Assisting School Management Teams to construct their school improvement plans: an action learning approach

Geoffrey Van
School for Education Research and Engagement
Nelson Mandela Metropolitan University
South Africa

Der Voort
School for Education Research and Engagement
Nelson Mandela Metropolitan University
South Africa

Lesley Wood firstname.lastname@example.com
Faculty of Education Sciences
COMBER
North-West University
Potchefstroom Campus

Assisting School Management Teams to construct their school improvement plans: an action learning approach
C2AAD385D9973BA18ECCD02E4DC61E3EAction learningaction researchCircuit Teamschool improvement planSchool Management Team(s)school self-evaluationsystems theory approachwhole-school developmentwhole-school evaluation
This article reports on a first cycle of a larger action research study conducted to determine how Circuit Teams could support School Management Teams of underperforming high schools towards whole-school development.Although it is a mandated requirement by the Department of Education, none of the four schools involved in the study had developed a school improvement plan, a necessary first step towards whole-school development.In this article we focus on the collaborative intervention we designed to meet the identified needs of the participants regarding the construction of a school improvement plan.A qualitative baseline study revealed the School Management Teams' general disregard towards the school improvement plan as well as limited insight into what skills they needed to develop it, and their imperfect understanding of whole-school development.We explain the action research process we took to facilitate a clearer understanding of the school improvement plan and how to develop it.The data analysis revealed that the collaborative learning experience ignited feelings of empowerment, increased motivation to collaborate with the Circuit Teams towards whole-school development, and generally assisted the School Management Teams' resolve to improve the management of their respective schools.These findings present evidence that suggests the value of an action learning approach to the professional development of School Management Teams, but the process could be equally useful to encourage sustainable change in varied contexts of continued professional development.

Introduction

If planning is the primary management function that School Management Teams have to perform (Van Deventer & Kruger, 2009), how can schools progress towards whole-school development if many do not have a written plan in place to guide their continuous improvement?The plan referred to in this context is the school improvement plan.The above question is posed in the light of reports that reveal a lack of understanding on the part of School Management Teams of the significance of school improvement plans in the context of school development in South Africa, as well as their lack of capacity to design and implement such plans (Department of Education, Eastern Cape, 2009).This report indicates that School Management Teams tended to have a very laissez-faire approach to strategic planning and that even if school improvement plans did exist, they were seldom implemented.

It appears therefore that the value of a school improvement plan to develop a culture of teaching and learning (Naidu, Joubert, Mestry, Mosoge & Ngcobo, 2008) is not recognised at many underperforming schools.Schools Our aim in this first cycle of action research with the School Management Teams was thus to raise awareness around the importance of a school improvement plan for whole-school development and evaluation, and to help them to acquire the knowledge, skills and will to construct one.We selected action learning (Revans, 2011) as the process to attain this outcome as it promotes learning and capacity building, leading to improved performance.Action learning enhances continuous reflection by people working on real-life issues with the intention of getting things done, thereby placing a strong emphasis on action-tobe-taken which benefits both the individuals and the organization (McGill & Brockbank, 2004).One such a real-life issue is the development of a school improvement plan where each school sets priorities, strategies and action plans to address the particular challenges.

We first provide an overview of the theoretical framework that guided our intervention and data analysis, before explaining our research design.Thereafter we present the findings of the qualitative data analysis and discuss the significance of our findings for supporting School Management Teams towards whole-school development, as well as the significance of the action learning process for professional development in general.

A systemic approach to whole-school development

We selected systems theory to inform our understanding of whole-school development as it specifically explains the interaction needed between the various components of the education system to reach a common goal (Naidu et al., 2008).The education system is an open organisational structure, composed of different components, relations, processes and programmes which are in constant interaction with the environment (Lunenburg, 2010).

This open system consists of five basic elements: inputs, a transformation process, outputs, feedback and environment (Lunenburg, 2010).The concepts of whole-school development and the related concepts of school self-evaluation are central to the Policy on Whole-School Evaluation (Department of Education, 2001a) which is aligned with the systemic understanding of school functioning.The policy identifies a number of inputs (resources that are given to schools to execute the task of teaching and learning), processes (the ways in which the schools seek to achieve their goals) and outputs (what the schools achieve in terms of academic standards, standards of behaviour and rates of punctuality and attendance) that need to be undertaken by every school in South Africa.

However, the policy does not mention the other two elements of systems theory: feedback and environment.From a whole-school perspective we perceive this to be a serious shortcoming as it means that the policy does not take schools operating in a disadvantaged context into consideration.All schools are given the same inputs and are expected to have the same outputs, but the context in which they function is ignored.

The policy identifies nine areas of evaluation against which every public school in South Africa is evaluated (Department of Education, 2001b) (see Table 1).The same guidelines, evaluation criteria and instruments used by the accredited wholeschool evaluation supervisors can be carried out by schools to perform school self-evaluation (Department of Education, 2001a).

School self-evaluation

School self-evaluation is another important concept related to school improvement plans and forms an integral part of the whole-school evaluation process (Van der Westhuizen, 2002).Naidu et al. (2008:49) explain that school self-evaluation must also be executed to "develop a school plan…in order to grow a culture of self-improvement…" which refers to the school improvement plan.Taking the above into consideration, school self-evaluation is utilised both for the purpose of whole-school evaluation and for the development of the school improvement plan.

The school improvement plan therefore forms the basis for continuous school improvement, as well as acting as a monitoring instrument to measure progress towards specific areas of whole-school development.From our interaction with underperforming schools we are aware that these schools have to learn to improve themselves on an on-going basis.Very often they do not get the required support from the Circuit Teams in this regard (Chinsamy, 2002).

The nine areas of whole-school evaluation inform both the external whole-school evaluation process as well as the internal school self-evaluation, both of them leading to the development of the annual school improvement plan.The aim of the school improvement plan is to ensure growth, development and improvement at school level.Ngubane (2005) stresses the importance of the quality of leadership and management at school level, as well as the importance of participative management which supports the idea of school-based decision-making.To provide such leadership and sustain whole-school development, School Management Teams have to build relations of trust, honesty, communication, competence, openness, a shared vision and values, collective responsibility, reflective professional inquiry and collaboration (Owens, 2010).It is for this reason that we adopted an action learning and action research design (Zuber-Skerritt, 2009) for the study: to support the schools and to provide them with the required skills to grow a culture of self-improvement.

Methodology

Guided by a critical theory paradigm (Neuman, 2006) we wanted to involve the participants in the intervention for change, and to encourage them to take ownership of the process, as befitted our action research design (Cohen, Manion & Morrison, 2007).We found the definition by Kermis and McTaggert (1988:5) as quoted by Cohen et al. (2007:298) to be all-encompassing for our study:

"Action research is a form of collective self-enquiry by participants in social situations in order to improve the rationality and justice of their own social and educational practices, as well as their understanding of these practices and the situations in which these practices are carried out.The approach is only action research when it is collaborative."As part of a larger action research project, this first cycle was aimed at raising awareness amongst the School Management Team members of the importance of a school improvement plan and how to explore whether their own negative perceptions of it might be impeding their ability to construct and implement one.True to practical outcomes of the action learning and action research design (Zuber-Skerrit, 2009) we wanted them to be able to construct a school improvement plan and begin to identify actions to implement it.

We purposefully selected (Neuman, 2006) four underperforming high schools in a large township area in the Cape Town metropolitan area.These schools were selected on the basis that they had performed poorly, had serious management To judge whether the school can function effectively and efficiently and realise its educational and social goals.

To assess the effectiveness of the leadership and management of the school.

To assess the effectiveness of the School Governing Body in giving the school strategic direction.

To estimate the quality of teaching and the educator development.

To evaluate the quality of the curriculum and how closely it matches the needs of the pupils and any national or local requirements.A judgement also has to be made on the range and quality of other activities that enhance the curriculum.

To assess the knowledge, skills, values and attitudes that learners have acquired.

To evaluate the extent in which the school knows about legislation and implements it; to check that the school is secure and the learners are safe; to evaluate the effectiveness of the school's disciplinary procedures.

To assess to what extent the school has sufficient and appropriate staff, resources and accommodation available for its purpose.

To gauge the extent to which the school encourages parental and community involvement in the education of the learners and how it makes use of their contributions to support learners' progress.

issues, and the School Management Teams were willing to participate fully in the study.

The communities they serve are poverty-stricken and suffer from related social problems typical of many such schools in the country (Westraad, 2011).In total, four principals, eight deputy principals and 23 heads of departments participated in the research.In addition, members of the Circuit Team who supported these schools towards whole-school development also participated, in particular the Circuit Team Manager and the two Institutional Management and Governance Managers.

We generated data through participant observation (Gibson & Brown, 2009) of the interaction during the intervention, focus group interviews and individual interviews (Gillham, 2000), and the analysis of relevant departmental and school-based documents (Gibson & Brown, 2009).

During this first cycle of the action research process individual interviews were held with each of the four principals, as well as with members of the Circuit Team.Structured interviews were used at this stage to gather responses which enabled us to construct a baseline of where each of the schools and the Circuit Team were in relation to whole-school development.We prepared a specific interview schedule for the principals and another schedule for the Circuit Team members.Using structured interviews enabled us to organize the initial data easily, and facilitated the drawing of comparisons.

We also used focus group interviews to generate a wider range of responses than with individual interviews as these assisted us to gain insight into what might have been pursued in subsequent individual interviews.These were also often quicker than individual interviews and therefore more timesaving.Focus group interviews were done with the members of the School Management Teams of each of the individual four schools.In addition, we used these during and after the workshop we conducted during this cycle of the action research to obtain information on how the participants perceived the intervention, as well as for our own reflection.Semi-structured interviews were used during the focus group interviews as these allowed us to follow up on aspects that participants mentioned, and which we felt warranted further investigation and probing.

In a qualitative study such as this one, the data gathered have to be analysed, looking for themes or categories before interpreting or drawing conclusions from the data (Creswell, 2003).The eight steps identified by Tesch (1990:142-145), as stated in Creswell (2003) were used to thematically analyse the data.Trustworthiness of data was ensured by triangulation of data sources, peer briefing, member checks, avoidance of inferences and generalisations, avoiding the selective use of data, as well as independent recoding (Flick, 2006).The usual ethical considerations applicable to qualitative research (Neuman, 2006) were employed in the research study.

The action research process

The focus of action research is to empower people to change their social situation, and to raise awareness on a particular issue.Welman, Kruger and Mitchell (2005:205) describe the action research process as being "cyclical" or "spiral" as each cycle progresses through a number of steps, which we adopted as explained in Table 2.

During the fieldwork we spent time with the participants, engaging with them in their offices, staff rooms and during the workshop.Our aim was to empower them to change the underperforming situation they found themselves in so that, through their active involvement in the roll-out of the research, they could become self-managing schools.

The action research process followed during the execution of this cycle is summarised in Table 2, and outlines the processes followed in each of the five steps of the cycle.

The workshop described in step three of Table 2 was purposefully constructed in a series of sequential activities that incorporated the following principles of action learning: • Collaboration (with others towards achieving a particular goal -in this case the development of a school improvement plan) • Critical reflection (on actions taken by means of dialogue, with the aim to learn valuable lessons) • Communicative action (with others to reach a common understanding of a situation) • Co-accountability (for action to reach a common goal), and • Commitment (to a single purpose, and sharing responsibility with others) (Zuber-Skerritt, 2009;Moloi, 2005;McGill & Brockbank, 2004).

Identification of the problem

Designing the action plan Implementing the action plan

Evaluating the action Reflection and lessons learnt

Interviews were held with the four principals on the achievements of each school, the obstacles facing them, as well as their priorities for the 2012 academic year.

A follow-up session with the School Management Teams of the four schools was held on their experiences related to the development of their school improvement plans.

After liaising with the Circuit Team, it was agreed to host a workshop for the four schools to develop their school improvement plans.We began the workshop by explaining the nature and purpose of school self-evaluation to the participants.The school self-evaluation instrument, based on the areas listed in table 1, was completed.The participants worked together in smaller groups of two to three people to maximise participation.

The sub-groups of each school reported their results and discussed them with the rest of their colleagues.

Second phase of the session: each school had to identify at least one, but not more than two priorities from each of the nine areas of whole-school evaluation that they considered to be significant.They then identified a maximum of four priorities from the entire list.A template containing the following headings was given to each group to fill in: Indicate what was outstanding and therefore needed to be attended to before the end of the 2012 academic year, in order to address the specific priorities.In this way, they were guided to start identifying the required action to be taken towards addressing each of their priority areas.Group interviews were held to determine participant experiences and their perceptions of their learning.Critical reflection on the processes and data enabled us to identify a number of lessons to inform our future practice.

Discussion of findings

In this section we report on data analysis of the participants' perceptions of the learning experience.From the analysis, four distinctive themes emerged:

Theme one: The workshop was an empowering and capacity-building exercise

There was a strong indication that the School Management Team members experienced the workshop as an empowering exercise, during which they gained the required knowledge and skills to develop a school improvement plan.Their responses also indicate that this was the first time that they were exposed to such an experience, and that they began to understand the school improvement plan as a tool for school improvement.The following views were expressed by one of the deputy principals:

Now I know that the school improvement plan is intended to be a living document for the school.It also outlines the specific activities, strategies and interventions that each school has to implement to ensure academic success for all students… .It empowers me because the school improvement plan offers a strategic and integrated process with the potential to deliver sustained improvements in schools by improving the performance of teachers and learners as well.The Education Improvement Commission (2000) confirms that the school improvement plan is indeed a living document: a road map that sets out the changes a school needs to make to improve the level of learner achievement, and to indicate how and when changes need to be made.Change involves learning (Dick, 2005) and this implies some form of change at the personal level at least.The response of a head of department indicated that change also took place with regard to their professional development: The most important lesson was learning how to design an action plan.I was also exposed to the role of management in developing programmes for the school.

The quotation is evidence that participants not only learned about how to design an action plan, but also began to understand the role of the School Management Team in leading the development of the school improvement plan.

In terms of action learning, individual learning capacity must be enhanced before effective organizational change can occur (McGill & Beaty, 1995).Participation in the problemsolving process encourages deep learning to take place (Revans, 2011).

The Department of Education, Kwa-Zulu Natal (2007) lists specific aspects that School Management Teams have to undertake when developing the school improvement plan.These include: specific knowledge of the whole-school development process, and their willingness to share information in this regard with all the stakeholders involved.They also have to monitor the implementation of the school improvement plan.The fact that the participants were beginning to understand this role in the development of the school improvement plan, is a first step towards effective fulfilment of these duties.

The last aspect that emerged from the participants' responses in relation to empowerment and capacity-building was the issue of increased confidence, which is an evidence-based outcome of action learning (Moloi, 2005).One of the participants, a deputy principal, had the following remarks:

The session for me was intimidating at first as I was not prepared and not aware of what was going to be asked.As the session was going on, I became more confident to respond to the questions.Action learning promotes empowerment and self-reliance (Pedler, 2011) and also significantly elevates the self-confidence of participants (Revans, 2011).The evidence presented here suggests that our action learning approach has led to better understanding of the roles and responsibilities of School Management Teams with regard to school improvement and enhanced personal efficacy (Bandura, 1997) to begin to take on the responsibility to do this.

Research on school improvement in China (Lee & Williams, 2006) revealed that one of the greatest obstacles in school improvement is principals' lack of understanding school improvement planning.

Theme two: Interaction with School Management Team members from other schools was a powerful learning experience

The fact that the participants were provided the opportunity to display their initial school improvement plans to each other during the workshop presented the opportunity to give input and critique each others' improvement plans.This form of interaction between School Management Team members of the four schools had a very profound influence on the learning that took place.A deputy principal expressed the following views:

Meeting managers from other schools was exciting.Sitting together, discussing the individual school's challenges, I noted that these challenges were commonly the same for all schools.What makes them unique to each other is how they are addressed individually by the schools.The discussions were empowering in that they encouraged enquiries so that one does not sit with the problem alone.Assistance can be obtained if you work with other people.A foundation has been laid for the possible support from managers of other schools.This participant realised that he is not alone in having to deal with problems, and that solutions to such problems can be found through interaction with one another.Fryman, Wilson and Wyer (2000) emphasize that solutions to problems ultimately come from the people within the working environment, and that continuous improvement occurs when individuals collaborate with one another through engaging in critical questioning and reflection.

The participants realised that regular, open and honest discussion with colleagues is important to empower each other to address the barriers they are facing:

Sitting down as School Management Team members around the issues that affect our schools, showed me the seriousness around bringing solutions to these problems.I also learnt that honesty and transparency are most important when it comes to problems that surround us, in order to be helped.After these sessions I felt so empowered and able to tackle some of the problematic issues within the department.With the confidence that I gained from these brainstorming sessions I feel such kinds of sessions can be held time and again (Head of Department).It is important for colleagues to interact with one another in this way, and for them to make deliberate time and space available to engage in reflective learning (McGill & Brockbank, 2004).Our findings reveal that the novel of collective and reflective learning helped them to realise the importance of making the necessary time to get together so that they can support each other in their quest for school improvement.

International research (Townsend, 2007) found that enhancing the skills and capacities of individual school managers through setting up such learning communities is extremely beneficial for the development of school leadership.

Theme three: The participants realised the importance of reflection on management practices

In order to grow towards whole-school development, it is essential for School Management Teams to reflect constantly on the actions they have taken, the directions they have set for their institutions, and ideas for improving their management practices (Fryman, Wilson & Wyer, 2000).Reflection was an important part of participants' learning.A deputy principal made the following remarks:

We also had time to reflect on what we had already implemented since January 2012 and what still needs to be done… .I have learnt that it is important that the School Management Team members meet on a regular basis to reflect on progress with activities.This enables managers to pick up immediately if there are due dates that are not honoured and intervention strategies that can be implemented immediately.According to Moloi (2005) a learning organisation constantly reflects on its practices.Quality improvements within schools as learning organisations can only be achieved through open communication, reflection and inquiry processes that collectively contribute to school improvement.

School Management Team members should therefore allocate the necessary time and opportunity to reflect constantly on the improvements they have implemented, evaluate the effectiveness thereof to reach the intended outcome, and put the required measures in place for the following cycle of action that needs to be implemented en route towards whole-school development (McGill & Brockbank, 2004).

Theme four: Appreciation was expressed for the gradual (step-by-step) way in which the workshop was conducted Both the activities and the content that formed part of the workshop were sequentially structured to guide the participants to construct their individual school improvement plans.The action learning process allowed participants to acquire the necessary skills and knowledge to develop their plans.A head of department expressed his/her gratitude for the way in which the workshop was scaffolded:

I have learnt a lot because I was able to focus specifically on certain areas of the school improvement plan.I also learnt that I needed to look at one thing at a time, e.g.looking at three areas of development (three focus areas).

Although development is a process, I have to a certain extent been able to set achievable targets.I think I still need some time to master the process.Where possible, I would be glad if I can go through the process again.The action learning process allows for participants to learn how to learn and develop rather than just regaling them with facts and telling them what they should be doing to improve their management.The interactive cycle of action and reflection allows for deep learning to take place (Revans 2011).During the workshop all members of each School Management Team were actively involved in the school self-evaluation exercise and totally engrossed in the development of their school improvement plans.Within a workshop situation one normally finds that people wander off or do not participate actively.This was not the case with the session we facilitated.It was often difficult to stop them at the end of an activity (either to get feedback or to move on to the following leg of the process) because they continually requested more time to wrap up their discussions.Throughout the workshop we gained a very strong impression that this may have been the first time that they were afforded the opportunity to engage fully in whole-school development -our observation was later confirmed by one of the Circuit Team members:

I have not yet seen such focus and concentrated effort from these school managers.They have not yet been exposed to something of this kind before.Action learning also stresses the importance of life-long learning over once-off capacity building (Fryman, Wilson & Wyer, 2000).School Management Teams will therefore require ongoing and focused support.Since the Circuit Team members also participated in the workshop they will be better able to drive the process in the future.

What did we learn from this experience?

Our reflection on the workshop resulted in significant learning on our part that guided our next cycle of action to improve the management of these underperforming schools.

The School Management Teams reported a change in their thinking regarding whole-school development at their institutions of learning.They began to view the school improvement plan as an important mechanism towards becoming selfmanaging schools.They recognised the value of whole-school development, and could link this to the school improvement plan.In addition, they acquired the necessary skills and knowledge to successfully construct their own school improvement plans.

We are convinced that the changes in the participants' thinking were brought about by action learning.According to Revans (2011) one of the many reasons for the success of action learning is that it tackles real problems faced by the participants.They benefit from the discussions of these issues and by adapting their thinking, are able to find potentially new solutions to their problems.

It was clear that the members of the School Management Teams were willing to be active participants in implementing the strategies listed in their school improvement plans.This was evident in that fact that they agreed to take responsibility for the activities listed in the plans.In addition, the fact that they could identify action steps that they had already taken in addressing some of their priorities was proof of their commitment to turn around the situation they faced.Based on Zmuda, Kuklis and Kline's (2004) explanation of a competent system there was growing evidence that these schools began to focus on becoming self-managing institutions.

It was evident from the commencement of the workshop that the members of the School Management Teams had a clear picture of the problems that their respective schools experienced.They discussed and listed the issues on the worksheets provided to them: not for one moment did they struggle to identify problems.This reminded us of the inherent capacity of people to solve their own problems if they are just given some direction and afforded the time and opportunity to reflect on their schools' situation.Our intervention provided a platform for them to learn how to take action to improve their own schools.In addition, we were able to identify areas that we needed to improve on during the action research process.

The templates we gave the participants to work out their school improvement plans only allowed them to identify their priorities, the appropriate action plans to be undertaken, identify the person(s) responsible to lead the process and link it to a deadline.In hindsight, in order to have a more complete document, the template needed to be extended to include budgets and physical resources.

Only the members of the School Management Teams were involved in the development of the school improvement plans.Other important stakeholders, such as the administrative and teaching staff members, members of the Representative Council of Learners, School Governing Body members, as well as community leaders were at this stage left out of the picture.The National Policy on Whole-School Development (Department of Education, 2001a) emphasises the importance that all stakeholders need to be involved in school improvement.Since the School Management Teams have been capacitated to drive the process of whole-school development, they need to ensure that these stakeholders are brought on board of the process in the future.From this experience, we learnt that this aspect had to be changed during future interventions.

The participants were so preoccupied with achieving improved learner outcomes at the end of the year that the aspect of basic functionality (see table 1) did not feature as strongly in the school improvement plans as it should have.As Westraad (2011) argues, there has to be a strong focus on ensuring that the school is basically functional before attending to other areas of development.In future, we will ensure that more attention is given to this aspect in the school improvement plan.

We also realised that, although each school set a specific target for the overall pass rate at the end of the year, there were no subject-specific issues included under the priority of learner achievement.For example, no subject (such as Geography) was mentioned by name, and there were no indications of the specific needs that had to be addressed to support enhanced learner achievements in the subject, such as map work.This will have to be taken up in the schools' improvement plans for the following year and it is something that we need to emphasise in the future.

Conclusion

The events that occurred during the workshop represented a significant departure from the traditional, bureaucratic, topdown approach which is commonly followed by the Department of Education in their training interventions (MacMaster, interview 2010).The action research design allowed a more participative relationship to develop between the School Management Team members of the four schools.

The action learning approach adopted in this research study enabled and capacitated the participants to develop suitable school improvement plans.Participants had to rely on their interaction with one another, and learn from each other, as well as by means of reflection and constructive feedback.The fact that it was at times difficult to stop them at the end of activities highlighted the fact that authentic learning took place during the workshop (McGill & Beaty 1995).

Although this small study was limited in scope, the findings are significant for school improvement on an international scale.Schools can only progress towards whole-school development if properly constructed school improvement plans are in place.The management teams, of the four underperforming high schools in this study, learnt not only how to develop their school improvement plans, but also the importance of having them to improve the functioning of their schools and their own management practices.The process of action learning will enable them to sustain this learning.These outcomes emphasise the value of interventions based on the principles of action learning for the development of school leadership.Such learning can, in turn, lead to enhanced functionality, thereby breaking the cycle of underperforming schools in any similar contexts.

Table 1
1

Key areaPurpose of the key areaBasic functionalityLeadership, management and communicationGovernance and relationshipsQuality of teaching and learning, and educatordevelopmentCurriculum provision and resourcesLearner achievementSchool safety, security and disciplineSchool infrastructureParents and the community

• Identify and name the four priority areas • Indicate what had been done (completed) up to that stage in 2012 with regards to each of the priorities, and •

Self-Efficacy: The Exercise of Control. A Bandura, 1997FreemanNew York

Successful school improvement and the Education District Office in South Africa: some emerging propositions. Developed under the District Development Support Programme Project: USAID. B Chinsamy, 2002. June 2014

What I have learnt from working with underperforming schools. A Clarke, School Management and Leadership. 522011. June 2014

. L Cohen, L Manion, K Morrison, 2007RoutledgeLondonResearch methods in education. 6th ed

Implementation guidelines: safe and caring child-friendly schools in South Africa. J W Creswell, Research design: Qualitative, Quantitative and Mixed Methods Approach. KwaZulu-NatalCalifornia: Sage Publications. Department of Education2003. 2001a. 22512. June 2014. 2001b. 2007. June 2009. 2008. June 2014. 2009. April 2008 -30 March 2009. June 201422433Department of Education, Province of the Eastern Cape

Making process accessible: robust processes for learning, change and action research. B Dick, 2005

The School Improvement Planning Handbook: Getting focused on turnaround and transition. D L Duke, M Carr, W Sterrett, 2013Rowman and LittlefieldLanham, MD

School Improvement Planning: A Handbook for principals, teachers, and school councils. 2000. May 2013Toronto: Education Improvement Commission

An introduction to qualitative research. U Flick, 2006SageLondon3rd ed

The power of collaborative leadership: lessons for the learning organization. B Fryman, I M Wilson, J Wyer, 2000Butteworth-HeinemannWoburn, MA

Working with qualitative data. W J Gibson, A Brown, 2009SageLondon

School improvement: international perspectives. B Gillham, Case study research methods. Continuum, J C Lee, M Williams, London; New YorkNova Science2000. 2006

Schools as open systems. F C Lunenburg, 2010. 23 June 20141

. G F Macmaster, 2010. August 2010

Action learning: a guide for professional, management and educational development. I Mcgill, L Beaty, 1995Kogan PageLondon

The action learning handbook. I Mcgill, A Brockbank, 2004Routledge FalmerLondon

The school as a learning organization. K C Moloi, 2005Van SchaikPretoria2nd ed

Education management and leadership: a South African perspective. A Naidu, R Joubert, R Mestry, J Mosoge, T Ngcobo, 2008Cape TownOxford University

W L Neuman, Social Research Methods: Qualitative and Quantitative Approaches. BostonPearson Education20066th ed

An investigation into the implementation of participative management in a rural school in the Pietermaritzburg district. W S Ngubane, 2005GrahamstownRhodes UniversityMEd dissertation

Creating a Successful Professional Culture: Reorganizing to Rebuild a Challenging School. M A Owens, Journal of Cases in Educational Leadership. 132010

Action learning in practice. M Pedler, FarnhamGower20114th ed

ABC of action learning. R Revans, 2011GowerFarnham

International handbook of school effectiveness and improvement. Townsend T2007SpringerDordrecht

An action learning model to assist Circuit Teams to support School Management Teams towards whole-school development. G H Van Der Voort, 2013Port ElizabethNelson Mandela Metropolitan UniversityDEd thesis

Schools as organizations. P C Van Der Westhuizen, PretoriaVan Schaik20022nd ed

An educator's guide to school management skills. Van Deventer I & Kruger AG2009Van SchaikPretoria6th Impression

C Welman, F Kruger, B Mitchell, Cape Town. Oxford University Press20053rd ed

Changing Schools in Challenging Contexts: the documentation of a South African whole-school development journey. S Westraad, 2011GM South Africa FoundationPort Elizabeth

Transforming schools: creating a culture of continuous improvement. A Zmuda, R Kuklis, E Kline, Action learning and action research. 2004. 2009Sense PublishersAssociation for supervision and curriculum development


Diagnostic Pathology Virtual health care center in Georgia

Thomas Schrader
Department of Pathology
University Hospital Berlin -Charite
10117-BerlinGermany

Ekaterina Kldiashvili
Georgian Telemedicine Union (Association)
0171TbilisiGeorgia

Diagnostic Pathology Virtual health care center in Georgia
10.1186/1746-1596-3-S1-S4BioMed Central Page 1 of 5 (page number not for citation purposes) Proceedings * Corresponding author The project "Virtual Health Care Knowledge Center in Georgia" was the NATO Networking Infrastructure Grant dedicated for development of telemedicine in non-NATO countries. The project implemented a pilot to organize the creation of national eHealth network in Georgia and to promote the use of innovative telemedicine and eLearning services in the Georgian healthcare system. In June 2007 it was continued under the NATO Networking Infrastructure Grant "ePathology -Virtual Pathology Center in Georgia as the Continuation of Virtual Health Care Center".
Application of telemedicine systems to cover distant geographical areas has increased recently. However, the potential usefulness of similar systems for creation of national networks does not seem to be widely appreciated. The article describes the "Virtual Health Care Knowledge Center in Georgia" project. Its aim was the set up of an online integrated web-based platform to provide remote medical consultations and eLearning cycles.

Introduction

Telemedicine involves providing health care services between two or more locations through the use of telecommunication technology. A number of medical services including radiology, pathology as well as consultations in specialized disciplines like neurology, dermatology and cardiology can readily be delivered or accessed remotely using information technology [1]. Telepathology is a part of telemedicine, which can be defined as the practice of pathology over a distance by viewing images transmitted from a remote site [2,3]. The former classification of telepathology differentiates between the static and dynamic mode. In the static mode, a small number of digitized images are captured and transmitted to a remote telepathologist. In the dynamic mode, images of the microscopic slides are transmitted and visualized in real time. Some of the dynamic systems allow the robotic remote control of the microscope. Hybrid telepathology systems combine features of both static-image and dynamic-robotic telepathology systems. The current development of virtual microscopy using whole slide images (WSI) allows the static mode as well as the dynamic mode.

The images may be used for primary diagnosis, consultation, quality assurance, and proficiency testing and distance education. Telepathology has the potential to increase access to general or subspecialty pathology serv- ice in remote areas, decrease costs by reducing turn around time for consultations, and reduce professional isolation of the rural pathologist [4].

In this article NATO Networking Infrastructure Grants "Virtual Health Care Knowledge Center in Georgia" and "ePathology -Virtual Pathology Center in Georgia as the Continuation of Virtual Health Care Center" as well as barriers and perspectives of telepathology practice are presented.

Methods and discussion

Description

The project "Virtual Health Care Knowledge Center in Georgia" started at March 2005. Its topic was the implementation, evaluation and adaptation of telemedicine services for Georgia. The first step of this project implementation which aimed set up and installation of the teleconsultation server realized by NATO-country project codirector, Dr. Thomas Schrader has been completed at June 2005. The service can be reached at http://vhcc.charite.de. Three main services are available on the server: eGroup-Ware (GroupWare), Moodle (Online Course Management System/LMS), Simple Machines Forum (TeleConsulting). eGroupWare is a type of software that allows users to share documents, calendar and addresses, plan projects or manage news. The main aspect for choosing it is large community and the fact that Virtual Health Care Knowledge Center in Georgia (VHCC) is "young" project with a promising future. Within the scope of telemedicine, teleconsulting is an important sub area, where several cases can be discussed with experts all over the world. The main idea for TeleConsulting tool was the possibility to create a case by an external team. The essential data are stored on the server and they are viewable by all interested groups. The last one can comment the questions and requests. After finalization the case is stored on the server and can be viewed by the users. Simple Machines Forum (SMF) is used for teleconsulting. A learning management system (LMS) is a software application of web-based technology used to plan, implement and access a specific learning process. There are several LMSs. The Moodle was determined as the most suitable and appropriate tool.

The usage of VHCC's teleconsultation server started at July 2005. The medical discussion group cared more than 140 cases. Other groups are specialized in Medical Informatics and Pathology. More than 250 pupils use the eLearning Platform of the VHCC with 15 different courses and about 25 teachers. The VHCC represents a living community with a high activity. Second opinion consultations at Tel-eConsulting are implemented on English and on Georgian. eLearning platform is realized on English, Georgian and German languages. For videoconferencing the Skypetool was used.

In June, 2007 the project "ePathology -Virtual Pathology Center in Georgia as the Continuation of Virtual Health Care Center in Georgia" started. The main goal is to expand the infrastructure of Virtual Health Care Center (VHCC) in Georgia and to develop a new model to implement and promote second opinion consultations and education in the medical field of pathology (telepathology). The project proposes to create a unified, resilient and transparent infrastructure, available on demand, in order to expedite pathology consultants between rural pathology laboratories and specialized medical centers. Special emphasize is placed on: (1) distribution of computational resources; (2) development of image processing algorithms; (3) combination of image data with patient's medical data; (4) interoperability of databases of heterogeneous content for medical and research purposes. This model should assure a timely and secure access of medical data, as well as combine a wide variety of distributing resources, which should work under a single and unified environment. It should be especially described, that VHCC project's patient-record is based on "events", i.e., episodes that occur during the patient's contacts with the healthcare organization. The patient's record is the collection of all his/her events; these medical data could be heterogeneous, ranging from numerical values to radiographical images. A relevant step forward is that information is gathered during routine patient treatment, not during activities explicitly dedicated to scientific research within Universities or research Institutes. Educational module slides will be already collected in a central database.

To ensure the implementation of VHCC in the most effective degree the content management system will be created. This will be the virtual model of diagnostical center, which will realize the concept of digital medical history.

Barriers

The probability of an incorrect handling of a relevant medical data, still dangerously high, mainly is due to:

• Environmental factors -Many medical organizations are not fully able to face every disease, e.g., in a peripheral hospital only the most frequent pathologies for that geographical area are treated.

• Instinctive factors -The decision making of a physician is usually mainly based on the limited number of cases in her/his experience and/or on a static medical knowledge available from databases of main published slides. This factor is very variable between different specialists and general practitioners.

• Emotional factors -Medical decisions are often influenced by the opinions and the decisions that have been taken by the physicians that already have examined the same patient.

As a consequence the probability of a serious error occurrence could be high and the probability of its recognition and correction very low. This frequently causes a repetition of exams in the same time or in different medical units and it slows down the diagnostic process (resources waste) and the proper treatment. So, proper actions for improving the working procedures have to be taken.

Correct medical information management and transmission is a key point [5], hence the introduction of telepathology can be relevant. There are several diagnostic discrepancies due to sampling error; those are a serious problem in telepathology. The difficulty of image standardization in telepathology is that so many factors can influence image quality [6,7]. The discussion about medical image standards commonly includes the discussion of required image resolution, the number of colours, monitor resolution, compression ratio, format etc. Pathology imaging has a wide range of requirements, and is subject to significant human factors and non-imaging-related parameters that make a single standard for pathology imaging problematic. Defining a required "pixel resolution" is meaningless if the optical focus or staining quality is not defined, and even if these parameters could be defined, the image type and quality required for some aspects of pathology is radically different from that required for others. One could decide on a file format for file transfer, but this would not address some of the more basic issues in pathology imaging. The important concepts for pathology imaging standards to consider are: 1. Systems should be able to share image files.

The standards should allow the transmission of information on baseline colours and recommended display parameters.

3. The images should be useful to the pathologist, not necessarily better or worse than direct examination of a slide under the microscope. 4. A mechanism to evaluate image quality objectively should be present. 5. A mechanism to adjust and correct minor errors of tissue processing should be developed.

A public organization should support pathologists in the development of standards.

To move pathology imaging into a space where standards can be effectively applied there are two main areas of attack. One involves formal training of pathologists in imaging and image-related activities. The second area is the development of technical mechanisms to remove human factor issues in the image capture process. The goals are to correct (or at least identify) differences between systems and materials, to develop technical protocols for evaluating and/or grading image quality objectively, and finally, to deploy colour standardization technology.

Image quality evaluation is another important factor. Currently, the methods used to evaluate image quality are very subjective and vary between individuals and institutions. This subjectivity does not necessarily affect diagnosis by telepathology and/or the imaging system [7]. However, as telepathology systems become more popular and more ubiquitous, it will become necessary to develop more objective image quality assessment methods. Even something as new and untested as the whole-slide imager is making rapid inroads into telepathology, and several commercial systems are available on the market. Each system gives a different visual impression of the images, and different models of the same system give different impressions and image quality. We do not know what level of quality of image we really need for clinical uses, for education or for research purposes, complicating the problem of standardization. The health care systems, and the education of health care personnel, have to be re-organized to systems that function in a cross-border fashion [8]. Prerequisites for this development shall be a specific emphasis on equity of access, interoperability and standardization of systems and protocols, security and legal aspects. There are technical, legal, organizational, and financial problems to be solved [9].

Perspectives

The most important and perspective application of telepathology is education of health care professionals at a distance, so called distance education (eLearning). It has the abilities to apply new concepts, and ideas in which the learner becomes an owner of that knowledge, without any respect to distance. As such, telemedicine overall, and in particular telepathology education, is significantly part of health care revolution, since the event of modern medicine. Telepathology education process as a culture uses for the most part, distance education as the medium of dissemination of advanced information, and while it is an important aspect of today's education process, this medium should not be distracting, and the principles of learning and education should be unchanged. The addi-tion of technology should not substitute for failed pedagogical process, but technology should allow that educational process, and the message to be disseminated, and tailored to individual groups and professionals, by retraining along some of the educational principles of traditional education.

While distance learning benefits are not challenged by most, it is difficult to estimate the impact on education overall. It should be measured by the content of the curriculum, which should be based on the process, perception, product and the mode of delivery. As such distance learning should be scrutinized just as traditional curriculum has been in the past and continue to be so. The only "change" should really be the medium of dissemination. Not the content per se, not the overall approach, and certainly not the end product, which is the education of the students, health professional and, the patients themselves. The differences between classical teaching and learning, and the new and modern form of teaching as well as learning is substantial in this new era. Instead of confined classroom teaching and learning, the entire universe has become a workplace, a learning environment, anywhere, anytime, 24 hours a day. This creates a sense of shared knowledge and virtual networking alliances. The demand for distance learning stems from the common sense of its applicability, but it requires the same standards of production, and evaluation of such programs. The main reasons to implement distance learning in health education are:

• Health care professional, in the information age, will acquire new skills and new knowledge without major disruption of their work.

• The need to reduce the cost of obtaining such education on new information (travel expenses, lodging, registration fees on venues like clinical conferences, congresses, and other forms of meetings).

• Need for better convergence of information age health care professional on communication and computing technologies.

Telemedicine in pathology training could supplement greatly pathology education of pathologists in countries with middle and low incomes without the expenses of moving those pathologists from one country to the other for supplemental education. Eventually, pathology education could be advanced to pathology telementoring, which could assist in the provision of pathology care to underserved areas and potentially facilitate the teaching of advanced pathology skills worldwide. Telepathology education is a very important element of overall progress in the telepathology. In order to be able to advance this, as an accepted culture and part of the daily practice of health care professionals, there are many initiatives that need to be taken, or an existing one to be supported.

Conclusion

Perspectives and strategies for telepathology are currently evolving; as emerging operative requirements would allow self-sustainable large scale exploitation while recent technological developments are available to support integrated and cost-effective solutions to such requirements. However, as far as we know few telepathology services have proceeded to large scale exploitation, even after successful technological demonstration phases. Main exploitation drawbacks, problems and deficiencies have been:

1. Partial solutions approach instead of integrated total approach to health care assistance needs.

2. Lack of economical drive and consequently no self-sustainability for large scale exploitation.

Insufficient networking approach for medical operators and scientific/clinical structures.

Telemedicine and telepathology are the most important for ensuring safe medical care. It is well known, that the first contact with patients needing medical help is the contact with the local primary care health center. Second opinions from specialists are often required in primary care health centers. An efficient and appropriate strategy of medical care can be worked out at the initial steps of patient's contact with health care. Such an approach can avoid unnecessary hospitalization, and will be a substantial contribution to the reduction of health costs.

By comparison with the usual health services telemedicine introduces added value and a positive impact at social, economic and cultural levels. Therefore, telemedicine is beginning to have an important impact on many aspects of healthcare in non-NATO countries. When implemented well telemedicine may allow these countries to leapfrog over their developed neighbours in successful healthcare delivery.

from 9th European Congress on Telepathology and 3rd International Congress on Virtual Microscopy Toledo, Spain. 15-17 May 2008
(page number not for citation purposes)
Publish with Bio Med Central and every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours -you keep the copyright Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentral
AcknowledgementsThe Virtual Health Care Center (VHCC) is supported by NATO: completed project "Virtual Health Care Knowledge Center in Georgia" and ongoing one "ePathology -Virtual Pathology Center in Georgia as the Continuation of Virtual Health Care Center in Georgia". Authors thank NATO Networking Infrastructure Programme for support. This article has been published as part of Diagnostic Pathology Volume 3 Supplement 1, 2008: New trends in digital pathology: Proceedings of the 9thEuropean Congress on Telepathology and 3rd International Congress on Virtual Microscopy. The full contents of the supplement are available online at http://www.diagnosticpathology.org/supplements/3/S1
. Diagnostic Pathology. 3Diagnostic Pathology 2008, 3:S4 http://www.diagnosticpathology.org/content/3/S1/S4

References 1. International Telecommunication Union: Making Better Access to Healthcare Services. References 1. International Telecommunication Union: Making Better Access to Healthcare Services. 2005.

L Beolchi, Telemedicine Glossary. 5th editionBeolchi L: Telemedicine Glossary. 5th edition. 2003.

Fjw-M Leong, Telepathology and the World Wide Web -Internet resources applicable for telepathology. XXIII International Congress of The International Academy of Pathology and 14th World Congress of Academic and Environmental Pathology. Leong FJW-M: Telepathology and the World Wide Web - Internet resources applicable for telepathology. XXIII Interna- tional Congress of The International Academy of Pathology and 14th World Congress of Academic and Environmental Pathology 2000.

Global E-Health Strategy Draft for Consultation. Geneva, World Health Organization. J Dzenowagis, Dzenowagis J: Global E-Health Strategy Draft for Consulta- tion. Geneva, World Health Organization; 2004.

Ministerial Declaration 22 May made at 2003 e-Health MinisterialConference. E-Health , E-Health Ministerial Declaration 22 May made at 2003 e-Health MinisterialConference 2003 [http://ec.europa.eu/information_society/ eeurope/ehealth/conference/2003/doc/min_dec_22_may_03.pdf].

The Economics of Telepathology -A Case Study. Della Mea, V Cortolezzis, D Beltrami, C A , J Telemed Telecare. 6SupplDella Mea V, Cortolezzis D, Beltrami CA: The Economics of Telepathology -A Case Study. J Telemed Telecare 2000, 6(Suppl 1):S168-S169.

The Virtual Double-Headed Microscope: Telepathology for All? Histopathology. P Furness, J Rashbass, 36Furness P, Rashbass J: The Virtual Double-Headed Microscope: Telepathology for All? Histopathology 2000, 36(2):182-3.

More Towards than Action. Towards Unity for Health -Coordinating Changes in Health Services and Health Professions. P Kekki, Distance Communications, Learning, 2002.2/2000Kekki P: Communications and Distance Learning: More Towards than Action. Towards Unity for Health -Coordi- nating Changes in Health Services and Health Professions, Practice and Education. WHO/EIP/OSD/NL/A/2002.2/2000(2) :30-31.

A: Education via Internet. A Moura, Del Giglio, Rev Assoc Med Bras. 461Moura A, Del Giglio A: Education via Internet. Rev Assoc Med Bras 2000, 46(1):47-51.


An afebrile heartwater-like syndrome in goats
23 Oct. 2013

Rhoda Leask firstname.lastname@example.com
Department of Production Animal Studies
University of Pretoria
South Africa

Kenneth P Pettey
Department of Production Animal Studies
University of Pretoria
South Africa

Gareth F Bath
Department of Production Animal Studies
University of Pretoria
South Africa

Private Bag X04
0110OnderstepoortSouth Africa

An afebrile heartwater-like syndrome in goats
23 Oct. 2013AC8D230A4FED69A19A6D911E127F86A710.4102/jsava.v84i1.955Received: 07 Nov. 2012 Accepted: 16 Apr. 2013
Heartwater is a serious limiting factor for sheep and goat production in the major endemic area of sub-Saharan Africa and therefore most knowledge, research and control methods originate from this region.Whilst the usual or common clinical presentations can be used to make a presumptive diagnosis of heartwater with a good measure of confidence, this is not always the case, and animals suffering from heartwater may be misdiagnosed because their cases do not conform to the expected syndrome, signs and lesions.One aberrant form found occasionally in the Channel Island breeds of cattle and some goats is an afebrile heartwaterlike syndrome.The most constant and characteristic features of this heartwater-like syndrome comprise normal temperature, clinical signs associated with generalised oedema, and nervous signs, especially hypersensitivity.The presumption that the disease under investigation is the afebrile heartwater-like syndrome entails a tentative diagnosis based on history and clinical signs and the response to presumed appropriate treatment (metadiagnosis).The afebrile heartwater-like syndrome presents similarly to peracute heartwater but without the febrile reaction.Peracute cases of heartwater have a high mortality rate, enabling confirmation of the disease on post-mortem examination.Recognition of the afebrile heartwater-like syndrome is important to prevent deaths and identify the need for appropriate control measures.

Introduction

Heartwater has been well documented in the past and the causative organism is currently classified as an α-proteobacterium, Ehrlichia ruminantium (Allsopp 2009).Cattle are less susceptible to heartwater than sheep and goats and a considerable variation in susceptibility between breeds has been reported (Donkin et al. 1992;Uilenberg 1983).Matheron et al. (1987) demonstrated genetic resistance in Creole goats in Guadeloupe due to a recessive sex-linked gene, whereas Angora goats are highly susceptible to heartwater (Du Plessis, Jansen & Prozesky 1983).Whether an animal will develop heartwater or not also depends on factors such as species, breed, age, degree of natural resistance and immune status (Bath, Van Wyk & Pettey 2005).Oberem and Bezuidenhout (1987) discussed the role of wild ruminants, guinea fowl, tortoises and scrub hares as reservoir hosts and their importance where stringent tick control in domestic animals is practised.The presence of these wild reservoirs, immunological strain differences of E. ruminantium and cross protection between strains are important factors in the epidemiology of heartwater (Du Plessis et.al. 1989;Jongejan, Uilenberg & Franssen 1988).Infection rate in ticks, fluctuations in tick abundance and tick control also play a role (Uilenberg 1983).

The course of heartwater can be peracute, acute, subacute or chronic (Kusiluka & Kambarage 1996).The most common clinical signs include listlessness, poor appetite, decreased milk yield and nervous symptoms ranging from mild incoordination to pronounced convulsions (Bath, van Wyk & Pettey 2005).Fever of 40 °C or higher usually persists for 3-6 days and is followed by a drop to subnormal levels shortly before death (Bath, Van Wyk & Pettey 2005).However, not all clinical cases appear to develop a fever reaction and may exhibit other neurological signs such as hind limb paralysis and unusual behaviour patterns.Experience of the authors and other investigators (Dr A.F. Fisher & Dr S.R. van Amstel, pers. comm. 2012) indicates that there may be another form of heartwater, usually peracute in onset but lacking the typical fever reaction.Van Amstel first referred to cases that he had observed as having 'cold heartwater' and postulated that the presence or absence of fever reactions may be due to the amounts of interleukin (IL) 6 and tumour necrosis factor present at the time (S.R. van Amstel, pers. comm. 2012), but these cases were never recorded.Certain goat breeds and Channel Island cattle breeds may be more prone to develop this afebrile heartwater-like syndrome.

Three cases of afebrile heartwater-like syndrome in goats are described.

Read online:

Clinical cases

The following cases were either seen by the authors or reported to the authors by private practitioners.Other cases have been discussed with the authors previously but were not recorded and so have not been included.

Case 1

A male, eight-tooth Saanen goat developed neurological signs including hyperaesthesia, nystagmus and paddling.The rectal temperature of the goat was 39 °C, which is normal for the goats in the Onderstepoort region.The temperature of the goat was monitored on the morning and evening of admission and again the following morning.The temperature did not rise or fall during that time.A tentative diagnosis of pituitary abscessation as the main cause of the clinical signs was made owing to the absence of a febrile reaction.The temperature was taken again the following morning with no changes recorded and the goat died later that day despite being treated with broad spectrum antibiotics (drug and dosage unknown) and was sent for necropsy where a diagnosis of heartwater was confirmed on brain smear examination.Hydrothorax and hydropericardium were also present at necropsy.

Case 2

A young (no permanent teeth) Boergoat presented as 'behaving strangely', according to the owner.The goat was attempting to climb out of the stall and also showed occasional head pressing although the rectal temperature was normal.This goat was immediately treated with tetracycline at a dose of 10 mg/kg and recovered uneventfully.A presumptive diagnosis of heartwater was made on response to treatment.The goat was kept under observation in the clinic for three days and then discharged.Rectal temperature was recorded daily and at no time was a fever reaction recorded.

Case 3

Twenty-two Boergoats in the Cathcart region (A.F. Fisher, pers. comm. 2012), all male, with does that were running in an adjoining camp, had died during the week.Approximately 30-40 had been reported dead in the neighbouring Gwatyu region.Some had been treated by the owner with tetracyclines (dosages and trade names unknown).Of those treated, some showed signs of improvement and some died.Two goats were seen by Dr Fisher and normal temperatures were recorded at the time of clinical evaluation.The goats died and brain smears were examined but no Ehrlichia organisms were seen and the smears were sent to a pathologist for evaluation.The presence of Ehrlichia organisms was confirmed by the pathologist.Another two goats were presented to Dr Fisher for further examination.Clinical signs included hind limb paralysis (as seen in the goats on the farm) that appeared to develop overnight, as no clinical signs were observed previously by the farmer.The goats were described as eating and alert, with one being slightly aggressive (possibly due to its inability to escape owing to the paralysis).The temperatures of the goats were 39.1 °C and 39.0 °C respectively.Over the next 24 h -48 h the clinical signs progressed to opisthotonus, nystagmus, galloping and hyperaesthesia.Over the two days the rectal temperature of the goats did not increase or decrease.The worst affected goat died and a necropsy was performed by Dr Fisher.Lesions observed included hydropericardium, slight splenomegaly, 3+ Haemonchus contortus (on a scale of 1+ being very few and 4+ being very many) infestation and the presence of approximately 12 Amblyomma (male) ticks.No lung oedema was observed macroscopically.Heartwater was confirmed on brain smear examination.The remaining goat was treated using tetracycline at 10 mg/kg and recovered.

Discussion

The goats in all three cases showed some signs of neurological involvement but no febrile reaction.The goat breeds affected included Boergoats and Saanens.The afebrile heartwater-like syndrome has not been diagnosed in any indigenous breeds other than Boergoats.

Diagnosis of heartwater in live animals is almost invariably based on clinical signs.It is conceded that a clinical diagnosis based only on signs and response to treatment is not as certain as a diagnosis based on specific, reliable and rapid tests.However, tests for heartwater in any manifestation are not always reliable.

Currently the only definitive way of confirming a diagnosis of E. ruminantium is by demonstration of the organisms in Giemsa or CAM's Quick-stained brain smears (Bezuidenhout et al. 1994).However, demonstrating the organism on brain smears does not necessarily confirm heartwater as some strains of E. ruminantium do not cause clinical heartwater and some do not cause any clinical signs (Allsopp et al. 2007).

As serum tests such as IFA are not specific for E. ruminantium, a polymerase chain reaction (PCR) test has been developed to provide a more specific test (Steyn et al. 2008).PCR will detect heartwater, but with the extraordinary genetic variability of the organism (Allsopp 2009) a positive result does not always indicate that observed clinical signs were due to heartwater, as some genetic variants are more pathogenic than others.For example, 70 clinically healthy Boergoats tested positive using PCR in a heartwater-free area (Allsopp et al. 1997).

According to an authority on heartwater (B.A. Allsopp, pers. comm. 2013), although PCR can demonstrate the presence of E. ruminantium it must be noted that the definition of what comprises E. ruminantium is not entirely certain (Loftis, Levin & Spurlock 2008).Furthermore, the current cost of the test is approximately R320 per sample (Dr H.C. Steyn, Onderstepoort Veterinary Institute, pers. comm. 2013) and only if the concentration of genetic material is high enough can the laboratory sequence the sample and compare it with the database.Farmers and private practitioners do not routinely use these tests to confirm suspected cases where animals have been treated and recovered, as it is too costly and impractical.As Allsopp (2009) noted, definitive diagnoses are not often performed in endemic areas.Thus diagnosis has to rely on signs, circumstances and reactions to treatment for the foreseeable future.Heartwater is by no means unique in this respect, since there are many other diseases like pneumonia that have to be dealt with in the same way.In order to save lives, it is extremely important to reach the presumptive diagnosis timeously and initiate appropriate treatment, while bearing in mind other possible differential diagnoses.

Since heartwater is usually closely associated with a fever, often > 40 °C, it is understandable and usual to attribute clinical signs not featuring fever to some other disease.Peripituitary abcessation in goats is an important differential diagnosis since it also does not involve fever (Bath, Van Wyk & Pettey 2005).However, the clinical signs are less pronounced, the animal is more depressed, there is usually a relative or absolute neutrophilia in blood samples, and animals seldom respond to a single treatment with tetracyclines.At postmortem examination, there is no sign of oedema, brain smears are negative for heartwater and signs of bacterial infection around the hypothalamus can be seen, with a range of bacteria visible in smears of these lesions (Bath & De Wet, 2000).Other important differential diagnoses include plants causing neurological signs, and ionophores.There are 21 plants known to cause neurological or locomotor signs that could be confused with heartwater (Kellerman, Coetzer & Naudé 1990).Since they are all toxic, no fever would be expected but there would be no response to treatment with tetracyclines or related drugs.Only plants that occur in heartwater-prone areas would need to be considered, which reduces the list to less than ten.Clinical signs of ionophore toxicity include feed refusal, listlessness, stiffness, abnormal gait and diarrhoea, but again there would be no response to treatment with tetracyclines.

During the early febrile stages of heartwater, administration of tetracyclines at a dose rate of at least 10 mg/kg usually results in recovery (Bath, Van Wyk & Pettey 2005).More pathogenic strains of E. ruminantium may require daily treatment with tetracyclines (10 mg/kg) for up to five days.An initial dose of 20 mg/kg administered slowly intravenously may be necessary in these cases.The patient should then be monitored for signs of hypocalcaemia and treated for this where necessary.This applies to afebrile heartwater-like cases as well.In the advanced stages of the disease, additional supportive therapy must be considered (Bath, Van Wyk & Pettey 2005), although this is not always successful.Supportive treatments include stabilisation of membranes and blocking the effect of vasoactive compounds released with cellular death (Van Amstel & Oberem 1987) and drugs active in reducing oedema (Shakespeare et al. 1998).Partial exsanguination may help alleviate the symptoms, presumably by reducing oedema by drawing extra-vascular fluid back into the circulatory system (Bath, Van Wyk & Pettey 2005).

When there is no fever present, a presumptive diagnosis must nevertheless be made on the presence of other characteristic clinical signs, history and often the response to presumed appropriate treatment.A fairly consistent clinical sign of heartwater also seen in afebrile heartwater-like cases is hyperaesthesia.Tapping the affected animal on the head and eliciting a hyperaesthetic reaction that includes rapid blinking of both eyes can assist with the early diagnosis of heartwater-like syndromes in afebrile cases.

Although preventative measures should always be preferred over treatment for all livestock diseases, in the case of heartwater, prevention is limited as an option due to a number of factors.Firstly, the 'vaccine' is not a true vaccine but an infection, and it can lead to severe clinical signs and death if reaction to the vaccine is not followed up with sufficient treatment.Secondly, another follow-up treatment is often required.Thirdly, the vaccine has to be kept at very low temperatures (on dry ice) to remain infective.Fourthly, the vaccine on thawing must be rapidly injected intravenously.Fifthly, the time lapse before a fever reaction triggers treatment can vary considerably and thus animals have to be monitored for extended periods.Sixthly, not all animals respond with a fever reaction.In these cases, where there are valuable animals involved, enzyme-linked immunosorbent assay (ELISA) has been used in the past to demonstrate whether or not vaccination has resulted in the production of antibodies.This is not always reliable.Seventhly, a few animals may die without showing clinical signs.Eighthly, vaccinated animals must be continuously exposed to field challenges (natural boosters) by maintaining sufficient infected ticks.This is very difficult to gauge since the degree of infection in a tick population cannot be measured.Ninthly, the common practice of regular blocking of the entire herd or flock with tetracyclines is not only timeconsuming and expensive, it also leads to a heartwater-prone group of animals and will probably lead to the emergence of tetracycline-resistant organisms.Lastly, the practice of 'dipping clean' is also problematic.Any breakdown in dipping can lead to disease outbreaks; the animals are completely susceptible and regular dipping of all livestock will lead to the build-up of ticks resistant to ectoparasiticides.Thus, until better preventive measures are developed (especially a true vaccine), the control of heartwater must include early recognition of the disease and prompt treatment.The ability to recognise all the different forms of heartwater that may be encountered is a key requirement for treating animals early and effectively.

Conclusion

Although in some of the reported cases Ehrlichia was demonstrated on brain smears, as discussed above it cannot be confirmed beyond all doubt that these cases were heartwater.Also, in those that recovered after treatment for presumed heartwater, other Ehrlichia species may have been the cause of this afebrile heartwater-like syndrome.The importance of this case report is thus to inform veterinarians that heartwater-like clinical signs without a fever reaction may respond to treatment usually given for heartwater and that heartwater should not be ruled out as a differential diagnosis in such instances.It is clear that more research is required in the fascinating field of heartwater.

AcknowledgementsThe authors would like to thank Dr Alan Fisher for the information provided in Case 3. Publication of this article was sponsored by the Faculty of Veterinary Science, University of Pretoria.Competing interestsThe authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.Author's contributions
B A Allsopp, 10.1016/j.vetpar.2009.09.014Natural history of Ehrlichia ruminantium. 2009167

Different organisms associated with heartwater as shown by analysis of 16S ribosomal RNA gene sequences. M T Allsopp, E S Visser, J L Du Plessis, S W Vogel, B A Allsopp, 10.1016/S0304-4017(97)00012-5Veterinary Parasitology. 711997

Ehrlichia ruminantium variants which do not cause heartwater found in South Africa. M T Allsopp, M F Van Strijp, E Faber, A I Josemans, B A Allsopp, 10.1016/j.vetmic.2006.10.026Veterinary Microbiology. 120171237502007

G F Bath, J De Wet, Sheep and goat diseases. Tafelberg, Cape Town2000

Control measures for some important and unusual goat diseases in southern Africa. G F Bath, J A Van Wyk, K P Pettey, 10.1016/j.smallrumres.2005.06.007Small Ruminant Research. 602005

Infectious diseases of livestock with special reference to Southern Africa. J D Bezuidenhout, L Prozesky, J L Du Plessis, S R Van Amstel, J.A.W. Coetzer, G.R. Thomson & R.C. Tustin1994Oxford University PressCape Town

Resistance of indigenous and crossbreed goats to heartwater (Cowdria ruminantium). E F Donkin, C G Stewart, R G Macgregor, H C Els, P A Boyazoglu, International Conference on Goats. New Delhi, India; New Delhi1992. 2-8 March 1992Recent advances in goat production. International Goat Association

Heartwater in Angora goats. I. Immunity subsequent to artificial infection and treatment. J L Du Plessis, B C Jansen, L Prozesky, PMid:6634087Onderstepoort Journal of Veterinary Research. 501983

The heterogenicity of Cowdria ruminantium stocks: Cross-immunity and serology in sheep and pathogenicity to mice. J L Du Plessis, L Van Gas, J A Olivier, J D Bezuidenhout, PMid:2812704Onderstepoort Journal of Veterinary Research. 561989

'Antigenic differences between stocks of Cowdria ruminantium. F Jongejan, G Uilenberg, F F J Franssen, PMid:3387670Research in Veterinary Science. 441988

Plant poisonings and mycotoxicoses of livestock in Southern Africa. T S Kellerman, J A W Coetzer, T W Naudé, 1990Oxford University PressCape Town

Diseases of small ruminants: A handbook. Common diseases of sheep and goats in Sub-Saharan Africa, VETAID, Midlothian, viewed. L Kusiluka, D Kambarage, 1996. 30 October 2012

Two USA Ehrlichia spp. cause febrile illness in goats. A D Loftis, M L Levin, J P Spurlock, 10.1016/j.vetmic.2008.01.010PMid:18328644Veterinary Microbiology. 1302008

Genetic resistance of Guadeloupe native goats to heartwater. G Matheron, N Barre, E Camus, J Gogue, Onderstepoort Journal of Veterinary Research. 5434485691987PMid

Heartwater in hosts other than domestic ruminants. P T Oberem, J D Bezuidenhout, PMid:3329317Onderstepoort Journal of Veterinary Research. 541987

Treatment of heartwater: Potential adverse effects of furosemide administration on certain homeostatic parameters in normal sheep. A S Shakespeare, F Reyers, S R Van Amstel, G E Swan, J S Van Den Berg, 10.4102/jsava.v69i4.841PMid:10192086Journal of the South African Veterinary Association. 691998

A quantitative real-time PCR assay for Ehrlichia ruminantium using pCS20. H C Steyn, A Pretorius, C M Mccrindle, C M Steinmann, M Van Kleef, 10.1016/j.vetmic.2008.04.002PMid:18511221Veterinary Microbiology. 1312008

Heartwater (Cowdria ruminantium infection): current status. G Uilenberg, PMid:6359836Advances in Veterinary Science and Comparative Medicine. 271983

The treatment of heartwater. S R Van Amstel, P T Oberem, PMid:3329331Onderstepoort Journal of Veterinary Research. 541987