Presentation on theme: "Health, Hygiene & Sanitation in Remote Areas"— Presentation transcript:
1 Health, Hygiene & Sanitation in Remote Areas Remote Areas Emergency Medicine and Survival
2 Preventative medicine PreplanningEnvironmentTemp / terrainPathogens / vectorsSocial / legalWaterFoodToilet
3 PreplanningDetailed risk assessments and planning to counter identified health threats
4 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
5 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
6 North American Wilderness Summer Minor trauma, orthopedicsContact dermatitis, sunburnFood / water / hand washing contaminationmajor trauma auto, quad, motorcycle, falls, logging, aircraftHeart attack, stroke, seizure etc…Heat/cold injury/exposure/dehydrationDrowning / technical rescue environmentPenetrating trauma, logging, criminals, animals, snakebiteExotic: lightning, west nile, diving, altitudeThis list would be different for a fire crew
7 Sources of information for international travel Local newspapersMissionary groups, NGOLocal physiciansMinistry of health publicationsRemember to focus on regions regardless of borders. Local info is the best, sometimes local treatments may be betterCDC Yellow bookWHO essential drugs list
8 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, boatP air travel with visaA maritime travel or paid driver to border countryC consulate, shelter in placeE local clothes, stow away on train, boat
9 Planning on the spotCheck own pulse first, often you have time Size up the whole situation Undue haste makes waste Remember where you are Vanquish fear and panic Improvise Value living Act like the locals Learn skills before the crisis, rehearse actions
10 Stinging Insects avoid or eradicate Mosquitoes: West Nile virus, Yellow fever, Malaria, Dengue Fever, Filariasis, Encephalitis, Eastern Equine Encephalitis and Japanese Encephalitis. deetSand Flies: Oroya fever, Leishmaniasis, pappataci fever virus, kala azar, Oriental sore, espundia, and bartonellosis PermetherinTsetse Flies: Sub-Saharan Trypanosomiasis (African Sleeping Sickness) picardin, deet.Black Flies: tropics and subtropics filariasis picardin, deet.Biting Midges: visceral filariasis. PermetherinBot Flies: vaselineAnts: premetherin paint
11 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.permetherinMites: Rickettsialpox and Scrub typhus, Scabies, Chiggers Lindane Permethrin 5% Sulphur 4% MalathionFleas: Plague, Epidemic typhus, Sylvatic typhus, Cat flea rickettsiosis, Murine typhus and Cat-scratch disease. Bug bombLice: Epidemic typhus, Sylvatic typhus and Trench fever RID,Spiders: premetherin paint or string
12 Diptera: big fancy word for mosquito Many problems can be easily mitigated by proper insect control measuresWorldwide, mosquitoes transmit diseases to 700,000,000 annuallyMalaria kills 3,000,000 annuallyMosquitoes will cause the deaths of 1 out of 17 people now alive
13 Skin productsDeet 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 absorbedIn Queensland rainforest field trial:Picaridin 19% gave 95% protection > 9 hrPicaridin 9% gave 95% protection > 2 hrDEET 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)
14 DEET Complete protection from Aedes aegypti: OFF 23.8% DEET 302 min Controlled Release 20% DEET minSoybean Oil 2% minCitronella 10% minAvon SSS Bath Oil minDEET wristband 9.5% min15 Volunteers, Arm-in-Cage Design (Fradin & Day NEJM 2002)
15 Permethrin on clothing Long lasting. Persists after washing. Light stableNongreasy. Nearly odorlessSkin transfer mg/kg/d (Snodgrass ’92)Rapidly metabolized. No tissue accumulationNot carcinogenic. Not mutagenicIn clothing provides 74% protection against chiggers (Breeden et al ‘92)In clothing more effective than DEET against ticks (Evans et al ‘90)
16 PermethrinSheep 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
17 Mechanical barriers Bed nets with permethrin Window screens with permethrinInsect tents for food preparation areas and toilet areasLids, bagsEat food right after preparation
18 Traps Mosquito traps (CO2 and attractant) Fly bait UV light for flies in eating areas and at entrancesGood old fly swatter for that pesky one that got in anyway
19 SumiOne EmanatorsMetofluthrin (SumiOne), a vapor-active pyrethroid effective against mosquitoesMetofluthrin impregnated paper emanators placed 1.2 m to sides of volunteers in fieldPre and post-tx bite counts after minIn FL >90% reduction Ochlerotatus bitesIn WA >95% reduction Aedes bites(Lucas et al. J Am Mosq Contr Assoc, 2007)
20 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
21 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 waterLarge scale permethrin fogger around buildings, camp. somewhat effectiveDucks, fishMuscovy ducks for flies, guinea hens/chickens for ticksFuture…. Transgenic mosquitoes?
22 Bigger Critters Mice Rats Bats Snakes and lizards Skunks, feral cats, dogsMonkeys and bearsOh my!
23 Mice & Rats Food/medicine contamination Hantavirus Plague Destruction of equipment/packsPoison & trapsMetal containers for supplies (paint cans)
24 Bats Rabies, lethal if symptomatic Pre vaccinate in endemic areas/caversIf bat is found and someone has been sleeping must vaccinate if not done and must give immune globulin alsoSleeping in the open discouragedBy far most North American rabies is from bats
25 Snakes and Lizards Painful bites Poisonous bites Salmonella, wash hands after touching before eating or preparing raw foodEncourage a no touch policyTetanus vaccine
26 Skunks, feral cats, wild dogs Avoid contactSecure 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
27 Monkeys, Raccoons, and Bears Secure foodSecure it some moreReally secure itElevation and metal containersMonkey and racoon bite = rabies prophylaxisBear = trauma center or body bag
28 Field Water Treatment HAND WASHING! Boiling Chemical disinfection - Chlorine-Iodine-Chlorine dioxideFiltrationUVSedimentation, Coagulation/flocculation, Granular activated charcoalSODIS 35 deg lat
29 Water and Sanitation Globally 1.1 billion persons without access to potable water2.4 billion persons without adequate sanitation4 billion episodes of diarrhea/year2.2 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
30 Sierra Nevada Water 55 lakes and streams in National Parks 40% positive for coliformsMost very low levels31 lakes and streams in Wilderness areas45 % positive for coliformshigh levels at 8 sitesCorrelated with human and animal (beaver) activityDerlet RW et al. Wild Environ Med 2004
31 Toilets Pre prepared: park service, hand washing, floor washing Blue lagoon! (blue water backsplash)5 gal pail with liner and lidZiplock skillsSlit trench, fenced areasPaper, water, Rock, leaf, wipe plan (cultural)Surface deployed poop next to water (what most people and all animals do)
32 Helping you “go green!” Bacterial Viral 17-130 days in H2O Protozoan ParasiticE coliHepatitis AGiardia2-3 months in H2OAscarisShigellaNorwalk EhistolyticaT soliumCampylobacter3-5 weeks in H2OPolio virusCryptosporidium12 months in H2OLiver flukeV cholera4-5 weeks in H2OHepatitis ECyclosporaDracunculosisS typhiMore than 120enteric virusesBlastocystisY enterocoliticaI belliB coli
33 Water treatment is secondary to good hygiene Individual Practices:-hand-washing, bathing, toilet practicesGroup Practices-campsite selection, group toilets, food / water choice and preparation, food waste disposal, dish washingWater treatment should accompany a comprehensive approach to hygieneWaterborne pathogens are only one potential source of disease in the backcountry. Water treatment should accompany a comprehensive approach to hygiene. Focusing on clean water without paying attention to hand-washing, personal cleanliness, or dish washing, will be counterproductive.Human feces potentially contain a broad range of pathogenic bacteria and viruses, but it should also be pointed out that that significant percentages of the general population can be asymptomatic carriers of both Giardia (4–7%) and Cryptosporidium (1–3%)A gram of fecal material may contain between 105 and 107 Giardia or Cryptosporidium (oo)cysts and viruses on the order of 105–1012. It has also been shown that mere bathing can release measurable amounts of fecal material into surface water.
34 Handwashing camp sanitation After toiletBefore eatingSimple foot pump deviceIn large camps must be enforcedLiquid soap can be dispensed by monitor in lineToilets need bleach water spray QD to QID based on use. Not in toilets unless cholera outbreak.Spray toilets with permethrin for fliesGarden sprayers work greatBathe, do laundry, wash dishes, away from the well head.
35 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.
36 Military applications More died in WWI from disease than combatSoviets 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.
37 Boiling water Fuel and time intensive Works great at most elevations Most pathogens die well before boilingRolling boil is the only reliable temp, small bubbles are not consistantTime at boil shown not to be significant just getting to a boil is reliably adequate
38 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 CEnteric viruses-Seconds at 80º -100º CHepatitis A-1 minute at 85º CEnteric bacteria-1 minute at 65º C-Seconds at 100º CElevation Boiling Point-10,000 ft. 90º C-14,000 ft 86º C-19,000 ft 81º C
39 Choice of Methods: Chemicals WATER TREATMENTChoice of Methods: ChemicalsIodine and Chlorine:-widely used and inexpensive-ineffective against cryptosporidium-effectiveness decreases with lower temperatures and higher turbidity-byproducts a concernChlorine 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)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 ClO2Like heat, all effective inactivation with chemicals is a product of concentration and time. Concentration is usually expressed in mg/L (1mg/L = 1 ppm) and time in minutes. The product of the two is referred to as a constant for a particular agent against a particular organism at a particular temperature, turbidity, and pH. Concentration and time are inversely related, and either can be modified as long as the CT product is maintained. The CT concept introduces the possibility of shortening contact times by raising the dose. High doses relate to byproducts.Chlorine: byproducts result from interaction with dissolved organic carbon (DOC); the clearer the water the fewer are created. They are Haloacetic Acids (HAAs) and Trihalomethanes (TMHs). Both linked to cancer after prolonged (as in years) use. At doses required for effective field disinfection, taste can be objectionable.Iodine: at high doses can interfere with thyroid function and can react with some drugs (lithium, for example).ClO2 byproducts: chlorites are associated with neurodevelopmental defects in lab animals and some correlation with SGA-term babies. Like nitrites, they limit red blood cells’ ability to take up oxygen. Chlorates have been less studied but are tracked in California. ClO2 systems designed for backcountry or emergency use exceed municipal byproduct guidelines. As with other chemcals, prolonged use or use at high doses is not recommended. It is contraindicated for those with anemia or blood disorders and pregnant women.Pristine and Aquamira are the same product in different bottles. Its EPA registration confirms its ability to kill bacteria only.Micropur’s EPA registration confirms its claims against viruses, bacteria, and protozoa.Mixed Oxidants: show lower levels of HAAs and TMHs than straight chlorine and negligible levels of chlorites and chlorates. Mixture includes chlorine, chlorine dioxide, and ozone, but manufacturer cannot say in what combination.
40 Iodine/chlorine May miss cryptosporidium. (Illinois river) Safe Water System CDC, WHO, PAHOInternational Network to Promote Household Water Treatment and Safe StorageSodium hypochlorite and closed mouth containers with spigotReduced diarrhea24% in Bangladesh25% in Guatemala30% 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-Cryptosporidiumresistance
41 Chlorine tipsDifferential Dx of diarrhea and or nausea too much chlorine or iodine.Chlorine at 1-2 ppm is bacteriostatic4-5 ppm it gives you the “quick step”Carry a few pool test strips to check camp water where chlorine is routinely usedAllow over treated water to sit and off gas the chlorine or add more water
43 FiltersMay 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
44 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 damageChlorine Dioxide less taste, improved cold water performance, cryptosporidium coverageMiox Pen multiple chemicals derived from salt, requires powerSawyer/MSR Microfiltration? Unproven
45 Sedimentation Large inorganic particles like sand and clay settle by gravityLet water sit forminutesDecant or filter clearwaterDoes not disinfect
46 Coagulation - Flocculation ClarifiesRemoves Colloids (fine suspended matter)Partially removesMicroorganismsMetallic compounds and mineralsDissolved chemicals (phosphates)Bad taste, smell, colorUse small amounts of alumFound in grocery store for picklingRemoves up to 90% of bacteriaRemoves up to 89% of viruses
47 Alum flocculationzinc and heavy metalsorganic solidsoilpoop
48 Granular Activated Charcoal Action Adsorbs dissolved chemicals, pesticides, oil, uranium?Improves taste, odor, colorDoes not disinfectFinite capacity for adsorption
49 Filtration Simple process No taste imparted Special equipment Pore size limitationGradual cloggingOrganism Maximum pore size (um)Parasitic eggs and larvae 20Giardia, E histolyticaCryptosporidiumEnteric bacteriaVirusesCommon micro-filters
50 SODISSODIS requires relatively clear water (turbidity less than 30 NTU)SODIS is not useful to treat large volumes of waterRegions well suited for SODIS are locatedbetween latitude 35°N and 35°S6 hours under bright or up to 50% cloudy sky2 consecutive day under 100% cloudy skyDuring days of continuous rainfall, SODIS does not perform satisfactorily.Water boiling or rainwater harvesting is recommended during these days.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 nm) of the sunlight destroys the pathogens.A synergy of UV-A and temperature occurs, if the water temperature rises above 45°C.
52 WATER TREATMENT Risk Assessment Factors 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)Protozoa, Helminth:encased in a shell (cyst or oocyst) and dormant in water, > 1 micronEgs: Giardia, Crypto speciesHelminth egs: Hookworms, Roundworms, TapewormsBacteriaVary in size and shape, tend to be > 0.1 micronEgs: E. Coli, Salmonella, CampylobacterViruses<<0.1 mircon, on the order of nanometersEgs: Hepatitis A, Adenovirus, RotavirusRisk varies with location. Any presence of livestock implies animal fecal contamination and the risk of bacteria and protozoa. Any risk of human fecal contamination--from sewage overflow, wastewater outflow, questionable toilet practices in recreational areas--suggests the possibility of contamination with protozoa, bacteria, and viruses. In wilderness areas, distinguish between pulse and widespread contamination.Be aware of local conditions and the possibility of endemic pathogens (eg Echinococcus granulosis in Isle Royale National Park) and local toxins.Risk assessment includes assessing a group’s tolerance for risk. Consider the characteristics of the trip and the group.
53 Water summaryUnderstand the advantages and disadvantages of each system and apply them appropriately to your situationHeatUltravioletChlorine DioxideFiltration+Halogenation or UV
55 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.Dishes and hair washing at the well headDish drying on the ground with feetNo soap mixed meat and ffv cuttingFirst in first outActually okay!
56 A fly has six legs… that’s six bad things on your food! Remember:A fly has six legs… that’s six bad things on your food!And:Keep your rice off the ground…and your butt off the rice!!No cover on puddingFood bowls on floor stackedFfv with feet, rice on ground, sitting on rice, birds and rodents