Nursing in the world's most challenging places

Josie Gilday has worked in some of the world's most challenging places, including Haiti after the devastating earthquake and civil war-plagued Ivory Coast.

[Overcoming the global impact of neglected tropical diseases and challenges]

The global impact of neglected tropical diseases has been much more recognized recently. The elimination and eradication of these diseases is significant for achieving the millennium development goals, for societies and for global healthcare. WHO already drew the roadmap to accelerate the work on eliminating and eradicating the selected diseases for 2015 and 2020 respectively. The present review demonstrates the current situation and progress of controlling these neglected tropical diseases and the challenges faced, and emphasizes the action of China.

[To overcome neglected tropical diseases by global health governance]

Neglected tropical diseases (NTDs) are common infections of the poorest people of the world. The WHO publication of a roadmap that lays out the vision for ending the misery caused by NTDs has inspired the London Declaration on NTDs, which demonstrates that the global public-health agenda now embraces NTDs. This review discusses the advantages of global health governance in overcoming NTDs, and points out the potential ways of the involvement of China in global health through international collaboration.

[Medical clearance for missions abroad (EEU): definitions, recommendations for use and performance]

Standards for medical clearance for private or business missions abroad are--at least in the German speaking countries--not clearly defined and mostly derived from the old terminus "Tropentauglichkeit" which means fit for mission in the tropics. The authors now define a new standard, called "Entsendungstauglichkeitsuntersuchung" which means clearance of fitness for all types of missions abroad, independent of distinct climatic zones. To meet the inhomogenous requirements of different institutions and different types of missions the medical examination proposed follows a modular structure to optimize economic and medical use of resources. Moreover, as Austria, Germany and Switzerland have different legal and economic postulates, the medical examination has to be adapted to the different premises. The definition and description of this special type of "medical clearance for missions abroad" is supplemented by recommendations for definitions of clients who should undergo such an investigation and the professionals who should perform this type of investigation. Additionally, results of this type of medical clearance are defined and prophylactic aspects in terms of pre-travel advice are mentioned.

Neglected tropical diseases

These diseases could be controlled or eliminated in our lifetimes if efforts are better coordinated

A student-led campaign to help tackle neglected tropical diseases

The authors propose that innovative student-led campaigns to address neglected diseases can and do make a practical difference.

Early risk assessment for viral haemorrhagic fever: experience at the Hospital for Tropical Diseases, London, UK

OBJECTIVES

To implement a policy of systematic screening for viral haemorrhagic fever (VHF) among travellers returning from African countries with fever, commencing at initial clinical contact.

METHODS

A protocol based on UK Advisory Committee on Dangerous Pathogens guidance was developed collaboratively by medical, nursing and laboratory staff. Audit was carried out to quantify resource demands and effects on time to diagnose malaria, the main differential diagnosis.

RESULTS

A protocol is now implemented for all patients presenting to HTD with fever, with clear guidelines for interaction with clinical and laboratory staff at each stage. The protocol required moderate amounts of clinical and laboratory staff time and resulted in some additional hospital admissions. The time to a diagnosis of malaria increased from a median of 90 (range 50-125) min in patients without VHF risk to a median of 140 (range 101-225) min (p=0.0025) in those assessed as at risk.

CONCLUSIONS

Although all acute medical services need to have robust procedures for early detection of patients with serious transmissible conditions, few implement such a policy. Our protocol requires increased human and other resources but has no important impact on the rapidity of diagnosis of malaria, and is now embedded in local practice.

Integrating evidence based medicine into routine clinical practice: seven years' experience at the Hospital for Tropical Diseases, London

PROBLEM

Introduction and evaluation of evidence based medicine (EBM) into routine hospital practice.

STRATEGY FOR CHANGE

Routine EBM meetings introduced in 1997.

DESIGN

Review of outcomes of meetings from 1997 to 2004, focusing on their effect on clinical practice.

SETTING

Referral centre for tropical and domestic infectious diseases. KEY MEASURE FOR IMPROVEMENT: Outcome of meetings, classified as resulting in a change in practice; confirmation or clarification of existing practice; identification of a need for more evidence; and outcome unclear.

EFFECTS OF CHANGE

Examples include a change from inpatient to day case treatment of New World cutaneous leishmaniasis; development of guidelines on the treatment of coinfection with visceral leishmaniasis and HIV; and identification of the need for more data on the efficacy and toxicity of atovaquone-proguanil (Malarone) compared with quinine plus sulfadoxine-pyrimethamine (Fansidar) in the treatment of uncomplicated falciparum malaria, which resulted in a clinical trial being set up.

LESSONS LEARNT

Incorporation of EBM meetings into our routine practice has resulted in treatment guidelines being more closely based on published evidence and improvements to care of patients. Written summaries of the meetings are important to facilitate change.

A re-evaluation of the occupancy factors for effective dose estimate in tropical environment

In the estimation of the effective dose to the public, outdoor and indoor occupancy factors have been an important parameter. These factors vary, depending on the prevailing environmental condition in a particular location. The factors have been estimated for the rural and urban areas in Nigeria. An outdoor factor of 0.3 and 0.22 have been estimated for rural and urban dwellers, respectively. The rural outdoor factor is 50% above the value recommended as the world average by the UNSCEAR. The urban outdoor factor is 10% higher than this value. The total outdoor gamma dose rate in the air due to (40)K, (238)U and (232)Th in the soil for some rural population in the southern part of Nigeria is 29.50 +/- 3.80 nGy h(-1) and the average outdoor effective dose has been estimated to be 54.28 +/- 6.95 microSv y(-1) using the present occupancy factor.

Strategic emphases for tropical diseases research: a TDR perspective

Setting priorities for health research is a difficult task, especially for the neglected diseases of the poor. A new approach to priority setting for tropical diseases research has been adopted by the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (known as the TDR). Priorities are defined on the basis of a comprehensive analysis of research needs and research opportunities for each of the ten major tropical diseases in the TDR portfolio. The resulting strategic emphases matrix reflects the priorities for tropical diseases research from the perspective of the TDR. Its purpose is not to impose global research priorities, but we believe the results could be useful to other organizations.

Tropical trials: the problems of research in the tropics

Eleven scientists who, like Herbert Gilles, have spent many years in the study of tropical disease, responded to an inquiry about the most problematic aspects of conducting intervention trials in the tropics. Areas of challenge or difficulty that figured most frequently in the replies were: (1) the proper interests, involvement and perceptions of the studied community; (2) maintaining a research team's standards and motivation over long periods; (3) good study design; (4) communications; and (5) the provision of adequate remuneration and incentives to local scientists. Other problems mentioned included the need to translate results into policy, the importance of a long-term view, the correct use of controls, the attitudes of donors, and the influences of national and local politics. Careful attention must be given to these aspects in the planning and conduct of international research.