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BPHC TA Enrichment Call: Caring for Patients from Abroad: Uncommon Conditions That Are Not So Uncommon June 19, 2012 2:00PM – 3:30PM ET. Learning Objectives.

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BPHC TA Enrichment Call: Caring for Patients from Abroad: Uncommon Conditions That Are Not So Uncommon June 19, 20122:00PM – 3:30PM ET


Learning objectives
Learning Objectives Uncommon Conditions That Are Not So Uncommon

  • Participants will learn about interview techniques and tools to identify less common diseases among health center patients born and raised in another country and to examine the financial benefits and quality of life of early diagnosis.

  • Participants will learn about the experiences and techniques of one HRSA health center grantee in the diagnosis and treatment of uncommon diseases.

  • Participants will learn about the world and US epidemiology of leprosy including the occurrence of endemic leprosy in the Gulf Coast region of the US as well as dealing with stigma.

  • Participants will learn about the free services (diagnostic, consultations, anti-HD drugs, reconstructive surgery, and special rehabilitation) provided to private sector physicians and their HD patients through National Hansen’s Disease Program.


Why do we care about uncommon conditions
Why Do We Care about Uncommon Conditions? Uncommon Conditions That Are Not So Uncommon

  • Community Health Centers serve millions of patient every year.

  • A significant number of those patients are immigrant/ migrant populations.

  • Limited medical care: Long term complications and advanced disease

  • Frequent travel to endemic areas


Us immigration
US Immigration Uncommon Conditions That Are Not So Uncommon


Hrsa grantees vs immigration patterns
HRSA Grantees vs. Immigration Patterns Uncommon Conditions That Are Not So Uncommon


Rare in the u s but

Rare in the U.S. but…. Uncommon Conditions That Are Not So Uncommon

Malaria: 300 Million cases/yr

Tuberculosis: 1.5 Million deaths/yr

Hansen’s Disease: 200-300,000 Cases

Typhoid: 215,000 deaths/ yr

Rabies: 55,000 deaths/yr

Cholera: 120,000 deaths/ year

Schistosomiasis: 230 Million Cases

Dengue Fever: 50-100 Million Cases


What is malaria
What is Malaria? Uncommon Conditions That Are Not So Uncommon

  • Parasitic Infection that affects primarily the Liver and Red Blood Cells (RBCs)

  • Five known types

    • Plasmodium Falciparum (P. Falciparum)

    • P. Vivax

    • P. Ovale

    • P. Malariae

    • P. Knowlesi (found mainly in Malaysia)

  • P. falciparum causes more severe and acute infections, highest mortality


Brief history
Brief History Uncommon Conditions That Are Not So Uncommon

  • Noted in historical texts for more than 4,000 yrs

  • Know to be prevalent in wet, swampy areas. Term literally means “bad air” in Italian (Mal’ aria)

  • Treatments (quinine and artemisinin) have been know for nearly 2000 years

  • Efforts to eradicate Malaria

    • Panama Canal

    • TVA

    • DDT

    • Malaria Control in War Areas (MCWA)

  • Four Noble Prizes have been awarded for malaria related discoveries


Biology review
Biology Review Uncommon Conditions That Are Not So Uncommon

Vector: Anopheles mosquito

Life cycle

Sporogonic (Mosquito)

Exo-erythrocytic

Erythrocytic

Pathway starts in the liver where it invades and replicates

Hepatocyte (liver cell) ruptures and spreads to blood stream

Pathogen infects RBCs and replicates & matures, finally rupturing the cell membrane

Incubation time

2 days (P. falciparum, vivax, ovale)

3 days (P. malariae)


Epidemiology
Epidemiology Uncommon Conditions That Are Not So Uncommon

Nearly ½ of the world population is at risk for contracting malaria (3.3 Billion)

200-300 million cases and >1 million deaths each year

35 countries (30 in Sub Saharan Africa & 5 in Asia) account for 98% of deaths

5th leading cause of mortality from infection worldwide.

2nd in Sub Saharan Africa (behind HIV)


Malaria in us
Malaria in US Uncommon Conditions That Are Not So Uncommon

  • Relatively Rare

    • Approximately 1500 cases/ yr

  • Effectively eradicated in the 1950’s

  • Most cases found in travelers or immigrants who have been in an endemic area

  • Other transmission methods:

    • Blood transfusions

    • Organ donation

    • IV needle sharing

    • Continued threat of re-introduction: The three species of mosquito responsible for transmission are still found in the US.


Clinical diagnosis
Clinical Diagnosis Uncommon Conditions That Are Not So Uncommon

  • Classic Malaria: Fever, Chills, and Sweats

    • Attacks last 6-10 hrs

    • Consist of cold stage, hot stage and sweating stage

    • Attacks occur every 2-3 days

      • P. falciparum, vivax, and ovale (2 days)

      • P. malariae (3 days)

  • Additional Symptoms include: Headache, Nausea, vomiting, body aches, malaise.

  • Physical findings: weakness, enlarged spleen/ liver, mild jaundice.


Differential diagnosis
Differential Diagnosis Uncommon Conditions That Are Not So Uncommon

  • Because of the small number of cases, malaria is often misdiagnosis in the United States.

  • Conditions that could be confused with malaria include:

    • Influenza

      • Fever, headache, muscle aches, malaise

    • Enteric Fever (Salmonella)

      • Nausea, vomiting, fever, malaise, myalgias

    • Bacteremia / Sepsis

      • Fever, hypotension, altered mental status, multi organ dysfunction


When to suspect malaria
When to Suspect Malaria Uncommon Conditions That Are Not So Uncommon

  • People with travel to locations where malaria is endemic.

    • CDC reports that 30 million people a year travel to malaria endemic areas

    • Within the last 3 months, though consider for up to 2 years

    • Contact with travelers who have been to endemic areas

      • Family members

      • Those that work in or near airports

      • Do not rule out patients with self reports of chemoprolaxis.


Diagnosis treatment
Diagnosis & Treatment Uncommon Conditions That Are Not So Uncommon

Treatment should be guided by the following factors:

Type of parasite

Area where it was acquired and known drug resistance

Clinical status

Co-morbid conditions

Pregnancy

Allergies

Other medications

Diagnostic and Treatment guidelines can be found at:

http://www.cdc.gov/malaria/

  • Diagnosis should be lead by clinical suspicion

  • Testing methods: Blood Smear, Antigen/ antibody testing, PCR

    • Due to the rapid progression of disease, therapy should not wait for confirmation (although confirmation is recommended).

    • Malaria is a reportable disease in the US


Summary
Summary Uncommon Conditions That Are Not So Uncommon

  • While endemic to large sections of world’s population, malaria is still rare in the US.

  • The malaria parasite is uniquely adapted for easy transmission.

  • Symptoms are fairly consistent, but can easily be mistaken for other more common diseases.

  • Diagnosis should be led by clinical suspicion (i.e. foreign travel and symptoms).

  • Treatment should be guided several factors including type of malaria, drug resistance patterns and clinical status.


Contact information
Contact Information Uncommon Conditions That Are Not So Uncommon

Justin Mills, MD, MPH

Senior Clinical Advisor

Bureau of Primary Health Care,

Southwest Division

Health Resources and Services Administration

Department of Health and Human Services


Refugee care at san francisco general hospital family health center s newcomers program

Refugee Care at San Francisco General Hospital, Family Health Center’s: Newcomers Program

Alan Curtis Wands, PA-C

Lead Clinician for the Refugee Team

San Francisco General Hospital

Family Health Center


Learning objectives1

How to institutionalize screening for atypical diseases in the refugee population

How to keep on the front burner: Mental Health Issues in Refugee Primary Care

What have been the top illnesses detected in the previous year at the SFGH/FHC Newcomers Program

Remember to maintain a high clinical suspicion of atypical illnesses by in service training.

Learning Objectives


Screening for atypical diseases in the refugee population
Screening for atypical diseases in the refugee population the refugee population

  • Prescreening by health coaches / educators, preferably in concordant language and documented on the form when the provider arrives:

    • Immunization

    • family hx

    • ROS

    • Medical hx

    • Social hx

    • Allergies


Standing orders
Standing Orders the refugee population

  • For all pt’s

    • CBC

    • Hepatitis Panel (A, B, C)

    • RPR, HIV

    • QFT (not ppd)

    • Stool O&P

  • Preventive studies according to age

    • Lead screening <5 y/o

    • Chlamydia/GC

    • Mammogram >50 y/o

    • PAP >21 y/o

    • FIT Colon CA > 50 y/o

    • Lipid Panel >35 y/o


Top diagnoses in the past 6 months
Top Diagnoses in the past 6 months the refugee population

  • Mental health d/o (17%)

    • Depression

    • PTSD

    • Anxiety

    • Stress and adjustment d/o

  • Unspecified parasitic dz (10%)

  • Dorsalgia (8%)

  • Blindness and low vision (7%)

  • Respiratory TB (6%)

  • Skin diseases (5%)

  • Chronic viral Hepatitis (3%)

  • Dental Caries (3%)

  • Essential HTN (3%)

  • GERD(3%)


Differential dx to be aware of
Differential dx to be aware of: the refugee population

  • TB

    • Paragonymus (lung flukes)

    • non pulmonary TB

  • GERD (H pylori)

  • Skin lesions

    • Hanson’s (Leprosy)

    • Tinea / Candida

    • Leishmaniasis

    • cutaneous larva migrans

    • Bott fly

  • Seizure d/o

    • Neurocystercercosis

  • Chagas

  • Fever of Unknown origin

    • Malaria

    • Typhoid/Paratyphoid

    • Dengue

    • Brucellosis


Refugee care at san francisco general hospital family health centers newcomers program
Refugee Care at San Francisco General Hospital, Family Health Centers: Newcomers Program

Alan Curtis Wands-Bourdoiseau, PA-C

Clinician Lead for the Newcomers Team

(415) 206-5997

[email protected]


Refugee health program

Refugee Health Program Health Centers: Newcomers Program

Anthony L. Jordan Health Center

Roksolana Kuchma MD

Laurie Donohue MD


Whom do we serve
Whom do we Serve Health Centers: Newcomers Program

  • Early 1980’s: refugees from Vietnam, Cambodia and Laos

  • Early 1990’s: Former USSR republics – primarily Ukraine and Russia; Cuba

  • Late 1990’s: Somalia

  • Last 10 years: Sierra Leone, Liberia, Congo Burma, Bhutan; Iraq


Barriers to care
Barriers to care Health Centers: Newcomers Program

  • Cultural:

    • patient’s poor understanding of Western medicine (preventative care – mammograms, colonoscopy, pap, dental, dietary influences on illnesses – DM, HTN, Strokes

    • Patient’s poor understanding of US medical system and lack of resources to help patients navigate it

    • lack of organized and centrally located resources for providers and staff to provide culturally sensitive care and ongoing development of cultural competency

    • lack of female specialists and female interpreters for Muslim women


Barriers to care1
Barriers to care Health Centers: Newcomers Program

  • Logistical:

    • Minimal federal and state fiduciary support for interpreter services

    • transportation to clinic and specialists’ visits

    • coordination of care (lack of specific social work services)

    • inefficient time with provider (15min visit for non-English speaking patients with interpreter)

    • Fragmented medical care – lack of communication, exchange of ideas and sharing of resources between health systems that provide medical care to refugee populations

    • lack of adequate medical insurance to cover medical costs (minimal wage jobs that provide little to no medical insurance coverage)


Barriers to care2
Barriers to care Health Centers: Newcomers Program

  • Medical Care:

    • Current PCP providers are at limit or quickly reaching limit for ability to accept new patients

    • Limited number of providers practice refugee medicine – limiting expertise to a defined circle of providers, which in turn limits non-refugee providers to accept new refugee patients

    • Limited number of trained interpreters that are able to provide in person interpretation

    • Provider lack of understanding of culturally appropriate treatments for medical illnesses (herbal/animal products, dietary restrictions)


Staff training
Staff training Health Centers: Newcomers Program

  • Cultural competency training

  • Active involvement of entire team in provision of medical care

  • Encouragement to attend International Refugee Conference held here in Rochester, NY

  • Ongoing distribution of printed resources to develop cultural understanding of refugee communities

  • Monthly interpreter meetings


Frequent diagnoses
Frequent diagnoses Health Centers: Newcomers Program

  • PTSD with somatization disorder

  • Depression with anxiety

  • Medical complications due to prolonged stress state: GERD, HTN, Constipation, Chronic fatigue and chronic pain syndrome, LBP, chronic abdominal pain without clear etiology.

  • In children: elevated lead level due to poor housing conditions, eczema with atopy

  • In women: grand multiparity, DM II with obesity and increased cholesterol, DV.

  • In men: HTN, GERD, ETOH/tobacco abuse, ED


Needs to run an effective program
Needs to run an effective program Health Centers: Newcomers Program

  • Financial support from state and federal government

  • Reimbursement for interpretation services and allowance for additional time to accommodate non-English patients

  • SW support for case management and coordination of care

  • Ongoing health promotion within refugee communities (currently piloted at BS – women and HS girls participated in monthly meetings learning about medical topics of their choice)


Needs to run an effective program1
Needs to run an effective program Health Centers: Newcomers Program

  • Rochester Integrated Health Network refugee provider subcommittee – providers from major health care systems in Rochester work together to develop center of excellence for refugee medical care.

  • Encourage, support and promote refugee advocacy groups at local, state and federal levels.


Caring for patients from abroad uncommon conditions that are not so uncommon leprosy in the u s a
“Caring for Patients from Abroad: Health Centers: Newcomers ProgramUncommon ConditionsThat Are Not So Uncommon”Leprosy in the U.S.A.

James L. Krahenbuhl, Ph.D., Director

David M. Scollard, M.D., Ph.D. Chief, Clinical Branch

Division National Hansen’s Disease Programs

BPHC / HRSA


Leprosy in the u s
Leprosy Health Centers: Newcomers Programin the U.S.?

In 2012?

You gotta

be kidding!

HRSA In charge of program


National Hansen’s Disease Programs Health Centers: Newcomers ProgramTreatment , Management, Rehabilitation Training and Education Intramural Basic Biomedical Research


The need for leprosy awareness
The Need for Leprosy Awareness: Health Centers: Newcomers Program

Most leprosy problems in the USA result from:

It is an uncommon disease here

  • Low index of suspicion

    • Consider the diagnosis

    • Confirm diagnosis by biopsy to NHDP

    • Manage leprosy with NHDP support

      including cost free services, drugs, consultations

      4. Referral for complications not manageable locally


New cases of leprosy in u s
# New Cases of Leprosy in U.S. Health Centers: Newcomers Program

Currently

  • 3877 receiving treatment

  • 3311 in 13 ACP Clinics

  • 566 by private practice

    physicians


Leprosy in the u s 2001 2010
Leprosy in the U.S. (2001-2010) Health Centers: Newcomers Program

Two “sources”

  • Immigrants & migrants from endemic countries

  • U.S. “endemic cases”

    • U.S. born, no travel history

    • Southern U.S. (Gulf Coast)

    • Armadillo to human transmission proven

      NEJM 364:1626-1633, April 28, 2011.

      Country of Birth Frequency Percent

      U.S.A 344 21.2

      Mexico 238 14.6

      W Pacific Islands 209 12.9

      Brazil 151 9.3

      India 127 7.8


Leprosy
LEPROSY Health Centers: Newcomers Program

The most misunderstood infectious disease


Leprosy1
Leprosy Health Centers: Newcomers Program

  • A chronic bacterial infection (Mycobacterium

    leprae)

  • Skin and mucous membranes of the upper

    respiratory tract

  • Only bacterium with a predilection for

    peripherals nerves

    ALWAYS

    NERVE DAMAGE

    Deformity and disability are

    the hallmarks of leprosy


Leprosy s uniqueness confounding factors
LEPROSY’s Health Centers: Newcomers ProgramUniqueness & Confounding factors


Nhdp ambulatory care outpatient clinics
NHDP Ambulatory Care Outpatient Clinics Health Centers: Newcomers Program





Early diagnosis prompt treatment lowers morbidity of leprosy
Early Diagnosis & Prompt Treatment 2000-2010Lowers Morbidity of leprosy


The a b c s of managing a case of leprosy in the u s
THE A B C’s of MANAGING A CASE 2000-2010OF LEPROSY IN THE U.S.


The presentation of a leprosy patient in your clinic
The presentation of a leprosy 2000-2010patient in your clinic

The importance of

an awareness of leprosy


Clinical presentation s of hd
Clinical presentation(s) of HD 2000-2010

  • Patient ‘sick’ due to HD

    • Less common

    • Clinic or ER

    • Probably a leprosy reaction

    • Clinic visit for other problem

      • Rash noted

      • Rash on accompanying family member – child, sibling, etc.

History very important: Country or U.S. area

of origin


Presenting findings of hd
Presenting Findings of HD 2000-2010

  • Chronic skin lesion, macular or nodular

    • Not responding to usual treatments

  • Loss of sensation

    • Reduced sensation in lesions

    • Burns & wounds without pain

  • Enlarged, tender nerves

  • Loss of eyebrows

  • Nodular lesions – ears, face




Images of hansen s disease2
Images of Hansen’s Disease 2000-2010

Courtesy of Dr. C. Chun


Summary the need for leprosy awareness
Summary 2000-2010The Need for Leprosy Awareness:

Most leprosy problems in the USA result from:

It is an uncommon disease here

  • Low index of suspicion

    • Consider the diagnosis - history

    • Confirm diagnosis by biopsy to NHDP

    • Manage leprosy with NHDP support

      including cost free services, drugs, consultations

      4. Referral for complications not manageable locally


Contact information1
Contact Information 2000-2010

  • James L Krahenbuhl, Ph.D.

  • Director, National Hansen’s Disease Programs

  • [email protected]

  • David M. Scollard, M.SD., Ph.D.

  • Chief, Clinical Branch

  • [email protected]

  • National Hansen’s Disease Programs

  • 1770 Physicans Park Dr.

  • Baton Rouge, LA 70816

  • http://www.hrsa.gov/hansensdisease/



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