International Health H.O.

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International Health H.O.
Rosalind Franklin University School of
Medicine Med II Preventive Medicine Tues, 12 Apr
05, 1000-1100

• Lecture by
• Jesse Monestersky,DO,MS,MPH,DTMH
• CAPT,MC,USNR(FS,HMO)
• Contact info
• (W) 847-688-6712x5081
• Email jesse.monestersky_at_nhgl.med.navy.mil

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Enabling Objectives

• To understand causes magnitude of CHEs
• To know 6 major causes of infectious disease
  death worldwide
• To understand difference between emerging
  reemerging diseases, surveillance, risk factors
• To become acquainted with sources for IH
  rotations
• To become familiar with travel medicine focus
• To become aware of sobering realities the good,
  the bad, the ugly
• To become familiar with key TM diseases

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ROE

• Potpourri of topics
• Fire hose approach
• Keep your seatbelts fastened
• Happy to serve as a future resource
• Maybe will even excite one of you to pursue
  career in IH
• There will be a few questions on your exam from
  this lecture

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References

• Textbooks
• Auerbach, PS Wilderness Medicine Management of
  Wilderness Environmental Emergencies, CV Mosby,
  2001
• Cook, GC AI Zumla PEC Manson-Bahr DR Bell -
  Mansons Tropical Diseases, 21st Ed., WB
  Saunders, 2002
• Jong, EC R McMullen The Travel Tropical
  Medicine Handbook, WB Saunders, 2002
• Magil, AJ Hunters Tropical Medicine Emerging
  Diseases, WB Saunders Co., 2000
• Steffen Dupont Wilder-Smith Manual of Travel
  Medicine Health, 2nd Ed., BC Decker, UK, 2003
• Zuckerman, JN Principles Practice of Travel
  Medicine, John Wiley Sons Publisher, 2001
• Societies
• American College of Tropical Medicine
• American Society of Tropical Medicine Hygiene
• International Society of Travel Medicine
• Royal Society of Tropical Medicine Hygiene (UK)
• Educational credentials
• MPH (Master of Public Health) (Schools of Public
  Health, PrevMed Departments in Medical Schools)
• CTH (Certificate of Travel Medicine)
• DTMH (Diploma in Tropical Medicine Hygiene)
  (LSTM, London SH)

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Bottom Line, Up Front

• International Health
• To provide background, educational opportunities
  your potential role
• Try to do a medical rotation overseas, esp.,
  developing country
• Gain experience in nutrition esp., peds,
  malnutrition marasmus (calorie) vs. kwashikor
  (protein), environmental health (food water
  sanitation), entomology (medical), infect dx
  (measles, TB, malaria), diarrhea (ORS)
• Think about MPH degree or dual MD/MPH (IH, Epi,
  MCH)
• Consider eventual paid or volunteer work abroad
  e.g., PC (volunteer, PCMO), USDOS (RMO), DoD
  (A/D), NGO (MSF)
• Become more familiar with CHE, Mass disasters,
  Refugee Medicine
• International medical perspective mind-broadening
• You can make a difference (even one person at a
  time)
• Even consider specialty you choose if you want
  overseas work (e.g., IM/ID/TM, Ortho, GenSurg,
  ENT, Ophthal)
• Requires change in frame of reference to gain
  from experience!
• Carefully preplan your trip to make it meaningful
  safe
• Learn a language or improve your language skills

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Relevance???

• Are tropical diseases of just historical
  interest?
• Emerging reemerging diseases
• Global warming is changing disease distribution
  (e.g., WNF, malaria)
• With international jet travel, patients can show
  up anywhere even at a Midwest doc-in-the-box!
• Future pandemics (e.g., Avian influenza)?
• Bioterrorism (e.g., smallpox, anthrax)
• Many diseases remain major killers world-wide
  (measles, diarrhea, malaria, TB)
• Developing countries a Petri dish for rest of
  world

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Monkeypox

• Ref CDC MMWR 52(23)537-540 6/13/03
  Multi-state Outbreak of Monkeypox IL, IN, WI
• The 1st case presented to Marshfield Clinic WI
  for Tx of an infected bite from a pet prairie dog
  (6/03).
• Marshfield thought it was an orthopox by EM
  specimen sent to CDC lab, which confirmed Dx by
  PCR.
• This orthopoxvirus is similar in appearance to
  smallpox with low CFR.
• Human monkeypox was 1st identified in the
  Democratic Republic of the Congo in a a region
  where smallpox had been eradicated in 1968.
• 53 cases resulting in 14 hospitalizations (26).
• SS Preceding febrile illness, papular rash,
  lymphadenopathy, sore throat. Rash progressed
  through states of vesiculation, pustulation,
  umbilication, encrustation. Rashes occurred on
  hands, trunk, extremities many patients had
  initial satellite lesions on palms, soles,
  extremities. Rashes were generalized in some pts.
• Epid All pts had contact with animals (Cynomys
  sp.) 1 pt reported contact with a Gambian giant
  rat (Cricetomys sp.). Investigation revealed
  that a common distributor was responsible, who
  housed prairie dogs and Gambian giant rats
  together. Records revealed that the Gambian
  giant rats were shipped from Ghana to Texas and
  then, on to Illinois. Exposures were at a pet
  swap meet in N. WI.
• FDA CDC issued an immediate ban on importation
  of all rodents from Africa (order Rodentia)

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Malaria

• Airport malaria in France
• Between 1969-98, 63 cases of airport malaria have
  been reported in W. Europe, 24 of which occurred
  in France.
• Most cases due to Plasmodium falciparum.
• In 1994, 7 cases occurred in around Roissy
  Charles de Gaulle airport (CDG), showing 4 types
  of exposure employees working on airstrips or
  opening containers, among residents living near
  airport, among people living at some distance
  from airport after a secondary transport of
  vectors, by vectors transported in luggage.
• Prevention is by disinsectization of aircraft,
  with permethrin aerosol though there is some
  pyrethroid resistance in Anopheles gambiae in W.
  Africa.
• Ref Guillet, P MC Germain, T Giacomini, F
  Chandre, M Akogbeto, O Faye, A Kone, L Manga L, J
  Mouchet Origin Prevention of Airport Malaria
  in France. Trop Med Int Health 3(9)700-5 Sep
  1998

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I. Complex Humanitarian Emergencies
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Definition of CHE

• Def Human disaster that occurs during follows
  war civil strife
• Inciting event either natural or man-made
• Characterized by displacement (internal,
  external)
• Loss of existing societal infrastructure
• Concerns for personal security
• 90 of war related mortality is among civilian
  non-combatants

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Refugees vs. IDPs

• Flight across border (R) or within border (IDP)
• 14M refugees
• 15 20M IDPs
• UN international protections vary
• Difficulty in assistance (e.g., Tsunami in Sri
  Lanka)

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Priority Needs

• Sanitary food
• Sanitary water
• Sanitary waste disposal
• Shelter (planned layout of camp)
• Identification of vulnerable populations
• Appropriate health interventions for these
  populations
• Immunizations
• Nutritional assessment
• Food appropriate to population
• Security
• Communications
• Transportation distribution scheme
• Internal help (military, govt, healthcare
  workers)
• Outside help
• UNHCR
• ICRC
• NGO (e.g., Medecins sans Frontieres)
• Office for Coordination of Humanitarian Affairs
• USAID (Office of Foreign Disaster Assistance)

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Government-Civilian Agency Cooperation in Crisis
Management

• Civil-Military Cooperation
• C4 (command, control, communications,
  coordination) security logistical
  capabilities (resources, transportation)
• DoD vs. coalition partners (e.g., NATO)
• HA, MOOTW aid agencies
• Sometimes friction
• Emergencies disasters (e.g., hurricane
  response)
• USDOS-Civilian Cooperation
• USAID, NGOs (local experts), Embassy,
  Beneficiary partnership
• Uni/bi/multi-national, UN

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II. Major Disease Killers Worldwide
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Leading Infectious Causesof Death 2002

• Acute RI 3.8M
• HIV/AIDS 2.8M
• Diarrheal dxs 1.8M
• TB 1.6M
• Malaria 1.2M
• Measles 0.8M
• Ref WHO, World Health Report, 2003

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III. Emerging vs. Reemerging Diseases
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Emerging Diseases

• Newly identified disease
• Increased incidence over past 2 decades
• Incidence expected to increase over next 2
  decades
• Examples
• WNF
• Avian influenza
• SARS
• CDC Emerging Infectious Diseases
  (http//www.cdc.gov/ncidod/eid/index.htm)

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Reemerging Diseases

• Smallpox
• TB
• Plague

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Ingredients for Emergence

• Pathogen adaptation change
• Virulence
• Adherence
• Invasiveness
• Toxin production
• Evasion of host immune defenses
• Antibiotic Resistance
• Expansion to new environments, reservoirs,
  vectors (microbial traffic)
• Increased populations at risk
• Genetic predisposition
• Co-infection
• Urban migration poverty
• Crowding poor hygiene
• Impaired immunity
• Inadequate public health infrastructure

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Combating Emerging Reemerging Diseases

• Facilitate early recognition control of new
  diseases
• Tracking by US Overseas Labs
• Train host-nation epidemiologists
• Assess control threats
• US CDC (e.g., MMWR), USAMRIID (US Army Medical
  Research Institute for Infectious Dxs , GEIS
  (Global Emerging Infections Surveillance
  program), ESSENCE (Electronic Surveillance
  System for the Early Notification of
  Community-Based Epidemics)
• Network with foreign health agencies WHO
  (Outbreak Reports), ISID (Promed)
• Monitor drug resistant organisms e.g.,
  Plasmodia, enteric other pathogens (VRE, MRSA)
• Monitor for leptospirosis, yellow fever, dengue,
  hantaviruses

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Powder Kegs for the Next Great Pandemic

• In the Shadow of the City
• Worlds great slums
• Cairo, Smokey Mountain (Manila), Rio, Calcutta,
  Mexico City
• Worlds slums are growing rapidly (UN-HABITAT
  Human Settlements Program Report)
• Now at 1B mark, making up 32 of global urban
  population
• Figure will double to 2B in next 30yr unless
  concerted effort undertaken
• In developing countries slum dwellers account for
  43 of population in contrast to about 6 in more
  developed countries
• Slums represent worst of urban poverty
  inequality
• No sanitation, no education, uncounted census
• Worlds rural population has reached its peak
  almost all further population growth will be
  absorbed by urban settlements

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Smokey Mountain Manila
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Recommended Movies!

• City of Joy (1992)
• Beyond Rangoon (1995)

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4. International Health Rotation
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International Health Rotations

• Learn about advanced disease, in austere
  settings!
• New skill set
• Public health in action
• Get to see much do much
• May become impetus for career in international
  health, public health
• Will change you forever

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Some International MedicalVolunteer Organizations

• International Medical Volunteers Association
  (http//www.imva.org)
• International Medical Corps (http//www.imcworldwi
  de.org/index.shtml)
• Health Volunteers Overseas (http//www.hvousa.org)
  
• Doctors Without Borders (http//www.doctorswithout
  borders.org)
• MEDICO (http//www.medico.org)
• Medicine For Peace (http//www.medpeace.org)

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How Where

• International Health Central American Institute
  Foundation (http//www.ihcai.org/programs.htm)
• Global Medicine (http//www.globalmedicine.org/GMN
  /student.html)
• AMA International Electives (http//www.ama-assn.o
  rg/ama/pub/category/12557.html)
• Office of Global Health (http//www.health.ufl.edu
  /ogh/oghpages/externships.html)
• American Academy of Family Physicians
  (http//www.aafp.org/ihcop/electives.html)
• The Center for International Health
  (http//intlhealth.med.utoronto.ca/Links/linksjob.
  html)

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5. Travel Medicine(Emporiatrics)
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Travel Medicine

• Travel Medicine Clinics (govt, private)
• Medical concerns of departing returning
  traveler (business traveler, tourist)
• Critical is current medical intelligence
• CDC, USDOS, WHO, I-SOS, Military (AFMIC)
• Most important aspects
• Preplanning (do not leave for last minute)
• Immunizations chemoprophylaxis
• Mosquito avoidance repellents (DEET, pyrethrum),
  netting, clothing, habits
• Sanitary food water
• Medical repatriation insurance (e.g., I-SOS)
• Major causes of death (MVA, AMI)
• Carry medical current medical summary
• Bring sufficient supply of Rx
• Documents (yellow shot record, passport)

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6. Tropical Diseases
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Tropical Diseases

• Diseases to eventually come to know love
• Malaria, dengue, hemorrhagic fevers (Ebola,
  Hanta, Lassa, YF, CCHF), leishmaniasis, HIV,
  trypanosomiasis, worms nematodes (roundworms),
  cestodes (tapeworms), trematodes (flukes),
  typhoid, hepatitis, vaccine-preventable dx,
  diarrhea, trichinosis, dracunculiasis,
  filariasis, schistosomiasis, trop derm,
  envenomization (insect, marine, snake), rabies,
  tetanus, strongyloides, pneumonias, trop mycoses,
  leprosy, prion dxs (Kuru), med entomology
  (mosquitoes, phlebotamine sandflies, blackflies,
  triatomine bugs ).
• Drugs
• Antimalarials, anti-TB, antihelminthics

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Clinical CasesWhat is this stuff?

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7. Some sobering realities
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Downside Realities

• Pick your location carefully, both regarding
  endemic diseases, civil stability unrest
• Be sure to have medical repatriation insurance
• Check in with AmEmb consular section
• Let folks know where you are
• Dont be a flagrant (ugly) American
• Being a diplomat, aid work, or health
  professional not automatic immunity from bad
  things happening

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Afghanistan Entire 5-person MSF team
assassinated (2 Jun 04)
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Tsunami

• Following 9.0 magnitude earthquake off coast of
  Sumatra, massive tsunami hit Sri Lanka on
  12/26/04, killing gt30,000, with gt4300 still
  missing. Relief efforts in Sri Lanka hampered in
  north east by Tamil Tiger Rebels.
• gt150,000 killed across Indian Ocean region, with
  hardest hit, Thailand, Indonesia, Sri Lanka.

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Current Hotspot

• Sudan Sudan-Chad (Darfur border Chad (Darfur
  border region)
• Now 2M at risk
• Looming Humanitarian disaster
• Sudanese fleeing across border into Chad

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Upbeat Realities
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My Range of Experiences

• Embassies
• Military exercises
• Club Med
• Travel Medicine Clinics
• Civilian military training programs

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Wide Range of Experiences Are Awaiting You!

• As a medical student
• International health rotations
• As a medical practitioner
• Refugee camps
• Medical missionary hospitals
• International medical volunteer work

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8. Role of the International Community in
Todays World
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Missions of the haves (inc., UN, WB)

• Why done? Regional stability security
• Processes
• Conflict stage
• Peace making/keeping/building
• Provision of food, supplies
• Post-conflict
• Nation building, reconstruction
• Economic development, debt relief
• If help, success stories Kosovo, Bosnia
• If dont help, tragedies Rwanda (1994) with 1M
  dead

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Concluding Remarks

• Just do it - Go overseas!
• Join the ranks of public health oriented
  physicians!
• Study TropMed
• Consider exotic diseases in your D/D
• Enjoy your undergraduate medical school
  experience
• Good luck in your careers

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Discussion Questions