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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. Preplanning. - PowerPoint PPT Presentation
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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.
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: