WCPCCS2013 Day 2 newsletter

NEWSLETTER - DAY 02 TUESDAY 19th FEBRUARY

Call to provide penicillin to all

A

ll children who present themselves

By SUE SEGAR to South African clinics with sore throats should be treated with practiced increasingly in South Africa. penicillin: That would go a long way Studies had shown this was the best towards preventing rheumatic fever and strategy for the country. rheumatic heart disease in the country.

“In an area such as ours, where Penicillin reduces the risk of rheumatic fever and rheumatic heart developing rheumatic fever by 80 disease are still very common, a percent, making it as effective as a strategy of treating all children who vaccine, said Professor of Medicine present to the clinic with pharyngitis at Groote Schuur Hospital and the with an intra-muscular injection is University of Cape Town Bongani the least costly strategy. If there is Mayosi. a clinician who is able to look for the “We must treat all,” Mayosi known physical signs, then in terms told delegates during the of cost-effectiveness, it may be better plenary session on Eradicating to use a clinical decision by which you Rheumatic Heart Disease in our examine the patient – and if they have Lifetime. two of the physical signs, then you Mayosi, a graduate treat them with penicillin,” of the University of Mayosi said.

KwaZulu-Natal and The strategies Oxford University, and which involve laboa former president ratories, such as culof the SA Heart turing, appeared to be Association who prohibitively expensive. has a major interest “This information is in rheumatic fever, said important and relevant to those the strategy was being Bongani Mayosi of us who practise in developing

countries because children in rural areas, in particular, which have the heaviest burden of rheumatic fever and rheumatic heart disease, often present to the nurse in the clinic. We need to give clear advice on what to do when the child presents with symptomatic sore throat.”

The penicillin option – as opposed to the option of clinical assessment – was the best option for SA because most clinics are staffed by nurses.

“We are promoting this with Ministry of Health who are receptive to it,” said Mayosi.

“Our proposal is in line with their thinking. We are providing now the scientific evidence to back that up and to show that it is cost-effective to do so on a large scale. “ Mayosi said the groundbreaking scientific evidence came from work done at UCT. It was uplifting to have the research “which addresses an area that has been controversial because up till now people have been questioning the value of treating sore throats as a way of preventing rheumatic fever.”

Investment in specialist training is necessary

By RAY JOSEPH

R

Build local capacity

egional medical centres have a greater chance of success where there is an investment in research and specialist training, said Dr Rachel Nugent, of the Department of Global Health at the University of Washington.

About one million children are born with congenital heart diseases (CHD) in middle income countries each year, with the highest death rate in developing nations.

Addressing the issue of the cost of care, Nugent proposed several options, including medical tourism, specialised visiting teams and the development of regional centres of excellence.

But with 50 percent of CHDs requiring surgery, which she said can be cost effective in some instances, “local surgical capacity needs to be looked at as a platform”.

Nugent also spoke about the

inequality of the burden surgery places on low and middle income families and says the cost of surgery needs to include transport and money to pay a caregiver.

“It (surgery) affects the family, diverts funds and can be very disruptive. Early deaths because of lack of care and catastrophic costs affect livelihoods and impose emotional and mental strain,” said Nugent, adding that 25 to 30 percent of children will require surgery as adults.

Prevention, including targeting obesity and diabetes in children, can help cut costs and it is important to first pursue cost effective interventions before considering surgery, she said.

“We need to seek synergies among global health advocates and funders. But to do this, better data is needed to identify major constraints, costs and human resources in order to find ways to ameliorate high costs of treatment.

Improvisation can save lives

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octors need to “come out of their high tech ivory towers” to deal with the challenge of delivering adequate care to the average citizen, says Dr Krish Kumar, Consultant Paediatric Cardiologist at the Amrita Institute of Medical Sciences in India.

“With an adequate programme and the right mindset you can take care of 95 percent of children with CHD,” Kumar said in a paper delivered on his behalf.

Krish Kumar

By RAY JOSEPH “With financial restraints and an absence of expensive new high tech equipment, you sometimes might have to do some procedures that might not make sense,” says Dr Kumar, adding that multi-tasking was essential for doctors working in an environment with limited resources.

“Multi-tasking is essential. You need to explore funding for individual patients without the means to pay, and to make sacrifices in hours and salary.

Sometimes nurses, for example, work 16 hour shifts with no additional pay.”

Improvisation was essential, including reducing manpower requirements and using less expensive equipment.

“It is always a struggle between quality and keeping costs in check and we need to learn to say no to isolated long term, difficult cases,” says Kumar, adding: “We need to learn to work with fewer resources in the face of rising costs.

Money often stands in the way of health

Weighing up the ross procedure O

ne of the world’s top cardiologists has paid tribute to SA-born heart surgeon Donald Ross at the Sixth World Congress of Paediatric Cardiology and Cardiac Surgery, currently being held in Cape Town.

Describing Ross, who performed the first pulmonary autograft operation in 1967 in the UK, as “Kimberley’s most brilliant gem”, Professor Frank Hanley critically assessed the relevance of the socalled Ross procedure which he said remains an important development in the field of cardiac surgery.

The exact procedure involves the replacement of the patient’s diseased aortic valve with his or her pulmonary valve. A pulmonary allograft which is taken from a cadaver then replaces the patient’s own pulmonary valve.

Paul Stelzer, one of the strongest proponents of the Ross procedure in the US, describes the operation as the “extensive reconstruction of the high-pressure ‘plumbing’ of the aortic root using the delicate material of the pulmonary artery”.

“For aortic disease, the Ross procedure at first placed a strong emphasis on maintaining the native aortic root,” said Hanley. “There was the benefit of living tissue, but no mention was made of possible growth of the valve, for example, in child patients.”

However, since then the technique has evolved considerably.

“There have been a total of 652 academic publications in the 46 years since the first pulmonary autograft

Donald Ross

By KATHERINE GRAHAM was performed,” said Hanley. “This is partly due to an expansion of the concept and the technical variations to the procedure.”

One of the unanticipated developments of the Ross procedure has been the wide adaption of aortic root replacement techniques.

“This is something that Ross himself does not approve of,” said Hanley, referring to the aortic root replacement technique which many surgeons prefer because it is easier to perform. Ross, however, favours the original inclusion technique which has fewer negative side effects.

“Currently, the feeling among surgeons is divided equally when it comes to whether they should perform the Ross procedure on adult patients or not,” said Hanley. “The long-term risks of the operation include the development of neo-root dilation and aortic insufficiency (AI), specifically in male patients with dilated aortic annulus who suffered from preoperative AI.” While cardiac surgeon Nicholas Kouchoukos and others have called for a moratorium on the Ross procedure, Hanley believes the operation has its merits, particularly for young patients.

“When dealing with critical aortic stenosis in the neonate, there is a need for something other than balloon valvotomy, where the only real patient selection is whether the infant is a hypoplast or not,” he said.

Explaining the benefits of the socalled Ross-Konno procedure, Hanley

Frank Hanley Tim Noakes

said the question was not whether it should be used for neonatal aortic stenosis, but why it wasn’t being used more often. “Young children have the greatest potential to benefit from the growth of the graft,” he said. “As opposed to adults, the root replacement technique is well suited in this patient population: infants have a tiny left ventricular outflow tract, the pulmonary root is prepared, while the extension to a Konno operation adds minimal risk.”

In conclusion, Hanley said that despite its detractors, the Ross procedure is likely to continue to be performed for many years to come. “He was a courageous pioneer who added massively to the body of knowledge of cardiac surgery.

Clearly the Ross principle will stay with us, but it does need to be modified.”

Invest in your arteries during childhood T

he current treatment of coronary disease – particularly in developing countries - must be changed drastically to include the prevention of the disease from as early as childhood.

So said Professor of Cardiology at University College, London (UCL) John Deanfield.

Atherosclerosis has traditionally been seen as a disease of adults, and mostly people over 50, but recent research has found traces of the disease in children in their first decade of life.

In addition, 17% of teenagers and 85% of adults aged 40 in the US have atherosclerosis.

Addressing the plenary session entitled Lifetime Risk of Atherosclerosis: Investing in Your Arteries from Childhood, Deanfield said the practise of only treating patients after a clinical event such as a heart attack or a stroke was not going to alter the burden of disease in the population.

Neither would such a practise serve to protect the next generation of people.

“We have to prevent the disease - and prevention should start in childhood,” Deanfield said. “We have to invest in our arteries in the same way as

By SUE SEGAR we invest in our retirement pensions.”

This message was particularly crucial for developing countries, Deanfield said.

“They are at a different stage of coronary disease development. As other diseases are sorted out, the risk factors driving arterial disease are becoming much more common.

“We can expect heart disease to become a huge problem in developing countries in the next twenty years – due largely to the development of unhealthy habits in those countries.

“In the next twenty to thirty years, they are going to have an explosion of coronary disease because of the change in the demographics and behaviour of the population.

“If they don’t do something to halt it, the disease that is coming will overwhelm their medical systems.

“This has already been seen in China, India, the Caribbean, Indonesia and in Africa. Mauritius has a huge incidence of coronary disease.”

The increases in coronary disease could be put down to a range of

John Deanfield

factors, including urbanisation, changes in lifestyle, changes in working behaviour, less exercise and bad eating, in addition to genetic predispositions to the illness.

This was being exacerbated by health systems which did not have well-developed preventative medical services.

Deanfield said it was crucial for doctors, families and governments to start focusing on risk factors for the disease from childhood.

“We have to manage lifestyles better, educate the public and pick up high risk people who may require additional drug therapy earlier on,” he said.

“In Britain we are developing new national risk strategy which will change the way we look at lifestyle risk factors. In New Zealand, new guidelines have already been published, and the us is expected to follow suit soon.”

Deanfield said this year’s conference was “unique and visionary” in that while most previous conferences had dealt exclusively with the immediate problems which children had, the 6th World Congress had changed its focus to include taking care of the children with heart disease who had become adults over their lifespan.

“The field has moved on from being a paediatric speciality to being an adult speciality because there are more adults with congenital heart disease alive now in many parts of the world than there are children as the success of the subject evolves. “

M edical schemes want low er do ctors’ bills

By RAY JOSEPH

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edical inflation South Africa last year was double the consumer price index (CPI), says Jonathan Broomberg, CEO of Discovery Health, which has 30 percent of the private health market in SA. “We need to change the way we fund and deliver healthcare.

Globally medical inflation in health care is rising faster than the consumer CPI,” he says. “In South Africa medical inflation last year was 11 percent, compared to a CPI of 5.5 percent.”

Doctors’ tariffs were just one driver of high costs. Others included hospital and equipment costs, while patients with a chronic conditions claimed four times as much as those without.

“New technology also means that doctors are able to treat patients who just two years ago would have been considered inoperable. The gap between expectation and reality is growing daily and patients want access to the latest technology at a low cost and while doctors want to maximise income medical aids must find a balance,” says Broomberg. The collection and intelligent use of data to monitor trends and costs could also help to reduce the cost of medical treatment.

“For an average paediatric cardiology treatment 20 percent of the fee went to the doctor,” he says.

Broomberg suggested that if doctors choose more cost effective procedures or treatments, the medical schemes could pay them 50 percent more.

Broomberg cited a recent pilot programme with a group of doctors that had dramatically brought down the cost of a hip replacement operation, while substantially increasing the doctors’ earnings.

Jonathan Broomberg

S u rgeon c alls for government funds to be diverted to save lives M

ore surgery could be done in South Africa if government diverted funds from other programmes, says Dr John Hewitson, a cardiac thoracic surgeon at Red Cross Children’s Hospital, who used a slide of Arms Deal equipment purchased at a cost of billions of rand to hammer home his point.

Government also needed to play its part in reducing cost of surgery as the cost of operating was directly related to the price of the device, he says.

“But this is affected by import duties and if we had the government on our side it could done far more cheaply.

Referring to the situation in Africa, Hewitson says the issue of scarce resources being allocated for life saving medical programmes was a problem in many parts of the continent where the comparison of the number of inoculations, for example, that could be done for the price of a single heart operation was often part of the decision making process when funds were allocated.

While there are parts of Africa with no access to health care - with some countries experiencing a shocking infant

By RAY JOSEPH mortality rate of as high as 400 deaths to a 1000 births - on the opposite end of the spectrum “access is infinite in the United States”.

Many deaths could be avoided before resorting to surgery, he argues.

“The statistic that is well known is that seven percent of the world has access to 90 percent of cardiac surgery,” argues Hewitson, but a “proper question” that should be asked is whether to do surgery or not and what other interventions were appropriate.

“When you start with a surgery programme you need to prioritise who is treated first, but how do you choose?” he says.

“First come, first served is a problem and choosing at random might be justified; but choosing by urgency can be a good place to start.

Strategic plan to reduce RHD mortality by 25%

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he World Heart Federation has announced a strategic plan to reduce premature deaths caused by rheumatic fever (RF) and rheumatic heart disease (RHD) by 25% in patients under the age of 25 years old by 2025.

Speaking at the Sixth World Congress of the Paediatric Cardiology and Cardiac Surgery currently being held in Cape Town, Dr Bo Remenyi of the WHF said that it was unacceptable that RHD had been virtually eliminated in the Western world, but remained the single most common acquired heart disease in developing countries.

“There are between 15 to 19 million people worldwide who suffer from RHD, with approximately 282 000 new cases and 233 000 deaths every year. Better living conditions and access to antibiotics have nearly eliminated rheumatic fever in most developed countries, but it remains common among children and adolescents in Africa, Asia, the Pacific and some areas of South America,” she said.

She said the goal of the WHF’s special task team was to eliminate RF and minimise the burden of RHD in low- and middle-income countries, as well as to learn valuable lessons from industrial nations who have succeeded in overcoming these diseases.

By KATHERINE GRAHAM Further WHF objectives include ensuring that 90% of countries with endemic RHD have integrated and comprehensive control programmes by 2025 and securing availability of high-quality benzathin penicillin for 90% of patients with RHD in 90% of countries with a high burden of this disease within 10 years. “We’d also like to foster one prominent public figure as a RHD champion to advocate for disease control efforts in every country where RHD is endemic,” she said.

Acknowledging that these were ambitious targets, Remenyi conceded that, to date, smallpox is the only human disease that has been completely eradicated.

“We believe that an incidence rate of below 10 RF patients per 100 000 of the overall population per annum is feasible,” she said.

“Elimination of RF below a certain threshold has been achieved in certain developed countries, for example the non-indigenous population of New Zealand.”

The number one challenge of eradicating RF is undoubtedly neglect, Remenyi asserted. “Only $1.7 million was spent on RF research and development in 2010.”

A further obstacle is a lack of data.

However, she said efforts were

Bo Remenyi

underway to collect better data in developing countries, which may ironically lead to a rise in mortality figures in the short term.

In addition to improving medical understanding of RF epidemiology and immunology, she said that access to essential health care was needed. In Africa alone, one million health care workers are required to meet the Millennium Developmental Goals. “We need to have a consistent supply of highquality penicillin, essential cardiac medicines, diagnostic modalities, anticoagulation monitoring and lifesaving cardiac surgery in order for these outcomes to be achieved.”

Delegates learn to limbo at the exhibition

This newsletter was produced by the team at HIPPO. www.hippocommunications.com