Impact of migration on health care: When medicine meets politics Some case reports. Dr. Louis Ide, senator

Transcription

1 Impact of migration on health care: When medicine meets politics Some case reports Dr. Louis Ide, senator

2 Case 1 In February to March, 2008, four patients were diagnosed with tinea capitis. Wood s light exam showed a fluorescent discoloration of the infected hairs. Mycological examination of the clinical specimens was carried out by direct microscopic examination and fungal culture.

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6 M. audouinii grew slowly on SDA. Colonies were flat, spreading, dense, silky, and white to light rust-brown in color. Reversing the colony showed a salmon pigment. The microscopic morphology showed thickwalled terminal and a large number of intercalary chlamydoconidia. The macroconidia were irregular, elongated, and thick-walled. On polished rice, a brown diffusible pigment was detected.

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13 As described in the medical literature, a meeting was organized with the school board, the school physician, our laboratory, health inspectors from the Flemish regional government, and a mycologist from the Institute of Public Health. Briefly, school physicians and the school board were not really keen on screening all children (asymptomatic and symptomatic) because of the associated and potential stigmatization increase and potential workload, while our laboratory and the mycologist of the Institute of Public Health wanted to screen the entire school population, with the health inspector serving as the liaison.

14 A compromise was reached in which 17 children were screened anonymously. The children were related to members of known positive families; one child was found to be positive. As an outcome of this compromise, step 2 should have been followed. This would include a total screening of the already positive families and their households, in combination with a total screening of the school, barbers, kindergartens, etc. Unfortunately, resistance was met from the school board. Even when a 10th case was confirmed. An 11th case (African origin) was detected again several months later.

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17 Conclusion Tinea capitis is the most common type of dermatophytosis in children. Over the last few years there have been some significant changes in incidences of tinea capitis in Europe. Especially the anthropophilic infections augment. Consecutively we believe, especially for the M. audouinii cluster, a communitybased survey is warranted. Political conclusion: Refusal! Denial of health care problems. Taboo!

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25 Conclusion TB declines in Belgium, but international proportion augments. Could have repercussions on the civil society (MRTB). Ignorance. Patient & political.

26 Case 3 23 year old male, USA, living in Belgium. February 2011: sinusitis. April 2011: athralgia, pneumonia, 1 lymph node, cough and loss of weight (70 kg => 59.3 kg). Eosinophilia (16%). Hematuria and elevated creatinin. Malignancy? TB?

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28 Sputum

29 Coccidioidomycosis Spherules of various sizes (10 to 100 µm) with multiple endospores (2 to 5 µm) are characteristic of coccidioidomycosis. The walls of some of the spherules may appear to be ruptured, and the endospores spill into surrounding tissues.

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31 Why disseminated? What s wrong with the patient?

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33 Conclusion Diagnose was made but patient went shopping (3 hospitals in total). Not only poverty and health care problems.

34 Case 4 Subcutaneous nodules, an unexpected diagnosis, 20 years ago after a fall in Namibia.

35 Communication with the pathologist 30-year-old black male. Subcutaneous nodules right trunk, no ulceration, painless. Namibia Lommel. All fixed, no culture. Something tropical?

36 Communication with the surgeon Umicore, laborour, zinc factory. Blood analysis totally normal (eosinophils, CRP, serology, ). Chronic problem (20 years). Large surgical excision removed all noduli.

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42 Communication with the patient At the age of 10 years : problems started. He lives in Nothern Namibia the town of Ongwediva, situated in Ovambo.

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45 What s your diagnosis? Help?!?

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49 Diagnosis: mycology bacteriology? kleur afmetingen consistentie histologie verwekkers zwart 1 5 mm hard specifiek Madurella mycetomatis zwart 0,5 - < 2 mm zwart 0,3 0,6 mm zwart 0,2 0,5 mm hard fungisch Leptospheria senegalensis + andere hard fungisch Pyrenochaeta sp., Madurella grisea zacht fungisch Exophiala jeanselmei wit 0,5 1 mm zacht fungisch Pseudallescheria boydii wit/geel 0,5 1 mm hard fungisch Acremonium sp., Aspergillus nidulans, Neotestudinia rosatii wit/geel < 0,3 mm zacht genusniveau Nocardia brasiliensis, N. asteroides, N. caviae wit/geel 0,5 2 mm hard specifiek Streptomyces somaliensis wit/geel 1 3 mm zacht specifiek Actinomadura madurae rood 0,3 0,5 mm stevig specifiek Actinomadura pelletieri

50 Rippon Medical Mycology, 3th edition.

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52 Confirmation? PCR negative Serology, relevant? Culture, negative (no reanimation ). Ignace Surmont, Rod Hay. P. Destombes: specific histology.

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58 Conclusion Reimbursement posaconazole: CTG. Reimbursement via sickness funds? After 3 hours explanation Free samples? Rare diseases: problem.

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64 Figures % of all demands for regularisation based on medical grounds 2009: 33% (=8.575 demands) 2010: 34.3% (= demands) 2011: 51% (=? Demands) 2010: 56.43% of demands based on medical grounds declined. 2011:

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66 Final Conclusions Migration, travel, possible modification of environmental circumstances and geoecological changes may all interfere with our endemic medical landscape. Lack of exotic or poverty-associated diseases may lead to a significant delay in diagnosis. But treatment, taboos, patient compliance can also generate problems. Problems with patients, health care providers, the system, organization, religion, exact figures (!), habits, taboo, ignorance (political & patients) How will/should politics deal with that?