Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> vol. 110 num. 8 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>The unanticipated costs of COVID-19 to South Africa's quadruple disease burden</b>]]> <![CDATA[<b>The Critical Care Society of Southern Africa guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa</b>]]> <![CDATA[<b>Supernumerary registrars: The unsung heroes facing unprecedented predicaments</b>]]> <![CDATA[<b>COVID-19 in South Africa: An occupational disease</b>]]> <![CDATA[<b>Congenital bicuspid aortic valve: Differential prevalence across different South African population groups</b>]]> <![CDATA[<b>Maximising the efficiency of surveillance for COVID-19 in dialysis units in South Africa: The case for pooled testing</b>]]> <![CDATA[<b>Evolution of the SAMPLAR box: A multipurpose tool to facilitate limited re-use of personal protective equipment in low- and middle-income countries</b>]]> <![CDATA[<b>Preventing intrahospital transmission of COVID-19: Experience from the University Hospital Zurich in Switzerland</b>]]> <![CDATA[<b>Desperate times call for desperate measures: Adapting antiretroviral service delivery in the context of the COVID-19 pandemic</b>]]> <![CDATA[<b>Fine-needle aspiration cytology of head and neck masses: Is ultrasound guidance routinely warranted?</b>]]> <![CDATA[<b>COVID-19: UCT-Africa Virtual ENT transcends academic silos through videoconferencing academic meetings and ward rounds</b>]]> <![CDATA[<b>A call to action: Promoting mental wellbeing in South African healthcare workers</b>]]> <![CDATA[<b>Lothar Bohm</b>]]> <![CDATA[<b>Prioritising action on diabetes during COVID-19</b>]]> <![CDATA[<b>Guideline for medical certification of death in the COVID-19 era</b>]]> <![CDATA[<b>COVID-19 lockdowns in low- and middle-income countries: Success against COVID-19 at the price of greater costs</b>]]> <![CDATA[<b>COVID-19 and the school response: Looking back to learn what we can do better</b>]]> <![CDATA[<b>COVID-19 in pregnancy in South Africa: Tracking the epidemic and defining the natural history</b>]]> <![CDATA[<b>Managing and preventing childhood pneumonia in South Africa: Updated South African guidelines</b>]]> <![CDATA[<b>Management of community-acquired pneumonia in children: South African Thoracic Society guidelines (part 3)</b>]]> BACKGROUND. Pneumococcal conjugate vaccine (PCV) administration and other advances have been associated with a shift in the aetiological spectrum of community-acquired pneumonia, necessitating reconsideration of empiric antibiotic treatment guidelines. Management strategies have also evolved in the last decade. OBJECTIVES. To produce revised guidelines for the treatment of pneumonia in South African (SA) children, including ambulatory, hospital and intensive care management. METHODS. An expert subgroup, reviewing evidence on the management of childhood pneumonia, was convened as part of a broader group revising SA guidelines. Evidence was graded using the British Thoracic Society (BTS) grading system and recommendations were made. RESULTS. Antibiotic treatment depends on the child's age, possible aetiology, antimicrobial resistance patterns, previous treatment, as well as factors affecting host susceptibility, including HIV, and nutritional and vaccination status. All children with signs of severe pneumonia should receive antibiotics. Children <1 month of age with pneumonia should be hospitalised and treated with ampicillin and an aminoglycoside. For treatment of ambulatory children &gt;1 month of age, high-dose amoxicillin remains the preferred antibiotic. For severe pneumonia in this age group, hospitalisation and empiric treatment with amoxicillin-clavulanate orally is recommended; if oral therapy is not tolerated, intravenous therapy is recommended. Generally, 5 days of therapy is proposed, but longer duration may be needed in cases of severe or complicated disease. A macrolide antibiotic should be used if pertussis, mycoplasma or chlamydia pneumonia is suspected. Most hypoxic children can receive oxygen via nasal cannulae, but respiratory support should be individualised and extends to non-invasive and invasive ventilation in some cases. Children should be fed enterally; if this is not possible, administer intravenous isotonic fluids at <80% of maintenance, with monitoring of sodium levels. Empiric antibiotic treatment is the same in HIV-infected, HIV-exposed uninfected and HIV-uninfected children, although treatment for pneumocystis pneumonia and/or cytomegalovirus pneumonia should be considered in HIV-infected infants, especially in the absence of combination antiretroviral therapy. CONCLUSIONS. Updated guidelines optimise the management of childhood pneumonia in the context of changing epidemiology, improvements in HIV prevention and new evidence on management. <![CDATA[<b>Prevention of community-acquired pneumonia in children: South African Thoracic Society guidelines (part 4)</b>]]> BACKGROUND. More comprehensive immunisation regimens, strengthening of HIV prevention and management programmes and improved socioeconomic conditions have impacted on the epidemiology of paediatric community-acquired pneumonia (CAP) in South Africa (SA). OBJECTIVES. To summarise effective preventive strategies to reduce the burden of childhood CAP. METHODS. An expert subgroup reviewed existing SA guidelines and new publications focusing on prevention. Published evidence on pneumonia prevention informed the revisions; in the absence of evidence, expert opinion was used. Evidence was graded using the British Thoracic Society (BTS) grading system. RECOMMENDATIONS. General measures for prevention include minimising exposure to tobacco smoke or air pollution, breastfeeding, optimising nutrition, optimising maternal health from pregnancy onwards, adequate antenatal care and improvement in socioeconomic and living conditions. Prevention of viral transmission, including SARS-CoV-2, can be achieved by hand hygiene, environmental decontamination, use of masks and isolation of infected people. Specific preventive measures include vaccines as contained in the Expanded Programme on Immunisation schedule, isoniazid prophylaxis for tuberculosis, co-trimoxazole prophylaxis for HIV-infected infants and children who are immunosuppressed, and timely diagnosis of HIV, as well as antiretroviral therapy (ART) initiation. HIV-infected children treated with ART from early infancy, and HIV-exposed children, have similar immunogenicity and immune responses to most childhood vaccines as HIV-unexposed infants. VALIDATION. These recommendations are based on available published evidence supplemented by the consensus opinion of SA paediatric experts, and are consistent with those in published international guidelines. <![CDATA[<b>Caesarean section rates in South Africa: A case study of the health systems challenges for the proposed National Health Insurance</b>]]> Broader policy research and debate on the issues related to the planning of National Health Insurance (NHI) in South Africa (SA) need to be complemented by case studies to examine and understand the issues that will have to be dealt with at micro and macro levels. The objective of this article is to use caesarean section (CS) as a case study to examine the health systems challenges that NHI would need to address in order to ensure sustainability. The specific objectives are to: (i) provide an overview of the key clinical considerations related to CS; (ii) assess the CS rates in the SA public and private sectors; and (iii) use a health systems framework to examine the drivers of the differences between the public and private sectors and to identify the challenges that the proposed NHI would need to address on the road to implementation. <![CDATA[<b>The use of disinfection tunnels or disinfectant spraying of humans as a measure to reduce the spread of the SARS-CoV-2 virus</b>]]> In endeavouring to mitigate the spread of the SARS-CoV-2 virus, a concerning practice of spraying individuals with disinfectant via so-called 'disinfection tunnels' has come to light. The Allergy Society of South Africa supports the World Health Organization in strongly condemning all human spraying, owing to lack of efficacy and potential dangers, especially to patients with coexisting allergic conditions. <![CDATA[<b>But is it publishable? Mastering the MMed message</b>]]> The research requirement for South African specialist registration offers opportunities and challenges. For some clinicians it may spark a lifelong interest in clinical investigation, while for many others it may provide a potential publication opportunity. Integrating the specific requirements of an MMed mini-dissertation with those of standard medical publications can be difficult for first-time authors and their supervisors; published guidance caters to full-length laboratory Master's or doctoral research. We suggest that research is more likely to be publishable if it is locally relevant, has a clear clinical message and is coherently presented. <![CDATA[<b>Research in COVID-19 times: The way forward</b>]]> The COVID-19 pandemic has had a major impact on research at universities. Universities around the world, including in South Africa, have been or are still closed as part of national lockdown strategies. Students have not been attending classes or doing hands-on experimental work, and students and academics have been working from home. Many thousands of students have had their university education interrupted, and for them, the resumption of learning programmes online, and where possible in research laboratories, is critically important. There is no question that as we emerge from lockdown we will not be entering a world that resembles a 'norm' as lived in the pre-COVID-19 era, and many changes will be required. Here we discuss the importance of research, the urgency to get things up and running again, and strategies that will need to be implemented to ensure that research activities continue. At the same time, it is necessary to ensure that students and staff are not exposed to risk in their research endeavours, which will require the development and implementation of risk management plans. <![CDATA[<b>Convalescent plasma or hyperimmune immunoglobulin for people with COVID19</b>]]> Convalescent plasma is being considered as a potential therapy for COVID-19. We highlight and contextualise the findings of a recent Cochrane rapid review that evaluated the effectiveness and safety of convalescent plasma or hyperimmune immunoglobulin transfusion in the treatment of people with COVID-19. The review found low-certainty evidence of the therapeutic effectiveness and safety of convalescent plasma. As the novel coronavirus continues to spread in South Africa (SA), convalescent plasma may offer a therapeutic ray of hope for mitigating the morbidity and mortality burdens of the disease. Further investigation of the clinical benefits of the therapy in well-designed studies is needed to provide more evidence that will guide COVID-19 treatment decision-making in the SA context. <![CDATA[<b>Diabetes mellitus and COVID-19: A review and management guidance for South Africa</b>]]> This article reviews the association between diabetes mellitus (DM) and COVID-19. We report on the convergence of infectious diseases such as coronavirus infections and non-communicable diseases including DM. The mechanisms for the interaction between COVID-19 and DM are explored, and suggestions for the management of DM in patients with COVID-19 in South Africa are offered. <![CDATA[<b>A narrative review on spinal deformities in people with cerebral palsy: Measurement, norm values, incidence, risk factors and treatment</b>]]> Spinal deformities are common in people with cerebral palsy (CP), and there is a concern of an increase during the adult ageing period. There is especially a worry about the increase of scoliosis, thoracic hyperkyphosis, lumbar hyperlordosis, spondylolysis and spondylolisthesis incidence, though supporting literature is lacking. Therefore, the aim of this narrative review is to provide a scientific overview of how spinal curvatures should be measured, what the norm values are and the incidence in people with CP, as well as a description of the risk factors and the treatment regimens for these spinal abnormalities. This review can be used as a guideline relevant for a range of clinicians, including orthopaedic and neurosurgeons, radiologists, physiotherapists, and biokineticists, as well as academics. <![CDATA[<b>A historical overview of paediatric surgery at Wits University: From embryo to adult</b>]]> History provides wonderful insights into how society develops, providing innumerable lessons that can be used as individuals and institutions move into the future. The history of medicine provides particular value, yet it is so often overlooked by the present, society taking for granted what has often been a tremendous struggle to achieve. This overview of the history of paediatric surgery at the University of the Witwatersrand provides amazing insights into what has been achieved in a period spanning three centuries. <![CDATA[<b>A multisectoral investigation of a neonatal unit outbreak of <i>Klebsiella pneumoniae </i>bacteraemia at a regional hospital in Gauteng Province, South Africa</b>]]> BACKGROUND. Rates of healthcare-associated infections (HAIs) among babies born in developing countries are higher than among those born in resource-rich countries, as a result of suboptimal infection prevention and control (IPC) practices. Following two reported deaths of neonates with carbapenem-resistant Klebsiella pneumoniae bloodstream infections (BSIs), we conducted an outbreak investigation in a neonatal unit of a regional hospital in Gauteng Province, South Africa. OBJECTIVES. To confirm an outbreak of K. pneumoniae BSIs and assess the IPC programme in the neonatal unit. METHODS. We calculated total and organism-specific BSI incidence risks for culture-confirmed cases in the neonatal unit for baseline and outbreak periods. We conducted a clinical record review for a subset of cases with K. pneumoniae BSI that had been reported to the investigating team by the neonatal unit. An IPC audit was performed in different areas of the neonatal unit. We confirmed species identification and antimicrobial susceptibility, and used polymerase chain reaction for confirmation of carbapenemase genes and pulsed-field gel electrophoresis (PFGE) for typing of submitted clinical isolates. RESULTS. From January 2017 to August 2018, 5 262 blood cultures were submitted, of which 11% (560/5 262) were positive. Of 560 positive blood cultures, 52% (n=292) were positive for pathogenic organisms associated with healthcare-associated BSIs. K. pneumoniae comprised the largest proportion of these cases (32%; 93/292). The total incidence risk of healthcare-associated BSI for the baseline period (January 2017 - March 2018) was 6.8 cases per 100 admissions, and that for the outbreak period (April - September 2018) was 10.1 cases per 100 admissions. The incidence risk of K. pneumoniae BSI for the baseline period was 1.6 cases per 100 admissions, compared with 5.0 cases per 100 admissions during the outbreak period. Average bed occupancy for the entire period was 118% (range 101 - 133%), that for the baseline period was 117%, and that for the outbreak period was 121%. In a subset of 12 neonates with K. pneumoniae bacteraemia, the median (interquartile range (IQR)) gestational age at birth was 27 (26 - 29) weeks, and the median (IQR) birth weight was 1 100 (880 -1 425) g. Twelve bloodstream and 31 colonising K. pneumoniae isolates were OXA-48-positive. All isolates were genetically related by PFGE analysis (89% similarity). Inadequate IPC practices were noted, including suboptimal adherence to aseptic technique and hand hygiene (57% overall score in the neonatal intensive care unit), with poor monitoring and reporting of antimicrobial use (pharmacy score 55%). CONCLUSIONS. Overcrowding and inadequate IPC and antimicrobial stewardship contributed to a large outbreak of BSIs caused by genetically related carbapenemase-producing K. pneumoniae isolates in the neonatal unit. <![CDATA[<b>Compliance with hygiene practices among healthcare workers in the intensive care unit</b>]]> BACKGROUND. Intensive care unit (ICU)-related healthcare-associated infections (HCAIs) are two to three times higher in lower-income countries than in higher-income ones. Hand cleansing and other hygiene measures have been documented as one of the most effective measures in combating the transmission of HCAIs. There is a paucity of data pertaining to hygiene practices in the ICU in developing countries. OBJECTIVES. To determine compliance with hygiene practices among healthcare workers in a tertiary hospital ICU. METHODS. Hygiene practices of healthcare workers in a tertiary academic hospital ICU in Johannesburg, South Africa, were discreetly observed over an 8-week period. Compliance with hand cleansing and other hygiene practices was documented and analysed. Retrospective consent was obtained, and subject confidentiality was maintained. RESULTS. A total of 745 hygiene opportunities were observed. Of the 156 opportunities where handwashing with soap and water was indicated (20.9%), compliance was noted in 89 cases (57.1%), while an alcohol-based hand rub was inappropriately used in 34 cases (21.8%) and no hand hygiene was performed in the remaining 33 cases (21.1%). Of the 589 opportunities where an alcohol-based hand-rub was indicated, it was used in 312 cases (53.0%). Compliance with the donning of disposable surgical gloves, disposable plastic aprons and being 'bare below the elbows' was noted in 114 (90.6%), 108 (71.1%) and 355 (47.7%) opportunities, respectively, where these were indicated. CONCLUSIONS. Overall compliance with hygiene measures among healthcare workers in the ICU was suboptimal in this study, but in keeping with general international trends. Regular retraining of staff, frequent reminders, peer oversight and regular audits may improve compliance. <![CDATA[<b>Nicotine dependence, socioeconomic status, lifestyle behaviours and lifetime quit attempts among adult smokers in South Africa</b>]]> BACKGROUND. Smoking cessation is a complex process influenced by factors such as smokers' nicotine dependence levels, socioeconomic status (SES) and other lifestyle behaviours. Little is known about these relationships in South Africa (SA). OBJECTIVES. To explore the relationship between nicotine dependence, SES, lifestyle behaviours and lifetime quit attempts among adult smokers in SA. METHODS. This study used data from 2 651 participants aged >16 years in the 2011 South African Social Attitudes Survey. Information on SES (measured by asset ownership), binge drinking, physical activity, fruit and vegetable intake, intention to quit smoking and lifetime quit attempts was extracted. Nicotine dependence was measured using the Heaviness of Smoking Index (HSI). All data were weighted to account for the complex survey design and to yield nationally representative estimates. Data analysis included binary logistic regression with high nicotine dependence (HND) defined as HSI >4 and lifetime quit attempts as separate outcomes. RESULTS. The prevalence of smoking was 20.1% (31.6% for males and 9.5% for females), and was highest in the mixed-ancestry group (37.0%). Overall, 14.5% of smokers had HND, with a higher proportion in the high-SES group. The odds of HND increased with every 10 years of smoking history (odds ratio (OR) 2.05; 95% confidence interval (CI) 1.40 - 3.00) but decreased among participants who reported frequent physical activity (OR 0.4; 95% CI 0.18 - 0.86) and those who planned to quit (OR 0.37; 95% CI 0.19 - 0.75). Quit attempts were more likely among participants who reported frequent fruit and vegetable intake (OR 1.8; 95% CI 1.07 - 2.98) and less likely among those reporting binge drinking (OR 0.31; 95% CI 0.16 - 0.59) or assessed as having HND (OR 0.32; 95% CI 0.17 - 0.58). CONCLUSIONS. Most adult smokers in SA have low nicotine dependence. However, the association of HND with high SES in this study suggests that although cessation treatment based on an integrated lifestyle behavioural intervention package may suffice for most smokers, a more intense cessation treatment package is needed for smokers of higher SES. <![CDATA[<b>Risk factors for female and male homicidal strangulation in Johannesburg, South Africa</b>]]> BACKGROUND. There is a paucity of research on homicidal strangulation by gender. OBJECTIVES. A sex-disaggregated and comparative research approach was used to investigate individual-level risk factors for female and male homicidal strangulation in Johannesburg, South Africa (2001 - 2010). METHODS. Data were drawn from the National Injury Mortality Surveillance System. Logistic regressions were used to examine associations between each of the independent variables and homicidal strangulation in females and males relative to all other female and male homicides, respectively. RESULTS. The risk of fatal strangulation was high for both females and males aged >60 years, but markedly high only for male children and adolescents. Temporal risk for females was undifferentiated for day of the week, and the risk for males was high during weekdays. Females were more likely to be strangled in public places, and males in private locations. CONCLUSIONS. The study underlines the importance of disaggregating homicide by external cause and gender. <![CDATA[<b>The effect of the introduction of an electronic booking system to appropriately prioritise gastroscopies at a regional hospital in South Africa</b>]]> BACKGROUND. The National Institute for Health and Clinical Excellence (NICE) guidelines state that patients with dyspepsia as well as alarm symptoms, or those that are 55 years and older with new onset dyspepsia, urgently require an upper endoscopy within two weeks. The 'Be Clear on Cancer Campaign' launched by Public Health England estimated that 9% of deaths due to gastric and oesophageal cancers could have been avoided if the diagnosis was made at an earlier stage. Worcester Provincial Hospital (WPH) is a regional hospital in the Western Cape, South Africa, that due to resource constraints was unable to comply with these guidelines. An electronic endoscopy booking system was implemented in June 2014 to assist referring clinicians. OBJECTIVES. To evaluate the ability of the booking system to appropriately prioritise and accommodate clinically appropriate patients for an urgent gastroscopy within 2 weeks at WPH. METHODS. Retrospective analysis of patients booked for urgent gastroscopies using the online booking system at WPH from July 2014 to June 2017. RESULTS. A total of 1 589 gastroscopies were performed, with 1 085 (65%) categorised as urgent by the booking system algorithm, during the study period. The median (interquartile range) waiting time for urgent gastroscopies was 19 (8 - 31) days and 437 (40%) patients underwent a gastroscopy within the recommended 2-week period. Of the patients undergoing gastroscopy within 2 weeks, 87 (20%) were diagnosed with upper gastrointestinal malignancies and 73 (17%) had significant benign pathology (stricture or ulcer). A total of 150 malignancies were diagnosed in the urgent patients of whom 87 (58%) were scoped within 2 weeks. CONCLUSIONS. The volume of patients requiring urgent gastroscopy at WPH outstrips the available resources. The introduction of the online algorithm-based booking system was effective in prioritising patients. The use of this system facilitated a malignancy diagnosis rate which compares favourably with similar fast track endoscopy services in more developed countries. <![CDATA[<b>The ethicolegal framework relevant to human faecal microbiota transplants in South Africa: Part 1. A legal vacuum</b>]]> The legal regulation of faecal microbiota transplantation (FMT) in South Africa (SA) is currently unclear. The purpose of this article, the first of three in a series, is to explore the nature, role and clinical application of FMT in SA in order to determine, from a legal perspective, the appropriate regulatory pathways governing FMT as a procedure that may combine approaches for the treatment of drugs, human tissue for transplantation, or clinical treatment as part of the practice of medicine. FMT has been shown to be a novel, safe and effective treatment for recurrent Clostridioides difficile infection (CDI). Stool banks are instrumental in enabling access to FMT for patients and clinicians and help to catalyse research in the microbiome. However, the regulatory landscape in SA remains unclear. Microbial therapies such as FMT are necessary, especially in a time of rising microbiome-associated inflammatory diseases and increasing resistance to traditional antibiotics. FMT is now considered as part of the standard of care for recurrent CDI overseas, but is currently only being used for research purposes in a minority of clinical cases of CDI in SA. This article, which lays the foundation for consideration of this question in three parts, suggests that the relevant regulatory system would depend on the categorisation of human stool as tissue, the exact composition of the FMT, how it is administered to patients, and the relevant levels of manipulation of the stool for FMT-derived products. <![CDATA[<b>The ethicolegal framework relevant to human faecal microbiota transplants in South Africa: Part 2. Human stool as tissue?</b>]]> Faecal microbiota transplantation (FMT) has been shown to be an effective treatment for recurrent Clostridioides difficile infection. The purpose of this article, the second of a series of three articles, is to explore the legal framework governing human FMT in South Africa (SA). FMT involves different modes of administration that require different regulatory considerations. The focus of this article is to explore the legal classification of human stool as tissue in terms of the National Health Act 61 of 2003, as well as the regulation of human stool banks as tissue banks. The article concludes with specific recommendations aimed at improving the current regulatory vacuum relating to the regulation of FMT in SA. <![CDATA[<b>The ethicolegal framework relevant to human faecal microbiota transplants in South Africa: Part 3. Stool as a 'drug' or medicine</b>]]> The purpose of this article, the last in a series of three exploring the legal framework for the regulation of faecal microbiota transplantation (FMT) in South Africa (SA), is to determine the regulatory framework that applies to microbial-based treatments involving a level of manipulation that exceeds that of basic stool transplantation, e.g. processed FMT-derived products in capsule form. The article highlights the legal requirements for the registration of these products as biological medicines in SA law. Although human stool banks are not regulated in terms of the National Health Act 61 of 2003 (NHA) and regulations, the earlier articles point out that human stool fits the definition of human tissue and human biological material as defined by the NHA. For this reason, stool banks should be considered tissue banks in terms of the NHA and regulations. Healthcare practitioners and researchers involved in FMT banking and transplantation should strive to comply with these regulations in the absence of clear legal direction at present.