Ethical dimensions of current issues regarding safe blood donation

ABSTRACT In the HIV/AIDS literature, a perspective that has not received a great amount of attention concerning blood donation per se and the duties and obligations of Blood Transfusion Services (BTS)i when held to the question of fairness raised by socially marginalised persons (or groups) who altruistically wish to donate blood in the face of the HIV/AIDS pandemic is addressed in this research report. The represented marginalised group I use is Men who have Sex with Men (MSM)ii Acquired Immunodeficiency Syndrome, commonly called AIDS first came to the attention of the public in the 1980s. From an unknown unnamed emerging infectious diseaseiii ,it has grown into a pandemic familiar to all. Primarily transmitted either sexually or via contaminated needles, the HIV infected individual is initially an asymptomatic carrier. Once an individual Once an individual is infected with the virus, he or she can pass it on to others by way of body fluids, e.g. blood and semen. HIV, whether treated or not, will eventually develop into AIDS for which there is currently no known cure. AIDS is uniformly mortal. i In this research report, I will refer to the industry as “Blood Transfusion Services” although in some countries it is referred to as “Blood Bank Services” ii Men who have Sex with Men (MSM) according to the London-based PANOS Institute include men who have sex with both men and women, men who have sex with only other men, men who have sex with boys and men, male sex workers and their clients, male transvestites and transsexuals, male street children and men in prison (McKenna 1999:1) iii As defined by Lashley, F, (2006) Emerging Infectious Diseases are ‘diseases of infectious origin whose incidence in humans has increased within the past two decades or threatens to increase in the near future’ The media abounds with literature concerning HIV/AIDS looking at it from various perspectives. iv Moreover, and correctly, in South Africa we are knowledgeable that what once was considered as a threat only to homosexualsv or IV drug users – individuals marginalised by their nonconformance to society’s norms – is now epidemiologically a disease spread in our society primarily by non-drug using heterosexuals. The tension between promoting the public good in the face of an pandemic while simultaneously protecting against unjust discrimination against individuals or groups represents an ethical dilemma faced by all public health organisations including BTS. Principally contextualised in iv e.g. clinical research in, guidelines pertaining to, ethical issues about, legal precedents concerning, duties of medial personnel towards, epidemiological analysis, psychological monitoring …and so on. v At the end of the 19th century, homosexuality was profiled as a mental illness by the German psychiatrist Richard von Krafft-Ebing in his reference book Psychopathis Sexualis.v In the absence of scientific evidence to prove otherwise, this view became widely accepted . Eventually, many different societies perceived homosexuals including MSM as unstable and this reinforced discriminatory practices against them. v Even today, the harmful consequences of homophobia impact on MSM in many different ways. Meyers describes three negative conditions or practices common to the experience of MSM. They are: the internalisation of homophobia to the extent that they accept rejection from society; the experience of social stigmatisation; and overt discrimination and violence.v From some religious aspects, homosexuality is considered a “sin against nature” and is often seen as a link to AIDS, which is again seen as God’s punishment for a “life against nature”.v The Koran suggests punishment for those involved in homosexual acts on the basis of harm to society, and Sharia law admits no tolerance towards homosexuality.v. Predominantly Catholic Latin American countries enforce socio-cultural and legal restrictions to prohibit homosexuality. (Mckenna 1999:11) From Buddhist perspective, homosexuals are not permitted to become a monk and to practice through monk-hood the ultimate goal of attaining the highest level of enlightenment (Nirvana) (Ven Chanmyay Sayadaw Janakabhivamsa 1997:9 ). However, they are as equal as are others when following the paths taken that may lead them to attain Nirvana (Personal communication with Ven Ashin Manijoti, Theravada Buddhist Dhammodaya Monastery, Pietermaritzburg). the milieu of South Africa but practiced globally, the responsibility of BTS’s may broadly be grouped into two areas: 1) the provision of blood & its products to a given population based upon their estimated need; and 2) the assurance of blood and blood-product safety. While these may be considered only technical issues, they are not so clear-cut. Rather, they include conflicts of values and social-political agendas. Historically, BTSs have used discriminatory practices to exclude certain groups from blood donation. Independent of country or nation and in spite of advancements in blood screening science, the existent social-political order has influence on the policies and practices of BTSs such as the separation of groups into “high-risk” and ”low risk” blood donor categories. On the surface, such separations may appear to be straightforward scientific and prudential public health policy. However, when one considers the most common manner of HIV transmission - as occurring during intimate sexual acts which take place within society’s emphasis on private and individual rights but when such acts are considered by society to be ‘deviant ‘ - one might ask how the terms high- and low- risk are influenced by societal perceptions of the group in question. In other words, I suggest that societal (including political, religious, and economic) perceptions of a marginalised group’s private sexual acts influence public health policy; private acts have social consequences. Weighing the pros and cons of ethical arguments, this research report concludes that because of advanced blood transfusion science, it is morally justifiable to accept blood from all altruistic competent adult individuals volunteering to donate. Moreover, in this regard, it is the duty of BTS to safeguard the national blood supply by means other than excluding marginalised groups. To do otherwise is ethically unwarranted and constitutes unfair discrimination. In addition, through identifying that the act of blood donation is based on altruism or the “gift relationship,” the exclusion of marginalised groups from altruistic blood donation, serves only to further excludes them from an act, which is in essence humanitybinding. That being said, to achieve this end, all altruistic competent adults who wish to donate blood are obliged to understand the purpose, nature, and duties BTS’s have and adopt a renewed sense of social responsibility broadening our vision of the public good.

Public health systems strengthening in Africa: The role of South Africa Field Epidemiology and Laboratory Training Programme

The South Africa Field Epidemiology and Laboratory Training Programme (SAFELTP) was created in 2006 after recognizing the need to build and sustain the country's human resource capacity in field (applied) epidemiology and public health practice. The programme was formed as a collaboration between the South Africa Department of Health (DoH), the National Institute for Communicable Diseases (NICD), the National Health Laboratory Services (NHLS), the US Centers for Disease Control and Prevention (CDC) and the University of Pretoria. The primary goal of the programme was to produce field-trained epidemiologists equipped with knowledge and practical skills to effectively and efficiently address the public health priorities of South Africa. SAFELTP is a 2-year full-time training, consisting of a combination of classroom-based instruction (30%) and mentored field work (70%). The training places emphasis on public health surveillance, investigation of disease epidemics, public health laboratory practice and communication of epidemiologic information, among other aspects of epidemiology research. At completion, residents are awarded a Master of Public Health (MPH) degree from the University of Pretoria. Since its inception in 2006, 48 residents have enrolled onto the programme and 30 (62%) of them have completed the training. Over the past 5 years, the residents have conducted more than 92 outbreak investigations, 47 surveillance evaluations, 19 planned studies, analyzed 37 large databases and presented more than 56 papers at local and international conferences. In recognition of the high-quality work, at least five SAFELTP residents have received awards at various international scientific conferences during the 5 years. In conclusion, the South Africa FELTP is now fully established and making valuable contributions to the country's public health system, albeit with innumerable challenges

A pharmacovigilance study of adults on highly active antiretroviral therapy, South Africa: 2007 – 2011

BACKGROUND: Of the 1.6 million South African people infected with human immunodeficiency virus (HIV), approximately 970,000 (55%) have been initiated on HAART. Despite these numbers, very little has been published about the safety profile of antiretroviral (ARV) medicines in the country. This study was performed at the Medunsa National Pharmacovigilance Centre and aimed to describe the demographic characteristics of patients enrolled in the pharmacovigilance surveillance study; highly active antiretroviral therapy (HAART) initiation regimen patterns; reasons for regimen changes; and adverse effects of ARV medicines. METHODS: A cohort study of HIV-infected individuals aged 15 years or older who were on ARV medicines was conducted at four sentinel sites. RESULTS: After HAART initiation, with an average lapse of 17.8 months (range: 0 – 83.8 months), 2,815 patients were enrolled into the study. Results show that patients were observed for 1,606.2 person-years for pharmacy visits (collection of ARV medicines) and 817.1 person-years for clinical visits (consultation with the doctor). Females constituted 69.6% (1,958/2,815) of the study population. Almost all patients initiated HAART on first-line regimens (2,801/2,815). Some patients (6.7%, 190/2,815) dropped out of the study after HAART initiation. Reasons for regimen changes were not recorded for 2.5% (22/891) of the patients who changed regimens. The primary reason for regimen changes was drug-related toxicity (76.1%, 678/891), mostly evident in patients taking first-line regimens. Adverse effects experienced by patients were polyneuropathy (24.0%, 163/678); lipodystrophy (23.9%, 162/678); neuropathy (10.6%, 72/678); and suspected lactic acidosis (3.8%, 26/678). CONCLUSION: The majority of prescribers complied with the HAART guidelines and initiated most patients on first-line regimens. However, adverse effects are evident in patients taking first-line regimens. We recommend that the Department of Health should introduce less toxic first-line ARV regimens. Future efforts will aim to initiate patients on HAART and enrol them into the study simultaneously to determine early risk profiles of ARV medicines.The South African Field Epidemiology and Laboratory Training programme (SAFELTP) funded by the Centers for Disease Control and Prevention (CDC).http://www.panafrican-med-journal.com

Nursing staff dynamics and implications for maternal health provision in public health facilities in the context of HIV/AIDS

This study, carried out in Limpopo, KwaZulu-Natal, and Mpumalanga provinces in South Africa, aimed to document nursing staff dynamics in maternal health services, and to explore the factors associated with these dynamics. The study found that a high percentage of nursing staff working in public facilities were demotivated, burnt out, and were considering leaving the facility where they were working. A range of factors, both financial and nonfinancial, were associated with nurses considering going overseas: inadequate pay, poor promotion, feeling unsupported by management, and having bad relationships at work were all associated with lack of organizational commitment. As a result of high numbers of nurses feeling demoralized, there is not a conducive environment for policy interventions. Policymakers need to pay more attention to how policies are implemented and the impact of policies on the relationships between nurses, and nurses and managers in facilities

A pharmacovigilance study of adults on highly active antiretroviral therapy, South Africa : 2007-2011

BACKGROUND: Of the 1.6 million South African people infected with human immunodeficiency virus (HIV), approximately 970,000 (55%) have been initiated on HAART. Despite these numbers, very little has been published about the safety profile of antiretroviral (ARV) medicines in the country. This study was performed at the Medunsa National Pharmacovigilance Centre and aimed to describe the demographic characteristics of patients enrolled in the pharmacovigilance surveillance study; highly active antiretroviral therapy (HAART) initiation regimen patterns; reasons for regimen changes; and adverse effects of ARV medicines. METHODS: A cohort study of HIV-infected individuals aged 15 years or older who were on ARV medicines was conducted at four sentinel sites. RESULTS: After HAART initiation, with an average lapse of 17.8 months (range: 0 – 83.8 months), 2,815 patients were enrolled into the study. Results show that patients were observed for 1,606.2 person-years for pharmacy visits (collection of ARV medicines) and 817.1 person-years for clinical visits (consultation with the doctor). Females constituted 69.6% (1,958/2,815) of the study population. Almost all patients initiated HAART on first-line regimens (2,801/2,815). Some patients (6.7%, 190/2,815) dropped out of the study after HAART initiation. Reasons for regimen changes were not recorded for 2.5% (22/891) of the patients who changed regimens. The primary reason for regimen changes was drug-related toxicity (76.1%, 678/891), mostly evident in patients taking first-line regimens. Adverse effects experienced by patients were polyneuropathy (24.0%, 163/678); lipodystrophy (23.9%, 162/678); neuropathy (10.6%, 72/678); and suspected lactic acidosis (3.8%, 26/678). CONCLUSION: The majority of prescribers complied with the HAART guidelines and initiated most patients on first-line regimens. However, adverse effects are evident in patients taking first-line regimens. We recommend that the Department of Health should introduce less toxic first-line ARV regimens. Future efforts will aim to initiate patients on HAART and enrol them into the study simultaneously to determine early risk profiles of ARV medicines.The South African Field Epidemiology and Laboratory Training programme (SAFELTP) funded by the Centers for Disease Control and Prevention (CDC).http://www.panafrican-med-journal.com

Repeatability of manual coding of cancer reports in the South African National Cancer Registry, 2010

Data validity is a very important aspect of cancer registries in ensuring data quality for research and interventions. This study focused on evaluating the repeatability of manual coding of cancer reports in the South African National Cancer Registry (NCR). This cross-sectional study used the Delphi technique to classify 48 generic tumour sites into sites that would be most likely (“difficult”) and least likely (“not difficult”) to give rise to discordant results among coders. Reports received from the Charlotte Maxeke Academic Hospital were manually recoded by five coders (2 301 reports, e.g. approximately 400 reports each) for intracoder agreement; and by four coders (400 reports) for inter-coder agreement. Unweighted kappa statistics were calculated and interpreted using Byrts’ criteria. After four rounds of the Delphi technique, consensus was reached on the classification of 91.7% (44/48) of the sites. The remaining four sites were classified according to modal expert opinion. The overall kappa was higher for intra-coder agreement (0.92) than for inter-coder agreement (0.89). “Not difficult” tumour sites reflected better agreement than “difficult” tumour sites. Ten sites (skin other, basal cell carcinoma of the skin, connective tissue, other specified, lung, colorectal, prostate, oesophagus, naso-oropharynx and primary site unknown) were among the top 80% misclassified sites. The repeatability of manual coding at the NCR was rated as “good” according to Byrts’ criteria. Misclassified sites should be prioritised for coder training and the strengthening of the quality assurance system.This study was carried out by Nomathemba Dube in partial fulfilment of the requirements for her Master’s degree in Public Health in the School of Health Systems and Public Health at the University of Pretoria.The South African Field Epidemiology and Laboratory Training Programme (SAFELTP), funded by the Centers for Disease Control and Prevention (CDC)http://www.sajei.co.za/index.php/SAJEIam2014ay201

Outbreak of Rift Valley fever affecting veterinarians and farmers in South Africa, 2008

Background. During 2008, Rift Valley fever (RVF) virus re-emerged in South Africa as focal outbreaks in several provinces. Aims. To investigate an outbreak affecting cattle farmers and farm workers, and the staff and students of a veterinary school, assess the prevalence of infection during the outbreak, document the clinical presentation of cases, and identify potential risk factors. Methods. We conducted a cross-sectional serological survey of exposed veterinarians and farmers, who were examined to determine the presence of current or recent illness. Blood specimens were collected for virus isolation, nucleic acid detection and serology. A subset was interviewed using a standardised questionnaire to obtain data on recent exposures and risk factors for infection. Results. Of 53 participants potentially exposed to infected domestic ruminants, 15% had evidence of recent infection and 4% evidence of past exposure to the RVF virus. The prevalence of acute infection was 21% in veterinarians compared with 9% in farmers and farm workers. After a mean incubation period of 4.3 days, the most frequent symptoms experienced included myalgia (100%), headache (88%) and malaise (75%). No asymptomatic cases were identified. Transmission by direct contact with infected animals was the major risk factor in these professional groups. Performing animal autopsies was significantly associated with acute infection (risk ratio 16.3, 95% confidence interval 2.3 - 114.2). Conclusions. Increased risks associated with veterinary practices highlight a need for the use of personal protective equipment, and identify veterinarians as a primary target group for future vaccination. Results. Of 53 participants potentially exposed to infected domestic ruminants, 15% had evidence of recent infection whilst 4% of past exposure to the RVF virus. The prevalence of acute infection was higher in veterinarians (21%) in comparison to farmers and farm workers (9%). After a mean incubation period of 4.3 days, the most frequent symptoms experienced included myalgia (100%), headache (88%) and malaise (75%). No asymptomatic cases were identified. Transmission by direct contact with infected animals was identified as the major risk factor in these professional groups. Performing animal autopsies was significantly associated with acute infection (risk ratio 16.3, 95% CI 2.3-114.2). Conclusions. Increased risks associated with veterinary practices highlight a need for the use of personal protective equipment, and identify veterinarians as a primary target group for future vaccination

Morbidity and mortality due to malaria in Est Mono district, Togo, from 2005 to 2010 : a times series analysis

BACKGROUND: In 2004, Togo adopted a regional strategy for malaria control that made use of insecticide-treated nets (ITNs), followed by the use of rapid diagnostic tests (RDTs), artemisinin-based combination therapy (ACT). Community health workers (CHWs) became involved in 2007. In 2010, the impact of the implementation of these new malaria control strategies had not yet been evaluated. This study sought to assess the trends of malaria incidence and mortality due to malaria in Est Mono district from 2005 to 2010. METHODS: Secondary data on confirmed and suspected malaria cases reported by health facilities from 2005 to 2010 were obtained from the district health information system. Rainfall and temperature data were provided by the national Department of Meteorology. Chi square test or independent student’s t-test were used to compare trends of variables at a 95% confidence interval. An interrupted time series analysis was performed to assess the effect of meteorological factors and the use of ACT and CHWs on morbidity and mortality due to malaria. RESULTS: From January 2005 to December 2010, 114,654 malaria cases (annual mean 19,109 ± 6,622) were reported with an increase of all malaria cases from 10,299 in 2005 to 26,678 cases in 2010 (p<0.001). Of the 114,654 malaria cases 52,539 (45.8%) were confirmed cases. The prevalence of confirmed malaria cases increased from 23.1 per 1,000 in 2005 to 257.5 per 1,000 population in 2010 (p <0.001). The mortality rate decreased from 7.2 per 10,000 in 2005 to 3.6 per 10,000 in 2010 (p <0.001), with a significant reduction of 43.9% of annual number of death due to malaria. Rainfall (β-coefficient = 1.6; p = 0.05) and number of CHWs trained (β-coefficient = 6.8; p = 0.002) were found to be positively correlated with malaria prevalence. CONCLUSION: This study showed an increase of malaria prevalence despite the implementation of the use of ACT and CHW strategies. Multicentre data analysis over longer periods should be carried out in similar settings to assess the impact of malaria control strategies on the burden of the disease. Integrated malaria vector control management should be implemented in Togo to reduce malaria transmission.AFENET and SAFELTPhttp://www.malariajournal.com/content/11/1/389am2013ay201

Southeast Asia must narrow down the yield gap to continue to be a major rice bowl

Southeast Asia is a major rice-producing region with a high level of internal consumption and accounting for 40% of global rice exports. Limited land resources, climate change and yield stagnation during recent years have once again raised concerns about the capacity of the region to remain as a large net exporter. Here we use a modelling approach to map rice yield gaps and assess production potential and net exports by 2040. We find that the average yield gap represents 48% of the yield potential estimate for the region, but there are substantial differences among countries. Exploitable yield gaps are relatively large in Cambodia, Myanmar, Philippines and Thailand but comparably smaller in Indonesia and Vietnam. Continuation of current yield trends will not allow Indonesia and Philippines to meet their domestic rice demand. In contrast, closing the exploitable yield gap by half would drastically reduce the need for rice imports with an aggregated annual rice surplus of 54 million tons available for export. Our study provides insights for increasing regional production on existing cropland by narrowing existing yield gaps

Socio-Demographic Determinants of Condom Use Among Sexually Active Young Adults in Rural KwaZulu-Natal, South Africa

AIM: To investigate patterns, levels and socio-demographic determinants of condom use and consistency of use among young adults aged 15-24 years.BACKGROUND: Condoms are known to prevent HIV infection. However, HIV prevalence and incidence remain high.METHODS: This study was conducted in the Africa Centre Demographic Surveillance Area (ACDSA) in rural KwaZulu-Natal. Analysis focused on resident young adults aged 15-24 years in 2005. In univariable and multivariable analyses, determinants of condom use and consistency of use among 15-24 year olds were estimated using data collected in 2005. 'Ever' condom use was defined as the proportion who reported having used a condom; consistent use among those ever using as "always" using condoms with most recent partner in the last year.RESULTS: 3,914 participants aged 15-24 years reported ever having sex, of whom 52% reported condom use. Adjusting for age, sex, number of partners, residence of partner, partner age difference, type of partner and socio-economic status (SES), having an older partner decreased likelihood (aOR=0.69, p&lt;0.01), while belonging to a household in a higher SES increased likelihood of ever using condoms (aOR=1.82, p&lt;0.01). Being female (aOR=0.61 p&lt;0.01) and having a regular partner (aOR=0.65 p&lt;0.01) were independently associated with low consistent condom use.CONCLUSIONS: In this rural South African setting, condom use remains low, especially among females and with an older partner, situations commonly associated with increased HIV acquisition. Targeted supportive interventions to increase condom use need to be developed if HIV prevention programmes are to be successful