WHO Guidelines for Childhood Pneumonia in Developing Countries

            Acutepneumonia remains the leading cause of death in children throughout the world,killing 1.6 million children each year, the vast majority in developingcountries.  Some 20+y years ago theWorld Health Organization developed a set of guidelines for pneumoniamanagement designed for community settings in developing countries.  The aim was to reduce pneumonia relateddeaths.  These guidelines werelater incorporated into the WHO Integrated Management of Childhood IllnessGuidelines., designed both for primary care and hospital based case management.

            Theseguidelines call for diagnosis on the basis of three signs, cough, rapidbreathing, and lower chest in drawing or retractions.  Cases are then separated into not severe, severe, and verysevere, based on the degree of difficulty.  Not severe cases are treated locally by the community healthworker with either amoxicillin or co-trimoxazole.  Those with severe or very severe pneumonia are referred tothe nearest health facility for treatment with injectable antibiotics.  This approach does not distinguishbetween viral and bacterial causes, nor does it clearly separate pneumonia fromother causes of respiratory distress, notably bronchiolitis in infants, orcroup.  Concerns overdifferentiating pneumonia from reactive airway disease (asthma) have persuadedWHO to add a trial of a bronchodilator with those children with audiblewheezing to the guidelines. Widespread use of these guidelines has created a clearer plan for thecommunity health worker.  A numberof extensive studies have demonstrated a 25-50% reduction in mortality in thosethird world settings that adopt the guidelines.  Some studies have shown that treatment of severe pneumoniaat home with antibiotics under the guidelines is as effective as referral tothe regional center, and resolves the often difficult problems oftransportation and follow-up.

Ref:  Graham,S.M. et al.  Challenges toImproving Case Management of Childhood Pneumonia at health Facilities inResource Limited Settings:  BullWorld Health Org  86, May 2007

Submitted by Roger Boe MD.

ZINC SUPPLEMENTATION IN CHILDREN WITH DIARRHEA

Acute diarrhea remains one of the leading causes of death in children throughout the world.  Nearly two million children die each year, mainly in developing countries.  Half of these deaths are exacerbated by acute and chronic malnutrition.  We need to look no further than our TV screen to see the dire effects of this lethal combination unfolding in Somalia and Sudan.  In recent years a multitude of studies have shown a substantial benefit of zinc supplementation in reducing severity, duration and mortality in infants and children with diarrheal disease.  This benefit is most marked in areas where on-going zinc deficiency is prevalent.  Some localities report an incidence of 75% or greater.  Contributing factors include inadequate dietary intake, excessive losses because of diarrhea, and decreased intestinal uptake of zinc, usually caused by chronic diarrhea.

Zinc deficiency causes a destabilization of cell membranes and disrupts the mucosal lining of the intestinal tract. This effect increases the severity and duration of diarrhea.  Zinc deficiency also causes impairment of immune function and a delay in wound healing.  Chronic deficiency can also cause a stunting of growth.

On the basis of many studies over the past decade, the World Health Organization has recommended that a supplement of zinc be administered to every infant and child with acute or chronic diarrhea who is at risk for zinc deficiency.  The dose is 10-20 mg of elemental zinc (usually given as zinc sulfate or acetate), once or twice daily for the duration of the diarrhea.  

Administration is particularly critical if the child is malnourished.  Occasional increase in vomiting is the only observed side effect.  Zinc sulfate is widely available in liquid or tablets, and is very inexpensive. (1)  Some question has arisen as to whether infants under 6 months of age, in particular those who are exclusively breast-fed, will benefit from zinc supplementation.   Breast milk is a reliable source of dietary zinc, but may not be enough to counter the increased losses associated with diarrhea. (2).   A recent WHO report showed a definite benefit of zinc in infants from 2-6 months of age, and recommends its routine use in this age group. (1)

The evidence is overwhelming that administration of zinc should be a routine component of treatment for children with diarrhea in developing countries.

Ref: 

1. Mazunder et. Al.  Effectiveness of Zinc Supplementation plus Oral Rehydration Salts for Infants Aged Less Than Six Months in Haryana State India.  Bull WHO 88:754, 2010.


2. Fischer Walker, C et. Al.  Zinc Supplementation for the Treatment of Diarrhea in Infants in Pakistan, India and Ethiopia.  Journal of Pediatric Gastroenterology and Nutrition 43:357, 2006.

Submitted by Roger Boe MD

ROTAVIRUS: IMPLEMENTATION OF A NEW VACCINE PROGRAM IN SUB-SAHARAN AFRICA

           On July 18^th, just two weeks ago, the first doses of pentavalent rotavirus vaccine were given to thousands of young children in Northern Sudan.  Under the direction of GAVI, the Global Alliance for Vaccines and Immunization, plans are underway to introduce the vaccine in more than 40 countries by 2015, including the six Sub-Saharan countries with the highest mortality from rotoviral disease. 

Rotavirus infections are the most common cause of diarrhea in young children throughout the world, resulting in over 500,000 deaths each year, mostly in developing countries.  Rotavirus gastroenteritis causes more deaths in children each year than HIV, malaria and measles combined.  Transmission is by the fecal-oral route.  Treatment is supportive, and consists of re-hydration fluids and more recently by zinc supplementation.  Preventive measures include improved sanitation, provision of safe water, and better hand washing.  The most effective intervention, and the best hope for preventing the severe complications of rotavirus infection, however, is vaccination.  Rotavirus vaccine is currently part of routine immunization in infants throughout the USA and Europe.  Multiple trials that have taken place in Malawi, Mali and Kenya, and administration on a large scale in India and South Africa have shown a 50-70% reduction in severe cases of rotavirus diarrhea.  This experience has prompted the World Health Organization to recommend widespread administration in all developing countries. 

Although there were initially some concerns about the association in early vaccine trials with an increased incidence of intussusception, this problem has not recurred after subsequent modification of the vaccine. 

The widespread implementation of the GAVI Rotavirus Initiative has largely been enabled by an offer from Glaxo Pharmaceuticals to furnish 125 million doses of rotavirus vaccine at a 95% reduction in price. 

How exciting it is for us to consider that, at this very moment, low cost vaccines are being distributed throughout developing countries that are effective against rotavirus diarrhea and also against pneumococcal pneumonia, worldwide the two leading causes of death in young children.  

Submitted by Roger Boe MD

Mission to Maua

As most of you are aware, most of my writing for the Health Care Blog has been about medical diseases and treatment.  This time I want to relate a personal experience.  My wife Donna and I served as volunteers this May and June at Maua Methodist hospital in Kenya. We participated under the auspices of the Individual Volunteer Program Area of the UMC Board of Global Ministries.   Maua Hospital was founded by the British Methodist Church in 1928.  The hospital serves a largely rural population of nearly a million in the Kenyan Central Highlands.  As you might imagine, the 280 bed hospital is incredibly busy, with 12,000 admissions, 3000 deliveries, and 100,000 outpatient visits per year.  In addition they support a variety of outreach programs, including dispensaries, and programs for palliative care and for AIDS orphans.  A long-standing School of Nursing, a new intern program and training for clinical officers (like our PAs), provide many opportunities for teaching and training.  With the exception of four long time missionaries, two from the US and two from Britain, all of the medical and nursing staff are Kenyan.

When I decided to go to Maua I was faced with a dilemma.  How can I best help the hospital mission during my two-month stay?    The answer came when the UN and the World Health Organization cited the continued high neonatal mortality in Sub Saharan Africa, a finding that has caused a flurry of articles in major medical journals, and a concerted effort by a number of organizations including the American Academy of Pediatrics to address the issue.  I decided to devote my major efforts toward teaching newborn resuscitation skills.  The problem was that I had not done any newborn care for 20 years.  I took several workshops and carefully prepared how I was going to teach.  Using small, hands on sessions, everyone had a chance to practice their skills.  One session bore fruit within a week when 2 interns expertly and successfully resuscitated an apneic premature infant.

            The pediatric ward at Maua was crowded and often chaotic, filled with acute pneumonias, meningitis, malnutrition and malaria, mixed in with conditions that would challenge the expertise of a US tertiary medical center. I was able to serve both as a pediatric consultant, and do a lot of one on one teaching with the interns.  The nursery facility was quite primitive by our standards, and at times their capacity to care for sick newborns and premature infants was exceeded.

My wife Donna has no health care training, but she found her niche by participating in some of the many outreach programs supported by the hospital.  

We were impressed with the ability of the hospital staff to accomplish miracles of care in the face of severe financial constraints, critical shortage of nurses, antiquated equipment, and limited labs.  It was an inspiration and a pleasure to work with them.  I certainly learned a lot about acute care tropical pediatrics.  In turn, I believe that I was able to help them make some improvements in the care of sick newborns.  Donna is prepared to be an advocate for several of Maua Hospital’s outreach programs. Throughout our stay we participated in the many worship opportunities that the hospital provides, and felt guided by the presence of the Spirit in our lives and work.

We can highly recommend Maua in terms of the facility, the provided housing, and the quality of the experience. Their rapidly expanding education program for nurses, interns and clinical officers, and the projected affiliation with an area medical school will provide many opportunities for teaching. The hospital staff is very supportive of volunteer physicians who are willing to teach and consult, particularly in specialty areas.

For more information on Maua, the hospital website is mckmauahospital.org.  We have written a blog about our experience, mission2maua.blogspot.com.  You may contact us for further information at boeroger@cableone.net, or call us at 208 233 5651.

Roger and Donna Boe

            

Resuscitation of Newborn Infants: from Oxygen to Room Air.

About 10% of newborns have some difficulty initiating respirations.  Many of these infants respond quickly following brief stimulation.  Others require some mechanical help with an ambu bag or anesthesia bag to begin breathing.  For many years it has been assumed that using supplemental oxygen, even 100% oxygen, improved outcomes, and was used uncritically wherever available.  A recent large study (1), showed that newborns resuscitated using 21% oxygen (room air) had higher Apgar scores, and took their first breath an average of 30 seconds earlier.  The most important finding, however, was that using the lower oxygen concentration was associated with a lower mortality.  Metanalysis of other studies showed a 30% reduction in mortality when babies were resuscitated with room air.  Saugstad(1) points out that this means 100,000 newborn lives could be saved each year by switching from oxygen to ambient air for the initial treatment of newborn babies who require assistance with breathing.  These findings are of major significance for those of us who work with village midwives and health workers.  We can reassure them that routine use of Oxygen is not indicated for resuscitating newborns at delivery.  A better use of resources would be to provide them with simple Ambu bages and train them in their use.

Saugstad, O.  Resuscitation of Newborn Infants:  from Oxygen to Room Air.  Lancet 376, p1970-71, Dec 2010.

Submitted by Roger Boe MD  UMVIM Medical Consultant

Nasogastric Rehydration for Children with Diarrhea in Resource-Limited Countries

Each year an estimated 1.7 million children die from dehydration caused by acute diarrhea. The vast majority of deaths occur in resource-limited countries, where incidence of gastroenteritis is higher, and access to therapy is limited. In the past several decades, Oral Rehydration Solution (ORS), has been widely used, both in developed and in resource-limited countries, and has markedly reduced the death rate. If ORS therapy fails, or dehydration is severe, the alternative in developed countries is hospitalization and intravenous therapy. This IV option is expensive and often logistically difficult in resource-limited countries. What viable treatment options are available then for the child who fails ORS therapy? A recent review article by Rouhani et. al.(1) evaluates a number of studies that compare several alternative therapies. A number of randomized controlled trials show that administration of fluids by nasogastric tube is as effective as intravenous therapy in patients who fail ORS. Another large study of over 4000 patients showed that nasogastric administration of fluids had an 88% success rate in moderate and severe dehydration, and a low incidence of side effects, mainly persistent vomiting. Only one case of aspiration occurred. The fluids are given at the same rate as for intravenous replacement, 20-25 cc/kilo per hour. This approach greatly reduced the need for intravenous fluids in this large study.
Nasogastric fluid replacement should be considered as a viable, safe alternative to IV therapy for dehydration, particularly in the field, where IV fluids may not be available or easily administered.

Ref 1. Rouhani, S, et al: Alternative Rehydration Methods: A Systematic Review and lessons for Resource-Limited Care. Pediatrics 127, March 2011, pp e 748-e757.

Submitted by Roger Boe MD.

THE TRADE IN COUNTERFEIT DRUGS: An Emerging Worldwide Epidemic.

The black market in counterfeit medicines has rapidly spread throughout the world in recent years, particularly in developing countries.  The epidemic is most severe in countries where regulatory and policing agencies are weakest.  The extent of this problem is truly amazing.  The size of the market is estimated at 75 to 200 billion dollars annually.  

The highest incidence is in Sub Saharan Africa, followed by the poorer countries in Latin America and Southeast Asia. The Pharmacy Board of Sierra Leone estimates that  $150 million worth of counterfeit drugs are brought into their country yearly.  An estimated 20% of drug sold in sub Saharan Africa are fake.   Fifty percent of antimalarials sold in the marketplace in these countries contain no active ingredients.  The consequences of this situation are obvious.  People with severe illness spend their meager resources for medicines that are of no value.  It is estimated that 700,000 people die each year because of counterfeit drugs.  Some efforts are being made to control this trade, including more rigorous customs inspection.  A sophisticated scanning system is in development that will identify chemical variations from the real drug.  Yet the incidence seems to be increasing, due to a combination of weak economies, rising drug prices, and increasing sophistication and organization of the illicit manufacturers and dealers.  The counterfeiters have become increasingly clever at mimicking the genuine drug, exactly matching the appearance and packaging, making it impossible to tell visually the fake from the real.  Another recent development is that of widespread internet selling which has become a problem in countries both rich and poor. As health care volunteers we need to be acutely aware of the widespread nature of this problem.  We need to purchase our medicines only through indisputably reputable sources, and to advise our patients to use this same caution when they purchase additional meds.  There has been a recent trend among health care teams to purchase medicines locally to support the local economy.  Any potential source must be investigated  thoroughly before making any such purchase.

BOOK REVIEW; JUST AND LASTING CHANGE

When Communities Own Their Futures, by Daniel Taylor-Ide and Carl E Taylor, Baltimore: the Johns Hopkins University Press, 2002


Once in a great while a real synthesis occurs of the issues and ideas surrounding a topic, one that puts together a summary of years of writings, worlds of experiences and principles. The book JUST AND LASTING CHANGE accomplishes this task in regard to Community Based Health Care. Although broad in scope, covering many aspects of community development in the developing world, its major emphasis is on health issues. Dr. Carl Taylor, the senior author, was born in India, the son of missionary physicians. He trained in medicine and public health and subsequently served as a missionary to India and several other locations. Later he returned to the US to found the School of International Health at Johns Hopkins, where he trained and inspired several generations of future luminaries, including Raj and Mabelle Arole, Jim Grant, and Dan Fountain. He was the chief Medical Consultant for the World health Organization at the 1978 Alma ATA Conference, which is considered the beginning of world attention and acceptance of Community Based Primary Health Care. The other author, Daniel Taylor-Ide, is Carl’s son, and a renowned community developer and organizer in his own right. Together they have fashioned a unique book that summarizes the noble experiments in community-based health care that span the 20th century. Then they insightfully analyze the reasons for the successes and the failures of these programs, and synthesize these insights into a plan for future projects that combines the best principles and premises of community development with what has worked in the field. This plan is described by the acronym SEED-SCALE. SEED stands for Self Evaluation for Effective Decision-making. The process begins by requiring the community to change its behavior by self-examination and evaluation, using needs assessment and community meetings, then to combine that data with the experiences of other communities to initiate a development project. Three principles are keys to initiating this community change in behavior that ensures the success of a community project.

1. Three-way equal partnerships with full collaboration are necessary between the people of the community, outside experts, and government officials. One partner cannot be dominant over the others.

2. Subsequent decisions and actions need to be based on locally specific data, collected at the community level by members of the community (assessment and evaluation of needs). Measurable results are necessary.

3. Development and health are impossible without basic changes in the attitudes and behaviors of the community.

The SCALE part of the acronym defines the specific three steps that communities need to take on the path to community development. First, the community selects, learns from and promotes a project that has been successful elsewhere, and defines the changes that need to take place in their community in order to make it happen. During the second step they transform those initial demonstration projects into learning centers that pass the experience on to others. The third phase promotes the systematic expansion of the project throughout societies by policy development and financing. Those of us familiar with the history of the Jamkhed Project will realize how closely the Aroles followed this SEED-SCALE plan in developing their program.

The book closes with this statement:

“Success will only come if we remain humble, expecting more mistakes than successes. If we are humble, we can take real next steps and sequence them into a continuing journey. In taking these steps we must remember that development is not a product but a process; it is not a solution but a way by which each community can create an evolving and unique pattern to achieve a more just and lasting future.”

It is impossible to summarize in brief form the many complex ideas and insights and the depth of experience covered in this challenging and thought provoking book. I feel that it is a must read for all of us who are concerned about health care in developing countries, particularly Community Based Primary Health Care.

Submitted by Roger Boe MD

CHRONIC NONCOMMUNICABLE DISEASE

---A NEW EPIDEMIC IN DEVELOPING COUNTRIES


For most of our short-term UMVIM Health Care Teams the main diagnostic and treatment concerns have involved acute infections. Evaluation is relatively straightforward for these diseases, and they usually can be managed successfully in one or two visits. Our teams have provided much needed immediate health care to the people we serve. However, we need to be very much aware of the massive changes in the health needs of developing countries that have taken place in the past few decades. Chronic noncommunicable diseases have replaced infections as the major cause of illness throughout the entire world. In fact, chronic disease now causes 60% of deaths and nearly 50% of disability in developing countries. These chronic noncommunicable conditions can in large part be considered diseases of life style.

They include:

1. Cardiovascular disease—including coronary artery disease, hypertension and stroke
2. Chronic lung disease, including COPD and asthma
3. Type 2 diabetes
4. Certain types of cancer

They are no longer just diseases of affluence, restricted to developed nations. Cardiovascular disease now accounts for 30% of deaths in poor countries. Three times as many people die from cardiovascular disease in developing countries than the total for HIV, malaria and tuberculosis combined. Four out of 5 deaths from chronic diseases now occur in low and middle-income countries. To add to this burden these chronic diseases affect all age groups, resulting not only in premature death, but also long term disability and lack of productivity. It is also important to note that these conditions, because of their chronicity and long-term disability contribute to a vicious cycle of increasing poverty in countries that are already poor.

A recent comprehensive report from the World Health Organization named the leading risk factors associated with these chronic diseases. They include high blood pressure, physical inactivity, high glucose levels, obesity, high cholesterol levels, and above all tobacco use. Some demographic changes have contributed to the increasing incidence of these risk factors, including

1. Urbanization: the past few decades have seen a massive migration from rural areas to the cities. Soon over 50% of the world’s population will live in cities. Inactivity has increased as many go from farm work to no work. Diets go from grains, milk and eggs to high fat, high sugar processed food with little nutritional value. Obesity and elevated cholesterol develop, as well as increased stress from cultural and family upheaval.

2. Globalization has brought many life style changes, more than just the presence of McDonald’s. Traditional cultures, customs, family ties, and even languages are disappearing. Processed, high caloric foods are uniformly available, highly promoted and sought after. Increased industrialization has stimulated further urbanization.

The critically important question is, What can be done to combat this epidemic of chronic disease? Health systems, particularly in developing countries are currently not equipped to handle the demands placed on them by this burden. These health systems cannot ignore acute infectious disease, but they can place greater emphasis on, and devote funding to an integrated model aimed at more continuity of care, preventive measures and above all on health education. Some of the funding support from aid organizations should be redirected from a single disease elimination model to a more comprehensive integrated approach, one that supports a broad scope of community-based preventive measures and health education programs. Some have suggested that dealing with this new epidemic should wait until infectious diseases, including the vexing problems of malaria, HIV and tuberculosis, are further controlled. Others have voiced concern that delays will further devastate the health and economies of countries that are already impoverished. They feel that we can’t wait. Others worry about the cost. In actuality, according to WHO, inexpensive, effective screening programs are already available. A most important factor is that 80% of these devastating conditions can be prevented or modified by community-based programs that provide health education and continuity of treatment. These programs need to promote education and preventive measures aimed at life style changes, including healthy diets, activity and exercise, and cessation of alcohol and tobacco abuse. What is needed now is better international recognition of the extent and importance of these chronic diseases and support for local health systems enabling them to gear up for this integrated approach.

For our health volunteers this new epidemic requires no less than a change in our way of thinking, from an acute care quick intervention oriented model, to one with more emphasis on health education and prevention, working in conjunction with the local health system We need to raise our awareness about the presence of these chronic diseases in the populations we serve. Most of all, we need to support and partner with local health systems in providing ongoing health education and ongoing care for these important problems.

References:

1. Preventing chronic diseases: a vital investment---WHO global report. Geneva; World Health Organization, 2005.

2. Narayan, et al: Global Noncommunicable Diseases---Where Worlds Meet NEJM 363, 1196-8: 2010

3. Anderson, G.F Expanding Priorities---Confronting Chronic Diseases in Countries with Low Income: NEJM, 356: 209-11; 2007.

Submitted by Roger Boe MD

The Eradication of Polio: Not Over Until It's Over

For many years polio was thought to be a disease mainly of wealthier nations. Then in the 1960s and ‘70s more extensive surveys revealed that the disease was much more common in developing countries.  The astonishing success of the Salk (injectable) and Sabin (oral) vaccines has now entirely eliminated polio from the Western Hemisphere.  However, in spite of an intensive worldwide campaign, and the expenditure of eight billion dollars, pockets of disease from virus types I and III, (Type II has been completely eliminated), have occurred in many parts of Asia and Africa.  Over the past several years, cases and mini-epidemics have occurred in more countries, and in greater numbers.  The reasons for the failure of the Polio Eradication Campaign failure are manifold:  India blames their failure on the inadequacy of oral vaccine, along with overcrowding, poor sanitation and diarrheal disease..  Nigeria had an inadequate public health infrastructure, and until recently, a lack of political will.  A new problem has also surfaced, the emergence of Sabin vaccine derived viruses that have reverted toward increased virulence and are causing paralytic polio in several locations.  Although currently occurring only as isolated cases, the concern is that these viruses will continue to mutate, and eventually cause more widespread and more virulent disease.  

Critics have spoken out about whether the relatively huge cost of continuing the active campaign is justified, stating that the massive expenditures of billions of dollars for an eradication campaign aimed at a single disease would be better spent on integrated (read community based) programs aimed at control of a broader spectrum of global health problems and the buildup of local health systems.

Meanwhile as health care volunteers, we need to be aware of the continuing presence of polio in those affected countries in Asia and Africa, and also be aware of the continuing need to stay up to date on our polio vaccination as we travel to these at risk countries.

Ref:  Modlin, J. F.  The Bumpy Road to Polio Eradication: NEJM 362: 2346, June 24, 2010.

Submitted by Roger Boe MD.

IVERMECTIN: A New Treatment Option for Resistant Scabies and Head Lice

Two of the most common infestations confronting the health care volunteer working in developing countries are scabies and head lice. Although neither is life threatening, both can cause significant discomfort and at times interfere seriously with quality of life.
Scabies is caused by the invasion of an almost microscopic mite into the skin, where it completes its life cycle. The most common sites are usually on the hands and arms, but can involve the entire body in small children and debilitated or aged adults. After some time the host develops an allergic very itchy rash, which more quickly recurs with re-infection. A number of treatments have been used. Lindane lotion is effective, but has fallen into disuse because of concerns about neurotoxicity. Permethrin cream is currently the most widely prescribed, but treatment failures and recurrences are common. Oral Ivermectin, widely used as a vermifuge, has been successfully used in a number of trials as a single dose of 200-400 micrograms/kg, repeated after one week. Success rates of 95% have been reported, even in cases of treatment failure with other approaches or difficult to treat cases of extensive generalized scabies.

Head lice have posed somewhat similar treatment difficulties. Lindane shampoo is no longer recommended. Permethrin 1% cream has been effective in the past, but is showing increased resistance. A recent study showed that ivermectin at a dose of 400 micrograms/kg repeated after one week in combination with nit combing resulted in a 97% clearance rate at 15 days, far superior to any other treatment regimen.

Ivermectin is currently available as 3 and 6 mg tablets. Only the brand name Stromectol is currently available for purchase in the US and is prohibitively expensive at around $6 per 3mg tablet. However, mission supply houses such as Blessings International have generic ivermectin available to health care volunteers for overseas use only, at about 20 cents per 6 mg tablet. Although ivermectin is not currently FDA approved for the treatment of either scabies or head lice, it is becoming more widely used throughout the world for this purpose. The side effect profile is low. It seems prudent for us to continue to use permethrin for the routine treatment of uncomplicated infestations with scabies and head lice, particularly in small children and women who are pregnant or breast feeding. Ivermective can be considered as a viable, safe alternative in cases of treatment failure, for institutional epidemics where mass local treatment is impractical, or for massive infection in immuno-compromised patients.

Submitted by Roger Boe, M. D.

References

1. Currie, B.J. et. Al. Permethrin and Ivermectin for Scabies. N. Engl. J Med 2010; 362: 717-725.

2. Chosidow, O. et. Al. Oral Ivermectin versus Malathion Lotion for Difficult-to Treat Head Lice. N. Engl. J Med 2010; 362: 896-905.

3. Boe, R. W. Scabies: An Update on Treatment; www.umvim4health blogspot.com 2009.

JET LAG and the United Methodist Volunteer

Jet lag is one of the most common problems confronting the world traveler, and our mission volunteers are certainly not immune. Though not life threatening, this disturbance of the sleep cycle can seriously interfere with our ability to function at full capacity. We often need to hit the ground running, take on major responsibility, make critical decisions and work long hours under difficult conditions. We do not usually have the luxury of spending several days recuperating from a jet lag caused hangover, so it becomes important to consider the cause and possible ways to lessen its severity.

Jet lag is a sleep disorder that results from crossing time zones too rapidly for our circadian clock to keep pace. This clock, located in the brain’s hypothalamus, regulates alertness during the day, and sleepiness at night, in response to alternating patterns of light and dark In addition to setting time for sleeping and waking, circadian rhythms also dictate times for eating and some hormone regulation. Of interest, the severity of jet lag is not related to the length of the flight, but to the number of time zones crossed. It is also worse when traveling from the West to the East than in the reverse direction. If traveling in a North South direction, you may get tired and sleep deprived, but do not get jet lag. Some of the symptoms resulting from jet lag can be insomnia, sleepiness during the day, dysphoria, and most importantly, diminished physical performance and even cognitive impairment. There is a wide person-to-person variation in severity and specific type of effect following a given disturbance of the light dark cycle.

Many treatment strategies have been recommended for jet lag, some with more evidence of effectiveness than others. A recent review (1), recommends three approaches:

1. Promoting a realignment of the body’s circadian clock by using an appropriately timed exposure to light and the administration of melatonin,

2. Planning an optimal timing and duration of sleep

3. Using medication to counteract the symptoms of insomnia and/or daytime sleepiness.

You can readjust your circadian clock by exposing yourself to bright sunlight or strong artificial light, in the morning after eastward travel and in the afternoon after traveling to the west. Also plan to stay in the dark or in subdued light for the first few hours of daylight after long eastward fights or a few hours in the afternoon after long flights heading west. Two or three days of such a regimen should be sufficient.

Melatonin is a hormone secreted by the body during nighttime hours that has an effect on circadian rhythm opposite to that of sunlight. The ideal dose and timing of administration have not been clearly established, but it is commonly taken in a dose of 0.5 to 3mg at bedtime after arrival at your destination. It is available as a nutritional supplement in a 3mg tablet.

Plan a strategic sleep schedule prior to the trip, gradually shifting by 1-2 hour increments toward matching the projected schedule at your destination.. Flying first or business class usually means more restful sleep, as does eating sparingly and avoiding alcohol. Hypnotic agents can be used to counteract insomnia caused by jet lag. Short acting agents such as Ambien or Lunesta in modest doses are recommended to avoid next day sleepiness. The use of such agents during actual travel may be more problematic, unless the flight is of very long duration. Caffeine in moderate amounts may be useful to counteract daytime sleepiness, but taken late in the day may interfere with sleep. A relatively new agent, Nuvigil (Armodafinil), has been used to promote wakefulness in patients with narcolepsy and other conditions that cause daytime sleepiness. It is not currently FDA approved for use with jet lag, but showed promise in a recent study to promote wakefulness in patients with day sleepiness associated with jet lag.

In his review (1), Sack points out that much more research is needed to more completely uncover the causes of jet lag, and to determine the most effective treatment measures. I recommend reading this article if you want to learn more about this fascinating and troubling condition.

(!) Sack, R.L. Jet Lag: NEJM 2010;362; 440-47.

Roger Boe MD

Routine Adminstration of Rotavirus Vaccine in Developing Countries??

Rotavirus is the single leading cause of severe, potentially fatal diarrhea in the world today. 600,000 children, mainly infants in developing countries, die each year from Rotavirus infections. In comparison with enterotoxigenic E. coli, the second most common cause of fatal diarrhea in infants, rotavirus is more likely to cause fever, vomiting and abdominal pain, and antibiotics are totally ineffective in the treatment of this viral infection. Partial immunity is produced by initial infection, making subsequent exposure less likely to cause severe diarrhea. Severe clinical disease is also less likely in the first three months of life, probably due to residual maternal antibodies. Specific diagnosis can be made by rapid antigen detection, but is of limited value in clinical settings. Treatment is entirely supportive, mainly fluid replacement.
An effective vaccine has been available for over a decade. The initial preparation was associated with an unacceptably high rate of intussusception in infants, and was withdrawn. Two replacement vaccines are available which do not cause this problem. The vaccine is given orally at 2, 4, and 6 months of age. Extensive experience in developed countries has shown a total protection rate of 74% after 3 doses of vaccine, and a 98% reduction in cases of severe diarrhea. Thus far the vaccine has not been used extensively in developing countries for three reasons

1. The cost is prohibitive, basically unaffordable for routine use.
2. The vaccine requires refrigeration----that is an unbroken cold chain

3. The excellent protection noted above requires 3 doses at set intervals, a difficult task given the realities of immunization scheduling in developing countries.

Two recent large-scale Rotavirus vaccine studies in developing countries have been reported, one in Africa, the other in Mexico.(1). Both show excellent protection against severe rotavirus diarrhea, and demonstrate the feasibility of using the vaccine on a larger scale. Co-financing would make the vaccine much more affordable, and has been offered by the Global Alliance for Vaccines and Immunization, (GAVI), at least on a temporary basis. According to Shantosam (1), rotavirus vaccine should be introduced immediately in areas with high mortality from rotavirus infection. Combined with other proven interventions, routine immunization with rotavirus vaccine can substantially reduce the 1.8 million deaths from diarrhea that now devastate the developing world.

1. Santosham, M. Rotavirus Vaccine—A Powerful Tool to Combat Deaths from Diarrhea. NEJM 2010; 362:358-360.

Submitted by Roger Boe MD

URBANIZATION: A Threat to Health in Developing Countries

The past fifty years have seen a world population shift totally unprecedented in history. In 1950 only one quarter of the world’s people lived in cities. In the year 2000, that figure was over 50%. This means that in the span of a half-century over 1.5 billion people, mostly the poor in developing countries, moved from rural areas to rapidly growing cities. A number of mega-cities (those over 15 million) have resulted, the majority in developing countries. Most of these internal migrants are desperately poor. They move in order to find work and a better life for themselves and their families. Cities offer the promise of a way out of misery and poverty, opportunities for education, employment and expectation of better health. This promise is not fulfilled. Those who go to the city end up being squatters, with no title to the land, and no services. There is often no work. Few jobs can support a family. People live under squalid conditions. Their houses are crowded together, built out of plastic sheeting and scraps of metal, and lack adequate cooking facilities, latrines, and potable water. The people have no political recognition, and are either ignored or persecuted by government forces.

This move to the cities has a particularly dramatic impact on health. The combination of overcrowding and the lack of potable water and sanitation render the population susceptible to epidemics of contagious disease. The Aedes mosquitos that carry Dengue Fever and Hemorrhagic Fever thrive in stagnant pools throughout the slums. Diarrhea and respiratory illnesses are more common. Despite closer theoretical proximity to health care, mortality in infants and children under five is actually higher among the urban poor than it is in the countryside. There is also disintegration of the extended family and kinship support system usually available in rural areas. Long standing cultural traditions are often lost. This lethal combination causes severe psychological stress and family breakup. Because there is no money to buy food and no place to grow crops, malnutrition, particularly in children is rampant. Ironically, lifestyle changes, including decrease in exercise and increased consumption of junk food contribute to a major increase in obesity, diabetes and cardiovascular problems.

Some government health systems have attempted to respond to this complex crisis, but are overwhelmed by the scope of the problem and the costs involved. Other governments remain indifferent. In 1992 the UN Conference on Environment and Development, more commonly known as the Earth Summit, formed a committee that addressed the global issue of urbanization, and formed a plan for human settlement development. This committee continues to meet every four years, but has had little impact on the problem. As health volunteers, we need to be aware of global urbanization and the marked effect it has on the health of the countries we serve. We also need to consider an increasing emphasis on supporting local health systems and serving the health needs of these urban poor.
Roger Boe MD
References:
Patel, R. B. et al. Urbanization—An Emerging humanitarian Disaster. NEJM 2009; 361:741-43.
Moore, M. et al. Global Urbanization and Impact on Health. Int J. Hyg. Envirn. Health 2003; 206:269-278.

Cholera in Zimbabwe

Lack of clean drinking water has unleashed a cholera epidemic in Zimbabwe


Zimbabwe is currently in the midst of a major epidemic of cholera, a disease that all but disappears even in Sub-Saharan Africa when there is a basic public health system in place and those affected have access to basic medical treatment. The World Health Organization estimates that as of March 1st 2009, 85,000 cases were reported, and 4000 deaths, and the epidemic is beginning to spread to neighboring countries. Doctors without Borders, who are actively working in the area, say that the epidemic is “a massive medical emergency rapidly spiraling out of control.” One new case is appearing in their clinics every minute. This epidemic represents a tragedy on many levels. It is a tragedy when so many lives are lost needlessly for want of basic interventions with oral re-hydration solution and a few days of inexpensive antibiotic. With any kind of treatment the mortality of cholera is 1% or less. In Zimbabwe the mortality is 5%, an indication that their health system infrastructure, once a model for Africa, is now dysfunctional and without resources. At another level it is a tragedy because the epidemic has resulted from a breakdown in water supply and basic sanitation. It is also a tragedy because this epidemic is occurring in a country that was once the Bread Basket of Southern Africa, a land of prosperous farms and a healthy populace. Cholera has always been a barometer of inadequate access to safe drinking water and basic sanitation. A cholera epidemic signals that the water supply is severely contaminated with human feces. Reports from Zimbabwe describe water pipes that contain no water, sewer pipes that are clogged, and garbage is piled high on the streets
Eric Mintz (1) points out that the current epidemic represents a fundamental failure of governance. He also states that “the failure of the global community to mobilize the resources needed to prevent and to treat cholera among the less fortunate reflects our lack of commitment to equity and social justice”.
The current epidemic of cholera is just one symptom of a terrible social and political disease that has taken over this beautiful country. We can mobilize an effort to treat the symptom of cholera, but can we do anything to stop the greater political disease that is destroying Zimbabwe?
Ref: Mintz, Eric, Guerrant, Richard. Global Health: A Lion in Our Village—The Unconscionable Tragedy of Cholera in Africa. NEJM 2009;360:1060-1063.
Submitted by Roger Boe MD, Medical Consultant

Scabies: An Update on Treatment

Scabies is a skin infestation caused by an almost microscopic mite, Sarcoptes scabei. Although distribution is worldwide, scabies occurs more frequently in tropical resource poor countries. The life cycle is completed entirely on the human host. The gravid female mite burrows into the top layer of skin to lay her eggs. The larvae hatch, reach the skin surface, mate and complete the cycle. Transmission is by skin-to-skin contact, and is most likely within families, in institutions or schools, or by sexual contact. The initial infestation is asymptomatic for approximately one month. Then an intense inflammatory immune mediated reaction occurs, associated with intense persistent itching, which is the major hallmark of the condition. Re-infection produces a more immediate reaction within 48-72 hours. Other characteristic findings are the presence of a linear burrow (which is often obscured by excoriation) and a distribution pattern of lesions on the webs of fingers, the wrists, the axillae, and on the genitalia in the case of sexual contact. Infants are more likely to have a generalized body rash. If infection occurs in an immunocompromized or elderly person, a particular pattern of generalized rash occurs with thick scaling. Called Norwegian scabies, this variety involves thousands of mites in contrast to the 10-50 found in the usual adult infestation, and is highly contagious. The diagnosis of scabies can be established by microscopic examination of skin scrapings for eggs or mites, but is more commonly made by the characteristic pattern of lesions, the presence in other family members or close contacts, and the presence of intense itching. Institutional epidemics can occur.
A number of treatment options are available. Thorough cleaning and heat drying of bed clothing is indicated, as the mite may survive for as long as 3 days away from the host. A 10% sulfur in petrolatum ointment, which is over the counter, has been used for many years. It is safe to use in small infants. It is messy, requires repeat applications, and is less effective than more recently introduced agents. Benzoyl benzoate is moderately effective but not available in the US. Lindane (Kwell) lotion is no longer widely used because of concerns about neurotoxicity, and may be difficult to obtain. It should not be used in children or pregnant women. A 5% permethrin cream (Elimite) has recently been the topical treatment of choice. The cream is applied to the entire body except the face and washed off after 8 hours. A second treatment is applied after one week. Permethrin is non-toxic, and can be used in children as young as two months of age. It is not recommended for pregnant women. Recently Ivermectin, which has been widely used as a vermifuge, has been found to be highly effective and safe in treating scabies, in a single dose of 200 micrograms per kilogram. It is not currently FDA approved, however, for this use. Therefore it is prudent to continue to use permethrin cream as the first line treatment. Ivermectin can be considered in cases of treatment failure, with institutional epidemics where mass local treatment is impractical, or for massive infection in immunocompromized patients, the so-called Norwegian or crusted scabies.
1. Leme PA. Scabies and Pediculosis pubi, an Update of Treatment Regimens and General Review. Clinical Inf. Disease, 2007:44: s153-59.
Fawcett R. Invermectin Use in Scabies. Am. Fam. Physician, 2003: 68:1089-92.
Roger Boe MD

Traveler's Diarrhea: A Volunteer's Aggravation

Rifaximin, (Xifaxan R): A New Treatment Consideration for Traveler’s Diarrhea.
Traveler’s Diarrhea certainly remains one of the major medical problems confronting short-term missionaries. The most common causative agents are coliform bacteria that are the usual inhabitants of the intestinal tract, but cause diarrhea in patients who are not immune to the enterotoxins which some strains produce or because of the tendency of some types to adhere to the wall of the intestine. (See the article on Enteraggregative E. coli following). Although usually not a cause of serious illness, traveler’s diarrhea can significantly interfere with participation in mission and productivity, and may become a major problem in small children or patients with chronic underlying medical problems such as diabetes or immune deficiency. Those patients who require prolonged Rx with H2 blocking agents for GE reflux disease are uniquely susceptible to traveler’s diarrhea because lowered gastric acidity deprives the body of its first line of defense. In situations such as these, prophylaxis should be considered. In recent years ciprofloxacin (Cipro) has been the most widely used antibiotic for treatment and prophylaxis, and coliform bacteria have thus far not shown a major resistance pattern. Rifaximin (Xifaxan), used in Europe for a number of years, has recently been FDA approved for treatment of diarrhea caused by non-invasive forms of Coliform bacteria. A number of clinical trials have shone a success rate comparable to Cipro. Unlike Cipro, it is not absorbed from the GI tract. Because of this lack of absorption, side effects are few, and because of its more limited use, resistance is less likely to develop. The drug is fairly expensive, comparable in price to brand name Cipro. Unlike Cipro it is not effective against any of the dysentery organisms, such as Salmonella/Shigella and Campylobacter. Rifaximin should not be considered either as treatment or prophylaxis in areas with a high incidence of Campylobacter. Rifaximin may be considered as a treatment or preventive alternative to Cipro, but in the event of fever, blood in the stool or worsening diarrhea, rifaximin should be discontinued, and an alternate antibiotic selected.
Roger Boe MD
UMVIM Medical Consultant

Ref: DuPont, H. Therapy for and Prevention of Traveler’s Diarrhea. Clinical Infectious Diseases 45: 2007 Suppl S78-84.

Enteroaggregative E. Coli: An Under-recognized Cause of Traveler’s Diarrhea
The majority of cases of traveler’s diarrhea are caused by variants of the common coliform bacteria that are usual inhabitants of the intestinal tract. It has been assumed in the past that the typical illness (self-limited watery diarrhea without fever), was caused by enterotoxins that some strains produce in persons who were not immune to that particular toxin. Recently another type of E. coli has been widely identified as a cause of diarrhea in travelers. Called Enteroaggregative E. Coli, it has been identified in many developing countries. In a recent study involving travelers to Mexico, it was demonstrated as the causative agent in 25% of cases. Similar findings have been reported in many developing countries. This organism has also been discovered to be the cause of a number of outbreaks in industrialized nations. There is rising evidence that it is involved in a large number of deaths in young children, particularly in the presence of malnutrition. The incidence of Enteroaggregative E Coli infection is most likely vastly underestimated, as awareness of this newly discovered threat is low, and diagnostic testing is not as yet widely available. These bacteria cause illness by adhering to cells in the wall of the small and large intestine. A thick film of mucus is formed, allowing the bacteria to persist and multiply. There is also some evidence of a low-grade inflammatory reaction. Infection produces a more protracted course than with the enterotoxigenic strains, often lasting 7-14 days. Mucus production is characteristic, and a significant minority of patients will have blood in the stool, and/or low-grade fever, making clinical differentiation very difficult between this coliform infection and disease caused by Campylobacter and Salmonella. Diagnosis can be established by demonstrating the aggregative effect (AA) after incubation with tissue culture cells. A DNA probe has also been developed. At present these tests are available for research application only, as they are expensive, labor intensive, and time-consuming. Treatment with floxacin antibiotics, azithromycin, or rifaximin has thus far been uniformly successful. It is important for us as short-term health volunteers to be aware of this new wrinkle in the management of traveler’s diarrhea, and also to be aware of the real danger that infection with Enteroaggregative E. coli poses for malnourished children.
Roger Boe MD
UMVIM Medical consultant
Ref: Nataro, J.P. Enteroaggregative Escherichia coli, Emerging Infectious Diseases, 4 #2, 1998

Update: What Short-term Health Volunteers Should Know about HIV/AIDS

Most of us are all too familiar with the grim statistics that identify HIV/AIDS as the Great Plague of the late 20th Century, a plague that promises to continue for many years to come. According to 2007 estimates, 34 million people are currently living with HIV/AIDS. An equal number have already died. 2.5 million new cases were diagnosed last year, and 2.1 million people died, including 333,000 children. Current estimates show 15 million AIDS orphans, children who have lost one or both parents to the disease. There is no vaccine currently available, and little hope for one in the near future. Although treatment with antiretroviral agents prolongs life and improves the quality of life, there is no cure for HIV/AIDSIt is important that we put a human face on these statistics. HIV/AIDS has totally devastated the entire health system in many countries of the world, particularly in Sub-Saharan Africa. The effect on families and communities has been even more devastating. Large numbers of young and middle-aged adults, including community leaders, heads of families, and most importantly mothers, have died or are seriously ill. Nine year-old children are in charge of entire families. Large numbers of AIDS orphans have become street children. In many African countries, it is considered a sacred obligation to take in and adopt children who have lost their parents. Fifteen years ago few orphanages existed, even in countries torn apart by war. Now because of AIDS there are too many orphans for even the most caring families and communities to take in. More orphanages have been built, but they are woefully understaffed. Each caregiver may be responsible for 100 or more babies and children.

In recent years many governments, including the US, and many funding agencies such as the Gates Foundation, have contributed large amounts of money to help fight HIV/AIDS. The major thrust of this funding has been to scale up treatment efforts, and to support existing health care facilities. According to Dr Maureen Kelley, who has spent the past 10 years working with street children in Zambia, most of whom are AIDS orphans, few of these donated dollars are expended to deal with the psychosocial problems created by this massive number of orphans. The needs of these children are so great!!! In overcrowded orphanages, babies are dying for want of human touch and basic nurturing. Young children are suffering irreparable psychological damage, and older ones leave the orphanages to wander homeless in the streets.
Dr Kelley feels that faith-based organizations such as UMVIM and our Individual Volunteers Program are more sensitive to these needs and can better recognize and help provide for the basic requirements of these children for nurturing and support. We need to ask ourselves, “What is the future for a country whose children grow up unloved and uncared for.” In addition to asking what Jesus would do, we have to ask ourselves, “What would John Wesley do?” For Wesley, ministering to the poor and sick was included in the job description of every Methodist. It is my feeling that we can respond to the needs of these children that go beyond treatment with antiretrovirals (50% of AIDS orphans are infected with HIV). Preventive measures and AIDS education are critically important, but are too late for these children. There are many opportunities to work in the orphanages in a variety of capacities, or with organizations that are working with the street children. Many concerns have been expressed by potential care-givers about the risks of contracting HIV. It is important for us to keep in mind that this risk is extremely small, and that minor risk is almost eliminated by careful hand washing with soap and water.

In addition to direct work with HIV/AIDS victims, we can financially support two important programs developed by GBGM/UMCOR.
The Orphan Trust, Advance #982842, supports community efforts to care for orphans by assisting them with their daily necessities, school fees, and moral and spiritual support.
The United Methodist Global Aids Fund, Advance # 982345 supports education, prevention, care and treatment programs for people living with HIV/AIDS, both in the US and abroad.
We must continue to reach out to the innocent victims of this nightmare disease.
Roger Boe, MD
UMVIM Medical Consultant