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