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Telemedicine service on way

RURAL Eastern Cape residents will benefit from a R20 million telemedicine project to be launched next week, according to the provincial health department. Thanks to a computer link-up, the service allows specialists in cities to examine patients at rural hospitals. The system will operate at six hospitals, but will eventually be accessible to every health institution in the province. It will initially offer the services of radiologists, dermatologists and cardiologists, but the department is investigating adding opthamology and psychiatry.

SAPA, 13 March 2009

Home-based TB treatment offers hope

AN ALTERNATIVE way of treating drug-resistant tuberculosis (TB) piloted in Khayelitsha has resulted in an increase in the number of patients being enrolled for treatment and a lower rate of default, a Cape Town city council health official said yesterday.

The preliminary results of the pilot project were released yesterday ahead of World TB Day today.

Khayelitsha has the highest rate of TB in the world, with at least 1 500 people in 100 000 infected each year.

The township also has an estimated 400 cases of drug resistant TB (DRTB) a year, or an incidence of about 60 per 100 000 people - also one of the highest rates in the world.

Of the nearly 6 000 people diagnosed with TB in Khayelitsha last year, 196 were diagnosed with DRTB and 74% of these were also infected with HIV.

The pilot project was launched towards the end of 2007 by Médecins Sans Frontières (MSF) with the support of the city of Cape Town and the Western Cape government.

It involves patients suffering from DRTB being treated in their homes, which are subjected to infection-control measures instead of being isolated in hospital wards for several months.

The project aims to increase the diagnosis of DRTB, improve treatment outcomes and lower the rate of its transmission.

Government policy requires those suffering from DRTB to be treated in specialised treatment centres where they often have to spend at least six months, far from their families. This has proved unpopular and there has been a high rate of default with up to a third of patients refusing to remain in care.

DRTB treatment lasts for two years and involves taking a cocktail of six drugs which are difficult to tolerate and have nasty side- effects.

Cape Town health department's sub-district manager for Khayelitsha, Dr Virginia Azevedo, said it was still too early to reach conclusions about the pilot project but preliminary results showed that there had been an increase in the number of people enrolling for treatment.

There had also been fewer defaults than on the national programme of centralised treatment.

"We are convinced that more patients will be diagnosed and successfully treated if they are supported to follow treatment in their homes and communities rather than being isolated in specialised hospitals," Azevedo said.

MSF medical co-ordinator in SA Dr Eric Goemaere said the situation in Khayelitsha required a radically new approach.

"We are applying lessons learnt in providing HIV/AIDS treatment to tackle this complex medical challenge. In addition to new models of care we urgently need better, rapid diagnostic tools to detect DRTB earlier and less toxic, better tolerated and more affordable drugs to treat patients," Goemaere said.

Linda Ensor: Business Day, 24 March 2009

World TB Day

FOR FAR too long the battle against TB has been fought in the shadows. A much more glamorous cause for rock stars, world leaders and philanthropists, HIV/AIDS has demanded and received more attention than any other disease in the history of the world.

It is right that the AIDS epidemic should mobilise resources and attention. But it is time for TB too to receive the urgent attention demanded by a disease that infects more than nine million people annually, of whom at least half a million are known to be resistant to the available first line drugs.

More than one million of those infected also have HIV, which is one of the main reasons why a disease that the world thought had been beaten is making such a comeback.

Today is World TB Day and in Rio de Janeiro more than 1 000 TB experts are meeting to try to inject new momentum into efforts to beat this disease. Next week, governments and ministers from the high burden countries will meet in Beijing to discuss the spread of drug-resistant TB.

South Africa will be represented in China by Health Minister Barbara Hogan, who early on expressed her concern over South Africa's raging TB epidemic, which is not only an outflow of our HIV epidemic, but an indication that our health system is failing to protect and treat people.

The TB drugs and the diagnostic tools are old, but they work, and for now they are all we have.

TB is preventable and curable.

Other developing countries such as Brazil have shown huge political commitment. And they are reaping the fruits. The TB incidence rate is dropping and they are on course to meet the Millennium Development Goals.

South Africa should not top the list of high burden TB countries. On the contrary, with a firm commitment from the state, this country can become an example of how this disease can be beaten.

Editorial Comment: The Cape Times, 24 March 2009

Meningitis under microscope

MEDIA reports of meningitis have understandably caused considerable concern. Meningitis is a feared disease that can be rapidly fatal or result in severe permanent disability. Coupling the word outbreak to meningitis adds a further element of disquiet, if not alarm.

Not surprisingly there has been a degree of frustration at the "official" response that there is no outbreak and no cause for panic. Unfortunately, the confusion has been aggravated by some incorrect and misleading reporting in the media.

What is meningitis? Meningitis means, simply, inflammation of the meninges, the membrane covering the brain and spinal cord. It may be caused by viruses - a common but usually mild form of meningitis - or bacteria.

Of the bacteria, it is only the meningococcus (Neiserria meningitidis) that is responsible for epidemics of meningitis. It is a common and generally harmless resident of the upper respiratory tract of up to 10 percent of the population.

However, in certain circumstances, particularly where individuals are crowded together, for example in military barracks or boarding schools, the risk of infection may increase leading to outbreaks.

Spread of the organism from person-to-person occurs through close contact with a healthy carrier or an infected individual by inhalation of infected respiratory droplets.

The next question is do we have an epidemic or outbreak here? Defining an epidemic is not always easy. What is scientifically understood by "epidemic" is the occurrence of a disease in a community, which clearly exceeds what is normally expected. In the case of an infectious disease an outbreak occurs when cases are clustered or linked and generally caused by a single infectious organism.

To date, up to week 10 of this year, 40 cases of meningococcal meningitis have been reported in South Africa - down from 50 for the same time last year - from seven provinces. Gauteng and West Cape have accounted for the most cases with 17 and 12, respectively.

Almost all cases were sporadic and not linked to each other. Also, four different "strains", scientifically referred to as serogroups, were isolated - further evidence against this being an outbreak.

Finally, the total number of cases to date is, if anything, somewhat lower than last year and well within the two per 100 000 expected for the country.

How should we respond? Meningococcal disease deservedly is a cause for serious concern for public health officials as for the public. Firstly, a vaccination programme is not indicated at present for several reasons.

As mentioned above, infections have been caused by a number of serogroups, not all of which are covered by current vaccines.

The vaccines available in South Africa are not suitable for administration to children under 2 years - the age group mainly affected and usually immunised to achieve adequate population immunity.

Lastly the number of cases occurring in the country, as tragic and disquieting as they are, would not warrant a vaccination programme, given that other control measures could be successful.

Vaccination is generally reserved for travellers to the "meningitis belt", a string of countries in sub-Saharan Africa from Senegal in the west to Ethiopia in the east, where extensive epidemics are a regular occurrence, as well as travellers for the annual Hajj or Umrah pilgrimages.

There also needs to be some clarity on the vaccine called Prevenar, which is to be introduced into the routine immunisation programme of South Africa from next month. This is primarily to prevent pneumonia due to a different bacterium, the pneumococcus, which can also cause meningitis but not outbreaks.

What is of prime importance with meningococcal disease is early detection of infection, treating it promptly with appropriate antibiotics and providing antibiotic protective cover to close contacts of the infected individual.

The advent of antibiotics has dramatically reduced mortality. Today death or serious permanent disability should be less than 10 percent.

In practice early diagnosis may be problematic in sporadic cases because, at this stage of the illness, symptoms are often non-specific - usually resembling those of flu, such as fever, headache and fatigue. Suspicion should definitely be aroused if the headache intensifies and is accompanied by neck stiffness, nausea and vomiting and, in some cases, a rash often appears over the buttocks and the back of the legs.

If antibiotic treatment is administered quickly, then the prognosis is good with over 90 percent of patients recovering completely with no complications.

What of the people who come into contact with an infected individual? Those at risk would be close contacts such as household contacts, close classroom contacts - who may be sharing eating and other utensils, crèche contacts and so on.

A single dose of an antibiotic, like Ciprofloxacin, should be administered as soon as possible and this would give solid protection.

Vaccination would not be appropriate to give to contacts as it takes too long - 10 to 14 days - to become effective.

Professor Barry D Schoub is the executive director of the National Institute for Communicable Diseases/National Health Laboratory Service

Barry Schoub: The Star, 23 March 2009

Government confident SA will have enough paramedics for 2010

THE government has conceded that advanced paramedics are being poached from SA, but has given the assurance that there will be enough emergency health professionals to cover the influx of tourists expected for this year's Confederations Cup and next year's Soccer World Cup. This follows reports at the weekend that SA's dire shortage of advanced paramedics could place lives at risk. The report also suggested SA had too few paramedics to cater for domestic needs and the influx of football supporters. Only advanced paramedics can administer certain drugs and perform certain procedures that can save lives. The ideal is to have one for every ambulance, but in SA that is not possible. If intermediate paramedics at a scene find a need for the skills of an advanced paramedic, they have to be called. This can extend the critical period in which intervention can save a life beyond acceptable levels. In response to a question at a briefing by the government's social cluster, Health Minister Barbara Hogan said her department was deeply engaged in the country's preparations for the World Cup. Health director-general Thami Mseleku said a need to begin intensive training at intermediate level had been identified and training had begun. He said SA had agreements with neighbouring states that would ensure the manpower requirements for 2010 would be met. He said SA was concentrating on training the mid-level of paramedics because they would not be poached, whereas those with advanced training would be "taken" by other countries. Hogan said the spread of cholera in SA was under control and there had been significant decreases in cholera infections in Limpopo and Mpumalanga, but the situation was still being monitored closely. Since November, the disease had claimed 59 lives in SA, with 12 000 people infected. This comes at a time when cholera deaths north of the Limpopo River have topped 4 000 and infections identified by the World Health Organisation (WHO) have reached 89 000. The Minister said her department had managed to decrease the rate of people defaulting on treatment for drug-resistant TB from 10 percent to just under 8 percent, while TB cure rates had increased from just over 50 percent to 60 percent. The Health Department had trained more than 800 health workers on drug-resistant TB infection control and 567 staff members on the electronic TB register, she revealed.

Wyndham Hartley: Business Day, 10 March 2009

Budget for big changes

BURIED deep in Finance Minister Trevor Manuel's Budget speech - and couched in typically vague terms - was a short comment that could have important implications for medical scheme members in South Africa. The upshot was that Manuel said there would be what really amounted to little more than a reshuffling of the monthly monetary caps on medical scheme contributions.

Nothing to get too excited about there. But far more important was a proposal for the replacement of the medical scheme contribution deduction with "a non-refundable tax credit". What could that mean for scheme members?

Graham Earle, Durban tax director at BDO Spencer Steward, explains how the current system works. "At present, R625 is a non-fringe benefit amount that can be deducted. So, for example, a husband and wife could each claim R625 as the first two beneficiaries. And if there are two children, a further R380 could be claimed for each. That gives R2 010 that can be deducted."

The member can also claim anything in excess of 7,5% of taxable income on medical costs that fall outside medical scheme claims and employee contributions.

"Now they're proposing to scrap that system and allow a nonrefundable tax credit," says Earle. "It seems they're proposing that will be at 30% of the prevailing deductions. And it's being further proposed that it be brought in by 2011. The underlying reason is that employers and the SA Revenue Service are having difficulty monitoring those amounts."

But, Earle adds, as always there are the uncertainties. Such as what exactly is 30% of prevailing deductions and what are allowable exemptions?

Asked his personal view on which system was better for medical scheme members, Earle says the existing one. "It looks like Manuel is trying to give lower income earners the possibility of a full deduction while higher income earners will have a limited deduction."

And that really was the theme that ran through Manuel's Budget.

Blum Khan, CEO of Metropolitan Health Group, says employers should perhaps take a closer look at the proposal! "It seems it might be trying to incentivise lower income workers to join medical schemes. That could also possibly be one of the first blocks in the process leading towards a national health scheme."

Broader health proposals were aimed very much at improving services for poorer people. One emphasis was "revitalising" rural hospital and clinic facilities - which it's well known are in a shocking condition and seriously understaffed, from nurses to doctors. The trick will be getting that spending accepted by the relevant provinces.

Any move to encourage medical aid membership, especially among lower income earners, is to be welcomed. However, I look forward to the day - hopefully, but by no means certainly before he dies of old age - when we're all treated equally. Perhaps I'm naive: but that's what I thought democracy and the principles in our fine Constitution were all about.

Shaun Harris: Finweek, 26 February 2009