-users, p=0.002). However, those using contraception had lower levels of consistent condom use than other youth (23.6% v. 38.9%, p<0.001). One-third of sexually active women perceived themselves to be at high risk of HIV infection (34.6%). Perceptions of risk for HIV varied by race and contraceptive method. Perceptions of high risk were

markedly higher among black Africans than other race groups. Some 46.2% of black African women currently using injectables felt they were at high risk for HIV infection, higher than levels among black Africans using oral contraceptives (38.6%) and sterilisation (30.7%), or those not using any methods (38.3%). Less than 5% of white, coloured or Indian/Asian women perceived themselves at risk for HIV, with similar levels between women using different contraceptive methods. Interestingly, perceptions of HIV risk were high among women who used emergency contraception (43.1%), but they also reported high levels of consistent condom use (47.2%). HIV-positive women were less likely than HIV-negative women to use oral contraception, IUDs or to have been sterilised. Use of injectables did not vary by HIV status.

Discussion

In this national survey of women, about 41.0% were using modern contraception. Gradual increments have been made in contraception prevalence over time in SA, although the rate of increase appears

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to be slowing. Consistent with rises in contraception use, the total fertility rate has declined gradually, from 2.7 children per woman in 2002 to 2.3 in 2013.[25] The fastest rate of change in fertility occurred in the Eastern Cape and KwaZulu-Natal, provinces with among the highest levels of contraceptive prevalence in this study. Of note, we found that about two-thirds of all pregnancies were unintended, similar to levels reported in several smaller studies.[26-28] The rate of unintended pregnancy was even higher in young women, who commonly experience stigma and economic difficulties during pregnancy,[29] and especially high levels of maternal morbidity and mortality.[30-32] Low levels of knowledge and frequent misconceptions about contraception among women of 15 - 19 years are particularly concerning.[33,34] These findings cast doubt on how effectively the national Integrated School Health Policy[35,36] is being implemented. The policy recommends that school health services act as a delivery platform for the provision of sexual and reproductive health services, such as contraception and condom distribution.[37] Legally, anyone aged ≥12 years has the right to receive contraception without parental consent.[38] The provision of contraception in schools, however, requires the explicit permission of individual school-governing bodies – few have, however, given permission.[39] When contraception services are made available, school-based services will need to be carefully designed to counter adolescents’ concerns around privacy,[35] as also noted in studies of HIV testing in schools.[40] Youth-friendly services in community-based primary care facilities are another important option for improving adolescent access to contraception. Over the past two decades, many initiatives have been made in this direction in SA.[36,41] These programmes reached high coverage and performed well against predefined standards relating to services provided and clinical environment.[42,43] In recent years, however, several reports have noted weaknesses in these programmes and the need for strengthening of these services.[36,43,44] In the public sector, more broadly, supply-side barriers include strong provider preferences for particular methods, lengthy waits at clinic services, and staff with negative attitudes, e.g. towards young women requesting contraception or an abortion.[45] Although, overall, women largely make use of the public sector for healthcare,[46] a large proportion of women in our study turned to private sector doctors or pharmacists, where they are offered a wider mix of methods. This suggests that the government’s policy, that women requesting contraception should receive the method of their choice, has not been fully actualised, especially in primary health clinics and community centres. Contraception use and method type are strongly associated with race in this study and also with SES at an individual and geographical level. Marked differentials between poor and wealthy districts were noted in other studies.[47-49] All the abovementioned reasons relating to age and SES mean that younger poorer women are particularly vulnerable to unintended pregnancies, and much remains to be done to mitigate their risk.[33,49,50] The National Contraception and Fertility Planning Policy and Service Delivery Guidelines[51] in 2012 marked an important step away from methods requiring users’ adherence, and placed particular emphasis on LARC methods, aiming to raise choice and contraceptive effectiveness (a quarter of women who had a pregnancy reported contraceptive failure in our study). The guidelines state that clients should have access to ‘accurate, unbiased information about all available methods to make an informed choice’. In practice, what is available in primary level facilities varies and coverage of services for sterilisation, and even IUD insertion, is extremely limited in some districts.[36] Facilities such as those for HIV treatment seldom offer contraceptive services. Ensuring adequate stocks of the wide range of contraceptive methods is contingent on accurate

forecasting of the demand for each method. This is difficult to achieve, given the limited data available in the public sector to predict the anticipated demand, especially for new methods.[36] With injectable contraception, which comprises three-quarters of the modern methods used, method discontinuation, timeliness of repeat injections, and switching remain key contributors to contraception failures in SA.[17,18,21] Up to half of women in a study in the Eastern and Western Cape were late for their re-injection appointment.[18] Women, however, have limited knowledge of and experience with the ‘newer’ contraceptive methods.[26,33,34,52,53] Only half of our participants had heard of emergency contraception, the same portion as a study among female university students in 2011,[54] but higher than the 30.0% knowledge found in a Cape Town study of women in public sector clinics in 2004/2005.[53] Clearly, the introduction of LARCs and future multipurpose technologies will require intensive awareness campaigns, encompassing efforts to address health worker misperceptions of these technologies.[10,11] Encouragingly, despite these problems, uptake of sub-dermal implants, rolled out in 2014 in SA and accompanied by substantial promotion efforts, has been encouraging.[55] Training manuals covering implant insertion were developed and >6 000 providers were trained, mainly nurses. While as many as 800 000 devices had been inserted by the end of 2014,[56] the delivery of the method has been hampered by poor data for monitoring adverse effects, such as early removal of the device, and poor communication by the National Department of Health around concerns of drug interactions between the antiretroviral drug efavirenz and the synthetic progesterones in the implant.[36] Injectable contraception, particularly DMPA, has been associated with an increased risk of HIV acquisition in some, but not all, studies.[57,58] Overall, systematic reviews and an individual patient data meta-analysis suggest about a 1.5-fold increased risk of HIV acquisition with DMPA exposure,[59,60] but many studies included in these reviews have important methodological flaws.[61] After many years of calls for a randomised controlled trial to deeply examine this relationship, a trial will commence shortly.[62,63] Until further data are available, it is likely that the benefits of discouraging DMPA use would be outweighed by the risks of unwanted pregnancy and maternal deaths. This is especially true of countries such as Madagascar, with high maternal mortality risks,[64] but perhaps less so in SA. In our study, HIV-positive women were less likely than HIVnegative women to use oral contraception and IUDs. Some evidence indicates that many health workers hold misconceptions about interactions between contraception and antiretroviral treatment, and offer HIV-positive women different contraceptives than other women.[10,26,65-68] Other studies, however, have found that HIVpositive and HIV-negative women have a similar methods mix and fertility goals.[26,65,68-70] Integration of family planning within services for antiretroviral treatment and for prevention of motherto-child transmission holds much promise in raising contraceptive prevalence among HIV-positive women,[1,27,71] although it is not without challenges.[72]

Study limitations

This article provides population-level representative data for the country, a uniquely important dataset. However, cross-sectional studies such as this one do not allow for observation of temporal relationships. This study cannot ascertain which contraceptive method was used at the time of HIV acquisition and thus cannot investigate causal associations between HIV infection and contraception method, for example. Additional limitations include a reliance on self-reporting of contraceptive use. It was therefore not possible to assess methods

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dispensed, but not actually used, or used incorrectly (especially user-dependent methods such as oral contraception and condoms).[73] Finally, while the study provides some measure of unmet need for contraception, this indicator is hard to measure, and the variable used (unintended pregnancy) only provides limited information.[74,75]

Conclusion

Even though levels appear to be rising slowly over time, less than half of SA women were using a modern contraceptive method in 2012. Women with only primary school education and of lower SES were less likely to report contraceptive use. In light of high unintended pregnancy rates and contraceptive failure noted in this study, it is hoped that SA’s new contraceptive policy and clinical guidelines[51,76] will be fully implemented as a national health priority. Additional emphasis on access to LARCs, particularly among women in poorer provinces and with lower SES, is necessary in the coming years to further improve the SA family planning services. Until then, injectable contraception remains an important contraceptive method for women in this country, particularly for black African women and those with lower SES, who do not yet have access to a range of methods. In common with other countries,[77] young women had low contraception use and poorer levels of knowledge about these methods, making it clear that the reproductive health component of the School Health Programme needs to be considerably strengthened. It is very disappointing that many young women leave school with little knowledge of contraception. In summary, access to contraception and choice of a range of methods are key interventions to improve population health, particularly that of women. Increased political and economic investment is necessary to decrease disparities in access to contraception between population groups and to raise overall levels of contraception. 1. Feucht UD, Meyer A, Kruger M. Missing HIV prevention opportunities in South African children – a 7-year review. BMC Public Health 2014;14(1):1265-1273. https://doi.org/10.1186/1471-2458-14-1265 2. Michalow J, Chola L, McGee S, et al. Triple return on investment: The cost and impact of 13 interventions that could prevent stillbirths and save the lives of mothers and babies in South Africa. BMC Preg Child 2015;15(1):456. https://doi.org/10.1186/s12884-015-0456-9 3. Cleland J, Harbison S, Shah IH. Unmet need for contraception: Issues and challenges. Stud Fam Plann 2014;45(2):105-122. https://doi.org/10.1111/j.1728-4465.2014.00380.x 4. Darroch JE, Singh S. Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: An analysis of national surveys. Lancet 2013;381(9879):1756-1762. https://doi.org/10.1016/s01406736(13)60597-8 5. United Nations (UN) Department of Economic and Social Affairs Population Division. Model-based estimates and projections of family planning indicators, 2013 revision. http://un.org/en/development/ desa/population/theme/family-planning/cp_model.shtml (accessed 12 December 2016). 6. Massyn N, Day C, Peer N, et al. District Health Barometer 2013/14. Durban: Health Systems Trust, 2014. https://health-e.org.za/wp-content/uploads/2014/10/DHB_2013-14.pdf (accessed 14 December 2016). 7. National Department of Health. South Africa Demographic and Health Survey. Pretoria: NDoH, 2003. 8. Alkema L, Kantorova V, Menozzi C, Biddlecom A. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: A systematic and comprehensive analysis. Lancet 2013;381(9878):1642-1652. https://doi.org/10.1016/S0140-6736(12)62204-1 9. Blanchard K, Chipato T, Ramjee G, Nhemachena T, Harper CC. Clinicians’ perceptions and provision of hormonal contraceptives for HIV-positive and at-risk women in Southern Africa: An original research article. Contraception 2014;90(4):391-398. https://doi.org/10.1016/j.contraception.2014.04.010 10. Morse J, Chipato T, Blanchard K, et al. Provision of long-acting reversible contraception in HIVprevalent countries: Results from nationally representative surveys in southern Africa. Br J Obstet Gynaec 2013;120(11):1386-1394. https://doi.org/10.1111/1471-0528.12290 11. Gutin SA, Mlobeli R, Moss M, Buga G, Morroni C. Survey of knowledge, attitudes and practices surrounding the intrauterine device in South Africa. Contraception 2011;83(2):145-150. https://doi. org/10.1016/j.contraception.2010.07.009 12. Ross JA, Agwanda AT. Increased use of injectable contraception in sub-Saharan Africa. Afr J Reprod Health 2012;16(4):68-80. 13. Volscho T. Racism and disparities in women’s use of the Depo-Provera injection in the contemporary USA. Crit Sociol 2011;37(5):673-688. https://doi.org/10.1177/0896920510380948 14. Metoyer AB. Racial and socioeconomic disparities in use of long-lasting contraception. In: Ronenfeld JJ, ed. 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Accepted 13 December 2016.

April 2017, Print edition

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

RESEARCH

Wound infection secondary to snakebite M Wagener,1,2 MB ChB; M Naidoo,2 MB ChB, FCS (SA); C Aldous,2 PhD Department of Paediatric Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 2 College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa 1

Background. Snakebites can produce severe local and systemic septic complications as well as being associated with significant overall morbidity and even mortality. Objective. A prospective audit was undertaken to determine the bacterial causation of wound infection secondary to snakebite, and attempt to quantify the burden of disease. Methods. The audit was undertaken at Ngwelezane Hospital, which provides both regional and tertiary services for north-eastern KwaZuluNatal Province, South Africa, over a 4-month period. Records of patients who required surgical debridement for extensive skin and softtissue necrosis were analysed. At the time of debridement, tissue samples of necrotic or infected tissue were sent for bacteriological analysis as standard of care. Microbiology results were analysed. Results. A total of 164 patients were admitted to hospital for management of snakebite, of whom 57 required surgical debridement and 42 were included in the final microbiological analysis. Children were found to be the most frequent victims of snakebite; 57.8% of patients in this study were aged â&#x2030;¤10 years and 73.7% â&#x2030;¤15 years. Culture showed a single organism in 32/42 cases, two organisms in 8 and no growth in 2. Eight different types of organisms were cultured, five of them more than once. Thirty-five specimens (83.3%) grew Gram-negative Enterobacteriaceae, the most frequent being Morganella morganii and Proteus species. Thirteen specimens (31.0%) grew Enterococcus faecalis. Gram-negative Enterobacteriaceae showed 31.4% sensitivity to ampicillin, 40.0% sensitivity to amoxicillin plus clavulanic acid, 34.3% sensitivity to cefuroxime, 97.1% sensitivity to ceftriaxone, and 100% sensitivity to ciprofloxacin, gentamicin and amikacin. E. faecalis was 92.3% sensitive to amoxicillin, 92.3% sensitive to amoxicillin plus clavulanic acid, 100% sensitive to ciprofloxacin, 92.3% resistant to erythromycin and 100% resistant to ceftriaxone. Conclusion. Children are particularly vulnerable to snakebite, and the consequences can be devastating. While the majority of patients in this study were shown to have secondary bacterial infection, debridement and subsequent wound management is considered the mainstay of treatment. Common organisms are Enterobacteriaceae and enterococci. There appears to be a role for antibiotics in the management of these patients. A good antibiotic policy is strongly advocated. S Afr Med J 2017;107(4):315-319. DOI:10.7196/SAMJ.2017.v107i4.12084

Snakebites can produce severe local and systemic septic complications in addition to the expected morbidity and even mortality caused by venom alone. In the majority of snakebite victims presenting to hospital, envenomation involves painful progressive swelling as the predominant symptom.[1,2] Other envenomation syndromes, including acute life-threatening coagulopathy, muscle weakness and respiratory paralysis, are rare.[1-4] Cases of severe envenomation are often characterised by subsequent wound infection and skin and soft-tissue necrosis.[1,2] While the role of antivenom administration in the treatment of acute envenomation has been well described,[4] treatment of the complex wounds that result from subsequent necrosis and infection needs further investigation. In a 1999 study by Blaylock[5] at Eshowe District Hospital, KwaZulu-Natal (KZN) Province, South Africa (SA), the bacterial aetiology of wound infection secondary to snakebite was described. Gram-negative aerobic Enterobacteriaceae were the most commonly isolated organisms in that study, but antibiotic susceptibility was not reported. In areas of high snakebite prevalence outside SA, a similar spectrum of bacterial species has been found and antibiotic sensitivities reported.[6-9] The bacterial cause of infected snakebite wounds in northern KZN has been determined by previous work, but antibiotic susceptibility remains untested. A current description of associated morbidity is also required. Treatment of complex wounds resulting from cytotoxic snake envenomation poses multiple challenges. A multidisciplinary approach is required. Current treatment strategies need to be examined in order to reduce morbidity.

Numerous authors have recognised that the public health impact of snakebite has been underestimated.[9-12] Importantly, since the type of snake responsible for the majority of severe envenomation will vary between regions, the clinical problems associated with snakebite will also be unique for each region. The main envenomation syndrome in KZN is cytotoxicity.[1,2] It is postulated that the tissue destruction, disfigurement, amputation and physical disability that result from predominantly cytotoxic snake envenomation are responsible for the majority of the untold burden of disease in our region.[13,14] Indices to quantify this morbidity include length of hospital stay and objective assessment of resulting physical disability.[15] The snakes that cause the greatest human suffering are those that bite frequently and have bites resulting in severe envenomation. [9,14] Snakes that bite frequently are those with behaviour associated with a high incidence of human contact. Snake species with these characteristics vary between regions.[9] The types of snake responsible for the majority of morbidity in our study population were examined. Rural populations are at the greatest risk of snakebite.[10-12] Of particular concern is that in rural communities, the majority of snakebite victims are children.[1-4] The reasons for this phenomenon need to be examined. Novel strategies used to prevent bites may be possible, thus reducing long-term social and economic consequences.

Objective

A prospective audit was undertaken to determine the bacterial causation of wound infection secondary to snakebite in KZN, as well as attempt to quantify the burden of disease.

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RESEARCH

Description of the sample

16 14 12 10 8 6 4 2 0

Of the 42 cases included in the final microbiological analysis, 76.2% (n=32) showed single growth, 19.0% (n=8) grew two organisms, and in two cases (4.8%) there was no growth. Eight different types of organisms were cultured, five of them more than once. Fig. 2 shows the various bacteria cultured. Thirty-five specimens (83.3%) grew Gramnegative Enterobacteriaceae. Enterococcus faecalis was found in 13 specimens (31.0%). The two most frequent Gram-negative Enterobacteriaceae were Morganella morg-

29.8% 18 29.8% 28.1% 28.1% 16

Snakebite victims, n

Microbiological analysis

14 12 10 8

15.7%

6 4 2 0

7.0%

3.5%

1.7% 1.7%

A total of 164 patients were admitted with snakebite wounds during the study period, 57 (34.8%) of whom required surgical debridement. Fifteen patients were not included in the final microbiological analysis for the following reasons: (i) the wound had broken down spontaneously or been informally debrided elsewhere

3.5%

1.7%

3.5%

1.7%

3.5% 1.7% 1.7% 1.7% 0 1.7% 1.7% 5 0 0 0 5 0 0 5 0 5 5 5 5 2 1 7 5 4 3 75 2 3 0- 6- 1-1 6- 1- 6- 1- 6- 1-4 6- 0-5 6-6 1-6 6- 12 6 4 3 3 7 1 2 1 5 5 6 4 3.5%

3.5%

5 20 25 30 35 40 45 50 55 60 65 70 75 5 10 - 6- 0- 6- 1- 6- 10 - 6 - 1 - 1 6 - 1 - 6 - 1 - 6 -Age1(years) 2 6 4 3 3 7 1 2 1 5 5 6 4 Age (years)

Fig. 1. Age distribution of patients. Morganella morganii

40.5%

Enterococcus faecalis

31.0%

Morganella morganii Proteus species

40.5%

23.8%

Salmonella Enterococcus faecalisenterica

7.1%

31.0%

4.8%

Enterobacter cloacae complex

Proteus species

Bacteria

Results

aged ≤10 years. Most of the victims in this study were aged ≤10 years (57.8%), and 73.7% were aged ≤15 years (Fig. 1). The majority of the bites occurred at night, 33/55 (60.0%) between 22h00 and 08h00 and 17/55 (30.8%) in the evening between 18h00 and 22h00. Five bites (9.1%) occurred in the daylight hours of 08h00 18h00. Most of the victims (86.0%) were bitten while sleeping.

(n=5 patients); (ii) tissue specimens had been lost (n=6); (iii) tissue specimens had been incorrectly processed (n=2); and (iv) debridement had been done for skin necrosis without any evidence of infection, and microbiological analysis confirmed no bacterial growth (n=2). Thirty-three patients (57.9%) were referred from rural district hospitals, either acutely (n=19, 57.6%) or as non-urgent cases referred to the department of surgery with wound complications after spending time at a peripheral hospital (n=14, 42.4%). Those with delayed referral spent a mean of 8.85 days (range 3 - 20) at the peripheral hospital prior to referral. In 28 cases (49.1%), patients or their caregivers claimed to have identified the snake with confidence. Of the 28 positively identified snakes, 26 (92.9%) were Mozambique spitting cobras (Naja mossambica), or ‘M’fezi’. The most frequent victims of snakebite were found to be children, particularly those

Snakebite victims, n

The study was conducted at Ngwelezane Tertiary Hospital, situated in a semi-rural settlement outside the town of Empangeni, KZN, and serving a predominantly rural population. It is the referral centre for 22 peripheral hospitals and sees an alarming number of snakebites each year,[1,2] mainly in the summer months.[1-4] During the 4-month period December 2014 - March 2015, patients requiring surgical debridement of snakebite were enrolled prospectively. No new protocols were put in place for the purpose of the study, and study information represented standard patient management. A sample of necrotic tissue was taken from each patient and sent for bacteriological analysis. Pathogens isolated and antibiotic susceptibilities were recorded. In vitro culture of debrided tissue was done using blood agar and MacConkey agar culture media, and susceptibility testing was performed using the disc-diffusion method as per standard National Health Laboratory Service protocols. Other data obtained to determine morbidity included anatomical location of debridement, extent of debridement, need for re-debridement, method of wound closure, skin graft take, length of hospital stay and objective functional impairment. Each patient, or the caregiver if the victim was a child, was questioned on the type of snake they had been bitten by. Age and sex of victims were recorded. Patients were included in the analysis of overall treatment but excluded from microbiological analysis if the wound had broken down spontaneously or had been informally debrided elsewhere, specimens had been lost or incorrectly processed, or the debridement had been done for skin necrosis only without any evidence of infection. Data from each patient were recorded on an individual data collection pro forma. Data were then inserted into an Excel spreadsheet, version 15.27 (Microsoft, USA), for analysis. Ethics approval was obtained from the Biomedical Research Ethics Committee of the University of Kwa-Zulu Natal. (ref. no. BE006/15).

Bacteria

Methods

Escherichia coli

2.4%

Klebsiella pneumoniae

2.4%

Salmonella enterica

23.8%

7.1%

4.8%

Enterobacter cloacae complex

2.4%

Citrobacter freundii

Escherichia coli

2.4%

Klebsiella pneumoniae

2.4%

Frequency of culture, n

2.4% Citrobacter freundii Fig. 2. Organisms grown from infected snakebite wounds. 0

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Frequency of culture, n

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29.8% anii, which occurred in28.1% 40.5% of specimens, 16 followed by Proteus species, which occurred 14 in 23.8%. No anaerobes were found.

Bacteria

Snakebite victims, n

in 20/27 patients (74.1%), and only one patient had complete skin graft failure. One patient in this cohort required fasciotomy. 12 Four patients required digital amputations, but there were no major limb amputations. Antibiotic resistance 10 15.7% Two patients had severe and life-threatening Gram-negative 8Enterobacteriaceae showed sepsis as a result of wound infection. 68.6% resistance to ampicillin, 60.0% resis6 The average length of hospital stay was tance to amoxicillin plus clavulanic 7.0% acid, 4 31.3 days and 65.7% resistance to second-generation 3.5% patients 3.5% 3.5% (range 3 - 74). Seven 2 1.7% 1.7% 1.7% 1.7% were assessed as 1.7% having objective functional cephalosporins. These organisms were 97.1% 0 impairment in the form of digital amputasensitive to ceftriaxone and 100% sensitive to 5 20 25 30 35 40 45 50 55 60 65 70 75 5 10 - (n=2) -difficulty - 6 - (n=4), - in walking 0 - 6 - 1 - 1 6 - E.Â faec and ciprofloxacin and aminoglyosides. 21 26alis 31 tion 3 1 1 41 46 50 56 61 66 71 impaired elbow flexion (n=1). showed 92.3% sensitivity to both ampicillin and amoxicillin plus clavulanic acid, as well as Age (years) 100% sensitivity to ciprofloxacin. Enterococci Discussion were 92% resistant to erythromycin and The majority of patients in this study 100% resistant to cephalosporins. were shown to have secondary bacterial Thirty-two patients (56.1%) received infection. The clinical significance of these empirical antibiotic therapy, either at preinfections was variable. Clinically significant Morganella morganii sentation or shortly before debridement. wound infection was considered 40.5% to be Amoxicillin plus clavulanic acid was the present in all patients included in the final Enterococcus faecalis most commonly used antibiotic. Cloxacillin, microbiological analysis. 31.0% These infections metronidazole, amoxicillin, ceftriaxone and may affect wound healing, skin graft take Proteus species 23.8% gentamicin were also used (Fig. 3). and possibly even long-term morbidity. Salmonella enterica While debridement and subsequent wound 7.1% management is considered the mainstay of Morbidity and treatment outcomes 4.8% Enterobacter cloacae complex treatment, antibiotic therapy is considered Of the 57 patients, 32 (56.1%) sustained upper limb bites, 20Escherichia (35.1%) coli lower limb 2.4% to be an important adjunct in these cases. Presence of a systemic inflammatory resbites, 5 (8.8%) bites to the torso and 2 (3.5%) 2.4% ponse as a result of wound infection was not Klebsiella pneumoniae facial bites, while 1 patient (1.8%) was bitten included in the data collection. Two patients on the occiput of the head. Four patients 2.4% Citrobacter freundii had severe and life-threatening sepsis as a (7.0%) sustained multiple bites. result of wound infection. The average delay from injury to surgical 2 4 Gram-negative 6 8 10 Enterobacteriaceae 12 14 16 18 and debridement was 7.8 days (rangeÂ 30 - 22). E. faecalis were the most commonly isoAmong patients presenting to the hospital Frequency of culture, n lated organisms. Gram-negative Enterowithin 48 hours of the bite, the delay in bacteriaceae showed high resistance to debridement was 5.2 days from admission. ampicillin (68.6%), amoxicillin plus clavuSixteen patients (28.1%) required re-debrilanic acid (60.0%), and second-generation dement. In 27 cases (47.4%) a skin graft was cephalosporins (65.7%). Sensitivity was necessary, in 26 cases (45.6%) wounds were adequate to ceftriaxone (97.1%) and ciprosmall enough to heal by secondary intention, floxacin, gentamicin and amikacin (all and in 4 cases this information was not 100%). E. faecalis showed good sensitivity to recorded. Skin graft take was 80 - 100%

Frequency prescribed, n

30 25

20 15 10 5

6 3

s le lin zo plu cil lin cid loxa ida l i n a ic C tro ox nic Me Am vula cla

illi

ic ox Am

ftr Ce

ici

on iax

tam en

Antibiotic

Fig. 3. Antibiotic use.

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ampicillin (92.3%), amoxicillin plus clavulanic acid (92.3%) and ciprofloxacin (100%). We believe that cultured organisms represent true infection rather than contaminants, because the organisms grown are similar to those found in mouths of KZN snakes[16] and because wounds that had either broken down or been informally debrided elsewhere were excluded from the microbiological analysis. Current recommendations advise against the prophylactic use of antibiotics in snakebites.[4,17] These recommendations are based on research showing a paucity of bacteria in snakesâ&#x20AC;&#x2122; mouths and that venom has antibacterial properties.[16,18] There does, however, appear to be a role for antibiotics in the managenent of severe local and systemic septic complications from snakebite, and we conclude that antibiotics play an important role in therapy of infected snakebite wounds. This study demonstrated that use of antibiotics in the management of snakebites was widespread and not directed. Amoxicillin plus clavulanic acid was the most commonly used antibiotic, to which Gramnegative bacteria from wounds cultured in this series showed 60.0% resistance. Cloxacillin was the next most commonly used antibiotic, and would have been of no benefit because staphylococcal infection has not been shown to occur in these patients. In cases where empirical therapy is deemed necessary, antibiotics need to cover Gram-negative Enterobacteriaceae and E. faecalis. According to these data, Gram-negatives would be covered by ciprofloxacin, an aminoglycoside or a thirdgeneration cephalosporin. E. faecalis would be adequately covered by ampicillin or ciprofloxacin. A good antibiotic policy is strongly advocated. Snakebite wounds are particularly unforgiving wounds to treat. There is often exposure of non-granulating surfaces and superimposed infection. In addition, victims are frequently young children who comply poorly with rehabilitation and pose challenges for dressing changes (Fig. 4). Upper limb and torso injuries pose particular difficulties. Nevertheless, by applying standard wound care principles, involving rehabilitation professionals early on and using a combination of delayed primary closure and skin grafting, it is possible to achieve a satisfactory result. This study demonstrates the significant burden of disease caused by cytotoxic snakebite. This can be quantified firstly by length of hospital stay, (average 31.3 days).

RESEARCH

Fig. 4. Exposure of tendons in a necrotic septic snakebite wound after debridement.

Additionally, patients in this study showed objective functional impairment in terms of digital amputation (n=4 cases), difficulty in walking (n=2) and impaired upper limb mobility (n=1). Of concern is that many patients, especially children, suffer permanent functional impairment that could not be adequately quantified by methods used in this study. Children with devastating extremity injuries are likely to have difficulty learning basic life skills, playing and performing at school. With focused care and more aggressive treatment and rehabilitation, we believe that the average length of hospital stay can be reduced. When patient care is evaluated using the results of this study, this will be an area to focus on. Victims’ identification of the offending snake has been described as unreliable in the literature,[2,4] but in this study 49.1% of patients or their caregivers confidently identified the snake, the majority being identified as M’fezi. Our opinion is that the majority of these reports are accurate. Most bites ascribed to the M’fezi occurred at night while sleeping, which is in keeping with the behaviour of this snake.[9,19,20] Secondly, many wounds showed characteristic features of M’fezi bites: necrosis involving skin and subcutaneous soft tissue, with patches of skin necrosis separated by normal-looking skin producing characteristic ‘skip lesions’ (Fig. 5)[9,19,21] or with extensive undermining of tissues (Fig. 6). Lastly, the snake is justifiably feared by the local population and is therefore well known. This study demonstrates that rural populations are most at risk of snakebite: 57.9% of victims were referred from outlying rural hospitals. The likelihood of humans coming into contact with snakes is considerably increased in rural areas. Rural-dwelling families are at risk in their homes, and farmers and herders are at risk in their occupation. Confirming what has been found in previous audits, children are particularly vulnerable to snakebite.[1-4] This has traditionally been thought to be a consequence of children’s naturally inquisitive behaviour,[2,4] but since the majority of patients in this study were bitten at night while sleeping, another explanation is needed. It is possible that these bites occur because children in our rural communities often sleep on the floor, while more senior members of the household occupy a bed. In addition to children being particularly vulnerable to snakebite, local and systemic envenomation syndromes occur more frequently and with greater severity in this age group.[4] This is probably due to the higher venom-to-mass ratio, as suggested by Blaylock.[1,16] The numbers in this study were higher than those collected by Wood et al.[4] in their series from the same hospital in 2007/2008. That study recorded the highest number of snakebites in the months December - March, these being the only months during which data were collected in our study. During the same time

Fig. 5. Characteristic ‘skip lesions’ of M’fezi bite.

Fig. 6. Necrotic snakebite wound presumed to be from M’fezi bite.

frame, Wood et al. had 132 patients, compared with 164 in our study. The reason for the discrepancy is likely to be twofold. Firstly, in 2007/2008 Wood et al. examined only patients presenting to the emergency department of Ngwelezane Hospital, while a number of patients in our study were referred to the department of surgery as non-urgent cases with wound complications after spending time at a peripheral hospital. Secondly, since 2012 referral patterns have changed, resulting in a greater number of district hospitals referring to Ngwelezane. There are no previous studies from Ngwelezane examining the number of snakebite victims requiring surgical debridement. A delay of 5 - 7 days before debridement of necrotic snakebite wounds is recommended to allow demarcation of dead tissue. [16,22] In this study, this recommended time frame was achieved in patients presenting acutely to our hospital, with an average of 5.2 days to debridement. However, patients referred from elsewhere experienced a longer delay to debridement owing to time spent at a peripheral hospital and time required for treatment with antibiotics after arriving at our hospital (Fig. 7), accounting for the longer overall delay to debridement for patients in this study. Two patients in our study experienced cardiorespiratory collapse as a complication of grossly infected wounds (Fig. 8), and in these cases we performed the debridement as an emergency in order to achieve source control in the treatment of severe sepsis. The role of antivenom in preventing these devastating local and regional complications of snakebite is largely unknown. In a randomised, double-blind, placebo-controlled trial, antivenom was shown to accelerate oedema resolution in bites from green pit vipers in Thailand.[23] Antivenom has also been demonstrated to decrease compartment pressure with rattlesnake envenomation in an animal model from the USA.[24] However, these effects remain untested in Africa. The efficacy of antivenom in reducing skin and

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Study limitations

This analysis was confined to snakebites with the most severe necrosis requiring formal debridement in theatre. Anaerobic culture was not performed, as methods of specimen collection and culture require protection from oxygen for anaerobic organism identification. This procedure is not routine and was not implemented for the purpose of the study. Quantitative bacterial cultures were not performed. Incomplete data from lost or inappropriately processed specimens may have compromised results.

Conclusions and recommendations

We recommend that antibiotics should be used in selected cases, treatment being commenced only when the results of sensitivity tests are known. In cases of severe sepsis where empirical antibiotic therapy is needed, use of ciprofloxacin is recommended in adults and children, as this covers Gram-negative Enterobacteriaceae and E. faecalis, avoids the need for combination therapy, and is considered safe in children.[27,28] It is recommended that debridement be delayed until necrosis demarcates, usually after 5 - 7 days. Rare cases where the patient becomes systemically toxic should be treated with emergency debridement.

Fig. 7. Patient referred with septic snakebite wound after being managed expectantly at a peripheral hospital.

Fig. 8. Child with severe sepsis complicating snakebite to left shoulder.

soft-tissue necrosis is also unknown. In a retrospective study from Thailand, antivenom was found to have no effect on the development of dermatonecrosis after green pit viper envenomation. [25] Current guidelines maintain that there is a role for antivenom administration for predominantly cytotoxic snakebite.[16,21] Owing to the significant potential risks of antivenom administration,[4,16] a risk/benefit evaluation needs to be employed in each individual case.[26] We maintain that the most important aspect of managing these patients after the acute phase is good initial debridement and robust postoperative care.

1. Blaylock R. Epidemiology of snakebite in Eshowe, KwaZulu-Natal, South Africa. Toxicon 2004;43(2):159166. https://doi.org/10.1016/j.toxicon.2003.11.019 2. Coetzer PW, Tilbury CR. The epidemiology of snakebite in northern Natal. S Afr Med J 1982;62(7):206-217. 3. Wilkinson D. Retrospective analysis of snakebite at a rural hospital in Zululand. S Afr Med J 1994;84(12):844847. 4. Wood D, Webb C, DeMeyer J. Severe snakebites in northern KwaZulu-Natal: Treatment modalities and outcomes. S Afr Med J 2009;99(11):814-818. 5. Blaylock RS. Antibiotic use and infection in snakebite victims. S Afr Med J 1999;89(8):874-876. 6. Chen CM, Wu KG, Chen CJ, Wang CM. Bacterial infection in association with snakebite: A 10-year experience in a northern Taiwan medical center. J Microbiol Immunol Infect 2011;44(6):456-460. https:// doi.org/10.1016/j.jmii.2011.04.011 7. Garg A, Sujatha S, Garg J, Acharya NS, Chandra Parija S. Wound infections secondary to snakebite. J Infect Developing Ctries 2009;3(3):221-223. https://doi:10.3855/jidc.39 8. Mao YC, Liu PY, Hung DZ, et al. Bacteriology of Najaatra snakebite wound and its implications for antibiotic therapy. Am J Trop Med Hyg 2016;94(5):1129-1135. https://doi.org/10.4269/ajtmh.15-0667 9. Ashe S, Chisale MGP. Guidelines for the Prevention and Clinical Management of Snakebite in Africa. Brazzaville: World Health Organization, Regional Office for Africa, 2010. 10. Chippaux JP. Estimate of the burden of snakebites in sub-Saharan Africa: A meta-analytic approach. Toxicon 2011;57(4):586-599. https://doi.org/10.1016/j.toxicon.2010.12.022 11. Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global burden of snakebite: A literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med 2008;5(11):e218. https:// doi.org/10.1371/journal.pmed.0050218 12. Wood D, Sartorius B, Hift R. Estimating the burden of snakebite on public hospitals in KwaZulu Natal, South Africa. Wilderness Environ Med 2016;27(1):53-61. https://doi.org/10.1016/j.wem.2015.11.005 13. Habib AG, Kuznik A, Hamza M, et al. Snakebite is under appreciated: Appraisal of burden from West Africa. PLoS Negl Trop Dis 2015;9(9):e0004088. https://doi.org/10.1371/journal.pntd.0004088 14. Habib AG. Public health aspects of snakebite care in West Africa: Perspectives from Nigeria. J Venom Anim Toxins Incl Trop Dis 2013;19:27. https://doi.org/10.1186/1678-9199-19-27 15. Spiller HA, Bosse GM. Prospective study of morbidity associated with snakebite envenomation. J Toxicol Clin Toxicol 2003;41(2):125-130. https://doi.org/10.1081/CLT-120019127 16. Blaylock R. Normal oral bacteria flora from some southern African snakes. Onderstepoort J Vet Res 2001;68(3):175. 17. Blaylock RS. The identification and syndromic management of snakebite in South Africa. S Afr Fam Pract 2014;47(9):48-53. https://doi.org/10.1080/20786204.2005.10873288 18. Blaylock RS. Antibacterial properties of KwaZulu Natal snake venoms. Toxicon 2000;38(11):1529-1534. https://doi.org/10.1016/S0041-0101(00)00085-4 19. Tilbury CR. Observations on the bite of the Mozambique spitting cobra (Naja mossambica mossambica). S Afr Med J 1982;61(9):308-313. 20. Vermaak SS, Visser A, le Roux TLB. A deadly bed partner: m’Fesi (Mozambique spitting cobra). SA Orthop J 2010;9(4):58-62. 21. Muller GJ, Modler H, Wium CA, Veale DJH, Marks CJ. Snake bite in southern Africa: Diagnosis and management. CME 2012;30(10):362-382. 22. Hall EL. Role of surgical intervention in the management of crotaline snake envenomation. Ann Emerg Med 2001;37(2):175-180. https://doi.org/10.1067/mem.2001.113373 23. Rojnuckarin P, Chanthawibun W, Noiphrom J, Pakmanee N, Intragumtornchai T. A randomized, doubleblind, placebo-controlled trial of antivenom for local effects of green pit viper bites. Trans R Soc Trop Med Hyg 2006;100(9):879-884. https://doi.org/10.1016/j.trstmh.2005.10.006 24. Tanen DA, Danish DC, Clark RF. Crotalidae polyvalent immune Fab antivenom limits the decrease in perfusion pressure of the anterior leg compartment in a porcine crotaline envenomation model. Ann Emerg Med 2003;41(3):384-390. https://doi.org/10.1067/mem.2003.80 25. Chotenimitkhun R, Rojnuckarin P. Systemic antivenom and skin necrosis after green pit viper bites. Clinical toxicology 2008;46(2):122-125. https://doi.org/10.1080/15563650701266826 26. Hadley GP. Snakebites in children in Africa: A practical approach to management. Surgery in Africa Monthly Reviews, 2006. http://ptolemy.ca/members/archives/2006/Snake_Bites.htm (accessed 25 July 2016). 27. Grady R. Safety profile of quinolone antibiotics in the pediatric population. Pediatr Infect Dis J 2003;22(12):1128-1132. https://doi.org/10.1097/01.inf.0000101994.25947.12 28. Schaad UB. Fluoroquinolone antibiotics in infants and children. Infect Dis Clin North Am 2005;19(3):617628. https://doi.org/10.1016/j.idc.2005.05.005

Accepted 19 December 2016.

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

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Pulmonary scar carcinoma in South Africa N Jenkins, MB ChB; E M Irusen, MB ChB, FCP (SA), PhD, FCCP; C F N Koegelenberg, MB ChB, MMed (Int), FCP (SA), FRCP (UK), Cert Pulm (SA), PhD Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa Corresponding author: C F N Koegelenberg (coeniefn@sun.ac.za)

Background. The association between lung scarring and the subsequent development of cancer remains controversial. South Africa has one of the highest incidences of tuberculosis in the world, and resultant scarring may predispose to malignancy. The country also carries a very high burden of smoking and smoking-related diseases that may be synergistic in malignant transformation. Objective. To assess the frequency of pulmonary scarring in patients with lung cancer. Methods. All patients with confirmed lung cancer and a staging computed tomography (CT) scan of the chest were included in this 2-year retrospective study. Pulmonary scarring was categorised according to location as present in: (i) the same lobe as the primary tumour, (ii) a different lobe of the same lung, or (iii) the contralateral lung; or (iv) as diffuse. Post-obstructive bronchiectasis and other changes secondary to cancer were considered not to represent scarring. Results. We identified 435 cases of primary lung cancer. In total, 95 patients (21.8%) had CT evidence of pulmonary scarring. Eighty-three of 85 patients (97.6%) had focal scarring in the same lobe as the primary tumour. Of these, 37 (43.5%) also had scarring involving a different lobe of the same lung, whereas only one (1.2%; p<0.001) had scarring isolated to a different lobe of the same lung. Moreover, 21 patients (24.7%) also had scarring of the opposite lung, but only one patient (1.2%; p<0.001) had scarring isolated to the contralateral lung. Ten patients had diffuse scarring, caused by bronchiectasis (n=5), idiopathic pulmonary fibrosis (n=4) and silicosis (n=1). Conclusion. At least one in five patients with lung cancer had scarring, which was significantly more likely to be present in the same lobe as the tumour, suggesting a predisposition to malignancy. S Afr Med J 2017;107(4):320-322. DOI:10.7196/SAMJ.2017.v107i4.12158

The concept of a scar carcinoma was first introduced almost 80 years ago.[1] The presence of dense hyaline scarring in the centre of many primary peripheral lung carcinomas led to recognition of the phenomenon of a lung scar carcinoma, although it was not clear whether the relevant area of scarring preceded the carcinoma or was caused by the carcinoma.[1,2] In recent years there has been renewed interest in scar carcinomas, also referred to as â&#x20AC;&#x2DC;scar-cinomasâ&#x20AC;&#x2122;.[2] It has been reported that the presence of large numbers of fibroblasts and myofibroblasts is a hallmark of carcinomas.[3] Moreover, malignant cells hijack the host wound-repair response to promote formation of the tumour stroma, which is fundamental for cancer progression.[3] The persistence of activated mesenchymal cells is therefore critical to the pathobiology of both fibrosis and cancer.[2,3] The Western Cape Province of South Africa (SA) has one of the highest recorded incidences of pulmonary tuberculosis (TB) in the world, and also carries a high burden of smoking-related diseases including lung cancer.[4] However, the potential association between pulmonary scarring and lung cancer has never been described in the local population.

Objective

The main objective of this study was to assess the frequency of pulmonary scarring in all patients with lung cancer, and whether or not scarring was likely to be present in the same lobe as the lung cancer.

Methods

We retrospectively identified all patients with primary lung cancer who had presented to Tygerberg Academic Hospital and had their information captured on a prospective registry updated weekly

during the combined multidisciplinary chest oncology meeting from January 2012 to December 2013. Tygerberg Hospital is a 1 380-bed tertiary facility in Cape Town, SA. It is one of two referral centres in the city and renders a tertiary service to a population of about 1.5 million with a TB incidence of approximately 1 000/100 000 population.[5] We collected data on all patients with a known diagnosis of lung cancer and who underwent a staging computed tomography (CT) scan. Routine demographic and clinical data were collected, including smoking status (to qualify as a smoker, a patient had to have smoked at least 10 packyears per lifetime) and performance status according to the Eastern Cooperative Oncology Group (ECOG). All patients had access to positron emission tomography-CT, bronchoscopy with endobronchial ultrasound-guided transbronchial needle aspiration with rapid onsite evaluation, transthoracic imageguided biopsy (ultrasound or CT) and related diagnostic techniques that were performed at the discretion of the treating physicians as per standard operating procedures. Patients were subsequently staged according to the 2009 International Association for the Study of Lung Cancer TNM staging system (7th edition).[6] Pulmonary scarring (Fig. 1) was assessed by two experienced radiologists (blinded to the histological diagnosis) and categorised according to location as present in: (i) the same lobe as the primary tumour, (ii) a different lobe of the same lung, or (iii) some part of the contralateral lung; or (iv) as diffuse. Post-obstructive bronchiectasis and other changes secondary to the lung cancer itself were considered not to represent scarring.

Ethics approval

Ethics approval for this retrospective analysis was received from the Stellenbosch University Research Ethics Committee (ref. no.

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Fig. 1. An adenocarcinoma (arrow) in the background of structural lung disease (previous pulmonary TB).

S13/04/078). The application included a waiver of consent owing to the retrospective nature and anonymity of the study design.

Statistical analysis

Descriptive statistics and χ2 comparisons of proportional data were performed. A p-value <0.05 in a two-tailed test of proportions (χ2) was considered significant.

Results

Of 508 patients with lung cancer identified, 435 had staging CT scans (mean age (standard deviation (SD)) 60.1 (10.4) years), 266 males) (Table 1). Of these, 95 patients (21.8%) had CT evidence of pulmonary scarring. Patients with scarring were younger than those without scarring (mean 57.9 (10.2) years v. 60.7 (10.4) years; p=0.02), with a male predominance in both groups (62/95 (65.3%)

and 204/340 (60.0%); p=0.35). Cigarette smoking exposure between the groups was equal, with regard to both proportion of smokers (85/95 (89.5%) v. 308/340 (90.6%); p=0.89) and pack-years (27.9 v. 31.0; p=0.22). The distribution of non-small-cell lung cancer (NSCLC) (n=375) and small-cell lung cancer (SCLC) (n=60) was comparable between the groups, as was tumour staging (Table 1). Eighty-three of 85 patients (97.6%) had focal scarring in the same lobe as the primary tumour. Of these, 37 (43.5%) also had scarring involving a different lobe of the same lung, whereas only one (1.2%; p<0.001) had scarring isolated to a different lobe of the same lung. Moreover, 21 patients (24.7%) also had scarring of the opposite lung, but only one patient (1.2%; p<0.001) had scarring isolated to the contralateral lung. Ten patients had diffuse scarring; causes included bronchiectasis (n=5), idiopathic pulmonary fibrosis (n=4) and silicosis (n=1).

Discussion

We found a very strong association, albeit it not a temporal association, between pulmonary scarring and lung cancer. At least one in five patients who presented with lung cancer had radiological evidence of associated scarring. Moreover, scarring was significantly more likely to be present in the same lobe as the tumour than in a different lobe, suggesting an association between scarring and lung cancer. Patients with pulmonary scarring and lung cancer were significantly younger than those without scarring, but gender, histological features, staging and smoking history were comparable between the two groups of patients. Our study largely echoed findings of previous studies with regard to the existence of a strong anatomical relationship between a pulmonary malignancy and an associated area of fibrosis, as well as a predominance of adenocarcinomas in these malignancies. However,

Table 1. Demographics, lung cancer type, staging and performance status of all patients (N=435) Age (yr), mean (SD) Gender, n (%) Males Smoking status Smokers, n (%) Pack-years, mean (SD) Lung cancer type, n (%) Adenocarcinoma Squamous cell Poorly differentiated SCLC Other NSCLC staging (N=375)*, n (%) I II IIIA IIIB IV SCLC staging (N=60), n (%) Limited Extensive ECOG performance status, n (%) 1-2 3-4

Scarring present (N=95) 57.9 (10.2)

Scarring absent (N=340) 60.7 (10.4)

p-value 0.02

62 (65.2)

204 (60.0)

0.35

85 (89.5) 27.9 (16.0)

308 (90.6) 31.0 (19.3)

0.89 0.22 0.76

41 (43.2) 26 (27.4) 13 (13.7) 14 (14.7) 1 (1.1)

137 (40.3) 77 (22.6) 67 (19.7) 46 (13.5) 12 (4.7)

3 (3.7) 4 (4.9) 3 (3.7) 13 (16.0) 58 (71.6)

9 (3.4) 14 (5.3) 19 (7.2) 65 (24.6) 187 (70.8)

3 (21.4) 11(78.6)

10 (27.8) 36 (78.2)

61 (64.2) 34 (36.8)

231 (67.9) 109 (32.1)

0.89

1.00

0.49

*Of the 375 patients, 81 had scarring and 264 had no scarring.

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we found a larger proportion of scar carcinomas in comparison with previous studies. Auerbach et al.[7] reported autopsy findings on 1 186 cases of primary lung cancer and showed that 82 cases (6.9%) had an associated focus of pulmonary fibrosis. Raeburn and Spencer,[1] who performed an autopsy study on 400 cases of lung cancer, found that 15 (3.8%) of the cancers fitted the definition of a scar carcinoma. Freant et al.[8] observed a 20% prevalence of pulmonary scar carcinomas in 94 surgically excised primary lung cancers. The higher proportion in our population is probably related to the high prevalence of post-tuberculous lung disease in the Western Cape. Patients with a history of pulmonary TB have been shown to display a two-fold increase in risk for the subsequent development of lung cancer.[9] The pathogenesis of lung fibrosis is accepted to be due to the accumulation of activated reparative mesenchymal cells (myofibroblasts) and their persistent unopposed deposition of extracellular matrix (ECM).[10] It is hypothesised that this unopposed accumulation of ECM interacts malignantly with surrounding epithelial cells by disturbing their normal cell cycles and promoting subsequent mutations.[11] Studies evaluating fibrotic biopsies from patients with idiopathic pulmonary fibrosis (IPF) have shown a paucity of apoptosis, similar to that of malignancies, which may indicate a synonymous ability of both fibrotic and malignant tissue to evade cell death.[2,10] A possible explanation for this lack of apoptosis could be explained by overexpression of anti-apoptotic protein kinases, such as survivin.[12] Furthermore, the process of autophagy, by which cell death occurs via the lysosomal pathway, has been shown to be impaired in IPF as well as fibroblast models. Impaired autophagy is a commonly accepted mechanism of tumourigenesis.[2] Sustained proliferative signalling is also considered to be a hallmark of tumourigenesis, in which sustained exogenous stimuli ‘hijack’ the cell cycle.[13] This overexpression of proliferative signalling networks has been shown also to be present in fibroblasts from IPF biopsies. Another accepted hallmark of malignant tissue is its ability to evade growth suppressors. Prostaglandin E2 (PGE2) is a cell mediator that inhibits proliferation, differentiation and collagen synthesis of normal fibroblasts as well as promoting their susceptibility to apoptosis. However, fibroblasts within IPF, similarly to malignant cells, have been shown to demonstrate less sensitivity to the effects of PGE2.[2,13] Our study has implications for both routine clinical care and future research. Although not specifically designed to test the hypothesis,

our findings suggest that scarring (from any cause) should be viewed as a risk factor for lung cancer, and that extra vigilance is required when following up patients with existing scarring, particularly if they are smokers or have any clinical or radiological features of cancer. Prospective studies are needed to gauge the true risk associated with pulmonary scarring, particularly secondary to TB.

Study limitations

Our study has some limitations, most notably its retrospective nature and the lack of histological confirmation of apparent scarring observed on CT scanning. Moreover, our registry was not set up to capture HIV status or a history of previous pulmonary TB. However, in the vast majority of cases with focal scarring, the CT scan was consistent with changes of previous TB.

Conclusion

At least 20% of patients with lung cancer had scarring, which was significantly more likely to be present in the same lobe as the lung cancer than elsewhere in the lungs, suggesting a predisposition to malignancy. 1. Raeburn C, Spencer H. A study of the origin and development of lung cancer. Thorax 1953;8(1):1-10. 2. Horowitz JC, Osterholzer JJ, Marazioti A, Stathopoulos GT. ‘Scar-cinoma’: Viewing the fibrotic lung mesenchymal cell in the context of cancer biology. Eur Respir J 2016;47(6):1842-1854. https://doi. org/10.1183/13993003.01201-2015 3. Schäfer M, Werner S. Cancer as an overhealing wound: An old hypothesis revisited. Nat Rev Mol Cell Biol 2008;9(8):628-638. https://doi.org/10.1038/nrm2455 4. Koegelenberg CFN, van der Made T, Taljaard J, Irusen E. The impact of HIV infection on the presentation of lung cancer in South Africa. S Afr Med J 2016;106(7):666-668. https://doi.org/10.7196/ SAMJ.2016v106i7.10737 5. World Health Organization. Global Tuberculosis Report 2014. Geneva: WHO, 2014. http://apps.who. int/iris/bitstream/10665/137094/1/9789241564809_eng.pdf (accessed 25 November 2016). 6. Detterbeck FC, Boffa DJ, Tanoue LT. The new lung cancer staging system. Chest 2009;136(1):260-271. https://doi.org/10.1378/chest.08-0978 7. Auerbach O, Garfinkel L, Parks V. Scar cancer of the lung: Increase over a 21 year period. Cancer 1979;43(2):636-642. 8. Freant L, Joseph W, Adkins P. Scar carcinoma of the lung. Fact or fantasy? Ann Thorac Surg 1974;17(6):531-537. 9. Liang H, Li X, Yu X, et al. Facts and fiction of the relationship between preexisting tuberculosis and lung cancer risk: A systematic review. Int J Cancer 2009;125(12):2936-2944. https://doi.org/10.1002/ijc.24636 10. Thannickal V, Henke C, Horowitz J, et al. Matrix biology of idiopathic pulmonary fibrosis: A workshop report of the national heart, lung, and blood institute. Am J Pathol 2014;184(6):1643-1651. https://doi. org/10.1016/j.ajpath.2014.02.003 11. Horowitz J, Thannickal V. Epithelial-mesenchymal interactions in pulmonary fibrosis. Semin Respir Crit Care Med 2006;27(6):600-612. https://doi.org/10.1055/s-2006-957332 12. Ajayi I, Sisson T, Higgins P, et al. X-linked inhibitor of apoptosis regulates lung fibroblast resistance to Fas-mediated apoptosis. Am J Respir Cell Mol Biol 2013;49(1):86-95. https://doi.org/10.1165/ rcmb.2012-0224OC 13. Grimminger F, Günther A, Vancheri C. The role of tyrosine kinases in the pathogenesis of idiopathic pulmonary fibrosis. Eur Respir J 2015;45(5):1426-1433. https://doi.org/10.1183/09031936.00149614

Accepted 1 December 2016.

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Hip and knee arthroplasty waiting list – how accurate and fair? T Kavalier,1 2nd-year medical student; M Nortje,2 MB ChB, MMed (Orth), FCS (Orth); R N Dunn,3 MB ChB, MMed (Orth), FCS (SA) Orth Division of Orthopaedic Surgery, Faculty of Health Sciences, University of Cape Town, South Africa Division of Orthopaedic Surgery, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, South Africa 3 HOD/Pieter Moll and Nuffield Chair, Division of Orthopaedic Surgery, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, South Africa 1 2

Corresponding author: R N Dunn (robert.dunn@uct.ac.za) Background. Resource-intensive procedures require the use of patient waiting lists in an attempt to increase fairness of access to surgery and improve surgical efficiency. Total hip and knee arthroplasty has waiting lists in excess of years. Objectives. To analyse our tertiary state institution’s hip and knee arthroplasty waiting list to assess its accuracy. Methods. At Groote Schuur Hospital, our hospital-maintained database was compared with the surgeons’ personally maintained database. Patients were then telephoned to confirm their contactability, and to discover whether they still wanted the procedure, or if they had already had it. Waiting duration and patient demographics were then calculated. Results. Of the 655 patients on the hospital waiting list, only 454 were contactable. Three hundred and nine patients still wanted the surgery, 93 had already undergone surgery and 52 no longer wanted surgery. The last group was the oldest and had had the longest waiting time. Those still waiting had waited 451 days (minimum - maximum (SD), 90 - 1 593 (228.5)), those that had had surgery 371 days (0 - 1 728 (296)) and those no longer interested 523 days (138 -1 881 (260.9)). A total of 429 patients were present on the surgeons’ list but not on the hospital list. They had had longer waiting times than those on the hospital list. Conclusion. The arthroplasty waiting list is inaccurate due to the existence of two concurrent lists and poor data management, particularly of current contact details. The unfairness of a wide range of waiting times was identified, with patients only on the surgeons’ personal database disadvantaged. These deficiencies have prompted the introduction of a scoring-based prioritisation system incorporating clinical, radiographic and societal parameters, in an effort to improve fair and appropriate access to this high-cost care. S Afr Med J 2017;107(4):323-326. DOI:10.7196/SAMJ.2017.v107i4.12145

Objectives

We undertook to analyse our tertiary state institution’s hip and knee arthroplasty waiting list to assess its accuracy.

Methods

At GSH, in the Department of Orthopaedic Surgery, surgeons have historically maintained personal waiting lists on an Excel (Microsoft, USA) spreadsheet. The hospital recently introduced a Clinicombased (CompuGroup, Slovakia) electronic waiting list, where clerks are responsible for maintaining the data. However, owing to the surgeons’ circumspection, both lists were still being maintained during the consolidation period. The hospital-maintained database was interrogated at the end of November 2015, and an Excel spreadsheet was generated with all patients on the waiting list at the time. This dataset included their name, hospital number, contact details, date of birth, date when placed on the waiting list and whether it was for a hip or knee replacement. We then compared the hospital list with the list personally maintained by the arthroplasty surgeons, to identify any patients who were missing from the hospital list. All the patients on the hospital list were contacted telephonically. Three repeated attempts were made on different days at different times before a patient was classed as ‘not contactable’. If the patient was not contactable, the hospital system was interrogated to see whether the patient was still active in the outpatient system between December 2015 and June 2016. Once contacted, the patient was asked if they still wanted the booked procedure, and if not, why not.

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Patients on the surgeons’ personally maintained list and not appearing on the hospital list were tracked on the state hospital Clinicom system regarding theatre activity. The data were analysed for the duration patients had waited so far. This was calculated by determining the number of days they had waited from when placed on the waiting list to the last day we called patients (30 November 2015). Age demographics were compared for the groups who wanted to remain on the list as opposed to those no longer wanting the surgery, as well as those who had in fact undergone the procedure but had not been taken off the list. These differences were assessed statistically with an unpaired t-test.

Results

There were 655 patients on the hospital list (Fig. 1). An additional 429 cases were identified on the surgeons’ personal list that were absent from the hospital list; 162 names were present on the hospital list that were absent from the surgeons’ personal list. Of the 655 patients on the hospital list, 454 (69%) were contactable and 201 (31%) were non-contactable. Of the 201 patients who were not contactable, we confirmed via the outpatient booking system that 88 had attended the clinic in the last 7 months. Therefore, 542 patients (83%) were still visibly active on the state waiting list. Of the 454 contactable patients, 309 patients (68%) still wanted to have the surgery. Fifty-two patients (11%) were no longer interested in having the surgery and requested to be removed from the waiting list. Ninety-three patients (20%) had already had the surgery performed. The main reasons for the 52 patients no longer wanting surgery were that they no longer had pain or were no longer interested in the surgery (Table 1). The mean age of the patients who wanted to be taken off the list was 67 years (37 - 84 (10.5)), the patients who still wanted to be on the list averaged 62 years (23 - 83 (11.0)), and the patients who had already had the surgery but were not removed from the list averaged 64 years (30 - 91 (12.0)). The patients who wanted to be taken off the list were on average significantly older than the group that still wanted surgery (p=0.0009). Of the 93 patients who had already undergone surgery but remained on the list, 71 had had their surgery at GSH, while 22 had decided to have their surgery elsewhere, primarily at private hospitals. Total patients on hospital list N=655

Non-contactable n=201

Want to be off n=52

Had surgery n=93

Age (years): 62 (23 - 83 (11.0))*

Age (years): 67 (37 - 84 (10.5))*

Age (years): 64 (30 - 91 (12.0))*

WT (days): 451 (90 - 1 593 (228.5))*

WT (days): 523 (138 - 1 881 (260.9))*

WT (days): 371 (0 - 1 728 (296))*

P-values of ages and WT between the three contactable groups Three groups contactable Off v. on Off v. had surgery On v. had surgery

Age 0.0009 0.0800 0.0400

WT 0.0210 0.0018 0.0058

Fig. 1. Findings from the hospital list with average age and WT for each group. (WT = waiting time. *mean (range (SD).)

Discussion

Waiting lists are necessary to improve fair access to healthcare such as high-cost surgical procedures. They should ensure the optimal use of time for the healthcare workers and patients. Ideally, patients should be stratified by means of a predetermined scoring system to match needs, skills and outcomes. However, many waiting lists are poorly managed, and anecdotal experience suggests that fairness to access is impeded by difficulty contacting patients, owing to inaccurate contact details and the surgeons’ practice of calling in the last seen patient when there is a last-minute cancellation. However, clinicians and services are increasingly being assessed by their waiting periods and lists, especially by increasing numbers of hospital management staff. Patients waiting longer than 6 months for their surgery have been shown to experience greater preoperative anxiety, depression and dissatisfaction than those waiting less than 6 months.[2] Generally, neither pain nor function seemed to worsen for patients waiting less than 6 months for knee or hip replacements.[3] Our hospital waiting list had a wide range of waiting times, which ranged from 0 to 1 880 days. The mean waiting time for all groups was longer than 6 months. Although we did not investigate the patients’ Table 1. Reasons given by patients who wanted to be taken off the hospital waiting list

88 have still attended the clinic in 2016

Want to remain on n=309

The time on the waiting list was calculated from the time up to 30 November 2015, the date of our data collection. For those who had in fact had their surgery but erroneously remained on the list, the waiting time was calculated from the time they were placed on the list to their individual date of surgery. This latter group had had a significantly shorter wait than those still waiting to have their surgery (p=0.0058). They waited 371 days (0 - 1 728 (296)). Patients still waiting to have their surgery waited 451 days (90 - 1 593 (228.5)). The patients who indicated that they no longer wanted surgery had waited ~523 days (138 - 1 881 (260.9)). When reviewing the 429 patients who were on the surgeons’ personal list, but not present on the state list, 98 patients had already had surgery, having waited an average of 990 days. The patients still waiting for their surgery had waited on average 1 662 days. There was a significant difference between the patients who had already had the surgery in the hospital and were on the surgeons’ list (p<0001), and the patients who were still waiting for the surgery (p<0001). When comparing hip and knee arthroplasty, knee patients had waited on average 461 (90 - 1 513 (222.8)) days, while patients waiting for hip replacements waited on average 412 (104 - 1 593 (242.3)) days (p=0.06).

Reason for wanting to be taken off list

Respondents, n

No longer felt pain

Not interested any more

Died

Too old

Too sick

Operation cancelled

Scared

Felt they had waited too long

No reason given

Total

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psychological and emotional status, this may have contributed to the 11% who requested to be removed from the waiting list. Conner-Spady et al.[4] found that patients thought that the maximum acceptable waiting time should be 4 months, well below the actual times found in this study. Conner-Spady et al.[4 reported an ideal waiting time of 2 months, where patients could prepare for the surgery emotionally and physically and get their affairs in order. In our study, the 20% of patients who had already had the surgery but were not taken off the list had had the shortest mean waiting time. The majority of these patients had had their operation at GSH, while the rest had resorted to private hospitals. Our unit offers privately funded additional lists when the funding is made available by corporate and philanthropic partners. Suitable, low-risk patients on these additional lists are treated at GSH and are taken off the standard waiting list. It appears that the administration did not keep up and remove the patients from the list as they did not follow the usual admission procedure. Other patients were treated at our satellite hospitals, indicating that some patients consult at different entry points to the system. A few took advantage of lowcost philanthropic options provided by our sessional staff through a not-for-profit trust. The patients no longer wanting surgery and opting to be taken off the list were significantly older than the rest. In fact, their reasons for this decision were often that they felt too old or too sickly. Surgeons need to effectively council patients regarding surgery before adding them to the waiting list, rather than be preoccupied with radiographical changes, to avoid this situation. Many of the patients on the state waiting list were non-contactable. This was due to the wrong telephone numbers being recorded, outdated contact information and in some cases no contact information at all. This highlights the need for active data management and regular updating of information when patients present at the various clinics. This has improved somewhat with mobile phones and the Regulation of Interception of Communications and Provision of Communication-Related Information Act (RICA) requirements, which result in less frequent change in mobile numbers. Owing to surgeons’ reluctance to trust the newer hospital-based electronic waiting list, they have continued to use a concurrent personally maintained list. However, poor co-ordination has resulted in neither list being representative of all the patients waiting. It appears that patients on the surgeons’ personal list and not on the hospital list were disadvantaged by longer waiting times. This may be due to reduced access by all parties to the personal list. In order for the waiting-list system to work optimally, surgeons need to adopt a single hospital-based waiting list that is actively managed by competent administration staff. It has been shown that change and maintenance are best improved when the surgeons ‘buy into’ the system, are involved in strategy planning and have a sense of shared leadership.[5] Ackerman et al.[3] reported that the mean waiting time for knee replacements was longer than that for hip replacements. Although showing only a mean difference of 6 weeks, our study echoes this. This may well be due to the slightly longer duration of knee replacement surgery. As many theatre allocations are based on a morning or afternoon list, it prevents two knees being done on one list, whereas replacing two hips is possible. Clearly, in order to reduce the waiting-list time, more resources are needed in the orthopaedic department to increase the throughput. Waiting lists improve equality and fairness of access to surgery by using a prioritisation system based on multiple demographic and

clinical factors. Prioritisation is important because it allows patients to wait a shorter amount of time on the list according to their need for the surgery, which improves fairness.[6] One study found that 84% of waiting patients felt that it was fair if another patient was placed ahead of them if they had worse pain or greater limitation of daily functions.[4] However, Tebé et al.[7] reported on primary knee arthroplasty waiting lists and concluded that the priority system had no effect on implementing prioritisation for patients based on their severity. Our study showed a broad range of patients’ waiting times, from a few days to several years. Although this may be based on ad hoc clinical prioritisation, it is more likely owing to patient contactability and short notice availability, which is unfair in terms of access to care. This may be due to the surgeons having a tendency to call the last patient they remember consulting with when an unexpected slot opens, instead of phoning the next patient on the waiting list. Despite this, we can also hypothesise that the more extreme waiting times are outliers, which may mean that some of the patients who have been waiting for years have stopped coming to the clinic but were never removed from the waiting list. The problem with the state waiting list is going to take time and resources to amend, even if there is immediate action in improving our administration system. Therefore, it is important to think of strategies that may be advantageous to patients who are waiting long times for their surgeries. Some studies have found that there is a deterioration in patients who have to wait a long time for their surgeries, in terms of functional limitations and pain.[8] In an attempt to combat this problem, several Australian states have implemented a system that addresses the issues of long waiting times and prioritisation.[9] They have appointed musculoskeletal co-ordinators to routinely assess patients who may be experiencing deterioration in function prior to their surgery, and to determine whether they need to be placed higher on the list or need emergency intervention. This is a productive strategy as it strengthens the prioritisation system and reduces waiting times for those patients who are most in need. Another practice that may reduce patient default is the implementation of a maximum waiting time for patients, dependent on their priority score.[7] An open-ended amount of time may leave the patient feeling hopeless.[4] Therefore, if some idea of how long they will have to wait is provided, the probability of the patient remaining on the list will be increased. The deficiencies identified in this study prompted our unit to introduce a scoring-based prioritisation system incorporating clinical, radiographic and societal parameters in an effort to improve fair and appropriate access to high-cost care.

Conclusion

This study confirms that the current arthroplasty waiting list is inaccurate, owing to the existence of two concurrent lists, and to poor data management in terms of current patient contact details. It highlights the long waiting times, with the wide range in such times experienced by patients. Those patients who were only on the surgeons’ personal database were disadvantaged by even longer waits. A single, actively managed, electronic system integrated into the hospital’s system for accurate demographic data is recommended. However, this needs surgeon confidence and buy-in. With this, further predetermined clinical, radiographic and societal parameters can be utilised to prioritise the patients and improve fair and appropriate access to high-cost care.

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Acknowledgement. The authors would like to thank Ms Noluthando Marotola for her administrative help in tirelessly calling all the patients on the waiting list. 1. Dunn RN. Musculoskeletal burden of disease: Do we have any idea? SA Orthopaedic J 2012;11(2):20-22. 2. Lizaur-Utrilla A, Martinez-Mendez D, Miralles-Muñoz F, Marco-Gomez L, Lopez-Prats F. Negative impact of waiting time for primary total knee arthroplasty on satisfaction and patient-reported outcome. Int Orthop 2016;40(11):2303-2307. https://doi.org/10.1007/s00264-016-3209-0 3. Ackerman I, Bennell K, Osborne R. Decline in health-related quality of life reported by more than half of those waiting for joint replacement surgery: A prospective cohort study. BMC Musculoskelet Disord 2011;12(1):2-7. https://doi.org/10.1186/1471-2474-12-108 4. Conner-Spady B, Sanmartin C, Johnston G, McGurran J, Kehler M, Noseworthy T. ‘There are too many of us to fix’. Patients’ views of acceptable waiting times for hip and knee replacement. J Health Serv Res Policy 2009;14(4):212-218. https://doi.org/10.1258/jhsrp.2009.00812 5. Amar C, Pomey M, SanMartin C, De Coster C, Noseworthy T. Sustainability: Orthopaedic surgery wait time management strategies. Int J Health Care Qual Assur 2015;28(4):1-11. https://doi.org/10.1108/ IJHCQA-11-2013-0131

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6. Román R, Comas M, Mar J, Bernal E, et al. Geographical variations in the benefit of applying a prioritization system for cataract surgery in different regions of Spain. BMC Health Serv Res 2008;8(1):8-32. https://doi.org/10.1186/1472-6963-8-32 7. Tebé C, Comas M, Adam P, Solans-Domènech M, Allepuz A, Espallargues M. Impact of a priority system on patients in waiting lists for knee arthroplasty. J Eval Clin Pract 2014;21(1):91-96. https:// doi.org/10.1111/jep.12248 8. Desmeules F, Dionne C, Belzile É, Bourbonnais R, Frémont P. The impacts of pre-surgery wait for total knee replacement on pain, function and health-related quality of life six months after surgery. J Eval Clin Pract 2010;18(1):111-120. https://doi.org/10.1111/j.1365-2753.2010.01541.x 9. Witt J, Scott A, Osborne R. Designing choice experiments with many attributes. An application to setting priorities for orthopaedic waiting lists. Health Econ 2009;8(6):681-696. https://doi. org/10.1002/hec.1396

Accepted 16 January 2017.

The benefit of pharmacological venous thromboprophylaxis in foot and ankle surgery

N P Saragas,1,2 MB BCh, FCS (SA) Orth, MMed (Orth Surg); P N F Ferrao,1,2 MB ChB, FCS (SA) Orth; B F Jacobson,3 MB ChB, MMed (Haem), FRCS (Glasg), FC Path (SA), PhD (Med); E Saragas,3 MB BCh, FFPath (Haem) (SA); A Strydom,1,2 MB BCh, FC Orth (SA), MMed (Orth Surg) Orthopaedic Foot and Ankle Unit, Netcare Linksfield Hospital, Johannesburg, South Africa Foot and Ankle Unit, Division of Orthopaedic Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg; and National Health Laboratory Service, Johannesburg, South Africa 1 2

Corresponding author: N P Saragas (saragas@global.co.za) Background. Ten percent of patients with a deep-vein thrombosis (DVT) will develop a fatal pulmonary embolism (PE), often initially asymptomatic. The risks and benefits of pharmacological thromboprophylaxis are well documented in respect of total joint arthroplasty and hip fractures, but little is understood about the incidence of venous thromboembolism (VTE) or the potential risks and benefits of chemoprophylaxis in foot and ankle surgery. Objective. To determine whether prophylactic chemoprophylaxis had any impact on the prevention of VTE in a cohort of foot and ankle surgical patients requiring the combination of below-knee cast immobilisation and non-weightbearing for ≥4 weeks. Methods. Between March 2014 and April 2015, a prospective cohort study of 142 patients was performed. All completed a thrombosis risk assessment form prior to surgery and were commenced on rivaroxaban (Xarelto) 10 mg/d postoperatively. The primary outcome measure was clinical VTE confirmed by compression ultrasonography (DVT) or a ventilation/perfusion scan (PE). Results. Three patients (2.1%) developed a clinical DVT. Two did so well beyond the immobilisation and anticoagulation period, and one was non-compliant with therapy. The average risk factor score in this subgroup was 7. No patient had a DVT while on the prescribed regimen of anticoagulant therapy. Five patients (3.5%) developed wound breakdown, two requiring surgical debridement with local skin flap closure. One case of menorrhagia that may have been linked to the anticoagulant therapy was reported. When compared with a previous study, pharmacological thromboprophylaxis significantly reduced VTE risk (p=0.02). Conclusions. Oral pharmacological thromboprophylaxis significantly reduces the risk of VTE in patients requiring cast immobilisation and non-weightbearing following foot and ankle surgery. The risk/benefit ratio favours this treatment as opposed to the treatment of major morbidity following non-fatal VTE. S Afr Med J 2017;107(4):327-330. DOI:10.7196/SAMJ.2017.v107i4.10843

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i4.10843

April 2017, Print edition

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

RESEARCH

Available data sources for monitoring non-communicable diseases and their risk factors in South Africa M Wandai,1 BSc, MSc; J Aagaard-Hansen,2 MD, MPH; C Day,1 BSc (Pharm), MMedSci; B Sartorius,3 BSc, BSc Hons, MSc, PhD; K J Hofman,4 MB BCh, FAAP Health Systems Trust, Johannesburg, South Africa Steno Diabetes Centre, Gentofte, Denmark; and South African Medical Research Council Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 3 Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban; and South African Medical Research Council/University of KwaZulu-Natal Gastrointestinal Research Centre, Durban, South Africa 4 PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 1 2

Corresponding author: M Wandai (muchiriwandai@gmail.com)

Background. Health information systems for monitoring chronic non-communicable diseases (NCDs) in South Africa (SA) are relatively less advanced than those for infectious diseases (particularly tuberculosis and HIV) and for maternal and child health. NCDs are now the largest cause of premature mortality owing to exposure to risk factors arising from obesity that include physical inactivity and accessible, cheap but unhealthy diets. The National Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013 - 17 developed by the SA National Department of Health outlines targets and monitoring priorities. Objectives. To assess data sources relevant for monitoring NCDs and their risk factors by identifying the strengths and weaknesses, including usability and availability, of surveys and routine systems focusing at national and certain sub-national levels. Methods. Publicly available survey and routine data sources were assessed for variables collected, their characteristics, frequency of data collection, geographical coverage and data availability. Results. Survey data sources were found to be quite different in the way data variables are collected, their geographical coverage and also availability, while the main weakness of routine data sources was poor quality of data. Conclusions. To provide a sound basis for monitoring progress of NCDs and related risk factors, we recommend harmonising and strengthening available SA data sources in terms of data quality, definitions, categories used, timeliness, disease coverage and biomarker measurement. S Afr Med J 2017;107(4):331-337. DOI:10.7196/SAMJ.2017.v107i4.11438

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i4.11438

Perceptions of healthcare professionals regarding their own body weight in selected public hospitals in Mpumalanga Province, South Africa M C Phetla,1 BSc Dietetics, MPH; L Skaal,2 BSc Physiotherapy, MPH, DrPH 1 2

Department of Nutrition, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa Department of Public Health, School of Health Care Sciences, University of Limpopo, Polokwane, South Africa

Corresponding author: L Skaal (linda.skaal@ul.ac.za, lskaal@ul.ac.za)

Background. Obesity has been cited as a public health problem in both developing and developed countries. There is evidence that rates of obesity have increased among healthcare workers (HCWs) in South Africa (SA), especially those who do night shifts, with a negative effect on health. Perceptions of body weight contribute significantly to the desire to lose weight or not to do so. Objective. To determine perceptions of HCWs regarding their own body weight in selected public hospitals in Mpumalanga Province, SA. Methods. The study design was a cross-sectional survey. A total of 210 HCWs were sampled. Data were collected using self-administered questionnaires. Anthropometric measurements such as weight and height were objectively measured and body mass indices (BMIs) were calculated. Results. Of the sample of HCWs 82.4% were females, with a mean age of 37.8 years. About half (51.9%) were obese and 21.4% were overweight. They tended to misperceive their body weight compared with actual BMI classification, with the majority of obese and overweight individuals considering themselves to be of normal weight.

April 2017, Print edition

RESEARCH

Conclusions. The results indicate that HCWs misclassify their own body weight, which is a risk factor for obesity. It is important to focus on the health of this group of workers, on whom the health of South Africans depends and who should be the drivers of healthy living for all. Correct classification of their own body weight will encourage people to take action in a bid to combat their own and othersâ&#x20AC;&#x2122; obesity. S Afr Med J 2017;107(4):338-341. DOI:10.7196/SAMJ.2017.v107i4.12174

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i4.12174

Cross-sectional evaluation of the Bronchitis Severity Score in Egyptian children: A move to reduce antibiotics E M I Moawad, MD; M A E Haron, MD; R M A Maher, MD; E A A Abdallah, MD; H Hussein, MD; N M Badawy, MD, M E A El-Rheem, MB BCh Department of Paediatrics, Faculty of Medicine, Cairo University, Egypt Corresponding author: E M I Moawad (eimanmoawad@yahoo.com, iman.moawad@kasralainy.edu.eg)

Background. Despite evidence of limited benefit of antibiotics in acute bronchitis, most paediatric patients are prescribed them. Objectives. To assess the validity of the Bronchitis Severity Score (BSS) in assessing the clinical response to treatment of acute bronchitis, and determine whether clinical data and basic laboratory measurements can be used to guide antibiotic prescription. Methods. We enrolled 200 patients (age range 6 months - 12 years) with clinically diagnosed acute bronchitis. They were divided into three groups according to age. All patients were evaluated three times during the bronchitis episode (days 0, 5 and 7). The primary outcome measurement was the change in the BSS from day 0 to day 7. Results. On the initial visit, the mean (standard deviation (SD)) BSS was 8.36 (2.6), indicating moderate severity of bronchitis. The mean BSS decreased to 4.03 (2.3) on day 5 and to 2.36 (1.45) on day 7. Initial blood tests showed anaemia (80%), leucocytosis (6%), bandaemia (3%) and lymphocytosis (52%). Only four patients were positive for C-reactive protein, while the erythrocyte sedimentation rate was elevated in 98% of cases. There were significant correlations between bandaemia, fever grade (p<0.001) and white blood cell count with clinical variables such as the presence of secretions on chest auscultation (p<0.05) and toxic facies on general examination (p<0.05). Conclusions. Acute bronchitis in children is a self-limiting disease that does not require routine administration of antibiotics. The BSS is a simple and practical clinical scoring system that is useful in evaluating disease severity and monitoring disease resolution in acute bronchitis. S Afr Med J 2017;107(4):342-345. DOI:10.7196/SAMJ.2017.v107i4.11428

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i4.11428

Prevalence of hepatitis B, hepatitis C and human immunodeficiency viruses, and evaluation of risk factors for transmission: Report of a population screening in Nigeria U C Okonkwo,1 MD, FWACP, FMCP; H Okpara,2 MD, MPH, FMCPath; A Otu,3 MD, MPH, FWACP; S Ameh,4 MD, MPH, FMCPH, FWACP; Y Ogarekpe,2 MD; H Osim,1 MD; M Inyama,5 MD, FMCPath Gastroenterology/Hepatology Unit, Department of Internal Medicine, University of Calabar Teaching Hospital, Cross River State, Nigeria Department of Chemical Pathology, University of Calabar Teaching Hospital, Cross River State, Nigeria 3 Infectious Disease Unit, Department of Internal Medicine, University of Calabar Teaching Hospital, Cross River State, Nigeria 4 Department of Community Medicine, University of Calabar Teaching Hospital, Cross River State, Nigeria 5 Department of Haematology, University of Calabar Teaching Hospital, Cross River State, Nigeria 1 2

Corresponding author: U C Okonkwo (ucsuizes@yahoo.co.uk)

April 2017, Print edition

RESEARCH

Background. Hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV are common blood-borne infections unevenly distributed across regions in Nigeria. Few population-based prevalence studies have been done in Nigeria. Objective. To determine the prevalence of HBV, HCV and HIV and risk factors for infection with these viruses in a Nigerian population. Methods. Hepatitis B surface antigen, anti-HCV and HIV were assayed in 1 498 healthy adult participants. A structured questionnaire was used to assess risk factors for viral acquisition. Bivariate analysis was used to compare differences in sociodemographic characteristics. Significant risk factors were identified by stepwise logistic regression. A p-value <0.05 was considered significant. Results. The prevalences of HBV, HCV and HIV were 8.8%, 10.0% and 12.9%, respectively, with urban/rural disparity. HBV/HCV positivity was higher among males than females. The reverse was true for HIV. Age was significantly associated with being HBV-, HCV- or HIVpositive. Communal use of a toothbrush was significantly associated with HBV positivity in the final model (odds ratio 2.46, 95% confidence interval 1.45 - 4.18). Conclusions. The prevalence of HBV, HCV and HIV infection is high in Nigeria, with urban/rural disparity. HCV may be more of a public health concern than HBV in some communities. Population-based studies are required to provide vital data to inform optimal national control strategies. S Afr Med J 2017;107(4):346-351. DOI:10.7196/SAMJ.2017.v107i4.12198

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i4.12198

Problematic alcohol and other substance use among patients presenting to emergency services in South Africa: Who is ready for change? K Sorsdahl,1 PhD; D J Stein,2,3 MB ChB, FRCPC, PhD, DPhil; T Naledi,4 MB ChB, FCPHM; E Breuer,1 MPH; B Myers,2,5 PhD Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa 2 Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa 3 Medical Research Council Unit on Risk & Resilience in Mental Disorders, Cape Town, South Africa 4 Western Cape Department of Health, Cape Town, South Africa 5 Alcohol and Drug Abuse Research Unit, South African Medical Research Council, Cape Town, South Africa 1

Corresponding author: K Sorsdahl (katherine.sorsdahl@uct.ac.za) Background. Studies that identify factors associated with intervention uptake are urgently needed in poorly resourced healthcare systems. This is important, as knowing who is likely to engage may lead to intervention targeting, which is an efficient use of scarce health resources. Objective. To identify patient characteristics that predict the acceptance of a brief intervention for substance use delivered in emergency departments (EDs). Methods. Patients presenting to three EDs were screened for substance use using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). All patients identified as at risk for substance use problems were offered a brief psychotherapy intervention focused on substance user education. Data were collected on patientsâ&#x20AC;&#x2122; age, sex, presenting condition (injury/no injury), type of substance used, and severity of substance use. Logistic regression analysis was used to identify variables that predicted acceptance of the offer of a brief intervention. Results. Being between the ages of 25 and 39 years increased the likelihood of accepting an offer of help compared with 18 - 24-year-olds. Polysubstance users were less likely to accept an offer of help than patients with problematic alcohol use only, while patients with higher ASSIST scores were more likely to accept an offer of help than those with lower scores. Conclusions. Findings suggest that more work is needed to understand the mechanisms underlying treatment acceptance. Brief interventions delivered in ED services in countries such as South Africa should target alcohol users with higher ASSIST scores in order to ensure the efficient use of scarce health resources. S Afr Med J 2017;107(4):352-353. DOI:10.7196/SAMJ.2017.v107i4.10791

Full article available online at https://doi.org/10.7196/SAMJ.2017.v107i4.10791

April 2017, Print edition

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CPD

APRIL 2017

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 Tuberous sclerosis complex in the Western Cape, South Africa (SA): The clinical presentation features 1. Referral of children with tuberous sclerosis complex to neurology services was typically because of recurrent seizures. 2. Hypomelanocytic macules may be present at birth.

Problematic alcohol and other substance use among patients presenting to emergency services in SA: Who is ready for change? 9. Older patients, aged 25 - 39 years, were more likely to accept an offer of help with problematic alcohol use than younger people. 10. Patients with problematic alcohol use alone were less likely to accept an offer of help than patients with polysubstance abuse.

Contraception coverage and methods used among women in SA: A national household survey 3. Two-thirds of the women in this study had an unintended pregnancy in the past 5 years, a quarter of which were due to contraceptive failure. 4. The rise in the number of terminations of pregnancy in SA among all age groups suggests that substantial deficiencies remain in accessing family planning services.

CME Energy poverty, shack fires and childhood burns 11. Energy poverty is a key driver of burn injury in SA. 12. High burn mortality occurs in the first 3 years of a child’s life and again in adolescence. 13. Flame burn injuries are associated with paraffin stoves, wood and candles, while liquid and food burns are associated with electricity. 14. Non-pressure paraffin stoves are the main cause of fires and burn injuries in SA. 15. The SA Bureau of Standards-approved stove design incorporating self-extinguishing mechanisms is safe and effective in prolonged use.

Wound infection secondary to snakebite 5. Most snakebite victims present to hospital with painful progressive swelling as the main symptom. 6. Envenomation syndromes, including life-threatening coagulopathy, muscle weakness and respiratory paralysis, are common. Available data sources for monitoring non-communicable diseases and their risk factors in SA 7. Non-communicable diseases (NCDs) are now the largest cause of premature mortality owing to exposure to risk factors arising from obesity that include physical inactivity and accessible, cheap but unhealthy diets. 8. In SA, health information systems for major infectious diseases function relatively better than those for NCDs.

Promote buckling up and save a child’s life 16. In road traffic crashes, passenger injuries are the most lethal after pedestrian injuries. 17. Up to 40% of children presenting to Red Cross War Memorial Children’s Hospital with road traffic crash injuries do not need admission. 18. Seat belts were originally designed to keep pilots inside their gliders. 19. SA introduced seat belt legislation in 1973 and updated it in the National Road Traffic Act No. 93 of 1996. 20. The rate of use of appropriate child restraints in motor vehicles in SA has been found to be as low as 10%.

Erratum CPD question 13, March 2017

CPD question 13 in the March 2017 SAMJ (Vol. 107, No. 3), ‘Ingestion of a multiple small strong rare-earth (Neodymium) magnetic ball presents a high risk of enterocutaneous fistula formation even if no other metal objects are swallowed’, was erroneously marked as true, when it is false. S Afr Med J 2017;107(4):354. DOI:10.7196/SAMJ.2017.v107i4.12470

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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April 2017, Print edition

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