Monday, April 21, 2014

The Spatial Epidemiology of Malaria - Part 2

In my previous post, I described the striking variation in the RDT positivity rate seen among different villages of the Bugoye sub-county. For example, from the village of Bugoye, we observed that 30% of RDTs were positive for malaria, while from the neighboring village of Izinga, the rate was more than twice as high. In fact, patients from Izinga accounted for nearly 20% of all positive RDTs at the health center. These differences suggest that local malaria transmission has a significant spatial component. In order to understand these trends, we must first understand the geography of the sub-county.

Cows crossing the Mubuku River near the Bugoye Power Station
For the last six months, my partners from the Mbarara University of Science and Technology (MUST) and I have been using GPS devices to construct a map of the sub-county. Guided by members of the local community, we record the locations of village health workers, community leaders, and health centers, in addition to outlining political boundaries. We have journeyed hundreds of miles up and down the hills and valleys of the sub-county. On the narrow paths, we have learned a lot about life in the villages in ways we had not been able to understand or appreciate before. In doing so, we have gained new insight into malaria risk factors, infrastructure challenges, and health-seeking behaviors.

Last week, we visited Izinga. At the bridge over the Mubuku River, we met the village health team that would lead us around the village. As we walked, we learned that Izinga was essentially a low-lying island situated between the Mubuku and Kitakena Rivers. In addition, a spillway for the hydroelectric plant supplying power to the nearby cobalt mines runs directly through the village. These features make the village particularly prone to seasonal flooding. The cold, fast-moving rivers are normally unsuitable for mosquitos, but when the water surges over its banks, it creates thousands of pools of warm, stagnant water that are ideal breeding sites.

Woman walking across damaged bridge over the Kitakena River
In May 2013, massive flooding devastated many areas of the Kasese District, which includes the Bugoye sub-county. Tons of mud and stone came crashing down through the valleys, destroying everything in its path. Thousands of residents from places like Kilembe, where the district referral hospital is located, were displaced. The sheer force of the floods cut new paths through the earth, changing the course of Mubuku River and washing away homes, livestock, and crops. As the water receded, once arable areas were turned to “swamps.” Unfortunately, the flooding has affected more than just agriculture. Compared to the previous two years, more patients from Izinga are being admitted to the health center for severe malaria. At this time last year, immediately before the flooding, patients from Izinga accounted for only 7% of inpatient admissions for malaria. This year, they account for 20%.

The town of Kilembe after massive flooding in May 2013
The case of Izinga is a classic example of how geography impacts human health. Geography, however, is not destiny. One need only to recall the devastation that Hurricane Katrina wreaked upon the city of New Orleans to know that Western Uganda is not unique in its experience with natural disasters. The difference is the resources. In New Orleans, Blackhawk helicopters, which cost about $6 million dollars each, quickly arrived on the scene to rescue victims from rooftops. Later, the Army Corps of Engineers rebuilt the levies, reportedly stronger than ever before, at a cost in the billions of dollars. In Izinga, there are no helicopters or engineers and certainly no billions of dollars.

Standing water in Izinga
How, then, do we respond to this epidemic? Minimizing the impact of future floods is the long-term solution, but this requires infrastructure investment that is not realistic given local resource constraints. In the meantime, malaria transmission will remain high as the mosquitos continue to flourish and the parasites infect more and more residents. Soon, we may see the RDT positivity rates in neighboring villages begin to climb. With relatively modest resources, such as bed-nets and insecticides, we can prevent the situation from getting worse. Even these interventions, however, are beyond the means of the community. But now that we understand the problem, we can begin to argue for the resources.

Ross M. Boyce MD, MSc
PGY-2, Internal Medicine
Global Primary Care Program
Massachusetts General Hospital

Friday, April 18, 2014

Understanding the spatial epidemiology of malaria in Western Uganda

The Bugoye Health Center (BHC) is located in the Kasese District of Western Uganda. This health center functions as the highest level of care for residents of the Bugoye sub-county, serving a rural population of approximately 50,000. The closest higher-level facility, Kilembe Mines Hospital, is located sixty minutes away when traveling by motorcycle. BHC is staffed by clinical officers and nurses from the Ugandan Ministry of Health and provides care at no charge. In addition to the outpatient clinic, there is an inpatient ward of twenty beds and a small laboratory with trained staff capable of performing basic diagnostic tests. As in many other resource-limited settings, the health center suffers from an irregular power and water supply and often faces shortages of key medications.

Entrance to Bugoye Health Center, Level III
Even with these limitations, BHC is always busy. Total reported outpatient attendance was 18,722 in 2013; a number that translates to more than seventy outpatient visits per day. While accurate population statistics are not available, malaria clearly represents the major burden of disease. Like most of Uganda, the climate in Bugoye permits stable, year-round transmission. According to health center reports, there were 7,753 cases of malaria at BHC in 2013. Rapid diagnostic tests (RDTs) have largely replaced light microscopy for the diagnosis of malaria, and are used preferentially given the ease of use and time constraints placed on laboratory staff.
Examining blood smears for malaria parasites in the laboratory

Since their introduction in 2011, nearly 7,000 RDTs have been performed at BHC, two-thirds of which were performed in the last year as the supply became more reliable. Accordingly, the number of parasitologically confirmed cases has increased to 42% in the last six months. While there is room for improvement, the introduction of RDTs has resulted in a marked change from the past, when all febrile patients were presumptively treated for malaria. This approach, while simple, contributed to the over-prescription of anti-malarial drugs and the under-recognition of serious bacterial infections.

Outpatient Clinic, Bugoye Health Center
The RDT positivity rate, which measures the percentage of all RDTs that were positive and is often used as a marker of malaria incidence, was 33% in 2013, with monthly rates as high as 51%. Yet even within this small community, there is significant variation between villages. For example, over the past three months, the RDT positivity rate among patients presenting from the villages of Bugoye, Ndughutu, and Bunyangoni was approximately 30%. Among those presenting from the villages of Muramba and Izinga, the positivity rate was 45% and 68%, respectively.

Looking down on Bugoye from the village of Muramba

Why is the positivity rate in these villages, many of which border each other, so different? Understanding this question is central to my work in Bugoye, and ultimately to developing sustainable malaria control interventions. Given that much of life varies little from village to village, I believe that the difference is best explained by geography. The local terrain ranges from mountain highlands in the west, often reaching altitudes of more than 2,000m near the borders of the Rwenzori National Park, to the densely vegetated wetland areas along the banks of the Sabo and Mubuku Rivers. Many of these “micro-environments” are ideal sites for mosquito breeding, and likely fuel the local variations in malaria incidence. Of course, identifying these high-risk areas, especially in a setting where there are no maps, can be challenging. In my next post, I will describe how we are tackling this issue, drawing on our recent experience in the village of Izinga.

Ross Boyce MD, MSc
PGY-2, Internal Medicine
Global Primary Care Program
Massachusetts General Hospital

Thursday, April 17, 2014

Bhutan Epilepsy Project 4/7/2014

April 7, 2014

Gasa, Bhutan

    Over the last two days, I had the opportunity to travel outside of Thimphu to explore epilepsy care in more remote areas of Bhutan.
    We left early in the morning, with our goal destination the town of Gasa, the main city in the Gasa district in the north part of Western Bhutan, and home to about 3,000 people. There is essentially only one route to Gasa, the final 18km of which was recently completed. Leaving early in the morning was an attempt to beat the construction road blocks that can close the road for up to 2hrs at a time. Though there are only 60-70km between Punakha and Gasa, that leg of the journey takes about 4 hours as the vehicle carefully weaves its way along narrow roads that cling to the sides of mountains. The views along this journey are spectacular, and I can only marvel at the challenge that road construction in this part of the world must represent.
View approaching Gasa:

     The town of Gasa hosts the town (and district's) health unit. We were pleasantly greeted by the staff of this facility, all of whom were no strangers to the challenges that care in this type of setting represents. The region has strong traditional beliefs and firm cultural roots. As such, the facility (similar to many hospitals in Bhutan) shares care with a traditional medicine service. The facility has access to diazepam, phenobarbital, and phenytoin. If patients need to be transported to a larger facility, they have to make a similar journey to our own.
Traditional Medicine Unit and Gasa Hospital:

     Neurocysticercosis is suspected to be a significant contributor to the burden of epilepsy in Bhutan, but the exact prevalence is unknown. This disease is primarily contracted via undercooked pork, and studies done in neighboring countries to Bhutan have shown a high burden of disease. Cysts deposit in the brain and act as a focus for seizure activity, particularly in the cortex. While healthcare workers in Bhutan are well aware of neurocysticercosis, in talking with local individuals in areas like Gasa, there is sometimes little awareness of this condition or the risk that consuming dried, raw pork may represent.

     Our trip to Gasa allowed us the opportunity to view medical care in more remote areas of Bhutan. The potential for telemedicine, particularly in the form of epilepsy care, has much potential for regions such as Gasa. Learning more about the topography of Bhutan, the cultural beliefs, and the range of access to medical care has been enlightening and will help strengthen the foundation of our project.    

Bhutan Epilepsy Project

April 2nd, 2014

Thimphu, Bhutan

Greetings from Bhutan!
Flying into Bhutan, one immediately gains an appreciation for the unique position of the country. Nestled in the Himalayas, the flight into Paro requires a skilled pilot to navigate the beautiful mountains that surround Paro's airport. There are a limited number of flights that come into the country each week, and as such, the country continues to maintain a feeling of beautiful seclusion.

Bhutan is steeped in rich Buddhist tradition and culture. Over the last several years, the country has evolved while seeking to maintain firm roots in Bhutan's culture heritage. Walking down the streets, people can be seen wearing the traditional gho and kira, while simultaneously listening to the latest music hits from Lady Gaga and Katy Perry. Cars and taxis have become more common throughout the country, though the capital continues to be one of only two capitals in the world that does not have a traffic light, instead employing traffic guards at the city's hub.
It is a country of approximately 1 million people, many of whom live in rural areas separated by mountains and connected by narrow roads. The urban center of Bhutan is the capital, Thimphu, which also houses the country's primary referral center, the Jigme Dorji Wangchuck National Referral (JDWNR) Hospital. Medical care is free in Bhutan for all citizens, and all lab tests and imaging are also covered by the government.
JDWNR Hospital:

I was intrigued to learn about access to neurologic care in Bhutan upon my first visit to the hospital. There are no neurologists in the country of Bhutan, and most epilepsy care is provided by psychiatrists, who are very familiar with seeing referred cases of epilepsy from many parts of the country. According to the physicians I met at JDWNR, neurocysticercosis is a common problem in the country (exact prevalence unknown) and may contribute significantly to the burden of epilepsy. Neurocysticercosis is a disease caused by tapeworm cysts which infect the brain parenchyma, commonly transmitted via undercooked pork. In Bhutan, neurocysticercosis is primarily diagnosed by imaging. The JDWNR facility has an MRI machine (the only one in the country), a CT machine, and access to at least five different anti-epileptic medications. There is no EEG machine in Bhutan, and no epilepsy specialists that would be able to interpret such a test.
I am looking forward to learning more about epilepsy care in Bhutan during my visit, and I am grateful for the warm welcome I have received in this beautiful country.

Tuesday, April 15, 2014

Child Health & Human Rights in the Autonomous, Indigenous Communities of Chiapas, Mexico

Greetings from Altamirano, Chiapas, Mexico!

The entrance of Hospital San Carlos on Palm Sunday.
Whether providing clinic care on the pediatric ward or outpatient clinic at Hospital San Carlos, conducting neonatal resuscitation training for nursing students and other hospital staff, or working with Dr. Juan Manuel Canales in surrounding autonomous, indigenous communities, my time in Chiapas has thus far been full of rich, rewarding, and thought-provoking experiences.  At every turn, I am struck by the challenges of providing high quality and accessible healthcare and promoting the health and dignity of children and families here, amidst powerful socioeconomic, political, and systemic determinants and stark health disparities. 

First, a bit of a history lesson … On the day of NAFTA’s signing in 1994, the Zapatista uprising began in Chiapas to defend and demand indigenous rights.  After negotiations with the government stalled, the Zapatistas vowed resistance, refused government services, and created their own autonomous systems of health and education. Thousands were displaced and decades-long militarization and low-level paramilitary violence followed. While Mexico’s human development index has been on a consistent rise over the past several decades, Chiapas has seen little of this progress, despite nationwide development efforts such as Opportunidades.  The state faces Mexico’s highest infant mortality rate and mortality from gastrointestinal infections.  Half of children under five remain stunted, highlighting the high prevalence of chronic malnutrition and the concomitant increased risk of child death.  Notably, most of the children I have cared for in the hospital have been at least moderately stunted (< -2SD ht/age) and wasted (< -2SD wt/ht). Furthermore, paramilitary attacks against the autonomous communities, most recently at the end of January this year, have occurred with impunity and the blind eye of the government. 

Dr. Canales and a promotor on their way to a
vaccination campaign. No photos were taken
in the communities, to protect their privacy.
As I learned on my trips to several autonomous communities with Dr. Canales, the autonomous health systems can include basic clinics run by promotores/promatoras as well as vaccination campaigns. With the support of Doctors for Global Health (DGH), Dr. Canales works with various Zapatista communities, providing training to these promotores/promatoras and helping them plan preventative activities.  Per Zapatista philosophy and official policy, the health promoters are not compensated for their services to their communities. Importantly, vaccinations are always transported and given by the community health workers in order to maintain trust.  While vaccination coverage is strong in these communities, there are often supply shortages.  During the pediatric vaccination campaign that I attended two weeks ago with Dr. Canales and MGHfC Division of Global Health’s, Dr. Jennifer Kasper (who was able to join me for a portion of my trip), HBV, PCV7, and BCG were not available.

In the distance, families walk along the gravel road;
travel to the hospital can take many hours to a day.
Last week, I had the opportunity to conduct a newborn health / warning signs capacity-building session in one of these communities.  We used videos of ill newborns from the Global Health Media Project to challenge them to identify various such signs.  None of the health promoters had ever seen a newborn with sepsis or severe jaundice, as ill newborns self-triage and make the long trek directly to the hospital.  Typically, this is Hospital San Carlos, a non-government-affiliated safe haven run by an impressive group of Mexican nuns, which I’ll describe more in my next entry.  Though the health promoters I met had not recently experienced any physical violence, they did speak about verbal threats on their homes and land and their day to day struggles, farming corn and coffee, and feeding their families.

Never having worked in the context of autonomous, indigenous communities, I wondered how one would apply a health and human rights framework.  Namely, considering that human rights, including child and adolescent rights to health and education, refer to government obligations to their people, who then is to be held accountable to the children and families in the autonomous communities? In the absence of an accessible and acceptable alternative, the autonomous communities have chosen to have their own autonomous systems of healthcare.  At the same time, they continue to call for the fulfillment of their rights, including their right to health and healthcare.  It seems that this is in line with the United Nations Declaration on the Rights of Indigenous Peoples, a standard to which Mexico is a signatory.  Article 5 of the Declaration states, “Indigenous peoples have the right to maintain and strengthen their distinct political, legal, economic, social and cultural institutions, while retaining their right to participate fully, if they so choose, in the political, economic, social and cultural life of the State.”  Per Articles 21 and 23, and of course other, equally relevant human rights doctrines such as the Convention on the Rights of the Child, this includes, among others, education, sanitation, and health.

Certainly, the Mexican government has the obligation to respect (to not directly violate) and protect (to prevent violation by others) the rights of these indigenous communities.  Impunity in response to paramilitary violence marks an ongoing and unacceptable failure to protect.  Perhaps the obligation to progressively fulfill or realize the rights of indigenous children and families in fact lies at once in the hands of the Zapatista leaders and the Mexican government.  While the State bides its time and turns a blind eye, Dr. Canales and Hospital San Carlos continue their slow and steady campaign in solidarity with the self-determining, indigenous communities of Chiapas, an effort that DGH would call, Liberation Medicine: The conscious, conscientious use of health to promote human dignity and social justice.”  

The beautiful, rolling green landscape of Chiapas.

And I am so grateful to have this opportunity to share in and bear witness to their journey.

Ashkon Shaahinfar, MD, MPH
MassGeneral Hospital for Children
Pediatrics, PGY3