EXPERIENCE REPORT OF THE TROPICAL MEDICINE EXCURSION (TROPMEDEX) FOR HEALTHCARE PROFESSIONALS TO GHANA 2014
Dr. med. Jörg Brommer, Chief Medical Officer, Kome 5 Chad; INTERNATIONAL SOS Registered in Germany (162154) and the UK (4685876) GP, DTMPH, ACLS, ATLS, ITLS, OGUK (2011/1634)

“In my opinion, the training for healthcare providers in the areas of clinical tropical medicine and travellers’ health in non-tropical countries has yet to reach an adequate standard. Each year, more and more tourists choose travel destinations in tropical and subtropical regions, often without immunization or Malaria prophylaxis. Returning travellers succumb to Dengue Fever and other tropical infectious diseases simply because the infections are recognized too late, if at all, by medical professionals in American, European, and Australian hospitals. More asylum seekers from the tropics come to the developed world with “unknown” infections. Due to global warming tropical diseases have spread to temperate climate zones. Practice-oriented training programs for healthcare professionals in the tropics are essential to the prompt, correct diagnosis and treatment of tropical infections diseases.”
A very special 11 day Ghana round-trip excursion lay ahead of me, which I would later come to regard as an incredible experience.
Upon landing at Accra International Airport, I was driven to our hotel where I met the other 10 participants – medical colleagues from Australia, Austria Canada, Germany, Sweden Switzerland and the USA - as well as the excursion leader, Kay Schaefer (MD, PhD, MSc, DTM&H), a German consultant in Tropical Medicine and Travelers’ Health. Over the last 20 years he has organized TROPICAL MEDICINE EXCURSIONS (TROPMEDEX) for healthcare professionals to Kenya, Uganda, Tanzania and Ghana (in total 45 excursions with over 450 participants from ‘round the world’). These are done in collaboration with leading teaching hospitals and medical institutions in Africa. He and local experts supervise individual on-site bedside teaching, lead laboratory sessions (hands-on microscopy of parasites in blood, stool and urine), and give lectures. The curriculum (60 CME hours accredited by the Medical Association in Germany) covers the epidemiology, clinical manifestations, diagnosis, treatment, prevention and control of Africa’s most important tropical infectious diseases. In addition, the participants gain insight into the local healthcare system and explore the fantastic scenery and prolific flora and fauna in Africa during epidemiologic field excursions.
Schistosomiasis field excursion on the Volta River
In the colonial atmosphere of the hotel, Dr. Schaefer outlines the planned course of the trip. He describes the itinerary taking us from Accra to Akosombo at the Volta Dam (the largest of its kind in Africa), continuing on to Kumasi (home of the Ashante Kingdom) and via Cape Coast back to Accra. This would cover approximately 1200 km on tarmac roads in a comfortable air-conditioned bus with a safe, experienced local English speaking driver.
The first lecture is dedicated to the recent Ebola Virus Disease (EVD) outbreak in West Africa. Although Ghana has never had suspected or confirmed cases of EVD (up to April 2015), the disease is of great concern to the neighbouring countries. Dr. Schaefer stresses out why EVD has spread in Liberia, Guinea and Sierra Leone so fast. ”The virus has hit West Africa for the first time. Nobody was prepared. Those affected countries are resource-poor countries already coping with major health challenges. Their borders are porous and movement between countries is constant. Healthcare infrastructure is inadequate and health workers and essential supplies including personal protective equipment are scarce. Traditional practices such as bathing of corpses before burial have facilitated transmission. The epidemic has spread to cities, which complicates tracing of contacts. Decades of conflict have left the populations distrustful of authority figures such as healthcare professionals.” Dr. Schaefer sighs and continues: “Adding to these problems a rapidly spreading virus with a high mortality rate and the scope of the challenge becomes clear.” On the road to a sophisticated laboratory (where EVD can be diagnosed) in Greater Accra area we see billboards spreading information about the prevention and control of Ebola.
Laboratory session
In the evening I dine with Dr. Mirzanejad, an Infectious Diseases expert from Vancouver, Canada. He had participated at the TROPMEDEX excursion to Uganda in 2012 and was eager to return to Africa again. He talks at length about what attracts him to come back to this vibrant, chaotic and challenging continent.
After a morning lecture on Schistosomiasis we drive to Akosombo. Schistosomiasis Haematobium is widespread in the Volta region. More than 50% of the population is affected, most of them schoolchildren. They mainly complain about bloody urine and pain during micturition. Some of them suffer from renal failure and even bladder carcinoma. During a boat ride on the Volta River we visit a fishing village with Dr. Ampia, the director of the Prevention and Control Program for Schistosomiasis in the Volta region. He says” It is impossible to eradicate Bilharzia here. The fisherman fish and the children play in the river. They get infected, they are treated, and then they infect themselves all over again when they are exposed to the fresh water. It’s a vicious circle.” In the afternoon we visit Joanthan Porter at Kpong Airstrip, not far away from the Volta Dam. He is a British pilot who has founded the Non Governmental Organization “Medicine on the Move” back in 2006. The mission is to air drop medicines and medical equipment from his plane while flying over villages, inaccessible by road. Yesterday he had dropped packages stuffed with Praziquantel, (the drug of choice for Schistosomiasis) over 5 remote healthcare centres in the Volta region. The next day we discuss Malaria. Dr. Schaefer emphasizes that Malaria Tropica (Plasmodium falciparum) is a medical emergency. Cerebral Malaria can kill within a matter of hours. For this reason alone, doctors in the developed world should ask each patient with a fever if he or she has visited the tropics within the past 6 months. Later that same day we see how life-threatening Cerebral Malaria can be, in a 8 month-old-girl with convulsions and a fever of 40 degrees, admitted to the paediatric ward at Akosombo General Hospital. She has immediately received IV Dextrose solution and Diazepam. With the help of a Paracetamol suppository and fanning motions, a nurse tries to reduce the fever. Afterwards, the attending physician examines her and takes a thin blood smear, explaining: “it is much more important to stabilize the life-threatening condition, before any thought can be given to a diagnosis. Anyway, in most cases, it’s Malaria. Nevertheless, one should at least consider the possibility of Meningitis, and perform a lumbar puncture in case the Malaria therapy with Quinine or Artesunate doesn’t show an effect.” During the rainy season, the Anopheles Mosquitoes breed very rapidly, and a distinct rise in Malaria cases can be seen in hospitals, above all in the paediatric wards. Malaria Tropica is still the number one killer of children under the age of 5 years in Africa.
X-ray session in Akosombo Hospital
Infant with Malaria
A couple of days later we drive through Cape Coast, a laid back University town and fishing port on the Atlantic ocean. It is hot and humid. Cape Coast castle is sitting on a huge rock, its canons directed versus the open sea. The British, the Portuguese, the Swedish, the Danish, and the Dutch have been here and shipped slaves, gold and ivory to the Americas and Europe. When we enter the gate to the castle two middle-aged male beggars with swollen legs and feet approach us. Dr. Schaefer points out, that they have late stage Lymphatic Filariasis. Despite the implementation of the mass drug administration program (once a year Albendazole and Ivermectin) by the Ministry of Health in Cape Coast area a lot of people are still suffering from this disfiguring worm infection. Later on we see a female patient with a massive swollen infected right leg when we attend rounds with Dr. Richards on the surgical ward at the Cape Coast University Teaching Hospital.
Patient with Lymphatic Filariasis
“Despite health education she didn’t do what we had told her: to wash her leg and foot twice daily with soap and water, raise the affected limb at night, exercise to promote lymph flow, keep nails clean, wear shoes and use antibiotic creams to treat small wounds or abrasions. We fear Osteomyelitis and probably will have to perform an amputation if she doesn’t respond to our treatment .” Next to her lies a patient who had undergone surgery 3 days ago. She had an acute abdomen and peritonitis due to Typhoid Fever. “It was an emergency” says Dr. Richards, who performed the operation. “The intestinal perforation was in the distal ileum. It is a very serious complication, most often occurring in the 3^rd week of infection.” The 30 year old patient, Susan K., smiles when Dr. Richards shakes her hand and checks the fever curve in the medical file. “She is improving and should soon be able to leave the hospital.”
Ward rounds
Diarrhoeal diseases cause a lot of morbidity and mortality in Africa. A reminder of the recent cholera epidemic in Ghana is the huge, white tent on the lawn in front of the Cape Coast University Hospital, where a number of patients had been treated in the previous weeks. Between June and November 2014 in total 17527 cases (173 of them died) have been reported in 9 regions of Ghana. The bulk of infections occurred in the greater Accra region. Fortunately the number of new cases is decreasing. It wasn’t easy to bid farewell to our colleagues. Over the course of the past 11 days, we grew together as a family, learning from each other as well as from the excursion. We have covered the better part of all major tropical infectious diseases, in a wide variety of hospitals, clinics and prevention and control projects. On numerous excursions we gained familiarity and appreciation not only for the healthcare system in Ghana and its public health challenges but also for the land, the people and their rich culture.
Dr. med. Jörg Brommer Forthcoming TROPMEDEX excursions: Ghana 25^th November – 5^th December 2015 Uganda 14^th February – 26^th February 2016 Tanzania 13^th March – 25^th March 2016 Ghana 30^th November – 10^th December 2016 Further information check www.tropmedex.com TROPMEDEX excursions are listed on the website of the: 1. American Society of Tropical Medicine & Hygiene www.astmh.org > Education & Training > Events/Calendar 2. International Society of Travel Medicine www.istm.org > Travel Medicine Meetings > MeetingsCalendar > Courses/Educational Travel