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Introduction and Welcome - DOC

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									Table of Contents
Introduction………………………………………………………………………..3

Day one Clinical Immunology
Women Travelers…………………………………………………………………..6 Women’s medical kit………………………………………………….14 Pharmacology of Travel Medicine…………………………………………….…19 Antivaccinationists………………………………………………………….…..…29 Vaccine Safety…………………………………………………………………...…31 Immunizing Health Care Personnel……………………………………………...52 Cruise ship Health……………………………………………………………….…58 Mefloquine and Madness……………………………………………………….…74

Day 2 Expedition Medicine
Skin Cancer………………………………………………………………………….79 Medical Entomology for Backpackers …………………………………….………81 Third World Dentistry (Belize and Haiti) & Dental Emergencies in the Wilderness…………………………………….…95 Flu, Colds, ad Avian Flu………………………………………………………..….103 Cultureshock………………………………………………………………………..110 SCUBA medicine……………………………………………………………………113 Arctic Medicine Meeting……………………………………………………………120

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Introduction and Welcome Thank you for your interest in this years meeting. We have some new speakers and have divided the sessions into a clinical day and an expedition day. Our Clinical medicine day focuses on Pharmacology and Nursing and common scenarios will be explored. Some of the topics we will be explored are very lengthy so we decided to focus on specific scenarios for general debate and use these as springboards for discussion. By this we hope that our attendees will be learn more practical issues and be able to research solutions using the reference information we have provided in this syllabus. Jacinda Wagner is a Compounding Pharmacist with Shoppers Drug mart. She is experienced in formulating medications to allow precise doses to be delivered in new ways. She will speak on the actions of immunizations and medications used to prevent illnesses in travelers. Often many doctors and pharmacists are unfamiliar with these drugs and her talk will introduce these products. She will also host a workshop that will examine drug interactions and contraindications. Shane Woods RN, ONH is a registered nurse wit a specialty in occupational health nursing at Red River College. Shane manages, interprets, and is responsible for health related course student‟s immunization records according to WRHA guidelines and with respect to students practicing in facilities under the direction of the WRHA. He will speak on the Immunization record required for Health Care Students at Red River College, which also includes the Mantoux test for Tuberculosis. He will also host a workshop on immunization. Candace Corroll is an Office Manager at the Skylark Travel Medicine Clinic and frequently assists prospective travelers in obtaining information for their trips. Her talk on Women travelers will focus on short vignettes involving women travelers with diverse and unique problems. She will go over these scenarios with possible solutions. A comprehensive reference guide will be included but not emphasized during he talk. We decided to focus on the specific cases to springboard discussion and emphasize the process on how we arrived at the solutions and not the solutions themselves. Dr Gary Podolsky is the Conference Coordinator and Director of his Travel clinic. He will cohost the workshops on the Adverse effects of Immunizations with Shane Woods and another on Antivaccinationists in Winnipeg. These will be a series of scenarios with emphasis on real issues and controversies that revolve around the safety and effectiveness of immunizations. We have included an extensive reference document to back up this evidence. We wish for all of our delegates to be able to use this information to help educate the general public about misconceptions about immunizations. Gary has also expressed a wish that if anyone has problems regarding vaccine issues they may contact him after the conference. He will also later talk on “Cruise Medicine” He will explore issues of safety and health aboard cruise ships. His talk on “Dive Medicine” will be a brief overview on the injuries that occur in recreational SCUBA. Dr Simon Trepel is Psychiatry resident who will present two lectures- “Mefloquine and Madness” and “Fears in Travelers”. He will examine specific travel related problems from the perspective of a clinical psychiatrist. This will include a critical appraisal of the literature on such issues such as mefloquine-induced psychosis, traveller‟s culture shock and substance abuse among travelers. In

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researching psychiatry and travel we have found that although this subject has been spoken of lightly in the past there are many areas to explore in improving mental health in travellers. Simon will define these psychiatric issues for non-psychiatrists as well so that we all may communicate these important discoveries to our own patients.

Dr Richard Heyday is a Dermatologist practicing at the Winnipeg clinic and is an Associate Professor with the Faculty of Medicine, University of Manitoba. He has trained at the University of Manitoba for both his MD and BSc Med and has additionally trained in New York with specialization of a Diplomate of the American Board of Dermatology (DAB Derm) University Skin and Cancer 1980 and an FRCP at the University of Manitoba 1983 He will discuss Dermatological problems in Travelers and will include emphasis on skin cancers in travellers, tropical illnesses in travelers and fungal infections. He has lectured on this for our group in the past and will include updates on the new powerful immunolgic drugs that are now being used routinely to treat skin cancers. This aspect of medicine is still one of the most important and exciting topics for clinicians- to learn about a non-toxic effective treatment for some severe cancers. This topic gives hope to very ill people and has been enthusiastically received at a number of sessions by both clinicians and non-clinicians alike. Dr Terry Galloway is an Entomologist at the University of the Medicine. He has lectured to us several times and has always both entertained and informed us with accounts of the life of Insects. This year his talk will focus on Mosquitoes and he will also discuss the role mosquitoes played in the development of Malaria in the Dominican Republic this past winter. Dr Elsa Hui-Derksen is a practicing Dentist with the Cholakis Dental group. She will present “Dental Emergencies in the Wilderness” as well as help define important components of a dental emergency kit. Her colleague Dr Eric Parsons will also present his recent dental relief work in Haiti.

Dr Scott Clifford, Veterinarian was tentatively scheduled to speak on the Avian Flu, continuing his previous years lecture on Zoonoses. He had defined emerging zoonoses as more likely with the increased communication among previously isolated biovars that had increased speciation in the past. As these isolated plants, animals, bacteria and viruses were brought together new recognized human diseases emerge as zoonoses through chance jump to humans. Scott is unable to join us because of work commitments but we wish him the best. Dr Podolsky will talk on Avian Flu in relation to the common cold and other flus and will add recent updates from the Public Health Agency of Canada that were recently presented here in Winnipeg at the National Antiviral Meeting. Our Volunteers We have volunteers from both our local Nursing and Medical Schools that will be attending the conference. We believe that it is important to include them as part of our forum as they will have fresh perspectives on a variety of topics and have much to contribute. Delegates to our previous meeting might notice that some of the speakers this year were previously in the audience. We are always looking for new topics and new presenters and plan to rotate topics. We have done kept some lectures the same because there wide popularity but we plan on changing these as well. Special Thanks to Candace Corroll, Gail Oborne and Kyoung-Hee Lee for their help in organizing this conference.

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Feedback Please fill in the feedback questionnaires and remember to take your certificate of attendance. This meeting is eligible for up to eleven M2 medical credit hours for physician and 10.75 CEUs for pharmacists. Pharmacists may also receive special accreditation cards on request. We have tried to improve our meeting based on past feedback. This year we are having more formal meal breaks with a formal dinner and lunch set aside for our delegates to decompress. We will be providing our volunteers with question sheets so that anyone who wishes to ask a question. If in our question period we are unable to answer all questions we will have our faulty respond later. We are in the process of arranging two additional conferences that will expand on some of our present ideas. European Neurology Conference in Odessa, Ukraine April 20th,2004.. Dr Podolsky will be attending and intends to bring some donations of medications that he will personally deliver to registered medical organizations there. He has asked for any clinicians who have any medications or useful medical equipment to please contact him. He is unable to accept cash only medications. Arctic Medicine conference Oct 6,7,8,and 9 will take place on Thanksgiving weekend in Churchill Manitoba. This will involve 16 hrs of CME in the evenings. We have negotiated a group rate for accommodations that will also include a Tundra Buggy (Polar Bear Safari), Cultural program and a tour of Churchill- the Polar bear capital of the world. Delegates do not have to participate in any of the extra conference activities in order to attend our scientific meeting as our meeting is held separately and are welcome to stay at other accommodations. Our keynote lecturer is Dr James Wilkerson one of the founder of the sub discipline of Wilderness Medicine. Those who register before September first will also receive a signed copy of his book “Medicine for Mountaineers”. For those who cannot travel to Churchill a satellite symposium “Winter Sports Medicine” will be held in Winnipeg on October 5th, which will focus on more Sports medicine topics. For more information on both please see the page at the back of this manual. Advanced Wilderness Life Support is a new course that uses the ACLS and ATLS format. Dr Podolsky has recently been accredited as an instructor and may teach the course in Winnipeg. If interested please se him or one of our volunteers to go over the course. Our Tropical medicine Meeting in Havana, Cuba is currently scheduled for February 2006. We are awaiting finalization with the Cuban government. This is planned to be a 36-credit conference with emphasis on Tropical Medicine and topics relevant to Cuba. We will be selecting our lecturers from Winnipeg and also plan on working with local Cuban physicians where Canadian and International people will be able to observe how the Cuban medical system works. Our goal is that by more direct interaction we may be able to help our colleagues financially and also learn valuable insights from their Medical system. We are still working on our program. Please see our volunteers for any questions and to be put on our mailing address update.

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Women Traveller Scenarios
Candace Corroll When women are travelling they may experience unique gender specific problems due to their physical differences from men and due to social forces. The purpose of this session is to highlight common problems women may face and offer various solutions. Abby is a 22 year woman going to Korea to teach English as a Second Language. She is going alone, although she has some contact phone numbers of people from her organization. She has never travelled before. She is physically healthy and has received all her immunizations but wants to know if there is anything else she should do before she leaves. Abby has had a recent physical. She is sexually active but has not had a PAP test done recently. It is strongly recommended that she do so before she leaves. She is also taking the birth control pill and wishes to stay on it even though she will not have a current sexual partner. She was concerned about getting traveller‟s diarrhea or taking other medication (such as antibiotics) that would affect the effectiveness of the pill. Her doctor discussed the new Birth control Patch (Evra) which is put on the skin for 3 weeks of the month and is not affected by nausea or stomach upset which can happen with travellers diarrhea. Because she was going to be away for so long she was given information on how to find a doctor in Korea: www.istm.org (The International Society of Travel Medicine lists available clinics in many countries), www.iamat.com (International Association Medical Assistance to Travellers has a free list of Clinics that also agree to standardize their prices, www.voyage.gc.ca (gives a list of Canadian Embassies and Consuls that will not provide medical services but will give information).

Barbara is an 18-year-old mother of two twins age 8months. She is going to return to Ghana to visit her parents and show her children. Barbara wants to leave her 2 twins in Ghana for at least a year so she can finish her school. She wants them to receive all the immunizations they need including Yellow fever. Barbara was informed of the various vaccinations related to travel to Ghana for her 3-week trip. Based on what she will be doing it was recommended that she receive Tetanus-diptheria, Polio, Typhoid, Hepatitis A and B; and Yellow fever along with mefloquine for malaria. Her twins were healthy with 38-week gestation births now at 8 months of age with normal developmental milestones and no problems. They are under the care of a regular paediatrician. They are up to date on their regular childhood immunizations. It was recommended that they receive an early MMR vaccine (which does not actually count toward the recommended 12 month vaccination since circulating maternal antibodies may partially neutralize the MMR, yet this vaccine will cover them for their immediate trip. Twinrix Junior was recommended and started. The hepatitis B component is specifically emphasized for children visiting Developing countries or long periods, as a great burden of Hepatitis B is acquired from innocent activities- such as roughhousing with other Hep B positive children in routine play, or living in a household with Hep B. The Hep A component is normally recommended for children over 12 months but in this instant these children would be living long term in Ghana and not be breast fed so the doctor recommended this to them off label. They were too young for the typhoid vaccine or the multivalent (menomune) meningitis vaccine. Yellow fever is prohibited in children less than 9 months because of the risk of encephalitis yet these children would be at high risk of yellow fever in Ghana. Barbara was offered the choice of waiting for

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them to be a few months older and receiving it in Ghana versus receiving it just after their turning 9 months in Canada. She chose the latter. Lastly a 3-month supply of mefloquine was prescribed for each twin with instructions to continue antimalarial treatment after the children are reassessed in Ghana. Barbara was repeatedly cautioned of the importance of continuing an effective malaria treatment and to ensure that her Mother also continues this medication. Because of the children‟s likely weight gain over the next few months the doctor felt it would be harmful to recommend a static prescription without periodic reassessment. Barbara‟s twins were an extremely complicated case and all decisions were well discussed in detail. Cara is a 25-year old nurse who just returned from Hawaii. She went to a bar with her girlfriend and later woke up the next day alone in an empty house with her clothing missing. She realized that a man must have put something in her drink and has no memory of what had happened. This happened 2 weeks ago and she wants to be checked out. Despite what has happened to her she does not seem anxious or upset. At this point the chain of evidence is so weak that forensic evidence is difficult or impossible to establish. The main focus should be on Cara‟s health. Counselling by a nurse or doctor skilled in Rape management should be initiated. Blood tests for Syphilis, Hepatitis B, C and HIV were ordered. This case happened before routine use of post exposure antivirals was widespread. In this case it is probably too late to be of benefit (these medications have significant side effects as well) A proper gynacological exam was done with swabs for gonorrhea and chlamydia sent. After these were taken antibiotics were given to empirically treat for these conditions. Lastly Cara was examined for any other injuries. She was offered follow-up both for results as well as for further counselling. The police in Hawaii were notified and a bartender admits to having seen a man put a pill into her drink but did nothing. No charges were laid.

Dian is a backcountry camper and is going with some girlfriends to camp in Northern Thailand for two weeks. She would like to put together a first aid kit, which will include items for feminine problems. Dian is specifically asking for tests and medications to diagnose and treat bladder infections. A dipstick urinalysis was recommended with a prescription for Ciprofloxacin to treat any positive results. Two of Dian‟s friends are nurses and can do this easily. Dian‟s group are also all taking doxycline for antimalaria prevention but they know that doxycycline is associated with increased incidence of yeast infections. Additional items for their “female” first aid kit include canestin inserts and Diflucan (Fluconazole) pills. Ella age 26, is Dian’s friend and wants to go as well but just found out she is pregnant. Can she still go, and are all the medications recommended for Dian all right for Ella to take? Ella is healthy and is not having any problems with her pregnancy. It has been established that her pregnancy will be in the 2nd trimester during her trip to Thailand. Unfortunately she will be travelling to a very drug resistant malaria area. This area of Thailand is resistant to both Chloroquine and Mefloquine. She may not take Doxycline because this will stain childrens‟ teeth. The medication Malarone will work in that area but its safety in pregnancy has not yet been established. Malaria is often more severe in pregnant women. At present there is no good effective antimalarial for pregnant women going to this part

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of Thailand. Ella‟s situation highlights that many drugs or immunizations are different for pregnant women . The website www.motherrisk.com is very detailed in describing both theoretical and proven risks from medications and is a good resource. Fiona, Dian’s other friend just delivered her baby and wants to now take her 12-month old son with her. She wants advice for her and her baby. She was advised of the same vaccines and antimalarials as the others. Doxycline is not recommended for breast-feeding mothers. Motherisk was again consulted for each medication or drug. Fiona then decides that she will instead spend her vacation in Dominican Republic where she has heard there is a malaria drug that she may take. Fiona is informed that the vaccines commonly recommended for the Dominican Republic- tetanus diptheria and Hepatitis A are safe for her but she still needs to take an anti-malarial such as chloroquine or mefloquine and these do cross over into breast milk. However, her son is not protected by her breast milk and must take his own medication adjusted for his weight. Anti malarial drugs are not pediatric sized so Fiona may want to take the prescription to a compounding pharmacist to adjust for the proper dose. Her son is up to date on all his childhood vaccines including the newer pneumonia, varicella, and meningitis shots so the only vaccine he needs is the pediatric Hepatitis A vaccine. Lastly Fiona was counselled that even though her son is up to date on his basic childhood immunizations and has received both hepatitis A and appropriate malarial medication, travel is still difficult on the very young as their immune system are still immature. Fiona should be meticulous with hygiene and see a doctor promptly or any problems encountered by her son.. Geraldine is 83 and lives alone but enjoys going on trips by herself. She wants to go to Bhutan on a trek but her Daughter doesn’t think she should. They come in together and want to speak about what the actual risks are. Geraldine is taking medication to anticoagulate her blood, which has to be checked every day. Is there any compromise that can be reached so that Geraldine may still travel? Geraldine represents a small but growing type of adventure traveller- seniors who are now travelling to remote areas. Many of these trips are well organized but clinicians may be called upon to give a risk assessment. Traditionally this has been with regards to infectious diseases but now may include a fitness to travel assessment. It may be beyond the doctor or nurse to be able to assess all risks but we should be able to help establish some facts and allow the patient to make an informed decision. Geraldine has several medical problems, so it is recommended that she have a full medical exam by her family physician, making sure he knows what she will be doing. If she is going to a remote area she should have enough medications. The remoteness of her travel and failure to be able to be speedily evacuated must be understood. Portable Coagulocheks are now available for people on anticoagulants to be able to monitor themselves. (www.coaguchek.com) The proper risks are explained for Geraldine so that she can make an informed decision. On speaking with her and her daughter she appears competent and clear minded with no signs of Alzheimer‟s or other dementia, and the final decision will rest with her. Her daughter is still anxious but attending with her mother has helped her to articulate her concerns. At her insistence Geraldine has agreed to make sure her insurance will also cover Helicopter evacuation and Overseas Funeral arrangements. This has also led Geraldine to modify some of the more risky parts of her trip.

Helena came in with her husband 3months ago and received several immunizations. At the time she did not believe that she was pregnant, but has now found out that she is 4 months pregnant. She and her husband are very worried that her immunizations may have hurt their baby. Helena‟s vaccine record was reviewed. On the form she had checked off that she was not pregnant and had written the date of her last normal period, which is important for clinics to ask and document. 8

She had received tetanus-diptheria, inactivated polio, Hepatitis A and Hepatitis B, all of which are fine in pregnancy; but she also received the live MMR vaccine. The MMR vaccine would normally not be given, but this was recommended because she had never received it before and was going to an area of the world high in measles. It is well recognized that infection with measles, mumps, and rubella during pregnancy can cause birth defects. The MMR vaccine is attenuated but still not recommended for use in pregnant women. There are no documented fetal malformations caused by the MMR vaccine yet it is still not recommended for pregnant women. Women are advised not to conceive for 3 months after receiving the vaccine. This patient had also seen a Genetics counsellor to reassure them. The Geneticist who advised them of the likelihood of a normal birth (compared with baseline). The inadvertent use of MMR is not a reason for a therapeutic abortion. Iris is planning to go on a trip around the world with her partner Janice. They want to know what countries are friendly to Lesbian couples and if there is anything they need to know. At this point they do not know which countries they are going to yet. Many countries have different laws and beliefs with regards to open displays of homosexuality, so that assumed rights may be very different abroad. Open displays of sexuality may lead to prejudice and violence in some countries. The International Lesbian and Gay Association www.ilga.com has a data base of specific countries and their attitudes and can help travelers abroad. Kellie, a patient seen 6 months ago calls long distance from Suriname worried that she has caught an STD and might also be pregnant. She does not have any people she can talk to and doesn’t trust the local doctor. In this case we had Kellie check to see if she was pregnant as this is something that every doctor can easily diagnose all over the world. When it was established that she wasn‟t we gave her the contact number for the Canadian Embassy. They found her a gynecologist in the Capital. At first she did not want to pay extra to see him. We spoke with the Agency that sent her (while maintaining her anonymity) and we were ale to establish her insurance would cover this and rely this back to her. We stressed that several types of STDs may cause severe problems (infertility and Pelvic Inflammatory Disease) and must be treated. She agreed and was treated. If she was pregnant and wanted an abortion there is a serious exists concerns of unsafe back door abortion clinics. They still exist in many parts of the world. The Marie Stopes Foundation provides information about emergency contraception and abortion listed by country. (www.mariestopes.org.uk/abortion1icpd.html)

A Brief Outline of information for Women Travelers: Compiled by Candace Corroll and Dr Gary Podolsky Emergency Contraception Women travelling the world may become pregnant. Proper birth control methods, such as condoms or female condoms, should be arranged before you depart. Many countries do offer emergency contraception i.e.) the morning after pill. The consortium for emergency contraception website will give travelers up to date information about where they are going: http:/www.path.org/cec.htm Emergency contraception website: http://not-2-late.com Emergency contraception hotline: 1-888-NOT-2-LATE

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Women travelers, as with men, may acquire tropical infectious diseases and their treatments can significantly affect women. Often the complications and severity of tropical infections are worse for pregnant women.

Spermacides

Cap

Sponge

Diaphragm

Condoms Female Condoms

Male Condoms Latex

Lambskin/natural condoms Hormonal Methods Progesterone Pill

Contraception and Travel -easy to carry, can bring from home -long-term use may cause mucosal injury that may increase risk of HIV transmission. -needs to be fitted -can use up to 48hrs, but need practice in correct use -rubber may deteriorate in heat and humidity -protects for 24hrs and may be left in place for 6hrs after intercourse -one size, some types must be moistened with water, remove within 24-30 hrs to prevent Toxic Shock Syndrome -easy to use and carry -gives protection for 6hrs -needs fitting and use of extra spermacide with repeated intercourse -after use, leave in for 6hrs -use good grade -check for expiration date or poor quality -spermacide not required -one use only -may insert 8hrs prior -does not deteriorate in heat and humidity -possible allergy -some oil based lubricants destroy them -“male controlled” -may breakdown in heat and humidity -do not prevent viruses -may use if unable to take estrogen -take everyday at the same time -decrease menstrual cramps, less bleeding -can use when breastfeeding -useful for older women and smokers -may have irregular bleeding -does not prevent STD‟s -increase regularity of cycles -less blood loss, cramping -less pelvic inflammatory disease -can be used for emergency contraception (need special preparation and instructions) -should not take if at risk for blood clots -need to take every 24hrs -does not prevent STD‟s 10

Combined Pill (estrogen and progesterone)

-watch for drug interactions -intramuscular injection every 3months Side Effects Depo-Provera -weight gain -menstrual irregularities -acne -mood changes -decreased libido -good for women who can‟t take estrogen -no memory for daily pill required -capsule under skin giving progesterone Norplant Implant -implants difficult to remove -weight loss, acne -not recommended if; blood clots, liver tumors, breast cancer -long-term protection 3-5yrs -irregular bleeding or no bleeding -increased risk of infection at time of insertion IUD Three patches replaced weekly on, then one week off Estrogen Patch Isn‟t affected by diarrhea or antibiotics Ring with reservoir of estrogen fits around cervix Estrogen ring Isn‟t affected by diarrhea or antibiotics Many other different methods of contraception exist. For more information, check Maria Stopes International website: http://www.mariestopes.org.uk/abortion.html

Pregnant Travelers Travelling is discouraged if: -congenital or acquired heart disease -history of blood clots -severe anemia -chronic lung disease -obstetric risk factors If pregnant, all women should be assessed early in their pregnancy, prior to travelling. PAP tests for all women are also recommended to screen for cervical cancer. Immunizations During Pregnancy Vaccine Measles, Mumps, Rubella Polio Varicella Tetanus-diphtheria Influenza Meningitis Typhoid Hepatitis A Hepatitis B

Live or Not Live IPV (inactivated) Live Not Live Not Live Not Live Ty21a Live Typhim VI Not Live Not Live Not Live

Safe or Not Not Safe Safe Do Not Take Safe Recommended 2/3 trimester Safe but only if needed Not recommended Use if needed Safe Safe

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Japanese Encephalitis

Not Live

Tick Borne Encephalitis Lyme Disease Rabies Immune Globulin

Cholera

Not recommended in Canada Medications Safe for Pregnant and Lactating Women Medication Pregnancy Breastfeeding Tylenol (acetaminophen) Safe-low dose Safe Anti-inflammatory Drugs Safe in 1&2 trimester Safe (Ibuprofen, Motrin) Safe Safe Antibiotics (Amoxicillin, Zithromax) Cephalosporins Safe Safe Clindamycin oral or Avoid 1st trimester Safe vaginal Cloxacillin Safe Safe Doxycycline Can stain fetal teeth Not Safe Erythromycin Safe Safe Nitrofurantoin Safe-good for urinary tract Safe infections Septra Safe Safe Anti-diarrhea Medication Not Safe Not Safe Comotil Immodium Antacids Bismuth(pepto-bismol) H2 Blockers Cimetidine (Tagamet) Ramitidine (Zantac) Gravol Anti-nausea Accupressure Bands Non-pharmaceutical Ginger Meclizine Vitamin B6 (Pyridoxine) Milk of Magnesia Psyllium Safe Safe Not Safe Safe Safe Safe Safe Safe Not Safe Safe Safe Safe

Inactivated Vaccine no longer available Not Live Serums for: Snake/spider bites Diphtheria, Rabies, Hep B Rabies, Tetanus, Varicella Live

Side effects, not recommended unless high risk of infection Not recommended

Not unless high risk Only if high-risk

Safe Safe Safe Safe Small amounts safe Safe

Safe Safe Safe Safe Safe Safe

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Hemmorhoids- increase fibre and fluid in diet. -Anusol HC suppository safe-minimal use Upper Respiratory Infections: Antihistamines Benadryl Claritin Sudafed Saline Nasal Spray Topical nasal decongestants Nasal Steroids Inhaled Steroids Inhaled Ventolin Anti-Malarials Mefloquine Chloroquine Malarone (Avovaquone/Proguanil) Doxycycline Primaquine Halofantrine Proquanil Fansidar Quinine Azithromyacin Insect Repellents DEET Anti-parasites Albendazole Metronidazole Anti-virals Acyclovir Altitude Medication Acetazolamide (Diamox) Dexamethasome (Decadron) Calcuim Channel Blocker (Nifedipine XL) Water Purification Iodine

Safe-use caution Safe-use caution Not safe in 1st trimester Safe Safe Use if indicated Safe Safe Not safe in 1st trimester Not safe in 1st trimester

Not Safe Unknown Unknown Safe Safe Safe Safe Safe Safe-does not protect infant Safe-does not protect infant Unknown Not Safe Not Safe Not Safe Unknown Safe short term Unknown Unknown Safe Unsafe Use caution 1dose therapy and delay B/F 12-24hrs Safe Not Safe Not Safe Safe

Unknown Not Safe Not Safe Not Safe Safe-not effective as single Not Safe near term May cause severe Hypoglycemia Unknown Safe – sparingly Avoid 1st trimester Avoid 1st trimester

Safe if indicated Not safe in 1st trimester unless indicated Safe Only used to treat severe Pulmonary Anemia Not Safe

Not Safe

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Additional Website links for women: Office of Population Research Emergency Contraception -website with information on emergency contraception searchable by country.http://ec.princeton.edu/worldwide/default.asp Marie Stopes International-provides information about emergency contraception, abortion, and sexual health by country httpwww.mariestopes.org.uk/abortion.html .The Centre for Reproductive Law and Policy provides list of countries where abortion is legal and what restrictions exist. http:www.crlp.org/abortion1icpd.html WHO Gender and Health Technical Paper -article on gender and health. (use search engine as site frequently changes) http:www.who. int Organization of Tetrology Information Services For further information on drugs in pregnancy, see: http://orpheus.ucsd.edu/CTIS/index.html The Canadian Dept of Foreign Affairs Publication “On Your Own” specifically developed for Women travellers is available free from www.voyage.gc.ca. and is a handt resource for women travelers

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Suggestions For A Medical Kit For Women Travelers
Menstrual Supplies -calendar -supplies – pad, moist towelettes, plastic bags, PMS medication (Ibuprofen, Mefanamic acid) -medication for dysfunctional uterine bleeding -premarin -oral contraceptive pill -Ibuprofen Urinary Infections -Ciprofloxicin 500mg PO BID x 3 days (also good for traveler‟s diarrhea) -Macrobid 100mg PO BID x 7 days, if pregnant, urinary dipsticks Vaginitis -Yeast infection (PH paper<4.5 likely to be a yeast infection) -vaginal creams (Monostat) -oral medication (Diflucan 150mg) -mild soaps (Dove) -change of breathable clothing -Bacterial Vaginosis (PH paper >4.7) -metrogel cream, clindamycin cream, or metronidazole pills -Trichomonas (can be women diagnosed by woman herself) -metronidazole pill Contraception -chart to keep track of pills wrist watch timer to record when to take pills while crossing time zones -male/female condoms -spermacide -pregnancy test Emergency Contraception -can discuss with doctor how to use the morning after pill -available as Plan-B in Canada or use equivalent dose of birth control pills/ and gravol Post HIV Prophylaxis - if at high risk for unprotected sex. This can be very expensive and people often get sick from the medication. Use updated recommendations Pre-Menopause/Menopause -vaginal dryness (estrogen cream) -hot flashes -estrogen replacement -vitamin E -ClonidineOsteoporosis -calcium -vitamin D -Fosamax Pregnancy Supplies -blood pressure cuff with stethoscope -urine protein and glucose strips -leukocyte esterase strips -supplies for lactating mothers -breast pumps/pads -nipple cream Personal Safety -alarms -pepper spray -lessons in self-defense

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Appendix: Vaccines for Children Traveling Children travelling with their parents may need their vaccinations adjusted either because of the decreased availability of pediatric follow up where they are going, or because of the increased risk of diseases in areas they will be visiting.

Changes in Schedule for Routine Immunization due to Travel
Vaccine
DTaP - Diphtheria, Tetanus, Pertussis Hepatitis B (note: Hep B is given much earlier in the U.S than in Canada) MMR – Measles, Mumps, Rubella Polio

Age Routinely Given Accelerated Schedule
2,4,and 6 months Birth, 1, 6-12 months Grade 4 in Manitoba 6wks, 10wks, and 14wks 0,1 month, 2 months, booster12 months (Hep B is given much earlier in U.S than Canada. 6 months 6wks, 9wks,and 12 wks

12-15 months 2, 4, and 6 months

Note: When vaccines are given younger than routinely recommended or when vaccine intervals are shortened, vaccinations may need to be repeated at a later date. Special Notes on Immunizations for Children Cholera Vaccine – Is not recommended. The risk of Cholera to travelers is very low. Breastfeeding protects children. In older children close attention to food and water will help to protect them. Hepatitis A – is given to children over 1 yr old. (This is 2 years in the US literature) Breastfeeding protects small infants by way of passive immunoglobins from mothers‟ milk. (Immunoglobulin is now de-emphasized for children as the vaccine or mothers milk gives better protection. The immunoglobulin now in use contains less antibodies against Hepatitis A since this is reflective of current blood donors not having anti-hep A antibodies compared with prior generations.) Japanese Encephalitis Vaccine is given to children over 1yr old who are travelling to rural areas endemic with this infection during the peak transmission season. Japanese Encephalitis is recommended if persons are staying in areas near rice paddies or pig farms, where the risk of JEV mosquitoes is high. Rabies – Children may be more susceptible to rabid animal attacks than adults. Parents may consider this vaccine if their child is staying in a high-risk area for rabies. Typhoid – Breast fed infants are protected from this. For older children careful boiling or chlorinating water prevents this disease. The new injectable vaccine is given to children between ages 2-6. An oral typhoid vaccine is available for older children. Yellow Fever – Vaccination against this mosquito borne infection is required for travel to some countries. It is never recommended to children under 4 months, and only in exceptional circumstances for children 6-9 months. Infants greater than9 months may be vaccinated if they require it.

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Other Travel Concerns for Children
Diarrhea – No good vaccine exists yet but Pepto-bismol can also be given for children to prevent traveller‟s diarrhea. Pepto-Bismol Preventative-Treatment, to be started on the day of travel and up to 3 weeks. This will decrease traveler‟s diarrhea by 50%. Children may take Pepto-Bismol providing they have no allergy to ASA AGE DOSE 7-12 yrs 2tbs (30ml) 9-12 yrs 1tbs (15ml) 6-9 yrs 2tsp (10ml) 3-6 yrs 1tsp (5ml) 0-3 yrs ½ tsp (2.5ml) Each dose may be taken every 4 times per day Children and Bugs – Preventing insect bites is very important in preventing many diseases. The following are recommended: 1. Placing nets over baby carriages and cribs 2. Eliminating standing water around living quarters 3. Stay inside between dusk and dawn. 4. Dress children carefully in long sleeved clothing over neck, wrists, and ankles 5. Not allowing children to go barefoot 6. Cover skin with DEET 20-30% - This is higher than what many others recommend. DEET is safe to use on children when used correctly. Apply on exposed skin, but not on irritated skin and wash it off after use. 7. Use a flying insect spray in living and sleeping quarters 8. Sleep in an air-conditioned area when possible Malaria Medication and Children Children are very susceptible to malaria and over 2 million die of it each year. Chloroquine is safe and well tolerated but has a bitter taste. Eating adult strength doses can harm children. Chloroquine should be kept in a safe place away from children. Mefloquine (Larium) Is very safe in children. Neurological agitation from mefloquine is not seen in children as with some adults. Malarone is a new medication and is more expensive. It is taken daily according to weight. WEIGHT DOSE 10-20 kg 1 Pediatric strength tablet 21-30 kg 2 Pediatric strength tablet 31-40 kg 3 Pediatric strength tablet 40+ kg 1 Adult strength tablet Doxycycline is safe for 9+yrs. And is safe in lactating mothers, but not in pregnant mothers.

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Adolescent Health Visits Infant and childhood vaccinations have greatly decreased the incidence of many childhood infections. Teens and young adults still remain susceptible to vaccine preventable diseases like Hepatitis A and B, Measles, Mumps, and Rubella. In order to protect young adults and teens an adolescent health visit is recommended at age 11 or 12. This is a good opportunity for parents and their family doctor to discuss the recommended vaccines and decide what immunizations their child needs. This visit can also affirm the adolescent‟s comfort level with attending the doctor‟s office in the future.

Immunizations Required For Adolescents
Hepatitis B -Should be considered if never received. At present this is at patients cost unless attending the grade 4 school schedule. Hepatitis B is so far the only vaccine against a sexually transmitted disease. nd MMR-Measles, Mumps, Rubella -A 2 dose is recommended if not previously given. Td-Tetanus-Diphtheria Booster -the only regular vaccine that requires boosting throughout adulthood Note: aP Acellular pertussis was recently added to the Td Varicella -If no prior immunization or history of the disease. A simple blood test can check if the person has had a previous asymptomatic infection and subsequent immunity. -This is an optional vaccine but may be recommended for Hepatitis A people planning to work in health care, daycare, or will be doing international travel

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The Pharmacology of Travel Health Medicine Jacinda Wagner BscH(biology), Bsc(Pharm) Introduction
Medications to prevent travel related illnesses are becoming more commonly prescribed. This talk will discuss medications and vaccines and their methods of action. Important contraindications and interactions with other medications will be discussed.

I. Hepatitis A
- An infectious virus that causes inflammation of the liver - Transmission occurs via contaminated food or water - Individual presents with nausea, vomiting, diarrhea and fever - Active disease may last up-to 12 weeks with some developing jaundice +/- proving fatal - Vaccination is available: Havrix, Avaxim, Vaqta, and Twinrix A. Havrix 1440 (18yrs +), Havrix 720 (2-18 yrs), Vaqta, Avaxim 1. Dose and schedule - Initial dose at day 1 provides immunity up-to 12 months - Booster dose between 6 & 18 months after initial dose may provide immunity up-to 10 yrs + - Shake vial well prior to IM administration into deltoid (avoid gluteal region due to sub-optimal response as it deposits into fat tissue rather than muscle) 2. Precautions - Consider delaying administration in those who present with acute febrile illness - Use with precaution in those with thrombocytopenia or bleeding disorders due to risk of bleeding following IM injection - Those with immunodeficiency, receiving radiation therapy or taking high dose Corticosteroids may have a dampened immune response to vaccination and thus require additional doses to achieve immunity 3. Contraindications - Because Havrix may contain trace amounts of neomycin, individuals with allergies to this substance - Relative contraindication: consider delaying administration in those who present with acute febrile illness 4. Drug interactions - Since these are inactivated vaccines, concomitant administration with other inactive vaccines is generally unlikely to cause interference with the immune response Note: Havrix, Vaqta and Avaxim are considered interchangeable and equal B. Twinrix (18 yrs +), Twinrix jr (2-18 yrs) - When administered appropriately, provides immunity against hepatitis A and B - since hepatitis D does not tend to occur in the absence of the hepatitis B virus, it is thought, in theory, twinrix should - protect against hepatitis A, B, and D 1. Dose and schedule nd -Traditionally a 3 dose schedule with the 2 dose a minimum of 4 weeks after the initial dose rd and the 3 dose 6 months after the initial dose. nd - Dose 1 gives some protection, but needs a 2 dose which gives up-to 12 months of immunity, and a third scheduled dose gives prolonged protection of 10-20 yrs + for hepatitis B and ~10-20 yrs for hepatitis A 2. Precautions - Consider delaying administration in those who present with acute febrile illness

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- Use with precaution in those with thrombocytopenia or bleeding disorders due to risk of bleeding following IM injection - Those with immunodeficiency, receiving radiation therapy or taking high dose Corticosteroids may have a dampened immune response to vaccination and thus require additional doses to achieve immunity 3. Contraindications - Relative contraindication: consider delaying administration in those who present with acute febrile illness 4.Drug interactions - since this is an inactivated vaccine, concomitant administration with other inactive vaccines is generally unlikely to cause interference with the immune response

II. Hepatitis B
- An infectious inflammation of the liver, which may progress into chronic liver disease or liver cancer - Individual presents with nausea, vomiting diarrhea, fever +/- yellowing of the skin, abdominal pain and anorexia - Transmission occurs via contaminated bodily fluids A. Engerix B 1mL (adults) and 0.5 mL (jr £ 19 yrs) and Recombivax HB 1. Dose and schedule - Canadian pediatric society recommends routine vaccination of all infants; this is just a recommendation not a guarantee & so Inquire! - Traditionally patient receives 2nd dose 1 month after the first, and the 3rd dose 6 months after the first - Doses should be separated by a minimum of 4 weeks -Shake vial gently prior to administration - An accelerated induction may be achieved by dosing at 0, 1 and 2 months with a 4th dose 12 months after the first for those who desire prolonged protection - A rapid induction at 0, 7, and 21 days (adults only) is currently used for those previously non-vaccinated individuals being vaccinated within 1 month prior to intended travel (last minute planners!) The 1st 3 doses in this schedule provide immunity for up-to 12 months, while a 4th dose may provide prolonged immunity up-to 10-20 yrs + - Intended for IM injection into deltoid region - Avoid gluteal region due to sub optimal immune response when vaccine deposits into fatty tissue rather than muscle - Infants and newborns should receive IM injection into their anterolateral region due to the small size of their deltoids. - in special circumstances SC injection may be administered for those with severe bleeding disorders 2. Precautions - ?????speculation that immune response to Hepatitis B vaccination may be reduced in those > 40 years of age???????? - Use with precaution in those with thrombocytopenia or bleeding disorders due to risk of bleeding following IM injection - Those with immunodeficiency, receiving radiation therapy or taking high dose Corticosteroids may have a dampened immune response to vaccination and thus require additional doses to achieve immunity - A preservative (thimersol) free product is available and recommended for newborns and infants 3. Contraindications - Hypersensitivity or allergies to yeast and /or other components of the vaccine - Relative contraindication: consider delaying administration in those who present with acute febrile illness

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4. Drug interactions - since these are inactivated vaccines, concomitant administration with other inactive vaccines is generally unlikely to cause interference with the immune response Note: Engerix B and Recombivax are considered equal and interchangeable III. Traveler‟s Diarrhea - Advise your patients to take necessary precautions "cook it, peel it, boil it or forget it" - Drink bottled water - Avoid raw eggs, meat and fish - Avoid milk or milk products (uncertain about pasteurization practices) - Eat items off menus in restaurants - Eat foods that physically hot - Wash foods with iodinated water - Wash your hands frequently A. Pepto Bismol - Bismuth 1. Dose and schedule Prevention - starting 1 to 2 days before traveling and continue up-to 2 weeks 0-3 yrs ½ tsp (2.5 mLs) QID* 3-6 yrs 1 tsp (5 mLs) QID* 6-9 yrs 2 tsp (10 mLs) QID* 9-12 yrs 1 tbsp (15 mLs) QID* Adults 2 tablets QID* * Regular strength liquid and tablets Treatment - Pepto Bismol may be used for mild symptoms but antibiotics are recommended for short-term treatment 0-3 yrs ½ tsp (2.5 mLs) q 30-60 minutes Maximum 20mL/24 hours 3-6 yrs 1 tsp (5 mLs) q 30-60 minutes Maximum 40mL/24 hours 6-9 yrs 2 tsp (10 mLs) q 30-60 minutes Maximum 80mL/24 hours 9-12 yrs 1 tbsp (15 mLs) q 30-60 minutes Maximum 120mL/24 hours Adults 2 tablet q 30-60 minutes maximum 8 tablets/24 hours 2. Precautions - Salicylates should be used with caution in those less than 18-21 years of age due to the risk of Reye‟s Syndrome especially in the presence of a viral infection (which may be silently present!) - Due to its salicylate nature Pepto Bismol should be avoided during pregnancy, there are enough treatment alternatives available that its use need not be contemplated. - Use with caution in those with a history of GI bleeds - Black tongue is likely with prolonged use 3. Contraindications - Avoid in active GI bleed - Avoid in ASA allergy - Avoid in 3rd trimester of pregnancy (preferred that its use be avoided all together during pregnancy) - Avoid in hemophiliacs 4. Drug interactions - Warfarin (due to increased effect of anti-coagulant) - Acetazolamide (due to increased effect of cationic anhydrase inhibitor) - Ciprofloxacin, tetracycline, doxycycline, levofloxacin (due to the formation of non-absorbable complexes) - Prednisone (due to decreased effect of salicylate)

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B. Septra - Sulfamethoxazole + trimethoprim 1. Prevention - prophylactic antibiotics are not recommended except occasionally in highrisk individuals (people with compromised immune function &/or disorders of the digestive tract) Treatment- worldwide misuse and overuse has led to worldwide resistance 2. Precautions - Worldwide resistance, not drug of choice anymore - Use with caution in those with blood dyscrasia (avoid if possible) - Photosensitivity - Requires plenty of water with use therefore have to consider the availability of noncontaminated water - G6PD deficiency (avoid if possible) - Caution in hepatic insufficiency and alcoholism due to risk of liver toxicity and disulfiram reaction 3. Contraindications - Sulfa allergies - Avoid in 3rd trimester of pregnancy especially the last 2 weeks prior to anticipated delivery date due to risk of kernicterus 4. Drug interactions - Warfarin may risk of increase effect of anticoagulant? C. Ciprofloxacin 1. Dose and schedule Treatment dose: 500 mg BID x 3 days Or 1000 mg (one dose) 2. Precautions - Not recommended in those 15 years of age or younger or during pregnancy -(potential damage in bone/joint formation) 3. Contraindication allergy to cipro 4. Drug interactions - Warfarin (increased anticoagulant effect) calcium, aluminum, magnesium, iron, and zinc may form insoluble, non-absorbable complexes and potentially rendering ciprofloxacin inactive) D. Azithromycin (Zithromax) 1. Dose and schedule Treatment dose: Adults 500mg once daily x 3 days Children 10mg/kg/24 hours x 3 days Pregnant women 500mg once daily x 3day 2. Precautions Since the major route of elimination for azithromycin is via the liver, precaution should be adhered to in the case of significant hepatic disease/disorder 3. Contraindications Those having known hypersensitivity or allergic reaction to the erythromycin family or macrolide antibiotics

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4. Drug Interactions - Antacids, dairy and other products containing calcium, magnesium, aluminum, iron and zinc should not be administered simultaneously with this agent due to the risk of formation of nonabsorbable complexes. Note: treatment antibiotics should show optimal results and significantly decrease symptoms within the first 24-48 hours but if the individual is still sick after 2 to 3 days he/she should contact the nearest Canadian embassy and get their assistance in finding medical attention locally E. Loperamide 2mg (Immodium) 1. Dose and schedule - Treatment dose: (adults) 2 tablets at onset then 1 tablet after each substantial loose bowel movement to a maximum of 8 tablets in a 24-hour period (children) routine use not recommended but for acute diarrhea in 1st 24 hours (maintain hydration!!!!) -2 to 5 yrs (10 to 20 kg) 1mg TID (3 mg daily dose) -6 to 8 yrs (20 to 30 kg) 2 mg BID (4 mg daily dose) -8 to 12 yrs (> 30 kg) 2 mg TID (6 mg daily dose) 2. Precautions -Exceeding the maximum recommended dose of 16mg/24 hours could bring about rebound constipation - Ensure proper hydration, replacing electrolytes if the problem persists beyond the first 24 hours, showing no signs of improvement despite treatment - Use with caution in the case of hepatic insufficiency 3. Contraindications - Avoid its use in those in whom constipation must be avoided - Avoid in the case where blood, mucous and/or fever accompanies stool - Avoid in psuedomembranous colitis - Avoid in shigellosis 4. Drug interactions - None mentionable

IV.

Malaria

- A disease caused by a parasite and spread through the bite of an infected mosquito - Initial symptoms are minor and flu-like and can go on to result in severe complications such as respiratory and kidney failure, liver problems, anemia and even prove fatal - It is always better to prevent than treat when you consider the long-term consequences of malaria A. Chloroquine - The drug of choice in chloroquine sensitive areas - Available in tablet form for adults and can be compounded into a weight based suspension and flavored to taste for children and infants - Suitable in pregnancy and “for all ages” but over-doses are frequently fatal so verify the dose if uncertain - Symptoms of overdose may include headache, drowsiness, visual disturbances, CV collapse, seizures, respiratory and cardiac arrest - Acidification of the urine enhances its elimination 1. Dose and schedule (Prevention) (adults) 500mg/week* (on the same day each week) (children) 8.3mg/kg/week* *Doses are expressed in terms of the chloroquine phosphate salt (250mg of the phosphate salt = 150mg base and either can be used in the compounding of tailored doses) - Dosing should begin 1 week prior to intended departure to the malarious area and continue weekly while in the malarious area and for 4 consecutive weeks after departing from the malarious area.

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2. Precautions - Get the advise of a travel health expert based on each individuals travel itinerary and medical history to determine the most appropriate anti-malarial to use - Appears to be a safe choice in pregnancy and while breast-feeding (keep in mind that although considered safe during breast-feeding, maternal administration does not protect the suckling infant) - Take with food - Bitter to taste - May cause discoloration of urine - May cause reversible yellowish corneal deposit in prolonged use (i.e. long term trip) - Avoid taking antacids at the same dosing time as chloroquine - Use with caution in the case of alcoholism - May? Exacerbate symptoms of psoriasis - May cause photo-sensitivity 3. Contraindications - Allergies to chloroquine, hydroxy-chloroquine or primaquine - Avoid in dialysis (hemo and peritoneal) 4. Drug interactions - Methotrexate, as it may reduce the efficacy of methotrexate temporarily - Cyclosporin, as it may increase the blood concentrations of cyclosporin requiring temporary dosage reduction during such co-administration - Chlorpromazine, as it may increase the blood concentration of chlorpromazine thus requiring close monitoring for signs of increased neuroleptic effects B. Hydroxy-chloroquine (Plaquenil) - Traditionally used for arthritis but may be indicated as an anti-malarial 1. Dose and schedule (prevention) - Prevention (adults) 400mg/week# (pediatric/children) 6.5mg/kg/week# - Starting 2 weeks prior to travel, continuing while in malarious area and for 8 consecutive weeks after leaving malarious area # Doses are expressed in terms of the hydroxy-chloroquine sulfate salt (200mg sulfate salt = 155 mg base) 2. Precautions - Since related to chloroquine, it is extrapolated that hydroxy-chloroquine is safe for use during pregnancy although its actual safety is unknown - Its appear to be safe for use while breast-feeding due to lack of evidence suggesting otherwise but benefit must always outweigh possible risk in terms of both pregnancy and breast-feeding when it comes to the use of chemicals and drugs - Bitter to taste - May cause reversible yellowish corneal deposit in prolonged use (i.e. long term trip) - Avoid taking antacids at the same dosing time as hydroxy-chloroquine - Use with caution in the case of alcoholism - May? Exacerbate symptoms of psoriasis - May cause photo-sensitivity - Take with food 3. Contraindication - Pre-existing retinopathy of the eye 4. Drug interactions - Concomitant use with digoxin therapy may result in elevated serum digoxin levels thus necessitating the close monitoring of patients receiving both; watch for signs of nausea, vomiting, anorexia, visual disturbance (unfortunately arrhythmias may be the first recognized sign)

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C. Mefloquine (Larium) 1. Dose and schedule (prevention) - Adults and pediatric patients > 45kg - 1 tablet at least 1 week prior to travel to malarious area - 1 tablet once weekly (on same day of the week) while in malarias area - 1 tablet once weekly for 4 weeks after leaving malarious area - > 30kg to 45kg - ¾ of a 250mg tablet = 187.5mg - > 20kg to 30kg - ½ of a 250mg tablet = 125mg - 5kg to 20kg - ¼ of a 250mg tablet = 62.5mg 2. Precautions - May want to limit or avoid activity that requires mental alertness or fine motor control - Use with caution in those with cardiac conduction disorders, mild anxiety disorders or seizure disorders or tendencies - May use during pregnancy and breast-feeding but does not protect the infant (some suggest that its use be postponed until after 16 weeks of pregnancy due to lack of studies revolving around teratogenicity) 3. Contraindications - Concomitant administration of Mefloquine with quinine, quinidine, chloroquine or antiepileptics may increase the risk of convulsions and minimize seizure control, respectively - In patients with unstable psychiatric disturbances or overt, uncontrolled anxiety alternative suggestions should be considered 4. Drug interactions - None mentionable (see precautions and contraindications) D. Doxycycline (Vibramycin) 1. Dose and schedule (prevention) (adults) 100mg daily (children 9yrs +) 2mg/kg daily (maximum daily 100mg) - Starting 2 days prior to intended travel, while in malarias area and continue for 4 consecutive weeks after leaving malarious area 2. Precautions - Not recommended in pregnancy, especially beyond 14 weeks gestation week the fetus‟ teeth are scheduled to begin calcification process - Classified as a code D in pregnancy by Briggs: Drugs in Pregnancy and Lactation - Little to no evidence of harm to a breast-fed infant - Overall recommend avoidance during pregnancy - Photo-sensitivity - Avoid use in children < 9 yrs due to increased risk of permanent tooth discoloration - Women prone to yeast infection while on antibiotic treatment should make typical lifestyle/dietary modifications while on antibiotic treatment (i.e. yogurt acidophilus/lactobacillus) 3. Contraindications - Individuals with hepatic or renal insufficiency - Allergy to tetracyclines 4. Drug interactions - Concomitant use with digoxin therapy may result in elevated serum digoxin levels thus necessitating the close monitoring of patients receiving both; watch for signs of nausea, vomiting, anorexia, visual disturbance (unfortunately arrhythmias may be the first recognized sign) - Antacids, dairy and other products containing calcium, magnesium, aluminum, iron and zinc should not be administered simultaneously with this agent due to the risk of formation of nonabsorbable complexes.

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- ~Birth control, women who rely on the oral contraceptive may and should practice an alternate means of protection while using antibiotics in general E. Atovaquone and proquanil (Malarone) 1. Dose and schedule - Adults 1 tablet daily starting 2 days before intended travel, continue daily while on trip and for an additional 7 days upon leaving malarious area 2. Precautions - Use with caution in those with a history of uncontrolled psychiatric disorder(s) or epilepsy -Little to no evidence surrounding its use in pregnancy or lactation (clinician and travel health expert should determine its need based on the potential risk vs. benefit in each individual case 3. Contraindications - Still fairly new medicine, none mentionable 4. Drug interactions - Avoid administration with other anti-malarial medications V. Altitude Illness prevention Medicine A. Acetazolamide (Diamox) - Aids the acclimation process when used in conjunction with safe acclimation practices 1. Dose and schedule (adults) 125 mg (1/2 of a 250mg tablet) twice daily starting 1 day prior to climbing and continuing for ~ 3days 2. Precautions - Best to avoid during pregnancy and breast-feeding (risk and tolerance is unknown) - Common side effects (> 10%) include diarrhea, generalized malaise, increase volume (dehydration?), muscle weakness and nausea 3. Contraindications - Avoid in those with known sulfonamide allergies (may be beneficial to look into nature of such allergies given that acetazolamide is one of the only options here) 4. Drug interactions - Salicylates tend to increase the effect of the carbonic anhydrase inhibitor B. Dexamethasone (Decadron) 1. Dose and schedule (Adult) 4mg every 6 (~12) hours - Possibly given in the case of allergy to acetazolamide - Mainly reserved for rescue efforts to dampen the symptom when altitude gets the best of a climber, thus buying time in the rescue attempt -OR in those well trained individuals who cannot take acetazolamide but must ascend quickly - Be very careful of this drugs ability to quickly wear off leaving the individual with the risk of rebound altitude sickness symptoms C. Viagra (Sildenafil) and Cialis (tadalafil) - ?may improve blood flow when pulmonary edema is a threat? Summary Many of the immunizations and medications mentioned today may be novel for pharmacists and doctors but are becoming more frequently prescribed with newer products being developed. Understanding their mode of action will help avoid ineffective doses, conflicts with other medications and contraindications with specific diseases.

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References: •Grabenstein JD ImmunoFacts: Vaccines and Immunologic Drugs St.Louis, MO: Wolters Kluwer Health, Inc.; 2005 •CPS 2004 •http://7005/hw_vigilance_monograph •Dr. Gary Podolsky M.D.(personal communications)

Pharmacology Scenarios Jacinda Wagner Sarah and John and their 6-year-old son Arnold are going to the Dominican Republic. Their doctor has prescribed 500mg of Chloroquine per week for each adult and 165mg for their 20kg son. On checking at the pharmacy none of those doses exist. What should they do? Chloroquine (Aralen) has traditionally been prescribed as 300mg base or as 500mg chloroquine phosphate salt. In this case we are referring to the salt, which is the most common designation although the old notation may persist. In Canada, Chloroquine comes as a 250mg salt dose, so each adult will require 2 pills per week starting one week before exposure, and continued every week of their trip and for 4 weeks post trip. Arnold will need 8.3mg/kg salt once weekly. A 250mg tablet may be scored into quarters of 62.5 mg but for lower doses having a compounding pharmacist prepare exact doses is preferable. Chloroquine also has a very bitter taste. Edmund is going mountain climbing and has been prescribed Acetazolamide (diamox) for the prevention of altitude illness but his pharmacist has noted a previous allergy to sulpha drugs. What should be done? First it would be best to find out what the previous allergy was and to what drug. Distinguishing a mild rash from a full-blown severe anaphylactic or Stevens Johnson Syndrome due to a sulphonamide drug is essential. Acetazolamide contains a sulfaryl group, which is distinct from a sulphonamide group. In the history of only a mild rash the Acetazolamide may be given however caution must be used when severe reactions had occurred in the past however unlikely. Given enough time a referral to an allergist could be arranged but this is unlikely to be practical. If Edmund urgently needs Acetazolamide a trial dose may be tried at home prior to departing on his trip.

Mrs Smith is leaving to go to Guatemala in 2 weeks and has a history of Psoriasis and is on metaprolol, a beta-blocker, digitalis and adalat. Are antimalarials safe for her? Chloroquine should not be prescribed for those with psoriasis. Mefloquine should not be used in those with heart conduction (it is not the beta blocker that is a contraindication but the underlying heart conduction defect), nor for those with underlying anxiety or depression. Doxycycline or Malarone would be good choices. Guatemala malaria strains are chloroquine sensitive all of the above medications are suitable choices provided the individual has no contraindications or medication interactions with the medications.

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Mary wants to know the differences between the typhoid oral vaccine (Vivotif-ty21a, Berna) and injectable typhoid (typhim vi, Aventis; Typherix, Glaxo). Both brands of the injectable typhoid vaccines are inactivated and give protection for 3 years. They are much less side effects from modern typhoid injectable vaccines than from the injectable typhoid vaccines of the 70s that required 3 weekly injections and were painful. Injectable vaccine may be safely given to children, HIV infected individuals and to pregnant women. The ty21 vaccine (vivotif) is a live attenuated oral vaccine taken in 4 dosed at 0,2,4,and 6 days and should not be taken by anyone whom a live vaccine could be unhealthy (such as pregnant women, AIDS patients). Some questions about the vaccine may be found at www.bernaproducts.com/abt_faq.cfm Can Alcohol be taken with the oral dose? Alcohol should not be taken for 1 hour after the vaccine is given as this may dissolve the capsule in the stomach not in the intestine where it is absorbed effectively. Can the capsule be opened up instead of swallowed whole? No the capsule must be taken whole so it is absorbed correctly in small intestine.. What happens if I miss a dose of Vivotif? If 3 doses are taken properly a delay of up to 72hrs is acceptable. If 2 doses are taken properly a delay of 24-48 hrs for the 3rd dose is ok but the 4th dose must be taken 2 days later.

If only one dose was taken, the course should be discontinued and the 4 capsule series must be restarted. Vivotif is the one exception to the general rule about immunizations that normally it is acceptable to allow extra time may pass between vaccination doses without penalty and without one having to restart the series.

Are Antibiotics all right to take with Vivotif? No, they kill off the attenuated typhoid

Are antimalarials all right to use at the concurrently with the oral typhoid? Both chloroquine and mefloquine may be used with no interaction with oral typhoid. Doxycycline is an antibiotic and will kill off the attenuated typhoid oral vaccine. Malarone should not be used until 10 days after vivotif is given for a theoretical interaction A client asks about the use of antibiotics to stop travelers’ diarrhea. Do they still recommend this? Current evidence supports that antibiotics do help with Traveller‟s diarrhea Antibiotics are no longer recommended to be taken prophylactically (that is before getting sick) as this increases bacterial resistance and increases side effects. Pepto-bismol taken at 2 pills four times daily will decrease the risk of traveller‟s diarrhea by 50% and may be used for up to 3 weeks.

Antibiotics are now recommended to be taken at the onset of symptoms. Septra was previously widely used but now has worldwide resistance and is no longer effective.

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Instead a broad-spectrum fluoroquinolone such as Ciprofloxacin will be helpful at 500mg po bid for up to 3 days. This will work against enteric bacteria that cause travellers diarrhea. It will of course not kill viruses and parasites. Recently Captylobacter bacteria in Cambodia have resistance to Ciprofloxacin.. Pregnant women and children under 15 may use Azithromycin instead of Ciprofloxacin.

A new antibiotic Rifaximin (Xifaxan) has been developed but is not yet available in Canada. It may perhaps replace Ciprofloxacin, as it may be more effective and safer for pregnant women.

Eve has called the pharmacy asking for Ledum Palustre or Malaria 0fficinalis to prevent malaria on the advice of a homeopathic website. She can buy these products through the site but wants to know if the pharmacy is cheaper. A recent review of homeopathic medication for the prevention and treatment of malaria did not find these preparations to be helpful (British Medical Journal http:bmj.bmjjournals.com/cgi/content/full/321/7271/1288/a). At present the CDC, Health Canada and WHO have not authorized any homeopathic product for use in the prevention of malaria. One new natural product of interest is the Chinese shrub Artisinea that is a very good antimalarial. It is beginning to be marketed in North America and is use in other parts of the world.

Examining the Anti-Vaccination Movement Gary Podolsky MD There are many people who do not believe in Immunization in Manitoba. One may chose several reasons to reject a treatment such as immunization either for themselves or their children. In Manitoba it is legal for parents to opt their children out of the Public Vaccination program prior to entering school. Professional health colleges in Manitoba do require specific vaccines for entry, which are a reflection of the WRHA, National Advisory Committee on Immunization, Heath Canada, and CDC guidelines. We live in a society that permits a plurality of views regarding religion, politics and other freedoms. It is important to preserve peoples right to make informed decisions regarding their health. But it is also important that they receive the correct information and are not over influenced from either the pharmacology industry or special interest groups with evidence that is not scientifically valid. Anti-vaccinationists lobbyists rarely define themselves as “Anti-vaccinationists” as this has a distinct negative image. Instead titles such as “Concerned Parents for Immunizations” and the “Eagle Foundation” are used to connect themselves as a positive group seeking to disassemble a corrupt medical establishment. They present themselves as a group seeking balance but do not provide information that is in anyway provaccine so describing them as antivaccinationists is still true. Public Health Groups have encountered this problem and tend to respond in one of two ways passively or aggressively.

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Passive Approach A passive approach is often taken, giving the critics of vaccines equal time in forums with the intention to not escalate confrontations (adding fuel to the fire). This approach is deeply flawed when it confers approval of unsubstantiated alternative health care philosophies and does not actual address gross inaccuracies in the attacks on vaccines. At a recent public health exhibition on immunization in 2002 a forum was held, open to the public. The event was well publicized and speakers included Paediatricians, Victims of polio, and other Physicians from public health that spoke on a variety of issues all promoting vaccinations. Members of Winnipeg‟s Anti-immunization group arrived near the end and began distributing their own literature (theirs was free while parents would have to pay approximately $25 for the Health Canada Publication directed at parents) One prominent Chiropractor then made the claim that immunization with H Influenza clearly causes diabetes. He was allowed to continue making several erroneous attacks all unchallenged while all of the Public Health doctors stood by and allowed the parents in the audience to accept this. I spoke to one of the Health officers and she steadily maintained that everyone was entitled to their opinion even in the face of my protestations that Public Health had paid and organized the event to educate the public. A poll was taken at the end and less than half of the parents present claimed they would vaccinate their children based on what was said that day.
An active approach to antivaccinationism has been perceived by some as to brutal, a very characteristic arrogance of a medical elite dictating what people should have while this elite authority ignores mounting unsafety of immunizations. This perception is often true of medicine. Although an education campaign may be won in the short term (forcing meningitis vaccines on High School students) long term distrust of Public health may persist.

Over belief in medicine can also approach an irrational fanaticism similar to that of vaccine critics with both sides ignoring each other‟s evidence. By dismissing critics of immunization too quickly and ignoring that there are limitations to immunizations proponents of immunization programs may lose their arguments as well.
It is necessary to promote immunization in a positive way that is open to examination and critiscm especially since cost is an important consideration. Several medical interventions including drugs and vaccines were previously thought to be very safe but later were withdrawn. If we depend too much on the integrity on any specific intervention we may be inevitably be let down such as in the recent case of Vioxx. As Health Professionals and Consumers it is important to maintain a healthy level of critical thinking and be prepared to adjust our practices according to the best evidence available. At present the best evidence is that most vaccines are a good idea. In the remainder of this talk I will emphasize key points about vaccinations I wish to communicate to other Health care Professionals and People in Manitoba. For the remainder of this article I would like to avoid labelling any individuals as Anti-vaccinationists as this term is a broad classification that covers many heterogeneous individuals with a variety of beliefs regarding vaccines. Antivaccinationism as a philosophy or set of beliefs may be better dealt with than attacking a set of individuals with those beliefs. People who have been misinformed or have an incomplete understanding of the science of immunization are good candidates to spend extra time explaining immunization with. By correcting misunderstanding these people may come to accept immunization on their own terms without being bullied or cajoled.

Debating Antivaccinationism
Antivaccinationism Activists who pursue an agenda against public health and the widespread use of immunizations are less likely to be reasoned with. Time should not be spent on debates where the rules and conduct are similar to brawls in the street. Debates with defined rules and equal time to both sides have been held

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between both groups with the provaccination group usually coming out ahead. In venues controlled by critics of immunization such as at Alternative Health Fairs debates are usually of poorer quality since a debater may be more easily shouted down or given ridiculous evidence they may not be able to refute or contest. Clinicians focusing on educating the public and individual patients should focus on well-established facts on the benefits of immunization. The limitations that vaccines have should be openly admitted and discussed. Side effects are infrequent and often only trivial but transparency in the surveillance and reporting of any perceived side effects must be maintained.

Immunization Questions continue after the vaccine is administered
Our clinic tends to insist on a face-to-face review of perceived vaccine side effects. This will reassure patients and has the added benefit of accurately diagnosing patients immediately. One patient received Twinrix from us and had severe dizziness over the next several days. She had seen a medical doctor in follow up who did not examine her or give her a diagnosis or any type of treatment. In frustration she had seen her homeopathic physician who then told her she had multiple sclerosis caused by the vaccine and wanted to begin immediate homeopathic treatment. She began these but finally returned to us where I examined her with a very mundane Otitis media. She was prescribed antibiotics and I made sure she had a follow-up with me to ensure she had a full recovery.

Key Concepts in Promoting Immunizations
Immunization has saved Millions of Lives Routine vaccines are safe The eradication of diseases prevented by vaccines outweighs unconfirmed adverse reactions Vaccine scares are common Parental Concerns should be taken seriously Health Professionals have a duty to provide accurate information to enable parents to make a truly informed decision regarding their Child‟s vaccinations. The following pages go into great detail on many issues in current vaccinology.

Why Vaccines Work in Protecting Us: A Message To Parents and Clinicians Compiled by Gary Podolsky MD This article is intended to help both clinicians and parents learn the most up to date information on vaccines. Parents have to make important and sometimes difficult decisions for their children, and often the most difficult decisions are in regards to healthcare. There are several concerns in our community concerning vaccine safety without merit. The purpose of this talk is to correct misinformation. We all want to make the right choices regarding what is right for our children and protect the general public health as a community. A recent article in the British Medical Journal explained how all Healthcare workers and Teachers in Britain are always given new information on immunization practices, regardless of their actual role in immunizing children. This constant reinforcement of the need for immunizations helps them to be able to inform their patients to make informed decisions about their health. We designed this booklet to meet the needs for information on behalf of Canadian parents, health care professionals, school nurses, childcare providers and others in order to: 1. Provide information about immunizations and vaccine-preventable diseases, in a similar format to information presented on car seats, bike helmets, and age appropriate toys.

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2. Balance the benefits and risks of immunizations to assist you in making an informed decision. 3.Clarify inaccuracies or misinformation about vaccinations and vaccine-preventable diseases. This booklet is arranged so that each section may be read independently. We have used a question and answer format. We hope that you will spread our messages about the importance of immunization with your patients. Information on immunization is rapidly changing so extensive links are included. Immunization Saves Lives Immunization is one of the most successful medical discoveries in human history and has saved millions of lives in the 20th century. Many serious childhood diseases are preventable by using vaccines routinely recommended for children. Since the start of these vaccinations, rates of disease such as polio, measles, mumps, rubella, diphtheria, pertussis (whooping cough) and meningitis from Haemophilus influenza B, have declined by 95-100%. Before immunizations hundreds of thousands of children were affected each year with thousands dying each year (U.S. figures). In under-immunized countries there are still 600,000 children dying each year from pertussis alone. Without routine vaccinations diseases we are now protected from will return. They will sicken and kill many infants and children while many survivors of severe illness will go on to have chronic health problems. Many countries are having problems because they stopped vaccinating against diseases that were felt to be under control. (The rebound incidence of diphtheria in the former U.SS.R. is a good example of this). It is only after a specific disease is no longer found in people and exists nowhere else (eg. soil, water or animals) that a vaccine can be safely discontinued. Smallpox vaccination lead to smallpox‟s official eradication and vaccinations were discontinued once this was certain.

Immunizations Prevent the Spread of Disease Diseases spread through communities by infecting un-immunized people and the small percentage of people for whom immunizations do not work. For some highly contagious diseases like measles, even a small number of susceptibles can lead to outbreaks. In 1989-1991 a measles outbreak occurred in the U.S. due to the failure to vaccinate preschool children on time. This epidemic was responsible for 55,000 cases of measles. At least 120 deaths occurred in children under age 5 months who had not been vaccinated. In 1998, all of the measles cases in the US were cases that originated from other countries. With widespread globalization and travel to other countries, dangerous infectious diseases are only a plane ride away. By being well vaccinated as a population, we also increase our „herd immunity‟ such that if an infectious agent does enter our population it will be blocked immediately from spread to others. Immunizations are Safe Immunizations are extremely safe and getting safer and more effective due to ongoing research. Immunizations are given to keep healthy people well. They are held to the highest safety standards. The number of vaccinations available keeps expanding as more and more diseases are being studied. Immunizations Save Money Every dollar spent on vaccinations saves seven dollars in medical costs and 25 dollars in overall costs (i.e. missed work). Complications from hepatitis B related liver diseases exceed 32

500 million dollars U.S. (U.S. figures). This total cost includes direct (medical costs) and indirect (lost work) but doesn‟t include human suffering. Immunizations are Strong Protection Immunization is the single most important way parents can protect their children against serious disease. Children who are not immunized are at a far greater chance of becoming infected with severe disease. Immunizations work naturally by using the body‟s immune system and make it stronger and more effective at fighting disease. There are no other effective alternative ways to prevent many of these diseases. Breastfeeding is helpful in preventing some diseases among babies but is not effective against preventing all serious diseases. Other Important Facts: Infants are often affected more severely than older children by the same diseases. Their immune systems are weaker and cannot fight off bacteria or viruses as well. Even if a disease is not currently reported in a region the bacteria or viruses may still be present. Disease outbreaks are prevented by routine vaccinations. Most vaccines are provided free through Manitoba Health. Many are covered in other jurisdictions but not Manitoba. In Manitoba, Hepatitis B is covered for grade 4 children only. Varicella (chicken pox), meningitis and pneumococcal pneumonia are now covered by Manitoba Health for children born in 2004. Immunizations such as Hepatitis A are not covered in Manitoba.

How the Immune System Works The immune system is the body‟s defense system against disease. Medical research has developed vaccines to help the immune system fight disease. When you get an infection the body produces antibodies. Antibodies will attack antigens (invading bacteria or viruses) and help fight illness. Antibodies will stay in the body after the original disease is gone to protect you from getting that disease again. This memory of the immune system is called immunity. Mother‟s milk confers immunity temporarily as antibodies in the mother‟s milk are passed on to protect the infant. These antibodies wane with time leaving no memory or lasting immunity. Therefore infants need to be vaccinated in order to develop their own immunity. In making a vaccine against a bacteria or virus, the infectious agent is weakened so that the vaccine does not cause illness. The body is tricked into responding to the antigens of a vaccine so that the specific immunity it develops will be effective against real bacteria or viruses. Vaccines are available in different types. Live vaccines are made from weakened (attenuated) viruses or bacteria. Live vaccines are extremely effective and produce lifelong immunity after only 1 or 2 doses. Inactivated vaccines are dead viruses and require multiple doses to buildup a good immune response. Some inactivated vaccines require boosters throughout life (like tetanus-diphtheria which is repeated every 10 years).

Questions and Answers
Question: Do vaccines really work? Answer: Yes. Everywhere where vaccination occurs, diseases have declined in incidence.

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Question: Why do some children still get measles after vaccination? Answer: We know that one dose of measles does not protect 100% of people immunized and that 5-10% will still be susceptible to a measles infection. That is why a second shot is later given. There are always small amounts of people who may not respond well to vaccines and are not immune. If they get ill they usually are still protected by the vaccine from developing full-blown disease. Question: Isn‟t catching a natural infection such as wild measles, better than an artificial immunization from a vaccine in giving immunity? Answer: No. In neither case are infections or vaccines natural. A „natural infection‟ with an agent like measles, will also carry the risk of disease. The vaccine is intended to stimulate the immune system without getting the disease. Vaccines are made to optimize immune function. Some diseases such as tetanus do not even induce immunity after an infection, while others may (Hepatitis A infection survivors will have lifelong immunity). It is also unnatural to have a child‟s spine manipulated, adjusted, or jostled, which will not affect the immune system. Question: Doesn‟t immunity wear off after time? Answer: Yes. Different vaccines give different immune responses after the proper schedule is carried out. Some like tetanus and diptheria, need to be boosted every 10 years for adults while others like measles, will require no further boosters. Question: Can vaccines cause seizures? Answer: Indirectly yes. Vaccines can cause a fever that may then cause convulsions in some children (3% of otherwise healthy children) but these seizures are not a sign of brain injury. Several large studies have looked at febrile (fever associated) seizures and found that there is no evidence of brain damage from any vaccine. If a child has a fever it is recommended that the child take an antifever medication such as children‟s Tylenol. Question: Can vaccines cause cancer? Answer No. There is no evidence of this. There is strong evidence that the Hepatitis B vaccine will prevent cancer. The BCG vaccine is actually used to treat bladder cancer. Question: Are the preservatives in vaccines (Formaldehyde, Aluminum, Mercury, Thimersol) toxic? Answer: The amount of chemicals used as preservatives in vaccines is very minute and nontoxic, even for infants. These preservatives are reviewed by Health Canada and felt to be safe. Some vaccines do contain antibiotics or egg products, which should not be used if a history of allergies exists. Regarding eggs, if a child is able to eat an egg without difficulty then the vaccine may be given. Manufacturers of vaccines plan to substitute thimersol in their products not because of any health concerns, but to avoid further controversy. There is still no good evidence that thimersol in vaccines causes problems. Question: Does any vaccine contain brain tissue, which transmit Mad Cow Disease? Answer: No. Question: Why do Chiropractors, Homeopaths, and Naturopaths, advise against immunization? Answer: The Policy of the Faculty of Homeopathy at the London Royal Homeopathic Hospital is: “Where there is no medical contraindication, immunization should be carried out in the normal manner, using conventionally tested and approved vaccines”. The Manitoba

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Chiropractors Association has also formally stated that they approve of vaccinations. Despite these statements from official organizations, many alternative “practitioners” strongly oppose vaccination. Anti-vaccinationists have been around for a long time, and may use false claims for any number of reasons but they do this without any support from their governing bodies and are hence are themselves “denatured”. Many early vaccines had well documented severe adverse effects but modern vaccines should not be confused with these. Anyone may state an opinion, but using a professional title to advocate a view that cannot be scientifically supported, is wrong.

Question: Do vaccines alter or weaken the immune systems own natural ability to fight off disease? Answer: No, a vaccine only evokes an immune response specific to a specific group of antigens. For example, the vaccine for polio will have no effect on the body‟s ability to handle hepatitis B since each infectious agent is recognized differently. This is why it is important to be vaccinated against all the diseases available. Question: Does breastfeeding replace the need for vaccination? Answer: Although breast fed babies receive antibodies in mothers milk that protect them in their early years, they are not protected from all diseases. Vaccines give specific and long lasting protection. Question: Does giving more than one vaccine on the same day „overload‟ the immune system? Would it not be better to give only one vaccine at a time? Answer: No. Receiving more than 1 vaccine at a time does not harm a child‟s body. Vaccines only use a tiny part of the body‟s immune system. Many childhood vaccinations are given at the same time for convenience because this ensures that the child doe not miss important dates and also means fewer needles. As a person eats and breathes, their immune system is constantly exposed to many infectious agents. Vaccines represent a small fraction of the antigens a person is regularly exposed to. Question: Is the method of injection of vaccines harmful? Answer: No. Injecting vaccines is a safe method and has been used for decades. Vaccines are never injected into the bloodstream. Most are injected either into the muscle or into the fat just beneath the skin. Each needle and syringe is disposed of after use as they are only used once. Question: Can someone get a disease that they had been vaccinated against? Answer: Yes, modern vaccines are extremely effective but are still not perfect. If a vaccine is 90% effective then 10% of people will not develop sufficient antibodies to prevent disease. If an infection rolls into town the susceptible individuals (all of the un-vaccinated and 10% of those vaccinated) are likely to become infected. Those 10% may still have partial immunity in that they will experience a milder form of disease. If a community is well vaccinated, diseases will be harder to catch since person- to person contact is blocked. This „herd immunity‟ protects those susceptible individuals. Many vaccines also require more than 1 dose to be effective. Some antibodies (such as tetanus) will wane with time and require future booster shots.

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Question: I have heard that the real reason that these vaccine-preventable diseases began to disappear was because of better hygiene and sanitation and not because of vaccines. Is this true? Answer: No. Many infectious diseases did become better controlled with better public health improvements but they remained serious threats due to periodic outbreaks in susceptible populations. It wasn‟t until vaccines were introduced that the actual rates of incidence went down dramatically. But fighting diseases involves many issues. Vaccines have definitely been assisted by other factors such as: 1. Better nutrition 2. Less crowded living conditions with better sanitation 3. More effective treatments such as antibiotics But in spite of these improvements, vaccine-preventable diseases still occur due to lack of vaccination. A good example of the effect of a vaccine after its introduction occurred with the Hib vaccine. In 1984 when it was first introduced in Washington State there were 80 cases of Haemophilus per year. Rates steadily decreased in the next 2-7 years to essentially 0 cases by 1998. Sanitation did not change much during this time. The Hib vaccine was the only new variable. Similarly in 1963 there were 500,000 measles cases (with 500 deaths that year) in the U.S. In 1998 there were 100 cases reported with no deaths. Question: Isn‟t it still better to become immune from natural sources rather than through a vaccine? Answer: No. Vaccine preventable diseases can still be lethal, or cause permanent damage (brain damage from measles or pertussis, liver cancer (from hepatitis B), or paralysis (from polio). Some vaccines such as tetanus are even better at creating immunity than the natural infection. Vaccines prevent disease without risking an adverse effect from an infection. A good example is chicken pox. Chicken pox in an adult can be a very serious illness whereas most children only become mild to moderately ill. Previously before immunizations were available, parents were encouraged to have their children deliberately exposed to other children with chickenpox (“chicken pox parties”), so that their child would receive lifelong immunity. This was a rational approach at that time, since the risk to that child later in life as an adult could be life threatening if they missed their being infected as a child. We no longer advocate chicken pox parties because the varicella vaccine uses a live attenuated virus to prevent chicken pox illness in children without the associated risks of disease. Vaccinating Children-To Wait or Not Parents frequently wonder why vaccines are given to children so early in life. They may ask to wait until their child is about to enter school before getting immunized. Question: Is it all right to wait until school starts to get immunized? Answer: No, waiting too long may put your daughter or son at an unnecessary risk of contracting serious disease. Maternal antibodies fade during the first year of life. This also occurs when children are more frequently exposed to other children and adults. Many of the vaccine –preventable diseases are more severe in very young children. For example, the peak vulnerability of children for Haemophilus disease is at ages 6-7 months, therefore for the vaccine to be most effective it should be given before this time. In a measles epidemic in the U.S. (1990) 40% the of cases were in children less than 4 years old. Most of these could have received their measle vaccinations at 15 months but did not. 36

Now children get their measle vaccinations as early as 12 months of age (and 6 months during outbreaks). Question: Can my child catch up if they missed or are behind on vaccines? Answer: Yes, but it is best to stay close to the recommended schedule. An interruption in the schedule does not mean having to restart the series. Until the vaccine series is finished, the child will not have maximum protection against the disease. If the child‟s immunization schedule is behind parents should speak with their family doctor, immunization nurse or public heath clinic. If a child is going to live overseas regular vaccinations may be given earlier to adjust for the increased risk of some diseases in certain countries. If planning an oversees trip consult a Travel Medicine Clinic for appropriate advice. Question: Are immunizations safe even If my child has a minor illness? Answer: Yes, immunizations may be given even if your child has a mild illness such as a mild fever, cold, diarrhea, or is taking antibiotics. The vaccine will still be effective since your immune system is always working and the vaccines do not overload it or prevent it from working against other illnesses. Vaccines will not make other illnesses worse. Receiving immunizations on time is a way of cutting down on unnecessary doctor‟s visits. Question: But are there some instances when vaccines should not be given? Answer: Yes, there are some medical reasons for not giving or for delaying vaccines. These instances are uncommon but should be followed. Generally a person should not receive a vaccine if they have significant allergy to one of its components. Components like neomycin or gelatin are added to some vaccines, and should be avoided in individuals sensitive to them. Another example is the yellow fever vaccine, which is prepared with egg products and should not be taken by individuals allergic to eggs. If a person can eat one egg without vomiting or being sick then they may have this vaccine. The yellow fever vaccine is given only to international travelers going to South and Central America or Africa and is NOT routinely given to children. Children with medical conditions, whose treatments or medications could reduce the effectiveness of the vaccines, may delay receiving vaccinations until they have finished their treatment. Examples include: receiving recent blood products (immunoglobulin or blood transfusion) and high dose corticosteroids both of which may impair the immune systems ability to respond to the vaccine. These children may not respond as well to some vaccines but they are also more susceptible to infections. Very sick individuals (cancer patients, HIV positive people and those with other illnesses affecting immunity) should still receive vaccinations. Some people with impaired immune systems or immunosuppression treatments may not respond as well to vaccines, and may require additional booster doses. Families should speak with their family physician or specialist to determine how to proceed with vaccination or delay. In most cases vaccines may be given if the child is breastfed, has an ear infection, is taking antibiotics, has mild diarrhea, or has a milk allergy. Check with a health case provider who administers vaccinations if you have specific questions. There is no need to delay vaccinations for: minor cough, colds or diarrhea; high fever 40°C after a previous vaccine dose; prolonged tiredness after a previous vaccine dose; local skin

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reactions after vaccine; history of convulsions with or without fever; active allergy; allergy to eggs; being on current antibiotics; being born prematurely; those with family history of Sudden Infant death Syndrome (SIDS); infants breastfeeding (both mother or child can get vaccine); or a child‟s mother is pregnant.

Vaccine Preventable Diseases According to the World Health Organization (W.H.O), immunization programs save 3 million lives per year. The following are diseases that we can prevent through vaccination. Research is so that immunizations for other infectious diseases will be added to this list. Diptheria, Tetanus, and Pertussis Diptheria is easily spread through coughing or sneezing and can cause paralysis, breathing and heart problems, and death. Recent outbreaks have occurred in the former U.S.S.R, which had temporarily abandoned diphtheria vaccinations, which has made a large segment of their population vulnerable. Prior to vaccination in the 1920‟s, there were 12,000 cases per year with 1,000 deaths per year in Canada. Diptheria still kills 1 in 10 of those infected. Tetanus (lock jaw) occurs when a tetanus germ enters a cut or wound and can cause muscle spasms, breathing and heart problems, and death. The tetanus bacteria are found in soil and are everywhere. A booster is recommended every 10 years. Before vaccination, about 5000 cases per year occurred in the U.S. Even with modern treatment 10-20% of these infected will die. Pertussis (whooping cough) is spread through coughing or sneezing and can cause long spells of coughing actually making it difficult to eat, drink or even breathe. Pertussis can cause lung problems, seizures, brain damage and death, especially in infants less than 1 year old. Before vaccination 5 out of 1000 children died of pertussis before age 5. Hygiene improvements as well as vaccination have decreased this statistic. Pertussis still kills 3 children per year in Canada. Question: What is the difference between “whole – cell DTP and the new acellular DTaP?” Answer: The new vaccines (available since 1997) are known as acellular or non-cellular. They contain only the antigens necessary to give immunity and not the “whole cell”. The older “whole cell” Pertussis vaccine contained the whole killed Pertussis bacteria, which lead to a higher rate of local reactions like redness, swelling, and pain at the injection site, and a fever also. Health authorities now recommend that all Pertussis vaccines be acellular as this higher generation of vaccine has much less local effects. Question: So what are the effects of the DTaP vaccine? Answer: Most children receiving the DtaP will have no adverse reactions or experience only minor discomfort. The most common reactions are soreness, swelling, and redness at the injection site usually after the 4th and 5th DtaP. They last 1-2 days. Serious adverse reactions are rarely reported with the acellular Pertussis.

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Question: How effective is DTaP and is it worth receiving? Answer: A full series of 4 DTaP by 18 years of age is recommended to get full immunity. A full series protects 80 out of 100 children from getting severe Pertussis, 95 out of 100 from Diphtheria, and 100% are protected from tetanus. In the 20% of those vaccinated who do develop Pertussis they will have a milder form of the illness. Small children and infants who catch Pertussis are often critically ill. Insufficient immunization in a community contributes to a higher rate of Pertussis there. Most people vaccinated with DTaP are protected for many years. Adults are recommended to have TD (Tetanus-Diphtheria) shots every 10 years to boost themselves. Because it is so contagious the possibility of a child getting severe Pertussis when exposed is far greater than the possibility of experiencing a severe adverse reaction from the vaccine.

Haemophilis Influenza Type B (Hib) Hib bacteria can cause meningitis (inflammation of the brain) infections of the joints, skin and blood, brain damage and death. It is most serious in infants less than 1 year. Since vaccinations for this disease began, incidence of this disease has dramatically declined. Before 1985, about 1500 cases of meningitis from Hib occurred per year. Vaccination has dramatically decreased the incidence of severe Hib infection. Hepatitis AHepatitis A is a virus that causes infection of the liver. It can be passed from mother to child during birth, through blood or body fluids, and poor hygiene in food and water. Infected people can transmit it to others in the same household through casual contact. Symptoms include diarrhea, jaundice, hepatitis and death. Adults and elderly people are more severely affected. After exposure the average incubation time is 15-50 days (average 28 days). Illness does not usually last longer than 8 weeks although about 10-20% of those affected could have symptoms for 6 months. Question: If Hepatitis A is most commonly transmitted by contact with the stool of infected people, why should we get vaccinated if we keep clean? Answer: Cleanliness such as hand washing after using the washroom or changing diapers is essential for hygiene but still not 100% effective. People who are infected with hepatitis A often transmit the virus for 1-2 weeks before they feel sick. Children will less often show signs of infections in Canada and U.S. mostly due to improvements in hygiene. New cases are acquired through people visiting other countries and bringing the infection home. Routine Hepatitis A vaccination of children is currently not strongly recommended. Parents planning trips to underdeveloped countries may consider Hepatitis A for themselves and their children. Cruise ship holidays would be included as well. Hepatitis B- is a different viral infection of the liver. It is transmitted through blood and bodily fluids and intimate contact. It is more common, easier to catch and kills more people than AIDS annually. Infection may cause liver damage, liver cancer and death. It is the second most common cause of human cancer. The incubation period of Hepatitis B can be 45-60 days (average 120 days). Initially the preictal phase consists of malaise, anorexia, nausea, abdominal pain, fever, headache, arthritis, and dark urine. This usually lasts 3-10 days. Next the jaundice or ictal phase occurs and lasts 1-3 weeks. Jaundice, light or gray stools, liver tenderness or enlargement characterize it. Next convalescence occurs for weeks or months with persistent malaise and fatigue. Most people with Hepatitis B infections recover with

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immunity and clearance of the virus from the body but some do not. Fulminate hepatitis occurs in 1-2%. This liver failure can be severe with mortality ranging from 63-93%. Another 10% of cases go on to develop chronic hepatitis B infection. These people may not be symptomatic but they can infect others. They are also prone to fulminant hepatitis, liver failure cirrhosis, and especially liver cancer. Question: Why are we vaccinating children against Hepatitis B since most of the people getting Hepatitis B are adults? Answer: National recommendations for both Canada and the U.SA. recommend routine vaccinations of all children against Hepatitis B because it is impossible to predict who will be exposed to Hepatitis B in the future. Hepatitis B is acquired through blood routes (IV drugs, unprotected sex, non-sterile medical procedures, unscreened blood, and any body fluidnon intact skin or mucous membrane contact) all of which are unlikely for children but 30% of Hepatitis B cases are unknown in how they got the disease. Most of these cases are believed to have occurred from being bitten or scratched, from sharing a utensil, or having some type of close contact with a playmate or family member. The earlier in life a child acquires Hepatitis B the more likely they are of becoming a chronic carrier. In the U.S. Hep B is given to infants while in Manitoba it is given at grade 4 (which is more for administrative purposes rather than a decreased increased risk between U.S. and Manitoba). In the U.S Hep B infects 200,000 people per year, with many being adolescents or young adults. As yet there is no specific treatment for acute Hepatitis B. The virus may cause liver damage, liver cancer, and death. In the U.S. 1.25 million people are infected. The Hepatitis B virus is more common than, easier to transmit, and kills more people than the HIV virus causing AIDS, yet is vaccine preventable. People at high risk for Hepatitis B, are recommended to be vaccinated. Recommending vaccination to high-risk individuals has not been effective in decreasing the incidence of Hepatitis B, since many people at risk for infection do not fit into the stereotype of a high-risk person (promiscuous or drug users), universal vaccination is now recommended or children. Question: Does Hepatitis B vaccination cause Multiple Sclerosis (MS) or Sudden Infant Death Syndrome (SIDS) or Autism? Answer: No. Multiple Sclerosis is an autoimmune disease where antibodies attack the bodies own myelin in the nerves causing many types of neurological problems that may stay stable or get worse throughout life. The cause of MS is still unknown but medical experts believe that certain patients are genetically at risk for the disease and that some environmental factors can trigger the disease. There is no evidence that vaccination with Hepatitis B can cause MS or be one of the triggers. One French study analysed over 60 million people hepatitis B immunizations given between 1989-1997 and found that people vaccinated against Hepatitis B were less likely to have neurological disease than unvaccinated people. A recent study in the New England Journal of Medicine also confirms this. The Multiple Sclerosis Society supports the wide and general use of this vaccine. There is some evidence that people vaccinated against Hepatitis B may be less likely to get MS. Sudden Infant Death Syndrome (SIDS) is the name for increased mortality in apparently healthy infants. Investigators are continuing to find all of the possible causes for this syndrome including the observation that sleeping on the stomach may increase this.

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In the U.S., infants receive Hepatitis B immunizations starting as early as the first day of life (since 1991). There has been a steady decrease in the number of newborn deaths as the number of Hepatitis B vaccines administered has increased. The American Institute of Medicine has reported: “All controlled studies that have compared immunized versus non-immunized children have found no association or decreased risk of SIDS among vaccinated children.” To learn more about SIDS please check with your pediatrician or obstetrician or check the references at the back of this booklet. Autism – There is no evidence to suggest that Autism is related to Hepatitis B vaccines. See the section on Measles, Mumps, and Rubella for more information on Autism. Question: Isn‟t the preservative in Hepatitis B (Thimersol) related to mercury and could my child get mercury poisoning from the Hepatitis B vaccine? Answer: There is Thimersol in some Hepatitis B vaccines. Some manufacturers are now using other preservatives instead. It is still felt that the amounts of Thimersol in each dose of Hepatitis B vaccine are insignificant to cause problems. The Hepatitis B vaccine has been scrutinized carefully before being approved in Canada, the U.S, and abroad and is felt to be safe for use. Polio One hundred years ago, Polio infection was one of the major crippling diseases. The last epidemic in Canada involved 2,000 cases of paralytic Polio (1959). Polio infection can cause fever and may lead to meningitis and lifelong paralysis. Persons infected with poliovirus shed the virus in the stool and spread it to others. With ongoing immunizations the World Health Organization‟s (W.H.O.) goal date of eradication is 2005. Sometime thereafter if no new polio cases are reported worldwide, immunization will discontinue, possibly by 2007.

Question: Isn‟t the Poliovirus supposed to be extinct? Answer: No, not yet. The World Health Organization originally had set out to destroy it by 2000 but recent outbreaks of confirmed Polio cases in Africa and India, have confirmed it is still active. This failure was partly due to a failure to fully vaccinate children in developing countries. Polio vaccination is still recommended for international travelers going to those countries. Polio vaccination must continue until confirmation of no known cases of the wild type has occurred. It is only spread among people so as soon as the last person is infected or immunized then it will be extinct. It is still recommended to continue with routine childhood Polio vaccinations because if a susceptible person were to bring a Polio infection back to North America it could precipitate an outbreak among those who are not immune to polio. Efforts are being made overseas to vaccinate countries that have not had up to date Polio vaccinations with the new goal date of eradication being 2005. It is likely that vaccination will continue for some time after that and then stopped, as was the case with Small Pox eradication. The Polio vaccine used in North America is the IPV or Inactivated Polio Virus, which has no significant side effects. The OPV or Oral Polio Vaccine is no longer used since this was known to have side effects including vaccine induced Polio (1 in 2.5 million chance) It was still recommended at that time despite its very rare side effects, it still saved lives and helped make polio disappear from North America). There is no good reason to use the OPV in Canada now, with the safer profile of the IPV.

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Influenza Influenza- (which is a different disease from the similarly named Haemophilis Influenza type B mentioned above) is a highly contagious viral disease with epidemics regularly occurring. Infection causes sudden onset of fever, chills, muscle aches, cough, headache, and may lead to pneumonia. Sneezing, coughing, or direct contact spreads it with the infected person. Children and adults with long-term illnesses such as asthma and diabetes are more prone to serious flu complications such as pneumonia, dehydration, meningitis, and even death. Influenza infection is a major cause of death in the elderly. The virus has 3 subtypes A, B, and C. Type A causes moderate to severe disease, affects only humans and affects all age groups. Type B causes mild disease and affects only humans, mostly children. Type C affects animals and rarely humans and is not associated with epidemics. The influenza virus also mutates frequently. Antigenic shifts and drifts are major and minor changes in the antigens (or parts of the virus recognized by the body‟s immune system). These changes allow the virus to persist in the population and give rise to epidemics of the flu. Epidemics occur when the incidence of influenza cases increase and mortality rises. Pandemics occur with high incidence in all age groups and increased mortality. An influenza pandemic could affect up to 200 million people with an estimated 400,000 deaths. Sporadic outbreaks occur when clusters of cases occur in families, schools or small communities. The virus is acquired from respiratory droplets. It replicates in the trachea and bronchi causing local destruction and is shed for 5-10 days. Maximal communicatability occurs 1-2 days before onset and 4-5 days after. Symptoms appear after an incubation of 1-2 days. Abrupt onset of fever, muscle aches, non-productive coughs, and headaches occur. Severity is less if the person has encountered a similar antigened virus before. Only 50% of people have the above classical symptoms of influenza. Symptoms last 2-3 days and rarely more than 5. Aspirin should not be taken by children with flu, because of the association with Reye‟s syndrome, an often-fatal affliction. Complications that occur with the flu include pneumonia (either a bacterial super infection on top of the influenza or an influenza pneumonia which is rarer). Reye‟s syndrome is a rare complication in children with the development of coma and some types of brain swelling. Other complications include myocarditis (heart inflammation), and worsening of chronic bronchitis. Death occurs in 0.5-1 cases per 1000 cases, usually in those ages greater than 65 years. Diagnosing influenza can be difficult and is largely based on clinical appearance along with the influenza prevalence in the community. Influenza peaks between December and March in temperate climates but can vary. It is year long in the tropics and outbreaks are common aboard cruise ships. Vaccination against influenza- is done with an inactivated virus of circulating strains of type A and B influenza. Egg protein is present. The vaccine is effective in protecting 70% of healthy adults but only 30-40% of the elderly. It is not highly effective in preventing illness but is effective in preventing complications and death particularly in the elderly. The vaccine is most effective if given 2-4 months prior to flu exposure and is usually available in September. The vaccine may be given annually. Children from 6 months to 9 years receiving it for the first time should receive 2 doses 1 month apart. (Ideally the second dose should be before the end of November).

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Flu shots are recommended for all people over 50 (those over 65 are covered by Manitoba Health), children >6 months with chronic disease, long term care residents, health care workers, students, travelers, pregnant women, and persons 6 months to 18 years taking chronic aspirin therapy (so that they do not develop Reye‟s Syndrome). Any person who wishes to decrease the likelihood of becoming ill from influenza should receive the flu shot although Manitoba Health does not cover all the above groups. With a possible pandemic this recommendation may change.

Manitoban Groups Eligible for Free Influenza and Pneumococcal Vaccine
September 2005) Groups eligible for free vaccine under the Manitoba Health program People aged 65 years and older Residents of long-term care or Chronic care facilities Adults and children (> 2 years old) with chronic health conditions, such as lung disease, heart and kidney disease, diabetes, aspleenia, splenic dysfunction, immunosuppression ( due to disease or therapy) Children and adolescents being treated for long periods with acetylsalicylic acid Health care workers and other personnel who have significant contact with high-risk individuals People at high risk of complications traveling to destinations where influenza is likely to be circulating Household contacts (including children) of: Persons who are immunocompromised or 65 years or older Children aged 2-23 months and household contacts of children under 23 months

(As of

Pneumococcal
Vaccine

Influenza Vaccine

X X X
(excluding asthma)

X
X X
(including asthma)

X X X X X

Adverse effects of the Flu Vaccine Local reactions occur at the site of vaccination with soreness and redness lasting 1-2 days in 15-20% of people. Non-specific fever and aches last 1-2 days in <1% of people. Hives and allergic reactions occur rarely, particularly in people allergic to eggs. People with egg allergies should not receive the vaccine. At present the flu vaccine is injected but a nasal preparation is being developed in the US. For people with flu like symptoms antiviral therapy is available with new drugs that can block viral replication and prevent illness if started as early as possible (within 48 hrs). Vaccination still remains the best way of controlling the flu. Measles, Mumps, and Rubella are all spread by coughing, sneezing, or talking.

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Measles- causes a high fever and cold-like symptoms. It can cause hearing loss, pneumonia, brain damage (1 in 1000 cases), and death. It is spread very easily so an non-immunized child will very likely get the disease if exposed to a measles case. The measles virus can remain infectious in a room for two hours. Before vaccination in 1963, 350,000 cases of measles occurred, causing 50-75 deaths. In 1995 only 2000 cases of measles were reported in Canada. Vaccination against measles saves 1 million lives worldwide per year. The W.H.O‟s goal date to eradicate measles is 2007. Mumps- can cause headache, fever, and swelling of the lymph nodes on the face and neck. Mumps can also cause encephalitis, meningitis, and sterility in men. Rubella- will cause pregnant women who are infected to lose their babies, or have birth defects (such as hearing loss, heart problems and mental retardation), which is call Congenital Rubella Syndrome. In Canada, prior to vaccination, 2000 cases of CRS occurred. Since 1990, when Canada started immunizing all children at 1 year and checking pregnant women to see if they were immune, cases markedly decreased. Question: Is there any evidence associating the MMR vaccine and Autism? Answer: No. The best available science indicates that the development of Autism is completely unrelated to MMR or any other vaccine. One study based on 12 children seemed to suggest a link but this has been disproven by larger, better-designed studies. The researcher who had suggested causation was financially backed by individuals looking for proof between autism and measles for their lawsuits. He neglected to mention this conflict when reporting his findings and is now held in Academic contempt. Experts in Autism agree that Autism is most likely a genetic disorder that occurs before birth. The exact cause is still being researched. The American National Institute of Health in 1995, reached a consensus that Autism is a genetic factor. Symptoms of Autism first appear at 1830 months of age. The MMR vaccine is usually given at 12-15 months of age. Symptoms of Autism are detected in the weeks or months following vaccination but this does not imply a casualty. The incidence of autism has also not increased with the increased widespread use of the MMR vaccine. The diagnosis of Autism can be very disturbing to parents. Research is continuing and up to date information is available at the Canadian Autism Society. Pneumococcal Disease Pneumococcal Disease is the leading cause of bacterial meningitis (swelling of the brain and spinal cord) of children 5 and younger. It can also cause severe blood infections (bacteremia) and lung infections (pneumonia). This is spread to people by droplets of bacteria that are breathed in. For bacteremia and meningitis fatality per case is 10-20% in infants and up to 80% in elderly people. According to W.H.O. 500,000-1.4 million deaths occur from pneumococcal pneumonia worldwide, each year.

There are two types of pneumococcal vaccines: The Pneumococcal polysaccharide vaccine is recommended for children over 2 of years with high risk of disease (they lack a functioning spleen; or have sickle cell disease, nephritic syndrome, CSF leak, or immunosuppression including HIV infection). This vaccine is also recommended for adults 65 years and older, those with chronic diseases, immunocompromization, HIV infection, and in high-risk occupations. One vaccination is enough but people at very high risk may have a single booster after 5 years. This vaccine is not effective in children under 2 years of age.

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The pneumococcal conjugate vaccine is recommended for children <24 months and is given at 2,4,6 and 12-15 months. Unvaccinated children >7 most need fewer boosters. It is recommended to consider vaccinating all children aged 24-59 months as well. Vaccination with the conjugate vaccine (Prevnar) For Healthy children at birth: is: Three doses are given in the first year of life followed by one booster in the second year Dose 1 at 2 months pf age Dose 2 at 4 months Dose 3 at 6 months Dose 4 at 12-15 months. (The recommended interval between doses is 4-8 weeks) Vaccination for Healthy Children after 7 months until 9 years of age (Prevnar) Age at first dose Total number of doses Dosing information 7-11 months 3 -2 doses 4weeks apart -3rd dose after 12mos old -3rd dose 2months after 2nd 12-23 months 2 -2 doses 2months apart ≥24 months to 9 years 1 -1 dose Adverse effects of immunization include local reactions (polysaccharide 30-50%, Conjugate 10-20%) and fever or muscle aches (polysaccharide <1%, conjugate 5-24%) but there are no severe reactions. Question: What is Pneumococcus disease? Answer: The pneumococcal bacteria are the most common cause of pneumonia, meningitis, sepsis, sinusitis, and ear infection, in children under 2 years. A pneumococcal vaccine has been available for many years but had not been recommended for children under 2 years old because it was not effective in this age group. A new pneumococcal conjugate vaccine has recently became available. This vaccine targets the 7 most common disease-causing types of Pneumococcus. Pneumococcal infections can be treated with antibiotics but vaccination is becoming an important method of prevention since bacterial resistance to antibiotics is becoming a problem.

Varicella (Chicken pox)
Chicken pox is a very contagious infection causing a rash and fever. It is spread by coughing or by direct contact with the rash. Children can develop bacterial skin infections, rarely flesh eating disease infections, meningitis, and pneumonia. Very rarely a severe infection will cause strokes in children. Adults who are affected are often very sick. Pregnant women may have birth defects or stillbirths. Re-eruption of the chicken pox virus (which remains dormant in infected persons nerves) can reactivate later in life causing Zoster or Shingles. Shingles are painful eruptions of the varicella virus along an affected nerve distribution. Question: Since Chicken Pox isn‟t a serious disease, why vaccinate against it now? Answer: For the majority of those affected, Chicken Pox (Varicella) is a febrile illness that can make a child unwell, and cover the body with painful sores (some of which may scar), but the disease is self-limiting. Complications can occur from varicella, such as Pneumonia, Encephalitis, Bone infection, and secondary infection with the “Flesh Eating” bacteria. Chicken Pox also rarely causes childhood

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stroke. In an adult, infections can be life threatening, and in pregnant women, can lead to birth defects. The Varicella virus will stay in the nerve bodies and can later in life erupts as Shingles. This is not a reinfection, but a reactivation of the same varicella virus. A new vaccine is being developed to strengthen the immune system in older people so they don‟t get shingles. Question: Does immunity from the Chicken Pox vaccine last? Answer: Current information suggests that the vaccine lasts at least 20 years. Based on other similar vaccines it is believed that immunity will remain high throughout life. Question: Why wasn‟t Chicken Pox a regular recommended vaccine? Answer: Chicken Pox is now recommended, and is now covered by Manitoba Health for some children. It has been a routine vaccine in the United States but to receive it in Manitoba, parents of children not eligible for it must either pay for it or check their drug plans. Recently, children born in 2004 are eligible to receive it trough Manitoba Health.

Legal Requirements and Considerations Question: Are vaccines required by law prior to attending school? Answer: Vaccination is strongly recommended but not required by law in Canada. It is important that each parent understands the reason for vaccination and makes the decision to vaccinate their children for the right reasons. We want you to consider all the available information. Opposition to Public Immunization Programs There are several anti-vaccination groups openly criticizing public funded vaccine programs. They have given their organizations official sounding names and titles. We would like you to understand what their qualifications and authority actually are. We want you to listen to us not only because of our credentials, but because our statements are supported by good evidence. Vaccination and immunization is a complex medical concept and it is often poorly understood or explained to people so numerous misconceptions exist. The purpose of this forum is to provide an easy overview of established facts on vaccination, so each parent can make an informed decision about what is best for their child. All of the facts presented here are organized so that they can be verified with good references.

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Vaccinations Required for Health Care Workers
Prior to entering certain programs at Red River College and the University of Manitoba the following vaccinations are required prior for admission: Tetanus, Diphtheria, Polio, Measles, Mumps, Rubella, Hepatitis B, and Chicken Pox (or blood proof of immunity). A test for Tuberculosis is also required. Other health care programs have similar requirements.

Vaccinations for International Travel
Vaccines recommended for travel vary depending upon the location traveled to and the medical history of each person. The only required vaccines for travel that exist today are for: 1.Yellow Fever vaccination (to countries where yellow fever is present or if a country mandates that travelers arriving from Yellow fever endemic countries have proof of vaccination). 2.Meningoccocal meningitis for travelers to Saudi Arabia. 3. Cholera is no longer officially on this list but some countries irregularly insist on proof of immunization. The W.H.O does not support this practice. It is advisable to contact a travel medicine specialist for further advice, for each person and trip. Rabies vaccine should be considered in children over 1 year old who would be spending extended time in high-risk areas.

Vaccine Safety
Parents have concerns about vaccine safety. In licensing vaccines, Health Canada and the U.S Food and Drug Administration have developed scientific criteria for approving vaccines and monitoring side effects once approval has been given.

Approval of Vaccines
The approval process for vaccines is regulated and involves clinical trials in three phases.

Phase One Phase Two

Involves studies concerned primarily with learning more about the safety of a product with a few study volunteers. Their studies are longer and involve more study volunteers. These studies are designed to demonstrate the ability of the vaccine to induce antibodies and also further evaluate side effects and risks. Studies involve a large number of study volunteers for a longer time. They verify that a vaccine is effective in preventing a particular disease as well as giving information about the risks and benefits of the vaccine. Clinical trials are ongoing for years before a vaccine is ever licensed.

Phase Three

After completing the three phases, the manufacturer submits the data on safety and effectiveness to Health Canada or to the FDA in an application for license to sell the product. Health Canada has the responsibility to review the clinical studies data, the available facilities, and the methods used for manufacturing the product. On average it may take over 5 years

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from the time of application for licensing to occur. Approval does not occur until the safety and effectiveness of the product is assured.

Monitoring Vaccine Safety After a product is approved vaccine safety is monitored by a variety of ways including on site inspection of the manufacturing facility. A review of the manufacturer‟s testing of the vaccine is done for safety, purity, and potency. Health Canada and the FDA may repeat some of these tests themselves. There is also a national system in Canada and in the United States to report any possible adverse effects reported by health care providers, patients, parents or anyone with a concern of a possible adverse effect after receiving a vaccine. Health care providers and vaccine manufacturers are required by law to report serious adverse events.

Question: Are there certain vaccine lots that have more adverse effects? Answer: No, to date no vaccine lots in the modern era have been found to be unsafe. The vaccine reporting system monitors vaccine lots. Occasionally people have misinterpreted data leading to unsubstantiated media reports about “unsafe lots” of vaccines. All reports of adverse effects are accepted. Larger lots of vaccines (1 million doses) are more likely to receive more reports of adverse effects than smaller lots (10 thousand doses). The fact that there are more reports for a particular lot does not mean that the lot was unsafe or that the vaccine caused the event. If a lot has a number of reports leading it to be believed to be possibly unsafe, it will immediately be recalled. There is no benefit to either the manufacturer or to Health Canada to allow an unsafe vaccine on the market. Question: Do vaccines cause chronic diseases such as Diabetes, Crohn‟s disease, and Cancer? Answer: After decades of vaccine use there is no evidence that vaccines cause chronic illnesses. Many people are concerned that autoimmune diseases have been “triggered” by immunizations but the immune system does not work that way. Vaccine safety research is continuing to investigate theories linking vaccination with chronic diseases to assure that the public is receiving safe vaccines. Researchers have published articles about their theories suggesting vaccines cause chronic illnesses, but when other researchers attempt to duplicate these studies, they cannot. Medical conclusions about vaccine safety and the cause of disease must be based on the quality of the medical research. Because no vaccine is without risk, when medical and public health workers recommend vaccines they must balance the scientific evidence of risk, and benefit from the vaccine with the cost of producing it. This balance changes as diseases are eliminated. One example is that with the eradication of small pox, the risk of adverse effects from the small pox vaccine far outweighs any benefit from receiving the vaccine, so it was discontinued from regular use. Question: How do we know that vaccination adverse effect reporting works? Answer: The reporting system is an effective system for monitoring vaccine safety. An example is the rotavirus vaccine, which became available in 1999 but is not presently used. Rotavirus is a common cause of severe diarrhea in infants and children. After the vaccine was

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released in the U.S.A, reports of bowel obstruction among infants who received this vaccine increased. Even though there were not enough reports to establish a relationship. The Center for Disease Control (CDC) recommended further evaluation. At present it is not used.

Comparing The Risk Disease vs. Immunization
Risk of Disease and Serious Complications Risk of Serious Reaction from Immunization

Haemophilus Influenza Type B (Hib)
-Before vaccination 1 in 200 children developed meningitis or other serious Hib diseases by age 5 -Before vaccines, Hib was the leading cause of bacterial meningitis -60% of cases occurred at an age less than 12 months old -Neurological damage occurred in up to 45% of children with severe infection - Death occurred in 1 in 20 children with severe disease

Hib Vaccine
-No known association with serious adverse effects -In one study 50% of recipients had pain, swelling, and redness at injection site that resolved within 24 hours -Fever and irritability following vaccination are rare and transient in duration

Polio
- 38,000 cases yearly (U.S. data) including 21,000 cases with paralysis -During the 1970‟s several outbreaks occurred in the U.S from non-vaccinated populations, but none have happened since 1979

Inactivated Polio
-No known association with IPV and no serious side effects -The old OPV vaccine did cause polio 1 in 2.5 million doses

Measles-Mumps-Rubella
MMR Vaccine: Thrombocytopenia- temporary decrease in platelets leading to increased bleeding occurs in 1 in 30,000 Fever occurs in 5-15% of cases about 7-12 days after vaccination and lasts 1-2 days without other symptoms

Measles
Prior to vaccination: -100,000 cases/year -Pneumonia – 1 in 20 -Encephalitis – 1 in 1,000 -Thrombocytopenia – 1 in 6,000 -Deaths – 1-3 in 1000

MMR-Measles Component
-Severe allergic reaction in less than 1 in 30,000

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-Complications and death-more common in malnourished children but also in healthy children

Mumps
-200,000 cases/year without vaccine -3-5,000/year (U.S. data) -Encephalitis – 2 in 100,000 -Testicular swelling-1 in 5 adults -Deafness-1 in 20,000 -Death-1 in 3,000

MMR – Mumps Component
-Severe allergic reaction in less than 1 in 30,000 -There is no evidence that this vaccine causes aseptic meningitis, encephalitis, sensineural deafness, or orchitis (Institute of Medicine 1993)

Diptheria
Prior to vaccination: -200,000 cases/year -15,000 deaths/year -In U.S.S.R over 50,000 deaths/1995 -Deaths occur in 1 in 10 of those infected

DtaP Component
-No known association with serious adverse effects. Very rare allergies to diptheria component

Tetanus
Prior to vaccination: -600 cases/year in U.S. -After vaccine – 100 cases/year -World wide today, 7500,000 deaths/year

Tetanus Component
-Severe neuritis (inflammation of nerve) 1 in 100,000 -Severe allergic reaction 1 in 1 million

Hepatitis A
-125,000-200,000 cases/year in U.S. -10-15% may be sick up to 6 months -Deaths 70-100/year (U.S. Data)

Hepatitis A Vaccine
-No Known association with serious adverse effects -A very low-grade fever in <10%

Hepatitis B
-Infection causes signs of severe hepatitis up to 2 months with recovery for most -1-2% develop fulminate hepatitis which has a 63-93% mortality rate -10% develops chronic hepatitis B leading to cirrhosis, liver cancer, etc. -Estimated >100,000 new infections per year in the U.S.A -Lifetime risk of hepatitis B >20% -Over 200 million carriers of hepatitis B world wide

Hepatitis B Vaccine
-Pain at injection site (13-29% adults, 30% children) -Mild complaints (fatigue, headache-11-17% Adult, 0-20% children) -Fever-<37.7°C (1% Adults, 4-6% children) -Rare allergies to Hep B vaccines Baker‟s yeast is a component but allergies to baker‟s yeast have not been reported

Influenza
Symptoms may appear after an incubation of 1-2 days. Abrupt onset of fever, muscle aches, non-productive coughs, and headaches occur. Severity is less if the person has encountered a similar antigened

Flu Vaccine
Local reactions can occur at the site with arm soreness and redness, lasting 1-2 days in 15-20% of people. Non-specific fever and aches last 1-2 days in <1% of people.

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form of influenza before. Only 50% of people have the above classical symptoms of influenza. Symptoms last 2-3 days and rarely more than 5. Aspirin should not be taken because of its association with Reye‟s syndrome in children, which is often a fatal affliction. Complications of the flu include: -Pneumonia (bacterial super infection or influenza pneumonia which is a rarer type) Reye‟s syndrome is a rare type of complication in children causing the development of coma and brain swelling. Other complications include: -Myocarditis (inflammation of the heart) and Worsening of chronic bronchitis. Death occurs in 0.5-1 cases, usually in ages >65 years. Hives and allergic reactions occur rarely particularly in people allergic to eggs. People with egg allergies should not receive the vaccine. At present the flu vaccine is injected but a nasal preparation is being developed. (there has been some use in the USA).

Pneumococcal Disease

Both Pneumococcal Vaccines 7-Valent Conjugate Vaccine 23-Valent Polysaccharide Vaccine
-No serious adverse effects -Severe allergic reaction in less than 1 in 10,000 people

-3,000 meningitis/year -50,000 bacteremia (blood infection) per year -40,000 deaths/year (very young and the elderly)
              

References: Canadian Pediatrics Society: Your Child’s Best Shot – A parents guide to vaccination. 1997 Atkinson,Wm; Gantt, J; Mayfeild, M ; Epidemiology and Prevention of Vaccine-Preventable Diseases th (The Pink Book) U.S Department of Health and Human Services, January 2000, 6 Edition. Humiston, Sharon G., MD, MPH and Good, Cynthia. Vaccinating Your Child: Questions and Answers for the Concerned Parent. Peachtree Publishers, LTD., Atlanta, GA 2000. 2000 Red Book, Report of the Committee on Infectious Diseases, American Academy of Pediatrics Offit Childhood Disease: Guidelines for Parents.” 1994. Paul A., MD and Bell, Louis A., MD What Every Parent Should Know About Vaccines, Macmillan Publishing Company, New York, NY, 1998. rd Public Health – Seattle & King Country, Plain Talk about Childhood Vaccinations, 2000, 3 Edition. U.S. Center for Disease Control and Prevention; “Six Common Misconceptions about Vaccination and How to Respond to Them”; January 1996. American Academy of Pediatrics; “What Parents Need to Know About Vaccination and Immunization Resources American Academy of Pediatrics www.aap.org/family/parents/vaccine.htm Bill and Melinda Gates Children‟s Vaccine Program www.childrensvaccine.org Children‟s Hospital of Philadelphia www.vaccine.chop.edu/index.shtml Food and Drug Administration (FDA) Vaccine Safety and Regulations www.fda.gov/cber Healthy Mothers, Healthy Babies Coalition of Washington www.hmhbna.org Immunization Action Coalition www.immunize.org Institute for Vaccine Safety at John Hopkins www.vaccinesafety.edu

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  

National Network for Immunization Information www.immunizationinfo.org Public Health – Seattle + King Country www.metroke.gov/health U.S. Center for Disease Control and Prevention and National Immunization Program website. www.cdc.gov/hip Website Resources General Advice Travel Advice Unit www.fco.gov.uk/travel U.S State Department Bureau www.travel.state.gov/ CIA Website www.odci/cia/publications/factbook Resources for the Frequent Traveler www.roadnews.com/ Medical Website www.vnh.org/usvirtualnavalhospital www.merck.com/ -Online Merck Manual www.healthtouch.com -General Health Information Travel Health Websites Canadian Lab Center for Disease Control www.lhc-sc.gc.ca/hpb/lcdc Australia Version www.tmvc.com.au/ Other www.healthlink.mcw.edu/travel-medicine/

    

Immunizing Health Care Workers Shane Woods RN OHN Red River Community College As the manager of both Health & Recreation Services at Red River College it is my responsibility to coordinate, implement, and deliver immunizations and tuberculosis testing for students in health related programs. I have been doing this for about 10 years and have seen numerous changes to our immunization policies during this time. Since Red River College took over the Victoria Hospital nursing training program in the early 70‟s, the College has been providing immunizations and TB testing in one form or another to nursing students. In the early 80‟s the immunization program was expanded covering not just nursing students but students in Medical Radiology, Medical Lab Sciences, Health Care Aide, Dental Assisting, and the RN Refresher programs. At one time even students in child care programs like Early Childhood Education, and Child and Youth Care were required to have immunizations. The College has since discontinued immunization requirements for child and youth care programs considering immunizations are not an industry standard in child care related jobs. The Health Centre at the College reviews and manages immunization records for over 1000 students in health related programs annually. As you can appreciate certain programs like HCA 52

have more than one intake per year, so the 1000 number is conservative at best. Immunization records are a challenge for both the College and the students in programs requiring immunizations and tuberculosis testing. When I started at the College the immunization program was vastly different than it appears today. At that time we would pick a mutually agreeable date with the program coordinator for the course, and have all the students in the program line up outside the Health Centre and bring into the Health Centre 5-6 students at a time. Students were informed to bring with them any documents indicating previous immunizations-which in most cases students did not have a record of previous immunizations which only complicated and slowed down the immunization process in the Health Centre. Each student would meet the first nurse to review any history with exposure to TB and any previous known immunizations and document them on that student‟s immunization record. The student would then proceed to the second nurse and receive their step one TB test and any other immunizations required. This process was the same for every student in any health related program. Then each class was scheduled for a second visit to read the results of their mantoux test. In the cases where a positive mantoux result appeared the student was sent to their own MD for a CXR to rule out active tuberculosis. Remember most of these students were relatively fresh graduates from high school and lining them all up outside the Health Centre like livestock for branding seriously concerned me. As you can appreciate students were extremely nervous and as a result created undue stress amongst one another talking about how painful it is going to be, etc. It didn‟t help that those students who completed the process as they left the Health Centre stopped at those still in line and although jokingly made untrue comments about the process only added to the stress of those still in line. We had them fainting, shaking, and literally turning as white as a sheet with this process. Remember, most of these students had never visited any type of clinic without at least one parent accompanying them. This would even delay the whole process as we would have to stop the immunization process to deal with these fainters, etc. These faints were not the result of any allergy or sensitivity to the vaccines or tuberculin, but rather a simple stress reaction to receiving immunizations partly due to the fact the students knew very little if anything about immunizations. This immunization and TB testing process was not only extremely stressful for the students, it was very costly for the College in terms of staffing and supply costs. The immunization program was also interrupted whenever an emergency occurred on campus as it is the Health Centre‟s staff responsibility to respond to all emergencies on campus. Whenever this occurred the remaining students in line would be even more stressed considering the program would have to be postponed, and they would have to return another date and time and go through the whole process again. Also during this time immunization and TB testing were not mandatory even though students in these programs are at risk for exposure to communicable diseases and in contact with patients and/or materials from infected patients. Numerous students signed waiver forms based on their own or their parent‟s beliefs about immunizations. Some even convinced their doctors to write letters to the College recommending no immunizations or TB testing without any rational explanation from the doctor. This really concerned me considering the College would be graduating health care professionals who did not seem to have much regard for their patients and risking transferring infections to their patients, or acquiring a vaccine-preventable disease from their patients who may not be diagnosed yet. As a result of these increasing number of waiver forms the College implemented a policy stating that immunization waiver forms would only be accepted with a written doctor‟s letter with a medical reason attached as to why they are not recommending immunizations or TB testing. In other words personal beliefs or religious beliefs were not acceptable reasons for refusing immunizations or testing. We certainly had our issues

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with this new policy but if nothing else we were immunizing more students and protecting the patient‟s whey would be coming in contact with. The University of Manitoba who graduates degree nurses had similar policies for their student nurses. Immunization programs at both the college and university changed when a University student challenged the immunization policies in a court of law. The end result was that the student lost her case but recommendations were made through the court that the Winnipeg Regional Health Authority adopts immunization guidelines in respect to students practicing in their facilities. On the screen in Red River College‟s Immunization record which is based on the WRHA guidelines. As you can see the immunizations are categorized as “Required” or “Recommended”. Previous to these WRHA guideline the College followed the immunization recommendations for health care workers from the Canadian Immunization Guide. But after all these were recommendations only and the College had little rationale or back up in making immunizations mandatory considering these guidelines were recommendations only. Of course this all changed in 2001 with the immunization policies put forth by the WRHA in response to the court recommendations. About this same time the cost of tuberculin testing solution increased over 100%, so the College decided to make immunizations a pre-entrance requirement.

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What this means in that as soon as a prospective student applies for a health related course they are sent with their application package an immunization record which requires completion prior to being accepted into the program. Considering this enrolment activity is done by the Enrolment Services department of the College it remains the Health Centre‟s responsibility to receive and review the submitted records and keep Enrolment Services aware of submitted complete-to-date immunization records. Enrolment Services would then remove this restriction off the student‟s application and grant them a seat in the program. With the College making immunizations an entrance requirement our costs of immunizing and TB testing each health related course student dropped significantly. With the WRHA guidelines students could no longer sign a waiver form refusing immunizations unless they had a doctor‟s letter attached stating a medical reason for no immunizations. Even in these cases the College forwards these records and letters to the WRHA for their final review and approval prior to the student being accepted in their chosen program of study. Most importantly though, was the fact students did not have to experience he herd mentality of lining up outside the Health Centre for their immunizations and experience all the issues which I described earlier. Although these changes were positive from both mine and the College‟s perspective, it does not come without its challenges; CHALLENGES  Financial-Students would now have to pay of immunizations and TB testing. Many prospective students find the costs very high considering immunization providers can charge whatever they want for this process. Time Management-Prospective students are given deadlines to submit their record and if deadline is not met students will loose their tentative reserved seat in the program.

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Finding Immunization Providers-Some family physicians do not offer immunizations or TB testing leaving the prospective students to search out other immunization providers. With the formation of travel health clinics like Skylark Medical this situation has been somewhat resolved as family doctors will now refer their patients to these clinics for immunizations related to entering health related programs. History of Previous Immunizations-this is not a new challenge but students continue to have difficulty tracking down previous immunizations mostly due to the fact their parents did not keep a record of their immunizations or the family physician are no longer practicing and it is virtually impossible to retrieve these old records.

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Inconsistencies in Health Authorities Immunization Guidelines-not all Health Authorities in Manitoba have adopted the WRHA guidelines. Rural areas may require few if any immunizations to practice in their facilities. I understand this is changing in the very near future as all the health authorities in Manitoba are going to adopt the Winnipeg Health Authority guidelines in respect to immunizations and TB testing.

When the WRHA developed these guidelines they separated immunizations into “Required” or “Recommended” based on the effectiveness of the vaccine, probability to/transmission of the disease, and the consequences of the disease in vulnerable patients groups. All the WRHA immunization 56

guidelines are in accordance with The National Advisory Committee on Immunizations developed by Health Canada. Although the College encourages health related course students to receive even the recommended immunizations (like the annual flu shot for example), we do not reject submitted immunization records if the recommended section on the record is not completed. Considering the number of records we review it is almost a full-time job for the nurse in the Health Centre. Common Reasons for Rejecting Records, As you can see the record has a significant amount of information to be completed and the College revises the record annually based on the previous year‟s questions from both the student and those providing the immunizations. I would like to highlight where mistakes are made on the record which would prompt a rejection. It is certainly not unusual to have records rejected 2-3 times based on incomplete information like no signatures or an improperly conducted mantoux test.  Personal Identifying Information-frequently the student fails to sign their record or include their assigned student number or program of study on the record. At the bottom of the form is a space for the immunization provider to sign and date the record reason being the immunization record is considered a legal document and can be called into evidence in a court of law and thus will be rejected without the required signatures Varicella Vaccine-Current WRHA guidelines require either a physicians or patient/parent diagnosed history of chickenpox. If history of disease cannot be established the immunization is required. Frequently enough the immunization provider does not complete the antibody test after vaccination to determine immunity and in these cases the record is rejected until which time immunity is determined by the antibody test.

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Hepatitis B-The Health Centre receives significant number of calls from prospective students about how they are going to complete their whole Hep B series (3 shots over 6 months) along with the antibody test by their submission deadline from Enrolment Services. We of course explain that as long as their Hepatitis B series are up-to-date and according to schedule the record would be accepted if all other information on the record is complete to date. We also experience a significant number of records where the antibody test being ordered to determine immunity after immunization is the wrong antibody test. Often we see the Hepatitis B Surface Antigen being ordered which only determines whether or not the student is a carrier of Hepatitis whereas the Antibody to Hepatitis B Surface Antigen is the test which determines an immune response to Hep B vaccination. Historically the Health Centre sees numerous records where the Hep B series is far off schedule and the College will accept such records with reasonable explanations such as sick when due for their second Hep B shot. Mantoux testing-Now comes the one requirement on the record that causes everyone from the student to the immunization provider the most for the lack of a better word-GRIEF. Although the College no longer administers this test or reads the results, Mantoux testing continues to haunt us in some respects. Some family physicians do not provide mantoux testing leaving the student to seek alternate sources to complete this test. There is also significant controversy in the immunization community about mantoux testing itself and how and when it should be done, along with how often it should be done. Although the WRHA guidelines are in accordance with the “Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and Other Institutions” from Health Canada this remains an area with significant different interpretations. Most frequently we reject records when the window

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period of 7-21 days between step one and step two are not adhered to in the testing process. The intent is that the step 2 test boosts immunity memory best if done between 7-21 days from the first test, and although there is evidence to suggest the step 2 can illicit immunity memory response even after 21 days the College has adopted the Gold Standard of 7-21 days between step one and step two, otherwise we could simply be all over the map with mantoux testing, and risk the possibility of students infecting patients. Up until recently facilities under the direction of the WRHA had different policies in respect to mantoux testing. Recently I became aware that the Occupational Health departments in each facility are working toward the same standards and policies in respect to TB testing. Currently there is controversy indicating that a one-step mantoux test is all that may be necessary. It is anticipated that the WRHA revised guidelines ill address this controversy. Some immunization providers still accept that a current CXR replaces the need for mantoux testing, and occasionally records are rejected when mantoux testing is not performed and replaced with a CXR. Although the directions on both the front and back of the record are quite specific in respect to immunizations and TB testing immunization providers continue to make errors in mantoux testing and the record would be rejected in these cases.

As mentioned earlier these records being considered a legal document require the signatures of both the student and the immunization provider especially in the event of an exposure while the student is practicing in the facility. As an example, in the event of a needle stick injury a copy of this record would be forwarded to the Occupational Health department of that facility to assist in determining the need for certain post-exposure testing.

Immunizations initially carry with them many challenges. The goal of the College is not simply to produce academically prepared graduates but to graduate students who are prepared with the necessary vaccines to prevent vaccine-preventable diseases in both their patients and themselves. The vast majority of the funding for the College comes from provincial tax dollars. The College is graduating health care professionals who will be working in your communities caring for Manitobans and others, and the College has a responsibility to reduce the risk of infection from any graduate.

Cruise Ship Medicine
Gary Podolsky MD
Learning Objectives: 1. Introduce clinicians to the on board environment aboard a Cruise ship 2. Learn the common and important illnesses and injuries to passengers and crew at sea 3. Discuss Medical Officers role in Sanitation, Outbreaks and Occupational needs of the cruise 4. Discuss Human Rights Issues aboard for Crew members and Passengers Safety concerns 5. Advice for Family Medicine and Travel Medicine Professionals to prepare their patients for cruise travel: pre-trip physicals, immunization, chemoprophylaxis and education about inherent risks of cruise travel and limits of resources

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Introduction When I first decided to talk about my experiences as a cruise ship physician I simply told my experiences as they unfolded to me. There are many idyllic views of working aboard a cruise ship and I had to reconcile these with my experiences and the stories I had heard from my fellow crewmembers. There are many authorities on the state of health aboard cruise ships.1-13 Many of the testimonials from physicians I had heard were solely praising the merits of working afloat and did not mention any of the problems I found myself confronted with. I find it hard to believe we worked in the same media .The travel industry barely mentions any form of risk in their pamphlets. In preparation for this talk I read several recent guidebooks on cruising. Other than a description of the facilities they offered nothing on safety issues. Several watchdog groups have raised many serious concerns about human rights violations, lack of safety, and risky behaviors aboard. Many successful lawsuits have been won against the cruise industry to give further credibility to these claims 14-17 It is generally difficult to sue a cruise ship company because often passengers live outside the port of jurisdiction and there is also a time limitation effect. The number of completed lawsuits may represent the tip of the iceberg against the industry. I have included statements and from American College of Emergency Physicians (ACEP) and the Centre for Disease Control (CDC) on their guidelines towards Cruise Medicine19-20. It should be noted though that they are only guidelines and not always watched. Hopefully by forcible confronted with these problems the Cruise industry will reform by progressive actions. This is unlikely to evolve by itself and existing and proposed guidelines 16, 17,27-29will need to be enforced from without by watchdog organizations. I have also included some information regarding legal liability and the rights of passengers and crews15-17,29. This is a difficult subject to summarize The medico legal environment aboard is an important part of this talk and must be included although I can only comment on how it affected the past treatment and disposition of the cases on my ships and do not wish to generalize to the whole industry. I have included many good resources that will help readers find answers to the current status of some issues I raise. All of the case histories recorded did happen but the names of individuals and companies have been left out or changed.

Life aboard a Cruise Ship
I will discuss the basic operations of a cruise ship and explain how the doctors and nurses fit into the hierarchy. Injuries and illnesses that occur can be divided into those that will occur when any large groups of people are congregated together as well as the types of problems specific to a remote marine environment. Cruise ships are a popular type of leisure travel with people having images of the “Loveboat”. The reality can be quite different. I have worked as Chief Medical Officer on several large cruise ships. The following is a brief description of the cruise environment. Captain The captain is the master of the ship and runs the ship according to International Law and the rules of the cruise line. He is also in charge of medical evacuations, not the physician who must convince the Captain of the necessity of evacuation. Staff Captain The Staff Captain and his staff assist the Captain. It is the Staff Captain who is in charge of disciplining all cruise ship employees. The deck crews are also under the staff captain and perform a variety of maintenance and repair work necessary for the ships function The Hotel Manager runs the 'Hotel' part of the ship, with the Chief Purser and the rest of the pursers running the accommodations. The Food and Beverage Manager also is responsible for the catering and dining services aboard. Hygiene is a very crucial issue and will be discussed later. There is an important coresponsibility shared with the Chief Medical Officer for ensuring that the Ships Sanitation record is clean. The Chief Steward is responsible for the stewards, who run guest services such as room service delivery and the cleaning of rooms. The Cruise Director is an important liaison with the passengers and is in charge of the cruise staff. This includes the dancers and shore excursions. This image is best exemplified as “Julie” from the “LoveBoat” and of all the perceived stereotypes this is the one that most holds true to the TV show. The Casino Manager also has an important role as he oversees the management of gambling a significant revenue for the ship. Chief Engineer is responsible for the running of the engines and other systems Other Separate Department heads include: the Chief Radio Officer who was responsible for communications, Child Care Director who manages all the day care staff, Beauty Salon Manager, and the regular Shop Manager.

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The departments work together to service the passengers. Every week the captain holds a meeting, which all the major departments attend. Security Chief is responsible for ensuring the safety of the passengers and crew from each other and from external threats. If there is an altercation aboard ship people were told not become involved unless absolutely necessary and instead wait for security.
Before strict guidelines were issued, there were frequent brawls among crew members, usually over unattended women. (After our cruise line revised its chaperones policy “allowing persons under 21 years of age as passengers only if accompanied by an escort over 25 years” there has been a significant reduction in fights.) During one incident there were multiple victims and blood was smeared over the entire Lido deck. The injured parties were escorted off the ship and told to pursue civil lawsuits against each other in the U.S., as the incidents had occurred in international waters. Generally, the ships‟ security unit adopts a passive approach to surveillance, since there is “no place to run.” If caught, they will be processed, and if necessary, confined to an empty pantry, which also doubles as the morgue. I had missed reporting a woman being beaten by her husband, because no one had pointed out her bruises to me while I was in another room treating her husband with a broken hand. Spousal abuse especially among newlyweds is not unknown on cruise ships. As with mainland laws, unless someone brings forth a complaint, there is nothing that can be done. During our weekly Captain‟s Meeting we were briefed on how to look out for drug smugglers we were informed that it was highly likely that they would try to come aboard. We were to look closely for anyone who resisted having their photo with our Parrot, Giant Lizard or Pirate since this would be one sign that would give them away!

The crew is truly international being from all over the world. We had members from China, Philippines, Indonesia, Caribbean, South America, Europe, and Australia. It may surprise people to know how little English was spoken or understood. The Captain, Staff Captain and the remaining Staff were all from Italy and few spoke English good to well. I was told that our company only hires members of the Staff department from Italy because of a prior agreement the company had made with the Italian government. There was a big problem in communication with the rest of the departments. Language was a major problem as many senior officers could barely speak English. On routine day-to-day events this was merely an inconvenience but during emergent and urgent situations this as a major obstacle. When examining patients I would always insist on an interpreter since communication became too difficult. With enough effort I was always able to find an interpreter which greatly facilitated understanding. The Medical Department Depending on the size of the ship, there are one or more doctor(s) and at least 2 nurses. Medical staff may be from anywhere in the world but generally speak English. There has been criticism in the past about the composition and training of medical staff as not all are board certified. Although the American College of Emergency Physicians (ACEP) has made guidelines (See Appendix 1) the cruise ship industry is not under obligation to follow these and ships are not monitored nor inspected by ACEP. The infirmary is open during regular office hours for both passengers and crew, and is open 24 hours for emergencies. Each ship‟s infirmary has different capabilities, but generally includes IV fluids, splints, ACLS medications and a defibrillator. (Appendix 1) Medical staff can perform minor procedures, treat accidents, dispense medications and begin treatment for cardiac problems. Most ships have the capabilities to communicate with backup experts on shore. Our ship had a satellite phone to communicate with a Miami Emergency Physician to provide Medical backup advice. This is useful for both medical and legal considerations. In general the consulting physician would generally agree with me that an evacuation was advisable in situations that I deemed to be emergent.. This was exceptionally useful when I had to advise patients to be evacuated, since both the patients and Cruise Officers did not want to organize an evacuation. Infirmary beds are available for quarantine or for observation of ill patients. Passengers are responsible for infirmary costs, and these can be significant. Medical insurance with evacuation coverage is strongly recommended. Prices for medications are usually higher when compared with home. On our ship minor medications –analgesics, cough and flu meds and anti-nauseates were for purchase in the gift store by passengers. Anyone requiring an assessment or refill was required to see a physician.

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Treating Passengers Vaccinations for Cruise Ships Immunizations are recommended for both the port destinations as well as for the ship itself. For short cruises a booster tetanus, diphtheria, and polio, hepatitis A, typhoid, influenza and possible hepatitis B (for those exposed to high risk situations) is recommended. Outbreaks of influenza, rubella and other diseases occur on cruises 31-33. Ports of call may be in developing countries, and people often eat on shore so vaccinations must also cover the itinerary. Also, the ship‟s food handlers come from many developing countries and sanitation is not always optimal. One crew member was a little upset when he found a gnawed toothpick in his salad one night. Passengers usually embark on day trips to shore and are usually back ashore before nightfall. They usually will not require antimalarial medications. They may be exposed to insect borne diseases like yellow fever and dengue fever among others. This is something we did not directly address with passengers, as they should receive this type of advice with their pre trip check up. We had 2 crewmembers with chickenpox during our voyages while I was working. Passengers and crew should be confirmed to be immune before joining the ship. Adults who come from equatorial countries are apt to be susceptible since not all adults may be assumed to have had varicella infections previously. Our crew members had to be carefully quarantined, which is not simple aboard ship. The hotel manager had to carefully search the ship for empty beds and crew were quarantined with room service for the duration of their contagiousness. Pregnant women should be confirmed to be immune to rubella and varicella before they travel since many outbreaks have occurred. Yellow Fever Immunization Yellow fever immunization for cruise ship travelers is controversial. Yellow fever vaccination is firstly recommended for anyone at risk for significant exposure to yellow fever. This may occur through daytime exposure to infected Aedes egytii mosquitoes. The vaccine had previously been thought to be very safe but recent concerns about viscerotropic side effects causing symptoms similar to actual yellow fever have been observed in patients immunized for yellow fever. These patients have been older so those who are over 65 or immunocompromised are thought to be more susceptible to these side effects. It is recommended that yellow fever vaccination be used with caution in high-risk individuals although even apparently healthy young people can also become very sick.. Yellow fever vaccination is also required by certain countries for entry from travelers who are entering from countries where yellow fever is present or the possibility of yellow fever exists (yellow fever endemic areas). This is to protect that country from any imported yellow fever virus being introduced into their mosquitoes so that an urban cycle of yellow fever does not start. For reference of each country‟s yellow fever requirements the CDC provides updated information1. Some cruise itineraries take place through yellow fever endemic countries and ports of call may include cities where travelers may do a shore leave. Yellow fever may not exist in the port but in the surrounding countryside, which, although travel to is unlikely, is still accessible by day-trippers. Balancing out the needs of the passengers to fulfill their entry requirements may be difficult. Yellow fever waivers are given for true medical contraindications and will allow people with egg allergies and immunocompromised statuses to travel but waivers should not be abused since these very individuals who have their yellow card waived can also become the perfect vehicle to spread yellow fever. Common medical problems aboard ship for Passengers With a large passenger count and a crew almost as large basically anything can happen aboard. Clinicians may expect to see anything, as passengers will often minimize their illnesses despite what their tickets warn against. Peake34reports a breakdown of common complaints aboard which reflects a distribution similar to an urgent care facility.

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Table 1.Breakdown of Infirmary visits by Main Diagnosis34 Principal Diagnosis All Patient visits Visits to infirmaries 17147 100 % Distribution

Neoplasm related
Endocrine/Immune Mental Illness Nervous System Circulatory Respiratory Digestive Genitourinary Skin Musculoskeletal Injury related (total) Other non specified

15
56 51 653 239 2077 635 230 182 224 1299 893

.2
.8 .7 9.1 3.3 29.1 8.9 3.2 2.5 3.1 18.2 12.5

Traveller’s diarrhea This condition can generally be averted by careful attention to what you eat, especially on shore. The cruise doctor is responsible for doing a weekly "diarrhea log" of all affected passengers and crew. If the ship has an incidence of 3%, it is considered significant and must be submitted to the CDC35-46. They generally investigate large outbreaks. Part of the assessment of cruise ship hygiene depends on the regular submission of the weekly diarrhea log and failing to comply will cost points off the ships rating, so this is done scrupulously and is one of the major duties of the ships doctor. Sea Sickness. It usually takes a few days to get your "sea legs". Avoiding excessive alcohol and sunburn, helps prevent dehydration. Medications such as Gravol, Meclizine, and Phenergan, all help in controlling symptoms (during the first few days). Injections of Phenergan are available and are usually effective. Pregnant women may have prescriptions from their own doctors (for Gravol or Diclectin) or may try ginger. To avoid seasickness it is recommended to stay in the middle of the ship, near the center of gravity where there is less sway). Avoid reading. If above deck, focus on far away objects. Sea bands to provide acupressure to prevent and alleviate seasickness were very popular although there was very little evidence that they helped anyone. Sexually Transmitted Diseases (STDs) Many of the crew, especially officers are openly promiscuous with passengers47-48. The crew appeared to have little knowledge of STD prevention, which is very worrisome considering the prevalence of HIV in many parts of the world. Many crew members had multiple partners and some had literally a „girlfriend in every port‟. The crew is not regularly tested for STD's. Both male and female crew members will be fired if they are found in any passengers‟ cabin, unless they are working there. Occasionally there are charges of rape or other forms of assaults against crew or other passengers. Such incidences can generally be avoided by using one‟s common sense. If there is an occurrence, seek out a security officer and they will deal with the dispute. Remember, depending on where actions occur, there may be "no law" and the ship is under the Captain‟s jurisdiction.. Disabilities Cabins specifically designated for people with disabilities are not always available. One of our passengers, a 21year woman with metastatic spinal cancer, had requested such a cabin and became severely injured when a malfunctioning door crashed into her, further limiting her mobility. Although the cabin was designated as “handicap accessible,” it had not been properly maintained as such and the stewards responsible for this cabin did not have the proper training to do so. Many special themed cruises are available. Among these are dialysis cruises with specialized medical care49.

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Accidents Incidents whether on or off the ship, should be reported and documented by the ship‟s security staff as well as medical personnel. Most injuries are simple and similar those in an urgent care clinics34. As mentioned above, simple fights break out. X-rays were unavailable on board but available at all ports if required for non-urgent problems. Some accidents were from stumbles and falls. After a fall in a previously safe part of the ship the Captain‟s staff would post another ubiquitous “Watch your step” sign near the offending area so as to limit future liability. There were a small minority of accidents brought to our attention by “career passengers” which were people who had sustained previous falls on prior cruises and would again attempt to get future free trips. These passengers were always examined for free and a detailed report was forwarded to security. The hotel manager would then decide if any compensation was appropriate. I did see one bad case of jellyfish envenomation although we did not identify the species. Hazards like marine animal encounters and SCUBA related problems are possible since many vacationers also embark on a variety of activities at port50-52. Assaults There are many recorded assaults on both guests and crewmembers by both passengers and crew. The cruise ship is looked on as a finite area and security is ever present. Crewmembers are instructed not to get involved in altercations and simply observe until security officers arrive.
A DJ was assaulted by a teenager causing a severe tendon injury In his dominant hand. He was injured while attempting to stop the boy from stealing music. Surprisingly many of the security officers were diminutive and not at all physically imposing and would not help the DJ against the boy. He was surprised he was criticized for defending company property. It was generally believed among crew that the main purpose of security was to observe and keep them from violating the company‟s rules and not to protect them or passengers.

When I first worked for the cruise line altercations between young men were common over women. Our cruise line made a very clever change to their rules, which made theses types of fights less common. It was observed that fights often occurred as groups of men came aboard to meet college spring break coeds. The company changed its admission rules that limited anyone under the age of 21 from coming aboard unless they had a chaperone over the age of 25 years. This prevented groups coming aboard with one member over 21 acting as the chaperone.16
One big fight turned into a riot after two groups fought over one girl on the lido deck three o‟clock in the morning. One man had extensive lacerations that were caused when another broke a beer bottle over his head and another individual had a broken nose. Blood had been smeared across the entire lido deck as drunken bystanders had spread the blood in a panic. Clearly from eyewitnesses and the amount of damage done, security was unable to deal with the situation. I treated several of the major participants but those with minor injuries typically did not present to the infirmerary. A security officer gave the men their reports and both men were told to take their grievances to a civil court in Florida if they wanted to litigate against each other.

Sexual attacks and rapes have frequently been reported aboard cruise ships and are generally under reported and settled out of court14-17,53. Several successful lawsuits and prosecutions have been completed for rape and child molestation accusations against cruise ship employees. For our company, officially no crewmember was allowed to be in a passenger‟s room unless allowed to attend on official business and they were found they would be fired. However, if they brought a passenger back to their own quarters any relation that occurred was implied to be consensual and was overlooked since the company would not be liable for rape. Aboard the ship there was clear demarcation along class ranks. For simple laborers (galley workers, stewards) a zero tolerance attitude was taken. For other “middle class” worker (shop staff, cruise hospitality workers and junior officers) a more indulgent attitude was allowed. For senior staff (department chiefs) more rules did not apply. Senior officers would have their wives and children aboard with them during a one-week stretch only to have a mistress come on the following week. Musicians freely admitted to having contests to see who would sleep with certain passengers first and would claim up to five different women in one week. Clearly much of the time their relations are consensual and equally sought by both passengers and crew but many passengers have reported excessive harassment by senior officers.
Lydia One evening a 19-year-old woman mentioned to me how one of the senior engineers (50 years old) had attempted to drag her by her wrists towards his cabin. She had resisted and told me she had reported the episode to security. I spoke with the Security Chief and he

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denied that he had heard anything.. I talked to her again and she admitted that she had decided to not pursue a complaint, as she did not want to get the poor man in trouble. Later that cruise during the Captains weekly staff meeting a complaint letter from another passenger was being reviewed. One complaint stated as the Captain summarized that the “Italian Officers were getting too aggressive in the disco‟. The Captain wanted to find out who had written it and when he found out it was from a 50 year old married women he chuckled and dismissed it out of hand. “Deena” During one of the nights, one of the beauty salon girls was attacked by her boyfriend in a public corridor (in full view of other passengers and crew) and dragged into her cabin. Her boyfriend worked on another cruise line and was visiting. While I was examining her in my office for superficial bruises and abrasions the staff Captain appeared and demanded that she decide within ten minutes to press charges. If she would, her attacker would be deported back to his home country and if not he would resume his job on the other Cruise company. While waiting to disembark at the next port of call she was forced to confront her assailant as he also waited to disembark. Security had made no effort to separate the two. The cruise industry has a long history of sending its problems away quickly to side step liability and lawsuits.

Working with Shore Doctors in Foreign Countries Ships try to maintain list of doctors at ports of call that seem to provide reasonable treatment. But sometimes patients chose their own doctors, with variable results. For example, we visited one practitioner to whom we had been referring crew to and found him and his facility acceptable but some patients returned with expensive prescriptions for multivitamins or very poor advice. When interacting with shore doctors its best to work with people you know best. Often the local Embassy of your country can provide a list of practitioners in the area and while they may not specifically endorse any they can tell you about recent complaints. The international society of travel medicine also has a listing of travel clinics worldwide but not every country is represented54. We used a local Dentist in Mazatlan to replace fillings for crew. I was curious to visit so I inspected it once. The Dentist was very apprehensive about his attention to sterility. Although it was not my intention to grade him I found his office very professional and clean with a working autoclave.

Safety Drills -Man Overboard
People do go overboard and it is important to know the proper ways to respond to emergencies. Passengers are shown the proper safety measures and responses when boarding and while participating in lifeboat drills. For man overboard situations, witnesses should point at the spot where the person was last seen while someone runs to stop the boat. By maintaining a bearing it becomes easier to find the lost person.
“One of the passengers had been standing on the upper rails, urinating while intoxicated, and fell into the sea. Many cruise ships and rescuers were diverted to that area. Roughly 12 hours later, he washed up on shore alive and well! Back on his ship everyone who had been mourning him, now wanted to kill him for ruining their cruise!” 16

All crewmen are trained as sea men and are required to practice mustard drills several times to be proficient. During one drill I was required to take my place in Lifeboat number one, which in the case of an emergency would contain the Captain, Chief Radio Officer and me, Chief Medical Officer. In this drill ropes on tethered pulleys physically lowered us into the water and back again. The Chief Radio Officer explained to me that the Captain never went into the Lifeboat because he didn‟t trust them16 especially since a boat had flipped from bad ropes and caused a crewmember to crush his legs. This was settled out of court. The Radio Officer also pointed out that in the event of an emergency that would tilt the boat significantly starboard or port due to the ships height and placement of the lifeboats, not all lifeboats would be serviceable! The Mustard Drill for the Medical team was the infirmary, which for our ship was deck 3. We were to gather there and wait for casualties. As this was close to the bottom levels we were also told to quickly evacuate on our own initiative if we saw water coming up the stairwell! Our drill team did not perform well during our fire drill with 2 members of the stretcher drill not showing up. The crew was able to put out a real fire aboard in the laundry, which was self limited and only lasted 30 seconds, or less.

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Inspection Day It is well known that cruise ships are inspected by the Coast Guard and Center for Disease Control (CDC). The CDC publishes a green sheet based on random inspections of cruise ships see Table 2. I should point out that inspections are not completely random because there is enough time for companies to touch up. The inspection for our fleet only occurred in American ports. So while at least four of our boats were inspected the rest of the fleet had a few days warning when they would be inspected as they arrived into US waters from foreign ports. Our traveler‟s diarrhea log was completed each week and was required for the green sheet so that was one aspect of the green sheet that was easy to control. We never exceeded the 3% incidence necessary to take action. The night we were scheduled to arrive in port we had a near collision with a fishing boat. The crew and I were told that it was in our lane but air on board radar was on the wrong setting. At the last instant our ship veered to miss it. The next morning I awoke to find a mess in my room as all bundles had fallen out of cabinets, chairs and tables. In the infirmary, things were worse with all the medical supplies on the ground and a few glass items broken. I called all staff in off duty or otherwise and in the next two hours we cleaned up everything, fixing any damages or duty items. The inspector came in and passed us with only a few points off (none of it was medical).The passengers had been told we had hit a few large waves in the night but the Los Angeles Times reported the event16 . The Company had been worried because two of our sister ships had failed. One had failed because of a dead cockroach that had been found in a public ice cream machine. On the ship I had worked on cockroaches were acknowledged permanent guests. To combat them poison was spread by the staff crew around the drains in the sinks and restrooms. Our other ship had failed when one of the onboard swimming pools was over chlorinated while another was under chlorinated conditions, which have been linked with Legionella outbreaks55-58. When a similar review by the Coast Guard was due the Captain knew it was coming so it was no surprise. Table 2. The Vessel Samaritan Program Covers
     Score is out of 100 and focuses on ship‟s water supply (storage, distribution, protected and disinfected) Ships spa and pools (filtration and disinfections) Ship‟s food (storage, protection, service potential for food and water contaminates) Practices and personal hygiene of employees General cleanliness and physical condition of the ship (includes absence of insects and rodents) Ships training programs in general environment and public health practices



Occupational and Family Medicine Aboard for Crew Members
There is a good proportion of occupational medicine among the crew, especially musculoskeletal overuse problems59. If a crewmember is very sick the medical staff may recommend evacuation. For less urgent problems consultation with portside consultants in the USA and in other countries can be made while a ship is in port. This included referrals to dentists, physiotherapists, internists and sub specialists and gynecologists. Interestingly cruise physicians were forbidden to do gynecology exams on female crew except in emergencies. No reasons were given for this but undoubtedly reflect prior boundary issues in the past. The general crew was multinational and made up of members of all 6 continents and many had variable states of health care, some of them claimed to never having seen a doctor in their life. Members from developed countries had claimed to have a pre-crew physical as well as an HIV test. I myself had no physical or confirmation of prior vaccinations done. All crewmembers were compelled to complete a Panamanian physical on the ship that I worked on which was registered in Panama. This consisted of a simple history and physical checklist and cursory review of systems to satisfy the Panamanian authorities. All crew had to pay $50 US for this procedure. This examination had very low predictive value in determining any type of illness and was more of a financial incentive than anything else. Most of the crew despite coming from poor backgrounds are hardworking and honest. The deck hands may work more than 12 hours a day at less than minimum wage and are often treated poorly by other staff and passengers. 65

They often depend on tips from customers yet may do very well from the tips they make relative to working in their native countries. “Flags of Convenience “Our cruise line had its ships registries under Panamanian or Liberian registrations, as this was significantly cheaper than being US registered and we were not subject to US laws while at sea. These registries under “Flags of Convenience “enable companies to avoid paying taxes and establishment of unions and are crucial to the high profitability of the cruise industry. I had noted that while on a Liberian registered vessel our home country was in the middle of a violent civil war. Because we were under a flag of convenience regular rules and regulations that one would expect in North America were absent. There is no minimum wage for workers or labour protection laws. Some crew worked in excess of 12 hrs per day at less than 1 dollar per hour. While it is true that they may indeed do better aboard a cruise ship than they would in their own home developing country this is still exploitation. Most crewmembers are passive and accept what is meted out to them but I observed a sudden change or “Last Day Syndrome” where previously quiet crew would speak out if challenged by the usual authorities. They knew that they were going home regardless and didn‟t care anymore.
One casino worker violently let out that she was glad that she would no longer be treated like an animal and allowed to walk down a hallway without constantly under suspicion of breaking company rules. Supervisors knew well enough to stay away from crew near their last day. Case Study: Luis, the Ideal Worker I had noticed that one of the older cooks aboard had been particularly subdued and pleasant to everyone. He had attended the clinic with a translator because he only spoke Spanish. A week later, the Food and Beverage Manager had praised him on what a great worker he had been and all he ever did was get up and go to work and then go back to sleep causing no problems and always being reliable. This sounded very suspicious to me and I couldn‟t t stop thinking about it. I remembered that one entry in his chart had mentioned he was on digoxin and I started to think- if I had been there for weeks who else could have given him any? I immediately called him in and found that he hadn‟t taken either his digoxin or lasix for a few months and was fluid overloaded with CHF. After resuming his medication after a week he had a normal affect and even took to wearing a print Hawaiian shirt apart from his Cook‟s uniform during his time off. Case Study Lorelei, The Non-Ideal Worker I had been seeing a manager from the casino with recurrent right shoulder pain for several weeks after a lighting fixture in her room had fallen on her at night. She had received anti-inflammatory medication and physiotherapy during our ports of call. Finally we referred her to a shore side orthopedic doctor who ordered an MRI and gave one cortisone injection. She failed to improve and was mostly miserable in her job. Company policy was for her o return home to Columbia and get definitive care there. The cruise we were on traveled in a circuit starting from Tampa to Grand Cayman to Cozumel and then New Orleans before Tampa again. She had been told that she would disembark in Tampa. The company secretly arranged for her to be disembarked 3 days earlier in New Orleans. From there she would be returned to Columbia so as to have no chance of meeting with any US based lawyers to either apply for landed immigrant status or initiate an injury lawsuit.

FAMILY AND GENERAL PRACTICE
Many of the Crew Staff had regular medical conditions and quite a number were over 55 years. My impression was that the Company doctor was they‟re for them to see twice a day between or during their shifts but previous physicians did not encourage this. This population could have any conceivable condition and some were aboard for over 12 months. Our cruise line had a strict policy that if their female employees get pregnant, they are sent home. And the employee‟s superior must report the pregnancy to the company, or lose their job as well. Requests for abortions were referred off shore and not recorded by the medical department. The infirmary did not recommend birth control pills because our cruise lines did not officially endorse the pills. I had spoken with the Medical Director specifically and he confirmed this. He also had added “that the company officially did not promote birth control pills for employees because of the unknown long term side effects but they were welcome to see a shore doctor and get these privately”.

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Case Study, D was a young woman who had recently discovered she was pregnant. She knew that she would be sent home but told her supervisor anyway. Both she and her boss came to the infirmary and asked for a therapeutic abortion. As is the custom in Canada I immediately started to fill out a shore side referral for a gynecologist referral. My nurse at the time took my referral and ripped it into small pieces, and took out some torn pages from the New Orleans Yellow pages directory. She gave the girls the name and contact number for an abortion clinic at our next port stop and added, “don‟t you ever tell anyone who gave this to you”. She later explained that this is how this was done onboard.

Clearly there may be a conflict in doing what is best for the patient while following the company‟s guidelines. Although cruise lines have guidelines for accepting passengers with advanced pregnancy or other serious severe medical problems we encountered several people who “pushed the envelope” of what was acceptable safe travel. Although tickets told passengers they could not come aboard with certain advanced illnesses we frequently would see patients cart their own oxygen aboard. Rarely some patients preregistered with us by giving us a copy of their old medical records and an introductory letter from their physician in case they had a problem. Confidentiality – “Friends of the Clinic” This next section is a topic that I don‟t believe has been addressed anywhere. I am referring to the number of nonmedical people who used the infirmary space for personal use, which compromised patient confidentiality. The infirmary clinic hours were run during two specific times although we always would accommodate emergencies. The nurses aboard are given considerable autonomy in the running of the clinic. This is expected since many of the physicians filled temporary positions on our line and were generally temporary whereas the nurses had larger six month plus contracts. This led to many nurses acquiring friends that would stop over during working hours making it difficult to keep them from learning that other crew were there. As the ship is a small environment, rumors would easily get around. In one case one married nurse‟s onboard lover would stay overnight, as her cabin was located in a separate confined section of the infirmary, and would leave as I arrived for work. This same nurse was later removed from the ship and transferred to another on the grounds that another nurse who was the Chief Engineer‟s mistress wanted her position! Medical staff would also make gifts of medical supplies or favors to crew staff. This seemingly innocent practice rapidly polarized the crew‟s staff against the other nursing staff responsible for inventory.
Irregularities in Dispensing Medication One nurse had been giving young women surgical dressing so that they would not have to pay for sanitary napkins. This was a minor offence but created great resentment among other staff who were responsible for overhead. Later this same individual was found dispensing morphine to a young male crewmember for mild back pain without my prescription or knowledge. In this case we had a long talk with her and she professed to reform but resumed her ways very quickly. As Chief Medical Officer I was faced with a dilemma. If I fired her, and I didn‟t believe I had authority enough to do this, I would be condemning the rest of the nursing staff to do more work until we reached the next port or were able to find a replacement. This was also during a portion of the cruise where our satellite phone did not work and I could not consult the Fleet Chief Medical Officer for direction.

Because of the infirmary‟s close quarters special sensitivity should be used in guarding crew‟s medical information. The crew was very apprehensive at first from receiving medical care aboard. They seemed to generally feel that there was little attention to their prior problems by either nurses or physicians. As many Doctors viewed their job as a vacation they often let many nurses do their job for them.
Case Study Emily One woman had told me she had approached a previous doctor with complaints of fixed suicide ideation including active plans of throwing herself overboard but was told by him there was nothing he could do for her depression. He also specifically told her he was too busy to arrange any time to speak or console her and didn‟t believe that any pharmacotherapy would benefit her so he declined any therapy. I found that some days I had four to five hours of free time and such a response to a person is inexcusable. This same doctor had been prescribing continuous doxycycline indefinitely for a man for 6 weeks for no other reason than that he might have a STD. In another instance the nurses had covered for him because he was too intoxicated to attend to a patient suffering myocardial infarction resuscitation.

There were enough similar accounts backed with records to affirm that crewmembers often received substandard medical care. In another situation neither of the nurses aboard was capable of putting a very easy intravenous line 67

on a stable patient. Physicians and nurses who had experience in Family Practice and Emergency were much more skilled and professional in dealing with emergencies in general while those who had cruise careers were noticeably less skilled in attending emergencies. It would suggest that many incapable individuals may possibly gravitate towards a cruise career as they would be freer to do what they may with less professional supervision. Several crewmembers related that they obtained their own medications- birth control, antibiotics, and analgesics from Mexican pharmacies without prescriptions so they would not get hassled in the clinics. They preferred to pay for their own medications even though the company would dispense many for free. Another crew stated there was a thriving trade in street drugs aboard although I myself never saw any evidence of this.

Significant Injuries Requiring Evacuations Medical evacuations are indicated for patients who are very ill, badly injured or in need of immediate treatment. But evacuation is not always practical, and always very expensive. The Captain and Chief Medical Officer will make arrangements to evacuate patients to the nearest appropriate hospital. The ship‟s doctor can only recommend evacuations, not order them, but no reasonable captain would go against their doctor's medical opinion. Some of the medical emergencies we encountered included myocardial infarcts; strokes, deep vein thrombosis, and open fractures. The U.S. Coast Guard will evacuate passengers from ships that are within 100 miles of the U.S. coast. Many cruises, obviously, travel much further than that. And there are watershed areas where there is about one to one and a half days between ports. When passing through these watersheds, evacuation becomes difficult for many reasons, including: logistics, many passengers/patients are reluctant to leave the ship; and changing course if necessary, angers lots of passengers. Sometimes the ship is reversed to the last port or sped up past its cruising speed. Although in the Caribbean the arrival time between islands is usually given as a day, it can usually be accomplished in a few hours. This is not widely done, in part because the company benefits more from keeping the passengers in international waters longer so they can gamble more in the casinos. Transport time for sick patients will vary according to where in the cruise the event takes place. One study showed a main time from the physician calling for an evacuation to arrival at hospital was 16.6 hours60,61. Each cruise has a preplanned course that gives in a set pattern. On ocean going cruises with sea days there are certain known “watershed areas” of where access for help or speedy evacuation will be very difficult. One hotel manager had confided with me that this is specific information they keep from the new doctors so as not to worry them. If a passenger has an incident while traveling away from a port of call and with no significant air evacuation available, this will obviously cause a delay in patient transfer. Some urgent emergency situations that had occurred for me are:
Deep vein thrombosis in the deep blue sea A young woman with a prior pulmonary embolism from a deep vein thrombosis presented to our infirmary in the middle of the Gulf of Mexico with symptoms of her previous deep vein thrombosis. After consulting with a physician in Miami and the patient, we agreed to initiate a heparin infusion empirically and take blood to establish a baseline PT, PTT. The woman had an uneventful transfer to Tampa. Open fracture On a cruise out of Grand Cayman a deckhand had crushed his index finger with an open wound. Although not life threatening, an open dirty wound could not wait for air next port of call and I advised evacuation. In this instance the ship had to be turned around back to the Grand Cayman. The staff was very unhappy with my decision and I was shown a bill for all the “wasted fuel” that my diversion has caused by one of the junior engineers. Second open Fracture from doing the Jitterbug While leaving Tampa an elderly couple had been dancing the jitter bug and the lady had sustained an open fracture of her right wrist. A small cube of wrist bone was actually located on the dance floor. I had wanted to attempt to identify it but it was thrown out like waste before I could secure it. Since the cruise was still in American water I had assumed that it would be an easy evacuation. Initially the cruise was only two hours out of port heading for the Caribbean at 900 pm. The coast guard was contacted and despite our Captain‟s protests that I just put a cast on it until we get to Grand Cayman I understood that we would get an evacuation. After three hours of waiting I found the Captain had changed the plan to meet a coast guard ship in 15 hours. I spoke with the coast guard again this time impressing that this woman had at least a limb threatening injury and given her diabetes and past medical health a risk for sepsis. The coast guard agreed to send a helicopter. The husband who had previously been told he could not go with his wife now would be allowed to go. At three a.m. I received a phone call from one of the Italian officers informing me that the „helicopter is

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broken‟. He followed with a pregnant pause, which I believe he expected me to yell at him. (I didn‟t) I asked and found that the next one would be available at 0500. The copter arrived with a wire litter basket and hoisted the patient up. In this case the patient was seen in Fort Lauderdale and had a 3.5-hour debridement surgery. Her husband hearing of her state was forced to have his cruise by himself until we reached Grand Cayman one and a half days later. Indeterminate Chest Pain and denial During a trip out of our San Fernando Port, one of our elderly patients had syncope without chest pain. He had a strong history of vascular disease and stroke. After his collapse his physical exam was unremarkable and EKG only showed non-specific ST changes. I contacted Miami and discussed the situation. Of coarse there was no way of ruling out an event since we had no way of assessing enzymes available. After a talk with the patient I advised him to treat this as a myocardial event and he should he on oxygen and transferred. He disagreed and wished to remain a passenger. He had that right and we could not transfer him while at sea against his will. This ship would also charge him for oxygen and observation in the infirmary so he declined all treatment. This was all happening as we were leaving US water and we would shortly be in a position where air evacuation would be impossible. To make things worse one of the nurses I had previously disciplined for giving narcotics without my knowledge (see other anecdote) was now advising the patient not to listen to me. After we passed out of US waters the patient remained stable. At the Captain‟s discretion we created a port we would not normally go to at Cabot San Lucas. By now being “at port” we had the discretion to force the patient to receive medical attention. He was transferred via a launch since our ship remained at sea. Now unhappy with being in a Mexico hospital he arranged a separate jet evacuation himself to return to Los Angeles. During the time I spent assessing him I had originally attempted to obtain his prior EKG from his family physician in Santa Monica, but the sat phone which wasn‟t always working broke down and although I was able to speak with his doctors office I was unable to receive the fax of his prior records and EKG. I strongly advocate all cardiovascular patients to bring with them a recent EKG and legible list of their medications and relevant medical history. This makes working in the dark easier. Stroke in Port On arrival in Tampa one man presented with numbness and hemiparesis just as I was departing the ship. I put him on ASA and oxygen but I found that I was on my own. The porters seemed disinterested in calling for an ambulance because they has so much to do and my nurse who like myself was ending her current contract left the ship in the middle of the resuscitation! After much convincing I persuaded the remaining staff to help me and we transferred him off.

Each of these situations exemplifies the variability of available resources at different times on the same type of cruise. Communication with a multilingual crew is difficult and advanced planning is necessary and the same approach will not work each time. Conclusion Cruise ship vacations are currently a very popular form of travel and offer several advantages for travelers with handicaps, special needs (including dialysis) and the elderly all of who may vacation in a controlled environment. Concerns due to remoteness of specialized care and questionable onboard practices may spoil this idyllic solution. Travelers should first be sure that they are fit enough for remote travel 62-64, and have with them their current medical records and enough medication. If questionable they should review their health with their family physician and ensure that they have all the recommended immunizations including if appropriate, yellow fever. Cruise ships must have competent medical staff. At present whether adequate care exists is questionable,65,66. Published guidelines exist but are not mandatory and it is unclear how closely they are followed among all ships and companies. It is also difficult to declare standards since an infirmary will never be equal to an emergency department yet many of the successful lawsuits suggest that much more improvements need to be made. Infectious outbreaks occur regularly on ships. Not all passengers or crew are fully immunized or screened so this is likely to continue and cruise guests must accept some risk. Seniors are encouraged to have their influenza and pneumococcal immunizations and all women susceptible to varicella or rubella should be vaccinated before their pregnancies. The shipboard environment has previously been thought to be a blank slate but crewmembers from all over the world may also carry polio, tuberculosis, typhoid, hepatitis A and B, and HIV so passengers should consider the ship as another country unto itself in their pre-trip planning. Finally Cruise ship physicians must be prepared to deal with occupational and family practice health issues. Issues of Human Rights and Sanitation are intimately related with Health although not “part of the job description”. Raising the problems with “Flags of Convenience” will lead to the discontinuation of many health issues and ultimately aid passenger, crew and cruise line in the long term.

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APPENDIX 1 RECOMMENDATIONS FOR ONBOARD MEDICAL STAFFING ABOARD CRUISE SHIPS
The specific medical needs of a cruise ship are dependent on variables such as: ship size, itinerary, anticipated patient mix, anticipated number of patients' visits, etc. These factors will modify the applicability of these guidelines especially with regards to staffing, medical equipment and the ships' formulary. Medical care on cruise ships would be enhanced by ensuring that cruise ships have: 1. A ship medical centre with medical staff (physicians and registered nurses) on call 24 hours per day, examination and treatment areas and an inpatient medical holding unit adequate for the size of the ship. A medical centre with adequate space for diagnosis and treatment of passengers and crew with 360° patient accessibility around all beds / stretchers and adequate space for storage.  One examination / stabilization room per ship  One ICU room per ship  Minimum number inpatient beds of one bed per1000 passengers and crew  Isolation room or the capability to provide isolation of patients  Access by wheelchairs / stretchers  Wheelchair accessible toilet on all new builds delivered after January 1, 1997  A contingency medical plan defining:  One or more locations on the ship that should: o be in a different fire zone (from the primary medical centre) o be easily accessible o have lighting and power supply on the emergency system.  Portable medical equipment and supplies including: o Documentation and planning material o Medical waste and personal protective equipment o Airway equipment, oxygen and supplies o IV Fluids and supplies o Immobilization equipment and supplies o Diagnostic and laboratory supplies o Dressings o Treatment - medications and supplies o Defibrillator and supplies  Communication equipment for each member of the medical staff  A clear procedure in case the primary medical space cannot be used  Crew assigned to assist the medial staff Medical staff who have undergone a credentialing process to verify the following qualifications:  Current physician or registered nurse licensure  Three years of post-graduate / post-registration clinical practice in general and emergency medicine OR Board certification in: o Emergency Medicine or o Family Practice or o Internal Medicine  Competent skill level in advanced life support and cardiac care.  Physicians with minor surgical skills (i.e. suturing, I&D abscesses, etc)  Fluent in the official language of the cruise line, the ship and that of most passengers A medical record and communication system that provides:  Well organized, legible and consistent documentation of all medical care  Patient confidentiality Emergency medical equipment, medications and procedures:

2.



3.

4.

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5.

6. 7.

Equipment: o Airway equipment - bag valve mask, ET tubes, stylet, lubricant vasoconstrictor, suction equipment (portable) o Cardiac monitor and back-up monitor (2) o Defibrillators, two (2) portable, one of which may be semi automatic o External cardiac pacing capability o Electrocardiograph o Infusion pump o Pulse oximeter o Nebulizer o Automatic or manual respiratory support equipment o Oxygen (including portable oxygen) o Wheelchair o Stair chair and stretcher o Refrigerator / Freezer o Long and short back boards cervical spine immobilization capabilities o Trauma cart supplies  Medications Emergency medications and supplies for management of common medical emergencies, to include: o Thrombolytics and sufficient quantities of advanced life support medications, in accordance with international ALS guidelines, for the management of two complex cardiac arrests o Gastro-intestinal system medications o Cardiovascular system medications o Respiratory system medications o Central nervous system o Infectious disease medications o Endocrine system medication o Obstetrics, gynaecology and urinary tract disorder medications o Musculoskeletal and joint disease medications o Eye medications o Ear, nose and oropharynx medications o Skin disease medications o Immunological products and vaccines o Anaesthesia medications  Procedures o Medical operations manual as required by international safety management code o Medical staff orientation to the medical centre o Maintenance for all medical equipment as recommended by manufacturer o Code team trained and updated regularly o Mock code and contingency medical plan drills on a recurrent basis and as recommended by ships' physician o Emergency preparedness plan as required by the international safety management code o Internal and external audits Basic laboratory and X-ray capabilities  Haemoglobin / haematocrit estimations, urinalysis, pregnancy tests, blood glucose (all with quality control program as recommended by the manufacturer)  X-ray machine for new builds delivered after January 1, 1997 A process whereby passengers (prior to embarkation) are requested to provide information regarding any medical needs that may require medical care on board. (FYI-ACEP Board) A health, hygiene and safety program for medical personnel  A regular health, hygiene and safety program for medical personnel





An annual TB screening program for all medical personnel

References 1.Center for Disease Control Cruise Ship Travel: Health Recommendations

www.cdc.gov/travel/other/cruiseship_recommend.htm 2. Cruise MD’s Treat Thousands at Sea www.cnn.com/2004/health/01/26/cruise.doctors.ap/ Contains criticism of current standards aboard cruise ships 71

3.Cruise Ships Via Health Services www.viahealth.org/disease/travelmedicine/ships.htm A brief overview about infectious diseases and the Samaritan on Cruises 4.The Good, The Bad and the Ugly of Cruise Ship Medicine By Dr. Richard Fort www.healthlinks.net/archive/drrick/html Personal Experiences of a Cruise Ship Doctor 5.Shipboard Medicine: A New Niche for Emergency Medicine. Digioranna et al Annals of Emergency Medicine 21:12 December 1992 6.Cruise Ship Electives www.ranterventures.com/cme.htm Description of a four week elective for medical residents through Yale Emergency Residing Program 7.“Sailing into Sickness” Web MD Health http://my.webmd.com/content/article/57/66054.htm 8.Guidelines of Care for Cruise Ship Medical Facilities Ann Emerg Med, June 1996; 27: 846 9.Travel Medicine-Cruise Ships University of Utah Health Science Center www.med.utah.edu/healthinfo/adult/travel/ships.htm 10. Reflections on the Medical Profession during an Alaskan Cruise, Tan Sy Singapore Med J 2002 Vol. 43(2) pp 57-59 11.Safety at Sea: How Cruise Ships Take Care of their Passengers www.magiccarpetjournals.com/cruise_safety.htm 12.Cruise Ship Medical Faculties www.cruise4.com/medical.html Consumer information for general public on medical faculties aboard cruise ships 13.Interview with a Cruise Ship Nurse. Diane Wrobleski. Journal of Emergency Nursing 1996; 22: 546-8 14.Cruise Law Litigation Cases Against Cruise Ships www.cruiselaw.com Collection of Litigation Cases Arrived from Miami Herald 15.The Cruise Passengers Rights and Remedies www.courts.state.hg.us/tandv/cruiserights/html 16.Death by Chocolate Ross Klein Breakwater Press St John‟s Newfoundland 2001 17.Cruise Ship Blues Ross A Klein New Society Publishers Gabriola Island BC 2002 18.Health Care Guidelines for Cruise Ship Medical Facilities American College of Emergency Physicians www.acep.org/1,594,0.html 19.Section of Cruise Ship and Maritime Medicine American College of Emergency Physicians http://ourworld.compusevre.com /homepage/vims/socsmm.htm Medical Research and Health Care on Cruise Ships 20.Cruise Ship Medicine: Optimizing Health Care at Sea By Dr. Robert Wheeler www.mersante.com/cruiseshipmed.htm 21.Statement of Cruise Ship Medicine International Council of Cruise Lines www.lccl.org/policies/medical3.cfm An explanation about the International Council of Cruise Lines 22.Current Trends Vessel Sanitation Scores MMWR Weekly Feb 26, 1988/37 (7); 114-7 23.Sick at Sea: Outbreaks Prompt Reinstatement of Cruise Ship Inspectors, Korcok, Milan CMAJ, Vol. 136, June 15, 1987 24.Health Care Guidelines for Cruise Ships Facilities Consumers Affairs www.consumeraffairs.com/travel/cruise_medical.html Summary of ACEP guidelines for cruise ship faculties 25.Vessel Samaritan Program Homepage www.cdc.gov/nceh/vsp/default/htm Contains Information about the program and recent “Green sheets” detailing results of inspection 26.Consumer Reports: Ocean Liners’ Medical Care May Not be Ship shape

www.cnn.com/travel/news/9905/13/cruise.health/ 27.Cruises MD’s Treat Thousands, But How Well? www.usatoday.com/travel/news/2003-12-08-cruise docsx.htm
28.Cruise Medicine: Call for an International Standard, Dahl. Internat. Marit. Health, 2001, 25, 1-4, pp 24-26 29.Cruise Ship Medical Facilities: Caveat Emptor Brad Tenier J. Florida M.A. Oct 1997, Vol. 84 No. 7; 461-462 30.Rubella Among Crew Members of Commercial Cruise Ships- Florida, 1997 JAMA, Feb 4, 1998: Vol. 279; No.5 pp3489. 31.Outbreak of Pneumonia Associated with Cruise Ships, 1994. JAMA, August 10, 1994; Vol. 272, No. 6 pp 425 32.Rubella Outbreaks on Cruise Ships JAMC, Feb 24, 1998; 158 (4) 33.Cruise Ships: High-risk Passengers and the Global Spread of New Influenza Viruses Miller, Joy Clinical Infectious Diseases 2000; 31: 433-8 34.Descriptive Epidemiology of Injury and Illness Among Cruise Ship Passengers . Peake D.W. et al. Annals of Emergency Medicine , 33:1 January 1999 pp 67-73 35.Travelers Diarrhea at Sea: Three Outbreaks of Waterborne Enterotoxaemia Escherishia coli on Cruise Ships Daniels et al, Journal of Infectious Disease 2000; 181: 1491-5 36.Epidemilogy of Diarrheal Disease Outbreaks on Cruise Ships, 1986 through 1993, Koo Denise et al JAMA, February 21,1996: Vol. 275, No. 7 pp 545-547 37.Shigellism on an Italian Cruise Ship.The Lancet, Vol. 379, December 7, 1996 pp 1593-94 38.Outbreak of Shigella Flatneri 2a Infections on a Cruise Ship JAMA, November 9, 1994: Vol. 272, No. 18 pp 1404 39.Outbreak of Brainerd Diarrhea Among Travelers to the Galapagos Islands Mintz et al. The Journal of Infectious Diseases 1998; 177: 1041-5 40.Cruise Ships trying to Prevent Further Outbreaks Health link College of Wisconsin www.healthlink.mcw.edu/article/1031002194.html Discusses Norwalk virus outbreak among cruise ships 41.Outbreak of Shigella; Flexneri 2a Infections on a Cruise Ship; MMWR Morb Mortal Wkly Rep 19947; 42: 657 42.Typhoid at Sea: Epidemic aboard an Ocean Liner; Daries J.W., Cox K.G. Simon W.R. Can Med Ass J 1972; 106: 877-883 43.Staphylococcal Food Poisoning on a Cruise Ship; Waterman S.H., DeMarcus T.S., Wells J.G., Blake P.A., Epidemic Infect

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1987; 99: 349-353 44.An Outbreak of Gastroenteritis on a Passenger Cruise Ship; O‟Mahony M.C., Noak N.D., Evans B., Harper D.; J Hyg 1976; 97: 229-236 45.On Shore Catering Increases the Risk of Diarrheal Illness Among Cruise Ship Passenger Pugh et al. CDI Vol. 25, No.1 46.Investigation and Management of Infectious Diseases on International Conveyances; Maloney S. and Cetron M. Textbook of Travel Medicine and Health Ed. Dupont and Steffen 2001 B.C. Decker London p 519-530 47.HIV-Risk Behaviors of American Spring Break Vacationers: A Case of Situational Disinhibitation? Apostolopoulos, Y. International Journal of STD & AIDS 2002; 13: 799-743 48.Sex and Travel: Studies of Sexual Behavior, Disease and Health Promotion in International Travelers- a global review, Mulhall, Blain International Journal of STD & AIDS 1996; 7: 455-65 49.Shipboard Dialysis Shapiro, WB and Porush J.G, Journal of Dialysis 1 (8), 852-829 (1977) This article discusses planned dialysis support for renal patients 50.Dive Medicine 3rd ed Alfred Bse WB Sander Bore and Davis 1997 51.Diving and Subaquatic Medicine 4th Ed Carl Edmonds London 2002 52.Divers Alert Network www.diversalertnetwork,com DAN is the definitive diving medical resource 53.Passenger Mortalities Aboard Cruise Ships, Dah, E Internat. Marit. Health, 2001, 25, 1-4, pp 19-23 54.International Society of Travel Medicine www.istm.org Reference of travel clinics worldwide 55.Update: Outbreak of Legionnaires’ Disease Associated with a Cruise Ship, 1994. JAMA, September 28, 1994, Vol. 272, No. 12 56.Outbreak of Legionnaires’ Disease Among Cruise Ship Passengers Exposed to a Contaminated Whirlpool Spa Jernigan et al. The Lancet, Vol. 347, Feb 24, 1996 57.Outbreak of Legionnaire’s Among Cruise Ship Passengers Exposed to a Contaminated Whirl pool Spa, Jernigan P.B., Hoffman J., Cetron M.S. et al, Lancet 1996; 347: 494-499 58.Legionnaire’s Disease on a Cruise Ship Linked to the Water Supply System: Clinical and Public Health Implications, Caslellani, Pastoris M., Manoco R.L., Goldini P., et al ,Clin Infect Dis

1999; 28: 33-38 59.Occupational Accidents Aboard Merchant Ships Hansen et al, Occup Environ Med 2002; 59: 85-91
60.Evacuation of Emergency Patients from Cruise Ships; Prina et al, Journal of Travel Med 2001; 8: 285-292 61.Air Evacuation of Critically Ill Patients from Cruise Ships; Journal of Travel Med 2001, 9: 335 62.Stay Ship Shape on you Next Cruise American College of Emergency Physicians www.acep.org/1,32849,0.html Suggestions for preventative health directed at cruise passengers 63.Advice for Passengers on Cruise Health www.cruisediva.com/cruise%20care.html 64.Cruise ship safety tips: Staying Ship Shape on your Next Cruise Pennsylvania chapter of American College of Emergency Physicians www.paacep.org/cruise_ship_safety.htm 65.Cruise Junkie www.cruisejunkie.com deals with many criticisms of the cruise industry 66.Consumer Reports Travel Letter www2.cdc.gov/neeh/vsp/vspmain.asp ; a non-profit independent information letter reference) noted that although many cruise liners claim to meet or exceed the International Commute of Cruise Liner and American College of Physicians but neither organization enforce their guidelines or inspect them. Consumer reports recommend making these enforceable laws to actually make them meaningful.

Other Useful resources relative to remote Health at Sea
Wilderness Medical Society Practice Guidelines 2nd Edition, Edited By William W. Forgey; Guide ford Connecticut 1995 Pocket Guide to Wilderness Medicine and First Aid, Paul Gill Jr. International Marine/Ragged Mountain Press Camden, Marine 1997 Wilderness and Travel Medicine, Eric A. Weiss; Adventure Medical Kits 1997 How to Survive on Land and Sea, Frank C. Craighead Jr. and John J. Craighead, Naval Institute Press Annapolis, Maryland 4 th Edition 1984 Medicine for Mountaineering 4th Edition, Edited by James Wilkerson, The Mountaineers 1992, Seattle Washington Medicine for the Outdoors, Paul Anevbach, Lyons Press New York NY 1999 Field Guide to Wilderness Medicine 1st Edition, Auerbach, Donner and Wiess, Advanced First Aid Afloat 4th ed Peter F Eastman Cornell Maritime Press, Inc 1995 Centreville Marland International Medical Guide for ships 2nd Edition World Health Organization Geneva 1988

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Mefloquine and Madness: Psychotic Disorders Related to Travel
Simon Trepel, MD, 4th Year Psychiatry Resident University of Manitoba, Faculty of Medicine

Learning Objectives 1) To recognize travel as a potential psychological stress, causing symptoms 2) To become familiar with Mefloquine‟s potential to cause psychological stress 3) To briefly reinforce the necessity of pre-travel vaccinations, and dispel potential myths associated with vaccines Introduction Travel has been associated with psychological diseases in the medical literature. Prior studies have linked the phenomenon of “Jet Lag” to Hypomanic symptoms. Major Depressive Episodes have been associated with travel from an Eastern to a Western destination 5. A change in usual surroundings, as occurs with travel, has been found to cause Delirium in elderly people 9. There are many sources of stress related to travel, if we consider time zone changes, vast cultural differences, logistics of travelling- like companions, mode of transport and accommodations, new strange environments, and various other variables 3. The relationship between travel and psychological disorders is better understood if we think of travel as a “stress”. Most Psychiatric Diseases are understood using a “Stress-Diathesis” Model.

Stress-Diathesis Model
We understand that the onset of many Psychiatric disorders is linked to an interaction between Nature and Nurture, or Genes and Environment. Thus the occurrence of psychiatric disorders is predictable if we are able to estimate one‟s genetic susceptibility (DIATHESIS), and balance this against the demands of the environment (STRESS). Said another way, stress is able to cause psychiatric symptoms in vulnerable individuals. What do I mean by Psychiatric Symptoms?

Crash Course in Psychiatry
Psychiatry uses the DSM4, a manual (or cookbook) that describes all currently recognized psychiatric diseases as a constellation of various symptoms (or ingredients). Similar disorders are lumped into general categories. The main categories of Psychiatric disease include: Mood, Anxiety, Psychosis, Substance Use, Due to a Medical Condition, Adjustment, and Personality9.
5

Jahuar P, Psychiatric Morbidity and Time Zone Changes: A Study of Patients from Heathrow Airport, British Journal of Psychiatry, 1982, 140; 231-235 9 Kaplan, Synopsis of Psychiatry, 2001 3 Van Riemsijk, MM. Mefloquine Increases the Risk of Serious Psychiatric Events During Travel Abroad: A Nationwide Case-Control Study in the Netherlands, Journal of Clinical Psychiatry 2005; 66: 199-204. 9 Kaplan, Synopsis of Psychiatry, 2001

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Psychosis
This talk will focus on factors related to travel, and their ability to produce psychotic symptoms. Psychosis is defined as “a loss of ego boundaries or a gross impairment in reality testing”. It usually involves Hallucinations, (which are abnormal sensory perceptions – like “hearing voices”) and Delusions (which are fixed false beliefs - like paranoia). Typical Psychotic Disorders in Psychiatry include Schizophrenia, Delusional disorder, Substance Induced, Psychotic Depression, and Delirium. Excess Dopamine in the mesolimbic area of the brain is thought to produce psychotic symptoms, and drugs that block dopamine in this area have been shown to produce a remission in hallucinations and delusions. There are many other causes of psychosis that are not so readily understood to involve Dopamine, however. Delirium, or “Psychosis due to a Medical Condition”, is thought to be caused by a wide variety of drugs, such as Anticholinergics, Opioids and Benzodiazepines10. This paper will focus on one such medications, Mefloquine, an anti-malarial that has been shown to produce both Neuro-Psychiatric symptoms in some, as well as save other‟s lives from the deadly disease Malaria.

Malaria
Malaria is the most important preventable disease for travellers to be aware of, and prepare for, when travelling many parts of the world. Malaria is a systemic disease caused by a blood parasite from the Genus Plasmodium. There are 4 species that infect humans, the most serious being Plasmodium falciparum, which is prevalent in Africa. According to the WHO in 2003 there were 300-500 million people infected worldwide, with 2 million dying per year4.

Pre-Travel Vaccinations
Death due to malaria has been linked to inappropriate chemoprophylaxis or non- compliance with an anti-malarial agent. Anti-malarial drugs may prevent or treat disease, where they are able to kill asexual blood stages of the parasite prior to colonization in the liver, via schizonticide. There are many prophylactic preparations because as resistance develops to various agents worldwide, new antimalarials have been developed. The geographic extension of chloroquine-resistant Plasmodium falciparum in many tropical areas of the world has prompted use of alternative medications, such as Mefloquine4.

Mefloquine
Mefloquine Hydrochloride (or Larium) is one of the most effective antimalarial drugs available. It is a synthetic 4-quinoline methanol derivative chemically related to quinine. It is well absorbed and highly bound to plasma proteins, concentrated in the red blood cells, and is extensively distributed to the tissues, including the Central Nervous System. It is prepared
10 4

Katzung B, Basic and Clinical Pharmacology, 1998 Spira, A, Preparing the Traveller, Lancet, 2003, 361; 1368-1381. 4 Spira, A, Preparing the Traveller, Lancet, 2003, 361; 1368-1381.

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orally, in a prophylactic dose of 250mg weekly, given over 3 weeks. Plasma levels of 200300ng/ml are needed to prevent or treat falciparum infection. Mefloquine‟s half-life is between 15-33 days. While Mefloquine is very effective, it has many potential side effects, especially when doses exceed 1000mg, or 15mg/kg 10.

Side Effects of Mefloquine
Mefloquine has been associated with many side effects, which may be divided into mild, moderate, and severe categories 2 Mild- headache, nausea, vomiting, diarrhea, dizziness, vertigo, fatigue, asthenia, and poor concentration. Moderate- ataxia, agitation, confusion,. anxiety, dysphoria, blurred vision, and altered sleep and wake cycles. Severe- seizures, acute psychosis with delusions, hallucinations, and disorganization, mania, „anxiety neurosis‟, altered levels of consciousness, Major Depressive Episode, and delirium. Death has not been reported.

Mefloquine in the Medical Literature
Weinke, T. Neuropsychiatric Side Effects After the Use of Mefloquine, American Journal of Tropical Medicine, 45(1), 1991, pp. 86-91. The Authors interviewed 12 people at Infectious Disease Units in Germany who had suffered adverse events after using Mefloquine. Subjects were white, had no prior psychiatric disease, and no allergies. The average age was 34 years old, there was an even gender distribution, and 10 of 12 were tourists. 7 of 12 had severe reactions characterized by acute psychosis with hallucinations, delusions and disorganized though processes, psychomotor agitation, seizures and sleep wake changes. Whereas 5 of 12 had moderate reactions, characterized by agitation, vertigo, confusion, nausea, and ataxia. Severe reactions were seen in prophylactic and treatment doses, as well as in people who had not had a serious reaction with prior Mefloquine use, and those with therapeutic (i.e. not toxic) mefloquine blood levels. The Authors speculate that the overall risk of moderate to severe side effects when using Mefloquine are about 1 in 8000. 1 in 13000 experienced moderate side effects when using the prophylactic dose, whereas 1 in 215 had a similar reaction while using treatment doses. Thus the risk of serious side effects is about 60 times higher in treatment vs. prophylactic doses. Van Riemsijk, MM. Neuropsychiatric Events During Prophylactic Use of Mefloquine Before Travelling, European Journal of Clinical Pharmacology, (2002) 58: 441-445. The authors attempted to control for the possible confounder of travel itself in producing symptoms associated with Mefloquine. This study looked at Mefloquine use and side effects in 179 people, during the first 3 weeks, before they travelled. The authors used the Profile of
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Katzung B, Basic and Clinical Pharmacology, 1998 Weinke, T. Neuropsychiatric Side Effects After the Use of Mefloquine, American Journal of Tropical Medicine, 45(1), 1991, pp. 86-91.

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Mood states (POMS), and the Diary of Adverse Events to describe symptoms. 32.1% of individuals endorsed neuropsychiatric events, women had twice (45%) the symptomatology vs. men (22%). First time users had more side effects than prior users of Mefloquine. Typical side effects included fatigue, anxiety, dysphoria, and vertigo.

Mechanism of Neuropsychiatric Symptoms Mefloquine is known to have Acetylcholinesterase Inhibiting properties. Prior studies of these agents have shown symptoms of anxiety, poor memory, confusion, sleep changes and seizures. It has been proposed that disruption of Acetylcholine metabolism is linked to Dementia, Delirium, and seizures. Mefloquine has also been shown to cause “quinine like effects”, thus promoting cardiac arrhythmias9.

Importance of Vaccinations While every vaccine has the potential to cause side effects, we must not forget the importance of protecting ourselves and our patients from potentially deadly endemic diseases worldwide. There are many important variables in deciding whether to vaccinate, and in choosing specific medications. Anti-vaccination groups have attempted to use anecdotal information in order to induce fear and avoidance of vaccines in some populations. There are well-described side effects, and complications to some vaccines. There have been attempts made to link Vaccinations to Autism, Mercury Poisoning, Multiple Sclerosis, Type 1 Diabetes, GuillainBarre Syndrome, and others7. Several Authors have examined MMR vaccines and the potential to cause autism. To date, there is not a single example of causal evidence to link MMR and autism in the entire medical literature. Taylor (1999) examined 498 children with autism, and Patja (2000) looked at 1.8 million who had received a total of 3 million MMR vaccinations over 14 years. Both authors concluded “our analysis do not support a causal associations between MMR vaccine and autism. If such an association occurs, it is so rare that it could not be identified in (our) large regional sample”8. Clinicians must educate themselves using evidence-based techniques to guide their understanding and treatment recommendations.

Recommendations on the Use of Mefloquine Various authors have looked at the specific types of side effects produced by Mefloquine, and arrived at the following recommendations1; Do not use Mefloquine in the following circumstances (prior history); Psychiatric disease – including psychotic and mood disorders Seizures Cardiovascular conditions or prescribed medications Prior reaction to Mefloquine (Allergy or Sensitivity)
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Kaplan, Synopsis of Psychiatry, 2001 Kimmel S, Vaccine Adverse Events: Separating Myth from Reality, 2002; 66, 2113-2120 8 MacIntyre C, Immunization Myths and Realities: Responding to Arguments Against Immunization, Journal of Paediatric Child Health, 2003; (39), 487-491. 1 Van Riemsijk, MM. Neuropsychiatric Events During Prophylactic Use of Mefloquine Before Travelling, European Journal of Clinical Pharmacology, (2002) 58: 441-445

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High Risk Groups to be aware of; Women Low BMI Low body fat content First time users General Guidelines Monitor for the first 4 weeks of use Do not exceed total doses of greater than 1000mg or 15mg/kg Avoid other sources of mosquito bites (netting, insect repellent etc) Avoid tasks related to fine motor control or concentration if possible Choose Mefloquine for short trips to areas of Choloquine-Resistance

Conclusions Mefloquine has recently emerged as an effective malaria prophylactic and treatment in various parts of the world. Mefloquine has been causally linked to specific side effects. Caution should be exercised in using Mefloquine in specific populations. Clinicians must educate themselves to be effective resources for their patients who travel, allowing appropriate choices to be made, to maximize health and to minimize disease and suffering.

References 1. Van Riemsijk, MM. Neuropsychiatric Events During Prophylactic Use of Mefloquine Before Travelling, European Journal of Clinical Pharmacology, (2002) 58: 441-445. 2. Weinke, T. Neuropsychiatric Side Effects After the Use of Mefloquine, American Journal of Tropical Medicine, 45(1), 1991, pp. 86-91. 3. Van Riemsijk, MM. Mefloquine Increases the Risk of Serious Psychiatric Events During Travel Abroad: A Nationwide Case-Control Study in the Netherlands, Journal of Clinical Psychiatry 2005; 66: 199-204. 4. Spira, A, Preparing the Traveller, Lancet, 2003, 361; 1368-1381. 5. Jahuar P, Psychiatric Morbidity and Time Zone Changes: A Study of Patients from Heathrow Airport, British Journal of Psychiatry, 1982, 140; 231-235. 6. Linton C, Travel-Induced Psychosis in the Elderly, International Journal of Geriatric Psychiatry, 2000; (15) 1070-1072. 7. Kimmel S, Vaccine Adverse Events: Separating Myth from Reality, 2002; 66, 2113-2120. 8. MacIntyre C, Immunization Myths and Realities: Responding to Arguments Against Immunization, Journal of Paediatric Child Health, 2003; (39), 487491. 9. Kaplan, Synopsis of Psychiatry, 2001 10. Katzung B, Basic and Clinical Pharmacology, 1998.

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Skin Cancer
R.P. Haydey Reference The Surgical Clinics of North America, Malignant Melanoma, Part 1, February 2003 Cancer Statistics…2004 • Estimated 145,000 new cases of cancer in Canada in 2004 • Estimated 68,300 cancer deaths in Canada in 2004 Cancer vs. Skin Cancer • Total number of cancer patients…145,000 • 50,000 of these will be skin cancer patients Skin Cancer Statistics 2004 • Basal cell carcinoma (BCE)…38,000 • Squamous cell carcinoma (SCC)…7,800 • Malignant melanoma (MM)…4,200 / 850 What Causes Skin Cancer? • Sunburn (UVB) causes permanent damage to the DNA of skin cells • Chronic light exposure (UVA) damages the skin’s immunosurveillance system • 20 - 30 years after the sunburn, skin cancers begin to form Immunosurveillance • How the body protects itself from cancer and infection Immune Response Modifier • Something that will enhance the bodies natural ability to heal • Something that can enhance immunosurveillance Cream, Aldara™ (imiquimod ) 5% Imiquimod (Aldara)

•

• • • •

Is an immune response modifier Indirectly enhances the bodies natural ability to heal… Induces innate and cell mediated pathways Stimulation of these immune pathways leads to the synthesis and release of cytokines Interferon- Tumour necrosis factor- Interferon- Interleukin-12

Human Immunity Cytokine Production

• • • •

Enhanced Cell Activity

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• • • •
• • •

Natural killer cells Macrophages B lymphocytes Langerhans cells

Skin CancersProven to Respond to Aldara Actinic keratosis (AK) Actinic cheilitis Superficial basal cell carcinoma (SBCE)

Skin Cancers Which May Respond to Aldara

• • • • •
• • •

Basal cell carcinoma (BCE) Squamous cell carcinoma insitu (Bowen‟s disease Squamous cell carcinoma Lentigo maligna Lentigo maligna melanoma

Melanoma Cutneous T-cell lymphoma (CTCL) Cutaneous extramammary Paget‟s disease (EMPD)

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MEDICAL ENTOMOLOGY FOR BACKPACKERS AND TRAVELLERS Terry D. Galloway Department of Entomology, Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2 All the World Over Canadians are world travellers, and they often visit exotic locations, sometimes seeking true wilderness adventures, or visits with indigenous people. Canadians also make extended excursions into remote areas in North America and the tropics, on holidays, working on special assignment or working with a variety of aid agencies. We too often forget in our travels, that we become exposed to local wildlife that isn‟t as obvious or as photogenic as zebras, hippopotami, lions, elk or deer. These include the flies, the fleas, the ticks and bugs that are potential vectors of disease-causing organisms. To be infected with these agents may mean an unscheduled visit to a local hospital, mild to severe illness, and sometimes death. If you plan to travel, particularly to tropical or subtropical parts of the globe, it is wise to learn as much as you can about insects and ticks that may transmit pathogens to you and your family, and about the pathogens and diseases involved. In this short summary, there is no way that I can cover all the details of every potential vector and all possible pathogens. I am not a physician, so it is not my intention to provide you with information about prophylactic drugs that may be essential for your survival in some parts of the world. I am not going to discuss the ants, bees, wasps, spiders, and scorpions which may cause life-threatening allergic reactions or envenomization by their bites or stings. What I do hope to do, is to introduce you to the groups of insects and their relatives that you may encounter, to provide you with some selected elements of their biology and vector potential, and to provide you with a list of just some of the diseases it is possible to pick up through an encounter with these insects and ticks.

Be Prepared There are a couple of basic principles to keep in mind when you travel to the tropics. First of all, you may only rarely encounter the kind of biting fly pressure we see nearly every summer in Manitoba. You know what I mean. There are those memorable times each summer when we have gorgeous, warm evenings when it would be just great to get out and barbecue in the back yard, or to go for a leisurely stroll around the neighbourhood......but you can‟t, because the second you step out the door, you are smothered by an army of hungry mosquitoes. Or when you take that extended holiday to canoe that Whiteshell route you always wanted to do, and the mosquitoes drive you into your tent at dusk, and the black flies and stable flies drive you to distraction all day. You may not ever encounter this kind of biting fly pressure in the tropics. The risk is that when you travel to these parts of the world, there may be so few mosquitoes around, that you hardly notice. Who would bother with repellent where you get only a few bites per hour. Or in some cases, there may be just a few mosquitoes biting, mainly at night while you sleep. However, where some of these biting insects are involved in the transmission of pathogenic organisms, it may take only one bite for you to acquire an infection. Whether or not you become infected may depend on the proportion of the flies biting that are themselves infected, and at what level the pathogen occurs in their bites. You can think of it as a lottery. There may only be one in a hundred mosquitoes that is infected, but what are the

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chances that that one mosquito successfully feeds on you? That brings me to my second point. If there are infected insects biting, the longer you are in the area where they occur, the greater the probability that eventually you will become infected if you don‟t take adequate precautions. In some cases, with yellow fever virus or malaria for example, one bite from a suitably infected mosquito is sufficient for you to become infected. In the case of other pathogenic organisms, in elephantiasis or river blindness for example, clinical disease usually only develops where people are exposed over a considerable period of time, perhaps over decades, where they are bitten repeatedly by infected flies. The bottom line is that you must know what the potential is for transmission locally where you visit. If you have paid for a luxury tour where you are staying in the best hotels and making only short excursions out into the countryside, you are usually less at risk than if you take off on a Morocco to South Africa safari, living out of a rickety old caravan, travelling the backwaters of the continent. Serious research into the insects you will encounter on each stage of your trip, the pathogens they transmit, and the precautions you need to take will pay dividends, and allow you to enjoy the experience you are looking for to the fullest.

Insects are People Too I do want you to keep in mind that there are probably more than 30 million species of insects. If you consider that each one of these different insects does things just a little differently from all other species, that means there is a lot of room for insects to make use, in one or another, of every conceivable resource. Unfortunately, the insects I am going to talk about here mostly require vertebrate blood to reproduce. In some groups, males need blood to develop sperm (e.g stable flies), while females may need blood to develop their eggs (e.g. mosquitoes and black flies). Some insects (e.g. lice and fleas) are obligate parasites of birds and mammals. They are found only on the bodies of their hosts, in the case of the lice, or they may be intimately tied to the host and its nest environment, as for most fleas. In other groups of blood-sucking organisms, (e.g., true bugs, flies and ticks) there may be species which are obligate parasites and which are very host specific, or there may be species which will attack almost any warm-bodied animal for blood. These insects are doing only what they have to do to survive, so don‟t take it personally that they want your blood.

Nasty but not Necessarily Dangerous There are many insects which have developed the annoying habit of having adapted to living in the same places we live, or even on ourselves. These insects usually draw shrieks of anguish and shudders, but in the long run, as much as we may hate the idea, they really don‟t do us all that much harm. Here are a few to set you mind at ease. 1) Cockroaches There are more than 4,000 species of cockroaches, most of which are tropical and subtropical. They vary in size from the tiny Nocticola (3mm long) to the giant among cockroaches, Macropanesthia rhinoceros, which is 65mm long, and weighs up to 20 grams. There are numerous cosmopolitan species that have accompanied humans around the world and live together in our homes and workplaces, including in Manitoba. Even on the University of Manitoba campus, if you walk quietly along the

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tunnel connecting the Agriculture buildings, you may be fortunate enough to see one of these interesting little beasts. There has been all out war declared on our faculty's cockroach population in the last nine or ten years, but there are still a few around. There are native wood roaches in Canada, usually found in rotting logs, under bark or in forest leaf litter. These wood roaches, Parcoblatta sp., were unknown in Manitoba until the summer of 1997, when specimens turned up in light traps along the Winnipeg River and in Nopiming Provincial Park. They are probably quite widely distributed in eastern Manitoba, but it‟s just that few people take the time to look for them. All six legs of cockroaches are similar and they can run surprisingly fast - just try to catch one. The body is oval-shaped and flattened, and the head is hidden from above by the front of the thorax. Cockroaches are generally creatures of the night and they will avoid the light if they can. Hence, their antennae are extremely long and filamentous, and serve as one of the foremost sensory organs. When we had American cockroaches infesting our building, they liked to take shelter under the toilet seats during the lights were turned on in the morning. Imagine the reaction when contemplative visitors would be seated there, and the antennae of a hidden cockroach would brush their exposed buttocks! Most, but not all, species are winged, with four wings lying flattened over the back at rest. The forewings are parallel-sided and somewhat leathery, while the hind wings are larger, membranous and folded beneath the forewings. There are usually two distinct cerci at the tip of the abdomen. Cockroaches will eat almost anything organic using their chewing mouthparts. Unfortunately, they are messy eaters, and contaminate food items with saliva and faeces, imparting a characteristic and decidedly unpleasant odour. It is for this reason that cockroaches have such an unsavoury reputation. One of the disadvantages of working in entomology is that most people learn to recognize the smell associated with cockroaches and it can be rather off-putting when trying to enjoy a meal in an infested restaurant! Cockroaches will also consume paper, labels from jars, and books. However, more than 99% of the known species are not found in association with humans, and are confined to very specific habitats. Females of many species enclose their eggs in capsules called oothecae, and tuck these oothecae in cracks and crevices or in corrugations in cardboard. There are a few species that retain the ootheca until the eggs hatch and then appear to give birth to live young. Juveniles look very much like small adults, but do not have wings. In warm climates, many species of cockroaches move freely in and out of buildings, flying about at night, attracted to lights. Don‟t be surprised if you see them in you hotel room or cabana on the beach. They can be everywhere. The list of potentially pathogenic organisms that have been isolated from cockroaches is truly impressive. Most of these organisms cause gastrointestinal disorders, and include such things as Salmonella, Shigella, and Clostridium. The precise role of cockroaches in the dissemination of these pathogens is unclear, but who wants cockroach vomit or faeces in the food anyway? Of greater concern is the evidence that under certain conditions, cockroaches may be responsible for the spread of infectious hepatitis. If you can, avoid crowded housing and places where there are clearly large numbers of cockroaches about. It has now also been shown that prolonged exposure in cockroach-infested living quarters may be responsible for development of severe respiratory allergies. This comes as no surprise to entomologists who have studied cockroaches for many years, over which time they will have spent long hours looking after their cultures of roaches.

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2) Bedbugs These wafer-thin little devils are a scourge wherever they occur. There are nearly 100 described species, all of which are wingless, and most of which you are unlikely to ever encounter. They are parasites of bats. However, the human pest, the bed bug (Cimex lectularius), is the most dreaded. They require blood for development and reproduction, and take this at night from their unsuspecting, sleeping hosts. They especially like to feed around the neck and scalp area, but they will feed elsewhere on the body as well. During the day, they hide in cracks, crevices, bed springs and mattress seams. Sometimes the only sign that they are present will be tiny specks of blood on the pillows, or greasy black faecal deposits in areas where the bugs hide, their harbourages. Infestations usually become established when someone brings a used bed or bedding into a home from an infested area. It is sometimes recommended that the bedposts can be set into cans of water or oil, and the bed bugs can't swim across to get to the bed. However, I was once told that under these circumstances, a fellow discovered that the bed bugs crawled up the walls, across the ceiling, and then fell down onto their sleeping victim below! An innocent intruder, often mistaken for the bed bug, is the swallow bug, Oeciacus vicarius. This bug is intimately associated with the Cliff Swallow in North America, although there are records of occurrence in the nest of other species of swallow. You can distinguish these bugs, which do not normally bite humans, from bed bugs because swallow bugs are hairy. Although bedbugs are known to acquire a variety of pathogenic organisms, there is no conclusive evidence that they are important vectors of any of them. If you have to sleep in a room where there are bedbugs, you can take comfort in knowing that you probably won‟t be infected with anything unpleasant, and that you will have contributed to the continued survival of their population. And it seems that the probability of this happening is increasing in many developed countries around the world. You will find media reports claiming that the prevalence of bedbugs is on the rise. Whether this is the result of greater restrictions on the use of effective residual insecticides for domestic use, the development of insecticide resistance in bedbug populations, or increased awareness and media hype is difficult to tell. 3) Head Lice and Crab Lice There are well over 500 species of sucking lice world-wide, all of which feed exclusively on blood. Most species are very host specific, though as a group, they are found on a wide variety of mammals, including seals, though, oddly, none are parasitic on bats. For those of you that have been infested with lice, you know that they may be extremely irritating, especially when they are present in large numbers. Female head lice (Pediculus humanus capitis) cement their eggs (also called nits) to hairs on the head. There is another subspecies, known as the body louse (Pediculus humanus humanus) which lays its eggs among the clothing as well. The head louse is a curse for school teachers and health nurses, as epidemics commonly will sweep through the children under their supervision. At one time, head lice were easily controlled using insecticidal shampoos. However, since the early 1990's, there have been increasing reports of product failures in many parts of the world, and it appears that there are widespread populations of head lice which are now resistant to many registered control products. A person usually becomes infested with head lice as the result of close contact with an infested person. Lice walk very inefficiently of bald surfaces, so prolonged periods of head-to-head contact favour transmission. It is possible to become infested

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by sharing combs or brushes with infested people, or by wearing an infested person‟s hat. However, head lice do not live long when they are not on their host and they are very good at holding onto the hair of their host, so your chances of picking up lice randomly in the environment are not great. Crab lice (Pthirus pubis) are fantastic looking animals with broad shoulders and enormous claws. They are smaller than most people imagine, if you have never seen one. They are normally found clutching human pubic hair, but in the case of heavy infestations, they may also be found in the hair of the armpits, eye brows, beard or moustache, anywhere that coarse hair grows. As with head lice, they lay their eggs on the hair follicles and feed only on blood. In this case too, infestation most often occurs as a result of prolonged, intimate contact, hence their common name in French, “papillons d‟amour”. In rare instances, crab lice may be transmitted on contaminated towels, bed clothing, and perhaps even on toilet seats. Fortunately, neither head lice nor crab lice are known to transmit serious, disease-causing pathogens, and a person can always shave themselves for complete louse control. Body lice, or cooties, on the other hand, are cause for greater concern. Body lice transmit a rickettsial pathogen, called Rickettsia prowazekii, the causative agent of epidemic typhus in humans. Although there has not been an outbreak in North America for more than 100 years, there are known enzootic foci in flying squirrels in the eastern United States. Transmission in humans as a result of a body louse infestation is more likely in parts of Africa or China, where epidemics have occurred within the last 15 years. Epidemic typhus is extraordinarily infectious, and a person becomes infected when the contaminated faeces of infected lice are scratched through the skin, rubbed into the mucous membranes or inhaled. 4) The Human Bot Fly There are many species of flies that may deliberately or accidentally invade the flesh of a living person. If this happens, it is a condition known as myiasis. However, I only want to describe for you the one species that I see with surprising frequency, the human bot fly or tórsalo (Dermatobia hominis) of Central and South America. This is a truly amazing fly that you might encounter along wooded areas in river valleys and lowland areas from Mexico to Argentina. The adult flies are quite large, about the size of a small bumble bee, and they have no mouthparts. As adults, they never feed. The females mate and then abduct other flies that they use to transport their eggs to a warm-blooded host. They may tackle a mosquito or stable fly, for example, and cement their eggs onto the abdomen of the other fly. When this fly lands on a host to take its own blood-meal, the attached eggs of the bot fly hatch, and the tiny maggots burrow under the skin, often through the opening left from the bite of their taxi fly. This fly is not very host specific, and other animals, including monkeys, cattle, dogs, and sheep, as well as humans may be infested. The bot fly maggot begins to feed and increases enormously in size, twisting and gyrating inside the pocket that forms around them beneath the skin. They must create a hole in the skin through which to breathe, so there is always an opening associated with the swelling and pain created by their presence. Here they remain for the duration of their development, which can last for one to three months. I most often see people who have visited the neotropics and have returned home, completely oblivious to the developing surprise they will find later, one that they failed to report to Agriculture and Agri-Food Canada when asked if they are bringing any live animals into the country. If no action is taken, the maggot will complete its development and eventually squeeze out through the hole in the skin and fall to the ground, where it

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will eventually pupate and emerge as an adult fly. It would be only the most curious and tolerant traveller that would wait for this to happen, though I have tried to convince a few to do so. Typically, infested people see their physician and have the poor, unsuspecting maggot removed before it completes its development. It is interesting that only very rarely is there any secondary infection associated with a bot fly infestation. 5) Those Pesky, Pesky Flies I am going to include a whole range of different, closely related flies in this section. Most of them breed in decaying organic matter, sometimes including animal faeces and manure. For that reason alone, you may not desire close contact with these flies. House flies (Musca domestica - cosmopolitan), face flies (Musca autumnalis North America and Europe), bazaar flies (Musca sorbens - Africa, Asia and many Pacific Islands), and bush flies (Musca vetustissima - Australia) are all non-biting flies that can drive people to distraction by their persistent habits of crawling all over our homes, our food, and our bodies. They all must feed on a liquid diet, but they can obtain the nutrients from solid food by repeatedly vomiting on it and softening it with their sponging mouthparts, until it is sufficiently dissolved to be able to slurp it up. They frequently regurgitate their gut contents and defaecate where they walk, and consequently, as with cockroaches, may spread various potentially pathogenic organisms that are responsible for gastrointestinal distress. On the other hand, they may crawl about your face, exploring every orifice, enjoying the patches of moisture that they find. Stable flies (Stomoxys calcitrans) are very similar to house flies in appearance. However, the principle difference here is that the stable flies, both males and females, feed exclusively on blood. They have shiny, black, dagger-like mouthparts with which to penetrate the skin, and in so doing produce a sharp, stabbing pain. They are very fast and responsive to your defenses, so you may not even see them at first, especially because they prefer to attack your ankles. If you have ever shared a canoe trip with a few stable flies, you know that they can bite through socks, denim, almost anything, it seems, and they will follow you to the ends of the earth. Despite the stress they may bring you, they are not known to transmit any pathogenic organisms to humans.

Nasty and Maybe Even Downright Deadly Now we move on to the rogues‟ gallery of blood-feeding arthropods. These are the animals that may transmit pathogens to humans in their quest for blood. These are the ones that you do need to be concerned about, and to consider as possible threats while travelling abroad. 1) Kissing Bugs or Conenoses Most of the more than 100 species of blood-feeding kissing bugs (Reduviidae, Triatominae) are found in South America, though there are a few found in India and Southeast Asia. They are known as kissing bugs because of their habits of creeping out at night to feed from the lips of their sleeping victims, using their long, needle-like mouthparts. Their bites are almost painless, so the sleeping victim seldom stirs as a bug feeds, even as they take in many millilitres of blood. Before humans took up residence in thatched huts, kissing bugs likely were content to feed on the variety of

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tree-top and hole-nesting mammals. However, with the advent of the thatch hut constructed by humans, and perhaps even with the domestication of animals, many species have adapted to the readily available blood source by sharing accommodations with us. Very often, in gathering the thatch for their homes, people actually acquired these bugs in the process, and incorporated them right along with construction. Even the immature stages require a blood meal, and it is, in fact, the engorgement with blood that triggers moulting to the next developmental stage. After they mate, females will feed and then begin laying their eggs in sheltered areas, often by cementing them singly or in small clusters to the substrate. Nearly all species of kissing bugs seem to be possible vectors for an important pathogen, the protozoan (Trypanosoma cruzi) which causes Chagas‟ disease, and one which infects humans and more than 100 different species of wild mammals. However, there are only about a dozen species of kissing bugs, all found in Mexico, Central or South America, that are considered important vectors for human infection. It is interesting that most of these species defaecate at the same time as they are feeding, and this is a critically important characteristic. Although the bite of the kissing bug is relatively painless, there is often a delayed sensitivity reaction that creates considerable itching some hours after the bug has fed and fled the scene. When a person who has been bitten wakes up in the morning, they respond to the intense itching, and begin to scratch. In so doing, they scratch some of the bug‟s faeces into the bite wound, or through the skin. Of course the infective stage of the pathogen is found in the bug faeces, and so a person becomes infected. The pathogen undergoes development in the infected person, and eventually stages infective to a feeding kissing bug appear in the blood, to complete the cycle. You are most likely to encounter kissing bugs where housing is rustic. The bugs do best where they have lots of places to hide during the day, so houses constructed of thatch and loosely fastened materials are usually home to the greatest numbers of bugs. The best control for these bugs is improved housing construction and, in some cases, the application of residual insecticides on the walls and ceilings of a home. 2) Mosquitoes You might think that all Manitobans need to know about mosquitoes is that there can be a lot of them! In fact, apart from their abundance in the province, there are at least 45 different species recorded. That‟s nothing to the more than 3,000 species described worldwide, among some of the most important vectors of human pathogens. In Manitoba, most of our species belong to the genus Aedes or Ochlerotatus, which includes our most important pest species. Aedes and Ochlerotatus larvae develop in snow-melt pools, spring runoff, summer flood-water, or tree holes. All of these species overwinter as eggs, and hatch under suitable environmental conditions of water levels and temperature. The larvae are aquatic, and have a long breathing tube (called a siphon) on the end of the abdomen, through which they take in air directly from the surface. The pupae are comma-shaped, very active, and they breathe air at the surface, but through a pair of respiratory trumpets on the top of the thorax. Only adult females may feed on blood, using their thin, needle-like mouthparts which they insert directly into capillaries. However, as you travel toward the tundra regions of Manitoba, there may be a higher incidence of autogeny (i.e. females can lay eggs without a blood-meal). One hypothesis for this phenomenon is that in the north, potential hosts are less predictable, and weather conditions more often restrict flight periods for blood-seeking females. Therefore,

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females that can reproduce without the requirement for blood, at least for the first batch of eggs, will be more successful. There are several other genera of mosquitoes in Manitoba. Culex and Culiseta deposit their eggs in rafts which float on the surface of semi-permanent pools, and the larvae hatch directly into the water. Culex tarsalis is rarely as abundant as the Aedes and Ochlerotatus mosquitoes in Manitoba and has little nuisance status. However, it is considered to be the primary vector of the Western Equine Encephalitis and West Nile Viruses to horses and humans and is the target of surveillance using light/carbon dioxide traps and flocks of sentinel chickens. Anopheles spp. are found in weedy, permanent water, and include the species of mosquitoes known to transmit the malaria parasites to vertebrates. Fortunately, we don't have human malaria in Manitoba, though there are species found in birds. Mansonia perturbans is an unusual species found in permanent marshes and slow-moving streams. It is a savage mosquito, and is most active just after dark during mid summer. The larvae are bizarre because they have abandoned the mode of surface respiration, and instead, have a special attachment on the abdomen that allows them to tap into the stems of aquatic plants and take oxygen directly from the plant tissues. Wyeomyia smithii is our only entirely autogenous species of mosquito. These delicate adults lay their eggs inside the leaves of purple pitcher plants, which grow only in acid sphagnum bogs. Also peculiar for Manitoba mosquitoes, W. smithii overwinters as a larva, frozen into a core of ice inside the pitcher plant leaf beneath the snow. In the tropics, mosquitoes may breed in a great variety of standing water habitats. Water may be in tree holes, axils of plants, rock pools, coconut husks, crab holes, or in containers around human habitation. They may even be breeding in the water jugs that are in the same room where you sleep. In the tropics, you must concern yourself with the possibility that you may be infected by any of a number of important pathogens, even though the numbers of mosquitoes you see about are not anywhere near the numbers that you encounter at home in Manitoba. These pathogens may be protozoan, such as malaria, or viruses, such as Yellow Fever Virus, Dengue Haemorrhagic Fever Virus, or Murray Valley Encephalitis Virus, to name a few, or nematode worms, such as the parasite that may cause the spectacular symptoms associated with elephantiasis. The number of specific pathogens is far too large to try to cover here. However, regardless of the type of pathogen involved, the infective agents are transmitted with the bite of the female mosquito. In most cases there is some degree of development of the pathogen within the mosquito, and sometimes there may even by replication of the pathogen, so that the probability of transmission may increase over time. When a person becomes infected, the outcome may vary, depending on the nature of the specific pathogen. When some pathogens (e.g. West Nile virus) are innoculated into a person being bitten by an infected mosquito, the person may not necessarily become ill, but even if they do, there is rarely enough virus circulating in their blood for another mosquito to become infected when it feeds. With other pathogens (e.g. Yellow Fever Virus or malaria), a person may become infected following the bite of the mosquito, and after some time, they may become ill, and the pathogen will replicate in their body, ultimately becoming freely available in the blood to be picked up when other mosquitoes feed. As if all this isn‟t complicated enough, you must understand that not all species of mosquitoes are able to transmit all pathogens, and among those that can transmit a particular pathogen, not all species of mosquitoes are equally efficient at doing so. Even in an area where there is a species of mosquito that is very good at

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acquiring and transmitting a pathogen, not every female mosquito will be infected, and the proportion of mosquitoes in a population that is infected will vary over time. The bottom line is that unless you have an awful lot of sophisticated and up-to-date information about the epidemiology of a pathogen in an area you are visiting, you will not be able to figure out the probability that the mosquito feeding on your arm is going to infect you. Phewf! I told you it was like a lottery. When travelling to a particular area, you should check with public health authorities before you go, to learn what you can about any pathogens that are prevalent in that area during the time you expect to be there. You must conduct your research immediately before you leave for such areas, as recent outbreaks of malaria in the Dominican Republic demonstrate. In this case, many resort communities were considered to me safe, where it was assumed that no malaria was being transmitted to humans. However, in November of 2004, human cases of malaria in recent visitors to these areas began to emerge. As a result, travel advisories were issued, and prophylactic treatments were recommended for travellers. Make absolutely certain that you are vaccinated where it is appropriate, and that you are taking the effective prophylactic drugs. Remember that the malaria parasites, for example, have developed resistance to some drugs. You should not rely on past experience in obtaining prophylactic drugs, but rather you should seek expert advice about the best precautions to take, before you travel, and follow the instructions you are given to the letter unless there is some medical or practical reason for you to do otherwise. If you are in an area where it is known that mosquitoes are carrying human pathogens, minimize you exposure. Wear protective clothing during periods of peak mosquito attack, or schedule your own outdoor activity to minimize your likelihood of exposure, if you can. Apply repellents if it is practical to do so. Make certain that you use bed nets at night where they are recommended. Bed nets are often treated with residual insecticides, such as permethrin, to increase their efficiency. Now, that‟s a lot to remember, but by taking appropriate precautions, you may reduce the risk that you will become infected. 3) Black Flies Canada is notorious for its black flies. Poems have been written about them; they have been immortalized in song. Anyone who has spent time outdoors in the north and boreal regions of Canada has learned to hate these fierce little devils. My grandfather always maintained that a black fly would cut a piece of flesh from your body and then fly away with it to eat its meal while sitting on a fence post! This is not quite true, even though it might feel like it sometimes. Rather, the female black fly uses its scissor-like mouthparts to create an open wound in the skin, and then it laps up the blood as it pools in the wound. This is in contrast to the mosquitoes, which have needle-like mouthparts that are inserted directly into the blood vessels. Black flies breed exclusively in running water, and the larvae are highly adapted to survive in this challenging habitat. They attach themselves to the substrate using a circlet of hooks which latches into a patch of silk they lay down specifically for this purpose. The larvae are essentially legless (though they do have one anterior proleg), but have enlarged feeding fans with which they filter passing organic matter from the water column. They pupate directly on the substrate, often inside slippershaped cocoons, and emerge into a gas bubble which rises to the surface and releases the adult. Some species are partially or entirely autogenous, but it is the blood-feeders that cause significant annoyance and economic losses to humans, livestock and wildlife.

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Wherever black flies that feed on humans occur, they can be extremely annoying. They may be numerous enough to drive people to distraction. More serious is when people develop sensitivity to the saliva in their bites. When this happens, people may develop enormous welts and bumps, and may suffer from black fly fever or even anaphylactic shock. Black flies are not generally known for their ability to transmit pathogenic organisms to humans, but there is one notable example among the filarial nematodes - onchocerciasis or river blindness. The adult worms are found coiled up in nodules under the skin or deep in the tissues. The males are relatively small, only 3-5cm long, but a female may attain a total length of 80cm. Just think about that for a moment. These adult females release the infective stage (microfilariae) into the bloodstream, and these make their way to the capillaries under the skin. The adult female worms may live for more than a decade, releasing the microfilariae the whole time. In fact, it is the large numbers of microfilariae over many years which move through the tissues and through the eyes that eventually may cause blindness and structural changes in the skin. Humans become infected when bitten by a variety of species of black flies which are found in Africa and in central and South America. However, it takes many years of heavy exposure before the symptoms of blindness to appear in infected people. Black flies bite mainly during the day, and personal protection is by far the most effective means of avoiding adverse reactions sustained from their bites and possible infection with filarial worms. In some parts of the world, there have been massive efforts to reduce or even eliminate species of black flies that transmit onchocerciasis. 4) Tsetse Flies Tsetse flies are a fascinating group of just over 20 species found throughout southwestern, central and east Africa. Males and females feed only on blood, and their bites can be extremely painful and annoying. They are persistent biters, and never fail to ruin a picnic when they are around. The really peculiar element of their life history is that female flies have a special adaptation in their reproductive tract. There is a structure referred to as a “uterus”, in which the female nurtures each of her developing maggots, one at a time. The egg hatches in the uterus, the maggot begins feeding from a gland that produces its food, and eventually matures there. The female gives birth to a fully mature maggot, one which pupates immediately and eventually emerges as an adult fly. Unfortunately, these interesting flies also have the ability to transmit a protozoan parasite that causes trypanosomiasis, or African sleeping sickness in humans. A fly acquires the parasite from the blood of an infected person, the parasite develops and multiplies inside the fly, and when the parasites migrate into the salivary glands of the fly, they may be transmitted to another host when the tsetse fly feeds. Although there have been enormous efforts directed to the control and elimination of tsetse flies in Africa, they are still present in many areas where you will be at risk of infection. Treatment for trypanosomiasis is based on a number of drugs that may cause any number of unpleasant side affects. However, the best advice to you is to avoid being bitten. 5) Sand Flies I am using the term “sand flies” here in a strict sense. A sand fly to a New Zealander or Australian is a black fly to us. The sand flies I am referring to here belong to a small group of about 600 or so species of what are also more precisely

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called phlebotomines, mostly found at tropical and semitropical latitudes around the world. These blood-feeding flies breed in the soil, rock pools, animal burrows, manure, and many different areas where there are accumulations of damp organic matter. The adults are generally small, less than 5 mm in length, but the females can often be recognized by their peculiar habit of running over the skin, stopping briefly, and then running again. There are many harmless relatives, called moth flies, that are a common nuisance in homes in Manitoba, where they breed in the traps of kitchen and bathroom fixtures, feeding as larvae on the built-up gunk you find there. Among the most common pathogens picked up by travellers to Central and South America, or in tropical and subtropical Africa, Asia and Europe, is cutaneous leishmaniasis. This condition is caused by a protozoan parasite that normally infects a variety of native mammals. When a person is infected, they may exhibit no signs of infection for several months, making a correct diagnosis, long after you have returned home, less certain. Then at the site of the bite, they may develop a mild to severe ulcer. Secondary ulcers may occasionally develop, in some cases causing hideous disfigurement. Visceral leishmaniasis, or kala azar, may begin as a lesion or ulcer at the site of the bite, but it ultimately progresses into lesions on the major organs. If untreated, visceral leishmaniasis usually results in death. Sand flies may also transmit a variety of exotic viral pathogens. Protective clothing and repellents are the most effective means of avoiding sand fly bites. Bed nets are commonly used where sand flies are a problem. 8) No-see-ums The common name of this group of flies is as good description as you need to remember. Species that bite humans are usually very small, perhaps only 2-3 mm in length. Many of the important species have spotted wings, but you will have to look very closely to be able to see this feature. Most of the troublesome species breed in damp soil and organic matter or in a wide range of aquatic and semi-aquatic habitats. Only the females take blood, but they do so with impressive style for such a tiny fly. Your most frequent encounters with no-see-ums (also sometimes called sand flies, incidentally) will usually result in no more than severe annoyance. People often fail to notice that they are being bitten, either because these flies are most active at dusk so they don‟t show up easily, or because they are so small that most people can‟t imagine them to be a problem, even if they do see them. Their saliva is very potent, however, and many people have very strong reactions to the bites, a reaction that may not develop into the characteristic, super itchy, running sores until a day or two after being bitten. Most of the viral pathogens transmitted by no-see-ums affect domestic animals and wildlife. Exceptions which may cause disease in humans are Oropouche virus (South America and the Caribbean), Crimean-haemorrhagic fever virus (Africa and Asia) and Dugbe virus (Africa). Personal protection is generally the only practical means of avoiding attack from no-see-ums. Protective clothing and repellents are effective, but it might also be wise to avoid activity outside during periods of peak flight of these little devils. Unfortunately, some species will also enter houses quite readily. If this turns out to be the case, bear in mind their small size when you decide to purchase screen for the windows. 7) Horse Flies and Deer Flies - Tabanidae The 50 species of tabanids in Manitoba have been the subject of research for many years. The Manitoba Horse Fly Trap, was first developed here at the University

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of Manitoba by A.J. Thorsteinson and his students and colleagues in the 1960's, and is now the standard means of collecting and studying this group of flies all over the world. The tabanids can be very broadly divided into two groups, the horse flies and the deer flies. The horse flies include Hybomitra and Tabanus spp., which are large and robust, attack mainly large animals, and which inflict major pain with their bite. They can be serious pests of pastured cattle, horses, and wildlife. I have seen moose come charging out of the forest onto the road and run for their lives, trying to escape these persistent hunters. If you have ever parked a vehicle at the roadside where these flies are abundant, you know that it is wise to keep the windows rolled up! If you don‟t, you will find the inside of the vehicle alive with hundreds or even thousands of horse flies dancing about the windows. Deer flies (Chrysops spp.), on the other hand, are smaller, with darkly patterned wings, and which sit at rest in a delta design. These flies also have a painful bite, but in particular, they fly around the head and shoulders, causing considerable annoyance just by their presence. You know they are going to nail you...it's just a matter of when. We do have a few other unspecified genera of tabanids in the province, Atylotus spp., for example. However, these species are rarely encountered, are of no economic consequence, and therefore have attracted little attention. Worldwide there are well over 4,000 different species, most of which are most active on bright, warm sunny days. The larvae of tabanids are aquatic, or at least are found in wet soils. Many are predacious, and have savage mouthparts. If you try to pick up larvae of the larger species, they have the ability to lacerate the skin and draw blood. They feed on other invertebrates in the habitat, including their conspecifics. There are published records of larger larvae attacking and feeding upon small vertebrates, toads, for example. Horse flies and deer flies most often transmit pathogens mechanically. That is, they acquire a pathogen while feeding on an infected host. Because they cause so much pain when they bite, they often elicit a strong defensive reaction from that animal, and the feeding fly is disturbed. They are very persistent, and will continue to attempt to feed until they are full. If they resume feeding on a different but nearby host, the pathogens adhering to the mouthparts may be inoculated into the next host. In these cases, there is no development or replication of the pathogens on the mouthparts of the fly at all. A variety of viruses, bacteria and protozoa may be transmitted in just this way. One exception is African eyeworm (Loa loa) that causes loiasis. This nematode must undergo development inside the female fly before it can be transmitted to a new host. The adult worms, which may be up to 7 cm in length, are found under the skin, particularly in the upper body regions. They get their common name, eyeworm, by their disconcerting habit of moving about under the conjunctiva of the eye. 8) Fleas Adult fleas are highly sophisticated ectoparasites of mammals and birds. They are wingless and laterally flattened so that they can move easily among the hairs and feathers of their hosts. Their bodies are covered with rows of backward-directed hairs some of which on the head, thorax or abdomen may be heavily sclerotized and modified to form conspicuous combs, called ctenidia. The mouthparts are adapted for piercing the skin and sucking blood. The heads of males have a dorsal groove into which the ventral margin of the female abdomen fits during mating. The antennae of the males are prehensile, and during mating are extended dorsally to clasp either side of the female's abdomen. The hind legs of most species are adapted for making incredible leaps, enhanced by a nearly perfect elastic protein called elastin. There are

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several species which are largely confined to their host‟s nests and in which the ability to jump has been lost. The larvae are generally conservative in structure, white, legless, and covered by numerous long hairs called setae. The larvae are most often found in the nest of the host and feed on organic debris and faecal pellets from the adults, though there is morphological evidence that larvae of some species must be predators. There are several rather peculiar larvae that are nearly always found on the body of their host, for example on arctic hares on the Barren Grounds of Canada's arctic islands. Fleas are notorious as vectors of the bacilli that cause Black Death, bubonic plague, transmitted primarily from rats and other rodents to humans. Although plague is now found all over the world where suitable rodent hosts and fleas are found, you don‟t have to travel far from home to become infected. Plague has never been found in Manitoba, but it is known in southwestern Saskatchewan, Alberta and British Columbia. At one time, it was isolated in Border County, North Dakota, a little too close for comfort! Most species of fleas are found in association with various mammals, but there are many species which specifically attack birds. Some fleas are host specific, and may be found on only one host species. At the other extreme, there are species which seem to be able to attack a wide variety of hosts. Most are free living as adults, but females of the tropical chigoe fleas are an interesting exception. Female chigoes are initially only about 1 mm in length when they attach to their host, in humans often between the toes or under the toe nails. They are slowly engulfed by host tissue, where they increase greatly in size until they attain the size of a pea under the skin. At this stage, only the anus and reproductive opening protrude through an opening in the skin surface. The irritation caused by these infestations is something you can easily do without! There are a few interesting examples where reproduction in the flea is regulated by reproduction in their host by the presence of circulating reproductive hormones in the blood. In an interesting example of convergence, larvae of the Australian flea, Uropsylla tasmanica, are found living as parasites under the skin of dasyurid marsupials, and look very much like the larvae of warble grubs found on cattle. 9) Ticks After mosquitoes, ticks are probably the most important group of arthropods as vectors of pathogens. They aren‟t insects, since the adults have eight legs instead of six, but that makes them no less important. For some strange reason, most people absolutely detest ticks. I‟m not sure why that is. Perhaps it‟s because they hide in the long grass and get onto your body without your knowing. Then they stealthily crawl over your skin until they find a suitable place to feed, where they embed their mouthparts, and slowly begin to extract your blood, all without being detected, until they are engorged and the size of a grape! Yup, that‟s probably why. There are two types of ticks: soft ticks and hard ticks, the latter being the far more important in public health. Most hard ticks hatch from eggs as tiny six-legged larvae. These larvae attach to a passing host, take a blood meal, and then moult to an eight-legged nymph. The nymph takes a blood-meal and then moults to the adult stage. The adults feed and mate, and the females fall from their host and lay their eggs, as many as 3000 or more, somewhere on the ground. Depending on the species of tick, they may spend their entire active life cycle on one host, as is the case for the winter moose tick that is such a problem in some parts of Manitoba, or, more commonly, they may drop off each host to moult to the next stage. Our wood tick

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does this, and must wait in the grass for a new host before they can get a blood-meal and resume their development. The life cycle of our wood ticks generally takes two years to complete, the first winter spent as a larva, and the second winter as an adult. Ticks may transmit a wide variety of different pathogens, including viruses (e.g., tick-borne encephalitis, Powassan encephalitis), bacteria (e.g., Lyme borreliosis, ehrlichiosis), rickettsiae (e.g., Rocky Mountain spotted fever), and protozoans (e.g., babesiosis). To add to the grief of pathogens transmitted by ticks, many people suffer severe localized sensitivity to tick bites, or they may acquire secondary bacterial infections that may require treatment. Some species of ticks found in western North America (including British Columbia) and in Australia are also known to cause tick paralysis. This toxic response to the saliva of a feeding tick can result in paralysis and even death, if the tick is not removed in time. It is a flaccid, ascending paralysis, which usually begins as weakness in the legs, progressing to the trunk, ultimately causing paralysis of respiratory muscles. Personal protection is by far the most effective means of avoiding ticks bites and tick-borne infections. If you are in an area where ticks are present, tuck you pant legs into your socks to keep ticks, initially at least, on the outside of your clothing. Ticks are more easily seen on light-coloured clothing, too. If you are going to spend a lot of time in tick-infested habitat, you might even consider cutting your hair short, so the little devils will be easier to find. Treatment of socks and pant legs with repellent will also provide some protection. Before you settle in after a long day of tramping in the field, check yourself carefully for any ticks that are wandering around on you, or that may have begun to feed. If you find an attached tick, grasp the tick gently with tweezers, or with your fingers, and pull them out using gradual, steady pressure. Do not squeeze them, smash them, twist them, burn them, or smother them in petroleum jelly or mineral oil. You don‟t want to irritate them and have them regurgitate saliva into the wound. Remember that in most cases, even if you have been attacked by an infected tick, the sooner you remove it, the less likely you are to be infected. Happy Trails What I really hope to have accomplished in this brief sojourn into the world of arthropod vectors, is to raise you level of awareness and to peak you interest. Carry with you the warning that a little knowledge can be a dangerous thing. With that in mind, I make the following suggestions for you to have a safe and enjoyable trip: 1) Read, read, read - When you prepare for the trip of a lifetime, you probably go to great lengths to study tourist brochures, maps, guides to the sites, currency, local culture and language. How much time do you spend reading about the insects you may encounter or the pathogens they can transmit? Go to your local library, surf the internet, talk to friends with experience in the places you are to visit, consult with your physician and with public health officials. Do whatever it takes to know what to expect when you arrive. 2) Be prepared - Consult with your physician and with provincial or federal tropical disease specialists. Make sure that you have been vaccinated against pathogens that you may encounter where you are going, and that while you are there, you take every precaution to reduce the risk of exposure. 3) Relax - Once you are aware of the risks of vector-borne diseases and you are armed with the best information and medical precautions you can, you can rest assured that you are in the best position possible to enjoy your travel experience

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Third World Dentistry (Belize and Haiti) & Dental Emergencies in the Wilderness
Dr. Eric Parsons - DDS Dr. Elsa Hui-Derksen, DMD Winnipeg, Manitoba Kindness in Action – Belize 2004 Kindness in Action Service Society of Alberta is a group of concerned individuals, motivated by a belief in the dignity of all people and their right to basic human needs. Their primary focus is oral health. The Mayan glyph for "helping hands" is their logo. The objectives of Kindness in Actions are as follows:    To provide dental health services, doing as much as we can with what we have. To honor, support and empower those with less and assist them in becoming self-sufficient. To educate and raise awareness of Developing World Issues. Kindness in Action has been in existence for 11 years and sends teams to the countries of Guatemala, Honduras, Nicaragua, Mexico, Belize, Peru, Phillipines, India and Thailand. KIA focuses on the relief of pain for the greatest number of people and serving communities. The 2004 trip to Belize was the first of its kind for Kindness in Action. I was involved with a team of 23 individuals on a one week trip to a small village in the north eastern part of Belize called Sartenja. Discussion for today: a) History of the country and need for dentistry b) The making of a makeshift dental clinic c) The need for a reliable liaison when volunteering in a foreign country d) Risks and rewards

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Dental Emergencies Statistics – How much at risk are you? 1. Dental health prevention for the traveller:
a) Need for regular dental visits b) Mouthguard

2. Management and treatment of dental emergencies in the wilderness:
a) Toothache from a Cavity and Lost/Broken Fillings b) Tooth Abscess c) Pericoronitis d) Loose crown e) Dental Injuries Fractured tooth Avulsed tooth (Knocked Out Tooth)

3. Know what to include in an emergency dental kit

1. Dental health prevention for the traveller
Dental emergencies can happen when leased expected. You could be in the middle of a hike on the West Coast Trail, mountain climbing in Alaska, or camping in Banff National Park where access to a dentist may not be readily available. It is important to know which dental emergencies can be temporarily treated in the wilderness and which ones require immediate attention. The best prevention is to have regular dental visits and/or to visit your dentist prior to going on a long trip. A leaky filling can cause a problem at high altitudes or below sea level. This is especially applicable to mountain climbers and scuba divers. Bring essential dental care supplies on your trip – toothbrush, toothpaste, and floss. Floss and brush after every meal to avoid food being lodged into the gums, which can result in an aggravating gum infection. Sugarless chewing gum can also become a good friend during long trips. When brushing and flossing are not ideal, chewing sugarless gum helps to promote saliva flow and clear the teeth and gums of excess food particles.

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Mouthguards can be important for those travelling and enjoying high impact sports. Mouth protectors, which typically cover the upper teeth, can cushion a blow to the face, minimizing the risk of broken teeth and injuries to the soft tissues of the mouth.

2. Management and treatment of dental emergencies in the wilderness
Toothache from a cavity and broken fillings
A toothache is a common dental emergency that is often caused by a cavity in the tooth. Bacteria inside the mouth use food particles left on the teeth to produce an acid, which destroys the enamel and dentin resulting in a hole in the tooth. The pulp tissue often becomes inflammed eliciting a pain response. Broken fillings can occur from an active process of decay under an existing restoration. Broken fillings are often sharp to the tongue and cheeks and may or may not be sensitive, depending on whether the dentin is exposed. Exposed dentin may cause the tooth to be sensitive to pressure, air or temperature of foods. Signs and Symptoms Pain which is intermittent and often hot or cold sensitive. Hot or cold sensitivity often lasts for a few seconds and goes away. Treatment 1. Locate the offending tooth and moisten a piece of cotton or cotton pellet with eugenol. Apply the cotton to the tooth. 2. Fill the cavity with temporary filling material such as Cavit®, zinc oxide and eugenol cement, or dental wax. Cavit® requires no premixing and is applied directly over the tooth. Intermediate restorative material is prepared by adding a few drops of clove oil to powdered zinc oxide to make as dry a “dough” as possible. (Zinc oxide and eugenol combination cements are advantageous in that they have an anesthetic effect and can be mixed to different consistencies, depending upon whether they are to be used as filling material or adhesives. However, the liquid can leak from its container, and the cement is sticky and more difficult to work with than Cavit®). 3. Smooth the temporary filling material with your finger or a wetted toothpick. 4. Give pain medication as needed. (Ibuprofen 600 mg q4-6h prn) 5. Such fillings set after exposure to saliva and usually have to be replaced every few days. Follow-up Treatment See your dentist after your travel and have the tooth filled with a permanent filling.

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Abscesses and gum infections
A tooth abscess is a collection of infected material (pus) resulting from bacterial infection of the center (pulp) of a tooth. A tooth abscess can cause unbearable pain and discomfort to the traveler. Tooth abscesses are a complication of tooth decay. It may also result from trauma to the tooth, such as when a tooth is broken or chipped. Openings in the tooth enamel allow bacteria to infect the center of the tooth (the pulp). Infection may spread out from the root of the tooth and to the bones supporting the tooth. Infection results in a collection of pus (dead tissue, live and dead bacteria, white blood cells) and swelling of the tissues within the tooth. This causes a painful toothache. If the pulp of the tooth dies, the toothache may stop, but the infection remains active and continues to spread and destroy tissue. If not treated, the infection can spread from the tooth to the floor of the mouth, the face and neck resulting in severe illness.

Signs and Symptoms
1. Toothache - Severe and continuous pain - Sharp, shooting pain - Throbbing pain 2. Pain upon biting and chewing to the effect the tooth feels longer 3. Redness and swelling around the gums and at the root of the tooth 4. Presence of a gum boil near the root of the tooth that may or may not drain 5. General malaise and discomfort 6. Bad breath and foul taste in the mouth 7. Swollen glands in the neck area - lymphadenopathy 8. Swollen face and neck indicating a very serious condition 9. Fever may be present Complications     Loss of the tooth Spread of infection to soft tissue (facial cellulitis, Ludwig‟s angina) Spread of infection to the jaw bone (osteomyelitis of the mandible or maxilla) Spread of infection to other areas of the body resulting in cerebral abscess, endocarditis, pneumonia, or other disorders

Treatment
1. Administer oral antibiotics.

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Pen V 500 mg 2 tabs stat then 1 tab qid until finished 2. Rinse mouth with warm salt water (1 teaspoon of salt in 1 cup of warm water) every 4 hours. Salt water rinses are good as they alkalinize the mouth creating an environment less favorable for bacteria. 3. If there is a soft, pointing abscess adjacent to the offending tooth, apply orajel and then puncture the boil with a sharp scalpel if available. This will help relieve the pressure and the pain. 4. Reduce pain and fever with oral analgesics (Ibuprofen 600mg every 4-6 hours).

Follow-up Treatment
Upon returning from your trip, visit your dentist for definitive treatment. Root canal treatment is most likely required to remove the infected pulp tissue and decay. The tooth is then restored with a core and crown after the root canal treatment.

Pericoronitis
Pericoronitis is an infection of the gum flap that overlies a tooth that has only partially advanced (“erupted”) into the mouth. This is most common with a lower third molar and usually indicates an infection with Streptococcus bacteria.

Signs and Symptoms
1. Bad taste or foul breath 2. Pain resulting in limited range of motion and inability to open completely (trismus) 3. Pain may be mild but is usually quite intense and may radiate to the external neck, the throat, the ear, or the oral floor 4. Cervical lymphadenopathy, fever, and malaise are common signs and symptoms

Treatment
1. Rinse with warm salt water rinses every 4 hours. 2. If hydrogen peroxide is available, attempt to irrigate the area with a syringe to remove food debris, plaque and pus. 3. Administer oral antibiotics. Pen V 500mg 2 tabs stat then 1 tab qid until finished 3. A soft diet is advisable.

Follow-up Treatment
Visit your dentist immediately after your trip to have a referral to an oral surgeon. The condition will persist until the tooth is removed.

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Loose or lost crowns
Loose crowns can also pose a problem while travelling. A loose crown is dangerous as it can be aspirated or even swallowed if not careful. A loose crown should be recemented to prevent sensitivity and further bacterial contamination.

Signs and Symptoms
1. A loose crown may feel like you are not biting like you normally do 2. Hot and cold sensitivity due to exposed dentin

Treatment
1. Wash away any debris and food particles around the tooth with a cotton tip applicator or toothbrush. 2. Remove remainder of cement in the crown 3. Mix zinc oxide and eugenol into a temporary cement consistency and place into the crown. Alternatively, prepared dental cements, such as Dentemp®, are premixed and are simple to carry and place. 4. Place crown back on the tooth in the correct position and bite down until the cement is set. 5. Clean off any excess cement with a toothpick and floss between the teeth.

Follow-up Treatment
Visit your dentist as soon as your travel is over for definitive treatment. The tooth may require a new crown or may simply need to be re-cemented with permanent cement and adjusted into occlusion. Complications Crowns that are not recemented will cause further problems as the occlusion will be affected and the adjacent and opposing teeth will shift out of position. The tooth is vulnerable and weak and needs to be restored immediately to prevent loss of the tooth.

Traumatic dental injuries Fractured tooth
A fractured tooth can be saved depending on where the fracture occurs and if the nerve is exposed. Most teeth fractures occur in the front teeth, however some fractures occur on posterior teeth such as the molars.

Signs and Symptoms
1. Pain and sensitivity when breathing in air 2. Hot and cold sensitivity 100

3. Bleeding around the gums at the injured site 4. Mobility may or may not be present

Treatment
1. Place temporary restorative filling material into the fractured area of the tooth if it will hold. 2. Avoid hard foods and maintain a soft diet. 3. Avoid very hot and very cold drinks. 4. Check other areas of the mouth for lacerations or broken teeth fragments.

Follow-up Treatment
If the no pulp exposure occurs the tooth can be restored with a simple filling upon returning to civilization. If the nerve is exposed and a pinpoint bleed can be seen at the site of the fracture, the tooth can sometimes be restored with a base and filling. Larger exposures will require root canal treatment.

Dislodged and avulsed teeth (knocked out tooth)
A dislodged tooth involves a tooth that has come out of position in its socket. An avulsed tooth is one that is completely knocked out of its socket and requires immediate attention in order to save it. The single most important factor in the success of reimplantation of an avulsed tooth is the speed of reimplantation. The first 15-20 minutes are crucial, after that the periodontal ligament cells lose their normal physiological function.

Treatment
1. Clean any dirt and debris off the tooth by gently rinsing with saline. Do not scrub the root surface, as it will damage vital cells required for reimplantation. 2. Irrigate the socket gently of any debris or dirt. 3. Carefully place the tooth back into the socket in the correct position and orientation. 4. Remember to hold the tooth at the crown portion to avoid disrupting the periodontal ligament cells. 5. See your dentist immediately to have the tooth splinted into place. 6. If seeing your dentist is impossible, splint the tooth to the adjacent teeth by placing a strip of wax across a span of two teeth to the right and left of the affected tooth. Do the same on the inside surface of the teeth. 7. Soft diet is advisable for at least two weeks. If the tooth cannot be reimplanted easily, the best transport media to place the tooth in is milk, followed by saliva. Milk maintains vitality of the periodontal ligament cells

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for up to 3 hours whereas saliva maintains cells for 2 hours. Immediate dental treatment should be sought.

3. Emergency dental kit
An emergency dental kit may prove handy during long trips in the wilderness. Dental emergencies can cause a lot of grief and take away the enjoyment of a trip. An emergency dental kit is easy to pack and lightweight. They can be purchased or made at home. Essential items to include: Dental examining gloves Dental mirror Dental tweezers or cotton pliers Dental spatula Dental wax Dental floss Temporary filling material – zinc oxide powder and eugenol Temporary crown & bridge cement Topical analgesics Cotton tip applicators Cotton rolls Cotton gauze pads Toothbrush with toothpaste

Resources:
Cohen S, Burns RC, Pathways of the Pulp, 8th Edition, St. Louis: Mosby, 2002:636637. Peterson LJ, Ellis E, Hupp JR, Myron RT, Contemporary Oral and Maxillofacial Surgery, 3rd Edition. St. Louis: Mosby, 1998:219. Weiss, EA., Backpacker Wilderness 911. 3rd Edition, Seattle: The Moutaineers, 2003.

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Avian Flu and Other Respiratory illnesses
Gary Podolsky MD Respiratory illnesses Each year respiratory infections are very common. Often people will self diagnose themselves with a „cold‟,‟ flu‟ or „strep throat‟ on the basis of their symptoms. Likewise many practitioners may reinforce these spot diagnoses without taking an adequate history or physical. In order to treat people best it is important to have a specific diagnosis and a specific treatment for the correct illness. This is as important for mundane illnesses such as the common cold and flus as well as more severe infections such as Group A Streptococci (“strep throat”), tuberculosis and even non-infectious illnesses such as lung cancer. Recently both SARS and Avian flu have become newcomers to the differential diagnosis. Respiratory symptoms such as malaise, sore throat, sore muscles, fever and a cough with or without phlegm only describe illnesses and do not define any specific entity but provide a starting point towards forming an accurate diagnosis. Table 1 Differences between Colds and Influenza
COLD NONE OR MILD ONLY IF FEVER RARE SLIGHT SLIGHT RARE COMMON COMMON EARLY LASTING 2-3 D MILD RARE FLU ALWAYS AND HIGH USUAL COMMON INTENSE EXTREME UP TO 2-3 WEEKS SOMETIMES SOMETIMES SOMETIMES COMMON WORSE BY DAY 2-3 COMMON HACKING COUGH SOMETIMES

SYMPTOM
FEVER CHILLS PROSTATION ACHES AND PAINS FATIGUE AND WEAKNESS SHORTNESS OF BREATH RUNNY/STUFFY NOSE SNEEZING SORE THROAT CHEST DISCOMFORT DIARRHEA/ VOMITING

Common Colds Colds as a group are benign and are caused by over 200 viruses. There are wide variations in severity and duration of different types of colds. Colds tend to have a gradual onset with a slight sore throat. A sickly feeling develops behind the ears along with sneezes and sniffles. Later, a runny nose with a more sore throat and dry hacking cough develops. People are usually achy although fever is usually below 120 degrees F. On average symptoms may last 7-10 days but may last longer. Children develop more colds because of the way they are cloistered and average about 6/year with adult 3/year. Parents with children develop more colds than single adults living alone. Colds are a year round phenomena but there is an increase in incidence beginning Late August with a peak in September and October. A second peak of incidence occurs in Late Spring. When outdoor temperatures drop indoor heating is started. This dries out the air, which also dries the mucous membranes of the nose and throat, impairing the body‟s first line of defence against infections. Infection In order to catch an infection the immune system must be overwhelmed. The body‟s first lines of defences include ciliary action in the respiratory tract, secretory immune globulins and barrier protection from the skin. Moist mucous membranes are the first lines of defence. When dry they are much less effective and this is also true when the body is dehydrated. Smoking will paralyse ciliary action as well as less direct effects (Arsenic, Carbon Monoxide) on the immune system. Stress in general adversely affects the immune system whether it is physical or mental. Exercise in moderate amounts leads to optimal immune function, but both undertraining (unfit) and overtraining have been shown to decrease T cell function. 103

Common misunderstandings regarding catching colds include- not wearing a hat, being overheated, being chilled and having wet hair. Catching a cold Approximately one half to three quarters of people with colds do not develop symptoms. Cold viruses incubate for 1-4 days before sickness. They are contagious during that interval even though they may not be aware that they are sick. Cold viruses are transmitted by inanimate objects (fomites such as telephones, doorknobs) and respiratory droplets released into the air and then inhaled. Kissing rarely spreads colds. Treating colds Colds have many proposed treatments with many divergent opinions on what works best. There are over 200 strains of cold viruses making a vaccine very difficult to develop. The military has developed an adenovirus vaccine with limited success. Interferon treatments do not wok. Vitamins have also been intensely studied and evidence shows that Vitamin C has some modest effects. Vitamin C will not prevent colds but it may alleviate symptoms and shorten the duration of sickness. A dose of 1000mg every 4-6 hours and this is only effective against some colds about a third of the time. Influenza Influenza or the “flu” is named after the early medieval belief that those afflicted were under “the influence” of Astrological phenomena. In general individuals may develop influenza from once per year to every several years on average. Prevalence per year has been estimated as up to 10-25% of the populace. Average deaths per year in US are 10-20,000. Influenza A is the most common (97%) circulating disease. Type B is currently at low levels and Influenza C is rarely a cause of human disease. In the 2003 Southern Hemisphere Winter and 2003-2004 Northern Hemisphere Winter 97% of Flus were due to Type A and of these 99% were H3N2 by the end of the season. Symptoms of influenza typically begin with a sudden onset high fever of 102-104 degrees F, headache, extreme fatigue, weakness, and muscle aches and pains. Less commonly are symptoms of runny nose and sneezing. The sore throat generally gets worse over 2-3 days with a dry hacking cough. Sometimes vomiting and diarrhoea also develop. The duration of illness usually lasts for 3-7 days although some may have fatigue and lassitude for weeks. Flu season typically begins in November/December until May/April in the Temperate Northern Hemisphere. It is an all year phenomena in Tropical Equatorial countries and in the Southern Hemisphere occurs from April to October. Travellers may also spread flu from one geographic area to another. The two hemispheres also may have different circulating strains of the flu at different times so that yearly immunization may not necessarily cover imported flu strains. Catching a Flu Influenza is more easily spread than colds. Both airborne water droplets released by sneezing, coughing and conversation; and inanimate objects spread it. Both flu and cold viruses can persist on hands and inanimate objects for 1-3 hours. Incubation times between encountering the viruses and becoming sick may vary between 1-3 hours. This follows then that many apparently well people are infectious. Flu patients are also infectious for another 5-7 days after onset of symptoms.

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The influenza virus is a specific virus that is constantly changing its surface proteins. The N and H type proteins expressed on their surfaces type flu viruses. (There are 15 H proteins and 9 N proteins). Both antigen shifts and drifts occur which allows the influenza to continue to not be recognized by individual immune systems that have never encountered that specific strain of flu before. Haemophilis Influenza is a bacterium with a similar sounding name to influenza and is not related. Hib vaccine against Haemophilis does not confer any protection against influenza. Vaccine effectiveness The vaccine is felt to be effective between 70-90% from developing disease or significant illness in young healthy adults. Older adults, those with chronic illnesses and the very young have less of a response to the vaccine but do benefit from protection against severe illness. By immunizing a large amount of the healthy population they become protected from the flu but they also indirectly provide herd immunity for those who are much more susceptible- very young and very old and sick. Several large studies have shown the flu shot to be protective and cost effective even for young healthy adults. Travellers and Flu Influenza may quickly travel throughout households, institutions and in close confined areas. In one case an aircraft with one known influenza case was kept grounded for 3 hours and led to 72% of the crafts 54 patients developing the flu. In another study 42% of a naval ship‟s crew were similarly infected from one index case. Cruise ships are known for frequent outbreaks. The cruise ship company, Holland America has reacted to this by immunizing all crew and stockpiling antiviral medications at the earliest warning of an outbreak among the passengers and crew (Personal communication SAILS II meeting, November 2004). Immunizing Travellers as a distinct risk group Special considerations for immunizing travellers include: travel aboard cruise ships (year round), travel to tropics (year round), travel with large organized groups, and travel during flu season (Northern Hemisphere Nov-April, Southern Hemisphere April –Oct). Although one must travel to the right hemisphere to get the right flu vaccine there is some talk that Southern Hemisphere Flu vaccines be made available in specialized travel clinics for far reaching travellers. The “wrong hemisphere” vaccine will give some protection since the two are often similar. A Traveller to Australia might also be encouraged to seek a local physician there to receive the correct vaccine while away. The flu vaccine may take up to one week to be effective. This is an important concept as such travellers may serve as carriers of atypical strains on their return. In North America the Flu vaccine is typically recalled and destroyed in June (April in Manitoba) so that the stock may not be inappropriately used next year. It is still safe and effective into August but clinicians are not encouraged to use it. Immunizing more than once with one years‟ vaccine is not felt to be of any benefit. Birds and Influenza Birds remain a large reservoir of Influenza A viruses. Even Influenza A may be thought of as a zoonosis. Currently two main circulating strains of Influenza A are H3N2 and H1N1. Pandemics of Flues occur every several years with the last one developing in 1968. H1N1 emerged in 1971 without a pandemic because there were enough people who had previous contact with this strain. Unfortunately a flu pandemic has been considered long overdue by pessimists expecting one soon. Based on information collected on antigenic shifts and drifts the WHO makes 2 annual vaccine recommendations:

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In February for the next Northern Hemisphere winter season (November-April); and in September for the next Southern Hemisphere winter (April-Oct). Every February and September manufacturers make their respective vaccines for the next season. Currently using chicken embryo viral growth techniques this takes 6 months although faster alternative technologies are being explored. In 2002 the Fujian H3N2 strain emerged too late to make corrections for both the Northern and Southern Hemisphere vaccine production lines. The vaccine did not resemble the Fujian strain enough to reap maximal benefit but there were enough cross-antigenic matches to make it effective enough to lessen the severity. For the next Southern vaccine the Fujian strain will be replaced by the Wellington strain because of its relative current prevalence.

Most Recent North and South Flu Vaccine Recommendations Trivalent Influenza for 2004 Southern Hemisphere Winter (April 2004-Oct 2004) A/Fujian/411/2002(H3N2) like virus A/ New Caladonian /20/99 (H1N1) like virus B/Hong Kong/990/2001 like virus 2004-2005 (Nov 2004-April2005) Trivalent Influenza vaccine for Northern Hemisphere Winter (Nov 2004-April 2005) A/Fujian/411/2002(H3N2) like virus A/ New Caladonian /20/99 (H1N1) like virus B/Shanghai/361/2002 like virus (Note while attending a meeting aboard Holland America I had noticed that they were using a bivalent flu vaccine because the trivalent was unavailable) Trivalent Influenza for 2004 Southern Hemisphere Winter (April 2005-Oct 2005) A/Wellington/1/2004(H3N2) like virus A/ New Caladonian /20/99 (H1N1) like virus B/Shanghai/361/2002 like virus

Other causes for Flu like symptoms In clinical medicine the term “flu like illnesses” have come to describe a variable set of symptoms that are most commonly associated with the flu. This reflects the wide variety of other illnesses that are often confused with the flu. Local epidemiology helps since in a flu epidemic the diagnosis of one more case seems likely enough, conversely an isolated case in the summertime is much less likely to a true flu case. A differential diagnosis may commonly include allergies, ear infections, sinus infections, strep throat and even other colds such as adenovirus. More exotic or uncommon alternatives include pneumonia, meningitis, tuberculosis, SARS, malaria, tropical illnesses, as well as cancers. The history and physical will help to clinically sort these out but this may not be so obvious earlier in their presentation. Specialized tests to detect specific febrile conditions Condition Tests possible Influenza Rapid test currently not widely used Strep Throat Rapid Strep test Available in many doctors offices Tuberculosis Mantoux ( 1or 2 step test) , Chest Xray Meningitis Prompt Lumbar puncture, rash may or may not be present 106

Imported malaria (Returning from Dominican Republic)

Immediate penicillin asap- may be life saving Wbc- should be normal Platelets decrease is a subtle hallmark of malaria Thick and thin blood smears- must repeat if suspicious

Antiviral Flu drugs Immunizations are still the first line in prevention against the flu. Antivirals also have a role in people with early influenza disease, those who cannot take the flu shot or if it is unavailable. The class of M2 inhibitors (amantadine) work effectively against influenza A but not B.. Neuramnidase inhibitors (Oseltmivar-tamiflu) work against both type A and B and is the only effective treatment for unknown or type b infection as well as the Avian Flu. Amantadine also has several side effects when used. It is generally agreed that neuramindase inhibitors are preferred over M2 inhibitors and new ones besides Oseltmivar are being researched. The cruise ship industry will do rapid test flu tests on pharyngeal swabs for sick passenger s and crew to confirm a Type A outbreak. In this case amantadine is used in both prophylaxis and treatment aboard the ship. Outside of closed populations it is unlikely amantadine will be used. Treatment of flu with Oseltmivar is most effective within 72hrs of symptoms and preferably 48hr where it may limit illness by 1.5 days. The dose is 75 mg twice per day for 5 days. Prophylaxis with Oseltmivar is 90% effective if started within 48hr of exposure. A minimum duration of 7 days is suggested and evidence of safety and usefulness of up to 6 weeks has been reported. For adults one daily pill is used. A pediatric version exists for ages 1-12. Safety in pregnancy has not been established. Avian Flu Widespread outbreaks in chickens and ducks of the highly pathogenic Avian Flu – Influenza A H5N1 began in December 2003 in South Korea, Vietnam, Japan, Thailand, Cambodia, Laos, China, and Indonesia. Initially infected animals were culled but the virus appeared to be permanently established by Aug 2004 in ducks, and chickens in Thailand, China, Indonesia, and Vietnam. H5N1 is transmitted by direct contact with ill birds and their faeces. Between Dec 2003 and Sep 2004, 40 humans were infected with 28 deaths. There is no human immunity against the H5 protein and not enough similarity with it and H3 or H1 so infections tend to be very severe and devastating. The greatest concern is that a human infected with H5N1 might also have a regular flu infection concurrently and that the Flu virus might reassort itself to acquire enough genes to make it easily transmissible among humans. By encouraging universal vaccination against human flus circulating this scenario becomes less likely. Research is moving towards an Avian Flu vaccine but there have been enough difficulties with developing regular flu vaccines. Antiviral treatment for Avian Flu Many governments have begun to stockpile Oseltmivar (Tamiflu). This drug which may prevent and treat influenza is currently not used much and if needed will become scarce. A comparison to the irrational hoarding of Ciprofloxacin against the recent perceived Anthrax threat is worrisome. Health Canada has begun to stockpile Oseltmivar for release during an impending Flu Pandemic or Avian Flu outbreak. In both situations there may be rapid spread of a very virulent flu that most people would not have immunity to. It is estimated that the first wave of a flu outbreak may last for 6 weeks and that hopefully an effective avian flu vaccine will be developed before a second wave occurs. Health

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Canada has begun to run strategies to make the best use of what antivirals we will have and use them efficiently for the greatest good. A treatment dose would require Tamiflu 75 mg BID for 6 days A preventative prescription would involve Tamiflu 75mg once daily for 42 days (based on the proposed 6 week duration of the average first wave based on prior flu pandemics and modern demographics) The following proposal has been put forth by the Public Health Agency of Canada: Health Canada Priorities of Use of Antiviral Oseltmivar 1.Treatment of persons Hospitalised with Influenza. Here the goal is to reduce mortality. Treatment is only started in the first 48hrs of illness. (estimated 14,000 doses) 2.Treatment of Ill Healthcare workers and Emergency Care workers. The goal here is to maintain these valuable individuals in a good state of health and also indirectly help others as well. (Estimated 1.8 million). Only those ill less than 48hrs will be treated. 3.Prevention treatment for Frontline Health Care workers and Health Decision Makers. The Goal here is to give daily preventative antiviral treatment in the hope that a vaccine is coming. This would involve 42 pills per person and estimate need is 8.9 million doses. 4.Treatment of high-risk people in the community. These would have to prevent within 48hrs and be identified as “high risk” for flu complications and be a potential drain on the healthcare system. (estimated 4.3 million doses) 5.Prevention of remaining health care workers (12.7 million doses-300,000 people for 6 weeks) 6.Control Outbreak in high risk residents of institutions (19,000 for treatment or 157,000 for prevention) 7.Prevention for Emergency Service Workers (15.6 million for 370,000 to receive 6weeks prevention) 8.Prevention of high-risk persons hospitalised for illnesses other than influenza. These would be at risk of influenza in hospital (1.3 million doses needed for 36,000 people to receive 6 weeks) 9.Prevention of High risk in Community (174 million to prevent 4.1 million people for 6 wks) This accomplishes treatments for 2 % of the population and prevention for 16%. Note that this model has assumptions that may not hold true- equal distribution of outbreaks among cities, the attack rate of 20% of the population, and the degree that people will actually follow these guidelines under duress. These guidelines are presented statically but may obviously be modified if information changes during an outbreak. Summary What may clinicians do? First when confronted with a febrile or respiratory illness make a clinical decision-is this a selflimited cold? Is the patient significantly sick to have a reasonable suspicion of something worse? Is Influenza circulating? Are their any atypical respiratory infections reported by public health? (SARS, Para influenza, Pertussis, Imported malaria, avian flu or anything else) If reasonably convinced of a flu diagnosis consider starting antiviral treatment within 48hr (This may not be possible but is worth keeping in mind) If someone asks for antiviral prophylaxis during the flu season consider this if clinically warranted and patient knows the price. Patients may also ask for flu chemoprophylaxis for sick relatives.

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The flu shot is still recommended as a first line treatment with antiviral treatment for all those who get infected with the flu. Some individuals may not be able to take a flu shot (scarcity, allergies) and these may be offered a 5-day treatment course or a 6-week prevention course. In the face of flu pandemic it is very likely that there will be a shortage of Oseltmivar. But there is no current shortage. Purchasing their medication from the pharmacy now may be an effective way to protect patients in advance by having them obtain this medication now and store it securely with its long shelf life. This will not interfere with Health Canada obtaining their stock now either so there is no ethical dilemma that may occur later when the demand for Oseltmivar exceeds supply. Also there is only one maker of Oseltmivar, Hoffman Roche for the world. In a pandemic the entire world will look to them to obtain stock. Health Canada is investigating if large companies will initiate their own stockpiles for their own employees to remove some of the burden from the government. In the so-called interpandemic flu period (now) clinicians should familiarize themselves with the appropriate use of Oseltmivar and prescribe it for their eligible patients now so that they will be familiar with this useful therapeutic option when a pandemic occurs. This is also felt to increase confidence in antivirals for both doctors and patients. Educating our patients is important and clinicians will find it daunting to now recommend that people seek consultation within 2 days for high fever while avoiding superfluous visits for likely cold symptoms. In the face of a pandemic it is very likely that specialized fever clinics may be established to sort people with symptoms and expedite treatment. During such a crisis the clinical encounter will be complicated by also trying to isolate potentially contagious patients regular hospital and clinic patients.

References and Further reading: Influenza: Changing Approaches to Prevention and treatment in Travellers. Freedman and Leder. J of Travel Medicine 2005;12:36-44. Influenza in the World. Wkly Epidemiol rec 2004;79;94-96 Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) Harper SA, Fukuda K,Uyeki TM,. et al MMWR Recomm Rep 2004;53:1-40. Influenza A outbreak on a cruise ship. Can Commun Rep 1998;24:9-11. Influenza a common viral infection among Hajj pilgrims: time for routine surveillance and vaccination. Balkhy HH, Memish ZA, Bafaqeer S, lmuneef MA. J Travel Med 2004; 11:82-86 Effectiveness of Neuraminidase inhibitors in treatment and prevention of Influenza A and B: systemic review and meta-analyses of randomised controlled trials. Cooper NJ, Sutton AJ, Abrams KR, et al. BMJ 2003;326:1235-1240. Pandemic Influenza and the global vaccine supply. Fedson DS. Clinic Infect Dis 2003; 1552-1561. WHO consultation on priority public health interventions before and during an influenza pandemic.2004 World Health Organization. www.who.int/csr/dis/avian_influenza/consultation/en/ Canadian National Anti-viral Conference Public Health Agency of Canada Winnipeg Manitoba, March 22-23 2005 (Proceedings soon to published ) Health Canada Flu watch www.hc-sc.gc.ca/pphb-dgspsp/fluwatch/index.html Centre for disease control Flu Prevention www.cdc.gov/ncidod/diseases/flu/weekly.htm European Influenza Surveillance System www.eiss.org/index.cgi Current WHO Vaccine recommendations www.who.int/csr/disease/influenza/vaccinerecommendations/en/

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Culture Shock
Simon Trepel, MD, 4th Year Psychiatry Resident University of Manitoba, Faculty of Medicine

Learning Objectives 1. 2. 3. To become familiar with concepts of culture To Understand Culture Shock To recognize possible symptoms of culture shock

Introduction People generally assume that the experience of travel will be an enjoyable and memorable one. With proper planning and realistic appraisals of potential problems, a majority of our vacations and extended trips will in fact live up to our positive expectations. There are many sources of stress related to travel, however, if we consider time zone changes, vast cultural differences, logistics of travelling- like companions, mode of transport and accommodations, new strange environments, and various other variables. An often overlooked potential source of stress and difficulty is the transition in our thinking, feelings and behaviour that takes place when we are immersed in a foreign culture. This transition represents the changes that must inevitably take place when we travel, or re-locate, from one culture to another. Sometimes the transition is fraught with many physical and mental symptoms that actually preclude enjoying the trip itself. Adverse symptoms while attempting to adjust to a new culture has been described as “Culture Shock”

Culture Culture is an amorphous process that shapes everything about our understanding of ourselves, others, and the world around us. We take our own culture with us wherever we go. Culture has been described as the “software of the mind” because it is a type of information that is learned in a collective context distinct from human nature and personality. One‟s own culture may be hard for one to describe or conceptualize, until one is immersed in another culture, and able to appreciate the differences. Trying to observe and understand another culture has been described as “watching chess without knowing the rules”. The moves people make will appear random or be difficult to understand without becoming familiar with the behavioural rules. The stress of attempting to modify our own thoughts and behaviours while in another society has been defined as Culture Shock. Culture Shock Oberg first described Culture Shock in 1959 as a “shock of the new”. It is understood as a consequence of strain and anxiety resulting from contact with a new culture and the feelings of loss, confusion, and impotence resulting from the loss of accustomed cultural cues and social rules. Taft defined Culture Shock as a “feeling of

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impotence from the inability to deal with the environment because of an unfamiliarity with the cognitive aspects and role-playing skills”. Culture Shock is a normal multifaceted experience resulting from the numerous stressors that occur in the context of contact with a different culture. Culture Shock has been associated with tourists, business-people on extended assignments, refugees, and international students.

Stages of Culture Shock There have been many models proposed to describe the various symptoms seen in culture shock. Most authors conclude that there exists a pattern of stages that are experienced in a specific order. While the order does not change, one may regress to an earlier stage based upon the severity and type of stress one encounters. Typical stages of Culture Shock are: Contact-Fascination-Honeymoon Stage Interest, excitement, euphoria, insomnia, positive expectations and idealization of host culture, any anxiety and stress is interpreted positively.

Disintegration-Hostility-Crises-Culture Shock Stage
Emerges within weeks-months. Characterized by irritability, pre-occupations with cleanliness, safety, devaluation of host culture, multiple physical/psychological problems related to cortisol-mediated stress responses. Symptoms include anxiety, agitation, panic, conversion-hysteria, anger, aggression, poor concentration/sleep/energy/appetite, loneliness, and even suicidal ideation. One wants to go home!

Reintegration-Acceptance-Reorientation-Gradual Recovery Stage
In order to be able to function effectively, there must be some adaptation to the new cultural environment. Without adaptation, one attempts “flight or isolation”. Resolution of the Culture Shock stage entails making acceptable adaptations to the new rules, roles and behaviours of the host country. Adaptations will require problem solving, and gaining new perspectives on one‟s own culture and the new host culture. Central to this process are concepts of empathy and nonjudgement. Problems and stressors do not end in this stage, but rather preparations are made to enhance functioning.

Adaptation-Resolution-Acculturation-Autonomy Stage One is able to develop stable adaptations that are successful at resolving new and current problems. One gains an awareness of cultural similarities and differences with their own, as existing on a continuum of adaptive human behaviour. One accepts the new culture without idealization or devaluation.

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Conclusions There has been little systematic research to address the mechanism and manifestations of Culture Shock, despite its first description over 40 years ago. Culture Shock is a phenomenon that occurs in specific individuals placed in foreign cultures for varying lengths of time. It is an important area of concern for immigrants, travellers, tourists, international business people, as well as international students. Culture Shock is a well-described process that occurs via predictable stages. Preventing difficulties and symptoms may be difficult, but clinicians should use an educational approach, stressing intercultural education, empathy, non-judgment, and the utilization of appropriate problem solving approaches to ensure that Culture Shock does not affect one’s ability to enjoy and function in the new society, or hinder a return to one’s own culture.

References 1. Winkleman M, Cultural Shock and Adaptation, Journal of Counselling and Development, 1994 (73) 121-126. 2. Stewart L, Culture shock and Travellers, Journal of Travel Medicine, 1998, 5(2): 84-88. 3. Mumford DB, The measurement of Culture Shock, Social Psychiatry, 1998 (33): 149-154. 4. Lockie C, Travel Medicine and Migrant Health, 2000.

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SCUBA Dive Medicine
Gary Podolsky MD SCUBA (Self Contained Underwater Breathing Apparatus) diving is a safe sport enjoyed by millions with a fatality rate less than downhill skiing (estimated at 1 in 95000 dives.) The risks of serious injuries are either from breathing compressed air or by the other environmental factors exists. Scuba diving requires that the participant be healthy and be able to respond to problems under water. In the same way that an individual should be competent to drive a car, divers should be held to a higher level of competence since problems could endanger not only themselves but also other divers and rescue workers. WHEN NOT TO DIVE Absolute conditions are those diseases or injuries where a person should not dive under any circumstances. These may be temporary as some conditions will change but are often permanent. An individual who was previously cleared to dive may acquire a condition temporary or permanent that would disqualify them from diving. It is every divers responsibility to disclose any conditions that may make him or her endangered, as well as anyone attempting to rescue them. Relative contradictions are conditions that may or may not prevent someone from diving, depending on an individual review by a physician who has knowledge in scuba. PREVENTION Proper scuba technique and medical screening may help minimize these hazards. Scuba diving should be learned from a properly organized course, and not in a compressed afternoon. Panic has also been a major determinant for disaster in diving. Experience and training will help minimize this. Avoid diving partners who are immature, intoxicated or using street drugs. If you don’t like your diving partner(s), break up with them before you agree to go in the water, otherwise, stick with them until the dive is over. ILLNESS Divers can be affected in many ways by dive related diseases, as well as the mundane types. It is often difficult for even experienced physicians to make a correct diagnosis in an ill diver. Any illness should be cleared with a dive physician or by checking with the Divers Alert Network (D.A.N). If in doubt, don‟t dive. No matter how expensive the trip was, remember you always can enjoy a snorkel, which does not have the risk of dysbarism, since you are not breathing compressed air.

CONDITIONS THAT MAY PREVENT PEOPLE FROM DIVING Because of the varied severity of many conditions, this list is deliberately vague and incomplete and persons with specific medical problems should always clear them with a physician knowledgeable in diving. People generally do diving over 16 years of age, but frequently children wish to dive. Children as young as 12 years may be considered for diving but this should be very carefully thought out. Cardiac – Any serious cardiac conditions should not dive unless screened by a Cardiologist and are able to perform 13 METS on an exercise treadmill.

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Pulmonary - Any asthma or lung disease should be assessed by a Respirologist, chest xrays, spirometry and possibly exercise challenge may be needed. Neurological – Patients with alterations in consciousness or uncontrolled seizures should not dive. Prior decompression illness should be carefully reviewed to evaluate if they should ever dive again. Ear/Nose/Throat – Divers with hearing in 1 ear or prior ear surgery should not dive. Sudden ear or sinus infections should also not dive till conditions improved (there is a risk of accident and they will have a painful dive anyways). Gastrointestinal – Divers with digestive diseases have had increased incidences of injuries. Diseases should be stabilized before diving is allowed. Diabetes – Diabetics with poor control or end organ damage are not recommended to dive. Other endocrine problems should be well controlled. Extreme obesity has had a higher incidence of decompression illness. Pregnancy – Women who are or many become pregnant (during dive trip) should not dive. The fetus is vulnerable to dive injuries and the hyperbaric chamber as well. Blood diseases – Severe anemia and sickle cell diseases should not dive. Orthopedic – People with severe back pain or recent fractures should not dive. Prior aseptic necrosis (a disease seen in commercial divers) should stop diving. Behavior – Any psychiatric condition that limits an individual‟s ability to cooperate with others, solve problems, or react to stress should not dive. Divers themselves should screen unknown diving buddies for incompatibilities before the dive begins. There should be no use of street drugs or alcohol with diving. Dental – All cavities and closed spaces should be managed prior to diving. Drugs – People on medications that interfere with thinking, concentration, or cause sedation should not dive. Any other condition not mentioned above, that may interfere with the thinking or performance, may also limit diving. Consider not diving if you are unwell. Definitely do not dive with an ear or sinus infection or any type of respiratory wheeze. One of the main concerns about diving injuries is that many divers will minimize their symptoms or deny them. It is important to have a plan if something goes wrong, agree with your diving partner(s), and always follow through. Panic and not following through with a simple backup plan are frequently cited as a caus of accident and death.

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PRE-DIVING PLANNING In addition to proper certification, divers should be up to date in their vaccinations if travelling, be counselled on malaria and traveller‟s diarrhea prevention, be knowledgeable in the prevention of parasites (from swimming in infected water), and seafood poisoning. Divers should be knowledgeable in the water conditions where they are diving. OTHER DIVING CONCERNS Divers should all know CPR to initiate treatment for drowning (those who have heart arrest from lack of oxygen) and near drowning (those who experience a lack of oxygen without a cardiac arrest, but whom also need to be watched carefully). Taking a CPR course at the same time as diving certification could be very valuable. Divers should also know the prevention and treatment of hyperthermia and hypothermia, which can both occur in diving. An oxygen provider is also available through D.A.N.

SOME CONDITIONS RELATED TO BREATHING PRESSURIZED GAS Nitrogen Narcoses (Rapture of the Deep) This usually occurs at depths of 30 feet or 40 meters and is similar to feeling intoxicated. This may be hard to recognize in beginners, so they should limit their depths when starting. Symptoms may range from poor judgment, over confidence, inappropriate behavior and even stupor or coma. The treatment is ascension, until symptoms clear. Central nervous system oxygen toxicity occurs when breathing mixed gas combinations (not regular air) at greater depths. Symptoms include; nausea, dizziness, ringing ears, altered vision, and even convulsion. If convulsing at depths, the buddy should either reduce the oxygen partial pressure by switching tanks or by gentle ascension will also decrease the oxygen pressure, but managing an underwater seizure is difficult.

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Managing Underwater Seizures If warning symptoms occur, the diver should alert his buddy and make a controlled ascent. If a seizure starts, the buddy should:  Get behind the diver and release the buddy‟s weight belt (if victims are wearing a dry suit, leave on as this affects the balance).  Leave the regulator in the victim‟s mouth. If it is out, do not replace it.  Grasp the victim around the chest, above the underwater breathing apparatus. If it‟s difficult, use the best possible method to control.  Make controlled ascent to surface, while keeping slight pressure on victim‟s chest to help exhalation.  If additional buoyancy activates victim‟s life jacket, do not drop your own weight belt or use your own life jacket.  Inflate the victim‟s life jacket at the surface if it has not done so.  Remove the victim‟s mouthpiece and switch valve to SURFACE (for rebreather masks, as this could flood the unit and weigh the victim down).  Signal for help.  Once the convulsions are over, open victim‟s airway by lifting head back.  Mouth to mouth breathing if necessary.  Transfer victim to dive medicine facility. Reference: U.S Navy Dive Manual Volume 2 Revised CARBON DIOXIDE TOXICITY This can happen under heavy exertion, by skip breathing (slow breathing), or equipment failure. Symptoms include shortness of breath, headache, nausea, dizziness, and confusion. Divers may develop rapid breathing, muscle twitches, and unconsciousness. If breathlessness occurs, divers should stop and rest until breathing returns to normal, if not, then ascend.

LUNG OVERPRESSURE SYNDROME
These problems can occur independently or with an air embolism. They all represent that the lung is injured and an embolism should be suspected.  Pneumothorax usually is felt as chest pain or shortness of breath and occurs when air enters the space between the lung and chest wall. This problem worsens with time and treatment in a hospital with needle or chest tube decompression is essential.  Mediastinal Emphysema is when air becomes trapped in the space between the heart and the lungs, and is felt as chest pain, shortness of breath and faintness. This must also be followed in a hospital.  Subcutaneus Emphysema is when escaped air from the lungs is trapped under the skin, usually at the neck. A swelling and crackling is felt at the neck, with a change of voice and difficult swallowing. This is a simple condition and no treatment is required for it alone. Breathing 100% oxygen will help resolve all types of over- pressure problem. MOTION SICKNESS - should be anticipated and medication should be used with caution since they all cause some drowsiness. It is advisable to cancel a dive if sickness is severe. Some will take meclizine 25 mg taken 2 hrs before dive (lasts 6-12h). Some illnesses require recompression therapy. They can be subtle but should be acted on promptly if suspected.

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DECOMPRESSION ILLNESS - is the broad term to describe both air gas embolism (AGE) and decompression syndrome (caused by nitrogen bubbles forming in the body). Signs and symptoms of AGE include – any type of neurological problem, chest pain, personality change, bloody froth, paralysis, convulsions, and death. Symptoms can occur immediately after surfacing. Airplane travel can also precipitate nitrogen bubble formation. DAN recommends not to fly 12 hours after the last non- stop diver. The U.S Air Force recommends 24hrs. Longer time is needed if the dive is a complicated one. Decompression illness symptoms may also include fatigue, itch, pains in muscles or joints, and a blotchy rash. Even muscular symptoms are worrisome since bubbles could soon form in the nervous tissue. Once you suspect Decompression illness the diver may be categorized as Emergent, Urgent, and Timely. Emergent cases are obviously very sick. Begin CPR, and arrange evacuation. Check for foreign bodies and place patient on back (if vomiting, turn onto side) 100% oxygen should be supplied. Isotonic IV fluids without glucose should be given (this corrects dehydration and reduces hemoconcentration) Give 1 litre over 30 minutes then 100-175 cc/hr. If trained, insert urine catheter to monitor urine output. After stabilization, contact D.A.N for nearest chamber location. Transfer even if the victim is improving. Take a detailed history, and evaluate neurological status. If flying, pressurized aircraft is recommended. In cerebral arterial gas embolisms, having the head slightly down, theoretically reduces further emboli towards the brain. Some believe that this can also increase cerebral pressure. A compromise is to keep the victim level with the body and tilted to the left side. In Decompression sickness, muscular or other body movements can dislodge venous emboli so patients should not move. Near-drowning victims movements may redistribute fluid causing decreased lung compliance. Patients with coexistent hypothermia should not be jostled as this could precipitate a cardiac arrhythmia a in a chilled heart. Additional treatments that have some evidence to support them, include giving ASA (chewable baby aspirin may stops platelets accumulate around bubbles and lidocaine (dose is the same as for cardiac patients). Lidocaine, given in 1 or 2 boluses, acts to increase cerebral blood flow and may prevent leukocyte activation. Corticosteroids like decadron are sometimes also given but there is less evidence of their usefulness. Urgent – These patients are those with severe pain that has unchanged or become worse over hours. Their neurological status appears normal. They should be placed on 100% oxygen and given oral fluids. Contact DAN and arrange a transfer. Timely - These patients have vague complaints with abnormal sensations. Phone DAN and go to the nearest medical facility. Note that any decompressive symptoms are distressing since they represent nitrogen bubbles in parenchymal tissue (skin, muscle, nerve). Skin and muscle can tolerate hypoxia well but nerve (spinal chord and brain) cannot. Even in those divers only complaining of muscular aches, their bodies are supersaturated with nitrogen that is starting to precipitate out. Other critical tissues may be at risk as this process continues.

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Many divers present days after their symptoms have started and by that time the over saturation may be over. Symptoms may persist because of past nerve damage so there is then no value in recommending hyperbaric oxygen therapy. But if symptoms are evolving or unclear check with DAN as they will help everyone who calls.

Dive History – This information is very helpful to D.A.N. Find out all dives (dive logs), symptoms (onset and progressive), all first aid measures, description of rashes, and any other medical information. Neurologic history of injured divers should include: 1. 2. 3. 4. 5. 6. 7. Orientation (to name, place, and time) Check movement of eye following a finger, check pupil size and vision Look for symmetry of facial muscles, facial sensation Hearing (check ability to hear rustled hair at each ear) Watch the swallowing reflex Check if tongue is straight when stuck out Check muscle strength – ask patient to shrug shoulders against resistance, check the strength of both arms and legs by asking the patient to bend and extend while you resist movement. Look for symmetry in all findings. 8. Check sensory perception to light touch along left and right side of body. 9. Balance and coordinate. Have divers walk heel to toe in a straight line if able, forward and backward. Then stand with feet together, eyes closed and palms held straight out. Check for ability to maintain balance and be prepared to catch the person. Check the divers ability to touch your finger and their own nose while you move your hand. By doing these tests early and regularly at 30-60 min intervals, valuable information about a neurological injury is obtained while awaiting evacuation. (Tests 1,7, and 9 are the most important)

   

OTHER PROBLEMS Sinus Squeeze -occurs as acute pain in sinuses Mask Squeeze- painful pressure build-up around mask Ear Barotraumas- acute pain in ear. Should not dive till healed. Inner ear disturbance should be treated as a possible urgent referral to D.A.N (it might only be a perilymph problem in the inner ear but it cannot easily be differentiated from AGE or DCI Marine animals and envenomations are beyond the scope of this talk but should be treated by experienced people.

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Suggested Divers First Aid Kit (Basic)
             Vial of rubbing alcohol (to neutralize jelly fish stings) Package of baking soda Decadron 8mg or Prednisone 50mg (for anaphylaxis) Motion sickness tablets (meclizine, phenergan, gravol, ginger) Epipen Mechanical suction device Resusitube (combi-tube) with training Tourniquet (stop bleeding) Water-proof bandages Rubber cement (to pull out spines, envenomations) Oxygen and training First aid training Pressure bandage to slow venom from sea snakes and blue octopus bites

Emergency contacts for injured divers
Emergency Telephone Numbers DAN Diving Emergency Numbers DAN America +1.919.684.8111 or +1.919.684.4DAN(4326) (-4DAN accepts collect calls) DAN America-Mexico +52-5-629-9800 code 9912935 DAN Europe +41.1.1414 DAN Japan +81.3.3812.4999 DAN Southern Africa (outside South Africa) +27.11.242.0112 (inside South Africa) 0800.020.111 DAN Southeast Asia-Pacific region Diving Emergency Services (DES) DES Australia (within Australia) 1.800.088.200 DES Australia (from overseas) +61.8.8212.9242 DES New Zealand +64.9.445.8454 Singapore Naval Medicine Hyperbaric Center +65.750.5546 DAN S.E.A.P.-Philippines +63.2.815.9911

References: 1) 2) 3)

4) 5) 6) 7) 8) 9) 10)

Dive and Marine Medicine (3 Conference. March 2000, sponsored by The Undersea and Hyperbaric Medical Society. Dive and Travel Medical Guide Ed Thalmann, Editor, Revised 1999, published by D.A.N. Divers Alert Network (D.A.N.) is a non-profit organization that gives information and advice to the general public. They support diving research and have a 24-hour emergency phone number (1-919-684-2948) for dive accidents. Members are eligible for very good travel insurance packages while on dive-related vacations. Bore, Alfred A and Davis, Jefferson C. (1990) Pub W.B Saunders. Diving Medicine. nd Edmonds (1978) Diving and Sub Aquatic Medicine 2 Edition. Divers Alert Network. Report on Decompression Illness and Diving Fatalities 2000 Edition. Undersea and Hyperbaric Medical Society Inc. (July 21, 1995) Published meeting. Are Asthmatics Fit to Dive? th Rose, S (2001) International Travel Health Guide 12 Edition Divers Alert Magazine Published by D.A.N. D.A.N Website link: http://www.diversalertnetwork.org/ For your convenience we have prepared downloadable pamphlets on Fitness to Dive and Scuba First Aid. Also available at www.skylarkmedicalclicin.com

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Arctic Medicine Conference Our Arctic Meeting will include discussions on topics relevant to people living in the Canadian Circumpolar environment as well as other Arctic climes around the world. Our conference is scheduled for Oct 7,8,9 and 10th which involves Canadian Thanks Giving. Registrants will also be able to return on Thanksgiving to their families. We have planned for our meeting to take place in Churchill Manitoba during the peak in Polar Bear Sightings around Churchill. Churchill is well known as a good place to view these bears in the wild via Tundra Buggies. On a Tundra Buggy tour visitors are able to view and photograph these animals as well as other Arctic Wildlife in a way that does not threaten or endanger them. These tours are run by Naturalists. Our planned sessions include 14 hours on the following topics: 1.Arctic and Circumpolar Medicine 2.Arctic Animal Attacks 3. Wilderness Water Disinfection 4.Drowning ad Barotrauma 5.Anthrax- Manitoban Perspective 6. Arctic rabies 7. Ebola (which is definitely not Arctic but included as an extra topic) 8.Inflight Emergencies and the Transfer of Arctic Patients 9.Hypothermia Update-What‟s new 10.Tuberculosis- In Northern Canada and the World 11.Influenza Update 12.Arcic Scuba and other specialized Scuba Environments 13. Seasonal Affective Disorder (SAD) and Depression in the North. 14 Effects of Pollution on Arctic Wildlife and People We have been able to get a group package rate for people attending our conference at the Lazy Bear Lodge that will include lodging, 2 daytime Tundra buggy tours and sight seeing tours during times when the conference is not on. Registrants may choose to stay anywhere in Churchill and attend our conference but are encouraged to stay with the main group as we have been able to secure a very competitive package deal. We are able to secure a price of 1700$ Canadian double accommodation which will include all tours, Tundra buggies and rooms. Please see our room registration for a complete list of this package. www.lazybearlodge.com For those who cannot attend the main conference, or are arriving in Winnipeg the day before, we will also be having a separate satellite symposium on Thursday, Oct 6th in Winnipeg- Winter Sports Medicine. This will be complementary to the Churchill one but not involve repetition. The Winter Symposium is planned as 1. Introduction to Splinting in Remote Environments (Hands on Worksop) 2. Avalanche Safety, Prevetion, and Rescue

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3. 4. 5. 6. 7. 8.

Sky and Snowboarder Injuries Blood Borne Infections in Sport Altitude Illness in Recreational Sports Tick Borne Diseases in North America Trauma in the BackCountry Treating pain in Remote areas.

Our Speakers:

Dr James Wilkerson is one of the first authors of a Wilderness Medicine book and had helped developed the Wilderness Medical Society. He is a Pathologist, now retired and has spoken on a number of Wilderness Medicine Topics and is well travelled. As a special bonus to all registrants who register for the conference before Sept 15th they will receive a signed copy of his landmark book “Medicine for Mountaineers”. Dr Gary Podolsky practices Travel Medicine and Sports Medicine at the Skylark Medicine Clinic in Winnipeg. He has worked with the Northern Medical Unit in the past and wanted to bring a conference into Churchill to highlight this interesting place and the unique medical situation here. He is conference coordinator and may be contacted for all questions on the conference. CME We are applying for the equivalent of MainproC credits through the Wilderness Medical Society Registration Fees for the conference are: Winnipeg Winter Sports Medicine Conference:October 6th All lectures, lunch and workshop Before September 15th $100 After Sept ember 15th $125 Same day Registration $150 Churchill Arctic Medicine Conference (This also includes Dinner on lecture days) Before September 15th $300 with signed book After September 15th $400 Registry on site $500 Accomodations through our Group Plan Double person Occupancy at the Lazy Bear inn $1700 This includes Churchill Airport pickup, Baggage transfers Breakfests and one dinner per day (Upgrades available for all meals inclusive) Additional tours included Dogsled Ride, and tour of Churchill

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Getting there: We cannot arrange flights but will be able to assist interested persons in finding information. The website: www.creighton.edu/~hutchens/churchill.html Gives complete information on the town of Churchill, Alternative lodgings and different ways to get there. Churchill may be reached only by rail from Thompson Manitoba or Air usually out of Winnipeg but there are other destination cities. We urge attendees to carefully research their accommodations and travel plans as during peak season prices go up and choices may become limited.

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