Enhanced skills in global health and health equity: Guidelines for curriculum development.

INTRODUCTION: Global health addresses health inequities in the care of underserved populations, both domestic and international. Given that health systems with a strong primary care foundation are the most equitable, effective and efficient, family medicine is uniquely positioned to engage in global health. However, there are no nationally recognized standards in Canada for postgraduate family medicine training in global health. OBJECTIVE: To generate consensus on the essential components of a Global Health/Health Equity Enhanced Skills Program in family medicine. METHODS: A panel comprised of 34 experts in global health education and practice completed three rounds of a Delphi small group process. RESULTS: Consensus (defined as ≥ 75% agreement) was achieved on program length (12 months), inclusion of both domestic and international components, importance of mentorship, methods of learner assessment (in-training evaluation report, portfolio), four program objectives (advocacy, sustainability, social justice, and an inclusive view of global health), importance of core content, and six specific core topics (social determinants of health, principles and ethics of health equity/global health, cultural humility and competency, pre and post-departure training, health systems, policy, and advocacy for change, and community engagement). CONCLUSION: Panellists agreed on a number of program components forming the initial foundation for an evidence-informed, competency-based Global Health/Health Equity Enhanced Skills Program in family medicine.

Family Medicine in Ethiopia: Lessons from a Global Collaboration.

BACKGROUND: Building the capacity of local health systems to provide high-quality, self-sustaining medical education and health care is the central purpose for many global health partnerships (GHPs). Since 2001, our global partner consortium collaborated to establish Family Medicine in Ethiopia; the first Ethiopian family physicians graduated in February 2016. METHODS: The authors, representing the primary Ethiopian, Canadian, and American partners in the GHP, identified obstacles, accomplishments, opportunities, errors, and observations from the years preceding residency launch and the first 3 years of the residency. RESULTS: Common themes were identified through personal reflection and presented as lessons to guide future GHPs. LESSON 1: Promote Family Medicine as a distinct specialty. LESSON 2: Avoid gaps, conflict, and redundancy in partner priorities and activities. LESSON 3: Building relationships takes time and shared experiences. LESSON 4: Communicate frequently to create opportunities for success. LESSON 5: Engage local leaders to build sustainable, long-lasting programs from the beginning of the partnership. CONCLUSIONS: GHPs can benefit individual participants, their organizations, and their communities served. Engaging with numerous partners may also result in challenges-conflicting expectations, misinterpretations, and duplication or gaps in efforts. The lessons discussed in this article may be used to inform GHP planning and interactions to maximize benefits and minimize mishaps.

Global Health in Family Medicine Summer Primer: Course for residents and faculty.

PROBLEM ADDRESSED: Despite the rapid emergence of global health training across North American universities, there remains a gap in educational programs focusing on the unique role of family medicine and primary care in global health. OBJECTIVE OF PROGRAM: The objective of the Global Health in Family Medicine Summer Primer, developed in 2013 by the Department of Family and Community Medicine at the University of Toronto in Ontario, is to strengthen global health competencies among family medicine residents and faculty. PROGRAM DESCRIPTION: The course covers the meaning of global health; global health ethics; the place of family medicine, primary care, and primary health care in the global health context; epidemiology; infectious diseases; the social determinants of health; and care of vulnerable populations locally and globally. The course is delivered in an intensive 5-day format with didactic lectures, group discussions, interactive workshops, and lived-experience panels. CONCLUSION: The Global Health in Family Medicine Summer Primer has proven to be a successful educational initiative and provides valuable lessons learned for other academic science centres in developing global health training programs for family medicine residents and faculty.

Health status of newly arrived refugees in Toronto, Ont: Part 1: infectious diseases.

OBJECTIVE: To determine the prevalence of selected infectious diseases among newly arrived refugee patients and whether there is variation by key demographic factors. DESIGN: Retrospective chart review. SETTING: Primary care clinic for refugee patients in Toronto, Ont. PARTICIPANTS: A total of 1063 refugee patients rostered at the clinic from December 2011 to June 2014. MAIN OUTCOME MEASURES: Demographic information (age, sex, and region of birth); prevalence of HIV, hepatitis B, hepatitis C, Strongyloides, Schistosoma, intestinal parasites, gonorrhea, chlamydia, and syphilis infections; and varicella immune status. RESULTS: The median age of patients was 29 years and 56% were female. Refugees were born in 87 different countries. Approximately 33% of patients were from Africa, 28% were from Europe, 14% were from the Eastern Mediterranean Region, 14% were from Asia, and 8% were from the Americas (excluding 4% born in Canada or the United States). The overall rate of HIV infection was 2%. The prevalence of hepatitis B infection was 4%, with a higher rate among refugees from Asia (12%, P < .001). Hepatitis B immunity was 39%, with higher rates among Asian refugees (64%, P < .001) and children younger than 5 years (68%, P < .001). The rate of hepatitis C infection was less than 1%. Strongyloides infection was found in 3% of tested patients, with higher rates among refugees from Africa (6%, P = .003). Schistosoma infection was identified in 15% of patients from Africa. Intestinal parasites were identified in 16% of patients who submitted stool samples. Approximately 8% of patients were varicella nonimmune, with higher rates in patients from the Americas (21%, P < .001). CONCLUSION: This study highlights the importance of screening for infectious diseases among refugee patients to provide timely preventive and curative care. Our data also point to possible policy and clinical implications, such as targeted screening approaches and improved access to vaccinations and therapeutics.

Health status of newly arrived refugees in Toronto, Ont: Part 2: chronic diseases.

OBJECTIVE: To determine the prevalence of selected chronic diseases among newly arrived refugee patients and to explore associations with key demographic factors. DESIGN: Retrospective chart review. SETTING: Primary care clinic for refugee patients in Toronto, Ont. PARTICIPANTS: A total of 1063 refugee patients rostered at the clinic from December 2011 to June 2014. MAIN OUTCOME MEASURES: Demographic information (age, sex, and region of birth) and prevalence of abnormal Papanicolaou test results, anemia, elevated blood pressure (BP), and markers of prediabetes or diabetes (elevated random glucose, fasting glucose, or hemoglobin A1c levels). RESULTS: More than half of our patients were female (56%) and the median age was 29 years. Patients originated from 87 different countries of birth. Top source countries were Hungary (210 patients), North Korea (119 patients), and Nigeria (93 patients). Most patients were refugee claimants (92%), as opposed to government-assisted refugees (5%). Overall, 11% of female patients who underwent Pap tests had abnormal cervical cytology findings, with the highest rates among women from Asia (26%, P = .028). The prevalence of anemia among children younger than 15 years was 11%; for children younger than 5 years the prevalence was 14%. Approximately 25% of women older than 15 years had anemia, with the highest rates among African women (37%, P < .001). Elevated BP was observed in 30% of adult patients older than 15 years, with higher prevalence among male patients (38%, P < .001) and patients from Europe (42%, P < .001). Laboratory markers of prediabetes or diabetes were identified in 8% of patients older than 15 years, with higher rates among patients from Europe (15%, P = .026). CONCLUSION: This study found a notable burden of chronic diseases among refugee patients, including anemia, elevated BP, and impaired glycemic control, as well as abnormal cervical cytology findings. These results underscore the importance of accessible, comprehensive primary care for refugees, with attention to prevention and management of chronic diseases in addition to management of infectious disease.

Impact of asymptomatic herpes simplex virus type 2 infection on mucosal homing and immune cell subsets in the blood and female genital tract.

HSV-2 infection is common and generally asymptomatic, but it is associated with increased HIV susceptibility and disease progression. This may relate to herpes-mediated changes in genital and systemic immunology. Cervical cytobrushes and blood were collected from HIV-uninfected African/Caribbean women in Toronto, and immune cell subsets were enumerated blindly by flow cytometry. Immune differences between groups were assessed by univariate analysis and confirmed using a multivariate model. Study participants consisted of 46 women, of whom 54% were infected with HSV-2. T cell activation and expression of the mucosal homing integrin α4ß7 (19.60 versus 8.76%; p < 0.001) were increased in the blood of HSV-2-infected women. Furthermore, expression of α4ß7 on blood T cells correlated with increased numbers of activated (coexpressing CD38/HLA-DR; p = 0.004) and CCR5(+) (p = 0.005) cervical CD4(+) T cells. HSV-2-infected women exhibited an increase in the number of cervical CD4(+) T cells (715 versus 262 cells/cytobrush; p = 0.016), as well as an increase in the number and proportion of cervical CD4(+) T cells that expressed CCR5(+) (406 versus 131 cells, p = 0.001; and 50.70 versus 34.90%, p = 0.004) and were activated (112 versus 13 cells, p < 0.001; and 9.84 versus 4.86%, p = 0.009). Mannose receptor expression also was increased on cervical dendritic cell subsets. In conclusion, asymptomatic HSV-2 infection was associated with significant systemic and genital immune changes, including increased immune activation and systemic α4ß7 expression; correlation of the latter with highly HIV-susceptible CD4(+) T cell subsets in the cervix may provide a mechanism for the increased HIV susceptibility observed in asymptomatic HSV-2-infected women.

Prevalence of selected preventable and treatable diseases among government-assisted refugees: Implications for primary care providers.

OBJECTIVE: To discover the prevalence of 4 preventable and treatable diseases among newly arriving refugees. DESIGN: Retrospective cohort study. SETTING: An immigrant-friendly family medicine centre in Ottawa, Ont, that offers newly arriving refugees a clinical preventive program following a specially designed protocol. PARTICIPANTS: A total of 112 adult government-assisted refugees seen during 2004 and 2005 within 6 months of arrival. MAIN OUTCOME MEASURES: Demographic information and prevalence of HIV infection, latent tuberculosis (TB), chronic hepatitis B surface antigen-positive status, and intestinal parasites. RESULTS: Descriptive analysis revealed that 71% of the adults were younger than 35 years and 83% of them had come from sub-Saharan Africa. Disease prevalence rates were 6.3% for HIV (95% confidence interval [CI] 1.8 to 10.8), 49.5% for latent TB (95% CI 39.5 to 49.8), 5.4% for chronic hepatitis B surface antigen-positive status (95% CI 1.2 to 9.5), and 13.6% for intestinal parasites (95% CI 7.2 to 20.0). Most refugees (83%) successfully completed the preventive care program. Performing chi(2) analysis revealed a statistically significant higher risk of latent TB among the men (P < .032). Most of the women had never had a Papanicolaou test. CONCLUSION: Refugees are a vulnerable population with unique, but often preventable or treatable, health issues. This study demonstrated substantial differences in the prevalence of HIV, TB, chronic hepatitis B, and intestinal parasites between government-assisted refugees and Canadian residents. These health disparities and the emerging field of health settlement are new challenges for family physicians and other primary health care providers.