Durrheim, David N. (2002) Operational research for enhanced control of communicable diseases of humans in Mpumalanga Province, South Africa. PhD thesis, James Cook University.

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Abstract

The operational research model was utilised to enhance communicable disease policy, public health practice and patient management in Mpumalanga Province, South Africa. The value and scope of this approach for improving malaria, measles, leprosy and cholera control was investigated.

Confidential inquiries identified contributory health system related factors in deaths due to malaria and cholera in Mpumalanga Province. A multi-disciplinary medical, laboratory and public health team carefully reviewed the clinical records and special investigations of patient deaths attributed to malaria between 1 January and 30 June 1996. The record review was supplemented by interviews with next-of-kin and confidential reports by health staff to determine the presence of avoidable factors or deviations from minimum acceptable standards of case management that may have contributed to the deaths. Confidential inquiries were conducted into all suspected cholera deaths between 1998-2001. This approach resulted in corrective action to prevent future deaths.

Malahapanga, a remote spring in the Kruger National Park, South Africa, has proven a valuable site for original research on the behaviour of Anopheles arabiensis, the most important malaria vector in southern Africa. An evolving operational research agcnda has defined preferred feeding periods and anatomical feeding sites, biting patterns, including distance from breeding site, and the effect of mechanical barriers and application of topical N,N-diethyl-m-toluamide (DEET) to ankles and feet on Anopheles arabiensis feeding. Research findings have directly influenced national malaria prevention guidelines, larviciding around residential camps in nature reserves, and malaria outbreak response in a rural African village.

The Mpumalanga Malaria Control Programme traditionally relied on light microscopy of Giemsa-stained thick blood films for malaria diagnosis. A series of operational research studies documented the shortcomings of microscopic diagnosis, the appropriateness and accuracy of rapid malaria card tests and led to the first introduction of card tests for primary diagnosis of malaria in a public health program. The Mpumalanga results highlighted the potential role of rapid tests for "Rolling Back" malaria in selected areas. A resulting national appreciation of the importance of standardised field evaluation of malaria diagnostic tests has led to Mpumalanga being requested to perform routine evaluation of new malaria diagnostic tests prior to introduction through the national purchasing system.

The first African sentinel surveillance site for routinely evaluating in vivo efficacy of sulfadoxine-pyrimetbamine(SP) against Plasmodium falciparum by 42-day follow-up was established in Mpumalanga Province. This followed a successful chloroquine in vivo study during 1997 that led to a change in treatment policy from chloroquine to SP for first-line P. falciparum malaria therapy. In vivo SP studies in 1998 and 2000 in Mpumalanga and in KwaZulu-Natal, a neighbouring province in 2000, confirmed treatment efficacy, provided a more comprehensive understanding of drug resistance evolution, and allowed investigation of the differential resolution of clinical symptoms and peripheral parasitaemia, an initial evaluation of the adequacy of the recommended SP dosage for adults exceeding 60 kilograms, and determination of gametocyte levels at different stages following therapy. The recognised success of the Mpumalanga sentinel surveillance site for influencing treatment policy has resulted in a sentinel surveillance network for epidemiological research into malaria in South Africa.

The feasibility of measles elimination in southern Africa was studied in Mpumalanga using an operational research model. Coverage levels, obtained from a comprehensive district-based population survey in 1997, make elimination highly improbable by routine vaccination alone, and a strong negative correlation between routine and campaign coverage supported the complimentary approach of combining routine and supplementary immunisation for measles elimination. Mass immunisation campaigns have dramatically impacted on the measles disease burden, reflected by notified deaths and admissions reviewed during a Mpumalanga hospital register review in April 1999. Analysis of coverage levels achieved during recent inununisation campaigns in South Africa supported the contention that judicious timing of campaigns is essential if high coverage is to be achieved.

A simple telephonic survey during March 2001 proved valuable for verifying the availability of appropriate patient management following potential rabies exposures. This rapid survey technique provided valuable information for correcting the official database of rabies vaccine and immunoglobulin availability and resulted in training of provincial pharmaceutical managers on rabies. Rapid telephonic surveys may be appropriate for auditing other health programs, particularly where a means for independently validating responses is readily available.

To explore positive and negative attributes of operational research that impact on its value for influencing communicable disease control policy and practice, the grounded theory approach was used with groups of experienced Masters of Public Health students in South Africa and Australia to analyse the series of operational research studies conducted between 1995 and 1999 to refine malaria diagnosis in Mpumalanga Province. A key theme was the extraordinary relevance of local operational research, which takes account of disease epidemiology, available material and human resources, and the local biological, political, soeio-economic and technological environment. It emerged that where research is planned and conducted in equal partnership with control program staff, there is rapid application of research findings for control and decreased resistance from decision-makers.

The central role which operational research can play in gathering the evidence necessary for effectively planning communicable disease control programs and bridging the gap between evidence and enhanced policy and practice, is illustrated in this thesis by drawing all a wide range of operational research interventions conducted in Mpumalanga Province, South Africa, between 1995 and 2001.

Item ID:	23459
Item Type:	Thesis (PhD)
Keywords:	cholera, communicable disease, Deet, diagnosis, diagnostic tests, disease control, infectious diseases, leprosy, malaria, malaria tests, measles, Mpumalanga Malaria Control Programme, Mpumalanga Province,Mpumaluanga, prevention, public health, sulfadoxine-pyrimetbaminechloroquine, vector control
Related URLs:	http://eprints.jcu.edu.au/13632 http://eprints.jcu.edu.au/13615 http://eprints.jcu.edu.au/13694 http://eprints.jcu.edu.au/13616
Additional Information:	David Durrheim received a JCU Outstanding Alumni Award in 2011. Publications arising from this thesis are available from the Related URLs field. The publications are: Durrheim, D.N., and Govere, J.M. (2002) Malaria outbreak control in an African village by community application of 'Deet' mosquito repellent to ankles and feet. Medical and Veterinary Entomology, 16 (1). pp. 112-115. Durrheim, D.N., Fourie, A., Balt, E., le Roux, M., Harris, B.N., Matebula, M., de Villiers, M., and Speare, R. (2002) Leprosy in Mpumalange province, South Africa: eliminated or hidden? Leprosy Review, 73 (4). pp. 326-333. Durrheim, D.N., Speare, R., and Petzer, M. (2002) Rabies post exposure management in South Africa: a telephonic survey used as a rapid tool for operational research. Tropical Medicine & International Health, 7 (5). pp. 459-461. Durrheim, David N., Speare, Richard, and Harries, Anthony D. (2002) Research that influences policy and practice: characteristics of operational research to improve malaria control in Mpumalanga Province, South Africa. Malaria Journal, 1 (9). pp. 1-7.
Date Deposited:	18 Jan 2013 00:21
FoR Codes:	11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111706 Epidemiology @ 50% 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111716 Preventive Medicine @ 50%
SEO Codes:	92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920404 Disease Distribution and Transmission (incl. Surveillance and Response) @ 50% 92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920412 Preventive Medicine @ 50%
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