World Health: the magazine of the World Health Organization: December 1987 [full issu]: taking off!

Mf.:\Gf.:\ZI ~ e r' Correction: Due to a printing er- ror, the figure for WHO's 1988-89 biennial budget appeared on page 30 of our November issue as US $33,980,000. This should have read US $633,980,000. We apologise to readers for this mistake. Cover: Taking off! Cover design of Concorde and travel cartoons by Peter Davies IX ISSN 0043-8502 World Health is the off icial illustrated magazine of the World Health Organ izat ion. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English , French, Portuguese. Russtan and Spanish. and four t imes a year in Arabic and Fars1. The German edit ion IS obtainable from German Green Cross. Schuhmarkt 4, 3550 Marburg, FRG . Articles and photographs not copyrighted may be reproduced provided cred it is given to the World Health Organ ization . Signed arttc les do not necess- arily ref lect WHO's views . World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Travellers' health by Richard Dawood Biting insects by Chris Curtis .. .. Malaria and you by Louis Molineaux and Jose A. Najera . 3 6 8 Beasts that bite by John Debbie and Takao Fujikura. 11 AIDS and the traveller by Jonathan Mann .. Be a healthy traveller . . Safe water 14 16-17 by Hemda Garelick . .. ....... . . 18 The art of defensive eating by Richard Dawood 20 Immunization is not enough by John Clements 21 Viral hepatitis by Arie J. Zuckerman . 24 Childline by John Madeley . 26 Women and smoking by Eileen Crofton . 28 i\lews Page ...... . .. ... . . 30-31 Travellers' health by Richard Dawood More people travel abroad than ever before in human history- of course they do ! They go not only for tourism but on business, on pilgrimage , in search of jobs, as political refugees or in flight from warfare . Record-break- ing growth in international travel has now been the norm for many years , and will remain so. More travel , however, means more travel-related illness . Surveys indicate that roughly half of all international travellers experience some kind of adverse effect on their health as a direct result of their trip. Such surveys have their short- comings (though they probably underestimate the true scale of the problem), and there are particular difficulties in obtaining accurate epidemiological information on this subject. But by any standards, this is an impressive toll of inconve- nience, misery, illness or worse . Such suffering is in fact unneces- sary : almost all of the possible ·problems are preventable , or under a considerable degree of individual control. The health problems of travel are very diverse , but they tend to be most often of an infectious or para- sitic nature , such as diarrhoea, hepatiti's A and malaria . Diarrhoea afflicts around two-fifths of all international travellers , of whom 30 per cent of sufferers may be con- fined to bed, and 40 per cent may be compelled to change their travel plans. Some people accept diar- rhoea as an inevitable part of trav- el , but that is plainly not so. Hepa- titis A remains the most common serious infectious illness in travel- lers. Malaria rates in returning trav- ellers continue to rise, drug resis- tant malaria continues to spread, Everywhere in the world, tourism is a growth industry-and an industry that requires certain health safeguards. Photo L. Sirman © W oRLD HEALTH, December 1987 and the choice of effective drugs available for prophylaxis is now seriously limited by toxicity. Other hazards deserve attention. Since people from temperate cli- mates have been taking holidays in sunny places in ever greater num- bers, the incidence of skin cancer has risen significantly- to a level HarE'l that recently prompted the Royal College of Physicians in London to prepare a special report on the problem. Skin cancer is now known to have a clear relationship not just with long-term exposure to ultra- violet light but also with acute epi- sodes of sunburn. Climatic ex- tremes hold hazards that are not merely of academic interest, or im- portant only for those bound for unusual destinations: a freak heatwave around the Mediterra- nean last summer affected thou- sands of holiday-makers as well as local residents , and caused many deaths from heatstroke. Altitude sickness also claims a few victims every year among those who have not been alerted to the risks or who fail to take them seriously. Medical treatment abroad can it- self be a source of danger. Public interest in AIDS has drawn atten- tion to hazards from blood transfu- sion in countries with inadequate screening facilities , but AIDS is not the only risk: hepatitis , cytomega- lovirus, syphilis and malaria can be spread by transfusion. There are also important non-infective hazards: transfusion with badly matched blood causes severe reac- tions and can be fatal , and has im- portant long-term consequences in girls or women, leading to serious antibody reactions between mother and fetus in a subsequent pregnan- cy ; allergic reactions and febrile re- actions may occur, and the risk of these is greater when blood storage conditions are poor. AIDS and hepatitis B can also be spread by contaminated needles, and medical or dental instruments as well as through unsafe sexual relations. There may be risks from medica- ments that have not been stored cor- rectly, have lost their effectiveness or are used inappropriately. Locally produced rabies vaccine, in some circumstances, may even pose a haz- ard as great as that of rabies itself! Yet by far the commonest cause of death or serious injury abroad, especially in young people, are accidents ; and in almost all cases there is a preventable element. Consider the island-in-the-sun sce- nario: holiday-makers rent mopeds or motorcycles to explore an island -often the only means of getting around. They are inexperienced riders, the roads are unfamiliar, in poor conditions and unsuitable for fast driving. Drunk driving rules Dr Richard Dawood is the editor of "Travellers' health : how to stay healthy abroad," a guide compiled by an interna- tional team of 43 experts (pub- lished by Oxford University Press, 116 High Street, Oxford OX1 4BR, England; paperback price £6.95. In the USA published by Viking Press and entitled " How to stay healthy abroad" . 3 are not respected, and the heat makes crash helmets and protective clothing unattractive. Most island hospitals are small , have no inten- sive care facilities, and cannot pro- vide adequate care for foreign pa- tients with serious head injuries. The accident rate in many popular island holiday destinations has now reached epidemic proportions. Quarantine was once the key public health measure that was en- forced to control the spread of dis- ease between different countries . Today, the focus of efforts by gov- ernments and public health bodies is immunization, applied against a number of serious infections. The success of vaccination in the global eradication of smallpox is now al- most legendary, a unique human achievement; the immediate pros~ pects for repeating this success with any other disease , however, are re- mote indeed. Most of the immuni- zation requirements of different countries are agreed under Interna- tional Health Regulations, adminis- tered by WHO. Relatively few regu- lations now remain in force, and 4 there is confusion in the public mind about their exact function. Many requirements exist primarily to protect countries from imported disease , rather than for the welfare and protection of the individual traveller, and this is especially true with regard to yellow fever. Some countries still insist on cholera im- munization certificates for travel- lers arriving from infected areas, though the efficacy of cholera vac- cine in providing personal protec- tion or as a public health measure is seriously in doubt. Confusion about the function of immunization requirements is dangerous. Merely complying with a country's requirements must never be interpreted as meaning that everything possible or reason- able has been done to protect the health of a prospective visitor, and that no other precautions are neces- sary. And to be told by a travel agent, embassy official or a doctor that "nothing is necessary" for travel to a particular country may give a misleading impression that the health risks are insignificant . Governments and public health organizations usually formulate additional recommendations for their own travelling public. Immu- nization in childhood against teta- nus, poliomyelitis and diphtheria does not confer lifelong protection ; measles has been the target of an energetic public health campaign in the USA, and many Americans born after 1957 will not have been exposed to it, may not have been immunized, and will be at risk when they travel. BCG immuniz- ation to protect travellers against tuberculosis is a controversial is- sue; because immunization against this group of diseases tends to be associated with childhood rather than with travel , it often tends to be neglected. Typhoid vaccine, effec- tive in roughly 70 per cent of recipi- ents, and hepatitis A gammaglobu- lin are the two remaining immu- nizations that are commonly recommended for travel. There are also vaccines against Japanese B encephalitis, meningitis and plague, but they are not often given. Effective, new "designer" W oRLD HEALTH , December 1987 International Travel Medicine Almost 50 million persons each year travel to another conti- nent and many millions more travel within their own continent. To devise ways of protecting the health of travellers, the Institute for Social and Preventive Medi- cine at the University of Zurich, Switzerland, has convened a ma- jor conference on International Travel Medicine, to be held on 5- 8 April 1988. The conference will bring to Zurich medical person- nel of international, national and local health organizations, provid- ers of health advice to travellers, specialists in tropical medicine, travel agents and the news me- dia. wHo is a eo-sponsor of the conference. Left: The paraphernalia of business and tourist travel. Make sure you are a healthy traveller. Right: A truckload of American tour- ists. Unfortunately traffic accidents do happen, and are usually beyond the control of the passengers. Photos WHO/M. Jacot vaccines are available against rabies and hepatitis B, but both are ex- pensive. A new, long-lasting vac- cine against hepatitis A is in pros- pect, and it too will be expensive. The need for an effective vaccine against malaria has never been greater, and research is at an ad- vanced stage ; but this objective is still a long way off. There are hopes for an improved vaccine against ty- phoid, and a vaccine against den- gue fever would be most welcome. The fact remains that more and better vaccines, available tomor- row, would not solve all the prob- lems of travellers' health that demand to be addressed. Any strat- egy that revolves around the con- cept of specific measures to combat individual diseases, one by one, is flawed. There are a great many travel-related diseases that are wor- thy of prevention ; health problems abroad do not have to be life- threatening or disabling to wreak havoc upon a trip; and, as I have already suggested, many of the most pressing problems are not in- fectious disease hazards at all. WoRLD HEALTH, December 1987 What should now be done that will have the greatest impact on the challenge of travellers' health? Only one single measure is capable of accomplishing the dramatic change that is needed, and that is health education. Until now it has received insufficient priority, yet it costs little and depends upon no major new technological break- through . To be effective, it must be broad, comprehensive and detailed. Health precautions for travel are not complicated. The objective should be to give prospective trav- ellers enough information to con- vince them to observe precautions even when these may seem unrea- sonable; lists of do's and don'ts, to be taken on trust, are simply not enough. Everyone needs health education for travel-even doctors, who are often as unfamiliar with hazards that occur outside their own envi- ronment as anyone else. People from developed countries with a so- phisticated public health service and high general safety standards rarely have to think about such things at home, and are particularly in need of health education. We are all travellers now, and at different times will travel for pleasure, on business as pilgrims, as refugees or as job-seekers. Health education should focus on general principles that apply anywhere. Reliable in- formation about hazards abroad is often most lacking from the coun- tries with the greatest risk, and ad- vice should not be too closely ori- ented to specific destinations ; it is better to travel in a general state of preparedness. Learning to stay healthy abroad takes a little effort, and the neces- sary information is sometimes diffi- cult to obtain. Ultimately, travel- lers have to take responsibility for their own health abroad, and have to look after themselves; they can- not afford to do otherwise. Experts who have knowledge of the hazards of travel should develop the skills and the means to communicate this knowledge to the travelling public, as effectively and as widely as possible. • 5 Biting insects Biting insects may cause dis-tress to the traveller on two scores: firstly, because they are a nuisance to which he or she may not be accustomed, and sec- ondly, because they transmit the causative agents (pathogens) of cer- tain diseases. The nuisance effect may be encountered by the travel- ler in any region of the world, but is perhaps worst of all in the arctic summer. For some unfortunate in- dividuals , allergy to insect bites causes so much suffering that they are unwilling to travel to places which they know, or suspect, to be infested with biting insects. Insect-borne diseases are now broadly speaking limited to the tropics. The pathogens causing them include viruses, protozoa and worms, and these start the journey from one human to another by being sucked up when an insect "bites," that is takes a meal of blood. In most species it is only the female insect which bites, as in these species blood is only needed for egg development. After the pathogen has been sucked into the insect, it generally undergoes a process of development before being passed on when the insect bites another person. For most diseases, at most places and times, there is only a remote chance of pathogens being trans- mitted by any one insect bite. So the risk to short-stay travellers from these diseases is remote, especially as most of these travellers will avoid insect bites because of their lifestyle (for example, tourists stay- ing in air-conditioned hotels) or will take steps to prevent them because of the annoyance. However, the case of malaria is different. Human malaria parasites are only transmitted by Anopheles mosquitos, and in tropical Africa more than one in twenty of female Anopheles may have pathogens of malaria already in their salivary glands ready to be transmitted 6 by Chris Curtis whenever they bite. The remorse- less spread of resistance to anti-ma- larial drugs means that prophylactic drugs can no longer be relied on, so precautions to minimise mosquito biting are vital. The next article deals in more detail with malaria. Bed nets have long been used against night-biting insects, and travellers to tropical areas should consider taking with them a light- weight nylon net. Hungry mos- quitos-which may transmit many other diseases besides malaria- are very persistent and will find places where a net is torn or not tucked in . Conical nets have the advantage over rectangular ones of requiring only one attachment point, but this is outweighed by the greater risk of the body touching the net during the night and allowing the insects to bite through the net. Impregnating the net with the pyrethroid insecticide permethrin is an added precaution. This sub- stance is safe for humans , but rap- idly drives away or kills mosquitos and other pests. If one sits under an untreated or permethrin treated net, one sees a dramatic difference in mosquito behaviour. On an un- treated net the insects stand for minutes at a time probing and searching for a way in, whereas their contacts with a treated net are so fleeting that at any instant only one or two are on the net ; a later search of the floor may reveal that even fleeting contacts have been enough to kill a good proportion of the attackers. Some people find conventional fine-meshed bed nets uncomfort- able in a hot climate. Ventilation is better with a broader-meshed net and a mesh of up to 8 mm is effec- tive against mosquitos if impreg- nated with permethrin , apparently because they do not fly straight through the holes but pause on the net long enough to pick up an effec- tive dose of the chemical. The same thing seems to be true on a smaller scale with sand flies , which transmit leishmaniasis and which can find their way through a conventional mosquito net unless it is impreg- nated with permethrin. Impregnated nets are not yet on the market, but if one obtains an emulsifiable concentrate of per- methrin it is easy to impregnate a net for oneself. More portable than a net , and effective before or after bedtime , is a small electric hot-plate on which one places a vapourising mat (tab- let) containing a pyrethroid such as bio-allethrin which evaporates slowly at the temperature of the hot-plate. The mat needs replacing after about ten hours of use. Indoor tests showed an almost complete prevention of mosquito bites, with many insects falling dead or dying to the floor. The plates are now available to fit all the world's vari- ous electrical systems and can also work from a 12-volt battery. A non- electrical version fuelled with alco- hol (but without a flame) is now available for tents or other dwell- ings without electricity. Mosquito coils which smoulder and emit py- rethroid smoke are cheaply avail- able in most tropical countries , but in our tests they proved not quite as effective as a vapourising mat. W oRLD HEALTH , December 1987 The " repellent buzzer" was busily buzz- ing-but the mosquito enjoyed its meal anyway. Photo W HO/C. Webb/Eisevier Publicat ions, Cambridge Some people complain of waking with a headache caused by the smoke from a burning coil. Apart from heaters for vapouris- ing mats, other electrical "anti- mosquito" gadgets , widely adver- tised for protection against mos- quitos, are best avoided . Although some people still believe in them, all comparisons with a buzzer on and with it off show no difference in the biting rate. Ultra-violet lights with electrocuting grids are effec- tive against flies but far less so against mosquitos. In air-conditioned rooms, the fact that doors and windows are normally kept tightly shut prevents insects entering. In other rooms in the tropics, doors and mosquito screens over windows should be closed at dusk, when mosquitos start to hunt for blood . To kill those which may have entered dur- ing the day , an aerosol can of pyre- throid insecticide is effective and safe to use , if food is covered first. On aircraft travelling from coun- tries with endemic insect-borne dis- eases to those without them, cabin staff are required by international health regulations to spray the cabin and baggage hold to kill " stowaway" insects. This is a sensi- ble precaution ; there have been W oRLD HEALTH , December 1987 more than 20 cases of malaria, some fatal , in people living near, or working at European airports, which have been attributed to bites by infected Anopheles mosquitos arriving on aircraft from malarious countries. And there is always con- cern about the possible introduc- tion of yellow fever virus into Asia, where it has never been recorded even though the mosquito which can transmit it-Aedes aegypti-is abundant. In the special case of vehicles touring African game parks, aero- sol insecticides can also be useful against tsetse flies, which have the habit of following and entering such vehicles ; they can give a painful bite and have been known to trans- mit sleeping sickness to tourists. Bedbug-infested beds are one of the less pleasant aspects of low cost tourism, and bedbugs may play a role in disease transmission (see box) . Aerosol insecticides generally only flush out bed-bugs from their hiding places without killing them . They prefer to bite in complete darkness, but not under bed clothes . So leaving a light on while sleeping is a useful precaution, and so is the application of the insect repellent di-ethyl toluamide ( deet) to the hands and face (but avoiding eyes and lips). For use against outdoor biting insects, chemical repellents are almost the only effective measure. Mosquito-repellent lotions , roll-on sticks, creams, aerosols and soap are available. Most contain deet as the active ingredient, but others contain di-methyl phthalate, ethyl hexanediol , citronella and so on. All of these substances can be shown to repel biting insects but on the skin they are not very long-last- ing. Some individuals find them unpleasant on the skin or, in rare cases, dangerous. It may therefore be preferable to impregnate a cot- ton garment with the repellent sub- stance. If the garment is sealed in a plastic bag or box when insects are not biting, the repellent vapour is not wasted and one impregnation can give protection for several weeks. Against day-biting mosqui- tos and midges in the temperate zone and the arctic, a deet-impreg- nated netting jacket with a hood is very effective. When sitting out in the evening in the tropics or sub- tropics, most mosquitos bite around the ankles ; cotton anklets about 10 cm wide impregnated with deet give a considerable degree of protection at very low cost and with several weeks of effective life from one impregnation. Though this article has been con- cerned with the needs of travellers, several of the recommendations are increasingly appropriate for inhabi- tants of tropical countries who bear the brunt of the danger and nui- sance associated with insect bites. • Bedbugs, hepatitis B and AIDS Hepatitis 8 (serum hepatitis) virus can persist in bedbugs after they have sucked it up from a victim, though it does not multi- ply in them (as malaria parasites do in mosquitos) . lt seems possi- ble that the virus may some- times be transmitted on the pro- boscis of infected bugs or if bugs are crushed or defaecate on the skin of an uninfected person . That this is unlikely to occur in the case of AIDS (HIV) virus is indicated by the fact that AIDS transmission is almost exclusive- ly associated with sexual con- tact, transmission at birth from infected mothers or contact with infected blood via transfusion or shared hypodermic needles. Afri- can children who have not had such contacts, but who are fre- quently bitten by bedbugs, do not get AIDS, .but many do get hepatitis B. 7 Malaria and vou by Louis Molineaux and Jose A. Najera Malaria is arguably the most important health risk run by travellers, and the problem is getting larger and more complicated thanks to the increase in travel, the deterioration of the malaria situation in many areas, and the increase in drug resistance. The days are gone when a single very safe drug, chloroquine , afford- ed almost total protection against all species of malaria everywhere . The new, more complex, situation requires travellers to take increas- ing responsibility for their own pro- tection against malaria and its con- sequences , and therefore to seek the relevant information. There are about 100 million new cases of malaria every year, and it causes several hundred thousand deaths each year. Malaria eradica- tion has succeeded in some- mainly temperate and relatively devel- aped-countries, but has failed in many others, mainly tropical and relatively less developed. In many areas the situation is deteriorating, for a variety of reasons, including resistance of the vectors to insecti- cides and of the parasites, especially the malignant parasite Plasmodium falciparum, to antima- larial drugs. The countries affected are, in cooperation with WHO, adapting their malaria control strat- egies to the changing situation. Malaria is transmitted from per- son to person by mosquitos of the genus Anopheles, biting between sunset and sunrise. For an infected mosquito to become infective re- quires a warm ambient temperature and a period of one to two weeks. The traveller's first line of defence is to protect himself or herself from mosquito bites. (See article on Biting insects.) The abundance of infective mos- quitos varies enormously between the malarious countries of the world, and also within the same malarious country. The worst af- fected areas are rarely visited by tourists; thus within Thailand, the malaria risk is negligible in Bang- kok, high near the Kampuchean border; within Kenya, the risk is negligible in Nairobi , high in the coastal area; within China, the risk is negligible in all areas commonly visited by tourists, high near the Burmese and Vietnamese borders. There are different species of malaria parasites, one malignant (Plasmodium falciparum), the oth- ers (mainly Plasmodium vivax) rel- atively benign. In certain malarious areas , the infected mosquitos in- oculate the benign parasites either exclusively (e.g. the malarious areas of Peru, Paraguay, Afghani- Epidemiological assessment of the status of malaria, 1985 8 Indicating areas that are free from malaria, those where there is a slight risk, and those where the disease poses a threat to unprotected travellers Q Areas in which malaria has disappeared, @) Areas with limited risk @) Areas where malaria transmission occurs I I ©World Health Organi zation 1987 WoRLD HEALTH, December 1987 stan and Turkey) or predominantly (e.g. most of the malarious areas of China, India and Pakistan). In Africa south of the Sahara , how- ever, the malignant parasites predominate . The malignant parasites incubate for nine to 30 days in the liver before emerging in the blood and causing disease ; the benign para- sites may incubate longer. There- fore a disease starting less than nine days after first exposure is most probably not malaria; a disease starting more than 30 days after last exposure is most probably not ma- lignant malaria , but may be benign malaria. It follows too that , if a short-term traveller is infected with malaria , the disease will often man- ifest itself only after return to the home country (where the doctor may fail to think about it , and the laboratory may lack expertise !) All of the drugs recommended for prophylaxis act on the parasites after their emergence from the liver ; hence the need to continue prophylaxis for 30 days after the last exposure. In addition , one of those drugs (proguanil) also acts on the malignant species of malaria parasites in the liver. W ORLD HEALTH, December 1987 Plasmodium falciparum is be- coming increasingly resistant to an increasing number of drugs in an in- creasing number of countries , so recommendations about drug regi- mens, either prophylactic or thera- peutic, require regular updating. Even if the most up-to-date recom- mendations are obtained and fol- lowed, no prophylactic regimen is 100 per cent protective ; hence the diagnosis of malaria should not be dismissed because the patient was on drug prophylaxis. Equally, even Cysts of a malarial parasite developing on the wall of a mosquito 's stomach. Scanning electro-micrograph by M.D. Smith if a prophylactic regimen fails to protect against the occurrence of infection and disease, it may never- theless succeed in rendering the disease milder and less threaten- ing to life. The typical manifestations of ma- laria are bouts of high fever lasting a few hours , starting dramatically with shaking chills , subsiding dra- matically with profuse sweating, and reappearing at regular inter- vals , most commonly every 48 hours . But symptoms are often atypical in the first few days and are less typical in malignant than in be- nign malaria ; so malaria should be thought of in all otherwise unex- plained cases of fever in travellers who may have been exposed. Malignant malaria kills many people even though it is relatively easy to diagnose and cure. The most important survival factors are early diagnosis and treatment. A traveller who may have been ex- posed and who develops a fever at 9 Spraying against mosquito swarms in southern France. Photo WHO/P. Almasy the appropriate time should be aware that it might be malaria and should seek prompt medical atten- tion. It is vital to remind the doctor that it might be malaria, of which most doctors in non-malarious countries have little experience. In certain situations, prompt medical attention may not be avail- able. So the traveller may be ad- vised to carry certain specified anti- malarial drugs for emergency self- treatment, and should still seek medical attention at the earliest opportunity. No drug is totally devoid of un- pleasant side-effects in all people , and some drugs cause serious, even life-threatening, adverse reactions in a few people. Certain drugs may be contra- indicated for certain groups of 10 Three things travellers can do about malaria 1. Inquire beforehand about the ma- laria risk and appropriate measures for the specific areas they consider visiting. Sources of information: their physician; specialised national and international institutions; WHO's "Vaccination Certificate Require- ments and Health Advice for Interna- tional Travel" published every Near in English, French, Spanish, German. Some countries, such as Thailand, offer the arriving traveller pertinent printed information, to which it is wise to pay careful attention. 2. Protect themselves as much as possible against mosquito-bites. 3. Be aware that they may have been exposed to malaria, that no chemoprophylactic regimen gives total protection to everybody, that malaria may occur several months, even (exceptionally) years, after ex- posure, and that the symptoms of . mqlaria may not be easy to reco- gnise; seek medical attention in case of fever and remember to men- tion to the physician the possibility of exposure to malaria. Malaria and you individuals. Sulfadoxine-pyrimetha- mine and sulfalene-pyrimethamine should not be given to persons with a history of allergy to any sulfona- mide. Infants and pregnant women should not be given these drugs , nor mefioquine , without medical super- vision; but they can, at the recom- mended doses, safely be given chlo- roquine, proguanil and quinine. Research on the development of new antimalarial drugs and of ma- laria vaccines is actively being pur- sued by many scientists, and some of the expected products will be useful for the protection of travel- lers . Another kind of research that is useful for improving and updat- ing the advice given to travellers consists of surveys addressed to the travellers themselves, inquiring about their travel, health and protective measures used. By cooperating with such surveys, today's travellers can help tomor- row's travellers-which may include themselves ! • W oRLD HEALTH, December 1987 Beasts that bite by John Debbie and Takao Fujikura Careful travellers are advised to enquire about the risks that prevail in the area of the world they intend visiting, and about the availability of anti-ven- oms for insect- and snake-bite , and of rabies vaccines. Rabies-infected animals may be encountered in most countries but the following are reported to be rabies-free : Australia , Bermuda, many of the Caribbean islands (but not Cuba, Grenada , Haiti , Puerto Rico, or Trinidad), Finland, Gibraltar, Iceland, Ireland, Japan , Malta , New Zealand , Norway (except the island of Svalbard) , the Pacific islands, Papua New Guinea , Portugal, Spain, Sweden , and the United Kingdom. Rabies is the first thing to think of when an animal bites , but teta- nus and other bacterial wound in- fections from animal bites or scratches also require medical at- tention. All travellers should know about the threat from animal bites and should take precautions to en- sure they have up-to-date tetanus immunization. Those who are trav- elling extensively in the tropical areas of the world where dog rabies is still prevalent might consider pre- exposure rabies immunization with licensed tissue culture or suckling mouse brain rabies vaccines. If they want to keep up their rabies vaccine protection, booster doses should be administered at intervals of one to three years. The best protection against ani- mal bites is to be aware of the risk, particularly of rabies transmission , and to avoid being bitten. Most ani- mals are wary of humans and will keep their distance unless encour- aged to approach . The best advice that can be given is to leave animals alone. Do not try to catch, feed or pet strange or wild animals , whether dogs , cats , bats , monkeys or wildlife carnivores. A visit to friends in their home does not nec- essarily mean that pets or farm ani- W oRLD HEALTH, December 1987 mals are friendly towards a visitor. If animals are sick with rabies , or a multitude of other diseases , they often act strangely, and this should be a clue that something is wrong. Thus a wild animal that is generally elusive or nocturnal will appear in broad daylight and appear timid and easily approached. Docile dogs which become rabid may show ag- gressive behaviour but the opposite can also occur: a highly-strung, nasty animal can become friendly and loving. The cardinal rule is-do not inter- fere with animals. If they are eating or fighting , resting or working, leave them alone. It is rare to be attacked by an unprovoked animal, but it is inevitable that a provoked animal will sooner or later respond in a defensive or aggressive way. A rabies vaccination certificate should be filled out for all individ- uals who receive rabies vaccine, either post- or pre-exposure . The certificate should indicate the type of vaccine used , the date, the man- ufacturer, lot number, schedule used , antibody titre if determined, and allergic status of the individual. This certificate should be carried with the traveller at all times. If an animal does bite you , the wound-no matter how superficial -should be thoroughly cleaned with soap and water immediately, and either alcohol, tincture or aqueous solution of iodine or quaternary ammonium compounds should be applied. Bandage the bit- ten area and do not put sticking plaster on the wound. Medical as- sistance should then be sought. Try to identify the animal and its own- er, if possible, so that official fol- low-up is made easier. If the animal is owned , the owner should be told to restrain the animal and keep it restrained until official action is taken. Should post-exposure rabies treatment be warranted, there are many different vaccines in use for protecting humans. It might be advisable to check with the local authorities about the availability of rabies vaccines and types before travelling. Antirabies serum and its globulin fractions are of proven ef- fectiveness as an adjunct to vaccine treatment. Some 2500 different kinds of snakes are known to exist in the world , but fewer than 200 snakes are dangerous to man. Poisonous snakes are not generally found in very cold climates, although a very robust viper is known to exist in Scandinavia and within the Arctic Circle , extending into Siberia. In North America , poisonous snakes are not known north of the south- ern borders of Canada. By con- trast , poisonous snakes are abun- dant throughout the continent of Africa and are also found in most parts of Asia and South America , with the exception of the high mountain tops. Sea snakes occur near the coasts of Southern Asia and Northern Australia. Snake-bite, in some regions of the world, is a common cause of se- rious disability and death . Epidemi- ological information obtained from 23 provinces of one Asian country showed a mortality rate from snake-bite of four to five per cent. 11 Beasts that bite Travellers would be well advised to seek information from a travel agent , a doctor or the health auth- ority on the species of poisonous snakes existing in the area to be visited , and the extent of the risk. In snake-infested areas , go equipped with boots , since snakes tend to bite the lower extremities such as toes, feet , lower part of the 12 . . . Docile dogs which become rabid may show aggressive behaviour . .. Photo WHO/P. Almasy legs , and thighs , and also take a first-aid kit. If possible , avoid trav- elling in remote areas alone ; in par- ticular, avo.id walking at night when snakes are still active and where lack of visibility increases the risk of disturbing them. Do not enter bush and grassland without taking precautions (such as carrying a stick) and, if walking at night, use a torch. Examine shoes and clothing with caution, before dressing, par- ticularly in the morning , as snakes can shelter in them. Don't put your hands into holes and crevices or un- der rocks , and try to avoid defecat- ing in the bush or grassland. If trav- elling in fairly remote areas , obtain in advance the address of a health centre or hospital in the area to be visited . If your are bitten , clean the wound with soap and water and ap- ply iodine ; find transport to get you to a health centre or hospital as soon as possible , where anti-snake venom can be given. Apply a tight bandage around the limb, above and below the bite marks. An expe- rienced travelling companion will know how to suck out the liquid which is coming from the wound, for five to ten minutes , immediately spitting out the liquid; or use an as- pirator, if available. Keep the limb still and , if possible , in a splint. Make a note of the time of the bite. If the snake has been killed, put it in a container and take it to the hospital or health centre for identification. Anti-snake venoms are produced against the effect of most poisonous snakes in about 30 countries , al- though these may not be available in all areas . If bitten by a snake, try to stay calm. Not all snakes are poi- sonous and snake-bite can be treat- ed . Fear, excitement and drinking alcohol can only increase the spread of poison to the rest of the body. As for scorpions , about 30 spe- cies exist, mainly in tropical and sub-tropical zones, and only a few are poisonous. They live under logs , stones and in buildings. Inside houses , scorpions may hide in shoes and clothing. So it is advisable to check boots, sleeping bags , bedding and clothes before using them. In the South-western United States and in Mexico , most fatal cases of scorpion sting occur in children. Potentially lethal species also live in Brazil , Egypt and other countries. Similar first-aid measures to those for snake-bite can be applied to scorpion bites. Anti-scorpion venom is produced in a number of W oRLD HEALTH , December 1987 Beasts that bite countries for some of the more dan- gerous species (such as Algeria, Iran, Mexico, South Africa, United Kingdom, USA), and may be life- saving if administered within a few hours of the sting occurring. All spiders have venom glands, but only a few species of two gen- era are dangerous to man ; these ~ are commonly called the "Black § Widow" spider and the "Brown ~ Recluse" spider. These are wide- § spread in distribution and may be ~ numerous both locally and § seasonally. ti: These spiders usually bite people only in self-defence or when guard- ing their egg sacks. Commonly, the spider bites occur when a person dons clothing in which the spider has hidden. The bites are not im- mediately painful but progress through localised swelling to the development of a depressed ulcer. Rabies researchers can track the fox's movements when it has been fitted with a tiny radio transmitter. Photo WHO Systemic reactions, affecting the body as a whole, do occur and are especially dangerous in children. Travellers who are bitten by a spi- der should consult the closest dis- pensary or hospital for treatment and advice. Anti-spider venom is produced in Australia, South Afri- ca, and the USA, as well as a num- ber of other countries. • WoRLD HEALTH, December 1987 Snakes that cause serious~disability or death Area North America Mexico, Central America, and South America North and middle Africa Southern Africa Eastern Mediterranean South-East Asia Western Pacific Australia, Pacifjc Islands Europe Name of snake Eastern diamond-back rattlesnake/ Agkistrodon piscivorus!Crotalus viridis Western diamond-back rattlesnake Barba amarilla Central American rattlesn~ke Mexican rattlesnake Western diamond-back rattlesnake Jararaca/Wied' s lance- head/painted jararaca South American rattlesnake/cascabel Puff adder/Spitting cobra/ Naja mossambica Saw-scaled viper . Puff adder/Spitting cobra Indian cobra Levantine viper Palestine viper Puff adder Saw-scaled viper Indian cobra Malayan pit viper Russell's viper Saw-scaled viper Beaked sea snake Chinese habu Indian cobra Habu Eastern brown snake/Death adder/Tiger snake · European viper (adder) Some countries which produce anti-venoms USA USA, Mexico Brazil, Colombia, Ecuador, Mexico, Peru, USA, Venezuela Costa Rica Mexico Mexico, USA Argentina, Brazil Argentina, Brazil, Colombia, Mexico, USA, Venezuela South Africa South Africa {France, India, Iran, USSR) South Africa India, Thailand (France, USSR) Iran Israel (South Africa) India, Iran India, Thailand (France, USSR) Thailand India, Thailand India, Iran (France, USSR) China Thailand, ln'dia (France, USSR) Czechoslovakia, France, Federal Republic of Germany, Italy AIDS and the traveller by Jonathan Mann I f you are planning a trip , or al-ready on your way, here are some basic facts about AIDS . AIDS, the acquired immuno-de- ficiency syndrome, is a viral disease which breaks down the body's im- mune system leading to fatal infec- tions and cancers. AIDS knows no geographic, social, racial or cultural boundaries. First described in 1981, AIDS is now recognised through- out the world, with more than 120 countries officially reporting cases to WHO. Should the traveller be alarmed about AIDS? Whether at home or travelling, avoiding AIDS is mainly up to you. If constitutes a global health prob- lem. No matter where you live or travel , you need to know about AIDS. However, you can easily protect yourself against this disease during your travels by knowing and following some simple rules. Fear of AIDS should not prevent travel to any part of the world. How is AIDS spread? The virus responsible (human immuno-deficiency virus, or HIV) spreads most frequently through sexual activity. The virus can be transmitted from any infected per- son to his or her sexual partner (from man to woman, from woman to man, and from man to man). But it is also spread by contaminated blood-in transfusions, on needles , or on any skin-piercing instru- ments. In addition, an AIDS- infected mother can transmit the virus to her child before , during or shortly after birth. Is AIDS spread by casual contact? No. AIDS is not spread by daily and routine activities ("casual con- tact") such as sitting next to some- one or riding in the same vehicle or working with people. Nor is it spread by insects or insect bites . 14 And AIDS is not spread by hand- shakes, swimming pools , public transport , food , cups, glasses, plates, water, air, touching or hug- ging, coughing, sneezing or using toilets. How can sexual spread of AIDS be prevented? First, those people who are not in danger from the sexual spread of AIDS are : " My message to the business- men of this country w hen they go abroad on business is that there is one thing above all they can take w ith them to stop them catching AIDS, and that is - their wife." Mrs Edwina Currie, Junior Minister of Health, United Kingdom - People who are not infected and who only have sexual inter- courses with a faithful uninfected partner, and-of course-people who abstain from sex. For others, the best advice is : - Do not have sex with prostitutes or casual acquaintances, even in countries that claim there is no AIDS problem. You cannot tell by appearances if someone is infected . However, if you do have sex with a partner who might be infected (or you are not sure) : - Remember, any vaginal, anal or oral sex can spread AIDS. - Always use a condom, each time, from start to finish. - Limit the number of sexual part- ners to lower the risk of exposure to the AIDS virus. What about AIDS and blood transfusions? When travelling away from home , you can reduce the risk of serious injury, which may require blood transfusions, by taking ordi- nary, everyday precautions. Wear a seat belt and drive carefully. Don 't mix alcohol or drugs with driving , boating or other sporting activities that could lead to injury. If you are injured or ill , avoid or postpone any blood transfusion , unless it is absolutely required. In many places , before blood is used for a transfusion, it is tested for AIDS virus contamination. If you need blood, try to ensure that screened blood is used. Since more and more countries around the world are now testing blood for the AIDS virus, blood transfusions will increasingly be protected from AIDS virus contamination. What about injections? Avoid injections for treatment , unless they are absolutely neces- sary. (Pills often do just as well and hurt less!) If you must have an in- jection , make sure the needle and syringe come straight from a sterile package or have been sterilised properly (by steam, boiling water or chemicals). For example, a needle and syringe which have been cleaned and then boiled for 20 minutes will be safe for re-use. Don't take your own needles with you unless you have a pre- scription or a doctor's authoris- ation. Customs officials in some WoRLD HEALTH, December 1987 ... Don't take risks during your travel that could send AIDS home with you . .. Photo WHO/Zafar countries are very alert for sus- pected drug addicts. Finally if you inject drugs-no matter what kind-never use any- one else's equipment. What about skin-piercing instruments? Instruments that pierce the skin (like tattoo and acupuncture need- les , earpiercing equipment and dentists' instruments) must always be sterile (used only once or steri- lised between each use). As with needles and syringes, proper steri- lising of these instruments elimi- nates risk. In general, you should avoid any procedures which pierce the skin unless they are absolutely necessary. W oRLD HEALTH, December 1987 AIDS: knowledge is the key to prevention You can protect yourself against AIDS- and therefore prevent AIDS-everywhere in the world , at home or travelling. Don't take risks during your travel that could send AIDS home with you. If this advice sounds strict, remember this: since there is no cure and no vaccine so far for AIDS, prevention is vital. For more information about AIDS, please consult your local doctor or health care provider, or your local, state, regional, provin- cial or national health authority, ministry or department . WHO works only through the governments of its 166 Member States and is not able to answer individuals' queries. But as the specialised agency of the United Nations responsible for di- recting and coordinating interna- tional health work , WHO is leading the global fight against AIDS. • To screen or not to screen The question frequently arises whether or not to screen various categories of persons for evidence of infection with the HIV virus which causes AIDS. Proposals have been discussed in severa l countries regarding the screening of international travellers, foreign workers, students, and segments of, or even entire, populations. Last March WHO's Special Pro- gramme on AIDS convened an expert group of epidemiologists and disease control experts to discuss several diverse aspects of international travel and HIV. The consultation concluded that H IV screening of international travellers: - would be extraordinarily difficult to implement; - would not be able under any cir- cumstances to prevent the in- troduction and spread of HIV infections ; - would divert resources away from educational programmes on AIDS and measures to pro- tect the blood supply from HIV contamination; - at best, and at great cost, would retard only briefly the spread of HIV globally or w ith respect to any particu lar country. Rather than screening, the con- sultation recommended education programmes directed to both na- tional and international travellers. wHo shares the concern that, while screening for HIV may ap- pear a relatively simple approach to some of the complex problems associated with AIDS, in fact screening for HIV is extraordinarily complex from an epidemiological, economic, legal, logistic, political and eth ical perspective. On the one hand, screening for HIV infec- tion among blood donors is a well- accepted and effective, albeit complex, public health measure. In contrast, HIV screening of inter- national travellers would be, a cost- ly, inefficient public health mea- sure with minimal or no beneficial effect. wHo does not take a general posi- tion for or against HIV screening as a public health policy, but believes that the entire range of complex issues inherent in any HIV scree- ning programme must be con- sidered and resolved before such a programme is implemented. Otherwise, HIV screening pro- grammes may contribute extreme- ly little to, or may actually reduce, the effectiveness of the overall public health programme for AIDS prevention and control. • 15 Whether you travel on business, in search of a job, on pilgrimage or on holiday, it makes sense to take basic precautions before, during and after your journey to avoid the mcon- venience, stress and cost of ill-health. • W HO/UNICEF 16 Scurvy Seafarers on long ocean voyages and polar explorers used to suffer from a disease which made their limbs swell while "their teeth were loose and decayed and their gums rotting and foul," as a 16th century traveller wrote . This disease, scurvy, was simply due to a lack of vitamin C. The mariners eventually learnt that a diet of dried beef and weevil-infested ship's biscuits must be supplemented by plenty of orange, lime or lemon juice. Today's travellers too should drink plenty of fresh fruit juice . • W oRLD HEALTH , December 1987 WHO's medical pack WHO staff members who travel on duty are each given a medical pack. Its contents are regularly revised, but have to meet the following criteria: - items of first aid - drugs with no contra-indica- tions or side-effects - drugs that can be used in self- medication without danger - products that pose no serious problems of long ·conservation - items that are not too bulky; the kit should fit in the traveller' s hand-luggage, so bandaging and dressings are kept to a minimum. The wHo medical pack in- cludes: - Tetracycline hydrochloride: 30 tablets of 250 mg. An antibiotic active against many pathogenic bacteria responsible for digestive, respiratory and urinary infections with fever. - Rehydration salts: 4 packets. In case of serious diarrhoea. - Flumetason pivalate and clio- quinol, 15 gm tube. This cream in- cludes an antibacterial and anti- fungal drug as well as a cortisone derivative with anti-inflammatory action. Useful for minor skin in- fections, insect bites and fungal eczemas. - Chloroquine for the prevention and treatment of malaria. - Undecylenate powder and anti- mycotic cream . To prevent cuta- neous mycoses, athletes' foot and so on. - Insect repellent and insecticide powder. . - Three syringes and needles, · one-use-only. These permit the traveller to have an injection or blood test without any . risk of contam.ination or infection with diseases such as AIDS. A note explaining the presence of the syringes is included in case any · airport official suspects drug abuse. • Tourists-take care! Swimming is excellent exercise -provided you don't take risks or swim in polluted waters. Sunbathing too is fashionable today - but skin cancer has a clear relationship w ith long-term ex- posure to ultra-violet light and with acute episodes of sunburn. As for ca- sual sexual encounters, the advent of A IDS is affecting attitudes worldw ide ; the w ise traveller thinks "no sex" or only "safe sex". • WHO/Zafar Sale water by Hemda Garelick T he average person consumes between two and five litres of water a day through food and drink , but of course the amount varies greatly in different communi- ties and depends mainly on its availability. A minimum of a fur- ther 20 to 50 litres per person will be needed for general hygiene pur- poses, such as personal and domes- tic washing. Both the quality and quantity of the water used have a pronounced effect on the health of the user. Water sources and supplies be- come contaminated almost invari- ably as a result of human activities . Most often these involve letting domestic, industrial and farm waste-sewage, chemicals, ferti- lisers and pesticides-enter the water. Chemical contamination , unless it is very high , will affect the travel- ler less than biological contami- nation. It often has a cumulative effect on people and the resultant damage is relative to the length of exposure time. Biological contami- nation from pathogenic micro- organisms, on the other hand , can have a more marked effect on trav- ellers than on local people, who may have acquired partial or full immunity to endemic infections. Safe water for the traveller in this context is therefore water clear of biological contamination . Most wa- ter-related infections can be trans- mitted either by consuming water or food contaminated with enteric bacteria or viruses , or through direct contact with contaminated water, as in the case of schistoso- miasis or guinea-worm . Without a doubt, the most important source of infection in water related dis- eases is human faeces . Tap water is usually safe , but centralised supplies of piped water can leave the purification plant clean but may get contaminated due to faults in the distribution sys- tem . Intermittent piped water sup- 18 plies (water supplies which are not continuous) are particularly vulner- able. Water scooped or drawn from unprotected wells , lakes or streams should be regarded as suspect. So travellers to areas where wa- ter supplies are of uncertain quality are advised to take certain precau- tions. On short visits it is best to avoid drinking water and keep to hot drinks or freshly opened bot- tled or canned drinks (preferably carbonated) of well-known brand names. It is also advisable to avoid eating salads and instead to eat well-cooked foods or fruits which can be peeled , such as bananas or oranges. Ice is only as safe as the water it is made from. Drinks should be cooled by placing the ice outside the container and not in the drink . Ice cream should be avoided. Long stay visitors or people who visit very primitive areas may have to consider purifying water for their use , and it should be collected from the safest source available. Tap water, well water and rainwater are preferable to any surface sources such as rivers or lakes. The treat- ment of small quantities of water is based on the same principles used in municipal water treatment plants , and includes clarification and filtration followed by disinfec- tion or sterilisation. It is best to filter very turbid wa- ter before any further treatment. This will improve the look and taste of the water, and will remove some pathogens which are attached to the suspended matter. It will also improve the efficacy of further treatment such as chemical disin- fection. Filtration through a closely woven cloth is adequate , but in many countries commercial filtra- tion bags are available. Remember that , although the water may now look clear, it has not been made safe by this treatment and will require sterilisation either by boiling, chemical disinfection or fine filtration. The most effective way of ren- dering water safe is by boiling, and this method should be used when- ever possible. Water which has been boiled vigorously for ten min- utes is safe for drinking. The flat taste of boiled water is caused by the removal of dissolved gases. Cooling the water for a few hours in a half full , covered container (preferably the container in which it was boiled) will help to improve the taste. Where boiling is impractical , , chemical disinfection may be used to sterilise the water. The most widely used chemical disinfectant is chlorine; it has very considerable oxidising powers which cause the inactivation of living organisms. But chlorine added to the water will react with all forms of organic mat- ter and this can interfere with its capacity to inactivate pathogens. Pathogens adsorbed to suspended matter will also have a degree of protection. This is why it is impor- tant to clarify the water before disinfection. Iodine, which works in a similar way to chlorine is a more effective disinfectant , especially against amoebic cysts . Both chlorine-based and iodine-based disinfection W oRLD HEALTH, December 1987 tablets are available commercially. When these are used, it is essential to follow the manufacturers' instructions. Liquid chlorine laundry bleach and first aid tincture of iodine will also work, but care should be taken to find out the exact constituents and concentration of the solutions involved. Laundry bleach usually contains four to six per cent of available chlorine, and one to two drops of the solution should be add- ed to one litre of water. If the chlo- rine concentration is not known, a slight taste of chlorine in the water would indicate there is sufficient chlorine for disinfection. Tincture of iodine usually contains two per cent iodine, and four drops of the solution should be added to one litre of water. The water should be allowed to stand for 20 to 30 min- utes or a few hours if it is very cold before use. Iodine used in this way is unlikely to be harmful, though regular long- term use should be avoided. People who suffer from thyroid disorders should consult their doctor before adding iodine to their water. Sterilising filters remove micro- organisms from the water by a pro- cess of straining. Ceramic filter "candles" are available commer- cially. They have a very fine pore size-the finer the better-and will remove most pathogens found in water (bacteria, amoebic cysts and some viruses). The wide range of filters available extend from tap- connected, pump-driven filters to simple, portable ones. Some are impregnated with silver which has a bacteriocidal effect. Again, always follow the manufacturers' instruc- tions about the operation and main- tenance of these filters . They should be examined regularly for cracks and leaks, and scrubbed and boiled when clogged and at weekly intervals. Filters that use disposable paper should be kept moist, other- wise the paper filter may shrink or crack. Carbon filters are not recom- mended for the production of safe water. They are designed to re- move taste and odour. They re- move organic matter, dissolved chlorine and pathogens by a mech- anism of adsorption and not by straining. But when overloaded they can shed adsorbed material ! The efficiency of the filter over a W oRLD HEALTH, December 1987 . .. Travellers to areas where water sup- plies are of uncertain quality are advised to take certain precautions . .. Photo WHO/P. Almasy period of time will depend on the organic load of the water, and it is always tempting to keep the filter going as long as possible. It will be very difficult for the traveller to determine when the filter is exhausted. Some ceramic filter "candles" in- clude a secondary filter of activated carbon in order to improve the taste of the water. It is important to ensure that the purification process relied upon is filtration through the ceramic and not through the car- bon. Only in cases of high chemical contamination will it be advanta- geous to health to add activated carbon to the filter. Many carbon filter manufacturers make exagger- ated claims about the effectiveness of their product ; these should be treated with caution. It is all too easy to recontaminate treated water by handling it without due care. Treated water is best stored in the same containers in which it was treated. If this is im- practical , make sure that the stor- age container is clean and either sterile or disinfected. It should always be covered and preferably should have a tap at the base as the water outlet. An alternative is a narrow neck container which allows for water to be dispensed by tipping and pouring. Dipping is not recom- mended as it might introduce con- tamination. Treated water contain- ers should be kept as far as possible from sanitary facilities, away from children and preferably in a cool place. Some fresh vegetables and fruits are easily contaminated and are an- other source of possible infection. They should be washed in clean soapy water and then rinsed in treated water. This procedure will not inactivate all pathogens ad- sorbed to the fruit or vegetable but will physically remove a large pro- portion of them. Further treatment may be necessary. This can be done either by soaking the fruit or veg- etable in water containing three times the amount of chlorine or iodine that is recommended for drinking water, or else by dipping them into boiling water. Raw veg- etables and other cold or uncooked food prepared by others should be avoided. When this is impractical, as much lemon or vinegar as possi- ble should be added . Swimming in fresh water (lakes , rivers and pools) should be avoided in countries where schistosomiasis (bilharziasis) or guinea-worm are prevalent, or in the vicinity of sew- age disposal sites. Swimming in the sea is usually safe unless waste dis- posal sites are close by. Remember though that swimming in the sea may incur other hazards that are unrelated to water quality. Bon voyage ! • 19 The art ol defensive eating "B e careful what you eat" is a piece of advice that most travellers are familiar with but few truly understand. Detailed advice about the general principles of food hygiene is of crucial importance . Diarrhoea may cause anything from embarrassment and inconve- nience to misery that may wreak havoc upon travel and business plans ; other diseases spread by poor hygiene include dysentery, giardiasis , hepatitis A , typhoid , polio and parasitic infestations. For- tunately, the precautions against all of these conditions are very similar. In hot countries, and countries where hygiene standards are poor, the average prevailing standard of hygiene is what matters most. Trav- ellers are potentially at risk from the hygiene standards of others, at every meal. Local flies do not sud- denly become safe within the con- fines of an expensive hotel. Careful choice and preparation of food offer the best protection ; unfortunately, contaminated food can seem most appetlsmg, but ap- pearance is no guide to food safety. The urge to eat what's available and what has been paid for when one is hungry can be irresistible. Eating safely when travelling means that one won't always be able to eat when , where , and what one wants. Food that has been freshly and thoroughly cooked is generally safe. 20 Under conditions of poor hy- giene, high risk foods include: - Raw or inadequately cooked shellfish or seafood (seafood needs at least eight minutes' vig- orous boiling to be made safe) ; - raw salads and fruit that have not been thoroughly washed in clean High-risk foods include raw or inadequately cooked shellfish or seafood. Below : Where there is no alterna- tive to unsafe food- cpnsider missing a meal! Photos W HO/P. Almasy water, or that one cannot peel oneself; - food that has required intricate preparation with inuch handling ; - food that has been stored and inadequately reheated after cooking; - food left out in warm tempera- tures- hotel buffet lunches , for example; bacteria multiply fast under such conditions ; - food on which flies may have settled. When there is no alternative to unsafe food , smaller quantities may be safer; gastric acid has a protec- tive effect. Consider missing a meal-many travellers can afford to lose a little weight, and it is better to do so from choice rather than through illness. Under conditions of poor hy- giene, foods most likely to be safe include: - food that must have been freshly cooked-for example , a fried egg, or an omelette ; - freshly boiled food, such as rice or sweetcorn ; - fresh fruit or vegetables that are easily peeled or cut open-such as bananas , citrus fruits, melon and papaya; - food from sealed packs or cans ; - food that one has prepared , or watched cooking, oneself. When travelling in areas with low standards of environmental sani- tation, hands should be washed at every opportunity. Food should only be handled with hands that are scrupulously clean. Plates and ·cutlery need to be washed with detergent, rinsed with hot water, and protected from flies. The risk from contaminated plates can be reduced by rinsing with hot weak tea or boiling water or an al- cohol-soaked cotton swab. Alterna- tively , paper plates and one's own cutlery should be used. Cups and glasses should be swilled out with hot tea or boiling water before use. Flies often settle on rims-the rim of a teacup can be rinsed by pouring away a little tea. Bottled drinks should be taken di- rect from the bottle. Alternatively, one's own cup or water bottle should be used. Hospitality poses a difficult di- lemma ; no traveller likes to give of- fence to a host who has taken great trouble to prepare a meal. Person- ally , I believe that one should never relax one's own standard of food hygiene when travelling , under any circumstances . Richard Dawood W oRLD HEALTH , December 1987 Immunization is not enough Vaccines are amongst the greatest gifts to mankind from medical science. Not only can protection of the individ- ual be achieved, but control of some diseases and eradication of others become possible . Today the traveller can benefit from a large number of vaccines. However, not all are necessary , and their efficacy and side-effects vary considerably. There is a danger that , because they have received a vaccine against one particular disease , trav- ellers may assume they are immune to all similar infections. In reality , immunization must go hand in hand with safe health behaviour if dis- eases are to be avoided during tra- vel-which puts much of the onus for health on the traveller himself. Take the cholera vaccine , for ex- ample. We are now in the seventh pandemic which began in 1961 and has so far affected 92 countries. In bygone times , cholera shadowed Islamic pilgrims from the Far East on their way west to Mecca. Ships returning to Europe from Arabia were kept anchored off shore for 40 days in "quarantine " (the Ital- ian word for 40 is " quaranta ") ; the principle was that anyone harbour- ing the cholera organism would be either dead or better in that time. The advent of the vaccine using the killed organism raised hopes that cholera would be ousted as a cause of fatal diarrhoea. However, cholera basically at- tacks the lining of the gut so any effective vaccine must provide pro- tection at the mucosal level (the layer of lining cells) within the gut itself. This poses problems , since vaccines are usually given by injec- tion, a route which does not pro- duce immunity at the mucosal lev- el. Such a vaccine has had only modest effect in volunteer studies and limited effect in field trials. Ad- ditionally it was apparent that the vaccine was not preventing trans- mission of the disease or asymp- W oRLD HEALTH. December 1987 by John Clements tomatic infection. This is why the need for a valid cholera vaccination certificate was withdrawn as a re- quirement for international travel. One preliminary study of an oral cholera vaccine using non-living subunits of the organism gave around 70 per cent protection against infection. On the other hand, it looks as if an injectable vaccine containing a live form of the organism which has been atten- uated may provide nearly 90 per cent protection- but with an unac- ceptably high rate of adverse reac- tions such as diarrhoea . But some individuals may consider that , de- spite the limited protection provid- ed by the vaccine and the very low risk of travellers actually contract- ing the disease , it may be worth being immunized if a long time is to be spent in a genuine cholera endemic area. Vaccines against typhoid fever have been administered for many years and have a much better track record, producing between 65 and 70 per cent protection. But they need to be given by injection and are of limited acceptability because of a high incidence of reaction which may prostrate the recipient. Again , research has come up with some promising new vaccines which are given orally. In contrast to cholera , there is little doubt that typhoid vaccine is effective and that the risk of infection for travel- lers is not trivial. Travellers who are given one or both of the cholera and typhoid vaccines may develop immunity and be protected from developing the diseases . But they are far from safe from the scores of other food- and water-borne diseases contract- ed in the same way as cholera and typhoid . The only way a traveller can protect himself (or herself) against all of them is by paying fas- tidious attention to what he drinks and eats. Only chlorinated water sources afford significant protection against viral and bacterial water- borne diseases. Even chlorine , at the levels used in routine disinfec- tion of water, does not kill the cysts of Giardia Iamblia and Entamoeba histolytica, the organisms respon- sible for giardiasis and amoebiasis respectively . In areas where chlori- nated water is not available and where hygiene and sanitation are poor, only the following may be safe to drink : - Hot beverages, such as tea and coffee , made with boiled water. - Canned or bottled carbonated beverages , including carbonated bottled water and soft drinks. - Beer and wine. Where water is contaminated, ice must also be considered suspect , and may in turn contaminate con- tainers used for drinking unless the containers have been thoroughly cleaned with soap and hot water af- ter the ice has been discarded . Ice cream may also be a source of in- fection . It is safer to drink directly from a can or bottle of a beverage than from a questionable container. Water on the outside of cans or bot- tles of beverages , as well as ice , may be contaminated. So wet cans or bottles should be dried before being opened , and surfaces which come in direct contact with the 21 Immunization is not enough mouth when drinking should first be wiped clean. If no other source of safe drinking water is available, tap water that is uncomfortably hot to the touch is usually safe and, af- ter being allowed to cool at room temperature in a clean container, can be used for brushing teeth as well as for drinking. But boiled water is obviously preferable. Food should be selected with care to avoid illness. In areas of the world where hygiene and sanitation 22 are poor, it is best to avoid unpas- teurised milk and milk products, such as cheese, and to eat only what can be peeled or has been thoroughly cooked and is still hot. Cooked food served after it has cooled may be loaded with bacteria and should be avoided. It is advisable to avoid uncooked salad vegetables in developing countries, as they are sometimes fertilised with human faeces. This often results in contamination with amoebic cysts, parasite ova or pathogenic bacteria. Uncooked meats and fish should be avoided, as many helminth (parasitic worm) infestations are transmitted in this way. Uncooked or incompletely cooked shellfish may carry typhoid, cholera, polio- virus, hepatitis and Vibrio para- haemolyticus. Diseases spread by insects are dealt with elsewhere in this issue. The most effective form of preven- tion against all insect-born diseases is to take steps not to be bitten by an insect carrying the disease. Children as travellers are a special case. Being up-to-date with immunization according to the re- commended schedule at home is important, but may not be enough, particularly in the first few months of life. Although all the required shots may have been given, full im- munity may only develop after doses not yet administered. If chil- dren are to mix with local children Above: Pilgrims' tents near Mecca in Saudi Arabia. Prevention of diarrhoea! diseases is vital in such circumstances. Left: "A court for King Cholera ": this cartoon from the English weekly Punch in the 1850s acknowledges that insani- tary conditions played a part in spread- ing disease. Photos WHO W oRLD HEALTH, December 1987 during travel (and who can prevent them?) , they are likely to be at greater risk of exposure to the six main childhood diseases normally included in childhood immuniz- ation programmes, in particular po- lio and measles. If children are nine months of age or more at the time of travel and not yet immunized, they should be given measles vac- cine , regardless of the recommend- ed schedule at home. Nine months seems to be the earliest age when most maternal antibodies have dis- appeared from the child's body, and the vaccine is likely to be pro- tective . If possible at least three doses of oral polio vaccine should have been given and at least three doses of diphtheria-pertussis- tetanus (DPT). The BCG vaccine against tuberculosis should be given on a discretionary basis after dis- cussion with a physician. Good protection is now available against two forms of hepatitis . For 40 years gamma globulin has been recommended as protection against hepatitis A. The globulin is collect- ed and pooled from donors known to have had the disease. This form of immunization is known as pas- sive protection because the recipi- ent uses someone else's defence system and generates no antibodies of his own. Protection soon after the injection is of the order of 80 or 90 per cent but falls off rapidly with time . Additional injections are needed in order to maintain immu- nity , and all too many travellers ne- glect to arrange for the appropriate repeat doses. For most travellers , hepatitis B does not pose a major risk as infec- tion generally comes from close physical contact. But those who put themselves at risk from job-related infection or infection from occa- sional sexual encounters (be they homosexual or heterosexual) may obtain protection with either the first generation plasma-derived vac- cines or the newer second genera- tion recombinant DNA vaccine. Both give excellent levels of protec- tion. However, the sexually adven- turous may be lulled into a false sense of security, not realising that no protection has been provided against AIDS and a variety of other sexually transmitted diseases. The condom is the nearest thing to a panacea in such circumstances, but no one is quite sure how good it W oRLD HEALTH , December 1987 really is. However stuffy and out- of-date it sounds, sexual abstinence seems to be catching on. The best news for travellers is the development of vaccines against yellow fever and meningococcal in- fection. Providing the right type of vaccine has been given, protection against meningococcal meningitis is in the order of 90 per cent. How- Vaccination Certificate Requirements and Health Advice for International Travel Vaccines available * Cholera (only recommended when required by an ind ividual country) * Yellow fever **Polio ** Diphtheria ** BCG (against TB) **Measles ** Tetanus ** Pertussis Typhoid Gamma globulin (against hepatit is A) Hepat itis B Influenza Rabies Meningitis Anthrax Plague Japanese Encephalitis * Disease subject to the Internat ional Health Regulations for which vaccination may be required. **The six vaccines recommended in chi ld- hood by WHO for inclusion in the Expanded Programme on Immunization. ever, not too many travellers need this. The "cerebrospinal meningitis (CSM) belt" extends through the semi-arid region south of the Saha- ra, where meningitis is hyperende- mic with periodic epidemic waves at 10- to 15-year intervals. Other re- cent epidemics have centered in Nepal and Delhi. Because the or- ganism is spread easily in confined spaces (historically, army recruits in cramped sleeping accommo- Immunization is not enough dation caught it), visitors sleeping in crowded quarters may be at risk. But the vaccine has to be of the right serogroup. Most epidemics involve types A and C, and good vaccines are available for these . One shot of yellow fever vaccine will provide excellent protection for at least ten years, and severe reac- tions are extremely rare -less than once every million shots. Anyone contemplating a trip to countries near the yellow fever belts of Africa and South America would be fool- ish not to be immunized (unless they are pregnant) , given that the fatality rate in travellers can be as high as 50 per cent. Countries with yellow fever are identified in " Vac- cination certificate requirements and health advice for international travel ," published annually by WHO. If the place to be visited is in the throes of an influenza epidemic, the traveller would be well advised to be immunized. But the influenza virus leads scientists a merry dance and always seems to be one step ahead. The virus continually changes itself as it travels round the globe , and advice even from the most up-to-date source may recom- mend immunization against a strain of virus that has already been superseded by another. Visitors to countries where rabies is endemic should not normally require the vaccine. The best advice is to stay away from dogs. Some feel it necessary to be immunized because they will be at special risk -people such as veterinarians, agri- cultural advisors or laboratory workers. The human diploid cell rabies vaccine is the vaccine of choice because of its efficacy and freedom from complications and ease of administration. However, individuals who receive pre-expo- sure immunization should not as- sume they are immune ; there is a slight risk that they may not have formed sufficient antibodies to the vaccine, so anyone bitten should seek professional advice, whether or not they have had the vaccine. Although there are still problems and pitfalls associated with the use of vaccines for travellers, there is no doubt that the individual can re- ceive a high level of protection against certain diseases. One final point however : immunization will only be effective if it is accompa- nied by safe health behaviour. • 23 Viral hepatitis by Arie J. Zuckerman V iral hepatitis is a major pub-lic health problem through-out the world. At least five different viruses may be the cause : hepatitis A , referred to in the past as infectious hepatitis or epidemic jaundice; epidemic non-A hepati- tis; hepatitis B , known in the past as serum hepatitis; hepatitis D (Delta hepatitis); and non-A, non-B hepatitis , which is caused by several different viruses. The illness in all types of hepati- tis is similar, and results from acute inflammation of the liver. It is fre- quently heralded by symptoms such as fever, chills, headache , fatigue , generalised weakness , and aches and pains. A few days later, there may be loss of appetite , nausea , vomiting, right upper abdominal pain or tenderness followed closely by dark urine , light-coloured fae- ces, and jaundice (yellowing) of the skin or the sclerae (the white of the eyeballs). Many infections , particu- larly in early life , are without symp- toms or without jaundice. In oth- ers, the symptoms and jaundice may be severe and prolonged ; liver failure may occur, and the patient may lapse into a coma. Hepatitis A is common in all parts of the world , but the exact in- cidence is not known and difficult to estimate, because of the high proportion of asymptomatic cases, infections without jaundice, and differing patterns of disease. Sur- veys of antibody to hepatitis A have shown that while the prevalence of hepatitis A in industrialised coun- tries (particularly northern Europe, North America and Australia) is decreasing , the infection is virtually universal in, most other regions, particularly in warm-climate coun- tries. The antibodies persist for many years, often for life , and provide immunity. The virus is spread by the faecal- oral route, usually by person-to- person contact, and infection is par- ticularly common in conditions of poor sanitation and overcrowding. 24 Outbreaks result most frequently from faecal contamination of drink- ing water and food , although water- borne transmission is not a major factor in industrialised countries or where piped water supply has been adequately treated and chlorinated. It is very rarely transmitted by blood transfusion or inoculation. Food-borne outbreaks , which have become more important and frequent in developed countries , result from the shedding of virus in the faeces of infected food handlers during the incubation period of the illness : the source of the outbreak can often be traced to cooking. The consumption of raw or inad- equately cooked shellfish cultivated in sewage-contaminated tidal or coastal water, or of raw vegetables grown in soil fertilised with un- treated human faeces and excreta , is associated with a high risk of infection. Control of the infection is diffi- cult . Since faecal shedding of the vi- rus is at its highest during the incu- bation period , the strict isolation of cases is not necessary. Spread of infection is reduced by simple hygienic measures and the sanitary disposal of excreta. Normal human immunoglobulin , commonly re- ferred to as gamma-globulin , con- taining hepatitis A antibody will prevent or lessen the severity of the illness . Immunoglobulin injections may be required every four to six months for people at risk , for personal and family contacts of patients with hepatitis A , and for those exposed to contaminated food. Immunoglobulin is recom- mended for travellers without hepatitis A antibody who are visit- ing countries where this infection is very common. Vaccines against hepatitis A are under development. Other measures include com- monsense precautions, strict per- sonal hygiene , avoiding eating raw or inadequately cooked shellfish and raw vegetables, and avoiding drinking untreated water or raw milk. Epidemic non-A hepatitis, simi- lar to hepatitis A and usually trans- mitted by water contaminated with sewage, has been noted in India , Burma , Nepal , central-south USSR, parts of the Middle East, North and East Africa and Mexico and in returning travellers from these areas. This new virus has been seen in the electron micro- scope, but specific laboratory tests are not yet available. General pre- cautions against the infection are as outlined for hepatitis A. Immuno- ., globulin prepared from the plasma obtained in industrialised countries · does not contain antibodies to this virus and is ineffective. There is no specific treatment. Hepatitis B, essentially a blood- borne and sexually-transmitted in- fection, occurs throughout the world. The continued survival of the infection is ensured by a large number of individuals who are car- riers of the virus (persistent infec- tion), estimated to number over 285 million worldwide. It can be spread either from carriers or from people with no apparent infection, or during the incubation period, illness or early convalescence. The prevalence of hepatitis B carriers varies from one region of the world to another. In northern Europe, North America and Aus- tralia , the prevalence of carriers is about 0.1 per cent (at least among blood donors) ; in central and east- ern Europe up to 5 per cent; in southern Europe, countries border- ing the Mediterranean and parts of Central and South America WoRLD HEALTH, December 1987 frequency is higher ; and in parts of Africa, Asia and the Pacific area as many as 20 per cent or more of the apparently healthy population may be carriers. Not all carriers are infectious. The incidence of the disease tends to be higher among adults living in urban communities and among those living in poor socio- economic conditions. Certain groups of people are at consider- ably increased risk of contracting it because of the mode of transmis- sion. These include recipients of blood transfusions and infusions of certain blood products ; health care and laboratory personnel; staff in institutions for the mentally-handi- capped; homosexual males; prosti- tutes; and abusers of injectable drugs and narcotics. Transmission of the infection may result from accidental inocu- lation of minute amounts of blood or body fluids contaminated with blood such as may occur during medical, surgical and dental proce- dures , immunization with inad- equately sterilised syringes and needles, intravenous and percuta- neous drug abuse, tattooing, ear piercing and nose piercing, acu- puncture , laboratory accidents and accidental inoculation with razors and similar objects which have been contaminated with blood; and transfusion of unscreened blood and blood products. But hepatitis B is also found in other body fluids contaminated with blood such as saliva, menstrual W oRLD HEALTH , December 1987 Radio-immunological assay for hepatitis B at a Melbourne hospi- tal, Australia. Photo WHOfT. Farkas Below: Hepatitis B virus in serum. Electron-micrograph by WHO/A. Zuckerman and vaginal discharges and seminal fluid , and these have been implicat- ed as vehicles of transmission of the infection. There is much evidence for transmission by intimate contact and by the sexual route . The sexu- ally promiscuous, particularly male homosexuals, are at very high risk of infection with hepatitis B. Results of investigations into the role that biting insects play in the spread of hepatitis B are conflict- ing, but no convincing evidence of multiplication of the virus in insects has been obtained. Mechanical transmission of the infection via an insect's biting parts remains a possibility. The symptoms and manifes- tations of hepatitis B are similar to those of the other types of viral hepatitis. But the picture is compli- cated by the carrier state and by chronic liver disease, which may follow the infection. Chronic liver disease may be severe and may pro- gress to primary liver cancer which, in some parts of the world, is one of the commonest human cancers, particularly in men. Hepatitis B immunoglobulin is available for use after a single acute accidental inoculation injury in the laboratory. It is not required for travellers, but they should use com- monsense precautions for reducing the risk of hepatitis B, with particu- lar attention to the modes of trans- miSSIOn outlined above. They should employ great caution in any intimate or sexual contacts (par- ticularly any male homosexual con- tacts) with possible hepatitis B car- riers. And they should avoid any procedure involving penetration of the skin, for example tattooing, and so forth. Vaccines against hepatitis B are available for people at high risk of infection and for certain groups of expatriates residing in highly en- demic areas for longer than a few months. Delta hepatitis infection always occurs in association with hepatitis B (the carrier state). The mode of transmission of this infection, its prevention and control are identical to those for hepatitis B. Immuniz- ation against hepatitis also protects against delta infection. Non-A, non-B hepatitis: im- proved laboratory diagnosis of hepatitis A and hepatitis B led to the identification of a previously unrecognised form. It is now the most common form of hepatitis oc- curring after blood transfusion and the administration of blood-clotting factors in areas of the world where blood is screened for hepatitis B. It has been found in every country in which it has been sought, has some features in common with hepatitis B , and has also been detected in patients on dialysis and among drug addicts. In several countries, a sig- nificant number of cases are not as- sociated with transfusion , and such sporadic cases account for up to 15 to 20 per cent of all adult patients with clinical viral hepatitis. In general, the illness is mild, often without jaundice or other symptoms. There are no known methods of preventing non-A, non-B hepatitis, beyond the precautions applicable to hepatitis B. • 25 Childline by John Madeley W hen a television pro-gramme called " Child-watch" was shown in the United Kingdom in October 1986, a problem was uncovered that was far worse than anyone had expect- ed. The programme asked children who had been victims of sexual abuse to telephone a number that was given on the screen. " We expected to be answering about 500 to 800 calls a day ," said Mr Paul Griffiths, director of Childline, an organization set up to help children who had been abused and were afraid to report what had happened to them. Within two days of " Childwatch " being screened, more than 10,000 British children rang up to ask for help. A horrific picture emerged, that of "a secret nightmare world, shared by mil- lions of young· people ," says Griffiths. A team of seven telephone coun- sellors was quickly expanded to 22, whilst some 200 volunteers formed a back-up team. Over 90 per cent of the children who rang did not want to give their name; it was a relief for them to talk with someone about it and to receive help and guidance over the phone on how to handle the problem. "The most important thing is to listen," says Griffiths. "We might suggest we put them in touch with a caring organization near to them, but there is a great gulf between most of the children ' and official services, often because they are afraid that the person who violated them might be sent to prison. If we are frightened that their lives might be at risk we tell them who they can see in their area and ask them if we can make an appointment for them. " He believes that much can be done in the schools to alert chil- dren to the dangers of sexual abuse. Childline is the world's first national free-phone service for abused children-although the idea behind it is not new. Telephone helpline services for children exist 26 in Australia , the Federal Republic of Germany, the Netherlands , New Zealand, Sweden and the United States. These services have met an enormous need and revealed grim facts about the extent of sexual abuse of children . They have shown that children will talk about sexual abuse if they can remain anonymous. A recent survey in Britain , car- ried out by an experienced opinion The First International Confer- ence on Incest, held in Zurich, Switzerland, last August, was told that there might be as many as 40,000 cases of sexually abused children in Switzerland, but in 1986 only four offenders were convicted. Dr Genevieve Piret of Geneva, herself a victim of abuse, com- mented : "We want to find a way of developing solidarity towards child victims. We want better justice combined with therapy applicable both to the abuser and to the abused." poll group, estimated that one in ten British adults were sexually abused as children. Other studies of western countries suggest that the figure could be higher. Professor Ihsan Dogramaci of Turkey, Executive Director of the Interna- tional Pediatric Association, told a conference on battered children and child abuse at Berne , Switzer- land , in December 1985 that , in a sample of 930 women in San Fran- cisco , "16 per cent reported at least one experience of inter-familial abuse before the age of 18. Extra- familial abuses were even more fre- quent , having occurred to 31 per cent of the women before the age of 18." Almost one in three young women were therefore victims. Comprehensive surveys of sexual abuse in developing countries have yet to be made , but the problem is unlikely to be any less serious. In "rural and agricultural societies, child abuse may be equally exten- sive, albeit not as well diagnosed or documented ," says the report of the Berne conference* (which was eo-sponsored by the Council for International Organizations of Medical Sciences and WHO). It adds: "Hospital data on so-called accidental injuries that are also attributable to wilful abuse indicate that the problem may be equally serious in developing countries." In poorer societies, child abuse is compounded by juvenile prostitu- tion . In a number of Asian coun- tries , children- both boys and girls and sometimes as young as nine years old-are forced to work as prostitutes to bring additional in- come into the family home. The growth of international tourism has exacerbated this problem. Harsh economic exploitation of children was common in Europe's industrial revolution in the 18th and 19th cen- turies , when children as young as five years old were made to sweep chimneys, work in cotton mills and go down coal mines . But public revulsion led eventually to such abuses being outlawed. Few historical surveys have been done on sexual abuse, but the ex- tent of the problem is now better known and there is growing aware- ness among health workers of the need to develop programmes to overcome it. The London-based Child Assault Preventive Programme (CAPP) es- timates that in the UK 80 per cent of sexual assaults on children are committed by someone the victim knows- family member, friend, neighbour and so on. It says that children rarely lie about such abuse, unless they deny it to protect someone. Abused children often go to great lengths to prevent what has happened to them becoming known. Sometimes this is out of fear that what has happened was their fault ("children are never re- sponsible for child abuse," says CAPP), or because they do not wish to get the offender into trou- ble with the law. In industrialised countries there has been a dramatic increase in * " Battered Children and Child Abuse". Highlights and Recommendations , CIOMS/ WHO Conference, Berne, December 1985. W oRLD HEALTH, December 1987 public awareness of the problem. " Childline has certainly made what was once a taboo subject , not to be talked about, into an issue on everyone's lips," said a recent re- port in the young people's section of the British Sunday newspaper The Observer. Childline keeps British children aware of its services by regular up-dates on a popular television programme, " That's Life ," which is presented by the organization's chairman, television personality Esther Rantzen. It also has over 100,000 stickers plastered in public telephone booths and directories , schools, shops and hamburger bars. Paul Griffiths says that, in its first five months , Childline helped 14,000 children on the phone; there is no face-to-face contact. Apart from a £50,000 grant from the UK government , it is funded by volun- tary donations and planned to spend about £2 million on helping children in its first year. Griffiths believes that the phone service should be free so that there is no charge to the children. "Every day over 2,000 children are ringing for help - but at present our lines can only cope with 500 calls ," he says. Childline is hoping to expand its number of lines and also develop " safe " places where abused chil- dren can go if they do not want to go to official social services. CAPP points to a number of ways in which people can tell if a child is being abused. A sudden change in school performance and an inability to concentrate , a per- sonality change, becoming inse- cure , a need for constant reassur- ance , lack of trust in a familiar adult or not wanting to be alone with a babysitter or child minder. Other behaviour signs include being isolated from friends, day or night wetting, nightmares or dis- turbed sleep, being affectionate in a sexual way inappropriate to the child's age , aggressive or unusually compliant behaviour, not wanting to be alone. Both prevention and treatment programmes are needed to tackle the problem, as the Berne confer- ence was advised by Dr Richard D. Krugman , director of the C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect , based in Den- ver, Colorado. Subsequently, the W oRLD HEALTH , December 1987 "A horrific picture emerged, of a secret nightmare world, shared by millions of young people. " Photo W HO/J. Donatsch conference put forward a number of recommendations . Govern- ments , it believed, should designate national focal points with responsi- bility for gathering information on the incidence of child abuse , com- piling and disseminating technical documentation on the problem, providing advice and training mate- rials and advising all other national authorities on the subject. Surveys into child abuse should be carried out to serve as a basis for policy and action. It urged WHO and other agencies to prepare a survey of policies, laws and practices relating to the pre- vention of child abuse in selected developed and developing coun- tries. WHO should also establish a task force that would respond to requests for technical cooperation. And coordinating mechanisms should be set up at international level to provide a channel for an improved flow of information to in- crease awareness of the problems and ways of tackling it. "The global answer to child abuse," says Paul Griffiths, "is that children should have a better place in society. They should participate in decisions which affect them and should be treated on more equal terms with adults. " • 27 Women and smoking by Eileen Crofton W omen are now recognised to be at particular risk from an extension of the smoking epidemic. Just as smoking has passed from the developed to the developing . world , so women are becoming increasingly involved in this preventable public health disaster. In many industrial countries smoking is declining in both sexes , though more rapidly in men than in women. However, the current up- take of smoking by teenage girls is very disturbing. In at least 19 coun- tries more girls than boys smoke , and in others the rates are equal. In developing countries generally, 28 probably only about five per cent of women smoke cigarettes, but the proportion varies widely. On the American continent , it appears that in Uruguay and Brazil there are now more women smok- ing than in Canada and the USA, and in Chile there are almost as many. A survey of young pregnant women in Argentina , Brazil and Venezuela showed that between 29 and 48 per cent smoked. In Asia , smoking rates are gener- ally low but there are some surpris- ing exceptions. For instance 67 per cent of women in Andhra Pradesh (India) smoke , as do 40 per cent in some rural areas in Thailand. China A breath-test for royalty . The non- smoking Princess of Wales blows into a device which registers the amount of carbon-monoxide in the lungs. Photo Keystone © and Nepal both have very high rates of smoking in men (80 to 90 per cent) , but the women behave very differently. In China smoking by women is very rare , whereas in Nepal almost as many women smoke as men. Other forms of tobacco use (sucking or chewing) are common on the Indian sub- continent. Few African women smoke, though limited surveys reveal quite high rates in Zambia and Senegal. One survey in Lagos College of Education (Nigeria) found that 53 per cent of the female students smoked cigarettes. In Australasia , particularly high rates are recorded in Papua New Guinea and among New Zealand Maori women (who also have one of the highest rates of lung cancer in the world). In Europe , with the exception of Sweden , more men than women are smokers. The highest rates in women (prevalence over 40 per cent) are recorded in Belgium, France, Denmark and the Nether- lands , with lower rates in Eastern Europe. In the Federal Republic of Germany cigarette-smoking among men declined by 16.5 per cent be- tween 1960 and 1980, and increased among women by 60 per cent. M<;trked social class differences are found. For instance, in the United Kingdom 15 per cent of women in the professional class smoke , com- pared to 37 per cent in the unskilled manual . classes. Higher rates are also recorded in the unemployed and in women who are widowed, divorced or separated. WHO concludes : " What evidence we have indicates strongly that the epidemic is repeating the pattern we have already seen in developed countries, and smoking in women is on the increase. Though still very low indeed in some countries , in others it already rivals rates in developed countries-especially in South America. " In developed countries , ciga- rettes are by far the commonest form of tobacco use , but the recent introduction into Europe from the USA of new tobacco products for W oRLD HEALTH, December 1987 chewing and the plans of the manu- facturers to enter the world market are disturbing. Use of these prod- ucts is widespread among boys and young men in the USA but the company also reports " an interest- ing degree of female usage." Tradi- tional forms of sucking-and chew- ing- tobacco are already common in some developing countries and in India , for example , oral cancer is already the leading form of cancer death; so the introduction of yet another form backed by sophisti- cated marketing techniques is ommous. Women are subject not only to the health risks that apply to men, but also to others specific to their sex. In the past, the risks for wom- en were underestimated , probably because of women's lower mortal- ity rates , and those estimates reflect past rather than present smoking habits. Women themselves under- estimated the danger (which poss- ibly explains , at least in part , their slower rate of cessation), as did health professionals, who have tended to concentrate on the male sex and , in so far as they have ad- dressed women, have emphasised their responsibility to others rather than to themselves . Women who smoke have a high- er overall mortality than women who do not; they also make greater demands on the health services, and lose more time from work (as do girls from school) . WHO estimates that , in countries with reliable cancer statistics, 127,000 new cases of lung cancer occur each year in women. In England and Wales, lung cancer in men is now declining in all age groups under 65, but in women it is still rising. In men lung cancer is the leading cause of cancer death and in women it is second only to W oRLD HEALTH, December 1987 breast cancer. In Scotland and in 15 states of the United States, how- ever, it has now overtaken breast cancer, and this will probably be the case for the whole of the USA within a very few years. Women are also susceptible to the other forms of smoking-induced cancers that affect men, but recent studies suggest that cigarette-smok- ing may also have an important and independent effect in the compli- cated aetiology of cancer of the uterine cervix. A very common cancer in the developing world, this may have serious implications for women, especially those living in South America. The US Surgeon General has stated : " Cigarette smoking is the major cause of obstructive lung dis- ease in the US for both men and women". In most countries the prevalence of chronic bronchitis and cor pulmonale is greater in men ; but in Nepal the prevalence is equal in the two sexes. Nepalese women not only smoke but are also exposed to domestic smoke pol- lution from cooking fires, and this combination is particul~rly harmful. Coronary heart disease in women under the age of 55 increases with cigarette consumption just as it does in men, though the actual rates are lower. The risk of circu- latory disease is increased by the use of the contraceptive pill as well as by s.moking , but again the combi- nation of the two factors multiplies the risk, especially in older women. Strokes also have recently been shown to be related in women to the amount they smoke. Smoking can affect fertility. Twice as many female smokers as non-smokers fail to conceive within five years of stopping contraception in order to start a family . Female smokers also experience an earlier menopause. The risk of an unsuccessful preg- nancy is substantially increased if the mother smokes. Birth weight is reduced and the effects of this are particularly harmful in the presence of other adverse factors such as anaemia and malnutrition , so com- mon in women in poor countries. The perinatal mortality rate among children of female smokers in a study in Bangladesh was double that among children of non- smokers. Infants and young children run a greatly increased risk of serious chest infection if the parents smoke, and later on they are more likely to smoke themselves. The mother's example seems to be par- ticularly important, especially to girls. The motives of boys and girls in starting to smoke may not be very ·different , but a UK study found that girls believe cigarettes will keep their weight down. Adoles- cents (of both sexes) learn to use cigarettes to control swings of mood ("it calms me down ") and this may be particularly important for girls. Advertising certainly plays a part, and women's magazines read by teenagers carry numerous tobacco advertisements. Certain forms of sponsorship and pro- motion are clearly targeted to young women. Understanding and awareness of this issue of smoking by women is growing, and it is now recognised as a priority area. Women are more involved themselves, and the changing climate of opinion on smoking in general should be help- ful. Certainly, if the global smoking epidemic is to be fought success- fully , the needs and problems of women cannot be ignored. • 29 Public Outcry Led to Success Against Smoking Four countries which had scored successes against smoking by the mid-1980s- particularly in decreasing the number of male smokers- owe their achievements, in large part, to the initiative of ordinary citizens. Thei r outcry against tobacco-related dis- eases, combined with a spirit- ed public debate in the mass media, spurred governments on to act. The call to action occurred in the 1960s and 1970s, accord- ing to stories of anti-tobacco campaigns from Finland, Nor- way, Sweden and the United Kingdom told in "Successes Against Smoking," a 20-page booklet released by WHO for the 6th International Conference on Smoking or Health, held from 9-11 November 1987 in Tokyo. Here is a chronology of developments. Finland: In 1971, Finns peti- tioned their government to act following studies that showed them w ith the highest male mortality rates in the world from coronary heart disease. In 1976 the government launched a country-wide information and education programme under the National Bureau of Health, and Parliament passed the Finnish Tobacco Act. The result : by the early 1980s, the number of male smokers in North Karelia, the county w ith highest mortality, had decreased by 14 per cent - from 52 per cent in 1972 to 38 per cent in 1982. Norway: In 1967, a commit- tee set up by Norway's health ministry drew up a report, " In- fluencing Smoking Behaviour," proposing a national anti-tobac- co programme. This followed public outcry that resulted from front-page press coverage of the report on smoking and health by the U.S. Surgeon General in 1964 linking smok- ing to disease. In 1970, the Norwegian par- liament established a National Council on Smoking and Health, charging it w ith the task of carrying out " govern- ment measures against the harmful effects of tobacco." In 1975 it passed the Act on Re- strictive Measures for Market- ing of Tobacco Products. The result: by the early 1980s the number of male 30 The Villager's Voice: Prevent Tooth aches ! Even though no community is free from tooth decay or gum diseases, most health planners do not usually place oral health care high on a list of priorities. But when people liv- ing in small rural communities are asked, accord ing to WHO ex- perts, they invariably rank oral health care amongst their top problems. lt is easy to under- stand why - a toothache hurts, and pain is immediate. As a consequence of increa- sed sugar consumption, and a lack of preventive program- mes, more people in the devel- oping world than in the indus- trialised world suffer from Photo: WHO/Peter Ozorio toothaches today. "A toothache hurts, and The answer to decayed, pain is immediate." loose or missing teeth does not lie in training more and more dentists - it's too costly, and it takes too long. lt is rather through prevention by teams of ora l health workers led by a dentist. In courses lasting up to two weeks, Thailand is training personnel, called oral health examiners, to recogn ise a range of dental il ls; educators, to teach concepts of oral hygiene (for instance, " Clean your mouth daily," "Use sugar intelli- gently - limit sweets between meals"); and scalers, to re- move tartar from teeth. This preventive model project could serve as an example for other developing countries, where diseases of lifestyles are already emerging as problems. A major advantage of good ora l hygiene, wHo experts point out, is that it heightens awareness of the need for overall healthy lifestyles. ...... ....... ... ... ... ...... ...... ..... . .......... . ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ... ... ....... ... ... ... ...... ....... ... ... ... . ..... . ... ... ....... ... ... ... ....... . ......................... . ••• ••• ••••••• ••• ••• ••• •••••• • •••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• smokers had decreased by 13 per cent - from 53 per cent in 1974 to 40 per cent in 1982. In addition the numbers of teen- age smokers had also declined -for boys from 40 per cent to 26 per cent, and for girls from 41 per cent to 22 per cent. Sweden: In 1963, respond- ing to a call by 25 scientists for a tobacco campaign, Sweden established the National Smok- ing and Health Association to serve in an advisory capacity to its National Bureau of Health and Welfare. The results: by the mid- 1980s, the number of male and female smokers between 1970 and 1984 had dropped to 30 per cent - in the case of males from 50 per cent, and of fe- males from 33 per cent. In addition, the number of 13- year-old smokers had sharply declined-for boys from 40 per cent to 5 per cent, and for girls from 16 per cent to 6 per cent. United Kingdom: In 1962 and 1971 the Roya l College of Physicians published reports on "Smoking and Health" that led to the founding of Action on Health, a citizens' group dedi- cated to ra llying voluntary ac- tion against smoking. In response the government established in 1986 what is re- nam ed now the Health Educa- tion Authority, and later the Scottish Health Education Group, to advise its Depart- ment of Health and Socia l Se- curity on campaigns against what was described as the leading avoidable cause of death in the United Kingdom. The result: by the early 1980s, the number of male smokers had declined by 27 per cent - from a high of 65 per cent in the late 1940s to 38 per cent in 1982 . And the number of female smokers dropped from 41 per cent to 8 per cent over that period. • A Study to Show How to " Keep Arteries Clean " A five-year study to deter- mine,how atheroscleros is-the narrowing of arteries-is condi- tioned upon lifestyles is now under way in 27 countries, five in Africa, seven in As ia ten in Europe and five in Latin America . The study is being carried out by WHO and the Inter- national Society and Federation of Card iology. Called the Study of pathobiological determinants of atherosclerosis in youth (PBDAY), its aim is to prevent disorders of the heart or blood. "The child is father of the man," WHO officials say. "it's little use starting at age 45. We need to say to the young : Keep your arteries clean." Earlier stud ies, of so ldiers in war, had shown individuals in the prime of life already aff li cted with signs of athero- sclerosis. Thus researchers plan to examine the structural changes in arteries of those be- tween ages 5 and 34 w ho die from other than cardiovascular diseases. Among the most common cardiovascu lar diseases is atherosclerosis, arteries so clogged by a build-up of fatty deposits that the flow of blood through them is impeded. Heart diseases result, or heart attacks ensue. The principal factors associ- ated w ith an increased risk of heart disease are a high-fat diet, a lack of exercise, and smoking - in short, unhealthy lifestyles . The habits of a life- time begin in childhood. Strokes, high blood pressure, rheumatic heart disease, and heart muscle disease are also Photo: WHO/Zafar "lt's little use starting at age 45." WoRLD HEALTH, December 1987 common form s of cardiovascu- lar disease. Taken together, they represent the No. 1 health problem in the industrialised world, and are fa st becoming a major worry to the developing countri es as well. Preventive measures have been aimed, by and large, at adu lts. No longer should this be so. Pointing to the example of regular dental check ups, some cardiologists even foresee a regular cardiovascular check-up for chi ldren. • Senior Citizens Not Responsible For Deficits The deficits in national health or social security schemes are often blamed on longevity. More people live longer and need more medical care, the argument goes, therefore cost- ing more money. Now a report by the Inter- national Labour Organ isation entitled "Demographic Devel- opment and Social Security " suggests that "other factors have helped to send medica l costs spira lling," namely, "more people seeking treat- ment more often, and more ex- pensive techniques of diagno- sis and cure resulting from new technology. » Studies in France and the Netherlands show that even though illnesses increase steadily with age, the effects of longevity on health schemes are "modest and cou ld be esti- mated at 0.5 per cent a year between 1985 and 2015." Yet since 1975 a number of European countries have cut back on expenses covered by national schemes, by passing more costs on to patients and by limiting the extent of ca re . In the United Kingdom, how- ever, the ILO report points out, the national health services pays doctors a higher fee for caringforpatientsover65, and in Yugos lavia senior citizens are "considered a va luable group and are accorded easier access to health care." Over 15 per cent of Europe- ans wi ll be 65 or older by the year 2015, accord ing to the UN demographic projections. They w ill include the follow ing per- centage of populations : • 15 to 20 per cent in coun- tries of eastern Europe, • 20 to 25 per cent in Den- mark, the Federal Republic of Germany, Luxembourg and Sweden, and • 25 per cent and over in Switzerland . • WoRLD HEALTH, December 1987 Newsbriefs • By Presidential Hand. Presi- dent Andre Kolingba, adminis- tered a polio shot to an infant at a health centre in Bangui to launch the accelerated phase of his country's programme to protect children against six diseases. Almost a half of the children in the Central African Republic die before reaching their fifth birthday from diseases prevent- ed by immunization. " Immunization, " he said, paraphrasing WHO's World Health Day theme, "gives every child a chance for survival. " • Lobbying for Health. Readers of the Journal of Pain and Symptom Management, a quarterly published by the Depart- ment of Anaesthesiology, University of Wisconsin, in Madison, were asked by editor George Heidrich, to write to members of the US. Congress on behalf of WHO " Programmes like the cancer pain relief ("Freedom from Cancer Pain "), and efforts to control AIDS, affect persons in all nations, and depend on coordination from wHo, " he said in an open letter that urged readers to lobby for payment in full of the US. contribution to wHo. Wisconsin is a wHo demonstration state in cancer pain relief. • Off the Press. A ship's crew today is no longer likely to be all male. Thus, a chapter on pregnancy and women's medical problems has been added to the International Medical Guide for Ships in its first updating in nearly two decades. There are other new chapters in the second edition, for instance, on the medical care of castaways, and-reflecting the phenomena of the "boat people " - of rescued persons. Intended for those with little or no medical training, the guide is written in simple language. • Phasing-Out Smoking by Phases. Last April WHO's regional office for Europe in Copenhagen banned smoking from more public places - in addition to conferences rooms, where smok- ing had already been prohibited, in lobby and reception areas. In April, it offered cessation courses for smokers ; in Septem- ber it asked staff to voluntarily refrain from smoking in offices. Effective 1 January 1988, it becomes - except for certain designated areas-a smoke-free environment, the sixth of six regional offices committed to clean indoor air. In addition, Copenhagen relinquished the privilege of tax- free tobacco purchases accorded by the host government, Denmark. And it is making clear its preference to hiring non- smokers by stating in vacancy notices that "WHO promotes a tobacco-free working environment. " • Tobacco-Free Vojvodina. The province of Vojvodina in Yu- goslavia passed legislation, effective from last July, prohibiting smoking in work places and public spaces, according to Tanyug, the country's news agency. The law, the first of its kind in Yugoslavia, resulted from an initiative by the Union of Cancer Societies. In the next issue On 7 Apri l 1988, WHO wi ll ce lebrate 40 years of effort in international public health . The World Health Day issue of World Health, January-February, wi ll have a share in the celebrations, and wi ll underline the sense of public involve- ment in public health that is conveyed in our slogan for the Day : " Health for all - al l for health." Author~ of the Month Dr Richard DAwooo- himself an inveterate traveller- is the editor and compiler of "Travel- lers' Health." He practises medicine at University College Hospital , London , UK. Dr Chris CURTIS is especially interested in "appropriate tech- nology" for mosquito control and has field projects in Tan- zania. He works in the labora- tory at the London School of Hygiene and Tropical Medicine in the UK. Dr Louis MOLINEAUX is a medi- cal officer with WHO's unit of Epidemiological Methodology and Evaluation in the Malaria Action Programme, and Dr Jose A. NAJERA is Director of the Programme. Dr John DEBBIE, formerly a Scientist wi th WHO's Veterinary Public Hea.lth unit is now with the New York State Department of Health; Dr Takao FUJIKURA is a Scientist with the Veterinary Public Health unit in Geneva. Dr Jonathan MANN is Director of WHO's Special Programme on AIDS. Dr Hemda GARELICK is a re- search Fellow in the Department of Medical Microbiology at the London School of Hygiene and Tropical Medecine , UK. Dr John CLEMEN'"(S is a Medical Officer with WHO's Expanded Programme on Immunization. Professor Arie J. ZUCKERMAN is Professor of Microbiology in the University of London and Di- rector of the WHO Collaborating Centre for Reference and Re- search on Viral Hepatitis , Lon- don School . of Hygiene and Tropical Medicine , UK. Mr John MADELEY, a freelance journalist specialising in devel- opment and health, is based in the UK. - Lady Eileen CROFrON was for- merly Director of the Scottish Committee of Action on Smok- ing and Health , and lives in Edinburgh. WORLD HEALTH For readers everywhere 1987 Subscription Rates One year Two years Three years US$ Sw. fr. 14.- 25.- 24.75 45.- 33 .~ 60.- ORDER FORM Please enter my subscription to "World Health" as follows: dne year D Two years D Three years D I enclose cheque/international postal order in the amount of: - Name: ________________ __ Street: --------"--- City: _______ _ __ Country: --------- World Health, WHO, Avenue Appia, 1211 Geneva 27. Switzerland "To trJJVel hopefu.Uy is a better thing than to arrive "-Robert Louis Stevenson. Photo WHO/M. Jacot