International Health H.O.

1. JH Monestersky 1 International Health H.O. Lecture by: Jesse Monestersky,DO,MS,MPH,DTM&H CAPT,MC,USNR(FS,HMO) Contact info: (W) 847-688-6712x5081 Email: jesse.monestersky@nhgl.med.navy.mil

2. JH Monestersky 2

3. JH Monestersky 3 ROE Potpourri of topics Fire hose approach Keep your seatbelts fastened Happy to serve as a future resource Maybe will even excite one of you to pursue career in IH There will be a few questions on your exam from this lecture

4. JH Monestersky 4 References Textbooks: Auerbach, PS: Wilderness Medicine: Management of Wilderness & Environmental Emergencies, CV Mosby, 2001 Cook, GC; AI Zumla: PEC Manson-Bahr & DR Bell - Manson�s Tropical Diseases, 21st Ed., WB Saunders, 2002 Jong, EC; R McMullen: The Travel & Tropical Medicine Handbook, WB Saunders, 2002 Magil, AJ: Hunter�s Tropical Medicine & Emerging Diseases, WB Saunders Co., 2000 Steffen; Dupont; Wilder-Smith: Manual of Travel Medicine & Health, 2nd Ed., BC Decker, UK, 2003 Zuckerman, JN: Principles & Practice of Travel Medicine, John Wiley & Sons Publisher, 2001 Societies: American College of Tropical Medicine American Society of Tropical Medicine & Hygiene International Society of Travel Medicine Royal Society of Tropical Medicine & Hygiene (UK) Educational credentials: MPH (Master of Public Health) (Schools of Public Health, PrevMed Departments in Medical Schools) CTH (Certificate of Travel Medicine) DTM&H (Diploma in Tropical Medicine & Hygiene) (LSTM, London SH)

5. JH Monestersky 5 Bottom Line, Up Front International Health: To provide background, educational opportunities & your potential role Try to do a medical rotation overseas, esp., developing country Gain experience in nutrition [esp., peds, malnutrition [marasmus (calorie) vs. kwashikor (protein)], environmental health (food & water sanitation), entomology (medical), infect dx (measles, TB, malaria), diarrhea (ORS) Think about MPH degree or dual MD/MPH (IH, Epi, M&CH) Consider eventual paid or volunteer work abroad; e.g., PC (volunteer, PCMO), USDOS (RMO), DoD (A/D), NGO (MSF) Become more familiar with CHE, Mass disasters, Refugee Medicine International medical perspective mind-broadening You can make a difference (even one person at a time) Even consider specialty you choose if you want overseas work (e.g., IM/ID/TM, Ortho, GenSurg, ENT, Ophthal) Requires change in frame of reference to gain from experience! Carefully preplan your trip to make it meaningful & safe Learn a language or improve your language skills

6. JH Monestersky 6 Relevance??? Are tropical diseases of just historical interest? Emerging & reemerging diseases Global warming is changing disease distribution (e.g., WNF, malaria) With international jet travel, patients can show up anywhere even at a Midwest doc-in-the-box! Future pandemics (e.g., Avian influenza)? Bioterrorism (e.g., smallpox, anthrax) Many diseases remain major killers world-wide (measles, diarrhea, malaria, TB) Developing countries a Petri dish for rest of world

7. JH Monestersky 7 Monkeypox Ref: CDC MMWR 52(23):537-540; 6/13/03 � Multi-state Outbreak of Monkeypox � IL, IN, WI The 1st case presented to Marshfield Clinic WI for Tx of an infected bite from a pet prairie dog (6/03). Marshfield thought it was an orthopox by EM; specimen sent to CDC lab, which confirmed Dx by PCR. This orthopoxvirus is similar in appearance to smallpox; with low CFR. Human monkeypox was 1st identified in the Democratic Republic of the Congo in a a region where smallpox had been eradicated in 1968. 53 cases; resulting in 14 hospitalizations (26%). S&S: Preceding febrile illness, papular rash, lymphadenopathy, sore throat. Rash progressed through states of vesiculation, pustulation, umbilication, encrustation. Rashes occurred on hands, trunk, extremities; many patients had initial & satellite lesions on palms, soles, extremities. Rashes were generalized in some pts. Epid: All pts had contact with animals (Cynomys sp.) & 1 pt reported contact with a Gambian giant rat (Cricetomys sp.). Investigation revealed that a common distributor was responsible, who housed prairie dogs and Gambian giant rats together. Records revealed that the Gambian giant rats were shipped from Ghana to Texas and then, on to Illinois. Exposures were at a pet swap meet in N. WI. FDA & CDC issued an immediate ban on importation of all rodents from Africa (order Rodentia)

8. JH Monestersky 8 Malaria Airport malaria in France Between 1969-98, 63 cases of airport malaria have been reported in W. Europe, 24 of which occurred in France. Most cases due to Plasmodium falciparum. In 1994, 7 cases occurred in & around Roissy Charles de Gaulle airport (CDG), showing 4 types of exposure: employees working on airstrips or opening containers, among residents living near airport, among people living at some distance from airport after a secondary transport of vectors, & by vectors transported in luggage. Prevention is by disinsectization of aircraft, with permethrin aerosol though there is some pyrethroid resistance in Anopheles gambiae in W. Africa. [Ref: Guillet, P; MC Germain, T Giacomini, F Chandre, M Akogbeto, O Faye, A Kone, L Manga L, J Mouchet: Origin & Prevention of Airport Malaria in France. Trop Med Int Health 3(9):700-5; Sep 1998]

9. JH Monestersky 9 I. Complex Humanitarian Emergencies

10. JH Monestersky 10 Definition of CHE Def: Human disaster that occurs during & follows war & civil strife Inciting event either natural or man-made Characterized by displacement (internal, external) Loss of existing societal infrastructure Concerns for personal security 90% of war related mortality is among civilian non-combatants

11. JH Monestersky 11 Refugees vs. IDPs Flight across border (R) or within border (IDP) 14M refugees 15 � 20M IDPs UN & international protections vary Difficulty in assistance (e.g., Tsunami in Sri Lanka)

12. JH Monestersky 12 Priority Needs Sanitary food Sanitary water Sanitary waste disposal Shelter (planned layout of camp) Identification of vulnerable populations Appropriate health interventions for these populations: Immunizations Nutritional assessment Food appropriate to population Security Communications Transportation & distribution scheme Internal help (military, govt, healthcare workers) Outside help: UNHCR ICRC NGO (e.g., Medecins sans Frontieres) Office for Coordination of Humanitarian Affairs USAID (Office of Foreign Disaster Assistance)

13. JH Monestersky 13 Government-Civilian Agency Cooperation in Crisis Management Civil-Military Cooperation: C4 (command, control, communications, coordination) + security + logistical capabilities (resources, transportation) DoD vs. coalition partners (e.g., NATO) HA, MOOTW + aid agencies Sometimes friction Emergencies & disasters (e.g., hurricane response) USDOS-Civilian Cooperation: USAID, NGO�s (local experts), Embassy, Beneficiary partnership Uni/bi/multi-national, UN

14. JH Monestersky 14 II. Major Disease Killers Worldwide

15. JH Monestersky 15 Leading Infectious Causesof Death 2002 Acute RI: 3.8M HIV/AIDS: 2.8M Diarrheal dxs: 1.8M TB: 1.6M Malaria: 1.2M Measles: 0.8M [Ref: WHO, World Health Report, 2003]

16. JH Monestersky 16 III. Emerging vs. Reemerging Diseases

17. JH Monestersky 17 Emerging Diseases Newly identified disease Increased incidence over past 2 decades Incidence expected to increase over next 2 decades Examples: WNF Avian influenza SARS CDC Emerging Infectious Diseases (http://www.cdc.gov/ncidod/eid/index.htm)

18. JH Monestersky 18 Reemerging Diseases Smallpox TB Plague

19. JH Monestersky 19 Ingredients for Emergence Pathogen adaptation & change Virulence Adherence Invasiveness Toxin production Evasion of host immune defenses Antibiotic Resistance Expansion to new environments, reservoirs, vectors (�microbial traffic�) Increased populations at risk Genetic predisposition Co-infection Urban migration & poverty Crowding & poor hygiene Impaired immunity Inadequate public health infrastructure

20. JH Monestersky 20 Combating Emerging & Reemerging Diseases Facilitate early recognition & control of new diseases Tracking by US & Overseas Labs Train host-nation epidemiologists Assess & control threats US [CDC (e.g., MMWR), USAMRIID (US Army Medical Research Institute for Infectious Dxs , GEIS (Global Emerging Infections Surveillance program), ESSENCE (Electronic Surveillance System for the Early Notification of Community-Based Epidemics)] Network with foreign health agencies & WHO (Outbreak Reports), ISID (Promed) Monitor drug resistant organisms [e.g., Plasmodia, enteric & other pathogens (VRE, MRSA) Monitor for leptospirosis, yellow fever, dengue, hantaviruses

21. JH Monestersky 21 Powder Kegs for the Next Great Pandemic In the Shadow of the City World�s great slums Cairo, Smokey Mountain (Manila), Rio, Calcutta, Mexico City World�s slums are growing rapidly (UN-HABITAT Human Settlements Program Report): Now at 1B mark, making up 32% of global urban population Figure will double to 2B in next 30yr unless concerted effort undertaken In developing countries slum dwellers account for 43% of population in contrast to about 6% in more developed countries �Slums represent worst of urban poverty & inequality: No sanitation, no education, uncounted census World�s rural population has reached its peak & almost all further population growth will be absorbed by urban settlements

22. JH Monestersky 22 Smokey Mountain Manila

23. JH Monestersky 23 Recommended Movies! City of Joy (1992) Beyond Rangoon (1995)

24. JH Monestersky 24 4. International Health Rotation

25. JH Monestersky 25 International Health Rotations Learn about advanced disease, in austere settings! New skill set Public health in action Get to see much & do much May become impetus for career in international health, public health Will change you forever

26. JH Monestersky 26 Some International MedicalVolunteer Organizations International Medical Volunteers Association (http://www.imva.org) International Medical Corps (http://www.imcworldwide.org/index.shtml) Health Volunteers Overseas (http://www.hvousa.org) Doctors Without Borders (http://www.doctorswithoutborders.org) MEDICO (http://www.medico.org) Medicine For Peace (http://www.medpeace.org)

27. JH Monestersky 27 How & Where International Health Central American Institute Foundation (http://www.ihcai.org/programs.htm) Global Medicine (http://www.globalmedicine.org/GMN/student.html) AMA International Electives (http://www.ama-assn.org/ama/pub/category/12557.html) Office of Global Health (http://www.health.ufl.edu/ogh/oghpages/externships.html) American Academy of Family Physicians (http://www.aafp.org/ihcop/electives.html) The Center for International Health (http://intlhealth.med.utoronto.ca/Links/linksjob.html)

28. JH Monestersky 28 5. Travel Medicine(Emporiatrics)

29. JH Monestersky 29 Travel Medicine Travel Medicine Clinics (gov�t, private) Medical concerns of departing & returning traveler (business traveler, tourist) Critical is current medical intelligence: CDC, USDOS, WHO, I-SOS, Military (AFMIC) Most important aspects: Preplanning (do not leave for last minute) Immunizations & chemoprophylaxis Mosquito avoidance [repellents (DEET, pyrethrum), netting, clothing, habits] Sanitary food & water Medical & repatriation insurance (e.g., I-SOS) Major causes of death (MVA, AMI) Carry medical current medical summary Bring sufficient supply of Rx Documents (�yellow� shot record, passport)

30. JH Monestersky 30 6. Tropical Diseases

31. JH Monestersky 31 Tropical Diseases Diseases to eventually come to know & love: Malaria, dengue, hemorrhagic fevers (Ebola, Hanta, Lassa, YF, CCHF), leishmaniasis, HIV, trypanosomiasis, worms [nematodes (roundworms), cestodes (tapeworms), trematodes (flukes)], typhoid, hepatitis, vaccine-preventable dx, diarrhea, trichinosis, dracunculiasis, filariasis, schistosomiasis, trop derm, envenomization (insect, marine, snake), rabies, tetanus, strongyloides, pneumonias, trop mycoses, leprosy, prion dxs (Kuru), med entomology (mosquitoes, phlebotamine sandflies, blackflies, triatomine bugs ). Drugs: Antimalarials, anti-TB, antihelminthics

32. JH Monestersky 32 Clinical Cases:What is this stuff?

33. JH Monestersky 33 7. Some sobering realities

34. JH Monestersky 34 Downside Realities Pick your location carefully, both regarding endemic diseases, civil stability & unrest Be sure to have medical & repatriation insurance Check in with AmEmb consular section Let folks know where you are Don�t be a flagrant (ugly) American Being a diplomat, aid work, or health professional not automatic immunity from bad things happening

35. JH Monestersky 35 Afghanistan: Entire 5-person MSF team assassinated (2 Jun 04)

36. JH Monestersky 36 Tsunami

37. JH Monestersky 37 Current Hotspot

38. JH Monestersky 38 Upbeat Realities

39. JH Monestersky 39 My Range of Experiences Embassies Military exercises Club Med Travel Medicine Clinics Civilian & military training programs

40. JH Monestersky 40 Wide Range of Experiences Are Awaiting You! As a medical student: International health rotations As a medical practitioner: Refugee camps Medical missionary hospitals International medical volunteer work

41. JH Monestersky 41 8. Role of the International Community in Today�s World

42. JH Monestersky 42 Missions of the haves (inc., UN, WB) Why done? Regional stability & security Processes: Conflict stage: Peace making/keeping/building Provision of food, supplies Post-conflict: Nation building, reconstruction Economic development, debt relief If help, success stories: Kosovo, Bosnia If don�t help, tragedies: Rwanda (1994) with 1M dead

43. JH Monestersky 43 Concluding Remarks Just do it - Go overseas! Join the ranks of public health oriented physicians! Study TropMed Consider exotic diseases in your D/D Enjoy your undergraduate medical school experience Good luck in your careers

44. JH Monestersky 44 Discussion & Questions