Infectious Diseases and Vaccine Sciences: Strategic Directions

Despite substantial progress, infectious diseases remain important causes of ill-health and premature deaths in Bangladesh. Bangladesh has experienced a >90% reduction in the incidence of deaths due to childhood diarrhoea over the last 25 years. Further reductions can be achieved through the introduction of effective vaccines against rotavirus and improvements in home hygiene, quality of drinking-water, and clinical case management, including appropriate use of oral rehydration solution and zinc. Pneumonia is now the leading cause of childhood deaths in Bangladesh, and the pneumonia-specific child mortality is largely unchanged over the last 25 years. Reductions in mortality due to pneumonia can be achieved through the introduction of protein conjugate vaccines against Haemophilus influenza type b and Streptococcus pneumoniae, improvements in case management, including efforts to prevent delays in providing appropriate treatment, and the wider use of zinc. Tuberculosis is responsible for an estimated 70,000 deaths each year in Bangladesh. Although services for directly-observed therapy have expanded markedly, improved case finding and involvement of private practitioners will be important to reduce the burden of disease

Clinical approach to respiratory mucormycosis in a bottlenose dolphin (Tursiops truncatus) calf under human care

Dissertação de Mestrado Integrado em Medicina VeterináriaSeveral fungi are described to cause invasive infections in dolphins, the respiratory system being a common site of involvement. Mucormycosis is considered one of the most devastating fungal infections in dolphins, associated with an elevated mortality rate, where hyphae are capable of invading blood vessels, producing tissue infarction and necrosis. A one-year-old male bottlenose dolphin (Tursiops truncatus) calf presented with a history of recurrent episodes of leukocytosis and occasional respiratory signs. During a routine faecal examination, a myriad of hyphae were found. Fungal culture revealed a mucormycete isolation, the aetiologic agent of mucormycosis. Molecular studies allowed to identify Cunninghamella bertholletiae. Thoracic radiographs showed the presence of a bronchoalveolar pattern on both the right and left lung apexes. A bronchoscopy was performed, which revealed multiple whitish lesions, diffusely distributed on the tracheal and bronchial submucosa. The antifungal therapy prescribed was a combination of posaconazole and aerosolized liposomal amphotericin B. Adjunctive therapies included bromhexine, vitamin C, vitamin B complex, probiotics, silymarin, Imuno-2865™ and ozone therapy. Follow-ups were conducted with haematology and blood biochemistry, faecal and sputum culture and direct microscopy, and bronchoscopies. There was a good overall response to treatment and antifungal therapy was discontinued. However, the infection relapsed and posaconazole therapy was restarted. Serum concentrations of posaconazole were retrospectively evaluated and the set of results did not appear to show subtherapeutic concentrations as a plausible explanation for the relapse. Although complete clinical resolution was not obtained during the timeframe considered, this case corroborates the idea that medical management of mucormycosis is possible, especially with a prompt diagnosis and treatment as well as a tight follow-up protocol. As described in the literature, mucormycosis treatment may take several years and relapses are common.RESUMO - Maneio médico de mucormicose respiratória numa cria de golfinho-roaz (Tursiops truncatus) em contexto zoológico - Várias espécies de fungos estão descritas como agentes etiológicos de infeções invasivas em golfinhos, sendo o sistema respiratório um dos locais comuns de infeção. A mucormicose é uma das infeções fúngicas invasivas com efeitos mais devastadores, associada a uma elevada taxa de mortalidade em cetáceos. Nesta dissertação é apresentado um caso clínico referente a uma cria de golfinho-roaz (Tursiops truncatus) com um ano de idade, com uma história clínica que incluía episódios recorrentes de leucocitose e ocasionais sinais clínicos de etiologia respiratória. Como parte do programa de medicina preventiva instituído, uma análise microscópica de fezes permitiu a visualização de estruturas fúngicas. A cultura fúngica permitiu o isolamento de um mucormicete, o agente etiológico da mucormicose, e através de PCR e sequenciação foi possível identificar Cunninghamella bertholletiae. Estudos imagiológicos demonstraram a presença de um ligeiro padrão broncoalveolar nos ápices pulmonares e o exame endoscópico permitiu visualizar múltiplas lesões esbranquiçadas, difusamente distribuídas pelas mucosas traqueal e brônquica. O tratamento antifúngico consistiu na administração de comprimidos gastrorresistentes de posaconazol e nebulizações com anfotericina B lipossómica. Tratamentos adjuvantes incluíram bromexina, silimarina, suplementação vitamínica, probióticos, Imuno-2865TM e ozonoterapia. O acompanhamento do caso foi feito com base em dados hematológicos e bioquímicos, análises microscópicas/cultura de fezes e exsudado respiratório e broncoscopias. O tratamento com posaconazol foi descontinuado após 95 dias de terapia, tendo em conta os resultados constantemente negativos na cultura e observação microscópica de amostras fecais e exsudado respiratório. No entanto, verificou-se a recidiva da infeção e o tratamento antifúngico foi recomeçado. As concentrações séricas do fármaco ao longo do caso clínico foram retrospetivamente analisadas e esta monitorização permitiu descartar a hipótese de não terem sido atingidas concentrações séricas terapêuticas como causa da recidiva da infeção. Apesar de não ter existido uma completa resolução clínica no período considerado, este caso corrobora o facto do maneio médico da mucormicose em cetáceos ser possível, através de um diagnóstico e tratamento precoces, além de um plano apertado de seguimento clínico. Como descrito na bibliografia, o tratamento da mucormicose pode demorar vários anos e recidivas são comuns.N/

Effects of Asbestos in the Human Respiratory Tract

The aims of this investigation were to study differences in the protein composition and cellular content of the sputum from workers in an asbestos textile factory and also to reconstruct the sequence of events that occurs when inhaled chrysotile is retained in the human respiratory tract. The mean value of total protein in the sputum from workers exposed to chrysotile without asbestosis was lower than that from workers in the unexposed and the asbestotic groups. Within the group 'exposed without asbestosis' sputum total protein was correlated with all electrophoretic fractions except beta/gamma globulin whereas within the group 'exposed with asbestosis' sputum protein levels were correlated only with beta/gamma globulin. Immunoanalysis showed increased transferrin in sputa from exposed donors but no specific marker protein for asbestosis was found. A non-serous, PAS reacting protein with beta^ electromobility was isolated by cation exchange separation from all sputa examined. Cytological analysis showed that half of the exposed donors possessed Type 1 pneumocytes in their sputa; Type 2 pneumocytes and iron-containing histiocytes were also found but with lower frequency. Histiocytes with endocytosed chrysotile or asbestos bodies were found only in sputa from asbestotic donors and extracellular asbestos bodies were found five times more frequently in these sputa than in those from exposed donors without asbestosis. None of these findings were seen in sputa from unexposed donors. A negligible amount of water was taken up by chrysotile from wet air at 37°C during the inhalation period, 1.74 seconds, but when chrysotile was immersed in sputum, water uptake proceeded protein adsorption. About 45 mg protein/g chrysotile was taken up in the proportion 1:1:3:1 of albumin: alpha globulin: beta/gamma globulin: lysozyme independent of sputum protein concentration and about two thirds of all adsorbed protein was PAS positive protein. When chrysotile was coated with sputum protein, its cytolytic property was markedly attenuated and viable histiocytes were still present after 25 hours exposure to the coated fibre. The results indicate that some part of retained chrysotile reaches the lung alveoli causing loss of alveolar epithelial cells although in exposed persons without asbestosis the capillary endothelium probably remains intact

The Development of A Systematic Discharge Planning Process For the Care of Copd Patients In A Small Urban Community Hospital

Background: Several attempts have been made to examine factors that influence 30-day readmissions in a hospital setting to ensure that inpatient care is accompanied by an effective post-discharge plan that can decrease 30-day readmissions to guide hospitals to use practices that increase hospitals ‘quality implications (Shah et al., 2015; Kripalani et al., 2007; Rinne et al., 2017, Jenks, Williams and Coleman, 2009, Shah, Press, Husingh-Scheetz & White, 2016; Sickler et al., 2015; Pruitt, 2018; Hansen et al., 2013; Simmering et al., 2016; Alper, O’Malley, & Greenwald, 2019). Purpose: To determine the role of post-discharge care in 30-day readmissions along with the typical clinical outcomes identified, we examined a small urban hospital population and the patient characteristics in each post-discharge care setting (HSC, HHC, LTAC, and SNF). Patients and Methods: A retrospective study was conducted in patients with COPD hospitalizations using the data from a small urban community hospital from 2014 to 2019, n = 1,008. Results: Home health care was identified as having the highest readmission rate in this small urban community hospital using a test of proportions. The weighted variables from a researcher-developed covariate scoring table were analyzed using a Chi-square analysis. The findings provided a reference framework for a systemized discharged planning process according to how the variables/groups were score

Pneumonia perceptions and management: an ethnographic study in urban squatter settlements of Karachi, Pakistan

Childhood pneumonia continues to be the second highest contributor to childhood morbidity and mortality in all ethnic groups in Pakistan. Information on community perceptions and management is largely limited to the Punjabi populace. In this study, ethno-specific illness terminologies, recognition and severity indicators and resort to treatment options for childhood pneumonia are explored among the two main ethnic groups in Sindh. Results are based on focus group discussions with 90 caretakers and 16 case history interviews. The findings indicate that pneumonia recognition is almost universal. The main recognition and severity indicator was pasli chalna (chest indrawing) followed by signs and symptoms relating to the quality of breathing and presence of high fever, lethargy and anorexia. Recognition of rapid breathing was low and mostly associated with fever. Exposure to thand (cold) through a variety of mechanisms was perceived to be the dominant causal model. The concept of contagion was virtually non-existent. Despite this, belief in efficacy of allopathic care was very high. Most caretakers reported seeking outside care within one to three days of the onset of symptoms. However, unrealistic expectations of cure often led to change in physicians and treatment regimen, if no improvement was observed by the second day. On the other hand, the quality of care provided by the physicians (both licensed and unlicensed) left much to be desired. Female autonomy and mobility did not appear to be a major constraint in seeking outside care other than for hospitalisation. Implications of these findings for the national acute respiratory infections control programme and future research are discusse