Transcript Slide 1

HEALTHCARE GUIDE
FOR EXPATRIATE PERSONNEL
Edited by Claudio Ceravolo – COOPI
English translation by Elena Recchia
Graphic and page layout by Alessandro Boscaro – COSV
Published by SISCOS – Servizi per la Cooperazione Internazionale
This document is released under CC-BY-SA License
INTRODUCTION
The aim of this handbook is to provide some simple behavior norms for the
many health problems that all NGO operators have to face when they are on
mission abroad.
These are part of a process aimed to grant the maximum safety to our
operators, though we are well aware that the major threat to our cooperants’
health is not represented by microbes and viruses, but rather by street
accidents.
This handbook must in any case be included in a whole range of safety
procedures, which any NGO should draft by taking into account local
conditions, that may even substantially change from a country to another.
Good work to everybody.
“ZERO RISK” DOES NOT EXIST
Anytime we are facing a travel to destitute areas and countries with high
health risk, we are facing risks, more or less high depending on local
epidemiological conditions and the traveler's health state. Prevention
measures often exist, but we have to assess on a case-by-case basis whether
they are worthwhile (economic costs, drug-induced diseases, real benefits).
PER 1000 EUROPEANS TRAVELLING FOR
ONE MONTH TO TROPICAL COUNTRIES:
≈ 600 report some kind of illness, or took medicines during the
travel
≈ 150 report a subjective feeling of illness
≈ 70 were forced to lie in bed for one or more days
≈ 4 are unable to resume working after return
WHICH DISEASES ?
Traveller’s diarrhoea:
30-80% of travellers
 Malaria ≈ 2-4 %
 Acute respiratory infection with fever ≈ 1-2 %
 Hepatitis (of any type) 0,5 %
 Dengue 0,2 %
 Gonorrhoea 0,1 %
 Typhoid fever 0,05 %
 HIV 0,01 %
 Cholera, meningitis, Legionella infections < 0,001%

BUT:
THE REAL “BIG KILLER”

By far, the highest risk of
death is associated with
traffic accidents

A young adult has 2-3 times
more chances of dying in a
traffic
accident
in
a
developing country than in
Europe

Traumas
(from
traffic
accidents or criminal attacks,
the former being much more
likely than the latter) are the
most frequent cause of
evacuations organised by
Europ Assistance
Risk of death/10,000
circulating vehicles
Reducing the risk of accidents
NO ALCOHOL
 It is essential that every local office provides
clear procedures for:

◦
◦
◦
◦
Managing local drivers
Repairing motor vehicles
Travelling by night, in dangerous areas etc.
How to behave in case of an accident
Traveller’s diarrhoea
Definition: 3 or more unformed stools in a
24-hour period, of which at least one with
symptoms (abdominal pain, fever, nausea
and/or vomiting, mucus or blood in faeces).
Average duration 4 days (but it may last over
one month in 1 per cent of cases).
INVOLVED
MICROORGANISMS
organism
Latin Am. %
Asia
%
Africa %
Enterotoxic E. coli
(ETEC)
17-70
6 – 37
8 – 42
Shigella Spp
2 – 30
0 – 17
0–9
Salmonella Spp
1 – 16
1 – 33
4 – 25
Campylobacter jejuni
1–5
9 – 39
1 – 28
Rotavirus
0–6
1–8
0 – 36
Various parasites
1–2
0–9
0–4
24 – 62
10 – 56
15 - 53
No pathogen
identified by testing
Prevention
The only real
prevention is
attention to
food hygiene:
Antibiotic prophylaxis
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The relevant drugs are Chinolonic
(Ciprofloxacin, Levofloxacin and others).
1 case out of 5 is not protected after treatment.
It should be kept up for the duration of the mission.
It should be limited to extremely peculiar cases:
◦ People under anti-ulcer treatment (H2-antagonists
or pump inhibitors)
◦ Immunodepressed people
◦ People who know they will be unable to comply
with hygienic norms
Self-treatment
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REHYDRATION: drink mostly recently boiled drinks
(teas). It is most recommended to use WHO rehydration
salts, easily found in DCs (but with unpleasant taste).
Loperamide (Lopemid, Dissenten): recommended
only for slight and medium cases. Do not use in case
of blood in faeces.
Chinolonic for three days: in severe cases with fever
(e.g Ciproxin 500 mg every 12 hours).
Bismuth salicylate (not commercialized in Italy).
Non-absorbable antibiotics (Normix 4-600mg/day).
Intestinal disinfectants (Mexaform, Enterovioformio,
Reasec) have been withdrawn from market due to
serious damages to the nervous and visual systems.
Malaria
 From 1985 to 1995, 77,683 imported cases have
been reported in EU countries, with a mortality
rate (from P. Falciparum) of 1.1 per cent.
 Risk is highly varying from country to country:
P. Falciparum malaria cases (on 10.000 visits)
among residents in G.B. 1989-99
Factors reducing risk
Risk is substantially reduced by prophylaxis
(see below) and by any other intervention
reducing exposure to mosquito bytes, notably
by night.
Entomological innoculation rate EIR

It is the number of infectious mosquito bites a
person is exposed in one year.

It is the most accurate available indicator of the
risk of contracting the disease; unfortunately it is
available only for few countries.

It ranges from less than 1 EIR (Thailand) to 2-300
(Kenya) to 7-800 EIR (Tanzania – that is over two
bites per night).

It increases in the rainy season, is reduced by
sleeping in climatized rooms, falls to zero over
2,000 meters of altitude.
The ABCD of prevention
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be aware of the risk
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(of mosquitoes): avoid them
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with adequate chemoprophylaxis
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quick diagnosis and treatment
Chemoprophylaxis:
Recommended schemes
It is the longest-used prophylaxis, with few side
effects.
Unfortunately, it cannot be used anymore in
chloroquine-resistant areas (all Africa).
It can still be used in Central America, Haiti, North
Africa and Middle East (all countries with a very
low EIR).
Cost: € 7/year
Chemoprophylaxis:
Recommended schemes
It is a safe combination, also recommended in
pregnancy .
Efficacy is lower than 70%, and in some central
African countries even less.
Cost: € 98/year
Chemoprophylaxis:
Recommended schemes
Efficacy is over 90%, even in sub-Saharan Africa
High rate of side effects
• Mild neuropsychiatric effects (strange dreams,
anxiety)
• Gastrointestinal effects (nausea, diarrhoea)
• Severe neuropsychiatric effects (convulsions,
severe depression: about 1 case out of 13,000
in prophylaxis, 1 case out of 100 in treatment)
Cost: € 150/year
Chemoprophylaxis:
Recommended schemes
Effective, recommended in cases of intolerance to
mefloquine
Not recommended in pregnancy and breastfeeding
It causes photosensibilization
It causes nausea and vomiting or vaginal
candidiasis in 3-7% of cases
Cost: € 160/year
Chemoprophylaxis:
Recommended schemes
Effective (resistance cases have not yet been
reported)
Few side effects
Not recommended for periods longer than 4 weeks,
because safety is only proven for 12 weeks.
But according to recent studies, it is well
tolerated for long periods as well.
Cost (theoretical) € 1,680/year
Homeopathy and malaria
Though prophylaxis by homeopathic products or
herb-based treatment are very trendy among
cooperants, several cases – some fatal – of acute
episodes in travellers using these methods have been
reported, so that the UK Advisory Committee on
Malaria Prevention in UK Travellers (ACMP) has
formally warned against them.
Self treatment
Guidelines have been accepting for years selftreatment on the occurrence of early symptoms
(fever > 38° after 7 days from arrival), without
waiting for thick drop testing or other.
 Such behaviour is justified by the dangerousness
of severe malaria attacks.
 It must be done ONLY when no medical advice
is actually available.
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Self treatment schemes
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WHO’s recommendations for
subsaharan Africa (March 2010)
◦ Lumefantrine + Arthemeter (RIAMET, COARTEM) 4 tablets at
hours: 0 __8______24______48_____(72)____(96)

IF they have not been used in
prophylaxis
 LARIAM 750 mg (3tbl) + 2 tbl after 8 hours
 MALARONE 4 tbl/day 3 three days.

In case of resistance:
◦ Quinine solph. 650 mg/8 h for 3 days + Fansidar 3 tbl on the last
day
New treatments
In recent years, new combinations have been made available, launched
by Impact Malaria and distributed at very low prices in Africa thanks to
companies’ waiving of royalties and GFATM’s support. These are:
Artesunate+ Amodiaquina (AS+AQ) 100+270 mg
Artesunate + Mefloquine (AS+MQ) 100+200 mg
For both, adults should take two tbl per three days
PROS: simplicity of treatment, low cost, wide availability where they
are distributed by NGOs.
CONS: increasing diffusion of amodiaquine- and mefloquine-resistant
strains; at present the former have been reported in India, Brazil, Kenya
and Tanzania; the latter in Cambodia and Thailand, but they are likely
bound to extend.
Malaria self-diagnosis
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By basing only on symptoms, overtreatment is
reported in one case out of 2 (and considering
any fever as “malaria” involves the risk of
undervaluing many other diseases)
Kits are now available providing diagnosis in 20’.
By buying kits online from the producer, prices
range from 0.9-1.3 $ each.
Good sensitivity if used in laboratories, mixed
opinions concerning use by non-trained
personnel.
Our coordination offices make available kits to
the personnel: get information locally
They are not very simple to use, and ways of
use are different from one kit to another: please
comply with the attached instructions
They can help to avoid treating simple viral
pathologies as malaria, or delaying the diagnosis
of other diseases
Sexually transmitted diseases

In spite of AIDS prevention campaigns, still too many
cooperants have risky intercourses

Among NGO expatriate personnel, 0.4 of Dutch, 1.1 of
Belgian and 8.6 of Danish operators are HIV + (rates 2400 times higher than in original populations)

According to another survey of 600 Dutch expatriates,
41 per cent reported sexual intercourse with occasional
partners in African countries, and only 63 per cent of
these used condoms
It is essential
that cooperants adopt
responsible behaviours, remembering that in
unsafe areas sexual approach is often used to
subsequently rob or kidnap the expatriate. The
NGOs’ policy is respectful of anybody’s
personal sphere, provided that it does not put
at risk other people’s safety.
VACCINATIONS
Only one vaccination is mandatory, that is yellow fever;
for some countries, only for travellers coming from an
endemic area.
Before leaving, please check your vaccination coverage:
 Except few exceptions, we are all vaccinated against
◦ Poliomyelitis
◦ Tetanus (remember the booster every 10 years)
◦ Diphtheria
 Younger people are also vaccinated against
◦ Measles, Parotitis and Rubella

The fact that a vaccine exists does not necessarily imply
that vaccination is recommended.
Example: CHOLERA VACCINATION
• the real prevention is complying with food hygiene
• the old parenteral vaccine is not recommended (low
effectivess, only for few months)
• now available oral vaccine (Dukoral)
• it must be taken in two doses, 1 week apart
• maximum coverage is 2 years
• it covers only some vibrio strains
• in case of outbreak, check with epidemiologists
present in the area whether the responsible serotype is
covered by the vaccine
Recommended vaccinations:

Typhoid Fever
◦ Parenteral (TYPHIM VI)
 Effective in less than 60% of cases
 Often causing illness and fever
 Not recommended in pregnancy
◦ Oral (VIVOTIF tbl 200 mg)
 Effective against Ty21 strain, less against others
 It must be taken for 3 alternate days (1-3-5); in the
week of the treatment and the next one no
antibiotics can be administered
 Treatment must be started at least 2 weeks before
departure.
Recommended vaccinations:

Rabies
◦ only for personnel at high risk (veterinary,
etc…)
◦ new vaccine (RASILVAX f.) on 1st, 7th, 21st
and 28th days, then every two years
Recommended vaccinations:

Meningitis
◦ high risk notably in the Sahel belt
◦ epidemic outbreaks every 7-10 years
◦ vaccination is strictly required in case of an ongoing
outbreak, but only if the responsible serotype is
covered by the only one available vaccine (by GSK,
active against A, C,W135 and Y groups)
◦ coverage for 3, max. 5 years (after then, boosting is
required)
Recommended vaccinations:

Hepatitis B
◦ Is mandatory only for children born after 1992
◦ Strongly recommended to anyone travelling in the Third
World
◦ It is recommended to make it immediately: protective
antibody levels are reached after the second dose in
70% of cases, after the third dose in 95% of cases
◦ The quickest possible scheme involves administering
the vaccine on the 0, 30, and 60 days, then after one
year
◦ After the third dose protection lasts at least 10 years,
possibly all life long
Recommended vaccinations:

Hepatitis A
◦ Less severe then hepatitis B, but more easily
transmitted
◦ Strongly recommended to anyone travelling in
the Third World, especially in presence of
previous hepatic disorders
◦ One dose is already protective; antibody rates
increase after 15 days from infection
◦ By taking a second dose after 6-12 months,
coverage lasts for 25 years
Recommended vaccinations:

Tuberculosis
◦ In the past it was recommended to all those
negative to tuberculin and staying in DCs for over
one month
◦ Effectiveness is debated, notably following some
wide studies showing that effectiveness in adults
is near to zero
◦ In Italy, it was made mandatory between 19752001 for healthcare operators; then the law was
repealed just because of low effectiveness
◦ Now early treatment of infected cases is instead
recommended
Recommended vaccinations:

Others:
◦ Japanese Encephalitis:
 Only for missions in Southern India – Southeast
Asia
◦ Pneumococcus
 For immunodepressed and splenectomized people
◦ Smallpox
 Officially eradicated (therefore vaccination is not
mandatory anymore) but risks of biological warfare
and bioterrorism should be considered
Summarizing:
Poliomyelitis,
Diphteria, You should be already vaccinated since
Parotitis, Rubella, Measles
childhood
Tetanus
Idem, but get a booster every 10 years
Hepatitis A and B
Much recommended
Typhoid Fever, Cholera and Recommended, effective vaccines, but
Meningitis
check that serotypes are matching; then
get medical advice before
Rabies, Japanese Encephalitis, Only for selected groups (working with
Pneumococcus
animals, travelling in South East Asia,
immunodepressed patients)
Tuberculosis
Not recommended
What to put in your luggage
Prophylaxis against malaria
 Malaria self-treatment (≠ prophylaxis)
 (eventual malaria quick test)
 Water treatment (chemicals or portable filter)
 Wide-range antibiotics (e.g. Ciprofloxacin). Only in cases of
extreme need
 Loperamide
 Eye drops
 Antihistamines against insect bites
 Some non-steroidal anti-inflammatory drug (e.g. Brufen or
Toradol)
