Here is a special guest blog post from Dr. Bo Vaughan who recently traveled to the Dominican Republic as part of a US-based team to help evaluate tuberculosis identification and management.
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| Tuberculosis Educational Campaign |
Dominican Republic
June 15-21, 2013
I was afforded the opportunity to join a medical mission
team of four individuals headed for Santo Domingo, Dominican Republic in
mid-June 2013. This trip was an
expedient response to the Dominican Ministerio Salud Pública (Ministry of
Public Health), which had expressed growing concerns regarding the control of
tuberculous and nontuberculous mycobacterial infections plaguing their
citizens. The goals as outlined by our
sponsor, Physicians for Peace, involved providing guidance on nation-wide
tuberculosis and diagnostic protocols, recommendations for best practices with
the resources available, as well as collaboration with local leaders in the
Ministry of Health to develop a step-wise plan for executing these goals.
My mission leader, Dr. Fred Ward, had extended the
invitation to me because I have had some recent
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| US team with Dr. Marcelino |
experience not only treating
non-tuberculous mycobacterial infections but also HIV co-infections as a
graduating infectious diseases fellow at Virginia Commonwealth University in
Richmond, Virginia. Unlike other medical
mission trips, this trip was unique for me because the impact of our
recommendations could truly impact a broad scope of individuals across a
nation, as opposed to the more familiar opportunity of volunteering at a local
clinic for a week where our impact could be only temporary at best. The truth be told, another reason why I agreed
to join the team is that Dr. Ward is a marine and it is usually advisable to
say “yes” to marines when they request your help.
Aside from me, our team was comprised of Dr. Ward, director
of Richmond’s State Health Department Tuberculosis and Chest Clinic; Vanessa
Johnson, R.N, Dr. Ward’s nurse and translator; and Landon Funiciello, a premed
major at William & Mary University and NCAA Division I gymnast.
We were greeted by our in-country contact and Director
General de Habilitacion y Accreditación, Dr. Ramón Lopez in the Santo Domingo’s
international airport on June 15th.
I rarely have seen a more patriotic person for his country than Dr.
Lopez, beaming upon our arrival shouting “welcome to our country.” He would later make such remarks as “rainbows
are members of the family,” and “you will never meet a more appreciative person
than a Dominican.” There would be
incredible truth to this statement as we toured some of the public hospitals
around Santo Domingo.
Our first order of business was to meet the local leaders of
the Programa Nacional Control de la Tuberculosis, Drs. Belkys Marcelino and
Maria Rodriguez as well as the rest of their team. Their core group was composed of five
physicians, one clinical pharmacist, three lead nurses, and one
epidemiologist. With 14 people huddled
around a boardroom table, a large map of the Dominican Republic hanging over
our heads, we listened to the current state of TB and its control in all of its
provinces. Not surprisingly, the most
affected populations were prisoners, immigrants, and the homeless much like in
the States, but the prevalence of active disease (not latent) was 83/100,000
citizens. This is alarmingly higher than
the United States’ rate of 3.4/100,000.
Before we climbed into the government vehicles, the ministry
wanted us to understand the “lay of the land”, so to speak. The country has been divided into 9
municipalities and serving these municipalities are a total of 1,539 health
care facilities of varying capacities.
Nationwide there are thirteen state laboratories where tuberculosis
could be cultured. Dominican Republic as
a whole has a population just over 10 million people and 63% of those people
live in an urban environment. The
country’s population growth rate is 1.6% per year. The
Ministerio Salud Pública divided its TB program into a hierarchical system
beginning with national, then regional, provincial and finally local. But, much like the United States, its borders
and port cities provide a sizeable obstacle for TB control. To the country's credit, the Dominican
government has partnered well with that of neighboring Haiti for a collective
effort to not only stop the spread of disease but minimize drug resistance as
best possible. The goals set forth by
the national TB program are to decrease the national incidence of active
pulmonary tuberculosis by 50% as well as decrease the incidence of TB
meningitis in children less than five years of age. We were called to assist the Dominican
Republic in this pursuit.
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| Meeting with Ministry of Health officials |
Another request from the ministry was to help make sense of
what appeared to be a growing number of nontuberculous mycobacterial cases. I delivered a brief overview of the clinically
relevant nontuberculous mycobacterial infections that they may encounter and in
what clinic context they might arise, for example Mycobacterium avium complex in undiagnosed HIV-positive
patients. The first day concluded with a
better understanding of our objective and what the Ministry of Health was
wanting from us.
Over the next two days, our American team toured a number of
facilities some of which bore the names Hospital Luis Edwardo Aybar, Hospital
Santo Socorro, Centro Sanitario de Santo Domingo, as well as the Programa de TB
y Servicio de VIH (HIV). Most of the
hospital rooms were communal, between 10-15 patients per room. Patient to nurse ratio was roughly 40:1 in
one hospital and the TB ward housed upwards of 6-10 patients who were acid fast
bacteria (AFB) smear positive on Ziehl Neelson staining. These AFB positive patients were treated
empirically for TB provided they demonstrated typical symptomatology, however
AFB cultures on first smears are not always performed.
Another difficulty is that identification of the AFB as TB
or non-TB cannot be performed because of lack of resources, though some labs in
the country do have some capabilities.
When an individual is diagnosed as having TB, they are removed from
work, the state pays for their 4 drug therapy and at one month and again at two
months if need be, another sputum sample will be taken to see if conversion has
occurred. If the smear is still positive
at 2 months, then sensitivities are performed to rule out multidrug resistant
TB. In the United States, weekly sputa
are taken until conversion and a patient is only considered fit for work duty
(ie no longer contagious) when three consecutive sputum samples return
negative, each a day apart.
Sensitivities are performed on the first positive culture. Plus, we are very fortunate in the United
States to have molecular techniques such as DNA probes that will identify M.
tuberculosis or M. avium complex immediately from sputum samples without having
to wait for growth on culture media (which can take 6 weeks). With this molecular based test, tailored
therapy can be started upfront and those individuals with nontuberculous
mycobacterium can return to work safely without worry since these species have
no human-human spread, unlike TB.
We were given a stark contrast during our journey through
the public health system when we received a tour of the Consultorios de Visa
Americana. The United States as well as
a few other western countries including Canada and Australia funded the health
facility designed for the screening of all emigrating Dominicans requesting
citizenship to their soil. Dr. Angel
Contreras kindly guided us through the well-oiled, efficient machine of
screening for communicable diseases in emigrating Dominicans. Unlike the public hospitals, this facility
had access to the Referencia Laboratorio Clinico that had all the sophisticated
tests (including DNA probes of AFB positive Sputum) that we at university centers
take for granted. They too at the
Consultorio had noted a handful of nontuberculous mycobacterium cases in
patients with cavitary or invasive pulmonary disease. It was at this facility where we learned the
head radiologist utilized an Xray view rarely done in the USA that seemed quite
effective at picking up the illusive upper lobe cavitary lesions. The patient flexed at the hips to roughly 45
degrees, chin pointed at the Xray machine with shoulders pulled back, the head
radiologist named it the Duarte view jokingly named after himself, Dr. Orlando
C. Duarte.
Much like other countries around the world, the Dominican
Health System was divided into public and private. In fact many of the practicing doctors at the
Ministerio maintained a panel of private patients as a supplement to their
public works. Dr. Angel Contreras at the
Consulorios de Visa Americana was the facility’s director but also was a
cardiologist at a private health facility in the afternoon.
On June 20 after all of our tours had completed, our team of
four Americans led by Dr. Fred Ward delivered our observations before the
Ministerio Salud Pública. Our
observations began with our acknowledgement of countless positive aspects to
their efforts: such as a nationwide partnership with Haiti in managing TB, the
institution of an outreach worker program who delivers anti-tuberculosis
medication to the homes of sick patients, the nationwide public campaign of TB
awareness on billboards and other street advertisements, and finally the public
awareness of the link between TB and HIV.
We then put forth a 16-point recommendation list of ways the
nation could enhance countermeasures to contain and treat TB, nontuberculous
mycobacterium, HIV in both adults and children, as well as HIV-Mycobacterium
co-infections. Our recommendations
highlighted the need to limit the over-the-counter availability of most
antibiotics, such as those that have activity against TB; support a
nationwide campaign to have HIV testing available to the public in a broader
scope; and encouraged the bolstering of Dominican medical school curricula to
incorporate more TB management skills in hopes of off-loading the incredible
burden on the limited providers presently.
We also requested that the necessary funds be diverted if possible to
have a more robust microbiology state laboratory, the major hope being the
acquisition of molecular testing so that the appropriate drugs can be
administered to the proper patient in real-time. Some of our recommendation may take years to
implement, considering the other competing infrastructural needs facing the
Ministerio.
Regardless of whether some of our thoughts were a little far
reaching, our recommendations fell on extremely appreciative ears, just as our
in-country contact had promised. I have
been afforded the opportunity to travel quite a bit over the years but I must
admit, I have not met a kinder nation of people who took such pride in
accommodating their guest and making sure we were enjoying our stay. Dr. Ramon Lopez did say, “I’ve never met a
visitor who only visited once.” That
will be tough to deny.
Bo Vaughan, MD
The WHO report is significant in that this is the first time we have seen sustained transmission of this disease in the Caribbean. It's not surprising that we are seeing this (see here for a blog post I wrote about the potential for the disease to emerge in the US) as one of the primary mosquito vectors (Aedes aegypti) is the same for dengue and Chikungunya, and Aedes aegypti mosquitoes and dengue are already widespread in the Caribbean and Latin America. Disturbingly, Chikungunya is also transmissible by Aedes albopictus ("Asian Tiger") mosquitoes; this species has a wider geographic range than Aedes aegypti and can thrive as far north as Chicago.
