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Learning Objectives

Learning Objectives

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Learning Objectives

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

  2. Learning Objectives • 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.

  3. Why Do We Care about Uncommon Conditions? • 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

  4. US Immigration

  5. HRSA Grantees vs. Immigration Patterns

  6. Rare in the U.S. but…. 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

  7. What is Malaria? • 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

  8. Brief History • 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

  9. Biology Review 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)

  10. Epidemiology 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)

  11. Malaria in US • 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.

  12. Clinical Diagnosis • 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.

  13. Differential Diagnosis • 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

  14. When to Suspect Malaria • 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.

  15. Diagnosis & Treatment 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: • 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

  16. Summary • 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.

  17. Contact Information 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

  18. 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

  19. 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

  20. Screening for atypical diseases in 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

  21. Standing Orders • 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

  22. Top Diagnoses in the past 6 months • 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%)

  23. Differential dx to be aware of: • 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

  24. 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

  25. Refugee Health Program Anthony L. Jordan Health Center Roksolana Kuchma MD Laurie Donohue MD

  26. Whom do we Serve • 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

  27. Barriers to care • 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

  28. Barriers to care • 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)

  29. Barriers to care • 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)

  30. Staff training • 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

  31. Frequent diagnoses • 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

  32. Needs to run an effective 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)

  33. Needs to run an effective 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.

  34. “Caring for Patients from Abroad:Uncommon 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

  35. Leprosy in the U.S.? In 2012? You gotta be kidding! HRSA In charge of program

  36. National Hansen’s Disease Programs Treatment , Management, Rehabilitation Training and Education Intramural Basic Biomedical Research

  37. The 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 • Confirm diagnosis by biopsy to NHDP • Manage leprosy with NHDP support including cost free services, drugs, consultations 4. Referral for complications not manageable locally

  38. # New Cases of Leprosy in U.S. Currently • 3877 receiving treatment • 3311 in 13 ACP Clinics • 566 by private practice physicians

  39. Leprosy in the U.S. (2001-2010) 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

  40. LEPROSY The most misunderstood infectious disease

  41. Leprosy • 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

  42. LEPROSY’sUniqueness & Confounding factors

  43. NHDP Ambulatory Care Outpatient Clinics

  44. Private Sector Physicians Managing at least 1 HD case 2000-2010

  45. NHDP Mission Statement

  46. The “Cost” of Late Diagnosis of Leprosy

  47. Early Diagnosis & Prompt TreatmentLowers Morbidity of leprosy


  49. The presentation of a leprosypatient in your clinic The importance of an awareness of leprosy

  50. Clinical presentation(s) of HD • 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