As the Ebola outbreak continues, here is an update on this rapidly changing situation as well as advice for Global Rescue members regarding travel:
The current outbreak of Ebola virus disease (EVD) in West Africa began in Guinea in December of 2013; however it was not identified as Ebola until March 2014. This delay likely allowed the virus to gain significant traction within the locales where EVD is now present. By May, EVD spread to Liberia and Sierra Leone, likely aided by very porous regional borders. EVD was imported to Nigeria by a single sick traveler in July from Guinea, which is not geographically contiguous with any of the original affected countries. Senegal also reported an imported case in late August. A Senegalese student who had been studying in Guinea was infected, developed symptoms and returned home to Senegal. There have been no confirmed cases of EVD importation elsewhere in the continent, or world, since the Senegal case.
As of the most recent World Health Organization (WHO) Situation Report dated 18 September, the current total number of cases associated with the West Africa outbreak is 5,335. This figure includes 2,622 fatalities as of 14 September. Currently, the only countries affected by the West Africa outbreak are Guinea, Liberia, Sierra Leone, Nigeria, and Senegal. Widespread transmission exists in Guinea (942 total cases), Liberia (2,710 total cases), and Sierra Leone (1,673 total cases). In Sierra Leone, dozens of new Ebola cases and deaths were recorded as the country concluded its three-day nationwide lockdown on 21 September. Nigeria, and Senegal have fewer than 25 total combined cases, and thus far have not seen the intense transmission noted in other affected countries. This is likely due to aggressive isolation efforts within both countries once import-vectors were identified, as well as public-health campaigns and response posturing by international healthcare organizations.
Unrelated Outbreak – Democratic Republic of Congo
There is an additional outbreak of EVD in Equateur province in the Democratic Republic of Congo. While the strain identified in the DRC is the same as the strain affecting West Africa, it has been confirmed to be epidemiologically unrelated. The DRC outbreak is believed to have started in the village of Ikanmongo, where a pregnant woman died on 11 August. She was reported to have recently butchered a bush animal, and then fell ill with flu-like symptoms. As of 17 September, there have been 71 cases reported, and 40 fatalities.
The outbreak zone within the DRC is remote – approximately 1,200 kilometers from Kinshasa. There are no major transportation routes that connect the zone with other regions of the DRC, and risk of transmission/importation to other major population centers is considered unlikely. U.N. analysis suggests that the outbreak there is under control at this time
Prevention is primarily guided by awareness of how the disease is transmitted, and practicing safe hygiene. These preventative measures may include:
- Avoid nonessential travel to Liberia, Guinea, and Sierra Leone.
- If you must travel, please make sure to do the following:
- Practice safe hygiene. Avoid contact with blood and body fluids of people who are sick with Ebola. Regular hand-washing is essential and highly recommended.
- Do not handle items that may have come in contact with an infected person’s blood or body fluids.
- Avoid funeral or burial rituals that require handling the body of someone who has died from Ebola.
- Avoid contact with wild animals and with raw or undercooked meat (bushmeat).
- Avoid hospitals where Ebola patients are being treated. Global Rescue can provide advice on facilities that are suitable for your needs.
Is it safe to travel during an outbreak?
While travelers should always be vigilant with regard to their health and those around them, the risk of infection for travelers is very low since person-to-person transmission results from direct contact with the body fluids or secretions of an infected patient.
Is it safe to travel to West Africa?
The risk of travelers becoming infected with Ebola virus during a visit to the affected areas and developing disease after returning is extremely low, even if the visit included travel to the local areas from which primary cases have been reported. Transmission requires direct contact with blood, secretions, organs or other body fluids of infected living or dead persons or animals, all of which are unlikely exposures for the average traveler. That being said, the Centers for Disease Control and Prevention (CDC) has issued Level 3 (Avoid Nonessential Travel) notices for Liberia, Guinea, and Sierra Leone. Should travel to one of these locations be necessary, be mindful of the prevention guidance noted above.
Snakes are an integral part to many ecosystems and, as an outdoor enthusiast, it is only a matter of time before you encounter one in the backcountry. Venomous snakes are most prevalent in temperate and tropical climates, with April-October being peak snakebite season. There are roughly 15-20 deaths per year in North America related to venomous snakes. The risk of dying from a venomous bite increases when multiple bites are involved and when the bite occurs in the very young, old, or in persons with underlying respiratory or cardiovascular problems. In the US, venomous snakes account for only about 20% of all snakebites and out of that 20%, many do not result in envenomation. Some studies suggest that up to 20% of rattlesnake bites are deemed ‘dry’ bites, with no venom being injected. Dry biting is a sign of maturity in the snake; more experienced snakes will use a dry bite as they try to gauge the level of a perceived threat and since snakes do not have an infinite amount of venom they will try to use it sparingly.
The majority of poisonous snakes in the US are pit vipers. Rattlesnakes, copperheads, and cottonmouth (water moccasins) snakes are in this family, known as Crotalidae. Typically, pit viper victims tend to be young males, 11-19 years old, who are bitten on the hand while trying to pick up the snake. Alcohol has been shown to be a common factor in these incidents.
The best guideline for snakes is complete avoidance. The old adage that ‘it’s more afraid of you than you are of it’ is generally true, and most snakes only bite when they feel threatened. If snakes are encountered, give them a wide berth and continue on your trek.
As there are many types of snakes, venomous vs. nonvenomous, and different types of venom, hemotoxic vs. neurotoxic, opinions on treatment methodologies can be as numerous as the different snakes themselves. However, many experts tend to agree that certain folklore treatments should be avoided. These include pouring alcohol over the bite, making an incision over the bite site, cauterization, amputation, use of electric shocks, and packing the extremity in ice. Many of these so-called treatments are urban legends. The use of suction (attempting to ‘suck’ the venom out of the bite) is controversial but all experts agree that if attempting this technique you should not use your mouth to apply suction.
Field management for snakebites should focus on limiting the systemic spread of the venom and rapid evacuation of the victim to a hospital equipped to handle envenomations. During the evacuation, you should do the following:
1. Keep the patient calm and inactive. Remove jewelry and constrictive clothing.
2. Clean around the bite site and keep the wound free from dirt and debris by covering with a sterile dressing.
3. Immobilize the limb in a neutral position.
4. Avoid the use of compression bandages unless bite is from a neurotoxic snake (coral snake, cobra, krait, or other).
For those with advanced medical training, continue to monitor vital signs, ensure airway is patent, be prepared to treat victim for anaphylaxis, nausea/vomiting, and pain. The patient should be continuously monitored for the first 4-6 hours. If after 6 hours the victim does not display any adverse signs or symptoms, it is generally safe to suspect a bite without envenomation. Support hydration orally if possible, start an IV in an unaffected limb if available. Defer food ingestion during prompt evacuations; if a prolonged evacuation is presented, nourishment will become important to support strength and health. Avoid alcohol intake. Evaluate victim’s tetanus status and consider giving tetanus toxoid. Antivenin is the only proven therapy for snakebite but only when it is specific for the snake involved. DO NOT try to kill or capture the snake for identification purposes. Dead snakes, even several hours later, can reflexively bite injecting venom causing either a second bite or biting another member of the group. Embrace technology and snap a photo with your smartphone…using the zoom!
Wherever your travel takes you, Global Rescue encourages you to do a thorough area study of your destination and research the native flora and fauna that might be harmful.
Read here about a medical evacuation we conducted for a member bitten by an African cobra in Namibia.
With the spread of the Ebola virus in West Africa, many organizations are seeking guidance on how to best protect their employees in the region. The majority of questions have been about the risk of travelling into the affected and nearby countries: Is it safe to travel? Should there be suspension of employee travel to certain countries? If so, for how long?
Global Rescue recommends evaluation of the best course of action for your organization within a range of possible options and your decision-making process.
The World Health Organization (WHO) declared an international public health emergency on August 8th, signifying the outbreak of the Ebola virus as an extraordinary event with possible international consequences if the virus continues to spread. The situation on the ground is very fluid, with new cases and deaths being reported daily in the three primary affected countries (Sierra Leone, Liberia, and Guinea). In addition, there have been 13 cases, including two deaths, identified in Nigeria as of August 11th. Health screenings have been implemented at airports and border crossings in the region, and multiple airlines have ceased their activities to and from the three primary affected countries. Authorities in the affected areas are implementing strict screening and quarantine measures, and movement of people across borders, with illness symptoms similar to those found in Ebola (fever, vomiting, diarrhea) will likely be impossible. Despite these control measures, the outbreak is expected to continue for a period of at least one or more months.
Three alternatives exist for travel policy as current choices for organizations doing business in the geography impacted by Ebola:
Option #1: No restrictions on travel
This choice provides for corporate travel into the impacted area with the understanding that the risk to your employees is very low --- assuming they are not engaged in direct healthcare activities, preparations of remains for burial, or ingestion of infected animal products. It assumes that your employees can aggressively and consistently adhere to the recommended avoidance and protection practices recommended by the WHO and the Centers for Disease Control and Prevention (CDC). It also assumes your employees will monitor alerts and other travel warnings in their region, and that they will be able to take action to adjust their travel and movement as needed to minimize further risk.
There are indeed many organizations and corporations which are currently employing this strategy (within the affected areas), particularly if their work is mission-critical, and unable to be interrupted.
Risks to consider with this option:
--Travel may become limited or restricted further, i.e. employees may not be able to move out of the country when they need or want to.
--Limited access to safe and adequate health care in local or nearby facilities. There is no way to guarantee that a facility will not have Ebola cases in house. Transmission within the hospital setting is a very real concern in the affected areas.
Option #2: Restriction of travel to business critical
The second option is a curtailment of travel to business critical trips only. The CDC has recommended against all non-essential travel to Liberia, Sierra Leone, and Guinea. This strategy prohibits non-essential travel to these areas, as well as recommends strong consideration for removing personnel currently in these areas. An organization’s management would need to be able to define what activities and projects are “business critical,” both in terms of requiring on-the-ground presence and that the activity cannot be deferred until the outbreak is over.
Global Rescue has a number of clients that are adopting this strategy for the three affected areas as well as Nigeria.
Option #3: Banning travel
The highest level of protection for employees is a complete ban on corporate travel to one or more of the affected countries. This approach also includes consideration of facility shutdown and potential removal of all employees currently in the named country.
While providing the highest level of protection against possible exposure to the Ebola virus, this option severely limits an organization’s ability to continue business-as-usual in these areas, and may require shifts in project timelines and resource allocation. This kind of restriction can be very disruptive, but is sometimes chosen in very high risk situations.
There are a number of corporations and/or organizations that have adopted this strategy in response to this current Ebola outbreak, despite the disruption to business activity. For example, the Peace Corps has temporarily removed its volunteers from Liberia, Sierra Leone and Guinea.
Only an organization’s management can decide what is their best approach given the risks to their employees. Global Rescue is available to provide guidance, information, training and support to our members regarding travel to West Africa and other countries of concern. Stay informed with alerts from GRID, the travel risk product from Global Rescue. Contact us at 617-459-4200 or visit www.globalrescue.com for assistance in developing your corporate travel advisory policy and for additional recommendations on employee education and pre-travel procedures.
The growing Ebola crisis prompted the U.S. Centers for Disease Control and Prevention to issue a warning on July 31 against non-essential travel to Guinea, Liberia, and Sierra Leone, the West African countries experiencing the outbreak. Also on July 31, the government of Sierra Leone declared a public health emergency to ensure a proper response plan was being implemented to handle the outbreak of the Ebola virus. Additionally, the Ghanaian government announced on July 31 that enhanced medical screening in the form of body temperature scans will take place for those arriving at border crossings as well as at Kotoka International Airport (ACC) in the capital, Accra. Quarantine areas will also be set up at ACC and the country’s border crossings.
Global Rescue is advising our members to closely adhere to the World Health Organization guidelines:
· Infection by the Ebola virus is by contact with blood or body fluids of an infected person or animal, or by contact with contaminated objects:
- Contact with blood or bodily fluids of a person or corpse infected with the Ebola virus.
- Contact with or handling of wild animals, alive or dead or their raw or undercooked meat.
- Having sexual intercourse with a sick person or a person recovering from Ebola virus disease (EVD) for at least 7 weeks.
- Having contact with any object, such as needles, that has been contaminated with blood or bodily fluids.
- Symptoms include fever, weakness, muscle pain, headache and sore throat. This is followed by vomiting, diarrhea, rash, and in some cases, bleeding.
- Persons who come into direct contact with body fluids of an infected person or animal are at risk.
- There is no licensed vaccine.
- Practice careful hygiene and other preventive measures:
- In case of a passenger presenting with symptoms compatible with EVD (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhea, bleeding) on board of an aircraft, the following measures should be immediately considered, in accordance with operational procedures recommended by the International Air Transport Association (IATA):
- Distancing of other passengers if possible from the symptomatic passenger (re-seating); with the ill travelers preferably near a toilet, for his/her exclusive use.
- Covering nose and mouth of the patient with a surgical facemask (if tolerated).
- Limiting contacts to the passenger to the minimum necessary. More specifically, only one or two (if ill passenger requires more assistance) cabin crew should be taking care of the ill passenger and preferably only the cabin crew that have already been in contact with that passenger.
- Hand washing with soap after any direct or indirect contact with the passenger.
- Immediate notification of authorities at the destination airport in accordance with procedures promulgated by the International Civil Aviation Organization (ICAO).
- Immediate isolation of passenger upon arrival.
- Avoid all contact with blood and body fluids of infected people or animals.
- Do not handle items that may have come in contact with an infected person’s blood or body fluids.
- Avoid contact with wild animals. Do not eat primate meat (“bushmeat”).
- Practice good hand washing.
- If you have stayed in the areas where Ebola cases have been recently reported, seek medical attention if you feel sick (fever, headache, achiness, sore throat, diarrhea, vomiting, stomach pain, rash, or red eyes).
- The incubation period of EVD varies from 2 to 21 days. Person-to-person transmission by means of direct contact with infected persons or their body fluids/secretions is considered the principal mode of transmission. In a household study, secondary transmission took place only if direct physical contact occurred. No transmission was reported without this direct contact. Airborne transmission has not been documented during previous EVD outbreaks.
The following link can be accessed for more information: http://www.who.int/ith/updates/20140421/en/
Call Global Rescue immediately at 617-459-4200 if you are a traveling Global Rescue member and have questions, symptoms, or concerns about your health.
For the first time in their extensive travels, Lorne and Mary Liechty purchased a Global Rescue membership. For the first time, they needed it. On only his second day in Zimbabwe, Lorne found himself with an eye irritant that felt as if someone had stuck a needle in his eye. Four hours from the nearest medical facility, Mary turned to Global Rescue.
“We were trying as hard as we could to do what we knew to do,” Mary explained. She had attempted to flush the piece of debris out twice after Lorne complained that it felt as if it were poking into his cornea. “We talked to his personal ophthalmologist and then to his specialist. He has macular degeneration, and the specialist assured us it had nothing to do with the MD, and that it was likely something foreign in his eye. He said, ‘put the drops in, if it hurts don’t keep using them.’ So, we put one drop in and it was extremely painful, excruciatingly painful, so we didn’t put anymore in,” Mary said. In the midst of these attempts to ease Lorne’s pain, Mary called Global Rescue.
“I hadn’t even remembered to call you until I prayed and I just really felt like that was my answer for that moment, to be able to be at ease with what we were doing,” Mary continued. She spoke with several Global Rescue operations personnel over the course of multiple calls using a satellite phone from their remote location amidst connectivity issues.
The next morning, when Lorne’s condition had not improved as they had hoped, Mary packed up all their belongings in case they needed to be evacuated, and drove to Bulawayo to see an optometrist and an ophthalmologist. “The doctor put some kind of dye in Lorne’s eye. Everything that was damaged showed up red in his eye. It was more than a third, I would say close to half of his entire cornea that had been injured,” Mary said. “It was pretty amazing to me how much damage a little speck of nothing could do.”
Next a nurse at the facility professionally flushed Lorne’s eye. “Immediately he felt better,” said Mary. “He sat up and opened his eyes without pain for the first time in 24 hours.”
Mary theorized that the foreign object was a small piece of thatch from their cabin roof. Once the situation was resolved, the couple stayed over in Bulawayo for the night before returning for the remaining seven days of their trip without further incident.
Praising the affordability of Global Rescue membership, she continued, “I saw it as a good financial investment in my peace of mind for this particular trip. I told my husband it was very nice to have someone I could turn to when I was completely at my wit’s end, someone to share the unknown with.”
Mary continued, “More than anything else, I think Global Rescue gave me an opportunity to feel that there was an ‘out’ for this – that there was a way to handle our problems and not feel like I was on my own there in the middle of Africa, four hours from the closest doctor. Talking with Global Rescue gave me the confidence and assurance that, even if I am handling this on my own, I am not alone.”
Casey Conaway at the source of the Nile in Burundi
Global Rescue member Casey Conaway recently wrote to thank the Global Rescue team after a close call in Burundi, Africa. When a car accident caused several injuries, Casey turned to Global Rescue as her primary source of medical consultation.
“I am a missionary nurse in Burundi, a small country in East Central Africa. As one of the poorest countries in the world, Burundi is completely void of modern healthcare. What is available could be described as primitive and limited. Very basic healthcare at best is available in the capital city of Bujumbura.
“On April 17, 2013, I was traveling with my teammates in a Land Cruiser in a remote part of the country. We hydroplaned on a wet road and slammed into a concrete pillar and many tree stumps. I was thrown from the back seat to the front seat. (Seat belts in back seats are not required here by law and many vehicles do not even have them). I hit my head on the roof of the cabin, rammed my belly into the front seat bench, and somehow hurt my elbow. My friends arranged careful transport to the capital city where I saw a doctor and got an X-ray of my arm, an ultrasound of my belly, and the diagnosis of a concussion.
“A few days passed and I wasn't sure that my arm was not broken, as reported by the local doctor. I phoned Global Rescue for a consultation. Because cell phone and internet signals can be problematic here, Global Rescue was patient with me and very helpful in securing a line of communication. My call was received by a well-trained critical care professional who assessed my situation and injuries and provided some calm and reassurance. The Global Rescue team decided that my X-rays needed to be emailed to them, and advised me on the technical how-tos for emailing a clear picture. I was told to expect a reply in 24 hours, and that was indeed the case. My reply was in my inbox by morning. My accident did not require medical evacuation, however, Global Rescue followed my recovery and provided stand-by assistance. My regret in working with Global Rescue was that I did not utilize their services earlier. (I phoned three days after my accident).
“Global Rescue should not be thought of as only an evacuation option, but also as an organization that can help you stay in the field and recover with resources available locally. I would describe my experience with Global Rescue as professional, practical, and peaceful. An accident in the developing world can be traumatic on a whole different level. Global Rescue understands this and knows how to help.”
“Global Rescue Member in Action” April Mayhew submitted this “Ballers of Moshi-Town, Tanzania” image to our photo contest. Read about her trip to Mt. Kilimanjaro, her surprise encounter with the scenery and natives, and her game of soccer with the boys.
“I shot this picture in Moshi, Tanzania, while walking along the abandoned train tracks with a group of clients that had just arrived in country and were preparing to begin climbing Mt. Kilimanjaro the following day. We passed by the field, and I looked back to watch the boys play. Mt. Kilimanjaro had just appeared through the clouds (the backdrop), and the clients oohed and awed their delight bedside me.
“This game was the first in which the ‘Ballers of Moshi-town’ were wearing proper jerseys. To my surprise, the shadows and clouds captures the overall busyness of the moment, and I was able to fit in details like the old rubber tires lining the field and Kilimanjaro in the distance.
“This photo captures the movement and light while showcasing some of the exquisite qualities of one of my favorite places in the world.
“Once during a walk, the Ballers invited me to join them. I'm not sure what surprised me more: that my skills hadn't withstood the test of time, or that the boys could truly dribble a ball up one side of me and down the other.”
Do you have a great story to share about your travels? We want to hear about it! If you (or someone you know) would like to be considered as a “Global Rescue Member in Action,” tell us why in an email to firstname.lastname@example.org.
In today’s fast-paced world, cellular phones have become a primary means of communication. The technology has advanced rapidly and now people carry sleek smartphones full of apps you did not even know you needed. Cell phones operate off of cellular towers, with your cell phone bouncing its signal to the closest tower, which then relays that signal onward. As you travel farther from urban areas or travel into terrain that is hilly or mountainous, that cellular signal disappears as you are able to connect with fewer and fewer towers. How do you communicate when you are in an area with no cellular towers or where the terrain inhibits your connection to these towers? Satellite phones.
Satellite phones, or sat phones, are mobile two-way communication devices that use satellites orbiting the Earth to receive and transmit data. Sat phones rely on line-of-sight with their satellites to establish a connection. Since they rely on line-of-sight, they work best in open areas with a clear view of the sky. Using them indoors, in vehicles, and even in a city surrounded by tall building and wires will hinder your signal. Satellite constellations are either configured as geosynchronous or low Earth orbit.
Geosynchronous satellites, also called high earth orbit or GEO, are very large satellites that maintain a high altitude (around 22,000 miles) orbit and follow the Earth as it spins. This means that they are always centered along the Equator and generally remain in a constant location in the sky. A constellation of perhaps four satellites will be able to provide coverage for nearly the whole globe. Because of their size, these satellites are able to handle large volumes of data. However, because of their height, they have significant delays in transmission, resulting in momentary pauses for the person on the other end of the line. Since sat phones rely on line-of-sight, polar coverage is hindered and it may be difficult or impossible to get a signal if you are in a canyon or a mountainous area.
Low Earth orbit, or LEO, satellites offer a significantly lower orbit, around 900 miles. They are much smaller and lighter when compared to their GEO counterparts, and there are more of them in orbit. A typical LEO constellation consists of up to 60 satellites orbiting the earth at high speeds. This means that at any one time you will have line-of-sight to at least two or three satellites, giving you more reliable coverage if you are in a polar or mountainous region. Since LEO satellites are much smaller, they are more suited to voice transmission or short text/SMS messaging.
These days almost anyone can benefit from owning a sat phone. Are you a mountain climber or trekker who routinely travels far up in the mountains in small groups? Do you fish in exotic locales, isolated beaches, far down rivers that time forgot, or clear high-mountain lakes? Does the thrill of an African safari stir something deep and primal within you? Even for those who do not typically travel abroad, our own backyards are ripe with places where there is little to no cellular coverage. Anyone who likes to be prepared should know that cellular networks will be the first to crash and/or become overloaded in an emergency or disaster situation while satellite networks will be much more reliable. No matter your pleasure or purpose, satellite phones are a reliable communication alternative.
You can expect to spend in the range of $500-$1500 on a sat phone, depending on your particular needs. Pricing structure for airtime varies with each manufacturer, but a safe estimate is around $2 per minute, plus a monthly service fee. This is significantly lower than roaming charges offered through some cellular networks. Many vendors also rent sat phones for about $75 per week plus airtime.
It is worth noting that, since Global Rescue requires two-way communication with our members, a sat phone is just one method of enabling this.
Satellite phone use is restricted, and in some cases illegal, in a number of countries. Examples include: North Korea, India, Myanmar, Cuba, Iran, Libya, Sudan, Poland, Hungary, and Angola. Please confirm coverage details with your provider prior to purchasing or renting a phone and research possible restrictions imposed by the countries you’ll be visiting.
Should you have questions or wish for further information on sat phones, please post a comment below or feel free to contact Global Rescue at 617-459-4200.
April 25 is World Malaria Day. Malaria is found most often in Africa, Southern Asia, Central America, and South America, and is relatively rare in the United States.
Malaria is caused by a bite from a parasite-infected mosquito. Symptoms of malaria can include fever, chills, sweats, body aches, and muscle pain. Fever that goes away and comes back is fairly common. Nausea, vomiting, abdominal pain, backache, and dark urine are also possible symptoms. More severe forms involving altered mental status and organ involvement typically require hospitalization. Left untreated, malaria can be fatal.
According to the Centers for Disease Control and Prevention:
--3.4 billion people live in areas at risk of malaria transmission in 106 countries and territories.
--The World Health Organization estimates that in 2012, malaria caused 207 million clinical episodes, and 627,000 deaths.
--About 1,500 cases of malaria are diagnosed in the United States annually, mostly in returned travelers.
Dr. Phil Seidenberg, who spent five years living and working in Zambia as Global Rescue’s African Regional Medical Director, has treated many malaria patients in the course of his career. Dr. Seidenberg points out that significant global progress has been made with malaria over the past decade, with better control of malaria and fewer deaths from malaria for multiple reasons. We spoke with Dr. Seidenberg and posed five common questions that travelers may have about the risks, prevention and treatment of malaria.
1. How do I know if malaria is an issue where I’m traveling?
For updated information on countries with malaria, use the resources available through either the Center for Disease Control (CDC) or the World Health Organization (WHO). Both of these organizations have maps with malaria risk levels indicated by country, and for regions within countries as well. Global Rescue members can contact Global Rescue for specific malaria advice.
Travelers headed to Africa should be aware that, while progress has been made in controlling malaria on the continent, an estimated 91% of deaths from malaria in 2010 were in the African Region (CDC). According to the WHO, in recent years, four countries have been certified by WHO as having eliminated malaria: the United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010), and Armenia (2011).
It is important to consider the time of year of your travel. If a country has malaria, there is usually some seasonality to it. Typically malaria follows the rainy season, and is particularly active in the middle to the late part of the rainy season when water is pooling in areas; standing water allows malaria-carrying mosquito larva to populate.
Another consideration is how rural will your travel be, because in general malaria is more common in rural areas. In locations around the world where there is greater control, such as in capital cities, travelers will likely face less risk. However, if travelers are planning on rural travel and there is malaria in these countries, they need to be well informed and take preventive measures.
2. Who are the people greatest at risk?
Anyone who is not native to an area certainly faces an increased susceptibility to malaria. There is a level of tolerance that develops over time in those who are born and live in areas with malaria. A look at global statistics shows that greater than 75% of people who die from malaria are kids under five years old. If you are thinking of bringing kids along to areas with malaria, it is not a definite no-no but it is something to weigh carefully because the kids are the ones who do more poorly. The elderly are the next at-risk population, and the third class of traveler at an increased risk is pregnant women.
3. If I go to a malarial area, should I take medication?
There are anti-malarial prophylactic medications (preventative therapies) that one can take. It is important to note, however, that none of these treatments is 100 percent effective. You should seek advice from your regular healthcare provider, or a provider experienced in travel medicine to help decide which of these medications might be best for your individual health profile.
The primary recommendation I usually give is to choose a simple option such as Doxycycline, which is available everywhere. It needs to be taken only one to two days prior to travel, and the dose is just 100 milligrams once a day. It is contraindicated for kids younger than eight, mainly for cosmetic reasons because it stains teeth. Doxycycline is not a first choice medication for pregnant women, but may be okay to use during pregnancy in certain situations. The major side effect with its use is sun sensitivity. It causes a small number of people to burn really quickly and often the locations with malaria are sunny and tropical. Doxycyline can also be used for skin infections and, among other things, as treatment for some types of pneumonia, so it is in many ways useful to have in a travel case.
Malarone is another great option. It is a very good, safe medication and very well-tolerated, although a little bit more difficult to find outside of travel clinics. Malarone is taken daily, and needs to be started only one to two days before travel. Side effects are minimal. Importantly, Malarone consists of a two-drug punch that greatly reduces the chance of contracting a resistant malarial strain. This medication cannot be used by pregnant women. Malarone is more expensive than the other options, and since it is taken daily, cost could be a factor for some, especially on longer trips.
A third option is mefloquine, or Lariam. It is preferred by some people because it is taken on a weekly, not daily, basis. Lariam, which is safe for pregnant women, must be started at least two to three weeks before travel, and continued for up to four weeks upon completion of travel. While it is less expensive than some other options, Lariam has been shown to have more side effects than any other anti-malarial drug. However, many travelers use Lariam and are just fine. People always ask about Lariam because they hear about people reporting crazy dreams. Psychotic side effects are anecdotal, never really proven, but there is enough anecdotal evidence that typically I suggest other options first.
4. Are there other steps I can take or products to help protect against malaria?
Definitely. Take precautions such as wearing long sleeves, using DEET repellants to ward off mosquitoes, and sleeping under netting. Most countries typically have mosquito nets in stores and even supermarkets, but if you’re concerned that you won’t be able to find them, it is a good idea to buy them in advance. The insecticide treated nets are really the ones to use. People sometimes pre-treat their clothing, too.
It is important to know that the two peaks for malaria transmission are right at dusk and then right before sunrise. These are times when the mosquitoes are a little bit more active and more people are in contact with active mosquitoes, which is probably why transmission occurs most frequently between those two periods. Be especially cautious at these times.
5. What do I do if I’m traveling and I think that I may have malaria?
The first step is to determine if you have malaria. In most African capital cities, you can go into almost any pharmacy and pick up a Rapid Diagnostic Test (RDT). It involves a simple finger prick, a few drops of blood, and a 15-minute wait for results. RDTs are part of the reason that malaria is under control, because we are no longer indiscriminately treating kids and people with fevers that are not malaria. Be cautious about the expiration dates, however, and do not buy anything that has expired. The RDTs are no different for kids versus adults. Another option is to go to a clinic. Almost any clinic operating in malarial countries will be able to do a very quick blood smear or a Rapid Diagnostics Test, too.
What do you do if you have malaria? Most hospitals in malarial countries are more than capable of diagnosing and treating malaria. For treatment, the WHO recommends Artemisinin Combination Therapy, or ACT. However, do not assume that ACT is necessarily what you will receive. Absolutely ask for ACT by name. Most healthcare providers should know what that means, even though there are different trade names in some parts of the world. It is worth knowing that for almost all simple malaria, even complicated malaria, artemisinin compounds are the ones to use. Those that only have single artemisinin are, over time, quite bad for our malaria treatment options because the parasite develops resistance early. (Emerging artemisinin resistance is a major concern, according to the WHO, in certain areas of the world.) The combination therapy hits the parasite with two active medications working against it.
For severe malaria, usually defined by altered mental status or organ dysfunction, in some places they are starting to do artemisinin IV drips. This approach has been shown to be better than good old quinine, which still is very effective. But typically if someone were hospitalized with severe malaria, quinine versus artesunate are the only real options for treatment.
It is extremely important to be vigilant upon returning home. First, if travelers are taking a prophylactic that requires them to continue to take it for a few weeks afterwards, they must make sure to do that. Second, and even more dangerous in my view, is that it is hard to get malaria diagnosed in the States unless someone really thinks about it. In fact, this happened to friends of mine when they came back with their kids from Africa. It is an easy thing for a lab to take a look at a blood smear under with a microscope, but when medical professionals don’t ever see malaria that often, they’re not going to think about it. So, if someone comes back, gets sick and they’re worried about malaria, they need to really be careful that they tell whoever is seeing them, “By the way, I was in Haiti. Can you check me for malaria?” It could be a couple of months before travelers should consider themselves no longer at risk after returning home.
Again, it is always a good idea for travelers to check in with their primary care provider or a travel medicine professional before traveling for a detailed discussion of their risk for malaria.
It is impossible to know exactly when or where an injury will occur. While hunting deep within the triple canopy forests of Cameroon, a Global Rescue member thought he had seen it all. Despite having been charged by a buffalo and challenged by a gorilla in the preceding days, the member was unharmed and determined to continue on with the hunt. He understood the inherent dangers of hunting in Africa and felt that he had taken the necessary precautions to deal with the native animals and insects. What he had not envisioned, though, was that the most terrifying moment of the trip would come from an object as seemingly harmless as an elastic band.
Several days into his trip, the member was struck in the eye by an elastic band that had broken under tension. Immediate pain and a flash of bright light were followed by the loss of vision in the member’s eye. Over the next few hours, his vision slowly began to return but it remained blurry. Soon after the initial injury, the member contacted Global Rescue.
Immediately upon receiving the call, Global Rescue critical-care paramedics began to gather more information from the patient. Utilizing improvised items, including the Global Rescue Membership card, as a basic reading chart, the patient was asked to read the phone number from his outstretched arm. Unable to complete the tests, the patient acknowledged sensitivity to light, and noticed that his injured right eye felt a bit firmer to the touch than his left. Having consulted ophthalmologists at Johns Hopkins and given the risk for a permanent loss of vision in the eye, Global Rescue began making plans to evacuate the member.
Deep within the forest, the hunting party began their four hour journey to the nearest airstrip. Global Rescue then secured rights to the only air provider permitted to land on the unlit grass runway. While our operations team was confirming with the patient that a plane would arrive at first light to take him out of the forest to Douala, they were also busy arranging and coordinating transportation to a hospital with a world class ophthalmology department in Belgium. Upon arrival in Douala, he boarded a flight to Belgium, where the staff at the hospital was awaiting his arrival.
The patient was soon examined by the ophthalmologist, who examined the injured eye and provided the required treatment. After consulting with the doctors at Global Rescue, the member was deemed sufficiently stable to return home for continued care in the United States.