AIR AMBULANCE INTERNATIONAL
 
Injury is a major cause of premature death and disability worldwide. Most existing injury
control strategies focus on primary prevention – that is, avoiding the occurrence of
injuries or minimizing their severity – or on secondary prevention – providing adequate
medical response to enhance treatment and thereby minimize harm following an injury.
 


Comments

Doctor

Sat, 05 Dec 2009 19:16:30

In 2000, a group of international experts attending a special meeting convened by the World Health Organization (WHO) in Geneva agreed that there is a pressing need to strengthen the quality and availability of systems of prehospital trauma care throughout the world.To achieve this goal, they proposed a collaboration that would identify the
core strategies, equipment, supplies and organizational structures needed to create effective and adaptable prehospital care systems for injured persons worldwide.

 

Doctor

Sat, 05 Dec 2009 19:17:49

This document is the realization of this objective. It focuses on the most promising interventions and components of prehospital trauma care systems, particularly those that require minimal training and relatively little in the way of equipment or supplies.
These elements can and should form the foundation of any emergency care system,
regardless of the level of resources available. Once these elements are in place, additional components may be added at the discretion of local, regional or national planners and policy-makers, contingent on available resources and a clear understanding of the likely costs and benefits of each intervention. Recommended organizational strategies for
training, record-keeping, supervision and accountability are also included.

 

Doctor

Sat, 05 Dec 2009 19:20:26

This document is based on several fundamental principles.
An effective prehospital trauma care system should be simple, sustainable,
practical, efficient and flexible.
Whenever possible, prehospital care should be integrated into a country’s
existing health-care, public health, and transportation infrastructures.
Effective systems for prehospital trauma care will form the foundation for all
emergency care wherever they are established and will also quickly be tasked with the responsibility of addressing a broader range of health concerns, including
paediatric, adult medical and obstetrical emergencies.

The principles outlined in this document should be valid for the care of injured
people in the majority of emergency situations, whatever their cause or consequence.
The focus of this document is on the development of prehospital trauma care
systems. Accordingly, it addresses key elements of such a system, including organization
and oversight, accountability, documentation of care, communications, and important
ethical and legal considerations.

Director, Department of Injuries and Violence Prevention
WHO
Geneva, Switzerland

 

Doctor

Sat, 05 Dec 2009 19:22:13

First responder care

Where no prehospital trauma care system exists, the first and most basic tier of a system can be established by teaching interested community members basic first aid techniques.These first responders can be taught to recognize an emergency, call for help and provide treatment until formally trained health-care personnel arrive to give
additional care. It may be possible to identify particularly motivated or well-placed workers, such as public servants, taxi drivers, or community leaders, and train them to provide a more comprehensive level of prehospital care. In addition to learning a
more extensive range of first-aid skills, this group could be taught the basic principles of safe rescue and transport.With this level of training, a kit of simple equipment and
supplies and access to a suitable vehicle, these individuals can provide an acceptable level of trauma care while transporting an injured person to an appropriate healthcare facility.

 

Doctor

Sat, 05 Dec 2009 19:23:06

Basic prehospital trauma care

The second tier of care can be provided at the community level by those who have
been trained in the principles of basic prehospital trauma care (also known as basic life support).These providers should have extensive formal training in prehospital care,scene management, rescue, stabilization and the transport of injured people.Those who provide this basic care form the backbone of formal prehospital trauma care systems,
where these presently exist.

 

Doctor

Sat, 05 Dec 2009 19:24:08

Advanced prehospital trauma care.

If local considerations and imperatives dictate and if sufficient resources can be secured,a third, significantly more sophisticated, tier of prehospital care may be added: advanced prehospital trauma care (also known as advanced life support).The decision to provide
this level of care should not, however, be made at the expense of the more basic elements of prehospital care.

 

Doctor

Sat, 05 Dec 2009 19:25:18

Despite the high costs of advanced life support interventions, there is little evidence that advanced prehospital interventions benefit more than a small subset of the most critically ill or injured victims. If adopted without regard for cost, advanced life support
programme techniques can inadvertently harm prehospital systems by diverting precious resources from less glamorous but clearly effective interventions that benefit far more people. For this reason,we urge planners to use caution when considering whether to adopt advanced life support options and to base their decisions on a clear understandingof the costs of implementation versus the anticipated benefits.

 

Doctor

Sat, 05 Dec 2009 19:26:22

Core administrative elements

In addition to implementing basic systems of care, certain administrative elements must be in place to ensure that a prehospital care system is both effective and sustainable.
For example, each episode of care should be documented, not only because it is important to monitor the processes and outcomes of care, but also because incident records
provide important insights into the nature and location of community hazards and how many injuries might be prevented.

 

Doctor

Sat, 05 Dec 2009 19:27:11

Legal and ethical considerations-

Finally, for prehospital trauma care systems to function effectively, certain ethical and legal principles must be established and followed. Bystanders must feel both empowered
to act and confident they will not suffer adverse consequences, such as legal liability, as a result of aiding someone who has been injured. Most of the legal and ethical concepts
that underlie the provision of prehospital care are universally respected, regardless of a country’s religious, ethical and cultural traditions.

 

Doctor

Sat, 05 Dec 2009 19:28:04

A call to action-

The global burden of injury, which is already a major cause of death and disability worldwide, is growing. If steps are not taken, the rapid increase in the availability of motor vehicles in developing countries will dramatically increase the human toll of injuries during the next decades.This must not be allowed to happen.

 

MBA

Sat, 05 Dec 2009 19:31:13

Designing and administering
the system.

Setting up the system
Prehospital trauma care systems cannot function in isolation.They must be fully integrated into a nation’s existing public health and health-care infrastructure. Prehospital systems
are designed to provide citizens with prompt, safe and effective access to the healthcare system in times of urgent need. Each system must be defined by local needs and assessments of capacity and developed with due regard for local culture, legislation,
infrastructure, health-system capacity, economic considerations and administrative resources.
When available, existing emergency medical service systems should be utilized and strengthened.This will enable countries to leverage their existing infrastructure and
local expertise to maximum advantage. However, this approach may prove difficult if new concepts and operational reforms are regarded as threats to individuals and
established patterns of practice.To avoid duplication of effort or needless competition,existing regional health-service administration structures should be incorporated whenever feasible. Decisions about the allocation of resources should be based on objective measures of need.At the regional level, an administrator should be identified and assigned the responsibility of monitoring the training, operations, reporting and
quality assurance activities of the local prehospital systems within his or her jurisdiction.

 

MBA

Sat, 05 Dec 2009 19:32:40

To facilitate buy-in, local community leaders and members of the populations being served should be directly involved in developing and administering the system.Community
members should be asked to share their insights, provide suggestions and assist in designing the system. Ensuring that community members are involved from the beginning
increases the likelihood that they will accept, support and sustain the system.The definition of a community member may be different in different areas.
The financing of emergency care systems varies around the world. In Mexico, for
example, most of those who provide prehospital care belong to voluntary or nonprofit organizations. In contrast, in Karachi, Pakistan, most prehospital care providers work for profit-generating businesses, although some work for nonprofit organizations. In
other countries, systems may be supported by municipal or governmental financing.

 

MBA

Sat, 05 Dec 2009 19:34:08

Identifying a lead organization -

The safe operation of a prehospital system requires leadership at several levels. National and regional leadership is essential not only to develop the system but also to educate
citizens about its use. Ideally, a lead agency should be identified to oversee the implementation of the system. It may be necessary to enact legislation to ensure the success of the system.The lead agency or ministry should have the authority to implement changes when necessary and should be held accountable for developing the programme.
This lead agency must assume responsibility for the overall organization of the system
and for its financing. In some countries, the ministry of health or department of health may assume this role. In others, the interior ministry or transportation ministry may
serve as the lead agency. Regardless of which agency holds primary responsibility for
prehospital care, all appropriate sectors of the government (e.g., transportation, health
and public safety) must be involved in planning and implementing the system. Once the enabling framework is established, the creation of a separate agency to manage the prehospital system on an ongoing basis should be considered.

 

MBA

Sat, 05 Dec 2009 19:35:00

An entity must also be responsible for coordinating prehospital care at the local level. In many instances a regional hospital may be the most appropriate organization.
This is because the most severely injured patients are transported to hospitals and the greatest concentration of medical expertise is often found there.Additionally, the physical facilities, equipment for training and data for quality assurance are most likely to exist
in a hospital setting.

 

MBA

Sat, 05 Dec 2009 19:37:23

System models -
System Model itself may determine which individual or agency is best suited to administering the system, including
hiring personnel, financing the system, training prehospital care providers, conducting quality assurance audits, managing communications, exercising medical direction, providing
logistical support and overseeing operations.
The most common models are:

PREHOSPITAL TRAUMA CARE SYSTEMS
Box 2. Key elements in administering a prehospital trauma care system
● Lead national agency: Designate a lead national agency to govern the system.This agency’s
responsibilities should include legislative development, regulatory oversight, organization
of the system and financing.
● Support: Ensure there is regional and local support and involvement that includes
members of the local community.
● Local administration: Develop local administration and oversight, taking into account
the local context and resources.
● Medical direction: Ensure that medical director is providing the essential coordination
of care, training and education, and quality improvement initiatives.
● Political support:Develop political and legislative support.These are essential for ensuring
the operational and financial viability of the system.

 

MBA

Sat, 05 Dec 2009 19:38:42

Private systems: Private emergency medical service companies, operating
either as nonprofit or for-profit organizations, may contract with authorities to provide prehospital services throughout a specific neighbourhood, city or region.
● Hospital-based systems: These systems are often the simplest to establish
and maintain because they utilize the personnel, resources and infrastructure
of a central or referral hospital.The hospital and its staff govern all aspects of the system.
● Volunteer systems: These systems depend on prehospital providers who
donate their time and services to their community.This model is particularly
common in rural and remote areas.
● Hybrid systems: Many systems combine components of the models described
above to provide prehospital care for a particular community.The decision about
whether to combine different models depends on local political, financial and administrative concerns.

 

MBA

Sat, 05 Dec 2009 19:40:34

Medical Director

At the local level, a knowledgeable and committed health-care professional should be identified to serve as the medical director. In urban areas, an experienced hospital-based physician trained in accident and emergency medicine, anaesthesiology or critical care, or trauma surgery, and ideally trained or experienced in prehospital care, may be best suited to this role.
In rural communities where a physician may not be available, the most experienced nurse or paramedical professional should fill this role. It is important that qualified
individuals be assigned responsibility for assuring the availability and quality of prehospital care in their community, whether it is delivered through paid health-care providers or
local volunteers.
The medical director should recruit and train care teams, conduct needs assessments,oversee the continuing education of providers, develop and refine clinical protocols,
take part in quality improvement efforts, review reports, provide direct feedback to teams and conduct critical-incident debriefings.
The importance of securing a capable and motivated medical director to oversee the clinical operations of the system cannot be overemphasized. Standards and protocols articulated at the national level will have little local impact if they are not conscientiously applied and vigorously enforced by a medical director.

Disaster Management- Medical director

 

MBA

Sat, 05 Dec 2009 19:41:46

Financial considerations-

Because prehospital trauma care is a potentially life-saving or limb-saving service, access should not be restricted only to those who can pay for it.However, it may be necessary
to make reasonable efforts to recover costs in order to ensure the financial viability of the service, and various financing schemes may be needed to fund the system, such as health insurance or public funding. Nonetheless, care should not be withheld because
a patient or his or her family is unable to pay at the time of care, nor should fear of the cost of treatment hinder appropriate requests for care.
It is challenging to invest in and maintain a prehospital care system, especially in countries where competing priorities in health budgets make it difficult to secure adequate funding. In addition, the absence of health insurance and cost-recovery mechanisms may further complicate the issue. In these instances, stakeholders may
want to explore innovative strategies for generating resources, such as dedicating a proportion of highway construction budgets; allocating a proportion of vehicle registration
fees, traffic fines and penalties; or levying a tax on fuel.

 

Admin

Sat, 05 Dec 2009 19:44:32

Political considerations
The support of high level government and political leaders is essential in order to ensure the operational and financial viability of any prehospital system. Emergency care services
cannot function adequately without leaders from the community, politics and government who are engaged with the system and who are willing to draft enabling legislation and regulations, secure adequate funding and support the efforts of local medical directors
to enhance the quality and availability of prehospital care. A lack of political support and the presence of corruption or administrative infighting may undermine the best efforts of prehospital care personnel.
Because prehospital care frequently unfolds in public settings it is inherently political.
However, the interaction between systems of prehospital care and politics must be kept in balance. If the prehospital system is consistently in the spotlight, decisions such as
where personnel or resources are deployed may be driven by political rather than medical considerations.This can disrupt the functioning and efficiency of the system.
The medical directors of these systems must have the backing of the political community and be free from interference when making decisions.
Legislative advocacy is often necessary to engender the political will needed to
create and sustain public health programmes.To ensure the broad-based support of the community and its political leadership, those who work in prehospital care systems
should educate the public as well as key elected and appointed officials about the importance of this care. Leaders of prehospital care systems should closely monitor legislative and regulatory activities and make policy recommendations when necessary.
Medical professionals can play a particularly helpful part in this process because they are often viewed as credible and influential members of the community. In addition,
patients who have survived serious injury may form powerful lobbying and advocacy groups as a result of their first-hand experience of the human and economic consequences of injury.They should be encouraged to share their stories with the public and with governmental and political leaders.
Medical professionals must learn about the legislative decision-making processes in their jurisdiction to be able to influence policy effectively. Although the political process
is frequently complicated, a thorough understanding of how decisions are made is essential for medical professionals hoping to influence the direction of public policy. Gaining support for issues may involve collaborating across public and private lines to secure
the cooperation of several branches of government in different political jurisdictions. It may also involve facilitating consensus. Policies implemented on the basis of impulsive
decisions are usually less successful and less likely to be sustainable than sound planning.

Political support and Medical transport.
decisions made by building support for important issues.

 

Usha

Sat, 05 Dec 2009 19:57:23

Disaster management-
Medical Emergency

Early warning systems have limitations in terms of saving lives if they are not combined with “people-centered” networks. To be effective, early warning systems must be understandable, trusted by and relevant to the communities that they serve. Warnings will have little value unless they reach the people most at risk, who need to be trained to respond appropriately to an approaching hazard. The International Federation, therefore, gives its full support to the development of warning systems but stresses the importance of:

*
establishing local networks that can both receive and act on warnings and that raise awareness and educate communities to take action to ensure their safety;
*
utilizing local networks to develop warning systems progressively so that they meet the needs of the communities and situations for which they are designed;
*
taking a multi-hazard approach to ensure sustainability by providing active alert, awareness and relevance.

www.flyingairambulance.com

 

Usha

Sat, 05 Dec 2009 19:58:37

About disasters

What is a disaster?

A disaster is a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources. Though often caused by nature, disasters can have human origins.
VULNERABILITY + HAZARD = DISASTER
CAPACITY

www.flyingairambulance.com

 

triage

Sun, 13 Dec 2009 05:04:08

Blast Lung Injury: Prehospital Care


Current patterns in worldwide terrorist activity have increased the potential for casualties related to explosions, yet few civilian emergency medical service providers in the United States have experience treating patients with these injuries. One direct consequence of high-explosive detonations upon the body is blast lung injury—or, BLI. It is characterized by respiratory difficulty and hypoxia. BLI can occur, although rarely, without obvious external chest injury. Persons in enclosed-space explosions or in close proximity to the explosion are at highest risk. BLI presents unique triage, diagnostic, and management challenges.

Clinical Presentation
•Symptoms may include dyspnea, hemoptysis, cough, and chest pain.
•Signs may include tachypnea, hypoxia, cyanosis, apnea, wheezing, decreased breath sounds, and hemodynamic instability.
•Victims with skull fractures, injuries penetrating torso or head, or burns covering more than 10% body surface area (BSA) are more likely to have BLI.
•Hemothoraces or pneumothoraces may occur.
•Due to pulmonary or vascular tearing, air may enter the arterial circulation (air emboli) and result in embolic events involving the central nervous system, retinal arteries, or coronary arteries.
•Clinical evidence of BLI is typically present at the initial evaluation; however, reports show that evidence of BLI can appear 24 to 48 hours after an explosion.
•Other injuries are often present.
Prehospital Management Considerations
•Initial triage, trauma resuscitation, and transport of patients should follow standard protocols for multiple injured patients or mass casualties.
•Explosions in confined spaces result in a higher incidence of primary blast injury, including lung injury. Note the patient’s location and the surrounding environment at the time of injury.
•Patients with suspected or confirmed BLI should receive supplemental high-flow oxygen to prevent hypoxemia.
◦A compromised airway requires immediate intervention.
◦If ventilatory failure is imminent or occurs, patients should be intubated; however, prehospital providers must realize that mechanical ventilation and positive pressure may increase the risk of alveolar rupture, pneumothorax, and air embolism in BLI patients.
◦High-flow oxygen should be administered if air embolism is suspected, and the patient should be placed in a prone, semi-left lateral, or left lateral position.
•Clinical evidence or suspicion of a hemothorax or pneumothorax warrants close observation. Chest decompression should be performed for patients clinically presenting with a tension pneumothorax. Close observation is warranted for any patient suspected of BLI who is transported by air.
•Fluids should be administered judiciously, as overzealous fluid administration in the patient with BLI may result in volume overload and worsen pulmonary status.
•In accordance with community response plans for mass casualty events, patients with BLI should be rapidly transported to the nearest appropriate facility.
•Patients with BLI should be transported rapidly to the nearest, appropriate facility, in accordance with community response plans for mass casualty events.

www.hiflyingcharters.com

 

bioterrorism

Sun, 13 Dec 2009 05:07:24

What is Bioterrorism?
A bioterrorism attack is the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants. These agents are typically found in nature, but it is possible that they could be changed to increase their ability to cause disease, make them resistant to current medicines, or to increase their ability to be spread into the environment. Biological agents can be spread through the air, through water, or in food. Terrorists may use biological agents because they can be extremely difficult to detect and do not cause illness for several hours to several days. Some bioterrorism agents, like the smallpox virus, can be spread from person to person and some, like anthrax, can not. For information on which bioterrorism agents can be spread from person to person, please see the alphabetical list of bioterrorism agents.

Bioterrorism Agent Categories
Bioterrorism agents can be separated into three categories, depending on how easily they can be spread and the severity of illness or death they cause. Category A agents are considered the highest risk and Category C agents are those that are considered emerging threats for disease.

Category A
These high-priority agents include organisms or toxins that pose the highest risk to the public and national security because:

•They can be easily spread or transmitted from person to person
•They result in high death rates and have the potential for major public health impact
•They might cause public panic and social disruption
•They require special action for public health preparedness.
Category B
These agents are the second highest priority because:

•They are moderately easy to spread
•They result in moderate illness rates and low death rates
•They require specific enhancements of CDC's laboratory capacity and enhanced disease monitoring.
Category C
These third highest priority agents include emerging pathogens that could be engineered for mass spread in the future because:

•They are easily available
•They are easily produced and spread
•They have potential for high morbidity and mortality rates and major health impact.

www.vibha.info
www.hiflyingcharters.com

 

Hot

Sun, 13 Dec 2009 05:35:35

Extreme Heat: A Prevention Guide.

Heat-related deaths and illness are preventable yet annually many people succumb to extreme heat. Historically, from 1979-2003, excessive heat exposure caused 8,015 deaths in the United States. During this period, more people in this country died from extreme heat than from hurricanes, lightning, tornadoes, floods, and earthquakes combined. In 2001, 300 deaths were caused by excessive heat exposure.

People suffer heat-related illness when their bodies are unable to compensate and properly cool themselves. The body normally cools itself by sweating. But under some conditions, sweating just isn't enough. In such cases, a person's body temperature rises rapidly. Very high body temperatures may damage the brain or other vital organs.

Several factors affect the body's ability to cool itself during extremely hot weather. When the humidity is high, sweat will not evaporate as quickly, preventing the body from releasing heat quickly. Other conditions related to risk include age, obesity, fever, dehydration, heart disease, mental illness, poor circulation, sunburn, and prescription drug and alcohol use.

Because heat-related deaths are preventable, people need to be aware of who is at greatest risk and what actions can be taken to prevent a heat-related illness or death. The elderly, the very young, and people with mental illness and chronic diseases are at highest risk. However, even young and healthy individuals can succumb to heat if they participate in strenuous physical activities during hot weather. Air-conditioning is the number one protective factor against heat-related illness and death. If a home is not air-conditioned, people can reduce their risk for heat-related illness by spending time in public facilities that are air-conditioned.

Summertime activity, whether on the playing field or the construction site, must be balanced with measures that aid the body's cooling mechanisms and prevent heat-related illness. This pamphlet tells how you can prevent, recognize, and cope with heat-related health problems.

What Is Extreme Heat?
Conditions of extreme heat are defined as summertime temperatures that are substantially hotter and/or more humid than average for location at that time of year. Humid or muggy conditions, which add to the discomfort of high temperatures, occur when a "dome" of high atmospheric pressure traps hazy, damp air near the ground. Extremely dry and hot conditions can provoke dust storms and low visibility. Droughts occur when a long period passes without substantial rainfall. A heat wave combined with a drought is a very dangerous situation.

During Hot Weather
To protect your health when temperatures are extremely high, remember to keep cool and use common sense. The following tips are important:

Drink Plenty of Fluids
During hot weather you will need to increase your fluid intake, regardless of your activity level. Don't wait until you're thirsty to drink. During heavy exercise in a hot environment, drink two to four glasses (16-32 ounces) of cool fluids each hour.

Warning: If your doctor generally limits the amount of fluid you drink or has you on water pills, ask how much you should drink while the weather is hot.

 

Hot

Sun, 13 Dec 2009 05:36:20

Don't drink liquids that contain alcohol, or large amounts of sugar—these actually cause you to lose more body fluid. Also avoid very cold drinks, because they can cause stomach cramps.

Replace Salt and Minerals
Heavy sweating removes salt and minerals from the body. These are necessary for your body and must be replaced. If you must exercise, drink two to four glasses of cool, non-alcoholic fluids each hour. A sports beverage can replace the salt and minerals you lose in sweat. However, if you are on a low-salt diet, talk with your doctor before drinking a sports beverage or taking salt tablets.

Wear Appropriate Clothing and Sunscreen
Wear as little clothing as possible when you are at home. Choose lightweight, light-colored, loose-fitting clothing. Sunburn affects your body's ability to cool itself and causes a loss of body fluids. It also causes pain and damages the skin. If you must go outdoors, protect yourself from the sun by wearing a wide-brimmed hat (also keeps you cooler) along with sunglasses, and by putting on sunscreen of SPF 15 or higher (the most effective products say "broad spectrum" or "UVA/UVB protection" on their labels) 30 minutes prior to going out. Continue to reapply it according to the package directions.

Schedule Outdoor Activities Carefully
If you must be outdoors, try to limit your outdoor activity to morning and evening hours. Try to rest often in shady areas so that your body's thermostat will have a chance to recover.

Pace Yourself
If you are not accustomed to working or exercising in a hot environment, start slowly and pick up the pace gradually. If exertion in the heat makes your heart pound and leaves you gasping for breath, STOP all activity. Get into a cool area or at least into the shade, and rest, especially if you become lightheaded, confused, weak, or faint.

Stay Cool Indoors
Stay indoors and, if at all possible, stay in an air-conditioned place. If your home does not have air conditioning, go to the shopping mall or public library—even a few hours spent in air conditioning can help your body stay cooler when you go back into the heat. Call your local health department to see if there are any heat-relief shelters in your area. Electric fans may provide comfort, but when the temperature is in the high 90s, fans will not prevent heat-related illness. Taking a cool shower or bath or moving to an air-conditioned place is a much better way to cool off. Use your stove and oven less to maintain a cooler temperature in your home.

Use a Buddy System
When working in the heat, monitor the condition of your co-workers and have someone do the same for you. Heat-induced illness can cause a person to become confused or lose consciousness. If you are 65 years of age or older, have a friend or relative call to check on you twice a day during a heat wave. If you know someone in this age group, check on them at least twice a day.

Monitor Those at High Risk
Although anyone at any time can suffer from heat-related illness, some people are at greater risk than others.

•Infants and young children are sensitive to the effects of high temperatures and rely on others to regulate their environments and provide adequate liquids.

•People 65 years of age or older may not compensate for heat stress efficiently and are less likely to sense and respond to change in temperature.

•People who are overweight may be prone to heat sickness because of their tendency to retain more body heat.

•People who overexert during work or exercise may become dehydrated and susceptible to heat sickness.

•People who are physically ill, especially with heart disease or high blood pressure, or who take certain medications, such as for depression, insomnia, or poor circulation, may be affected by extreme heat.
Visit adults at risk at least twice a day and closely watch them for signs of heat exhaustion or heat stroke. Infants and young children, of course, need much more frequent watching.

Adjust to the Environment
Be aware that any sudden change in temperature, such as an early summer heat wave, will be stressful to your body. You will have a greater tolerance for heat if you limit your physical activity until you become accustomed to the heat. If you travel to a hotter climate, allow several days to become acclimated before attempting any vigorous exercise, and work up to it gradually.

Do Not Leave Children in Cars
Even in cool temperatures, cars can heat up to dangerous temperatures very quickly. Even with the windows cracked open, interior temperatures can rise almost 20 degrees Fahrenheit within the first 10 minutes. Anyone left inside is at risk for serious heat-related illnesses or even death. Children who are left unattended in parked cars are at greatest risk for heat stroke, and possibly death. When traveling with children, remember to

 

Hot

Sun, 13 Dec 2009 05:37:07

Heat Stroke
Heat stroke occurs when the body is unable to regulate its temperature. The body's temperature rises rapidly, the sweating mechanism fails, and the body is unable to cool down. Body temperature may rise to 106°F or higher within 10 to 15 minutes. Heat stroke can cause death or permanent disability if emergency treatment is not provided.

Recognizing Heat Stroke
Warning signs of heat stroke vary but may include the following:

•An extremely high body temperature (above 103°F, orally)
•Red, hot, and dry skin (no sweating)
•Rapid, strong pulse
•Throbbing headache
•Dizziness
•Nausea
•Confusion
•Unconsciousness
What to Do
If you see any of these signs, you may be dealing with a life-threatening emergency. Have someone call for immediate medical assistance while you begin cooling the victim. Do the following:

•Get the victim to a shady area.
•Cool the victim rapidly using whatever methods you can. For example, immerse the victim in a tub of cool water; place the person in a cool shower; spray the victim with cool water from a garden hose; sponge the person with cool water; or if the humidity is low, wrap the victim in a cool, wet sheet and fan him or her vigorously.
•Monitor body temperature, and continue cooling efforts until the body temperature drops to 101-102°F.
•If emergency medical personnel are delayed, call the hospital emergency room for further instructions.
•Do not give the victim fluids to drink.
•Get medical assistance as soon as possible.
Sometimes a victim's muscles will begin to twitch uncontrollably as a result of heat stroke. If this happens, keep the victim from injuring himself, but do not place any object in the mouth and do not give fluids. If there is vomiting, make sure the airway remains open by turning the victim on his or her side.

Heat Exhaustion
Heat exhaustion is a milder form of heat-related illness that can develop after several days of exposure to high temperatures and inadequate or unbalanced replacement of fluids. It is the body's response to an excessive loss of the water and salt contained in sweat. Those most prone to heat exhaustion are elderly people, people with high blood pressure, and people working or exercising in a hot environment.


www.vibha.info
www.hospitalfamily.com

 

Hot

Sun, 13 Dec 2009 05:38:08

Recognizing Heat Exhaustion
Warning signs of heat exhaustion include the following:

•Heavy sweating
•Paleness
•Muscle cramps
•Tiredness
•Weakness
•Dizziness
•Headache
•Nausea or vomiting
•Fainting
The skin may be cool and moist. The victim's pulse rate will be fast and weak, and breathing will be fast and shallow. If heat exhaustion is untreated, it may progress to heat stroke. Seek medical attention immediately if any of the following occurs:

•Symptoms are severe
•The victim has heart problems or high blood pressure
Otherwise, help the victim to cool off, and seek medical attention if symptoms worsen or last longer than 1 hour.

What to Do
Cooling measures that may be effective include the following:

•Cool, nonalcoholic beverages
•Rest
•Cool shower, bath, or sponge bath
•An air-conditioned environment
•Lightweight clothing
Heat Cramps
Heat cramps usually affect people who sweat a lot during strenuous activity. This sweating depletes the body's salt and moisture. The low salt level in the muscles may be the cause of heat cramps. Heat cramps may also be a symptom of heat exhaustion.

Recognizing Heat Cramps
Heat cramps are muscle pains or spasms—usually in the abdomen, arms, or legs—that may occur in association with strenuous activity. If you have heart problems or are on a low-sodium diet, get medical attention for heat cramps.

What to Do
If medical attention is not necessary, take these steps:

•Stop all activity, and sit quietly in a cool place.
•Drink clear juice or a sports beverage.
•Do not return to strenuous activity for a few hours after the cramps subside, because further exertion may lead to heat exhaustion or heat stroke.
•Seek medical attention for heat cramps if they do not subside in 1 hour.
Sunburn
Sunburn should be avoided because it damages the skin. Although the discomfort is usually minor and healing often occurs in about a week, a more severe sunburn may require medical attention.

Recognizing Sunburn
Symptoms of sunburn are well known: the skin becomes red, painful, and abnormally warm after sun exposure.

What to Do
Consult a doctor if the sunburn affects an infant younger than 1 year of age or if these symptoms are present:

•Fever
•Fluid-filled blisters
•Severe pain
Also, remember these tips when treating sunburn:

•Avoid repeated sun exposure.
•Apply cold compresses or immerse the sunburned area in cool water.
•Apply moisturizing lotion to affected areas. Do not use salve, butter, or ointment.
•Do not break blisters.
Heat Rash
Heat rash is a skin irritation caused by excessive sweating during hot, humid weather. It can occur at any age but is most common in young children.

Recognizing Heat Rash
Heat rash looks like a red cluster of pimples or small blisters. It is more likely to occur on the neck and upper chest, in the groin, under the breasts, and in elbow creases.


What to Do
The best treatment for heat rash is to provide a cooler, less humid environment. Keep the affected area dry. Dusting powder may be used to increase comfort.

Treating heat rash is simple and usually does not require medical assistance. Other heat-related problems can be much more severe.

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Doc

Sun, 13 Dec 2009 22:50:04

Deep Vein Thrombosis and Pulmonary Embolism

Venous thromboembolism (VTE) consists of two related conditions: 1) deep vein thrombosis (DVT) and 2) pulmonary embolism (PE). DVT occurs when there is a partial or complete blockage of a deep vein by a blood clot, most commonly in the legs. The clot may break off and travel to the vessels in the lung, causing a life-threatening PE.

VTE associated with air travel was first described in the early 1950s. Previous studies have shown a two- to four-fold increased risk of VTE following air travel. In 2001, the World Health Organization set up the WHO Research into Global Hazards of Travel (WRIGHT) Project, a large collaborative research study to confirm the association between VTE and air travel. The goals of this project are to determine the magnitude of the risk of VTE due to air travel, to determine the effect of other factors on the association, and to study the effect of preventive measures on risk. The results of Phase I of the project were published recently. Phase II will address the effect of preventive measures.
Risk for Travelers

Several factors have been associated with an increased risk for developing VTE

Combined effects have been observed between these established risk factors and different forms of travel. A population-based case-control study of adults receiving treatment for their first VTE found that long-distance travel (≥4 hours) doubled the risk of VTE. The effect was greatest in the first week after travel but remained elevated for 2 months. Travel by air increased the risk to the same extent as travel by bus, train, or car, suggesting that the increased risk of air travel is due primarily to prolonged immobility. Synergistic effects were noted with factor V Leiden mutations, women who used oral contraceptives, BMI >30 kg/m2, and height >1.9 m (approximately 6 ft 3 in). Some of these effects were greatest following air travel. Furthermore, people shorter than 1.6 m (approximately 5 ft 3 in) had an increased risk of VTE only after prolonged air travel. These findings suggest that additional factors related to air travel may be involved in the increased risk for VTE.
Box 2-4. Risk factors for venous thromboembolism (VTE)

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Doc

Sun, 13 Dec 2009 22:50:53

Risk factors for developing VTE include:

* Recent major surgery1
* Paralytic spinal cord injury
* Multiple trauma
* Malignancy
* Congestive heart failure or respiratory failure
* Hormone replacement therapy, oral contraceptive
* Previous venous thromboembolism
* Inherited hypercoagulable condition
* Acquired hypercoagulable condition
* Pregnancy
* Age >40 years
* Obesity
* Immobility
* Male

1Especially cardiothoracic, abdominal, major orthopedic surgery.
Adapted from Anderson FA Jr, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I9–I16.
Occurence

Two recent retrospective cohort studies address the issue of air travel-associated VTE incidence. The first was a cohort of 2,499 healthy Dutch commercial pilots. The incidence of VTE in this group was 0.3 per 1,000 person-years. When the data were adjusted for age and sex, the rate was not different from that in the general Dutch population. There was no association between the number of hours flown.

The second study was among 8,755 employees of several international organizations. The overall incidence of VTE following flights >4 hours was 1.4 per 1,000 person-years. The absolute risk of VTE was 1 per 4,656 flights. The rates of VTE were higher in women, especially those using oral contraceptives. Incidence was also higher in employees with a BMI >25 kg/m2 and those with height <1.65 m (5 ft 5 in) or >1.85 m (6 ft 1 in). The risk of VTE increased with flight duration and with the number of times the employee flew during an 8-week period; the risk of VTE tripled in employees who went on five or more long-haul (≥4 hours) flights. Each extra flight increased the risk of VTE 1.4-fold. The risk of VTE was highest in the first 2 weeks after a long-haul flight and gradually decreased to baseline after 8 weeks.

Both these studies were performed among populations that are younger (mean age 35–40 years) and healthier than the general population and are not, therefore, generalizable to a higher-risk population.
Clinical Presentation

Symptoms of DVT include swelling, redness, pain, or tenderness, and increased warmth over the skin. It may be difficult to distinguish from muscle strain, injury, or skin infection.

Symptoms of PE range from mild and nonspecific to acute, resembling heart attack or stroke. Once a clot has traveled to the lungs, common symptoms of PE are chest pain and shortness of breath. Other symptoms include dizziness, fainting, anxiety, and malaise. PE can occur in the absence of overt signs of DVT.
Diagnosis

Specialized imaging tests (e.g., duplex venous ultrasound, venography, computed tomography (CT) scans, and magnetic resonance imaging) are needed to make a definitive diagnosis of DVT. Helical CT or ventilation–perfusion scans are commonly used to diagnose PE.
Preventive Measures for Travelers

Several randomized, controlled trials have been performed to assess the effect of prophylactic measures on VTE risk after air travel. All studies examined the risk of asymptomatic DVT in travelers making flights ≥7 hours. All travelers were encouraged to do regular exercises and to drink nonalcoholic beverages during the flight. DVT was diagnosed by venous ultrasound from 90 minutes to 48 hours after the flight. Interventions that were studied include compression stockings, aspirin, low-molecular weight heparin, and various natural extracts with anticoagulant properties. No significant effect was seen in any of the pharmacologic interventions. Compression stockings (10–20 mm Hg and 20–30 mm Hg) were shown to significantly reduce the risk of asymptomatic DVT; however, four travelers wearing compression stockings in one study developed superficial thrombophlebitis. Symptomatic DVT and PE were not observed in any of the travelers enrolled in the studies.

All travelers should keep hydrated, wear loose-fitting clothing, and make efforts to walk and stretch at regular intervals during long-distance travel. Compression stockings may be beneficial to travelers with other risk factors for VTE. Currently no convincing data suggest that pharmacologic interventions reduce the risk of significant VTE during travel.

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Doc

Sun, 13 Dec 2009 22:51:33


The American College of Chest Physicians published the 8th edition of their Antithrombotic and Thrombolytic Therapy Evidence-Based Clinical Practice Guidelines in a June 2008 Supplement to Chest. Recommendations for long-distance travel associated VTE are the following:

* For travelers who are taking flights >8 hours, the following general measures are recommended: avoidance of constrictive clothing around the lower extremities or waist, maintenance of adequate hydration, and frequent calf muscle contraction (Grade 1C).
* For long-distance travelers with additional risk factors for VTE, we recommend the general measures listed above. If active thromboprophylaxis is considered because of a perceived high risk of VTE, we suggest the use of properly fitted, below-knee graduated compression stockings (GCS), providing 15–30 mm Hg of pressure at the ankle (Grade 2C), or a single prophylactic dose of low-molecular-weight heparin (LMWH), injected prior to departure (Grade 2C).
* For long-distance travelers, we recommend against the use of aspirin for VTE prevention (Grade 1B).

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Gas

Mon, 14 Dec 2009 11:47:38

Persistent Travelers’ Diarrhea.

The pathogenesis of persistent travelers’ diarrhea generally falls into one of three broad categories: persistent infection or co-infection, chronic underlying gastrointestinal illness unmasked by the enteric infection, or a postinfectious process. The contribution of each of these to the total number of persistent travelers’ diarrhea patients is often related to the duration of symptoms following the acute episode of diarrhea.

Persistent Infection

Most cases of travelers’ diarrhea are the result of infection with bacteria. Persistent symptoms, however, suggest protozoan parasites as the etiology. Parasites as a group are the pathogens most likely to be isolated from patients with persistent diarrhea, and their probability relative to bacterial infections increases with increasing duration of symptoms. Parasites may also be the cause of persistent diarrhea in those already appropriately treated for a bacterial pathogen.

Giardia is by far the most likely persistent pathogen to be encountered in these patients. Suspicion for giardiasis should be particularly high when upper gastrointestinal symptoms predominate. Untreated, symptoms may last for months even in the immunocompetent host. The diagnosis can often be made through stool microscopy. However, as Giardia infects the proximal small bowel, even multiple stool specimens may fail to detect it, and a duodenal aspirate may be necessary for definitive diagnosis. Given the high prevalence of Giardia in persistent travelers’ diarrhea, empiric therapy is a reasonable option in the appropriate clinical setting after negative stool microscopy and in lieu of duodenal sampling.

 

Worm

Mon, 14 Dec 2009 11:48:11

Other intestinal parasites that may cause persistent symptoms include Cryptosporidium parvum, Entamoeba histolytica, Isospora belli, Microsporidia, and Dientamoeba fragilis, as well as Cyclospora cayetanensis.

Bacteria in general rarely cause persistence of symptoms, although there are reports of persistent diarrhea in children infected with enteroadherent Escherichia coli. A notable exception to this self-limited nature of bacterial diarrhea is seen with Clostridium difficile. C. difficile-associated diarrhea may follow treatment of a bacterial pathogen with a fluoroquinolone or other antibiotic or may even follow malaria chemoprophylaxis. It is especially important to consider in the patient with persistent travelers’ diarrhea that seems refractory to multiple courses of empiric antibiotic therapy. The initial work-up of persistent travelers’ diarrhea should always include a C. difficile stool toxin assay. Treatment is with metronidazole or oral vancomycin, although increasing reports of resistance have been noted.

Other causes of persistent travelers’ diarrhea associated with microbial pathogens include tropical sprue and Brainerd diarrhea. In each case, the offending microbial pathogen has not been identified, but there is an abundance of evidence that all these are infectious diseases. Tropical sprue is a syndrome of persistent travelers’ diarrhea associated with malabsorption, fatigue, and deficiencies of vitamins absorbed in both the proximal and distal small bowel. It most commonly affects longer-term travelers, but even short-term visitors to the tropics have been afflicted. The epidemiology of tropical sprue has changed in the past few decades, insofar as there now seem to be fewer cases of tropical sprue diagnosed.

Brainerd diarrhea was first described in 1983 when an epidemic of chronic diarrhea occurred in Brainerd, Minnesota, in which unpasteurized milk from a local dairy was epidemiologically identified as the source, although no specific microbial pathogen was ever identified. At least seven subsequent Brainerd epidemics have been reported since this initial description, including one on a cruise ship in the Galápagos Islands of Ecuador.

 

Digest

Mon, 14 Dec 2009 11:48:45

Underlying Gastrointestinal Disease

In some cases, persistence of gastrointestinal symptoms relates to chronic underlying gastrointestinal disease or susceptibility unmasked by the enteric infection. Most prominent among these is celiac sprue, a systemic disease manifesting primarily with small bowel changes. In genetically susceptible individuals, villous atrophy and crypt hyperplasia are seen in response to exposure to antigens found in wheat, leading to malabsorption. The diagnosis is made by obtaining appropriate serologic tests, including antigliadin and tissue transglutaminase antibodies. A biopsy of the small bowel showing villous atrophy confirms the diagnosis. Treatment is with a wheat (gluten)-free diet.

Idiopathic inflammatory bowel disease (IBD), both Crohns and ulcerative colitis, may be seen following acute bouts of travelers’ diarrhea. A prevailing hypothesis of the pathogenesis of IBD suggests that an initiating endogenous pathogen sets in motion, in genetically susceptible individuals, the conditions for the development of disease. In cases following travelers’ diarrhea, this hypothetical process appears to be greatly accelerated.

In the appropriate clinical setting and age group, it may be necessary to do a more comprehensive search for other underlying causes of chronic diarrhea. Colorectal cancer should be considered, particularly in those passing occult or gross blood per rectum or with the onset of a new iron deficiency anemia.
Postinfectious Phenomena

In a certain percentage of patients who present with persistent gastrointestinal symptoms, no specific etiology will be found. Concurrent with recognition of the importance of persistent travelers’ diarrhea as a presenting complaint has been the observation that in a certain number of patients with irritable bowel syndrome, the onset of symptoms can be traced to an acute bout of gastroenteritis. Irritable bowel syndrome that develops after acute enteritis has been termed postinfectious irritable bowel syndrome (PI-IBS). In the context of travelers’ diarrhea, PI-IBS has been defined as new IBS symptoms by the Rome III criteria.

* At least 3 months of symptoms, with an onset of symptoms at least 6 months previously.
* Recurrent abdominal pain or discomfort associated with two or more of the following features:
o Improvement with defecation
o Onset associated with a change in the frequency of stool
o Onset associated with a change in form (appearance) of stool
* To be labeled PI-IBS, these symptoms should follow an episode of gastroenteritis or travelers’ diarrhea if the work-up for microbial pathogens and underlying gastrointestinal disease is negative.

Postinfectious IBS is most often characterized by diarrheal symptoms; however, an array of gastrointestinal symptoms is reported, including bloating, gas, and constipation. Although only recently recognized as an important diagnosis in returning travelers, the syndrome was described more than a half century ago as “postdysenteric colitis,” describing continuing symptoms of diarrhea in British troops after successful treatment of amebic dysentery. A decade later, Chaudary and Truelove described 130 patients with IBS, 34 of whom dated the onset of their symptoms to an attack of bacterial dysentery. Since then, others have suggested a high incidence of IBS postgastrointestinal infection, with estimates ranging from 4% to 31%.

Studies in the past decade have elucidated some of the pathophysiology associated with the symptoms of PI-IBS. Patients appear to be unable to down-regulate intestinal inflammation. In a recent study of selected IBS patients, there was a decreased prevalence in those with anti-inflammatory cytokines, IL-10, and TGF-beta, implying more susceptibility to prolonged and severe inflammation. Markers of mucosal inflammation are consistently elevated in patients with postinfectious IBS. The inflammatory cytokine interleukin 1-beta was present in higher levels both during and 3 months after an episode of acute gastroenteritis in the rectal mucosa of eight patients who developed postinfectious IBS, compared with seven patients whose bowel habits returned to normal. Macroscopic and conventional histologic assessment of the intestinal mucosa of patients with postinfectious IBS generally appeared normal within 2 weeks of the acute infectious illness, but chronic inflammation—as revealed by quantitative histology—persists. These changes were seen even 52 weeks after the acute episode. Some evidence indicates that postinfectious IBS may be associated with small bowel bacterial overgrowth and may be effectively treated with nonabsorbable antibiotics that reduce small bowel bacterial counts.

Evaluation of the Patient with Persistent Travelers' Diarrhea

The evaluation of the patient with persistent travelers’ diarrhea includes evaluations for persistent i

 

Gas

Mon, 14 Dec 2009 11:49:24

Evaluation of the Patient with Persistent Travelers' Diarrhea

The evaluation of the patient with persistent travelers’ diarrhea includes evaluations for persistent infection or co-infection, stool microscopy with at least three ova and parasite stool examinations, Clostridium difficile toxin assay, D-xylose test, duodenal aspirate, or empiric treatment for Giardia. For underlying gastrointestinal disease, an initial evaluation should include serologic tests for celiac and inflammatory bowel disease. Subsequently, gastrointestinal endoscopy with duodenal aspirate and biopsies may be considered.

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hi

Mon, 14 Dec 2009 11:51:06

Amebiasis

Infectious Agent

Amebiasis is caused by the protozoan parasite Entamoeba histolytica.
Mode of Transmission

Transmission occurs via the fecal–oral route, either directly by person-to-person contact (e.g., diaper changing, sexual practices) or indirectly by eating or drinking fecally contaminated food or water.
Occurrence

* Amebiasis occurs worldwide, but it is more common in areas of poor sanitation, particularly in the tropics. Most infections, morbidity, and mortality occur in Africa, Asia, and Central and South America.
* Only an estimated 10%–20% of individuals infected with E. histolytica become symptomatic. Among these, approximately 50 million cases of invasive E. histolytica disease occur each year, with up to 100,000 deaths. Prevalence and presentation of symptomatic amebiasis vary geographically (e.g., amebic colitis may be the predominant presentation in one country, whereas amebic liver abscesses may predominate in another country).
* The prevalence of asymptomatic infection also varies geographically, ranging from 1% to 21% in persons in developing countries based on stool tests.

 

hi

Mon, 14 Dec 2009 11:52:01

Risk for Travelers

* E. histolytica can infect persons of all ages.
* Persons at high risk for severe disease include pregnant women, immunocompromised individuals, and patients receiving corticosteroids. Associations with diabetes and alcohol use have also been reported.
* The rate of amebic diarrhea in returning travelers varies by travel destination. One study found rates of 1.5% in travelers returning from Southeast Asia and 3.6% in those returning from Central America. The overall rate in travelers returning from all regions was 2.7%. Other studies among travelers to the tropics provided similar estimates.
* Risk of infection for both travelers and residents is highest in settings with poor sanitation where barriers between human feces and food and water (including ice) are inadequate.

Clinical Presentation

* The clinical spectrum of E. histolytica ranges from asymptomatic infection to amebic diarrhea and dysentery to fulminant colitis and peritonitis to extraintestinal amebiasis.
* Acute amebiasis can present as amebic dysentery, with frequent, urgent, small bloody stools.
* Chronic amebiasis can present with alternating diarrhea and constipation every few days, combined with fatigue and weight loss.
* The incubation period is commonly 2–4 weeks but ranges from a few days to years.
* Occasionally, the parasite may spread to other organs (extraintestinal amebiasis), most commonly the liver (amebic liver abscess). Amebic liver abscess presents with fever and right upper quadrant abdominal pain, usually in the absence of diarrhea.

Diagnosis

* Microscopy does not distinguish between the amebas E. histolytica (pathogenic) and E. dispar (nonpathogenic). Enzyme immunoassay (EIA) or polymerase chain reaction (PCR) is needed to confirm the diagnosis of E. histolytica. Contact your state health department reference laboratory for recommendations on E. histolytica-specific testing.
* The recognition of two identical-appearing species, one pathogenic and one not, may explain the observation that some people with apparent E. histolytica infection were “asymptomatic cyst passers.” Based on this new knowledge, some people passing apparent E. histolytica cysts, but having no symptoms, may be infected with E. dispar and not require treatment.
* The sensitivity of serologic tests varies depending on clinical presentation (approximately 90% extraintestinal and 70% intestinal) and cannot distinguish between current and past infection.

Treatment

* Travelers with either asymptomatic E. histolytica infection or symptomatic E. histolytica disease should be treated if the organism can be proven to be E. histolytica. Otherwise, asymptomatic travelers do not need to be treated.
* For asymptomatic infection, iodoquinol or paromomycin are the drugs of choice.
* For symptomatic intestinal infection and extraintestinal disease, treatment with metronidazole or tinidazole should be followed by treatment with iodoquinol or paromomycin.

Preventive Measures for Travelers

No vaccine is available. Travelers to developing countries should be advised to follow food and water precautions.


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hi

Mon, 14 Dec 2009 11:53:27

Chikungunya

Infectious Agent

Infection is caused by the chikungunya virus (CHIKV), a single-stranded RNA virus that belongs to the family Togaviridae, genus Alphavirus.
Mode of Transmission

* Transmission is vector-borne, occurring via the bite of an infected mosquito of the Aedes spp., predominantly Ae. aegypti and less frequently Ae. albopictus.
* Nonhuman and human primates are the main reservoirs of the virus, with anthroponotic (human-to-vector-to-human) transmission occurring.
* Blood-borne transmission is possible, with one documented case to date.
* The risk of an individual transmitting the disease to a biting mosquito or through blood is greatest when the patient is viremic during the first 2–6 days of illness.
* Maternal–fetal transmission has been documented during pregnancy. The highest risk occurs when a woman is viremic at the time of delivery, with a vertical transmission rate of 49%.
* CHIKV does not appear to be transmitted through breast milk.

Occurrence

* CHIKV has been identified in many countries in Africa and Asia and is responsible for numerous epidemics in these areas.
* Since a re-emergence of the disease in 2004, millions of cases have occurred throughout countries in and around the Indian Ocean.
* Transmission has also been documented in a limited area of Italy, after an infected traveler transmitted the virus to local Ae. albopictus mosquitoes, leading to autochthonous transmission.
* Given the large CHIKV epidemics, high level of viremia in humans, and the worldwide distribution of Ae. aegypti and Ae. albopictus, there is a risk of importation of chikungunya virus into new areas by infected travelers.
* For information on current outbreaks, consult CDC’s Travelers’ Health website (www.cdc.gov/travel).

Risk for Travelers

* Risk for travelers to become infected with CHIKV is greatest with travel to areas with ongoing epidemics of the disease.
* Most epidemics occur during the tropical rainy season and abate during the dry season. However, the recent outbreaks in Africa occurred after years of drought where open water-holding containers served as vector-breeding sites.
* Risk of CHIKV infection exists throughout the day, as the primary vector, Ae. aegypti breeds in household containers and aggressively bites in the daytime.
* In 2006 and 2007, 52 cases of laboratory-confirmed chikungunya fever were reported in U.S. travelers returning from areas with ongoing disease activity.

Clinical Presentation

* Approximately 3%–25% of persons infected with CHIKV will remain asymptomatic.
* The incubation period is typically 3–7 days (range 2–12 days).
* Disease is most often characterized by sudden onset of high fever (typically greater than 102° F) and severe joint pain. Other symptoms include rash, headache, fatigue, nausea, vomiting, and myalgias.
o Fevers typically last from several days up to a week. The fever can be biphasic.
o Joint symptoms are severe and often debilitating. They are usually symmetric and occur most commonly in hands and feet, but they can affect more proximal joints.
o Rash usually occurs after onset of fever. It is typically maculopapular, involving the trunk and extremities, but can also include palms, soles, and face.
* Rare but serious complications of the disease can occur, including myocarditis, ocular disease (uveitis, retinitis), hepatitis, and neuroinvasive disease, such as meningoencephalitis, Guillain–Barré syndrome, paresis, or palsies.
* Fatalities related to chikungunya virus are rare. Older age and comorbidities are likely risk factors for poor outcomes.
* Following the acute illness, some patients have prolonged fatigue lasting several weeks. Additionally, some patients have reported incapacitating joint pain or tenosynovitis, which may last for weeks or months. Some studies have reported joint stiffness and/or pain more than a year after the initial infection.
* Pregnant women have symptoms and outcomes similar to those of other individuals, and most CHIKV infections that occur during pregnancy will not result in the virus being transmitted to the fetus. However, when intrapartum transmission does occur, it can result in complications for the baby, including neurologic disease, hemorrhagic symptoms, and myocardial disease. There are also rare reports of first-trimester spontaneous abortions following maternal CHIKV infection.

Diagnosis

* Preliminary diagnosis is based on the patient’s clinical features, places and dates of travel, and activities.
* Laboratory diagnosis is generally accomplished by testing serum to detect virus-specific IgM and neutralizing antibodies.
* During the first week after onset of symptoms, CHIKV can often be diagnosed by using viral culture or nucleic acid amplification on ser

 



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