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Table of Contents
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Title page
Copyright page
Editor and Editorial Board
Contributors
About the Editor
Preface
How to Use Your Textbook
Features Contained within Your Textbook
The Anytime, Anywhere Textbook
About the Companion Website
Acknowledgments
Part 1: Introduction
CHAPTER 1: Working Clinically in Resource-Limited Settings
Orientating to the Health System
The Clinician's Role Working in a Resource-Limited Setting
Clinical Diagnosis and Case Management in Resource-Limited Settings
Additional Resources
References
CHAPTER 2: Healthcare Systems
Stewardship
Financing
Resource Generation
Models for Health Program Implementation
Other Challenges for Healthcare Systems in Low-Income Countries
Millennium Development Goals
Primary Care and Universal Health Coverage
Conclusion
Additional Resources
References
CHAPTER 3: Health Program Development and Evaluation
Context and Approach to Health Initiatives
Conducting a Needs Assessment
Designing and Developing Healthcare Facilities and Programs
Monitoring and Evaluation
Introduction to Quality Improvement Methodology
Additional Resources
References
CHAPTER 4: Preparing for Travel and Staying Safe Abroad
Preparing for Travel
Understanding Your Local Environment
Caring for Yourself Abroad
Ethical Issues and Medical Practice in Resource-Limited Settings
Conclusion
Additional Resources
References
Part 2: Newborn and Child Health
CHAPTER 5: Overview of Child Health
Socioeconomic Determinants of Child Health in Developing Countries: Roots of Health
Inequities
Essential Interventions
Vaccine-Preventable Diseases
Reaching Every Child
Effective Delivery Strategies: Integrated Management of Childhood Illness
Additional Resources
References
CHAPTER 6: Newborn Care
All Newborns need essential newborn care
Preterm Newborns Need Extra Care
Sick and Very Small Newborns Need Emergency Care
Newborn Care: Where to Start?
Future Steps
Additional Resources
References
CHAPTER 7: Birth Asphyxia
Preparing for Delivery
Newborn Resuscitation in Developing Countries
Overview of Newborn Resuscitation
Advanced Resuscitation
Additional Resources
References
CHAPTER 8: Acute Respiratory Infections
Pneumonia Presentation
Diagnosis of Pneumonia
Pneumonia Treatment
Other Acute Respiratory Infections
Prevention
References
CHAPTER 9: Diarrheal Illness and Rehydration
Epidemiology
Approach to the Patient with Diarrhea
Prevention
Additional Resources
References
CHAPTER 10: Malaria
Geographic Distribution and Economic Impact of Malaria
Human Genetic Resistance or Susceptibility to Malaria
Life Cycle
Pathophysiology, Presentation, and Clinical Course of Infection with P. falciparum
Diagnosis
Treatment
Prevention
Conclusion
Additional Resources
References
CHAPTER 11: Measles
Clinical Course, Physical Examination, and Diagnosis
Management of Uncomplicated Measles
Complications
Management of Measles Complications ()
Vaccination and Measles Control
Additional Resources
References
CHAPTER 12: Malnutrition and Micronutrient Deficiencies
Presentation
Diagnosis
Treatment
Micronutrient Deficiencies
Additional Resources
References
CHAPTER 13: Child Development
Causes of Developmental Disability
Normal Child Development
Diagnosis and Treatment
A Toolkit for Assessing and Fostering Child Development
Treatment
Review of Successful Programs
The Future of Global Child Development
Additional Resources
References
Part 3: Adolescent, Reproductive, and Maternal Health
CHAPTER 14: Adolescent Health
The Imperatives to Invest in Adolescent Health
Adolescent Development
Major Health Issues for Adolescents
Making Health Services Adolescent-Friendly
The Clinical Consultation with a Young Person: Putting It into Practice
Additional Resources
References
CHAPTER 15: Sexual and Reproductive Health and Rights
Contraception
Comprehensive Abortion Care
Infertility
Sexual Violence and Female Genital Mutilation
Additional Resources
References
CHAPTER 16: Sexually Transmitted Infections
STIs by Clinical Presentation
Infections Causing Genital ulcer Disease and Buboes
Infections Causing Vaginal Discharge
Infections Causing Urethritis or Cervicitis and Pelvic Inflammatory Disease
Human Papillomavirus Infection
Prevention
Additional Resources
References
CHAPTER 17: Maternal Health
Antenatal Care
Peripartum Care
Treatment for, and Prevention of, Leading Causes of Maternal Mortality
Family Planning and Contraception
Additional Resources
References
Part 4: Infectious Diseases
CHAPTER 18: HIV/AIDS
Basic HIV Biology
Presentation and Clinical Diagnosis
Diagnosis and Testing
HIV-Associated Conditions and Clinical Staging
Treatment
Common HIV-Associated Conditions
Prevention
Community-Based Approach to HIV Prevention and Care
Additional Resources
References
CHAPTER 19: Tuberculosis
Pathogenesis
Drug Resistance
Clinical Presentation
Diagnosis
Treatment
Tuberculosis Control and Vaccination
Future Directions
Additional Resources
References
CHAPTER 20: Neglected and Other Tropical Diseases
Parasitic Diseases
Arthropod-Borne Infections
Other Tropical Diseases
Additional Resources
References
Part 5: Non-Communicable Diseases
CHAPTER 21: Cardiovascular Disease
Presentation
Diagnosis
Treatment
Prevention
Additional Resources
References
CHAPTER 22: Chronic Respiratory Disease
Risk Factors
Presentation
Evaluation of the Patient with Suspected Chronic Respiratory Disease
Diagnosis and Treatment of Major Diseases
Additional Resources
References
CHAPTER 23: Diabetes and Endocrinology
Diabetes
Diagnosis
Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State
Chronic Medical Management
Complications of Diabetes
Psychosocial and Cultural Implications
Endocrine Disorders
Thyroid Disorders
Adrenal Disorders
Vitamin D Deficiency/Rickets
Hypertension
Additional Resources
References
CHAPTER 24: Cancer and Blood Disorders
Screening
Presentation
Evaluation
Diagnosis and Treatment of Common Cancer and Blood Disorders
Additional Resources
References
CHAPTER 25: Trauma and Emergency Care
Initial Trauma Evaluation
Head Trauma
Neck Trauma
Thoracic Trauma
Abdominal Trauma
Conclusion
Additional Resources
References
CHAPTER 26: Critical Care
Intensive Care Units
Disease Processes and Interventions
Patient Safety and Quality
Ethical Considerations
Additional Resources
References
CHAPTER 27: Mental Health and Neurological Disorders
Global Initiatives Focused on Closing the Treatment Gap between HICs and LMICs
Providing Mental Health Care in Resource-Limited Settings: Task-Shifting
Providing Mental Health Care in Resource-Limited Settings
Additional Resources
References
CHAPTER 28: Dermatology
History
Examination and Morphology of Skin Lesions
Distribution and Characteristic Patterns of Skin Lesions
Bacterial Infections
Fungal Infections
Parasitic and Ectoparasitic Infections
Viral Skin Infections
Conclusion
Additional Resources
References
CHAPTER 29: Oral Health
Pediatric and Adult Tooth Numbers and Normal Oral Anatomy
Basic Oral Hygiene and Risk Factors for Oral Disease
Identification, Diagnosis, and Treatment of Common Oral Conditions in Developing
Settings
Early Oral Manifestations of Common Systemic Conditions in Low-Income Regions
Conclusions
Additional Resources
References
CHAPTER 30: Blindness and Visual Impairment
Definition of Blindness and Visual Impairment
Epidemiology of Blindness and Refractive Error
Common Causes of Global Blindness
Innovations in the Delivery of Eye Care in the Developing World
Additional Resources
References
Part 6: Other Global Health Topics
CHAPTER 31: Essential Laboratory Skills
Quality and Safety in the Clinical Laboratory
Essential Laboratory Procedures
Additional Tests and Techniques
Learning Laboratory Skills Prior to Your Trip
Additional Resources
References
CHAPTER 32: Nursing Care
Definition of Nursing
Gaps in Human Resources and Current Status of Nursing
Importance of Working as a Clinical Team
Optimizing Nursing Care
Fundamentals of Nursing Practice in All Settings
Conclusion
Additional Resources
References
CHAPTER 33: Pharmacy
What Are Essential Medicines?
What Needs to Be in Place to Improve Access to Medicines?
What Are the Main Barriers to Access to Medicines?
Managing Medicines at Health Facilities
Using Medicines in the Treatment and Prevention of Disease
References
CHAPTER 34: Humanitarian Assistance
Refugees and Internally Displaced Persons
Overview of Organizations Involved in Disaster Management
Acute and Chronic Effects of Displacement
Acute Needs and Interventions
Additional Resources
References
CHAPTER 35: Technologies in Global Health
Diagnostics and Disease Monitoring
Therapeutics and Preventive Treatments
Medical and Surgical Procedures
Conclusions
Additional Resources
References
CHAPTER 36: Illness in the Returning Traveler
Diarrhea
Fever
Dermatoses
Other Illnesses
Additional Resources
References
CHAPTER 37: Developing a Career in Global Health
Considerations When Planning a Career in Global Health
Opportunities During Medical Training
Career Models
Types of Organizations Involved in Global Health
Conclusion
Additional Resources
References
Index
End User License Agreement
List of Tables
Table 1.1 Some key considerations relating to clinical practice in resource-limited settings.
Table 1.2 Small diagnostic tools you may consider taking to a resource-limited setting (in
addition to these diagnostic tools, see Chapter 4 for a general list of items to pack when traveling
abroad).
Table 2.1 Key functions of a healthcare system.
Table 2.2 Services that may be in a basic or essential health package.
Table 3.1 Political questions to consider when developing a health program (Marmot & Wilkins,
2005).
Table 3.2 Components of a healthcare facility that need assessment.
Table 3.3 Example of a programmatic goal and corresponding objectives.
Table 3.4 Sample health facility budget.
Table 3.5 Types of indicators (Marmot & Wilkins, 2005; American Red Cross and Catholic Relief
Services, 2013).
Table 4.1 Some commonly prescribed medications and common immunizations for travellers.
Table 4.2 Common prophylactic antimalarial medications for travelers.
Table 4.3 Risk of transmission of blood-borne pathogens by exposure type.
Table 5.1 Essential interventions to improve child survival.
Table 5.2 Routine immunizations recommended by the World Health Organization as of 2014.
Table 6.1 Packages of newborn care (Lawn et al., 2013).
Table 6.2 Recommended total daily fluid volumes* for term or >2500 g newborns according to
age in days.
Table 6.3 Diagnosis and management of neonatal infection.
Table 6.4 Diagnosis and management of superficial infections of the skin, umbilicus, and eyes.
Table 6.5 Common drugs used in newborns.
Table 6.6 Diagnosis and management of neonatal jaundice.
Table 6.7 Treatment of jaundice based on serum bilirubin level.
Table 6.8 Diagnosis and management of neonatal encephalopathy.
Table 6.9 Tools, technologies, and innovations required for the care of newborns.
Table 8.1 Differential diagnosis of pneumonia.
Table 8.2 Recommended antibiotic therapy for pneumonia and severe pneumonia.
Table 8.3 Features of other common respiratory infections in children.
Table 9.1 Common causes of infectious diarrhea in resource-limited settings.
Table 9.2 Assessment and treatment of dehydration.
Table 9.3 Estimated replacement fluid volume in children with some dehydration.
Table 9.4 Fluids used for rehydration (values in mmol/L).
Table 10.1 Classification of malaria by severity of symptoms.
Table 10.2 The Blantyre Coma Scale (BCS) is used to assess for malarial coma in children who
are too young to follow verbal commands or speak a language, which is the typical age group
affected by cerebral malaria. Coma is defined by a BCS ≤ 2.
Table 11.1 Clinical phases of measles.
Table 11.2 Vitamin A dosing for treatment of measles.
Table 11.3 Management of measles complications.
Table 12.1 Schedule for the inpatient management of severe acute malnutrition.
Table 12.2 Clinical manifestations of vitamin deficiencies.
Table 12.3 Clinical manifestations of mineral deficiencies.
Table 13.1 Risk factors associated with poor growth and development.
Table 14.1 Developmental characteristics of adolescence.
Table 14.2 Major health issues for adolescent and young people globally.
Table 14.3 Improving a health service to make it more adolescent-friendly.
Table 14.4 HEADSS psychosocial assessment.
Table 15.1 Overview of commonly available contraception methods.
Table 15.2 Key considerations for clients with special needs.
Table 15.3 Comparing methods of induced abortion in first trimester.
Table 15.4 Treatment of infertility according to etiology.
Table 15.5 Components of a medical forensic examination.
Table 15.6 Treatment and follow-up for survivors of sexual violence.
Table 16.1 Treatment recommendations for genital ulcer disease, by infectious etiology.
Table 16.2 Treatment recommendations for vaginal discharge, by infectious etiology.
Table 16.3 Treatment for cervicitis and urethritis.
Table 16.4 Treatment regimen for PID.
Table 16.5 Treatment for genital warts.
Table 17.1 Recommended tasks at each of the four WHO antenatal visits.
Table 17.2 Antenatal care: infectious disease treatments and prophylaxis.
Table 17.3 Signal functions of EmOC facilities.
Table 17.4 Stages of labor.
Table 17.5 Danger signs during and immediately after childbirth (Lawn & Kerber, 2006). If any of
these danger signs are present, mother and newborn should be immediately brought for care at a
hospital or health center.
Table 18.1 HIV testing modalities.
Table 18.2 WHO recommended testing approach for infants.
Table 18.3 HIV clinical staging conditions.
Table 18.4 Commonly used ARVs.
Table 18.5 First-line ART regimens for adults, adolescents, pregnant and breastfeeding women,
and children.
Table 18.6 WHO guidelines for initiation of ART for adults, adolescents, children, and infants.
Table 18.7 WHO recommended second-line ART regimens.
Table 19.1 Interpretation of the tuberculin skin test (TST).
Table 19.2 Tuberculosis medications.
Table 20.1 Selected tropical diseases by exposure risk factor.
Table 20.2 Common helminth infections in humans.
Table 20.3 Common filarial infections.
Table 20.4 Select arbovirus infections in humans.
Table 20.5 Rickettsial infections.
Table 20.6 Overview of other notable tropical diseases.
Table 20.7 Neglected tropical diseases causing fever in travelers by geographic location. See
Chapter 36 for full discussion of illnesses in returning travelers.
Table 21.1 Relationship between cardiovascular disease (CVD) and stages of development.
Table 21.2 Primary prevention of cardiovascular disease stratified by risk of future disease.
Treatment is adjusted based on the patient's risk of having a fatal or non-fatal vascular event in the
next 10 years.
Table 22.1 Staging of COPD based on severity of obstruction (GOLD criteria) in patients with
post-bronchodilator FEV1/FVC <70%.
Table 23.1 Difference between type 1 and type 2 diabetes.
Table 23.2 Screening criteria for diabetes.
Table 23.3 Diagnostic criteria and alternative diagnostic tools for diabetes.
Table 23.4 Cerebral edema treatment.
Table 23.5 Complications of diabetes.
Table 23.6 Interpretation of thyroid function tests.
Table 24.1 List of recommended risk-reduction strategies, screening, and early diagnostic
procedures for cancer and blood disorders, specifically in LMICs.
Table 24.2 Common adult oncologic emergencies.
Table 24.3 Common pediatric oncologic emergencies.
Table 24.4 Common oncologic diseases in adults.
Table 24.5 Common oncologic diseases in children.
Table 24.6 Common hematologic diseases in adults and children.
Table 24.7 Simplified staging system for breast cancer.
Table 24.8 Staging of prostate cancer use the TNM staging system, which evaluates tumor size
(T), involvement of lymph nodes (N), and any metastasis (M).
Table 25.1 Essential equipment for trauma care.
Table 25.2 Glasgow Coma Scale in adults, children, and infants. Whenever different, the
corresponding response of pre-verbal children/infants is noted in parentheses.
Table 25.3 Tetanus vaccination and tetanus immune globulin (TIG).
Table 25.4 Common thoracic injuries and management.
Table 26.1 ICU resources. It is important to have the following equipment and medications
immediately available on-site.
Table 26.2 Normal vital sign ranges by age.
Table 26.3 Common causes of shock.
Table 26.4 Definitions of sepsis syndromes.
Table 26.5 Common causes of altered mental status.
Table 27.1 Common presentations of mental health disorders.
Table 28.1 Nomenclature for description of skin lesions.
Table 29.1 Tooth eruption chart (primary, mixed, permanent dentition).
Table 29.2 Triage and treatment of dental caries.
Table 29.3 Diagnosis and treatment of dental trauma in permanent and deciduous teeth.
Table 29.4 Common oral manifestations of HIV/AIDS.
Table 29.5 Oral manifestations of malnutrition.
Table 30.1 WHO definitions of blindness and visual impairment.
Table 30.2 Other important causes of global blindness.a
Table 31.1 Interpretation guide to urine sediment abnormalities
Table 31.2 Interpretation guide to white blood cell differentials in peripheral blood.
Table 31.3 Macroscopic assessment of cerebrospinal fluid.
Table 31.4 Microscopic assessment of cerebrospinal fluid.
Table 32.1 Shortages of healthcare workers by region.
Table 32.2 Knowledge and implementation of skills for basic global nursing.
Table 33.1 Main barriers to access to medicines at individual, household, community, and health
service delivery levels.
Table 33.2 Assessment of medication use: five prime questions.
Table 34.1 International disaster relief organizations and agencies.
Table 34.2 Average water requirements per personper day.
Table 34.3 Water treatment methods.
Table 34.4 Types of housing during a disaster: advantages and disadvantages.
Table 34.5 Immunizations during a disaster.
Table 34.6 Reaction to a disaster based on age and development.
Table 35.1 mHealth Applications in Global Health. The application of mobile phones within the
health sector is known as mHealth. With increasing mobile phone ownership and decreasing costs
of more advanced mobile phones, there are several global health initiatives that have taken
advantage of these trends.
Table 36.1 Diagnostic stool tests for returned travelers with diarrhea.
Table 36.2 Common causes of diarrhea in returned travelers.
Table 36.3 Causes of fever from published series (UK, Canada, Australia).
Table 36.4 Febrile conditions associated with specific exposures.
Table 36.5 Incubation periods.
Table 36.6 Typical levels of eosinophilia among parasitic infections in travelers. The degree of
eosinophilia may differ in individual patients. Non-parasitic causes of eosinophilia include
allergic disorders (including asthma), HIV, tuberculosis, leprosy, some fungal infections, some
forms of lymphoma and leukemia, etc.
Table 36.7 Travel-associated dermatoses diagnosed in 269 French travelers presenting to a
tropical medicine clinic in Paris.
Table 37.1 Examples of post-residency training opportunities. Please note that this list is by no
means intended to be comprehensive but simply illustrative of opportunities.
List of Illustrations
Figure 1.1 Tiers of the typical healthcare system, with the corresponding WHO guidelines for
each level of care. The district hospital plays a key role in terms of clinical mentoring, supporting
a referral network, consultations, and supportive supervision. Source: World Health Organization.
Reproduced with permission of the World Health Organization.
Figure 1.2 “Sara” is brought by her parents to the local health center, where she is found to be
febrile and breathing fast. Source: Science Photo Library.
Figure 1.3 Two-by-two table on the relationship between test and disease: the basic concepts of
clinical diagnosis in all settings. TP, true positive; TN, true negative; FP, false positive; FN, false
negative; PV, predictive value. Likelihood ratio (LR) can also be computed from any such twoway table: LR of a positive test or finding = TP/FP; LR of a negative test = FN/TN. A positive
high-specificity test tends to “rule in” the suspected diagnosis (remembered as SpIn+). A negative
high-sensitivity test tends to “rule out” the suspected diagnosis (remembered as SnOut–).
Figure 1.4 Fagan nomogram demonstrating the relationship between pre-test probability,
likelihood ratio, and post-test probability (see Figure 1.3 for the definition of likelihood ratio).
Many diagnostic calculations, including those in this chapter, are available on several smartphone
apps, including MedCalc (www.medcalc.com/bayes.html). Alternately, in the field, one can use
the Fagan nomogram and a straight edge. This nomogram, often used for laboratory tests, can also
be used to conceptualize clinical decision-making. The red and green lines represent two
individual patients who each present with a single clinical finding suggestive of a particular
disease. The likelihood ratio is arbitrarily 2 in these examples. However, it is only the patient who
comes from a setting where this disease is prevalent (high pre-test probability, red line) that is
likely to have that disease. The blue line demonstrates that the presence of multiple or convincing
clinical findings for a particular disease (arbitrarily, here, a likelihood ratio of 50) greatly
increases the post-test probability of that disease, even in the context of low pre-test probability.
Figure 1.5 Syndromic diagnosis: a Venn diagram of acutely febrile children in sub-Saharan
Africa. Total area of rectangle indicates all acutely febrile children in sub-Saharan Africa. Area of
colored circles indicates prevalence of each of four clinical signs: cough (black), tachypnea
(green), pallor (blue), and altered mental status (red).
Figure 2.1 Comparing health expenditure ratios in low-income, middle-income, and high-income
countries. Source: WHO Health Statistics 2013. Adapted from WHO (2013a).
Figure 2.2 Data needs and sources at different levels of the healthcare system. Source: AbouZhar
& Boerma (2005), figure 1, p. 580. Reproduced with permission of the World Health Organization.
Figure 2.3 Health workforce density per 10,000 population. Source: WHO Health Statistics 2013.
Adapted from WHO (2013a).
Figure 2.4 Goals of the post-2015 development agenda. Source: United Nations (2013).
Figure 2.5 Three dimensions to consider when moving toward universal health coverage. Source:
WHO (2010). Reproduced with permission of the World Health Organization.
Figure 3.1 Local health systems pyramid.
Figure 3.2 The WHO Health System Framework building blocks. Source: WHO (2007).
Reproduced with permission of the World Health Organization.
Figure 3.3 Sample Gantt chart for improvements to a non-communicable disease (NCD) clinic.
Figure 3.4 The Model for Improvement and PDSA cycle (Uganda Network of AIDS Service
Organizations, 2005; WHO, 2007). Adapted from NHS Institute for Innovation and Improvement
(2008a) and Langley et al. (2009).
Figure 3.5 Fishbone diagram addressing the problem of insufficient number of pediatric HIV
cases diagnosed.
Figure 4.1 A traditional birth attendant serves her community in South Sudan. Source: B.D.
Nelson, Harvard Medical School, Boston, Massachusetts, USA. Reproduced with permission of
B.D. Nelson.
Figure 4.2 A local USB modem can provide internet access via the local cellular network. Source:
iStock © Liens.
Figure 4.3 Global distribution of malaria, including areas of drug resistance to Plasmodium
falciparum from studies in sentinel sites, up to 2004. Source: World Health Organization (2005).
Reproduced with permission of the World Health Organization.
Figure 4.4 Global distribution of countries or areas at risk of dengue transmission, 2008. Source:
World Health Organization (2010). Reproduced with permission of the World Health
Organization.
Figure 4.5 Geographic distribution of schistosomiasis. Source: CDC Public Health Image Library.
Figure 4.6 Schistosomiasis transmission cycle.
Figure 4.7 The “W” model of culture shock.
Figure 5.1 Under-five mortality rate (deaths per 1000 live births), 2011. Source: WHO (2012).
Reproduced with permission of the World Health Organization.
Figure 5.2 Causes of under-five and neonatal mortality worldwide in 2012. Sources: CHERG and
WHO, Global Health Observatory http://www.who.int/gho/child_health/mortality/causes/en/ and
Lawn et al. 2012. Reproduced with permission.
Figure 5.3 Framework of underlying socioeconomic determinants of health.
Figure 5.4 An example of a child health card. Adapted from a card produced by the Ministry of
Health and Child Welfare (Zimbabwe).
Figure 5.5 Factors influencing coverage of interventions.
Figure 5.6 Health services delivery systems.
Figure 5.7 Respiratory illness flowchart: an example of how the algorithms in the WHO's
Integrated Management of Childhood Illnesses can be applied.
Figure 6.1 Causes of under-five and neonatal mortality worldwide in 2012. Source: CHERG and
WHO, Global Health Observatory http://www.who.int/gho/child_health/mortality/causes/en/ and
Lawn et al. 2012. Reproduced with permission.
Figure 6.2 Pyramid of 135 million births with need for various levels of care.
Figure 6.3 A hand-made phototherapy box in Nicaragua for the treatment of neonatal jaundice.
This box was developed by pediatric and internal medicine residents during their global health
electives. Source: Drs A. Bjorklund, J. Nordell, and T. Slusher. Reproduced with permission of A.
Bjorklund.
Figure 7.1 Helping Babies Breathe algorithm. Used with permission of the American Academy of
Pediatrics, Guide for implementation of Helping Babies Breathe (2011).
Figure 7.2 Innovative newborn resuscitation training mannequin (NeoNatalie) and equipment.
Source: Laerdal Global Health. Reproduced with permission of Laerdal Global Health.
Figure 7.3 The basic steps in newborn resuscitation: (a) warming and drying; (b) bulb suction and
stimulation; (c) cutting the umbilical cord; and (d) bag–mask ventilation.
Figure 8.1 Infections of the respiratory tract.
Figure 8.2 Community health workers (CHWs) play a critical role in the identification and
community case management (CCM) of ARIs and other health conditions. Source: World Health
Organization/United Nations Children's Fund (2012). Reproduced with permission of the World
Health Organization.
Figure 8.3 IMCI algorithm for the facility-based management of ARIs in (a) young infants up to 2
months of age and (b) children 2 months to 5 years.
Figure 8.4 Signs suggestive of pneumonia in children.
Figure 8.5 Chest X-rays with findings consistent with pneumonia. (a) Normal chest X-ray: the
lungs are clear and there are no consolidations. (b) Lobar pneumonia: note the consolidation in the
right lower lobe (consolidations can occur in any of the lobes of the lung). (c) Staphylococcal
pneumonia: a serious bacterial pneumonia shown here with fluid-filled abscesses and
pneumatoceles. (d) Pneumothorax: while not a type of pneumonia, collapse of a lung can cause
shortness of breath. An X-ray of a pneumothorax may show a more transparent margin without
lung markings around the periphery of the collapsed lung, and the collapsed lung may also appear
more dense, as illustrated here. Whereas, a non-collapsed lung will have lung markings all the way
to the periphery. (e) Hyperinflated chest X-ray: features are an increased transverse diameter, ribs
running more horizontally, a small contour of the heart, and flattened diaphragm. (f) Miliary
tuberculosis: tuberculosis can cause symptoms similar to pneumonia but typically looks different
on chest X-ray. Note the small patchy consolidations diffusely throughout the lung.
Figure 8.6 A general flow chart for the management of children with ARI symptoms, based on
symptom severity.
Figure 9.1 Causes of under-five and neonatal mortality worldwide in 2012. Source: CHERG and
WHO, Global Health Observatory http://www.who.int/gho/child_health/mortality/causes/en/ and
Lawn et al. 2012. Reproduced with permission.
Figure 9.2 (a) Rice-water stool, consistent with cholera. (b) Blood/mucus stool, consistent with
dysentery. Source: Photo (a) courtesy of Jason Harris and (b) courtesy of Mohammod Jobayer
Chisti.
Figure 9.3 Child with delayed skin pinch recovery and sunken eyes.
Figure 9.4 Cholera cot used for measuring ongoing stool output.
Figure 9.5 Nasogastric tube placement.
Figure 9.6 Oral rehydration solution recipes. When pre-packaged sachets are not readily available,
home-made oral rehydration solution can be mixed (a) in a 1-liter bowl or (b) in a drinking glass.
Figure 10.1 Distribution of malaria over time. Source: Roll Back Malaria Partnership (2011),
figure E.1, p. 9. Reproduced with permission of Roll Back Malaria.
Figure 10.2 Estimation of world malaria burden compared with estimations of world poverty
showing strongly overlapping distributions. Similar maps appear for HIV and tuberculosis; world
poverty is influenced by multiple factors in addition to malaria. Source: RBM data. Jeffrey Sachs
1990, Reproduced with permission of Jeffrey Sachs.
Figure 10.3 Distribution of malaria in Africa (a) compared with distribution of percent of the
population heterozygous for hemoglobin S (b). Source: Wikimedia © Anthony Allison.
Reproduced under the Creative Commons license.
Figure 10.4 Population dynamics of the malaria parasite in the mosquito and human hosts.
Figure 10.5 Parasite, host, geographic, and social factors determine the severity and outcome of a
malaria infection. Source: Miller et al. (2002), figure 1, p. 673. Reproduced with permission from
Nature.
Figure 11.1 Number of annual measles cases and percent coverage by first measles vaccine
(MCV1), 1980–2011. Source: WHO (2013b). Reproduced with permission of the World Health
Organization.
Figure 11.2 Mean annual incidence of measles over the past 10 years. Cases are by country report,
as listed by the World Health Organization (WHO, 2013a). Source: Emily Carnahan at the Institute
for Health Metrics and Evaluation, based on data from WHO (2013a). Reproduced with permission
of the World Health Organization.
Figure 11.3 Koplik spots. Source: CDC Public Health Image Library.
Figure 11.4 (a, b) Classic measles rashes in a lightly pigmented child (a) and a more darkly
pigmented child (b). Source: (a) CDC Public Health Image Library; (b) Wikimedia © Mike Blyth.
Reproduced under the Creative Commons license.
Figure 11.5 Bitot spot. Source: The University of Iowa, Iowa, USA and EyeRounds.org. Used with
permission of The University of Iowa and EyeRounds.org
Figure 12.1 By-country estimates of rates of wasting (weight-for-height) among children less than
5 years old. Source: World Health Organization (2012), figure 2, p. 10. Reproduced with
permission of the World Health Organization.
Figure 12.2 Classification of different types of malnutrition.
Figure 12.3 Phenotypes of acute malnutrition: (a) marasmus and (b) kwashiorkor. Marasmic
kwashiorkor may also occur as a mixture of the two phenotypes.
Figure 12.4 For a child under 2 years of age, measure length using a simple length board.
Figure 12.5 Mid-upper arm circumference (MUAC) is a useful screening tool for severe acute
malnutrition.
Figure 12.6 Packets of F-75 and F-100 formulas for the treatment of severe acute malnutrition.
Source: B.D. Nelson, Harvard Medical School, Boston, Massachusetts, USA. Reproduced with
permission of B.D. Nelson.
Figure 13.1 The integrated eco-bio-developmental framework: understanding the promotion of
health and prevention of disease.
Figure 13.2 Human brain development. Copyright © 2001 by the American Psychological
Association. Reproduced with permission from Thompson RA, Nelson CA (2001) Developmental
science and the media: early brain development. Am Psychol 56:5–15. The use of APA information
does not imply endorsement by APA.
Figure 13.3 Fine motor skills include, progressively, (a) palmar, (b) raking, and (c) pincer grasps.
Figure 13.4 Evaluation of normal motor development (a) and language and psychosocial
development (b), ages 0–5 years. Source: Werner (2009). Reproduced with permission of The
Hesperian Foundation.
Figure 13.5 Cards for counseling families on child development. Source: World Health
Organization (2012). Reproduced with permission of the World Health Organization.
Figure 13.6 Child in Istanbul playing football. Source: B.D. Nelson, Harvard Medical School,
Boston, Massachusetts, USA. Reproduced with permission of B.D. Nelson.
Figure 14.1 World map: adolescents and young adults as a proportion of national populations.
Reprinted from The Lancet, 379, Sawyer SM, Afifi RA, Bearinger LH et al. Adolescence: a
foundation for future health, 1630–1640 (2012), with permission from Elsevier.
Figure 14.2 Conceptual framework for adolescence. Reprinted from The Lancet, 379, Sawyer SM,
Afifi RA, Bearinger LH et al. Adolescence: a foundation for future health, 1630–1640 (2012), with
permission from Elsevier.
Figure 14.3 Care plan.
Figure 15.1 Total vs. abortion-related maternal deaths per 100,000 live births in Romania, 1970–
2005. Source: Benson et al. (2011), figure 2, p. 5.
Figure 15.2 Manual vacuum aspirator. Source: Ipas/Stephen C. Edgerton, reproduced with
permission of Ipas.
Figure 15.3 Causes of infertility.
Figure 15.4 Types of female genital mutilation. Source: Clarice Illustrations, reproduced with
permission of Clarice Illustrations.
Figure 16.1 Flowchart for genital ulcer disease, male or female. Source: WHO (2005), flowchart
3, p. 109. Reproduced with permission of the World Health Organization.
Figure 16.2 Flowsheet for inguinal bubo, male or female. Source: WHO (2005), flowchart 4, p.
114. Reproduced with permission of the World Health Organization.
Figure 16.3 Flowsheet for vaginal discharge. Source: WHO (2005), flowchart 1, p. 101.
Reproduced with permission of the World Health Organization.
Figure 16.4 Flowsheet for urethritis in males. Source: WHO (2005), flowchart 5, p. 116.
Reproduced with permission of the World Health Organization.
Figure 16.5 Flowsheet for suspected pelvic inflammatory disease (PID). Source: WHO (2005),
flowchart 2, p. 105. Reproduced with permission of the World Health Organization.
Figure 17.1 Maternal mortality ratio worldwide, 2010. The maternal mortality ratio is the annual
number of female deaths per 100,000 live births from any cause related to or aggravated by
pregnancy or its management (excluding accidental or incidental causes). The MMR includes
deaths during pregnancy, childbirth, or within 42 days of termination of pregnancy, irrespective of
the duration and site of the pregnancy, for a specified year. Source: Wikimedia © Mikael
Häggström. Reproduced under the Creative Commons license.
Figure 17.2 Maternal ultrasound images. (a) The fetal head is easily identified by the smooth,
bright, fetal skull. The markings show the measurement of the obstetric biparietal diameter. (b)
The dark central area is a fetal sac in the fallopian tube with a small fetus inside, consistent with
an ectopic pregnancy.
Figure 17.3 The three delays of care. This model describes three key activities in the process of
accessing obstetric care: deciding to seek care, reaching a health facility, and receiving adequate
care at the facility. Reprinted from Thaddeus S & Maine D. Too far to walk: maternal mortality in
context, Soc Sci Med 38, 1091–1110, 1994 with permission from Elsevier.
Figure 17.4 Phases of labor. Source: Cohen & Friedman (2011), figure 3.9, p. 43. Reproduced with
permission from John Wiley & Sons, Inc., Hoboken, NJ.
Figure 17.5 A sample partograph, properly completed. In this partograph, the patient was found to
be in active labor with 4 cm of cervical dilation at 10:00. She had no cervical change 2 hours later.
At 13:00 her contraction frequency decreased. At 14:00 she was started on oxytocin, with
subsequent labor progress and a vaginal delivery. Source: WHO (2003), figure S-7, p. S-61.
Reproduced with permission of the World Health Organization.
Figure 17.6 Equipment for intrauterine balloon tamponade.
Figure 18.1 HIV prevalence by country. Source: WHO (2013c). Reproduced with permission of
the World Health Organization.
Figure 18.2 Steps in the HIV replication cycle. Source: reproduced courtesy of the National
Institute of Allergy and Infectious Diseases.
Figure 18.3 Clinical course of HIV/AIDS. Source: Pantaleo et al. (1993). Reproduced with
permission of The New England Journal of Medicine.
Figure 18.4 HIV tests commonly available in resource-limited settings. (a) Rapid test for HIV
antibody. Immediate results are available and can be delivered at the initial visit. (b) Dried blood
spot (DBS) for HIV DNA PCR. DBS is highly portable and stable at room temperature, making it
ideal for resource-limited settings where on-site virologic testing may not be available. Logistical
arrangements must be made for rapid transmission of results to patients (e.g., via SMS messaging)
if the DBS is sent to another laboratory. Source: J. Kim, Johns Hopkins University, Baltimore,
USA. Reproduced with permission of J. Kim.
Figure 18.5 Chest radiograph in a patient with Pneumocystis pneumonia, showing bilateral
interstitial infiltrates. Source: CDC Public Health Image Libary/Jonathan W.M. Gold.
Figure 19.1 Estimated HIV prevalence in new tuberculosis cases, 2012. Source: World Health
Organization (2013), figure 2.4, p. 14. Reproduced with permission of the World Health
Organization.
Figure 19.2 Natural course of tuberculosis infection. Source: Reprinted by permission from
Macmillan Publishers Ltd: Nature Reviews Immunology 2005;5:661–67.
Figure 19.3 Chest radiograph showing a cavitary lesion in the right lower lobe from tuberculosis.
Source: CDC Core Curriculum on Tuberculosis.
Figure 19.4 Placing a Mantoux test involves intradermally injecting a small amount of purified
protein derivative obtained from M. tuberculosis. Source: CDC Core Curriculum on Tuberculosis.
Figure 19.5 Interpreting a Mantoux test by measuring the diameter in millimeters of any
induration (raised hardened area), but not the area of erythema. Source: CDC Core Curriculum on
Tuberculosis.
Figure 19.6 Acid-fast bacilli (stained red) on smear microscopy. Source: CDC Core Curriculum
on Tuberculosis.
Figure 20.1 Proportion of children 1–14 years of age in the country requiring mass drug
administration for soil-transmitted helminths, 2011. Source: WHO (2011). Reproduced with
permission of the World Health Organization.
Figure 20.2 Loeffler syndrome is a pneumonitis caused by inflammatory response to helminth
larval migration through the lungs. It classically occurs with Ascaris, Strongyloides, and
Schistosoma infections. If diagnosis is uncertain, treatment with albendazole is given empirically.
Source: Pasricha et al. (2011), figure 3, p. 206. Reproduced with permission from Oxford
University Press.
Figure 20.3 A guinea worm is slowly extracted from where it emerged in a lower extremity.
Source: CDC Public Health Image Library.
Figure 20.4 Advanced elephantiasis caused by lymphatic filariasis. Source: CDC Public Health
Image Library.
Figure 20.5 (a) Cutaneous leishmaniasis. Source: CDC Public Health Image Library/D.S. Martin.
(b) Mucocutaneous leishmaniasis. Source: CDC Public Health Image Library/Mae Melvin.
Figure 20.6 Unilateral eye swelling, or Romaña's sign, in a young boy in Panama with acute
Chagas infection. Source: CDC Public Health Image Library/Mae Melvin.
Figure 21.1 Estimated proportions of age-standardized mortality rates by cause in sub-Saharan
Africa. Mortality estimates were standardized to the WHO World Standard Population. Source:
Dalal et al. (2011), figure 1, p. 887. Reproduced with permission of Oxford University Press, from
data sourced from World Health Organization. Global Burden of Disease. Projections of mortality
and burden of disease, 2002–2030.
Figure 21.2 (a) Age-standardized mortality rates from ischemic heart disease. (b) Agestandardized mortality rates from cerebrovascular disease. Source: World Health Organization,
2013 (World Health Organization, 2011b, 2013), figures 1 and 2, p. 9. Reproduced with permission
of the World Health Organization. (c) Prevalence of high blood pressure, one of the major risk
factors for CVD. Source: World Health Organization (2011a,b). Reproduced with permission of
the World Health Organization.
Figure 21.3 (a) Cardiac ultrasound images demonstrating (i) subxiphoid or subcostal probe
placement; (ii) normal subxiphoid view of the heart; (iii) large tuberculosis pericardial effusion
with fibrinous strands; (iv) dilated cardiomyopathy with four-chamber dilation (note how all four
chambers appear dilated compared with normal subxiphoid view); (v) isolated dilation of the left
ventricle and atrium with normal-sized right atrium and ventricle; (vi) rheumatic heart disease
with mitral valve thickening. (b) Inferior vena cava (IVC) ultrasound demonstrating (i) probe
placement for IVC imaging; (ii) dilated IVC; and (iii) collapsed IVC. (c) Endomyocardial fibrosis
(EMF): (i) normal heart in subxiphoid view compared with (ii) heart with EMF (note small
fibrosed right ventricle and massively dilated right atrium).
Figure 21.4 A graduated approach to interventions as cardiovascular risk increases. Adapted from
Prevention of Cardiovascular Diseases, World Health Organization (2007) and Yusuf et al.
(2001b).
Figure 22.1 The “energy ladder”: the relationship of wealth to type of household energy. Source:
WHO (2006), figure 2, p. 9. Reproduced with permission of the World Health Organization.
Figure 22.2 Chest radiography in major chronic respiratory diseases. (a) COPD: hyperinflation
and decreased vascular markings. (b) Bronchiectasis: “tram-track” appearance of thickened
airways, primarily in the right middle lobe and lingual. (c) Apical scarring related to prior
tuberculosis infection. (d) Silicosis: extensive scarring from progressive massive fibrosis. (e)
Interstitial fibrosis: extensive fibrosis which can be associated with workplace exposures or with
idiopathic pulmonary fibrosis. (f) Pulmonary hypertension: enlarged pulmonary arteries. Source:
Dr Matthew Gilman, Massachusetts General Hospital, MA, USA. Reproduced with permission.
Figure 22.3 Spirometry findings in (a) normal, (b) restrictive, (c) obstructive, and (d) combined
obstructive and restrictive ventilatory deficits.
Figure 22.4 How to make an inhaler spacer from a plastic water bottle. Source: Zar et al. (2005),
figures (a) and (b). Reproduced with permission of South African Medical Journal and H. Zar.
Figure 23.1 Pathophysiology of diabetic ketoacidosis.
Figure 23.2 Insulin serves as a key to glucose entry into the cell.
Figure 23.3 Algorithm for the treatment of DKA in adults and children. BG, blood glucose; ORS,
oral rehydration solution; SQ, subcutaneous; UOP, urine output. Adapted from International
Diabetes Federation (2011).
Figure 23.4 An example of a form that can be used for monitoring a patient in DKA.
Figure 23.5 Types of insulin.
Figure 23.6 Twice-daily insulin regimen.
Figure 24.1 Preparation of thin peripheral blood smears.
Figure 24.2 Peripheral blood smear of a 2-year-old boy with acute lymphoblastic leukemia (ALL)
and a high presenting white blood cell count at risk for tumor lysis syndrome. Note the large
number of lymphoblasts. They are larger than the red blood cells and have very little cytoplasm.
Figure 24.3 Peripheral blood smear of a 2 year old with iron-deficiency anemia. Note the large
central pallor of the erythrocytes, small size compared with neighboring lymphocyte, and pencil
cells, often seen in iron-deficiency anemia. Source: Oski et al. (in press). Reproduced with
permission of Elsevier and C. Brugnara.
Figure 24.4 Peripheral blood smear of child with HbS β0-thalassemia, a type of sickle cell anemia.
Note the sickle-shaped cell located in the center of the blood smear and surrounded by target cells,
which are characteristic in HbS β0-thalassemia and HbSC disease.
Figure 24.5 While childhood cancers can occur at any age, they tend to occur within certain age
groups. This helps narrow the differential diagnosis; however, the final diagnosis must be
confirmed via biopsy in almost all cases. ALL, acute lymphoblastic leukemia; AML, acute
myeloid leukemia; CML, chronic myeloid leukemia; NHL, non-Hodgkin lymphoma.
Figure 25.1 Cervical spine stabilization. (a) Manual cervical spine stabilization should be
maintained immediately, followed by application of a cervical collar and backboard. (b) Full
spinal immobilization. (c) Spinal immobilization can be improvised if the standard cervical collar,
backboard and head blocks are not available. Sandbags, rolled towels, or T-shirts may be used.
Figure 25.2 Jaw thrust. Use the index and middle fingers to push the posterior aspect of the jaw
anteriorly, preventing the tongue from occluding the airway. The jaw thrust is the preferred
method of opening the airway in patients with potential C-spine injury.
Figure 25.3 Oropharyngeal and nasopharyngeal airways. The oropharyngeal airway (a) should be
inserted in the anatomic position, using a tongue depressor to keep the tongue out of the way. The
nasopharyngeal airway (b) should be lubricated and inserted into the more patent nare.
Figure 25.4 Needle decompression. A large-bore intravenous catheter is inserted into the second
intercostal space in the mid-clavicular line until a rush of air is heard. The needle should be
removed and the catheter left in place until a chest tube can be placed.
Figure 25.5 Three-way taped occlusive dressing. Apply petroleum-soaked gauze or a foil wrapper
to the chest wound and tape on three sides.
Figure 25.6 Insertion of a thoracostomy tube, as described in Box 25.1.
Figure 25.7 Pelvic binding sheet. In suspected pelvic injuries, prevent exsanguination by wrapping
a folded bedsheet circumferentially around the patient's pelvis, pulling the ends to apply adequate
compression.
Figure 26.1 Sample patient monitoring chart for the ICU. Source: World Health Organization
(2011), p. 209. Reproduced with permission of the World Health Organization.
Figure 26.2 Simple bubble CPAP can be made from common hospital supplies (adapted from
AdaptAir.org). The PEEP delivered with bubble CPAP can be adjusted by changing the depth the
tubing is immersed in water.
Figure 26.3 Seizure recovery position.
Figure 27.1 Assessment and management guide for depression. Source: WHO (2010), pp. 10–12.
Reproduced with permission of the World Health Organization.
Figure 27.2 Assessment and management guideline for self-harm or suicide. Source: WHO
(2010), pp. 74–76. Reproduced with permission of the World Health Organization.
Figure 28.1 Algorithm for developing a dermatological differential diagnosis.
Figure 28.2 Typical locations of various dermatologic conditions.
Figure 28.3 Secondary sphyilitic lesions. Secondary syphilis can present as mucous membrane
lesions, like those located at the labial commissures (a), or as a maculopapular rash with frequent
palmoplantar distribution (b). Source: (a) CDC Public Health Image Library/R. Sumpter; (b) CDC
Public Health Image Library/M.F. Rein.
Figure 28.4 A young woman in Pakistan with a scrofulodermal scar resulting from the breakdown
of skin directly overlying tuberculosis-infected lymph nodes. Source: CDC Public Health Image
Library.
Figure 28.5 Examples of paucibacillary (a) and multibacillary (b) forms of leprosy. Source: (a)
CDC Public Health Image Library/A.J. Lebrun; (b) CDC Public Health Image Library/A.E. Kaye.
Figure 28.6 A radiograph image showing extensive subcutaneous fungal infection in madura foot.
Source: Wikimedia © Haitham Alfalah. Reproduced under the Creative Commons license.
Figure 28.7 Cercarial dermatitis, or “swimmer's itch,” as a result of acute schistosomiasis
infection. Source: CDC Public Health Image Library.
Figure 28.8 Larva currens rash in strongyloidiasis. Source: CDC Public Health Image Library.
Figure 28.9 Dermatological findings among individuals in South Sudan with onchocerciasis.
These lesions include fibrotic nodules called onchocercomata (a) and skin lichenification and
“leopard skin”-like dyschromia (b). Source: D. Harris, Baltimore, 2012. Reproduced with
permission of D. Harris.
Figure 28.10 Loa loa can present as transient Calabar swelling (a, on right hand) as well as visible
migration of the worm across the conjunctiva (b). Source: (a) Guerrant et al. (1999), reproduced
with permission of Elsevier; (b) reprinted from Eye 25, 389–391 by permission from Macmillan
Publishers Ltd, copyright 2011, figures 1 and 2, p. 390.
Figure 29.1 Primary and adult dentition.
Figure 29.2 Normal anatomical characteristics of a tooth and supporting periodontal structures.
Figure 29.3 A Venn diagram of the causes of dental caries.
Figure 29.4 Examples of chewing sticks. Source: R. Khandelwal, Harvard School of Dental
Medicine, Boston, USA. Reproduced with permission of R. Khandelwal.
Figure 29.5 Dental instruments discussed in this chapter. (a) Anesthetic syringe; (b) hand scaler
(close-up in inset); (c) mirror; (d) explorer; (e) periodontal probe (close-up in inset); (f) spoon
excavator (close-up in inset); (g) periodontal elevator; (h) periosteal elevator; (i) forceps.
Figure 29.6 Examples of dental caries, infected pulp, abscess, gingival inflammation (gingivitis),