October 2009

Meet Fiona Genasi, ISTM President-elect

One of the many reasons that the ISTM continues to be a vibrant, innovative and successful society is the calibre and the varied backgrounds of the leaders that it has chosen for the Society. In its mere twenty or so years of existence, ISTM presidents have come from the U.S., Canada, Switzerland, France, Germany and Nepal. The executive board and committee heads have been from about three dozen countries.

Our new president-elect further widens the "varied background" aspect of our Society. She will be the second woman to serve in that capacity, the first president from the United Kingdom (Scotland, to be more precise - and politically correct), and the first non-physician. Fiona is an RN by profession. This reflects the ever more important role that non-physicians - nurses and pharmacists, in particular - are playing in our Society and in travel medicine.

A more qualified person than Fiona to serve as president would be difficult to find. The degrees after her name only hint at her qualifications and accomplishments: RN, MN, (Hon) DTM (RCPSG), FFTM (Glasgow). It bears out the old saying, if you want something done - and done well and promptly - ask the busiest person you know.

Fiona has been an ISTM member since its inception and has served in most of the leadership roles: Counsellor on the Executive Board, 2000-2004; founding Chair of the Practice and Nursing Issues Committee; original member of the Certificate in Travel Health^TM Exam Committee; Member of the Scientific Programme Committee for CISTM meetings in 1999 and 2007; and Associate Chair of the CISTM11 Scientific Programme Committee, Budapest 2009. And she served as Organising Chair of the Northern European Conference in Travel Medicine in Edinburgh 2006, a highly successful ISTM regional meeting which attracted over 900 delegates.

Fiona is the only Nurse Consultant in Travel Health Medicine in the UK. She is responsible for national travel medicine programmes at Health Protection Scotland, the agency that oversees travel medicine there. In that capacity she develops policy and services in travel and international health for the Scottish Government and for its physicians, nurses, pharmacists, other health professionals and organisations, and the general public. This includes directing the Yellow Fever Vaccination Programme; provision of evidence-based travel health information and guidance (and the websites TRAVAX and FitForTravel); and research and surveillance activity. And she remains clinically active in both pre- and post-travel settings.

And Fiona has accomplished all of this (and much more) in an astonishingly short time. She qualified with a nursing degree in 1984 and then specialised in Infectious Diseases, Tropical and Travel Medicine. She gained a Master's degree from the University of Glasgow in 1992, and is an Honorary Lecturer in Epidemiology within the Public Health Medicine Department there. In 2006 she was admitted to the Royal College of Physicians and Surgeons of Glasgow as a Founder Fellow within the Faculty of Travel Medicine. She sits on the College Examination Board for the Diploma in Travel Medicine and regularly teaches and examines at post-graduate level. She has co-authored three textbooks in travel medicine and numerous other publications on the topic.

Fiona has travelled extensively, and worked abroad in India and Iraq on education, research and humanitarian projects. She is an active member on various national and international groups and committees, including the UK Advisory Committee on Malaria Prevention (ACMP) and the exciting new EuroTravNet initiative of ISTM. (Please see the article on EuroTravNet in this issue of NewsShare.) Fiona was actively involved in the genesis of the winning proposal for EuroTravNet (September 2008), designed to build a network to support travel and tropical medicine related activities in Europe. The project is funded by the European Centre for Disease Prevention and Control (ECDC).

Vision for the ISTM

Fiona's primary goals during her presidency will be:

• Expanding and evaluating the evidence base for travel medicine practice. She strongly believes that it is essential for nurses, physicians, pharmacists, and others in the travel medicine and related fields to have standards and guidelines.
• Enhancing ISTM membership benefits, especially by providing additional opportunities in training, education and information.
• Developing more web-based information for members - an area in which she has much experience. "The web is a powerful vehicle that lends itself to this perfectly."
• Allowing people from different countries and cultures to share scientific collaboration, compare guidance and recommendations, and voice opinions. She believes that this should be a key strength of the ISTM. Inevitably, there will be differences. (And no one is better than Fiona at getting people with strong opinions to compromise, an art one has to be born with.) She has the proven ability and willingness to communicate well with individual members, national societies and groups, and would like to use these skills to help the Society forge partnerships, co-ordinate opinion and build consensus, wherever possible.

Fiona is married and has one son. She says "I am 100% Scottish [no question about that when you hear her speak]. I was born near Glasgow, but my husband is half Guatemalan, quarter French, quarter Italian - so I have always hankered after things with an international flavour! I am very proud of my Scottish heritage - my mother is a kilt maker - but one of my personal goals is to be able to shake off my Scottish accent for a while and speak Spanish fluently. And it goes without saying that I love to travel. I especially love water sports, particularly windsurfing, and, being Scottish, also golf."  
 

Welcome, Madame President.

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Preparing Travellers for Healthy and Safe Travel: Results of a Survey of ISTM Members

Compiled by Karl Neumann MD, FAAP

Spending at least 30 minutes in face-to-face conversation is the optimum strategy for travel health professionals to educate pre-trip clients about staying healthy and safe when travelling.

The thirty minutes - and, ideally, longer - should be spent in several-minute-long talks about salient points specific to the upcoming trips, distributing pertinent handouts, writing down important facts or underlining such facts in the handout, encouraging questions, and giving clients the opportunity to call (or, increasingly, to email) back for clarifications.

This was the consensus of our latest survey regarding the nuts and bolts of the office practice of travel medicine. The survey was emailed to about 1400 subscribers to the ISTM ListServ. There were 81 responses, a smaller number than in most previous surveys.

The questions we asked were:

• How much time does your travel clinic devote to clients - a healthy client going to Equatorial Africa for the first time, for example?
• Does your clinic provide written instructions, handouts, audiovisual shows or other supplements?
• Do you yourself administer vaccines and provide the tutoring? Or is it done by non-travel medicine personnel? If so, what is their training?

Here are some representative and interesting responses:

"The time I spend with clients varies with how busy I am, but it is usually -30-45 minutes, more for first time travellers. This is not cost effective, but fun."

"Handouts are effective only if you limit them to several, and if you spend a few minutes talking about each specific handout. Otherwise, most people do not read them."

"My face-to-face time is about 30 minutes. Then clients spend additional time with my nurse: typically 10 minutes to receive the vaccines and another 10 minutes for the nurse to fill out the paperwork. I then return to the room to review the handouts and to answer questions."

"The client's appointment is 20 minutes, but in practice a client travelling to Africa for the first time would probably take 40 minutes."

"I provide a great deal of material (written by myself) for clients to read and I give the key points verbally. I also supply websites to consult. I keep my written material up to date, in simple language, and as clear as possible. I do everything myself - risk assessment, advice, vaccinations, medications."

"Don't give too much advice. Read the following: Rombo, L. Travel Health Advice - a personal approach. British Travel Health Association Journal 2005; 6: 9-12."

"We do not use handouts or audiovisual shows. We refer all patients to the CDC website and Shorelands Tripprep to learn more."

"When clients call for an appointment we refer them to our website and encourage them to spend time looking it over, especially the parts that are pertinent to their upcoming trips. Our website has links to other websites, if necessary. We tell clients to write down questions. This has actually shortened the time we have to spend in face-to-face interviews. This makes the consultation more interactive and less overwhelming."

"Our patients are seen by the RN which is me. I have a Certificate in Travel Health^TM.  The usual appointment is 30 minutes, unless there is a complicated itinerary.  We subscribe to SOS International and a packet based on their itinerary is given to each patient.  I also give a written handout that reiterates what I tell them about insect repellents and travellers' diarrhea. I administer the vaccines.  …We have implemented a new Electronic Medical Records System (Travis Med), which is wonderful.  Patients are emailed an invitation to complete the medical and immunization history and travel itinerary portion prior to their visit.  Not all do this, but when they do it allows even more time for patient teaching."

"A new healthy patient on an uncomplicated itinerary is scheduled for 45 minutes. A new client with a complicated medical history or a new healthy patient with a complicated itinerary is scheduled for 60 minutes. Returning, established patients get either: a) a 15-minute appointment for a follow-up injection, prescription refill, etc., or b) 30 minutes for a new trip and itinerary. I provide oral, written, and video patient education materials. I am an RN and I do everything during all visits except for the prescriptions which are done by our onsite physician, physician's assistant, or nurse practitioner."  

"Our average appointment for a first-time traveller is forty-five minutes to one hour. We provide a report with country-specific information, a pamphlet with information about deep vein thrombosis, food and water safety precautions, information about the vaccines, and other handouts if needed, altitude sickness, for example. The nurse administering the vaccines provides the education. The nurses have attended seminars and conferences, as available, in addition to having "on the job" training using reference materials."

"Personal consultation with the trained provider is essential to preparing travellers properly. It is not just a one-way lecture but a discussion allowing for questions and concerns that may not be routinely covered. The vaccines are just a small part of preparation."

"We are a university-based travel clinic and we see students, faculty and staff. The typical appointment is one half hour with either the doctor or the nurse practitioner. The traveller is given handouts including Travax and Culturegram, food and beverage, insect precautions, malaria information, etc. The traveller then sees the travel nurse (who is also the clinic coordinator) for vaccines and vaccine related teaching.  Most of the students are seen for group education (a 30-40 minute PowerPoint presentation) given by the nurse or nurse practitioner, followed up by an individual appointment for vaccines with the nurse. Students are screened for personal health issues, health-related travel or complicated itineraries and seen by the doctor as needed."

"I schedule a half hour visit for a single person or a couple with this itinerary (Africa). This allows time if there is a language barrier and for patients who lack immunization records. If it turns out to be a quick visit I use the time for returning calls, electronic medical record completion and answering staff questions.  I have a nurse who gives the vaccines and reinforces instructions, reviews prescriptions, fills out yellow books and reminds patients to make follow up appointments. Currently she is a part-time employee but fills in the office (primary care and infectious diseases). I see 18-24 patients per day."

"Every patient receives an educational brochure prior to the visit covering all topics discussed, with a place for notes specific to their trip.  I print out all prescriptions rather than fax them, as most folks do not fill them immediately.  I believe having the paper is a reminder for them (though not as eco-friendly). We do have reminder cards to send for follow-up appointments."

"Our clinic devotes a considerable amount of time to each traveller: 10 minutes research after learning the traveller's destination, length of stay, planned activities, etc.; another 10 minutes determining which vaccines and/or malaria prophylactic medications are indicated; then 20 minutes counseling on various health hazards which may be encountered. Then, another 15 minutes administering the vaccinations and filling out the International Certificate of Vaccination; and finally, 20 minutes waiting in the lobby in case there are any allergic reactions to the immunizations.  I myself do the evaluations and counseling. I developed the informational handouts. The nurses administer the injections. I record the information on the International Certificate of Vaccination, with the exception of the vaccine lot numbers, which are recorded by the nurses. The nurses provide the Vaccine Information Sheets to the traveller."

"I personally give a 20-30 minute interactive educational session supplemented by handout "crib" notes. It covers vector-borne diseases, environmental factors (altitude, sun, sea, plants, toxic plants, etc.), what and what not to eat and drink, and how to treat diarrheal diseases if they happen. I shoot everyone myself 90% of the time or retain my long-time RN assistant for group immunizations during which I lecture and she shoots. A properly done "show" needs a fair amount of time and energy to do it right.  In consequence, the fee must reflect the quality of the service."

"While your surveys are informative and should be continued, they have some obvious shortcomings. I strongly suspect that you do not hear from clinics that give inferior services - and, unfortunately, there are many of those"

"Clients tell us that they have been to travel clinics where they were immunized and given prescriptions - with virtually no explanations. I am aware of several cases where travellers were given incorrect immunizations or the wrong malaria medication. I believe that the ISTM should publicize the Certificate in Travel Medicine as a standard for travel medicine A person with a Certificate is more likely to be competent, and likely, and hopefully, honest. Can the ISTM do anything to improve the quality of travel medicine rendered at such facilities?"

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ISTM News

United Kingdom: Retirement of Dr Gil Lea (October 2009)

Dr Gil Lea, a pioneering force in Travel Medicine in the UK and long-standing member of the ISTM, has announced that she is retiring in order to spend some hard-earned relaxation time with her husband on the Hampshire coast.

Gil has had a long and varied career in Travel Medicine dating back to 1971 when she worked as a Flight Medical Officer for British Overseas Airline Corporation at the Victoria Air Terminal in London. Soon afterwards the BOAC medical service (long haul) joined with the British European Airways medics in advance of the full merger of the two Air Corporations to form British Airways.

Gil developed the original British Airways Immunisation Unit at the Victoria Terminal. It became one of the busiest travel clinics in the world, responsible for the administration of at least 500 vaccines daily during the busy months. She recounts performing 1200 smallpox vaccinations in one day in 1978. That was the time that the variola (smallpox) virus escaped from a laboratory in Birmingham, UK, and, sadly, a medical photographer died. Everyone travelling from the UK suddenly required vaccination until the situation resolved.

Gil then worked as Senior Medical Officer for British Airways, overseeing the main Travel Clinics in central London until 1990. Along with an excellent team of doctors and nurses, she helped make the name of British Airways synonymous with travel medicine. More recently she worked as Chief Adviser in Travel Medicine (and Head of Travel Clinic) for the busy Trailfinders Clinic in Kensington High Street, London. There she advised a very wide range of travellers, able to tailor the recommendations to the individual and their travel risks and prescribe as necessary.

In the early years of travel medicine there was extremely little guidance for those performing adult travel vaccinations. She was keen to improve this situation whilst maintaining a clinical practice. So, during the 1990's, she took up a part-time post as the first Consultant within the newly formed Travel Medicine Section at the Health Protection Agency, and later at the National Travel Health Network and Centre. This position lasted until 2005. During this time, she conceived and produced the first travel medicine national guidelines published for doctors and nurses in the UK. She was also the first joint editor of `Health Information for Overseas Travel' (1995).

In recent years, Gil has been part of the Advisory Committee for Malaria Prophylaxis, the group who produce the `Guidelines for Malaria Prevention for Travellers from the UK'. Recognising the need for national policy development, Gil joined with colleagues in Liverpool and London to obtain funds from the Department of Health for a national travel medicine centre in England, Wales and Northern Ireland (the National Travel Health Network & Centre), and contributed to the formation and establishment of this centre in 2001. She also gave much-respected input to national policy-making in Scotland through her participation on the TRAVAX© (Health Protection Scotland) Advisory Group.

In recognition of her contribution to Travel Medicine in the UK, Gil was recently made a founder Fellow of the Faculty of Travel Medicine (Royal College of Physicians & Surgeons, Glasgow).

Although Gil is retiring from Travel Medicine, we hope it is not the last we will see of her at ISTM conferences, and that she will keep us updated on what is happening in that coastal hamlet in Hampshire.

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EuroTravNet - the European Travel Medicine Network

In response to a tender issued by the European Centre for Disease Prevention and Control (ECDC), a new European travel medicine network (EuroTravNet) was established by the International Society of Travel Medicine (ISTM). All the founding members of EuroTravNet belong to the ISTM and to ISTM's GeoSentinel® Global Surveillance Network.

This new network EuroTravNet (www.eurotravnet.eu) has three main goals:

• Coordinating a multi-disciplinary travel medicine network in Europe and organizing an annual meeting for members. Participation in this annual meeting is organized in collaboration with (ECDC). 

  To become a EuroTravNet member, applicants need to fulfill the following criteria: be located in a European country; be an ISTM Member; be affiliated with a clinical site seeing significant number of post-travel patients; and be willing to participate in network activities. To apply, please fill in and submit the Registration Form. Benefits of membership include recognition as being a member of an ECDC collaborative network and receiving accelerated alerts and advisories.

• Creating an inventory of travel medicine resources in Europe.
  www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19245

  One component of this inventory is an on-line questionnaire that is open to all travel medicine practitioners in EU and associated countries regardless of membership in societies or networks. Click here to take our first survey.

• Providing epidemiologic support to ECDC and respond to outbreaks. This activity is particularly important for travel-related disease that poses a threat to Europe.

For additional information, please contact:

SECRETARIAT AND INFORMATION MANAGEMENT
Dr. Philippe PAROLA,
Marseille, Project Director
secretariat@eurotravnet.eu

TRAVEL MEDICINE INVENTORY IN EUROPE
Dr. Patricia SCHLAGENHAUF,
Zurich, Co-ordinator
review@eurotravnet.eu

EPIDEMIC INTELLIGENCE AND RESPONSE
Dr. Philippe GAUTRET,
Pr. Fabrice SIMON,
Pr. Philippe BROUQUI,
and Dr. Philippe PAROLA;
Marseille, Co-ordinators
surveillance@eurotravnet.eu

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Pediatric table temporarily removed from ISTM website

The "Drugs and Vaccines for Pediatric Travellers: An Integrated Table" has been temporarily removed from the Education and Scientific Information Section of the ISTM website. The table is being updated. Caroline S. Zeind, PharmD, RPh, one of the original authors of the table, has graciously agreed to do the updating. Caroline is the Associate Dean for Professional and Academic Affairs, Chair and Professor, Department of Pharmacy Practice School of Pharmacy-Boston Massachusetts College of Pharmacy and Health Sciences.

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Reckless Behavior by Young Travelers: Should travel medicine practitioners assume a more proactive role in controlling self destructive activities?

Please read the following three related postings, two from websites and one from an Australian newspaper. Please comment. Send responses to the editor of ISTM NewsShare at travhealth@Aol.com

Item 1. This is a posting on a website popular with young travelers "out to have a good time."

The Spanish Steps Pub Crawl - a Must

A few years ago when staying in Rome, me and my travel buddies stumbled upon a tour called The Spanish Steps Pub Crawl. It is great! It takes away a backpackers biggest problem. How do I have a really good night out, visit all the best bars and clubs and avoid paying eight euros for a bottle of beer and the cover fee to a club, only to find the club is quite crappy inside.

If that sounds like you, I can't recommend this highly enough. It costs only 20 euros. And in Rome two drinks and entrance to a club can be more than that. You meet at the Spanish Steppes at around 8.30. You are greeted by the guides. They are an awesome bunch of guys.

Then for the next hour you drink as much wine and beer as your belly can handle. And as you know after a few drinks, everyone's confidence is on a high and you really start to mingle with everyone. It is really great.

Then the tour begins, I can't remember exactly how many bars and clubs we went to that night, and the rest of the details of the night are sketchy. But you get a house drink of something in each bar you visit. And a pretty cool T-shirt. You also take part in loads of drinking games.

In conclusion, if you are visiting Rome and want a great night out and meet loads of people and not break your budget, this is for you. It is also great for all ages, 18 plus, of course. And I would do this on the first or second night of your stay. It really sets you up for the next few days with all the people you meet. Checkout their web site for more details.

One last thing. Make sure you have where you are staying written on a piece of paper or something. It really helps. I had a bugger of a time getting home, as all I remembered that I was staying near the Central Station. But some of my friends actually spent the night in a cardboard box bed, which a homeless man set up for them.

Item 2. This is from a clipping in a Queensland (Australia) newspaper:

Australian Tourist whose body was recovered from a river in Rome had been partying on an organised pub crawl before he died.

The body of the 20-year-old man, who had a severe head wound, was pulled from the Tiber River after the body was spotted by a passer-by. He had apparently fallen from a bridge. The Australian embassy in Rome is liaising with the Italian police to obtain further information regarding the man's death. Consular staff at the Department of Foreign Affairs and Trade in Canberra is providing assistance to the man's family in Australia.

A spokesman for the Spanish Steps Pub Crawl confirmed the man was one of its customers the previous night. The spokesman said the man's death had occurred after the pub crawl ended. "I think it was an accident — I don't think it was any violence," he said. The young man's body was identified from papers found in his wallet.

Item 3. This is a posting from the Spanish Steps Pub Crawl that sponsored the event that led to the young man's death.

One Night of Insomnia.

We take groups of up to 120 people at a time on pub crawls. The only requirement for customers is that they speak a little English and "like drinking." Every night there is a different theme to our crawl. Monday night, for example, is "One Night of Insomnia."

We give you wings every Monday, says the website. What a better way to spice up the start of the week! Luckily, we enjoy some fruitful collaboration with Red Bull (an energy drink that contains much caffeine) and we treat our customers with some extra stuff on Mondays. Other than the Open Bar of beer and wine everyone gets 3 mixed drinks with Red Bull. And the usual stuff is on the schedule - 3 bars on the road with a welcome shot at the door of each one, drinking games and body shots, vast selection of music and you get to party with the coolest staff in Rome! Do it!"

Parts of this article were submitted by Dr. Irmgard Bauer, Senior Lecturer, Academic Advisor, School of Nursing, Midwifery and Nutrition, James Cook University Townsville Qld 4811 Australia.

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Report of my experiences with a tropical medicine expedition for healthcare professionals in Tanzania, 2009

Arthur Dover, MD, DTMH

In my opinion, the training for healthcare providers in the areas of clinical tropical medicine and travelers health in non-tropical countries has yet to reach an adequate standard. Each year, more and more tourists choose travel destinations in tropical and subtropical regions, often without immunization or malaria chemoprophylaxis. Returning travellers still succumb to malaria and other tropical infectious diseases simply because the infections are recognized too late, if at all, by medical professionals in American and European hospitals. Practice-oriented training program for doctors and other travel medicine professionals is essential to the prompt, correct diagnosis and treatment of tropical infectious diseases.

A very special two-week Tanzanian excursion lay ahead of us, which we would later come to regard as an incredible experience. I traveled with my wife Dilma, who works as a nurse in my travel clinic in California.

Upon landing at Kilimanjaro International Airport, we met the other 12 travelers - medical colleagues from Belgium, Switzerland and Germany.

Arriving at the Arusha Coffee Lodge, we met our excursion leader, Kay Schaefer (MD, PhD, MSc, DTM&H), a consultant in Tropical Medicine and Travelers' Health in Cologne, Germany. He had added Tanzania as a new destination for his "Tropical Medicine Expeditions" to East Africa. Since 1995 he has organized tropical medicine expeditions to Kenya and Uganda (in total 32 excursions with over 250 participants from `round the world') for healthcare professionals. These are done in collaboration with leading medical institutions and hospitals in East Africa. He and local experts supervise individual on-site bedside teaching, lead laboratory exercises (hands-on microscopy of parasites in blood, stool and urine), and give lectures. The curriculum (60 CME hours) covers the epidemiology, clinical manifestations, diagnosis, treatment, prevention and control of Africa's most important tropical infectious diseases. In addition, the participants gain insight into the local healthcare system and explore the fantastic scenery and prolific flora and fauna in East Africa during epidemiologic field excursions.

In the colonial atmosphere of the lodge, Dr. Schaefer outlined the planned course of the trip. He described the itinerary taking us from Arusha to Karatu in the Ngorongoro Conservation Area, continuing on to Lake Eyasi in the East African Rift Valley and then back to Arusha. This would cover approximately 450 miles in comfortable 4x4 extended Land-Cruisers with safe, experienced local drivers. During the second week we were to travel by plane from Arusha to Zanzibar to visit hospitals, clinics and field projects.

The next morning, we discussed malaria. Dr. Schaefer emphasized that malaria tropica (Plasmodium falciparum) is a medical emergency. Cerebral malaria can kill within a matter of hours. For this reason alone, doctors in the US and Europe should ask each patient with a fever if he or she has visited the tropics within the past 6 months. Later that same day we saw how life-threatening cerebral malaria can be, in an 8-month-old boy with convulsions and a fever of 104° F, admitted to the pediatric unit at the St. Elisabeth Hospital in Arusha (Photo 1). He immediately received IV dextrose solution and diazepam. With the help of a paracetamol suppository and fanning motions, a nurse tried to reduce the fever. Afterwards, the attending physician examined him and took a thin blood smear, explaining "It is much more important to stabilize the life-threatening condition, before any thought can be given to a diagnosis. Anyway, in most cases, it's malaria. Nevertheless, one should at least consider the possibility of meningitis, and perform a lumbar puncture in case the malaria therapy with quinine doesn't take effect." During the rainy season, the Anopheles mosquitoes breed very rapidly, and a distinct rise in malaria cases can be seen in hospitals, above all in the pediatric wards. Malaria tropica is still the number one killer of children under the age of 5 years in Africa.

A most important progress in malaria control is the development and distribution of impregnated bed nets. We visited a production facility on the outskirts of Arusha (Photo 2). The nets' fibers are permeated with Permethrin, a "knock-down" repellent, creating a physical and also chemical barrier against the mosquitoes. The French entomologist Dr. Kouchner, who works in the area, assured us that this protection lasts for at least 5 years - even after multiple washings. The bed nets are manufactured in several sizes and are used in different malaria control projects worldwide with great success, according to the World Health Organization.

Father Pat Patten is priest, physician and pilot all rolled into one. Over 30 years ago this American founded the Flying Medical Service (FMS) at the foot of nearby Mount Meru (15,000 ft). With small planes, healthcare workers reach very remote regions, otherwise inaccessible. We visited the headquarters of this small donation-funded organization. Two physicians from our group had the opportunity to spend two days with an FMS team. In outlying Maasai villages they examined pregnant women and inoculated small children.

After their return, everyone wanted to learn about their experience. "A complete and utter contrast to our high-tech medicine in Europe. It's incredible how people can be helped with so little equipment and medication," said Dr. Pöttgen from Frankfurt.

Along the journey toward Tarangire National Park we drove through a vast steppe landscape where sleeping sickness is endemic. After a lecture by Dr. Chalamka on human African trypanosomiasis in Magugu Hospital, we visited the wards. On a rusty pallet lay a 30-year-old man with severe meningoencephalitis. The day before he had been diagnosed with sleeping sickness. At his bedside, we discussed with Dr. Chalamka the advantages and disadvantages of Melarsoprol therapy, a highly toxic arsenic compound. He concluded by informing us that "with increasing frequency, tourists in East African national parks are being bitten by the tsetse fly. Regarding differential diagnosis, travellers to tropical regions returning home with a fever should be examined for malaria as well as sleeping sickness, insofar as they have visited endemic areas. Both diseases can be detected in a thin blood smear." In a field laboratory, we learned this important technique (Photo 3).

The day ended with a field excursion through the Lake Manyara National Park, where we ventured into the habitat of antelopes - the main reservoir of the Trypanosomiasis rhodesiense parasite. An experienced public health expert and an entomologist from the Ministry of Health in Tanzania explained the control measures taken in surrounding villages.

The following morning, we travelled along the edge of the magnificent Ngorongoro Crater (UNESCO World Heritage), reaching the Endulen Mission Hospital, staffed by a Dutch physician. She described the brucellosis cases, also known as undulant fever, which are often seen in the hospital. The patients complain of sudden fever and enlargement of the spleen and liver. The treatment calls for doxycycline and streptomycin. "Unfortunately, the patients, primarily the Maasai, return after a while with the same symptoms. They seem to have difficulty making a habit of cooking (pasteurizing) their cow's milk before drinking it, and therefore they infect themselves over and over again." As in the other hospitals we visited, we saw patients with pneumonia, AIDS, tuberculosis, malnutrition, and infants with diarrhea and dehydration.

As we drove across the sweeping Serengeti steppe and over to the Olduvai Gorge (the Cradle of Mankind), I observed the tall Maasai warriors with their cattle herds or trekking great distances across the arid plain in the heat of the day. Today the Maasai live as they have for centuries and are apparently not interested in changing their lifestyle.

At the Meserani Snake Park in Arusha, we saw many live venomous African snakes about which Dr. Schaefer had lectured the prior evening. Snakes usually avoid humans and retreat into hiding when disturbed. On the other hand, the puff adder is fairly sluggish and is therefore most often a threat when approached. Then there is the black mamba, by far the quickest and most poisonous snake in Africa. Its neurotoxic venom paralyzes the respiratory muscles and can lead to death by suffocation within minutes. The owner of the snake park, Dr. Berry Bale, is widely known as a snake expert. In return for snakes taken to him by the locals, he produces and provides antivenoms and also teaches about correct treatment following bites.

In the early evening we boarded our plane to fly from Arusha to Zanzibar. A hot and humid climate welcomed us when we arrived. The pelting tropical rain evaporated on the asphalt runway. Dr. Jiddawi, assistant minister for health in Zanzibar, received us in the modest arrival hall with a hearty "Inshallah." He is, as are most Zanzibaris, a devout practicing Muslim.

The drive from the airport to our hotel north of Stone Town (another UNESCO World Heritage site) was like an enchanted journey through the One Thousand and One Nights. Along the roadside, merchants hawked their wares by candlelight. In their faces I recognized traces of Africa, India, Arabia and Europe. Our bus driver informed us that most of them are in fact Zanzibaris, and that the population has mixed with other races and peoples over the centuries. What unites them is Islam and the Kiswahili language.

After the morning prayer, Dr. Khalfan, director of the Schistosomiasis/Elephantiasis Institute, welcomed us in his office in Stone Town. From here he coordinates prevention and control projects on Zanzibar. He is rightfully proud to report to us that in 2008, hardly any new cases of lymphatic filariasis were registered on Zanzibar after mass drug administration. Zanzibar was the first area to complete five rounds of treatment for the entire population using a combination of albendazole and ivermectin, reducing both the prevalence and intensity of Wuchereria bancrofti. "Factors crucial to its success include high-level political commitment, the development of appropriate social mobilization strategies, the involvement of communities in drug distribution, and the introduction of morbidity management for individuals with lymphedema. Unfortunately, with Schistosomiasis we're not that far along yet," he commented.

During the drive to a school in Kinyasini in the northern part of Zanzibar, Dr. Khalfan explained why this is so. "It's mainly because the schoolchildren bathe during the day in ponds and rivers. They get infected, they are treated, and then they infect themselves all over again when they jump in the water. It's a vicious circle."

An hour later we witnessed this phenomenon as we drove past a group of children in the midday heat - over 90° F (32° C), with relatively high humidity - splashing or doing their wash in a creek (Photo 4). Here they come in close contact with freshwater snails, the intermediate host for Schistosoma haematobium, hundreds of whose shells we found in the surrounding reeds. It is no surprise to learn that infection with urinary schistosomiasis is extremely high here.

It wasn't easy to bid farewell to our colleagues. Over the course of the past two weeks, we grew together as a family, learning from each other as well as from the course. We had covered the better part of all major tropical infectious diseases, in a wide variety of hospitals, clinics and research centers. On numerous excursions we gained familiarity and appreciation not only for the Tanzanian healthcare system and its public health challenges but the land, the people and the extraordinary flora and fauna.

(Formerly CDC, US Public Health Services), Watsonville, California, USA, dover@arthurdovermd.com

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Letter to the Editors:

Dear Sirs:

World Rabies Day (WRD) was observed worldwide on 28 September 2009 under the sponsorship of the WHO, the U.S. CDC, and numerous other respected national and international organizations. The impetus and leadership for WRD was provided by the Alliance for Rabies Control (ARC, U.K.) and the Global Alliance for Rabies Control (GARC, USA) - (www.worldrabiesday.org and www.rabiescontrol.net)

In its first two years of implementation (2007 and 2008), the WRD initiative has proven to be an extremely effective focal point around which to increase global education about preventing this disease. WRD has been endorsed by a multinational group of global stakeholders including international health organizations, national governments, educational institutions, NGOs and industry, as well as individuals living at daily risk of exposure. In 2007, 75% of all reported participants in WRD activities came from Asian countries. In 2008, 22 Asian countries participated in WRD activities and the number of animals reported to be vaccinated in association with WRD reached nearly 617,000 in Asia alone. Personal accounts from individual event coordinators demonstrated the dimensions of the growing campaign throughout Asia.

I recommend that the ISTM takes an active role in future WRDs. The ISTM and its members are in an ideal position to make the travelling public more aware of the presence of rabies in many parts of the world.

The mission of WRD is to raise awareness about the impact of human and animal rabies, how relatively simple it is to prevent it, and how to eliminate the main global sources. Even though the major impact of rabies occurs in regions of the world where many other needs are present, rabies should no longer be neglected. The tools and technology for human rabies prevention and dog rabies elimination are available. Through the WRD initiative, partners will be Working Together to Make Rabies History!

Global education is the essential and critical factor in eliminating the disease. The latest edition of the newsletter of the ARC (Alliance for Rabies Control, www.rabiescontrol.net) provides information. It reflects the emphasis on vaccination of pets/livestock, and efforts to vaccinate/sterilize stray dogs. Presently, stray dogs present the biggest problem globally, especially in Asia and Africa. You can subscribe to this newsletter free of charge. I encourage you to share this information with colleagues, family, and friends.

Sincerely,

Robert E. Dedmon MD, MPH, FACP, FACOEM
Theda Clark Medical Center, Neenah, Wisconsin
Clinical Professor Population Health - Public Health
Medical College of Wisconsin , Milwaukee,
EMAIL: drbobred@aol.com
Member, Editorial Advisory Board, Asian Biomedicine,
Chulalongkorn University, Bangkok