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PubMed2003

West Nile virus infection of Thoroughbred horses in South Africa (2000-2001).

REASONS FOR PERFORMING STUDY: West Nile virus (WNV) infection is endemic in southern Africa. With the recent emergence of WNV infection of horses in Europe and the USA the present study was performed to estimate the risk of seroconversion to WNV in a cohort of 488 young Thoroughbred (TB) horses. OBJECTIVES: To estimate the risk of seroconversion to WNV among a cohort of South African TB yearlings sold at the 2001 National Yearling Sales (NYS) and to determine whether the risk varied geographically. Two horses were also infected with a recent South African isolate of WNV to evaluate its virulence in horses. METHODS: Serum samples were collected from the cohort of 488 TB yearlings at the 2001 NYS. Serum samples that were collected from the same horses at the time that they were identified were sourced from our serum bank. Sera from 243 of the dams that were collected at the time that the foals were identified were also sourced from our serum bank. These sera were subjected to serum neutralisation (SN) tests for antibody to WNV. RESULTS: Approximately 11% of yearlings seroconverted to WNV on paired serum samples collected from each animal approximately 12 months apart. Studfarms with WNV-seropositive yearlings were widely distributed throughout South Africa and SN tests on sera from their dams indicated that exposure to WNV was even more prevalent (75%) in this population. Neurological disease was not described in any of the horses included in this study and 2 horses inoculated with a recent lineage 2 South African isolate of WNV showed no clinical signs of disease after infection and virus was not detected in their blood. CONCLUSIONS: Infection of horses with WNV is common in South Africa, but infection is not associated with neurological disease. POTENTIAL RELEVANCE: In contrast to recent reports from Europe, North Africa, Asia and North America, the results of our field and experimental studies indicated that exposure of horses to the endemic southern African strains of WNV was not associated with neurological disease.

Animals↗
PubMed1999

A review of literature on drug use in Sub-Saharan Africa countries and its economic and social implications.

The drug problem in Africa cannot be seen as an isolated phenomenon but rather as part of the larger narcoscape which partakes of the fluid yet disjunctive qualities of Appadurai's landscapes. In this volatile environment, the transformation of Sub-Saharan Africa (SSA) nations from transit points in an international drug network to consumer countries seems inevitable. At the same time, Africa has undergone rapid economic and social changes that have facilitate this shift. A review of the literature reveals that there is a pressing need to investigate current trends and patterns of drug use in the countries of SSA. These nations, struggling with the consequences of AIDS, famine, refugees, and political unrest, could ill afford to address the consequences of widespread drug use. It is critical, therefore, that they address the drug problem before it reaches crisis proportions. To do so, they need information describing the magnitude of the problem as well as a firm understanding of the relationships between drug use and crime, unemployment, violence, and the breakdown of family life. The more that is known about the nature and complexity of drug use in Africa, the better policymakers can formulate a sound and effective strategy to curtail the drug "epidemic."

Adult↗
PubMedDate not supplied

Family medicine in South Africa: where are we now and where do we want to be?

OBJECTIVES: This paper outlines the development of family medicine in South Africa with special reference to the process leading to the recognition of this discipline as a medical specialty. It also examines the constraints under which the discipline has had to function, considers where the discipline should be, seeks to identify the barriers to its further development and suggests ways in which to overcome these. METHODS: A short review was carried out of the available South African literature to record the advancement of the discipline and the international literature was searched for articles supporting this direction. RESULTS: The situation in South Africa is complicated by the existence of many doctor groupings claiming to represent the generalist and the perception that family medicine only addresses the needs of middle-class citizens. A flawed consultative process leading up to the present stage has contributed to this perception. CONCLUSIONS: The available literature supports the establishment of family medicine as a speciality. Developments in South Africa, such as raising the status of Family Medicine and creating a compulsory rotation through family medicine as an extended internship and the creation of registrar posts in family medicine will advance the discipline in a positive manner, whilst possibly attempting to resolve the medical migration issues that are presently destroying Sub-Saharan Africa's health services.

Family Practice↗
PubMedDate not supplied

Emergence of the M phenotype of erythromycin-resistant pneumococci in South Africa.

Erythromycin-resistant pneumococci have been isolated in South Africa since 1978; however, from 1987 to 1996, resistance to macrolides was only detected in 270 (2.7%) of 9,868 blood or cerebrospinal fluid (CSF) pneumococcal isolates, most of which were obtained from the public sector. In South Africa, macrolide use in the public sector is estimated at 56% of that in the private sector. Most erythromycin-resistant strains (89%) exhibited resistance to erythromycin and clindamycin (macrolide-lincosamide-streptogramin B phenotype). In the United States, most erythromycin-resistant pneumococci exhibit the newly described M phenotype (resistance to erythromycin alone), associated with the mefE gene. The M phenotype in South Africa increased significantly in the last 10 years, from 1 of 5,115 to 28 of 4,735 of blood and CSF isolates received from 1987 to 1991 compared with 1992 to 1996 (p = 5 x 10(-7)). These data suggest that, although macrolide resistance in pneumococci remains low in the public sector, the mefE gene is rapidly emerging in South Africa.

Anti-Bacterial Agents↗
PubMed2001

Psychiatric research in South Africa: a systematic review of Medline publications.

BACKGROUND: There is debate about the future path that medical and psychiatric research in South Africa should take. In particular, there have been calls to make research more relevant to the needs of the population. There is, however, little systematically collected data on the nature, strengths, and flaws of past psychiatric research in this country. METHODS: We undertook a MEDLINE search to gather all manuscripts that fell under the umbrella of psychiatric research and published by South Africa-based authors during the years 1966-1997. Several kinds of data were collated from each of the articles, including information about the authors and the journal, as well as information on the focus and type of article. RESULTS: While publications from South Africa continue to grow in number, relatively few involve collaborative research groups and few authors write more than one paper. Many papers relevant to psychiatry were published in general medical journals and many were from general medical departments. While blacks and females have been included in research, a number of important areas have received little attention. CONCLUSIONS: Psychiatry research in South Africa requires additional fostering, including additional resources for research training and arguably additional development of subspecialty focuses. Given the limited resources, and the nature of modern research, increased emphasis on collaboration seems advisable. A number of areas in psychiatry deserve particular attention from future researchers.

Humans↗
PubMed2001

Strike action by nurses in South Africa: a value clarification.

The Labour Relations Act (South Africa, 1991) made provision for protected strike action by employees, subject to certain conditions, procedures and negotiated agreements. This led to the removal of the strike clause in the Nursing Act (South Africa, 1992). The labour rights of all citizens are entrenched in the Constitution of the country (South Africa, 1996). Participation in strike action by the nurse/midwife, regardless of the legal requirements and specifications, does, however, pose an ethical question. It is therefore necessary to conduct a value clarification on strike action by nurses in South Africa. The purpose of this research is to explore and describe the perceived values of participants from an accessible population on this phenomenon. A qualitative, exploratory and descriptive research design was deployed. The perceived values of nurses on strike action were collected by means of an open-ended questionnaire/sketch. Over a period of three years a purposive and convenient sampling method was used, involving all the enrolled post basic nursing/midwifery students/learners at a particular Nursing Education Institution. The justification of the sample was further enhanced by also collecting data on the participants' age and provincial distribution location. Although a 63% sample realisation (of the accessible population) was achieved, this represents only 1.5% of the registered nursing/midwifery population in the country. A descriptive analysis of the participants' age and provincial distribution was undertaken, as well as a content analysis of their perceived values on strike action. The mean age of the participants was 48 years, which could be attributed to the fact that most of them were enrolled for a post-basic Diploma in Community Nursing Science. Most of the responses (52.7%) were against strike action and 32.5% supported strike action by nurses as a constitutional and legal right. A fairly substantial number of participants (14.8%) expressed mixed views as to whether strike action by nurses is right or wrong. Some respondents (15.7%) also reflected confusion regarding the enactment of strike action and the removal of the strike clause from the nursing legislation. Although this study does not claim external validity due to inappropriate representation of the nursing profession, the nurse of today opposes strike action. It is recommended that the study be replicated at national level and that the values be entrenched and published in position papers of and by the regulatory and organised nursing profession.

Adult↗
PubMed2003

Molecular analysis of bovine viral diarrhoea virus isolates from South Africa.

The presence of bovine viral diarrhoea virus in South Africa has been confirmed by several serological surveys. However, little is known about its biological properties. Twenty five isolates obtained by isolation in tissue culture and detected by means of the antigen capture ELISA from clinically sick cattle and from foetal calf serum in South Africa were characterized on the basis of analysis of the 5' non-translated (NTR) region of the genome. A reverse-transcription polymerase chain reaction (RT-PCR) was used to amplify specific sequences from the 5'NTR of the genome. The oligonucleotide primers corresponding to positions 105-125 and 399-378, respectively, in the sequence of BVDV strain NADL were used to generate the PCR products. Both strands were sequenced directly with these primers and fluorescence-labelled dideoxynucleotides in an automated nucleic acid sequencer. Reference strains of pestiviruses [(BVDV type I, BVDV type II, border disease virus (BDV) and hog cholera virus (HCV)] and isolates from a previous investigation on BVDV in southern Africa were included for comparative purposes. All the BVDV strains obtained during this study belong to subgroups of BVDV genotype I. No association could be demonstrated between the geographic origin of the isolates. A number of isolates formed another branch separate from the existing branches Ia, Ib and Ic. These findings suggest that extensive genetic diversity can be found within BVDV type I isolates from southern Africa. Isolates that group with the classical BVDV type I strains, particularly of American origin, coexist with variants that appear to represent a local genetic pool and or variants evolving from the classical strains.

5' Untranslated Regions↗
PubMed1993

Etiology of acute diarrhea among United States military personnel deployed to South America and west Africa.

A study of acute diarrhea was conducted from 1985 to 1987 among U.S. military personnel participating in routine shipboard exercises in South America and West Africa and ground troops deployed to coastal Ecuador. An enteropathogen was identified in 146 (51%) of 289 acute cases of diarrhea. Enterotoxigenic Escherichia coli, found in 50 (17%) patients with diarrhea, was the most commonly identified enteropathogen. Viral enteropathogens were also found in a high percentage of acute cases of diarrhea: rotavirus was detected in 11% of the patients and Norwalk virus infection in 10%. Most enteric pathogens were acquired in equal frequencies in South America and West Africa, except for rotavirus infection which was identified more often in West Africa and enteroaggregative E. coli infection which was identified more often in South America. Bacterial enteropathogens were frequently resistant to trimethoprim/sulfamethoxazole, but no resistance to quinolone drugs was observed, indicating that quinolone drugs have become important agents for the treatment of diarrhea in South America and West Africa.

Acute Disease↗
PubMed1998

Monitoring for mefloquine-resistant Plasmodium falciparum in Africa: implications for travelers' health.

The effectiveness of mefloquine to prevent malaria caused by Plasmodium falciparum is influenced by the sensitivity of the malaria parasites to this drug. Concern has been raised that resistance to mefloquine may develop in sub-Saharan Africa as has been observed in Southeast Asia. Case reports, along with blood smears to confirm the diagnosis and blood samples to determine the mefloquine concentration, were provided on any Peace Corps volunteer serving in sub-Saharan Africa who was diagnosed with malaria. We defined prophylaxis failures probably due to mefloquine resistance as patients with P. falciparum malaria confirmed at the Centers for Disease Control and Prevention, reported compliance with prophylaxis, no ingestion of mefloquine between date of illness onset and date of blood drawing, and a mefloquine level > or = 620 ng/ml in blood drawn within five days of onset of illness. Between January 1, 1991 and September 6, 1996, 44 (31%) of 140 volunteers with confirmed P. falciparum had blood drawn within five days of onset of illness. Twenty-nine (66%) had not fully complied with prophylaxis. Five of 15 prophylaxis failures in four countries had mefloquine levels > or = 620 ng/ml. Failure of mefloquine prophylaxis is primarily due to noncompliance. Evidence of probable resistance to mefloquine among strains of P. falciparum was found in five Peace Corps volunteers in sub-Saharan Africa. Clusters of well-documented prophylaxis failures need to be followed-up by therapeutic in vivo studies to document parasite resistance to mefloquine. Reduced sensitivity to mefloquine does not (yet) appear to be a significant problem in sub-Saharan Africa.

Adult↗
PubMed2005

Diabetic ketoacidosis: risk factors, mechanisms and management strategies in sub-Saharan Africa: a review.

BACKGROUND: Diabetic ketoacidosis is the most common hyperglycaemic emergency in patients with diabetes mellitus, especially type 1 diabetes. It carries very high mortality in sub-Saharan Africa, both in the treated patients and those who are presenting to hospital with diabetes for the first time. OBJECTIVE: To review the risk factors, mechanisms and management approaches in diabetes ketoacidosis in published literature and to discuss them in the context of why a significant proportion of patients who develop diabetic ketoacidosis in sub-Saharan Africa still have high mortality. DATA SOURCE: Literature review of relevant published literature from both Africa and the rest of the world. DATA SYNTHESIS: The main causes or precipitants of DKA in patients in SSA are newly diagnosed diabetes, missed insulin doses and infections. The major underlying mechanism is insulin deficiency. Treated patients miss insulin doses for various reasons, for example, inaccessibility occasioned by; unavailability and unaffordability of insulin, missed clinics, perceived ill-health and alternative therapies like herbs, prayers and rituals. Infections also occur quite often, but are not overt, like urinary tract, tuberculosis and pneumonia. Due to widespread poverty of individuals and nations alike, the healthcare systems are scarce and the few available centres are unable to adequately maintain a reliable system of insulin supply and exhaustively investigate their hospitalised patients. Consequently, there is little guarantee of successful outcomes. Poor people may also have sub-optimal nutrition, caused or worsened by diabetes, more so, at first presentation to hospital. Intensive insulin therapy in such individuals mimics 're-feeding syndrome', an acute anabolic state whose outcome may be unfavourable during the period of treatment of diabetic ketoacidosis. CONCLUSIONS: Although mortality and morbidity from diabetic ketoacidosis remains high in sub-Saharan Africa, improved healthcare systems and reliable insulin supply can reverse the trend, at least, to a large extent. Individuals and populations need empowerment through education, nutrition and poverty eradication to improve self-care in health and living with diabetes.

Africa South of the Sahara↗
PubMedDate not supplied

[Competition for the promotion of essential generic drugs in Africa].

STATEMENT OF THE PROBLEM: in most sub-Saharan countries, an extensive economic crisis coupled with a low level of existing resources has put most pharmaceuticals beyond the reach of the general public. This situation was worsened by the devaluation of the Franc CFA in 1994. The supply of lowprice drugs and the improvement of rational drug use is now a priority. Unfortunately, essential generic drugs are little known and used in Africa. OBJECTIVE: 1. To improve the knowledge of and confidence in essential and generic drugs among providers, prescribers and consumers, through the participation of the general public in an incentive-based, creative competition; 2. To collect locally-adapted promotional material, to be used in the future promotion of essential and generic drugs in Africa. Design, setting and method: a competition was announced in June 1995, via various networks, in French-speaking Africa: the population was invited to create one or several items promoting essential generic drugs. These items included slogans, posters, songs and short plays. Over 550 entries were received before the deadline (15 October 1995), from 22 countries (mostly Sub-Saharan and French-speaking). The entries included 387 slogans, 94 posters, 22 plays, and various (photos, comic strips, songs, poems). RESULTS: 1. Greater awareness of essential generic drugs in Western Africa, through the publicity given to the competition; 2. Selection of a pool of approximately 200 promotional items, produced by the target populations, to be published in a catalog and distributed in African countries; 3. Insights into popular practices and representations of Western medications, and local re-interpretation of the concept. CONCLUSION: this public competition was effective at achieving three important goals: 1. Dynamic promotion (the competition was the opportunity for school projects, radio talkshows, etc. on generic drugs); 2. Re appropriation of a policy, thanks to a participative approach; 3. Analysis of the population's general comprehension of pharmaceuticals, through analysis of competition entries.

Advertising↗
PubMed1997

Urbanisation and women's health in South Africa.

For many decades the migrant labor system and the influx control legislation in South Africa exacerbated male-dominant patterns of migration typical of Africa. In recent years, however, and especially following the easing of influx control legislation in 1986, migration in South Africa has increasingly involved women. This paper reports on a study conducted in Khayelitsha, Cape Town, which explored the relationship between urbanisation and the health of women. The objectives were to relate age, migration, length of stay in urban areas, employment status, and occupation to the health, including reproductive health, of women living in Khayelitsha. Interviews with 659 women (61 households had no senior woman) revealed that women enjoyed considerable social support through their neighbours, church organisations, and women's organisations. Women who lived in the most deprived section of Khayelitsha enjoyed more support from their neighbours but reported less satisfaction with the area in which they lived. Child-care support was poor and a considerable proportion of the women were disempowered by their male partners. More than 90 percent of the women had access to antenatal care. Recent immigrants had more pregnancies, were less aware of screening for cervical cancer, less likely to have had a Pap smear, less knowledgeable about where to have a Pap smear done, and less likely to have heard AIDS. More women were aware of AIDS (86%) than Pap smears (45%). More than half of those of childbearing age used contraception, mainly intramuscular hormones (76%). A significant proportion (53%) of the women reported that they had had their first pregnancy as teenagers and younger, less educated women were more likely to have had adolescent pregnancies. Policy makers are confronted by a compelling need to redress well-known urban-rural inequalities in health care in South Africa. Policy attention must also be given to the increasing urbanisation of women and the growing health care needs in urban areas.

Adult↗
PubMed1998

Chemoprophylaxis for tuberculosis in HIV-infected individuals in sub-Saharan Africa.

OBJECTIVE: To examine the role of chemoprophylaxis as a public health strategy for the control of tuberculosis in sub-Saharan Africa. DATA SOURCES: Published literature regarding efficacy, cost-effectiveness and operational feasibility of chemoprophylaxis programmes. STUDY SELECTION: Studies mainly published from countries in sub-Saharan Africa and other low income countries. DATA EXTRACTION: Manual search of journals and computer search of data bases. DATA SYNTHESIS: Latent infection with tuberculosis among adults in sub-Saharan Africa is more than 50% and HIV infection in the same age group is more than 10%. TB treatment programmes in the region are overwhelmed by increasing numbers of clinical TB. The efficacy and safety of isoniazid preventing TB among HIV infected individuals has been demonstrated in various studies. Though data on its cost-effectiveness is limited, computer modelling show that chemoprophylaxis for HIV associated tuberculosis is more cost-effective than chemotherapy. A national chemoprophylaxis programme need to achieve three broad objectives: HIV testing and counselling; tuberculin testing and exclusion of active TB; and to achieve high enough compliance rates. These objectives are best achieved by co-operation between National TB and AIDS control programmes. CONCLUSIONS: Because chemoprophylaxis for HIV associated TB makes economic and epidemiological sense, large national programmes should be initiated in sub-Saharan Africa. Operational research is necessary to define the best ways to deliver chemoprophylaxis to the majority of the HIV infected persons and to test the cost-effectiveness of chemoprophylaxis in established national programmes.

AIDS-Related Opportunistic Infections↗
PubMed1999

Anthelmintic resistance in South Africa: surveys indicate an extremely serious situation in sheep and goat farming.

Surveys to determine the prevalence and degree of resistance of Haemonchus spp. of sheep and goats to the available anthelmintics in South Africa indicate that small ruminant production is entering a crisis situation. Three surveys employing the faecal egg count reduction (FECR) test to determine resistance were conducted in some of the main sheep-producing areas in the summer rainfall region of South Africa, where H. contortus is the principal worm species in sheep. After analyzing the data recorded in the surveys by six different methods, including the RESO test at two different levels of confidence, the results obtained in the least stringent one (geometric mean reduction of the worm egg counts of drenched, vs untreated group of sheep) are reported in this paper, so that if any bias was obtained it would be in the favour of the anthelmintic. In Mpumalanga and KwaZulu-Natal there was anthelmintic resistance in Haemonchus spp. on all the 52 farms surveyed. Sixteen percent of the strains of H. contortus were < 60% susceptible to three of the four anthelmintics tested, and 8% of the strains were < 40% susceptible to all four of the anthelmintics. FECR tests of sheep in six localities in the Lebowa district of Northern Province indicated that even in previously disadvantaged communities where anthelmintic treatment is less intensive, anthelmintic resistance is developing, and is possibly at the level at which the situation on commercial sheep and goat farms in South Africa was 25 years ago. From the data it appears that the level of anthelmintic resistance of H. contortus in South Africa is possibly the highest that has so far been recorded in the world and that strains of it are emerging that may soon not be controllable by treatment with any of the existing anthelmintics. Farmers in the summer rainfall region, if not the whole country, must be alerted to the immediate need for testing the parasite burdens of their sheep for susceptibility to preparations in all four groups of anthelmintic compounds currently available. Alternative methods of integrated worm control, including biological, must be sought and implemented with urgency, to reduce further selection for resistance and to induce reversion of the resistance that has already developed.

Albendazole↗
PubMed1999

Opportunities, problems and perspectives for malaria control in sub-Saharan Africa.

Environments conducive to high malaria transmission and widespread poverty are at the roots of the 'malaria giant', which affects 46 countries in Africa. The recent interest in and momentum of work on malaria, in endemic countries and the international community, is unprecedented and opens new perspectives for controlling the disease. Significant steps included: (i) the allocation of US$20 million by WHO for accelerated implementation of malaria control in 34 African countries in 1997-98; (ii) the Declaration on Malaria by the Heads of States of the Organization of African Unity and the establishment of the African Initiative for Malaria Control in 1997; (iii) the concomitant mobilisation of the research community in the Multilateral Initiative on Malaria; (iv) the G8 Summit in 1998 in Birmingham asking for higher commitment to malaria control, particularly in Africa; and (v) the Roll Back Malaria initiative set as a WHO priority project in 1998. However, experiences have proved the alarming 'resilience' of the malaria system in Africa, showing devastating consequences when malaria returns to the original levels after intensive control is interrupted. Effective malaria control in Africa requires long-term action, firmly rooted in the social development of the country.

Africa South of the Sahara↗
PubMed1999

A birthweight nomogram for Africa, as a malaria-control indicator.

Low birthweight (LBW) attributable to malaria in pregnancy is a significant risk for millions in Africa. Infants born to primigravidae are at greatest risk and it is proposed that this excess risk can be used as a simple indicator of malaria transmission and exposure in pregnant women in Africa. Birthweight data from different regions in 11 malarious and three non-malarious African countries were investigated. A regression analysis of the excess risk of low birthweight in first pregnancies, compared with later ones, was completed and interpreted in relation to malaria-transmission intensities. The aim was to develop a simple birthweight chart (nomogram) as a tool for monitoring malaria transmission or malaria control in pregnancy. Low-birthweight risk in first pregnancies was associated with levels of malaria-transmission intensity amongst different African countries. The nomogram distinguished longitudinal changes in malaria exposure, related to season and changes in antimalarial-drug policy. Malaria is one of the most important causes of LBW in first pregnancies in Africa. As birthweight and parity are routinely recorded in many delivery centres across Africa, the nomogram provides a simple, available and inexpensive tool for monitoring malaria transmission and exposure in pregnant women and the effectiveness of malaria-control activities for this high-risk group.

Africa↗
PubMed2000

Air pollution and respiratory health in Africa: a review.

OBJECTIVE: To bring into focus the existence of respiratory hazards due to air pollution as a result of industrialization, tobacco smoking (personal pollution), domestic pollution and vehicular fuel combustion on the African continent; and to stimulate health workers, and the various governments in Africa, to devote more attention to the subject of air pollution by engaging in and encouraging multidisciplinary research so that appropriate and effective control measures can be put in place. DATA SOURCES: Medline literature search through internet using the keywords: air pollution, cigarette smoking, domestic pollution, respiratory morbidity, Africa. The author's contributions to the subject of air pollution and respiratory morbidity are included. STUDY SELECTION: Relevant studies or articles from eastern, western, northern, southern and central parts of Africa are included in the review. DATA EXTRACTION: From individual study or article. DATA SYNTHESIS: Evidence of respiratory hazards sequel to the four main sources of air pollution in each part of Africa, are synchronised under the headings: introduction, respiratory impairment and the future. CONCLUSIONS: Respiratory impairment from the four main sources of air pollution is a major but highly neglected problem on the African continent. There is need for concerted efforts on the part of African governments, health administrators and health workers to ensure that necessary attention is given to multidisciplinary research on the subject so that meaningful control measures can be formulated, thereby ensuring clean air for the people to breathe.

Africa↗
PubMed2000

Stroke therapy clinical guideline. South African Medical Association-- Neurological Association of South Africa Stroke Working Group.

OBJECTIVE: To describe the prevention, management and rehabilitation of stroke in South Africa as provided by a range of caregivers. OPTIONS: Emphasis should predominantly be on finding the cause, preventing, and treating stroke in the transient and mild stroke group. Moderate stroke patients require maximal rehabilitation and secondary prevention. Severe disabling stroke patients require home and community care. OUTCOMES: The most effective use of resources (personnel and facilities) in relation to the different types of stroke. These should be used to decrease stroke incidence, increase stroke awareness, improve acute stroke therapy, and improve access to rehabilitation. EVIDENCE: Based on international reports and research. Meta-analyses were used when the topic warranted such specific literature review. Stroke consensus has been achieved internationally and widely reported. A wide range of South African reviewers from various health fields, including representatives of local and national health groups, were consulted. Evidence-based documents were considered and incorporated. VALUES: As far as possible, cultural and economic preferences were given major emphasis. The aim of the guideline is to optimise stroke care from the point of view of individual patients, health practitioners, reimbursing agencies and society as a whole. Where possible, best-practice stroke care of international standard has been used in this document. However, at no stage has the Working Group deviated from the unique set of South African stroke problems, namely differing risk and preventive factors, multi-cultural, genetic and traditional practices and the problems of cost saving from best-practice funding for stroke care. BENEFITS, HARMS, COSTS: It is difficult to assess the local situation without prospective research. However, stroke causes the following in South Africa: between 8% and 10% of all reported deaths 7.5% of deaths in the workforce (25-64 years of age) age-standardised mortality rate of 125-175/100,000. More can be done to improve the cost-effectiveness of available resources by increasing education of health care professionals and patients. RECOMMENDATIONS: Assess and treat all cerebral vascular events within 6 hours if possible; categorize the stoke into mild, moderate or severe; transient ischaemic attack (TIA), minor or reversible stroke should be intensively investigated to find the cause and this should be treated vigorously; all risk factors should be treated; moderate strokes require active rehabilitation; secondary prevention is required to prevent another stroke; when vegetative symptoms persist after 7 days, therapy should be supportive. VALIDATION: This guideline is similar to others produced in other countries but with reference to South Africa, and has been developed in collaboration with the Neurological Association of South Africa. The initial document was developed in 1997 with a multidisciplinary group with special interest in the management of stroke. In July 1998 a nationally representative stroke consensus meeting was held and the document was widely scrutinised. The guideline is endorsed by the South African Medical Association.

Algorithms↗