Social determinants of access to timely elective surgery in Ontario, Canada: a cross-sectional population level study.

BACKGROUND: Equitable access to surgical care has clinical and policy implications. We assess the association between social disadvantage and wait times for elective surgical procedures in Ontario. METHODS: We conducted a cross-sectional analysis using administrative data sets of adults receiving nonurgent inguinal hernia repair, cholecystectomy, hip arthroplasty, knee arthroplasty, arthroscopy, benign uterine surgery and cataract surgery from April 2013 to December 2019. We assessed the relation between exceeding target wait times and the highest versus lowest quintile of marginalization dimensions by use of generalized estimating equations logistic regression. RESULTS: Of the 1 385 673 procedures included, 174 633 (12.6%) exceeded the target wait time. Adjusted analysis for cataract surgery found significantly increased odds of exceeding wait times for residential instability (adjusted odd ratio [OR] 1.16, 95% confidence interval [CI] 1.11-1.21) and recent immigration (adjusted OR 1.12, 95% CI 1.07-1.18). The highest deprivation quintile was associated with 18% (adjusted OR 1.18, 95% CI 1.12-1.24) and 20% (adjusted OR 1.20, 95% CI 1.12-1.28) increased odds of exceeding wait times for knee and hip arthroplasty, respectively. Residence in areas where higher proportions of residents self-identify as being part of a visible minority group was independently associated with reduced odds of exceeding target wait times for hip arthroplasty (adjusted OR 0.82, 95% CI 0.75-0.91), cholecystectomy (adjusted OR 0.68, 95% CI 0.59-0.79) and hernia repair (adjusted OR 0.65, 95% CI 0.56-0.77) with an opposite effect in benign uterine surgery (adjusted OR 1.28, 95% CI 1.17-1.40). INTERPRETATION: Social disadvantage had a small and inconsistent impact on receiving care within wait time targets. Future research should consider these differences as they relate to resource distribution and the organization of clinical service delivery.

Epidemiology of Clostridioides difficile in South Africa.

BACKGROUND: Clostridioides difficile (CD) is the most common healthcare-associated enteric infection. There is currently limited epidemiological evidence on CD incidence in South Africa. AIM: To estimate the burden of CD infection (CDI) in the South African public sector between 1 July 2016 and 30 June 2017. METHODS: A retrospective cohort study utilizing secondary data was conducted to describe the epidemiology of CD in South Africa. We assessed the patient-level association between variables of interest, CD, and CD recurrence, by undertaking both univariate and multivariable analysis. Adjusted incidence rate ratios (aIRR) were calculated utilizing multivariable Poisson regression. The incidence of CD, CD recurrence and CD testing was estimated by Poisson regression for various levels of care and provinces. RESULTS: A total of 14 023 samples were tested for CD during the study period. After applying exclusion criteria, we were left with a sample of 10 053 of which 1 860 (18.50%) tested CD positive. A positive and significant association between CDI and level of care is found, with patients treated in specialized tuberculosis (TB) hospitals having a five-fold increased adjusted incidence risk ratio (aIRR) for CDI (aIRR 4.96 CI95% 4.08-6.04,) compared to those managed in primary care. Patients receiving care at a secondary, tertiary, or central hospital had 35%, 66% and 41% increased adjusted incidence of CDI compared to those managed in primary care, respectively. National incidence of CDI is estimated at 53.89 cases per 100 000 hospitalizations (CI95% 51.58-56.29), the incidence of recurrence at 21.39 (CI95% 15.06-29.48) cases per 1 000 cases and a recurrence rate of 2.14% (CI95% 1.51-2.94). CONCLUSION: Compared to European countries, we found a comparable incidence of CD. However, our estimates are lower than those for the United States. Compared to high-income countries, this study found a comparatively lower CD recurrence.

Is There a Relationship between Lead Exposure and Aggressive Behavior in Shooters?

Lead exposure has been associated with psycho-neurological disorders. Elevated blood lead levels have been found in shooters. This study assesses the association between the blood lead levels of shooters and their levels of aggression. An analytical cross-sectional study was conducted in Gauteng, South Africa. Participants were recruited from four randomly selected shooting ranges with three randomly selected archery ranges used as a comparison group. A total of 118 (87 shooters and 31 archers) participants were included in the analysis. Aggressiveness was measured using the Buss-Perry Aggression Questionnaire. Shooters had significantly higher blood lead levels (BLL) compared to archers with 79.8% of shooters versus 22.6% of archers found to have a BLL ≥ 5 μg/dL (p < 0.001). Aggression scores were significantly higher in shooters (p < 0.05) except for verbal aggression. In the bivariate and regression analyses, shooters with BLLs ≥ 10 μg/dL were significantly associated with the hostility sub-scale (p = 0.03, adjusted odds ratio (OR) 2.83, 95% confidence interval (CI) 1.103⁻7.261). Shooters have a significantly higher BLL and aggressiveness compared to archers. However, elevated blood lead levels were significantly associated with hostility only. Interventions need to be put in place to prevent continued exposure and routine screening of populations at risk should be implemented.

Nudging for Prevention in Occupational Health and Safety in South Africa Using Fiscal Policies.

Currently, in some countries occupational health and safety policy and practice have a bias toward secondary prevention and workers' compensation rather than primary prevention. Particularly, in emerging economies, research has not adequately contributed to effective interventions and improvements in workers' health. This article, using South Africa as a case study, describes a methodology for identifying candidate fiscal policy interventions and describes the policy interventions selected for occupational health and safety. It is argued that fiscal policies are well placed to deal with complex intersectoral health problems and to focus efforts on primary prevention. A major challenge is the lack of empirical evidence to support the effectiveness of fiscal policies in improving workers' health. A second challenge is the underprioritization of occupational health and safety partly due to the relatively small burden of disease attributed to occupational exposures. Both challenges can and should be overcome by (i) conducting policy-relevant research to fill the empirical gaps and (ii) reconceptualizing, both for policy and research purposes, the role of work as a determinant of population health. Fiscal policies to prevent exposure to hazards at work have face validity and are thus appealing, not as a replacement for other efforts to improve health, but as part of a comprehensive effort toward prevention.

Exposure to lead in South African shooting ranges.

INTRODUCTION: Lead exposure in shooting ranges has been under scrutiny for decades, but no information in this regard is available in respect of African settings, and in South Africa specifically. The aim of this study was to determine the blood lead levels in the users of randomly selected private shooting ranges in South Africa's Gauteng province. METHODS: An analytical cross sectional study was conducted, with participants recruited from four randomly selected shooting ranges and three archery ranges as a comparator group. RESULTS: A total of 118 (87 shooters and 31 archers) were included in the analysis. Shooters had significantly higher blood lead levels (BLL) compared to archers with 36/85 (42.4%) of shooters versus 2/34 (5.9%) of archers found to have a BLL ≥10µg/dl (p<0.001). CONCLUSION: Shooting ranges may constitute an import site of elevated exposure to lead. Improved ventilation, low levels of awareness of lead hazards, poor housekeeping, and inadequate personal hygiene facilities and practices at South African shooting ranges need urgent attention.

Systematic Review of Screening and Surveillance Programs to Protect Workers from Nanomaterials.

BACKGROUND: Screening and surveillance approaches for workers exposed to nanomaterials could aid in early detection of health effects, provide data for epidemiological studies and inform action to decrease exposure. The aim of this review is to identify such screening and surveillance approaches, in order to extract available data regarding (i) the studies that have successfully been implemented in present day, (ii) identification of the most common and/or toxic nano-related health hazards for workers and (iii) possible exposure surveillance markers. This review contributes to the current understanding of the risk associated with nanomaterials by determining the knowledge gap and making recommendations based on current findings. METHODS: A systematic review was conducted. PubMed and Embase were searched to identify articles reporting on any surveillance-related study that described both exposure to nanomaterials and the health indicators that were measured. Four reviewers worked in pairs to independently assess the eligibility of studies and risk of bias before extraction of data. Studies were categorised according to the type of study and the medical surveillance performed, which included the type of nanomaterial, any exposure details provided, as well as health indicators and biomarkers tested. RESULTS: Initially 92 studies were identified, from which 84 full texts were assessed for eligibility. Seven studies met all the inclusion criteria, i.e. those performed in Taiwan, Korea, Czech Republic and the US. Of these, six compared health indicators between exposed and unexposed workers and one study described a surveillance program. All studies were at a high risk of bias. Workers were exposed to a mix of nanomaterials in three studies, carbon-based nanomaterials in two studies, nano-silver in one study and nano-titanium oxide in the other study. Two studies did not find a difference in biomarkers between exposed and unexposed workers. In addition, differences in early effects on pulmonary function or neurobehavioral tests were not observed. One study found an increased prevalence of allergic dermatitis and "sneezing" in the exposed group. CONCLUSIONS: This review of recently published data on surveillance studies proves that there is a gap in the current knowledge, where most of the surveillance-related studies reported do not follow a set format that provides the required information on ENM characterisation, the type of exposure and the measured indicators/biomarkers. Hence, there is very low quality evidence that screening and surveillance might detect adverse health effects associated with workplace exposure. This systematic review is relevant because it proves that, although surveillance programs have been initiated and preliminary results are being published, the current studies are actually not answering the important questions or solving the overall problem regarding what the potential health hazards are among workers either handling or potentially exposed to ENMs. The recommendations, thus proposed, are based on an obvious need for (i) exposure registries, where longitudinal follow-up studies should inform surveillance, (ii) known exposure measurements or summary indices for ENMs as a reference (iii) validation of candidate biomarkers and (iv) studies that compare the effects of these surveillance approaches to usual care, e.g. those commonly followed for bulk-size hazardous materials.

Household Factors Associated with Self-Harm in Johannesburg, South African Urban-Poor Households.

INTRODUCTION: Low and middle income countries bear the majority burden of self-harm, yet there is a paucity of evidence detailing risk-factors for self-harm in these populations. This study aims to identify environmental, socio-economic and demographic household-level risk factors for self-harm in five impoverished urban communities in Johannesburg, South Africa. METHODS: Annual serial cross-sectional surveys were undertaken in five impoverished urban communities in Johannesburg for the Health, Environment and Development (HEAD) study. Logistic regression analysis using the HEAD study data (2006-2011) was conducted to identify household-level risk factors associated with self-harm (defined as a self-reported case of a fatal or non-fatal suicide attempt) within the household during the preceding year. Stepwise multivariate logistic regression analysis was employed to identify factors associated with self-harm. RESULTS: A total of 2 795 household interviews were conducted from 2006 to 2011. There was no significant trend in self-harm over time. Results from the final model showed that self-harm was significantly associated with households exposed to a violent crime during the past year (Adjusted Odds Ratio (AOR) 5.72; 95% CI 1.64-19.97); that have a member suffering from a chronic medical condition (AOR 8.95; 95% 2.39-33.56) and households exposed to indoor smoking (AOR 4.39; CI 95% 1.14-16.47). CONCLUSION: This study provides evidence on household risk factors of self-harm in settings of urban poverty and has highlighted the potential for a more cost-effective approach to identifying those at risk of self-harm based on household level factors.

Exploring corruption in the South African health sector.

Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption.

Nosocomial Outbreak of New Delhi Metallo-ß-Lactamase-1-Producing Gram-Negative Bacteria in South Africa: A Case-Control Study.

OBJECTIVE: New Delhi metallo-ß-lactamase (NDM)-producing Gram-negative bacteria have spread globally and pose a significant public health threat. There is a need to better define risk factors and outcomes of NDM-1 clinical infection. We assessed risk factors for nosocomial infection with NDM-1-producers and associated in-hospital mortality. METHODS: A matched case-control study was conducted during a nosocomial outbreak of NDM-1-producers in an adult intensive care unit (ICU) in South Africa. All patients from whom NDM-1-producers were identified were considered (n=105). Cases included patients admitted during the study period in whom NDM-1 producing Gram-negative bacteria were isolated from clinical specimens collected ≥48 hours after admission, and where surveillance definitions for healthcare-associated infections were met. Controls were matched for age, sex, date of hospital admission and intensive-care admission. Conditional logistic regression was used to identify risk factors for NDM-1 clinical infection and associated in-hospital mortality. FINDINGS: 38 cases and 68 controls were included. Klebsiella pneumoniae was the most common NDM-1-producer (28/38, 74%). Cases had longer mean hospital stays (44.0 vs. 13.3 days; P < 0.001) and ICU stays (32.5 vs. 8.3 days; P < 0.001). Adjusting for co-morbid disease, the in-hospital mortality of cases was significantly higher than controls (55.3% vs. 14.7%; AOR, 11.29; P < 0.001). Higher Charlson co-morbidity index score (5.2 vs. 4.1; AOR, 1.59; P = 0.005), mechanical ventilation days (7.47 vs. 0.94 days; AOR, 1.32; P = 0.003) and piperacillin/tazobactam exposure (11.03 vs. 1.05 doses; AOR, 1.08; P = 0.013) were identified as risk factors on multivariate analysis. Cases had a significantly higher likelihood of in-hospital mortality when the NDM-1-producer was Klebsiella pneumoniae (AOR, 16.57; P = 0.007), or when they had a bloodstream infection (AOR, 8.84; P = 0.041). CONCLUSION: NDM-1 infection is associated with significant in-hospital mortality. Risk factors for hospital-associated infection include the presence of co-morbid disease, mechanical ventilation and piperacillin/tazobactam exposure.

Nitrogen mineralization from sludge in an alkaline, saline coal gasification ash environment.

Rehabilitating coal gasification ash dumps by amendment with waste-activated sludge has been shown to improve the physical and chemical properties of ash and to facilitate the establishment of vegetation. However, mineralization of organic N from sludge in such an alkaline and saline medium and the effect that ash weathering has on the process are poorly understood and need to be ascertained to make decisions regarding the suitability of this rehabilitation option. This study investigated the rate and pattern of N mineralization from sludge in a coal gasification ash medium to determine the prevalent inorganic N form in the system and assess the effect of ash weathering on N mineralization. An incubation experiment was performed in which fresh ash, weathered ash, and soil were amended with the equivalent of 90 Mg ha sludge, and N mineralization was evaluated over 63 d. More N (24%) was mineralized in fresh ash than in weathered ash and soil, both of which mineralized 15% of the initial organic N in sludge. More nitrification occurred in soil, and most of the N mineralized in ash was in the form of ammonium, indicating an inhibition of nitrifying organisms in the ash medium and suggesting that, at least initially, plants used for rehabilitation of coal gasification ash dumps will take up N mostly as ammonium.

Recommendations to improve the National Development Plan for Health.

In November 2011, a draft National Development Plan (NDP) was released that addresses two of South Africa's major challenges: poverty and inequity. Health and economic development are interdependent, presenting an important opportunity through the NDP to integrate health within goals of broader socio-economic development. Reviewing the NDP identified gaps based on evidence and the epidemiological risk profile of South Africa. Recommendations to improve the NDP and to deal with poverty and inequity should focus on prevention and addressing the social determinants of health, including: (i) a multisectoral approach to establish a comprehensive early childhood development programme; (ii) fiscal and legislative policies to bolster efforts to reduce the burden of non-communicable diseases; (iii) promoting and maintaining a healthy workforce; (iv) and promoting a culture of evidence-based priority setting. Achieving the goal of 'a long and healthy life for all South Africans' will require healthy public policies, well functioning institutional and physical infrastructure, social solidarity, and an active and conscientious civil society.