Medical Tourism: A Cost or Benefit to the NHS?

‘Medical Tourism’ – the phenomenon of people travelling abroad to access medical treatment - has received increasing attention in academic and popular media. This paper reports findings from a study examining effect of inbound and outbound medical tourism on the UK NHS, by estimating volume of medical tourism and associated costs and benefits. A mixed methods study it includes analysis of the UK International Passenger Survey (IPS); interviews with 77 returning UK medical tourists, 63 policymakers, NHS managers and medical tourism industry actors policymakers, and a review of published literature. These informed costing of three types of treatments for which patients commonly travel abroad: fertility treatment, cosmetic and bariatric surgery. Costing of inbound tourism relied on data obtained through 28 Freedom-of-Information requests to NHS Foundation Trusts. Findings demonstrate that contrary to some popular media reports, far from being a net importer of patients, the UK is now a clear net exporter of medical travellers. In 2010, an estimated 63,000 UK residents travelled for treatment, while around 52,000 patients sought treatment in the UK. Inbound medical tourists treated as private patients within NHS facilities may be especially profitable when compared to UK private patients, yielding close to a quarter of revenue from only 7% of volume in the data examined. Costs arise where patients travel abroad and return with complications. Analysis also indicates possible savings especially in future health care and social costs averted. These are likely to be specific to procedures and conditions treated. UK medical tourism is a growing phenomenon that presents risks and opportunities to the NHS. To fully understand its implications and guide policy on issues such as NHS global activities and patient safety will require investment in further research and monitoring. Results point to likely impact of medical tourism in other universal public health systems.     

South–South Comparisons: A Syntegrated Approach to the Teaching of the Arts for Primary School Teacher Preparation in South Africa and Australia

In light of the tendency to present the arts in an integrated fashion in many education systems worldwide, this article examines the consequences of integration for discrete art forms. In particular, we investigate the advantages of adopting a syntegrated approach to the facilitation of arts in teacher preparation. A specific comparison between the implementation of arts curricula in South Africa and Australia is made. The disjuncture between policy and practice in arts education that has been reported internationally needs constant monitoring. We conclude that the heart of curriculum transfer and transformation lies in the classroom.     

The “ART” of Linkage: Pre-Treatment Loss to Care after HIV Diagnosis at Two PEPFAR Sites in Durban,South Africa

Background

Although loss to follow-up after antiretroviral therapy (ART) initiation is increasingly recognized, little is known about pre-treatment losses to care (PTLC) after an initial positive HIV test. Our objective was to determine PTLC in newly identified HIV-infected individuals in South Africa.

Methodology/Principal Findings

We assembled the South African Test, Identify and Link (STIAL) Cohort of persons presenting for HIV testing at two sites offering HIV and CD4 count testing and HIV care in Durban, South Africa. We defined PTLC as failure to have a CD4 count within 8 weeks of HIV diagnosis. We performed multivariate analysis to identify factors associated with PTLC. From November 2006 to May 2007, of 712 persons who underwent HIV testing and received their test result, 454 (64%) were HIV-positive. Of those, 206 (45%) had PTLC. Infected patients were significantly more likely to have PTLC if they lived ≥10 kilometers from the testing center (RR = 1.37; 95% CI: 1.11–1.71), had a history of tuberculosis treatment (RR = 1.26; 95% CI: 1.00–1.58), or were referred for testing by a health care provider rather than self-referred (RR = 1.61; 95% CI: 1.22–2.13). Patients with one, two or three of these risks for PTLC were 1.88, 2.50 and 3.84 times more likely to have PTLC compared to those with no risk factors.

Conclusions/Significance

Nearly half of HIV-infected persons at two high prevalence sites in Durban, South Africa, failed to have CD4 counts following HIV diagnosis. These high rates of pre-treatment loss to care highlight the urgent need to improve rates of linkage to HIV care after an initial positive HIV test.     

The Meaning of ‘Self-Starvation’ in Impoverished Black Adolescents in South Africa

Recent surveys in South Africa have demonstrated that disordered eating is equally common among black and white female students. Self-report measures have been used in these surveys to establish levels of disordered eating. One study in Tanzania, where a two-stage design was implemented, showed that upon interview the majority of participants did not present with disordered eating. The absence of two-stage studies in South Africa brings into question some of the findings from these surveys. In the present study, we surveyed a sample of black and white high school students in South Africa to establish the prevalence of disordered eating. In the second phase of this study, we attempted to interview those black students from one particular school who scored high on the eating disorder measures. This process proved both challenging and elucidating. While a significant number of young black females endorsed eating disorder symptoms on self-report, interviews with some participants showed that self-starvation and related symptoms had a different meaning from what we would typically expect from someone with an eating disorder. Consequently, this study highlights the need to revisit the methods typically employed in cross-cultural research in eating disorders. Careful consideration of a variety of cultural factors that may alter the meaning of standard measures is called for.     

The Impact of Health Behaviours on Incident Cardiovascular Disease in Europeans and South Asians – A Prospective Analysis in the UK SABRE Study

Background

There is consistent evidence on the impact of health behaviours on risk of cardiovascular disease (CVD) in European populations. As South Asians in the UK have an excess risk of CVD and coronary heart disease (CHD) compared to Europeans, we investigated whether a similar association between combined health behaviours and risk of CVD and CHD among this high-risk group exists, and estimated the population impact.

Methods and Findings

In a prospective cohort of 1090 Europeans and 1006 South Asians (40–69 y) without prevalent CVD at baseline (1988–1990), followed up for 21 years to 2011, there were 601 incident CVD events [Europeans n = 255; South Asians n = 346] of which 520 were CHD events [n = 207 and 313 respectively]. Participants scored between 0 to 4 points for a composite score including four baseline healthy behaviours (non-smoker, moderate alcohol intake, physically active, frequent fruit/vegetable intake). Adjusted hazard ratios (95% confidence intervals) for incident CHD in Europeans who had three, two, one, and zero compared to four health behaviours were 1.33 (0.78–2.29), 1.96 (1.15–3.33), 1.36 (0.74–2.48) and 2.45 (1.18–5.10), respectively, p-trend = 0.025. In South Asians, corresponding HRs were 2.88 (1.33–6.24), 2.28 (1.06–4.91), 3.36 (1.53–7.39) and 3.48 (1.38–8.81), p-trend = 0.022. The results were similar for incident CVD; Europeans HR 2.12 (1.14–3.94), p–trend = 0.014; South Asians HR 2.73 (1.20–6.21), p-trend = 0.018. The population attributable fraction in Europeans was 43% for CHD and 28% for CVD. In South Asians it was 63% and 51% respectively.

Conclusions

Lack of adherence to four combined health behaviours was associated with 2 to 3-fold increased risk of incident CVD in Europeans and South Asians. A substantial population impact in the South Asian group indicates important potential for disease prevention in this high-risk group by adherence to healthy behaviours.     

The zooplankton communities of an artificially divided subtropical coastal estuarine–lake system in South Africa

Nhlabane coastal lake and estuary system in South Africa is divided by a permanent barrage constructed at the outlet of the lake. This study compared the zooplankton assemblages of the lake and estuary systems after 15 years of separation. Before sampling commenced the mouth of the estuary closed and remained so throughout the duration of the study. The lake was completely fresh and the estuary had a low salinity not exceeding 4‰. Both the estuary and lake are shallow systems (less than 2 m) and were well mixed. Turbidity levels were generally below 10 NTUs. Temperature fluctuated seasonally between 18.5 and 30°C. Oxygen levels ranged between 4.3 and 9.9 mg/l but were mostly above 5 mg/l for both systems. The estuarine and lake plankton was dominated by copepod instars, especially of the calanoid Pseudodiaptomus hessei. During the entire study period the lake also supported high densities of rotifers. Rotifers only appeared in the estuarine plankton at the end of the sampling period. During the first sampling sessions zooplankton diversity in the estuary was higher but declined thereafter to levels within the range calculated for the lake. Estuarine relict species recorded reflect the estuarine history of the lake. Multivariate analyses indicated a change in the composition of the zooplankton community in the estuary during the duration of the study, while that of the lake remained comparatively stable. Species composition analyses showed that this change in the estuary was due to a shift from an estuarine to a more freshwater zooplankton assemblage. During this change some estuarine species declined in abundance or were not recorded anymore. These changes in the zooplankton community of the estuary may well illustrate the changes that occurred in the lower (south) section of the lake after completion of the barrage which isolated it from the estuary. This revised version was published online in July 2006 with corrections to the Cover Date.     

The Spectrum of Fungal Infections with a Special Reference to Dermatophytoses in the Capital Area of Kuwait During 2000–2005: A Retrospective Analysis

Background  

Fungal infections constitute a major health problem all over the world. Signs and symptoms induced by various dermatophytic infections are difficult to distinguish clinically from each other. So, characterization by in vitro culture is required for appropriate diagnosis and treatment as well as to study the epidemiological characteristics in a region.     

The South to North Variation of Norovirus Epidemics from 2006–07 to 2008–09 in Japan

Background

Norovirus (NoV) is a major cause of gastroenteritis during the autumn and winter seasons in Japan as well as in other temperate climate regions. Most outbreaks are thought to occur by secondary attacks through person-to-person infection by fecal-oral route. Severe cases are found in young children or patients with chronic diseases. Clarifying the patterns of epidemic diffusion is important for considering effective monitoring and surveillance as well as possible prevention.

Methods

We considered the predominant viral genotype from the laboratory result obtained from Infectious Agents Surveillance Report (IASR) of National Institute of Infectious Diseases (NIID). We investigated the increase of NoV cases nationwide for the 2006–07 to 2008–09 seasons using sentinel gastroenteritis data collected from about 3000 pediatric clinics on National Epidemiological Surveillance of Infectious Diseases (NESID) acquired from the kriging method in the geographic information system (GIS).

Results

During these three seasons, the majority of the detected virus was GII.4, which ranged from 60.4 to 88.9%. The number of cases (per sentinel site) at the peak week was 22.81 in the 2006–07 season and it decreased in the following seasons. NoV cases began to increase earlier in the southern areas and gradually extended into the northern areas, similarly, over the seasons. The average period from when the increase of cases was detected in the southern area to when it reached the northern area was 12.7 weeks.

Conclusion

The decrease of the number of sentinel cases at the peak week may suggest the development of herd immunity after a period of high prevalence. Although the NoV epidemic is thought to be associated with cold weather, its cases first increased in the southern area with relatively warm temperature, indicating there are other climate factors involved. Geographic study using the sentinel data could enhance the monitoring and surveillance of and preparedness against epidemics.     

Persistent Difficulties in Switching to Second-Line ART in Sub-Saharan Africa — A Systematic Review and Meta-Analysis

Objectives

Switching to second-line antiretroviral therapy (ART) largely depends on careful clinical assessment and access to biological measurements. We performed a systematic review and meta-analysis to estimate the incidence of switching to second-line ART in sub-Saharan Africa and its main programmatic determinants.

Methods

We searched 2 databases for studies reporting the incidence rate of switching to second-line ART in adults living in sub-Saharan Africa. Data on the incidence rate of switching were pooled, and random-effect models were used to evaluate the effect of factors measured at the programme level on this incidence rate.

Results

Nine studies (157,340 patients) in 21 countries were included in the meta-analysis. All studies considered patients under first-line ART and conditions to initiate ART were similar across studies. Overall, 3,736 (2.4%) patients switched to second-line ART. Incidence rate of switch was in mean 2.65 per 100 person-years (PY) (95% confidence interval: 2.01–3.30); it ranged from 0.42 to 4.88 per 100 PY and from 0 to 4.80 per 100 PY in programmes with and without viral load monitoring, respectively. No factors measured at the programme level were associated with the incidence rate of switching to second-line ART.

Conclusion

The low incidence rate of switching to second-line ART suggests that the monitoring of patients under ART is challenging and that access to second-line ART is ineffective; efforts should be made to increase access to second-line ART to those in need by providing monitoring tools, education and training, as well as a more convenient regimen.     

In Situ Enrichment of a Diverse Community of Bacteria from a 4–5 km Deep Fault Zone in South Africa

The extreme environment of South Africa's ultra-deep gold mines offers an opportunity to discover novel microorganisms (e.g., Alkaliphilus transvaalensis), including extremophiles that may provide insight into the origins of life on earth and offer industrial applications because of their thermophilic enzymatic properties. This study employed culture-independent methods to examine the bacterial diversity in water (T = 55° C, pH = 9, Cl^? = 1000 ppm and age = 4–53 Ma) emanating from an exploration borehole in a South African Au mine that intersected a quartzite-hosted fault at 3.3 km below land surface. The more adhesive strains of sulfate reducing bacteria were effectively selected and enriched from the planktonic community by forcing water from a flowing borehole through a sand/agar cartridge that was installed within the borehole. The cartridge's agar contained sulfate and lactate that diffused from the agar into the cartridge. DNA was extracted from the sand, after which a bacterial 16S rDNA gene clone library was generated. Analysis of clone sequences indicated that the groundwater bacterial community was quite diverse, including members of the α-, β-, and γ-Proteobacteria (20%), Actinobacteria (6%), Firmicutes (57%), Chloroflexi (3%), and Deinococcus-Thermus (14%) phyla. One of the most frequently detected clone types was associated with Desulfotomaculum (a known SRB). Another predominant clone type was closely related to Meiothermus cerbereus. A proportion of Proteobacteria clones were closely related to Ralstonia, Alishewanella, Hydrogenophaga, or Methylobacterium species. Some of the Firmicutes clones were closely related to Alkaliphilus transvaalensis, which was isolated from a nearby South African Au mine, or to Clostridium thermocellum. Of the total 21 OTUs identified from the cartridge sand, 6 most likely represent novel species of Firmicutes given their dissimilarity to other 16S rDNA sequences in the GenBank database.     

The cushion–star Parvulastra exigua in South Africa: one species or more?

The cushion–star Parvulastra exigua (Lamarck, 1816) is a widely distributed member of the temperate intertidal fauna in the southern hemisphere. In South Africa, it occurs in sympatry with the endemic Parvulastra dyscrita (Clark, 1923), the two species being differentiated predominantly by gonopore placement. Several recent studies have suggested that there may be additional cryptic species within the Parvulastra exigua complex in South Africa, based variously on color morphology, genetic evidence and the differential placement of the gonopores. This paper attempts to resolve whether one or more species are represented within Parvulastra exigua. A total of 346 Parvulastra exigua and 8 Parvulastra dyscrita were collected from sites on the west and south–west coasts of South Africa; morphological, anatomical and genetic analyses were performed to determine whether cryptic species and/or Parvulastra exigua specimens with aboral gonopores were present. Results show that neither cryptic species nor Parvulastra exigua specimens with aboral gonopores occur at these sites. This study thus refutes previous claims of the existence of aboral gonopores in South African Parvulastra exigua, and suggests that a single species is represented. The distinction between Parvulastra exigua and Parvulastra dyscrita is also confirmed, and features separating these two species are clarified and documented.     

Epidemiology of Leptospirosis in Africa: A Systematic Review of a Neglected Zoonosis and a Paradigm for ‘One Health’ in Africa

BackgroundLeptospirosis is an important but neglected bacterial zoonosis that has been largely overlooked in Africa. In this systematic review, we aimed to summarise and compare current knowledge of: (1) the geographic distribution, prevalence, incidence and diversity of acute human leptospirosis in Africa; and (2) the geographic distribution, host range, prevalence and diversity of Leptospira spp. infection in animal hosts in Africa.MethodsFollowing Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we searched for studies that described (1) acute human leptospirosis and (2) pathogenic Leptospira spp. infection in animals. We performed a literature search using eight international and regional databases for English and non-English articles published between January 1930 to October 2014 that met out pre-defined inclusion criteria and strict case definitions.

Results and Discussion

We identified 97 studies that described acute human leptospirosis (n = 46) or animal Leptospira infection (n = 51) in 26 African countries. The prevalence of acute human leptospirosis ranged from 2 3% to 19 8% (n = 11) in hospital patients with febrile illness. Incidence estimates were largely restricted to the Indian Ocean islands (3 to 101 cases per 100,000 per year (n = 6)). Data from Tanzania indicate that human disease incidence is also high in mainland Africa (75 to 102 cases per 100,000 per year). Three major species (Leptospira borgpetersenii, L. interrogans and L. kirschneri) are predominant in reports from Africa and isolates from a diverse range of serogroups have been reported in human and animal infections. Cattle appear to be important hosts of a large number of Leptospira serogroups in Africa, but few data are available to allow comparison of Leptospira infection in linked human and animal populations. We advocate a ‘One Health’ approach to promote multidisciplinary research efforts to improve understanding of the animal to human transmission of leptospirosis on the African continent.