Guidelines for short-term medical missions: perspectives from host countries.

BACKGROUND: In the past decade, there has been increasing guideline development for short-term medical missions (STMMs) traveling from high-income to low- and middle-income countries for the purpose of supporting health care services. The ethics of STMMs is criticized in the literature and there is frequently a lack of host country collaboration. This typically results in guidelines which are developed through the lens of the sending (high-income) countries' staff and organizations. The aim of this paper is to evaluate an existing best practice guideline document from the perspective of host country participants with knowledge of STMMs from Honduras, Malawi, and the Philippines. METHODS: The guideline used for the evaluation consisted of nine best practice elements that were discerned based on literature and the experience of those working within the field. Semi-structured interviews were conducted in a cross-sectional study with participants (n = 118) from the host countries. Thematic analysis was conducted by two researchers and the results were assessed by working group members to confirm interpretations of the data. RESULTS: Overall, participants expressed a strong interest in having more structured guidance surrounding STMM practices. There was a positive response to and general acceptance of the proposed STMM guidelines, although participants found the 24-page document onerous to use; a companion checklist was developed. The key themes that emerged from the interviews included collaboration and coordination, care for hard-to-reach communities, capacity building, critical products and essential medical supplies, and opportunity and feasibility. CONCLUSIONS: Host input suggests that the guidelines provide structured regulation and coordination of the medical mission process and have the potential to improve the way STMMs are carried out. The guidelines have also proven to be a useful tool for the actual implementation of STMMs and can be a tool to strengthen links and trust between mission teams and local health staff. However, local contexts vary considerably, and guidelines must be adapted for local use. It is recommended that STMM teams work in conjunction with host partners to ensure they meet local needs, increase capacity development of local health workers, and provide continuity of care for patients into the local system.

ANTECEDENTES: En la última década, ha habido un incremento en el desarrollo de guías para las misiones médicas de corto plazo (STMM) que viajan desde países de ingresos altos a países en vías de desarrollo con el fin de apoyar los servicios de atención médica. La ética de las (STMM) es criticada en la literatura y hay una falta frecuente de colaboración entre los países anfitriones. Esto normalmente da como resultado directrices que se desarrollan a través de la lente del personal y las organizaciones de los países que envían (países de altos ingresos). El objetivo de este documento es evaluar un documento guía de mejores prácticas existente desde la perspectiva de los participantes del país anfitrión con conocimiento de las misiones médicas de corto plazo (STMM) de Honduras, Malawi y Filipinas. MéTODOS: la directriz utilizada para la evaluación consistió en nueve elementos de mejores prácticas que se discernieron en base a la literatura y la experiencia de quienes trabajan en el campo. Se realizaron entrevistas semiestructuradas en un estudio transversal con participantes (n = 118) de los países anfitriones. El análisis temático fue realizado por dos investigadores y los resultados fueron evaluados por miembros del grupo de trabajo para confirmar las interpretaciones de los datos. RESULTADOS: En general, los participantes expresaron un gran interés en tener una guía más estructurada en torno a las prácticas de las misiones médicas de corto plazo (STMM). Hubo una respuesta positiva y una aceptación general de las pautas de las misiones médicas de corto plazo (STMM) propuestos, aunque los participantes encontraron oneroso el uso del documento de 24 páginas y se desarrolló una lista de verificación complementaria. Los temas clave que surgieron de las entrevistas incluyeron colaboración y coordinación, atención a comunidades de difícil acceso, desarrollo de capacidades, productos críticos y suministros médicos esenciales, y oportunidad y viabilidad. CONCLUSIONES: Los comentarios del anfitrión sugieren que las directrices proporcionan una regulación y coordinación estructuradas del proceso de la misión médica y tienen el potencial de mejorar la forma en que se llevan a cabo las misiones médicas de corto plazo (STMM). Las pautas también han demostrado ser una herramienta útil para la implementación real de de las misiones médicas de corto plazo (STMM) y pueden servir para fortalecer los vínculos y la confianza entre los equipos de misión y los sistemas de salud locales. Sin embargo, los contextos locales varían considerablemente y las pautas deben adaptarse para el uso local. Se recomienda que los equipos de las misiones médicas de corto plazo (STMM) trabajen en conjunto con los socios anfitriones para garantizar que satisfagan las necesidades locales, aumenten el desarrollo de la capacidad de los trabajadores de salud locales y brinden continuidad de atención a los pacientes en el sistema local.

Fatal Pediatric Cerebral Malaria Is Associated with Intravascular Monocytes and Platelets That Are Increased with HIV Coinfection.

Cerebral malaria (CM) is a major contributor to malaria deaths, but its pathophysiology is not well understood. While sequestration of parasitized erythrocytes is thought to be critical, the roles of inflammation and coagulation are controversial. In a large series of Malawian children hospitalized with CM, HIV coinfection was more prevalent than in pediatric population estimates (15% versus 2%, P < 0.0001, chi-square test), with higher mortality than that seen in HIV-uninfected children (23% versus 17%, P = 0.0178, chi-square test). HIV-infected (HIV(+)) children with autopsy-confirmed CM were older than HIV-uninfected children (median age, 99 months versus 32 months, P = 0.0007, Mann-Whitney U test) and appeared to lack severe immunosuppression. Because HIV infection is associated with dysregulated inflammation and platelet activation, we performed immunohistochemistry analysis for monocytes, platelets, and neutrophils in brain tissue from HIV(+) and HIV-uninfected children with fatal CM. Children with autopsy-confirmed CM had significantly (>9 times) more accumulations of intravascular monocytes and platelets, but not neutrophils, than did children with nonmalarial causes of coma. The monocyte and platelet accumulations were significantly (>2-fold) greater in HIV(+) children than in HIV-uninfected children with autopsy-confirmed CM. Our findings indicate that HIV is a risk factor for CM and for death from CM, independent of traditional measures of HIV disease severity. Brain histopathology supports the hypotheses that inflammation and coagulation contribute to the pathogenesis of pediatric CM and that immune dysregulation in HIV(+) children exacerbates the pathological features associated with CM. IMPORTANCE : There are nearly 1 million malaria deaths yearly, primarily in sub-Saharan African children. Cerebral malaria (CM), marked by coma and sequestered malaria parasites in brain blood vessels, causes half of these deaths, although the mechanisms causing coma and death are uncertain. Sub-Saharan Africa has a high HIV prevalence, with 3 million HIV-infected (HIV(+)) children, but the effects of HIV on CM pathogenesis and mortality are unknown. In a study of pediatric CM in Malawi, HIV prevalence was high and CM-attributed mortality was higher in HIV(+) than in HIV-uninfected children. Brain pathology in children with fatal CM was notable not only for sequestered malaria parasites but also for intravascular accumulations of monocytes and platelets that were more severe in HIV(+) children. Our findings raise the possibility that HIV(+) children at risk for malaria may benefit from targeted malaria prophylaxis and that adjunctive treatments targeting inflammation and/or coagulation may improve CM outcomes.

Typhoid Fever in an inner city hospital: a 5-year retrospective review.

BACKGROUND: Typhoid is a leading cause of fever in returning travelers. The prevalence is highest in migrants visiting friends and relatives (VFR travelers) in the Indian subcontinent, where reports of resistance have been of concern. This study is a retrospective analysis of patients with typhoid, seen over a 5-year period, in a tertiary center that serves a large immigrant population. METHODS: Patients with blood cultures positive for Salmonella Typhi were identified between 2006 and 2010. Charts were reviewed for demographic data, travel history, symptoms and signs, basic laboratory results, susceptibility profiles, treatment, and clinical course. Resistance to nalidixic acid was used as a marker of decreased susceptibility to quinolones. RESULTS: Seventeen patients were identified with S Typhi. The median age was 12 years (range: 2-47 y) and 94% (16 of 17) were hospitalized with a median stay of 7 days; two were admitted to the intensive care unit. Fourteen patients (82%) had a history of recent travel. Twelve were VFR travelers in Bangladesh and Pakistan and two had recently immigrated. In our study, typhoid patients had low eosinophil counts and elevated transaminases. Seventy-six percent (12 of 17) of all isolates were resistant to nalidixic acid, 23.5% (4 of 17) were resistant to ampicillin and co-trimoxazole, and one was resistant to ciprofloxacin. All isolates were susceptible to third-generation cephalosporins. CONCLUSIONS: Younger VFR travelers appear to be at greater risk of acquiring infection and developing complications. Absolute eosinopenia and increased liver function test values could be useful early diagnostic clues in a returning traveler with fever, once malaria has been excluded. There was a high rate of decreased susceptibility to fluoroquinolones, confirming that the use of third-generation cephalosporins or macrolides in patients from the Indian subcontinent is most appropriate. Prevention in VFR travelers to South Asia is critical and efforts should be targeted at better education and pre-travel immunization.

HIV in the tropics: staging in the resource-limited setting.

PURPOSE OF REVIEW: In 2010, the WHO updated HIV treatment guidelines for adults and children, expanding the eligibility of HIV-infected individuals for antiretroviral therapy (ART) on the basis of immunological staging. We discuss the barriers to HIV staging in under-resourced settings. RECENT FINDINGS: In industrialized countries, HIV-infected patients are immunologically staged using CD4 lymphocyte counts measured using flow cytometry, but reliable and timely CD4 testing is still not readily available for all patients in many poorly resourced countries. Often CD4 testing is only available in central hospitals and clinics and depends upon availability of reagents. This leaves clinical staging as the standard of care in many places. Significant discrepancies exist between clinical and immunologic staging. Lack of immunologic staging can lead to delayed or inappropriate initiation of ART, increased attrition before ART, and overall poorer outcomes as patients often initiate ART at lower CD4 cell count baselines. This has led to intensive efforts to develop cost-effective laboratory testing, particularly for accurate low-cost CD4 testing. SUMMARY: Simplified, low-cost alternatives for immunologic staging are vital to continued scale up of ART programs globally. Point-of-care CD4 testing in particular has shown promise in decreasing attrition rates before ART and improving overall mortality in resource-limited settings.

Blastocystis: to treat or not to treat...

Parasites in the genus Blastocystis comprise several subtypes (genotypes) and have a worldwide distribution. In some surveys, these are the most common parasites found in human stool specimens. An emerging literature suggests that the pathogenicity of Blastocystis is related to specific subtypes and parasite burden, although even individuals with small numbers of cysts may be symptomatic. Some data suggest an association between infection with Blastocystis and irritable bowel syndrome. However, there are few clinical studies demonstrating a direct relationship between the presence of this parasite and disease, few animal models to explore this relationship, and no consensus as to appropriate treatment. We recommend that asymptomatic individuals with few cysts not be treated. However, those who have gastrointestinal or dermatologic signs and symptoms and many cysts in stool specimens may require treatment. Metronidazole is the drug of choice. Additional studies are required to determine pathogenicity and appropriate therapy.