Parliamentary Portfolio Committee Briefing NHLS Successes Sagie Pillay

Parliamentary Portfolio Committee Briefing NHLS Successes Sagie Pillay : CEO - NHLS 3 rd November 2010

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING OVERVIEW IT GIVES ME GREAT PLEASURE TO PRESENT THE NATIONAL HEALTH LABORATORY SERVICE ANNUAL REPORT FOR THE FINANCIAL PERIOD ENDING 31 ST MARCH 2010. THE NHLS IS PROUD TO HAVE MADE CONSIDERABLE ACHIEVEMENT IN SUPPORT OF THE NATIONAL DEPARTMENT OF HEALTH. THE NHLS RECEIVED AN UNQUALIFIED AUDIT FROM THE AUDITOR-GENERAL. SURPLUS REVENUE WAS R 206. 2 M, WHICH CONSTITUTES 6. 8% OF TURNOVER. AVERAGE PRICES AT AFFORDABLE LEVELS, IMPROVEMENTS IN EFFICIENCY AND PRODUCTIVITY YEAR-ON-YEAR RESULTED IN BELOW INFLATION PRICE INCREASES OVER THE LAST FOUR YEARS. COST EFFECTIVENESS AND RESPONSIVENESS TO NHLS CUSTOMER NEEDS. NHLS ACHIEVED 57% ON THE ANNUAL TARGETS SET. EXTRAORDINARY DEDICATION AND PASSION OF ALL STAFF. A HIGH PERFORMING ORGANISATION FOCUSSED AND RESILIENT TO CHANGE IN SUPPORT OF THE NEW STRATEGIC DIRECTION. TARGETS IN SOME AREAS HAVE NOT BEEN ACHIEVED; HOWEVER, THESE WERE

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING PROJECTS AIMED TO INFORM PROVINCIAL AND NATIONAL CONCERNS HAVE BEEN INITIATED IN THE AREAS OF: GATE-KEEPING TOOLS AND SYSTEMS AIMED AT MINIMISING INAPPROPRIATE AND UNNECESSARY TESTS; COMPARISON OF COSTS BETWEEN THE NHLS AND THE PRIVATE SECTOR; A LABORATORY POLICY FOR THE PUBLIC HEALTH LABORATORY SERVICE; EVALUATIONS OF NEW POINT-OF-CARE TESTS TO IMPROVE ACCESS AND TURNAROUND TIMES COST CONTAINMENT; DEVELOPMENT OF AN ESSENTIAL TEST LIST BY LEVEL OF CARE; IMPROVING EFFICIENCY AND REDUCING WASTAGE ACROSS LABORATORIES; STRENGTHENING AND EXPANDING NHLS CAPACITY TO RESPOND TO SURVEILLANCE AND OUTBREAKS; IMPROVING TURNAROUND TIMES OF TEST RESULTS. THE FULL BENEFITS OF MANY OF THE PROJECTS INITIATED DURING THE FINANCIAL YEAR, WILL ONLY BE REALISED OVER THE NEXT FEW YEARS AS THEY ARE LONG TERM PROJECTS.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING AREAS OF PARTICULAR RELEVANCE ARE HIGHLIGHTED BELOW: CUSTOMER FOCUS A STRONG CUSTOMER FOCUS RESULTED IN THE ACHIEVEMENT OF A CUSTOMER SATISFACTION SURVEY WHICH ESTABLISHED A BASE-LINE AGAINST WHICH CUSTOMER PERCEPTIONS WILL BE MONITORED ANNUALLY. NEW REPORTING MECHANISMS AND ROBUST BILLING INFORMATION PROVIDE OUR CUSTOMERS WITH MONTHLY ACTIVITY AND FINANCIAL DATA, WHICH ENABLES HOSPITALS AND CLINICS TO BETTER MANAGE THEIR SCARCE RESOURCES. ADDITIONAL TRAINING PROGRAMMES INTRODUCED CLINICIANS TO APPROPRIATE USE OF DIAGNOSTIC TESTING. THE NHLS BEGAN REVIEWING AND REPLACING SYSTEMS AND MODELS TO RESPOND TO THE NEW CHALLENGES. TRAKCARE LAB SYSTEMS, A NEW BILLING AND LABORATORY INFORMATION SYSTEM IN KWA ZULU-NATAL DEMONSTRATES THE READINESS FOR THE MOVE FROM A FLAT FEE REVENUE MODEL TO A “FEE FOR SERVICE” SYSTEM WHICH AIMS AT IMPROVING BILLING INTEGRITY, TRACKING OF SPECIMENS AND RESULTS, TURNAROUND TIMES FOR RESULTS FROM LABS TO CLINICIANS AND PROVIDES ACTIVITY DATA TO USERS AND MANAGERS THEREBY ENABLING

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING COST CONTAINMENT INCREASE IN TEST VOLUMES: 58. 9 MILLION TESTS CONDUCTED, A 16% GROWTH FROM THE PREVIOUS FINANCIAL YEAR; 2. 3 MILLION WERE CD 4 TESTS (20% INCREASE) AND 5. 9 MILLION CONSTITUTED VARIOUS TB TESTS. VIRAL LOAD TESTING INCREASED BY 17%. THIS INCREASE IN VOLUME HAS CONTRIBUTED TO THE INCREASE IN PROVINCIAL HEALTH DEPARTMENT SPEND, CONTRARY TO THE PERCEPTION THAT THIS INCREASE IN SPEND IS PRICE RELATED. SOLUTIONS TO KEEP COSTS DOWN WITHOUT COMPROMISING ACCESS OR QUALITY, NHLS PARTNERED WITH THE WESTERN CAPE AND GAUTENG, PROJECTS WERE INITIATED TO DEVELOP TOOLS TO MINIMISE INAPPROPRIATE AND UNNECESSARY TESTS.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING HUMAN CAPITAL ATTRACTING AND RETAINING EXPERIENCED PROFESSIONAL STAFF, PARTICULARLY IN RURAL AND SMALL TOWNS IS A CHALLENGE. RECRUITING DOCTORS INTO PATHOLOGY REGISTRAR TRAINING AND HIGH CALIBRE HIGH SCHOOL GRADUATES INTO TECHNOLOGIST AND TECHNICIAN TRAINING PROGRAMMES, PROGRESS WITH PATHOLOGY REGISTRARS REMAINS SLOW. THE SCHOOL RECRUITMENT PROGRAMME SUPPORTED BY A STRONG BURSARY SUPPORT PROGRAMME, IS HIGHLY SUCCESSFUL. HIGHER CALIBRES OF MATRICULANTS ARE CHOOSING MEDICAL TECHNOLOGY AS A FIRST OPTION CAREER CHOICE. SALARIES OF PATHOLOGISTS, TECHNICIANS, TECHNOLOGISTS AND SCIENTISTS ARE LAGGING IN COMPARISON TO PUBLIC HEALTH SECTOR AND OTHER STATE ORGANISATIONS. BUDGET DISCIPLINE AND PRESSURE TO CONTAIN COSTS MADE IT DIFFICULT TO ADDRESS

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING TRAINING A TOTAL OF R 5, 6 MILLION WAS INVESTED IN TRAINING AND SKILLS DEVELOPMENT INTERVENTIONS INTERNALLY, NATIONALLY AND INTERNATIONALLY NHLS EMPLOYED 1, 025 REGISTRARS AND INTERNS FOR THE PERIOD AT A COST OF R 177 MILLION BURSARIES WERE AWARDED TO 155 UNDERGRADUATE STUDENTS AT VARIOUS UNIVERSITIES AT A COST OF R 1, 84 MILLION REGRETTABLY, STUDENT MEDICAL TECHNOLOGY PASS RATE DROPPED FROM 69% TO 53% (2009/20010); BUT WAS STILL 6% ABOVE THE NATIONAL AVERAGE RECRUITMENT DRIVE WAS INTENSIFIED WITH NHLS BRANDING TO ATTRACT QUALITY STUDENTS THROUGH VISITS TO SCHOOLS ACROSS SOUTH AFRICA WORKPLACE SKILLS PLAN WAS SUBMITTED AND APPROVED BY THE

Research Various research studies was made possible through grants from the National Department of Health to the value of R 34. 7 m and subsidised by the NHLS for a further R 61. 4 m. Increased demands on the NICD, together with the challenge of reduced grant awards year-on-year from the National Department of Health added greater pressure onto NHLS to fund the difference.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING 5 YEAR FINANCIAL SUMMARY (R 000’s) Year 2005/6 ex KZN 2006/7 2007/8 2008/9 2009/10 Turnover 1, 323, 500 1, 745, 558 2, 232, 292 2, 676, 092 3, 049, 497 Net Surplus / (Deficit) 170, 423 183, 234 245, 183 189, 010 206, 171 Net Surplus % of Turnover 12. 9% 10. 5% 10. 9% 7. 1% 6. 8% Change in Working Capital (13, 787) (138, 508) (256, 414) (263, 606) (83, 417) Capex 56, 376 126, 647 126, 537 178, 126 213, 309 Capex % of Turnover 4. 3 % 7. 3 % 5. 7 % 6. 7 % 7. 0 % Net Increase / (Decrease) in Cash 199, 914 42, 526 (74, 874) (116, 582) 121, 052

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING 2009/10 Debtors vs. Cash on Hand-Rm 1400 1200 1000 800 Debtors 600 Cash 400 200 0 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING DEBTORS DAYS

Parliamentary Portfolio Committee Briefing OUTSTANDING DEBTORS BY PROVINCE (RM) Mar '09 Mar '10 Sep '10 535 468 438 211 50 40 Mpumalanga 31 33 Northwest 28 49 82 73 63 60 44 40 Kwa Zulu Natal 83 31 Northern Cape 23 Eastern Cape Limpopo Free State 33 179 Western Cape 98 19 Gauteng 136 117 191 163

Parliamentary Portfolio Committee Briefing OUTSTANDING DEBTORS DAYS BY PROVINCE DSO Mar '09 DSO Mar '10 DSO Sep '10 260 212 183 196 193 178 186 163 152 131 117 155 132 83 115 49 94 62 69 64 43 Mpumalanga Northwest Northern Cape 115 Eastern Cape Limpopo Free State 46 Western Cape 66 Gauteng 41 40 Kwa Zulu Natal 194

Parliamentary Portfolio Committee Briefing Information Technology Laboratory Information Systems - (LIS) continues to implement and upgrade, custom development provided to support and ensure quality assurance. Implementation of the Trak. Care Lab LIS 52 laboratories in Kwa. Zulu-Natal, 1, 090 staff trained on the system. The implementation of over 200 laboratory analysers and the installation of over 700 personal computers. An immediate benefit was the ease with which results could be accessed. A Health Level 7 (HL 7) interface between the Trak. Care Lab system and the Meditech Hospital Information System (HIS) at Addington Hospital was implemented. Clinicians at the hospital can order directly on the HIS, have the specimens processed in the NHLS laboratory and receive the results back in the HIS for viewing. The Trak. Care Lab Web. Viewer was implemented, allowing clinicians to access results via the Kwa. Zulu-Natal intranet or via the internet. A short message system (SMS) system for sending results to cellular phones which allows for TB and CD 4 results to be sent to registered and authorised clinicians. The Trak. Care Lab billing Financials system was implemented, which allows the NHLS to implement fee-for-service billing from 1 April 2010. Trak. Care Lab LIS ensures that all patient data are kept in a single database that can be accessed from any laboratory. Patient searches are quick and easy. These results are also available via the Web. Viewer. Key staff in the NHLS can view and authorise results from multiple laboratories which is particularly useful in sites where there is a shortage of pathologists.

Parliamentary Portfolio Committee Briefing Information Technology Disa*Lab software upgrades to the latest version (16. 04). Ten laboratories, at the following sites, were upgraded: Dr George Mukhari Hospital, Charlotte Maxeke (Johannesburg) Academic Hospital, Tygerberg Hospital, Groote Schuur Hospital, Steve Biko Academic Hospital, Braamfontein Central, Chris Hani Baragwanath Hospital, Kimberley Hospital, Universitas Hospital, and the TB laboratory in Port Elizabeth. The laboratories of Rustenburg, Witbank, Ellisras and Tshilidzini were upgraded to v 16. 03, a precursor to upgrading the site to version 16. 04. Over 1, 000 laboratory staff were trained during the course of the upgrades. Corporate Data Warehouse (CDW) access to national priority programmes To support the antiretroviral (ARV) programme, a number of new reports have been developed. A detailed Kwa. Zulu-Natal paediatric polymerase chain reaction data supports the ARV programme reporting. The electronic supply of data to ARV clinics using Therapy Edge Patient Management System is underway. In support of the tuberculosis (TB) programme, enhancements to support the data associated with the rollout of the TB line probe testing is developed. An interface developed for the electronic supply of multidrug-resistant TB data to the Do. H. A similar interface is planned for the Cape Town City Health TB patient management system. Reports developed for the cytology programme. SMS notifications to selected individuals in the surveillance unit of the National Institute for Communicable Diseases (NICD) and will be extended to Department of Health surveillance coordinators. A suite of reports have been developed to support the Prevention of Mother to Child Transmission Programme.

Parliamentary Portfolio Committee Briefing Human Resources Workforce Profile The overall headcount increased by 2. 4% African male and female representation in the executive management increased. 67% of executives are black. Senior management increase was across the employment equity categories. Significant increase in the category of professional women as noted below: African female executives African and white female senior management African female medical technologist and technicians African and Indian female medical scientist Student medical technologist decreased by 11%; student technicians were increased by 18% to improve the quality of lab support.

Parliamentary Portfolio Committee Briefing Employment Equity Executive management was (20%) females and (80%) males; an improvement on female representation. Senior management has a high representation of white females and black males. Laboratory management is predominantly African males (29%) and females (26%). White females are also adequately represented at (23%). Pathologists and other medical professionals still dominated white males (29%) and females (34%). An increase is noted among Indian male and female while decrease is noted among black males. Black registrar increased from 31% to 57% in line with the EE drive to influence the race and gender profile of pathologists in the medium term Medical scientists are predominantly female (75%) the majority is white females (46%). Medical technologists are predominantly black (75%). A further 21% comprises white female technologists. Attraction of the disabled is a challenge being addressed.

Parliamentary Portfolio Committee Briefing Workforce profile: NHLS regions: 31 March 2010 OPERATIONS Central Race and gender Coastal CORPORATE SURVEILLANCE Northern KZN NICD Corporate and SAVP NIOH TOTAL Mar-09 Mar-10 Mar-09 Mar-10 African female 813 811 420 423 506 619 605 630 97 119 31 36 73 88 2, 545 2726 African male 422 412 188 311 351 427 444 74 68 31 30 109 121 1, 562 1614 Coloured female 78 77 260 234 10 15 3 11 4 6 1 2 20 18 376 363 Coloured male 28 30 119 130 11 10 9 4 3 2 2 2 7 9 179 187 Indian female 74 82 23 21 193 199 13 11 21 21 7 9 15 14 346 357 Indian male 30 28 8 9 135 127 11 10 8 8 3 3 16 16 211 201 White female 309 281 324 304 53 46 139 145 75 72 16 13 40 37 956 898 White male 84 81 100 99 10 12 39 34 17 19 8 6 25 22 283 273 TOTAL 1, 838 1, 802 1, 442 1, 408 1, 229 1, 379 1, 246 1, 289 299 315 99 101 305 325 6, 458 6619 100% Percen-tage of workforce 28% 27% 22% 21% 19% 19% 5% 5% 2% 2% 5% 5% Mar-10 18

Parliamentary Portfolio Committee Briefing NHLS occupational categories: 31 March 2010 African Employee Category Female Coloured Male Female Indian Male Mar-09 Mar 10 Mar 09 Executive management 1 2 2 3 0 0 0 Senior management 7 11 12 19 0 0 Laboratory management 84 94 101 103 10 Pathologist and medical officer 22 22 13 10 Registrar 32 40 18 Medical scientist 21 30 Medical scientist - intern 29 Medical technologist Student medical technologist Female Male Female TOTAL Increase or Decrease Male Mar 09 Mar 10 Mar 09 Mar 10 No of staff % 0 0 0 3 3 0 0 2 2 8 10 2 25 3 0 2 4 7 7 15 20 12 11 58 72 14 24 10 11 12 17 15 17 17 91 82 28 27 359 360 1 0 2 3 2 2 23 23 15 18 77 70 61 59 215 207 -8 4 20 6 3 6 6 39 35 16 14 50 51 43 38 210 207 -3 1 10 11 5 5 2 3 20 25 7 7 97 95 31 31 193 207 14 7 24 12 9 0 2 0 1 15 16 3 4 14 13 4 5 77 74 -3 4 492 528 260 265 97 92 32 31 107 31 25 302 287 47 50 17 1 253 229 112 106 23 13 3 6 13 9 4 1 17 15 3 4 428 383 -45 11 Medical technician 153 237 129 146 17 24 15 20 27 40 22 24 30 30 6 7 399 528 129 32 Student medical technician 164 171 97 143 15 14 7 8 11 8 5 6 4 10 2 1 305 361 56 18 Laboratory support 1, 168 1, 143 661 607 160 152 77 72 50 41 53 46 176 116 10 9 -169 7 Corporate support 119 195 135 172 41 45 21 26 22 34 28 29 83 109 34 29 639 156 32 6, 45 6, 61 8 9 161 2. 4 Grand total Mar-09 10 10 White 2, 54 1, 56 1, 61 376 363 179 2, 726 5 2 4 187 346 357 211 201 956 898 283 273 1, 368 1, 385 2, 355 2, 186 483

Parliamentary Portfolio Committee Briefing Governance and Management HR Committee of the NHLS Board: Held quarterly meetings and updated the Board on key strategic initiatives for decision making. Executive management: Met twice a month to address key operational matters and make decisions accordingly. Policies: review of several HR policies was commenced and the process is at the Board level for approval. Employee relations environment is stable. Engagement between labour representative and management is healthy. Personnel costs: the total increased by from R 1, 298 billion to as a result of the 10% across the board salary increase for permanent staff.

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR OCCUPATIONAL HEALTH & NATIONAL CANCER REGISTRY Immunology & Microbiology and Analytical Service Labs have maintained SANAS and ISO 15189 accreditation Occupational Hygiene continued as an Approved Inspection Authority with Do. L MOUs with NIOSH (USA), FIOH (Finland); MHSC; DPSA Renewed link with IARC (France) to support the NCR Partnered with Do. H to finalise the Cancer Regulations Commissioned by DMR to conduct a survey on HIV & TB in mining sector Provided support to Do. H with Forensic Toxicology including temporary relocation of Johannesburg laboratory Established a task team of subject matter experts to work on Point of Care Testing

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING National Institute for Occupational Health & National Cancer Registry CURRENT ACTIVITIES Strategic thrust in HIV/TB in the workplace Supporting DPSA on occupational health services for public sector Developing OHS for NHLS Assisting DMR / Do. H with HIV/TB/Silicosis workplace initiatives Partnering with Defence and the office of the Surgeon-General on technology assessment / occupational health services Enhanced links with trade unions and private sector National Cancer Registry concluded the appointment of senior management positions 6

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES Surveillance Suspected measles case-based surveillance Accredited by the World Health Organization (WHO) to perform measles and rubella Ig. M testing for national case-based surveillance, the NICD tested 15, 291 specimens from cases of rash and fever for suspected measles case-based surveillance. Of these, 39% were positive for measles, and 20% for rubella. Acute flaccid paralysis surveillance The NICD serves as national isolation laboratory for South Africa and six other southern African countries, i. e. Angola, Botswana, Lesotho, Mozambique, Namibia and Swaziland. Of the 428 South African cases with onset of paralysis in 2009, one specimen only was received from 74 cases, and two or more specimens from 354. The date of onset of paralysis was known for 383 (89. 5%) cases. Two specimens taken at least 24 hours apart and within 14 days of onset were received from 280/428 (65. 4%) cases. Non-polio enteroviruses were isolated from 86, and non-enteroviruses from 17 of the 685 specimens (non-polio isolation rate 12%), and poliovirus, identified as Sabin type poliovirus from four specimens of three patients. Respiratory virus surveillance Four influenza surveillance programmes, each focusing on different aspects of influenza epidemiology, are coordinated. These are: Viral Watch, severe acute respiratory infections (SARI), respiratory morbidity data mining surveillance system and influenza-associated mortality surveillance programme.

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES Surveillance Viral Watch surveillance system In early 2009, 24 new sites were added in Limpopo and the Western Cape, bringing the total number of sites to 243. In response to the emergence of pandemic influenza A H 1 N 1, Enhanced Viral Watch centers at 12 public hospitals in 8 provinces were enrolled to detect influenza strains in hospitalised patients. SARI surveillance The SARI surveillance describes trends in numbers of patients admitted with SARI at sentinel hospitals and determines the relative contribution of influenza and other respiratory viruses to SARI presentation in a setting with high HIV prevalence. The first site, Chris Hani Baragwanath Hospital started enrolling patients in February 2009, followed by Mapulaneng and Matikwana hospitals (Agincourt, Mpumalanga) in April 2009 and the last site, Edendale Hospital (Kwazulu-Natal) in September last year. Respiratory morbidity data mining surveillance system During 2009 there were 1, 132, 331 consultations reported to the NICD through the respiratory morbidity mining surveillance system. Of these, 3. 4% (38, 044) were due to pneumonia or influenza.

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES Surveillance Rotavirus surveillance In 2009, active surveillance for rotavirus infection was implemented at five sentinel hospitals in four provinces (Gauteng, Mpumalanga, Northwest and Kwazulu-Natal). The programme aims to estimate the number of hospitalisations due to severe diarrhoea and laboratoryconfirmed rotavirus infection in HIV-infected and -uninfected children as well as determine the prevalent rotavirus strains in different geographical areas of South Africa and monitor trends in rotavirus disease following the introduction of the Rotarix® vaccine into the expanded programme on immunisation in August 2009. Data collection started first in Dr George Mukhari Hospital (Northwest) in the first week of April, in Chris Hani Baragwanath (Gauteng) in the fourth week of April and in Mapulanen and Matikwana hospitals in Agincourt (Mpumalanga) in May 2009; surveillance at Edendale Hospital in Kwazulu-Natal was initiated in 2010. A total of 962 cases of diarrhoea were reported to the rotavirus surveillance programme in 2009. Of 830 patients, 398 (48%) tested positive for rotavirus. Rotavirus circulation occurred throughout the surveillance period but two seasonal peaks were observed: the first from week 17 -25 and the second lower peak from week 29 -38.

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES OUTBREAKS Rift Valley Fever outbreak, centred in Free State, E Cape, N Cape, and North West provinces Started Feb 2010, 237 human cases to date, 26 deaths NICD assisted with field investigation (FELTP), laboratory diagnosis (SPU) and outbreak response (EPID) FELTP students assisting the Free State vet and health dept

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES OUTBREAKS Crimean-Congo haemorrhagic fever • Provided laboratory diagnosis (Special Pathogens Unit) and management support. 5 confirmed human cases for the period of reporting

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES OUTBREAKS A major measles outbreak started in Tshwane in February 2009, and spread throughout the country. Between April 2009 and March 2010, 9500 cases were laboratory confirmed at the NICD virology Division. The Epidemiology division provided outbreak support and data management

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES OUTBREAKS Pandemic influenza A H 1 N 1 (2009) 12 000 cases were labconfirmed in South Africa July 2009 – October 2009, following the influenza pandemic that started in Mexico and the southern USA and spread globally. The NICD set up lab testing for the pandemic strain , developed guidelines for response. Viral Watch South Africa 2009: Positive samples by type and subtype & detection rate

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES Cholera outbreak 2008 -2009 NHLS and NICD provided lab diagnostics and outbreak support and data management 22 nd April 2009 12, 706 cases 65 deaths CFR 0. 51%

Parliamentary Portfolio Committee Briefing NATIONAL INSTITUTE FOR COMMUNICABLE DISEASES Diphtheria One fatal case confirmed in Cape Town

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING SUCCESS OF THE NHLS REGIONAL FOOTPRINT COASTAL REGION SERVICE DELIVERY ANTIRETROVIRAL PROGRAMME - HIV POLYMERASE CHAIN REACTION (PCR) LABORATORY CAPACITY FOR NEONATAL AND PAEDIATRIC TESTING OF HIV HAS INCREASED DUE TO SETTING UP ANOTHER SITE IN THE EASTERN CAPE (DORA NGINZA HOSPITAL). NOW TWO SUCH MOLECULAR TESTING SITES OPERATE IN EACH OF THE PROVINCES (ONE EACH IN MTHATHA, DORA NGINZA, TYGERBERG AND GROOTE SCHUUR HOSPITALS). THIS HAS INCREASED ACCESS TO MOTHERS WHOSE CHILDREN NEED TO BE TESTED, WITH A SHORTER TURNAROUND TIME. CD 4 TESTING LABORATORIES HAVE BEEN ADDED AT BUTTERWORTH, GRAHAMSTOWN AND QUEENSTOWN, IN THE EASTERN CAPE. THE FIRST TUBERCULOSIS (TB) PCR LABORATORY WAS ESTABLISHED IN PORT ELIZABETH. ANOTHER TB PCR SITE OPERATES FROM GREEN POINT LABORATORY. THE INTRODUCTION OF THESE TWO SITES HAS REDUCED THE TURNAROUND TIME ON FIRST-LINE DRUG SUSCEPTIBILITY TESTING FROM SIX WEEKS TO 48 HOURS. AS A RESULT OF THE MOLECULAR TECHNOLOGY, TB DRUG MANAGEMENT HAS BEEN IMPROVED DRAMATICALLY. TO INCREASE ACCESS TO TB MICROSCOPY AND OTHER PUBLIC HEALTHCARE LEVEL EXAMINATIONS, NEW LABORATORIES HAVE OPENED AT KARL BREMER, KNYSNA, MOSSEL BAY AND KHAYELITSHA IN THE WESTERN CAPE, AND IN HEWU

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING SUCCESS OF THE NHLS REGIONAL FOOTPRINT CENTRAL REGION SERVICE DELIVERY 495 SMS PRINTERS TO IMPROVE TURNAROUND TIME FOR TB RESULTS DELIVERY TO RURAL CLINICS IN THE NORTHERN CAPE AND FREE STATE. TB MICROSCOPY RESULTS DELIVERY IMPROVED FROM 24 HRS IN 2008/2009 TO 17. 98 HRS. FIVE SITES FOR TB PCR WERE COMPLETED WITH THREE ALREADY FUNCTIONAL. PLANS TO TO STANDARDISE THE DECONTAMINATION PROCEDURE IS UNDERWAY, TO ENSURE THAT ALL MICROSCOPY POSITIVE SPECIMENS ARE PROCESSED FOR DETECTION OF MULTI-DRUG-RESISTANT STRAINS OF TB. ALL TERTIARY LABORATORIES AND GENERAL LABORATORIES WHERE TB PCR IS PROCESSED HAS BEEN UPGRADED TO DISA 16. 04 INFORMATION SYSTEM. THE ROLL-OUT OF LAPTOP COMPUTERS AND BLACKBERRY PHONES IS UNDER WAY TO ALL FACILITIES IN THE FREE STATE TO IMPROVE TURNAROUND TIME THROUGH DIRECT ACCESS TO RESULTS BY CLINICIANS.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING SUCCESS OF THE NHLS REGIONAL FOOTPRINT KWA ZULU NATAL SERVICE DELIVERY 84% ACHIEVED FOR DAILY COVERAGE OF PUBLIC HEALTHCARE FACILITIES. 147 SMS PRINTERS INSTALLED AT CLINICS TO IMPROVE TURNAROUND TIMES FOR TUBERCULOSIS AND CD 4 RESULTS. TRAKCARE LIS HAS BEEN ENABLED TO SUPPLY VIRAL LOAD AND POLYMERASE CHAIN REACTION (PCR) RESULTS VIA SMS IN ADDITION TO TB MICROSCOPY AND CD 4 RESULTS. 1110 EMPLOYEES BENEFITED FROM SKILLS AND TRAINING INTERVENTIONS. KZN PRIDES ITSELF ON ACHIEVING THE HIGHEST EXAMINATION PASS RATE FOR INTERN MEDICAL TECHNOLOGISTS CONSISTENTLY FOR THE PAST THREE YEARS. A TOTAL OF 43 TECHNICAL INTERNS WERE APPOINTED IN JANUARY 2010 AND PLACED IN ACCREDITED TRAINING LABORATORIES. COMPREHENSIVE QUALITY ASSURANCE PROGRAMMES ARE IN PLACE ACROSS ALL LABORATORIES IN THE REGION AND PERFORMANCE INDICATORS IMPROVED FROM 45% IN 2009/10 TO 61% FOR 2009/10.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING SUCCESS OF THE NHLS REGIONAL FOOTPRINT NORTHERN REGION SERVICE DELIVERY - CONTINUED GROWTH IN TEST VOLUMES, PARTICULARLY IN THE HIV/AIDS AND TUBERCULOSIS (TB) NATIONAL PRIORITY PROGRAMMES. VIRAL LOAD TESTING INCREASED BY 63%, WHILE CD 4 AND HIV POLYMERASE CHAIN REACTION (PCR) TEST VOLUMES INCREASED BY 23% AND 42%, RESPECTIVELY. TB PROGRAMME, DIRECT TB MICROSCOPY INCREASED BY 17% AS COMPARED TO THE PREVIOUS FINANCIAL YEAR. HOWEVER, TESTS FOR THE CERVICAL CANCER SCREENING PRIORITY PROGRAMME DECREASED BY 4%; THIS DECREASE WAS MAINLY DUE TO STAFF SHORTAGES EXPERIENCED BY CYTOLOGY LABORATORIES. DAILY SPECIMEN COLLECTION FROM CLINICS INCREASED FROM 95% TO 99. 6%, AS COMPARED TO PREVIOUS FINANCIAL YEAR. 205 SMS PRINTERS INSTALLED IN CLINICS IN AN EFFORT TO IMPROVE TB MICROSCOPY RESULTS TURNAROUND TIME. THE TOTAL NUMBER OF SMS PRINTERS IN THE REGION TO 405, DISTRIBUTED AS FOLLOWS: 190 IN LIMPOPO, 110 IN NORTH WEST AND 105 IN MPUMALANGA

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING QUALITY ASSURANCE ACCREDITATION DURING THE REPORTING PERIOD, NINE LABORATORIES ACHIEVED ACCREDITATION STATUS; BRINGING THE TOTAL NUMBER OF NHLS ACCREDITED LABORATORIES TO 72. THE STRATEGIC TARGET WAS FOR ALL ACADEMIC LABORATORIES TO BE ACCREDITED BY THE END OF THIS FINANCIAL YEAR; HOWEVER, 13% DID NOT ACHIEVE THE TARGET. DURING THE SAME PERIOD, 30% OF REGIONAL LABORATORIES WERE PRIORITISED FOR ACCREDITATION BY THE SOUTH AFRICAN NATIONAL ACCREDITATION SYSTEM (SANAS), BUT ONLY 17% WERE ACCREDITED. THE FEASIBILITY OF DEVELOPING AN ‘INTERNAL’ ACCREDITATION PROCESS FOR SMALLER LABORATORIES WILL BE INVESTIGATED. Branch % Academic Labs Accredited % Regional Labs Accredited Central 100 7 Coastal 48 54 KZN 0 0 100 8 Northern

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING QUALITY ASSURANCE RESEARCH OUTPUTS DESPITE THE INCREASE IN RESEARCH FUNDING, RESEARCH OUTPUTS IN THE FORM OF PUBLICATIONS DECREASED FROM THE 485 IN THE PRIOR YEAR TO 328 IN THE YEAR UNDER REVIEW (A DECREASE OF 32%). THUS, THE STRATEGIC OBJECTIVE OF INCREASING THE NUMBER OF PUBLICATIONS BY 2% ON PRIOR YEAR WAS NOT ACHIEVED. HOWEVER, WHEN REVIEWING ALL RESEARCH OUTPUTS INCLUDING CONFERENCE PROCEEDINGS, THESE AMOUNTED TO 647.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING QUALITY ASSURANCE RESEARCH PUBLICATIONS BY DISCIPLINE IN REVIEWING PUBLICATIONS BY DISCIPLINE, WHILE THE FOUR MAJOR DISCIPLINES OF ANATOMICAL PATHOLOGY, CHEMICAL PATHOLOGY, HAEMATOLOGY AND MICROBIOLOGY SHOW HIGHER PUBLICATIONS OUTPUTS, PUBLICATIONS IN THE DISCIPLINE OF VIROLOGY CONSTITUTE 32% OF ALL PUBLICATIONS, REFLECTING THE HEALTH NEEDS AND BURDEN OF DISEASE IN SOUTH AFRICA, IN TERMS OF HIV/AIDS.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING QUALITY ASSURANCE PEER REVIEWED PUBLICATIONS BY INSTITUTIONS IN REVIEWING PUBLICATIONS BY INSTITUTION (FIGURE 7), IT REMAINS EVIDENT THAT THOSE UNIVERSITIES THAT WERE HISTORICALLY ADVANTAGED REMAIN SO. IT IS OF GREAT CONCERN THAT UNIVERSITY OF KWAZULU-NATAL (UKZN) OUTPUTS HAVE DECREASED IN THE YEAR UNDER REVIEW, AND THAT WALTER SISULU UNIVERSITY (WSU) AND UNIVERSITY OF THE WESTERN CAPE (UWC) HAVE HAD NO OUTPUTS. NO PUBLICATIONS REFLECTED FROM UNIVERSITY OF LIMPOPO MAY BE REFLECTIVE OF 0% OUTPUT, OR SIMPLY LACK OF SUBMISSION OF INFORMATION.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING NATIONAL PRIORITY PROGRAMMES Strategic Alignment of HIV and TB activities 80%TB patients are HIV-co-infected • Greatest laboratory synergies likely to arise in molecular testing at both a POC and centralized laboratory level • Laboratory planning needs to occur around mutual technology platforms, skill and support needs.

350, 000 Apr-09 Apr-09 May-09 Jun-09 Jul-09 Jul-09 Aug-09 Sep-09 Sep-09 Oct-09 Nov-09 Dec-09 Dec-09 Jan-10 Feb-10 PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING CD 4 Test Volumes 2009/10 300, 000 250, 000 200, 000 150, 000 100, 000 50, 000 §Total number of CD 4 determinations Apr ‘ 09 – Mar ‘ 10: 3 095 037

140, 000 Apr-09 Apr-09 May-09 Jun-09 Jul-09 Jul-09 Aug-09 Sep-09 Sep-09 Oct-09 Nov-09 Dec-09 Dec-09 Jan-10 Feb-10 PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING HIV Viral Load Test Volumes 2009/10 120, 000 100, 000 80, 000 60, 000 40, 000 20, 000 § Total number of VL determinations Jan - Aug: 1 202 448

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING Affordable CD 4 testing All available CD 4 technologies have been evaluated A highly automated, low cost, accurate CD 4 test has been developed for SA national roll-out program (PLG CD 4) An African EQA program has been established serving over 500 laboratories in the region Current validation of POC assays at regional clinics: laboratory, clinical and costing evaluation.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING Affordable viral load testing All available technologies have been evaluated All assays have been optimized for use with dried blood spots; facilitating collection and transport Alternative approaches such as flow based activation markers under evaluation for screening (CD 38 expression on CD 8 cells) –would significantly reduce number of VL Early evaluation of POC options Local R&D projects around POC assay development National viral load EQA pilot program in development

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING Affordable resistance testing In-house assay developed and in routine use (costs one third of commercial assays) New short sequence RT assay under developed Pooled assay using UDS sequencing under development (NIH) Resistance testing can be conducted on dried blood spots to facilitate collection Ongoing R&D aimed at combining assays for viral load and resistance testing Active investigation of current first and second line treatment failures HBV resistance assays developed to monitor HIV-HBV co-infected on ARV treatment

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING Early infant diagnosis of HIV Evaluation of new assays: DNA/RNA/TNA Large scale automated implementation: clinical and laboratory staff involved from NHLS Dried blood spots has facilitated access significantly

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING NATIONAL PRIORITY PROGRAMMES TUBERCULOSIS

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING NATIONAL PRIORITY PROGRAMMES TUBERCULOSIS

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING Highlights NATIONAL PRIORITY PROGRAMMES TUBERCULOSIS Roll-out of Line Probe Assay – Volumes exceed conventional MGIT DST Introduction of Inter-Laboratory comparison and automated reader for standardisation and quality control for Line Probe Assay. Recruitment and Training of 60 TB technicians Expansion of the Blinded Rechecking Quality Assurance for Smear Microscopy

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING NATIONAL PRIORITY PROGRAMMES: TUBERCULOSIS

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING Awards for outstanding performance during the year It is clear that the intellect and contribution of the NHLS staff does not go unnoticed, NHLS is proud of their achievements. • Professor Hendrik Koornhof who received the Order of Mapungubwe – Silver in recognition of his distinguished service in biomedical sciences. • Professors Valerie Mizrahi and Keith Klugman were both awarded A-ratings by the National Research Foundation, recognising them as international leaders in their field. • Professors Koornhof and Mizrahi were both elected to Fellowship in the American Academy of Microbiology. • Professor Maureen Coetzee received the 2009 -2010 National Science and Technology Forum award for ‘Research and its outputs over the last five to ten years or less’, particularly for her substantial contribution to the understanding and control of malaria in Africa. Professor Coetzee was the second runner up in the Department of Science and Technology/L’Oreal 2009 Women in Science awards. • Dr Lizette Koekemoer received the Southern African Association for the Advancement of Science British Association Medial (Silver) for 2009. • Professor Richard Hunt received the Elsdon Dew Award through the Parasitological Society of Southern Africa. • Dr Elin Gray received the Wits Health Sciences Faculty Postgraduate Degree Award for the best Ph. D degree in 2009. 6

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING Footage courtesy of S-planes

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING UAVS (UNCREWED AERIAL VEHICLES) TECHNOLOGY DEVELOPED FOR WAR HAS BEEN TURNED TO THE SAVING OF LIVES. ENGINEERS HAVE CONVERTED UNCREWED MILITARY AIRCRAFT INTO ROBOTIC CARRIER PIGEONS THAT COULD FERRY MEDICAL SAMPLES FROM REMOTE REGIONS TO LABS FOR TESTING, OR DELIVER SNAKE ANTIVENOM TO STRICKEN VICTIMS. CLINICS IN REMOTE AREAS OF SOUTH AFRICA CAN ONLY BE REACHED ON UNPAVED ROADS THAT ARE IMPASSABLE IN RAIN. EVEN IN GOOD WEATHER, THE TRIP TO THE NEAREST LAB IS A LONG ONE FOR THE COURIERS, TAXIS, OR AMBULANCES TRANSPORTING SAMPLES, PRODUCING LONG DELAYS IN DIAGNOSING AND TREATING DISEASES LIKE TUBERCULOSIS. "THE IMPLICATIONS OF THESE DELAYS ARE HUGE FOR THE INDIVIDUAL AND FOR THE COMMUNITY, " SAYS PROJECT LEADER BARRY MENDELOW OF THE SOUTH AFRICAN NATIONAL HEALTH LABORATORY SERVICE. "THE PATIENT IS WAITING FOR TREATMENT, AND IN THE MEANTIME THEY COULD BE PASSING ON A VERY CONTAGIOUS DISEASE. “ INSPIRED BY CARRIER PIGEONS, THE UAVS (UNCREWED AERIAL VEHICLES) ARE DESIGNED TO BE LAUNCHED FROM CLINICS AND PILOT THEMSELVES ALONG A PRE-PROGRAMMED ROUTE TO THE NEAREST LAB, USING GPS AND MICROELECTRONIC GYROSCOPES TO GUIDE THEM. THEY DROP THEIR CARGO AT A PREDETERMINED SPOT, OR ON DIRECTIONS FROM THE GROUND, AND RETURN ALONG THEIR FLIGHT PATH. THE UAV CAN LAND AUTOMATICALLY, OR UNDER REMOTE CONTROL BY STAFF. THE PILOT PROJECT HAS SUCCESSFULLY TEST-FLOWN TWO DIFFERENT UAVS ORIGINALLY DESIGNED FOR MILITARY SURVEILLANCE. BOTH COULD LAUNCH, FLY AND DROP DUMMY SAMPLES IN WIND SPEEDS OF UP TO 45 KILOMETERS PER HOUR.

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING THE TEAM WORKED TO MODIFY A SMALLER, CHEAPER UAV, WHICH CAN BE LAUNCHED BY HAND LAND ALMOST ANYWHERE. ITS SMALL SIZE POSES LITTLE DANGER TO PEOPLE ON LANDING OR TAKEOFF. THE PLANE CAN CARRY OVER 20 SMALL, DRY AND LIGHT SPUTUM SAMPLES STORED ON BLOTTING PAPER THAT ARE USED BY NEWER DNA-BASED TESTS. THESE DRY SAMPLES ARE ALSO STERILISED, SO THERE IS NO RISK OF LIVE BACTERIA OR VIRUSES ESCAPING IN THE EVENT OF A CRASH LANDING. LAB RESULTS ARE ALREADY SENT TO REMOTE CLINICS WITH UNRELIABLE WIRED TELEPHONE CONNECTIONS BY CELLPHONE TEXT MESSAGE, SO PATIENTS NEED NOT WAIT FOR A UAV TO RETURN. THE AIRCRAFT SHOULD ALLOW PATIENTS TO GET RESULTS WITHIN A DAY OF PROVIDING A SAMPLE, SAYS MENDELOW. THE TEAM ARE WAITING FOR AUTHORISATION FROM THE SOUTH AFRICAN CIVIL AVIATION AUTHORITY TO BEGIN TRIALS TRANSPORTING SAMPLES FROM A REAL CLINIC. HTTP: //WWW. NEWSCIENTIST. COM/ARTICLE/DN 14718 -ROBOT-SPYPLANES-GET-NEW-ROLE-ASMEDICAL-COURIERS. HTML&REASON=0

CONCLUDING COMMENTS GOING FORWRAD Alignment with Ministers 10 point plan Joint planning stronger partnership Reviewing costs and reimbursement model Deliver model under review Improving logistics Putting pathology at the centre of good clinical practice Evidenced based Revieweing research outputs and relevance Strengtheining Role of POCT Building networks, Partnesrhips. JV’s and international collaboration Exploring VAT exemption Pushing ahead on a HPTG conditional grant Information management

PARLIAMENTARY PORTFOLIO COMMITTEE BRIEFING THANK YOU TO THE PORTFOLIO COMMITTEE FOR THE OPPORTUNITY TO PRESENT THE ACHIEVEMENTS OF THE NHLS. YOUR INTEREST AND SUPPORT IS VALUED IN DRIVING THE NHLS TO BETTER SERVE THE SOUTH AFRICAN PUBLIC TOWARDS A HEALTHY FUTURE. NHLS LEAD CHANGE , DELIVER RESULTS