Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420170006&lang=en vol. 107 num. 6 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Surplus people</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600001&lng=en&nrm=iso&tlng=en <![CDATA[<b>The World Health Organization excludes <i>Mycobacterium tuberculosis </i>from the 2017 priority pathogens list</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Bridging non-communicable disease burden research to clinical care: A rising tide or a tidal wave?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600003&lng=en&nrm=iso&tlng=en <![CDATA[<b>30 days in medicine</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Cecil John Tainton Craig (4 September 1927 -2 August 2016)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600005&lng=en&nrm=iso&tlng=en <![CDATA[<b>South Africa's vital statistics are currently not suitable for monitoring progress towards injury and violence Sustainable Development Goals</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600006&lng=en&nrm=iso&tlng=en <![CDATA[<b>Exploitation of the vulnerable in research: Responses to lessons learnt in history</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600007&lng=en&nrm=iso&tlng=en The Nuremberg Trials raised insightful issues on how and why doctors who were trained in the Hippocratic tradition were able to commit such egregious and heinous medical crimes. The vulnerable were considered to be subhuman, of decreased intelligence, of no moral status and lacking human dignity. The reputation of the medical profession had been undermined, professionalism questioned and the doctor-patient relationship damaged as a result of the Nazi medical experiments. The World Medical Association's Declaration of Helsinki has been hailed as one of the most successful efforts in rescuing medical research from the darkness of the scandals and tragedies in health research. The first Research Ethics Committee in South Africa was established in 1966 at the University of the Witwatersrand. From the mid-1970s other institutions followed suit. The promulgation of the National Health Act No. 61 of 2003, in 2004, resulted in strong protectionism for research participants in the country. <![CDATA[<b>When students become patients: TB disease among medical undergraduates in Cape Town, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600008&lng=en&nrm=iso&tlng=en BACKGROUND. Medical students acquire latent tuberculosis (TB) infection at a rate of 23 cases/100 person-years. The frequency and impact of occupational TB disease in this population are unknown. METHODS. A self-administered questionnaire was distributed via email and social media to current medical students and recently graduated doctors (2010 - 2015) at two medical schools in Cape Town. Individuals who had developed TB disease as undergraduate students were eligible to participate. Quantitative and qualitative data collected from the questionnaire and semi-structured interviews were analysed with descriptive statistics and a framework approach to identify emerging themes. RESULTS. Twelve individuals (10 female) reported a diagnosis of TB: pulmonary TB (n=6), pleural TB (n=3), TB lymphadenitis (n=2) and TB spine (n=1); 2/12 (17%) had drug-resistant disease (DR-TB). Mean diagnostic delay post consultation was 8.1 weeks, with only 42% of initial diagnoses being correct. Most consulted private healthcare providers (general practitioners (n=7); pulmonologists (n=4)), and nine underwent invasive procedures (bronchoscopy, pleural fluid aspiration and tissue biopsy). Substantial healthcare costs were incurred (mean ZAR25 000 for drug-sensitive TB, up to ZAR104 000 for DR-TB). Students struggled to obtain treatment, incurred high transport costs and missed academic time. Students with DR-TB interrupted their studies and experienced severe side-effects (hepatotoxicity, depression and permanent ototoxicity). Most participants cited poor TB infection-control practices at their training hospitals as a major risk factor for occupational TB. CONCLUSIONS. Undergraduate medical students in Cape Town are at high risk of occupationally acquired TB, with an unmet need for comprehensive occupational health services and support. <![CDATA[<b>Beware: The femoral haemodialysis catheter -a surgeon's perspective</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600009&lng=en&nrm=iso&tlng=en BACKGROUND. Medical students acquire latent tuberculosis (TB) infection at a rate of 23 cases/100 person-years. The frequency and impact of occupational TB disease in this population are unknown. METHODS. A self-administered questionnaire was distributed via email and social media to current medical students and recently graduated doctors (2010 - 2015) at two medical schools in Cape Town. Individuals who had developed TB disease as undergraduate students were eligible to participate. Quantitative and qualitative data collected from the questionnaire and semi-structured interviews were analysed with descriptive statistics and a framework approach to identify emerging themes. RESULTS. Twelve individuals (10 female) reported a diagnosis of TB: pulmonary TB (n=6), pleural TB (n=3), TB lymphadenitis (n=2) and TB spine (n=1); 2/12 (17%) had drug-resistant disease (DR-TB). Mean diagnostic delay post consultation was 8.1 weeks, with only 42% of initial diagnoses being correct. Most consulted private healthcare providers (general practitioners (n=7); pulmonologists (n=4)), and nine underwent invasive procedures (bronchoscopy, pleural fluid aspiration and tissue biopsy). Substantial healthcare costs were incurred (mean ZAR25 000 for drug-sensitive TB, up to ZAR104 000 for DR-TB). Students struggled to obtain treatment, incurred high transport costs and missed academic time. Students with DR-TB interrupted their studies and experienced severe side-effects (hepatotoxicity, depression and permanent ototoxicity). Most participants cited poor TB infection-control practices at their training hospitals as a major risk factor for occupational TB. CONCLUSIONS. Undergraduate medical students in Cape Town are at high risk of occupationally acquired TB, with an unmet need for comprehensive occupational health services and support. <![CDATA[<b>Complementary medicines: When regulation results in revolution</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600010&lng=en&nrm=iso&tlng=en Medicines have evolved over time and so has the realisation of the importance of quality control and regulatory processes. The regulatory practices include all the steps from the development and manufacture of the active ingredients until the medicines reach the consumer. The Medicines Control Council (MCC) is mandated to regulate medicines in South Africa. Complementary medicines were previously perceived to be unregulated, although the Medicines Act does not distinguish between allopathic and complementary medicine. As the era of unregulated complementary medicine ended, the requirements in terms of dossier content left many role-players at odds. However, the MCC has a mandate to ensure that the registration of a medicine is in the interest of the public and that complementary medicine is manufactured in a facility adhering to good manufacturing practice, according to which efficacy and safety are supported by reliable data with a known shelf-life. <![CDATA[<b>Establishing an academic biobank in a resource-challenged environment</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600011&lng=en&nrm=iso&tlng=en Past practices of informal sample collections and spreadsheets for data and sample management fall short of best-practice models for biobanking, and are neither cost effective nor efficient to adequately serve the needs of large research studies. The biobank of the Sydney Brenner Institute for Molecular Bioscience serves as a bioresource for institutional, national and international research collaborations. It provides high-quality human biospecimens from African populations, secure data and sample curation and storage, as well as monitored sample handling and management processes, to promote both non-communicable and infectious-disease research. Best-practice guidelines have been adapted to align with a low-resource setting and have been instrumental in the development of a quality-management system, including standard operating procedures and a quality-control regimen. Here, we provide a summary of 10 important considerations for initiating and establishing an academic research biobank in a low-resource setting. These include addressing ethical, legal, technical, accreditation and/or certification concerns and financial sustainability. <![CDATA[<b>Audits of oncology units - an effective and pragmatic approach</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600012&lng=en&nrm=iso&tlng=en BACKGROUND. Audits of oncology units are part of all quality-assurance programmes. However, they do not always come across as pragmatic and helpful to staff. OBJECTIVE. To report on the results of an online survey on the usefulness and impact of an audit process for oncology units. METHODS. Staff in oncology units who were part of the audit process completed the audit self-assessment form for the unit. This was followed by a visit to each unit by an assessor, and then subsequent personal contact, usually via telephone. The audit self-assessment document listed quality-assurance measures or items in the physical and functional areas of the oncology unit. There were a total of 153 items included in the audit. The online survey took place in October 2016. The invitation to participate was sent to 59 oncology units at which staff members had completed the audit process. RESULTS. The online survey was completed by 54 (41%) of the 132 potential respondents. The online survey found that the audit was very or extremely useful in maintaining personal professional standards in 89% of responses. The audit process and feedback was rated as very or extremely satisfactory in 80% and 81%, respectively. The self-assessment audit document was scored by survey respondents as very or extremely practical in 63% of responses. The feedback on the audit was that it was very or extremely helpful in formulating improvement plans in oncology units in 82% of responses. Major and minor changes that occurred as a result of the audit process were reported as 8% and 88%, respectively. CONCLUSION. The survey findings show that the audit process and its self-assessment document meet the aims of being helpful and pragmatic. <![CDATA[<b>Sentinel lymph node biopsy and neoadjuvant chemotherapy in the management of early breast cancer: Safety considerations and timing</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600013&lng=en&nrm=iso&tlng=en Over the last decades, breast cancer treatment has become more personalised. Treatment plans are based on the biology of the tumour rather than the stage. Consequently, neoadjuvant chemotherapy (NACT) is commonly the primary therapy for early breast cancer as well as locally advanced disease. Sentinel lymph node biopsy (SLNB) is standard axillary management for women with node-negative disease. This review looks at the relevant literature and gives guidance on the timing of SLNB when NACT is planned and evaluates the safety of performing an SLNB rather than an axillary clearance. <![CDATA[<b>Training and support to improve ICD coding quality: A controlled before-and-after impact evaluation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600014&lng=en&nrm=iso&tlng=en BACKGROUND. The proposed National Health Insurance policy for South Africa (SA) requires hospitals to maintain high-quality International Statistical Classification of Diseases (ICD) codes for patient records. While considerable strides had been made to improve ICD coding coverage by digitising the discharge process in the Western Cape Province, further intervention was required to improve data quality. The aim of this controlled before-and-after study was to evaluate the impact of a clinician training and support initiative to improve ICD coding quality. OBJECTIVE. To compare ICD coding quality between two central hospitals in the Western Cape before and after the implementation of a training and support initiative for clinicians at one of the sites. METHODS. The difference in differences in data quality between the intervention site and the control site was calculated. Multiple logistic regression was also used to determine the odds of data quality improvement after the intervention and to adjust for potential differences between the groups. RESULTS. The intervention had a positive impact of 38.0% on ICD coding completeness over and above changes that occurred at the control site. Relative to the baseline, patient records at the intervention site had a 6.6 (95% confidence interval 3.5 - 16.2) adjusted odds ratio of having a complete set of ICD codes for an admission episode after the introduction of the training and support package. The findings on impact on ICD coding accuracy were not significant. CONCLUSION. There is sufficient pragmatic evidence that a training and support package will have a considerable positive impact on ICD coding completeness in the SA setting. <![CDATA[<b>Analysis of HIV disease burden by calculating the percentages of patients with CD4 counts <100 cells/</b><b>μL across 52 districts reveals hot spots for intensified commitment to programmatic support</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600015&lng=en&nrm=iso&tlng=en BACKGROUND. South Africa (SA)'s Comprehensive HIV and AIDS Care, Management and Treatment (CCMT) programme has reduced new HIV infections and HIV-related deaths. In spite of progress made, 11.2% of South Africans (4.02 million) were living with HIV in 2015. OBJECTIVE. The National Health Laboratory Service (NHLS) in SA performs CD4 testing in support of the CCMT programme and collates data through the NHLS Corporate Data Warehouse. The objective of this study was to assess the distribution of CD4 counts <100 cell/μL (defining severely immunosuppressed HIV-positive patients) and &gt;500 cells/μL (as an HIV-positive 'wellness' indicator). METHODS. CD4 data were extracted for the financial years 2010/11 and 2014/15, according to the district where the test was ordered, for predefined CD4 ranges. National and provincial averages of CD4 counts <100 and &gt;500 cell/μL were calculated. Data were analysed using Stata 12 and mapping was done with ArcGIS software, reporting percentages of CD4 counts <100 and &gt;500 cell/μL by district. RESULTS. The national average percentage of patients with CD4 counts <100 cell/μL showed a marked decrease (by 22%) over the 5-year study period, with a concurrent increase in CD4 counts &gt;500 cell/μL (by 57%). District-by-district analysis showed that in 2010/11, 44/52 districts had &gt;10% of CD4 samples with counts <100 cell/μL, decreasing to only 17/52 districts by 2014/15. Overall, districts in the Western Cape and KwaZulu-Natal had the lowest percentages of CD4 counts <100 cell/μL, as well as the highest percentages of counts &gt;500 cell/μL. In contrast, in 2014/15, the highest percentages of CD4 counts <100 cell/μL were noted in the West Rand (Gauteng), Vhembe (Limpopo) and Nelson Mandela Bay (Eastern Cape) districts, where the lowest percentages of counts &gt;500 cell/μL were also noted. CONCLUSIONS. The percentages of CD4 counts <100 cell/μL highlighted here reveal districts with positive change suggestive of programmatic improvements, and also highlight districts requiring local interventions to achieve the UNAIDS/SA National Department of Health 90-90-90 HIV treatment goals. The study further underscores the value of using NHLS laboratory data, an underutilised national resource, to leverage laboratory test data to enable a more comprehensive understanding of programme-specific health indicators. <![CDATA[<b>Cytomegalovirus retinitis in Cape Town, South Africa: Clinical management and outcomes</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600016&lng=en&nrm=iso&tlng=en BACKGROUND. Cytomegalovirus (CMV) retinitis is a vision-threatening opportunistic infection that occurs mainly in immunocompromised individuals. Limited data on treatment protocols and management outcomes are available in South Africa (SA). OBJECTIVES. To review the clinical presentation, management and outcomes of patients who were diagnosed and treated for CMV retinitis at Groote Schuur Hospital, Cape Town, SA, over a 10-year period, and to compare treatment protocols of 13 public hospitals in SA that treat patients for CMV retinitis. METHODS. A retrospective case review was performed of all patients treated for CMV retinitis at Groote Schuur Hospital between 2003 and 2013. In addition, a questionnaire was sent to 13 public hospitals in SA that treat patients with CMV retinitis. RESULTS. A total of 141 eyes in 91 patients were polymerase chain reaction-positive for CMV. Of these patients, 98.6% were HIV-positive and 72.5% were on highly active antiretroviral therapy (HAART) at the time of presentation. Patients who were on HAART at presentation had better mean final visual acuity (VA) than those who were not on HAART (p<0.001). There was a significant association between the number of retinal quadrants involved and final visual outcome (p=0.009). Macular (central vision) involvement had a significant adverse effect on visual outcome compared with cases in which the macula was uninvolved (p=0.005). CONCLUSIONS. Independent risk factors that predict final visual outcome include presenting VA, number of retinal quadrants involved, macular involvement and being on HAART at presentation. The diagnosis and management of CMV retinitis differ among treatment centres in SA. <![CDATA[<b>Characteristics and outcomes of gunshot-acquired spinal cord injury in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600017&lng=en&nrm=iso&tlng=en BACKGROUND. Spinal cord injuries (SCIs) caused by assault present a unique challenge facing the healthcare system, in that very little is known about how these injuries manifest compared with other causes of injury. Understanding the nuances of gunshot SCIs could contribute towards better care provision. OBJECTIVE. To determine the characteristics of gunshot SCI and compare both injury characteristics and outcomes between gunshot SCI and all other traumatic causes taken together. METHODS. The gunshot SCI sub-cohort was derived from a 1-year prospective, population-based study, including both tertiary-level hospitals providing SCI care in the Cape Metropolitan area of South Africa (SA). All consenting 145 survivors, after a window period of 7 days, were included, and their demographic and injury characteristics were captured according to the International SCI Core Basic Data Set. Further, selected secondary medical complications (outcomes) were prospectively and routinely assessed throughout acute care. Both descriptive and inferential statistics were used to describe and compare characteristics and outcomes, respectively. RESULTS. Of the 145 survivors of traumatic SCIs, 45 (31%) injuries were caused by gunshots. The gunshot SCI group consisted mainly of males (n=43; 96%), and the average age of injury onset was 26 years. Most survivors of the gunshot SCI group were paraplegic (69%), had complete lesions (69%) and vertebral injuries (96%), and presented with significant associated injuries (84%). When comparing gunshot SCI with all other traumatic causes, significant differences were found in relation to demographic and injury characteristics and adverse outcomes, indicating that those survivors with gunshot SCI were typically younger males with complete paraplegia, had more frequent secondary medical complications, and a longer hospital stay. CONCLUSION. This study contributes to the knowledge base of survivors with gunshot SCIs in a region of SA. Efforts should be made to reduce the occurrence of all gunshot SCIs, since those injuries impact survivors negatively in terms of injury characteristics and adverse outcomes. <![CDATA[<b>Screening for gestational diabetes mellitus in a South African population: Prevalence, comparison of diagnostic criteria and the role of risk factors</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600018&lng=en&nrm=iso&tlng=en BACKGROUND. The prevalence of gestational diabetes mellitus (GDM) is increasing. Most major world organisations now recommend universal screening for GDM based on the International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria. Currently there is a lack of consensus on the diagnostic criteria for GDM used in South Africa (SA). The Society for Endocrinology, Metabolism and Diabetes of South Africa's revised guidelines recommend the use of the IADPSG criteria for the diagnosis of GDM. OBJECTIVES. To determine the prevalence of GDM in an SA population. We compared the prevalence of GDM using the various diagnostic criteria and evaluated the risk factors associated with GDM. METHODS. This was a prospective cohort observational study carried out at a level 1 clinic in Johannesburg, SA. All pregnant women at <26 weeks' gestation were recruited. Patients known to have GDM were excluded. At recruitment, a data questionnaire was completed and bloods were drawn for a random glucose test and measurement of the glycated haemoglobin level. A 75 g 2-hour oral glucose tolerance test (OGTT) was scheduled before 28 weeks' gestation. RESULTS. Five hundred and fifty-four patients (55.4%) completed the OGTT. The prevalence of GDM was 25.8% if universal screening and the IADPSG criteria were used. If universal screening and the National Institute for Health and Care Excellence (NICE) criteria were used, the prevalence was 17.0%. If selective risk factor-based screening was used, only 254 (45.8%) of the women would have had an OGTT. The prevalence of GDM in this instance would have been 15.2% with the IADPSG criteria and 3.6% with the NICE criteria. Two hundred and fifty-four patients (45.8%) had at least one risk factor for GDM. The presence of one or more risk factors had a poor sensitivity (58.7%) and specificity (58.6%) for the detection of GDM in our study population. CONCLUSIONS. The prevalence of GDM would be substantially increased if universal screening with the IADPSG criteria were to be employed. Risk factors are a poor screening test for GDM. <![CDATA[<b>Effects of exogenous human insulin dose adjustment on body mass index in adult patients with type 1 diabetes mellitus at Kalafong Hospital, Pretoria, South Africa, 2009 - 2014</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600019&lng=en&nrm=iso&tlng=en BACKGROUND. To maintain fasting blood glucose levels within near to the normal range in type 1 diabetes mellitus (DM), frequent insulin dose adjustments may be required with short-, intermediate- and long-acting insulin formulations. Patients on human insulin generally experience weight gain over time, regardless of the level of glycaemic control achieved. OBJECTIVES. To determine the effects of human insulin, adjusted quarterly to achieve glycaemic control, on body mass index (BMI), and establish dose regimens that achieve optimal glycaemic control without increasing BMI in patients with type 1 DM at the Kalafong Diabetes Clinic in Pretoria, South Africa. METHODS. The sample size (N=211, 48.8% male) was obtained by non-probability convenience sampling of all available records of patients with type 1 DM aged &gt;18 years at baseline at the clinic. The longitudinal relationships of covariates with time-varying BMI, as well as with time-varying glycated haemoglobin (HbA1c) levels, were explored using multilevel mixed-effects linear regression modelling. RESULTS. The majority of the patients (84.8%) received the twice-daily biphasic human insulin regimen and the remainder received the basal neutral protamine Hagedorn (NPH) plus prandial regular human insulin regimen. The multivariable multilevel mixed-effects linear regression model indicated that time-varying BMI was significantly positively related to time-varying twice-daily biphasic insulin dosage (β (standard error) 0.464 (0.190), p=0.015), baseline HbA1c (0.092 (0.026), p<0.001) and baseline BMI (0.976 (0.016), p<0.001). There were significant inverse associations with the number of years spent in the study (-0.108 (0.052), p=0.038), time-varying HbA1c (-0.154 (0.031), p<0.001) and male sex (-0.783 (0.163), p<0.001). There were non-significant negative longitudinal associations of age (-0.005 (0.006), p=0.427) and current smoking status (-0.231 (0.218), p=0.290) with BMI outcomes. CONCLUSIONS. There was no evidence that optimal quarterly-prescribed daily dosage adjustments of insulin improved and maintained blood glucose control without increasing body weight. When compared with the basal NPH plus prandial insulin regimen, twice-daily biphasic insulin was associated with a statistically significant increase in subsequent BMI. Baseline HbA1c and BMI were also significantly positively associated with time-varying BMI. However, males appeared to be at a lower risk than females of an increase in BMI during insulin therapy. A question for further research is whether the analogue insulins will be associated with the same increase in BMI, as well as the same modest improvements in HbA1c, seen in this sample. <![CDATA[<b>The status of vaccine availability and associated factors in Tshwane government clinics</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600020&lng=en&nrm=iso&tlng=en BACKGROUND. Vaccines have greatly contributed to the control of vaccine-preventable diseases and to human development. Efforts by many countries to introduce new vaccines are a significant move towards achieving the sustainable development goal for health. However, effective vaccine supply chains that ensure an uninterrupted supply of vaccines are pivotal to attaining universal access to life-saving vaccines and sustainable development. The introduction of new vaccines puts a strain on supply chains; South Africa (SA) is no exception, as there are indications of vaccine stock-outs in clinics. OBJECTIVE. To establish the status of vaccine availability and associated factors in government health facilities of Tshwane Health District in Gauteng Province, SA. METHODS. A cross-sectional study was conducted in a sample of randomly selected government clinics in the Tshwane health district of Gauteng Province. Data were collected using a structured measurement instrument in participating clinics. Data were analysed using Excel-based software (Microsoft, USA). RESULTS. A total of 31 clinics participated. In the preceding 12 months, clinics had experienced vaccine stock-outs, especially of the three newer vaccines: pneumococcal conjugate vaccine, rotavirus and Pentaxim. These were also out of stock for a long duration; for over 2 weeks in a majority of clinics. The causes of vaccine stock-outs were: poor management of stock, district depot out of stock, unreliable deliveries, lack of pharmacy assistants and limited fridge capacity. Further burdening the situation is the ineffective emergency-ordering system. CONCLUSION. Significant shortages of vaccines, which are essential drugs, occur in Tshwane government clinics. Vaccine supply chain issues and vaccine shortages should be treated as a priority at all levels of the healthcare system; therefore, a similar study should be conducted at national level. It is recommended that the vaccine supply chain should be restructured and overhauled with the use of advances in technology and could be linked with current initiatives such as MomConnect. <![CDATA[<b>Report on the first government-funded opioid substitution programme for heroin users in the Western Cape Province, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742017000600021&lng=en&nrm=iso&tlng=en BACKGROUND. Although pharmacological opioid substitution treatment (OST) is a well-established treatment modality for heroin addiction, it is a relatively recent introduction in low- and middle-income countries. OBJECTIVE. To report on a pilot OST programme initiated in 2013 that was the only public-funded programme in South Africa (SA) at the time. Participants were offered standard care only (n=68) or, for the OST group (n=67), standard care plus Suboxone (Reckitt Benckiser), a synthetic partial opioid agonist, in a 12-week clinician-monitored programme. METHODS. Clinical records of 135 participants in the rehabilitation programme at Sultan Bahu Rehabilitation Centre in Mitchell's Plain, Cape Town, SA, from 1 January to 31 December 2014 were reviewed. Data collected included demographics and duration in treatment (retention) as well as number of urine samples provided, positive tests or self-reported use events and dates of first positive/negative tests. RESULTS. Significantly more participants in the OST group (65.7%) than controls (44.1%) completed the treatment (p=0.019). Among the non-completers, retention was higher in the OST group than in the standard care group (48.2 v. 30.1 days; p=0.001). The groups did not differ in respect of number of missed appointments and time to first positive test. However, the proportion of participants testing positive was higher in the OST group (80.6%) than in the standard care group (61.8%), although the former were tested nearly three times (18.3 v. 6.6 times) more. Consequently, the positive rate (proportion of positive tests) was substantially lower in the OST group (16.8%) than in the standard care group (23.3%). CONCLUSIONS. The results demonstrate modest success of this pilot OST programme in terms of completion and retention and should argue for a move to increase availability of and accessibility to OSTs for the management of opioid use disorder.