Exploring medical students' perceptions of family medicine in Kyrgyzstan: a mixed method study.

BACKGROUND: Despite knowing that health systems with strong primary care improve overall health outcomes within a population, many countries are facing a global trend of declining interest and shortage of family doctors. This is the case of the Kyrgyz Republic, in which rural areas are struggling to attract and retain family medicine (FM) doctors. This study aims to explore how Kyrgyz medical students perceive FM and the factors that influence their specialty choice. METHODS: This study used a cross-sectional explanatory sequential design, including quantitative survey and focus group discussions that were carried out at the Kyrgyz State Medical Academy (KSMA) in Bishkek in 2017. Overall, 66% (953 out of 1449) of medical undergraduate students registered in year 1, 4 and 6 completed the survey, and 42 participated in the focus groups. The results were organized around 7 factors influencing perceptions and attitudes towards FM identified through a qualitative systematic review. RESULTS: The interest of Kyrgyz students for FM was the lowest of all specialties. Access to high medical technologies, career opportunities, salary, patient interaction and possibility to work abroad were the five most important factors influencing specialty choice. FM was perceived as a difficult profession, yet with poor prestige, insufficient remuneration, limited career possibilities and poor working conditions, especially in rural areas. The academic discourse, which disregards FM specialty had a negative influence on student's perceptions and prevented students' ability to identify with the practice of family medicine. However, students' awareness of their social accountability arose as a positive leverage to increase the choice of FM, provided other problems were solved. CONCLUSION: This study highlighted key factors responsible for the low number of students choosing to become FM in Kyrgyzstan. The first major factor, presumably specific to many low- and lower-middle- income countries was the poor working conditions in remote areas. The second factor, common to many countries, was the distorted image of FM and its specialty transmitted through the medical schools' institutional culture which does not value FM through positive role models. This study served as a basis to establish a strategy to promote FM within the KSMA and potentially at National level.

Reforms in medical education: lessons learnt from Kyrgyzstan.

Human resources are one of the six building blocks of a health system. In order to ensure that these resources are adequately trained to meet the evolving needs of populations, medical education reforms are needed. In Kyrgyzstan, like in many other low- and middle-income countries, human resources for health are a key challenge for the health system in both the quantity and having their training aligned with the health system priorities. Here we present the experience of the Medical Education Reform Project, a project aimed at improving the quality of health professionals through reforming medical education, funded by the Swiss Agency for Development and Cooperation, as a collaborative effort between partners in Kyrgyzstan and Switzerland since 2013. We used a qualitative study taking a cooperative inquiry approach with an experiential perspective in order to present the implementation of the Medical Education Reform Project in Kyrgyzstan. In order to look at the different components impacting the reform process, a framework comprising: Setting the direction; Building a consensus; Engaging stakeholders; Pilot projects and evaluation; Capacity building; Timing, and Key partners was used to disentangle the lessons learnt. Champions and partnering with key institutions were essential in building consensus, as was the catalytic and facilitating role the project played. This enabled active engagement of a variety of stakeholders in the reform process using different means of interaction ranging from large roundtable discussions, workshops, trainings and even study tours. Pilot projects and research provided tangible actions that could be used to further the reforms. For capacity building, the project offered a wide range of activities that improved clinical competencies, empowered stakeholders, and strengthened organizational capacity. The timing of this reform process in medical education was facilitated by the overall reforms and policies in the health system.

Geneva Health Forum: The Forum of Innovative Practices in Global Health.

In the past years, Global Health has interfaced with important challenges related to several dynamic changes. Technological progress, the digital revolution and the emergence of new actors in the field of health, increase the possibility of finding solutions to these unprecedented challenges. Starting from these assumptions, the idea of providing an adequate platform for good management of the health system has flowed into the creation of a meeting place that would allow a wide exchange of information, ideas sharing and proposals for new collaborations: the Geneva Health Forum (GHF). The GHF is a global health conference that aims to promote critical reflections and constructive debates on contemporary global health issues, thus influencing and informing policy formulation with experience from the field. The profile and impact of the Geneva Health Forum has grown year on year, establishing itself as a unique forum, ranging from more traditional sessions to innovative events.

Mefloquine at the crossroads? Implications for malaria chemoprophylaxis in Europe.

Since its introduction to the market in 1985, mefloquine has been used for malaria chemoprophylaxis by more than 35 million travellers. In Europe, in 2014, the European Medicines Agency (EMA) issued recommendations on strengthened warnings, prescribing checklists and updates to the product information of mefloquine. Some malaria prevention advisors question the scientific basis for the restrictions and suggest that this cost-effective, anti-malarial drug will be displaced as a first-line anti-malaria medication with the result that vulnerable groups such as VFR and long-term travellers, pregnant travellers and young children are left without a suitable alternative chemoprophylaxis. This commentary looks at the current position of mefloquine prescribing and the rationale of the new EMA recommendations and restrictions. It also describes the new recommendations for malaria prophylaxis that have been adapted by Switzerland, Germany, Austria and Italy where chemoprophylaxis use is restricted to high-risk malaria-endemic areas.

Regional variation in travel-related illness acquired in Africa, March 1997-May 2011.

To understand geographic variation in travel-related illness acquired in distinct African regions, we used the GeoSentinel Surveillance Network database to analyze records for 16,893 ill travelers returning from Africa over a 14-year period. Travelers to northern Africa most commonly reported gastrointestinal illnesses and dog bites. Febrile illnesses were more common in travelers returning from sub-Saharan countries. Eleven travelers died, 9 of malaria; these deaths occurred mainly among male business travelers to sub-Saharan Africa. The profile of illness varied substantially by region: malaria predominated in travelers returning from Central and Western Africa; schistosomiasis, strongyloidiasis, and dengue from Eastern and Western Africa; and loaisis from Central Africa. There were few reports of vaccine-preventable infections, HIV infection, and tuberculosis. Geographic profiling of illness acquired during travel to Africa guides targeted pretravel advice, expedites diagnosis in ill returning travelers, and may influence destination choices in tourism.

Travel-associated diseases, Indian Ocean Islands, 1997-2010.

Data collected by the GeoSentinel Surveillance Network for 1,415 ill travelers returning from Indian Ocean islands during 1997-2010 were analyzed. Malaria (from Comoros and Madagascar), acute nonparasitic diarrhea, and parasitoses were the most frequently diagnosed infectious diseases. An increase in arboviral diseases reflected the 2005 outbreak of chikungunya fever.

Effectiveness of rapid transport of victims and community health education on snake bite fatalities in rural Nepal.

Snake bite is a major public problem in the rural tropics. In southern Nepal, most deaths caused by neurotoxic envenomation occur in the village or during transport to health centers. The effectiveness of victims' transport by motorcycle volunteers to a specialized treatment center, combined with community health education, was assessed in a non-randomized, single-arm, before-after study conducted in four villages (population = 62,127). The case-fatality rate of snake bite decreased from 10.5% in the pre-intervention period to 0.5% during the intervention (relative risk reduction = 0.949, 95% confidence interval = 0.695-0.999). The snake bite incidence decreased from 502 bites/100,000 population to 315 bites/100,000 population in the four villages (relative risk reduction = 0.373, 95% confidence interval = 0.245-0.48), but it remained constant in other villages. Simple educational messages and promotion of immediate and rapid transport of victims to a treatment center decreased the mortality rate and incidence of snake bite in southeastern Nepal. The impact of similar interventions should be assessed elsewhere.

Acute and potentially life-threatening tropical diseases in western travelers--a GeoSentinel multicenter study, 1996-2011.

We performed a 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. We identified 3,655 patients (4.4%) with a total of 3,666 diagnoses representing 13 diseases, including falciparum malaria (76.9%), enteric fever (18.1%), and leptospirosis (2.4%). Ninety-one percent of the patients had fever; the median time from travel to presentation was 16 days. Thirteen (0.4%) patients died: 10 with falciparum malaria, 2 with melioidosis, and 1 with severe dengue. Falciparum malaria was mainly acquired in West Africa, and enteric fever was largely contracted on the Indian subcontinent; leptospirosis, scrub typhus, and murine typhus were principally acquired in Southeast Asia. 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 our large case series.

Spectrum of illness in international migrants seen at GeoSentinel clinics in 1997-2009, part 2: migrants resettled internationally and evaluated for specific health concerns.

BACKGROUND: Increasing international migration may challenge healthcare providers unfamiliar with acute and long latency infections and diseases common in this population. This study defines health conditions encountered in a large heterogenous group of migrants. METHODS: Migrants seen at GeoSentinel clinics for any reason, other than those seen at clinics only providing comprehensive protocol-based health screening soon after arrival, were included. Proportionate morbidity for syndromes and diagnoses by country or region of origin were determined and compared. RESULTS: A total of 7629 migrants from 153 countries were seen at 41 GeoSentinel clinics in 19 countries. Most (59%) were adults aged 19-39 years; 11% were children. Most (58%) were seen >1 year after arrival; 27% were seen after >5 years. The most common diagnoses were latent tuberculosis (22%), viral hepatitis (17%), active tuberculosis (10%), human immunodeficiency virus (HIV)/AIDS (7%), malaria (7%), schistosomiasis (6%), and strongyloidiasis (5%); 5% were reported healthy. Twenty percent were hospitalized (24% for active tuberculosis and 21% for febrile illness [83% due to malaria]), and 13 died. Tuberculosis diagnoses and HIV/AIDS were reported from all regions, strongyloidiasis from most regions, and chronic hepatitis B virus (HBV) particularly in Asian immigrants. Regional diagnoses included schistosomiasis (Africa) and Chagas disease (Americas). CONCLUSIONS: Eliciting a migration history is important at every encounter; migrant patients may have acute illness or chronic conditions related to exposure in their country of origin. Early detection and treatment, particularly for diagnoses related to tuberculosis, HBV, Strongyloides, and schistosomiasis, may improve outcomes. Policy makers should consider expansion of refugee screening programs to include all migrants.

Expatriates ill after travel: results from the Geosentinel Surveillance Network.

BACKGROUND: Expatriates are a distinct population at unique risk for health problems related to their travel exposure. METHODS: We analyzed GeoSentinel data comparing ill returned expatriates with other travelers for demographics, travel characteristics, and proportionate morbidity (PM) for travel-related illness. RESULTS: Our study included 2,883 expatriates and 11,910 non-expatriates who visited GeoSentinel clinics ill after travel. Expatriates were more likely to be male, do volunteer work, be long-stay travelers (>6 months), and have sought pre-travel advice. Compared to non-expatriates, expatriates returning from Africa had higher proportionate morbidity (PM) for malaria, filariasis, schistosomiasis, and hepatitis E; expatriates from the Asia-Pacific region had higher PM for strongyloidiasis, depression, and anxiety; expatriates returning from Latin America had higher PM for mononucleosis and ingestion-related infections (giardiasis, brucellosis). Expatriates returning from all three regions had higher PM for latent TB, amebiasis, and gastrointestinal infections (other than acute diarrhea) compared to non-expatriates. When the data were stratified by travel reason, business expatriates had higher PM for febrile systemic illness (malaria and dengue) and vaccine-preventable infections (hepatitis A), and volunteer expatriates had higher PM for parasitic infections. Expatriates overall had higher adjusted odds ratios for latent TB and lower odds ratios for acute diarrhea and dermatologic illness. CONCLUSIONS: Ill returned expatriates differ from other travelers in travel characteristics and proportionate morbidity for specific diseases, based on the region of exposure and travel reason. They are more likely to present with more serious illness.

Real-life versus package insert: a post-marketing study on adverse-event rates of the virosomal hepatitis A vaccine Epaxal® in healthy travellers.

There are various methods to collect adverse events (AEs) in clinical trials. The methods how AEs are collected in vaccine trials is of special interest: solicited reporting can lead to over-reporting events that have little or no biological relationship to the vaccine. We assessed the rate of AEs listed in the package insert for the virosomal hepatitis A vaccine Epaxal(®), comparing data collected by solicited or unsolicited self-reporting. In an open, multi-centre post-marketing study, 2675 healthy travellers received single doses of vaccine administered intramuscularly. AEs were recorded based on solicited and unsolicited questioning during a four-day period after vaccination. A total of 2541 questionnaires could be evaluated (95.0% return rate). Solicited self-reporting resulted in significantly higher (p<0.0001) rates of subjects with AEs than unsolicited reporting, both at baseline (18.9% solicited versus 2.1% unsolicited systemic AEs) and following immunization (29.6% versus 19.3% local AEs; 33.8% versus 18.2% systemic AEs). This could indicate that actual reporting rates of AEs with Epaxal(®) may be substantially lower than described in the package insert. The distribution of AEs differed significantly between the applied methods of collecting AEs. The most common AEs listed in the package insert were reported almost exclusively with solicited questioning. The reporting of local AEs was more likely than that of systemic AEs to be influenced by subjects' sex, age and study centre. Women reported higher rates of AEs than men. The results highlight the need for detailing the methods how vaccine tolerability was reported and assessed.

Urbanisation and infectious diseases in a globalised world.

The world is becoming urban. The UN predicts that the world's urban population will almost double from 3·3 billion in 2007 to 6·3 billion in 2050. Most of this increase will be in developing countries. Exponential urban growth is having a profound effect on global health. Because of international travel and migration, cities are becoming important hubs for the transmission of infectious diseases, as shown by recent pandemics. Physicians in urban environments in developing and developed countries need to be aware of the changes in infectious diseases associated with urbanisation. Furthermore, health should be a major consideration in town planning to ensure urbanisation works to reduce the burden of infectious diseases in the future.

Mental and physical health of Kosovar Albanians in their place of origin: a post-war 6-year follow-up study.

PURPOSE: Long-term outcome of traumatic experiences among war-exposed civilians living in their home country has been seldom documented. The present study examined change in posttraumatic stress disorder (PTSD) frequency and perceived physical and mental health in a cohort of Kosovar Albanians over 6 years (2001-2007). METHODS: Of 996 Albanian Kosovar civilians included in the 2001 survey, 551 subjects (55.3%) were recalled and interviewed in 2007. Diagnoses of PTSD and major depressive episode were assessed using the Mini International Neuropsychiatric Interview. Subjective physical and mental health were investigated using the Medical Outcomes Study 36-Item Short-Form (SF-36). A list of traumatic events adapted from the Harvard Trauma Questionnaire and other stressful life events was also considered. RESULTS: Posttraumatic stress disorder was significantly less frequent in 2007 than in 2001 (14.5% vs. 23.2%, p < 0.001). For 18.0, 5.3 and 9.3% of participants, PTSD remitted, persisted and developed over the 6-year follow-up period, respectively. Ill health without having access to medical care and major changes in responsibilities at work were associated with both persistence and new occurrence of PTSD. While the SF-36 mental component summary score significantly improved (mean change +4.5, p < 0.001), the physical component summary score did not change between 2001 and 2007, after adjustment for age (mean change -0.8, p = 0.14). CONCLUSIONS: Results point at the importance of economic and health system reconstruction programs with respect to public health in post-conflict countries.

Travel and migration associated infectious diseases morbidity in Europe, 2008.

BACKGROUND: Europeans represent the majority of international travellers and clinicians encountering returned patients have an essential role in recognizing, and communicating travel-associated public health risks. METHODS: To investigate the morbidity of travel associated infectious diseases in European travellers, we analysed diagnoses with demographic, clinical and travel-related predictors of disease, in 6957 ill returned travellers who presented in 2008 to EuroTravNet centres with a presumed travel associated condition. RESULTS: Gastro-intestinal (GI) diseases accounted for 33% of illnesses, followed by febrile systemic illnesses (20%), dermatological conditions (12%) and respiratory illnesses (8%). There were 3 deaths recorded; a sepsis caused by Escherichia coli pyelonephritis, a dengue shock syndrome and a Plasmodium falciparum malaria.GI conditions included bacterial acute diarrhea (6.9%), as well as giardiasis and amebasis (2.3%). Among febrile systemic illnesses with identified pathogens, malaria (5.4%) accounted for most cases followed by dengue (1.9%) and others including chikungunya, rickettsial diseases, leptospirosis, brucellosis, Epstein Barr virus infections, tick-borne encephalitis (TBE) and viral hepatitis. Dermatological conditions were dominated by bacterial infections, arthropod bites, cutaneous larva migrans and animal bites requiring rabies post-exposure prophylaxis and also leishmaniasis, myasis, tungiasis and one case of leprosy. Respiratory illness included 112 cases of tuberculosis including cases of multi-drug resistant or extensively drug resistant tuberculosis, 104 cases of influenza like illness, and 5 cases of Legionnaires disease. Sexually transmitted infections (STI) accounted for 0.6% of total diagnoses and included HIV infection and syphilis. A total of 165 cases of potentially vaccine preventable diseases were reported. Purpose of travel and destination specific risk factors was identified for several diagnoses such as Chagas disease in immigrant travellers from South America and P. falciparum malaria in immigrants from sub-Saharan Africa. Travel within Europe was also associated with health risks with distinctive profiles for Eastern and Western Europe. CONCLUSIONS: In 2008, a broad spectrum of travel associated diseases were diagnosed at EuroTravNet core sites. Diagnoses varied according to regions visited by ill travellers. The spectrum of travel associated morbidity also shows that there is a need to dispel the misconception that travel, close to home, in Europe, is without significant health risk.

Predicted 30-year protection after vaccination with an aluminum-free virosomal hepatitis A vaccine.

Few studies have examined the duration of protection following vaccination against hepatitis A virus (HAV) with currently licensed HAV vaccines. This study explored the long-term immunogenicity in individuals vaccinated with the virosomal hepatitis A virus, Epaxal. Adult volunteers (N = 130) previously enrolled into four different studies between 1992 and 1994 and who had completed a 0/12-month immunization regimen (primary and booster dose) were asked to participate in this follow-up study. Yearly anti-HAV titers up to 6 years following booster vaccination, and then once 9-11 years after booster were measured using two assays, Enzygnost and AxSYM HAVAB 2.0. Based on the Enzygnost assay, the seroprotection rate 9-11 years after booster was 100%, with a geometric mean concentration (GMC) of anti-HAV antibodies of 526 mIU/ml. Females had markedly higher GMCs than males (741 mIU/ml vs. 332 mIU/ml). Using an anti-HAV cut-off titer of >or=10 mIU/ml, a linear mixed mathematical model predicted a median duration of protection of 52.1 years. A duration of protection >or= 35.7 years was predicted for 95% of subjects. A more stringent cut-off of >or=20 mIU/ml shortened the median predicted duration of protection to 45.0 years. In conclusion, a two-dose Epaxal vaccination regimen confers in healthy adults a real-time protection of at least 9-11 years; this protection is predicted to last at least 30 years in over 95% of individuals. Further studies are necessary to assess the real duration of seroprotection and whether an additional booster is necessary later.

Travel case scenarios as a demonstration of risk assessment of VFR travelers: introduction to criteria and evidence-based definition and framework.

BACKGROUND: Travel-associated health risks need to be balanced against the positive opportunities associated with interregional travel. As the perceived and real spectrum of health risks related to international travel increase both quantitatively and qualitatively, the need for more discriminating tools in clinical assessment for the purpose of mitigation, public health management, and research are needed. One group of international travelers identified as having increased risk of poor travel-related health outcomes are those who travel with the specific intent of visiting friends or relatives (VFR travelers). Due to variations in defining VFR travel in the health context there are issues in applying this designation uniformly from multiple perspectives. This article supports the standardization of VFR traveler definitions based on objective criteria and provides illustrations of the application of this definition through an illustrated approach to risk assessment based on these criteria and the differentials in the determinants of health between source and destination regions. METHODS: A working group was established by the Migration Health Sub-committee, International Society for Travel Medicine to assess the literature on VFR travel and health, review an evidence-based approach to managing health risk related to travel, and to propose criteria-based definition for VFR travel. The new definition of a VFR is a traveler whose primary purpose of travel is to visit friends or relatives where there is a gradient of epidemiological risk between home and destination. RESULTS: A case scenario discussion of VFR travel defined by criteria and risk assessment based on differential determinants of health is presented in this article. DISCUSSION: The goal of this article is to encourage discussion on travel health evaluation for the most "at risk" populations and to standardize the application of clinical, public health, and research approaches to defining VFR travelers in a risk management context.