In order to attain universal healthcare coverage, the world needs an additional 43 million health workers, according to research from the Institute for Health Metrics and Evaluation (IHME) published in The Lancet. Sub-Saharan Africa, South Asia, and North Africa and the Middle East were found to have the largest shortfalls in health worker coverage.
“These are the most comprehensive estimates to date of the global health care workforce,” said senior author Dr Rafael Lozano, Director of Health Systems at IHME. “Health care workers are essential to the functioning of health systems, and it’s very important to have these data available so that countries can make informed decisions and plan for the future.”
Four categories of health worker were studied: physicians, nurses and midwives, dental personnel, and pharmaceutical personnel. In 2019, they estimated that more than 130 countries had shortages of physicians and more than 150 had shortages of nurse and midwives. When comparing current levels of health care workers to the minimum levels needed to meet a target score of 80 on the universal health coverage (UHC) effective service coverage index, researchers estimated a shortage of more than 43 million health care workers, including 30.6 million nurses and midwives and 6.4 million physicians.
“We found that the density of health care workers is strongly related to a nation’s level of social and economic development,” said lead author Dr. Annie Haakenstad, Assistant Professor at IHME. “There are different strategies and policy approaches that may help with addressing worker shortages, and these should be tailored to the individual situation in each country. We hope that these estimates can be used to help prioritize policy interventions and inform future planning.”
The study revealed more than a 10-fold difference in the density of health care workers across and within regions in 2019. Densities ranged from 2.9 physicians for every 10 000 people in sub-Saharan Africa to 38.3 per 10 000 in Central Europe, Eastern Europe, and Central Asia. Cuba also stood out, with a density of 84.4 per 10 000 compared to 2.1 in Haiti.
Similar disparities were observed in measuring numbers of nurses and midwives, with a density of 152.3 per 10 000 in Australasia compared to 37.4 per 10 000 in Southern Latin America. Despite steady increases in the health care workforce between 1990 and 2019, substantial gaps persisted.
The researchers cited existing literature that highlights factors that contribute to worker shortages, including out-migration of health workers, war and political unrest, violence against health care workers, and insufficient incentives for training and retention. They noted that high-income locations should follow WHO guidelines on responsible recruitment of health personnel to avoid contributing to workforce gaps in lower-income regions.
The study findings demonstrated just how poorly prepared the world was when the COVID pandemic struck, further straining health systems that already were short of crucial frontline workers. These estimates will help policymakers, hospitals, and medical clinics prepare for future pandemics by focusing on training and recruitment. The authors also note that there is still much to learn about the impact of the pandemic on the health workforce. This includes gender dynamics in human resources for health (HRH) and how the departure of women from formal employment for care-taking duties at home may have depleted the health workforce, among other stressors on HRH during the pandemic.
Delegates at the 21st Annual Board of Healthcare Funders (BHF) Conference currently being held in Cape Town.
19 May 2022: Healthcare – Cape Town, South Africa: The healthcare system in South Africa and on the continent is beset with structural challenges and skewed political priorities that hamper the attainment of universal healthcare coverage, therefore a fundamental overhaul of the healthcare system and renewed political will is required to improve citizen’s access to quality healthcare services.
Connected virtually, South Africa’s Minister of Health, Dr Joe Phaahla invited the private sector to submit recommended solutions to strengthen the country’s healthcare systems, emphasising the need for a collaborative approach to transform healthcare.
Dr Phaahla conceded that the health system in the country was already weak before the outbreak of COVID and inequality in access to reliable health services is inextricably linked to the economic and social inequality that our country is facing.
The Minister added, “The country’s healthcare system should be restructured to focus more on preventative services rather than the current curative approach.”
“The socio-economic inequality is perpetuated further by our own health services, which are highly heavily commodified. Our two-tiered healthcare system with one being driven by the private sector for a few who can afford it and the other by the public sector being provided for the majority of the population does not bode well for the future prospects of the country. This system is unsustainable and if we are going to talk about a change in strengthening the health system, we cannot avoid talking about the need to accelerate the creation of a more equitable health system.”
He acknowledged that the passing of the NHI Bill will not in itself be a silver bullet in the transformation of our health system, however, will lay a good foundation for the country to timely start to fundamentally transform our health system towards equity.
Speaking about the relationship between politics and healthcare, Professor Patrick Lumumba, former Director of the Kenya Anti-Corruption Commission, said, “Politics is at the very heart of the provision of sound healthcare systems.”
He challenged some of the perceptions around the delivery of national healthcare insurance across Africa, asking governments and the private sector to closely examine suitable healthcare solutions that will consider the continent’s current different types of conflicts.
He highlighted that considerations should be made in the best interest of the continent’s populations when making the decision on an approach to be taken for the continent’s healthcare needs, bearing in mind what is affordable to the different countries across the continent, especially given that the continent’s entire GDP is less than that of Italy, which has just under 60 million people.
“The continent is currently under different types of conflict at various intensities, and these conflicts are in turn undermining the provision of healthcare,” said Prof Lumumba.
He noted that in Africa, there is a lack of political will to spend more on healthcare despite the commitments made at Abuja, Nigeria, in 2001 to invest a minimum of 15% of their national budget in healthcare.
“Politicians are rich in making promises. The evidence we have in different countries is that universal health care as promised by politicians and as desired by the population is not easily achievable,” he said.
He cautioned against the temptation to compare the healthcare system in Africa with that of developed countries, citing a lower tax base and GDP in Africa to fund a healthcare system that services a substantially larger population.
“The entire GDP of Africa is slightly over two trillion US dollars, which is smaller than the GDP of Spain, which has a population of no more than 50 million people, it is critical that the private and public sectors; and politicians work together to come up with a system that is going to be beneficial to the majority of Africa’s people,” said Professor Lumumba.
He said the envisaged economic revival of Africa cannot be sustained if the continent’s healthcare needs are not adequately addressed.
“If the continent of Africa is to enjoy the perceived economic growth that is expected, then the population must be healthy. Healthcare is about creating healthcare systems that are also able to retain the skills that are required for Africa’s emerging or growing economies. There is also a clear need for collaboration in the delivery of health services,” said Lumumba.
Dr Millicent Hlatshwayo Chairperson of the Government Employees Medical Scheme (GEMS) reiterated the need for the private healthcare sector to play a meaningful role towards shaping the proposed healthcare funding model to ensure its sustainability.
She acknowledged that the healthcare sector is faced with several systemic challenges, and this is reflected in our international rankings; where South Africa ranks 49th out of 89 countries on the 2022 Global Healthcare Index. Though South Africa is the highest-ranked African country in this index, it has been rated below its peers in BRICS such as China and India, which are rated 40th and 44th respectively.
Dr Hlatshwayo said, “Proposed reforms such as the implementation of the NHI can help to facilitate better cooperation between the public and private sectors. We cannot afford to be passive observers in these deliberations, because our failure to act on these opportunities will be an indictment on the industry.”
Dr Hlatshwayo said from its inception, GEMS has been aligned with the transformation of the healthcare industry and supportive of the principles of universal health coverage.
She said universal health coverage can only be achieved if we get the basics in place, namely qualified staff, equipment and technology, infrastructure and working systems.
Effective anti-vaping advertisements geared to teens have the greatest impact when they emphasise the adverse consequences and harms of vaping e-cigarettes, use negative imagery, and avoid memes, hashtags and other ‘teen-centric’ communication styles, according to a first-of-its-kind study by researchers in the journal Tobacco Control.
The researchers also found that certain messaging content currently being used, especially sweets and flavour-related imagery, increases the appeal of vaping and should be avoided when designing prevention messages.
“E-cigarettes and vaping have become a major public health concern, with nicotine addiction and other harmful outcomes looming large for youth,” said Seth M. Noar, PhD, the paper’s corresponding author and UNC Lineberger professor. “The percentage of teens vaping increased from about 5% in 2011 to over 25% in 2019,” Prof Noar said. “That is an alarming trend, making an understanding of effective vaping prevention messages especially urgent.”
Since the introduction of e-cigarettes, numerous US health departments have created their own anti-vaping messaging geared to teens, as have national health organisations such as the US Food and Drug Administration and Centers for Disease Control and Prevention.
The online study asked 1501 teens to rate seven randomly selected vaping prevention ads from a pool of more than 200 ads. Vaping prevention ads that clearly communicated the health harms of vaping, or compared vaping to cigarette smoking, were comparatively more effective. Neutral or less personally relevant content, such as referencing the environmental impact of vaping or the targeting of youth by the tobacco industry, was less impactful.
“Although we anticipated that vaping prevention ads with neutral or pleasant imagery would not be as effective, we were alarmed to find that flavour-related messages actually heightened the attractiveness of vaping,” said Marcella H. Boynton, PhD, first author
“In retrospect, it stands to reason that by reminding teens about pleasurable aspects of e-cigarettes, even within the context of a prevention ad, we run the risk of doing harm. Notably, we found that flavour-related prevention ad content was associated with vaping appeal among both users and non-users of e-cigarettes, which is a good reminder of how much candy and fruit flavours in e-cigarettes have driven the youth vaping epidemic.”
The researchers hope to next investigate the effects of other types of anti-vaping ads on a wide range of audiences. They also are developing a series of messages and a companion website to test the ability of a text message-driven intervention to reduce youth vaping. In that regard, Prof Noar noted that “We have been developing our own evidence-based messages based on the latest science about the harms of vaping. Our messaging approach has been greatly influenced by the insights generated by this study.”
The study used UNC’s Vaping Prevention Resource, a website designed to provide practitioners, researchers and communities with vaping prevention media content from around the world, as well as strategies and resources for youth vaping prevention. It is the largest repository of free, open-access vaping prevention materials, all available for download at https://vapingprevention.org/.
Investigating the state of affairs in public clinics, Spotlight’s Daniel Steyn and Vusi Mokoena investigate whether the right technology could help them out of their predicament.
“I never look forward to clinic day,” says Nomtsato Tsietsi, 74, on a Monday morning while standing in the queue at Kayamandi Clinic in Stellenbosch, which she visits up to three times a month to collect pills, consult with a doctor, and have her blood tests taken.
Tsietsi has several diseases including diabetes and hypertension (high blood pressure). “We sit there for too long, sometimes all day,” she says.
Her experience is typical for people visiting state clinics. But for about 80% of South Africans, this is the only option: for most people private healthcare is unaffordable and public clinic services are free.
Some patients in the Kayamandi clinic queue said they sometimes pay people up to R80 to stand in the queue for them. One man, who had been paid by someone to stand in the queue, said that he had been there since 5am.
For employed people, a day at the clinic typically means taking a day off work, often without pay.
The pubIic health system is beset with problems: long waiting times, insufficient record keeping, poorly maintained infrastructure, and poor service delivery.
A 2018 study of nurses and doctors in Cape Town found that of 16 essential skills, ten were not performed in more than half of the consultations. In more than 60% of consultations, nurses and doctors in Cape Town did not greet patients, and in 90% of consultations, they did not attempt to understand the patient’s perspective. In nother study, 76% of Cape Town-based doctors in primary care reported that they are suffering from burnout.
During our visit to Kayamandi Clinic, we asked patients whether they would embrace technological solutions to make the experience more efficient. They all said they would. Almost all of them are smartphone users and some said they could not understand why appointments cannot be made and managed digitally, or why they cannot communicate with health workers online rather than in person.
Innovative technology solutions for primary care exist in South Africa.Phukulisa Health Solutions, for example, offers a platform that mimics a consultation with a healthcare practitioner. Equipped with Bluetooth sensors, the platform can screen patients for a range of health issues, focused specifically on HIV, TB, diabetes, and heart diseases.
Phukulisa’s CEO Raymond Campbell says that this testing and screening platform offers a more efficient screening service with a faster turnaround time. For example, the platform has been tested at an antenatal unit in Mamelodi, where the platform provided test results within 14 minutes, opposed to the usual 23 hours.
But Campbell says there is little interest from the public sector in his technology. Instead, he is finding more success licensing the platform to players in the private sector.
There have been some attempts to use innovative computer technology in public sector clinics. In Limpopo, the deputy director-general of the health department, Dr Muthei Dombo, has the vision to create a “clinic in the cloud”.
In 2018, Dombo partnered with theMint Group to conduct a trial funded by Microsoft at Rethabile clinic. Dombo provided the team at Mint Group with several problems to solve.
The team, led by Peter Reid, developed a technology to alleviate the high rate of fraud at medicine dispensing points, the difficulty of transferring medical records between different clinics, and the long waiting times.
When a patient entered the clinic, they would register at reception. Their identity document would be scanned and a picture would be taken of the patient. At every station in the clinic visited by the patient, a camera would identify the patient and the patient’s records would pop up on the screen. When the patient left the station, the profile would automatically lock.
This ensured that only patients due for specific medication would receive that medication, thereby eliminating fraud. Because the records were all kept in the cloud, the records could easily be transferred to another clinic. Without this technology, patients need to return to the same clinic every time they need to restock their medication.
The trial also assisted with queue management. Upon entering the clinic, patients would choose a “journey” based on their reason for visiting the clinic. The system would then guide the patient from one station to the next on big screens on the wall. This made the journey more seamless while also providing visual feedback to officials at the clinic helping them to manage the queues more effectively.
The trial ended shortly before the start of the Covid pandemic. The project has not yet been restarted.
One project that has been implemented widely in the public sector is Vula Mobile. Founded by Dr William Mapham in 2014, Vula aims to bridge the gap between health workers and specialists.
There is a shortage of specialist doctors in the public sector and health workers at the primary care level often lack the information to refer patients to a relevant specialist.
With the Vula app, a nurse seeing a patient can be linked with the closest specialist. Through the built-in chat function, the nurse can provide the specialist with all the necessary info and refer the patient.
The app is available in six provinces with an emphasis on the Eastern Cape. More than 24,000 health workers are registered on the system.
But other innovators in the health space, frustrated by the public sector, are focusing on providing affordable private healthcare. This follows a growing trend in South Africa, as medical aid providers increasingly offer more affordable packages targeted to lower-income earners.
At the Kayamandi clinic during GroundUp’s visit, Mcoleseli Mlenze, a 34-year-old father who often visits the clinic for hypertension medication or when his son is sick, said that while he uses the clinic to collect medication, he has started seeing a private doctor when he is sick.
He says he cannot really afford the private doctor, which costs upwards of R350 per consultation. If there was some middle-ground where he could pay R150-R200 for a consultation at a clinic that is faster and more efficient, he would happily do so.
Others in the queue said they would pay up to R50 for a better healthcare experience.
Saul Kornik, the founder of Healthforce and the Kena App, aims to lower the cost of quality primary health care so that millions of people have access to it.
Available in almost 500 pharmacies throughout the country, Healthforce’s technology enables nurses to conduct all necessary screenings and diagnostic procedures. If and when a doctor becomes necessary, the nurse presses a button to start a video call with one of the doctors in the Healthforce network.
The nurse and patient can both see the doctor and the doctor, with the help of the nurse, can consult the patient. This reduces the amount of time that the doctor is needed, thereby reducing the cost.
The patient ends up paying on average R70 to R90 for the nurse and R115 to R250 for the doctor. If needed, the doctor can prescribe medication that the patient can purchase at the pharmacy or pick up from a government dispensary.
There are Healthforce doctors available to speak any of the 11 official languages and they are available seven days a week.
In March, Healthforce launched the Kena Health app, through which patients can have consultations with nurses, doctors and mental health practitioners via chat, voice or video. The first three consultations per year are free.
After the consultation, if necessary, the doctor can provide a script for medication and a sick note.
At Kayamandi clinic, Gcobisa Malithafa, a 30-year-old mother of a toddler told GroundUp that although she would pay a small amount for a better experience, it should not have to come to that.
Malithafa suggests that instead, the clinic’s management should consult the community on a regular basis and make immediate improvements to the running of the clinic. “This thing of having one doctor at the clinic is not right,” she says.
She is struggling to get her child immunised, having visited the clinic many times without success.
Whether they use technology or not, she says, something has to change.
Despite the greater safety and efficacy of a new short course treatment for HIV-related cryptococcal meningitis (CM), access to the treatment in South Africa will be a challenge, according to a pair of articles by Spotlight.
Following positive results of a trial, the World Health Organization last week announced new recommendations for the treatment of CM, with a single high dose of L-AmB followed by two weeks of flucytosine and fluconazole.
Using L-AmB (AmBisome) and flucytosine for the treatment of CM will be a welcome change for South Africa, which has the world’s highest burden of the condition. This shorter course with fewer side effects than the current treatment involving amphotericin-B could save lives as well as clinical resources in the public sector, but at present the treatment is hamstrung by pricing and availability uncertainty, with a course of L-AmB currently only available at a steep cost.
“Amphotericin B [deoxycholate] is a drug that doctors and nurses used to call ampho-terrible,” Amir Shroufi, Médecins Sans Frontières (MSF) Southern Africa board member told Spotlight.
He explained that “it’s a really nasty drug, doctors and nurses don’t like it because it can cause severe anaemia. It’s toxic to the kidneys, so it can cause kidney damage and even kidney failure… and the infusion line used for the drug can often become infected and it can cause inflammation of the veins where it’s going into the body.”
L-AmB is a “much better drug”, he said, with great benefits of administering it for one day as opposed to a week or two. The seriousness of CM meant hospitalisation will still be required, pointed out Dr Jacqui Miot, division director of the Wits Health Economics and Epidemiology Research office, but means that patients won’t be tethered to a drip and may be able to go home sooner.
Under the treatment regimen, a patient receives a single high dose of L-AmB on the first day of treatment, followed by a 14-day course of flucytosine and fluconazole pills.
For a 60kg patient at the recommended dosage, twelve 50mg vials of L-AmB are needed, which at Gilead’s promised access price would be R2 880. Key Oncologics’ currently charges R34 560 for 12 vials.
Even given the availability of L-AmB, Shrouifi warns that “whatever you’re doing, you have to have flucytosine. That’s your baseline, even if you’re giving liposomal amphotericin B, you have to have the flucytosine”.
Flucytosine is an old, off-patent medicine developed in the 1950s. Despite its age and its demonstrated efficacy in the landmark ACTA trial four years ago, flucytosine was only recently authorised for use in South Africa and is only slowly being rolled out.
Amir Shroufi warned that access to the life-saving medicine remains a major issue. “Doctors are not being given the tools they need to treat [CM],” he said. “The first tool they have to have is flucytosine and they still don’t have flucytosine. So, that’s the thing that needs to happen urgently, you know, tomorrow! Everyone with cryptococcal meningitis must get access to flucytosine.”
Like L-AmB, Mylan’s 250mg and 500mg flucytosine tablets were only registered recently, in December 2021. The Department of Health’s target price for a pack of 100 tablets is R1 500. Fortunately, it appears that the Clinton Health Access Initiative (CHAI) will be able to secure packs of 100 at R1 470 each for use in South Africa’s flucytosine access programme.
The next steps for rollout of flucytosine will be inclusion on the national essential medicines list and in CM treatment guidelines before tenders can be put out.
Having to cope with the strain of COVID on an already fragile healthcare system, a few hospitals in the Western Cape have been introducing robotics for specialised tasks – but are they worth the hype?
Robotics was able to fill an unprecedented need during the COVID pandemic – the ability to remotely conduct ward rounds from remote locations. Tygerberg Hospital made use of ‘Quintin’, a robot that is essentially a tablet on a mobile stand that allows users to remotely communicate and inspect the area, but it can’t physically interact with its environment.
Robotics offers greater surgical precision, which may translate into reduced healthcare load. IOL reported that the provincial Department of Health plans to use a pair of new robotic surgery machines installed at the Groote Schuur and Tygerberg hospitals to fast-track surgeries and address the province’s surgical backlogs caused by COVID. These robotic surgery units will be used for procedures on colorectal, liver, prostate, kidney and bladder cancers, and women with severe endometriosis. In the province’s private sector, Netcare Christiaan Barnard Memorial Hospital also makes use of robotic-assisted surgery.
Robotic surgery has a number of advantages. The small robotic arms allow for smaller incisions and faster recovery times, reducing the strain on hospitals. A liver resection that would have a patient in hospital for a week can be reduced to one or two days with robotic surgery. More complex surgery becomes possible, eg in difficult to access areas or in patients with obesity. Robotic surgery allows surgeons to be off their feet, easing an extremely fatiguing job, and the software automatically compensates for any tremor in the surgeon’s hands.
However, robotic surgery still has drawbacks – chief among them is cost and the need to have trained personnel to operate them. There is also some latency between the surgeon’s hands movements and the corresponding movement of the robot, leading to possible errors. Shorting of the electrical current running through the robotic arms can also cause burns to the patient’s tissue, and there is also the possibility of nerve compression injuries due to the positioning of the patient. Furthermore, operator errors, especially when operators are inexperienced or robotic surgery is performed in lower volumes, is always a possibility.
Robotics have promising applications in sanitation – they can easily disinfect areas using UV light, for example – and can also assist nurses with certain tasks, such as making a 3D vein map prior to a venipuncture. Some robots can even assist the elderly, conversing with them and can perform simple tasks like calling a nurse. Other applications include the much simpler technology of exoskeletons, a wearable frame which amplify users’ strength (though nowhere near that of the fictional Iron Man) and are useful in rehabilitation and for enhancing mobility in the elderly. Other applications include increasing strength of care staff for assisting patients, freeing up other staff.
Some exoskeletons are even purely mechanical, merely readjusting loads without any sophisticated electronics or motors. Yet even these are prohibitively expensive: the Phoenix Medical Exoskeleton goes for about US$30 000 each.
While promising, robotic systems are at present still hugely expensive, limited in function and can only assist with a small fraction of the tasks that healthcare workers perform. Even if the cost could be reduced enough to help ease healthcare worker burden in South Africa to help, that still leaves the problem of enough experienced and motivated healthcare workers, beds and neglected rural areas.
A report by IOL revealed mixed reviews by experts and patients for the Western Cape’s healthcare system, which, while providing mostly excellent service in certain hospitals, is seen to be especially lacking in rural areas, infrastructure and handling of patients.
Award-winning service
Along with receiving the highest marks for efficiency, Western Cape healthcare has earned recognition such as through the Batho Pele Excellence Awards, with a silver medal going to Dr Barry Smith who worked in frontline COVID hospitals in Cape Town, where as medical manager he organised efforts to deal with devastating COVID waves.
A total of R29.4 billion has been allocated to the province’s 2022–2023 budget to deal with a serious backlog of unmet TB, HIV and other medical care put off during the COVID waves, along with a new surge in mental health issues.
A critical view
The ANC’s Rachel Windvogel said that while Western Cape is said have the country’s ‘most efficient’ health-care system, it is deteriorating and “nearing collapse”.
Dilapidated infrastructure in hospitals such as Groote Schuur and Tygerberg Hospitals is a challenged, with “sections that are cordoned off and not functioning.”
The knock-on service pressure across all district hospitals has resulted in patients having to sleep in chairs or on the floor.
Windvogel said that the Khayelitsha District Hospital is a prime example, with R150 million allocated for upgrades by the hospital but with no provincial government funding forthcoming.
She said that the provincial government’s boasts about a leading healthcare system does not match the situation. This can be seen in rural communities where people wait days for an ambulance transfer to city hospitals, she said, and doctors only visiting rural clinics to issue prescriptions without examining patients.
From the wards
Speaking to IOL, on the condition of anonymity, a nurse with over 15 years of experience currently working at a local government hospital said that while they try their best to deliver a service to residents, the sector has so much lacking.
The quality of new nurses has been steadily declining, she said. “As nurses, we are inundated with work but we manage, however, as an experienced nurse seeing how the ‘latest intakes’ have no feeling towards patients is sad.”
There have been deaths from “incorrect triages” as well as problems with nurses not knowing how to speak to the community, resulting in “pissing off the very community we took an oath to serve,” she said.
While she believes nursing is her calling, she is considering moving over to the private sector, driven by a high workload, crime, poor pay and lack of experienced assistance.
A patient’s experience
Candice van der Rheede, director of the Western Cape Missing Persons Unit (WCMPU) has been through a string of hospitals since 2020 following a collapsed lung, and her experiences reflected problems with staffing and gender segregation.
She first stayed at Mitchells Plain District Hospital, and her ward was “spotless” with security “always there”. “If help was needed and you buzzed for help, nurses came immediately,” she told IOL.
The thoracic ward at Groote Schuur Hospital was also praiseworthy – except that her ward was in the middle of the men’s section.
“One night I woke up and saw one of the men standing and watching us ladies with no nurses on the inside,” Van der Rheede said.
However, entering the ICU ward after theatre, her experience took a turn for the worse, being roughly handled when check for bed sores, despite her having a large surgical wound.
In November, Van der Rheede had to overnight in the trauma section at Tygerberg Hospital due to a check-up. While she was generally satisified with the hospital and its staff, there was a major sticking point for her – in the trauma section, “we were men and women sleeping in one room which I had a big problem with. Using one toilet. I could not sleep that night.”
While she has her reservations about the state of hospitals in the province, Van der Rheede told IOL she commended the Mitchells Plain District Hospital for its impeccable service, and the Symphony Clinic in Delft which she currently attends is of the highest standard of service and cleanliness.
NYU School of Global Public Health researchers have found that some cannabis edibles have a striking resemblance to popular snack foods such as Doritos, and may be easily confused for them, especially by young children, finds a new study published in Drug and Alcohol Dependence.
These “copycat” edibles also have levels of the psychoactive ingredient tetrahydrocannabinol or THC that far exceed the limits set by cannabis regulations in US states.
“At first glance, most of the packages look almost exactly like familiar snacks. If these copycat cannabis products are not stored safely, there is the potential for accidental ingestion by children or adults,” said Associate Professor Danielle Ompad, lead author of the study.
Edibles are a popular and growing segment of the cannabis market. In states where cannabis use is legal, more than half (56%) of cannabis users consume edibles.
Some edibles that use similar branding and imagery to mimic popular snack foods have been highlighted by the media. These copycat cannabis products are a public health concern given that people – including children – could mistake them for snacks and accidentally consume them. From 2017 to 2019, US Poison Control Centers handled nearly 2000 cases of young children ages 0 to 9 consuming edibles.
To gain a deeper understanding of copycat edibles, the researchers collected hundreds of photos of cannabis products and analysed their packaging, including branding, names, imagery, and THC content. Looking at the photos for 267 edibles, they found that 8% (22 photos) closely resembled 13 different snack products.
Twelve of the products were candies or sweet snacks (fruit chews, fruit snacks, rice and marshmallow treats, and gummies) and one was a salty snack (chips). Eight of the 13 packages used the exact brand or product name of the original product; the remaining five used names that were similar (for instance, “Stoner Patch Dummies” instead of “Sour Patch Kids”). Seven of the packages used the same cartoon or brand character as the original product.
Most US states that have legalised cannabis limit the amount of THC in edibles, generally 5–10mg of THC per dose and 100mg per package. According to the packaging information, these edibles contained an average of 459mg of THC with a range of 300 to 600 mg per package, far exceeding the maximum limits.
“While each package is likely intended to include multiple doses, few packages indicate the serving size or number of servings,” said Dr Ompad. “Moreover, if we’re considering 10mg a standard dose, these products could contain an alarming 30 to 60 doses per package.”
The findings highlight the risk that these copycat products could be attractive to children, given the colourful packaging and use of familiar branding and characters.
“Policies to prevent cannabis packaging from appealing to children haven’t stopped copycat products from entering the market — nor have food brands taking legal action against cannabis companies for copyright infringement,” said Dr Ompad. “People who purchase edibles that look like snack foods should store them separately from regular snacks and out of reach of children.”
Public health officials are puzzling over cases of severe hepatitis in children reported in Europe and the US. A number of the cases have tested positive for adenovirus and/or SARS-CoV-2, though what role these viruses play is not yet clear.
On 5 April 2022, UK authorities notified the World Health Organization was of 10 cases of severe acute hepatitis of unknown aetiology in previously healthy young children ranging in from 11 months to five years old across central Scotland. Nine had onset of symptoms in March 2022, and all cases were detected on hospitalisation. Symptoms included jaundice, diarrhoea, vomiting and abdominal pain. An article published in Eurosurveillance detailed the cases.
Further investigations across the UK identified a total of 74 cases as of 8 April (including the 10 cases) that fulfilled the case definition. The clinical syndrome in identified cases is of acute hepatitis with markedly elevated liver enzymes, often with jaundice, sometimes preceded by gastrointestinal symptoms, in children principally up to 10 years old. Some cases have required transfer to specialist children’s liver units and six children have undergone liver transplantation. As of 11 April, no death has been reported among these cases and one epidemiologically linked case has been detected.
Laboratory testing has excluded hepatitis type A, B, C, and E viruses (and D where applicable) in these cases while SARS-CoV-2 and/or adenovirus have been detected in several cases. The United Kingdom has recently observed an increase in adenovirus activity, which is co-circulating with SARS-CoV-2, though the role of these viruses in the pathogenesis is not yet clear. They have however been linked to bladder inflammation and infection, and on occasion to hepatitis, but it is rare in children who are not immunocompromised.
To date, no other epidemiological risk factors have been identified, including recent international travel. Overall, the aetiology of the current hepatitis cases is still considered unknown and remains under active investigation. Laboratory testing for additional infections, chemicals and toxins is underway for the identified cases.
Following the notification from the UK, less than five cases (confirmed or possible) have been reported in Ireland, further investigations into these are ongoing. Additionally, three confirmed cases of acute hepatitis of unknown aetiology have been reported in children (ranging in age from 22 months-old to 13 years old) in Spain. A further 9 have been reported in the US state of Alabama, with five testing positive for adenovirus.
Karen Landers, district medical officer for the Alabama Department of Public Health, said that the cases were spread across the state, and no links were found among the children.
“It is not common to see children with severe hepatitis,” Landers told STAT in an interview. “Seeing children with severe [hepatitis] in the absence of severe underlying health problems is very rare. That’s what really stood out to us in the state of Alabama.”
Vigorous exercise produces a similar level of aerosol particles as speaking, but high-intensity exercise produces more, according to new research published in Communications Medicine. This is the first study to measure exhaled aerosols generated during exercise, to help inform the risk of airborne viral transmission of SARS-CoV-2 for gyms and indoor physical training.
Inhalation of infectious aerosol is considered to be the main route of SARS-CoV-2 transmission. In this study, researchers performed a series of experiments to measure the size and concentration of exhaled particles (up to 20µm diameter) which are generated in our respiratory tracts and breathed out, during vigorous and high-intensity exercise.
Using a cardiopulmonary exercise test, 25 healthy participants (13 male, 12 female) with a range of athletic abilities were recruited to undertake four different activities (breathing at rest, speaking at normal conversational volume, vigorous exercise and high-intensity exercise) on a cycle ergometer. Airflow and particles emitted were measured by particle counter. Experiments were carried out in an orthopaedic operating theatre — an environment with ‘zero aerosol background’, letting the researchers to unambiguously identify the aerosols generated by the participants.
The results showed that the size of airborne particles emitted during vigorous exercise was consistent with those emitted while breathing at rest. However, the rate of aerosol mass exhaled during vigorous exercise was found to be similar to speaking at a conversational volume.
Jonathan Reid, scientific lead on the paper, said: “COVID has profoundly impacted sports and exercise, and this study provides a comprehensive analysis of the mass emission rates of aerosol that can potentially carry infectious virus produced from an individual during exercise. Our research has shown that the likely amount of virus that someone can exhale in small aerosol particles when exercising is comparable to when someone speaks at a conversational volume. The most effective way to reduce risk is to ensure spaces are appropriately ventilated to reduce the risk of airborne transmission.”
