Introduction
For this assignment, the simulated scenario is that you have been chosen to be the school infectious disease prevention and treatment agent. Several groups in your school are going on service, mission and educational trips to other countries. They will potentially be exposed to infectious diseases while they are in foreign countries. They could also carry diseases from our country to other countries and some countries have requirements that all travelers to their countries are up to date on all their vaccinations. While your school mates are traveling they could also contract infectious disease for which there are no vaccinations. Working under you, there will be student agents who go on the trips who will be responsible for doing appropriate tests such as cultures to determine the causes of the diseases. They will have to be familiar with the symptoms and signs of these infectious diseases, so that they will know what tests to do. It is your responsibility to train these students to recognize these symptoms, and how to do gram stains on draining wounds, sputum, or urine and how to perform and interpret cultures on drainage, sputum, urine and stool. You will also need to train them on the appropriate treatment such as antibiotics, antiviral agents, or just symptomatic treatment and who needs to wear face masks and be placed in quarantine. Unfortunately, there will be very little access to professional medical care. Your student agents will have to be the doctors. You will have to make a list of the supplies they will need to carry with them to perform their tasks including which medicines to take. Before the students leave the United States, you will have to make sure they have had all of the vaccinations they need to maximally protect them from infectious disease they will encounter. You will also need to make sure they have had all their vaccinations that any American of their age should have had to prevent the spread of infectious diseases from this country to other countries.
Task
Your task will be to review the websites and videos that follow in the Process section in order to created a print document and a related Google Slides or Powerpoint presentation. The document will include narrative, algorithms and videos that specify each step in preventative vaccinations, diagnostic tests and treatment to be provided by the student agents who will be on each of the student trips. The Powerpoint presentations will be used for your instructions which you will give to the student agents to prepare them for their roles as health care provides in the absence of professional medical providers in the third world. There will be student groups from your school going to Haiti, Liberia in West Africa and to Northern India. You will also make a list of supplies that will be needed in order for your student agents to perform their diagnostic and therapeutic roles on the trips.
Process
The following web site will be your first step. You will use it to find out what infectious diseases are endemic in the countries to which the student groups are traveling. Once you have opened the link you will go to the "for clinicians" portion. Under that heading there will be a drop down under "Traveler destination" so that you can select each of the countries to which the students are traveling. You will also select such factors as the length of the visit and the purpose of the visit. There will be a list of diseases and the recommended vaccinations and when they are to be given. Some need to be given several weeks before travel. You will need to include in your plan, the dates that the students need to come in for their vaccinations. Some of the diseases such as Malaria, do not have vaccinations, but there are medications that need to be taken before and during the trip. The students will need supplies of these medicines to start taking at the appropriate time before the trip and enough to last them while they are on the trip. Some of the vaccinations are only required if the students are going to rural areas or where they will be at risk for a bite by an animal such as a bat, or mosquito so the season of travel will be a factor. There will need to be discussion of avoidance of bites by mosquitoes and other insects by using repellents and netting and appropriate clothing if these are risks in the particular country or the area of the country where the students will travel. This web site is for the United States Center for Disease Control: https://wwwnc.cdc.gov/travel
Download and use the following table to plan what vaccinations and medications are required for each group, the doses, and the schedules.
| Disease | Cholera | Hepatitis A | Hepatitis B | Japanese Encephalitis | Malaria | Yellow Fever | Rabies | Typhoid |
| Haiti Yes/No | ||||||||
| Dose | ||||||||
| Date | ||||||||
| India Yes/No | ||||||||
| Dose | ||||||||
| Date | ||||||||
| Liberia Yes/No | ||||||||
| Dose | ||||||||
| Date |
Go to the following link to determine that each student is up to date of recommended immunizations for Americans: https://www.cdc.gov/vaccines/schedules/hcp/imz/child-ado
lescent.html
Advice for Non-Vaccine-Preventable Diseases: https://wwwnc.cdc.gov/travel/destinations/clinicians/none/haiti?s_cid=ncezid-dgmq-travel-single-002 These recommendations will be the same for all three destinations in the scenario. These diseases include Dengue, HIV and Tuberculosis
The following is a Youtube with some important general health preventative measures to take before and during foreign travel:
The following is a real life testimonial of an American who contracted Malaria on a trip to West Africa. This describes symptoms of Malaria and the importance of taking prescribed medications and using mosquito nets. It includes statistics on the high prevalence of Malaria in Africa including a large number of deaths. This information will be important for all the students traveling on the trips and especially for the student agents who will help with diagnosis and treatment if any of their classmates show signs of malaria or other infectious diseases:
The following video explains more about malaria which has killed more people than any other infectious disease in history. Malaria is an organism in the domain Eukarya and the kingdom Protista. The species is Plasmodium. A protist is defined as a eukaryote that does not fit the descriptions of plant, animal or fungus.
As you can see from the above map, all three of the destinations of our student groups, Liberia, Haiti and Northern India are at risk of Malaria transmission.
Another problem which can develop is traveler's diarrhea (does not include the diarrhea produced by cholera or typhoid). There are no prophylactic measures for this except being very careful about what is eaten, eating only well cooked hot food and drinking only bottled drinks without ice. If it is still contracted, the treatment varies based on country and severity. The following link explains this in detail: https://www.uptodate.com/contents/travelers-diarrhea-clinical-manifestations-diagnosis-and-treatment?search=travelers-diarrhea-clinical-manifestations-diagnosis-and&source=search_result&selectedTitle=1~105&usage_type=default&display_rank=1
. This will help in deciding which medications for this condition should be added to the list of supplies and will give guidelines to the student agents on the trip including when to use peptobismol, rifamaxin, cipro, azithromycin, loperamide, IV hydration or nothing at all.
The following chart explains the physical findings in a person with diarrhea to determine the degree of dehydration: https://www.uptodate.com/contents/image?imageKey=ID%2F74796&topicKey=ID%2F2704&search=cholera&rank=1~85&source=see_link
The symptoms, diagnosis and treatment of cholera are described in the following link: http://www.uptodate.com/contents/cholera-clinical-features-diagnosis-treatment-and-prevention?search=cholera§ionRank=1&usage_type=default&anchor=H9382
A picture of the "rice water stool" that is seen in severe cholera is noted in this link: https://www.uptodate.com/contents/image?imageKey=ID%2F93210&topicKey=ID%2F2704&search=cholera&rank=1~85&source=see_link
Hepatitis A and B are preventable with the vaccines. For hepatitis A the same food and water handling advice as for cholera pertain. Both diseases can be sexually transmitted so precautions such as abstinence or barrier methods should be used. The symptoms do not develop for several weeks so for our student trips, the symptoms would not develop during the trip and the student agents would not be faced with diagnosis or treatment. Although if the eyes become yellow ( jaundiced) then the student should be sent for blood work including liver enzymes and hepatitis antigen and antibody testing.
Japanese Encephalitis is very rare with only one in one million travelers developing it. There may be some subsets of travels who require vaccination. The CDC link above discusses this, but further information is in the following link: https://www.uptodate.com/contents/japanese-encephalitis?search=japanese%20encephalitis&source=search_results&selectedTitle=1~42&usage_type=default&display_ra
Typhoid is a relatively common infectious disease caused by some strains of the bacterial salmonella. It is usually contracted in poor areas with poor hygine. Cases in the United States are usually related to travelers who return from travel to area of high incidence. Most cases in the United States were brought back from South Central Asia. This is seen in the red bar in the following world map. https://www.uptodate.com/contents/image?imageKey=ID%2F90927&topicKey=ID%2F2708&search=typhoid&rank=1~108&source=see_link.
However, cases of typhoid have come from all of the areas where our students will be traveling.
Typhoid has several differences from cholera. A significant percentage of patients have constipation rather diarrhea. The symptoms include fever, chills and abdominal pain. The symptoms can start as early as five days after ingestion of contaminated food or water. (So our student agents may have to deal with diagnosis and treatment of this disease) The vaccine is not as effective as the vaccines for the other infectious diseases the travelers face, especially for the salmonella paratyphi. Severe cases can result in colon perforation. Rice water stool is not seen in typhoid as in cholera. There are frequently neurologic symptoms such as headaches. The differential diagnosis for febrile illnesses in these countries include dengue, leishmaniasis, Q fever, leptospirosis, rickettsial infections, amebiasis, and malaria. Slow heart rate (bradicardia) and abdominal skin rose spots, may occur. For more details on this interesting disease, read the following link: http://www.uptodate.com/contents/epidemiology-microbiology-clinical-manifestations-and-diagnosis-of-enteric-typhoid-and-paratyphoid-fever?search=typhoid&source
Rabies: Although a rabies vaccine was developed in 1885 by Louis Pasteur, between 30,000 and 70,000 people die worldwide each year of rabies. Most of these are in developing countries. There are only about 2 cases per year in the United States and many of these are in people who were exposed to rabid animals in endemic area such as Haiti, El Salvador, the Philippines or Afghanistan). Bites from rabid dogs account for 90% of cases. In the United States wild animals are the most likely source (bats, raccoons, skunks and foxes) The incubation time from the bite to the disease is one to three months, so no students would develop the disease while on the trip, but the student agents need to know what steps to take if there is suspicion that a student has been bitten by a rabid mammal. The following links will explain more details about the virus, the disease and prevention/treatment, and care of all types of animal bites.
The other disease encountered by international travelers for which there is a vaccine is yellow fever. This is a viral disease transmitted by mosquitoes, but a different mosquito than the one responsible for the transmission of malaria. As you may know there was a major epidemic in our area, the lower Mississippi in the 1870's. Many towns in the area have Yellow Fever cemeteries. There were 3,227 deaths from yellow fever in Mississippi in 1878. This sounds like a lot, but it is dwarfed by the 70,000 that die still yearly in sub-Saharan Africa. You may remember the outbreak in Brazil in 2016 that threatened to limit participation in the summer olympics. The areas in the world of concern now are South America (not Haiti which is Carribean, so a little north of South America and Sub-Saharan Africa which does include Liberia. The disease gets its name from the yellow color of the skin and whites of the eyes that develops with the jaundice of severe liver disease that occurs is severe cases of yellow fever. For more details about this disease go to the following link.https://www.uptodate.com/contents/yellow-fever?source=history_widget
Other infectious diseases may be encountered in each country, in addition to the one treated with prophylactic medicines or vaccines. the following three links include lists of these diseases:
The third of the three links dealing with travel to the Caribbean has a helpful breakdown of which diseases produce which symptoms such as fever, diarrhea, jaundice, and rashes. It also lists diseases by how they are contracted such as by mosquito bite, oral intake, or by swimming in certain types of water. One interesting fact is that some mosquito transmitted diseases are contracted during the night(malaria, Japanese Encephalitis, West Nile Virus) and some are contracted during the day(dengue, chikungunya, zika, and yellow fever). Other than the diseases discussed above for which vaccinations are suggested, some of more common diseases are dengue, rickettsial diseases like typhus, leishmaniasis, and chikungunya. Details concerning these diseases are included in the above three links.
Since many of these diseases are transmitted by mosquito, black flies, fleas, ticks, tsetse flies, and other bites, it is important to know how to properly use netting and repellents. The following link and video should help with this. https://www.uptodate.com/contents/prevention-of-arthropod-and-insect-bites-repellents-and-other-measures?source=history_widget
Once the groups have arrived in the destination countries, if they develop illnesses such as infected skin lesions, diarrhea, respiratory infections with sore throats or cough with sputum production, there will be a need to perform stains of secretions for examination under a microscope and cultures to determine the causes of the disease and to help guide treatment. The following videos explain how to do these tests.
Gram Stain Technique:
Interpretation of Gram Stain
Use the following tables to help organize your diagnostic process for these infectious diseases you may encounter:
| GRAM POSITIVE COCCI BACTERIA | GRAM NEGATIVE COCCI BACTERIA | GRAM NEGATIVE ROD BACTERIA | GRAM POSITIVE ROD BACTERIA | VIRUS | FUNGUS | PROTOZOA | RICKETSIA | MYCOPLASM | |
| MALARIA | |||||||||
|
HEPATITIS |
|||||||||
| JAPANESE ENCEPHALITIS | |||||||||
| CHOLERA | |||||||||
| TYPHOID | |||||||||
| TYPHUS | |||||||||
| DENGUE | |||||||||
| POLIO | |||||||||
| YELLOW FEVER | |||||||||
| RABIES | |||||||||
| TUBERCULOSIS | |||||||||
| LEISHMANIASIS | |||||||||
| CHIKUNGUNYA | |||||||||
| ZIKA |
| SYMPTOMS | VECTOR | INCUBATION PERIOD | PREVENTION | TREATMENT | |
| MALARIA | |||||
| HEPATITIS A | |||||
| HEPATITIS B | |||||
| CHOLERA | |||||
| TYPHOID | |||||
| TYPHUS | |||||
| DENGUE | |||||
| JAPANESE ENCEPHALITIS | |||||
| POLIO | |||||
| YELLOW FEVER | |||||
| RABIES | |||||
| TUBERCULOSIS | |||||
| LEISHMANIASIS | |||||
| CHIKUNGUNYA | |||||
| ZIKA |
| NUMBER | SPACE REQUIRED | WEIGHT | EASILY BREAKABLE | FLAMMABLE | TEMPERATURE REQUIREMENT | |
| DIAGNOSTIC LAB MATERIAL | ||||||
| PREVENTATIVE MATERIAL | ||||||
|
MEDICATIONS |
||||||
| WOUND CARE MATERIAL | ||||||
Another helpful chart that describes the incubation periods for the most common of these infectious diseases is within the following link. The incubation time is the time from exposure to the organism until the appearance of signs and symptoms of the disease.https://www.uptodate.com/contents/image?imageKey=ID%2F113655&topicKey=ID%2F3883&search=diseased%20potentially%20acquired%20by%20travel%20to%20central%20america%20and%20caribbean&rank=3~150&source=see_link
Evaluation
| ELEMENTS | COMPLETE | PARTIAL | MAJOR DEFICITS | OMITTED | |
| VACCINATIONS AGAINST ENDEMIC DISEASES AS RECOMMENDED BY CDC FOR EACH COUNTRY | 10 POINTS | 8 POINTS | 4 POINTS | 0 POINTS | |
| VACCINATIONS RECOMMENDED FOR ALL U.S. CITIZENS BY CDC AGE APPROPRIATE AND UP TO DATE | 10 | 8 | 4 | 0 | |
| VACCINATIONS CORRECTLY SCHEDULED TO HAVE MAXIMAL PROTECTION BY THE TIME OF POSSIBLE EXPOSURE TO ORGANISMS | 10 | 8 |
4 |
0 | |
| APPROPRIATE SUPPLIES PLANNED FOR DIAGNOSTIC PROCEDURES | 10 | 8 | 4 | 0 | |
| APPROPRIATE SUPPLIES PLANNED FOR TREATMENT OF DISEASES THE MIGHT BE CONTRACTED | 10 | 8 |
4 |
0 | |
| APPROPRIATE SUPPLIES SUCH AS NETS AND REPELLANT AND ADVICE ON FOOD AND DRINK AS PREVENTATIVE MEASURES | 10 | 8 | 4 | 0 | |
| POWERPOINT PRESENTATION TO TEACH STUDENT AGENTS REFLECTS UNDERSTANDING OF THE PROCEDURE OF GRAM STAN AND OTHER STAINS AND PERFORMING CULTURES | 10 | 8 | 4 | 0 | |
| POWERPOINT PRESENTATION REFLECTS UNDERSTANDING OF THE APPEARANCE OF DIFFERENT ORGANISM ON STAIN AND IN CULTURE MEDIUM | 10 | 8 | 4 | 0 | |
| POWERPOINT PRESENTATION REFLECTS UNDERSTANDING OF SYMPTOMS, INCUBATION PERIOD, VECTOR, AND PHYSICAL FINDINGS FOR THE MOST COMMON DISEASES THAT MAY BE CONTRACTED | 10 | 8 | 4 | 0 | |
| POWERPOINT PRESENTATION REFLECTS AN UNDERSTANDING OF PROPER TREATMENT FOR THE DISEASES THAT MAY BE CONTRACTED INCLUDING WHICH MUST BE QUARANTINED AND WHICH STUDENTS NEED TO BE TRANSPORTED TO A HOSPITAL OR RETURNED TO THE UNITED STATES | 10 | 8 | 4 | 0 | |
| TOTAL |
THE TOTAL NUMBER OF POINTS EQUALS THE PERCENTAGE SCORE.
THIS PROJECT WILL BE 10% OF THE SEMESTER GRADE
Conclusion
This webquest has led you through the thought process that medical doctors and nurses go through to protect travelers from the numerous infectious diseases in the world. Since the time of Louis Pasteur in the late 1800's, scientists have worked diligently to seek an understanding of these devastating diseases. Much progress has been made that allows people in the developed, wealthy countries to travel anywhere in the world with relative safety. Despite everything that has been learned, there is still significant risk, so steps beyond vaccination are required to avoid contact with the infecting organisms. As you have also seen in your study, there are still thousands of people dying each year from infectious diseases, some of which have had effective vaccines for over 100 years. Although you would not really be giving the vaccinations or treating those who contracted disease, this knowledge is practical if you travel to other countries. You will be able to ask the right questions and double check that all the appropriate precautions have been taking. You will certainly be an asset to remind the people you are traveling with to eat safe foods, drink safe drinks, apply repellants correctly and use nets and other measures to prevent insect and other bites. This is all practical knowledge. You have learned facts by planning preventative measures and diagnostic and therapeutic measures, that were easier to learn by inserting yourself into the scenario than they would have been if you were simply trying to memorize facts. I hope you will take the challenge and make the world safer from infectious disease in your lifetime.
Credits
Multiple authors (2018) Centers for Disease Control and Prevention Travelers' Health retrieved from https://wwwnc.cdc.gov/travel
Multiple authors (2017) 2017 Recommended Immunizations for Children 7- 18 retrieved from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-ado
lescent.html
Multiple authors ( 2018, March 12) Health Information for Travelers to Haiti retrieved from https://wwwnc.cdc.gov/travel/destinations/clinicians/none/haiti?s_cid=ncezid-dgmq-travel-single-002
[Mass General Hospital]. (2016, Oct. 11) Healthy Travel Check List --> -->. Retrieved from https://www.youtube.com/watch?v=w0pA4fzEIEc
[MalaikaChannel].(2012,Feb. 19) Malaria:A Survivor's Story --> -->. Retrieved from https://www.youtube.com/watch?v=-cLHPhMoz4
[Business Insider].(2016,Sep. 8) Malaria is the deadliest disease in history --> --> --> retrieved from https://www.youtube.com/watch?v=5IwyDX1-gnl
LaRocque, Regina(2018, Apr. 18) Travelers' diarrhea: clinical manifestations, diagnosis, and treatment retrieved from https://www.uptodate.com/contents/travelers-diarrhea-clinical-manifestations-diagnosis-and-treatment?search=travelers-diarrhea-clinical-manifestations-diagnosis-and&source=search_result&selectedTitle=1~105&usage_type=default&display_rank=1
Swerdlow, D.L. (1992)JAMA 267:1495. Assessment of Severity of Volume depletion among patients with acute diarrhea retrieved from https://www.uptodate.com/contents/image?imageKey=ID%2F74796&topicKey=ID%2F2704&search=cholera&rank=1~85&source=see_link
LaRocque, Regina (2018, Feb. 8) Cholera: Clinical Features, diagnosis, treatment and prevention retrieved from http://www.uptodate.com/contents/cholera-clinical-features-diagnosis-treatment-and-prevention?search=cholera§ionRank=1&usage_type=default&anchor=H9382
LaRocque, Regina (2018, Feb 8) Rice-water stool in cholera retrieved from https://www.uptodate.com/contents/image?imageKey=ID%2F93210&topicKey=ID%2F2704&search=cholera&rank=1~85&source=see_link
Hills, Susan (2017, Mar. 22) Japanese Encephalitis retrieved from https://www.uptodate.com/contents/japanese-encephalitis?search=japanese%20encephalitis&source=search_results&selectedTitle=1~42&usage_type=default&display_ra
Jensenius,M.(2013)Am J Trop Med Hyg 2013:88:397 Infections in returning travelers by region of exposure, 1996 to 2011 retrieved from https://www.uptodate.com/contents/image?imageKey=ID%2F90927&topicKey=ID%2F2708&search=typhoid&rank=1~108&source=see_link.
Ryan, Edward(2017, Nov 27) Epidemiology, microbiology, clinical manifestations,and diagnosis of enteric (typhoid and paratyphoid) fever retrieved from http://www.uptodate.com/contents/epidemiology-microbiology-clinical-manifestations-and-diagnosis-of-enteric-typhoid-and-paratyphoid-fever?search=typhoid&source
Harper, Marvin (2017, Oct. 13) Clinical Manifestations and initial management of animal and human bites and DeMaria, Alfred (2018, Feb. 02) When to use rabies prophylaxis retrieved from https://www.uptodate.com/contents/clinical-manifestations-and-initial-management-of-animal-and-human-bites?search=rabies%20prophylaxis&source=search_result&s
Monata, Thomas (2018, Mar. 30) Yellow Fever retrieved from https://www.uptodate.com/contents/yellow-fever?source=history_widget
Murdoch, David (2017, June 22) Diseases potentially acquired by travel to West Africa retrieved from https://www.uptodate.com/contents/diseases-potentially-acquired-by-travel-to-west-africa?source=autocomplete&index=0~4&search=diseases
Murdoch, David (2017, Nov 30) Diseases Potentially Acquired by Travel to South Asia retrieved from https://www.uptodate.com/contents/diseases-potentially-acquired-by-travel-to-south-asia?search=diseases%20potentiallyacquired%20by%20travel%20to%20India&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Leung, Daniel (2018, Jan 09) Approaches to illness associated with travel to Latin America and Caribbean retrieved from https://www.uptodate.com/contents/approach-to-illness-associated-with-travel-to-latin-america-and-the-caribbean?search=diseases%20potentiallyacquired%20by%20travel%20to%20haiti&source=search_result&selectedTitle=10~150&usage_type=default&display_rank=10
Breisch, Nancy (2016, Nov 17) Prevention of Arthropod and insect bites: Repellents and other measures retrieved from https://www.uptodate.com/contents/prevention-of-arthropod-and-insect-bites-repellents-and-other-measures?source=history_widget
[Operation Blessing International]. (2011, Nov. 21) Giving Mosquito Nets to Help Prevent Malaria in Niger --> -->. retrieved from https://www.youtube.com/watch?v=0kfHy6gdAbM
[Coach Helder].(2016,Apr. 28) Military Issued Mosquito Netting Barrier Review --> --> -->.retrieved from https://www. youtube.com/watch/v=4mqJ-bpuv_U&t=17s
[Professor Simms]. (2015, Jun. 7) Lab 4: Bacterial Structure, Simple, Negative Diff Stains. --> --> --> retrieved from https://www.youtube.com/watch?v=RjSOjnw9H0c
[POCTCTR]. (2010, Jan 4) Introduction to Microbiology Culture Technique. --> --> -->. retrieved from youtube.com
Ryan,E.T.,(2002) N Engl J Med 2002; 347:505. Common travel-associated infections and their incubation periods retrieved from https://www.uptodate.com/contents/image?imageKey=ID%2F113655&topicKey=ID%2F3883&search=diseased%20potentially%20acquired%20by%20travel%20to%20central%20america%20and%20caribbean&rank=3~150&source=see_link