Substance use disorder treatment in the community is a superior alternative to incarceration for offenders with a substance misuse background, according to a recent study evaluating the effectiveness of the contract treatment sanction in Sweden.
Contract treatment refers to a criminal penalty in which the offender voluntarily consents to treatment in accordance with a specific implementation plan.
“Contract treatment is an alternative to incarceration. It is mainly used when the offence is deemed to have occurred as a result of substance misuse or some other condition requiring treatment,” says Suvi Virtanen, a University Lecturer in Psychology at the University of Eastern Finland.
A rehabilitation period is always planned based on individual needs. In addition to psychosocial treatment, it may include opioid substitution therapy.
In addition to Sweden, a sanction similar to contract treatment is in use in, e.g., Norway and many EU countries; however, not in Finland. The United States, in turn, has adopted a model of specialised drug courts.
Contract treatment carries a smaller risk of recidivism
Although contract treatment has been in use in Sweden since the late 1980s, its effectiveness has not been studied until now. The present study combined data from the Swedish Prison and Probation Service’s client register with other national registries, including data on visits to specialised health care. The study cohort included 11 893 individuals who were serving a contract treatment sanction between 1999 and 2012, and they were followed up for at least two years.
“With the introduction of contract treatment, criminal behaviour and substance-related adverse health events, such as overdoses and hospitalisations due to psychiatric and somatic reasons, decreased significantly compared to the period before contract treatment,” Virtanen says.
A significant proportion of those sentenced to contract treatment had also served community sanctions and prison sentences. In the within-individual research design, an individual’s risk of recidivism and adverse health events during contract treatment was examined compared to periods when the individual was serving a community sanction or was on parole after a prison sentence.
“The risk of recidivism and adverse health events was lower during contract treatment than during a community sanction or probation,” Virtanen notes.
Providing treatment yields better results than punishment
Substance misuse problems and criminality often go hand in hand. The most effective way to prevent recidivism is to address its root causes, which often are, in one way or another, linked to the use of substances.
“Substance use disorders are increasingly understood as a health issue that should primarily be addressed by means of health care. Usually, prison is not the best place for an individual who needs appropriate treatment and support for recovery,” Virtanen says.
The results of the study provide support for the notion that, from the viewpoint of societal security and public health, providing treatment can lead to better outcomes than penalties that emphasise punishment.
In the future, the researchers intend to study the effectiveness of contract treatment in more recent data.
In an age where healthcare integrity is of the utmost importance, a coalition of industry pioneers and technological trailblazers must lead the charge in driving transformation to combat fraud, waste and abuse (FWA) in the healthcare sector.
As a focal point of discussion on day two of the 2024 BHF Annual Conference, Vusi Makanda, HFMU Deputy Chairperson, and Manager of Fraud Management at Bonitas, set the stage for an interactive discussion on these healthcare issues.
“Collaboration is paramount in addressing the challenges of healthcare FWA, evidenced by the erosion of trust and substantial financial losses highlighting the call for collective action,” says Makanda.
Dr Hleli Nhlapo, MD of the medical schemes division at Dental Information Systems (DENIS), echoed Makanda’s sentiments. To this end, Nhlapo set the scene on the current state of FWA in the healthcare industry, suggesting that it exerts unnecessary pressure on resources while undermining trust between stakeholders.
“Perpetrators are employing increasingly sophisticated tactics, leveraging technology and syndicates to orchestrate large-scale schemes, while regulatory delays and prosecutorial challenges hinder effective resolution,” says Nhlapo. “Despite this, collaboration among healthcare funders has emerged as a crucial solution, with recent initiatives indicating a promising shift towards industry-wide cooperation in addressing these complex challenges.”
Following Nhlapo’s address, Roxane Ferreira, Head of Department at the Association of Certified Fraud Examiners (ACFE), alluded to several global trends in FWA that are plaguing the global industry.
The impact of these is extensive and has led to concerning financial situations for healthcare systems around the world. So much so that Ferreira’s insights suggest that in the United States, it is estimated that as much as $68 billion is lost every year on the back of FWA.
“In South Africa, the problem is not much better, with between R8 billion and R13 billion being lost annually to this. With between 15-35% of all claims submitted regarded as being fraudulent or abusive, the plight is adding approximately R22 billion to the cost of private healthcare,” adds Ferreira.
Healthcare fraud is perpetrated by a variety of actors within the system, ranging from medical scheme staff to service providers and even syndicates. These perpetrators exploit vulnerabilities at different points in the healthcare process, whether through falsifying claims, overbilling or engaging in other deceptive practices.
Moreover, medical scheme members themselves, as well as patients, may also be complicit in fraudulent activities, while brokers and manufacturers can also play a role in facilitating these plans.
Ferreira highlighted the multifaceted approach employed in identifying healthcare fraud, citing that 70% of cases stem from tip-offs or received information, while the remaining 30% are uncovered through data mining, audits and investigations.
“Healthcare fraud encompasses various deceptive practices,” suggests Ferreira. “ Some of the most common ones include merchandising, where pharmacies sell non-healthcare merchandise, but claim for a healthcare service; false claims by claiming for services rendered; ATM scams where doctors submit false claims and provide cash to patients; card farming where members lend their membership cards to non-members; code gaming that involves doctors manipulating billing rules to increase revenue; and lastly, the hospital cash plan fraud that entails doctors and members colluding to arrange unnecessary hospital admissions.”
In response to the escalating challenges of healthcare fraud, Ferreira adds that the sector is increasingly turning to innovative solutions, with the integration of Artificial Intelligence (AI) emerging as a pivotal strategy.
“AI technology offers the capability to analyse large volumes of data rapidly and accurately, enabling the identification of suspicious patterns and behaviours,” she says. “By leveraging AI algorithms, healthcare providers can proactively identify questionable activities, thereby safeguarding resources and maintaining the integrity of healthcare systems”
Using these advanced algorithms, AI can swiftly identify irregularities, such as sudden spikes in billed procedures and visit rates. Furthermore, it can compare billing practices, verify purchases, compare the geographical location of a patient against the practice, and treatments billed for the same or similar treatment by other practices.
In the fight against healthcare FWA, collaboration and technological innovation are emerging as critical pillars. By harnessing advancements such as AI, healthcare systems can effectively detect and prevent fraudulent activities, thus safeguarding resources, upholding the integrity of patient care and rebuilding trust.
The world’s largest study of cerebral palsy (CP) genetics has discovered genetic defects are most likely responsible for more than a quarter of cases in Chinese children, rather than a lack of oxygen at birth as previously thought.
The study, published in Nature Medicine, used modern genomic sequencing and found mutations were significantly higher in CP cases with birth asphyxia, indicating a lack of oxygen could be secondary to the underlying genetic defect. The results are consistent with smaller studies globally.
More than 1500 Chinese children with CP were involved in this collaborative effort between the University of Adelaide and Fudan University Shanghai, Zhengzhou University, Zhengzhou and associates.
The Australian team was led by obstetrician and University of Adelaide’s Emeritus Professor Alastair MacLennan AO and human geneticist, Professor Jozef Gecz.
“24.5 percent of Chinese children in the study had rare genetic variations linked to cerebral palsy. This revelation mirrors our earlier findings in our Australian cerebral palsy cohort, where up to one third of cases have genetic causes,” said Professor Gecz, who is the University of Adelaide’s Head of Neurogenetics at the Adelaide Medical School and the Robinson Research Institute.
“Our research shows at least some babies who experience birth asphyxia and are diagnosed with CP may have improper brain development as a result of the underlying genetic variants rather than a lack of oxygen.
“Crucially, clinically actionable treatments were found in 8.5 percent of cases with a genetic cause. It is exciting to see how genetic pathways to cerebral palsy inform tailored treatments for these individuals.”
Cerebral palsy affects movement and posture and is the most common motor disability in children. The disorder is diagnosed in up to 2 per 1000 children globally and is sometimes in association with epilepsy, autism and intellectual difficulties. Symptoms often emerge during infancy and early childhood and can range from mild to severe.
The research team identified 81 genes with causation mutations in the children with CP. These genes are known to play important roles in neural and embryonic development and may affect the molecular pathways responsible for respiration.
Oxygen deprivation frequently claimed in medical litigation
“A lack of oxygen at birth is often claimed to be the cause of CP in medical litigation following a diagnosis and this has led to the presumption that the condition is preventable with better obstetrics or midwifery. This is simply not the case,” said Professor MacLennan, who has spent the past 30 years advocating that there is little scientific evidence to support the myth that cerebral palsy is due to trauma or lack of oxygen at birth.
Professor MacLennan said frequent litigation has been associated with a high increase in “defensive” caesarean delivery and high insurance premiums for obstetricians.
“These results highlight the need for early genetic testing in children with cerebral palsy, especially those with risk factors like birth asphyxia, to ensure they receive the right medical care and treatment.
“All children with cerebral palsy merit modern genetic screening as early and customised interventions really can make a difference and improve their long-term outcomes,” he said.
Ongoing genetic research is also investigating other types of contributing genetic variation to the cause of CP and, as a result, the researchers expect that the overall genetic diagnosis rate is likely to increase.
A new study by a global team of researchers has revealed that areas of age-related damage in the brain relate to motor outcomes after a stroke – a potentially under-recognised phenomenon in stroke research. The study was published in Neurology.
A stroke often leads to motor impairment, which is traditionally linked to the extent of damage to the corticospinal tract (CST), a crucial brain pathway for motor control. Signaling along the CST is involved in a variety of movements, including walking, reaching, and fine finger movements like writing and typing. However, stroke recovery outcomes aren’t fully predicted by damage to the CST, suggesting other factors are at play.
The new observational from the Enhancing Neuroimaging Genetics through Meta-Analysis (ENIGMA) Stroke Recovery working group. It examines how one such factor could be white matter hyperintensities (WMHs) – areas of age-related damage in the brain’s white matter, which represent vascular dysfunction and are known to impact cognitive functions. The goal of the ENIGMA Stroke Recovery working group is to understand how changes in the brain after stroke relate to functional outcomes and recovery. ENIGMA Stroke Recovery has data from over 2100 stroke patients collected across 65 research studies and 10 countries, comprising the most extensive multisite retrospective stroke data collaboration to date.
Study leader Sook-Lei Liew, PhD, said: “We are grateful for our many collaborators around the world who lead independent stroke research programs and who are willing to come together and enable large-scale investigations into these critical questions about the role of overall brain health in stroke recovery and rehabilitation.” Dr Liew is an associate professor at the Keck School of Medicine of USC.
The study analysed data from 223 stroke patients across four countries and found that larger WMH volumes were associated with more severe motor impairment after a stroke (e.g., difficulty moving or using their arm for daily tasks), independent of CST damage. WMHs are related to chronic hypertension, diabetes, high cholesterol, and smoking, among other factors and conditions, and have been strongly related to cognitive impairment, but not extensively studied in the context of motor impairment. Interestingly, the relationship between CST damage and motor impairment varied based on WMH severity. Patients with mild WMHs showed a typical relationship between CST damage and motor impairment, while patients with moderate to severe WMHs did not have this relationship. Instead, motor impairment was related to WMH volume, not CST damage.
These findings suggest that WMHs, indicative of cerebrovascular damage from a variety of sources, could provide additional context to understand an individual’s potential for recovery post-stroke. Therefore, assessing WMH volume could improve predictive models for stroke recovery.
“WMHs are related to overall cardiovascular and brain health as we age. By integrating assessments of age-related brain health, we may be better able to predict stroke recovery and tailor rehabilitation to individual needs. This personalised approach could open avenues to improve outcomes after stroke,” says lead author Jennifer K. Ferris, PhD, of Simon Fraser University.
The researchers’ next step is to pursue longitudinal studies to confirm their findings. This insight lays the groundwork for developing more accurate markers for recovery, which could transform post-stroke care and rehabilitation.
The more gender equal a society is, the more similar men and women will be, adopting more similar interests, personality traits and behavioural patterns. Or so many people seem to believe.
Statements like this might sound like truisms, but science shows reality may be more complicated.
Several studies have found that some psychological sex differences, such as those in personality, are larger in more gender-equal countries. The same goes for countries that are more educated, prosperous and otherwise have better living conditions. This has become known as the gender-equality paradox.
Until recently, it was unclear how widespread this pattern might be. My team, which included research assistant Kare Hedebrant, tried to address that in a recently published study, where we investigated which psychological sex differences are associated with living conditions and, if so, how.
The study covered a range of themes, from personality and cognitive functions to sexting and circadian rhythm. Our study focused on mostly western countries but used some data from other countries such as India and Kenya.
We reviewed 54 articles that analyse the relationship between magnitudes of psychological sex differences and country-level indicators of living conditions. We also used data from 27 meta-analyses (reviews of previous research) of psychological sex differences and conducted new analyses to determine associations between sex differences and national economy, education, health, gender equality and more.
Sex differences
Each study used data from at least five countries, usually spanning several decades.
We grouped the many psychological dimensions covered by these studies into six categories: personal characteristics, cognition, interpersonal relations, emotion, academic preferences (such as a pull towards science, technology, engineering and maths) and morals and values.
Our findings paint a complex picture, showing that variation in psychological sex difference did not follow a uniform pattern. In countries with better living conditions, males and females are more alike in some regards and more different in others.
For example, differences in personality characteristics were frequently found to be larger in countries with better living conditions. This includes traits such as extroversion, agreeableness and altruism, which research seems to show are more strongly associated with women. The same was true for sex differences in some dimensions of emotion, specifically negative emotions in which females tend to score higher, such as shame.
There were also exceptions to the gender-equality paradox. Sex differences in sexual behaviour, like engaging in casual sex, were consistently found to be smaller in countries with better living conditions. This is probably because women in these countries, where there are more permissive norms, have better access to contraceptives.
A complicated phenomenon
For cognitive functions, sex differences were sometimes larger, sometimes smaller in countries with better living conditions. Interestingly, the sex differences were larger in cognitive domains where women have strengths.
For instance, episodic memory (memory for experienced events) and verbal ability, where females typically do better than males, saw larger sex differences as living conditions improved. Females got better at episodic memory when they had better living conditions. By contrast, sex differences in semantic memory (memory for facts) and mathematical ability, where males tend to do better, decreased when living conditions improved.
This suggests that, when it comes to cognitive abilities, females benefit more than males from improvements in living conditions. The performance gap increases in domains where females have an advantage and closes in domains where males are ahead.
Not all psychological sex differences were associated with living conditions in the same way. So, can we say that there is a gender-equality paradox? Yes, to some extent, since more sex differences grew, rather than decreased, in countries with better living conditions.
In most cases, however, psychological sex difference magnitudes were not significantly associated with living conditions. This suggests that, in general, psychological sex differences are not greatly affected by living conditions but seem instead quite stable. For instance, research often finds females get higher grades at school across different subjects. It’s also common for researcher to find males have greater interest in maths. But neither seems to be affected by living conditions.
Even in cases where the magnitude of sex differences did vary in relation to living conditions, the pattern of male and female advantages usually remained the same. So, for example, though the female advantage over males in episodic memory ability is greater in some countries than others, females outperform males in almost all countries.
In summary, we found little support for the idea that psychological sex differences will vanish as societies develop. Policymakers probably cannot rely on that if they hope to achieve equal distributions of men and women in different professions. Instead, it appears that the dominant feature of psychological sex differences is their robustness in the face of social change.
South Africa has seen the quickest and most alarming rise of diabetes on the continent; from an estimated 1.9 million people living with the condition in 2011 to 4.2 million by 2021 – with 7.5 million predicted to be afflicted by 20451. South Africa also has the fastest rising prevalence on the continent with an estimated 20% of the adult population either diabetic or pre-diabetic1. Globally, diabetes prevalence is predicted to rise by 46% between 2019 and 20452. It currently stands at some 537 million people worldwide1.
This emerged at the recently held annual Sanofi medical meeting, the Cardio-Metabolic Axis Forum from April 19th–21st in Cape Town. This was a meeting of leading endocrinologists, specialist physicians, nephrologists, diabetes-treating doctors, academics and Patient Advocacy Groups (PAGs).
Speaking at the conference, specialist physician and endocrinologist, Dr Landi Lombard – former editor of the South Africa Journal of Diabetes and Vascular Disease – told delegates that the risk of death associated with diabetes in cardiovascular conditions is more than twice that of people with non-diabetes, while in all-cause mortality, it’s just under twice that of a person living without diabetes. Of the estimated 537 million people living with diabetes globally, only about half are diagnosed, of whom 25% receive care, 12.5% achieve treatment targets, and 6% live a life free of diabetes-related complications1.
Dr Lombard said that the pandemic is being driven by poor lifestyle choices and diet, lack of exercise and widespread obesity in the population, so better healthcare worker communication and education of patients is vital to stem the tide of diabetes.
Professor Robert Ritzel of the Department of Endocrinology, Diabetology and Angiology at Schwabing Hospital in Munich, said the Pacific Islands and the Middle East led the world with diabetes prevalence at between 25 % and 40 %. He said what precipitated a surge in diabetes was the speed at which a nation changed from a traditional to a modern lifestyle. When this happened within a few years, diabetes prevalence was likely to range between 20% and 40%. However, when change occurred over many generations, it gave epidemiologists and clinicians time to adapt.
Lombard said one of the biggest challenges was what diabetologists called ‘therapeutic inertia’ which contributes to a patient living with sub-optimal blood sugar control for many years. This term embraced physician, patient and healthcare system factors, patient injection related factors, time and resource constraints among physicians and the lack of a proper healthcare system plan. He said that in people with Type 2 diabetes, the median time it takes for the disease to intensify while taking one or more anti-diabetic drugs is 2.9 years. However, the use of an injectable slowed intensification down to 7.2 years or more.
Reasons for failure to intensify treatment or progress to injectable therapies varied between specialist and primary care physicians but were mainly because of a patient fear of injection, too many injections, perceptions of this being a ‘last resort’ treatment, fear of weight gain, fear of low blood sugar, and poor communication with patients.
Lombard said even 1 year of poor blood sugar control in people with Type 2 diabetes could result in an increase in the cumulative incidence of kidney disease of 18%, neuropathy of 8%, retinopathy of 7% and a significantly increased risk of heart attack (67%), heart failure (64%), stroke (51%) and composite cardiovascular events (62%).
Professor Naomi ‘Dinky’ Levitt, former Head of Endocrinology and Diabetic Medicine at the University of Cape Town and Groote Schuur Hospital and Director of the Chronic Disease Initiative for Africa, highlighted gestational diabetes as one of the greatest challenges.
Described as the “doyenne” of endocrinology in South Africa (SA), Levitt said one third of women who have gestational diabetes go on to develop diabetes within 6 years of giving birth, so post-partum intervention is crucial.
According to Levitt, lifestyle interventions had about a 20% positive effect, mainly because new mothers were pulled in all directions by family, the baby, husband, and domestic and work needs.
She said that with 31.4% of SA women estimated to have developed gestational diabetes, it would be ideal to screen all pregnant women at 24 and 28 weeks. However, this would collapse the healthcare system because of the healthcare staffing demands, so the alternative was to focus on risk factors such as being over 30 years old or being overweight.
She said that focusing on women with gestational diabetes would have the greatest impact on the pandemic, as treatment can help avoid pre-eclampsia and improve foetal development, resulting in fewer admissions to the neonatal ICU.
Speaking on behalf of Sanofi the conference sponsor, Dr Asafika Mbangata said: “Sanofi puts patients first and the aim of the conference was to empower stakeholders with the right information to help make critical care decisions for patients by sharing the latest data on advancements in treatments and technologies, along with insights into global and local policy changes impacting diabetes care.”
“As we chase the miracles of science to improve people’s lives, we know we cannot shape the future of diabetes management without partnerships with healthcare professionals and other stakeholders. Collaboration across all medical disciplines is essential if we are to overcome this pandemic, and we’re hopeful the conference opened the door to future robust collaborative actions that improve patient outcomes,” concluded Dr Mbangata.
References
Adapted from IDF Diabetes Atlas (10th edition). International Diabetes Federation. 2022. http://www.diabetesatlas.org/. Accessed 23 April, 2024.
A preclinical study from Karolinska Institutet offers hope for treating severe neurodegenerative diseases with an existing drug: clofazimine, which is used to treat leprosy, may be effective in the treatment of Huntington’s disease.
The research group examined whether existing drugs could reduce the toxicity of so-called polyQ proteins. These proteins are found in patients with certain hereditary neurodegenerative diseases, including Huntington’s disease, for which there is no cure.
Screening hundreds of drugs, they found that the leprosy drug clofazimine reduces the toxicity of polyQ proteins and restores mitochondrial function in zebrafish and worms. The finding, published in eBioMedicine, supports the previous hypothesis that polyQ diseases are associated with the dysfunction of mitochondria, the organelles in charge of producing energy within cells.
“Our work not only suggests the interest of a specific drug for the treatment of polyQ neurodegenerative diseases, but also helps us to better understand what causes these diseases. It is possible to find new uses for old drugs, which reduces the time needed to find novel therapies”, says last author Oscar Fernandez-Capetillo, Professor and research group leader at the Department of Medical Biochemistry and Biophysics at Karolinska Institutet.
Clofazimine is not very efficient in entering the nervous system, however. The research group are now trying to figure out solutions to this limitation, by testing the efficacy of clofazimine in mammalian models of neurodegenerative disease.
“We hope that our discovery can be developed into a new medicine, but there are still some hurdles that need to be overcome,” says Oscar Fernandez-Capetillo.
The researchers are also conducting similar drug screens in other age-related pathologies such as cancer and other neurodegenerative disorders.
In South Africa, and across many developing nations, the discourse leading up to elections often centre on fundamental issues that directly impact the daily lives of citizens, such as the cost of living and access to clean water and sanitation. As the world witnesses a significant portion of its population gearing up to vote in 2024, it becomes evident that the voting criteria in developing countries vastly differ from those in developed ones.
While developed nations may debate topics like climate change and immigration, citizens in developing countries like South Africa are primarily concerned with securing basic necessities for survival and dignity. The disparity in voting patterns reflects the stark contrast in the challenges faced by people living in different parts of the world.
Elevating the discussion on South Africa’s paradox
South Africa, despite being regarded relatively highly in terms of election fairness, grapples with persistent challenges in providing access to clean water and adequate sanitation facilities. Our democratic process works, but it needs to be leveraged correctly for the benefit of our people. Many communities across the country continue to suffer due to the absence of proper sanitation infrastructure, perpetuating cycles of poverty and disease. The lack of clean water exacerbates these challenges, posing significant obstacles to health, dignity, and economic progress.
The interconnectedness of health, dignity, and economic progress
It is worth noting that the voting populace in South Africa has shifted its focus from ideological differences to practical concerns about the delivery of basic human rights. This shift underscores the importance of addressing the immediate needs of citizens before delving into broader policy discussions. Without access to clean water and sanitation, individuals and communities struggle to break free from the cycle of poverty and disease, hindering their ability to participate fully in economic and social life.
The impact of inadequate sanitation and clean water access extends beyond health and dignity – it also affects economic progress. Families burdened with preventable illnesses spend precious resources on healthcare instead of investing in education and livelihoods. Children often sacrifice their education to care for sick family members, further perpetuating the cycle of poverty. To address these challenges, practical solutions must be prioritised that ensure equitable access to clean water and sanitation for all citizens to break the cycle of poverty and disease and pave the way for economic growth.
Solving South Africa’s challenges starts with sanitation
These solutions include investing in infrastructure that can provide clean water and adequate sanitation facilities to all communities, especially those in rural and underserved areas, while at the same time investing in the repair and maintenance of existing infrastructure.
Implementing technologies such as water purification systems and innovative sanitation solutions tailored to local needs can help bridge the gap in access. Additionally, community engagement and education programs are essential to promote hygiene practices and ensure the long-term sustainability of water and sanitation initiatives. By prioritising these solutions, South Africa can make significant strides towards ensuring equitable access to clean water and sanitation for all its citizens.
Advocating for real change beyond election promises
Citizens have a central role to play in advocating for real commitment from political candidates. By elevating the discussion around sanitation and clean water access, voters are better informed to hold leaders accountable for delivering on their promises. Political parties must recognise the importance of addressing basic needs and commit to implementing sustainable solutions that uplift communities and promote dignity. For political parties this will be one of the most effective ways to win and retain the vote.
As we get closer to election date, it is essential to correctly prioritise the basic needs of citizens, including access to clean water and sanitation. This is not a critique of the government but a call to action – a recognition of the fundamental rights that must be upheld for all individuals to thrive. By addressing sanitation challenges, South Africa can pave the way for a future where every citizen has the opportunity to live a healthy, dignified life and contribute to the nation’s prosperity.
Creative artwork featuring colourised 3D prints of influenza virus (surface glycoprotein hemagglutinin is blue and neuraminidase is orange; the viral membrane is a darker orange). Note: Not to scale. Credit: NIAID
By Elri Voigt for Spotlight
COVID-19-related factors resulted in several years of lower-than-normal rates of the flu, but experts say that is now something of the past. As this year’s flu season gets under way, Elri Voigt asks several local experts what their expectations are, which flu vaccines are available this year, and whether we should be concerned about new strains of bird flu.
While most people who get the flu experience only mild to moderate symptoms, some can get severe symptoms and even die, especially the very young and the old. As Spotlight previously reported, the influenza virus causes around 11 000 deaths per year in South Africa, with around 40 000 people hospitalised.
Dr Sibongile Walaza, a medical epidemiologist and the Head of Epidemiology at the Centre for Respiratory Disease and Meningitis at the National Institute for Communicable Diseases (NICD), says that it is difficult to predict what a flu season will look like beforehand.
Nicole Jennings, spokesperson for the South African Pharmaceutical company Pharma Dynamics, agrees. “Influenza is a global disease and the spread of the virus in other parts of the world can influence the trajectory of flu seasons in different regions. For now, it’s too early to make any predictions,” she says.
It is difficult to predict the trajectory of flu seasons ahead of time, Jennings says, because of a “complex interplay” of factors, including the fact that influenza viruses are constantly mutating. This makes it difficult to accurately predict which strains of the influenza virus will dominate and how they will behave.
“The level of immunity in the population can also vary from year to year due to factors, such as vaccination rates, previous exposure to similar strains and so forth,” she adds. “However, surveillance efforts, modelling and ongoing research conducted by the NICD can help the public to prepare for the cold and flu season as best possible.”
NICD guidelines published in April 2023 already stated that since the COVID-19 pandemic, there have been some changes in the timing of flu transmission.
The transmission reduction strategies – like masking and social distancing – during the pandemic had an impact on the rates of flu transmission and the duration of the flu season between 2020 to 2022, according to Dr Jocelyn Moyes, a medical epidemiologist at the Centre for Respiratory Disease and Meningitis at the NICD.
Back to normal?
Although the numbers were still much lower, it appears that the winter flu season’s peak had started to return to levels seen pre-COVID-19 in 2022 and 2023, Walaza confirms.
“In 2023, the flu season was a little bit longer than we’d seen before [COVID-19], but it started on time. So, in terms of the timing, it was similar to what we would see before COVID-19,” she says.
When exactly the winter flu season starts each year varies, Walaza says, but on average it can start anytime from the third week of April and can circulate until August. It has been known to go on longer though.
At the time of the interview, the NICD had only detected sporadic cases of flu but had not yet seen the sustained uptick in transmission which usually signals the start of the flu season. The latest surveillance data published by the NICD indicate that 108 cases of influenza had been detected so far this year. The real number of flu cases will be much higher since most cases of flu are not diagnosed.
This year’s vaccines
Walaza explains that the flu vaccine is updated each year based on the World Health Organization’s (WHO) recommendations. This is to ensure it provides protection against evolving influenza viruses seen in global surveillance programmes.
Photo by National Cancer Institute
Flu shots used in South Africa are inactivated influenza vaccines. This means they do not contain live virus and cannot cause flu.
In the public healthcare sector, the government this year procured the trivalent vaccine which protects against three strains of the influenza virus – two influenza A strains (H1N1pdm 2009 and H3N2) and one influenza B strain (known as the B/Victoria), Walaza says. These jabs should be in public health clinics by the first week of May.
In the private healthcare sector, she says a trivalent and a quadrivalent vaccine are available. The quadrivalent shot includes protection against a second influenza B strain (B/Yamagata), but that strain has not been seen circulating in a few years. These flu shots are already available in the private healthcare sector.
The level of protection provided by the flu shot varies and generally it ranges in effectiveness against infection from about 30% to 60%, according to Walaza, but importantly it protects against severe illness.
How effective this year’s flu shot will be depends on which influenza strain or strains circulate in the country. “The hope is that if an individual gets infected by any of those strains [in the vaccine], then that individual is protected or has some level of protection [against these strains] and will have some protection against severe illness” she says.
However, she adds, it’s difficult to predict how effective this year’s flu shot will be against preventing someone from getting the flu or experiencing symptoms of the flu. This is because there is always the chance that the strains which do circulate this season are different from the ones in the vaccine or have mutated so the shot becomes less effective.
Should we worry about bird flu?
At the start of April, the WHO reported that one case of avian influenza A (H5N1), one of the avian/bird flu viruses, had been detected in a person in the United States after they had come into contact with a cow who was presumed to be infected. This was the second human case of influenza A (H5N1) detected in that country, and the first case of a person being infected with this strain after coming into contact with a non-avian species.
So far, the risk to the general public is low, according to the WHO.
“Since the virus [avian influenza A (H5N1)] has not acquired mutations that facilitate transmission among humans and based on available information the WHO assesses the public health risk to the general population posed by this virus to be low and for occupationally exposed persons, the risk of infection is considered low-to-moderate,” the WHO statement said.
There are many subtypes of influenza A viruses, Moyes tells Spotlight, and avian influenzas are similar to human influenza A viruses. And so, she explains, there is always a possibility that these viruses mutate, enabling them to infect humans, or more importantly develop the ability to transmit effectively from one person to another. This could potentially cause a pandemic.
She tells Spotlight that over the last decade sporadic cases of human avian influenza have been described related to global outbreaks in birds. These cases have all been in people who have had very close contact – usually during the culling process – with sick birds. She advises that people involved in the management of avian influenza outbreaks take precautions, such as using appropriate personal protective equipment to prevent infection.
When asked whether people in South Africa need to be concerned about a potential bird flu outbreak, Walaza says so far, no cases of bird flu infection in humans – even during the recent widespread outbreaks in birds – have been identified in the country. But it is something that the NICD is aware of and surveillance for human cases during outbreaks of bird flu in the country is being conducted.
“What’s important though to note is that even when cases have been detected [in other countries] the risk of person-to-person transmission is extremely low,” she adds.
Launch of Cough Watch SA
Walaza tells Spotlight that most of the data gathered by the NICD on influenza is from surveillance in healthcare facilities, which means that not all cases of influenza are necessarily identified.
To gather additional data, the NICD is in the process of rolling out an additional digital surveillance system to detect influenza cases, called Cough Watch SA. This online web application allows the public to report influenza symptoms.
People who sign up are asked to provide basic demographic data like age and postal code. Participants will then be sent a weekly prompt asking if they’ve had any flu symptoms. If they have had symptoms, according to Walaza, then they will be asked to provide more information. This data will then be linked to the NICD database where it will be compared to other surveillance data to see if the platform could serve as an early warning system for a flu outbreak.
Cough Watch SA will be launched in the week of 7 May, says Moyes, who urged the public to help keep an eye on flu by signing up.
A 3D map of the islet density routes throughout the healthy human pancreas. Source: Wikimedia CC0
An experimental monoclonal antibody drug called mAb43 appears to prevent and reverse the onset of clinical type 1 diabetes in mice, in some cases lengthening the animals’ lifespan, report scientists at Johns Hopkins Medicine.
The drug is unique, according to the researchers, because it targets insulin-making beta cells in the pancreas directly and is designed to shield those cells from attacks by the body’s own immune system cells. The drug’s specificity for such cells may enable long-term use in humans with few side effects, say the researchers. Monoclonal antibodies are made by cloning, or making identical replicas of, an animal (including human) cell line.
The findings, published in Diabetes, raise the possibility of a new drug for type 1 diabetes, an autoimmune condition which has no cure or means of prevention. Unlike type 2 diabetes, in which the pancreas makes too little insulin, in type 1 diabetes, the pancreas makes no insulin because the immune system attacks the pancreatic cells that make it.
The lack of insulin interferes with the body’s ability to regulate blood sugar levels.
According to Dax Fu, PhD, associate professor of physiology at the Johns Hopkins University School of Medicine and leader of the research team, mAb43 binds to a small protein on the surface of beta cells, which dwell in clusters called islets. The drug was designed to provide a kind of shield or cloak to hide beta cells from immune system cells that attack them as “invaders.” The researchers used a mouse version of the monoclonal antibody, and will need to develop a humanised version for studies in people.
For the current study, the researchers gave 64 non-obese mice bred to develop type 1 diabetes a weekly dose of mAb43 via intravenous injection when they were 10 weeks old. After 35 weeks, all mice were non-diabetic. One of the mice developed diabetes for a period of time, but it recovered at 35 weeks, and that mouse had early signs of diabetes before the antibody was administered.
In five of the same type of diabetes-prone mice, the researchers held off giving weekly mAb43 doses until they were 14 weeks old, and then continued dosages and monitoring for up to 75 weeks. One of the five in the group developed diabetes, but no adverse events were found, say the researchers.
In the experiments in which mAb43 was given early on, the mice lived for the duration of the monitoring period of 75 weeks, compared with the control group of mice that did not receive the drug and lived about 18-40 weeks.
Next, the researchers, including postdoctoral fellows Devi Kasinathan and Zheng Guo, looked more closely at the mice that received mAb43 and used a biological marker called Ki67 to see if beta cells were multiplying in the pancreas. They said, after treatment with the antibody, immune cells retreated from beta cells, reducing the amount of inflammation in the area. In addition, beta cells slowly began reproducing.
“mAb43 in combination with insulin therapy may have the potential to gradually reduce insulin use while beta cells regenerate, ultimately eliminating the need to use insulin supplementation for glycaemic control,” says Kasinathan.
The research team found that mAb43 specifically bound to beta cells, which make up about 1% or 2% of pancreas cells.
Another monoclonal antibody drug, teplizumab, received US Food and Drug Administration approval in 2022. Teplizumab binds to T cells, making them less harmful to insulin-producing beta cells. The drug has been shown to delay the onset of clinical (stage 3) type 1 diabetes by about two years, giving young children who get the disease time to mature and learn to manage lifelong insulin injections and dietary restrictions.
“It’s possible that mAb43 could be used for longer than teplizumab and delay diabetes onset for a much longer time, potentially for as long as it’s administered,” says Fu.
