Author: cjdor

Global Health and Diabetic Retinopathy-“Protect your vision: Steps for someone with Diabetes”

by cjdor, posted in APHA IH Section, Chronic Disease

“Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body’s systems, especially the nerves and blood vessels.” -WHO (2018)

The prevalence of Diabetes has increased in low and middle-income countries. Diabetes increases the risk of a range of eye diseases, but the main cause of blindness associated with diabetes is diabetic retinopathy.

According to the World Health Organization (WHO), diabetic retinopathy causes blindness in almost 5 million people worldwide. As the leading cause of vision loss in working-age adults, diabetic eye disease thus represents a significant global socioeconomic and healthcare problem.

What is diabetic retinopathy and what causes it? 

Diabetic retinopathy is an eye condition caused by diabetes. It affects the small blood vessels and light sensitive tissues in the back of the eye (retina). This condition is primarily caused due to high blood sugar levels and if left untreated can lead to vision loss.

Am I at risk for vision problems? 

If you have any type of diabetes you can get diabetic retinopathy. This includes people with type 1, type 2, and gestational diabetes, which is diabetes that occurs during pregnancy. Your risk gets higher the longer you have diabetes. More than 2 in 5 Americans with diabetes have some stage of diabetic retinopathy. The good news is that you can lower your risk by controlling your diabetes!

When should I get an eye exam?

The best diagnostic for diabetic retinopathy is a dilated eye exam.

  • If you have diabetes, get a dilated eye exam once a year
  • If you have diabetes and become pregnant, get a dilated eye exam as soon as possible and ask your doctor if you will need more eye exams during your pregnancy

What can I do to prevent diabetic retinopathy?

Losing your vision to diabetic retinopathy is sometimes permanent, but can be prevented. Studies have shown that the best ways to prevent it are to:

  • Keep your blood sugar level close to normal (this also reduces getting kidney and nerve diseases)
  • Control any elevated blood pressure and cholesterol
  • Exercise regularly
  • Choose healthy foods
  • Follow your doctor’s instructions for taking any medications and ask questions about your health

Is there a treatment for diabetic retinopathy?

Yes. However, treatment for diabetic retinopathy is often delayed as symptoms are unnoticeable until the condition starts to progress, or when Diabetic Macular Edema (DME) occurs. DME is when blood vessels leak fluid into the back of the eye, causing swelling. In this case, eye exams would be needed more often, as it becomes more severe. People with more severe cases may need a dilated eye exam as often as every 2 to 4 months. It is important to know that early detection and treatment can reduce the risk of blindness on a global scale.

World Heart Day 2018

by cjdor, posted in APHA IH Section, Chronic Disease, Food/Nutrition

Today, September 29, marks World Heart Day (WHD) around the world. World Heart Day brings awareness to the prevention and control of cardiovascular diseases (CVDs) which plays a significant role in our daily lives contributing to our overall health and wellness.

What are Cardiovascular diseases?

Cardiovascular diseases are a group of disorders of the heart and blood vessels and they include:

  • Coronary heart disease – disease of the blood vessels supplying the heart muscle;
  • Cerebrovascular disease – disease of the blood vessels supplying the brain;
  • Peripheral arterial disease – disease of blood vessels supplying the arms and legs;
  • Rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria;
  • Congenital heart disease – malformations of heart structure existing at birth;
  • Deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

According to the World Health Organization (WHO), cardiovascular diseases take the lives of 17.7 million people every year, and accounts for 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke.

Projects around the world

The global fight against CVDs is happening throughout the world. Some examples include:

– Through the HEARTS project based in Manila, Philippines, WHO and partners like the United States Centers for Disease Control and Prevention (CDC), are supporting ways to fight cardiovascular disease through training, planning and implemention.

– A two-year Standardized Hypertension Treatment project launched in 2015 by the Pan American Health Organization (PAHO) and CDC on the Caribbean island of Barbados, enacted a mission to improve hypertension treatment and control among Barbadians with raised blood pressure through standardizing care for hypertensive patients, prescribing and making available the most effective medicines for treating each person’s condition. The principal investigator of the project highlighted, “It was also encouraging to see the cultural and behavioural change in the clinics among health workers who had to deliver a more focused form of care.” It is important to also note how cultural and social factors play a vital role to behavioral change when it came to seeing patients achieving satisfactory blood pressure control.

Specific intervention activities included: (1) Developing salt reduction and tobacco control plans, (2) Implementing simplified and standardized management protocols, (3) Improving access to medicines and technologies, and (4) Building capacities of health and other providers.

http://www.who.int/news-room/feature-stories/detail/treating-cardiovascular-disease-in-barbados

http://www.who.int/news-room/feature-stories/detail/philippines-embraces-efforts-to-step-up-cardiovascular-disease-care

Key messages to protect heart health

There are small, yet very impactful ways to make “heart health at the heart of all health”. Here are some facts/tips!

  • Tobacco use, an unhealthy diet, and physical inativity increase the risk of heart attacks and strokes.
  • Engaging in physical activity for at least 30 minutes every day of the week will help to prevent heart attacks and strokes.
  • Eating at least five servings of fruit and vegetables a day, and limiting your salt intake to less than one teaspoon a day, also helps to prevent heart attacks and strokes.

When it comes to reducing cardiovascular diseases and improving heart health, it is pivotal to identify those individuals with or at highest risk of CVDs due to risk factors such as hypertension, diabetes, hyperlipidaemia or an already established disease to ensure they receive appropriate treatment in order to prevent premature deaths. During 2015, 17 million premature deaths occurred from noncommunicable diseases (under the age of 70) with 82% of deaths reported in low- and middle-income countries, and 37% caused by CVDs (WHO, 2017). Although there has been great strides toward the prevention of cardiovascular diseases, inequalities including access to noncommunicable disease medicines, and basic health technologies in all primary health care facilities is essential to those in need of receiving treatment and education.

The epidemic of cardiovascular diseases has also impacted my life with my grandmother,mother, and all 4 of my aunts and uncles suffering from hypertension. In March 2018, my cousin at the age of 35 suffered from a massive stroke and is successfully recovering. I spent bringing awareness to this day by cooking popular caribbean dishes with a healthy spin and educating family and friends across the United States and Caribbean on the importance of having and maintaining a healthy heart. In addition, I took a 2 mile walk through my neighborhood taking in the beautiful Florida scenery and cool breeze.

How did you celebrate World Heart Day?

 

Empowering Women to Take Control of their Sexual Health

by cjdor, posted in APHA IH Section, Health Equity, HIV/AIDS, Infectious Disease, Stories from the Field, Women's Health

Two weeks ago, I attended a powerful and motivating summit hosted by Florida International University (FIU) Robert Stempel College of Public Health and Social Work on empowering women to take control of their sexual health through knowledge of biomedical HIV prevention methods, connecting to community resources, and mobilizing key community stakeholders and providers.

What was most unique about this summit was the rawness of the various conversations. These conversations included voices of state congresswoman Frederica Wilson and Ileana Ros-Lehtinen, community women and activists, a panel of diverse physicians and nurse practitioners, researchers, and LGBT and minority women working across different sectors in the HIV prevention field. When it comes to empowering women surrounding their sexual health, pre-exposure prophylaxis (PrEP) is viewed as the driving vehicle. The problem is that there is a lack of awareness among women particularly LGBT and minority women, and providers about PrEP and post-exposure prophylaxis (PEP). During the engaging providers panel comprised of various physicians working in South Florida, a Haitian physician expressed that before the conference he decided to call several of his provider friends that practice within the local Haitian community and asked them if they have heard of PrEP. How many do you think said, “Of course, I know about PrEP”? The answer is…0. Not one single doctor whom was asked said they have heard of PrEP. We have a lot left to do. The work has not yet been done!

Miami’s HIV Epidemic

So maybe you are wondering…well why host this conference? The county of Miami-Dade continues to lead the nation in new HIV infections. Not too far away is the neighboring county of Broward which continues to compete with Miami when it comes to high prevalence rates as well.

Due to the rising rates of HIV in Miami-Dade County, city officials have responded to the epidemic with the development of a “Getting to Zero” task force comprised of city commissioners and individuals representing various public health agencies throughout Miami-Dade County as well as the state of Florida. The task force devised a multi-pronged action plan with priority goals for the next two years. The plans include to (1) reduce the rates of reported AIDS cases, (2) reduce the percentage of newly diagnosed HIV cases among residents aged 13-19 (3) increase the percentage of newly identified HIV-infected persons who are linked to care within 90 days of diagnosis and are receiving appropriate preventive care and treatment services in Miami-Dade County and (4) reduce the number of newly reported HIV cases in Miami-Dade County (http://www.miamidade.gov/releases/2016-09-29-mayor-getting-to-zero.asp).

Prep around the globe

PrEP has served as a vehicle for prevention and is being used worldwide. Countries such as the United States has large scale PrEP programs while others are still in the stages of development and some have not implemented as of yet. There has been many PrEP initiatives enacted. The US Agency for International Development (USAID) is currently supporting 5 Microbicide Product Introduction Initiative (MPii) projects in Kenya, South Africa, Zimbabwe, Malawi, and Uganda from 2015-2020 focused on gender-based violence, drug resistance, creating demand, introducing new products, and models for delivering services. Another program is the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) initiative, a collaborative effort between US President’s Emergency Plan for AIDS Relief (PEPFAR), Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare. DREAMS aims to reduce the incidence of HIV by 40% among adolescent girls and young women by 2020 in the highest HIV burden countries including Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. Of the 10 countries, 5 have included PrEP for adolescent girls and young women in their strategic plans to address HIV. Recent data from PEPFAR shows significant declines in new HIV diagnoses among adolescent girls and young women. In the 10 African countries implementing PEPFAR’s DREAMS partnership, the majority of the highest HIV-burden communities or districts achieved greater than a 25 percent–40 percent decline in new HIV diagnoses among young women (https://www.usaid.gov/what-we-do/global-health/hiv-and-aids/technical-areas/dreams). In other areas of the globe such as Latin America and the Caribbean, a combination of biomedical, structural, and behavioral interventions is greatly needed in order to reach target objectives and goals and ultimately increase HIV prevention efforts. I am excited to see the future of PrEP.

Women’s Perspectives

During the women’s perspectives breakout sessions, workshops were broken down into specific focus groups including African American, Latina and Haitian. Amongst the African American women breakout session, some key topics that were addressed included stigma, specifically communication between the medical provider and client such as clear language on how to ask questions during the appointment while also considering time constraints, policy, and the need for funding toward effective behavioral interventions for HIV negative black women in the community.

Sistas Organizing to Survive (SOS) is a grassroots mobilization of black women in the fight against HIV and AIDS. In Florida, one in 68 non-Hispanic black women are known to be living with HIV/AIDS and has been the leading cause of death among black women aged 25-44 years within the state. (http://www.floridahealth.gov/diseases-and-conditions/aids/administration/minority-initiatives.html)

Call to Action

Miami is the #1 city in the United States with new HIV infections. This is a huge public health issue. We have a call to action to advocate for ourselves and others when it comes to ending the epidemic. We have made significant strides, but the work has not yet been done. Sexual health including HIV prevention should be something that we freely discuss with our family, colleagues, peers, physicians, and anyone that we come in contact with that is willing to listen. It is these conversations that we can decrease stigma surrounding HIV. Women across the counties of Broward, Miami-Dade, and Palm Beach have answered the call to action by organizing and advocating for all women. We have accepted the call to action together that we can get Miami to Zero!

“A future where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

–Quote from the National HIV/AIDS Strategy Updated to 2020: Strategy Vision

For additional information, please visit http://www.who.int/hiv/topics/prep/en/ http://amp4health.org/ and http://getting2zeromiami.com/

Is Zika still a thing? My experiences as a Zika Case Manager in the field (South Florida)

by cjdor, posted in APHA IH Section, Infectious Disease, Stories from the Field

Zika was a hot topic, but now it seems like it is a thing of the past. People always ask me…”Is Zika still is a thing?” And my response is, “Of course! Just because it has declined, certainly does not mean that it isn’t still a public health threat.”

Interesting enough, comments like “Is Zika still a thing” come from physicians and various public health professionals as well as individuals living in regions with active Zika transmission. Those that express more of a concern include individuals that have planned future travel to the state of Florida and are planning to conceive, or a close family member of someone who is currently pregnant.

What is Zika?

Perhaps you never heard of Zika, or still quite aren’t sure what Zika is exactly. Zika can be described as a virus that spreads to people primarily through the bite of an infected Aedes species mosquito. It is closely related to other flaviviruses such as Zika can also be transmitted sexually from a person that has Zika to their partner as well as from a pregnant woman to her developing fetus, which can result in serious birth defects. Want to learn more about Zika? Check out some other IH section blog posts about Zika here.

My role, criteria for testing, testing/funding limitations

I was hired as one of two Zika Case Managers within my local county health department through funding allocated to the state of Florida by the CDC. One of my duties is to coordinate the testing of suspected local, or travel cases, pregnant women, and any infant born to a potentially exposed pregnant woman. The testing criteria for pregnant women include those who traveled to a Zika-active transmission area, had sexual exposure during pregnancy, or 8 weeks prior regardless of the mother’s testing status, as well as those with any abnormal ultrasound results. Testing is also recommended if the mother was not previously tested. Just like other reportable infectious diseases, it takes effective communication between health professionals at all levels to get quality information across regarding Zika. In order to get the job done, we collaborate with infection control practitioners of local hospitals, nurses, physicians, and other public health clinicians to get samples of babies collected at birth for Zika testing while also making sure that a head ultrasound and hearing test are performed on the baby. This is very important because once the baby leaves the hospital it is almost impossible to get samples collected. A majority of the pediatric clinics don’t have the means to ship the specimens to the state laboratories. Some of the general responses we have received from these clinics include not knowing how to properly prepare the specimens for shipping, having the money to do so, and lack of knowledge about billing the patient’s insurance for the procedure. Although the county health department has the access and ability to ship specimens, it would be a liability for us to ship the specimens if another facility collected the samples.

As of March 2017, the department of health has conducted Zika virus testing for more than 13,020 people statewide. At Governor Scott’s direction, all county health departments were mandated to offer a free Zika risk assessment and testing to pregnant women. Unfortunately, due to a decline in cases, and federal funding allocated to state programs winding down, free testing is no longer accessible to the community, and is only provided on a case by case basis. Zika tests can be pretty expensive ranging anywhere from $200 – $400 when conducted at a commercial laboratory and even more in some cases.

State laboratories have just about depleted federal funds received for testing initiatives. If a patient does not meet testing criteria at our department of health, we recommend testing through affiliated commercial laboratories. In addition to the many changes in testing criteria including requiring patients to show proof of insurance, there has been issues with the insurance companies and patients’ have been incorrectly billed over $1000 for their Zika tests when in fact the test was free. This has been a big issue with tests conducted as far back as November and December which we have recently been made aware of. Mosquito control services specifically for Zika efforts provided by our county health department’s Environmental Health program has ended.

Management of Infants with confirmed, or possible Zika Infection

Currently, we have reached the stage where the pregnant women that are case managed have already given birth. We are now tasked with conducting 24 month active follow-ups of all infants exposed to a positive mother via in utero. We conduct follow-up of the infants exposed regardless of whether the infant tested negative, or positive. These infant follow-ups occur at 2, 6, 12, 18, and 24 months. This is because abnormalities can still occur during child development. A majority of our babies being followed are currently between the 12 and 18 month mark.

Out of all the babies we have tested, and are currently following, only one is confirmed to be microcephalic. Looking into the future, at the 18 month follow-up mark, the infants being followed will have to be re-tested in order to confirm if the antibodies are indeed negative or positive. Another complication with testing these babies will be whether the baby has traveled since it has been born. There is a possibility that the baby could have been infected during travel and not in utero. As of July 31st 2018, Zika contracts for our county health department will end and it is unsure who will take on the responsibility for maintaining the case management of these families.

Community Outreach

Best practices we have utilized as a county has been community outreach which we collaborate across the division of communicable diseases. I have been able to work closely with a CDC field assigned Zika Community outreach nurse to assemble and distribute Zika prevention and testing kits with a specific focus on obstetrician-gynecologist and pediatricians. We have been able to identify the gaps in testing and communication among our health department and local hospitals, clinics, and private physician offices. Additional community outreach activities of focus include visiting women, infant, and children (WIC) clinics throughout the county in order to conduct health education on Zika as well as community health fairs primarily within the Haitian population due to Haiti being one of the top countries which we get the most amount of travel related cases. Unfortunately, these outreach efforts will also end at the end of this summer due to the depletion of funds, and our CDC field assigned nurse’s contract ending.

Where we are now

As of right now, Florida still does not have any identified areas with ongoing, active Zika transmission. Florida is a hotspot for vacationers, especially the counties of Miami-Dade and Broward. Since the local transmission of Zika in 2016 in both counties, it seems that very few individuals consider Zika as being a major concern. Very few physicians’ are screening for Zika. Some still aren’t sure what it is exactly, and how it can affect an unborn fetus. Congenital Zika infection is still a global health threat to pregnant women and their infants. Zika is still a fairly new infectious disease, and we are learning as we go, especially the risks after pregnancy. The reality is that Zika is here to stay. Funding for zika prevention and treatment should be a top priority in order to aid in the health and wellbeing of children and families across the United States.