Monthly Archives: July 2011

mHealth! Mobiles for Improving Healthcare

In place of a JIDC Postcard this week, the fabulous Derek Ng has written a piece on mHealth.  The potential of mobile phones to deliver health advice and/or information is exciting.   I already see many people using this technology here in Canada.  For instance, many of my pregnant friends receive weekly up-dates on the progression of their pregnancies on their mobile phones.  Although powerful, challenges for implementing these technologies do exist.  In this Blog Post Derek has reviewed the compelling advances in mHealth as well as discussing the challenges. 

What are your thoughts on mHealth and how well do you think it will be accepted in your area?  Are you using mHealth technologies in your area?  Or are you trying to implement a new mHealth technology?  If you have comments or would like to share your experiences in mHealth we would like to hear from you.  Particularly I am interested in the use of mobile devices to track infectious disease outbreaks.  

Alyson

The advent of mobile phones has made it considerably easier for people to communicate regardless of where they were in the world. By the mid-2000s, these phones were becoming increasingly powerful with miniaturized computer chip technology that made it possible for users to complete more complex tasks. The mobile phone has evolved from a device that was essentially a phone that individuals could use away from home to something more resembling a handheld computer – an aptly named “smartphone.” Today, users can perform tasks beyond that of simply calling and texting, such as e-mailing, surfing, video recording, word processing and more. The integration of computer-like capabilities to the phone has also resulted in the development of applications that can be designed to perform specialized tasks. One interesting twist in the mobile world is that of mobile health (mHealth).

What is mHealth?

The World Health Organization (WHO) defines mHealth as “the use of mobile and wireless technologies to support the achievement of health objectives,” where the WHO has published a write-up on mHealth.  The concept of mHealth has already caught on with cell phone applications that assist health-care providers by providing up-to-date lists of drugs, information on diseases and so forth. This has already aided physicians in supplementing their point-of-care service. It is also available on the outpatient or receiving end of health care by providing patients with schedules for medications or how to eat or exercise better. The possibilities appear to be even more promising as mobile technologies are still rapidly advancing. Although we can see real applications and benefits for this technology in industrialized countries, the same remains to be seen for developing countries as well.

How have mobile phones changed the developing world?

Cell phone usage in developing countries has skyrocketed in the past and continues to do so in areas such as South America, Africa and Asia [1]. The technology has helped countries without infrastructure to bypass the need to construct landlines which were previously required for telephony to occur. By constructing modern radio towers instead, these countries can leapfrog the older and more expensive telephone technology, which has resulted in countries that possess a well-established mobile network despite lacking paved roads, electricity or landline internet connections [1]. This situation has allowed for an unprecedented number of individuals who are now connected to each other, as well as the internet. One key aspect about this far-reaching technology is that it has been made very affordable in these areas. For example, China and India have over 800 million cell phone subscribers each, whereas in contrast, Canada has 24 million active cell phone accounts [1]. When I visited China, I spent about 20 Canadian dollars on a prepaid plan that offered me more minutes and data usage than I could use in a month. In Canada, my cell phone plan is often over 50 dollars a month.

Why mHealth?

An advantage of mHealth is that it can be utilized to allow a broad base of users (many of which are already subscribed to a cell phone plan) to be instantly informed on wide range of issues. These topics could range from outbreak detection and notification, drug or therapy adherence (such as that seen in TB treatment), HIV awareness, and so forth. For example, Grand Challenges Canada is promoting innovative ways in which to solve global health issues [2]. Furthermore, the use of mHealth to improve healthcare has been reported in countries such as Kenya and Cameroon [3–8]: some articles of which are Open Access, Implementing medical information systems in developing countries, what works and what doesn’t by Fraser 2010, The Cameroon mobile phone SMS (CAMPS) trial: a protocol for a randomized controlled trial of mobile phone text messaging versus usual care for improving adherence to highly active anti-retroviral therapy by Mbuagbaw et al., 2011, and Global Networking of Cancer and NCD Professionals Using Internet Technologies: The Supercourse and mHealth Applications by Linkov et al., 2010.

Two interesting proposals of the Canadian Rising Stars in Global Health from Grand Challenges Canada we recently came across here at the JIDC were ‘using mobile phone text messaging to reduce maternal and infant death in rural areas in China’[8] and ‘mHealth for Maternal and Newborn Health: Clinical decision support for community health workers in Western Kenya’[9]. The first idea, proposed by Ri-Hua Xie from the Ottawa Hospital Research Institute and University of Ottawa, is to deliver educational material from the World Health Organization to expecting mothers who might not have received the information otherwise. Her proposal aims to reduce both maternal and infant deaths, by connecting healthcare providers to expecting and new mothers in rural areas.  You can watch a video describing her idea here.

The latter proposal by Astrid Christoffersen-Deb at the University of Toronto is in collaboration with Moi University Schoolof medicine inKenya. She would like to provide citizens with a unique barcode and identifying health card, which can be scanned by a community health worker. This provides the workers access to electronic medical records for sending and receiving information to and from medical facilities.  You can watch a video describing Astrid’s idea here.

Thus far about 80% of all WHO member states offer at least one mHealth service – the majority of which are in higher-income countries[1]. The highest reported rate of mHealth use was in countries inEurope, whereas Africa was least active. The majority or about two-thirds of projects in mHealth are still in a pilot stage, which poses some problems in its widespread implementation.

The challenges in implementing mHealth

However, not everyone is as optimistic about the impact of mobile phones in these countries. In fact, mHealth faces several barriers, despite the many promising ideas outlined earlier. Some issues include the lack of convincing studies that outline a positive benefit for the cost of implementing mHealth. The studies also need to show more evidence that mHealth can improve health outcomes. In countries where funding is already limited, the governments may decide to fund other important health care programs whose outcomes are better established. There is also a lack of standardization because some of the studies have been launched to tackle one specific problem in that one region. The WHO is currently developing a tool kit that may offer a standardized set of guidelines for using mHealth in the future.

The future of mHealth and summary

mHealth offers a promising way to deliver different health care programs and services to the individuals who have traditionally had difficulty accessing such resources. With the increasing capabilities of mobile technology and its penetration into remote and rural areas, we can look forward to emerging fields within mHealth. Ideally such applications (some of which previously mentioned) would benefit both health-care providers and patients alike. Health-care providers may see advanced telehealth technologies for communicating with experts for assistance in complex or difficult procedures outside of sophisticated care facilities, such as in remote or underserviced areas. An extension of this is that it could also allow physicians to more easily follow-up and monitor their patients. Yet another application branching from this is education of citizens for public health purposes.

With any new emerging technology, it is important to assess its benefits and risks. Studies must be made to produce a standardized set of guidelines – an undertaking which is already in progress through the WHO. Following such guidelines, it would also be useful to validate the technology according to the needs of an individual country and its citizens, since disease burdens and health-care services would vary.

While the verification of the benefits of mHealth and whether it is a valuable investment over other health services in countries where resources are already limited are important considerations, there appears to be a potential for mHealth to make a significant impact on health care in the future

Derek Ng

What are your thoughts on mHealth?

Please feel free to leave a comment.

Derek is from Toronto, Canada and is now a second year medical student at the University of Western Ontario.  Comments or questions contact Derek: cng2014@meds.uwo.ca or myself:  akelvin@jidc.org 

Derek on Left

 

Reference List

 

      1.   World Health Organization W (2011) mHealth New horizons for health through mobile technologies.

      2.   2011 July) Grand Challenges Canada. http://www.grandchallenges.ca/.

      3.   Chang LW, Kagaayi J, Arem H, Nakigozi G, Ssempijja V, Serwadda D, Quinn TC, Gray RH, Bollinger RC, Reynolds SJ (2011) Impact of a mHealth Intervention for Peer Health Workers on AIDS Care in Rural Uganda: A Mixed Methods Evaluation of a Cluster-Randomized Trial. AIDS Behav . 10.1007/s10461-011-9995-x [doi].

      4.   Tamrat T, Kachnowski S (2011) Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World. Matern Child Health J . 10.1007/s10995-011-0836-3 [doi].

      5.   Mbuagbaw L, Thabane L, Ongolo-Zogo P, Lester RT, Mills E, Volmink J, Yondo D, Essi MJ, Bonono-Momnougui RC, Mba R, Ndongo JS, Nkoa FC, Ondoa HA (2011) The Cameroon mobile phone SMS (CAMPS) trial: a protocol for a randomized controlled trial of mobile phone text messaging versus usual care for improving adherence to highly active anti-retroviral therapy. Trials 12: 5. 1745-6215-12-5 [pii];10.1186/1745-6215-12-5 [doi].

      6.   Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball TB, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA (2010) Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 376: 1838-1845. S0140-6736(10)61997-6 [pii];10.1016/S0140-6736(10)61997-6 [doi].

      7.   Fraser HS, Blaya J (2010) Implementing medical information systems in developing countries, what works and what doesn’t. AMIA Annu Symp Proc 2010: 232-236.

      8.   Linkov F, Padilla N, Shubnikov E, Laporte R (2010) Global Networking of Cancer and NCD professionals using internet technologies: the Supercourse and mHealth applications. J Prev Med Public Health 43: 472-478. 201011472 [pii];10.3961/jpmph.2010.43.6.472 [doi].

      9.   RI-HUA XIE, Canadian Grand Challenges (2011 July) USING MOBILE PHONE TEXT MESSAGING TO REDUCE MATERNAL AND INFANT DEATHS IN REMOTE AREAS IN CHINA. http://www.grandchallenges.ca/canadianrisingstars_round1grantees/rihuaxie_en/.

    10.   ASTRID CHRISTOFFERSEN-DEB, Canadian Grand Challenges (2011 July) MHEALTH FOR MATERNAL AND NEWBORN HEALTH: CLINICAL DECISION SUPPORT FOR COMMUNITY HEALTH WORKERS IN WESTERN KENYA. http://www.grandchallenges.ca/canadianrisingstars_round1grantees/astridchristoffersendeb_en/.

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Documentary on Male Circumcision for HIV Prevention

Launching of a new film documenting Male Circumcision for HIV/AIDS Prevention

Increasing evidence has shown male circumcision to be a primary tactic in the fight against the spread of HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immunodeficiency Syndrome) in continental Africa [1].  Wednesday June 22, 2011, a short film describing Voluntary Medical Male Circumcision (VMMC) for decreasing the spread of HIV was released [2].  This film entitled In It to Save Lives: Scaling Up Voluntary Medical Male Circumcision for HIV Prevention for Maximum Public Health Impact, was produced by AIDSTAR-One and the film was made by Lisa Russell.  AIDSTAR-ONE is a PEPFAR-funded USAID project [2].

About the AIDSTAR-ONE Film on Male Circumcision for HIV/AIDS transmission reduction

The film discusses how Kenya and Swaziland have supported male circumcision for HIV prevention in of the epidemic in their countries [2].  The film provides information on how to implement circumcision for HIV/AIDS and includes interviews with a HIV/AIDS experts and policymakers.  Importantly the video and shows that VMMC programs can be implemented in other affected areas and provides instruction on how to maximize VMMC participation for improving HIV/AIDS statistics.

How does male circumcision help decrease HIV/AIDS transmission?

At first glance, how male circumcision participates to decrease HIV/AIDS transmission does not seem obvious.  However, there is growing evidence that circumcision can reduce transmission up to 50%.   It is estimated that there was a majority of males circumcised, then HIV realted deaths could potentially be reduced by 3 million [1,3].  In a papers published in JIDC, the Journal of Infection in Developing Countries and the New England Journal of Medicine, the authors discuss how voluntary male circumcision has partially prevented HIV transmission in African nations

Map from Lonely Planet

[1,3].  Three groundbreaking studies have set the trend for randomized, controlled trials of circumcision [4–6].  These studies showed a significant reduction in transmission following circumcision.  The published paper describes Orange Farm, South Africa, to be the first community to participate in a voluntary circumcision trial that statistically showed this practice decreased HIV transmission where HIV infection in heterosexual men was reduced by 60% [4].  Following the results of this trial, Kenya and Uganda since also participated in similar trials and confirmed the results from South Africa in two papers by Gray and Bailey [5,6]. 

Currently the scientific theory behind circumcision decreasing HIV transmission suggests the foreskin to be reservoir for secretions that contain viruses such as HIV [1,3].  This reservoir then concentrates the interaction between virus and target cells as well as increases the contact time maximizing the possibility for infection. 

Since male circumcision only partially prevents new HIV/AIDS infections, the WHO has established a set of guidelines for HIV prevention, entitled a HIV prevention package [7].  Along with circumcision, the WHO recommends HIV testing and counselling services, treatment for other sexually transmitted diseases, campaigning of safe sex procedures, and the administration of condoms for both males and females.  A PLoS One paper published in April 2011 reviews the current challenges and future directions of implementing voluntary circumcision for HIV prevention programs. 

 

Alyson

References

 

        1.    Addanki KC, Pace DG, Bagasra O (2008) A practice for all seasons: male circumcision and the prevention of HIV transmission. J Infect Dev Ctries 2: 328-334.

        2.    AIDSTAR-ONE  (2011 July) In It to Save Lives: Scaling Up Voluntary Medical Male Circumcision for HIV Prevention for Maximum Public Health Impact. http://www.cvent.com/events/aidstar-one-premiere-of-the-short-film-in-it-to-save-lives/event-summary-4dec87f1a8fb4eaa9d4a0996fc455642.aspx.

        3.    Katz IT, Wright AA (2008) Circumcision–a surgical strategy for HIV prevention in Africa. N Engl J Med 359: 2412-2415. 359/23/2412 [pii];10.1056/NEJMp0805791 [doi].

        4.    Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2: e298. 05-PLME-RA-0310R1 [pii];10.1371/journal.pmed.0020298 [doi].

        5.    Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, Williams CF, Campbell RT, Ndinya-Achola JO (2007) Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 369: 643-656. S0140-6736(07)60312-2 [pii];10.1016/S0140-6736(07)60312-2 [doi].

        6.    Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, Kiwanuka N, Moulton LH, Chaudhary MA, Chen MZ, Sewankambo NK, Wabwire-Mangen F, Bacon MC, Williams CF, Opendi P, Reynolds SJ, Laeyendecker O, Quinn TC, Wawer MJ (2007) Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 369: 657-666. S0140-6736(07)60313-4 [pii];10.1016/S0140-6736(07)60313-4 [doi].

        7.    2011 July) WHO Male circumcision for HIV prevention. http://www.who.int/hiv/topics/malecircumcision/en/index.html.

 

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Derek: Infection and Immunity Summer Training Course in China

 

I am happy to present this incredibly thoughtful Postcard from Derek Ng.  Derek is from Toronto, Canada and participated in the Summer Training Course in China in 2009 focusing on Infectious Diseases.  Derek’s reflection is a striking example of how education is imperative in and out of the classroom.  I am inspired by Derek’s story and recommend international training as an essential component of science and health care instruction.  Derek is incredibly studious but he is always conscious to add heart and thoughtfulness to his work as well as daily life.  He is now a second year medical student at the University of Western Ontario.  Further questions for Derek, he is happy to help: cng2014(at)meds(dot)uwo(dot)ca.  If you have any questions or are interested in the Summer Training Courses please contact me, akelvin(at)jidc(dot)org. 

Alyson

Hi there!

University of Western Ontario

My name is Derek Ng and I am currently starting my second year of medicine at the University of Western Ontario in Canada. I would like to share my international research experience that has left a positive impression on my young scientific/medical career.

Two years ago, I was a fourth year undergraduate student at McMaster University, in Hamilton, Canada, majoring in Biology. I was specifically very fond of infection and immunology, so I had focused on courses related to these topics. I selected my fourth year thesis in a mucosal immunology lab, working on a project aimed at characterizing immune homeostatic responses upon colonization of germ-free mice. The experience helped me refine both my skills and knowledge, as well as solidify my interest in immunology.

Summer Training Course in Infectious Diseases

I had a good friend who knew about my passion towards infectious diseases and she informed me about a training opportunity in Shantou, China, entitled a Summer Training Course in China Focusing on Infectious Diseases. The training course was coordinated by

 

Dr. David J. Kelvin of the University of Toronto. Furthermore the course is a joint collaboration between the University of Toronto, Shantou University, The University of Sassari, and Hong Kong University.  The course was open to all students of any country and university and provided financial stipends and travel support. 

I was so excited when I saw the advertisement that I prepared and submitted my application immediately without hesitation. Following a Skype interview and later confirmation of acceptance, I was well on my way to travelling to the other side of the world.

I never travelled very much before

Shantou, China Map from WebCarta.et

and consequently the idea of pursuing research abroad – least of all in China – never occurred to me as a potential direction in which I could steer my career.

My first destination was Hong Kong, which was where I would meet the other students for our bus ride toShantou. I scheduled my flight early because this place was special to me (Hong Kong was my birth place). It was my second time meeting my relatives and it turned out to be a very pleasant time for me. Living there shortly was an easy transition since English is commonly used and I am able to speak Cantonese as well. Despite the fun with my family, I was very eager to meet the rest of the students and make the trip into the mainland. I had never visited China before and I really did not know what to expect apart from things I had heard from my family and read on the internet.

 

Upon our departure from Hong Kong, I was greeted by Dr. David Kelvin (our fearless leader, professor, mentor and program coordinator) as well as the other students.  Dr. D. Kelvin is a scientist at the University Health Network, Toronto Ontario, The International Institute of Infection and Immunity in Shantou, China and a Professor at the University of Sassari, Italy.  His research mostly focuses on the immune response to influenza infection.

Institute of Infection and Immunity

This was my first time meeting the students and David, although we had previously communicated a bit over the internet. There were only ten of us, but we brought with us a very diverse background of experience. Collectively our previous knowledge spanned across biochemistry, biology, engineering science, health science, immunology, medicine and microbiology. We were a very well-balanced group and bonded quickly. One interesting anecdote I have here is that we were traveling in the midst of the 2009 H1N1 influenza outbreak.  When we were crossing the border fromHong Kong into China, our bus was boarded by officials with temperature sensors. We had all passed the initial screen, but when we entered the checkpoint building we had our temperatures taken again. Some of my colleagues were separated for even further screening (this time it was an axillary temperature). When we emerged from the other side of the border, there were only nine of us. One of the students was taken from us for an overnight quarantine at the hospital (he was fine and would meet up with us the next morning). This experience had undoubtedly set the tone for the course.

Chaozhou Group

Shortly after reaching Shantou, it had sunk in that I was definitely not in Toronto anymore. I was in a beautiful place surrounded by lush green mountains with a river running out towards the open ocean. I was surrounded by throngs of motorcycles, cars, people and a way of life that, although seemed foreign to me, was normal for the citizens. Also, the main language spoken here was Mandarin although a local Chaozhou dialect was in use as well. The language barrier made my stay more interesting because I was often trying to communicate with people by figuring out the Mandarin equivalent of words that I already knew in Cantonese.

We stayed at the international student residences at ShantouUniversity, the campus of which was quite stunning and picturesque. We were introduced to the staff and scientists that worked at the International Institute of Infection and Immunology, located at a separate medical campus in the city. As stated by the Institute:  The mission of the institute is to increase our understanding of human infectious diseases through the use of genomics, proteomics and molecular epidemiology. Frieda Law, the representative of the Li Ka Shing Foundation at Shantou, gave us a tour of the medical building, explained some of the history of the medical school and what the facilities had to offer. She also introduced to us the philanthropist activities of Li Ka Shing, which ranged from rural health projects to even funding activities such as our trip. The staff working there were a group of exceptional people and well-versed in their knowledge and ability to teach. Everyone involved was friendly and very accommodating to us during our time in Shantou.

We were given daily lectures on various topics infectious diseases in the mornings such as . Professors included David Kelvin, Michael Ratcliffe, Salvatore Rubino, Piero Cappuccinelli, Giacamo Spissu, Honglin Chen, Jiang Gu,  Guan Yi, Liqun Jin, Yong Xiao, Krystal Lee, Alberto Joseph Leon, Amber Farooqui.  In the afternoons we would learn how to apply our knowledge in a lab setting.  We were assigned various tasks to complete during our one-month excursion. For example, we were taken to see traditional Chinese medical doctors and collect herbs known to be prescribed for flu-like symptoms. Each student was then

Mackenzie Howatt and I in our shantou university medical college lab coats

assigned an herb to investigate in terms of its properties, usage, and extraction of active ingredients. Following lectures on influenza, we were given the opportunity to grade histological slides as well as grow virus in chicken eggs. I personally enjoyed the way we learned because the design of the course created a very interactive learning experience that helped solidify concepts.

There is undoubtedly a difference between knowledge acquired in a classroom and that gained from real experiences. For a student to sit in the comfort of a lecture hall and learn about how pandemic influenza and recombination occur is undoubtedly important. However, what complements this textbook knowledge is to be in a place where you can see these concepts in action. For example, Dr. D. Kelvin specifically wanted us to see Shantou’s live poultry markets, in which ducks, geese and other birds were kept together in close proximity to each other and people. Upon further inquiry, we were told that unsold birds were brought back to a common, large farm at the end of the day. This helped me appreciate the complexity for public health officials or scientists in assessing the origins and spread of an infectious outbreak.

There are many things that come to my mind when I think about what I learned inShantou. For one, it reinforces the idea that science is not only being conducted in developed countries. I also better understand part of the rationale behind open access scientific journals in helping to provide fair access to information for scientists in resource-limited situations. By promoting science in places like this, it helps to secure the future of scientific progress on a global stage where the vast majority of today’s youth is situated. On

an example of a poultry market where different breeds of birds are housed together for sale

a personal level, I had gone to China without any international experience and came back to Canada as a more passionate individual towards issues in global health. We had met scientists from around the world and even officials such as the former President of Sardinia, Mr. Giacomo Spissu. Our conversations on health policy allowed me to gain a better understanding of how an outbreak is dealt with on the government level. By the end of the course, I could associate all the levels of collaboration during an outbreak in terms of basic scientific research, epidemiology, health policy, economics and even the psychosocial or cultural aspects.

I hope this offers you a sufficient glimpse into my one month spent in paradise. There is so much more I could say about this experience, because it opened my eyes to the world and changed my life for the better. I would like to express my deepest appreciation to Dr. D. Kelvin, his staff, colleagues and friends for making this all possible by organizing and participating in such an incredible course.

JoAnne, Mackenzie, myself, volunteers from HKU *hong knog university* and STU *shantou university*, and children from a rural area in China

 

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Ana: Salmonella in Sardinia

I am please to present a Postcard written by the lovely Ana Carolina!  Ana is a microbiologist from Brazil who carried out part of her PhD in Sardinia, Italy studying salmonella.  I was lucky enough to work in Sardinia at the same time as Ana Carolina while I was completing my Visiting Professorship at the University of Sassari.  Ana works incredibly hard but always with a smile on her face.  It was a delight to see her everyday. I am happy to call Ana a colleague and a friend!

I went to Sardinia!

In 2008 I started my PhD in food microbiology at the Federal University of Rio Grande do Sul (UFRGS), in Porto Alegre, Brazil. It was a moment of transition, because I did my master’s degree working with mycotoxins and now I decided to work with Salmonella. I was accepted to a group that has studied the occurrence of outbreaks of salmonellosis in the state of Rio Grande do Sul (RS) (southern Brazil) for 10 years, the Laboratory of Food Microbiology of the ICTA/UFRGS.

 
 

This research group had already made several discoveries regarding Salmonella Enteritidis (S. Enteritidis).  In previous work done in the Laboratory of Food Microbiology, the spvR gene (Salmonella plasmid virulance)was identified in 82.7% of S. Enteritidis infections involved in food poisoning cases which occurred in RS from 1999 to 2000 [1] . These isolates were also characterized according to their antibiotic resistance, and it was shown that there was a high percentage of sensitivity to most of the drugs tested [1] . Oliveira et al. [2] demonstrated that strains of S. Enteritidis isolated from these outbreaks which occurred in RS in 2001 and 2002 showed similar resistance profiles as the lines of the preceding period.  Interestingly, it was identified that one strain of S. Enteritidis was involved in more than 95% of the salmonellosis cases which occurred in RS [2]. Importantly, other work from the laboratory evaluated the resistance of S. Enteritidis SE86 to disinfectants commonly used in food industries [2]. It was concluded from this work that peracetic acid, sodium hypochlorite and quaternary ammonium were able to inactivate S. Enteritidis SE86; however, this strain was more resistant to the concentration of 200 ppm sodium hypochlorite (commonly used in Brazil).
 

Salmonella by gyalogbodza.hu

Continuing the investigation into the strains of S. Enteritidis which are responsible for salmonellosis and acid resistance in RS, my PhD project aims to investigate the expression of resistance genes which may contribute to the involvement of this predominant strain of S. Enteritidis in food in Brazil. That was the part of the thesis that took me to the Laboratorio di Microbiologia at Univesrsità degli Studi di Sassari.

 

So, with the desire of live outside Brazil and to enrich the Brazilian science, I went to Sardinia or Sardegna, Italy.  Sardinia is a large Island in the Mediterranean Sea.

 

To realize this dream, I sent emails to  Professore Salvatore Rubino (Editor-in-Chief of JIDC) and Professore Sergio Uzzau, asking if I could perform one year of research in their laboratory. After their positive response, I applied for a scholarship to Capes, a Brazilian funding agency for research. The result was one year living in Sassari (2009 to 2010), developing my thesis.

Landscape of Sardinia

Landscape of Sardinia by Travel around the World

In Sardinia genetic modifications in the Brasilian S. Enteritidis (strain SE86) were preformed. With the help of Doctoressa Donatella Bacciu, we performed knockout techniques [3] and epitope tagging [4] in four different genes to check the expression of these strain’s forward acidity and high temperatures, results which I am currently writing up.

It was an incredible experience! Sardinia has breathtaking landscapes, incredible history and very nice people. The university gave me all necessary support for my research; with great colleagues guiding me … I learned a lot, both inside and outside the laboratory. I returned to my country with lots of knowledge: the language, the laboratory techniques, dear friends. I love Sardinia!

 Today I am writing the articles and the thesis, because I have to finish my PhD

The Italian Island of Sardinia by Hikenow.net

by March 2012.

 Post doc? Why not? Science takes us to places that we never dreamed… 

Ana

 Ana is 31 years old. She studied biology (2000 until 2004), then did a two year master degree ( between 2005 and 2007) working with  Aspergillus flavus (food microbiology). In 2008, she started her PhD (food microbiology) at the Federal University of Rio Grande do Sul (UFRGS) in Porto Alegre, Rio Grande do Sul, Brazil. Ana’s story to be post in Portuguese soon!

 

 

Silvia, Francesca, me, Massimo and Donatella: friends and colleagues of the microbiology laboratory in SardiniaAna in Sardinia, ItalyAna in Sardinia

Amazing food and wine

Reference List

 

    1.    Geimba MP, Tondo EC, de Oliveira FA, Canal CW, Brandelli A (2004) Serological characterization and prevalence of spvR genes in Salmonella isolated from foods involved in outbreaks in Brazil. J Food Prot 67: 1229-1233.

    2.    de Oliveira FA, Brandelli A, Tondo EC (2006) Antimicrobial resistance in Salmonella enteritidis from foods involved in human salmonellosis outbreaks in southern Brazil. New Microbiol 29: 49-54.

    3.    Datsenko KA, Wanner BL (2000) One-step inactivation of chromosomal genes in Escherichia coli K-12 using PCR products. Proc Natl Acad Sci U S A 97: 6640-6645. 10.1073/pnas.120163297 [doi];120163297 [pii].

    4.    Uzzau S, Figueroa-Bossi N, Rubino S, Bossi L (2001) Epitope tagging of chromosomal genes in Salmonella. Proc Natl Acad Sci U S A 98: 15264-15269. 10.1073/pnas.261348198 [doi];261348198 [pii].

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Olga: From Mozambique to Brazil!

 

I am sooooooo excited to share this Postcard from Olga Andre Chichava.  Her post made me laugh, cry and most importantly think!  Olga is a science mom from Mozambique who studied Leprosy in Brazil.  Her post encompasses the vision of the JIDC Postcard and I am proud to have her on the Blog.  There is no doubt Olga has a bright future ahead of her!   

Alyson

  

 

 A Challenge!! An Opportunity!!

My name is Olga André Chichava, and I’m a young biologist from Mozambique!

It has always been my dream to study abroad, to know how others do research and then hopefully help to improve the Health Sector back in my home country.

The opportunity arose in February 2009, when I was awarded a Brazilian Government “PEC-PG” scholarship (CNPq) and was accepted at the Public Health Master program at Ceará Federal University (Fortaleza, Brazil) under the supervision of Prof. Jörg Heukelbach.

The decision to go to Fortaleza was not easy, since I had a 3-year-old daughter and my husband was also abroad, enrolled in a PhD program in Japan. After a lot of discussions, we came to the agreement of leaving our daughter with my parents in Mozambique and took all provisions so she could have a “normal life” (expect our warm love and affection) while we both were abroad.

Upon choosing the hard way, and despite the semester starting at the end of that same month, a painful two-month waiting period followed, because the travel expenses, which were to be provided by my government, were still not available. I lost several classes and was informed that the ticket had been purchased, just a day before my departure on March 17, 2009!

In Brazil, I was welcomed by nice people but also with a long bureaucratic process regarding my student registration, which had to be done while attending classes and trying to recover the lost credits. This ended up adding further complications and delays in receiving my scholarship funds. So I had to live for several months without any funds. But Brazilians helped me a lot so that I was able to conclude all mandatory lectures and get the credit points.

I then joined the research team of the MAPATOPI project, an interdisciplinary approach to improve the leprosy control program in Brazil, coordinated by Prof. Heukelbach.

Leprosy is an infecto-contagious disease with a chronic evolution and high infectivity, though low pathogenicity, caused by the intracellular and acid-resistant bacteria Mycobacterium leprae (Fogos AR et al., 2000). The transmission occurs to people who have been in contact with a sick, non-medicated person; its immunogenic power is responsible for the high incapacitating potential of the illness.

Foot lesion, rural Lizarda, Tocantins State – 2009 Photo by Kathrin Hafner

Despite numerous efforts and advances to control leprosy in the world, the disease is still a serious public health’s problem in Brazil and several other countries (Galvao et al., 2008; Goulart IMB et al., 2002; ). Until 2007, Mozambique was the nation with the highest prevalence rate in Africa (Griffiths S & Ready N 2001;  Honrado ER et al., 2008). According to the World Health Organization (WHO), the annual detection rate of leprosy in the endemic regions has considerably declined since 2002, and the number of new cases as of 2008 was about 249.000, confirming that the disease hasn’t been yet eliminated from the Asian, South American and African continents (El Hassan LA et al., 2002; Heijnders ML 2004).

 

 

So, I found it interesting to join this team of professionals and took up the challenge of researching not just about this contagious disease, but to also excel myself in epidemiology investigation, so needed to contain many other diseases back home.

Interviewing a patient in his house, rural Miracema, Tocantins State – 2009. Photo taken by Friederike Walter

The study was conducted in 78 municipalities in Tocantins State, Central Brazil, a leprosy endemic area. Tocantins is the State with the highest leprosy annual detection rate (about 88.5 new cases per 100.000 population/year) (Kerr-pontes LR et al., 2006). So this was a real exciting challenge! We visited all these 78 districts and included all leprosy patients from these districts in the study. The field work was done in four months, in which we conducted scheduled interviews with patients usually in the local Health Centers, in both periods of the day. However, on several occasions we had to go after the patients because they did not show up, either because they lived far away, were at work, or their health condition was too poor. This situation was common in the rural areas and an extra effort was put in place to reduce the non-participation bias (Chalise SC 2005). The daily number of interviews ranged from 12 to 25, and we included a total of about 1,000 individuals with leprosy in the study.

Conducting an interview at the local Health Center, Miracema City, Tocantins State – 2009. Photo taken by Friederike Walter

 

 

My task was to identify risk factors for defaulting multidrug therapy that usually lasts 6-12 months. I have perceived that adherence to therapy is a result of a complex interaction between different socio-cultural, service-related, drug-related and economical factors (Aagard-Hansen et al., 2010; Altice FL & Friedland G 1998; Coebergh JA & Buddingh H 2004; Fogos AR et al., 2000; Ignotti E et al., 2001; Kar S et al., 2010; Nsagha DS et al., 2009; Natal S et al., 1999; Trindade LC et al., 2009). Intermittent problems of drug supply need to be resolved and many people complained of problems swallowing the drugs; thus producers should consider oral drug formulations that may be more easily accepted by patients (Chichava OA et al., 2011; Rao PS 2008). I have seen how complex public health interventions can be, and that an integrated approach is needed to further improve adherence and other aspects of leprosy control, such as early diagnosis. Improved adherence to treatment will further improve the leprosy control programs and in addition minimize the risk of possibly upcoming drug resistance. I am happy that I could contribute to the control of such an interesting disease and I learned a lot about epidemiological studies, not only in theory, but also in practice. I defended my Master’s thesis in less than two years, and the results of my study were published in two scientific journals: “Reasons for interrupting Multidrug Therapy against Leprosy: The patient’s point of view; Lepr Rev (2011) 82, 78-79” (Chichava OA et al., 2011) and “Interruption and Defaulting of Multidrug Therapy against Leprosy: Population-Based Study in Brazil’s Savannah Region; PLoS Negl Trop Dis (2011) 5(5): 1031” (Heukelbach J et al., 2011).

 

 

I am currently living with my lovely daughter and husband in Japan for the remainder of his PhD course, while we repair our broken family links and boost ourselves for the service of our country, starting probably mid next year!

Thank you very much for allowing me to share my little story with all of you in this blog.

Warm regards

Olga André Chichava 

 

Olga Andre Chichava was born in Maputo, Mozambique, and is 35 years old.  She attended primary school at “Escola Primaria 7 de Setembro”, junior high-school at “Escola Secundaria Josina Machel”, high-school at “Escola Secundaria Francisco Manyanga” and college at “Universidade Eduardo Mondlane”, all in Mozambique’s capital city Maputo. After college she worked at the private clinical laboratory “LAC-Laboratorio de Analises Clinicas”, before studying in Brazil.

References

AAGARD-HANSEN, J. H.; NOMBELA, N. & ALVAR, J. Population movement: a key factor in the epidemiology of neglected tropical diseases. Tropical Medicine and International Health, 15(11): 1281-1288, 2010.

ALTICE, F. L. & FRIEDLAND, G. H. The era of adherence to HIV therapy. Annals of Internal Medicine, 129(6): 503-505, 1998.

CHALISE, S. C. Leprosy disease in Nepal: Knowledge and non-compliance of patients. Journal of Nepal Medical Association 44(158): 39-43, 2005.

CHICHAVA, O. A.; ARIZA, L.; OLIVEIRA, A. R.; FERREIRA, A. C.; MARQUES  DA SILVA, L. F.; BARBOSA, J. C.; RAMOS JR., A. N.; HEUKELBACH, J. Reasons for interrupting multidrug therapy against leprosy: the patients’ point of view. Leprosy Review, 82, 78-79, 2011.

COEBERGH, J. A. & BUDDINGH, H. Non-adherence to leprosy treatment in Western Sudan; the people behind the numbers. Leprosy Review, 75(4): 404, 2004.

EL HASSAN, L. A.; KHALIL, E. A. & EL-HASSAN, A. M. Socio-cultural aspects of leprosy among the Masalit and Hawsa tribes in the Sudan. Leprosy Review, 73(1): 20-28, 2002.

FOGOS, A. R.; OLIVEIRA, E. R. A. & GARCIA, M. L. T. Análise dos motivos para abandono do tratamento – o caso dos pacientes hansenianos da Unidade de Saúde em Carapina/ES. Hansenologia Internationalis, 25(2): 147-156, 2000.

GALVÃO, P. R. S.; FERREIRA, A. T.; MACIEL, M. D. G. G.; ALMEIDA, R. P.; HINDERS, D.; SCHREUDER, P. A.; KERR-PONTES, L. R. An evaluation of the SINAN health information system as used by the Hansen’s disease control programme, Pernambuco State, Brazil. Leprosy Review, 79(2): 171-182, 2008.

GOULART, I. M. B.; ARBEX, M. H. C.; RODRIGUES, M. S.;GADIA, R., Efeitos adversos da poliquimioterapia em pacientes com hanseníase: um levantamento de cinco anos em um centro de saúde da Universidade Federal de Uberlândia. Revista da Sociedade Brasileira de Medicina Tropical, 35(5):453-460, 2002.

GRIFFITHS, S. & READY, N. Defaulting patterns in a provincial leprosy control programme in Northern Mozambique. Leprosy Review, 72(2): 199-205, 2001.

HONRADO, E. R.; TALLO, V.; BALIS, C. A.; CHAN, G. P.; CHO, S. N. Noncompliance with the World Health Organization multidrug therapy among leprosy patients in Cebu, Philipines: Its causes and implications on the leprosy control program. Dermatologic Clinics, 26(74): 221-229, 2008.

HEIJNDERS, M. L. An exploration of the views of people with in Nepal concerning the quality of leprosy services and their impact on adherence behavior. Leprosy Review, 75(4): 338-347 2004.

HEUKELBACH, J.; CHICHAVA, O. A.; OLIVEIRA, A. R.; HAFNER, K.; WALTER, F.; MORAIS DE ALENCAR, C. H.; RAMOS JR., A. N.; FERREIRA, A. C.; ARIZA, L. Interrupting and defaulting of multidrug therapy against leprosy: Population-Based study in Brazil’s Savannah Region. Neglected Tropical Diseases, 5(5), e 1031, 2011.

IGNOTTI, E.; ANDRADE, V. L. G.; SABROSA, P. C.; ARAÚJO, A. J. G. Estudo da adesão ao tratamento da hanseníase no município de Duque de Caxias – Rio de Janiero. Abandonos ou abandonados? Hansenologia Internationalis, 26(1): 23-30, 2001.

KAR, S.; PAL, R. & BHARATI, D. R. Understanding non-compiance with WHO-multidrug therapy among leprosy patients in Assam, India. Jornal of Neurosciences in Rural Practice, 1(1): 9-13, 2010.

KERR-PONTES, L. R.; BARRETO, M. L.; EVANGELISTA, C. M.; RODRIGUES, L.C.; HEUKELBACH, J.; FELDMEIER, H. Socioeconomic, environmental, and behavioural risk factors for leprosy in Northeast Brazil: results of a case-control study. International Journal of Epidemiology, 35(4): 994-1000, 2006.

KUMAR, R. B. C.; SINGHASIVANON, P.; MEHAISAVARIYA, P.; KAEWKUNGWAL, J.; SHERCHAND, J. B.; PEERAPAKORN, S.; MAHOTARN, K. Gender differences in epidemiological factors associated with treatment completion status of leprosy patients in the most hyperendemic district of Nepal. Southeast Asian Journal of Tropical Medicine and Public Health, 35(2): 334-339, 2004.

LOCKWOOD, D. & SUNEETHA, S. Leprosy: too complex a disease for a simple elimination paradigm. Bulletin of the World Health Organization, 83(3): 230-235, 2005.

NSAGHA, D. S.; BAMGBOYE, E. A. & OYEDIRAN, A. B. O. O. Operational barrier to the implementation of multidrug therapy and leprosy elimination in cameroon. Indian Journal Dermatol Venereol Leprol, 75 (5): 469-475, 2009.

NATAL, S.; VALENTE, J.; GERHARDIT, G.; PENNA, M.L. Modelo de predição para o abandono do tratamento da tuberculose pulmonar. Boletim de Pneumologia Sanitária, 7(1): 65-78, 1999.

RAO, P. S. A study on non adherence to MDT among leprosy patients. Indian journal leprosy, 80: 149-154, 2008.

TRINDADE, L. C.; ZAMORA, A. R. N.; MENDES, M. S.; CAMPOS, G. P.; AQUINO, J. A. P.; CANTÍDIO, M. M.; HEUKELBACH, J. Fatores associados ao abandono do tratamento da hanseníase em João Pessoa, Estado de Paraíba. Cadernos Saúde Coletiva, 17(1): 51-65, 2009.

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Filed under Infectious Disease, Leprosy, Mozambique, Postcards