Background Information:
A recent review article in NEJM evaluated what effects globalization and climate change can be expected to have on human health. If global population increases and temperatures continue to rise, diseases that were once limited by either remoteness or climatologic regions may have new geographical spread.
Pertinent Conclusions:
There are three primary ways which climate change may be expected to affect health:
- Primary: Direct biologic consequences (i.e. heat waves, extreme weather events, air pollution)
- Secondary: Risks caused by process changes (i.e. decreased crop yields, tropical vectors with increased spread)
-Tertiary: More diffuse effects (mental health issues in failed farmers, conflict due to scarce water)
Bottom Line:
No matter what your views are on the causes, the current trend is that the overall climate is getting warmer and human population is increasing. Anticipation of possible consequences is key to planning for the future.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
-MERS-CoV (Middle East Respiratory Syndrome) is a novel coronavirus that produces a SARS-like syndrome. (You might have seen a pearl about this from us in March...)
-Since that time there have been a total of 102 laboratory-confirmed cases with 42 deaths (almost half!)
-All known cases had links to the Arabian Peninsula, although there has been some local non-sustained transmission
Relevance to the EM Physician: Consider MERS-CoV in patients with SARS-like syndrome who have traveled or had contact with someone who has traveled to the Arabian Peninsula within the past 14 days.
Bottom Line: Ask about recent travel in patients with severe acute respiratory illness. If you suspect MERS-CoV, contact your local health department.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
·You must know the diagnosis to deliver effective and high quality care to patients; likewise for health systems to be effective, it is necessary to understand what the global burden of disease is.
·In 1991, the World Bank and World Health Organization launched the Global Burden of Disease Study which as of 2010 evaluates 291 disease and injuries as well as 1160 sequelae of these causes.
·In order to compare the burden of one disease with that of another, you must consider death and life expectancy of persons affected by the disease as well as disability imposed by the condition.
·The combined composite summary metric is termed disability adjusted life years (DALYs).
·There have been three major worldwide studies to date (1990, 2005, 2010) attempting to quantify the burden of disease yet no study to date has ever attempted to quantify the burden of disease requiring emergent intervention.
Bottom Line:
DALYs are a useful tool for quantifying the burden of disease and provides essential input into health policy dialogues to identifies conditions and risk factors that may be relatively neglected and others for which progress is not what was expected. To date, there has been no rigorous scientific effort to quantify the burden of disease worldwide that requires emergent intervention to avoid death and disability.
University of Maryland Section of Global Emergency Health
Author: Emilie J. B. Calvello, MD, MPH
General Information:
XDR TB is “extensively drug resistant tuberculosis”—resistant to isoniazid, rifampin, any fluoroquinolone, and at least one of the 3 injectable 2nd line drugs
Clinical Presentation:
- Identical to regular TB (weight loss, fevers, night sweats, cough, hemoptysis)
- Suspect in patients who are failing usual treatment
-Exposure in Eastern Europe or Russia (highest prevalence, although 84 countries have had documented XDR, including the US.)
Diagnosis:
- Plating on agar or liquid media for drug susceptibility testing
Treatment:
- Should be guided by susceptibility testing
- Isolate the patient!
Bottom Line:
XDR TB is increasing in prevalence, have a high index of suspicion in patients with persistent symptoms who are receiving treatment and isolate if any concerns.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
·You must know the diagnosis to deliver effective and high quality care to patients; likewise for health systems to be effective, it is necessary to understand what the global burden of disease is.
·In 1991, the World Bank and World Health Organization launched the Global Burden of Disease Study which as of 2010 evaluates 291 disease and injuries as well as 1160 sequelae of these causes.
·In order to compare the burden of one disease with that of another, you must consider death and life expectancy of persons affected by the disease as well as disability imposed by the condition.
·The combined composite summary metric is termed disability adjusted life years (DALYs).
·There have been three major worldwide studies to date (1990, 2005, 2010) attempting to quantify the burden of disease yet no study to date has ever attempted to quantify the burden of disease requiring emergent intervention.
Bottom Line:
DALYs are a useful tool for quantifying the burden of disease and provides essential input into health policy dialogues to identifies conditions and risk factors that may be relatively neglected and others for which progress is not what was expected. To date, there has been no rigorous scientific effort to quantify the burden of disease worldwide that requires emergent intervention to avoid death and disability.
University of Maryland Section of Global Emergency Health
Author: Emilie J. B. Calvello, MD, MPH
General Information:
As of July 30th, 2013, there have been 378 cases of Cyclospora infection from multiple states in the US. Cyclospora is most common in tropical and sub-tropical regions, and is spread via fecal-oral route. While the cause of the most recent outbreak is unknown, outbreaks in the US are generally foodborne.
Clinical Presentation:
- Symptoms usually begin 7 days after exposure
- Watery diarrhea, cramping, bloating, nausea, fatigue, increased gas, vomiting, low grade temperature
- Can persist several weeks to > 1 month
Diagnosis:
- Concentrated Stool Ova and Parasites— viewed under modified acid fast or fluorescence microscopy (labs can submit photos to the CDC for “telediagnosis”)
Treatment:
- TMP-SMX DS one tab po bid x7-10 days
- No effective alternate for failed treatment or sulfa allergy
- Most will recover without treatment but S/S can persist for weeks to months
Bottom Line:
Consider Cyclospora as a cause of prolonged diarrheal illness, treat with TMP-SMX.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
· Caused by the ameboflagellate Naegleria Fowleri
· Case fatality rate is estimated at 98%
· Commonly found in warm freshwater environments such as hot springs, lakes, natural mineral water, especially during hot summer months
· Incubation period 2-15 days
Relevance to the EM Physician:
· Clinical presentation: resembling bacterial meningitis/encephalitis
· Final diagnostic confirmation is not achieved until trophozoites are isolated and identified from CSF or brain tissue
· Treatment: Amphotericin B
Bottom Line:
· History of travel to tropical areas or exposure to warm or under-chlorinated water during summer time should raise the suspicion for Naegleria Fowleri. The amoeba is not sensitive to the standard meningitis/encephalitis therapy and amphotericin B must be added to the treatment regimen.
University of Maryland Section of Global Emergency Health
Background:
Infection with the Hepatitis C virus can result in mild to severe liver disease. Morbidity and mortality from Hep C is increasing the US--many of the 2.7-3.9 million persons with Hep C are not aware of their infection.
Pertinent Information:
- Hepatitis C is now curable for many patients
- Current treatment recommendations are a combination of medications (pegylated interferon plus ribavirin plus a protease inhibitor).
- Research in this field is very active--treatment is likely to change in the next 3-5 years.
- Risk reduction strategies to protect the liver (i.e. eliminating alcohol and Hep A and B vaccination) are also recommended.
Critical New Recommendation
As much of the disease burden is in the “Baby Boomers,” the CDC now recommends one time testing of all persons born between 1945 and 1965.
Bottom Line:
While emergency department management is focused on the treatment of acute complications of liver disease, it is also important to have all age appropriate patients follow-up for testing and treatment of Hepatitis C with their primary care provider.
General Information:
An estimated 70 children in the world die every 5 minutes-- 99% of these deaths are from developing countries, half in Sub-Saharan Africa , and two-thirds from preventable or easily treatable causes.
Area of the world affected:
One study examining the quality of hospital emergency care of 131 children in 21 hospitals in 7 developing countries found:
· 66% of hospitals did not have adequate triage; 41% of patients had inadequate initial assessment;
· 44% received inappropriate treatment and 30% had insuf cient monitoring.
· Frequent essential drugs, laboratory and radiology services supply outages
· Staffing and knowledge shortages for medical and nursing personnel
Relevance to the US physician:
The International Federation of Emergency Medicine (IFEM) used a consensus approach to develop the International Standards for Emergency Care of Children in Emergency Departments, published in July 2012.
· The standards covering initial assessment, stabilization and treatment, staf ng and training
· Guidelines for coordinating, monitoring and improving the pediatric emergency care are addressed
Bottom Line:
The IFEM International Standards for Emergency Care of Children provide an excellent resource for both clinicians and hospital managers in developing countries.
University of Maryland Section of Global Emergency Health
Author:Terrence Mulligan DO, MPH,FIFEM, FACEP, FAAEM, FACOEP, FNVSHA
--thanks and acknowledgments to Baljit Cheema, University of Cape Town and Stellenbosch University, South Africa
General Information:
Hepatitis A is a food-borne illness that is prevalent in developing countries. Currently in the US we are experiencing an outbreak in 8 states related to a frozen blend of organic berries. (Linked to Townson Farms brand sold at Costco and Harris Teeter)
Clinical Presentation:
- Case definition: sudden onset of S/S + jaundice or elevated liver enzyme levels
- S/S: nausea, anorexia, fever, malaise, abdominal pain
Diagnosis:
- Hepatitis A IgM
Treatment:
- Exposed patients should be given the Hep A vaccine within 2 weeks of exposure
- Exposed patients >40 yrs old, <1 yr old, immunocompromised, or with chronic liver disease: give immunoglobulin instead (risk of more severe disease)
- Supportive care
Bottom Line:
Patients potentially exposed to Hepatitis A in the past 2 weeks should be given either the vaccination or immunoglobulin, depending on comorbid conditions. Treatment of active infection is supportive.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
-Listeria can cause serious infections in vulnerable groups: adults >65 years old, pregnant women, newborns, immunocompromised
-In a recent CDC report, infection with Listeria was associated with a 20% mortality rate.
Clinical Presentation:
- History of cantaloupe, soft cheese, or raw produce ingestion
- Non-specific symptoms: fever, myalgias, occasionally preceded by GI symptoms
-Can have headache, stiff neck, confusion, AMS, miscarriage or stillbirth in pregnant women
Diagnosis:
- Blood, CSF, or amniotic fluid culture showing Listeria monocytogenes
- Listeria is a reportable disease
Treatment:
- Ampicillin and Penicillin G are the drugs of choice
- Add gentamycin in CSF infection, endocarditis, the immunocompromised, and neonates.
Bottom Line:
Listeria infections have a high mortality rate and can be found worldwide. Suspect in patients who have febrile syndromes and travel to areas where they may consume unpasteurized cheese.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
-The global health world is faced with an unprecedented challenge of a trio of threats:
1. Infections, undernutrition, reproductive health issues
2. Rising global burden of non-communicable diseases and risk factors
3. Challenges arising from globalization (climate change and trade politics)
-Definitions of global health are variable and can emphasize anything from types of health problems, populations of interest, geographic area or a specific mission. This makes governance and analysis difficult.
-During the past decade there has been an explosion of more than 175 initiatives, funds, agencies, and donors. Health is increasingly influenced by decisions made in other global policymaking areas.
-The major governance challenges for global health are:
1. Defining national sovereignty in the context of deepening health interdependence
2. Maximizing cross-sector interdependence
3. Developing clear mechanisms of accountability for non-state actors
Relevance to the US physician:
The Global Health System and its governance affects our ability to work effectively within the US and how we structure efforts to expand the reach of timely, effective emergency care worldwide.
Bottom Line:
The Global Health System has become more complex. Any development of Emergency Care Systems must take into account the complexity of actors in the field of global health.
The University of Maryland Section of Global Emergency Health
Author: Emilie J. B. Calvello, MD, MPH
Background Information:
Each year, an estimated 50 million travelers from Western countries visit tropical regions all over the world.
Given the potentially serious consequences for the patients and, their close contacts and healthcare workers it is important that life threatening tropical diseases are swiftly diagnosed.
Pertinent Study Design and Conclusions:
- Descriptive analysis of acute and potentially life threatening tropical diseases among 82,825 ill western travelers reported to GeoSentinel from June of 1996 to August of 2011.
- Of these travelers, 3,655 (4.4%) patients had an acute and potentially life threatening disease.
- The four most common conditions being falciparum malaria (76.9%), typhoid fever (11.7%), paratyphoid fever (6.4%), and leptospirosis (2.4%).
Bottom Line:
Western physicians seeing febrile and recently returned travelers from the tropics need to consider a wide profile of potentially life threatening tropical illnesses, with a specific focus on the most likely diseases described in this case series.
University of Maryland Section of Global Emergency Health
Author: Walid Hammad, MB ChB
Clinical Presentation:
- A 40-year-old Hispanic man was admitted to the hospital after being found unconscious. He had a 2-day history of disorientation that manifested itself as his being unable to recognize family members.
- Upon admission he regained consciousness, becoming alert and oriented, but developed urinary retention and was unable to move or feel his lower extremities.
- Spinal MRI (with and without gadolinium) showed the spinal cord to be abnormally diffuse, with swelling and edema in the cervicothoracic region.
Diagnosis:
- After an extensive work up for lymphoma and CNS infection, he was discovered to have toxoplasmosis and was found to be HIV positive, which was previously undiagnosed.
Discussion:
- Approximately 10% of patients with AIDS present with some neurological deficit as their initial complaint, and up to 80% will have CNS involvement during the course of their disease.
- Myelitis is a known complication of AIDS and is occasionally the initial complaint.
The incidence of myelopathy may be as high as 20%, with 50% of the cases reported post-mortem
- Toxoplasmosis is the most common cause of cerebral mass lesions in patients with AIDS
Occurring in 3–10% of patients in the United States and in up to 50% of AIDS patients in Europe, Latin America, and Africa
Bottom Line:
New neurological deficit in any patient should raise suspicion of HIV infection
Most patients with AIDS that present with evolving myelopathy, characterized by extremity weakness, sensory involvement, spinal cord enlargement, enhancing lesions in brain or spinal cord CT or MRI, have toxoplasmic myelitis
University of Maryland Section of Global Emergency Health
Author: Terrence Mulligan DO, MPH
General information:
· Salmonella typhi – transmission through fecal-oral, contaminated food, human carriers
· Most cases in the US acquired abroad – Africa, Latin American, Asia
· Vaccine available – not life-long immunity, need 1-2 weeks to take effect
Clinical Presentation:
· sustained high fever (103-104)
· Faget sign: fever and bradycardia (also seen in yellow fever, atypical pneumonia, tularemia, brucellosis, Colorado tick fever))
· Abdominal pain, GI bleed/perforation, hepatosplenomegaly, delirium
· “Rose spots” – erythematous macular rash over chest and abdomen
· Without treatment sx can resolve after 3-4 weeks, mortality from secondary infections 12-30%
Diagnosis:
· Pan-culture for S. typhi
· Serologic: Widal test (negative for 1st week of symptoms, 7-14 days to result)
Treatment:
· Abx: amoxicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin
· MDR typhoid: ceftriaxone or Azithromycine 1st line
Bottom Line:
· Get vaccinated if travelling to endemic areas 1-2 weeks before travel
· Suspect in travelers to endemic areas with sustained high fevers
· Spontaneous resolution does occur but may become carriers without abx
Famous victims or Typhoid fever:
· Wilbur Wright (Wright brothers)
· Prince Albert (Queen Victoria’s husband)
· Hakaru Hashimoto (discovered Hashimoto’s thyroiditis)
· Abigail Adams (1st Lady, wife of John Adams)
University of Maryland Section of Global Emergency Health
Author: Veronica Pei, MD
Case Presentation:
A Spanish speaking man in his late 20s is brought in by ambulance for severe dyspnea. Given the language barrier and his clinical status you are unable to obtain any history. He is tachypnic, had a low pulse ox, and was placed on BiPAP. On exam you hear bibasilar rales and a faint holosystolic murmur.
Clinical Question:
What should be included in the differential?
Answer:
Rheumatic heart disease is the result of valvular damage due to an abnormal immune response following a group A streptococcal infection. It affects 15.6 to 19.6 million people worldwide. Most patients present with dyspnea between the ages 20-50. The most common valvular disease is mitral insufficiency, but it may present with mitral stenosis or aortic regurgitation. The disease is most prevalent in sub-Saharan Africa and among the Indigenous population of Australia but it can be found in many developing countries. People who live in rural areas without access to medical care are those at highest risk for developing rheumatic fever and subsequently rheumatic heart disease.
Bottom Line:
Rheumatic heart disease should be considered in patients who present from an endemic region.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg, MD, MPH
General Information: Antibiotics are generally classified as time- and concentration-dependent.
Concentration-dependent antibiotics
-Fluoroquinolones (i.e. Levofloxacin)
-Aminoglycosides (i.e. Gentamicin)
-Azithromycin
Relevance to the EM Physician:
Concentration-dependent antibiotics should be given at the highest appropriate dose for the target tissues (i.e. Levofloxacin 750mg for pneumonia is preferable to 500mg). This is also the rationale for high dose, extended-interval dosing for Gentamicin (>5mg/kg initial dose).
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
The two main units used by medical laboratories are "conventional (used in the US) and SI (used by most other countries).
Pearls to know:
Relevance to the EM Physician:
These tips will help you convert labs to familiar values when reading medical literature, when working in another country, or when working with international colleagues.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
General Information:
A parasitic infection caused by the tissue-dwelling filarial nematode worm Wuchereria bancrofti; a wide range of mosquitoes transmit the infection. When the worm is mature, it inhabits lymph nodes and produces sheathed microfilarial larvae that circulate in the peripheral blood.
Clinical Presentation:
- Infection with the adult worms produces painless subcutaneous nodules that are usually less than 2 cm in diameter, typically over bony prominences.
- Symptoms depend on where the microfilariae migrate to, and vary accordingly. They include: pruritus, papular dermatitis, dermal atrophy and depigmentation or hyperreactive skin disease (Sowda), keratitis, iritis, chorioretinitis, optic atrophy and eventually blindness, orchitis, hydrocele, chyluria, elephantiasis, pulmonary eosinophilia, cough, wheezing, and splenomegaly.
Diagnosis:
- Peripheral blood smear taken between 11pm and 1am or after provocation using diethylcarbamazine (DEC).
- Filarial antigen test.
- Eosinophilia, and specific antiflarial IgG and IgE antibodies.
Treatment:
- DEC which must be obtained directly from the CDC.
- Alternatively Doxycycline. Both drugs are effective against both macro and micro-filaria.
Bottom Line:
One billion people globally are at risk for infection with filaria. 120 million already have the infection. Suspect the infection in patients that have been to Africa, Asia, especially India, Western pacific, Haiti, the Dominican Republic, Guyana and Brazil.
University of Maryland Section of Global Emergency Health
Author: Walid Hammad, MD
Spring is in the air... and so is rotavirus.
Area of the world affected:
· Diarrheal illnesses were responsible for 1.6 million deaths for children under 5 globally in 2002.
· This number has improved over the years, in part due to oral rehydration salts (ORS) which were developed for cholera.
Relevance to the US physician:
http://www.cdc.gov/surveillance/nrevss/rotavirus/region.html#top
· ORS are also important for rotavirus treatment and uncomplicated gastroenteritis in children and adults.
· Commercially prepared solutions have different concentrations of ingredients, but all will work as better treatment and rehydration than common household products like sports drinks and juice.
Bottom line:
Consider ORS in patients with uncomplicated acute gastroenteritis.
University of Maryland Section of Global Emergency Health
Author: Jennifer Reifel Saltzberg, MD, MPH
