Scanning electron micrograph image of Vibrio cholerae. Source: Wikimedia CC0
The Hammanskraal cholera outbreak continues with 17 deaths from the disease reported so far. Poverty is exacerbating the situation, with residents being advised to drink bottled water – but unable to afford it. According to GroundUp, the microbiological compliance (a measure of faecal bacteria) at sewage treatment plants was as low as 2% and 0%, where below 50% is considered ‘bad’.
Characterised by watery diarrhoea and dehydration, cholera is caused by infection by the bacterium Vibrio cholerae and in some cases can cause death within hours. It is spread through contaminated water, and asymptomatic individuals can contribute to the spread by shedding bacteria in faeces for seven to 14 weeks.
The National Institute for Communicable Diseases (NICD) says that treatment is with oral rehydration solution (ORS), with intravenous ringer’s lactate for severe dehydration and antibiotics recommended in hospitalised patients.
For acute cases of watery diarrhoea, the National Institute for Communicable Diseases (NICD) advises the following course of action:
– Notify the case as suspected cholera by completing a Notifiable Medical Conditions case notification form. Do this immediately; don’t wait for laboratory results.
1. Assess and reassess the degree of dehydration frequently.
2. Replace fluid and maintain hydration status based on the degree of dehydration (see flowchart)
3. Antibiotic therapy is recommended for hospitalised patients. Ciprofloxacin is currently the antibiotic of choice: Paediatric dose: 20 mg/kg (max 1g) po stat Adult dose: 1g po stat
4. Children < 5 years of age should be given zinc supplementation.
5. Patients should be fed as soon as they can tolerate food
6. Patients who are no longer dehydrated and can take ORS and have decreased frequency of diarrhoea may be discharged.
In the RADIANT-TB randomised controlled trial carried out in Khayelitsha, researchers found that tuberculosis (TB) patients with HIV taking a double dose of dolutegravir had similar viral suppression to those taking a single dose plus placebo. The findings, published in The Lancet HIV, suggest that a only once-daily dolutegravir is feasible in patients with HIV-associated tuberculosis.
WHO’s preferred first-line antiretroviral therapy (ART) regimen for adults and adolescents with HIV is dolutegravir, combined with tenofovir and lamivudine or emtricitabine. A disadvantage of dolutegravir is substantial drug–drug interaction with rifampicin, which is important as tuberculosis is the most common cause of hospitalisation and mortality among people living with HIV.
The drug–drug interaction between rifampicin and dolutegravir can be overcome by supplemental dolutegravir dosing, but is a challenge in resource-constrained settings. The researchers sought to investigate whether virological outcomes with standard-dose dolutegravir-based ART are acceptable in people with HIV on rifampicin-based antituberculosis therapy.
RADIANT-TB was a phase 2b, randomised, double-blind, non-comparative, placebo-controlled trial in Khayelitsha, Cape Town, South Africa. Participants were aged over 18 years, with plasma HIV-1 RNA >1000 copies/mL, CD4 count > 100 cells/μL, ART-naive or first-line ART interrupted, and on rifampicin-based antituberculosis therapy for less than three months. Participants were assigned (1:1) to receive either tenofovir disoproxil fumarate, lamivudine, and dolutegravir plus supplemental 50mg dolutegravir 12h later or the same drugs but with placebo in place of the supplemental dolutegravir. Participants received standard antituberculosis therapy (rifampicin, isoniazid, pyrazinamide, and ethambutol for the first two months followed by isoniazid and rifampicin for four months). The primary outcome was the proportion of participants with virological suppression (HIV-1 RNA <50 copies/mL) at week 24 analysed in the modified intention-to-treat population.
No treatment-related dolutegravir resistance emerged in the trial, and though not significant, an increase in insomnia was noted in the supplemental dolutegravir arm. In terms of future research, it is questionable whether a phase 3 trial would be needed given the significant time required for a policy change. Limitations included the study not being powered to compare efficacy.
The authors concluded, “Our findings suggest that twice-daily dolutegravir dosing might be unnecessary in people with HIV-associated tuberculosis. More evidence, from cohort studies or possibly a phase 3 trial, might be necessary to change policy on the need for a supplemental dolutegravir dose with rifampicin-based antituberculosis therapy.”
Millions of doses of the Pfizer-BioNtech COVID-19 vaccine procured by the South African government have expired and the shot is largely unavailable to people in the country.
Several people who have contacted Spotlight have expressed “frustration” and “dismay” that despite government having announced in February that it was sitting on a massive stockpile of almost 30 million vaccines, they are struggling to access the Pfizer shot.
Explaining the vast quantity of unused vaccines, the Health Department at the time said vaccine uptake has been low due to decreasing cases, people’s erroneous perception that the pandemic is over, and hesitancy affected by vaccine disinformation.
Expired but not expired?
National Department of Health spokesperson Foster Mohale confirmed that seven million Pfizer doses had expired but they would not be disposed of. Instead, the vaccine manufacturers would test the vaccines to ensure continued safety and efficacy. The South African Health Products Regulatory Authority (SAHPRA) will review the test results and, if satisfied that the vaccine will still work as well as data showed before, they will approve an extended shelf life.
The remaining estimated 23 million Johnson and Johnson (J&J) vaccine doses in South Africa are due to expire in 2024 and 2025.
“The expiry of a vaccine is not the same as the expiry date of food which cannot be extended,” Mohale says, adding that the Pfizer vaccine has a short shelf life and that the vaccine’s expiry date has been extended twice in the past. He says the testing should be done by June and the Pfizer shots would become available in July.
Photo by Mat Napo on Unsplash
A mother from East London, who is hoping to emigrate to the United States, told Spotlight that she was “frantically” trying to get shots for her 12-year-old son in time to leave. In South Africa, none of the currently available COVID-19 vaccines have been authorised for use in children under the age of 16. Elsewhere in the world, for example, in the United States, the Pfizer vaccine has been tested and authorised for use for children from the age of 12. “It is mandatory that he get the vaccine before entering the United States,” she says.
An intern responding to people’s questions on the Department of Health’s hotline says, “Many callers have phoned in stressing about travelling, emigrating, or getting vaccinated for the first time. We have been told that there are very few sites that still have some stock. If people have had two Pfizer doses, they can boost with a J&J dose. However, if they have only had one Pfizer, they will have to wait.”
The public exasperation expressed directly to Spotlight and on social media also relates to the health department’s vaccination website being outdated and it being hard to find places to get vaccinated. As GroundUp reported in January, getting a COVID-19 booster jab is not as easy as it should be.
‘The pandemic is not over’
Referring to the World Health Organization’s (WHO) lifting of the COVID-19 Public Health Emergency of International Concern(PHEIC) on May 5th, Mohale says, “The pandemic is not over and people, especially those who are at highest risk of severe disease and death should get vaccinated.” These included people with co-morbidities and the elderly. He says vaccination for COVID-19 has been integrated into routine primary healthcare facilities, which is where people should go for their jabs.
WHO director-general Tedros Ghebreyesus said it was the end of the emergency phase but not the end of the threat of COVID-19. In the week prior to the announcement, he said the disease claimed a life (globally) every three minutes, “and that’s just the deaths we know about”.
The decision to lift the emergency was based on the decreasing number of deaths and hospitalisations from COVID-19, the high levels of population immunity against SARS-CoV-2, and the widespread availability of COVID-19 vaccines and treatments.
Ghebreyesus warned that the COVID-19 pandemic is not over and that the virus could still pose a serious threat to public health. The WHO has urged countries to continue to monitor the situation closely and to maintain preparedness measures, such as surveillance, testing, and contact tracing.
Some experts have criticised the WHO’s decision to end the emergency phase, arguing that it is premature and could lead to a resurgence of the pandemic. Others have defended the decision, arguing that it is based on the best available evidence and that it is important to give countries the flexibility to manage the pandemic in a way that best suits their own circumstances.
‘Momentous’ announcement
Professor Salim Abdool Kariem, Director of CAPRISA, described the announcement as “momentous”. Writing in his regular COVID-19 updates blog, he says, “… we are still living in the midst of a pandemic with thousands of cases each day. Since SARS-CoV-2 is going to be with us for a long time, a pragmatic decision was needed as the COVID-19 pandemic emergency has been steadily receding and a new variant of concern has not emerged in the last 17 months. But the risk of a new variant of concern is ever-present, even if it is getting progressively smaller with time. The public is also tired of the pandemic and many have simply put it out of sight and out of mind.”
Kariem writes that globally there are currently far more COVID-19 cases, hospitalisations, and deaths each day than we had on the day (30 January 2020) that COVID-19 was initially declared a PHEIC. “So, it (the WHO decision) was not based on the situation getting to a point pre-PHEIC. Waiting to reach that point may take many years or may never happen and so ending the PHEIC is a judgement call, taking many factors into consideration.”
‘Still with us’
Speaking at a recent webinar, hosted by Internews, science writer David Quammen, who wrote a book on COVID-19 called ‘Breathless: The Scientific Race to Defeat a Deadly Virus’ and before that, ‘Spillover’, says, “The coronavirus is still with us, it’s circulating worldwide among humans, and circulating also among whitetail deer, feral mink, and probably other wild mammals.”
He says efforts currently need to be directed to approaching COVID-19 as a long-term cause of human illness, suffering, and death, not “a short-term catastrophe”.
He says laboratory techniques need to be improved as well as manufacturing capacity for updated COVID-19 vaccines. Inequitable access to vaccines will need to be solved. “We will need to dissolve vaccine reluctance and refusal – among the privileged but obdurate, and also among those historically ill-served by Western medicine – with better communication and education.” Diagnostic testing needs to be maintained and not reduced, as well as the sequencing of genomes from patient samples to detect and trace new and immune-evasive variants, he says.
“We will need to prepare, not just for the next coming of SARS-CoV-2 (when it emerges from some infected human, or some deer or mink) but also for the next coronavirus or influenza virus (more than likely H1N1) or other highly adaptive animal-borne virus (there’s a whole rogue’s list of possibilities) that appears in humans, seemingly out of nowhere,” he says. “But they don’t come out of nowhere. They come from nature.”
While HIV and tuberculosis (TB) rates in South Africa are slowly declining, indications are that rates of non-communicable diseases (NCDs) like hypertension and diabetes are on the rise. One response to this shift is to bring some of the strategies used in combatting HIV to NCDs.
Hypertension, more commonly known as high blood pressure, has been described as a “silent killer” because there are often no symptoms associated with having it. Hypertension is when someone’s blood pressure is consistently higher than normal, which can lead to a host of complications, including stroke, heart attack, and kidney disease. Someone’s risk of developing hypertension is influenced by a number of things, including lifestyle, genetics, age, and family history as well as conditions like diabetes. (Spotlight previously reported on the state of hypertension in South Africa.)
90-60-50
For much of the last decade, UNAIDS’s 90-90-90 targets have been central to how governments have kept track of their HIV responses. The first 90 measured the success of testing programmes, the second 90 measured the success of efforts to get people on to treatment, and the third 90 provided information on how well people are doing once on treatment.
South Africa’s National Strategic Plan (NSP) for the prevention and control of NCDs (2022-2027) sets out similar targets for hypertension and diabetes. As with HIV, the three hypertension indicators will paint a picture of how South Africa is doing on testing, getting people onto treatment, and finally how well people are doing once on treatment.
The hypertension targets are as follows:
90% of people over 18 will know whether they have raised blood pressure.
60% of people with raised blood pressure will receive interventions.
50% of people receiving interventions for hypertension will have controlled blood pressure levels.
Implementation will be key
Local experts interviewed by Spotlight agree that the NSP is a step in the right direction but are clear that much more will be needed.
Professor Brian Rayner, Emeritus Professor in the Division of Nephrology and Hypertension at the University of Cape Town, says he finds the NSP lacking in practical details of how the targets will be achieved. “I’d love for the government to have the plan for how they can achieve this and not another document actually… they need to actually say how are we going do this,” he says.
Professor Angela Woodiwiss of the School of Physiology at the University of the Witwatersrand, and member of the board of the Southern African Hypertension Society has similar concerns. She says the objectives and deliverables in the NSP are sound, but it is short on details when it comes to implementation.
Ways to address this, according to Woodiwiss, is to include “examples of cost-effective practical approaches such as the establishment of cardiovascular screening centres at all district clinics where measurements of blood pressure are done; monthly screening drives at community centres over weekends to increase accessibility to those that work during the week; [and] awareness campaigns at shopping centres”. Another suggestion is for awareness and education campaigns on hypertension to be conducted on media platforms like TV and radio.
“In order to reduce the burden of disease, this target needs to be raised. I would therefore suggest 90-80-70 as the proportions,” she adds.
Professor Andre Kengne, the director of NCD research at the South African Medical Research Council, who was also part of the planning committee for this version of the NSP, says the plan is only a starting point. “The plan says that these [NSP targets] are the entry point, so it’s going to be a catalyst,” he says. “That’s why we just need to start somewhere and then improve on that and again, I think that’s exactly the approach that the plan is taking, This is let’s start small but with the aim of actually progressing.”
Screening: 90% of people over 18 will know whether they have raised blood pressure
A major challenge with NCDs such as hypertension and diabetes is that we don’t have very good epidemiological data in South Africa. Experts referred Spotlight to data from two sources.
Kengne says that based on data collected by the NCD Risk Factor Collaboration, a global network of health scientists that provide data on NCDs, which he is part of, about 40% of adult men and about 42% of adult women in South Africa had hypertension in 2019. Only about 38.5% of men with hypertension were diagnosed at the time and 61.5% of women.
Woodiwiss cites data collected through ‘May Measure Month’ (MMM) South Africa, of where she is a principal investigator. MMM is a global campaign run by the International Society of Hypertension to raise awareness. She cites data collected from screenings conducted from 2017 to 2022.
“The proportion of hypertensive adults aware that they have hypertension ranged from 42.5 to 56.7%,” she says.
When looking at the South African population as a whole, Woodiwiss calculates that this means that only around 13.6 to 19.6% of all people over the age of 18 are aware of whether they have hypertension or not. “We, therefore, have a long way to go in order to achieve the target of 90% of all adults being aware of whether they have raised blood pressure or not,” she adds.
Whichever of the two data sources you look at, South Africa seems to fall well short of the 90% target.
To improve the country’s performance on this measure, experts interviewed by Spotlight agree that there needs to be greater awareness of hypertension (including the importance of checking your blood pressure regularly) and better opportunities for screening.
“There will be no other way of actually improving the numbers without screening people,” Kengne says.
“The current screening approach is essentially hospital-based, and it’s not even yet comprehensive. Meaning only those in contact with the health system are likely, for a proportion, to get their blood pressure measured and then eventually diagnosed with hypertension,” he explains. “The first focus is really to optimise that hospital-based screening, to make sure that everything is in place to measure the blood pressure of whoever gets in contact with the health system.”
Ultimately, Kengne suggests what is needed is to implement community-based approaches to blood pressure screening. One way to do this would be to couple HIV community screening efforts with hypertension screening. As well as to empower community healthcare workers to check blood pressure when doing household visits and then refer people with elevated blood pressure to clinics if needed.
“There need to be national awareness campaigns on TV and radio. These campaigns can be used to encourage individuals to have their blood pressure measured at free screening sites such as community centres, shopping malls, and university campuses as is done as part of the May Measure Month campaign,” Woodiwiss suggests. She adds that a celebrity ambassador would be a great asset for such campaigns.
Treatment: 60% of people with raised blood pressure will receive interventions
“About 85% of those [men] who are diagnosed [with hypertension] are on treatment. And in women it’s about 86%,” Kengne says.
He adds that this is where the NSP targets are maybe not as ambitious as they could be because when you look at the data in the context of everyone who has hypertension (not just those with diagnosed hypertension), only 33% of men and 53% of women are on treatment.
In Woodiwiss’s data, the proportion of hypertensive adults who were receiving medication for hypertension ranged from 36.1 to 49.2%.
Either way, both data sources suggest that one of the biggest challenges to getting people onto treatment is actually diagnosing them in the first place. There is a question, however, whether the health system will be able to cope with the increased treatment load should diagnosis improve.
Kengne suggests that facilities, specifically public health sector facilities, may not be able to cope with the increased demand. “We’re going to need to prepare the health system to cope with the high demand for hypertension care subsequent to increased screening,” he says.
He thinks task-shifting may be part of the solution. Task-shifting was critical to the scaling up of South Africa’s HIV treatment programme, for example, by allowing qualifying nurses to prescribe antiretroviral treatment. Similarly, more healthcare workers, including community healthcare workers, nurses, and field workers can be trained to screen for and treat hypertension.
Woodiwiss stresses the importance of education and awareness when it comes to treatment.
“To facilitate the participation of individuals in the management of their blood pressure, education, and awareness are paramount… An important aspect is to empower individuals to be part of the management of their blood pressure; to re-enforce that hypertension is a chronic problem that requires daily management; and to dispel any notions of stigmatisation due to having high blood pressure,” she says.
Another important practical step would be to reduce the pill burden on hypertension patients in the public sector, according to Rayner. While medication is relatively cheap in this sector, there has not been a move towards combining multiple blood pressure drugs into a single pill, which would make patient adherence easier.
He adds that the process of prescribing blood pressure medication in the private sector needs to be simplified. In line with the idea of task-shifting, Rayner suggests allowing nurses to prescribe medication for straightforward hypertension cases in the public sector as a cost-effective way of treating hypertension.
Control: 50% of people receiving interventions are controlled
About 43% of men in South Africa with hypertension and who are on treatment have controlled blood pressure compared to 54.6% of women, according to Kengne. “Now taken as a proportion of all those with hypertension, I mean our target of 50% controlled will narrow down to about 27% of all people with hypertension [being controlled],” he says. “Using that as the estimate among men currently only 14% of all those with hypertension are controlled and among women, 29% are controlled.”
Data from Woodiwiss suggested that “the proportion of treated individuals with controlled blood pressure ranges from 49.6 to 57.5%.”
For this target then, the country isn’t too far off the 50% target.
But Kengne stresses that blood pressure control is not straightforward. “Diagnosing, it’s not that difficult. Starting treatment it’s not difficult, but actually treating to target it’s a challenge and a number of factors can come into play. Some factors [are] linked to people with hypertension [and] some linked to healthcare providers and the health system,” he says.
For patients, issues like adherence to treatment can be difficult. He suggests using mobile technology, like text messages, to remind patients to take their medication. As well as reducing the pill burden by investing in combination medications.
From the healthcare provider side, Kengne says there needs to be monitoring of patients so that changes to the treatment plan can be made if needed so that the patient can achieve blood pressure control.
“Improving the proportion of treated individuals who have controlled blood pressure requires ongoing monitoring and regular blood pressure checks. As the vast majority of South Africans cannot afford home blood pressure monitors, easy access to blood pressure checks at community clinics, pharmacies, etc. should be provided country-wide,” Woodiwiss says. “It would be ideal if companies could all have corporate wellness days for employees.”
UCT Lab technician Fadheela Patel, pictured here preparing mastermix in the clean room
In a first for the African continent, researchers at the University of Cape Town are using a cutting-edge technique to fast-track the diagnosis of disease, ensuring patients receive the correct treatment sooner.
Clinical microbiologists Professor Adrian Brink and Dr Gert Marais at UCT’s Faculty of Health Sciences have operationalised clinical metagenomics in South Africa, transforming the procedure from a complex logistical procedure to a routine test.
Clinical metagenomics fast tracks the medical diagnostic process, cutting turnover time down – from sample to result – from weeks or even months to just a few days. It can also be used as a ‘sentinel surveillance tool’ to spot new infectious diseases and sound an early warning alarm for future pandemics.
“This kind of technology has never been used in South Africa and as far as we know, the African continent. “Certainly there’s no diagnostic lab in South Africa that does it,” says Brink. He and Marais believe they are the first to develop a clinical metagenomics service in Africa.
The genetic sequences appearing in a sample are compared to a database of all known organisms, allowing any and every pathogen present within the patient to be detected at the same time from just one sample. This metagenomic approach is sometimes referred to as “agnostic sequencing”.
Key steps in Brink and Marais’ clinical metagenomics study on the brain 1) A medical sample is obtained (from cerebral spinal fluid in their study) and treated to extract and purify all the nucleic acids (genetic material) it contains. These DNA fragments are then made into a ‘library’ by attaching short molecules called adaptors to the ends. This prepares the sample to be run through a sequencing machine. 2) The genetic code of the library is read in real-time by running it through a sequencing machine. This generates a series of ‘reads’ (DNA sequences). 3) The reads are compared to an online database of all known organisms’ genetic codes, allowing any and every pathogen present within the patient’s brain to be detected at the same time from just one sample. 4) The results are examined for matches with infections organisms and used to determine appropriate patient treatment.
By contrast, conventional diagnostic testing requires testing individually for a specific suspected disease. If the result comes back negative, a new sample will need to be taken and sent for a different test – a lengthy process when lives are at stake.
“In some cases we investigated, patients had a disease that could have been treated if it had been identified initially. But because the diagnosis could only be made months later, it was too late [to save them]. That’s where the idea for our study originated,” says Marais.
Brink recounts the case of a cancer patient who developed neurological symptoms. “Because he was highly immunocompromised, the list of potential causes for these symptoms was a page long,” says Brink.
The patient passed away, and clinical metagenomics testing of a sample taken at the autopsy revealed he was suffering from Aspergillus, an aggressive fungal infection that requires specific treatment.
Although he was already very sick due to cancer, Brink says the untreated central nervous system aspergillosis may have led to the patient’s death. “If clinical metagenomics methods had been available at the time, the right therapy could have been started weeks earlier, potentially changing the outcome for this patient,” he says.
Brink and Marias used clinical metagenomics to diagnose neurological disorders and study the effects of COVID-19 on the brain. It’s an area of health care where a timely diagnosis is particularly important. “Once the brain is damaged, there’s no going back,” says Marais. This research is currently under review for publication and expected to be released shortly.
While metagenomics has been applied in research settings in Africa before, this is the first time the method has been fully operationalised for clinical applications on the continent – meaning that all sample processing and analysis can now be done in the same laboratory in real time.
Previously, researchers in Africa have had to send samples overseas to Europe or the United States for processing. The reason: the chemical reagents required to run clinical metagenomic tests, despite in some instances being as easy to access in Europe as a DHL order, were not readily available in Africa.
Supported by funding from Oppenheimer Generations Research and Conservation, Brink and Marias remedied this by establishing a reagent supplier pipeline for South Africa, a tricky task when the pandemic had interrupted global supply chains. With a reliable source of reagents, samples can now be processed in labs in South Africa, opening the door for advances in medicine and research on the continent.
Building capacity instead of ‘helicopter research’
Marais emphasised their focus on upskilling and building capacity for Africa, in contrast to the ‘helicopter research’ that has defined clinical metagenomic work on the continent up to this point. “Our goal was to increase the capacity for infectious disease diagnostics going forward, rather than just coming in, testing a few samples, publishing a paper and leaving,” he says.
According to Marias, most prior metagenomics work in Africa has been in the form of discreet research projects with an international collaborator or as field work for an international lab, with little investment in local medical infrastructure and capabilities.
Their initial work so far has already created opportunities for skills transfer in genetic sequencing and bioinformatics at UCT medical school and medical research departments, and at institutes in Johannesburg.
Although the high cost of reagents and lack of standardised protocols remain challenges for a clinical metagenomics rollout in Africa, Brink and Marais are confident that the technology can become a cost-effective tool to improve patient individual care and to identify novel pathogens in low- and middle-income countries (LMICs).
A vast range of applications
Their new paper, co-authored with Associate Professor Diana Hardie and published in The Lancet Microbe in December 2022, calls for the expanded infrastructure developed in LMICs for COVID-19 monitoring to be leveraged to improve infectious disease diagnostics through clinical metagenomics.
“We applied clinical metagenomics to the COVID-19 brain, but the picture is bigger than that,” says Brink. Clinical metagenomics can be used for diagnosing an array of diseases across many health disciplines. In collaboration with colleagues at Cape Town’s Groote Schuur Hospital, Brink and Marias are now exploring the application of the technology in orthopaedics, neurosurgery, haematology-oncology and cardiothoracic surgery.
Specifically, they’re looking at patients with prosthetic joint infections, heart valve infections, brain tumours and leukaemia. The team welcomes collaborators and asks researchers and health care professionals across the continent interested in utilising clinical metagenomics to reach out to them.
Brink and Marias are also examining patients suffering from severe respiratory tract infections without a diagnosis, another area where clinical metagenomics is particularly revolutionary.
Because the genetic sequences found in patient samples are compared to a database of all known organisms, if a sequence yields no match to the database, there’s a chance it could be a novel pathogen.
This application is particularly relevant in LMICs where novel pathogens pose a higher risk due to socioeconomic factors and a lack of infrastructure to deal with local outbreaks. However, despite this, infectious disease surveillance infrastructure is more developed and readily available in high income nations.
While hurdles remain to be navigated before clinical metagenomics can be widely accessible across Africa, the team is confident that technology holds real promise for advancing the continent’s capabilities for medical research and diagnosis. “There aren’t a lot of people doing this kind of thing [in Africa], but this is the future,” says Brink.
Loadshedding is affecting waiting times at the Dunoon Community Health Centre in Cape Town, with patients saying they queue for hours and are still sent home without their medication.
Dunoon resident Mavis Matomane, 54, said she woke up early on Thursday 11 May to be at the clinic in time for an appointment made five months ago.
When she arrived at 7am, she joined a long queue standing outside in the rain. Matomane needs medication for arthritis and high blood pressure. She said the clinic was serving people who had arrived the day before but had not been seen to and had been told to return on 11 May.
She was seen by nurses for diagnosis after 11am and only left the hospital with her medication at 3pm.
Neliswa Bobotyana, who lives in Ibaleni informal settlement in the township, said she accompanied her boyfriend to the Dunoon centre on Monday 8 May. He was seen by a doctor and told to wait to get X-rays, but the X-ray facility closed while he was still waiting. On Tuesday his condition had deteriorated and she took him back to the health centre where he was told to open a new folder. He was sent back home and returned on Wednesday 10 May and was taken to the New Somerset Hospital where he was finally given medication.
Other residents have complained on a neighbourhood online group.
Western Cape Department of Health spokesperson Natalie Watlington said as a result of loadshedding and problems with the data centre in George, pharmacy applications for patient medication were offline on 10 May.
“Our pharmacist therefore requested patients to return the next day for their medication. We acknowledge that at times loadshedding may affect our phone lines and IT systems. It may take more time to draw your folder or process your details as a patient,” said Watlington.
She said on average 150 adults and 180 children arrived without appointments every day. This was on top of about 120 clinician appointments and 100 family planning appointments per day.
She said there were problems when patients who did not arrive on their appointment day arrived as walk-in patients on other days. There were an average of 80 missed appointments a day, Watlington said.
Watlington said patients sticking to appointment times did not need to arrive early. Waiting times differed according to the nature of the complaint and the treatment.
Today we celebrate Nurses as we do every year on 12 May. The International Council of Nurses proclaimed this year’s slogan as ‘Our Nurses, Our Future’, but what is the future of nurses in South Africa?
During the height of the COVID pandemic, we saw a huge campaign launched by the World Health Organization, uplifting the stature of nurses and midwives and showcasing them as the backbone of health systems at a global level. In the South African context, the story goes that they will also be central to the health system once National Health Insurance is implemented yet there are many red flags raised as we continue the planning discussions in preparation for this change with little to no answers about that future.
“I will never be a nurse”
By the time my mother had to decide on a career, nursing was one of those professions that provided stability and security to black and coloured women during Apartheid. You had two choices – become a nurse or a teacher. That’s how my mother began her nursing journey, but she was so passionate about it so that it would probably have been her choice, regardless.
Her passion was not what spurred me on to become a nurse, though. I looked at her long hours and tireless devotion to her community and the mental health fraternity and literally uttered the words, “I will never be a nurse”. Then I met a young staff nurse during a youth weekend away. She was so proud of her profession. She just oozed pride, and at that moment, I went from a potential engineering student to a nursing student.
My father was livid. He could not comprehend why his only daughter would observe the work hours of her mother and still choose to become a nurse. But in many ways, I believe nursing chose me. Once I made the decision, I never looked back. I remember being mocked and berated for my choice in social circles, but feeling a deep connection to this calling.
I have not entered it blindly though. I was aware of my privilege and the weight of caring for people at their most vulnerable. The experiences I have made while holding the hand of someone taking their last breath, supporting a mother delivering a stillborn baby, to engaging with my first person living with HIV, or watching someone slip away after a huge battle with cancer have been deeply embedded in my consciousness. I do not believe these experiences to be without life-altering potential and believe it has shaped me into the healthcare worker I am today.
Threats to nurse autonomy
It is often believed that nurses are the handmaiden to the doctor and we should not think but do. Those sayings were so wrong, but even today, the inferiority of the quality of nurse training, lack of supervision, and only very limited mentoring all threaten the autonomy of the nurse.
Nurses, despite having a day and even a week dedicated to celebrating them, are still, for the most part, underpaid, overworked, and professionally stunted. By stunted I am referring to the lack of mandatory continuous professional development and upskilling. Somehow, as the backbone of primary healthcare, they are often unable to take time out for much-needed training.
One often hears of nurses being rude and impatient. Though some may very well display these horrible traits, for the most part, people have entered this profession to improve healthcare services to individuals, families, and communities at large. In my 21 years of experience, the issue is hugely exacerbated by the healthcare system, which does not support nurses. The hours are long and gruelling – exacerbated by staff shortages in facilities. The environment is hostile, the workload unequal, and the pay shoddy. Many nurses find themselves moonlighting to make ends meet.
Advocate for us
Though not an excuse for unprofessional behaviour, I do want activists and health advocates to fight for better working conditions, upskilling opportunities, and a larger health workforce in our public health sector.
The mental health of our clients and communities appears topical at the moment, but what about the nurse? The trauma of loss, observation of patient suffering, and abuse by many of the actors in the health space can take its toll on the mental health and well-being of our nurses, too. When we plan for the public, we must remember to include the healthcare workers and their health and well-being.
This is even more critical now as we embark on establishing the National Health Insurance (NHI) system.
As NHI looms, the threat that nurses will be ill-equipped to render quality healthcare services is a glaring reality. The South African Nursing Council (SANC) notes that 47% of the nurses on its database are older than 50 years of age. This narrative of aging nursing personnel started years ago and if we had a proactive plan to address this, South Africa may in fact have had some fighting chance to implement NHI smoothly.
In a damning article published in February, the Democratic Nursing Organisation of South Africa (DENOSA) highlighted that the South African public health sector has a deficit of 27 000 nurses and yet there are 5 000 nurses currently unemployed. How can this be acceptable? It further noted that the South African government has placed certain nursing specialities on a scarce skills list in the hope of recruiting from other countries instead of planning to upskill and uplift domestically.
Part of me wants to speak about accountability, collaboration, and change management, but the other part bleeds for nurses as the workload and responsibilities increase and the work environment becomes more hostile. All this makes it hard to see the silver lining.
I do, however, believe that if the South African Nursing Council and National Department of Health actually engage the people on the ground, those at the coal face, those with expertise, and review their current implementation plans, they will see the same glaring gaps that we see every day.
There must be a call to action for all nursing leadership, nursing activists, nurses, and nursing education establishments to collectively take a stand and demand that we revise our current approach to the nursing curriculum and work on making nursing more appealing to the youth. This could be one step in the right direction.
When I qualified as a nurse, it was a four-year course. The nursing degree I completed included Community Nursing, Psychiatric Nursing, General Nursing, and Midwifery, and although I might not practise it all, I am able to fall back on that knowledge during client or patient engagements. Now it is a five-year course with one qualification with the nurse trained as a generalist. The fear is how does that serve our communities? We need midwifery, for example, to do NIMART (initiate people on HIV treatment) and you need community nurses to be working in primary healthcare, If you come out with one general qualification – how exactly will this pan out?
We need a rethink of how we train nurses and how we can strengthen the curriculum so that we can get nurses who can address HIV and all issues in primary healthcare. In my programme – HIV testing, for example, nurses don’t get trained on HIV testing. It is just monkey see, monkey do and unfortunately, that doesn’t translate into quality service.
Very often nursing practice is see one, do one, and then you’re the expert. I’m arguing that these things must be part of the curriculum. For example, why must a nurse come out of nursing school and then only learn IMCI (Integrated Management of Childhood Illness) Why is IMCI not being done practically in the facility and the theory in class, as part of the curriculum?
Nurses, today, are expected to know everything, which is impossible but we are not upskilling them and making sure the curriculum is so robust that it addresses all disease profiles and our communities’ healthcare needs. We are talking about integrative and holistic healthcare so we cannot be only training nurses in one way. There is a malalignment of what our communities need and what nursing schools are churning out.
We must fix that.
We need an urgent change in the curriculum of nurses to ensure we can support the needs of the health system and communities, build great leadership for the future, and ensure quality health services for all.
* Sparks is a nurse, health equity advocate, and Tekano and Aspen New Voices Fellow with 21 years’ experience working across South Africa with a focus on ensuring equitable and just access to quality healthcare for all.She is also a Quote This Women + Voice of the Year Award Winner.
Chris Hani Baragwanath Academic Hospital (CHBAH) has been hit with shortages of essential foods as contractors fail to deliver the quantities of food tendered for, Daily Maverick reports.
Last week, a head of department at CHBAH notified Daily Maverick of the developing crisis, saying “So once again there is a food crises at Bara – suppliers weren’t paid, also no soap and hand towels and as a result infections spreading 😡.”
The unnamed healthcare worker said that the crisis was due to small suppliers being unable to fulfil the quantities for tenders they secured. Dry goods were particularly affected, and protein substitutes were having to be purchased from petty cash which was now depleted. This was verified by another healthcare worker, who described a situation of hospital kitchens having to borrow from one another.
One doctor spoke of elective surgeries being cancelled due to financial pressure, and an atmosphere of intimidation. Motalatale Modiba, spokesperson for the Gauteng Department of Health, denied that there was a food shortage situation, but said that delivery of some protein food items, such as chicken and fish, had been withheld due to administrative payment delays.
South Africa’s long-awaited new National Mental Health Policy Framework and Strategic Plan 2023 – 2030 has been published. The policy framework was presented at the SA mental health conference this week. PHOTO: DOH/Twitter
But even though there has been a gap from 2020 to 2023, speaking to Spotlight at the conference, Minister of Health Dr Joe Phaahla said that it doesn’t mean there was a gap in terms of updating. “Every either three or five years, we revise the policy. So, it is not that there has been a gap. There has been a policy, which has been guiding,” he said.
“But as things change, and in each cycle of the strategy and planning, we have a particular timeframe so that we can evaluate. And so now we have evaluated, and that’s why we are adding [additional things], as we learned from the previous implementation.”
Phaahla said that gaps in the country’s mental health services are not because of a lack of policy and plans but due to implementation issues and sometimes the shortage of resources and psychiatrists.
“If you look at the area of psychiatrists, it is just the two-tier system of our health service, which makes it very difficult because what psychiatrists can earn providing the services to more of the insured patients – it is something we can’t really match with the public sector salaries generally,” he said. Phaahla said that psychiatrists, who mostly work in the private sector, were typically trained at public-sector teaching hospitals. “But once they’re qualified, they stay for one year or so, then they are attracted by better income,” he told Spotlight.
According to Phaahla, to deal with the shortage of psychiatrists in provinces such as the Northern Cape where there are only three psychiatrists, the department plans to contract psychiatrists from other provinces. “We can have part-time psychiatrists, maybe take some from Gauteng where the majority are and in Western Cape and contract them to provide services in Northern Cape. Even if it’s on a weekly rotation,” he said.
Concerns over delays
While several mental health experts have welcomed the new policy framework and agree with Phaahla about the importance of implementation, they are not happy about the delays.
“We’re now sitting in 2023, three years late,” said Cassey Chambers of the South African Depression and Anxiety Group (SADAG). What that means, she said, is that civil society did not have a working document with which to engage government at provincial or district level.
Bharti Patel of the South African Mental Health Federation expressed similar concerns. “As the Federation for mental health, we are disappointed that it has taken this long for the policy to be reviewed, given the fact that the initial policy was launched in 2013,” said Patel.
“We had a crisis during that period from 2013 to 2020. We have witnessed mental healthcare users losing their lives during Life Esidimeni. The [Health] ombud report, the South African Human Rights Commission Report, have all given recommendations,” Patel said. Patel argues that those recommendations should have informed policy and implementation more quickly.
Implementation problems
Chambers described the previous strategic policy framework as a “very good document”. Then, she said, the problem came in the implementation. “And I think perhaps this is [why there was a] delay in having an updated document that is now running from 2023 to 2030. It is because the document was good, the policy was good. However, how it was implemented was not happening,” she said.
Speaking to Spotlight, Professor Crick Lund, Co-Director, of the Centre for Global Mental Health at King’s College London, explained that there are a number of factors that create implementation challenges. “The one is ignorance on the part of senior decision-makers about mental health, ignorance about the scale of the problem, and ignorance about the fact that something can be done about it,” he said.
According to Lund, the new policy framework has stronger implementation monitoring mechanisms and implementation can be tracked in a much clearer way over time.
For the new policy framework to work better than the previous one, Lund believes there is a need to create greater public awareness about mental health and about the mental health policy. He says, “We need to get all the sectors involved working together – the Department of Health, Education, Social Development, the criminal justice system, and also the NGO sector.”
Along similar lines, Patel stressed the importance of getting more government departments involved. “While the policy is developed at the national level, the National Department of Health is responsible for training the provinces and not only the Department of Health; they need to train all government departments within the province who have bought this policy,” she said. “You can’t have the Department of Health alone implement a policy. This is a policy that requires inter-sectoral collaboration so that different departments can also put budgets towards implementation.”
Lund said that there is a lot of common agreement on what the priorities are and a lot of energy going forward. “So I’m hopeful that we can move things forward.”
Budgets and human resources
While there seems to be consensus on the need for more training and getting wider buy-in, there is also a shared awareness that successful implementation will depend on the availability of sufficient funds and human resources.
“We need to see structured action plans in the provinces with budgets allocated so that we can hold the government departments accountable,” said Patel.
Chambers agrees that in order to get implementation of the new policy framework right, we will have to get the budgets right. “You need to allocate a budget in order to help with the implementation plan, especially knowing that our previous policy framework was not implemented. So, we have to overcompensate for that now, which is concerning because this year, the health budget has been reduced. Therefore, meaning that the national mental health budget has been reduced,” she said.
According to the new policy framework, the case for investing in mental health is strong. It states that at a societal level, lost income associated with mental illness far exceeds public sector expenditure on mental healthcare – in other words, it costs South Africa more to not treat mental illness than to treat it. The impact of mental illnesses such as depression and anxiety has been estimated to cost the economy more than US$3.6 billion (R61.2 billion) in lost earnings per year. Certain conditions such as perinatal depression and anxiety have lifelong cost consequences. For example, it is estimated that the lifetime costs of perinatal depression and anxiety in South Africa amount to US$2.8 billion (R47.6 billion) per annual cohort of births.
Chambers also stressed that we are facing shortages of human resources and appropriate facilities. “We don’t have the human resources or the capacity to fulfil that implementation plan and that’s a worry and a concern,” she said.
NHI and provincial plans
According to the new policy framework, mental health will be financed according to the principles adopted for all health financing in South Africa, and people will be protected from the catastrophic financial consequences of mental ill-health.
According to the policy framework, in the financing of the National Health Insurance (NHI) system, mental health services will be given parity with other health conditions, in proportion to the burden of disease and evidence for cost-effective interventions. NHI will specifically include packages of care for mental health, in line with the evidence for the most cost-effective interventions. The policy framework states that private medical aid schemes should be required to provide similar parity between mental health and other health conditions.
“Budget will be allocated to meet targets set for the implementation of the policy and regular discussions will be held with provinces to discuss strategies and monitor progress with implementation. At provincial level, mental health budgets will be reviewed annually to align mental health with national priorities, for each of the areas for action in 2023 and annually thereafter,” the policy framework reads.
The policy also says that all provinces will develop provincial strategic plans for mental health, in keeping with national policy, which outlines specific strategies, targets, timelines, budgets, and indicators in 2023 and annually thereafter, informed by specific unique local challenges.
Scanning electron micrograph of human respiratory syncytial virus (RSV) virions (colourised blue) and labelled with anti-RSV F protein/gold antibodies (colourised yellow) shedding from the surface of human lung epithelial A549 cells.
Credit: National Institute of Allergy and Infectious Diseases, National Institutes of Health (NIH)
Respiratory syncytial virus (RSV) is a dangerous early childhood viral infection, but results of a vaccine trial promise to change things radically.
A new study published in the New England Journal of Medicine, the world’s most prestigious medical journal, on 5 April that examined the effect of an RSV vaccine on pregnant women found that it reduced the risk of severe lower respiratory tract infections in newborns by 82%.
RSV is the most common cause of acute lower respiratory infection – or pneumonia – in infants. Globally, it was responsible for just over 100,000 deaths (with a lower bound of 84,000 deaths and an upper bound of 126,000 deaths) of children under five in 2019. Of these deaths 45% were infants (younger than six months), and nearly all deaths occurred in lower income countries (half in Africa alone). In an article in Spotlight in June 2022, Professor Cheryl Cohen, head of the Centre for Respiratory Diseases and Meningitis at the National Institute for Communicable Diseases (NICD), said that, pre-COVID, RSV led to 44 615 hospitalisations and 490 deaths in children under five each year in South Africa.
RSV causes cold-like symptoms, but can lead to severe symptoms like pneumonia. At present, there is no licensed RSV vaccine, though the virus was first identified in the 1960s.
The study was a phase three, double-blind trial (which compares a new treatment to standard care, and leads the way to regulatory approval and production) conducted in 18 countries, led by Beate Kampmann, Professor of Paediatric Infection and Immunity at the London School of Hygiene and Tropical Medicine, Shabir Madhi, Dean of the Faculty of Health Sciences and Professor of Vaccinology at the University of the Witwatersrand, and Iona Munjal, Director of Clinical Research & Development at Pfizer. It builds on earlier work by Madhi and others.
Women who were between 24 and 36 weeks pregnant were given an injection of a protein–based vaccine (RSVpreF) and a placebo. Pregnant women can passively transfer their immunity to viruses and diseases to their foetuses in utero.
They were then monitored to see if they suffered a severe RSV-associated lower respiratory tract illness that required medical attention, and if their newborns required medical attention for RSV-associated lower respiratory tract illness up to six months after birth.
A total of 7,358 women participated across the two trial groups, and 7,128 babies were monitored, and no safety concerns were identified over the course of the trial.
In November last year, Pfizer announced that it planned to submit a licence application to the US Food and Drug Administration after trials showed that the vaccine was highly effective at reducing severe RSV cases in the first 90 days of an infant’s life.
In a Twitter thread announcing the results, Madhi said that the next challenge would be to ensure that the vaccine is licensed across lower income countries, where most infant RSV deaths occur. Madhi said that there is a “moral responsibility on pharma to licence [the RSV] vaccine in LMIC [Lower and Middle Income Countries] at [an] affordable price.” Governments in poorer countries, “need to act to protect children in their counties by funding and deploying the vaccine timeously,” he said.
Madhi also informed GroundUp that coincidentally in the same issue of the New England Journal of Medicine, a medicine called nirsevimab was found to protect infants against RSV-associated hospitalisation and severe lower respiratory tract infections. Madhi and his team at Wits also participated in this trial.
This medicine is “administered as a single dose at the onset of RSV season,” Madhi explained. “The two approaches [the vaccine and nirsevimab] will be complementary.”
