1. Health, Hygiene & Sanitation in Remote Areas
Remote Areas Emergency Medicine and Survival

2. Preventative medicine
Preplanning
Environment
Temp / terrain
Pathogens / vectors
Social / legal
Water
Food
Toilet

3. Preplanning
Detailed 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, 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

7. 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

8. 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

9. 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

10. 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

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.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

12. 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

13. 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)

14. DEET Complete protection from Aedes aegypti: OFF 23.8% DEET 302 min
Controlled Release 20% DEET min
Soybean Oil 2% min
Citronella 10% min
Avon SSS Bath Oil min
DEET wristband 9.5% min
15 Volunteers, Arm-in-Cage Design (Fradin & Day NEJM 2002)

15. Permethrin on clothing
Long lasting. Persists after washing. Light stable
Nongreasy. Nearly odorless
Skin transfer 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)

16. 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

17. 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

18. 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

19. 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 min
In FL >90% reduction Ochlerotatus bites
In 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 water
Large scale permethrin fogger around buildings, camp. somewhat effective
Ducks, fish
Muscovy ducks for flies, guinea hens/chickens for ticks
Future…. Transgenic mosquitoes?

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

23. Mice & Rats Food/medicine contamination Hantavirus Plague
Destruction of equipment/packs
Poison & traps
Metal containers for supplies (paint cans)

24. 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

25. 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

26. 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

27. 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

28. Field Water Treatment HAND WASHING! Boiling Chemical disinfection
- Chlorine
-Iodine
-Chlorine dioxide
Filtration UV
Sedimentation, Coagulation/flocculation, Granular activated charcoal
SODIS 35 deg lat

29. 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

30. 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

31. 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)

32. 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

33. 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.

34. 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.

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 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.

37. 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

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 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

39. 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.

40. 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

41. 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

43. 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 (
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 damage
Chlorine Dioxide less taste, improved cold water performance, cryptosporidium coverage
Miox Pen multiple chemicals derived from salt, requires power
Sawyer/MSR Microfiltration? Unproven

45. Sedimentation Large inorganic particles like sand and clay settle
by gravity
Let water sit for
minutes
Decant or filter clear
water
Does not disinfect

46. 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

47. Alum flocculation
zinc and heavy metals
organic solids
oil
poop

48. Granular Activated Charcoal Action
Adsorbs dissolved chemicals, pesticides, oil, uranium?
Improves taste, odor, color
Does not disinfect
Finite capacity for adsorption

49. 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
Cryptosporidium
Enteric bacteria
Viruses
Common micro-filters

50. 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 nm) of the sunlight destroys the pathogens.
A synergy of UV-A and temperature occurs, if the water temperature rises above 45°C.

51. Solar box cooker

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 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.

53. 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

54. Dish washing
Wash Rinse Sanitize

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 head
Dish drying on the ground with feet
No soap mixed meat and ffv cutting
First in first out
Actually 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 pudding
Food bowls on floor stacked
Ffv with feet, rice on ground, sitting on rice, birds and rodents