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Death, Denial And Fear: What Listeriosis Cost South Africa

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December 25, 2017, was the worst Christmas for the Warmback family.

The festivities began two days before with the arrival of Keith and Glenda Warmback’s children from the US. There was food and celebration as the couple saw their one-year-old granddaughter for the first time.

“That evening, we went out and my wife had a chicken salad [from one of the fast food restaurants]. The following day my wife Glenda started having a tummy ache. She went to lie down for a while. She fell asleep and I woke her up around 5PM and she said she couldn’t get out of bed because she wasn’t feeling well and had a running tummy,” says Keith.

Keith says he was woken up by barking dogs, in their room where Glenda was asleep, at about midnight.

“I went to see what was going on and I found Glenda on the floor. She said she thought she had a stroke,” he recalls.

He bundled her up and rushed her to the nearest private hospital.

“The staff was disastrous… They were disinterested in my wife’s condition and three others who were there with similar symptoms,” says Keith.

According to Keith, it was just the beginning of a series of mistakes. Eventually, Glenda’s lungs collapsed and she died at 2AM on Christmas day. She was 61 years old; they had been married for 41 of those.

“The painful thing is the incompetence at the hospital,” says Keith.

Keith Warmback lost his wife Glenda to Listeriosis on the Christmas day of 2017. Photo by Motlabana Monnakgotla.

Doctors sited natural causes as a cause of death. The problem is, just 20 days before, the health minister had announced a foodborne outbreak called listeriosis. According to Keith, Glenda had all the symptoms and blood tests indicated she had it but she was never treated for it.

READ MORE: The Rat Race Against The silent Killer

At the time of going to press, Glenda was one of 183 South Africans who had died from this disease since January 2017; 978 had been infected. It is the world’s worst outbreak of listeriosis, according to the World Health Organization (WHO).

“Listeriosis is the name of a disease that people develop when they eat food that is contaminated with the bacterium called listeria,” says Dr Juno Thomas, head of the Centre for Enteric Diseases at the National Institute for Communicable Diseases (NICD).

According to Thomas, this bacterium is found worldwide. It can be in soil, water and even faeces in many animals.

“Once in the environment, it is very difficult to get rid of because it attaches to things very easily. Once it attaches itself in an environment, it produces a layer of a sticky sugary slime that sticks onto the surfaces and makes it difficult to remove and resistant to disinfectants,” says Thomas.

According to Health Minister Aaron Motsoaledi, South African hospitals saw and treated an average of 60 to 80 patients affected by listeria between 2013 and 2016 with no problems.

Then, in July last year, doctors started seeing more cases of newborn babies born with listeria.

Keith looks at an image of his wife (right), Glenda Warmback. Photo by Motlabana Monnakgotla.

It was a cause for concern. They informed the NICD. A search, led by Thomas, began. On November 29, they found that at the time, 557 people had been infected.

“A team from the NIDC interviewed 109 patients to obtain details about foods they had eaten in the month before falling ill. Eighty five percent of the people reported eating ready-to-eat (RTE) processed meat products, of which polony was the most common, followed by viennas/sausages and then other ‘cold meats’,” says Motsoaledi.

Sixty percent of cases were reported in Gauteng, 13% in the Western Cape and 7% in KwaZulu-Natal.

“We think it affected Gauteng the most because of consumer behavior. Things like sausages, polony and viennas are staple street and household foods in Gauteng because they are affordable and quick to prepare. The economy of Gauteng also plays a factor. There are many more people who can afford to buy these items than other provinces,” says Thomas.

Even armed with this information, the source of the outbreak remained unknown.

Symptoms of Listeriosis:

  • Fever
  • Diarrhoea
  • Vomiting

“When you have an outbreak like this you have no idea where it comes from. We also had not seen many cases of listeriosis in the country, meaning it wasn’t a big health priority compared to all the other issues we have to deal with. For example, we saw 30,000 cases of malaria last year, rabies is a big concern, TB and many others were more severe,” says Thomas.

With hard work and vigilance, the outbreak was traced from Soweto.

Nine crèche kids under the age of five got ill and were admitted to the Chris Hani Baragwanath Hospital. Tests revealed that they had been infected. A team went to the crèche the very day and found kids had eaten polony manufactured by Enterprise Foods, owned by Tiger Brands.

“We then visited the Enterprise Foods factory in Polokwane that makes this brand. We took over 28 samples and they tested positive for the outbreak strain. The conclusion from this is that the source of the present outbreak can be confirmed to be the Enterprise Food production facility in Polokwane,” she says.

On Sunday March 4, Motsoaledi ordered a safety recall of all products from Tiger Brands.

READ MORE: A Deadly $75-Billion Business

After Motsoaledi’s announcement, Tiger Brands shares fell more than 10% when the market opened on Monday.

“It is devastating for me that our business is linked to this outbreak… we detected low levels of listeria in our products on the 14th of February. We took immediate precautionary measures which included immediately halting production of the affected product, quarantining all affected product within our distribution center and withdrawing all affected products manufactured on that day,” says Tiger Brand CEO Lawrence MacDougall at a press briefing the next day.

MacDougall, however, controversially denied any responsibility for the deaths.

“There is no direct link with the deaths to our products that we are aware of at this point. Nothing… All of our tests and results indicate that we kept a very high standard of quality protocols within those sites. The expectations going forward is that those standards are significantly increased if there is going to be a zero detection of listeria going forward,” he says.

Motsoaledi argues that there is proof the ST6 strain was found at their facilities.

“The fact remains that we have had an outbreak of listeria, we informed them [Tiger Brands], in terms of fair administrative justice, that we got the results and we were going public with them. I don’t think they did enough to make sure their produce is safe for consumption by the public. I believe the best way is for this to be a civil case rather than a government case,” says Motsoaledi.

Renowned corruption buster and private forensic investigator Paul O’Sullivan agrees. He is filing criminal charges against the board of Tiger Brands and has called upon them to step aside pending the outcome of the investigations.

O’Sullivan has teamed up with human rights lawyer Richard Spoor to bring charges.

“What is particularly shocking is that Tiger Brands, in its most recent annual report, placed product quality as number nine on the list of risks facing the company, when it should have been be at number one. We cannot think of a greater risk to the sustainability of any food company, than that of killing off your customers through recklessness or gross negligence. We are 100% certain that it will rank top of the list in next year’s annual report.”

What O’Sullivan finds completely unacceptable is that Tiger Brands is still in denial.

“On the one hand they close and deep-clean all the affected facilities, on the other hand they deny culpability and say they will meet each civil claim on its own merits, thereby indicating they will make it a long-haul for the litigants,” he says.

Gareth Lloyd-Jones, Chief Commercial Officer at hygiene and sanitation service provider Ecowize, however says government is to blame. He argues there should be a surveillance system that protects consumers.

“This type of rigorous investigation has been going on for the past couple of months, which is admirable, relevant and necessary and should have been part of a more robust routine surveillance and monitoring process in terms of food safety and legislation requirements,” he says.

According to retail analyst Syd Vianello, this can tarnish a brand that has spent decades trying to live up to high standards.

“How long is it going to take [Enterprise Foods] to convince consumers that the Enterprise brand is good for purchase again? We are talking about the value of the brand and the protection of the brand equity, insurance won’t even cover you for those kinds of losses. These can carry on for a very long time,” he says.

There is also a rub-off effect.

Ronald Dube, a manager at a supermarket in Johannesburg, says people have been returning all cold meats regardless of brand.

“People are afraid and have been returning all sorts of meat. We have also noted that sales of processed foods have gone down, no matter the brand,” he says.

Many people have also thrown away their cold meats but, according to Dr Johan Schoonraad, waste expert and group tactical specialist at EnviroServ Waste Management, there are only two options for disposing of listeria infected food waste – incineration or treatment and landfill disposal.

“The scale of the problem is too big for the incineration industry to deal with in any sort of reasonable timeframe, which leaves waste management companies with the option to do treatment and disposal to landfill,” he says.

Schoonraad says treatment can take many routes. You could sterilize the food waste, heating it and ensuring the material internally gets to 100 degrees which would kill the bacteria.

“If this was done, we could then landfill it without further treatment being required before disposal,” he says.

The other option is to chemically treat it prior to disposal.

According to Schoonraad, the problem is municipal landfills often have poor access control. The risk here, he says, is that the informal sector could enter and scavenge food material, which is then sold or eaten and could spread the disease.

“However, licensed hazardous waste sites have strict access control with no scavenging allowed at these facilities,” he says.

Nevertheless, South Africa remains in fear of this deadly disease.

Who is mostly at risk:

  • Pregnant women
  • Neonates (first 28 days of life)
  • Very young infants
  • Elderly persons >65 years of age
  • Anyone with a weakened immune system (due to HIV infection, cancer, diabetes, kidney disease, liver disease, people with transplants and those on immunosuppressive therapy such as oral corticosteroids, chemotherapy, or antiTNF therapy for auto-immune disease)

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Why Anti-vaccine Beliefs And Ideas Spread So Fast On The Internet

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There’s been a recent increase globally in outbreaks of vaccine-preventable diseases. This can be seen in recent measles outbreaks in parts of the world where it was thought to have been eradicated.

This has prompted the World Health Organisation to list “vaccine hesitancy” (the reluctance or refusal to vaccinate despite the availability of vaccines) as one of 10 global health threats in 2019.

While there are many complex reasons why people choose not to vaccinate, changes in the way that information is accessed may provide one explanation for the rise in vaccine hesitancy.

We are involved in projects at the South African Research Chair in Science Communication at Stellenbosch University which explores vaccine communication. In a world where people are increasingly encountering science information online, particularly on social media, it’s important to understand why people are vulnerable to anti-vaccination messages and why this kind of information spreads so easily.

Effective communication strategies will be crucial if scientists want to counter the worrying trend of increases in vaccine hesitancy.

New media change the way people process science

In recently completed research, author Francois shed some light on how the anti-vaccination movement uses social media to amplify doubt and fuel hesitancy. The research found that “anti-vaxxers” select and share scientific information from open access journal articles on social media to escalate uncertainty in the broader population.

Anybody, including activists with specific agendas, can produce and share information online. This is heightened on social media, where people are connected in real time on a global scale.

Most online media don’t benefit from the quality control of journalists and editors that shapes the content of traditional mass media. Consequently, content is generated by experts and quacks alike, and opinion and facts become blurred. This makes it hard to judge if information is credible or not.

To complicate matters, people are able to create virtual communities of like-minded individuals who seek out information sources that they feel comfortable with. So people get more information they already agree with and few (if any) alternative views in online “echo chambers”. This results in anti- and pro-vaccine messages being shared and replicated in isolated groups, which polarises the contesting views even further.

So how can false information about vaccines shared on social media be countered? Scientists may think that sharing peer-reviewed, factual evidence about the safety of vaccines could change people’s views. Sadly, this is not the case.

Facts alone are not enough

One-way, top-down communication simply does not work. This is especially true when communicating about a controversial topic rooted in science.

That’s because a lack of information is not the problem. The issue is the way people process that information. Sometimes, people simply “refuse to know” what scientists are trying to tell them. This is what may cause vaccine opponents to reject years of research proving that vaccines don’t increase the risk of autism, even in vulnerable children.

Facts may even backfire. Research shows that bombarding vaccine-hesitant parents with evidence about the safety of vaccines may make them more vaccine-resistant. These studies confirm that it’s particularly difficult to dislodge incorrect information from someone’s memory. And it’s possibly even harder to change a person’s mind if they hold strong beliefs about a contested issue.

People’s views about contested issues in science are polarised by “cognitive bias” and “motivated reasoning” that result from their personal beliefs and values. If they are inclined to like new scientific information, they will view it more positively. But if new information dispels preexisting views, they won’t be receptive.

The so-called “negativity effect” also comes into play. People are more likely to share stories and images about harm and tragedy, than neutral or positive content. This explains why messages about the alleged dangers of vaccines, often accompanied by emotive images of sick children, are amplified more powerfully via social media compared with pro-vaccine messages.

New research

To address these issues, two new research projects are underway at the South African Research Chair in Science Communication at Stellenbosch University.

The first focuses on two public pages on Facebook that are specifically aimed at South African audiences. One is opposed to vaccines; the other is in favour.

The objective is to understand the nature and origins of anti- and pro-vaccination claims and images, as well as to explore the evidence provided in support of these claims. It’s hoped that a better understanding of claims made by these opposing groups via social media may provide a starting point for constructive dialogue between these groups.

A second study will examine how scientific information about vaccines and other contested issues is fed into online social networks by ideologically-motivated social movements to advance their cause. A better understanding of how scientific information flows from the formal science communication system to online communication networks will provide important insights about how to protect scientific information from strategic abuse.

Marina Joubert; Science Communication Researcher, Stellenbosch University

-Francois van Schalkwyk; Research Fellow, Centre for Research on Evaluation, Science and Technology (CREST), Stellenbosch University

-The Conversation

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Millennial Burnout: Building Resilience Is No Answer – We Need To Overhaul How We Work

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In a popular BuzzFeed article, Anne Helen Petersen describes how millennials (people born between 1981 and 1996) became “the burnout generation”. She describes some of the stark consequences of edging towards burnout and identifies what she calls “errand paralysis”, marked by a struggle to do even simple or mundane tasks.

Many of the factors contributing to this burnout are rooted in the challenging job and economic conditions that millennials face, according to Petersen. She also describes “intensive parenting” as a contributing factor, because millennials have been relentlessly trained and prepared for the workplace by their parents. They have internalised the idea that they need to be working all the time or engaging in the never-ending pursuit of self-optimisation.

READ MORE | Burnout, stress lead more companies to try a four-day work week

Similarity to work burnout

Millennial burnout has a lot of similarities with regular burnout, otherwise known as work burnout. Burnout is a response to prolonged stress and typically involves emotional exhaustion, cynicism or detachment, and feeling ineffective. The six main risk factors for work burnout are having an overwhelming workload, limited control, unrewarding work, unfair work, work that conflicts with values and a lack of community in the workplace.

People who have to navigate complex, contradictory and sometimes hostile environments are vulnerable to burnout. If millennials are found to be suffering higher levels of burnout, this might indicate that they face more problematic environments. It is quite possibly the same stuff that stresses everyone, but it is occurring in new, unexpected or greater ways for millennials, and we haven’t been paying attention.

For example, we know that traditional social comparison plays a role in work burnout. For millennials, social competition and comparison are continually reinforced online, and engaging with this has already been shown to be associated with depressive symptoms in young people.

READ MORE | 10 Rules Of Email That Will Reduce Your Stress Levels

Even if you avoid social media, using technology and going online can be physically and emotionally exhausting. Excessive internet use has been linked to burnout at school. These are just some of the ways that millennials have been increasingly exposed to the same stressors that we know can negatively affect people in the workplace.

We know very little about how millennials experience burnout. Early research suggests there are generational differences. Specifically, millennials respond to emotional exhaustion (often the first stage of burnout) differently to baby boomers (people born between 1946 and 1964). When feeling emotionally exhausted, millennials are more likely to feel dissatisfied and want to leave their job than baby boomers.

Burnout research shows that complex environments and stressors, coupled with high expectations, create the conditions for traditional work burnout. The same can be said for the millennial burnout, which draws on similar notions of perfectionism.

Perfectionists, especially the self-critical ones, are at greater risk of burnout. Naturally, the self-critical type of perfectionist works hard to avoid failure, thereby putting themselves at high risk of burnout.

Resilience as protection

A recent approach to tackling work burnout is to train people to be more resilient. This is underpinned by the assumption that highly competent people can improve their working practices to avoid burnout. However, as I recently argued in an editorial in the BMJ, highly competent, psychologically healthy and seemingly resilient people are likely to face an increased risk of burnout.

It seems counterintuitive, but one of the earliest studies on workplace burnout showed that workers who were happier, less anxious and more able to relieve stress were more likely to develop burnout than those in a comparison group without these traits.

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This largely forgotten study involved air traffic controllers in the US in the 1970s; it followed over 400 of them for three years. Most of the cohort (99%) had served in the US Armed Forces, so we can expect that they had experience of extreme stress and most likely had developed resilience.

This study shows us some of the conditions for creating burnout in this seemingly high functioning and resilient group. Their work was continually becoming more complex, with new technologies being introduced, without the necessary training to use them. They worked long shifts without breaks and had poor environments to work in. Their hours and rotas were challenging and could be unpredictable. These characteristics probably look quite familiar to millennials and anyone working in the gig economy.

Opposite effect

The recent focus on training workers to avoid burnout by encouraging them to be more resilient is likely to become another stress, pressure or high ideal. It is likely that this serves to increase the risk for burnout, especially for the types of perfectionists who are highly self-critical.

The importance of our ideals, our view of what we are and should be, also shows us why labelling millennials as “snowflakes” is probably harmful. Similarly, any intensive parenting that attempts to create resilient children may be counterproductive. This is because the core messages of intensive parenting are actually about social control and conformity, and these probably feed into children’s internal and external ideals for the future.

What we can learn from burnout trends is that work is becoming rapidly and overwhelmingly more difficult and complex. This is driving higher burnout levels in many professions and in informal workers, such as caregivers, and also, potentially, in millennials. The solution is to simplify complex, contradictory and hostile work and personal environments, rather than giving us all another job of training ourselves to be more resilient to these environments.

-Rajvinder Samra; Lecturer in Health, The Open University

The Conversation

The Conversation

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Kenyan Hospital Opens Human Milk Bank – A Rarity In Sub-Saharan Africa

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Kenya’s first human milk bank has opened at Pumwani Maternity Hospital. Moina Spooner, from The Conversation Africa, spoke to the team spearheading APHRC’s research efforts in the establishment of Kenya’s first milk bank.

How long has it taken to open? What were the biggest obstacles?

The process of establishment of human milk banking in Kenya started in 2016. It was spearheaded by the NGO PATH, in partnership with APHRC and Kenya’s Ministry of Health, among other partners. It was rolled out in two phases.

During phase one we assessed people’s perceptions and acceptability of using donated human milk. We also looked at how feasible it would be to set a bank up. The results were encouraging. About 90% of participants were positive about it, 80% would donate their breast milk, and about 60% indicated that they would allow their children to be fed with donated human milk.

A committee was also set-up to provide oversight and guidance on human milk bank work in Kenya. They were sent to South Africa to learn more about the human milk banking process. Finally, local strategies were developed.

READ MORE | Johnson & Johnson Moves to Limit Impact of Report on Asbestos in Baby Powder

We are now in phase two of the project: the establishment of a pilot human milk bank in Pumwani Maternity Hospital. This includes the launch of a research project which examines its feasibility, effectiveness, acceptability and aims to estimate the cost of establishing an actual human milk bank in Kenya.

There have been challenges. Being a new concept, there have been some logistical challenges, for instance some of the equipment wasn’t locally available so it took longer to get it all done and installed.

There have also been concerns by some community members and health workers over the safety and quality of the donor human milk.

However, we’ve had support from the government which has been critical in addressing the logistical challenges. Advocacy and communication activities are also being rolled out to create awareness on human milk banking and address any concerns.

What is a milk bank and how does it work?

Human milk banks are facilities that systematically collect, pasteurise, test, store, and distribute donated breast milk.

An effective system has many operational processes to ensure it provides safe, high quality donor milk. They start with screening and recruiting donors who must be healthy mothers with surplus milk beyond the needs of their own child’s. Donors must undergo health checks including tests that screen for HIV, syphilis, and hepatitis B and C. Diseases could be passed to children through breastmilk.

READ MORE | Kenyan Approach Holds Promise for Boosting Early Childhood Education

Donors must then express milk in hygienic conditions, after which the milk is pasteurised. This involves heating the milk in a water bath at 62.5°c for 30 minutes followed by rapid cooling.

At the bank, the milk is frozen and stored at -20c. When needed, it’s thawed to room temperature and issued to children who don’t have access to their own mothers’ milk. A prescription by a qualified health professional is needed for this.

Why are they needed?

Although breastfeeding is the most natural and best way to feed infants, many babies may lack access to their mother’s milk. This could’ve happened for many reasons – maybe the mother is sick, hasn’t got enough breast milk or is dead.

From our formative research, 44% of newborns in urban health facilities were separated from their mothers for varying periods of time. This ranged from less than an hour to more than 6 hours and even days after birth. Of these infants, only 14% were fed on mother’s own milk during separation. 36% of the newborns weren’t fed on anything during this period and an additional 23% were fed on formula or cow’s milk.

When breastfeeding is not an option, the World Health Organisation (WHO) recommends donated human milk as a lifesaving alternative. Particularly for babies that were born early, have low birth weight, are orphaned, malnourished or are severely ill.

Evidence paints a very strong picture in favour of donated human milk over infant formula. It’s more effective in reducing the risk of disease and infections – like inflammatory bowel disease, leukemia and respiratory tract infections – in newborn babies and is better tolerated by babies that are born prematurely.

In the US and Brazil, the use of donated human milk was reported to reduce the length of hospital stay for sick infants and save on the cost of health care.

Given the benefits of using donated human milk over infant formula, the WHO has called for the global scale-up of human milk banks. These are expected to increase access to safe donor human milk.

Is this the first of many?

Although WHO recommends that the milk banks be set up, Kenya is just the second, after South Africa, to establish a human milk bank in sub-Saharan Africa – even though it is a pilot.

We hope that human milk banking will be scaled up in Kenya and the rest of sub-Saharan Africa, using the evidence we generate from our research.

-The Conversation

-Elizabeth Kimani-Murage; Research Scientist at the African Population and Health Research Center and Adjunct Assistant Professor, Brown University

-Milka Wanjohi, Taddese Zerfu, Esther Anono and Eva Kamande from the African Population and Health Research Center contributed to the writing of this article.

The Conversation

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