Tiered healthcare in South Africa exposes deficiencies in management and more patients with infectious etiology of primary adrenal insufficiency

Abstract

Objective We wished to determine the prevalence, etiology, presentation, and available management strategies for primary adrenal insufficiency (PAI) in South Africa (SA), hypothesizing a prevalence greater than the described 3.1 per million. There is great inequity in healthcare allocation, as two parallel healthcare systems exist, potentially modifying PAI patients’ clinical profiles, private being better resourced than public healthcare. Methods An online survey of physicians’ experience relating to PAI. Results The physicians were managing 811 patients, equal to a prevalence of 14.2 per million. Likely causes of PAI in public/ academic vs private settings included: AIDS-related [304 (44.8%) vs 5 (3.8%); p<0.001], tuberculosis [288 (42.5%) vs 8 (6.0%); p<0.001], autoimmune disease [50 (7.4%) vs 88 (66.2%); p<0.001], malignancy [27 (4.0%) vs 7 (5.3%); p = 0.500], genetic including adrenoleukodystrophy (ALD) [5 (0.7%) vs 16 (12.0%); p<0.001], respectively. Overall, more patients presented with nausea [101 (74.3%) and vomiting 89 (65.9%), than diarrhoea 76 (58.9%); p = 0.008 and 126 (15.5%) in adrenal crisis. Features suggestive of a crisis were hypoglycaemia [40 (78.4%) vs 42 (48.8%); p = 0.001], shock [36 (67.9%) vs 31(36.9%); p<0.001], and loss of consciousness [25 (52.1%) vs 27 (32.9%); p = 0.031]. Greater unavailability of antibody testing in the public vs. the private sector [32 (66.7%) vs 30 (32.1%); p = 0.001], [serum-ACTH 25 (52.1%) vs 16 (19.5%); p<0.001] and glucocorticoids were [26 (54.2%) vs 33 (40.2%); p = 0.015]. Many patients, 389(66.7%) were not using identification, indicating that they need steroids in an emergency. Conclusion A survey of South African physicians suggests a higher prevalence than previously reported. Patients presented with typical symptoms, and 15.5% presented in adrenal crisis. Significant disparities in the availability of physicians’ expertise, diagnostic resources, and management options were noted in the public versus private settings. Greater awareness among health practitioners to timeously diagnose PAI is required to prevent a life-threatening outcome.

Knowledge of crisis prevention strategies are highly effective, whereas vulnerability scores may elicit Addison’s disease crises

“…The majority (66%) of our cohort suffered from at least one crisis in the previous 5 years, which is considerably higher than reported by Meyer et al [6], in which there is a 5%-17% likelihood of having an AC and 6 per 100 patient years, as described by Arlt et al [7]. Explanations for this vastly increased risk in SA are not apparent, but low doctor patient ratios, competing communicable disease demands, poor allocation of health-care resources, and unmet needs, may account for this [19]. Patients living in SA are at increased vulnerability, due to their poor economic circumstances, exposure to suboptimal healthcare delivery, and widespread crime.…”

“…The prevalence of AC varies, depending on the country and in South Africa, the reported a prevalence is 15% [18]. Both a cross-sectional case nding study in South Africa and a nationwide online questionnaire, revealed a prevalence of 15% [19]. This may be under-recognised, due to a discordance in the proportion of patients with compatible symptoms, with an AC and an ultimate diagnosis of an AC.…”

Characteristics and Challenges of Primary Adrenal Insufficiency in Africa: A Review of the Literature

“…The high background population of HIV and tuberculosis in Africa may also contribute to this underdiagnosis, as symptoms of PAI may be misconstrued as being associated with these aforementioned communicable diseases [ 12 ]. In a survey of physicians managing patients with PAI in South Africa, though not designed to determine the prevalence, we inferred a prevalence of 14.2 per million [ 13 ]. This prevalence is much lower than the reported 144 per million in Western countries [ 14 ].…”

Management of adrenal insufficiency: A survey of perceptions and practices of physicians from the Middle East and North Africa

“…[22] This is particularly relevant to clinical practice in developing regions of the world, where more challenges have been observed. [13,14] The German study came from a specialized endocrine department which limits the generalizability. In contrast, our study included both endocrinologists and nonendocrinologists, giving a more representative sample of doctors whom AI patients may face at the time of stress.…”

“…[9][10][11][12] Significant barriers to diagnosis and management of AI were identified in some developing regions of the world with indicators of tiered healthcare that may expose deficiencies in management. [13,14] Therefore, we aimed to examine AI management's current knowledge and perceptions among a sample of physicians from the Middle East and North Africa (MENA) region and in various specialties. Our long-term goal is to identify critical deficiencies in AI Introduction: Treatment of adrenal insufficiency (AI) requires correct lifelong use of glucocorticoids (GCs) with early dose adjustments to cover the increased demand in stress to avoid life-threatening emergencies.…”