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Taking it all in - obstetrics and gynecology in Senegal


This is my first time in Senegal and my first time providing clinical care outside of the United States.  I have made a fair number of rather long journeys to similar locals, but never in a clinical capacity.  In the past I had generally embarked on the journey expecting that I had an idea as to what my role would be, either in a school, a clinic, a public health project, but without an explicit job description. I had been comfortable with that. Coming fresh from a month of nights on a busy labor floor, I stepped off the plane in Senegal and I felt like I should enter back into constant movement and flurry of activities.  The first day at the hospital, I was relieved to find an awaiting cesarean section � I felt immediately useful.  And when down time followed, I found myself anxious about how I would maximize my time �how should I integrate into the resident team?  what should I do in my free time? should I join in a research project?  which presentations should I prepare for my colleagues? I was searching for ways to find the affirmation as an individual that I was accustomed to in residency. 

But I did not come to Senegal to simply be my American resident self, I was here to begin to learn how to be a doctor in a place where I don�t have every amenity and test at my fingertips.  I shifted my outlook over those first few days and paid attention, observed, listened, and asked questions, so that I could begin to understand the system I was going to be working in.  This is a glimpse of what I found.

The labor room.  Only for women ready to push.  As opposed to Boston�s spacious, private rooms with epidurals overflowing, there are three gynecology beds in a row, for three women to labor side-by-side, each to her own rhythm.  The only pain relief is delivery. 



The nursery.  You may have noticed the �nursery� in the picture above.  After birth the babes are cleaned, swaddled and placed in a row on an open table, under regular lamps to keep them warm.  Spooning babies is surprisingly effective soothing while mom is recovering after her delivery.  




The Pinard.  My co-resident pictured above is expert and I am always wishing that I had smuggled a bedside Doppler into my luggage to find each babies� heartbeat. 



The operating room.  No bells and whistles, but with everything we need.  After scrubbing and prior to opening the sterile box of instruments, it is always a mystery as to which instruments you will find.  It is typically no more than 15 instruments, many of which are different from the last kit used.   We return to surgical basics and make instruments work for us.


Anesthesia.  General is rarely needed though available with manual ventilation as pictured below.  Nearly all gynecologic procedures are performed under regional anesthesia.  Fortunately, both the gynecologists and general surgeons do extremely challenging surgeries within the time constraints of regional anesthesia.  


Indications for surgery.  Fibroids were by far the most common reason for gynecologic surgeries.  These are typical specimens from one patient - every last one comes out.  



Operating with general surgeons.  I have not assisted a general surgeon, let alone had a male patient on the operating table since my third year of medical school. Yet the general surgeons here do a fair amount of gynecologic surgery and thus are incredibly valuable teachers. 

Fortunately, despite some of the contrasts highlighted here, the human body and gynecologic pathology are fairly constant whether you are in Boston or Senegal.  That keeps me breathing easy while I continue on this incredible and humbling journey.

Rebecca Luckett MD MPH

Ebola outbreak in Guinea: 13-lab confirmed cases, 73 more suspect, includes 59 deaths

Schematic of an Ebola virus virion.
Its a work in progress but feel free to use.
Just cite Ian M. Mackay, PhD and
http://newsmedicalnet.blogspot.com.au/

Click to enlarge.
There's an outbreak of Ebola virus (species Zaire ebolavirus) haemorrhagic fever going on in Guinea just now (see the map for where that is within Africa).

Haemorrhagic fever? That's the scary stuff that books get written about and movies based on - bleeding from tissues and person-to-person spread to infected healthcare workers and grieving family carers...horrible, scary stuff for those in the thick of it. If anything can be said to be good news to this, it is that usually (to date) cases do not pass several hundred (see Storify article of tonight's Twitter information [5]) because the virus does not transmit as easily as influenza for example (no aerosol route; spread is by bodily secretions);  scary bleeding from everywhere is not as common as the movie make out and there are survivors of infection. 

A very digestible backgrounder on Ebola that will get you up to speed on this virus and disease can be found at Mike Coston's Avian Flu Diary, here [9].

On 22-March, the World Health Organization (WHO) was made aware of an outbreak in the west African country by its Ministry of Health [1]. The outbreak of febrile disease commenced 9-Feb. When the Minister of Health released a statement, 22-Mar, he noted the disease was characterized by fever, diarrhoea, vomiting, fatigue and sometimes bleeding. 


Guinea and surrounds, Africa.
Maps purchased from maptorian.
Click on image to enlarge.
Since then, haemorrhagic fever cases in the country's capital, Conakry, have been shown to be due to something other than the Ebola virus according to testing results from the Pasteur Institute Dakar [3]. 

The Institut Pasteur in Lyon had earlier identified Ebola virus (so far in 13 cases) in Guekedou, Macenta, Nzerekore and Kissidougou districts; they also genotyped some strains using the L gene as a PCR target[10]. This led to identifying the species Zaire ebolavirus.
The Emerging and Dangerous Pathogens Laboratory Network (EDPLN) is working with the Guinean VHF Laboratory in Donka, the Institut Pasteur in Lyon, the Institut Pasteur in Dakar, and the Kenema Lassa fever laboratory in Sierra Leone to make available appropriate Filo-virus diagnostic capacity in Guinea and Sierra Leone [1]
There is no specific treatment or vaccine for Ebola disease. The first Ebola virus outbreak was identified in 1976. Ebola virus is the conversational name of the viruses that are members of the Family Filoviridae, Genus Ebolavirus and exist as 5 species [4]:
  1. Species: Tai Forest ebolavirus ("Tai Forest virus")
  2. Species: Reston ebolavirus ("Reston virus")
  3. Species: Sudan ebolavirus ("Sudan virus")
  4. Species: Zaire ebolavirus ("Ebola virus")
  5. Species: Bundibugyo ebolavirus ("Bundibugyo virus")
"Multidisciplinary teams have been deployed to the field to actively search and manage cases; trace and follow-up contacts; and to sensitize communities on the outbreak prevention and control. M�decins Sans Fronti�res, Switzerland (MSF-CH) is working in the affected areas and is assisting with establishment of isolation facilities, and also supported transport of the biological samples from suspect cases and contacts to international reference laboratories for urgent testing." [1]
But where was the crack team of experts laden with ultra cool tech capable of diagnosing the tiny beast within minutes, containing it within hours and saving more people from becoming afflicted in days? 

Unfortunately no such crack team or timeline exists, except in the movies anyway. But as we are going to see in the coming days as diagnostic delays cause headaches for those multidisciplinary teams trying to educate the locals and begin helping contain, confirm cases and trace the disease, there is a real need for faster identification of the causes of acute and serious disease outbreaks worldwide. 

Wouldn't it be great if the world's governments and biotech industries could come together to assemble and maintain some sort of rapidly deployable multinational pathogen detection force? Several teams of scientists and healthcare workers assembled and trained by the world's best, and remaining linked to them, carrying with them all the (perhaps bespoke) tech they'd need to identify any pathogen (unbiased molecular methods). They could analyse their data on the fly or rapidly send it to others for help using satellite links. The "Force" could be funded by the contributing States, biotech and Pharma; coordinated by the WHO perhaps. I'd love to see a dedicated set-up for pathogen identification; a kind of virus/bacteria/parasite-hunting fire department that can down its regular tools and jump on a plane ASAP; someone whose number is on every country's speed dial. 

Ahh 'tis to dream. 

In the meantime, I have a lot to learn about Ebola; something that is more nightmare than dream to me.


References..

  1. WHO situation report as of 22-Mar-2014 [PDF]
    http://www.afro.who.int/en/clusters-a-programmes/dpc/epidemic-a-pandemic-alert-and-response/outbreak-news/4063-ebola-hemorrhagic-fever-in-guinea.html
  2. Epidemic hemorrhagic fever in Guinea after 29 deaths, the Health Minister announces new measures
    http://www.lejourguinee.com/index.php/fr/societe/3072-epidemie-de-fievre-virale-hemorragique-en-guinee-apres-29-morts-le-ministre-de-la-sante-annonce-des-nouvelles-mesures
  3. Guinea: fever cases detected in Conakry are not due to Ebola.
    http://www.france24.com/fr/20140324-guinee-conakry-ebola-virus-fievre-hemorragique-epidemie-institut-pasteur/
  4. Prof Vincent Racaniello's Virology blog on Ebola virus naming
    http://www.virology.ws/2012/08/07/is-it-ebolavirus-or-ebola-virus/
  5. Storify: Early timeline of the events in the Guinea Fever outrbreak
    http://storify.com/MackayIM/early-timeline-of-the-eventsin-the-guinea-fever-ou
  6. WHO webpage on the Guinea Ebola outbreak
    http://www.afro.who.int/en/clusters-a-programmes/dpc/epidemic-a-pandemic-alert-and-response/outbreak-news/4063-ebola-hemorrhagic-fever-in-guinea.html
  7. WHO primer on Ebola haemorrhagic fever
    http://www.who.int/mediacentre/factsheets/fs103/en/
  8. Avian Flu Diary (Mike Coston) on WHO Twitter Messaging On Ebola
    http://afludiary.blogspot.com.au/2014/03/who-twitter-messaging-on-ebola.html
  9. Avian Flu Diary (Mike Coston) on A Brief History Of Ebola
    http://afludiary.blogspot.com.au/2014/03/a-brief-history-of-ebola.html
  10. Guinea Ebola outbreak believed to be deadly Zaire strain
    http://www.reuters.com/article/2014/03/24/us-guinea-ebola-idUSBREA2L0MI20140324

Avian influenza A(H7N9) virus cases hit 400

While everyone was looking at Guinea and the Ebola Zaire outbreak, that stealthy H7N9 has gone and infected a total of 400 people that we know of. It is of course, just another milestone and not an indication of anything changed about the virus. In fact the trend for few cases per day is continuing. One constant in s sea of change and new things.

Another constant, the up-to-date nature of the FluTrackers case list - check it out here

I have to run - much to learn about Ebola!

References...

  1. FluTrackers H7N9 case list
    http://www.flutrackers.com/forum/showthread.php?t=202713


Google Flu Trends: What did you expect?

I posted this on Crawford Kilian's H5N1 blog in response to his positing yet another story whacking Google Flu Trends for its "failure".

In case you can't tell - I'm a little sick of the number of electrons being wasted on writing the same thing about this paper in Science. I know, there is no shortage of electrons. Still, I hope to see this same degree of ire elicited by and directed toward other places, corporations and States who have trouble providing data to the public within the expected realms of accuracy. I'd also hope for more focus on what and how we test now and how representative that is of what a virus is doing; or what we might be missing.


I think Olson et al said it well when noting GFT's earlier failure to predict the H1N1 2009 pandemic's influenza-like illness activity..
"Current internet search query data are no substitute for timely local clinical and laboratory surveillance, or national surveillance based on local data collection"
The post...

Okay. Google Flu Trends (GFT) was not 100% accurate. Wow. Who'd would have thunk it? Who could possibly have guessed this would happen? The disappointment is clearly widespread. A predictive computer-based system set up for devising regulatory guidelines, formulating vaccine formulations, ensuring suitable laboratory testing capacity and preparation or national surveillance guidelines failed. Wait. What? It wasn't setup for any of that! It�s really just a pretty thing you can go look at to get an estimate of flu activity near you; much easier to wade through than some country's public health efforts. Estimate. When did we expect an estimate to be perfect?

Come on people-interpreting-this-paper. GFT isn't a failure unless you were honestly expecting it to be 100% correct.

Of course it couldn't ever be that. THERE. WAS. NO. VIRUS. TESTING. Not done by GFT anyway. Some lab testing went into it apparently, but even that was a sliver of a slice of a shard. And if you know anything about respiratory virus testing, then you know that even the testing we do, represents only a tiny fraction of the amount of virus-positive cases out there, extrapolating from those. That testing even varies from place-to-place in type, quantity and extent of reporting. The choice of what to test (sampling) is itself biased in a number of ways, not the least of which is that we favour testing pretty sick people or those that feel crook enough to present to a Doctor. We�re comparing GFT�s �fail� to an estimate. You�re all comfortable with using that to lambaste GFT? You�re comfortable to call that a total fail?

"The folks at Google figured that, with all their massive data, they could outsmart anyone."

Really? Is that what the folks thought? Did Google really get bitten by the flu bug?; can Google truly not track the flu? Certainly catchy headlines one and all. I guess no-one would read something entitled "Google Flu Trend's estimates not in agreement with some national testing data which also represents only a portion of those who get infected". I can see where that might not be a real mouse-wheel turner.

GFT was and could only ever be a predictive system. Just like that shiny App you have on your phone that predicts the weather forecast. Let's drag "big weather" through the interwebs flailing it at every turn so we can suitably express our righteous indignation at its failure to predict the rain we wanted on the weekend. It failed! OMG! Now I have to water my lawn to stop it from drying up. But that's all I have to do. No-one died when the clouds held their watery payload. My child was no more or less safe because the weather bug bit the Bureau of Meteorology here in Queensland. I didn�t have to get a new lawn because it is now 24-hours drier.

Does GFT's overestimate of the number of predicted cases by 0.5-2 fold (depending on the story you read) really have a real-world impact on anyone? Seriously? Keep in mind that its estimates still followed the trend of flu activity pretty closely; they peaked when actual flu was peaking, just not (my other estimates) perfectly. But apparently someone 100% concordance between lab sampling and GFT estimate data.

GFT has been doing a perfectly good job given what it is and what it could ever hope to be in its current setup. Perhaps centralizing and plotting the WORLD'S lab-based data alongside Google �flu�-related search-result data would be a useful next step for GFT. Then we could make up our own
minds.

In the meantime, keep it in context people.


References...

Learning about Task Shifting


Pictured above: Sangath, Goa

Neuropsychiatric diseases like unipolar depressive disorders, addictions, bipolar disorder and schizophrenia make up 28% of the global burden of disease among noncommunicable diseases and are economically more disabling than cardiovascular disease or cancer. When you add infectious diseases, neuropsychiatric disorders make up 14% of the entire global burden of disease. While access to mental health is essential to improving quality of life among people and economies of the world, there is a dearth of resources. How do we address the need? Vikram Patel MD, a psychiatrist at the London School of Hygiene and Tropical Medicine is doing fascinating research in task shifting, the idea of training community health workers to handle psychiatric interventions with supervision, as an answer to the need. I was lucky to get a chance to visit his clinical trial center in Goa, India.

With India's population of over 1 billion people, they require at least 150,000 psychiatrists. Currently, they have around 3000 psychiatrists meeting about 2% of the country's need.  The idea of task shifting is to train community health workers to carry out psychosocial interventions. Chosen community health workers are those who are dedicated to their community's psychological health and understand the cultural contexts within which mental illness exists in their society. I got a chance to meet these wonderful women at Sangath, Goa. They go out to primary care centers to do prescribed therapies that have shown to be helpful in addiction and depression.




For the trial Sangath recently did (MANAS trial), the community health workers use depression and addiction scales to screen and triage patients in primary care centers who are having trouble with depression and alcohol abuse. Those who screened positive would either be assigned to the control group or see a community health worker for 6-8 cognitive behavioral therapy sessions to treat depression or addiction. In the picture below, you will see the packets the community health workers use to do the therapy and assess improvement behind them.


The community health workers get supervision weekly with more senior counselors on difficult cases and meet with a psychiatrists at least once a month. They are connected to referral services for urgent and more medically complicated cases. These trials have shown a significant impact to improving depression and addiction in this community.

It was a wonderful experience for me to see people trying creative solutions to major problems to accessing mental health care. It's a great way to involve the community, to help create sustainable resources, build capacity in a health system, and reduce the stigma of mental health.

Jhilam Biswas, MD

More camel mentions among MERS-CoV cases...

Click on image to enlarge.
Special thanks to Professor Andrew Rambaut ([4]; @arambaut) for keeping such great track of the number of human cases in which camels has been mentioned.
Also thanks to Prof Rambaut and Ellen Knickmeyer  (@EllenKnickMeyer) for putting up with my stupid questions.

The current tally is now 11 human cases with a link to camels; 3 more than my earlier post on this topic.

The charts still show that cases outside of the Kingdom of Saudi Arabia (KSA) are proportionately more likely to identify human contact with camels than are MERS cases acquired within the KSA. 


The first case from Qatar with a camel link was from Sept-2012; from the United Arab Emirates (UAE) on Oct-2012; from Oman 20-Dec-2013. The very first (index) case of MERS-CoV to be announced to the world on Sept-2012, that from a 60-year old man living in Bisha in the KSA, also had contact with his 4 pet camels which we learned of in an article in the New York Times ([1] and later in an article late February 2014 [3]). 


I have not added the case of a Qatari male who owned a camel and goat farm [5], because the report in Eurosurveillance notes he claimed no direct contact with sick animals. I do wonder about contact with healthy or asymptomatic animals though. 

References...

  1. New York Times article on Prof Memish et al's mBio paper.
    http://www.nytimes.com/2013/08/22/health/mystery-virus-thats-killed-47-is-tied-to-bats-in-saudi-arabia.html
  2. Prof Memish et al's mBio paper (does not mention camels though)
    http://wwwnc.cdc.gov/eid/article/19/11/13-1172_article.htm
  3. Alagaili et al's paper noting camels were a contact of 60M index MERS case
    http://mbio.asm.org/content/5/2/e00884-14.full.pdf+html
  4. Professor Andrew Rambaut's MERS-CoV case list
    http://epidemic.bio.ed.ac.uk/coronavirus_background
  5. Eurosurveillance contact study of 45-year old male from Qatar (FluTracker's Case #6)
    http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20406

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