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FORCE HEALTH PROTECTION BRIEF Republic of the Philippines 31 October 2012
FORCE HEALTH PROTECTION Philippines Historical diseases present in area: Diarrhea, hepatitis A/B, typhoid,dengue, malaria, JEV, chikungunya, typhus, leptospirosis, hantavirus Recent Disease Reports: Chikungunya, Hepatitis A, Leptospirosis, Hand, Foot, and Mouth Disease (EV71), Rabies, Schistosomiasis, Measles, Ciguatera Force Health Protection Requirements: Up-to-date immunizations, anti-malarial protocols, JE vaccination required for RON personnel, day and night time insect precautions, Pre/Post Deployment PPD, and use approved water and food sources. Medical infrastructure: Private hospitals have better quality of care than public. For severe illness or injuries utilize Commander 7th Fleet Annex “Q” requirements for medical treatment. Environmental Hazards: 15-20 typhoons per year. Untreated water throughout the country and in resorts. Food contamination risk is high. Rainy season May-October. Assessment: High risk for infectious diseases. 31 Oct 2012
FORCE HEALTH PROTECTION Points of Contact • International SOS/TRICARE Operations Coordinator • Tel: + (65) 6338 9277 (Medical Assistance) • Customer Service: 1-877-563-9228 • www.tricare.mil/overseas • Fleet Liason USNH Okinawa: • NHOki-Fleet@med.navy.mil • Phone: 090-6861-4208
FORCE HEALTH PROTECTIONNCMI Definitions HIGH RISK: High operational impact due to disease affecting large percentage or causing severe disease in smaller percentage of personnel. INTERMEDIATE RISK:Disease affects smaller numbers, causes mild symptoms in larger numbers. Diseases with unknown impact may fit here as well. LOW RISK: Minimal impact on operations due to low likelihood of cases.
FORCE HEALTH PROTECTION Food & Water • Water is poorly treated even in municipal systems • Drink only from approved sources • Treat field water IAW military public health recommendations • Eat only from approved sources • If necessary, follow these rules • Eat fully cooked veggies/beans/rice/meats while they are hot (and watch them being cooked) • Breads, hard skinned fruits you peel yourself (bananas, oranges), hot tea are lower risk • High risk: reef fish (even well cooked), dairy, undercooked/uncooked meats/vegetables, leftovers, opened beverage containers, ice, frozen dessert, juice, locally canned/packaged products • Wash hands before eating!!
FORCE HEALTH PROTECTION Personal Protective Measures • Insect Precautions • 30-35% DEET is adequate • Reapply DEET every 4-5 hours • Both day and night biting mosquitoes • Treat uniforms/outer wear with Permethrin • Mosquito netting/screens in windows • Blood/Secretion Borne Pathogens • Avoid sexual contact with local population (HIV, GC, Chlamydia, Hep B risks) • Respiratory Precautions • TB risk is intermediate
FORCE HEALTH PROTECTION Hand Washing • Timing: • BEFORE eating • BEFORE smoking • AFTER bathroom • Hand Sanitizer: • 70% Alcohol • Not as effective as washing
Causative Agent: Virus (Flavivirus). Transmission: Bites of Aedesmosquitoes--day biters. Symptoms: Fever, severe headache (retroorbital), backache, joint pains, nausea, vomiting, eye pain and rash (hemorrhagic fever and shock syndrome are rare without prior exposure). Treatment:Supportive (bed rest, fluids, fever control, NSAIDs, avoid aspirin and salicylates) Prevention: No vaccine available; eliminate artificial containers that hold water, personal protective measures (DEET, permethrin, netting). FORCE HEALTH PROTECTION Dengue and Dengue Hemorrhagic Fever
Dengue Map FORCE HEALTH PROTECTION
FORCE HEALTH PROTECTION Chikungunya Fever • Agent - alpha virus of Togaviridae family • Vector - Aedesaegypti and Aedesalbopictus(pictured, right)mosquitoes (day biters) • Signs/Symptoms - fever, severe joint pains, headaches, muscle aches, back pain, rash (7-10 days) • Prevention - Insect repellent (DEET on skin, permethrin on clothing/bed nets), screens for doors and windows, eliminate standing water • Treatment – Support (rest, fluids, NSAIDs (steroids/narcotics if unresponsive to NSAIDs)
FORCE HEALTH PROTECTION Malaria • Agent - Plasmodiumfalciparum (60-75%), P. vivax (20-40%) • Vector – Anopheles flavirostris(night biters). • Signs/Symptoms - Cycles of chills, fever, sweating, vomiting and yellowing (jaundice) of the skin/eyes. • Prevention - Deet, permethrintreated bed nets/clothing and use of insecticides. • Prophylaxis – Doxycycline, Malarone, Mefloquine • Treatment – Quinine + (doxycycline or clindamycin) or Malarone or Artemesin
Malaria Map FORCE HEALTH PROTECTION
FORCE HEALTH PROTECTION Japanese Encephalitis Virus • Agent – Flavivirus, JEV • Vector – Culexspp (mosquitoes), night biters • Signs/Symptoms – acute encephalitis, aseptic meningitis, fever, headache, vomiting • Prevention – Deet, permethrintreated bed nets/clothing and use of insecticides. • Vaccine – Ixiaro (2 shot series); If staying >30 days in higher risk area or shorter stays with significant rice field/rural exposure • Treatment - Supportive
JEV Map FORCE HEALTH PROTECTION
Causative Agent:Leptospira, a spirochete Transmission: Infection of abrasions, mucus membranes from contact with infected water, soil, urine, reproductive fluids Symptoms: May have mild flu-like illness or as bad as Weil’s syndrome with jaundice, renal failure, hemorrhage, myocarditis, arrhythmias, meningitis, pulmonary hemorrhage. Treatment: Doxycycline, IV PCN (severe cases); monitor closely Prevention: Avoid contact with potentially contaminated fresh water; vaccinate animals. If water contact unavoidable, consider doxycyclineprophylactically. FORCE HEALTH PROTECTION Leptospirosis
Schistosomiasis • Moderate risk in Mindanao, Samar, Leyte Islands, Sorsogon (south Luzon), eastern Mindoro • Avoid exposure to freshwater • No chemoprophylaxis measures available • Larvae penetrate intact skin
Rabies control is poor. Do not feed or attempt to touch animals, including birds and monkeys. Wash bites immediately with water and soap (preferably betadine). Report bites immediately. Consider rabies preexposure prophylaxis if working with animals FORCE HEALTH PROTECTION Local Animals
FORCE HEALTH PROTECTION Travelers’ Diarrhea • Transmission: Various; tainted food and water, poor sanitation. • Signs/Symptoms: Abdominal cramping/pain, fever, and loose watery stools lasting 3-4 days. • Prevention:See previous slide on food/water preparation. • Treatment:Ciprofloxacin for 3 days and Imodium AD (Loperamide). Do not take Imodium if you have blood in your stool.
Causative Agent: Bacteria (Mycobacterium tuberculosis). Transmission: Airborne droplet via respiration. Symptoms: Cough, fatigue, night sweats, fever and rapid heart rate. Treatment: Antibiotics and respiratory isolation. Prevention: No vaccine available, avoid contact with persons with active TB, and annual screening for TB. Avoid prolonged periods in enclosed public spaces and on public transportation. Wear N95 mask in contact with known cases. FORCE HEALTH PROTECTION Tuberculosis (TB) M. tuberculosis
HIGH=Hepatitis B INTERMEDIATE RISK= Gonorrhea, HIV/AIDS, Chlamydia. FHP Requirements Avoid sexual contact. Use latex condoms if sexually active. Use Condom Sense! FORCE HEALTH PROTECTION Sexually Transmitted Disease
Required Health Measures Immunizations (see next slide) Malaria chemoprophylaxis Mosquito & insect bite prevention Pre-mission health assessment Include Tuberculosis (TB) screening test Obtain personal medication FORCE HEALTH PROTECTION 21
Required Immunizations Routine: Tetanus/diphtheria/ pertussis Measles (MMR) Polio Varicella (chicken pox) Mission-specific: Hepatitis A Hepatitis B Typhoid Seasonal Influenza Rabies** FORCE HEALTH PROTECTION • Start vaccinations early to accommodate vaccines that require several doses within a series ** For high risk groups only – obtain specific guidance 22
FORCE HEALTH PROTECTION Summary • Philippines is a country with frequent natural disasters and internal turmoil • Philippines has a high infectious disease risk • Personal protective measures go a long way (hand washing, mosquito precautions, animal avoidance, food and water safety)
FORCE HEALTH PROTECTION References • CDC Yellow Book: http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm • NCMI: https://www.intelink.gov/ncmi/index.php • Vector Control: http://phc.amedd.army.mil/topics/envirohealth/epm/Pages/MosquitoBorneDiseaseandControl.aspx • ShorelandTravax (subscription required): http://www.travax.com • Travel Alerts (State Department): http://travel.state.gov/travel/cis_pa_tw/cis/cis_999.html • Latest Disease Alerts (PROMED Mail): http://www.promedmail.org/
Questions? • Please contact your local health care provider • Navy Environmental and Preventive Medicine Unit No. 6 Duty Phone: 808-471-0237 NEPMU6-THREATASSESSMENT@med.navy.mil • Navy Environmental and Preventive Medicine Unit No. 5 Duty Phone: 619-556-7070 firstname.lastname@example.org