Home
This site is intended for healthcare professionals
Advertisement

Tropical Medicine

Share
Advertisement
Advertisement
 
 
 

Summary

Join us in this engaging session where our speaker, with vast experience in expedition work and humanitarian service with Medecins sans Frontieres, provides unique insights into tropical diseases. This session is designed to be a comprehensive thought-starter, provoking thinking around recognizing, managing, planning for, and preventing tropical diseases. It will be particularly relevant for those who may travel or work in locations where such diseases are endemic. The speaker will discuss prevention strategies (with an emphasis on chemoprophylaxis), share anecdotes from her experiences in locations like Belize Jungle and Northern Sri Lanka, and discuss handling diseases like malaria or dengue. Remember, this session is a starting point and further research should be a top priority!+

Generated by MedBot

Description

Wilderness First Responder - Lectures & Pre-Course Learning

The pre-course learning can be found in 'catch up content'

Learning objectives

  1. By the end of the teaching session, learners should be able to identify the common tropical diseases found in Belize and understand the difference in prevalence depending on the regional setting.

  2. Participants should learn the key strategies for preventing tropical diseases, with particular emphasis on bite prevention, treatment of water sources, and appropriate clothing.

  3. Participants will understand the importance of pre-travel health promotion and preventive education for expedition teams or participant groups travelling to tropical areas.

  4. Learners should be able to recognize the common symptoms of tropical diseases and understand how to differentiate between different diseases based on the presenting symptomatology, location and disease prevalence in the visited country.

  5. By the end of the session, participants should be well versed in contemporary malaria prophylaxis options and understand the necessity of accessing up-to-date information from reputable sources such as the WHO, CDC, or UK Travel Health guidance.

Generated by MedBot

Similar communities

View all

Similar events and on demand videos

Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

And I have been invited to deliver a short lecture or presentation on tropical diseases. Now, I am in no way an expert on tropical diseases. However, I have engaged in work that has taken me all over the world and involved in managing and recognizing many tropical diseases. My work has included expedition work, humanitarian work, working for Medecins sans Frontieres and deploying to various humanitarian emergencies. I've also completed the diploma in tropical Medicine and Hygiene at Liverpool School of Tropical Medicine. This is a snapshot and I would encourage you to go off and read further around any of the diseases that take your interest or are going to be relevant to you depending on where you are working or traveling. This is no way, fully comprehensive, but I hope it gives you some insight into thinking around the tropical disease and planning and prevention of tropical diseases for yourself and for your team, for your participant group, depending on what your role is going to be. So I hope you enjoy it. I would welcome any thoughts and feedback. And as I said, it's sort of a snapshot into the world of tropical diseases. I'm going to go around the world in 10 tropical diseases and it will give you a little bit of insight and hopefully be quite thought provoking. So we're gonna make a start. So let's say that you are going to be tasked to go or your first expedition is going to be to the Belize jungle. And this is a very common place for a lot of medics to go in their first trip overseas, let's say in the capacity of being a medic for an expedition. And it's a beautiful part of the world in South America or just between North and South America. And it's right also with various potential tropical diseases. And so I think it's important, first of all to know your participants, your group and know what their health conditions are and their risk of transmitting and or contacting and transmitting a tropical disease. And also what's really, really important is prevention strategies. And I'm going to repeat that for every one of the diseases we talk about because that is the key and prevention is going to be fairly similar across all the diseases and are going to be key around chemoprophylaxis. So for example, malaria prophylaxis bite prevention. So wearing repellent, thinking about impregnating clothes, mosquito nets, that sort of thing, thinking about the breeding habitats and when mosquitoes and other vectors are around and preventing exposure during those areas and thinking about location of where you perhaps set up camp or where you are staying and the risk around bikes in that location and at certain times of the day. And so educating your teams on prevention is really, really crucial and it is your responsibility as well, particularly if you are a lead medic for the trip. And I give you an example is that one of my missions or my mission with MSF was to Northern Sri Lanka and there are some mosquito borne diseases there that can occur. And I read around, I looked at where we were staying. I looked at the incidence and prevalence and I made a decision to do bite prevention and avoidance of getting bitten really as best as possible. And I chose not to take antimalarials. The risk there was also dengue and there is obviously no prophylaxis for dengue apart from bite prevention. And so I adhered to that, I wore long sleeves. I avoided sitting out when mosquitoes were most lively. I was aware of the breeding sites and I don't recall really getting bit more than once or twice. I don't recall a lot of mosquito bites and I didn't get malaria or dengue and actually neither did the wider team. So it's about being informed really. And I would encourage you all to make sure that that is a big part of your discussion, pre trip, pre expedition, pre going overseas to work. And that health promotion, that part of that health promotion is not always not just about nutrition and keeping, making sure you don't get sunburn and water hygiene, toileting all of those things, but definitely bite prevention and avoidance of contracting and transmitting any tropical diseases as well. So we're going to make a start so be jungle and just know your participant group because often this is the trip that lots of young adults take teenagers, gap years, that's going to be different to a group of, let's say more mature adults who perhaps have had travel experience. And so making sure you are targeting your pre health advice to that particular group and then you need to study the area. So in Belize, what are the common tropical diseases that may occur? And this will vary across the region, whether you are in an urban area, whether you are in a jungle or forestry area, whether you are in grasslands, what sort of climate as well, whether you have contact with water and you really need to be up to date on all of those elements. And this is where we went to Belize. I was with a media crew doing a filming and we went into the what is called the secondary rain forest jungle environment. And it's a very, it's a very kind of hyper allergenic environment. I guess there's a lot of risk from getting stung. There's a lot of risk from contact to flora and fauna that might be poisonous or might cause a reaction. Um And there's a lot of dangers from deadfall, from trip hazards from snake bites and from vector habitats. And you can see here, we've got a picture of, uh, we are sat for lunch, I think having a break in fairly water that isn't fast flowing. And so straight away, you're thinking, what sort of habitat might this, this encourage and your mosquitoes are going to be potentially breeding here, aren't they? They probably like it a little bit darker but actually in the humidity, but there will be areas here that are mosquito breeding size. Now, the middle of the day, probably less likely to get bitten. And as you can see, nearly everyone there has long sleeves on or the potential to have long sleeves, everyone has boots on so that will minimize against snake bites, etc, and twisting ankles. Um And uh, they are, um, probably covered in. Indeed, I would hope they are because that was one of the talks we did both pre expedition and also during the day, but this is a vector breeding site. Ok. So being aware of that. All right, this is another site we went to and this is where we camped actually, which probably wasn't the most sensible place to camp because this is a very much a stagnant pool. And that stagnant pool is definitely going to be a site where potential mosquitoes. And you can see here the bucket with the water in and what we are doing is we are filtering and making water suitable for drinking. And at sites such as that, which is a stagnant water, there is going to be a quite a thick layer of algae over it and we need to, first of all make sure that we are collecting the water, we are filtering it through a cloth or similar that should clear that scum, that kind of obvious visual debris, collecting it into a container and then it's boiled for a good length of time. And then it's cleaned again with either a chlorine tablet. Back then, we used iodine, which is less available now. And there's lots of different ways you can sterilize that water. But there was a three step process for that. So again, we are avoiding waterborne diseases such as giardia. But also I'm looking at that site and thinking probably not the best site because of the vector breeding. But then let's bring in some other measures as well to try and prevent bites. So, you know, long sleeves, deep clothing impregnated with deet nets, impregnated with deet. If you are sitting around the camper at night, you've got the fire, you've got the smoke that will all put mosquitoes off. So what's going to happen at this sort of site? What's the risk? Well, you can see here, this is a graft. This is an old graft and it's just to give you the kind of trend of what you might see in someone who starts to get unwell. And the differential for many of the triple diseases unfortunately is very similar because they all cause a fever, they all cause aches, body aches, muscle aches, they might cause a rash, they might cause diarrhea and they might cause nausea. And so actually, you need to kind of almost take some of the clinical features as a group. So that's going to be the same across many of the tropical diseases. So how else can you differentiate? Well, you can think about location, you can think about breeding season. When are these mosquitoes, let's say most rife. What is the disease prevalence in that country? Um So, and you know, where are we in the world and bringing all those things together? You know, are we going to be thinking about typhoid? Well, probably not in that region. Are we going to think about malaria? Yes. Are we going to think about Dengue? Well, Dengue. Dengue tends to come from the Aedes mosquito which is much more urban um breeding and we are very much in the jungle and in the vegetation. So, what are we thinking about? So we've got things like sanies possibly is that rife in that region, possibly um malaria, the uh anopheles. Yes, quite possibly. This is what it's going to be. And so your differential has got to consider a lot of factors. Ok. The pattern of the temperature may be useful unless you keep a graph, it's probably not, but you know, high fever spikes and then a drop, high fever spikes and a drop with other illnesses. You can sometimes see a difference in, in perhaps the the pulse in, in, in related to a temperature. It's not rising as much as you would think. Um you can see some rashes that associate it as well. So you are trying to work out what might be happening here. But basically you want to make sure that you are treating early if you are concerned about this being malaria, um most of your group should be on malaria prophylaxis if they have read around it, made that decision. Ok. And there are lots of options. We're going to talk a little bit about that, but I would urge you to make sure you are most up to date by reading the most up to date information on who website CDC website UK guidance, travel health guidance. There are no vaccinations for travelers at the moment for malaria. Um There is obviously a malaria vaccination program going on in parts of the world for local. Um So yeah, so if you're worried, the best thing is to treat. Um and the reason for that is where you are is going to be perhaps difficult to CASAC. There might not be any local health facilities. If there are local health facilities, they are often very good at treating endemic diseases and actually they will receive more cases than you and I will perhaps So, just having that plan about CASAC about what our local health resources are, is again, really, really important. So what is our vector for malaria? And most people will generally know this from having read around it or having been familiar with it or having done the diploma and it's the anopheles mosquito. And you can see there, there's a, it's a kind of chunky mosquito with this slight color pattern to their wing as well. And they will come out and bite you dusk and dawn is common and they will come and bite you and potentially to transmit the parasite. It's very important to be aware of the other types of mosquito vectors. And we've got the culex and the AEDs and both of those transmit different diseases. And just to be aware, now you are not going to be asked to identify the mosquito necessarily at the time. And that might not be feasible in any way, but get familiar with what mosquito transmits what and then where they breed and then where they are when they are most likely. And that will help you understand the disease as well. And we are going to come back to these mosquitoes. Now, understanding where malaria is prevalent. Now, this map shows malaria free zones and where malaria never existed or has disappeared without specific who measures. There's a couple of web links at the bottom which are worth looking at. So the first web link is showing this map and this is a 2024 map. And the second map is showing where the most threats are at the moment for emerging cases of malaria. And you can see there it's all very much the southern continent. Although in Australasia, there is no presence of malaria and actually the southern tip of South America as well. And then obviously UK is all generally free from malaria. So again, being familiar, so if you are traveling to parts of Africa, know where these regions arrive, again, most of Africa is going to have a problem and some of South America as well, so be really up to date with the changing mapping, the changing zones and this is all available on who there are some very strategies in the world going on at the moment to try and reduce the transmission of malaria. Obviously, it's a massive global health burden. There's a lot of young deaths from malaria, particularly babies and often these are preventable deaths. And so there's an enduring health challenge and there's quite a lot of good information about the malaria vaccine programs on who. And this is just an example of the recent updates on the vaccine program and a lot of money has been spent from multiple countries around the world to try and look to not necessarily eliminate malaria but reduce the burden the health burden on it. So worth having a read as well. The vaccines are not available for travelers at the moment. So one of the things I would also encourage you to look at because it's fascinating, to be honest is the life cycle. And it's really clever actually. And very many of these parasites are quite clever. But why it's important is to understand that actually, there is a kind of a period where the malaria parasite can almost become dormant in the liver and a couple of types of malaria parasite do this. And therefore, when you are thinking about treating, knowing which type of malaria parasite is prevalent in that region. So fasciculin, for example, is that the commonest or is it vivax or ovale? And understanding that helps you know whether you need to treat those dormant malaria parasites that sit within the liver and they can, people can have a relapse quite a few months if years later and often they could go to their primary care provider months down the line of having traveled somewhere where malaria is prevalent and actually not be thought about as a differential diagnosis. And so it is really important that this part, this liver, this the hypnos in the liver are treated as well as any active parasitemia as well. So just get familiar with the life cycle. This is from nature. In 2009, there is going to be various good articles on the life cycle. Well, when I first did expeditions, there wasn't the option of rds. It was um they weren't available back then or there were a few available actually, it was many years ago, 20 years ago. However, now you can buy these on ebay pretty much checking your source, obviously. And these will test for certain types of malaria parasite as well. And they can be quite specific for the type and there are some generic ones, but you basically, it's like a pregnancy test where you put a drop of blood on a reagent and it will give you a positive mark if there is a presence of that um parasite. But you can see that you can get five test kits for 7 lbs. Now all of the med kits should have them. And then again, they are reassuring, they are an adjunct for your diagnosis. Um perhaps not a rule out completely but a useful one to say yes, this is definitely malaria. So be familiar with that as well. Um So I just go back a step. So there's other ways that you can look uh treat uh and explore malaria, just bear with me one sec, thick and thin film. So this is really important as well. So when I was with the MSF, we didn't have the rapid diagnostic test at the time and we did a thick and thin film. And so in the parasitemia phase, when the person has a fever is to get a thick and thin film and they are what they say. So a thick film and to look under the microscope for the evidence of the parasite and red blood cells and a thin film. So a scraped blood film and a thick one. And generally you need three or four really when the person has a fever is most useful. And the parasite team is like to be high to have a look and they can give you a positive result but often can be negative even in the presence of malaria because you are not finding those red blood cells that necessarily have infection. So the R DTs and the thick and thin films are useful. So how are we going to treat malaria? Well, again, I would recommend you look up the up to date guidelines, but they are the artemesinin based combination therapies, which are really, really important. And there's a lot of options, they are much cheaper than they used to be. And there are different options for treating the non severe malaria. So that's fasciaria often in the traveling population and also severe malaria as well where people can become very sick, particularly things like having hypoglycemia seizures, particularly in Children. And we don't see very severe malaria often in travelers because it is treatable. And obviously people tend to go on prophylaxis prior to going out to that region, but read up on the commonest treatment and make sure it is in your medical care or you have you have access to it. Um This is a little bit slow. There we go severe malaria again, looking up what your, what your treatment options are. And this is an important the primaquine treatment as well. And this is to prevent a relapse of vivax and ovale. And this is where we talked about that stage in the liver where they can go dormant and relapse after six months a year or so. And this needs to be added to your treatment regime as well. But the treatment strategies are all available in who and they are quite clear and it's making sure you have that available to you and you know, fairly straightforward to treat, catch it early and making sure you treat it. So this is what we spoke about before. This is really, really important prevention and it's easy prevention. It's about educating, it's about making sure that people have long sleeves. It's making sure that they have chemoprophylaxis and there's a lot of different options for that, have a read on the UK guidance which is 2022. So that's a couple of years old, but there will be updated one and they will talk you through what type of chemoprophylaxis is available. I have been on Doxy, I was fine on Doxy. It doesn't suit everyone. It gives some sensitivity also, you must take it with food. Otherwise it makes you feel awful and risks of gastric ulcer. It's one tablet daily and also that covers other diseases. Actually, it covers tick borne diseases and things like leptospirosis as well. So, quite a useful drug to have in your medical pack. Certainly mefloquine. And then there are some other options as well. Difference in prices, but one taking it weekly perhaps is easier for some. There may be side effects to each of these as well. So just giving people the information is very important. So in summary, for malaria and also this goes for any other mosquito borne disease is that don't feed them prevention. Ok. Where are you staying? What's your habitat like? Where are their breeding sites? How active are they in the day long sleeved bite prevention measures such as bite spray, repellent, impregnated nets, impregnated clothing. Um and then picking up early signs and symptoms that someone may have malaria lots more to read about malaria and a fascinating subject and ongoing research. There's some really good up to date resources on about the strategies for the areas that have widespread malaria and what strategies globally are occurring there to try and reduce the health burden. Ok. So we're going to move on to our next country and we are going to case study two, which is in the Philippines and this was post typhoon Hian. So this is where I went after the after the typhoon with a British team to support the humanitarian response. Now, there are many tropical diseases that can emerge following a disaster and that's when one area that perhaps might have a prevalence of the disease then becomes perhaps having more and more outbreaks of that disease. And that's because of the changing environment. Water sanitation habitat, displaced internally displaced people who then camp or live in one area which is then overburdened by having a large population. There. Food wastes attract predators that risk things like snake bites. Water sanitation is impacted by disaster that promotes waterborne diseases. Cholera giardia, those sort of things but also displaced populations create a little mini urban environment and that can give rise to things like Dengue. So we're going to talk a little bit about Dengue. And here are some photos from BBC archive showing the sort of destruction that can occur after a typhoon. And there has been many more since this was 2013. But you can see that people are displaced, they are living in tents. And if you look in that picture, you can see on the right here, you can see a barrel with a wooden plank across. And this basically is important because it's a barrel full of water is a breeding site for mosquitoes, particularly the aedes mosquito where Dengue can be transmitted. And actually that plank on top will help prevent that as a breeding site. So things like that are very important but also as a medic in these areas, thinking what can emerge here, what diseases can emerge? And Dengue is certainly one of them. Ok. Clinical presentation, myalgia, high, high fever, muscle ache retroorbital pain and this fine rash and actually a good friend of mine literally last week got Dengue in Malaysia in the urbanized area in Malaysia just got a very high fever. His rest of his family were fine and he got Dengue. So he's just been discharged from hospital, having had quite a rough course and I'll talk through those that clinical presentation. So you start off with a temperature very high. So 40 what will happen is that in that critical phase, your temperature might drop a bit, but your platelets start to drop as well and his platelets went down to 26. So that is pretty scary. Spontaneous bleeding tends to occur with platelets below 10. But you know, you don't want to have a spontaneous bleed. You don't want a traveler with a spontaneous bleed, but it is conservative management. So it's about things like analgesia antipyretic avoid ibuprofen because of the renal impact. It can have on the kidney function platelets. But paracetamol fluids, IV fluids often and then conservative management often in a hospital, I've seen both Dengue and dengue hemorrhagic fever and the hemorrhagic fever is pretty horrific and it's when people start to bleed bleeding gums, bruising, te subarachnoid bleeds pr bleeding and it's life threatening. And so it can be a really nasty disease. But you get this critical phase of illness where your platelets drop, your temperature normalizes a little bit and then your platelets will start to climb again and his platelets are now on the way up and they've done that themselves. He hasn't had a platelet transfusion. So, again, Aedes mosquito, urban dwelling, biting again, morning and evening bite avoidance is your way forward because there isn't a vaccination for this. There isn't a chemoprophylaxis. It is bite avoidance. That's key. And that's why we try and say that's a really important part of tropical medicine awareness is that a lot of this is bite prevention, prevent getting an illness and you won't have to deal with the repercussions. Um So in terms of treatment options, I've just gone through, let's take the slide, move forward. Um is uh conservative as I mentioned, fluids hydration, um antibiotics just um this is an up to date map from um this month. So this is showing where there's new cases and this can be linked into the website on the link to the left. And you can see that South America is fairly right with Dengue as well. A little bit in Malaysia, Indonesia as well. So showing that the number of cases and this is 2024 situation, recent outbreaks as well and recent outbreaks will occur because of this sort of situation. This is 2010 from Haiti earthquake where you can see that there is a wonderful breeding ground there for the Aedes mosquito with all that rubbish and little pools of water where they were set up and nest, lay their eggs. And then all those people to bite in the distance. So lots of emerging outbreaks for Dengue, I've gone through this and just making sure you do seek health care. And actually a lot of fluid hydration is the way forward for Dengue, viral hemorrhagic fever often. So this can happen if someone has already had Dengue once and then gets Dengue again. So again, that's where prevention comes in. But there are four serotypes, 1 to 4, there really is no prophylaxis you can take to prevent it and it's nasty when you get it. That's when you get the bleeding from different areas of the body and it can be fatal. And I had a couple of cases in Sri Lanka that had Dengue, they all survived but they were poorly recent outbreak in Iran. So June 14th, 2024 1st two locally acquired cases of Dengue in the country. And that's, you know, the total number of acquired cases have risen to 12. So that is a new and evolving outbreak. They've also had Dengue outbreaks in India and Delhi particularly and this was in 2015 where there was a huge surge in Dengue as well. So just to be aware, read the disease outbreak news of who and be aware of what your recent outbreaks are and Dengue can occur with other diseases as well. For example, Dengue and Zika can occur together as well. So just to be aware of that, ok, case study three adventure race across Nepal. It's a beautiful country. I've been there a few times. We did adventure race with some corporate teams and as well as looking at trauma bri and you're also looking at prevention of diseases. And one of the areas that we cross in the, in the Nepalese regions is the paddy fields, beautiful areas we cycled across here and we also trekked. And what makes you, did you think of when you think of paddy field, it's quite a rare disease, but there have been a few cases. Um and it's the culex mosquito. This is the one that is fairly bland in design compared to the eighties and anal but prevalent in those rice fields. So again, think about where you set your camp up, think about where you stay and think about what the risks are to being bitten, bite prevention is the key. Now, unlike dengue and different to malaria is you can get the vaccine prior to going away. And I would highly recommend this particularly if you are going to this area. And the vaccine is um for Japanese encephalitis and you take three doses. So you've got to plan ahead. You can't sort of decide to go next week and then get you three doses in. I think it's 07 and 21 days before you go. There isn't treatment for Japanese encephalitis and it's a horrible illness, mainly impacting causing neurology, impact of the nervous system. And CNS, it's a high mortality and morbidity as well. And so bite prevention and vaccinations are key here. So for malaria, you've got chemoprophylaxis dengue, you are just working on bite prevention and here you've got vaccinations. People would choose not to have the vaccine and then it's bite prevention. So this is the story from a few years ago now, but this young lady called Sophie Williams. This is all public knowledge and the news was a Bangor University. I think phd student studying on the rice field and got Japanese encephalitis and now is quite severely disabled by the virus and is undergoing, still undergoing I believe, neurorehabilitation for that. So really severe illness. And so again, prevention is the key. OK. Case study four, we are trekking through the US National Park. This is not actually somewhere where I've been, but I have seen these diseases from this, but this is classic because it's grasslands. Um and um these are rife for tickborne diseases and we see tick borne diseases in the UK, don't we? We have Lymes disease which I've seen in the Royal London Hospital in East London um from a someone's back garden, but we can associate lymes disease with those that tend to work out in the field from dogs. We check our dogs, we live in the countryside and we check our dogs in the summer for ticks as well because it can, it can be transmitted. Ok. Clinical presentation is classic. It's that target lesion. Um And you don't often see, you don't always see that. I saw that in my case in the Royal London brilliant target lesion on their thigh doesn't recall getting a tick and we treated them and she came in early and we treated them, but they can get quite nasty symptoms and progression of clinical illness if it's not picked up early. And that's in a way why Doxycycline is good to have with you on the pack because DOXY can be used to treat tick borne diseases as well. And it's not just lymes, it's other diseases as well from ticks. Most of you will be familiar with ticks. Um, this is a tick and they cause again, fever, a rash, a headache, muscle ache. Ok. The same as malaria, the same as dengue, the same as probably Japanese encephalitis, but they don't. Well, not all of the tick borne disease have the neuro side, but tick borne paralysis can have a neurological side to it. And if you've ever watched house, they had a good episode where a student got bitten by a tick and got a tick borne um paralysis from it. And it was quite informative episode actually. So ticks. Yes, lots of different diseases, Rocky Mountain spotted fever, lyme disease, and they can have any sorts of symptoms. So high suspicion treat and fairly straightforward to treat actually. But remember bite prevention. So if you wear deep, if you wear long trousers if you avoid or if you go through grassy and grasslands, do a tick clinic that night. So in the jungle, we did a tick clinic. Everyone basically stripped off to their underwear and checked under the armpits in the groin on the back and the front for any ticks. And then they are quite easy to remove really and reduce the risk of disease transmission. You can see that is a tick, a nice big fat tick that has had a feed. I took them off the dogs in the summer and I just got a pair of tweezers very gently held the body and just rotated it anticlockwise or clockwise. The reason being is that your, the head of the tick, two little antennae or little pincers and they go in and they twist and so you want to untwist gently to release them and if you untwist gently and pull, you'll see their legs wiggling and then you can flick them out somewhere and just remove them. If you'd kill them when they are on you, their head will often be left in and you can get, they will regurgitate the contents. And therefore that disease transmission is increased risk of disease transmission. And also a local cellulitis is at risk as well. So fairly easy to remove. Ok. There is a picture. You can get tick removal, tweezers. It's not needed. You can just use normal tweezers as well, but gentle with them. As well. You don't want to be snipping their head off treatment, treat early doxycycline doxy is great for a lot of stuff you've got to eat when you have your doxy though. And it can cause some sensitivity. It does risk a gi also as well. So just to be aware, but it is fairly straightforward to treat. Um in terms of exposure, as I said, by prevention and long sleeves, long legs and arms, et cetera and not wearing vest tops, etc going through the grasslands. Ok. How can we diagnose it? Well, there's various options. Um symptomology. So um you're in an area where there's ticks, you're getting the symptoms, you're seeing the rash, you're seeing some of the lesions. Uh and that can also include neurological features. Um chronic lymes, I think you've probably, you know, heard about that. Read up. I think there are some celebrities who say they've got chronic lymes that can be very nasty and that's very difficult to treat. So, getting treatment in early and often with the tropical disease, what I would say is that if you've got a suspicion, you're not sure what it is is to start a treatment. So, Doxy, for example, is a relatively safe treatment to start providing. You look at the way that you take the medication, as I said with food and you look at the risk of side effects. But actually, if you are suspicious of a tick borne disease in an area where you are known to have tickborne diseases and you are going to be remote for quite a long time. You can't get someone back to health facility. Then I would suggest you treat it but they lie to test is available in hospitals, urine and blood serology, etc to look for lymes. And people get picked up with chronic lymes like that as well. So, yes, familiar I films were the types of tick diseases, prevention, prevention, prevention, treatment, early treat early if you are worried about it. Ok. And be aware, it can come in the UK very easily. I said I saw one in the Royal London last time a few years ago now, actually from a lady just working in a garden. Ok. 75. Well, as soon as I say river rafting and Borneo, you should know what disease I'm worried about here. It is rife in this region and they are also very experienced at treating it over in Malaysia. And this is leptospirosis. We can see it in the UK. We see it in kayakers, canoeist farmers exposure of water that has in fact sort of got the spiro in to mucous membranes, cuts that sort of thing. So it's quite easy to pick up. Actually, the transmission from water is relatively easy. And I've seen three or four of my colleagues have this, one of whom ended up on intensive care with hemofiltration and was pretty poorly. And that was a delayed diagnosis or partial treatment, maybe but one was delayed diagnosis and one was partial treatment. So again, be aware if you are a primary care practitioner, really be aware of the fact that someone has been traveling and what they, what risks they have in that region. And could it be possible that even though they've been back for X number of weeks or days or months, could they possibly have? This disease? River rafting is classic particularly after the rainy season. So this is a rodent, urine carries the spiro sheets and gets flooded. Obviously, the banks get flooded, pick up that and into the water, you raft, you topple in, you swallow a bit of water. You've got a cut somewhere on your finger, you get it in your eyes and it, that's the risk. And we did have from one of our sabo trips, we had a couple of cases and even though we took good precautions and you know, after the river rafting, everyone had a shower, we said to what to look out for. Now, interestingly during this trip, I chose to go on Doxycycline as a prevention for malaria, but I knew that Doxycycline would also be a good prevention of leptospirosis as well. So again, thinking a little bit wider, thinking around the type of chemoprophylaxis you might use for one disease could help treat another. What are the symptoms and signs? Red eye conjunctivitis, muscle ache, fever, feeling generally unwell flu like symptoms. And so both people that got sick, one presented to their GP with flu like symptoms. I don't think men, they had been in Borneo two weeks before, didn't, wasn't treated with anything then presented with the hospital a few days later and had to have IV one of the cephalosporins, the other one again presented late and was on intubated, ventilated hemofilter on intensive care because it's quite hard to treat once it gets the clinical course progresses and you get hepato renal failure as well is a risk. So, really catching this early, it's easy to treat if you catch it early, really important when you're in a hospital setting or you've got the tests available. Um You can look for renal function, you can look at LFTs, you can do a urine serology as well and look at these for these Spiros that are available to see on both urine serology etc, but it can cause nasty illness, myocarditis, arrhythmias, renal failure, etc. Um as I said, treatment, Doxy Azithromycin is a very good one as well. So these are all good medicines to have in your packs actually, and they are fairly safe to start if you are again suspicious. If you are suspicious, get those things, get those thoughts into alignment. What are the symptoms? Am I in an area where there is a risk of this illness? Is this person on chemoprophylaxis? And if they are this generally should, if they are on doxy. They shouldn't be getting leptospirosis. They are not on anything. There is a risk. Um, you know, should I treat? Where am I, where is the health facility? Can I get a diagnostic test done? Yes or no. Ok. Severe. You're going to be looking at the, uh, Ketrax of some kind. Um, and it can lead to, as I said, dialysis and support. Ok. So we've gone through five already. We've gone through malaria. We've gone through Japanese encephalitis. We've gone through Dengue, we've gone through tick borne diseases and we've gone through leptospirosis. So we're going to move on to case study six, which is in a conflict zone. I haven't seen a case of this, but it's becoming more apparent certainly in areas of conflict. And this is because of a changing environment and a changing habitat or, or a habitat being made more available for some of these vectors. And that is a really important part to think about as well. So this is an example of a BBC picture from Syria. You can see that there's loads of debris, that debris creates pools of water, those pools of water create a vector habitat. And this area you are looking at the sandfly, the sandflies are small. Ok? If you have sandflies in tropical regions, which you will, for example, the jungle, they will get through a normal mosquito net. So you can double net, you can get a sandfly net impregnate the net again, deep clothing spray with deet long sleeves. I think the dusk and dawn again and they tend to, by ankle level, they tend to not to fly higher than ankle level. So again, boots, socks, etc and have your hammock if you are sleeping in a rain forest, particularly have it slightly higher, higher up. So they fly low. So again, prevention is the key. But this is an example of an illness that has evolved in an area where the landscape has changed. And the vector breeding sites have developed and this is leishmaniasis, this cutaneous and visceral. And in fact, Ben Fogle had, I think he had cutaneous. Actually, I can't remember exactly which one, but he was quite a famous TV personality who had leishmaniasis. And this is very, can be very common to the local population, less common than travelers. But something to be aware of the lesions are quite noticeable and they often call it the flesh eating lesion because they will cause necrosis of the skin and that skin to die and it looks like something to eat on the skin. Um and the visceral um um visceral leishmaniasis is organ injury. So, um splenomegaly, um fever anemia and you get this acute illness at the start called Kala Azar where you get a high fever, um and muscle ache, etc. And that's almost the start of the, the leishmaniasis. So, yes, be aware of it, please. Sandfly. Again, prevention, prevention, prevention. I haven't seen a case of this, but I'm sure people have, who have been away and it's harder to treat than it is to prevent in terms of bite prevention. Some examples of the kind of lesions you might see and it does affect the community a lot because if you get one of these lesions on your face such as this lady, this is a BBC image, you know, her chances of being married off fitting into community are massively affected and you get stigmatized and excluded from community. So it's a really serious illness in many of the communities. This is I think in South America and he said in Syria, so a really nasty illness and again, understanding the reading sites, understanding the disease profile and how we prevent it. Treatment is liposomal amphotericin, not easy to get hold of, particularly if you are overseas or sodium gate and these are often given via the tropical medicine hospital. So I think Liverpool London in the UK. So you would probably, I don't know for sure whether you need to casi back someone home, but you certainly need to know where your treatment centers are for leishmaniasis. But it really is important by prevention. And that's why I say about why I didn't take malaria prophylaxis in Sri Lanka, it's called pale, wasn't the Rife disease. It was actually probably Dengue. And so I needed to do really good bite prevention. And so if I did really good bite prevention. I wasn't going to get bitten and I did a little bit but really barely a handful of bites. Over that nine months I was there and I was just very strict in my regime of bite prevention. So it can be done and it's really important. Just a couple of examples there, of the outbreaks of leishmaniasis and so up to date, read the who CDC websites, UK, traveling websites on what is up to date and what's happening in the world. OK. I think we're moving on to the next case study. Rally International. So again, a very common place that people go the police jungle again. And this is a trip that many gap peers take. It might be a trip you go on as a medic. First of all, I think Rally International is still up and running. There's other other examples of similar organizations that take long standing projects to a relatively safe area with an experience there of expeditions and that's quite helpful as a medic. So this is the bot fly. Yes, the bot fly. Um This is, this is causes quite a lot of interest I think from travelers. So this is a mainly just a horrible thing rather than disease transmission. It can transmit disease most commonly in locals but not so much in travelers prevention is the key. Ok? Things like spraying your clothes with deet when you hang your clothes out overnight in a camp, shaking them down to get any larva or eggs off the clothing, spraying them with deet. All of those things will prevent these being patched under your skin. And basically what happens is that you'll get the but fly will lay its eggs on your clothing. The larva a hatch burrow under the skin and they cause these crater like bites, almost bit like mosquito bites. And they feed, they have little feeding organs that kind of pop out the top of that crater and then eventually they will emerge and they'll change into the fly. Now they can migrate to other areas of the body. They have been found in locals, in parts of the brain, etc, but I don't think they cause common illnesses apart from them being horrible and can get obviously a cellulitis around it in travelers. But prevention, prevention, prevention is the key rally. Talk about bo box squeezing competitions. You know, you can potentially squeeze them out, you can leave them to hatch, you can put Vaseline over the top, they kind of suffocate, but then you've got to get the larva out otherwise they cause a local infection. So it's trying to prevent them even hatching. And then when you are in the first place, really, this is a very rare case. It's probably not even a genuine image to be honest, but I know that they can migrate to other areas of the body and they are just not very pleasant really. I've been in the jungle lots of times. And I've never had one because again, taking really good care of where I oh hang on. We've gone back a couple where I um uh how I manage my clothes, how I use deet, again, prevention. OK. So just some funny, interesting images there that's from the top of my head. Um If you do get a local infection from either a bite or this sort of thing, then flucloxacillin is good. And you've got lots of stories. This is over 10 years ago, but he went to the Gambia and he had but fly maggots under his skin. And so they would be able to treat them in hospital as well and they would get cover with flucloxacillin. Probably again, prevention is the key. Ok. We're nearly through this hour or so of a rapid overview of tropical medicine. So case study seven, if my slides would like to move on. Here we go, Lake Malawi. Straight away. You should all know what I'm going to talk about. I've never been, I've not seen a case but um common in Lake Malawi. It's schistosomiasis, fascinating illness. And I did a lot of looking at the eggs of the Sisto when I was at the diploma of tropical medicine. Um It's common this illness in Lake Malawi. Ok. It's known for travelers. It's known for locals. You can get a swimmer's itch. Ok as well, which is quite a common symptom prevention is the key. But also understanding the life cycle. If you understand the life cycle, you understand potentially how to prevent it. So um the eggs are released in poo, they are released in wee. Um they are released in coughing sometimes. Um and the eggs hatch um the myrica penetrate a snail. So there is a co host. The Bill Harps snail is the host of these miracid. And these will then evolve into spores. So they kind of act as the organ in which these we kind of develop. And these are then released into the water by the snail. They are called cerura. Now, the snails live by the reeds. So if you walk through the reeds in Lake Malawi and you don't have shoes on the snails and these little ceraria that are released are attracted and they will get drawn towards the skin and maybe it's the heat. I don't know what it is and they will then penetrate the skin generally in the feet, but can be anywhere and they will then migrate and they can live really in the gut, in the bladder and in the lungs as well. And so if you're in the bladder, you'll be peeing out the eggs. If you are in the gut, you'll be pooing out the eggs. And if you are in the lungs, you'll be coughing up and they can be really nasty illnesses. And you can see here that they penetrate the skin, the CIA lose their tails and they can become s schistosome and they migrate, as I said, and they mature into adults and so they can stay there for a long time. It's a chronic illness and it can be common in the locals. Treatment is fairly straightforward to be honest. But prevention is the key. And again, prevention is by wearing shoes, not swimming in the areas where you know, there is Bill Harzia and being aware of the signs and symptoms. This is an example of a chronic condition. Again, a photo from BBC archive of hepatosplenomegaly from schists in the gut. And again, a chronic illness, this is a lung of schistosomiasis. Again, I've not seen it. But again, in your differentials, someone has come back from Lake Malawi, been traveling, got a cough chest X ray looks like this. Could it be schistosomiasis? So, again, really interesting to think around the transmission and the pathology of these types of diseases. Prevention is the key wearing de wearing shoes in the water, try to prevent the penetration, avoid the reeds where the snails are. So the snails are that host. OK. And then hand hygiene. So if you've been around the mud around the lake and then you need to wash your hands etc before eating praziquantel two doses for one day. That is it. So it's easy to treat, but you've got to identify it first, not so easy when it's chronic and in the local population. But praziquantel should be part of your med kit if you are going in that direction of the world. OK. Case study nine. We're looking at Vietnam and we've got lots of flooding and hurricanes. We're looking at a change in environment again and this is an illness I've seen quite a lot of and you can see here it's got a very fine red rash, harder to see on some skin types, but there's a very fine rose tinted sort of rash there. And slightly, I think it's slightly raised actually. Um common in many places. You can have a vaccination and it's good water hygiene and hand hygiene to prevent this. It causes a kind of pattern of high temperature peaks and troughs often can cause a heart rate that doesn't really link in with the high temperature. So it doesn't get fast, it doesn't go high and there are some clues and it can cause quite a few complications. And this is a very much distended bowel from Typhoid, which is the illness. So it can cause a megacolon, um which can be very, make someone very, very sick as well. I've seen a few cases both in locals and in travelers. Um and again, it's fairly straightforward to treat. So think about your source. So think about water sanitation, think about the area you're in bottled water. How do you sterilize your water, hand hygiene, toileting, all of those things will help prevent illness. What are your what vaccinations have your team come out with? Ok. Have you had your typhoid? Are you up to date? Again? There is a preventable strategy there as well. So it's very important that we are looking at the preventative strategies in order to avoid getting this if people get the disease and it's kind of diagnosed by this high fever. Um, pulse can be quite low. Um This fine red rash can be very sore abdomen, perhaps, um nausea, vomiting, diarrhea, all of the above treatment. Chloramphenicol tablet. Actually in many countries is a very good treatment but or amoxicillin, azithromycin and a cephalosporin. So you've got different options. Really look for the most up to date. This is, this is a little bit out of date 2003. But the treatment often links around chloramphenicol as well. So it hasn't changed hugely and Azithromycin can be very useful as well, but do look for the most up to date treatments there. Again, avoidance is the key think about your areas where it's rife and then your water sanitation methods. Typhoid is horrible. I've seen one case in the UK from a traveler, he had returned from India. Actually, it was it was traveling, traveled from India and had this kind of 78 days history. It was very poorly, I think uh blood counts were low as well and uh massively high fever and then um Typhoid was, was diagnosed. So yeah, really interesting illness. Um Remember that it can occur. So this was um interesting in Hood in Switzerland many, many years ago. But there was an outbreak because of, again, let's think about the water sanitation measures. Um This was a 62 year old, died in hospital. Um And this was all tourists from the ski area. There was a big spread of infection and so they quarantined the area and avoid people, obviously going there and reducing the risk. This was in um Bali. So she got Dengue and Typhoid. Ok. Well, he got Dengue and Typhoid, an additional Australian traveler and thought they were immune, perhaps didn't get vaccinated and got very sick. So this was about 5, 10 years ago. So it does happen and it is preventable. So again, your job is to make sure there is prevention in place. Ok. Number 10 IDP counts. I spoke about these earlier is when you get a big displacement of the population and they all habitats in one area and you get a change in um debris, food waste, food waste attracts predators such as snakes. Sorry, rodents, rodents attract things like snakes and snakes come in and snakes are a problem. And I have seen a lot of snake bites in Sri Lanka. Lots and lots. It is one of the biggest in elected tropical diseases and the deaths from an envenomation rank high amongst the tropical diseases. You can see there. We talked about leishmaniasis, we talked about Dengue, we talked about Japanese encephalitis. We know about cholera yet snake bite is one of the biggest problems. And there is a huge label program on bite prevention and treatment prevention is the key wearing boots, avoiding food, debris, avoiding rodents, being safe to ensure you don't risk bites. And that will be in the jungle in the urban areas. And we have certainly had a risk in the jungles and we have had a snake bite which I'm going to tell you about. I saw plenty in, we had a snake about an expedition which I can tell you about. I saw plenty of snakes in Sri Lanka. This was in our compound. This was a crate. This is neurotoxic. Very big. There's my flip flop, see how big it is. They come in at night, they curl up next to people sleeping on the ground in tents, in displaced population tents, they curl up, person rolls, snake gets disturbed, bites them. They might not notice they then get some signs of neurotoxicity. If they are envenomate. A lot of bites are dry. A lot of bites are dry bites. They don't give the envenomation, but a lot aren't as well. So, neuro symptoms from this spike would be things like ptosis, drooping of the eyelid, unable to swallow, unable to cough. And I saw plenty of these in Sri Lanka and they came in quite late stage and they move on to get respiratory muscle paralysis, but fully aware and awake but unable to breathe. So they need ventilating and they need, we gave them polyvalent antivenom. So it can be very serious. This was another case and this person has given permission for to use the slides. This was a cobra bite in Sri Lanka on the foot. So a lot of farmers go barefoot. A lot of people walk barefoot. This is a hemo and neurotoxic snake. So it's going to cause bleeding and neuro symptoms. This gentleman you can see had ptosis and he has given permission for these slides to be used. You could see drooping of the eyelids, he couldn't swallow and he had a very weak cough and we, the next stage was going to be ventilating him. He had myoglobinuria. So this is a brown, red colored urine from a kidney failure and bleeding. And this was one way for us to detect it because we didn't have blood tests there. We had full blood count was our only test, which was done by a lab technician using those squared slides where you count per 10 slides, times it by 10 to be nine etc. So we couldn't get ees, we couldn't get electrolytes, we couldn't find what the potassium was, but we could through other methods. Do an ECG. Were there any signs of hyperkalaemia treat? Anyway, give some calcium, give fluids. What was the renal function likely to be like when you've got myoglobinuria like this? So we treated him with multiple vials of polyvalent antivenom. Polyvalent is the most commonly available, often not taken on trips in packs but very easily accessible from local health facilities. Make sure the source of it is known though because some of them are not effective and make sure you know where your health facility is and how to access polyvalent. There is a risk of anaphylaxis with it. We tended to give some steroids and Pyraton first and have adrenaline ready. Um And he didn't have any anaphylaxis, but you can because it's made of multiple different types of proteins from horses. Um polyvalent rather than monovalent and it's not specific for the snake, but it can be effective. He had probably 30 vials, I think he got serum sickness afterwards, which is quite common but was treated, I think with steroids for that. And he did very well. And this is about three weeks later. He came back to visit us, didn't need ventilating. Platelets must have dropped, time worsened. He bled from his gums and his abdomen and pr bleeding and had myoglobinuria had ptosis, didn't progress to any more neurological symptoms. And so yes, it's very much salvageable, but you've got to treat early. Ok. And just to finish on really is that this is a case of an expedition. We went on many years ago, about 1012 years ago to the jungles of Costa Rica. We were doing adventure race which included a mountain biking rafting and trekking and an overnight stay in the jungle. We took the group up, all were junior medics of some kind and I had three medics with me. I was expedition leader in the jungle setting up camp. We had a local guide cleared the area, everyone was wearing boots, long sleeves, etc, we've done a lot of promotion about bite prevention and snakes. And then one of the female participants walked just past a tree between the fire area and the tree and she walks past and s out and she goes, I've been bitten occasion. So nearly nighttime, top of a jungle in Costa Rica, about five or six hour trek to get there. Plus a river crossing. And she says she's been bitten, she's got trousers on. Do you think it's a snake bite or do you think it's a twig? Ok. So you've got to make that call first of all. So while the local guy went off to find, to see if there was a snake, we had a look at her, the guide came back with a snake head. Now, I we didn't ask for the snake to be killed, but he did kill the snake. Um And this was the snake that we thought had bitten her. So you can see some enormous fangs and rolling up her trousers, which were proper cargo trousers. This was the bite. So I was like, OK, she has been bitten. So immediately I put her in the Hammock put a cannula in her, uh gave her some pyriton and had out some steroids and also asked her to keep her legs still. And I wrote a time, a bite time down on her legs. So we knew what time it was. In the meantime, my colleague arranged a team to evacuate her through the jungle, which was hard work and it was carrying improvised carriage through a rucksack carrier stretcher carry, basically minimizing the movement of her leg. We didn't strap the limb, we just splinted it using improvised splintage so that she kept it quite immobile and this reduces the use of muscles which then potentially pump this venom around the system. Now, about half an hour in an hour in, I was pretty sure this was a dry bite and the reason being is that there was no local bruising around that site and that she had no other symptoms. She wasn't developing any symptoms. However, I wasn't 100% sure. So I was quite nervous about, you know, what might happen. And if she had been envenomate, this would have been potentially fatal. So we'd already wrecked the local health facility. We knew the area well, we had a local guide and a leader, but we knew it was about two hours away and that was the local facility and that had blood facility and it had polyvalent antivenom as well. So we carried on evacuating her down. It was very tough. It was a good few hours. And at the bottom, this was our camp, by the way where she was bitten and at the bottom, we crossed the river with her and then into the back of a four wheeled truck and then I carried on with her to the health facility with the main leader. Meanwhile, my colleague went back up with the team. No, back to the camp with the team. There was already a medic in the site up high. And then first thing in the morning they carried on up. So I had three medics with me. Luckily because you couldn't leave the rest of the team without a medic or a co leader. So it's really important to plan for that as well. And this is why we talk about expedition companies needing to ensure they have the right resources and medical kit. So what are the risks? But there is about 50% of dry bites. That means they are not injected venom. You're not going to know that though. So you've got to evacuate that patient. Really? Will you carry polyvalent with you? That's up to you really? But I haven't ever carried it. But I know where the source of polyvalent is time critical. If they are envenomate, they are manageable. You can treat snake bites and there is a risk of compartment syndrome in the limb. So mark the limb. We don't tend to bandage it, do a compression bandage. You can loosely bandage it, splint it, evacuate that patient, get them to the hospital where they would do the bloods and they would start treatment if they feel that there is a risk of animation. Our patient was stayed in overnight bloods all fine and came out the next day and we were very lucky, but we took a lot of precautions. She still got bitten. So, yes, really important. Just quickly. There are hemo and neurotoxic snakes. We could talk all day about snakes. Be a little bit familiar with where you are going and what the risks are. Know the different types of pathology if they get bitten and really do know the local health center that's really important. Ok. Read around it about immediate treatment. Have your periton, have your steroids, have your adrenaline ready if they get given polyol antivenom as well. Some may have monovalent and be sure of the type of snake that has been bitten. But many places don't. Australia has a lot of monovalent antivenom, but they are familiar with the snakes. Ok? And this is just an example, this is actually very easy to get hold of but making sure it is a good one, unknown. So look at where it is produced and there was a recent report on the effectiveness of poly antivenom, somewhat, not effective at all. So just again, do a bit of research, ok? Know what you are looking for. Ok. So I think we are pretty much finished around the world. In 10 tropical diseases, there are 100s more diseases to talk about. There is things like Zika virus, there is things like smallpox and recent outbreaks. There is things like Ebola, there are things like Coronavirus, but I am not going to talk about that now because I've done an era of the common topical diseases and hopefully this will trigger you perhaps to read a little bit more about them as well. And to look up, if you are going to an area where there is monkeypox, then know where there monkeypox know the transmission, know how to prevent it, which is key, know about your personal protection equipment and your disease profile. If someone does get it, know about your vaccination schedules for your diseases, it's really, really important. You empower yourself and your team with prevention, health, health, disease prevention prior to going away. Ok. And when you go away, if you are going an expedition, does that company have the right CASAC set up? Are they familiar with the local health resources? Do you have a good equipment list and kit list? What are your participant group like? Are they compliant? Are they aware? What pre briefings can you do? Can you do them in person? Can you do them online? How much of that can you work on to try and prevent disease? It makes your life a lot easier if you don't get exposed to this, if you are going with an organization such as the Red Cross or MSF. They are normally very well set up, read around their policies, read around the risk yourself, make your informed choice about whether you are going to take prophylaxis etc. And remember that tropical diseases are one risk. Road transfer, road travel is by far the greatest risk for many of these countries. So there's not just the tropical diseases to be aware of but also road safety etc, but that's a whole another topic I'll stop there. I hope this has been useful and enjoy your travels. Many thanks.