Illness in Journalists and Relief Workers Involved in International Humanitarian Assistance Efforts in Somalia, 1992-93

Zoonoses research in Somalia: A scoping review using a One Health approach

Zoonoses are likely to cause a substantial burden on both human and animal health systems in Somalia, given the close proximity between the pastoralist majority and their livestock. However, decades of instability leading to weak disease surveillance have meant that data on the burden of zoonoses is lacking. The aim of this scoping review was to assess and synthesize the available literature on the presence and burden of zoonoses in Somalia. We used keywords to search Web of Science for relevant publications. Studies were included if they contained relevant data on a zoonosis and were undertaken in Somalia or were undertaken in another country where exposure could reasonably be assumed to have occurred in Somalia (e.g., migrants/refugees, returning soldiers, exported animals). Studies were not included if they focused on Somali ethnic communities permanently living elsewhere or if zoonotic aspects were not considered. We extracted data on disease(s) reported, geographic focus, data reported (human, animal, environment), study design and author affiliation. A total of 22 zoonotic infections were documented in 76 publications. The most frequently studied diseases were Rift Valley Fever (n = 15, 17%), brucellosis (n = 13, 14%) and hepatitis E (n = 10, 11%). Around 30% of papers reported data from relevant populations outside Somalia. Only 18 papers undertook laboratory analysis within Somalia. Most papers reported data on humans (45%) and animals (36%) with limited research on the environmental domain. Descriptive studies (47%) dominated and most were led by non-Somali researchers (89% in first authors and 95% of last authors). This study highlights the need for well-designed zoonoses research in Somalia supported by capacity building of local researchers and investments in diagnostic laboratories.

Effect of interventions to reduce malaria incidence among military personnel on active duty: study protocol for a cluster randomised controlled trial of the impact of etofenprox-treated uniforms, permethrin-treated uniforms and DEET insect repellent

BACKGROUND

While there is strong evidence that bite protection methods such as permethrin-treated clothing and topical insect repellents are protective against insect bites, there are few studies assessing the impact on malaria infection. This study will estimate the protective efficacy of treated uniforms and DEET insect repellent on the incidence of malaria infection among military personnel in an operational setting. Permethrin-treated uniforms used with DEET lotion will be compared to etofenprox-treated uniforms with DEET lotion. The effect of DEET lotion will be estimated by comparing permethrin-treated uniforms with DEET or placebo lotion.

METHOD

A cluster randomised double-blind placebo-controlled trial is planned to evaluate the effectiveness of the interventions on preventing malaria infections in soldiers on active duty at Mgambo National Service Camp in Tanga, Tanzania. The arms are (1) permethrin-treated uniform with 30% DEET liposome formula; (2) permethrin-treated uniform with placebo lotion; (3) candidate insect repellent system, i.e. etofenprox-treated uniform with 30% DEET liposome formula; and (4) placebo, i.e. untreated uniforms with placebo lotion. The primary outcome is the incidence of Plasmodium falciparum malaria infection detected by polymerase chain reaction (PCR) by active case detection using surveys every 2 weeks for 12 months. Rapid diagnostic tests will be used for the diagnosis of participants with symptoms. The unit of randomisation will be combania: companies formed by recruits aged 18 to 25 years; combania do activities together and sleep in the same dormitory. Unequal randomisation will be used to optimise statistical power for the primary comparison between permethrin-treated uniforms with DEET and etofenprox-treated uniforms with DEET.

DISCUSSION

This trial will provide the estimate of the effects of permethrin with DEET compared to those of the new fabric treatment etofenprox with DEET and any additional effect of using DEET. The results will inform strategies to protect military personnel and civilians who have more outdoor or occupational malaria exposure than the general public.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02938975 .

An assessment of household water quality among Peace Corps volunteers in Guatemala

Background

Gastrointestinal (GI) illness is the most commonly reported health concern among Peace Corps Volunteers (PCVs) serving in Guatemala. This project identified water types and treatment and storage practices used by PCVs and measured select water quality parameters in their household water.

Methods

A survey about water types and practices was conducted of PCVs in Guatemala. The water type most frequently consumed in the household ("primary drinking water") and other water types present in the household ("secondary water") were tested for free chlorine residual (FCR) and for the presence of Escherichia coli and total coliforms. A negative binomial regression model was used to analyze data on incidence of self-reported GI illness.

Results

Tambo (commercially purified water in a 5-gal bottle) was the water type most frequently (64%) reported as primary drinking water in 39 PCV households. Most (74%) PCVs reported drinking water other than primary drinking water ≥1 day per week; the incidence rate of GI illness per PCV per month was significantly lower among PCVs who reported never consuming water other than primary drinking water compared to those who did (0.4 and 1.6 GI illnesses per PCV per month, respectively) (p < 0.05). E. coli was not detected in any primary drinking water sample, but was detected in 35% of secondary water samples. Total coliforms were detected in more than two-thirds of primary drinking water and secondary water samples. Nearly all water samples had an FCR of < 0.2 mg/L.

Conclusions

Consuming primary drinking water exclusively likely contributes to reducing the rate of GI illness among PCVs. However, most PCVs reported drinking multiple water types, which may include contaminated secondary water types in the household. All water intended for consumption, including secondary sources within and outside the household, should be properly treated and safely stored.

Travelers' diarrhea: update on the incidence, etiology and risk in military and similar populations - 1990-2005 versus 2005-2015, does a decade make a difference?

BACKGROUND

Travelers' diarrhea remains a prevalent illness impacting individuals visiting developing countries, however most studies have focused on this disease in the context of short term travel. This study aims to determine the regional estimates of travelers' diarrhea incidence, pathogen-specific prevalence, and describe the morbidity associated with diarrheal disease among deployed military personnel and similar long term travelers.

METHODS

We updated a prior systematic review to include publications between January 1990 and June 2015. Point estimates and confidence intervals of travelers' diarrhea and pathogen prevalence were combined in a random effects model and assessed for heterogeneity. Eighty-two studies were included in the analysis, including 29 new studies since the prior systematic review.

RESULTS

Military personnel were evaluated in 69% of studies and non-military long term travelers in 34%, with a median duration of travel of 4.9 months, and travel predominantly to the Middle East, Southeast Asia, and Latin America and the Caribbean. Sixty-two percent of tested cases were due to bacterial pathogens, with enterotoxigenic E. coli (ETEC), enteroaggregative E. coli (EAEC), and Campylobacter predominating, and significant regional variability. The incidence of TD from studies with longitudinal data was 36.3 cases per 100 person-months, with the highest rates in Southeast Asia, Latin America and the Caribbean, and the Middle East, with higher estimates from those studies using self-reporting of disease. Morbidity remained significant, with 21% being incapacitated or placed sick in quarters (SIQ) by their illness, 15% requiring intravenous fluids, and 3% requiring hospitalization.

CONCLUSIONS

In comparison to results from the prior systematic review, there were no significant differences in incidence, pathogen prevalence, or morbidity; however there was a trend toward improved care-seeking by sick individuals.

A Survey of the Health Experiences of International Business Travelers

Occupational health professionals need to know more about the health, worklife, and family life of international business travelers (IBTs). This descriptive correlational study, in two parts, examines the physiological and psychosocial experiences associated with business travel for a sample of 140 employees from western Canada's oil and gas industry. Results for Part One show that 76% of IBTs report travel related health problems, 74% have jet lag, 45% have travelers' diarrhea and gastrointestinal complaints, 12% to 16% have climate adaptation problems, and 2% report accidents and minor injuries. High risk behaviors include not carrying a first aid travel kit (54%); drinking more alcohol than ordinarily (21%); and neglecting food, water, and antimalarial precautions (6% to 14%). Other risk factors include age, length of stay, destination, pre-travel medical examinations, pre-travel advice, and eating and accommodation facilities. Findings show that IBTs are at risk for travel related physiological health problems. Implications for practitioners call for increased occupational health expertise in pre-travel preparation, follow up post-travel and regular health surveillance for employees who travel on international business.

Dengue and hepatitis E virus infection in pregnant women in Eastern Sudan, a challenge for diagnosis in an endemic area

Dengue fever and hepatitis E virus infection are both a public health problem in developing countries due to poor sanitation. Infection with viral hepatitis and dengue fever can present with similar clinical such and fever, headache and abortion. This study was conducted in Port-Sudan city in the eastern part of the country. ELISA and Real Time PCR tests were used to detect the infection. A total number of 39 pregnant women with a mean age 26 ±7.8 were included in the study. All of them had fever, 32 (92.3%) admitted with headache, 11 (28.2%) of them had vomiting, and abortion was reported in two cases (5.1%). The study showed that 4 (10.3%) of pregnant women were positive for the Hepatitis E virus, 5 (12.8%) positive for Dengue virus IgG, and only one sample (2.6%) was positive for IgM capture ELISA and real time PCR. Death due to hepatitis E infection was reported in one case with 7^th month of pregnancy. Most of hepatitis cases were reported in the central sector of the Portsudan city. The diagnosis of hepatitis E virus and dengue virus in an endemic area is a great challenge for health care staff working in these areas. Both Dengue virus and Hepatitis E virus infection should be considered in pregnant women especially in similar settings.

Health hazards and medical treatment of volunteers aged 18-30 years working in international social projects of non-governmental organizations (NGO)

The specific health risk profile and diversity of treatments sought by young volunteers participating in international social projects should differ from those of their older colleagues. In the absence of any data to identify whether this was correct, a retrospective analysis was performed using a standardized questionnaire. Questions included what diseases occurred, and details of the frequency and types of treatment sought during their stay - (e.g. self-treatment, medical/dental intervention, or local healer). The 153 participants were aged 18-30 years and worked in a non-governmental organization for >6 months. The participants were: 53% female, mean age 20 years, and mean duration of stay was 11.2 months. Their NGO placement abroad was in Latin America 65.4%, 14.4% in Africa, and 9.8% in Asia. 83% of the young volunteers had received some advice regarding travel medicine before their departure. However, they suffered from more injuries compared to private travellers, and febrile infections were more common when compared to older studies. 21.2% suffered from dental problems and 50% of them sought medical treatment. This study highlights a previously unreported higher risk profile of specific health problems occurring in young NGO volunteers, including some potentially life-threatening diagnoses that differed from their older colleagues and normal travellers. It is recommended that young volunteers should receive age specific, comprehensive pre-departure training in health and safety, first aid, and management of common health problems. A medical check-up upon returning home should be mandatory. The provision of a basic first aid kit to each volunteer before departure is also recommended.

Dengue fever, tuberculosis, human immunodeficiency virus, and hepatitis C virus conversion in a group of long-term development aid workers

BACKGROUND

Development and humanitarian aid workers are a diverse group of travelers who, because of the nature of their travel, may have specific travel-related health risks. The main objective of this study was to quantify the risk of dengue fever virus (DFV), tuberculosis (TB), human immunodeficiency virus (HIV), and hepatitis C virus (HCV) infections in a group of long-term development aid volunteers.

METHODS

Medical files of Volunteer Service Abroad (VSA) volunteers and their accompanying family/partner/spouse serving over 17 years (1995-2011) were reviewed. Demographics, destination, months spent in-country, and, where available, results of pre- and post-assignment testing for DFV, TB, HCV and HIV infections were extracted.

RESULTS

Results from 652 assignments were audited. Conversion rates were calculated when both pre- and post-assignment results were available. Evidence of dengue fever seroconversion was found in 6.3% of 205 volunteers [at a rate of 3.4 per 1,000 person months (pm) on assignment], with assignments in Southeast Asia having the highest risk. Evidence of TB during assignment was found in 2.9% of 336 volunteers converting at a rate of 1.4 per 1,000 pm. There were no HIV or HCV infections detected. On post-assignment questioning, 6.7% of volunteers reported unprotected sex with someone other than their regular partner and 9.8% reported a potential exposure to blood and/or blood products.

CONCLUSIONS

Infection with DFV and TB occurred in this group at rates similar to that seen in other groups of long-term travelers, and screening would appear to be warranted. While none contracted HIV or HCV infection, reported behavior did put them at risk of blood- and body fluid-borne diseases. It is important that pre-assignment travel health preparation in this group focuses on strategies to minimize these risks.

Health risks and risk-taking behaviors among International Committee of the Red Cross (ICRC) expatriates returning from humanitarian missions

OBJECTIVE

To assess self-reported health risk and risk-taking behavior of humanitarian expatriates.

METHODS

A self-administered anonymous questionnaire was completed by International Committee of the Red Cross (ICRC) expatriates returning during May 2003 to September 2004, covering perceived health status before and after mission, malaria prevention, prevalence of exposure to stress, accidents and violence, and risk-taking behaviors.

FINDINGS

More than one-third (36.4%) reported worse health on return from the mission. A third (35%) of expatriates returning from Sub-Saharan Africa excl. South Africa reported not having followed ICRC's recommendation on taking malaria prophylaxis in spite of stating a high degree of awareness of the risks and availability of effective drugs. Over 40% reported the mission having been more stressful than expected, mostly due to the working environment; 10% reported injury or accidents and 16.2% exposure to at least one act of violence. Almost one-third of the respondents reported having engaged in casual sexual relationships. Of these, 64% reported using condoms at every sexual contact, and women reported lower usage of condoms than men. Many (27%) reported involvement in risk-taking behavior.

CONCLUSION

This study shows that humanitarian aid workers experience significant worsening of their health during overseas missions. Many are at risk of experiencing violence, accidents, or injuries. Despite awareness of the risks, many expatriates engage in behaviors that could endanger their health. Improved selection of expatriate staff, training programs emphasizing areas of concern, strengthening social support locally, and follow-up in field may help to alleviate these problems.

Geographic expansion of dengue: the impact of international travel

Dengue has emerged as an international public health problem. Reasons for the resurgence of dengue in the tropics and subtropics are complex and include unprecedented urbanization with substandard living conditions, lack of vector control, virus evolution, and international travel. Of all these factors, urbanization has probably had the most impact on the amplification of dengue within a given country, and travel has had the most impact for the spread of dengue from country to country and continent to continent. Epidemics of dengue, their seasonality, and oscillations over time are reflected by the epidemiology of dengue in travelers. Sentinel surveillance of travelers could augment existing national public health surveillance systems.

Dengue vaccines for travelers

Dengue is an arthropod-borne infection caused by a flavivirus and spread by the Aedes mosquitoes. Many of the countries where dengue is endemic are popular tourist destinations and the disease is an increasingly important problem encountered by international travelers. Personal protection against the day-feeding dengue vectors is problematic, indicating the urgent need for a dengue vaccine. This review discusses the challenges of vaccine development, current vaccine strategies and the prospects for the availability of a vaccine for travelers in the future. Cost-effectiveness studies will need to take into account many factors, including the attack rate of dengue in travelers, the proportion of travelers who will need hospitalization, the cost of altered travel itineraries, the cost of the vaccine, duration of travel, destination and season. To be licensed as a travelers' vaccine, vaccine trials must address safety, immunogenicity, duration of protection, schedules and boosters in adults (in particular in immunologically naive adults), trials that may differ from those conducted in endemic countries. Vaccine schedules with long intervals would be a major obstacle to the uptake of the vaccine by travelers. Enhanced reactogenicity or interference with immunization must be effectively excluded for travelers with prior or concurrent vaccination against other flaviviruses, such as yellow fever or Japanese encephalitis. Licensing dengue as a travelers' vaccine poses unique challenges beyond the development of a vaccine for the endemic population.

Vaccine-preventable diseases in long-term expatriates

The term "expatriates" refers to professionals and their families who live abroad for several months or years. Owing to potential prolonged exposure, and living conditions that may be closer to those of the local population, they are at higher risk of acquiring infectious diseases that are endemic in their new place of residence. They often have reduced access to medical services, putting them at higher risk of complications and more severe outcomes. Vaccination is probably one of the most effective means of preventing expatriates from acquiring endemic or epidemic diseases. Incapacitation or sickness in the field may cause serious disruption to project activities and impose an extra workload on the local team. It may also result in repatriation, with further extra direct and indirect costs for the organization. Predeparture advice and preparation, to promote risk reduction behavior, coupled with adequate support in the field are key ingredients to ensure effective and successful activities of collaborators. Institutions and organizations sending expatriates to developing countries have a clear responsibility, and it is in their own interests to promote the health of their employees working abroad.

Health-related challenges in United States Peace Corps Volunteers serving for two years in Madagascar

BACKGROUND

The United States Peace Corps has nearly 8000 Volunteers (PCVs) working in more than 70 countries, predominantly in the developing part of the world. The volunteers are challenged by many new and unfamiliar health problems, as a result of change in living conditions during their service. The goal of this study was to assess the health problems of PCVs in Madagascar, and to use this information to evaluate the effectiveness of the current PCV health support program.

METHODS

PCVs, finalizing their 2 years of service, were enrolled in the study. Data were retrieved from individual Peace Corps service medical records, the close of service (COS) physical evaluation, and a PCV questionnaire, which elicited additional self-reported health problems and concerns.

RESULTS

Sixty-nine PCVs took part in the study. Median age at COS was 24 years (95% CI 23-26 years), and the male/female ratio was 1 : 3.6 (15 males and 54 females). Skin, gastrointestinal and respiratory infections constituted the three most common reported health problems. Among the registered parasitic infections were ova and parasites in the stool (42.0%), confirmed and presumptive malaria (15.9%) and schistosomiasis (11.6%). Female PCVs more frequently reported dermatologic manifestations than male PCVs: postadolescent acne (48.2% vs. 13.3%) and telogen hair loss (33.3% vs. 6.7%). Amenorrhea, as the most commonly reported menstrual alteration during service, was reported by 15 (27.7%) female PCVs.

CONCLUSIONS

The PCVs in Madagascar encounter a broad range of health-related problems, most of which are preventable infectious diseases. Reinforcement of the preservice personal health-training curriculum later during service is needed. Reported dermatologic and menstrual disturbances in female subjects may be associated with stress-related estrogen imbalance. More studies are warranted to assess the stress impact of long-term travel on the female physiology.

Incidence of health crises in tourists visiting Jamaica, west indies, 1998 to 2000

BACKGROUND

Tourism is important to the Jamaican economy accounting for approximately 25% of the gross domestic product. Health problems in tourists could have significant impact on the health of the local population, the scarce health service resources, and the tourist industry. This study was conducted to identify health problems most commonly occurring in tourists visiting Jamaica and examine how these problems are managed.

METHODS

Records of health problems occurring in tourists who visited principal tourist areas on the north coast from June 1998 to June 2002 were reviewed for the type of illness and how the problem was handled. The data were analyzed using Epi-Info software (Centers for Disease Control and Prevention, Atlanta, GA) and Statistical Analysis System software (SAS Institute, Cary, NC).

RESULTS

Accidents were the most common health crises reported by tourists. Gastrointestinal, respiratory, and cardiovascular problems occurred less frequently. Those less than 40 years of age more frequently reported accidents or injury, gastrointestinal problems, and drug abuse, whereas respiratory and cardiovascular problems were more common among those above 40 years of age. Cardiovascular problems, drug abuse, and death were more common in men than in women. Hotel nurses handled most of the cases and were more likely to refer patients to private physicians or hospitals than to public hospitals (p <.05). Factors influencing the way the crisis was handled were age (p =.0441); who handled the crisis (p <.0001); and the method of payment (p =.0072). The factors that influenced hospitalization were gender (p =.0615); who handled the crisis at the onset (p =.0497); how the crisis was dealt with (p =.0336); and previous health problems (p =.0056). Men were more likely to be hospitalized and to be referred to a public hospital than women. Medical insurance covered the costs for 11% of tourists, and 75% paid out of pocket.

CONCLUSION

The information provided by this study can be used to implement changes to reduce health problems in tourists and improve emergency health services in tourist areas.

Medical evacuations and fatalities of United Nations High Commissioner for Refugees field employees

BACKGROUND

Over the last 20 years, the number of conflicts and humanitarian interventions has steadily increased, as has the level of insecurity on operation sites. So far, little information is available concerning the morbidity and mortality of expatriates and local employees working in the field for humanitarian agencies.

METHODS

A retrospective study was conducted in order to review the causes of medical evacuations and deaths of the United Nations High Commissioner for Refugees field employees. All medical records reported to the headquarter's medical services over 2 years (1994-1995) were collated and analyzed.

RESULTS

A total of 199 cases (162 medical evacuations, 37 deaths) was reported over these 2 years for a monthly average of 4,151 field employees. Ninety-four men and 68 women were evacuated, 34 men and 3 women died. Expatriate employees represented two-thirds of the cases. Expatriates from Europe, North America, and Japan represented 58 in 122 evacuated expatriates and 2 in 9 deaths of expatriates. The major causes for evacuation were infectious diseases (17%), obstetric-gynecological conditions (15%), accidents (15%), ophthalmology/ear, nose, throat/dentistry (11%), gastrointestinal diseases (10%). The major causes of fatalities were infectious diseases (41%), cancer (24%), accidents (16%), cardiovascular diseases (11%). Firearms caused 4 fatalities and 2 medical evacuations. Fifty-nine percent of the cases occurred in Africa.

CONCLUSIONS

Infectious diseases remain a leading cause of fatalities and medical evacuations, particularly AIDS-related diseases among local African employees. A large number of accidents and obstetric-gynecological conditions was also noted. Special emphasis should be put on preventive measures and access to health care for nationals. Systematic data collection and surveillance would help in designing properly adapted strategies to minimize risks for relief workers in the field.