While They Were Away: Resident Contributions Abroad

1. While They Were Away:Resident Contributions Abroad

2. Where are the residents traveling?

3. Objectives for International Rotations • Observe and participate in the care of patients • Learn about and evaluate: • Common childhood diseases • Factors that contribute to the high mortality rate of children • Barriers to disease prevention and recognition • Analyze the influence of culture and values on research studies • Complete a site-specific academic project during the elective

4. Today • Ashley Balsam (MP3)Phototherapy/Lightbox Project, Nicaragua • Katie Durrwachter Erno (PL3)Antibiogram Project, Cambodia • Ross Perko (PL3)Medicine Cabinets Project, Uganda • Amanda Webb (PL3)Neonatal Resuscitation Project, Ethiopia

5. Neonatal Jaundice and Phototherapy Boxesin Nicaragua Ashley Balsam, M.D.: 3rd-year Med-Peds Resident JanielleNordell, M.D.: 3rd-year Peds Resident Faculty Mentors: Teri Reid, M.D. and Tina Slusher, M.D.

6. If you build it, they will come.

7. Nicaragua • Largest country in Central America • Bordered by: • North: Honduras, South: Costa Rica • East: Caribbean Sea, West: Pacific Ocean • Second-poorest C. American country • 27% of population suffers from undernutrition, largest % in C. America • 20% of children less than age 5 are CHRONICALLY malnourished • Child mortality 11/100 • 48% live below poverty line, 80% live on less than $2.00/day • Widespread underemployment rate, second lowest per capita income in the western hemisphere

8. Background: Jalapa and Los Pipitos • “Los Pipitos”: Association of children and families of children with disabilities in Nicaragua • Disabilities range from strabismus to mental retardation to cerebral palsy • Many pipitos reportedly “born without complications” and “normal at birth” Clinical question arises: Is there a preventable cause for some of the disability?

9. Neonatal Jaundice Background and Stats • Neonatal morbidity and mortality remain very high in developing countries • Neonatal hyperbilirubinemia remains a leading cause of preventable brain damage, physical and mental handicap, and early death in many communities (BMC public health, 2006)

10. Neonatal Jaundice Background and Stats • Almost all infants develop some degree of jaundice (bilirubin >1), risk determined by level based on nomogram and/or clinical appearance • AAP recommends pediatricians evaluate neonates within 48-72h of discharge to assess jaundice • In Jalapa and many developing countries, many births are not in the hospital, and hospital stay is 8h post-partum or less • Estimated in 2005 that 33% of poor women in Nicaragua have access to a “trained attendant” during and after birth

11. Neonatal Jaundice and Los Pipitos • Could neonatal jaundice be going undetected and untreated? • Could there be a connection between “los pipitos” and untreated hyperbilirubinemia?

12. The Project • Step 1:Discussionwith local pediatricians • “Really don’t have problem with neonatal jaundice in Jalapa” • Not much treatment given, closest place > 2 hours away and expensive travel for the family • Step 2:Clinical assessment and TCB testing of all neonates born in the hospital during our 2-week stay • Step 3:Construction of simple phototherapy box with fluorescent lights for the hospital in Jalapa • Step 4:Educational session for nurses, medical students, residents and physicians about newborn hyperbilirubinemia and sequelae if untreated

13. TCB Testing • Transcutaneous bilirubin monitor used to test 10 babies within 24 -48h of birth • 2 found with treatment level hyperbilirubinemia based on TCB nomogram • Follow-up labs: ABO incompatibility • So we showed that neonatal jaundice is a problem... Now what?

14. The Light Box • Constructed a wooden phototherapy box with 2 banks of lights for treatment • Finished just in time to treat first treatment level jaundice neonate • Resistance to use: the importance of education and discussion

15. Education • Neonatal jaundice presentation for nurses, physicians, and trainees • How to diagnose (clinical, lab exam) • Risk factors • Treatment options • How to use the phototherapy box • Consequences if untreated • And, most importantly: why we care

16. Plans For the Future • How to diagnose jaundice: • Unable to leave TCB monitor for testing • Pediatricians without an intact plan for a follow-up exam • Suggestions/Ideas: • Lab testing for ABO and 24h observation for infants with risk factors? • Education of mothers prior to leaving hospital • Serum bilirubin level for jaundice appearance ($ = problem-- $3.00 for bilirubin level)

17. Lasting Impact? • Accomplishments before we left: • Constructed phototherapy box • Left knowledge of the design • Education on jaundice and plan to disseminate knowledge • The day we left: • OB physician asked for $$ to check serum bili and ABO on 2 recently born infants who she feared would be jaundiced • The week after we left: • Received email requesting funds for a second phototherapy unit • Over the past 3 months • About 10 infants treated • Return trip in July 2010: Meeting planned with local birthing clinic directors (surrounding Jalapa) for education and possible phototherapy box construction

18. Antibiogram ProjectAngkor Hospital for ChildrenSiem Reap, Cambodia Katie Durrwachter-Erno, M.D. and Tara Zamora, M.D., 3rd-year Peds ResidentsFaculty mentor: Stephen Swanson, M.D.

20. Cambodia Location: SE Asia Population: 14 million Ethnic Groups: Khmer (90%), Vietnamese 5%, Chinese 1% Recent History:Foreign occupation, civil wars, Khmer Rouge genocide

21. Health Challenges of Cambodia’s Children 33% under age of 14 Under-five mortality rate: 91 per 1,000 36% of children < 5 yrs moderately to severely underweight 600,000 children orphaned 1 in 7 children will die before their 5th birthdays Source: UNICEF

22. Angkor Hospital for Children (AHC) • Freestanding children’s hospital • Friends Without A Border • All care is free • Cambodia’s only pediatric training hospital

23. Angkor Hospital for Children in 2008 • 113,000 children treated > 300 per day • 2,800 inpatient admissions • 1,360 surgeries performed • Over 2,000 healthcare workers educated • 2,800 homecare visits made • 97% staffed by Cambodians

24. Low Acuity Unit Transition from hospital to home 10-bed ward Patients transferred from inpatient department

25. Homecare Program Serves children with chronic conditions > 200 visits per year by AHC staff Children with HIV/AIDS, malnutrition, and underlying cardiac disease

26. Antibiogram: Background Widespread use and abuse of antibiotics Unknown resistance patterns Limited availability for susceptibility testing Antimicrobial selection based on literature from developed countries

27. Antibiogram Reviewed all bacterial isolates from Jan 1 2006 – Nov 22, 2008 Culture sources: blood, CSF, urine, pleural fluid, wound (tissue, pus) AHC Microbiology Lab supported by Wellcome Trust-Mahidol University Oxford Program in Bangkok

28. Antibiogram: Data Analysis and Cleaning Eliminated from analysis: Duplicate culture results from same patients Rare bacteria Gram negative Bacilli and Streptococcus not fully identified by species

29. Antibiogram: Results Remaining bacteria: 556 gram positive organisms 574 gram negative organisms

30. Antibiogram : Angkor Hospital for Children

31. Antibiogram : Angkor Hospital for Children

32. Antibiogram : Angkor Hospital for Children

33. Antibiogram : Angkor Hospital for Children

34. Gram Positive Organisms

35. Gram Negative Organisms

36. Antibiogram: Limitations Results may be biased towards more resistant bacteria Many patients have negative cultures due to prior antibiotics Hospitalized patients Cultures not always obtained Important antibiotics not always tested

37. Improving Health Care Limitations of in vitro susceptibility testing Previous use of gentamicin for treating Staph aureus Role of the antibiogram changing clinical practice

38. Sustainability • Only antibiogram with pediatric data in Cambodia • Used on wards • Continues to be updated

39. Ar kun (Thank you!)

40. Medicine Cabinet Use in Ugandan Orphanages Ross Perko M.D., 3rd-year Peds Resident Faculty Mentor: Troy Lund, M.D., Ph.D. with Rachel Perko, R.N. and Margaret Perko, M.S.I.

41. Faculty Sponsor: • Troy Lund M.D., Ph.D. • U of MN Peds BMT • Ugandan Colleague: • Angella Kabatooro, M.D. • 2002 census data: • 18 yrs or less = 56% of pop • 15 yrs or less = 49% of pop • 13.7 million children • 1.8 million orphans • 13% orphaned • 1% increase from 1991 • Causes of death in this orphan population: • Diarrhea • Dehydration • Lung infections • Malaria

43. Pilot Study • Supply basic, in-home, medical supplies • Orphanages with NO established formal medical care • 3 separate orphanages • Standard “medicine cabinet” contents • Initial quiz to “orphanage mothers” • Teaching of the contents and review of the quiz, follow • Assess effectiveness of the cabinet and the education over time • Quiz ?’s focus on, fever/infection, diarrhea, dehydration, ORT, wound care, signs of illness

44. Medicine Cabinet Contents • Hydrogen peroxide • Ibuprofen • Diphenhydramine • Clotrimazole • Bandages • Antibiotic cream • Thermometer • Acetaminophen • Oral rehydration pkts • Hydrocortisone • Medical tape • Gauze pads • Measuring cup

47. Conclusions • Tremendous need! • Education is required and will improve quality of initial care • Future • Follow up • Re-testing • Medication supply • Enroll more orphanages

49. www.medicineforsickkids.org