Health, Hygiene & Sanitation in Remote

Areas

Remote Areas Emergency Medicine and Survival

Preventative medicine Preplanning Environment

Temp / terrain Pathogens / vectors Social / legal

Water Food Toilet

PreplanningDetailed risk assessments and

planning to counter identified health threats

Preplanning example

Bangladesh.-viral illness in airport-Traffic accidents- use local drivers, use American, Toyota, Mercedes vehicles only.-Malaria- doxycycline prophylaxis, DEET, permetherin, educate on S/S-parasites- no swimming in fresh water-violence- terrorist, criminal, quasi police, food riots

Focus on real risks not sensationalism

“On a typical trip to Everest base camp traffic accidents enroute from the airport to the start of the walk are a greater risk than the climb”. -Paul Auerbach, MD July 08

North American Wilderness Summer

Minor trauma, orthopedics Contact dermatitis, sunburn Food / water / hand washing

contamination major trauma auto, quad,

motorcycle, falls, logging, aircraft Heart attack, stroke, seizure

etc… Heat/cold

injury/exposure/dehydration Drowning / technical rescue

environment Penetrating trauma, logging,

criminals, animals, snakebite Exotic: lightning, west nile,

diving, altitude

Sources of information for international travel

Local newspapers Missionary groups, NGO Local physicians Ministry of health publications Remember to focus on regions regardless

of borders. Local info is the best, sometimes local treatments may be better

CDC Yellow book WHO essential drugs list

Evacuation plans

Primary Alternate Contingency plans Emergency

P air travel with visaA maritime travel or paid driver to border country. Hired medical evac serviceC consulate, shelter in place, local hospitalE local clothes, stow away on train, boat

Planning on the spotCheck own pulse first, often you

have timeSize up the whole situationUndue haste makes wasteRemember where you areVanquish fear and panicImproviseValue livingAct like the localsLearn skills before the crisis,

rehearse actions

Stinging Insects avoid or eradicate Mosquitoes: West Nile virus, Yellow fever, Malaria,

Dengue Fever, Filariasis, Encephalitis, Eastern Equine Encephalitis and Japanese Encephalitis. deet

Sand Flies: Oroya fever, Leishmaniasis, pappataci fever virus, kala azar, Oriental sore, espundia, and bartonellosis Permetherin

Tsetse Flies: Sub-Saharan Trypanosomiasis (African Sleeping Sickness) picardin, deet.

Black Flies: tropics and subtropics filariasis picardin, deet.

Biting Midges: visceral filariasis. Permetherin

Bot Flies: vaseline

Ants: premetherin paint

Ticks: Lyme disease, African tickbite fever, Aneruptive fever, Australian spotted fever, Far Eastern spotted fever, Flinders Island spotted fever, Thai tick typhus, Lymphangitis associated rickettsiosis, Maculatum infection, Mediterranean spotted fevers, North Asian tick typhus, Oriental spotted fever, Queensland tick typhus, Rocky Mountain spotted fever, Sao Paulo exanthematic typhus, Minas Gerais exanthematic typhus, Brazilian spotted fever, Tick-borne lymphadenopathy (TIBOLA), Dermacentor- borne necrosis and lymphadenopathy (DEBONEL), Unnamed rickettsiosis, Q fever, Ehrlichosis and Anaplasmosis.permetherin

Mites:  Rickettsialpox and Scrub typhus, Scabies, Chiggers Lindane Permethrin 5% Sulphur 4% Malathion

Fleas: Plague, Epidemic typhus, Sylvatic typhus, Cat flea rickettsiosis, Murine typhus and Cat-scratch disease. Bug bomb

Lice: Epidemic typhus, Sylvatic typhus and Trench fever RID,

Spiders: premetherin paint or string

Diptera: big fancy word for mosquito

Many problems can be easily mitigated by proper insect control measures

Worldwide, mosquitoes transmit diseases to 700,000,000 annually

Malaria kills 3,000,000 annually Mosquitoes will cause the deaths of

1 out of 17 people now alive

Skin products Deet 50% or greater in standard formulation

reapply q 4 hours. Cumulative absorption. Increased absorption with sunscreen (in monkeys)

Lower % in controlled release. Lasts longer less absorbed

In Queensland rainforest field trial: Picaridin 19% gave 95% protection > 9 hr Picaridin 9% gave 95% protection > 2 hr DEET 20% (Sawyer) 95% protection > 6 hr (Scheinfeld. J

Drugs Dermatol 3:59, 2004) Eucalyptus very weak for 2-3 hours

(controversial) Bite blocker, 97% protection against Aedes 3.5

hours after application (U Guelph, Ontario, Canada)

DEET

Complete protection from Aedes aegypti: OFF 23.8% DEET 302

min Controlled Release 20% DEET 234

min Soybean Oil 2% 95

min Citronella 10% 20 min Avon SSS Bath Oil 10

min DEET wristband 9.5% 0.2

min 15 Volunteers, Arm-in-Cage Design (Fradin & Day NEJM 2002)

Permethrin on clothing Long lasting. Persists after washing.

Light stable Nongreasy. Nearly odorless Skin transfer .0006 mg/kg/d (Snodgrass

’92) Rapidly metabolized. No tissue

accumulation Not carcinogenic. Not mutagenic In clothing provides 74% protection

against chiggers (Breeden et al ‘92) In clothing more effective than DEET

against ticks (Evans et al ‘90)

Permethrin Sheep dip permethrin (non FDA)

on outer clothing. Mix solution dunk and dry (swartz and team 08 Bangladesh no bites, we lived)

May spray window screens, bednets, door sills, twine around sleeping, paint strip, tent, sleeping pad, ER/OR, shoes, etc…

Sawyer products also has spray on premetherin (FDA aproved)

Permethrin bug bombs (raid) for rooms. Hang your clothes out in room

Mechanical barriers

Bed nets with permethrin Window screens with permethrin Insect tents for food preparation

areas and toilet areas Lids, bags Eat food right after preparation

Traps

Mosquito traps (CO2 and attractant) Fly bait UV light for flies in eating areas and

at entrances Good old fly swatter for that pesky

one that got in anyway

SumiOne Emanators

• Metofluthrin (SumiOne), a vapor-active pyrethroid effective against mosquitoes

• Metofluthrin impregnated paper emanators placed 1.2 m to sides of volunteers in field

• Pre and post-tx bite counts after 10-30 min– In FL >90% reduction Ochlerotatus bites– In WA >95% reduction Aedes bites(Lucas et al. J Am Mosq Contr Assoc, 2007)

An Effective combo

Alaska study (Lillie et al. J Med Entomol ‘88)

-control 1,188bites in 1 hour -Permethrin on clothes and DEET on

skin 1 bite in 1 hour -99.9% effective over 8 hours

Mosquito reduction Remove or treat standing water ½ mile -Tablets in water -Vegetable oil clogs breathing of larvae in

H2O -Fuel oil may contaminate drinking water Large scale permethrin fogger around

buildings, camp. somewhat effective Ducks, fish Muscovy ducks for flies, guinea

hens/chickens for ticks Future…. Transgenic mosquitoes?

Bigger Critters

Mice Rats Bats Snakes and lizards Skunks, feral cats, dogs Monkeys and bears Oh my!

Mice & Rats

Food/medicine contamination Hantavirus Plague Destruction of equipment/packs Poison & traps Metal containers for supplies (paint

cans)

Bats

Rabies, lethal if symptomatic Pre vaccinate in endemic

areas/cavers If bat is found and someone has

been sleeping must vaccinate if not done and must give immune globulin also

Sleeping in the open discouraged By far most North American rabies

is from bats

Snakes and Lizards

Painful bites Poisonous bites Salmonella, wash hands after

touching before eating or preparing raw food

Encourage a no touch policy Tetanus vaccine

Skunks, feral cats, wild dogs

Avoid contact Secure food…solves most problems .22 semi automatic rifle with scope,

pistol if trained (Katrina) Gopher poison in cat food (non

selective) Skunk, cat, bat, and canine bite =

rabies prophylaxis

Monkeys, Raccoons, and Bears

Secure food Secure it some more Really secure it Elevation and metal containers Monkey and racoon bite = rabies

prophylaxis Bear = trauma center or body bag

Field Water Treatment HAND WASHING! Boiling Chemical disinfection

- Chlorine -Iodine -Chlorine dioxide

Filtration UV Sedimentation, Coagulation/flocculation,

Granular activated charcoal SODIS 35 deg lat

Water and SanitationGlobally

1.1 billion persons without access to potable water

2.4 billion persons without adequate sanitation

4 billion episodes of diarrhea/year 2.2 million deaths/year (most under 5

years-old) Safe water, sanitation, and hygiene can:• reduce diarrhea disease mortality by 65%• reduce mortality by 26%WHO and UNCF Global water supply and sanitation assessment 2000 report

Sierra Nevada Water

55 lakes and streams in National Parks 40% positive for coliforms Most very low levels 31 lakes and streams in Wilderness areas 45 % positive for coliforms high levels at 8 sites Correlated with human and animal

(beaver) activityDerlet RW et al. Wild Environ Med 2004

Toilets

Pre prepared: park service, hand washing, floor washing

Blue lagoon! (blue water backsplash) 5 gal pail with liner and lid Ziplock skills Slit trench, fenced areas Paper, water, Rock, leaf, wipe plan

(cultural) Surface deployed poop next to water

(what most people and all animals do)

Helping you “go green!”Bacterial Viral

17-130 days in H2O

Protozoan Parasitic

E coli Hepatitis A Giardia2-3 months in H2O

Ascaris

Shigella Norwalk E histolytica T solium

Campylobacter3-5 weeks in H2O

Polio virus Cryptosporidium12 months in H2O

Liver fluke

V cholera4-5 weeks in H2O

Hepatitis E Cyclospora Dracunculosis

S typhi More than 120enteric viruses

Blastocystis

Y enterocolitica I belliB coli

Water treatment is secondary to good hygiene

Individual Practices:-hand-washing, bathing, toilet practices

Group Practices-campsite selection, group toilets, food /

water choice and preparation, food waste disposal, dish washing

Water treatment should accompany a comprehensive approach to hygiene

Handwashing camp sanitation

After toilet Before eating Simple foot pump device In large camps must be enforced Liquid soap can be dispensed by monitor in line Toilets need bleach water spray QD to QID based

on use. Not in toilets unless cholera outbreak. Spray toilets with permethrin for flies Garden sprayers work great Bathe, do laundry, wash dishes, away from the

well head.

Benefits of hygiene with students in a large outdoor

training program NOLS data covers a well studied group

before and after program wide interventions. Rates of gastrointestinal illnesses (nausea, vomiting, and diarrhea) dropped from 0.51 per 1000 program days to 0.22 per 1000 program days over the same time period.

These hygiene issues include emphasizing hand washing and camp hygiene, educating students, and instructors on food-born illnesses, expecting all wilderness drinking water to be disinfected, and repeatedly restating the hygiene expectations to the course participants.

Military applications

More died in WWI from disease than combat

Soviets in Afghanistan: disease degraded war fighting capability greater than all other causes combined. Examples include entire battalions hospitalized from food borne Hepatitis A from one cook.

Boiling water

Fuel and time intensive Works great at most elevations Most pathogens die well before

boiling Rolling boil is the only reliable temp,

small bubbles are not consistant Time at boil shown not to be

significant just getting to a boil is reliably adequate

Thermal Death-Water pasteurized at a

boil- Giardia, E histolytica

cysts-2-3 minutes at 60º C

(140º F) Cryptosporidium

oocysts-2 minutes at 64º C-1 minute at 72º C Enteric viruses-Seconds at 80º -100º C Hepatitis A-1 minute at 85º C Enteric bacteria-1 minute at 65º C-Seconds at 100º C

Elevation Boiling Point

-10,000 ft. 90º C

-14,000 ft 86º C

-19,000 ft 81º C

WATER TREATMENT

Choice of Methods: Chemicals

Iodine and Chlorine: -widely used and inexpensive-ineffective against cryptosporidium-effectiveness decreases with lower temperatures and higher turbidity-byproducts a concern

Chlorine Dioxide (ClO2): -stronger disinfectant than both chlorine and iodine: more resistant to low temperatures and high turbidity -some effectiveness against cryptosporidium (with extremely long contact times)-byproducts a concern

Mixed Oxidants: -on-site generated combination of chlorine, chlorine dioxide, and ozone-similar to ClO2 in effectiveness, but more susceptible to turbidity-fewer byproducts than ClO2

Iodine/chlorine May miss cryptosporidium. (Illinois river)

Safe Water System CDC, WHO, PAHO

International Network to Promote Household Water Treatment and Safe Storage

Sodium hypochlorite and closed mouth containers with spigot

Reduced diarrhea 24% in Bangladesh 25% in Guatemala 30% among persons with

HIV infection in rural Uganda

-Inexpensive-Widely available-Flexible dosing-Large volumes-Multiple variables (temp,

sediment, concentration, time, pathogen sensitivity, ph)

-Taste-Potential toxicity? No

evidence-Corrosive, stains-Requires contact time-Cryptosporidium

resistance

Chlorine tips

Differential Dx of diarrhea and or nausea too much chlorine or iodine.

Chlorine at 1-2 ppm is bacteriostatic

4-5 ppm it gives you the “quick step”

Carry a few pool test strips to check camp water where chlorine is routinely used

Allow over treated water to sit and off gas the chlorine or add more water

Filters

May need back up halogen for viruses especially in areas with slow water and lots of people. (Bangladesh, Illinois river)

New viral filters 0.2 micron now available however how do you do quality control?

USACHPPM website (http

://chppm-www.apgea.army.mil/)for testing overview of most models on

the market

New stuff Steri-Pen Ultraviolet-Effective against virtually all

pathogens-leaves no byproducts-requires power-turbidity absorbs and

scatters light; essential that source water is clear or pre-filtered

-leaves no residual disinfectant in water; re-growth and repair are possible

-UV light is harmful to our eyes; devices must be used properly to avoid damage

Chlorine Dioxide less taste, improved cold water performance, cryptosporidium coverage

Miox Pen multiple chemicals derived from salt, requires power

Sawyer/MSR Microfiltration? Unproven

Sedimentation Large inorganic

particleslike sand and clay settleby gravity Let water sit for 30-

120minutes Decant or filter clearwater Does not disinfect

Coagulation - Flocculation

Clarifies Removes Colloids

(fine suspended matter)

Partially removes Microorganisms Metallic compounds

and minerals Dissolved chemicals

(phosphates) Bad taste, smell, color

Use small amounts of alum

Found in grocery store for pickling

Removes up to 90% of bacteria

Removes up to 89% of viruses

Alum flocculation

Granular Activated CharcoalAction

Adsorbs dissolved chemicals, pesticides, oil, uranium?

Improves taste, odor, color Does not disinfect Finite capacity for adsorption

Filtration Simple process No taste imparted Special equipment Pore size limitation Gradual clogging

Organism Maximum pore size (um)Parasitic eggs and larvae 20Giardia, E histolytica 5Cryptosporidium 1Enteric bacteria 0.2-0.4Viruses 0.01Common micro-filters 0.1-0.4

SODIS

Contaminated water is filled into transparent plastic bottles and exposed to the full sunlight for 6 hours.

UV-A radiation SODIS, Solar water disinfection is a simple method to improve the quality of drinking water by using sunlight to inactivate pathogens causing diarrhoea(wavelength 320-400nm) of the sunlight destroys the pathogens.

A synergy of UV-A and temperature occurs, if the water temperature rises above 45°C.

SODIS requires relatively clear water (turbidity less than 30 NTU)

SODIS is not useful to treat large volumes of water

Regions well suited for SODIS are locatedbetween latitude 35°N and 35°S

6 hours under bright or up to 50% cloudy sky

2 consecutive day under 100% cloudy sky

During days of continuous rainfall, SODIS does not perform satisfactorily.

Water boiling or rainwater harvesting is recommended during these days.

Solar box cooker

WATER TREATMENTRisk

AssessmentFactors to Consider:-potential pathogens (protozoa, bacteria, viruses)-potential toxins-location (wilderness, rural, urban, farmland)-local knowledge, awareness-group characteristics (duty, age, susceptibility, immune status, medical conditions, expectations)-characteristics of trip (length, difficulty, medical support, remoteness)

Water summary

Understand the advantages and disadvantages of each system and apply them appropriately to your situation

HeatUltravioletChlorine DioxideFiltration+Halogenation or UV

Dish washing Wash Rinse

Sanitize

Sources of “grocery outlet” syndrome

Washing dishes and bathing at the wellhead.

Drying dishes in contaminated areas.

Cutting salad and raw meat together.

First in-last out storage.

Bare feet. No soap.

Actually okay!

A fly has six legs…that’s six bad things on your food!

Keep your rice off the ground…and your butt off the rice!!

Remember:

And: