The fight against tuberculosis (TB) is argued to have failed children: the share of paediatric TB is increasing, and children have not escaped the rising tide of drug-resistant strains, according to new research presented at the South African TB Conference, which was held from 1–4 June 2010. Dr Ntombi Mhlongo-Sigwebela, TB programme director at the University Research Company, a public health consultancy, told the conference in Durban that TB in children under four years of age now accounted for about 9% of all national TB cases annually. Dr Kalpesh Rahevar, a World Health Organization (WHO) medical officer, said inconclusive conventional TB skin tests (to determine whether a patient has a latent TB infection) and the inability to get sputum samples from young children made paediatric TB more difficult to diagnose and treat than in adults. Paediatric drug formulations and international treatment guidance for children were also inadequate, said Dr Ben Marais of the University of Stellenbosch, in Western Cape Province.
Equitable health services
In this paper, a simple method based on the end-user as the denominator was employed to classify individuals into one of four insecticide-treated net (ITN) use categories: living in households not owning an ITN; living in households owning, but not hanging an ITN; living in households owning and hanging an ITN, but who are not sleeping under one; and sleeping under an ITN. This framework was applied to survey data designed to evaluate distribution of long-lasting insecticidal nets (LLINs) following integrated campaigns in five African countries, including Madagascar and Kenya. The study found that the percentage of children <5 years of age sleeping under an ITN ranged from 51.5% in Kenya to 81.1% in Madagascar. Among the three categories of non-use, children living in households without an ITN make up largest group, despite the efforts of the integrated child health campaigns. The percentage of children who live in households that own but do not hang an ITN ranged from 5.1% to 16.1%. The percentage of children living in households where an ITN was suspended, but who were not sleeping under it ranged from 4.3% to 16.4%. Use by all household members in Madagascar (60.4%) indicate that integrated campaigns reach beyond their desired target populations. The framework outlined in this paper may provide a helpful tool to examine the deficiencies in ITN use. Monitoring and evaluation strategies designed to assess ITN ownership and use can easily incorporate this approach using existing data collection instruments that measure the standard indicators.
The Perinatal Mental Health Project in Cape Town, which offers counselling to mothers throughout their pregnancy, is playing a role by tackling depression in the initial stages of the pregnancy. While most programmes only tackle cases of depression among pregnant women after the birth of the baby, the Perinatal Mental Health Project (PMHP) at the University of Cape Town intervenes during the early stages of pregnancy. Simone Honikman, director of the project said severe cases of depression could be treated more successfully if detected early. According to PMHP, South Africa’s postnatal depression (PND) prevalence is three times that in developed countries. For over eight years the PMHP has screened about 8,000 pregnant women for mental health conditions, while up to 1 234 women have been counselled as part of this free service. The PMHP model is one of integration. Mental health care is provided on site together with antenatal care services. This means that the mothers needing help can access this service at the same service point where they receive other health care related to the pregnancy.
Global efforts focusing on eliminating malaria are counterproductive to the fight against the disease in Africa, experts have warned. They emphasise the importance of maintaining, and building on, control strategies rather than aiming for a target that may not be met. Buoyed by a reduction in malaria mortality in Africa, health leaders in 2007 switched their primary goal from control to elimination. But researchers from the Kenya Medical Research Institute-Wellcome Trust Research Programme in Nairobi now say that the emphasis on elimination or eradication in strategic plans for the next 10 to 20 years in Africa is 'at best irrelevant and at worst counterproductive', raising expectations that cannot be met. Increased use of insecticide-treated bed nets, improved rapid diagnostic tests and the replacement of failing drugs with artemisinin-based combination therapy are among the interventions that have helped to reduce malaria transmission and incidence substantially across the continent. On the coast of Kenya, for example, the incidence of severe malaria has fallen by more than 90% in the last five years. However, the researchers warn that positive results are not universal throughout Africa. A substantial funding gap remains to meet the estimated US$4 per head needed to treat malaria, which currently stands at less than US$1 per head.
In this study, an initial assessment of hospital management systems demonstrated weak functioning in several management areas. In response, the authors developed a novel Master of Hospital Administration (MHA) programme, a collaborative effort of the Ethiopian Ministry of Health (MoH), the Clinton HIV/AIDS Initiative, Jimma University and Yale University. The MHA is a two-year executive style educational programme to develop a new cadre of hospital leaders, consisting of 5% classroom learning and 85% executive practice. It has been implemented with 55 hospital leaders in the position of chief executive officer within the MoH, with courses taught in collaboration by faculty of the North and the South universities. The programme has enrolled two cohorts of hospital leaders and is working in more than half of the government hospitals in Ethiopia. Lessons learned include the need to: balance education in applied technical skills with more abstract thinking and problem solving; recognise the interplay between management education and policy reform; remain flexible as policy changes have direct impact on the project; be realistic about resource constraints in low-income settings, particularly information technology limitations; and manage the transfer of knowledge for long-term sustainability. The authors hope that this programme will set a precedent for other sub-Saharan countries wishing to improve their health sector management.
According to this study, clinically protective malaria vaccines consistently fail to protect adults and children in endemic settings, and at best only partially protect infants. It identified and evaluated 1,916 immunisation studies between 1965 and 2010, and excluded partially or nonprotective results to find 177 completely protective immunisation experiments. Detailed re-examination revealed an unexpectedly mundane basis for selective vaccine failure: live malaria parasites in the skin inhibit vaccine function. It show how published molecular and cellular data support a testable, novel model where parasite-host interactions in the skin induce malaria-specific regulatory T cells, and subvert early antigen-specific immunity to parasite-specific immunotolerance. This ensures infection and tolerance to re-infection. The paper concludes that skinstage-initiated immunosuppression, unassociated with bloodstage parasites, systematically blocks vaccine function in the field. The model it uses exposes novel molecular and procedural strategies to significantly and quickly increase protective efficacy in both pipeline and currently ineffective malaria vaccines, and forces fundamental reassessment of central precepts determining vaccine development. This has major implications for accelerated local eliminations of malaria, and significantly increases potential for eradication.
Reproductive health problems among teenagers are the focus of a new European Union-funded project, which will investigate the effectiveness of existing programmes and identifying the structural drivers that restrict access to adolescent reproductive health (ARH) services in Niger and Tanzania. The INTHEC ('Health, education and community integration: evidence based strategies to increase equity, integration and effectiveness of reproductive health services for poor communities in sub-Saharan Africa') project has received EUR 2.75 million in funding under the European Union's Seventh Framework Programme. The project, launched in March 2010 and scheduled to end in February 2014, will also address the cultural barriers that currently limit access to or curb the effectiveness of ARH services in the two countries. Led by the Liverpool School of Tropical Medicine in the United Kingdom, the INTHEC consortium consists of experts from the fields of reproductive health research and interventional implementation, as well as leaders in governance and policymaking in Belgium, Niger and Tanzania. The government ministries responsible for ARH in Tanzania and Niger are partners in the programme, meaning that the outcome of the research will be genuinely owned by the key policymakers, helping ensure the impact of this research beyond the life of the project.
Primary health care in rural South Africa is predominantly provided by remote clinics and health centres. In 1994, health centres were upgraded and new health centres developed to serve as a health care filter between community clinics and district hospitals. This study set out to describe the spectrum of clinical problems encountered at a new health centre in an area of high economic deprivation and compare this with an adjacent community clinic and district hospital. The International Classification of Primary Care-2 (ICPC-2) was used to code data collected over a 13-week period from patients presenting at a community clinic, health centre and district hospital. Altogether, 4,383 patient encounters were recorded across all three sites in 2001. Most contacts at the clinic (97%) and the health centre (80%) were with a nurse. Females over 15 years of age comprised over half of all contacts at health facilities (53%). The most common diagnosis category was respiratory (23%). Cough was the most common symptom. Thirty per cent of children up to 5 years of age were seen for immunisations. Most childhood immunisations (79%) were carried out at the health centre. The study concluded that, of all the health care facilities surveyed, the health centre had the highest throughput of patients, indicating that the health centre is an efficient filter between the community and hospital. In this light, the ICPC-2 system can be successfully used to monitor encounters at similar African health care facilities.
This study aimed to describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. It conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. It identified 1,701 malaria cases, of which 1,548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals, while 1,149 (68%) patients were male. Most (84%) infections were acquired in Mozambique. While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. The study recommends that providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.
Oral polio vaccine (OPV) is recommended to be given at birth together with BCG vaccine. This study investigated the effect of OPV given simultaneously with BCG at birth on the immune response to BCG vaccine. It compared the in vitro and the in vivo response to PPD in the infants who received OPV and BCG with that of infants who received BCG only. The study is the first to address the consequences for the immune response to BCG of simultaneous administration with OPV. The authors expressed concern that the results indicate that the common practice in low-income countries of administering OPV together with BCG at birth may down-regulate the response to BCG vaccine.