Jonathan Reisman, Pneumococcal colonization in Alaska Native people

PGY-2 Med-peds resident at MGH

I received a Centers of Excellence travel grant to conduct a research project under the auspices of the CDC-Arctic Investigations Program (AIP) in Anchorage, AK. I studied the socioeconomic and demographic risk factors for nasopharyngeal colonization with Streptococcus pneumoniae in Alaska Native people of all ages. Historically, Alaska Native children have had some of the highest rates of several vaccine-preventable infections - including H. flu, pertussis, measles, and hepatitis B. Interestingly, in the early part of the 20th century, the Iditarod mushing race trail was used to get diphtheria anti-toxin to Nome because of an outbreak there among native children. The prevalence of many of these infections has been dramatically reduced by vaccination.

Currently, the AIP is conducting ongoing surveillance of Strep pneumoniae, as Alaska Native children have some of the highest rates in the world, and a vaccine was recently introduced. Each spring, the AIP visits eight villages in Western Alaska along the cachement basin of the Bering Sea. Interviews are conducted with families and nasopharyngeal swabs are taken. Swabs are cultured for pneumococcus, and serotypes and antibiotic sensitivities are determined. PCV-7 was introduced into this population in 2000, and surveillance studies showed that it reduced invasive disease rates. "Replacement disease" with non-vaccine serotypes was seen throughout the country, however, it was much more pronounced among Alaska Natives than in non-native populations. This suggests that colonization remains an important source of transmission of these infecting serotypes. In terms of colonization, prevalence of nasopharyngeal carriage did not change after PCV7, but rather non-vaccine serotypes simply replaced vaccine serotypes. PCV13 was introduced in 2008 and studies now are ongoing concerning infections and colonizations.

My project was to look at the last 4 years of colonization data, and to determine whether colonization is significantly impacted by risk factors such as age, gender, region of Alaska, access to in-home running water, household crowding, number of people in the house, recent antibiotic use, and recent infections. This data had not been analyzed in this way to date. I helped swab children in the Yup'ik villages of Koliganek and Manokotak.

Marjory Bravard, Mbarara, Uganda, Technology in Global Health Exploration II

Let’s talk a little bit about leapfrogging and global health technology.  The basic idea of leapfrogging is going from an underdeveloped state to a modern one without going through the historical intermediate steps.  A good discussion of leapfrogging technology can be found here.  The classic example is cellphones: countries going from few landlines to many people with cellphones, skipping over the slow creep of landline networks throughout the land.

The first great leapfrog project in global health I heard of was at Fogarty orientation a few years ago, when Krista Pfaendler spoke about her work in Zambia in cervical cancer (1 and 2).  At the time Zambia had one of the world’s highest incidence of cervical cancer, and only one pathologist who could read pap smears.  Obviously a pap-smear based screening program would not work.  This project leveraged the relative abundance of nurses and midwives relative to doctors to allow screening for cervical cancer using visual inspection with acetic acid.  A cheap digital camera is used by the nurses/midwives in the screening to ensure quality control and for assistance with clinical decision making and triage, with the assistance of an attending gynecologist.  What most impressed me about this project was the ability of a cheap digital camera to leverage the assets of a developing world health setting - nurses and midwives – to reach patients with useful interventions.  In 2.5 years the program was able to screen 20,000 women for cervical cancer in a country with a very high incidence of cervical cancer where there was previously no real screening program.  I’m incredibly impressed!  I think this is an excellent demonstration of the global health technology that works.  

While in Mbarara I checked out a few global health technology projects.  One is the UARTO study, which monitors treatment adherence in HAART treatment for HIV.  The study currently uses a device called Wisepill

to monitor treatment adherence.  Wisepill is a digital pillbox that sends a signal through the cellphone networks every time it is accessed.  If no signal is received by the study center for 48 hours, that is considered a treatment interruption and a field team goes out to see if it is a wisepill problem or if the person has stopped taking their meds, and why.  I went on an interruption visit one day (photo at left).  One of the participants we visited only needed a new battery for his wisepill, another had stopped for unclear reasons since her husband had been released from prison, and a 3^rd wasn’t home when we visited.  I think it’s an excellent approach to monitoring and helping with treatment adherence, and again one that uses technology to optimally use human resources.

In many parts of the world travelling to clinic to get results of tests costs a lot: both literally and in terms of opportunity cost with missed work. There is clearly tremendous potential to use cellphone networks to deliver test results in these settings.  Dr. Mark Siedner and I sat down to talk about a project he is developing to look at the feasibility and acceptability of delivering testing results via mobile phone.   Given issues of confidentiality and follow up treatment or testing it will be interesting to see where the project goes.  This is an under-developed area with a lot of potential.

Technology can be also used in decision aids.  Dr. Data Santorino, a Ugandan pediatrician, and I sat down to talk about a project he runs which uses smart phones to guide village health workers through algorithms for clinical decision making for treating and triaging sick children.  In this way, community volunteers with a few hours of training can used symptoms-based algorithms to treat common diseases like pneumonia and malaria, and refer to a health center when appropriate.  The data is reviewed by Dr. Santorino in the referral hospital at which time he can contact the village health worker to follow up or change triage decisions where appropriate.

Global health technology does not have to mean the fanciest new device that can detect x disease with 100% sensitivity and specificity.  To me it means the utilization of appropriate technology to leverage local assets in a way that benefits the local population in a cost-effective manner.  A development technology example I love is sanitary napkins to keep girls in school.  Educated women and their children have better health outcomes, and this is an incredibly simple way to impact school attendance.

My excitement about global health technology is its potential to help with resource allocation, clinical decision making, training, and development to be able to multiply the effect of people working hard to improve the health and lives of those in their own communities.  I leave you with a great website on global health devices to whet your appetite for the future ...

Marjory Bravard, Mbarara, Uganda, Technology in Global Health Exploration

I am a 2nd year resident in internal medicine from MGH and just spent one month in Mbarara, Uganda learning about ongoing technology research projects and working on the medical wards.  Happily, I have just received word that I was awarded a Center for Global Health Travel grant to help fund this work.  I would like to use this forum to write a bit about the setting and explore existing technology projects and some ideas for the future of global health technology.

Mbarara (at left) is a town of about 87,000 in western Uganda.  It is located only about 2 hours drive from the equator, but is at an altitude of about 1400 meters and so the climate is rather mild, although the sun is, as expected, quite hot.  Also as a result of the altitude, malaria is less of a problem here than in many lower-lying areas.  This is notable given that in Uganda, malaria is the number one cause of morbidity and mortality.  

Here are some sobering malaria statistics for Uganda (see links 1 and 2 for more):

-       cause of 25-40% of outpatient visits, 15-20% of hospital admissions, 9-14% of hospital deaths

- number of malaria deaths /100,000 population (2008): 103... Just to emphasize, that’s 1/1,000 each year

- percentage of households with greater than 1 mosquito net: 34%

- percentage of insecticide treated net coverage: 12.8%

Malaria is so ubiquitous, in fact, that in Ugandan English, the word “malaria” is used to denote fever.  With limited diagnostics, in fact, one often is equivalent to the other.  By this I mean, when in doubt, fever is treated with antimalarials (and often ceftriaxone if there is concern for bacterial sepsis) until paristemia results can be obtained.   I sat down and spoke with Margarita Riera Montes, director of the MSF Epicenter in Mbarara, to talk a little bit about their malaria work.  They are doing some studies looking at malaria heterogeneity across a small geographic area (village to village) and also looking at the use of inhaled nitric oxide as an adjunctive treatment in cerebral malaria.  Fascinating stuff – I can’t wait to see the results.

But where does technology fit in, you ask?  Well one interesting missing piece is bednet adherence.  While insecticide-treated bednets are really the core of malaria prevention (see links 1 and 2), there are no good studies that objectively look at utilization, since all studies have been done with bednet use self-reported by study participants.   So Paul Krezanoski, a co-resident of mine at MGH, is working with Data Santorino, a Ugandan pediatrician, on building a bednet monitoring device as part of a study to look at actual bednet utilization: when it is used, by which family members, and crucially, when it is not used.  This information would be critical to really gauge how best  to improve bednet utilization and also to give real data to parents on how to prevent malaria in their children.  For example, how many nights under a bednet prevent one case of malaria (number needed to treat)?  I’m very excited about this work.  It's very powerful to be able to get at the truth of utilization of bed net technology... and in the future be able to assess the impact of interventions to improve utilization.

Disability and Global Health Equity: The Call to Action (Entry 3/3)

Cheri Blauwet, MD

PGY-3, Physical Medicine and Rehabilitation

St. Marc, Haiti

Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

As my month in Haiti is now nearly complete, I am compelled to write about my perspective of disability as a component of global health equity. Although this concept has previously been outlined and discussed within the global discourse of health as a human right, it deserves further emphasis given that disability, unlike many aspects of chronic or infectious disease, is often overlooked within health and health care-related advocacy efforts. 

I will start with the basic facts. It is estimated via the World Health Survey of 2002-2004 that approximately 15%-20% of the global population are individuals with a disability. This figure includes those with “significant difficulty with functioning in everyday life,” and can include those with traditionally defined disability such as amputation, stroke, spinal cord injury, brain injury, etc., however also include those with disability related to chronic disease or mental illness. The prevalence of disability also increases acutely at times of natural disaster or domestic and international conflict. It is commonly accepted that individuals with disabilities remain one of our most vulnerable populations globally. As often stated in disability and
international development initiatives, “disability is both a cause and consequence of poverty.” ¹

If I hadn’t already believed this to be true, my time in Haiti certainly offered unequivocal confirmation of this theme. As initially described in Entry #2, our Rehabilitation Team continued to engage in home visits in keeping with the ZL/PIH “accompagnateur” model. With this, patients work closely with a local community health worker to create sustainable, culturally-appropriate system of medical and psychosocial support. Our Team visited patients of various backgrounds and complex needs, to include amputees (both traumatic and vascular), those who had experienced strokes, a gentleman with incomplete C2 spinal cord injury as the result of Potts, a man who had experienced tabes dorsalis as a component of tertiary syphilis, and several others. As expected, our patients had extensive rehabilitation needs such as impairments in mobility, range of motion, activities of daily living, cognition, and poorly-controlled pain. Even more striking, however, was the invariable context of extreme economic insecurity in which they all lived. Subject to difficult circumstances simply due to disability, many were also abandoned by spouses and family as the result of physical and functional limitations. Parents with disabilities were often left to raise their children alone and without a reliable source of income. Likely due to stigma, almost none were able to hold employment or vocation, leading to even greater resource insecurity and reliance on extended family members or neighbors in the community. In addition to physical or cognitive disability, many also experienced poor health due to medical conditions such as poorly-controlled hypertension and diabetes. Most were at high risk for abuse and neglect.

Given this context, it is our priority to promote psychosocial empowerment while also providing medical rehabilitative care. As a capstone of my experience and acting as an illustration of this, our team co-sponsored an event in Port au Prince focused on disability advocacy and inclusion. With this, we wished to create an environment of celebration through which people with disabilities came together to promote community. The event was titled “Respect Me,” and pocket cards as well as posters of this slogan were distributed both in English and Creole. The phrase “Respect Me” was then used as an acronym to emphasize the concepts of: respect for dignity, empowerment, support autonomy, participation, equality of opportunity, communication, tasks of daily living, mobility, and environmental accessibility. We were honored to have the presence of Gerard Oriol, the Haitian Secretary of State for the Inclusion of People with Disabilities. All in all, it was a tremendous success and a call to action for us all – physicians, advocates, leaders, followers, people with disabilities, and their colleagues/friends.

I continue to stand by the notion that an empowerment and self-respect are the cornerstone of promoting both health and health care for people with disabilities in Haiti. With this in mind, there is much more work to be done. That said, we can also enjoy and be proud of how far we have come. It is my hope that those who attended our event can carry the phrase of “Respect Me” in the front of their minds, and use it when societal barriers hold them back from achieving true health. 

¹ “Disability, Poverty and Development.” A thematic report from the UK Department for International Development (DFID). February 2000.