SOUTH AFRICA PUBLIC HEALTH SEPTEMBER 23 ISSUE

UNCLAS SECTION 01 OF 05 PRETORIA 003917

SIPDIS

DEPT FOR AF/S; AF/EPS; AF/EPS/SDRIANO
DEPT FOR S/OFFICE OF GLOBAL AIDS COORDINATOR
STATE PLEASE PASS TO USAID FOR GLOBAL BUREAU KHILL
USAID ALSO FOR GH/OHA/CCARRINO AND RROGERS, AFR/SD/DOTT
ALSO FOR AA/EGAT SIMMONS, AA/DCHA WINTER
HHS FOR THE OFFICE OF THE SECRETARY/WSTEIGER, NIH/HFRANCIS
CDC FOR SBLOUNT AND DBIRX
STATE FOR AID

E.O. 12958: N/A
TAGS: ECON KHIV SOCI TBIO EAID SF
SUBJECT: SOUTH AFRICA PUBLIC HEALTH SEPTEMBER 23 ISSUE

Summary
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1. Summary. Every two weeks, USEmbassy Pretoria publishes a
public health newsletter highlighting South African health
issues based on press reports and studies of South African
researchers. Comments and analysis do not necessarily reflect
the opinion of the U.S. Government. Topics of this week's
newsletter cover: Delmas Still Suffering with Typhoid;
University Helps Search for Typhoid Source; Report Shows Few
Towns Test Water; Durban Tries to Substitute Chocolate for
Glue; Khayelitsha Trials Set to Continue; South Africa Health
Review Highlights Health Statistics; Staff Shortage Constraint
on ARV Plan; Common Vaginal Infection may Double HIV Infection
Risk; and HIV Disproportionately Affects Young Women in South
Africa. End Summary.

Delmas Still Suffering with Typhoid
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2. In Delmas, Mpumalanga, poor planning by local government
authorities has been cited as a reason for the recent typhoid
outbreak. By September 14, two Delmas residents had died, more
than 400 had symptoms of typhoid and health facilities were
treating at least 400 cases of diarrhea a day. The figures are
expected to rise in the next three to six weeks because of the
incubation period of the disease. Minister of Health Manto
Tshabalala-Msimang has blamed the typhoid outbreak in Delmas on

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local authorities, and Democratic Alliance MP Dan Maluleke says
evidence points to poor planning on the municipality's part.
The outbreak has occurred in the middle of a massive transfer
program of water services schemes to municipalities by the
national Department of Water Affairs and Forestry. Minister
Buyelwa Sonjica told the National Council of Provinces (NCOP)
earlier this year that she expected all water services to be in
the hands of municipal authorities by March 2006. Helgard
Muller, Executive Manager of water services in the Water
Affairs and Forestry Department, cited poor management of
sewage works spilling into underground water as well as
inadequate disinfection of water supplies as reasons for the
outbreak. Overloading of the sewage system and the bucket
system used by Botleng township residents have also been
blamed. An estimated 16 million people in South Africa still
live without basic sanitation and 231,000 households across the
country use the bucket system. At least 800,000 household
sanitation units have to be introduced every year in order to
reach the government target of wiping out the backlog by 2010.
Meanwhile, residents of Delmas are demanding to know why this
is the second typhoid outbreak they have experienced in the
past 12 years. The last typhoid outbreak was caused by the
overloaded sewage system seeping into the ground water that
people are using. Residents of Delmas protested about the lack
of municipal oversight and handed a protest memorandum to
Mpumalanga premier Thabang Makwetla outlining their concerns.
Source: IOL, The Star, Mail and Guardian, September 16.

University Helps Search for Typhoid Source
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3. A team from Free State University will use a method similar
to that of forensic police to establish whether water in Delmas
has the bacteria that causes typhoid. Polimerase chain
reaction technology will pick up traces of Salmonella Typhi's
DNA even if the bacteria is no longer present in the water, and
results should be available by September 26. If there was no
evidence of the bacteria, typhoid would most likely have come
to Delmas through another route, probably related to personal
hygiene. Previous sampling by the University of Port
Elizabeth's virology institute showed that water in Delmas had
been responsible for typhoid and diarrhea in the minority of
cases. There were multiple routes the infection could take and
that these could vary from household to household. Salmonella
Typhi only lives in humans. Persons with typhoid fever carry
the bacteria in their bloodstream and intestinal tract.
Source: SAPA, IOL, September 20.

Report Shows Few Towns Test Water
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4. According to an unpublished report commissioned by the
Water Affairs and Forestry Department, half of the local water-
service authorities in Mpumalanga believe they comply with
government standards for drinking-water quality, but only a
quarter of them actually monitor it. Water-service authorities
are responsible for providing safe drinking water to the
country. The water-service authorities' survey suggests the
lack of monitoring of drinking water is not confined to
Mpumalanga, and many more people may be at risk of waterborne
diseases. Officials have not ruled out contaminated water as
the cause of the deadly typhoid outbreak that has rocked Delmas
in Mpumalanga Province, claiming at least four lives. Many
other towns are struggling to maintain safe water supplies.
Earlier the town of Chrissiesmeer in Mpumalanga Province cut
off drinking water to 8000 inhabitants following the discovery
of e.coli bacteria, which cause diarrhea, in one of the town's
reservoirs. Delmas reported in the survey that it considered
its water to be up to standard, and said it regularly monitored
and tested the quality of its drinking water with the
assistance of an accredited laboratory. But this was not
independently assessed by external auditors. The survey was
alluded to by Water Affairs Minister Buyelwa Sonjica during her
budget speech in May, when she said that 63 percent of
municipalities could not confirm that they met guidelines for
drinking-water quality, but at the time neither she nor her
officials provided further details. The survey, based on the
self- assessed performance of South Africa's 170 water-service
authorities, found 61 percent of them perceived their drinking
water to be of "good" or "ideal" standard, yet only 58 percent
regularly monitored it. Only half met the South African Bureau
of Standards quality guidelines for drinking water.


5. The provinces with the worst drinking water were Eastern
Cape, KwaZulu-Natal, Limpopo, Mpumalanga, Northern Cape and
North West, which all performed below the national average,
according to the survey. In the Eastern Cape, six out of 17
authorities said they monitored the quality of drinking water.
By contrast, in the Free State, 20 out of 21 said they
regularly tested drinking water. The problems were largely
confined to rural areas, with Ekhurhuleni (east Johannesburg)
the only metropolitan area failing to regularly test water.
The report cites insufficient monitoring and evaluation
systems, a lack of effective water treatment and a poor
management culture, as weaknesses in the water delivery
program. Source: Business Day, September 22.

Durban Tries to Substitute Chocolate for Glue
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6. Durban's street children are being weaned off glue by
chocolate although the eThekwini Municipality may run out of it
soon. Religious and other groups are being urged to donate
chocolate to increase supplies. There is a substance in
chocolate which substantially reduces the craving for glue and
street children are giving glue bottles in exchange for
chocolate. A bottle of glue costs R5 and is usually shared
among friends. The effect of glue sniffing lasts about six
minutes and the urge to have more becomes very overpowering
within a short space of time. Source: IOL, Daily News,
September 19.

Khayelitsha Trials Set to Continue
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7. Top government health officials seem poised to let the Dr
Rath Health Foundation continue clinical trials on people with
HIV in Khayelitsha. Health director general Thami Mseleku
stated that a preliminary report submitted to his office by the
Health Department's Law Enforcement Directorate had not found
anything wrong with what is happening in Khayelitsha. Mseleku
said it was now up to the Medicines Control Council (MCC),
which he said was an independent body, to investigate the
matter further. However, the Health Department's Director of
Nutrition, Lynne Moeng, criticized the inadequate labeling on
Vita Cell, one of the Rath Foundation products, as well as the
high dosages being prescribed. Moeng said taking high doses of
vitamins would among others cause nausea and vomiting and
impair liver function. Moeng said that there were regulations
stipulating that a high dose vitamin should be registered with
the MCC, however, a complementary product does not have to get
MCC approval. The Treatment Action Campaign (TAC) is preparing
a legal action against the Health Minister and MCC after both
failed to act against Rath and his foundation. TAC
spokesperson Nathan Geffen says no response has been received
two weeks after their stated deadline. MCC registrar Dr
Humphrey Zokufa declined to comment on the MCC's investigation
into the Rath Foundation's activities, claiming that the Health
Department Law Enforcement Directorate's investigation was not
yet complete. Source: Health e-News, September 15.

South Africa Health Review Highlights Health Statistics
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8. The latest South Africa Health Review highlights health
figures by province, showing significant health staffing and
spending differences. The North West province has the least
doctors and professional nurses per capita in the country, with
21 doctors and 90 nurses for every 100,000 people and spends
the least on health, R771 per person. The Western Cape almost
doubles this amount at R1383 per person. There are not enough
medical specialists in Mpumalanga, having a total of 15
specialists, or one for every 200, 000 people),while there are
serious shortages in Limpopo and North West. KwaZulu-Natal has
the least dentists per capita in the country, followed by the
Eastern Cape and Limpopo. There are only seven psychologists,
15 physiotherapists and 35 pharmacists in the whole of the
Northern Cape. Nurses in the province also have one of the
heaviest workloads, seeing an average of 47 patients a day.
Over the past few years, nurses' workloads have steadily
increased from 23.5 patients a day to 29.4, undoubtedly because
there are now 109 professional nurses per 100,000 people
whereas five years ago, there were 120. But there has been an
improvement in vacancies. Whereas in 2003, 31 percent of posts
were vacant, this year the number has dropped to 27 percent.
Almost 40 million of the country's 46.8 million people depend
on the public health sector. In 2004, there were 100,000
hospital beds available, a decrease of 7,000 since 1998. While
malaria cases have dropped by two-thirds over the past four
years, measles cases have tripled over the same period,
indicating that not enough children are being immunized against
the disease. TB cases have jumped from 349 per 100,000 people
in 2000 to 550 in 2003, with the worst affected provinces being
the Northern Cape, Western Cape and KwaZulu-Natal. Almost 30
percent of pregnant women are testing HIV positive in antenatal
clinics, with 38.5 percent of women aged 25 to 29 testing
positive. KZN has the highest rate by far (40.7 percent),
followed by Gauteng and Mpumalanga. It is estimated that 16
percent of South Africa's total population is infected with
HIV. Source: Health e-News, September 14.

Staff Shortage Constraint on ARV Plan
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9. According to the South Africa Health Review, the ARV
treatment plan is drawing health staff away from other
services, while at the same time needs more staff to expand.
Over the next five years, government's HIV/AIDS care, support
and treatment plan will need about 13,800 more staff if it is
to be implemented properly. Approximately 3,200 doctors, 2,400
nurses, 765 social workers, 765 dieticians, 112 pharmacists and
2,000 data workers will be needed by 2009 to implement the full
roll out of the antiretroviral component of the plan. By
April, over 1,000 health professionals had been recruited and
more than 7 600 trained. An estimated 100,000 people are now
getting ARV treatment at government sites, although accurate
figures are hard to come by as the national monitoring system
is not yet operating. Both the Western Cape and Gauteng have
exceeded their patient enrolment targets, while KwaZulu-Natal
has the most ARV sites. Source: Health e-News, September 14.

Common Vaginal Infection may Double HIV Infection Risk
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10. Researchers at the University of Cape Town found that
bacterial vaginosis (BV),the most common vaginal infection in
women of childbearing age, may double a woman's susceptibility
to HIV infection, according to the results of a South African
study published in the October 15th edition of The Journal of
Infectious Diseases. Bacterial vaginosis (BV) is a condition
in women where the normal balance of bacteria in the vagina is
disrupted, resulting in a change from an acidic to an alkaline
environment. Although it is sometimes accompanied by symptoms
such as discharge, odor, pain, itching, or burning, it is often
asymptomatic. Although no pathogen has been isolated as the
cause, it is considered to be a sexually transmitted infection
(STI),and, since it affects between 20 - 25 percent of the
general population, and up to 50 percent of women attending
sexual health clinics, it is the most common STI worldwide.
Several - but not all - epidemiological and prospective studies
have found an association between BV and HIV infection. In
addition, in vitro studies suggest that BV has the potential to
increase susceptibility to HIV infection, possibly through
increased production of interleukin (IL)-10 and/or increased
secretion of tumour necrosis factor-alpha (TNF-) and IL-1a.

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11. Investigators, at the University of Cape Town, conducted a
case-control study, nested within a randomized controlled trial
evaluating cervical cancer screening in Khayelitsha, near Cape
Town. Of the 5,110 women who were HIV-negative at enrollment
(between June 2000 and December 2002),the investigators
selected all women who had seroconverted by December 2003 for
this study. The majority of seroconversions (64 percent) were
identified at the 6-month follow-up visit, although the
investigators report that risk of seroconversion remained
constant throughout the 36-month follow-up period. A further
324 age-matched women were selected at random from the cohort
as controls.
Women who seroconverted were significantly more likely to be
unmarried, to report having had more than one sex partner in
the month before enrolment, and to report having a new sex
partner at the 6-month follow-up visit. In multivariate
analysis, after adjusting for demographic characteristics,
other STIs and sexual behaviors, women with BV were
significantly more likely to seroconvert than women with normal
vaginal flora.


12. The investigators point out several limitations to their
study, including the fact that BV was assessed only once and
HIV seroconversions were identified over three years. During
this time, vaginal flora may have changed, and a baseline BV
assessment may not accurately reflect presence of BV at the
time of seroconversion. The investigators also did not assess
the presence of ulcerative STIs, including herpes simplex virus
2 (HSV-2),which have been found to increase HIV acquisition
risk. It is also possible that other unknown confounding
measures may have inflated the association between BV and HIV
acquisition. Source: AIDSMAP, September 16.

HIV Disproportionately Affects Young Women in South Africa
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13. Fifteen percent of young South African women, aged between
15 and 24 are HIV-positive, compared to only 5 percent of South
African males in the same age group, according to a study
published in the September 23rd edition of AIDS. The
investigators found that older sexual partners, sexually
transmitted infections and inconsistent condom use were amongst
the risk factors for HIV infection, but they also found that
young people who had participated in South Africa's loveLife
HIV prevention activities were less likely to be HIV-infected.
In 2003 investigators conducted a nationally representative
survey of young South Africans and collected data on HIV
prevalence, HIV-risk factors, and knowledge of and
participation in national HIV prevention campaigns. Almost
12,000 young people from across South Africa were interviewed
for the study and had a voluntary HIV test. The majority of
individuals participating in the study were black (82 percent).
Just under half (47 percent) of the total study population were
living in townships or in informal rural settlements, a quarter
reported living in households without electricity and only 38
percent of 20 - 24-year-olds had completed high school
education. HIV prevalence was 16 percent in young females
compared to 5 percent in young males. HIV prevalence increased
with age. Whereas only 4 percent of 15 and 16-year-old females
were HIV-infected, by the age of 21 this had increased to 31
percent. A similar pattern was present among young males, with
HIV prevalence being between 2- 3 percent amongst 15- and 16-
year- olds, increasing to 12 percent in 21-24-year-olds.


14. Of the individuals who reported ever having sex, a quarter
of men and 45 percent of women reported having more than one
sexual partner. Inconsistent condom use was reported by 61
percent of sexually active men and 71 percent of sexually
active women. Circumcision was reported by a third of men.
Males reported that their sexual partners were an average of
one year older than them whereas females reported that their
sexual partners were on average four years older. There was a
high level of knowledge about national HIV prevention
campaigns, with 85 percent reporting having heard of the
loveLife campaign and 25 percent of women and 15 percent of men
reported ever having had an HIV test.

15. The investigators emphasized the gender inequality of HIV,
with young South African females being many times more likely
to be HIV-infected than young males. The study found that 15-
to 19-year-old females in their study had sexual partners an
average of one to four years older. The researchers noted
study limitations, in particular the self-report of sexual risk
activities, commenting that 3 percent of men and 4 percent
women who reported never having had sex tested HIV-positive.
Source: Aidsmap, September 16.

TEITELBAUM