Travel Clinic

Today for travel clinic, we seemed to be having a special on people getting ready for permanent change of station (PCS) moves. There are some things that are nice about these--for one, they're going somewhere with a military base or embassy, so they have access to American healthcare overseas--but there are things that are more difficult, mainly that they're going to be gone for three years.

The first patient of the day was a 23-year-old wife of a Marine moving to Okinawa, Japan. This is normally a pretty easy appointment (I had a similar one last week), but was made more interesting by the fact that she recently found out she was pregnant. Normally, I order vaccines for typhoid (not because they need it in Japan, but because most people who live in Japan do a lot of travel in Asia) and Japanese encephalitis (which we don't even have in clinic, currently). Since she's not planning on doing any travel outside Japan while pregnant, we deferred the typhoid vaccine until some time she's ready to travel, and Japanese encephalitis vaccine until after she's no longer pregnant. I did remind her that it's important that she protect herself against mosquitoes in the meantime.

The second family (husband, wife, four-year-old son) is going to be moving to New Delhi, India for three years. This is a map of where malaria is in India, which, as you can see, is almost everywhere. There's no malaria in New Delhi itself, but there is in the surrounding areas. We discussed the risks and benefits of malaria prophylaxis for all three years, and ultimately decided that they'd be spending most of their time in the city and wouldn't need it. I did remind them that anytime they're going to travel around or outside India, that they need to see their physician for malaria prophylaxis. They also needed typhoid vaccine and Japanese encephalitis vaccine, which presented another problem (in addition to the fact that our clinic didn't have it). The current JE vaccine in the US is only licensed for adults. That's not because it's unsafe for children, but because it hasn't been studied (we don't do studies in kids in the US, usually). It can be ordered off-label by a physician, so after discussing risks and benefits with the parents, that's what I did (and gave them phone numbers of the other military immunization clinics in the area so they could make sure they have it in stock before driving across DC). The son also got rabies vaccine, because there's a lot of rabies in India, and you can't trust four-year-olds to tell you when they've been bitten by a dog (or cat or monkey, etc, etc).

The final family of the day (mom, dad, eight- and five-year-old boys) is going to be moving to Morocco. This was probably the easiest appointment of the day, not because of the location (although, being a desert country, there's really not a lot of tropical risk), but because the family has done a lot of traveling and is pretty savvy about things. In fact, the mom grew up in Egypt, so the Sahara is not a new location to them. They actually did get a lot of vaccines, though, because they're planning on doing some traveling to sub-Saharan Africa in the three years that they'll be in Morocco. Everyone got yellow fever vaccine (except dad, who just got it three years before), meningococcal vaccine (except dad, who already had it), typhoid, and rabies. I also prescribed a few courses of azithromycin and loperamide for traveler's diarrhea, but after that, they'll have to go the embassy clinic for more. They'll also have to go to the embassy clinic for malaria medications before any of that travel to sub-Saharan Africa.

In all, not a bad day at travel clinic. A lot of notes had to be written (each person has to have his or her own note, even if the family was all seen together), but everyone was friendly and excited about traveling, so that was okay. That's the best part of travel clinic--everyone is happy, relatively healthy, and the only thing they complain about is the number of shots they have to get.

Bailey K. Ashford and Robert A. Phillips Research Awards

Last week I ended up spending more time than I would have liked at Walter Reed National Military Medical Center, because on Monday and Wednesday, I was competing for the two research awards at the hospital the Bailey K. Ashford Award and Robert A. Phillips Award. It was the first year that preventive medicine residents from WRAIR were allowed to compete, so I submitted my abstract on poisoning hospitalizations that I did at AFHSC several months ago, and was selected as a finalist for both.

Here's a picture of Bailey K. Ashford. He was an Army physician in the Spanish American War. After the war, he was sent to Puerto Rico to command the medical department troops (which today would a job given to a Medical Service Corps officer, not a doctor, because it's a pretty thankless job and kinda like herding cats. We don't listen to directions well). While he was there, he noticed that the Puerto Ricans were not only shorter than Americans, but that most of them were anemic. This led him to discovering a new species of hookworm and spent a year working on treating around 300,000 Puerto Ricans, reducing the death rate from anemia by 90% on the island. After this, he established the Puerto Rican Institute of Tropical Medicine and Hygiene, which is now part of the University of Puerto Rico School of Medicine. 

And this is Robert A. Phillips. He was a Navy physician and served in the Naval Reserves during WWII. In 1945-46, he was sent to Cairo to study typhus and ended up establishing the US Navy Medical Research Unit #3 (NAMRU-3), which is still there today. His first big assignment as the commanding officer of NAMRU-3 was a cholera outbreak in Egypt. In that outbreak, his research on cholera and treatment made him pretty much the world expert in it until he died in 1976.

In the good old days of the National Capital Region, when the Army had Walter Reed and the Navy had Bethesda, these were two separate competitions (Bailey K. Ashford at Walter Reed and Robert A. Phillips at Navy), and the two had nothing to do with each other. Four years ago, however, we all had to learn how to play well together, and both competitions were open to residents and fellows from either service. The main difference is that Bailey K. Ashford is for graduating residents, and Robert A. Phillips is for any resident. So there was quite a lot of overlap in the people competing for these awards, including me.

I didn't get the Robert A. Phillips award--it went to an Army orthopedic surgery resident who came up with a new system of classifying lumbosacral fractures--and the Bailey K. Ashford won't be announced until residency graduation in June, but I'm not exactly holding my breath. These are clinical research awards, which judges who are clinicians, and these people rarely consider epidemiology to be clinical research. Whatever. I was just happy that I was selected to be a finalist in both, because that meant that: a) someone recognizes the value of epidemiologic research; and/or b) someone thought my research was interesting enough that they wanted to hear me talk about it. And it got me out of clinic for two days, which is always a plus.

Last Day of the TB Course

Today was the last day of the Denver TB Course (in case you couldn't tell from the title of the post). Most of the lectures today were about non-tuberculous Mycobacteria, or NTM. These are bacteria that are related to TB, but a little bit different, and so they cause a little bit different kind of disease. They're also usually more difficult to treat, sometimes requiring medication for years to a lifetime, sometimes requiring surgery. Fortunately, they are also a lot less likely to affect people who are otherwise healthy. Most people who get NTM infections have other diseases, such as HIV, cystic fibrosis, diabetes, cancer, or other diseases that require steroid medication. That isn't to say that otherwise healthy people can't get NTM infections, it's just more rare.

That being said, because TB is becoming so rare in the United States (and chronic diseases are becoming more common), most of the Mycobacteria in the US is actually NTM.

We also talked about multi-drug resistant TB (MDR) and extensively drug resistant TB (XDR), which are becoming increasingly common around the world (remember the report in the news a few years ago of the guy who flew all over the place with TB? He had MDR, and ended up at National Jewish). MDR and XDR are increasing around the world in large part because people don't completely treat their TB infections. It's a long course of a lot of medications--a typical TB infection in the lungs requires two months of taking four drugs, followed by four months of two drugs--and while the WHO calls for all of that to be directly observed therapy (DOT) to make sure that all of the doses are taken, resource-limited countries aren't all that great at always doing it. People who take the medicines for a short time and then stop, or take some medicines but stop others, increase their chances of ending up with a drug-resistant form of TB that is very difficult to treat.

In all, the TB course was pretty valuable and I feel like I learned a lot that will help me in the future. There was some stuff that isn't necessarily relevant for a preventive medicine physician (if I get a person with MDR-TB, I'm not going to be treating him or her; I'm going to be calling my friendly infectious disease physician and handing the case over), but it was still interesting. So you can rest assured that your tax dollars went to a good place (at least this once).

Not quite timely, but still appropriate:

TB Course, Days 2 and 3

I realized this morning that I forgot to write about my day at the TB course yesterday. Oops. So today's entry will serve for both days. First of all, here's a picture of National Jewish Hospital back when it opened as a TB sanitarium in 1899:

Yesterday was a mix of helpful and not helpful information, which mostly means things I will need to know as a preventive medicine physician and things I don't need to know. How to screen people for latent TB is something that I need to know, because that's something that preventive medicine physicians do. Here's the reason why:

 

What this says is that if you have 100 people who are exposed to TB, 70 will be fine and 30 will become infected, which is known as latent TB infection. Since TB is such a slow-growing bacteria, for 27 of those, the infection will always be latent and they will never have active TB. For the remaining 3, half will have disease within two years, and the other half will have disease later in life (okay, bad example, since you can't have half a person, but you get the idea). The point of treating people with latent TB is to reduce their risk of having active disease in their lifetime from roughly 10% to less than 1%.

And this is how you screen someone for latent TB. When you have a person at high risk, such as someone born outside of the US or someone who has been around someone with active TB, you do either a TB skin test, which is also known as a PPD; or a blood test (IGRA, or immunoglobulin release assay). If that comes back positive, you do a chest x-ray to look for active TB. If the chest x-ray is abnormal, you probably end up treating for active TB, but if it's normal, they're said to have latent TB. And again, the reason why we treat people with latent TB is to reduce their risk of progression from 10% in their lifetime to less than 1%.

That was a good deal of yesterday and a bit of today. Today we also did a workshop for TB outbreak investigations, which was interesting, because there's a change I'll be in charge of one of those someday. It was kinda a good feeling that I got during this workshop, because I felt like I had a better handle on the situation than most people in my group, which makes me think that if I have to do that someday, that maybe I won't mess it up too bad.

Here's a parting thought for tonight, from the CDC doctor who was sent to Colorado to close their sanitariums and ended up staying for the rest of his life:

Denver TB Course

As seems to be the trend for this year, I'm again away from DC, this time to Denver for the Denver TB Course at National Jewish Hospital. Here's a picture of the building the course is in:

This is the 49th year of the TB course at National Jewish, which established itself as a TB mecca of knowledge, so to speak, back in the days of sanitariums. What I didn't realize until the History of TB lecture today is that the practice of sanitariums started in Europe, in the Alps, around 1865. In the States, it started in the Adirondacks in 1884 with Trudeau (the great-great-grandfather of the comic strip artist, I believe), a physician in New York, who was diagnosed with TB. At the time, that was pretty much a death sentence, as they didn't yet have antibiotics to treat it. So he left his practice and went up the Adirondacks to relax, and his symptoms improved. They thought it was the elevation. Well, since the Adirondacks are pretty miserable for most of the year, and the Rockies are fairly nice, the practice of traveling to sanitariums moved from upstate New York to Colorado. More people traveled to Colorado for TB treatment than to strike it rich at the gold rush.

After our History of TB lecture, most of the lectures were introductory, covering topics such as transmission, immunology, diagnostics, and chest x-ray findings. Most of it was pretty dull, actually, although I did pick up a few pointers in the x-ray lecture. I'm hoping tomorrow will be more exciting. We'll be discussing some challenging cases that they've seen here at National Jewish, than latent TB infection (which is pretty much all preventive medicine physicians deal with, in terms of TB), and more about treatments and drugs. Should be a good time.