HEALTHCARE GUIDE FOR EXPATRIATE PERSONNEL

1. HEALTHCARE GUIDE FOR EXPATRIATE PERSONNEL

2. 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

3. 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.

4. “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).

5. 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

6. 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:

7. 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

8. Risk of death/10,000 circulating vehicles

9. 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

10. 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).

11. INVOLVED MICROORGANISMS

12. Prevention The only real prevention is attention to food hygiene: Bolt it, cook it, peel it or forget it

13. Antibiotic prophylaxis • 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

14. Self-treatment • 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.

15. 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

16. Factors reducing risk Risk is substantially reduced by prophylaxis (see below) and by any other intervention reducing exposure to mosquito bytes, notably by night. REPELLENTS MOSQUITO NETS

17. 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.

18. The ABCD of prevention • Awareness • Bites • Compliance • Diagnose • be aware of the risk • (of mosquitoes): avoid them • with adequate chemoprophylaxis • quick diagnosis and treatment

20. Chemoprophylaxis:Recommended schemes Chloroquine 300 mg (2 tbl. once a week) 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

21. Chemoprophylaxis:Recommended schemes Chloroquine once a week + Proguanil 200 mg/day 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

22. Chemoprophylaxis:Recommended schemes Mefloquine (LARIAM) 250 mg/ week • 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

23. Chemoprophylaxis:Recommended schemes Tetracycline (Doxycycline – BASSADO) 100 mg/ day 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

24. Chemoprophylaxis:Recommended schemes Atovaquone + Proguanil (MALARONE) 250 mg: 1 tbl /day 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

25. 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.

26. Self treatment • Guidelines have been accepting for years self-treatment 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.

27. Self treatment schemes • 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 tblafter 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

28. 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.

29. Malaria self-diagnosis • 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

30. 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 2-400 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

31. It is essentialthat 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.

32. 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

33. 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

34. 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.

35. 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

36. 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)

37. 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

38. 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

39. 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 1975-2001 for healthcare operators; then the law was repealed just because of low effectiveness • Now early treatment of infected cases is instead recommended

40. 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

41. Summarizing:

42. 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)