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 Honduras. This 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). 

Yellow Fever Vaccination Boosters: Unnecessary per WHO

Aedes aegypti mosquito (the mosquito that transmits the
yellow fever virus); cdc.gov

Here is a press release from the World Health Organization regarding yellow fever vaccination; this is a 'game changer' for immunization programs in endemic countries as well as for people traveling to endemic areas.

"Yellow fever" refers to the disease caused by the yellow fever virus that is transmitted by mosquitoes in areas of Africa and South America. This a hemorrhagic fever virus associated with substantial mortality and high morbidity. Worldwide there are approximately 200,000 cases yearly with 30,000 deaths. Although a safe and effective vaccine is available for this disease, there is no treatment (other than supportive care) for people who contract it. 

The press release refers to an analysis that was done looking at whether "booster" doses of yellow fever vaccine are needed following initial vaccination. The current practice is to administer a booster dose every 10 years. Yellow fever is (nearly) unique in that it is one of the only vaccine-preventable diseases where there is an international requirement to have documentation of having received the vaccine (or having a medical contraindication) to allow travel to many countries in Africa and South America. The vaccine is generally well tolerated, although it is a live virus vaccine and is contraindicated for people with immune-suppressing conditions. 

The press release noted that over 600 million doses of yellow fever vaccine have been administered since the 1930s when yellow fever vaccination began. There have only been 12 cases of yellow fever following vaccination and these did not occur greater than 10 years following vaccination; all told, the analysis was inconsistent with waning immunity and need for booster immunization. 

This is welcome news, although time will tell how this will effect vaccination programs as well as international travel requirements for yellow fever vaccination. 

More on the VCU Global Health Symposium

VCU Global Health Symposium speakers

More on the recent First Annual VCU Global Health Symposium can be found on the university's global education website here.

The meeting took place on Saturday, April 27th, and brought together students, residents and faculty from across the university. One of the key goals of the meeting was to provide a platform for sharing ideas, networking and developing the framework for future collaboration. The meeting featured short talks focused on research at both the community and international levels, and a poster session.

Our group (the VCU Global Health and Health Disparities Program, or GH2DP) provides both medical care and public health interventions to approximately 2,000 people living across 17 villages in rural Honduras. As a result of the VCU Global Health Symposium we have new contacts and new ideas including improving mental health services in the region as well as clean water infrastructure. 

Going Global: Workshop on Providing Global Health Experiences to Residents Presented at Spring APDIM Meeting

With Drs. Cosco and Sam at the Association of Program
Directors in Internal Medicine conference in Orlando, Florida

I had the great opportunity to co-lead a workshop on providing global health experiences to residents at this week's Association of Program Directors in Internal Medicine's Spring conference in Orlando, Florida.

With colleagues from Emory and Kaiser Permanente, we discussed barriers, resources and different models of providing global health experiences to internal medicine residents. The slides from our talk can be found here.

There is an enormous amount of interest in global health at both the medical student and resident levels; providing these experiences can be difficult, however. Some of the key issues include finding international partners, securing adequate funding, providing adequate supervision as well as many other logistical challenges.

To date, we have been able to provide global health experiences to approximately 60 medical and pharmacy students as well as over 20 internal medicine residents via the VCU Global Health & Health Disparities Program (GH2DP). Students and residents work with patients and communities in rural Honduras, where they participate in direct medical care and public health work.

We had a good turnout at the workshop and hope that we have created a framework via which medicine programs can continue to share ideas and best practices in providing global health experiences to residents moving forward.