Background. Human papillomavirus (HPV) infection is well known to be associated with head and neck cancers (HNCs). HPV-associated HNCs are related to sexual behaviour, particularly the lifetime number of oral sex partners, but the epidemiology of oral and oropharyngeal HPV in South African men has not yet been studied.
Objectives. To determine the oral and oropharyngeal HPV strain prevalence and associated factors in a selected male population in Pretoria, South Africa (SA).
Methods. Male factory workers were recruited. Oral rinse and gargle samples were tested for 37 HPV types using the Linear Array HPV Genotyping Test (Roche Molecular Systems). A questionnaire was used to obtain information regarding age, medical conditions, substance and alcohol use and sexual behaviour. HIV testing was optional.
Results. The HPV prevalence was 5.6% among men (N=125) aged 17 - 64 years. High-risk HPV (hrHPV) types 16 and 68 were found in two men. Oral sex seemed to be an uncommon practice in the majority of respondents, but the two respondents with hrHPV did practise oral sex. There was a statistically significant association between HPV infection and an increased number of sexual partners (p=0.027), but not between HPV and substance use, HIV status or clinical mucosal pathology.
Conclusion. The prevalence of oral and oropharyngeal HPV was lower than reported in other countries. An association between oral HPV and having multiple sexual partners was found. A larger nationwide study would give a more representative view of the burden of oral and oropharyngeal HPV infection in SA.
Background. Standardised tuberculosis (TB) treatment through directly observed therapy (DOT) is available in South Africa, but the level of adherence to standardised TB treatment and its impact on treatment outcomes is unknown.
Objectives. To describe adherence to standardised TB treatment and provision of DOT, and analyse its impact on treatment outcome.
Methods. We utilised data collected for an evaluation of the South African national TB surveillance system. A treatment regimen was considered appropriate if based on national treatment guidelines. Multivariate log-binomial regression was used to evaluate the association between treatment regimens, including DOT provision, and treatment outcome.
Results. Of 1 339 TB cases in the parent evaluation, 598 (44.7%) were excluded from analysis owing to missing outcome or treatment information. The majority (697, 94.1%) of the remaining 741 patients received an appropriate TB regimen. Almost all patients (717, 96.8%) received DOT, 443 (59.8%) throughout the treatment course and 274 (37.0%) during the intensive (256, 34.6%) or continuation (18, 2.4%) phase. Independent predictors of poor outcome were partial DOT (adjusted risk ratio (aRR) 3.1, 95% confidence interval (CI) 2.2 - 4.3) and previous treatment default (aRR 2.3, 95% CI 1.1 - 4.8).
Conclusion. Patients who received incomplete DOT or had a history of defaulting from TB treatment had an increased risk of poor outcomes.
Background. Human resource management (HRM) practices have the potential to influence retention of doctors in the public health sector.
Objective. To explore the key human resource (HR) practices affecting doctors in a medical complex in the Eastern Cape, South Africa.
Methods. We used an open-ended questionnaire to gather data from 75 doctors in this setting.
Results. The most important HR practices were paying salaries on time and accurately, the management of documentation, communication, HR staff showing that they respected and valued the doctors, and reimbursement for conferences and special leave requests. All these practices were judged to be poorly administered. Essential HR characteristics were ranked in the following order: task competence of HR staff, accountability, general HR efficiency, occupation-specific dispensation adjustments and performance management and development system efficiency, and availability of HR staff. All these characteristics were judged to be poor.
Conclusion. HRM practices in this Eastern Cape medical complex were inadequate and a source of frustration. This lack of efficiency could lead to further problems with regard to retaining doctors in public sector service.
Background. Triage is one of the core requirements for the provision of effective emergency care and has been shown to reduce patient mortality. However, in low- and middle-income countries this strategy is underused, under-resourced and poorly researched.
Objective. To assess the inter- and intra-rater reliability and accuracy of nurse triage ratings when using the South African Triage Scale (SATS) in an emergency department (ED) in Timergara, Pakistan.
Methods. Fifteen ED nurses assigned triage ratings to a set of 42 reference vignettes (written case reports of ED patients) under classroom conditions. Inter-rater reliability was assessed by comparing these triage ratings; intra-rater reliability was assessed by asking the nurses to re-triage 10 random vignettes from the original set of 42 vignettes and comparing these duplicate ratings. Accuracy of the nurse ratings was measured against the reference standard.
Results. Inter-rater reliability was substantial (intraclass correlation coefficient 0.77; 95% confidence interval (CI) 0.69 - 0.85). The intrarater agreement was also high with 87% exact agreement (95% CI 67 - 100) and 100% agreement allowing for a one-level discrepancy in triage ratings. Overall, the SATS had high specificity (97%) and moderate sensitivity (70%). Across all acuity levels the proportion of overtriage did not exceed the acceptable threshold of 30 - 50%. Under-triage was acceptable for all except emergency cases (66%).
Conclusion. ED nurses in Pakistan can reliably use the SATS to assign triage acuity ratings. While the tool is accurate for 'very urgent' and 'routine' cases, importantly, it may under-triage 'emergency' cases requiring immediate attention. Approaches that will improve accuracy and validity are discussed.
The management of breast cancer requires a multidisciplinary approach in its broadest sense. In keeping with this ethos, the May edition of CME contains articles written by surgeons, oncologists, epidemiologists, nurses, physiotherapists, occupational therapists and patient advocates.
Communicable diseases are the major cause of mortality in lower-income countries. Consequently, local and international resources are channelled mainly into addressing the impact of these conditions. HIV, however, is being successfully treated, people are living longer, and disease patterns are changing. As populations age, the incidence of cancer inevitably increases. The World Health Organization has predicted a dramatic increase in global cancer cases during the next 15 years, the majority of which will occur in low- and middle-income countries. Cancer treatment is expensive and complex and in the developing world 5% of global cancer funds are spent on 70% of cancer cases. This paper reviews the challenges of managing breast cancer in the developing world, using sub-Saharan Africa as a model.
We aimed to investigate the stage of breast cancer at first diagnosis and assess possible determinants of late-stage presentation. A consecutive series of women with newly diagnosed breast cancer at Chris Hani Baragwanath Academic Hospital (CHBAH), Soweto, South Africa were analysed. We retrospectively reviewed electronic patient records. Data were extracted for: (i) stage and year at diagnosis; (ii) travel distance (estimated straight-line distance from GPS-coded residential address to CHBAH); (iii) receptor subtypes; and (iv) age of patient. Generalised linear models were applied to estimate risk ratios for late- v. early-stage disease.
Of the patients (N=1 071) studied, the mean age was 55 years and 90% were black Africans. Patients who lived >20 km from the hospital (n=347; 61.8%) presented with late-stage disease (stage 3/4) compared with 50.2% who lived ≤20 km from the hospital (n=724; p=0.02). The majority of patients (74%) >70 years of age who lived >20 km away presented with advanced breast cancer. However, in younger patients, age showed no clear association with stage at presentation. Travel distance was an important predictor of later-stage disease at diagnosis, which was more noticeable in elderly patients. Patients with more aggressive triple-negative and HER2+ tumours presented with later-stage disease.
Systemic treatment for breast cancer is given as neoadjuvent therapy to reduce tumour bulk before surgery, and as adjuvant therapy after surgery to control micrometastatic disease, reduce tumour bulk and improve quality of life in metastatic disease. Systemic therapy is divided into endocrine therapy, chemotherapy and biological response modifier therapy. All therapies will cause a higher rate of anxiety and depression, and loss of libido, which for many is a major problem. In pre-menopausal patients fertility issues should be discussed as the agents used can cause a decrease in or, in some cases, loss of fertility.
Lymphoedema is a chronic debilitating condition characterised by an accumulation of protein-rich fluid in interstitial spaces due to insufficient functioning of the lymphatic system. The condition may be referred to as primary (congenital malformation) or secondary (damage to the lymphatic system) lymphoedema. Lymphoedema is currently incurable, but can be alleviated with appropriate treatment. However, if ignored, it can progress and become difficult to manage.
Breast cancer in developing nations is characterised by late diagnosis. The causes are multifactorial and many are addressed in other articles in this edition of CME. Breast cancer is also seen in younger women. The late-presentation trend is slowly changing in some areas, and an increasing number of women are presenting with early disease. These patients, if managed appropriately, have a more favourable prognosis. As a result, developing nations must now begin to consider the concerns of breast cancer survivorship. In developed countries, there are a number of organisations that support breast cancer survivors. In this article, we highlight some of the psychosocial aspects of living with breast cancer in low-resource areas.
Locally advanced breast cancer (LABC) comprises a heterogeneous group of diseases. It incorporates a subset of stage IIB (T3N0) disease, stage III disease and inflammatory breast cancer. In the developed world, 7% of breast cancer patients have stage III disease at diagnosis. In developing countries, LABC constitutes about 30 - 60% of all cases, most probably attributable to a lack of education and poor socioeconomic status. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute, USA demonstrates a median survival of 4.9 years, while the 5-year relative survival rate for this group of women is 55% with multimodality treatment, excluding biologics.
Caring for a patient with locally advanced breast cancer requires a multidisciplinary approach, whether cure or palliation. Patient expectations need to be discussed, while alternative and holistic approaches help to reinforce the patient's belief that their decision regarding care is correct. It is important to recognise that a patient's decision to choose 'no treatment' should be treated with respect. Psychological support and care are vital, requiring a non-judgemental relationship built on trust.
Breast and cervical cancer are leading causes of cancer-related mortality in South African women. Early detection of breast cancer is imperative to improve survival rates. However, public awareness is lacking and healthcare facilities for the diagnosis and treatment of the disease, particularly in the public sector, are inadequate. A cancer alliance, Advocates for Breast Cancer (ABC), was formed in 2014 to campaign for a national breast healthcare policy for South Africa to prioritise the management of this disease.