My India Stint Starts with an Adventure

I was supposed to fly from NYC to Delhi via London, leaving JFK Sunday Dec 28th, arriving in Delhi on Tuesday Dec 30th at 2am. Fifteen minutes before landing, the captain announced on the loudspeaker that he could not land due to the poor visibility. The plane would be diverted to Mumbai.

Now I'm now stuck at a hotel in Mumbai until further notice. It was a bit scary to arrive in the middle of the night, 2 hours by air from my destination. One billion people in this country, and I don't know anybody! Luckily, I was able to contact the team in Delhi to let them know what happened. I will fly to Delhi as soon as British Air is ready, brief with the team in Delhi, then fly to Bihar state the following day.

Bihar India

In three days, I will leave for Bihar India to work on another MSF project. Bihar is one of the poorest States in India. It is in the Northeast part of the country, just south of Nepal and West of Bhutan. The project is on diagnosis, prevention, and treatment of visceral leishmaniasis (also known as Kala-Azar). Kala-Azar is a protozoal infection transmitted by the sandfly. More on this disease in future posts.

I first heard about the project just two weeks ago, when I was in Liverpool, finishing up my tropical medicine course. I have not had enough time prepare for this trip, but I am excited nonetheless. I feel lucky to have the opportunity to work in Asia (my fourth continent in three years!).

Leptospirosis Outbreaks in Triathletes and Adventure Sportspeople

Leptospirosis is a bacterial infection of rats and other rodents. It can be transmitted to humans when they swim in fresh water bodies contaminated by rodent urine. Although many American doctors regard this disease as an exotic tropical infection, leptospirosis infections actually occur world-wide. The organism is a spirochete-- a coiled bacteria similar in shape to the organisms that cause syphilis and lyme disease (see electron micrograph pic at left).

Most people who get leptospirosis have a non-specific flu-like illness about a week or two after exposure. About ten percent of patients get serious complications, including kidney and liver failure (Weil's disease). Textbook cases present with subconconjunctival hemorrhage (red eyes), but of course this symptom is hardly sensitive or specific.

I was surprised to learn that there have been several outbreaks of leptospirosis in triathletes and adventure sportspeople. The largest outbreak in the United States was after a triathlon near Lake Springfield in 1998, when 12% of participants reported a post-triathlon febrile illness. Of 474 participant blood samples tested, 11% were spirochete positive (Clin Infect Dis. 2002 Jun 15;34(12):1593-9. Epub 2002 May 24). ] In 2000, there was an outbreak in Athletes who competed in the 10-day Borneo "Eco Challenge 2000, multisport endurance race." The event included jungle walking, swimming, kayaking, spelunking, climbing, and mountain biking. About half the athletes got leptospirosis. There's an interesting report of the epidemiological investigation in CDC's Emerging Infectious Diseases, Sejvar J, Bancroft E, Winthrop K, Bettinger J, Bajani M, Bragg S, et al. Leptospirosis in "Eco- Challenge" athletes, Malaysian Borneo, 2000. Emerg Infect Dis [serial online] 2003 Jun. The CDC suggests that athletes who participate in these events might want to consider taking Doxycycline for pre-adventure sport prophylaxis!

Hookworm

Hookworm is a major cause of anemia-related morbidity in the developing world. The Ancyclostoma Duodenale hookworm species looks scary under the electron microscope. Actual size is only 8-11 mm. The worm sinks those teeth into the wall of the small intestine and drinks blood from the capillary rich mucosa.

Each adult worm can consume up to about 0.25ml of blood per day. Many patients--especially children--are heavily infected. An infection of 100 worms could cause 25 cc blood loss per day, which is one unit of blood every 10 days. On top of HIV, tuberculosis, malaria, sickle cell, and poor nutrition in subsaharan Africa (all causes of anemia), it is easy to see how hookworm-related anemia is a big problem.

Kristof on XDR-TB

Kristof has a column in the New York Times today on XDR-TB in Armenia. Nothing new here, but I find it reassuring that other people are getting as worried about this as I am.

Excreta Control and the VIP Latrine

I am reviewing the water and sanitation module this morning. One of our practice essay questions: "describe briefly how you would provide an excreta control programme in a refugee camp during the first few weeks of an emergency."

Let's see... well, I would definitely pull out my Sphere Project Humanitarian Response and Minimum Standards in Disaster Response handbook. The sphere project was started in 1997 by a group of humanitarian NGOs. They collaborated on a comprehensive disaster response handbook, which is free and downloadable from www.sphereproject.org. WHO also publishes a "Guide to the development of on-site sanitation." Of course there is always MSF's "Refugee Health: An Approach to Emergency Situations,"also free and downloadable.

These resources say that at the start of an emergency, you might only have time to build shallow trench latrines, which are essentially shallow pits that are covered by a thin layer of soil after defecation.

After a day or two, you will need to build something mroe permanent, such as a simple pit latrine, or better yet a Ventilated Improved Pit Latrine (VIP). A simple pit latrine is just a slab with a hole over a pit that is at least 2m deep. The bottom of the pit needs to be at least 1.5 meters above the water line under the soil, so that the excreta doesn't leak into the surface water supply. There should ideally be at least one latrine for each 20 people.

The ventilated improved pit latrine (VIP) has several clever features that make it a better option than the simple pit latrine. There is a superstructure over the latrine part that keeps the it darker inside than outside. There is also a ventilation pipe that exits the latrine roof. Odors from the latrine exit from the pipe. Flies and mosquitoes are also attracted to the light of the pipe, rather than the dark of the pit. You can put a trap at the top of the pipe to kill the insects as they fly towards the light. Image from Water Aid, an International Charity that helps poor people gain access to safe water, sanitation, and hygiene.