Whitman-Walker and Travel Clinics

In trying to stay up to date on the blogging, I'm writing about yesterday's and today's clinics. I was going to write yesterday, but I decided to go out to dinner with friends instead.

Yesterday I was at Whitman-Walker Clinic, which started as a HIV/AIDS clinic in DC and is now mostly primary care for HIV-positive patients (among other things, but the primary care in HIV patients is what we do). Every three months, the patients come in for blood work, including a full chemistry panel, blood count, HIV viral lode, and CD4 count (the white blood cells that HIV attacks). Twice a year they also get blood work for hepatitis B and C and syphilis.

All the patients I saw yesterday are doing very well, as far as their HIV. In fact, for all of them, that was the least of their complaints. One recently had a heart attack, one was recently diagnosed with diabetes and colon cancer, and one fell and hurt his shoulder (there were others, too, but I don't remember if they had any complaints). I wonder if the people who started HIV care thirty years ago imagined that the disease would be so manageable that chronic diseases would be more of a concern than the HIV.

That was yesterday. Today was travel clinic at Ft. Myer. I had four patients, three different trips (the middle two patients were a husband and wife traveling together). Here's where they're going and what I did:

Tanzania:

The first patient is going on a two-week safari in Tanzania. She got a yellow fever vaccine (there's no yellow fever in Tanzania, but there is in Kenya and she has a connecting flight. Tanzania requires official WHO documentation of a yellow fever vaccine for everyone coming from Kenya) and a bunch of other vaccines, including typhoid, meningococcus, hepatitis A and B, polio, and flu. She also got a prescription for doxycycline for malaria prophylaxis (the map above is the malaria map, so you can see that it's everywhere) and prescriptions for Immodium and ciprofloxacin for traveler's diarrhea. I also discussed with her safe food and water, insect avoidance (wear DEET, sleep under mosquito nets, etc), avoiding animals (because they all have rabies), and standard safety information and how to register her trip with the State Department (so they know she's there if anything happens).

Southeast Asia:

The couple traveling together is a retired lieutenant colonel and his wife, going on a two week cruise to Southeast Asia. They needed surprisingly little for their trip. Both needed two shots--typhoid for both, influenza for him and pneumococcal for her--and I gave them prescriptions for traveler's diarrhea, but there's no malaria in any of the cities where they're stopping, so they didn't need anything for that. I did give them some DEET, because there is dengue, and the mosquitoes that carry dengue bite during the day, which is when they're going to be off the ship.

Eritrea:

My final patient was born in Eritrea and lived there until she was 13. This is her first time going back; she's going to visit friends and family for two months. She's mostly going to be in the capital, Asmara, where there is no malaria (the white spot in the middle of the map). Since she is planning on visiting people outside (in the giant red areas), we discussed malaria prophylaxis. There were a few choices: no prophylaxis, a few short courses of prophylaxis just for when she's outside Asmara, or prophylaxis the whole time. She decided on prophylaxis the whole time, so I prescribed mefloquine, since it's only once a week. She also needed a couple of shots--typhoid, flu, and polio. There's no yellow fever in Eritrea, so she didn't need that. I also gave her a few courses of Immodium and cipro in case of diarrhea, and we discussed the standard safety things and travel insurance and whatnot.

Not a bad two days. In other news, I have a couple of presents under my tree, so that makes me happy :)

ASTMH

This past week, I was hanging out in Philadelphia for the American Society of Tropical Medicine and Hygiene conference. It was pouring rain, but since the conference was indoors, that wasn't really that big of a deal (until my deputy program director insisted I go play tourist, but I'm getting ahead of myself).

The conference started on Sunday night with a student and trainee reception, which wasn't terribly exciting, but it did include free appetizers and wine. I got to talk to a couple of medical students, grad students, and people applying for medical school about the things that they've done and want to do, so that was pretty neat. After that was the first plenary session, which was mostly focused on how global aid is dropping and the impacts that will have on global health and disease prevention and treatment.

Monday started the endless series of sessions, each an hour and forty-five minutes long and consisting of a series of speakers, each talking for fifteen to twenty-five minutes. I went to sessions on a variety of topics, from dengue (since I'm doing my residency project on it) to global health, clinical sessions, and neglected tropical diseases. I actually really enjoyed the sessions on neglected tropical diseases (which are diseases that only affect the poorest of the poor and don't have a lot of research dollars associated with them). Of these diseases, there are a few that the WHO is slated for elimination or eradication.

Let me back up to explain the difference between those terms: elimination is the cessation of transmission in a given geographical area. For example, polio has been eradicated in the Americas. Eradication means that there is no more transmission anywhere in the world. The only disease that has been eradicated is smallpox. The next step, after eradication, is extinction, meaning that there is no more anywhere, and no diseases fall under that definition, including smallpox (there are still lab samples and who-knows-what from the former Soviet Union).

So, back to what I was saying. There are four diseases that the WHO wants to eliminate/eradicate by 2015 (yes, it's coming up quick). One is trachoma, which is the number one cause of blindness from an infectious disease worldwide. I would include a picture, but pictures of eyes gross even me out. It's actually a Chlamydia bacteria that infects the eyelids, causing scarring that scratches the eye and leads to blindness. The treatment (before one is completely blind) is surgery and antibiotics (azithromycin). The prevention is facial hygiene and clean water. Another is onchoceriasis, also known as River Blindness. This is slated for elimination from the Americas by 2015. They'll focus on eradication at some other point.

As you can see, they're close to elimination in the Americas, and there's still a lot of work to be done in Africa. It's a parasitic infection that causes (wait for it...) blindness, and is transmitted by the bite of a black fly.

Number three is lymphatic filariasis, also known as Elephantitis. Here's an illustration (less gross that way):

It's also caused by a parasite, which blocks lymphatic flow, causing backup and the swelling, like in the picture.

The final one is Chagas Disease, which only occurs in the Americas:

Once again, caused by a parasite, transmitted either by the bite of a kissing bug or from mother to child. There's much less transmission from bug bites now, but there's still quite a lot from mother to child or from blood transfusions.

That was a lot more about that than I anticipated writing. Anyway, that was my Monday and Tuesday, and then on Wednesday, it was sessions in the morning and playing tourist in the afternoon. The hotel was only about half a mile from Independence Park, with the Liberty Bell and Independence Hall. Unfortunately, it was pouring rain, so I was quite soaked, but fortunately, it being a Wednesday afternoon and with that weather, I didn't have to deal with large crowds. Here are some pictures:

Inside Independence Hall, where the Continental Congress met and discussed both the Declaration of Independence and the Constitution. The chair in the middle was where George Washington sat when they approved the Constitution.

Liberty Bell. I wasn't all that impressed.

And the outside of Independence Hall. And yes, there's construction going on. And yes, it was really raining.

Next week, back to clinic.

Clinic, Week 2

I meant to write this while at work on Friday, and then yesterday during my day of doing absolutely nothing (no, really--I woke up, went on a run, and then only got off my couch to get food. It was kinda glorious). But I didn't, so I'm writing on Sunday night.

So here's how this past week of clinic work went:

Monday: No clinic (my preceptor at Whitman-Walker was still on vacation from Thanksgiving). So I sat at WRAIR and worked on work. And went to a two hour long safety briefing, which was incredibly boring, even with the company of my two fellow residents.

Tuesday: Travel clinic at Ft. Myer. I actually had patients! It was a lot of fun (and actually fairly busy). I had a retiree who is now a consultant who will be going to Afghanistan for twelve months, so he got a couple of vaccines and a year's prescription of doxycycline, which is an antibiotic that is also used as an antimalarial. He'll have to get a two-week prescription for primaquine, another antimalarial, to take when he gets back. The next patient was another retiree, going to Ghana for his mother-in-law's funeral. He's been out of the service for almost twenty years, and despite still having family (well, family he married into) in Ghana, he has never been to Africa, so he got quite a few vaccines, and also a prescription for antimalarials (Malarone, in his case, which is a drug with very few side effects but a pretty high price tag), as well as all sorts of counseling about how to take care of himself while he's traveling. Patient number three is a dependent (meaning she was never in the military, but her husband was) who was born and raised in El Salvador and is going back for Christmas. El Salvador does have malaria, but not much, so I gave her some bottles of bug lotion with DEET and told her to be careful going out at night (which is when the malaria mosquitoes bite), but she didn't need any medications. She did need a couple of vaccines, though, which we were more than happy to provide. The final patients were a family (mother and three kids under 10) who were going to Bahrain to visit the husband/father, who is stationed there temporarily. Bahrain is a pretty safe place, when it comes to diseases, so all they needed were typhoid shots and prescriptions for antibiotics in case they get diarrhea, and they were good to go. No malaria there.

Moral of the story: whenever you're traveling to the developing world, go see a doctor. You're probably going to need a few shots and drugs before you go.

Wednesday: This was supposed to be prev med clinic at Bethesda (excuse me... Walter Reed National Military Medical Center), but instead, we had a talk about the embassy bombing in Nairobi in 1998, by the doctor who was in charge of the research lab then (she is now retired but still working for the Army). It was a really interesting talk, if for no other fact than to demonstrate how far we've come as a military when it comes to treating and evacuating casualties from big, traumatic events. And this bombing was a big, traumatic event--there were around 400 killed and 1200 injured.

Thursday: TB clinic at Montgomery County. This was, well, not what I expected. I pretty much just observed while the medical director saw patients. The first was an elderly woman who recently immigrated from China and had a positive TB skin test and x-rays that looked like she had TB in the past. She never had any sort of treatment, so she was given a prescription for four months of isoniazid and rifampin (two drugs that are used to treat latent, or inactive, TB), and then a whole bunch of counseling on why it was important. The next few patients were all follow-ups who have active TB and come into the clinic once a month to check on the symptoms, see how they're progressing, and so on and so forth.

Friday: No clinic (there's never clinic on Friday). I finalized my orders for attending the American Society of Tropical Medicine and Hygiene conference in Philadelphia (where I am right at this moment) and did some mandatory online training, and that was about it.

So now I'm in Philly, with one day of the ASTMH conference down and four to go (it's a pretty long conference). I'm not presenting anything, just going to the sessions and, I hope, learning stuff. We'll see how that goes.