Provincial Health Department Research Articles

Decadal epidemiology of malaria in KwaZulu-Natal, a province in South Africa targeting elimination

BackgroundAlthough malaria remains a noteworthy disease in South Africa, the provinces are at differing stages of the malaria elimination continuum. KwaZulu-Natal has consistently reported the lowest number of cases over the past 5 years and it is expected that the goal of elimination will be achieved in this province over the next few years. The study reports on few key indicators that realistically represents the provinces progress over the past decade. Local and imported morbidity and mortality is seen as the key indicator as is malaria in children under the age of five and pregnant women. The only vector control intervention in the province is indoor residual spraying (IRS) and this gives an estimate of the population protected by this intervention.MethodsTrend analysis was used to examine the changing epidemiology in KwaZulu-Natal over the past decade from 2008 to 2018. The data used in this decadal analysis was obtained from the provincial Department of Health. Since malaria is a medically notifiable disease, all malaria cases diagnosed in the province are reported from health facilities and are captured in the malaria information system in the province.ResultsThe results have shown that imported cases are on the increase whilst local cases are decreasing, in keeping with an elimination objective. Preventing secondary cases is the key to reaching elimination. Only 10% of the cases reported occur in children under 5 years whereas the cases in pregnant women account for about 1% of the reported cases. Over 85% of the houses receive IRS and this is also the same proportion of the population protected by the intervention.ConclusionSeveral challenges to elimination have been identified but these are not insurmountable. Although there are major impediments to achieving elimination, the changing epidemiology suggests that major strides have been made in the past 10 years and KwaZulu-Natal is on track to achieving this milestone in the next few years.

Burden of Sexually Transmitted Infections (STI) in Rural and Peri-Urban KwaZulu-Natal, South Africa: Findings from a Population-Based Household Survey

Background: Sexually transmitted infections (STI) contribute to enhancing HIV transmission and acquisition; however, population level prevalence of STI from high HIV burden settings are limited Methods: A population-based household survey undertaken between June 2014 and June 2015 enrolled 15–49 year old males and females in the Vulindlela and Greater Edendale areas of KwaZulu-Natal, South Africa. Data collected includedself-reported sociodemographic, behavioral, and clinical variables. For curable STIs, first-pass urine (males) or self-collected vulvo-vaginal swabs (females) were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium using multiplex real-time polymerase chain reaction (PCR) and for syphilis serum sample was tested using a non-treponemal rapid plasma reagin (RPR) assay. Herpes simplex virus type 2 (HSV-2) and HIV antibodies were assessed by enzyme-linked immunosorbent assays. Prevalence of all STIs was measured and the association between participant characteristics and curable STIs was estimated using Poisson regression. Findings: Among the 9812 enrolled participants, 38·9% were under the age of 25 years and 63·9% were females. Among males and females, the prevalence of HIV was 28·0% and 44·1%, p<0·001; HSV-2 was 46·1% and 68·8%, p<0·001. Overall, 15·5% of males and 27·8% of females tested positive for any curable STI; syphilis was 1·5% and 1·7%, p=0·62; N. gonorrhoeae 1·8% and 3·7%, p<0·001; C. trachomatis was 5·1% and 9·0%, p<0·001; T. vaginalis was 3·9% and 13·8%, p<0·001 and M. genitalium was 5·7% and 5·2%, p=0·43. Most STIs were higher in females and in HIV positive individuals. Infection with curable STIs in males was associated with age, drug use, and HIV positive status. In females, infection was associated with age, relationship status, number of lifetime partners, concurrent relationship, alcohol use, and HIV status. Viral suppression was associated with lower STI prevalence in both HIV positive males and females. Conclusions: The prevalence of curable STIs, HSV-2 and HIV was high in this population. These findings have important public health implications for HIV transmission and acquisition and justify the importance of population-based surveillance to monitor STIs in order to reduce STI related morbidity and mortality, improve the quality of sexual and reproductive health, and to reduce the STI and HIV syndemic. Funding Statement: Supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of operative agreement 3U2GGH000372-02W1. ABMK is supported by the joint South Africa–US Program for Collaborative Biomedical Research from the National Institutes of Health (R01HD083343). Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: The protocol, informed consent and data collection forms were reviewed and approved by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal, (Reference number BF269/13), and the KwaZulu-Natal Provincial Department of Health (HRKM 08/14). The protocol was also reviewed in accordance with the Centers for Disease Control and Prevention (CDC), United States of America human research protection procedures and was determined to be research, but CDC investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes.

Inflammation and Endothelial Function Relevant Genetic Polymorphisms and Carotid Plaque in Chinese Population

Background: Inflammation and endothelial function play important roles in the pathogenesis of atherosclerosis. The genetic influence on carotid atherosclerotic plaque is mostly unclear. The aim of current study was to examine the association of carotid plaque with variants in genes involved in inflammation and endothelial function. Methods: This was a multi-center, cross sectional survey in southwestern China from May 2015 to September 2015. The residents aged ≥ 40 years volunteered to participate in face-to-face survey in 8 communities at random. A total of 2377 subjects with high stroke risk population were enrolled. Carotid plaque and plaque phenotype were assessed by carotid ultrasound. Genotypes of 19 variants in 10 genes related to inflammation and endothelial function were examined. Gene-gene interaction was analyzed by generalized multifactor dimensionality reduction (GMDR). Finding: Carotid plaques were found in 852 (35.8%) subjects, 454 (53.3%) had stable plaques, 398 (46.7%) had vulnerable plaques. PPARA rs4253655, HABP2 rs7923349 and IL1A rs1609682 were associated with the carotid plaque presence, and NOS2A rs2297518 and PPARA rs4253655 were associated with vulnerable plaque in univariate analysis. GMDR analysis observed that there was a significant gene-gene interaction among HABP2 rs7923349, ITGA2 rs1991013, IL1A rs1609682 and NOS2A rs8081248, and the high-risk interactive genotype among the 4 variants was independently associated with a higher risk for carotid vulnerable plaque after adjusting the covariates (OR, 2.86, 95% CI: 1.32-7.13, P = 0.003). Interpretation: Prevalence of carotid plaque was very high in the high risk stroke population in southwestern China. Variants in genes involved in endothelial function and inflammation were associated with the carotid plaque and plaque vulnerability. The high-risk interactive genotype among rs7923349, rs1991013, rs1609682 and rs8081248 was independently associated with a higher risk for vulnerable plaque, and might be potential markers for plaque vulnerability. Funding Statement: This study was supported in part by grants from the Scientific Research Foundation of Sichuan Provincial Health Department (Grant No. 16ZD046), the Sichuan Science and Technology Agency Research Foundation (Grant No.2018JY0164), and Universal Application Program, Health and Family Planning Commission of Sichuan Province in China (Grant No.17PJ084). Declaration of Interests: The authors stated: None. Ethics Approval Statement: The survey protocol was reviewed and approved by the Ethics Committee of the participating hospitals (People’s Hospital of Deyang City, Suining Central Hospital, and the Affiliated Hospital of Southwest Medical University), and informed consent was obtained from all participants during recruitment.

Public sector optometrists’ perspectives on a decentralised model of clinical training for optometry in KwaZulu-Natal, South Africa

Background: Optometry training in KwaZulu-Natal has embraced a decentralised approach in keeping with other health professions. Decentralised clinical training enables health science students to gain clinical exposure at public hospitals during their undergraduate training using a service learning strategy. The perspectives of key stakeholders in this collaborative agreement between the provincial department of health and local academic institutions were unexplored. Aim: The research aimed to explore KwaZulu-Natal’s public sector optometrists’ perspectives on decentralised clinical training in optometry. Setting: This study involves optometrists employed within public health facilities in KwaZulu-Natal. Methods: The research followed a qualitative design. Sampling was purposive, with the sample population including all public sector-employed optometrists within the KwaZulu-Natal Department of Health. Questionnaires were used to collect data, which were thematically analysed to gain insight into participants’ perspectives relating to the decentralised clinical training (DCT) in optometry. Results: In KwaZulu-Natal, DCT in optometry as a revised clinical training strategy is generally supported by public sector optometrists. It presents opportunities for expanded access to eye care for public sector patients and a mutual learning opportunity between students and practitioners. However, resources required for comprehensive optometric assessments are significantly lacking within the public health sector. Training for public sector optometrists who would be expected to serve as clinical educators was also an identified need. Conclusion: While there are various challenges facing optometry practice within the public health sector in KwaZulu-Natal, decentralised clinical training holds promise for the improved eye care service capacity in KwaZulu-Natal.

Surveillance for Lyme disease in Canada: 2009-2015

ObjectiveThis study aims to describe incidence over time, geographic and seasonal distribution, demographic and clinical characteristics of Lyme disease cases in Canada.IntroductionLyme disease (LD), a multisystem infection that is manifested by progressive stages (1), is emerging in central and eastern provinces of Canada due to northward expansion of the geographic range of Ixodes scapularis, the main vector in these regions (2). In 2004, approximately 40 human cases of LD were reported in Canada. In 2009, LD disease became nationally notifiable, with provincial and territorial health departments reporting clinician-diagnosed cases to the Public Health Agency of Canada (PHAC). This study summarizes seven years (2009-2015) of national surveillance data for LD in Canada.MethodsNational Lyme disease surveillance data is collected through two surveillance systems, the Canadian National Disease Surveillance System (CNDSS) and the Lyme disease enhanced surveillance system (LDES). The CNDSS collects only demographic data (age and sex), and information on episode date and case classification. The LDES system captures additional data, including: possible geographic location of infection (for both locally acquired and travel-related cases); clinical manifestations; and results of laboratory testing. Nine provinces out of ten participate to LDES that means they provide a part of or all the data elements of this surveillance system. The 2009 national Lyme disease case definition (3) that distinguishes confirmed and probable cases (Table 1) is used to classify and report cases diagnosed by clinicians.This study describes the incidence over time, seasonal and geographic distribution, demographic and clinical characteristics of reported LD cases. Logistic regression was used to explore variations among age groups, sex and year of reporting clinical manifestations to better understand potential demographic risk factors for the occurrence of LD. Different models were used with as outcomes absence or presence of: erythema migrans (early Lyme disease), neurologic and cardiac symptoms and multiple erythema, migrans (early disseminated Lyme disease); and arthritis (late disseminated Lyme disease). The most parsimonious multivariate models were sought by backward elimination of nonsignificant variables until all factors in the model were significant (P&lt;0.05).ResultsThe number of reported LD cases increased more than six-fold, from 144 in 2009 to 917 in 2015, mainly due to an increase in infections acquired in Canada. For the provinces participating into the LDES system, the month of illness onset for Lyme disease cases acquired in Canada was available for 2010 cases. Most cases were reported during the summer months of June (20.7%), July (35.4%) and August (17.3%) (Figure 1). An increase in incidence of LD was observed in provinces from Manitoba eastwards (Figure 2). This is consistent with our knowledge of range expansion of the tick vectors in this region. In the western provinces the incidence has remained low and stable. All cases reported by Alberta, Saskatchewan and Newfoundland and Labrador were acquired outside of the province, either elsewhere in Canada or abroad. There was a bimodal distribution for LD by age with peaks at 5–9 and 45–74 years of age (Figure 3). The most common presenting symptoms were a single erythema migrans rash (74.2%) and arthritis (35.7%) (Figure 4). In the multivariate analysis for clinical manifestations, children aged 0–9 years had a greater number of cases reported as early LD (erythema migrans only) than patients aged 10–19 and 30–39 years (P&lt;0.05). For early disseminated manifestations, young adults 20–29 years of age reported more neurologic manifestations, cardiac manifestations or multiple erythema migrans than the reference age group of 0–9 years (P&lt;0.05). For late disseminated manifestations, children under 15 years of age were more frequently reported as having arthritis than other age groups.ConclusionsLyme disease incidence continues to increase in Canada as does the geographic range of ticks that carry the LD bacteria. This increasing of LD incidence might also be due to changing in knowledge, attitudes, and practices of clinicians who diagnose the disease and or of the public health workers who collect and report the data. Ongoing surveillance, preventive strategies as well as early disease recognition and treatment will continue to minimize the impact of LD in Canada.

Positioning public nursing colleges in South African higher education: Stakeholders' perspectives.

BackgroundPublic nursing colleges (PNCs) are currently redeploying from provincial departments of health to higher education to become part of a unified higher education system in South Africa. As primary producers of nurses, this migration process needs to be managed carefully, with stakeholders having a common understanding of this process.ObjectivesThis study aimed to explore the stakeholders’ perspectives on the positioning of PNCs in higher education.MethodThe study followed a qualitative grounded theory design. Purposive and theoretical sampling were utilised to achieve a sample size of 40 participants, including representatives from the Department of Higher Education and Training; professional associates; nursing educators; student leaders; nursing leaders; and nurses from the healthcare setting. Data were collected through observations, interviews and document analysis.ResultsIt emerged from the study that the integration of PNCs into higher education is a result of the country’s political and legal context. A number of policy and legal frameworks emerged as contextual conditions that provided a basis for the change. The integration of PNCs into higher education was conceptualised as a functional shift in the governance of colleges; a political tool to transform nursing education; a means to enhance the quality of college-based nursing programmes, and a vehicle for the greater professionalisation of nursing. Conflicting legislation and funding emerged as two issues of concern.ConclusionIntegrating PNCs with higher education came about because of political changes and the resolution of the ruling party to improve the quality of graduates produced, who will in turn improve the quality of healthcare service delivery offered.

South Africa field epidemiology training program: developing and building applied epidemiology capacity, 2007\u20132016

In 2007, South Africa (SA) launched a field epidemiology training program (SAFETP) to enhance its capacity to prevent, detect, and respond to public health threats through training in field epidemiology. The SAFETP began as a collaboration between the SA National Department of Health (NDOH), National Institute for Communicable Diseases (NICD), and the University of Pretoria (UP), with technical and financial support from the U.S. Centers for Disease Control and Prevention (CDC). In 2010, the CDC in collaboration with the NICD, established a Global Disease Detection (GDD) Center in SA, and the SAFETP became a core activity of the GDD center. Similar to other FETPs globally, the SAFETP is a 2-year, competency-based, applied epidemiology training program, following an apprenticeship model of ‘learn by doing’. SAFETP residents spend approximately 25% of the training in classroom-based didactic learning activities, and 75% in field activities to attain core competencies in epidemiology, biostatistics, outbreak investigation, scientific communication, surveillance evaluation, teaching others, and public health leadership. Residents earn a Master’s in Public Health (MPH) degree from UP upon successfully completing a planned research study that serves as a mini-dissertation.Since 2007, SAFETP has enrolled an average of 10 residents each year and, in 2017, enrolled its 11th cohort. During the first 10 years of the program, 98 residents have been enrolled, 89% completed the 2-year program, and of these, 76 (87%) earned an MPH degree. Of those completing the program, 88% are employed in the public health sector, and work at NICD, NDOH, Provincial Health Departments, foreign health institutions, or non-governmental organizations. In the first 10 years of the program, the combined outputs of trainees included over 130 outbreak investigations, more than 150 abstracts presented at national and international scientific conferences, more than 80 surveillance system evaluations, and more than 45 manuscripts published in peer-reviewed scientific journals. The SAFETP is having an impact in building epidemiology capacity for public health in South Africa. Developing methods to directly link and measure the impact of the program is planned for the future.

Outbreak detection of influenza-like illness in Prey Veng Province, Cambodia: a community-based surveillance.

ABSTRACTOn June 4, 2016, the Prey Veng Provincial Health Department reported a total of 107 patients with influenza-like illness (ILI) from Chakhlanh village to the Cambodian Ministry of Health. To confirm the outbreak and evaluate its clinical and epidemiological characteristics, the investigation team visited the village and reviewed the case-based surveillance (CBS) data on severe respiratory infection (SRI) and patients’ records in health facilities. The team interviewed all households in the village from May 1 to June 5, 2016 and obtained the following data: age, medical history, date of onset, treatment, symptoms, and history of contact with patients or dead poultry. Nasal swab samples were collected from suspected ILI cases to test for influenza virus by RT-PCR. The investigation detected 498 suspected ILI cases, including 288 females. Although the incidence of suspected ILI cases who visited health centers was 63.0 per 1,000 persons per month, the attack rate was 27.1 per 100 population. The major age group was 5–14 years followed by 0–4 years. Major symptoms were cough, fever, runny nose, and headache. Six of seven nasal swab samples were positive for influenza A/H1N1 pdm09 virus. Most children with flu symptoms had contact with previous cases. This study showed that the ILI outbreak might be caused by seasonal influenza A/H1N1 pdm09 spread from person to person. Poor living conditions and poor hygiene and sanitation practices were environmental factors that caused the outbreak. As the CBS system was unable to identify this epidemic, it needs to be improved.

The work of the Transbaikal Provincial Department of Health on health education in 1923–1926

The work of the Transbaikal Provincial Department of Health on health education in 1923–1926

Pharmacists' immunization experiences, beliefs, and attitudes in New Brunswick, Canada.

Background:The expansion of pharmacist scope of practice to include provision of immunizations has occurred or is being considered in various countries. There are limited data evaluating the experiences of Canadian pharmacists in their role as immunizers.Objective:To describe the experiences of pharmacists in the Canadian province of New Brunswick as immunizers, including vaccines administered and perceived barriers and facilitators to providing immunizations.Methods:An anonymous, self-administered, web-based questionnaire was offered via email by the New Brunswick Pharmacists’ Association to all its members. The survey tool was adapted, with permission, from a tool previously used by the American Pharmacists Association and validated using content validity and test-retest reproducibility. Pharmacist reported immunization activities and perceived facilitators and barriers to providing immunization services were assessed.Results:Responses from 168 (response rate of 26%) were evaluable. Approximately 90% of respondents worked in community practice full time, 65% were female and 44% were practicing for 20 or more years. Greater than 75% reported administering: hepatitis A and B, influenza, and zoster vaccines. The majority of respondents felt fully accepted (agreed or strongly agreed) as immunization providers by patients, local physicians, and the provincial health department (97%, 70%, and 78%, respectively). Most commonly reported barriers were: lack of a universally funded influenza immunization program, insufficient staffing and space, and concerns around reimbursement for services.Conclusions:Pharmacists in New Brunswick, Canada are actively participating in the provision of a variety of immunizations and felt fully supported by patients and other healthcare providers. Barriers identified may provide insight to other jurisdictions considering expanding the role of pharmacists as immunizers.

Vaccine-preventable disease control in the People’s Republic of China: 1949–2016

BackgroundChina's immunization program is one of the oldest and largest in the world. Rates of vaccine-preventable diseases (VPD) are comparable to those in high-income countries. The program's evolution has been characterized by ambitious target setting and innovative strategies that have not been widely described. MethodsWe reviewed national and provincial health department archives; analyzed disease surveillance, vaccination coverage, and serosurvey data from 1950 through 2016; and, conducted in-depth interviews with senior Chinese experts involved early VPD control efforts. ResultsWidespread immunization began in the 1950s with smallpox, diphtheria, and Bacillus-Calmette Guerin vaccines, and in the 1960s with pertussis, tetanus, polio, measles, and Japanese encephalitis (JE) vaccines. The largest drops in absolute VPD burden occurred in the 1970s with establishment of the Rural Cooperative Medical System and a cadre of trained peasant health workers whose responsibilities included vaccinations. From 1970 to 1979, incidence per 100,000 population dropped 48% from 3.3 to 1.75 for diphtheria, 50% from 152.2 to 49.4 for pertussis, 77% from 2.5 to 0.6 for polio, 60% from 450.5 to 178.3 for measles, and 72% from 18.0 to 5.1 for JE, averting an average of 4 million VPD cases each year. Until the early 1980s, vaccines were delivered through annual winter campaigns using a coordinated ‘rush-relay’ system to expedite transport while leveraging vaccine thermostability. Establishment of the cold chain system during in the 1980s allowed bi-monthly vaccination rounds and more timely vaccination resulting in rates of diphtheria, pertussis, measles and meningitis falling over 90% from 1980 to 1989, while polio and JE rates fell 40–50%. In the 1990s, progress stalled as financing for public health was weakened by broad market reforms. Large investments in public health and immunizations by the central government since 2004 has led to further declines in VPD burden and increased equity. During 2011–2016, the incidence per 100,000 population was <2.0 for measles and <0.2 for pertussis, JE, meningococcal meningitis, and hepatitis A. From 1992 to 2014, the prevalence of chronic hepatitis B infection in children <5 years fell from 9.7% to 0.3%, a 97% decline. China was certified polio-free in 2000 and diphtheria was last reported in 2006. ConclusionsLong-term political commitment to immunizations as a basic right, ambitious targets, use of disease incidence as the primary metric to assess program performance, and nationwide scale-up of successful locally developed strategies that optimized use of available limited resources have been critical to China's success in controlling vaccine-preventable diseases.

Improving Lives by Accelerating the Sustainable Development Goals for Adolescents Living with HIV

Background: The lives of adolescents in low and middle income countries would be improved by countries attaining the multifaceted Sustainable Development Goals (SDGs). For the most vulnerable young people this presents a major challenge. In response, the UNDP has proposed a new concept of 'development accelerators': provisions that simultaneously impact multiple SDGs. These may represent an opportunity for policy and provision to maximise the return on health and social investments. This study is the first to empirically test this concept, using a highly vulnerable sample of adolescents living with HIV in South Africa. Methods: Longitudinal data from 1060 adolescents living with HIV were gathered using community tracing from clinical records in 52 government clinics (90·1% reached, 93·5% 18-month retention). Standardised measures recorded eleven SDG-aligned targets across four goals, six potential accelerator provisions, and nine socio-demographic and HIV-related covariates. Associations of provisions with SDG outcomes were established by multivariable logistic regressions controlling for baseline outcomes, with adjustment for multiple outcome testing, and potential cumulative effects were tested by marginal effects modelling. Findings: Three provisions were 'development accelerators': each associated with positive outcomes across at least three SDGs: schools without physical violence ('safe schools'), government cash transfers and high parental monitoring (all p<0·05). For 9 out of 11 SDG-aligned targets, a combination of two of these accelerators showed cumulative positive associations, suggesting 'super-accelerator' effects of combination provisions. Interpretation: Findings suggest the validity of UNDP's 'accelerator' concept, identifying and providing services with multi-SDG impacts; and extend it to super-accelerators, that have cumulative effects. For adolescent sub-populations at elevated risk, development accelerators may provide a pathway to achieving health-focused SDG targets, and simultaneously impacting multiple SDG goals. Funding Statement: Nuffield Foundation, UKAID, Janssen Pharmaceutica, International AIDS Society, John Fell Fund, Economic and Social Research Council, European Research Council, Philip Leverhulme Trust, UNICEF. Declaration of Interests: LC, MO, LCa, ET, LS, AC and DW declare no conflicts of interest. LS reports grants from Sweden/Norad, grants from NIH, grants from MRC, personal fees from Gilead, other from AIDSImpact, editorial fees from Taylor and Francis, outside the submitted work. LC reports grants from Nuffield Foundation, UKAID and Sweden-Norad, Janssen Pharmaceutica South Africa, International AIDS Society, UNICEF Eastern and Southern Africa, John Fell Fund, European Research Council, Philip Leverhulme Trust, Economic and Social Research Council during the conduct of the study. Dr Webb is an employee of the UN Development Programme. Ethics Approval Statement: Ethical approval was given by the University of Cape Town (CSSR 2013/4), Oxford University (CUREC2/12-21), Provincial Departments of Health and Education and participating hospitals. All adolescents and their primary caregivers gave written informed consent at both time points in their language of choice (Xhosa or English), and read aloud in cases of low literacy.

Malaria programme personnel\u2019s experiences, perceived barriers and facilitators to implementing malaria elimination strategy in South Africa

BackgroundSouth Africa has set an ambitious goal targeting to eliminate malaria by 2018, which is consistent with the United Nations Sustainable Development Goals’ call to end the epidemic of malaria by 2030 across the globe. There are conflicting views regarding the feasibility of malaria elimination, and furthermore studies investigating malaria programme personnel’s perspectives on strategy implementation are lacking.MethodsThe study was a cross-sectional survey conducted in 2014 through a face-to-face investigator-administered semi-structured questionnaire to all eligible and consenting malaria programme personnel (team leader to senior manager levels) in three malaria endemic provinces (KwaZulu-Natal, Mpumalanga, and Limpopo) of South Africa.ResultsThe overall response rate was 88.6% (148/167) among all eligible malaria personnel. The mean age of participants was 47 years (SD 9.7, range 27–70), and the mean work experience of 19.4 years (SD 11.1, range 0–42). The majority were male (78.4%), and 66.9% had secondary level education. Awareness of the malaria elimination policy was high (99.3%), but 89% contended that they were never consulted when the policy was formulated and few had either seen (29.9%) or read (23%) the policy, either in full or in part. Having read the policy was positively associated with professional job designations (managers, EHPs and entomologists) (p = 0.010) and tertiary level education (p = 0.042). There was a sentiment that the policy was neither sufficiently disseminated to all key healthcare workers (76.4%) nor properly adapted (68.9%) for the local operational context in the elimination strategy. Most (89.1%) participants were not optimistic about eliminating malaria by 2018, as they viewed the elimination strategy in South Africa as too theoretical with unrealistic targets. Other identified barriers included inadequate resources (53.5%) and high cross-border movements (19.8%).ConclusionsMost participants were not positive that South Africa could achieve the malaria elimination goal by 2018, citing the high cross-border movements and lack of resources as key barriers. The National and relevant Provincial Departments of Health should consider investing more time and resources in further stakeholder engagement for more effective implementation of malaria elimination strategy in South Africa.

Leprosy case investigation - Limpopo province, South Africa, December 2016

Introduction : leprosy remains an important public health problem globally. In Africa, 6 countries including Mozambique and Tanzania accounted for 14% of new cases reported globally in 2015. Prevalence in South Africa (SA) is below 1 per 10,000. On December 8, 2016, the Provincial Department of Health was notified of 2 confirmed leprosy patients. Case investigation was initiated to identify the source of infection, close contacts of the patients, and to follow contacts for any signs of leprosy. Methods : we reviewed medical records and interviewed both patients. We conducted Household visits were conducted to assess close contacts for any signs and symptoms of leprosy. A case of leprosy was any person who consulted at a tertiary hospital in Limpopo province in November 2016 having one or more of the following: hypo-pigmented or reddish skin lesion(s) with definitive loss of sensation on hands and feet; and positive skin-smear for acid-fast bacilli. A contact was defined as any person living in the same household of known leprosy patient. Results : patient 1 was a newly diagnosed 50-year-old, HIV positive male with grade 1 disability. Patient was referred to the hospital after numerous incorrect diagnoses in the nearby clinic. He worked in Tanzania, Mauritius and Namibia since 2007. He started multidrug therapy (MDT) in November 2016. Patient 2 was a 29-year-old female with grade 0 disability. She lived in Mozambique for 17 years until her return to SA in 2011 when she began experiencing symptoms. She started MDT in December 2014, defaulted and reinitiated treatment in November 2016. A total of 24 contacts were reported, 18 were clinically examined and none showed signs of leprosy. Current patients were educated on treatment adherence and follow-up. Contacts were advised to report to hospital if experiencing similar symptoms. Conclusion : the two reported patients are unrelated and both lived in leprosy endemic countries outside SA. Due to the long incubation period of leprosy and low prevalence in SA, we conclude that infection likely occurred outside SA. We recommended training of health workers in leprosy-specific skills to improve early diagnosis and treatment throughout SA.

South African clinical practice guidelines: A landscape analysis.

South Africa (SA) is in the process of implementing National Health Insurance (NHI), which will require co-ordination of health provision across sectors and levels of care. Clinical practice guidelines (CPGs) are tools for standardising and implementing care, and are intended to influence clinical decision-making with consequences for patient outcomes, health system costs and resource use. Under NHI, CPGs will be used to guide the provision of healthcare for South Africans. It is therefore important to explore the current landscape of CPG developers and development. To identify and describe all CPGs available in the public domain produced by SA developers for the SA context. We conducted a cross-sectional evaluation using a two-part search process: an iterative, electronic search of grey literature and relevant websites (161 websites searched), and a systematic search for peer-reviewed literature (PubMed) after publication year 2000. CPGs were identified, and data were extracted and categorised by two independent reviewers. Any discrepancies were referred to a third reviewer. Data extracted included a description of the developer, condition, and reporting of items associated with CPG quality. A search conducted in May 2017 identified 285 CPGs published after January 2000. Of those, 171 had been developed in the past 5 years. Developers included the national and provincial departments of health (DoH), professional societies and associations, ad hoc collaborations of clinicians, and the Council for Medical Schemes. Topics varied by developer; DoH CPGs focused on high-burden conditions (HIV/AIDS, tuberculosis and malaria), and other developers focused on non-communicable diseases. A conflict of interest statement was included in 23% of CPGs developed by societies or clinicians, compared with 4% of DoH CPGs. Accessing CPGs was challenging and required extensive searching. SA has many contributors to CPG development from the public and private sectors and across disciplines, but there is no formal co-ordination or prioritisation of topics for CPG development. Different versions of the CPGs were identified and key quality items were poorly reported, potentially affecting the usability and credibility of those available. There was substantial variation in CPG comprehensiveness and methodological approach. Establishing a national CPG co-ordinating unit responsible for developing standards for CPG development along with clinical quality standards, and supporting high-quality CPG development, is one essential step for moving forward with NHI.

INTEGRATING THE ROLES OF STAKEHOLDERS IN PREVENTING THE HIV/AIDS TRANSMISSION IN EAST JAVA, INDONESIA

HIV/AIDS prevention is very important and absolutely necessary. HIV transmission is now entering a fairly alarming level, in which people with HIV/AIDS in certain subpopulations are emerging. Special steps and resources are thus needed to cope with the condition. There are some phenomena potentially encourage HIV transmissions, such as the increasingly common free sex, homosexuality, the use of unsafe and unsterile syringes in narcotics consumption, commercial sex workers and various high-risk sexual activities. One of the crucial concerns that arises when sending prostitutes back to their hometowns without any coordinated and holistic mechanism is that the prostitutes may cause the spreading of HIV/AIDS in their hometowns. The research objective is to provide the material (input) how the prostitutes themselves may cause the spreading of HIV/AIDS. The research employed descriptive method with a qualitative approach. The results showed that the implementation and the role division in the closure have been highly coordinated and holistic. The leading sector in the role division is the Social Welfare epartment of the Government in Surabaya. In terms of health aspects for the former prostitutes sent back to their hometowns, there has been no policies related to medical screening designed to identify the disease early. Screening is very important for early diagnosis during the post-closure phase. The screening mechanism is that the Provincial Health Department has to optimize the monitoring, coordination, cooperation, agreements and partnerships with stakeholders such as the Local Health Department and the National/Provincial/Distric AIDS Commission, NGOs that are concerned with the problems of HIV-AIDS, international organizations, professional organizations, community leaders, religious leaders and universities.

Challenges faced by caregivers of children on antiretroviral therapy at Mutale Municipality selected healthcare facilities, Vhembe District, Limpopo Province.

BackgroundChildren depend solely on caregivers who can be either parents or guardians for drug administration to enhance adherence to antiretroviral treatment (ART), which might pose any number of challenges.PurposeThe purpose of this study was to explore and describe the challenges faced by caregivers of children on ART at Mutale Municipality, Vhembe District, Limpopo Province.Research design and methodThe research design was qualitative, explorative, descriptive and contextual in nature. The population consisted of 16 caregivers who were 18 years of age and above, and mentally capable, irrespective of educational qualifications, caring for children aged between 0 and 15 years who were on ART between April 2013 and October 2014. Non-probability, purposive sampling was used to select the 16 caregivers. Required permission, approval and ethical clearance were obtained from the University of Venda Higher Degree Committee, Limpopo Provincial Health Department and relevant institutions. An in-depth, individual, unstructured interview method was used to collect data. One central question was asked: ‘What are the challenges you experience when caring for a child on antiretroviral treatment?’ Subsequent questions were based on the participants’ responses to the central question. Qualitative data were analysed by means of Tesch’s open-coding method.ResultsThe findings of this study revealed that participants, that is, caregivers of children on ART, experienced financial burdens because of transport costs needed to comply with follow-up dates and insufficient of money for food, clothing the child in need of care, pocket money for lunch boxes during school hours and time lost while waiting for consultations. Participants reported some level of stigmatisation against children on ART by family members, especially the husbands or in-laws of the secondary caregivers. Many primary and secondary caregivers seemed to have given up seeking support from government and community structures.ConclusionThe conclusions drawn from this research are that caregivers hardly receive any support from family members or the community. Fear of disclosing the HIV-positive status of children resulted in the delay of financial support from the government, thus leading to serious financial burden on the caregivers.

The Crux of the Medicine Prices' Controversy in Pakistan.

Drugs are regulated in Pakistan under the Drug Act 1976 and DRAP Act, 2012, under which the sales, storage, and distribution of drugs are regulated at provincial level while the manufacturing (licensing), registration, pricing, import, export, and monitoring of controlled drugs comes under the domain of federal government. The Drug Regulatory Authority of Pakistan (DRAP) established under the DRAP Act 2012 works under the federal government to regulate the aforementioned matters including fixation of prices. Prices are fixed by the Federal government under Section 12 of Drugs Act, 1976 after a recommendation of the Drug Pricing Committee (DPC) constituted the Statutory Regulatory Orders (SRO) on 6th August 2013 under the Cost and Pricing Division, DRAP. DPC is comprised of representatives from provincial health departments, Ministry of Finance and consumer bodies along with stakeholders as observers to proceedings of committee. In retrospective, the Pakistani government, particularly Drug Regulatory Authority of Pakistan (DRAP) in collaboration with provincial health departments are responsible for regulating the medicine prices and has taken various regulatory measures to address the issue of medicines accessibility, particularly on the medicines affordability and availability. Since 2001, there is a moratorium on price increase on 821 and 108 medicines through statutory regulatory orders SRO-100, SRO-328, respectively, before the establishment of DRAP. There are media reports that between June and August 2016, DRAP has approved price increases for four times but pharmaceutical companies were reported to have increased prices for at least five times (Chaudhry, 2016) but these reports are misleading. During the price moratorium, drug prices have not been revised despite of multifactorial burdens including increase in dollar exchange rate, fuel prices, inflation, material costs. Only with the exceptional cases of failure of a pharmaceutical manufacturer to continue manufacturing at the fixed price and accessibility of that drug was not ensured for general public. Moreover, some pharmaceutical companies increased prices of their medicines and were able to get stay orders from a provincial High Court to keep their price increased until the matter was resolved. DRAP's statutory power to regulate medicine prices were heavily opposed by the pharmaceutical industries who struggle to optimize their revenues due to limited wholesale mark-ups, ranging 2% (Cameron et al., 2009) to 10% (Mendis et al., 2007). It was getting practically non-viable for many companies including the multinationals to market their products in the same price as approved in 2001. These factors also led to stock-outs of essential medicine in healthcare institutions, especially public-funded hospitals. As a solution, to ensure the sustainability of local pharmaceutical industries and the accessibility of medicines, the first ever comprehensive Drug Pricing Policy 2015 was introduced (Drug Regulatory Authority of Pakistan, 2015). This new policy has laid down a transparent mechanism for fixation and price adjustment with an objective to help increasing availability of drugs at rational prices and discourage hoarding. Moreover, DRAP has also devised a monitoring mechanism with the coordination of the provincial health authorities working under the Provincial Quality Control Board to ensure that drugs are not sold in the market at prices higher than the approved range. According to this policy, prices of new drugs shall be fixed on the basis of average prices in India and Bangladesh and if new drug is not available in these countries price shall be fixed at the lowest level of the developing countries which regulate drugs prices or wholesale prices in UK, Australia, New Zealand. Moreover, a new concept of price reduction up to 30% on originator brands has been introduced with three staggered annual decrements. Drug Pricing Policy 2015 links the annual increase in medicine prices with the Consumer Price Index (CPI) as announced by Pakistan Bureau of Statistics, Government of Pakistan, with a maximum cap of 4% for scheduled drugs and 6% for non-scheduled drugs. For 2016, the proposed price increase in scheduled drugs and non-scheduled drugs was merely 1.43% and 2.00% respectively, based on CPI. It must be noted that the price hike is in fact unlawful as it had not been approved by Pakistani Federal Government.

Overview of the infant and young child feeding policy environment in Pakistan: Federal, Sindh and Punjab context

BackgroundAppropriate infant and young child feeding (IYCF) practices have been identified as important for appropriate child growth and development. (Ministry of Planning and Development, Ministry of National Health Services, Regulations and Coordination (2012)) Children in Pakistan still experience high rates of malnutrition, indicating a likely need for stronger IYCF policy. The purpose of this study was to identify major stakeholders who shape the IYCF policy environment and analyze which policies protect, promote and support IYCF practices, either directly or indirectly.MethodsThis study was conducted at the federal level, and in the provinces of Sindh and Punjab. We identified policies relevant to IYCF using a matrix developed by the South Asian Infant Feeding Research Network (SAIFRN), designed to capture policies at a range of levels (strategic policy documents through to implementation guidelines) in sectors relevant to IYCF. We analyzed the content using predetermined themes focused on support for mothers, and used narrative synthesis to present our findings. For the stakeholder analysis, we conducted four Net-Map activities with 49 interviewees using the Net-Map methodology. We analyzed the quantitative data using Organizational Risk Analyzer ORA and used the qualitative data to elucidate further information regarding relationships between stakeholders.ResultsWe identified 19 policy documents for analysis. Eleven of these were nutrition and/or IYCF focused and eight were broader policies with IYCF as a component. The majority lacked detail relevant to implementation, particularly in terms of: ownership of the policies by a specific government body; sustainability of programs/strategies (most are donor funded), multi-sectoral collaboration; and effective advocacy and behavior change communication. Data collected through four Net-Map activities showed that after devolution of health ministry, provincial health departments were the key actors in the government whereas UNICEF and WHO were the key donors who were also highly influential and supportive of the objective.ConclusionThis analysis identified opportunities to strengthen IYCF policy in Pakistan through increased clarity on roles and responsibilities, improved multisectoral collaboration, and strong and consistent training guidelines and schedules for community health workers. The current policy environment presents opportunities, despite limitations. Our Net-Map analysis indicated several key government and international stakeholders, who differed across Federal and Provincial study sites. The detailed information regarding stakeholder influence can be used to strengthen advocacy.

A situational analysis of ocular health promotion in the South African primary health‐care system

BackgroundSouth Africa has a serious burden of avoidable blindness and visual impairment, which may be due to poor ocular health promotional policies and programs or implementation. Therefore, this paper sought to critically analyse the South African primary health‐care policies and programs, to identify the components of ocular health promotional policies and programs as well as how they are currently being implemented and to suggest areas that can be improved in order to minimise the burden of blindness and visual impairment.MethodsTriangulated quantitative and qualitative research methods were used in the study. Questionnaire and interviews were used to solicit data from national and provincial managers of different health directorates. Eye‐care managers from each province also completed the questionnaire. Furthermore, relevant health policy and program documents from national and provincial departments of health were studied to identify areas relating to ocular health promotion.ResultsThe study found varying degrees of implementation of various ocular health promotional activities in the provinces with the majority of respondents (62 per cent) indicating that ocular health promotion was not part of their responsibility and another 81 per cent revealing that vision screening does not form part of their health promotional programs. It further revealed a lack of a dedicated directorate for ocular health‐care issues and the absence of an integrated ocular health promotional policy.ConclusionOcular health promotional activities were absent in other provinces. This may be a major contributing factor to poor ocular health promotion in South Africa and hence, the high prevalence of blindness and visual impairment. Therefore, it is recommended that an integrated ocular health promotional model (directorate and policies) be developed and be part of the South African primary health‐care system.