South African Medical Journal - Volume 104, Issue 8, 2014
Volumes & issues
Volume 104, Issue 8, 2014
Source: South African Medical Journal 104, pp 556 –557 (2014) http://dx.doi.org/10.7196/SAMJ.8511More Less
Intimate partner violence (IPV) is a common and devastating feature of partnerships worldwide, and South Africa (SA) is no exception. In 2013, the publication of World Health Organization (WHO) clinical and policy guidelines for responding to IPV and sexual violence supported the growing acknowledgement that IPV should be viewed as an issue directly related to health, and outlined an appropriate response from policy makers and healthcare providers. IPV is important to health systems because of the wide-ranging and serious health effects experienced by exposed women, as well as the unique opportunity afforded to healthcare providers to enquire about violence. IPV and gender inequality are also features of the complex network of causes driving the HIV epidemic in sub-Saharan Africa. In SA, where there is an extremely high burden of interpersonal violence, gender-based violence and HIV, IPV should be treated as a priority health concern.
Professionalism is key in providing services to lesbian, gay, bisexual, transgender and intersex South Africans : editorialAuthor Alexandra MullerSource: South African Medical Journal 104, pp 558 –559 (2014) http://dx.doi.org/10.7196/SAMJ.8447More Less
I recently interviewed a young gay man who was hospitalised after he fractured both his arms while fleeing a group of men who threatened to beat him up for being gay. The nurse in the emergency ward to which he was admitted abruptly changed her caring attitude towards him when he explained why he was running away from his attackers. She asserted that he deserved the attack, berated him for his 'un-Christian' behaviour, and ridiculed him in front of other nurses. He has not attended any health facility since this experience. In another interview, a young lesbian woman described her attempt to get tested for HIV at a voluntary counselling and testing facility. Upon hearing that she had had sex only with women, the HIV counsellor told her that she did not qualify for an HIV test because she was not at risk, and told her to go home.
Time to reduce CD4+ monitoring for the management of antiretroviral therapy in HIV-infected individuals : editorialSource: South African Medical Journal 104, pp 559 –560 (2014) http://dx.doi.org/10.7196/SAMJ.8299More Less
The relative importance of laboratory monitoring in HIV/AIDS programmes in low- and middle-income countries has been the subject of considerable debate over the past decade. The recent changes in South Africa (SA)'s HIV treatment guidelines focus primarily on maintaining a low viral load (VL) (preferably undetectable VL: <40 copies/ml) to reduce the risk of transmission and drug resistance. Monitoring of HIV/AIDS and associated opportunistic infections represents a significant challenge to resource-limited countries, where the potential total cost of disease monitoring may exceed the annual health budget. Many obstacles are noted in the provision of affordable and accessible laboratory monitoring for HIV/AIDS, including limited laboratory infrastructure, absence of technical skills, high reagent costs and large capital outlay costs for sophisticated equipment.
Source: South African Medical Journal 104, pp 561 –562 (2014) http://dx.doi.org/10.7196/SAMJ.8287More Less
Morality in medicine was long dominated by paternalism: the belief that you could do almost anything to a patient as long as the principles of beneficence (best interests) and non-maleficence (no harm) were upheld. Kant and Mill reflected on autonomy and self-determination in philosophy, but it is only a century ago that the concept of informed consent, a strong expression of autonomy, was introduced into the law in the New York judgment quoted above.
National sentinel site surveillance for antimicrobial resistance in Klebsiella pneumoniae isolates in South Africa, 2010 - 2012 : researchAuthors: O. Perovic, A. Singh-Moodley, A. Duse, C. Bamford, K. Swe Swe-Han, R. Kularatne, W. Lowman, A. Whitelaw, T. Nana, J. Wadula, R. Lekalakala, A. Saif, M. Fortuin De-Smidt, O. Perovic, A. Singh-Moodley, A. Duse, R. Kularatne, W. Lowman, T. Nana, J. Wadula, C. Bamford, G. Elliott, K. Swe Swe-Han, W. Lowman, A. Whitelaw and R. LekalakalaSource: South African Medical Journal 104, pp 563 –568 (2014) http://dx.doi.org/10.7196/SAMJ.7617More Less
Background. The increasing rates of antimicrobial resistance observed in the nosocomial pathogen Klebsiella pneumoniae are of major public health concern worldwide.
Objectives. To describe the antibiotic susceptibility profiles of K. pneumoniae isolates from bacteraemic patients submitted by sentinel laboratories in five regions of South Africa from mid-2010 to mid-2012. Molecular methods were used to detect the most commonly found extended-spectrum beta-lactamase (ESBL) and carbapenemase resistance genes.
Methods. Thirteen academic centres serving the public healthcare sector in Gauteng, KwaZulu-Natal, Free State, Limpopo and Western Cape provinces submitted K. pneumoniae isolates from patients with bloodstream infections. Vitek 2 and MicroScan instruments were used for organism identification and susceptibility testing. Multiplex polymerase chain reactions (PCRs) were used to detect blaCTX-M, blaSHV and blaTEM genes in a proportion of the ESBL isolates. All isolates exhibiting reduced susceptibility to carbapenems were PCR tested for blaKPC and blaNDM-1 resistance genes.
Results. Overall, 68.3% of the 2 774 isolates were ESBL-positive, showing resistance to cefotaxime, ceftazidime and cefepime. Furthermore, 46.5% of all isolates were resistant to ciprofloxacin and 33.1% to piperacillin-tazobactam. The major ESBL genes were abundantly present in the sample analysed. Most isolates (95.5%) were susceptible to the carbapenems tested, and no isolates were positive for blaKPC or blaNDM-1. There was a trend towards a decrease in susceptibility to most antibiotics.
Conclusion. The high proportion of ESBL-producing K. pneumoniae isolates observed, and the prevalence of ESBL genes, are of great concern. Our findings represent a baseline for further surveillance in SA, and can be used for policy and treatment decisions.
A cross-sectional analytical study of geophagia practices and blood metal concentrations in pregnant women in Johannesburg, South Africa : researchSource: South African Medical Journal 104, pp 568 –573 (2014) http://dx.doi.org/10.7196/SAMJ.7466More Less
Background. Geophagia, a form of pica, has been shown to be widely practised in sub-Saharan Africa, especially among pregnant women.
Objective. To assess the prevalence of geophagia and examine exposure to selected metals and associated risk factors in women attending an antenatal clinic at Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa, during June and July 2010.
Methods. We conducted a cross-sectional study on a convenience sample of 307 pregnant women, ranging in age from 18 to 46 years. Structured interviews were conducted to understand geophagia practices. Blood samples were collected to determine haemoglobin values and concentrations of arsenic, cadmium, mercury and lead. Statistical analyses using the X2 test, Wilcoxon's rank-sum test and logistic regression analyses were performed as appropriate.
Results. Mean parity was 1.4 and the mean (standard deviation) gestational age 30.3 (6.0) weeks. Geophagia was reported by 60 women (19.5%), and the majority purchased soil from street vendors (83.3%). The prevalence of anaemia in the study sample was 16.9% (95% confidence interval 13.1 - 21.6%). Geophagic women had significantly higher blood lead levels than non-geophagic women (2.1 v. 1.4 µg/dl; p<0.001). Anaemia, the use of African traditional medicines and craving of non-nutritive substances in a previous pregnancy were associated with geophagia.
Conclusions. Geophagia is practised by a considerable proportion of pregnant women in Johannesburg, especially migrant women. Greater vigilance in respect of pica, especially geophagia, may be needed as part of antenatal care programmes to avoid potentially detrimental health effects of the practice.
Loss of detectability and indeterminate results : challenges facing HIV infant diagnosis in South Africa's expanding ART programme : researchSource: South African Medical Journal 104, pp 574 –577 (2014) http://dx.doi.org/10.7196/SAMJ.8322More Less
Background. Early infant diagnosis with rapid access to treatment has been found to reduce HIV-associated infant mortality and morbidity considerably. In line with international standards, current South African guidelines advocate routine HIV-1 polymerase chain reaction (PCR) testing at 6 weeks of age for all HIV-exposed infants and 'fast-track' entry into the HIV treatment programme for those who test positive. Importantly, testing occurs within the context of increasing efforts at prevention of mother-to-child transmission (PMTCT) by means of maternal and infant antiretroviral therapy (ART). In addition, infants already initiated on combination ART (cART) may be retested with PCR assays for 'confirmatory' purposes, including assessment prior to adoption. The potential for cART to compromise the sensitivity of HIV-1 PCR assays has been described, although there are limited and conflicting data regarding the effect of PMTCT regimens on HIV-1 PCR diagnostic sensitivity.
Methods. We describe a case series of three infants with different ART exposures in whom HIV diagnosis, confirmation or the result of retesting for adoption purposes were uncertain.
Results. These cases demonstrate that ART can be associated with a loss of detectability of HIV, leading to 'false-negative' HIV-1 PCR results in infants on cART. Furthermore, current PMTCT practices may lead to repeatedly indeterminate results with a subsequent delay in initiation of cART.
Conclusion. The sensitivity of HIV-1 PCR assays needs to be re-evaluated within the context of different ART exposures, and diagnostic algorithms should be reviewed accordingly.
Climate change : one of the greatest threats to public health in the 21st century : CME - guest editorialSource: South African Medical Journal 104 (2014) http://dx.doi.org/10.7196/SAMJ.8606More Less
The impact of climate change on human health and well-being has already been observed. Direct effects such as those related to heat, cold, floods, storms and solar ultraviolet radiation have been documented. Some vector-, food- and water-borne diseases and other infectious diseases influenced by ecosystems are likely to increase in incidence. Respiratory health is affected by near-surface ozone exposures, episodes of acute air pollution, and aero-allergens. Indirect health impacts also exist. For example, changes in agricultural production, and loss of crop yield and the nutritional value of food have detrimental effects on nutrition. Increasing ambient temperatures can lead to loss of work capacity and occupational health concerns. The impact on mental health, mass migration, conflict and violence associated with changes in climate should not be underestimated.
Source: South African Medical Journal 104, pp 579 –582 (2014) http://dx.doi.org/10.7196/SAMJ.8603More Less
Climate change is projected to lead to warmer temperatures, especially in southern Africa, where the warming is predicted to be 2°C higher than the global increase. Given the high burden of disease already associated with environmental factors in this region, this temperature increase may lead to grave challenges for human health and quality of life. HIV/AIDS, poverty, food and water insecurity together with inequality and unemployment will further complicate the manner in which we will need to address the challenges of a changing climate. The health impacts are direct, such as increased temperatures leading to heat exhaustion, and indirect, such as likely increases in infectious diseases from contaminated water and changes in the distribution and/or magnitude of vector-borne diseases. The most effective measures for adapting to climate change to ensure healthy populations are to implement basic public health systems and services. These range from a continuous supply of clean water to adequate primary healthcare services. Support for required interventions is required not only from government, but also from healthcare professionals and communities. The need for disease surveillance, data capturing and more focused research is paramount.
The HIV/AIDS epidemic in South Africa : convergence with tuberculosis, socio-ecological vulnerability, and climate change patterns : CME - articleSource: South African Medical Journal 104, pp 583 –586 (2014) http://dx.doi.org/10.7196/SAMJ.8645More Less
Recent assessment reports suggest that climate change patterns are threatening social and ecological vulnerability and resilience, with the strong potential of negatively affecting human health. Persons living with HIV/AIDS (PLWHA) have weakened physiological responses and are immunologically vulnerable to pathogens and stressors in their environment, putting them at a health disadvantage in climate-based rising temperatures, water scarcity, air pollution, potential water- and vector-borne disease outbreaks, and habitat redistributions. These climatic aberrations may lead to increased surface drying and decreased availability of arable land, threatening food/nutrition security and sanitary water practices. Coupled with HIV/AIDS, climate change threatens ecological biodiversity via a larger-scale socioeconomic recourse to natural resources. Corresponding human and environmental activity shape conditions conducive to exacerbating high rates of HIV/AIDS. In South Africa, this epidemic is forming a 'syndemic' with tuberculosis (TB), which has come to include multidrug-resistant TB (MDR-TB) and extremely drug-resistant TB (XDR-TB) strains. Because of high convergence rates, one epidemic cannot be addressed without understanding the other. Concurrent climate change mitigation and adaptation strategies are becoming increasingly important to curb changes that negatively affect the biospheres on which civilisation is ultimately dependent - from an agricultural, a developmental, and especially a health standpoint. Mitigation strategies such as reducing carbon emissions are essential, but may be only partially effective in slowing the rate of surface warming. However, global climate assessments assert that these are not sufficient to halt climate change patterns. The roles of regionally specific climate research, socio-ecologically sustainable industrialisation paths for developing countries, and adoption of health system strengthening strategies are therefore vital.
Source: South African Medical Journal 104, pp 587 –588 (2014) http://dx.doi.org/10.7196/SAMJ.8605More Less
The South African government has taken several steps in response to climate change and its associated threats to human health. The National Climate Change Response Plan White Paper defines government's vision for effective climate change response and transitioning to a climate-resilient, low-carbon economy. The White Paper identifies potential health challenges for South Africa (SA), including vector- and water-borne diseases and heat stress. The National Climate Change and Health Adaptation Plan (the Plan), prepared by the National Department of Health, expands on these health challenges, raising not only additional ones, but also related socioeconomic risk factors, such as housing and settlements. Community participation was adopted as one of the guiding principles for implementing the Plan, especially as behavioural change is likely to be important for adaptation and coping strategies. Multisectorial co-operation is also imperative, as many of the climate-related health risks involve multiple multidisciplinary stakeholders to implement appropriate interventions. Addressing inequalities and poverty in SA is critical to ensure that the health impacts from climate change are mitigated, particularly as current evidence suggests that the largest health risks are possibly among communities already most impacted by climate-related diseases. More research is needed to determine the impact of climate on health and which communities are the most vulnerable. Tailored monitoring and evaluation systems, linked with climate surveillance, will provide an opportunity to collect health data on key health risks to inform decision-making.
Socially, politically and economically mediated health effects of climate change : possible consequences for Africa : CME - articleSource: South African Medical Journal 104, pp 589 –591 (2014) http://dx.doi.org/10.7196/SAMJ.8604More Less
In Africa, as elsewhere in the world, climate change looms as a profound health challenge in this century. Socially, politically and economically mediated ('tertiary') effects will probably be the most significant consequences of climate change, substantially exceeding the probable burden of its direct effects and infectious diseases. Climate change will decrease crop yields in many low-latitude areas, decreasing food security in many countries, including those in Africa. Under-nutrition will worsen, aggravated by diminished economic growth - one of the most widely predicted consequences of climate change. Furthermore, migration will increase, which will stretch and could even overwhelm health systems in destination areas, in addition to sapping donor locations of the financial and human capital they could use for further development. Mass migration heightens the risk of conflict, as does resource scarcity caused by climate change. Consequently, the capacity of states to meet the expectations of their citizens and impose law and order could further decrease, incentivising unscrupulous leaders to initiate or sustain conflict to enhance their support base. In summary, health systems on the African continent will be severely challenged by the increased demands caused by climate change, while their capacity will be diminished by its direct effects, reduced economic growth, additional migration and conflict. Adaptation is frequently treated as the best climate change response, but it is especially difficult in poorer countries, where even general development is threatened by these challenges. Reliance on adaptation would exacerbate the health gap. Global climate change mitigation is the surest way to preserve health, in Africa and elsewhere.
Source: South African Medical Journal 104, pp 592 –596 (2014) http://dx.doi.org/10.7196/SAMJ.8646More Less
A number of aspects of human health are caused by, or associated with, local climate conditions, such as heat and cold, rainfall, wind and cloudiness. Any of these aspects of health can also be affected by climate change, and the predicted higher temperatures, changes in rainfall, and more frequent extreme weather conditions will create increased health risks in many workplaces. Important occupational health risks include heat stress effects, injuries due to extreme weather, increased chemical exposures, vector-borne diseases and under-nutrition. In South Africa (SA), and many other parts of the world experiencing a hot season each year, the effects of heat stress may be of greatest relevance to the large working populations in mining, agriculture, construction, quarries and outdoor services. Factory and workshop heat will also become an increasing problem in the numerous workplaces without effective cooling systems. SA was the location for some of the most detailed research on heat effects at work in mines in the 1950s and 1960s, and the future will bring new challenges not only for mines, but also for many other workplaces. The climate model trends for this century indicate that the heat exposure may increase by 2 - 4°C during the hottest months, and this would change the occupational heat situation from 'low risk' to 'moderate or high risk' in much of SA.