Herpesviruses are ubiquitous and commonly cause neurological syndromes. A paucity of data exists describing the clinical profiles and outcomes of these viruses in cerebrospinal fluid (CSF). To describe the clinical profile and outcomes of patients with a positive CSF viral panel testing for six herpesviruses (herpes simplex virus 1 and 2 (HSV1; HSV2), varicella zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV) and human herpesvirus 6 (HHV6)). A retrospective descriptive study included all hospitalised patients aged 13 years and older in whom a herpesvirus was detected by a herpesvirus panel performed on CSF. A folder review was performed to acquire demographic, clinical and laboratory information. We identified 204 CSF herpesviruses in 184 patients. Most were people living with HIV (n=137/184, 74.5%). EBV was the most frequently identified herpesvirus (n=152/204, 74.5%). The herpesvirus was considered the cause of the clinical neurological syndrome in 20 patients (20/184, 10.9%), of whom most had VZV (7/20, 35%). Patients with VZV presented with encephalopathy (4/11, 36.4%), meningoencephalitis (3/11, 27.3%) and stroke (3/11, 27.3%). Encephalopathy, seizures and lower-limb weakness (n=5/19, 26.3%) were more common in patients with CMV. Those with HSV1 presented with seizures (n=2/5, 40%) and those with HSV2 with encephalopathy (n=3/6, 50%) and meningoencephalitis (n=2/6, 33.3%). EBV was the most common herpesvirus in patients with tuberculosis (TB) (45/49, 91.8%). Antiviral therapy was prescribed in 19/184 (10.3%) patients. The in-hospital mortality rate of all patients was 21.7%. EBV was the most common herpesvirus detected on CSF. Most patients with TB and HIV had EBV detected in their CSF, which may represent reactivation in these patients. This study highlighted the undertreatment of CMV and overtreatment of EBV. Greater awareness regarding the clinical indications for antiviral therapy in this setting is needed.
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Infection poses a serious risk in children and adolescents with cancer, often leading to severe morbidity and occasionally, death. Inconsistent management of fever with neutropenia (FN) may affect clinical outcomes. Despite the frequent occurrence of this complication during cancer treatment, no South African (SA) clinical practice guideline (CPG) has been developed to support clinicians in its management. To develop an evidence-based CPG providing recommendations for diagnosis, prognosis and management of children and adolescents with FN undergoing cancer treatment in SA. We developed an evidence-based CPG for managing this condition, tailored to the unique and diverse healthcare system in which children and adolescents with cancer are treated in SA. We established a working group comprising representatives from the clinical care pathway for SA children and adolescents with cancer. We then employed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to formulate the CPG recommendations. We present two definitions and 29 recommendations for managing children and adolescents with FN. The CPG development process has yielded recommendations similar to those of other FN CPGs; however, they reflect the unique context of SA, and guide elements such as tuberculosis evaluation, focusing on essential factors including availability, accuracy, affordability and diagnostic capacity. Furthermore, the systematic review conducted as part of the evidence synthesis emphasises the need for high-quality evidence from SA settings.
Pulmonary embolism (PE) is a leading cause of death in pregnant and postpartum women. To evaluate the clinical presentation, management and outcomes of pregnancy-related PE managed by a multidisciplinary team. A retrospective review was conducted of pregnant and postpartum women diagnosed with PE between 2018 and 2024 at a tertiary hospital in Johannesburg, South Africa. Pretest probability scores (pregnancy-adapted YEARS and Geneva) were applied in a subgroup with D-dimers available. Seventy-seven women were included: 33 with antepartum and 44 with postpartum PE. The median (interquartile range) age was 29 (9) years, and most were of black African ethnicity. PE risk factors were present in 85% of antepartum and 96% of postpartum cases. Women with antepartum PE more frequently presented with chest pain, shortness of breath and palpitations (p<0.05). Pretest probability scores were assessed in a subgroup with D-dimers available. Based on the pregnancy-adapted YEARS and Geneva scores, imaging would have been required to rule out PE in 87.8% and 73.5% of cases, respectively. Computed tomography pulmonary angiography was the preferred diagnostic modality in 74.0%. Most women (97.4%) were treated as inpatients, and 57% required management in the intensive care and/or high care units. The median length of hospital stay was 14 (8) days. Low-molecular-weight heparin was the most frequently prescribed anticoagulant, with a median treatment duration of 3 (1) months. The live birth rate was 84.4%. One maternal death occurred due to sepsis, unrelated to venous thromboembolism. Antepartum/secondary postpartum major bleeding and primary postpartum major bleeding occurred in 6.5% and 3.9%, respectively. Pregnancy-associated PE managed by a multidisciplinary team was associated with favourable maternal and fetal outcomes.
Individuals with oculocutaneous albinism (OCA) face a significantly heightened risk of developing skin cancer owing to increased sensitivity to ultraviolet (UV) radiation. Data on the epidemiology and geographical distribution of cutaneous malignancies among persons with albinism (PWA) in KwaZulu-Natal Province (KZN), South Africa, remain limited. To investigate the demographic and regional patterns of primary cutaneous malignancies within this high-risk population. We conducted a retrospective descriptive analysis of all PWA diagnosed with histologically confirmed primary cutaneous malignancies treated at a tertiary healthcare centre in KZN between January 2002 and June 2022. Sociodemographic, geographical and tumour characteristics were extracted from electronic medical records. A total of 221 patients (56.6% female, 43.4% male) with a mean (standard deviation) age of 37.9 (12.5) years contributed 618 histologically confirmed malignant lesions. 132/221 patients (59.7%) presented before 40 years of age. Female patients presented slightly earlier (37.1 (12.9 years)) than males (39.0 (12.0 years)). Geographical clustering was observed in eThekwini (43.0%), uMkhanyakude (20.8%) and King Cetshwayo (11.8%) municipalities. Squamous cell carcinoma (SCC) (50.2%) and basal cell carcinoma (BCC) (49.7%) were nearly equally distributed across all the districts; one cutaneous melanoma was identified. In KZN, PWA tended to develop skin cancer at a younger age than the general population. Notably, the proportions of SCC and BCC were roughly equivalent - a finding that contrasts with historical data, which show a predominance of SCC. The high incidence of skin cancer in coastal and rural districts aligns with elevated ambient UV exposure, and highlights disparities in healthcare access within these regions. These findings highlight the urgent need for targeted screening programmes, improved photoprotection strategies and culturally sensitive education initiatives to reduce morbidity and mortality among this vulnerable population.
During the COVID-19 pandemic, there was a notable increase in maternal deaths across South Africa (SA). Pre pandemic, the Western Cape Province, SA, had made significant strides towards reducing maternal mortality, including HIV-related deaths. However, this progress was reversed in the pandemic period despite a relative protection of maternity services. The direct biological impact of SARS- CoV-2 may not be the sole reason for the increase in mortality. To evaluate the relative change in the maternal death rate (MDR) for non-SARS-CoV-2-related deaths during the pandemic v. pre pandemic in 2019. We conducted a retrospective cohort study including all pregnant women with a pregnancy outcome enumerated in the Provincial Health Data Centre in the Metro West region of Cape Town from 1 January 2019 to 31 January 2022. Cause of in-facility maternal death and relationship to SARS-CoV-2 infection was determined by folder review. We used interrupted time series (ITS) analysis to assess the impact of the pandemic period on non-SARS-CoV-2 causes of maternal mortality. Over 98 000 women were included, with 68 deaths reviewed. The ITS model demonstrated no statistically significant change in the MDR for non-SARS-CoV-2-related deaths during the pandemic, with confidence intervals (CIs) that crossed the null for both a step change at the start of the pandemic (3.12/10 000 pregnancy outcomes; 95% CI -1.66 - 7.90) and a subsequent attenuation in the pre-pandemic downward gradient in MDR (slope change 0.47/10 000 pregnancy outcomes per month (95% CI -0.02 - 0.96). Folder review of deaths demonstrated an increase in opportunistic infections as a cause of death relative to the pre-pandemic period, mainly in women with HIV. Maternal healthcare services were largely protected from service disruptions during the COVID-19 pandemic. However, the increase in HIV-related opportunistic infections suggests that optimising maternal health requires an all-encompassing, functional healthcare ecosystem that can robustly maintain services for all health conditions.
Acute appendicitis is one of the most common surgical emergencies in South Africa (SA), yet local histopathological data on appendectomies remain limited. To determine the incidence and histological patterns of appendicitis at an SA regional hospital over a 2-year period. A retrospective review was conducted on all appendectomies performed at Tambo Memorial Hospital (TMH) in Boksburg, SA, from 1 January 2022 to 31 December 2023. Histological data, using Gomes score, which was correlated with microscopy and macroscopy from the SA National Health Laboratory Service, as well as patient demographics, were analysed. Logistic regression and χ2 tests were used to assess associations between variables. A total of 283 appendectomies were reviewed. None was excluded. The cohort was predominantly male (64%), with a mean age of 26.99 years. Histologically normal appendices (grade 0) were found in 25.4% of cases. Grade 4 appendicitis (gangrenous/perforated) was the most prevalent pathological finding (39.9%). Males were significantly more likely to present with appendicitis, particularly advanced grades of appendicitis (p=0.00005; odds ratio (OR) 3.305, 95% confidence interval (CI) 1.869 - 5.915). Lymphoid hyperplasia was significantly associated with grade 0 appendices (p=0.00205; OR 0.282, 95% CI 0.125 - 0.631), suggesting possible alternative diagnoses such as gastroenteritis, mesenteric adenitis or pelvic inflammatory disease. Appendicular neoplasms (2.1%), faecoliths (17.3%) and parasites (1.4%) were not uncommon. No significant monthly variation was observed. The overall negative predictive value of clinician-directed appendectomy at TMH was 25.4%, in keeping with or better than rates reported at various tertiary hospitals - despite TMH lacking afternoon sonography and having no after-hours sonographic or radiological reporting services. Appendicitis at TMH showed a high rate of complicated cases, especially among males. Male sex was a significant predictor of appendicitis, whereas lymphoid hyperplasia was associated with negative histology and may represent an important clinical differential diagnosis. Other findings included benign neoplasms, faecoliths and parasites. These findings highlight clinical acumen in a resource- limited setting and the value of histological confirmation in appendicitis diagnoses.
Medical doctors face occupational stressors threatening their mental health, particularly junior doctors in South Africa. There is a higher prevalence of depressive symptoms among medical doctors compared with the general population. The consequences of this to health systems and the patients doctors treat is a major public health concern. In South Africa, prevalence of depressive symptoms among community service doctors servicing public sector healthcare is largely unknown. To determine the prevalence of possible depression, and predictive factors thereof, among doctors in their community service year in South Africa. A national descriptive cross-sectional survey was distributed electronically between October and December 2022. The Patient Health Questionnaire 9 (PHQ-9) was used to screen for depression. Demographic, occupational and individual characteristics were included as potential predictive factors. A total of 217 participants were included in the analyses. Prevalence of depressive symptoms was 96.3% (standard error 0.13, 95% confidence interval 92.87 - 98.40%). Predictors of higher scores included: women, drug use, feeling neutral or disagreeing that one worked outside of normal working hours, working in KwaZulu-Natal or North West, burnout (emotional exhaustion), working in orthopaedics, obstetrics and gynaecology departments or the National Health Laboratory Service, first choice of placement, financial difficulties, and accessing mental health services. Predictors of a lower score included: perceiving sufficient resources at work, using colleagues to cope, good work-life balance, and certain departments, particularly neurosurgery. There is an extremely high prevalence of depressive symptoms among community service doctors. Supporting these doctors at an individual, organisational and structural level should be a priority for national policy-makers.
Hereditary cancer syndromes, caused by pathogenic variants in specific genes, substantially increase an individual's risk for cancer, and are estimated to cause 10% of all uterine cancers and 20% of all ovarian cancers. However, these data are primarily based on high-income countries, and to date there are no published data on the known pathogenic variants or testing of cancer predisposition genes associated with gynaecological cancers in South Africa. To investigate the uptake and type of molecular testing performed on patients with a suspected hereditary cancer syndrome associated with gynaecological cancer, and to assess whether patient characteristics impacted the detection of pathogenic variants. A retrospective file review was performed for patients with a confirmed diagnosis or family history of gynaecological cancer, seen by a single clinical genetics centre in Johannesburg between 2003 and 2023. Demographic information, family history and medical information were recorded and analysed. A total of 104 records were included in analysis. The majority (73/104, 70.2%) of patients were seen in the private healthcare system, of whom most (41%) were of European ancestry. Of the remaining 31 public healthcare patients, the majority were of indigenous African ancestry (42%). Most (78/104, 75.0%) underwent diagnostic genetic testing. Of these, 25 (32.1%) were positive for pathogenic variants, 41 (52.6%) were negative and 12 (15.4%) returned a variant of unknown significance. Test results were significantly different between patients of European and non-European ancestry (p<0.05), with those of non-European ancestry 30% less likely to have a pathogenic variant detected (odds ratio 0.7, 95% confidence interval 0.22 - 2.21). A disparity exists not only in genetic testing availability but also clinic attendance between the public and private healthcare systems, which likely limits the ability to diagnose hereditary cancer syndromes associated with gynaecological cancers in public healthcare hospitals.
Human papilloma virus (HPV), the most prevalent sexually transmitted infection worldwide, and in particular HPV 6 and 11, contribute to >90% of anogenital warts (AGW) cases, and high-risk HPV serotypes cause >95% of cervical cancers in South Africa (SA). The healthcare resource utilisation (HCRU) and costs related to AGW in SA remain poorly understood, in both the public and private sectors. To assess the HCRU patterns and associated treatment costs for AGW across the public and private sectors. A descriptive, questionnaire-based study was conducted, involving 50 subject matter experts (SMEs) from SA: 24 from the private sector and 26 from the public sector. The study explored resource use, treatment patterns and cost estimation based on SME responses. Findings revealed that public-sector SMEs treated a larger volume of AGW patients per month (1 - 300) than private-sector SMEs (0 - 20). Most AGW patients were female, comprising 78% in the public sector and 72% in the private sector. The occurrence of AGW was higher in the public sector, ranging between 21.4% and 34.4%, while in the private sector, the occurrence ranged from 13.1% to 23.2%. The weighted cost per patient per episode was higher for females than males in both sectors. In the private sector, costs were ZAR22 482 for females and ZAR17 812 for males, while in the public sector, costs were ZAR19 220 for females and ZAR14 271 for males. The higher costs for females were driven by invasive diagnostic procedures, including vulvar colposcopy and biopsy, and a higher frequency of medical visits (2.0 - 4.4 visits in the public sector). Recurrence rates of AGW were reported at 37.6% in the private sector and 43.9% in the public sector. The total estimated treatment cost of AGW was notably higher in the public sector for both males (ZAR93.6 - ZAR138.5 billion) and females (ZAR135.2 - ZAR207.7 billion), compared with the private sector (males: ZAR11.0 - ZAR19.4 billion; females: ZAR16.7 - ZAR28.3 billion). Female patients experienced a higher burden of diagnosis, recurrence and complications than males. AGW imposes a substantial burden on SA's healthcare system, particularly in the public sector, where female patients face significant costs and complications. The use of a quadrivalent or nonavalent HPV vaccine, rather than a bivalent vaccine, could reduce the impact of AGW and its associated healthcare demands.
Occupational stress affecting junior doctors poses a serious risk to mental health, with consequences such as anxiety, burnout, substance misuse and suicide. To evaluate the utility of a life skills training programme (LSTP) developed and implemented at Nelson Mandela Academic Hospital in the Eastern Cape Province, South Africa, in improving stress levels and coping abilities among second-year medical interns. We used a quasi-experimental pre-post quantitative design without a control group. Identical surveys were administered before and after the intervention, including the Perceived Stress Scale (PSS-10) and items on coping behaviours. Descriptive statistics, paired t-tests and Wilcoxon signed-rank tests were used for analysis. Of 56 eligible interns, 45 (80.4%) completed both pre- and post-intervention assessments. Stress scores decreased significantly (from mean 2.92 to 2.51, p<0.001), while coping scores improved (from mean 3.26 to 3.48, p=0.001). Wilcoxon tests confirmed significant gains, with enhanced confidence in ethical reasoning (Z=-5.014, p<0.001), professionalism (Z=-2.673, p=0.008) and teamwork (Z=-2.357, p=0.018). Participants who were single or lived alone showed higher stress levels. Subgroup analysis also revealed that interns who were single or lived alone had lower coping scores. The LSTP improved interns' mental wellbeing and coping mechanisms. Findings support integrating life skills training into internship programmes.
Individuals infected with SARS-CoV-2 who develop COVID-19 are susceptible to persistent symptoms and sequelae, referred to as post-acute sequelae of SARS-CoV-2 (PASC). The prevalence of PASC is estimated to range between 10% and 30%. However, there is a paucity of data from African countries. To investigate the prevalence and sociodemographic determinants of PASC in a peri-urban township and an informal settlement in South Africa (SA) during the COVID-19 pandemic. A prospective cohort study was conducted among individuals residing in sampled households within the Soweto and Thembelihle Health and Demographic Surveillance System in Gauteng Province, SA. Between August 2021 and January 2022, all individuals from 214 sampled households were tested for SARS-CoV-2 and followed up for 6 months for symptoms. The prevalence of PASC, defined as persistence of symptoms through to at least 30 (PASC-30) and 90 (PASC-90) days, was evaluated, and determinants of PASC were identified using logistic regression models. There were 268 individuals with documented COVID-19 illness identified, of whom 65.3% (n=175) were female. The median age was 24 years. The overall prevalence of PASC-30 was 23.9% (95% confidence interval (CI) 19.2 - 29.3), including 24.6% (95% CI 19.7 - 30.3) and 12.5% (95% CI 3.5 - 36.0) in individuals who were unvaccinated or had received a COVID-19 vaccine, respectively (p=0.283). The overall prevalence of PASC-90 was 2.2% (95% CI 1.0 - 4.8). Factors associated with PASC-30 included living in an informal (39.2%, 105/268) v. formal settlement (60.6%, 163/268) (adjusted odds ratio (aOR) 4.1, 95% CI 2.1 - 8.3), although participants living in larger households (aOR 0.8, 95% CI 0.7 - 0.9, p=0.011) were less likely to report PASC-30 than those from smaller households. Age, gender, marital status, level of education, employment status, vaccination status and the presence of comorbidities were not significantly associated with PASC. PASC-30 (23.9%) was prevalent at the population level in individuals with documented COVID-19, particularly among residents of informal settlements, while PASC-90 (2.2%) was low. Further exploration into PASC within informal settlements is imperative to comprehensively understand these findings.
South Africa (SA) bears a significant burden of hepatitis B virus (HBV) infection, with a significant prevalence of hepatitis B surface antigen (HBsAg) among pregnant women. In response, the National Department of Health has recommended targeted birth-dose vaccination for infants born to HBsAg-positive mothers. While we commend the move towards antenatal HBsAg screening to identify infected pregnant women, we reiterate that a universal HBV birth-dose vaccination strategy would be a simpler, more equitable and more effective approach to preventing vertical transmission and reducing the overall HBV burden in SA.
Artificial intelligence (AI) is rapidly reshaping clinical practice, and has prompted the Health Professions Council of South Africa to publish Booklet 20 - its first ethical framework for AI use in healthcare. This review critically evaluates Booklet 20 through the lens of the South African Medical Association AI Task Team, examining its alignment with national legislation, emerging regulatory mechanisms, broader policy commitments and the ethico-social context. Drawing on the Protection of Personal Information Act, the South African Health Products Regulatory Authority's 2025 guidance for AI‑enabled medical devices, the National AI Policy Framework and the 2024 National Health Research Ethics Council ethics guidelines, the analysis identifies key operational gaps relating to human oversight, disclosure, data sovereignty, equity, accountability and risk categorisation. The article argues that while Booklet 20 establishes an important foundation, its principles require concrete implementation tools, including risk‑tiered safeguards, structured consent templates, meaningful governance co-ordination and context‑appropriate standards for transparency, explainability and bias mitigation. Grounding these enhancements in South Africa's communitarian ethic of ubuntu highlights the need for relational accountability, fairness and community participation to ensure safe and equitable AI integration. The article concludes with a set of practical recommendations aimed at strengthening ethical governance and supporting patient trust and professional integrity as AI becomes embedded in clinical workflows.
Adverse events following COVID-19 vaccination have been studied extensively in recent years. However, there remains a paucity of data directly comparing adverse events among COVID-19 vaccinees and individuals with SARS-CoV-2 infection within the insured population in South Africa (SA). Moreover, the breadth of conditions assessed in this study exceeds that of most existing research, providing a unique perspective on potential immune-mediated outcomes. This study therefore contributes to a more comprehensive understanding of the risk-benefit profile of COVID-19 vaccination across different age groups. To evaluate the rate of adverse events occurring in COVID-19 vaccinees compared with individuals who have had SARS-CoV-2 infection. We conducted a retrospective cohort study, matching vaccinated individuals and those who have had a SARS-CoV-2 infection with comparable unexposed counterparts. Incident risk rates for 99 possible immune-mediated adverse events were compared between populations over a 42-day observation period to estimate relative risk ratios and confidence intervals. We used data from Discovery Health, a large managed care organisation in SA. A total of 3 112 918 individuals aged ≥12 years who received a COVID-19 vaccination were included in the study, with an average of 76% successfully matched to a suitable comparator based on their risk profile. Additionally, 443 220 individuals with documented SARS-CoV-2 infection were analysed, with an average of 99.7% matched to an appropriate comparator. For recipients of the BNT162b2 vaccine, aged 12 - 17 years, we found an increased risk of lymphadenopathy and vertigo, compared with an increased risk of appendicitis, arrhythmia, encephalomyelitis, lymphadenopathy, myocarditis, seizure, syncope, type 1 diabetes and vertigo post SARS-CoV-2 infection. For those aged ≥18 years, we found no increased risk for any conditions post BNT162b2 vaccination. Additionally, no conditions post AD26.COV2.S vaccination had an increased risk for any age group. Post documented SARS-CoV-2 infection for persons in age groups 18 - 39, 40 - 59 and ≥60 years, we found an increased risk of acute kidney injury, anaemia, appendicitis, arrhythmia, axonal and neuronal neuropathy, cerebrovascular accident, deep-vein thrombosis, encephalomyelitis, endometriosis, eosinophilic oesophagitis, fibrosing alveolitis, glomerulonephritis, inflammatory bowel disease, intracranial haemorrhage, lymphadenopathy, myocardial infarction, myocarditis, myositis, pericarditis, pulmonary embolism, rheumatic fever, seizure, syncope, thrombocytopenia, type 1 diabetes, urticaria, vertigo, multiple sclerosis, cholangitis and/or pancreatitis. Notably, not all conditions presented with an increased risk in each age group. Across all age subgroups analysed, the risks associated with SARS-CoV-2 infection exceeded the increased risks following COVID-19 vaccination.
Female breast cancer has become the most frequently diagnosed cancer globally. The incidence of cancer in South Africa (SA) is projected to double by 2030, and services to address the growing burden of disease are urgently needed. The distribution and capacity of existing breast cancer surgical services in SA haVE not been reported. To provide a quantitative descriptive analysis of the status of breast cancer surgical services in the public healthcare sector in SA. A descriptive cross-sectional analysis of breast cancer surgical services was performed, including the burden of disease, stage of diagnosis, available diagnostic and therapeutic modalities, waiting time to surgery and barriers to care. Clinicians at every public sector healthcare facility providing surgical care to breast cancer patients were approached to complete a quantitative survey for the year 2019. Data from 43 hospitals across all nine SA provinces were included. Clinicians reported a greater proportion of late-stage breast cancer (67%) than early breast cancer (33%) at diagnosis. The less urban provinces had poorer access to diagnostic and staging modalities. Most facilities were able to provide breast-conserving surgery (79%), while fewer facilities could offer sentinel lymph node biopsy (SLNB) (53%) and still fewer could offer breast reconstruction (35%). Clinicians cited the foremost barriers to standard of care as advanced disease at diagnosis, inadequate access to surgical expertise and lack of access to essential equipment. The national average waiting time for surgery (28 days) is within the recommended timeframe from decision to treat. The representation of the multidisciplinary team across facilities does not comply with national staffing recommendations for a breast unit. Broad disparities exist in access to essential staging and diagnostic modalities between facilities in different provinces. In many settings, there is limited capacity to provide key surgical interventions, particularly SLNB and breast reconstruction. These findings suggest that breast cancer care in most settings within the public healthcare sector is not concordant with proposed national guidelines. There is an urgent need to address the deficits in the distribution and capacity of breast cancer surgical services in SA.
South Africa (SA)'s National Health Insurance (NHI) Act, signed into law in May 2024, represents an ambitious attempt at healthcare transformation through universal health coverage (UHC). However, this perspective argues that despite laudable intentions, the NHI faces fundamental deployment obstacles rooted in systemic policy misalignment, fragmented governance structures and legal constraints. We present a critical analysis of five major constitutional violations, multi-departmental co-ordination failures and financial sustainability concerns that threaten the NHI's transformative potential. Our perspective challenges current execution strategies, and proposes that without comprehensive organisational reforms addressing constitutional alignment, inter-departmental co-ordination and fiscal realities, the NHI risks becoming an aspirational policy rather than an operational reality. This analysis aims to promote scientific discourse about the need for systemic reform as a prerequisite for successful UHC deployment in SA.
Traumatic haemorrhage is a leading cause of preventable injury-related deaths. Tranexamic acid (TXA) has demonstrated a 38% all-cause mortality reduction when administered to severe haemorrhagic shock patients in South Africa (SA). Yet its prehospital utilisation in SA remains limited owing to prehospital provider qualification restrictions, despite the region's high trauma burden. Among the 4% of prehospital providers licensed to administer TXA, prehospital eligibility and TXA administration is poorly reported. This utilisation gap suggests multifactorial barriers beyond the current scope of practice restrictions that impede effective implementation of this evidence-based intervention. To assess patterns of TXA administration and omission during prehospital emergency care in the Western Cape Province, SA. This is a secondary analysis from the EpiC prospective multicentre study. The current study examined 4 094 patients at risk of haemorrhage in the Western Cape from August 2021 to December 2024. First, we assessed patient and injury characteristics as well as prehospital and hospital treatments among three prehospital treatment groups: those who received TXA; those who received a lifesaving circulation intervention and no TXA; and those who received neither. Second, a subset of patients was selected for three clinical scenarios: patients with moderate to severe risk of shock; those with severe shock meeting TXA eligibility criteria; and those requiring hospital-based interventions for haemorrhage. Prehospital provider qualifications, clinical interventions and outcomes were assessed using descriptive statistics, and Sankey diagrams were used to visually depict the quantity and flow of prehospital trauma patients stratified by prehospital provider qualification. Only 2.8% (n=116) of all haemorrhage-risk patients received prehospital TXA despite 82% (n=3 325) presenting within the 3-hour window for administration. Among eligible patients with severe risk of shock who were managed by an advanced prehospital provider (n=161), only 19% (n=30) received TXA. Basic and intermediate prehospital providers, who cannot administer TXA under current regulations, managed 67% (n=326) of these patients. These providers frequently delivered other life-saving circulatory interventions (70 - 79%). This study reveals that only a small percentage of eligible trauma patients receive TXA despite its established mortality benefit. The principal barrier identified is the current scope-of-practice restriction preventing basic and intermediate prehospital providers from administering TXA, despite managing two-thirds of eligible patients and possessing the knowledge and skills to deliver TXA. We strongly recommend that the scope of TXA be extended to intermediate prehospital providers in SA.
Shock index is (SI) obtained by dividing heart rate by systolic blood pressure (SBP). Previous studies have shown that SI >0.9 is a predictor of mortality and of a need for blood transfusion in trauma patients. To determine whether SI can predict mortality and the need for blood transfusion in a rural South African provincial referral hospital cohort. A retrospective observational cross-sectional study of trauma patients with injury severity score (ISS)>15 in two central hospitals in a rural province was undertaken using data from January 2018 to December 2020. Data collection included demographics, heart rate, blood pressure, SI and modified shock index (MSI) at the time of admission to the emergency department. Univariate and multivariate analyses were performed to identify whether SI predicted death or need for transfusion. The cohort comprised 324 patients. Only emergency department SI and MSI were calculated. In multivariate analysis, χ2 tests showed that SI was a good predictor of mortality (p<0.011) and need for blood transfusion (p<0.001). SI with area under curve 0.673 is a fair predictor of mortality. Student's t-test showed that patients who died had lower mean SI than those who survived, with a mean difference of -2.78 (p=0.006). In multivariate analysis, severe SI predicted the need for blood transfusion (p=0.032). SI is a useful predictor of mortality and the need for blood transfusion in this cohort of referred patients to two central facilities in a rural province. There is likely an impact from resuscitation prior to arrival at the central hospitals.
The November 2023/2024 national health budget cuts represent the largest reduction in public health expenditure in South Africa's post-apartheid history. This article critically examines the implications of these budget cuts within the context of the country's post-apartheid health system reforms and macroeconomic strategies. Specifically, it documents the historical evolution of fiscal policies and health expenditure across three distinct periods: the 2008 - 2013 period, which witnessed a counter-cyclical fiscal strategy that improved healthcare access and began addressing apartheid-era disparities; the years 2013 - 2023, marked by economic and political instability, culminating in a national debt crisis exacerbated by COVID-19, which eroded health system resilience under fiscal consolidation policies; and the post-November 2023/2024 period, which represents a distinct threat to two decades of progress in health equity and outcomes under further fiscal consolidation measures. The article discusses the impact of these austerity measures on healthcare workers and patient populations and the implementation of the National Health Insurance, while exploring the ethical and legal implications. It concludes by proposing recommendations for system-wide reforms to mitigate the negative effects of these budget cuts and prevent systemic collapse.