CIWEC – Travel Medicine Center of International Repute Prativa Pandey, M.D Medical Director CIWEC Hospital CIWEC Clinic Travel Medicine Center

Case 1 37 yr old American male arrived in Nepal in May after extensive travel Feb-May Climbed Mt. Kilimanjaro and visited serengeti national park in Tanzania

37 yr old American male traveled to: Travel to Brazil, Argentina, South Africa, Zimbabwe, Zambia, Tanzania, Kenya, Bahrain and then Nepal, climbed Mt. Kilimanjaro and visited Serengeti national park. From Tanzania, he went to Kenya to fly into Nepal via Bahrain. He was seen at the CIWEC Clinic 2 days after arrival in Kathmandu.

Seen 2 days after arrival in Nepal Fever and chills x 8 hrs insect bite to left foot with pain and swelling

Case presentation Started on antibiotic for probable skin infection Did not improve Ongoing fever, chills x 3 days, slightly short of breath All tests normal Special test done

Diagnosis: East African Trypanosomiasis or Sleeping Sickness

Trypanosomiasis - East African Sleeping Sickness Tsetse flies only found in Africa Medicine to treat this disease, Suramin not available in all of Asia Patient flown back to Boston after phoning doctors in Boston about his diagnosis Suramin brought urgently from CDC and was ready when patient reached the ER in Boston

Highlights of the case High index of suspicion on account of travel history helped confirm diagnosis Early notification of treating doctors in U.S. helped obtain quick treatment. Following this case several cases were discovered in East Africa This is the value of Travel Medicine

The Practice of Travel Medicine

History of the CIWEC Clinic Established in 1982 to take care of expatriates working for a Canadian water project: Canadian International Water and Energy Consultants (CIWEC) Gradually other expatriates and foreign tourists began to use the clinic Clinic made it into the guide books

David Shlim joined the clinic in 1983 and worked for 15 years Kitchen of rented house was the laboratory Medical research conducted on traveler/expat issues Prativa Pandey joined in 1993

Select Publications Etiology of diarrhea among travelers and foreign residents in Nepal. Taylor DN, Houston R, Shlim DR, Bhaibulaya M, Ungar BLP, Echeverria P. Journal of the American Medical Association 1988;260:1245-1248. Helicopter rescues and deaths among trekkers in Nepal. Shlim DR, Houston R. Journal of the American Medical Association 1989;261 Rabies immunoprophylaxis strategy in travelers. Shlim DR, Schwartz E. Houston R. Journal of Wilderness Medicine 1991;2:15-21. Viral hepatitis in foreign residents and travelers in Nepal. Schwartz E, Innis BL, Shlim DR, Snitbhan R. Journal of Wilderness Medicine 1991;2 An alga-like organism associated with an outbreak of prolonged diarrhea among foreigners in Nepal. Shlim DR, Cohen MT, Eaton M, Rajah R, Long EG, Ungar BLP. American Journal of Tropical Medicine and Hygiene 1991;45:383-389.

CIWEC Clinic Travel Medicine Center- 2005

What has helped us grow? Name recognition – have been around for 32 years We provide what the travelers need Have consistently provided good quality work Stay connected with the global Travel Medicine community High profile presence in the International Society of Travel Medicine (ISTM) – 2 of our Medical Directors have been the ISTM Presidents Be an expert in your area of work Participate in Scientific research work and publish papers

Challenges of growth – from a clinic to a hospital From 20 staff to 100 staff Had to hire managerial staff at multiple levels Multiple power back up systems Biomedical engineering staff on standby Fiscal discipline Although bigger, try to preserve a small clinic environment

Global Surveillance Network of the ISTM and CDC - GeoSentinel First developing country clinic to join GeoSentinel Monitor emerging and re-emerging diseases in travelers Many research papers that have identified: disease trends in travelers high risk travelers country or region specific risk

What is it that we do, we do well Cleanliness/hygiene Motivated staff Confidentiality issues Compassionate care

What is it that we do, we do well Diagnose before treating Communicate – patients, third party payers Explanation of treatment and explain what may not be known Explain what is the best treatment for this condition even if that is not available in Nepal Patient centric approach

Good management starts with good communication!