By: Lunga Memela (Communications Officer)
Imagine falling ill with an infection, your health practitioner prescribes the best medication to cure you, you take it diligently – for added benefit you also adjust your diet and lifestyle but, over time, it becomes apparent that the bacteria in your body has become resistant to the antibiotic. What then?
This has been the sad reality for many individuals diagnosed with Tuberculosis (TB), for example, and subsequently multidrug-resistant TB (MDR TB) which at times results in extensively drug resistant TB (XDR TB). The challenge is heightened in countries like South Africa, for instance, where the past few decades has seen a dreadful number of cases of TB and HIV co-infection, with many-a-citizen having limited access to the relevant treatment.
A soaring number of people are contracting drug-resistant infections globally, and this why there is an urgent mandate for the pharmaceutical industry, private and public health sectors to join forces in eradicating the problem and to speak in unison beyond 18–24 November, which is World Antimicrobial Awareness Week (WAAW). This annual event aims to increase awareness of global antimicrobial resistance (AMR) by encouraging best practices among the general public, health workers and policy makers to avoid the further emergence and spread of drug-resistant infections.
In the spirit of promoting expert opinions and finding innovative ways to raise health awareness, Health Systems Trust spoke to Professor Sabiha Essack, the South African Research Chair in Antibiotic Resistance & One Health, a Professor of Pharmaceutical Sciences and the Director of the University of KwaZulu-Natal's Antimicrobial Research Unit. She is a prolific researcher and Vice-President and General Secretary of the Academy of Science of South Africa (ASSAf).
Essack said in order to raise antimicrobial awareness, it is important to understand that, "Antimicrobial resistance occurs when a micro-organism can survive or continue to thrive in the presence of an antimicrobial medicine that previously killed the micro-organism." Micro-organisms or microbes are microscopic organisms that are not visible to the naked eye; they are made up of viruses, bacteria, fungi and other parasites.
She explained that AMR is an overarching term that encompasses resistance to anti-viral, anti-bacterial, anti-fungal and anti-parasitic medicines. In particular, she described antibiotic resistance as specific to bacteria that occurs when bacteria no longer respond to antibiotics that previously killed the bacteria and cured infection.
Essack said AMR is evident in both community- and hospital-acquired infections and, of concern, is the fact that resistance to broad-spectrum antibiotics is escalating at community level. AMR exists and is escalating in South Africa as it is in other parts of the world. "South Africa, like other countries around the world, has reported resistance to every single antibiotic in clinical and veterinary practice, even the last resort antibiotics for 'difficult-to-treat' infections, but the nature, extent and sequalae is unquantified because we are yet to put into place comprehensive surveillance systems. Surveillance in human health is most advanced in blood stream infections from the public and private sector, surveillance in food animals is in its infancy, while surveillance in the environment is limited to research projects at academic institutions," she explained.
South Africa's commitment to combatting AMR
There is hope! According to Essack, AMR has been prominent on the global public health and political agendas since 2015 (although it was recognised as a public health threat since 1998) when the World Health Organization published its Global Action Plan on AMR. "All countries have committed to develop[ing] National Action Plans on AMR as signatories of the World Health Assembly Resolution and the United Nations General Assembly Political Declaration on AMR.
According to Essack the Global Action Plan has five strategic objectives, the first being improving awareness of AMR through communication, education and training. The vast majority of countries have instituted AMR awareness campaigns, particularly during World Antimicrobial Awareness Week. South Africa has also launched the Antibiotic Guardian Campaign where everyone from government ministers to civil society can pledge to use antibiotics correctly to ensure their efficacy for future generations.
Understanding AMR in the time of COVID-19
Although it goes unnoticed by many, AMR is the slow-moving pandemic that is adversely affecting humans, animals, crops, the environment, and their various interfaces and ecologies. "AMR is a One Health issue and its impact is so much more far-reaching than COVID-19," said Essack. "COVID-19 highlighted the lack of preparedness of health systems to deal with pandemics and it is imperative that our health, agricultural and environmental health systems are capacitated to prevent, contain and mitigate AMR as a matter of urgent priority, especially as AMR surveillance stewardship appears to be deprioritised as resources were channelled to deal with COVID-19."
The slogan for WAAW 2020 is "Antimicrobials: handle with care" applicable to all sectors, as declared by the World Health Organization. The theme for the human health sector for WAAW 2020 is "United to preserve antimicrobials".
Because millions of South Africans live with chronic conditions such as diabetes, high blood pressure or HIV, HST encourages patients on chronic medication to register for a free and convenient service called CCMDD (Central Chronic Medicine Dispensing and Distribution) – the National Department of Health's programme which dispenses and distributes medicine from a central point to patients with a chronic condition who are stable on their medication. To find out more about it you have to visit the HST-managed website for the CCMDD campaign funded by the Centers for Disease Control and Prevention called Get checked. Go collect..
Just like cattle need to graze; birds to fly; the sun to shine; as well as jets need their fuel, service and safety measures; so do humans need to feed their bodies and souls. The basic human right of sustaining mental and physical wellness through the supply of regular nutritious meals in order to perform optimally is not, unfortunately, possible for a significant segment of the world's population.
The National Department of Health and the African continent at large, observes Africa Food and Nutrition Security Day and uses the opportunity to remind us that many communities still live below the poverty line. The geographical, psycho-social, psycho-physical and psycho-economic disparities presented by food (in)security amongst some of the communities situated in the most marginalised contexts, especially during the COVID-19 pandemic, spells hunger! The written word and philanthropy can draw attention to this other "pandemic", but witnessing it with the naked eye really brings home the plight of many right on our door step.
It was a humble gesture for Health Systems Trust (HST) employees to reach out on 30 October to commemorate Africa Food and Nutrition Security Day by donating food parcels – mainly toiletries, non-perishable goods, face masks and hand sanitisers – to Uthando Home-Based Care (a non-profit organisation based in Verulam, eThekwini) for distribution amongst families in desperate need of food during the COVID-19 pandemic that has left many without.
HST was thankful to its Stakeholder Engagement affiliate, Simamisa Mkhize, for his help with identifying an entity that would be suitable to distribute its donated goods fairly on this day. On the day HST delivered the donation it became clear that the charity and community it serves still needs so much, as do many others. If you are keen to help them please contact email@example.com.
It was Beth Bechdol, the Deputy Director-General of the United Nations' (UN) Food and Agriculture Organization (FAO), who said these words in her opening remarks of a recent podcast:
"The number of food insecure people in the world prior to the COVID-19 pandemic was already surprisingly high, and unfortunately, trends in trying to eliminate hunger around the world and in the most vulnerable countries are not good trends… We've got more work to do! And so, when you add the COVID-19 pandemic to that and add the economic implications: soaring unemployment rates, income losses, rising food costs – all of these begin to jeopardise food access in both developed and developing countries."
FAO mentions in its article, Impact of COVID-19 on people's livelihoods, their health and our food systems, that the economic and social disruption caused by the pandemic is devastating: tens of millions of people are at risk of falling into extreme poverty, while the number of undernourished people, currently estimated at nearly 690 million, could increase by up to 132 million by the end of the year.
A report published by FAO in July 2020, The State of Food Security and Nutrition in the World 2020: Transforming food systems for affordable healthy diets, highlights that the burden of malnutrition in all its forms continues to be a challenge. The report complements the usual assessment of food security and nutrition with projections of what the world may look like in 2030, if trends of the last decade continue. The World Health Organization expanded on the matter, publishing a stimulating article headlined: As more go hungry and malnutrition persists, achieving Zero Hunger by 2030 in doubt, UN report warns.
As part of its 75th anniversary and the 5th anniversary of the adoption of the Sustainable Development Goals, the UN declared Goal 2 of these as #ZeroHunger. The biggest question is: Is the world on track to achieve Zero Hunger by 2030? The Sustainable Development Goals are the blueprint to achieve a better and more sustainable future for all. They address the global challenges we face, including poverty, inequality, climate change, environmental degradation, peace and justice.
The reality is that no nation will thrive to reach its full potential until we open our hearts and take collective action to make a difference.
Why Global Citizens Should Care?
"Food insecurity is the state of not having reliable access to sufficient food, and is one of the leading causes of chronic hunger in Africa. The United Nations' Global Goal 2 calls for an end to world hunger, and also aims to achieve food security and promote sustainable agriculture. This goal can only be obtained if Africa has reliable and consistent access to food. Join the movement and take action on this issue here."
HST remains committed to taking action to address the influence of the social determinants of health on the burden of disease.
By: Lunga Memela (Communications Officer)
A bouquet of scientific research, vaccine development debate, issues of equity, accessibility and overall public health enquiry has commanded global attention across industries as the novel coronavirus pandemic (COVID-19) took centre-stage over the past couple of months. But, lest we forget, equal effort still needs to be invested into other illnesses, such as preventing the upsurge of non-communicable diseases.
As #BreastCancerAwarenessMonth rapidly draws to a close, raising awareness about breast cancer prevention and the importance of its early detection amongst young and old males and females will remain critical and must be sustained.
To maintain momentum, Health Systems Trust (HST) interviewed some key role players who shared their insights and experiences, especially in view of the local South African context which remains in dire need of health systems strengthening through proactive research, community outreach, innovative thinking and health promotion.
We spoke to the President of the Association of Surgeons South Africa, Dr Ines Buccimazza who is also a Senior Specialist in the Department of Surgery at the University of KwaZulu-Natal's Nelson R Mandela School of Medicine and heads Inkosi Albert Luthuli Central Hospital's Breast and Endocrine Clinical Unit. She said breast cancer is the most common malignancy in women world-wide, including in South Africa – the global incidence is 24.2% and in South Africa 23.6%; the lifetime risk of an average South African woman (up to the age of 74 years) of developing breast cancer is 1:26.
"Whereas breast cancer is the most common cause of death in women globally (15%), it is the second leading cause of death in South African women (16%), after cervical cancer: annually 19.1% of South African women die as a result of cervical cancer. Thus, breast cancer is associated with a significant healthcare burden and it is imperative that the necessary resources are available to manage the large numbers that present to our healthcare facilities," she explained.
Buccimazza said there have been tremendous advances in the treatment of breast cancer, particularly in optimising treatment. "This 'de-escalation' of treatment does not mean that less therapy is given; on the contrary, the treatment is more tailored to the disease and thus can be administered with less morbidity. The caveat is that de-escalation is more applicable to early stage disease. Therefore, creating awareness helps to detect the disease at an early stage, when the treatments are not only more effective, but associated with less morbidity due to less invasive surgical, regional and systemic therapies."
"One way of detecting disease early is to be aware of its presence, [being] educated on how it presents and the methods of early detection. The latter falls is the preserve of screening programmes."
Her sentiments were echoed by Dr Laura Stopforth who heads the clinical unit of Greys Hospital's Oncology Department and doubles as acting Academic Head of Department for Radiotherapy and Oncology at UKZN. She added that, "Any stigma related to breast cancer is detrimental and unnecessary. De-stigmatising breast cancer also helps to combat stigma associated with other cancers."
Male breast cancer exists
This brought us to the topic of male breast cancer which, while considered rare (accounting for only 1% of all breast cancers), it must be noted that men also have breast tissue, and male breast cancer usually always presents at an advanced stage in our setting. "Unlike female breast cancer, where early stage breast cancer is seen in around 40% of patients locally, the diagnosis of early breast cancer in males is very unusual. This is largely due to the fact that very little breast tissue is present in males; undiagnosed cancers continue to proliferate in the minimal breast tissue and eventually ulcerate through the skin," Buccimazza explained. "These differences aside, the diagnosis, management and prognosis of male breast cancer, stage for stage, is similar to that of their female counterparts."
Breast cancer prevalence in young women
"Although uncommon, breast cancer does occur in young women (<40 years). It presents and is diagnosed in a similar manner as in older women, but the treatment plan has to consider fertility and long-term health matters," Buccimazza advised.
"Certainly, in families where there is a suggestion of a hereditary predisposition for breast cancer (multiple [3 or more] first degree members; two successive generations; affected member(s) under the age of 50 years), the awareness in family members of all ages and genders should be heightened and clinical assessment mandatory to exclude a genetic mutation that may be transmitted across generations."
On doctor-patient relationships
Early detection is key because it enables early intervention which weighs less on medical professionals too. "The management of breast cancer is multimodal, sequential treatment that spans many months and, in some cases, (those with endocrine-responsive tumours) many years. As surgeons, our involvement commences with diagnosing the cancer and continues over the initial phases of treatment. A relationship of trust is forged with the patient and family during this time. Being empathetic while remaining emotionally detached in order to retain objectivity, is difficult."
The South African context
Another challenge highlighted was that most South African patients are socio-economically disadvantaged and every visit to the hospital incurs an expense many cannot afford. "It saddens me that the healthcare system in the state sector is not designed to fast-track all the investigations upfront and that there are no social support systems to aid patients financially. Many patients simply default their treatment and never return. We unfortunately do not have the resources to track all these patients nor the means to aid them financially."
Breast examination by trained nurses are available at clinics, community health centres and hospitals, as well as training on how to perform a breast self-examination, Stopforth highlighted. "Whilst not as sensitive in detecting breast cancer as mammograms, they are easily accessible and a reasonable second-best option."
It was even more encouraging when Hlengiwe Madonsela shared her lived experience as a breast cancer survivor. Born in Marrianhill, Durban and now one of HST's very own Psychosocial Advisors, growing up, Madonsela could have never imaged that one day she would get diagnosed with breast cancer in addition to other chronic illnesses. It was in May 2019 when the doctor confirmed the news after Madonsela had done a self-check and discovered a lump in her breast. The healing process, which led her to undergoing chemotherapy and a mastectomy, has not been easy. She stressed that early detection is key, and that having a good support system at home and at work really goes a long way.
"The clinics do teach women's health – nurses hold health talks, there are posters on the walls etcetera, so it's important that we continue raising awareness to avoid ignorance and promote prevention," Madonsela said.
Fortunately, there is breast cancer custodianship across provinces in South Africa with initiatives such as the Pink Drive and the Cancer Association of South Africa (CANSA) who do arrange mobile cancer screening and they can be contacted to determine when and where their next screening event is being held.
SPEAK TO A PROFESSIONAL:
Email, Phone or WhatsApp CANSA
Help Desk: 0800 22 66 22 (toll free)
WhatsApp: 072 197 9305 (English and Afrikaans)
WhatsApp: 071 867 3530 (isiXhosa, isiZulu, siSwati, Sesotho and Setswana)
Helen Joseph Breast Care Clinic Phone:
Phone: 011 489 0130
When we hear the name we automatically associate it with ageing – something far off, but the reality is that it's among us and must be managed with compassion and a collective investment in brain health.
Imagine waking up one day with your ability to speak suddenly impaired, not being able to think clearly, or to recollect what recently happened or what someone said just minutes ago? This experience is well-known to sufferers of Alzheimer's disease (AD).
"The condition is one of several types of disorders affecting the brain that cause damage to various areas of the brain resulting in loss of corresponding cognitive and bodily functions. This group of disorders are referred to as dementia or neurocognitive disorder," explains psychiatrist and academic leader at the University of KwaZulu-Natal's Nelson R Mandela School of Medicine, Dr Suvira Ramlall. "It starts insidiously and progresses slowly, its cause is unknown, no treatment or cure is currently available and it has a fatal outcome."
Amongst many equally important days listed on the global health calendar, September is marked as World Alzheimer's Month and World Alzheimer's Day falls on the 21st – calling for recognition of the impact of dementia but also action to support those affected globally. A co-ordinated global voice on dementia ensures that this action is taken to advance awareness, care and science all year round.
Nourish, stimulate, protect and detox the brain advises Dr Ramlall! Here's how:
Nourish: What you eat also feeds the brain. A healthy nutritious diet will provide the necessary fuel for healthy brain function. Certain nutritional deficiencies can, in themselves, cause dementia and worsen it if present. The important point is that these are preventable causes and if identified and corrected early, can reverse the dementia symptoms. Equally important, what you feed the brain through the senses – seeing, listening, thinking, feeling – also directly or indirectly impacts on the brain.
Stimulate: 'use it or lose it' is the adage. The more you use the brain the more nerve connections the brain makes between nerve cells. These connections make the brain more resilient against disease processes. 'Cognitive reserve' refers to such a 'positive brain balance' and the bigger the 'reserve' you build up in life, the more protected you will be against AD – it has been shown that even if you have AD, plaques in your brain, you may not show signs of the disease in life or show them much later and to lesser degrees of severity if you have more reserve. So, activities such as reading, learning new languages, doing intellectually stimulating work or games, playing musical instruments and engaging in hobbies are all stimulating for the brain. Exercise is also necessary for the brain and simply walking regularly has been shown to be healthy for the brain and protects against AD. Lastly, we need to engage in social interactions with other people; our brains thrive on healthy human interaction; social isolation is not healthy for the brain.
Protect: The brain must be protected from harmful substances and activities: smoking, alcohol consumption, head trauma, and stress all affect the brain size and functioning. Abusing drugs can also cause brain damage. Managing stress is important as chronic stress has a direct impact on the brain. Psychiatric disorders such as depression and bipolar disorder increase your risk for cognitive impairment and it's advised that you seek treatment for these.
Detox: Nature's priceless secret for good mental and physical health is a good night's sleep. Sleep is a brain tonic and essential for brain health as it is during sleep that the brain does its 'house-keeping' and flushes out toxins that have built up during the day, including those plaques associated with AD. Poor sleep increases your risk of AD, and AD in turn results in poor sleep. Maintaining regular and good sleep habits is a simple necessity for health.
Dr Ramlall says many mistake AD for normal age-related brain changes and vice versa. "AD is not inevitable as we age; its features are quite different from that of normal 'old age' but in the early stages, it may be difficult to make the distinction. The public should not try to self-diagnose; even trained clinicians can have difficulty making a diagnosis in the early stages of the disease so it is best to get assessed by a professional. A diagnosis is a lengthy but comprehensive process of assessment and investigations but if you are noticing changes in your functioning that are increasing in frequency or are causing you concern or affecting your functioning, consult a health professional."
"Apart from brain functions such as memory, concentration, executive functioning, and speech being affected, psychiatric symptoms can develop: mood changes, suicidal tendencies, psychosis (e.g. paranoia), behavioural disturbances (restlessness, wandering, aggression), and sleep disturbances. In the advanced stages patients may no longer be able to bathe, feed, or dress themselves or go to the toilet independently; urinary and faecal incontinence, inability to swallow and breathe may occur terminally."
It is important to reiterate that there are both reversible and irreversible causes of dementia/NCD or similar symptoms. It is therefore important to be thoroughly assessed, as early as possible after symptoms are first noticed, to exclude possible treatable/reversible conditions such as vitamin deficiencies such as Vitamin B12; thyroid hormone deficiency, and a brain bleed/tumour.
Why raise Alzheimer's awareness?
Even though AD is not a function of growing old, it is diagnosed most frequently in older persons >60 years. However, research has shown evidence that the disease starts much earlier in life –-the characteristic brain plaques of AD have been detected in people in their 30s. With advancing age, these plaques accumulate until they reach a critical level when functioning starts to be affected and symptoms manifest. Raising awareness is important for three reasons:
Early recognition is important to make a correct diagnosis. Even though there is no treatment or cure, early diagnosis will ensure that risk factors are treated early to minimise the exacerbation of the symptoms and patient functioning. Treatable conditions that can also cause further brain damage can be better controlled, e.g. it is common to find AD together with brain damage due to vascular disease (e.g. hypertension) or heart disease. The adverse effects on the brain become additive so treating and controlling blood pressure and diabetes, for example, helps to limit further insult to the brain. This, in turn, means that the patient's deterioration can be slowed and this makes a difference in terms of the level of care that will be needed over time.
The world is greying, meaning that people are living longer than ever before. We are therefore more likely to see people with the disease.
People are becoming more aware of their health in general, but while they remember to check their blood sugar and pressure and go for cancer screening, few people remember that the brain also has needs. It is the organ in your body that controls all other bodily functions as well as the ability to walk, talk, hear, see, smell, taste, think, remember and do all the simple and complex tasks of daily living and your job. We need to be taking care to nourish it, stimulate it and protect it from the day we are born; we can replace a kidney or heart that has failed but not the brain. So few people consciously remember to look after their brains… until it is too late.
A call to collective action:
Caring for a loved one who has AD or any dementia is a painful, stressful, demanding, financially costly and heart-breaking experience. It can also be a rewarding, loving, blessing to care for an ailing partner or parent. Families should ensure they are equipped with knowledge, but guided by a professional in their approach because each patient is unique in how they present and progress in their care needs. "Caring for the patient starts with caring for the carer: the caregiving can take its toll on the caregiver emotionally, physically and financially and caregiver burnout and depression are real and frequent occurrences so they should get the necessary support for all these domains. It is important to seek emotional and mental health support to deal with grief, depression, anger and the various emotions the illness and the patient will evoke in you."
AD in the South African context summarised:
Poverty, malnutrition, low education levels, high rates of trauma, substance abuse, hypertension and diabetes mellitus – which are often poorly or not treated at all – are risk factors that are more prevalent locally and place our population at higher risk for cognitive impairment. Another challenge locally are traditional beliefs about the cause of dementia in African communities. The belief that those suffering from dementia are possessed by evil spirits or are witches have led to the abuse, ostracisation and even murder of patients. Financial difficulties also result in families neglecting or abandoning patients. There are inadequate community support services for patients or their families and there is no government policy or service dedicated to dementia care.
AD healthcare for the eThekwini District
A Memory Clinic is held monthly at Inkosi Albert Luthuli Central Hospital in Durban which offers diagnostic and treatment services, however, community-level education, health promotion and psychosocial support for affected persons and their caregivers are sorely needed. The Bessie Makatini Foundation works with people living with dementia and the elderly with mental illness. Their services are free and they are community-based with offices in Lamontville butwork all over eThekwini and surrounding areas (Umlazi, KwaMashu, Klaarwater, Wentworth, Chatsworth, Amanzimtoti, Inanda, Mbumbulu etc). You can reach them on 071 451 7551 / 072 339 5953.
"AD is a devastating disease that robs people of the essence of what it means to be 'alive' – we take so much of what we are able to do and enjoy every second of our lives for granted. As AD evolves, sufferers lose essential functions and feelings, adults become more helpless than babies, a parent or spouse you have known and loved for decades no longer recognises you… these are humbling moments when we need to appreciate and preserve the faculties we have been blessed with. Start taking care of your brains TODAY; it is too late to start worrying about AD when you feel you are 'getting old'," Ramlall says.
Alzheimer's SA National Office
011 792 2511
By: Lunga Memela (Communications Officer)
The latest report on levels and trends in child mortality by the United Nations Children's Fund (UNICEF) confirms that despite dramatic reductions in child and youth mortality over the last 30 years, the global burden of child and youth deaths remains immense. With this in mind, perhaps the most precious gift a mother can give her new-born baby is avoiding alcohol during pregnancy in order to afford them life-long health and to unlock their inherent development potential.
According to the Association for Alcohol Responsibility and Education (aware.org), fetal alcohol spectrum disorders (FASD) remain the leading cause of preventable birth defects and developmental disabilities in children around the world. The key message is that the damage caused by FASD is permanent, but it is 100% preventable. "Their tomorrow starts when you don't drink… All you need to do is to NOT drink when you are pregnant," warns the organisation.
International Foetal Alcohol Syndrome Day (FASDay) is observed annually on 9 September. It was first commemorated on the date 9/9/99 – the day being chosen so that on the ninth day of the ninth month of the year, the world would remember that during the nine months of pregnancy a woman should abstain from alcohol.
Every parent wants what's best for their baby, and surely this shouldn't only begin once the baby arrives. Instead, because parenthood comes with the intrinsic joy and responsibility to love and care for new life created, why not treasure the gift, put down the bottle, and give your new-born the best possible future?
Associate Honorary Professor at the University of KwaZulu-Natal and attached to the Fetal Unit at Inkosi Albert Luthuli Hospital's Foetal Unit, Prof Ismail Bhorat said FAS is a condition in a child that results from alcohol exposure during the mother's pregnancy that causes brain damage, neurobehavioral developmental anomalies, growth problems and birth defects. The problems caused by FAS vary from child to child but defects caused by FAS are generally not reversible.
"The reason that it is crucial for women to know about the dangers of consuming alcohol in pregnancy is that many of the disabilities that it causes are not reversible. There are serious anomalies that can occur in the offspring, in particular, facial feature anomalies, cognitive anomalies (learning disabilities, attention deficit anomalies, intellectual problems) central nervous system anomalies, birth defects and growth problems. So the woman is exposing her offspring to serious problems," he explained.
Fathers should not be left out of the conversation
Bhorat said fathers-to-be are crucial to the discussion as they could play a vital supporting role and comfort base. "If the fathers are drinkers they should be able to stop too as a support statement to their partners. Also, as fathers, they too will be impacted by anomalies, both functional and anatomical, of their child so they are part and parcel of the unit."
If a pregnancy is being planned, the mother to be should stop alcohol consumption before conception. If the pregnancy was unplanned, alcohol consumption should stop immediately as the mother confirms the pregnancy. "Alcohol intake in the first trimester is associated with increased risk for abortions and stillbirths," Bhorat advised. "If the mother is breastfeeding after delivery, she should abstain from consuming any alcohol until after the lactating period."
The social impact of FASD
"The lives of families living with children affected by FAS varies and differs depending on the severity and degree of the anomalies expressed in the children," said Bhorat. "In severe cases where there is a substantial intellectual deficit it would have a massive impact both emotionally and financially on the family as these children may end up in a 'special needs' education track. Lesser problems of attention deficit disorder, learning disabilities, cognitive disorders and hyperactivity can still impact substantially on families."
Dealing with alcoholism and pregnancy
Alcoholics who fall pregnant will need to seek professional help. A multidisciplinary team involving the obstetrician, physician, counsellor, psychologist/psychiatrist and possibly her general practitioner should be assembled to deal with, treat, monitor and support the patient.
"The isolation and social distancing that comes with COVID could impact on women who consume alcohol as these social mechanisms to combat the disease in itself can induce stress and worsen the habit. It may make it even more difficult for these patients to access help. In these scenarios it is crucial for their partners and families to be involved in helping them cope and to be able to identify when professional help is required," said Bhorat,
Towards raising continuous awareness
FAS is the most common preventable form of mental disability in the world and South Africa has the highest reported rate of FAS in the world. Statistics reveal that on the west coast of South Africa, 64 children per 1000 are affected (6.42%) making it one of the highest in the world. While there are continuous and joint efforts from institutions of higher learning, non-governmental organisations and health practitioners and social workers to raise awareness about FAS, more work is to be done to undo the general ignorance of the effects of alcohol on pregnancies.
Awareness can be increased by delineating special days of awareness, education at women's health clinics, and promoting media awareness programmes. Schools and universities, in particular, should be included in these awareness programmes.
By: Judith King (SA SURE Plus Copy and Content Editor)
Few among us would look forward to being pierced with a needle of any size, much less waiting for several hours at a clinic to have this done – and when this procedure is necessary to determine one's HIV status, it can be even more challenging for clients.
HIV self-testing – or HIV self-screening (HIVSS) – offers a fast, reliable and painless alternative to the fingerprick blood test. Using the OraQuick test-kit (quality-assured and approved by the National Department of Health), clients can collect their own oral-fluid sample by swabbing their gums and testing it with the kit materials, which yields a result within 20 minutes.
Health Systems Trust is supporting the introduction of HIVSS as a formal HIV Testing Services (HTS) intervention in facilities and communities, in collaboration with the Department of Health (DoH). Trained HST and DoH Lay Counsellors work from facility entry points − waiting areas or consultation rooms − in high-burden facilities to assist clients with the HIVSS process, and the service is delivered by Outreach Teams in communities.
At facilities, clients who are interested in carrying out the test immediately may do so in the Lay Counsellor's office or in pop-up tents on the clinic premises (which ensures client confidentiality during screening and interpretation of results). The Counsellors provide pre- and post-test counselling, and guidance on how to administer the test and interpret the result, whether positive or negative.
If an HIV-positive result emerges, the client is referred immediately to a nurse who assesses the person's readiness for initiation on antiretroviral therapy (ART). If the result is negative, the client is encouraged to return to the facility in six weeks' time for a confirmatory test.
The clients' contact information is recorded for follow-up phone calls and home visits, which are important for providing emotional support and ensuring that they understand the need to be re-tested and receive treatment if necessary, along with the offer of testing for partners and children.
Assisted HIVSS at Mpumuza Clinic
At Mpumuza Clinic in the uMgungundlovu District of KwaZulu-Natal Province, six HST and three DoH Lay Counsellors are instituting HIVSS for clients in the Acute, Mother and Child, and Chronic Streams. First, the Counsellors provide health education about HIVSS and the OraQuick test to promote the service. Willing clients are then ushered to one of three pop-up tents just outside the clinic building, where they can self-administer the OraQuick test under the Lay Counsellor's guidance and supervision.
Members of the HST team that assisted HIVSS at Mpumuza Clinic in uMgungundlovu
"The involvement and support of the clinic's Operational Manager has been key to securing the DoH staff's buy-in for the service," explains Palesa Jali, HST's Area Co-ordinator. "He understood that the concept enables management of approximately three client HIV tests within 30 to 40 minutes, including pre- and post-test counselling. This improves the clinic's performance towards reaching its HIV testing targets. It also shortens the clients' waiting time and helps to decongest the clinic space, which is especially important during the COVID-19 pandemic."
HIVSS pop-up tents outside the Mpumuza Clinic
HST Area Co-ordinator Palesa Jali discusses HIVSS with a client
The primary benefit of HIVSS is its patient-centred focus in enhancing access to and acceptability of HTS and linkage to care. Assisted HIVSS ensures that people in HIV high-burden populations who are undiagnosed or hard to reach – notably men and adolescents – have more options for knowing their status. In turn, this contributes to achievement of the UNAIDS global '90-90-90' and 2030 testing, treatment and viral suppression goals.
Mpumuza Clinic's Facility Team Leader, Phumzile Mtolo, confirms that although women make up the majority of the facility's HIVSS clientele, good numbers of men and young people are taking up the service. "We've found that youth in the 12- to 15-year age group and men are happy to use the OraQuick test because they can avoid the needles. Also, men prefer not to be inconvenienced, so if there is a group of male friends, they can do their own testing in the tents simultaneously and this works – they don't procrastinate."
"If the client has been well educated beforehand, it's much easier for them," adds Mtolo. "They appreciate seeing the result for themselves, whatever it may be, and accept that it's as accurate as a blood test. Those whose first results have been negative are also returning for their confirmatory tests six weeks later. The quality of pre-counselling is therefore vital because it's a new service, but if it's done correctly, people are open to it."
DoH Lay Counsellor Busiswe Mthetwa agrees. "Together with the HST teams, we support each other with implementing HIVSS, which clients love because there is no fingerprick required. Initially some don't believe that the test can be done with oral fluid, so it's very important that we relay the correct messages to them, as guided by our HIVSS training. We take care to inform clients that the OraQuick test is optional; we don't want to infringe on their rights and we must respect their decisions, although very few clients refuse this option. We listen to the clients' concerns and reassure them."
"I chose HIVSS because it's much easier in the mouth than the fingerprick," says client Nonhlanhla Nxumalo. "This is my six-week re-check, and I came back for it because there's no pain. I enjoy the pre-test counselling, as it reminds me of things I may have forgotten when the initial counselling and test were done. I did not doubt my result, as the Lay Counsellor explained everything so well."
Uptake of HIV treatment
Immediate enrolment on treatment among HIVSS clients whose result is HIV-positive is not as easy. "Many are still not ready," Mtolo says. "Last week a 15-year-old was very upset about her result, but she came back for treatment. Some refuse point blank and probably don't want to disclose, so they make excuses about having to bring their partner back with them… but the Lay Counsellor will arrange with the Index Contact Testing team to follow up with them."
HIVSS integration with index contact testing
In both facility- and community-based settings, index contact testing is an integral approach for reaching untested populations. All client interactions include an offer for the patient's partner or child to use HIVSS kits, with support for partner notification.
Re-testing in the community is also being implemented by Outreach Teams. "Our current concern is the low headcounts in the clinics because of COVID-19 and other factors like multi-month script dispensing, so we're not seeing the usual number of clients coming into the facility," says Jali. "We should see better HIVSS uptake once more clients come in, but in parallel, the Outreach and Index Contact Testing teams are finding clients for HIVSS at household level."
"The uptake of HIVSS is currently higher in facilities than in the community," notes Felicity Basson, HST's HIV Testing Services Co-ordinator for KwaZulu-Natal. "This can be attributed to HIVSS being rolled out at facilities by our staff with the support of DoH personnel, and that we cover more facilities with direct service delivery than the Outreach Teams do."
Collaborative training, tools and roll-out plans
Earlier this year, HST and the Provincial Department of Health jointly developed an HIVSS Standard Operating Procedure and screening tools, and a revision of the HTS Register to include HIVSS. Training of DoH staff on these tools will be rolled out in other HST-supported districts. Prior to the outbreak of COVID-19, HST introduced assisted HIVSS at colleges, universities, factories and farms during wellness campaigns.
"HIVSS targets will be set for all teams at facility and community level," says Basson. "We hope to leverage private pharmacies in eThekwini to supply the OraQuick test-kits, and to extend HIVSS implementation to other workplaces and truck-stops, all the while observing COVID-19 precautions."
All applications of HIVSS conform to the World Health Organization's 'Five Cs': Consent, Confidentiality, Counselling, Correct test results, and Connection.
By: Jennifer Ngcobo (Clinical Advisor)
Since 20 April 2020 a team of clinical advisors from HST's Unfinished Business for Adolescent and Paediatric HIV project joined the eThekwini district COVID-19 screening and testing teams to assist with testing activities in the field. Following a half-day's training on the testing protocol l, we were allocated to different field teams covering various parts of the district. These teams had already been at work in the field and were comprised of various stakeholders, such as Department of Health and municipality nursing staff, partners supporting health services, metro police and community leaders from surrounding communities.
On a typical day in the field each team meets at a specified location in the morning for a briefing. During this meeting the team leaders provide a directive on what the day will look like, including an allocation of testing sites for the teams. The briefing meeting also involves a reflection on the previous day's work and reporting on the total number of tests conducted by the team. A complete testing and screening team consists of a driver mobilizer, outreach nurses and metro police.
The briefing session is also used to replenish supplies, such as test kits and stationery, in preparation for the field work. This task is not allocated to a single individual to complete, rather all team members contribute to ensuring that the team is prepared and ready. After the briefing teams travel to the field to conduct testing as per the schedule. The current strategy is to provide testing for all clients, with the aim of reaching a specified testing target every day.
Normally, the day before testing is to be conducted in a residential area a mobiliser will visit the area to get buy-in from the community leaders, in preparation for the testing activities. However, when teams are allocated to malls and shopping centres mobilization in the area happens on the day of the testing. When testing is done in complexes one team member — normally the person leading the team — asks for permission to enter the building.
Once in the specified area the team sets up stations in preparation for the day's work. Often this includes setting up the mobile health units and gazebos. The team lead then assigns each member a task: one member is allocated to testing, another assists the tester and others are responsible for completing the relevant forms that are part of the screening and testing process.
At the end of each day the team lead checks the specimen cooler boxes to see if the specimens and lab forms match, before taking the specimens to the NHLS mobile unit and ensuring that any waste is discarded properly.
Although this is how a typical day is structured, one soon learns that field work is often unpredictable. In the two weeks that I've spent on a COVID-19 community screening and testing team I have learnt the following:
Below are some photos from the field.
One of HST's testing teams outside a mobile unit, dressed in their PPE
A closer look at the PPE that our field staff are required to wear
Someone once said that the true meaning of Christmas is not to open gifts, but to open our hearts. Despite the commercialisation of this holiday, it is always a time when communal spirit rises and spreads out through acts of charity and kindness.
In the daily round of their work throughout the year, the SA SURE project's Youth Ambassadors (YAs) – who form part of our district teams supporting the Department of Health's Adolescent and Youth-friendly Services (AYFS) – encounter many young people in dire and often tragic circumstances. While running a holiday programme at the end of 2019 in eThekwini, the YAs sought additional ways to relieve the plight of several orphaned and vulnerable youngsters – donating their own funds to do so.
Under the guidance of AYFS Champions, the YAs' role entails engaging with youth in facility-based Youth Care Clubs and running activities in AYFS Chill Rooms, to mobilise HIV Testing Services, distribute condoms, and educate groups about teenage pregnancy, gender-based violence and general health issues. When young clients in need are identified, the YAs facilitate their access to health and social services through referrals to the clinic and relevant government departments, and recruit them for support groups and psychosocial advice where necessary.
Ten more Youth Ambassadors were added to the eThekwini team in the latter part of 2019, bringing the total of YAs are supporting the facilities to 50. They worked through the festive season to strengthen AYFS implementation, creating a surge in condom distribution, which is so important because safe sex practices reduce HIV infection incidence and prevalence.
The YAs function collectively and in strong partnership with the eThekwini Metro Department of Health to respond to youth health needs. Nthabiseng Malakoane of the Metro's Health Unit explains: "We work with HST's Youth Ambassadors and AYFS Co-ordinators to implement the Department of Health's Adolescent and Youth Health Programme. During December 2019, we identified several child-headed households in Verulam with young clients in urgent need of support in the form of food and toiletries."
"One young girl, whose caregiver grandmother had passed away that month, was not sure how she would be able to return to school in 2020. As a team, we felt that it was important to take personal and practical action in such cases. We gathered donations from colleagues to fund supplies of groceries and school fees. The Youth Development Office in the eThekwini Mayoral Parlour helped with provision of school uniforms."
After giving a health talk to promote AYFS and HIV testing at Amaoti Clinic in Phoenix, the YA referred a young girl who was feeling ill for testing, and she was found to be HIV-positive. She had previously been enrolled on HIV treatment in Stanger, but had defaulted on her medication when she moved back to her late parents' house after being raped by her uncle. The girl was re-initiated on antiretroviral therapy and received adherence and psychosocial counselling, and her sexual assault case was referred to the Department of Social Development. Through staff donations, the YA team supported the girl with provision of groceries.
Youth Ambassador Mbali Mzobe secured sponsorship from Vodacom for school stationery, which was delivered to Montarena High School in Chatsworth and Ndukwenhle High School in Umlazi R section on 12 February 2020.
Learners with their Vodacom-sponsored stationery packs.
Our AYFS team members are diligent and passionate about recognising their young clients' dignity and translating this commitment into creative, tangible support. Nthabiseng concludes: "Together, we want to do more to help young people and give them hope."
Health Systems Trust, together with the TREATS consortium, and the London School of Hygiene and Tropical Medicine (LSHTM), offered a Masters Fellowship to a promising young statistician who is now pursuing a Masters degree in medical statistics at the LSHTM. At the end of 2020 he will return to South Africa for a one-year work attachment to the South African TREATS study site with the research programme of the Tropical Epidemiology Group (TEG) at LSHTM.
Read more about the TEG Fellowship here.
Meet Jacob Busang – South African TREATS TEG Fellow 2019.
1. Tell us a little bit about yourself? What program are you in at the LSHTM?
My name is Jacob Busang and I was born and bred in Shakunyaneng Village, in the North West Province, South Africa. I completed high school in 2014 at Thomas Makgatho High School (now called Mmamogwai Secondary School). I completed a Bachelor of Science (BSc) Mathematical Sciences at the Sefako Makgatho Health Sciences University (SMU), majoring in Mathematics and Statistics, in 2017. Followed by a BSc Honours in Statistics at SMU in 2018. All these degrees were conferred with distinction pass (cum laude).
On the 1st of April 2019 I started my internship with the National Research Foundation (NRF) and was placed as a Biostatistician at the Perinatal HIV Research Unit (PHRU), a division of WITS Health Consortium.
I am Currently doing a Masters in Medical Statistics at the LSHTM. It's a one-year full-time taught masters which commenced in September 2019.
2. When did you realise that you wanted to pursue a career in statistics or research?
At first my interest was in Actuarial Science, however, I pursued a BSc with the hope of eventually moving into Actuarial Science. Along the journey of my BSc I just fell in love with statistics and decided to pursue a career in statistics.
3. Which aspect of the health sector gets you most excited?
I'm most interested in applying my statistical skills and knowledge in public health with a focus on TB and HIV/AIDS given the high burden of HIV and TB in South Africa.
4. Where do you see yourself in 10 years?
By then I would hope to have completed a PhD and be Dr Busang and hopefully one of the leading statisticians in South Africa. I hope to be part of one of the leading research institutions doing important research that brings about positive impact and change to our lives and the health sector overall.
5. What is the best piece of advice you've received?
Explore the world and collaborate. Basically, this means that "no man is an island. No one is self-sufficient; everyone relies on others".
6. Who inspires you? Who are some of your role models?
I've been inspired by many people I've met in my life, the likes of Dr Mathews Katjene, Prof Solly Seeletse, Dr Neil Martinson, my friend Keatlegile Mabena (author of Breaking the Chains), the list is just too long. Last but not least is Prof Kennedy Otwombe (PHRU), who is the one who encouraged me to apply for the TREATS TEG Fellowship.
7. What advice would you give to students looking to pursue either studies or a career in statistics?
Statistics is a growing field and statisticians are in demand, especially in Africa. But one must not find oneself in a career simply because it is in "demand". A person pursuing studies or a career in statistics must demonstrate a love and interest for it, possess problem-solving skills and understand data and numbers. One will need analytical skills and the ability to apply critical thinking.
by Roma Ramphal, CCMDD Provincial Co-ordinator: KZN
Health Systems Trust (HST) has embarked on a journey with Technovera, a South African company founded by South African engineer Neo Hutiri, who invented the Pelebox Smart Locker to improve access to medicine for patients with chronic diseases in under-serviced communities.
The purpose of the Pelebox is to establish a cost-effective, convenient, quick and efficient alternative medicine parcel collection system.
Pelebox can accommodate up to 1 500 collections in a month, so that if a facility has fewer than this number of patients, all CCMDD medicine parcels held at the facility may be collected from the Peleboxes installed on its premises.
The Pelebox allows a facility to dissolve its Spaced Fast-Lane Appointment (SFLA) collection point − a facility-resourced internal pick-up point where patients registered on the Central Chronic Medicine Dispensing and Distribution (CCMDD) queue for their medicine parcels. The Pelebox thereby relieves the facility staff of managing the SFLA and helps to decongest the clinic.
By making patients' access to medicine more convenient, rapid and efficient, usage of the Pelebox also helps to increase their adherence to medicine, and thus supports South Africa's achievement of the second and third '90s' of the UNAIDS 90-90-90 targets.
HST assessed several potential Pelebox sites according to Technovera's criteria for installation − which include an undercover area with minimal exposure to the weather, an electrical power source, Internet connectivity, interoperability with existing CCMDD systems, and proper drainage for the cooling system. HST has installed Peleboxes at Prince Cyril Zulu Communicable Disease Centre, Savannah Park Clinic, Mzamo Clinic, Chesterville Clinic and Umlazi N Clinic in the eThekwini District of KwaZulu-Natal.
What's inside the lockers?
The lockers contain CCMDD-registered patients' medicine parcels packaged in brown boxes.
What type of medicines are offered through the CCMDD Programme?
The programme offers medicines that are prescribed for all types of chronic conditions.
Who can choose the Pelebox?
Any patient who is registered on the CCMDD Programme can choose the Pelebox as a collection-point option. The patient must have a cellphone number or access to a cellphone number through which to receive an SMS that provides him or her with a one-time Personal Identification Number (PIN).
When can a patient come to the Pelebox to collect a parcel?
If the Peleboxes are stationed outside the clinic, they are accessible 24 hours a day, seven days a week. At some clinics, the Peleboxes are installed inside the clinic and are accessible only during the clinic's hours of operation.
What happens if a patient loses his or her one-time PIN?
The patient can access the locker with his or her 13-digit ID Number and cellphone number. The patient can also request the system to resend the PIN.
What happens if the locker does not open?
The patient should enter the clinic and ask for the help of the Pharmacist Assistant.
Does the Pelebox system allow the patient to update his or her cellphone number when collections are made?
Yes, it does.
What is Health Systems Trust?
Health Systems Trust is a non-government organisation that supports health systems in partnership with the Department of Health to improve public health patients' experience of service delivery.
HEALTH SYSTEMS TRUST - CONTACT DETAILS
34 Essex Terrace, Westville, Durban, 3630
+27(0)31 266 9090