Global Health: Three Issues to Watch During Summer 2016

April 28, 2016 Maria Wilson Leave a Comment

By: Maria Wilson

Global Health Office Outreach Assistant

Another academic year is coming to an end. Thousands of Dalhousie University students are heading home for the summer months, but that doesn’t mean the global health learning has to end! We hope you continue your interest in global health, and to make things easier, we have compiled a list of three global health issues that we think will be “hot topics” during the summer heat. Look out for these issues in the media, in your travels, and even in your own back yard.

Zika virus

Zika virus has dominated global health news in 2016, and its coverage in the media will only grow with the Rio Olympics taking place in the country at the center of the outbreak – Brazil. This event, to be held in August 2016, will draw hundreds of thousands of visitors from around the world – from athletes, to coaches, to spectators. Although mosquito control efforts in Brazil have been scaled up enormously in recent months, the risk of infection still exists [1]. Whether, and to what extent, Zika virus will spread to other countries through infected travelers remains to be seen.

Eradicating polio

Poliomyelitis, often referred to as polio, is a distant memory in most of the world. Since 1988, when the Global Polio Eradication Initiative was formed, polio case numbers have decreased by more than 99%. A cost-effective, oral polio vaccine (OPV) exists, and the Global Polio Eradication Initiative is on a mission to ensure that every child, worldwide, is immunized. There are currently only two countries where polio transmission has not been stopped: Afghanistan and Pakistan. With only 98 cases reported in 2015, eradicating polio in the near future is a very real possibility. Expect eradication efforts to go into overdrive this summer, in what will hopefully be the final push to make this disease history [2].

Mental health

Global health has its origins in targeting infectious disease threats, such as TB, HIV and malaria. However, the field of global health has grown to encompass so much more: from health systems, to non-communicable diseases. Expect mental health to receive increased attention in the months, and years, to come. One in four people in the world will be affected by a mental or neurological disorder during their lifetime, and 450 million people are currently suffering from such conditions [3]. The United Nations has recognized the importance of mental health by including it in the new set of 2030 Sustainable Development Goals (SDGs) [4]. The World Health Organization and the World Bank presented to ministers of finance and development agencies on the expected economic, health and social returns from investing in mental health services in Washington DC earlier this month [5]. Important discussions are happening on this topic, let’s hope that policy action begins to take shape this summer.

The Health Association of African Canadians – Student Organization (HAAC-SO)

April 27, 2016 Maria Wilson Leave a Comment

Founders of HAAC-SO, from left to right: Akila Whiley, Michelle Patrick, Leah Jones.

The Health Association of African Canadians – Student Organization (HAAC-SO) was formed by Michelle Patrick, Akila Whiley and Leah Jones in the summer of 2015. Patrick is the Promoting Leadership in Health for African Nova Scotians (PLANS) coordinator at Dalhousie, while Whiley and Jones are both students at Dalhousie Medical School. Throughout the 2015-2016 academic year, this group has been involved in raising awareness of African Canadian health issues. We recently interviewed Jones and Whiley to learn more about HAAC-SO.

Who are the members of HAAC-SO exec?

Kristine Yarney – Secretary (Pharmacy)

Celeste Williams – Faculty of Dentistry Rep (Dentistry)

Cinera States – Faculty of Medicine Rep (Medicine)

Tiffany Richards – Member at Large (Nutrition)

Korede Akindoju – Faculty of Health Professions Rep (Physiotherapy)

Leah Jones – Co-Chair (Medicine)

Akila Whiley – Co-Chair (Medicine)

Michelle Patrick – Liaison to Health Association of African Canadians (Promoting Leadership in Health for African Nova Scotians)

What are the goals of HAAC-SO?

The Health Association of African Canadians – Student Organization (HAAC-SO) is a sub group of the Health Association of African Canadians (HAAC), which addresses African Canadian health issues and the systemic inequities affecting health. The goal of the student society is to bring students together from Dalhousie University, and beyond, to create a community of learning centered on Black health issues, career development and community engagement.

What events has HAAC-SO been involved with during the 2015-2016 academic year?

Since the start of the school year, HAAC-SO has been involved in a variety of events of awareness events, both at Dalhousie University and in the community. Some of these are listed below:

September 2015 – HAAC-SO Kickoff Social, Dalhousie Society and Volunteer Expo (recruiting new members)

October 2015 – Living Library (contributed a human “book” to educate attendees on ANS Health)

November 2015 – Pathways to Education (participated in a Health Education and Nutrition workshop with local youth)

January 2016 – Poverty Inc. screening and discussion at Dalhousie Medical School

February 2016 – Elephant in the Room speaker series, Talk About Health

March 2016 – Screening of Black Mother Daughter at Dalhousie Medical school featuring spoken word from Verena Rizg and Monique Thomas

April 2016 – End of year potluck

In your experiences with HAAC-SO, how have partnerships helped you to achieve your goals?

Throughout the year we have made many partnerships; from the Global Health Office, Human Rights Equity and Harassment Prevention Office and many local activists. This has made it possible to host successful events, by event promotion through their networks and financial support. We are thrilled to have had the opportunity to form these valuable partnerships as we are a new organization just getting off the ground!

Over the course of one year, HAAC-SO has managed to make a significant impact on Dalhousie campus. The Global Health Office can’t wait to see what this hard-working group has planned for next year!

From Dalhousie to Tanzania: An Interview with Queen Elizabeth Scholars Matt Jalink and Keisha Jefferies

April 27, 2016 Maria Wilson 1 Comment

The Canadian Queen Elizabeth II Diamond Jubilee Scholarship Program (QES) aims to build a dynamic community of young global leaders in Canada and across the Commonwealth. Queen Elizabeth Scholars engage in projects both at home and abroad, encompassing international education, discovery and inquiry, and professional experiences. Queen Elizabeth Scholars undertake projects that provide meaningful learning experiences, with the potential to create lasting impact. Dalhousie University has teamed up with its partners in the Caribbean, Uganda and Tanzania to develop an international student mobility project, funded by QES, for current Dalhousie students and students in other Commonwealth countries looking to study at Dal. The Global Health Office manages the relationship between our partner associations and Dalhousie, collaborating with many units across campus, and within the QES network, to make these projects possible.

We recently sat down with two Queen Elizabeth Scholars who are both heading to Tanzania this summer, Matt Jalink (Intern) and Keisha Jefferies (Scholar), to learn about their projects.

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Matt Jalink

Keisha Jefferies

Tell us about yourselves in 30 seconds or less!

Keisha: I’m from New Glasgow, Nova Scotia, born and raised. I went to Mount Saint Vincent University to take a Bachelor’s degree in Biology. I decided I wanted to go into nursing, so after my Biology degree I came to Dalhousie. I worked for two years in the neo-natal intensive care unit (NICU) at the IWK Health Centre. After that, I decided it was time to go back to school and I enrolled in the Master’s of Nursing program here at Dal, and I am currently finishing up my first year. I’m in the health policy practicum as part of that program, so I’m looking to do some work around administration, policies and programming, both at the local and global level. I am interested in maternal and newborn health, which came from my experience working in the NICU. Outside of academics, I love to play basketball and do yoga.

Matt: I’m originally from Calgary, but I moved around a lot when I was younger. I did my undergraduate degree here at Dalhousie in Biochemistry. I had a pretty keen interest in health, but I wanted to get outside of the lab and experience research from a social perspective. This led me to the Master’s of Community Health & Epidemiology program at Dalhousie, which I thought was an excellent fit. I just finished my first year in that program, and I’ve really enjoyed it so far. I’ve completed all of my course requirements, so now I’m focusing on my thesis. I’ll be conducting research on pediatric respiratory tract infections. My interest in pediatrics was fueled by my previous experiences working as a camp counsellor and sailing instructor. In my spare time I’m an avid rock climber, and I enjoy playing pool as much as I can.

What projects are you undertaking in Tanzania this summer as QES interns/scholars?

Matt: I will be undertaking an internship with Pastoral Activities and Services for people with AIDS Dar es Salaam Archdiocese (PASADA). I had a meeting with my preceptor recently where we discussed potential projects. There is a project on tuberculosis and HIV co-infection currently underway, with a number of sites around Dar es Salaam participating in data collection. I will be involved with data analysis, and subsequently writing a report on the findings. I will also be drafting a number of proposals for future research studies that will hopefully begin during my stay. These projects will use qualitative research methods, and will be focused on pediatrics. One of the topics we hope to explore is non-compliance to antiretroviral drugs (ARV), and social factors influencing this non-compliance.

Keisha: I will be working at Muhimbili University of Health Sciences (MUHAS), where there is currently a qualitative study underway looking at nurse midwives’ and physicians’ perspectives on post-partum care in the community and hospital, using a feminist post-structural approach. I may be involved in the analysis piece of that project until it is complete. After that, I will be working on a research proposal related to the mother’s perspective of post-partum care in the community and hospital. That’s all I know at the moment, but my projects might change based on need!

What do you hope to accomplish and/or gain through these internships?

Keisha: I’m hoping to gain research experience. Coming from a practice background, I’m mostly involved with bedside nursing at the moment, so I don’t have a lot of experience in any sort of research (analysis, data collection, etc.). I haven’t done a lot of travel in the past, so I’m looking to gain some new perspectives related to different cultures, and ways of practicing nursing and healthcare. The work I will be doing has significant implications for the way we go about delivering maternal care throughout pregnancy, during the postpartum period, and for women in general. Although the work is focused locally in Tanzania, I think the concepts would be transferable here in Canada.

Matt: Similar to Keisha, I don’t have a ton of experience in research. It will be nice to apply a number of the course-based skills I have gained in a workplace scenario. I’ve always had a really keen interest in Global Health, and I’ve been fortunate enough to do some travelling in past, but any chance I have to travel more and apply my health interest to that is ideal. I love trying to pick up new languages and learn about new cultures, so while I’m there I’m going to try to build on the limited Swahili I picked up the last time I was in Tanzania. Despite HIV having a very prominent spotlight, there are some aspects that aren’t as well explored or researched. There is a fair amount of focus on biological mechanisms, and the pathophysiology of the virus, but my research will take a more qualitative approach. We will look at aspects such as how children born with the virus are living and dealing with a debilitative condition.

What did you do to prepare for this experience?

Matt: Through the Global Health Office there were a number of pre-departure training sessions that were very helpful. These sessions covered adapting to a new culture, living and working in a different healthcare system, and much more. I also took a Global Health course this year with Shawna O’Hearn through the MSc. Community Health & Epidemiology program, which proved very beneficial in learning about different healthcare systems – how to think conscientiously about your practices versus practices in different countries. I have been trying to become as fluent as I can in Swahili, so I can be more of an asset. Having been to Tanzania before is helpful in knowing what to expect when I arrive.

Keisha: Said Msabaha and the rest of the Global Health Office have been extremely helpful throughout this whole process. Like Matt mentioned, the pre-departure sessions were very beneficial. There is also a pre-departure workshop series that I just finished today on BBLearn. I’ve met with a fellow student who is doing her PhD at the University of Ottawa, and has been to Tanzania three times. We had a discussion on what to expect, and she gave me some tips and techniques! She has been involved with some of the researchers that I will be working with, and has been to MUHAS. I’ve also met with a few Dalhousie professors who have travelled to Tanzania to learn more about what to expect when I arrive. The Travel Clinic nurse was also very helpful in getting everything set up.

What do you think describes an effective partnership?

Matt: One key part of an effective partnership is communication – making sure everyone is on the same page. Ensuring you are respectful of each other’s ideas and practices, and understanding that the way you do something isn’t necessarily the way other people do the same thing.

Keisha: Definitely communication, and meeting people where they are. It’s not effective to try and impose your own ideas or beliefs on others. Embracing the differences and diversity that’s already there is key.

Why are you interested in Global Health?

Matt: Global Health combines two things I am really interested in: travel and health. Any opportunity you have to experience another culture helps us learn and grow. There are different practices, traditions, and ways to do things. Looking at health through different cultural lenses really interests me.

Keisha: I would like to become a global citizen and take this opportunity to enhance partnerships and relationships, as well as contribute to global maternal and newborn health. I’m really interested in learning what other people are doing, either differently or similarly, to what we do here in Nova Scotia.

Both Keisha and Matt would like to thank the Canadian Queen Elizabeth Diamond Jubilee Scholarship Program for funding their internships in Tanzania this summer. We wish them the best of luck with this amazing opportunity to grow and learn. Check back with our blog in September for a post-internship update!

The Canadian Queen Elizabeth II Diamond Jubilee Scholarships (QES) is managed through a unique partnership of Universities Canada, the Rideau Hall Foundation (RHF),Community Foundations of Canada (CFC) and Canadian Universities. This program is made possible with financial support from the Government of Canada, provincial governments and the private sector.

2016 Global Health Office Photo Contest Winners Announced

April 19, 2016 Maria Wilson Leave a Comment

The Dalhousie Global Health Office would like to thank all those who submitted photos to our 2016 Global Health Photo Contest, and congratulate our winners Darrell Lewis (1st place) and Pamela Lai (2nd place)! Both winning photos, and their accompanying stories, are featured below. We will be showcasing the rest of our amazing entries on the blog throughout the month of April, so stay tuned! Submissions to the Global Health Photo Contest from previous years can be viewed on our Instagram account.

The 2016 GHO Photo Contest winner: Pediatric Shy-Eye Exam submitted by Darrell Lewis.

Darrell Lewis took this stunning photo in Accra Ghana in 2010. The 2016 Photo Contest winner depicts a mother and her two and a half year old girl during a rural village eye health screening initiative. Lewis has since gone into Ophthalmology Residency at Dalhousie, and cites international outreach as a major motivating factor in his career choice.

2016 GHO Photo Contest runner-up: The Tie of Love, submitted by Pamela Lai.

Our colourful 2016 GHO Photo Contest runner-up was taken by Pamela Lai in Kathmandu, Nepal in 2011. On the day of this photo, it was both a Hindu and secular holiday in Nepal – Janai Purnima (Hindu) and Raksha Bandhan (religious and secular). People from miles away had traveled for days to celebrate this important day in the capital. Mr. Joshi is seen offering new Janai to men, symbolizing their control of one’s “body, sense and mind.” He is also offering new Doro to men, women, and children, as it is believed to provide protection and good luck. The Doro is also used to celebrate the bond between siblings, biologically related or not.

Congratulations to Darrell, Pamela, and all those who submitted pictures and stories to our 2016 Photo Contest. There were so many amazing entries our committee had a tough time choosing two! Best of luck in your future endeavours! To all those passionate about global health and photography, we encourage you to start thinking of potential submissions for the 2017 Photo Contest. You could win awesome prizes, and have your photo featured on Global Health Office social media outlets.

What is Global Health? Towards an Updated, Universal Definition

April 5, 2016 Maria Wilson Leave a Comment

By: Maria Wilson

Global Health Office Outreach Assistant

Global Health is an attractive and high profile field. We encounter global health issues on a daily basis, often without even realizing. In 2014, the West African Ebola outbreak was sensationalized in the media for months, featured heavily on every major Canadian media outlet. Several of the world’s largest charitable organizations – which you may work with, donate to, or benefit from – target global health issues. Poverty and health inequities continue to affect both our local and global communities. Students are being encouraged more and more to engage in international experiences in order to become well-rounded “global citizens.” Global health is all around us.

But what does “global health” really mean? If we asked five experts in the field to define global health, chances are each would provide a different response. Why? Because global health has grown over the years to encompass a variety of ideas and notions, including interdisciplinary cooperation, infectious and non-infectious disease, international development, social justice, food security, maternal and newborn child health, and environmental issues…and the list goes on. Global health is broad in scope, and each one of us may approach our work in slightly different way.

Academics have tried to define global health in past. Perhaps the most well-known and widely accepted definition of global health is that of Koplan et al. from 2009:

“Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide” [1].

While this definition touches on many important aspects of global health like equity, and a worldwide reach, it fails to address the “how.” We can study, research and practice global health, but what are the best ways to engage in our work? How do we find common ground?

I must admit, I don’t have the answers to these complex questions (yet), but I’m hoping that in the near future the global health community comes together to arrive at a solution. Until then, these are questions we should all be cognizant of when we approach our work in global health. Just like Koplan et al. called for the adoption of a common definition in global health in 2009, I am calling for an updated, universal definition of global health in 2016.

Why is it important to come to a consensus on what global health means? As global health continues to grow and become a part of our everyday lives, we must come together to determine a more clear purpose, and path for the future. With everyone working with a common framework in mind, towards shared goals, we will achieve the best outcomes moving forward.

Mobile Outreach Street Health – An Interview with Becky Marval

March 29, 2016 Maria Wilson Leave a Comment

The MOSH van, which acts as a mobile treatment centre for underserved populations in the HRM (Source: GHO Blog, 2012).

Mobile Outreach Street Health (MOSH) has provided accessible primary care services to several underserved populations in the Halifax area since 2009: those who are homeless, insecurely housed and street involved. You may recognize the MOSH van (pictured above), which travels around the community acting as a mobile treatment centre. The MOSH website provides a comprehensive overview of their relationship-based care model, as well as their weekly schedule. In order to learn more about this amazing community organization, we interviewed Becky Marval, who works as an occupational therapist (OT) with MOSH.

How large is the population you serve?

The number of individuals who stayed in a homeless shelter in the Halifax Regional Municipality was 1,973 in 2011 [1]. However, not all those that MOSH serves are homeless, and MOSH does not serve the entire homeless population. According to a 2011 North End Community Health Centre program evaluation, MOSH had an average of 350-400 encounters per month [2].

You work as part of an interdisciplinary team. What members are on that team, and why do you think an interdisciplinary approach is important?

The core team has two full-time nurses, along with a part-time OT (Becky), a few part-time family physicians and part-time “jack-of-all-trades” administrative support. There is also a Housing First branch at MOSH, consisting of team lead EJ Davis and four intensive case managers, with support from an OT and a mental health outreach nurse through a partnership with the Nova Scotia Health Authority.

There are lots of reasons an interdisciplinary/transdisciplinary approach is important. One would be that the folks we’re seeing have complex needs that require different perspectives as well as different personalities. Relationship-based care requires that we have many different options for people, necessitating differences in personalities and skills. We are also able to share and learn from each other because of these different approaches. A transdisciplinary team has overlap and shared responsibilities that aren’t anyone’s job in particular, like handing out food or bus tickets. We also don’t have a social worker on the team, so wherever the scope permits, we stretch our scope as long as it can be ethically stretched in order to help the people we serve in terms of resource navigation. Having an interdisciplinary team allows us to do our work in a more holistic fashion.

What types of services do you provide as an Occupational Therapist with MOSH?

The types of services I provide are pretty broad. Occupational therapy is focused on allowing individuals to perform their activities of daily living (ADLs), like helping them take care of themselves or their apartment, assisting with mobility and transport, coping with chronic disease (both physical and addictions), and helping them find work or schooling. The focus on occupation can also mean helping individuals to determine meaningful things to do with their time, and how to adapt despite various challenges.

As previously mentioned, the role has to be broad because our team doesn’t have other specialist like a social worker or recreation therapist. Another piece of this work is helping to change the environment so it meets the needs of people. This can involve anything from working toward policy changes, to education around common topics that can be troublesome for staff that are trying to help clients, to building a ramp with limited resources to improve accessibility. There are a couple recent MOSH initiatives that benefit the population in innovative ways. The first is matching people with donated bikes, helmets and locks to facilitate mobility. The other is our history project, where people are encouraged to tell their stories. This provides a bit of a diving board for people to see themselves as experts and share their wisdom.

Have you partnered with Dalhousie University before? If so, in what capacity?

We have an established partnership with Dalhousie Dentistry as part of another partnership with the North End Clinic. This involves a dental clinic a few days per week where dental students come and practice under supervision. MOSH constantly has Dalhousie students from a variety of backgrounds doing work and service placements. A lot of student projects look for real life problems and situations, and MOSH can provide them with the opportunity to conduct program evaluations and literature reviews.

What do you think describes an effective partnership?

Aspects that are helpful include communication and mutual regard (respect, trust and awareness of strengths and weaknesses). Things that are not helpful include territoriality, guarding/protection of resources, and only looking out for oneself. Partnerships require similar philosophies, or at least the ability to arrive at a common ground or purpose. Finally, partnerships need to make sense for the target population. With MOSH that means achieving effectiveness with limited resources.

What do you find most rewarding about your work with MOSH?

I find it really rewarding when I’m surprised at how well things can work out. I shouldn’t be surprised anymore, but just when I think we’ve run out of options, it’s very rewarding to find out we have endless possibilities and options to consider! It makes me hopeful, and reminds me there’s no reason to ever give up.

All of us at the GHO would like to thank Becky for taking time out of her busy schedule to be interviewed! If you are interested in getting involved with MOSH by becoming a committed volunteer or by donating, their contact information is available online. For more information, you can also follow MOSH on Twitter.

Health Care Teams Addressing Poverty and Determinants of Health

March 16, 2016 Maria Wilson Leave a Comment

The Dalhousie Global Health Office, in collaboration with the Healthy Populations Institute, The National Collaborating Centre for Determinants of Health and Upstream, hosted the “Health Care Teams Addressing Poverty and Determinants of Health” event on March 3^rd. This event featured three speakers, who shared stories of addressing the social determinants of health in their work, and participated in a panel discussion.

Dr. Hamilton-Hinch, Dr. Forbes and Dr, Meili, our panel for the Healthcare Teams Addressing Poverty and Determinants of Health event.

Dr. Ryan Meili, the Executive Director of Upstream and a family doctor in Saskatoon, shared his experience as both a doctor treating patients in inner city Saskatoon affected by poverty, and as an advocate for health equity. Dr. Cindy Forbes talked about her experiences in advocating for health equity as the President of the Canadian Medical Association. Dr. Barb Hamilton-Hinch provided local context to this global issue, by discussing the barriers to healthcare faced by the African Nova Scotian population. All three speakers had common themes in their work: the need for policy change, the importance of story sharing to drive impact, and of course, the priority of addressing the social determinants of health in healthcare.

Dr. Meili speaking at the Healthcare Teams Addressing Poverty and Determinants of Health event.

Dr. Meili sharing stories from his work with Upstream at the Healthcare Teams Addressing Poverty and Determinants of Health event.

Dr. Meili shared the story of one of his HIV-positive Aboriginal patients who was facing several barriers to proper healthcare access. “She’s not sick with HIV,” Dr. Meili said after introducing us to her story, which was initially puzzling. However, if you take a moment to ponder this statement, it makes a lot of sense. By listening to her story, we learned that his patient has been sick with poverty, historic marginalization, poor living conditions, low education and addictions throughout her life. These factors have contributed to her HIV infection, and subsequent difficulty accessing care. This way of thinking is the fundamental to addressing the social determinants of health, and to the upstream approach. For a refresher on the social determinants of health in Canada, see our blog post from January. To learn about the upstream approach, check out this video created by Upstream, where Dr. Meili acts as the Executive Director. Upstream thinking requires us to reframe the public discourse around addressing the social determinants of health. We should be focusing more resources on the things that have the greatest influence on our health, including income, education, housing and nutrition, rather than pouring our resources into the healthcare system down the line.

Dr. Cindy Forbes, President of the Canadian Medical Association, at the Healthcare Teams Addressing Poverty and Determinants of Health event.

Building a body of evidence, and sharing these findings are both important pieces to guiding policy change. But as Dr. Forbes noted “evidence doesn’t make people feel empathy.” Upstream also aims to share stories through a variety of media in order to creatively engage citizens, showing them they have a personal stake in the social determinants of health. Citizen engagement can lead to a political push for evidence-based, forward-looking policy innovations to address these determinants so people can live longer, fuller and healthier lives.

Dr. Hamilton-Hinch highlighted the importance of not only addressing policy change, but ensuring that power dynamics shift to reflect the diverse makeup of our Canadian population. Dr. Hamilton-Hinch is involved with PLANS (Promoting Leadership in Health for African Nova Scotians) at Dalhousie. PLANS seeks to improve health outcomes within the African Nova Scotian community (about 2.3% of the NS population), while creating mentoring and outreach opportunities. In order to facilitate access to healthcare for African Nova Scotians, Dr. Hamilton-Hinch discussed the need for change in our healthcare system. Change to the way healthcare professionals are educated by challenging curriculum, change to the way healthcare professionals practice in order to reflect cultural proficiency, and most importantly, change in the disparity between the small numbers of African Nova Scotian healthcare professionals and the much larger population they serve.

Dr. Barb Hamilton-Hinch of Dalhousie University, discussing the health of African Nova Scotians at the Healthcare Teams Addressing Poverty and Determinants of Health event.

The Global Health Office would like to thank Dr. Meili, Dr. Forbes and Dr. Hamilton-Hinch for sharing their stories with over 80 attendees. The stories you have shared will go on to impact the way that we approach our learning, practice and advocacy.

World Tuberculosis Day Part III – Treatment & Drug Resistance

March 8, 2016 Maria Wilson Leave a Comment

The World Health Organization (WHO) has declared March 24, 2016 as World Tuberculosis (TB) Day [1]. Over the month of March, the Global Health Office will be publishing a series of blog posts about TB in hopes of raising awareness of its worldwide impact. WHO’s “End TB Strategy” has a goal of ending the TB epidemic by 2030, by targeting poverty, improving testing and treatment, ending stigma and discrimination, and driving research and innovation. Put simply, TB is not yet a disease of the past, but if we unite and focus our efforts, we can make TB history.

Last week we talked about diagnosing TB, and the importance of determining an appropriate treatment course along with that diagnosis. But how is TB treated, and why is drug resistance an issue with TB in particular?

Although those with latent TB infection do not present symptoms, and cannot spread TB bacteria to others, treatment can still be provided to stop them from developing TB disease. This step is important in eliminating and controlling TB around the world, but should only be initiated once the possibility of TB disease has been excluded. In the United States, four treatment regimens are approved, using combinations of isoniazid, rifampicin and rifapentine. Treatment for latent TB can last anywhere from 3 months to 9 months, necessitating between 12 and 270 doses (minimum) of anti-TB drugs [2].

Treating those with active TB disease is a much more pressing matter, as they have the potential to spread the disease to others. Treatment regimens for active TB disease can last between 6 and 30 months depending on resistance, a process which burdens patients and treatment providers alike [3]. With a treatment course this long, some patients inevitably fail to complete the full regimen, for many reasons including finances, social pressures and inadequate access to proper treatment. To provide a glimpse at the financial burden of TB, each case in Canada cost the healthcare system $47,290 [4]. This can lead to acquired drug resistance, which can then be passed on to others when the infected person, coughs, sneezes or spits, releasing TB bacteria into the air [5].

There are two types of drug-resistant TB: multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). MDR-TB bacteria does not respond to (at least) the two most widely used and powerful first line TB drugs: isoniazid and rifampicin [6]. XDR-TB involves resistance to isoniazid and rifampicin, in addition to resistance to any of the fluoroquinolones (ofloxacin, etc.), and to at least one of three injectable second-line drugs (amikacin, capreomycin or kanamycin) [7]. Both MDR-TB and XDR-TB take longer than regular TB to treat (at least 18 months) and have lower treatment success rates. Furthermore, patients often experience more harsh side effects from treatment, leading to increased hospitalization [8]. In order to maximize the potential for positive treatment outcomes, it is important that further tests are undertaken after initial diagnosis to determine whether bacteria is drug-resistant, and provide appropriate treatment [7].

According to the WHO Global TB Report, in 2014 an estimated 3.3% of new TB cases and 20% of previously treated cases had MDR-TB. More than half of these cases occur in India, China and the Russian Federation. Additionally, an estimated 190,000 people died of MDR-TB in 2014. As of 2015, XDR-TB had been reported in 105 countries. The map below shows the number of patients in these countries with laboratory-confirmed XDR-TB who started treatment in 2014 [9].

Map of the world, showing the number of laboratory-confirmed cases of XDR-TB receiving treatment by country, 2014. (Source: World Health Organization).

In response to treatment non-adherence, and to combat the spread of drug-resistant TB, the directly observed therapy, short-course (DOTS) strategy was developed by WHO in 1994. Health workers meet with patients regularly to help with treatment, adherence, and to provide support and education. This strategy also advocates for increased allocation of domestic and international funding and resources to combat TB [10]. Tuberculosis is also highlighted in two recent worldwide strategies, the WHO End TB Strategy, and the UN Sustainable Development Goals (SDGs), which will be discussed in our next post.

World Tuberculosis Day Part II – Tuberculosis Testing and Diagnosis

March 2, 2016 Maria Wilson Leave a Comment

Mycobacterium tuberculosis scanning electron micrograph. Mag 15549X. Source: CDC.

Now that you have an idea of how TB is spread, its symptoms and its worldwide burden, let’s talk about how TB is diagnosed.

When a patient presents with the symptoms discussed in the last blog post (coughing up blood, cough lasting longer than 3 weeks, unexplained weight loss, etc.), a medical history is taken to determine whether TB infection is probable. Questions that are asked include whether they have been in close contact with someone with TB, if they have a previous history of TB infection, and whether they have an immunocompromising condition (such as HIV) that could increase the risk of latent TB infection progressing to TB disease [2].

There are two primary types of tests that are used to determine if a patient has been infected with TB bacteria: the tuberculin skin test and TB blood tests. The tuberculin skin test (also called the Mantoux tuberculin skin test) involves injecting a small amount of fluid (tuberculin) into the skin of the lower arm. After 48-72 hours have passed, a trained health care worker will look for a raised, hard area or swelling, to determine whether infection is present. TB blood tests (interferon-gamma release assays or IGRAs) measure how a person’s immune system reacts to TB bacteria by testing a blood sample in the laboratory. Blood tests are preferred for those who have had a TB disease vaccine, or who would have difficulty returning for a second appointment. Testing positive on either of these tests does not differentiate between latent TB infection and TB disease, it simply means the person’s body is infected with TB bacteria [3].

Diagnosing active TB involves a series of other tests. Chest X-rays can be used to check for lung abnormalities, but X-rays alone cannot provide a definitive TB disease diagnosis. Sputum Smear Microscopy (SSM) is one of the techniques used to diagnose active TB. Sputum is examined under a microscope for Mycobacterium tuberculosis. SSM can provide results in 24 hours, but it cannot always distinguish between TB and other infections. Polymerase Chain Reaction (PCR) testing can be used to detect genetic material specific to TB in bacteria; however, this test is complicated and can be much more expensive than SSM. Diagnosing TB outside of the lungs can include tests such as a biopsy, lumbar puncture, urine culture or CT scan [4].

Culture techniques, where TB bacteria can be grown in a laboratory from a variety of specimens, are also used to diagnose active TB, though it can take 1-6 weeks to obtain results. Culture techniques are particularly useful in determining an antibiotic treatment course, an important step in combatting TB. One of the largest issues in TB treatment is properly identifying and targeting drug resistance in order to provide appropriate treatment, a topic that will be discussed in our next post [5].

World Tuberculosis Day Part I – What is TB?

March 1, 2016 Maria Wilson Leave a Comment

Tuberculosis (TB), caused by the bacillus Mycobacterium tuberculosis, is an airborne disease that primarily affects the lungs (pulmonary TB) [2]. This means that when people with pulmonary TB cough, sneeze or spit, TB bacteria are propelled into the air, giving them the potential to spread from person to person via inhalation. TB can affect other sites as well, including the brain, the kidneys and the bones [3]. An ancient disease, TB has affected humans for over 4,000 years [2].

In many cases, the immune system will fight off the TB bacteria, and no infection occurs. If the immune system is not able to completely fight off the bacteria, some inactive bacteria may stay in the body, leading to latent TB infection (no symptoms). If the immune system does not respond sufficiently, active TB infection occurs (TB disease), and symptoms begin to manifest [4]. People with latent TB infection cannot spread TB bacteria to others, but can go on to develop active TB over time. WHO estimates that about one-third of the world’s population is infected with latent TB [5]. Symptoms of TB disease include a persistent cough of 3 weeks or longer, pain in the chest, coughing up blood or sputum, weakness or fatigue, weight loss, loss of appetite, chills, fever and night sweats [6].

The burden of TB is mainly concentrated in low and middle income countries, where 95% of TB deaths occur. In 2014, there were 1.5 million TB deaths, and 9.6 million people developed TB disease [5]. TB is one of the leading causes of deaths from infectious diseases worldwide [7]. The map below, produced by WHO, shows estimated TB incidence rates, by country, in 2014.

Map of the world showing estimated TB incidence rates, by country, in 2014 (Source: World Health Organization).

This map provides a visual representation of the worldwide burden of TB, with the lowest rates in Western Europe, Canada, the United States of America, Australia and New Zealand. This has led to a common misperception in higher income countries that TB is a disease of the past. However, in many countries, including Lesotho, South Africa, Swaziland and Mozambique, rates are still above 500 cases per 100,000 population [7].

Keep reading our series of blog posts on TB to learn more about risk factors, diagnosis, treatment and much more.

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