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Sub-Saharan Africa (SSA) carries 24% of the global disease burden but employs only 3% of the world’s health workers [1]. Unique workforce considerations exist in SSA including a paucity of skilled health professionals and fluctuant political climates [1,2]. Shazia Peer offers a balanced view of the reality faced by paediatric otolaryngologists in this region as well as the strides they have made.

 

SSA has the highest under-five mortality rates in the world [3]. Whilst there are many projects focused on infectious diseases and malnutrition, paediatric surgical conditions that constitute a large burden in low- and middle-income countries (LMIC) are not prioritised [4]. Improving children’s surgical services should be a necessary component to improving paediatric health.

A recent survey [5] of paediatric services in Africa found that, whilst basic ear and airway interventions were available, there was a deficiency in many lifesaving airway procedures. Nonetheless, the study disclosed that most of the countries surveyed had access to paediatric facilities where such subspecialist services could be established. This emphasises the need for specialist training centres of excellence to be established in SSA [2].

“In the last two years, Africa has been abuzz with many exciting paediatric ENT activities”

Notwithstanding this climate, in the last two years, Africa has been abuzz with many exciting paediatric ENT activities with the attainment of a few key milestones. Through collaborative commitments, we have seen the development of sustainable projects encompassing leadership, education and training in the subspecialty of paediatric otolaryngology.

 

 

Below are a few highlights of the activities from the continent.

A) PENTAFRICA

Having founded a Paediatric ENT Service at Harare Children’s Hospital in Zimbabwe in 2017, Dr Clemence Chidziva (University of Zimbabwe), Dr Peter J Koltai (Stanford University School of Medicine), and Professor Christopher Prescott (University of Cape Town & Red Cross Children’s Hospital), set their sights on their shared dream of a Paediatric ENT Society in Africa (PENTAFRICA).

In May 2018, The Zimbabwe Society of Otolaryngologists hosted the 1st PENTAFRICA conference. It included an airway workshop and symposium that was well-attended by ENT surgeons, and other health professionals from Africa and the wider international community. The goals of the fledgling society include sharing knowledge of ENT conditions in African children; developing training and educational programmes for otolaryngologists, paediatricians, audiologists and speech therapists as well as networking with established international paediatric ENT societies.

Perhaps more relevant to Africa, the society has committed to improving the paediatric ENT services across the continent in a way that unites and links new units with existing African units. In 2020, the second PENTAFRICA meeting will join AAENTA and form part of an expanded Kenyan ENT Society meeting. PENTAFRICA is also part of the International Working Group of Paediatric Otolaryngology (IWGPO).

 

 

Figure 1. First meeting of PENTAFRICA in May 2018.

 

B) Advances in paediatric airway services in Cape Town, South Africa

The Cape Town Paediatric Airway Team is affiliated to both the Red Cross War Memorial Children’s Hospital and Chris Barnard Memorial Hospital. Sustained ‘buy-ins’ from other paediatric subspecialty shareholders have afforded this sentinel Paediatric Airway ENT Unit in Africa to further expand. One example is the paediatric cardiothoracic surgery collaboration that has strengthened the airway reconstruction clinical service to now also include slide tracheoplasties. Another is the paediatric surgery collaborative support with regards to foetal intervention surgery.

In the last two years there have been two EXIT procedures - a first for Groote Schuur Hospital where the first operation on placental support (OOPS) tracheostomy was successfully performed for laryngeal atresia. Due to increased cross-pollination of private and public paediatric airway expertise, exposure to the subspecialty has grown, and awareness of many overlooked paediatric airway conditions increased.

 

Figure 2. The first EXIT procedure for CHAOS secondary at Groote Schuur Hospital, Cape Town, SA (Drs S Peer / J McGuire).

 

C) Paediatric ENT Fellowship in Africa

In July 2018 the University of Cape Town’s ENT department introduced the Karl Storz Paediatric ENT Fellowship. The fellowship is based on the African model successfully implemented by Professor Johan Fagan, the department’s chairman. Now in its 13th year, the head and neck fellowship boasts a 100% retention of specialists in Africa. It has led to the formation of an African Head & Neck Society and encourages ongoing networking long after completion of the fellowship. Africa-based fellowships have shown to be a good model for developing countries by making a sustainable impact on subspecialist care. Dr Wale Gellaw from Ethiopia is the first Karl Storz paediatric ENT fellow.

 

Figure 3. Dr Wale Gellaw, the first Karl Storz UCT Paediatric ENT Fellow.

 

D) International presentations and collaborations

Dr Titus Dzongodza from the University of Zimbabwe presented a collaborative paper at the European Society of Pediatric Otolaryngology (ESPO) in Stockholm, Sweden, entitled ‘Thymic lesions in the pediatric neck: a case series.’ Dr Dzongodza is also completing a paediatric ENT Fellowship at the Royal Children’s Hospital in Melbourne, Australia. In July 2019 he will join only a handful of African specialists with paediatric fellowships.

In October 2018, at the American Head & Neck Society Meeting in Atlanta, Georgia, a panel on ‘Pediatric Airway services in the limited resource setting’, was presented by Dr Shazia Peer (UCT / RCWMH, Cape Town, SA), Dr Claudia Schweigger (Hospital de Clinicas de Porto Alegre, Brazil), Dr Michael Rutter (Cincinnati Children’s Hospital, Cincinatti, USA) and Dr Kishore Sandu (CHUV, Lausanne, Switzerland). The collaborative commitment from both established experts in paediatric airway management, Dr Rutter and Dr Sandu, has been critical in advancing the progress of the Cape Town Paediatric Airway Team to new heights.

There certainly exist many opportunities for paediatric ENT surgeons from developed countries to provide much needed mentoring for training, clinical cases and clinical research to developing world units. With the introduction of PENTAFRICA, a sustainable approach to offering loco-regional and international collaborations is potentiated.

 

References

1. Mulwafu W, Ensink RJH, Kuper H, Fagan J. Survey of ENT services in sub-Saharan Africa: Little progress between 2009 and 2015. Global Health Action 2017;10(1):1289736.
2. Fagan JJ. Workforce considerations, Training, and Diseases in Africa. Otolaryngol Clin N Am 2018;51:643-9.
3. Brault MA, Ngure K, Haley CA, et al. The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013. PLoS One 2017;12(8):e0181777.
4. Butler EK, Tran TM, Nagarajan N, et al. Epidemiology of pediatric surgical needs in low-income countries. PLoS One 2017;12(3):e0170968.
5. Peer S, Vial I, Numanoglu A, Fagan J. What is the availability of services for paediatric ENT surgery and paediatric surgery in Africa? European Annals of Otorhinolaryngology, Head and Neck Diseases 2018;135(5S):S79-S83.

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CONTRIBUTOR
Shazia Peer

MBBCh, FCORL(SA), MMED(Otol), Head of Division of Otolaryngology, Red Cross Children’s Hospital, Cape Town, South Africa.

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