The authors of this study prospectively assessed resistance to second-line anti-tuberculosis drugs in eight countries, including South Africa. From 1 January 2005 to 31 December 2008, they enrolled consecutive adults with locally confirmed pulmonary multi-drug-resistant (MDR) tuberculosis at the start of second-line treatment. Among 1,278 patients, 43.7% showed resistance to at least one second-line drug, 20% to at least one second-line injectable drug and 12.9% to at least one fluoroquinolone. A total of 6.7% of patients had extremely drug-resistant (XDR) tuberculosis. Previous treatment with second-line drugs was consistently the strongest risk factor for resistance to these drugs, which increased the risk of XDR tuberculosis by more than four times. Fluoroquinolone resistance and XDR tuberculosis were more frequent in women than in men. Unemployment, alcohol abuse and smoking were associated with resistance to second-line injectable drugs across countries. Other risk factors differed between drugs and countries. The authors recommend that representative drug-susceptibility results should guide in-country policies for laboratory capacity and diagnostic strategies.
Equitable health services
This study was initiated to establish if any South African ethnomedicinal plants (indigenous or exotic) that have been reported to be used traditionally to repel or kill mosquitoes may exhibit effective mosquito larvicidal properties. Researchers tested extracts of a selection of plant taxa sourced in South Africa for larvicidal properties. Preliminary screening of crude extracts revealed substantial variation in toxicity with 24 of the 381 samples displaying 100% larval mortality within the seven-day exposure period. The researchers then selected four of the high-activity plants and subjected them to bioassay guided fractionation. The results of the testing of the fractions generated identified one fraction of the plant Toddalia asiatica as being very potent against the An. arabiensis larvae. These results have initiated further research into isolating the active compound and developing a malaria vector control tool.
Induction of labour is being increasingly used to prevent adverse outcomes in the mother and the newborn. In this study, researchers assessed the prevalence of induction of labour and determinants of its use in Africa. They performed secondary analysis of the WHO Global Survey of Maternal and Newborn Health of 2004 and 2005 and assessed unmet needs for specific obstetric indications at country level. A total of 83,437 deliveries were recorded in the seven participating countries, including Angola, the Democratic Republic of Congo, Kenya and Uganda. The average rate of induction was 4.4% and the researchers found that induction was associated with reduction of stillbirths and perinatal deaths. Unmet need for induction ranged between 66% and 80.2% across countries. Determinants of having an induction were place of residence, duration of schooling, type of health facility and level of antenatal care. As utilisation of induction of labour in health facilities in Africa is very low and unmet need very high, the authors call for improvements in social and health infrastructure.
To explore perceptions of malaria and utilisation of insecticide-treated bed-nets after a noticeable reduction in malaria incidence in Zanzibar, the authors of this study conducted 19 in-depth interviews with caretakers of children under five in North A district on the island. They found that awareness of malaria among caretakers was high but the illness was now seen as easily curable and uncommon. The discomfort of sleeping under a net during the hot season was identified as the main barrier to consistent bed-net usage. The main cue to using a bed-net was high mosquito density, and children were prioritised when it came to bed-net usage. Caretakers had high perceived self-efficacy and did not find it difficult to use bed-nets. Indoor Residual Spraying (IRS), which was recognised as an additional means of mosquito prevention, was not identified as an alternative for bed-nets. A barrier to net ownership was the increasingly high cost of bed-nets. The authors call on the government to continue providing bed nets through sustainable and affordable delivery mechanisms.
In this study, researchers assessed challenges and enablers for the Expanded Programme on Immunisation (EPI) in South Africa, in light of the approaching 2015 deadline for the Millennium Development Goals. Between September 2009 and September 2010 they requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. Systematic reviews on the effectiveness of the proposed solutions were added. Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes. The findings from reliable systematic reviews indicate that interactive educational meetings, audits and feedback, and supportive supervision improve healthcare worker performance. The authors conclude that numerous promising strategies for improving EPI performance in South Africa were found but their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation.
In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy. In the last decade, the disproportionate majority of global health funding has been allocated to vertical programmes targeting HIV and AIDS, malaria, and tuberculosis. The renewed calls for action to raise the priority of chronic non-communicable diseases in global health planning and research are encouraging, however, the authors note. Funding commitments from domestic governments, international funders, nongovernmental organisations, industry, and private philanthropists will be critical, the authors argue, to scaling up access to anti-epileptic medications and building capacity in human resources for epilepsy care in sub-Saharan Africa. A Global Fund for Epilepsy should be established to accelerate support from external funders and coordinate programme development and implementation.
This study had two purposes: to evaluate the impact of a universal coverage campaign (UCC) of long-lasting insecticidal nets (LLINs) on LLIN ownership and usage, and to identify factors that may be associated with inadequate coverage. In 2011 two cross-sectional household surveys were conducted in 50 clusters in Muleba district, north-west Tanzania. Prior to the UCC 3,246 households were surveyed and 2,499 afterwards. The proportion of households with at least one ITN increased from 62.6% before the UCC to 90.8% afterwards. Eighty percent of households surveyed received LLINs from the campaign. ITN usage in all residents rose from 40.8% to 55.7%, and after the UCC, 58.4% of households had sufficient ITNs to cover all their sleeping places. Households with children under five years and small households were most likely to reach universal coverage, while poverty was not associated with net coverage. The authors conclude that UCC in Muleba district of Tanzania was equitable, greatly improving LLIN ownership and, more moderately, usage. However, the goal of universal coverage in terms of the adequate provision of nets was not achieved. Multiple, continuous delivery systems and education activities are required to maintain and improve bed net ownership and usage.
This study aimed to assess feasibility, uptake, yield, treatment outcomes and costs of adding an active tuberculosis case-finding programme to an existing mobile HIV testing service in South Africa. All HIV-negative individuals with symptoms suggestive of tuberculosis and all HIV-positive individuals, regardless of symptoms, were eligible for participation. Of the 6,309 adults who accessed the mobile clinic, 1,385 were eligible and 1,130 (81.6%) were enrolled. The prevalence of smear-positive tuberculosis was 2.2%, 3.3% and 0.4% in HIV-negative individuals, individuals newly diagnosed with HIV, and known HIV+ individuals, respectively. Of the 56 new tuberculosis cases detected, 42 started tuberculosis treatment and 34 (81%) completed treatment. The cost of the intervention was US$1,117 per tuberculosis case detected and US$2,458 per tuberculosis case cured. In conclusion, mobile active tuberculosis case finding in deprived populations with a high burden of HIV and tuberculosis was found to be feasible, and had high uptake, yield and treatment success. Further work is now required to examine cost-effectiveness and affordability, and to establish if the same results may be achieved after scaling up services.
In this study, researchers compared vaccine coverage achieved by two different delivery strategies for the quadrivalent human papillomavirus (HPV) vaccine in Tanzanian schoolgirls. In a cluster-randomised trial, 134 primary schools were randomly assigned to class-based or age-based vaccine delivery. Of the 3,352 and 2,180 eligible girls included in the study, HPV vaccine coverage was 84.7% for dose 1, 81.4% for dose 2, and 76.1% for dose 3. For each dose, coverage was slightly higher in class-based schools than in age-based schools. Vaccine-related adverse events were rare. Reasons for not vaccinating included absenteeism (6.3%) and parent refusal (6.7%). In conclusions, the authors argue that HPV vaccine can be delivered with high coverage in schools in sub-Saharan Africa. Compared with age-based vaccination, class-based vaccination located more eligible pupils and achieved higher coverage. HPV vaccination did not increase absenteeism rates in selected schools. Innovative strategies will also be needed to reach out-of-school girls.
Current malaria control strategies rely heavily on repeated application of single neurotoxic insecticides that quickly kill adult mosquitoes, yet the effectiveness of insecticide-treated bed nets (ITNs) and indoor insecticide sprays to control adult mosquito vectors is being threatened by the spread of insecticide resistance. This narrow insecticide-based paradigm is beginning to fail, the authors of this paper argue, as it did in agriculture, as well as in previous malaria eradication campaigns of the '50s and '60s. They note that ITNs, indoor spraying programmes and other malaria control measures should be integrated in the same way as pest management is integrated in agriculture. Integrated approaches have the potential to provide more effective and durable pest management. To achieve the equivalent for malaria control requires additional tools to manage malaria vectors, as well as a better understanding of the impact of individual tools and their interactions, appropriate training for end users and strategies that maximise impact and fit the local ecological and socioeconomic context. Given the current lack of any clear alternative to the current insecticide paradigm, the authors urge researchers, policy makers, and funding agencies to act now to support this more diverse and adaptive approach.