Arrival in Kiev

For those of you who didn't know I was going to be spending a week in Ukraine teaching epidemiology... Surprise! I'm in Ukraine for a week to teach epidemiology. After far too many hours of travel by plane, train, and automobile (okay, just plane and automobile, no trains involved on this trip...so far), I checked into my hotel in Kiev. And what a lovely hotel room it is.

 My preceptor for this trip, Dr. Smoak, has been here for a week already doing the first part of the training (two weeks total: week one is to teach them epidemiology, week two is to evaluate them teaching the same lectures back. That's the part I'll be doing), so after I unpacked and cleaned up somewhat, she took me out to see the part of the city where we are and do some souvenir shopping. Here is one of the churches (I don't remember the name, but I'm going to find out):

This church also had a memorial for the 1932-33 famine in Ukraine, pictured below:

To try to explain this famine briefly, without getting into complicated Soviet politics and history, in the Soviet system, there were common fields that all peasants were supposed to work, as well as small plots that individual/families maintained. In 1932, there was a pretty severe drought, and they discovered that people didn't really do anything in the common fields when there was work to be done on their own fields. So grain production was really, really far down. The Soviet solution to this was to take from the Ukrainian peasants who managed to produce anything, because they blamed the failure of the common fields on Ukrainian nationalism. In two years, millions of Ukrainian peasants starved to death due to the Soviet distribution policies, which was later determined to be a form of genocide. If you look at censuses that were done around this time (a few years before and a few years after), the Ukrainian region was the only part of the USSR that had a decrease in population. So the Soviets were selectively starving Ukrainian. They were bad people. But we knew that.

On a happier note, here's another church. Dr. Smoak said that this one had specific cultural/historical significance, but she couldn't remember what it was.
 

And, finally, a picture of the statue of the architect of Kiev.

That was my day/last couple of days. A bit hectic and definitely exhausting, which is why I'm about to go to bed. Tomorrow, possibly more walking around/souvenir shopping, and then Monday we have to go to work.

ACPM 2012

I spent Tuesday through Sunday in Orlando for the 2012 conference of the American College of Preventive Medicine, which has been a combination of a lot of fun and a lot of work (well, as much work as sitting in rooms in a conference center is).

The conference started on Wednesday (Tuesday was just a travel day) with a session on health economics and cost-effective analyses (yes, it was as exciting as it sounds). Thursday was a very long day, with a run in the morning before breakfast (a little more than 4 miles through Downtown Disney and surrounding areas), followed by sessions all day, poster presentation in the evening, and one more session that ended at 9:30. Long day. Here's a (not great) picture of my poster:

Friday was a slightly shorter day, mostly because I didn't see anything interesting to go to for one of the sessions and I decided to take a nap instead. The day also ended earlier, with the last session ending at 4:30 and my fellow residents and I deciding to go out to Universal City Walk for dinner afterwards. There were some big-name restaurants there, but it being a Friday night, the wait at some was rather ridiculous. We tried to go to Emeril's, but when they told us it was a 2-2.5 hour wait, we decided to hit Hard Rock Cafe instead. And because it was Hard Rock, we went to the store, where Derek decided to model the merchandise:

Saturday morning started with a long run, again through Downtown Disney and around the golf course. I actually got lost around the golf course, which made for a nice run, and amazingly enough, I made it back to the hotel with almost exactly the right mileage for the run (six miles). Here was my course:

Most of the sessions on Saturday (at least, most I attended) were part of the Uniformed Service Academy of Preventive Medicine offerings, which included a business meeting (terribly exciting), followed by a session on measuring behavioral health in the Army, then a session on vaccine surveillance in the military. In the evening was the awards banquet, which was a dress-up event. Derek and Raul only kinda understand the concept of dressing up:

Derek ended up getting an award for his oral presentation on degenerative disc disease, so we're very proud of him.

In all, it was a good conference, and I hope that next year I'm not too busy with work to go again.

82nd Civil Affairs Battalion, Ft. Stewart, GA

Again, I'm a bit behind on posting big news. Last Wednesday (as in, a week and a half ago), I received word that I will be becoming the preventive medicine officer for the 82nd Civil Affairs Battalion of the 85th Civil Affairs Brigade. For those of you confused about what the difference between a battalion and brigade is, here's a chart for you:

The 85th Civil Affairs Brigade is brand-new (activated 16 SEP 2011), which means my battalion (based in Ft. Stewart, GA) is brand new--as in, the stand-up date is SEP 2012. So I'll be coming into a brand-new position, which is kinda cool and really scary. Cool because I get to drive what my position is, scary because I have to drive what my position is. The whole, "Am I really smart/talented enough for this?" question that will, I hope, be answered soon (and answered to the positive).

Little bit of background as to the brigade and battalion. The 85th CA Brigade was stood up because the Army realized it needed more civil affairs assets, and decided to put that in the active component, instead of the reserves, where most of the other CA assets are (nine reserve CA brigades and one active duty to support special operations existed previously). There are 5 battalions in the new brigade: the 81st is at Ft. Hood (activated in 2011); 82nd at Ft. Stewart, one (forget the number) at Ft. Bragg, to be activated in September; and one at Ft. Lewis and one at Ft. Bliss to come in 2013. Each of the battalions takes a different part of the globe, with the 82nd taking Africa. The only other part of the world I think would be more interesting to go (in terms of health needs and diseases) would be the Pacific, and that's going to belong to Ft. Lewis, once that battalion exists. I've started convincing my friend Raul, who will be graduating next year, that that's the job he wants.

As far as what I'll be doing, here's the official guidance in the field manual for Preventive Medicine Services (Field Manual 4-02.17, in case you were wondering):

3-14. Civil Affairs Units
In CA units, assigned PVNTMED personnel assess the public health capabilities of a country or area, but
are not responsible for directly providing PVNTMED services to them. As such, PVNTMED personnel
are assigned to CA companies, detachments, brigades, and commands. The type and number of PVNTMED
personnel assigned is dependent upon the unit. Since the staff's role is advisory, it has no organic
equipment and must coordinate for support from PVNTMED detachments and the AO supporting medical
laboratory. If available, CA units are also supported by PVNTMED detachments.

That's what I'll be doing when I'm in the field, but in the meantime, I'm still waiting for my official orders to appear and trying to figure out what training I need to do before September, but I am excited about it. 

Executive Summary and Information Paper

It's been a week since the end of my POPM, so I've been a bit of a slacker about writing about the end of it. Sorry. Overall, it was a really good rotation and taught me a lot about the necessary steps in making policy (it's not a short nor simple process).

Most of my work during the rotation involved reading memos and proposed regulations and comparing them to current regulations to see how they fit (and that was an oversimplification of the whole thing). I also researched current issues that were coming in to POPM (things that people from outside the Office of the Surgeon General thought needed attention) and tried to make a decision about how important it would be. One of those issues was a report of twelve cases of swine flu (a different swine flu, not H1N1) in five states. After doing research, which mostly consisted of reading what the CDC has to say about it, I wrote an executive summary and information paper. Also easier said than done.

An executive summary is a short and concise summary of an issue, and there are very specific formatting rules for it, from the font and size to the fact that it has to be fewer than fifteen lines of information. Here's my EXSUM (we like acronyms):

(U) 12 HUMAN CASES OF INFLUENZA A(H3N2)v IN THE US.  (U) (DASG-PPM-NC)  Since August 2011, the Centers for Disease Control and Prevention (CDC) reported 12 human cases in five states of swine-origin influenza A (H3N2)v.  No cases have been reported among DoD beneficiaries.  Severity of illness is similar to seasonal influenza with three hospitalizations and no deaths.  The majority of cases occurred in children who have had contact with swine, with evidence of limited human-to-human transmission.  CDC provides interim guidance to clinical and laboratory personnel for surveillance and testing.  MEDCOM provided guidance to Army medical treatment facility laboratories on 13 Jan 2012 regarding typing and subtyping of specimens. Preventive medicine personnel will report all confirmed, probable, or suspected influenza A(H3N2)v cases in Disease Reporting System Internet and to local public health authorities.  Healthcare personnel should encourage beneficiaries to be immunized against seasonal influenza, as this may confer partial protection against influenza A(H3N2)v virus.     

If, after reading an EXSUM, someone wants more information, they request it and are provided an information paper, which, as it sounds, contains more information. It's supposed to be less than one page (again, very specific formatting rules), but can be longer. Mine was about a paragraph onto the second page, and I won't subject you to that.

So now that I'm done with POPM, I'm spending a little bit of time hanging out at WRAIR on what we refer to as "research downtime". Unfortunately, my research project happens to be at that exact place where there is nothing I can do to accelerate it, which makes my research downtime more of just, well, downtime. It's given me the opportunity to work out during the lunch hour, which is quite enjoyable, and get my poster ready to present at the ACPM conference in a couple of weeks. And get caught up on sleep, which after the commute I had to go down to Falls Church, was a bit lacking.

Pandemic Influenza Table Top Exercise

On Thursday and Friday (I'm only a couple of days behind, go me), I participated in a table top exercise about pandemic influenza preparedness. It had a tendency to drag on and get into the weeds at time, but was overall fairly educational.

One thing I didn't know before going into this is that we have definitions of pandemic severity, based on the case fatality ratio (below). In terms of pandemic influenza, the H1N1 (or swine flu) from 2009 was a category 1 pandemic (I feel like I need to back-up for a second and define 'pandemic'. It doesn't mean 'bad disease'; it means a disease outbreak that is spread around the world. An epidemic, on the other hand, is an outbreak that is in one area or part of the world. So H1N1 is a pandemic, because it's found everywhere, but obesity is an epidemic, because it isn't). Anyway, back to what I was saying: H1N1 is a category 1, because while there were a lot of cases, there weren't a lot of deaths. The 1918 flu, on the other hand, was a category 5 pandemic, and was the only category 5 influenza pandemic in history.

For the table top exercise, we were using a pandemic influenza modeling tool developed by the Innova Group, where you can enter in the severity of the pandemic (from 1-5), duration (typically 6-12 weeks for influenza, depending on the size of the geographic area you're talking about), the population size and age distributions, and expected attack rate by age (for example, children tend to have higher attack rates for influenza than adults). You enter in all that stuff, and then it spits out a bunch of reports about how many healthcare workers you need, how many gloves, the amount of storage space required for everything you're going to need, etc, etc. 

For this exercise, they modeled the Northern Region Medical Command, which is all the Army treatment facilities from the Canadian border through North Carolina, and a category 3 pandemic. The people running the table top were logisticians, not epidemiologists, so they didn't know all the right terminology of influenza surveillance or epidemiology and some of the things just didn't make sense. For example, based on the scenario, we knew there was a pandemic coming before the first cases hit the United States, which isn't the situation. With H1N1, it had been going on in Mexico for a couple of months before anybody typed the virus in San Diego and realized that it was a new influenza. So a little unrealistic, at least at the beginning of the outbreak, but it still generated a lot of good discussion about what we can do to prepare and how individual treatment facilities have to respond.

Overall, I don't know how much it taught me about policy (which is what I'm supposed to be learning on this rotation), but still educational overall.

Periodic Health Assessment

Today was a meeting of the Joint Preventive Medicine Policy Group (another acronym: JPMPG, pronounced jip-em-pig), which is a group of preventive medicine people from all of the services (Army, Navy, Air Force, Coast Guard, sometimes foreign militaries, etc), and the topic of the meeting was the periodic health assessment.

The periodic health assessment is done by each of the services, but each one is different, which in today's fairly integrated military, makes things a bit difficult. There's an online portion that each service member completes on his/her own time, and then there's a face-to-face with a medical provider (doc, PA, NP, etc). The problem comes in for the face-to-face... if a sailor goes to an Army clinic to do the PHA, there's no guarantee that that Army doc knows how to do a Navy PHA (or even knows which computer program to use). For the record, I don't know how to do Navy or Air Force PHAs, nor do I know what programs they use. As you can figure, that creates some problems on joint bases.

So the purpose of the meeting (which extends into tomorrow, but I won't be going to, because I'll be at WRAIR for didactics), is to figure out 1) what the purpose of the PHA is (that's an entirely different conversation, which I won't get into); 2) if the multiple different PHAs can be standardized into one form; and 3) what that might look like.

Easier said than done. There's a lot more to policy than meets the eye.

Proponency Office for Preventive Medicine at the Office of the Surgeon General

That's where I'm rotating now (today was the first day). Or, because the military likes acronyms the way normal people like breathing, POPM/OTSG (which we just call POPM, pronounced pop-'em).

To put it (very) simply, POPM is where medical policy in the Army comes from. Whenever there's a question about the way things are done in the Army medical department (AMEDD, back to the acronym thing), it goes to POPM, they check the research and what the civilian side and other services are doing and get the opinions of subject matter experts, and then make policy. Yes, that was very simplified.

Today I spent the morning doing the standard for a new rotation: in-processing. Fortunately, every Army prev med resident as rotated through POPM since 2008, so they know what they're doing (which is impressive; usually when someone should know better, they act as if it's never been done before and the wheel needs to be reinvented). Then the afternoon was taken by a teleconference about the new regulation for the Army program, which mostly turned into public health nurses bashing just about everyone else (including prev med docs). That took over three hours, and when it was done, they sent me home, because the snow was falling pretty heavily (not sticking, but still falling). Unfortunately, people around here become idiots on the road when there's weather involved (and I mean any weather... snow, rain, sunshine, hurricane, earthquake...). It's a little more than 15 miles from work to home, and it took me almost two and a half hours. I was not happy with that commute.

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.