May/June 2002

Newsletter of the International Society of Travel Medicine 2002 May/June Society News Certificate of Message from the President Knowledge in Dear Fellow Member, Travel Medicine ince my last message in NewShare, the world and travel medicine have been slowly recovering from the events of 9/11. Now we are influenced by the tragedy taking Examination Splace in the Middle East. Again, the travel industry has been seriously affected, the result of feelings of uncertainty, and concern about possible retaliations. Update In the last four months of 2001 the World Tourism Organisation reported a decrease of about 24% in international arrivals in North America, the Middle East and South Asia. May, 2002 Since the beginning of 2002, travel is increasing again, and we are seeing more travelers Question Writing Drive Underway: The coming to our clinics. This shows how volatile the travel industry is and how quickly question writing drive for the Certificate countries depending on tourism revenues can be badly hit. The same applies to travel of Knowledge Examination is underway. medicine doctors and nurses whose source of revenue depends on this kind of client. The Examination Committee has received Let me give you an update on the Society. First, the May 2003 New York conference: both over 400 questions thus far. The goal is the organizers, Brad Connor in particular, and the scientific committee chairs and co-chairs 500 questions. The Exam Committee will have been extremely active over the last few months. A very attractive program is being review all questions and 200 questions will set up and should be finalized after being reviewed by the executive board mid-May in be selected for use on the examination. Florence. Organization-wise, things are moving fast and several initiatives have been The Examination Committee Co-chairs, taken to make this venue as successful as our last conference in Innsbruck. It will be very Drs. Phyllis Kozarsky, Jay Keystone, Rob- different from the Alpine beauty of Innsbruck, as it will be held in Times Square, at the very ert Steffen, and Francesco Castelli would heart of this unique city. This conference will certainly be inspired by the spirit of New like to thank everyone who has partici- York, and its place as a city of departure and arrival on the American continent. pated in the question writing process. When the chairs and co-chairs of the scientific committee met in New York in early April, Dr. Keystone acknowledged, “Without we visited Ellis Island. This is an island off the southern tip of Manhattan. It is at Ellis the talent, dedication and energy put forth Island where about 19 million immigrants arrived in America and had medical examinations by the question writers, this exam would before being allowed into the country. Up to 5000 newcomers a day were screened. Also not be possible. It takes a tremendous known then as the Island of Hope, the screening center closed in the 1950s. Ellis Island is amount of time and thought to write good now a museum, devoted to the history of immigration and its health-related aspects. It is exam questions. We really value the con- a very impressive place to visit. For travel medicine professionals, it can be seen as tributions of this group.” marking the beginnings of health services monitoring large population movements, and the health-related problems inherent to human mobility. Immigrants were certainly not First Examination Committee Meeting Set: tourists, but they were bringing with them all the questions and issues of prevention and The first face-to-face meeting of the Ex- treatment related to mobility. amination Committee will take place May 30- 31 in Atlanta. The group will come A week after visiting Ellis Island, I had the opportunity to visit Riyadh, Saudi Arabia, and together to review the examination ques- participate in the first conference on travel medicine ever organised there. In this very tions and discuss strategy. different environment, health professionals are also facing the impact of human mobility. Affluent Saudi travelers visit Europe, North America and other parts of the world, and Continued on page 9 experience the standard health problems that we see in our travelers. Simultaneously, every year two million pilgrims visit Mecca for the Hajj pilgrimage. They come from all over the world, generating the most formidable mixing of germs, cultures and mentalities, all in a matter of a few days. How can the situation be controlled? How should epidemics be prevented and care provided for those in need during the pilgrimage? Unique and very Society News ...... 1 impressive expertise has been developed by Saudi doctors confronting these issues. Certificate of Knowledge in When we discussed travel medicine in Saudi Arabia, we also had to talk about migrants Travel Medicine ...... 1 and foreign workers coming there and to the neighbouring Gulf States. Close to half of the Desert Survival ...... 2 22 million resident population of Saudi Arabia comes from North Africa, Southeast or Southern Asia. Again, these are difficult health problems that must be handled in an Melioidosis ...... 5 efficient and adequate manner. This is a further demonstration that travel medicine cannot Dear Editor ...... 6 concentrate exclusively on tourists and affluent travelers if it is to tackle in a professional Calendar ...... 7

Continued on page 2 Travel Medicine NewsShare 2002 May/June

“Society News,” continued from page 1 By Edward J. Otten, MD way contemporary realities of global mo- Desert Survival bility of populations and individuals. It is important to use a broader perspective, as lessons learned for one group of travelers can then be used for another group. In North America and Europe, for example, an increasing number - in some cases the majority - of imported cases of malaria are seen in foreign-born residents who have returned home to visit friends and rela- tives. The situation is the same for tuber- culosis and hepatitis A seen in foreign- born residents. Therefore, even those diseases which most concern travel medicine are increasingly found amongst migrants, a high risk category of traveler. Other members of the Society are working hard with Professor Lin Jianway to eserts comprise about 15 per cent of the earth’s land area. An area is considered prepare the October 2002 conference in to be desert if it has less than 25 centimeters of rain, unevenly distributed through Shanghai. It will be the first conference D out the year. Most deserts - Sahara, Arabian, Australian, and Kalahari (Southern on travel medicine held in China, orga- Africa), for example - are found between 30 degrees South and 30 degrees North latitude, nized by the Asia Pacific Travel Health making them hot as well as dry. There are several large areas of “cold” desert, the Gobi, Society, with the support of the ISTM. Great Basin, and Patagonian deserts, for example, which are found beyond 40 degrees The program will cover broad issues in North and South latitudes and have variable temperatures. travel medicine, but will concentrate on There are several climatic processes that produce desert areas. The most important of the issues unique to this part of the world. these are the six cells of air currents that descend at the poles and near the Tropic of This conference will well complement our Cancer and Tropic of Capricorn. These air currents, driven by the sun and the rotation of biennial conference. Finally in May, the the earth, create areas of relatively warm, dry climate. The second important process is the 3rd European Conference on Travel Medi- problem of rain shadows caused by mountain ranges along the western edge of the cine will be held in Florence, Italy, on the continents. These areas lie to leeward of the prevailing winds and moist oceanic air is theme of « Travel and Epidemics ». These unable to rise over the mountains before it cools and loses its moisture on the western three major events illustrate that travel slopes. The dry air then rises over the mountain and descends to the land drying it. The medicine is certainly very much alive, as Andes shadow the Patagonian Desert, the Sierra Nevada and Cascades shadow the Great is your society! Basin and Mojave in the U.S., and the Great Dividing Range in Australia places most of I am convinced that in order to grow and that continent in a rain shadow. expand, the ISTM needs to consider and The dry land that is formed is unable to sustain a large amount of plant life. This lack of address the needs of all types of travel- vegetation allows the sun’s energy to directly heat the ground, allowing the heat to ers: tourists and businessmen, students concentrate in the soil and in the air directly above it. In a forested region the plants give and expatriates, migrants and refugees. off moisture via transpiration. This along with the plants themselves absorb most of the We have already included in the ISTM sun’s energy before it can heat the soil. The large surface area of the vegetation also bylaws that the ISTM aims to disperses the heat energy so that the temperature on a forest floor rarely rises above 39 C promote”the protection of health of trav- (100 F). The combination of solar radiation, high winds and hot temperatures causes an elers and migrants…”. Should we con- increase in the evaporation of any moisture that does reach the desert. sider modifying the name of our society to the International Society of Travel and The same factors that cause a high temperature during the day allow for a rapid loss of Migration Medicine? Please send com- heat during the night. Temperatures may vary 25 degrees C in a single 24-hour period. It ment to NewShare. would seem that this climate would only allow for a sparse flora and fauna. This is not the case. Death Valley, where air temperatures have been recorded at 56 degrees C, has 600 species of plant, 30 species of mammal, 25 species of reptile, and 2 species of fish. The Dr Louis Loutan plants and animals that have evolved in this environment have developed ingenious President of the ISTM methods for adapting to the aridity and extremes of temperature. Man, in order to survive in the desert, must adopt some of the same methods used by the indigenous organisms.

Continued on page 3

“Desert Survival,” continued from page 2

Preparation for a Desert develop a sense of “aequanimitas” deal- cially at higher elevations. Corneal abra- Climate ing with emergencies on a daily basis. Jet sions from blowing sand are quite com- pilots seem to have a similar trait. While mon and preventable. Obviously the more prepared you are for the ‘will to survive” is not exactly the Leather gloves protect the hands from hot a particular climate the more likely you same as these it may arise in unlikely indi- objects as well as cactus spines and will survive, all other things being equal. viduals, just like courage in a battle. Things are never equal however, and luck thorns. Footwear can be leather or is probably the most important, albeit, the The clothing most suitable for the desert manmade materials and should be ankle most uncontrollable factor. There are sev- is similar to that worn in most wilderness high or higher. Low cut shoes will allow eral controllable factors namely physical areas only the type of material may be sand to enter and do not give adequate conditioning, clothing, survival kit, and different. Polypropylene, wool, pile, and ankle support. Jungle boots with metal survival skills that may prevent needless goretex are the choices of the mountain- spike protection and running shoes may deaths in the desert. eer whose enemy is hypothermia. While get extremely hot in the desert soil and hypothermia is a possibility on the desert, are not a good choice for desert travel. Physical conditioning and acclimatization hyperthermia and dehydration are more Polypropylene or polypropylene and is probably just as important with desert likely. Ripstop cotton is ideal due to its wool socks seem to decrease the amount travel as it is with mountaineering. The evaporative ability, and long sleeve shirts of blistering and give adequate cushion- body’s need for water cannot be lessened and trousers made from this material are ing and insulation to the feet. by these methods but the amount of elec- excellent for desert conditions. A light trolytes lost and the efficiency of the color should be chosen to help reflect Survival Kit sweating apparatus can be optimized. solar radiation. A pile jacket or wool Strength in the lower extremities may help sweater is needed at night in many desert The survival kit should have the neces- prevent minor injuries, an ankle fracture, areas. Most novices traveling in the sary equipment and supplies to help you for example. In the desert environment desert remark on how cold it is at night survive yet be small enough to be carried such injuries can be fatal if you are un- and how ill prepared they were for it. with you wherever you hike in the desert. able to get help or water. Prior to a trip to The principle component should be wa- the desert for the unacclimatized indi- A rule of thumb is “expose as little skin as ter or the means of acquiring it. Unfortu- vidual, I recommend a level of fitness at possible.” The skin must be protected from nately water weighs about a kilo per liter least equivalent to an aerobic workout to heat, ultraviolet rays, blowing sand, in- and this limits the amount that an indi- 80% of maximum heart rate for 30 minutes, sects, and water loss. A hat is an abso- vidual can carry to about one days’ sup- 4 times a week. lute necessity and should be broad ply. A solar still should be carried along brimmed or a kepi to protect the neck and with water purifying tablets or iodine. The Upon arriving in the desert you should face. A cravat or large handkerchief can best way out of a survival situation is to spend at least 3 days acclimatizing before be used as an emergency hat if the other be rescued, therefore signaling equipment starting out on any long hikes (more than is lost. It can also be used as a towel or is essential. Survival kit items should be 8 kilometers). This will allow for the in- soaked in water and placed between the selected that have multiple uses and they creased intake of water which may be 9 to head and the hat to act as a solar air con- must be of high quality. Do not spare ex- 15 liters per day, the adjustment to the ditioner. Sunscreen and chapstick should pense in purchasing equipment that your lack of vegetation, increased solar radia- be used frequently to protect exposed life may depend on. The following list is tion, and the large temperature variations. skin. Sunglasses or goggles are needed an example of a basic kit that may be car- Most activity should take place between to protect the eyes. Ultraviolet keratitis ried in a relatively small pack: dawn and 10 AM and between 3 PM and similar to snowblindness can occur espe- dusk. Between 10 AM and 3 PM, the hot- Continued on page 4 test time of the day, it is best to stay in the shade and sleep, read or handle domestic duties. The most important conditioning is men- Example of Kit Items: tal conditioning or “the will to survive”. Nylon canteen, 5 liters Penlight Canteen cup Throughout the survival literature this is Space blanket Clear plastic sheet, 1.5 x 1.5 meters Sunscreen constantly cited as the one thing that Plastic tubing, 1.5 meters Signal mirror Iodine crystals brought survivors through their ordeal. Whistle Plaster bandages Sunglasses Unfortunately this cannot be taught. For- Swiss Army knife Parachute cord, 15 meters Waterproof matchbox tunately, however, the potential is in all of Compass Insect repellant Hard candy us but may only appear in extreme cir- Safety pins Needle/thread cumstances. Many medical personnel

“Desert Survival,” continued from page 3

When weight is not a consideration, for water. The metabolism of food and excre- temperature within the shelter. Metal ve- example, traveling in an automobile, for tion of waste products requires unneces- hicles will be like ovens and it is better to example, the following items should also sary usage of water. Water obtained from sit on a seat cushion in the shade of an be carried: lakes, streams, wells or springs should be automobile or under the wing of an air- considered contaminated and purified plane than to be inside. Try to build the • Plastic water container, 5 liters/person before drinking. Water may sometimes be shelter in the shadow of a cactus, tree or • Folding shovel found by digging at the outside bend of a large rock. Avoid dry stream beds (arroyo, • Toilet paper dry riverbed or stream. Vomiting and diar- wadi or dry wash) that may turn into a • First aid kit rhea caused by contaminated water can killer flood in a matter of minutes after a • Nylon tarp be quickly fatal in the desert. Rainwater, cloudburst kilometers away. Desert ani- • Gloves dew and water obtained from solar or veg- mals will seek out shelter during the day etable stills are relatively pure. Urine, sea- also and may venture into your shade. • Extra clothing water or brackish water should never be Reptiles may be venomous and mammals • Food drunk in a survival situation. Liquid from may carry diseases such as rabies or • CB radio radiators is contaminated by glycols and plague. Most of them can be scared off Necessity being the mother of invention, should never be drunk. Many plants such with a stick or rock. many items from vehicles can be used in as barrel cactus and traveler’s tree and an emergency; the rear view mirror can be animals such as the desert tortoise con- Waiting for rescue or trying used to signal, the hubcaps to collect tain water. Such water can be used in an to find civilization water, batteries to start fires, oil to pro- emergency. One of the earliest decisions that you will duce smudge for signaling. A solar still can be made by stretching a have to make is whether to wait for res- The best survival kit is of no use if you 1.5 x 1.5 meter piece of clear plastic over a cue or to attempt to find your way back to do not have the skills to use it correctly. hole dug in the ground into which veg- civilization. You need to look at all the These skills must be learned and prac- etation, urine, or brackish water has been factors that may decide your survival. ticed regularly or they will be lost. Until placed. The sun will cause water to evapo- What is the chance that you will be res- you have actually built a solar still you rate and collect on the underside of the cued? If you filed an itinerary or flight cannot anticipate the problems encoun- plastic and then drip back into a container plan, if you have signaling equipment, a tered. An experienced person can pro- at the bottom of the hole. A tube can be radio or emergency locator transmitter, duce a solar still in 15 minutes. An ama- used to remove the water from the con- water, shelter and food; then you prob- teur will take 60 minutes and lose more tainer without dismantling the still. The ably should stay where you are. sweat than the still will produce in a week. amount of water produced will depend on Your chances for rescue will be much bet- Direction finding, fire building, shelter con- the amount of moisture in the hole; bone ter if you are near an object such as an struction and signaling are all necessary dry sand will not be very productive. Build airplane or automobile that can be seen skills that must be learned before getting the still at night to conserve water. Dew, by search and rescue personnel. If you into a situation where your life may depend rainwater and edible animals may also be do decide to travel mark a large arrow on on them. It is too late to learn to swim after collected in the still as a bonus. the ground in the direction of travel and you have fallen out of the boat. Shelter leave a note stating your direction of travel and plans. Travel in the cool of the “The rules of threes” Shelter is essential if the effects of the night to conserve water, although the foot- Priorities in a survival situation is based sun during the midday are to be amelio- ing may be more hazardous. Before trav- on the “rule of threes”, you can live 3 rated. The temperature in the desert will eling in the desert or anywhere, obtain an minutes without oxygen, 3 hours without vary both above and below the ground. up-to-date topographic map of the area warmth, 3 days without water and 3 The temperature at the ground surface will and learn how to use a compass. Memo- months without food. Assuming that be the highest. It will decrease as one goes rize major physical and manmade features there are no immediate medical problems below the ground and rises above it. so that if you get lost without your map or environmental hazards, i.e. fractured Therefore a shelter that protects from di- and compass, you will still be able to find pelvis, landslide, flash flood, etc., the top rect solar rays and has within it either a a road, river or powerline that may lead to priority in a desert survival situation will trench 30 x 45 centimeters deep or a plat- help. Direction can be approximated by probably be water. form 30 x 45 centimeters high will be cooler using the shadow tip method or a watch than one in which you must be in contact during the day or the stars at night. If there is a limited amount of water avail- with the ground. A second roof sus- able, then food should not be eaten un- pended 30 x 45 centimeters above the first less the food contains a large amount of will trap a layer of air and decrease the Continued on page 5

4 Newsletter of the International Society of Travel Medicine © 2002 ISTM Travel Medicine NewsShare 2002 May/June “Desert Survival,” continued from page 4 Melioidosis Signaling can best be accomplished during the day using a mirror and reflecting David Dance, MB, CHB, FRCPath the sun off the mirror towards the horizon elioidosis is the name given to any infection caused by Burkholderia (formerly in the direction of potential help. If an air- Pseudomonas) pseudomallei. The organism is closely related to B. mallei (the craft is spotted, do not shine the mirror causative agent of glanders) and B. cepacia. It has a wide host range including directly on the aircraft but rather alternate M mammals (especially sheep, goats and pigs), birds and occasionally reptiles. flashing the mirror from the ground to the aircraft. A signal such as this can be seen Epidemiology popolysaccharide, an extracellular cap- at 9,000 meters. At night, a fire or penlight sule, and numerous enzymes. There is The bacterium is an environmental can also be seen at great distances if some evidence that intracellular persis- saprophyte found in mud and water (e.g. shone from a high point. A mirror cannot tence contributes to the recalcitrant na- rice paddy). It is endemic in south and be used up but penlight batteries and fire- ture of the infection. wood can, so wait until you hear the south east Asia (especially Thailand and sound of an aircraft or rescuers before Singapore) and northern Australia. It is signaling by these methods. occasionally reported elsewhere in the Clinical tropics and is probably greatly Melioidosis has a broad spectrum of mani- Nature is neutral; it is neither for us or underdiagnosed. The disease is highly festations. Overall, 60% of cases are against us. The game of survival like all seasonal, some 80% of cases presenting bacteremic. Most of them have a commu- games of life is based on our control of during the rainy season. Infection is usu- nity-acquired sepsis syndrome with a nature to the extent that we need to sur- ally acquired through inoculation, occa- high mortality, although some have a more vive. This includes the nature inside of sionally aspiration or inhalation of con- sub-acute ‘typhoidal’ presentation. Half us as well as outside of us. The first step taminated water, and hence is associated have an obvious primary focus, usually in any survival situation is to gain con- with soil contact (e.g. rice farmers). The in the lungs, sometimes in skin or soft trol of ourselves, then to try to control role of ingestion is unclear, and person- tissue. Metastatic abscesses are common those things outside ourselves such as to person spread is very rare. Iatrogenic in any site, especially the lung, liver, climate and terrain. infections have occasionally been re- spleen, kidney, prostate, and skin or soft ported. In endemic areas, exposure is wide- tissue. The remaining 40% have localized Bibliography: spread (80% children in northeast Thai- infections, again in any organ, but par- Adolph, EF, Physiology of Man in the land have antibodies by 4 years of age), ticularly the lung, liver and spleen in Desert. New York, Hafner Press, 1969. but disease is rare, and usually opportu- adults, and these sites plus the parotid in nistic (approximately 75% of individuals children. Chronic foci often become Craighead, FC and Craighead, JJ, How to with severe infections are granulomatous. Survive on Land and Sea, 4th ed. Annapo- immunocompromised, especially by dia- lis, Md, Naval Institute Press, 1984. betes mellitus, chronic renal failure, Diagnosis MacMahon, JA, Deserts. New York, thalassaemia, steroids, alcoholism and Consider melioidosis in anyone who has Alfred Knopf, 1985. liver disease). Disease is commonest in males aged 40-60 years. The incubation ever lived in endemic area who presents U.S. Air Force Publication AFM 64-3, period is variable - it may be as short as 2- with sepsis and/or abscesses, especially Survival Training Edition, Headquarters 3 days, but the organism may remain la- if they are diabetic. However, most im- Dept of the Air Force, Washington, DC, tent for up to 30 years before infection ported infections will present within a few 1969. becomes apparent, usually at times of in- weeks of travel to an endemic area. The organism is easy to culture from sterile U.S. Army Publication FM21 -76 Survival. tercurrent stress. sites (e.g. blood, pus, urine), but selec- Headquarters Dept of the Army, Wash- tive media increase the isolation rate from ington, DC, 1986. Pathogenesis sputum, swabs etc. Identification of B. Wagner, FH, Wildlife of the Deserts, New The likelihood of disease developing de- pseudomallei requires a degree of suspi- York, Harry Abrams, 1984. pends on a balance between the host im- cion, since it is often thought initially to mune system (in which cell-mediated im- be a contaminant, although most commer- Mel is the immediate past president of the munity and, particularly, interferon-gamma cial kits should identify it correctly. B. Wilderness Medical Society and the Di- production appears to play a key role), pseudomallei is also a containment level rector, Division of Toxicology and Pro- the inoculum and, presumably, the intrin- 3 pathogen (UK classification), so warn fessor of Emergency Medicine and Pedi- sic virulence of the infecting strain. Im- the laboratory if melioidosis is suspected. atrics, University of Cincinnati College of portant virulence factors include li- PCR and antigen detection systems are Medicine, Cincinnati, Ohio, USA Continued on page 6

“Melioidosis,” continued from page 5 under development, but are not yet in place in 1998. Proceedings of a follow- 24-27. widespread use. Numerous serological up meeting in September 2001 should The two most recent published stud- tests (e.g. indirect hemagglutination, be published in due course. ies of maintenance treatment. ELISA, immunofluorescence) for both IgG 2. Dance DAB. Melioidosis and glan- and IgM antibodies are available, but 8. Suputtamongkol Y et al. Risk factors ders. In: Topley and Wilson’s Micro- these have poor specificity and sensitiv- for melioidosis and bacteremic melioi- biology and Microbial Infections. ity in endemic areas, although they may dosis. Clin Infect Dis 1999; 29: 408-13. Ninth edition. Volume 3. Bacterial In- be more useful in visitors from non-en- fections. Hausler WJ Jr. and Sussman The only case-control study of risk demic countries. The high background M, eds. Arnold, London, 1998. Chap- factors for melioidosis seropositivity rates in endemic areas may ter 46, pp. 919-29. partly result from exposure to a recently 9. Woods DE et al. Current studies on described, avirulent environmental organ- This is a fairly comprehensive, exten- the pathogenesis of melioidosis. ism, B. thailandensis. sively referenced review of the sub- Microb Infect 1999; 2: 157-62. ject up to 1996, when it was written, A good summary of current work on and is a good starting point for fur- Management virulence of B. pseudomallei, a rapidly ther reading. Some more recent key developing field, using molecular tech- Supportive treatment, including drainage references are given below. of abscesses, is important. B. niques to study pathogenesis. 3. Bart J. Currie et al. Endemic Melioido- pseudomallei is intrinsically resistant to David is a physicians and a medical sis in Tropical Northern Australia: A many antibiotics, including penicillin and microbiologist and presently the Di- 10 Year Prospective Study and Review aminoglycosides. Newer beta-lactams rector of the Public Health Laboratory of the Literature. Clin Infect Dis 2000; substantially reduce mortality rates, but in Plymouth, UK. He has studied more 31: 981-6. their cost limits their use in endemic ar- than 1500 patients with melioidosis in eas. There is a lifelong risk of relapse, An excellent and comprehensive re- Thailand. which may be reduced (but not abolished) view of the disease from an Austra- by long antibiotic courses. Antibiotic re- lian perspective sistance may develop during treatment. 4. Simpson AJH et al. Comparison of Antibiotic treatment can be divided into imipenem and ceftazidime as therapy the acute phase of treatment (usually for severe melioidosis. Clin Infect Dis Dear Editor: about two weeks) and the maintenance 1999; 29: 381-7. phase (to complete 20 weeks of total treat- The NewsShare newsletter of Mar/ ment). Various antibiotic regimens are 5. Chetchotisakd P et al. Randomized, April 2002 has an excellent review available for both phases of treatment. double-blind, controlled study of article, Shark Attacks, by Dr. Paul Ceftazidime, imipenem or meropenem are cefoperazone-sulbactam plus Auerbach. But in view of ISTM’s im- currently the treatments of choice during cotrimoxazole versus ceftazidime plus portant role in immunization infor- the acute phase. Medications for the cotrimoxazole for the treatment of se- mation, an error in this article is maintenance phase include appropriate vere melioidosis. Clin Infect Dis 2001; worth correcting. On page three, it doses of chloramphenicol, but co- 33: 29-34. says, “tetanus toxoid 0.5 mL IM and amoxiclav is preferable for children and tetanus immune globulin must be The two most recent published stud- given.” I wouldn’t quibble what with pregnant women. A recent study found ies of acute phase treatment. 12 weeks of ciprofloxacin plus all the shortages now about using azithromycin to be associated with an 6. Chaowagul W et al. A comparison of diphtheria tetanus, but the use of unacceptably high relapse rate (22%). chloramphenicol; trimethoprim- tetanus immune globulin is neces- sulfamethoxazole, and doxycycline sary only in those individuals who have not had a series of tetanus tox- References and Further with doxycycline alone as maintenance therapy for melioidosis. Clin oid injections. It is a rare patient in Reading Infect Dis 1999; 29: 375-80. the US that has not had this immuni- 1. Acta Tropica. Volume 74, issue 2-3, zation. 7. Chetchotisakd P et al. Maintenance February 2000. therapy of melioidosis with Keep up the excellent articles and This whole issue is devoted to melioi- ciprofloxacin plus azithromycin com- news. dosis and contains a number of re- pared with cotrimoxazole plus doxy- views of the subject, as presented at cycline. Am J Trop Med Hyg 2001; 64: John A. Knowles, MD an international meeting that took

6 Newsletter of the International Society of Travel Medicine © 2002 ISTM Travel Medicine NewsShare 2002 May/June Calendar: Travel Medicine Conferences, Courses, Educational Travel Conferences Lecture material in English while lab in- the Instituto de Higiene e Medicina Tropi- struction will be in English and French. cal. his Conference will concentrate on III European Conference Location: Concordia University tropical medicine, travel medicine, migra- on Travel Medicine: amphitheatre in downtown Montreal. tion, medicine, and international health , Travel and Epidemics. Contact: Kelly Ann McCulloch-Glover, involving different experts to explore fu- March Florence, Italy. May 15- Coordinator, McGill University Health ture innovative collaboration. Official lan- 18, 2002. A broad over- 15-18 Centre Continuing Education Office, The guage: English. Local Committee Chair- view of the latest in travel medicine from Montreal General Hospital, 1650 Avenue man: Professor Dr. F. Antunes, Instituto leaders in the field. Sponsor: WHO Col- Cedar, Montreal, Quebec, H3G 1A4. Tel: de Instituto de Higiene e Medicina Tropi- laborating Centre for Tourist Health. Offi- (514) 937-6011 ext.44173 Fax: (514) 934- cal, Rua da Junqueira, 96 PT-1600 Lisbon cial Language: English. Contact: Dr. 1779. E-mail: [email protected]. Tel: ++351-21-365-2638 Fax: ++351-21-797- Walter Pasini Viale Dardanelli, 64 47900 6242 Email: [email protected] Web address: Rimini, ltaly Tel. +39-0541-24301 or +39- Travel Health Care www.kit.de/tropical2002 0541-53209. Fax +39-0541-25748. E-mail: Training Course for wpasini©rimini com. Or contact: Confer- Registered Nurses, Diploma Course in ence Secretariat: Travel Agency June Nurse Practitioners, and Travel Health and Medi- Girovagare, Viale Milton n. 81, 1- 50129 21-22 Physicians. Briarcliff cine. London UK. Firenze, Italy. Tel: 39 055 494949. Fax: 39 Manor, Westchester County, NY (adja- Oct- Course taught each 055 476393. cent to New York City). June 21-22, 2002. July Monday, 1000-1600, from Presented by travel Well of Westchester. October 2002-July 2003. Provides post- Third Scandinavian Fo- Small group (maximum 20). 2-day course. graduate education and a qualification rum for Travel Medicine. Introduction to pre-travel health care and within the field of travel medicine to those Copenhagen, Denmark. update, and review in a unique and actively involved or with a keen interest May May 22-24, 2002. Spon- friendly educational format. 16 CEUs ap- in the provision of travel advice. Open to sors: Travel medicine so- 22-24 plied for. Email: nurses@travelhealth both registered medical practitioners cieties in Denmark, Sweden and Norway nursing.com Tel: 914 793-9283 qualified with MBBS and nurses quali- in collaboration with WHO. A focus on fied with RGN, and other health care pro- the scientific basis for travel medicine Third Annual Study Day fessionals holding relevant through state-of-the-art reviews, sympo- in Travel Health. Lon- qualifications. A Diploma in Travel Health sia, and free communications. Health risks don. UK July 10, 2002. and Medicine (Royal Free & University when traveling to Eastern European coun- July The course is open to all College London Medical School, Univer- tries. Official language: English - with par- Health Care Profession- 10 sity of London) will be issued to those allel sessions in Scandinavian languages. als with an interest in travel medicine. It that successfully complete the course. Contact: Conference secretariat: ICS A/S will be a useful update for those provid- Contact: Ruth Hargreaves, Course Ad- Copenhagen, Strandvejen 171, P.O. Box ing pre-travel health advice in a primary ministrator (Dr Jane N Zuckerman, Course 41, DK-2900 Hellerup Denmark. Tel: +45 care setting. Contact: Ruth Hargreaves, Director) Academic Centre For Travel 3946 0500 Fax: +45 3946 0515. Email: Course Administrator, Academic Centre Medicine and Vaccines Royal Free and [email protected] Web address: for Travel Medicine & Vaccines, Royal University College London Medical www.ics.dk Free Campus, Rowland Hill Street, Lon- School Rowland Hill Street London don NW3 2PF Tel: +44 020 7472 6114, Fax: McGill Tropical Dis- NW3 2PF United Kingdom Tel: (44) 020 +44 020 7830 2268. Email: eases Course. Montreal, 7472 6114 Fax: (44) 020 7830 2268 Email: [email protected] Canada. May 22-24, 2002. [email protected] May A review of clinical and Third European Con- Fourth Biennial Asia Pa- laboratory tropical medi- gress on Tropical Medi- 22-24 cific Travel Health Con- cine. Sponsor: McGill University Centre cine and International ference. Shanghai, China: for Tropical Diseases. Objectives: to as- Sep Health. Lisbon, Portugal Oct October 22-25, 2002. sist clinicians, nurses and laboratory per- September 8-12, 2002. 8-12 Travel Health in the Asia sonnel dealing with tourists, overseas “Tropical Medicine: A Global Challenge.” 22-25 Pacific Region: New Frontiers and Chal- employees, immigrants, refugees and mis- Under the auspices of the Federation of lenges. Sponsor: Asia Pacific Travel sionaries. Problem oriented. Includes the European Societies for Tropical Medi- Health Society Official language: Official hands-on clinical laboratory sessions. cine and International Health. Hosted by language: English – with simultaneous

© 2002 ISTM Newsletter of the International Society of Travel Medicine 7 Travel Medicine NewsShare 2002 May/June Calendar (continued) translation of the plenary meetings into CISTM-New York Con- Medical Practice with Chinese. Contact: Ms. Zhou Yifan, Secre- ference of the Interna- Limited Resources. tariat of 4APTHC, Room 1705, No. 2669 May tional Society of Travel June Ifakara, Tanzania. June 8- Xie Tu Road, Shanghai 200030 China. Tel: Medicine. New York. 28, 2002. Organized by 86-21 64398193. Fax: 86-21 7-11 May 7-11, 2003. Contact: 8-28 the Swiss Tropical Insti- 64398194. Email: apthc2002@sh163.net CISTM8 Conference Secretariat: Talley tute. Three-week course to teach clinical Web address: www.2002APTHC.NET Management Group, Inc., 19 Mantua Rd. tropical medicine within the health facili- Mt. Royal, NJ 08061 USA. Tel: (856) 423- ties of tropical countries. Official lan- SAILS 2002: Shipboard 7222 Ext 218. Fax: (856) 423-3420. Web ad- guage: English. Contact: Swiss Tropical Assessment, Interven- dress: www.istm.org. Institute, Course Secretariat, Socinstrasse tion and Life Support for 57, CH - 4002 Basel, Switzerland. Tel: +4161 Nov Cruise Ship Medicine. 284 82 80. Fax: +41 61 284 81 06. Email: November 10-17, 2002. Courses/Educational Travel 10-17 [email protected] Web address: Aboard the ship GTS Millennium. Sails Tropical Medicine Expe- www.sti.unibas.ch from Ft. Lauderdale, Florida. Sponsor: ditions to East Africa: Voyager Medical Seminar and New Hamp- Feb 7th Expedition to The Gorgas Course in shire Chapter of the American College of Uganda, February 2- Clinical Tropical Medi- Emergency Physicians. For physicians 2-14 February 14, 2003 and Jan cine. Lima, and the and nurses interested in promoting and Feb 23- 10th Expedition to Andes and Amazon re- enhancing the delivery of quality medical Kenya, February 23- 27 & gions, Peru. Course services on board cruise ships. Computer March March 7, 2003. In collabo- March scheduled for January technology including syllabi on PALM 7 ration with the Univer- 27- March 28, 2003, and OS handheld computer and CD-ROM. The sity of Nairobi and Dr. Kay Schaefer (MD, 28 for 2004. Sponsored by conference brochure and registration PhD, MSc, DTM&H) Cologne, Germany. the University of Alabama and the forms are available at www.vms4csm.com. Official language, English. The expedition IAMAT Foundation. Includes lectures, Contact: Robert E. Wheeler, MD, FACEP, is designed for a limited number of physi- case conferences, diagnostic laboratory Voyager Medical Seminars, 9 Corduroy cians, public health experts and scientists. procedures, and bedside teaching in a 36- Rd. Amherst, NH 03031-2724. Voice/Fax During the 2 week-expedition the partici- bed tropical medicine unit. Official lan- (603) 672-5775. e-mail: vms@compu pants will visit different hospitals and guage: English. International Faculty. 380 serve.com health projects in urban and rural areas. contact hours. Contact: David O. Freed- man, M.D. Gorgas Memorial Institute, Vascular Symposium in Includes individual bedside teaching, University of Alabama at Birmingham, 530 Hawaii – The Fourth Pa- laboratory work, and lectures in epidemi- Third Avenue South, BBRB 203, Birming- cific Vascular Symposium ology, clinical findings, diagnosis, treat- ham, AL 35294. Fax: 205-934-5600 Or call: Nov on Venous Disease: The ment and control of important tropical in- The Division of Continuing Medical Edu- Aggressive Approach. fectious diseases. Also, updates on 12-16 cation at 800-UAB-MIST (U.S.) or 205- November 12-16, 2002, Mauna Lani Bay Travel Medicine and visit to the “Flying 934-2687 (from overseas) Email: Hotel & Bungalows, Kohala Coast, Big Doctors” headquarters in Nairobi. 50 con- [email protected] Web address: Island of Hawaii, USA. Forty interna- tact hours. Accredited certificate given. www.gorgas.org. tional guest faculty. The program will be Contact: Dr. Kay Schaefer, Tel/Fax: +49- a “Venous Symphony,” with five contro- 221-3404905, E-Mail: versial themes: (1) Acute Venous Throm- [email protected] Homepage: boembolism, (2) Air-Travel Related www.tropmedex.com Venous Thromboembolism, (3) Chronic Venous Disease, (4) Diagnosis of CVD, and (5) Varicose Veins. Targeted to sur- geons, radiologists, and others interested IMPORTANT DATES in venous disease. Contact: Straub Foun- dation, 1100 Ward Avenue, Suite 1045, Conference May 7-11, 2003 Honolulu, Hawaii 96814-1617; Tel: 808- Early Registration December 2002 524-6755, Fax: 808-531-0123, Email: Regular Registration March 2003 [email protected] Website: www.straub-foundation.org Abstract Submission January 2003 Hotel Reservation March 2003

“Certificate of Knowledge in Travel Medicine Examination Update,” continued from page 1 ISTM STAFF ISTM EXECUTIVE BOARD “We eagerly anticipate this meeting and look forward to welcoming everyone to PRESIDENT: Louis Loutan, M.D., Switzerland Atlanta. We are pleased to have such a PRESIDENT-ELECT: Phyllis Kozarsky, USA hard-working and skilled group of experts PAST-PRESIDENT: Charles Ericsson, M.D., USA committed to establishing this exam as the COUNSELOR: Santanu Chatterjee, M.D., India first internationally recognized credential COUNSELOR: David Freedman, M.D., USA in the field of Travel Medicine,” stated COUNSELOR: Fiona Raeside Genasi, RN, UK Dr. Kozarsky. COUNSELOR: Prativa Pandey, M.D., Nepal SECRETARY/TREASURER: Frank von Sonnenburg, M.D., Germany EDITOR, JOURNAL OF TRAVEL MEDICINE: Charles Ericsson, M.D., USA WEB EDITOR: Karl Neumann, M.D., USA “The Certificate SPECIAL ADVISOR: Stephen Ostroff, M.D., USA SPECIAL ADVISOR: Robert Steffen, M.D., Switzerland of Knowledge 7TH CISTM CHAIRPERSON: Frank von Sonnenburg, M.D., Germany TH Examination will 8 CISTM CHAIRPERSON: Bradley Connor, M.D., USA ISTM COMMITTEE CHAIRS be administered at ELECTRONIC COMMUNICATIONS: David Freedman, M.D., USA HEALTH OF MIGRANTS AND REFUGEES: Brian D. Gushulak MD., Canada the Marriott HOST COUNTRIES: Santanu Chatterjee, M.D., India INDUSTRY LIAISON: Robert Steffen, M.D., Switzerland Marquis hotel in MEMBERSHIP: Albie de Frey, South Africa LONG RANGE PLANNING: Michel Rey, M.D., France PRACTICE AND NURSING ISSUES: Fiona Genasi, R.G.N., United Kingdom New York on PROFESSIONAL EDUCATION & TRAINING: Eli Schwartz, Israel PUBLICATIONS: Christoph Hatz, M.D., Switzerland Wednesday, May 7, RESEARCH: Pat Schlagenhauf, M.D., Switzerland 2003. TRAVEL INDUSTRY & PUBLIC EDUCATION: Bradley Connor, M.D., USA ” ISTM SECRETARIAT The Marriott Marquis is also the site of ADMINISTRATIVE DIRECTOR: Susan Stokes, USA the 8th CISTM is being held May 7-11, ADMINISTRATIVE ASSISTANT: Brenda Bagwell, USA 2003. P.O. BOX 871089 Body of Knowledge: The Body of Knowl- STONE MOUNTAIN, GA 30087-0028 USA edge is being published in the March/ PHONE: 770-736-7060 April issue of the Journal of Travel Medi- FAX: 770-736-6732 cine. It can be found on pages 112-115. It has also been posted on the ISTM EMAIL: [email protected] website (www.istm.org). You will find it by selecting “Travel Med. Exam” from the Japan: Yuka Ujita left-hand menu on the home page. Peru: Eduardo Gotuzzo Philippines: Francois Ausseil Eligibility: We would remind everyone that Singapore: Helen M.L. Oh the exam is open to all licensed travel Editor: Karl Neumann, USA medicine practitioners including nurses, Assistant Editor: Eric Walker, UK Administrative Assistant: Camilo Benitez Assistant Editor: Peter Leggett, Australia physicians, pharmacists, and physician’s ISTM NewsShare assistants. Both ISTM members and non- Regional Editors: 108-48 70th Road members are eligible to participate. Colombia: Juan Gemot Forest Hills, NY, USA 11375 Hong Kong: Abu S. M. Abdullah For additional information and updates, Tel: 718-263-2072 India: Santanu Chaterjee Fax:718-575-0290 please visit the ISTM web site at Indonesia: Hanny G. Moniaga www.istm.org or e-mail Lori Kalata, Exami- E-mail: [email protected] nation Coordinator, at: [email protected]. © 2002 ISTM. All rights reserved. May not be reproduced without permission.