Climate change, extreme heat and heat waves

Climate change, extreme heat and heat wave

Bridging the gap in rural and underserved areas through AI‐enabled solutions

Healthcare disparities between urban and rural populations remain one of the most pressing challenges in global health. In underserved areas, patients face numerous obstacles, including a lack of healthcare infrastructure, long distances to medical facilities, shortages of skilled professionals, and limited access to real-time medical resources. These challenges result in poor health outcomes, higher mortality rates, and increased disease burden in rural communities. However, artificial intelligence (AI) is emerging as a transformative tool in addressing these healthcare gaps. By leveraging AI-driven solutions, we can create sustainable and scalable healthcare models that improve access, enhance the quality of care, and optimise resources for underserved populations. This article explores how AI is revolutionising rural healthcare, with a focus on the practical applications that can make a meaningful difference

Thrombosis and bleeding outcomes with warfarin conversion to rivaroxaban during the COVID-19 pandemic

Background. In 2020, during the coronavirus disease 2019 (COVID‐19) outbreak, eligible patients were converted from warfarin to rivaroxaban therapy to limit the transmission of COVID‐19 infection. Objective. To assess the thrombosis and bleeding outcomes associated with converting patients on warfarin therapy to rivaroxaban during the COVID‐19 pandemic. Methods. A retrospective audit was performed that identified 190 participants with venous thromboembolism (VTE) and 112 participants with non‐valvular atrial fibrillation at the anticoagulation clinic service at Charlotte Maxeke Johannesburg Academic Hospital, South Africa. Participants were converted to rivaroxaban 20 mg for a median (interquartile range) period of 4 (2) months between April and October 2020. Follow‐ups were conducted telephonically and face‐to‐face on conversion back to warfarin. Rates of COVID‐19 infections, bleeding and thrombosis were objectively confirmed. Results. The COVID‐19 infection rate among participants was 3.3% (95% confidence interval (CI) 1.6 ‐ 6.0), with five (1.7%) hospital admissions and two (0.7%) COVID‐19‐related deaths. The deaths occurred in one participant on rivaroxaban, and in another after switching back to warfarin. One week after switching to rivaroxaban, the rate of clinically relevant non‐major bleeding was 0.7% (95% CI 0.02 ‐ 2.54), while minor bleeding occurred at a rate of 9.2% (95% CI 6.16 ‐ 13.40). No major bleeding events were reported, and bleeding rates on rivaroxaban were not significantly higher compared with warfarin. Additionally, two (0.7%) myocardial infarctions were recorded. One occurred on rivaroxaban and the other after switching back to warfarin. A single (0.3%) VTE presenting as a newly diagnosed pulmonary embolism was reported in a participant on rivaroxaban. Conclusion. This study provides practical insights regarding the conversion of eligible participants from warfarin to rivaroxaban during the first wave of COVID‐19, with the aim of informing future public health interventions in similar crisis settings.

Real-world effectiveness of Ad26.COV2.S or BNT162b2 booster vaccines against severe COVID-19 in adults who received a primary dose of Ad26.COV2.S in South Africa during the Delta period: A retrospective cohort study using medical scheme data

Background. From March 2020 to June 2022, South Africa (SA) confronted successive waves of COVID‐19, each linked to emerging SARS‐CoV‐2 variants. Vaccines played a critical role in preventing severe disease and death, but as new SARS‐CoV‐2 variants emerged, with increasing breakthrough infections, questions arose about the real‐world effectiveness of first‐generation vaccines containing the ancestral strain against evolving variants including Delta and Omicron BA.1 and BA.4/5 SARS‐CoV‐2. Objectives. To assess the real‐world effectiveness of ancestral strain booster doses (either Ad26.COV2.S or BNT162b2) in preventing severe COVID‐19 outcomes, including hospitalisation, admission to critical care and death, among essential workers in SA who received a primary dose of Ad26.COV2.S against emerging SARS‐CoV‐2 variants. Methods. A retrospective cohort study was conducted using data from a large private health insurance scheme. Individuals who received a single dose of Ad26.COV2.S as their primary vaccination were included. Time‐varying Cox regression models were used to assess the effectiveness of boosting with either Ad26.COV2.S or BNT162b2 v. not boosting against severe COVID‐19 outcomes associated with emerging variants, adjusting for various demographic and clinical factors. Results. By August 2021, a total of 407 961 individuals received a first dose of Ad26.COV2.S, of whom 350 688 were eligible for and 332 286 included in the vaccine effectiveness (VE) analysis. Of these, 206 359 (62%) received no further doses, while 113 957 (34%) received a second dose of Ad26.COV2.S and 11 970 (4%) received a second dose of BNT162b2 by August 2022. During the follow‐up period (November 2021 ‐ August 2022), 1 125 COVID‐19‐related hospital admissions, 198 admissions to critical care and 41 COVID‐19‐related deaths were recorded. Adjusted relative VE against severe outcomes was 34% (95% confidence interval (CI) 19 ‐ 45) for hospital admission, 51% (95% CI 22 ‐ 70) for critical care admission, and 89% (95% CI 13 ‐ 98) for COVID‐19‐ related death. Conclusion. While most participants remained unboosted, administration of either ancestral strain Ad26.COV2.S or BNT162b2 vaccination provided protection against severe COVID‐19 outcomes among essential workers in SA during the dominance of the Omicron BA.1 and BA.4/5 variants, demonstrating cross‐strain protection

Intravenous antibiotic use in a private mining hospital in North West Province, South Africa

Background. The misuse and overuse of intravenous (IV) antibiotics contribute to the spread of multidrug resistance, consequently increasing mortality. These effects can be minimised through treatment reviews that aim to optimise antibiotic therapy without compromising patient clinical outcomes. There is therefore a need to evaluate and monitor intravenous antibiotic usage in hospitals. Objectives. To describe IV antibiotic use in admitted patients at a private hospital in North West Province, South Africa. Methods. A cross-sectional study design was followed using retrospective data from patient files and the hospital electronic healthcare software (TriMed) between 1 January and 31 December 2022. A Microsoft Excel spreadsheet was used to capture demographic information for each patient profile that met the inclusion criteria, and data on IV antibiotic use were captured for each admission episode. The data were analysed using IBM statistical software. Results. Demographic data were recorded for 677 patient profiles, with males representing 53.8% (n=364). A total of 731 admissions occurred during the study period. The most prevalent indication for IV antibiotic use, according to the provisional diagnosis, was upper and lower respiratory tract disorders, which represented 25.2% of the total admissions. Staphylococcus aureus was the most commonly treated micro-organism, representing 22.8% (n=23) of the total isolated micro-organisms. IV antibiotics were initiated 885 times, and amoxicillin-clavulanic acid was the most used antibiotic (51.2%). Most antibiotics (48.2%) were used at a dose of 1 200 mg, with a dosing frequency of three times a day (72.3%). A total of 806 review actions, out of 885 intravenous antibiotic initiations, were conducted (91.1%). The prevalence of IV-to-oral switch was 49.0%, while 41.3% of IV antibiotics were stopped after review. IV antibiotic de-escalation represented 7.2% of the total reviews, while an oral antibiotic was added to 1.7% of the IV antibiotics after review. At review, the prevalence of adding IV antibiotics to another IV antibiotic was 0.7%. The average length of hospital stay was 5.8 days, while patients continuously received IV antibiotics for 3.4 days on average. Conclusion. There is a need to monitor IV antibiotic use and encourage IV antibiotic de-escalation to limit the rampant use of broad- spectrum antibiotics and manage the most prevalent infections effectively in the shortest possible time, consequently reducing the average duration of hospitalisation. IV antibiotic treatment review is therefore pivotal to optimise antibiotic therapy, the transition of IV to oral antibiotics, and discontinuation of IV antibiotics when they are no longer necessary

Optimising insulin use in people living with type 2 diabetes at primary healthcare facilities: The Tshwane Insulin Project

Background. In South Africa (SA), glucose control for individuals with type 2 diabetes follows a stepwise approach. According to the guidelines, insulin therapy is started after using two oral agents. However, various challenges may delay the initiation of insulin. Objectives. To implement a nurse-led, telehealth-assisted programme to address these challenges, aiming to transition patients to insulin safely to achieve better glycaemic control. Methods. From 2021 to 2023, we conducted a single-arm, unblinded before-and-after study in primary care facilities in Tshwane District, Gauteng Province, SA. Participants were on insulin or two oral agents at maximum doses. Study nurses monitored glycated haemoglobin (HbA1c) results, and participants with HbA1c levels of ≥8% (≥10% during the COVID-19 pandemic) were counselled about insulin use. During an initiation visit, participants received demonstrations and education on using insulin and glucose meters. The participants then tested their glucose levels at home according to a fixed schedule. Over 14 weeks, we implemented monthly clinic visits supplemented by home visits facilitated by community healthcare worker teams. During these visits, glucose results were communicated to the clinic physician via the Vula mobile app, allowing timely adjustments to insulin therapy. Results. Of the 293 participants, 65% (n=192) were women and 35% (n=101) were men. The mean (standard deviation (SD)) age was 53 (10) years, with a baseline mean (SD) HbA1c level of 12.1% (1.7%). Of those initiated, 169 (58%) were on oral agents and 124 (42%) were on insulin. Biphasic mixed human insulin was prescribed to 185 participants (63%) and intermediate human neutral protamine Hagedorn (NPH) insulin to 108 (37%). Immediately after baseline assessment and during the 14-week study period, 72 participants (23%) were lost to follow-up, and seven were hospitalised during the study period. Glucose values decreased over 14 weeks, with approximately one-third of participants having no insulin adjustments, one-third having one adjustment, and one-third having more than one adjustment. The mean (SD) HbA1c level decreased from 12.1% (1.6%) to 8.8% (1.6%) over the 14 weeks in 240 paired samples (p<0.001). Ten percent of these participants achieved HbA1c levels <7%, and 34% had levels <8%. Conclusion. The nurse-led, telehealth-supported intervention successfully transitioned participants onto twice-daily mixed insulin or night-time intermediate NPH insulin, resulting in a significant decrease in HbA1c from 12.1% to 8.8%. However, clinics will require additional resources to initiate or intensify insulin therapy in primary care settings