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Dheda K, Charalambous S, Karat AS, von Delft A, Lalloo UG, van Zyl Smit R, Perumal R, Allwood BW, Esmail A, Wong ML, Duse AG, Richards G, Feldman C, Mer M, Nyamande K, Lalla U, Koegelenberg CFN, Venter F, Dawood H, Adams S, Ntusi NAB, van der Westhuizen HM, Moosa MYS, Martinson NA, Moultrie H, Nel J, Hausler H, Preiser W, Lasersohn L, Zar HJ, Churchyard GJ. A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2. Afr J Thorac Crit Care Med 2021; 27:10.7196/AJTCCM.2021.v27i4.173. [PMID: 34734176 PMCID: PMC8545268 DOI: 10.7196/ajtccm.2021.v27i4.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 12/21/2022] Open
Abstract
SUMMARY Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death. RECOMMENDATIONS Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.
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Affiliation(s)
- K Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for
the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - A S Karat
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - A von Delft
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- TB Proof, South Africa
| | - U G Lalloo
- Gateway Private Hospital Medical Centre, Umhlanga Ridge, South Africa
- Durban International Clinical Research Site, Durban, South Africa
| | - R van Zyl Smit
- Division of Pulmonology and Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - R Perumal
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for
the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - B W Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - A Esmail
- Clinical Trials Unit, University of Cape Town Lung Institute, South Africa
| | - M L Wong
- Division of Pulmonology, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A G Duse
- Clinical Microbiology & Infectious Diseases, School of Pathology of the NHLS & University of the Witwatersrand, Johannesburg, South Africa
| | - G Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Feldman
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Mer
- Department of Medicine, Divisions of Pulmonology and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K Nyamande
- Department of Pulmonology, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | - U Lalla
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - C F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - H Dawood
- Greys Hospital, Pietermaritzburg, South Africa
| | - S Adams
- Division of Occupational Medicine, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - N A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - H-M van der Westhuizen
- TB Proof, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
| | - M-Y S Moosa
- Department of Infectious Diseases, Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Southern African HIV Clinicians Society
| | - N A Martinson
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, MD, USA
| | - H Moultrie
- National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
- Clinical Microbiology & Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Nel
- Division of Infectious Diseases, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - H Hausler
- TB HIV Care, Cape Town, South Africa
| | - W Preiser
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town,
South Africa
| | - L Lasersohn
- South African Society of Anaesthesiologists
- Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Critical Care, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - H J Zar
- Department of Paediatrics & Child Health, Red Cross Children’s Hospital and SAMRC Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
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Dahim M, Mitha M, Connolly C, Nyamande K. Pulmonary hypertension: Spectrum of disease, clinical presentation and treatment outcomes at the main respiratory pulmonary hypertension clinic in KwaZulu-Natal Province, South Africa. Afr J Thorac Crit Care Med 2021; 27:10.7196/AJTCCM.2021.v27i1.118. [PMID: 34240040 PMCID: PMC8203056 DOI: 10.7196/ajtccm.2021.v27i1.118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND There are many causes of pulmonary hypertension (PH). However, the aetiology, management and treatment outcomes in South Africa (SA), which has a high burden of HIV, are lacking in the literature. OBJECTIVES To characterise patient demographics, aetiology, clinical presentation and management of patients presenting to the only government-funded PH clinic in Durban, SA. METHODS We retrospectively reviewed electronic charts of patients with confirmed PH who attended the respiratory PH clinic between 2011 and 2018. Demographic and clinical data, symptoms, pulmonary function testing, pulmonary artery pressure on echocardiography and treatment were analysed. Patients with group 2 PH were excluded from the present study as they were managed by cardiologists. RESULTS We identified 93 patients with confirmed PH and the majority were female (82.8%; n=77). The majority of the patients were between the ages of 30 and 39 years at the time of diagnosis. Most patients were black African (64.5%; n=60), followed by Indians (26.9%; n=25) and whites (8.6%; n=8). The most common cause of PH was group 1 (75%; n=70), followed by group 4 (13%; n=12) and then group 3 (12%; n=11). HIV-associated PH accounted for 27% of all patients and was the main cause of PH in those classified in group 1 (38%; n=29). Two-thirds (66%) of patients were treated with sildenafil, the only treatment that was available. Patients on treatment showed significant improvement indicated by the World Health Organization functional class, mean 6-minute walk test and reduction in mean pulmonary artery pressure on echocardiography. CONCLUSION HIV-associated PH is the most common cause of PH in SA. Sildenafil, the only drug available in our setting, is beneficial to most patients with PH.
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Affiliation(s)
- M Dahim
- Department of Pulmonology and Critical Care, Groote Schuur Hospital, Cape Town, South Africa
| | - M Mitha
- Department of Pulmonology and Critical Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - C Connolly
- Department of Biostatistics, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - K Nyamande
- Department of Pulmonology and Critical Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Abdool-Gaffar MS, Ambaram A, Ainslie GM, Bolliger CT, Feldman C, Geffen L, Irusen EM, Joubert J, Lalloo UG, Mabaso TT, Nyamande K, O'Brien J, Otto W, Raine R, Richards G, Smith C, Stickells D, Venter A, Visser S, Wong M. Guideline for the management of chronic obstructive pulmonary disease--2011 update. S Afr Med J 2011; 101:63-73. [PMID: 21526617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
OBJECTIVE To revise the South African Guideline for the Management of Chronic Obstructive Pulmonary Disease (COPD) based on emerging research that has informed updated recommendations. KEY POINTS (1) Smoking is the major cause of COPD, but exposure to biomass fuels and tuberculosis are important additional factors. (2) Spirometry is essential for the diagnosis and staging of COPD. (3) COPD is either undiagnosed or diagnosed too late, so limiting the benefit of therapeutic interventions; performing spirometry in at-risk individuals will help to establish an early diagnosis. (4) Oral corticosteroids are no longer recommended for maintenance treatment of COPD. (5) A therapeutic trial of oral corticosteroids to distinguish corticosteroid responders from non-responders is no longer recommended. (6) Primary and secondary prevention are the most cost-effective strategies in COPD. Smoking cessation as well as avoidance of other forms of pollution can prevent disease in susceptible individuals and ameliorate progression. Bronchodilators are the mainstay of pharmacotherapy, relieving dyspnoea and improving quality of life. (7) Inhaled corticosteroids are recommended in patients with frequent exacerbations and have a synergistic effect with bronchodilators in improving lung function, quality of life and exacerbation frequency. (8) Acute exacerbations of COPD significantly affect morbidity, health care units and mortality. (9) Antibiotics are only indicated for purulent exacerbations of chronic bronchitis. (10) COPD patients should be encouraged to engage in an active lifestyle and participate in rehabilitation programmes. OPTIONS Treatment recommendations are based on the following: annual updates of the Global Obstructive Lung Disease (GOLD), initiative, that provide an evidence-based comprehensive review of management; independent evaluation of the level of evidence in support of some of the new treatment trends; and consideration of factors that influence COPD management in South Africa, including lung co-morbidity and drug availability and cost. OUTCOME Holistic management utilising pharmacological and nonpharmacological options are put in perspective. EVIDENCE Working groups of clinicians and clinical researchers following detailed literature review, particularly of studies performed in South Africa, and the GOLD guidelines. BENEFITS, HARMS AND COSTS. The guideline pays particular attention to cost-effectiveness in South Africa, and promotes the initial use of less costly options. It promotes smoking cessation and selection of treatment based on objective evidence of benefit. It also rejects a nihilistic or punitive approach, even in those who are unable to break the smoking addiction. RECOMMENDATIONS These include primary and secondary prevention; early diagnosis, staging of severity, use of bronchodilators and other forms of treatment, rehabilitation, and treatment of complications. Advice is provided on the management of acute exacerbations and the approach to air travel, prescribing long-term oxygen and lung surgery including lung volume reduction surgery. VALIDATION The COPD Working Group comprised experienced pulmonologists representing all university departments in South Africa and some from private practice, and general practitioners. Most contributed to the development of the previous version of the South African guideline. GUIDELINE SPONSOR: The meeting of the Working Group of the South African Thoracic Society was sponsored by an unrestricted educational grant from Boehringer Ingelheim and Glaxo-Smith-Kline.
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Affiliation(s)
- M S Abdool-Gaffar
- Department of Pulmonology and Critical Care, Inkosi Albert Luthuli Hospital, Durban.
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Nyamande K, Lalloo UG, Vawda F. Comparison of plain chest radiography and high-resolution CT in human immunodeficiency virus infected patients with community-acquired pneumonia: a sub-Saharan Africa study. Br J Radiol 2006; 80:302-6. [PMID: 17005518 DOI: 10.1259/bjr/15037569] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The objective of the study was to determine the proportion of patients with missed lesions on plain chest radiographs compared with high-resolution computed tomography (HRCT) in 49 human immunodeficiency virus (HIV) infected patients with community-acquired pneumonia (CAP). Patients underwent plain chest radiography and HRCT scans of the chest at admission. Microbiological investigations for CAP were performed. An experienced radiologist, without knowledge of clinical or pathological data, reported the chest radiographs and HRCT scans. The study group included 26 females and 23 males, aged 18-53 years (mean age 36 years). Organisms were isolated from 26 patients (53%). In 40 patients (82%), the HRCT scans demonstrated lesions not visualized on the plain chest radiographs. There was 100% correlation between plain radiographic and HRCT scan findings in nine cases (18%). Lesions that were not visualized on the plain radiographs but elucidated on HRCT included: pleural effusion (n = 14), ground-glass opacification (n = 20), pericardial effusion (n = 8), cavitation (n = 4), cysts (n = 4), bullae (n = 4), abscess (n = 1) and pneumothorax (n = 1). In 20 of 23 cases, hilar lymphadenopathy, identified on HRCT, was not recognized on plain chest radiographs. In patients in whom an organism was isolated, a correct HRCT diagnosis of pulmonary tuberculosis, bacterial pneumonia and Pneumocystis carinii pneumonia (PCP) was made in 80%, 84% and 100% of cases, respectively. The proportion of patients with missed lesions on plain chest radiographs in HIV infected patients with CAP was high. This has important implications for management and prognosis. HRCT scans correlate well with the microbiological diagnosis when reported by an experienced radiologist.
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Affiliation(s)
- K Nyamande
- Department of Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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