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Screening and surveillance approaches for workers exposed to nanomaterials could aid in early detection of health effects, provide data for epidemiological studies and inform action to decrease exposure. The aim of this review is to identify such screening and surveillance approaches, in order to extract available data regarding (i) the studies that have successfully been implemented in present day, (ii) identification of the most common and/or toxic nano-related health hazards for workers and (iii) possible exposure surveillance markers. This review contributes to the current understanding of the risk associated with nanomaterials by determining the knowledge gap and making recommendations based on current findings. A systematic review was conducted. PubMed and Embase were searched to identify articles reporting on any surveillance-related study that described both exposure to nanomaterials and the health indicators that were measured. Four reviewers worked in pairs to independently assess the eligibility of studies and risk of bias before extraction of data. Studies were categorised according to the type of study and the medical surveillance performed, which included the type of nanomaterial, any exposure details provided, as well as health indicators and biomarkers tested. Initially 92 studies were identified, from which 84 full texts were assessed for eligibility. Seven studies met all the inclusion criteria, i.e. those performed in Taiwan, Korea, Czech Republic and the US. Of these, six compared health indicators between exposed and unexposed workers and one study described a surveillance program. All studies were at a high risk of bias. Workers were exposed to a mix of nanomaterials in three studies, carbon-based nanomaterials in two studies, nano-silver in one study and nano-titanium oxide in the other study. Two studies did not find a difference in biomarkers between exposed and unexposed workers. In addition, differences in early effects on pulmonary function or neurobehavioral tests were not observed. One study found an increased prevalence of allergic dermatitis and \"sneezing\" in the exposed group. This review of recently published data on surveillance studies proves that there is a gap in the current knowledge, where most of the surveillance-related studies reported do not follow a set format that provides the required information on ENM characterisation, the type of exposure and the measured indicators/biomarkers. Hence, there is very low quality evidence that screening and surveillance might detect adverse health effects associated with workplace exposure. This systematic review is relevant because it proves that, although surveillance programs have been initiated and preliminary results are being published, the current studies are actually not answering the important questions or solving the overall problem regarding what the potential health hazards are among workers either handling or potentially exposed to ENMs. The recommendations, thus proposed, are based on an obvious need for (i) exposure registries, where longitudinal follow-up studies should inform surveillance, (ii) known exposure measurements or summary indices for ENMs as a reference (iii) validation of candidate biomarkers and (iv) studies that compare the effects of these surveillance approaches to usual care, e.g. those commonly followed for bulk-size hazardous materials.

Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption. Tout récemment, les chercheurs se sont focalisés sur les lacunes de la gouvernance et sur les effets négatifs de la corruption sur la prestation des services de santé. En se basant sur la théorie de la délégation, cet article traite de la corruption dans le secteur de la santé en Afrique du Sud. Nous avons utilisé une combinaison de méthodes de recherche et des données triangulées tirées de trois sources: les rapports du vérificateur général d’Afrique du Sud pour chaque province sur une période de 9 ans; 13 entretiens semi-structurés avec des témoins privilégiés du secteur de la santé et une analyse de contenu des rapports des médias imprimés sur une période de 3 ans. Les conclusions des rapports du vérificateur général ont révelé une tendance à la détérioration des résultats de la vérification avec des variations notables dans chacune des neuf provinces. Les témoins privilégiés ont indiqué que la corruption a un effet négatif sur les soins aux patients et sur le moral des agents de santé. La majorité des rapports des médias imprimés sur la corruption concerne le secteur de la santé publique (63%) et les services provinciaux de la santé (45%) Les caractéristiques et la complexité du secteur de la santé publique peuvent accroître sa vulnérabilité face à la corruption, mais le binaire public-privé constitue une fausse dichotomie puisque la corruption implique souvent les agents des deux secteurs. Malgré l’absence d’indicateurs mondiaux validés pour mesurer la corruption, nos conclusions suggèrent que la corruption est un problème dans le secteur de la santé en Afrique du Sud. La corruption est influencée par la sélection de l’agent défavorable, le manque de mécanismes pour détecter la corruption et l’incapacité à sanctionner les personnes impliquées dans des activités de corruption. Nous concluons que la législation appropriée est une intervention nécessaire, mais pas suffisante pour réduire la corruption. Nous proposons que les mécanismes visant à réduire la corruption intègrent la volonté politique afin d’instaurer des services de santé exempts de corruption, un gouvernement suffisamment efficace pour appliquer les lois, les systèmes appropriés, l’engagement et le plaidoyer des citoyens pour exiger que les fonctionnaires aient à rendre des comptes. Et surtout, parmi les interventions cruciales dans la lutte contre la corruption, on peut mentionner l’institutionnalisation d’une bureaucratie fonctionnelle et de fonctionnaires compétents, les qualifications, l’éthique et les systèmes de valeurs dont les intérêts sont conformes aux objectifs du système de santé. La atención académica reciente se ha centrado en gobernanza débil y en los efectos negativos de la corrupción en la prestación de servicios de salud. Usando la teoría de la agencia, este artículo analiza la corrupción en el sector de salud de Sudáfrica. Se utilizó una combinación de métodos de investigación y datos triangulados de tres fuentes: informes del Auditor General de Sudáfrica para cada provincia que abarca un período de 9 años; 13 entrevistas semi-estructuradas con informantes clave del sector de la salud y un análisis de contenido de los informes de prensa escrita que cubren un período de 3 años. Los resultados de los informes del Auditor General mostraron una tendencia al empeoramiento en los resultados de la auditoría con una variación marcada a través de las nueve provincias. Los informantes claves indicaron que la corrupción tiene un efecto negativo en la atención al paciente y en la moral de los trabajadores de la salud. La mayoría de los informes de la prensa escrita sobre la corrupción se refiere al sector de la salud pública (63%) y los departamentos de salud provinciales involucrados (45%). Las características y la complejidad del sector de la salud pública pueden aumentar su vulnerabilidad a la corrupción, pero el binario públicoprivado constituye una falsa dicotomía ya que la corrupción implica a menudo a agentes de ambos sectores. A pesar de la falta de indicadores globales validados para medir la corrupción, nuestros hallazgos sugieren que la corrupción es un problema en el sector sanitario de Sudáfrica. La corrupción está influenciada por la selección adversa del agente, la falta de mecanismos para detectar la corrupción y la falta de sanciones a las personas involucradas en actividades corruptas. Llegamos a la conclusión que la legislación apropiada es una intervención necesaria, pero no suficiente para reducir la corrupción. Proponemos que los mecanismos para reducir la corrupción deben incluir la voluntad política para manejar los servicios de salud libres de corrupción, un gobierno eficaz para hacer cumplir las leyes, sistemas apropiados, participación ciudadana y apoyo para hacer responsables a los funcionarios públicos. Es importante destacar que la institucionalización de una burocracia funcional y le existencia de servidores públicos con habilidades, competencias, sistemas éticos y valores correctos, y cuyos intereses estén alineados con los objetivos del sistema de salud, son intervenciones críticas en la lucha contra la corrupción. 最近的学术研究集中在无カ的政府管理和腐败对于提供医疗 服务的负面效应。本文采用代理理论来研究南非医疗领域的 腐败。我们采用联合的研究方法和来自三个资源的三角測量 数裾：一份覆盖9年的南非各省的审计报告；13分对医疗领域 关键信息人的半结构化访问；对ー份纸媒三年间报道的内容 分析。从审计报告中可以看到越来越糟糕的审计結果，9个省 份间方差很明显。从对关键信息人的访谈中可以看出腐败对 于服务的提供和医疗エ作者的士气有负面影响。纸媒对腐败 报道的大多数都与公共医疗领域有关 (63%) 并涉及省级医疗 部门 (45%). 公共医疗领域的特点和复杂性使其面对腐败时更 加脆弱，但腐败经常是公私两个领域都涉及。尽管缺少全球通 用的指标来测量腐败程度，我们的研究依然发现腐败是南非的 医疗领域的ー个问题。腐败受到代理选择、缺少发现腐败的 机制和惩罚腐败活动的失败影响。我们的结论是适当的立法 是必要的，但对于減少腐败还是不够的。我们提议減少腐败的 机制必须包括提供无腐败医疗服务的政治意愿、有效的政府 执法，合适的体系，公民的參与以及呼吁政府官员的责任。重 要的是，有效的官僚体系的机构化，以及公务员有正确的技 能、竞争力、道德和价值体系，他们的利益应与医疗系统的目 标相一致，这些都是打击腐败的关键措施。

Clostridioides difficile (CD) is the most common healthcare-associated enteric infection. There is currently limited epidemiological evidence on CD incidence in South Africa. To estimate the burden of CD infection (CDI) in the South African public sector between 1 July 2016 and 30 June 2017. A retrospective cohort study utilizing secondary data was conducted to describe the epidemiology of CD in South Africa. We assessed the patient-level association between variables of interest, CD, and CD recurrence, by undertaking both univariate and multivariable analysis. Adjusted incidence rate ratios (aIRR) were calculated utilizing multivariable Poisson regression. The incidence of CD, CD recurrence and CD testing was estimated by Poisson regression for various levels of care and provinces. A total of 14 023 samples were tested for CD during the study period. After applying exclusion criteria, we were left with a sample of 10 053 of which 1 860 (18.50%) tested CD positive. A positive and significant association between CDI and level of care is found, with patients treated in specialized tuberculosis (TB) hospitals having a five-fold increased adjusted incidence risk ratio (aIRR) for CDI (aIRR 4.96 CI95% 4.08-6.04,) compared to those managed in primary care. Patients receiving care at a secondary, tertiary, or central hospital had 35%, 66% and 41% increased adjusted incidence of CDI compared to those managed in primary care, respectively. National incidence of CDI is estimated at 53.89 cases per 100 000 hospitalizations (CI95% 51.58-56.29), the incidence of recurrence at 21.39 (CI95% 15.06-29.48) cases per 1 000 cases and a recurrence rate of 2.14% (CI95% 1.51-2.94). Compared to European countries, we found a comparable incidence of CD. However, our estimates are lower than those for the United States. Compared to high-income countries, this study found a comparatively lower CD recurrence.

New Delhi metallo-β-lactamase (NDM)-producing Gram-negative bacteria have spread globally and pose a significant public health threat. There is a need to better define risk factors and outcomes of NDM-1 clinical infection. We assessed risk factors for nosocomial infection with NDM-1-producers and associated in-hospital mortality. A matched case-control study was conducted during a nosocomial outbreak of NDM-1-producers in an adult intensive care unit (ICU) in South Africa. All patients from whom NDM-1-producers were identified were considered (n=105). Cases included patients admitted during the study period in whom NDM-1 producing Gram-negative bacteria were isolated from clinical specimens collected ≥48 hours after admission, and where surveillance definitions for healthcare-associated infections were met. Controls were matched for age, sex, date of hospital admission and intensive-care admission. Conditional logistic regression was used to identify risk factors for NDM-1 clinical infection and associated in-hospital mortality. 38 cases and 68 controls were included. Klebsiella pneumoniae was the most common NDM-1-producer (28/38, 74%). Cases had longer mean hospital stays (44.0 vs. 13.3 days; P < 0.001) and ICU stays (32.5 vs. 8.3 days; P < 0.001). Adjusting for co-morbid disease, the in-hospital mortality of cases was significantly higher than controls (55.3% vs. 14.7%; AOR, 11.29; P < 0.001). Higher Charlson co-morbidity index score (5.2 vs. 4.1; AOR, 1.59; P = 0.005), mechanical ventilation days (7.47 vs. 0.94 days; AOR, 1.32; P = 0.003) and piperacillin/tazobactam exposure (11.03 vs. 1.05 doses; AOR, 1.08; P = 0.013) were identified as risk factors on multivariate analysis. Cases had a significantly higher likelihood of in-hospital mortality when the NDM-1-producer was Klebsiella pneumoniae (AOR, 16.57; P = 0.007), or when they had a bloodstream infection (AOR, 8.84; P = 0.041). NDM-1 infection is associated with significant in-hospital mortality. Risk factors for hospital-associated infection include the presence of co-morbid disease, mechanical ventilation and piperacillin/tazobactam exposure.

Canadian health systems fare poorly in providing timely access to elective surgical care, which is crucial for quality, trust, and satisfaction. We conducted a cross-sectional analysis of surgical wait times for adults receiving non-urgent cataract surgery, knee arthroplasty, hip arthroplasty, gallbladder surgery, and non-cancer uterine surgery in Ontario, Canada, between 2013 and 2019. We obtained data from the Wait Times Information System (WTIS) database. Inter- and intra-hospital and surgeon variations in wait time were described graphically with caterpillar plots. We used non-nested 3-level hierarchical random effects models to estimate variation partition coefficients, quantifying the proportion of wait time variance attributable to surgeons and hospitals. A total of 942,605 procedures at 107 healthcare facilities, conducted by 1,834 surgeons, were included in the analysis. We observed significant intra- and inter-provider variations in wait times across all five surgical procedures. Inter-facility median wait time varied between six-fold for gallbladder surgery and 15-fold for knee arthroplasty. Inter-surgeon variation was more pronounced, ranging from a 17-fold median wait time difference for cataract surgery to a 216-fold difference for non-cancer uterine surgery. The proportion of variation in wait times attributable to facilities ranged from 6.2% for gallbladder surgery to 23.0% for cataract surgery. In comparison, surgeon-related variation ranged from 16.0% for non-cancer uterine surgery to 28.0% for cataract surgery. There is extreme variability in surgical wait times for five common, high-volume, non-urgent surgical procedures. Strategies to address surgical wait times must address the variation between service providers through better coordination of supply and demand. Approaches such as single-entry models could improve surgical system performance.

Long wait times for scheduled surgery are a major problem in Canadian health systems. We sought to determine the extent to which single-entry referral models (next available consultation), team-based care models (next available surgery regardless of consulting surgeon), or both could affect wait times for consultations and surgery. We performed a discrete-event simulation study of wait times for consultations and surgeries for knee and hip joint replacement in Ontario’s 5 postal regions using prospectively collected data on surgical wait times. We simulated the effects of coordinated referral models on the wait time for consultation (wait 1) and surgery (wait 2). Coordinated models led to larger reductions in high-outlier wait times (as reflected by the 90th percentile and the percentage of patients exceeding wait-time targets) than on median wait times when compared with the status quo. Single-entry referral models largely influenced wait 1, and team-based models of care affected only wait 2. Fully integrated models incorporating both single-entry referral and team-based care largely prevented patients from exceeding both wait-1 and wait-2 targets; the percentage of patients exceeding wait-1 targets in these models was 0% in all regions, and the percentage exceeding wait-2 targets was 0% except for Ontario West (2.0%, from 35.7% at baseline), East (1.1%, from 22.7% at baseline), and North (1.0%, from 25.1% at baseline). Coordinated referral and practice models improve access to scheduled surgery in Canadian health systems. Implementation of these models could largely eliminate prolonged wait times for joint replacement surgery in Ontario.

Little is known about the existing structure and function of referral networks in the prevalent referral system for specialized surgical care in Canada, which is based on direct physician referral to specialists in a largely unmanaged referral marketplace. Our objective was to describe and analyze the referral networks of referring physicians and surgeons for common surgical procedures in Ontario, to better understand potential barriers to single-entry models. We analyzed referral networks for patients between referring physicians and surgeons for 9 common scheduled surgical procedures from 2016 to 2019 using administrative data sources in Ontario. We described the connectedness of referring physician-surgeon pairs using descriptive measures and graphical social network analysis. The median number of surgeons connected to a referring physician for patients having a particular surgical procedure ranged from 1 (interquartile range [IQR] 1-3) for spine surgery to 3 (IQR 1-4) for knee arthroplasty and 3 (IQR 2-5) for noncancer uterine procedures. Referral network structure varied according to the procedure studied. Spine surgery was highly clustered with a small number of larger groups; gallbladder, inguinal hernia, and noncancer uterine surgery were highly distributed with many small groups within the referral network. Breast cancer surgery occurred in a largely distributed network, but with a skewed distribution reflecting a few small groups with large numbers of patients. Improving surgical wait times by coordinating surgical referrals will require approaches that address the structure of existing referral networks. Most physicians refer their patients to a very small number of surgeons, suggesting that referring physicians largely do not individualize referrals to multiple different surgeons based on specific patient characteristics.

Low and middle income countries bear the majority burden of self-harm, yet there is a paucity of evidence detailing risk-factors for self-harm in these populations. This study aims to identify environmental, socio-economic and demographic household-level risk factors for self-harm in five impoverished urban communities in Johannesburg, South Africa. Annual serial cross-sectional surveys were undertaken in five impoverished urban communities in Johannesburg for the Health, Environment and Development (HEAD) study. Logistic regression analysis using the HEAD study data (2006-2011) was conducted to identify household-level risk factors associated with self-harm (defined as a self-reported case of a fatal or non-fatal suicide attempt) within the household during the preceding year. Stepwise multivariate logistic regression analysis was employed to identify factors associated with self-harm. A total of 2 795 household interviews were conducted from 2006 to 2011. There was no significant trend in self-harm over time. Results from the final model showed that self-harm was significantly associated with households exposed to a violent crime during the past year (Adjusted Odds Ratio (AOR) 5.72; 95% CI 1.64-19.97); that have a member suffering from a chronic medical condition (AOR 8.95; 95% 2.39-33.56) and households exposed to indoor smoking (AOR 4.39; CI 95% 1.14-16.47). This study provides evidence on household risk factors of self-harm in settings of urban poverty and has highlighted the potential for a more cost-effective approach to identifying those at risk of self-harm based on household level factors.

Classification of waste is an essential part of waste management to limit potential environmental pollution; however, global systems vary. The objective was to understand the waste classification of high density sludge (HDS) from acid mine drainage (AMD) treatment, according to selected global systems. Three sludges from two limestone treatment plants, and three others from a limestone and lime treatment plant from the Mpumalanga coalfields of the Republic of South Africa (RSA) were evaluated. Systems for the RSA, Australia, Canada, China, and the United States Environmental Protection Agency (USEPA) were considered. The USEPA system rated all six sludges non-hazardous, Canadian and Chinese systems allocated a hazardous status to one sludge from the limestone treatment plants based on Ni solubility. The RSA system considered two of the sludges from limestone treatment plants to be higher risk materials than did the other countries. This was due mainly to the RSA system’s inclusion of Mn and use of appreciably lower minimum soluble levels for As, Cd, Pb, Hg, and Se. None’s use of lime resulted in higher soluble Mn. Minimum leachable concentration thresholds for Cd, Hg, Pb, As, and Se in the RSA system were below method detection limits for Toxicity Characteristic Leaching Procedure (TCLP) extracts, making the guidelines impractical, and revision is advised. Considering all the systems, the probability that the HDS from the coalfields of Mpumalanga, South Africa will be classified as hazardous waste increases if the material is only subjected to limestone treatment because of Ni solubility.

Rehabilitating coal gasification ash dumps by amendment with waste-activated sludge has been shown to improve the physical and chemical properties of ash and to facilitate the establishment of vegetation. However, mineralization of organic N from sludge in such an alkaline and saline medium and the effect that ash weathering has on the process are poorly understood and need to be ascertained to make decisions regarding the suitability of this rehabilitation option. This study investigated the rate and pattern of N mineralization from sludge in a coal gasification ash medium to determine the prevalent inorganic N form in the system and assess the effect of ash weathering on N mineralization. An incubation experiment was performed in which fresh ash, weathered ash, and soil were amended with the equivalent of 90 Mg ha−1 sludge, and N mineralization was evaluated over 63 d. More N (24%) was mineralized in fresh ash than in weathered ash and soil, both of which mineralized 15% of the initial organic N in sludge. More nitrification occurred in soil, and most of the N mineralized in ash was in the form of ammonium, indicating an inhibition of nitrifying organisms in the ash medium and suggesting that, at least initially, plants used for rehabilitation of coal gasification ash dumps will take up N mostly as ammonium.