South African Medical Journal - Volume 104, Issue 3, 2014
Volumes & issues
Volume 104, Issue 3, 2014
Cardiometabolic markers to identify cardiovascular disease risk in HIV-infected black South Africans : researchSource: South African Medical Journal 104, pp 195 –199 (2014) http://dx.doi.org/10.7196/SAMJ.7739More Less
Background. The prevalence of HIV is the highest in sub-Saharan Africa; South Africa (SA) is one of the most affected countries with the highest number of adults living with HIV infection in the world. Besides the traditional risk factors for cardiovascular disease (CVD) in the general population, in people living with HIV there are specific factors - chronic inflammation, metabolic changes associated with the infection, therapy, and lipodystrophy - that potentially increase the risk for developing CVD.
Objective. This study proposes a screening discriminant model to identify the most important risk factors for the development of CVD in a cohort of 140 HIV-infected black Africans from the North West Province, SA.
Methods. Anthropometric measures, systolic blood pressure, diastolic blood pressure and the carotid-dorsalis pedis pulse wave velocity were determined. Blood was analysed to determine the levels of total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol, triglycerides (TGs) and glucose. Partial least squares discriminant analysis was performed as a supervised pattern recognition method. Independent Student's t-tests were further employed to compare the means of risk factors on interval scales; for comparison of categorical risk factors between groups, X2 tests were used.
Results. A TG:HDL-C ratio ≥1.49, TC:HDL-C ratio ≥5.4 and an HDL-C level ≤0.76 mmol/l indicated CVD risk in this cohort of patients living with HIV.
Conclusion. The results have important health implications for black Africans living with HIV as these lipid levels may be a useful indicator of the risk for CVD.
High pleural fluid adenosine deaminase levels : a valuable tool for rapid diagnosis of pleural TB in a middle-income country with a high TB/HIV burden : researchSource: South African Medical Journal 104, pp 200 –203 (2014) http://dx.doi.org/10.7196/SAMJ.7428More Less
Background. South Africa has the highest burden of tuberculosis (TB) in the World Health Organization (WHO) African region. Using traditional TB diagnostic tools, the diagnosis of pleural TB (PTB) is highly unrewarding. Elevated levels of pleural fluid adenosine deaminase (FADA) have been shown to be useful in the diagnosis of PTB; however, similar levels may be found in some other medical conditions leading to misdiagnosis. Following queries from clinicians concerning the likely high false-positive (FP) rate of FADA from our laboratory, we performed a retrospective audit of all high FADA results generated over a 12-month period.
Objectives. To determine the positive predictive value (PPV) of FADA, the frequent causes of FPs in our laboratory and the demographic characteristics of tuberculous pleural effusions (TPEs) and non-tuberculous pleural effusions (NTPEs).
Methods. High FADA results generated in the past year were extracted with corresponding TB culture results, fluid cell count, cytology/histology results, radiology reports and HIV results. Hospital records were reviewed for the final diagnosis in each case. Diagnosis of PTB was based on the WHO case definition of TB.
Results. A total of 159 results were reviewed: 133 (83.6%) were TPE, hence FADA had a PPV of 83.6%. Neoplasm was the most common cause of an FP in 13/26 (50%) NTPEs. While TPE was more common than NTPE in younger people, both groups had an equal gender distribution.
Conclusion. FADA had a high PPV for PTB in our laboratory. We recommend its continued use as a rapid and reliable diagnostic tool for PTB.
Integration of TB and ART services fails to improve TB treatment outcomes : comparison of ART/TB primary healthcare services in Cape Town, South Africa : researchSource: South African Medical Journal 104, pp 204 –209 (2014) http://dx.doi.org/10.7196/SAMJ.7696More Less
Background. The combined tuberculosis (TB) and HIV epidemics in South Africa (SA) have created enormous operational challenges for a health service that has traditionally run vertical programmes for TB treatment and antiretroviral therapy (ART) in separate facilities. This is particularly problematic for TB/HIV co-infected patients who need to access both services.
Objective. To determine whether integrated TB facilities had better TB treatment outcomes than single-service facilities in Cape Town, SA.
Methods. TB treatment outcomes were determined for newly registered, adult TB patients (aged ≥18 years) at 13 integrated ART/TB primary healthcare (PHC) facilities and four single-service PHC facilities from 1 January 2009 to 30 June 2010. A X2 test adjusted for a cluster sample design was used to compare outcomes by type of facility.
Results. Of 13 542 newly registered patients, 10 030 received TB treatment in integrated facilities and 3 512 in single-service facilities. There was no difference in baseline characteristics between the two groups with HIV status determined for 9 351 (93.2%) and 3 227 (91.9%) patients, of whom 6 649 (66.3%) and 2 213 (63%) were HIV-positive in integrated facilities and single-service facilities, respectively. The median CD4+ count of HIV-positive patients was 152 cells/µl (interquartile range (IQR) 71 - 277) for integrated facilities and 148 cells/µl (IQR 67 - 260) for single-service facilities. There was no statistical difference in the TB treatment outcome profile between integrated and single-service facilities for all TB patients (p=0. 56) or for the sub-set of HIV-positive TB patients (p=0.58).
Conclusion. This study did not demonstrate improved TB treatment outcomes in integrated PHC facilities and showed that the provision of ART in the same facility as TB services was not associated with lower TB death and default rates.
Source: South African Medical Journal 104, pp 209 –211 (2014) http://dx.doi.org/10.7196/SAMJ.7384More Less
Background. Rates of tuberculosis (TB) transmission in prisons are reported to be high worldwide. However, a recent systematic review identified only 19 published studies reporting TB incidence in prisons, most of them from the last century and only one from sub-Saharan Africa.
Objectives. To assess the persisting risk of smear-positive pulmonary tuberculosis (PTB) among prison populations benefiting from a comprehensive TB/HIV control programme in Cameroon, compared with that in the community.
Methods. This descriptive and prospective study evaluated PTB incidence rates over a 1-year period. The study population was inmates of 10 major prisons, sampled by convenience, comprising about 45% of the country's prison population. As PTB incident cases, all prisoners with incident PTB after a prison stay of ≥90 days were considered. The prison TB incidence rate was compared with that of the corresponding male population in the community.
Results. The mean annual PTB incidence in Cameroonian prisons in this study was 1 700 cases in 100 000 person-years at risk, the incidence rate ratio being 9.4 (95% confidence interval 8.1 - 10.9).
Conclusion. Findings suggest that internationally recommended prison TB control measures alone may not help protect prisoners from within-prison spread of TB. Imprisonment policies and conditions therefore require fundamental changes.
Author Graham FieggenSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8094More Less
Open spina bifida (also known as myelomeningocele (SBM)) is the most complex birth defect involving the nervous system, and children born with this condition face a lifetime of medical care with numerous interventions. It is hard to think of another condition where initial management has such a profound effect on survival and ability.
Source: South African Medical Journal 104, pp 213 –217 (2014) http://dx.doi.org/10.7196/SAMJ.8079More Less
Open spina bifida or myelomeningocele (SBM) is the most common birth defect involving the central nervous system, second only in incidence to congenital cardiac disease. Outcomes in this disorder were poor until the mid-20th century, when modern neurosurgical techniques (closing the lesion and treating hydrocephalus) and treatment for the neuropathic bladder addressed the major causes of mortality, although SBM may still be poorly treated in the developing world. Initial management - or mismanagement - has a profound impact on survival and long-term quality of life.
Source: South African Medical Journal 104, pp 218 –221 (2014) http://dx.doi.org/10.7196/SAMJ.8039More Less
Spinal neural tube defects (NTDs) result from failure of neural tube closure that normally occurs at 15 - 28 days after conception. Birth prevalence figures for spina bifida vary, but on average are around 0.1%. There are no recent figures for South Africa, but previous studies have shown an incidence of 0.77 - 6.1/1 000 live births, with higher incidences in rural areas. The true incidence of NTDs is thought to be higher, but is difficult to calculate as this includes both spontaneous and therapeutic pregnancy losses.
Source: South African Medical Journal 104, pp 222 –224 (2014) http://dx.doi.org/10.7196/SAMJ.8038More Less
The management of patients with myelomeningocele is largely dependent on the timing of the diagnosis, i.e. ante- or postnatally. Antenatal diagnosis can be made using a combination of maternal serum alpha-fetoprotein measurement, fetal ultrasonography and, where necessary, amniocentesis.
Progress towards the Millennium Development Goals in SA : foreword - Progress towards the Millennium Development GoalsAuthor Peter BarronSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.7924More Less
The Millennium Declaration, together with the Millennium Development Goals (MDGs), was signed by member states of the United Nations, including South Africa (SA), in September 2000. While all the MDGs are related to health, goals 4, 5 and 6 are directly related to health and the functioning of the healthcare system: goal 4 relates to reducing child mortality, goal 5 to improving maternal health, and goal 6 to combating HIV/AIDS, malaria and other diseases, such as tuberculosis (TB). Targets were set for countries to reach by 31 December 2015, using the year 1990 as a baseline. This supplement contains a number of papers that describe the progress SA has made and some of the continuing challenges that need to be overcome to meet the targets, or at least get as close to reaching them as possible.
Successfully controlling malaria in South Africa : malaria control - Progress towards the Millennium Development GoalsSource: South African Medical Journal 104, pp 224 –227 (2014) http://dx.doi.org/10.7196/SAMJ.7600More Less
Following major successes in malaria control over the past 75 years, South Africa is now embarking on a malaria elimination campaign with the goal of zero local transmission by the year 2018. The key control elements have been intensive vector control, primarily through indoor residual spraying, case management based on parasitological diagnosis using evidence-based drug policies with artemisinin-based combination therapy since 2001, active health promotion in partnership with communities living in the malaria transmission areas, and cross-border collaborations. Political commitment and long-term funding for the malaria control programme have been a critical component of the programme's success. Breaking the cycle of transmission through strengthening of active surveillance using sensitive molecular tests and field treatment of asymptomatic persons, monitoring for antimalarial drug resistance and insecticide resistance, strengthening cross-border initiatives, and ongoing programme advocacy in the face of a significant decrease in disease burden are key priorities for achieving the elimination goal.
Source: South African Medical Journal 104, pp 225 –227 (2014) http://dx.doi.org/10.7196/SAMJ.8046More Less
Paediatric neuropathic bladder dysfunction can cause irreversible renal damage and urinary incontinence. Aetiologically, this condition is usually caused by a congenital neural tube defect. The majority of affected children can be successfully managed with the standard medical treatment of clean intermittent catheterisation and anticholinergic medication (typically oxybutynin). A small subset of patients who receive oral oxybutynin experience severe side-effects or insufficient suppression of detrusor overactivity. This group may require alternative medical or surgical management.
Effectiveness of pneumococcal conjugate vaccine and rotavirus vaccine introduction into the South African public immunisation programme : impact of new childhood vaccines - Progress towards the Millennium Development GoalsSource: South African Medical Journal 104, pp 228 –234 (2014) http://dx.doi.org/10.7196/SAMJ.7597More Less
Immunisation has contributed greatly to the control of vaccine-preventable diseases and therefore to improvements in health and survival, especially among young children, and remains one of the most successful and cost-effective public health interventions. This remains true for many of the newer, more expensive vaccines. Vaccines against invasive pneumococcal disease and rotavirus infection were introduced into the South African Expanded Programme on Immunization in April 2009. This article describes the rationale for and process of the introduction of these two vaccines, pneumococcal conjugate vaccine and rotavirus vaccine. It also aims to evaluate the success of and challenges related to their introduction, in terms of both achieving universal coverage and improving survival and health in South African children.
An approach to the developmental and cognitive profile of the child with spina bifida : CME - articleSource: South African Medical Journal 104, pp 228 –230 (2014) http://dx.doi.org/10.7196/SAMJ.8048More Less
Myelomeningocele, or open spina bifida (SBM), is the most common congenital defect of the central nervous system. The brain anomalies described in SBM are varied and contribute to the complex phenotypic outcomes in neurocognition and behaviour. Several factors have an impact on the severity and type of cognitive outcome. The strongest association with cognitive dysfunction is the presence of hydrocephalus and its complications. Hydrocephalus occurs in 80 - 95% of cases and typically results in attenuation of cerebral white matter, particularly in the posterior aspects of the brain, which is important in the development of spatial skills.
Laboratory information system data demonstrate successful implementation of the prevention of mother-to-child transmission programme in South Africa : prevention of mother-to-child transmission - Progress towards the Millennium Development GoalsSource: South African Medical Journal 104, pp 235 –238 (2014) http://dx.doi.org/10.7196/SAMJ.7598More Less
Background. Monitoring the prevention of mother-to-child transmission (PMTCT) programme to identify gaps for early intervention is essential as South Africa progresses from prevention to elimination of HIV infection in children. Early infant diagnosis (EID) by an HIV polymerase chain reaction (PCR) test is recommended at 6 weeks of age for all HIV-exposed infants. The National Health Laboratory Service (NHLS) performs the PCR tests for the public health sector and stores test data in a corporate data warehouse (CDW).
Objectives. To demonstrate the utility of laboratory data for monitoring trends in EID coverage and early vertical transmission rates and to describe the scale-up of the EID component of the PMTCT programme.
Methods. HIV PCR test data from 2003 to 2012 inclusive were extracted from the NHLS CDW by year, province, age of infant tested and test result and used to calculate EID coverage and early vertical transmission rates to provincial level.
Results. Rapid scale-up of EID over the first decade of the PMTCT programme was evident from the 100-fold increase in PCR tests to 350 000 by 2012. In 2012, 73% of the estimated 270 000 HIV-exposed infants requiring an early PCR were tested and the early vertical transmission rate had fallen to 2.4% as a result of successful implementation of the PMTCT programme.
Conclusions. Laboratory data can provide real time, affordable monitoring of aspects of the PMTCT programme and assist in achieving virtual elimination of paediatric HIV infection in South Africa.
Elimination of mother-to-child transmission of HIV in South Africa : rapid scale-up using quality improvement : prevention of mother-to-child transmission - Progress towards the Millennium Development GoalsSource: South African Medical Journal 104, pp 239 –243 (2014) http://dx.doi.org/10.7196/SAMJ.7605More Less
Background. South Africa (SA) is committed to achieving the goal of eliminating mother-to-child transmission (MTCT) of HIV by 2015. To achieve this, universal coverage of quality antenatal, labour, delivery and postnatal services for all women has to be attained. Over the past decade, the prevention of mother-to-child transmission (PMTCT) programme has been scaled up to reach all healthcare facilities in the country. However, challenges persist in achieving 100% coverage and access to the programme.
Objectives. We describe the process undertaken by the National Department of Health (NDoH), in collaboration with partners, to develop, implement and monitor a data-driven intervention to improve facility, district, provincial and national PMTCT-related performance.
Methods. Between 2011 and 2013, the NDoH developed and implemented an intervention using data-driven participatory processes to understand facility-level bottlenecks to optimise PMTCT implementation and to scale up priority PMTCT actions nationally.
Results. There was remarkable improvement across all key indicators in the PMTCT cascade over the 3 years 2011 - 2013. Simple monitoring tools such as a visual dashboard and data for action reports were successfully used to improve the performance of the PMTCT programme across SA. MTCT has shown a significant downward trend.
Conclusions. It is feasible to implement district-level, data-driven quality improvement processes at a national scale to improve the performance of the PMTCT programme at the local level.
Tuberculosis control in South Africa : successes, challenges and recommendations : tuberculosis control - Progress towards the Millennium Development GoalsSource: South African Medical Journal 104, pp 244 –248 (2014) http://dx.doi.org/10.7196/SAMJ.7689More Less
Tuberculosis (TB) remains a global health threat, and South Africa (SA) has one of the world's worst TB epidemics driven by HIV. Among the 22 countries with the highest burden of TB, SA has the highest estimated incidence and prevalence of TB, the second highest number of diagnosed multidrug-resistant TB cases, and the largest number of HIV-associated TB cases. Although SA has made notable progress in reducing TB prevalence and deaths and improving treatment outcomes for new smear-positive TB cases, the burden of TB remains enormous. SA has the means to overcome this situation. In addition to better implementing the basics of TB diagnosis and treatment, scaling up the use of Xpert MTB/RIF as a replacement for sputum smear microscopy, strengthening case finding in and beyond healthcare facilities and a greater focus on TB prevention for people living with HIV, particularly earlier initiation of and scaling up antiretroviral therapy and scaling up continuous isoniazid preventive therapy, will have a substantial impact on TB control. New TB drugs, diagnostics and vaccines are required to further accelerate progress towards improved TB control in SA and beyond.
A brief history of South Africa's response to AIDS : history of HIV in SA - Progress towards the Millennium Development GoalsSource: South African Medical Journal 104, pp 249 –251 (2014) http://dx.doi.org/10.7196/SAMJ.7700More Less
The story of the AIDS response in South Africa over the past 4 years is one of great progress after almost a decade of complex and tragic denialism that united the world and civil society in a way not seen since the opposition to apartheid. Today the country can boast >2 million people on antiretroviral therapy, far and away the largest number in the world. Prevention efforts appear to be yielding results. The estimated number of annual new HIV infections declined by 79 000 between 2011 and 2012. New HIV infections among adults aged 15 - 49 years are projected to decline by 48% by 2016, from 414 000 (2010) to ~215 000 (2016). The national incidence rate has reached its lowest level since the disease was first declared an epidemic in 1992, translating into reductions in both infant and under-5 mortality and an increase in life expectancy from 56 to 60 years over the period 2009 - 2011 alone. This is largely thanks to a civil society movement that was prepared to pose a rights-based challenge to a governing party in denial, and to brave health officials, politicians and clinicians working in a hostile system to bring about change.