An isolated outbreak of diphtheria in South Africa, 2015.

An outbreak of respiratory diphtheria occurred in two health districts in the province of KwaZulu-Natal in South Africa in 2015. A multidisciplinary outbreak response team was involved in the investigation and management of the outbreak. Fifteen cases of diphtheria were identified, with ages ranging from 4 to 41 years. Of the 12 cases that were under the age of 18 years, 9 (75%) were not fully immunized for diphtheria. The case fatality was 27%. Ninety-three household contacts, 981 school or work contacts and 595 healthcare worker contacts were identified and given prophylaxis against Corynebacterium diphtheriae infection. A targeted vaccination campaign for children aged 6-15 years was carried out at schools in the two districts. The outbreak highlighted the need to improve diphtheria vaccination coverage in the province and to investigate the feasibility of offering diphtheria vaccines to healthcare workers.

The Australian Master of Applied Epidemiology Program: Looking back, moving forward.

The Master of Applied Epidemiology Program is Australia's Field Epidemiology Training Program. It was established in 1991 and was run out of the National Centre for Population Health (NCEPH) at the Australian National University. The Program has a strong track record in using field-based training to produce competent applied epidemiologists who have contributed to public health in Australia and globally. A new funding model for the program was implemented in 2012, backed by funds from field placement partners and NCEPH. In this paper we review the program's origins and achievements, discuss the ongoing needs of the program and outline a vision for the future. Commun Dis Intell 2016;40(3):E326-E333.

Intra-orbital knife blade foreign body: a case series.

OBJECTIVE: To describe cases of intra-orbital knife blade foreign body following stabs to the orbit, together with a novel technique for removal. METHODS: Retrospective case series of 3 patients. RESULTS: All 3 patients had knife blades embedded in the orbit as a result of assault. The blades assumed the same direction within the orbit with varying degrees of depth, one causing serious vascular injury. In 2 cases the globes were intact after foreign body removal, with good visual outcomes. The third patient required enucleation. Two of the 3 knife blades were removed using a 'double bone nibbler' technique. The third was embedded without a handle and required removal with minor manipulation of the globe. CONCLUSIONS: Thorough investigation for vascular injury must be done before any attempted surgical removal. Visual outcomes can be good after removal of a knife blade foreign body. The double bone nibbler technique is promising for the controlled removal of embedded blades that are rigidly fixed.

TB testing in HIV-positive patients prior to antiretroviral treatment.

BACKGROUND: TB diagnosis in patients with HIV is challenging due to the lower sensitivities across tests. Molecular tests are preferred and the Xpert® MTB/RIF assay has limitations in lower-income settings. We evaluated the performance of loop-mediated isothermal amplification (LAMP) and the lipoarabinomannan (LAM) test in HIV-positive, ART-naïve clinic patients.METHODS: A total of 783 eligible patients were enrolled; three spot sputum samples of 646 patients were tested using TB-LAMP, Xpert, smear microscopy and culture, while 649 patients had TB-LAM testing. Sensitivity, specificity, and negative and positive predictive values were estimated with 95% confidence intervals.RESULTS: Sensitivities for smear microscopy, TB-LAMP and Xpert were respectively 50%, 63% and 74% compared to culture, with specificities of respectively 99.2%, 98.5% and 97.5%. An additional eight were positive on TB-LAM alone. Seventy TB patients (9%) were detected using standard-of-care testing, an additional 27 (3%) were detected using study testing. Treatment was initiated in 57/70 (81%) clinic patients, but only in 56% (57/97) of all those with positive TB tests; 4/8 multidrug-resistant samples were detected using Xpert.CONCLUSION: TB diagnostics continue to miss cases in this high-burden setting. TB-LAMP was more sensitive than smear microscopy, and if followed by culture and drug susceptibility testing as required, can diagnose TB in HIV-positive patients. TB-LAM is a useful add-in test and both tests at the point-of-care would maximise yield.

Antimicrobial prescribing in the surgical and medical wards at a private hospital in KwaZulu-Natal, South Africa, 2019.

BACKGROUND: Appropriate antimicrobial use is imperative owing to the misuse of antimicrobials, which has resulted in a growing burden of antimicrobial resistance. Evidence-based guidelines should be adhered to in order to ensure the sustainability of effective antimicrobials. OBJECTIVES: To assess the appropriateness of antimicrobial prescribing at a private hospital in Durban, KwaZulu-Natal, South Africa. METHODS: The records of patients admitted to the surgical and medical wards over a 2-month period were reviewed to assess the choice, dose and duration of prescribed antimicrobials. The guidelines used to determine the appropriateness of the prescriptions were: the Standard Treatment Guidelines and Essential Medicines List for South Africa - Hospital Level Adults, 2015 edition, the antimicrobial indications and prescribing instructions in the South African Medicines Formulary, the South African Antibiotic Stewardship Programme guidelines and the evidence-based surgical prophylaxis guidelines adopted by the hospital group where the research was conducted. RESULTS: During the study period, 466 patients were admitted and prescribed an antimicrobial, of whom 220 (47.2%) were admitted to the surgical ward and 246 (52.8%) to the medical wards. A total of 779 antimicrobials were prescribed. Of the 660 antimicrobials prescribed for empirical treatment, 305 (46.2%) were appropriately prescribed based on drug choice, dose and duration. Of the 38 antimicrobials that were classified as targeted, 36 (94.7%) were prescribed at the correct dose and 33 (86.8%) for the correct duration. Of the 81 antimicrobials prescribed for surgical prophylaxis, only 32 (39.5%) met the criteria for appropriateness in terms of drug choice, dose and duration. CONCLUSIONS: Our findings suggest that compliance with evidence-based guidelines for the use of antimicrobials is not optimal in hospitals in the private sector. Antimicrobials are prescribed inappropriately for empirical treatment and for surgical prophylaxis. Private hospital groups should consider adopting antimicrobial prescribing guidelines that are mandatory for doctors to adhere to in order to promote rational antimicrobial prescribing, and thereby reduce the burden of antimicrobial resistance.

COVID-19: The role of artificial intelligence in empowering the healthcare sector and enhancing social distancing measures during a pandemic.

Indiscriminatory in its spread, COVID-19 has engulfed communities from all social backgrounds throughout the world. While healthcare professionals work tirelessly testing for the virus and caring for patients, they too have become casualties of the pandemic. Currently the best way to attempt to curb the spread of the virus, echoed by almost all nation leaders, is to distance ourselves from one another socially or physically. However ideal this may seem, social distancing is not always practical in densely populated lower-income countries with many citizens below the breadline. With the majority of South Africans living in poverty, communities in overcrowded households are unable to distance themselves from one another appropriately. In addition, as a nation we struggle with high HIV and tuberculosis rates, malnutrition and an already overburdened healthcare system, emphasising the extreme vulnerability of our people. These factors, coupled with the fact that many of our healthcare professionals lack the necessary personal protective equipment to prevent them from contracting the virus themselves, highlight the gravity of the damaging repercussions that we may face in the coming months, after the complete national lockdown in force at the time of writing is lifted and we move towards a partial lockdown state. Nationally, there needs to be a shift in mindset towards exploring alternative technology-based preventive measures that may empower the healthcare sector in the long term and enhance social distancing.

Privacy rights of human research participants in South Africa must be taken seriously.

Letter by Thaldar and Townsend, following an article by the same authors (Thaldar D, Townsend B. Genomic research and privacy: A response to Staunton et al. S Afr Med J 2020;110(3):172-174. https://doi.org/10.7196/SAMJ.2020.v110i3.14431) and both commenting on an article by Staunton et al. (Staunton C, Adams R, Botes M, et al. Safeguarding the future of genomic research in South Africa: Broad consent and the Protection of Personal Information Act No. 4 of 2013. S Afr Med J 2019;109(7):468-470. https://doi.org/10.7196/SAMJ.2019.v109i7.14148); and response to article and letter by Staunton et al.

Strengthening field-based training in low and middle-income countries to build public health capacity: Lessons from Australia's Master of Applied Epidemiology program.

BACKGROUND: The International Health Regulations (2005) and the emergence and global spread of infectious diseases have triggered a re-assessment of how rich countries should support capacity development for communicable disease control in low and medium income countries (LMIC). In LMIC, three types of public health training have been tried: the university-based model; streamed training for specialised workers; and field-based programs. The first has low rates of production and teaching may not always be based on the needs and priorities of the host country. The second model is efficient, but does not accord the workers sufficient status to enable them to impact on policy. The third has the most potential as a capacity development measure for LMIC, but in practice faces challenges which may limit its ability to promote capacity development. DISCUSSION: We describe Australia's first Master of Applied Epidemiology (MAE) model (established in 1991), which uses field-based training to strengthen the control of communicable diseases. A central attribute of this model is the way it partners and complements health department initiatives to enhance workforce skills, health system performance and the evidence-base for policies, programs and practice. SUMMARY: The MAE experience throws light on ways Australia could collaborate in regional capacity development initiatives. Key needs are a shared vision for a regional approach to integrate training with initiatives that strengthen service and research, and the pooling of human, financial and technical resources. We focus on communicable diseases, but our findings and recommendations are generalisable to other areas of public health.

Global injustice in sport: The Caster Semenya ordeal - prejudice, discrimination and racial bias.

The International Association of Athletics Federations (IAAF) requires the blood testosterone level of female athletes with differences of sex development to be reduced to below 5 nmol/L for a continuous period of at least 6 months, and thereafter to be maintained to below 5 nmol/L continuously for as long as the athlete wishes to remain eligible. Its ruling is based on questionable research findings. Medical decisions and interventions should be based on evidence from well-designed and well-conducted research and confirmatory studies. Caster Semenya, the reigning 800-meter Olympic champion since 2015, has challenged this ruling. Gender verification was instituted with women's participation in the Olympics in 1900, and female athletes were subjected to invasive, embarrassing and humiliating procedures. In its many decades of harsh scrutiny of successful female athletes, especially those from backgrounds similar to Semenya's, the IAAF has disrespected human rights and medical ethics and allowed prejudice, discrimination and injustice to infringe on their dignity and relentlessly obstruct their international sporting careers.

Protecting participants in health research: The South African Material Transfer Agreement.

The need to transfer human biological materials (HBMs) across national boundaries has become increasingly important in view of increased biobank and commercial activities globally. In light of South Africa (SA)'s history of colonisation and racial discrimination, coupled with well-known instances of exploitation of research participants in the developing world, it is critical that the management of HBMs from and to other jurisdictions is explored and regulated. Material transfer agreements (MTAs) represent an important point of departure in such a process. This article explores the need for a uniform MTA in SA and discusses some aspects of the recently gazetted national MTA, which provides a framework that can serve as a safeguard for cross-border transfer of HBMs in the absence of the National Health Act's chapter 8 regulations in this regard.

Safeguarding the future of genomic research in South Africa: Broad consent and the Protection of Personal Information Act No. 4 of 2013.

Genomic research has been identified in South Africa (SA) as important in developing a strong bio-economy that has the potential to improve human health, drive job creation and offer potential solutions to the disease burden harboured by low- and middle-income countries. Central to the success of genomic research is the wide sharing of biological samples and data, but the true value of data can only be unlocked if there are laws and policies in place that foster the legal and ethical sharing of genomic data. The introduction and entry into force of SA's Protection of Personal Information Act (POPIA) No. 4 of 2013 is to be welcomed, but the wording of POPIA as it pertains to consent for the processing of personal information for research purposes has sparked a debate about the legal status of broad consent. We argue that a purposive interpretation of the legislation would permit broad consent for the processing of personal information for research. Although there are ongoing debates surrounding the ethical use of broad consent in Africa, the objective of this article is not to engage with the ethics of broad consent itself, but rather to focus on the legal status of broad consent for genomic data sharing under POPIA.

Age-specific risk factors for sporadic Campylobacter infection in regional Australia.

In a case-control study in the Hunter region of New South Wales, Australia, 354 cases and 593 controls were recruited to investigate meat, other food, and environmental exposures as potential risk factors for domestically acquired Campylobacter illness. In a multivariable model, illness was significantly associated with household exposure to diarrheal illness, consumption of restaurant chicken or beef, eating two or more "fast" food meals in a week, and overseas travel. Comparing exposures for the 0- to 4-year and 5-year and older age groups allowed detection of additional risk factors. Eating restaurant-prepared red meat and swimming were significantly associated with Campylobacter illness in the older group only. These findings demonstrate age-specific differences in risk factors for campylobacteriosis.

The National Education, Health and Allied Workers' Union (NEHAWU) strikes: South Africa's healthcare battlefield.

The right to strike is a fundamental right entrenched in section 23 of the Bill of Rights. Strikes are an almost everyday occurrence in South Africa and strikes in healthcare facilities raise difficult and complex moral and ethical questions. The right to strike is conditionally limited by section 36 of the Constitution and for workers engaging in essential services it is further limited under section 65 of the Labour Relations Act. Healthcare practitioners, including emergency care personnel, and much-needed healthcare facilities have come under attack during the National Education, Health and Allied Workers' Union (NEHAWU) strikes, which have prevented patients from accessing healthcare and threatened the training of undergraduate students and registrars. While generally security and policing have been lacking at targeted facilities, many doctors stood by their patients despite threats to their safety. Healthcare facilities, vehicles and practitioners must be protected. Solutions must come from politicians and include preventive actions and enforcement of the law.

Cost of intensive care services at a central hospital in South Africa.

BACKGROUND: Intensive care services are one of the largest cost drivers in a hospital. Increasing life expectancy and comorbidities have resulted in an increased need for intensive care beds. OBJECTIVES: To conduct a cost analysis of intensive care services at a central hospital in the public sector in South Africa (SA). METHODS: A retrospective cost analysis for the 2015/16 financial year was conducted across two intensive care units (ICUs), a trauma ICU (10 beds) and a combined ICU for neurosurgery, medicine and surgery (18 beds). A mixed-methods costing approach was used based on the availability of data. The bottom-up approach was used to calculate the cost of clinical support, pharmaceuticals, consumables and human resources. The top-down approach was used to allocate the cost of equipment and goods and services. RESULTS: There were 544 admissions resulting in 4 987 inpatient days during the study period. The total estimated inpatient cost across the two ICUs was ZAR114 055 104, with a cost per patient day of ZAR22 870. The combined ICU cost per patient day was 58% higher than the cost per patient day in the trauma ICU (ZAR26 954 v. ZAR17 021). The mean cost per admission was ZAR157 883 in the trauma ICU and ZAR245 087 in the combined ICU. Human resources costs were the highest ICU cost driver (55%), followed by direct patient activity costs (medical consumables, pharmaceuticals, laboratory tests, radiology and blood products), which contributed 24%. CONCLUSIONS: This is the first reported cost analysis of intensive care services in SA. Our cost per patient day was higher than that reported in other lower-income countries, but lower than that in high-income countries. These costs vary owing to the different types of ICUs, wide spectrum of disease presentation and availability of diagnostic and treatment options. This study provides useful data that could assist in the planning and provision of intensive care services.

A comparison of private and public sector intensive care unit infrastructure in South Africa.

BACKGROUND: Intensive care units (ICUs) are designed to care for patients who are often at increased risk of acquiring healthcare-associated infections. The structure of ICUs should be optimally designed to facilitate the care of these critically ill patients, and minimise their risk of infection. National regulations (R158) were developed to govern the building and registration of private hospitals, and until recently equivalent regulations were not available for public hospitals. OBJECTIVE: To assess and compare the compliance of ICUs in the private and public sectors with the R158 regulations. METHODS: A cross-sectional study design was used to assess the infrastructure of 25 private sector and 6 public sector ICUs in eThekwini Health District, KwaZulu-Natal Province, South Africa. We used the R158 checklist, which was developed by the KwaZulu-Natal Department of Health Private Licensing Unit and Infection Prevention and Control Unit. The aspects covered in the R158 checklist were categorised into the design, general safety and patient services of the ICUs. RESULTS: Most of the ICUs in both sectors met the general safety requirements. There were varying levels of compliance with the design criteria. Only 7 (28.0%) and 1 (16.7%) of the private and public ICUs, respectively, had sufficient space around the beds. Twenty-two private ICUs (88.0%) and 4 public ICUs (66.7%) had isolation rooms, but only some of these isolation rooms (15 private and 2 public) had appropriate mechanical ventilation. None of the ICUs had clinical hand-wash basins in the nurse stations and dirty utility rooms. The majority of the ICUs had the required number of oxygen and electric outlets at the bedside. None of the public ICUs met the light intensity requirement over the bed area. CONCLUSIONS: Adequate spacing in ICUs is an issue in many cases. Interventions need to be put in place to ensure that ICUs meet the relevant design standards. There is an urgent need to revise the R158 regulations to reflect current best practices, particularly with regard to infection control. The same standards should be applied to ICUs in the private and public health sectors to maintain quality of care to patients.

Ownership and human tissue - the legal conundrum: A response to Jordaan's critique.

The debate over whether there should be a property or non-property approach with regard to human tissue is only the tip of the iceberg, because the issues involved are very complex, reflecting profound considerations on the nature of the self and the structuring of society; the balance of power between the citizen, the government and commercial interests; and human beings' perceptions of themselves and their bodies. This article responds to a publication by Donrich Jordaan titled 'Social justice and research using human biological material: A response to Mahomed, Nöthling-Slabbert and Pepper' in the July 2016 SAMJ. The original article to which Jordaan's critique refers and that provides the source for his response appeared in the South African Journal of Bioethics and Law in 2013, titled 'The legal position on the classification of human tissue in South Africa: Can tissues be owned?'. It is our contention that Jordaan's critique is based on a misinterpretation of the issues raised relating to the ownership of human tissue, an issue extensively debated in the academic sphere for many years. Jordaan's critique focuses on selected aspects of the original article and draws unjustifiable inferences from these. The purpose of this article is to contextualise Jordaan's critique and reaffirm the validity of the arguments made in the original article in 2013. There are, however, certain aspects of Jordaan's critique that we as authors of the original article acknowledge and appreciate in the spirit of academic discourse.

Detecting Mycobacterium tuberculosis using the loop-mediated isothermal amplification test in South Africa.

SETTING: In South Africa, KwaZulu-Natal is the epicentre of the human immunodeficiency virus (HIV) epidemic, where approximately 70% of people with tuberculosis (TB) are co-infected with HIV. Undiagnosed TB contributes to high mortality in HIV-infected patients. Delays in diagnosing TB and treatment initiation result in prolonged transmission and increased infectiousness. OBJECTIVE: To evaluate the LoopampTM MTBC Detection kit (TB-LAMP; based on the loop-mediated isothermal amplification assay), smear microscopy and Xpert test with the gold standard of mycobacterial culture. METHODS: Sputum samples were collected from 705 patients with symptoms of pulmonary TB attending a primary health care clinic. RESULTS: The TB-LAMP assay had significantly higher sensitivity than smear microscopy (72.6% vs. 45.4%, P < 0.001), whereas specificity was slightly lower (99% vs. 96.8%, P = 0.05), but significantly higher than Xpert (92.9%, P = 0.004). There was no significant difference in sensitivity of smear-positive, culture-positive and smear-negative, culture-positive sputum samples using TB-LAMP vs. Xpert (respectively 95.9%/55.9% vs. 97.6%/66.1%; P =0.65, P = 0.27). The positive predictive value of TB-LAMP was significantly higher than that of Xpert (87.5% vs. 77.0%; P = 0.02), but similar to that of smear microscopy (94.2%; P = 0.18). The negative predictive value was respectively 91.9%, 92.5% (P = 0.73) and 83.1% (P = 0.0001). CONCLUSION: Given its ease of operability, the TB-LAMP assay could be implemented as a point-of-care test in primary health care settings, and contribute to reducing treatment waiting times and TB prevalence.

Low-level fluoroquinolone resistance among Campylobacter jejuni isolates in Australia.

BACKGROUND: Ciprofloxacin-resistant Campylobacter jejuni isolates obtained from infected patients in Australia have not been detected in studies of isolates from specific geographic areas. The Australian government has prohibited the use of fluoroquinolone in food-producing animals. To assess the impact of this policy, we have examined the antimicrobial susceptibility of isolates from 5 Australian states. METHODS: We conducted a period-prevalence survey of the susceptibility of C. jejuni isolates to 10 antimicrobial agents. C. jejuni isolates obtained from 585 patients from 5 Australian states (Queensland, South Australia, Tasmania, Victoria, and Western Australia) were identified by means of notifiable disease databases and were systematically selected from September 2001 to August 2002. RESULTS: Among locally acquired infections, only 2% of isolates (range, 0%-8% in different states) were resistant to ciprofloxacin. The locally acquired isolates also exhibited resistance to sulfisoxazole (55%), ampicillin (46%), roxithromycin (38%), tetracycline (7%), nalidixic acid (6%), chloramphenicol (3%), erythromycin (3%), gentamicin (2%), and kanamycin (0.2%). Treatment with antimicrobial agents in the 4 weeks before onset was not associated with ciprofloxacin resistance. CONCLUSIONS: The very low level of ciprofloxacin resistance in C. jejuni isolates likely reflects the success of Australia's policy of restricting use of fluoroquinolones in food-producing animals.