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 Detailed 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 This list would be different for a fire crew

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 visa A maritime travel or paid driver to border country. Hired medical evac service C consulate, shelter in place, local hospital E local clothes, stow away on train, boat P air travel with visa A maritime travel or paid driver to border country C consulate, shelter in place E local clothes, stow away on train, boat

Planning on the spot Check 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

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 Sanitation Globally 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) activity Derlet 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 Giardia 2-3 months in H2O Ascaris Shigella Norwalk E histolytica T solium Campylobacter 3-5 weeks in H2O Polio virus Cryptosporidium 12 months in H2O Liver fluke V cholera 4-5 weeks in H2O Hepatitis E Cyclospora Dracunculosis S typhi More than 120 enteric viruses Blastocystis Y enterocolitica I belli B 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 Waterborne 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.

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

Choice of Methods: Chemicals 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) 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 Like 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.

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 particles like sand and clay settle by gravity Let water sit for 30-120 minutes Decant or filter clear water 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 zinc and heavy metals organic solids oil poop

Granular Activated Charcoal Action 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 20 Giardia, E histolytica 5 Cryptosporidium 1 Enteric bacteria 0.2-0.4 Viruses 0.01 Common micro-filters 0.1-0.4

SODIS 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. 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.

Solar box cooker

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 micron Egs: Giardia, Crypto species Helminth egs: Hookworms, Roundworms, Tapeworms Bacteria Vary in size and shape, tend to be > 0.1 micron Egs: E. Coli, Salmonella, Campylobacter Viruses <<0.1 mircon, on the order of nanometers Egs: Hepatitis A, Adenovirus, Rotavirus Risk 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.

Water summary Understand the advantages and disadvantages of each system and apply them appropriately to your situation Heat Ultraviolet Chlorine Dioxide Filtration+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. Dishes and hair washing at the well head Dish drying on the ground with feet No soap mixed meat and ffv cutting First in first out Actually okay!

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 pudding Food bowls on floor stacked Ffv with feet, rice on ground, sitting on rice, birds and rodents