global health: peru · •abnormal bleeding, jaundice, hemoglobinuria or severe anemia (hemoglobin...
TRANSCRIPT
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Global Health: Peru
Jacqueline Allen, R3
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• Topics:
• The Journey to Santa Clotilde
• Centro de Salud
• Backround/History
• Hospital Capacity & Resources
• Daily Routines
• The Medicine & Cases
• Malaria
• Tuberculosis
• GI bugs
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Source: http://www.utexas.edu/inside_ut/peru/graphics/peru_map_small.jpg
Source: http://toi.boi.go.th/bpanel/upload/news/2015/08/20150811150044_peru_map.jpg
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Source: http://4.bp.blogspot.com/-
GpQHyzRWIdk/TrxK-
kBwdKI/AAAAAAAAAGk/HoOpkgHianU/s1600/
DSCN3138.JPG
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Santa Clotilde
• North-eastern Peru, on the Rio
Napo
• It is accessible only by boat or, less
commonly, by float plane
• Nearest major city is Iquito -
accessible only by boat or by plane.
• Inhabited by indigenous people.
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Source: http://user.xmission.com/~wooding/Peru/images/Peru-Hidronav-400-Rio_Amazonas.jpg
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Source: http://user.xmission.com/~wooding/Peru/images/Peru-Hidronav-400-Rio_Amazonas.jpg
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https://viajeporlatinoamerica.files.wordpress.com/2013/05/p1120568_1024x768.jpg
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Centro de Salud Santa
Clotilde
(CSSC)
• Santa Clotilde itself is the referral center for what is
known as the “Micro Red Napo”.
• The Micro Red Napo:
• A chain of rural health outposts linked by the Napo River.
• Outposts are staffed by a full-time nurse who lives on site
(and sometimes a SERUM)
• Santa Clotilde serves as the primary center for supplies,
patient referrals, and logistical support.
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Source: http://user.xmission.com/~wooding/Peru/images/Peru-Hidronav-400-Rio_Amazonas.jpg
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Centro de Salud Santa
Clotilde
(CSSC)
• After WWII: the Peruvian government gave the
Agricultural Station of Santa Clotilde to the
Canadian Franciscans.
• 1951: the Missionary Sisters of Our Lady of the
Angels of Quebec Canada
• Developed education and health system in Santa
Clotilde.
• provided medical attention to the river population for
40 years under the direction of several nurse-nuns.
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Centro de Salud Santa
Clotilde
(CSSC) • In 1986 the physician-priests Fr. Jack
McCarthy and Fr. Maurice Schroeder established a de facto hospital.
• Now the CSSC includes a 30-bed hospital with a general medical area, a labor and delivery, an operating room, a clinic, and a laboratory.
• CSSC is the head of a network of 12 health establishments along 400km of the Napo River and serves 100+ villages and a population of over 20,000.
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CSSC: Background
• Patients unable to be treated at the CSSC are stabilized and transferred to Iquitos via a one day boat trip and if needed flown to Lima, all of which is paid for by the CSSC.
• Patients are given a bill and all are expected make a form of payment.
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CSSC: Services
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Laboratory
• Manual blood counts, hematocrits, platelets, thick and thin films, creatinine, stool exams, urine microscopy, pregnancy tests, ALT, AST, ESR, HIV (rapid tests only), VDRL, sputums for AFB, and agglutination test for typhoid / paratyphoid.
• They cannot do electrolytes, cultures, screening for Hep B or C, or HIV confirmatory testing.
• If needs dictate they collect blood locally and send samples to Iquitos for additional special tests, such as serology for dengue or leptospirosis. HIV confirmatory testing is done in Iquitos.
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Additional Testing/Imaging
• EKG machine (broken)
• Xray machine (broken)
• Ultrasound (working)
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Pharmacy
• Variety
• Individual donations -
inconsistent.
• Some meds are beyond
their official expiry date.
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Daily Routine
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Daily Routine
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The Medicine &
Cases
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Malaria
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Malaria: Epidemiology
• Over 40% of the world's population live in malaria-
endemic areas.
• Estimated 300 to 500 million cases and 1.5 to 2.7
million deaths occur each year.
• Disproportionately affects the poor:
• 60% of malaria deaths worldwide occur in the poorest
20% of the population.
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Malaria
• Which species of plasmodia causes the most cases of malaria worldwide?
A. Plasmodium falciparum
B. Plasmodium malariae
C. Plasmodium vivax
D. Plasmodium ovale
• The majority of cases and almost all deaths are caused by Plasmodium falciparum
• Plasmodium vivax, Plasmodium ovale and Plasmodium malariae cause less severe disease.
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Source: www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf
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www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf
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Source:
http://www.nature.com/nature/journal/v462/n7271/images/462298a-
f1.2.jpg
Transmission
• The parasite is transmitted by night-biting Anopheles mosquitoes.
• Warm climates with high humidity and abundant rain create favorable conditions for mosquitoes by increasing breeding areas and prolonging survival
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Source: http://d1vn86fw4xmcz1.cloudfront.net/content/royptb/366/1579/2806/F1.large.jpg
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Malaria: Symptoms
• >85% Nonimmune travelers will not experience symptoms until they return to their non-endemic countries.
• 8 weeks for falciparum
• 2-3 months for vivax
• Most infections will be symptomatic w/in 1yr
• Fever above 38C, rarely in classic pattern- more commonly fever pattern is hectic, chills, myalgias, HA, cough, GI sx.
• Malaria until proven otherwise
• A delay in diagnosis can lead to catastrophic outcomes
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Source: https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcRrzxkWkaFtA3dnbclCm8l9Oa40qW2V9G_woveJWlnGoBVAxtQ4
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Malaria
• Red blood cell lysis/destruction causes anemia
• Waves of parasites rupture red blood cells, which
leads to classic cycles of fever and chills
Source: http://d1vn86fw4xmcz1.cloudfront.net/content/royptb/366/1579/2806/F1.large.jpg
Source:https://lh5.googleusercontent.com/-jUiqhho3ZAU/TXkflRF6-
bI/AAAAAAAAHiQ/Mb7fIlP7ps8/s1600/malaria_blood.jpg
Source:
http://courses.bio.unc.edu/2010Spring/Biol402/powerpoints/
Malariaintro2010.ppt
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Malaria
• Changes adhesive properties of infected RBCs,
leading to occlusion of blood vessels and tissue
hypoxia
Source: http://courses.bio.unc.edu/2010Spring/Biol402/powerpoints/Malariaintro2010.ppt
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Complications
• Severe malaria, as defined by the World Health Organization (WHO), refers to a parasitemic person with 1 or more of the following:
• Prostration (inability to sit up without help) or impaired consciousness,
• Seizures
• Respiratory distress or pulmonary edema,
• Circulatory collapse,
• Abnormal bleeding, jaundice, hemoglobinuria or severe anemia (hemoglobin < 50 g/L or hematocrit < 15%).
• Respiratory distress, seizures and severe anemia are more common in children.
• Renal failure and jaundice occur more frequently in adults.
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Diagnosis • A high degree of suspicion
• “Gold standard” is Giemsa stain of thick and thin peripheral blood smears.
• Malaria smears permit both species identification and quantification
• Malaria should not be excluded until at least 3 negative blood smears have been obtained within 48 hours.
• Rapid antigen detection tests (RDTs)
• detect parasite proteins in finger-prick blood samples
• can identify only P. falciparum and P. vivax
• unreliable as tests of cure
• sensitivity and specificity of RDTs for the detection of falciparum malaria are over 90%. However, sensitivity falls dramatically with lowlevel parasitemia.
Gota gruesa
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Source: http://www.southsudanmedicaljournal.com/assets/images/Articles/4_1_feb_11/Malaria_2.jpg
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Malaria Treatment
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Treatment
Source: JAAM, CDC
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Malaria- Treatment
• P. vivax
• Chloroquine combined with Primaquine
• P. falciparum
• Mefloquine, and Artesunate, Primaquine
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Source: http://image.slidesharecdn.com/antiprotozoalprotozoanematodescestodes-140423235051-phpapp02/95/antiprotozoal-protozoa-nematodes-cestodes-trematodes-malaria-amebiasis-and-
balantidial-dysentery-leishmaniasistrypanosomiasistrichomoniasis-and-giardiasis-30-638.jpg?cb=1398297246
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Case: malaria with anemia
• 9yo M presented to clinic with 1 day h/o fever and body aches.
• He was diagnosed with M falciparum and discharged with Artesunate, Mefloquine and Primaquine.
• He receives one dose but does not return to clinic to complete therapy.
• He returns to clinic 2 weeks later with persistent fever, body aches and marked pallor.
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Case: malaria with anemia
• Repeat testing is positive for M vivax and Hct is 24.
• Pt is given treatment for Vivax with Chloroquine and
Primaquine.
• He returns to clinic 2 day later for follow-up and is
found to have a Hct of 17.
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Case: malaria with anemia
• We admitted the patient, continued treatment for M. vivax and restarted treatment for M. falciparum, and gave IVFs.
• LFTs were borderline elevated. Bilirubin level was nl.
• Unable to get haptoglobin or LDH.
• RBCs appeared to have macrocytosis per lab tech. Retic count elevated.
• We also looked for a blood donor w/ O+ blood (mother breastfeeding, father candidate)
• Over the next 2 days, pt’s Hct increases to 19, then 21, but he was saturating in the mid-80s with ambulation and requiring 2-3L O2.
• Would you transfuse?
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Case: malaria with anemia
• We held off on transfusion despite his symptoms b/c
there is more allergic reactions, side effects when
whole blood is given. And Hct was uptrending.
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How do we solve the malaria
problem?
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WHO – Roll Back Malaria Program
• Global partnership
• 4 main components
• Access to effective treatment
• Preventing malaria during pregnancy
• Reducing mosquito-human contact by widespread use of insecticide-treated bednets
• Ensuring timely and appropriate action during malaria epidemics
Source: http://exploregram.com/wp-content/uploads/2016/02/A-baby-sleeps-under-a-mosquito-net.-The-World-Health-Organization-has-declared-the-ZikaVirus-microce.jpg
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Not that long ago….
www.columbia.edu/itc/hs/medical/pathophys/parasitology/2006/PAR-05Color .pdf
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Tuberculosis
• 9.6 million people in 2014, including 1.2 million people living with HIV.
• 1.5 million TB deaths in 2014.
• Globally in 2014, an estimated 480,000 people developed multidrug resistant TB (MDR-TB).
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Sites of TB Disease
• Pulmonary TB occurs in the lungs • 85% of all TB cases are pulmonary
• Extrapulmonary TB occurs in places other than the lungs, including the: • Larynx
• Lymph nodes
• Brain and spine
• Kidneys
• Bones and joints
• Miliary TB occurs when tubercle bacilli enter the bloodstream and are carried to all parts of the body
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TB Transmission
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Latent TB vs. Active TB Disease
LTBI TB Disease
Tubercle bacilli in the body
TST or QFT-Gold® result usually positive
Chest x-ray usually normal Chest x-ray usually abnormal
Sputum smears and cultures
negative
Symptoms smears and cultures
positive
No symptoms Symptoms such as cough, fever,
weight, loss
Not infectious Often infectious before treatment
Source: http://globaltb.njms.rutgers.edu/downloads/products/Mantoux_Appendices/FundamentalsofTB.ppt
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Recommended treatment for new cases of drug-susceptible
TB is a six-month regimen of four first-line drugs:
Source: https://upload.wikimedia.org/wikipedia/commons/0/08/Tuberculosis-drugs-and-actions.jpg
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Challenges of Treatment
• Most TB is curable, but… • Four or more drugs required for the simplest regimen
• 6 or more months of treatment required
• Person must be isolated until non-infectious
• Directly observed therapy to assure adherence/completion recommended
• Side effects and toxicity common • May prolong treatment
• May prolong infectiousness
• Other medical and psychosocial conditions complicate therapy • TB may be more severe
• Drug-drug interactions common
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Case 2
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• Vision
• A world free of TB. Zero deaths, disease and suffering due to TB.
• Goal
• End the global tuberculosis epidemic.
• Indicators
• 95% reduction by 2035 in number of TB deaths compared with 2015.
• 90% reduction by 2035 in TB incidence rate compared with 2015.
• Zero TB-affected families facing catastrophic costs due to TB by 2035.
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Case 3
• 11yo presents with 1 day h/o fever 39C, bilious vomiting. No diarrhea. Brother with malaria. Ill-appearing w/ AMS, unable to walk, does not respond appropriately to questions. Looks around the room.
• Given 3 bolus of 20cc/kg. Now able to walk around.
• Begins to have watery diarrhea requiring diapers. Unable to check a BMP. Negative for malaria.
• Rehydration solution
• Day 2 Able to converse better. Does not remember anything that happened.
• Stool positive: Giardia lamblia/intestinalis, and Ascariasis lumbricoides
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Giardia
42
188
https://s-media-cache-ak0.pinimg.com/564x/ee/61/f2/ee61f21d0d73dbc9c57375a8e43a29cc.jpg
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Giardia Treatment
• Effective treatments include metronidazole,
tinidazole, and nitazoxanide.
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Ascariasis lumbricoides
https://learnzoology.files.wordpress.com/2014/04/ascariasis-roundworms-in-the-rectum.jpg
http://2.bp.blogspot.com/-Yky2lkOwZ6Y/TV6EV-
XBbPI/AAAAAAAAAAc/P-o4TebhKS0/s1600/ascariasis-pictures-
5.jpg
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Ascariasis lumbricoides
• The largest nematode (roundworm) parasitizing the
human intestine.
• Adult females: 20 to 35 cm
• Adult male: 15 to 30 cm
• A female may produce approximately 200,000 eggs
per day, which are passed with the feces
• Adult worms can live 1 to 2 years.
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Ascariasis lumbricoides
• Often show no symptoms.
• Mild abdominal discomfort.
• Heavy infections can cause intestinal blockage and
impair growth in children.
Source: Source: /images/Ascaris_egg_dpdx.jpg
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Treatment
• 1-3 day course of albendazole, mebendazole, or
ivermectin
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References
• Am J Respir Crit Care Med 2003 Feb 15;167(4):603
• Am J Trop Med Hyg 2008 Aug;79(2):185
• D W T Crompton, L Savioli. Handbook of helminthiasis for public Health. CRC Press: Taylor & Francis Group. Boca Raton, FL; 2007.
• Escobedo AA, Cimerman S. Giardiasis: a pharmacotherapy review. Expert Opin Pharmacother. 2007;8(12):1885-1902.
• Dr. Videsh Kapoor ,Kelly Jacobs, Dr. Brian Medernach and Dr. Antoinette Lullo. Santa Clotilde: Resident and Student Handbook.
• JAMA 2010 Nov 10;304(18):2048
• Lancet 2012 Feb 4;379(9814):413
• N Engl J Med 2006 Jan 12;354(2):119
• Seltzer E, Barry M, Crompton DWT. Ascariasis. In: Guerrant RL, Walker DH, Weller PF, editors. Tropical infectious diseases. Principles, pathogens & practice. 2nd ed. Philadelphia: Elsevier; 2006. p. 1257-1264.
• Solaymani-Mohammadi S, Genkinger JM, Loffredo CA, Singer SM. A meta-analysis of the effectiveness of albendazole compared with metronidazole as treatments for infections with Giardia duodenalis. PLoS Negl Trop Dis. 2010;4(5):e682.
• Trans R Soc Trop Med Hyg 2000 Apr;94 Suppl 1:S1
• WHO. Global Tuberculosis Report 2015. http://apps.who.int/iris/bitstream/10665/191102/1/9789241565059_eng.pdf ?ua=1
• WHO. World Malaria Report 2015. http://www.who.int/malaria/publications/world_malaria_report/en/
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Thank You!
• Toni Lullo
• Gita Sivasubramaniam
• CSSC staff