tag:blogger.com,1999:blog-66371901956447116892024-02-20T02:15:53.175-07:00Helping Children in Haiti and Nicaraguawlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.comBlogger156125tag:blogger.com,1999:blog-6637190195644711689.post-33472544161581857912016-03-11T07:21:00.002-07:002016-03-11T07:23:07.530-07:00Zika Virus Infection<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: "arial" , "helvetica" , sans-serif;">During my recent trip to Haiti I was bitten by a mosquito that carried Zika virus and I developed clinical symptoms.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">On the day after Christmas I woke up with a generalized rash. The rash was on my chest, back, arms, and legs. There was no rash on my face, palms, or soles. The rash consisted of small flat irregular-shaped spots less than 5 mm in diameter. My skin felt a bit itchy.The whites of my eyes were red (conjunctivitis). I had a headache and felt a somewhat achy generally. I otherwise felt well and I worked that day and the next.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The rash and the red eyes lasted about a week. I measured my temperature every night for the first 3 or 4 nights and the highest I recorded was 37.8 degrees.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I did not have a sore throat, runny nose, or cough. I did not have specific pains in my large or small joints.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">During the day before the rash developed (Christmas) I had two watery poops and after the second liquid poop I decided to take Cipro just in case this might be the start of a bacterial gastroenteritis. My poops stayed fine thereafter. I have never taken Cipro before and when the rash developed the next day I wondered if perhaps this might be a</span><span style="font-family: "arial" , "helvetica" , sans-serif;">n allergic reaction to the antibiotic.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The rash and the other symptoms slowly resolved over about a week and during this time I decided the rash was either a viral infection or an allergic reaction to the Cipro.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">After I returned home I had blood, urine and poop tests done, and I had a TB skin test. I routinely get checked out when I return from working abroad. My sedimentation rate test (ESR) was elevated and this suggested inflammation somewhere in the body. This test does not imply a specific infection or disease. The other tests were normal.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">By the time the lab results were available the rash and other symptoms had long resolved but I was keen to track down the cause. By this time Zika was in the news and my reading from the Center for Disease Control suggested this was a likely cause for the symptoms. I had another blood test to look for Zika virus and for other viruses that might cause the symptoms. These tests take time. In early March I was notified that my Zika virus IgM studies were positive. IgM is an antibody protein that increases after a recent infection with the virus. This test implies my symptoms were due to Zika virus.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">I had done my very best to avoid insect bites in Haiti. I set up a mosquito net and I routinely slept under the canopy every night. I was careful to tuck the net in around the bed. </span><span style="font-family: "arial" , "helvetica" , sans-serif;">The mosquito that transmits Zika virus usually feeds (bites) during the daytime.</span><span style="font-family: "arial" , "helvetica" , sans-serif;"> I left for work at dawn and was usually back in the dormitory at nightfall. I wore long pants, shoes with socks, and a t-shirt. My arms, neck and face were therefore exposed during the daytime. I did not see mosquitoes in the hospital but I did see a few in the dormitory. I do not recollect a bite.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Even though I saw very few mosquitoes, and even though I took good precautions, I was still bitten and infected with Zika virus. Based on this, my sense is that infection with Zika Virus is likely inevitable for travellers to endemic areas. If the virus is proved to cause congenital malformations, this is indeed a serious public health problem for pregnant women.</span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Zika Virus was first discovered in 1947 and until recently was only reported in tropical Africa, Southeast Asia, and the Pacific Islands. In May 2015 the Pan American Health Organization (PAHO) confirmed the first case of Zika virus in Brazil and on February 1, 2016 the World Health Organization (WHO) declared Zika virus to be a public health emergency of international concern. </span></div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-34245917160168123332015-12-27T12:41:00.000-07:002015-12-27T12:41:00.164-07:00My Mother's Stories<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial; font-size: 18.0pt;">My mother's
family was very poor. Her Icelandic mother did not speak English and her
Scottish father did not always have work. When I was a little boy, my Mom often
told me stories that I could not believe. I could not fathom the poverty she
described. My Dad had a very good job and we were certainly not poor and there
was no poverty I could see in Calgary. However, my Mom was one of seven
children who were born during the years from World War One through the Great
Depression. They did not have enough money for anything. There was no money for
food, for shoes, for schoolbooks, or for medical care. Mom told me they often
survived on bread, fat drippings, and salt. She left school to work after grade
seven. One memorable story is that after my Mom cut her thumb seriously with a
knife, her mother was obliged to take her to the doctor to have the thumb sewn
back together. As my Mom describes the situation, her mother alternately cried
and screamed in Icelandic all the way to the doctor because the family could
not afford to pay the medical fees. Because of the accident the family did not
eat for a few days.</span></div>
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<span style="font-family: Arial; font-size: 18pt;">My mother
has been in my thoughts a lot during this trip to Haiti. The families in Haiti
are likely even poorer than my mother's family, but maybe not. Many children in
Haiti cannot afford school and this reminds me that my mother's education was
cut short. When I purchased three pairs of shoes for my interpreter I thought
of my Mom without shoes as a little girl in Vancouver. Many remark that there
is a circle of life. This can mean many things. I think there are many circles,
and in a strong sense, this trip helped me to complete a circle started with my
mother's stories.</span><span style="font-family: Arial; font-size: 18pt;"> </span></div>
</div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-10368234275674534472015-12-26T12:39:00.000-07:002015-12-26T12:39:07.757-07:00The Little Girl and I Both Exhaled<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial; font-size: 18.0pt;">For the
last week I have cared for a 2.5 year-old girl with pneumonia. She had only
mild respiratory distress on admission. Pneumonia is one of the most common
diagnoses on the paediatric ward. Most of these children respond well to an
antibiotic, hydration, oxygen, a drug to open up the lungs, time, and the
resilience of the human body.</span></div>
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<span style="font-family: Arial; font-size: 18pt;">The initial
x-ray on the little girl showed pneumonia in her right lung and the pattern
implied a bacteria rather than a virus. She was admitted by the Head of
Paediatrics and treated with the usual first line antibiotic available at the
hospital. On the third day she got worse and notwithstanding a change to the
usual second line antibiotic, she continued to get worse. On the fifth day I
was very concerned and shared my concern with the person in charge of the ward.
She looked very tired and "toxic," the way critically ill children
look. My sense at that time was that she might have a collection of infected
pus (empyema, lung abscess) in her lung. Until an abscess is drained, even the
correct antibiotic will not work. I repeated the x-ray and to my eyes the image
suggested that a collection of pus was likely. The x-ray images at this
hospital are not as good as in Canada and the technician was not able to
accomplish the views I requested to localize the pus. Since I am not a lung
x-ray expert, I could not be sure. Still, I thought this was the likely
diagnosis. I talked this over with the head physician but she did not agree.
She recommended another antibiotic change. The third and even a fourth
antibiotic did not make any difference. I repeated the x-ray on the sixth day and
this time, the head physician agreed with my diagnosis. I found the surgeon and
made sure he saw her early in the morning. He asked for another x-ray (no idea
why) and I made sure this happened early in the day. Once the x-ray was done I
found the surgeon and took him to see the x-ray. I have learned to be
persistent to insure that anything urgent is done. If I had not personally
"driven the system," the x-ray might not have been done until later
in the day, by then the surgeon would have finished his holiday rounds and gone
home, and an entire and perhaps critical day might have passed. My persistence
paid off and the surgeon agreed to operate the same day. I attended in the OR.
The surgeon placed a chest tube and drained some bloody pus. My relief to
witness the pus drain out of her lung was a Christmas present, both for the
little girl and for me. Back on the ward, for the first time in a week, I could
hear air entering her right lung.</span></div>
</div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-18466357913293573822015-12-25T15:25:00.000-07:002015-12-25T15:25:03.456-07:00Christmas Day <div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The Mellon family is an ongoing legend in Deschappelles. Everyone
has a Mellon story and they are all positive. The original Dr. and Mrs. Mellon
had compassion, a vision, and the financial resources to make things happen. Their
descendants continue to encourage the original vision. I do not know anything
about the current financial support but I imagine the annual cost to support
the hospital is considerable. Kudus to the Mellon family. Well done!</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">H</span><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">ô</span><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">pital</span><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"> Albert Schweitzer shows signs of age
as everything does over time but there are ongoing renovations and refurbishing
of the various facilities. Today I saw men preparing the hospital entrance for
new paint. The climate is harsh. The salt water rusts the metal. The sun and
the humidity degrade the wood.</span></div>
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<br /></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">When built, the hospital must have looked like a palace to
the citizens. You can feel the grandeur of this place. For the time, the
facilities were likely "state of the art." Notwithstanding the daily
press of illness through the doors, the facility still functions very
well.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The grounds are well landscaped. I read that Haiti had no
trees because the people cut them down for fuel. Not so here. The trees and
shrubs have been well tended and nurtured. The poor and the sick at least look
out over the verdant lushness of their native land. The flowers and the music
are the happy things about Haiti.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">One of the overwhelming aspects of this trip has been my
isolation as literally the only white face in a sea of poor and sick black
faces. My previous trips to Haiti were with teams of white physicians, nurses,
and other medical personnel who worked alongside the Haitian personnel. I
expected to see white faces here. This was intimidating at the start but feels
much less so now as I end my stay.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The eleven consecutive days I have worked on in the hospital
has been just enough for me to figure out how this works, or doesn't work. The
nurses and physicians have been very patient with me. Thank goodness for the
interpreters.</span></div>
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<o:p></o:p></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-7652502761791022542015-12-24T13:29:00.001-07:002015-12-24T13:29:18.767-07:00Christmas Eve<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The hospital feels deserted. The hallways are empty of
stretchers. There are empty beds in the wards.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Disease does not take time off for any holiday but the
inpatient census goes down over Christmas all over the Christian world. The
walking wounded return home to their families.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">I did my share and discharged three children this morning.
The three infants were all improved and ready to go even if this were not
Christmas Eve. Some of the children live a long distance away and there is no
efficient transportation. Sending a sick child home prematurely might be a
disaster.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The mother of the sickest child that I follow, a 2.5
year-old girl with very serious pneumonia, told me her husband is coming and
they want to take the child home. This is her right, but I suggested she should
keep her in the hospital. Today, for the first time, her fever is down and a
blood test showed modest improvement. She is still very weak. Apart from
treating children with cystic fibrosis, I do not recollect a sicker child with
pneumonia. I am happy her temperature is down but the x-ray shows that her
right lung is not contributing much at all to her breathing. She needs oxygen.
She cannot tolerate oral feedings. She is on three intravenous antibiotics. If
the parents stop the oxygen and antibiotics, I do not think she will survive
long. The Mom is very discouraged. She has been in the hospital a week. The
little girl is modestly malnourished. She was sick but looked better during the
first two days in hospital and then she got much worse. The antibiotics were
changed twice and the last change seems to have made a difference. Over the last
36 or so hours she has started to slowly improve. I hope they don't take her
home.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Since the clinic is closed today I went with Renold, my
interpreter, to the market. I asked if I could purchase something for his three
children. He picked out three pairs of shoes, which don't look like much, but Renold
was very happy about this gift. His wife died from hypertension seven years ago
and his mother has also passed on. His 80 year-old father was formerly a cook
for the hospital and he still lives with them.</span></div>
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<o:p></o:p></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-72275865977573950122015-12-23T15:23:00.000-07:002015-12-23T15:23:03.670-07:00So Many Absurd Situations<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The patients who arrive in the outpatient clinic often wait
for hours to be seen but without any good reason. The child is there. The
physicians are there. But the clinic nurse does not give the chart to a
physician. I keep asking the interpreter to ask for a chart but I cannot seem
to make this process speed up. There is an inherent slowness to the system. No
one seems to be concerned. The patients wait in silence. I do not understand
this.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Today I saw a three month-old baby brought in by a mother
whose breast milk stopped 8 days ago. She has been giving the baby soda pop for
food. I wrote a prescription for formula and she will be able to get this for
free.</span></div>
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<br /></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">I did not see a child who was brought to the clinic by a
friend of the mother. The child was in hospital a few weeks ago and asked to
return for follow up. The requested follow up was for yesterday but the family
could not come. Instead they sent the child today. The hospital number on the follow-up note was
wrong by one digit so they could not find the chart. I sent the interpreter to
help but he said nothing could be done. I took the note to the paediatric ward
and asked the clerk to look up the child and we found the correct number. The
child went back to administration for the chart but they refused to allow the
child to be seen because the child was not with the mother. I do not understand
this.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">A man who spoke good English asked me to sign a note
so his child could be assessed in the clinic today. I signed the note. Later I
saw the child with the mother. The mother looked very well turned out. This is
not your usual poor Haitian family. The story was fever every night since
November 30th. The mother was very specific. The fever started exactly 23 days ago and has continued every night. The child is otherwise well. The boy is happy and he eats, plays, and sleeps fine. He has no other
symptoms except fever. The six year-old boy had a completely normal physical
exam. I could find nothing wrong. I think the parents wanted a check up by the
Canadian doctor.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Mothers are obliged to take their child to the lab or x-ray
to have these procedures. They are also obliged to go to the pharmacy to pick
up oral medications. My job is to fill out a requisition or prescription and
give this to the nurse who explains the process to the mother. The mother is
supposed stop by at hospital administration for the requisition or prescription to be officially stamped. About a quarter of the time the mother returns to say
they were not allowed to have the test or to be dispensed the medication
because there was no official stamp. This is a daily frustration. I cannot
fathom how the communication breaks down so often. I do not understand why
these forms are not stamped on the ward.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">There are no bathrooms on the ward for the children or
parents. The older children sit on pails to poop or pee.</span><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"> </span><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">There is a very public bathroom by the
entrance. Mothers take naked sponge baths in this open bathroom. Modesty is a luxury that these poor people cannot afford.</span></div>
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<o:p></o:p></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-69826211871069685522015-12-22T16:33:00.001-07:002015-12-22T16:33:33.067-07:00Misery Begets Misery<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The parents of the children are tired, sad, and worried. The
mothers keep a mostly silent vigil by the bedside. I see resignation in their
faces. When I ask them if they have any questions, they hardly ever do. I asked
Renaldo, my new interpreter, about a song I heard the mothers signing. The song
is common he replied. The main lyric, repeated many times is, <i style="mso-bidi-font-style: normal;">I don't need to worry because God is with me</i>.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Today, to make a sad day of suffering so much worse, a
mother dropped dead in the hospital. She was 15 years old. This was quickly a
hospital-wide event. People congregated in the hallway to see what had
happened. You could not walk in the hallways. Movement stopped much like
highway traffic does when there is an accident to witness. Humans seem unique
in our curiosity about injury and death. I presume this is because that while we
understand our mortality, we do not know how this will present. Death is a
compelling personal mystery.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">People started to shout. Rumours circulated about the death.
My interpreter wanted to share the gossip with me but I told him I did not need
to know. Likely no one will really know what happened. Later, in the middle of
the afternoon I passed her shrouded body. She was alone. At end-of-day rounds
there was no one by the crib of the baby who lost her mother. I passed the
shrouded mother again on my way out of the hospital, but this time she had
a modest retinue of people with her.</span></div>
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<o:p></o:p></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-42445288733420456692015-12-21T16:02:00.000-07:002015-12-21T16:02:03.690-07:00Time Warp<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">I entered a time warp, two time warps in fact. Must be a Star Trek thing. Perhaps I fell though a worm hole and I am now in a parallel world. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The first time warp is very familiar and takes me back to
1973 to 1979, when I was a young resident at Sick Kids in Toronto. At that time
my job was to see my patients in the hospital, talk to the parents and
children, write orders, review the orders with the nursing staff, follow up on
lab and x-ray results, and then reassess the patients at the end of every day.
This feels a lot like my time as a resident.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The second time warp is totally unfamiliar. This time warp
goes back before my time as a doctor. Ostensibly, this time warp has transported me to well before my training, before immunizations, and to the dark ages of health care in Canada when medicine was not socialized and when health care was not accessible to every citizen as a right.</span></div>
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<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Today I admitted two very sick children from the outpatient
service. I had just returned from a quick lunch. The next two children
presented with acute infections that I have never seen before. Since I am older
and have seen a lot, for me to see two brand new infectious diseases
back-to-back is nothing short of amazing.</span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The first patient is a 6 year-old boy with tetanus. Tetanus
disappeared from Canada before my time. Routine immunizations made this happen.
I had presumed that I would never see a case of tetanus. Go figure. The boy cut
his leg on a metal gate 8 days ago and today he presented with spasms of his
muscles in the typical fashion of tetanus. He has "lock jaw!"</span><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"> </span><span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Fortuitously I had reviewed tetanus a few
weeks ago. "Why not," I thought. Glad I did. There is good and bad
news for this boy. He came in early with the symptoms and the neural toxin has
not spread very far. The bad news is that there is no Tetanus Immune Globulin
(TIG) in the hospital. This makes a bid difference to neutralize the toxin. All
I could offer today was an antibiotic to kill the remaining germs. The toxin
already present will continue to cause neurological symptoms. I went to the
pharmacist and asked about TIG. He confirmed there is none. I asked if we could
obtain some in Port-au-Prince. He replied that he did not know but that the Medical Director, Dr. Sannon, would know. I tracked down Dr.
Sannon and he agreed to find out. Cost is likely an issue.</span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The second patient is a 3 year-old boy with mastoiditis. I
have looked for mastoiditis all my life because early in my career this was
still a possible diagnosis in Canada. Since immunizations were introduced for H. influenzae and S. pneumonia, the most common causes of mastoiditis,
the problem has become even less common. The boy today had classic mastoiditis.
I treated him with IV antibiotics and asked for the surgeon to see him. He
might need the infection drained. </span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">My academic interest is piqued but mostly my heart is saddened to see these serious but very preventable diseases. </span></div>
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<o:p></o:p></div>
</div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-17006378924491229232015-12-20T12:20:00.004-07:002015-12-20T12:20:53.975-07:00Sounds of Haiti<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Every day at least one church group visits selected children
in the paediatric ward. The minister shouts and screams. He sounds angry. I
think he is exorcising the illness that "devils" the child. Then the minister and
his followers sing. I enjoy the songs.</span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Inside the hospital there are large signs in every area with a picture of a Haitian nurse
with her finger over her lips. The word "Silence" is written in very
large font at the bottom of the sign. The sign makes good sense but the people
are not silent. How could they be with so many people crowded into so small a
place? In the paediatric ward there five rooms that each hold 15 to 20 children
and their families, packed cheek-to-jowl around the outside. The rooms are the
size of an ordinary living room in a Canadian home. There is not enough room to
walk between the children. The parents sleep on the floor or sit and rock their
child. Mostly I examine a child while the mother breastfeeds. She has the child
in her lap and I kneel on the ground to do the exam. Kneeling is a gesture of
supplication, as with genuflecting to acknowledge the power of a God. In my
case, my posture acknowledges the power of poverty and misery. I am certainly
humbled.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxwSfX04oNFZXdB3LGx-5FtU9d1xfO0tYwrdAVbmN1FsAAbYaitRclWIbDO5_JfGDKlWrSEQfLelM1SXDXA6mUonK_xxJp3z5VIuJi0yeq9LSM3mgn6LMgqPL6pUjvodEOF7CU5ouFP-AG/s1600/IMG_0097.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxwSfX04oNFZXdB3LGx-5FtU9d1xfO0tYwrdAVbmN1FsAAbYaitRclWIbDO5_JfGDKlWrSEQfLelM1SXDXA6mUonK_xxJp3z5VIuJi0yeq9LSM3mgn6LMgqPL6pUjvodEOF7CU5ouFP-AG/s400/IMG_0097.JPG" width="400" /></a></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">While I am in the building where I sleep, a baby goat bleats
about every hour or so and periodically the animal bleats continuously ten or
so minutes. Until now I never realized how similar the bleat of a baby goat is
to the cry of a human baby. Likely the bleat and the cry are for the same thing;
to be fed, to be cuddled, to be loved.</span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Dogs race around the compound. Overnight and occasionally
when I am around by day, I hear dogfights. I presume the fights are
territorial. There are clearly coveted spots to rest; usually soft earth
without stones and in the shade of a tree. Since the dogs are not vaccinated, I
give them all a wide berth.</span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><br /></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The other common sound is the roosters who crow mostly at
dawn but over the entire day.</span></div>
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<br /></div>
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">In the
evenings there is singing in many of the homes that are close the building I sleep in. The songs have a religious
cadence. One person sings a line and then there is a chorus of people who
respond. Often the same line is repeated over and over again, as many a dozen times. Still, the music
is pleasant.</span><!--EndFragment-->
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Elections are ongoing in Haiti. There are trucks with loudspeakers that extol the virtues of one of the candidates.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">One sound that is uncommon is the sound of spoken English. I have only seen five other white faces since I arrived. </span><br />
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-72112051835564764462015-12-19T10:47:00.001-07:002015-12-19T10:47:03.859-07:00Day five<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Arial, Helvetica, sans-serif;">Saturday, so no outpatient clinic, but not as many physicians for the hospital service. Dr. Touissant, the head of Paediatrics phoned me today from Port-au-Prince to advise he is on official leave to marry and a well deserved vacation from his regular onerous duties. I congratulated him. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Dr. Isadore and I managed to cover the inpatients in about five hours. She did about 75% of the children. I don't seem to be able to take less than 15 minutes for any one patient. I saw about 20 and she saw many more. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The boy with meningitis is better this morning. He is apparently a good student and his only question for me was whether the meningitis would make it hard for him to do well in school. My sense is that if he is smart enough to ask this question, then everything will be ok. His hearing however might not come back. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">I "created" a social problem. Gerard, my interpreter is poor. I have had him back to the place where I sleep and shared my lunch with the him on two days last week. This is apparently against the rules. My sense was that the ladies who cook always make three times as much as I can eat and that Gerard should be able to eat too. Apparently not. This became a big problem that involved the Head of Paeds, the Medical Director of the Hospital, and Junior, the Visitor Coordinator. I offered to pay for Gerard to eat with me and this seemed to be possible ($10 per lunch, which does not make sense), but in the end Gerard refused. He thinks he will get in trouble with the Medical Director and might not get more work as an interpreter. I understand. Too bad.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The photo below shows how much the ladies make me every day for lunch. I always leave most of the food. Too bad. The table that day was set for two so Gerard could eat, but he never came. </span><br />
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-81041544435283002542015-12-18T15:22:00.002-07:002015-12-18T15:22:14.370-07:00Day Four<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: arial, helvetica, sans-serif; font-size: large;">Now that I understand the routines, the work seems more straightforward. The day flies by with lots of patients. </span><br />
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<span style="font-family: arial, helvetica, sans-serif; font-size: large;">I took on four new patients today and discharged two. I see problems that are no longer seen in Canada because we have such a good immunization system. For instance, today one of the new patients is a 10 year-old boy with bacterial meningitis. This problem is now rare in Canada. Worse, the boy already has hearing loss in his left ear. Ouch! This usually means the hearing will not come back in that ear. He was very sick this morning and less sick late this afternoon.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif; font-size: large;">The photo above shows my sleeping arrangements. The mosquito net above the bed fell onto me the first night and I replaced this with the mosquito net that I brought. The room is clean. The bed is flat and firm, which works for me.</span></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-72820402034145477822015-12-17T15:51:00.001-07:002015-12-17T15:51:05.126-07:00Day Three<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">Today I asked Dr. Toussaint if I could take over the care of children in one of the five major rooms on the paediatric ward. He was OK with that. During the first two days I accepted care for about half and tomorrow I will start early at 7 AM so that I can review and take over care for the other half. The children in this room are infants and toddlers, most with infectious disease problems. I believe I can handle the ten children in this room. The severity ranges from getting ready to go home to one who almost died last night.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The child who almost died is 4 months old, was admitted with pneumonia and anemia 10 days ago and deteriorated after a blood transfusion the night before. The child is working very hard to breath, doesn't move much, and is still in a precarious situation. I checked up on this child multiple times over the day and revised the IV orders and thankfully the child was a bit better by the end of the day, which is encouraging. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The photo above shows my desk in the paediatric outpatient clinic. This clinic is outside and much cooler than the inpatient sweatshop. There are flowering hibiscus and bougainvillea surrounding the clinic, which makes this a very pleasant place to work. The better chairs are chained to the table to avoid theft. The metal chairs can be moved around and make a terrible screeching sound when dragged over the concrete floor.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The Mellon family founded Hopital Albert Schweitzer and the family still plays an active role in the hospital. Today was the annual Christmas luncheon for the hospital staff. I dropped by for about 10 minutes and met Mrs. Mellon who hosted the event. I enjoyed a coke and then returned to check on the sick child. </span><br />
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-12146732289116431952015-12-16T04:01:00.000-07:002015-12-17T15:26:48.286-07:00Day Two<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: "arial" , "helvetica" , sans-serif;">Very different day. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The inpatient service is much the same. Busy and noisy. The acoustics in the hospital are terrible. The walls and floors are concrete and the fixtures are metal. There is nothing to absorb the sound except the families, who are social and talk a lot. Sometimes the families are not so social. Last night a fight broke out on the ward and security had to intervene. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The halls are crowded with patients on stretchers because the rooms are full. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">During end-of-day rounds a church group visited every room on the ward. They danced and sang religious songs. </span><span style="font-family: "arial" , "helvetica" , sans-serif;">Many parents have a bible by the bedside. Religion is a very important part of this culture. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Gerard, my interpreter, continues as a great help. I learned today he has five children and no regular job. His work as an interpreter is sporadic. He really appreciates this work. Like every man he wants to provide for his family. I am advised that the wage for an interpreter is $10 per day. During my first visit to Haiti in March 2010, the NGO I worked with paid the interpreters the same amount. The poor wages have not changed in six years! Gerard looks chronically tired and often puts his head down to rest between patients. </span><span style="font-family: "arial" , "helvetica" , sans-serif;">Yesterday after lunch I noticed that he ate two hard candies.</span><span style="font-family: "arial" , "helvetica" , sans-serif;"> Curious, I inquired if that was his lunch and he confirmed it was. Ouch! Today he came back to the house and ate with me. He ate at least three or four times as much as I did. He was very hungry. This worries me. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Gerard tells me that life was better under the Baby Doc regime! At that time, notwithstanding the dictatorship and the political oppression and corruption, there were at least jobs available and men could provide for their families. There was money for food. Now, he explains, there is only "misery." I certainly see the despair in the families in the hospital.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The outpatient service today was quiet and I was able to see my share of children. No one was seriously ill. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">A very young looking Mom brought in her one week-old baby. The Mom looked 14 but told Gerard she is 16 years old. She presented as overwhelmed by motherhood and breastfeeding. The baby looked fine but unless Mom can sort out the rhythm of breastfeeding, the baby will not thrive. She will come back in two days to be weighed. I reviewed breastfeeding basics with the Mom and watched her feed to insure she has the basics of position and latch. She and the baby live with the maternal grandmother, which is positive. There are no breastfeeding nurses in the hospital. Mother nature, my advice, and grandma will have to do.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Half of the inpatient service are infants less than one or two months of age. Prematurity is common, likely due to less optimal prenatal care. Malnutrition is common. Most of the babies are admitted with sepsis. </span><br />
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-87255599642206120232015-12-15T16:04:00.000-07:002015-12-17T03:40:08.658-07:00First Day <div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: "arial";">Without two prior trips to
Haiti, this first day might have been overwhelming. Nothing like experience!</span></div>
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<span style="font-family: "arial";">Hôpital Albert Schweitzer
has a very dedicated and small medical staff for the number of patients. Back
in the "dark ages" during my fellowship at Sick Kids in Toronto,
there were substantially more physicians per inpatient. That was 40 years ago!<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "arial";">Hard work, organization, a
dedicated support staff, and spirit compensate for the lack in medical staff.
I'm impressed. <o:p></o:p></span></div>
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<span style="font-family: "arial";">The day starts with teaching
rounds at 7 AM. Today the topic was Benign Prostatic Hyperplasia - a urology
topic. Go figure!<o:p></o:p></span></div>
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<span style="font-family: "arial";">From 8 AM, the children
admitted to hospital are reviewed. Today there were five physicians - the head
of paediatrics, a family physician who works full time at the hospital, two
interns who spend one month in paediatrics, and me.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "arial";">I have the most experience
or the least, depending on the patient and the perspective. I have only modest
experience with the culture, the language, and the various tropical infectious
diseases. However, if you add up my years of paediatric experience, I have more
than all the other four combined! They are all very young!<o:p></o:p></span></div>
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<span style="font-family: "arial";">Fortune smiled on me for my
first patient. The prior night a 6 year-old boy was admitted with generalized
swelling and heart failure. The swelling and heart failure is due to
glomerulonephritis, a kidney problem. Nice to start out with a problem in my
specialty!<o:p></o:p></span></div>
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<span style="font-family: "arial";">I am slower with the
inpatient assessments because I needed to learn how the system works. As well, the
medical chart notes are written in a mixture of French or English. My ability
to read medical French is OK and physician handwriting being what it is; the
language difference is not a big deal. My interpreter could not read the French
notes any better than I could read the English!<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
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<span style="font-family: "arial";">My interpreter, Gerard, has
good experience at the hospital and he is very helpful. Thank you Gerard. <o:p></o:p></span></div>
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<span style="font-family: "arial";">And so it went for three
hours in the hospital. <o:p></o:p></span></div>
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<span style="font-family: "arial";">From 11 AM, four of the
docs, including me, saw patients in the outpatient clinic. Only about 45
children were assessed and again I was the slow poke. I only saw 7 of the
children, which implies the other three docs each saw about 12 patients. My
assessments got faster as the afternoon progressed. <o:p></o:p></span></div>
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<span style="font-family: "arial";">The medical problems at the
outpatient clinic were similar to what a paediatrician might see in the office
in Canada. Bronchitis, pneumonia, ear infection, anemia, and so forth. Nothing
complicated today. <o:p></o:p></span></div>
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<span style="font-family: "arial";">Later in the afternoon the
head of paediatrics was called to attend an emergency Cesarean section for
fetal distress. The baby did not cooperate and breathe for the first 1 to 2
minutes, which was tense. Everything worked out pretty well with some suction
and bagging with oxygen. <o:p></o:p></span></div>
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<span style="font-family: "arial";">At 4 PM the docs make rounds
on every patient in the hospital. This was not a very thorough round, but the
head of Paediatrics is on call and he knows them all very well. He is very
capable and confident. He is the major reason why the unit functions so well
notwithstanding the limited number of physicians. He knows his paediatrics and
would do well in any North American hospital. <o:p></o:p></span></div>
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<span style="font-family: "arial";">Once the night orders were
written, I left in the dusk for the house where I eat and sleep.</span><br />
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<span style="font-family: arial;">Each day will be much the
same but I will get better and faster and hopefully by the end of my stay I
will be able to keep up with the rest.</span></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-53506627205465688212015-12-14T12:00:00.000-07:002015-12-14T12:00:01.485-07:00Finding Common Cause<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: "arial" , "helvetica" , sans-serif;">To reach Haiti I need to fly in three countries and navigate four airports. My flight itinerary takes me from Calgary via Los Angeles and Miami to Port-au-Prince. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Airports offer a microcosm of the world that flies in and out of each city. The world seems very small.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Modern airport security procedures are a great equalizer. We are all the same when security is concerned. Everyone is obliged to follow the same rules. Airport security ignores gender, age, disability, colour, culture, faith, and everything else to insure the collective safety of the travellers and the airport personnel. Seems to me that this is good practice for the 21st century. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Canada will welcome 25,000 Syrian refugees over the next few months. I am very proud to be a Canadian. I believe Justin Trudeau. Canada is back. Good on us!! </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">I am wearing the same pants that I wore when I first travelled to Haiti in March 2010. I arranged for a Canadian flag to be sewn onto my pant leg for that trip. I wanted the world to know that Canadians cared and wanted to help. I didn't care if anyone new my name. I was not looking for personal fame or fortune, but I was happy to advertise Canada. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">While negotiating security at the LAX airport one of the security workers called me Mr. Canada, and this pleased me. Earlier in that same line I watched while a person ahead of me waited very patiently for a disabled man to get his gear in the trays. The disabled man had a movement disorder and his coordination was poor. He managed the task, but he struggled, and you could sense that he felt bad about holding up the line. He indicated to the person behind to go ahead. The next man, however, waited and I applaud that fellow for his patience. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The world is small. The problems in the world will get better if the citizens of the world unite in patience and tolerance. I believe this will happen, notwithstanding the recent climate of terrorism and the ugly racist responses of the political right in America and Europe. I believe that someday soon the world will unite in a common cause. We will be obliged to unite because as the world becomes progressively smaller, we will not be able to escape the recognition of our similarities. Differences will no longer drive the equation. Common cause will bind us together. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">I think this is why helping out in Haiti is so important. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-20985535325532669792015-12-13T10:44:00.000-07:002015-12-13T10:44:00.631-07:00Cholera in Haiti <div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Arial, Helvetica, sans-serif;">In October 2010, in the aftermath of the earthquake, cholera arrived in Haiti. The strain was likely brought into the country by well-meaning workers from Asia. Sadly, the setting was ripe for the rapid spread of this scourge. <b>Within a year of the outbreak there were over a third of a million cases of cholera and 5,500 deaths!</b> Within several years there were more than two thirds of a million cases and 8000 deaths. Cholera persists and the government has an ambitious program to eradicate the disease within a decade.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Cholera can kill within hours. Vibrio cholerae, the infecting bacteria, produces a toxin that interferes with salt and water transport in the duodenum and the upper jejunum, the first portions of the small intestine. The toxin activates adenylate cyclase, which increases cyclic adenosine monophosphate, which blocks sodium and chloride absorption, and promotes chloride and water secretion in the bowel. This results in profuse watery diarrhea that can rapidly lead to severe dehydration, shock, and death.</span><br />
<i style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN-US"><br /></span></i>
<i style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN-US">V cholerae</span></i><span lang="EN-US" style="font-family: Arial, Helvetica, sans-serif;"> is a saltwater organism that lives in association with plankton.</span><br />
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<span lang="EN-US"><span style="font-family: Arial, Helvetica, sans-serif;">Cholera has 2 main reservoirs,
humans and water. The bacteria is ingested in contaminated water or food. The bacteria is inactivated by acid in the stomach and infection depends on a large enough dose to circumvent the acid. Anything that reduces stomach acidity (antacids, histamine receptor blockers, proton pump inhibitors, H pylori infection) increases the risk for cholera.</span></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Infection rates in household contacts range from 20 to 50%. Past infection results in antibodies to cholera and immunity to repeat infection.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Rapid rehydration with intravenous fluids is life saving.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Antibiotics are administered for moderate or severe infections. A single dose of tetracycline, doxycycline, or ciprofloxacin is effective to reduce the duration and volume of diarrhea. Single dose doxycycline is the preferred antibiotic. This antibiotic can cause permanent discoloration of the teeth if administered to children under the age of 8 years but the risk is small with a single dose.</span><span style="font-family: Arial; font-size: 17.3333px;"> </span></div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-83505010634972134752015-12-13T08:09:00.000-07:002015-12-13T08:09:00.607-07:00Tetanus in Haiti<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: arial;"><span style="font-size: 17.3333px;"><b>Haiti is the only country in the Western Hemisphere where neonatal tetanus has not been eliminated. </b></span></span><br />
<span style="font-family: arial;"><span style="font-size: 17.3333px;"><br /></span></span>
<i><span lang="EN-US" style="font-family: "arial"; font-size: 13.0pt; mso-bidi-font-family: Arial;">Clostridium tetani</span></i><span lang="EN-US" style="font-family: "arial"; font-size: 13.0pt; mso-bidi-font-family: Arial;">
is a bacteria that forms spores that are resistant to heat, desiccation, and
disinfectants. The bacteria is found in soil, house dust, animal intestines,
and human feces.</span></div>
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<br /></div>
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<span lang="EN-US" style="font-family: "arial"; font-size: 13.0pt; mso-bidi-font-family: Arial;">To germinate, the spores require specific anaerobic
conditions such as wounds with dead or devitalized tissue or a foreign body. <span style="font-size: 17.3333px;">The source of infection is often a minor wound such as a wood or metal splinter, or a thorn. Stepping on a nail is a common antecedent injury.</span> Once the spores germinate, the typical symptoms are caused by
a toxin that is released from the spores.</span><br />
<span style="font-family: arial; font-size: 13pt;"><br /></span>
<span style="font-family: arial; font-size: 13pt;">Tetanospasmin is the toxin responsible for the symptoms. By weight this toxin is one of the most potent known. The estimated lethal dose is only 2.5 nanograms per kg body weight!</span><br />
<span style="font-family: Arial; font-size: 13pt;"><br /></span>
<span style="font-family: Arial; font-size: 13pt;">Tetanus usually presents with the acute onset of
hypertonia, painful muscular contractions of the muscles of the jaw
and neck, and generalized muscle spasms without any other apparent medical cause.</span><br />
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<span lang="EN-US" style="font-family: Arial; font-size: 13.0pt; mso-bidi-font-family: Arial;">Generalized tetanus usually presents with trismus (lockjaw), which is the inability to open the mouth
secondary to masseter muscle spasm. Risus sardonicus, the scornful smile of tetanus,
results from facial muscle involvement. Localized tetanus presents with persistent rigidity in a muscle group close to the injury site. <o:p></o:p></span></div>
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<!--StartFragment--><span lang="EN-US" style="font-family: Arial; font-size: 13.0pt; mso-ansi-language: EN-US; mso-bidi-font-family: Arial; mso-bidi-language: AR-SA; mso-fareast-font-family: "MS 明朝"; mso-fareast-language: JA; mso-fareast-theme-font: minor-fareast;">The "spatula test" is a simple diagnostic bedside test
that involves touching the back of the throat with a tongue depressor. In a normal
individual this should elicit a gag reflex and the patient should try to expel the tongue
depressor. In a person with tetanus, the patient develops reflex spasm of the
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<span style="font-family: Arial; font-size: 17.3333px;"><b>In countries without a comprehensive immunization program, tetanus mostly develops in neonates and young children. </b></span></div>
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<span lang="EN-US" style="font-family: Arial; font-size: 13.0pt; mso-bidi-font-family: Arial;"><br /></span></div>
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<span lang="EN-US" style="font-family: Arial; font-size: 13.0pt; mso-bidi-font-family: Arial;">Neonatal tetanus </span><span style="font-family: Arial; font-size: 13pt;">results from umbilical cord contamination during delivery. </span><span style="font-family: Arial; font-size: 17.3333px;">The risk factors for neonatal tetanus include an unvaccinated mother, home delivery, unhygienic cutting of the umbilical cord, a history of neonatal tetanus in a previous child, and application of a potentially infected substance to the umbilical stump (mud, clarified butter).</span></div>
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<span style="font-family: Arial; font-size: 13pt;">At the end of the first week of life, infected infants become irritable, suck and feed poorly, and
develop facial grimacing and severe spasms and rigidity precipitated by touch. Mortality with neonatal tetanus exceeds 70%.</span></div>
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<span lang="EN-US" style="font-family: Arial; font-size: 13pt;">Antimicrobials are used to reduce the number of bacteria and production of the toxin. Metronidazole has superseded penicillin as the drug of choice. </span><span lang="EN-US"><o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial; font-size: 13.0pt; mso-bidi-font-family: Arial;">Passive immunization with human tetanus immune
globulin <span style="font-size: 17.3333px;">(3,000-6,000 units as 1 dose)</span> shortens the course of tetanus and might lessen its severity.</span></div>
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<span style="font-family: Arial; font-size: 13pt;">Once the tetanospasmin becomes fixed to nerve cells, the toxin cannot be neutralized by tetanus immune globulin. Recovery of nerve function requires the formation of new nerve terminals and the formation of new synapses. Recovery is slow and usually occurs over 2 to 4 months. </span></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-66952294721814891352015-12-12T07:10:00.000-07:002015-12-12T07:10:04.342-07:00Rabies in Haiti<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: "arial" , "helvetica" , sans-serif;">Haiti has the <b>highest incidence of rabies in the Western Hemisphere</b>. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white;">Rabies is a viral (Lyssavirus) infection </span><span style="background-color: white;">transmitted in saliva or other secretions from infected animals, typically via a bite. Unvaccinated dogs are the most common animal. Other potential reservoirs include cat, coyote, wolf, fox, skunk, raccoon, and bat species. </span></span><br />
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<span style="background-color: white;"><span style="font-family: "arial" , "helvetica" , sans-serif;">The virus is highly neurotropic (likes nerve cells). After the bite, the virus infects the local peripheral nerves and then slowly travels along these nerves towards the brain. There is a long incubation period (20 to 90 days) before the cells reach a spinal ganglion. Once the virus reaches this level the first symptoms develop with pain or paresthesia at the site of the bite. Thereafter the virus travels rapidly into the brain. <b>Once the virus reaches the central nervous system the infection is 100% fatal! </b></span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Once the brain is infected, the individual develops muscle fasciculation (twitching), focal or generalized convulsions, and this is followed by paralysis, coma, and death. Autonomic instability might develop with rapid heart and respiratory rate, high blood pressure, tearing, sweating, and salivation.</span><br />
<span style="background-color: white; font-family: "arial";"><br /></span>
<span style="background-color: white; font-family: "arial";">The best treatment is prevention with rabies vaccination of domesticated animals. Domesticated dogs are not routinely vaccinated in Haiti, and this provides the opportunity for human infection. Individuals who work with animals should be routinely vaccinated. </span><br />
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<span lang="EN-US" style="background: white; font-family: "arial";">If an individual is bitten by a potentially rabid animal, treatment should include human rabies immune globulin (HRIG) or one of two inactivated rabies vaccines and this must be accomplished as soon as possible during the incubation period and before the virus reaches the central nervous system. If the vaccination status of the animal is not known, the animal should be observed for ten days for signs of canine rabies. </span></div>
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<span lang="EN-US" style="background: white; font-family: "arial";">The Center for Disease Control recommends post exposure prophylaxis with intramuscular administration of either of two</span><span lang="EN-US" style="font-family: "arial";"> different inactivated rabies vaccines. The dose for prevention </span><span style="font-family: "arial"; text-indent: -18pt;">is 1 ml of the vaccine administered in the deltoid or in the upper outer thigh in infants.</span><span style="font-family: "arial";"> </span></div>
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<span lang="EN-US" style="background: white; font-family: "arial";">HRIG should be administered to any person not
previously vaccinated against rabies, at a dose of 20 IU/kg (for adults and
children). <b>As much of the HRIG dose as
possible should be administered at the injury site</b> and the remainder as a deep intramuscular injection in the
gluteal area. HRIG may be administered as long as 7 days after the first dose
of vaccine if it is not immediately available.</span><span lang="EN-US" style="font-family: "arial"; mso-bidi-font-size: 10.0pt;"><o:p></o:p></span></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-13293111941082857202015-12-11T06:51:00.000-07:002015-12-11T06:51:00.092-07:00Immunizations in Haiti<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: Arial, Helvetica, sans-serif;">I believe in immunizations.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">During my career, immunizations have arguably made the single biggest positive influence in health care in Canada. Canadians enjoy the luxury of freedom from diseases that were common and potentially fatal during my early years as a paediatrician. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Sadly this is not the case in Haiti. Illnesses that are rarely encountered in Canada still cause death and disability in Haiti. </span><span style="font-family: Arial, Helvetica, sans-serif;">For instance, Haiti is the only country in the Americas where neonatal tetanus has not been eliminated. Haiti has the highest incidence of human rabies in the Western Hemisphere. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Since the earthquake and courtesy of a lot of work by local Haitian health care services and support from the Center for Disease Control, WHO, and other international organizations, immunization programs have substantially reduced the risks of many preventable illnesses in Haitian children. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">In 2012 the "five-in-one" pentavalent vaccine was introduced in Haiti. This vaccine protects for diphtheria, tetanus, whooping cough, hepatitis B, and H influenzae type b. Rotavirus vaccination was introduced in 2014. Pneumococcal vaccine is scheduled for introduction during 2015. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">The table below outlines the current schedule in Haiti for the most common vaccines and the most recent WHO estimate of how many children complete the full series of immunizations in each category. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
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<span lang="EN-US" style="font-family: Arial;">Vaccine <o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">WHO estimate 2015<o:p></o:p></span></div>
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<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">birth<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">76<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">DTPHibHebB<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">6, 10, 14 weeks<o:p></o:p></span></div>
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<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">48<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">OPV<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">6, 10, 14 weeks, <o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">4 to 5 years<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">55<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">Rotavirus<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">6, 10 weeks<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">40<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">MR<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">9 months<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN-US" style="font-family: Arial;">MMR<o:p></o:p></span></div>
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<br /></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-12715099784918060652015-12-10T09:00:00.000-07:002015-12-10T09:47:53.364-07:00Tuberculosis in Haiti <div dir="ltr" style="text-align: left;" trbidi="on">
<div class="MsoNormal">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Haiti has the highest prevalence of TB in the Western Hemisphere.</b> About 300 individuals per 100,000 Haitians have active TB. Humans
are the only known reservoirs for <i>M. tuberculosis</i>. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">TB
is transmitted by inhaling the tubercle bacilli. A variety of factors can increase the risk of transmission. TB can cause cavitation lesions in the lungs and these lesions have very high concentrations of the bacilli, and individuals with these lesions are more contagious. Contagion is increased in poorly ventilated situations and with prolonged exposure. Malnourished individuals have reduced cell-mediated immunity and are at higher risk. Treated individuals are </span></span><span style="font-family: "arial" , "helvetica" , sans-serif;">much less infectious than those who have not received any treatment. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Once the TB bacilli is established in the body, the bacteria is spread in the lymph or vascular systems to other lymph nodes, the kidney, long bones, spine, and to the brain. </span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">The body does fight back. A
cell-mediated immune response terminates the unimpeded growth of the <i>M. tuberculosis</i> 2-3 weeks after initial infection. CD4 helper T cells activate macrophages to kill the intracellular bacteria with resultant epithelioid
granuloma formation.</span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">Any
child with pneumonia, pleural effusion, or a cavitary or mass lesion in the
lung that does not improve with standard antibacterial therapy should be
evaluated for TB. Also, children with fever of unknown origin,
failure to thrive, significant weight loss, or unexplained lymphadenopathy
should be evaluated for TB.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">Frequent
sites of lymph node involvement include the neck, below the jaw, and above the clavicles. </span></span><br />
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">Multiple drug-resistant TB is a problem in Haiti. First-line
agents to treat TB include rifampin, isoniazid (INH), pyrazinamide, ethambutol, and
streptomycin. Hepatitis, a recognized adverse effect of </span></span><span style="font-family: "arial" , "helvetica" , sans-serif;">isoniazid is rare in children</span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">Recommendations
for the treatment of pulmonary tuberculosis (TB) include a 6-month course of
isoniazid and rifampin, supplemented during the first 2 months with
pyrazinamide. Ethambutol (or streptomycin in children too young to be monitored
for visual acuity) may need to be included in the initial regimen until the
results of drug susceptibility studies are available.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">Because
poor adherence to these regimens is a common cause of treatment failure,
<b>directly observed therapy (DOT) is recommended</b> for treatment of TB. DOT means a
health care provider or other responsible person must watch the patient ingest
the medications. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span lang="EN-US"><span style="font-family: "arial" , "helvetica" , sans-serif;">I reviewed a recent article on TB in Haiti that showed the statistically significant difference between DOT and non-DOT patients. <o:p></o:p></span></span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span lang="EN-US">2001 - </span>There were 143 patients in the non-DOT group and 138 patients in the DOT group. <o:p></o:p></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
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<span style="font-family: "arial"; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">29<o:p></o:p></span></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-193656994185031522015-12-09T07:47:00.000-07:002015-12-09T07:47:00.967-07:00Malaria vs Dengue Fever vs Chikungunya<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: "arial" , "helvetica" , sans-serif;">The table below compares clinical information that helps to differentiate Malaria, Dengue Fever, and Chikungunya. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">
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<span lang="EN-US" style="font-family: Arial;">Malaria<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: Arial;">Dengue<o:p></o:p></span></div>
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<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">Chikungunya<o:p></o:p></span></div>
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<div class="MsoNormal">
<br /></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
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<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Mosquitoes feeding<o:p></o:p></span></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Night<o:p></o:p></span></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Day<o:p></o:p></span></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">Day<o:p></o:p></span></div>
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<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Peak season<o:p></o:p></span></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Nov
to Feb<o:p></o:p></span></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Apr
- June,<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Oct
- Nov<o:p></o:p></span></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Apr
- June,<o:p></o:p></span></div>
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Oct
- Nov</span><span lang="EN-US" style="font-family: Arial;"><o:p></o:p></span></div>
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<tr style="mso-yfti-irow: 4;">
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<div class="MsoNormal">
<br /></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
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<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
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<tr style="mso-yfti-irow: 5;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Percent of febrile
illnesses in Haiti<o:p></o:p></span></div>
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<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">0.5%<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">2
to 4%<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 7;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Incubation<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">8
to 18 days<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">4
to 7 days<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">3 to 7 days<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">High fever<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">++<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">++<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">++<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 10;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Joint pain<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">+<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">+++<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 11;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Rash <o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">++<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">++<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 12;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Headache <o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">+<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">++<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">++<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 13;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Pain behind eyes<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">+++<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">+<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 14;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Muscle and bone pain<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">+<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">+++<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span lang="EN-US" style="font-family: Arial;">+<o:p></o:p></span></div>
</td>
</tr>
<tr style="mso-yfti-irow: 15; mso-yfti-lastrow: yes;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10.0pt; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">Other common symptoms<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">vomiting,
seizures<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: Arial; mso-ansi-language: EN-CA; mso-fareast-language: EN-US;">facial
flushing<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 110.7pt;" valign="top" width="111">
<div align="center" class="MsoNormal" style="text-align: center;">
<br /></div>
</td>
</tr>
</tbody></table>
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<w:WordDocument>
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<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
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<w:EnableOpenTypeKerning/>
<w:DontFlipMirrorIndents/>
<w:OverrideTableStyleHps/>
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<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-36554529693543672792015-12-08T09:04:00.000-07:002015-12-08T09:04:00.107-07:00Chikungunya in Haiti <div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: "arial" , "helvetica" , sans-serif;">Chikungunya is a "new infection," especially in the Western Hemisphere. The first infections in this hemisphere were noted in 2013. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The name derives from Swahili and translates as "to be bent over," which refers to the stooped-over-posture noted in infected individuals who suffer from the chronic incapacitating joint pains in the spine. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The infection is transmitted by mosquito bites and the symptoms are similar to those of Dengue Fever, which is transmitted by the same species of mosquito. The incubation period is an average of 3 to 7 days. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The most common symptoms are fever and joint pain. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The infection presents with a sudden fever that can be as high as 105 degrees and last for 2 or 3 days. There might be shaking chillls with the fever. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The joint pains are usually in multiple joints and include the small bones of the hands, wrists, and ankles. Spine involvement is common. Larger joints (shoulder, knees) are less commonly involved. The joint pains are symmetrical and can migrate. When multiple joints are involved the patient might be incapacitated. Pain is worse in the morning and improves with slow exercise. Joint symptoms resolve completely within 1 or 2 weeks in most patients. However, a third develop chronic joint symptoms, which persist for 3 to 6 months in 30%, 20 months in 15%, and for 3 to 5 years in 12%. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-35896332573316448522015-12-07T06:08:00.000-07:002015-12-07T06:08:00.359-07:00Dengue Fever in Haiti<div dir="ltr" style="text-align: left;" trbidi="on">
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<span lang="EN-US" style="color: black; font-family: "arial" , "helvetica" , sans-serif;">Dengue
is the most common mosquito-related illness in humans. There are four serotypes
of the RNA flavivirus. <o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
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<span lang="EN-US" style="color: black; font-family: "arial" , "helvetica" , sans-serif;"><b>In
50 to 90% of individuals the infection is asymptomatic.</b> Some, especially
children, experience a non-specific febrile illness. <b>Classic Dengue Fever is
more common in non-immune, non-indigenous adults and children.</b> <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: "arial" , "helvetica" , sans-serif;">With
classic Dengue the infection often starts with chills, a red mottling of the
skin, and facial flushing, which is a sensitive and specific feature of Dengue
Fever. There is a rapid onset of high fever up to 41 degrees, headache,
retro-orbital pain, muscle and bone pain, weakness, vomiting, and sore throat.
Dengue fever is typically a self-limiting disease with a mortality rate of less
than 1%.<o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
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<span lang="EN-US" style="font-family: "arial" , "helvetica" , sans-serif;">The rash begins
on day three and lasts 2 or 3 days. The rash is macular popular or macular
confluent and shows on the face, thorax, and flexor surfaces. The muscle pain
is prominent in the lower back, arms, and legs. The joint pain is usually in
the knees and shoulders. <o:p></o:p></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
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<span lang="EN-US" style="color: black; font-family: "arial" , "helvetica" , sans-serif;">A
small percentage of persons who have previously been infected by one dengue
serotype develop Dengue Hemorrhagic Fever (DHF) when infected with another
dengue serotype. DHF typical develops 3 to 7 days after infection with a second
dengue serotype. When treated, dengue hemorrhagic fever has a mortality rate of
2-5%, but when untreated, the mortality rate is as high as 50%.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "arial" , "helvetica" , sans-serif;">Most cases are
self-limited and should be treated with analgesic, hydration, and rest. The
fever might last 5 to 7 days and recovery takes another 5 to 7 days. <o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "arial" , "helvetica" , sans-serif;">Patients with
dengue fever should have their platelet count and hematocrit measured daily
from the third day of illness until 1-2 days after the fever resolves to look
for evidence of DHF.</span><br />
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<span lang="EN-US" style="background: white; color: #403838; font-family: "arial" , "helvetica" , sans-serif;">I performed a Google Scholar search on Dengue in Haiti. Two
articles contained pertinent information. <o:p></o:p></span></div>
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<span lang="EN-US" style="background: white; color: #403838; font-family: "arial" , "helvetica" , sans-serif;">2010 - A study of 166 children 7 to 36 months of age revealed
<o:p></o:p></span></div>
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<span lang="EN-US" style="background: white; color: #403838; font-family: "arial" , "helvetica" , sans-serif;">evidence of past infection with Dengue virus serotype 1 in
40%, serotype 2 in 12%, serotype 3 in 11%, and serotype 4 in 2%. <b>Fifty-three
percent of infants and young children less than 12 months of age had already
experienced infection with a Dengue virus and by 36 months this rose to 65%. </b><o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: "arial";"><span style="font-family: "arial" , "helvetica" , sans-serif;">2014 - <span style="background: white; color: #333333;">A two-year prospective study in an
outpatient clinic in Léogane found that <b>2% of patients presenting with undifferentiated
fever tested positive for Dengue infection</b></span><span style="color: #333333;"><b>.<span style="background: white;"> Similarly, 4% of 885
patients with fever admitted to four hospitals in
Haiti during 2012–2013 tested positive for Dengue.</span></b></span></span><span style="font-family: "arial";"><o:p></o:p></span></span></div>
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wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-41210871795383917112015-12-06T05:55:00.000-07:002015-12-06T09:05:30.450-07:00Malaria in Haiti <div dir="ltr" style="text-align: left;" trbidi="on">
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<br />
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "arial"; font-size: 12pt;">During my
review of articles published in the New England Journal of Medicine, I learned
that the island of Hispaniola (Haiti and the Dominican Republic) is the <b>only
remaining foci of </b><span style="font-family: "arial" , "helvetica" , sans-serif;"><b>endemic
malaria</b> </span><b>among the Caribbean islands</b>. <span style="background: white;">Children are the worst affected, especially children aged 6 months to 5
years. In parts of the world where malaria is endemic, malaria might cause as
many as 10% of all deaths in children.</span><o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="background: white; font-family: "arial"; font-size: 12pt;"><br />
Malaria is due to a protozoal blood parasite transmitted by a mosquito bite. In the
Western Hemisphere Plasmodium vivax is usually the most common parasite but in
Haiti, P. falciparum is common. P. falciparum can cause cerebral
malaria. </span><span style="font-family: "arial"; font-size: 12pt;"><o:p></o:p></span></div>
<div style="margin: 0cm 0cm 0.0001pt;">
<span style="background: white; font-family: "arial"; font-size: 12pt;"><br />
Congenital malaria due to transplacental transfer can be significant in
populations of mothers who are semi-immune to malaria. The mother might have
placental parasitemia, peripheral parasitemia, or both, without any fever or
other clinical manifestations. Vertical transmission of this infestation can be
as high as 40% and is associated with anemia in the baby. </span><span style="font-family: "arial"; font-size: 12pt;"><o:p></o:p></span></div>
<div style="margin: 0cm 0cm 0.0001pt;">
<br /></div>
<div style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "arial"; font-size: 12pt;">In endemic areas, children younger than age 5 years have repeated
and often serious attacks of malaria. The survivors develop partial immunity.
Thus, older children and adults often have asymptomatic parasitemia. <u1:p></u1:p><b>Most
deaths resulting from malaria occur in children younger than age 5 years
because they do not have immunity</b>.<o:p></o:p></span></div>
<div style="background: white; margin-bottom: .0001pt; margin: 0cm;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="background: white; font-family: "arial"; font-size: 12pt;">Fever is usually continuous and might be very high (40°C)
from the first day. Chills and sweats are common with a high fever. Vomiting is
common.</span><br />
<span style="background-color: white; font-family: "arial"; font-size: 12pt;"><br /></span>
<span style="background-color: white; font-family: "arial"; font-size: 12pt;">The liver may be slightly tender. Splenomegaly takes many days, especially in
the first attack in nonimmune children. In children from an endemic area,
severe splenomegaly sometimes occurs.</span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="background-color: white; font-family: "arial"; font-size: 12pt;"><br /></span>
<span style="background-color: white; font-family: "arial"; font-size: 12pt;">Children living in an area where malaria is endemic have
frequent infections and develop and maintain partial immunity. These children
often develop only a low-grade fever, anemia, poor appetite, and malaise.</span><br />
<span style="background-color: white; font-family: "arial"; font-size: 12pt;"><br /></span>
<span style="background-color: white; font-family: "arial"; font-size: 12pt;">Prolonged malaria can cause anemia. With heavy parasitemia
and large-scale destruction of red blood cells, mild jaundice and hypoglycemia
might occur.</span><br />
<span style="background-color: white; font-family: "arial"; font-size: 12pt;"><br /></span>
<span style="background-color: white; font-family: "arial"; font-size: 12pt;">Chloroquine is the most commonly used drug, at a dose of 5
mg/kg once a week.</span><br />
<span style="background-color: white; font-family: "arial"; font-size: 12pt;"><br /></span>
<span style="background-color: white; font-family: "arial"; font-size: 12pt;">I did a Google Scholar search of malaria in Haiti. Below is pertinent information from recent articles.</span><br />
<span style="background-color: white; font-family: "arial"; font-size: 12pt;"><br /></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "arial"; font-size: 12pt;">2010 -
Center for Disease Control report that P. falciparum malaria is endemic to Haiti.<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "arial"; font-size: 12pt;">2011 - During
a period of 14 weeks from Nov 2010 to Feb 2011, a total of 61 cases
of P. falciparum malaria were diagnosed in a Leogane clinic. The cases
accounted for 47% of 130 patients with undifferentiated fever.<span class="apple-converted-space"> </span><b>This seems too high. There are too
many causes of fever for one infection (malaria) to cause almost half the
cases. </b>The ages of the malaria patients ranged from 3 to 67 years.
About 40% were younger than 16 years.<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "arial"; font-size: 12pt;">2012 - In
sharp contrast to the situation in other regions of the world, <b>P. falciparum
parasites in Haiti remain susceptible to chloroquine.</b> This study of 49 patients
with P. falciparum malaria in Leogane did not find chloroquine resistance or
treatment failure.<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "arial"; font-size: 12pt;">2014 -
Study from Grand'Anse reported that 17.4% of hospital consultations for fever
were due to malaria.<o:p></o:p></span></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<br /></div>
<div style="margin-bottom: .0001pt; margin: 0cm;">
<span style="font-family: "arial"; font-size: 12pt;">2015 -
The national prevalence of malaria in febrile outpatients reported to be 0.5%.<span class="apple-converted-space"> </span><b>Compared to the 2011 and 2014
studies above, this seem very low. </b><o:p></o:p></span></div>
<!--EndFragment--></div>
wlmrobson@gmail.comhttp://www.blogger.com/profile/15559889587944028424noreply@blogger.com0tag:blogger.com,1999:blog-6637190195644711689.post-38518502680610706172015-12-05T06:48:00.000-07:002015-12-05T07:26:34.468-07:00Filariasis in Haiti<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: "arial" , "helvetica" , sans-serif;">My recent review of New England Journal of Medicine articles revealed that <b>Haiti is home to 90% of the cases of filariasis in the Western Hemisphere</b>. Filariasis is an infection with a nematode parasite and is the cause of elephantiasis, a chronic disfiguring disease. The WHO reports that filariasis is the second leading cause of permanent disability in the world after leprosy. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The parasite is transmitted to the human host by a mosquito bite. The first stage larvae are microfilariae. Mature worms are one to five inches in length and survive for five years. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The microfilariae cause inflammation and swelling in the lymphatic system. The blocked lymphatic channels lead to swelling in the legs, arms, testicles, vulva, and breasts. The most common nodes affected are femoral and epitrochlear. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Filariasis is first contracted in childhood, and most individuals in endemic areas are exposed by the third or fourth decade. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The infection can present with episodes of acute lymphadenitis with sudden fever and painful glands. The symptoms abate within a week but episodic attacks might develop. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Hydrocele is the most common sign of infection in a male who lives in an endemic area. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The skin over the swollen areas is abnormal with hyperkeratosis, acanthosis, loss of elastin, and fibrosis. Skin nodules and large transient areas of localized nonerythematous subcutaneous edema can develop. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Eye lesions can lead to blindness. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">The parasite can cause allergic symptoms with itchiness and hives and the blood eosinophil count is high. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Prevention is the best strategy because the damage is irreversible. Mass treatment with albendazole and ivermectin is a recommended intervention. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">I performed a Google Scholar review of articles published on filariasis in Haiti since 2000. I found 35 articles and pertinent information from these articles is found below. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2003 - Adverse reactions following mass treatment with diethylcarbamazine and albendazole are common. <b>Overall 24% had one or more adverse reactions. Most were minor (91%)</b> and some were moderate (9%). </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2004 - Blood collected from Haitian school children aged 6 to 11 years showed that <b>4% of 22,365 children were positive for Wuchereria bancrofti </b>antigen. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">2010 - <b>After seven rounds of mass drug administration in Leogane, Haiti, the prevalence of microfilaremia was reduced to <1% from levels as high as 15.5%. </b>Continuing transmission of filariasis seemed to be linked to rates of noncompliance. </span></div>
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