Global health

Question 1

Explain the intent of the Sustainable Development Goals and identify their potential impact on global health

Answer 1

are the blueprint to achieve a better and more sustainable future for all. They address the global challenges we face, including poverty, inequality, climate change, environmental degradation, peace, and justice.

Question 2

what are the differences between the MDG and the SDG

Answer 2

Whilst building on from the Millennium development goals, the SDGs do have some key differences.
- These goals apply to all countries (not just 3rd world countries)
- They are much broader goals (that attempt to tackle the underlying causes, not just the outcomes)
- They also consider the economic, environmental and social factors
- They also include some goals around the means of implementations (how they are going to get funding, data collection, partnerships etc.)
- They have been criticised as being too broad and to general, meaning they risk losing focus and instead will become vague things that are impossible to meet

Question 3

what are some factors that impact global health

Answer 3

− Whilst to date a number of positive changes have been made in the field of global health, there are still a number of challenges impeding development. Some of these include;
- We are still yet to achieve basic universal healthcare across the globe
- International aid is poorly aligned between those who provide it, there is no agreed upon common goal
- There is a shortage of basic health infrastructure
- There is a shortage of health and personal education
- Globalisation has caused a rise in non-communicable disease

Question 4

Understand the principle and relevance of universal health coverage

Answer 4

− Is any system that provides quality medical services to all citizens (regardless of their ability to pay)
equity in access to primary health services
services provided should be quality (provides beneficial services, staff are trained, the medicines required are available etc.)
financial risk-protection system

Question 5

Describe risk transition and the implications for global health patterns

Answer 5

− Is the process by which new health issues arise within a community after development. In other words, risk transition refers to the changing patterns of disease that occurs with time and with changes to a society
− This has largely been driven by improvements to infectious and perinatal causes of mortality which has led to the emergence of diseases of ageing populations and chronic disease (as people survive longer)
− Simply put, risk transitions are a shift from traditional risks to modern risks as a result of;
1. Improvements in health care
2. Ageing populations
3. Public health interventions

Question 6

Explain the concept of community engagement and its application to public health programs

Answer 6

involving communities in the decision-making process
− As the level of community engagement increases, so does the control the community has over the program and success it will likely have
− There are 5 main levels of community engagement;
1. Information
2. Consultation
3. Involvement
4. Empowerment

Question 7

Identify links and associations between poverty of opportunity and health outcomes as they apply to topics throughout the semester

Answer 7

Refers to poverty that results from circumstances that are beyond the control of an impoverished individual
− Some examples include;
1. Climate change
2. Politics and Economics
3. War and Internal conflict
4. Communicable diseases

− If a person experiences poverty, the associated poor nutrition, overcrowding and lack of clean water typically will result in ill-health
− On the flip side, if a person experiences ill-health, the reduced work productivity and sometimes huge out of pocket payments for healthcare can in turn cause poverty
− What this basically indicates is that money and an income is not always the cause and / or solution. The issue is multi-faceted and much more complex than throwing money at it

Question 8

Discuss the main causes of death in children globally

Answer 8

− 45% of deaths of children under 5 years of age are due to malnutrition
− Furthermore, over half of the neonatal causes are as a result of diarrhoea and pneumonia secondary to malnutrition (with the other half often in some way showing links to diarrhoea and pneumonia)
− What this means is that over half of the deaths under the age of 5 years of age can be prevented by using very simple interventions that combats this malnutrition
− It is important to note that of the 45% of malnutrition caused deaths under 5 years of age, very few are caused by starving to death or by severe acute malnutrition, instead most of these arise as malnourished children have an increased vulnerability to other killer diseases (like diarrhoea and pneumonia)

Question 9

Define and describe the clinical features of stunting

Answer 9

− Is the impaired growth and development that children experience from poor nutrition, repeated infection or inadequate psychosocial stimulation
− A child is considered stunted if their height-for-age is more than two standard deviations (z-scores) below the WHO Child Growth charts
- Between -2 and 3: Normal
- Between -3 and -2: Moderately stunted
- Below -3: Severely stunted
− Stunting is predominately caused by poor nutrition in utero and during early childhood
− The children that suffer may never fully attain their physical and cognitive potential
− These children live the rest of their lives at a huge disadvantage. They face learning difficulties, they earn less as adults and face huge barriers to participation in communities
− Stunting is generally due to a chronic situation (unlike wasting which is acute)

Question 10

Define and describe the clinical features of wasting

Answer 10

− Is a child whose weight-for-height information is below two standard deviations (Z-Score) from the median the WHO Growth Charts
- Between -2 and 3: Normal
- Between -3 and -2: Moderate wasting
- Below -3: Severe wasting
− In children, wasting is the life-threatening result of poor nutrient intake and/or disease
− Children who suffer from wasting have weakened immunity, are susceptible to long term developmental delays and ultimately are at an increased risk of death (particularly when wasting is severe)
− Wasting, unlike stunting is generally due to an acute situation

Question 11

Define and describe the clinical features of underweight

Answer 11

− Is a child whose weight-for-age measurement is below two standard deviations (Z-Score) from the median the WHO Growth Charts
- Between -2 and 3: Normal
- Between -3 and -2: Moderately underweight
- Below -3: Severely underweight
− As weight is easy to measure, it is this indicator for which we have the most date for
− There is a significant body of evidence which shows that the mortality risk of children who are even slightly underweight is increased (with severely underweight children at even greater risk)
− A child who is underweight could be suffering from wasting, stunting or a mix of both

Question 12

✔ Define and describe the clinical features of obesity

Answer 12

− As malnutrition is defined as a condition caused by either excess of deficiency’s in a person’s energy / nutrient intake, it is important to realise that overweight individuals are also considered malnourished
− In recent years, childhood overweight and obesity has been an emerging face of malnutrition, as currently there are over 40 million overweight children globally
− When measuring this nutritional status, we use the weight-for-height chart, and BMI
− BMI = Weight (kilograms) / height2 (metres)

Question 13

Analyse the underlying causes of child malnutrition and relate these to the relevant SDGs Give examples of ways in which meeting SDG targets could improve child nutrition

Answer 13

− When all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life

1. Availability
   - Domestic production, Import capacity, Food aid
2. Access
   - Income distribution/poverty, Access to assets (land), Markets, and infrastructure capacity
3. Stability
   - Weather variability, Price variability, Security, and political stability

Question 14

Discuss micronutrient deficiencies including iron

Answer 14

− Is probably the most common micronutrient deficiency
− People with this deficiency have reduced productivity, energy levels and cognitive functioning

• There is a huge spike in prevalence of anaemia in children under 2 (this can be explained by the huge increase in energy requirement due to the intense growth they are going through, plus mix-feeding which inhibits the child’s absorption of iron)
• 30% of women of childbearing age have anaemia
  − Iron is a fundamental aspect of haemoglobin meaning if the body lacks iron a persons red blood cells that a reduced ability to carry oxygen, resulting in iron deficiency anaemia

Question 15

Discuss micronutrient deficiencies including Vit A

Answer 15

− Vitamin A is an incredibly important micronutrient which is necessary for the normal functioning of a person’s;
- Vision system
- Immune system
- Growth and development
− Vitamin A is found in; Dairy products, Liver, Yellow and red fruit and vegetables as well as Green leafy vegetables

VIT A DEFICIENCY – XEROPHTHALMIA

1. Night blindness
   - Which is impaired vision, particularly in reduced light
2. Bitot’s spots
   - Are foamy accumulations on the conjunctiva
3. Corneal Xerosis
   - Dryness, dullness or clouding of the cornea
4. Keratomalacia
   - Is the softening and ulceration of the cornea

Question 16

Discuss micronutrient deficiencies including Vit D

Answer 16

− Vitamin D is manufactured in the body when skin is exposed to sunlight, and is incredibly important in the development of strong bones
− Vitamin D is found in Fish, Liver oils and dairy products
− A Vitamin D deficiency typically arises as a result of reduced Calcium or Vitamin D intake (which causes secondary hyperparathyroidism, a condition in which a disease outside the parathyroid glands causes them to become enlarged and hyperactive)
− The lack of calcium, and increased excretion of Parathyroid hormone increases calcium absorption from the bone, causing rickets in children and osteomalacia in adults
− It is particularly apparent in the following populations;
- Eastern Europe, desert areas
- Populations forced to remain inside due to shelling or fighting etc.
− Vitamin D deficiency is an issue with pregnant women as they pass their deficiency onto their children and in premature babies
− The solution / treatment of vitamin D deficiency is simply sun exposure
− Children with rickets show the following clinical signs and symptoms;
- Reduced bone growth
- Are anaemic
- Prone to respiratory infections
- Delayed closure of fontanelles (soft spots on baby’s heads)
- Swollen wrists and ankles
- Squared head caused by swelling of frontal bone structure

Question 17

Discuss micronutrient deficiencies including iodine

Answer 17

− Iodine is an essential part of thyroid hormones
− Iodine is found in natural sources of food like Seafood and some plants
− Currently the global population is doing incredibly well due to the fortification of iodine in salt (iodized salt).
− Deficiencies in iodine can lead to
1. Cretinism (stunted physical and mental growth)
2. Stillbirth and miscarriage
3. Mental retardation
4. Goitre (swelling of thyroid gland in the neck)
- There are 3 grades of goitre: Grade 0, Grade 1 and Grade 2
- Grade 0: No enlarged thyroid can be felt or visible noticed
- Grade 1: A palpable but not visibly enlarged thyroid with the neck in a normal position
- Grade 2: A palpably and visible enlarged thyroid with the neck in a normal position
− Iodine deficiency is especially damaging during pregnancy and in early childhood, and is a major cause of preventable mental retardation

Question 18

Describe the contributing factors and consequences of anaemia in the global context

Answer 18

IRON DEFICIENCY ANAEMIA: Iron is incredibly important in the formation of haemoglobin, without it, haemoglobin production cannot occur

MEGALOBLASTIC ANAEMIA: Is caused by Vitamin B12 and Folate deficiency which diminishes the ability of the blast cell to replicate DNA and divide

− Anaemia is an incredibly important disease state to consider for a number of reasons. Some of these include;
- As it has accounted for more disability adjusted years than chronic respiratory diseases, injuries and major depression put together
- It is a major cause of disability worldwide (9% of the global burden of disease)
- Anaemia increases your susceptibility to other diseases and reduces your immunity to infections
- It can also worsen your prognosis for other diseases
- Increases maternal mortality and low birth weight babies
- It makes day to day functioning difficult (which limits productivity, school attendance and educational attainment)
- It also negatively impacts on a person’s cognitive development
− The key drivers of anaemia reduction for children were improved health and nutrition interventions, and for pregnant women were improved education and wealth (or the alleviation of poverty)

Question 19

Health approach to anemia: Nutrition specific

Answer 19

NUTRITION SPECIFIC
− Are those that tackle the immediate causes (like nutritional iron intake, blood loss and recurrent inflammation).
1. Dietary diversification
- Strategies that promote a wider range of nutritious food
- Also includes strategies that increase the bioavailability of iron e.g. taking iron supplements with orange juice (vitamin C) which increases iron uptake
2. Breastfeeding
- Exclusive breastfeeding increases iron uptake in babies (whereas mix feeding leads to inhibition of iron absorption)
3. Mass fortification
- Involves taking a staple food eaten by most people and fortifying it with iron
- Food fortification is a process in which micronutrients are added to food
- Is an extremely cost effective and sustainable management solution
- It is currently done in Australia with bread
4. Targeted fortification
- Involves looking at specific groups that are susceptible and targeting their food
- For example, fortifying baby formula for children
5. Point-of-use fortification
- When you add the iron directly to your food
- E.g. Sprinkling iron on like salt
6. Biofortification
- Involves genetically modifying the food to have increased micronutrients
- This is currently being developed
7. Supplementation
- Taking extra iron and folic acid in addition to your normal food
8. Social and behavioural change through communication and education
- Which basically is putting out the right messages, changing and educating the mindset of people to improve their nutritional intake

Question 20

Health approach to anemia: Nutrition sensitive

Answer 20

NUTRITION SENSITIVE
− Nutrition Sensitive are those strategies that tackle the intermediate, underlying and fundamental causes of iron deficiency (the big-ticket items like food availability, health care, economic circumstances, health policies, agricultural output and disease control). Some examples of these include;
1. Parasitic infection control
- Malaria control
- Soil transmitted helminth and schistosomiasis control
2. Water, sanitation and hygiene measures
3. Reproductive health practices
- Introduction of family planning and child spacing (when a women has children too close together see can’t replace her iron stores in time)
- Making mothers aware of post partem haemorrhage (which is vaginal blood loss in excess of 500mL following childbirth) etc.
4. Intersectoral actions
- Refers to actions outside the health sector that will affect health outcomes
- Things like addressing poverty, access to education, income equality etc.

Question 21

Outline the main principles of management for acute severe malnutrition

Answer 21

− Is the most extreme and visible form of undernutrition
− A diagnosis of severe acute malnutrition should be made if any of the following is true;
1. Child has severe wasting (Below a Z-score of -3 in their weight-for-height)
2. Nutritional Oedema
3. Visible severe wasting
− There is a very high mortality rate associated with Severe Acute Malnutrition (between 30-50% for under 5’s)
− Recent studies show that SAM in children over 6 months of age with no other medical complications can be managed at the community level using specially formulated read-to-use therapeutic foods (RUTFs) otherwise they have to be managed in a hospital setting
− Management of patients with severe acute malnutrition is multifaceted and does not simply consist of feeding a child as there are a number of other deficiencies which need to be corrected as well i.e. social support (we do not need to know the management specifically)

Question 22

Describe the contribution of pneumonia to childhood mortality and analyse the immediate, underlying, and basic causes.

Answer 22

− Pneumonia is an infection of the lungs that results in inflamed, fluid filled lungs
− Pneumonia and malaria are 2 of the most common causes of child mortality
− A majority of mortalities associated with these conditions can be fundamentally linked to the patient’s nutritional status

Question 23

Describe the strategies recommended by the Integrated Global Action for Pneumonia and Diarrhoea (GAPPD) program under the three headings of “protect, prevent and treat”.

Answer 23

PROTECT
− Basically, refers to the need to establish good practice from the very start of a child’s life
1. Exclusive breast feeding for 6 months
2. Adequate complementary feeding
- Refers to the food given as you wean a child from the breast

PREVENT
− Is the second arm of the action plan that aimed to prevent children becoming ill with pneumonia and diarrhea in the first place
− Some of the specific prevention strategies include;
1. Vaccination
- Pneumococcal vaccine
- Haemophilus influenza type B vaccine (Hib vaccine)
- Measles vaccine
- Pertussis vaccine
- Influenza vaccine
2. Hand washing
3. Reduce household air pollution
- Smoking cigarettes
- Indoor cooking on biomass material, wood, cow dung, kerosene is also an extremely common cause of air pollution (that can lead to pneumonia)
4. Prevention of HIV in children
5. Cotrimoxazole prophylaxis for HIV-infected children

TREAT
− Is the arm of the action plan that we are going to mainly focus on
− It involves treating children who are ill from pneumonia and diarrhoea with appropriate treatment
1. Improved care seeking and referral
- Patients are less likely to seek appropriate care if they are poor, uneducated or rural
- Community based case management are proven to break down the access barriers that improves this care seeking behaviours (increasing access)
2. Case management at the health facility and community level
- A program known as the Integrated Management of Childhood Illness (IMCI) has been running for 20+ years and has substantially reduced child deaths simply by improving case management
3. Supplies
- There must be adequate supplies (easier said than done) E.g. antibiotics and oxygen
4. Continued feeding
- Given the huge role that nutrition plays in these pathologies, it is imperative that treatment does not affect a child’s nutritional status

Question 24

✔ Describe the basis of Integrated management of childhood illness (IMCI)

Answer 24

− The program itself consists of 3 main components;
1. Improving the skills of health workers
2. Strengthening the health systems (by improving access to supplies and by improving referral systems)
3. Improving family and community practices (which aims to improve prevention, lowering the disease incidence in the first place)

• Health worker training
• Use of simple, standardized guidelines for identification and treatment of illness
• Classifying severity of illness and giving a standardized management plan
• Drug supplies and referral pathways
• Prevention and follow-up guidelines that takes on a holistic approach (including checking feeding, nutrition and vaccination status)
• Counselling the parent

Question 25

IMCI process for pneumonia

Answer 25

− The actual IMCI process is outlined below (for pneumonia);
1. Check for general danger signs
- Not able to drink or breastfeed
- Persistent vomiting (vomiting everything)
- Convulsions
- They are lethargic or unconscious
- Stridor in a calm child
- Malnutrition
- If a child is positive for any of these danger signs, it indicates that the child is very sick and requires immediate attention, probably referral
2. Assess the main symptoms
- Cough
- Difficulty breathing
- Diarrhoea
- Fever
- Ear problems
3. Assess nutrition, immunization status and potential feeding problems (and check for other problems)
4. Classify condition and identify treatment actions
- The IMCI is predominately concerned with pneumonia and diarrhea
- There are 3 levels of severity, Pink (most severe), yellow and green
- Pink: If the patient has any general danger signs or stridor in a calm child. These children must be referred to hospital and given an appropriate dose of antibiotic
- Yellow: If the patient has chest indrawing or fast breathing. These children can be treated in outpatient health care facilities
- Green: If the patient has no signs of pneumonia or other severe diseases. These children can be treated at home following counselling on how to give oral drugs, continue feeding, when to return immediately and when to come back for a follow up
5. Provide treatment
- Using the above guidelines treatment should be provided appropriately
6. Counsel and Follow-up
- How to treat
- What to watch for
- When to come back
- Prevention advice
− It is important to note that the IMCI has deliberately been kept simple so that they are more accessible and user friendly for community-based health workers (who aren’t doctors or nurses)

Question 26

Discuss the significance of malaria as a global health problem and contributor to childhood mortality.

Answer 26

− Is a mosquito borne infectious disease caused by the plasmodium parasite
− It is an incredibly serious infectious disease, which has a number of extremely severe effects (particularly in communities where malaria transmission is uncontrolled) for example;
- Low Birth Weight
- Stillbirth
- Child Mortality
- Sick or anaemic adults
- Reduced productivity / economic activity
- Costs to the health system
− When considering what we can do to reduce the burden of malaria in communities, it is important that we look at the different patterns of transmission
− The reason it is important to consider the patterns of transmission is because it can have an effect on both the clinical presentation of the disease and the preventative measures that can be implemented to improve the community’s situation

Question 27

two important patterns of malaria transmission are;

Answer 27

1. Stable transmission
   - Describes communities where rates of malaria are high and constant
   - Malaria is around all the time, and people are being infected constantly and will always have some sort of parasitaemia (parasites in the blood) going on
   - In these areas (e.g. Sub-Saharan Africa) adults develop a level of immunity meaning whilst they may have a parasitaemia or small degree of anaemia, they are rarely sick with malaria
   - Instead, those at risk in these populations are children (who have not yet built up an immunity), pregnant women and those with HIV. It is these populations that typically develop a severe illness
2. Unstable transmission
   - Occurs in populations where there are typically low transmission rates, with occasional epidemic outbreaks
   - Because adults have not developed immunity, they too get severe disease (meaning there are different clinical patterns)

Question 28

Discuss the lifecycle of the plasmodium parasite in relation to preventive efforts and analyse recent advances in malaria prevention and control

Answer 28

− Plasmodium is the parasite responsible for the mosquito born disease malaria
− The incubation period varies, but usually falls between 9 to 18 days
− Basically, this parasite wants to get in, multiple, then get out to infect someone else
− The lifecycle of plasmodium follows the following progression;
1. A mosquito bites a human and inject sporozoites into the blood stream along with their saliva (which causes anticoagulation to increase the amount of blood they can take)
- Antibodies attack these sporozoites
2. These sporozoites infect the liver cells known as hepatocytes where they go in and multiply
- CD4 and CD8 T Cells kill intrahepatic parasites
- CTLs kill infected hepatocytes
3. Once they have multiplied, they burst out of the cell as merozoites and go into the blood stream once again
- Antibodies target merozoites by blocking cytoadherence to RBCs
4. Once here they infect RBCs and develop into schizont cells
- Cell mediated immunity and ADCC is important in this stage
5. Some of these cells will develop into gametocytes which are picked up by a mosquito biting a human
- Antibodies block this stage
6. These gametocytes then go into the mosquito and form sporozoites starting the process once again (takes several days)
− Symptoms include: headache, nausea, vomiting and diarrhea, severe anaemia, organ failure (brain, lung, liver, kidney all from hypoxia), periodic fevers and death
− It is important to note that plasmodium has a number of essential lifecycle stages within mosquitos meaning that it doesn’t bite someone, then immediately have the ability to transfer the disease to another person. Instead it requires a week or two to develop within the mosquito

Question 29

Describe the features of uncomplicated malaria and of severe malaria and discuss the rationale for introduction of artemisinin combination therapy (ACT) and rapid diagnostic testing (RDT).

UNCOMPLICATED

Answer 29

− Is defined as a patient who presents with symptoms of malaria, has a positive parasitological test (Microscopy or Rapid Diagnostic Test), but has no features of severe malaria
− The signs and symptoms of uncomplicated malaria are very nonspecific, which are outlined below;
- Headache and fatigue
- Lassitude (a state of physical or mental weakness, lacking in energy)
- Abdominal discomfort
- Muscle and joint aches
- Fever and chills
- Anorexia
- Sweating, vomiting and worsening malaise
- Can also have a cough / diarrhoea (which makes the differential diagnosis even wider)
− Because of its nonspecific symptoms, it is often over-diagnosed in endemic areas

• Need to perform a blood smear
• Check Growth and Nutrition status
• Check immunisation status
• Check Hydration status
• Take respiratory rate (check for fast breathing)
• Check glucose and whether he is anaemic

Question 30

Describe the features of uncomplicated malaria and of severe malaria and discuss the rationale for introduction of artemisinin combination therapy (ACT) and rapid diagnostic testing (RDT).
COMPLICATED

Answer 30

− Is nearly always caused by Plasmodium Falciparum that shows one or more of the following clinical features;
1. Impaired consciousness (Glascow Coma Scale less than 11)
2. Seizures
3. Severe anaemia (less than 50g/L)
4. Acidosis
5. Hypoglycaemia (less than 2.2 mmol)
6. Other less common features include;
- Prostration
- Severe jaundice
- Renal failure
- Shock
- Pulmonary oedema
- Significant bleeding
- Hyper-parasitaemia (more than 10% of RBC’s are infected)
− Patients with severe malaria have an extremely high case fatality rate (10 – 20% even with treatment)
− This type of malaria commonly occurs in pregnant ladies and children in areas of stable transmission, travellers to areas of stable transmission or anyone in areas of unstable transmission

Question 31

Describe the features of uncomplicated malaria and of severe malaria and discuss the rationale for introduction of artemisinin combination therapy (ACT) and rapid diagnostic testing (RDT).
DIAGNOSTIC TESTS

Answer 31

1. Rapid Diagnostic Test (RDT)
   - They are quick, cheap, can be used at a community level and do not require a microscope or lab technician
   - It is important to note that once a child has caught malaria, they remain positive for a while, meaning that it may not be malaria causing the fever this time (furthermore, in stable malaria transmission areas, many people constantly have a low parasitaemia which will cause a positive result)
   - These RDTs also don’t provide any information on the parasite count and species of parasite, which can be extremely useful clinically
2. Thick and thin blood films
   - Thick films are used to make the diagnosis and have higher sensitivity
   - Thin films are used to look at the parasite count and the species
   − If after the above investigations have been performed the child gets a positive malaria reading, they must be treated for malaria

Question 32

Give examples of ways in which meeting SDG targets could improve outcomes for children with pneumonia or malaria

Answer 32

Question 33

Causes of diarrhoeal diseases.

8==D

Answer 33

Aside from infectious causes, here are the others
1. Inadequate access to basic needs
- Clean water:
- Sanitation:
- Food security and Safety
- Access to healthcare
2. Environmental and Living conditions
- Natural and man-made disasters
- Overcrowding or displacement
- Lack of protection from the elements
- Dry environment
- Insecurity

3. Culture and Education
   - Food preparation (e.g. no refrigeration)
   - Use of latrines/toilets
   - Funeral practices (e.g. a person’s body that has died from cholera is highly infectious, so when you pair that with the cultural practice of everybody visiting the deceased, you run into issues with infectious control)

− It is important to realise that there are a number of very serious complications associated with diarrhoea. Some of these include;
- Dehydration (most people that die from diarrhoea die from dehydration)
- Hypoglycaemia
- Electrolyte disturbances
- Acute renal failure
- Malnutrition
- Predisposition to other infections (due to weakened immunity)

− From a public health perspective, we would then want to investigate any potential outbreaks (particular if Shigella or Cholerae is the cause) that may have caused the diarrhoea, so that we can manage that concurrently (to prevent further cases)
− We also need to asses any special circumstances that may affect the management of the case like their nutrition status (if they are malnourished it changes the rehydration treatment plan), whether they have any co-existing infections

Question 34

Describe the clinical picture, transmission, and prevention, of common water borne diseases
- TYPHOID

Answer 34

− Transmission is via Salmonella Typhi/paratyphi through contaminated food or water
− Clinical features include;
- Prolonged fever plus some of
- Severe malaise
- Abdominal pain
- Headache, confusion, delirium
- Diarrhoea or constipation
- Cough
- Anorexia
− Diagnosis is via blood culture and is treated with antibiotics (resistance)
− Prevention is through access to safe water and sanitation, hygiene among food handlers and vaccinations (moderately efficacy with limited duration)

Question 35

Describe the clinical picture, transmission, and prevention, of common water borne diseases
- HEP A

Answer 35

− Transmission is via contaminated food or water, direct contact with an infectious person
− Clinical features include;
- Fever
- Malaise
- Loss of appetite, diarrhoea, nausea, vomiting and abdominal discomfort
- Dark urine and jaundice
− Treatment is non specific (supportive, symptom management) and recovery can be slow
− Prevention is through vaccine (effective), sanitation/hand washing, safe water, and food

Question 36

Describe the clinical picture, transmission, and prevention, of common water borne diseases
GIARDIA DUODENALIS

Answer 36

− Clinical features include;
- Acute or chronic diarrhoea
- Greasy stool
- Cramps, bloating and flatulence
- Fatigue, anorexia
- Nausea, weight loss
− Symptoms can last weeks to months
− Diagnosis is through stool microscopy for cysts or trophozoites
− Treatment includes metronidazole if symptoms persist

Question 37

Apply the WHO protocols for rehydration (Plans A, B &C) to case examples.

Answer 37

Question 38

✔ Analyse the evidence around the use of ORS and zinc.

Answer 38

Oral rehydration salts
- It is a special combination of sodium and potassium, sugar and water
- This assists in rehydration as sodium and glucose are co-transported across the GIT lumen (if you want to absorb more sodium, you need glucose with it)
- The sodium then aids water reabsorption in the dehydrated patient
- This decreases stool output and vomiting

ZINC SUPPLEMENTATION
− Zinc is an important micronutrient for overall health and development
− It is lost in high quantities in patients with diarrhoea
− Zinc supplementation as apart of treatment of acute diarrhoeal illness has been shown to;
- Reduce the duration by 25%
- Reduce the volume by 30%
- Lower the incidence of diarrhoea in the following 2 – 3 months
− In terms of dosage, as per treatment Plan A, the following guide should be used;
1. Up to 6 months: 1⁄2 tablet per day for 10 – 14 days (10 mg)
2. 6 months or more: 1 tablet per day for 10 – 14 days (20 mg)

Question 39

Discuss the role of vaccination in the prevention of waterborne diseases.

Answer 39

VACCINATION
− Vaccinations against a number of infectious agents are fundamental and extremely successful in prevention of diarrheal illness
− Rotavirus is the most common cause of severe diarrhoea, which causes more than 215,000 deaths in children under 5 years of age every year. We already have an extremely effective vaccination against this making these deaths highly preventable
− Other vaccine preventable causes of diarrhea include Measles (weakens a person’s immunity making them more susceptible to diarrhoea) and Cholera

Question 40

✔ Discuss SDG6 and targets 6.1 and 6.2, relating to water and sanitation

Answer 40

− Ensure access to water and sanitation for all
- 6.1 By 2030, achieve universal and equitable access
- 6.2 By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations
− By completing this goal, we are addressing one of the most significant underlying factors that contribute to diarrhoea

Question 41

Describe global trends in HIV and TB prevalence, and the factors leading to change.

Answer 41

HIV
− Globally ~38 million people are HIV in 2020 with 1.5 million being newly diagnosed
− Since 2010, new HIV infections have declined by 31%
− In Australia we have a low prevalence as it stands at 0.1% in 2017. Similarly incidence declined by 7% from 2013-2017 with 90% of diagnoses made in males
− Higher rates of diagnosis in Indigenous Australians than non-Indigenous (4.6 to 2.8/100,000)
− Higher proportion attributed to heterosexual contact and injecting drug use
− People with HIV have experience more severe outcomes and have higher comorbidities
TB
− Is the leading cause of mortality from a single infectious agent
− Estimated 10 million people fell ill with TB in 2019 but the global incidence is falling at approximately 2% per year but numbers of MDR-TB increased by 10% in 2019
− Incidence of TB in Australia remains one of the lowest in the world with ~1300 per year
− Incidence of TB in Indigenous Australians remains 6x higher than non-Indigenous Australians
− Cross border movements between Papua New Guinea and the Torres Strait by traditional inhabitants poses risk of TB spread especially MDR-TB

Question 42

Give examples of ways in which meeting SDG targets will contribute to control of HIV

Answer 42

− HIV:
1. No poverty – economic empowerment removes risk factors and increases opportunities to get treatment
3. Good health and well-being - universal health coverage to get access to care
5. Gender equality - women more adversely affected (stigma, violence, abuse)
8. Decent work and economic growth - care can reach more people (migrants, bisexual, etc.) and people with HIV are 3x more likely to be unemployed (stigma, discrimination)
16. Peace, justice, and strong institutions - people centred accountability provides a platform for inclusive and appropriate services

Question 43

Give examples of ways in which meeting SDG targets will contribute to control of TB

Answer 43

− TB:
1. No poverty - inverse relationship between income and TB incidence rates for countries
2. Zero hunger - undernutrition which can lead to TB
3. Good health and well-being - access to universal health care to get treatment as well as addressing co-morbidities
5. Gender equality - females have a lack of access to care (present later to care) thus under detection and notification of TB in women
7. Affordable and clean energy - air pollution (indoor with cooking or outdoor) increases risk of infection of TB, so clean energy can improve air quality and decrease risk of TB

Question 44

Discuss the interaction between TB and HIV infections

Answer 44

− Refers to patients who are infected to both HIV and Tuberculosis (active or latent forms)
− The risk of death from tuberculosis is much greater in HIV positive patients compared to their HIV negative counterparts
− This is incredibly damaging for patients as HIV speeds up the progression of latent tuberculosis to active tuberculosis whilst TB accelerates the progression of the HIV infection
− Acquisition of these diseases however is still separate (that is, a person still needs to be infected by HIV and the Mycobacterium Tuberculosis along their normal disease progressions. Simply having HIV doesn’t mean you all of a sudden get TB or vice versa)
− People that should be screened for co-infection are people living with HIV in Australia who are from or have travelled to high-burden TB countries
− Latent TB infection
- Diagnosis can occur through TST (Mantoux) or IGRA (QuantiFERON-TB Gold) tests
- Lower cut-offs used for TST in HIV-positive population
- False positive TSTs can be seen in patients who have previously received BCG vaccine
- Several preventative treatment options (QH preferred regime is 9/12 INH and Vit B6)
− Active TB infection
- Prompt initiation of anti-TB drug regime and combined ART
- Monitor for development of TB-IRIS (unmasking vs paradoxical)

Question 45

Discuss PMTCT (prevention of mother to child transmission) of HIV

Answer 45

− Transmission in pregnancy may occur antepartum, intrapartum (most common) and postpartum
− Primary determinant of transmission is absence of maternal ART
− Prevention of mother to child transmission can occur through:
- Universal antenatal HIV screening
- Maternal ART (transplacental transmission) and postnatal ART for newborn (breastmilk transmission)
- Avoidance of breast feeding

Question 46

Describe the main classes of anti-retroviral drugs and their mechanism of action.
- nucleoside/tide reverse transcriptase inhibitors

Answer 46

− Are a class of antiretroviral drug that act as competitive substrate inhibitors (or in other words act as false substrates)

• These drugs are analogues of specific naturally occurring nucleosides/tides
• Once inside, nucleosides (not nucleotides) are phosphorylated by cell enzymes
• Because they are structurally similar, once inside the cell they act as competitive substrate inhibitors by competing with natural deoxynucleotides for incorporation into the viral DNA chain
• However, unlike natural deoxynucleotides, NRTIs lack the 3’hydroxyl group required to extend the DNA chain
• As a result, the viral DNA chain is terminated, stopping viral DNA synthesis

Question 47

Describe the main classes of anti-retroviral drugs and their mechanism of action.
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

Answer 47

− Are a class of antiretroviral drug that work by inhibiting reverse transcriptase
− Unlike NsRTIs, these drugs do not require intracellular phosphorylation to become activated
− The complete mechanism of action is outlined below;
- These drugs enter the cell and non-competitively block the reverse transcriptase enzyme (RNA-dependent and DNA dependent polymerase)
- They do this by binding and inducing a conformational change that reduces the efficiency of the catalytic site of the enzyme (meaning it can’t do its usually job)
- Reverse transcriptase is the enzyme responsible for making a DNA copy of the viral RNA, meaning that if its action is blocked, viral DNA synthesis is reduced
− These drugs can cause nausea, vomiting and occasionally a rash
− These drugs are potent inducers of cytochrome P450 meaning they will reduce the concentration of some drugs

Question 48

Describe the main classes of anti-retroviral drugs and their mechanism of action.
HIV-PROTEASE INHIBITORS (PI)

Answer 48

• As is outlined in the above virology of HIV, mRNA that has been transcribed from the provirus is translated into too biochemically inert polyproteins
• Without these proteins, HIV maturation and replication cannot occur
• HIV-Protease inhibitors work by blocking the action of this protease, preventing the formation of a functioning virus (which stops infection of new host cells)
  − These have a number of GI adverse effects, and even cause hyperglycaemia (due to inhibition of GLUT 4 transporters)

Question 49

Describe the main classes of anti-retroviral drugs and their mechanism of action.
INTEGRASE INHIBITORS

Answer 49

• This chromosomal integration is facilitated by a viral enzyme known as Integrase
• Integrase inhibitors work by blocking the effect of this enzyme, which prevents the insertion of the viral DNA ends into the hosts genome

Question 50

Describe the main classes of anti-retroviral drugs and their mechanism of action.
ENTRY INHIBITOR – MARAVIROC

Answer 50

− Is a chemokine receptor antagonist used as an antiretroviral drug
− The complete mechanism of action is outlined below;
- In order for HIV to bind and enter into a host cell, a number of interactions must occur (gp120 AND gp41 on HIV must bind to CD4 receptors, as well as CCR5 co-receptors)
- Maraviroc works by inhibiting the chemokine receptor 5 (CCR5) located on the surface of some immune cells (macrophages)
- If this occurs, HIV binds to the CD4 receptors, however is unable to interact with the co-receptors CCR5, which prevents fusion of the virus envelope with the host cell membrane
- Effectively blocking HIV entry into the host immune cell

Question 51

Describe the main classes of anti-retroviral drugs and their mechanism of action.
FUSION INHIBITOR – ENFUVIRTIDE

Answer 51

− Is an antiretroviral drug that works in a similar fashion to entry inhibitors
− The complete mechanism of action is outlined below;
- In order for HIV to bind and enter into a host cell, a number of interactions must occur (gp120 AND gp41 on HIV must bind to CD4 receptors, as well as CCR5 co-receptors)
- Fusion inhibitors work by binding to gp41, which prevents the initiation of fusion of the virus envelope and the cell membrane
- HIV is therefore unable to gain entry into the host immune cell
− These drugs are only used as a last line for most patients (as they incredibly expensive and not available in Australia anymore)

Question 52

Describe the main classes of anti-retroviral drugs and their mechanism of action.
BOOSTERS

Answer 52

• These drugs inhibit the effects of CYP3A4 (which normally breaks down a number of drugs, including a number of antiretroviral drugs that are mentioned above)
• Because many antiretroviral drugs are expensive and have a number of side effects, these drugs (ritonavir) are used in conjunction with Protease Inhibitors to reduce cost and permit the use of lower doses (avoid the adverse effects)

Question 53

List the first line drugs used for TB,

Answer 53

− When treating a patient with drug sensitive tuberculosis, the minimum treatment course is 6 months using four drugs (which can be remembered by the acronym RIPE);
1. Rifampicin
2. Isoniazid
3. Pyrazinamide
4. Ethambutol
− All four drugs should be used for the first 2 months, followed by Rifampicin and Isoniazid for the next 4 months (4 for 2 then 2 for 4)

Question 54

outline the pillars and principles of the WHO End-TB strategy

Answer 54

END TB STRATEGY
− Is a WHO initiative that wants to end TB by 2030
− The strategy itself has 3 main targets;
1. 90% reduction in number of TB deaths
2. 80% reduction in TB incidence rate
3. Zero TB-affected families facing catastrophic costs due to TB
− In order to achieve this goal it requires;
- Expanding the scope and reach of interventions
- Eliciting full benefits of health and development policies and systems
- Pursuing new scientific knowledge and innovations
- Provide universal health care with access to treatment

Question 55

Outline the principles of HAART

Answer 55

− Refers to any HIV treatment that uses a combination of two or more drugs
− Without ART, most patients with HIV will eventually develop progressive immunodeficiency that is marked by;
- Progressive CD4 T lymphocyte depletion
- AIDS defining illnesses
- Premature death
− The primary goal of ART is to prevent HIV-associated morbidity and mortality (by inhibiting HIV replication which keeps the viral load / plasma HIV-1 RNA) levels below limits of detection
− This is because high viral load is a major risk factor for HIV transmission
− Effective ART can reduce viremia and transmission of HIV to sexual partners by more than 96%
− The secondary goal of ART is to reduce

Question 56

Describe the main adverse effects of anti-retroviral drugs

Answer 56

− It is important to note some of the key adverse effects of ART, which are outlined below;
1. Lipodystrophy
- Is a condition in which the body is unable to produce and maintain healthy fat tissue
- It causes peripheral lipoatrophy and central fat accumulation, as well as insulin resistance and dyslipidaemia
- Occurs with NRTIs and HIV-Protease Inhibitors
2. Hyperglycaemia
- Caused by HIV-Protease Inhibitors
3. CV disease risk
4. Lactic acidaemia
- Seen with NRTIs
5. Hepatotoxicity
- As a result of the mitochondrial toxicity
6. Bone loss and Rash

Question 57

Describe the problem of MDR and XDR Tuberculosis and possible strategies to contain its spread

Answer 57

− Is a form of tuberculosis that is resistant to drugs
− Treating drug resistant TB is harder, takes longer, has more side effects and is more expensive
− There are 2 different types of drug resistant Tuberculosis;
1. Multi-drug Resistant Tuberculosis
- Is resistant to Isoniazid and Rifampicin
2. Extremely Drug Resistant Tuberculosis
- Is resistant to Isoniazid and Rifampicin, as well as to Fluoroquinolones and one of the injectable second line drugs
− Drug resistant TB is either primarily acquired or as a result of mismanagement of a normal case of tuberculosis (either as a result of drug mismanagement or by inadequate clinical care)

− As with all these horrible things, there is a global plan that is attempting to prevent it from wiping us out. This plan has 5 main priority actions to address the emerging global MDR-TB crisis;
- Prevent the development of drug resistance through high quality treatment of drug-susceptible TB
- Expand rapid testing and detection of drug resistant TB cases
- Provide immediate access to effective treatment and proper care
- Prevent transmission through infection control
- Increase political commitment within financing

Question 58

Discuss the epidemiology of NCDs in low- and middle-income countries (LMICs).

Answer 58

− These 4 main disease all share the same big 4 modifiable risks factors; Physical inactivity, alcohol abuse, tobacco use and an unhealthy diet
− Non-communicable disease account for 70% of deaths worldwide, 15 million of which occur before the age of 70
- Almost ¾ of the total deaths occur in low- and middle-income countries
- Of the early deaths (that occur before the age of 70), 85% are in low- and middle-income countries

Question 59

Analyse the implications of rising NCD rates for global health and development.

Answer 59

− NCDs are on the rise, which is driven by urbanisation, economic situations and infrastructure
− Poverty contributes to non-communicable disease (through exposure to modifiable risk factors), and non-communicable disease contributes to poverty (because if you are unwell or disabled, you cannot earn an income. Furthermore, the cost of healthcare also tends to force families into poverty). Plus NCDs are a large cost to the health system

Question 60

Describe the implications of NCDs for health services and health service provision

Answer 60

CLINICAL FACTORS
− Clinics perspective of non-communicable differs greatly from that which they are used too
− Typically they treat a patient until they are better, and only see a patient again if it hasn’t worked
− Another factor that needs to be addressed from the clinical perspective is the lack of patient education. It is important that clinics contribute to patients understanding of their condition so that they can follow their treatment
− So, just as how the patients need to change, so do the clinics
− Some interventions at a clinic level to develop of we manage people with chronic disease includes things like;
1. Regularly review patients (appointment system) and patient-centred care
2. Require a recall system with increased team work and referral
3. Because their will be more people coming in, they need strategies to manage increased numbers of patients (so staff need to learn new management protocols)
4. Record keep is crucial
5. Need to educate patients as they are responsible for some of the care
6. Ongoing medication is required to treat these conditions, so need to consider supply and cost considerations

HEALTH SERVICE
− Interventions to improve how the health service manages non-communicable disease include things like;
1. Medication availability / cost (ongoing medication needed)
2. Referrals and shared care system set up
3. Health practitioner training and increasing numbers of the workforce
4. Protocols for best practice strategies to reduce the burden of disease

Question 61

Outline the thinking behind the WHO best buys for NCD’s and WHO-PEN (Package of essential NCD interventions).
BEST BUYS

Answer 61

− Are the interventions that are identified by the WHO to be the most effective in terms of benefit and cost regarding non-communicable disease prevention and management
− More specifically they are interventions that been chosen because they;
- Have demonstrated measurable effect
- Show a clear link to one of the NCD targets
- They have a cost-effective analysis of less than $100 per Disability Adjusted Life Year (DALY)
- They are feasible
- They impact on health equity
− These best buys aim to;
1. Reduce harmful alcohol use
2. Improve diets
3. Reduce physical inactivity
4. Manage CVD and Diabetes
5. Manage COPD
6. Strengthen health systems
7. Manage tobacco use and cancer
− The theory is that these best buys provide nations with good recommendations so that they can start rapidly on the fight against non-communicable diseases (because they’ve already done the hard work for them by coming up with the solutions)

Question 62

Outline the thinking behind the WHO best buys for NCD’s and WHO-PEN (Package of essential NCD interventions).
WHO PEN

Answer 62

WHO-PACKAGE OF ESSENTIAL INTERVENTIONS FOR NCDS (WHO-PEN)
− Is a tool to improve access to cost effective interventions for the poor even in resource constrained settings
− They are a package that can be used to develop detection, prevention, treatment and care of risk factors for the 4 main non-communicable diseases (cardiovascular disease, diabetes, chronic respiratory disease and cancer) in the primary health care setting
− The package itself involves the following things;
1. Essential medicines list
2. Minimum equipment / technology list
3. Staff training
4. Auditing and data collection
5. Patient records
6. Evidence based protocols for screening, assessment and treatment of common conditions
7. Health education messages
8. Referral pathways
− The theory is, a struggling health care system can grab this package and dramatically improve the detection, prevention, treatment and care they can provide for their patients

Question 63

Discuss the role of primary health care, and the ideal of universal health coverage, in relation to the NCD burden.

Answer 63

UNIVERSAL HEALTH CARE IN NCDs
− 5 priorities include:
1. Prevention
2. Primary health care
3. Equitable access to medicines
4. Sustainable financing and investments
5. Engaged and empowered communities

TARGETS
− For the past few years (since 2007) there have been a global set of voluntary targets for preventing and controlling non-communicable disease
− The targets were established for completion by 2025, and are relative to a countries baseline
− The complete list of targets is provided below;
1. A 25% relative reduction in overall mortality from cardiovascular disease, cancer, diabetes or chronic respiratory disease.
2. At least 10% relative reduction in the harmful use of alcohol, as appropriate, within the national context.
3. A 10% relative reduction in prevalence of insufficient physical activity.
4. A 30% relative reduction in mean intake of salt or sodium.
5. A 25% relative reduction in the prevalence of hypertension or maintain the prevalence of hypertension in accordance with the national circumstances.
6. Halt the rise in diabetes and obesity.
7. At least 50% of eligible patients should receive drug therapy and counselling to reduce the incidence of myocardial infarctions and stroke.
8. An 80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major non-communicable disease in both public and private facilities.

Question 64

Discuss ways in which implementation of the SGDs could impact NCD rates and management – and in which high NCD rates impede progress towards SDG’s.

Answer 64

Question 65

Describe the principles of international humanitarian law.

Answer 65

− Is a set of rules within international law which seek to limit the effects of armed conflict by;
1. Protecting persons who are not participating in the hostilities
2. Restricting the means of warfare (e.g. the types of weapons and war tactics)
3. Definitions of refugees and asylum seekers
4. Outlines the rights of refugees and asylum seekers

Question 66

Describe the work of the UNHCR in emergency situations

Answer 66

− Stands for the United Nations High Commission for Refugees
− The UNHCR declares that everyone has the right to seek asylum and fine safe refuge in another state by either returning home, integrating or resettling
− In emergency situations, the UNHCR aim to;
1. Coordinate agencies
2. Provide emergency assistance
3. Advocacy
4. Registration and Legal protection
5. Long term solutions (resettlement, repatriation, integration)
− They provide clean water, sanitation, healthcare, shelter, blankets, household goods and food supplies, as well las arrange transport and assistance packages for people who return home and income generating programs for those who resettle
− Registration with UNHCR gets a person a refugee card
− Every refugee goal aligns with the SDGs

Question 67

✔ Differentiate between asylum seekers, internally displaced people, and refugees.

Answer 67

− Prima facie refugees is the term used for refugees who experience a mass movement due to conflict or violence
− An asylum seeker is an individual whose process for a refugee status have not yet been processed
− Internally displaced people are those who flee from their homes due to the aforementioned reasons, but do not cross a border into another country (for whatever reason)

Question 68

✔ Discuss the main priorities when managing a refugee or displaced person’s camp.

Answer 68

− Attend to the immediate health needs of the individuals
− There are a number of important logistical things to consider about refugee camps;
1. Registration
2. Site planning and safety
3. Water and Sanitation
4. Rubbish, Waste and Vector Control
5. Food and Nutrition
6. Health care in an emergency
7. Education

Question 69

Refugee camps registration

Answer 69

REGISTRATION
− Registration of refugees as they enter the camp is the responsibility of the host government as it is a vital aspect of planning
− Individuals should be provided with documents that enable them to access services (like ration and healthcare cards)

Question 70

✔ Describe the options of integration, repatriation and third country re-settlement.

Answer 70

− Refugees should be asked about their end goal, whether that is;
1. Voluntary repatriation
- Is the return of refugees to their home country, of their own free will once conditions have become safe
- There must be a guarantee of protection from their country’s government
2. Resettlement
- Is the organised movement of refugees from refugee camps or other temporary situations into a third country where they can live permanently
- It is the only way to guarantee protection of a refugee who is at risk of forcible return or who faces serious problems in that country
3. Local integration
- When refugees seek to attain rights similar to those enjoyed by the citizens of the country in which they have sought refuge
- Some may be able to attain citizenship

Question 71

Refugee planning : SITE PLANNING AND SAFETY

Answer 71

− The site should be planned in accordance with the following guidelines;
- 30 – 45m2 of space per person
- Firebreaks every 50 to 300m
- 1 to 1.5m between tents
- Roads should account for 20 – 35% of the site (to ensure access for supplies and emergency services)
− Local resources and business should be utilised in order to provide an economic benefit to the country which is hosting the camp
− Resources should be identified and provided including clothing, bedding, tents, stoves, fuel and lighting
− Some organisations who help in this process include; UNCHR, UNICEF, UN organisations, MSF and the Red Cross

Question 72

Refugee planning: water and sanitation

Answer 72

WATER AND SANITATION
− In order to provide the camp with adequate water and sanitation infrastructure, the following provisions should be made;
1. Water
- Approximately 20L per person per day of water is required as a minimum for drinking, cooking and hygiene in an emergency there should be 5L
- To achieve this, one tap per 250 should be provided (the water supply must be approximately 7.5L/minute) as well as 2x 10 – 20L water containers per household
2. Soap
- 250g of soap per month per person
- Does not include a plan for handwashing at the toilet and cooking facilitates
3. Acceptable material for menstrual hygiene
- Needs to be culturally appropriate
- Liaising is required with the refugees
4. Toilets
- 1 toilet per 50 people is a minimum but ideally 1 toilet for each house
- Needs to be segregated by sex
- They need to be closer than 50m from the dwellings to ensure access
- They must not contaminate groundwater sources (must be 30m away from groundwater sources, bottom of the toilets need to be a minimum of 1.5m above the groundwater level)

Question 73

refugee planning waste control

Answer 73

WASTE CONTROL
− Vectors like mosquitoes, mice, rats and lice must be controlled
− 100L bins should be provided per every 10 households (collected 2 times a week and taken to pits a minimum of 100m away from the households)
− Appropriate medical waste and corpse disposal should be implemented

Question 74

refugee planning food supply

Answer 74

FOOD SUPPLY
− Food and nutrition should be supplied locally to support the host country whilst being acceptable to the refugee’s culture to ensure they are aware of how to prepare the food
− Needs to be diverse to prevent malnutrition and nutritional deficiencies (2100 calories/day)
− Needs to be age-appropriate food available and can test middle upper arm
− There should be a method for orderly access to the food supply

Question 75

refugee planning health care

Answer 75

HEALTHCARE
− Should initially address the immediate threats to life including mental health, compromised physical injuries, communicable disease and non-communicable diseases
− It should be organised such that it can;
- Cope with high volumes of patients
- Have an active case finding capability (because refugees may not be trusting of the health services) – diagnose, document, manage and prevent
- Provide basic level of care for a variety of illnesses
- Be flexible enough in order to adapt to challenges (like outbreaks i.e., leptospirosis)
− Both curative and preventative mechanisms are required so vaccinations programs should be implemented. Still require primary health care with referrals and dental services
− In terms of the requirements of healthcare;
1. Outpatient department should be provided 1 per 5000
2. Inpatient department should be provided 1 per 10,000
3. Referral hospitals are those within the host country (surgery, labour, endemics such as malaria, HIV, TB, tetanus, diphtheria, measles)

Question 76

refugee planning womens rights

Answer 76

CONFLICT RELATED SEXUAL VIOLENCE
− As of February 2019, The penal code has been revised to include conflict-related sexual violence as a war crime
− The aim is to humiliate women which has a flow on effect to humiliate men (further exacerbated if children are implicated)
− An individual’s vulnerability to experiencing conflict related sexual violence continues through the movement process, creating a risk of unwanted pregnancies and the children resulting from them

Question 77

refugee camps and measles

Answer 77

− Symptoms: fever, rash, coryza/conjunctivitis/cough
− Management:
- Active case findings and early intervention
- Nutrition via food supplements and vitamin A
- Antibiotics – RTI, otitis media and pneumonia
- Supportive management – skin sores, mouth ulcers, encephalitis
- Diarrhoea – oral rehydration solution
− Prevention: vaccination

Question 78

refugee camps cholera

Answer 78

− Investigate and confirm outbreak
- Definition: severe dehydration/death with watery diarrhoea
- Diagnosis: positive cholera in stool or vomit
− Management:
- Oral rehydration for mild/moderate cases
- IV fluids and possible antibiotics for severe cases
− Prevention: chlorinate water, infection control and health promotion (food, water and toileting)

1. Reducing mortality
   - Can be achieved through Cholera Treatment Centres and by Effective Case Management
2. Reducing epidemic spread
   - Can be achieved by improving water and sanitation, developing hygiene practices and through public education
3. Co-ordination
   - Can be really challenging are there are a number of different parties involved
   - As an example of the parties involved: Ministry of Health, WHO, World Food Programme, Other non-government organisations, Local leaders and community groups, within your own organisation your working with

Question 79

Develop a basic understanding of Australia’s treatment of refugees and asylum seekers

Answer 79

− Refugee healthcare is based on the principle ASK;
1. Ask
2. Screening and health check-ups
3. Kindness
− The majority of the medical care provided to refugees in Australia is free, including;
- Public hospital including in-patient, out-patient, emergency and elective surgery
- Ambulance
- Community health
- Dental health
- Catch-up immunisations
- Interpreters

Question 80

Describe an approach to the initial health assessment for a refugee in Australia

Answer 80

ASK
− It is important to take a full and comprehensive history including aspects which may unique to a refugee patient
− The important aspects of the history and medical history are outlined below;
1. Refugee history
- Country of origin and transit countries to determine which diseases should be screened for
- Ethnic background as some ethnicities are risk factors for diseases
- When did the patient arrive in Australia, what type of visa and time spent in detention (as detention is a risk factor for developing a mental health condition)
- Languages spoken, preferred language and interpreter preference.
- Occupation and access to education in their country of origin
- Current stressors including housing security, housing condition, financial stress, education, training and work-related stress
- Gender preference – this is important in some cultures as it may be deemed culturally inappropriate to discuss sensitive manners with the opposite sex
- Current priorities about their health and personal needs
2. Medical history
- History of or contact with patients with an infectious disease (e.g. TB, malaria, HIV)
- History of non-infectious diseases including any complications with hearing, vision and dentition, pregnancy as well as CVD, COPD, diabetes and cancer
- Perinatal and postnatal history for all children, growth and nutrition history to identify malnutrition and micronutrient deficiencies and developmental milestones
- Past medical history including family, allergies and medication
- Current health (SNAP)
- Mental health should be assessed through asking about sleep, appetite, mood, anxiety and behaviour (It is not advisable to ask directly about a patient’s experience of torture or trauma)

Question 81

Describe important issues in refugee health care including mental health

Answer 81

MENTAL HEALTH
− Common mental health issues present within the refugee population include PTSD, depression, anxiety, substance abuse, cognitive impairment and somatisation (making something psychological physical)
− Substance abuse is particularly prevalent offshore as medications may not be accessible

Question 82

Describe important issues in refugee health care including trauma recovery.

Answer 82

TORTURE AND TRAUMA
− 1 in 3 refugees will have experienced trauma – however, the number is much higher if they have experienced offshore detention
- 80% of women will have experienced sexual abuse or torture
- 70% of refugees will have experienced physical or psychological violence
− Asylum seeker syndrome is prevalent but almost never registered (It is clinically referred to as post-traumatic stress syndrome (PTSD)
− Patients who have experienced torture and trauma should be referred to the Queensland Programme for Assistance of Survivors of Torture and Trauma (QPASST) as they are entitled to counselling and support

Question 83

✔ Discuss the role of the TIS (translating and interpreting service) and the use of interpreters in health care

Answer 83

− Critical situations that require an interpreters include taking the first clinical history, getting consent for procedures/treatment, pre and post-surgery information, results given, etc.
− Why can’t use family/friends
- Inaccuracy (is a specialist skill)
- Possible withholding or distorting information
- Non-objective viewpoint as the family member
- Possible inadequate communication
- Confidentiality standards may not be met
− Consider language, political, religious or cultural sensitivities, gender or whether specialist knowledge is required
− 2 types of interpreters are available. The advantages of both are seen below:
- On-site: non-verbal cues, better for longer and stressful interviews
- Telephone: cheaper, available anywhere and at any time and anonymity

Question 84

✔ Describe barriers those from refugee backgrounds may face in accessing health care (7)

Answer 84

− Refugees encounter a variety of barriers including;
1. Language and education
2. Torture and trauma
3. Prolonged poverty
4. Family separation and loss
5. Unfamiliar with the Australian healthcare system
6. Uncertainty about the future
7. Racism

Question 85

Investigations to complete on refugees

Answer 85

INVESTIGATIONS
− Investigations which may be of benefit for refugee populations include;
1. Eosinophil level as eosinophilia is indicative of parasitic infections.
2. Hepatitis B
3. Strongyloidiasis
4. HIV
5. LTBI
6. H. Pylori
7. STI
8. Nutritional deficiencies
− Investigations which should be provided for patients dependent upon their risk level include;
- Schistomiasis
- Malaria
− The actual tests include: serology, nutrition screening, stool and urine testing

Question 86

✔ Discuss ways to reduce maternal mortality around the world including access to contraception, skilled birth attendants, BEmONC/CEmONC: Contraception

Answer 86

CONTRACEPTION
− Access barriers include knowledge, agency and availability
− Contraception reduces maternal mortality rate (MMR)
- Fewer unintended pregnancies and less exposure to risk of unsafe abortion
- Fewer pregnancies per woman and fewer complications per pregnancy (if reduce pregnancy in very young or older mothers
- Users of contraception are more likely to access other health care
- Possible improved economic standard of living and more likely to be able to pay for emergency obstetric care if required
− When contraception fails it often results in unsafe abortion (cause of 8% of maternal death)
− Complications of unsafe abortion include:
- Incomplete abortion
- Haemorrhage
- Infection
- Uterine perforation
- Damage to genital tract

Question 87

✔ Discuss ways to reduce maternal mortality around the world including access to contraception, skilled birth attendants, BEmONC/CEmONC: Skilled birth attendants

Answer 87

SKILLED BIRTH ATTENDANTS
− Are accredited and educated health professionals (midwife, nurse or doctor)
− May attend home delivery or work from clinic or hospital
− Proportion of births attended by an SBA is climbing (80% globally)
− They are strangers to the community and can often be dispassionate. However they have the ability to;
1. Access necessary equipment and medications
2. Access referral centres
3. Develop birth and emergency plans
4. Monitor progress and identify complications early
5. Provide antenatal care (including antiretroviral HIV treatment)

Question 88

✔ Discuss ways to reduce maternal mortality around the world including BEmONC/CEmONC:

Answer 88

BASIC ESSENTIAL OBSTETRIC CARE
− Is the basic care all pregnant women should receive by healthcare centres. It includes the following aspects;
1. Parenteral antibiotics (e.g. ampicillin and gentamycin)
2. Parenteral oxytocic drugs, which should be given prophylactically to all women at the 3rd stage of labour to reduce the risk of haemorrhage (are the drugs which cause uterine contractions)
3. Parenteral anticonvulsants for pre-eclampsia and eclampsia (e.g. magnesium sulfate)
4. Manual removal of placenta
5. Removal of retained products of conception
6. Assisted vaginal delivery (vacuum extraction)
7. Newborn resuscitation
COMPREHENSIVE EMERGENCY OBSTETRIC CARE
− Is provided by district hospitals, and should include the basic essential obstetric care in conjunction with;
1. Surgical intervention (caesarean section)
2. Blood transfusions

Question 89

6 PRIORITIES FOR WOMEN AND HEALTH

Answer 89

1. Elevate the position of women in the health and care workforce
2. Increase women’s participation and leadership in science and public health
3. Reduce non-communicable diseases among women
4. Ensure quality sexual and reproductive health for all
   - Maternal mortality rate (MMR), Discrimination, Harmful practices, Contraception
5. Prevent and respond to violence against women
   - Human trafficking
6. Address gender inequality in the COVID-19 response and recovery

Question 90

SOCIOCULTURAL FACTORS PREVENTING WOMEN FROM QUALITY HEALTH SERVICES

Answer 90

− Unequal power relationships between men and women
− Social norms that decrease education and paid employment opportunities
− An exclusive focus on women’s reproductive roles
− Potential or actual experience of physical, sexual and emotional violence

Question 91

MATERNAL MORTALITY causes and some factors leading to it

Answer 91

There are 3 key contributing factors of this maternal mortality;
1. Delay in seeking care (they don’t recognise a complication so there is a delay in deciding to act and seek help such as low status, previous poor health experiences)
2. Delay in arrival at health care facility (travel issues, financial problems)
3. Delay in the provision of adequate care (lack of resources)

The main causes of maternal mortality include; 
Pre-existing conditions (indirect)
Haemorrhage
Pregnancy induced hypertension
Infections
Obstructed labour
Abortion complications Blood clots/embolis (indirect – biggest cause in Australia

Question 92

womens health and antenatal care: when it should occur

Answer 92

ANTENATAL CARE
− WHO recommends at least a minimum of 8 antenatal care
− Benefits include emotional support and advice, medical care and relevant and timely pregnancy information
− There are 3 phases to antenatal care:
- Early: dates and screening e.g. ultrasound, syphilis, HIV, Hep B, Hb, give iron and tetanus vaccine
- Mid x2: checking BP, fetal growth, maternal wellbeing and anaemia
- Late: fetal lie, delivery planning (where, with SBA, education on recognising problems, having a transport plan, etc.)

Question 93

✔ Describe female genital mutilation/cutting (FGM/C), the issues arising from it, and the steps being taken internationally to oppose this practice

Answer 93

– FEMALE GENITAL MUTILATION (FGM)
− FGM compromises of all procedures involving the removal of the external female genitalia or other injury to the female genital organs for non-medical reasons
− Is a human rights violation and is illegal in most countries
− Short term medical complications: pain, infection, haemorrhage and tetanus
− Long term medical complications: dyspareunia, dysmenorrhoeal, dysuria, incontinence, PTSD and obstetric complications

Question 94

✔ Describe the problem of human trafficking and identify the signs that help recognise a person may have been trafficked.

Answer 94

− Is the recruitment, harbouring or transporting of people into a situation of exploitation through the use of violence, deception or coercion and are forced to work against their will
− There are many different forms of exploitation including forced prostitution, forced labour, forced begging, forced criminality, domestic servitude, forced marriage and forced organ removal
− Individuals who are victims of human trafficking are preyed on in accordance with their vulnerabilities
− Patients may experience severe physical, sexual and psychological abuse which may result in sexually transmitted disease and unwanted pregnancies
− Patients who have experienced human trafficking may be hesitant to speak and defer to a partner when asked questions. They may also be unable to engage in a private examination

Question 95

✔ Discuss the impact of COVID-19 on health of women

Answer 95

Question 96

✔ Discuss the human rights, social and medical implications associated with obstetric fistulas

Answer 96

− A common problem that occurs with adolescent pregnancy is obstetric fistulas. This is an abnormal hole between the vagina and the rectum or bladder caused by prolonged labour
- It is caused by the compression of the urogenital organs during prolonged labour which causes ischemia and therefore necrosis of the tissues forming a fistula
- Obstetric fistulas cause urinary or bowel incontinence, meaning these women leak and smell causing social ostracism (shame, stigma and even outcast from family/community)
− Obstetric fistulas are preventable through;
1. Delaying age of the first pregnancy (allows the pelvis to develop more)
2. Cessation of harmful traditional practices (e.g. female genital mutilation)
3. Timely access to obstetric care

Question 97

Explain the principles of One Health and the interactions between humans, animals and ecosystem health

Answer 97

One health recognises health of people is connected to health of animals and ecosystems.
Collaborative, multisectoral and transdisciplinary approach – working at local, regional, national and global levels
Transdisciplinary – team of people; question each other in expert knowledge from the community
Not necessarily just zoonosis
Understanding systems thinking – thinking in loop structure; behaviour emerges from structure of its feedback loops. Root causes are not individual nodes – they are forces emerging from other feedback loops.

Health individual does not exist in isolation. All members of larger community with multisectoral interactions with different animals.

Climate change, urbanisation and poor environmental regulation results in deforestation and destruction of habitat.

Global trade is easy, travel is fast meaning previously isolated pandemics potential to rapidly spread.

The environment, animals and disease all overlap. New diseases emerge.

Our efforts to secure a safe, adequate food and water supply, our efforts to protect the environment and our efforts to prevent and protect from human disease must subsequently all overlap 🡪 One Health approach which fosters collaborative relationships between human, animal and environmental health with improved communication between sectors, coordination of disease surveillance and delivery of uniform messaging to the public

Question 98

Give examples of a One Health understanding of disease causation and management

Answer 98

Human populations are growing and expanding into new geographic areas 🡪 as a result, more people live in close contact with wild and domestic animals. Close contact provides more opportunities for diseases to pass between animals and people
The earth has experienced changes in climate and land use, such as deforestation and intensive farming practices 🡪 disruptions in environmental conditions and habitats provide new opportunities for diseases to pass to animals.
International travel and trade has increased 🡪 diseases can spread rapidly across the globe.

Question 99

Describe the epidemiology, lifecycle, transmission and common clinical features of Schistosomiasis,

Answer 99

Schistosomiasis

Clinical importance:
Acute infection – rash from penetration of cercariae. Fever, myalgia, eosinophilia (Katayama Fever)
Chronic infection leading to inflammation and fibrosis as an immune reaction to the eggs laid in the worm
Intestinal (Several species) – in intestine and liver: abdominal pain, diarrhoea, blood in stool, signs of portal hypertension – e.g. hepatomegaly, ascites
Urogenital (Schistosoma haematobium) – bladder, genital lesions: haematuria, dysuria, longterm bladder cancer or infertility
Distribution: Africa, China and PNG +/- Some parts of South America (Brazil, Puerto Rico, Venezuela)

Question 100

Describe the epidemiology, lifecycle, transmission and common clinical features of Leptospirosis.

Answer 100

Leptospirosis
Leptospirosis is an infection in rodents and other wild and domesticated species
Outdoor and agricultural workers (rice-paddy and sugar cane workers for example), recreational hazard to those who swim or wade in contaminated waters
In endemic areas – number of cases may peak during the rainy season and may reach epidemic proportions in case of flooding because the floods cause rodents to move to the city

Question 101

Describe the epidemiology, lifecycle, transmission and common clinical features of Cysticercosis

Answer 101

Cysticercosis
Clinical importance: primary neurocystercosis causing epilepsy or other neurological symptoms
Cysts can be in the brain, eye or spinal cord
Taenia Solium tapeworm mostly asymptomatic – people tend to present for treatment only if they notice passage of segments of tapeworm in their stool
Taenia Solium: Human ingests infected pork, poorly cooked and laden with cysts 🡪 T solium eggs are ingested by pork which is intermediate host. Also can spread to humans via ingestion of faeces – human cysicercosis

Question 102

Apply One Health principles to address Schistosomiasis

Answer 102

Schistosomiasis
Control of schistosomiasis will require collaboration between human health, animal health and environmental sectors. Humans can be treated to eliminate parasite excretion and prevent clinical illness but if this is the only strategy, reinfection happens very rapidly. The snail vector needs control and a suggested method is by protecting fish stocks - which in turn requires alternative agricultural and aquaculture methods of generating food. Sanitation is also needed to prevent contamination of water sources by infected people.

Question 103

Apply One Health principles to address Leptospirosis,

Answer 103

Leptospirosis
Control human infection via wearing protective clothing for individuals with occupational risk and avoidance of swimming in water that could potentially be contaminated. Leptospirosis can be controlled in vectors via targeted vaccination, focused culling programs, rodent control. Finally, environmental (built and natural) factors can be mitigated through climate change mitigation (flood-spoofing infrastructure in flood-prone areas) and public health education to reduce exposures to risk environments.

Question 104

Apply One Health principles to address Cysticercosis

Answer 104

Cysticercosis
Controlling human infection through treatment of taeniasis cases, improved sanitation, health education including general hygiene and food safety. Controlling the vector can involve intervention in pigs (vaccination plus anthelmintic treatment) together with strategic mass drug administration for taeniasis. Improved environmental practices – improved pig husbandry, meat inspection and regulation.

Question 105

Apply One Health principles to address NCDs

Answer 105

NCDs
Need for coordinated, multisector actions in order to appropriately manage the direct manifestation of noncommunicable disease in the individual, for example, testing and case-management of Chronic Obstructive Respiratory Disorder (COPD).

Wider systemic considerations needed too – for example, in regard to environmental health. Accordingly a multi-sectoral action may be minimization of fossil fuel use, leading to lesser carbon emissions and subsequent decreases in air pollution. This is inherently a causal relationship in which poor environmental health (i.e. polluted air) contributes to human disease and as such a coordinated, transdisciplinary approach is needed between the public health, government and environmental scientists.

Question 106

Discuss the public health response to emergent or modified infectious diseases in epidemics and pandemics and the responsibilities of health practitioners in this response.

Answer 106

Epidemic: increased number of infectious illness above expected levels in place of region
Pandemic: Extension epidemic beyond regional boundaries.

Information needed – cases so far: symptom profile, deaths, locations and potential sources of infection.
Features of the disease: symptoms, incubation period, modes of transmission, infectivity period, expected fatality rate, available treatment, effective, preventative strategies and historical data.
Recognise outbreaks and prepare to investigate – normal rates, cases related to each other?
Verify diagnoses and confirm outbreak exists
Establish case definition and find cases –
Determine risk population
Develop hypotheses – what is it? Where did it come from? How is it spreading? Who is at risk? Why now?
Test hypotheses epidemiologically – as necessary, reconsider, refine and re-evaluate
Carry out further studies if necessary
Implement control and prevention measures specific to the situation
Communicate findings

Question 107

Discuss the impact of climate change on the health of communities using examples.

Answer 107

Climate change and disruption of natural ecosystems has resulted in considerable disruption of the insect population in certain regions. This has significant implications for changing patterns of Dengue and Malaria transmission. Need for public health adaptation measures (WHO 2008 working document dedicated to this).
Vastly changing ecosystems will affect different populations in different ways.

Question 108

Demonstrate an understanding of disease transition from communicable to non-communicable predominance and outline how this is impacting future directions in global health strategy. Examples

Answer 108

Large mediator of climate change can be linked to anthropogenic climate emissions, particularly in the form of CO2 from burning fossil fuels. This has clear links with Chronic Obstructive Pulmonary Disease (COPD) and other respiratory disorders – bidirectional relationship between the things we as humans doing affecting our environment (air we breathe) and the air we breathing affecting out health. In order to tackle this, there needs to be concerted and multi-sectoral approach to health, understanding that wider civil society, government regulation and individual choice are all critical factors in ameliorating carbon emissions and improving respiratory disease
Need for planning for disaster risk reduction and mitigation in communities which will be affected the most. The United Nations Development Programme was introduced as a pilot program which aimed at increasing capacities of National Health systems to the effects of climate change. Focus on early warning of disasters and outbreaks and early intervention:
Jordan has been working on control of diarrhoeal disease through improved sanitation (risk is mediated through lack of water 🡪 open defecation in waterways that supply drinking water). Climate change will worsen water supply and salinity risk.
Bhutan and Kenya are rolling out vector-disease risk reduction in highland areas.
China is focusing on greening metropolitan centres which retain heat and pose threats of heat stroke

Question 109

Discuss the information to be gathered in a pre-travel consultation.

Answer 109

Question 110

Analyse an itinerary in the light of a travel medicine website to plan appropriate malaria prophylaxis and vaccinations.

Answer 110

− Malaria chemoprophylaxis can be achieved by any of the below 3;
1. Doxycycline
- Taken daily from 1 day before, to 4 weeks after leaving the malarious area
- Side effects: Photosensitivity, GI upset
- It is cheap
- It requires prolonged use and compliance
2. Atovaquone-proguanil (Malarone / Promozio)
- Taken daily from 1 day before, for 1 week after leaving the area
- Side effects: vomiting and diarrhoea (less common)
- Shorter duration than doxycycline however they are expensive
3. Mefloquine (Larium)
- Taken once weekly
- Side effects are rare, but some may experience neuropsychiatric complications
− It is also important to give travellers that won’t have access to medical care: Rapid test kits and an initial treatment course (Artemether-lumefantrine)
− A fever in a traveller up to 3 months after returning from an at-risk country is malaria until proven otherwise
− Requires a blood film for diagnosis

Question 111

Identify common travel-related vaccinations and discuss the risks mitigated by their use.

Answer 111

− The basics that we want to cover with every traveller is listed below;
1. Childhood vaccines
- MMR, Varicella, Polio, Hep B and HiB
2. Tetanus (10 years, 5 years for bad wound) / Whopping cough / Diphtheria
3. Influenza
4. Pneumonia (child or over 65)

Others include Hep A, Typhoid (Salmonella Typhii) , RabiesMeningococcus (Neisseria Meningitidis), Cholera (Vibrio Cholerae), Malaria, Yellow Fever, Japanese Encephalitis

Question 112

Non-bloody travel diarrhoea prevention and vax

Answer 112

Non-Bloody Travel Diarrhoea

The most common illness from neglecting basics of:
Hand hygiene
Safe drinking water
Boil, bottle and peel
Food handling is a significant contributor
Avoid cooked food that has been allowed to cool
Beware of seafood and dairy products
Biggest culprits are ice cubes and ice cream
No Vaccination.

Question 113

Hep A prevention and vax

Answer 113

Hepatitis A
Faecal oral transmission, typically transmitted by undercooked shellfish, or inadequately cooked or frozen fruits, vegetables or other foods.

Budget travel, backpackers and trekkers have greater risk
Standalone vaccination = Avaxim:
3 year coverage with booster at 6-12 months giving lifelong immunity

Question 114

Typhoid prevention and vax

Answer 114

Typhoid (Salmonella Typhii)
Food and drink contaminated with faeces.

10% fatality in untreated cases.

Highest in Asia, Africa and ME
90% protection with vaccination

HepA+Typhoid = Typhim injection: coverage for 3 years

Question 115

Rabies prevention and vax

Answer 115

Rabies
Progressive CNS infection from Lyssavirus

Dogs, monkeys or any mammal

NEED post-exposure prophylaxis or universal mortality.
IM: 3 doses needed at days 0,7,28

Booster needed at 3y depending on risk/titre

If pre-exposure prophylaxis = need to post-exposure vaccines only at day 0 and 3

No PReP = Rabies Ig + Vax @ days 0,3,7,14

Question 116

Meningococcus prevention and vax

Answer 116

Meningococcus (Neisseria Meningitidis)
Potentially fatal bacterial infection
6 major serogroups – A,B, C, W, X, Y

Highest incidence:
C and W: Sub-saharan Africa (Meningitis belt) and pilgrimage to Mecca
B and C: Industrialised countries, schools and close quarters
Approved for >2years (on immunization schedule at 12 months)

Quadrivalent vaccination recommended for travel (ACWY) – currently on immunization schedule. Approved up to 55 years old.

Question 117

Cholera prevention and vax

Answer 117

Cholera (Vibrio Cholerae)
Contaminated water
Free living bacteria – invade crustaceans and fish too
Dukoral (oral inactivated)
Primary course needed is 2 doses at least 1 week apart
Booster at 2 years, repeat course if longer than 5 years
Efficacy of 85%, declining from 6 months
Also coverage for Enterotoxigenic E. Coli (efficacy of 60%, 3-6 months)

Question 118

Malaria prevention and vax

Answer 118

Malaria
Most common cause of fever in returned travels
Prominent in Australian travel community
Prevention is key – Chemoprophylaxis:
Doxycycline daily – 1 day before, 4 weeks after leaving malaria area. SE: photosensitivity and GI upset. Cheap but need prolonged course and adherence.

is Vaccination

Question 119

Yellow fever prevention and vax

Answer 119

Yellow Fever
Flavivirus transmitted by Aedes Aegypti, common in Sub-Saharan Africa and South America

Low risk of transmission but very high risk of mortality
Stamaril – live vaccination, do not give to IC, breastfeeding or pregnancy

Given to protect individual and prevent international spread

Lifelong protection

Question 120

Jap encephalitis prevention and vax

Answer 120

Japanese Encephalitis
Flavivirus spread in Asia through Culex mosquito
Year round transmission in SE Asia, seasonal in China and Japan. High risk in agricultural regions
30% fatality + serious neurological sequelae
JEspect vaccination – inactivated, 2 doses, 96% cover

Imojev – live attenuated, single injection from >9 months, 95% cover.

Question 121

Altitude sickness prevention and vax

Answer 121

Altitude Sickness
Acute Mountain Sickness, High-Altitude Cerebral Oedema (HACE) and High-Altitude Pulmonary Oedema (HAPE)

Prevent via acclimatization and slow ascent
Acetazolamide (Diamox) – for rapid ascent to altitudes >2,800m. Improves acclimatization