EDITOR'S CHOICE

Childhood tuberculosis

South Africa has the highest tuberculosis (TB) notification rates in the world, and these rates are highest in crowded urban areas. Implementation of directly observed therapy, short course (DOTS) has not significantly affected TB transmission and incidence in Africa. Adult TB disease comprises a combination of recent infections and reactivation of latent TB, therefore representing recent and past TB exposure. HIV co-infection increases the progression to disease of recent and latent infection. In children, infection is acquired predominantly from adults, as child-to-child transmission is uncommon. Young children have a greater risk for progression to active disease than adults.

Middelkoop and colleagues¹ studied the relationships between TB exposure, infection and disease in children <15 years of age with exposure to adult HIV-positive and HIV-negative disease on residential plots in a peri-urban township heavily affected by HIV in Cape Town.

They found that childhood infection and disease were quantitatively linked to infectious adult TB prevalence in an immediate social network. Childhood TB should be monitored in high-burden settings as a marker of ongoing TB transmission. Improved knowledge of township childhood and adult social networks could also facilitate targeted active case finding, which may provide an adjunct to currently failing control strategies.

Smoking gains

The previous health minister, Dr Manto Tshabalala-Msimang, is remembered for a disastrous reign during which South Africa's HIV/AIDS policies and actions became the laughing stock of the world and a tragedy for those infected in our communities. On her watch, the public health sector also declined seriously. It is therefore good to be able to report an achievement during this time that has had significant health benefits for the nation. Peer, Bradshaw, Laubscher and Steyn report on trends in adult tobacco use from two South African demographic and health surveys conducted in 1998 and 2003.²

South Africa has the highest smoking rate in Africa. Comprehensive tobacco control policies were introduced in the 1990s to address the growing epidemic of tobacco use. These included the introduction of health warnings on cigarette packs and advertising material, and steep rises in excise taxes that increased real cigarette prices by 115% between 1992 and 2003.

While there was a significant decline of smoking among selected subsets of men, over a third of the male population still smoke, with higher rates among the poorer and less educated. Also highlighted were the constant smoking prevalence among women, adolescents and young adults, and the unacceptably high rates for coloured women.

Public perceptions about National Health Insurance

Indications are that political forces will ensure that a National Health Insurance (NHI) will be introduced in South Africa. There are good reasons for considering new alternatives to our existing health care system, as South Africa has dismal health status indicators compared with other countries at similar levels of economic development and huge disparities between the funding and resources of the public and private sectors. There are some key prerequisites that need to be put in place before an NHI can achieve these goals. Di McIntyre and colleagues explored public perceptions on what changes are necessary to ensure acceptability and sustainability of an NHI.³

They found that there is dissatisfaction with both the public and private sectors, suggesting that South Africans are ready for health system change. There are concerns about the current poor quality of public health services and about the affordability of medical schemes and how the profit motive affects private providers' behaviour. Public engagement is essential to improve understanding and to gain support for various aspects of the proposed NHI.

Antiretroviral treatment programmes for children

South Africa's paediatric antiretroviral treatment (ART) programme is the largest in the world, with an estimated 32 000 children <15 years of age on treatment at the end of 2007. However, less than half of those estimated to need ART are reached. A large collaborative programme representing 20% of the South African national treatment programme studied the paediatric ART outcomes and their associations.⁴

Dramatic clinical benefit for children accessing the national ART programme is demonstrated. Higher mortality in infants and those with advanced disease highlights the need for early diagnosis of HIV infection and commencement of ART.

JPvN

1. Middelkoop K, Bekker L-G, Morrow C, Zwane E, Wood R. Childhood tuberculosis infection and disease: A spatial and temporal transmission analysis in a South African township. S Afr Med J 2009; 99: 738-743.         [ Links ]

2. Peer N, Bradshaw D, Laubscher R, Steyn K. Trends in adult tobacco use from two South African demographic and health surveys conducted in 1998 and 2003. S Afr Med J 2009; 99: 744-749.         [ Links ]

3. McIntyre D, Goudge J, Harris B, Nxumalo N, Nkosi M. Prerequisites for National Health Insurance in South Africa: Results of a national household survey. S Afr Med J 2009; 99: 725-729.         [ Links ]

4. Davies M-A, Keiser O, Technau K, et al. Outcomes of the South African National Antiretroviral Treatment Programme for children – the IeDEA South Africa collaboration. S Afr Med J 2009; 99: 730-737.         [ Links ]