VCU's Global Health & Health Disparities Program Sets Off for Honduras

Drs. Mason, Stevens and Bearman meeting with community
leaders and the minister of health, Olanchito, Honduras,
January 2012

Today our team leaves to meet with community leaders and the ministry of health in Yoro, Honduras. 

Traveling to La Hicaca

Since 2008 we have been serving people across a series of 17 villages in and around the La Hicaca area of rural Honduras. There are approximately 2,000 people in this area, 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). We have a large-scale water filter program in the area, and participate in direct medical care, as well. We work closely with our community partners to support health projects they identify as being high yield (some past examples of such projects include a water chlorination education campaign, an anemia point prevalence survey and a survey project examining indoor air pollution).

Drs. Mason, Bearman and Stevens working on the
water filter program, La Hicaca

Every January a small group of us goes down to meet with our community partners and the ministry of health. Our purpose with these trips is three-fold: to prepare for our (larger) June medical trip, to identify new ways in which we can support the people we serve, and to report back on our findings from the previous trip’s work. This year we will be presenting our data from the anemia point prevalence survey, from our survey project on indoor air pollution, and from our study examining the clinical and microbiologic efficacy of our water filter program. Of note, the 2 lead student researchers on the two latter studies just presented their data at yesterday's Virginia ACP Associates' meeting. 

Working on the anemia point prevalence survey, La Hicaca,
June 2012

Since the inception of our program (the VCU Global Health & Health Disparities Program, or GH2DP), we have had over 8,000 direct medical and pediatric encounters, and have distributed over 200 water filters (each of which will provide clean drinking water to an entire family for 2+ years). We also provide de-worming therapy and have been involved in numerous other projects since 2008.

Providing clinical care, La Hicaca, June 2012

For anyone interested in our work, please consider following along as we conduct our planning trip. I will attempt to blog "from the field," and will provide updates in as close to real-time as I am able.

Congratulations Jim, Audrey and Jackie! VCU Students and Residents Present at the VA ACP Associates' Meeting

Congratulations to Audrey Le, Jackie Arquiette and Dr. Jim Pellerin, all of whom have done research with our group, who presented their respective research projects at the Virginia American College of Physicians Associates' Meeting today. Their research really spans the gamut of "Bugs, Drugs & Global Health."

Audrey Le presenting her research 

Audrey Le, a second year medical student at VCU, presented her project looking at indoor air pollution in and around the remote village of La Hicaca in northern Honduras. She found a link between stove location and respiratory symptoms, and her data will inform our future efforts to improve indoor air quality in this area.

Jackie Arquiette presenting her research 

Jackie Arquiette, also a second year VCU medical student, presented on her research looking at the clinical and microbiologic efficacy of our water filter program in this same area. She found decreased self-reported diarrheal illness in patients with water filters, and she found little diarrhea-genic bacteria in the water she tested from our water filters. Her findings support the continuation (and expansion) of our water filter program.

Dr. Jim Pellerin presenting his research 

Dr. Jim Pellerin, a VCU medicine resident, presented his findings categorizing and assessing compliance with antibiotic stewardship recommendations at our medical center. His findings are compelling and will help us refine our stewardship program efforts moving forward.

I know I speak for my research collaborators when I say we are very proud of all three of these very talented student and resident researchers.

Influenza Activity in the US: New CDC Data

Here are the latest influenza activity maps from the CDC; influenza activity continues to be widespread in the United States. The maps below illustrate how influenza activity has ramped up over the past few weeks (the most current map, including data for the week ending January 11, appears last). For orientation, states appearing in brown are states where there is widespread flu activity.

You can find up to date information on influenza from the CDC here. Here is a nice article that was just posted on CNN about influenza, as well. And remember: it's still not too late to get your flu shot!

Rainfall, Temperature and Dengue Risk: New Insights from Rio

Aedes aegypti mosquito (cdc.gov)

Here is a study by researchers from Brazil that looked at the relationship between dengue activity and climate in Rio de Janeiro from 2001 to 2009. Using statistical modeling, they found that a 10-millimeter rise in rainfall led to a 6% increase in dengue cases in the subsequent month, and a 1 degree celsius rise in temperature led to a 45% increase.

Dengue is a viral infection transmitted by Aedes aegypti (and Aedes albopictus) mosquitoes; it is the most common mosquito-borne viral infection. It causes an acute febrile illness characterized by severe pain (giving it its colloquial name: "breakbone" fever). The disease is associated with significant morbidity.

The findings in the above study are not surprising: increased temperature allows the mosquitoes that carry dengue to breed and feed more efficiently. Increased rainfall can increase potential breeding sites for these mosquitoes (which breed in freestanding water). This study adds to the growing body of literature linking climate and infectious disease activity.

A warmer world is one in which the various vectors for tropical infections (especially mosquitoes) will enjoy a broader environment in which to breed and feed. More research into the relationship between climate change and emerging infectious diseases is warranted.

Hottest Year on Record for the Contiguous US: Implications for Emerging Infectious Diseases?

http://climate.ncdc.noaa.gov

Here is an article from the Huffington Post discussing National Oceanic and Atmospheric Administration (NOAA) data from 2012, noting that 2012 was the "hottest year on record for [the] lower 48 [United] states." The article is compelling and contains some nice images that outline how the average temperature has increased in the contiguous United States over the past century; it is believed that climate change has played a role in this mean temperature increase.

A byproduct of increasing global temperatures is the expansion of insect habitats that can harbor viral infections (such as dengue, chikungunya and yellow fever).  As I have previously noted, this phenomenon may have contributed to a dengue outbreak in southern Florida, and may lead to other viral infections (such as chikungunya) emerging in other parts of the United States, as well. A recent study from Mexico found the mosquitoes that can carry dengue (as well as the chikungunya and yellow fever viruses) at higher elevations than previously identified; this may represent expansion of the mosquitoes' habitat due to global warming.

If the world continues to grow warmer, the medical and public health communities need to be aware (and vigilant in surveillance) of the potential for traditionally "tropical" infectious diseases to emerge in (what were once) more temperate climates.

Influenza in the US: Now Widespread

According to the CDC, influenza activity in the United States has now become widespread. The maps below demonstrate this (states appearing in brown have widespread flu activity; you can see how activity has ramped up across most of the middle of the country over the course of a single week).

This is shaping up to be at least a moderately severe influenza season; only time will tell how this season will compare to others. As this year's (Northern hemisphere) vaccine pretty closely matches the circulating flu strains detected to date, it is not too late to get a flu shot.

An Update on Tuberculosis

Here is an excellent article on tuberculosis published in Nature.

Tuberculosis (TB) is caused by a bacteria and is spread largely through the air (when someone with TB in his or her lungs coughs, et cetera). TB commonly causes lung disease, but can involve many other parts of the body, as well. Most people who are exposed to TB do not develop active infection; rather, they develop "latent" infections where they are not infectious and the bacteria are dormant. Although people with latent infections can go on to later develop active infections, the majority do not. If a person develops an immune-system compromising disease (such as HIV) he or she is then much more likely to develop active TB infection. TB is a deadly illness; in 2011 there were 1.4 million TB deaths globally.

It is estimated that one-third of people worldwide are infected with TB.

The Nature article provides a comprehensive overview of what is currently going on with TB globally, and discusses the problem of TB drug resistance in great detail. Identifying drug resistance in TB is time-consuming and difficult and testing for this is far from universal. The article also highlights what has contributed to the emergence of drug-resistant TB, including the breakdown of public health infrastructure and TB control programs.

What are needed are better antibiotics for drug-resistant TB and, the "holy grail" for TB control, a highly effective vaccine. Additionally, tests for drug resistance need to get better, faster and cheaper, and TB control programs need to be supported aggressively.

Measles Deaths on the Rise in Pakistan

Child with measles (cdc.gov)

Here is an article from The Washington Post reporting on measles deaths in Pakistan in 2012. 306 children died of measles in Pakistan in 2012, up from 64 in 2011. Pakistan is also one of the only countries in the world where polio is still endemic.

The article cites public distrust of vaccination and damage to health infrastructure from flooding as potential reasons for the increase in measles cases. Sadly, there have been multiple reports in recent weeks of aid workers being killed in Pakistan, a fact that also may compromise child vaccination efforts in this country.

Measles is a highly contagious viral illness that mostly affects children; it causes high fever, cough and rash. Although most people recover from the illness it can cause serious complications, including encephalitis (brain inflammation), blindness, pneumonia, and death. Efforts to prevent developing the illness (such as vaccination) are key as there is no specific treatment for the illness once acquired.

Transmission electron micrograph image of a
single measles virion (cdc.gov)

In 2010 139,300 measles deaths were reported. These deaths were mostly in developing countries with poor health infrastructure. We have a safe, cost-effective measles vaccine available and there is an international push to vaccinate all children against this deadly viral illness. According to the World Health Organization (WHO), progress has been made over the past decade: between 2000 and 2010 there was a 74% drop in global measles deaths, and in 2010 approximately 85% of children globally had received at least one dose of measles vaccine (up from 72% a decade earlier). According to data in the recently released Global Burden of Disease study, in 1990 measles was the number 12 most important cause of global years of life lost; in 2010 it had dropped to number 38.

Measles is not only a problem in the developing world, however. In recent years a dramatic rise in measles cases has been seen in France and England, largely related to inadequate vaccination rates in younger people.

Globally, progress has been made over the past twenty years in combating vaccine-preventable viral illnesses. The current increase in measles deaths in Pakistan is a good reminder, however, that there is still much more to be done.

Giant Pandas: Source of New Antibiotic?

wikipedia.org

Here is an interesting article from The Telegraph reporting on research into antimicrobial compounds encoded in giant panda DNA. A compound called "cathelicidin-AM" was found to have potent antimicrobial activity.

The article notes that this compound can be created synthetically (e.g., giant pandas, which are few in number, do not have to be the primary source of compound production). The results of this research are intriguing but much is uncertain at this point: will cathelicidin-AM have a role in combating human infections? Only more research (and more time) will tell.

Certainly this research does highlight the fact that many antimicrobial compounds exist in the natural world (the vast majority of human antimicrobials are derived from natural products) and, predictably, there are numerous potential compounds still 'out there' to be discovered. As humans encroach more on the natural world there is the danger that we may lose many of these compounds before they are discovered.

Update on Flu Activity in the United States

Detailed updates on influenza activity are produced weekly by the CDC and can be found here.

For the week ending on 12/22/12 here are the highlights (for the United States): 

1) 31 states reported widespread influenza activity (including my 'neck of the woods,' Virginia)

cdc.gov

2) There have been 16 pediatric deaths due to influenza since September 30, 2012. Overall the percentage of deaths due to influenza and pneumonia was below the "epidemic threshold" 

cdc.gov

3) Influenza A (H3N2) viruses have been most prominent, followed by influenza B; 2009 H1N1 (responsible for that season's pandemic) have been relatively rare

4) 312 infections with "variant" influenza viruses have been detected; these were mostly H3N2v. These viruses normally circulate in pigs and human infections have been attributed to prolonged contact with pigs at agricultural fairs; no sustained community spread of H3N2v has been detected

Influenza activity is now widespread in the US; this year's (Northern hemisphere) vaccine includes many of the circulating viral strains: it is not too late to get your flu shot!