Who is this famous American?

Americans love to fight. All real Americans love the sting of battle

General George S. Patton

Fought in WWII, survived dangers of bullets, tank

shells, the Germany Armys battle of the Bulge Was riding in back of a car going around a country road, unseen truck came in front of the carRoad Accident Low Speed Accident; two other passengers were uninjured Patton was thrown forward and head hit a partitionCervical Spinal Cord Injury Death Patton Museum at Fort Knox, south of Louisville

Road Accidents
Car & motorcycle crashes are the leading cause of injury in

travelers and expats Not drinking and driving Wearing seat belt, using car seats or booster seats for children. Following local traffic laws Wearing helmets when your ride motorcycles, bicycles Not getting on an overloaded bus or minibus Hiring a local driver Avoid night driving

Who were these famous Americans?

Gold is a treasure and he who possesses it does all he wishes to in this world.. Capitalism is the legitimate racket of the ruling class

Christopher Columbus and Al Capone

Both spent time in prison (Columbus for being a

vicious governor after his 3rd voyage) Al Capone died in prison, his days hastened by Nuerosyphilis Theories go back and forth whether Syphilis was brought to Europe by Columbus and his sailors In Columbus final days he was experiencing urinary symptoms; frequency and burning ?Diagnosis

Sxually Transmitted Infections

Sexually Transmitted Infections

Sexually Transmitted Infections (STIs) are a frequently encountered health issue
Living as an expatriate can lead to behavior one may not entertain while living in ones home country (e.g. cuisine choices) Alcohol consumption is a predisposing factor for STIs Quoth the Boxing Referee to the two pugilists Protect Yourself At All Times

Who is this (In)famous American?

(Typhoid) Mary Mallon (1869-1938)

Typhoid Mary
She was the first recognized asymptomatic carrier of Salmonella

typhi, causing the disease Typhoid She was probably infected at birth (her mother had Typhoid) Between 1901-1915 she infected 53 known people with Typhoid (and probably many more unknown), 3 died She was forcibly quarantined 1907-1910 by NY State She agreed in 1910 to become a luandress rather than a home cook and released. She changed her name and went out cooking again until 1915, infecting another 25 more people. Quarantined to the end of her life; At Autopsy she was found to have Salmonella typhi in Gallbladder

Typhoid
Acute (4 weeks) illness, with fever, abdominal pain,

headache, sometimes a rash (bacteria that cause can invade through the gut) 22 million cases/year worldwide; 200,000 -600,000 deaths/year worldwide Considered a Disease of the Most Impoverished (expats are usually not in this category) Humans are the only host, transmitted by fecescontaminated water & can be transmitted by close contact with the infected, food preparation by infected/infected carriers Viet Nam Incidence; approximately 7,000 cases/year but it is very regional; Most affected provinces; Lai Chau, Soc Trang, Dong Thap, An Giang, Son La, Nhin Thuan, Kien Giang. HCMC has a very minimal incidence.

Typhoid Vaccination
Typhim Vi; Single dose, with booster every two years if

continued exposure is expected Age 2 years and above Side effects; Injection site tenderness, fever at low rate, headache, bodyaches Not 100% protective; from 50-80% protective Pregnancy; No studies; Pregnancy Class C

Who is this famous North-American (Canadian)?

Its great to be a blondewith such low expectations its easy to impress

Pamela Sue Anderson

Pamela Sue Anderson is a person who has/had Viral

Hepatitis (Hepatitis C); obtained she reports from shared tattoo needle that her and rock musician Tommy Lee had in common Hepatitis C cannot be vaccinated against unfortunately Hepatitis A and Hepatitis B, ARE vaccine preventable illnesses fortunately

Hepatitis A
Hepatitis A is the most vaccine-preventable illness

in travelers and expats A virus that is transmitted by fecal-oral route; e.g. poor hygiene in infected restaurant workers with diarrhea from the infection When it infects children, usually does not cause a problem, resulting in a non-specific diarrhea. Adults >35 have the highest risk from complications; prolonged illness, months-long hepatitis, liver failure, rarely death

Hepatitis A
Its a one time illness and does not lead to a chronic

state It is not sexually-transmitted, (unlike Hepatitis B) Immunity comes from prior infection or from vaccination.

Hepatitis A Vaccine
As one of the biggest threats in travelers in developing

countries getting vaccinated is very prudentbest vaccine for your money Comes as vaccine for only Hepatitis A itself (HavRix); 2 dose series; Day 0 and at 6 months Also comes as part of joint Hep A/Hep B vaccine called TwinRix; Day 0, Day 30 and 6 months

Hepatitis A Vaccine #2
After the first dose of Hepatitis A you can generate

protective antibody between 2-4 weeks A single dose will protect 90% of those vaccinated A second dose is added to achieve a near 100% protection of vaccinated individuals Pregnancy; No studies; Pregnancy Class C

Hepatitis B
Can be easily transmitted by blood-to-blood contact,

can be transmitted sexually (not as effectively as blood-to-blood), and can be transmitted congenitally from mother to child Highly Endemic to Viet Nam; 50% have had infection Discarded Hypodermic needles on the beach, infectious Hepatitis B particles can hang around for weeks under right conditions

Hepatitis B #2
Upon infection, most cases are asymptomatic
The Hep B virus DNA inserts into our own DNA and

remains for life 85% of infected individuals will clear the infection to the point that no more viral proteins are made. 15% will become carriers, chronic producers of Hep B surface (s) Antigen protein and may also have low grade ongoing hepatitis with elevated liver enzymes

Hepatitis B #3
A small percentage of infected individuals will

continue to produce the Hep B surface Antigen and the Hep B envelope (e) Antigen Hep e Antigen positive patients are highly infectious and are producing fully capable viral particles Chronic infection over years leads to an increased risk of Liver Cancer; actual degree of risk depends on many factors

Hepatitis B Vaccination
Also a great bargain, and important to have in living in

Viet Nam, S.E. Asia, China Universal vaccination is now taking place in Viet Nam and in most countries Vaccination available as Engerix-B alone or in combination with Hepatitis A (TwinRix); Day 0, Day 30, 6-12 months Pregnancy: No studies, appears safe; Class C

Hepatitis B Vaccination #2
Protective Antibody is generated after this 3 dose series

in 90% of individuals A 10% failure rate is good enough if you are living in the USA, Canada, Japan..low endemic areas In Viet Nam, recommend checking the 100 to find the 10 that fail to generate protective antibody due to high risk, high endemic environment. Check for protective antibody 6 months after 3rd dose. Failure to generate protective antibody requires a new series of three doses

Who is this famous American?

Take thy beak from out of my heart, and take thy form from off my door! Quoth the Raven, Nevermore

Edgar Allan Poe

Died 4-5 days after being found in a delirium on the

street, wearing clothes that were not his own His treating physician at the time documented his symptoms; a waxing and waning delirium, with periods of lucidity, and then agitation An anonymous case of a 39 year old male was presented to University of Maryland Medical Investigators of Poes symptoms Most Likely Diagnosis they settled on?

Rabies
An invariably fatal disease if rabies virus infects

without having been vaccinated Viet Nam; 1980s approximately >3,000 victims/year, 1994-558 deaths, 2004-81 deaths recorded Thailand study; 7% street corner dogs carriers of Rabies 2 years ago an outbreak in Bali claimed the lives of several tourists

Rabies #2
Largest resevoir of Rabies in S.E. Asia is domestic dogs.
Other possible sources can be monkeys, while bats are

a source of some cases of cryptic rabies Vaccination; Pre-Exposure Vaccination versus PostExposure Vaccination

Post-Exposure Rx and Vaccination

Category I; touching or feeding animal, licks on intact

skin No treatment required Category II; Nibbling of uncovered skin, minor scratches or abrasions, without bleeding Immediate vaccination and local treatment of wound

Post-Exposure Rx #2
Category III; Single or Multiple transdermal bites or

scratches or abrasions, licks on broken skin; contamination of mucous membrane with saliva from licks, exposure to bats These exposures require immediate vaccination and administration of Rabies Immune Globulin (RIG); local treatment of the wound(s)

Post-Exposure Rx #3
Post-Exposure Vaccination is with Rabies Vaccine Verorab; Series of 5 doses; Day 0, 3, 7, 14, 28
Rabies Immune Globulin; Human Rabies Immune Globulin (HRIG; very expensive) and Equine Rabies Immune Globulin (ERIG; cheap, but 3-5% of serum sickness reaction) Pregnancy is not a contraindication to vaccination; No studies however; Pregnancy Class C

Pre-Exposure Vaccination
Pre-Exposure vaccination; series of 3 doses; Day 0, 7, 28 (or Day 21). It has numerous advantages. If exposure does occur, then only two doses are needed at time of exposure; Day 0, 3 No form of Rabies Immune Globulin is then required Children are most likely to be bit or have a Category II or III exposure Children may not tell a parent for various reasons about the exposure

Who is this famous....?

Japanese Encephalitis (J.E.)

Transmitted by Culex species mosquitoes Pigs and wading birds are the targets of the mosquitoes,

but humans are good for a blood meal if the opportunity arises Culex mosquitoes bite outdoors, in the evening/night time, and around agricultural areas harboring the natural hosts (therefore stay away from pig pens at night) Humans are a dead end host for the J.E. virus, as there is usually low levels of virus generated in the blood and cannot be transmitted to new mosquitoes Only 1% of human infections result in symptomatic disease, most are asymptomatic or with few symptoms

Japanese Encephalitis
J.E. is closely related to West Nile Virus, St. Louis

Encephalitis Virus, and Murray Valley Encephalitis Virus After Polio Vaccination programs eliminated Polio Virusinduced neurologic disease, J.E. virus has become the most prevalent cause of virus-induced neurologic complications in Asia 50,000 diagnosed cases of J.E. in Asia with 10,000 mortalities; In 2007 Vietnam recorded 17 deaths from J.E. , likely an underestimate. Malaria mortality is around 34/year. In symptomatic disease, however, there is a 30-50% rate of permanent neurologic deficits in survivors

J.E. Vaccine #1
JE-Vax; Three dose series; Day 0, 7, 28; two doses not very

effective, 3 doses gives neutralizing antibody in 87-100% Unknown how long effectiveness lasts, 3 year booster recommended for those at risk Vaccine does contain a number of components (thimerosal, gelatin, and proteins of rodent origin) that can cause allergic responses from 1-3 days after and up to 10 days post-vaccination. Person receiving the vaccine are not to travel outside of an area of adequate medical attention for 10 days after receiving the vaccination (no commercial flights)

Reccommendations for J.E. Vaccine

Expatriates based in urban areas but who are likely to travel

to into endemic agricultural, rural areas at high risk periods (warm, rainy climates) High Risk activities; spending substantial time outdoors in agricultural areas, especially in evening or night. Participating in extensive outdoor activities; camping, hiking, trekking, biking, fishing, hunting, farming. Staying in accommodations without air conditioning, screens, or bed nets in rural/agricultural areas Travelers to endemic areas not certain of their activities, destinations, duration of travel

Who is this famous A?

Dengue; The Virus

Four Subtypes of Dengue Virus; #1-4
The 4 types of Dengue Virus are closely related but

serologically distinct Transient or weak cross protection occurs among the 4 serotypes, persons living in Dengue hyperendemic regions can be infected with three probably four different serotypes during their lifetime

It takes two to Tango: Dengue; The Vector

Aedes aegypti mosquitoes are the principal vector, but also

Aedes albopictus carries the virus A. aegypti/albopictus have many characteristics which make them ideal vectors for dissemination A. aegypti/albopictus breed in or close to houses, laying eggs in man-made or natural water containers Typical flight distance is short Daytime feeders and typically go unnoticed; A. aegypti like to bite around dawn, or cooler parts of day. A. albopictus bites in middle parts of day

Dengue; The Vector #2

A. aegypti are easily interrupted and move onto other

hosts frequently Take multiple blood meals in a single breeding cycle A single infected mosquito can transmit the infection to several individuals within a small area. Family members at home during the day, typically women and children are at highest risk

Dengue; The Vector #3

An infected A. aegypti mosquito remains infected for

its life Infected female mosquitoes can pass the virus into the next generation by infected fertilized eggs (occurs infrequently however) Humans are the main amplifying host for the virus

Dengue; Transmission
Two patterns of Transmission have occurred; Epidemic

and Hyperendemic Epidemic transmission occurs when introduction of the Dengue virus into a region occurs as an isolated event involving a single strain Incidence of infection in this situation is often 25-50%, and can be considerably higher

Dengue; Transmission #2
Transmission of Dengue Virus before World War II

almost always followed this pattern Seaports were the epicenters and served as the reservoir to spread outwards Ambient temperature is important; A.aegypti is widely distributed between latitude 45 N and 35 S

Dengue; Transmission #3
Hyperendemic transmission refers to the continuous

circulation of multiple Dengue virus serotypes in the same area Requires year round presence of competent mosquito vectors, large population base, and steady movement of individuals into the region Incidence of infection from year to year varies but follows with regular spikes every 3-4 years

Dengue Transmission #4
Viet Nam has been a Hyperendemic region/country

for > 40 years. Risk to travelers is greater in Hyperendemic areas Factors contributing; Increased vector density, shorter incubation period of mosquitoes (higher ambient temperatures), population growth, poorly planned urbanization, overcrowding, changing lifestyles relying on plastic containers and tires, modern transportation, and lack of effective mosquito control measures

Dengue; The Infection

Asymptomatic Infection; In a study done under high

surveillance in Thailand; 53 % of dengue virus infections were not associated with a recognized febrile illness in school aged children Almost all infections in adults are symptomatic Incubation Period; symptoms develop between four and seven days after the bite of an infected mosquito, range may be 3-14 days

Dengue; The Infection #2

Classic Dengue; an acute fever often accompanied by;
Headache Retroorbital pain Marked muscle and joint pains which had evoked the

moniker break-bone fever Fever typically lasts for 5-7 days, some patients display a saddleback fever curve

Dengue; The Infection #3

Primary Infection (first event) and Secondary

Infection (second, third or fourth infection event) Rashes are more common in primary dengue virus infection and in females Gastrointestinal symptoms were more common in patients experiencing a secondary infection

Dengue; The Infection #4

Symptom occurrence in frequency
Constitutional symptoms; Fever 90%, headache, eye

pain, body and joint pain 75% Rash; slightly more than 50% Gastrointestinal symptoms; Nausea and Vomiting 50%, and diarrhea 30% Upper Respiratory tract symptoms; cough, sore throat, nasal congestion 33%

Dengue; The Infection

Dengue Fever; Far majority are recovered from. Fever

for 1 week, but it may take 1 month to get fully back on your feet. Dengue Hemorrhagic Fever and Dengue Shock Syndrome are the most feared complications Names can be confusing as a patient can have Dengue Hemorrhagic Fever without having signs of bleeding

Dengue; Prevention
The most effective measures are community measures;

landmark study was performed in the provinces of Viet Nam, seeding water vessels with copepods that eat mosquito larvae. Eliminated transmission of Dengue in 32 rural communities Very difficult to implement in a large Urban environment, however Singapore makes strong attempts (The Mosquito Police) Insecticide spraying by government programs in response to Dengue Outbreaks are not very effective as the mosquitoes frequently breed inside homes

Dengue; Prevention #2
Wear long and covering clothing
Use of Insect Repellents (with DEET) Mosquito netting; coated with permethrin best;

although the mosquitoes are day-feeders, use of these may protect your kids in their afternoon nap, or when you sleep late Saturdays/Sundays Extremely difficult to turn your house and its immediate environs into a Dengue free-zone, but try to eliminate sources of standing water

Who is this famous American?

I have always been afraid of banks

Andrew Jacksons Diseases

President Andrew Jackson fought in duels, fought the Native American Indian Wars, and had a lifelong hatred for the British and fought them as well He had ball ammunition wounds to his chest from duels and the British wars, and arrow wounds from the Indian Wars festering lung and chest abscesses All these wounds would not take his life; Lung Tuberculosis would

Tuberculosis (TB); Burden

2 billion people today are infected with latent or active

TB Viet Nam; TB is highly endemic; up to 70% of the population has latent TB Therefore placing 70% of the population on treatment of latent TB cannot be done Living in Viet Nam we will at some time come into contact with people having active TB

Tuberculosis #2
Most common form of TB is Pulmonary or Lung TB; cough, bloody sputum, night sweats, weight loss, other symptoms
Many other forms of TB; of lymph node, of meninges, of skin, of bone, of Gastrointestinal tract, KidneyIt is the Great Imitator in Medicine/Medical History

Active TB requires treatment of course, Latent TBcomplicated; low or high endemic country

Tuberculosis #3
BCG vaccination for TB is given in Viet Nam
BCG vaccination when given on a population-wide

basis reduces the occurrence of extra-pulmonary forms of TB (e.g. TB Meningitis, TB of the Bone) in the population BCG vaccination does not reduce the incidence of Pulmonary or Lung TB

Tuberculosis #4
Viet Nam has implemented the WHO programme for

developing countries to reduce incidence of TB The Public Health/Medical System & Infrastructure if it can diagnose 75% of Active cases of TB, and successfully treat 80% of such casesyear-over-year incidence of TB will decline

Tuberculosis #5
Situation: Teenager Student at International School comes down with active TB. His classmates are N. Americans, Aussies, U.K., European, Korean, Japanese, and Vietnamese students.
Parents call up their primary care doctors back in their home countries and get several different recommendations, when taken all together many

contradict each other; which one is right? Should all students be prophylactically treated?

Tuberculosis #6
In the USA or low incidence countries, a case of TB

would undergo contact investigation Individuals may end up receiving treatment prophylactically based upon their degree (closeness) of contact. These measures are often Public Health driven to stop possible outbreaks that could spread, but may have individual benefit

Tuberculosis #7
Contact Investigation and prophylactic treatment is impossible in Viet Nam, essentially everyone is a contact, or becomes a contact. You live here long enough you could have several rounds of prophylactic treatment for each subsequent contact with an active case of TB Caveat: Infants, young children I defer to my Pediatric colleagues/experts An annual CXR, or if high risk exposure, then closer follow-up can be performed

Who is this famous American?