Friday, December 13, 2013

Chikungunya: Now in the Caribbean

Map needs to be updated to now include
the Caribbean (cdc.gov)
It's official: Chikungunya has now been reported in the Caribbean. According to the World Health Organization (WHO) there have been 2 confirmed, 4 probable and 20 suspected cases of the mosquito-borne viral illness in Saint Martin (as of 12/10/13).

Chikungunya is a viral illness carried by mosquitoes that was first isolated in Tanzania in the 1950s. The name derives from the Kimakonde language and means "to become contorted." Profound joint pain leads to a 'stooped over' appearance, thus the name.

Symptoms of acute infection are nonspecific and are similar to dengue, with fever, headache, nausea, muscle and joint pains and fatigue. Peculiar to this virus, some people can have longstanding joint pain that can last for months, even years. There is no vaccine to prevent this illness and no treatment (other than supportive care).

Chikungunya is endemic in Southeast Asia and Africa. In recent years the disease "emerged" in these areas; in 2005 there were outbreaks on islands in the Indian Ocean with subsequent spread across India; a related outbreak occurred in Italy in 2007, as well.

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.

Unfortunately the Chikungunya outbreak in Saint Martin likely heralds future sustained transmission throughout the region. Although rarely deadly, the disease can be associated with significant morbidity (long-term joint pain and fatigue). Aggressive surveillance and mosquito control efforts are needed.

Click here for the WHO report.

Tuesday, December 3, 2013

Drs. Lee, Collins and Bucheit Honored for Their Work with the Stewardship Interest Group of Virginia

The blogger with Drs. Lee, Collins and Bucheit in April 2013
Congratulations to Drs. Kim Lee, Rebeccah Collins and John Bucheit who were honored with the Clinical Pharmacy Practice Achievement Award at the Virginia Society of Health-System Pharmacists' Fall meeting for their work in creating the Stewardship Interest Group of Virginia (SIGoVA). SIGoVA is an interest group for people involved in Antimicrobial Stewardship in (and around) Virginia, and is a forum for people to come together to share ideas and best practices in stewardship.

To find out more about SIGoVA please visit the SIGoVA website or email stewardship@vshp.org.

Congrats again to Drs. Lee, Collins and Bucheit!

Sunday, December 1, 2013

World AIDS Day: Many Gains, Much to Do

Today is World AIDS Day; this is the 25th anniversary of the event. In the past quarter century there have been incredible gains in both HIV prevention and treatment, turning the disease into one that was nearly universally fatal to what is for many a chronic illness with a near-normal life expectancy. On the patient level the gains that have been made are due to antiretroviral drugs ("ART"); access to these life-saving drugs is still a major issue in much of the world, however.

In 2012 there were 2 million new HIV infections and 1.6 million HIV/AIDS related deaths. There are an estimated 35 million people living with HIV globally, with approximately 75% of all new infections occurring in sub-Saharan Africa.

I volunteered providing medical care in a small village in rural Kenya back in 2001. I remember having a conversation with a local health worker about HIV in this particular community and was amazed when she told me the HIV prevalence was over 40%. At the time the people living in the area had essentially no access to life-saving ART and many of the patients I saw had findings consistent with advanced HIV/AIDS and more likely than not are now dead. HIV/AIDS absolutely has devastated many communities in sub-Saharan Africa.

cdc.gov
The picture is not entirely grim, however. The President's Emergency Plan for AIDS Relief (PEPFAR) has led to millions of people in Africa receiving ART, and it is estimated that one million new infections in children have been prevented over the past decade. Many people who once had little to no hope of obtaining ART (such as those living in the community I described above) can now do so.

In the United States it is estimated that 1.1 million people are living with HIV, with 1 in 5 people
cdc.gov
unaware they have the infection. There are an estimated 50,000 new infections per year. There are racial disparities in HIV infection risk that are believed to be due, at least in part, to differences in access to care, poverty and discrimination. Although the incidence of new infections is going down in some subgroups (such as black women), it is increasing in others (such as men who have sex with men).

Much more needs to be done to prevent new infections, identify new infections early and to get patients with HIV into care. Health disparities need to be addressed both in the U.S. and globally. New therapies need to be developed (including a preventive vaccine).

See here for some terrific resources on HIV/AIDS, including more about World AIDS Day.

Tuesday, November 26, 2013

Medical Literary Messenger: Inaugural Issue Now Available

Congratulations to my friend and colleague Dr. Gonzalo Bearman, whose brainchild The Medical Literary Messenger has published its first issue! Special congratulations also go out to Brie Dubinsky and Rachel Van Hart, as well, whose phenomenal editing has produced a terrific product.

The Medical Literary Messenger is an online literary journal focused on the "healing arts," publishing works in a variety of formats. The first issue can be found here.

Monday, November 25, 2013

CDC Releases Health Disparities and Inequalities Report

The CDC released their second report on Health Disparities and Inequalities last week in the Morbidity and Mortality Weekly Report (MMWR).

This report is a detailed, comprehensive examination of the health status of people living in the United States broken down by race and socioeconomic status. The 187 page report contains numerous individual studies investigating a host of things (morbidity, mortality, unemployment, education, health behaviors, rates of HIV infection, obesity, tuberculosis, access to healthy food, cancer screening, homicide rates, et cetera).

Not surprisingly, substantial differences in health were identified across all health parameters by race as well as socioeconomic status.

A few of the key findings are highlighted below (this is far from a comprehensive list):

1) Black adults are > 50% more likely than white adults to die from heart disease
2) Diabetes is more prevalent in hispanic and black Americans than in whites
3) Infant mortality is > 2 times higher for blacks (than whites)
4) Poverty was associated with a higher risk for diabetes, HIV and hypertension, as well as a decreased likelihood of being screened for colorectal cancer or receiving influenza vaccination

The report does highlight a few successes in addressing health disparities in the US, including the Vaccines for Children program (helping provide economically disadvantaged children access to vaccines) as well as healthcare access expansion via the Affordable Care Act.

There is an enormous amount of work to be done to address healthcare inequity in the US. The CDC is making strides in the right direction by producing comprehensive, actionable data to help identify at risk populations and target interventions. Hopefully we will continue to see these data monitored and reported on at regular intervals.

Friday, November 15, 2013

GH2DP Participants Present at ASTMH Conference in Washington, DC

Dr. Wang, Kate Pearson, Dr. Donovan, at the ASTMH
conference in Washington, DC
Congratulations to Dr. Jeff Wang, Dr. Summer Donovan and to Kate Pearson (a 4th year medical student at VCU) who presented their research at the annual conference of the American Society of Tropical Medicine and Hygiene in Washington, DC, yesterday. Jeff, Kate and Summer all worked on GH2DP-related projects in Honduras this past June.

Kate and Jeff looked at satisfaction with brigade care on our last medical outreach trip to Yoro, Honduras.

Town of La Hicaca; this is one of the sites where we see
patients in Honduras; Chagas disease is a major problem in the area
Our group provides medical and public health services to approximately 2,000 people living in 17 villages in the Yoro area of northern Honduras. Because of logistical issues (lack of road access) our primary clinical site is in the village of La Hicaca; people from the surrounding villages come see us there. Unfortunately, distance to the clinic is a significant barrier for many people, with some people having to walk upwards of 6 hours to come and see us.

Kate and Jeff found that satisfaction with brigade care differed on whether survey respondents were
Data from Jeff and Kate's survey
from La Hicaca or one of the surrounding villages (with the former group more satisfied with the services we provide, on the whole). Also, their work identified differences in the services requested, with mental health services being the second most commonly requested service in the surrounding villages (this was the 4th most requested service in La Hicaca).

Their work will significantly impact our future efforts to reach more individuals at remote village sites. It will also help us to tailor and expand the services we provide moving forward.

Dr. Donovan's work focused on knowledge and perceptions of Chagas disease in the communities we serve; we were asked to undertake this project by our local contacts in the health ministry.

Chagas disease is one of the neglected tropical diseases, and is an insect-borne parasitic infection that affects people in the Americas, especially parts of rural Latin America.

The insect vectors for the disease are known as "kissing bugs." They live in the walls and roofs of houses made of adobe, mud, straw and thatch, and emerge at night to feed on people's faces (I am not making this up). The insects thereafter defecate and the parasite (Trypanosoma cruzi), which is in the stool, gets inoculated through the skin when a person scratches.

It is estimated that 11 million people are currently living with this infection, and untreated these diseases persist for life. Chagas disease is associated with major morbidity: over time the infection can lead to heart failure and death from arrhythmias, as well as dilatation of the esophagus and colon with attendant gastrointestinal issues.


Dr. Donovan found that many people reported the presence of the vector in their homes (65% for people in La Hicaca, 76% for people in the surrounding villages) and that although general awareness about the disease was good (around 90% of survey respondents) understanding how the disease is transmitted was low (0%). This has implications for future control and educational efforts in the region. 


Chagas disease survey findings (LH: La Hicaca, SV:
surrounding villages) 
Again, congratulations to Jeff, Kate and Summer! They are phenomenal young researchers whose work will significantly impact the people we serve in Honduras. We look forward to more great things from them moving forward. 

Thursday, October 31, 2013

Free Antimicrobial Stewardship Educational Materials for Use in Medical Schools

Methicillin-resistant Staphylococcus aureus (MRSA)
(CDC)
Here is a Letter to the Editor from Dr. Luther and colleagues at Wake Forest that was published in the November 1st edition of Clinical Infectious Diseases highlighting a free Antimicrobial Stewardship curriculum for use in medical schools.

This curriculum was developed as a joint venture by the Wake Forest School of Medicine, the Association of American Medical Colleges and the Centers for Disease Control and Prevention; it is available free online.

The above is a great resource and includes both didactic lectures and small group activities, for use in both the pre-clinical and clinical years.

It is estimated that 50% of antibiotic use is inappropriate; hopefully the above material (or similar educational programs) will help inform the next generation of physicians about optimal antibiotic prescribing.

Wednesday, October 30, 2013

Antibiotic Resistance: Getting Some Well Deserved [Bad] Press

Graphic from CDC report
Some really great resources have recently been released focused on the problem of antibiotic resistance.

The first is CDC's 2013 Antibiotic Resistance "Threat Report," available here. This document outlines, in a clear and easily understandable way, the current problem of antibiotic resistance and the implications of this. Basically, the following is true:

1) Antibiotic resistance is complex and ancient
2) Antibiotic use (appropriate and inappropriate) drives resistance
3) Resistance has outpaced the development of new antibiotics
4) Certain organisms are particularly worrisome: some have developed resistance to all known antibiotics

The report is definitely worth taking a look at and is a compelling, easy read.

Graphic from CDC report
The next resource is a "FRONTLINE" segment called "Hunting the Nightmare Bacteria," available here.
This video powerfully captures just how nightmarish the problem of antibiotic resistance is.

I lecture about antibiotic resistance to college and medical students and often quote from Sir William Osler's19th century medicine textbook where he states:

"The treatment of septicaemia and pyaemia is largely a surgical problem... we have no remedy... the brilliant and remarkable results which follow complete evacuation of the pus with thorough drainage give the indication for the only successful treatment of this condition."

Picture of "bloodletting" in 1860s
(wikipedia.org)
Essentially what he is saying is that for some patients with serious infections the only chance for cure (and often survival) is to cut the infected part out; this is 19th century medicine prior to the development of antibiotics.

What is alarming is that for many patients we have returned to practicing 19th century medicine; this is expertly, and disturbingly illustrated in the FRONTLINE segment. The two patients highlighted in the show had essentially untreatable infections and to achieve cure the infected tissue had to be surgically removed.

It has only been 70 years since the widespread introduction of antibiotics in the 1940s and many patients have already entered the "post-antibiotic era." Both the CDC report and the FRONTLINE segment highlight just how dire this problem is and are well worth taking a look at.

*Many consider Sir William Osler to be 'the father' of modern internal medicine 

Monday, October 14, 2013

Global Burden of Disease Study: More Free Online Interactive Graphics

In preparing for a journal club I am leading later today on one of the excellent Global Burden of Disease (GBD) study articles I came across some new interactive graphics available online at the Institute for Health Metrics and Evaluation (IHME) site. One particularly nice feature is the "GBD Insight" graphic which provides annotated data by country and displays a variety of different metrics.  Below are some screenshots:

Honduras displayed in the "GBD Insight" program (IHME)
A close up of the data for Honduras (IHME)
The data from the GBD study are really impressive. More impressive still is the excellent way the IHME is able to translate these data into meaningful and easy to understand interactive graphics. Definitely worth taking a look!

Honduras: DALYs in 2010 (IHME); note: high burden of non-infectious diseases (in blue)
including major contributions from violence and road injuries (green)  

Sunday, September 1, 2013

Antibiotic Resistance and the Environment

Here is a link to an excellent article on antibiotic resistance and the environment published by Finley and colleagues in this month's Clinical Infectious Diseases.

These authors provide a nice overview of what is known about the relationship of antibiotic resistance and the environment, including a discussion on the origins of antibiotic resistance, selective pressures related to human waste disposal, antibiotic use in animals, et cetera.

All of the antibiotics that have been discovered have largely been adopted from environmental organisms. Microorganisms have been using these compounds (antibiotics) to combat one another for millennia; it is therefore not surprising that the mechanisms for inactivating or bypassing these compounds already exist in the environment. Finley and colleagues refer to the milieu of resistance elements in the environment as the "resistome."

What is highly concerning is that human activities are affecting the 'environmental resistome.' Antibiotic use in animals can lead to environmental contamination with antibiotic resistant bacteria that can thereafter disseminate across human and animal populations. Additionally, resistance that originates from antibiotic selective pressure from use in animals can also spread via water and food contamination.

The authors call for more regulation of non-human antibiotic use and a coordinated "One Health" approach to addressing the problem of antibiotic resistance. One thing is certain: antibiotic resistance is ancient and human activities are driving antibiotic resistance. It has been less than a century since the discovery and widespread use of antibiotics; if we want to continue to benefit from the amazing advances that antibiotics have facilitated much will need to be done to both understand and minimize the impact of environmental health pressures on antibiotic resistance.

Monday, July 22, 2013

Update on VCU's Global Health & Health Disparities Program (GH2DP) Presented at Infectious Diseases Grand Rounds

With Dr. Bearman
Today my friend and colleague Dr. Gonzalo Bearman and I presented an update on our work in Honduras at VCU's Infectious Diseases grand rounds.

We provided a brief overview of the evolution of our work in the Department of Yoro, Honduras, since 2005, highlighting our 4 part mission (direct patient care, public health, student and resident exposure to global health concepts and research) and discussed the evolution of the Global Health and Health Disparities Program here at VCU.

Since 2008 we have distributed 400 water filters and now provide clean drinking water to approximately 1,500 people living across 17 villages. The incidence of severe diarrheal illness being reported to the local Ministry of Health has been halved since the inception of our program, and no child deaths from diarrhea have been reported in the past 18 months. Although our program is small in scope we believe it is having a positive impact on the communities we partner with.

To boot, we now support a residency track within VCU's Internal Medicine Training Program designed to give particularly motivated residents robust education in and exposure to global health concepts. As well, we have started a Student Scholars program that will afford similar opportunities to medical students.

To find out more please visit our website. To find out how to support our program ($25 dollars will buy a family a water filter that will provide clean drinking water for 2 years or more!) please follow this link.


Saturday, July 13, 2013

VCU Global Health & Health Disparities Program (GH2DP) featured on School of Medicine Website

The VCU Global Health & Health Disparities Program (GH2DP) and our first graduate (Dr. Jeff Wang) are featured on the VCU School of Medicine's website (the story can be found here). Congrats Jeff!!!

The GH2DP residency track exists within VCU's Internal Medicine Residency Program and is designed to give particularly interested and motivated residents robust opportunities focused on global health. Residents have both domestic and international clinical opportunities focused on serving underserved populations, and are responsible for graduate level coursework, independent study and quality improvement and research projects, as well.

Dr. Jeff Wang examines a patient in La Hicaca, Honduras
We are looking forward to expanding our work to include motivated medical students this upcoming year; this program is known as the "GH2DP Student Scholars Program."

Providing global health education and experience to students and residents is only one facet of GH2DP's activities. Fundamentally, the GH2DP exists to improve the health of underserved populations. Our primary focus is on a series of 17 villages in northern Honduras with approximately 2,000 people with little to no access to care.
Dr. Wang supervising water filter assembly,
La Hicaca, Honduras

You can find out more about GH2DP here.

Wednesday, July 3, 2013

Preventing "Summer Fevers": Article Published on Tick and Mosquito-Borne Diseases in Central Virginia

Here is an article published in Chesterfield Monthly looking at tick and mosquito-borne diseases in central Virginia. The article provides a nice overview of several key diseases, including information on their incidence and presentation. The article concludes with some great general advice on preventing these illnesses from the Virginia Department of Health.

Tuesday, July 2, 2013

Special Guest Blog Post From Dr. Bo Vaughan: Evaluating TB Efforts in the Dominican Republic


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. 

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
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.

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

Tuesday, June 18, 2013

Congratulations Gabriela Halder-Manuscript Published on Research in Honduras

Here is a blog post (used with permission) from my friend and colleague Dr. Gonzalo Bearman about work one of our students did in Honduras (great work Gaby!); the original post can be found here.

Congratulations Gabriela Halder! As a member of our Honduras research and clinical team (2011), Gaby has successfully published a manuscript on water sanitation, access and self reported diarrheal illness in rural, mountainous Honduras.

For the full manuscript in PDF, click here.

Gaby's work was presented at the American Public Health Association national conference in 2011 where she was recognized with a research award.

Fantastic work!

Dr. Gonzalo Bearman

Saturday, June 15, 2013

Congratulations to Dr. Jeff Wang on Graduating from the GH2DP Residency Track!

Dr. Wang examines a patient in Yoro, Honduras
Congratulations are in order to Dr. Jeff Wang, who is the first graduate of VCU's Global Health & Health Disparities Program (GH2DP) residency track.

The GH2DP residency track exists within our Internal Medicine Residency Program, and is designed to provide motivated residents with a robust curriculum in/ exposure to global health issues. The program has both domestic and international components, and residents have to apply and be accepted into the track.

Dr. Wang completed approximately 15 hours of online modules, graduate level coursework in
public health, a quality improvement project related to our medical records system in Honduras and an IRB-approved survey project looking at satisfaction with brigade care.

Dr. Wang certainly has set a high standard for our GH2DP residents, and we look forward to seeing the great things he will accomplish moving forward.

Wednesday, June 5, 2013

VCU Global Health & Disparities Program's May-June Northern Honduras Trip

Hi everyone, I have posted new information about our May 26-June 3rd medical and public health relief trip to the Department of Yoro area of northern Honduras on the Global Health & Health Disparities Program (GH2DP) site.

Click here for a slideshow of pictures from the trip.

You can read more about the trip here.

Saturday, June 1, 2013

2013 GH2DP Brigade: Initial Statistics

We are just getting back to Olanchito after a highly successful 5 days in the mountains of rural Honduras.

This year we saw approximately 330 adults (and another 360 children); we screened and provided anti-worm therapy to all adults and screened for diabetes, hypertension and anemia, as well.

We also distributed 150 water filters; 75% of the households across the 17 villages we serve now have access to clean drinking water. We also facilitated over 80 Pap smears.

We administered over 190 satisfaction surveys and over 170 Chagas disease surveys, as well.

Additionally, we provided education about the dangers of indoor air pollution and feedback about things people can do to improve respiratory health.

All in all a great 5 days in the mountains! Stay tuned for pictures and more information about the trip.





Saturday, May 25, 2013

VCU's Global Health & Health Disparities Program/ HOMBRE Team Sets Off for Honduras! [Again!]

Tomorrow our team leaves on our medical and public health brigade to the La Hicaca area of northern Honduras. 

Town of La Hicaca; this is one of the sites
where we see patients in Honduras
Since 2008 we have been serving people across a series of 17 villages in and around the La Hicaca area of rural HondurasThis is the 6th consecutive year where we have held large-scale medical clinics in the region.  

Since the inception of our program (the VCU Global Health & Health Disparities Program, or GH2DP), we have had over 8,000 direct patient encounters, and have helped distribute over 200 water filters (each of which will provide clean drinking water to an entire family for 2+ years). We also have provided de-worming therapy multiple times a year according to WHO standards. 

Traveling to La Hicaca
It is important to note we are absolutely indebted to our community partners (see here for an interview with Father Pedro O'Hagen) as well as our non-profit partners the Honduras Outreach Medical Brigada Relief Effort (HOMBRE) and the Golden Phoenix Foundation. The work we do is a collaborative effort across multiple non-profit organizations and involves myriad professional schools and training programs as well as many independent healthcare professionals. Simply put, there are a lot of moving parts to these brigades!

This year our group includes 5 rising 2nd year medical students, 2 rising 4th year medical students, 2 pharmacy students, 3 internal medicine residents, 2 pediatrics residents, 1 pediatric fellow, 2 nurses, 3 attending physicians, 1 PhD microbiologist among others; all told there will be nearly 30 people in our group. 

Drs. Mason, Bearman and Stevens working on the
water filter program, La Hicaca
There are approximately 2,000 people in the area we serve, most of whom have extremely limited access to healthcare (see here for a study we did in 2011 looking at people’s ability to access care in this area). The nearest public hospital is two and half hours away by truck, making routine (and oftentimes even emergent) access to medical care nearly impossible. For the majority of people we see we function as their only access to healthcare. 

We had a small team 'on the ground' in the area back in January (see here for previous blog entries related to that trip). During the January trip we laid the groundwork for our current brigade, meeting with community partners, defining our mission and navigating logistical issues (what services we will provide, where we will set up the clinics, et cetera). 

Scouting out sites for our medical clinics in Lomitas,
January 2013 (these buildings are where we will hold
clinics for several days during our current brigade)
Although a big component of our work is focused on providing medical care, we have multiple public health programs as well. One of these projects is the aforementioned large-scale water filter program. To date, we have distributed 200 water filters and estimate that approximately 75% of the population in the region now has access to clean drinking water. Our data indicates that these filters have both microbiologic and clinical efficacy, and we have incidence data on diarrheal illness from the Ministry of Health that indicates diarrheal disease has been cut roughly in half since we started this program. More importantly, there has not been a single pediatric death from diarrheal illness in the region over the past 18 months. This year we will distribute another 100 water filters; our ultimate goal is to provide everyone in the area with access to clean water. 

Meeting with local health minister, Olanchito,
January 2013
Another big project for us over this past year has been assessing the impact of indoor air pollution on the health of people in the region; our local partners noted this was a major issue and asked us to do a formal needs assessment. In June of 2012, Audrey Le, now a rising third year medical student at VCU, did a needs assessment looking at indoor air pollution in the region. She found that indoor air pollution was associated with negative health effects, although many people were unaware of the dangers of indoor air pollution. On further examination of the issue this past January, we discovered that indoor air pollution was at least partly related to improperly installed (versus degraded) stove ventilation pipes. On our current brigade Audrey Bowes, a rising second year medical student at VCU, is leading an education program focused on raising awareness of the negative health effects of indoor air pollution and how stoves can be repaired to improve indoor air quality. We are excited about this project and believe it has the potential to significantly improve the health of the people we serve. 
Example of a properly installed ventilation
pipe; many of the pipes we inspected had
gaps between the pipe and either the stove
or wall (via which smoke could escape and
pollute the indoor environment)

An additional project we are doing on this brigade is a survey on Chagas disease that is being led by Dr. Summer Donnovan, a pediatric infectious diseases fellow at VCU; our community partners have identified this as a major issue in the region. Chagas disease is one of the neglected tropical diseases, and is an insect-borne parasitic infection that affects people in the Americas, especially parts of rural Latin America. It is estimated that 11 million people are currently living with this infection, and untreated this disease persists for life. Chagas disease is associated with major morbidity: over time the infection can lead to heart failure and death from arrhythmias, as well as dilatation of the esophagus and colon with attendant gastrointestinal issues.

Finally, we a have a third project that is looking at people's overall satisfaction with, and the limitations of, the care we provide on our brigades. This is a quality improvement project being led by Dr. Jeffrey Wang and Kate Pearson, a rising 4th year VCU medical student. 

We are very excited about this brigade and are hopeful our efforts will improve the health of people living in the region we serve. For anyone interested in our work, please consider following this blog for updates on the brigade. My friend and colleague Dr. Gonzalo Bearman will also be providing updates on the trip (his blog can be found here).