1000 Patients a Day with Cholera - Acute · PDF file1000 Patients a Day with Cholera ... Some...

1000 Patients a Day with Cholera

Dr Mark Pietroni

Director of Public Health & Consultant in Acute

Medicine

South Gloucestershire

Integrated Rural Health

and Development

LAMBLAMB

Vision

“Healthier people – better lives through evidence based solutions”

Mission

“We will help solve significant public health challenges facing the people of Bangladesh and beyond, especially the most vulnerable, through the generation of knowledge and its translation into policy and practice.”

Key International Collaborators

WHO/UNICEF Joint Statement 2004

• Provide children with 20mg per day of zinc supplementation for 10-14 days (10mg per day for infants under six months old).

Global Emergency Response Teams, 1994-2010

2007 Cholera Epidemic, Dhaka

2007 Cholera Epidemic, Dhaka

43,359 patients (July -September)

34% had culture confirmed cholera

84% had severe dehydration

75% of cholera patients presented within 24 hours of diarrhea onset

93% of the patients required intravenous fluids for their management

Saved 13,000 lives at a cost of approx. $15 per patient treated or $50 per life saved.

Click on photo for ‘Dhaka’s Cholera Wars’

https://www.youtube.com/watch?v=C6Bxp1S2rbo


Diarrhoeal Disease Surveillance System

• Established in 1979

• Enrolls 2% systematic sample of all patients attending ICDDR,B hospitals and treatment centers.

• Monitors:

– sociodemographic

– clinical, and

– microbiologialcharacterictis; and

– antimicrobial susceptibility of V. cholerae and Shigella

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Esti

mat

ed

nu

mb

er

of

case

sIsolation of Specific pathogens

Dhaka Hospital , 2010

VCO1 ETEC Shigella Rota

Dehydration status of attending

patients, July 2010

Dehydra

tion

Dhaka

Hospital

Matlab

Hospital

Mirpur

Treatment

Centre

None 34.7 47.8 23.1

Some 40.4 47.8 46.2

Severe 24.9 4.4 30.8

TriageThe initial assessment should be brief but must:

• Confirm the diagnosis of acute watery diarrhea

• Assess the level of dehydration

• Assess the presence or absence of malnutrition

• Recognise any other co-morbidities

Clinical assessment of dehydration by“Dhaka Method"

TASK FINDINGS

ASSESS

Condition* Normal Irritable/Less active* Lethargic/Comatose*

Eyes Normal Sunken

Mucosa Normal Dry

Thirst* Normal Thirsty* Unable to drink*

Skin Turgor* Normal Reduced*

Radial Pulse* Normal Uncountable/Absent*

DIAGNOSIS No Sign of

Dehydration

If at least two signs, including

one key [*] sign is present,

diagnose

Some Dehydration

If some dehydration plus one of

these key [*] signs are present,

diagnose

Severe Dehydration

Body Wt. Loss 0-4% 5-10% >10%

TREATMENT Prevent

Dehydration

Reassess

Periodically

Rehydrate with

ORS Solution UNLESS

Unable to Drink

Frequent Assessment

Rehydrate with IV Fluid

More Frequent Reassessment

Treatment Plan

Assessment Treatment Objective

Severe dehydration Plan CRehydrate urgently with

IV fluids, give abx

Some dehydration Plan BRehydrate at health

centre with ORS

No sign of

dehydrationPlan A

Treat at home to prevent

dehydration

Patients with severe dehydration require an immediate intravenous fluid bolus of 100ml/kg given over 3 hours with 1/3 in the first 30 minutes (double the duration in children less than 1 year and malnutrition)

28/01/09

Improving Compliance

Audit current practice

Implement improvements

Re-audit practice

28/01/09

Antibiotics vs Dehydration

Antibiotic

received

Dehydration Status

No sign

n=27

Some

n=43

Severe

n=17

Azithromycin 9(33.3) 26(60.5) 17(100)

Ciprofloxacin 1(3.7) 3(7.0) 0

NA 17(63.0) 14(32.6) 0

28/01/09

Conclusion

60.5% of some dehy. And 33.3% of no dehy.

patient receive Azyth for AWD management

All severe dehydration cases received

Antimicrobial therapy

Assumed all severe dehydration received iv

therapy

Sheba Quality Indicator Meeting

• Multidisciplinary

• No-blame

• Set own indicators

• Agree standard

• Implement own solutions

28/01/09


• 100% IV therapy for severely dehydrated patients

• Review by a doctor within 30 minutes

• Antibiotics only to severely dehydrated patients

• No investigations

• 100% name, dob, address, mobile phone number

recorded

28/01/09


28/01/09

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w

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Weekly patient visit during 2007-2009Dhaka Hospital, ICDDR,B, Dhaka

2007

2008

2009

Success Criteria

• Management support, autonomy and authority

• Invert the staff pyramid, listen to (junior) clinical staff

• Continuity of care

• Team work

• Implement own solutions

28/01/09

Acknowledgements & Thanks

28/01/09

Chief PhysiciansDr Azhar I KhanDr PK Bardhan

Nursing OfficersMomtaz BegumCatherine Costa

Acknowledgements & Thanks

28/01/09

Acute Medicine –South African solutions to British problems?

Izak HeysAcute Medicine

Gloucestershire Hospitals NHS Foundation Trust

Aims of the talk

1. Differences in health care systems

2. Suggestions and possible solutions

3. Open discussion

SAMBristol • 7 May 2015 • Acute Medicine in South Africa

1. Differences in health care systems


Current challenges to the NHS

• An ageing population and lifestyle factors

• Front and back door pressures

• Changing public expectations and rising costs

• Advances in medicine and technology


www.myhealth.london.nhs.uk/your-health/


www.sciencemag.org/content/339/6122/961


www.who.int/countries/

South Africa United Kingdom

• Upper middle income country

• 0.8 physicians / 1000

• 5.1 nurses / 1000

• 5.9 / 1000

• High income country

• 2.8 physicians / 1000

• 8.8 nurses / 1000

• 11.6 / 1000


http://data.worldbank.org/indicator


www.indexmundi.com/map/

2.84 Hospital beds / 1000 3.38 Hospital beds / 1000


www.ons.gov.uk/ons

“Acute Medicine” in South Africa


2. Suggestions and possible solutions


24hrs in Acute Medicine in South Africa


07.00 – Post take round

• Ward round with on-call team

• Clerking doctor presents all the cases

• Hand-over @ 8am

• Bedside teaching


07.00 – Post take round

• Most procedures performed bedside

• Bedside radiology seldom available

• Important to maintain skills and confidence with procedures

• Opportunity for junior staff

• Not be dependant on other specialities



Thorax 2010;65(Suppl 2):ii61eii76


www.acutemedicine.org.uk/what-we-do/training-and-education/skills/

08.00 – Hand-over


www.rcplondon.ac.uk/sites/default/files/act8_registrarshttp://www.acutemedicine.org.uk/wp-content/uploads/2012/06/acute-care-toolkit-1-handover

10.00 – Ward round

• Clear record keeping and plan

• Nursing staff on ward rounds



https://www.rcn.org.uk/__data/assets/pdf_file/0007/479329/004342

10.00 – Post-post take round


• Nursing staff on ward round

• Laboratory investigations – cost and volume



Ann Thorac Surg. 2015 Mar;99(3):779-84


Clin Chem. 2003 Oct;49(10):1651-5


• Why is test ordered• What are the consequences of NOT ordering the test• How good is it at discriminating between health vs diseases• How will it influence management and outcome

• Treat the patient, not the laboratory result

LabMedicine 2009, 40, 105-113


Ann Clin Biochem 2008; 45: 33–38

10.00 – Post-post take round


• Nursing staff on ward round

• Laboratory investigations – cost and volume

• Imaging and special investigations – clear pathways

• Subarachnoid haemorrhage

• Pulmonary emboli

• In-patient echocardiography


Afternoon and evening handover


Teaching, post-take and “down time”

Night shifts


Summary• Team dynamic – clerking team (EWTD? Start of

rounds?) and nursing staff on ward rounds

• Laboratory and other special investigations

• Minimise duplication – continuity of care

• Clear guidelines for common conditions

• Maintain procedural skills (dedicated procedure room, HDU)

• Teaching and “down time” as a team


Emerging and Re-emerging Infectious Diseases

of the 21st Century

Global Health Challenges

Markus Hauser Gloucestershire Hospital NHS Foundation Trust

Purpose and Outline

• Outline the historical context of emerging infectious disease

• Discuss current factors that contribute the development of EID

• Case study discussion on current and emerging epidemic infections.

• Our responses to tackle and limit the spread of EID in the 21st century

Introduction

The spread of infectious diseases

– Modern demographics & Ecological conditions

• Rapid population growth

• Poverty

• Urban Migration

• Frequent movements across boarders

• Alternations in the habitats of animals and arthropods

• Changes in food production & distribution

Contributing factors

• Microbial adaptation – as seen in E. coli strain O157:H7

• Climate and weather – (e.g., heavy rains can result in increased breeding sites for

mosquito vectors and increases in mosquito-borne infectious diseases)

• Changing of eco systems contributing to changing vector ecology

– Rift Valley Haemorrhagic fever in Egypt

Contributing factors (2)

• Human demographics & behavior – Close interaction with birds, poultry, pigs, “camels”

• International travel and commerce – Aedes egypti and culex travelled in tires to the americas

– Out break of cyclosporiasis in the United States through Guatemalan raspberries

• Technology and industry – (e.g., use of mass treatment with fluoroquinolones to

treat E. coli infections in chickens, resulting in antimicrobial resistance in humans to other organisms).


• Breakdown of Public Health Measures such as Vaccination programs

• Vector control: increased abundance and distribution of Aedes aegyptii– spread of dengue hemorrhagic fever to the Americas

• War and famine – Vaccination programs

– Crowded areas with refugees

– Increased risk of exploitation, famine.

– Violence and sexual predators


• The Lack of political will to address global health issues

• The lack of global surveillance and global reporting – Economical loss

– Political reasons

– Inability to recognize the underlying cause

• Intent to harm – Anthrax / Bioterrorism

Microbial Threats to Health: Emergence, Detection, and Response" (Smolinski, Hamburg, & Lederberg, 2003)

• 1992, with the emergence of Sin Nombre virus (cause of hantavirus pulmonary syndrome),

• Start of 21st century with an outbreak of SARS due to a newly identified coronavirus;

• human cases of avian influenza in Asia; • Outbreaks of Marburg hemorrhagic fever in Angola and

Ebola hemorrhagic fever in the Democratic Republic of the Congo;

• the establishment of West Nile virus as endemic in North America.

Selected EID: Poliomyelitis

– Likely present endemically in the 18th Egyptian

Dynasty (1580–1350 BCE)

– Spread by faecal-oral contamination

– Poliomyelitis epidemic result of dramatic change in

human lifestyle

• Improving interrupted the normal pattern of

infection

• Delay of infection - increased risk for developing

paralytic disease

• Jonas Salk and Albert Sabin (vaccine)

Selected EID: Poliomyelitis

– Recent difficulties in Polio immunization has contributed to

continuous wild virus infection outbreaks in Afghanistan,

Pakistan and Nigeria

– A number of countries remain vulnerable for re-introduction

to the infection

• Horn of Africa – importation Belt

– International Intervention:

• Case reporting to identify success

• synchronized supplementary immunization activities in

vulnerable countries and regions

• Single stranded RNA virus • West Nile Virus first identified 1937 in a Woman

in the West Nile district in Uganda • Most frequently transmitted from the bit of an

infected mosquito: Culex• Over complex cycle of transmission between

viremic wild bird reservoirs and other infected vertebrates (horses and humans)

• Outbreaks infrequent until 1996 with outbreaks in Romania, Russia and Israel

Selected EID: West Nile Virus


– Spread to North America identified investigations

into a cluster of unusual cases of encephalitis in New

York City

– Called “Perfect microbial storm due to factors

present at the time

• Large, “non-immune animal and human

population” allowing for transmission

• Multiple hosts

• Favorable environment for transmission and

dissemination

• Spread quickly across the continent now

established endemically in the USA and the

central American nations

Review Article: West Nile virusLaura D Kramer, Jun Li, Pei-Yong Shi, Lancet Neurol., 2007 Feb;6(2):117-81.


• Phytogeneticlineage of the virus has help identify how the virus differentiatedAnd spread through Africa,Europe and the Americas


University of Washington, Immunology Department, distribution of West Nile Virus world wide: depts.washington.edu/galelab/west_nile.html

• First pandemic of the 21st century

• Late 2002 first reports of an “unusual” respiratory disease in southern China

• Initially thought to be an unusual strain of influenza

• In Feb 2003, a physician who was incubating SARS traveled from China to Hong Kong

• Further transmission to local residents and travellers who travelled back home to Vietnam, Singapore, Canada, and Taiwan

• Infection escalated to May 2003 – total of 8500 cases

Selected EID: SARS - CoV

• Case studies revealed a high attack rate under health care provided

• Clustering of cases in community setting such as apartment buildings

• Identified the need for Isolation as an important containment measure

• Airborne spread, especially with air travel

• consideration to limit travel for students, business related travel with global financial impact

Selected EID: SARS

Comparing SARS, Avian Flu and Severe Acute Respiratory Infections associa

Virus SARSSAR-CoV (2003)

Avian influenzaH7N9 (2013)

Origin Fu Shan city, China China

Source Civet cat, wild animals (bats) Birds, Poultry

Spread Animal to human, then human-to-human

Avian to human, limited human-to-human

Principal symptoms Fever, respiratoryPneumonitis

Fever, respiratoryPneumonitis

Travel history Yes Yes

Morbidity 8500 infected 131 infected

700 case fatalities 31 deaths

Mortality Low (<10%) High (24%)

Antivirals and treatment

Supportive, ribavirim + corticosteroids

Supportive, oseltamivir

SARS vs Avian Influenza H7N9Hon K. Travel Med Infect Dis 2013; 11: 285 – 287

Isolation of a Novel Coronavirus from a Man with

Pneumonia in Saudia Arabia

Ali M. Zaki, M.D., Ph.D., Sander van Boheemen, M.Sc., Theo M. Bestebroer, B.Sc., Albert D.M.E. Osterhaus, D.V.M., Ph.D., and Ron A.M. Fouchier, Ph.D.

Fever, cough, SOB, Acute Pneumonitis

Possibilities of response

How do we stay informed

How do we stay informed

• Regular updates are available on the WHO Global alert and response pages • http://www.who.int/csr/en/

• Regular newsletters and weekly updates from the ECDC • Regular emails and alerts can be subscribed

• CDC homepage and weekly update available

http://www.who.int/csr/en/

Global & Local

• Awareness of the global treats / strengthening Surveillance

• Awareness throughout the organization

• Maintaining frontline awareness of the risks and responsibility – Especially in A&E and Acute Medical Units

– Clinical Leadership and Lines of Responsibility

• Appropriate protocols to respond to the imminent risks that are practical and applicable

• Supporting herd immunity in reinforcing our responsibility to partake in Vaccinations programs

“Knowing is not enough; we must apply.

Willing is not enough; we must do!”

- Goethe

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