ISSN 2309 - 4605

Volume 10. Number 2. May 2017

www.southsudanmedicaljournal.com SSMJSouth Sudan Medical Journal

Implementing the Sustainable Development Goals in South Sudan

• Maternal near-miss in Chad

• Trust in medical professionals

• How to read liver function tests

• RTAs in Juba

Vol 10. No 2. May 2017 25 South Sudan Medical Journal CONTENTS

EDITORIAL South Sudan Medical Journal ISSN 2309 - 4605 Sustainable Development Goals SSMJ implementation in the context of South Volume 10. No. 2. www.southsudanmedicaljournal.com Sudan Lul Riek ...... 27 A Publication of the South Sudan Doctors’ Association EDITOR-IN-CHIEF ORIGINAL RESEARCH Dr Edward Eremugo Luka South Sudan Doctors’ Association Maternal Near-miss in N’Djamena Mother and Child Hospital, Chad Gabkika Bray Ministerial Complex Madoue, Saleh Abdelsalam, Doumbia Juba, South Sudan Madjouma Badara Aliou, Adoum Of, Sabre [email protected] Twitter: @eremugo Emile, Ehdjolbo Pallai, Askemdet Obelix . 28 ASSOCIATE EDITORS What causes patents to trust medical Dr Wani Gindala Mena professionals? Insights from mothers in Juba Department of Ophthalmology Rachel Ayrton with Christne Mori Lado and Juba Teaching Hospital, Edward Eremugo Luka ...... 33 PO Box 88, Juba South Sudan Causes of road trafc accidents in Juba [email protected] Akway M. Cham, Anthony Lasuba, Riing Y. Chan, Angelo L. Jockmet, Asmaa S. Korokon, Dr Eluzai Abe Hakim Malong A. Aguer, John L. Otwari ...... 37 Department of Adult Medicine & Rehabilitation St Mary’s Hospital, Newport, MAIN ARTICLE Isle of Wight PO30 5TG, UK [email protected] How to interpret liver functon tests Christna Levick ...... 40 EDITORIAL BOARD Dr James Ayrton SHORT ITEMS [email protected] Dr Charles Bakhiet Case Report: From traditional birth [email protected] attendants to hospital: a maternal Professor James Gita Hakim near-miss Ogunlaja OA, Fehintola [email protected] AO, Ogunlaja IP, Idowu A, Abiola OO, Dr Ayat C. Jervase Bojuwoye MO ...... 31 [email protected] Quiz on liver function tests ...... 43 Dr David Tibbutt [email protected] Funding for South Sudanese ...... 44 Prof. John Adwok [email protected] Hello and goodbye ...... 45 Dr. Charles Ochero Cornelio Langoya [email protected] The Small Baby Series ...... 45 EDITORIAL ADVISOR Ann Burgess Care groups in emergencies in Unity [email protected] State ...... 46

DESIGN AND LAYOUT BACK COVER South Sudan Medical Dr Edward Eremugo Luka Journal Call for submissions ...... 48 The South Sudan Medical Journal is a quarterly publication intended for Healthcare Professionals, both those working in the South Sudan and those Front cover photo: Smoke inhalaton in the house from in other parts of the world seeking information on health in South Sudan. biomass fuel may cause respiratory disease in adults and The Journal is published in mid-February, May, August and November. children (fle photo credit: Richard A Lewis) South Sudan Medical Journal 26 Vol 10. No 2. May 2017 EDITORIAL

Sustainable Development Goals implementation in the context of South Sudan

On 25 September 2015, world leaders adopted the 2030 Agenda for Sustainable Development, which includes a set of 17 Sustainable Development Goals (SDGs), 169 targets and at least 300 indicators to end poverty, fght inequality and injustice, ensure peace and stability, and tackle climate change and environmental degradation by 2030 as well as putting in place a robust global partnership in support of the realization of the goals. The overreaching goal of the SDGs is poverty eradication that focuses on fve Ps - people, planet, prosperity, peace, and partnership. SDGs place a strong focus on equity, expressed most frequently as “no one will be left behind.” Furthermore, the SDGs success will not be achieved simply by reaching numerical averages. Rather true success of the SDGs will be realized by improving the lives of the most disadvantaged and hardest to reach populations. The SDGs agenda recognizes that each country has primary responsibility for its own economic and social development. The SDGs are about development and not just about developing countries. The SDGs were developed through extensive consultation with all levels of society to constitute a comprehensive development plan. With the SDGs, a country like South Sudan has the opportunity to act upon its vision for the future. Building on lessons learned in implementing the Millennium Development With the SDGS, a Goals (MDGs) from 2000-2015, South Sudan is well positioned to engage country like South in the domestication of the SDGs. The Ministry of Finance and Economic Planning should lead the process, with strong support from the UN and SuDan haS the other developmental partners. opportunity to act The Government of South Sudan should commission an initial gap analysis upon itS viSion for the to answer the following question: which targets and indicators from the future. SDGs are already being monitored, given that most MDG targets are also embedded in the SDGs? The outcome of this analysis would help the Government prepare a plan to domesticate and prioritize the new elements in the SDGs, and to estimate the cost. The overall objective in the analysis is to assess which SDGs indicators are already refected in the National Development Framework and more specifcally to: • Identify which SDGs targets and indicators are already refected within the national development documents namely Vision 2040, South Sudan Development Plan and Sector Strategic Plans - and which are not, • Analyse where possible adjustments needed to national documents to respond to the SDGs’ targets and indicators, • Conduct key consultations to further explore the challenges, gaps, and opportunities to domesticate and implement the SDG agenda.

Dr. Lul Riek, MD, MPH Public Health Specialist and Former Director General for International Health, Ministry of Health, South Sudan Email: [email protected]

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Maternal near-miss in N’Djamena Mother and Child Hospital, Chad

Gabkika Bray Madouea, Saleh Abdelsalama, Doumbia Madjouma Badara Alioua, Adoum Ofa, Sabre Emilea, Ehdjolbo Pallaia, Askemdet Obelixb a N’Djamena Mother and Child Hospital, Chad b University Hospital Le Bon Samaritn, N’Djamena, Chad

Correspondence: Gabkika Bray Madoue [email protected]

BACKGROUND: Maternal near-miss describes a woman who almost died but survived a complicaton that occurred during pregnancy, childbirth or within the 42 days following pregnancy terminaton. The prevalence of maternal near-miss is variable around the world. In Chad no previous survey has been performed on maternal near-miss. OBJECTIVE: To describe the characteristcs of patents afected by maternal near-miss in N’Djamena mother and child hospital. RESULTS: During the 6-month period (January 1st to June 30th 2016) of data collecton there were 4,857 live births. The 100 most severe cases of near-miss (2.06 % of all deliveries) were selected. The majority of these patents (96%) were ≤ 35 years old. Seventy six per cent had had 0-3 prenatal consultatons. A high proporton of women had been referred (84%). Main morbidites were: haemorrhage (62%) and hypertensive complicaton (24%) followed by aborton (6%). CONCLUSION: Maternal near-miss is ofen recorded in our hospital. Haemorrhage and hypertension are the main pathologies registered. Key words: Near-miss, N’Djamena mother and child hospital Chad.

Introducton following pregnancy termination [8]. The prevalence of Reduction of maternal morbidity is one of the United maternal near-miss is variable around the world. Data Nations Millennium Development Goals [1]. The from a systematic review of 46 countries demonstrate that number of maternal deaths refects the socioeconomic the prevalence varies from 0.04 to14.98 %, with higher level and the quality of medical assistance, and is inversely rates in lower income regions in Africa and Asia [9]. related to the degree of human development. Maternal In Chad no previous survey has been performed on mortality is unequally distributed among developed and maternal near-miss cases. Information on maternal near- developing countries, and developing countries account miss cases is scarce. Thus, the aim of the current study for 99% of all known maternal deaths in the world [1,2]. is to describe the characteristics of maternal near-miss Maternal mortality in Chad is still high and was patients. estimated at 860/100,000 live births in the year 2015[3]. Patents and Methods The main causes of maternal deaths were: haemorrhage, hypertension/eclampsia abortion, complications of This was a retrospective and descriptive survey of labour, sepsis and infectious disease [4,5]. Studies on six months from January 1st, 2016 to June 30th, 2016 the physiopathology of pregnancy, child-birth and the performed at the maternity of N’Djamena Mother and postpartum period have revealed a wide spectrum of Child hospital. N’Djamena Mother and Child hospital is clinical conditions in women, ranging from a healthy a level III hospital located in N’Djamena city, which is pregnancy to the other extreme of maternal death. surrounded by 4 district hospitals and many health centers. Severe maternal morbidity forms part of this range of These health facilities often refer patients to N’Djamena clinical conditions and begins with the occurrence of a Mother and Child hospital for better care. complication that could progress to maternal death. The 100 most extreme patients who almost died but Another extremely critical group that merits particular survived a complication that occurred during pregnancy, emphasis concerns cases that are referred to as near-miss childbirth or within the 42 days following pregnancy which is a more severe condition than severe maternal termination were included. Those with incomplete fles morbidity [6,7]. In 2009, the World Health Organization were excluded. The data collections were done due to the (WHO) defned maternal near-miss as a woman who resuscitation feld fles, obstetrical fles, emergency fles almost died but survived a complication that occurred and the surgical reports. The data analyses were made by during pregnancy, childbirth or within the 42 days Epi Info 6TM.

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Table 1. Age and parity of 100 patents Table 2. Main maternal morbidites of 100 patents Characteristc Percentage Aetology Percentage Age (Years) Hypertensive complicaton 24 15- 20 12 Severe preeclampsia (n=14) 21-25 26 Eclampsia (n=10) 62 26-30 20 Haemorrhages 31-35 38 Third bleeding stage (n=20) Abrupton placenta (n=10) 36-43 04 Clot disorder (n=14) Parity Prævia placenta (n=4) Uterine rupture (n=6) Primipara 33 Ruptured ectopic pregnancy(n=8) Paucipara 13 Aborton complicatons Multpara 54 6 Septc shock (n=4) Incomplete aborton (n=2) Results Puerperal infecton (n=2) 2 Frequency Anaemia (n=2) 2 During the 6-month period of data collection, 4857 Total 100 live births, 383 women with severe maternal morbidity, 100 cases of maternal near-miss (2.06 % of all deliveries), and 31 maternal deaths (0.64 % of all deliveries) were The majority of the 100 cases of maternal near-miss in identifed this study were young women (96% were aged less than Age 35 years). The median number of prenatal visits attended by the patients affected with maternal near-miss in the The mean age of patients was 27.9 years with a range present study was in lower than WHO recommendations of 15 to 43 years; the majorities (96%) were 35 years old - i.e. at least four visits [15]. Recent studies showed that with 38% aged 31-35 years. The majority of patients women who are older, who have less education, have (54%) were multipara. had fewer prenatal consultations, are without a married Admission mode, matrimonial status and pregnancy partner, or who have had a previous Caesarean section surveillance have the greatest risk of near-miss [16-17]. This fnding refects the need to increase the prenatal coverage at Seventy six patients (76%) had had 0-3 prenatal primary health care level in Chad. Looking at the two consultations, the median number being 1.6. All the main morbidities, antenatal care should include planning patients were married. The majority (68%) lived in a rural to prevent haemorrhage in the third stage of labour by zone; 84% were referred. ensuring access to oxytocic drugs where the women The majority of patients (62%) had presented with deliver. This is very relevant for women who have had haemorrhagic complications; 20% with the third bleeding several children and are therefore more likely to bleed. stage; 24% presented with hypertensive complications. Clotting disorders are often associated with a dead fetus The management of haemorrhage had required blood and infection indicating delayed referral. transfusion in 56 cases (56%), Caesarean section in 28% Antenatal care should detect those who are hypertensive and obstetric hysterectomy in 10%. and refer them to a level 3 hospital reducing pre-elampsia, eclampsia and abruption. Discussion In the present study, the frequency of maternal near- A high percentage of patients (84%) in the study had miss was low compared to that found in Tananarive [10], been referred from other centers. This is higher than in Burkina Faso [11] and Nigeria [12] which ranged from Iran [18] where 34% patients had been referred. The 3.9 to 14% of all deliveries. Maternal near-miss occurs in high proportion of referred patients in this study can be about 1 in 250 deliveries, in developed countries, for an explained by the fact that N’Djamena Mother and Child overall rate of 4.38 per 1000 deliveries [13]. hospital is a level 3 hospital in N’Djamena city. The second reason is due to the application of the politics of A systematic literature review published on this subject exemption for medical fees in emergencies in this hospital. indicated a prevalence that ranged from 0.04% to 15% depending on the criteria used to defne it [15]. In the present study, the most frequent determinants

Vol 10. No 2. May 2017 29 South Sudan Medical Journal ORIGINAL RESEARCH of maternal near-miss were haemorrhages (62%), similar Maternal Deaths at N’Djamena Mother and Child to that found previously by Gabkika [4] and Foumsou Hospital, Chad. African Journal of Integrated Health [5] on the cause of maternal mortality. These fndings 2016; 6(1): 13-17 showed the need for sensitization of the population 6. Geller SE, Rosenberg D, Cox SM, Brown ML and al. about haemorrhage. In our country blood products are The continuum of maternal morbidity and mortality: unavailable in emergency situations. Then, antenatal factors associated with severity. Am J Obstet Gynecol care should include planning to prevent haemorrhage by 2004;191:939–944. screening the risk factor. Hypertensive disorders causes had represented 28% of the near-miss cases. Earlier studies 7. Sousa MH, Cecatti JG, Hardy EE, and al. Severe found a similar fnding with an important proportion of maternal morbidity (near-miss) as a sentinel event of hypertensive disorders [19]. maternal death. An attempt to use routine data for surveillance. Reprod Health 2008 ; 5:16-9 Conclusion 8. Pattinson R, Say L, Souza JP, and al. WHO Working This study showed that the main pathologies causing Group on Maternal Mortality and Morbidity the maternal death are the same causes of maternal near- Classifcations: WHO maternal death and near- miss. Characteristics of affected patients are that they miss classifcations. Bull World Health Org 2009; come from rural areas and have had poor pregnancy 87(10):734. surveillance. According to our fndings it is clear that for the reduction of maternal near-miss and mortality we need 9. Tunçalp O, Hindin MJ, Souza JP, and al. The a good sensitization of the population about pregnancy prevalence of maternal near-miss: a systematic review. surveillance in remote areas. Planning for delivery and BJOG. 2012;119(6):653–61 speedy referral as soon as there is any cause for concern 10. Rabenasolo H, Raobijaona H , Rasolofondraib E. Near- must improve. miss: epidemiologie et prise en charge. 100 cas vus au Authors’ approval: All authors approve the submission chu de Tananarive. Médecine d’Afrique Noire 2006 ; 53 of this work. (11): 81-86. Confict of interest: All authors have declared that there 11. Ouedraogo C, Testa J, Sondo B, and al. Analyse is no confict of interest. des facteurs de risque de morbidité maternelle severe à Ouagadoudou, au Burkina Faso, Médecine d’Afrique Funding: No fnancial assistance or grants were solicited Noire 2001; 48 (10) :67-9 or obtained during the course of preparing this article. 12. Olufemi T. “Near-miss” obstetric events and maternal Consent: For this survey we got the agreement of the deaths in sagamu, Nigeria: a retrospective study. N’Djamena Mother and Child hospital and ethical Reproductive Health 2005; 2( 9):45-8 committee. 13. Victoria M, Melanie C, George C and al. Maternal References Mortality and Severe Maternal Morbidity Surveillance 1. Ogan MC, Foreman KJ, Naghavi M, et al: Maternal in Canada. J Obstet Gynaecol Can 2010;32(12):1140– mortality for 181 countries, 1980–2008: a systematic 1146 analysis of progress towards Millennium Development 14. Ana Paula P M, Sandhi MB, Valéria MAP. Incidence Goal 5. Lancet 2010; 375:1609–1623. and main causes of severe maternal morbidity in São 2. Say L, Souza JP, Pattinson RC. WHO working group Luís, Maranhão, Brazil: a longitudinal study. Sao Paulo on Maternal Mortality and Morbidity classifcations: Med J. 2011; 129(3):146-52 Maternal near-miss–towards a standard tool for 15. World Health Organization 2006. Guidelines for the monitoring quality of maternal healthcare. Best Pract treatment of Malaria. Geneva 240 Res Clin Obstet Gynaecol 2009 ; 23:287–296. 16. Oliveira Jr FC, Surita FG, Pinto e Silva JL, and al. 3. Institut National des statistiques des études Severe maternal morbidity and maternal near-miss in économiques et de démographie. (INSEED). Enquête the extreme of reproductive age: results from a national démographique et de santé III (EDST3). Ministère cross-sectional multicenter study. BMC Pregnancy de du plan et de la coopération. 2015. P 32 Childbirth. 2014;14:77-81 4. Gabkika BM, Damtheou S, Masngar K and al. 17. Dragoman M, Sheldon WR, Qureshi Z, and al. Analysis of maternal deaths in southern district Overview of abortion cases with severe maternal hospital (Chad). Borno Medical J.2015; 12(2): 79-85 outcomes in the WHO Multicountry Survey on 5. Foumsou L, Gabkika BM, Chingnabo L and al. Maternal and New born Health: a descriptive analysis. Analysis of Factors Associated with Avoidable BJOG 2014;121 Suppl. 1:25–31

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18. Mahvash Z, Javad M, Azam Af and al. Severe Maternal Further reading Morbidity and Near-Misses in Two Tertiary Referral World Health Organization 2011. Evaluating the Hospitals in Iran. Jentashapir J Health Res 2015; 6(2): quality of care for severe pregnancy complications The e25886. WHO near-miss approach for maternal health” World 19. Alberto P M, Andréa CR, Érica ZGL and al. Incidence Health Organization, Geneva http://apps.who.int/iris/ and determinants of severe maternal morbidity: a bitstream/10665/44692/1/9789241502221_eng.pdf transversal study in a referral hospital in Teresina, Piaui, Brazil. BMC Pregnancy and Childbirth 2015; 15:210-215.

CASE REPORT From traditional birth attendants to hospital: a maternal near-miss Ogunlaja OAa, Fehintola AOa, Ogunlaja IPb, Idowu Ac, Abiola OOd, Bojuwoye MOe a. Department of Obstetrics & Gynaecology, Bowen University Teaching Hospital, Ogbomoso, Nigeria b. Department of Obstetrics & Gynaecology, General Hospital, Ilorin, Nigeria c. Department of Community Medicine, Bowen University Teaching Hospital, Ogbomoso, Nigeria d. Department of Surgery, Bowen University Teaching Hospital, Ogbomoso, Nigeria e. Gastroenterology Unit, Department of Medicine, University Ilorin Teaching Hospital, Ilorin, Nigeria

Correspondence to: Olumuyiwa A Ogunlajal [email protected]

Introducton ‘Maternal near-miss’ is defned as a woman who nearly died during pregnancy or following delivery but survived. The story of many women in sub Saharan Africa is that of an escape from death if they do eventually have a safe delivery [1]. This situaton is not unconnected to several factors as it concerns these women, their families, the society and the choices they make. Case report A 43-year old para 5+0 (4 alive) woman presented in our hospital afer a departure against medical advice from a private hospital where she had had a Caesarean secton performed and subsequently developed a burst abdomen on the ffh post-operatve day. This was preceded by a history of labour pains of about 48 hours in a traditonal birth atendant (TBA) home where various manoeuvres were tried to facilitate the delivery of the foetus. She was however referred to the private hospital when it was observed that the foetal heart beats were not heard. On presentaton in our hospital she was acutely ill- looking, pale, jaundiced and mildly dehydrated. The pulse rate was 124 beats per minute and the blood pressure was 100/70mmHg. The respiratory rate was 40 breaths per minute and she was placed on supplemental oxygen. The abdomen was distended and the bowel sounds were hypoactve. There were copious purulent efuents from the abdominal wall wound. The devitalized uterus was seen at the base of the wound, with the wound edges showing devitalized skin, subcutaneous tssues and rectus sheath (Figure 1). Copious purulent discharge was notced in the vagina. Figure 1. Devitalized uterus at the Figure 2. During hysterectomy; the She was resuscitated with intravenous fuid base of the wound with devitalized devitalized lower uterine segment and intravenous antbiotcs were administered. edges involving the skin, subcutaneous with copious purulent discharge Investgaton results: Packed cell volume: 27%, white tssues and rectus sheath. (credit noted. (credit Ogunlaja et al) blood count revealed neutrophilia. There was a mild Ogunlaja et al)

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elevaton of urea, creatnine, bilirubin and alanine transaminase. A pint of blood was transfused immediately and she was prepared for wound debridement, closure and total abdominal hysterectomy. Operatve fndings revealed a devitalized lower uterine segment with copious purulent discharge (Figure 2). A total abdominal hysterectomy with peritoneal lavage and toiletng were carried out and the wound was closed with interrupted nylon sttches. Post operatvely, she had antbiotcs (amoxycillin+clavulanic acid and metronidazole), analgesics and intravenous fuids. Her post-operatve recovery was satsfactory. Discussion Despite various programmes and strategies embarked upon in the past, Africa contnues to have high maternal morbidity and mortality rates. This situaton is partcularly bad in the sub Saharan region [1]. Nigeria contributes about 10% to the maternal mortality fgures [2]. This is due to a dearth of medical facilites, poor training and retraining of health workers and increases in deliveries conducted by TBAs [3,4]. The roles of TBAs have been the subject of debate among health professionals and several studies have been conducted to ascertain the most efectve strategies [5 - 8]. An earlier study that reviewed intrapartum referrals by TBAs to a Mission Hospital in Southeastern Nigeria observed that such referrals resulted in over 60% of the maternal deaths recorded at the hospital [9]. The case presented above clearly shows the typical fate of many women of low socioeconomic status in our society. She presented frst in labour to a TBA home but she was only transferred to a private hospital afer observing that foetal death had occurred afer about 24 hours in labour. At the private hospital she was ofered a Caesarean Secton despite the fndings of intrauterine foetal death. She was only referred on afer her wound underwent complete breakdown about ffh day post operaton. It is important to state that Caesarean Secton should not be the frst modality of management in cases of intrauterine foetal death especially in Africa. The need for educaton of girl children, women and families cannot be over emphasized as this will help in making right choices about where, when and how to get help during pregnancy or delivery irrespectve of their socioeconomic situaton. Efectve training, engagement, monitoring and supervision of TBAs could improve maternal and newborn health in our environment. Conclusion Advocacy and legislaton should be strengthened to ensure improved educaton. Policies may be put in place to encourage TBAs who refer patents to the hospital especially before the onset of complicatons. Collaboraton between TBAs and health care workers should be encouraged.

Confict of interest: No author has any confict of interest to declare. Funding: None Ethical approval Patent’s consent was obtained

References 1. Neilson JP. Traditonal birth atendant training for improving health behaviours and pregnancy outcomes: Cochrane update. Obstet Gynecol 2007;110:1017-8. 2. Federal Ministry of Health. Maternal Mortality Situaton and Determinants in Nigeria. Abuja Nigeria: Federal Ministry of Health; 2004. p. 1-10. 3. Ahmed O, Odunukwe N, Raheem Y, Efenemokwu G, Junaid M, Adesesan S, etal. Knowledge, attude and percepton of HIV/AIDS among traditonal birth atendants and herbal practtoners in Lagos State, Nigeria Afr J AIDS Res 2004;3:191- 6. 4. Imogie AO, Agwubike EO, Aluko K. Assessing the role of traditonal birth atendants (TBAs) in health care delivery in Edo State, Nigeria. Afr J Reprod Health 2002;6:94-100. 5. Ana J. Head to Head: Are traditonal birth atendants good for improving maternal and perinatal health? Yes. Britsh Medical Journal. 2011;(342): d3310. 6. Sibley LM, Sipe TA & Koblinsky M. Does TBA training increase use of professional antenatal care services: a review of the evidence. Journal of Midwifery and Women’s Health. 2004; 49(4): 298-305. 7. Darmstadt GL, Lee AC, Cousens S, Sibley L, Bhuta ZA, Donnay F et al. 60 million non-facility births: who can deliver in community setngs to reduce intra-partum-related deaths? Internatonal Journal of Gynaecology & Obstetrics. 2009;107 (Suppl 1): S89-112. 8. Harrison KA. Head to Head: Are traditonal birth atendants good for improving maternal and perinatal health? Britsh Medical Journal. 2011; 342:d3308. 9. Umeora OU, Ejikeme BN, Igberase GO. Intrapartum referrals from traditonal birth atendants in Southeast Nigeria: Paterns and outcoms. Trop J Obstet Gynaecol 2007;24:24-9.

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What causes patients to trust medical professionals? Insights from mothers in Juba Rachel Ayrtona with Christne Mori Ladob and Edward Eremugo Lukac a Post-Graduate Researcher, University of Southampton, UK b Lecturer & Deputy Dean, College of Social and Economic Studies, University of Juba c South Sudan Doctors’ Associaton

Correspondence: [email protected]

Trust in medical professionals is an important aspect of demand for health care in South Sudan, without which many patents may never atempt to access clinics and hospitals. This qualitatve research study used in-depth biographical interviews to explore family health histories according to the experiences of South Sudanese mothers in Juba. The resultng data demonstrates that trust in medical professionals is conditonal on patents’ partcular experiences. Partcipants acknowledged the resource constraints that medical professionals work under, and called on decision-makers to prioritse health services as an indicator of peace. Nevertheless, health care workers can take practcal steps to build trust through their day-to-day interactons with patents. In additon to medical competence, partcipants valued a respectul, atentve and supportve quality of care, and working practces that ensured accountability in the way this care was delivered.

Key Words trust, quality, care, accountability, qualitatve

Introducton Methodology “Arguably, there are few relationships where concerns Using a qualitative approach, I conducted 13 in-depth about trust loom larger than in the relationship between biographical interviews with mothers in Juba during July- patients and their physicians.” [1] August 2012. The participants were all South Sudanese, Developing health care systems in South Sudan current carers of at least one child aged 14 years or is a long-term task. The Ministry of Health and its younger, with a range of educational levels, from P1 to development partners take a strategic lead in this, while master’s degree. Some mothers had experienced raising dedicated health-care workers on the ground also play an their children in the context of the second civil war (1983- important role in constantly improving standards of care. 2005), including in the bush and/or refugee camps and in One important issue is the supply of health care, through the context of attacks, while mothers of young children the provision of accessible, equipped health facilities [2], had given birth and raised their children in peace time. along with the trained staff to operate them [3]. Another, Where necessary I worked with an interpreter. less recognised problem is the demand for medical care, During the interviews I asked each mother to which is also beginning from a very low level in South tell me the story of her life, particularly focusing on Sudan [4]. This study examined the trust in medical her own and her family’s health. In order to enable professionals as an important factor that infuences participants to engage more actively in telling their patients’ decision to access medical care. stories and to introduce a visual medium into the data, The perspectives of mothers are vital in understanding I used a participative technique based on the timeline. the health needs of families in South Sudan due to Participants chose beads, shown in fgure 1, which they their primary care-giving role. Further, the indirect threaded on a piece of cord during the interview forming consequences of war, in particular poor health, have a a bracelet which represented their lives and experiences disproportionate impact on women and children [5]. The [7]. The experiences that they retold included treatment experiences of South Sudanese mothers therefore have by doctors, medical offcers, nurses and midwives, as well the potential to provide important messages for health as traditional healers, family members and self-help. care workers about how to provide the best possible care The interviews were audio-recorded, then I for patients, even where resources are limited. These transcribed them and undertook thematic analysis. The messages could hardly be more relevant given the severe names of participants have been changed to ensure their challenges to health care provision at present [6]. anonymity. Although this study included methodological

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Findings Mothers expressed respect for medical professionals in general, but this did not automatically translate to trust: for the majority of participants, trust was conditional on their experience of individual practitioners: “Some people trust … medical professionals, some do not trust. Why? Because if you get a good doctor who is able to give attention to you, then you trust that doctor. If you fnd a doctor that does not give attention to you then you don’t trust them. The reason is some people really have the interest of serving their patients, but some medical professionals do not have that interest.” (Rose, 07/08/12) The interview data clearly reveals the nuanced Figure 1. Materials used and example tmeline bracelet understanding mothers had of the institutional environment and constraints that medical professionals and theoretical fndings, in this article I focus particularly were working within; as one mother who had suffered an on substantive aspects of care by medical professionals avoidable miscarriage refected, “You can just blame the that may lead to greater trust among patients. whole situation” (Mama Emma, 25/07/12). Participants Trust - a theoretcal framework identifed the lack of medicines and facilities, as well as limitations to training opportunities, which can leave Although most people believe trust is important for medical professionals powerless to intervene, particularly social relations to function effectively, it is not easily in remote clinics where supplies are cut off through defned [8]. In this study I treat trust as a process that confict: “these doctors have nothing else but to resort to enables a person to take action in situations where they praying to God because there’s nothing else they can do” are vulnerable, where there is uncertainty about what the (Sandia 08/08/12). They also acknowledged that medical outcome will be and where they depend on others [9, 8]. professionals are “overloaded with the work” (Mama The process of trusting has four main stages: Emma 25/07/12) and often receive insuffcient payment interpretation, suspension, favourable expectation, and to provide for their families (Sue-Ann, 07/08/12). evaluation [10, 11]. Interpretation involves an evaluation Nevertheless, mothers expressed signifcant pride in of the ‘good reasons’ that someone might have to act in a their ability to protect their children despite considerable way that makes them vulnerable to another person. This suffering, and bright hopes for their futures. This was may involve both rational and emotional elements and is expressed by Praise (08/08/2012) through her choice of a deeply affected by the limited range of choices available silver-coloured bead for her timeline (see fgure 2): to a person. Interpretation does not take place in social isolation but involves advice and guidance within the “This one I took it I want to talk about the future, community; in some cases a trusted third party will yeah. I felt after all these sufferings and I was become a repository of trust that intervenes where reasons able to cover with all these children of mine … I to trust are insuffcient. Suspension involves the “leap wanted God to give them a bright future, so they of faith” where a person puts aside uncertainty and became children who are also to help build this vulnerability without eliminating them. This enables country of ours.” (Praise, 08/08/12) them to enter a state of favourable expectation, where The combination of mothers’ appreciation of resource they can act based on interpretative knowledge, treating constraints and aspirations for their children and their it as if it were momentarily certain [10, 11]. country translated to a clear message for South Sudan’s Trust is a dynamic process: it changes over time leaders. For the mothers interviewed, the state of health based on experience. The outcome of an instance where care provision is a primary indicator of how successfully trust was exercised informs the process of interpretation peace has been achieved: on future occasions through the stage of evaluation “The big people up there should consider the [12]. Qualitative, biographical interviews with situation of Southern Sudanese women, to mothers therefore provide an excellent tool for in-depth improve the situation in the hospitals so that there exploration of trust in health care contexts as they enable can be some peace in Sudan” (Sandia 08/08/12). refection on critical past experiences that inform present While structural improvements are essential, decisions on accessing health care. and participants hold decision-makers rather than

South Sudan Medical Journal 34 Vol 10. No 2. May 2017 ORIGINAL RESEARCH medical professionals responsible at that level, there are nevertheless important factors within the direct control of individual health care workers that affect the extent to which mothers trust them to care for their families. Competence The degree of competence that medical professionals exhibit is a key factor affecting trust. Many participants related a story involving a health care worker who they perceived to act rudely (including verbal abuse), negligently, or to be lazy. However, they also identifed key professional practices that convinced them of medical professionals’ competence and therefore contributed to greater trust, including: - Carrying out appropriate tests to confrm diagnosis prior to treatment; - Consistent diagnoses between colleagues; Figure 2: Beads selected by Praise - Calling a senior colleague in a timely manner when the case requires it; this caring approach to patients in a way that directly refected their description of the care a mother has for her - Ability to identify a serious case through triage and child. This has several characteristics. A trusted medical prioritise treatment accordingly; professional has a respectful relationship with their - Consistent follow-up of patients to check progress. patients, where “they talk to you, they ask you questions, Participants attributed the degree of competence they are concerned about you” (Nyidor, 06/08/12). They directly to the training that medical professionals are available to the patient, including being “attentive” received. This included both the quality of initial (Sandia, 08/08/12), maintaining a continual presence, training and participation in continued professional “the doctors are there all the time, attending, and all the development, such as reading journals and mentoring/ nurses are there to attend to you, and it was really very supervision by colleagues as well as formal training good” (Mama Emma, 25/07/12), and they follow-up courses. Those medical professionals who were trusted the patient, “[she] always goes to check her, look for her the most diligently maintained the professional standards every day” (Igbowalya, 03/08/12). They “talk politely” they had been trained in when working under adverse to patients (Mama Emma, 25/07/12), and are supportive conditions. to them, “they are just trying to comfort you and give you Care some courage” (Sue-Ann, 07/08/12). Finally, the patient Studies in Europe have indicated that patients’ trust is a priority and they will “rush to help you” (Igbowalya in health professionals is earned by their experience of 03/08/12), as Nyidor (06/08/12) explained: care and the nature of their relationship to the clinician, “This good one normally if she had something including concern and empathy [13][1]. In other words, she’d leave that something, she’s not go for the medical professionals are expected to care, as well as to breakfast until she treats you and she checks you cure [14]. In this study, the quality of the care provided up and after that she’d go over for breakfast.” to mothers was a powerful factor in determining their In order to build trust among medical professionals, trust in medical professionals. This caring capacity was competence alone is not enough: this quality of care is described as a particular gift or talent: a decisive factor affecting trust in medical professionals “God creates people in different ways, some their to whom South Sudanese mothers entrust their families. heart was created to do so, some their heart was Accountability not created to do good things.” (Betty, 31/07/12) The data indicated a general preference for private “The talent varies … that is what they have to do health clinics over state provision; however this was and what they have really determined to do in based on participants’ perception that there is greater their life, to help others.” (Yomina, 31/07/12) accountability in private health contexts. As Yomina “I was so impressed … he trusted the life frst, he (31/07/12) summarised, valued that life, he didn’t value his money … you know you need not to force yourself, it should be “Whoever works there you have to do your duty a call from your heart that I want to serve people.” because you have been hired to do that. Then if (Peninah, 24/07/12) you fail to do your work, which means you will be South Sudanese mothers described the qualities of sent away.”

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This accountability included a number of facets. http://www.southsudanmedicaljournal.com/archive/ Firstly, participants were confdent that an appropriately february-2014/the-current-crisis-in-human-resources- skilled person would be available at all times. Secondly, for-health-in-africa.html participants expect transparency in the role and level of 4. Taylor S. Beyond the health governance gap: Maternal, training of the person they are dealing with (e.g. nurse, newborn and child health in South Sudan. London: medical offcer, junior doctor, consultant), which should World Vision, 2012:4. be clear through uniform and through the introductions 5. World Bank. World Development Report: Confict, at a consultation. Thirdly, where medical professionals security and development. New York: World Bank, are part of a team with clear supervision arrangements 2011:60. https://openknowledge.worldbank.org/ between colleagues, patients are assured that practice handle/10986/4389 is monitored and high standards maintained. Finally, 6. Luka E. Editorial: Confict devastates health service safeguards such as complaints procedures ensure that delivery in South Sudan. S Sudan Med J 2016; 9 (3):51. patients’ right to good care is demonstrably upheld http://www.southsudanmedicaljournal.com/archive/ without the need for payment to act as a guarantee. While august-2016/editorial.-confict-devastates-health- there is a particular duty for those who undertake day-to- service-delivery-in-south-sudan.html day management of hospitals and clinics to formally put 7. Ayrton R. The bead method: a biographical approach to procedures in place, all medical professionals can adopt researching mothers and trust in post-war South Sudan. practices that embed these aspects of accountability in National Centre for Research Methods Methods News routine practice. 2012; Winter. http://www.ncrm.ac.uk/news/show. Conclusion php?article=5311 Even in the absence of suffcient resources to provide 8. Li PP. When trust matters the most: The imperatives optimal care, there are a number of steps that all medical for contextualising trust research. Journal of Trust professionals can take to increase their patients’ trust. In Research 2012; 2 (2):101-106. http://www.tandfonline. every patient interaction, health care workers have the com/doi/full/10.1080/21515581.2012.708494 opportunity to build trust in themselves as a particular 9. Brown P, Calnan M. Trusting on the edge: Managing practitioner, and in health professionals in general. They uncertainty and vulnerability in the midst of serious can do this by being diligent in applying the professional mental health problems. Bristol: Policy Press, 2012. standards they have been trained in and seeking out 10. Möllering G. The nature of trust: from Georg Simmel to professional development opportunities; by providing a a theory of expectation, interpretation and suspension. respectful, attentive and supportive quality of care akin to Sociology 2001; 35 (2):403-420. http://soc.sagepub. the care a mother provides to her child; and by conducting com/content/35/2/403.short themselves in a way that upholds accountability in the 11. Möllering G. Trust: Reason, routine, refexivity. health care context they work in. Oxford: Elsevier, 2006. Building trust among mothers is a critically important 12. Dietz G. Going back to the source: Why do people task, as it impacts on whether patients attempt to access trust each other? Journal of Trust Research 2012; 2 health care in formal settings at all. The simple measures (1):215-222. http://www.tandfonline.com/doi/abs/10. to increase competence, caring and accountability that 1080/21515581.2011.603514 participants have outlined therefore have the potential to 13. Calnan M, Rowe R. Researching trust relations make a signifcant tangible difference to health outcomes. in health care: conceptual and methodological challenges – an introduction. Journal of Health All fgures are by Rachel Ayrton Organisation and Management 2008; 20 (5):349- 358. http://www.emeraldinsight.com/doi/ References abs/10.1108/14777260610701759 1. Kramer R. Moving between laboratory and feld: a multi-method approach for studying trust judgements. 14. Malli G, Reichenpfader U. The mutual expectations of In: Lyon F, Möllering G, Saunders M, eds. Handbook GPs and their patients in lifestyle counselling: results of of Research Methods on Trust. 1st Ed. Cheltenham: focus group discussions in the context of the Austrian Edward Elgar, 2012:19-28. periodic health examination. Paper presented at the 9th European Sociological Association Conference. 2. Lewis L. Medair: Providing life-saving services to the University of Lisbon, September 2009. http://www. most vulnerable. S Sudan Med J 2016; 9 (3):70-71. ifgp.at/fles/Malli_ESA_fullpaper_Lissabon_2009.pdf http://www.southsudanmedicaljournal.com/archive/ august-2016/medair-providing-life-saving-services-to- the-most-vulnerable.html 3. Elkhalifa GO. The Current Crisis in Human Resources for Health in Africa. S Sudan Med J 2014; 7 (1):7-8.

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Causes of road traffic accidents in Juba Akway M. Chama, Anthony Lasubab, Riing Y. Chanc, Angelo L. Jockmetc, Asmaa S. Korokonc, Malong A. Aguerc, John L. Otwaric a. Assistant Professor/Head of Department; b. Lecturer; c. Student Department of Community Medicine, College of Medicine, University of Juba

Correspondence to: Akway M. Cham: [email protected]

Introducton: Road trafc accidents (RTAs) are a major cause of death and disability in South Sudan. The purpose of this study was to investgate whether violaton of trafc rules is the main cause of RTAs. Method: A cross sectonal study design was used with quanttatve data covering January – December 2014. The main objectve of the research was to understand the epidemiology of RTAs in order to develop preventve measures. A total of 1,725 cases from road RTAs data were extracted from the directorate of trafc police Central Equatoria state Juba and Juba teaching hospital. Results: Most (99.5%) of the RTA drivers were not under the infuence of alcohol. Most accidents were caused by male drivers (99%). The highest number of RTAs took place in August (11%). Drivers of private vehicles caused most accidents (37%). Most drivers (46%) were aged 20-30 years. RTAs occurred most ofen on city roads (89.83%). Conclusion: This leads us to conclude that a comprehensive safety system is needed that are premised on the idea of community-based awareness of trafc rules and safety regulatons. Resources are limited so there is a need to harness local resources including the local community. More eforts are needed to improve road safety educaton among the youth/ integrate safety into road design.

Key Words: Road trafc accidents, private vehicles, alcohol

Introducton buses and trucks were involved in a high proportion of crashes due to both a lack of safety standards and failure A road traffc accident (RTA) is defned as accident to adhere to existing ones [6]. which takes place on the road between two or more objects, one of which must be any kind of a moving motor In South Sudan, and particularly in Juba, which is vehicle. These accidents are among the leading causes of one of the fastest growing cities in the region with an death in many parts of the world resulting in economic estimated population of over one million, RTAs are a loss due to disability [1]. It is estimated that 3000 people major cause of deaths and disabilities [7]; because they die and 30,000 are seriously injured in the world every affect mainly younger people they contribute to the poor day with the majority of casualties coming from middle- economic development in the country. The long civil war income countries [2]. The issue of RTAs has become a has resulted in Juba’s infrastructure not being developed, great concern among the citizens of Juba city. so roads are very poor. The national parliament of South Sudan passed the In Africa, Nigeria has the highest rate of RTAs; with Road Traffc bill in 2011. However, there remains a lack accidents increasing by 43% and deaths by 110% between of awareness and enforcement of these traffc rules and 1977 and 1983 [3]. Similar trends have been reported in regulations. It is likely that poor availability/accessibility East Africa. Road traffc related fatalities in Kenya increased of public transport has resulted in an increased number by 578% and nonfatal causalities by 506% between 1962 of motorists, and subsequently, more RTAs. Although and 1992 [4]. In Tanzania RTAs accounted for 56% of Juba City Council has installed traffc lights at major all patients admitted to Muhimbili Medical Centre due to roundabouts, yet RTAs still occur. This is due to the fact injuries [4]. One of the contributing factors is the “road that drivers are not familiar with the road signs, in other user factor” (i.e. the human factor that signifes the driver words lack of road safety education remains a challenge. who is driving the vehicle or pedestrian who is using the road). In developing countries, including those in Africa, Method human factors are responsible for the most RTAs. These The study used a cross-sectional approach in which include road conditions (construction, surface, wet or data of RTAs from January 2014 to August 2015 were dry), obstacles (e.g. debris on the road) and the landscape collected. Microsoft Excel software version 2.0 was used near the road [5]. A study in Dar-es-Salam showed that to analyze the data.

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Table 1. Distributon of drivers by type of vehicle and driver’s conditon Driving under no infuence Driving under infuence of Vehicle Type Total of alcohol alcohol n % n % n % Private car 631 36.6 7 0.4 638 37.0 Pick up 53 3.1 0 0.0 53 3.1 Taxi 6 0.4 0 0.0 6 0.4 Toyota Hiace 149 8.6 1 0.1 150 8.7 Lorry 117 6.8 0 0.0 117 6.8 Bus 40 2.3 0 0.0 40 2.3 Heavy Truck 7 0.4 0 0.0 7 0.4 Motor cycle 462 26.8 0 0.0 462 26.8 Dafar (5 ton lorry) 13 0.8 0 0.0 13 0.8 Government land cruiser 111 6.4 1 0.1 112 6.5 Diplomatc vehicle 55 3.2 1 0.1 56 3.3 Trucks 71 4.1 0 0.0 71 4.1 Total 1,715 99.4 10 0.6 1,725 100.00

The study examined all the accidents that occurred in Discussion Juba collected from the State Directorate of Traffc Police Our results appear to suggest that RTAs in Juba are and Juba Teaching Hospital. Identifers were removed to caused by other factors than the infuence of alcohol on ensure confdentiality. drivers. In the vast majority of cases (99.5%) the drivers Results were not under the infuence of alcohol. The drivers of From a total of 3,214 RTAs cases identifed, 1,725 private vehicles had the highest number of accidents. drivers involved in RTAs including 72 fatalities were Motorcyclists accounted for a quarter of RTAs in our study analyzed after data cleaning. Fatalities were assessed - the second highest number compared to private cars. In through death certifcates from medical records. Table 1 a similar study in Kampala, Uganda, the highest number shows the distribution of drivers by type of vehicle and of RTAs was caused by motor cyclists [7]. Another study driver’s condition. conducted in Rwanda found that motorcycles accounted for about 14.5% of all RTAs [8]. The reason for this could Alcohol was not involved in 99.42% of cases. Of these be due to the poor training and easy access to the use of the highest proportion (36.58%) of RTAs was caused cars and motor cycles by individuals who might not have by drivers of private vehicles followed by motorcyclists a driving license. Few government vehicles (1%) were (26.78%). Taxi drivers caused the lowest proportion involved in RTAs; this could be explained by the restricted of RTAs. Of the 10 (0.58%) drivers driving under the movement of government vehicles at specifc times during infuence of alcohol (measured by a breathalyzer), seven the day, and the requirement for a driving license before (0.41%) were drivers of private vehicles. drivers were employed. The study found that the highest number of drivers Age appears to affect the incident of RTAs. The was aged 21-30 years followed by those aged 11 – 20 highest number of RTAs was among drivers aged 21-30 years, with the least number among those aged above 50 years (46.2%). This agrees to a similar fnding in South years. The average age was 34.5 years. India [9,10]. The age group of drivers with the highest The highest number of cases was recorded in August number of RTAs in Dar-es-Salaam, Tanzania was 15- with 189 (11%) and the least in January with 94 (5%) 44 years [11], and in Kampala, Uganda was 21-30 years cases (Figure 1). [12]. These fnding suggest that people of working age are most likely to be involved in RTAs, resulting in serious In the study males were by far the greatest number economic loss to the community. (99%) of cases than females. The highest number of RTAs was observed in August RTAs occurred most often on city roads (89.83%) (11%). In this month there is more frequent rainfall compared with 10.17% on highways. which is known to compromise road safety. The lowest

South Sudan Medical Journal 38 Vol 10. No 2. May 2017 ORIGINAL RESEARCH number was reported in January, likely due to the dry season and reduction of the population immediately after the December 2013 crisis. After the eruption of fghting in December 2013, many people left Juba. This impacted the number of vehicles on Juba city roads. Further study is required on the impact of season in relation to RTA. Most accidents occurred on city roads compared to highways or roads outside of the city. In our study male drivers were involved in the highest number of RTAs (99%) compared to female drivers (1%), perhaps because there are simply more male than female drivers. Conclusion Figure 1. Number of RTAs per month This leads us to conclude that a comprehensive safety system is needed that are premised on the idea of community-based awareness of traffc rules and safety 6. Mbaruku GMD. Motor traffc accidents in Dar es- regulations. Resources are limited so there is a need to Salam their effect on mortality, Dar-es-Salam Medical harness local resources including the local community. It Journal. 1980; 8: 16-20. is recommended that more efforts are needed to improve 7. Lado DK. Trauma, a new cause of death, disability and road safety education among the youth/integrate safety economic loss in Juba. South Sudan Medical Journal into road design. 2011. http://www.southsudanmedicaljournal.com/ archive/may-2011/trauma-a-new-cause-of-death- References disability-and-economic-loss-in-juba.html 1. Norman LG. Road traffc accidents, epidemiology, 8. Kigera JWM. Patterns of Injuries after Road Traffc control and prevention, 1962. WHO Geneva. Crashes, January 2010 Vol. 5 Annals of African Surgery 2. Worley H. Road traffc accidents increase dramatically Kampala, Uganda worldwide, 2006. Population Reference Bureau 9. Patel A, Krebs E, Andrade L, Rulisa S, Vissoci, Staton http://www.prb.org/Publications/Articles/2006/ CA. The epidemiology of road traffc injury hotspots RoadTraffcAccidentsIncreaseDramaticallyWorldwide in Kigali Rwanda from police data. BMC Public Health .aspx BMC series – open, inclusive and trusted 2016; 16:697 3. Atubi AO. Determinants of road traffc accidents 10. Bhandari A and Saha AL. Road Accident and emergent occurrences in Lagos State: Some lessons for Nigeria, problem in Calcutta. Journal of the Indian Medical International Journal of Humanities and Social Science. Association 53:588-592, (1969). 2012; 2 (6) [Special Issue – March] 256. http://www. ijhssnet.com/journals/Vol_2_No_6_Special_Issue_ 11. World Health Organization. Manual of the International March_2012/23.pdf classifcation of Diseases, injuries and causes of Death, 10th ed. Geneva: World Health Organization. 4. National Road Safety Council of Kenya. Accidents statistics, Nairobi: Ministry for Public works, 12. Zimmerman K. et al. Road accidents analysis and Government of Kenya, 1983 – 1990, 1992. prevention: retrieved from www.elsevier.com/locate/ aap. 2011. 5. Filani and Gbadamosi. Identifcation of cycles and periodic oscillation of road traffc accidents over 13. Moshiro C, Mswia R, Alberti K., Whiting D, Unwin N, Lagos State, Nigeria. 2007; 2 (24) http://www. Setel P. The Importance of Injury as a Cause of Death ijhssnet.com/journals/Vol_2_No_24_Special_Issue_ in Sub-Saharan Africa: Results of a Community-Based December_2012/35.pdf Study in Tanzania. Public Health. 2000;115:96–102.

Thanks to everyone who contributed to this issue especially John Acres, Nyakomi Adwok, Brendan Affey, Peter Jones, Nancy McKeith and Simon Taylor-Robinson.

Vol 10. No 2. May 2017 39 South Sudan Medical Journal MAIN ARTICLE

How to interpret liver function tests

Christna Levick Translatonal Gastroenterology Unit, University of Oxford, UK

Correspondence: Christna Levick [email protected]

Careful interpretaton of liver functon tests within the clinical context can help elucidate the cause and severity of the underlying pathology. Predominantly raised alkaline phosphatase represents the cholestatc patern of biliary pathology, whilst predominantly raised alanine aminotransferase and aspartate aminotransferase represent the hepatocellular patern of hepatocellular pathology. The severity of liver dysfuncton or biliary obstructon is refected in the bilirubin level and the degree of liver synthetc functon can also be indicated by the albumin level. Beyond the liver functon tests, prothrombin tme provides another marker of liver synthetc functon and a low platelet count suggests portal hypertension. Key words: Liver functon test, cholestatc patern, hepatocellular patern, liver synthetc functon.

Introducton times greater than their upper limit of normal (ULN) can Derangement of liver function tests (LFTs) is a be more informative than the absolute values. common problem that can be diffcult to interpret. The When ALP is raised more times its ULN than either clinical context is an important guide, but liver disease can ALT or AST, this suggests a cholestatic pattern indicating be asymptomatic until the late stages and abnormal blood biliary pathology. In the acute setting, a cholestatic pattern tests may be the frst indication of disease. This review of LFTs is seen with bile stones, when accompanied will guide you through the individual LFT’s and how to by colicky right upper quadrant pain or in cholestatic interpret them. drug-induced liver injury when there is a history of a What are the LFTs? new causative medication. A more chronic presentation may be due to pancreatic, liver or bile duct tumours or LFTs include liver enzymes, albumin and other cholestatic autoimmune liver disease such as primary proteins, and bilirubin. The liver enzymes are produced biliary cholangitis or primary sclerosing cholangitis. by cells within the liver. They include alkaline phosphatase (ALP), γ–glutamyl transpedtidase (GGT), alanine ALP is also produced outside the liver by organs such aminotransferase (ALT) and aspartate aminotransferase as bone, placenta, kidneys and gut. Hence ALP may (AST), but the combination of liver enzyme results you be raised in the presence of normal liver health, most receive depends on your local laboratory. The protein commonly due to bone disease or pregnancy. A raised components comprise total protein, albumin and GGT and/or other abnormalities in the LFTs would globulin [N.B. Total protein = Albumin + Globulins]. indicate a liver source of raised ALP. The ALP isoenzyme The globulins are a mixture of globular proteins such can also help differentiate a liver versus bone origin. If all as immunoglobulins, enzymes, carrier proteins and other liver tests are normal, raised calcium or phosphorus complement. levels may also indicate a bone source. The LFT’s refect a limited range of hepatic metabolic GGT is induced by alcohol and other drugs and so processes. Bilirubin is an indication of the detoxifcation/ lacks specifcity for many liver diseases, except in the excretory function and albumin refects the synthetic context of ALP. function. ALT and AST are produced mostly by hepatocytes. Typical normal ranges for LFTs and other blood tests However, ALT occurs at low concentrations in skeletal are shown in Table 1, but may vary according to your muscle and kidney, and AST is found in kidney, heart, local laboratory. brain, red blood cells and skeletal muscle [1]. Abnormalities in ALT and AST are fairly specifc to the liver however. Liver enzymes When ALT or AST are raised more times their ULN The liver enzymes are in two main groups – ALP and than ALP, this is described as a hepatocellular pattern. GGT, produced predominantly by the bile ducts; and This state refects disease processes affecting hepatocytes ALT and AST, produced predominantly by hepatocytes. such as viral hepatitis, metabolic liver diseases, drug or Liver enzymes are a poor refector of liver function, but alcohol toxicity and autoimmune hepatitis. Abnormalities rather of cholestasis and liver cell integrity, respectively [1]. in these liver enzymes are generally considered mild if Liver enzymes have different normal ranges, so <5 times the ULN, moderate if 5-10 times the ULN or assessment of their relative abnormalities by number of marked if >10 times the ULN.

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Bilirubin Table 1. Normal values for blood tests Bilirubin is the product of haemoglobin breakdown. Component Abbreviaton Normal range Lipid-soluble, unconjugated bilirubin is conjugated in the Bilirubin Bili <21 µmol/l liver, making it water-soluble, and then excreted into bile. Alkaline phosphatase ALP 30-130 IU/l When a raised bilirubin or clinical jaundice is found we should consider haemolysis (production of unconjugated γ –glutamyl transpedtdase GGT 11-55 IU/l bilirubin), liver cell function (conjugation and excretion Alanine aminotransferase ALT 15-45 IU/l of bilirubin) and biliary tree function (excretion of bile). Aspartate A raised bilirubin level is a strong indicator of underlying AST 15-42 IU/l aminotransferase pathology and should always be investigated with a careful Albumin Alb 35-50 g/l clinical history and appropriate investigations. A liver ultrasound is usually necessary. Globulin Glob 20-40 g/l In haemolysis, red cell rupture releases free Total protein TP 60-80 g/l haemoglobin, raising blood levels of unconjugated Haemoglobin Hb 135-185 g/l bilirubin. The diagnosis of haemolysis may be supported by reduced haemoglobin, reduced haptoglobins, increased Mean cell volume MCV 78-100 f reticulocyte count and an abnormal blood flm, whilst White cell count WCC 4-11 x109/l other LFTs and liver ultrasound are normal. 140-400 Platelets Plts Unconjugated bilirubin is also raised in Gilbert’s x109/l syndrome, a benign, inherited disease. Patients are well Prothrombin tme PT 9-12 s in Gilbert’s syndrome, but their bilirubin levels may rise particularly during inter-current illnesses, whilst other Internatonal normalized INR 0.9-1.2 liver tests and liver ultrasound remain normal. Gilbert’s rato syndrome can be diagnosed clinically. Urea Urea 2.5-7.8 mg/dl In liver cell or biliary pathology with a raised bilirubin, 60-110 Creatnine Creat a hepatocellular or cholestatic liver enzyme pattern is µmol/l often present and possible abnormalities in liver synthetic C-reactve protein CRP <5 mg/l function. Consideration of these other LFTs, the clinical history and a liver ultrasound to look for biliary obstruction, liver lesions or liver parenchymal change are In alcoholic hepatitis, an ALT over 300 IU/l is rare, but useful. increased AST/ALT ratio is often observed. In contrast, Unlike the liver enzymes, the bilirubin can be a useful the AST/ALT ratio is low in non-alcoholic steatohepatitis marker of liver function, as bilirubin rises with increasing [2], often accompanied by a modestly elevated GGT. severity of liver disease. Bilirubin has been incorporated Although there are many differential diagnoses for mild into a number of composite scores, which assess liver to modest elevations in ALT or AST, marked elevations disease severity including the Child Pugh [3] and model are usually only caused by acute drug-induced liver for end-stage liver disease (MELD) scores [4]. injury, viral hepatitis or ischaemic liver injury. Detailed Albumin history for drug and toxin exposure, viral hepatitis risk factors and inter-current illness resulting in hypotension Albumin is a protein synthesized exclusively in the should be taken. The patient should also be monitored for liver. As such it is a marker of liver synthetic function and fulminant liver failure. liver health. The half-life of albumin is 20 days and so a low albumin may be seen in chronic or sub-acute liver In reality, the pattern of LFTs may not be clear-cut disease, but may not be observed in acute liver injury [1]. and an apparently hepatocellular pattern can refect an Albumin levels can be reduced by many kinds of illnesses acute cholestatic cause such as biliary stones. Typically, and so has relatively low specifcity as a marker of liver the raised ALT or AST in this situation resolves quickly function. None-the-less a low albumin has prognostic once the obstruction is relieved. Clinical context and signifcance and forms part of the Child Pugh score. further assessments are therefore needed to help make the diagnosis. Other assessments of the liver functon The timing of liver enzyme abnormalities may The LFTs are not the only blood tests indicating liver differentiate acute from chronic liver disease, but note function. In particular the prothrombin time (PT) or that in the chronic setting, signifcant liver damage such as international normalised ratio (INR), and platelet count cirrhosis can exist with normal liver enzyme levels. Raised contribute to a more comprehensive assessment. liver enzymes are not a reliable screening test for cirrhosis. The PT is governed by the activity of clotting factors,

Vol 10. No 2. May 2017 41 South Sudan Medical Journal MAIN ARTICLE

Table 2. Chronic liver disease screen amongst others, so careful history and assessment of liver disease risk factors are still vital. Etology Investgaton In the acute setting, hepatitis A, hepatitis E, Epstein- Biliary obstructon, tumours Barr virus, cytomegalovirus, human immunodefciency Abdominal US and frank cirrhosis virus and stool examination for schistosomiasis ova may Viral hepatts Hepatts B and C serology also be considered. Autoimmune hepatts Liver autoimmune profle Simple non-invasive scores of liver fbrosis Haemochromatosis Ferritn Although the simple presence of raised liver enzyme levels is not a reliable way of diagnosing cirrhosis, liver Hepatocellular carcinoma α-fetoprotein function blood tests can be used in combination to Wilson’s disease Caeruloplasmin predict the presence of liver fbrosis. Detailed description α 1- anttrypsin defciency α1 - anttrypsin and discussion of these scores is beyond the scope of this article, but commonly used scores include the AST/ALT ratio [6], AST to platelet ratio index (APRI) [7], fbrosis 4 (FIB-4) [8] and NAFLD fbrosis risk score [9]. The which are produced by the liver and have a half-life of World Health Organisation recommends the use of APRI about one day [1]. The production of these clotting or FIB-4 scores for the assessment of chronic hepatitis C factors is dependent on adequate vitamin K and so clotting related liver fbrosis to aid decision-making on hepatitis C may also be prolonged by vitamin K defciency. In the treatment allocation [10]. absence of vitamin K defciency or anticoagulants (e.g. warfarin), PT is a good marker of liver function in both Summary acute and chronic settings. The international normalized Deranged LFTs are a common problem and their ratio (INR) also refects clotting and liver synthetic interpretation is complicated by the production of liver function in the same way and unlike PT, is standardised enzymes from multiple organs and the lack of specifcity across laboratories. Liver function must be quite severely for markers of liver function. Therefore it is important to impaired to affect PT or INR and so mild liver disease or interpret liver tests within the clinical context. Raised ALP a state of compensated cirrhosis will likely have normal refects biliary tree injury and cholestasis, whereas raised values. The PT and INR form part of the Child Pugh and AST and ALT levels usually refect hepatocyte injury. MELD scores, respectively. Raised bilirubin and low albumin are the LFT components Importantly, the liver makes both clotting and that can refect impaired liver function, whilst raised PT fbrinolytic products and so it should not be assumed that or INR also provide a marker of liver synthetic function. a raised PT indicates a hypocoagulable state in the context A low platelet count may be seen in cirrhosis and signify of liver disease. the onset of portal hypertension. Cirrhosis can cause increased pressure in the portal References vein that carries blood from the gut and the spleen to 1. Giannini EG, Testa R, Savarino V. Liver enzyme the liver. This is called portal hypertension. When this alteration: a guide for clinicians, CMAJ 2005; develops, the spleen becomes engorged with blood and 172(3):367-79. consumes platelets. A low platelet count is a marker of 2. Sorbi D, Boynton J, Lindor KD, The ratio of aspartate portal hypertension [5] and may be the frst indicator of aminotransferase to alanine aminotransferase: potential chronic liver disease. Portal hypertension causes many of value in differentiating nonalcoholic steatohepatitis the complications of chronic liver disease such as variceal from alcoholic liver disease, Am J Gastroenterol 1999; bleeds, ascites and hepatic encephalopathy and so the 94(4):1018-22. fnding of a low platelet count in this context is a poor 3. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, prognostic sign. Williams R. Transection of the oesophagus for bleeding The underlying etology oesophageal varices, Br J Surg 1973; 60(8):646-9. Despite meticulous interpretation of the LFTs, the 4. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, underlying cause of liver disease may still not be apparent. etal. A model to predict survival in patients with end- When presented with a patient with liver test abnormalities stage liver disease, Hepatology 2001; 33(2): 464-70. or a clinical suspicion of chronic liver disease, it is often 5. de Franchis R, Baveno VIF Expanding consensus in necessary to perform a liver screen. Detailed discussion of portal hypertension: Report of the Baveno VI Consensus the liver screen is beyond the context of this article, but is Workshop: Stratifying risk and individualizing care for summarised in Table 2. The liver screen does not contain portal hypertension, J Hepatol 2015; 63(3):743-52. specifc tests for alcohol-related liver disease, non-alcoholic fatty liver disease (NAFLD) or drug-induced liver injury 6. Williams AL, Hoofnagle JH. Ratio of serum aspartate

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to alanine aminotransferase in chronic hepatitis. 9. Angulo P, Hui JM, Marchesini G, etal. The NAFLD Relationship to cirrhosis, Gastroenterology 1988; fbrosis score: a noninvasive system that identifes liver 95(3):734-9. fbrosis in patients with NAFLD, Hepatology 2007; 7. Wai CT, Greenson JK, R.J. Fontana RJ. etal. A simple 45(4):846-54. noninvasive index can predict both signifcant fbrosis 10. World Health Organization. Guidelines for the and cirrhosis in patients with chronic hepatitis C, Screening, Care and Treatment of Persons with Hepatology 2003; 38(2):518-26. Hepatitis C Infection, Guidelines for the Screening, 8. Vallet-Pichard A, Mallet V, Nalpas B etal. FIB-4: an Care and Treatment of Persons with Hepatitis C inexpensive and accurate marker of fbrosis in HCV Infection, Geneva, 2014. infection. comparison with liver biopsy and fbrotest, Hepatology 2007; 46(1):32-6.

Quiz on Liver Functon Tests (see the artcle on page 40)

Test your knowledge and fnd the best matches between the A B C D E F following statements and the blood Bilirubin (µmol/l) 12 45 63 34 41 15 test results in the table. See page 47 Alkaline phosphatase for the answers. 199 338 371 173 49 56 (IU/l) γ–glutamyl 37 182 451 175 31 39 1. A 30-year old female presents transpedtdase (IU/l) to clinic with fevers, vomitng, Alanine lethargy and myalgia for 1 week. aminotransferase 18 63 1976 55 16 31 There is a mild contnuous right (IU/l) upper quadrant ache. She takes no medicatons or alcohol. Two of her Aspartate aminotransferase 21 63 1883 89 17 34 family members have also been (IU/l) similarly unwell. Albumin (g/l) 35 41 37 22 40 38 2. A 51-year old male presents with tense abdominal distension. He Globulin (g/l) 24 20 27 23 29 20 drinks 80 units of alcohol per week. Total protein (g/l) 59 61 64 45 69 58 3. A 76-year old male with known Haemoglobin (g/l) 136 149 138 115 81 141 prostate cancer presents with back Mean cell volume (f) 98 97 94 108 105 95 pain. White cell countTable 1. Age and parity of 100 patents 5.1 8.0 10.0 4.3 5.0 3.9 4. A 16-year old male presents with (x109/l) lethargy and breathlessness. Platelets (x109/l) 299 307 400 86 249 237 5. A 41-year old female with biopsy- Prothrombin tme (s) 11 10 12 15 11 10 proven HCV cirrhosis who had Internatonal successful HCV treatment 2 years 1.0 1.0 1.1 1.4 1.0 0.9 normalized rato ago. Urea (mg/dl) 6.5 5.9 6.4 2.0 3.5 3.8 6. A 40-year old female presents with 2 days of colicky right upper Creatnine (µmol/l) 127 109 97 49 67 57 C-reactve protein quadrant pain and nausea. 5 9 30 2 3 1 (mg/l)

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News on Funding for South Sudanese Doctors & others undertaking Postgraduate Studies

The Committee of the Gordon Memorial College Trust of Medicine in Obstetrics and Gynaecology - Fund (GMCTF) met in London on Tuesday 28th March Mbarara University of Science and Technology 2017 and awarded grants to eight South Sudanese 6. Taban, Dr. Moses Kenyi - Master of Medicine doctors undertaking postgraduate studies at Master of in Obstetrics and Gynaecology - Makerere Medicine (MMed) level in various specialities. The grants, University of varying size, will help these doctors meet fees and some subsistence costs. GMCTF At the same meeting funds provided by the Juba Link Executive Committee were distributed to a further 1. Koma, Dr. Akim - Master of Medicine in six deserving South Sudanese postgraduates to support General Surgery - Uganda Martyrs University their studies in the last year of their respective MMed 2. Natana, Dr. Gift - Master of Dentistry in Oral programmes in various universities in Uganda. All those and Maxilofacial Surgery - Muhimbili University, who received the grants had made explicit commitments Tanzania to the GMCTF committee (and the Juba Link) that on completing their studies they will return to South Sudan 3. Malik, Dr. Morbe - Clinical MD Otolaryngology to help in the development of health services there, and to - Cairo University deliver much-needed care. 4. Zachariah, Dr. Denis - Master Degree in Both sets of grants were awarded on merit using Paediatrics and Child Health - Aga Khan clearly predefned criteria. At present, most South University, Nairobi Sudanese recipients of grants from the GMCTF are 5. Deng, Dr. Amira - Master of Medicine Internal studying medicine, but the GMCTF also supports Medicine - Muhimbili University, Tanzania applicants from Sudan and South Sudan, and from other professional backgrounds, provided the skills they acquire 6. Ngoth, Dr. Deng Atwan Ater - Master of will contribute to developing Sudan and South Sudan. Medicine in General Surgery - Makerere Applications for the next round of GMCTF grants will University - open in early 2018 on the website at www.gmctf.org. 7. Morgan, Emmanuel Denis - Master of Medicine Individuals or institutions who would like to offer in Pathology - Makerere University donations to support the work of GMCTF should contact 8. Akol, Dr. Olang - General surgery - St. Paul’s the Secretary through the address on the website. Hospital, Addis Ababa, Ethiopia Those awarded grants from either the GMCTF or the The process is a competitive one: a further 6 applicants Juba Link are: were shortlisted, but their applications were not deemed suffciently strong to be funded; 36 doctors seeking Juba Link support for further studies did not reach the short list. Those applying are encouraged to pay close attention 1. Gel, Dr. Gawar Isaac Daian - Master of to the guidance notes for applicants which are available Medicine in Paediatrics and Child Health - through the website, and to provide the information Makerere University requested clearly and in the form requested. 2. Loro, Dr. Jada Francis - Master of Medicine in General Surgery - Makerere University Dr. Eluzai A Hakim, FRCP, FRCP Edin 3. Aputu, Dr. Viola Mark - Master in Diagnostic Radiology - Makerere University Medical Adviser and Vice Chairman Juba Link 4. Lumori, Dr. Boniface Amanee Elias - Master Member GMCTF Committee of Internal Medicine - Mbarara University of Honorary International Adviser to the Royal College Science and Technology of Physicians London on South Sudan 5. Kuany, Dr. Anthony Manyang Deng - Master

South Sudan Medical Journal 44 Vol 10. No 2. May 2017 SHORT ITEMS

Hello and Goodbye . . .

SSMJ is delighted to welcome: • Dr. Charles Ochero Cornelio Langoya, MBBS, MSc(TMID), MSc(Internal Medicine), MPH, PGDipHIV, HCMTC, MRCP (UK) who has been appointed to the Editorial Board. Charles is from South Sudan and is presently subspecialist registrar in clinical haematology at St James University Hospital, Leeds, UK. Charles was a core medical trainee through the Medical Training Initiative (MTI) of the Royal College of Physicians and has, after just 2 years, obtained his membership (MRCP-UK). • Gore Laku Loro, a South Sudanese IT expert living in Cambridge, UK, who has accepted to support us in managing and uploading content on SSMJ. Gore will eventually take over from Rob Flooks who will be leaving SSMJ due to other work commitments. Rob has uploaded all the issues of SSMJ onto the website over the past 9 years Dr. Charles Ochero Cornelio Langoya – so many thanks to you, Rob. • And the following who are helping to edit, proofread and/or review articles: Dr Nyakomi Adwok (Foundation year 1 trainee in West Yorkshire, UK), Peter Jones (Community Mental Health Nurse NHS, West Lancashire, UK), Dr Constantine S.L. Loum (Senior Lecturer, Faculty of Medicine, Gulu University, Uganda), Christine Ro (managing editor of another journal and freelance journalist, UK), Mitesh Shrestha (Researcher at Research Institute for Bioscience and Biotechnology, Kathmandu, Nepal), and Dr Grace Juan Soma (Registrar in Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya). Thanks to AuthorAid and HIFA who helped to locate some of these people. The Small Baby Series

The Small Baby Series are 27 short teaching videos demonstrate life-saving practices such as how to keep premature babies warm with skin-to-skin care, and how to feed them with a cup or feeding tube before they’re strong enough to breastfeed. The series also includes fve videos designed specifcally for mothers to demystify the needs of premature infants and help them care for their babies both in the hospital and at home. The series was flmed in Bangladesh, Uganda, and Nepal. Working in partnership with the American Academy of Pediatrics (AAP), we developed the content to complement their Essential Care for Small Babies training program based on the latest WHO guidelines. Newborn experts from AAP and WHO reviewed the videos to ensure they demonstrate international best practices. For example, watch: • Providing essential care at birth • Breastfeeding the small baby • Keeping the small baby warm The Global Health Media Project welcomes your feedback and would appreciate hearing your stories about how these videos help your training, practice, or care. The Small Baby Series is one of the series of videos under the Global Health Media – others cover Newborns, Child Birth, Breastfeeding and Cholera.The Small Baby Series was funded by the Laerdal Foundation and many individual and family donors from the Mad River Valley in Vermont, and beyond.

Vol 10. No 2. May 2017 45 South Sudan Medical Journal SHORT ITEMS

Care Groups in Emergencies in Unity State, South Sudan

Summary of an article in Field Exchange #54 February 2017 by Peter Ndungu and Julie Tanaka of Samaritan’s Purse – see http://www.ennonline.net/fex/54/ The Care Group model [1] emergenciesinsouthsudan The Programme Coordinator and Programme Supervisors train Promoters who train Leader Mothers who are formed Care Groups aim to promote behaviour change in into Care Groups. Leader Mothers then train women order improve infant and young child feeding (IYCF) (selected from lists from community leaders) usually in and are usually one component (together with feeding Neighbourhood Groups containing a set number of 10 programmes, food security and WASH interventions, -15 women. A Care Group project typically lasts 3-5 years. etc.) in nutrition and health interventions. This summary describes the adaption of the Care Group model in an acute emergency situation in Unity State. met minimum dietary diversity requirements, 28% met The county in Unity State where this Care Group minimum meal frequency standards, 26% had a minimum project was implemented has a transient population – the acceptable diet; and only 35% of infants were exclusively people are nomadic agro-pastoralists with fshing being breastfed with a majority receiving breastmilk along with part of people’s livelihoods. It is one of the most affected other liquids, including water and yogurt (Table 1). counties in the present confict with massive loss of life, Focus group discussions revealed local myths about babies destruction of property and infrastructure, and population needing oil and water for digestion before six months of movement. Most men are engaged in military activities, age, gaps in knowledge around a woman’s breastmilk with women acting as head of the household. This has supply, cultural beliefs around what constituted proper increased women’s workloads and energy expenditure, ‘children’s food’, and issues with women’s time and which in turn has increased their risk of malnutrition. workload that made breastfeeding and responsive feeding This also reduces the time they spend feeding and caring diffcult. for their children, which increases children’s risk of The Care Group project thus aimed to promote malnutrition. optimal IYCF practices to women of reproductive age In March 2014 an Initial Rapid Needs Assessment with the women’s mothers and mothers-in-law being indicated the need to promote good IYCF practices. It involved during home visits. The topics covered were: revealed that many believed that mothers could not timely initiation of breastfeeding; exclusive breastfeeding produce enough breastmilk because they did not have for the frst six months; complementary feeding after six enough food. Children as young as four months old months with soft foods and gradual increasing of amounts were being given undiluted animal milk to supplement and density with age; continued breastfeeding up to two breastmilk. Lack of staple foods meant there was years; adequate feeding with breastfeeding/meal frequency inadequate complementary feeding. three to four times a day; and a balanced diet for children. So, in December 2015, Samaritan’s Purse started By the end of the year the project had: a Care Group project in fve payams in Unity State. • Trained 320 Leader Mothers who had reached However a few months before this began, fghting in the 3,832 women. county escalated. Many people were killed, others fed into the swamps living there for weeks and even months, • Conducted two cooking demonstrations for the drinking dirty water and eating wild foods such as lily Leader Mothers on topics including hygienic pods. It was decided to proceed with the planned project handling, preparation and benefts of foods for but adapt it to the emergency context, particularly the nutrition. increased transience of the population, and the funding • Carried out 400 supervisory contacts by Promoters (from U.S. Offce of Foreign Disaster Assistance) being to ensure correct messages were given to the limited to one year. Neighbourhood Groups. A Knowledge, Attitudes and Practice (KAP) survey The endline KAP survey of 470 0-23-month old children of 1,132 caregivers provided a baseline of IYCF practices showed improvement of key WHO IYCF indicators and showed that only 19% of the children sampled (Table 1).

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SMART surveys on 6-59 month-old children carried Table 1. Improvement of key WHO IYCF indicators out at baseline (n=430) and endline (n=432) showed a deterioration in acute malnutrition with the prevalence Indicator Baseline Endline of global acute malnutrition (GAM) increasing from Timely initaton of 75% 85% 16.1% (already above the WHO emergency threshold) breasteeding to 19.6% and of severe acute malnutrition (SAM) from Exclusive breasteeding for frst 2.4% to 3.6%. Although the security situation stabilised 35% 74% during the year, a disrupted planting season and fooding 6 months continued to plague the county, perpetuating a tenuous Minimum dietary diversity 19% 59% food security situation. Minimum meal frequency 28% 58% The project in Unity State showed the Care Group model can be adapted for acute emergency situations – Minimum acceptable diet 26% 33% and improve IYCF indicators. In this project: • To expedite the selection of women and because accurate lists of women were not available, For more information, contact: Julie Tanaka, Promoters went to each village and, area by area, [email protected] registered women from 11 adjoining households. These Neighbourhood Groups each appointed their own Leader Mother. This ensured that all the targeted women could participate in the project. • Transient women were able to move in or out of Reference Neighbourhood Groups, and numbers were kept 1. The Technical and Operational Performance lower than usual to accommodate this. Leader Support Program (TOPS) 2016. Care Groups: A Mothers traced displaced women and connected Reference Guide for Practitioners. Washington, them to a local Neighbourhood Group which DC: The Technical and Operational Performance meant the women, in addition to learning helpful Support Program. health and nutrition information, found a support structure that helped them in their transition.

Figure 1 Woman in Unity State demonstratng ingredients for a diversifed Figure 2 Woman in Unity State cooking her meal (credit Samaritan’s Purse, meal (credit Samaritan’s Purse, South Sudan 2016) South Sudan 2016)

Answers to Quiz (from page 43) 1C, 2D, 3A, 4E, 5F, 6B

Vol 10. No 2. May 2017 47 South Sudan Medical Journal South Sudan Medical Journal Call for Submissions

The South Sudan Medical Journal (SSMJ) is the only scientfc/medical publicaton in South Sudan at the moment and its contnuous publicaton depends on submissions of artcles for publicaton from all of you. SSMJ publishes all types of artcles: original research, reviews, survey reports/KAP studies, discussions and commentaries as well as case studies and presentatons, leters to the Editor in all felds of medicine and public health. SSMJ Editorial Team will work with potental authors to fnalize their papers in preparaton for publicaton. SSMJ is now a member of the African Journals Online (AJOL) and is peer reviewed by distnguished reviewers from around the world. Send your artcles to the Editor-in-Chief at admin@southernsudanmedicaljournal. com and we shall take care of the rest. Encourage your peers to publish with us.

Every effort has been made to ensure that the information and the drug names and doses quoted in this Journal are correct. However readers are advised to check information and doses before making prescriptions. Unless otherwise stated the doses quoted are for adults. South Sudan Medical Journal 48 Vol 10. No 2. May 2017