Full document - International Hospital Federation

International 

Hospital 

Federation 

Internat 

atio 

nal Hospit 

ital 

F ed 

er 

ation | Fé 

dération Int 

nter 

erna 

national 

e de 

s Hôpi 

taux 

| Fed 

erac 

ació 

ión Inte 

ternac 

acio 

ional de Hos 

pi 

tale 

les 

Hospital and Healthcare Innovation Book 

2009/2010 

www.ihf-fih.org 

Innovati 

tion 

and 

str 

trat 

ateg 

y 

Crea 

tivi 

ty and 

healt 

lthcare mana 

nage 

ment 

Risk 

manag 

agem 

emen 

ent progra 

rammes 

Infe 

fect 

ctious 

dis 

ease 

surveil 

illa 

lanc 

nce 

Gl 

obal 

con 

ontr 

trol 

of hepa 

titi 

tis B 

Innova tion 

and 

cli 

lini 

nica 

cal specia 

lities 

Burn 

rns 

Cardiova 

vasc 

scul 

ular 

dis 

isea 

ease 

Onco 

logy 

Physical 

the 

hera 

rapy 

Surg 

ery 

Innovation in patien 

t ca 

re 

Surgical 

site infe 

ctio 

ns 

Patient ha 

ndling 

IHF Reference 

The international Ho 

spital 


Go 

ve 

rning Council 

Secretariat 

Membership

International 



ICT DEVELOPMENTS 

Xxxxxxx slug here 2008 

068 International XXXXXX 

na 

al 

Hospital Federation | 

Fédération Internationale na 

ti 

na 

ale 

des Hôpitaux | 

Federación Internacional de Hospitales 

XXXXXXXXXXXXXXXX 

Hospital and Healthcare Innovation Book 

2009/2010 

www.ihf-fih.org 

Pro-Brook Publishing 

The International Hospital Federation Reference Book Book 2008/2009 067 1

Introduction 

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2 International Hospital Federation Reference Book 2008/2009 

e-Mail: steriking@wipak.com

Contents 

Contents 

07 Foreword 

José Carlos Abrahão 

09 Introduction 

Eric de Roodenbeke 

Innovation and strategy 

14 Creativity and innovation in healthcare management 

Kenneth Hekman 

17 A comprehensive risk and emergency management 

programme for hospitals: a new approach 

Marcel R Dubouloz 

25 The Accelerating Access Initiative: experience with a 

multinational workplace programme in Africa 

S Van der Borght, V Janssens, MF Schim van der Loeff, 

A Kajemba, H Rijckborst, JMA Lange and TF Rink 

de Wit 

28 Strategy to enhance influenza surveillance worldwide 

Justin R Ortiz, Viviana Sotomayor, Osvaldo C Uez, 

Otavio Oliva, Deborah Bettels, Margaret McCarron, 

Joseph S Bresee and Anthony W Mounts 

34 Global control of hepatitis B virus: does treatment 

induced antigenic change affect immunization? 

C John Clements, Ben Coghlan, Mick Creati, Stephen 

Locarnini, Richard S Tedder and Joseph Torresie 

41 Using satellite images of environmental changes to 

predict infectious disease outbreaks 

Timothy E Ford, Rita R Colwell, Joan B Rose, Stephen 

S Morse, David J Rogers and Terry L Yates 

46 Use of unstructured event-based reports for global 

infectious disease surveillance 

Mikaela Keller, Michael Blench, Herman Tolentino, Clark 

C Freifeld, Kenneth D Mandl, Abla Mawudeku, Gunther 

Eysenbach and John S Brownstein 

Innovation and cinical specialities 

54 Burn management 

M Davey, B Ayeni, Y Ying and MJ Duncan 

68 Cardiovascular risk factor trends and options for 

reducing future coronary heart disease mortality in the 

United States of America 

Simon Capewell, Earl S Ford, Janet B Croft, Julia A 

Critchley, Kurt J Greenlund and Darwin R Labarthe 

76 The breast service psychosocial model of care project 

Lauren K Williams PhD and G Bruce Mann 

81 Supporting cancer control for indigenous Australians: 

initiatives and challenges for Cancer Councils 

Shaouli Shahid, Kerri R Beckmann and Sandra 

C Thompson 

88 Company profile: Technology of the 21st Century 

Pioneers in Diagnostic Imaging: Reliability and 

advanced technology add value and increase safe 

diagnosis 

Shimadzu Europa GmbH 

90 Breast Cancer – a review for African surgeons 

Adisa Adeyinka Charles MD and Alexandra M Easson 

109 Responding to challenges in physical therapy 

Catherine Sykes, Brenda Myers, Marilyn Moffat and 

Tracy Bury 

112 Population based surgery in low and middle income 

countries 

David A Spiegel, Richard Gosselin, Adam Kushnerand 

Stephen Bickler 

118 Company profile: Wipak Medical – Steriking ® 

specialized packaging for hospital sterilization 

WIPAK Medical 

Hospital and Healthcare Innovation Book 2009/2010 3

Contents 

Healthcare transformation 

We'll take 

you there. 

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Agfa and the Agfa rhombus are trademarks of Agfa-Gevaert N.V. or its affiliates. All rights reserved. 

4 International Hospital Federation Reference Book 2008/2009

Contents 

Innovation in patient care 

120 Surgical Site Infections (SSIs), antimicrobial agents, 

universal precautions and post-exposure prophylaxis 

Jonathan Samuel and Wakisa Mulwafu 

127 Have we created an alternative MSD risk from a 

reliance on hoisting solutions? An academic review of 

patient handling research 

M Fray 

IHF reference 

132 About the International Hospital Federation 

136 The IHF Governing Council 

137 The Secretariat Staff 

139 IHF Members 

144 Corporate member profiles 

Editorial Staff 

Executive Editor: 

Eric de Roodenbeke, PhD 

Desk Editor: 

Sheila Anazonwu, BA(Hons), MSc 

Editorial Board 

Dr René Peters 

Dutch Hospital Association 

Norberto Larroca 

Camara Argentina de Empresas de Salud 

Dr Harry McConnell 

Griffith University School of Medicine (Australia) 

Dr Persephone Doupi 

STAKES 

Editorial Office 

Immeuble JB SAY, 

13 Chemin du Levant, 

01210 Ferney Voltaire, France 

Email: info@ihf-fih.org 

Internet: www.ihf-fih.org 

Subscription Office 

International Hospital Federation 

c/o MB Associates 

52 Bow Lane, London EC4M 9ET, UK 

Telephone: +44 (0) 20 7236 0845 

Fax: +44 (0) 20 7236 0848 

ISBN 0 900590 40 8 

Published by Pro-Brook Publishing Limited for 

the International Hospital Federation 

13 Church Street, 

Woodbridge, 

Suffolk IP12 1DS, UK 

Telephone: +44 (0) 1394 446006 

Fax: +44 5601 525315 

Internet: www.pro-brook.com 

For advertising enquiries contact 

Pro-Brook Publishing Limited 

on +44 (0) 1394 446006 

Copyright 

Text © International Hospital Federation or 

otherwise stated 2009 

All rights reserved. 

No part of this publication may be reproduced, 

stored in a retrieval system, or transmitted in any 

form or by any means, electronic, mechanical, 

photo-copying, recording or otherwise without 

the permission of the Publisher. 

The information contained in this publication is 

believed to be accurate at the time of 

manufacture. Whilst every care has been taken 

to ensure that the text and listing information is 

correct, the Publisher and International Hospital 

Federation can accept no responsibility, legal or 

otherwise, for any errors or omissions or for 

changes to details in the text or in sponsored 

material. 

The products and services advertised are those 

of individuals or companies and are not 

necessarily endorsed by the or connected with 

the International Hospital Federation. The views 

expressed in this publication are not necessarily 

those of the Publisher or of the International 

Hospital Federation. 

Applications for reproduction should be made in 

writing to the Publisher. 



Hospi tal and Healthc 

are 

Association 

Leadership Summit 

1-2 June 2010 

Palmer Ho use 

H o t 

el, Chic 

ag 

go (USA) 

Th 

e 2 

nd IHF 

Hospital and Heal 

thcare 

Association Leadership 

Summit, will take plac 

e June 1 

2 nd , 2010, i 

n the Palmer 

House hotel i 

n Chicago (USA). 

This 

event is an opportunity to 

share experiences and knowledge with colleagues from around 

the world and will help to strengthen ties between hospital leaders. 

It is both 

a unique occasion to meet 

other leaders of hospital 

and healthcare 

organizations 

as well as 

a platform for free exchang 

e of ideas - a 

priority for IHF (Constitution, article 1.3). 

The 

event is open to IHF Full 

Members (maximum 2 people 

from each organization). 

Associate 

members 

are 

also 

welcome, 

but 

sub 

ject 

to availability. 

IHF 

Co rporate 

Partners 

are also 

invitedit to 

participate in the 2-day event 

Programme 

Day One: 

Tuesday, 

1 June 

Hospital Safety and Disaster preparedness 

Role of first-line hospitals 

Perspective of globalization of care 

Ro le 

of healthcar 

e facilities for 

edu cation 

Day Two: 

Wednesday, 

2 June 

Ethical 

hospita 

Accreditation: 

how does quality 

of care fits with the accreditation? International perspectives 

and 

evolution of process. 

Settt 

ing up international peer-reviewing exercise on hospital and healthcare performances: 

a 

future for IHF? 

High 5 initiative for Patient Safety: 

Which role for IHF? 

Perspectives 

for IHF 

st to 

Please contact 

Sev Lucas (s 

sev@ihf- 

-f 

fi ih.org 

g) 

at the IHF Secreta 

riat 

registration 

information. 

for 

a 

detailed 

pro 

g 

ramme 

and

Foreword 

Foreword 

JOSE CARLOS DE SOUZA ABRAHAO, MD 

President, International Hospital Federation 

Healthcare delivery to populations is constantly subject to change. With globalization, 

technological advances and new developments, large numbers of people can be 

reached quicker, with increasingly specialized and skilled levels in delivery of care. 

This scenario, which is being transformed by pursuit of healthier lifestyles, reduction in 

alcohol and tobacco consumption, and promotion of physical activity, is also a reflection of 

the strategies implemented in the field of preventive medicine. 

The International Hospital Federation (IHF), to echo these trends, has renamed the 

International Hospital Federation Reference Book – Hospital and Healthcare Innovation 

Book. In this renamed publication, the articles featured, highlight advancement and 

developments in healthcare delivery and health services management. Through this 

medium of exchange in knowledge, ideas and practices, it is hoped that the innovations 

may serve to ensure a better future for the sector and that high quality standards are 

maintained in service delivery. 

From this edition, leaders and professionals will gain knowledge in activities in the 

treatment of breast cancer; the management of burn patients; trends and alternatives to 

reduce the risks of heart diseases; and strategies for surveillance and immunization against 

infectious and contagious diseases such as the Influenza A (H1N1). 

Within the scope of sustainability, it is worth drawing attention to the role “green actions” 

should play in planning of healthcare facilities. The advancement in technology can be an 

ally in controlling the effects caused by environmental changes. An example is the use of 

satellite imagery in the monitoring of climatic and environmental conditions around the 

world, in order to predict and prevent the emergence of infectious and contagious diseases. 

These and other issues are featured in this first edition of Hospital and Healthcare 

Innovation Book. We hope that this exchange of knowledge produces new strategies and 

creates opportunities for healthcare managers around the world. Beyond the differences 

between countries, all health services are facing and will face, over the coming years, the 

challenge of developing ways to ensure provision of better healthcare to their population. 

With this thought we hope to contribute in a dynamic and innovative way for the future of 

health. 

We wish you all a good read. ❏ 

Hospital and healthcare Innovation Book 2009/2010 07

Introduction 

Introduction 

ERIC DE ROODENBEKE, PhD 

Chief Executive Officer, International Hospital Federation 

Innovation does involve a revolution, but rather the appropriate 

use of inventions to enhance the result of a process. 

Opportunities for innovation are very frequent in health services 

and this is the reason why International Hospital Federation (IHF) 

has decided to rename its reference yearbook The Hospital and 

Healthcare Innovation Book. This move is not to look more 

fashionable or to present a cutting edge image, but it is simply to 

emphasis the potential of adopting new approaches to enhance 

hospital performance. As a vehicle for cross fertilization of 

knowledge, IHF must also show that decision makers should not 

only constantly think out of the box but should also rely on 

activities that have achieved successful results in a given 

environment. 

Innovation does not involve systematically experimenting but it 

is more often customizing and introducing, at full scale or within a 

new environment, that which has been proven effective or initiated 

locally at a small scale. Innovation also presents leaders of health 

services the opportunity to observe evolution in the various 

healthcare related activities both beyond and across borders. This 

annual publication offers a chance to gain an insight into matters 

that would not ordinarily feature as priority in your daily schedule. 

It is the role of IHF to highlight all dimensions that may affect 

strategic development of healthcare facilities both in the 

developed and developing world. Because healthcare facilities 

confront life and death issues, there is little room for unproven 

experiences. There should, however, be readiness and openness 

to either explore or implement novel processes that may result in 

improved performance. 

It is also the role of IHF to encourage and assist decisionmakers 

of the individual facility in making choices as well as 

influencing policy-makers whose choices wrongly influence 

performance in service delivery. 

In this edition, you will have the opportunity to read how 

creativity can be applied to management and should not only be 

considered as the territory of artists. It is obvious that by bringing 

creativity in the organization, top managers can both engage the 

staff and create an extraordinary movement and stimulation. In an 

ever rapidly evolving world, it is important to reconcile the need to 

rely on data and the capacity to look for new approaches that 

cannot be documented. 

On the other hand, the reader will discover a new approach in 

risk and emergency confrontation. This concept is contrary to that 

of creativity, as it addresses the ways in which processes to 

reduce vulnerability and response to any potential disaster, can be 

reconciled in hospitals and healthcare facilities. This year, as past 

years, has witnessed catastrophes and with each event, the 

capacity of healthcare facilities to respond immediately to 

emergencies, has made a difference in survival and treatment of 

the injured. This very comprehensive article should be considered 

as a key tool for hospital decision-makers, with which to ensure 

they take seriously their role and responsibility in providing safety 

to the population they serve. If responding to the demand for care 

is an obvious function of hospitals it is not always the same for 

providing safety to the population. Recognition of this factor, 

before rather than after the occurrence of a disaster, is possible 

through advocating for and adoption of a comprehensive 

approach. Funding should not be an issue if politicians are 

convinced of such a role. Response to fire threats is an accepted 

priority around the world and fairly well resourced, healthcare 

decision-makers should, therefore, make a case for having a 

similar support when it comes to health threat. 

This year communicable diseases have been very much under 

the spotlight with the H1N1 flu threat. Although, to date, this threat 

has failed to manifest as a real public health issue when the death 

toll is compared with that from annual seasonal flu epidemics, 

hospitals and healthcare facilities have, nevertheless, been on the 

front line to respond. The IHF has surveyed major hospital and 

healthcare associations and found that they have all been involved 

in one form or another in the response strategies developed (Full 

survey results: www.ihf-fih.org). Enhancement of influenza 

surveillance in order to avoid excessive and costly mobilization 

should be the way forward, in order to prevent the consequences 

of lack of preparedness. When reading the other articles related 

to infectious diseases you will appreciate and come to understand 

emerging issues, one of which addresses the issue of coverage by 

immunization. The work done on hepatitis B vaccine provides a 

warning with regards to the use of treatment in facilities, which may 

stimulate resistance and thereby result in a reduction in the 

coverage of immunization programmes. The change in 

environment has an impact in the development of communicable 

diseases. Satellite images can help to shape adequate responses 

ahead of time, not through major investment but just by appropriate 

use of existing technologies. While advanced technology should 

not be disregarded the appropriate use of low-technology has still 

to be better mastered. The existing event-based outbreak 

systems can provide large support in decision-making by 

Hospital and Health-care Innovation Book 2009/2010 09

Introduction 

monitoring the evolution of an outbreak. 

All countries are currently facing the double burden of diseases 

with the growing importance of non-communicable diseases 

(NCDs) in the emerging and developing world. For this reason 

there is need to attach much importance to matters relating to 

responses to injuries like burn management as well as to 

cardiovascular risks and cancer, for such population groups in a 

deprived area of a rich country like Australia. We also have an 

opportunity to reflect on the fact that although enhanced medical 

knowledge helps in improving outcomes, illness is also related to 

psychosocial conditions. Failure to fully appreciate this treatment 

source can undermine potential success. 

The article which argues that surgery should be considered as 

part of the primary care package of services, demonstrates how 

by reconsidering the place of intervention and the role of health 

professionals, it is possible to provide response without mobilizing 

massive resources. The Human resource shortage calls 

professions to reconsider their ability to respond to growing 

challenges. By featuring the article on physical therapy, IHF has 

sought also to expose the diversity of skills needed in caring for 

patients. In relation with the role of physical therapists the issue of 

patient handling shows the importance of using best practices to 

face this situation while protecting the health of workers. 

Last but not least, it was not possible to cover a large spectrum 

of issues without having an article related to patient safety. 

Appropriate use of recommendations can make a big difference in 

results. Innovation can be simple things but well and 

systematically implemented. 

Finally, as there is now greater recognition of the role of the 

private sector in supporting health, it was important to highlight the 

role companies can play for the health of their workers. It is usual 

that in remote places where companies have a large workforce 

that they create their own facilities which in return benefit the 

population. For HIV treatments, it is also obvious that employers 

should play an important role in providing access. 

Like in any approach that covers a large spectrum of issues, it 

can be argued that there is not enough or too much on a topic and 

that some important topics are missing. This 2009/2010 edition is 

not intended to be comprehensive, but as mentioned above, it is 

to provide insight to decision-makers and enable them to embrace 

and absorb the full spectrum of available knowledge. 

I do hope you will have a pleasant reading and that one or 

another article will be a sparkle triggering innovation in your 

facility. ❏ 

10 Hospital and Health-care Innovation Book 2009/2010

Innovation and strategy 

14 Creativity and innovation in Healthcare management 

Kenneth Hekman 

17 Comprehensive risk and emergency management 

programme for hospitals: a new approach 

Dr Marcel R Dubouloz 

25 The Accelerating Access Initiative: experience with a 

multinational workplace programme in Africa 

S Van der Borght, V Janssens, MF Schim van der Loeff, 

A Kajemba, H Rijckborst, JMA Lange and TF Rink 

de Wit 

28 Strategy to enhance Influenza surveillance worldwide 

Justin R Ortiz, Viviana Sotomayor, Osvaldo C Uez, 

Otavio Oliva, Deborah Bettels, Margaret McCarron, 

Joseph S Bresee and Anthony W Mounts 

34 Global control of hepatitis B virus: does treatment 

induced antigenic change affect immunization? 

C John Clements, Ben Coghlan, Mick Creati, Stephen 

Locarnini, Richard S Tedder and Joseph Torresie 

41 Using satellite images of environmental changes to 

predict infectious disease outbreaks 

Timothy E Ford, Rita R Colwell, Joan B Rose, Stephen 

S Morse, David J Rogers and Terry L Yates 

46 Use of unstructured event-based reports for global 

infectious disease surveillance 

Mikaela Keller, Michael Blench, Herman Tolentino, Clark 

C Freifeld, Kenneth D Mandl, Abla Mawudeku, Gunther 

Eysenbach and John S Brownstein 


Innovation and strategy: creativity 

Creativity and innovation in 

healthcare management 

ARTICLE BY BY KENNETH HEKMAN, MBA 

President, Health Development International 

Creativity may be one of the most misunderstood topics in management. Creativity is usually associated with artists, 

those rare people who seem to be endowed with a mystical ability to make aesthetic sense out of colour, texture, shape 

and form. In the manager’s world, creativity is typically limited to picking out artworks for the walls of a new office or 

selecting a designer to develop a new logo. 

Some managers even find the topic of creativity to be 

threatening. In the logical world where decisions are based 

on statistical and financial data, working with abstractions 

rather than policies and procedures can be threatening. If artists 

do not use familiar methods, how can we measure their outcomes 

or judge their work? Likewise, how can creative geniuses 

appreciate managers’ logic and business acumen? We just don’t 

talk the same language. 

But artists, writers and inventors work with concepts that 

healthcare managers can benefit from learning. Their tools and 

language may be different, but their results can inspire, inform and 

enrich people in all walks of life. 

Why innovate? 

One area where artists and healthcare managers can agree is that 

the world is changing. Change is constant. Futurists tell us that 

knowledge is increasing at exponential rates and that we must get 

accustomed to the idea of change with increasing speed. In a 

single generation, we have seen the development of personal 

computers, faxes, email and the internet, with each creation 

bringing us closer to real-time transactions and communication 

options unimagined a few decades earlier. Change is the one 

constant in every aspect of our work and relationships. 

Change is often disruptive. It challenges routine ways of thinking 

and working. It makes us uncomfortable and requires us to adopt 

unfamiliar processes as we adapt to a new ways of thinking and 

working. Health care delivery seems to be at the apex of disruptive 

change. Laparoscopic surgical techniques are making some 

open-incision methods obsolete. New pharmaceutical options are 

reducing the length of hospital stays. A global recession is proving 

to challenge personal values and adjust priorities for funding 

agencies. 

Change can also stimulate creativity. Artists sometimes look for 

opportunities by studying contrasts and conflicts between light 

and dark, young and old, clean and dirty. Healthcare managers 

can also look for opportunities brought about by change. Eastern 

bloc countries are finding opportunities to improve healthcare 

delivery by adopting free market enterprise business models in 

contrast to the former state-run institutions. African hospitals are 

looking for ways to prevent malaria so they can reallocate limited 

inpatient resources for other diseases. Asian healthcare leaders 

are seeking ways to improve service attitudes of healthcare 

workers in an effort to stem the tide of conflicts from dissatisfied 

patients. Changes and conflicts stimulate adaptive ideas and 

behaviours. Healthcare managers who embrace changes and 

learn from conflicts are more able to anticipate the consequences 

and adapt more rapidly. 

Just as physicians on the cutting-edge of medical research find 

new diagnostic and treatment options for combatting disease, so 

also healthcare managers on the cutting-edge of innovative 

management techniques lead the way in discovering methods for 

improving clinical outcomes, gaining efficiencies and building 

healthier communities. Healthcare managers who are constantly 

searching for best practices worthy of adoption at their own 

hospitals and clinics gain a competitive advantage over others and 

advance the standards for quality of care and organizational 

performance. Innovators create new paradigms that make other 

methods obsolete. They introduce fresh ways of thinking and 

acting that advance civilization itself. 

What makes innovators different? 

Innovative healthcare managers can be found in every country and 

organizational setting. Innovation or creativity is not constrained by 

the presence of resources. In my experience as a healthcare 

consultant and trainer on five continents, some of the most 

innovative healthcare managers are those who become 

resourceful because of resource constraints. Adversity can 

stimulate invention rather than stifle it. 

Everett M Rogers, author of Diffusion of Innovations describes 

innovators as the earliest adopters of new technology and ideas. 1 

He describes them as venturesome, eager to try new ideas, 

sometimes desiring the hazardous, the rash, the daring and the 

risky. They comprise only about 2.5% of the population. Another 

13.5% are early adopters. They are more respectable opinion 

14 Hospital and Healthcare Innovation Book 2009/2010


leaders and are viewed as role models by their peers. 

Some of the most innovative healthcare managers exhibit the 

following qualities: 

✚ They are consistently curious and eager to learn. Their 

commitment to continuous learning also requires them to 

abandon ideas that are no longer useful or that get in the way 

of advancing knowledge and understanding. They invest in 

themselves and their teams by expanding their management 

skills, exploring trends in healthcare and in other industries, 

visiting other organizations and reading a wide variety of 

management literature. They may take online courses and 

local workshops to learn from leading experts in healthcare 

management and to extend their network with other healthcare 

managers. They may engage a mentor to help them honestly 

assess their competence and to guide their career path. 

✚ They foster a freedom to experiment, even if it means there 

will be failures. Innovative healthcare managers understand 

that employees grow and thrive when they have opportunities 

to express their ideas and try new methods for improving 

patient care. They also understand the need to preserve and 

protect patient safety, and they strike a healthy balance 

between experimentation and tradition by regularly reviewing 

policies and procedures. The key is to create an environment 

where employees feel safe in suggesting new ideas that 

advance the standards for quality assurance. 

✚ Innovative managers dare to take a creative approach to 

ordinary decisions. Nobel Prize winner, Albert Szent-Györgyi, 

said, “Discovery consists of looking at the same thing as 

everyone else and seeing something different.” For the 

healthcare manager, that might mean looking at the pressure 

of competition and seeing a niche that others have overlooked. 

A creative administrator might view patient complaints as 

opportunities for service improvements or look at compliance 

challenges for their potential to improve clinical quality. 

Discovery can be a simple thing like playing with scheduling 

options to improve throughput or being open to fresh ideas 

from employees to reduce turnover. The creative healthcare 

manager looks beyond traditional problems to “see something 

different.” They conduct brainstorming sessions to draw out 

the best ideas of front-line staff. The technique, which was 

translated at a workshop in Latin America as “a thunderstorm 

of ideas,” empowers employees to take personal responsibility 

for solving problems. Front-line staff members encounter 

operational problems first and often see solutions before 

managers do. 

✚ Innovators commit to strategic planning for their organizations. 

They devote a few days each year to assemble department 

supervisors and the management team to evaluate how well 

the organization is serving its community. They analyze the 

trends impacting the hospital’s future, assess their readiness to 

meet new challenges and set goals for achieving 

improvements in operations and in service to the community. 

Every organization can benefit from planning. It takes 

courageous leadership to initiate the process and follow 

through with the plan, applying creative solutions to business 

development challenges. 

Examples 

Innovators can be found in the executive suites and on the front 

lines in healthcare delivery systems. Creative managers are 

sometimes recognized for their innovation by public awards, but 

unsung heroes can also be found in the daily experiences at 

hospitals, clinics and public health programmes in every culture. 

Here are a few examples: 

✚ Quint Studer became the administrator of a hospital in Florida 

USA based on his reputation for improving patient satisfaction 

at his previous employer. When he started, he approached 

employees, one at a time to introduce himself. He said, “Hi. 

My name is Quint Studer. I’m the new administrator here and I 

work for you. What can I do for you today?” A nurse asked 

him to trim the bushes near where she parked her car so it 

would be safer for her when she finished her shift after dark. 

While she worked, he had the bushes trimmed and put up a 

small fence. She was impressed that this administrator cared 

about her safety and shared the story with her co-workers. He 

earned their trust for other, more significant changes as time 

went on. 2 

✚ An engineer at a hospital in the Philippines looked for a way to 

assure a reliable flow of oxygen from the central supply area to 

the surgical suites. He developed a simple pipeline and 

adapted a water pump by reversing the polarity to convert it to 

a low-cost, highly reliable tool for delivering the vital resource 

to where it was needed most. While this method may not be 

fully compliant with requirements in all countries, it was efficient 

and effective in this setting. 

✚ At Park Nicollet, a medical clinic in Minnesota USA, inventory 

of medications was the third highest expense. Managing the 

inventory was crucial to the financial health of the organization 

as much as keeping current medications was vital to patient 

care. Managers found that at three departments in one 

location, approximately 628 individual containers of medication 

were stored with an overall price tag of US$ 32,513. Of this 

amount, 28% were high-cost, low-use medications - items 

regularly stocked but infrequently used. By setting up a system 

that automatically signaled when new items were needed, 

improvement teams eliminated 29% of the stock in one 

location and reduced cost by 50%. 3 

✚ At Selian Lutheran Hospital in Tanzania, managers were 

frustrated that only 50% of HIV-AID patients in nearby villages 

would comply with the requirement for regular visits to the 

clinic to receive the medications needed to keep them alive. 

They rallied the assistance of some of the more responsible 

patients to become mentors to their co-sufferers. The 

voluntary adherence counselors befriended others with HIV- 

AIDS and raised the compliance rate to 90%. 4 

Examples like these may sound like simple common sense, but 

common sense often fails to become common practice. 

Innovative healthcare managers search for ways to improve clinical 

outcomes, employee engagement, resource usage and the 

satisfaction of patients, visitors and staff at every opportunity. They 

recognize that simple tactics can sometimes yield exponential 

results. 

I think I can 

If ingenuity doesn’t come naturally, you are not alone; but the good 

news is that creativity appears to be a learned behavior. Creativity 

begins with a positive attitude, confidence and belief in your 



abilities. Roger von Oech, author of A Whack on the Side of the 

Head, 5 describes an extraordinary insight from the experience of a 

major oil company. The management team was concerned about 

why some of their research and development people seemed to 

have more productive and better ideas than others. They brought 

in psychologists to study educational backgrounds, where people 

grew up, favourite colours and other issues. After three months of 

study, the psychologists concluded that the chief factor that 

separated the two groups was that the creative people thought of 

themselves as creative, and the less creative people didn’t. Those 

who held a creative self-concept allowed themselves to get into an 

innovative frame of mind and to play with their knowledge. Those 

who didn’t embrace their creativity were either too practical or 

were caught in routines in their thinking. 

Healthcare managers can learn to be creative, and their 

innovation can lead to improvements in clinical quality, financial 

results and community impact. Approaching problems with an 

innovative frame of mind can yield surprising results and restore 

a fresh motivation for making a difference as a healthcare 

manager. ❏ 

References 

1. 

Everett M Rogers, Diffusion of Innovations, New York: The Free Press, 2003 

2. 

Quint Studer, Hardwiring Excellence, Fire Starter Publishing, 2003 

3. 

John Black with David Miller, The Toyota Way to Healthcare Excellence, Health Administration 

Press, 2008 

4. 

Based on personal conversations with Mark Jacobson, MD, Administrator at Selian Lutheran 

Hospital, Arusha, Tanzania in 2006 

5. 

Roger von Oech, A Whack on the Side of the Head, Creative Think, 1983 

Kenneth Hekman is the President of Health Development 

International, a US-based global healthcare management training 

and consulting partner with IHF. www.healthdevelopment.org 


Innovation and strategy: risk management 

A comprehensive risk and emergency 

management programme for 

hospitals: a new approach 

ARTICLE BY MARCEL R DUBOULOZ 

Senior Medical Consultant, Health Development Counseling and Audit (HDCA) – Geneva 

This article looks at risk management in hospitals and the management of emergencies and disasters. It 

considers the models and policies that exist in private companies and the core components of a risk 

management strategy for hospitals. Building on this knowledge the author puts forward a new plan for 

hospitals called the Comprehensive Risk and Emergency Management Programme (CREMP) and explains the 

advantages of this approach. 

The World Health Organization (WHO) has, over the years, 

advocated adoption, by all Members States, laws and 

regulations for safer hospitals during major crisis and 

disasters. The United Nations International Strategy for Disaster 

Reduction (UNISDR) and WHO launched the 2008-2009 

campaign for “safe hospitals”, the primary focus of which is the 

reduction in “vulnerabilities” 1 , that result in major loss of life, 

services in hospitals. Global indicators show that lack or weak 

management of vulnerabilities in hospitals lead to catastrophic 

loss in services in both high and low-income countries. The 2009 

World Health Day was dedicated to “safe hospitals”. Besides 

providing care, hospitals also have a major role to play in 

management of public health programmes during disasters and 

health crisis. With hospitals acting as key sources of information in 

the surveillance system 2 , priority is now increasingly being given to 

development of the concepts of continuity of delivery of essential 

services and surge capacity. Hospitals are not isolated islands: 

therefore the objective should be to develop a global health 

system, prepared for disasters and major emergencies. There 

must be a continuum between the concept of “safer hospitals” 

(focus on reducing vulnerabilities) and mass casualty 

management. Management of hospital vulnerabilities is best 

addressed and controlled when brought into the broader concept 

of hospital risk management. 

Risk management in hospitals 

Many countries, over the years, have developed complex laws and 

regulations to regulate and control medical and other healthrelated 

activities 3 , such as medical practice, blood safety, quality 

assurance, safety and security, and accreditation. Ministries of 

Health (MoH) and/or specialized governmental institutions are 

often the bodies mandated to monitor compliance 4 . The majority 

of countries, however, have yet to develop exhaustive 

administrative and technical guidelines for full implementation of 

such policies as well as to identify and produce documentation on 

best practices. 

Management of emergencies and disasters 

Many countries have developed national multi-sectoral policies on 

management of emergencies 5 , particularly for mass casualty 

management (MCM) – also referred as Comprehensive 

Emergency Management Programme 6 (CEMP). The Ministry of 

Interior or a special Unit in the office of the Prime Minister is usually 

entrusted with the responsibility of developing and implementing 

the policies, from conception of plans to response management 7 . 

Some countries or States in USA have also adopted similar 

CEMPs for major governmental Institutions 8 . The trend is more 

and more to decentralize the response capacity 9 for MCMs. In 

these countries usually the MoHs have also developed their 

respective MCM policies, Emergency Medical Services (EMS) 

policies, and Hospital Emergency Response Plans 10 . The 

increasing trend is towards development of management of 

emergencies in hospitals within the framework of CEMPs 11 . 

Risk management in hospitals 

In parallel to development of the emergency (disaster) 

management strategies, many hospitals have introduced risk 

management approaches usually under the umbrella of 

Comprehensive 12 Risk Management Programmes 13 ”, the targets of 

which are regulated risks 14,15 , with the creation of specific 

committees for the different regulated risks. Many countries have 

national policies on risk management in hospitals, with technical 

guidelines for implementation 16 . The risks incorporated in these 

policies are primarily routine medical and clinical risks and the 

regulated risks. Disasters are not included in these programmes. 

Hospital accreditation is also a risk management-related 

regulatory tool applied in many countries. The prerequisite, 

however, for accreditation is the existence of a risk management 

programme as well as the existence of a hospital disaster plan. 

Often the process of accreditation is linked to the concept of 

quality assurance. Various methods (including checklists 17 ) are 

used to assess and monitor. Development of quality improvement 

strategies is gaining in importance with MoHs and hospitals. There 



Figure 1: Risk management cycle in hospitals Source: HDCA 2009 

are many methods and software available for managing these 

different hospital programmes (risks management; quality 

assurance; safety). Increasing numbers of hospitals appoint a full 

time “Risk Manager” to contribute to the development, 

implementation and the management of such programmes. Also, 

many universities, professional associations and private schools 

offer training courses for “Hospital Risks Managers 18,19 ”. Although 

the exact structure of a given hospital risk management 

programme depends on the size of the facility and the scope of 

patient care and other services it offers, several key structural 

components are common and necessary for all hospital risk 

management programmes. Part of the business of “hospital risks 

management” is in connection with “vulnerabilities”. This is a 

complex issue as hospitals have various types of vulnerabilities 

that, when they interact with hazards or threats (the source of risk), 

can contribute to create risks. WHO has published several key 

documents on this particular issue 20,21 and launched a campaign in 

2008 22 as a direct contribution to improve awareness in this area 

and to advocate for the further development of existing hospital 

risk management programmes. The ISO 31000 (under 

preparation) on Risk Management will be a major step forward in 

promoting the adoption of risk management principles as a routine 

part of the management of hospitals. 

Models and policy in private companies 

Most of what is practiced in hospitals as risk management comes 

from the experiences gathered in the private sector over many 

years and much literature exists on these issues. “Business 

continuity”, “business safety”, “enterprise risk management”, and 

“comprehensive risk management” are concepts that have been 

applied by private companies for many years. Most of the private 

companies have adopted this strategic approach to ensure 

business sustainability and prosperity and to avoid preventable 

losses while others are specialized in offering services aimed at 

assisting the companies to “manage risks”. The notion of 

“business continuity” (continuity of operations for hospitals: 

continuity in the delivery of essential services) is given increasing 

priority in these programmes together with greater attention to IT. 

Business process management is the newly adopted strategy in 

this area by private companies for ensuring the success of 

business continuity and risk management. 

The diversity of models and conceptual frameworks in 

hospital risk management programmes and in hospital 

emergency (disaster) management 

The great diversity of concepts and programmes in risk 

management and emergency management allows countries to 

adopt models that best suit the local context. Nevertheless there 

are several major problematic issues in the two areas of hospital 

risk management and hospital emergency response plans (ERP; 

including contingency plans): 

✚ The Terminology. Unfortunately there is no international 

consensus on the key terms (e.g. emergency; risks 23 ; 

vulnerabilities; readiness; prevention; mitigation, recovery, safe 

hospital, essential services and so fort). It is therefore very 

difficult to compare existing risk management programmes 



Figure 2: Comprehensive risk and emergency management programme Source: HDCA 2008 

(applicable to hospitals, private business or governmental 

institutions) or existing hospital ERPs. The various UN 

Agencies (ISDR; OCHA; WHO, etc.) have not yet agreed on a 

common terminology (adding to the existing confusion). 

✚ The great diversity of conceptual frameworks. There are 

several different conceptual frameworks dealing with the 

concepts of business continuity (continuity of operations for 

institutional agencies such as hospitals) and risk management; 

vulnerability analysis and reduction; hospital risks 

management. It is difficult to compare the various existing 

models due to the absence of clear indicators for assessing 

their usefulness, their effectiveness and their efficiency. The 

strategies adopted to pilot these programmes in hospitals also 

differ from one country to another or even from one hospital to 

the other in the same country. The indicators used to assess 

and monitor these programmes and the classification of types 

of risks also vary from one model to the other. In addition, the 

concept of ERP varies greatly from one country to other one: 

management systems; components 24 of the ERPs. The 

absence of universal references and best practices. There are 

no internationally agreed best practices, either for hospital risk 

management programmes or for hospital ERP. There are many 

different references in use and none of them claim to be of 

universal value. 

✚ The diversity of standards. Although there are international 

standards (ISO) for many activities, each country has 

developed its own standards for hospital risks management 

(regulated risks). 

✚ The great diversity of methodology, IT and software. In 

private businesses, risk management programmes have long 

been managed by using high technology and software. There 

are many computerized systems that are available for 

managing programmes and managing information 25 . They all 

have strengths and weaknesses. The data that are collected 

and processed vary greatly according to the IT used. There are 

several methods to assess the risks (especially to quantify the 

risks. Many different scales are in use to rank the risks). Many 

methods that are used in quality assurance process (which 

also includes a component on risk identification and 

management) are also used in RMP in hospitals. 

✚ The absence of a link between the hospital risk 

management programme and hospitals management 

during disasters and major crisis. Existing hospital risk 

management programmes focus mainly on the safety of 

patients and equipment and quality of medical care and 

services. There are very few programmes that also make 

mention of “risks arising from disasters”. There are no 

programmes that make clear and functional links between “risk 

management programmes” and “emergency management 

during major crisis and disasters”. In other words there are no 

programmes that clearly identify and specify the links between 

the Hospital Risk Management Programme and the ERP (of 

course the plan is made to facilitate the management of the 

response during emergencies). During disasters 26 hospitals 

have not only to focus on “continuity of operations” (especially 

for essential services) but they also must focus on the capacity 



of the hospital to provide more such services (surge capacity) 

in order to contribute to the management of mass casualty 

situations. Medical surge capacity and medical surge capability 

is a key emerging concept for preparing hospitals to respond 

in disaster situations 27 . 

The core components 28 of risk management programmes 29 

in hospitals 

Although the exact structure of a given hospital risk management 

programme depends on the size of the facility and the scope of 

patient care and other services it offers, several key components 

are common and necessary to all hospital risk management 

programmes. It is, therefore, possible to identify some “core 

components” that are found in most existing programmes. The 

components selected in each model depend on the goal and 

objectives of the institutional programme. The hospital risk 

management programme, like other hospital “functions”, requires 

certain documented policies and procedures to ensure programme 

consistency and uniformity. The plans, policies and procedures are 

usually approved and adopted in accordance with established 

hospital policy and in accordance with the existing laws and 

governmental monitoring mechanisms 30 . The most common 

objectives found in hospital risks management programmes are: 

✚ to identify and to prevent cause of injury or harm to patients, 

visitors, and employees and to treat the causes and or 

consequences should an adverse event happen; 

✚ to identify, to prevent or to manage events that can jeopardize 

the safety and security of the equipment and of the 

environment; 

✚ to manage as efficiently as possible the claims and lawsuits so 

that subsequent financial losses of the institution are minimized; 

✚ to contribute to quality improvement of services offered. 

In order to implement a risk management programme, as in any 

significant project in hospitals, the first step is usually to start with: 

✚ a census of existing regulations and laws applicable to the 

hospital (including safety and security) and to medical care and 

nursing services; 

✚ the establishment of the institutional long term vision, goal and 

objectives of the risk management programme; 

✚ the establishment of the planning committee and the 

identification and the description of the various components of 

the programme. This includes the strategic choice (when 

applicable) to decide how this risk management programme 

will include or not some other already existing “programmes”, 

such as quality assurance and accreditation; safety and 

security; clinical care safety; blood safety, drug safety; 

occupational medicine, etc. Usually all these existing 

programmes are integrated into this new “comprehensive 31 risk 

management programmes”. A major issue that the planning 

committee has to thoroughly discuss is the “management of 

information”. Indeed, hospital risk management programmes 

require the management of a huge quantity of data and an 

efficient system to computerize them. Clear indicators 32 must 

be identified and defined in order to monitor the programme 

and to revise the components of the programme when 

necessary; 

✚ identification of criteria for defining and classifying the events 

(critical event, etc.). 

The various components most frequently found in hospital risk 

management programmes are: 

✚ Organization and Programme Management System 

• Organogramme. 

• Roles and responsibilities of the various stakeholders. In 

almost all HRMP a “Hospital Risk Manager” (HRM) is 

appointed. This is a key position in the institution 33 . 

• Coordination mechanisms and management of information. 

Because of the wide range of risk management functions and 

the diversity of necessary activities, both formal and informal 

mechanisms for coordination and information exchange 

must exist between the risk management programme and 

other hospital departments and functions 34 . Coordination 

extends also to the outside world with local safety and rescue 

agencies (such as fire and ambulance services) and with 

governmental institutions having a normative role or a 

supervisory role (quality assurance; accreditation, etc.). 

• Methods and processes for “risk assessment”. There must 

be a system in place with the necessary tools and methods. 

The main steps are: 1) identification of risks; (2) analysis of 

risks identified; (3) treatment of risks; and (4) evaluation of 

risks treatment strategies: (5) ongoing monitoring (see figure 

135). There are many different methods for qualifying and 

quantifying risks 36 . Anyway an important step in identifying 

risk is to identify the “hazards” (or threats) that can engender 

risks when interacting with existing vulnerabilities 37 for that 

hazard. It is also vital to develop surveillance functions (early 

detection as much as possible; sentinel events, etc.) and 

monitoring functions in order to investigate all significant 

events, and to also assess the effectiveness of the treatment 

options and the evolution of the context and hazards. The 

notion of “readiness” is unfortunately sometimes mixed up 

with the notion of “resilience” in these programmes. 

Readiness is the major outcome of Emergency 

Preparedness Programmes. The use of modern technology 

contributes to safer management of the processes. 

• Funding of the programme and links with administration and 

finance department. 

• Training activities for key stakeholders of the programme and 

staff of the hospital. 

• Logistics and resources. 

✚ Description of “regulated risks” and safety of medical 

activities 38 that are often included into the HRMP: 

• blood safety; 

• drug safety; 

• nosocomial infection; 

• security measures and security equipment (especially for fire, 

gas, chemicals and nuclear products); 

• critical 39 equipment safety (including backup systems; 

redundancy, etc.); 

• clinical and medical safety (including activities performed by 

medical staff as well as the sustainability of the provision of 

these services by ensuring that the necessary environment40 

is adequate); 

• professional risks: those risks experienced especially by 

medical staff (doctors, nurses, etc.) performing clinical 

activities in relation with patient care. 

✚ Besides the above-mentioned “regulated risks”, there are 



other “non-regulated” risks and emerging risks that occur more 

frequently, with sometimes great potential for severe 

consequences and substantial losses. Many HRMP do not 

include the “non-regulated” risks and are limited to only the 

“regulated risks” and the safety procedures that are necessary 

for quality assurance and accreditation. The trend, 

nevertheless, seems to be towards increasing consideration of 

non-regulated risks as part of the business. 

✚ Information management. This is a major component as 

HRMP requires management of l many data. Several key 

issues must be solved: 

• selection of the necessary and useful data (what, when, who; 

forms, use of computers; etc.); 

• quality of data (from collection to processing and use in the 

decision making process) and of the source of data; 

• confidentiality of data (data concerning patients; sensitive 

data concerning the hospital); 

• reporting mechanisms of any event that has a link with the 

Programme (especially critical events, sentinel and precursor 

events 41 ). 

Use of modern technology 42 . The use of modern technology for 

managing information facilitates the management of data 

pertaining to the HRMP and the data collected as routine activity. 

It enhances early detection of emerging risks (detection of signals), 

adverse events and precursor events (software intranet based or 

internet based). 

The emergency response plans of hospitals (disaster plans) 

In many countries the MoH has defined its policy on Hospital 

Emergency Response Plans (from preparation of the ERP to the 

validation of the Plans). Contingency plans 43 (e.g. internal fire; 

bomb threat; Avian Influenza Pandemic, chemical incidents, etc.) 

are either included in the overall Hospital ERP as contingency 

procedures (SOP and Supplemental Emergency Response Plans 

of the various units and departments of the Hospital) or 

developed as contingency plans. Unfortunately in many 

countries the situation is chaotic: lack of national policy of the 

MoH (only few hospitals develop an ERP); lack of validation of 

the plans that are developed (no standardization; many plans are 

only paper documents that will never survive a real emergency). 

WHO has recommended a list of elements that must be included 

in the ERP of hospitals 44 . WHO has also developed toolkits for 

developing hospital ERP. 

Comprehensive Risk and Emergency Management 

Programme (CREMP) for Hospitals: the new approach 45 . 

The rationale for the integration of hospital risk management 

programmes (as a sub-programme) and hospital emergency 

management (as a sub-programme) into a cohesive overall 

Programme 

Many elements of the conceptual framework of Comprehensive 

Emergency Management used by communities (and 

governmental institutions at national or sub-national levels) can 

be applied to the management of hospitals during crisis and 

major emergencies. The preparation, the activation, and the use 

of the hospital ERP often mirror 46 the existing systems and 

mechanisms used in the wider community or at sectoral level, 

especially when focusing on special functions such as Incident 

Management Systems; EOC; Incident Command Group; logistic 

management; information management, etc. The adoption of a 

CREMP by hospitals must be based on the assessment of 

existing hazards (and threats) that could possibly affect the 

activities of the hospital or the assets (either impacting on them or 

requiring an important surge capacity in delivering essential 47 

service). In the context of Comprehensive Emergency 

Management in MCM, WHO advocates for capacity building at 

community level and for decentralization. The safe and efficient 

decentralization of the response capacity to sub-national levels 

and to community levels requires a clear national policy (and its 

application guidelines) and clear mechanism for transfer of 

authority, resources and financial means. Hospitals are a major 

assets to consider in MCM. 

The systems and the structures of the CREMP 

Clear rationale exists for integration of the Emergency 

Management System, as described in the ERP of the hospital, 

together with the various programmes dealing with risk 

management into an overall comprehensive programme. The 

general conceptual framework and the overall organization as 

well as the links between the components of these different subprogrammes 

are presented in the Figure 2. Emergency 

Management Australia (Governmental Agency) has already paved 

the way in this direction by combining together the subprogrammes 

of quality assurance and emergency risk 

management 48 . In this new conceptual framework, the notion of 

critical infrastructure is defined as follows: “A service, facility or a 

group of services or facilities, the loss of which will have severe 

adverse effects on the physical, social, economic or 

environmental well being or safety of the community”. It is 

particularly interesting to note that this notion also includes “a 

group of services or facilities”. Medical surge capacity largely 

depends on the effectiveness of the networks (as recommended 

by ADPC 49 ) that each hospital develops with the other 

stakeholders 50 . 

The main elements that of the various programmes (Quality 

Assurance; Emergency Management/ ERP; Hospital Risk 

Management Programme) are: 

✚ hazard and threat identification and assessment; 

✚ risk analysis (that requires also identification of vulnerabilities); 

✚ development and implementation of risk treatment options 

(which includes vulnerability reduction); 

✚ monitoring mechanisms; 

✚ coordination and management systems. 

The advantages of the CREMP 

The main advantages of adopting this integrated strategy in 

hospitals are: 

✚ Many management systems required for Emergency. 

Management/ERP and Risk Management Programmes/Quality 

Assurance are very similar. Indeed the management of severe 

events in Risk Management Programmes and the 

management of crisis during disasters require the mobilization 

of a “Command Group” and the development of an Incident 

Action Plan; the mobilization of resources (especially trained 

staff); the activation of special procedures and SOP; the 

management of information, etc. The pre-establishment of 

such structures and systems for responding to both situations 



will enhance efficiency and effectiveness, and will contribute to 

the rationalization of the cost (from equipment to training of 

key staff) and will facilitate the development of relevant and 

useful training activities 

✚ Many functions in both management systems are similar so 

that the use of common tools and methods (such as modern 

technology) will enhance the “reaction capacity” as early as 

possible (allowing for the selection of efficient treatment 

options as early as possible in order to prevent, to mitigate as 

many as possible adverse consequences). 

✚ Complementarities can be identified so that the acquisition of 

new resources can be rationalized and adequately selected, as 

well as training of staff. 

✚ The integration of the various “Committees” for regulated risks 

(e.g. Blood Safety Committee) into a cohesive whole, although 

the these technical Committees should still work in their field of 

competence. 

✚ The appointment of an Hospital Risk Manager in charge of 

contributing to the management of both Sub-Programmes is 

recommended. 

✚ The process for identifying vulnerabilities, hazards and risk is 

similar to all these programmes so that it is advisable to look 

for synergy and complementarities: 

• development of common procedures and tools; 

• data collection and reporting procedures; 

• data processing and information sharing; 

• training of stakeholders; 

• information management systems for hospital internal use 

and for coordination and reporting to higher levels. 

✚ Collection of many data as routine procedures are needed in 

all the sub-programmes to ensure surveillance, early warning, 

and the monitoring of both the efficiency of the programmes 

and of the management of risks. 

✚ The management of information 51 and the integration of all 

elements are now possible by using common integrated 

technology. 

✚ The pooling and sharing of information will contribute to 

improve the early identification of potentially severe adverse 

events or of infrequent events (such as cluster of unusual 

diseases or a new threat). 

✚ In many activities of these sub-programmes, the staff is the 

same, therefore enabling rationalization of training, awareness 

raising and development of a sense of ownership and 

stewardship. 

✚ Many treatment options are partly similar in these subprogrammes 

so that it is possible to use existing resources 

more efficiently (avoiding unnecessary duplication) or to acquire 

new resources in a coordinated manner. 

✚ Development of common terminology and of “institutional 

culture of risk and emergency management”. 

✚ Promotion of common national standards among all hospitals. 

✚ Promotion of cross-fertilized cooperation and coordination 

(avoiding vertical approach) within the hospital. 

✚ Enhancement of integration strategy of activities from all 

departments and units of the hospital. 

✚ Contribution to quality improvement. 

✚ Rationalization of the use of resources and of acquisition of 

new resources. 

✚ Contribution to a better understanding by the MoH of the 

actual problems and the priorities in the country, and 

identification of priority areas for further development (from 

policy making to monitoring and normative activities). 

✚ Contribution to an increased readiness of the health sector to 

respond to major emergencies and to detect new threats. 

✚ Contribution to better management of public health by the 

MoH. The creation of a national “risk observatory” fed by all 

hospitals in the country is recommended so that the MoH has 

a comprehensive view of the real context and of the priorities. 

This will also contribute to revision of national policies when 

necessary and to the development of national programmes 

when required. The development of this integrated CREMP in 

each hospital must also aim at contributing to a more efficient 

management of public health by the MoH and the provincial 

health departments. 

✚ Contribution to a more efficient management of resources 

such as selection by the MoH of equipment (safety; efficiency; 

costs, etc.) for hospitals. 

✚ Contribution to the development of efficient cooperation 

between hospitals (creation of networks of hospitals) in 

prevention as well as in response and crisis management. 

✚ CREMP will also contribute to identify the actual strengths and 

weaknesses of each hospital member of the network as 

services providers during crisis (either for receiving patients or 

as back up for logistics). 

✚ The identification of best practices applicable either to one of 

the Sub-Programmes or to both. 

✚ Cross-sectional sharing of lessons learned. 

Conclusion: Major issues that need further discussion at country 

level for developing this new approach 

Pre-requisite for launching CREMP project in an hospital 

First of all it should be clear that without a national policy (prepared 

by the MoH) on “regulated risks and quality assurance” on the one 

hand and an ERP on the other, hospitals would be undertaking 

major risks in considering implementation of an CREMP. 

Awareness-raising among all categories of staff is absolutely 

necessary in order to promote a strong sense of ownership by the 

hospital and of the stewardship by the MoH. It would, therefore, 

be advisable that there be agreement at administrative and care 

delivery decision-making levels on the necessity and on the 

rationale for developing the two Sub-Programmes and for their 

integration. 

In the case of hospitals with existing CRM and ERP Sub- 

Programmes (even though these may be if limited to a few 

regulated risks), launching of such a new approach for a new 

Integrated CREMP, is facilitated. It is still necessary, however, to 

engage strong commitment from key staff of both Sub- 

Programmes. 

Planning committee (roles, responsibilities; composition, 

activities) for integration of the two Sub-Programmes 

As in any major hospital project, it is vital to set up a planning 

committee. Indeed a CREMP will involve many stakeholders inside 

and outside of the hospital. As there is no “international model” for 

such a CREMP, each hospital will have to identify what are the 

exact planning activities that will be conducted either during the 

development of the two Sub-Programmes or for ensuring the 



efficient integration of the two Sub-Programmes when they 

already exist. This Committee will have to decide on key issues 

such as: management structure of the CREMP and of the two 

Sub-Programmes; the level of integration of the two Sub- 

Programmes; common information management systems; 

methods and tools to be used for assessing risks (even if there 

are already methods and tools in use; integration would call for a 

new approach), etc. It is important that all key stakeholders of the 

two Sub-Programmes are represented in the Committee, either 

as permanent members or as temporary advisers when 

necessary. Cross-fertilised participation by managerial and clinical 

staff is necessary. 

Management structure and systems 

Many hospitals already have a RMP and an ERP. These 

Programmes, where they exist, have their own management 

structure although some key functions (such as the director of the 

hospital: chief of security, etc.) are members of both structures. 

The challenge here is to integrate as much as possible the 

“management structure for all risks” (including the risk arising from 

disasters) into one single “command structure”. Both Programmes 

require the technical expertise of different stakeholders in parallel 

to the presence of a common “core management group”. 

Therefore it is necessary to consider running two Sub- 

Programmes as complementary and in synergy and to integrate 

them into one single command structure of the CREMP. 

Depending on the size of the hospital and the services it provides, 

the complexity of the two Sub-Programmes will vary and therefore 

the composition of the management board of each of them. 

Hospitals should consider the appointment of a “Hospital Risk 

Manager” (highly qualified; adequately trained; having a high 

position in the hierarchy; appropriate authority). 

Methodology for assessing vulnerabilities 

There are many different methods for assessing the vulnerabilities 

of communities, hospitals and systems, areas in which private 

companies, for many years, have been very active. It is necessary 

that hospitals desiring to develop a CREMP, select the methods 

that best suit their facilities’ needs. Selection must be done also in 

coordination with the local community, other hospitals that are 

members of the local network, and in accordance with the policy 

of the MoH (when available). The use of simple techniques 

(qualitative) for the first estimate, is recommended for small-sized 

hospitals. Very sophisticated computerized quantitative 

techniques do not add much in terms of programme development 

and in effectiveness of the whole process of risk management. 

However, computerization of data is of paramount importance 

(see information management). WHO has published a system for 

assessing hospital vulnerabilities 52 . Nevertheless, it is 

recommended that external vulnerabilities (present in the 

surrounding community or in the system in which the hospital is a 

member) that can impact on hospital activities, be included. When 

selecting a method, the Planning Committee must consider the 

resources that will be necessary as well as the competencies of 

staff involved. 

Methodology for identifying the hazards and threats 

Selection of the methods that can be used must be done 

according to validated pre-established criteria. 

Methodology for assessing risks and ranking risks 

It is vital that all hospitals in one country use the same 

methodology. Training activities must be considered for those in 

charge of contributing to either identification or treatment of risks. 

Roles, functions, responsibilities and composition of the 

Incident Command Group –ICG– (the “brain” of the two Sub- 

Programmes); activation; resources; location of the 

Command Room 

These issues are usually discussed during the development of the 

ERP. But is is necessary to identify the specific components and 

the systems pertaining to a CREMP. 

Administrative support 

The support from and direct involvement of Administration 

(including HR, Finance, etc.) is necessary as in any major project 

in hospitals. The clear identification of the roles of the various 

stakeholders is necessary (especially in Administration). 

Logistic support 

The two Sub-Programmes require resources (from back-up 

systems and equipment to sophisticated technology). The 

rationalization of the acquisition, mobilization, monitoring of 

resources must be a continuous effort, including necessary 

training of staff. 

Information management 

The management of information in both Sub-Programmes is a 

complex issue as it involves different systems. For integration of 

these systems the following issues need to be discussed: 

i. data: selection, processing, reporting; 

ii. software and IT; 

iii. ongoing surveillance activities and special surveillance 

during health crisis (e.g. syndromic based, active reporting); 

iv. links with the national “observatory for hospital risks”; 

v. links with national policy making; 

vi. links with quality assurance and accreditation. 

Management of information also includes sharing of information 

with the MoH (health system and its management). This includes 

the mechanisms for sharing the information and development of 

new structures 53 at national level, to enable management of the 

information gathered by hospitals. Development of a CREMP will 

involve many stakeholders from different programmes (quality 

assurance; blood safety, etc..) and therefore require integration of 

all efforts and existing systems into a cohesive whole. This does 

not mean that the various existing programmes are no longer 

necessary. They need to be complementary and coordinated. The 

development of a more comprehensive and more coordinated 

policy on all these issues will contribute to the development of 

CREMP by hospitals. 

Monitoring process 

Monitoring will consist of a complex set of activities in this new 

concept of CREMP. The main elements that would need 

addressing are: 

✚ assessment of implemented risk treatment options (in both 

Sub-Programmes) 

✚ assessment of the Programme, involving 



1. reorientation and revision 

2. new technologies 

3. evolution of context, risks, and vulnerabilities 

Training activities and exercises 

As in any activity, staff is the key resource. Training of staff is of 

paramount importance. Exercises (from exercising the ERP to 

security, etc.) are vital. Training and exercises must be developed 

in a systemic approach. Much guidance from the MoH is needed 

in this area. This is a weak element in hospital preparedness at the 

moment almost everywhere around the world. 

Implementation of risk management processes 

Finally, in management of risks by private companies, there is 

increasing use of the conceptual framework of “Business 

Management Processes”. Hospitals seeking to develop a CREMP 

can certainly benefit in the use of this approach. ❏ 

References 

1. 

In WHO vision there are three main categories of vulnerabilities : structural ; non structural ; 

and functional vulnerabilities 

2. 

Which goes much beyond the management of communicable diseases only 

3. 

E.g. in France, these laws and regulations are regularly updated and completed: Sécurité 

sanitaire dans les établissements de santé: réglementation applicable version n° 5 juillet 

2005 

4. 

Conformity of the practices with the existing legal framework 

5. 

Many different names are used such as crisis management, emergency management, 

disaster management. 

6. 

A comprehensive emergency management programme. A model for state & territorial courts- 

Colorado 2007 

7. 

Decentralization of the response capacity is a common finding in these countries 

8. 

The University Hospital of Houston has a well defined CEMP 

9. 

Mass Casualty Management Systems: strategies and guidelines for building health sector 

capacity. WHO; 2007 

10. 

Often these plans are called « Disaster Plans ». The national policy of the MOH on Hospital 

Disaster Plan for Mass Casualty Management is to link pre-hospital and hospital activities 

11. 

Usually a comprehensive approach (from prevention to recovery) and all hazards 

12. 

Although these programmes are usually not « comprehensive » for they target only limited 

risks such as regulated risks 

13. 

State University of New York Upstate Medical University; University Hospital, Syracuse. 2008 

14. 

Examples of regulated risks: blood safety; nosocomial infection prevention ; fire procedures 

15. 

identifying and preventing exposure of patients, visitors or employees to risks that could 

either cause injury in hospitals, jeopardize safety and security or result in costly claims and 

lawsuits. 

16. 

Developped by the MoH in its normative role 

17. 

Usually the focus in on « requirements for accreditation » only. An audit in Canada in 2004 

shown that ERP fulfilling criteria for accreditation were not functional plans. These checklist 

do not guarantee that the ERP will be effective. 

18. 

For example: “Health Care Risk Management”: Training Programme organized by Ontario 

Hospital Association (September 2008) 

19. 

Medical Professional Liability. by the American Academy of Orthopedic Surgeons. 2006 

20. 

WHO / WPRO Toolkit on Hospital Emergency Response Plan , 2009 

21. 

Safer hospitals: WHO campaign 2008-2009 

22. 

Safer hospital: WHO campaign 2008-2009 

23. 

E.g. in some programmes risk (harmful consequences) is mixed up with the source of risk 

(hazard) 

24. 

roles and responsibilities of the various management structures; organisation of work during 

crisis; triage protocols, etc. 

25. 

The same situation than for managing EMS Systems (the introduction of modern IT is a very 

important step forward) 

26. 

When the ERP is activated 

27. 

which is often not yet included into RMP in hospitals. 

28. 

In some HRMP the components are called « functions » of the Programme 

29. 

Overview. There are many « books » on that particular issues 

30. 

the hospitals risk management programme, policies are adopted by both the governing 

board and hospital administration 

31. 

So called although this programme do not include the management of services during 

disasters so that there is no link between this “comprehensive programme” and the ERP 

and contingency plans 

32. 

Four categories of indicators are usually used: process; activities; structure; results 

References continued 

33. 

The risk manager in a healthcare organization must maintain sufficient authority and respect 

to enact the changes in clinical practice, policy, and procedures and in employee and 

medical staff behaviors that are necessary to fulfill the essential functions of the risk 

management programme. The American Academy of Orthopedic Surgeons, 2004. 

34. 

The American Academy of Orthopedic Surgeons, 2004. 

35. 

Developed by HDCA-Geneva (Health Development Counseling and Audit) 

36. 

Some frequent methods: Qualitative and Quantitative Failure Modes and Effects Analysis 

FMEA. Failure Modes, Effects, and Criticality Analysis FMECA provides information to 

quantify, prioritize and rank failure modes. Qualitative and Quantitative Fault Tree Analysis 

(FTA). Probabilistic Risk Assessment (PRA). Delphi Technique 

37. 

Of the systems ; procedures ; human behavior ; skills and abilities of medical staff ; etc. 

38. 

In many countries these risks and the medical activities are precisely defined by the MOH 

through a bulk of laws and regulations 

39. 

This is not limited to only costly equipment but also to equipment that is critical for ensuring 

quality medical care and services (e.g. power backup system ; refrigeration towers, etc.) 

40. 

For instance that the equipment for intubation is available and adequate ; that the theater 

room has a backup system for electrical power, etc.) 

41. 

Here again the identification of indicators is critical. Precursor events are important for they 

should prompt an early treatment option (mitigation, response, etc.) while countermeasures 

can control the risks generated by the events before they develop into a severe situation 

42. 

Many software are available that integrate all components (functions) of HRMP and that 

allow for managing information in a systematic and holistic way 

43. 

Some hospitals have only one ERP and contingency procedures instead of separate 

contingency plans 

44. 

Mass Casualty Management Systems: strategies and guidelines for building health sector 

capacity. WHO; 2007 

45. 

Proposed by HDCA - Geneva 

46. 

E.g. the use of the concept of Incident Management System 

47. 

Under the concept of « critical services » during disasters more and more MOH also include 

the services needed by people suffering from chronic non-communicable diseases requiring 

regular treatment (haemodialysis, severe cardiac conditions, etc.). 

48. 

Critical infrastructure emergency risk management and assurance, 2003. 

49. 

Strategy and Recommendations in Developing EMS Systems; ADPC, 2005 

50. 

For instance in more and more countries Hospital are regrouped in « network » 

51. 

“Disasters or critical adverse events can be seen as primarily a failure to adequately 

manage information » (WPRO). 

52. 

Hospital Safety Index, PAHO, 2007 (computerized system). Free download possible. 


Innovation and stategy: Accelerating Access Initiative 

The Accelerating Access Initiative: 

experience with a multinational 

workplace programme in Africa 

ARTICLE BY S VAN DER BORGHT 

Heineken International Health Affairs, Amsterdam, Netherlands 

V JANSSENS 

PharmAccess Foundation, Amsterdam, Netherlands 

MF SCHIM VAN DER LOEFF 

GGD (Public health service), Amsterdam, Netherlands 

A KAJEMBA 

GGD (Public health service), Amsterdam, Netherlands 

H RIJCKBORST 

Heineken International Health Affairs, Amsterdam, Netherlands 

JMA LANGE 


TF RINK DE WIT 


Problem: A multinational company with operations in several African countries was committed to offer antiretroviral treatment 

to its employees and their dependants. Approach The Accelerating Access Initiative (AAI), an initiative of six pharmaceutical 

companies and five United Nations’ agencies, offered the possibility of obtaining brand antiretroviral drugs (ARVs) at 10% of 

the commercial price. PharmAccess, a foundation aimed at removing barriers to AIDS treatment in Africa, helped to establish 

an HIV policy and treatment guidelines, and a workplace programme was rolled out from September 2001. 

Local setting: Private sector employers in Africa are keen to take more responsibility in HIV prevention and AIDS care. An 

important hurdle for African employers remains the price and availability of ARVs. 

Relevant changes: The programme encountered various hurdles, among them the need for multiple contracts with multiple 

companies, complex importation procedures, taxes levied on ARVs, lack of support from pharmaceutical companies in 

importation and transportation, slow delivery of the drugs, lack of institutional memory in pharmaceutical companies and 

government policies excluding the company from access to ARVs under the AAI. 

Lessons learned: The launch of the AAI enabled this multinational company to offer access to ARVs to its employees and 

dependants. The private sector should have access to these discounted drugs under the AAI. A network of local AAI offices 

should be created to assist in logistics of drugs ordering, purchase and clearance. No taxes should be levied on ARVs. 

HIV is the largest threat to adult survival in sub-Saharan 

Africa. According to UNAIDS, 33 million people were living 

with HIV by December 2007, of whom 22 million were in 

sub-Saharan Africa. In 2007 an estimated 1.5 million sub- Saharan 

Africans died of AIDS and an estimated 1.9 million became 

infected with HIV. 1 Several international initiatives were launched to 

increase funding for antiretroviral therapy. This has led to a 

spectacular increase in access to antiretroviral drugs (ARVs) in 

Africa: by April 2007 an estimated 28% of eligible HIV patients in 

sub-Saharan Africa were on ARVs. 2 One initiative that aimed to 

increase access was the Accelerating Access Initiative (AAI). This 

paper reports practical experiences of a multinational company 

with the AAI. 

Approach 

In May 2000 five United Nations organizations – United Nations 

Population Fund (UNFPA), United Nations Children’s Fund 

(UNICEF), WHO, The World Bank and the Joint United Nations 

Programme on HIV/AIDS (UNAIDS) – announced a partnership 

with five pharmaceutical companies to address the lack of 

affordable HIV medicines in resourcepoor settings. 3 This 

partnership, the AAI, 4 was committed to offer ARVs at about 10% 

of the commercial price to the public sector and nongovernmental 

organizations that complied with three conditions (correct use, no 

mark-up, no backflow of drugs to markets in developed 

countries). By September 2006, an estimated 424 000 Africans 

were treated with ARVs provided through AAI arrangements, 5 

most of them in public sector treatment programmes. 

In July 2001, multinational brewing company Heineken 

International, with headquarters in the Netherlands and operating 

companies (OPCOs) in several African countries, decided to 

include ART among the medical benefits for employees and their 

dependants, including children. The company, itself selling a 

brand beer, preferred to purchase brand ARVs, and accepted that 

this would make the programme more expensive. The AAI price 

reductions made the provision of ARVs to employees and 

dependants affordable for the company. A partnership was 

established with PharmAccess, a foundation specialized in 



p p p g 

Table 1: Test results company, and 2001–2008 treatment uptake in six sub-Saharan African countries in the workplace programme of a multinational company, 

2001–2008 

Countries with 

operating companies 

with operational HIV 

workplace programme 

Adult target 

population as of 

1 January 2008 

Number of HIV 

tests done in 

adults a 

Number of 

HIV infections 

diagnosed 

Male/female 

ratio of HIV 

diagnoses 

Cumulative number 

of patients who 

started ARV therapy 

as of 25 July 2008 

Male/female 

ratio of 

patients on 

ARV therapy 

Burundi 1059 1283 77 1.40 57 1.38 

Congo 1214 980 68 1.61 38 1.85 

Democratic Republic 

3040 3828 64 1.06 28 1.42 

of the Congo 

Nigeria 3889 5605 154 1.33 77 1.19 

Rwanda 1000 949 115 1.74 73 1.25 

Sierra Leone 130 64 4 only male 0 0 

Total 10 332 12 709 482 1.45 273 1.34 

ARV, antiretroviral 

a Some people might have been tested more than once. Due to turnover of the workforce, it cannot be calculated which proportion of the current workforce has been tested 

removing barriers to AIDS treatment in Africa. 

PharmAccess conducted assessments, provided training, 

helped define treatment protocols, provided laboratory support, 

established a web-based database for patient follow-up6 and 

conducted monitoring, evaluation and quality control. 

PharmAccess interacted with AAI to guarantee a continuous 

availability of ARVs at the OPCOs. The programme was gradually 

rolled out at 14 OPCOs in 6 countries: Burundi, the Congo, the 

Democratic Republic of the Congo, Nigeria, Rwanda and Sierra 

Leone. The average size of the workforce per OPCO varied 

between 200 and 500 employees; including spouses and children, 

the total target population was ± 30 000 of which 10 332 were 

adults (Table 1). Through the company’s voluntary counselling and 

testing programme, 531 infections were diagnosed among 

employees and dependants, and 273 HIV patients had started 

highly active ARV therapy (HAART) by mid- 2008. 

PharmAccess arranged purchase and shipment of ARVs and 

the OPCOs organized customs clearance and storage. The 

chosen first and second line regimens implied procurement of 

eight drugs from six different pharmaceutical companies. 

PharmAccess signed agreements with these six companies. 

Because neither the pharmaceutical companies nor PharmAccess 

had local offices in most of the six countries, the local OPCO had 

to clear the goods at customs. If the products were not yet 

registered in the country, the OPCO had to arrange temporary 

import permits. In the rare cases that a pharmaceutical company 

had a local office, this did not assist in ordering and receiving 

drugs for the company. It was difficult to import newer ARVs as 

they were usually not registered. 

Challenges 

After some time it became possible in some countries to purchase 

ARVs (both generic and brand) locally. If the drugs were 

prequalified by WHO, the OPCOs obtained ARVs locally through 

government agencies. The Ministry of Health in one country felt 

that drugs purchased with a grant from the Global Fund to fight 

AIDS, Tuberculosis and Malaria should not be re-sold, so it 

stopped the provision of drugs to the OPCO. The same 

government declined to provide free ARVs to the OPCO, arguing 

that a for-profit private company should not have access to free 

drugs. Given these challenges, the company sometimes 

purchased generic ARVs. Generic drug companies were generally 

more helpful than brand pharmaceutical companies in the 

importation of products through their local representatives. For 

newer drugs, the AAI was the only source of supply. 

Procuring ARVs was complex. Several pharmaceutical 

companies had not yet developed AAI-agreement documents and 

practicalities differed from one to another. Sometimes a 

pharmaceutical company insisted that PharmAccess should sign 

one agreement per country rather than one general agreement 

covering all sub-Saharan countries. The high turnover of staff in 

the pharmaceutical companies affected institutional memory; at 

times PharmAccess had to explain AAI procedures to new staff at 

pharmaceutical companies. 

The price discount that was obtained was different per product 

and per company and varied between 77% and 93%. The doorto-door 

delivery time of small ARV orders varied between 1 and 5 

months. Despite the explicit assurance that pharmaceutical 

companies would carry transport costs of ARVs, this was not 

always the case in practice. Surprisingly none of the 

pharmaceutical companies ever requested PharmAccess to 

provide evidence of drug flows or absence of mark-up. 

Lessons learned 

The AAI was set up as a public sector, country-led process. 7 This 

implied that the private sector in most African countries could not 

benefit from the AAI. We argue that allowing the African private 

sector employers, private clinics and private health insurance 

companies to obtain ARVs through AAI will contribute to more 

sustainable access for all patients in sub-Saharan Africa. 8 

Private sector employers in Africa are keen to take more 

responsibility in HIV prevention and AIDS care. 9 An important 

hurdle for African employers remains the price of ARVs; allowing 

them access to ARVs under the AAI would make a big difference. 

The overstretched African public health care sector would 

indirectly benefit from this, allowing increased access for the poor. 

The second sector that would benefit from AAI support is the 

private health care sector. Private clinics in Africa provide care to a 

substantial and increasing part of the population. 10 National 

governments should allow these clinics to use ARVs obtained 



Box 1: Lessons learned 

• The private sector should have access to discounted ARVs 

under the AAI. 

• A network of local AAI offices should be created to assist in 

logistics of drugs ordering, purchase and clearance. 

• No taxes should be levied on ARVs. 

AAI, Accelerated Access Initiative; ARV, antiretroviral drugs. 

through AAI. The quality of the performance of these clinics should 

be assessed and monitoring is needed regarding markups on 

drugs; all private clinics providing ARVs should comply with 

national treatment standards. 11 

The third entity requiring access to AAI is the private health 

insurance sector in Africa. Private health insurance Africa but this 

situation is changing in several countries. 12 Health insurance and 

managed care may be instrumental in making African health care 

more self-supporting and less dependent on external donors. 

Therefore, African health maintenance organizations and health 

insurance companies should be given access to AAI-discounted 

ARVs. The launch of the AAI in the year 2000 enabled this 

multinational to provide ARV therapy to its employees, their 

spouses and children in Africa. The company’s experience with the 

AAI indicates the need for local AAI offices in African countries. 

Such offices could facilitate ordering, clearance and channel bulkprocurement 

of ARVs for the three private sector actors named 

previously. 

Registration of drugs is often problematic, importation is highly 

complex and taxes are being levied on ARVs. These issues should 

be addressed by African governments. The lessons learned are 

summarized in Box 1. 

and Gilead Sciences in 2004. 

Funding: The Workplace programme is funded by Heineken 

International. Competing interests: None declared. 

References 

1. 

2008 report on the global AIDS epidemic. Geneva: UNAIDS; 2008. 

2. 

World health report 2006: working together for health [Statistical annexes]. Geneva: WHO; 

2006. 

3. 

New public/private sector effort initiated to accelerate access to HIV/AIDS care and treatment 

in developing countries [media release]. Geneva: UNAIDS; 2000. Available from: 

www.essentialdrugs.org/edrug/archive/200005/ msg00027.php [accessed on 23 July 2009] 

4. 

Merck & Co. Inc. announces significant reductions in prices of HIV medicines to help speed 

access in developing world [media release]. Whitehouse Station, NJ: Merck & Co Inc.; 2001. 

Available from: www.cptech.org/ip/ health/firm/merck.html [accessed on 23 July 2009]. 

5. 

Accelerating Access Initiative (AAI): fact sheet. Geneva: International Federation of 

Pharmaceutical Manufacturers & Associations (IFPMA); 2007. Available from: 

www.ifpma.org/site_docs/Health/AAI_Factsheet_Jan_07_ Q3_2006.pdf [accessed on 23 

July 2009]. 

6. 

Clevenbergh P, Van der Borght S, Janssens V, van Cranenburgh K, Kitenge Lubangi C, 

Gahimbaza L, et al. Database-supported teleconferencing: an additional clinical mentoring 

tool to assist a multinational company HIV/AIDS treatment program in Africa. HIV Clin Trials 

2006;7:255-62. PMID:17162320 doi:10.1310/hct0705-255 

7. 

Sturchio JL. Partnership for Action: the experience of the Accelerating Access Initiative, 2000- 

2004, and lessons learned. In: Attaran A, Granville B, eds. Delivering essential medicines: the 

way forward. London: Chatham House; 2004. pp. 116-151. 

8. 

Caines K, Lush L. Impact of public-private partnerships addressing access to 

pharmaceuticals in selected low and middle income countries: a synthesis report from 

studies in Botswana, Sri Lanka, Uganda and Zambia. Geneva: Initiative on Public-Private 

Partnerships for Health; 2004. 

9. 

Private sector declaration against HIV/AIDS. In: World Economic Forum, Bangkok, July 2004. 

Available from: www.weforum.org/pdf/Initiatives/ Bangkok2004_AIDS_Declaration.pdf 

[accessed on 23 July 2009]. 

10. 

Marek T, O’Farrel C, Yamamota C, Zable I. Trends and opportunities in publicprivate 

partnerships to improve health service delivery in Africa [Working paper series 33646, Africa 

Region Human Development]. Washington, DC: The World Bank; 2005. 

11. 

Brugha R. Antiretroviral treatment in developing countries: the peril of neglecting private 

providers. BMJ 2003;326:1382-4. PMID:12816829 doi:10.1136/bmj.326.7403.1382 

12. 

Schellekens OP, Lindner ME, van Esch JP, van Vugt M, Rinke de Wit TF. Health care insurance 

for Africa. Ned Tijdschr Geneeskd 2007;151:2680-4. PMID:18179087 

Recommendations 

The AAI has led to substantial price reductions of brand drugs and 

increased access to ARVs. Administrative, logistical and regulatory 

hurdles have meant that the full potential of the AAI has not been 

fulfilled. The following four recommendations are made to 

strengthen the AAI and increase access to affordable good quality 

drugs in sub-Saharan Africa. (i) AAI eligibility should be extended 

beyond the public sector. Local private clinics, health insurers and 

health maintenance organizations should get access to AAI ARVs, 

under specific conditions. (ii) Governments should waive taxes on 

ARVs, simplify and harmonize the drug registration process and 

certify private clinicians. (iii) Private companies and non-profit 

organizations that wish to provide ART to their employees and 

dependants should be encouraged to do so and should benefit 

from AAI. (iv) The pharmaceutical companies within AAI should 

support the creation of a network of local AAI distributors of ARVs. 

International donor funds should invest in this network. ❏ 

Acknowledgements 

JMA Lange & TF Rinke de Wit are also affiliated with the Center 

for Poverty-related Communicable Diseases (CPCD), 

Academic Medical Center (AMC), University of Amsterdam, 

Meibergdreef 9, 1100 DE Amsterdam, the Netherlands. The 

pharmaceutical companies in the AAI were, initially, Boehringer- 

Ingelheim, Bristol Myers Squibb, GlaxoSmithKine, Merck&Co 

and F Hoffman-LaRoche. Abbott Laboratories joined in 2001 


Innovation and policy: disease surveillance 

Strategy to enhance influenza 

surveillance worldwide i 

ARTICLE BY JUSTIN R ORTIZ, 

University of Washington, Seattle, Washington, USA 

VIVIANA SOTOMAYOR, 

Ministerio de Salud, Santiago, Chile 

OSVALDO C UEZ, 

Instituto Nacional de Epidemiología, Mar del Plata, Argentina 

OTAVIO OLIVA, 

Pan American Health Organization, Washington, DC 

DEBORAH BETTELS, MARGARET McCARRON, JOSEPH S BRESEE and ANTHONY W MOUNTS 

Centers for Disease Control and Prevention, Atlanta, Georgia, USA 

The emergence of a novel strain of influenza virus A (H1N1) in April 2009 focused attention on influenza surveillance 

capabilities worldwide. In consultations before the 2009 outbreak of influenza subtype H1N1, the World Health Organization 

had concluded that the world was unprepared to respond to an influenza pandemic, due in part to inadequate global 

surveillance and response capacity. We describe a sentinel surveillance system that could enhance the quality of influenza 

epidemiologic and laboratory data and strengthen a country’s capacity for seasonal, novel, and pandemic influenza detection 

and prevention. Such a system would 1) provide data for a better understanding of the epidemiology and extent of seasonal 

influenza, 2) provide a platform for the study of other acute febrile respiratory illnesses, 3) provide virus isolates for the 

development of vaccines, 4) inform local pandemic planning and vaccine policy, 5) monitor influenza epidemics and 

pandemics, and 6) provide infrastructure for an early warning system for outbreaks of new virus subtypes. 

The emergence of a novel strain of influenza virus A (H1N1) in 

April 2009 and its subsequent rapid global spread have 

focused attention on influenza surveillance capabilities 

worldwide 1 . A consultation convened by the World Health 

Organization (WHO) in 2005 had previously concluded that the 

world was unprepared to respond to an influenza pandemic, due 

in part to inadequate global surveillance and response capacity 2 . 

The International Health Regulations 2005 call for strengthened 

surveillance for all events that may constitute a “public health 

emergency of international concern”; such events include 

individual human cases of influenza caused by a new subtype of 

influenza virus A 3 . As part of the International Health Regulations 

2005 core surveillance and response capacity requirements, each 

Member State must develop and maintain capabilities to detect, 

assess, and report disease events nationally and internationally to 

WHO within 48 hours of confirmation. However, reviews of 

national pandemic planning indicate that surveillance systems are 

often inadequate to support current preparedness strategies 4–8 . 

WHO has existing surveillance guidelines to help Member States 

implement universal surveillance for novel and pandemic 

influenza 9 , but the guidelines lack the specificity that would enable 

many countries to establish operational surveillance plans. Quality 

influenza surveillance systems are needed to enable countries to 

better understand influenza epidemiology, including disease 

incidence and severity, and help them implement appropriate 

prevention strategies. The challenges experienced by the United 

States and Mexico to rapidly determine the extent and severity of 

illness of the 2009 novel influenza A (H1N1) outbreak highlighted 

the need for systems that can reliably produce these estimates. 

Furthermore, global strategies to address other vaccinepreventable 

diseases have acknowledged the importance of 

establishing local disease burden (effects, severity, amount of 

illness, and costs) as a first step toward decisions about the 

introduction of vaccines into new countries. We describe a generic 

guideline for collecting data on severe acute respiratory infection 

(SARI), influenza-like illness (ILI), and laboratory-confirmed 

influenza that can be implemented in limited-resource settings. 

Current situation 

Global Influenza surveillance 

For 60 years, the WHO Global Influenza Surveillance Network 

(GISN) has provided virologic information used in the biannual 

process of selecting strains for the Northern and Southern 

Hemisphere influenza vaccine formulations. However, its capacity 

to provide epidemiologic data or an alert of an emerging pandemic 

is limited. GISN currently comprises 122 National Influenza 

Centers in 87 countries and 4 WHO Collaborating Centres for 

Reference and Research on Influenza 10 . Although this system has 

proven to be valuable, tropical and resource-limited countries 

(particularly in Africa) are underrepresented 11 . 

Influenza in developing countries 

Virus transmission or clinical presentation may be altered by 

i 

A prior version of this protocol was presented in poster form at the Options for the 

Control of Influenza Conference in Toronto, Ontario, Canada, 17 June, 2007. 



differences in cultural practices, the environment, geography, 

human genetics, and social structures. Enhanced influenza 

surveillance can permit assessment of a number of factors that 

may affect disease activity: population density, differences in 

prevalence and spectrum of chronic illness, proximity of the young 

and elderly, low proportion of elderly in the population, low school 

attendance, and school schedules that may not correspond with 

peak transmissibility season. The effectiveness of control measures 

such as social distancing and vaccination may differ between 

developed and developing settings because of these factors. 

Available epidemiologic evidence suggests that influenza is 

common in tropical regions and contributes substantially to 

disability and use of healthcare resources 12–16 . Data describing the 

seasonality and epidemiology of influenza in tropical areas are 

limited; however, some tropical countries report year-round human 

influenza activity 12 , unlike in temperate regions where transmission 

occurs with marked seasonality. Because of these limited data, 

most of the understanding of seasonal influenza is derived from 

epidemiologic data collected in western Europe and North 

America. Nevertheless, estimates of a pandemic impact indicate 

that most deaths will be in developing countries and that more 

than half will occur in southern Asia and sub-Saharan Africa 17 . A 

better understanding of the epidemiology of influenza in these 

areas would facilitate country-appropriate pandemic planning and 

vaccine policy development. 

Objectives 

The most efficient process for producing high-quality 

epidemiologic data for influenza-associated illness is sentinel 

surveillance. The primary limitation of most existing influenza 

sentinel-site networks that track ILIs has been that they often 

provide little epidemiologic data, do not produce data on disease 

incidence, and are focused on mild disease, which supports the 

notion that influenza is a benign disease. We propose that 

influenza surveillance should capture severe influenza outcomes 

as a primary measure. Hospital-based sentinel surveillance is the 

most efficient way to collect clinical data and laboratory specimens 

from persons with a prevalent and severe infectious disease. 

Carefully placed sentinel sites can provide adequate information 

on the epidemiology of influenza without the need for 

comprehensive national case ascertainment or reporting. 

Placing surveillance sites where population data are known 

would permit calculation of population-based estimates of disease 

rates according to age and other demographic variables. In 

addition, collection of clinical specimens from persons from whom 

epidemiologic data are also collected would ensure virus strain 

surveillance and provide isolates that can be used for vaccine 

development. A sentinel surveillance system can be used to 

monitor >1 disease, can be sustainable, and can integrate with 

and build upon existing systems. The system objectives are 1) 

describe the disease impact and epidemiology of severe, acute, 

febrile respiratory illness and define the proportion that is 

associated with influenza; 2) provide influenza virus isolates for 

monitoring changes in viral antigens and development of new 

vaccines; 3) contribute data for local pandemic planning and 

making decisions regarding vaccine policy; 4) provide 

Table 1: Influenza sentinel surveillance case definitions* 

CASE 

Influenza-like illness 

Severe acute respiratory 

infection in persons >5 years 

of age 

Severe acute respiratory 

infection in persons 38°C, AND 

• Cough or sore throat, AND 

• Absence of other diagnoses 

ALL OF THE FOLLOWING 

• Sudden onset of fever >38°C, AND 

• Cough or sore throat, AND 

• Shortness of breath or difficulty breathing, AND 

• Requires hospitalization 

EITHER 

IMCI criteria for pneumonia 

Any child 2 mo to 5 y of age with cough or difficult breathing and: 

• breathing faster than 60 breaths/min (infants


infrastructure for an early warning system for outbreaks of new 

subtypes of influenza A viruses and new strains of existing 

subtypes; and 5) serve as a monitoring tool for pandemic influenza. 

Components and processes 

Case definitions 

These surveillance guidelines use the existing WHO case definition 

for ILI and incorporate WHO guidance to define SARI in adults and 

children (Table 1). The case definitions fit within the existing 

framework for pandemic early warning, use existing definitions for 

ease of adoption, and rely on physical examination findings that do 

not require laboratory or radiographic criteria. In addition, SARI 

definitions may capture a broad spectrum of severe influenzaassociated 

illness, including exacerbations of asthma, chronic 

obstructive pulmonary disease, and decompensated congestive 

heart failure, which may account for ≈75% of hospitalized influenza 

patients 16,20,21 . 

Sentinel site selection 

Ideally, sites should represent a wide cross-section of ethnic and 

socioeconomic groups and should be in different climatic regions. 

Placement of sites in areas where the population denominator can 

be ascertained or estimated will facilitate incidence estimates. 

Ultimately, the choice of sentinel hospitals will often be based on 

practical issues such as human resources, communication 

infrastructure, and availability of specimen transport and testing. 

There is no ideal number of surveillance sites; the number chosen 

by a particular country will depend in part on sustainability and 

resources available. 

Data Collection 

Minimum data elements are outlined in Table 2. Data collected 

should be adequate for routine public health surveillance and 

description of key epidemiologic features of disease. Data can be 

broadened to include clinical signs and symptoms, potential 

exposures, laboratory data, and therapies. 

Specimen collection 

Respiratory specimens should be collected early from all SARI 

patients, following established protocols 24 . If resources do not 

allow collection from all patients, an unbiased systematic sampling 

scheme should be established. To develop quality estimates of 

incidence and severity, data and specimens from all or most SARI 

patients from a few facilities would be preferred over a small 

sample of SARI patients from multiple facilities. 

Because seasonality, attack rates, and public health priorities 

differ from country to country, there is no generic number of 

specimens to be collected by each site. The number must be 

determined by the primary surveillance objective (e.g., 

understanding of seasonality, risk factor analysis, or determination 

of clinical outcomes) and must represent climatic and geographic 

regions. For example, a country with coastal, mountainous, and 

tropical regions may have different influenza activity in each region 

and may thus require more surveillance sites and increased 

specimen collection than neighbors or similarly sized countries. 

Therefore, the number of specimens collected must be 

approached on a case-by-case basis and depends on objectives 

of a country, country-specific geographic and climatic issues, and 

public health priorities. 

Table 2: Sample data collection from cases of severe acute 

respiratory infection and influenza-like illness* 

RECOMMENDED ESSENTIAL MINIMUM DATA FOR SARI SURVEILLANCE 

General information 

• Unique identification number 

• Medical record number 

• Name (of patient and parent’s name, if a minor) 

• Date of birth 

• Sex 

• Address 

• Date of onset of symptoms 

• Date of collection of epidemiologic data 

• Suspected novel influenza case 

• Inpatient or outpatient 

Clinical signs and symptoms 

• Fever >38°C 

• Cough 

• Sore throat 

• Shortness of breath/difficulty breathing 

• Other clinical danger signs (19,22,23) 

Type of specimen collected and date of collection 

• Throat swab specimen, date of collection 

• Nasal swab specimen, date of collection 

• Other specimen (if collected), date of collection 

Preexisting medical conditions 

• Liver disease 

• Kidney disease 

• AIDS, cancer, or other immunocompromised state 

• Neuromuscular dysfunction 

• Diabetes 

• Heart disease 

• Lung disease 

• Smoking history 

Optional data collection for SARI surveillance 

General information 

• Diarrhea 

• Encephalopathy 

Exposure 

• Occupation of patient 

• Part of an outbreak investigation 

136 

• Contact with sick or dead poultry or wild birds 

• Contact with friend or family who has SARI 

• Travel in an area known to have endemic circulation of 

avian influenza (H5N1) 

• Other high-risk exposure (e.g., eating raw or undercooked 

poultry products in an area of influenza virus [H5N1] 

circulation) 

Vaccine/treatment history 

• Vaccination against influenza within the past year 

• Currently taking antiviral medicine 

*SARI, severe acute respiratory infection; ILI, influenza-like illness. 

Integration into national reporting systems 

In countries with established national disease reporting systems, 

such as the Integrated Disease Surveillance Reporting system 

used in Africa 25 , sentinel surveillance for SARI can be incorporated 

into the existing system. Because Integrated Disease Surveillance 

Reporting is generally a passive surveillance program, a few select 

sites should serve as embedded sentinel sites; intensive training 

and close follow-up should be conducted to ensure the quality of 



the reported data. 

Outpatient surveillance 

The highest priority should be to collect data on SARI cases 

because they contain the most influenza-associated disability and 

premature death. However, if resources permit, data collection at 

sentinel sites should be expanded to include ambulatory patients 

with ILI. Because the number of cases at ambulatory care sites is 

likely to be large, case counts would be aggregated, and clinical 

specimens and epidemiologic data would be collected from only a 

small sample of patients. Weekly case counts should be 

categorized by age group according to well-studied age-range 

categories (6–23 months, 2–4 years, 5–17 years, 18–49 years, 

50–64 years, and >65 years) 26 . Patients chosen to give detailed 

epidemiologic data and clinical specimens should be selected in 

as unbiased a manner as possible. The selection protocol must 

take into account local health-seeking behavior, such as 

differential use of evening and weekend clinics. Ideally, the weekly 

total number of patients seen by clinics would also be collected by 

age group to allow for proportion of ILI to be calculated. Rapid 

system expansion can compromise the quality of collected data; 

therefore, ILI surveillance should emphasize quality data collection 

from a few well-run sites. 

Laboratory testing 

Clinical specimens should be collected from a high proportion of 

SARI patients and a systematic sample of ILI patients. These 

specimens can be processed in sentinel site laboratories, but 

further analyses may require their transport to additional 

laboratories. Ideally, specimens would be tested for evidence of 

influenza viruses by reverse transcription–PCR (RT-PCR). A subset 

of specimens should undergo viral culture and antigenic 

characterization. Surveillance data should be submitted to WHO 

FluNet, and, if possible, national laboratories should work with a 

WHO Collaborating Center laboratory to submit sample virus 

isolates for vaccine strain selection. 

In countries where influenza spreads in seasonal epidemics, it 

may be adequate to collect less epidemiologic data and fewer 

specimens for laboratory testing by sampling a smaller proportion 

of SARI patients during the noninfluenza season. Knowledge of 

SARI rates outside influenza season will permit comparisons 

between peak season and baseline rates. Non–influenza season 

rates of SARI can also be monitored by public health authorities, 

because anomalies in SARI rates could represent outbreaks in 

need of investigation. However, high-quality, year-round data will 

be required for >1 season before assumptions can be made about 

seasonality in a region. 

Nasal and nasopharyngeal specimens have a higher yield for 

influenza virus detection in ILI cases than do oropharyngeal 

specimens 27 . However, the relative sensitivity of nasal versus 

oropharyngeal swabs to detect influenza virus infection in SARI 

cases is unknown. If both are collected, specimens can be placed 

in the same tube of viral transport media for processing. If SARI 

patients are intubated, endotracheal aspirates can also be used. 

Specimens can be frozen at –70°C for storage and possible future 

assessment of other respiratory pathogens. 

The sensitivity and specificity of any test for influenza will depend 

on the laboratory performing the test, the quality of the clinical 

specimen, the manner in which the specimen is processed, and 

the type of specimen collected. Generally, RT-PCR testing of 

respiratory specimens is the most sensitive laboratory test for 

influenza virus, but it is relatively expensive and is not useful for 

antigenic characterization 28 . If the proper primers and probes are 

used, RT-PCR can determine influenza virus A subtype and can 

detect novel influenza virus A subtypes. Fluorescent antibody 

tests, although less expensive, are less sensitive and specific than 

RT-PCR 27 . Rapid point-of-care tests are less sensitive and specific 

than RT-PCR or fluorescent antibody tests and are not generally 

recommended for use by sentinel surveillance. Virus culture has 

been the diagnostic standard for identifying influenza virus. Culture 

sensitivity depends on proper specimen handling and the 

experience of the laboratory. Virus culture should be performed on 

at least a sample of specimens to provide material for antigenic 

determination and potential isolates for vaccine production. 

Data analysis and reporting 

Timely analysis and reporting of surveillance data will facilitate 

treatment decisions by clinicians and control measures by public 

health officials. It will also encourage continued reporting of cases 

by clinicians in the surveillance system. Weekly reports of clinical 

and laboratory confirmed case counts should be disseminated 

throughout the surveillance system to participating healthcare 

providers and all stakeholders during peak seasons. The 

frequency of reports and the extent to which they are 

disseminated will depend on data timeliness and public health 

priorities. Sentinel surveillance reporting mechanisms should use 

existing public health communications systems and augment 

other reporting mechanisms such as FluNet through WHO GISN 29 . 

Basic analyses of surveillance data should include weekly 

frequencies of SARI and laboratory-confirmed influenza cases as 

well as the proportion of tested patients, by age group, who are 

influenza virus positive. If possible, proportions of SARI and 

influenza cases per total of weekly sentinel hospital admissions 

should be reported. Reports with case frequencies and 

proportions during prior weeks and years will demonstrate trends 

over time. At least once annually, analyses of surveillance data to 

determine risk factors for disease should be reported. These 

reports should use collected data on concurrent conditions and 

populationbased rates, if these can be determined. 

Understanding the epidemiology of severe influenzaassociated 

disease is essential for decisions related to vaccine 

recommendations. These data are prioritized in the guidelines 

because many developing countries have limited funds and 

competing healthcare priorities. However, data collected during 

SARI surveillance alone will be inadequate to describe aspects of 

influenza epidemiology such as transmission dynamics, costs, and 

occurrence of mild disease. 

Evaluation and auality assurance 

The usefulness of surveillance data will depend directly on the 

quality of the data; every system should have a quality assurance 

program. Quality indicators will reflect such attributes as system 

acceptability, timeliness, completeness, and representativeness of 

collected data. These attributes should be assessed routinely. In 

addition, the system should undergo regular data audits and 

systematic field evaluation. In 2001, the Centers for Disease 

Control and Prevention published comprehensive guidelines for 

the evaluation of public health surveillance systems 30 . 



These guidelines serve as a template for sentinel surveillance 

evaluation and quality recommendations. Several key quality 

indicators are recommended in the following section and in Table 3. 

Data validity 

Regular field evaluations and audits at a facility level must be a 

standard component of the system. This process can determine 

that cases are being counted appropriately, that reported cases 

meet the case definition, and that sampling procedures are being 

used uniformly without evidence of bias. Data values recorded in 

the surveillance system can be compared with standard chartreview 

values by a retrospective review of a sample of medical 

records. If a sampling procedure is used for specimen collection, 

audits can ensure that procedures are uniform and unbiased. 

Additionally, audits can determine whether clinical specimens are 

being taken, stored, processed, tested (if appropriate), and 

shipped properly and in a timely manner from all those who meet 

sampling criteria. 

Observance of expected trends in reporting and disease activity 

can provide an additional means of assessing data quality. 

Although it is not possible to define expected values for some 

parameters, such as the percentage of specimens testing positive 

for influenza virus or the number of SARI cases occurring in a 

given facility, aberrations in the data over time or substantial 

differences between facilities can signal problems at a given site. 

Trends assessed may include number of cases reported by 

month, number of specimens submitted by month, percentage of 

influenzapositive specimens, and number and percentage of SARI 

and ILI cases tested. 

Timeliness 

To be useful, collection and reporting of surveillance data must be 

timely. Timeliness of the following activities is appropriate for 

routine measurement as quality indicators for surveillance sites: 

data reporting, specimen shipment to the laboratory for testing, 

receipt of specimens by the laboratory, laboratory processing and 

testing of specimens, and reporting of laboratory results. 

One way to quantify timeliness is to calculate the percentage of 

times that a site achieves targets for specific intervals, for example, 

the percentage of times that a site sends reports or specimens to 

the appropriate place within a specified time frame. A hypothetical 

system may choose as a goal that 80% of data reports be sent 

within 48 hours of the reporting deadline or that 80% of specimens 

be shipped within 48 hours of specimen collection. Likewise, for 

the laboratory, the percentage of samples that are tested and have 

final results within a target time frame can be calculated. Targets 

will depend on site-specific circumstances and public health 

priorities. 

A similar quality metric that can be used is the calculation of the 

average time to accomplish surveillance activities. For example, a 

hypothetical site that is chronically late in sending data every 

month might average several days between the deadline for 

receipt (the day of the week or month on which reports are due) 

and actual receipt of data. For laboratory specimen processing, 

the average number of days between receipt of specimens and 

the reporting of the results can be measured and followed similarly. 

Site time averages can be compared to identify sites that are 

underperforming and to target improvements. Either percentages 

of sites achieving timeliness targets or time lag averages can also 

Table 3: Influenza surveillance evaluation and recommended 

quality indicators* 

1. Timeliness 

a. Several time intervals are appropriate for routine 

measurement as quality indicators. These include the 

duration of time from 

i. Target date for data reporting from the sentinel site to the 

next administrative level until the actual reporting date 

ii. Target date for data reporting from the next 

administrative level to the national level until the actual 

reporting date 

iii. Date of specimen collection at facility until shipment to 

laboratory 

iv. Date of result availability in laboratory until date of report 

to referring institution and physician 

v. Date of receipt of specimen in the laboratory until result 

availability 

b. Metrics. Two metrics can be used to reflect timeliness 

indicators: 

i. Percentage of time that a site achieves target for 

timeliness 

ii. Average number of days for each interval over time for 

each site 

2. Completeness 

a. Percentage of reports received from each site with complete 

data 

b. Percentage of data reports that are received 

c. Percentage of reported cases that have specimens 

collected 

3. Audit. Regular field evaluations and audits at facility level of a 

subset of medical records to ensure 

a. Cases are being counted appropriately and not being 

underreported 

b. Reported cases fit the case definition 

c. Epidemiologic data are correctly and accurately abstracted 

d. Respiratory samples are being taken, stored, processed, 

tested, and shipped properly and in a timely fashion from all 

those who meet sampling criteria 

e. Sampling procedures are being done uniformly without 

evidence of bias 

4. Data to be followed and observed for aberrations over time 

a. Number of cases reported by month for each site 

b. Number of specimens submitted by month for each site 

c. Percentage of specimens that are positive for influenza 

d. Number and percent of ILI and SARI cases tested 

*ILI, influenza-like illness; SARI, severe acute respiratory illness. 

be used as a quality metric to be followed over time. 

Completeness 

Indicators of completeness can be determined by analyzing 

reported data. They may include percentage of reports received 

from each site with complete data, percentage of total expected 

data reports received, and percentage of total expected cases 

that have specimens submitted to the laboratory (depends on 

sampling scheme devised for sites). 

Pandemic early warning systems and monitoring 

Emergence of new subtypes of influenza virus A in human 

populations is unusual and unlikely to be detected by a sentinel 

surveillance system, except by chance or if transmission is 

sustained. Control of a pandemic caused by the introduction of a 



new subtype of influenza virus A will require early detection and 

recognition of the event. Although sentinel surveillance as a standalone 

system may not accomplish this, it has value in establishing 

the infrastructure necessary to respond to a pandemic. In addition 

to providing a basic understanding of the epidemiology of 

influenza transmission and risk, a routine reporting system would 

produce an infrastructure for reporting, specimen processing and 

testing, and data collection and analysis. It would make data 

interpretation more routine (and thus more manageable in the face 

of a pandemic emergency) and drive interest in influenzaassociated 

disease and vaccination. 

After a novel strain of influenza emerges, monitoring its course 

is necessary to determine whether cases are increasing or 

decreasing, to detect changes in patient age distribution or other 

epidemiologic characteristics, to detect changes in mortality rates, 

and to monitor changes in susceptibility to antiviral agents. In the 

midst of an outbreak, national monitoring may not be necessary or 

feasible, and most, if not all, critical information can be gained from 

a few sentinel sites. Emergence of a new strain of influenza 

increases the data needs of health policy makers. Historical 

surveillance data for comparison can facilitate the understanding 

of answers to critical questions such as severity of the outbreak 

related to a new strain and its potential to adversely affect 

healthcare delivery. An existing surveillance infrastructure also 

provides the platform needed to describe the clinical course of 

emerging pathogens, risk factors for severe outcomes, and 

effectiveness of control measures. 

Conclusions 

Surveillance for SARIs can provide critical understanding of the 

contribution of influenza infection to the global burden of disease, 

provide a platform for the study of other common respiratory 

pathogens, and strengthen public health infrastructure. Such a 

system should be a part of a routine surveillance program to 

provide data needed for allocation of scarce healthcare 

resources. ❏ 


We thank the following people for their help with this project: 

Lynnette Brammer, Clovis Heitor Tigre, Thais Dos Santos, Melania 

Flores, Erika Garcia, Diane Gross, Monica Guardo, Ann Moen, Josh 

Mott, Camelia Savulescu, David Shay, Tim Uyeki, John C. Victor, 

and the manuscript peer reviewers. Dr Ortiz is a research fellow at 

the University of Washington and PATH (Program for Appropriate 

Technology and Health). His research interest is the clinical 

epidemiology of respiratory infections found in tropical regions. 

References 

1. 

Lipsitch M, Riley S, Cauchemez S, Ghani AC, Ferguson NM. Managing and reducing uncertainty 

in an emerging influenza pandemic. N Engl J Med. 2009 May 28; [Epub ahead of print]. 

2. 

World Health Organization. WHO consultation on priority public health interventions before and 

during an influenza pandemic; 2004 Mar 16–18; Geneva [cited 2007 Apr 22]. Available from 

http://www. who.int/csr/disease/avian_influenza/final.pdf 

3. 

World Health Organization. Resolution WHA 58.3: revision of the International Health Regulations 

[cited 2006 Nov 22]. Available from http://www.who.int/ipcs/publications/wha/ihr_resolution.pdf 

4. 

Oshitani H, Kamigaki T, Suzuki A. Major issues and challenges of influenza pandemic 

preparedness in developing countries. Emerg Infect Dis. 2008;14:875–80. DOI: 

10.3201/eid1406.070839 

5. 

Ortu G, Mounier-Jack S, Coker R. Pandemic influenza preparedness in Africa is a profound 

challenge for an already distressed region: analysis of national preparedness plans. Health Policy 

Plan. 2008;23:161–9. DOI: 10.1093/heapol/czn004 

6. 

Breiman RF, Nasidi A, Katz MA, Kariuki Njenga M, Vertefeuille J. Preparedness for highly 

pathogenic avian influenza pandemic in Africa. Emerg Infect Dis. 2007;13:1453–8. 

7. 

Mounier-Jack S, Jas R, Coker R. Progress and shortcomings in European national strategic plans 

for pandemic influenza. Bull World Health Organ. 2007;85:923–9. DOI: 10.2471/BLT.06.039834 

8. 

Coker R, Mounier-Jack S. Pandemic influenza preparedness in the Asia-Pacific region. Lancet. 

2006;368:886–9. DOI: 10.1016/S0140- 6736(06)69209-X 

9. 

World Health Organization. WHO guidelines for global surveillance of influenza A/H5. 2004 [cited 

2006 Nov 27]. Available from http:// www.who.int/csr/disease/avian_influenza/ 

guidelines/globalsurveillance. pdf 

10. 

World Health Organization. National influenza centres. 2008 [cited 2008 Aug 22]. Available from 

http://www.who.int/csr/disease/influenza/ centres/en/index.html 

11. 

World Health Organization. WHO Global Influenza Programme: survey on capacities of national 

influenza centres, January–June 2002. Wkly Epidemiol Rec. 2005;77:350–6. 

12. 

Nguyen HL, Saito R, Ngiem HK, Nishikawa M, Shobugawa Y, Nguyen DC, et al. Epidemiology of 

influenza in Hanoi, Vietnam, from 2001 to 2003. J Infect. 2007;55:58–63. DOI: 10.1016/j. 

jinf.2006.12.001 

13. 

Viboud C, Alonso WJ, Simonsen L. Influenza in tropical regions. PLoS Med. 2006;3:e89. DOI: 

10.1371/journal.pmed.0030089 

14. 

Katz MA, Tharmaphornpilas P, Chantra S, Dowell SF, Uyeki T, Lindstrom S, et al. Who gets 

hospitalized for influenza pneumonia in Thailand? Implications for vaccine policy. Vaccine. 

2007;25:3827– 33. 

15. 

Abdullah Brooks W, Terebuh P, Bridges C, Klimov A, Goswami D, Sharmeen AT, et al. Influenza A 

and B infection in children in urban slum, Bangladesh. Emerg Infect Dis. 2007;13:1507–8. 

16. 

Chow A, Ma S, Ling AE, Chew SK. Influenza-associated deaths in tropical Singapore. Emerg 

Infect Dis. 2006;12:114–21. 

17. 

Murray CJ, Lopez AD, Chin B, Feehan D, Hill KH. Estimation of potential global pandemic 

influenza mortality on the basis of vital registry data from the 1918–20 pandemic: a quantitative 

analysis. Lancet. 2006;368:2211–8. DOI: 10.1016/S0140-6736(06)69895-4 

18. 

World Health Organization. WHO recommended surveillance standards, second edition. 1999 

[cited 2007 Apr 22]. Available from http://www.who.int/csr/resources/ 

publications/surveillance/WHO_ CDS_CSR_ISR_99_2_EN/en 

19. 

World Health Organization. Handbook: IMCI Integrated Management of Childhood Illness. 2005 

[cited 10/21/08]. Available from http://whqlibdoc.who.int/publications/2005/ 9241546441.pdf 

20. 

Thompson WW, Shay DK, Weintraub E, Brammer L, Bridges CB, Cox NJ, et al. Influenzaassociated 

hospitalizations in the United States. JAMA. 2004;292:1333–40. DOI: 

10.1001/jama.292.11.1333 

21. 

Li CK, Choi BC, Wong TW. Influenza-related deaths and hospitalizations in Hong Kong: a 

subtropical area. Public Health. 2006;120:517–24. DOI: 10.1016/j.puhe.2006.03.004 

22. 

World Health Organization. Hospital care for children: guidelines for the management of 

common illnesses with limited resources. Geneva: The Organization; 2005 

23. 

World Health Organization. Acute care: integrated management of adolescent and adult illness. 

2005 [cited 2008 Oct 21]. Available from 

http://www.who.int/hiv/pub/imai/en/acutecarerev2_e.pdf 

24. 

World Health Organization. WHO guidelines for the collection of human specimens for laboratory 

diagnosis of avian influenza infection. 2005 [cited 2008 Jun 14]. Available from 

http://www.who.int/ csr/disease/avian_influenza/guidelines/humanspecimens/en 

25. 

World Health Organization Regional Office for Africa. Integrated disease surveillance in the 

African region: a regional strategy for communicable diseases 1999–2003. 2001 [cited 2007 

Apr 28]. Available from http://www.afro.who.int/csr/ids/publications/ids.pdf 

26. 

Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, et al. Prevention and control of 

influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. 

MMWR Recomm Rep. 2008;57:1–60. 

27. 

Uyeki TM. Influenza diagnosis and treatment in children: a review of studies on clinically useful 

tests and antiviral treatment for influenza. Pediatr Infect Dis J. 2003;22:164–77. 

28. 

Petric M, Comanor L, Petti CA. Role of the laboratory in diagnosis of influenza during seasonal 

epidemics and potential pandemics. J Infect Dis. 2006;194(Suppl 2):S98–110. DOI: 

10.1086/507554 

29. 

World Health Organization. FluNet. 2008 [cited 2008 Oct 20]. Available from 

http://gamapserver.who.int/GlobalAtlas/PDFFactory/Flu- Net/index.asp?rptGrp=1 

30. 

Centers for Disease Control and Prevention. Updated guidelines for evaluating public health 

surveillance systems: recommendations from the guidelines working group. MMWR Morb 

Mortal Wkly Rep. 2001;50:1–36. 


Innovation and clinical specialities: hepatitis B 

Global control of hepatitis B virus: 

does treatment induced antigenic 

change affect immunization? 

ARTICLE BY C JOHN CLEMENTS 

Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia 

BEN COGHLAN 

The Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Victoria, Australia 

MICK CREATI 

The Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Victoria, Australia 

STEPHEN LOCARNINI 

Research & Molecular Development, Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria, Australia 

RICHARD S TEDDER 

Virus Reference Department, Centre for Infections, Health Protection Agency, Colindale, London, England 

JOSEPH TORRESIE 

Department of Infectious Diseases, Austin Hospital, Heidelberg, The University of Melbourne, Parkville, Victoria, Australia 

Since its widespread introduction, the hepatitis B vaccine has become an essential part of infant immunization programmes 

globally. The vaccine has been particularly important for countries where the incidence of hepatitis B virus-related 

hepatocellular carcinoma is high. Effective treatment options for individuals with chronic hepatitis B infection were limited 

until 1998 when lamivudine, the first nucleoside analogue drug, was introduced. As a single treatment agent, however, 

lamivudine has a significant drawback: it induces lamivudine-resistant hepatitis B virus strains that may pose a risk to the 

global hepatitis B immunization programme. Mutations associated with drug treatment can cause changes to the surface 

antigen protein, the precise part of the virus that the hepatitis B vaccine mimics. However, the emergence of antiviral drug 

associated potential vaccine escape mutants (ADAP-VEMs) in treated patients does not necessarily pose a significant, 

imminent threat to the global hepatitis B immunization programme. Nonetheless, there is already evidence that current 

treatment regimens have resulted in the selection of stable ADAP-VEMs. Treatment is currently intended to prevent the longterm 

complications of hepatitis B virus infection, with little consideration given to potential adverse public health impacts. 

To address individual and public health concerns, trials are urgently needed to find the optimal combination of existing 

drugs that are effective but do not induce the emergence of ADAP-VEMs. This paper examines the mechanism of antiviral 

drug-selected changes in the portion of the viral genome that also affects the surface antigen, and explores their potential 

impact on current hepatitis B immunization programmes. 

Since its widespread introduction in 1983, the hepatitis B 

vaccine has become an essential part of infant 

immunization programmes globally, and is the key 

component of the global hepatitis B control programme for the 

World Health Organization. 1 Infection with hepatitis B virus (HBV) 

can cause acute liver disease, as well as chronic infection that may 

lead to liver failure or hepatocellular carcinoma. The vaccine has 

been particularly important for countries where the incidence of 

HBV-related hepatocellular carcinoma is high. In effect, the 

hepatitis B vaccine was the world’s first anticancer vaccine. 

Effective treatment options for individuals with chronic hepatitis 

B infection were limited until 1998 when lamivudine, the first 

nucleoside analogue drug, was approved for treatment. Newer 

agents have been developed, but lamivudine remains the 

mainstay therapy in many countries with high HBV prevalence 

because of its safety, efficacy and low cost. As a single treatment 

agent, however, lamivudine has a significant drawback: 

monotherapy has resulted in the appearance of lamivudineresistant 

HBV strains, a phenomenon that has been observed with 

single-drug regimens used to treat other infections such as 

tuberculosis and human immunodeficiency virus (HIV) infection. 2 

The emergence of these drug-resistant strains limits therapeutic 

options for individuals chronically infected with HBV; moreover, the 

spread of these strains may pose a risk to the global hepatitis B 

immunization programme. Mutations associated with drug 

treatment can cause changes to the surface antigen protein, the 

precise portion of the virus that the hepatitis B vaccine mimics. 

This article examines the mechanism of antiviral drug-selected 

changes in the part of the viral genome that also affects the 

surface antigen, and explores their potential impact on current 

hepatitis B vaccine programmes (Box 1). 

Features of the hepatitis B virus 

HBV is an enveloped, partly double-stranded DNA virus 

containing a compact, circular genome of overlapping reading 

frames (Figure 1). Human HBV causes both acute and longterm 

infections, including chronic and neoplastic liver disease. The virus 

exists as eight genotypes labelled A to H, with varied geographical 



distributions. Differences between genotypes involve 

approximately 8% of the genomic sequence. 3–5 HBV uses an 

encoded enzyme reverse transcriptase to replicate its viral 

genome. Reverse transcription is an error-prone process that 

generates a large number of nucleotide changes within the viral 

genome. This process results in new, closely-related viral species; 

as a result, at any given time in a particular host the viral population 

consists of a swarm of similar but discrete viruses. 6,7 

Hepatitis B vaccine escape mutants 

The hepatitis B vaccine is an effective means of preventing HBV 

infection, producing protective levels of antibodies in up to 95% of 

recipients. 8 The envelope gene of HBV produces proteins of three 

different lengths: two larger proteins, preS1 and preS2, as well as 

the smaller S protein. The commercially available hepatitis B vaccine 

used in most programmes is a yeast-derived recombinant surface 

antigen of the small S protein alone. Antibodies elicited by the 

hepatitis B vaccine specifically target the “a” determinant of the 

surface antigen (Figure 1). It has been recognized that the 

administration of hepatitis B vaccine can increase the mutation rate 

of the virus. In high-prevalence countries such as China, Thailand 

and Taiwan, monitoring for more than a decade has shown that 

hepatitis B immunization programmes have increased the incidence 

of HBV variants with mutations in the surface antigen protein 9,10 even 

as they reduce the overall burden of chronic hepatitis B infection. 11 

Mutations in and around the “a” determinant may lead to an 

alteration in the antigenicity of the surface antigen protein so that 

antibodies directed against the surface antigen protein may fail to 

neutralize the virus. 12–20 Infection of immunized individuals with a 

vaccine escape mutant (VEM) 20 is therefore possible. VEMs are 

typically characterized by the presence of single-amino-acid 

changes in the S protein. 12,21 Some of these variants are associated 

with high levels of viraemia and have persisted in the host for more 

than 10 years, suggesting they are stable and transmissible variants. 

In addition, the antibody responses against the surface antigen 

protein elicited by the recombinant yeast-derived vaccine now in use 

are weaker and more specific than those achieved with the previous 

plasma-derived surface antigen vaccine. 22–24 In Taiwan, up to 28% of 

children with chronic hepatitis B infection also harbour hepatitis B 

surface antigen mutants. So VEMs capable of causing infection in 

fully immunized individuals are not uncommon in countries with high 

rates of endemic HBV infection and universal hepatitis B infant 

immunization programmes. 12,20 However, to date the emergence of 

VEMs has not had a known negative impact on any country’s 

immunization programme. 25 

Treatment of HBV infection 

Five oral antiviral agents have been approved by the United States 

Food and Drug Administration for the treatment of chronic 

hepatitis B infection: lamivudine, adefovir, entecavir, telbivudine 

and tenofovir. 26,27 The same agents are licensed in the United 

Kingdom and Europe. Each of these nucleoside analogue drugs 

has an excellent safety and efficacy profile. Effective long-term 

suppression of HBV replication by these agents is associated with 

histological and clinical improvement. Before the approval of these 

direct antiviral agents, interferon, an immune potentiator, had been 

used to treat chronic hepatitis B infection. 28 However, interferon 

was not consistently successful when used as monotherapy. 26,27 

More recently, standard interferon has been replaced by interferon 

Box 1: Glossary of terms related with hepatitis B 

viral replication ADAP-VEM 

Antiviral drug-associated potential vaccine escape mutant. 

“a” determinant 

A specific region of the hepatitis B virus surface antigen. Neutralizing 

antibodies that recognize this antigen must form for the vaccine to 

provide protection against the disease. 

Code 

The verb “to code for” denotes the process of providing the genetic 

template for a specific protein. 

Codon 

Groups of three amino acids (nucleotides) that together form a unit of 

genetic code in a DNA or RNA molecule. 

Envelope gene 

A gene which codes for the surface antigen (envelope) of the hepatitis B 

virus. 

Genome 

The complete set of genes or genetic material (DNA and RNA) present in 

a cell or organism. 

Genotype 

The genetic constitution of an organism. 

Monotherapy 

Treatment with a single therapeutic agent. 

Polymerase 

An enzyme that acts in the polymerization of new DNA or RNA during the 

processes of replication and transcription. 

Reading frame 

A non-overlapping set of three-nucleotide sequence codons in DNA or 

RNA. whether reading starts with the first, second or third base in the 

sequence. For example, with the nucleotide sequence TGCTGCTGC, the 

three possible reading frames are TGC TGC TGC, GCT GCT GCT and CTG 

CTG CTG. 

Surface antigen 

The outer envelope protein of the hepatitis B virus. 

Transcriptase 

An enzyme that catalyzes the formation of RNA from a DNA template 

during transcription. 

Reverse transcription 

Genetic copying in the reverse direction in a small number of species 

(e.g. human immunodeficiency and hepatitis B viruses) compared with 

transcription in other species. 

Vaccine escape mutant 

A viral strain that has undergone changes in antigenicity that make the 

vaccinegenerated antibody response ineffective in vivo. 

conjugated with polyethylene glycol (PEGIFN). This combination 

administered for 48 weeks achieves a sustained response rate in 

about 30% of patients. 29,30 The combination of PEG-IFN plus 

lamivudine 29,30 does not improve the virological response compared 

with PEG-IFN alone. However, compared with lamivudine 

monotherapy, this combination was more effective in preventing the 

emergence of lamivudine-resistant HBV. 31 The combination of PEG- 

IFN with more potent nucleoside and nucleotide analogues such as 

entecavir or tenofovir needs to be tested. 

Problems with HBV drug therapy 

The HBV genome is circular and organized into four open reading 



Polymerase 

protein 

Points of action of 

nucleos(t)ide analogues 

Terminal Protein Spacer G F A B C D E RNA asH 

Surface antigen 

protein 

PreS1 PreS2 S 

Figure 1: Genome structure of the hepatitis B virus showing 

overlapping reading frames of the polymerase and surface antigen 

Individual with 

chronic HBV treated 

with NA 

Selects for VEMs 

Can infect naïve (anti-HBs-ve) 

individuals with VEMs 

Can infect HepB-immunized (anti-HBs-ve) 

individuals with VEMs 

Figure 2: Potential impact of hepatitis B vaccine escape mutants and 

antiviral drug-associated potential vaccine escape mutants on public health 

frames that overlap each other. As a consequence of this 

arrangement, the part of the polymerase gene that codes for the 

reverse transcriptase enzyme – the target of antiviral therapy – 

overlaps the neutralization domain of the surface gene that codes 

for the S protein – the target of antibodies elicited by the hepatitis 

B vaccine (Figure 1). Treatment of HBV-infected individuals with 

nucleoside analogues results in mutations in the polymerase gene, 

many of which are associated with alterations in the “a” 

determinant of the surface antigen. 32–34 Resistance to lamivudine is, 

in fact, common in patients on monotherapy, appearing in from 

15% after the first year of treatment to 67% when used 

continuously for 4 years. 35 The genomic changes can be stable, 

and in at least one case a drug-resistant strain has been 

transmitted to another individual. 36 Consequently, in populations 

where lamivudine has been widely used to treat patients 

continuously for periods of several years, viruses with alterations in 

the surface antigen are likely to occur relatively frequently, and 

some will be antiviral drug-associated potential vaccine escape 

mutants (ADAP-VEMs). Although drug-driven changes in the S 

protein have been well described, the effect of these changes on 

the antigenicity of the surface antigen has been little studied. 37,38 

Public health risk of escape mutants 

The use of nucleoside and nucleotide analogues in the treatment 

of chronic hepatitis B infection results in mutations in the 

HBV genome that can have an impact on public health (Fig. 

2). However, the emergence of such ADAP-VEMs in treated 

patients does not necessarily pose a significant, imminent 

threat to the global hepatitis B immunization programme. For 

instance, some ADAP-VEMs selected by lamivudine have 

been shown to be less fit virologically; that is, they are rapidly 

replaced when the drug is removed and are unlikely to be a 

dominant or co-dominant viral population in terms of virus 

transmission. 29 For a new viral species to pose a threat to an 

immunization programme, we propose that it must display 

the following characteristics: (i) it must be a stable mutant, (ii) 

the changes in antigenicity must be sufficient to prevent the 

antibody generated by the vaccine from neutralizing it (i.e. it 

must be a true ADA-VEM), (iii) it must be transmissible, 

cause infection in immunized individuals and have 

opportunities to spread and (iv) it must cause acute or 

chronic disease in infected individuals. Of these four 

characteristics, to date we have evidence that three have 

been fulfilled, although we do not know if ADAP-VEMs have 

the same propensity to cause disease as do strains of HBV 

that are already circulating. However, given the high rate of 

HBV drug resistance and the discovery of ADAP-VEMs in 

individuals who have received lamivudine therapy, we 

suggest at least two features of HBV treatment programmes 

may increase the likelihood that an ADAP-VEM of public 

health importance will emerge. The first feature of such 

programmes that can increase the risk is the type of antiviral 

agent. Lamivudine, although it is relatively inexpensive, has 

been shown to rapidly result in the selection of primary 

antiviral drug-resistant polymerase variants. 

These variants in turn also select for compensatory 

mutations, some of which may have altered surface 

antigens. 33,34,39 In contrast, the likelihood that mutants will be 

generated seems to be much lower for newer agents such 

as entecavir, and for combination therapies including PEG-IFN, 

although the risk is not zero. 30,35,38,40 All of these newer medications, 

however, are more expensive and their long-term efficacy is still 

being established. Consequently, for the foreseeable future many 

countries, especially in the Asia-Pacific region, will probably 

continue to treat chronic hepatitis B infection with lamivudine even 

though it is no longer considered the first-line treatment, and 

despite the fact that drug resistance may rapidly emerge. 41 The 

proliferation of medications and substandard drugs, as has 

occurred with treatments for malaria (for instance), is an additional 

risk as treatment programmes expand in developing countries. 

The second potentially problematic feature of current treatment 

programmes is the way patients are selected. Antiviral drugs are 

the only long-term treatment option for chronic hepatitis B 

infection, 40 and many investigators have argued that all patients 

who are viraemic should be treated. Because of the strong 

correlation between HBV viral load and the likelihood of developing 

cirrhosis and hepatocellular carcinoma, reducing viral replication 

as early as possible after infection is likely to be beneficial. In 

addition to being costly, this approach may generate antiviral drug 

resistance since current agents never lead to eradication of the 

virus, but only to control of replication. This effect, in turn, can 

complicate second-line therapies and may favour the appearance 

of ADAPVEMs. Treatment in industrialized countries is therefore 



usually reserved for patients likely to respond to therapy and those 

who have advanced disease. 41 However, there is no consensus 

globally regarding which patients to treat, and WHO has not yet 

produced international recommendations to guide therapy (Daniel 

Lavanchy, personal communication, 2008). Inappropriate inclusion 

criteria, improper application of these criteria or lack of compliance 

with treatment could greatly influence the emergence of both drug 

resistance and ADAP-VEMs. The public health risk of treatment 

programmes in different populations may also depend upon 

features of the circulating viral genotype. There is evidence that the 

genotype of the virus influences the speed and frequency of 

development of resistance to treatment, which may in turn 

influence the likelihood that ADAP-VEMs will emerge. For 

example, genotype A-1 (common in northwestern Europe and 

North America) more frequently develops surface protein changes 

with lamivudine therapy than genotype D-1 (concentrated in 

Mediterranean countries but distributed globally). 42 The viral 

genotype also influences how frequently infected individuals 

develop antibodies to the hepatitis B “e” antigen (HBeAg). During 

the natural history of chronic hepatitis B, persons infected with 

genotype D-1 are more likely to become HBeAg-negative than 

those infected with genotype A-1. 43 In general, when HBeAg is 

detectable in the blood, the infection is more transmissible. Among 

children born to mothers who are HBeAg-positive, 90% will 

become infected whereas only 10% of children born to HBeAgnegative 

mothers will become infected. The disease process can 

also be more active and more rapidly progressive in HBeAgpositive 

individuals, 43 although disease progression may also be 

influenced more by the underlying HBV genotype than by HBeAg 

status alone. 44,45 The proportion of infected individuals who are 

HBeAg-positive could therefore influence the total numbers of 

persons treated with antiviral medications, the risk of generating 

ADAPVEMs and the subsequent risk of secondary transmission of 

these mutants. Given these features, the likelihood that escape 

mutants will emerge as a result of HBV treatment programmes is 

probably greatest in settings of high HBV prevalence, where 

treatment is widely available and where regimens are inappropriate 

or adherence is uneven. Escape mutants may also appear in 

settings where HIV/HBV co-infection is prevalent since HIV is 

known to increase HBV replication, 46 but it has not been confirmed 

that co-infection alters the rate of developing resistance. Within 

these settings there may be subgroups of particular interest. For 

example, the efficiency of transmission from an HBeAg-positive 

mother to her child during the perinatal period creates a very high 

risk for chronic hepatitis B infection. This risk makes it important to 

monitor for ADAP-VEMs among treated women of childbearing 

age, especially if lamivudine is used as monotherapy, since neither 

hepatitis B immunoglobulin nor active immunization would prevent 

infection with an ADAP-VEM transmitted from mother to child. In 

addition, the child may then spread the ADAP-VEM to other 

children, immunized or not. Subsequent treatment of chronic 

hepatitis B in all persons infected when young is also complicated 

if they have been infected with a drug-resistant strain. On the other 

hand, it has been estimated that the proportion of all HBV 

infections acquired among children more than 5 years of age 

ranges from 10% where prevalence of hepatitis B infection is high 

to as much as 90% where prevalence is low. 47 These numbers 

suggest that monitoring for ADAP-VEMs may be needed in other 

populations in addition to HBVinfected HBeAg-positive women of 

childbearing age. Geographical sites of high risk for the 

emergence of ADAP-VEMs of public health importance should be 

mapped. To this end, official and unofficial treatment programmes 

that already record the type of antiviral treatment, treatment criteria 

and the extent of substandard medications could be combined 

with descriptive epidemiology (e.g. high burden of disease, viral 

genotype, proportion of HBV-infected individuals with surface 

antigen positivity) to identify high-risk settings. 

Discussion 

In this article we raise the possibility of a threat to the global 

hepatitis B immunization programme because of the use of 

lamivudine and other nucleoside or nucleotide analogue 

therapeutic agents to treat individuals with chronic hepatitis B 

infection. Although the threat is theoretical, there is already 

evidence that current treatment regimens have resulted in the 

selection of stable ADAP-VEMs. Even though the transmission of 

ADAPVEMs to individuals immunized with HBV vaccine has been 

observed in only one case, 36 VEMs generated by hepatitis B 

vaccine have spread more widely and caused infection in 

previously immunized individuals. 

Knowing this, what should our response be now? At the very 

least, we must learn more about ADAP-VEMs, their transmissibility 

and their potential to cause infection and disease in immunized 

individuals. This will require virological surveillance and clinical 

follow-up of infected individuals and those undergoing treatment, 

and also, possibly, surveillance of their close contacts. The initial 

focus of these activities should be highrisk settings until the level 

of risk is defined and understood better. Incident cases of HBV in 

these situations could also be examined for VEMs, especially if a 

new case is epidemiologically linked to an individual undergoing 

treatment for chronic hepatitis B infection. Follow-up of such 

cases of HBV, however, would depend on the availability of testing, 

and currently no suitable commercial tests are available. 

At present, treatment aims to prevent the long-term 

complications of HBV infection, with little consideration given to 

potential adverse public health impacts. The number of potent 

antiviral agents is limited, their development by manufacturers is 

episodic and trials that have evaluated combination therapies are 

lacking. Because of these factors, monotherapy remains the usual 

practice in most settings. As with other infections, more potent 

combination therapies for HBV would reduce the chance of 

drugresistance and lead to early and longer-lasting control of HBV 

replication. Such therapies would not only benefit the individual 

but would also simultaneously reduce the likelihood that ADAP- 

VEMs of global public health significance will emerge. Trials are 

urgently needed to identify the optimal combination of existing 

drugs that can address both individual and public health needs. 

International therapeutic guidelines for chronic hepatitis B such as 

those issued by the Asian-Pacific Association for the Study of the 

Liver, 48 the European Association for the Study of the Liver 

International Consensus Conference 49 and the American 

Association for the Study of Liver Disease 50 should ideally consider 

both of these elements, and will need to be refined as more is 

learned about ADAP-VEMs. More effective novel agents are clearly 

needed that target other parts of the virus. 

It is still essential to prevent the spread of wild, vaccine-sensitive 

strains of HBV. Well-tested measures such as safe sex and 

avoiding the risks associated with injection drug use will also help 



to reduce horizontal transmission of both the wild virus and VEMs. 

Hepatitis B immunization for infants of mothers with HBV will 

reduce perinatal transmission of the wild virus but may not prevent 

transmission of VEMs. The global hepatitis B immunization 

programme will continue to reduce new incident infections of 

hepatitis B and the burden of chronic HBV disease globally, 

although it is simultaneously generating VEMs. One simulation has 

predicted that the spread of VEMs selected out by immunization 

would result in relatively few new infections for the foreseeable 

future. 51 However, it is not yet clear whether the emergence of 

ADAP-VEMs in a population will be speeded up by the 

simultaneous use of both the vaccine and treatment. Of course, 

hepatitis B vaccines that incorporate HBV proteins not altered by 

immunization or drug therapy are the ultimate solution to prevent 

the appearance of viral escape mutants generated by vaccines or 

antiviral drugs. ❏ 


We thank Paul Desmond, the director of Gastroenterology 

Department of St Vincent’s Hospital, Melbourne, Australia, for 

advice on clinical and pharmacological aspects that affect 

treatment of individuals with chronic hepatitis B infection. 

Originally published in Bulletin of the World Health Organization; 

Article DOI: 10.2471/BLT.08.065722 

References 

1. 

Kane M. Global status of hepatitis B immunization. Lancet 1997;350:1102. 

doi:10.1016/S0140-6736(05)65598-5 

2. 

Hanson DL, Adjé-Touré C, Talla-Nzussouo N, Eby P, Borget MY, Ya Kouadio L, et al. HIV Type 1 

drug resistance in adults receiving highly active antiretroviral therapy in Abidjan, Côte 

d’Ivoire. AIDS Res Hum Retroviruses 2009; 25:498-95. 

3. 

Okamoto H, Tsuda F, Sakugawa H, Sastrosoewignjo RI, Imai M, Miyakawa Y, et al. Typing 

hepatitis B virus by homology in nucleotide sequence: comparison of surface antigen 

subtypes. J Gen Virol 1988;69:2575-83. PMID:3171552 PMID:3171552 doi:10.1099/0022- 

1317-69-10-2575 

4. 

Lindh M, Andersson AS, Gusdal A. Genotypes, nt 1858 variants and geographic origin of 

hepatitis B virus large-scale analysis using a new genotyping method. J Infect Dis 

1997;175:1285-93. PMID:9180165 PMID:9180165 doi:10.1086/516458 Publication: Bulletin 

of the World Health Organization; Type: Policy and Practice Article DOI: 

10.2471/BLT.08.065722 

5. 

Magnius LO, Norder H. Subtypes, genotypes and molecular epidemiology of the hepatitis B 

virus as reflected by sequence variability of the S-gene. Intervirology 1995;38:24-34. 

PMID:8666521 PMID:8666521 

6. 

Torresi J, Earnest-Silveira L, Civitico G, Walters T, Lewin SR, Fyfe J, et al. Restoration of 

replication phenotype of lamivudine resistant hepatitis B virus mutants by compensatory 

changes in the “fingers” sub-domain of the viral polymerase selected as a consequence of 

mutations in the overlapping S gene. Virology 2002;299:88-99. PMID:12167344 

PMID:12167344 doi:10.1006/viro.2002.1448 

7. 

Torresi J, Earnest-Silveira L, Deliyannis G, Edgtton K, Zhuang H, Locarnini SA, et al. Reduced 

antigenicity of the hepatitis B virus HBsAg protein arising as a consequence of sequence 

changes in the overlapping polymerase gene that are selected by lamivudine therapy. 

Virology 2002;293:305-13. PMID:11886250 PMID:11886250 doi:10.1006/viro.2001.1246 

8. 

Hessel L, West DJ. Antibody responses to recombinant hepatitis B vaccines. Vaccine 

2002;20:2164-5. PMID:12009268 PMID:12009268 doi:10.1016/S0264-410X(02)00117-2 

9. 

Theamboonlers A, Chongsrisawat V, Jantaradsamee P, Poovorawan Y. Variants within the “a” 

determinant of HBs gene in children and adolescents with and without hepatitis B 

vaccination as part of Thailand’s Expanded Program on Immunization (EPI). Tohoku J Exp 

Med 2001;193:197-205. PMID:11315767 PMID:11315767 doi:10.1620/tjem.193.197 

10. 

He C, Nomura F, Itoga S, Isobe K, Nakai T. Prevalence of vaccine-induced escape mutants of 

hepatitis B virus in the adult population in China: a prospective study in 176 restaurant 

employees. J Gastroenterol Hepatol 2001;16:1373-7. PMID:11851835 PMID:11851835 

doi:10.1046/j.1440- 1746.2001.02654.x 

11. 

Su FH, Chen JD, Cheng SH, Lin CH, Liu YH, Chu FY. Seroprevalence of Hepatitis-B infection 

amongst Taiwanese university students 18 years following the commencement of a national 

Hepatitis-B vaccination program. J Med Virol 2007;79:138-43. PMID:17177303 

PMID:17177303 doi:10.1002/jmv.20771 

12. 

Carman WF. The clinical significance of surface antigen variants of hepatitis B virus. J Viral 

Hepat 1997;4 Suppl 1:11-20. 

13. 

Wands JR, Fujita YK, Isselbacher KJ, Degott C, Schellekens H, Dazza MC, et al. Identification 

and transmission of hepatitis B virus-related variants. Proc Natl Acad Sci USA 

1986;83:6608-12. PMID:3462716 PMID:3462716 doi:10.1073/pnas.83.17.6608 

14. 

Karthigesu VD, Allison LM, Fortuin M, Mendy M, Whittle HC, Howard CR. A novel hepatitis B 

virus variant in the sera of immunized children. J Gen Publication: Bulletin of the World 

Health Organization; Type: Policy and Practice Article DOI: 10.2471/BLT.08.065722 Virol 

1994;75:443-8. PMID:8113769 PMID:8113769 doi:10.1099/0022- 1317-75-2-443 

15. 

Carman WF, Wallace L, Ward K, Hawkins A, Rice S, Tedder R. Fulminant reactivation of 

hepatitis B due to envelope protein mutant that escaped detection by monoclonal HBsAg 

ELISA. Lancet 1995;345:1406-7. PMID:7539089 PMID:7539089 doi:10.1016/S0140- 

6736(95)92599-6 

16. 

Carman WF, Trautwein C, van Deursen FJ, Colman K, Dornan E, McIntyre G, et al. Hepatitis B 

virus envelope variation after transplantation with and without hepatitis B immune globulin 

prophylaxis. Hepatology 1996;24:489- 93. PMID:8781312 PMID:8781312 

doi:10.1002/hep.510240304 

17. 

Carman WF. The clinical significance of surface antigen variants of hepatitis B virus. J Viral 

Hepat 1997;4:11-20. PMID:9097273 PMID:9097273 doi:10.1111/j.1365- 

2893.1997.tb00155.x 

18. 

Waters JA, Kennedy M, Voet P, Hauser P, Petre J, Carman W, et al. Loss of the common “a” 

determinant of hepatitis B surface antigen by a vaccineinduced escape mutant. J Clin Invest 

1992;90:2543-7. PMID:1281839 PMID:1281839 doi:10.1172/JCI116148 

19. 

Oon CJ, Lim GK, Ye Z, Goh KT, Tan KL, Yo SL, et al. Molecular epidemiology of hepatitis B 

virus vaccine variants in Singapore. Vaccine 1995;13:699-702. PMID:7483783 

PMID:7483783 doi:10.1016/0264- 410X(94)00080-7 

20. 

Hsu HY, Chang MH, Liaw SH, Ni YH, Chen HL. Changes of hepatitis B surface antigen 

variants in carrier children before and after universal vaccination in Taiwan. Hepatology 

1999;30:1312-7. PMID:10534356 PMID:10534356 doi:10.1002/hep.510300511 

21. 

Karthigesu VD, Allison LM, Fortuin M, Mendy M, Whittle HC, Howard CR. A novel hepatitis B 

virus variant in the sera of immunized children. J Gen Virol 1994;75:443-8. PMID:8113769 

PMID:8113769 doi:10.1099/0022- 1317-75-2-443 

22. 

Papaevangelou G, Dandolos E, Roumeliotou-Karayannis A, Richardson SC. Immunogenicity of 

recombinant hepatitis B vaccine. Lancet 1985;1:455-6. PMID:2857828 PMID:2857828 

doi:10.1016/S0140-6736(85)91171-7 

23. 

Stevens CE, Taylor PE, Tong MJ, Toy PT, Vyas GN, Nair PV, et al. Yeastrecombinant hepatitis B 




vaccine. Efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B 

virus transmission. JAMA 1987;257:2612-6. PMID:2952812 PMID:2952812 

doi:10.1001/jama.257.19.2612 

24. 

Jilg W, Schmidt M, Deinhardt F. Prolonged immunity after late booster doses of hepatitis B 

vaccine. J Infect Dis 1988;157:1267-9. PMID:2967336 PMID:2967336 

25. 

Basuni AA, Butterworth L, Cooksley G, Locarnini S, Carman WF. Prevalence of HBsAg 

mutants and impact of hepatitis B infant immunisation in four Publication: Bulletin of the 

World Health Organization; Type: Policy and Practice Article DOI: 10.2471/BLT.08.065722 

Pacific Island countries. Vaccine 2004;22:2791-9. PMID:15246613 PMID:15246613 

doi:10.1016/j.vaccine.2004.01.046 

26. 

Schalm SW, Heathcote J, Cianciara J, Farrell G, Sherman M, Willems B, et al. Lamivudine 

and alpha interferon combination treatment of patients with chronic hepatitis B infection: a 

randomised trial. Gut 2000;46:562-8. PMID:10716688 doi:10.1136/gut.46.4.562 

27. 

Lok AS, McMahon BJ. Chronic hepatitis B. Hepatology 2007;45:507-39. PMID:17256718 

PMID:17256718 doi:10.1002/hep.21513 

28. 

Thomas H, Foster G, Platis D. Mechanisms of action of interferon and nucleoside analogues. 

J Hepatol 2003;39 Suppl 1;S93-8. PMID:14708685 PMID:14708685 doi:10.1016/S0168- 

8278(03)00207-1 

29. 

Marcellin P, Lau GK, Bonino F, Farci P, Hadziyannis S, Jin R, et al. Peginterferon alfa-2a 

alone, lamivudine alone, and the two in combination in patients with HBeAg-negative 

chronic hepatitis B. N Engl J Med 2004;351:1206-17. PMID:15371578 PMID:15371578 

doi:10.1056/NEJMoa040431 

30. 

Lau GK, Piratvisuth T, Luo KX, Marcellin P, Thongsawat S, Cooksley G, et al. Peginterferon 

Alfa-2a, lamivudine, and the combination for HBeAg-positive chronic hepatitis B. N Engl J 

Med 2005;352:2682-95. PMID:15987917 PMID:15987917 doi:10.1056/NEJMoa043470 

31. 

Schalm SW, Heathcote J, Cianciara J, Farrell G, Sherman M, Willems B, et al. Lamivudine 

and alpha interferon combination treatment of patients with chronic hepatitis B infection: a 

randomised trial. Gut 2000;46:562-8. PMID:10716688 PMID:10716688 

doi:10.1136/gut.46.4.562 

32. 

Yeh CT, Chien RN, Chu CM, Liaw YF. Clearance of the original hepatitis B virus YMDD-motif 

mutants with emergence of distinct lamivudine-resistant mutants during prolonged 

lamivudine therapy. Hepatology 2000;31:1318- 26. PMID:10827158 PMID:10827158 

doi:10.1053/jhep.2000.7296 

33. 

Torresi J, Earnest-Silveira L, Civitico G, Walters T, Lewin SR, Fyfe J, et al. Restoration of 

replication phenotype of lamivudine resistant hepatitis B virus mutants by compensatory 

changes in the “fingers” sub-domain of the viral polymerase selected as a consequence of 

mutations in the overlapping S gene. Virology 2002;299:88-99. PMID:12167344 

PMID:12167344 doi:10.1006/viro.2002.1448 

34. 

Torresi J, Earnest-Silveira L, Deliyannis G, Edgtton K, Zhuang H, Locarnini SA, et al. Reduced 

antigenicity of the hepatitis B virus HBsAg protein arising as a consequence of sequence 

changes in the overlapping polymerase gene that are selected by lamivudine therapy. 

Virology 2002;293:305-13. PMID:11886250 PMID:11886250 doi:10.1006/viro.2001.1246 

35. 

Hoofnagle JH, Doo E, Liang TJ, Fleischer R, Lok ASF. Management of Hepatitis B: Summary 

of a Clinical Research Workshop. Hepatology 2007;45:1056-75. PMID:17393513 

PMID:17393513 doi:10.1002/hep.21627 

36. 

Thibault V, Aubron-Olivier C, Agut H, Katlama C. Primary infection with a lamivudine-resistant 

hepatitis B virus. AIDS 2002;16:131-3. PMID:11741175 PMID:11741175 

doi:10.1097/00002030-200201040- 00020 

37. 

Janssen HL, van Zonneveld M, Senturk H, Zeuzem S, Akarca US, Cakaloglu Y, et al. 

Pegylated interferon alfa-2b alone or in combination with lamivudine for HBeAg-positive 

chronic hepatitis B: a randomised trial. Lancet 2005;365:123-9. PMID:15639293 

PMID:15639293 doi:10.1016/S0140-6736(05)17701-0 

38. 

Locarnini S, Hatzakis A, Heathcote J, Keeffe EB, Liang TJ, Mutimer D, et al. Management of 

antiviral resistance in patients with chronic hepatitis B. Antivir Ther 2004;9:679-93. 

PMID:15535405 PMID:15535405 

39. 

Torresi J. The virological and clinical significance of mutations in the overlapping envelope 

and polymerase genes of hepatitis B virus. J Clin Virol 2002;25:97-106. 

40. 

Sheldon J, Soriano V. Hepatitis B virus escape mutants induced by antiviral therapy. J 

Antimicrob Chemother 2008;61:766-8. PMID:18218641 PMID:18218641 

doi:10.1093/jac/dkn014 

41. 

Papatheodoridis GV, Hadziyannis SJ. Review article: current management of chronic hepatitis 

B. Aliment Pharmacol Ther 2004;19:25-37. PMID:14687164 PMID:14687164 

doi:10.1046/j.1365-2036.2003.01810.x 

42. 

Sheldon J, Ramos B, Garcia-Samaniego J, Rios P, Bartholomeusz A, Romero M et al. 

Selection of hepatitis B virus (HBV) vaccine escape mutants in HBV-infected and HBV/HIV 

co-infected patients failing antiretroviral drugs with anti-HBV activity. J Acquir Immune Defic 

Syndr 2007;46:279-82. PMID:18167643 PMID:18167643 

doi:10.1097/QAI.0b013e318154bd89 

43. 

Fung SK, Lok AS. Hepatitis B virus genotypes: do they play a role in the outcome of HBV 

infection? Hepatology 2004;40:790-2. PMID:15382157 PMID:15382157 

44. 

Liu C-J, Kao J-H, Chen D-S. Therapeutic implications of hepatitis B virus genotypes. Liver 

Int 2005;25:1097-107. PMID:16343058 PMID:16343058 doi:10.1111/j.1478- 

3231.2005.01177.x 

45. 

Toan NL, Song L, Kremsner PG, Duy D, Binh V, Koeberlein B, et al. Impact of the hepatitis B 

virus genotype and genotype-mixtures on the course of liver disease in Vietnam. Hepatology 

2006;43:1375-84. PMID:16729315 PMID:16729315 doi:10.1002/hep.21188 

46. 

Matthews GV, Bartholomeusz A, Locarnini S, Ayres A, Sasaduesz J, Seaberg E, et al. 

Characteristics of drug resistant HBV in an international collaborative study of HIV-HBVinfected 

individuals on extended lamivudine therapy. AIDS 2006;20:863-70. PMID:16549970 

PMID:16549970 doi:10.1097/01.aids.0000218550.85081.59 

47. 

Alter MJ. Epidemiology of hepatitis B in Europe and worldwide. J Hepatol 2003;39:S64-9. 

PMID:14708680 PMID:14708680 doi:10.1016/S0168- 8278(03)00141-7 

48. 

Liaw YF, Leung N, Kao JH, Piratvisuth T, Gane E, Han KH, et al. Asian- Pacific consensus 

statement of the management of chronic hepatitis B: a 2008 update. Hepatology 

International 2008. 

49. 

Proceedings of the European Association for the Study of the Liver (EASL) International 

Consensus Conference on Hepatitis B. 14-16 September, 2002. Geneva, Switzerland. J 

Hepatol 2003;39 Suppl 1;S1-235. PMID:14964189 PMID:14964189 

50. 

Lok AS, McMahon BJ. Chronic hepatitis B. Hepatology 2007;45:507-39. PMID:17256718 

PMID:17256718 doi:10.1002/hep.21513 

51. 

Wilson JN, Nokes DJ, Carman WF. The predicted pattern of emergence of vaccine-resistant 

hepatitis B: a cause for concern? Vaccine 1999;17:973- 8. PMID:10067705 PMID:10067705 

doi:10.1016/S0264-410X(98)00313-2 


althcare transformation 

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Innovation and strategy: infectious disease surveillance 

Using satellite images of 

environmental changes to predict 

infectious disease outbreaks 

ARTICLE BY TIMOTHY E FORD, 

University of New England, Biddeford, Maine, USA 

RITA R COLWELL, 

University of Maryland, College Park, Maryland, USA and Johns Hopkins University Bloomberg School of Public Health, Baltimore, 

Maryland, USA 

JOAN B ROSE, 

Michigan State University, East Lansing, Michigan, USA 

STEPHEN S MORSE, 

Mailman School of Public Health, Columbia University, New York, USA 

DAVID J ROGERS, 

Oxford University, Oxford, UK 

TERRY L YATES, 

University of New Mexico, Albuquerque, New Mexico, USA 

Recent events clearly illustrate a continued vulnerability of large populations to infectious diseases, which is related 

to our changing human-constructed and natural environments. A single person with multidrug-resistant tuberculosis 

in 2007 provided a wake-up call to the United States and global public health infrastructure, as the health 

professionals and the public realized that today’s ease of airline travel can potentially expose hundreds of persons to 

an untreatable disease associated with an infectious agent. Ease of travel, population increase, population 

displacement, pollution, agricultural activity, changing socioeconomic structures, and international conflicts 

worldwide have each contributed to infectious disease events. Today, however, nothing is larger in scale, has more 

potential for long-term effects, and is more uncertain than the effects of climate change on infectious disease 

outbreaks, epidemics, and pandemics. We discuss advances in our ability to predict these events and, in particular, 

the critical role that satellite imaging could play in mounting an effective response. 

Atmospheric chemists and climate modelers have little doubt 

that the earth’s climate is changing. Concomitant with rising 

carbon dioxide levels and temperatures, severe weather 

events are increasing, which can lead to substantial rises in sea 

level, flooding, increased droughts, and forest fires 1 . In recent 

decades, infectious diseases have resurged, and previously 

unrecognized agents of disease have been characterized 2 . 

Evidence is accruing that these phenomena may in part be linked 

to environmental change 3 . Several questions have emerged from 

events that have occurred over the past 20 years: was 

cryptosporidiosis inevitable in Milwaukee, Wisconsin, USA, in 

1993, and was Escherichia coli O157 infection inevitable in 

Walkerton, Ontario, Canada, in 2000? Both events were preceded 

by heavy rains; had highly concentrated sources of pathogens in 

the form of untreated sewage and animal waste, respectively; and 

had vulnerable infrastructure. Although the situations were 

perhaps more complex, could we have predicted epidemic 

cholera in South America in 1991 after a 100-year absence and 

the emergence of a new strain of potentially pandemic cholera in 

India in 1992? 

A considerable body of knowledge has accumulated over the 

past decade or so about the relationships between environment 

and disease, yet far more information and resources are needed if 

we are to develop effective early warning systems through 

environmental surveillance and modeling as well as appropriate 

emergency response. In the United States, we face a crisis in 

funding that not only affects basic and applied research in this field 

but also undermines our ability to deploy remote sensing 

technologies that provide the most promising means for 

monitoring our environment. Using examples of waterborne and 

vectorborne disease, we will discuss how remote sensing 

technology can be used for disease prediction. We will then 

examine the lessons learned from these examples and provide 

recommendations for future modeling. 

Waterborne disease 

Water and climate go hand in hand, with precipitation and extreme 

events known to be associated with waterborne outbreaks 4 . 

Flooding is the most frequent natural weather disaster (30%–46% 

of natural disasters in 2004–2005), affecting >70 million persons 

worldwide each year (data for 2005 5 ). 

The most common illnesses associated with floods described in 

the literature are diarrhea, cholera, typhoid, hepatitis (jaundice), 

and leptospirosis. Unusual illnesses such as tetanus have also 

been reported. The etiologic agents identified include 

Cryptosporidium spp., hepatitis A virus, hepatitis E virus, 



Figure 1: Modeling cholera outbreaks in Bangladesh. Adapted from RR Colwell and 

J Calkins, unpub. data. 

Leptospira spp., Salmonella spp., and Vibrio spp. Severe 

outbreaks of cholera, in particular, have been directly associated 

with flooding in Africa and in West Bengal, India 6,7 . 

A rise in sea level, combined with increasingly severe weather 

events, is likely to make flooding events commonplace worldwide. 

The Climate Change 2001 Synthesis Report from the 

Intergovernmental Panel on Climate Change 8 suggests that the 

average annual numbers of persons affected by coastal storm 

surges will increase from 50% 10 . 

Although remote sensing technology is currently 

still a research tool, the example of cholera 

prediction through its use provides a compelling 

argument to maintain and adequately fund our 

satellite programmes; unless this is done, this 

extraordinary effort at disease prediction will fail. Some of the 

critical needs that must be met to predict the effect of 

environmental change on waterborne disease include the 

following: 

✚ better knowledge of disease incidence and pathogen 

excretion; 

✚ better characterization of the pathogens in sources (e.g., 

combined sewer overflows, septic tanks) and these sources’ 

vulnerabilities to climate change; 

✚ better monitoring of sewage indicators to gather source, 

transport, and exposure information (event monitoring); 

✚ improved understanding of sediments and other pathogen 

reservoirs; 

✚ more quantitative data for risk assessment; and 

✚ better health surveillance data. In turn, this information can be 

used to better use ground truthing in combination with remote 

sensing technologies as predictors of waterborne disease 

outbreaks. 

Using satellite technology to model prediction of Cholera 

outbreaks 

Effective prediction depends on many factors, not just the 

prediction of an event. Cholera may be the most studied and best 

understood of the waterborne diseases and, perhaps in hindsight, 

we could have predicted the occurrence of cholera in South 

America in 1991 9 . Models for cholera prediction, although country 

specific, are constantly improving. For example, considerable 

work has gone into predicting outbreaks of cholera in Bangladesh. 

Remote imaging technologies developed by the US National 

Aeronautics and Space Administration have been used to relate 

sea surface temperature, sea surface height, and chlorophyll A 

levels to cholera outbreaks (Figure 1) (RR Colwell and J Calkins, 

unpub. data). This process used a composite environmental 

model that demonstrated a remarkable similarity between 

predicted rates based on these three parameters and actual 

cholera incidence. These data are far from perfect and 

considerable uncertainty still remains. For example, rates of 

Vectorborne disease 

Other emerging and reemerging infectious diseases also are 

environmentally driven. Many are zoonotic, vector- 1342 Emerging 

borne, or both, and have complex life histories that make 

predicting disease emergence or reemergence particularly difficult. 

An insect or rodent vector can make it almost inevitable that a 

pathogen will be globally transported by plane or boat. With 

environmental change, disease range, prevalence, and seasonality 

may change in direct relationship to the vector or animal host. 

Therefore, to understand the life cycle of a pathogen and the risks 

of disease emergence, all stages of that life cycle and the life 

cycles of its intermediate hosts must be considered. 

To date, predicting vectorborne diseases has proved to be 

complex. Although climate change and other environmental 

stressors are major components, separation from human factors 

is difficult. Climate change undoubtedly affects the distribution of 

disease, but changes in human behaviour that increase exposure 

risk are also critical factors. Šumilo et al. 11 reported that climatic 

42 Hospital and healthcare Innovation Book 2009/2010


variables explain only 55% of spatial variation in tick-borne 

encephalitis in the Baltic States, which have seen an increase in 

disease incidence over the past 3 decades. These authors report 

that changes in predation pressure on intermediate hosts and 

shifting socioeconomic conditions that increase or decrease 

peoples’ visits to forests (for recreation, work, or berry and 

mushroom harvesting) are important factors in disease 

distribution 12 . 

Effective modeling of future risk for vectorborne disease 

outbreaks needs to take into account human behaviour that 

increases exposure, as well as other factors that effect the ecology 

of the vectors, such as predation pressure and habitat change. 

Coupled with remote sensing technologies that monitor 

environmental and climatic changes, human observations of 

population movement and distribution will be necessary. 

Malaria also presents a challenge. This disease continues to 

devastate sub-Saharan Africa and other parts of the developing 

world. Substantial resources over the past several decades have 

gone toward eradication, vaccination, treatment, and, more 

recently, prediction of malaria outbreaks. Satellite imaging has 

been used to predict the distribution of 5 of the 6 Anopheles 

gambiae complex species that are responsible for much of the 

malaria transmission in Africa 13 . However, human factors again 

make accurate prediction of disease events complex. Prediction of 

a disease event is complicated by host immunity effects, which 

can result in cycles of infection that would appear to bear no 

relationship to environmental variables. 

To predict malaria outbreaks, remote sensing technologies need 

to be coupled with a better understanding of how specific 

populations are effected by host immunity, which could allow 

population susceptibility at any given time to be estimated. 

Using satellite technology to model Hantavirus Pulmonary 

Syndrome 

Although considerable uncertainty exists in disease prediction 

through remote sensing technology, particularly for vectorborne 

disease as discussed above, satellite technology has been applied 

with some success to predictive modeling for cases of hantavirus 

pulmonary syndrome (HPS). The 1993 outbreak of HPS in the 

southwestern United States was believed to be linked to 

environmental conditions and, in particular, to abnormally high 

rainfall that resulted in increased vegetation with a subsequent 

explosion in the rodent populations. Several research groups have 

subsequently modeled conditions that led to an HPS outbreak, 

with mixed success. Engelthaler et al. 14 looked at 10 years of data 

on monthly precipitation and daily ambient temperature in the 

Southwest region (1986–1995) in relation to HPS cases 

(1993–1995). They found that cases tended to cluster seasonally 

and temporally by biome type and elevation and only indirectly 

demonstrated a possible association between the 1992/1993 El 

Niño precipitation events and HPS. Glass et al. 15,16 were also 

unable to make a definitive link with precipitation events in their 

analyses of HPS in the southwestern United States. They did, 

however, find a relationship between Landsat Thermatic Mapper 

(LTM) images recorded by satellite in 1992 and HPS risk the 

following year. LTM generates numbers that represent reflected 

light in 6 bands, 2 of which were associated with decreased risk 

and 1, in the mid-infrared range, with increased risk. The authors 

admit that considerable ground truthing is necessary to relate 

satellite imagery to the environmental variables being measured 

(i.e., vegetation, soil type, soil moisture) and their relation to rodent 

population dynamics. 

However, this work does demonstrate the utility of remote 

satellite imaging and the increasingly important role it can and 

should play in disease prediction. In 2006, Glass et al. 17 reported 

strong predictive strength from logistic regression modeling of LTM 

imagery from one year, when estimating risk of HPS the following 

year, for the years 1992– 2005. Their risk analysis for 2006, based 

on Landsat imagery for 2005, when precipitation levels increased 

dramatically over prior drought years, suggested an increased risk 

for HPS, particularly in northern New Mexico and southern 

Colorado. This prediction was unfortunately borne out in the early 

part of 2006 when 9 cases of HPS occurred within the first 3 

months, 6 of those cases in New Mexico and Arizona. However, 

the anticipated threat to Colorado did not occur, with a fairly 

typical number of 6 cases, compared with a total of 11 cases for 

the state in 2005 18 . 

However, these results are not necessarily a failure of prediction. 

In fact, they may illustrate that an early warning system serves to 

reduce exposure of persons to the deermice habitat. For example, 

USA Today highlighted HPS risks with a June 8, 2006, article 

titled “Officials warn of increased threat of hantavirus” 

(www.usatoday.com/news/ health/2006-06-08-hantavirus-x.htm). 

The role of the popular press is hard to quantify but undoubtedly 

does have an effect on human behavior patterns. Many health 

departments in the western states produce health advisories 

warning the public about the risks of exposure to the virus through 

inhalation of dust contaminated with rodent urine, feces, or saliva. 

The popular press may serve an important role in increasing 

awareness of a heightened health risk, which, in turn, promotes 

greater compliance with health advisories. 

Lessons learned and recommendations for future modeling 

The scientific community has a relative consensus that epidemic 

and pandemic disease risks will be exacerbated by environmental 

changes that destabilize weather patterns, change distribution of 

vectors, and increase transport and transmission risk. Predictive 

modeling may lead to improved understanding and potentially 

prevent future epidemic and pandemic disease. Many respiratory 

infections are well known as highly climate dependent or seasonal. 

Although we are not yet able to predict their incidence with great 

precision, we may well be able to do this in the future. 

Meningococcal meningitis (caused by Neisseria meningitidis) in 

Africa is probably the best known example. In the diseaseendemic 

so-called meningitis belt (an area running across sub- 

Saharan Africa from Senegal to Ethiopia), this is classically a dry 

season disease, which ceases with the beginning of the rainy 

season, likely as a result of changes in host susceptibility 19 . Many 

other infectious diseases show strong seasonality or association 

with climatic conditions 20 . Perhaps one of the most interesting is 

influenza, which is thought of as a wintertime disease in temperate 

climates but shows both winter and summer peaks in subtropical 

and tropical regions 21 . Although the reasons for seasonality are 

often poorly understood, the close dependence of such diseases 

on climatic conditions suggests that these, too, are likely to be 

amenable to prediction by modeling and remote sensing 22 . When 

we consider influenza, it is hard not to think about the future risks 

from pandemic influenza. Public health agencies in the United 

Hospital and healthcare Innovation Book 2009/2010 43


States and around the world are focusing on influenza 

preparedness, notably concerning influenza virus A 

subtype H5N1, which has captured attention because 

it causes severe disease and death in humans but as 

yet has demonstrated only very limited and inefficient 

human-to-human transmission. The severity of the 

disease raises images of the 1918 influenza epidemic 

on an unimaginably vast scale if the virus were to adapt 

to more efficient human-to-human transmission. Can 

predictive modeling using satellite or other imaging of 

environmental variables help in prediction of future 

influenza pandemics? Xiangming Xiao at the University 

of New Hampshire was funded in 2006 by the National 

Institutes for Health to lead a multidisciplinary and 

multi-institutional team to use remote satellite imaging 

to track avian flu. Xiao et al. have used satellite 

image–derived vegetation indices to map paddy rice 

agriculture in southern Asia 23 . They believe that a similar 

approach can be used in conjunction with the more 

traditional approach of analyzing bird migration 

patterns and poultry production 24,25 to map potential hot 

spots of virus transmission 26 . 

An interesting question is why did we not see disease epidemics 

in Indonesia, following the devastating tsunami disaster of 

December 2004? Could rapid public health intervention be 

credited with minimizing spread of disease? In the case of Aceh 

Province, many communities reported diarrhea as the main cause 

of illness (in 85% of children


ability to accurately link environmental variables, particularly those 

related to climate change, will improve. What has become clear 

over the past few years is that satellite imaging can play a critical 

role in disease prediction and, therefore, inform our response to 

future outbreaks. We conclude that infectious disease events may 

be closely linked to environmental and global change. Satellite 

imaging may be critical for effective disease prediction and thus 

future mitigation of epidemic and pandemic diseases. We cannot 

stress too strongly our belief that a strong global satellite 

programme is essential for future disease prediction. ❏ 

Acknowledgments 

This article is dedicated to Terry L Yates, an outstanding scientist 

and colleague whose substantial contributions to vectorborne and 

zoonotic disease research, in particular, his work on the ecology of 

hantavirus, will always be remembered. TEF was supported in part 

by grant no. P20 RR-16455-06 from the National Center for 

Research Resources, a component of the National Institutes of 

Health (NIH). SMM was supported by Centers for Disease Control 

and Prevention cooperative agreements A1010-21/21, 

U90/CCU224241 (Centers for Public Health Preparedness) and 

U01/CI000442, the Arts and Letters Foundation, and NIH/National 

Institute for Allergy and Infectious Disease cooperative agreement 

5U54AI057158 (Northeast Biodefense Center Regional Center of 

Excellence for Biodefense and Emerging Infectious Diseases 

Research). R.R.C. was supported in part by grant no. S0660009 

from the National Oceanic and Atmospheric Administration Dr Ford 

is Vice President for Research and Dean of Graduate Studies at the 

University of New England (UNE), in Biddeford and Portland, 

Maine, USA. He has conducted research on environmental 

microbiology, environmental health, and waterborne disease for the 

past 28 years and was founding director of the program in Water 

and Health at the Harvard School of Public Health. At UNE, he 

anticipates supporting programs that link terrestrial and marine 

ecosystems with human health. 

References 

1. 

Climate change 2007: synthesis report. Contribution of working groups I, II and III to the 

fourth assessment report of the Intergovernmental Panel on Climate Change. Geneva: 

Intergovernmental Panel on Climate Change; 2007 [cited 2008 Apr 19]. Available from 

http:// www.ipcc.ch/pdf/assessment-report/ar4/syr/ar4_syr.pdf 

2. 

Morens DM, Folkers GK, Fauci AS. The challenge of emerging and re-emerging infectious 

diseases. Nature. 2004;430:242–9. DOI: 10.1038/nature02759 

3. 

Wilson ME, Levins R, Spielman A, editors. Disease in evolution: global changes and 

emergence of infectious diseases. New York: New York Academy of Sciences; 1994. 

4. 

Curriero FC, Patz JA, Rose JB, Lele S. Analysis of the association between extreme 

precipitation and waterborne disease outbreaks in the United States, 1948–1994. Am J 

Public Health. 2001;91:1194–9. DOI: 10.2105/AJPH.91.8.1194 

5. 

Hoyois P, Scheuren J-M, Below R, Guha-Sapin D. Annual disaster statistical review: numbers 

and trends, 2006. Brussels: Center for Research on the Epidemiology of Disasters, School of 

Public Health, Catholic University of Louvain; 2007 [cited 2008 Apr 19]. Available from 

http://www.emdat.be/Documents/Publications/Annual% 

20Disaster%20Statistical%20Review%202006.pdf 

6. 

Sidley P. Floods in southern Africa result in cholera outbreak and displacement. BMJ. 

2008;336:471. DOI: 10.1136/bmj.39503.700903. DB 

7. 

Sur D, Dutta P, Nair GB, Bhattacharya SK. Severe cholera outbreak following floods in a 

northern district of West Bengal. Indian J Med Res. 2000;112:178–82. 

8. 

Climate change 2001: synthesis report. A contribution of working groups I, II, and III to the 

third assessment report of the Intergovernmental Panel on Climate Change. Cambridge: 

Cambridge University Press; 2001 [cited 2008 Apr 19]. Available from http://www. 

ipcc.ch/ipccreports/tar/vol4/english/002.htm 

9. 

Gil AI, Louis VR, Rivera ING, Lipp E, Huq A, Lanata CF. Occurrence and distribution of Vibrio 

cholerae in the coastal environment of Peru. Environ Microbiol. 2004;6:699–706. DOI: 

10.1111/j.1462- 2920.2004.00601.x 

10. 

Colwell RR, Huq A, Islam MS, Aziz KMA, Yunus M, Khan NH, et al. Reduction of cholera in 

Bangladeshi villages by simple filtration. Proc Natl Acad Sci USA. 2003;100:1051–5. DOI: 


10.1073/ pnas.0237386100 

11. 

Šumilo D, Bormane A, Asokliene L, Lucenko I, Vasilenko V, Randolph S. Tick-borne 

encephalitis in the Baltic States: identifying risk factors in space and time. Int J Med 

Microbiol. 2006;296:76–9. DOI: 10.1016/j.ijmm.2005.12.006 

12. 

Šumilo D, Asokliene L, Bormane A, Vasilenko V, Golovljova I, Randolph S. Climate change 

cannot explain the upsurge of tick-borne encephalitis in the Baltics. PLoS One. 

2007;2:e500. DOI: 10.1371/ journal.pone.0000500 

13. 

Rogers DJ, Randolph SE, Snow RW, Hay SI. Satellite imagery in the study and forecast of 

malaria. Nature. 2002;415:710–5. DOI: 10.1038/415710a 

14. 

Engelthaler DM, Mosley DG, Cheek JE, Levy CE, Komatsu KK, Ettestad P, et al. Climatic and 

environmental patterns associated with hantavirus pulmonary syndrome, Four Corners 

region, United States. Emerg Infect Dis. 1999;5:87–94. 

15. 

Glass GE, Cheek JE, Patz JA, Shields TM, Doyle TJ, Thoroughman DA, et al. Using remotely 

sensed data to identify areas at risk for hantavirus pulmonary syndrome. Emerg Infect Dis. 

2000;6:238–47. 

16. 

Glass GE, Yates TL, Fine JB, Shields TM, Kendall JB, Hope AG, et al. Satellite imagery 

characterizes local animal reservoir populations of Sin Nombre virus in the southwestern 

United States. Proc Natl Acad Sci USA. 2002;99:16817–22. DOI: 10.1073/ pnas.252617999 

17. 

Glass GE, Shields TM, Parmenter RR, Goade D, Mills JN, Cheek J, et al. Predicted hantavirus 

risk in 2006 for the southwestern U.S. Occasional Papers of the Museum of Texas Tech 

University. 2006;255:1–16. 

18. 

First hantavirus case reported for 2006–Coloradans urged to take precautions. Boulder (CO): 

Colorado Department of Public Health and Environment; 2006 [cited 2008 Apr 19]. Available 

from http:// www.bouldercounty.org/health/pr/2006/05112006hantaVirus.htm 

19. 

Greenwood BM, Blakebrough IS, Bradley AK, Wali S, Whittle HC. Meningococcal disease and 

season in sub-Saharan Africa. Lancet. 1984;1:1339–42. DOI: 10.1016/S0140- 

6736(84)91830-0 

20. 

Dowell SF, Ho MS. Seasonality of infectious diseases and severe acute respiratory 

syndrome–what we don’t know can hurt us. Lancet Infect Dis. 2004;4:704–8. DOI: 

10.1016/S1473-3099(04)01177-6 

21. 

Chew FT, Doraisingham S, Ling AE, Kumarasinghe G, Lee BW. Seasonal trends of viral 

respiratory tract infections in the tropics. Epidemiol Infect. 1998;121:121–8. DOI: 

10.1017/S0950268898008905 

22. 

Broutin H, Philippon S, Constantin de Magny G, Courel M-F, Sultan B, Guégan JF. 

Comparative study of meningitis dynamics across nine African countries: a global 

perspective. Int J Health Geographics. 2007;6:29 [cited 2009 Mar 20]. Available from 

http://www. ij-healthgeographics.com/content/6/1/29 

23. 

Xiao X, Boles S, Frolking SE, Li C, Babu JY, Salas W, et al. Mapping paddy rice agriculture in 

south and Southeast Asia using multi-temporal MODros Inf Serv. images. Remote Sens 

Environ. 2006;100:95–113. DOI: 10.1016/j.rse.2005.10.004 

24. 

Kilpatrick AM. Chmura AA, Gibbons DW, Fleischer RC, Marra PP, Daszak P. Predicting the 

global spread of H5N1 avian influenza. Proc Natl Assoc Sci. 2006;103:19368–73. DOI: 

10.1073/ pnas.0609227103 

25. 

Gilbert M, Xiao X, Domenech J, Lubroth J, Martin V, Slingenberg J. Anatidae migration in the 

western Palearctic and spread of highly pathogenic avian influenza H5N1 virus. Emerg 

Infect Dis. 2006;12:1650–6. 

26. 

Sims D. UNH Research uses satellite observation to track avian flu. Durham (NH): University 

of New Hampshire Media Relations; November 20, 2006 [cited 2008 Apr 19]. Available from 

http://www. unh.edu/news/cj_nr/2006/nov/ds20flu.cfm 

27. 

Brennan RJ, Rimba K. Rapid health assessment in Aceh Jaya District, Indonesia, following 

the December 26 tsunami. Emerg Med Australas. 2005;17:341–50. DOI: 10.1111/j.1742- 

6723.2005.00755. 

28. 

Jamieson C. Preventing the second wave. Operation Sumatra Assist, Australian Government, 

Department of Defense; 2005 [cited 2008 Apr 18]. Available from 

http://defence.gov.au/optsunamiassist/ news/article045/index.htm 

29. 

Faruque SM, Albert MJ, Mekalanos JJ. Epidemiology, genetics, and ecology of toxigenic 

Vibrio cholerae. Microbiol Mol Biol Rev. 1998;62:1301–14. 

30. 

Chakraborty S, Mukhopadhyay AK, Bhadra RK, Ghosh AN, Mitra R, Shimada T, et al. Virulence 

genes in environmental strains of Vibrio cholerae. Appl Environ Microbiol. 2000;66:4022–8. 

DOI: 10.1128/AEM.66.9.4022-4028.2000 

31. 

Hamner S, Broadaway SC, Mishra VB, Tripathi A, Mishra RK, Pulcini E, et al. Isolation of 

potentially pathogenic Escherichia coli O157:H7 from the Ganges River. Appl Environ 

Microbiol. 2007;73:2369–72. DOI: 10.1128/AEM.00141-07 

32. 

Martinez RJ, Wang Y, Raimondo MA, Coombs JM, Barkay T, Sobecky PA. Horizontal gene 

transfer of PIB-type ATPases among bacteria isolated from radionuclide- and metalcontaminated 

subsurface soils. Appl Environ Microbiol. 2006;72:3111–8. DOI: 10.1128/ 

AEM.72.5.3111-3118.2006 


Innovation and policy: infectious disease surveillance 

Use of unstructured event-based 

reports for global infectious 

disease surveillance 

ARTICLE BY MIKAELA KELLER, 

Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology, Boston, Massachusetts, USA, 

Children’s Hospital Boston and Harvard Medical School 

MICHAEL BLENCH, 

Public Health Agency of Canada, Ottawa, Ontario, Canada 

HERMAN TOLENTINO 

Centers for Disease Control and Prevention, Atlanta, Georgia, USA 

CLARK C FREIFELD 



KENNETH D MANDL 



ABLA MAWUDEKU, 

Public Health Agency of Canada, Ottawa, Ontario, Canada 

GUNTHER EYSENBACH 

University of Toronto, Toronto, Ontario, Canada and University Health Network, Toronto 

AND JOHN S BROWNSTEIN 



Free or low-cost sources of unstructured information, such as Internet news and online discussion sites, provide detailed local 

and near real-time data on disease outbreaks, even in countries that lack traditional public health surveillance. To improve 

public health surveillance and, ultimately, interventions, we examined three primary systems that process event-based 

outbreak information: Global Public Health Intelligence Network, HealthMap, and EpiSPIDER. Despite similarities among 

them, these systems are highly complementary because they monitor different data types, rely on varying levels of 

automation and human analysis, and distribute distinct information. Future development should focus on linking these 

systems more closely to public health practitioners in the field and establishing collaborative networks for alert verification 

and dissemination. Such development would further establish event-based monitoring as an invaluable public health 

resource that provides critical context and an alternative to traditional indicator-based outbreak reporting. 

International travel and movement of goods increasingly 

facilitates the spread of pathogens across and among nations, 

enabling pathogens to invade new territories and adapt to new 

environments and hosts. 1–3 Officials now need to consider 

worldwide disease outbreaks when determining what potential 

threats might affect the health and welfare of their nations 4 . In 

industrialized countries, unprecedented efforts have built on 

indicator-based public health surveillance, and monitoring of 

clinically relevant data sources now provides early indication of 

outbreaks 5 . In many countries where public health infrastructure is 

rudimentary, deteriorating, or nonexistent, efforts to improve the 

ability to conduct electronic disease surveillance include more 

robust data collection methods and enhanced analysis 

capability. 6,7 However, in these parts of the world, basing timely and 

sensitive reporting of public health threats on conventional 

surveillance sources remains challenging. Lack of resources and 

trained public health professionals poses a substantial 

roadblock. 8–10 Furthermore, reporting emerging infectious diseases 

has certain constraints, including fear of repercussions on trade 

and tourism, delays in clearance through multiple levels of 

government, tendency to err on the conservative side, and 

inadequately functioning or nonexistent surveillance infrastructure. 11 

Even with the recent enactment of international health 

regulations in 2005, no guarantee yet exists that broad 

compliance will be feasible, given the challenges associated with 

reporting mechanisms and multilateral coordination. 12 In many 



countries, free or low-cost sources of unstructured information, 

including Internet news and online discussion sites (Figure 1), 

could provide detailed local and near real-time data on potential 

and confirmed disease outbreaks and other public health 

events. 9,10,13–18 These event-based informal data sources provide 

insight into new and ongoing public health challenges in areas that 

have limited or no public health reporting infrastructure but have 

the highest risk for emerging diseases 19 . In fact, event-based 

informal surveillance now represents a critical source of epidemic 

intelligence – almost all major outbreaks investigated by the World 

Health Organization (WHO) are first identified through these 

informal sources. 9,13 

With a goal of improving public health surveillance and, 

ultimately, intervention efforts, we (the architects, developers, and 

methodologists for the information systems described herein) 

reviewed 3 of the primary active systems that process 

unstructured (free-text), event-based information on disease 

outbreaks: The Global Public Health Intelligence Network (GPHIN), 

the HealthMap system, and the EpiSPIDER project (Semantic 

Processing and Integration of Distributed Electronic Resources for 

Epidemics [and disasters]; www.epispider.net). Our report is the 

result of a joint symposium from the American Medical Informatics 

Association Annual Conference in 2007. Despite key differences, 

all 3 systems face similar technologic challenges, including 1) topic 

detection and data acquisition from a high-volume stream of event 

reports (not all related to disease outbreaks); 2) data 

characterization, categorization, or information extraction; 3) 

information formatting and integration with other sources; and 4) 

information dissemination to clients or, more broadly, to the public. 

Each system tackles these challenges in unique ways, highlighting 

the diversity of possible approaches and public health objectives. 

Our goal was to draw lessons from these early experiences to 

advance overall progress in this recently established field of eventbased 

public health surveillance. After summarizing these 

systems, we compared them within the context of this new 

surveillance framework and outlined goals for future development 

and research. 

The GPHIN project 

Background 

GPHIN took early advantage of advancements in communication 

technologies to provide coordinated, near realtime, multisource, 

and multilingual information for monitoring emerging public health 

events. 20,21 In 1997, a prototype GPHIN system was developed in 

a partnership between the government of Canada and WHO. The 

objective was to determine the feasibility and effectiveness of 

using news media sources to continuously gather information 

about possible disease outbreaks worldwide and to rapidly alert 

international bodies of such events. The sources included 

websites, news wires, and local and national newspapers 

retrieved through news aggregators in English and French. After 

the outbreak of severe acute respiratory syndrome (SARS), a new, 

robust, multilingual GPHIN system was developed and was 

launched November 17, 2004, at the United Nations. 

Epidemic curve 

SMS messaging 

Microblogging 

Emailing 

Internet searching 

Social networking 

Internet chatting 

Time 

Blogging 

Online news reporting 

Video/radio news reporting 

Health expert reporting 

Figure 1: Hypothetical timing of informal electronic sources available during an outbreak. SMS, short message service 



Data Acquisition 

Automated process 

The GPHIN software application retrieves relevant articles every 15 

minutes (24 hours/day, 7 days/week) from news-feed aggregators 

(Al Bawaba [www.albawaba.com] and Factiva [www. factiva.com]) 

according to established search queries that are updated regularly. 

The matching articles are automatically categorized into >1 GPHIN 

taxonomy categories, which cover the following topics: animal, 

human, or plant diseases; biologics; natural disasters; chemical 

incidents; radiologic incidents; and unsafe products. Articles with 

a high relevancy score are automatically published on the GPHIN 

database. The GPHIN database is also augmented with articles 

obtained manually from openaccess web sites. Each day, GPHIN 

handles ≈4,000 articles. This number drastically increases when 

events with serious public health implications, such as the fi nding 

of melamine in various foods worldwide, are reported. 

Human analysis process 

Although the GPHIN computerized processes are essential for the 

management of information about health threats worldwide, the 

linguistic, interpretive, and analytical expertise of the GPHIN 

analysts makes the system successful. Articles with relevancy 

below the “publish” threshold are presented to a GPHIN analyst, 

who reviews the article and decides whether to publish it, issue an 

alert, or dismiss it. Additionally, the GPHIN analyst team conducts 

more in-depth tasks, including linking events in different regions, 

identifying trends, and assessing the health risks to populations 

around the world. 

Data Dissemination 

Machine translation 

English articles are machine-translated into Arabic, Chinese 

(simplifi ed and traditional), Farsi, French, Russian, Portuguese, 

and Spanish. Non-English articles are machine-translated into 

English. GPHIN has adopted a best-of-breed approach in 

selecting engines for machine translation. The lexicons associated 

with the engines are constantly being improved to enhance the 

quality of the output. As such, the machine-translated outputs are 

edited by the appropriate GPHIN analysts. The goal is not to 

obtain a perfect translation but to ensure comprehensibility of the 

essence of the article. 

Information access 

Users can view the latest list of published articles or query the 

database by using both Boolean and translingual metadata search 

capabilities. In addition, notifications about events that might have 

serious public health consequences are immediately sent by email 

to users in the form of an alert. 

Project results 

As an initial assessment of data collected during July 1998 

through August 2001, WHO retrospectively verified 578 

outbreaks, of which 56% were initially picked up and disseminated 

by GPHIN. 9 Outbreaks were reported in 132 countries, 

demonstrating GPHIN’s capacity to monitor events occurring 

worldwide, despite the limitation of predominantly English (with 

some French) media sources. One of GPHIN’s earliest 

achievements occurred in December 1998, when the system was 

the fi rst to provide preliminary information to the public health 

community about a new strain of influenza in northern People’s 

Republic of China 20 . During the SARS outbreak, declared by WHO 

in March 2003, the GPHIN prototype demonstrated its potential as 

an early-warning system by detecting and informing the 

appropriate authorities (e.g., WHO, Public Health Agency of 

Canada) of an unusual respiratory illness outbreak occurring in 

Guangdong Province, China, as early as November 27, 2002. 

GPHIN was further able to continuously monitor and provide 

information about the number of suspected and probable SARS 

cases reported worldwide on a near real-time basis. GPHIN’s 

information was ≈2-3 days ahead of the official WHO report of 

confirmed and probable cases worldwide. 

In addition to outbreak reporting, GPHIN has also provided 

information that enabled public health officials to track global 

effects of the outbreak such as worldwide prevention and control 

measures, concerns of the general public, and economic or 

political effects. GPHIN is used daily by organizations such as 

Table 1: Characteristics of three primary systems that process event-based informal data sources* 

DATA SOURCES DATA DATA DISSEMINATION 

SYSTEM (LANGUAGES) CHARACTERIZATION INFORMATION FORMATTING ACCESS USER INTERFACE FORMAT 

GPHIN Factiva, Al Bawaba Automatic and Categorization, machine Subscription Boolean and Email alert 

(9 languages) human translation, geocoded only metadata query 

system (native) 

HealthMap Google News, Automatic Categorization,geocoded, Open Mapping, faceted RSS feed 

Moreover, ProMED, time coded, extra browsing (native) 

WHO, EuroSurveillance 

information 

(4 languages) 

EpiSPIDER ProMED, GDACS, CIA Automatic Categorization, Open Web exhibits, RSS, JSON 

Factbook (English only) geocoded, time coded, faceted browsing KML feeds 

extra information 

(imported) 

*GPHIN, Global Public Health Intelligence Network; WHO, World Health Organization; RSS, Really Simple Syndication; EpiSPIDER, Semantic 

Processing and Integration of Distributed Electronic Resources for Epidemics (and disasters); GDACS, Global Disaster Alert Coordinating System; CIA, 

Central Intelligence Agency; JSON, JavaScript object notation; KML, keyhole markup language. 



WHO, the US Centers for Disease Control and Prevention (CDC), 

and the UN Food and Agricultural Organization. 

The HealthMap Project 

Background 

Operating since September 2006, HealthMap 22,23 is an Internetbased 

system designed to collect and display information about 

new outbreaks according to geographic location, time, and 

infectious agent 24–26 . HealthMap thus provides a structure to 

information flow that would otherwise be overwhelming to the user 

or obscure important elements of a disease outbreak. 

Healthmap.org receives 1000–10 000 visits/day from around 

the world. It is cited as a resource on sites of agencies such as the 

United Nations, National Institute of Allergy and Infectious 

Diseases, US Food and Drug Administration, and US Department 

of Agriculture. It has also been featured in mainstream media 

publications, such as Wired News and Scientific American, 

indicating the broad utility of such a system that extends beyond 

public health practice. 24,26 On the basis of usage tracking of 

HealthMap’s Internet site, we can infer that its most avid users 

tend to come from government-related domains, including WHO, 

CDC, European Centre for Disease Prevention and Control, and 

other national, state, and local bodies worldwide. Although the 

question of whether this information has been used to initiate 

action will be part of an in-depth evaluation, we know from 

informal communications that organizations (ranging from local 

health departments to such national organizations as the US 

Department of Health and Human Services and the US 

Department of Defense) are leveraging the HealthMap data stream 

for day-to-day surveillance activities. For instance, CDC’s 

BioPHusion Program incorporates information from multiple data 

sources, including media reports, surveillance data, and informal 

reports of disease events and disseminates it to public health 

leaders to enhance CDC’s awareness of domestic and global 

health events. 27 

Data acquisition 

The system integrates outbreak data from multiple electronic 

sources, including online news wires (e.g., Google News), Really 

Simple Syndication (RSS) feeds, expertcurated accounts (e.g., 

ProMED-mail, a global electronic mailing list that receives and 

summarizes reports on disease outbreaks) 18 , multinational 

surveillance reports (e.g., Eurosurveillance), and validated offi cial 

alerts (e.g., from WHO). Through this multistream approach, 

HealthMap casts a unifi ed and comprehensive view of global 

infectious disease outbreaks in space and time. Fully automated, 

the system acquires data every hour and uses text mining to 

characterize the data to determine the disease category and 

location of the outbreak. Alerts, defined as information on a 

previously unidentified outbreak, are geocoded to the country 

scale with province-, state-, or city-level resolution for select 

countries. Surveillance is conducted in several languages, 

including English, Spanish, Russian, Chinese, and French. The 

system is currently being ported to other languages, such as 

Portuguese and Arabic. 

Data dissemination 

After being collected, the data are aggregated by source, disease, 

and geographic location and then overlaid on an interactive map 

for user-friendly access to the original report. HealthMap also 

addresses the computational challenges of integrating multiple 

sources of unstructured information by generating meta-alerts, 

color coded on the basis of the data source’s reliability and report 

volume. Although information relating to infectious disease 

outbreaks is collected, not all information has relevance to every 

user. The system designers are especially concerned with limiting 

information overload and providing focused news of immediate 

interest. Thus, after a first categorization step into locations and 

diseases, a second round of category tags is applied to the 

articles to improve filtering. The primary tags include 1) breaking 

news (e.g., a newly discovered outbreak); 2) warning (initial 

concerns of disease emergence, e.g., in a natural disaster area; 3) 

follow-up (reference to a past outbreak); 4) background/context 

(information on disease context, e.g., preparedness planning); and 

5) not disease-related (information not relating to any disease 2–5 are 

filtered from display]). Duplicate reports are also removed by 

calculating a similarity score based on text and category matching. 

Finally, in addition to providing mapped content, each alert is 

linked to a related information window with details on reports of 

similar content as well as recent reports concerning either the 

same disease or location and links for further research (e.g., WHO, 

CDC, and PubMED). 


HealthMap processes an average of 133.5 disease alerts/day 

(95% confidence interval [CI] 124.1–142.8); ≈50% are categorized 

as breaking news (65.3 reports/day). Looking 30 days back 

(default display), the system displays >800 breaking news alerts 

for any given day. From October 2006 through November 20, 

2007, HealthMap had processed >35,749 alerts across 171 

disease categories and 202 countries or semiautonomous or 

overseas territories. Most alerts come from news media (92.8%), 

followed by ProMED (6.5%) and multinational agencies (0.7%). 

The EpiSPIDER Project 

Background 

The EpiSPIDER project was designed in January 2006 to serve as 

a visualization supplement to the ProMED-mail reports. Through 

use of publicly available software, EpiSPIDER was able to display 

topic intensity of ProMED-mail reports on a map. Additonally, 

EpiSPIDER automatically converted the topic and location 

information of the reports into RSS feeds. Usage tracking showed, 

initially, that the RSS feeds were more popular than the maps. 

Transforming reports to a semantic online format (W3C Semantic 

Web) makes it possible to combine emerging infectious disease 

content with similarly transformed information from other Internet 

sites such as the Global Disaster Alert Coordinating System 

(GDACS) website (www.gdacs.org). The broad effects of disasters 

often increase illness and death from communicable diseases, 

particularly where resources for healthcare infrastructure have 

been lacking 28,29 . By merging these 2 online media sources 

(ProMED-mail and GDACS), EpiSPIDER demonstrates how 

distributed, event-based, unstructured media sources can be 

integrated to complement situational awareness for disease 

surveillance. 

Data acquisition and dissemination 

EpiSPIDER connects to news sites and uses natural language 



processing to transform free-text content into structured 

information that can be stored in a relational database. For 

ProMED reports, the following fields are extracted: date of 

publication; list of locations (country, province, or city) mentioned 

in the report; and topic. EpiSPIDER parses location names from 

these reports and georeferences them using the georeferencing 

services of Yahoo Maps (http:// maps.yahoo.com), Google Maps 

(http://maps.google.com), and Geonames (www.geonames.org). 

Each news report that has location information can be linked to 

relevant demographic- and health-specific information (e.g., 

population, per capita gross domestic product, public health 

expenditure, and physicians/1,000 population). EpiSPIDER 

extracts this information from the Central Intelligence Agency (CIA) 

Factbook (www.cia.gov/library/ publications/the-worldfactbook/index.html) 

and the United Nations Development Human 

Development Report (http://hdr.undp.org/en) Internet sites. This 

feature provides different contexts for viewing emerging infectious 

disease information. By using askMEDLINE 30 , EpiSPIDER also 

provides context-sensitive links to recent and relevant scientific 

literature for each ProMED-mail report topic. After EpiSPIDER 

extracts the previously described information, it automatically 

transforms it to other formats, e.g., RSS, keyhole markup 

language(KML; http://earth.google.com/ kml), and JavaScript 

object notation (JSON, a human-readable format for representing 

simple data structures; www. json.org). Publishing content using 

those formats enables the semantic linking of ProMED-mail 

content to country information and facilitates EpiSPIDER’s 

redistribution of structured data to services that can consume 

them. Continuing along this transformation chain, the SIMILE 

Exhibit API (http://simile.mit.edu) that consumes JSON-formatted 

data fi les enables faceted browsing of information by using scatter 

plots, Google Maps, and timelines. Recently, EpiSPIDER began 

outsourcing some of its preprocessing and natural language 

processing tasks to external service providers such as OpenCalais 

(www.opencalais. com) and the Unifi ed Medical Language 

System (UMLS) web service for concept annotation. This action 

has enabled the screening of noncurated news sources as well. 


Built on open-source software components, EpiSPIDER has been 

operational since January 2006. In response to feedback from 

users, additional custom data feeds have been incorporated, both 

topic oriented (by disease) and format specific (KML, RSS, 

GeoRSS), as has semantic annotation using UMLS concept 

codes. For example, the EpiSPIDER KML module was developed 

to enable the US Directorate for National Intelligence to distribute 

avian infl uenza event-based reports in Google Earth KML format 

to consumers worldwide and also to enable an integrated view of 

ProMED and World Animal Health Information 

Database reports 

EpiSPIDER is used by persons in North America, Europe, 

Australia, and Asia, and it receives 50–90 visits/hour, originating 

from 150–200 sites and representing 30–50 countries worldwide. 

EpiSPIDER has recorded daily visits from the US Department of 

Agriculture, US Department of Homeland Security, US Directorate 

for National Intelligence, US CDC, UK Health Protection Agency, 

and several universities and health research organizations. In the 

latter half of 2008, daily access to graphs and exhibits surpassed 

access to data feeds. EpiSPIDER’s semantically linked data were 

also used for validating syndromic surveillance information in 

OpenRODS (http://openrods. sourceforge.net) and populating 

disease detection portals, like www.intelink.gov and the Research 

Triangle Institute (Research Triangle Park, NC, USA). 

Discussion 

Despite their similarities, the 3 described event-based public 

health surveillance systems are highly complementary; they 

monitor different data types, rely on varying levels of automation 

and human analysis, and distribute distinct information. GPHIN, 

being the longest in use, is probably the most mature in terms of 

information extraction. In contrast, HealthMap and EpiSPIDER, 

being comparatively recent programs, focus on providing extra 

structure and automation to the information extracted. Their 

differences and similarities, summarized in the Table, can be 

analyzed according to multiple characteristics: What data sources 

do they consider? How do they extract information from those 

sources? And in what format is the information redistributed and 

how? 

For completeness, the broadest range of sources is critical. 

GPHIN’s data comes from Factiva and Al Bawaba, which are 

subscription-only news aggregators. Their strategy is to rely on 

companies that sell the service of collecting event information from 

every pertinent news stream. 

In contrast, HealthMap’s strategy is to rely on open-access 

news aggregators (e.g., GoogleNews and Moreover) and curated 

sources (e.g., ProMED and EuroSurveillance). EpiSPIDER, until 

recently, has concentrated on curated sources only (e.g., ProMED, 

GDACS, and CIA Factbook). This distinction between free and 

paid sources raises the question of whether the systems have 

access to the same event information. 

After the data sources have been chosen, the next step is to 

extract useful information among the incoming reports. First, at the 

level of the report stream, the system must fi lter out reports that 

are not disease related and categorize the remaining (diseaserelated) 

reports into predefi ned sets. Then, at a second level of 

triage, the information within each retrieved alert (e.g., an event’s 

location or reported disease) is assessed. GPHIN does this data 

characterization through automatic processing and human 

analysis, whereas HealthMap and EpiSPIDER rely mainly on 

automated techniques (although a person performs a daily scan of 

all HealthMap alerts and a sample of EpiSpider alerts). 

After a report in the data stream is determined to be relevant, it 

is processed for dissemination. GPHIN automatically translates 

the reports into different languages and grants its clients access to 

the database through a custom search engine. GPHIN also 

decides which reports should be raised to the status of alerts and 

sent to its clients by email. HealthMap provides a geographic and 

temporal panorama of ongoing epidemics through an openaccess 

user interface. It automatically filters out the reports that do 

not correspond to breaking alerts. The remaining alerts are 

prepared for display (time codes and geocodes as well as disease 

category and data source) to allow faceted browsing and are 

linked to other information sources (e.g., the Wikipedia definition of 

the disease). These data are also provided as daily email digests 

to users interested in specific diseases and locations. Although 

GPHIN and HealthMap provide their own user interface, 

EpiSPIDER explores conventional formats for reports, adding 



time-coding, geocoding, and country metadata for automatic 

integration with other information sources and versatile browsing 

by using existing open-source software. These reports are 

displayed under the name of Web Exhibits and include, for 

example, a mapping and a timeline view of the reports and a 

scatter plot of the alerts with respect to the originating country’s 

human development index and gross domestic product per 

capita. 

A division arises between the HealthMap and EpiSPIDER 

strategies and the GPHIN strategy regarding the level of access 

granted to users. This division is due in part to the access policies 

of the data sources used by the systems, as discussed previously. 

A discrepancy also exists in the amount of human expertise, and 

thus in the cost, required by the systems. These differences also 

raise the question of whether information from one system is more 

reliable than that of the others. Undertaking an evaluation of the 

systems in parallel is a critical next step. Also, all 3 systems are 

inherently prone to noise because most of the data sources they 

use or plan to use (Figure 1) for surveillance are not verified by 

public health professionals, so even if the system is supervised by 

a human analyst, it might still generate false alerts. False alerts 

need to be mitigated because they might have substantial undue 

economic and social consequences. Eventbased disease 

surveillance may also benefit from algorithms linked by ontology 

(formal representation of a set of concepts within a domain and 

the relationships between those concepts) detecting precursors of 

disease events. Measurement and handling of input data’s 

reliability is a critical research direction. 

Future development should focus on linking these systems 

more closely to public health practitioners in the field and 

establishing collaborative networks for alert verification and 

dissemination. Such development would ensure that event-based 

monitoring further establishes itself as an invaluable public health 

resource that provides critical context and an alternative to more 

traditional indicator-based outbreak reporting. ❏ 

Acknowledgments 

HealthMap (MK, CCF, KDM, JSB) is funded in part by a research 

grant from Google.org and by R21LM009263-01 from the National 

Library of Medicine, National Institutes of Health; GPHIN (MB, AM) 

is supported by the Government of Canada (Public Health Agency 

of Canada); EpiSPIDER is funded in part by a fellowship grant from 

the Oak Ridge Institute for Science Education, US Department of 

Energy. 

Reprint acknowledgment 

Keller M, Blench M, Tolentino H, Freifeld CC, Mandl KD, Mawudeku 

A, et al. Use of unstructured event-based reports for global 

infectious disease surveillance. Emerg Infect Dis. DOI: 

10.3201/eid1505.081114 2009 May; [Epub ahead of print] 

References 

1. 

Feldmann H, Czub M, Jones S, Dick D, Garbutt M, Grolla A, et al. Emerging and re-emerging 

infectious diseases. Med Microbiol Immunol (Berl). 2002;191:63–74. DOI: 10.1007/s00430- 

002-0122-5 

2. 

Lederberg J, Shope R, Oats S, editors. Emerging infections: microbial threats to health in the 

United States. Washington: National Academy Press; 1992. 

3. 

Wilson ME. Travel and the emergence of infectious diseases. Emerg Infect Dis. 1995;1:39–46. 

4. 

Morens DM, Folkers GK, Fauci AS. The challenge of emerging and re-emerging infectious 

diseases. Nature. 2004;430:242–9. DOI: 10.1038/nature02759 

5. 

Mandl KD, Overhage JM, Wagner MM, Lober WB, Sebastiani P, Mostashari F, et al. 

Implementing syndromic surveillance: a practical guide informed by the early experience. J 

Am Med Inform Assoc. 2004;11:141–50. DOI: 10.1197/jamia.M1356 

6. 

Chretien JP, Burkom HS, Sedyaningsih ER, Larasati RP, Lescano AG, Mundaca CC, et al. 

Syndromic surveillance: adapting innovations to developing settings. PLoS Med. 2008;5:e72. 

DOI: 10.1371/ journal.pmed.0050072 

7. 

Chretien JP, Lewis SH. Electronic public health surveillance in developing settings: meeting 

summary. BMC Proc. 2008;2(Suppl 3):S1. 

8. 

Butler D. Disease surveillance needs a revolution. Nature. 2006;440:6–7. DOI: 

10.1038/440006a 

9. 

Heymann DL, Rodier GR. Hot spots in a wired world: WHO surveillance of emerging and reemerging 

infectious diseases. Lancet Infect Dis. 2001;1:345–53. DOI: 10.1016/S1473- 

3099(01)00148-7 

10. 

Morse SS. Global infectious disease surveillance and health intelligence. Health Aff 

(Millwood). 2007;26:1069–77. DOI: 10.1377/ hlthaff.26.4.1069 

11. 

Woodall J. Offi cial versus unoffi cial outbreak reporting through the Internet. Int J Med 

Inform. 1997;47:31–4. DOI: 10.1016/S1386- 5056(97)00079-8 

12. 

Sturtevant JL, Anema A, Brownstein JS. The new international health regulations: 

considerations for global public health surveillance. Disaster Med Public Health Prep. 

2007;1:117–21. DOI: 10.1097/DMP.0b013e318159cbae 

13. 

Grein TW, Kamara KB, Rodier G, Plant AJ, Bovier P, Ryan MJ. Rumors of disease in the global 

village: outbreak verifi cation. Emerg Infect Dis. 2000;6:97–102. 

14. 

M’Ikanatha NM, Rohn DD, Robertson C, Tan CG, Holmes JH, Kunselman AR. Use of the 

Internet to enhance infectious disease surveillance and outbreak investigation. Biosecur 

Bioterror. 2006;4:293– 300. DOI: 10.1089/bsp.2006.4.293 

15. 

Heymann DL, Rodier G. Global surveillance, national surveillance, and SARS. Emerg Infect Dis. 

2004;10:173–5. 

16. 

Mawudeku A, Blench M. Global Public Health Intelligence Network (GPHIN). In: Proceedings of 

the 7th Conference of the Association for Machine Translation in the Americas 2006 [cited 

2007 Apr 26]. Available from http://www.mt-archive.info/MTS-2005-Mawudeku. pdf 

17. 

Paquet C, Coulombier D, Kaiser R, Ciotti M. Epidemic intelligence: a new framework for 

strengthening disease surveillance in Europe. Euro Surveill. 2006;11:212–4. 

18. 

Madoff LC, Woodall JP. The Internet and the global monitoring of emerging diseases: lessons 

from the fi rst 10 years of ProMED-mail. Arch Med Res. 2005;36:724–30. DOI: 10.1016/j. 

arcmed.2005.06.005 

19. 

Jones KE, Patel NG, Levy MA, Storeygard A, Balk D, Gittleman JL, et al. Global trends in 

emerging infectious diseases. Nature. 2008;451:990–3. DOI: 10.1038/nature06536 

20. 

Mawudeku A, Lemay R, Werker D, Andraghetti R, St. John R. The Global Public Health 

Intelligence Network. In: M’ikanatha NM, Lynfield R, Van Beneden CA, de Valk H, editors. 

Infectious disease surveillance, 1st ed. Lynn (MA): Blackwell Publishing; 2007 

21. 

Mykhalovskiy E, Weir L. The Global Public Health Intelligence Network and early warning 

outbreak detection: a Canadian contribution to global public health. Can J Public Health. 

2006;97:42–4. 

22. 

Brownstein JS, Freifeld CC, Reis BY, Mandl KD. HealthMap: Internet-based emerging 

infectious disease intelligence. In: Infectious disease surveillance and detection: assessing 

the challenges – finding solutions. Washington: National Academy of Science; 2007. p. 

183–204. 

23. 

Brownstein JS, Freifeld CC, Reis BY, Mandl KD. Surveillance sans frontières: Internet-based 

emerging infectious disease intelligence and the HealthMap project. PLoS Med. 

2008;5:E151. DOI: 10.1371/ journal.pmed.0050151 

24. 

Hadhazy A. World wide wellness: online database keeps tabs on emerging health threats. 

Scientific American; July 8, 2008 [cited 2008 Dec 17]. Available from 

http://www.sciam.com/article. cfm?id=world-wide-wellness 

25. 

Larkin M. Technology and public health: HealthMap tracks global diseases. Lancet Infect Dis. 

2007;7:91. DOI: 10.1016/S1473-3099 (07)70018-X 

26. 

Captain S. Get your daily plague forecast. Wired News 2006 [cited 2008 Dec 17]. Available 

from http://www.wired.com/science/ discoveries/news/2006/10/71961 

27. 

Rolka H, O’Connor JC, Walker D. Public health information fusion for situation awareness. 

Heidelberg: Springer Berlin; 2008. 

28. 

Waring SC, Brown BJ. The threat of communicable diseases following natural disasters: a 

public health response. Disaster Manag Response. 2005;3:41–7. DOI: 

10.1016/j.dmr.2005.02.003 

29. 

Ivers LC, Ryan ET. Infectious diseases of severe weather-related and fl ood-related natural 

disasters. Curr Opin Infect Dis. 2006;19:408–14. DOI: 

10.1097/01.qco.0000244044.85393.9e 

30. 

Fontelo P, Liu F, Ackerman M. askMEDLINE: a free-text, natural language query tool for 

MEDLINE/PubMed. BMC Med Inform Decis Mak. 2005;5:5. DOI: 10.1186/1472-6947-5-5 


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Innovation in clinical specialities 

54 Burn management 

M Davey, B Ayeni, Y Ying and MJ Duncan 

68 Cardiovascular risk factor trends and options for 

reducing future coronary heart disease mortality in the 


Simon Capewell, Earl S Ford, Janet B Croft, Julia A 

Critchley, Kurt J Greenlund and Darwin R Labarthe 

76 The breast service psychosocial model of care project 

Lauren K Williams PhD and G Bruce Mann 

81 Supporting cancer control for indigenous Australians: 

initiatives and challenges for Cancer Councils 

Shaouli Shahid, Kerri R Beckmann and Sandra 

C Thompson 

88 Company profile: Technology of the 21st Century 

Pioneers in Diagnostic Imaging: Reliability and 

advanced technology add value and increase safe 

diagnosis 


90 Breast Cancer – a review for African surgeons 

Adisa Adeyinka Charles MD and Alexandra M Easson 

109 Responding to challenges in physical therapy 

Catherine Sykes, Brenda Myers, Marilyn Moffat and 

Tracy Bury 

112 Population based surgery in low and middle income 

countries 

David A Spiegel, Richard Gosselin, Adam Kushnerand 

Stephen Bickler 

118 Company profile: Wipak Medical – Steriking ® 

Specialized Packaging for Hospital Sterilization 

WIPAK Medical 


Innovation and clinical specialities: burns 

Burn management 

ARTICLE BY M DAVEY AND B AYENI (PICTURED) 

McMaster University, Hamilton, Ontario, Canada 

Y YING AND MJ DUNCAN 

Department of Plastic Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada 

Pepita, 6 years old, was thrown into a fire by another child two years earlier and sustained an 8% burn of her 

lower back. The burn was initially thought to be superficial, but, months later, the wound is still open and has 

never been grafted. Pepita cannot stand upright because she has flexion contractures of both hips and one 

knee. Instead, she has to crawl. Her groin was not burned, and the burn on her knee was only a minor one. 

Her contractures are the result of failing to ensure that she used her unburnt and minimally burnt limbs 

during the acute stage of her injury. She has now been abandoned by her family 1 . 

The devastating effects of burns are long lasting at both an 

individual and societal level. These impacts are 

compounded in resource-poor settings, where the human 

and material resources necessary to deal with this complex public 

health problem are lacking. Developing nations are 

disproportionately affected – 95% of the 322,000 global firerelated 

deaths in 2002 occurred in low to middle-resource 

countries. 2 A structured and comprehensive approach to burn 

care must be applied to resource-poor settings in order to improve 

outcomes. 

A combination of improved management and prevention 

strategies has resulted in important declines in morbidity and 

mortality in the developed world. A recent US study demonstrated 

a 50% decline in burn-related mortality and hospital admissions 

over a 20 year period. 3 Patients are frequently surviving even the 

most devastating burns due to advances in infection control, 

antimicrobial and biologic wound coverings, as well as a better 

understanding of resuscitation and the systemic effects of burn 

physiology and associated lung injury in burn patients. However, 

a stark contrast is seen when comparing the burn related mortality 

rates in high and low-income countries. For example, the WHO 

Global Burden of disease database has reported an over 10 fold 

difference between mortality rates in South East Asia and Europe 

(11.6 vs 0.7 per 100 000 population respectively). 2 

Unfortunately, without adequate resources in first-aid, acute 

surgical management and rehabilitation facilities, patients that do 

survive their burn injuries in developing countries often have poor, 

disfiguring and disabling long term outcomes. A Ghanaian study 

found that 18 % of childhood burns patients had suffered a 

physical impairment or disability. 4 

As surgeons working in or supporting those who work in 

resource-poor countries, it is imperative that we understand the 

region-specific risk factors associated with burns, support 

preventative measures and provide rapid and appropriate 

resuscitation, surgical treatment and rehabilitation. 

Etiology and epidemiology 

In order to understand and overcome the challenges in the 

management and prevention of burns in low-income countries, a 

close look at the epidemiology and causal factors involved is 

required. It is also necessary to understand the local economic 

constraints and the available healthcare infrastructure. 

There exist numerous hospital or clinic-based studies describing 

epidemiological characteristics of their burn population. Forjuoh 

has published a review of 117 articles from 34 low and middleincome 

countries. 5 The majority of these studies dealt with the 

pediatric population, with the highest incidence of burns occurring 

in infants and toddlers (ages 0-4 years) who are dependant on 

others for their care. In a study from Angola which looked at all age 

groups, the pediatric population accounted for as much as one 

third of all burn victims. 6 A comprehensive population-based study 

in Ghana identified and calculated the strength of specific risk 

factors found in childhood burns; the presence of a pre-existing 

impairment such as epilepsy was associated with 6.7 greater odds 

of a burn, a finding supported by many other studies. 7 Other risk 

factors identified in case-control studies include history of a burn 

or burn-death in a sibling, low income, illiteracy, poor living 

conditions (overcrowding, lack of water supply) and careless 

7, 8, 9, 10 

practices (cooking equipment within reach of children). All 

these reflect the importance of identifying and developing 

prevention strategies that reach marginalized populations. 

In many countries in Africa and Asia, young women are also at 

particular risk. A reversal of gender distribution is seen compared 

to most other injury mechanisms. Women in East Asia account for 

26% of the burn deaths worldwide, the highest burn mortality 

rates of any population (16.9 per 100 000 population per year) 5, 11 . 

This risk is attributed to the domestic role of women cooking in the 

home, using unsafe ground-level stoves oil-lanterns or open-fires 

and frequently wearing highly flammable (yet inexpensive) 

synthetic, loose clothing 12 . Some authors have found that violence 

against women is a frequent underlying causal factor in fatal burns, 



often billed as suicide in newlywed young women. 13 

Most burns occur in the home, commonly in the cooking area, 

accounting for the high proportion of scald burns, followed by 

flame burns. Combined, they account for over 80% of all burns 

seen in low-income countries 4 . Electrical burns are also frequently 

seen in low-income areas where building codes may be less 

stringent and homes may be built near high tension wires. 

Although most studies report higher burn rates in urban settings, 

this could be due to a publication bias, with few district hospitals 

having the means to carry out and publish results. 14 Given the lack 

of first-aid resources and longer distances to travel to medical care 

in rural settings, it is not surprising that outcomes are worse in 

these locations. This is intuitively understood and is illustrated in a 

South African study showing that the average pre-hospital delay 

was 42 hrs in rural South Africa, with high rates of wound infection 

(22%), contractures (6%) and prolonged length of stay 15 . 

Prevention 

At a population health level, the true magnitude of the problem is 

not well defined with few standardized comprehensive statistical 

collection systems in many low-income countries. Some authors 

suggest that the global estimated death rate is a gross 

underestimation 14 . It is widely accepted that the social and 

economic costs of burn injuries to low-income populations are 

great and efforts to develop, evaluate, and implement prevention 

strategies specific to the local cultural and economic settings are 

urgently needed. Successful examples have been shown to work 

in developed countries such as Norway, where with a communitybased 

prevention program, the rate of burn-related hospital 

admissions was reduced by 52%. 5 

With over 2 billion people worldwide preparing meals using 

rudimentary traditional stoves or open fires 5 , much interest has 

been directed toward developing safer domestic appliances and 

energy sources. 14 An example of such a strategy is the inexpensive 

redesigned flat kerosene lamp, designed by burn surgeon Dr. 

Wijaya Godakumbura of Sri Lanka’s Safe Bottle Lamp Project. 16 

Although outcome studies have not formally been performed, with 

over 600 000 lamps distributed and accompanying community 

based education addressing basic fire-safety, this project is 

anticipated to have a major impact on the incidence of lamprelated 

accidents. 

Recognizing the complexity of the issue and its regional 

challenges, the WHO, in collaboration with international partner 

agencies, developed in 2008 an evidence-based global strategy 

for burn prevention and care. 5 

Pathophysiology of burns 

There are several processes involved in the local tissue responses 

after a burn. An increase in vascular permeability leads to the loss 

of water, electrolytes, proteins and heat. 11 The complement and 

coagulation cascades are activated and this results in thrombosis 

and the release of histamine and bradykinin. These mediators 

cause an increase in capillary leak and interstitial edema in distant 

organs and soft tissue. In addition, the activation of the 

inflammatory cascade can lead to immune dysfunction. All of 

these responses increase the patient’s susceptibility to sepsis and 

multiple organ failure. 17 These systemic responses are significant 

once a burn exceeds 20 percent of the patient’s body surface. 

Hypovolemia, immunosuppression, bacterial translocation from 

the gut, and Acute Respiratory Distress Syndrome (ARDS) can 

ensue. 11 

Initial management 

Primary survey 

The rapid implementation of the ABCs of trauma management 

(airway, breathing, circulation) also applies to burns. The initial 

physical examination of the burn victim should focus on assessing 

the airway and the patient’s hemodynamic status, as well as 

estimating the size and depth of the burn. Airway edema can 

result in airway obstruction and death. One hundred percent 

oxygen should be administered from the outset. If there are any 

concerns about the adequacy of the airway, prompt endotracheal 

intubation is mandated. 18 In addition, signs of inhalational injuries 

should be quickly recognized. 

If there are concerns of cervical spine injuries, nasotracheal 

intubation can be performed because it has the advantages of 

decreased cervical spine manipulation and the tube can be easily 

secured by suturing it to the nasal septum. The disadvantage of 

nasotracheal tubes is that they tend to be of smaller caliber, which 

are not as good for suctioning, and may increase the risk of 

sinusitis. In difficult cases, fiber-optic bronchoscopy (if available) 

can prove to be an invaluable tool in securing the airway. Vocal 

cords, directly injured from smoke, may be resistant to usual 

topical anesthesia and care must be exercised to avoid 

laryngospasm. Consideration should be given to securing the 

tube to the teeth with wires (or heavy sutures), rather than risking 

further damage to burned facial skin with tie-tapes. 

Once the airway has been addressed, the next step is to place 

two large-bore (at least 14 gauge) peripheral intravenous catheters 

through non-burned viable tissue. If necessary, these catheters 

can be placed through burned skin because the eschar is still 

sterile in the acute phase and more importantly, death can result 

from delays in fluid resuscitation. A Foley catheter should be 

placed to monitor urine output because this is the most 

straightforward and reliable indicator of intravascular volume 

status in the majority of these patients. Associated life-threatening 

injuries such as cardiac tamponade, pneumothorax, hemothorax, 

and flail chest must be identified and treated quickly 18 Tetanus 

toxoid should also be administered routinely to all burn patients, 

depending on immune status. 

Assessment of injury 

Quantifying the extent (Figures 1 & 2) of the burn is crucial in 

determining subsequent management. Burns are dynamic injuries, 

and damage to the skin can continue for 24 to 48 hours after the 

initial injury due to edema, coagulation of small vessels, pressure, 

desiccation, and infection. Thus daily evaluation is of paramount 

importance in reassessing burn depth and success of excision 17 . 

Superficial burns (1st degree) are generally red, painful, and 

involve the most superficial aspect of the skin; as such, they are 

not included in the calculation of total body surface area (TBSA). 

These blanch to the touch 19 and have an intact epidermal barrier. 

Examples include sunburn or a minor scald from a kitchen 

accident. These burns will heal spontaneously, will not require 

operative treatment, and will not result in scarring. Treatment is 

aimed at comfort with the use of soothing topical salves with or 

without aloe and oral non-steroidal anti-inflammatory agents. 

Surgery is not required for these patients. 20 



Partial-thickness (2nd 

degree) burns involve 

the dermis and 

the epidermis. Partialthickness 

injuries 

classified into two types: 

superficial and deep. All 

second-degree injuries 

involve some amount of 

dermal damage, and 

the division is based on 

the depth of injury into 

this structure. 

Superficial dermal 

burns are erythematous, 

painful, may blanch to 

touch, and often blister. 

Examples include 

Figure 1: Burn Depth Burns are usually 

classified into superficial, superficial 

partial thickness, deep partial thickness 

Figure 3: Lund and Browder chart 11 

and full thickness. Here we have given 

then letters A, B, C, D and E 1 

Figure 2: Adult compared to 

child burn surface areas 

scald injuries from overheated 

bathtub water and flash flame 

burns from open carburetors. 

These wounds will spontaneously 

re-epithelialize from retained 

epidermal structures in the rete 

ridges, hair follicles, and sweat 

glands in 7–14 days. The injury 

will cause some slight skin 

discoloration. 

Deep dermal burns into the 

reticular dermis will appear more 

pale and mottled, will not blanch to touch, but will remain painful to 

pinprick. These burns will usually heal in 14–28 days by reepithelialization 

from hair follicles and sweat gland keratinocytes, 

often with severe scarring. Some of these will require surgical 

treatment 20 . 

A full-thickness (3rd degree) burn generally is identified by a dry 

and leathery appearance, although a plastic-like texture and a 

hemorrhagic or purpuric pattern may also be seen. Classically, fullthickness 

burn wounds have been described as insensate, 

although there is often mixed distribution patterns which make 

sensation determination less reliable as a defining characteristic. 19 

Deep dermal and full-thickness burns require excision and 

grafting with autograft skin to heal the wounds in a timely fashion 19 , 

thus minimizing morbidity from protein loss, sepsis, and 

contracture. Since all the elements of the epidermis have been 

obliterated in full-thickness wounds, healing can occur only 

through wound contraction and/or spreading epithelialization from 

the wound edges. In a sizable wound, this process will take weeks 

to months to years to complete. 21 

Fourth-degree burns involve other organs beneath the skin, 

such as fat, muscle, bone, and the brain. 

In adults, the rule of nines can be used to quickly estimate the 

size of a burn. The anterior and posterior trunk is each l8%, each 

of the lower extremities is 18%, each upper extremity is 9%, and 

the head is 9%. This is depicted clearly in Figure 2. Unfortunately, 

the rule of nines is somewhat inaccurate in children and may 

overestimate burn size because the head accounts for a greater 

portion of the body surface area (BSA). In a 2-year-old child, this is 

19% of the TBSA Diagrams such as the Lund and Browder charts 

(Figure 3) are more accurate and should be used for calculating the 

burn size in children. 18 In small burns, the surface of the patient’s 

hand can be used to estimate the extent of the burn; it represents 

approximately 1% of the TBSA (from fingertips to wrist). 

Patient selection 

Patient selection is the key to improving the outcomes of burn 

injury within the resource constraints of a given environment. The 

mortality of a given size of burn injury increases in infants and the 

elderly. It is difficult to cite what size of burn constitutes a lethal 

injury as mortality varies so much around the world, but local 

experience will suggest what magnitude of injury is likely to be 

survivable given the treatments available. For patients with clearly 

lethal burn/inhalation injury it is humane to withhold fluid 

resuscitation and airway intervention and provide palliation with 

dressings and generous amounts of intravenous morphine. 

Depending on circumstances it may be prudent to ask a 

colleague to examine the patient and note their concurrence with 

the lethality of the prognosis. Patients with severe, but not clearly 

lethal burn injuries pose a difficult problem: they can consume an 

inordinate amount of scarce hospital resources (ICU days, total 

length of stay, dressing supplies, nursing and operating room 

time), and still die or have dreadful outcomes. Consultation and 

possible referral to a burn centre is helpful. Treatment with pain 

control, dressings, prevention of infection, nutritional support, 

good splinting and early mobilization of affected joints, and careful 

selection of patients for surgical intervention is a sound 

policy. Small but potentially disabling burns, especially in children, 

should be the main focus of surgical attention. It is in this group 

of patients that early surgery, meticulous graft care, splinting, 

pressure garments and aggressive physiotherapy will produce the 

most gratifying (and cost effective) outcomes. 

Fluid resuscitation 

The most commonly used formula for adults, for fluid resuscitation 

after a burn, is the Parkland formula. To calculate daily fluid 

requirements, a crystalloid solution at the rate of 4 mL/kg/%TBSA 

burn is given intravenously. The first half of the calculated amount 

of fluid is administered within the first 8 hours after the burn, and 

the remaining is given over the next 16 hours. In the first 24 hours 

post-burn, the initial resuscitation fluid is Lactated Ringers, which 

is isotonic to plasma. 



In children, maintenance requirements must be added to the 

resuscitation formula, and should be provide as a dextrose 

containing solution for infants due to the risk of hypoglycemia if 

they are not drinking. The addition of maintenance is less 

important in adults due to the large volumes and low risk of 

hypoglycemia. One formula that accounts for the maintenance 

requirements is the Shiners Burns Hospital SBH-Galveston 

Formula, which calls for initial resuscitation with 5000 mL/m 2 BSA 

burn/d + 2000 mL/m2 BSA/d of Lactated Ringers solution. 18 See 

http://www.halls.md/body-surface-area/bsa.htm to express BSA 

in M2. Again, the first half is administered within the first 8 hours 

post-burn, and the remaining is given over the next 16 hours. 

Another option to intravenous fluids, in cases of less severe 

burns or where intravenous solutions are at a premium, includes 

oral rehydration solution. The WHO describes a method for 

preparation of an electrolyte-balanced solution 62 . Although very 

time consuming, IV fluids may also be prepared on site at low 

cost. 63 

It is important to remember that these are only guidelines, and 

the infusion volumes must be titrated on a regular basis. Urine 

output is the usual indicator of adequate resuscitation. Urine 

output in a child should be maintained at 1 mL/kg/h. In an adult, 

0.5 mL/kg/h is sufficient (unless myoglobinuria is suspected in 

which case it should be over 2 mL/kg/h). It is essential to avoid 

over-aggressive resuscitation, which may lead to increased 

extravascular hydrostatic pressure and pulmonary edema. This is 

especially important in patients who have a cardiac history, as well 

as patients with a concomitant inhalation injury, because they will 

also have increased pulmonary vascular permeability. 

Administration of colloid or hypertonic solutions decreases the 

total amount of fluid requirements in the first 24 hours post-injury; 

however, no clear advantages in long-term outcomes over isotonic 

crystalloid resuscitations have been clinically documented. In 

general, crystalloid resuscitation with isotonic Lactated Ringers is 

the best option in the acute phase. 18 

If a patient is having increased fluid requirements, it should raise 

suspicion of concomitant inhalation injury, a delay in resuscitation, 

or another associated injury. It must be reiterated that the most 

important thing is to begin resuscitation as soon as possible after 

the time of injury. Unfortunately, delays in adequate resuscitation 

are common and lead to increased fluid requirements because of 

additive perfusion-reperfusion injury, which lead to unnecessary 

loss of life. 18 

Escharotomy 

With circumferential full thickness, or deep partial thickness burns, 

there must be a high index of suspicion for compartment 

syndrome. The decreased skin compliance does not 

accommodate the extreme edema from the inflammatory 

response. Swelling increases with fluid resuscitation and it is 

much better to release a limb with early escharotomies than to 

discover too late that compartment syndrome and myonecrosis 

have set in. The diagnosis of compartment syndrome in a burned 

patient is challenging. Pallor is difficult to determine because the 

eschar often is discolored, soot stained and can be pale and 

leathery or red and plastic-like to the touch. Most burn wounds are 

painful to the touch, unless an area of pure full thickness exists. 

Paresthesia and paralysis are late findings of compartment 

syndrome and are impossible to address in a patient that may be 

paralyzed or sedated. 

The absence of a pulse 

is similarly too late 

of a finding. Delayed 

escharotomies can lead 

to muscle necrosis 

and limb loss. Sufficient 

release can usually be 

noted as soon as the 

dermis is released, 

as the wound opens 

and subcutaneous 

tissue bulges out. 

Escharotomies may need 

to be done on any limb. 

(Figure 4) Escharotomy 

may be done with a 

scalpel or diathermy 

blade. While it is true that Figure 4: Escharotomy lines 

full thickness burns are 

usually insensate, it is not true that escharotomy can routinely be 

performed without some kind of pain control. Ketamine or 

fentanyl and versed are safe and effective. The incision should go 

through skin but not into fascia or muscle. The mid-medial and 

mid-lateral lines of each limb are incised. A small “T” where the 

incision meets normal skin will ease constriction at the end of the 

incision. 

Thoracic escharotomies are also occasionally required for 

improving chest-wall compliance and facilitate ventilation. This 

may require multiple incisions across the chest, both longitudinally 

and transversely to allow full chest expansion. Figure 4 shows 

possible thoracic escharotomy lines, but more lines may be 

required for very deep constricting burns. 

In electrical injury, the final extent of tissue injury can be difficult 

to predict. Frequent assessments and surgical debridements are 

required often in the face of progressive myonecrosis. With any 

high voltage electrical injury, the index of suspicion for a deep 

injury should be high. The skin wound is not a reliable indicator of 

the underlying damage. These injuries will require a fasciotomy, 

with release of all muscle compartments to minimize muscle 

damage. Patients should also be monitored for myoglobinuria 

which will require treatment with increasing urine output, 

alkalinization of the urine, and sometimes with very cautious use of 

diuretics. Untreated myoglobinuria can lead to deposition in the 

glomerular tubules and renal failure. 

Inhalation injury 

Inhalation injuries are associated with severe burns and poor 

outcomes. A retrospective review in Cape Town, South Africa 

found that inhalation injury was present in 63% of severe burn 

patients (>30% TBSA), which resulted in a mortality rate of 76%. 21 

However, it is believed that inhalation injuries are more frequently 

seen in high income countries due to the high prevalence of house 

burns, where victims are confined to enclosed spaces. Alcohol 

and smoking account for over half the deaths in developing 

countries, so prolonged exposure to smoke may occur as a result 

of intoxication. The prevalence of inhalational injury in low to 

middle income countries is unknown, but suspected to be lower. 

The reason for differences in prevalence is unclear, whether due to 



under diagnosis 20 or a true difference given that the vast majority 

of burns occur outdoors. Researchers have found prevalence 

rates of inhalational injury in South Africa of 2.2 % of pediatric burn 

patients 19 and 14.5% of adult burn patients. 21 

Successful management of inhalation injuries relies on early 

suspicion and resuscitation, as well as minimizing post-injury 

complications such as bronchopneumonia and acute respiratory 

distress syndrome (ARDS). 

In the early resuscitation phase (< 36hrs), it is key to suspect 

inhalation injury, consider early intubation and empirically 

oxygenate these patients. Patients who have had prolonged 

exposure to smoke (ie. trapped indoors), loss of consciousness, 

flash burns with singed facial hair, carbonaceous sputum, 

hoarseness should all be closely observed for impending airway 

obstruction. Suspicion should also be high in patient with facial 

scald injuries, where airway compromise is often misdiagnosed. 

Scald burns can be associated with direct thermal injury to the 

upper airway from ingestion of hot liquids or steam inhalation. 19 

Intubation with a large endotracheal tube (to enable suctioning) 

should be done in patients with stridor, increased work to 

breathing, respiratory distress, hypoxia, hypercapnea, deep burns 

to the face or edema/erythema of the oropharynx on 

laryngoscopic exam. Respiratory distress may not develop for 

several hours, and intubation should be performed in the case of 

transfer in high risk patients even in absence of stridor as 

obstruction may progress quickly as a result of airway 

inflammation from injury or edema from resuscitation. 22 

Smoke inhalation injury is often associated with significant 

carbon monoxide exposure, resulting in carboxyhemoglobinemia. 

Carbon monoxide poisonings account for the majority of deaths, 

which occur at the scene or early in the pre-hospital phase. 

Asphyxia or anoxic brain injury develop quickly; as the oxygencarrying 

capacity of the blood is decreased. The clinical 

manifestations of carbon monoxide poisoning are non-specific 

and can include headache, malaise, confusion, dyspnea, seizures 

and loss of consciousness. The diagnosis of carbon monoxide 

poisoning may be hard to confirm, given its imprecise 

presentation, unavailable carboxyhemoglobin levels, and 

misleading O 2 saturation measurement. Conventional pulse 

oxymetry monitors are unable to distinguish O 2 saturation from CO 

saturation, and therefore the patient may have a falsely normal O 2 

saturation reading. Patients may also appear pink/red and wellperfused, 

classically described as “cherry red”. PaO 2 should be 

confirmed by blood gas if possible. Clinical suspicion is the 

mainstay for diagnosis and treatment. Given poor outcomes 

associated with neurologic findings or loss of consciousness in the 

setting of carbon monoxide poisoning 23 , administration of high flow 

oxygen should be used liberally to reverse tissue hypoxia and to 

accelerate the displacement of carbon monoxide (as well as 

cyanide) from their binding sites. The half-life of 

carboxyhemoglobin can be decreased from 240 minutes to 75-80 

minutes by using 100% FiO 2 instead of room air (21% FiO 2). 24 

In the post-resuscitation phase (2-5 days) many competing 

factors can contribute to exacerbate pulmonary insufficiency. 

Direct thermal injury or exposure to bronchopulmonary toxins from 

smoke exposure can lead to airway edema, inflammatory changes 

and activation of systemic inflammatory response, as well as 

disruption of the muco-ciliary transport, increased capillary 

Table 1: Burn Wound Dressings [Modified from Sabiston 33 ] 

Antimicrobial Salves 

Silver sulfadiazine (Flamazine, Silvadene) 

Mafenide acetate (Sulfamylon) 

Bacitracin 

Neomycin 

Polymyxin B 

Nystatin (Mycostatin) 

Mupirocin (Bactroban) 

Broad-spectrum antimicrobial; painless and easy to use; does not penetrate eschar; deeply may leave black tattoos 

from silver ion; mild inhibition of epithelialization 

Broad-spectrum antimicrobial; penetrates eschar well; may cause pain in sensate skin; wide application causes metabolic 

acidosis, therefore only suitable for small areas; mild inhibition of epithelialization. 

Ease of application; painless; antimicrobial spectrum not as wide as above agents 

Ease of application; painless; antimicrobial spectrum not as wide 

Ease of application; painless; antimicrobial spectrum not as wide 

Effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate 

More effective staphylococcal coverage; does not inhibit epithelialization; expensive 

Antimicrobial Soaks 

0.5% Silver nitrate Effective against all microorganisms; stains contacted areas; leaches sodium from wounds; may cause methemoglobinemia 

5% Mafenide acetate Wide antibacterial coverage; no fungal coverage; painful on application to sensate wound; wide application associated with 

metabolic acidosis, and therefore generally used for small high-risk areas such as cartilage coverage in nose and ears. 

0.025% Sodium hypochlorite (Dakin solution) Effective against almost all microbes, particularly gram-positive organisms; mildly inhibits epithelialization 

0.25% Acetic acid Effective against most organisms, particularly gram-negative ones; mildly inhibits epithelialization 

Synthetic Coverings 

OpSite 

Biobrane 

Transcyte 

Integra 

Biologic Coverings 

Xenograft (pig skin) 

Allograft (homograft, cadaver skin) 

Provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transudate and exudate 

requiring removal; no antimicrobial properties 

Provides a wound barrier; associated with decreased pain; use complicated by accumulation of exudate risking invasive 

wound infection; no antimicrobial properties 

Provides a wound barrier; decreased pain; accelerated wound healing; use complicated by accumulation of exudate; 

no antimicrobial properties 

Provides complete wound closure and leaves a dermal equivalent; sporadic take rates; no antimicrobial properties. 

Allows for coverage with a very thin skin graft with no dermis. Very expensive product 

Completely closes the wound; provides some immunologic benefits; must be removed or allowed to slough 

Provides all the normal functions of skin; can leave a dermal equivalent; epithelium must be removed or allowed to slough 



permeability, mucosal necrosis and sloughing. As a result 

subsequent distal airway obstruction, from atelectasis, edema and 

inflammatory debris, leads to a high risk of bronchopneumonia; 

the most frequent complication seen in a cohort of children with 

inhalational injuries in South Africa, seen in 32% of patients 19 . 

Other compounding factors include non-cardiogenic pulmonary 

edema secondary to aggressive fluid resuscitation in burn 

patients, poor lung compliance and chest wall rigidity in the setting 

of trunk burns, secondary ventilatory-associated lung injury from 

aggressive high tidal volume, ventilator associated pneumonia, 

relative immunosuppression and the emergence of multi-drug 

resistance. 25 

Recent recommendations to minimize respiratory complications 

in burn patients have been shown to improve outcomes in high 

income countries. 25,26 These include using low tidal volume 

ventilation with PEEP (positive end expiratory pressure) to maintain 

alveolar patency and minimize baro-trauma, humidified 

oxygenation and elevating the head of the bed to improve 

pulmonary toilet and judicious use of antibiotics based on 

bronchoalveolar lavage cultures. Other interventions and 

treatments remain controversial including early tracheostomy 27 , 

adjunct inhalational therapies (heparin or N-acetylcysteine) or 

other modes of ventilation. Corticosteroids have been shown to be 

harmful in this patient population 28 . 

The final inflammatory-inflammation phase of injury (5 days and 

beyond) persists until complete lung healing and burn wound 

closure, during which time patients remain at risk for infectious 

complications. 

Most patients do not suffer from long-term respiratory 

complications as a result of their lung injury, with evidence of 

normal lung function seen in a study at 4 years post-injury 29 . 

Rarely, complications such as fibrosis and tracheal stenosis have 

been seen and should be managed independently of the causal 

etiology. 

Wound care 

Wound care is a fundamental pillar in the care of the burn patient, 

and an area of evolution partially responsible for improved survival 

seen since the 1960s. As a result of loss of dermal integrity, the 

burn wound loses its protective barrier against invasion by microorganisms 

and against evaporative losses. Therefore, until 

complete re-epitheliazation occurs, the burn dressing serves a 

number of functions: protection against micro-organism invasion, 

minimizing metabolic losses, limiting the pain of exposed burn 

surfaces, containing messy wound secretions, and hiding the burn 

to help prevent adverse psychological responses. 30 Most of the 

practices used in modern burn units are based on anecdotal or 

uncontrolled clinical observations. However, with the introduction 

of topical antimicrobial prophylaxis, occlusive dressing, and 

improved sterility as well as a goal of early wound closure, the 

incidence of burn wound infections have steadily declinedV. 

Burn wound care requires an experienced eye and knowledge 

of the dressing options available. Surgeons often lack the time to 

examine wounds as often as they should so developing expertise 

in the nursing staff is important. If dressings are changed each day 

by a nurse experienced in burns many problems will be averted 

and if staff understand well the importance of both splinting and 

early mobilization to prevent contracture functional results will 

improve. The routine inspection of wounds by a knowledgeable 

person is at least as important as the selection of the dressing 

material itself. This is the advantage of a burn team. 

Exposure Method: Leaving a burn open is a poor option but 

where dressings are not possible it may be the only option. The 

patients is washed daily and kept of clean dry sheets with another 

sheet or mosquito net draped over a frame to reduce the pain 

from air currents and to reduce contamination from the 

environment. Ambient temperature control is important to maintain 

normothermia. Exposure is less painful for full-thickness burns 

than for partial thickness burns but has little else to recommend it. 

Tubbing: Most modern burn units avoid the regular immersion 

of patients in water both because they practice early excision and 

grafting and because of the high risks developing resistant strains 

of bacteria in the tub environment and of patient cross-infection. 

That said, tubbing can be helpful to clean the wounds and gently 

remove eschar as it separates. When early wound infections 

develop suspect the tub! Avoid the routine immersion of infected 

patients in filthy bathtubs of cold water on the basis of ignorance 

and tradition. 

Bland Dressings: These provide a clean, moist wound healing 

environment, absorb exudates protect from contamination and 

provide comfort at a fraction of the cost of antibiotic dressings. 

Where antibiotic dressings are scarce bland dressings are a very 

acceptable solution for burns. Expensive topical antibiotic 

dressings may be reserved for infected wounds. Paraffin gauze is 

widely available and can be manufactured locally. Honey and ghee 

dressings were first advocated in Ayurvedic texts two thousand 

years ago and remain an excellent choice for bland burn 

dressings. Mix two parts honey with one part ghee (clarified butter) 

and pour over a stack of gauze dressings in a tray. Cover and 

store. Vegetable oil or mineral oil may be substituted for Ghee. 

Gauze sheets can be applied directly to the wound in a single layer 

and covered with plain dry gauze to absorb exudates, then 

wrapped. Dressings should be changed at least ever second day, 

or when soiled. 

Antimicrobial dressing: There exist numerous topical 

antimicrobial agents that are effective in delaying the onset of 

invasive wound infections, but none prevent them entirely. This is 

why they must be used in conjunction with a goal of early surgical 

wound closure when possible. A brief review of the agents most 

likely to be available to low and middle income countries will follow. 

There are also alternative synthetic wound coverings and newer 

silver-ionized agents that can be used; however they are often very 

costly and inaccessible in low-income countries. A more detailed 

review, as well as instructions for preparation, can be found in 

these references. 11,33 

Silver sulfadiazine (SSD, Flamazine), is by far the most frequently 

used agent, given its broad antimicrobial coverage, painless 

application and minimal toxicity. It is better to apply the SSD to 

large gauze squares and to apply these to the wound than to 

attempt to cover the burn in an even coat of cream before 

applying the gauze. A very loose plastic or surgical glove 

containing silver sulfadiazine and gently secured with tape around 

the wrists is a simple and excellent hand dressing. Splints can be 

applied outside the bag and the fingers can easily be mobilized to 



reduce swelling and prevent stiffening. 

There exist many other less expensive options worthy of 

mention. Honey has well established antimicrobial properties, and 

has demonstrated effectiveness in limited studies. 34 Tannins, as 

found in tea leaves, have also been shown to have antibacterial 

properties and may reduce the incidence of hypertrophic 

scarring. 64,65 Amniotic membrane, used as a biologic wound 

coverage has also been shown to be more effective than 

nitrofurazone in decreasing the incidence of wound infection 35 , as 

well as being cost-effective in reducing the length of stay and 

increasing epithelialization 36 . Obvious caution regarding the risk of 

disease transmission with the use of human tissue should be used 

and comprehensive donor viral screening performed prior to widespread 

adoption of this technique. Another innovative way to 

minimize cost yet still provide an occlusive dressing to prevent 

dehydration has been demonstrated in India with the use of 

Banana leaves. 37 Gore et al have shown an acceptable level of 

patient acceptance, in comparison to potato peels. Both options 

provide wound protection and healing at a fraction of the cost of 

conventional dressings. 

If despite vigilance, an invasive wound infection becomes 

evident on serial observations, one must consider altering the 

current treatment protocol. An invasive wound infection can be 

determined by clinical expertise or suggestive by wound cultures 

showing >10 5 organism per gram or invasion seen on tissue 

biopsy. Invasion of microorganism into viable tissues may lead to 

progression of the burn or systemic sepsis. It should be noted that 

elevated temperatures per se are not necessarily indicative of 

sepsis, but are common secondary to the inflammatory 

component of the burn wound process. The same organisms 

have been identified in serial wound cultures in both low and 

middle income countries, with Staph aureaus, Proteus, Klebsiella, 

E.coli and Pseudomonas being the most common. The problem 

of drug resistance is not confined to high income countries 38 . A 

recent Nigerian study, looking at serial wound cultures, concluded 

that systemic prophylactic antibiotics did not reduce invasive 

infection, but may in fact select more virulent, resistant strains of 

bacteria 39 , a notion which has gained wide spread acceptance. 

We should therefore guide our antimicrobial use by evidence of 

invasive infection, organism culture and sensitivities when these 

are known. Prophylactic antibiotics at the time of initial admission 

are not routinely advised. 

Medical management 

Severe burn wounds are known to induce systemic inflammatory 

response syndrome (SIRS) through the release of a series of proinflammatory 

endotoxins, exotoxins from infectious sources or 

from the wound itself. Although the exact mechanism is not well 

understood, it is clear that there is a systemic response which can 

lead to progressive infection, immuno-suppression, sepsis and 

eventually multi-organ failure. Supportive measures are needed 

early in the care of the severely burned patient to minimize the 

progression and attenuate the hypermetabolic response to burn 

injury. 

Nutritional support 

Early nutritional support is essential in burn patients, even more so 

in low-middle income countries where many patients present 

malnourished. Burn patients demonstrate levels of metabolism 

that can be as high as 200% normal and that are proportional to 

the severity of the burn. The metabolic rate does not return to 

normal until wound closure. Supporting this high metabolic rate 

with diets rich in carbohydrate and protein without overfeeding 

patients can decrease muscle wasting, and poor wound healing 

consequences of chronic malnutrition. Early feeding also avoids 

mucosal atrophy and bacterial translocation. 40 This is particularly 

important for intubated patients, for whom feeding is often not 

initiated at presentation, increasing the risk of bacterial sepsis. 

Strategies to achieve this goal include tube feeding, which should 

begin within 6 hours, weekly monitoring patients’ weights, and the 

creation of high protein high-caloric feeds from locally available 

produce. The frequency of the feeds should be adjusted to the 

severity of the burn (%TBSA) and the patient’s pre-existing 

nutritional status. 11 

Anemia 

Unfortunately the prevalence of underlying disease in burn patients 

is common in low to middle income countries and may influence 

treatment options. A Liberian study found that 61% of their 

patients had underlying medical co-morbidities, including epilepsy, 

anemia as a result of malaria, or iron deficiency and malnutrition 41 . 

Anemia and malnutrition contribute to infectious complications in 

these burn patients; however grafting was possible, albeit 

delayed, in this study, with surgery being performed between 5-96 

days (average 29.8 days) with reasonable graft take (mean 81%). 

There is no question that the benefits of early excision must be 

weighted against the risk of blood loss and physiological needs of 

these specific patients. However, new understanding of the 

potentially infectious complications of blood transfusion is 

emerging as a result of large prospective multi-centered ICU 

trials 42 . A recent multicentre retrospective cohort study that has 

shown an associated 13% rise in infectious complications per unit 

of blood transfused and an associated increased mortality rate 

even when accounting for burn severity 43 . This study underlined 

the importance of further research to establish appropriate 

transfusion guidelines. Strategies should be undertaken to 

minimize blood loss during surgery. Some techniques for 

minimizing blood loss are discussed in the surgical management. 

HIV 

Another important consideration in many low-income countries is 

the burn patient who is HIV positive. Until recently, little was known 

regarding clinical outcomes in this specific patient population. 

James et al conducted a study in a burn unit in Malawi 44 , showing 

a 31% HIV prevalence rate in their adult burn population (34 of 112 

patients) and in 3% of the pediatric burn patients (6 of 231 patients 

under the age of 15). The researchers found that HIV status was 

an independent risk factor for death, mostly from infectious 

complications with more marked immunosuppression, as 

indicated by a lower mean CD 4 count (383mm 3 vs. 937 mm 3 in 

HIV negative patients). They found no differences in bacterial 

cultures, need or outcome of skin grafting, transfusion or antibiotic 

requirements or length of stay. In a case-controlled study out of 

South Africa 45 , no differences in mortality or morbidity was found 

when comparing 33 patients with and without HIV, when matched 

for age, sex, burn severity and inhalational injury. Two patients with 

clinical AIDS died of infectious complications leading the authors 

to conclude that HIV positive patients, without the stigmata of 



AIDS should be treated in the same manner with similar outcomes 

expected. Further research is needed to understand the effect of 

HIV on immunosuppression in its early stages of disease. 

Surgical management 

After hemodynamic stabilization, a burned patient’s priority of 

treatment shifts to ‘burn-wound-management’ 46 . Preoperatively, 

several factors can pose a challenge to surgical patient care. In 

the developing world, many of the burns present late, already 

infected, or the poor general health of the patients makes them 

unfit for anesthesia. In addition, blood loss can be significant in 

burn wound excision, especially since inflamed and infected 

wounds tend to bleed more during tangential excision. Thus, burn 

surgery can be dangerous in high risk patients where blood 

transfusion facilities are not readily available. 

The options for the surgical management of burns includes early 

tangential excision and grafting for deep dermal burns and 

delayed escharectomy skin grafting for full thickness skin loss 47 . 

Tangential excision describes the sequential and layered excisions 

of devitalized tissues to a vital bed, generally recognized by 

punctuate bleeding. An inadequately excised wound is more likely 

to become infected and is unsuitable for graft take, necessitating 

further surgery. 19 The use of tumescence (discussed below) is 

good for decreasing blood loss from the burn site; however it 

makes judgment of adequacy of excision and of hemostasis more 

difficult. It can decrease blood loss to a minimal amount. Adequate 

debridement must instead be determined by tissue quality, and 

not by punctuate bleeding. 

The exact timing for wound excision is debatable. It is often 

suggested that burn wounds should be excised and grafted if they 

are not expected to heal within 21 days of injury. This is especially 

true for key functional and esthetic locations such as the hands 

and face. 19 The decision to perform extensive excisions in a single 

setting versus staged procedures is dependent upon the 

hemodynamic stability of the patient, the availability of resources, 

and the coordination of all parties involved in the care of the 

patient. 19 Conservative treatment of burn wounds, with silver 

sulfadiazine, followed by serial excision of the burn wound is 

currently the standard of care in many burn centres throughout the 

world. Burns are excised in areas of as much as 20% TBSA in one 

operative setting, and performing the entire excision of the burn 

wound in 10 days post-injury is the goal. All full-thickness burns 

can be excised first, so that deep dermal and indeterminate depth 

wounds are addressed later, preventing excision of potentially 

viable tissue. Early excision and grafting is the treatment of choice 

to potentially reduce scar contractures and hypopigmentation 47 . 

The disadvantages to serial excision are that the patient needs to 

return many times to the operative room, so that episodes of 

bacterial translocation, bacteremia, and cardiovascular instability 

are repeated. Other disadvantages include exaggerated blood 

losses, prolongation of the hypermetabolic response, and 

increased risk of infection and sepsis from remaining eschar in 

which bacteria proliferate. 

Near-total wound excision has been advocated as an alternative 

to serial debridement in massive burns. In near-total excision, all 

full-thickness and partial-thickness burns are excised within 24 

hours of admission, and the excised wounds are covered with 

autografts and skin substitutes are used if the burn exceeds the 

donor-site supply. Areas of the face are normally not excised in the 

first operation. Near-total burn excision has dramatically improved 

survival in massive burns 18 . However, it has been postulated that 

the surgical trauma of immediate burn wound excision, especially 

given the hemodynamic instability of burn patients during the first 

72 h after the injury, may aggravate the inflammatory and catabolic 

responses, leading to potentially fatal postoperative 

complications. 18,47 It should be clear that near-total wound excision 

is only meant for massive burns, and allograft/autograft/xenograft 

must be available for coverage, or the wounds would only have 

been converted to full thickness open wounds. 

General surgical principles 

The intent of burn wound operations is twofold: to remove 

devitalized tissue and restore skin continuity. For this process to 

take place and for the skin graft to take, four things are required: 

✚ A viable wound bed. 

✚ No accumulation of fluid between the graft and the wound 

bed. 

✚ No shear stresses on the wound. 

✚ Avoidance of massive micro-organism proliferation. 

Surgical debridement is performed using a Goulian blade for small 

areas or those with multiple irregular contours (e.g., hand or knee) 

and a Watson or Humby blade for larger areas. Inexpensive 

alternatives have been proposed for harvesting and debriding 

blades 48 . Burned tissue is excised tangentially and sequentially 

until the wound has been excised down to healthy dermis, fat, 

muscle, peritenon, or periosteum. The wound may then be 

covered with an autograft, allograft, or synthetic skin substitute. 

Graft depth should be adjusted in pediatric and geriatric 

populations for their thinner reticular dermis layer. If using a 

powered dermatome, it should be set at less than 10/1000th 

inch. The meshing pattern used for wound closure depends on 

burn surface area and donor site availability. Meshing of the skin 

graft has several advantages, including expanding the square 

centimeters of coverage, allowing for drainage of fluid from under 

the graft, and allowing for placement of the graft over contoured 

areas, such as the knee or ankle. The disadvantage of the meshed 

skin graft includes a permanent weave-like appearance of the 

healed scar site, and increased contraction. 17 

Many authors have described innovative methods for 

performing skin grafting in resource-poor settings 49 . With minimal 

financial resources, using readily available modified household or 

industrial materials a surgeon is able to sharpen the Humby knife 

48, 50 

and use a pizza cutter for meshing grafts. 

Methods of optimizing hemostasis and minimizing blood losses 

include meticulous attention to maintaining the patient’s core body 

temperature (operating in a warm environment, isolating surgical 

fields, warming intravenous fluids, warming humidified air circuits 

for anesthesia), the use of cautery, the application of topical 

epinephrine solutions or topical thrombin solutions, injecting dilute 

epinephrine tumescent solution below the eschar, and the use of 

topical fibrin sealants. 

The use of tumescence and tourniquet in burn excision 

significantly reduces intraoperative blood loss and facilitates 

accurate wound excision. Epinephrine is diluted in saline to a 

concentration of 1:500,000 (2mg/l) and large volumes are injected 

beneath the wound to be excised. Use a concentration of 

1:1,000,000 for children. The edges of the wound are scored with 



a scalpel and the burned dead skin is sliced away with a grafting 

knife. Tangential excision is continued to the point where the 

dermis looks healthy, clean and pearly white, fat appears shiny and 

yellow with no haem staining and small visible vessels have 

patency and flow. If the fat does not look healthy consider excision 

down to the fascia which is possessed of a better blood supply 

than the fat. Bleeding vessels are coagulated and the wound is 

wrapped in adrenaline saline soaked gauze while natural 

haemostasis takes place. Attention is the turned to the donor site 

and a template of gauze from the excised wound is used to 

measure the area of skin to be harvested. Adrenaline saline is 

injected beneath the donor site till the skin is taught and blanched 

then it is harvested with the humby knife or power dermatome. 

The donor wound is wrapped in adrenaline saline gauze while 

attention returns to the burn site. When hemostasis is satisfactory 

the grafts are applied and secured in place. Local anesthetic can 

also be added for small wounds, with 20ml of 1% xylocaine added 

to 1 L of solution. The addition of local anesthetic to the solution 

can decrease pain, reducing anesthetic agents and narcotics 

during surgery but the toxicity of xylocaine exceeds that of the 

adrenaline. A number of recent papers have addressed the safety 

of high dose adrenaline tumescence during burn excision and are 

cited here to placate anesthetic concerns. Atropine and ketamine 

are poor choices for tumescent burn excision as the patient will be 

tachycardic and hypertensive even before adrenaline infiltration is 

begun. Excision of burns from the extremities under tourniquet 

control can minimize bleeding significantly 

If possible, donor sites should be chosen that are inconspicuous 

and will have a good color match for the wound bed. Donor sites 

may develop hypertrophic scars and should not cross joints. 

Potential donor sites include the upper thigh or the buttock, which 

remain hidden with normal clothing and the back, which heals well 

but is technically difficult to harvest with a hand held grafting knife. 

Selection of the donor site should also consider the color match of 

the wounded area, which is most significant on the head and 

neck. A number of types of donor site dressings are available. The 

first type is a fine-mesh cotton gauze that may or may not be 

impregnated. Dressings of this type include Scarlet Red and 

Xeroform, which have the advantage of low cost and familiarity. 

These may need to be reinforced with more gauze initially that can 

be removed in 24-48 hours, and the inner layer left intact. The 

adherent gauze will start lifting in 1-2 weeks as the wound reepithelializes. 

The edges can be trimmed off as they 

spontaneously lift. An occlusive dressing such as 

OpSite/tegaderm can also be used, but may require a few holes 

to drain seromas. 47 

Loss of dermis leads to significant scarring and wound 

contracture. There are a number of dermis substitutes that can be 

used such as Integra and AlloDerm. These products allow the use 

of a very thin partial thickness skin graft on top of the dermis. 

These products require a very clean wound bed, and meticulous 

cleanliness post-operatively to prevent infection. These two 

options are very expensive, though, and are not mainstays of the 

armamentarium of burn surgeons in the developing world. 

Grafts must be held in place by sutures or staples. Some form 

of dressing is required to hold grafts in place. In more mobile 

locations, a bolster dressing may be placed on top of the graft. An 

inner layer that can maintain moisture (petroleum jelly or mineral oil 

product) should be placed before gauze. Grafts over joints will 

require casting/splinting for the time period for grafts to take, 

usually 10-14 days. Dressings are left intact during the time 

period. 

Specific anatomic considerations 

Particular anatomical regions require specific treatments. The 

head and neck region is well vascularized and this is protective 

against invasive infection. Excision and grafting of the face is 

ideally done in full aesthetic units (Figure 5). Early excision of 

eschar is not recommended in order to preserve any dermal and 

epidermal structures that may survive. Once the eschar separates 

in 10–14 days, the underlying wound can be grafted. The color of 

the skin in this area is relatively specific; therefore, autograft skin 

should be obtained from donor sites above the clavicles. The 

scalp is an excellent donor site for 

the face 21 . 

With regards to the breasts, 

keratinocytes are often found 

deep beneath the skin. These will 

proliferate and facilitate wound 

closure if left in place. The 

coloration of the areola is also 

very specific so the nipple/areolar 

complex should not be excised. 

The buttocks and perineum are 

in a very difficult position for skin 

grafts to take, since the dressings 

applied are often soiled from 

Figure 5: Anantomic subunits 

of the face 

excrement, and cleaning, often shearing the grafts. It may be 

necessary to leave the patient in the prone position at later 

operations after application of grafts to this area while they adhere. 

In extreme cases, a temporary defunctioning colostomy may be 

considered until the burn wounds in the perineum are closed. 

The penis and scrotum have an excellent blood supply, so they 

will usually heal in a timely fashion. The skin in this region occupies 

a highly important function, so, in general, excision is avoided. In 

the case of a small burn to the shaft of the penis, excision and 

primary closure akin to a circumcision can suffice. The scrotum is 

also a very good donor site because it heals well, is relatively 

hidden, and can be vastly expanded to provide a surprising 

amount of donor skin. 

The hands are very important in terms of function and cosmesis. 

Most burns of the hand are limited to the dorsal surface as the 

hand is clenched during injury. Unfortunately, sometimes the digits 

sustain a second injury associated with diminished perfusion 

during resuscitation. Escharotomies along the axial lines may 

salvage digits during resuscitation. Grafts placed on the hands 

should either be unmeshed or meshed tightly at a 1:1 ratio to 

improve cosmesis. Burns through to the extensor tendons can 

result in boutonniere deformities even with complete wound 

closure due to sliding of tendons medial and lateral around the 

proximal interphalangeal joint. Extension contractures at the 

metacarpophalangeal joint are also common because the burn 

and subsequent scarring are limited to the dorsal surface. For 

these two reasons, consideration should be given to fixing the 

digits in extension at the proximal interphalangeal joint and flexion 

at the metacarpophalangeal joint by insertion of threaded 

Kirschner wires which are removed after complete wound healing, 

at which time the position can be maintained easily with splints 21 



Burns to the palm of the hand should be treated conservatively 

with gentle debridement, as they will often heal spontaneously 

because of the depth of the skin. In the paediatric population 

contractures may develop, either in the acute phase or, years later, 

as the scar growth is less than that of the normal tissue. 

For the feet, great care must also be taken with excision of fullthickness 

eschar in this area, because the extensor tendons are in 

very close proximity to the skin. Autograft skin applied to this area 

should be of a narrow mesh to avoid hypertrophic scarring, which 

can make it difficult to fit shoes. The toes require the same 

considerations as the fingers. 21 

Rehabilitation 

The goals of the rehabilitation process are to maximize function 

and appearance of the scars. This is done by trying to counteract 

two main physiologic processes, scar hypertrophy and 

contracture. 

Hypertrophic Scarring 

Hypertrophic scarring generally does not develop in burns that 

require less than 2 weeks to heal. Hypertrophic scarring develops 

in 33% of wounds that take less than 3 weeks to heal, but 78% of 

wounds that take more than 3 weeks. It also affects skin grafts. 

Hypertrophic scars are thickened, red, and raised scars which can 

often be very itchy. Unlike keloids, hypertrophic scars do not 

outgrow their boundaries. They will also generally remodel and 

regress over time, but this may take a number of years, and 

contractures may develop in the interim. Although children 

generally heal quickly, they are at higher risk of hypertrophic 

scarring if there is delayed healing. In addition, individuals with 

darker skin pigmentation are also at greater risk of hypertrophic 

scarring and keloids. Tangential excision and grafting of burns that 

require greater than 3 weeks to heal can help prevent or reduce 

hypertrophic scarring. 

Scar compression is the mainstay of non-surgical hypertrophic 

scarring prevention and management. This can be achieved with 

customized compression garments, or with elastic tensor 

bandages. The goal is to have pressures of approximately 

25mmHg. If using tensor bandages, they must be wrapped from 

distal to proximal, taking care not to cause ischemia or venous 

stasis. Using tensors for compression over grafts should be 

initiated after grafts are well healed, approximately 2-3 weeks after 

grafting. This should continue until scar maturation, which can 

take up to 1-2 years, and is gauged by when the scar is softened 

and stabilized. 

Scar massage can also help with breaking down of excess scar 

tissue. This is often done in combination with stretching exercises 

to prevent scar contractures. Scar massage should be done 2-3 

times per day with a hypo-allergenic lotion or cream, or petroleum 

jelly (Vaseline). Moisturizing and massaging the scars, which can 

be dry due to the lack of glands in the scar tissue, may be sore at 

first, but usually becomes soothing, and can help with the 

itchiness of the scars. Massaging must press hard enough to 

blanch the pink scars. Maturation and flattening of the scars can 

take 1-2 years, particularly in children where the hypertrophic 

phase may be longer. Most scars will eventually fade and lose 

their pink colour over time, but the 1-2 year time frame may be 

longer. 

Silicone gel sheets can also be beneficial. The exact mechanism 

is unknown, but they appear to help soften the scar. To reap the 

benefits, they must be worn for long periods (over 20 hours a day) 

to be beneficial. They can be placed under compression 

garments, or simply taped on for areas not amenable to 

compression. These can be washed daily and reused. 

Contractures 

Joint contractures are one of the most challenging aspects of burn 

management, and are the main source of disability from thermal 

burns. Scar contracture is due to activity of the myofibroblasts 

which act to contract scars. When the scars are across joints, 

particularly flexion joints, these can lead to permanent flexion 

deformities. In addition, flexed positions are often positions of 

comfort during the acute phase of burn management, 

exacerbating the problem. To combat joint contractures, 

stretching and splinting is necessary. Stretching and range of 

motion exercises should be initiated from the beginning. With initial 

edema, movement may be a bit difficult but should be encouraged 

with daily exercises. 

To combat joint contractures, stretching, careful positioning and 

splinting are necessary. Necks should be hyperextended with a roll 

under the shoulders. Axillae should be carefully positioned. Upper 

thigh/lower abdominal burns require positioning to prevent flexion 

of the hips. Stretching and range of motion exercises should be 

initiated from the beginning. With initial edema, movement may be 

a bit difficult, but should be encouraged with daily exercises. 

Splinting 

Contractures are the most debilitating residual stigma of burns, 

and high-risk patients (deeper burns over flexion joint surfaces) 

can easily be identified. Contractures are much easier to prevent 

than to fix. Once developed, can be very difficult to manage and 

correct. Elevation of the burned limb reduces edema and 

facilitates early joint mobilization. Where surgical treatment is 

limited by resource issues; hyperalimentation, good dressings, 

splinting and aggressive stretching can still make a big difference 

to patient outcomes. Equally, surgical results will improve 

dramatically with good post-operative splinting and early 

mobilization as soon as the grafts are solid. 

Splinting should be considered when any loss of extension is 

noted across elbows and knees. Hands should be splinted from 

the onset. 51 Simple plaster slabs covered in elastic tube bandage 

or “stockinet” make excellent volar hand splints, can be wrapped 

on with tensor bandages and are re-usable till soiled. Splints are 

often applied overnight, allowing for mobilization and function in 

the daytime. 

There are numerous splinting techniques suggested. Both static 

and dynamic splints can be used. Dynamic splints may be better 

for reversing any contractures, as they may gain extension, not 

only maintain the gains during therapy. However, they are 

significantly more costly to produce, and long-term gains have not 

consistently been shown. Many local materials have been used to 

produce inexpensive splints, including easily malleable aluminum 

sheets. 

Neck collar braces, or custom thermoplastic splints may be 

used to prevent flexion contractures, and stretches should include 

both extension and lateral flexion. The splint should be properly 

padded to prevent pressure points. There are also alternative 

splinting techniques for the neck 52 . Axilla contractures can be 



challenging to splint, with various 

materials used for “airplane 

splints”. Because splinting in 

abduction can be uncomfortable 

and awkward, this is sometimes 

neglected. However, the inability to 

abduct the arms leads to 

Figure 6: Position of safety 

significant morbidity, and it severely 

for splinting hands 59 

limits overhead activities. 53 

The ankle can have contractures in both directions. Burns and 

scar contractures to the dorsum are more common, which must 

be combated with plantar flexion exercises and splints. However, 

the Achilles tendon may also become shortened with a prolonged 

planter flexion. For an ambulating patient, this is not a concern. 

However, for a patient who is bed-ridden, splinting should be 

initially for dorsiflexion to prevent Achilles tendon shortening. 

Fingers and hands should be splinted in the position of safety 

(Figure 6), with MCPs flexed and IPs extended. If there is a severe 

burn over the palmer aspect of the MCP joints, the MP joints can 

sometimes be splinted in extension, but it becomes very important 

to ensure that daily exercises maintain good flexion of the collateral 

ligaments of the MCP joint, which can tighten when in extension. 

Oral burns, particularly commissure burns can lead to 

complications of microstomia. These can be initially managed with 

mouth exercises, and gradually increasing the amount of mouth 

opening.Splints can also be fabricated to stretch the 

commissures. 54 

Surgical release 

Surgical release of burn contractures can involve local flaps for 

reorientation of the scar, but often also include a skin deficit which 

must be filled with a graft or flap. Skin grafts are also more prone 

to contractures, and aggressive post-operative therapy much be 

implemented. Repeat surgeries may be necessary. Thick (full 

thickness if the area is small enough) unmeshed grafts offer less 

contracture. Alternatives include artificial dermal substitutes that 

will allow decreased contracture with thinner split-thickness grafts. 

However, dermal substitutes such as Integra, a bovine collagen 

product, are commercial produced and extremely expensive. If 

skin or myocutaneous flaps are possible, they offer the advantage 

of coverage with minimal contracture and need for repeat surgery. 

These include both local flaps such as z-plasties and transposition 

flaps, but also pedicled or free vascularized flaps. The surgeons 

will require an armamentarium of possible flaps and grafts to apply 

to the situation. Figure 7 gives a possible algorithm for selective 

various surgical options. 55 Other general principles include the 

release of more proximal contractures before distal ones in limbs 

with multiple levels involved, such as elbow release followed by 

wrist, then fingers. Certain anatomic areas are more prone to 

contractures and have specific complications. 

Neck contractures 

Neck flexion is often associated with webbing of the neck. There 

is often a severe shortage of skin, and a significant size skin graft 

may be necessary for coverage of the defect after release. Unless 

very minor, or featuring a narrow band of scar, these are usually 

not amenable to z-plasties. Another challenge for severe neck 

contractures is difficulty with intubation. The release of the neck 

may need to be done under local anesthetic to allow for neck 

Figure 7: An algorithm for the cover of burn contractures of the 

extremities, after adequete release: band contracture (ROM = 

normal joint rnage of motion) 

extension before initiation of general anesthetic and reconstruction 

of the defect. If the injury is anterior only, a good alternative for 

coverage of the neck is a pedicled latissimus dorsi flap, which 

would provide normal skin coverage without risk of contracture 

recurrence. 56 

Hands 

Contractures in the hands include flexion contractures of the 

fingers and wrist, web space narrowing of the digits, as well as 

hyperextension of the MCP joints. 

Finger contractures can sometimes be released with z-plasties, 

if the burn area is isolated to the central palmer aspect of each 

finger. If z-plasties are used, care should be taken not to cause 

excess tension with closures leading to finger ischemia. Release of 

prolonged flexion contractures can also have ischemia from 

overstretching of shortened neurovascular bundles. Release may 

need to be staged, or stretched post-operatively with therapy. 

Kirshner wires may be beneficial for the first 1-2 weeks until the 

skin graft take is reasonable. They also facilitate the fabrication of 

post-operative splints which are best fashioned with the K-wires 

still in place. Web-space deepening is particularly important in the 

first web-space. A 4-flap or 5-flap z-plasty (Figures 8&9) will allow 

deepening of the webspace and increased abduction of the 

thumb. A 5-flap z-plasty (also known as a double Z-plasty with V- 

Y advancement) allows for more deepening, while a 4-flap allows 

for much greater lengthening. These are used primarily in the 1st 

webspace. Deepening of the other webspaces is often performed 

using techniques for congenital syndactyly, with a skin flaps used 

to reconstruct the base of the webspace to prevent future web 

creep. Skin grafts are often necessary to fill in the gaps on the 

sides of the fingers. 57 

Axilla 

Axillary scar contractures are also very common. These can at 



Figure 8: 4-Flap Z-plasty 63 

lengthened (such as tendons or joints), while 

others may limit the release to limited stages 

serial casting/splinting postoperatively. The 

exposure of tendons or nerves in the scar 

bed may require a flap rather than graft 

coverage. Preservation of the peritenon on 

the tendon/peritenon may allow for a 

primary skin graft to survive. However, if the 

tendon is in an area that requires significant 

mobility, the skin graft may tether the tendon 

leading to decreased mobility. Caution 

should be also taken when putting a skin 

graft on an exposed nerve, as this may lead 

to complications of neuromas, or 

hypersensitivity in the area. 

Figure 9: 4-Flap Z-plasty 63 

times be treated with a large 4-flap z-plasty, similar to for the first 

webspace, or multiple z-plasties or V-Y plasties. 58 Alternatively, 

they can sometimes also be managed with release and skin grafts. 

The use of skin grafts requires post-operative splinting, often in 

airplane splints to prevent recurrence. An alternative may be a 

Figure-of-8 splint which also helps to hold the graft in place. 59 

Recurrent or very tight contractures may be amenable to local 

flaps if the burn is localized to the axilla with sparing of chest or 

back tissue. These include latissimus dorsi, or pectoralis 

major/minor myocutaneous flaps. 60 

Deep structures 

Release of the scar may be insufficient for chronic contractures. 

Contractures may be limited by deep structures, such as joint 

capsules, tendons, or nerves. Some of these may be released or 

Burn TBSA, % 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Penicillin 

Resuscitation 

Burn centres 

More antibiotics 

Ventiilators 

Topical Rx 

Skin banks 

TPN 

More antibiotics 

Early excision 

1940 1950 1960 1970 1980 1990 

Burn LA 

50 

Nutrition 

ICU 

Face 

Eyelid contractures can be released with 

skin grafts. Patients with eyelid burns must 

be followed to watch for ectropion, which 

can lead to corneal abrasions. These can be 

release with preferably full thickness skin 

graft placement. Thin full-thickness skin can be harvested from the 

pre or post-auricular region if available. Microstomia and 

commissure burns can be treated initially with splinting and 

stretching exercises. Customized splints can be made, preferably 

with the ability to slowly expand the mouth. With severe 

microstomia, a commissureplasty using mucosa to recreate 

vermillion may be necessary. 54 Esselman et al. has a literature 

review of rehabilitation evidence in burn management. 61 

Conclusions 

Many accomplishments have been made in burn care over the 

past several decades, as illustrated below (Figure 10). 31 

Encouragingly, these have resulted in steady improvements in 

mortality rates. 

This progress has also been noted in a number of centres in 

resource-poor countries where a multidisciplinary, 

global approach to the burn 

patient has been embraced; from 

Excision common 

Figure 10: Advances in burn xare – a schematized time line of important advances in burn 

care ICU=intensive care unit, LA50=survival of half of patients, depending on the 

percentage of total body surface area (TBSA) burned, Rx=therapy, TPN=total parenteral 

nutrition 31 

prevention to rehabilitation. 

An excellent reference for burn surgeons 

in resource poor countries is the Burns 

Manual, written by Dr E J van Hasselt. The 

most recent 2008 edition should be made 

available to all surgeons. 

See Van Hasselt Burns Manual 

http://www.ptolemy.ca/members/library. 

htm. International collaboration is also 

available and encouraged through 

organizations such as Interburns, the 

International Network for Training Education 

and Research in Burns, who run courses 

such as Emergency Burn Care and other 

public awareness programs, http://www. 

interburns.org/index.htm 

This review has demonstrated that 

specific changes in clinical practice can and 

do improve outcomes. As medical 



professionals, we must not be paralyzed by the magnitude of the 

task ahead. Instead we must think of each small step as a 

significant improvement. With focused attention and the 

application of evidence-based knowledge, we will see change 

both measurable and meaningful in the treatment of burn patients. 

Recommendations 

The following recommendations capture the key elements of a 

simple, but effective approach to better burn management tailored 

to developing countries: 

✚ Community leaders and burn surgeons must collaborate in 

developing local prevention strategies as well as community 

education strategies on immediate first aid steps for burn 

victims and the critical importance of early transportation to the 

nearest source of appropriate medical services. 

✚ Medical personnel must be trained in resuscitation; including 

aggressive fluid resuscitation, monitoring for airway 

compromise, and high flow oxygen, all of which to be initiated 

within the first hours in the case of a major burn. The burns 

must be assessed for depth, size, need for escharotomy and 

risk of inhalation injury on presentation 

✚ Both physiotherapy, including early active and passive 

movements and splinting for high risk joints and high protein, 

high caloric frequent feeds should be in place as of the first 

day. 

✚ Wound care must be performed daily, with careful attention for 

signs of invasive infection. Appropriate analgesia, sterile 

conditions and topical antibiotics (SSD) should be used. 

✚ Whenever possible, deep second degree burns and third 

degree burns should be grafted within 10 days of the injury. 

Techniques to minimize blood loss such as tumescence and 

tourniquets should be standard practice. 

✚ Systemic antibiotics should be reserved for single-dose 

immediate pre-operative prophylaxis and treatment of invasive 

wound sepsis, tailored if possible to wound culture results and 

institutional resistance patterns. 

✚ All practicing physicians and surgeons working in areas 

without a regional burn center should receive training in skin 

grafting. 

✚ Blood transfusion should be limited to when physiologic need 

exists. 

✚ Life-long seizure prophylaxis and patient education regarding 

the importance of compliance must be part of burn care 

prevention in all epileptic patients. ❏ 

Acknowledgement 

Reprinted with kind permission from Surgery in Africa Monthly 

Review – October 2008 

Bimpe Ayeni, MD MPH is a fourth year Plastic Surgery resident at 

McMaster University in Hamilton, Ontario. He holds a Bachelor of 

Arts Degree from Yale University, a Masters in Public Health from 

Columbia University, and a Doctorate in Medicine from the 

University of Ottawa. 

References 

1. 

1. King, M., et al. Primary Surgery: Trauma 1990 [cited 2; Available from: 

http://ps.cnis.ca/wiki/index.php/Main. 

2. 

The injury chartbook: A graphical overview of the global burden of injuries. 2002, World 

Health Organization: Geneva. 

3. 

McGwin Jr, G., C. JM, and F. JW, Long-term trends in mortality accoding to age among adult 

burn patients. Journal of Burn Care & Rehabilitation, 2003. 24: p. 21-5. 

http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55190 

4. 

Forjuoh, S., B. Guyer, and H. Ireys, Burn-related physical impairments and disabilities in 

Ghanian children: prevalence and risk factors. Am J Public Health, 2001. 27: p. 291-26. 

5. 

Forjuoh, S., et al., Risk factors for childhood burns: a case-control study of Ghanaian 

children. J Epidemiol Community Health, 1995. 49: p. 189-93. 

6. 

Barss, P. and K. Wallace, Grass-skirt burns in Papua New Guinea. Lancet, 1983. 8327: p. 

733-4. 

7. 

WHO Burn Fact Sheet: WHO Injuries & Violence Prevention Non-communicable diseases and 

mental health and the International Society for Burn Injuries [cited; Available from: 

www.who.int/violence_injury_prevention/index.html. 

8. 

Singh, D., et al., Burn mortality in Chandigarh zone: 25 year autopsy experience from a 

tertiary care hospital of India. Burns, 1998. 24(2): p. 150-6. 


9. 

Gupta, R. and A. Srivastava, Study of fatal burn cases in Kanpur (India). Forensic Science 

International, 1988. 37(81-9). 

10. 

Peck, M.e.a., Burns and fires from non-electric appliances fires in low- and middle-income 

countries Part II. A strategy for intervention using Haddon Matrix. Burns, 2008. 34: p. 312-19. 


11. 

Van Hasselt, E., Burns Manual: A manual for health workers 2ed. 2008: Nederlandse 

Brandwonden Stichting. http://www.ptolemy.ca/members/library.htm 

12. 

Daisy, S., et al., Socioeconomic and cultural influence in the causation of burns in urban 

children of Bangladesh. Journal of Burn Care & Rehabilitation, 2001. 22: p. 269-74. 


13. 

Mock, C., et al. A WHO plan for burn prevention and care. 2008 [cited; Available from: 

http://www.who.int/violence_injury_prevention. 

14. 

Damo, C., et al., Epidemiological data on burn injuries in Angola: a retrospective study on 

7230 patients. Burns, 1995. 21: p. 536-8. 

15. 

Chopra, M., H. Kettle, and D. Wilkinson, Pediatric burns in rural South African district 

hospital. South African Medical Journal, 1997. 87(5): p. 600-3. 

16. 

Werneck, G. and M. Reichenheim, Paediatric burns and associated risk factors in Rio de 

Janeiro, Brazil. Burns, 1997. 23: p. 478-83. 


17. 

Grunwald, T. and W. Garner, Acute Burns. Plastic and Reconstructive Surgery, 2008. 121(5): 

p. 311e-319e. 


18. 

Ramzy, P., J. Barrett, and D. Herndon, Thermal Injuries. Critical Care Clinics, 1999. 15(27). 

19. 

Tenenhaus, M. and H. Rennekampff, Burn Surgery. Clinics in Plastic Surgery, 2007. 34(4): p. 

687-715. 

20. 

Barret, J., Surgical Approaches to the Major Burn, in Principles and Practice of Burn Surgery. 

21. 

Wolf, S., The Major Burn, in Principles and Practice of Burn Surgery. 

22. 

Mitchell, M., H. Oliveira, and M.e.a. Kinsky, Enteral resuscitation of burn shock using World 

Health Organization Oral Rehydration Solution: a potential solution for mass casulty care. . 

Journal of Burn Care Res., 2006. 27: p. 819. 


23. 

Munson, M. and P. Mertons, A system for making hospital solutions in the Third World. 

Tropical Doctor, 1988. 2: p. 54. 

24. 

Indications and Instructions for Escharatomy. [cited; Available from http://www.health.nsw. 

gov.au/ gmct/burninjury/docs/escharotomy_indications_instructions.pdf. 

25. 

Godwin, Y.W., SH, Major burns in CapeTown: a modified burns score for patient triage. Burns, 

1998. 24: p. 58-63. 


26. 

Whitelock-Jones, L., et al., Inhalation burns in children. Pediatric Surgery International, 

1999. 15: p. 50-55. 


27. 

Masanes, M., C. Legendre, and N.e.a. Lionet, Using bronchoscopy and biopsy to diagnose 

early inhalation injury. Chest, 1995. 107: p. 1365. 

28. 

Mandel, J. and C. Hales. Smoke Inhalation. 2008 [cited; Available from: www.uptodate.com. 

29. 

Seger, D. and L. Welch, Carbon monoxide controversies: Neuropsychologic testing, 

mecanisms of tocixity, and hyperbaric oxygen. Annals of Emergency Medicine, 1994. 24: p. 

242. 

30. 

Ipaktchi, K. and S. Arbabi, Advances in burn critical care. Critical Care Medicine, 2006. 

34(9(suppl)). http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55201 

31. 

Weaver , L., et al., Carboxyhemoglobin half-life in carbon-monoxide-poisoned patients 

treated with 100% oxygen at atmospheric pressure. Chest, 2000. 117: p. 801. 


32. 

Wahl , W., K. Ahrns, and M.e.a. Brandt, Bronchoalveolar lavage in diagnosis of ventilatorassociated 

pneumonia n patients with burns. Journal of Burn Care & Rehabilitation, 2005. 

26: p. 57-61. 


33. 

Monafo, Wound Care, in Total Burn Care, D.N. Herndon, Editor. 2002. 




34. 

Mann, R. and D. Heimbach, Prognosis and treatment of burns. Western Journal of Medicine, 

1996. 165: p. 215-20 


35. 

MacMillan, B., Burn Wound Sepsis – a 10 year experience. Burns, 1975. 2(1). 

36. 

Gallagher, J., S. Wolf, and D. Herndon, Burns, in Sabiston Textbook of General Surgery, C.e.a. 

Townsted, Editor. 2008. 

37. 

Molan, P., The role of honey in the management of wounds. J Wound Care, 1999. 8: p. 415- 

8. 

38. 

Halkes, S., J. du Pont, and M.e.a. Hoekstra, The use of tannic acid in the local treatment of 

bum wounds: intriguing old and new perspectives. Wounds, 2001. 13(4): p. 144-58. 


39. 

Chokoto, L. and E. van Hasselt, The use of tannins in the local treatment of burn wounds. . 

Malawi Medical Journal, 2005. 17(1): p. 19-20. 

40. 

Ghalambor, A., M. Pipelzadeh, and A. Khodadadi, The Amniotic Membrane: A Suitable 

Biological Dressing to Prevent Infection in Thermal Burns. Medical Journal of Islamic 

Academy of Science, 2000. 13(3): p. 115-8. 

41. 

Ramakrishnan, K. and V. Jayaraman, Management of partial thickness burn wounds by 

amniotic membrane; a cost effective treatment in developing countries. Burns, 1997. 23 

(Suppl 1): p. 533-6. 


42. 

Gore, M. and D. Akolekar, Evaluation of banana leaf dressing for partial thickness burn 

wounds. Burns, 2003. 29: p. 487-92. 


43. 

Ozumba, U. and B. Jiburum, Bacteriology of burn wounds in Enugu. Nigeria Burns, 2000. 26: 

p. 178-80. 

44. 

Ugburo, An evaluation of the role of systematic antibiotic prophylaxis in the control of burn 

wound infection at the Lagos University Teaching hospital. Burns, 2004. 30: p. 43-8. 


45. 

Herndon, D.N. and R. Tompkins, Support of the metabolic response to burn injury. The 

Lancet, 2004. 363. 


46. 

Manktelow, A., Burn injury and management in Liberia. Burns, 1990. 16: p. 432-6. 

47. 

Corwin, H., A. Gettinger, and R. Pearl, The CRIT Study: Anemia and blood transfusion in the 

critically ill. Current clinical practicie in the United States. Crit Care Med, 2004. 32: p. 39- 

52. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55211 

48. 

Palmieri, T., D. Caruso, and K.e.a. Foster, Effect of blood transfusion on outcome after major 

burn injury: a multi center sutdy. Crit Care Med, 2006. 34(6): p. 1602-7. 


49. 

James, J.e.a., The prevalence of HIV infection among burn patients in a burns unit in Malawi 

and its influence on outcome. Burns, 2003. 29: p. 55-60. 


50. 

Edge, J., et al., Clinical Outcome of HIV positive patients with moderate to severe burns. 

Burns, 2001. 27: p. 111-114. 


51. 

Prasanna, M., P. Mishra, and T. C., Delayed primary closure of the burn wounds. Burns, 

2004. 30: p. 169-75. 


52. 

Stevenson, J., et al., The establishment of a burns unit in a developing country: 

collaborative venture in Malawi. British Journal of Plastic Surgery, 1999. 52: p. 488-94. 


53. 

Bell, M. and M. Duncan, The Cutting Edge of Plastic Surgery: How to Sharpen Your Humby 

Knife. Plastic and Reconstructive Surgery., 1998. 101(3): p. 864-5. 


54. 

Bell, M., M. Duncan, and S. Shanhrokhi Ebrahimipour, Successful Skin Grafting in Developing 

Countries. Tropical Doctor, 2000. 30(3): p. 149-51. 

55. 

Bell, M. and M. Duncan, Need A Pizza Meshed Skin? A Simple Expansion Device. Tropical 

Doctor, 1997. 27(4): p. 229. 

56. 

Richard, R. and R.S. Ward, Splinting Strategies and Controversies. Journal of Burn Care & 

Rehabilitation, 2005. 26(5). 


57. 

Serghiou, M.A., A. McLaughlin, and D.N. Herndon, Alternative Splinting Methods for the 

Prevention and Correction of Burn Scar Torticollis. Journal of Burn Care & Rehabilitation, 

2003. 24: p. 336-40. 


58. 

Manigandan, C., et al., A multi-purpose, self-adjustable aeroplane splint for the aplinting of 

axillary burns. Burns, 2003. 29: p. 276-9. 


59. 

Germann, G. and K. Philipp, The Burned Hand, in Green’s Operative Hand Surgery, D.e.a. 

Green, Editor. 2005. 

60. 

Hashem, F.K. and Z.A. Khayal, Oral Burn Contractures in Children. Annals of Plastic Surgery, 

2003. 51(5): p. 468-71. 


61. 

Hudson, D. and A. Renshaw, An algorithm for the release of burn contractures of the 

extremities. Burns, 2006. 32: p. 663-8. 


62. 

Wilson, I.F., et al., Latissimus Dorsi Myocutaneous Flap Reconstruction of Neck and Axillary 

Burn Contractures. Plastic and Reconstructive Surgery, 2000. 105(27-33). 


63. 

Lee, W. and A. Salyapongse, Thumb Reconstruction, in Green’s Operative Hand Surgery, G.e. 

al, Editor. 2005. 

64. 

Gulgonen, A. and K. Ozer, The correction of post-burn contractures of the second through 

fourth web spaces. Journal of Hand Surgery, 2007. 32A: p. 556-564. 


65. 

Lin, T.-M., et al., Treatment of Axillary Burn Scar Contracture using opposite running Y-Vplasty. 

Burns, 2005. 31: p. 894-900. 


66. 

Obaidullah, H. Ullah, and M. Aslam, Figure-of-8 sling for prevention of recurrent axillary 

contracture after release and skin grafting. Burns, 2005. 31(283-9). 


67. 

Hallock, G.G., A Systematic Approach to Flap Selection for the Axillary Burn Contracture. 

Journal of Burn Care & Rehabilitation, 1993. 14: p. 343-7. 

68. 

Esselman, P., et al., Burn Rehabilitation-State of Science. Am J Phys Med Rehabil, 2006. 85: 

p. 383-413. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55229 


Innovation in clinical specialities: cardiovascular disease 

Cardiovascular risk factor trends 

and options for reducing future 

coronary heart disease mortality in 

the United States of America 

ARTICLE BY SIMON CAPEWELL 

Division of Public Health, University of Liverpool, England 

EARL S FORD 

Division of Adult and Community Health, Centers for Disease Control and Prevention, Atlanta, GA, USA 

JANET B CROFT 

Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA 

JULIA A CRITCHLEY 

Institute of Health and Society, Newcastle University, England 

KURT J GREENLUND 


DARWIN R LABARTHE 


One of the objectives of the Healthy People 2010 initiative in the United States of America (USA) is achievement of a 20% reduction 

in age-adjusted coronary heart disease (CHD) mortality rates. We examined the potential for changes in cardiovascular risk factors 

to achieve that target using a previously validated, comprehensive CHD mortality model. This model integrates information on 

trends in all the major cardiovascular risk factors, stratified by age and sex. The potential reductions in CHD mortality within the 

projected population of the USA aged 25 to 84 years in 2010 (198 million) from base year 2000 were calculated for three 

contrasting scenarios. In the first scenario, if age-adjusted CHD mortality rates observed in 2000 remained unchanged, some 388 

470 CHD deaths would occur in 2010. Continuation of recent risk factor trends should result in approximately 19 000 fewer coronary 

deaths (some 51 000 fewer deaths attributable to improvements in total cholesterol and men’s blood pressure, decreased smoking 

and increased physical activity, minus approximately 32 000 additional deaths attributable to adverse trends in obesity, diabetes 

and women’s blood pressure). In the second scenario, success in reaching all the Healthy People 2010 risk factor targets would 

achieve approximately 188 000 fewer deaths. In the third, additional reductions in risk factors to the levels already seen in the lowrisk 

stratum could potentially prevent approximately 372 000 deaths. Achievement of the Healthy People 2010 targets could almost 

halve predicted CHD deaths. Additional reductions in major risk factors could prevent or postpone substantially more CHD deaths. 

Coronary heart disease (CHD) accounted for over 450 000 

deaths in the United States of America (USA) in 2004. 1,2 

The burden of CHD is enormous, affecting more than 13 

million people and generating direct health-care costs exceeding 

US$ 150 billion annually. 1,2 Since the late 1970s, age-adjusted 

CHD mortality rates have been halved in most industrialized 

countries including the USA. However, between 1990 and 2000 

this decrease diminished, with clear flattening in younger age 

groups. 1,2 Many adults in the USA still demonstrate high levels of 

risk for cardiovascular disease. Total cholesterol levels exceed 200 

mg/dl among more than 100 million adults, approximately 70 

million have or are being treated for high blood pressure (a systolic 

blood pressure ≥140 mmHg or diastolic blood pressure ≥90 

mmHg) and over 50 million people still smoke. 2–4 

The Healthy People 2010 (HP2010) initiative promoted by the 

government of the USA contains targets for heart disease and 

stroke that explicitly address risk factor prevention, detection and 

management, along with prevention of recurrent events. HP2010 

objectives include a 20% reduction in age-adjusted CHD mortality 

rates (from 203 per 100 000 population in 1998 to 162 per 100 

000 in 2010).3 They also include specific targets for reducing 

cholesterol (to 199 mg/dl), smoking (to 12%), hypertension (to 

16%), diabetes (to 6%), obesity (to 15%) and inactivity (to 20%). 3 

Inactivity was measured in the Behavioral Risk Factor Surveillance 

System of the United States Centers for Disease Control and 

Prevention as the proportion of adults engaging in no physical 

activity.5 If those targets are achieved, what reduction in CHD 

mortality might actually result? 

Large meta-analyses and cohort studies have consistently 

demonstrated substantial reductions in CHD deaths related to 

decreases in each of the major cardiovascular risk factors among 

individuals covered by the studies. 6–8 However, it is difficult to 

attribute a decline in the mortality rate for an entire population 

either to specific risk factor changes or to more effective medical 

interventions because favourable trends in both often have 

occurred simultaneously. 9,10 Furthermore, risk factor improvements 

such as lower blood pressure or cholesterol may be achieved 

through medications, lifestyle changes or a combination. 1,2,8–10 



Table 1: Major risk factors a in coronary heart disease mortality 

Age groups (years) 

Risk factor 25–44 45–54 55–64 65–74 75–84 

Systolic blood pressure 7 

Men (log hazard ratio per 1 mmHg) -0.036 -0.035 -0.032 -0.027 -0.021 

Women (log hazard ratio per 1 mmHg) 

-0.046 -0.046 -0.035 -0.032 -0.026 

Total cholesterol 6 

Men & women: mortality reduction per 1 

mmol/l (38.6 mg/dl) change in total cholesterol 0.900 0.650 0.450 0.333 0.317 

Log coefficient -1.2942 -0.8238 -0.5245 -0.3719 -0.3512 

Body mass index (BMI) 8 

Age-specific relative risks per 1 kg/m 2 1.04 1.03 1.02 1.01 1.01 

c 

Men & women: log coefficients 

0.0363 0.0297 0.0165 0.0132 0.0099 

a Used as input for the IMPACT model for the United States of America 

Table 2: Relative risks a of smoking, diabetes and physical inactivity for coronary heart disease mortality 

Men 

Women 

55 years >55 years ≤65 years > 65 years 

Smoking 3·33 (2·80–3·95) b 2·52 (2·15–2·96) 4·49 (3·11–6·47) 2·14 (1·35–3·39) 

Exercise 1·02 (0·83–1·25) b 0·79 (0·66–0·96) 0·74 (0·49–1·10) 0·75 (0·46–1·22) 

Diabetes 2·66 (2·04–3·46) b 1·93 (1·58–2·37) 3·53 (2·49–5·01) 2·59 (1·78–3·78) 

Source: INTERHEART study 27 

a Used as input for the IMPACT model for the United States of America 

b 

Odds ratios for relative effect of ri sk factors with 99% confidence intervals 

A variety of CHD policy models have been developed to 

estimate the relative contributions and hence the population 

impact of medical and public-health interventions. Good models 

are able to integrate and simultaneously consider large amounts of 

data on patient numbers, treatments and population risk factor 

trends. 9–11 The CHD Policy Model developed in the USA was used 

successfully to examined trends in that country between 1980 and 

1990 9 and later demonstrated the potential advantages of a 

population-based approach to prevention, 12 consistent with 

European studies. 13-15 

Capewell et al. have subsequently developed, refined and 

applied the IMPACT model in a variety of populations. 10,16-19 

Approximately 44% of the substantial CHD mortality decline in the 

USA between 1980 and 2000 was attributable to changes in 

major risk factors and 47% to specific cardiological treatments, 10 

similar to findings in other industrialized countries. 16,17,19,20 Three 

earlier analyses suggested that further modest reductions in major 

risk factors could halve CHD deaths in the United Kingdom of 

Great Britain and Northern Ireland. 15,21–23 To determine whether 

similar gains may be possible for the population of the USA, or 

whether they would be negated by recent dramatic rises in obesity 

and diabetes, we used the previously calibrated IMPACT model 10 

for the USA to estimate the number of CHD deaths that could 

potentially be prevented or postponed in 2010, compared with the 

number in 2000. The model was applied to three contrasting 

scenarios, the most optimistic of which assumed that the 

prevalence of risk factors in the entire population reaches the 

levels already reported in its “low-risk stratum”. 24,25 

Methods 

The IMPACT model aims to explain changes in CHD mortality 

rates in a population. It quantifies the contribution from temporal 

trends in the major population 

risk factors (smoking, high 

systolic blood pressure, 

elevated total cholesterol, 

obesity, diabetes and physical 

inactivity) and from medical 

and surgical treatments given 

to CHD patients. 10,17,26 The 

model employs regression 

coefficients produced by large 

meta-analyses and cohort 

studies. 6-8 Each coefficient 

quantifies the independent (log linear) relationship between the 

absolute change in a specific cardiovascular risk factor, such as 

high systolic blood pressure or total cholesterol, and the 

consequent change in population mortality rates from CHD (Table 

1). 6-8 For each risk factor, the subsequent reduction in deaths in 

2010 from base year 2000 could then be estimated as the product 

of three variables: 

Number fewer deaths = number of CHD deaths observed in 

2000 × the risk factor reduction × the specific regression 

coefficient exponentiated. 10,22,23 

All the coefficients and relative risk values were obtained from 

multivariate logistic regression analyses and were assumed to be 

independent, having been adjusted for potential confounding from 

the other major risk factors. The total deaths prevented could 

therefore be summed. Independent regression coefficients were 

not available for smoking, diabetes and physical inactivity. An 

alternative methodology was therefore used, which involved 

population-attributable risk fractions 9,21,22 calculated for the 

INTERHEART study, a large, international multivariate analysis that 

included data from the USA27 (Table 2). 

The original 1980–2000 IMPACT model 10 was extended to 2010 

using United States Census Bureau population projections and 

mortality data for men and women aged 25–84 years. The number 

of CHD deaths (ICD-10: I20-I25) expected in 2010 was then 

calculated under three contrasting risk factor scenarios. 

Risk factor scenarios 

The first scenario assumed that recent risk factor trends would 

continue to 2010. Using data from the Third National Health and 

Nutrition Examination Survey (NHANES) 1988–1994, NHANES 

1999– 2002, and the Behavioral Risk Factor Surveillance System 



Table 3: 3. Risk factor levels in in 2000 base year and and projections to 2010 under three scenarios of cardiovascular risk factor change, 


Scenario 

Smoking prevalence 

(%) 

Total cholesterol 

(mg/dl) (mmol/l) a 

Systolic blood 

pressure (mmHg) 

Body mass index 

(kg/m 2 ) 

Diabetes 

prevalence (%) 

Prevalence of 

physical 

activity b (%) 

Men Women Men Women Men Women Men Women Men Women Men Women 

NHANES III (1988–1994) 31.6 24.7 206 (5.32) 210 (5.42) 123.5 119.6 26.87 26.73 9.0 8.9 70.4 68.0 

207 (5.35) 124.4 123.9 27.86 28.51 11.7 9.5 75.1 70.5 

In 2010, assuming recent trends continue 22.6 18.7 204 (5.28) 204 (5.28) 125.3 128.5 29.18 30.16 15.2 10.1 80.8 74.1 

In 2010, assuming Healthy People 

targets are achieved 

In 2010, assuming all in “low-risk 

stratum” 

12.0 12.0 199 (5.15) 199 (5.15) 119.4 c 118.9 c 25.00 d 26.00 d 6.0 e 6.0 e 80 80 

0 0 176 (4.54) 179 

(4.64) 

115.7 114.7 25.50 23.60 0.0 0.0 100 100 

NHANES, National Health and Nutrition Examination Survey 

a Cholesterol conversion factor mg/dl to mmol/l = 38.67 

b Any leisure time activity 

c Assuming a 5 mmHg decrease from 2000 

d Assuming that obesity prevalence falls to 15% 

e Total diabetes (diagnosed and undiagnosed), equivalent to HP2010 target of 25 per 1000 population diagnosed cases 

Table 4: Observed a and projected coronary heart disease mortality rates and deaths in the United States of America in 2000 and 2010 

Men 

25–34 

years 

35–44 

years 

45–54 

years 

55–64 

years 

65–74 

years 

75–84 

years 

Total 

men 

Population 

in 2010 

(thousands) 

CHD 

mortality 

rates per 

100 000 

observed 

in 2000 

Annual 

change in 

CHD 

mortality 

rates 

1997–2002 

(%) 

CHD 

mortality 

rates per 

100 000 

expected in 

2010 if 

trends 

continue 

Number of 

CHD 

deaths in 

2010 if 

recent 

trends 

continue 

Number of 

CHD deaths 

in 2010 if 

2000 rates 

unchanged 

Expected 

decrease in 

number of 

CHD deaths 

in 2010 

compared 

with 2000 

Decrease in 

CHD deaths 

in 2010 

compared 

with 2000 

(%) 

21 105 3.50 - 0.52% 3.32 700 739 -39 -5.2% 

20 552 25.78 - 0.52% 24.43 5 022 5 298 - 277 -5.2% 

22 064 103.52 - 2.70% 75.59 16 679 22 841 - 6 163 -27.0% 

17 438 290.20 - 4.14% 170.10 29 663 50 607 - 20 944 -41.4% 

9 797 705.19 - 4.03% 420.76 41 222 69 088 - 27 866 -40.3% 

5 272 1736.85 3.20% 1180.98 62 265 91 573 - 29 307 -32.0% 

96 229 236.00 -1.97% 161.65 155 550 240 145 -84 595 -35.2% 

Women 

25–34 20 541 1.17 +2.16% 1.42 292 240 +52 +21.6% 

years 

35–44 20 568 7.63 +2.16% 9.28 1 909 1 569 +339 +21.6% 

years 

45–54 22 763 29.93 - 1.56% 25.25 5 749 6 813 - 1 065 -15.6% 

years 

- 4.15% 

- 8 591 -41.5% 

55–64 

years 

18 747 110.39 

64.57 12 104 20 696 

65–74 11 473 340.32 - 3.69% 214.61 24 621 39 044 - 14 423 -36.9% 

years 

75–84 7 578 1055.16 - 3.14% 723.60 54 838 79 964 - 25 127 -31.4% 

years 

Total 

women 

10 1670 146.90 -1.12% 97.88 99 515 148 325 -48 815 -32.9% 

Total 

men & 19 7900 190.00 -1.5% 142.15 25 5060 388 470 -133 410 -34.3% 

women 

a Source: American Heart Association 1 



(1988–2002), 3,4 linear projections were made from 1988–1994 

through 1999–2002 to the country’s population in 2010 of recent 

trends in total cholesterol (mg/dl), smoking (%), systolic blood 

pressure (mmHg), body mass index (BMI) (kg/m 2 ), all diabetes (%) 

and any leisure-time physical activity (%), all stratified by age and 

sex 10,22,23 (Table 3). 

The second scenario assumed risk factor levels equal to the 

substantial but feasible reductions defined in the HP2010 

objectives. 3 In the absence of specific HP2010 targets for BMI, 

total diabetes and systolic blood pressure, we assumed that: (i) 

the 15% obesity target would equate to a population mean BMI of 

25 kg/m 2 for men and 26 kg/m 2 for women; (ii) the 25 per 1000 

population clinically diagnosed diabetes prevalence target would 

equate to a total (diagnosed and undiagnosed) type 1 and type 2 

diabetes prevalence of 6%; and (iii) the 16% hypertension 

prevalence target would equate to a population mean systolic 

blood pressure of 119 mmHg, representing a 5 mmHg reduction 

from 2000 levels (Table 3). 

In the third scenario, mean population risk factors were 

assumed to reach levels already observed in the “healthiest” 

stratum of cohorts in the USA, as defined by Stamler et al. 24 and 

Daviglus et al. 25 Levels for specific risk factors were as follows: (i) 

no smoking among men or women; (ii) 175.6 mg/dl (4.54 mmol/l) 

total cholesterol for men and 179.6 mg/dl (4.64 mmol/l) for 

women; (iii) a mean systolic blood pressure of 115.7 mmHg for 

men and 114.7 mmHg for women, representing a 10mmHg 

reduction from 2000 levels; (iv) a BMI of 25.5 kg/m 2 for men and 

23.6 kg/m 2 for women; (v) zero prevalence of diabetes among 

both men and women. 24,25 Physical activity was not specifically 

considered by in these studies, 24,25 so we defined the level in the 

lowest risk stratum as 100%, with everyone undertaking some 

leisure-time physical activity. (Table 3). To preserve the focus on 

risk factor changes, we assumed that the proportion of the 

population receiving medical and surgical treatments for CHD 

would remain constant. 

Sensitivity analysis 

Because of the uncertainties surrounding some of the estimates, 

a multi-way sensitivity analysis was performed using the analysis 

of extremes method. 28 Minimum and maximum estimates of 

deaths prevented or postponed were generated using minimum 

and maximum plausible values for the main parameters: 95% 

confidence intervals when available; otherwise, the best value 

±20%. 10,22,23,28 The Supplementary Appendix (available at: 

http://content.nejm.org/cgi/data/356/23/2388/DC1/1) provides 

worked examples of the calculations used in the model plus 

further details on the methods and data sources used. 10 

Results 

Trends and estimates 

Approximately 388 000 CHD deaths among people aged 25–84 

years would be expected in 2010 if the same age-specific death 

rates recorded in 2000 (the base year) were also observed in 

2010. This number would represent 15% more than the 338 000 

deaths observed in 2000, reflecting population aging 

compounded by an increase in population size (Table 4). 

Between 1997 and 2002, the overall annual declines observed 

in CHD mortality rates were 2% for men and 1% for women. 

Table base-year 5: Estimated following reduction changes in coronary in specific heart risk factors disease mortality in the United States of America in 2010 compared with the 2000 

base-year following changes in specific risk factors 

Risk factor changes 

Absolute values 

Fewer (additional) CHD deaths in 2010 with 

risk factor changes a 

MenBest 

estimate 

WomenBest 

estimate 

Men Women Best estimate Minimum Maximum 

Smoking prevalence in 2000 27.3% 21.9% 

If 

recent trends continue to 2010 

22.6% 18.7% -10 000 -8 000 -12 000 - 7 000 -3 000 

If 

HP2010 targets are achieved 

12.0% 12.0% -26 000 -21 000 -32 000 - 18 000 -8 000 

If 

all in low-risk stratum 

0% 0% 

-60 000 -48 000 -72 000 - 42 000 -18000 

Total cholesterol in 2000 205.0 206.9 

If 


204.2 204.3 -28 000 -17 000 -41 000 - 15 000 -14 000 

If 

HP 2010 targets are achieved 

199.0 199.0 -40 000 -24 000 -59 000 - 17 000 -24 000 

If 


175.6 179.6 -103 000 -70 000 -160 000 - 68 000 -35 000 

Population systolic blood pressure in 2000 124.4 123.9 

I f recent trends continue to 2010 

125.3 128.5 (+2 000) (+1 000) (+4 000) - 6 000 (+8 000) 

If 


119.4 118.9 -48 000 -39 000 -58 000 - 28 000 -20 000 

If 


115.7 114.7 -83 000 -75 000 -108 000 - 54 000 -29 000 

Body mass index (BMI) in 2000 27.86 28.51 

If recent upward trends continue to 2010 29.18 30.16 (+8 000) (+5 000) (+11 000) (+5 000) (+3 000) 

If 


25.00 26.00 -17 000 -10 000 -24 000 - 12 000 -5 000 

If 


25.50 23.60 -21 000 -12 000 -27 000 - 10 000 -10 000 

Diabetes in 2000 11.7% 9.5% 

If recent upward trends continue to 2010 15.2% 10.1% (+16 000) (+5 000) (+22 000) (+11 000) (+5 000) 

If 


6.0% 6.0% -44 000 -26 000 -66 000 - 24 000 -20 000 

If 


0% 0% 

-72 000 -49 000 -100 000 - 38 000 -34 000 

Physical activity in 2000 75.1% 70.5% 

If 


80.8% 74.1% -7 000 -6 000 -9 000 - 4 000 -2 000 

If 


80% 80% 

-12 000 -10 000 -14 000 - 6 000 -6 000 

If 


100% 100% -34 000 -27 000 -40 000 - 18 000 -16 000 

If recent downward trends continue (smoking, 

n/a n/a -51 000 -29 000 -57 000 - 32 000 19 000 

cholesterol, physical inactivity male BP) 

If recent upward trends continue (female BP, obesity, n/a n/a (+32 000) (+10 000) (+32 000) (+16 000) (+16 000) 

diabetes) 

Net 

effect if recent trends continue 

n/a n/a 

-19 000 -10 000 -25 000 - 16 000 -3 000 

If 


n/a n/a 

-188 000 -129 000 -252 000 -105 000 -83 000 

If 


n/a n/a 

-372 000 -281 000 -507 000 - 230 000 -142 000 

If only smoking, cholesterol and BP match low-risk 

n/a n/a -246 000 -194 000 -339 000 - 164 000 -82 000 

stratum 

If only BMI, diabetes and physical activity match low-risk n/a n/a -126 000 -87 000 -167 000 - 66 000 -60 000 

stratum 

HP2010, Health People 2010; BP, systolic blood pressure 



Table Table 6: 6. Reductions Reductions in coronary in coronary heart heart disease disease mortality mortality achievable achievable in in the the United United States States of of America America in 2010 in 2010 compared compared with with 2000 2000 

Age groups(years) Scenario Total Men Women 

If recent trends continue 

(+355 

) (+55) (+305) 

If HP2010 targets are achieved 300 225 75 

25–34 If all achieved low-risk stratum values 2 000 b 1 000 1 000 

I f recent trends continue 

(+2 000) (+380) (+1 000) 

If HP2010 targets are achieved 4 000 3 000 2 000 

35–44 If all achieved low-risk stratum values 12 000 8 000 4 000 

I f recent trends continue 

(+2 000) (+2 000) (+115) 



If 

recent trends continue 

1 000 2 000 -1 000 



If 


9 000 10 000 (+1 000) 



If 


12 000 7 000 5 000 



If recent trends continue 19 000 16 000 3 000 


Totals 

If all achieved low-risk stratum 

values 372 000 230 000 142 000 

HP2010, Healthy People 2010 

a Additional deaths shown as a positive value: e.g. (+355) 

b Number of deaths from coronary heart disease rounded to nearest 1000 on this and subsequent rows 

However, declines were minimal among men younger than 45 

years of age, and increases were seen among women in that age 

group. Three of the six major risk factors declined between 1988 

and 2002, while obesity and diabetes increased. Systolic blood 

pressure rates rose among women and fluctuated among men. 

Assuming continuation of the same trends, the overall result would 

be approximately 19 000 fewer deaths in 2010 than in 2000 

(minimum estimate 10 000 and maximum estimate 25 000). This 

represents some 51 000 fewer deaths because of improvements 

in total cholesterol and men’s blood pressure, less smoking and 

increased physical activity, minus approximately 32 000 additional 

deaths attributable to adverse trends in obesity, diabetes and 

women’s blood pressure (Table 5). 

Approximately 188 000 fewer CHD deaths than in 2000 

(minimum 129 000, maximum 252 000) could be achieved by 

reaching the specific reductions in cardiovascular risk factors 

called for in HP2010: (i) approximately 40 000 fewer deaths if 

population mean cholesterol levels declined to 199 mg/dl (5.15 

mmol/l) among both men and women; (ii) approximately 26 000 

fewer deaths if the smoking prevalence fell to 12% among both 

men and women; (iii) approximately 48 000 fewer deaths, 

assuming a decrease in mean systolic blood pressure to 119.4 

mmHg among men and 118.9 mmHg among women 

(representing a 5 mmHg reduction in all age groups); (iv) 

approximately 12 000 fewer deaths, assuming an increase in 

physical activity rates (to 80% among both men and women); (v) 

approximately 17 000 fewer deaths, assuming a substantial 

decrease in BMI to 25.0 kg/m 2 for men and 26.0 kg/m 2 for women; 

(vi) approximately 44 000 fewer deaths, assuming a substantial 

decrease in total diabetes prevalence to 6% among both men and 

women. If the ideal scenario were achieved, with mean population 

cardiovascular risk factors reduced substantially to levels already 

observed in the healthiest stratum of cohorts, 24,25 approximately 

372 000 CHD deaths (minimum 281 000, maximum 507 000) 

could be prevented or postponed (Figure 1). The 372 000 fewer 

deaths would be distributed as follows: (i) approximately 103 000 

fewer deaths if population mean cholesterol levels declined to 

175.6 mg/dl (4.54 mmol/l) among men and 179.6 mg/dl (4.64 

mmol/l) among women; (ii) approximately 60 000 fewer deaths if 

smoking prevalence fell to zero; (iii) approximately 83 000 fewer 

deaths, assuming a 10 mmHg decrease in mean systolic blood 

pressure to 115.7 mmHg for men and114.7 mmHg for women; (iv) 

approximately 34 000 fewer deaths if all men and women were 

physically active; (v) approximately 21 000 fewer deaths, assuming 

a decrease in BMI to 25.5 in men and 23.6 in women; (vi) 

approximately 72 000 fewer deaths, assuming a zero prevalence 

of diabetes (Table 5). 

Estimated mortality benefits 

Under the scenario in which current trends continued, 

approximately 16 000 fewer deaths would occur among men and 

3000 among women. In the two more optimistic scenarios, men 

would consistently benefit more than women, gaining 54% of the 

182 000 fewer deaths under the HP2010 reductions scenario and 

62% of the 372 000 fewer deaths if low-risk stratum levels are 

assumed (Table 5). Gains would predominantly occur among men 

aged 45–84 years and among women aged 65–84 years (Figure 

2). Of the 372 000 fewer deaths in the most optimistic scenario, 

252 000 (68%) would represent premature deaths avoided, that is, 

deaths among those under 75 years of age (Table 6). Extensive 

sensitivity analyses examined the impact of higher and lower 

values for model parameters. 28 Changing the values influenced the 



number of deaths postponed or prevented but did not alter the 

relative contribution of each risk factor (Table 5, columns 5 and 6). 

Thus, regardless of whether best, minimum or maximum 

estimates were considered, the most substantial contributions 

came from the changes in cholesterol, blood pressure and 

smoking (Table 5). 

Discussion 

Success in achieving the HP2010 targets could almost halve 

predicted CHD deaths in 2010, or indeed in 2015. Our findings are 

reassuringly consistent with earlier studies in the England, 23 

Scotland 22 and the USA 12 . In the United Kingdom, a modest 

reduction in mean population cholesterol level from 225 mg/dl to 

200 mg/dl could reduce CHD deaths by approximately half. 14,15,24 In 

contrast, a rather optimistic 25% reduction in the prevalence of 

obesity would probably prevent just 2% of CHD deaths. 15,24 A 

corresponding 25% reduction in the prevalence of inactivity might 

prevent 1% of CHD deaths. 15,29 

Although CHD death rates have been falling in the USA for four 

decades, they are now plateauing in young men and women. 2 

Recent declines in total cholesterol have been modest, blood 

pressure is now rising among women and obesity and diabetes are 

20 000 

0 

-20 000 

-40 000 

-60 000 

-80 000 

-100 000 

-120 000 

-140 000 

-160 000 

-180 000 

-5000 

-45 000 

-85 000 

-125 000 

-28 300 

-33 540 

C holes terol 

-103 080 

25-34 

355-300 

1525 2235 

-1525 

2190 

-48 635 

Systo lic B P 

-82 520 

35-44 

-4190 

-12 175 

Smoking 

-10 020 -6810 

-12 010 

-26 270 

-33 670 

-60 135 

IF Current trends continue to 2010 

IF Healthy People 2010 targets 

IF USA Low Risk stratum 

-20815 

45-54 

-45 770 

-1450 

IF Current trends continue to 2010 

IF Healthy People 2010 targets 

IF USA Low Risk stratum 

-43 615 

55-64 

-88 500 

8105 

BMI 

P hysical A ctivity 

-17 430 

-20 535 

-8775 

-52 300 

65-74 

-106 295 

15885 

rising steeply. Furthermore, population aging will increase the 

numbers of CHD deaths in that country and elsewhere. 30 There is 

no room for complacency. Continuation of recent risk factor trends 

should result in approximately 20 000 fewer coronary deaths in 

2010 than in 2000. This reflects some 50 000 fewer deaths 

expected from improvements in total cholesterol, smoking, physical 

activity and male blood pressure, but more than half of the gain is 

negated by approximately 30 000 additional deaths attributable to 

increases in rates of obesity and diabetes, plus systolic blood 

pressure increases among women. Increasing treatments could 

not compensate for these worsening risk factors. In 2000, barely 

40% of eligible patients received appropriate therapies. 10 Even 

raising this proportion to an optimistic 50% would only postpone 

approximately 60 000 additional deaths in 2010. 31 

Successfully achieving the specific risk factor reductions 

proposed in the HP2010 targets could prevent or postpone 

approximately 190 000 CHD deaths. This would potentially halve 

the mortality burden seen in 2000. The HP2010 objectives for 

cholesterol and physical activity remain potentially attainable. 

However, attaining the targets for obesity, diabetes and female 

blood pressure appear more challenging because of the need to 

actually reverse recent adverse trends. 3 Successfully reducing 

population risk factor levels to those already seen in 

the healthiest (lowrisk) stratum could result in 

approximately 370 000 fewer CHD deaths among 

people aged 25–84 years. This figure would represent 

a 96% decrease compared to the 2000 baseline of 

388 000 1,3 and is somewhat larger than the 85% 

reduction predicted by other studies. 24,25 Although 

probably an overestimate, the results for this third 

scenario show an aspirational ideal to highlight 

potential future gains. However, the “low-risk stratum” 

in the population of the USA remains frustratingly 

small, even when defined only by smoking, blood 

-71 860 

pressure and cholesterol: 6% in the 1970s 32 and, 

even now, only 7.5% among whites and 4% among 

African Americans. 33 

-43 900 

-11 840 

-61 790 

Diabetes 

Figure 1: Estimated reductions in coronary heart disease mortality in the United 

. States 2. Estimated of America reductions in 2010 under in coronary three different heart disease scenarios mortality in the United State 

75-84 

-119 705 

Figure 2: Estimated reductions in coronary heart disease mortality in the United 

States of America in 2010 by age group under three different scenarios 

Achieving risk factor reductions 

Although fashionable, screening and treating high-risk 

individuals would necessitate medicating 15% to 

25% of all adults. 34,35 Furthermore, the key goal is not 

intervention but sustained risk factor reductions. 35 The 

whole population approach described by Rose 13 

appears both more effective and cost-effective. 13–15 

Similar conclusions have been reported previously in 

Dutch, Finnish and American cohorts. 12,35 

Lowering cholesterol should therefore remain a 

priority in the USA, as it offers a potentially powerful 

1% mortality reduction for every 1 mg/dl decrease in 

total cholesterol. 6 Large cholesterol declines have 

already been achieved by comprehensive national 

policies elsewhere (-20% in Finland 18 and -15% in 

Mauritius 36 ). In contrast, in the USA between 1988 

and 2004 total cholesterol fell barely 3% in adults 

(from 206 to 201 mg/dl). 37 Furthermore, these levels 

remain well above the optimal, prompting recent 

national dietary policies to further reduce total 

cholesterol levels. 2,3,38 



Smoking prevalence remains above 20% overall in the USA and 

is even higher in certain groups. This represents substantial room 

for improvement. Success in reducing tobacco use requires two 

comprehensive strategies: preventing young people from starting 

to smoke, and promoting cessation among smokers. 39 Examples 

of successful efforts include intensive antismoking programmes in 

California (USA); 40 advertising bans in Finland, Iceland and Norway; 

and smoke-free environments legislation in Ireland, Italy, Scotland 

and New York City in the USA. 41 It is encouraging that many more 

states in the USA are now passing laws requiring smoke-free 

environments. 41 The recent blood pressure trends in women are 

alarming. This is a powerful risk factor; every 1 mmHg reduction in 

systolic blood pressure could prevent approximately 10 000 CHD 

deaths each year in the population of the USA. 7 Furthermore, 

population blood pressure has been decreasing in most 

industrialized countries in recent decades, reflecting dietary trends 

rather than use of medications. 42–44 The American Public Health 

Association has called on industry to reduce the salt content of 

processed food over the next decade, which could contribute to 

meeting the dietary guidelines for daily sodium intake of less than 

2300 mg. 44,45 

Our analysis suggested that the current adverse trends in the 

USA – increases in obesity and diabetes rates and blood pressure 

in women – will probably cause approximately 30 000 additional 

CHD deaths in 2010. Obese individuals with pre-diabetes can 

benefit from a combination of diet, exercise advice and 

behavioural therapy, 46 but prevention is preferable. Yet today’s 

obesogenic environment is reinforced by powerful commercial, 

political, economic and social factors, 47 and thus reversing these 

trends will require substantial efforts and appears daunting. 2,3,32 

Recent increases in physical activity in the USA are encouraging, 

echoing trends in Canada, Finland and elsewhere. 5,18,48 Although 

engaging in adequate physical activity confers many health 

benefits, our analyses found that the potential reductions in CHD 

mortality appeared modest in the USA, as elsewhere. 15,23 

Interventions promoting activity among individuals seldom show 

long-term sustainability. 48 However, physical activity in populations 

may be increased by 4% to 9% through multiple interventions. 23,49 

The IMPACT model 

Our current analyses used the validated IMPACT model for the 

USA. 10 Recent high-quality data from NHANES and other large 

national studies reflected many events in a very large population. 

The model is comprehensive and transparent; it uses recent, 

reliable and reasonably precise age-specific regression coefficients 

from substantial meta-analyses 6,7 and relative risk values obtained 

from the large INTERHEART study. 27 Every key assumption is 

addressed and justified in the Supplementary Appendix (available 

at: http://content.nejm.org/cgi/data/356/23/2388/DC1/1). All 

models are simplifications of reality, with clear limitations. First, this 

model considered only mortality, not morbidity. However, our 

estimates of fewer deaths can easily be translated into a 12-fold 

increase in life-years gained. 50 Second, the model only explained 

91% of the mortality decrease, leaving 9% unexplained. Third, 

several assumptions were necessary, for instance, that any delay 

in mortality reduction (lag time) would be relatively unimportant 

over a 10-year scenario. 10,17,23 

However, extending the projections from 2000–2010 to 

2000–2015 would generate very similar results. Although all 

coefficients were independent, coming from multivariate logistic 

regression analyses, 6,7,27 some may not have been fully adjusted 

and thus “residual confounding” may remain, along with some 

imprecision. 10 Furthermore, the population-attributable risk 

approach may have slightly overestimated the contributions of 

diabetes, smoking and physical activity. Some net overestimation 

of benefits is thus possible, particularly for the ideal scenario. 

Conversely, underestimation was also possible because the model 

assumed similar change across the population. 

Larger reductions among older, more motivated individuals with 

higher mortality rates might generate greater benefits. Model 

development and comparisons with other models may be useful, 

along with consideration of “novel” risk factors, such as high levels 

of C-reactive protein. 2,3,51 It may also be useful for future studies to 

address economic and ethnic analyses and seek to validate the 

model using 2010 data when it becomes available. However, our 

rigorous sensitivity analyses were reassuring and suggested that 

the key findings are unlikely to change substantially. 10,17,23 Moreover, 

even crude estimates are potentially valuable for planners and 

policy-makers. In conclusion, implementing evidence-based 

policies to better control tobacco use and achieve healthier diets 

could potentially halve future CHD deaths in the United States of 

America. ❏ 


We thank Wayne H Giles, Umed A Ajani and Thomas E Kottke for 

helpful comments on the original model. Funding: This study was 

supported by investigator salaries only – Higher Education Funding 

Council for England (SC, JAC) and United States Centers for 

Disease Control and Prevention (ESF, JBC, KJG, DRL). Competing 

interests: None declared. 

Originally published in Bulletin of the World Health Organization; 

Article DOI: 10.2471/BLT.08.057885 

References 

1. 

Heart disease and stroke statistics: 2008 Update. Dallas, TX: American Heart Association; 

2008. Publication: Bulletin of the World Health Organization; Type: Policy and Practice Article 

DOI: 10.2471/BLT.08.057885 

2. 

Ford ES, Capewell S. Coronary heart disease mortality among young adults in the US from 

1980 through 2002: concealed levelling of mortality rates. J Am Coll Cardiol 2007;50:2128- 

32. PMID:18036449 doi:10.1016/j.jacc.2007.05.056 

3. 

Department of Health and Human Services. Healthy people 2010: understanding and 

improving health and objectives for improving health. Washington, DC: Government Printing 

Office; 2000. Available from: http://www.cdc.gov/nchs/hphome.htm [accessed on 5 October 

2009]. 

4. 

Public health action plan to prevent heart disease and stroke. Atlanta, GA: Centers for 

Disease Control and Prevention; 2008. Available from: http://www.cdc.gov/dhdsp/ 

library/action_plan/index.htm [accessed on 5 October 2009]. 

5. 

Centers for Disease Control and Prevention. Prevalence of no leisure-time physical activity – 

35 states and the District of Columbia, 1988–2002. MMWR Morb Mortal Wkly Rep. 

2004;53:82-6. PMID:14762333 

6. 

Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum 

cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994;308:367- 72. 

PMID:8043072 

7. 

Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood 

pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 

prospective studies. Lancet 2002;360:1903-13. PMID:12493255 doi:10.1016/S0140- 

6736(02)11911-8 

8. 

Bogers RP, Bemelmans WJ, Hoogenveen RT, Boshuizen HC, Woodward M, Knekt P, et al. 

Association of overweight with increased risk of coronary heart disease partly independent 

of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including 

more than 300 000 persons. Arch Intern Med 2007;167:1720-8. PMID:17846390 

doi:10.1001/archinte.167.16.1720 

9. 

Hunink MG, Goldman L, Tosteson AN, Mittleman MA, Goldman PA, Williams LW, et al. The 




recent decline in mortality from coronary heart disease, 1980-1990. The effect of secular 

trends in risk factors and treatment. JAMA 1997;277:535-42. PMID:9032159 

doi:10.1001/jama.277.7.535 

10. 

Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the 

decrease in mortality from coronary heart disease in the United States between 1980 and 

2000. N Engl J Med 2007;356:2388-98. PMID:17554120 doi:10.1056/NEJMsa053935 

11. 

Weinstein MC, O’Brien B, Hornberger J, Jackson J, Johannesson M, McCabe C, et al. 

Principles of good practice for decision analytic modeling in health-care evaluation: report of 

the ISPOR Task Force on Good Research Practices – Modeling Studies. Value Health 

2003;6:9-17. PMID:12535234 doi:10.1046/j.1524-4733.2003.00234.x 

12. 

Goldman L, Phillips KA, Coxson P, Goldman PA, Williams L, Hunink MG, et al. The effect of 

risk factor reductions between 1981 and 1990 on coronary heart disease incidence, 

prevalence, mortality and cost. J Am Coll Cardiol 2001;38:1012-7. PMID:11583874 

doi:10.1016/S0735-1097(01)01512-1 

13. 

Rose G. The strategy of preventive medicine. Oxford: Oxford University Press; 1992. 

14. 

Emberson J, Whincup P, Morris R, Walker M, Ebrahim S. Evaluating the impact of population 

and high-risk strategies for the primary prevention of cardiovascular disease. Eur Heart J 

2004;25:484-91. PMID:15039128 doi:10.1016/j.ehj.2003.11.012 Publication: Bulletin of the 

World Health Organization; Type: Policy and Practice Article DOI: 10.2471/BLT.08.057885 

15. 

McPherson K, Britton A, Causer L. Coronary heart disease: estimating the impact of changes 

in risk factors. London: National Heart Forum; 2002:1-60 

16. 

Capewell S, Beaglehole R, Seddon M, McMurray J. Explanation for the decline in coronary 

heart disease mortality in Auckland, New Zealand, between 1982 and 1993. Circulation 

2000;102:1511-6. PMID:11004141 

17. 

Unal B, Critchley JA, Capewell S. Explaining the decline in coronary heart disease mortality 

in England and Wales between 1981 and 2000. Circulation 2004;109:1101-7. 

PMID:14993137 doi:10.1161/01.CIR.0000118498.35499.B2 

18. 

Laatikainen T, Critchley J, Vartiainen E, Salomaa V, Ketonen M, Capewell S. Explaining the 

decline in coronary heart disease mortality in Finland between 1982 and 1997. Am J 

Epidemiol 2005;162:764-73. PMID:16150890 doi:10.1093/aje/kwi274 

19. 

Critchley J, Liu J, Zhao D, Wei W, Capewell S. Explaining the increase in coronary heart 

disease mortality in Beijing between 1984 and 1999. Circulation 2004;110:1236-44. 

PMID:15337690 doi:10.1161/01.CIR.0000140668.91896.AE 

20. 

Bots ML, Grobbee DE. Decline of coronary heart disease mortality in the Netherlands from 

1978 to 1985: contribution of medical care and changes over time in presence of major 

cardiovascular risk factors. J Cardiovasc Risk 1996;3:271-6. PMID:8863098 

doi:10.1097/00043798-199606000-00002 

21. 

Vartiainen E, Puska P, Pekkanen J, Tuomilehto J, Jousilahti P. Changes in risk factors explain 

changes in mortality from ischaemic heart disease in Finland. BMJ 1994;309:23-7. 

PMID:8044063 

22. 

Critchley JA, Capewell S. Substantial potential for reductions in coronary heart disease 

mortality in the UK through changes in risk factor levels. J Epidemiol Community Health 

2003;57:243-7. PMID:12646537 doi:10.1136/jech.57.4.243 

23. 

Unal B, Critchley JA, Capewell S. Small changes in UK cardiovascular risk factors could 

halve coronary heart disease mortality. J Clin Epidemiol 2005;58:733-40. PMID:15939226 

doi:10.1016/j.jclinepi.2004.09.015 

24. 

Stamler J, Stamler R, Neaton JD, Wentworth D, Daviglus ML, Garside D, et al. Low riskfactor 

profile and long-term cardiovascular and noncardiovascular mortality and life expectancy: 

findings for 5 large cohorts of young adult and middle-aged men and women. JAMA 

1999;282:2012-8. PMID:10591383 doi:10.1001/jama.282.21.2012 

25. 

Daviglus ML, Stamler J, Pirzada A, Yan LL, Garside DB, Liu K, et al. Favorable cardiovascular 

risk profile in young women and long-term risk of cardiovascular and all-cause mortality. 

JAMA 2004;292:1588-92. PMID:15467061 doi:10.1001/jama.292.13.1588 

26. 

Unal B, Critchley J, Capewell S. IMPACT, a validated comprehensive coronary heart disease 

model: overview & technical appendices. Liverpool: Liverpool University; 2007. Available 

from: http://www.liv.ac.uk/PublicHealth/sc/bua/impact.html [accessed on 5 October 2009]. 

27. 

Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially 

modifiable risk factors associated with myocardial infarction in 52 countries (the 

INTERHEART study): case-control study. Lancet 2004;364:937-52. PMID:15364185 

doi:10.1016/S0140-6736(04)17018-9 Publication: Bulletin of the World Health Organization; 

Type: Policy and Practice Article DOI: 10.2471/BLT.08.057885 

28. 

Briggs A, Sculpher M, Buxton M. Uncertainty in the economic evaluation of health care 

technologies: the role of sensitivity analysis. Health Econ 1994;3:95-104. PMID:8044216 

doi:10.1002/hec.4730030206 

29. 

Naidoo B, Thorogood M, McPherson K, Gunning-Schepers LJ. Modelling the effects of 

increased physical activity on coronary heart disease in England and Wales. J Epidemiol 

Community Health 1997;51:144-50. PMID:9196643 doi:10.1136/jech.51.2.144 

30. 

Capewell S. Predicting future coronary heart disease deaths in Finland and elsewhere. Int J 

Epidemiol 2006;35:1253-4. PMID:16847019 doi:10.1093/ije/dyl158 

31. 

Capewell S, Unal B, Critchley JA, McMurray JJ. Over 20 000 avoidable coronary deaths in 

England and Wales in 2000: the failure to give effective treatments to many eligible 

patients. Heart 2006;92:521-3. PMID:16537767 doi:10.1136/hrt.2004.053645 

32. 

Daviglus ML, Liu K. Today’s agenda: we must focus on achieving favorable levels of all risk 

factors simultaneously. Arch Intern Med 2004;164:2086-7. PMID:15505120 

doi:10.1001/archinte.164.19.2086 

33. 

Hozawa A, Folsom AR, Sharrett R, Chambless LE. Absolute and attributable risks of 

cardiovascular disease incidence in relation to optimal and borderline risk factors: 

comparison of African American with white subjects - Atherosclerosis Risk in Communities 

Study. Arch Intern Med 2007;167:573-9. PMID:17389288 doi:10.1001/archinte.167.6.573 

34. 

Manuel DG, Kwong K, Tanuseputro P, Lim J, Mustard CA, Anderson GM, et al. Effectiveness 

and efficiency of different guidelines on statin treatment for preventing deaths from 

coronary heart disease: modelling study. BMJ 2006;332:1419-24. PMID:16737980 

doi:10.1136/bmj.38849.487546.DE 

35. 

Capewell S. Will screening individuals at high risk of cardiovascular events deliver large 

benefits? No. BMJ 2008;337:a1395 PMID:18755771 doi:10.1136/bmj.a1395 

36. 

Dowse GK, Gareeboo H, Alberti KG, Zimmet P, Tuomilehto J, Purran A, et al. Changes in 

population cholesterol concentrations and other cardiovascular risk factor levels after five 

years of the non-communicable disease intervention programme in Mauritius. Mauritius 

Non-communicable Disease Study Group. BMJ 1995;311:1255-9. PMID:7496233 

37. 

Carroll MD, Lacher DA, Sorlie PD, Cleeman JI, Gordon DJ, Wolz M, et al. Trends in serum 

lipids and lipoproteins of adults, 1960. JAMA 2005;294:1773-81. PMID:16219880 

doi:10.1001/jama.294.14.1773 

38. 

Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, American Heart Association 

Nutrition Committee, et al. Diet and lifestyle recommendations revision 2006: a scientific 

statement from the AHA Nutrition Committee. Circulation 2006;114:82-96. PMID:16785338 

doi:10.1161/CIRCULATIONAHA.106.176158 

39. 

Framework Convention for Tobacco Control [internet site]. Geneva: World Health 

Organization; 2004. Available from: http://www.who.int/fctc/en/ [accessed on 5 October 

2009]. 

40. 

Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with 

declines in cigarette consumption and mortality from heart disease. N Engl J Med 

2000;343:1772-7. PMID:11114317 doi:10.1056/NEJM200012143432406 Publication: 

Bulletin of the World Health Organization; Type: Policy and Practice Article DOI: 

10.2471/BLT.08.057885 

41. 

Pell JP, Haw S, Cobbe S, Newby DE, Pell AC, Fischbacher C, et al. Smoke-free legislation and 

hospitalizations for acute coronary syndrome. N Engl J Med 2008;359:482-91. 

PMID:18669427 doi:10.1056/NEJMsa0706740 

42. 

Tunstall-Pedoe H, Connaghan J, Woodward M, Tolonen H, Kuulasmaa K. Pattern of declining 

blood pressure across replicate population surveys of the WHO MONICA project, mid-1980s 

to mid-1990s, and the role of medication. BMJ 2006;332:629-35. PMID:16531419 

doi:10.1136/bmj.38753.779005.BE 

43. 

He FJ, MacGregor GA. How far should salt intake be reduced? Hypertension 2003;42:1093- 

9. PMID:14610100 doi:10.1161/01.HYP.0000102864.05174.E8 

44. 

Havas S, Roccella EJ, Lenfant C. Reducing the public health burden from elevated blood 

pressure levels in the United States by lowering intake of dietary sodium. Am J Public 

Health 2004;94:19-22. PMID:14713688 doi:10.2105/AJPH.94.1.19 

45. 

Dietary guidelines for Americans. Washington, DC: United States Department of Health and 

Human Services / Department of Agriculture; 2005. 

46. 

Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. 

Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl 

J Med 2002;346:393-403. PMID:11832527 doi:10.1056/NEJMoa012512 

47. 

Jain A. Treating obesity in individuals and populations. BMJ 2005;331:1387-90. 

PMID:16339251 doi:10.1136/bmj.331.7529.1387 

48. 

Craig CL, Russell SJ, Cameron C, Bauman A. Twenty-year trends in physical activity among 

Canadian adults. Can J Public Health 2004;95:59-63. PMID:14768744 

49. 

Tudor-Smith C, Nutbeam D, Moore L, Catford J. Effects of the Heartbeat Wales programme 

over five years on behavioural risks for cardiovascular disease: quasiexperimental 

comparison of results from Wales and a matched reference area. BMJ 1998;316:818-22. 

PMID:9549451 

50. 

Unal B, Critchley J, Fidan D, Capewell S. Life-years gained from modern cardiological 

treatments and population risk factor changes in England and Wales, 1981–2000. Am J 

Public Health 2005;95:103-8. PMID:15623868 doi:10.2105/AJPH.2003.029579 

51. 

Brotman DJ, Walker E, Lauer MS, O’Brian RG. In search of fewer independent risk factors. 

Arch Intern Med 2005;165:138-45. doi:10.1001/archinte.165.2.138 


Innovation and clinical specialities: oncology 

The breast service psychosocial 

model of care project 

ARTICLE BY LAUREN K WILLIAMS PhD 

Research Fellow, Clinical Research Department, Melbourne IVF and The Royal Women’s Hospital, East Melbourne, Victoria, Australia 

G BRUCE MANN MB BS, PhD, FRACS 

Professor, University of Melbourne, and Director of The Breast Service, Royal Melbourne Hospital and Royal Women’s Hospital, 

Parkville, Victoria, Australia 

Objective: It has been consistently demonstrated that many women with breast disease will experience psychosocial 

distress at some stage along the patient journey. Psychosocial care has recently gained more prominence and is 

increasingly recognised as an important aspect of care offered to patients with breast cancer. The purpose of this project 

was to develop a model that improved the way psychosocial services were provided to patients. The aim of this paper is to 

describe the process in developing this psychosocial model of care for patients with breast disease. 

Methods: Using in-depth semi-structured interviews with a sample of patients and staff, we examined psychosocial 

concerns experienced by breast patients and the factors associated with the effective assessment and delivery of 

psychosocial care. The project was approved by the Royal Women’s hospital ethics secretariat as a quality assurance 

project. 

Results: An inductive analysis of staff responses indicated that a standardised screening and referral pathway was needed 

in a context of well defined staff roles and a multidisciplinary team environment. An inductive analysis of patient responses 

indicated that psychosocial concerns were common, but varied, and a tailored approach to the provision of psychosocial 

care was warranted. 

Discussion: In line with these findings, a standardised assessment and referral pathway was developed for The Breast 

Service that may be extended for use in other clinical settings and tumour streams. 

Over 12 000 women are diagnosed with breast cancer in 

Australia each year. 1 Unsurprisingly, psychosocial distress 

plays a significant role in the journey experienced by 

women diagnosed with this disease. Many of the common 

psychosocial concerns of women with breast cancer include body 

image disruption, sexual dysfunction, treatment-related anxieties, 

depression, marital/partner communication and relationship 

difficulties, and existential concerns regarding mortality. 2-4 Although 

many women will encounter and manage some degree of 

psychosocial distress following diagnosis, it is estimated that as 

many as 30% of women will experience episodes of persistent 

psychosocial distress that will interfere with their ability to cope 

with cancer treatment and life in general. 2,4 

Psychosocial interventions such as support from a nurse/breast 

care nurse, exercise, telephone counselling, computer/online 

support, psychological and psychiatric care and social supports 

have all been found to improve the psychosocial status of women 

diagnosed with breast cancer. 5-7 As a result, the clinical practice 

guidelines from the National Health and Medical Research Council 

of Australia for the psychosocial care of adults with cancer 3 

highlight the need for further research regarding “strategies to 

improve the detection of psychological difficulties in people with 

cancer” and “optimal methods for psychosocial referral and 

practice strategies to improve uptake”. Enhanced knowledge 

about the best way to detect and respond to patients’ 

psychosocial needs is vital in empowering and equipping health 

professionals with the necessary skills and resources to help 

patients with the range of psychosocial issues that arise along the 

breast cancer treatment continuum. 

Setting 

Recently, the Royal Women’s Hospital and Royal Melbourne 

Hospital breast services merged to form The Breast Service in an 

attempt to connect existing resources and provide a more 

comprehensive breast cancer service. Strategies to detect and 

respond to patients’ psychosocial needs were identified as a key 

priority area for The Breast Service. Before the merging of 

services, psychosocial care coordination differed between sites 



Box 1: Issues with the psychological screening tool identified by staff and patients 

Issues identified by The Breast Service staff 

■ Staff not accessing the completed supportive care tool (SCT) in patient’s medical file 

■ More specialised tools needed for specific areas of concern 

■ Not specific to breast cancer/some questions not relevant 

■ Only used once. Supplement testing/brief version needed at different stages of the disease 

■ Some questions not included to screen for identified psychosocial concern (eg, body image) 

■ Absence of criteria for referral (eg, if patient answers “yes” to certain questions what is the process for referral? Criteria needed to 

facilitate consistency between clinicians) 

■ Questions regarding patient strengths to use for possible referral/support 

■ Section needed for patient comments 

■ Dichotomous responses (eg, yes/no) create limitations 

■ Area needed to record referral details/outcome. Possibly useful to combine details from referral form to SCT. Expansion of referral 

options 

■ Unclear psychometric validity 

■ Does not assess all risk factors 

Issues identified by The Breast Service patients 

■ Include questions that ask women whether they wanted to be linked in with a group 

■ Tailor SCT to patient’s individual situation given that some questions are not relevant 

■ Administer the SCT later given that concerns are greater after surgery (it is generally administered at preadmission clinic [PAC]) 

■ Administer the SCT twice, rather than once at PAC. Some experience concerns at later stages than before surgery and others 

don’t recognise their issues until later stages of the disease 

■ Include body image questions 

and was largely managed by the breast care nurses. Previous 

research has highlighted that a range of health professionals is 

optimal in assessing and managing the psychosocial needs of 

women diagnosed with breast cancer and to support breast care 

nurses who, in some cases, are not trained in making 

psychosocial assessments and referrals for patients. Furthermore, 

before the merging of services, the screening tool used to detect 

psychosocial concerns (entitled supportive care tool [SCT]) was an 

amalgamation of items from instruments utilised in other health 

care settings. Before the development of the current project, the 

SCT had not been evaluated since it was implemented into The 

Breast Service. A psychosocial working group and steering 

committee was developed to address challenges and 

opportunities arising from the merging of the two services, and 

involved clinicians from the departments of psychology, psychiatry, 

medicine, nursing, social work, pastoral care, women’s services 

and music therapy. A consumer representative was included and 

a project worker appointed to coordinate and execute the project 

objectives. 

Objectives 

The aim of the psychosocial model of care project was to develop 

a standardised way of screening for psychosocial distress and 

referring patients to the most appropriate clinician(s) and supports. 

The first objective of the project was to provide a reflection of the 

strengths and weaknesses of the current model of psychosocial 

care from relevant clinicians and to generate ideas on the most 

effective way to merge and coordinate existing services. The 

second objective was to provide a reflection from consumers 

regarding their psychosocial needs, the level of psychosocial 

support they received and their perceptions and opinions on the 

structure and delivery of the current psychosocial model of care 

from The Breast Service. 

Consultation with health professionals 

Methods 

A total of nineteen staff members who had (or wanted to have) a 

role in the screening, assessment and treatment of patients were 

interviewed by the project worker. Staff were recruited from social 

work, pastoral care, psychology, psychiatry, medicine, nursing and 

community support services (eg, BreaCan). A semi-structured 

interview guide was developed which focussed on (a) the method 

for screening and referring patients, (b) the role of different staff in 

providing psychosocial care, and (c) issues, barriers or concerns 

with the provision of psychosocial care. Data were analysed 

qualitatively using inductive thematic analysis. The project was 

approved by the Royal Women’s hospital ethics secretariat as a 

quality assurance project. 

Results 

It was found that the existing method of screening for 

psychosocial needs of patients with breast cancer relied heavily on 

the breast care nurses. Completion of a screening tool by patients 

at the time of initial diagnosis and surgical treatment was viewed 

as beneficial for identifying and recording psychosocial concerns, 

however the screening process relied on breast care nurses to 

administer the tool, evaluate the results and generate referrals at 

their discretion. In addition, The Breast Service staff identified 

several issues with the SCT (Box 1). Although the role of breast 

care nurses in screening psychosocial needs was viewed by most 

as valuable, it was commonly agreed that psychosocial 

assessment from additional health professionals would enhance 

the validity of the screening procedure. In addition, it was 

suggested that periodic rescreening was required to identify those 



with particular psychosocial needs that emerge subsequent to 

initial diagnosis and surgery. 

Consultations with patients attending The Breast Service 

The second step of the project was to consult patients about their 

psychosocial concerns and supports they received from The 

Breast Service staff. 

Methods 

A total of thirteen women diagnosed with breast cancer attending 

The Breast Service participated in either a focus group or 

individual interview. The age of participants ranged from 33 to 87 

years and four women were from non-English speaking 

backgrounds. A semi-structured interview guide which contained 

open-ended questions that assessed patients’ psychosocial 

concerns and their experience with The Breast Service 

(psychosocial screening and referral procedures) was developed. 

Patients were recruited from a list of all patients that had 

attended/were attending The Breast Service for the last 6 months. 

Interviews were conducted at The Royal Women’s Hospital in a 

private room and were later transcribed to facilitate coding and 

analysis. Data were analysed qualitatively using inductive thematic 

analysis. 

Results 

The most commonly reported psychological concerns were 

anxiety and depression. Anxiety was reportedly heightened at 

diagnosis, between appointments while waiting for results, before 

chemotherapy and in social situations for those with visual signs of 

cancer, such as hair loss. Patients reported feeling depressed 

during treatment, particularly those patients having chemotherapy. 

Other reported psychosocial concerns included body image 

concerns, relationship issues with their partners, family and 

friends, and concerns with mortality, survival and recurrence. Eight 

of 13 women interviewed (61.5%) had completed the screening 

tool, with most reporting no issues or distress in answering the 

questions. Specific comments are shown in Box 1. Psychosocial 

support accessed by patients varied. Some women reported 

accessing counsellors, psychologists and social workers. These 

services were offered through The Royal Melbourne Hospital or 

privately. Other women reported that they felt comfortable 

knowing that these supports were available, however were not 

ready or did not feel they would be able to assist them with their 

concerns. These women relied on community, family, peer and 

individual supports. Some women felt uneasy or awkward about 

attending group settings with strangers and would prefer 

alternative supports such as email, telephone or a casual 

unstructured group setting. These results suggest the individuality 

of women’s support needs and the need for a wide range or 

services that can address different concerns at different stages of 

the disease. 

The Breast Service Model of psychosocial care 

Based on the outcomes of this project, a revised model for the 

assessment and delivery of psychosocial care was developed and 

is currently being implemented. As highlighted in Box 2, and 

consistent with the previous pathway, at the first suitable visit 

(preferably soon after diagnosis), the breast care nurse uses a 

screening tool to identify patients who are potentially in need of 

more extensive assessment and intervention. The new screening 

tool combines a risk factor checklist, i a distress thermometer 

(0–10 ranking of distress) and a “yes/no” checklist of 

items/concerns; which differs from the original screening tool that 

relied solely on the latter. The patient is then discussed at a newly 

developed multidisciplinary psychosocial team meeting where a 

referral is made if appropriate. Review of patients and subsequent 

referrals also occurs in this forum. Given that some patients 

reported experiencing psychological concerns such as anxiety 

and depression and body image issues, referral options were 

extended to include a clinical psychologist, psychiatrist and a 

sexual counsellor. A music therapist is also available to assist 

patients. 

Unlike previously, where the screening tool was only 

administered once at initial presentation, the distress thermometer 

and checklist is administered again during and after definitive 

treatment. Re-presentation of the same patient occurs if significant 

distress or psychosocial need subsequently appears. Accurate 

execution of the revised pathway is overseen by the director of 

The Breast Service and staff attending the multidisciplinary 

meeting. Furthermore, patient results (completed screening tool, 

referrals forms, and related progress notes) are now inserted into 

the patient’s medical file to ensure accessibility by all relevant 

health professionals. 

Limitations and discussion 

One of the main challenges of this project was to build a team of 

clinicians with adequate time and resources committed to 

assisting with the project. The development of a working group, 

steering committee and mutually agreed project plan was the 

fundamental key to initiating this process. Staff provided the 

project worker with background information, details of current 

psychosocial practice and feasibility of new ideas. Another 

challenge was delegating and executing tasks, both in the 

development and implementation stages of the project. 

Clarification was particularly needed around “who is doing what 

and how”. These decisions are best made in the working group 

meetings, using existing staff and therefore reducing the need for 

additional resources. Furthermore, it proved pivotal to the 

cohesion and sustainability of the working/steering group that after 

each fundamental stage of the project (eg, focus groups) the 

execution of the findings was communicated to all relevant staff in 

an interactive forum (eg, email reports, meetings, in-services or 

workshops). 

Conclusion 

In summary, the psychosocial model of care project has 

transformed the way psychosocial care is provided to patients 

attending The Breast Service. We have implemented a 

standardised screening, assessment and referral process and a 

multidisciplinary team to provide a service of psychosocial care to 

all patients. Decisions about assessment, referrals and treatment 

no longer rely solely on the breast care nurse. Instead, 

collaborative recommendations are made for the patient in a forum 

i 

National Breast and Ovarian Cancer Centre and National Health and Medical 

Research Council guidelines for the psychosocial care of patients with cancer 

recommends assessing these risk factors to alert practitioners about certain subgroups 

of potentially “at-risk” patients. 



Box 2: The Breast Service Psychosocial model of care 

Step 1 First suitable visit 

Identify high risk factors. 

(The revised assessment tool will 

allow breast care nurses 

[BCNs] to document patient 

risk factors 

Step 2 Assess level of distress 

Step 3 Assess specific psychosocial 

concerns 

Risk factor check-list 

Is/has the patient: 

■ Younger 

■ Single, separated, divorced, widowed 

■ Living alone 

■ Children younger than 21 years 

■ Experiencing economic adversity 

■ A real or perceived lack of social support 

■ Poor marital or family functioning 

■ Had a history of psychiatric problems 

■ Had stressful life events 

■ Had a history of alcohol and/or substance abuse 

■ Been diagnosed with cancer 

■ In the advanced stages of the disease 

■ Received a poor prognosis 

■ Having/had treatment side effects greater than most 

■ Experiencing lymphoedema 

■ Experiencing chronic pain and/or having difficulties managing pain 

■ Significantly fatigued 

Does the patient appear or is the patient highly distressed/anxious? 

BCNs to distribute “distress thermometer” whereby patients will rank their 

perceived level of distress from 0 (no distress) to 10 (extreme distress) 

BCNs will distribute psychosocial checklist to patients where they can 

indicate (yes/no) whether they have experienced psychosocial distress 

on a range of dimensions (eg, depression, anxiety, body image, sexual health etc) 

Step 4 Psychosocial Assessment/ Patient is not Patient is Patient is considered high risk 

interview with BCN. BCN requires considered high risk considered high and is distressed 

expands on relevant areas and is not distressed risk and is urgent/immediate action 

identified by patient in the 

distressed and 

screening process (distress 

requires action 

thermometer and checklist) 

(not immediate) 

and records outcome on the 

screening forms. 

Patient completes the A referral is made Clinician pages mental health 

distress thermometer and the patient is service, social work or pastoral 

and checklist at next discussed at the care for urgent referral. A 

visit or as appropriate next Psychosocial referral is made using the 

Multidisciplinary referral form and the patient is 

meeting (PMDM) discussed at the next PMDM 

Step 5 PMDM 

Discuss patient’s risk factors, assessment of distress, BCN evaluation 

and checklist responses. Multidisciplinary referrals are made where 

applicable, referral outcomes are discussed 

Step 6 Psychosocial screening may 

be conducted at: 

1. Notification of diagnosis 

2. Post-surgery check-up 

3. During chemotherapy 

4. At the end of treatment 

5. 12-month follow-up Go to step 2 



that can ensure adequate follow-up and execution of accurate and 

targeted referrals. An evaluation of the revised process is planned. 

It is envisaged that these findings could assist researchers and 

clinicians with the process of developing a psychosocial 

assessment and referral pathway. The psychosocial model of care 

can also be adapted and utilised in other clinical settings where 

psychosocial distress and morbidity is likely. The psychosocial 

model of care is already being implemented in the gynaecological 

service and ward nurses are being trained in administering the 

screening tool. As the results from this quality assurance project 

suggest, strategies for detecting and responding to the 

psychosocial needs of patients is a vital and achievable 

component to the provision of health care. ❏ 


This project was generously funded by Western and Central 

Melbourne Integrated Cancer Service (WCMICS). The Breast 

Service staff would like to thank the WCMICS for its support in 

enabling the improvement of the quality of psychosocial care for 

women with breast cancer. The psychosocial model of care project 

team would also like to thank staff from the Royal Women’s Hospital 

and The Royal Melbourne Hospital who participated in the “health 

professionals” consultation phase and women attending The 

Breast Service who generously donated their time and thoughts in 

the focus groups and interviews. 

References 

1. 

Australian Institute of Health and Welfare and National Breast Cancer Centre. Breast cancer 

in Australia: an overview, 2006. Canberra: AIHW, 2006. (AIHW Cat. No. CAN 29.) 

2. 

Institute of Medicine. Meeting psychosocial needs of women with breast cancer [report 

brief]. Washington, DC: National Academies Press, 2004: 1-8. 

3. 

National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice 

guidelines for the psychosocial care of adults with cancer. Sydney: National Breast Cancer 

Centre, 2003. 

4. 

Schou I, Ekeberg O, Sandvik L, et al. Multiple predictors of health-related quality of life in 

early stage breast cancer. Data from a year follow-up study compared with the general 

population. Qual Life Res 2005; 14: 1813-23. 

5. 

Badger T, Segrin C, Dorros SM, et al. Depression and anxiety in women with breast cancer 

and their partners. Nurs Res 2007; 56: 44-53. 

6. 

McArdle JMC, George WD, McArdle CS, et al. Psychological support for patients undergoing 

breast cancer surgery: a randomised study. BMJ 1996; 312: 813-6. 

7. 

Shaw BR, McTavish F, Hawkins R, et al. Experiences of women with breast cancer: 

exchanging social support over the CHESS computer network. J Health Commun 2000; 5: 

135-59. 

Competing interests 

The authors declare that they have no competing interests. 

Article originally appeared in Australian Health Review 

(http://www.aushealthreview.com.au) and is reproduced with 

permission from the Australian Healthcare Association 

(www.aushealthcare.com.au) 


Innovations and clinical specialities: oncology 

Supporting cancer control for 

indigenous Australians: 

initiatives and challenges for 

Cancer Councils 

ARTICLE BY SHAOULI SHAHID MA, MSS PHD 

Student 

KERRI R BECKMANN MPH, BSC 

Senior Research Scientist Research and Information Science, The Cancer Council South Australia 

AND SANDRA C THOMPSON PHD, FAFPHM, MPH 

Associate Professor Centre for International Health, Curtin University of Technology, Perth, WA 

As in other developed countries, the Australian population is ageing, and cancer rates increase with age. Despite their 

substantially lower life expectancy, Indigenous Australians are also experiencing concerning cancer statistics, characterised by 

increasing rates, later diagnosis, higher mortality, and lower participation in screening than the non-Indigenous population. 

Eighteen months after the first national Indigenous Cancer Control Forum, this environmental scan within the statebased Cancer 

Councils was undertaken to map activities in service provision in Indigenous cancer control with a view to sharing the lessons 

learned. The findings show that although most of the organizations had tried to work with Indigenous communities on cancer 

issues, there have been difficulties in building and sustaining relationships with Indigenous organizations. Lack of having 

Indigenous staff internally, few Indigenous-specific resources, and few planned, long-term commitments were some of the 

major impediments. Some of these limitations can easily be overcome by building and improving regional or local partnerships, 

providing cultural awareness training to internal staff, and by building the capacity of Indigenous organizations. Health 

promotion projects of the Cancer Councils directed at Indigenous people could be more effectively implemented with such 

considerations. 

What is known about the topic? For many years cancer was not considered a high priority issue for Indigenous Australians as a 

consequence of social and other health issues. Cancer incidence and death rates of Indigenous Australians have been unclear 

as there has been limited epidemiological information and misclassification of Indigenous status. It is now evident that the 

pattern of cancer differs for Indigenous Australians, and Indigenous people tend to be diagnosed later, have poorer 

participation in treatment and a higher mortality rate for any equivalent stage of diagnosis. 

What does this paper add? This paper presents a snapshot of the staffing, projects, programmes and activities of the state 

Cancer Councils in early 2006 in terms of efforts to progress cancer control issues focussing on Indigenous Australians. Most 

successful initiatives began by establishing a relationship and working over the longer term to sustain programme activity. 

What are the implications for practitioners? Insights from the analysis of progress in the cancer field are relevant and 

applicable to practitioners in other areas of health where mainstream services have a role to improve the health of Indigenous 

communities. 

The number of recorded cancer deaths in Australia continues 

to increase, attributed in part to the increase in cancer 

incidence that occurs in an ageing and an expanding 

population. 1,2 Until recently, cancer was seldom identified as a 

priority health issue for Aboriginal and Torres Strait Islander 

(hereafter Indigenous) Australians. i, 3 The immediate health and 

welfare problems of Indigenous Australians across the lifecourse 

are well documented, 4-6 and these may have distracted attention 

from the fact that cancer has become one of the major causes of 

death for these people. Interest about cancer among Indigenous 

populations may also be affected by their lower incidence of many 

cancers and their shorter life expectancy. Moreover, cancer rates 

in Indigenous Australians may under-represent the real burden 

because of misclassification and under-ascertainment of 

Indigenous status. 7-9 

i 

Australia has two groups of Indigenous populations: Aboriginal, and Torres Strait 

Islanders. In this paper, we will use the term “Indigenous” to refer to both Aboriginal 

and Torres Strait Islander peoples. 



Nevertheless, available data show that Indigenous Australians 

are experiencing an increasing rate for some cancers. 3 For almost 

all cancers, they experience later diagnosis, lower 5-year survival 

and a higher mortality rate than non-Indigenous Australians. 10 

Indigenous women have lower participation in mammography and 

Pap smear screening than non-Indigenous women. 11,12 It has also 

been reported that the overall response rate was significantly 

lower for Indigenous people than the general population in the 

Bowel Cancer Screening Pilot Program that ran between 

November 2002 and June 2004 at three sites in Australia. 13 

Moreover, while the last two decades have seen a 30% reduction 

in cancer mortality rates in Australia, there has been little impact 

upon Indigenous cancer mortality. 14 The need to prioritise cancer 

prevention and control was recognised in the National Indigenous 

and Torres Strait Islander Health Strategy 2001, where cancer was 

documented as one of three major chronic diseases for 

Indigenous Australians. 15 

The first national forum to discuss Indigenous cancer issues, 

held in Darwin in August 2004, highlighted various gaps that exist 

around responding appropriately to these issues. Many strategies 

were proposed to improve their poorer cancer outcomes. 

Increased government funding, boosting research on cancer 

among Indigenous Australians by enhancing their ownership over 

the data, and involving them in partnership with non-Indigenous 

health professionals to ensure appropriate service design and 

delivery mechanisms were a few of the significant 

recommendations. At the conclusion of the forum, the peak nongovernment 

organizations providing advocacy for prevention and 

care for cancer in Australia. 

The Cancer Council Australia and its statebased affiliates, 

committed to factoring Indigenous issues into their policy 

development and advocacy for cancer prevention and care. 14 This 

paper summarises the findings of an environmental scan of current 

and past programmes and practice in Indigenous cancer control 

by state and territory member organizations of The Cancer Council 

Australia. It was primarily undertaken to inform the deliberations of 

The Cancer Council Western Australia (TCCWA) on its potential 

role and contribution in improving cancer-related services for 

Indigenous people in WA. Environmental scanning is a method 

most commonly used in business but is quite popular in the health 

care sector around the world, 16-18 and is used to identify emerging 

issues within the broader economic and political environment. 19 It 

is similar to situation analysis in which a review is undertaken of 

health strategies and policies, institutional support systems, 

programmes and interventions with the aim of strengthening 

health reform and health systems. It differs from audits which 

generally evaluate performance and are aimed at ascertaining the 

validity and reliability of information as part of quality control 

processes. Morrison argues that environmental scanning is a 

method that enables decision makers both to understand the 

external environment and the interconnections of its various 

sectors and to translate this understanding into an institution’s 

planning and decision-making processes. 20 The advantage of 

environmental scanning for organisational leaders is that knowing 

both the internal and external environment in which the 

organisation operates is helpful in planning their future course of 

action. 21 

The scan was undertaken to identify various Indigenous-specific 

programmes and experiences of the Cancer Councils of Australia 

12–15 months following the Darwin forum. This paper highlights 

the key issues, learning, successes and limitations of related 

initiatives that have been undertaken by the state Cancer 

Councils. 

Methods 

Environmental scanning was agreed to be a suitable method for 

learning about how a range of organizations across the sector had 

approached supporting Indigenous cancer control approaches 

and gathering information about successful initiatives and efforts 

that had been less productive, and this approach was accepted 

by a Steering Committee and approved by the Curtin Health 

Research Ethics Committee. 

An initial approach letter was mailed to the Chief Executive 

Officers/Directors (CEOs) of all the Cancer Councils, outlining the 

background to the survey. They were also requested to nominate 

appropriate staff members who could be interviewed about their 

organizations’ past or present initiatives to improve Indigenous 

engagement with cancer issues and to pass the background 

information about the study on to those they nominated. When the 

individuals were contacted and nominated others, these additional 

nominees were also interviewed if available and willing. A copy of 

the letter sent to their CEO was provided to the participants 

beforehand. 

Semi-structured interviews, either face-to-face or by telephone, 

were undertaken with the key nominated staff (Indigenous and 

non-Indigenous). The interview was based upon a theme list 

developed following a review of relevant literature and discussion 

within the research team. The list was also discussed with 

Indigenous colleagues and forwarded to a Steering Committee 

established to oversee the project of which this scan was a 

component. Key areas focusing on Indigenous Australians that 

were considered during the interviews, included: cancer 

prevention and education; cancer support services for Indigenous 

health organizations; healthcare delivery (workforce/access to 

healthcare services); research; advocacy/policy and human 

resources and any cross-organisational initiatives. Interviews were 

taped with the permission of participants, and the responses were 

coded following the key themes of the interview schedule. 

Thematic analysis was undertaken manually, in which the efforts 

and experiences of each Cancer Council were recorded against 

the major service areas. 

Staff from The Cancer Councils of the Australian Capital 

Territory, Tasmania, Victoria, New South Wales and the Cancer 

Foundation of Queensland participated in telephone interviews. 

Information was collected from staff at the Cancer Councils of 

Western Australia and South Australia through face-to-face 

interviews. Before submission of this article for publication, it was 

circulated to the CEOs of all participating Cancer Councils, giving 

them the opportunity to make additions or corrections, and 

appropriately represent their organisation, and suggested 

amendments were incorporated. 

Findings from the scan 

Most interviewees indicated that their organisation had tried to 

work with Indigenous communities on cancer-related issues. 

Working in partnership with Indigenous organizations was seen as 

important, and perhaps more effective than establishing 

Indigenous-specific positions within the organisation. However, a 



Jurisdiction 

ACT NSW Qld SA Tas Vic WA 

Organisational 

Indigenous person employed No Not No No No Yes No 

current 

Position with specific Indigenous No No No Yes (0.2 FTE)* No Yes No 

focus 

Cultural awareness training No Yes Yes No No Voluntary No 

Specific Indigenous action plan No No Recent No No Tobacco No 

Cervical 

screening 

Indigenous person on board No No No No No No No 

Indigenous representation on 

working parties No Yes No No No Yes No 

Links with ACCHOs Strong Beginning No Yes No Yes Ad hoc 

Specific programs 

Cancer awareness/health Yes Yes Yes Yes No Yes Yes 

promotion at Indigenous events 

Tobacco control Sustained Yes Yes Yes Sustained Yes 

Cervical screening Limited Yes Funds 

VAHS + 

Breast cancer awareness Ad hoc Ad hoc 

Aboriginal health worker training Yes Yes Yes 

Cancer support and care Yes For women 

Speakers No Yes No 

Indigenous-focussed resources Limited Limited Yes Limited Limited Yes Beginning 

Data on Indigenous cancer No Yes Beginning Yes No Yes Yes 

statistics 

* A non-Indigenous person spends 1 day a week on Indigenous cancer issue. ACCHOs=Aboriginal controlled community health 

organisations. 

Figure 1: Summary of progress in organisational and programme initiatives for indigenous cancer control by participating jurisdictional 

Cancer Councils, March 2006 

number of respondents noted the difficulty of building and 

sustaining relationships with Indigenous health agencies because 

they were under-resourced to respond and cancer is not 

prioritised among many competing social and health issues. Key 

findings related to Indigenous cancer control are summarised in 

the Box. Further details are reported according to core functional 

areas. 

Education and training 

Capacity building within the Indigenous health sector was 

identified as a priority area, in which respondents believed Cancer 

Councils could play an important supportive and advocacy role. 

Some success was reported in running training programmes with 

Aboriginal Health Workers (AHWs). The most promising example 

was initiated by The Queensland Cancer Fund (QCF). Based upon 

the priorities identified through consulting Indigenous groups and 

other key stakeholders, a cancer care course was developed for 

AHWs with assistance from an Indigenous advisory panel in 

developing the course content. The five-day programme 

introduced various aspects of cancer treatment and care, and 

provided site visits to various cancer support services. Overall, it 

was felt the course provided a good overview for the AHWs on the 

rationale and practical aspects of cancer treatment and insight into 

what patients go through during treatment. Scholarships were 

provided to 14 health workers from across Queensland to attend 

the first course, and this helped with the development of networks 

between AHWs and cancer service providers. Indigenous 

participants were generally identified through the regional officers 

of the QCF and contact with Indigenous communities. The 

desirability of oneto- one follow-up and support after training, 

utilising regional officers, was emphasised. The QCF has also 

trialled a less intensive version of education, for example, by 

adapting a mainstream 2- day training programme for community 

speakers around prevention and awareness of cancer for delivery 

to AHWs in northern Queensland. A small number of volunteer 

Indigenous speakers were trained through this programme to 

increase cancer awareness in their local communities. Cancer 

Councils in some other jurisdictions have also tried to arrange 

training programmes with AHWs, although some reported 

receiving a low level of interest from the stakeholders. TCCWA 



regularly contributes to teaching around cancer within 

metropolitan-based AHW training. Others, in partnership with 

Indigenous Community Controlled Health Organizations in their 

areas, have begun planning to incorporate cancer awareness 

into AHW training, but not all discussions have yet resulted in 

established commitment. The Cancer Council Victoria (TCCV) 

has, since 2001, been delivering training on cancer, screening 

and cervical cancer to AHWs undertaking the Certificate 4 in 

Women’s and Babies’ health which is delivered by the Victorian 

Aboriginal Community Controlled Health Organisation. The 

Cancer Council New South Wales (TCCNSW) had organised 

one-day training workshops for AHWs covering basic 

information about cancer biology, prevention, early detection, 

treatment and end of life which were jointly delivered by two 

Aboriginal consultants. However, the workshops have not been 

systematically and regularly conducted. The organisation now 

proposed to develop a more sustainable, organised programme 

with regional Aboriginal Health Services (AHSs) interested in this 

approach. Implementation may occur by extending the 1-day 

training workshop to 2 days, and shifting the focus to include 

more practical issues related to cancer care. Lack of availability 

of Indigenous-specific resources was mentioned as a barrier to 

education about cancer. TCCV has supported development of 

many Indigenous-friendly resources addressing smoking 

cessation and cervical screening. Respondents were also aware 

of resources in the process of development by other 

organizations such as The Centre for Excellence in Indigenous 

Tobacco Control, and felt that specific resources would be 

helpful in address Indigenous needs. It was considered 

important to develop educational and outreach materials that 

included artwork, pictures, role models and/or stories resonating 

culturally with the programme’s target population. It was also 

stressed that any resources produced must be appropriately 

used, because in some instances, good resources remain underutilised 

as a result of inadequate promotion, poor distribution or 

inadequate staff training in their appropriate use. Although there 

was recognition that resources designed in another jurisdiction 

were not always suitable and relevant elsewhere, some 

respondents noted a lack of capacity within their organizations in 

adapting these or developing new resources. 

Education of cancer staff about indigenous people 

Training and capacity building are not only necessary for AHWs 

and community members. Respondents acknowledged the need 

for awareness of Indigenous culture, cultural differences and 

beliefs to be taught and understood among the mainstream health 

service providers. The QCF runs cultural awareness training for 

staff twice a year, with training provided by the Department of 

Health and delivered by an Indigenous person. The TCCNSW has 

been running 2-day workshops on Indigenous culture for about 5 

years, and it is mandatory for all staff. TCCV have organised 

cultural awareness training in 2001 and 2005, and they now plan 

to deliver it annually. 

Cancer prevention education 

The focus within cancer prevention was strongest in the area of 

tobacco control, and primarily focussed on education and support 

initiatives. For instance, TCCWA provides support and advice to 

Say No To Smokes, the only Aboriginaltargeted tobacco control 

project in WA. Working in collaboration with the Say No To 

Smokes team, the partners have now submitted a joint funding 

proposal for another project, the brainchild of an Aboriginal exsmoker, 

to capture and tell in their own words the success stories 

of Indigenous people who have stopped smoking. The Australian 

Capital Territory Cancer Council in partnership with Winnunga 

Nimmitjah runs a smoking cessation programme No More Bunda 

for Indigenous people that includes access to free 

nicotinereplacement therapy (NRT). This programme was adapted 

from a standard cessation programme and has been running for 5 

years. TCCV is working in two programme areas — tobacco 

control and cervical screening — to take on an Indigenous-specific 

focus, and to train and support AHWs. TCCSA supports and plays 

partnership roles with the Aboriginal Health Council of South 

Australia to deliver a Quit Skills training programme to AHWs. 

TCCNSW appointed an Indigenous representative on the planning 

committee for a tobacco control conference and provided 12 

scholarships for Indigenous people to attend. In reporting on 

successful initiatives, respondents often described relatively smallscale 

local or regional initiatives where the kernel of the project 

came out of a personal or good relationship between a Cancer 

Council member and an Indigenous person working in a local 

health service or in the community. Such partnerships recognised 

that Indigenous Health Services are experienced in working with 

Indigenous people, while the Cancer Councils have expertise 

around cancer education and supporting people affected by 

cancer. Building relationships and reciprocity through sharing 

information and skills between organizations was valued by the 

informants. A local or regional approach was seen as better able 

to support the diverse needs of the Indigenous population within 

each state. 

Indigenous employment 

Involvement of Indigenous people was acknowledged as a crucial 

factor in every aspect of cancerrelated service delivery. However, 

only one of the Cancer Councils (TCCV) during the project period 

reported having an Indigenous staff member. While some Cancer 

Councils had experience in recruiting Indigenous staff, 

respondents recognised the inherent problems of appointing one 

Indigenous position to provide advice across the organisation. 

Based upon their observations and experience, respondents 

believed that it was difficult to recruit Indigenous staff with the skills 

and knowledge to hit the ground running. One respondent 

proposed the merits of two or three part-time positions working 

together on one project instead of one person across the whole 

organisation. 

Respondents were aware of the need to provide orientation, 

adequate direction and support to Indigenous staff in the same 

way as other staff members, but some noted that there had been 

difficulties in achieving this in practice. There were risks of 

Indigenous staff members feeling isolated, and either not 

performing to their ability or suffering burnout. Some respondents 

proposed the need to encourage Indigenous employees to 

network with other Indigenous people in the health sector if there 

were not other Indigenous employees within the organisation. In 

the absence of Indigenous staff members, some organizations are 

working with Indigenous volunteers and some with non- 

Indigenous staff, generally through linking with Indigenous health 

service organizations. 



Policy and advocacy 

The need for Indigenous people to be involved in setting the 

agenda and deciding priorities was consistently recognised by the 

respondents — as it is in the literature. But respondents also 

acknowledged that initiatives would have to fit within the Cancer 

Councils’ scope and priorities. Cancer Council staffs are aware of 

their reliance upon donors and fundraising events, and were 

cautious about undertaking activities that might offend donors or 

distract from their mainstream business. A number of the 

informants described their organisation as “white middle class”, 

not intended as criticism but rather as a statement of where they 

were in their historical development. In some jurisdictions, 

programmes for culturally and linguistically diverse populations 

were also acknowledged as relatively under-developed. The 

Cancer Councils generally had not adopted specific Indigenous 

action plans, although they had strategic plans that addressed 

social determinants of health inequalities, special needs groups 

and under-served populations. 

Informants generally felt that insufficient time and effort had been 

put into Indigenous cancer issues within their organizations to 

date. What had been undertaken was described by some as 

piecemeal, “just scratching the surface”. There were some 

criticisms that efforts had not generally been sustained over time. 

For example, one respondent reported that their organisation had 

been running programmes like a 1-day workshop on Quit skills to 

raise awareness; promoting discussion about priorities and areas 

for action to support Indigenous cancer support group; running 

projects with young Indigenous women smokers to quit smoking 

and so on. However, systematic efforts with follow through have 

only recently begun, and are still at an early stage of development. 

Some Cancer Councils have established a staff Aboriginal Health 

Interest Group. At TCCV a voluntary group with representatives 

from most Units was established in 2002 and meets quarterly to 

discuss Indigenous issues, provide cultural awareness 

opportunities and links with external Aboriginal health agencies. 

The group enables increased awareness of Indigenous needs and 

information goes back to Units to address. 

Cancer support services 

Cancer support services provide support across a range of needs 

to people during their cancer journey, from counselling newly 

diagnosed cancer patients, their families and friends, to providing 

emotional and practical support, advice, accommodation and 

assistance with palliative care. None of the Cancer Councils 

reported that Indigenous people were truly represented in their 

client groups. However, TCCSA had supported the establishment 

of an independent Indigenous Women’s Cancer Action Group that 

provides support to other women with cancer. 

Underlying issues for inclusion of Indigenous people in cancer 

care and support emerged during the interviews. With regard to 

accommodation facilities, some informants reported there had 

been tensions related to large families visiting and staying, mess, 

dirtiness and noise. It was widely reported that many staff felt ill 

equipped to deal with the cultural differences of Indigenous 

patients, and some staff were uncomfortable in dealing with 

Indigenous families. They did not understand the values and 

customs of Indigenous people, while language difficulties further 

impeded communication. Often there was no access to 

interpreters when the person spoke an Aboriginal language as 

their first and usual language. There were also issues with some 

Indigenous clients not wanting to be alone in private rooms, 

preferring being at floor level rather than bed height, having 

different dietary preferences and their preferred foods being 

unavailable. Despite challenges in communication, staff often 

understood the desire of rural patients to return home to die, but 

it generally had required dedicated effort and substantial cost to 

achieve this. A number of informants spoke of the importance of 

improving the quality of data around Indigenous cancer and 

needs. Good information serves as the impetus for setting 

priorities and directing resources, giving individuals a rationale for 

further work with a minority population. Baseline data for 

monitoring progress was seen as vital for people in the field. 

Discussion 

Cancer Councils in Australia have been highly effective nongovernment 

organizations with considerable expertise on all 

aspects of cancer control. As a result of their strategic approach, 

they are effective advocates around cancer screening, treatment 

and support services. As key players in cancer control, they 

contribute through education, training, research, advocacy and 

cancer support service functions, all of which are necessary 

components of achieving improved cancerrelated outcomes for 

Indigenous Australians. Cancer Council staff acknowledged the 

limitations of their organizations in addressing Indigenous cancer 

issues and their own deficiencies in understanding Indigenous 

culture and hence the “right” way to do things. But their 

willingness and enthusiasm to work with these communities was 

apparent in the organisation and participation at the 2004 

Indigenous Cancer Control Forum in Darwin, and this was 

followed by new initiatives within many of the Cancer Councils. 

These initiatives include planning for a state-based Indigenous 

Cancer Forum in South Australia (held in September 2006), 

training of AHWs, cultural safety training for non-Indigenous 

cancer support staff, and working in collaboration with local and 

regional Indigenous health organizations. 

Limitations identified in the environmental scan which impeded 

progress on Indigenous cancer issues were the lack of dedicated 

staff time for Indigenous issues, lack of Indigenous staff, limited 

commitment of significant resources on a sustained basis, and 

lack of Indigenous input into policy and programmes. There were 

no Indigenous Board members, and where an Indigenous person 

had been appointed as a staff member, often many demands were 

made upon them. Some were uncomfortable working in a 

mainstream organisation without Indigenous colleagues providing 

peer-support. While it was recognised as desirable to have 

Indigenous staff members working within the organizations, 

respondents appreciated the practical challenges of this, and that 

an Indigenous person per se was not a panacea. Most 

organizations therefore opted to develop linkages with Indigenous 

health organizations, and in some instances such projects had 

been sustained over a number of years, with resources committed 

over that time period. The linkage approach sometimes proved 

frustrating as it often relied upon individual relationships and 

required that the Indigenous organisation have both capacity and 

commitment to the partnership. Informants recognised the 

necessity to build capacity around cancer within the Indigenous 

health sector. Considerable activity, not all of which had yet come 

to fruition, had been initiated at planning and service levels 



subsequent to the Darwin forum, and the project funded by 

TCCWA, of which this scan is a component, exemplifies the 

interest in how Indigenous cancer control might be progressed. An 

intensive week of training with ongoing opportunities for 

networking and relevant professional development seems a 

particularly useful approach to increasing Indigenous capacity 

around cancer issues. Activities and projects catalysed by small 

seed project funding and initiated regionally or locally within 

established networks, were often cited as successes. However, 

such successes had not generally been translated into sustained 

activity or programmes. Participants consistently recognised the 

importance of long-term and well planned programmes with 

dedicated resources. Practitioners involved in health promotion 

with Indigenous clients advocated the use of “nonpreachy” 

methods, that is, approaches that appeal to an individual’s 

concern for the health and wellbeing of their family and the 

community rather than harms to their own health. Thus, messages 

around tobacco control might focus initially upon harm reduction 

by preventing passive exposure of family members to tobacco 

smoke. 

Cancer Councils provide support services for people with 

cancer that recognise the social, spiritual, emotional, and physical 

supports of cancer patients and their family members. However, 

most were aware of their own organisational limitations in 

understanding and capacity, particularly around Indigenous culture 

and values. Although there has been very limited exploration in 

Australia of what cancer means to Indigenous Australians, those 

interviewed recognised that Western psychosocial and support 

models might not be appropriate for Indigenous clients. This deficit 

in understanding made service providers feel that they lacked the 

knowledge and confidence in supporting Indigenous clients well. 

Staffs were keen to better appreciate Indigenous people’s sociocultural 

understanding of cancer and to use this knowledge in their 

practice in cancer service delivery. Many would welcome 

Indigenous cultural awareness training but wanted specific 

information around cancer beliefs, not just information about the 

historical context of Indigenous health. Although Cancer Councils 

have a well developed network of volunteers to help support 

people with cancer, training of existing staff and volunteers to 

support Indigenous people is needed. It may be helpful to provide 

Indigenous mentors for non-Indigenous staff who are 

inexperienced in working with Indigenous people. Recruitment 

and support for Indigenous volunteers and cancer survivors to 

assist in cancer advocacy work is in place in SA and Queensland, 

but not in other jurisdictions. One-to-one support services appear 

to be underutilised currently, and Indigenous-specific cancer 

survivor support resources using testimonials or story-telling may 

be helpful. An issue regularly raised within Indigenous cancer 

contexts was the use of traditional healers and traditional 

medicines, 22 although these issues were generally not mentioned 

by the informants interviewed. Support programmes that integrate 

cultural components (traditional medicine, selected ceremonies) 

may be acceptable and effective means of supporting Indigenous 

people to engage in cancer treatment. 

There are many similarities between the cancer issues 

experienced by Indigenous Australians and those of indigenous 

people in other developed countries. It is beyond the scope of this 

paper to discuss in detail the experience in cancer control and 

support strategies in indigenous populations in countries such as 

Canada, New Zealand and the United States. However, the 

authors have undertaken a comprehensive literature review of 

these populations and key lessons from international experience 

are: acknowledgement of past treatment and the impact of 

colonisation; acknowledgement of the cultural diversity of 

Aboriginal people; recognition of the impact of the structural 

causes of inequality; need to enable Indigenous ownership, 

participation, partnership and control, with Indigenous 

representation at all levels of decision making; and support for 

community-based and community-driven interventions. There 

have also been efforts to develop culturally appropriate resources 

and servicebased programmes, promoting Indigenous healing 

approaches concurrently with Western medical treatment. The 

reader is recommended to read further about these 

approaches 23,28 which were generally Indigenous community-led 

and government supported. 

While there has been a lack of Australian government leadership 

in this area, Cancer Councils can play both an effective practical 

and advocacy role at the local, state and national level to ensure 

Indigenous issues in cancer control are more effectively 

incorporated and heeded. Respondents recognised that this 

should be done “hand-in-hand in partnership with Indigenous 

communities”, and leadership is needed from The Cancer Council 

Australia to ensure that there is steady national progress with 

lessons shared across jurisdictions. The need for Cancer Councils 

to adopt a respectful approach that invests in learning and 

understanding about Indigenous issues, and the reciprocal 

benefits that might derive from such partnerships in enhancing 

Indigenous cancer control are recognised in the words of one 

informant: 

“The Darwin Forum was like... the Cancer Council people trying 

to learn from Aboriginal people... and if we maintain that theme all 

the way through our state-based work or national work, we will do 

ok... because we have developed lots of respect in taking that 

approach...” ❏ 


This project was funded by the Cancer Council of Western Australia 

(TCCWA). An Aboriginal Working Group had been established for 

the project by TCCWA to assist and guide the reviewers. The 

funding agency did not have any other involvement in the study 

design, data collection, analysis and interpretation other than 

participating in the study. The reviewers sent the draft of this article 

to all Cancer Councils and asked for their comments and feedback. 

Reprint acknowledgement 

Article originally appeared in Australian Health Review 

(http://www.aushealthreview.com.au) and is reproduced with 

permission from the Australian Healthcare Association 

(www.aushealthcare.com.au) 



References 

1. 

Australian Institute of Health and Welfare, Australasian Association of Cancer. Cancer in 

Australia: an overview, 2006. Canberra: AIHW; 2007. (AIHW cat. no. CAN 32.) 

2. 

Stewart BW, Kleihues P, editors. World Cancer Report. Lyon: IARC Press, 2003. 3. Condon JR. 

Cancer, health services and Indigenous Australians. Canberra: Cooperative Research Centre 

for Aboriginal and Tropical Health, 2004. 

4. 

Brown A, Blashki G. Indigenous male health disadvantage: linking the heart and mind. Aust 

Fam Physician 2005; 34: 813-19. 

5. 

Australian Institute of Health and Welfare, Australian Bureau of Statistics. The health and 

welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2005. Canberra: AIHW and 

ABS, 2005. (AIHW cat. no. IHW 14; ABS cat. no. 4704.0.) 

6. 

Procter NRN. Parasuicide, self-harm and suicide in Aboriginal people in rural Australia: a 

review of the literature with implications for mental health nursing practice. Int J Nurs Pract 

2005; 11: 237-41. 

7. 

Condon JR, Barnes T, Cunningham J, Armstrong BK. Long-term trends in cancer mortality for 

Indigenous Australians in the Northern Territory. Med J Aust 2004; 180: 504-7. 

8. 

Hall SE, Bulsara CE, Bulsara MK, et al. Treatment patterns for cancer in Western Australia: 

does being Indigenous make a difference? Med J Aust 2004; 181: 191-4. 

9. 

Condon JR, Armstrong BK, Barnes A, Cunningham J. Cancer in Indigenous Australians: a 

review. Cancer Causes Control 2003; 14: 109-21. 

10. 

Condon JR, Cunningham C, Barnes T, et al. Cancer diagnosis and treatment in the Northern 

Territory: Assessing health service performances for Indigenous Australians. Int Med J 2006; 

36: 498-505. 

11. 

Australian Institute of Health and Welfare. Cervical screening in Australia 2001–2002. 

Canberra: AIHW; 2004. (AIHW cat. no. CAN 22.) 

12. 

The Australian Institute of Health and Welfare and the Australian Government Department of 

Health and Ageing for the BreastScreen Australia Program. BreastScreen Australia 

monitoring report 2001-2002. Canberra: AIHW, 2005. (AIHW cat. no. CAN 24.) 

13. 

Bowel Cancer Screening Pilot Monitoring and Evaluation Steering Committee. A qualitative 

evaluation of opinions, attitudes and behaviours influencing the bowel cancer screening 

pilot program. Commonwealth of Australia: Woolcott Research Pty Ltd, 2005. 

14. 

Lowenthal RM, Grogan PB, Kerrins ET. Reducing the impact of cancer in Indigenous 

communities: ways forward. Med J Aust 2005; 182: 105-6. 

15. 

Condon JR, Armstrong BK, Barnes T, Zhao Y. Cancer incidence and survival for indigenous 

Australians in the Northern Territory. Aust N Z J Public Health 2005; 29: 123-8. 

16. 

Marton C. Environmental scan on women’s health information resources in Ontario, Canada. 

Information Res 2001; 7(1). 

17. 

El-Jardali F, Fooks C. An environmental scan of current views on health human resources in 

Canada: identified problems, proposed solutions and gap analysis. Prepared for the National 

Health Human Resources Summit; 2005 Jun 23. Toronto: Health Council of Canada, 2005. 

18. 

Thomas G. Addiction treatment indicators in Canada: an environmental scan. Ottawa: 

Canadian Centre on Substance Abuse, 2005. 

19. 

Harris H, Martin C. Environmental scanning in the Australian manufacturing sector: a 

discussion of some early results. In: Sohal A, Cooney R, editors. Proceedings of the Sixth 

International Research Conference on Quality Innovation and Knowledge Management; 2002 

17-20 Feb; Kuala Lumpur. p. 659-66. 

20. 

Morrison JL. Environmental scanning. In: Whitely MA , Porter, JD and Fenske RH, editors. A 

primer for new institutional researchers. Florida: The Association for Institutional Research, 

Tallahassee, 1992. 

21. 

Choo CW. Environmental scanning as information seeking and organizational learning. 

Information Res 2001; 7(1). 

22. 

Struthers R, Eschiti VS. The experience of indigenous traditional healing and cancer. Integr 

Cancer Ther 2004; 3: 13-23. 

23. 

Aboriginal Cancer Care Unit. Report of the Aboriginal Cancer Care Needs Assessment. 

Ontario: Cancer Care Ontario, 2002. 

24. 

Wellington School of Medicine and Health Sciences. Access to cancer services for Maori. 

Report prepared for the Ministry of Health (New Zealand), 2005. 

25. 

British Columbia Cancer Agency. Cancer control for Aboriginal people: a summary of known 

programs. Vancouver, BC; Cancer Strategy & IST International Cancer Control Congress; 

2005 Oct 23-26; BC Cancer Agency, 2005. 

26. 

Burhansstipanov L, Gilbert PHA, LaMarca K, Krebs LU. An innovative path to improving 

cancer care in Indian country. Public Health Rep 2001; 116 (September-October): 424-33. 

27. 

Burhansstipanov L. Cancer: a growing problem among American Indians and Alaska 

Natives. In: Dixon M, Roubideaux Y, editors. Promises to keep: public health policy for 

American Indians and Alaska Natives in the 21st century. Washington, DC: The American 

Public Health Association, 2001. 

28. 

Ministry of Health. DHB toolkit: cancer control to reduce the incidence and impact of cancer. 

Wellington: Ministry of Health, 2001. 


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Breast Cancer – a review for 

African surgeons 

ARTICLE BY ADISA ADEYINKA CHARLES MD, FWACS, FICS 

Director, Residency Training Program, Abia State University Teaching Hospital, Aba, Nigeria 

ALEXANDRA M EASSON MSC, MD, FRCSC, FACS 

Assistant Professor, Department of Surgery, General Surgery and Surgical Oncology, Mount Sinai Hospital and Princess 

Margaret Hospital, 610 University Avenue Toronto, Ontario, Canada 

Breast Cancer constitutes a major public health issue globally. In Africa, it is the commonest malignancy affecting women 

and the incidence rates appear to be rising. While mortality rates are declining in the developed world as a result of early 

diagnosis, screening, and improved cancer treatment programmes, the converse is true in the developing world. 

Breast cancer and its treatment constitute a great physical, psychosocial and economic challenge in resource limited 

societies as found in Africa. The hallmarks of the disease in Africa are clinically advanced disease, lack of adequate 

infrastructure for diagnosis, screening and treatment, preponderance of younger pre-menopausal patients. 

This Review is meant to provide practical guidance for the surgeon working in the developing world. 

There is an international/geographical variation in the 

incidence of Breast Cancer. Incidence rates are higher in the 

developed countries than in the developing countries and 

Japan. Incidence rates are also higher in urban areas than in the 

rural areas. 

In Africa, Breast Cancer has overtaken cervical cancer as the 

commonest malignancy affecting women and the incidence rates 

appear to be rising. 3,4 In Nigeria for example, incidence rate has 

increased from 13.8–15.3 per 100,000 in the 1980s, to 33.6 per 

100,000 in 1992 and 116 per 100,000 in 2001. 5 These increases 

in incidence are due to changes in the demography, socioeconomic 

parameters, epidemiologic risk factors, better reporting 

and awareness of the disease. While mortality rates are declining 

in the developed world (Americas, Australia and Western Europe) 

as a result of early diagnosis, screening, and improved cancer 

treatment programmes, the converse is true in the developing 

world as well as in eastern and central Europe. 6-8 

Breast cancer and its treatment constitute a great physical, 

psychosocial and economic challenge in resource limited societies 

as found in Africa. The hallmarks of the disease in Africa are 

patients presenting at advanced stage, lack of adequate 

mammography screening programmes, preponderance of 

younger pre-menopausal patients, and a high morbidity and 

mortality. 3,6 

This Review is meant to provide practical guidance for the 

surgeon working in the developing world. We have relied on the 

Chapter on Breast Cancer by Bland et al in Schwartz’s Principles 

of Surgery, 8th Edition. 9 

Material which is of interest but not immediately applicable has 

been placed in smaller print. In the Recommendations we have 

followed the principles developed in the Breast Health Global 

Initiative. 10-12 

History 

Breast cancer is one of the oldest known forms of malignancies. 

The earliest known documentation on breast cancer was the 

Smith Surgical Papyrus (3000-2500 B.C.) written in Africa (Egypt). 

It described 8 cases of tumors or ulcers of the breast that were 

treated by cauterization, with a tool called “the fire drill.” The 

writing says about the disease, “There is no treatment.” At least 

one of the described cases is male. There were few other historical 

references to breast cancer until the first century when Celsus 

recognized the relevance of operations for early breast cancer. 

In the second century, Galen inscribed his classical clinical 

observation: “We have often seen in the breast a tumor exactly 

resembling the animal the crab. Just as the crab has legs on both 

sides of his body, so in this disease the veins extending out from 

the unnatural growth take the shape of a crab's legs. We have 

often cured this disease in its early stages, but after it has reached 

a large size, no one has cured it. In all operations we attempt to 

excise the tumor in a circle where it borders on the healthy 

tissue.” 13 

Halsted and Meyer reported their operations for the local 

treatment of breast cancer in 1894. Both Halsted and Meyer 

advocated complete dissection of axillary lymph node levels I to III 

and removal of pectoral muscle along with the breast. By 

demonstrating locoregional control rates after radical resection 

and providing the first opportunity for cure, these surgeons 

established radical mastectomy as state-of-the-art treatment in 

the early part of the 20th century. Later in the century, there was a 

transition from the Halsted radical mastectomy to the modified 

radical mastectomy (MRM) as the surgical procedure most 

frequently used for breast cancer. This procedure maintained the 

en bloc dissection of the breast and lymph nodes, but left the 

pectoralis major muscle intact. 

The recognition in the 1950s that breast cancer was often a 

systemic disease at presentation shifted the management of 

primary breast cancer away from a purely surgical approach to a 

multidisciplinary one that uses systemic therapy, surgery and 

radiation. As a result surgery for breast cancer may now be 



Table 1: Early detection amd access to care 

LEVEL OF RESOURCE DETECTION METHOD (S) EVALUATION GOAL 

Basic Breast health awareness (education + self examination) Baseline assessment and repeated survey 

Clinical breast examination (clinical education) 

Limited Targeted outreach/education encouraging CBE for at-risk group Downstaging of eymptomatic disease 

Diagnostic ultrasound + diagnostic mammography 

Enhanced Diagnostic mammography Opportunities screening of asymptomatic patients 

Opportunitic mamographic screening 

Maximal Population-based mammographic screening Population-based screening of asymptomatic patient 

Other imaging technologies as appropriate: 

high-risk group, unique imaging challenge 

managed with more conservative and less locally ablative 

procedures such as lumpectomy. The past three decades has 

witnessed an enormous growth in the knowledge and 

understanding of the basic science of the disease especially the 

genetic and molecular basis of the disease. 

Anatomy of the breast 

The breast is a modified sweat gland and therefore ectodermal in 

origin. It is present in all mammals and becomes particularly 

prominent in females as the hallmark of pubertal development. It 

lies cushioned in adipose tissue between the subcutaneous fat 

layer and the superficial pectoral fascia. It extends from the clavicle 

above to the upper border of the rectus sheath below and from the 

midline to the posterior axillary line. It overlies the second to the 

sixth ribs, the pectoralis major, serratus anterior and the upper part 

of the rectus sheath. The area covered is wider than the visible 

protuberant breast. An axillary extension of the breast (axillary tail 

of Spence) always exists and its size is proportional to the total 

volume of the main breast mass. The innervation of the breast is 

derived from the anterior branches of the intercostal nerves 2 

through 6 with the nipple receiving its innervation from the 4th 

intercostal nerve. The major blood supply, in order of importance, 

are the internal mammary branches, the lateral thoracic, and the 

thoracodorsal perforating vessels from the pectoral branch of the 

throacoacrominal branch of the axillary artery, and small 

intercostals branches. The venous and lymphatic drainage parallel 

the blood supply. 

The glandular tissue consists mainly of epithelium, fibrous 

stroma, and fat. The breast is organized into roughly 20 lobular 

units made up of terminal ducts surrounded by fat and fibrous 

tissues and efferent ductules. These terminal ducts coalesce and 

drain towards the areola forming the 15-20 ducts of the nipple 

areolar complex. 

The lymphatic drainage is primarily to the axillary nodes (75%), 

divided into three levels by the Pectoralis minor muscle (level I 

nodes lie lateral, level II nodes behind and level III nodes medial to 

the muscle). Usually, but with some exceptions, lymphatic 

drainage is progressive through these levels. Drainage also occurs 

to the internal mammary chain of lymph nodes which lie in the 

intercostal spaces, the supraclavicular nodes, the opposite breast 

and axilla, and to the liver via the rectus abdominis muscle. 

Epidemiologic risk factors/etiology 

The precise etiology of breast cancer is largely unknown, but 

several risk factors have been identified. Table 1 lists the known 

risk factors. 14 

The risk factors include: 

✚ Age: The incidence of breast cancer increases with age and is 

rare before the age of 20 years. The breast cancer incidence in 

Caucasians is highest at age 50-59, after menopause, 

dropping after age 70. In Africa and African-Americans the 

peak age incidence is about one decade less, so that the 

majority of the patients are premenopausal. While numerous 

theories have been proposed to explain this difference, 

including age at menarche, time of first delivery, parity, sociodemographic 

factors, body mass index, and underlying genetic 

difference, none are completely satisfactory and more research 

is needed in this area. 3-5;15-17 

✚ Sex: Breast Cancer is 100 times more common in women 

than in men with male breast cancer accounting for


✚ Previous breast disease: Individuals who have a prior 

history of invasive carcinoma or ductal carcinoma in situ have 

a 0.5%-1% per year risk of developing a new invasive breast 

carcinoma. Women with atypical ductal or lobular hyperplasia 

have a four to five times higher risk of developing breast 

cancer. Proliferative lesions without atypia, such as moderate 

hyperplasia and sclerosing adenosis, are associated with a 

slightly increased risk (1.5-2%). Other common nonproliferative 

changes such as palpable cysts, fibroadenomas 

and duct papillomas are not associated with a significantly 

increased risk. 34 

✚ Enviromental Exposures: Exposure to ionizing irradiation 

increases the risk of developing breast cancer. Excess breast 

cancer has been observed in patients given multiple 

fluoroscopies, radiotherapy for ankylosing spondylitis, Hodgkin’s 

disease, or enlargement of the thymus gland and in survivors of 

the atomic bombings, painters of radium watch faces and X-ray 

technicians 28 . Environmental exposures to organic chlorines and 

other environmental/synthetic estrogens like cosmetics and 

phytoestrogens found in food have also been postulated to 

increase the risk, but so far there are no conclusive evidence 

linking organic chlorines to breast cancer. 31;35;36 

Lifestyle risks 

Anthropometric indices and physical activity: Height, obesity and 

high body mass index are risk factors especially in post 

menopausal women. In pre-menopausal women, obesity and high 

body mass index has an insignificant but inverse relationship to 

breast cancer risk that is reduced by physical activity. 37-39 

Diet, alcohol and smoking: alcohol and diets rich in fat especially 

saturated fat raises the risk while smoking does not appear to 

affect the risk. 40-42 

Family history and genetics 

A family history of breast cancer increases a woman's risk of 

developing the disease. A woman is considered to be at increased 

risk if the family member is a first degree relation with early age of 

onset (< age 50), if both breasts are involved, or if she has multiple 

primary cancers (such as breast and ovarian cancer). Women with 

one, two, and three or more first-degree affected relatives have an 

increased breast cancer risk when compared with women who do 

not have an affected relative (risk ratios 1.8, 2.9 and 3.9, 

respectively) 43 Such women are recommended to begin breast 

cancer screening at an age 10 years younger than the age at 

which the affected relative was diagnosed. 

Hereditary breast cancer caused by an underlying inherited 

gene mutation accounts for a small proportion (5-10%) of all 

breast cancers. The majority is accounted for by 2 germline 

mutations BRCA-1 (50%) and BRCA-2 (32%), which are inherited 

in an autosomal dominant fashion with varying penetrance. These 

tumor suppressor genes are important in the processing of DNA 

damage and preservation of genomic integrity. BRCA-1 is located 

on chromosome 17q while BRCA-2 is located on chromosome 

13q. 44 They are most commonly found in the European Ashkenazi 

Jewish population and their descendants, accounting for their 

relatively high prevalence in the developed world. In Europe and 

North America, BRCA1 is found in 0.1% of the general population, 

compared with 20% in the Ashkenazi Jewish population and is 

found in 3% of the unselected breast cancer population and in 

70% of women with inherited early-onset breast cancer. 9 Up to 50- 

87% of women carrying a mutated BRCA1 gene develop breast 

cancer during their lifetime. Risks for ovarian and prostate cancers 

are also increased in carriers of this mutation. BRCA2 mutations 

are identified in 10-20% of families at high risk for breast and 

ovarian cancers and in only 2.7% of women with early-onset 

breast cancer. The lifetime risk of developing breast cancer in 

female carriers is 25-30%. BRCA2 is also a risk factor for male 

breast cancer; male carriers have a lifetime risk of 6% for 

developing the cancer. BRCA2 mutations are associated with 

other types of cancers, such as prostate, pancreatic, fallopian 

tube, bladder, non-Hodgkin lymphoma, and basal cell carcinoma. 

Risk management strategies for BRCA-1 and BRCA-2 carriers 

include: 

✚ prophylactic mastectomy and reconstruction; 

✚ prophylactic oophorectomy and hormone replacement 

therapy; 

✚ intensive surveillance for breast and ovarian cancer; and 

✚ chemoprevention using Tamoxifen or raloxifene (postmenopausal 

women) 

In contrast, less is known about genetic mutations as a cause of 

breast cancer in the non-Caucasian population. Studies that have 

been done of African-Americans, whose genetic history includes 

Caucasians, have identified BRCA-1 and -2 mutations but of a 

different pattern. 17,45,46 In native Africans, a wide range of BRCA-1 

and BRCA-2 mutations and sequence variations have been found 

which are unique. This suggests that there may be significant 

differences in the genetics of hereditary breast cancer in Africa. 

A screening of 206 black South African women with breast 

cancer revealed 3 common BRCA1 mutations: 185delAG in exon 

2, 4184del4 in exon 11, and 5382insC in exon 2022. A second 

study of the coding regions of BRCA1 and BRCA2 genes from 70 

Nigerian patients diagnosed with breast cancer before the age of 

40 years revealed 2 novel BRCA1 truncating mutations, Q1090X 

and 1742insG; four BRCA1 missense variations; one BRCA2 

truncating mutation, 3034del4, previously unreported in anyone of 

African descent; and 20 nontruncating variants were detected in 

BRCA2.45 BRCA1 and BRCA2 mutations and sequence 

variations are potentially significant in cases of early-onset breast 

cancer within Africa. However, only a small portion of the 

mutations were protein truncating, fewer than those observed 

among white women 47 

Other rare genetic changes that account for predisposition to 

breast cancer include Li Fraumeni syndrome (TP53 gene mutation), 

Cowdens syndrome, Peutz-Jeghers and Muir-Torre syndromes, 

Ataxia Telangiectasia syndrome (caused by the ATM gene). 48-51 New 

breast cancer susceptibility genes are being reported and they 

include the CHEK2 or CHK2 gene, cytochrome P450 genes 

(CYP1A1, CYP2D6, CYP19), glutathione S-transferase family 

(GSTM1, GSTP1), alcohol and one-carbon metabolism genes 

(ADH1C and MTHFR), DNA repair genes (XRCC1, XRCC3, 

ERCC4/XPF) and genes encoding cell signaling molecules (PR, ER, 

TNFalpha or HSP70). All these factors contribute to a better 

understanding of breast cancer risk but the degree of penetrance 

of these genes are far less than the BRCA1 and BRCA2 genes 43,51 

Risk assessment 

Several statistical models are currently in use in North America to 



predict the risk of breast cancer, based on the above risk factors 

identified in the American Caucasian population. The universal 

applicability of these models can not, however be taken for 

granted as the data on which they rely on were generated from 

predominantly American Caucasian population and have not been 

tested for African women 43,52,53 

The most prominent statistical models are the Gail and the 

Claus models. Gail and colleagues developed the most frequently 

used model, which incorporates age at menarche, the number of 

breast biopsies, age at first live birth, and the number of firstdegree 

relatives with breast cancer. It predicts the cumulative risk 

of breast cancer according to decade of life. To calculate breast 

cancer risk with the Gail model, a woman's risk factors are 

translated into an overall risk score by multiplying her relative risks 

from several categories. This risk score is then compared to an 

adjusted population risk of breast cancer to determine a woman’s 

individual risk. A software programme incorporating the Gail 

model is available from the National Cancer Institute at 

http://bcra.nci.nih.gov/brc. 

Claus and colleagues, using data from the Cancer and Steroid 

Hormone Study, a case-control study of breast cancer, developed 

the other frequently used risk-assessment model, which is based 

on assumptions about the prevalence of high-penetrance breast 

cancer susceptibility genes. Compared with the Gail model, the 

Claus model incorporates more information about family history, 

but excludes other risk factors. The Claus model provides 

individual estimates of breast cancer risk according to decade of 

life based on knowledge of first- and second-degree relatives with 

breast cancer and their age at diagnosis. Risk factors that are 

less-consistently associated with breast cancer (diet, use of oral 

contraceptives, lactation), or are rare in the general population 

(radiation exposure), are not included in either the Gail or Claus 

risk-assessment models. 54 

Pathology 

Breast cancers are derived from the epithelial cells that line the 

terminal duct lobular unit. Cancer cells that remain within the 

basement membrane of the elements of the terminal duct lobular 

unit and the draining duct are classified as in situ or non-invasive. 

An invasive breast cancer is one in which there is dissemination of 

cancer cells outside the basement membrane of the ducts and 

lobules into the surrounding adjacent normal tissue. 

Classification of Primary Breast Cancer 

Noninvasive Epithelial Cancers 

✚ Lobular Carcinoma in situ (LCIS). 

✚ Ductal Carcinoma in situ (DCIS) or intraductal carcinoma: 

Papillary, cribriform, solid and comedo types 

Invasive Epithelial Cancers (percentage of total) 

✚ Invasive lobular carcinoma (10-15). 

✚ Invasive ductal carcinoma. 

✚ Invasive ductal carcinoma, (NOS) Not Otherwise Specified 

(50-70). 

✚ Tubular carcinoma (2-3). 

✚ Mucinous or colloid carcinoma (2-3). 

✚ Medullary carcinoma (5). 

✚ Invasive cribriform (1-3). 

✚ Invasive papillary (1-2). 

✚ Adenoid cystic carcinoma (1). 

✚ Metaplastic carcinoma (1). 

✚ Pagets disease (


International Union Against Cancer) and the American Joint 

Committee on Cancer (AJCC). Tables 2 and 3 show the latest 

TNM staging for Breast Cancer (AJCC classification (6th edition or 

revision) 55 , which incorporates both clinical information and 

changes related to the growing use of new technology (e.g., 

sentinel lymph node biopsy, immunohistochemical staining, 

reverse transcriptase-polymerase chain reaction). Patients with 

bilateral or multicentric breast cancer are staged according to the 

size of the largest tumor. 

Diagnosis 

Examination 

Early breast cancer causes no symptoms and is usually painless. 

The commonest symptom is a painless lump in the breast. 

Examination of the breast should be done in such a way to show 

respect for the privacy and comfort of the patient. A systematic 

approach to breast examination is important. Initial examination 

should start with the patient in an upright position with careful 

visual inspection of masses, skin and nipple changes, and 

asymmetries. Palpation should be done to include all the breast 

quadrants, the nipple-areola complex, the axillary tail and the 

axilla. Simple maneuvers like stretching the arms high above the 

head, tensing the pectoralis muscles may help accentuate 

asymmetries and dimpling. 

Other less frequent presenting signs and symptoms of breast 

cancer include (1) breast enlargement or asymmetry; (2) nipple 

changes, retraction, or discharge, including Paget’s disease; (3) 

ulceration or erythema of the skin of the breast including 

inflammatory carcinoma; (4) an axillary mass; and (5) systemic 

symptoms such as fatigue, cough, ascites or new musculoskeletal 

discomfort. 

Imaging 

Mammography, Ductography, Ultrasonography, MRI are imaging 

techniques useful in the screening and diagnosis of breast cancer. 

Mammography is the most useful test to differentiate between 

benign and malignant lesions and is the one that is recommended 

for breast cancer screening. Specific mammography features that 

suggest a diagnosis of a breast cancer include a solid mass with 

or without stellate features, asymmetric thickening of breast 

tissues, and clustered microcalcifications Mammography may also 

be used to guide interventional procedures, including needle 

localization and needle biopsy. 

Xeromammography techniques are identical to those of 

mammography with the exception that the image is recorded on a 

xerography plate, which provides a positive rather than a negative 

image Details of the entire breast and the soft tissues of the chest 

wall may be recorded with one exposure. 

Ductography and ductoscopy 

Mammary ductoscopy (MD) is a newly developed endoscopic 

technique that allows direct visualization and biopsy examination 

of the mammary ductal epithelium where most cancers originate. 

When combined with ductal lavage and cytology , it may reveal 

early carcinoma. 56-59 The primary indication for ductography is 

nipple discharge, particularly when the fluid contains blood. 

Radiopaque contrast media is injected into one or more of the 

major ducts and mammography is performed. Intraductal 

papillomas are seen as small filling defects surrounded by contrast 

media. Cancers may appear as irregular masses or as multiple 

intraluminal filling defects. 

Ultrasonography is an important method of resolving equivocal 

mammography findings, defining cystic masses, and demonstrating 

the echogenic qualities of specific solid abnormalities. 

Ultrasonography is used to guide fine-needle aspiration biopsy, 

core-needle biopsy, and needle localization of breast lesions. It is 

highly reproducible and has a high patient acceptance rate, but 

does not reliably detect lesions that are 1 cm or less in diameter 

Table 2: Diagnosis and pathology 

LEVEL OF RESOURCE CLINICAL PATHOLOGY IMAGING AND LABORATORY TESTS 

Basic History Interpretation of biopsies 

Physical examination 

Clinical breast examination 

Cytology or pathology report 

Surgical biopsy 

Fine-needle aspiration 

describe tumor size, 

lymph node staue, 

hiatologic type, tumor grade 

Limited Core needle biopsy Determination and reporting Diagnostic breast ultrassound+ 

Image-guided sampling of ER and PR statue diagnostic mammography 

(ultrasonographic+mammographic) 

Plain chest mammography 

Determination and reporting 

Liver ultrasound 

of margin satue 

Blood chemistry profile/CBC 

Enhanced Preoperative needle localization under On-site cytopathologist Diagnostic mammography 

mammographic or ultrasound guidance 

Bone scan 

Maximal Stereotactic biopsy HER2/new statue CT scanning, PET 

Sentinal node biopsy IHC ataining of aentinel nodes MIBI scan, breast MRI 

for cytokeratin to detect 

micrometastaes 

CBC, coomplete bloodcount; CT, computed tomography; ER, estrogen recaptor; IHC, immunohistochemistry; MIBI, 99mto-sastamibi; MRI, magnetic resonance imaging; 

PET, positron emission tomography; PR, progerterone receptor 



Table 3: Treatment and allocation of resources: stage I breast Cancer 

LOCAL-REGIONAL TREATMENT 

SYSTEMIC TREATMENT (ADJUVANT) 

Level of resource Surgery Radiation therphy Chemotherphy Endocrine therphy 

Basic Modified radical mastectomy Ovarian ablation 

Tamoxifen 

Limited Breast-conserving theraphy* Breast-conserving whole-breast Classical CMF** 

irradiation as part of breast-conserving 

therapy 

Postmasectomy irradiation of the chest 

wall and regional nodes for high-risk cases 

AC, EC or FAC** 

Enhanced Taxanes Aromatase inhibitors 

LH-RH agonists 

Maximal Sentinal node biopsy Growth factors 

Reconstructive surgery 

Dose-dense chemotherapy 

* Breast-conserving therapy requires mamography and reporting of margin status. 

** Requires blood chemistry profile and complete blodd count (CBC) testing 

AC, doxonubian and cyclosphamida; CMF, cyclophamide, methotrexate, and 5- fluorourcil; EC, epirubicin and cyclophosphamide; FAC, 5 - fluorourcil doxonubicin, and cyclophosphamide; 

LH+RG, lutelnizing hormone-releasing hormone 

and when used alone is a poor screening test. 60,61 

Magnetic Resonance Imaging is a non invasive, non radiating 

imaging technique. In the process of evaluating MRI as a means 

of characterizing mammography abnormalities, additional breast 

lesions have been detected. However, in the circumstance of both 

a negative mammogram and a negative physical examination, the 

probability of a breast cancer being diagnosed by MRI is extremely 

low. There is current interest in using MRI to screen the breasts of 

high-risk women and of women with a newly diagnosed breast 

cancer. In the first case, women with a strong family history of 

breast cancer or who carry known genetic mutations require 

screening at an early age, but mammography evaluation is limited 

because of the increased breast density in younger women. In the 

second case, a study of MRI of the contralateral breast in women 

with a known breast cancer showed a contralateral breast cancer 

in 5.7% of these women. 62-64 

Plain X-rays and Bone Scan are useful in the detection and 

diagnosis of metastasis especially to the bones. 

MRI, PET, CT Scans and bone scans are not readily available in 

most centers in the developing world, and when available, the cost 

of these procedures makes them virtually unrealistic for many of 

the patients. Ultrasonography and X-rays are however readily 

available and many patients will end up with these minimal 

investigations and the standard history and physical examination. 

Table 4: Treatment and allocation of resources: stage II breast Cancer 




Basic Modified radical mastectomy –* Classical CMF** Ovarian therapy 


Tamoxifen 

Limited Breast-conserving theraphy*** Breast-conserving whole-breast 

irradiation as part of breast-conserving 

therapy 


wall and regional nodes for high-risk cases 


Enhanced Taxanes Aromatase inhibitors 


Maximal Sentinal node biopsy Growth factors 

Reconstructive surgery 


* Chest wall and regional lymph node irradiation substantially decrease the risk of postmastectomy local recurrance, if available it should be used as a basic level resource 

** Requires blood chemistry profile and complete blodd count (CBC) testing 

*** Breast-conserving therapy requires mamography and reporting of margin status. 





Biopsy 

Pathologic diagnosis of a breast lesion can be achieved using a 

number of biopsy techniques. With a larger biopsy sample, greater 

accuracy and more information are obtained, but this is at the 

expense of increased invasiveness. Ideally, needle biopsies should 

be performed after imaging to help prevent distortions of imaging 

due to hematoma. The various needle biopsy techniques can be 

divided into two groups: 

✚ 1. Fine needle aspiration will provide cytology which will allow 

a diagnosis of malignant cells but will not differentiate between 

in situ or invasive disease. 

✚ 2. Tissue biopsy for histology which include Tru cut biopsy, 

Biopty cut, Mammotome. These relatively larger tissue samples 

will allow the diagnosis of invasive versus in situ cancer. 

Table 4 compares the accuracy of needle biopsy techniques. 

Open Biopsy (Excision or Incision biopsy) The ultimate diagnostic 

biopsy is open biopsy of a lesion, normally performed under 

general or local anesthetic. Open excisional biopsy should be 

reserved for lesions for which some doubt remains regarding 

diagnosis after less invasive assessment or for benign lesions that 

the patient wants removed. A wide clearance of the lesion is usually 

not the goal in diagnostic biopsies, thus avoiding unnecessary 

distortion of the breast. It is also useful for excision of 

mammographic lesions when percutaneous biopsy has failed or is 

equivocal. Where frozen section is available, open excisional biopsy 

may be performed at the same time the as definitive breast cancer 

surgery. Incisional biopsy is used only in cases where the lesion is 

very large and a percutaneous biopsy has been unsuccessful. 

Screening 

Annual screening mammography has been demonstrated to 

reduce breast cancer mortality among women older than 50 years 

by 20 –39%. The benefit in younger women is not yet established. 

For Caucasian women aged 40–49, the results of RCTs are 

consistent in showing no benefits at 5–7 years after entry, a 

marginal benefit at 10–12 years, and unknown benefit thereafter. 

This is primarily because when used as a screening tool, the 

detection rate per screened individual is lower because of denser 

breasts and an overall lower incidence. The controversy over the 

effectiveness of screening mammography among younger women 

(i.e., 40–49 years) has led to varying recommendations about its 

use for this age group. In patients with high risk factors a yearly 

mammography assessment from the age of 40 years is 

advisable. 65-67 Considering the younger demographic pattern of 

Breast Cancer in Africa, it is not clear what role screening 

mammography should have in Africa. 

Other methods of early breast cancer screening like Self Breast 

Examination and Clinical Breast Examination have not been 

demonstrated to improve mortality in patients; rather SBE has 

resulted in more breast biopsies due to false positive results, more 

physician visits and apprehension in patients 68 . It is pertinent to 

state that most of the studies that evaluated the role of SBE and 

CBE have been done in developed societies where cancers are 

small at diagnosis and this may not be relevant in Africa where the 

majority of patients present late. Incorporation of Breast 

Awareness programmes and health education into the Primary 

Health Care of African countries may very well be a useful option 

to allow for a diagnosis at an earlier stage. Cultural attitudes play 

important roles in the acceptance of screening programmes. 69 

Treatment 

Treatment strategy will depend on the stage of the disease. 

In situ breast cancer (DCIS and LCIS) 

LCIS: Observation alone with or without tamoxifen is the preferred 

option for women diagnosed with LCIS because their risk of 

developing invasive carcinoma is relatively low (approximately 21% 

over 15 years) and is equal in both breast.. 70 Follow-up of patients 

with LCIS includes physical examinations every 6 to 12 months for 

5 years and then annually. Annual diagnostic mammography is 

recommended in patients being followed with clinical observation. 

DCIS: Treatment options for DCIS are mastectomy, breastconserving 

surgery (BCS) plus radiotherapy or BCS alone. The 

goal of treatment for DCIS is to reduce local recurrence, because 

50% of the time that DCIS recurs it recurs as an invasive cancer. 

Factors that may modify treatment are: 

✚ the grade of the lesion, with higher-grade lesions more likely to 

recur in a short time; 

✚ the youth of the patient, with many more years at risk for 

recurrence and 

✚ the size of the lesion. 

For years the traditional surgical management of DCIS was 

mastectomy, with or without axillary dissection. Breast 

conservation technique and irradiation is now a preferred 

alternative where local breast radiation is available. Only small, low 

grade DCIS that has been excised with a large margin may be 

considered for BCS alone. Axillary lymph node staging is 

discouraged in women with apparent pure DCIS. However, a small 

proportion of patients with apparent pure DCIS will be found to 

have invasive cancer at the time of their definitive surgical 

procedure which will require a further axillary dissection. 71 Addition 

of Tamoxifen reduces the risk of developing contralateral breast 

cancer. 72,73 . Follow-up of women with DCIS includes a physical 

examination every 6 months for 5 years and then annually, as well 

as yearly diagnostic mammography. 

Early breast cancer (stages I and II or T1-3N0-1 M0): 

Staging for metastatic disease is standard for most patients 

diagnosed with early breast cancer and include a chest X-ray, 

bone scan and ultrasound of the abdomen. If negative, treatment 

intent is curative, and involve modalities that fight the cancer 

locally (surgery and radiation) and systemically (chemotherapy and 

endocrine therapy). 

Loco-regional treatment: 

Local treatment requires the treatment of the entire breast and the 

axillary lymph nodes with surgery, radiation, or a combination of 

both. Surgery can be breast conservation therapy (BCT) and 

axillary staging (SLNB or axillary dissection) or simple or total 

mastectomy with axillary staging (modified radical mastectomy). 

The surgical procedure for the excision of the breast in BCT 

goes by several names (Partial mastectomy, tylectomy, segmental 

resection, quadrantectomy or lumpectomy). 

The goal of breast-conserving surgery is to minimize the risk of 

local recurrence while leaving the patient with a cosmetically 

acceptable breast. The selection of BCT versus mastectomy 

depends on the size of the tumor relative to the rest of the breast 



and the availability of radiation. BCT and breast radiation together 

offers equivalent survival to total mastectomy provided the BCT 

removes the entire tumor with negative margins. Generally a tumor 

less that 1/4 of the breast is amenable to BCT; anything much 

larger will result in significant breast distortion after surgery and 

radiation. The procedure can be done safely with local anesthesia 

and sedation unless axillary dissection is part of the procedure. A 

curvilinear incision lying parallel to the nipple-areola complex is 

made in the skin overlying the breast cancer. Radial scars are 

avoided because of poor cosmetic results. Skin encompassing any 

prior biopsy site is excised, but skin excision is not otherwise 

necessary. The breast cancer is removed with an envelope of 

normal-appearing breast tissue. Meticulous hemostasis is 

important because a large hematoma distorts the appearance of 

the breast and makes re-excision and follow-up more difficult. 

The excised specimen is orientated for the pathologist using 

sutures, clips, or dyes. Additional margins (superior, inferior, 

medial, lateral, superficial, and deep) can be taken from the 

surgical bed to confirm complete excision of the tumor. These six 

margins are marked with titanic clips as this may help the 

Radiotherapist in planning the boost. In addition, it helps the 

surgeon to do an adequate re-resection if the margins are not free 

of cancer cells at definitive paraffin-embedded histology sections. 

Attempts to re-approximate the cavity in the breast should be 

avoided, because this will usually distort the breast contour, which 

may not be apparent when the patient is supine on the operating 

table. Similarly, drains are not used. Allowing the cavity to fill with 

serum and fibrin maintains contour in the early postoperative 

period and helps to avoid deformity. The procedure is completed 

with two-layer closure of the deep dermis and the subcuticular 

layer, and a light dressing is used. 

There is no firm consensus on the extent of the excision or 

margins required. The main benefit of BCT is preservation of body 

image for the woman, which greatly improves her quality of life. 

Several randomized controlled trials have shown that BCT and 

radiation has a similar survival advantage as mastectomy as there 

were no significant differences in the two groups in disease-free 

survival, distant-disease-free survival, or overall survival and even 

in loco regional control. 74-80 

Contraindications to breast conservation therapy (BCT) can be 

divided into absolute or relative. Absolute contraindications 

include lack of mammography facilities to ensure all tumors have 

been removed, adequate pathology facilities to ensure tumor- free 

resection margins and/or lack of radiotherapy facilities. 10,11 Other 

contraindications include pregnancy (first or second trimester 

because of the risk of radiotherapy to the fetus), patient’s 

preference, diffuse suspicious calcifications, inflammatory breast 

carcinoma, previous radiation to the region, and inability to achieve 

negative margins particularly with extensive intraductal carcinoma 

(EIC). Relative contraindications also include two or more gross 

tumors (multicentric disease) in different quadrants, tumor greater 

than 5 cm initially or after neoadjuvant chemotherapy, large tumorbreast 

ratio for cosmesis, and collagen vascular disease. 74 

In Africa, many of the factors above make the practice of BCT 

difficult and these include lack of adequate diagnostic oncology 

services like mammography and surgical pathology, lack of 

adequate therapeutic oncology services like radiotherapy, 

advanced stage disease and poor follow up culture. 5 Thus the 

majority of the patients with early breast cancer in Africa should 

still undergo total mastectomy and axillary clearance. 

In a total or simple mastectomy, the patient is placed in the 

supine position with the ipsilateral arm extended horizontally. 

General anesthesia is used. The incision is in the form of an ellipse 

is designed to include the skin overlying the tumor or biopsy scar 

and the nipple–areola complex. Superior and inferior skin flaps are 

then raised. The plane between the subcutaneous tissue and 

breast tissue is not always obvious and is most easily identified at 

the medial superior flap; it is therefore easiest to begin here. The 

skin flaps must be thin, to ensure that all the breast tissue is 

removed, and yet enough subcutaneous fat to ensure adequate 

blood supply to the skin. Superiorly the dissection must include 

the tail of Spence laterally. Inferiorly, the dissection ends at the 

inframammary fold. The entire breast, the skin ellipse, nippleareola 

complex are then dissected off the pectoralis fascia. The 

procedure is completed with an en bloc excision of the axillary 

lymph nodes level I and II (see description below). The 

mastectomy site and axillary nodal basin are then irrigated with 

saline solution, and meticulous hemostasis is achieved. The 

wound is closed with a closed suction drainage bottle fixed to a 

catheter brought out through a separate stab incision. 

Modified radical mastectomy can be done alone or in 

association with breast reconstruction. Reconstruction, using 

implants or myocutaneous flaps, provides many women with an 

enhanced body image and self-esteem, and better psychosocial 

adjustment, but it does not impact on the probability of disease 

recurrence or survival. 81,82 One method becoming widely used is 

the skin-sparing mastectomy (SSM) that conserves an extensive 

section of skin, as well as the more recent skin and nipple-sparing 

mastectomy that preserves the nipple-areolar complex. 83-85 SSM is 

clearly contraindicated in patients with direct involvement of the 

skin by the underlying tumor. Nicotine, previous radiotherapy, 

diabetes and obesity increase the risk of skin envelope ischemia, 

skin necrosis and infection. 

However, the additional cost of reconstruction is an issue 

especially in resource poor countries. 

Treatment of the axilla 

Axillary lymph node dissection (ALND) 

The status of axillary and internal mammary lymph nodes is the 

most significant prognostic factor for survival in patients with 

breast cancer. In breast cancer, the status of axillary and internal 

mammary lymph nodes is the most significant prognostic factor 

for survival. The axillary nodal basin has been the main target in 

lymphatic staging in breast cancer because over 75% of the 

lymphatic flow from the breast is directed to the ipsilateral axilla. 

Axillary clearance (ALND) has been the gold standard in axillary 

staging in breast cancer, providing valuable information about the 

planning of adjuvant therapy, prognosis and an excellent regional 

disease control as well. Removal of 10 or more nodes as assessed 

by the pathologist provides accurate information about the axillary 

nodal status of the patient. 

The most accepted surgical axillary clearance procedure is a 

level I and II axillary dissection, detecting 98.5% of cases with 

positive axillary nodes. 86 Either at the time of mastectomy, or 

through a separate incision (if BCT), the lateral border of pectoralis 

major muscle is identified. The clavipectoral fascia, extending 

laterally from the edge of this muscle, is divided parallel to the 

edge of the muscle to allow entry into the axilla. The superior 



border of the dissection is the lower border of the axillary vein; 

dissection above the vein runs the risk of damage to the brachial 

plexus. The nerves to latissimus dorsi (thoracodorsal) and to 

serratus (long thoracic) are identified and are the posterior border 

of the dissection. The lateral border is the floor of the axilla, 

consisting of skin and subcutaneous tissue. Retraction of the 

pectoralis minor muscle medially allows for the removal of level II 

nodes. All the fatty tissue within these borders is removed. The 

sensory intercostal brachial nerve runs through the axilla and may 

or may not be preserved. 

Sentinel node biopsy 

Although long considered the standard management of the axilla for 

breast cancer, ANLD is associated with significant arm morbidity 

(20-25% risk of lymphedema) and risk of damage to the axillary vein, 

nerve to the latissimus dorsi and serratus anterior and hypoesthesia 

of the arm and the thorax. For these reasons, other less invasive but 

accurate methods have been sought for axillary staging in breast 

cancer, especially in the developed world, where three-quarters of 

patients present with early node negative disease. Clinical 

examination of the axilla and available diagnostic imaging 

techniques like US, CT and PDG-PET are manifestly inaccurate for 

axillary staging. 

Less invasive than ALND, sentinel lymph node biopsy (SLNB) is 

now accepted as an alternative to routine ALND for the detection 

of occult lymph node metastases in patients with clinically nodenegative 

breast cancer. 87,88 SNLD is based on the observation that 

specific areas of the breast drain by way of afferent lymphatics to 

a specific ‘sentinel’ node. This node can be detected by injecting 

vital blue dye (isosulfan blue dye, methylene blue or patent blue V 

dye) or a radioactive suspension (Tc99m radioisotope labeled 

colloids). The route of injections include intra parenchymal (peritumorally), 

intradermal or subareolar. 88,89 . The use of vital dye is 

resource efficient (cheaper and less time consuming) and safer, 

but may miss non axillary sites and also carries the risk of 

anaphylactic reactions while radioactive agents are more 

expensive, carries the risk of exposure to staff, and requires that 

the hospital have a nuclear medicine department. 

There are five principal aims for the excision and 

histopathological analysis of the SN: 

✚ minimally invasive assessment of the nodal status; 

✚ selection of patients with positive SNs for elective lymph node 

dissection (ELND) or adjuvant therapy; 

✚ prevention of lymph node dissection and associated morbidity 

in SN negative patients; 

✚ detection of aberrant or alternative lymphatic drainage; 

✚ improvement of sensitivity of histopathological detection of 

lymph node metastasis. 90 

Further surgery of the axillary nodes now depends on the results 

of the sentinel lymph-node biopsy – if negative, ALND is avoided. 

While SLNB is becoming widely used in the developed world as a 

method to assess the axilla, ALND remains the recommended 

management for treatment in any hospital that does not have 

access to a nuclear medicine department or a dedicated breast 

pathologist able to use specialized immunohistochemistry markers. 

Radiotherapy in early breast cancer 

The aim of radiotherapy to the whole breast after BCT is to 

establish local control. Numerous studies have shown reductions 

in local recurrences from 12-35% to 2-10% at 5-10 years. This 

compares to local recurrence rates after mastectomy of 5%.(91) In 

most developed countries, the current standard of care for 

patients with early-stage breast cancer consists of breastconserving 

surgery, followed by 5–6 weeks’ postoperative 

radiotherapy used on the whole breast. Probabilities of adequate 

local control rates and good cosmetic results are high with the use 

of conventional fractionation. Patients who cannot receive 

radiation are treated with mastectomy. Some recent papers 

suggest a small survival advantage which was rather offset by the 

long term toxicity from radiotherapy resulting in deaths from 

vascular and cardiac injuries. 92 

Some data support the effectiveness of an additional dose 

applied to the tumor bed (i.e., boost irradiation) to reduce local 

recurrence. However, delivery of the boosting dose raises the rate 

of morbidity, which reduces cosmetic outcome. 

Recent advances in radiotherapy includes partial breast 

irradiation using various techniques such as such as low or highdose 

rate brachytherapy (interstitially or with an intracavitary 

balloon), conformal external-beam irradiation (including intensity 

modulated radiotherapy), and intraoperative radiotherapy (Electron 

Intra Operative Therapy-ELIOT). 93,94 

Most reports of partial breast irradiation have provided results 

much the same as those achieved with conventional external 

beam, even though some caution is needed until the safety and 

efficacy of such irradiation have been shown in appropriate 

patients and analysis of long-term treatment outcomes. 95-97 

Systemic treatment 

More than half the women with operable breast cancer who 

receive only locoregional treatment die from metastatic disease. 

This indicates that breast cancer is a systemic disease and that 

the micrometastatic process can occur early even independently 

from lymphatic spread. 76,98 The way to improve survival is to give 

these women systemic medical treatment, including endocrine 

therapy, chemotherapy, or targeted therapy with trastuzumab 

along with surgery/radiotherapy. 

Systemic treatment may be given after (adjuvant) or before 

(neoadjuvant, primary, or preoperative) locoregional treatment. 

Adjuvant treatment has been shown to be effective in randomized 

clinical trials, whereas the evaluation of neoadjuvant systemic 

therapy is ongoing. 

It is important to realize, especially in the African context, that any 

systemic therapy including hormonal therapies, will at least 

temporarily interrupt child bearing. The current recommendations of 

at least 5 years of Tamoxifen after diagnosis will significantly impact 

on the ability of a woman to bear many children. Chemotherapy will 

cause most women to stop menstruating and permanent premature 

menopause is common. These recommendations listed below, 

based on the culture of the developed world, may not be 

acceptable or applicable to African women. 

The choice of systemic adjuvant therapy in early breast cancer 

will depend on the following factors; estrogen (ER)/progesterone 

(PR) receptor status, menopausal status and over-expression of 

HER2. It will also depend significantly on the risk of recurrence and 

therefore the potential benefit of the treatment. Any systemic 

therapy carries with it a risk of toxicity, and can be quite expensive. 

A woman at high risk of recurrence will benefit significantly from 



Figure 1: Advanced breast cancer 

treatment while for a woman at low risk the benefit will be small yet 

she will be exposed to the same toxicity. For example, a 20% 

reduction with chemotherapy for a patient with a baseline 50% risk 

of recurrence will result in an absolute reduction to 10% (from 50% 

to 40%) where as a woman with a 10% recurrence risk reduces 

her risk of recurrence to 8%, only a 2 % absolute reduction. Some 

women would not choose chemotherapy for a 2% risk reduction 

and others might. The decision to take systemic therapy therefore 

is therefore very much dependent on the woman and her 

understanding of these risks. 99 

Adjuvant endocrine therapy is effective in ER and/ or PR positive 

tumors. The most commonly used endocrine therapy is the 

Selective Estrogen Receptor Modulator (SERM) Tamoxifen, used 

in premenopausal women. Other SERM agents like Toremifene 

and Raloxifene are equally effective. There is strong evidence to 

support the superiority of a 5 year Tamoxifen therapy over shorter 

durations. Tamoxifen in addition helps to maintain bone mineral 

density in post menopausal women and reduces the risk of 

developing cancer in the contralateral breast. The side effects of 

Tamoxifen include hot flashes, risk of thrombo-embolic disease, 

endometrial carcinoma and cataracts. 

For post-menopausal women, third generation selective 

aromatase inhibitors have been shown in recent trials to be more 

effective than Tamoxifen and have become the standard of care. 

Examples include non steroidal type (anastrozole and letrozole) 

and the steroidal type exemestane. Patients using aromatase 

inhibitors have less gynecological symptoms such as endometrial 

cancer, vaginal bleeding, and vaginal discharges. Fewer 

cerebrovascular events and venous thromboembolic events were 

also observed with patients receiving aromatase inhibitors. 

However, musculoskeletal effects (arthritis, arthralgia, and/or 

myalgia) and bone toxicity (bone fractures) are associated with 

aromatase inhibitors. 

The combination of endocrine therapy and cytotoxic 

chemotherapy provides benefits greater than the benefits from 

either therapy alone. They are therefore usually offered sequentially, 

with chemotherapy given right after surgery, local radiation therapy 

is then given, and endocrine therapy commenced. Premenopausal 

women are given Tamoxifen for five years. The optimal duration of 

the aromatase inhibitors has not yet been determined and 

postmenopausal women remain on them indefinitely. 

Ovarian ablation (e.g., surgical oophorectomy or radiation 

ablation) or suppression (e.g., use of the gonadotropin- releasing 

hormone or luteinizing hormone-releasing hormone analogues) is 

another effective way to reduce estrogen in premenopausal 

women. It can be used as an adjuvant treatment alone or to 

induce menopause in very high risk premenopausal women to 

allow the use of adjuvant aromatase inhibitors. 

Chemotherapy 

Chemotherapy has been shown to substantially improve the longterm, 

relapse-free, and overall survival in both premenopausal and 

postmenopausal women up to age 70 years with lymph nodepositive 

and lymph node-negative disease irrespective of the 

hormone receptor status. 

The administration of polychemotherapy (two or more agents) is 

superior to the administration of single agents. Four to six courses 

of treatment (3–6 months) appear to provide optimal benefit, with 

the administration of additional courses adding to toxicity without 

substantially improving overall outcome. Popular regimes include 

CMF (cyclophosphamide, methotrexate,fluorouracil), CAF, AC, 

FEC. Anthracycline based adjuvant therapy (with doxorubicin or 

epirubicin) result in a small (4-5%) but statistically significant 

improvement in survival compared with non-anthracyclinecontaining 

regimens. 100 . 

Trials using accelerated or dose dense chemotherapy (two 

weekly interval instead of the standard three weeks) with 

granulocyte colony stimulating factor (GCSF) support to overcome 

the risk of neutropenic sepsis has been demonstrated to improve 

both disease free survival and overall survival with fewer 

neutropenic crises. 

Trials using high dose chemotherapy with haemopoietic stem 

cell rescue on the other hand showed high morbidity and no 

benefit from this approach. 

Around 20% of breast cancers over express HER2, and this is 

associated with an adverse prognosis. Trastuzumab is a 

humanised monoclonal antibody directed against the external 

domain of the receptor with clinical activity as a single agent 

inpatients whose cancers over express HER2. 

Trastuzumab in combination with Taxanes and other drugs have 

shown considerable improvement in metastastic breast cancer. Its 

role in the adjuvant setting in early breast cancer has been so 

successful in HER2 positive breast cancer showing significant DFS 

and OS. Unfortunately, the cost implication is a drawback to its 

use in countries with limited resources. 

Bisphosphonates are drugs that inhibit osteoclast mediated 

bone resorption induced by tumors. Some adjuvant trials indicate 

that two years of oral clodronate reduces the incidence of bone 

metastases. One trial showed a small, but significant, 

improvement in overall survival. Further trials are underway with 

clodronate and the newer, more potent bisphosphonate 

zoledronate to define their long term effectiveness. 

They are very useful in patients taking Aromatase inhibitors 

because of the risk of bone loss and fractures. 

Advanced Breast Cancer (Stages III and IV): 

This includes Locally Advanced Breast Cancer (LABC), 

metastastic cancer and recurrent cancer. (see Figure 1) 

LABC 

LABC refers to Stage III tumors according to the TNM staging. 

Locally advanced breast cancer (LABC) accounts for at least half 



of all breast cancers in countries with limited resources and has a 

poor prognosis 12 . Locally advanced tumors include tumours that 

present with palpable lymph node metastases, ulcerations, tumors 

greater than 5 cm etc. 

A subtype of LABC that deserves some further discussion is 

Inflammatory Breast Cancer (IBC). Inflammatory breast cancer is a 

rare but aggressive subtype of breast cancer, which historically 

was considered uniformly fatal. Clinically, inflammatory breast 

cancer is characterized by the rapid onset of breast warmth, 

erythema, and edema (peau d’orange) often without a welldefined 

mass. 

Along with extensive breast involvement, women with 

inflammatory carcinoma often have early involvement of the axillary 

lymph nodes. In general, women with inflammatory breast cancer 

present at a younger age are more likely to have metastatic 

disease at diagnosis, and have shorter survival than women with 

non-inflammatory breast cancer. 101-103 The management of LABC 

requires a combined modality treatment approach involving 

surgery, radiotherapy and systemic therapy. 

Radiotherapy in LABC 

Radiotherapy after MRM or mastectomy to the chest wall or axilla 

is restricted to patients with high risk of recurrence. These include 

tumors larger than 5 cm in maximum diameter and those with 

four or more involved axillary lymph nodes, those with positive 

surgical margins on resection, and those with involvement of the 

skin or underlying chest wall. 12 It can also be a very effective local 

modality in controlling or shrinking tumors that are not amenable 

to surgical therapy. 

Preoperative and locoregional treatment 

The initial management should be neoadjuvant chemotherapy 

with Doxorubicin- or Epirubicin-based or Paclitaxel- or Docetaxel 

based chemotherapy. Patients with HER2 positive tumors should 

be considered for preoperative chemotherapy incorporating 

Trastuzumab. 

The advantages of neoadjuvant therapy include down staging of 

the tumor, improving operability of tumors and increasing the 

chances of BCT. 

For patients that respond to neoadjuvant chemotherapy, the 

following options are recommended 71,104-108 modified radical 

mastectomy, radiotherapy to the chest wall and supraclavicular 

nodes (plus internal mammary nodes if involved) with or without 

delayed breast reconstruction. In those women with LABC who do 

not have access to neoadjuvant chemotherapy because of 

economic constraints or radiotherapy, mastectomy with node 

dissection, when feasible, may still be considered in an attempt to 

achieve local-regional control. 12 The second option is BCT with 

surgical axillary staging, radiotherapy to the breast, supraclavicular 

nodes (plus internal mammary nodes if involved). 

However, for patients who fail to respond to preoperative 

chemotherapy, recommended treatment is to consider additional 

systemic chemotherapy and/or preoperative radiation. 

Adjuvant treatment 

Chemotherapy should contain an anthracycline. Acceptable 

regimens are 6 cycles of 5 Fluorouracil, Doxorubicin, 

Cyclophosphamide (FAC) or Cyclophosphamide, Epirubicin, 

5Fluorouracil (CEF). Sequential addition of Taxanes has also 

proven very effective. 

Tamoxifen for 5 years should be recommended to pre- and 

postmenopausal women whose tumours are hormone responsive. 

Aromatase inhibitors like Letrozole, Anastozole and Examestane 

can be used in post menopausal patients. 

Surgical oophorectomy causing ovarian ablation is a very 

effective therapy in the treatment of locally advanced and 

metastatic ER positive breast cancer in premenopausal women. 

This therapy is one that would be very feasibly applied in Africa 

provided that it was acceptable to the woman. 

Metastastic and recurrent cancer 

The standard evaluation procedure for this group of patients 

includes history and clinical examination, full blood count, liver 

function test, platelet count , chest X-ray, limited skeletal survey 

especially of any long or weight bearing bones that are painful, 

biopsy of recurrence, evaluation of hormone receptor status, 

ultrasound of the abdomen or CT where available. 

Others include bone scans, MRI, PET, and determination of 

HER2 status of the tumor. These are however tall orders in 

countries with limited resources and where there are no medical 

insurances to cover the cost of these investigations. Pragmatism 

is required in this setting. 

Treatment of local recurrence 

Local recurrence can occur in two settings; post BCT or MRM. 

Post MRM local recurrence should undergo local resection of 

the recurrence where feasible without unnecessarily endangering 

the lives of the patients. In addition, radiotherapy of the involved 

area should be done if the chest wall was not previously irradiated 

or if it could be done safely. 

Post BCT patients should undergo a total mastectomy. 

Systemic therapy for local recurrence could be adjuvant 

chemotherapy or endocrine therapy as in LABC. 

Addition of Hyperthermia to radiotherapy has been shown in 

some trials to cause a statistically significant increase in local 

tumor response and greater duration of local control. This is 

however technically demanding and resource intensive. 

Systemic disease 

Systemic recurrence and metastatic cancers are incurable, so the 

goals of therapy are to prolong survival, improve quality of life with 

minimal morbidity or toxicity from the therapy. 

Minimally toxic endocrine therapy is therefore preferred to the 

use of cytotoxic therapy whenever indicated. Endocrine therapies 

are indicated in women with hormone receptor status, bone or 

soft tissue disease only and those with limited asymptomatic 

visceral disease. For post menopausal women, the choice is 

between Tamoxifen and aromatase inhibitors, with aromatase 

inhibitors having a slight edge especially in those who have taken 

anti-estrogen previously. 

For premenopausal women who are anti-estrogen naïve, antiestrogen 

with or without LHRH agonist is the preferred choice. 

Oophorectomy is an excellent cheap alternative where drugs are 

not available. 

Since the majority of African women with breast cancer are 

hormone receptor negative, few will benefit from endocrine 

therapy, chemotherapy will be the option in most cases. 

Premenopausal patients who have taken anti-estrogen 



previously have a choice of either surgical or radiotherapeutic 

oophorectomy or luteinizing hormone-releasing hormone (LHRH) 

agonists with or without an antiestrogen. 

Endocrine therapies in postmenopausal women include 

selective, nonsteroidal aromatase inhibitors (anastrozole and 

letrozole); steroidal aromatase inhibitors (exemestane); pure 

antiestrogens (fulvestrant); progestin (megestrol acetate); 

androgens (fluoxymesterone); and high-dose estrogen (ethinyl 

estradiol). In premenopausal women, therapies include LHRH 

agonists (goserelin and luprolide); surgical or radiotherapeutic 

oophorectomy; progestin (megestrol acetate); androgens 

(fluoxymesterone); and high-dose estrogen (ethinyl estradiol). 

Chemotherapy is the best option in women with estrogen and 

progesterone receptor-negative tumors, symptomatic visceral 

metastasis, or endocrine therapy refractory disease. 

The higher rates of objective response and longer time to 

progression of combination chemotherapy are at the expense of 

increased toxicity with little survival benefit. 

Therefore, there is no significant advantage of combination 

chemotherapy over sequential single agents. 

Preferred first-line chemotherapies include sequential single 

agents or combination chemotherapy. Among preferred first-line 

single agents, are doxorubicin, epirubicin, pegylated liposomal 

doxorubicin, paclitaxel, docetaxel, capecitabine, vinorelbine (all 

category 2A), and gemcitabine (category 2B). Among preferred 

first-line combination regimens are cyclophosphamide, 

doxorubicin, and fluorouracil (FAC/CAF); fluorouracil, epirubicin, 

cyclophosphamide (FEC); doxorubicin, cyclophosphamide (AC); 

epirubicin, cyclophosphamide (EC); doxorubicin in combination 

with either docetaxel or paclitaxel (AT); cyclophosphamide, 

methotrexate, fluorouracil (CMF); docetaxel, capecitabine; 

gemcitabine, paclitaxel. 

Patients with tumors that are HER2-positive may derive benefit 

from treatment with trastuzumab as a single agent or in 

combination with selected chemotherapeutic agents. 27% of 

patients treated with a combination of Trastuzumab and 

doxorubicin/cyclophosphamide chemotherapy develop significant 

cardiac dysfunction making this regime unsafe and unpopular. 71 

Treatment of complications 

In Africa, a good number of women present with fungating/ 

ulcerating masses and many of them are so ill that they can not 

undergo surgery or radiotherapy immediately. The following are 

some useful supportive measures: 

✚ Dressing of the wound with honey and metronidazole 

cleanses and remove the odor. This measure in addition to the 

use of neoadjuvant chemotherapy has largely reduced the 

need for toilet mastectomy. 

✚ Clean malignant ulcers are prone to secondary hemorrhage; 

topical formalin is effective in this setting. 

✚ Pain is another significant problem and this may be due to the 

disease, therapy or depression. Optimal pain management is 

very crucial to improving the quality of life. If pain occurs, there 

should be prompt oral administration of drugs in the following 

order: non-opioids (aspirin and paracetamol); then, as 

necessary, mild opioids (codeine); then strong opioids such as 

morphine, until the patient is free of pain. To calm fears and 

anxiety, additional drugs – “adjuvants” – should be used. To 

maintain freedom from pain, drugs should be given “by the 

clock”, that is every 3-6 hours, rather than “on demand” This 

three-step approach (see figure 2) of administering the right 

drug in the right dose at the right time is inexpensive and 80- 

90% effective. Surgical intervention on appropriate nerves may 

provide further pain relief if drugs are not wholly effective. 109 

✚ Anemia as a result of the disease or chemotherapy is often 

under treated and underestimated in patients. It has a negative 

impact on quality of life and survival. It will require blood 

transfusion in some women. The introduction of recombinant 

human erythropoietin (epoetin) has provided an effective and 

convenient treatment of anemia without the risks of blood 

transfusion. Epoetin is also effective for the prevention of 

anemia and reduction of transfusion requirements in patients 

with a high risk of developing anemia during chemotherapy. 110-112 

✚ Lymphedema of the arm is a very distressing complication 

which may occur as a result of the disease itself or as a result 

of surgery or radiotherapy in the treatment of breast cancer. 

Treatment options include compression treatments (using 

compression bandage or garments and pneumatic 

compression devices), therapeutic exercises and 

pharmacotherapy (antibiotics, flavonoids, hyaluronidase, and 

selenium). Diuretics have not been found useful. 113,114 

✚ Respiratory distress in advanced breast cancer may be as a 

result of pleural effusion or deposits in the lungs. Closed 

thoracostomy tube drainage with pleurodesis using 

Tetracycline or Bleomycin is an effective treatment. Lung 

metastasis can be treated with steroids inhalers, bronchodilators, 

diuretics, anxiolytics, chest physiotherapy and oxygen. 5 

✚ Neurological complications include cerebral metastases, 

spinal, leptomeningeal, cranial and peripheral nerve 

metastases. 115 Treatment includes steroids, 

radiotherapy and surgery for localized metastases. 

Younger women with breast cancer are more prone to physical 

and psychological distress which makes them have poorer quality 

of life outcomes. These arise as a result of the disease and the 

complications of treatment. Gonadal toxicity leading to irregular 

menses, amenorrhea and premature menopause is especially 

disturbing for African patients, the majority of whom are in their 

reproductive age group. Other problems like Alopecia, fertility 

problems and the cost of treatment may severely affect 

relationship especially among young couples. In this context, a 

multi disciplinary approach is important which will involve 

psychologists, social welfare/support groups and various 

advocacy groups where survivors of breast cancer can share their 

experiences and support one another. 116-120 

Prognosis 

Natural history 

The natural history of breast cancer in 250 untreated women 

revealed the following statistics; Median survival of untreated breast 

cancer was 2.7 years after initial diagnosis. The 5- and 10-year 

survival rates were 18.0 and 3.6%, respectively. Only 0.8% survived 

for 15 years or longer. Autopsy data confirmed that 95% of these 

women died of breast cancer, while the remaining 5% died of other 

causes. Almost 75% of the women developed ulceration of the 

breast during the course of the disease. The longest surviving 

patient died in the nineteenth year after diagnosis. 121 

With modern treatment, the 5-year survival rate for stage I 



Table 5: Microscopic criteria for grading of invasive carcinoma 




Basic Modified radical mastectomy Neoadjuvant AC, Ovarian therapy 

FAC or classical CMF* Tamoxifen 

Limited 


wall and regional nodes 

Enhanced Breast-conserving theraphy** Breast-conserving whole-breast irradiation Tamoxifen Aromatese inhibitors 


Maximal Reconstructive surgery Growth factors 


*Requires blood chemistry profile and complete blodd count (CBC) testing 

** Breast-conserving therapy requires mamography and reporting of margin status. 



patients is 94%; for stage IIa patients, 85%; and for stage IIb 

patients, 70%, while for stage IIIa patients the 5-year survival rate 

is 52%; for stage IIIb patients, 48%; and for stage IV patients, 18%. 

Prognostic Iindicators: 

Tumor size 

Prognosis deteriorates with increasing tumor size, which is an 

independent predictor of survival in node-negative patients and 

correlates with the incidence of nodal metastases. 

Staging 

The status of the axillary lymph nodes is one of the most useful 

prognostic indicators for breast cancer, with average 10-year 

survival rates of 60-70% for node-negative patients, dropping to 

20-30% in node-positive patients. 

Histopathology 

✚ Histologic type 

• Carcinoma in situ, because it is a preinvasive condition, is 

curable if completely removed, although 16% of patients with 

carcinoma in situ develop invasive recurrence after local 

excision of ductal carcinoma in situ, usually high grade. 

Similarly, 18% of patients develop invasive recurrence after 

lobular carcinoma in situ excision. 

• Well-differentiated invasive cancers have a relatively good 

prognosis if they are tubular, mucinous, cribriform, or 

secretory. 

• Medullary carcinoma is probably of intermediate prognosis, but 

different studies have used different criteria for its definition. 

• Invasive ductal and invasive lobular carcinomas have a less 

favorable prognosis but are influenced heavily by other factors. 

✚ Cytologic grade 

• Cytologic grade is the best predictor of disease prognosis in 

carcinoma in situ but is dependent on the grading system 

used, such as the Van Nuys classification (high-grade, lowgrade 

comedo, low-grade noncomedo). 

• The grading of invasive carcinoma is also important as a 

prognostic indicator, with higher grades indicating a worse 

prognosis. Microscopic criteria for grading are shown in 

Table 5. 

✚ Lymphovascular: Lymphatic invasion, vascular invasion, 

microvessel quantification, and lymphoplasmacytic infiltration 

are associated with a worse prognosis. 

✚ Hormone receptor status: With the aid of gene expression 

studies using DNA microarrays and immunohistochemistry, 

several distinct biologic breast cancer subtypes have been 

identified. These subtypes differ markedly in prognosis and in 

the number of potential therapeutic targets they express. 

The intrinsic subtypes include 2 main subtypes of estrogen 

receptor (ER)–negative tumors (basal-likeand human epidermal 

growth factor receptor-2 positive/ER- [HER2_/ER-] subtype) and 

at least 2 types of ER+ tumors (luminal A and luminal B). The basal 

like subtype carries poor biologic (worse grade) and clinical 

prognostic indicators like positive axillary nodes. 

This subtype was found to be more prevalent in pre-menopausal 

African-American women compared to post menopausal African- 

American women and other races. 122 This finding may be one of the 

reasons why African-American women with breast cancer have 

high grade, late stage tumor and with poor prognosis and poor 

survival outcome. 

The similar clinical outcome of native African women with breast 

cancer may tempt one to extrapolate these findings seen in 

African-American women. To lend credence to this fact, the few 

studies on hormone receptor status of breast cancer in native 

African women show that the majority of them are Estrogen or 

Progesterone negative 123-125 . 

There are also several other provocative parallels between 

African-American and native African breast cancer patients which 

include a younger age distribution and a greater prevalence of high 

grade, estrogen-receptor-negative disease among breast cancer 

patients in the Ghanaian and Nigerian populations of western 

Africa similar to the patterns of breast cancer reported among 

African-American women. Western African populations served as 

the source for most of the slave trade to colonial North America, 

and therefore share a common ancestry with present-generation 

African Americans. These parallels suggest the possible 

contribution of founder effects. 16 

However, further research needs to be done in this area before 

reaching any conclusion is reached as the African-Americans are 



Table 6: Treatment and allocation of resources: Metastatic (stage IV) and recurrent breast Cancer 



Level of resource Surgery Radiation therphy Chemotherphy Endocrine therphy Supportive and pallative ther 

Basic Total mastectomy for Ovarian ablation Nonopioid and opioid 

ipeilateral breast tumor recurrance* Tamoxifen analgesics 

Limited Pallative radiation therapy Classical CMF** 

Anthracycline montherapy 

or in combination** 

Enhanced Taxanes Aromatese inhibitors Biophosphonates 

Capecitabine 

Trastzumab 

Maximal Reconstructive surgery Growth factors Fulvestrant 

Vinorebine 

Gemcitabine 

Carboplatin 

* Required resources are the same as those modified radical masectomy 

** Requires blood chemistry profile and complete blood count (CBC) testing. CMF, cyclophosphamides, methotrexate and 5-fluorouracil 

a heterogeneous group with mixed genetic heritage consisting of 

Hispanics, Caucasians and Africans. In addition other 

socioeconomic factors and environmental factors may contribute 

to the clinical outcome seen. 126,127 

✚ Immunohistochemistry 

• The most widely used tests are for the estrogen receptors (ER) 

and progesterone receptors (PR). Immunohistochemistry 

analysis of heat-treated paraffin sections has largely 

superseded the enzyme-linked immunosorbent assay (ELISA) 

ligand-binding assay. ER- and PR-positive status (ie, >10 fmol 

on ELISA; >15 H-score on immunohistochemistry) predict 

improved response to endocrine treatment, time to relapse, 

and overall survival. 

• Immunohistochemical positivity for c-erb-B2 and p53 is 

associated with a worse prognosis. 

• HER-2 status: The human epidermal growth factor receptor-2 

(HER-2/neu) is a well-characterized biomarker in the biology of 

breast carcinoma that has had immediate impact on clinical 

medicine. The positive status of HER-2/neu is associated with 

a younger age and several adverse prognostic factors, i.e., 

advanced stage, absence of estrogen and progesterone 

receptors, metastasis to axillary lymph nodes, and high 

nuclear grade. In addition, women diagnosed with 

positiveHER-2/neu breast carcinoma generally have relative 

resistance to anthracycline-based chemotherapy, tamoxifen 

therapy, and have shorter disease-free and overall survival. 128 

Other prognostic indicators 

Advances, in the knowledge of the molecular mechanisms that 

influence normal and aberrant cell growth, have led to the 

identification of an increasing number of surrogate biomarkers, 

which have been correlated with prognosis or used as predictors 

of response to specific treatments. These novel prognostic 

markers can be classified as follows: 

✚ Oncogene products 

• Bcl-2 

• p53 

• HER-2/neu 

• Cyclin D1 

• Nm23 

✚ Proteases 

• uPA 

• Cathepsin D 

• Tenascin C 

✚ Markers of proliferation - Ki-67 

HER-2/neu identifies patients with a poor prognosis. These 

patients are likely to respond to treatment with trastuzumab 

(Herceptin). 

Tumors positive for Ki-67 have a high metastatic potential and 

warrant the possible use of early aggressive therapy. 

uPA and cathepsin D identify poor prognosis node-negative 

tumors. In these cases, chemotherapy can be offered. 

The use of gene expression profiling to detect breast carcinoma 

has already shown that the differential expression of specific genes 

is a more powerful prognostic indicator than traditional 

determinants such as tumor size and lymph node status. These 

molecular assays are awaiting clinical validation. 

Prevention 

Screening as currently practiced can reduce mortality but not 

incidence, and then only in a particular age group. Advances in 

treatment have produced significant but modest survival benefits. 

A better appreciation of factors important in the etiology of breast 

cancer would raise the possibility of disease prevention. Currently, 

prevention strategies fall into two groups: chemoprevention and 

surgical prophylaxis. 

Chemoprevention is defined as the systemic use of natural or 

synthetic chemical agents to reverse or suppress the progression 

of a premalignant lesion to an invasive carcinoma 129 . Tamoxifen is 

currently the only agent that has been approved clinically for use 

in women with high risk of developing cancer. Raloxifene, 

selenium, retinoids, aromatase inhibitors and cyclo-oxygenase 2 

inhibitors require further clinical investigation before adoption in 

this context. 

Surgical prophylaxis: by either a bilateral mastectomy or 

oophorectomy, is another avenue of prevention. Some studies 



Table 7: Healthcare systems and public policy 

LEVEL OF RESOURCE SERVICE FACILITIES RECORD KEEPING 

Basic Primary care service Health facility Individual medical records and servvice-based patient registartion 

Surgical services 

Operating facility 

Pathology services 

Pathology laboratory 

Oncology services 

Pharmcay 

Nursing services 

Outpatient care facility 

Pallative services 

Linked Imaging services Imaging facility Facility-based medical records and centrilized patient registration 

Radiation oncology services Radiation theraphy 

Peer support services Clinical information systems Local cancer registry 

Early detection programme Health system network 

Enhanced 

Opportunistic screening programme Centralized referal cancer centre(s) Facility-based follow-up registry 

Cancer follow-up 

Rehabilitation services Population based cancer registry Regional Cancer registry 

Maximal Population based Sarellite (non-centralized National Cancer registry 

screening programme 

or regional) Cancer centre 

Individual psychological care 

have demonstrated that women with definite BRCA1 or BRCA2 

mutation may have an overall reduction in their breast cancer risk 

profile after such operation. 130 

Dietary intervention If specific dietary factors are found to be 

associated with an increased risk of breast cancer dietary 

intervention will be possible. However, reduction of dietary intake 

of such a factor in whole communities may well be difficult to 

achieve without major social and cultural changes. Dietary fat 

reduction and exercise decrease the circulating serum oestradiol 

level, but whether this in turn leads to a reduction in the incidence 

of breast carcinoma has not been determined conclusively. 131 

Breast cancer and pregnancy 

Pregnancy associated breast cancer is defined as breast cancer 

diagnosed during pregnancy or lactation or one year post partum. 

Breast cancer and pregnancy can be classified into three main 

situations; these are (a) breast cancer that is detected during the 

evolution of pregnancy, (b) breast cancer that is detected during 

lactation or postpartum, and (c) pregnancy in patients who have 

had a previous breast cancer. Cancer complicates approximately 

1 per 1000 pregnancies and accounts for one-third of maternal 

deaths during gestation. The prevalence of breast cancer during 

pregnancy is increasing due to delayed onset of childbearing. 

Breast cancer is diagnosed in approximately 1 in 3000 

pregnancies. The incidence ranges from 0.76% to 3.8% of breast 

cancer cases. The median age of pregnant women affected with 

breast cancer is 33 years. In a recent review in Nigeria, 12% of the 

patients with Breast Cancer were pregnant or lactating and 74% 

were premenopausal , making it the most frequently occurring 

malignancy during pregnancy, along with cancer of the uterine 

cervix.(5) Treatment decisions for breast cancer patients during 

pregnancy become most difficult because not only the mother but 

also the fetus is involved. The final advice should be based upon 

the following considerations: 

✚ the parents’ decision whether or not to continue with the 

pregnancy, 

✚ the period of pregnancy when the breast cancer is 

diagnosed, and 

✚ the stage of the breast cancer. 

A detailed guideline on the management of breast cancer in 

pregnancy can be found in the NCCN Clinical Practice Guidelines 

in Oncology Breast cancer V.1.2007 at www.nccn.org. 

Early studies have indicated that the prognosis of breast cancer 

in pregnancy is very poor; however, more recent studies with more 

careful consideration of age and the stage of the disease show no 

significant differences. Evidence is lacking that termination of 

pregnancy changes the outcome of breast cancer. Pregnancy 

after breast cancer does not alter the outcome of treatment. The 

ideal interval between treatment for breast cancer and subsequent 

pregnancy is unknown. 132 

Breast cancer in males 

Male breast cancer is an uncommon disease although the 

incidence has increased over the past 25 years. Less than 1% of 

all breast cancer patients are male. Rates of male breast cancer 

vary widely between countries: in Uganda and Zambia the annual 

incidence rates are 5% and 15%, respectively of all breast cancer 

cases. These relatively high rates have been attributed to endemic 

infectious diseases causing liver damage, leading to 

hyperestrogenism. By contrast, the annual incidence of male 

breast cancer in Japan is less than five per million, in parallel with 

the lower than average incidence of female breast cancer in that 

country. Jewish men are the only racial group with a higher than 

average incidence (2•3/100 000 per year), irrespective of living in 

Israel or the USA. 133 Risk factors for Breast Cancer include Genetic 

(BRCA2, Klinefelter’s syndrome), Lifestyle (Obesity, Alcohol, 

Estrogen intake), Work (High ambient temperature, Exhaust 

emissions), and Disease (Testicular damage, Liver damage, 

Radiotherapy to chest) The predominant histological type of 

disease is invasive ductal, which forms more than 90% of all male 

breast tumors. 

Much rarer tumour types include invasive papillomas and 

medullary lesions. Lobular carcinoma of the male breast has been 

reported not only in men with Klinefelter’s syndrome, but also in 

genotypically normal men with no previous history of oestrogen 

exposure or gynaecomastia. In large studies of male breast cancer, 



oestrogen receptor positivity has been reported in more than 90% 

of tumours, with 92–96% being progesterone-receptor positive. 

Some studies suggested that breast cancer has a worse 

prognosis in men than in women, but if age- matched and stagematched 

breast cancer is compared, there is no difference 

between the sexes 18;134;135 

Future trends and controversies 

✚ Diagnosis and early detection Several new technologies, 

apart from mammography are being evaluated to improve the 

early detection of breast cancer. These include non ionizing 

imaging techniques like Ultrasonography and MRI. Other 

imaging tools being evaluated include scintimammography, 

positron emission tomography, magnetic resonance 

spectroscopy, optical imaging, thermo-acoustic computed 

tomography, microwave imaging, Hall effect imaging etc. 

✚ Molecular targets and new drugs HER-2 Pertuzumab 

(also known as 2C4, Omnitarg) is a new recombinant 

humanised monoclonal antibody that also binds the 

extracellular portion of HER2, which causes steric hindrance 

and impairs receptor dimerisation. Ongoing phase-I testing 

has shown activity in patients with breast cancer that is either 

HER2-negative and trastuzumab-refractory HER2-positive. 

✚ Tyrosine kinase, cyclines, and proteosoma Most tyrosinekinase 

inhibitors are in preclinical investigations and only a few 

have been tested in patients with advanced breast cancer. 

Gefitinib is an inhibitor of the tyrosine kinase of human 

epidermalgrowth-factor receptor (HER1) and has shown some 

antitumour activity in preclinical studies and a phase II trial of 

patients heavily pretreated for metastatic breast cancer. 

✚ Insulin-like growth factor (IGF) IGF is an interesting 

therapeutic target in breast cancer because its ligands and 

receptors are often overexpressed and are implicated in 

proliferation, transformation, and metastasis. The IGF system 

includes ligands IGF-I and IGF-II, receptors IGF-IR and IGF-IIR, 

and six known IGF-binding proteins. These binding proteins 

are promising targets for the manipulation of endocrine 

responsiveness and resistance to Trastuzumab. 

✚ Angiogenesis Bevacizumab is a recombinant, humanised 

monoclonal antibody to vascular endothelial growth factor that 

has shown some efficacy when used alone in phase II clinical 

trials. Several anti-angiogenic drugs have been tested for 

efficacy, including thalidomide, endostatin, angiostatin, 

SU6668, SU11248, and cyclo-oxygenase 2 (COX-2) inhibitors. 

COX-2 also improves the efficacy of 

✚ Receptors as targets for radionuclides Efficacy of targeted 

therapy depends on the biologically relevant quality and 

quantity of the specific compound. This treatment needs to 

reach the target efficiently and accurately and exert a selective 

therapeutic effect. The development of biomarkers to assess 

in-vivo responses and the ability to use such biomarkers as 

targets for specific radionuclide treatment represent great 

challenges in cancer medicine. 

In situ ablation 

In situ ablation of the primary tumour has been suggested as an 

alternative to surgery. There are preliminary reports on methods 

using cryosurgery, or coagulating with heat, delivered by a laser 

fiberoptic technique . 

Who will perform breast surgery? 

Within the next decade the number of patients undergoing axillary 

surgery will diminish as a result of improved staging by sentinel 

node biopsy. A greater part of the patients will have only breast 

resection, and these operations can be performed as day-case 

surgery, even under local anaesthesia. The surgical challenges 

during the next decade will be immediate breast reconstruction 

and various oncoplastic procedures. Therefore breast surgery will 

increasingly be performed by plastic surgeons. General surgeons 

will not be so interested in carrying out all the other rather 

undemanding breast procedures. 136 

Controversies 

✚ Relevance. 

✚ The place of post mastectomy radiotherapy in early breast 

cancer especially in women with T1 ,T2 and one to three 

positive lymph nodes. 

✚ Sequencing of post mastectomy radiotherapy and breast 

reconstruction. 137 

✚ The impact of mammographic screening in reduction of 

mortality in breast cancer. 

Conclusion 

Management of breast cancer is a major challenge in resource 

limited countries. 

Efforts should be geared towards early diagnosis, prompt and 

standardized treatment to reduce the burden of advanced disease 

in African women, majority of who are worse hit in the most 

productive part of their life time. 

Our knowledge about breast cancer is evolving, but is still 

limited with respect to its etiology and biology, and with respect to 

its features in individual countries and cultures. 

Further research is needed to understand the role of genetics 

and environment in the etiology of breast cancer in Africa. 

Recommnedations 

In high-resource countries, evidence-based guidelines outlining 

optimal approaches to early detection, diagnosis, and treatment of 

breast cancer have been defined and disseminated. These 

guidelines unfortunately are not applicable in countries with 

resource constraints as they are not economically feasible or 

culturally appropriate. 

The following recommendations might be considered appropriate 

in the resource-poor countries of Africa. Following the Breast Health 

Global Initiative we have stratified the recommendations into Basic, 

Limited, Enhanced and Maximal. 10-12,138 

Definition of stratification terms 

✚ Basic level – Core resources or fundamental services 

absolutely necessary for any breast healthcare system to 

function. By definition, a healthcare system lacking any basiclevel 

resource would be unable to provide breast cancer care 

to its patient population. Basic-level services are typically 

applied in a single clinical interaction. 

✚ Limited level – Second-tier resources or services that 

produce major improvements in outcome, such as increased 

survival, but which are attainable with limited financial means 

and modest infrastructure. Limited-level services may involve 

single or multiple clinical interactions. 



✚ Enhanced level – Third-tier resources or services that are 

optional but important. Enhanced-level resources may produce 

minor improvements in outcome but increase the number and 

quality of therapeutic options and patient choice. 

✚ Maximal level – High-level resources or services that may be 

used in some high-resource countries, but nonetheless should 

be considered lower priority than those in the basic, limited, or 

enhanced categories on the basis of cost or impracticality for 

limited-resource environments. In order to be useful, maximallevel 

resources typically depend on the existence and 

functionality of all lower-level resources. 

Our own recommendations include: 

✚ Early Detection and Diagnosis: Possible less resourceintensive 

methods for earlier diagnosis of breast cancer like 

education in breast awareness, training in breast selfexamination 

(BSE), regular clinical breast examination (CBE) by 

experienced personnel and diagnostic ultrasound may be the 

option in resource limited countries as mammography 

screening may be resource intensive. 69 

✚ To improve breast pathological capacity and services in Africa, 

the following approaches may be explored; including training 

pathologists, establishing pathology services in centralized 

facilities, and organizing international pathology services. In 

particular it is important that estrogen and progesterone 

receptor status of tumors be identified. 

✚ As staging is crucial to treatment decisions and prognosis, a 

thorough clinical evaluation after the diagnosis of breast cancer 

to check for clinically obvious indications of metastases to the 

lymph nodes and other areas is crucial. In addition, tests to 

assess the presence of metastases to the lungs, liver, and 

bone provide valuable information, if available. Hormone 

receptor testing of pathology specimens should be part of the 

pathology services 

✚ More training for surgeons in BCT and Sentinel node biopsy. ❏ 


Recommendations are presented in tabular form and are 

reproduced with permission from the BHGI. 

References 

1. 

Veronesi U, Boyle P, Goldhirsch A, Orecchia R, Viale G, Veronesi U, et al. Breast cancer.[see 

comment]. [Review] [160 refs]. Lancet 2005 May 14;365(9472):1727-41. 

2. 

Parkin DM, Bray F, Ferlay J, Pisani P, Parkin DM, Bray F, et al. Global cancer statistics, 2005. CA: 

a Cancer Journal for Clinicians 2005 Mar;55(2):74-108. Abstract Only 

3. 

Vorobiof DA, Sitas F, Vorobiof G, Vorobiof DA, Sitas F, Vorobiof G. Breast cancer incidence in 

South Africa. [Review] [16 refs]. Journal of Clinical Oncology 2001 Sep 15;19(18 Suppl):125S- 

7S. 

4. 

Omar S, Khaled H, Gaafar R, Zekry AR, Eissa S, el-Khatib O, et al. Breast cancer in Egypt: a 

review of disease presentation and detection strategies. [Review] [44 refs]. Eastern 

Mediterranean Health Journal 2003 May;9(3):448-63. 

5. 

Adebamowo CA, Ajayi OO, Adebamowo CA, Ajayi OO. Breast cancer in Nigeria. [Review] [74 

refs]. West African Journal of Medicine 2000 Jul;19(3):179-91. 

6. 

Adesunkanmi AR, Lawal OO, Adelusola KA, Durosimi MA, Adesunkanmi ARK, Lawal OO, et al. 

The severity, outcome and challenges of breast cancer in Nigeria. Breast 2006 Jun;15(3):399- 

409. 

7. 

Hisham AN, Yip CH, Hisham AN, Yip CH. Overview of breast cancer in Malaysian women: a 

problem with late diagnosis. Asian Journal of Surgery 2004 Apr;27(2):130-3. Abstract Only 

8. 

Parkin DM, Bray F, Ferlay J, Pisani P, Parkin DM, Bray F, et al. Global cancer statistics, 2005. CA: 

a Cancer Journal for Clinicians 2005 Mar;55(2):74-108. Abstract Only 

9. 

Kirby I.Bland ea. The Breast. Schwartz’s Principles of Surgery 8th edition. 2007. Ref Type: 

Generic 

10. 

Anderson BO, Shyyan R, Eniu A, Smith RA, Yip CH, Bese NS, et al. Breast Cancer in Limited- 

Resource Countries: An Overview of the Breast Health Global Initiative 2005 Guidelines. The 


Review – February 2007 

Charles A Adisa, MBBS, FWACS, FACS- Dr Adisa is Professor of 

Surgery at the Abia State University(ABSU) and a honorary 

Consultant Surgeon to the Abia State University Teaching Hospital 

(ABSUTH) . He joined the division of surgery at ABSU in 1995 

where he served as the Chief of Surgery and the pioneer director 

of the residency training programme. He is currently the Head of 

the surgical oncology division in ABSUTH and the evolving 

minimally invasive surgical unit. His basic science research 

focuses on the role of pro inflammatory macrophages in breast 

cancer. His clinical interest is in surgical oncology especially 

breast, colorectal and prostatic cancers. He received his medical 

degree from the University of Ibadan, Nigeria with a distinction in 

Anatomy. He completed his general surgery residency at the 

University College Hospital, Ibadan and the University of Nigeria 

Teaching Hospital, Enugu, Nigeria. He was the best graduate in 

Surgery at the Fellowship examination of the West African College 

of Surgeons in 1995 with the award of the distinguished Jide Ajayi 

gold medal in Surgery.He was the American Colllege of Surgeons 

Guest Scholar in 2007 and the recipient of the American Society 

of Clinical Oncology International Development and Educational 

Award (IDEA) in 2008. He is an active member of several 

professional associations including the west African college of 

surgeons where he serves as an examiner, ASCO, AAS, 

AUA,ACS and several others. 

Dr Adisa’s first faculty position was as a Lecturer I (Assistant 

Professor) at the College of Medicine and Health Sciences, Abia 

State University in 1995. He is currently the Dean of Clinical 

Medicine at the Abia State University and the Chief Medical 

Director of Maranatha Specialist Hospital. Abia State University 

Teaching Hospital is the apex medical institution in Abia State 

South East Nigeria and caters for a population of over 5 million 

people from Abia state and the neighboring states. She was the 

second state funded teaching hospital in Nigeria to commence 

undergraduate medical education. 

Breast Journal 2006;12(s1):S3-S15. 

11. 

Eniu A, Carlson RW, Aziz Z, Bines J, Hortobagyi GN, Bese NS, et al. Breast Cancer in Limited- 

Resource Countries: Treatment and Allocation of Resources. The Breast Journal 

2006;12(s1):S38-S53. 

12. 

Robert W.Carlson M*BOAMRCMAEEMRJMRRLM*MMaGSMP. Treatment of Breast Cancer in 

Countries with Limited Resources. The Breast Journal 9, 67-74. 2003. Ref Type: Generic 

13. 

Breasted JH. The Edwin Smith Surgical Papyrus. Classics of Med Lib. Vol III., 405. 1930. 

Chicago, University of Chicago Press. 

Ref Type: Generic 

14. 

McPherson K, Steel CM, Dixon JM, McPherson K, Steel CM, Dixon JM. ABC of breast diseases. 

Breast cancer-epidemiology, risk factors, and genetics.[see comment]. [Review] [16 refs]. BMJ 

2000 Sep 9;321(7261):624-8. 

15. 

Ijaduola TG, Smith EB, Ijaduola TG, Smith EB. Pattern of breast cancer among white-American, 

African-American, and nonimmigrant west-African women. [Review] [45 refs]. Journal of the 

National Medical Association 1998 Sep;90(9):547-51. Abstract Only 

16. 

Newman LA, Newman LA. Breast cancer in African-American women. [Review] [117 refs]. 

Oncologist 2005 Jan;10(1):1-14. 

17. 

Polite BN, Olopade OI, Polite BN, Olopade OI. Breast cancer and race: a rising tide does not lift 

all boats equally. [Review] [21 refs]. Perspectives in Biology & Medicine 2005;48(1 

Suppl):S166-S175. 

18. 

Fentiman IS, Fourquet A, Hortobagyi GN, Fentiman IS, Fourquet A, Hortobagyi GN. Male breast 

cancer. [Review] [142 refs]. Lancet 2006 Feb 18;367(9510):595-604. 

19. 

Petrocca S, La TM, Cosenza G, Bocchetti T, Cavallini M, Di SD, et al. Male breast cancer: a case 

report and review of the literature. [Review] [39 refs]. Chirurgia Italiana 2005 May;57(3):365- 

71. Abstract Only 




20. 

Weiss JR, Moysich KB, Swede H, Weiss JR, Moysich KB, Swede H. Epidemiology of male 

breast cancer. [Review] [126 refs]. Cancer Epidemiology, Biomarkers & Prevention 2005 

Jan;14(1):20-6. 

21. 

Okobia MN, Osime U, Okobia MN, Osime U. Clinicopathological study of carcinoma of the 

breast in Benin City. African Journal of Reproductive Health 2001 Aug;5(2):56-62. Abstract 

Only 

22. 

Kidmas AT, Ugwu BT, Manasseh AN, Iya D, Opaluwa AS, Kidmas AT, et al. Male breast 

malignancy in Jos University Teaching Hospital. West African Journal of Medicine 2005 

Jan;24(1):36-40. 

23. 

Sano D, Dao B, Lankoande J, Toure B, Sakande B, Traore SS, et al. [Male breast cancer in 

Africa, Apropos of 5 cases at the Ouagadougou University Teaching Hospital (Burkina Faso)]. 

[French]. Bulletin du Cancer 1997 Feb;84(2):175-7. Abstract Only 

24. 

Loefler IJ, Loefler IJ. Male breast cancer.[comment]. British Journal of Surgery 1997 

Dec;84(12):1748. 

25. 

Bray F, McCarron P, Parkin DM, Bray F, McCarron P, Parkin DM. The changing global patterns of 

female breast cancer incidence and mortality. [Review] [85 refs]. Breast Cancer Research 

2004;6(6):229-39. 

26. 

Colditz GA, Colditz GA. Epidemiology and prevention of breast cancer. [Review] [46 refs]. 

Cancer Epidemiology, Biomarkers & Prevention 2005 Apr;14(4):768-72. 

27. 

Hortobagyi GN, de la Garza SJ, Pritchard K, Amadori D, Haidinger R, Hudis CA, et al. The global 

breast cancer burden: variations in epidemiology and survival. [Review] [78 refs]. Clinical 

Breast Cancer 2005 Dec;6(5):391-401. Abstract Only 

28. 

MacMahon B, MacMahon B. Epidemiology and the causes of breast cancer. [Review] [46 refs]. 

International Journal of Cancer 2006 May 15;118(10):2373-8. 

29. 

Basu A, Rowan BG, Basu A, Rowan BG. Genes related to estrogen action in reproduction and 

breast cancer. [Review] [277 refs]. Frontiers in Bioscience 2005;10:2346-72. Abstract Only 

30. 

Colditz GA, Colditz GA. Estrogen, estrogen plus progestin therapy, and risk of breast cancer. 

[Review] [39 refs]. Clinical Cancer Research 2005 Jan 15;11(2 Pt 2):909s-17s. Abstract Only 

31. 

Darbre PD, Darbre PD. Environmental oestrogens, cosmetics and breast cancer. [Review] [159 

refs]. Best Practice & Research Clinical Endocrinology & Metabolism 2006 Mar;20(1):121-43. 

32. 

Kristensen VN, Sorlie T, Geisler J, Langerod A, Yoshimura N, Karesen R, et al. Gene expression 

profiling of breast cancer in relation to estrogen receptor status and estrogen-metabolizing 

enzymes: clinical implications. [Review] [24 refs]. Clinical Cancer Research 2005 Jan 15;11(2 

Pt 2):878s-83s. 

33. 

Okobia MN, Bunker CH, Okobia MN, Bunker CH. Estrogen metabolism and breast cancer risk–a 

review.[see comment]. [Review] [81 refs]. African Journal of Reproductive Health 2006 

Apr;10(1):13-25. 

34. 

anten RJ, Mansel R, Santen RJ, Mansel R. Benign breast disorders. [Review] [89 refs]. New 

England Journal of Medicine 2005 Jul 21;353(3):275-85. 

35. 

Gikas PD, Mansfield L, Mokbel K, Gikas PD, Mansfield L, Mokbel K. Do underarm cosmetics 

cause breast cancer?. [Review] [17 refs]. International Journal of Fertility & Womens Medicine 

2004 Sep;49(5):212-4. 

36. 

Safe S, Papineni S, Safe S, Papineni S. The role of xenoestrogenic compounds in the 

development of breast cancer. [Review] [67 refs]. Trends in Pharmacological Sciences 2006 

Aug;27(8):447-54. Abstract Only 

37. 

Friedenreich CM, Friedenreich CM. Physical activity and breast cancer risk: the effect of 

menopausal status. [Review] [14 refs]. Exercise & Sport Sciences Reviews 2004 

Oct;32(4):180-4. 

38. 

Lorincz AM, Sukumar S, Lorincz AM, Sukumar S. Molecular links between obesity and breast 

cancer. [Review] [111 refs]. Endocrine-Related Cancer 2006 Jun;13(2):279-92. 

39. 

Kaur T, Zhang ZF, Kaur T, Zhang ZF. Obesity, breast cancer and the role of adipocytokines. 

[Review] [60 refs]. Asian Pacific Journal of Cancer Prevention: Apjcp 2005 Oct;6(4):547-52. 

40. 

Dumitrescu RG, Shields PG, Dumitrescu RG, Shields PG. The etiology of alcohol-induced breast 

cancer. [Review] [205 refs]. Alcohol 2005 Apr;35(3):213-25. 

41. 

Nagata C, Mizoue T, Tanaka K, Tsuji I, Wakai K, Inoue M, et al. Tobacco smoking and breast 

cancer risk: an evaluation based on a systematic review of epidemiological evidence among 

the Japanese population. [Review] [38 refs]. Japanese Journal of Clinical Oncology 2006 

Jun;36(6):387-94. 

42. 

Tsubura A, Uehara N, Kiyozuka Y, Shikata N, Tsubura A, Uehara N, et al. Dietary factors 

modifying breast cancer risk and relation to time of intake. [Review] [108 refs]. Journal of 

Mammary Gland Biology & Neoplasia 2005 Jan;10(1):87-100. 

43. 

Dumitrescu RG, Cotarla I, Dumitrescu RG, Cotarla I. Understanding breast cancer risk – where 

do we stand in 2005?. [Review] [107 refs]. Journal of Cellular & Molecular Medicine 2005 

Jan;9(1):208-21. 

44. 

Buchholz TA, Wu X, Hussain A, Tucker SL, Mills GB, Haffty B, et al. Evidence of haplotype 

insufficiency in human cells containing a germline mutation in BRCA1 or BRCA2. International 

Journal of Cancer 2002 Feb 10;97(5):557-61. 

45. 

Nanda R SLCSFJSLAFeal. Genetic testing in an ethnically diverse cohort of high-risk women: a 

comparative analysis of BRCA1 and BRCA2 mutations in American families of European and 

African ancestry. JAMA 94(15)., 1925-33. 2005. 

46. 

Kean-Cowdin R SFXLPCTDSDeal. BRCA1 variants in a family study of African-American and 

Latina women. Hum Genet 2005 116(6): 497-506and metastastic cancers are incurable. 

2005. 

47. 

Fregene A NL. Breast cancer in sub-Saharan Africa : how does it relate to breast cancer in 

African-American women? Cancer 103(8), 1540-50 Breast cancer in sub-Saharan Africa : how 

does it relate to breast cancer in African-American women? 2005. 

48. 

Lacroix M, Leclercq G, Lacroix M, Leclercq G. The “portrait” of hereditary breast cancer. 

[Review] [79 refs]. Breast Cancer Research & Treatment 2005 Feb;89(3):297-304. 

49. 

Rubinstein WS, Rubinstein WS. Hereditary breast cancer in Jews. [Review] [110 refs]. Familial 

Cancer 2004;3(3-4):249-57. 

50. 

Smith KL, Robson ME, Smith KL, Robson ME. Update on hereditary breast cancer. [Review] [50 

refs]. Current Oncology Reports 2006 Jan;8(1):14-21. 

51. 

Thull DL, Vogel VG, Thull DL, Vogel VG. Recognition and management of hereditary breast 

cancer syndromes. [Review] [80 refs]. Oncologist 2004;9(1):13-24. 

52. 

Antoniou AC, Easton DF, Antoniou AC, Easton DF. Risk prediction models for familial breast 

cancer. [Review] [89 refs]. Future Oncology 2006 Apr;2(2):257-74. 

53. 

Baltzell K, Wrensch MR, Baltzell K, Wrensch MR. Strengths and limitations of breast cancer risk 

assessment. [Review] [60 refs]. 2005 May;Online. 32(3):605-16. 

54. 

Vogel V, Vogel V. Chemoprevention in breast cancer. [Review] [5 refs]. Clinical Advances in 

Hematology & Oncology 2005 Jul;3(7):531-3. 

55. 

Singletary SE, Connolly JL, Singletary SE, Connolly JL. Breast cancer staging: working with the 

sixth edition of the AJCC Cancer Staging Manual. [Review] [28 refs]. CA: a Cancer Journal for 

Clinicians 2006 Jan;56(1):37-47. 

56. 

Yamamoto D, Tanaka K, Yamamoto D, Tanaka K. A review of mammary ductoscopy in breast 

cancer.[see comment]. [Review] [31 refs]. Breast Journal 2004 Jul;10(4):295-7. 

57. 

Leris C, Mokbel K, Leris C, Mokbel K. The role of mammary ductoscopy in the assessment of 

breast disease. [Review] [15 refs]. International Journal of Fertility & Womens Medicine 2004 

Sep;49(5):200-2. 

58. 

Sarakbi WA, Escobar PF, Mokbel K, Sarakbi WA, Escobar PF, Mokbel K. The potential role of 

breast ductoscopy in breast cancer screening. [Review] [22 refs]. International Journal of 

Fertility & Womens Medicine 2005 Sep;50(5 Pt 1):208-11. 

59. 

Sauter E, Sauter E. Breast cancer detection using mammary ductoscopy. [Review] [27 refs]. 

Future Oncology 2005 Jun;1(3):385-93. 

60. 

Fine RE, Staren ED, Fine RE, Staren ED. Updates in breast ultrasound. [Review] [105 refs]. 

Surgical Clinics of North America 2004 Aug 20;84(4):1001-34. 

61. 

Rubio IT, Henry-Tillman R, Klimberg VS, Rubio IT, Henry-Tillman R, Klimberg VS. Surgical use of 

breast ultrasound. [Review] [72 refs]. Surgical Clinics of North America 2003 Aug;83(4):771- 

88. 

62. 

Hylton N, Hylton N. Magnetic resonance imaging of the breast: opportunities to improve breast 

cancer management.[see comment]. [Review] [54 refs]. Journal of Clinical Oncology 2005 Mar 

10;23(8):1678-84. 

63. 

Lalonde L, David J, Trop I, Lalonde L, David J, Trop I. Magnetic resonance imaging of the 

breast: current indications. [Review] [24 refs]. Canadian Association of Radiologists Journal 

2005 Dec;56(5):301-8. 

64. 

Pavic D, Koomen MA, Kuzmiak CM, Lee YH, Pisano ED, Pavic D, et al. The role of magnetic 

resonance imaging in diagnosis and management of breast cancer. [Review] [121 refs]. 

Technology in Cancer Research & Treatment 2004 Dec;3(6):527-41. 

65. 

Barton MB, Barton MB. Breast cancer screening. Benefits, risks, and current controversies. 

[Review] [18 refs]. Postgraduate Medicine 1933 Jun 20;118(2):27-8. 

66. 

Duffy SW, Smith RA, Gabe R, Tabar L, Yen AM, Chen TH, et al. Screening for breast cancer. 

[Review] [100 refs]. Surgical Oncology Clinics of North America 2005 Oct;14(4):671-97. 

67. 

Retsky M, Demicheli R, Hrushesky W, Retsky M, Demicheli R, Hrushesky W. Breast cancer 

screening: controversies and future directions. [Review] [96 refs]. Current Opinion in Obstetrics 

& Gynecology 2003 Feb;15(1):1-8. 

68. 

Gaskie S, Nashelsky J, Gaskie S, Nashelsky J. Clinical inquiries. Are breast self-exams or 

clinical exams effective for screening breast cancer?. [Review] [10 refs]. Journal of Family 

Practice 2005 Sep;54(9):803-4. 

69. 

Smith RA, Caleffi M, Albert US, Chen THH, Duffy SW, Franceschi D, et al. Breast Cancer in 

Limited-Resource Countries: Early Detection and Access to Care. The Breast Journal 

2006;12(s1):S16-S26. 

70. 

Bradley SJ WDBDL. Alternatives in the surgical management of in situ breast cancer. A metaanalysis 

of outcome. American Surgeon 56, 428-432. 1990. 

71. 

Robert W.Carlson et al. NCCN ® Practice Guidelines in Oncology. 1, 1-100. 2007. 

72. 

Olivotto I, Levine M, Steering Committee on Clinical Practice Guidelines for the Care and 

Treatment of Breast Cancer., Olivotto I, Levine M, Steering Committee on Clinical Practice 

Guidelines for the Care and Treatment of Breast Cancer. Clinical practice guidelines for the 

care and treatment of breast cancer: the management of ductal carcinoma in situ (summary 

of the 2001 update). [Review] [8 refs]. CMAJ Canadian Medical Association Journal 2001 Oct 

2;165(7):912-3. 

73. 

Schwartz GF, Solin LJ, Olivotto IA, Ernster VL, Pressman PI, Schwartz GF, et al. Consensus 

Conference on the Treatment of In Situ Ductal Carcinoma of the Breast, April 22-25, 1999. 

[Review] [3 refs]. Cancer 2000 Feb 15;88(4):946-54. 

74. 

Hanley KY, Beckman A, Hayne M, Hanley KY, Beckman A, Hayne M. Advances in treating early 

breast cancer. [Review] [34 refs]. JAAPA 2005 Nov;18(11):54-62. 

75. 

Luini A, Gatti G, Galimberti V, Zurrida S, Intra M, Gentilini O, et al. Conservative treatment of 

breast cancer: its evolution. [Review] [17 refs]. Breast Cancer Research & Treatment 2005 

Dec;94(3):195-8. 

76. 

Guarneri V, Conte PF, Guarneri V, Conte PF. The curability of breast cancer and the treatment of 

advanced disease. [Review] [106 refs]. European Journal of Nuclear Medicine & Molecular 

Imaging 2004 Jun;31 Suppl 1:S149-S161. 

77. 

Meric-Bernstam F, Meric-Bernstam F. Breast conservation in breast cancer: surgical and 

adjuvant considerations. [Review] [53 refs]. Current Opinion in Obstetrics & Gynecology 2004 

Feb;16(1):31-6. 

78. 

Fisher B ASBJeal. Twenty-year follow-up of a randomized trial comparing total mastectomy, 




lumpectomy, and lumpectomy plus radiation for the management of invasive breast cancer. 

New England Journal of Medicine ;347, 1233-1241. 2002. 

79. 

Veronesi U CNMLeal. Twenty-year followup of a randomized study comparing breast 

conserving surgery with radical mastectomy for early breast cancer. New England Journal of 

Medicine 347, 1227-1232. 2002. Ref Type: Generic 

80. 

Early Breast Cancer Trialists’ Collaborative Group. Effect of radiotherapy and surgery in early 

breast cancer. New England Journal of Medicine 333, 1444-1445. 1995. 

81. 

Tachi M, Yamada A, Tachi M, Yamada A. Choice of flaps for breast reconstruction. [Review] [57 

refs]. International Journal of Clinical Oncology 2005 Oct;10(5):289-97. 

82. 

Taylor CW, Horgan K, Dodwell D, Taylor CW, Horgan K, Dodwell D. Oncological aspects of breast 

reconstruction. [Review] [84 refs]. Breast 2005 Apr;14(2):118-30. 

83. 

Chagpar AB, Chagpar AB. Skin-sparing and nipple-sparing mastectomy: preoperative, 

intraoperative, and postoperative considerations. [Review] [75 refs]. American Surgeon 2004 

May;70(5):425-32. Abstract Only 

84. 

Chagpar AB, Chagpar AB. Advances in the management of localized breast cancer: an 

overview.[see comment]. [Review] [25 refs]. Journal of the Kentucky Medical Association 2004 

May;102(5):202-8. Abstract Only 

85. 

Rainsbury RM, Rainsbury RM. Skin-sparing mastectomy. [Review] [48 refs]. British Journal of 

Surgery 2006 Mar;93(3):276-81. 

86. 

Pickren HW RJAHJ. Modification of conventional mastectomy: a detailed study of lymph node 

involvement and follow-up information to show its practicality. Cancer 18, 942. 1965. 

87.. 

Luini A, Gatti G, Ballardini B, Zurrida S, Galimberti V, Veronesi P, et al. Development of axillary 

surgery in breast cancer. [Review] [43 refs]. Annals of Oncology 2005 Feb;16(2):259-62. 

88. 

Leidenius MH, Leidenius MHK. Sentinel node biopsy in breast cancer. [Review] [123 refs]. Acta 

Radiologica 2005 Dec;46(8):791-801. 

89. 

Mark C.Kelley MDaNHMDbKMMMDPhDc*. Lymphatic mapping and sentinel lymphadenectomy 

for breast cancer. The American Journal of Surgery 188, 49-61. 2004. 

90. 

Schulze T, Bembenek A, Schlag PM, Schulze T, Bembenek A, Schlag PM. Sentinel lymph node 

biopsy progress in surgical treatment of cancer. [Review] [217 refs]. Langenbecks Archives of 

Surgery 2004 Nov;389(6):532-50. 

91. 

Morrow M SEBLea. Standard for breast conservation therapy in the management of invasive 

breast carcinoma. CA Cancer J Clin 52, 277-300. 2002. 

92. 

Yarnold J, Yarnold J. Latest developments in local treatment: radiotherapy for early breast 

cancer. [Review] [28 refs]. Annals of Oncology 2005;16 Suppl 2:ii170-ii173. 

93. 

Orecchia R, Veronesi U, Orecchia R, Veronesi U. Intraoperative electrons. [Review] [30 refs]. 

Seminars in Radiation Oncology 2005 Apr;15(2):76-83. 

94. 

Orecchia R, Luini A, Veronesi P, Ciocca M, Franzetti S, Gatti G, et al. Electron intraoperative 

treatment in patients with early-stage breast cancer: data update. [Review] [46 refs]. Expert 

Review of Anticancer Therapy 2006 Apr;6(4):605-11. 

95. 

Arthur DW, Morris MM, Vicini FA, Arthur DW, Morris MM, Vicini FA. Breast cancer: new radiation 

treatment options. [Review] [26 refs]. Oncology (Huntington) 1636 Nov;18(13):1621-9. 

96. 

Vicini FA, Arthur DW, Vicini FA, Arthur DW. Breast brachytherapy: North American experience. 

[Review] [28 refs]. Seminars in Radiation Oncology 2005 Apr;15(2):108-15. 

97. 

Keisch ME, Keisch ME. Accelerated partial breast irradiation: the case for current use. [Review] 

[31 refs]. Breast Cancer Research 2005;7(3):106-9. 

98. 

Smith I, Chua S, Smith I, Chua S. Medical treatment of early breast cancer. I: adjuvant 

treatment. [Review] [0 refs]. BMJ 2006 Jan 7;332(7532):34-7. 

99. 

KD Miller GS. Chemotherapy for early and advanced breast cancer . Cancer of the Breast 5th 

edition, 659-687 Elsevier Science St Louis . 2007. Elsevier Science St Louis . 

100. 

Smith I, Chua S, Smith I, Chua S. Medical treatment of early breast cancer. III: chemotherapy. 

[Review] [0 refs]. BMJ 2006 Jan 21;332(7534):161-2. 

101. 

Cariati M, nett-Britton TM, Pinder SE, Purushotham AD, Cariati M, nett-Britton TM, et al. 

"Inflammatory" breast cancer. [Review] [81 refs]. Surgical Oncology 2005 Nov;14(3):133-43. 

102. 

Cristofanilli M, Buzdar AU, Hortobagyi GN, Cristofanilli M, Buzdar AU, Hortobagyi GN. Update on 

the management of inflammatory breast cancer. [Review] [61 refs]. Oncologist 2003;8(2):141-8. 

103. 

Giordano SH, Hortobagyi GN, Giordano SH, Hortobagyi GN. Inflammatory breast cancer: clinical 

progress and the main problems that must be addressed. [Review] [31 refs]. Breast Cancer 

Research 2003;5(6):284-8. 

104. 

Apffelstaedt JP, Apffelstaedt JP. Locally advanced breast cancer in developing countries: the 

place of surgery. [Review] [69 refs]. World Journal of Surgery 2003 Aug;27(8):917-20. 

105. 

Shenkier T, Weir L, Levine M, Olivotto I, Whelan T, Reyno L, et al. Clinical practice guidelines for 

the care and treatment of breast cancer: 15. Treatment for women with stage III or locally 

advanced breast cancer.[see comment]. [Review] [73 refs]. CMAJ Canadian Medical 

Association Journal 2004 Mar 16;170(6):983-94. 

106. 

Giordano SH, Giordano SH. Update on locally advanced breast cancer. [Review] [105 refs]. 

Oncologist 2003;8(6):521-30. 

107. 

Giordano SH, Hortobagyi GN, Giordano SH, Hortobagyi GN. Inflammatory breast cancer: clinical 

progress and the main problems that must be addressed. [Review] [31 refs]. Breast Cancer 

Research 2003;5(6):284-8. 

108. 

Goble S, Bear HD, Goble S, Bear HD. Emerging role of taxanes in adjuvant and neoadjuvant 

therapy for breast cancer: the potential and the questions. [Review] [90 refs]. Surgical Clinics 

of North America 2003 Aug;83(4):943-71. 

109. 

World Health Organization G. Symptom relief in terminal illness. 1998. Ref Type: Generic 

110. 

Leonard RC, Untch M, Von KF, Leonard RC, Untch M, Von Koch F. Management of anaemia in 

patients with breast cancer: role of epoetin. [Review] [73 refs]. Annals of Oncology 2005 

May;16(5):817-24. 

111. 

Barrett-Lee P, Bokemeyer C, Gascon P, Nortier JW, Schneider M, Schrijvers D, et al. 

Management of cancer-related anemia in patients with breast or gynecologic cancer: new 

insights based on results from the European Cancer Anemia Survey. Oncologist 2005 

Oct;10(9):743-57. 

112. 

Schwartzberg LS, Yee LK, Senecal FM, Charu V, Tomita D, Wallace J, et al. A randomized 

comparison of every-2-week darbepoetin alfa and weekly epoetin alfa for the treatment of 

chemotherapy-induced anemia in patients with breast, lung, or gynecologic cancer. Oncologist 

2004;9(6):696-707. 

113. 

Kligman L, Wong RK, Johnston M, Laetsch NS, Kligman L, Wong RKS, et al. The treatment of 

lymphedema related to breast cancer: a systematic review and evidence summary. [Review] 

[30 refs]. Supportive Care in Cancer 2004 Jun;12(6):421-31. 

114. 

Morrell RM, Halyard MY, Schild SE, Ali MS, Gunderson LL, Pockaj BA, et al. Breast cancerrelated 

lymphedema. [Review] [60 refs]. Mayo Clinic Proceedings 2005 Nov;80(11):1480-4. 

115. 

Weil RJ, Palmieri DC, Bronder JL, Stark AM, Steeg PS, Weil RJ, et al. Breast cancer metastasis 

to the central nervous system. [Review] [69 refs]. American Journal of Pathology 2005 

Oct;167(4):913-20. 

116. 

Knobf MT, Knobf MT. The influence of endocrine effects of adjuvant therapy on quality of life 

outcomes in younger breast cancer survivors. [Review] [101 refs]. Oncologist 2006 

Feb;11(2):96-110. 

117. 

Edwards AG, Hailey S, Maxwell M, Edwards AGK, Hailey S, Maxwell M. Psychological 

interventions for women with metastatic breast cancer.[see comment]. [Review] [71 refs]. 

Cochrane Database of Systematic Reviews 2004;(2):CD004253. 

118. 

Maguire P, Maguire P. ABC of breast diseases. Psychological aspects. [Review] [0 refs]. BMJ 

1994 Dec 17;309(6969):1649-52. 

119. 

Mosher CE, noff-Burg S, Mosher CE, noff-Burg S. A review of age differences in psychological 

adjustment to breast cancer. [Review] [56 refs]. Journal of Psychosocial Oncology 2005;23(2- 

3):101-14. 

120. 

Walker LG, Eremin O, Walker LG, Eremin O. Psychological assessment and intervention: future 

prospects for women with breast cancer. [Review] [45 refs]. Seminars in Surgical Oncology 

1996 Jan;12(1):76-83. 

121. 

Bloom HJG RWHE. Natural history of untreated breast cancer (1805-1933): Comparison of 

untreated and treated cases according to histological grade of malignancy. 5299, 213. 1962. 

British Medical Journal. 

122. 

Lisa A.Carey et al. Race, Breast Cancer Subtypes, and Survival in the Carolina Breast Cancer 

Study. JAMA 295, 2492-2502. 6-7-2006. 

123. 

Mbonde MP, Amir H, Schwartz-Albiez R, Akslen LA, Kitinya JN, Mbonde MP, et al. Expression of 

estrogen and progesterone receptors in carcinomas of the female breast in Tanzania. Oncology 

Reports 2000 Mar;7(2):277-83. 

124. 

Nyagol J, Nyong'o A, Byakika B, Muchiri L, Cocco M, de Santi MM, et al. Routine assessment 

of hormonal receptor and her-2/neu status underscores the need for more therapeutic targets 

in Kenyan women with breast cancer. Analytical & Quantitative Cytology & Histology 2006 

Apr;28(2):97-103. 

125. 

Ikpatt OF, Ndoma-Egba R, Ikpatt OF, Ndoma-Egba R. Oestrogen and progesterone receptors in 

Nigerian breast cancer: relationship to tumour histopathology and survival of patients. Central 

African Journal of Medicine 2003 Nov;49(11-12):122-6. 

126. 

Cary Gross. New Research Suggests Access, Genetic Differences Play Role in High Minority 

Cancer Death Rate. Journal of the National Cancer Institute 98:10, 669. 2006. 

127. 

James J.Dignam. The Ongoing Search for the Sources of the Breast Cancer Survival Disparity. 

Journal of Clincal Oncology 24:9, 1326-1329 James J. Dignam. 2006. 

128. 

Azadeh T.Stark et al. Race Modifies the Association between Breast Carcinoma Pathologic 

Prognostic Indicators and the Positive Status for HER-2/neu. Cancer 104 / 10, 2189-2196. 2005. 

129. 

Houssami N, Cuzick J, Dixon JM, Houssami N, Cuzick J, Dixon JM. The prevention, detection, 

and management of breast cancer. [Review] [39 refs]. Medical Journal of Australia 2006 Mar 

6;184(5):230-4. 

130. 

R.S.Prichard ADKHBDEWMaNJO. The prevention of breast cancer. British Journal of Surgery ; : 

90, 772-783. 2003. 

131. 

Kotsopoulos J, Narod SA, Kotsopoulos J, Narod SA. Towards a dietary prevention of hereditary 

breast cancer. [Review] [240 refs]. Cancer Causes & Control 2005 Mar;16(2):125-38. 

132. 

Barthelmes L, Davidson LA, Gaffney C, Gateley CA, Barthelmes L, Davidson LA, et al. 

Pregnancy and breast cancer. [Review] [11 refs]. BMJ 2005 Jun 11;330(7504):1375-8. 

133. 

Fentiman IS, Fourquet A, Hortobagyi GN, Fentiman IS, Fourquet A, Hortobagyi GN. Male breast 

cancer. [Review] [142 refs]. Lancet 2006 Feb 18;367(9510):595-604. 

134. 

Giordano SH, Giordano SH. A review of the diagnosis and management of male breast cancer. 

[Review] [95 refs]. Oncologist 2005 Aug;10(7):471-9. 

135. 

Krause W, Krause W. Male breast cancer-an andrological disease: risk factors and diagnosis. 

[Review] [101 refs]. Andrologia 2004 Dec;36(6):346-54. 

136. 

von SK, von Smitten K. Surgical management of breast cancer in the future. [Review] [27 

refs]. Acta Oncologica 2000;39(3):437-9. 

137. 

Buchholz TA, Strom EA, Perkins GH, McNeese MD, Buchholz TA, Strom EA, et al. Controversies 

regarding the use of radiation after mastectomy in breast cancer. [Review] [24 refs]. 

Oncologist 2002;7(6):539-46. 

138. 

Anderson BO, Yip CH, Ramsey SD, Bengoa R, Braun S, Fitch M, et al. Breast Cancer in Limited- 

Resource Countries: Health Care Systems and Public Policy. The Breast Journal 

2006;12(s1):S54-S69. 


Innovation and clinical specialities: physical therapy 

Responding to challenges 

in physical therapy 

ARTICLE BY CATHERINE SYKES PT, MSC 

professional policy consultant, World Confederation for Physical Therapy 

BRENDA MYERS BScPT, MHSA 

Secretary General, World Confederation for Physical Therapy 

MARILYN MOFFAT PT, DPT, PhD, FAPTA, CSCS 

President, World Confederation for Physical Therapy 

TRACY BURY MSc Grad Dip Phys MCSP 

professional policy consultant, World Confederation for Physical Therapy 

This paper describes a range of contemporary challenges affecting the physical therapy profession and its 

practice around the world, and the way the profession is responding to them. 

Physical therapists (called physiotherapists in some 

countries) provide services to individuals and populations to 

develop, maintain and restore maximum movement, 

functional ability and quality of life throughout the lifespan. Their 

practice encompasses the spheres of promotion, prevention, 

treatment/intervention, habilitation and rehabilitation. Their work 

includes incorporating the aspects of physical, psychological, 

emotional, and social wellbeing into their practice. The practice of 

physical therapy includes treatments/interventions for 

patients/clients with a multiplicity of diseases, disorders and 

conditions of the musculoskeletal, neuromuscular, cardiovascular/ 

pulmonary, integumentary, genito-urinary, endocrine, and 

immunological systems. Working with patients/clients, other 

health professionals, families, caregivers, and communities, 

physical therapists examine movement potential and establish 

mutually agreed upon goals, using knowledge and skills unique to 

them. 

Physical therapists practise in a wide variety of settings: not only 

in hospitals and other acute care settings but also in the 

community, out-patient clinics, private practices, rehabilitation 

centres, schools, work places, recreational facilities and public 

places. As governments seek to reduce healthcare budgets, 

services are moved from the expensive hospital environment to 

more community-based service delivery settings. Physical 

therapists have responded to the increasingly diverse service 

delivery system in flexible, responsive and unique ways that are 

reflective of local needs and resources. 

As the international voice of the profession, the World 

Confederation for Physical Therapy (WCPT) is instrumental in 

leading the profession, providing strong communication on behalf 

of its member organisations. WCPT is the international body 

founded in 1951 to represent the global interests of physical 

therapists and their patients/clients. It represents 101 member 

organisations and more than 300 000 physical therapists 

worldwide, providing the sole international voice for the profession. 

Evolution of the profession of physical therapy 

Physical therapy firmly established itself in the 20th century. Its 

growth was triggered by the large numbers of people injured 

particularly in World War I and and by the raging polio epidemics 

leaving untold numbers of children and adults with paralysis. 

Educated at the highest levels, physical therapists now deliver 

services as autonomous practitioners. 

Professional challenges 

Physical therapy now faces a number of new challenges around 

the world, which are being addressed by the World Confederation 

for Physical Therapy (WCPT). 

These include the growth of lifestyle-related diseases, such as 

arthritis, cardiovascular disease, diabetes and asthma; new 

technologies such as robotics; increasingly complex service 

delivery systems; the supply of physical therapists to meet service 

Figure 1: A physiotherapist working on a young child 



delivery requirements; and public access to physical therapy 

services. 

The World Confederation for Physical Therapy is addressing this 

range of challenges through its policies, programmes and 

advocacy. 

Lifestyle related diseases 

Chronic and lifestyle related diseases are the primary causes of 

death and disability in many countries, including those with low 

and middle incomes. Physical therapists are increasingly 

undertaking a primary care role, specifically in relation to the 

prevention and management of those lifestyle diseases that are 

associated with low levels of physical activity. As experts in 

movement and exercise and with a thorough knowledge of 

anatomy, physiology and the effects of pathology on all systems, 

physical therapists are the ideal professionals to promote, guide, 

prescribe and manage exercise activities. Exercise promotes wellbeing 

and fitness. It is a powerful intervention for strength, power, 

endurance, flexibility, balance, relaxation, recreation and the 

remediation of functional limitations. There is evidence of the cost 

benefits that this intervention can bring: 

✚ One study showed statistically significant decreases in body 

mass index (BMI) over time in an intervention group of people 

with intellectual disabilities compared with a non-intervention 

group (Chapman et al 2009). 

✚ A home-based programme of strength and balance retraining 

exercises, individually prescribed by a physical therapist, was 

effective in reducing falls and injuries in women aged 80 years 

and older. The benefit, for those who keep exercising, 

continued over a 2-year period (Campbell et al 1999). The 

reduction in healthcare costs per individual for treating fallrelated 

injuries was 1.85 times higher than the cost of 

implementing a fall prevention programme (Hektoen et al 

2009). 

A range of policies and resources has been developed by WCPT 

for use by member organisations to support of the role of physical 

therapists in this area. 

New technologies 

Technology has been developing apace in recent years and, 

physical therapists with their educational background in the 

physical, biological, biomechanical, and kinesiological sciences 

can engage readily with these new technologies. 

Technology for delivering services 

Physical therapists have been using electronic channels, such as 

the telephone and the internet, to augment their service provision 

to patients and clients and to help to reduce the costs of service 

delivery. For example, a 12-week home-based tele-rehabilitation 

programme delivered to people with multiple sclerosis resulted in 

improved functional outcomes. The individualised exercise 

programmes devised during a face-to-face consultation with a 

physical therapist were monitored by online video conferencing. 

Advantages of this form of delivery included the ability to monitor 

performance, make progressions and address questions and 

complications promptly. Tele-rehabilitation was well accepted by 

the programme recipients and cost effective for providers 

(Finkelstein et al 2008). 

Web-based physical therapy advice is another means of 

providing prompt, cost-efficient access to physical therapy 

services, especially for those in remote areas. Simultaneous 

management of many people and access 24 hours a day are 

advantages of this form of self-management. The majority of users 

of this sort of low cost service were satisfied with the advice they 

received, did not require further health services and completely 

self-managed their condition (see: www.physioadvice.scot.nhs.uk). 

Technology as treatments/interventions 

As well as affecting how physical therapy is delivered, many new 

technologies have influenced treatments and interventions. 

Physical therapists are involved in the rapidly expanding field of 

exoskeletons and their varied uses, including gait training during 

post-stroke recovery and helping patients with neurological 

disorders. Robotic systems that augment physical therapy have 

shown improvements in the level and speed of recovery of 

functional performance of individuals with hemiplegic upperextremity 

impairments. New biofeedback mechanisms such as 

myoelectric signals enable the user to control prosthetic limbs 

(Moffat 2004). 

The Guidelines for Physical Therapist Professional Entry Level 

Education (WCPT 2007) ensure that physical therapists education 

constantly evolves to keep pace with new developments. 

Technology for evidence and communication 

Electronic health records (EHR) are the future for recording and 

monitoring health care provision, not only at the individual level, 

but also by aggregation of anonymised data for administrative 

reporting and statistics. The challenge is to ensure that functional 

status information is included in EHR in a way that is consistent 

and reliable across service settings such that the value of physical 

therapy can be demonstrated and communicated. For example, 

current administrative records use the International Classification 

of Diseases to describe the health condition (e.g. M06.0 

Seronegative rheumatoid arthritis); however this does not describe 

whether the upper limbs or lower limbs are affected, whether the 

person can care for herself/himself and get around, or the sorts of 

equipment that they need to remain independent. Functional 

status information complements information about the disease 

and can be used to describe how the person lives with rheumatoid 

arthritis. To this end the WCPT has endorsed the International 

Classification of Functioning, Disability and Health (WHO 2001) 

with the aim that it be used as the framework for describing the 

functional status of individuals as part of physical therapy practice. 

WCPT also promotes the use of the classification for evidencing 

the efficacy of physical therapy practice. High quality, reliable data 

collected in daily practice can be used to make comparisons 

between services, identify service training needs, highlight where 

research is needed, support evidence-based policies, and help 

identify the best balance of human resources for the health 

system. 

Many of these new developments are showcased at the WCPT 

Congress; an event conducted every four years, which brings 

together more than 3000 physical therapists from across the 

world. 

Education 

WCPT recognises that there is diversity in the social, economic, 



cultural, and political environments in which physical therapist 

education is conducted. Professional education equips physical 

therapists with the appropriate knowledge and skills to practise in 

a variety of settings, as well as promoting the value of practising in 

these settings. Internationally, the qualification to enter the physical 

therapy profession ranges from diploma to professional doctoral 

degree. 

With today’s level of physical therapist education, the research 

base for physical therapy has been expanded, supporting 

evidence-based practice. WCPT supports its member 

organisations as they develop new education programmes and 

revise existing programmes. It has done this by developing 

documents outlining the curriculum for entry level physical therapy 

education (WCPT 2007a), standards for physical therapy practice 

(WCPT 2007b) and guidelines for accreditation of physical therapy 

programmes (WCPT in preparation). 

Sufficient education programmes with qualified faculty 

particularly in low resource countries, is an impediment to ensuring 

adequate supply of physical therapists in these countries. WCPT 

uses its network to raise awareness of the need to recruit faculty 

members to work with local faculty in underserved areas on the 

development and sustainability of programmes. 

Resources for continuing education and development are a 

challenge for the profession. One key way to foster retention is to 

offer opportunities for physical therapists to continue postprofessional 

education studies even as they continue working in 

rural areas. WCPT’s focus on this issue through online courses, 

courses on DVDs and other initiatives will help to meet these 

education needs particularly where populations are least well 

served. 

Physical therapy service delivery 

Underserved areas 

In addressing the challenges of attracting physical therapists to 

underserved areas, WCPT has supported its member 

organisations by working alongside other health professional 

organisations and the Global Health Workforce Alliance (see: 

http://www.who.int/workforcealliance/en/) to produce the first 

guidelines on incentives for health professionals as part of the 

Positive Practice Environments campaign. 

The community based rehabilitation (CBR) movement and other 

grass roots level health services have been well supported by 

physical therapists. In many instances physical therapists have 

taken the lead in developing and running such services. 

Collaborative practice 

Physical therapists are active members of multi-professional 

teams, working in partnership with other health professionals to 

deliver services as equal partners. WCPT believes it is fundamental 

to professional autonomy that individual physical therapists should 

exercise their professional judgement as long as it is within the 

physical therapist's knowledge and competence. So it follows that 

their professional decisions cannot be controlled or compromised 

by persons from other professions (WCPT 2007c). 

In a growing number of countries, physical therapy has first 

contact/direct access status: in other words, a referral from 

another practitioner is not required, legally or ethically, before 

physical therapy services are provided. When physical therapists 

see patients without a referral, they can relieve the pressure on 

other health care providers (general practitioners and secondary 

referrals to hospitals). More people can be treated successfully at 

a lower cost to the health system and to the greater satisfaction of 

all involved (Holdsworth et al 2007). 

WCPT supports professions mutually recognising each others’ 

skills and collaborative working methods which optimise the 

outcomes for their clients/patients. 

Regulatory environments that permit direct access and 

appropriate scope of practice enable physical therapists to offer a 

greater range of skills, thus increasing their ability to practice 

independently. In doing so they can relieve pressure on other 

professionals, such as physicians, enhance services to areas 

poorly served by other health care providers and improve the 

patient/client experience and outcomes. 

Regulation of the profession 

Regulation provides the right to practise physical therapy by the 

appropriately qualified individuals under the appropriate legislative 

framework. The purpose of regulation is to protect the public from 

incompetent, unqualified or unethical practitioners. The form of 

regulation varies across jurisdictions, but generally involves 

registration of those appropriately qualified to practise, protection 

of professional title, a system of accreditation and standards of 

practice and a process whereby those failing to meet ethical or 

practice standards can be removed from the register. 

WCPT encourages open and fair regulatory systems and works 

to reduce restrictive practices. In assisting member organisations 

and potential new members, WCPT has developed a range of 

position papers and policies on various aspects of the profession 

to provide information to governments, international nongovernmental 

organisations, the media and the public. 

Conclusion 

Many of the contemporary issues for physical therapy are 

interdependent. Where there is high quality professional education 

in accredited education programmes and a regulatory 

environment that supports autonomous practice, direct access to 

physical therapy services and respectful and collaborative 

relationships amongst health care providers, there are excellent 

opportunities for enhancing the delivery of physical therapy 

services to all that need them. ❏ 

References 

Campbell AJ, Robertson MC, Gardner MM, Norton RN and Buchner DM (1999) Falls prevention 

over 2 years: a randomized controlled trial in women 80 years and older Age and Ageing 

28:6,513-518. 

Chapman M, Craven M, Chadwick D (2005) Fighting Fit? An evaluation of health practitioner 

input to improve healthy living and reduce obesity for adults with learning disabilities in 

Journal of Intellectual Disabilities, 9(2), 131-144. 

Hektoen LF, Aas E, Lurås H (2009) Cost-effectiveness in fall prevention for older women. 

Scandinavian Journal of Public Health, 37:6,584-589. 

Holdsworth L, Webster V, McFadyen A. (2007). What are the costs to NHS Scotland of self 

referral to physiotherapy?: Results of a national trial. Physiotherapy 93: 3-11. 

Moffat M (2004). Braving new worlds: To conquer, to endure. Physical Therapy 84:1056-1086. 

World Confederation for Physical Therapy (2007a) Guidelines for physical therapist 

professional entry level education. Accessed 24 August 2009 

http://www.wcpt.org/node/29550. 

World Confederation for Physical Therapy (2007b) Standards of Physical Therapy Practice. 

Accessed 24 August 2009 http://www.wcpt.org/node/29447. 


Innovation and clinical specialities: surgery 

Population based surgery in low 

and middle income countries 

ARTICLE BY DAVID A SPIEGEL MD, AND RICHARD GOSSELIN MD, MPH 

Division of Orthopaedic Surgery, Childrens Hospital of Philadelphia, University of Pennsylvania School of Medicine, 

& University of California at Berkeley School of Public Health 

ADAM KUSHNER MD, MPH 

Department of Surgery, Columbia University 

AND STEPHEN BICKLER MD 

Division of Pediatric Surgery, University of California at San Diego 

The burden of surgical diseases is large and is increasing, and there are enormous gaps in access to surgery 

between high and low income countries. Surgical services may be cost effective at the district level in LMICs, 

and providing access to essential surgery should be viewed as “primary prevention” of death and disability. 

The integration of essential surgical services into health systems, within the context of primary healthcare 

reforms, will surely improve population health. 

The world’s burden of surgical diseases is increasing, and 

considerable morbidity and mortality may be averted by 

providing access to safe and timely surgical care for injuries, 

acute abdominal conditions, complications of pregnancy, and 

many other diagnoses. 1-12 Injuries, especially due to road traffic 

crashes, have been recognized as emerging global public health 

concern. 1,2,7-9,11-17 For each death, many more individuals are left 

with a permanent disability. Although more than 230 million 

surgical procedures are estimated to be performed in the world 

each year, there are enormous gaps in access to surgical services 

both between and within countries 18 . Only 3.5% of major surgical 

procedures are performed in countries ranked in the lowest third 

in per capita health expenditure 18 . Surgery has been neglected as 

a population-based health strategy in low and middle income 

countries (LMICs), despite evidence to suggest that surgical 

conditions account for approximately 11% of the world’s disease 

burden 1 and basic surgical services may be cost effective even at 

the district level in LMICs 19-22 . 

The question is not whether universal access to “essential” 

surgical (including orthopaedics and anaesthesia) services would 

improve population-based health care in LMIC’s, but rather how 

this may be achieved. There has been a resurgence of interest in 

primary health care 23 as a means to strengthen health systems, 

and integration of essential surgery and anaesthesia within the 

context of primary healthcare reforms will undoubtedly improve 

population health. While recognizing that modern surgical services 

are usually available at a limited number of tertiary facilities in 

LMICs, there is a great need to provide access for the majority of 

the population, who reside in rural communities and are serviced 

by a district hospital or equivalent. This process will require a 

multidisciplinary, multisectoral effort, under the leadership of 

governments and their ministries of health. 

Barriers to the delivery of surgical and anaesthetic services 

Barriers to the delivery of safe and timely surgery and anaesthesia 

include deficiencies in capacity (infrastructure, physical resources, 

human resources) and quality (training and experience of 

caregivers). While recognizing the positive contributions from nongovernmental 

organizations and others in delivering surgical 

services, these vertical initiatives have often contributed to 

fragmentation within the health system, and may also foster 

complacency among health planners leading to inadequate 

resource allocation. In addition, the misperception that surgery is 

a high cost treatment benefitting only a limited segment of the 

population must be reversed if adequate resources are to be made 

available to support a functional district level surgical service. 

While considerable attention has been directed to addressing 

the global human resource crisis, there has been little mention of 

deficiencies in capacity of the health system to deliver surgical 

services, especially at the district level in LMICs 24,25 . Providing the 

capacity for facilities based services, including anaesthesia and 

surgery, is obviously more complex than many other health 

services such as immunizations, family planning, etc. Using the 

WHO’s surgical situational analysis questionnaire, significant 

deficiencies in capacity in Sierra Leone were identified, including 

shortages of water, electricity, supplies, and trained health 

workers 24 . Patients often had to purchase medical supplies prior to 

receiving treatment 24 . Kushner et al studied 132 district health 

facilities in 8 LMICs, and also identified significant shortfalls in 

infrastructure, physical resources, and in the procedures 

performed 25 . While incision and drainage of abscesses was 

performed at 73%, only 44% could perform a caeserian section. 

Only 33% of facilities treated open fractures, and 43% managed 

cases of osteomyelitis. Only 13% would treat a clubfoot. 

The capacity to deliver orthopaedic surgery is even more 

challenging, given the plethora of technological advancements 

from high income countries, which are resource intensive and 

costly. While attempting to transfer these technologies is 

unrealistic at the population level, we suggest that the majority of 

essential orthopaedic surgical procedures may be carried out at 

the district hospital, relying upon time honored methods of 

treatment and only the most basic equipment/implants, for 



example the closed management of fractures and dislocations, 

skeletal traction for fractures, irrigation and debridement for open 

fractures and infections (osteomyelitis, septic arthritis), 

amputations, and manipulation and casting for clubfoot. The 

challenge lies in teaching safe and reliable methods that have often 

been displaced by higher cost technologies, while maintaining 

similar outcomes. Another consideration is whether some of these 

technological advances may be adapted through low cost 

production and dissemination in LMICs 26-40 . The “SIGN” 

intramedullary nailing system for femur and tibia fractures is one 

example, although the implants are currently exported free of 

charge to low income countries, rather than being produced 

locally 41 . However, surgical complications from nailing fractures 

that were before successfully treated conservatively by traction or 

other means will need to be monitored. Another example of a low 

cost, transferable technology is the Ponseti method for clubfoot 

care, which relies upon serial casting followed by a minor surgical 

procedure (heelcord release) and then a long-term splinting 42-45 . 

While the method was developed in a high-income country (USA), 

excellent results have been achieved in several LMICs, even in 

patients up to 6 years of age 42 . The treatment may be delivered by 

nonmedical personnel, for example by orthopaedic clinical officers 

in Malawi or physiotherapists in Nepal 42-44 . 

Establishing and maintaining adequate capacity at the facilities 

level must begin with a situational analysis of all district level health 

facilities, to obtain a baseline and inform health planners as to 

which improvements are required. Furthermore, a mechanism for 

monitoring of capacity would be invaluable to ministries of health, 

and would contribute to strengthening each health information 

system. An example is the Service Availability Mapping (SAM) 

technology developed by the World Health Organization 

(WHO) 46,48 . Both district level and facilities based questionnaires are 

utilized, and health workers enter information into personal digital 

assistants (PDAs), and also record the location with a global 

positioning system device (GPS). The data is then processed 

(digital maps, graphs, etc.) and can be disseminated to help 

inform decision making and the development of health care 

policies. Mapping has been carried out in Tanzania 48 , Uganda, 

Albania, Rwanda, Kenya, and Zambia. Recently, a surgical 

questionnaire has been incorporated into this methodology, and a 

pilot project has been initiated in Mongolia in collaboration with the 

WHO and the ministry of health. Monitoring the capacity to deliver 

facilities based health services such as surgery will enhance the 

delivery of services. There is also the need to define the unmet 

need for surgical services at the population level, which will require 

community based surveys. This additional information will help 

prioritize services, and guide local allocation of resources. 

Once the capacity to provide basic orthopaedic and surgical 

services is available, trained health workers must be available to 

deliver the services. While only 10% of the world’s burden of 

disease is found in the Americas, this region has 37% of the global 

health work force and accounts for 50% of the world’s health 

spending 49 . In stark contrast, Sub Saharan Africa must utilize 3% 

of the world’s health work force to tackle 24% of the global 

disease burden, and accounts for less than 1% of the world’s 

health spending 49 . Brain drain has been an enormous problem, 

with workers migrating both between and within (rural to urban) 

countries 49-57 . There is a critical shortage of health workers in 57 

countries worldwide (36 in Africa) 49 . Common problems impacting 

health worker satisfaction include a lack of materials, inadequate 

salary, inadequate training or lack of supportive supervision, poor 

working conditions, inadequate living conditions, and inadequate 

professional recognition 50 . Other factors may include better 

opportunities in the private sector, with non-governmental 

organizations, and in other countries. A nationwide survey in 

Uganda demonstrated that less than 50% of health workers were 

satisfied, and more than 50% of physicians would prefer to 

emmigrate 51 . A mixture of both financial and non-financial 

incentives must be provided in order to retain health workers. 

There will never be enough surgeons to staff even the tertiary 

facilities in LMICs, let alone primary health care facilities, for 

decades to come. A recent report from Sierra Leone documented 

only 10 trained surgeons for a population of 5.3 million 25 . Any 

approach to human resources must strongly consider task shifting 

as a means to provide the necessary number of surgical 

caregivers, at least over the short term 58-75 . While there remains 

some controversy regarding the use of non-physician clinicians, 

especially for surgery, these health workers may be found in at 

least 25 of 47 Sub Saharan African countries 58 . While the training 

is shorter and less costly than for physicians (and is based on the 

local disease burden), the curriculum and scope of practice have 

not been standardized. Non-physician caregivers perform 

selected surgical services in Ethiopia, Angola, Ghana, Kenya, 

Mozambique, Tanzania, Malawi, and Uganda. Several reports 

have suggested that alternate cadres of health worker can safely 

and successfully perform caesarian section, as evidenced in 

Mozambique, Malawi and Tanzania 61-64 . Orthopaedic services have 

been shiften to non-surgeons effectively in Uganda and Malawi 65- 

67 

. Malawi has nine orthopaedic surgeons for a population of 

approximately 27 million, and Orthopaedic Clinical Officers (OCO) 

provide all of the district hospital level orthopaedic services for the 

country, under remote supervision from the few orthopaedic 

surgeons 65,66 . A diploma is offered after eighteen months of 

training, and core competencies include the treatment of 

musculoskeletal infections, burns, clubfoot, fractures and 

dislocations, and amputations 66 . Of 117 caregivers trained in this 

programme, only 11% have retired or relocated 66 . Uganda also 

utilizes 200 orthopaedic officers, as only 23 orthopaedic surgeons 

are available for a population of 28 million 67 . Another approach is 

the training of a “rural surgeon”; a pilot project has been initiated 

in India, and medical school graduates enroll in a 3 year training 

programme which focuses on competency in a finite number of 

common surgical procedures drawn from all of the surgical 

subspecialties, adapted to the local disease burden 74,75 . These 

individuals are typically recruited from a rural environment, and 

plan to practice in a rural environment. Further study will be 

required to evaluate the utility of this approach. 

Integration of surgical services in primary healthcare 

reforms 

The most recent World Health Report 23 focuses on how primary 

health care reforms may strengthen health systems and provide 

universal access to quality health services. Within this scheme, the 

primary care team serves to coordinate the delivery of health 

services, directly interfacing with communities and individuals. 

Despite the emphasis on primary care and preventive medicine, 

and the suggestion that hospital based services should be 

reduced, surgical care is recognized as an important component 



of the health system 23 . 

We feel that “essential” surgical care should be viewed as 

primary prevention of death and disability, and that the integration 

of surgical services at the district level in LMICs will strengthen 

population based health care. How can we reduce maternal 

mortality if access to caesarian section cannot be provided, or 

improve childhood survival without better care for the injured? 

Examples include not only the capacity to perform selected 

procedures such as cesaerean section, laparotomy, repair of a 

strangulated hernia, irrigation and debridement, or conservative 

management for fractures/dislocations, but also the ability to care 

for surgical diseases which might not require a procedure, such as 

closed head injury or blunt abdominal trauma. The vision of a 

comprehensive, horizontal approach must be emphasized, as 

illustrated by the WHO’s Emergency and Essential Surgical Care 

project (EESC) 4,6,76-79 , a diverse educational programme which has 

been introduced in 33 countries. In addition, the Global Initiative 

for Emergency and Essential Surgical Care (GIEESC) was 

launched in 2005, and represents the first coordinated effort to 

address global disparities in surgical care 79 . 

Integrating surgery and anaesthesia at the district level within 

the context of primary health care reforms will require commitment 

from multiple stakeholders, including governments and their 

ministries of health, funding agencies, non-governmental 

organizations, academic institutions, organizations outside the 

health sector, as well as community leaders and individual. 

Adequate resources must be allocated to upgrade and maintain 

capacity of the district health system (including surgery and 

anaesthesia), and mechanisms to train and retain health workers 

must be developed. Strengthening the deliver of essential surgical 

services will improve the capacity to deliver other hospital based 

services, enhance population based health care, and contribute to 

achieving the Millennium Development Goals. ❏ 

Dr David Spiegel attended Duke University for college, medical 

school, and his orthopaedic surgical residency. He then completed 

both a research and a clinical fellowship in pediatric orthopaedics 

at the Children's Hospital of Philadelphia. He works as a pediatric 

orthopaedic surgeon at the Children’s Hospital of Philadelphia, and 

is an Assistant Professor at the University of Pennsylvania School 

of Medicine. He serves as a Consultant in Orthopaedics and 

Rehabilitation at the Hospital & Rehabilitation Centre for Disabled 

Children in Banepa, Nepal. He currently serves as Chairman of the 

Committee on Childrens Orthopaedics in Underdeveloped Regions 

of the Pediatric Orthopaedic Society of North America, and has 

been on the Board of Orthopaedics Overseas, Global-HELP, and 

the Ponseti International Association. He has received the 

President's Call to Service Award (2006), from the President’s 

Council on Service and Civic Participation, for 4000 hours of 

community service. He has also received the Golden Apple Award 

by Health Volunteers Overseas (2009). He has served as a 

consultant to the World Health Organization, and is on the steering 

committee for the Global Initiative for Emergency and Essential 

Surgical Care (GIEESC). 

References 

1. 

Debas HT, Gosselin RA, McCord C, Thind A, “Surgery” in Jamison D, Evans D, Alleyne G, Jha 

P, Breman J, Measham A, et al. [Eds]. Disease Control Priorities in Developing Countries (2nd 

Edition), ed. 2006, pp.1245-1260. New York: Oxford University Press. 

2. 

Gosselin RA, Spiegel DA, Coughlin RR, Zirkle L. Injuries. The neglected burden in developing 

countries. Bull World Health Organization, 2009;87:266-247. 

3. 

Taira BR, McQueen KA, Burkle FM Jr. Burden of surgical disease: Does the literature reflect 

the scope of the international crisis? World J Surg 2009;33:893-898. 

4. 

Spiegel DA, Gosselin RA. Surgical Services in Low-income and Middle- Income Countries. 

Lancet 2007;370:1013-1015. 

5. 

Ivers LC, Garfein ES, Augustin J, Raymonville M, Yang AT, Sugarbaker DS, Farmer PE. 

Increasing access to surgical services for the poor in Rural Haiti: Surgery as a Public good 

for Public Health. World Journal of Surgery 2008:32;537-542. 

6. 

Bickler SB, Spiegel DA. Global surgery-defining a research agenda. Lancet. 2008;372:90-92. 

7. 

Bickler SW, Sanno-Duanda B. Epidemiology of pediatric surgical admissions to a government 

referral hospital in the Gambia. Bull World Health Org 2000;78:1330-1336. 

8. 

Spiegel DA. Editorial Comment. Clinical Orthpaedics and Related Research. 2008;466:2297- 

2305. 

9. 

Beveridge M, Howard A. The burden of orthopedic disease in developing countries. J Bone 

Joint Surg 2004; 86-A, 8: 1819-1822. 

10. 

Lavy C, Tindall A, Steinlechner C, Mkandawire N, Chimangeni S. Surgery in Malawi - a 

national survey of activity in rural and urban hospitals. Ann R Coll Surg Engl. 2007;89:722- 

724. 

11. 

Mock C, Cherian MN. The global burden of musculoskeletal injuries. Challenges and 

solutions. Clin Orthop Rel Res 2008;466:2306-2316. 

12. 

Spiegel DA, Gosselin RA, Coughlin RR, Joshipura M, et al. The burden of musculoskeletal 

injury in low and middle-income countries: challenges and opportunities. J Bone Joint Surg 

[Am], 2008;90:915-923. 

13. 

Peden M, McGee K, Sharma G. The Injury Chart Book. A Graphical Overview of the Global 

Burden of Injuries. Geneva, World Health Organization, 2002. 

14. 

Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Pub Health 

2000;90:523-526. 

15. 

Mock CN, Joshipura M, Goosen J. Global strengthening of care for the injured. Bull World 

Health Organization 2004;82:241. 

16. 

Norton R, Hyder AA, Bishai D, Peden M. Unintentional injuries. in Jamison D, Evans D, Alleyne 

G, Jha P, Breman J, Measham A, et al, [Eds]. Disease Control Priorities in Developing 

Countries (2nd Edition), ed. 2006, pp.737-753. New York: Oxford University Press. 

17. 

Mock C, Boland E, Acheampong F, et al. Long-term injury related disability in Ghana. Dis 

Rehab 2003; 25: 723-741. 

18. 

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, et al. An estimation of the global 

volume of surgery: A modeling strategy based on available data. Lancet 2008;372:139-144. 

19. 

Laxminarayanan R, Mills AJ, Breman JG, Measham AR, et al. Advancement of global health: 

Key messages from the disease control priorities project. Lancet 2006;367:1193-1208. 

20. 

Gosselin RA, Amardeep Thind A, Bellardinelli A. Cost/DALY Averted in a Small Hospital in 

Sierra Leone: What Is the Relative Contribution of Different Services? World J Surg 2006;30. 

21. 

Gosselin RA, Heitto M: Cost-effectiveness of a district trauma hospital in Battambang, 

Cambodia. World J Surg, Vol 32 (11):2450-2453, 2008 

22. 

McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: What it can mean for 

emergency obstetric care. Int J Gynaecol Obstet 2003;81:83-92. 

23. 

World Health Report. Primary Health Care: Now more than ever. World health Organization, 

Geneva, 2008. 

24. 

Kingham TP, Kamara TB, Cherian MN, Gosselin RA, et al. Quantifying surgical capacity in 

Sierra Leone. A guide for improving surgical care. Arch Surg 2009;144:122-127. 

25. 

Kushner AL, Cherian MN, Noel LPJ, Spiegel DA, et al. Addressing the millennium 

development goals from a surgical perspective: Deficiencies in the capacity to deliver safe 

surgery and anaesthesia in eight low and middle-income countries. Arch Surg, in Press. 

26. 

Bewes PC. Fractures of the femur in a tropical context: A reevaluation of Perkin’s traction. 

Tropical Doctor 2:64-68, 1974. 

27. 

Bach O, Hope MJ, Chaheka CV, et al. Disability can be avoided after open fractures in Africaresults 

from Malawi. Injury. 2004;35:846-851. 

28. 

Gates DJ, Alms M, Cruz MM. Hinged cast and roller traction for fractured femur. A system of 

treatment for the Third World. J Bone Joint Surg Br. 1985;67:750-756. 

29. 

Bassey LO. The use of P.O.P. integrated transfixation pins as an improvisation on the 

Hoffmann’s apparatus: contribution to open fracture management in the tropics. J Trauma. 

1989;29:59-64. 

30. 

Dagbue NA. An inexpensive and available external fixator. West Afr J Med. 2000;19:281- 

282. 

31. 

Jongen VHWM. Alternative external fixation for open fractures of the lower leg. Tropical 

Doctor 25:173, 1995. 

32. 

Lourie JA. Low cost external fixator for compound tibial fractures. PNG Med J 26:62-63, 

1983. 

33. 

Noor MA. A simple and inexpensive external fixator. Injury. 1988;19:377-378. 

34. 

Pulate A, Olivier LC, Agashe S, et al. Adaptation of Ilizarov ring fixator to the economic 

situation of developing countries. Arch Orthop Trauma Surg. 2001;121:79-82. 

35. 

Udosen AM, Ogbudu S. The use of external fixators: A review of literature and experiences in 

a developing world. Niger J Med. 2006;15:115-118. 

36. 

Bassey LO. Open fractures of the femur treated by the pin-in-plaster technique. Contribution 




to the art and practice of trauma surgery in the Third World. Arch Orthop Trauma Surg. 

1990;109:139-143. 

37. 

Strecker W, Fleischmann W, Thorpe RG. The transfixational plaster cast technique. Anal Soc 

Belge Med Trop 71:129-137, 1991. 

38. 

Bewes PC. Management of fractures in adverse circumstances. Tropical Doctor 17:67-73, 

1987. 

39. 

Strecker W, Elanga M, Fleischmann W. Indications for operative fracture treatment in tropical 

countries. Tropical Doctor 23:112, 1993. 

40. 

Garst RJ. Surgical implants for use in developing countries. Contemporary Orthopaedics 

17:25-28, 1988. 

41. 

Zirkle LG. Injuries in developing countries-How can we help? The role of orthopaedic 

surgeons. Clin Orthop rel Res 2008;466:2443-2450. 

42. 

Spiegel DA, Shrestha OP, Sitoula P, Rajbhandary T, Bijukachhe B, Banskota AK. Ponseti 

method for untreated idiopathic clubfeet in Nepalese patients from 1 to 6 years of age. 

Clinical Orthpaedics and Related Research. 2009;467:1164-1170. 

43. 

Pirani S, Naddumba E, Mathias R, Konde-Lule G, et al. Towards effective Ponseti clubfoot 

care: The Uganda Sustainable Clubfoot Care Project. Clin Orthop Rel Res 2009;467:1154- 

1163. 

44. 

Tindall AJ, Steinlechner CWB, Lavy CBD, et al. Results of manipulation of idiopathic clubfoot 

deformity in Malawi by orthopaedic clinical officers using the Ponseti method: A realistic 

alternative for the developing world? J Pediatr Orthop. 2005;25:627-629. 

45. 

Lourenco AF, Morcuende JA. Correction of neglected idiopathic club foot by the Ponseti 

method. J Bone Joint Surg Br 2007;89B:378-381. 

46. 

Report on Service Availability Mapping, (accessed September 26th, 2009). 

47. 

Service Availability Mapping, World health Organization (www.who.int/healthinfo/systems/ 

serviceavailabilitymapping/en/) (accessed September 26th, 2009). 

48. 

Report on Service Availability Mapping, United Republic of Tanzania. (www.who.int/ 

healthinfo/systems/SAM_CountryReport_Tanzania.pdf) (accessed September 26th, 2009). 

49. 

Anyangwe SCE, Mtonga C. Inequities in the global health workforce: The greatest 

impediment to health in Sub-Saharan Africa. Int J Environ Res Pub health 2007;4:93-100. 

50. 

Mathauer I, Imhoff I. Health worker motivation in Africa: The role of non-financial incentives 

and human resource management tools. Hum Res Health 2006;4:24. 

51. 

Hagopian A, Zuyderduin A, Kyobutungi N, Yumkella F. Job satisfaction and morale in the 

Ugandan health workforce. Healtrh Affairs 2009;28:w863-875. 

52. 

World Health Report 2006: Working together for health. World Health Organization, Geneva, 

2006. 

53. 

Omaswa F. Human resources for global health: Time for action is now. Lancet 

2008;371:625-626. 

54. 

Dussault G, Franceschini MC. Not enough there, too many here: Understanding geographical 

imbalances in the distribution of the health workforce. Hum Res Health 2006:4:12. 

55. 

McCoy D, Bennett S, Witter S, Pond B, Baker B, Gow J, Chand S, Ensor T, McPake B. 

Salaries and incomes of health workers in sub-Saharan Africa. Lancet 2008;371:675-681. 

56. 

Ozgediz D, Galukande M, Mabweijano J, Kijjambu S, Mijumbi C, Dubowitz G,Kaggwa S, 

Luboga S. The neglect of the global surgical workforce: experience and evidence from 

Uganda. World J Surg 2008;32:1208-1215. 

57. 

Scheffler RM, Mahoney CB, Fulton BD, Dal Poz MR, Preker AS. Estimates of health care 

professional shortages in Sub-Saharan Africa by 2015. Health Affairs 2009;28:w849-862. 

58. 

Mullan F. Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet 

2007;370:2158-2163. 

59. 

WHO. Task Shifting. Global recommendations and guidelines. Geneva, World Health 

Organization, 2008. (http://www.who.int/healthsystems/TTR-task shifting.pdf) (Accessed 

9/26/09) 

60. 

McPake B, Mensah K. Task shifting in health care in resource-poor countries. Lancet 

2008;372:8870-871. 

61. 

Fenton M, Whitty CJ, Reynolds F. Cesaerean section in Malawi: Prospective study of early 

maternal and perinatal mortality. BMJ 2003;327:587. 

62. 

McCord C, Mbaruku G, Pereira C, Nzabuhakwa C, Bergstrom S. The quality of emergency 

obstetrical surgery by assistant medical officers in Tanzanian district hospitals. Health Affairs 

2009;28:w876-885. 

63. 

Pereira C, Bugalho A, Bergstrom S, Vaz F, Cotiro M. A comparative study of caesarean 

deliveries by assistant medical officers and obstetricians in Mozambique. Br J Obstet 

Gynaecol 1996;103:508-512. 

64. 

Chilopora G, Pereira C, Kamwendo F, Chimbiri A, et al. Postoperative outcome of caesarean 

sections and other major obstetric surgery by clinical officers and medical officers in 

Malawi. Hum Res Health 2007;5:17. 

65. 

Lavy CBD, Mkandawire N, Harrison WJ. Orthopaedic training in developing countries. J Bone 

Joint Surg [Br] 2005;87:10-11. 

66. 

Mkandawire N, Ngulube C, Lavy C. Orthopaedic clinical officer program in Malawi: a model 

for providing orthopaedic care. Clin Orthop Relat Res. 2008;466:2385-2391. 

67. 

Naddumba EK. Musculoskeletal trauma services in Uganda. Clin Orthop Rel Res 

2008;466:2317-2322. 

68. 

Huicho L, Scherpbier RW, Nkawane AM, Victora CG, et al. How much does quality of child 

care vary between health workers with differing durations of training? An observational 

multicenter study. Lancet 2008;372:910-916. 

69. 

Kruk M, Pereira C, Vaz F, Bergstrom S, et al. Economic evaluation of surgically trained 

assistant medical officers in performing major obstetric surgery in Mozambique. BJOG 

2007;114:1253-1260. 

70. 

Garrido PI. Training of medical assistants in Mozambique for surgery in rural settings. S Afr J 

Surg 1997;35:144-145. 

71. 

Laloe V. Training programme for general practitioners in emergency surgery and obstetrics in 

Woldya, Ethiopia. Trauma Q 1999;14:339-344. 

72. 

Rennie JA. The training of GP’s in emergency surgery in Ethiopia. Trauma Q 1999;14:335- 

338. 

73. 

Vaz F, Bergstrom S, da Luz Vaz M, et al. Training medical assistants for surgery. Bull WHO 

1999;77:688-691. 

74. 

Jena TK, Agarwal AK. Surgical training-distance education. A training tool for rural surgeons. 

Ind J Surg 2003;65:50-54. 

75. 

Tongaonkar RR. Scope and Limitations of Rural Surgery. Indian J Surg 2003;65:24-29. 

76. 

Cherian MN, Noel L, Buyanjargal Y, et al. Essential emergency surgical procedures in 

resource-limited facilities: A WHO workshop in Mongolia. World Hosp Health Serv 

2004;40:24-29. 

77. 

Integrated Management of Emergency and Essential Surgical Care. World Health Organization 

(www.who.int/surgery/publications/imeesc). (Accessed 12/15/08) 

78. 

Surgical Care at the District Hospital. World Health Organization, Geneva, 2003 

(www.who.int/surgery/publications/scdh_manual). (Accessed 12/15/08) 

79. 

World Health Organization. Global Initiative for Emergency and Essential Surgical Care, 2005. 

Available at http://www.who.int/surgery/globalinititiative/en/. (Accessed 30 September 2009). 


Innovation in patient care 

120 Surgical Site Infections (SSIs), antimicrobial agents, 

universal precautions and post-exposure prophylaxis 

Jonathan Samuel and Wakisa Mulwafu 

127 Have we created an alternative MSD risk from a 

reliance on hoisting solutions? An academic review of 


M Fray 


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Innovations in patient care: infection control 

Surgical Site Infections (SSIs), 

antimicrobial agents, universal 

precautions and post-exposure 

prophylaxis 

ARTICLE BY JONATHAN SAMUEL, 

University of North Carolina, School of Medicine, Chapel Hill, North Carolina 

WAKISA MULWAFU, (PICTURED) 

Queen Elizabeth Central Hospital, Blantyre, Malawi 

SSIs represent a major cause of morbidity in surgical patients, affecting only around 2% of patients with 

clean cases, but upwards of 15-20% of patients undergoing contaminated cases. This article sets out to 

show the best ways of dealing with surgical site infections and makes specific recommendations for the 

best ways of treating SSIs. 

Awound is defined by the Center for Disease Control (CDC) 

as an interruption or break in the continuity of the external 

surface of the body or the surface of an internal organ, 

caused by surgical or other forms of injury or trauma. A surgical 

site infection (SSI) is clinically defined as presence of pain at a 

surgically created wound, which is accompanied by erythema, 

induration and local tenderness or presence of purulent discharge 

at wound site 1 . SSIs are not a modern phenomenon. As early as 

14-37AD there is documentary evidence that Cornelius Celsus (a 

Roman physician) described the four principal signs of 

inflammation and used “antiseptic” solutions. Another Roman 

physician, Claudius Galen (130-200 AD) had such an influence on 

the management of wounds that he is still thought of by many 

today as the “father of surgery”. 

Surgeons encounter wound infections in two major ways: 

patients present with an infection that requires surgical treatment, 

like drainage of an abscess; or infection complicates a surgical 

procedure, e.g. SSI. This problem was almost universal prior to the 

development of aseptic surgery in the last century but, in spite of 

our more sophisticated understanding of the nature of infection 

and an arsenal of antimicrobial agents, SSI still remains a major 

surgical problem today. 

SSIs have a significant impact on patients, increasing length of 

hospital stay, contributing to overuse of hospital stay, contributing 

to an overuse of antibiotics and increased associated costs, and 

contributing to increased mortality 2 . 

SSIs are common, comprising about 12% of all hospitalacquired 

infections. The rate of infection varies depending on the 

type of surgery undertaken. Especially high rates are associated 

with contaminated surgery, such as colorectal surgery or delayed 

surgery to traumatic wounds. 

Aetiology of SSIs 

SSIs are caused by the deposition and multiplication of 

microorganisms in the surgical site of a susceptible host. There are 

a number of ways microorganisms colonize and cause infection, 

including: a) direct contact – either from another patient, transfer 

from surgical equipment or the hands of the hospital staff; b) 

airborne dispersal – surrounding air contaminated with microorganisms 

that deposit onto the wound; and c) self-contamination 

(also known as endogenous infection) – physical migration of the 

patient’s own normal flora which are present on the skin, mucous 

membranes or gastrointestinal tract to the surgical site. Most 

surgical infection is due to bacterial and, more rarely, fungal 

infection. Viruses, such as human immunodeficiency virus (HIV) 

and the hepatitis B and C viruses are important to surgeons 

because they may contract these diseases from their patients. 

Due care has to be taken when managing such patients and 

infection significantly alters the host response to other diseases. 

The commonest organism causing SSI is Staphylococcus 

aureus. Other common causative organisms include other Gramnegative 

aerobes, Streptococcus spp. and anaerobes. A study by 

Erickson et al. in Tanzania showed that S. aureus was the most 

common isolate (n=22), followed by E. coli (n=12) and Klebsiella 



spp. (n=12) 2 . In another observational study in Tanzania, the overall 

rate of SSI was 24% among all surgical disciplines; wound 

classification associated with infection (dirty-infected wounds) had 

a risk ratio of 2.8 compared to clean wounds 3 . Overall, 144 of the 

618 patients studied developed SSIs, with the most common 

isolates being S. aureus (37%), E. coli (11%), and Enterococcus 

spp. (5%). Especially concerning was the isolation of one strain of 

methicillin-resistant S. aureus (MRSA) and three isolates of 

vancomycin-resistant Enterococcus. Of the patients with SSIs in 

the study, 35% had cultures that yielded no growth or “no clinically 

significant organism.” The authors do not specifically mention 

whether anaerobic cultures were done, and no obligate anaerobes 

were identified, so the high rate of negative cultures may be in part 

due to failure to identify obligate anaerobes. 

Risk factors associated with SSIs 

The likelihood of developing an SSI is influenced by a number of 

factors. These factors fall into four major groups, which are: 

patient factors, anaesthetic factors, wound status, and surgeon 

factors. 

Patient factors 

General patient characteristics that play a role in SSI include: 

immunosuppression, malnutrition, endocrine & metabolic 

disorders, obesity, age (young and elderly), malignant disease and 

others. All these factors have their influence by lowering host 

immunity to various infections. 

Given the high prevalence of HIV among patients in developing 

countries, the impact of HIV on surgical outcomes is a topic of 

considerable interest. For example, HIV infection leads to a lower 

rate of both skin graft survival (69% vs. 22%) 4 , and overall patient 

survival among burn victims (for 21-30% burns: 100% mortality 

versus 50% mortality in HIV negative patients) 5 . Among HIV 

positive patients undergoing anorectal procedures, wound healing 

is poor 6,7 . 

A considerable body of research exists on the topic of surgical 

site infections and HIV as well. In orthopaedic trauma patients, the 

risk of postoperative infection is considerably higher in HIV positive 

individuals (16.7% versus 5.4%) 8 , though in elective orthopaedic 

cases with intact skin and use of implants, the rate of infection 

Table 1: Classification of the risk of SSI 13 

WOUND CLASSIFICATION DESCRIPTION INFECTIVE RISK (%) 

Clean Uninfected operative wound, no acute


clots in the wound space and prevention of third spaces by tissue 

re-approximation. 

Prevention of SSIs 

Prevention is always better than a cure, and thus a careful 

assessment of risks related to SSIs is paramount. The goal of SSI 

management is to prevent or minimise the risk through careful 

planning. 

The following factors or methods external to the patient are 

critical to preventing SSIs: a) Theatre environment and care of 

instruments; maintenance of positive pressure ventilation of 

operating theatre, laminar airflow in high risk areas, and 

sterilisation of surgical instruments, sutures etc. according to 

guidelines, and b) Surgical team members educated in aseptic 

technique; staff with infections excluded from duty and scrubbing 

up followed by appropriate sterile attire. 

The following section outlines the evidence regarding hair 

removal, preparation of the sterile field, and wound closure 

technique. Prophylactic antibiotic use is discussed in section 6. 

Decisions regarding hair removal 

Hair removal is commonly performed prior to surgery, yet both the 

Centers for Disease Control and Prevention (CDC) and the 

Norwegian Centre for Health Technology Assessment recommend 

against hair removal 14 . The CDC recommends that, if performed, 

hair removal should be done by clipping or use of a depilatory 

cream, rather than by razor. A recent Cochrane Database of 

Systematic Reviews identified 11 studies that met criteria for 

inclusion in a meta-analysis of hair removal and infections; 3 of 

these studies compared shaving with clipping and found that 

shaving increased surgical site infections (relative risk 2.02, 95% 

confidence interval 1.21 to 3.36). Furthermore, shaving versus 

clipping leads to more skin trauma even under ideal conditions, 

providing further evidence that shaving should be avoided 15 . 

There were no studies meeting inclusion criteria that compared 

clipping of hair to no hair removal. Two studies compared shaving 

with no hair removal, and found that shaving increased infection 

(relative risk 1.59). However there were relatively few subjects in 

these two studies and hence the conclusion did not reach 

statistical significance. 

Evidence from within Africa supports the CDC recommendation 

against hair removal. Adeleye et al. recently reported their 

experience with 17 cranial procedures on black Africans, in which 

all of the fields were non-shaved, and reported no serious 

complications over a 2 to 6 month follow-up 16 . 

In conclusion, if hair is to be removed at all, it should be done by 

clipping and not by shaving. Furthermore, hair should not routinely 

be removed except in cases where the presence of hair interferes 

with the technical aspects of the surgery, which is a judgment that 

is best left to the operating surgeon within the context of these 

recommendations. 

Preparation of the surgical field 

Two factors relate to the surgical field – the choice of skin 

preparation, and the method of draping. In developing countries, 

the choice of drapes has been limited due to cost constraints, 

whereas in developed countries, sterile, adhesive iodineimpregnated 

drapes (commonly known as Ioban) are available. 

These adhesive drapes are placed over the skin after preparation 

and application of standard side drapes. However, this practice 

has demonstrated no benefit in randomized controlled trials. 

Furthermore, adhesive drapes without iodine increase SSI rates 

(relative risk 1.23, p=0.03) 17 . Thus the avoidance of adhesive 

drapes as an adjunct to standard cloth drapes is best avoided. 

Several methods of skin preparation are available, including 

chlorhexidine, iodine, spirit, and over-the-counter soap. Bibbo et 

al. compared chlorhexidine and isopropyl alcohol to povidoneiodine 

in a randomized of 127 patients undergoing foot surgery 

and found that chlorhexidine preparation resulted in a lower rate of 

culture-positive skin swabs (38% versus 79%) 18 . Chlorhexidine, an 

antiseptic solution that has been used worldwide since the 1950s, 

is a safe and effective product with broad antiseptic activity. 

Chlorhexidine gluconate is a water soluble, cationic biguanide that 

binds to the negatively charged bacterial cell wall, altering the 

bacterial cell osmotic equilibrium and is available in a variety of 

concentrations (0.5%–4%) and formulations (with and without 

isopropyl alcohol or ethanol). Chlorhexidine (0.05% solution) has 

broad activity against gram-positive and gram negative bacteria, 

facultative anaerobes and aerobes, yeasts, and some lipidenveloped 

viruses, including HIV. Chlorhexidine is not sporicidal 19 . 

Meier et al., recognizing the scarcity at times of conventional 

skin preparation solutions, compared the use of over-the-counter 

soap followed by methylated spirit, to the use of iodine 20 . The 

study randomized 200 patients undergoing elective inguinal hernia 

repair in Nigeria. In group 1, the subject’s skin was prepared by 

scrubbing with soap and water, blotting with a sterile towel, and 

applying spirit. In group 2, skin was prepared by scrubbing with 

povidone-iodine then blotting with a sterile towel and applying 

povidone-iodine paint. There was no difference in surgical site 

infections between groups 1 and 2 (5.1% versus 5.9%, 

respectively). 

To this date, no studies have compared using soap and spirit 

versus chlorhexidine. Thus the current evidence supports the use 

of chlorhexidine for preparation of the surgical site. If chlorhexidine 

is not available, scrubbing with soap followed by painting with 

spirit (70% alcohol/30% water) appears equally efficacious as 

scrubbing and painting with povidone-iodine. 

Wound closure techniques and use of drains 

There is little disagreement that clean wounds should be closed 

primarily. However, the choice of whether to close primarily or 

leave open, contaminated and clean-contaminated wounds is not 

as straightforward. If a wound is not closed primarily (closed at the 

time of surgery), it can be left open to heal by secondary intent, or 

evaluated for closure at a later date (delayed primary closure, or 

DPC). DPC of a surgical wound involves placing sterile dressing 

over the wound at the conclusion of the case, and then removing 

the dressing usually several days later. If the wound bed appears 

clean and without devitalized tissue, the wound is then closed with 

sutures. 

One prospective randomized study from Tanzania found that the 

rate of infection was higher when clean-contaminated or 

contaminated wounds were left open, as opposed to closed 

(30.2% versus 2.1%) 1 . It must be noted that those subjects in the 

group whose wounds were left open were heterogeneous, and 

included a combination of delayed primary closure (DPC) and 

secondary healing techniques. Marion et al. conducted a metaanalysis 

of primary versus DPC in complicated appendicitis, and 



found similar results, with a lower rate of infection in those wounds 

closed primarily (relative risk 0.64, 95% confidence interval 0.46 to 

0.91) 21 . 

The one exception in which DPC might be advisable is in the 

management of traumatic wounds. For DPC of traumatic wounds, 

the same general principles for DPC of surgical wounds apply: no 

wound should be closed if grossly contaminated, and any 

devitalized tissue should first be debrided. The management of 

neglected or chronic wounds by DPC is more complicated. The 

International Committee of the Red Cross provides a good 

overview of DPC in traumatic, neglected, and contaminated 

wounds 22 . 

Decisions surrounding placement of a surgical drain is beyond 

the scope of this review. However, in most cases the routine use 

of surgical drains should be discouraged, as is discussed in an 

excellent review by Schein 23 . Schein does note that select 

situations may be appropriate for drain placement, including noncollapsible 

abscesses (rare), high prediction of fluid leakage (bile, 

pancreatic juice, or urine), or drainage for a short duration of an 

“oozy” surface. One study compared the use of post-mastectomy 

drains for 4 days or 10 days, and found a significantly higher rate 

of infection among those drains left in place for 10 days (9.5% 

versus 2.2%) 24 , lending support to Schein’s recommendation of a 

short duration of drainage. 

Treatment of surgical site infections 

The following section outlines the diagnosis and surgical treatment 

of SSIs. Use of antibiotics is discussed in section 6, and is 

secondary to adequate drainage, discussed below. 

Diagnostic criteria 

An SSI is defined by both clinical and microbiological 

examinations. The isolation of bacteria from the wound alone is 

not diagnostic for an SSI without at least clinical evidence of 

infection (redness, localised swelling, pain or tenderness, purulent 

discharge, relative warmth to the touch). Often, SSIs are 

diagnosed and treated based on a constellation of signs and 

symptoms. However, samples from the wound can also be taken 

for culture. Pus or, if appropriate, a tissue biopsy is preferred over 

simple wound swabs. In patients where bacteraemia or sepsis is 

suspected, blood cultures should also be taken. 

Drainage 

“Never let the sun set on an abscess.” This frequently quoted 

surgical adage emphasizes the critical importance of timely 

diagnosis and treatment of SSIs. Though some SSIs may be 

limited to cellulitis, one should have a low threshold for incision and 

drainage, or reopening, either a portion or all of the incision, to 

drain pus if examination suggests the infection is more then 

cellulitis. 

Special note must also be made of necrotizing fasciitis, which 

can occur as a SSI. Signs that suggest necrotizing fasciitis 

include: 

✚ wounds with early drainage of clear brown fluid (“dishwater 

drainage”); 

✚ wounds in which the subcutaneous fat has a dark brown 

discoloration; 

✚ wounds in which normally adherent tissue planes separate 

easily; 

✚ wounds in which subcutaneous vessel thrombosis is present. 

Any of these signs or the presence of systemic toxicity, suggest 

a serious infection, and immediate debridement of all infected 

tissue is the mainstay of treatment. This may require debridement 

of skin, subcutaneous fat, and possibly muscle. (See Surgery in 

Africa, October 2005: Soft-tissue infections) 

Antibiotics and SSIs 

The goals of antibiotic prophylaxis are to achieve inhibitory 

antibiotic levels at incision and throughout the procedure in an 

effort to decrease the likelihood of developing a SSI. Antibiotics 

can also play an important role in the treatment of SSIs. 

Antibiotics for prophylaxis of SSIs 

Animal studies have shown that antibiotic prophylaxis is most 

effective in preventing post-surgical infections when administered 

before the start of surgery, and pharmacokinetic data suggest 

administration as near the time of incision as possible. Classen et 

al., in a prospective observational study, monitored the timing of 

antibiotic prophylaxis in 2847 patients in “clean” or “clean 

contaminated” surgery. Using a step-wise logistic regression 

model, they found that preoperative antibiotics within two hours of 

incision had the lowest rate of infection as compared to antibiotics 

given after incision or earlier than two hours prior 25 . 

In addition to being given preoperatively, prophylactic antibiotics 

should not be continued postoperatively. A five-month prospective 

survey of surgical-site infections (SSI) conducted in the 

department of general surgery at Kilimanjaro Christian Medical 

Center, Tanzania by Eriksen et al., showed that 77 (19.4%) of the 

397 patients studied developed SSI 2 . Twenty-eight (36.4%) of 

these infections were apparent only after discharge from hospital. 

A surprising eighty-seven percent of the patients who developed 

SSI had received antibiotics, the majority having received the 

antibiotics for several days. Such a practice is contrary to the 

current recommendation of a single preoperative dose, and 

prolonged inappropriate use of broad-spectrum antibiotics may 

contribute to increased emergence of resistance. 

The type of surgery (clean, clean/contaminated, contaminated, 

or dirty) (see Table 1) also impacts the role of antibiotic prophylaxis. 

An understanding of this classification, as well as knowledge of 

recommendations for specific procedures, is invaluable in making 

an appropriate choice regarding antibiotic prophylaxis. Antibiotic 

administration in dirty cases is not considered prophylactic as 

these cases represent treatment of infection rather than 

prophylaxis. 

Controversy exists regarding the use of antibiotic prophylaxis for 

clean cases. When antibiotic prophylaxis is given, the agent 

should target S. aureus, the most common organism causing SSIs 

in clean cases; cefazolin is a good choice 26 . When bone is incised, 

the use of prophylactic antibiotics is clearly recommended 27 . A 

good choice in this situation, or for cardiothoracic or vascular 

surgery, is cefazolin or cefuroxime (or clindamycin or vancomycin 

for penicillin allergic) 26 . For general surgical clean cases, the 

decision is less clear. A Cochrane Database of Systematic 

Reviews examined the use of prophylactic antibiotics prior to 

hernia surgery, and found that infection rates were lower with use 

of antibiotics (2.9% versus 3.9%) but concluded that “antibiotic 

prophylaxis for elective inguinal hernia repair cannot be universally 



recommended” because of overall low infection rates, a high 

number needed to treat, and a lack of a large, randomized 

controlled trial to prove efficacy 28 . Similarly, Osuigwe et al. studied 

the use of prophylactic antibiotics for paediatric surgery in a 

prospective, randomized, double-blind study of 289 children at a 

teaching hospital in Nigeria 29 . Patients were randomly assigned to 

receive either doses of ampicillin/cloxacillin (Ampliclox) with vitamin 

B (Group A, treatment group), or vitamin B only (Group B, placebo 

group). The doses were begun at induction and continued for five 

days postoperatively. Patients were evaluated for wound infection 

at postoperative day 5, and then again at postoperative day 7 to 

10 during suture removal. Wound infection was defined as the 

presence of erythema, induration, or discharge. Group A had a 

4.3% infection rate compared to 5% in group B, a difference that 

was not statistically significant. 

For clean-contaminated and contaminated cases, antibiotic 

prophylaxis is recommended. Colorectal surgery is the most 

thoroughly studied type of procedure in this category, and as such 

most recommendations are based on studies involving colorectal 

surgery. The most commonly encountered organism in cleancontaminated 

and contaminated SSIs is still S. aureus, though 

other aerobic as well as anaerobic bacteria are also culprits 30 . As 

such, prophylaxis should be broader than that used for clean 

cases. Song et al. reviewed all randomized controlled trials of 

antibiotic prophylaxis in colorectal surgery 31 . Four of these studies 

compared antibiotic regimens to no antibiotics and showed a 

convincing benefit of prophylactic antibiotics (odds ratio 0.24, 

95% confidence interval 0.13 to 0.43). Further analysis revealed 

that the most efficacious regimens include coverage against both 

aerobic and anaerobic organisms (such as a 2nd or 3rd generation 

cephalosporin, or gentamicin in combination with metronidazole), 

and cited certain regimens inadequate (metronidazole alone, 

doxycycline alone, piperacillin alone) 32 . Though data from Africa is 

limited, differences in efficacy between various 2nd and 3rd 

generation cephalosporins appear negligible 33 , and choice 

prophylaxis with a single-agent 2nd or 3rd generation 

cephalosporin can probably be dictated by availability or cost. For 

penicillin-allergic patients, clindamycin combined with gentamicin, 

aztreonam, or ciprofloxacin, or metronidazole combined with 

gentamicin or ciprofloxacin are adequate choices 26 . 

Antibiotics for treatment of SSIs 

Empiric treatment of an SSI after clean cases should be primarily 

directed against S. aureus. Clean-contaminated, contaminated, 

and dirty cases require broader empiric coverage to include both 

aerobic and anaerobic bacteria. Choices of empiric therapy, 

against SSIs suspected of being caused by S. aureus, such as 

SSIs after clean cases, include cloxacillin or in penicillin-allergic 

patients, clindamycin. For SSIs after clean-contaminated, 

contaminated or dirty cases, a second- or third-generation 

Cephalosporin (such as cefuroxime or ceftriaxone), metronidazole 

with gentamicin, or amoxicillin/clavulanate, are all reasonable 

choices that will provide aerobic and anaerobic coverage. 

It is also important to take note that in many surgical operations, 

patients will have previously received antibiotic prophylaxis. 

Prophylaxis can affect the flora and thus the cause of any 

subsequent infection. One study of antibiotic prophylaxis for 

cardiac surgery compared vancomycin to cefazolin, and found 

that SSIs in those receiving cefazolin were more likely to be 

Table 2: Possible regimens for post-exposure prophylaxis against 

HIV 40 

DRUG CLASS 

Two nucleotide reverse 

transcriptase inhibitors 

(NRTIs) 

AND 

One protease inhibitor (PI) 

EXAMPLES 

lamivudine and zidovudine (Combivir) 

tenofovir and emtricitabine (Truvada) 

tenofovir and lamivudine 

stavudine and lamivudine 

lopinavir 

saquinavir 

fosamprenavir 

ritonavir 

caused by methicillin-susceptible S. aureus compared to SSIs in 

those receiving vancomycin (3.7% versus 1.3%) 34 . As such it is 

important to determine the nature of any prior antibiotic therapy; a 

prudent approach is to choose a different regimen that the one 

used for prophylaxis at the time of surgery. 

Lastly, it should be re-emphasized that antibiotic administration 

for SSIs is secondary to the cornerstone of treatment—which is 

adequate drainage of the infection. Additionally, if antibiotic 

sensitivities are identified, it may be necessary to tailor antibiotics 

to the specific strains. Many surgeons use topical agents such as 

hydrogen peroxide, 2% acetic acid, or Dakin’s solution (0.5% 

sodium hypochlorite), but evidence in support of this is scant. A 

review of the evidence regarding Dakin’s solution, for example, 

found only three small prospective studies and concluded that 

there was no benefit to its use 35 . More important is the frequency 

of dressing changes when managing SSIs; dressings should be 

changed if they appear soiled or are foul-smelling, and must be 

changed no less frequently than once daily. Lastly, one should not 

forget to emphasize the importance of hand hygiene to the 

guardian, or any others involved in the care of the patient, which 

minimizes cross-contamination. 

Universal precautions and post-exposure prophylaxis 

Universal precautions mandate that health care providers assume 

all patients carry a transmissible infectious disease (such as viral 

hepatitis or HIV), and maintain precautions against contracting 

such infections. The nature of personal protective equipment is 

situation-dependent, and may include gloves, eye protection, a 

protective gown and/or boots, or a mask. Bodily fluids, including 

blood and saliva, as well as airborne particles, are considered an 

exposure risk. Testing all patients to identify individuals infected 

with transmissible diseases is not feasible, and thus universal 

precautions are required 36 . 

In addition to universal precautions, pre-exposure vaccination 

against hepatitis B is recommended. All health care workers 

potentially coming in to contact with bodily fluids should be 

vaccinated against hepatitis B, which is given as a series of three 

intramuscular doses. Despite the importance of hepatitis B 

vaccination, many health care workers are not vaccinated due to 

either not being aware of the vaccine’s efficacy, or being unable to 

afford the series of vaccinations 37 . 

HIV and hepatitis C pose risks to health care providers, and to 

this date there are no vaccinations available for pre-exposure 

prophylaxis. Therefore prevention relies solely on universal 

precautions and safe practices, such as not recapping used 

needles, using sharps containers appropriately, and properly 



passing sharp instruments in theatre (by a sharps container, or 

using verbal communication between the surgeon and the scrub 

nurse). 

To this date, there are no known cases of transmission of HIV 

from a patient to a health care provider in the operating room. 

However there are at least 57 documented cases of transmission 

to health care providers in settings outside of the operating room 38 . 

Hepatitis C poses a more serious risk of transmission, which is 

estimated to be 2% if the patient is infected with hepatitis C, and 

the health care provider as been stuck with a hollow needle 39 . 

After unintentional exposure, the site should be copiously 

washed, and consideration must be given to post-exposure 

prophylaxis against HIV. If possible, the patient should be tested 

for HIV. Factors influencing the choice for or against HIV post 

exposure prophylaxis include the type of exposure, whether the 

status of the patient is known at the time of exposure, and the 

availability of post exposure prophylaxis. The overall risk of 

transmission from a needle stick when the patient is HIV positive 

is estimated at 0.3%; high risk occupational exposure from an HIV 

positive patient is defined as a deep puncture with a hollow 

needle, a needle that is visibly contaminated, large bore needle, 

needle that was place directly in an artery or vein, high viral load of 

the patient, or a patient with end-stage disease 40 . Post-exposure 

prophylaxis should continue for 28 days and include both a 

nucleotide reverse transcriptase inhibitor (NRTI) and a protease 

inhibitor (PI); in the United Kingdom, the recommended regimen is 

now Combivir (lamivudine and zidovudine, both NRTIs) with 

lopinavir and ritonavir (PIs; supplied in combination as Kaletra) 

(Table 2). 

Summary of recommendations 

In conclusion, SSIs represent a major cause of morbidity in 

surgical patients, affecting only around 2% of patients with clean 

cases, but upwards of 15-20% of patients undergoing 

contaminated cases. 

1. To limit the chance of SSIs, one should treat any endocrine or 

metabolic disorders in the patient, and optimize nutritional 

status. 

2. Preoperative antibiotics should be given for clean-contaminated 

and contaminated cases (second or third generation 

cephalosporin). For clean cases, the evidence is mixed, and if 

given the best choice is a first generation cephalosporin. The 

antibiotic should be given before incision, but no longer than 60 

minutes before, and should not be continued for more than 24 

hours postoperatively. Antibiotics for dirty cases represent 

treatment of infection and thus are not considered prophylaxis. 

3. Body hair need not be removed, and if the surgeon chooses to 

remove hair, it should be done by use of clippers or a depilatory 

agent; shaving causes an increased chance of wound infections 

and must be avoided. 

4. Chlorhexidine is the best skin preparation agent. Soap followed 

by iodine, or 70% alcohol followed by iodone are the next best 

alternatives. 

5. Intraoperatively, patients should retain normothermia, 

normoglycemia, and adequate perfusion and oxygenation. The 

surgeon should minimize tissue devitalisation, adhere to sterile 

technique, avoid hematoma formation, and close potential 

spaces. 

6. Evidence supports closing primarily all wounds, and avoiding 

drain placement, or if used, such as in breast surgery, not 

leaving drains in post-operatively any longer than necessary. 

7. If one suspects an SSI (redness, localised swelling, pain or 

tenderness, purulent discharge, relative warmth to the touch), 

maintain a low threshold for opening the wound which is the 

primary treatment. Antibiotics are secondary to adequate 

drainage. There are a number of reasonable choices for treating 

SSIs, and the choice of an agent should be dictated by culture 

results when possible. 

8. Surgeons should be familiar with the risks of transmission of 

HIV, and the indications for and choices of post-exposure 

prophylaxis. All surgeons should be vaccinated against hepatitis 

B virus. ❏ 

Acknowledgement 


Review – November 2008 

Jonathan Samuel was born and raised in Santa Barbara, California. 

He completed his bachelor’s degree at Harvard University, and his 

Medical Degree from Northwestern University. He received a 

Master’s Degree in Public Health from the University of Michigan, 

prior to beginning his specialty training in general surgery at the 

University of North Carolina. For the past two years he has worked 

as a general surgeon and researcher at Kamuzu Central Hospital in 

Lilongwe, Malawi, where he currently resides. At KCH he is Director 

of Continuing Professional Development. He also lectures in 

surgery at the Malawi College of Health Sciences. He is a candidate 

member of the Association for Academic Surgery, and a resident 

member of the American College of Surgeons. 

Born in Chitipa, Malawi, and a fifth born in a family of eight, Dr 

Mulwafu went to Iponjola Primary School and proceeded to 

Chaminade secondary school. There he was selected to do further 

studies at Chancellor College in Zomba, Malawi, where he 

completed two years in the faculty of bachelor of science and then 

joined College of Medicine where he obtained his MBBS. From 

College of Medicine, Wakisa did his internship at Queen Elizabeth 

Central Hospital for two years and transferred to Kamuzu Central 

Hospital where he worked as a registrar in surgery for another two 

years. He specialized as an ENT surgeon at the University of Cape 

Town, where he completed one year of general surgery and four 

years of specialist training in ENT. 



References 

1. 

Ussiri E, Mkony C, Aziz M. Sutured and open clean-contaminated and contaminated 

laparotomy wounds at Muhimbili National Hospital: A comparison of complications. East and 

Central African Journal of Surgery 2004;9(2):89-95. 

2. 

Eriksen H, Chugulu S, Kondo S, Lingaas E. Surgical-site infections at Kilimanjaro Christian 

Medical Center. Journal of Hospital Infection 2003;55:14-20. 


3. 

Fehr J, Hatz C, Soka I, Kibatala P, Urassa H, Smith T, et al. Risk factors for surgical site 

infection in a Tanzanian District Hospital: A challenge for the traditional national nosocomial 

infections surveillance system index. Infection Control and Hospital Epidemiology 

2006;27(12):1401-4. 


4. 

Mzezewa S, Jonsson K, Sibanda E, Aberg M, Salemark L. HIV infection reduces skin graft 

survival in burn injuries: a prospective study. British Association of Plastic Surgery 

2003;56(8):740-5. 


5. 

James J, Hofland H, Borgstein E, Kumiponjera D, Komolafe O, Zijlstra E. The prevalence of 

HIV infection among burn patients in a burns unit in Malawi and its influence on outcome. 

Burns 2003;29(1):55-60. 


6. 

Lord R. Anorectal surgery in patients infected with human immunodeficiency virus: Factors 

associated with delayed wound healing. Annals of Surgery 1997;226(1):92-9. 


7. 

Morandi E, Merlini D, Salvaggio A, Foschi D, Trabucchi E. Prospective study of healing time 

after hemorrhoidectomy: Influence of HIV infection, acquired immunodeficiency syndrome, 

and anal wound infection rate. Diseases of the Colon and Rectum1999;42(9):1140-4. 


8. 

Paiement G, Hymes R, LaDouceur S, Gosselin R, Green H. Postoperative infections in 

asymptomatic HIV-seropositive orthopaedic trauma patients. Journal of Trauma 

1994;37(4):545-51. 

9. 

Harrison W, Lavy C, Lewis C. One-year follow-up of orthopaedic implants in HIV-positive 

patients. International Orthopaedics 2004;28(6):329-32. 


10. 

Norrish A, Lewis C, Harrison W. Pin-tract infection in HIV-positive and HIV-negative patients 

with open fractures treated by external fixation: a prospective, blinded, case-controlled 

study. Journal of Bone and Joint Surgery 2007;89(6):790-3. 


11. 

Urbani G, Vries Md, Cronje H, Niemand I, Bam R, Beyer E. Complications associated with 

caesarean section in HIV-infected patients. International Journal of Gynaecology and 

Obstetrics 2001;74(1):9-15. 


12. 

Mauermann W, Nemergut E. The anesthesiologist's role in the prevention of surgical site 

infections. Anesthesiology 2006;105(2):413-21. 


13. 

Gardner D, Tweedle D. Pathology for surgeons in training-an A-Z revision text. 3rd ed. 

London: Arnold Publishers; 2002. 

14. 

Tanner J, Moncaster K, Woodings D. Preoperative hair removal: A systematic review. Journal 

of Perioperative Practice 2007;17(3):118-32. 


15. 

Balthazar E, Colt J, Nichols R. Preoperative air removal: A randomized prospective study of 

shaving versus clipping. Southern Medical Journal 1982;75(7):799-801. 

16. 

Adeleye A, Olowookere K. Nonshaved cranial surgery in black Africans: a short-term 

prospective preliminary study. Surgical Neurology 2008;69(1):69-72. 


17. 

Webster J, Alghamdi A. Use of plastic adhesive drapes during surgery for preventing surgical 

site infection. Cochrane Database of Systematic Reviews 2007(4). 


18. 

Bibbo C, Patel D, Gehrmann R, Lin S. Chlorhexidine provides superior skin decontamination 

in foot and ankle surgery. Clinical Orthopaedics and Related Research 2005;438:204-8. 


19. 

Milstone A, Passaretti C, Peri T. Chlorhexidine: Expanding the armamentarium for infection 

control and prevention. Clinical Infectious Diseases 2008;46(2):274-81. 


20. 

Meier D, Nkor S, Aasa D, OlaOlorun D, Tarpley J. Prospective randomized comparison of two 

preoperative skin preparation techniques in a developing world country. World Journal of 

Surgery 2001;25(4):441-3. 


21. 

Marion C, Moss R. Primary versus delayed wound closure in complicated appendicitis: an 

international systematic review and meta-analysis. Pediatric Surgery International 

2005;21(8):625-30. 


22. 

Dufour D, Jensen S, Owen-Smith M, Salmela J, Stening G, Zetterstrom B. Surgery for Victims 

of War. 3rd ed. Molde A, editor. Geneva: International Committee of the Red Cross; 1998. 

23. 

Schein M. To drain or not to drain? The role of drainage in the contaminated and infected 

abdomen: An international and personal perspective. World Journal of Surgery 

2008;32(2):312-21. 


24. 

Clegg-Lamptey J, Dakubo J, Hodasi W. Comparison of four-day and ten-day postmastectomy 

passive drainage in Accra, Ghana. East African Medical Journal 

2007;84(12):561-5. 

25. 

Classen D, Evans R, Pestotnik S, Horn S, Menlove R, Burke J. The timing of prophylactic 

administration of antibiotics and the risk of surgical-wound infection. New England Journal 

of Medicine 1992;326:281-6. 


26. 

Bratzler D, Houck P. Antimicrobial prophylaxis for surgery: An advisory statement from the 

National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004;38:1706-15. 


27. 

Barie P, Eachempati S. Surgical site infections. Surgery Clinics of North America 

2005;85:1115-35. 

28. 

Sanchez-Manuel F, Lozano-Garcia J, Seco-Gil J. Antibiotic prophylaxis for hernia repair. 

Cochrane Database of Systematic Reviews 2007(3). 


29. 

Osuigwe A, Ekwunife C, Ihekowba C. Use of prophylactic antibiotics in a paediatric day-case 

surgery at NAUTH, Nnewi, Nigeria: a randomized double-blinded study. Tropical Doctor 

2006;36:42-4. 

30. 

Blumetti J, Luu M, Sarosi G, Hartless K, McFarlin J, Parker B, et al. Surgical site infections 

after colorectal surgery: Do risk factors vary depending on the type of infection considered? 

Journal of Surgery 2007;142(5):704-11. 


31. 

Song F, Glenny A. Antimicrobial prophylaxis in colorectal surgery: a systematic review of 

randomised controlled trials. Health Technology Assessment 1998;2(7):1-110. 


32. 

Song F, Glenny A. Antimicrobial prophylaxis in colorectal surgery: a systematic review of 

randomized controlled trials. British Journal of Surgery 1998;85(9):1232-41. 


33. 

Malomo A, Adeolu A, Odebode T, Komolafe E, Shokunbi M. Prospective comparative trial of 

ceftriaxone versus ceftazidime as prophylactic perioperative antimicrobials in neurosurgery. 

East and Central African Journal of Surgery 2007;12(1):89-92. 

34. 

Finkelstein R, Rabino G, Mashiah T, Bar-El Y, Adler Z, Kertzman V, et al. Vancomycin versus 

cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methacillinresistant 

staphylococcal infections. Journal of Thoracic and Cardiovascular Surgery 

2002;123(2):326-32. 


3 5. Abdulwadud O. What is the effectiveness of a dressing moistened with sodium hypochlorite 

(Dakin’s) solution compared to other dressings in improving wound healing? Clayton, 

Australia: Monash Medical Center 2000 November 28, 2000. 

36. 

Fry D. Occupations risks of infection in the surgical management of trauma patients. 

American Journal of Surgery 1993;165(2AS):26S-33S. 


37. 

El-Awady M. Hepatitis B vaccination rates among medical personnel at Ain Shams University 

Hospital and obstacles to vaccine uptake. Journal of the Egyptian Public Health Association 

1998;73(5-6):519-37. 

38. 

Fry D. Occupational risks of blood exposure in the operating room. The American Surgeon 

2007;73(7):637-46. 


39. 

Recommendations for prevention and control of hepatitis C virus infection and HCV-related 

chronic disease. Morbidity and Mortality Weekly Report 1998;47(19):1-39. 

40. 

Hamlyn E, Easterbrook P. Occupational exposure to HIV and the use of post-exposure 

prophylaxis. Occupational Medicine 2007;57(5):329-36. 



Innovation in patient care: patient handling 

Have we created an alternative MSD 

risk from a reliance on hoisting 

solutions? An academic review of 


ARTICLE BY AUTHOR M FRAY 

Research Fellow, Healthcare Ergonomics and Patient Safety Research Unit, Department of Human Sciences, Loughborough University, UK 

Many hospitals employ systems and personnel to reduce the effects of patient handling activities. Research has 

found limited evidence for the benefits of patient handling interventions and poor levels of evidence for the 

reduction of work-related MSDs in the healthcare setting. Historically the reduction of MSDs has been the primary 

purpose of patient handling interventions but other benefits have been identified. This paper describes the range 

of outcomes that have been identified in published research. Describes the type of intervention strategy that gives 

best results and suggests that hospitals and healthcare providers need to consider appropriate audit systems to 

collect suitable data to prove the success of their management systems. 

There is clear evidence to show that the size of patients entering 

healthcare is increasing in the western world. 

Some systems have been developed to help reduce the risks 

of managing the movement of larger people (Muir and Archer-Heese, 

2009). The focus of risk reduction in patient handling has rightly been 

on the reduction of lifting injuries as a priority. Given the development 

of a wide range of lifting equipment to assist with the movement of 

larger people the consensus is that we are in a relatively well controlled 

risk position. Evidence shows the provision of hoisting equipment 

reduces the risks of injury but the question raised in this review asks 

whether the risks are reduced enough? Recent studies have 

suggested that the push, pull and rotation forces required to move 

regular and large weight patients (Marras et al, 2008, Rice et al, 2009) 

exceed the much lower safe working limits for creating spinal damage 

from shear force in certain circumstances. This paper challenges the 

situations where current thinking would be to provide a mobile passive 

lifting hoist or mechanical means to transfer a larger adult. 

Literature analysis 

Patient handling 

A series of systematic reviews have failed to identify 

musculoskeletal disorder (MSD) reduction from patient handling 

interventions (Van Poppel, 2004, Bos et al, 2006, Amick et al 

2006, Haslam et al, 2006, Dawson et al, 2007, Martimo et al, 

2008). More inclusive reviews identify that other outcomes could 

be used to show success (Hignett et al 2003, Fray and Hignett 

2006, Fray and Hignett 2009). The volume of evidence for the 

reduction of known risk factors is growing and the development of 

multi-faceted ergonomics, equipment and education packages 

are showing improvements in practice (Nelson et al 2006, Collins 

et al 2004, Hignett 2003). 

Systems adopted in the UK were directed by the introduction of 

the Manual Handling Operations Regulations 1992 (HMSO 2004) 

and the subsequent development and support of both statutory 

providers and professional organisations. Though the countries of 

Europe all had the same EU directive the responses have not all 

been the same (Hignett et al, 2007). The North American systems 

and approaches have not had the pressure of national legislation 

but some state legislation has more recently been implemented 

from 2006 onwards. 

Risk reduction strategy 

The information and guidance contained in the documents relating 

to the management of health and safety in the workplace (HMSO 

1992 a,b,c) stated the need for a systematic assessment of 

workplace hazards, the reality of risk controls in patient handling is 

different. 

Research information identified that lifting people was the most 

easily identified risk (Owen and Garg 1989, 1990 and 1991, Takala 

and Kukkonen 1987, Zhang et al 1999, 2000 Menzel et al 2004) 

and the measure for lumbar compression was critical. 

Interestingly a comprehensive biomechanical study (Marras et al 

1999) using the lumbar motion monitor continued the evidence 

that compression values seriously exceeded the known 

recommended limits and should be rectified. It also showed that 

the methods for manual assistance also exceeded the safe limits 

for shear(anterior-posterior and/or lateral). 

The clear evidence presented related to lifting hazards, the 

reactive management style of the National Health Service and the 

chance of high return with simple process change lead to a large 



focus on the removal of hazardous lifting and transfer tasks with a 

lifting component. It has been the development of safer handling 

policies in their various definitions that have lead to much 

improvement in the management of patient handling risks. Proof of 

the success of developing multi-faceted interventions have mostly 

been recorded in studies from North America. Biomechanical and 

workload reductions have been recorded in a number of studies 

(Daynard et al 2001, Nelson et al, 2006, Ronald et al, 2002, Marras 

et al, 1999, Engst et al, 2005,). The cost benefits of such a process 

have also been recorded (Spiegel et al, 2002, Chhokar et al, 2005, 

Martin et al, 2009). Patient and staff perceptions improved with use 

of ceiling track systems (Alamgir et al 2009). These studies have 

also measured differences between the use of mobile hoists and 

ceiling track systems (Santaguida et al, 2005). 

Push-pull risks 

The focus of most of the biomechanical studies and workplace 

studies, above, have been on the lifting component and the 

resulting spinal compression loading. More specifically the 

concentration is on identification and then avoidance of any very 

high compression loading. This fails to address the more complex 

question of physical work done represented by force over time 

exposure. Daynard et al (2001) showed that when using handling 

aids and mechanical lifting the cumulative effort was increased, as 

the time taken was usually higher, but the peak forces were 

reduced. A recent study (Fray and Hignett, 2009) that restructures 

a lateral transfer task by the use of an innovative pressure reducing 

device showed significant savings in physical exposure by 

removing tasks and reducing the time taken to complete the 

transfer. This is the cumulative loading or exposure over time 

question that frequently taxes occupational injury research and 

prevention literature. 

Recent studies have, in addition, raised questions related to the 

potential problems of the pushing and pulling associated with 

healthcare tasks and in particular the use of hoists for patient 

transfers. Marras et al (2009) measured the spinal loads for a 

person manoeuvring a hoist across a fixed course and compared 

a ceiling tracked system with a floor based system. The key 

findings were that the patient weight affected the force needed with 

a floor based system but not a ceiling track system and the shear 

loading for the floor based system exceeded the safe working limit 

for shear during push tasks. Another study (Rice et al, 2009), which 

used hand held dynamometers to measure actual push pull forces 

for moving hoists, concurred with the relationships of weight to 

force for floor standing hoists and that floor standing hoists required 

more force than ceiling track systems. 

Importantly neither study investigated the forces required to 

obtain an ideal sitting or lying position or the complexities and 

postural loads of positioning the hoist sling. These two studies 

that measure the physical requirements of the solutions to 

handling issues may lead to further questions relating to some of 

our known risk reduction systems. It is worthy of note that these 

studies were completed with patients weighing up to 163kg and 

146kg respectively to identify the hazards of larger individuals. 

Population changes 

Recent observations have indicated that the size of western 

populations is increasing (DOH 2004, Heena 2005, Hedley et al 

2004). The growth in adult prevalence is matched by the increase 

in problems with increasing size and weight of infant populations 

(Stamatakis 2002, Hedley et al 2004). A systematic review (Baird 

et al 2005) showed there is agreement from many studies that 

childhood growth is a clear indicator for adult obesity. Given that 

a Cochrane review (Summerbell et al 2005) also indicated the 

general lack of success of intervention strategies for reducing 

population obesity for the long term and the desired weight in 

adult populations is also growing (Maynard et al 2006). Most of 

the evidence indicates to the providers of healthcare that the 

amount of overweight, obese and morbidly obese patients 

requiring healthcare interventions will increase over the 

foreseeable future. The reluctance to design environments and 

systems for these types of patients will be short-sighted and 

potentially hazardous for the carers delivering the hands on 

treatment. 

The development of products, equipment and management 

systems for the reduction of patient handling risks has seen 

improvements (Muir and Archer-Heese 2009, Hignett and 

Chipchase, 2007). The range of beds, hoists and handling aids 

allows healthcare providers access to a wider variety of physical 

solutions to the transfers of larger people. 

Summary of literature 

The management of patient handling risks has improved over the 

past 20 years. The use of education, equipment and management 

systems all have made an impact on practice but any reduction in 

MSD has not been proven. Recent studies have shown that the 

safer methods of mobile hoists and ceiling track systems have 

reduced the lifting loads on healthcare workers but there is some 

doubt over the push pull requirements to use some hoists. 

Evidence that handling bariatric patients is high risk has been 

confirmed in one study. Randall et al (2009) showed when 

bariatric patients (BMI>35kg/m2) were


Table 1: Effect of hoist provision on physical components of transfer tasks 

PHYSICAL ACTION MOBILE HOIST CEILING TRACK HOIST 

Locating and collecting hoist Manual 

Fit sling Manual Manual 

Lift from present surface Mechanical Mechanical 

Move hoist to new surface Manual Mechanical (if in line with track position) 

or 

Move new surface into position Manual Manual 

Reposition patient (sitting or lying) Mechanical 

Mechanical 

(if powered repositioning) (if powered repositioning) 

Lower to new surface Mechanical Mechanical 

Adjust patient to best position Mechanical Mechanical 

(if powered repositioning) (if powered repositioning) 

Remove sling Manual Manual 

2003). The interpretation of this research has focussed on the 

removal of lifting tasks and has not evaluated the push pull levels 

or the cumulative workload in as much detail. Warming et al 

(2009) and Knibbe and Friele (1999), both used self reported logs 

to identify the 24 hour exposure to physical loads with a good level 

of reliability. These studies show that the number of care related 

tasks (e.g. re-positioning, limb movement, push, pull) add 

significantly to the patient lifting risks of the lifting/hoisting tasks. 

Documented guidance to the safe use of hoists is in most UK 

care provider E.g. Fray et al 2001, Smith (Ed) 2005. A task analysis 

of the potential phases for hoisting show that many of the physical 

tasks may not be improved by the provision of the hoist device. 

Table 1 shows the different physical actions that may be included 

in a transfer task and whether the provision of different hoist types 

affects the completion of the task. 

When the use of hoisting systems is compared for the full range 

of physical tasks many components are not affected. If this 

transfer is compounded by the two surfaces being a significant 

distance apart then a transportation phase is also added. The 

present design of hoists do not allow for the transportation of 

patients over anything other than very short distances. Design 

options for the transport of people in a sitting or lying position have 

already indicated that for large patients a powered transport 

device would be suitable (Kim et al 2009). Some technological 

solutions are available to assist in this movement e.g. Bed movers, 

powered wheelchairs or trolleys and one motor driven hoist for the 

movement of larger patients (www.Smartlift.eu). The need to move 

people in a confined space also raises the force requirements and 

so powered systems may be indicated in more regular transfer 

tasks, e.g. bathing or toileting, with larger patients (Marras et al 

2009). The increase in the use of hoisting solutions for other 

activities, e.g. during rehabilitation, also suggests the 

consideration of powered hoists as a possible requirement. 

Financial considerations 

Publications that consider handling equipment options have 

identified the need for powered systems to assist with patient 

transport (Nelson and Fragala, 2004) but noted that the cost might 

be prohibitive for integrated powered systems e.g. trolleys. 

Charney (2004) and Siddarthan et al (2005) both discuss methods 

for calculating the direct, indirect and intangible costs of MSD 

resulting from patient handling injuries and guide the calculation of 

a cost benefit analysis for provision of any intervention strategy. 

The reality of potential losses in UK healthcare is guided by the 

NHS pay scales and the replacement fees for lost staff time. As an 

example one injury that leads to 3 months 

sickness absence of a mid level band 5 nurse 

(NHS Employees, 2009) could cost £8400 in the 

direct costs of not having the nurse at work, the 

same again for the replacement staff to complete 

the shift pattern. Without adding all the indirect 

expenses and costs this would amount to 

£16 800. 

The financial balance of prevention against 

losses always shows preference to the small fees 

for prevention but full investment in prevention 

solutions is rarely seen. Solutions for prevention 

are regularly delivered at cost minimal solutions so 

mobile hoists are preferred. The alternatives of 

powered or two dimensional ceiling track hoist systems are price 

comparable and might provide a better solution with a cost 

effective return through reduced accidents and ill health costs. 

Future considerations 

The provision of a vertical mechanism passive lifter has some 

benefits but it is important to appreciate the cumulative effects of 

the other assistive tasks, e.g. pushing, pulling, rolling, positioning, 

and transporting patients in the causation of fatigue and possible 

injury. The possible costs of increased sickness absence need to 

be considered when supplying the mechanical solutions for 

handling larger adults in the healthcare environment. 

This academic review raises questions that might need to be 

considered in the future design of patient handling and healthcare 

solutions for the movement and positioning of larger patients: 

✚ Improve the understanding of movement and positioning 

requirements of the larger individual. 

✚ Avoid the pushing and pulling loads by having powered 

movement e.g. bed movers and powered hoist movement. 

✚ Consider sling sizing and sling design to minimise risks for 

application and removal e.g. hoistable clothing. 

✚ Consider powered positioning for sitting/reclining, increased 

patient comfort and therapeutic benefits e.g. powered 

positioning in 3 axes. 

✚ Consider the combination of hoists with transport actions to 

reduce the in/out manoeuvres for sling application. 

✚ Ensure compatibility between the hoisting system and the bed 

mechanisms. 

✚ Encourage patient handling research to examine the 

cumulative load for patient handling tasks in addition to the 

single high risk lifting factors. 

These considerations are leading the provision of healthcare 

tasks towards full automation and the possible use of robots and 

intelligent communication to assist with care tasks. Intelligent bed 

systems (Hill-Rom 2009) offers patient status information linked 

directly to hospital networks. A recent study in the Norwegian 

Association of Local and Regional Authorities (Nursing Times 

2009) showed that carers would value the use of robots to free up 

carers to have more time for face to face duties. A BBC news 

(2009) article suggests that technological advances can already 

deliver a caring robot to assist with treatments, communication 

interventions and patient movement tasks. It is time to consider 

how much more we can utilise from innovative solutions rather 

than following traditional hoist design? ❏ 



References 

Alamgir H, Li O, Yu S, Gorman E, Fast C, Kidd C, 2009. Evaluation of ceiling lifts: Transfer time 

patient comfort and staff perceptions. Injury, Int J. Care Injured 40 (2009) 987-992. 

Amick B., Tullar J., Brweer S., Irvine E., Mahood Q., Pompeii L., Wang A., Van Eerd D., Gimeno 

D., Evanoff B. (2006). Interventions in health-care settings to protect musculoskeletal health: 

a systematic review. Toronto: Institute for Work and Health, 2006 

Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic 

review of size and growth in infancy and later obesity. BMJ, doi:10.1136/bmj.38586. 

411273.EO (published 14 October 2005) 

Bos E.H., Krol B., Van Der Star A., Groothof J.W., (2006), The effect of occupational 

interventions on reduction of musculoskeletal symptoms in the nursing profession. 

Ergonomics 49, 7, 706-723. 

Charney W, How to accomplish a responsible cost-benefit back injury analysis in the health 

care industry. Chapter 5, in Charney W and Hudson A (eds) 2004, Back injury in healthcare 

workers: Causes, solutions and impacts. Lewis Publishers, CRC Press, Florida. 

Chhokar R; Engst C; Miller A, Robinson D, Tate R, Yassi A, (2005). The three-year economic 

benefits of a ceiling lift intervention aimed to reduce healthcare worker injuries. Applied 

ergonomics. 2005 Mar; 36(2): 223-9 

Collins J., Wolf L., Bell J., Evanoff B. (2004) An evaluation of a ‘best practices’ musculoskeletal 

injury prevention program in nursing homes. Injury Prevention 2004; 10: 206-211 

Collins J, 2006. Safe lifting policies. Chapter 10 in Nelson A, (Ed) Safe patient handling and 

movement: A practical guide for health care professionals. 2006 Springer Publishing 

Company, Inc New York. 

Dawson A.P., McLennan S.N., Schiller S.D., Jull G.A., Hodges P.W., Stewart S. 2007, 

Interventions to prevent back pain and back injury in nurses: a systematic review. 

Occupational and Environmental Medicine, 2007; 64: 642-650 

Daynard D; Yassi A; Cooper J, Tate R, Norman R, Wells R (2001) Biomechanical analysis of 

peak and cumulative spinal loads during simulated patient-handling activities: a substudy of 

a randomized controlled trial to prevent lift and transfer injury of health care workers. 

Applied ergonomics. 2001 Jun; 32(3): 199-214 

Department of Health. Health survey for England 2003. London: Stationary Office, 2004. 

Engst C; Chhokar R; Miller A, et al 2005. Effectiveness of overhead lifting devices in reducing 

the risk of injury to care staff in extended care facilities. Ergonomics, 2005 Feb; 48(2): 187- 

99 

Fray, M. Hignett, S, (2006) An Evaluation of Outcome Measures in Manual Handling 

Interventions in Healthcare. In Pikaar, R.N., Konigsveld, E.A.P., Settels, P.J.M. (Eds.) 

Proceedings of the XVth Triennial Congress of the International Ergonomics Association, 

Meeting Diversity in Ergonomics 11-14 July 2006, Maastricht, Netherlands. 

Fray M and Hignett S (2009). Measuring the success of patient handling interventions in 

healthcare across the European Union. Proceedings of the 17th World Congress on 

Ergonomics, IEA 2009. 

Gallagher S. Bariatrics: Considering mobility, patient safety, and caregiver injury. Chapter 10, in 

Charney W and Hudson A (eds) 2004, Back injury in healthcare workers: Causes, solutions 

and impacts. Lewis Publishers, CRC Press, Florida. 

Haslam C, Clemes S, McDermott H, Shaw K, Williams C, Haslam R, (2007), Manual handling 

training : Investigation of current practices and development of guidelines. HSE Research 

Report rr583. HSE Publications London. 

Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight 

and obesity among US children, adolescents and adults, 1999-2002. JAMA 2004: 291: 

2847-2850. 

Santry H, Gillen D, Lauderdale D, (2005) Trends in bariatric surgical procedures. JAMA . 

2005;294(15):1909-1917 (doi:10.1001/jama.294.15.1909) 

Hignett S, (2003). Intervention strategies to reduce musculoskeletal injuries associated with 

handling patients: a systematic review. Occup Environ Med;60:e6. 

Hignett S, Crumpton, E., Alexander, P., Ruszala, S., Fray, M., Fletcher, B (2003) Evidence based 

patient handling- Interventions, tasks and equipment. London Routledge. 

Hignett, S., Fray, M., Rossi, M. A., Tamminen-Peter, L., Hermann, S., Lomi, C., Dockrell, S., 

Cotrim, T., Cantineau, J. B., Johnsson, C. (2007). Implementation of the Manual Handing 

Directive in the Healthcare Industry in the European Union for Patient Handling tasks. 

International Journal of Industrial Ergonomics 37, 415-423. 

HMSO (2004a). Manual Handling Operations Regulations 1992. Guidance on Regulations L23. 

HSE Books, London. 

HMSO (1999) Management of Health and Safety at Work Regulations 1999. Approved code of 

practice. L21 HSE Books, London.HSAW, 

HMSO (1998) Provision and Use of Work Equipment Regulations. Guidance on Regulations L22 

Books, London. 

Kim S, Barker L, Jia B, Agnew M, Nussbaum M. Effects of two hospital bed design features on 

physical demands and usability during brake engagement and patient transportation: A 

repeated measures experimental study. International Journal of Nursing Studies 46 (2009) 

317-325. 

Knibbe J.J.and FrieleR.D. (1999). The use of logs to assess exposure to manual handling of 

patients, illustrated in an intervention study in care home nursing. International Journal of 

Industrial Ergonomics 24:445-54 

Marras W, Davies K, Kirking B, Bertsche P, (1999). A compréhensive analysis of low-back 

disorder risk and spinal loading during the transferring and repositioning of patients using 

different techniques, Ergonomics 42 (7): 904-926. 

Marras W, Knapik G, Ferguson S, (2009). Lumbar spine forces during manoeuvring of ceilingbased 

and floor-based patient transfer devices. Ergonomics Vol 52, N0 3, March 2009, 384- 

397 

Martimo K.P., Verbeek J., Karppinen J., Furlan A.D., Takala E.P., Kuijer P., Jauhianen M., Viikari- 

Juntura E. (2008). Effect of training and lifting equipment for preventing back pain in lifting 

and handling: systematic review. BMJ doi: 10.1136/bmj.39463.418380.BE 

Martin P, Harvey J, Culvenor J, Payne W, (2009). Effect of a nurse back injury prevention 

intervention on the rate of injury compensation claims. Journal of Safety Research 40 

(2009) 13-19. 

Maynard LM, Serdula MK, Gillespie C, Mokdad AH. Secular trends in desired weight of adults. 

Int J of Obesity (2006) 30, 1375-1381. Nature Publishing Group. 

Menzel N, Brooks S, Bernard T, Nelson A, 2004. The physical workload of nursing personnel: 

association with musculoskeletal discomfort. Int. J. of Nurs Studies. 41 (2004) 859-867 

Muir M, Archer-Heese G. Essentials of a bariatric patient handling program. The Online Journal 

of Issues in Nursing Vol 14, No 1, Manuscript 5. www.nursingworld.org. 

Nelson et al 2006, Development and evaluation of a multifaceted ergonomics program 

to prevent injuries associated with patient handling tasks. Int J Nurs Stud 2006 Aug;43(6): 

717-33 

Nelson A, Fragala G. Equipment for safe patient handling and movement. Chapter 9, in 

Charney W and Hudson A (eds) 2004, Back injury in healthcare workers: Causes, solutions 

and impacts. Lewis Publishers, CRC Press, Florida. 

Owen B and Garg A 1989. The magnitude of low-back problem in nursing. West J. Nursing 

Res., 11(2)234-242. 

Owen B and Garg A 1990. Assistive devices for use with patient handling tasks, in Advances in 

Industrial Ergonomics and Safety, Das, B. Ed Taylor and Francis, Philadelphia U.S. 

Owen B and Garg A, 1991. Reducing risk for back pain in nursing personnel, AAOHN J., 39(1), 

24-33. 

Randall S, Pories W, Pearson A, Drake D, 2009. Expanded Occupational Safety and Health 

Administration 300 log as a metric for bariatric patient handling staff injuries. Surgery for 

Obesity and Related Diseases, Vol 5, Issue 4 July-Aug 2009, 463-468. 

Rice M, Wooley S, Waters T, (2009). Comparison of required operating forces between floorbased 

and overhead-mounted patient lifting devices. Ergonomics Vol 52, No 3, Jan 2009, 

112-120 

Ronald L, Yassi A, Spiegel J, Tate R, Tait D, Mozel M, 2002. Effectiveness of installing overhead 

ceiling lifts. AAOHN J., 50,3: 120-127. 

Santaguida P, Pierrynowski M, Goldsmith C, Fernie G, (2005). Comparison of cumulative low 

back loads of caregivers when transferring patients using overhead and floor mechanical 

lifting devices. Clinical Biomechanics 20 (2005) 906-916. 

Siddarthan K, Nelson A, Weisenhorn G. A business case for patient care ergonomic 

interventions. Nurs Admin Q Vol 29, (2005) No 1, pp. 63-71. 

Spiegel J, Yassi A, Ronald L, Tate R, Hacking P, Colby T, 2002. Implementing a resident lifting 

system in an extended care hospital. AAOHN J., 50, 3: 128-134. 

Stamatakis E. Anthropometric measurements, overweight and obesity. In:Sproston K, 

Primatesta P, eds. Health Survey for England 2002: the health of children and young people. 

London: Stationary Office, 2002. 

Takala E and Kukkonen R. (1987). The handling of patients on geriatric wards. Ergonomics 18 

(1): 17-22 

VISN8 2006. Safe Bariatric Patient Handling Toolkit. VISN8, Patient Safety Center of Enquiry, 

Department of Veteran Affairs, Florida. 

Warming S, Precht D, Saudicani P, Ebbehoj N. (2009) Musculoskeletal complaints among 

nurses related to patient handling tasks and psychosocial factors – Based on logbook 

registrations. Applied Ergonomics 40 (2009) 569-576. 

Van Poppel M, Hooftman W, Koes B, 2005. An update of a systematic review of controlled 

clinical trials on the primary prevention of back pain at the workplace. Occup Med, 2004 

Aug; 54 (5) : 345-352 

Zhuang Z, Stobbe T, Collins J, Hsiao H, Hobbs G, (2000). Psychophysical assessment of 

assistive devices for transferring patients/résidents. Appl Ergon 31 :35-44 

Zhuang Z, Stobbe T, Hsiao H, Collins J, Hobbs G, (1999). Biomechanical évaluation of assistive 

devices for transferring residents. Appl Ergon 30: 285-294 

Web References 

Baros Automatic Patient Hoist. www.smartlift.eu (Accessed 30/08/09) 

BBC News 2009. Japan looks to robots to fill jobs. http://news.bbc.co.uk/1/hi/world/ 

asia-pacific/8234463.stm. Published 2009/09/03. Accessed Sept 2009. 

Hill-Rom Intelligent Bed Products. http://www.hill-rom.com/usa/PatientSafety/Flash/ 

PatientSafetyDemo.htm (Accessed 15/09/09) 

NHS Employees 2009, Pay Circular (AforC) 1/2009. 

http://www.nhsemployers.org/Aboutus/Publications/PayCirculars/Documents/ 

pay_circular%20_AfC_%20%201_2009.pdf (Accessed Sept 2009) 

Nursing Times 2009. Care staff would welcome robot helpers. 

www.nursintimes.net/5004704.article. 

Published 1 Aug 2009. Accessed 8 Sept 2009. 


IHF reference 


IHF reference 

The International 

Hospital Federation 

Our vision is a world of healthy communities served by well 

managed hospitals and health services where all individuals 

reach their highest potential for health 

Origins and aims 

The International Hospital Federation (IHF), successor to the 

International Hospital Association, established in 1929 after the first 

International Hospital Congress in Atlantic City, USA, was revived 

under its new title — International Hospital Federation (IHF) — in 

1947. We are an international non-governmental organisation, 

supported by members from over 100 countries. As the worldwide 

body for hospitals and healthcare organizations we seek to develop 

and maintain a spirit of cooperation and communication among 

them, with the primary purpose of improving patient safety and 

promoting health in underserved communities. 

Mission, vision and activities 

Our vision is to become a world leader in facilitating the exchange 

of knowledge and experience in health sector management, with 

our main goals being: 

✚ To improve patient care quality around the globe, through the 

dissemination of evidence-based information. 

✚ To collect, collate, publish and facilitate the exchange of 

information and ideas on best practice in hospital and 

healthcare management. 

✚ To assist in the creation of environments that support 

organisations in the promotion and delivery of healthcare. 

✚ To foster international partnerships that promote interaction 

among public and private hospitals and healthcare 

organisations, the community and commercial entities. 

✚ To promote and protect the dignity, safety and welfare of 

patients. 

This vision is promoted through events, publications, networking 

and projects in line with our mission and values. These activities 

prioritize information on leadership and management of hospitals 

and health services. 

The IHF is driven by its founding ethos that it is the right of every 

human being irrespective of geographical, economic, ethnic or 

social condition to enjoy the best standard in quantity and quality 

of health and access to hospital and health care services. By 

promoting this value, IHF supports the improvement of the health of 

society. The provision of health and health care to all people, 

recognizes and accepts current best practice in medical standards 

and patient care as well as the ethical behaviour and standards of 

integrity required to govern, lead and manage health-care 

organizations. 

Membership and communications 

Through our membership and communications activities we seek 

to act as a bridge between members in order to facilitate and 

support cross-fertilization of knowledge and experience in 

management and leadership of health organizations. Through 

these activities, we also support the creation of new national 

hospital associations. Establishing strong and permanent 

communication between the IHF Secretariat and members is a 

priority goal. 

IHF offers three categories of membership: 

✚ Full Membership is open to any association or organizational 

body deemed representative of the national healthcare 

organizations, in particular but not exclusively hospitals, in a 

country, a polity or a circumscribed region of the world. 

✚ Associate Membership is open to healthcare organizations, 

in particular but not exclusively hospitals, and other institutions 

having a distinct relationship with the provision of healthcare, 

who are not eligible for Full Membership. 

✚ Honorary Membership is awarded to persons or 

organizations who have rendered exceptional services to the 

IHF. 


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The combined membership forms our General Assembly, 

which meets every second year during the IHF Biennial World 

Hospital Congress. Only Full Members have the right to vote and 

elect members to the Governing Council at the General Assembly. 

At present, there are some fifty two Full Members, and twenty-one 

Governing Council members. The Governing Council in turn elects 

from within its ranks an Executive Committee of four, namely the 

President, President Designate, Immediate Past President and 

Treasurer. The Executive Committee is responsible for conducting 

affairs between Council meetings 

Partnerships and relations with other organizations 

We are in official relations with the World Health Organization. We 

also have a network of international organisations with whom we 

are have good working relations, which include: 

✚ the International Council of Nurses; 

✚ the World Medical Association; 

✚ the Hospital Committee of the European Community; 

✚ the World Dental Federation; 

✚ the International Pharmaceutical Federation; 

✚ the Global Health Workforce Alliance (GHWA); 

✚ World Alliance for Patient Safety of the World Health 

Organization (WHO) 

✚ International Federation of Red Cross and Red Crescent 

Societies (IFRC) 

✚ Hôpitaux universitaires de Genève/(University Hospitals 

Geneva) 

✚ World Confederation for Physical Therapy 

Events 

These are organized and located to enable us to be present in all 

regions of the world. Our regional events are supported by the 

Biennial World Hospital Congress. The subject focus of each of 

these events is tailored to address the needs of the host region, 

thereby ensuring our contribution to regional health services 

management and development. Our events also provide both a 

IHF Affiliated hospital organizations in 2009 

IHF Full Members 

IHF Associate Members 

forum and meeting place for 

public and corporate actors. 

Biennial World Hospital 

Congress Seoul, S.Korea 

(2007); Rio de Janeiro, Brazil 

(2009); Dubai, UAE (2011) 

Publications 

These include: 

✚ World Hospitals and Health Services 

(WH&HS) Journal. First launched in 1929 as Nosokomeion, 

and renamed World Hospitals and Health Service, is published 

four times a year, featuring articles from leading international 

figures, in the field of hospital and healthcare management. It 

includes features such as surveys, country profiles, case 

studies and advertising. The paper and electronic journal, is 

available to all IHF members, free of charge, or by annual 

subscription to non-members. 

✚ International Hospital Federation Reference Book, our 

resource for sharing ideas and information about hospital 

management strategies, care regimens and the evaluation of 

medical equipment and treatments, among other topics. This 

publication forms an integral part of our 

communications strategy featuring annual 

assessments of the worldwide evolution in 

hospital care and facilities development. 

✚ Building Quality in Health Care 

(BQHC) journal, launched in October 2007, 

is published in collaboration with The 

Methodist Hospital (Texas, USA). It is 

intended to fill a gap in the publishing 

market on quality of health service, in that 

its aim is to bridge the gap between 

scientific evidence and actual practice in 

healthcare. It seeks to play a critical role in 

establishing global benchmarks in 

organizations whose primary focus is 

patient care and safety. Its mission also 

includes identification and dissemination of 

practical knowledge regarding sustainable 

applications that would contribute to 


C 

M 

Y 

CM 

MY 

CY 

CMY 

K 

with support from Li ly 

IHF reference 

Quality 4 FINAL.ai 20/10/09 09:00:58 

Vol. 3 No. 1 | 2009 

Building Quality in Health Care 

The Official Journal of Methodist International and the International Hospital Federation 

A Call to Action: Ensuring Global 

Human Resources for Health 

March 22-23, 2007 

International Conference Centre–Geneva, Switzerland 

Proceedings Report 


Fédération Internationale des Hôpitaux 

Federación Internacional de Hospitales 

improvement in healthcare quality and safety. The circulation 

for our publications is over 5000 in some 100 countries with 

an estimated readership of 20 000, the key recipients being 

ministers and ministries of health; national and regional hospital 

associations; hospital CEOs and managers, architects, 

engineers, doctors, nurses, members of hospital boards, 

libraries and commercial firms in the health field. 

✚ Ad Hoc Publications: Global Study Report “The performance 

of hospitals under changing socioeconomic conditions a global 

study on hospital sector reform”, prepared in collaboration with 

the World Health Organization (WHO) involving 20 countries of 

all six WHO regions. The Report analyses the performance of 

hospitals under changing socioeconomic conditions and 

provides a significant contribution to the WHO work on health 

systems development and service delivery. Proceedings Report 

(2007): A Call to Action: Ensuring Global Human Resources for 

Health. This Report is a summary of the key recommendations 

of the international conference, which brought together 

researchers, policy-makers, educators, organization leaders 

and healthcare professionals to launch a global dialogue and 

agenda to improve the scaling up of workforces and health 

systems structures. Language newsletters – La Lettre 

Hospitalière Francophone and Servicios de Salud en el Mundo, 

published in partnership with our French and Argentinean 

national member associations – French Hospital Federation 

and Camera Argentina. 

✚ E-Newsletter: The e-newsletter is a new service provided by 

the IHF secretariat, to be used as a platform for knowledge 

and information sharing. The objective of this electronic news 

letter is to provide an information ‘advisory’ service in health 

service delivery as well as to update members on IHF 

activities. The e-newsletter is part of IHF’s renewed 

communication strategy to better serve its members and the 

wider healthcare community. It provides direct access to 

critical and up-to-date information on health services and 

organizations. The e-newsletter is edited in-house. 

Contributions of members illustrate news about the healthcare 

sector in their own countries or organizations, report of events, 

etc. It is expected to serve as an 

interactive tool for members, to 

enjoy the opportunity to express 

themselves at an international 

level on topics of 

The International Hospital Federation 

Training Manual 

on 

Tuberculosis & Multidrug-resistant TB 

Control, Treatment & Prevention 

for 

Hospital/Clinic/Health Facility Managers 


IHF reference 

interest, and disseminate their own information. The newsletter 

is published five times a year. The first issue was published in 

March 2009. 

Activities 

The diverse and various initiatives include: 

✚ IHF Leadership Summit: 

The Leadership Summit is an invitation-only event, organised by 

the International Hospital Federation (IHF), for top level decision 

makers on hospital issues from National Hospital Associations, 

Ministries of Health and IHF Governing Council members. 

Industry representatives are also invited, with whom discussions 

are held on the needs and motivations of both suppliers and 

consumers in a non-commercial environment. 

The Summit marks the beginning of a new direction for the IHF 

and for its members, as it provides an initial opportunity for the 

leaders of IHF’s constituent organizations to reflect together on 

their individual and common goals and on the problems they 

collectively confront. The inaugural event was held in Paris, 

France, in May 2009. The next meeting is to be held in USA, in 

June 2010. 

✚ Development of a Training Manual for Tuberculosis (TB) and 

MultiDrug Resistant-Tuberculosis (MDR–TB) Control for 

Hospital/ Clinic/Health Facility Managers. The target audience 

of this manual are managers of hospitals, clinics and health 

service facilities, to prepare them to make informed decisions 

to support therapies and drugs used in the treatment of TB 

and MDR–TB; and to train them to implement infection control 

programmes so as to protect both staff and uninfected 

patients from TB transmission within healthcare facilities. This 

project, which remains ongoing, is part of the Lilly MDR –TB 

Partnership (www.lillymdr – tb.com) in which we became a 

partner in 2004. 

✚ MDR-TB Workshops: 

• TB Hospital Managers Training Seminar—Pretoria, South 

Africa (2006); Beijing, China (2008); Mumbai, India (2009) 

• Inter-professional MDR-TB Infection Control Training 

Seminars —Cape Town, South Africa (2007); Rio de Janeiro, 

Brazil (2009); Durban, South Africa (2009). 

✚ First Global Forum on Human Resources for Health—GHWA, 

Kampala, Uganda (2008). 

✚ Geneva Health Forum of the Hôpitaux Universitaires de 

Genève (HUG) - Switzerland (2006, 2008). 

✚ Representations: 

• Regular participation in conferences and workshops 

organised by the WHO, to represent interests of the hospital 

sector. 

• Regular participation in conferences and workshops 

organised by the WHO, to represent interests of the hospital 

sector. 

✚ Technical Assistance Programmes: 

• Collaboration with the Health Strategy Committee for Kuwaiti 

Health Care to articulate a long term vision for the healthcare 

system in Kuwait and to propose incremental steps in 

support of this vision (2008). 

• Mobility of Health Professionals (Mohprof), a European 

Comission – sponsored collaborative project, which brings 

together a partnership of expert scientific institutes and 

international healthcare and professional organisations to 

undertake research and policy development on health 

professional mobility, guidelines and recommendations 

(2009). 

• Collaboration with the Taiwan Export – Import Bank to under 

take an evaluation mission for a 600-bed university hospital 

project in Ouagadougou (Burkina Faso) (2009). 

• Collaboration with the International Association for Infant 

Food Manufacturers (IFM) to develop a safe food 

preparation, handling and feeding practices programme in 

healthcare facilities. This will involve field missions to 

hospitals/healthcare facilities in Peru and Indonesia (2009). 

• Collaboration with the Hamdan Bin Mohammed E-University, 

Dubai, UAE, to conduct a long distance and face-to-face 

accredited Senior Hospital and Health Services Managers 

course (2009). 

• Positive Practice Environment Campaign (PPE), a five-year 

partnership campaign of health professional organisations to 

improve well-being, health and safety in work environments 

and aid in recruitment and retention of health workers. 

National PPE campaigns are planned. y 


IHF reference 

IHF Governing Council 2009–2011 

THE EXECUTIVE COMMITTEE 

Dr JOSE CARLOS DE SOUZA 

ABRAHAO 

President 

CONFEDERACAO NACIONAL DE 

SAUDE (CNS) 

SRTVIS Quadra 701, Conjunto E 

Edificio Palacio do Radio 1 

Brasilia DF, CEP 70340-906 

BRAZIL 

Tel: +55 61 3321 0240 

Fax: +55 61 3321 0250 

Email: cns@cns.org.br 

President-Designate 

Mr THOMAS C DOLAN 

Chief Executive Officer 

AMERICAN COLLEGE OF 

HEALTHCARE EXECUTIVES 

One North Franklin Street 

Suite 1700 

Chicago, Illinois 60606-3491 

UNITED STATES OF AMERICA 

Tel: +1 312 424 9365 

Fax: +1 312 424 0023 

E-mail: tdolan@ache.org 

Immediate Past Presidents 

Dr IBRAHIM A AL ABDULHADI 

Assistant Undersecretary for Health 

Insurance Affairs 

MINISTRY OF HEALTH 

State of Kuwait 

PO Box 5, PIN Code 13001 

KUWAIT 

Tel: +965 486 3699 

Fax: +965 486 3524 

E-mail: drhadi@moh.gov.kw 

Mr GERARD VINCENT 

Délégué Général 

FEDERATION HOSPITALIERE DE 

FRANCE 

1 bis Rue Cabanis 

75014 Paris 

FRANCE 

Tel: +33 1 44 06 84 42 / 44 

Fax: +331 44 06 84 45 

E-mail: g.vincent@fhf.fr / 

l.maute@fhf.fr 

Dr LEKE PITAN 

Former Commissioner for Health – 

Lagos State 

House G40C, Road 2 

Victoria Garden City, Lagos 

NIGERIA 

Tel: +234 1 775 4544 / 

+234 803 7787834 / 

+44 7785 764 692 

Email: drlekepitan@yahoo.com 

Dr JUAN CARLOS LINARES 

Director Camara Argentina de Empresas de Salud CAES 

CAMARA ARGENTINA DE EMPRESAS DE SALUD (CAES) 

Tucuman 1668, 2 Piso 

Buenos Aires C.P. 1050 

ARGENTINA 

Tel: +54 34 88 466 844 / +54 11 4372 5915 / 5762 

Fax: +54 11 4372 3229 

Email: linaresjcarlos@yahoo.com.ar 

Prof HELEN LAPSLEY 

Research Professor 

CENTRE OF NATIONAL RESEARCH ON DISABILITY & 

REHABILITATION MEDICINE 

University of Queensland 

3 Keston Avenue 

Mosman, Sydney NSW 2088 

AUSTRALIA 

Tel: +612 99 692 346 

Fax: +612 99 684 987 

Email: cliveh@ip.net.au 

Prof GUY DURANT 

Administrateur général 

CLINIQUES UNIVERSITAIRES SAINT-LUC 

Avenue Hippocrate 10 

B - 1200 Bruxelles 

BELGIUM 

Tel: +32 2 764 15 22 

Fax: +32 2 764 15 25 

Email: durant@hosp.ucl.ac.be 

Dr GEORG BAUM 

Chief Executive 

GERMAN HOSPITAL FEDERATION 

Wegelystrasse 3 

10623 Berlin 

GERMANY 

Tel: +49 30 398 011 001 

Fax:+4930 398 013 011 

Email: g.baum@dkgev.de; m.schreiner@dkgev.de 

Dr LAWRENCE LAI 

Senior Advisor 

HONG KONG HOSPITAL AUTHORITY 

Room 1003, Administration Block 

Queen Mary Hospital 

102 Pokfulam Road 

HONG KONG (SAR) 

Tel: +852 2255 3253 

Fax: +852 2504 2784 

E-mail: laifm@ha.org.hk 

Dr MUKI REKSOPRODJO 

President Director & CEO 

RUMAH SAKIT METROPOLITAN MEDICAL CENTRE (MMCH) 

JlHR Rasuna Said Kav C-21 

Kuningan Jakarta Selatan 12940 

INDONESIA 

Tel: +6221 72791383, 72791404; 

Fax: +6221 7252026 

Email: mukirekso7@gmail.com 

Prof SHUZO YAMAMOTO 

President 

JAPAN HOSPITAL ASSOCIATION 

13-3 Ichibancho, Chiyodaku, Tokyo 

JAPAN 

Tel: +813 332 650 077 

Fax: +813 332 302 898 

Email: ouchi@hospital.or.jp 

Dr TAI-CHUN YOO 

President 

KOREAN HOSPITAL ASSOCIATION 

35-1, Mapo-Dong, Mapo-Gu, Seoul 

KOREA 

Tel: +822 718 754 Ext 183 

Fax: +822 718 7522 

Email: intlaffairs@kha.org.kr 

Dr ERIK KREYBERG NORMANN 

President 

NORWEGIAN HOSPITAL & HEALTH SERVICE ASSOCIATION 

Nedre Slottsgt. 7, 0157 Oslo 

NORWAY 

Tel: +47 22 40 25 50 

Fax: +47 22 40 55 51 

Email: erik.normann@helse-sorost.no 

Prof CARLOS PEREIRA ALVES 

Vice Chair 

ASSOCIACAO PORTUGUESA PARA O DESENVOLVIMENTO 

HOSPITALAR 

Av. António Augusto de Aguiar, 32-4º 

1050-016 Lisboa 

PORTUGAL 

Tel: +351 21 37 83 / 66 

Fax: +351 21 37 73 

Email: ihf@ihf.min-saude.pt 

Dr THABO LEKALAKALA 

Director – Hospital Management 

and Planning 

DEPARTMENT OF HEALTH 

Street Hallmark Building 

231 Proes Street 

001 Pretoria 

SOUTH AFRICA 

Tel: +27 12 312 0930 

Fax: +27 12 312 3388 

Email: lekala@health.gov.za 

Dr DELON WU 

President 

TAIWAN HOSPITAL ASSOCIATION 

25F, No29-5 

Sec. 2, Jung jeng E. Road 

Danshuei Township, Taipei County 

TAIWAN 

Tel: +886 22 808 3300 

Fax: +886 22 808 3304 

Email: hatw@hatw.org.tw 

Mrs ALISON KANTARAMA 

President 

UGANDA NATIONAL ASSOCIATION OF HOSPITAL 

ADMINISTRATORS (UNAHA) 

Mulago Hospital 

PO Box 7051, Kampala 

UGANDA 

Tel: +256 414 554 748 

Fax: +256 414 532 591 

Email: alisonkantarama@yahoo.com 

Mr ABDUL SALAM AL-MADANI 

President 

INDEX HOLDING 

Dubai Healthcare City 

Block B, Offices 203 – 303 

P.O.Box 13636, Dubai 

UNITED ARAB EMIRATES 

Tel: +97 14 362 4717 

Fax: +97 14 362 4718 

Email: index@emirates.net.ae 

Prof STEPHEN BARNETT 

Chief Executive 

NHS CONFEDERATION 

29, Bressenden Place 

London SW1E 5DD 

UNITED KINGDOM 

Tel: +44 (0) 20 7074 3281 

Fax: +44 (0) 844 774 4319 

Email: Steve.Barnett@nhsconfed.org; 

natasha.mal@nhsconfed.org 


IHF reference 

IHF Secretariat Staff 

2009/2010 

Eric de Roodenbeke 

Director General 

Eric de Roodenbeke assumed the position of 

Director General of the International Hospital 

Federation in June 2008. Between July 2007 and May 2008 he was 

Senior Health Specialist at the World Health Organization (WHO) for 

the Global Health Workforce Alliance (GHWA) during which time he 

was involved in support country action programmes to develop a 

response to the HRH crisis; development of strategies for regional 

networks in support of HRH development and was the focal point 

for follow-up actions in Francophone countries. He was Senior 

Health Specialist at the World Bank (AFTH2 & WBI) from 2004 to 

2006 in which time he was Team leader (TL) for various health 

intervention, educational, management and capacity building 

programmes mostly in Africa. He was Director of the 700-bed 

University Hospital of Tours, and Senior Officer responsible for 

hospital and health financing interventions at the French Ministry of 

Foreign Affairs from 2001 to 2003 and 1999 to 2001, respectively. 

Between 1996 and 1998, he was Senior Officer on hospital policy 

expertise at the French Ministry of Cooperation. From 1994 to 1996, 

he was Deputy Director of the 870-bed University Hospital of 

NANTES. 1989 to 1994, Dr de Roodenbeke was the Expert, task 

team leader for a project involving construction, equipment , 

management of a 500- bed hospital in, Burkina Faso. He was 

Deputy Director of Epinal- Vosges (France) General Hospital from 

1984 to 1989. Dr de Roodenbeke has published widely on hospital 

organisation, health systems reforms human resources and health 

facility management, health policy, insurance and financing in 

developed and developing countries. Dr de Roodenbeke holds a 

Ph.D. in health economics - University of Paris 1, Sorbonne (France); 

a Hospital Administration Diploma from ENSP Rennes (France); and 

a Diploma in Public Health from the University of Nancy (France). He 

speaks fluent French (native language) and English and basic Greek 

and German. He is a member of various social organizations and is 

affiliated to the French Health Economics Society. 

Honours degree in European and Social Sciences, with a major in 

French Language (University of East Anglia – Norwich, UK). She is a 

Christian and an active member in her local church. She speaks 

fluent French, English and Ibo (mother tongue). She enjoys 

international affairs, sports and has travelled widely. 

Sev Lucas 

Membership Manager 

Sev Lucas has a Masters degree in public health in 

developing countries and is a graduate of a Masters in 

health economics in developing countries from the University of 

Clermont Ferrand (CERDI, Center for Studies and Research on 

International Development). Sev joined IHF in January 2009. She is 

responsible for member liaison activities and support of designated 

IHF projects. She is also in charge of development of the health 

system knowledge database and in charge of the newsletter. 

Sev is from Bretagne, northwestern region of France and enjoys 

skiing, sailing, surfing, traveling and playing the saxophone. She 

speaks fluent French, Spanish, English and she is learning 

Portuguese 

Dwight Moe 

Dwight Moe joined the IHF in 2003 and was the 

Projects and Events Manager. Born in Honolulu, 

Hawaii, he lived in North America, Asia and Europe. 

Dwight did his studies at the University of Minnesota 

in International Relations and Chinese. He has over ten years of 

experience in event planning and operations. His career has led him 

around the world organising and managing travel events for major 

clients in the automotive, financial and pharmaceutical industries. He 

and his wife enjoy cooking, skiing and travel. 

Dwight left the IHF in December 2009 to pursue further career 

goals. 

Sheila Anazonwu 

Programme Development and Knowledge Manager 

Sheila Anazonwu, MSc, BA, is the Programme 

Development and Knowledge Manager at the 

International Hospital Federation. She joined the IHF in 1992 as 

Personal Assistant to the Director General. Prior to joining the IHF, 

Sheila worked in the private sector in development project 

management and human resource training. She also worked at the 

Economic Community of West African States (ECOWAS) Secretariat 

in Lagos, Nigeria. She has done voluntary work for Human Rights 

Watch (UK). She has a Master of Science degree in International 

Relations (University of Southampton, UK) and a Bachelor of Arts 

Cécile Reynes 

French Translator 

oined the IHF in 2000 as French Translator, on a parttime 

basis. Since 2004 began working on a free-lance 

basis. 

Loly Vaswani 

Spanish Translator 

joined the IHF as part-time Spanish translator in 1988. 

In 1990 she moved to Malaga, Spain, but continued 

to work for the IHF. Since 2004 she began working on 

a free-lance basis. 


IHF reference 

IHF Consultants 

Audit & Conseil de Leman 

13 Chemin du Levant, 01210 Ferney Voltaire, France 

Tel: +33 (0) 450 40 75 76 +33 (0) 450 40 75 76; 

Fax: +33 (0) 450 40 98 85 

email: info@ac-leman.com / Contact: M. Laurent Forstmann 

Haysmacintyre, Fairfax House, 

15 Fulwood Place, London WC1V 6A, UK 

Tel: +44 (0)20 7969 5500; F +44 (0)20 7969 5600 

Email: rpierce@haysmacintyre.com / Contact: Mr. Ray Pierce 

NBM-Europe.Com 

373 Route du Nant, ZA de Magny, 01280 Prevessin-Moëns, France 

Tel: +33 (0) 450 28 07 29 +33 (0) 450 28 07 29; 

Fax: +33 (0) 450 28 08 04 

email: infor@nbm-europe.com / Contact: M. Olivier Bail 


IHF reference 

National healthcare organizations 

Full members 

ARGENTINA 

CONFEDERACION ARGENTINA DE CLINICAS 

Tucuman 1668 2do - 4 piso 

1050 Buenos Aires, ARGENTINA 

Tel: +54 11 4373 2315; 

Fax: +54 11 4372 3229 

Internet: www.caes.com.ar 

CAMARA ARGENTINA DE 

EMPRESAS DE SALUD 

Tucuman 1668 2ndo-4 piso 

1050 Buenos Aires, ARGENTINA 

Tel : +54 11 4372 5915/5762 

Fax: +54 11 4372 3229 

Internet: www.caes.com.ar 

AUSTRALIA 

AUSTRALIAN HEALTHCARE ASSOCIATION 

Suite 4 Level 1 99 Northbourne Avenue 

2600 Turner, AUSTRALIA 

Tel : +61 2 6162 0780; 

Fax: +61 2 6162 0779 

Internet: www.aushealthcare.com.au 

AUSTRIA 

Abteilung VII/3 

BUNDESMINISTERIUM FÜR GESUNDHEIT, FAMILIE UND JUGEND 

Radetzkystraße 2, A-1030 Wien 

AUSTRIA 

Tel: +43 1 711 00-0; 

Fax +43-1 711 00-14300 

Internet: www.bmgfj.gv.at 

BAHRAIN 


PO Box 12 

Manama, BAHRAIN 

Tel: +973 17 252755 

Fax: +973 17 27 0044 

Internet: www.moh.gov.bh 

BELGIUM 

ASSOCIATION BELGE DES HOPITAUX - ASBL 

Place A. Van Gehuchten 4 

1020 Brussels, BELGIUM 

Tel: +322 477 3910 

Fax: +322 477 3920 

Internet: www.hospitals.be 

SANTHEA 

9 Quai au Bois de Construction 

1000 Brussels, BELGIUM 

Tel : +322 210 4270 

Fax: +322 511 0454 

Internet: www.santhea.be 

COORDINATION BRUXELLOISE DES INSTITUTIONS 

SOCIALES ET DE SANTE 

33 Rue Cesar Franck, 1050 Brussels, BELGIUM 

Tel: +322 644 0614 & 0173 

Fax: +322 644 0109 

Internet: www.CBI-bruxelles.be 

FEDERATION DES INSTITUTIONS HOSPITALIERES DE WALLONIE 

Ch. de Marche 604, 5101 Erpent, BELGIUM 

Tel: +32 81 327660 

Fax: +32 81 327676 

Internet: www.fih-w.be 

BRAZIL 

CONFEDERAÇÃO NACIONAL DE SAÚDE, HOSPITAIS, 

ESTABELECIMENTOS E SERVIÇOS (CNS) 

SRTV/S - Quadra 701, Conj. E - Ed. Palácio do Rádio I, Bl. 3, N° 

130 - 5° Andar. sa Sul 

Brasília - DF - CEP: 70340-901, BRAZIL 

Tel: +55 61 3321 0240; Fax: +55 61 3321 0250 

Internet: www.cns.org.br 

CANADA 

CANADIAN HEALTHCARE ASSOCIATION 

17 York Street, Ottawa, Ontario 

CANADA K1N 9J6 

Tel: +1 613-241-8005 

Fax: +1 613-241-5055 

Internet: www.cha.ca 

COLOMBIA 

ASOCIACION COLOMBIANA DE HOSPITALES 

Carrera 4a No. 73 – 15, Bogota, COLOMBIA 

Tel: +571 312 4411 

Fax: +571 3121005 

Internet: www.achc.org.co 

CYPRUS 


11 Byron Avenue, Nicosia, CYPRUS 

Tel: +357 22 605 318 

Fax: +357 222 434 203 

Internet: www.moh.gov.cy 

FINLAND 

ASSOCIATION OF FINNISH LOCAL AUTHORITIES 

Toinen Iinja 14, FI-00530 Helsinki, FINLAND 

Tel: +358 9 771 1 

Fax: +358 9 771 2291 

Website: www.kunnat.net 

FRANCE 

FEDERATION HOSPITALIERE DE FRANCE 

1 bis Rue Cabanis, 75014 Paris 

FRANCE MÉTROPOLITAINE 

Tel: +331 44 06 84 41 

Fax: +331 4406 8445 

Internet: www.fhf.fr 

FEDERATON DES ETABLISSEMENTS HOSPITALIERS ET 

D’ASSISTANCE PRIVE A BUT NON LUCRATIF (FEHAP) 

179 rue de Lourmel, 75015 PARIS 


Tel: +33 1 53 98 95 08 

Fax: +33 1 53 98 95 38 

Internet: www.fehap.fr 

GERMANY 

DEUTSCHE KRANKENHAUSGESELLSCHAFT 

Bereich Politik Wegelystrasse 3 

10623 Berlin, GERMANY 

Tel: +49 30398011014 

Fax: +49 30398013011 

Internet: www.dkgev.de 

GREECE 

MINISTRY OF HEALTH AND SOCIAL SOLIDARITY 

17 Aristotelous Street 

10187 Athens, GREECE 

Tel: +30 210 5248225 

Fax: +30 210 5236023 

Internet: www.mohaw.gr 

HONG KONG (SPECIAL ADMINIST. REGION: CHINA) 

HOSPITAL AUTHORITY 

5/F Hospital Authority Building 

147B Argyle Street 

Kowloon, HONG KONG 

(Special administ. Region: China) 

Tel: +852 2805 6769 

Fax: +852 2881 8058 

Internet: www.ha.org.hk 

HUNGARY 

MAGYAR KORHAZSZO VETSEG 

(Hungarian Hospital Associaton) 

Ibrahim u. 19, 1125 Budapest, HUNGARY 

Tel: +361 12145118 /+36 30 9967185 

Fax: +361 12145159 

Internet: www.korhazszovetseg.hu 

INDONESIA 

INDONESIAN HOSPITAL ASSOCIATION 

Jl. Boulevard Artha Gading A-7A 

No 28 Kelapa Gading 

14350 Jakarta Utara, INDONESIA 

Tel: +62214585783 

Fax: +62214585783 

Internet: www.pdpersi.co.id 

ITALY 

FEDERAZIONE ITALIANA AZIENDE SANITARIE ED OSPEDALIERE 

Corso Vittorio Emanuele II 24, 186 Roma, ITALY 

Tel: +39 06 6992 4145 

Fax: +39 06 6780907 

Internet: www.fiaso.it 


IHF reference 

JAPAN 

JAPAN HOSPITAL ASSOCIATION 

13-3 Ichiban-cho Chiyoda-ku 

1028414 Tokyo, JAPAN 

Tel: +813 3265 0077 

Fax: +813 32302898 

Internet: www.hospital.or.jp 

KOREA 

KOREAN HOSPITAL ASSOCIATION 

Mapo Hyun Dai Bldg 

35-1 Mapo-dong, Mapo-gu 

121-737 Seoul, KOREA 

Tel: +822 718 7503 

Fax: +822 7187522 

Internet: www.kha.or.kr 

KUWAIT 

MINISTRY OF PUBLIC HEALTH 

P O Box 5, 13001 Safat, KUWAIT 

Tel/Fax: +965 486 3703 

LEBANON 

SYNDICAT DES HOPITAUX DU LIBAN 

Ghazal Bldg - 7th Floor, PO Box 662-165 Adlieh 

662 Beirut, LEBANON 

Tel: +961 1 611011 

Fax: +961 1 616772/3/4 

Internet: www.syndicateofhospitals.org.lb 

LUXEMBOURG 

ENTENTE DES HOPITAUX LUXEMBOURGEOIS 

13-15 rue Jean-Pierre Sauvage 

2514 Luxembourg, LUXEMBOURG 

Tel: +352 424 142 

Fax: +352 425 550 

Internet: www.ehl.lu 

MEXICO 

ASOCIACION NACIONAL DE HOSPITALES PRIVADOS 

Pablo Casals 640 

44670 Guadalajara Jalisco, MEXICO 

Tel: +52 333 669 881 

Fax: +52 333 669 882 

NETHERLANDS 

NVZ vereniging van ziekenhuizen 

Postbus 9696, 3506 Utrecht, NETHERLANDS 

Tel: +31 30 273 9451 

Fax: +31 30 273 9780 

Internet: www.nvz-ziekenhuizen.nl 

NIGERIA 

IHF NIGERIA CHAPTER: Nigerian Hospital Association 

First Foundation Place 

36 Opebi Road, Ikeja, Lagos, NIGERIA 

Tel: +234 803 3547371 

Internet: www.ihfnigeria.org 

NORWAY 

NORSK SYKEHUS-OG HELSETJENESTEN 

Nedre Slottsgt 7, 1570 Oslo, NORWAY 

Tel: +47 22 402 555; 

Fax: +47 22 414 871 

Internet: www.nsh.no 

PERU 

FEDERACIÓN PERUANA DE ADMINISTRADORES 

DE SALUD (F.E.P.A.S) 

(Peruvian Federation of Health Administrators) 

PSJE, Jorge Buckley 340, DPTO 203 

San Antonio – Miraflores, Lima 18, PERU 

Tel: +51 1 999 100 628 / 971 56406 / 910 83575 

Internet: www.fepas.org.pe 

PHILIPPINES 

PHILIPPINE HOSPITAL ASSOCIATION 

14 Kamias Road, Quezon City, PHILIPPINES 

Tel: +63 2 922 7674/75 

Fax: +63 2 929 2219 

Internet: www.philhospitals.org 

PORTUGAL 

ACSS-ADMINISTRACAO CENTRAL DOS 

SERVICOS DE SAUDE 

Av.Antonio Augusto de Aguiar 32-4° 

1050-016 Lisbon, PORTUGAL 

Tel: +351 21 317 974 

Fax: +351 21 317 976 

Internet: www.apdh.pt 

PUERTO RICO 

ASOCIACION DE HOSPITALES 

DE PUERTO RICO 

Villa Nevarez Professional Center 

Suite 101- Villa Nevarez 

927 San Juan PR, PUERTO RICO 

Tel: +1 787 764 0290 

Fax: +1 787 753 9748 

Internet: www.asociacionhosppr.org 

SAUDI ARABIA 


International Health Department 

11176 Riyadh, SAUDI ARABIA 

Tel: +966 1 408 1233 

Internet: www.moh.gov.sa/en/ (Include) 

SOUTH AFRICA 

DEPARTMENT OF HEALTH 

231 Proes Street Hallmark Building 

001 Pretoria, SOUTH AFRICA 

Tel: +27 12 312 0930 

Fax: +27 12 312 3388 

Internet: www.doh.gov.za 

SWEDEN 

THE SWEDISH ASSOCIATION OF LOCAL 

AUTHORITIES AND REGIONS (SALAR) 

SE-118 82 Stockholm, SWEDEN 

Tel: +468 452 7200 

Fax: +46 8 452 7210 

Internet: www.skl.se 

SWITZERLAND 

H+ LES HOPITAUX DE SUISSE 

Lorrainestrasse 4a, 3013 Bern, SWITZERLAND 

Tel: +41 31 335 1111 / 335 11 14 

Fax: +41 31 335 1170 

Internet: www.hplus.ch 

TAIWAN 

HOSPITAL ASSOCIATION OF TAIWAN 

25F n 29-5 section 2 Chung Cheng East Road Damshui 

Township, Taipei Hsien, TAIWAN 

Tel: +886 2 2833 8829; +886 2 2808 3300 ext. 24; 

Fax: +886 2 2832 3571 

Internet: www.hatw.org.tw 

TUNISIA 

MINISTERE DE LA SANTE PUBLIQUE 

Tunis 1030 TUNISIA 

Tél : (216) 71 56 06 85 

Fax : (216) 71 26 04 74 

Internet: www.ministeres.tn/html/ministeres/sante/html 

UK – ENGLAND 

NHS CONFEDERATION 

29 Bressenden Place 

London SW1E 5ER, UK – ENGLAND 

Tel: +44 207 074 3280/1 

Fax: +44 207 074 3201 

Internet: www.nhsconfed.org 

USA 

AMERICAN HOSPITAL ASSOCIATION 

325 Seventh Street NW 

Washington DC 20004-2802, USA 

Tel: +1 312 626 2363/ +1 202 638 1100 

Fax: +1 202 626 2345 

Internet: www.aha.org 

UGANDA 

UGANDA NATIONAL ASSOCIATION OF HOSPITAL 

ADMINISTRATORS (UNAHA) 

c/o Mulago Hospital, PO Box 7051 

Kampala, UGANDA 

Tel: +256 414 554 748 

Fax: +256 414 532 591 


DEPARTMENT OF HEALTH AND 

MEDICAL SERVICES 

P O Box 4545, Dubai, 


Tel: +971 4 370 031 

Fax: +971 4 374 563 

Internet: www.dohms.gov.ae 


IHF reference 

Other organizations and institutions 

Associate members 

BELGIUM 

GHENT UNIVERSITY HOSPITAL 

Kliniekgebouw 11 K12 I.A, De Pintelaan 185 

9000 Gent , BELGIUM 

Tel: +32 9 240 4762 

Fax: +32 9 240 4860 

Internet: www.uzgent.be 

BENIN 

Assistant Technique en appui au 

RESHAOC Coopération Française 

CNHU H.K.MAGA 

01 BP 386, Cotonou, BENIN 

CANADA 

CENTRE HOSPITALIER MONT SINAI 

5690 Cavendish Boulevard 

Cote St. Luc, Quebec H4W 1S7 

CANADA 

Tel: +1 514 369 2222 

Fax: +1 514 369 2225 

Internet: ww.sinaimontreal.ca 

REGINA QU’APPELLE HEALTH REGION 

2180 - 23rd Avenue, Regina 

Saskatchewan S4S 0A5, CANADA 

Tel: +1 306 766 5279 

Fax: +1 306 766 5222 

Internet: www.rqhealth.ca 

ST MICHAEL’S HOSPITAL 

30 Bond Street 

Toronto, Ontaria M5B 1W8, CANADA 

Tel: +1 416 864 5617 

Fax: +1 416 864 5669 

Internet: www.stmichaelshospital.com 

TRILLIUM HEALTH CENTER 

100 Queensway West 

L5b1Mississauga, ON 

Tel: +905-848-7100 

Fax: 905-848-7356 

Internet: www.trilliumhealthcentre.org 

CHINA 

PHOENIX HOSPITAL GROUP 

Beijing Jiangong Hospital 

6 Rufuli, Xuanwu District, Beijing 100054 

CHINA 

Tel: +86 10 6352 9575 

Fax: +86 10 6351 6056 

Internet: www.phg.com.cn 

DENMARK 

DANISH INSTITUTE FOR QUALITY AND 

ACCCREDITATION IN HEALTHCARE 

(Institut for Kvalitet og Akkreditering i Sundhedsvæsenet (IKAS)) 

Olof Palmes Allé 13, 1. th. 

8200 Århus N, DENMARK 

Tel: +45 87 45 00 50 

HILLERØD HOSPITAL 

Helsevej 2, 3400 Hillerød, 

DENMARK 

Tel: +45 48 29 48 29 

Internet: www.hillerodhospital.dk 

FINLAND 

HOSPITAL DISTRICT OF HELSINKI AND UUSIMAN 

PO Box 100, FI 000 HUS, FINLAND 

Tel: +358 9 471 71200 

Fax : +358 9 471 71206 

Internet: www.hus.fi 

KUOPIO UNIVERSITY HOSPITAL 

P.O. Box 1777, FI 70211 Kuopio, FINLAND 

Tel: +358 17 17 33 11 / +358 17 17 35 90 

Fax : +358 17 17 35 99 

Internet: www.psshp.fi 

OULU UNIVERSITY CENTRAL HOSPITAL 

Kajaanintie 50, 90220 Oulu, FINLAND 

Tel: +358 8 315 2011; Fax: +358 8315 4499 

Internet: www.ppshp.fi 

PIRKANMAA HOSPITAL DISTRICT 

PO Box 2000, FI-33521 Tampere, FINLAND 

Tel: +358 3 311 66210/ +358 50 68048 /+358 3 311 66211 

Internet: www.tays.fi 

TURUN YLIOPISTOLLINEN KESKUSSAIRAALA 

Kiinamyllynkatu 4-8, PO Box 52 

20521 Turku, FINLAND 

Tel: +358 2 313 3601 / +358 2 313 0000 

Fax: +358 2 313 3613 

Internet: www.tyks.fi/en/ 

FRANCE 

CENTRE HOSPITALIER D'ARRAS 

Bvd Besnier BP 914 

62022 Arras, FRANCE MÉTROPOLITAINE 

Tel: +33 (0) 3 21 21 10 10 

Internet: www.ch-arras.fr 

CENTRE HOSPITALIER DE PERPIGNAN 

20, Avenue du Languedoc 

BP 49954, 66046 PERPIGNAN Cédex 9 


Tel: +33 (0)4 68 61 66 33 

Fax: +33 (0)4 68 61 68 33 

Internet: www.ch-perpignan.fr 

CLINIQUE LES SOURCES 

Avenue Roses 10 C Pietruschi 

06105 NICE CEDEX 2, FRANCE MÉTROPOLITAINE 

Tel: +33 (0)4 92 15 40 00 

Fax: +33 (0)4 92 15 40 11 

Internet: http://www.clinique-les-sources.org 

CENTRE HOSPITALIER SAINTE ANNE 

1 rue Cabanis 

75014 Paris 

FRANCE 

Tel: +33145658000 

Fax: +33145658503 

Internet: www.ch-sainte-anne.fr 

GERMANY 

LIPPISCHE NERVENKLINIK DR. SPERNAU GmbH & CO.KG 

Waldstraße 2, 32105 Bad Salzuflen, GERMANY 

Tel: +49 (0) 5222 188-103/ +49 (0)5222 188-0 

Fax: +49 (0) 5222 188-199 

NATIONS HEALTHCAREER SCHOOL OF MANAGEMENT GmbH 

Frankfurt Region Office 

Else-Kröner-Straße 1 

61352 Bad Homburg, GERMANY 

Tel: + 49 (0) 6172 608 4600 

Fax: + 49 (0) 6172 608 4601 

Internet: www.Nations-HealthCareer.com 

DEUTSCHER EVANGELISCHER KRANKENHAUSVERBAND 

Reinhardtstrasse 18 

10117 Berlin 

Tel: +49 30 8019860 

Fax: +49 30 80198622 

Internet: www.dekv-ev.de 

GREECE 

PRIVATE HOSPITAL & DIAGNOSTIC CENTER 

Kyanous Stavros S.A. 

102 Vas. Sofias Avenue, Athens, GREECE 

Tel: +30 210 746 8800 

Fax: +30 210 777 4304 

Internet: www.kyanousstavros.gr 

INDIA 

RAJAN BABU TB (R.B.T.B.) HOSPITAL 

Delhi 110009, INDIA 

Tel: +91 11 27433431 / +91 11 981072 1234 

THE MAHARASHTRA STATE ANTI TB ASSOCIATION (MSATBA) 

Koch’s House, Jerbai Wadia Road 

Outside Group of TB Hospitals 

Sewree, Mumbai 400 015, INDIA 

Tel: +91 22 2410 6583 / +91 98 69 105 521 

Fax: +91 22 2410 3673 

Internet: www.msatba.webs.com 

INDONESIA 

BETHESDA HOSPITAL 

Jl. Jenderal Sudirman 70 

Yogyakarta 55224, INDONESIA 

Phone: +62(0) 274 586 688 / 

+62 (0) 274 562 246 

Fax: +62(0) 274 563 312 

Internet: http://www.yakkum.or.id/bethesda/ 


IHF reference 

KENYA 

THE NAIROBI HOSPITAL 

PO Box 30026, Nairobi, KENYA 

Tel: +254(0) 20 284 5000 / 20 284 6000 / 

+254 (0) 722 204 114 

Fax: +254(0) 20 272 8003 / 20 272 5237 

Internet: www.nairobihospital.org 

MEXICO 

HOSPITAL SAN JAVIER 

Av. Pablo Casals 640, 

Col. Prados Providencia Esq. con Eulogio Parra 

Guadalajara, 44670 Jalisco. MEXICO 

Tel: +52 (33) 3640 1128 / 3669 0222 

Internet: www.sanjavier.com.mx 

MONGOLIA 

TEGS KHUSEL HOSPITAL 

49 Peace Avenue, Ulaanbaatar, MONGOLIA 

Tel/Fax: +976 11 458 191 

MOROCCO 

ASSOCIATION MAROCAINE DES 

GESTIONNAIRES HOSPITALIERS (A.M.G.H.) 

7 Rue Kharoub Hay Riad, Rabat, MOROCCO 

Tel: +212 53 37 71 63 96/ 661 14 40 52; 

Internet: www.amgh.ma 

NETHERLANDS 

AMC Academisch Medisch Centrum 

Meibergdreef 9, 1105 Amsterdam, NETHERLANDS 

Tel: +31 20 566 2106; Fax: +31 20 691 2796 

Internet: www.amc.uva.nl 

ACADEMISCH ZIEKENHUIS MAASTRICHT 

Postbus 5800, 6202 AZ Maastricht, NETHERLANDS 

Tel: +31 43 387 65 43 

Fax: +31 43 387 78 78 

Internet: www.azm.nl 

REVALIDATIECENTRUM RIJNDAM ADRIAANST 

Postbus 23181, 3001 KD Rotterdam 

NETHERLANDS 

Tel: +31 181 658 571; Fax: +31 181 626 848 

NIGERIA 

TOTAL HEALTH TRUST 

2 Marconi Road, Palmgrove Estate, 

Lagos State, NIGERIA 

Tel: +234 (0)1 774 7150 / +234 (0)1 804 5263 

Fax: +234 (0)1 555 0508 

Internet: www.totalhealthtrust.com 

PAKISTAN 

AGA KHAN UNIVERSITY HOSPITAL 

Stadium Road, P.O. Box 3500, 

Karachi 74800, PAKISTAN 

Tel: +92 21 3493 0051 

Fax: +92 21 3493 4294 / 3493 2095 

Internet: www.aku.edu 

SPAIN 

HOSPITAL PLATO FUNDACIO PRIVADA 

C/ Plato 21, 08006 Barcelona 

SPAIN 

Tel: +34 933 069 900 

Internet: www.hospitalplato.com 

SERVICIO DE SALUD DEL 

PRINCIPADO DE ASTURIAS 

Plaza del Carbayon 1, 33011 Oviedo 

SPAIN 

Tel: +34 98 510 6601 / +34 98 510 8500 

Fax: +34 98 506 633 / +34 98 510 8511 

Internet: www.asturias.es 

UNIO CATALANA D'HOSPITALS 

Carrer Bruc, 72 1r, 08009 Barcelona 

SPAIN 

Tel: +34 93 209 3699 

Fax: +34 93 200 8638 

Internet: www.uch.cat 

SWITZERLAND 

HOPITAL DU JURA 

Chemin de l’Hôpital 9, 2900 Porrentruy, SWITZERLAND 

Tel: +41 32 465 65 65 ; Fax +41 32 465 69 99 

Internet: www.h-ju.ch 

HOPITAL UNIVERSITAIRE DE GENEVE - HUG 

Hopital Cantonal Rue Micheli-du-Crest 24 

1211 Geneva, SWITZERLAND 

Tel: +41 22 372 6070 ; Fax: +41 22 372 6075 

Internet: www.hcugh.ch 

INSELSPITAL BERN 

Freiburgstrasse 18 

3010 Bern, SWITZERLAND 

Tel: +31 632 2801 / +41 31 632 2111 

Fax: +31 632 2828 

Internet: www.insel.ch 

INTERNATIONAL COUNCIL OF NURSES 

3 Place Jean-Marteau 


Tel: +41 22908 0100; Fax: +41 22 908 0101 

Internet: www.icn.ch 

INTERNATIONAL ASSOCIATION OF INFANT FOOD 

MANUFACTURERS 

Chemin Louis Dunant 7-9 


Tel: +41 22 788 3911 

Fax: +41 22 788 3912 

Internet: www.ifm.net 

USA 

AMERICAN COLLEGE OF HEALTHCARE EXECUTIVES (ACHE) 

One North Franklin Street, Suite 1700 

Chicago, IL 60606-3491, USA 

Tel: +1 312 424 9365 

Fax: +1 312 424 0023 

Internet: www.ache.org 

GRIFFIN HOSPITAL - PLANETREE 

130 Division Street, Derby, CT 06418, USA 

Tel: +1 203 732 1365 

Fax: +1 203 732 7569 

Internet: www.planetree.org 

ILLINOIS HOSPITAL ASSOCIATION 

1151 East Warrenville Road, PO Box 3015 

Naperville, Illinois 60566, USA 

Tel: +1 630 276 5710 / +1 630 276 5400 

Internet: www.ihatoday.org 

METHODIST INTERNATIONAL 

6560 Fannin ST 220, Houston, 

Texas 77030, USA 

Tel: +1 713 441 7500 / 441 2340 

Fax: +1 713 790 6618 / 793 7097 

Internet: www.methodistinternational.org 

NEW JERSEY HOSPITAL ASSOCIATION 

760 Alexander Road, PO Box 1 

Princeton, NJ 08543-0001, USA 

Tel: +1 609 275 4241 / 609 275 4000 

Fax: +1 609 452 8097 

Internet: www.njha.com 


HAMDAN BIN MOHAMMED e-UNIVERSITY (HBM eU) 

PO Box 71400, Dubai 


Tel: +971 4 424 1111; Fax: +971 4 439 3939 

Internet: www.hbmeu.ae 


IHF reference 

Honorary Members 

Members elected by the General Assembly for special services rendered to the IHF or to the healthcare field in general 

AUSTRALIA 

R H Kronborg MBE 

6 Pentland Road 

3225 Point Londsdale 

Victoria, AUSTRALIA 

Dr Errol Pickering 

13 Firestone Court 

Robina Woods 

The Gold Coast 

4226 Queensland, AUSTRALIA 

CANADA 

Jean-Claude Martin 

710-500 Rue de la Montagne 

Montreal H3C 4T6 

CANADA 

FINLAND 

Arvo Relander 

Luuvaniementie 3 A 5 

Helsinki 

FINLAND 

FRANCE 

L Peyssard 

12 Avenue Maurice Barres 

13008 Marseille 

FRANCE 

GERMANY 

Dr Klaus Proessdorf 

Theodor Schwannstr. 10 

50735 Koln-Riehl 

GERMANY 

HONG-KONG 

(SPECIAL ADMINISTRATIVE REGION – 

CHINA) 

Dr Een Kiong Yeoh 

Flat 18A, Tower II, Ruby Court 

55 South Bay Road 

Hong-Kong 

(SPECIAL ADMINISTRATIVE REGION – CHINA) 

MEXICO 

Dr G Fajardo Ortiz 

Juarez 14 Casa 11 

Tlacopac San Angel 

1040 Deleg Alvaro Obregon CP 

MEXICO 

THE NETHERLANDS 

Dr Ton Krol 

Postbus 2621 

2002 RC Haarlem 


Dr Rene Peters 

Weerdsingel O.Z.82 Bis 

3514 Utrecht 


POLAND 

Prof T Tolloczko 

Wiejska 9/9 

480 Warsaw, POLAND 

PORTUGAL 

Prof J M Caldeira Da Silva 

Av Antonio Augusto de Aguiar 144 - 2 D 

1050-021 Lisbon, PORTUGAL 

SWEDEN 

Prof Per-Gunnar Svensson 

Fockgrand 1 

260 93 TOREKOV 

SWEDEN 

T Thor 

Koltrastvagen 39 

183 51 Taby, Sweden 

SWITZERLAND 

Dr François Kohler 

Talgut Zentrum 22-602 

3063 Ittigen, SWITZERLAND 

Ferdinand Siem TJam, MD MPH 

Chemin du Ruisseau 2C 

1291 Commugny VD, SWITZERLAND 

Dr Andrei Issakov 

4b chemin Edouard Sarasin 

1218 Grand Saconnex 

SWITZERLAND 

UNITED KINGDOM 

D Maitland 

128 Osidge Lane 

London N14 5DN 

England - UK 

Dame Gillian Morgan 

Permanent Secretary 

Welsh Assembly Government 

Government Buildings 

Cathays Park, Cardiff CF10 3NQ 

Wales - UK 

Sir Reginald Wilson 

49 Gloucester Square 

London W2 2TQ, England - UK 

USA 

J A McMahon 

181 Montrose Drive 

Durham, NC 27707 

USA 

Mr Scott Parker 

757 S. Woodmoor Circle 

Bountiful, UT 84010 

USA 

L W Lehr 

3050 Minnesota World Trade Center 

30 Seventh Street East 

Saint Paul, Minnesotta 55101-490 

USA 


The International Hospital Federation and Pro-Brook Publishing 

would like to thank all the contributors to the publication and those 

involved in the production process. 

Pro-Brook Publishing 

Tim Probart, Publisher; Trevor Brooker, Publisher; Stephen King, Business 

development; Susan Pulman, Business development; Simon Marriott, Art direction 


Sheila Anazonwu, Commissioning editor 


IHF Corporate Member Profiles 

GE Healthcare 

The burden of surgical diseases is large and is increasing, and there are enormous gaps in access to surgery between high and 

low income countries. Surgical services may be cost effective at the district level in LMICs, and providing access to essential 

surgery should be viewed as “primary prevention” of death and disability. The integration of essential surgical services into 

health systems, within the context of primary healthcare reforms, will surely improve population health. 

Johnson Controls 

JOHNSON CONTROLS uses its 125 years of experience to help healthcare organizations create comfortable, safe and sustainable 

healing environments while providing measurable results. By utilizing our expertise in energy and sustainability, facilities, 

building and technology infrastructure, healthcare organizations can improve their financial results, the environment of care and 

their standing in the community. Johnson Controls provides design assist and construction management, funding solutions, 

network integration solutions for clinical and non-clinical systems, energy management and central utility plants, operations 

support and best practices, systems maintenance and facility management services. http://www.johnsoncontrols.com 

Aramark 

ARAMARK is a global leader in professional services, providing award-winning food services, management of facilities, assets, and 

clinical technology, and uniform/career apparel to healthcare institutions and other businesses. In FORTUNE magazine’s 2009 list 

of “World’s Most Admired Companies,” ARAMARK ranks number one in its industry, consistently ranking since 1998 as one of the 

top three most admired companies in its industry. ARAMARK seeks to responsibly address key issues by focusing on employee 

advocacy, environmental stewardship, health and wellness, and community involvement. Headquartered in Philadelphia, 

Pennsylvania (USA), ARAMARK’s 255,000 employees serve clients in 22 countries. Visit www.aramark.com to learn more. 

HCA International 

HCA International owns six leading private hospitals in London, each with international reputations for the highest standards of 

care. They are: The Wellington, the largest private hospital in the UK, The London Bridge Hospital, The Harley Street Clinic, The 

Portland Hospital for Women and Children, The Lister Hospital and The Princess Grace Hospital. 

HCA hospitals treat approximately 350,000 patients annually and specialise in complex medical procedures. The HCA Cancer 

Network, for example, is the largest private provider of cancer care in the UK and is the best equipped outside the NHS. 

In the past five years, HCA has invested over £100 million in capital expenditure including the latest diagnostic and treatment 

technology. HCA International is owned by Hospital Corporation of America, the largest for-profit hospital operator in the United 

States. 


Corp 

orate Partnership 

Program 

Supporting collaboration, 

ideas and 

innovation 

in 

global healthcare 

What Is the Corporate Partnership Program? 

An opport 

unity 

offered to 

major co 

rporations who seek to join with IHF members to work to 

improve h 

ospital performance around the world. The Program 

is run by World Hospit 

al 

(WH), 

a co 

mpany owned by the Inte 

ernational 


Federa 

ation (IHF) and dedicated 

to 

supporting 

IHF goals through collaborative events and publications. 

The program 

is open to a limited number 

of corporations that 

are fully engaged in the global 

health sector 

and have a good reputation as providers. 

Benefits 

include: 

Yea 

r-long access to decision 

makers from around the world. 

E x 

clusive opportunity for 

rel 

at 

ionship building a 

nd sh 

aring ideas 

and experienc 

es 

between corporate leaders 

and executives in the hospital 

sector. 

Accc ess to IHF policy and advocacy 

communications 

I 

 

 

- 

Advertising and marketing opportunities 

Corporate 

Partnership Pa 

ckage 

Please cont act Sheila 

Anazonwu ( sh 

eila@ihf-f ih.org 

) at the 

IHF 

Secretariat for more 

details 

an d 

a co 

rp 

orate package informatio 

on

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