The principles for developing National Health Insurance (NHI) as described in the Green Paper are to improve access to quality healthcare services for the whole population and to provide financial risk protection against health-related catastrophic expenditures (Table 1). Comprehensive healthcare will be provided through accredited and contracted public and private providers, with a strong focus on health promotion and prevention services at the community and household level. The first 5 years will focus on strengthening the public sector in preparation for new NHI systems, with the launch of the new central NHI fund envisaged in 2014/15. We review progress since the Green Paper was launched in August 2011, and summarise a more in-depth review just completed.
Triage - or sorting - is a keystone of good emergency practice. Emergencies must be prioritised according to need to avoid unacceptable delays, and for some patients poorer outcomes. Sadly, triage is not practised in many hospitals and health centres in Africa. Nolan et al. undertook a survey of mainly district-level hospitals in seven low-income countries in 2001 and found that triage, and with it much of emergency care, was badly done.
Asthma is the commonest chronic disease in children and also affects millions of adults throughout the world, with approximately 1 in 7 of the world's population affected. Data from the International Study of Asthma and Allergies in Childhood (ISAAC) have provided a reliable method for assessing time trends in the global prevalence of asthma in children, using standard written and video-presented questionnaires. ISAAC has shown that approximately 13% of 13 - 14-year-old adolescents worldwide have symptoms of asthma, and that the global prevalence is increasing.
Objective. To evaluate the efficacy of an adapted Emergency Triage Assessment and Treatment (ETAT) tool at a children's hospital.
Design. A two-armed descriptive study.
Setting. Red Cross War Memorial Children's Hospital, Cape Town, South Africa.
Methods. Triage data on 1 309 children from October 2007 and July 2009 were analysed. The number of children in each triage category red (emergency), orange (urgent or priority) and green (non-urgent)) and their disposal were evaluated.
Results.The October 2007 series: 902 children aged 5 days - 15 years were evaluated. Their median age was 20 (interquartile range (IQR) 7 - 50) months, and 58.8% (n=530) were triaged green, 37.5% (n=338) orange and 3.8% (n=34) red. Over 90% of children in the green category were discharged (478/530), while 32.5% of children triaged orange (110/338) and 52.9% of children triaged red (18/34) were admitted. There was a significant increase in admission rate for each triage colour change from green through orange to red after adjustment for age category (risk ratio (RR) 2.6; 95% confidence interval (CI) 2.2 - 3.1).
The July 2009 cohort: 407 children with a median age of 22 months (IQR 7 - 53 months) were enrolled. Twelve children (2.9%) were triaged red, 187 (45.9%) orange and 208 (51.1%) green. A quarter (101/407) of the children triaged were admitted: 91.7% (11/12) from the red category and 36.9% (69/187) from the orange category were admitted, while 89.9% of children in the green category (187/208) were discharged. After adjusting for age category, admissions increased by more than 300% for every change in triage acuity (RR 3.2; 95% CI 2.5 - 4.1).
Conclusions. The adapted ETAT process may serve as a reliable triage tool for busy paediatric medical emergency units in resource-constrained countries and could be evaluated further in community emergency settings.
Background. The major paediatric public health problem worldwide is injury or trauma. In 2004, 950 000 children died as a result of injury.
Objective. The aim of this study was to evaluate the logistics of medical care after paediatric polytrauma within the first hours after arrival into a trauma unit - the so-called Golden Hour.
Methods. Children presenting with polytrauma to the Trauma Unit at the Red Cross War Memorial Children's Hospital between May 2011 and August 2011 were considered for inclusion in the study.
Results. Fifty-five children were included in the final analysis. The median duration of stay in the Trauma Unit was 205 minutes (interquartile range 135 - 274).
Conclusion. Several factors were identified that unnecessarily prolonged the time that patients stayed in the trauma unit following arrival in hospital for polytrauma management.
Background and objectives. The aim of this study is to report the incidence of Clostridium difficile-associated disease (CDAD) in a tertiary-care hospital in South Africa and to identify risk factors, assess patient outcomes and determine the impact of the hypervirulent strain of the organism referred to as North American pulsed-field type 1 (NAP1).
Methods. Adults who presented with diarrhoea over a period of 15 months were prospectively evaluated for CDAD using stool toxin enzyme immunoassay (EIA). Positive specimens were evaluated by PCR. Patient demographics, laboratory parameters and outcomes were analysed.
Results. CDAD was diagnosed in 59 (9.2%) of 643 patients (median age 39 years, IQR 30 - 55). Thirty-four (58%) were female. Recent antibiotic exposure was reported in 39 (66%), 27 (46%) had been hospitalised within 3 months, and 14 (24%) had concomitant inflammatory bowel disease (IBD). Nineteen (32%) had community-acquired CDAD (CA-CDAD). The annual incidence of hospital-acquired CDAD (HA-CDAD) was 8.7 cases/10 000 hospitalisations. Two cases of the hypervirulent strain NAP1 were identified. Seven (12%) patients underwent colectomy (OR 6.83; 95% CI 2.41 - 19.3). On logistic regression, only antibiotic exposure independently predicted for CDAD (OR 2.9; 95% CI 1.6 - 5.1). Three (16%) cases of CA-CDAD reported antibiotic exposure (v. 90% of HA-CDAD, p<0.0001). Twelve (86%) patients had concomitant IBD (p<0.0001 v. HA-CDAD). CA-CDAD was significantly associated with antibiotic exposure (OR 0.04, 95% CI 0.01 - 0.24) and IBD (OR 9.6, 95% CI 1.15 - 79.8).
Conclusion. The incidence of HA-CDAD in the South African setting is far lower than that reported in the West. While antibiotic use was a major risk factor for HA-CDAD, CA-CDAD was not associated with antibiotic therapy. Concurrent IBD was a predictor of CA-CDAD.
Background. South Africa has no policy to prevent malaria in pregnancy, despite the adverse effects of the disease in pregnancy. However, malaria control measures consisting of indoor residual spraying and specific antimalarial treatment have been in place since the 1970s. Information on the burden of malaria in pregnancy in South Africa is needed to indicate whether a specific policy for malaria prevention in pregnancy is necessary.
Objective. To determine the burden of malaria in pregnancy in KwaZulu-Natal (KZN) province, South Africa.
Methods. Pregnant women were enrolled at their first antenatal care visit to three health facilities in Umkhanyakude health district in northern KZN during May 2004 - September 2005 and followed up until delivery. Data collection included demographic details, current and previous malaria infection during pregnancy, haemoglobin concentrations and birth outcomes.
Results. Of the 1 406 study participants, more than a quarter were younger than 20 years of age, and more than 90% were unemployed and unmarried. Although 33.2% of the women were anaemic, this was not related to malaria. The prevalence and incidence of malaria were very low, and low birth weight was only weakly associated with malaria (1/10).
Conclusion. The low burden of malaria in these pregnant women suggests that they have benefited from malaria control strategies in the study area. The implication is that additional measures specific for malaria prevention in pregnancy are not required. However, ongoing monitoring is needed to ensure that malaria prevalence remains low.
Background. The concurrent TB and HIV epidemics in sub-Saharan Africa place all healthcare workers (HCWs) at increased risk of exposure to Mycobacterium tuberculosis.
Aim. This study explores personal experiences, attitudes and perceptions of medical doctors following treatment for TB within the healthcare system.
Method. Sixty-two medical doctors who were diagnosed with and treated for TB during 2007 - 2009 agreed to participate and complete a semi-structured questionnaire.
Results. The response rate was 64.5% (N=40). The mean age of participants was 33.7 years (standard deviation ±10.6). A correct diagnosis of TB was made within 7 days of clinical presentation in 20% of participants, and was delayed beyond 3 weeks in 52.5%. Non-routine special investigations and procedures were performed in 26 participants. Complications following invasive procedures were reported by 8 participants. Multi-drug resistant TB (MDR-TB) was diagnosed in 4 participants. Nineteen considered defaulting on their treatment because of drug side-effects. The majority (n=36) expressed concerns regarding lack of infection control at the workplace, delays in TB diagnosis and negative attitudes of senior medical colleagues and administrators. Ninety per cent of participants indicated that their personal illness experiences had positively changed their professional approach to patients in their current practice.
Conclusion. The inappropriate delays in diagnosis in a large number of participants, coupled with a number of negative personal perceptions towards their treatment, are cause for concern. The results further amplify the need for improved educational and awareness programmes among all healthcare personnel (including hospital administrators), adherence to national health guidelines, effective infection control measures, pre- and post-employment screening in all HCWs, and changes in attitudes on the part of senior medical colleagues and administrators.
Background. Despite significant advances in measles control, large epidemics occurred in many African countries in 2009 - 2011, including South Africa. South Africa's control strategy includes mass vaccination campaigns about every 4 years, the last of which was conducted nationally in April 2010 and coincided with the epidemic.
Aim. A community survey was conducted in the Western Cape to assess measles vaccination coverage attained by routine and campaign services, in children aged 6 to 59 months at the time of the mass campaign, from high-incidence areas.
Methods. Households were consecutively sampled in high-incidence areas identified using measles epidemic surveillance data. A caregiver history of campaign vaccination and routine vaccination status from the child's Road to Health card were collected. Pre- and post-campaign immunity was estimated by analytical methods.
Results. Of 8 332 households visited, there was no response at 3 435 (41.2%); 95.1% (1 711/1 800) of eligible households participated; and 91.2% (1 448/1 587; 95% confidence interval 86 - 94%) of children received a campaign vaccination. Before the campaign, 33.0% (103/312) of 9 - 17-month-olds had not received a measles vaccination, and this was reduced to 4.5% (14/312) after the campaign. Of the 1 587 children, 61.5% were estimated to have measles immunity before the campaign, and this increased to 94.0% after the campaign.
Discussion. Routine services had failed to achieve adequate herd immunity in areas with suspected highly mobile populations. Mass campaigns in such areas in the Western Cape significantly increased coverage. Extra vigilance is required to monitor and sustain adequate coverage in these areas.
Background. Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis remain major infections around the world. In Angola, about 166 000 individuals are living with HIV, representing a prevalence of 1.98% in adults between 15 and 49 years of age. In a 2003 study in Luanda, 4.5% of pregnant women had antibodies to HIV and 8.1% to HBV, and 5.4% were infected with Treponema pallidum.
Objectives. The aim of this study was to determine the prevalence of HIV-1 and 2, HBV, HCV and T. pallidum serological markers, and hence the prevalence of these infections, in individuals attending a sexually transmitted disease clinic in Luanda, Angola, and the burden of these infections in the Angolan population.
Methods. Individuals attending a centre for anonymous testing for HIV were randomly included in the study. All samples were tested for HBV surface antigen (HBsAg), anti-HCV and anti-HIV-1 and 2 antibodies and antibodies to T. pallidum.
Results. A total of 431 individuals (262 women and 169 men) were studied, of whom 10.0% (43/431) were seropositive for T. pallidum and 4.6% had active syphilis; 8.8% (38/431) were seropositive for HIV-1 and/or HIV-2 (of these, 78.9% were HIV-1-positive, 2.6% HIV-2-positive and 18.4% co-infected); 9.3% (40/431) were HBsAg-positive, while 8.1% (35/431) had antibodies to HCV. Of 102 patients with positive results, 26 (25.5%, or 6.0% of the total of 431 patients) were positive for more than one of the organisms studied. Rates of co-infection were as follows: 2.3% (10/431) for HIV/HBV, 0.9% (4/431) for HIV/HCV, and 0.9% (4/431) for HCV/HBV. Three individuals with active syphilis had viral co-infection, hepatitis B in 1 case and HIV in 2. Five individuals (1.2% of the total) were seropositive for 3 infections: HIV, hepatitis B and hepatitis C in 3 cases and HIV, hepatitis C and syphilis in 2.
Conclusions. A high prevalence of co-infection with the infections studied was found in this population, including HIV infection (8.8%). These results demonstrate the need to improve screening for and treatment of HIV and other sexually transmitted infections in Angola, and for educational campaigns to prevent not only the morbidity and mortality associated with these diseases, but also their further transmission.